A case of basaloid-squamous carcinoma of the esophagus: immunohistochemical and ultrastructural studies

Basaloid Squamous Cell Carcinoma of the Esophagus Immunohistochemistry and Flow Cytometric DNA Analysis in Two Cases

Basaloid squamous cell carcinoma is a well-established anatomopathologic entity of the upper aerodigestive tract and is more aggressive than the conventional squamous cell carcinoma. Only seven cases of this variant have been reported in the esophagus. Two cases of basaloid squamous carcinoma in the middle and lower third of the esophagus in two men aged 59 and 60 years are presented. Tumor stages were IIA and IV at the time of total esophagectomy, and survival times were 34 and 4 months, respectively. Histologically, the two tumors were composed of nests of cells with a basaloid appearance, the first with a predominantly cribriform pattern and the second with a solid lobular pattern and intense comedonecrosis; in the adjacent squamous epithelium of both tumors, carcinoma in situ was observed focally. Immunoreactivity was poor for high-molecular-weight cytokeratins and absent for those of low molecular weight. Staining for epithelial membrane antigen was weakly positive, enolase was moderately positive, and no reactivity for carcinoembryonic antigen, S100 protein, and chromogranin was observed. The flow cytometric analysis showed both tumors to be hyperdiploid with an index of cell proliferation of over 50%.

A literature review on oral basaloid squamous cell carcinomas, with special emphasis on etiology

In the recent years, basaloid squamous cell carcinomas (BSCCs) have gained attention because of (1) observation of a relative increase in the number of tumors arising particularly in head and neck sites, (2) identification of human papillomavirus (HPV) in BSCCs arising predominantly in the oropharynx, and (3) controversies that exist regarding the biological aggressiveness of the tumor. The objective of the present review was to address the issues mentioned above by focusing primarily on oral BSCCs, using literature that has been published in the English language up to 2013. According to the literature review, oral BSCCs were found to be relatively more common in elderly patients with a mean age of 64 years. A male predominance with a male/female ratio of 3:1 was observed. The predominant site was the tongue, with almost half of the reported cases occurring at this site, followed by the floor of the mouth and palate. With reference to habit history, majority were found to be tobacco and alcohol users. However, only 3 studies revealed data on HPV status of purely oral BSCC, and according to the results of these studies, of the 17 tumors tested, 4 had harbored high-risk HPV. Furthermore, most oral BSCCs were in an advanced clinical stage, namely, stage III or IV with T3 or T4 lesions and cervical lymph node metastasis at initial presentation, whereas 41% of patients had presented with local recurrences and 45% had died of the disease. In conclusion, although, the present literature review found enough evidence to consider tobacco and alcohol as risk factors for the development of oral BSCC, steps should be taken to fill the gap in our knowledge that exist with reference to contribution of oncoviruses, particularly HPV in the etiology of oral BSCC.

Histological diversity in basaloid squamous cell carcinoma of the esophagus

Basaloid squamous cell carcinoma of the esophagus (BSCCE) is a distinct variant of esophageal cancer. This study investigated histopathological variations of BSCCE. Thirty-eight surgical and two endoscopically resected specimens of BSCCE were examined. Histological features were classified into five components: solid nest (SN), microcyst and/or trabecular nest (MT), ductal differentiation (DD), cribriform pattern (CP), and an invasive squamous cell carcinoma (SCC) component. The immunohistochemical phenotypes of each component were examined using antibodies against cytokeratin (CK) 7, CK14, and alpha smooth muscle actin (SMA). SN, MT, DD, CP, and SCC were present in 95.0, 97.5, 27.5, 32.5, and 82.5% of the cases, respectively, and combinations of SN & MT, SN & DD, SN, MT & DD, SN, MT & CP, and SN, MT, DD & CP were found in 50.0, 2.5, 10.0, 17.5, and 15.0%, respectively. All the intraepithelial lesions observed in 18 (45.0%) cases were SCC. Immunoreactivity for CK7, CK14, and SMA was seen in 10.5, 86.8, and 18.4% of SN; 30.8, 97.4, and 38.5% of MT; 54.5, 100.0, and 54.5% of DD; 7.7, 76.9, and 23.1% of CP; and 6.1, 97.0, and 0.0% of SCC, respectively. CK14 immunoreactivity was seen in the periphery of most of the SN component. CK7, CK14, and SMA immunoreactivity was seen in the inner layer, all layers, and the outer layer of DD, respectively. MT and CP showed partial peripheral positivity for CK14 and SMA in microcystic, trabecular, and cribriform-like pseudoglandular structures. BSCCE demonstrates various histopathological and immunohistochemical features including a ductal and cribriform growth pattern.

