Sarcomatoid Carcinoma in Head and Neck: A Review of 30 Years of Experience—Clinical Outcomes and Reconstructive Results

Sintilimab combined with anlotinib as first-line treatment for advanced sarcomatoid carcinoma of head and neck: a case report and literature review

Sarcomatoid carcinoma (SC) is a rare, complex, aggressive tumor that spreads rapidly, is highly malignant, and has metastasized. Surgical resection is the primary treatment, and it usually occurs in the lungs and kidneys but rarely in the neck. Patients with advanced sarcomatoid carcinoma (SC) of the head and neck (HN) have a poor progonsis. In recent years, immune checkpoint inhibitors (ICIs) have been established as treatments for many solid tumors; however, the effectiveness of ICIs in treating SC of HN is still little recognized. We report a case study of a middle-aged woman with primary sarcomatoid carcinoma of the neck. She developed sarcomatoid carcinoma of the contralateral neck 7 months after the first surgical treatment. Subsequently, disease recurrence and metastasis occurred 8 months after the second surgery. The patient did not receive any treatment after both surgeries. The tumor showed high programmed death-ligand 1 (PD-L1) expression, with a combined positive score (CPS): 95. The patient's response to treatment was assessed as partial remission (PR) after 2 cycles of anlotinib combined with sintilimab. The patient has survived for over 2 years and remains in PR status, despite experiencing grade 2 hypothyroidism as an adverse event during treatment. The case highlights the efficacy and safety of anlotinib and sintilimab as a first-line treatment.

Exploring the Aggressiveness of Sarcomatoid Carcinoma of the Oral Cavity - an Institutional Experience

Background: Sarcomatoid variant of squamous cell carcinoma in the oral cavity is a rare biphasic variant of squamous cell carcinoma. This aggressive variant of squamous cell carcinoma is characterized by invasive growth with marked local recurrence and distant metastasis resulting in poor prognosis. Sarcomatoid carcinoma can occur over a wide age range, incidence increases with older age and is a male-predominant disease. Methods: 23 patients with histologically proven Sarcomatoid SCC or with a sarcomatoid component (Group A) were compared with 23 randomly chosen patients with clinical stage IV (Group B) disease at the time of diagnosis, within the same time period and comparison was made between disease free survival and overall survival. Results: In group A, the mean DFS was found to be 12.4 months raging from 1 month to 36 months. 6 patients were therafter lost to follow follow up, in 11 patients the mean overall survival was found to be 8.72 months (ranging from 2 to 18 months) whereas 6 patients are alive till date. In group B, the mean DFS was found to be 19.56 months ranging from 6 months to 33 months. 4 patients succumbed to the disease with a mean overall survival of 24.25 years (ranging from 18 to 33 months), 4 patients were lost to follow up and the rest are alive till date. Conclusion: Sarcomatoid carcinoma of the oral cavity is an extremely rare but aggressive variant of conventional squamous cell carcinoma. We have to systematically understand their clinical, morphological and immunohistochemical features which is critical for their accurate diagnosis which aids in correct patient management. After radical surgery and adjuvant radiation therapy, strict follow up for development of recurrence and distant metastasis should be done.

Prognostic significance of head and neck spindle cell carcinoma

BACKGROUND

Our study investigates the prognostic significance of spindle cell histology on overall survival (OS) of conventional head and neck squamous cell carcinoma (HNSCC).

METHODS

The 2004 to 2017 National Cancer Database was queried for patients with head and neck spindle cell carcinoma (HNSpCC) (n = 1572) or HNSCC (n = 242 697) of the oral cavity, major salivary glands, sinonasal tract, oropharynx, hypopharynx, and larynx treated with curative intent.

RESULTS

Patients with HNSpCC presented more frequently with higher-grade tumors and cN0 disease than those with HNSCC (p < 0.001). In the oral cavity, the HR for death for SpCC compared with SCC was 1.33 (p < 0.001). In the oropharynx, the HR for death for SpCC compared with SCC was 1.47 (p = 0.028).

CONCLUSIONS

After adjusting for patient, tumor, and treatment characteristics, SpCC histology had an independent adverse prognostic effect on OS in the oral cavity and oropharynx. SpCC histology does not necessarily portend poorer survival in all HNSCC.

