Adenosquamous carcinoma of the pancreas: report of two cases

Clinical presentation and prognosis of adenosquamous carcinoma of the pancreas - Matched-pair analysis with pancreatic ductal adenocarcinoma

INTRODUCTION

Adenosquamous carcinoma of the pancreas (ASCP) is a rare subtype of pancreatic adenocarcinoma. The aim of this study was to investigate the characteristics and outcomes of ASCP in comparison to pancreatic ductal adenocarcinoma (PDAC).

MATERIALS AND METHODS

All patients with ASCP treated between December 2001 and December 2017 were identified from a prospective database. Clinicopathological and follow-up data were analyzed. A nested case-control-study with matched-pair analysis was performed to compare overall survival of ASCP and PDAC.

RESULTS

Of 4009 patients undergoing surgery for pancreatic adenocarcinoma 91 patients had ASCP. Compared to PDAC ASCP were larger (4.0 vs. 3.2 cm; p < 0.0001), more frequently involved lymph nodes (88% vs. 78%; p = 0.0216), more frequently showed poor differentiation (G3: 79% vs. 36%; p < 0.0001) and more frequently were located in the pancreatic tail (19% vs. 10%; p = 0.0179). Overall median post-resection-survival was shorter in ASCP (10.8 vs. 20.5 months in PDAC; p = 0.0085), but 5-year survival rates were comparable (18.2% vs. 17.5%). After matching for the unevenly distributed prognostic factors survival after resection of ASCP and PDAC was comparable (p = 0.8301). Localization in the head or several parts of the pancreas, high CA 19-9 levels, and M1 disease were independent predictors of survival in patients with ASCP.

CONCLUSION

ASCP is more aggressive with poorer differentiation and higher rates of lymph node metastases compared to PDAC. In spite of a shorter median survival, 5-year survival rates after surgical resection of about 18% can be expected in ASCP and support resection as part of a multimodal therapy as the treatment of choice in this rare cancer.

Prognostic Analysis and Influencing Serum Biomarkers of Patients With Resectable Pancreatic Adenosquamous Cancer

Objectives

There are few reports about the survival rate of patients with pancreatic adenosquamous cancer (PASC). This study evaluated and analyzed prognostic factors of patients with resectable pancreatic adenosquamous cancer (rPASC), which might fulfill the blank in the research of PASC.

Methods

In this study, we identified and analyzed 55 patients who were diagnosed with rPASC from January 2013 to May 2019 at the Pancreatic Disease Center of the Shanghai Ruijin Hospital affiliated with Shanghai Jiaotong University School of Medicine. Age, sex, BMI, tumor position, and other important demographic data were collected and analyzed. The follow-up was updated by December 31th, 2019 with a median follow-up of nine months.

Results

Among the 55 patients, 23 (41.8%) patients were female, and the mean age was 62.0 ± 10.3 years. The median overall survival (OS) time was 10 ± 2.1 months, and the median disease-free survival (DFS) time was 4 ± 0.9 months. The 1-year, 3-year, and 5-year survival rates were 40.9, 17.5, and 11.6%, respectively. The multivariate analysis showed that normal serum level of Ca199 (HR = 0.464, 95% CI = 0.222–0.970, P = 0.041) and Ca125 (HR = 0.441, 95% CI = 0.233–0.835, P = 0.012) were independent favorable prognostic factors.

Conclusion

Patients with rPASC had poor survival. The 5-year survival rate was only 11.6%. Normal serum levels of Ca199 and Ca125 were independent favorable prognostic factors that predicted prognosis.

CT and MR imaging features of pancreatic adenosquamous carcinoma and their correlation with prognosis

PURPOSE

To retrospectively investigate the computed tomography (CT) and magnetic resonance (MR) imaging features of pancreatic adenosquamous carcinoma (PASC) and the association between imaging findings and prognosis.

MATERIALS AND METHODS

CT, MR images of 26 patients with PASC were analyzed. Clinical symptoms, tumor markers, and patients' survival were recorded. Tumor attenuation, enhancement pattern and degree, vessel involvement, adjacent tissue invasion and metastasis were evaluated. The association between imaging features and overall survival (OS) were also assessed using Cox proportional hazards ratio model.

RESULTS

Fourteen masses were found in the head of the pancreas and 12 in the body/tail. The mean tumor size was 4.47 ± 1.76 cm. PASC usually showed ill-defined (96.2%), lobulated (76.9%) and predominantly solid mass (92.3%). Ring enhancement in the peripheral area of the tumor was commonly seen (76.9%). Vessel invasion was seen in 17 cases (65.4%), encasement of adjacent arteries in 7 cases (26.9%), upstream main pancreatic duct (MPD) dilatation in 16 cases (61.5%) and double duct sign in 9 cases (34.6%). Multivariate Cox proportional hazards model demonstrated that patients with vessel invasion may predict a poor prognosis (p = 0.037).