Superficial basaloid squamous carcinoma of the esophagus. A clinicopathological and immunohistochemical study of 12 cases

Basaloid squamous carcinoma (BSC) is a rare variant of squamous cell carcinoma (SCC). In this study, clinicopathological and immunohistochemical characteristics of 12 superficial esophageal BSCs were examined and compared with those of typical superficial SCCs. Eight cases were classified into an elevated type, and the other four into a depressed type. High-grade intraepithelial neoplasia was not observed around the invasive lesions in five cases, and only BSC components were apparent. High-grade intraepithelial neoplasia was demonstrated in seven cases, five of which had both BSC and SCC components in the invasive lesion. A cribriform growth pattern, comedo-type necrosis, and hyaline deposits were conspicuous histological findings. CK14 was positively stained in 90% of the series, but the proportion of positive cells was small in most cases. Type IV collagen was increased or well preserved in the basement membrane in 70% of cases, but heparan sulfate was decreased in the majority. In comparison with SCCs, lymphatic permeation was observed less frequently. However, regarding the frequencies of venous permeation, nodal metastasis, p53 protein expression, and Ki-67 labeling index, no significant differences were noted. Thus, esophageal BSCs demonstrate the pathological features characteristic of an early stage, but pathological parameters related to biological behavior do not significantly vary from those typical of SCCs.

Paget's disease of the oesophagus associated with mucous gland carcinoma of the lower oesophagus

AIM

To report a rare case of oesophageal Paget's disease and its rarer combination with submucosal gland carcinoma of the lower oesophagus.

METHODS AND RESULTS

A 74-year-old Saudi female was admitted with the complaint of dysphagia. Endoscopic examination showed an ulcerated tumour at the gastro-oesophageal junction. Initial biopsy showed an undifferentiated carcinoma with pagetoid spread in the oesophageal stratified squamous epithelium. Oesophago-gastrectomy specimen showed a lobulated, poorly differentiated mucous gland carcinoma at the gastro-oesophageal junction. The tumour showed focal acinar differentiation and obvious cancerization of the submucosal glands, somewhat similar to the breast lobular carcinoma in situ. One of the isolated and cancerized submucosal glands also showed carcinoma in situ of its duct. Oesophageal surface epithelium showed extensive pagetoid spread, both over and away from the main tumour. The pagetoid tumour cells showed selective positivity for cytokeratin 7, cytokeratin Cam 5.2, BerEP4 and to a lesser extent for CEA.

CONCLUSIONS

As far as we know, this is the fifth case report of oesophageal Paget's disease and the first report of its association with the underlying mucous gland carcinoma.

Carcinosarcoma of the esophagus characterized by myoepithelial and ductal differentiations

We report a case of carcinosarcoma of the esophagus characterized by ductal and myoepithelial differentiation. A 61-year-old man was operated on for a polypoid tumor of the distal esophagus. Histologically, this tumor was composed of ductal structures and sarcomatous spindle cells surrounding the ducts at the central area of the tumor. The tumor was also composed of squamous cell and basaloid carcinoma in the periphery. Immunohistochemically, a few spindle cells surrounding the ductal structures showed immunopositivity for alpha-smooth muscle actin and S-100 protein. Electron microscopy revealed that the spindle cells had tonofilament and pinocytic vesicles in the cytoplasm, and basal lamina adjacent to the cytoplasmic membrane. Both of the results strongly supported the suggestion that the spindle cells may be myoepithelial cells. Basaloid carcinoma showed a gradual transition to chondrosarcomatous cells producing the matrix, which had both immunopositivities for S-100 protein and cytokeratin. Therefore, chondrosarcomatous cells may be derived from carcinoma cells. The histogenesis of this tumor may be associated with a totipotent stem cell of esophageal mucosa, which has the potential to differentiate into squamous cells, ductal cells or myoepithelial cells.

