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Souza DLS, Kelley SR. Colorectal Sarcomatoid Carcinoma: 30-Year Experience. Am Surg 2024:31348241256073. [PMID: 38767188 DOI: 10.1177/00031348241256073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Background: Primary colorectal sarcomatoid carcinoma is a rare and aggressive malignant neoplasm that displays mixed epithelial and mesenchymal differentiation, with uncertain histogenesis. First described in 1986, there is a paucity of literature related to this condition and there are no evidence-based treatment guidelines. The aim of our study is to present our 30-year experience with primary colorectal sarcomatoid carcinoma. Methods: Retrospective single-center analysis of all patients treated for primary colorectal sarcomatoid carcinoma from 1992 to 2022. The primary outcome was response to treatment strategy and overall survival. Results: A total of six cases met eligibility criteria. Three were male (50%) with a mean age at diagnosis of 59 years (range, 49-72). Four neoplasms were located in the rectum (66%) and two in the colon. Mean tumor size at diagnosis was 4.8 cm (range, 2.8-7.0). Three patients were treated endoscopically and three underwent oncologic surgical resection. Five experienced recurrence and one expired from other comorbidities. The mean survival among those with colonic and rectal sarcomatoid carcinoma was 7 months (range, 3-11) and 39 months (range, 9-60), respectively. Discussion: Primary colorectal sarcomatoid carcinoma is a rare malignant tumor with poor prognosis. Treatment modalities have not been standardized and despite multimodal therapy, disease recurrence and/or metastasis is likely to occur. Further studies are necessary to determine optimal treatment to improve outcomes.
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Affiliation(s)
- Dante L S Souza
- Department of Surgery, TriHealth Good Samaritan Hospital, Cincinnati, OH, USA
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
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Golconda U, McHugh KE, Allende DS, Collins K, Henn P, Lacambra M, Bejarano PA, Groisman GM, Loughrey MB, Monappa V, Zhang X, Hornick JL, Gonzalez RS. Colorectal Carcinoma With Sarcomatoid Components: Report of 15 Cases and Literature Review of an Exceedingly Rare Carcinoma Subtype. Am J Surg Pathol 2024; 48:465-474. [PMID: 38155543 DOI: 10.1097/pas.0000000000002172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
Colorectal carcinoma with sarcomatoid components (which includes so-called carcinosarcomas and sarcomatoid carcinomas) is a rare subtype with 50 reported cases in the literature and overlapping criteria with undifferentiated carcinoma. We collected and described 15 cases from 10 men and 5 women, with a mean age of 66 years. Symptoms included abdominal pain and gastrointestinal bleeding. Most tumors presented in the rectosigmoid region, with a mean size of 8.2 cm. The sarcomatoid component, on average, represented 58% of the tumors and took many forms, including spindled (10 cases), anaplastic (9 cases), and rhabdoid (3 cases); one case showed osteoid matrix. Tumor budding was usually high, and tumor-infiltrating lymphocytes were usually low. The sarcomatoid component was keratin-positive in 10 cases. One case showed loss of mismatch repair protein expression, and 2 cases showed SMARCA4 loss (1 also with SMARCA2 loss). Molecular testing identified mutations in KRAS (n=1), NRAS (n=2), BRAF (n=2), APC (n=1), and TP53 (n=1) in a few cases. Tumors often presented at advanced stage, with 11 cases pT4, 9 cases with nodal metastases, and 7 cases with distant metastases. Follow-up was available for 10 cases (median: 2 months), with 2 alive without disease, 3 alive with disease, and 5 dead. Our findings roughly corresponded with those in previously reported cases. Colorectal carcinoma with sarcomatoid components is rare and aggressive, with a poor prognosis for many patients. We suggest that spindled cells, anaplasia, heterologous elements, and/or a component with definable sarcomatous lineage be used to distinguish colorectal carcinoma with sarcomatoid components from undifferentiated carcinoma.