LEVEL OF EVIDENCE: 4

A Rare Case of Neck Sarcomatoid Squamous Cell Carcinoma With Brain Metastases

Squamous cell carcinoma (SCC) is the second most prominent form of skin malignancy. It occurs most frequently in older males with fair skin complexion that have extensive sun exposure most commonly in their childhood. The metastatic presentation of SCC is rare and is most common in the lung. In this paper, we present the unique case of a 73-year-old patient with sarcomatoid squamous cell carcinoma in their posterior neck that metastasized to the brain.

Sinonasal carcinosarcoma with cartilaginous and rhabdomyoblastic components: A previously undescribed entity

Carcinosarcomas are rare, aggressive tumors seldom found in the sinonasal region. They classically consist of sarcomatous spindle cell and carcinomatous squamous cell elements. A 61-year-old woman presented reporting right-sided nasal discharge and obstruction. Examination demonstrated a large right-sided nasal mass, from which a biopsy was taken. Computed tomography and magnetic resonance imaging revealed a mass arising from the maxillary antrum and extending into the nasal cavity, ethmoid air cells, and frontal sinus. Right total maxillectomy with resection of the nasal tumour component was performed. Histological analysis demonstrated a high-grade malignancy with features consistent with carcinosarcoma with cartilaginous and rhabdomyoblastic elements, a histologic pattern that has not previously been described at this site. Magnetic resonance imaging 5 weeks postoperatively showed sizeable recurrence. Adjuvant chemotherapy and radiotherapy were commenced to excellent effect. Carcinosarcomas, though very rare at sinonasal sites, should be considered if biopsy demonstrates undifferentiated high-grade neoplasm with cytokeratin expression. These tumors require aggressive multimodal therapy for optimal outcomes.

Genomic landscape and tumor mutation burden analysis of Chinese patients with sarcomatoid carcinoma of the head and neck

BACKGROUND

Sarcomatoid carcinoma (SC) of the head and neck (HN) is a rare disease that has both sarcomatoid and cancerous components. The genetic background and mechanisms of tumorigenesis remain largely unrevealed, and the progress of precision therapy has been limited.

METHODS

Targeted DNA-based next-generation sequencing (NGS) was performed by a 539 genes panel of pan-cancer in 12 patients with SC of the HN to identify their genetic alterations and investigate clinically actionable mutations for use in precision treatment.

RESULTS

TP53 was identified as the most frequently mutated gene. Genes related to the cell cycling, chromatin remodeling and histone modification were found to be frequently mutated in patients with SC of the HN. Alterations in receptor tyrosine kinases (RTKs) were also found in six patients. In addition, four patients had mutations in members of the downstream RAS and PI3-kinase pathways, PIK3CA was identified as the most frequently mutated gene in this pathway. The tumor mutation burden (TMB) value ranged from 0.71 to 14.71 per megabase, with a median of 4.34. The TMB value of PIK3CA mutation patients was significantly higher than that of PIK3CA wild-type patients.

CONCLUSIONS

This was the first study to investigate genomic alterations specifically in Chinese patients with SC of the HN. Our research results showed that 10 out of 12 patients can match the targeted therapies or immunotherapy currently available in clinical practice or active clinical trials, suggesting precision therapy has the potential utility to improve the long-term prognosis for patients with the rare disease. Due to the small number of patients in this study, the findings need to be validated in a larger cohort.

Cervical carcinoma with histologic components of sarcomatoid carcinoma and multiple basaloid variants: A case report and review of the literature

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Basaloid cervical tumors are well-documented histologic variants and rarely exist in pure forms.

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Sarcomatoid carcinoma of the cervix is not yet classified as a histologic variant by the WHO.

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Squamous cell, basaloid and sarcomatoid carcinoma within a single cervical specimen is rare.

Cervical cancer with co-existing pathologic components of squamous cell carcinoma, basaloid morphology and sarcomatoid carcinoma is rare, with limited reports in the literature. Here we present a patient who underwent a modified radical hysterectomy for cervical cancer, with final pathology specimen demonstrating multiple histologic variants including basal carcinoma, adenoid cystic-like areas, basaloid squamous cell carcinoma and areas of high-grade transformation to sarcomatoid carcinoma.