CONCLUSION

PASC tends to be an ill-defined solid mass with peripheral ring enhancement, and relatively poor enhancement in the central area. PASC may also show vessel invasion, vessel encasement and upstream MPD dilatation. Vessel invasion may indicate a poor prognosis.

110 Patients with adenosquamous carcinomas of the pancreas (PASC): imaging differentiation of small (≤ 3 cm) versus large (> 3 cm) tumors

OBJECTIVE

This study examined radiological imaging features of small (≤ 3 cm) and large (> 3 cm) adenosquamous carcinomas of the pancreas (PASC) lesions to better understand the morphology of these lesions.

METHODS

Images from 110 patients with pathologically proven PASC (80 males and 30 females, mean age: 62.6 years) were retrospectively reviewed. Two radiologists analyzed images and reached a consensus regarding the following features: location, shape, margins, presence of solid and necrotic components, rim enhancement, density/intensity during the portal venous phase, invasion of surrounding organs, vascular invasion, venous tumor thrombus formation, and enlarged lymph nodes. Differences in the imaging features between the two groups were evaluated with the Chi-square test or Fisher's exact test.

RESULTS

There were 41 small PASC lesions (mean age: 60.59 years) and 69 large PASC lesions (63.74 years). Statistical analysis demonstrated significant differences in the location, shape, adjacent organ and vessel invasion, and venous tumor thrombus formation (P < 0.05). Small PASC lesions were more frequently detected in the pancreatic head and had an ovoid shape. There was no significant difference in the presence of solid and necrotic components (P = 0.090), including approximately 3/4 of the lesions with necrosis and 1/4 purely solid lesions, enlarged lymph nodes (P = 0.068) and other features.

CONCLUSION

Regardless of the tumor size, 75% of PASC lesions present with central necrosis while 25% are purely solid. Small PASC lesions can be associated with lymph node metastasis at a relatively early stage. Large PASC lesions are likely to invade adjacent tissues and be associated with venous tumor thrombus formation.

Comparative outcomes of adenosquamous carcinoma of the pancreas: An analysis of the National Cancer Database

BACKGROUND

A paucity of data exists regarding the natural history and outcome measures of adenosquamous carcinoma of the pancreas (ASCP), a histology distinct from pancreatic adenocarcinoma (PDAC). The aim of this study is to characterize the clinicopathological features of ASCP in a large cohort of patients comparing outcome measures of surgically resected patients to PDAC.

METHODS

We identified patients diagnosed with ASCP or PDAC from the National Cancer Database from 2004 to 2012. Patient demographics, tumor characteristics, treatment regimens, and overall survival were analyzed between the groups.

RESULTS

We identified 207 073 patients: 205 328 (99%) in the PDAC group and 1745 (1%) in the ASCP group. ASCP tumors were larger, located more frequently in a body/tail location (36% vs 24%, P < 0.001), undifferentiated/anaplastic histology (41% vs 17%, P < 0.001), and early stage presentation, (39% vs 32%, P < 0.001). There was no significant difference in OS when comparing all patients with PDAC and ASCP (6.2 months and 5.7 months, P = 0.601). In surgical patients ASCP histology was associated with worse OS (14.8 months vs 20.5 months, P < 0.001) but had lower nodal involvement (55% vs 61%, P < 0.001). ASCP histology was independently associated with worse OS, after adjusting for tumor characteristics, treatment, and patient demographics. In patients with only resected ASCP histology, negative lymph node status, R0 surgical resection, and receipt of chemotherapy was independently associated with improved overall survival following surgical resection.

CONCLUSION

Although patients with ASCP and PDAC tumors have similar survival when non-surgical and surgical patients are combined, ASCP is associated with worse survival in stage I/II resected patients.

Successful Treatment with GEMOX in Patient with Metastatic Pancreatic Adenosquamous Carcinoma

Background

Pancreatic adenosquamous carcinoma (PASC) is a rare subtype of pancreatic cancer characterized by a dual histological component and aggressive behavior. This form is not well known, its histogenesis is uncertain, and there are different opinions on the diagnostic histopathological criteria. The differential diagnosis with more common ductal adenocarcinoma, squamous cell carcinoma, squamous or adenosquamous metastases is complex. The available therapies do not improve the poor prognosis and it is difficult to find long-term survivors (more than 1 year), even after demolitive surgery with complementary therapies.

