Rapidly growing esophageal carcinosarcoma reduced by neoadjuvant radiotherapy alone

Multiregion exome sequencing indicates a monoclonal origin of esophageal spindle-cell squamous cell carcinoma

Esophageal spindle-cell squamous cell carcinoma (ESS) is a rare biphasic neoplasm composed of a carcinomatous component (CaC) and a sarcomatous component (SaC). However, the genomic origin and gene signature of ESS remain unclear. Using whole-exome sequencing of laser-capture microdissection (LCM) tumor samples, we determined that CaC and SaC showed high mutational commonality, with the same top high-frequency mutant genes, mutation signatures, and tumor mutation burden; paired samples shared a median of 25.5% mutation sites. Focal gains were found on chromosomes 3q29, 5p15.33, and 11q13.3. Altered genes were mainly enriched in the RTK-RAS signaling pathway. Phylogenetic trees showed a monoclonal origin of ESS. The most frequently mutated oncogene in the trunk was TP53, followed by NFE2L2, KMT2D, and MUC16. Prognostic associations were found for CDC27, LRP2, APC, and SNAPC4. Our data highlight the monoclonal origin of ESS with TP53 as a potent driver oncogene, suggesting new targeted therapies and immunotherapies as treatment options. © 2024 The Pathological Society of Great Britain and Ireland.

Investigating esophageal sarcomatoid carcinoma and its comparison with esophageal squamous cell carcinoma on clinicopathological characteristics, prognosis, and radiomics features: a retrospective study

Introduction

Esophageal sarcomatoid carcinoma (ESC) is a rare pathological subtype of esophageal carcinomas, wherein its epithelial component typically demonstrates squamous cell carcinoma (SCC). However, the clinicopathological features and prognosis of ESC remain unclear, alongside its unique aspects compared to esophageal SCC (ESCC).

Methods

Between January 2008 and December 2018, we retrospectively reviewed 67 ESC patients treated at West China Hospital. Among them, 51 patients with resected ESC were matched with 98 resected ESCC patients over the same period using propensity score matching at 1:2. The survival time and radiomics features of the two groups were compared.

Results

A total of 59 patients with resected ESC and eight patients with non-resected ESC were enrolled. Progression-free survival (PFS) and overall survival (OS) were significantly different in patients with different TNM stages (p < 0.001). A multivariate analysis showed that length of tumor was an independent factor for OS in resetable ESC (p = 0.041). Among matched ESC and ESCC patients, OS was significantly longer for patients with ESC than those with ESCC (5-year OS, 61.1% vs. 43.6%; HR 0.59, 95% CI 0.35-0.96; p = 0.032). A Rad-score for discriminating ESC from ESCC containing two CT-derived radiomics features was developed [area under the curve: 0.823 (95% CI 0.732-0.913) in the training cohort and 0.828 (95% CI 0.636-1.000) in the validation cohort, respectively].

Conclusions

ESC has a better prognosis when compared with ESCC. By developing a radiomics prediction model, we provide reliability and convenience for the differential diagnosis of ESC from ESCC.

A rare case of carcino-sarcoma of the esophagus with huge intrathoracic metastasis

Carcinosarcoma of the esophagus constitutes only 0.5%-2.8% of all malignant esophageal cancers. It is identified by the presence of both carcinomatous and sarcomatous components. A clear regimen of treatment has not been established due to the limited understanding of the disease. We present a case of carcinosarcoma of the esophagus with rapid recurrence and invasion to the intrathoracic cavity only 6 weeks after esophagectomy. Carcinosarcoma carries a poor prognosis, as it has a late tendency of hematogenous spread with a high growth rate.

Intensity modulated radiotherapy might be effective for locally advanced esophageal carcinosarcoma: A single center's experience and review of literature