Clinicopathologic features and outcome of head and neck mucosal spindle cell squamous cell carcinoma

Spindle cell squamous cell carcinoma (SpC-SCC) is rare, accounting for 0.4-4% of head and neck (HN) SCCs. Better understanding of HN SpC-SCC clinicopathologic characteristics, especially features that predict outcome, is needed. We present a clinicopathologic review of 71 HN mucosal SpC-SCC from three tertiary centers. The patient population showed a median age of 63 years (range 20-91), slight male predominance (M:F = 1.6:1), and a preponderance of smokers/ex-smokers (45/71, 64%). Most lesions involved oral cavity (42/71, 59%), especially oral tongue (n = 18), and larynx (n = 20, 28%). Polypoid/exophytic growth and surface ulceration were seen in 60% and 86% of cases, respectively. Histologically, most tumors showed sarcoma-like pattern (65/70, 93%), the remaining exhibiting granulation tissue-like or fibromatosis-like patterns, and 5 lesions showed osteosarcomatous/chondrosarcomatous elements. Most tumors (53/71, 74%) showed a conventional SCC (C-SCC) component, keratinizing (86%) or non-keratinizing/basaloid (14%). Nodal metastases, seen in 22 (31%) of resection specimens, showed SpC-SCC and/or C-SCC histomorphology. By immunohistochemistry, 76% of lesions showed immunoreactivity for keratin and 62/60% of lesions were p40/p63 positive. Ki-67 proliferation index ranged from 5 to 70%. Follow-up was available on 69 patients, median of 1.1 years from the time of SpC-SCC diagnosis. The 3-, 5-, and 10-year disease-specific survival (DSS) was 62, 37, and 12%, respectively. AJCC pN stage was an independent prognostic factor for DSS and distant metastasis-free survival (DMFS), whereas the presence of C-SCC was independently associated with improved DMFS. HN SpC-SCC is rare and might be diagnostically challenging. AJCC pN stage and co-existing C-SCC component appear to be prognostically relevant.

The predictive role of neutrophil-to-lymphocyte ratio in the outcomes of patients with sarcomatoid carcinoma of oral cavity

INTRODUCTION

The aim of the present study was to evaluate the prognostic value of the inflammatory response biomarkers and their impact on survival outcomes in the patients with sarcomatoid carcinoma (SC) of oral cavity, a rare variant of squamous cell carcinoma (SqC).

MATERIALS AND METHODS

Seventeen patients diagnosed with SC of oral cavity without metastases treated between Jan 2017 to June 2020 were identified and included in the present study. Pre- and post-operative inflammatory biomarkers and other prognostic markers were evaluated and their impact on disease-free survival (DFS) and overall survival (OS) was studied.

RESULTS

Seventeen patients (16 males and one female) were included in the present study with a median age of 42 years (IQR: 26-76 years). With the median follow-up of 15 months, nine of 17 patients had developed recurrence and were succumbed to either locoregional recurrence or distant progression. One-year Kaplan-Meier estimates of DFS and OS were 57% and 58.3% respectively. On univariate analysis, baseline NLR, PLR, and pathological bone/skin involvement were identified to be significant prognostic factors affecting the patient's DFS and OS. On multi-variate analysis, baseline NLR > 3 and pathological bone or skin involvement by tumour were emerged as some independent significant predictors.

CONCLUSION

For the first time, the predictive role of inflammatory markers is studied and proven significant affecting patients' survival outcomes. Hence, these inflammatory biomarkers may be considered for routine clinical use as reliable and low-cost prognostic markers to tailor the management of SC of oral cavity.