Case report

We report a case of advanced PASC with excellent progression-free survival and overall survival, 20 months and 29 months, respectively. Furthermore, an almost complete response was obtained to first-line chemotherapy with gemcitabine/oxaliplatin (GEMOX) followed by maintenance gemcitabine.

Conclusion

GEMOX followed by gemcitabine as maintenance could be an effective treatment for this pancreatic entity. Further reports are needed to confirm this outcome.

Angiogenesis in adenosquamous cancer of pancreas

Adenosquamous carcinoma of the pancreas (ASCP) is an uncommon variant of exocrine pancreatic malignancies, characterized by a histological admixture of adenomatous and squamous cell elements. This cancer is characterized by a poorly differentiated histology and a poorer clinical outcome compared to pancreatic ductal adenocarcinoma (PDAC). Unlike PDAC, that is characterized by a low microvascular density (MVD) and collapsed vasculature, no data are available about angiogenesis in ASPC. Immunohistochemical evaluation of MVD and trypatse-positive mast cells (MCs) were performed on a single case of ASCP compared to PDAC. Moreover, the levels of angiopoietin-1 and -2 (Ang-1, Ang-2), receptor tyrosine kinase with immunoglobulin and epidermal growth factor homology domain-2 (Tie-2), vascular endothelial growth factor A (VEGFA), hypoxia-inducible factor 1 alpha (HIF1A), miR-21-5p, miR-181a-5p, miR-122-5p, and miR-27a-3p were evaluated by real-time PCR. Higher number of tryptase-positive MCs and MVD are observed in the ASCP case compared to PDAC one. Lower levels of miR-122-5p and higher expression of VEGFA, HIF1A and Ang-2 genes were observed in ASCP. Furthermore, lower Ang-1 and Tie-2 transcript levels and higher increases of miR-21-5p, miR27a-3p and miR-181a-5p levels were found in the rarest form of pancreatic carcinoma. Our data demonstrate an important angiogenic activity in ASCP with a putative role of miR-21-5p, miR-181a-5p, miR-122-5p and miR-27a-3p in the regulation of this process.

Adenosquamous carcinoma of pancreas: CT and MR imaging features in eight patients, with pathologic correlations and comparison with adenocarcinoma of pancreas

PURPOSE

To reveal the CT and MR imaging features of adenosquamous carcinoma of pancreas (ASqC) in eight patients.

METHODS

This study was approved by our institutional review board. Eight patients with ASqC were included in this study. Radiologic and pathologic findings were reviewed in each lesion. Additionally, radiologic imaging findings were compared between ASqC and controlled adenocarcinoma groups.

RESULTS

Significant differences between ASqC and adenocarcinoma groups were noted in lesion shape, enhancement pattern on dynamic CT images, the presence or absence of necrosis, and tumor thrombus in the portal vein (PV) system. Compared with adenocarcinoma, ASqC tended to be round-lobulated shape (100% vs. 57.6%), have necrotic portions (100% vs. 39.4%), and have tumor thrombus in the PV system (37.5% vs. 6.1%). Extensive central necrosis was found in six (75%) of ASqC lesions. More lesions in ASqC group (62.5% vs. 12.1%) showed the highest absolute attenuation on pancreatic arterial phase (PAP) or portal venous phase (PVP) images, although the average attenuation values of all ASqC lesions on PAP, PVP, and delayed phase images were almost the same. Five (83.3%) of six resected lesions appeared as nodular type macroscopically. Microscopically, all lesions did not show infiltrating growth pattern, but showed an intermediate growth pattern, and were surrounded incompletely by fibrous tissue.

CONCLUSIONS

ASqC tended to be a round-lobulated lesion with extensive central necrosis. Additionally, tumor thrombus in the PV system was often present. These CT and MR imaging features could be a useful clue for diagnosing ASqC.

Contrast-enhanced multiphasic CT and MRI findings of adenosquamous carcinoma of the pancreas

OBJECTIVE

The objective was to retrospectively study computed tomography (CT) and magnetic resonance imaging (MRI) findings of adenosquamous carcinoma of the pancreas (PASC).

MATERIALS AND METHODS

Twelve patients (six women and six men; mean age, 61.3 years; range, 47-78 years) who presented with PASC as documented by pathologic examination underwent CT (n=10) or both CT and MRI (n=2) examination. Two radiologists evaluated the images and determined the location, size, margin, internal attenuation or signal intensity, contrast enhancement, and pattern for each tumor. Additionally, the presence of poorly enhanced areas, upstream main pancreatic duct (MPD) dilatation, pancreatic atrophy, and peripancreatic tissue metastasis were evaluated. Images were cross-referenced to surgical and pathologic findings.