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Affiliation(s)
| | - Kelsey E McHugh
- Department of Pathology, The Mayo Clinic Arizona, Phoenix, AZ
| | | | - Katrina Collins
- Department of Clinical Pathology and Laboratory Medicine, Indiana University, Indianapolis, IN
| | - Patrick Henn
- Department of Pathology, University of Colorado, Aurora, CO
| | - Maribel Lacambra
- Department of Anatomical and Cellular Pathology, The Chinese University ofHongKong, HongKong, China
| | | | | | - Maurice B Loughrey
- Department of Cellular Pathology, Royal Victoria Hospital, Belfast, Belfast Health and Social Care Trust, Belfast, Northern Ireland, United Kingdom
| | - Vidya Monappa
- Department of Pathology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Xuchen Zhang
- Department of Pathology, Yale University School of Medicine, New Haven, CT
| | - Jason L Hornick
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Raul S Gonzalez
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA
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Park CL, Rajadurai CV, Ton Nu TN, Mandilaras V. An Unconventional Regimen of Carboplatin and Paclitaxel in Metastatic Colorectal Carcinosarcoma: A Case Report and Review of Literature. Curr Oncol 2023; 30:4897-4903. [PMID: 37232827 DOI: 10.3390/curroncol30050369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 04/27/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023] Open
Abstract
Colorectal carcinosarcoma is an exceedingly rare subtype of colorectal cancer that displays the histological and molecular features of both mesenchymal and epithelial tumors. Due to its rarity, there are no guidelines regarding the systemic treatment of this disease. This report describes a case of a 76-year-old woman with colorectal carcinosarcoma with extensive metastatic burden treated with carboplatin and paclitaxel. After four cycles of chemotherapy, the patient had an excellent clinical and radiographical response to treatment. To the best of our knowledge, this is the first report addressing the use of carboplatin and paclitaxel in this disease. We reviewed seven published case reports of metastatic colorectal carcinosarcoma where various systemic treatments were offered. Remarkably, there are no previously published reports where even a partial response was noted, which underscores the aggressiveness of this disease. While further studies are required to validate our experience and assess long-term outcomes, this case suggests an alternative treatment regimen for metastatic colorectal carcinosarcoma.
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Affiliation(s)
- Changsu Lawrence Park
- Department of Medical Oncology, McGill University Health Center, McGill University, Montreal, QC H4A 3J1, Canada
| | - Charles Vincent Rajadurai
- Department of Medical Oncology, McGill University Health Center, McGill University, Montreal, QC H4A 3J1, Canada
| | - Tuyet Nhung Ton Nu
- Department of Pathology, McGill University Health Center, McGill University, Montreal, QC H4A 3J1, Canada
| | - Victoria Mandilaras
- Department of Medical Oncology, McGill University Health Center, McGill University, Montreal, QC H4A 3J1, Canada
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Maskrout M, Boutaggount F, Mokfi R, Ennibi G, Hnach Y, Tarchouli M, Rais G. Carcinosarcoma of the colon with extensive and extraordinary metastases detected on F-FDG18PET/CT: A case report. Ann Med Surg (Lond) 2022; 81:104450. [PMID: 36147121 PMCID: PMC9486715 DOI: 10.1016/j.amsu.2022.104450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Sarcomatoid carcinomas or carcinosarcomas are rare tumors with a double component, carcinomatous and sarcomatous. They most commonly arise from the head, neck, respiratory system and female genital tract. To the best of our knowledge, only thirty two cases of colorectal involvement have been reported in the medical litterature. Case report We report a case of sarcomatoid carcinoma of the colon in a 58 year old woman with unusual sites of metastasis revealed by a whole body 18F-fluoro-2-deoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), who presented with right iliac fossa pain. Physical examination revealed only tenderness of the right iliac fossa. A right hemi-colectomy was performed. The immunohistochemical study of the surgical specimen revealed 2 cellular contingents, one carcinomatous and the other sarcomatous, leading to the diagnosis of carcinosarcoma. The evolution was rapidly unfavourable, with death occurring 4 months after the initial surgery. Discussion Colorectal carcinosarcomas are very rare and aggressive tumors with high metastatic potential commonly in the liver, lymph nodes, and peritoneum. In our case, we order a FDG-PET/CT that revealed intriguing pattern of metastasis. Conclusion The purpose of presenting this case report is to raise awareness among clinicians to consider this clinical entity as a differential diagnosis of colorectal tumors and order more often FDG-PET/CT for a good clinical staging. Colorectal carcinosarcoma is rare and aggressive neoplasm. It is a biphasic tumor, exhibiting epithelial and stromal malignant differentiation. Whole body 18FDG-PET/CT is a potential modality for diagnosing advanced disease that might not be clinically apparent. Due to its rarity, the therapeutic management remains a challenge.