Complete response to radiation therapy for nasopharyngeal sarcomatoid carcinoma

Nasopharyngeal sarcomatoid carcinoma (SaCa) is extremely rare, and concurrent chemoradiation is the standard treatment for squamous cell-based nasopharyngeal cancer (NPC). This case report gives the first explanation of a nasopharyngeal SaCa patient treated with volumetric modulated arc therapy (VMAT) with simultaneous integrated boost (SIB), which is an excellent treatment modality that leads to complete response for locally advanced NPC. A 70-year-old male presented with nasal obstruction, epistaxis, and right neck node enlargements. Examination revealed an extensive tumor of nasopharyngeal tumor extending into the nasal cavity and right parapharyngeal space with bilateral lymphadenopathy on positron emission tomography (PET)-computed tomography images of focal hypermetabolic bone lesion in C4 body (stage T3N2M1). An excisional biopsy of nasopharyngeal wall mass showed a SaCa. He received concurrent chemoradiation which was VMAT and systemic chemotherapy (cisplatin 60 mg). A dose of 70 Gy was delivered to the planning target volume (PTV₇₀) (gross tumor volume plus margin 3-5 mm) and PTV_59.4(a wider margin around high-risk clinical target volume, including the clivus and neck nodes) all given in 33 fractions. Radiological examination such as magnetic resonance imaging (MRI) and PET images at the completion of external beam therapy revealed questionable residual disease. Follow-up MRI scans 4 weeks after radiotherapy revealed a complete tumor response. VMAT with SIB can be an effective treatment option for SaCa of the advanced nasopharynx.

Sarcomatoid Carcinoma in the Head and Neck: A Population-Based Analysis of Outcome and Survival

Objectives

To characterize sarcomatoid cell carcinoma (SaC) in head and neck, explore the value of radiotherapy (RT) and chemotherapy, and build a nomogram to predict the prognosis.

Study Design

Retrospective cohort study.

Methods

In total, 559 patients diagnosed with head and neck SaC from 2004 to 2015 were included from the Surveillance, Epidemiology, and End Results program. All the cases were divided into training (N = 313) and validation (N = 246) cohorts according to the year of diagnosis. The cases were analyzed on the age, site, sex, race, T stage, N stage, M stage, surgery, RT, and chemotherapy. Cancer‐specific survival (CSS) and overall survival (OS) were compared among disease‐related categories. The parameters significantly correlated with CSS were used to construct a nomogram.

Results

The multivariate analysis showed that age, T stage, N stage, and M stage were significantly correlated with CSS and OS. Overall, RT was correlated with improved CSS for Stage T3–4 and Stage N1–3. The subgroup analysis showed that RT was correlated with CSS in the Stage N1–3 patients after surgery while chemotherapy indicated an improved survival for Stage T3–4 and N1–3 patients without surgery. The prognostic nomogram was constructed and had a powerful discriminatory ability with the C‐index of CSS: 0.711.

Conclusion

Late‐stage head and neck SaC patients unfit for surgery need comprehensive treatment based on chemotherapy, and patients with node metastasis require adjuvant RT after surgery. Generally, RT might improve the survival of late‐stage patients. A reliable and powerful nomogram was established that can provide an individual prediction of CSS for head and neck SaC.

Level of Evidence

3 Laryngoscope, 131:E489–E499, 2021

Oral sarcomatoid squamous cell carcinoma: a retrospective study based on 14 cases

The treatment outcomes for oral sarcomatoid squamous cell carcinoma (OSSCC) are far from satisfactory in our hospital. The aim of this study was to retrospectively summarize the OSSCC cases admitted to our department. From 2003 to 2017, 14 patients were hospitalized and diagnosed with OSSCC. We summarized and analysed the medical histories, diagnostic examinations, treatment strategies, and clinical outcomes of the involved cases. Of the 14 cases, 8 were located in the gingiva. The imageological diagnosis identified the existence of a mass with an infiltrative morphology pre-operatively. The cytopathologic features revealed a malignant neoplasm with a mixture of squamous cell carcinoma (SCC) components and spindle cell neoplastic components. To confirm the diagnosis of OSSCC, the use of the immunohistochemical markers AE1/AE3 and Vimentin were more indicative. Complete follow-up data were available for 12 patients, and at the last follow-up, all 12 of the patients had died. The median overall survival for these patients was 11.67 months (range: 3-24 months). OSSCC patients respond poorly to the strategies solely referring to experiences from oral squamous cell carcinoma (OSCC) treatment. The effective diagnosis and treatment of OSSCC at an early stage is necessary. The treatment for OSSCC still poses a great challenge for clinical oncologists.