RESULTS

Masses were distributed throughout the pancreas (head, n=6; body, n=1; and tail, n=5). The tumor size ranged from 2.4 to 5.5 cm with an average size of 3.7 cm. Eight (66.7%) masses were ill defined, and seven (58.3%) were partially exophytic. Twelve (100%) masses showed heterogeneous and poorly enhanced areas. The lesions showed weak (n=5), moderate (n=5), or intense (n=2) progressive enhancement. The diameter of MPD in six patients ranged from 3.0 to 5.0 mm with an average of 3.7 mm. Pancreatic atrophy was not found. In 10 patients (83.3%), masses invaded the peripancreatic tissues. Two patients had metastatic liver disease at presentation.

CONCLUSION

PASC typically presented as an ill-defined, hypovascular mass with a poorly enhanced area, exophytic tendency, and peripancreatic tissue invasion. Lack of pancreatic atrophy and mild MPD dilatation were also distinct from common duct pancreatic adenocarcinoma.

Adenosquamous carcinoma of the pancreas: multidetector-row computed tomographic manifestations and tumor characteristics

OBJECTIVE

The purpose of this article was to present the adenosquamous carcinoma (ASqC) of the pancreas: multidetector-row computed tomographic (CT) features and tumor characteristics.

MATERIALS AND METHODS

The clinical data and CT studies of 12 patients with pathologically proven ASqC of the pancreas between the dates February 2001 and February 2010 were retrospectively analyzed.

RESULTS

The presenting symptoms of ASqC of the pancreas were nonspecific. Elevated serum levels of carbohydrate antigen 19-9, carbohydrate antigen 12-5, and carcinoembryonic antigen were noted. The tumor was most commonly involved in the pancreatic head in 6 patients, with the dilation of the common bile duct and the upstream main pancreatic duct. All ASqCs exhibited invasive growth. No calcification and intratumoral hemorrhage were noted in ASqCs. Ten tumors showed enhancement in the early arterial phase and persistent enhancement in the portal vein phase.

CONCLUSION

The typical CT appearance of ASqC was solitary oval or round without any capsule and a defined margin. The dilation of the main pancreatic duct and/or the common bile duct was always discovered. The huge infiltrative lesion outside the pancreas was detected in the tail and/or the body of the pancreas. Not only the elevation of carbohydrate antigen 19-9 is common, but also Ca12-5 and CEA, whereas human alpha fetoprotein elevation is not observed. The enhancement pattern of tumor showed persistence in the portal vein phase.

Primary adenosquamous cell carcinoma of the pancreas: a case report with a review of the Korean literature

The most common pancreatic cancer is adenocarcinoma. Primary adenosquamous cell carcinoma of the pancreas is very rare and aggressive. A 46-year-old man presented with a 3-month history of dyspepsia and a 7-kg weight loss. The physical examination showed tenderness of the right upper quadrant of the abdomen. There was no jaundice. Amylase and lipase were elevated. CA 19-9 was elevated to 566.7 U/mL. Gastroduodenoscopy showed a hard ulceroinfiltrative mass with a yellowish exudate that bled readily on touch in the second portion of the duodenum. Abdominal computed tomography showed a 7.1 × 6.3-cm heterogeneously enhancing mass in the pancreatic head. The pancreatic mass had invaded the duodenum wall, gastric antrum, and gastroduodenal artery sheath. Fine-needle aspiration biopsy of the pancreatic mass revealed adenosquamous cell carcinoma, anaplastic type. We concluded that an adenosquamous cell carcinoma of pancreas had invaded the duodenal mucosa causing ulceration.

415 patients with adenosquamous carcinoma of the pancreas: a population-based analysis of prognosis and survival

BACKGROUND

Adenosquamous carcinoma of the pancreas is rare. Our understanding of the disease and its prognosis comes mainly from small retrospective studies.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) database (1988 to 2007), we identified patients with adenosquamous carcinoma (n = 415) or adenocarcinoma (n = 45,693) of the pancreas. The demographics, tumor characteristics, resection status, and survival were compared between the groups.