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Harada N, Nobuhara I, Haruta N, Higashiura Y, Fujii H, Yamao K, Shimada K. Carcinosarcoma arising from high-grade serous carcinoma of the ovary without estrogen receptor, WT-1, and PAX8 immunoreactivity. Taiwan J Obstet Gynecol 2022; 61:110-114. [PMID: 35181017 DOI: 10.1016/j.tjog.2021.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2020] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE We encountered a case of high-grade serous carcinoma (HGSC) of the ovary which recurred as carcinosarcoma of the sigmoid colon. Tumor cells of both the primary carcinoma and the secondary carcinosarcoma were negative for estrogen receptor (ER), WT-1, and PAX8. It is well known that most ovarian carcinomas arising from the Müllerian duct are immunoreactive for these biologic parameters. To our knowledge, this is the first case report that provides the results of immunohistochemical analysis of WT-1 and PAX8 for a primary carcinoma and recurrent carcinosarcoma. CASE REPORT A 61-year-old woman had an advanced right ovarian HGSC. After a primary debulking surgery (hysterectomy, bilateral salpingo-oophorectomy and omentectomy) and adjuvant chemotherapy, complete remission was achieved. However, four and a half years later, a tumor arising beside the sigmoid colon was detected. A tumorectomy was performed through combined partial resection of the ileum and sigmoid colon. Microscopically, the tumor was diagnosed as carcinosarcoma of the sigmoid colon, which had originated from HGSC of the ovary. Interestingly, the malignant cells of the primary carcinoma and epithelial components of the recurrent carcinosarcoma were negative for ER, WT-1, and PAX8. These immunohistochemical features were unusual. Three cycles of chemotherapy with the previously used regimen and three additional cycles of doxorubicin and ifosfamide combination chemotherapy were administered. Currently, 3 years after the final chemotherapy was administered, the patient remains healthy. CONCLUSION HGSC of the ovary can recur as carcinosarcoma. Tumor cells of the primary HGSC without ER, WT-1, and PAX8 expression may have dedifferentiated and recurred as carcinosarcoma.
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Affiliation(s)
- Naoya Harada
- Department of Obstetrics and Gynecology, Nara City Hospital, 1-50-1 Higashikidera-cho, Nara- City, Nara- Prefecture, 630-8305, Japan.
| | - Ichiro Nobuhara
- Department of Obstetrics and Gynecology, Nara City Hospital, 1-50-1 Higashikidera-cho, Nara- City, Nara- Prefecture, 630-8305, Japan
| | - Noriko Haruta
- Department of Obstetrics and Gynecology, Nara City Hospital, 1-50-1 Higashikidera-cho, Nara- City, Nara- Prefecture, 630-8305, Japan
| | - Yumi Higashiura
- Department of Obstetrics and Gynecology, Nara City Hospital, 1-50-1 Higashikidera-cho, Nara- City, Nara- Prefecture, 630-8305, Japan
| | - Hajime Fujii
- Department of Obstetrics and Gynecology, Nara City Hospital, 1-50-1 Higashikidera-cho, Nara- City, Nara- Prefecture, 630-8305, Japan
| | - Kaho Yamao
- Department of Obstetrics and Gynecology, Nara City Hospital, 1-50-1 Higashikidera-cho, Nara- City, Nara- Prefecture, 630-8305, Japan
| | - Keiji Shimada
- Department of Pathology, Nara City Hospital, 1-50-1 Higashikidera-cho, Nara- City, Nara- Prefecture, 630-8305, Japan
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SMARCA4-deficient rectal carcinoma with a sarcomatoid component: a case report. Clin J Gastroenterol 2022; 15:419-426. [PMID: 35129794 DOI: 10.1007/s12328-022-01602-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/30/2022] [Indexed: 10/19/2022]
Abstract
A new classification of SMARCA4-deficient tumors was proposed recently for thoracic malignancies, and the tumors have some histopathological characteristics similar to those of carcinosarcoma. We encountered a case of SMARCA4-deficient rectal carcinoma with a sarcomatoid component. A 46-year-old man presented to our hospital with a prolapsing anal mass. Colonoscopy revealed an irregular, nodular, and elevated lesion in the rectum, and the biopsy revealed a moderately differentiated adenocarcinoma. Abdominoperineal resection of the rectum was performed. A macroscopic image of the resected specimen showed a complex tumor 3.5 cm × 3 cm in size with a papillary protrusion and an irregular ulcerative lesion. Histopathological examination revealed that the tumor was composed of moderately/poorly differentiated adenocarcinoma and atypical spindle cells. The adenocarcinoma component was positive for epithelial markers (AE1/AE3 and carcinoembryonic antigen) and showed deletion of SMARCA2 and SMARCA4, while the spindle cells expressed mesenchymal markers (α-smooth muscle actin and vimentin). The pathological diagnosis was poorly differentiated adenocarcinoma with a sarcomatoid component, pT3N2bM0, stage IIIc. Although our case had histological characteristics of carcinosarcoma, immunostaining revealed a deficiency of SMARCA4. This case presented a SMARCA4-deficient colorectal carcinoma with a sarcomatoid component, which was histopathologically similar to carcinosarcoma.