Oncologic Outcomes of Patients With Sarcomatoid Carcinoma of the Hypopharynx

Objectives: Sarcomatoid carcinoma (SaCa) of the hypopharynx is rare, and its clinical pathologic characteristics and prognosis remain unknown. Therefore, the study aimed to analyze the oncologic outcomes of patients with SaCa of the hypopharynx.

Methods: Patients with SaCa of the hypopharynx who were surgically treated in the period from January 1985 to December 2018 were enrolled from two clinical centers. A matched pair study was also performed, and each patient with SaCa of the hypopharynx was matched with one patient with squamous cell carcinoma (SCC) of the hypopharynx. The main study endpoint was disease-specific survival (DSS).

Results: A total of 62 patients (all male) were enrolled. Compared to patients with traditional SCC of the hypopharynx, patients with SaCa of the hypopharynx were older and had higher rates of perineural invasion, lymphovascular invasion and cancer cachexia. The 5-year DSS rate was 20% in patients with SaCa compared to 34% in patients in the matched group, and the difference was significant (p = 0.016). According to the univariate analysis, tumor stage, lymph node stage, disease stage, and cachexia were associated with DSS. According to the Cox model, neck lymph node metastasis and disease stage were independent predictors for worse DSS.

Conclusion: The prognosis of patients with SaCa of the hypopharynx is dismal, and this type of SaCa is associated with more aggressive biological behavior than traditional SCC of the hypopharynx; neck lymph neck node metastasis and disease stage were the most important predictors of DSS.

Clinicopathologic Diagnostic and Prognostic Factors of Spindle Cell Carcinoma of Upper Airway

Spindle cell carcinoma (SpCC) is a rare tumor, which occurs in upper respiratory tract, mainly in larynx. This study aimed to review the clinical and pathological characteristics for diagnosis and prognosis. Retrospective cohort study. All patients with SpCC in upper respiratory tract treated for curative intent was included. All patients were reviewed in search of epithelial component and immunohistochemistry when not found. It was evaluated rate of recurrence and disease-free survival with univariate and multivariate analysis with Kaplan Meier and Cox Regression model adjusted to propensity score indexes (PSI) according to age, gender, site of tumor, stage, surgical treatment, status of margins of surgical resection, lymphatic invasion. There were 16 cases of SpCC.31% were diagnosed with light microscopy and others with immunohistochemistry for epithelial marker. Disease-free survival was higher in early stage disease in univariate and multivariate analysis, as the main prognostic factor. Surgical treatment increases in 2.54 the rate of survival. The SpCC is a rare tumor considered a highly malignant variant of squamous cell carcinoma. It has male predominance and tobacco use as risk factors. Its treatment should follow the same recommendations for squamous cell carcinoma, with surgery as the maintain treatment. Immunohistochemistry is an adjuvant important tool for diagnosis of SpCC.

Sarcomatoid Carcinoma in the Parotid Gland: A Review of 30 Years of Experience

OBJECTIVE

The goal of this study was to analyze the results of clinical treatment of sarcomatoid carcinoma in the parotid gland by reviewing 30 years of experience.

METHODS

Thirty-five patients were enrolled in this study. The Kaplan-Meier methods were used to calculate the recurrence-free survival (RFS) and disease-specific survival (DSS) rates. The Cox model was used to determine the independent risk factor.

RESULTS

Mean age at presentation was 57.8 years, and most of the patients were staged as tumor (T)3 or T4. Perineural invasion was noted in 15 (42.9%) patients. Fifteen (42.9%) patients received neck dissection due to clinically suspicious nodes. Of those, three patients had pathologically positive nodes. Recurrence was noted in 14 patients; the most common pattern of treatment failure was local recurrence, and only 40% of the patients could receive salvaged surgical treatment. Disease-specific death was noted in 10 patients. The 5-year RFS and DSS rates were 67.3% and 65.7%, respectively. In a multivariate analysis, only the factor of perineural invasion was independently correlated with death.

CONCLUSION

Parotid sarcomatoid carcinoma carries a poor prognosis, and perineural invasion was the most important predictive factor.