RESULTS

Compared with patients with adenocarcinoma, patients with adenosquamous carcinoma were more likely to have disease located in the pancreatic body and tail (44.6% versus 53.5%, P < 0.0001). While the stage distribution was similar between the two groups, adenosquamous carcinomas were more likely to be poorly differentiated (71% versus 45%, P < 0.0001), node positive (53% versus 47%, P < 0.0001), and larger (5.7 versus 4.3 cm, P < 0.0001). For locoregional disease, resection increased over time from 26% in 1988 to 56% in 2007. The overall 2-y survival was 11% in both groups. Following resection, patients with adenosquamous carcinoma had worse 2-y survival (29% versus 36%, P < 0.0001). Resection was the strongest independent predictor of survival for patients with locoregional pancreatic adenosquamous carcinoma (HR 2.35, 95% CI = 1.47-3.76).

CONCLUSIONS

This is the first population-based study to evaluate outcomes in adenosquamous carcinoma of the pancreas. Compared with pancreatic adenocarcinoma, adenosquamous carcinoma was more likely to occur in the pancreatic tail, be poorly differentiated, larger, and node positive. The long-term survival following surgical resection is significantly worse for adenosquamous cancers; however, patients with adenosquamous carcinoma can still benefit from surgical resection, which is the strongest predictor of survival.

Adenosquamous versus adenocarcinoma of the pancreas: a population-based outcomes analysis

BACKGROUND

Pancreatic adenosquamous carcinoma has historically been characterized as having a more aggressive clinical course than ductal adenocarcinoma. The natural history of this disease, however, is essentially unknown.

METHODS

We evaluated the clinical characteristics of all patients with pancreatic adenosquamous carcinoma recorded in the California Cancer Registry 2000-2007 and compared them to those of patients with ductal adenocarcinoma.

RESULTS

Ninety-five patients with pancreatic adenosquamous carcinoma and 14,746 patients with ductal adenocarcinoma were identified. Demographics were similar between subtypes (p > 0.05). Disease stage at presentation was also similar; over 50% of each diagnostic group presented with metastatic disease (p = 0.62). Surgical resection was more common among patients with locoregional adenosquamous carcinoma than adenocarcinoma (p = 0.0004), but rates of adjuvant therapy administration were similar (p > 0.05). The cohorts' median overall survival durations were similar in a Cox proportional hazards model (p = 0.45); overall survival was also similar when only patients with resected disease were considered (p = 0.65). Early stage, resection and receipt of radiation or chemotherapy were favorable independent prognostic factors among patients with adenosquamous carcinoma. The median overall survival duration of patients with resected adenosquamous carcinoma was 12 months (95% CI, 8-52).

CONCLUSIONS

Adenosquamous carcinoma has a natural history similar to that of ductal adenocarcinoma when treated with prevalent clinical patterns of care.

Poorly enhanced areas of pancreatic adenocarcinomas on late-phase dynamic computed tomography: comparison with pathological findings

OBJECTIVES

The aim of the study was to retrospectively compare image findings of poorly enhanced areas (PEAs) of pancreatic adenocarcinomas that show almost no enhancement or obviously hypoattenuating area relative to the surrounding carcinoma on late-phase dynamic computed tomography (CT) with pathological findings.

METHODS

Thirty-nine patients with pancreatic adenocarcinoma underwent dynamic CT and surgery. Poorly enhanced areas were classified according to their size, attenuation value, position, and border on CT imaging and signal intensity on magnetic resonance imaging.

RESULTS

Of the 33 PEAs, 12 showed neoplastic duct-like structure that contained both large tumor gland and dilated pancreatic duct with atypia, 11 showed necrosis, 4 showed retention cyst, 2 showed dilated pancreatic duct without atypia or with limited invasion, 1 showed mucin, and 3 showed no remarkable differences in characteristics compared with surrounding tissue. Neoplastic duct-like structures tended to be well defined (P < 0.01). Necrotic portions tended to show a high attenuation value (P < 0.01) and central position (P < 0.01) and were ill defined (P < 0.01). Retention cysts tended to show a peripheral position (P < 0.01).

CONCLUSIONS

Poorly enhanced areas corresponded to cystic, necrotic, and mucinous components. Image findings demonstrated these characteristics. Necrotic component can be visualized and distinguished with other components and can be a prognostic factor.

Adenosquamous carcinoma of the pancreas: a distinct clinicopathologic entity

Among exocrine pancreatic tumors, adenosquamous carcinoma (ASC) is a rare, aggressive subtype with a worse prognosis and a higher potential for metastases compared to its more conventional glandular counterpart, adenocarcinoma. The disease distribution shows an approximately 1:1 male/female ratio and a median survival of circa five months. Although such features as central necrosis and hypervascularity are suggestive of pancreatic ASC, more research is necessary to identify other, more specific markers for this tumor subtype. Humoral hypercalcemia of malignancy has also been described with ASC of the pancreas, likely as a result of PTHrP production by the squamous component of the tumor. Similar to the therapeutics of pancreatic adenocarcinoma, adjuvant chemotherapy or chemoradiotherapy is currently indicated for resectable ASC of the pancreas, while gemcitabine or gemcitabine combinations are used for a more advanced disease. Both pathologic and molecular features of pancreatic ASC characterize it as a distinct subtype of pancreatic cancer. As a result, its molecular and genetic makeup could be exploited for both diagnostic and therapeutic quests in the future.