Esophageal carcinosarcoma is a rare type of esophageal cancer; however, few studies have investigated the effects of radiotherapy in locally advanced patients. This study aimed to report experience of the safety and efficacy of intensity-modulated radiotherapy for locally advanced esophageal carcinosarcoma and review the literature. By searching the institutional database between January 2010 and December 2020, along with the literature review, 25 patients were eligible for the study. The clinical and radiologic information of all patients with esophageal carcinosarcoma who underwent radiotherapy were collected. Survival outcomes were calculated using Kaplan-Meier plots. In our series, 5 patients were in the curative/neoadjuvant radiotherapy group and 10 patients were in the adjuvant group. Most tumors were protruding (n = 10, 66.7%). All patients underwent intensity-modulated radiotherapy. In the curative/neoadjuvant radiotherapy group, 2 patients underwent concurrent chemoradiotherapy before surgery, and the other three received radiotherapy alone as the initial treatment. The median follow-up time was 43.1 months. All patients showed a partial response at the efficacy evaluation. The median time of overall survival and progression-free survival were 40.2 months (95% confidence interval [CI], 13.1-67.3 months) and 19.0 months (95% CI, 13.9 months-24.1 months) for the entire cohort, but were not reached for curative/neoadjuvant radiotherapy group. Overall survival (hazard ratio [HR] 0.81, 95% CI, 0.15-4.43; P = .805) and progression-free survival (HR 1.68, 95% CI, 0.35-8.19; P = .514) did not differ significantly between the 2 groups. When considering the literature review data in the final analysis, overall survival (HR 0.84, 95% CI, 0.25-2.81; P = .779) and progression-free survival (HR, 0.68; 95% CI, 0.26-1.76; P = .425) were also not different between the 2 groups. Treatment based on intensity-modulated radiotherapy with neoadjuvant or curative intent may be an option for patients with unresectable esophageal carcinosarcoma. Further research with a larger sample size is needed to validate the reliability.

Major pathological response after neoadjuvant immunotherapy in esophageal spindle cell carcinoma: A case report

Esophageal spindle cell carcinoma (ESpCC) is a rare subtype of esophageal carcinoma, accounting for 1% of all esophageal malignancies. The clinical outcome is unknown due to the lack of treatment options. Here, we present the case of a 60‐year‐old male with initially unresectable ESpCC, in which platinum‐based concurrent chemoradiotherapy was unsuccessful. He was subsequently treated with neoadjuvant immunotherapy and after surgery achieved a complete pathological response; therefore, neoadjuvant immunotherapy might be a novel option for ESpCC patients.

Endoscopic palliative resection of a giant 26-cm esophageal tumor: A case report

BACKGROUND

Esophageal carcinosarcoma, usually presenting as a pedunculated polypoid mass, is a rare malignancy with coexisting sarcomatoid and carcinomatous components. Its imaging and endoscopic characteristics are similar to those of leiomyosarcoma, liposarcoma and so forth. The diagnosis needs histological confirmation. Surgical resection is the traditional therapy. Endoscopic resection is minimally invasive but still controversial. This paper reports the case of a patient with a giant esophageal carsinosarcoma who underwent a palliative endoscopic resection.

CASE SUMMARY

A 55-year-old male patient presented with dysphagia and weight loss for 1 mo. Imaging and endoscopy showed a gray-white, polypoid, stalk-like mass, with a bulky pedicle located in the middle and lower esophagus. The mass almost filled the whole esophageal lumen, but the endoscope could still pass through. Despite the suspicion of a malignancy, repeated biopsies indicated necrosis and inflammation. After multidisciplinary team consultation, an endoscopic resection to diagnose and relieve the obstruction was recommended. The pedicle of the mass was cut off, the bleeding was stopped, and the mass was cut into pieces and pulled out. The mass was 26 cm × 5 cm × 4 cm in size. The final diagnosis was esophageal carcinosarcoma. No postoperative complications occurred. After 1 mo, the patient gained 6 kg and endoscopic reexamination revealed no obstruction. Radical surgery with lymph node dissection was carried out successfully. This lesion was the largest endoscopically resected esophageal carcinosarcoma reported to date.

CONCLUSION

Endoscopic palliative resection can help obtain adequate tissue for diagnosis and relieve obstructions in patients with giant esophageal carcinosarcoma.

The controversy of esophageal carcinosarcoma: A case report and brief review of literature

RATIONALE

Esophageal carcinosarcoma (ECS) is defined as a relatively rare malignant neoplasm with both epithelial carcinomatous and sarcomatous components. Besides, there were so many various controversies in ECS. This article describes a case of ECS that was effectively treated with radical esophagectomy and adjuvant chemotherapy. Also, we discuss the presentation, differential diagnosis, treatment, and prognosis of ECS.

PATIENT CONCERNS

A 58-year-old man presented with a history of progressive dysphagia and precordial pain after swallowing for 1 month.

DIAGNOSIS

Esophagogastroduodenoscopy (EGD) revealed a large polypoid neoplasm that occupied the esophageal lumen 30 to 34 cm from the incisors. On the characteristic morphology, clinical symptom and biopsy findings, the ECS was the primary considerated. Computed tomography (CT) examination demonstrated no radiological evidence of metastatic disease.

INTERVENTIONS

The patient underwent an Ivor Lewis esophagectomy, coupled with adequate lymph node dissection (2-field lymphadenectomy). ECS was confirmed by pathology report of postoperative. Then, the patient underwent adjuvant chemotherapy with docetaxel, oxaliplatin, and capecitabine.