Esophageal basaloid carcinoma with marked myoepithelial differentiation

A case of esophageal basaloid carcinoma with marked myoepithelial differentiation in a 60-year-old man is reported. The tumor arose as an exophytic mass, measuring 65 x 60 mm, in the middle thoracic esophagus. Approximately two-thirds of the tumor surface was covered with non-cancerous esophageal epithelium. The depth of tumor invasion was limited to the submucosal layer. Histologically, about 70% of the tumor contained a typical basaloid carcinoma component and about 30% contained glandular and intercalated duct-like components with distinct epithelial and myoepithelial differentiation. The tumor presented no component of distinct squamous cell carcinoma, but a small portion of cribriform-like structure, which is typical of adenoid cystic carcinoma, was visible. The inner epithelium composing the intercalated duct-like structure showed immunohistochemical positivity for cytokeratin 14, and the outer epithelium lining adjacent to the stroma showed positivity for alpha-smooth muscle actin. These findings supported epithelial/myoepithelial differentiation. To our knowledge, our case is the first patient with an esophageal basaloid carcinoma showing marked myoepithelial differentiation.

Oesophageal basaloid squamous cell carcinoma: a unique clinicopathological entity with telomerase activity as a prognostic indicator

Oesophageal basaloid squamous cell carcinoma (BSCC) is uncommon and has been reported to have a worse prognosis than squamous cell carcinomas (SCCs), but this tumour has not been fully characterized. The aim of the present study was to analyse the clinicopathological features of a large cohort of patients with oesophageal BSCC treated at a single institution. The pathology of 756 primary oesophageal cancers treated between January 1989 and December 1998 was reviewed. Tumours that fulfilled the diagnostic criteria of BSCC were identified and were compared with SCC. Their expression of MIB-1, DNA ploidy, and telomerase activity were also studied. Thirty Chinese patients (25 men and five women) with BSCC were found, comprising 4% of patients with oesophageal cancer treated by surgical resection in the study period. Their median age was 67 years (range 40-78 years). Dysphagia was usually the main presenting symptom. Other concomitant malignant tumours were seen in three patients and paraneoplastic glomerulopathy in one. Five tumours were located in the upper third, 19 in the middle third, and six in the lower third. The median length was 5.8 cm (range 2-12 cm). The median MIB-1 score of BSCC was 750 (range 400-858) and was higher than that of SCC (p=0.003). The primary tumour and metastatic BSCC were aneuploid, as detected by flow cytometric analysis in nine patients. Telomerase activity was positive in 95% (19 out of 20) of the cases analysed. The 5-year survival of patients with BSCC was 12%. Distant metastases were seen in 53% (n=16); lung and liver were the most common sites. The median survival of patients with tumours which had a high level of telomerase activity was significantly shorter than those with low levels of telomerase activity (1 vs. 27 months) (p=0.001). The median survival of patients with BSCC and SCC was 26 and 16 months, respectively (p=0.3). In conclusion, BSCC has distinctive clinicopathological features and its long-term prognosis is no worse than SCC. The level of telomerase activity may have a prognostic role.

Comparative analysis of basaloid and typical squamous cell carcinoma of the oesophagus: a molecular biological and immunohistochemical study

Twenty-three cases of basaloid squamous cell carcinoma (BSCC) and 23 stage-matched pairs of typical squamous cell carcinoma (SCC) of the oesophagus were investigated for molecular aberrations. Polymerase chain reaction (PCR) was used to detect loss of heterozygosity at the APC, RB, and MCC gene loci, while differential PCR was carried out to detect amplification of the CDK4 gene. In addition, the level of expression of the p53 and RB proteins in the tumour tissue was assessed by immunohistochemistry. Loss of heterozygosity (LOH) at the APC and MCC loci was about twice as common in BSCC as in SCC (40% vs. 21% and 33% vs. 12%, respectively), with co-existence of LOH at both loci occurring only in BSCC. LOH frequency at the RB gene locus was not remarkably different in either BSCC or SCC (20% vs. 24%, respectively). On immunohistochemistry, accumulation of p53 protein was slightly more frequent in BSCC than in SCC (61% vs. 52%), whereas the rate of loss of RB protein expression was about equal in both types of carcinoma (9% vs. 13% BSCC and SCC, respectively). There was no detectable amplification of the CDK4 gene in either type of tumour. Although the observed differences did not achieve statistical significance, this work has further highlighted possible differences between the molecular pathogenesis of BSCC and SCC.