Clinicopathological features of adenosquamous pancreatic cancer

PURPOSE

Adenosquamous pancreatic cancer represents 0.9-4.4% of exocrine pancreatic neoplasms and is generally thought to be associated with a worse prognosis than the more common ductal adenocarcinoma. The aim of the current study is to describe the outcome of patients with adenosquamous pancreatic cancer in our institution who were managed in a multidisciplinary environment.

METHODS

In a retrospective analysis between February 1990 and February 2010, we identified from our database of 890 pancreatic lesions resected for malignancy six cases (0.67%) of adenosquamous cancer. We assessed the demographics, clinical and radiological features, surgical approach, histological details and follow-up data.

RESULTS

All patients underwent pylorus-preserving pancreatoduodenectomy. Two patients, one male and one female, died in the preoperative period due to sepsis and myocardial infarction, respectively. The remaining four patients received adjuvant chemotherapy. One male patient died with local recurrence after 13 months; however, one female and two male patients are still alive with Karnofsky status of 80-90% at 15, 14 and 39 months after the operation, respectively.

CONCLUSIONS

The prognosis of adenosquamous pancreatic cancer remains very poor, apparently worse than ductal pancreatic cancer. Nevertheless, our report and the review of literature seem to show that "curative" surgical resection associated with adjuvant treatment may offer the best results with a similar survival rate than ductal pancreatic cancer.

Adenosquamous carcinoma of the pancreas, a rare tumor entity: a case report

INTRODUCTION

Adenosquamous carcinoma of the pancreas is a rare variant of exocrine pancreatic tumor. This type of tumor is extremely rare as only few similar cases have been described in the literature.

CASE PRESENTATION

We present a case of a 72 years old male patient who was admitted to the hospital complaining of epigastric pain and jaundice. Pancreatic carcinoma of the head was diagnosed and a pylorus preserving pancreaticoduodenectomy was performed.

CONCLUSION

This type of cancer is a very aggressive tumor followed by a dismisal prognosis. Multimodality therapy seems to be a reasonable approach but more studies are needed, to propose the most effective treatment.

Resected pancreatic adenosquamous carcinoma: clinicopathologic review and evaluation of adjuvant chemotherapy and radiation in 38 patients

Pancreatic adenosquamous carcinoma is a rare morphological variant of pancreatic adenocarcinoma with an especially poor prognosis. The purpose of this study is to identify clinicopathologic features associated with prognosis, assess whether the percentage of squamous differentiation in pancreatic adenosquamous carcinoma is associated with an inferior prognosis, and examine the impact of adjuvant chemoradiation therapy on overall survival. Forty-five (1.2%) of 3651 patients who underwent pancreatic resection at the Johns Hopkins Hospital, Baltimore, MD, between 1986 and 2007 were identified with adenocarcinoma of the pancreas with any squamous differentiation. All pathologic specimens were re-reviewed. Statistical analyses were performed on the 38 patients amenable to adjuvant chemoradiation therapy for whom clinical outcome data could be obtained. Median age was 68 years (61% male). Sixty-one percent underwent pancreaticoduodenectomy. Median tumor size was 5.0 cm. Seventy-six percent of carcinomas were node positive, 37% were margin-positive resections, and 68% had 30% or more squamous differentiation. Median overall survival of the pancreatic adenosquamous carcinoma cohort was 10.9 months (range, 2.1-140.6 months; 95% confidence interval, 8.2-12.5 months). Adjuvant chemoradiation therapy was associated with superior overall survival in patients with pancreatic adenosquamous carcinoma (P = .005). Adjuvant chemoradiation therapy was associated with improved survival in patients with tumors 3 cm or larger and vascular or perineural invasion (P = .02, .03, .02, respectively). The proportion of squamous differentiation was not associated with median overall survival (< 30% versus > or = 30%, P = .82). Survival after pancreatic resection of pancreatic adenosquamous carcinoma is poor. Treatment with adjuvant chemoradiation therapy is associated with improved survival. The proportion of squamous differentiation in resected pancreatic adenosquamous carcinoma specimens does not appear to impact overall survival.