LEVEL OF EVIDENCE

2b Laryngoscope, 129:1137-1140, 2019.

Spindle cell carcinoma: the general demographics, basic clinico-pathologic characteristics, treatment, outcome and prognostic factors

Background

Owing to the rarity, the general demographics, basic clinico-pathologic features, management, outcome and prognostic factors of spindle cell carcinoma (SpCC) were unexplored.

Methods

A SEER analysis was performed with 2336 cases (1973-2016).

Results

A peak incidence occurred at 70~80 years without any gender predominance and 83.13% occurred in white people. The respiratory system was mostly affected tumor site (35%). Significant overall survival (OS) and disease specific survival (DSS) were found differentiated in gender, age, marital status, primary tumor location, AJCC stage, T stage, N stage, M stage, pathologic grade and treatment modality. In the multivariate Cox model, the age > 69 years (Hazard ratio [HR] = 1.427 for OS, P = 0.01 and HR = 1.491 for DSS, P = 0.003; Reference [Ref] age ≤ 69 years), tumor location in respiratory system (HR = 1.550 for OS, P = 0.041 and HR = 1.561 for DSS, P = 0.04; Ref: digestive system), N2 stage (HR = 1.962 for OS, P = 0.006 and HR = 1.982 for DSS, P = 0.004; Ref: N0 stage) and AJCC stage IV (HR = 4.601 for OS, P = 0.000 and HR = 5.107 for DSS, P = 0.000; Ref: stage I) were independently associated with worse OS and DSS.

Conclusions

SpCC mostly occurred in white people at 70~80 years old without predominance in any gender. The respiratory system was mostly affected site. The patient's age, primary tumor location, AJCC stage were independent prognostic indicators for both DSS and OS of SpCC.

Sinonasal spindle cell carcinoma presenting with bilateral visual loss: A case report and review of the literature

Spindle cell carcinoma (SpCC) is a rare variant of squamous cell carcinoma (SCC). SpCC of sinonasal origin is relatively rare and more aggressive than normal SCC. It most commonly involves the maxillary sinus, and rarely the sphenoid sinus. The present study reports a case of sphenoid sinus SpCC presenting with bilateral visual loss. Following endoscopic sinus decompression surgery, the patient was referred to the Oncology Department for a staging workup, and subsequently received concurrent chemoradiotherapy; however, the vision of the patient was not recovered, despite treatment. To the best of our knowledge, this is the first reported case of synchronous inverted papilloma of the sphenoid sinus and SpCC presenting with optic nerve compression.

Disease-Specific Survival with Spindle Cell Carcinoma of the Head and Neck

Objectives

(1) Determine factors influencing survival in patients diagnosed with spindle cell carcinoma (SpCC), a rare variant of head and neck squamous cell carcinoma (SCC). (2) Compare survival of patients with SpCC to those with conventional SCC.

Study Design

Retrospective cohort study.

Setting

Surveillance, Epidemiology, and End Results 18 database (years 2004-2009).

Subjects and Methods

Among patients receiving treatment for a single primary in the oral cavity, oropharynx, hypopharynx, or larynx, 118 subjects with SpCC and 18,298 subjects with SCC were identified with complete data for the variables of age, sex, grade, tumor size, stage group, and TNM stage. Disease-specific survival curves were compared. Univariate and multivariate analyses were used to examine the effects of each factor on survival over all sites and within each of 3 sites.

Results

Univariate analysis of the combination of the 3 anatomic subsites showed survival with SpCC was worse than with conventional SCC ( P < .001). Three-year disease-specific survival with SpCC was 49.5%, and 5-year disease-specific survival was 40.2%. Compared with conventional SCC, survival was worse for SpCC of the oral cavity ( P < .001) and oropharynx ( P < .001) but no different for the larynx and hypopharynx site ( P = .15). Multivariate analysis identified age ( P = .02), tumor size ( P = .006), and M stage ( P < .001) as the only variables significantly affecting survival with SpCC. All variables significantly affected survival with conventional SCC.

Conclusions

Spindle cell carcinoma carries a worse prognosis than SCC. Larger tumor size, older age, and metastatic disease portend worse survival with SpCC of the head and neck.