Basaloid squamous carcinoma of the oesophagus: a distinct neoplasm with multipotential differentiation

AIMS

Basaloid squamous carcinoma (BSC) is an uncommon variant of squamous cell carcinoma, with its prevalent sites being the hypopharynx, tongue base and larynx. In the oesophagus, BSC is rarer than in the head and neck region. This study was aimed to document the clinicopathological features of BSCs of the oesophagus, and to present their relative incidence and immunohistochemical findings.

METHODS AND RESULTS

Eighteen cases of BSC of the oesophagus, comprising 3.6% of 502 oesophageal carcinomas, were reviewed for their pathological and clinical features, and examined for the immunohistochemical expression of neuroendocrine markers, cytokeratins, p53, pRb and bcl-2. Oesophageal basaloid squamous carcinomas tended to be biphasic or multiphasic carcinomas, most commonly with basaloid and squamous components (eight cases), or with additional adenocarcinoma (three cases) or with small cell carcinoma (two cases). Each component was microscopically clearly distinguishable from the others, and metastasized separately, chiefly the basaloid component. The remaining five cases were apparently pure basaloid carcinomas, being characterized by lobules and nests of monotonous round undifferentiated cells with frequent comedo necrosis. They resembled, but were differentiated from, the small cell carcinoma on the basis of neuroendocrine markers and cytokeratin expression. p53, pRb and bcl-2 oncoprotein, which are known to normally present in the basal/parabasal cells of the oesophageal epithelium, were detected in 40-50% of cases, with a heterogeneous expression pattern. The patients were all male, with the age ranging 47-74 years (median 57) and presented at variable stages. The plotted 3 years survival rate was 51%, and the immunohistochemical expression of p53, pRb and bcl-2 was not related to the survival of the patients.

CONCLUSION

Basaloid squamous carcinoma of the oesophagus is a peculiar neoplasm with a capacity of multidirectional differentiation, often with heterogeneous oncogene expression, probably reflecting the pluripotential stem cell origin.

Expression of Bcl-2 and amplification of c-myc are frequent in basaloid squamous cell carcinomas of the esophagus

Basaloid squamous cell carcinoma (BSCC) of the esophagus is a rare, poorly differentiated variant of typical esophageal squamous cell carcinoma (SCC) characterized by high proliferative activity and frequent spontaneous apoptoses. In the present study, we investigated the expression of the apoptosis-suppressing protein Bcl-2 in 23 BSCC of the esophagus and 23 stage-matched typical esophageal SCC by means of immunohistochemistry. In addition, amplification of the apoptosis- and proliferation-inducing gene c-myc was determined by means of differential polymerase chain reaction. Bcl-2 expression was found significantly more often in BSCC than in SCC (86.9% vs. 17.4%, P < 0.0001). Amplification of c-myc was nearly twice as common in BSCC as in SCC (47.8% vs. 26.1%, not significant). Bcl-2 protein expression together with c-myc amplification was detected in 43.5% of the BSCC but in none of the typical SCC (P < 0.0001). Taken together, our findings indicate that the molecular pathogenesis of esophageal BSCC differs from that of typical SCC and frequently involves coactivation of c-myc and Bcl-2.

Basaloid squamous cell carcinoma of the esophagus: diagnosis and prognosis

BACKGROUND

Basaloid squamous cell carcinoma (BSCC) is a recently recognized, poorly differentiated variant of squamous cell carcinoma (SCC), which is located predominantly in the upper aerodigestive tract.

METHODS

In this study, clinical and pathologic parameters of 17 BSCCs and 133 typical SCCs of the esophagus that underwent potentially curative resection (no distant metastases, no residual tumor) were compared. In addition, light microscopic, electron microscopic, and immunohistochemical features of BSCC were investigated, to determine whether this type of carcinoma could be differentiated from other poorly differentiated carcinomas of the esophagus.