Surgical outcome of adenosquamous carcinoma of the pancreas

Adenosquamous carcinoma is rare, accounting for 3%-4% of all pancreatic carcinoma cases. These tumors are characterized by the presence of variable proportions of mucin-producing glandular elements and squamous components, the latter of which should account for at least 30% of the tumor tissue. Recently, several reports have described cases of adenosquamous carcinoma of the pancreas. However, as the number of patients who undergo resection at a single institute is limited, large studies describing the clinicopathological features, therapeutic management, and surgical outcome for adenosquamous carcinoma of the pancreas are lacking. We performed a literature review of English articles retrieved from Medline using the keywords 'pancreas' and 'adenosquamous carcinoma'. Additional articles were obtained from references within the papers identified by the Medline search. Our subsequent review of the literature revealed that optimal adjuvant chemotherapy and/or radiotherapy regimens for adenosquamous carcinoma of the pancreas have not been established, and that curative surgical resection offers the only chance for long-term survival. Unfortunately, the prognosis of the 39 patients who underwent pancreatic resection for adenosquamous carcinoma was very poor, with a 3-year overall survival rate of 14.0% and a median survival time of 6.8 mo. Since the postoperative prognosis of adenosquamous carcinoma of the pancreas is currently worse than that of pancreatic adenocarcinoma, new adjuvant chemotherapies and/or radiation techniques should be investigated as they may prove indispensible to the improvement of surgical outcomes.

Adenosquamous carcinoma of the pancreas associated with humoral hypercalcemia of malignancy (HHM)

We report a rare case of adenosquamous carcinoma of the pancreas associated with humoral hypercalcemia of malignancy (HHM) in which parathyroid hormone-related protein (PTH-rP) was identified as the causative factor of hypercalcemia. A 72-year-old Japanese man was admitted to our institution complaining of fever and abdominal pain. Abdominal computed tomography demonstrated a large tumor in the body of the pancreas, with multiple liver metastases. Both serum calcium and PTH-rP levels were elevated. No accumulation was observed on bone scan with technetium-99. The patient died of pneumonia 3 months after admission. Autopsy demonstrated that the neoplasm in the pancreas showed an abrupt histological transition from adenocarcinoma to squamous cell carcinoma. PTH-rP was identified in the primary pancreatic tumor cells by immunohistochemical examination and a reverse-transcription polymerase chain reaction (RTPCR) method. We concluded that PTH-rP was the causative factor of the HHM, based on the laboratory data, immunohistochemical examination, and messenger RNA (mRNA) expression. This is a very rare report of adenosquamous cell carcinoma of the pancreas associated with HHM.

Clinicopathologic features and outcomes following surgery for pancreatic adenosquamous carcinoma

BACKGROUND

Pancreatic adenosquamous carcinoma (ASC) is a rare pancreatic malignancy subtype. We investigated the clinicopathological features and outcome of pancreatic ASC patients after surgery.

METHODS

The medical records of 12 patients with pancreatic ASC undergoing surgical treatment (1993 to 2006) were retrospectively reviewed. Survival data of patients with stage IIB pancreatic adenocarcinoma and ASC undergoing surgical resection were compared.

RESULTS

Symptoms included abdominal pain (91.7%), body weight loss (83.3%), anorexia (41.7%) and jaundice (25.0%). Tumors were located at pancreatic head in 5 (41.7%) patients, tail in 5 (41.7%), and body in 4 (33.3%). Median tumor size was 6.3 cm. Surgical resection was performed on 7 patients, bypass surgery on 3, and exploratory laparotomy with biopsy on 2. No surgical mortality was identified. Seven (58.3%) and 11 (91.7%) patients died within 6 and 12 months of operation, respectively. Median survival of 12 patients was 4.41 months. Seven patients receiving surgical resection had median survival of 6.51 months. Patients with stage IIB pancreatic ASC had shorter median survival compared to those with adenocarcinoma.

CONCLUSION

Aggressive surgical management does not appear effective in treating pancreatic ASC patients. Strategies involving non-surgical treatment such as chemotherapy, radiotherapy or target agents should be tested.

Imaging Spectrum of Cystic Pancreatic Lesions: Learn from Atypical Cases

The classic radiologic findings of cystic pancreatic masses have been well recognized; however, diagnosing those lesions is still challenging since many cases show unusual radiologic findings. We reviewed the computed tomography, magnetic resonance, and endoscopic retrograde cholangiopancreatography findings of many pathologically proven cystic pancreatic masses and selected various atypical but instructive cases as well as rare pathologic cases from the past 10 years in our institution. This article presents atypical as well as rare pathologic cases of cystic pancreatic masses and correlates them with pathologic findings to obtain diagnostic clues to perform a correct diagnosis.