OUTCOMES

The patient remained alive without tumor recurrence at 24 months after multidisciplinary therapy.

LESSONS

It is generally treated by surgery, radiotherapy, and chemotherapy according to the protocols used for other esophageal cancers (EC). However, there is no recommended clinical treatment for ECS because of the rarity of the disease. Esophagectomy with extended lymphadenectomy followed by adjuvant chemotherapy with docetaxel, oxaliplatin, and capecitabine may be recommended treatment for ECS. Chemotherapy regimen with docetaxel, oxaliplatin, and capecitabine may be a suitable adjuvant therapy for ECS.

Esophageal carcinosarcoma that disappeared pathologically by palliative radiotherapy alone

Only a few cases of esophageal granulocyte-colony-stimulating-factor (G-CSF)-producing esophageal carcinosarcoma are reported, and patients with G-CSF-producing tumors are typically considered to have poor prognosis. An 89-year-old man was examined for low-grade fever and dysphagia. Chest computed tomography revealed a huge 80-mm tumor on the thoracic esophagus without direct invasion to surrounding organs. Esophagogastroduodenoscopy (EGD) showed a huge mass occupying the esophageal lumen with a superficial flat lesion. Histopathological examination revealed that the tumor was composed of bizarre giant cells and pleomorphic spindle cells with hyperchromatic nuclei. Laboratory data showed aberrant elevation of leukocyte and neutrophil counts and G-CSF levels. The tumor was finally diagnosed as a G-CSF-producing esophageal carcinosarcoma, stage II (T2N0M0, Union for International Cancer Control-TNM Classification of Malignant Tumors, 8th edition). Considering his general condition, we performed palliative radiotherapy (45 Gy/15 fr) alone after consultation with surgeons and radiation oncologists. Follow-up EGD demonstrated the disappearance of the tumor, and the histological assessment of biopsy specimens confirmed no evidence of malignancy. The leukocyte count and G-CSF levels decreased within normal range. This is a very rare case of G-CSF-producing esophageal carcinosarcoma in which a pathologically complete response was achieved using palliative radiotherapy alone.

The alterations of cytokeratin and vimentin protein expressions in primary esophageal spindle cell carcinoma

Background

The accumulated evidence has indicated the diagnostic role of cytokeratin (CK) and vimentin protein immunoassay in primary esophageal spindle cell carcinoma (PESC), which is a rare malignant tumor with epithelial and spindle components. However, it is largely unknown for the expression of CK and vimentin in pathological changes and prognosis of PESC.

Methods

Eighty-two PESC patients were identified from the esophageal and gastric cardia cancer database established by Henan Key Laboratory for Esophageal Cancer Research of Zhengzhou University. We retrospectively evaluated CK and vimentin protein expressions in PESC. Clinicopathological features were examined by means of univariate and multivariate survival analyses. Furthermore, the co-expression value of cytokeratin and vimentin was analyzed by receiver operating characteristic (ROC) curve.

Results

The positive pan-cytokeratins AE1/AE3 (AE1/AE3 for short) staining was chiefly observed in cytoplasm of epithelial component tumor cells, with a positive detection rate of 85.4% (70/82). Interestingly, 19 cases showed AE1/AE3 positive staining both in epithelial and spindle components (23.2%). However, AE1/AE3 expression was not observed with any significant association with age, gender, tumor location, gross appearance, lymph node metastasis and TNM stage. Furthermore, AE1/AE3 protein expression does not show any effect on survival. Similar results were observed for vimentin immunoassay. However, in comparison with a single protein, the predictive power of AE1/AE3 and vimentin proteins signature was increased apparently than with single signature [0.75 (95% CI = 0.68–0.82) with single protein v.s. 0.89 (95% CI = 0.85–0.94) with AE1/AE3 and vimentin proteins]. The 1-, 3-, 5- and 7-year survival rates for PESC patients in this study were 79.3%, 46.3%, 28.0% and 15.9%, respectively. Multivariate analysis demonstrated age and TNM stage were independent prognostic factors for overall survival (P = 0.036 and 0.003, respectively). It is noteworthy that only 17.1% patients had a PESC accurate diagnosis by biopsy pathology before surgery (14/82). 72.4% PESC patients with biopsy pathology before surgery had been diagnosed as squamous cell carcinoma.

Conclusion

The present study demonstrates that cytokeratin and vimentin protein immunoassay is a useful biomarker for PESC accurate diagnosis, but not prognosis. The co-expression of cytokeratin and vimentin in both epithelial and spindle components suggest the possibility of single clone origination for PESC.