RESULTS

Light microscopic study showed that BSCC was composed of relatively small tumor cells, arranged in solid lobules with abundant comedo-type necrosis. BSCC was almost invariably accompanied by areas of concomitant typical SCC, foci of squamous cell differentiation, and/or severe squamous cell dysplasia or carcinoma in situ of the adjacent mucosa. Ultrastructurally, BSCC inconsistently showed features of squamous cell differentiation. Immunohistochemically, BSCC displayed poor reactivity for antibodies against wide-range cytokeratins and cytokeratin subtypes that are typical of squamous cell epithelia (cytokeratin 13 and cytokeratin 14). Infrequently, expression of Leu7, smooth muscle actin, and S-100 protein was found. In comparison with typical SCC, the characteristic features of BSCC were older patient age, higher proliferative activity (MIB-1 labelling index), and higher apoptotic indices. No differences were found with regard to pT classification, pN classification, tumor size, blood vessel invasion, lymphatic vessel invasion, neural invasion, or patient gender. Moreover, no differences in overall survival rates were found.

CONCLUSIONS

BSCC is a distinct histopathologic variant of SCC, characterized by a poor degree of differentiation and high proliferative activity. However, after potentially curative resection, the prognosis of patients with BSCC of the esophagus does not differ from that of patients with typical SCC.

[Basaloid squamous epithelial carcinoma of the mouth mucosa]

The basaloid-squamous carcinoma (BSC) that was first described in 1986 by Wain et al. for the head and neck region is a rare distinct variant of squamous cell carcinoma (SCC). The cardinal histopathologic feature is a biphasic cellular pattern of basaloid and squamous components. BSC has been confused with solid adenoid cystic carcinoma (ACC). Although the number of reported cases is small, BSC appears biologically virulent, with a propensity to aggressive local behavior, early regional and distant metastasis, and subsequent poor survival. We report the clinicopathological characteristics of 4 new cases and compare their immunohistochemical features with those of solid ACC and conventional SCC. Our results show that BSC, ACC and SCC react to CK 5/6. SCC is CK 10- and CK 13-positive, while BSC and ACC are negative for these markers. BSC and ACC react to CK 8, but in ACC only the luminal cells are CK 8 positive: therefore ACC has a glandular pattern. Our findings indicate that the immunohistochemical differences between BSC and ACC can facilitate their differential diagnosis. Because the biologic behavior of BSC differs from ACC and SCC, distinction among these tumor types is warranted.

Basaloid-squamous carcinoma of the esophagus. A clinicopathologic, DNA ploidy, and immunohistochemical study of seven cases

Basaloid-squamous carcinoma (BSC) of the esophagus is a rare but interesting neoplasm that occurs primarily in the upper aerodigestive tract. In this study, we reviewed 371 cases of esophageal malignancies and detected seven cases (1.9%) of BSC. The clinicopathologic features, light and electron microscopic findings, and immunohistochemical localization of various differentiation-related antigens, including cytokeratin (CK) subtypes, p53, and epidermal growth factor receptor (EGFR), were examined. DNA ploidy was also determined in an effort to characterize the biologic features of these tumors. The tumors were classified as stage I (n = 1), IIB (n = 3), III (n = 2) or IV (n = 1). Six patients had lymph node metastasis, in four the metastatic carcinoma exhibited basaloid components. Histologically, all the tumors displayed a biphasic pattern of basaloid and squamous components. The former predominated in three cases, the latter in four cases. All the tumors contained solid growth of basaloid cells with microcystic patterns and stromal hyalinosis as well as palisading of cells. Ultrastructurally, markedly replicated basement membrane was observed. Immunohistochemistry revealed staining with only CK 14 and CK 19 antibodies in the periphery of the basaloid tumor nests. These antibodies were also positive in the basal layer of normal esophagus. Diffuse immunoreactivity for EGFR was demonstrated in all the tumors. Five tumors displayed p53 nuclear immunoreactivity. All of the basaloid components demonstrated aneuploidy by DNA image cytometry. We conclude that BSC is a distinct type of esophageal carcinoma that should be differentiated from the usual types of esophageal carcinoma and may be associated with aggressive biologic behavior.