Pancreatic ductal adenocarcinomas with cystic features: neither rare nor uniform

Cystic tumors of the pancreas are uncommon but important because of their diverse pathology and biology. Their wide spectrum also includes cystic variants of otherwise solid tumors, such as cystic endocrine tumors, cystic acinar cell carcinomas and ductal adenocarcinomas with cystic changes. In this study, we screened pancreatic ductal adenocarcinomas and their variants for macrocystic changes and determined the nature of the cysts (neoplastic vs non-neoplastic). Of 483 tumors 38 (8%) had cystic features. The largest group consisted of 24 pancreatic ductal adenocarcinomas showing a large-gland pattern with small cysts whose diameter varied between 0.5 and 1.8 cm. The epithelial lining of these cysts was generally positive for CEA (83%) and/or MUC1 (71%) and MUC5AC (74%). p53 was positive in 57% of the cases. The second group of cystic tumors (8/483) showed degenerative cystic cavities with diameters ranging between 1 and 6 cm. This group consisted of poorly differentiated pancreatic ductal adenocarcinomas, undifferentiated carcinomas with or without osteoclast-like giant cells and one adenosquamous carcinoma. In the third group of cystic tumors there were four pancreatic ductal adenocarcinomas containing tumor-related retention cysts. Their epithelial cells were positive for MUC5AC, but negative for CEA, MUC1 and p53. The fourth group consisted of two pancreatic ductal adenocarcinomas showing closely attached pseudocysts caused by tumor-associated pancreatitis. The results indicate that a considerable number of pancreatic ductal adenocarcinomas and their variants display cystic features and must therefore be considered in the differential diagnosis of cystic neoplasms of the pancreas. Moreover, not all of the cystic structures we observed were neoplastic in nature. They may also represent non-neoplastic changes, such as retention cysts and inflammatory pseudocysts.

Adenosquamous carcinoma of the pancreas: cytologic features in 14 cases

BACKGROUND

Adenosquamous carcinoma (ASCa) is a rare subtype of ductal adenocarcinoma of the pancreas with what to the authors' knowledge are limited cytologic descriptions. In the current study, the authors describe their experience with the fine-aspiration biopsy (FNAB) diagnosis of ASCa and characterize cytologic features in 14 cases.

METHODS

Fourteen cases of ASCa were identified from pathology case files. Cytologic material was examined for cellularity, grade, tumor cell necrosis, and specific features of glandular and squamous differentiation.

RESULTS

The 10 females and 4 males had an average age of 70 years. Nine patients (64%) were reported to have Stage IV disease at the time of presentation. All tumors were high grade, with moderate to high cellularity. Tumor cell necrosis was noted in 12. Nine of the 14 cases (64%) demonstrated predominantly squamous differentiation with keratinization. Seven of these nine contained at least focal intracellular mucin or honeycombed glandular sheets. Two of the nine had rare cytoplasmic vacuoles as the only evidence of glandular differentiation. Five cases (36%) were predominantly glandular. All but one of these five cases contained atypical to malignant keratinized cells. One of the five cases lacked keratinization but had tumor cells with dense cytoplasm; the diagnosis of ASCa was confirmed on histology. In 13 patients for whom followup was known, 12 had died of disease (mean, 5.6 months) and 1 was alive at 13 months of follow-up.

CONCLUSIONS

A specific diagnosis of ASCa is possible when aspirates show evidence of both squamous and glandular differentiation, although one component often predominates and features of dual differentiation may be focal. A purely squamous tumor should raise the suspicion of a metastasis, but also may represent undersampling of an ASCa.

Adenosquamous carcinoma of the pancreas: successful treatment with extended radical surgery, intraoperative radiation therapy, and locoregional chemotherapy

BACKGROUND

Adenosquamous carcinoma of the pancreas is a rare tumor with an extremely poor survival rate. No obvious evidence that multidisciplinary treatments improves the prognosis and survival has been reported.

PATIENT AND RESULTS

A 63-yr-old female with adenosquamous carcinoma of the pancreas underwent extended radical surgery, intraoperative radiation therapy, postoperative intraarterial chemotherapy, and external beam radiation therapy. The patient is alive at 40 mo after surgery with no recurrence.

CONCLUSIONS

Multidisciplinary treatments including aggressive surgery, intraoperative radiation therapy, and locoregional chemotherapy might improve the survival of patients with adenosquamous carcinoma of the pancreas to inhibit liver metastasis and local recurrence.