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Sarcomatoid Carcinoma of the Transverse Colon With Extremely Aggressive Brain Metastases. Int Surg 2021. [DOI: 10.9738/intsurg-d-20-00023.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction
Sarcomatoid carcinoma (SC) is a rare subtype of malignant neoplasm with a poor prognosis that involves both carcinomatous and sarcomatous components. Although it may develop in various organs, SC in the large intestine has rarely been reported. It is not rare for patients with SC to have distant metastasis, reflecting its highly aggressive oncologic features, but cases with brain metastasis on initial visit are rare. In this report, we described a case of SC in the transverse colon with brain metastases whose initial symptom was neurological disorder, and reviewed 31 reported cases of SC.
Case presentation
A 70-year-old man was admitted to our hospital with the chief complaints of gait disorder and severe dizziness. Head magnetic resonance imaging revealed tumor masses in the anterior lobe and cerebellum. A large tumor in the transverse colon was detected by colonoscopy and abdominal enhanced computed tomography (CT), and was diagnosed as undifferentiated adenocarcinoma by histology. Laparoscopic extended right hemicolectomy was performed to remove the obstruction, and the resected specimens revealed an invasive tumor consisting of a mixture of carcinomatous and sarcomatous components. According to the immunopathological study, the patient was diagnosed with SC. The clinical course was extremely aggressive, and the patient died on the 28th postoperative day because of disease progression.
Conclusion
To the best of our knowledge, this is the first case of SC in the transverse colon with a neurological disorder derived from brain metastases. This experience may contribute to the guidance regarding proper therapeutic options for SC.
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Kyriakos Saad M, Ghandour F, Ghandour El Hajj F, El Hajj I, Saikaly E. Colonic Carcinosarcoma: Report of a Rare Colorectal Malignancy and Review of Literature. Gastrointest Tumors 2021; 8:8-15. [PMID: 34568292 DOI: 10.1159/000510628] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/02/2020] [Indexed: 11/19/2022] Open
Abstract
Colonic carcinosarcoma is an extremely rare tumor composed of mixed malignant epithelial and mesenchymal cells. Due to its rarity, its pathogenesis is poorly understood, and there are no specific guidelines for its treatment.
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Affiliation(s)
- Melissa Kyriakos Saad
- General Surgery Department, Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
| | - Fatme Ghandour
- Pathology Department, Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
| | - Fatmeh Ghandour El Hajj
- Pathology Department, Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
| | - Imad El Hajj
- General Surgery Department, Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
| | - Elias Saikaly
- General Surgery Department, Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
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A case of 18 years disease-free survival after combined pancreatoduodenectomy and hemicolectomy for carcinosarcoma of the transverse colon. Surg Case Rep 2021; 7:76. [PMID: 33765265 PMCID: PMC7994500 DOI: 10.1186/s40792-021-01159-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/15/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Ascertaining the origin of large tumors located in the region of the pancreas head and adjacent mesocolon can pose a challenge preoperatively. En bloc pancreatoduodenectomy with hemicolectomy is often required towards curative tumor resection (R0) of malignant tumors in this region. CASE PRESENTATION Herein we report a case of a 48-year-old man with two contiguous masses each 5 cm in size, located in the pancreatic head. The masses were detected incidentally by abdominal ultrasonography at an annual health check. Endoscopic biopsies revealed inflammation with no malignancy. Cross-sectional imaging showed the tumor direct invasion of the uncinate process of the pancreas, and the third portion of the duodenum. Based on imaging, a malignant submucosal tumor originating from mesenchymal cells in the mesentery of the transverse colon was made preoperatively. The mass required en bloc pancreatoduodenectomy, right hemicolectomy, and resection of the superior mesenteric vein. The final pathology was carcinosarcoma of the transverse colon. The patient survived 18 years after surgery without recurrence. CONCLUSIONS Malignant tumors located in the region of the pancreas head should be considered for an en bloc curative tumor resection and adjuvant chemotherapy treatments offered that might be beneficial for carcinosarcoma.
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Wu J, Yang J, Lu X, Qiao Z. Sarcomatoid carcinoma of the colon: A rare cause of bowel obstruction. Asian J Surg 2021; 44:597-599. [PMID: 33468379 DOI: 10.1016/j.asjsur.2020.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 12/18/2020] [Indexed: 10/22/2022] Open
Affiliation(s)
- Jianzhong Wu
- Department of General Surgery, Suzhou Ninth People's Hospital, Affiliated Wujiang Hospital of Nantong University, Suzhou, China
| | - Jun Yang
- Department of Gastroenterology, Suzhou Ninth People's Hospital, Affiliated Wujiang Hospital of Nantong University, Suzhou, China
| | - Xialiang Lu
- Department of Pathology, Suzhou Ninth People's Hospital, Affiliated Wujiang Hospital of Nantong University, Suzhou, China
| | - Zhenguo Qiao
- Department of Gastroenterology, Suzhou Ninth People's Hospital, Affiliated Wujiang Hospital of Nantong University, Suzhou, China.
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11
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So-called carcinosarcoma of the duodenum with a chondrosarcomatous component. Clin J Gastroenterol 2015; 8:268-74. [PMID: 26249526 DOI: 10.1007/s12328-015-0595-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 07/20/2015] [Indexed: 10/23/2022]
Abstract
Carcinosarcoma is a biphasic malignant tumor consisting of both carcinomatous and sarcomatous components, and its occurrence in the duodenum is very rare. In the present report, we describe a case of so-called carcinosarcoma of the duodenum with a chondrosarcomatous component. A 79-year-old man was referred to our hospital because of anorexia, weight loss, and jaundice. A preoperative imaging examination showed a hypovascular mass located in the pancreatic head. Histological examination of specimens obtained through a forceps biopsy revealed anaplastic carcinoma (spindle cell type), and a pancreatoduodenectomy was performed. Histologically, the tumor showed an elevated lesion with a wide base in proximity to duodenal mucosal carcinoma. The tumor was found to be predominantly composed of sarcoma with carcinomatous and chondrosarcomatous components. There was a transitional zone between the carcinomatous and sarcomatous components, and a portion of the sarcomatous component was positive for cytokeratin, and negative for vimentin. As mentioned above, we diagnosed the lesion as so-called carcinosarcoma with a chondrosarcomatous component.
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12
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Peris Tomas N, García Lozano A, Martínez García R, Garrigós Ortega G, Martínez Abad M. [Carcinosarcoma of the colon: presentation of a case]. Cir Esp 2011; 91:62-3. [PMID: 22206658 DOI: 10.1016/j.ciresp.2011.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 05/31/2011] [Accepted: 07/02/2011] [Indexed: 11/30/2022]
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13
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Keramidaris D, Koukoutsis I, Gourgiotis S, Lagoudianakis E, Sampaziotis D, Gakis C, Gemenentzis G, Lahanas J, Varela Μ, Seretis C, Dimitrakopoulos G. Sarcomatoid Carcinoma of the Anorectal Junction: Struggling with an Extremely Rare Tumor. J Gastrointest Cancer 2011; 43 Suppl 1:S93-6. [PMID: 21894457 DOI: 10.1007/s12029-011-9319-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
| | - Ilias Koukoutsis
- Second Surgical Department, 401 General Army Hospital of Athens, Athens, Greece
| | - Stavros Gourgiotis
- Second Surgical Department, 401 General Army Hospital of Athens, Athens, Greece. .,, 41 Zakinthinou Street, 15669, Papagou, Athens, Greece.
| | | | | | - Christos Gakis
- Second Surgical Department, 401 General Army Hospital of Athens, Athens, Greece
| | - George Gemenentzis
- Second Surgical Department, 401 General Army Hospital of Athens, Athens, Greece
| | - John Lahanas
- Second Surgical Department, 401 General Army Hospital of Athens, Athens, Greece
| | - Μaria Varela
- Computer Tomography Department, 251 General Military Air force Hospital of Athens, Athens, Greece
| | - Charalampos Seretis
- Second Surgical Department, 401 General Army Hospital of Athens, Athens, Greece
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