Gastric carcinosarcoma with rhabdomyosarcomatous differentiation: a case report and review

Carcinosarcoma of the stomach: four cases that expand the morphologic spectrum of gastric cancer with a primitive phenotype

Carcinosarcoma of the stomach is a rare neoplasm characterized by the presence of both epithelial and mesenchymal malignant components. We describe four examples with a focus on the characterization of the epithelial components and the histogenetic implications for this unique tumor. All patients were men aged 40-79 years. All patients developed metastatic disease, and three of them died 4-19 months after the diagnosis. Sarcomatous elements included poorly differentiated spindle cell sarcoma without distinctive differentiation (n = 4), chondrosarcoma (n = 2), and rhabdomyosarcoma (n = 1). In two cases, the sarcomatous component was recognized only in metastatic lesions. Notably, carcinomatous components were characterized by multilineage and primitive cellular differentiation, including carcinoma with enteroblastic (n = 4), hepatoid (n = 3), yolk sac tumor-like (n = 1), trophoblastic (n = 1), and neuroendocrine (n = 1) differentiation, as well as conventional tubular adenocarcinoma (n = 4). On immunohistochemistry, all four cases showed varying degrees of positive expression of primitive phenotypic markers, including alpha-fetoprotein (AFP), glypican-3, or SALL4. All tumors showed mutant patterns of p53 staining, exhibiting either diffusely positive or completely negative staining. On the basis of these findings, at least some gastric carcinosarcomas are likely to be derived from carcinoma with a primitive phenotype, including AFP-producing adenocarcinoma. Our observations suggest that sarcomatous differentiation, as well as multilineage differentiation of epithelial components, may represent increased cellular plasticity of gastric carcinoma with a primitive phenotype.

Carcinosarcoma and sarcomatoid carcinoma of the stomach: Two case reports

RATIONALE

Carcinosarcoma and sarcomatoid carcinoma of the stomach are rare, malignant, and biphasic tumors with high mortality. The differential diagnosis of these 2 diseases remains challenging. In the present study, we present 2 cases of carcinosarcoma and sarcomatoid carcinoma of the stomach.

PATIENT CONCERNS

A 54-year-old woman was admitted with complaints of epigastric pain for 4 months, but she became serious for 10 days accompanied by melena. A 75-year-old man was admitted with complaints of epigastric pain for 1 month.

DIAGNOSIS

The female had a Borrmann type III irregular ulcerative lesion (5.0 × 4.0 × 1.0 cm) originating from the gastric antrum. The male had Borrmann type I tumor polypoid exophytic (5.0 × 4.0 × 2.0 cm) in the fundus of stomach near the cardia. Both cases were identified as malignant neoplasms by endoscopic biopsy and further confirmed by performing laparoscopic proximal gastrectomy, esophagogastrostomy, and palliative distal subtotal gastrectomy. The postoperative histopathological morphology and immunohistochemistry studies revealed sarcomatoid carcinoma for the female and gastric carcinosarcoma for the male respectively.

INTERVENTIONS

The female patient subsequently underwent laparoscopy-assisted radical distal gastrectomy for gastric cancer followed by systemic chemotherapy with oxaliplatin plus tegafur. The male patient underwent laparoscopic proximal gastrectomy and esophagogastrostomy were performed.

OUTCOMES

The female had a mixture of a little poorly-differentiated adenocarcinoma and abundant sarcomatoid spindle cell elements, and is still alive healthy up to date for 2 and a half years after surgery by phone follow-up. The male patient had both adenocarcinoma and fibrosarcoma in a single tumor, and died 1 month after the operation.

LESSONS

The present study provides insight into the clinical findings, differential diagnosis, and prognosis of carcinosarcomas and sarcomatoid carcinomas of the stomach. More cases are needed for further studies in the future.

Computed Tomography Features and Clinicopathological Characteristics of Gastric Sarcomatoid Carcinoma

Purpose

Gastric sarcomatoid carcinoma (GSC) is a very rare malignant tumor. The purpose of this study is to describe the clinical, computed tomography (CT), and pathologic features of GSC to increase awareness of this entity.

Methods

The CT features and clinical data of five patients with pathologically documented GSC were retrospectively analyzed and compared with the corresponding data of gastric adenocarcinoma and lymphoma.

Results

Among the 5 patients, 4 were male, and 1 was female. The median age was 59 years. Of the 5 cases of GSC, 3 were in the gastric fundus and cardia, 1 was in the gastric body, and 1 was in the gastric fundus. The gastric wall had local thickening in 4 cases and mass formation in 1 case, with stenosis and deformation of the adjacent gastric cavity. The long-axis diameter of the lesions ranged from 1.4 to 10.2 cm (mean, 4.97 cm) and was <10 cm in 4 cases and >10 cm in 1 case. The tumor showed predominantly inhomogeneous density, with radiodensity values ranging from 30 to 53 HU. In addition, ulcers with an irregular base and slightly raised borders were observed in 4 of 5 cases. After an injection of contrast material, heterogeneous (n = 4) or homogeneous (n = 1) enhancement was observed. After contrast medium injection, obvious enhancement was seen in 2 cases, and moderate enhancement was seen in 3 cases; the peak tumor signal was observed in the portal phase. Two of the patients demonstrated evidence of lymph node involvement, and in one patient, the boundary between the lesion and the left lobe of the liver was unclear, with low attenuation in the right lobe of the liver with circular enhancement. The remaining two patients showed no evidence of metastasis.

Conclusion

Although GSC is extremely rare, it should be considered in the differential diagnosis of gastric adenocarcinoma and lymphoma. CT findings, combined with patient age and sex, can provide support for the diagnosis of GSC. However, the final diagnosis must be confirmed with histopathology.

Adenocarcinosarcoma at the esophagogastric junction with long esophageal invasion: a case report

BACKGROUND

Carcinosarcoma of the esophagus or esophagogastric junction (EGJ) is a rare malignancy with both carcinomatous and sarcomatous components. There is no report of carcinosarcoma arising from the EGJ wherein the carcinomatous element was adenocarcinoma. We describe a patient with carcinosarcoma of the EGJ in which the carcinomatous element was adenocarcinoma.

CASE PRESENTATION

A 52-year-old man was diagnosed with carcinoma on his EGJ after complaining of appetite loss. All tumor markers (carcinoembryonic antigen, squamous cell carcinoma antigen, alpha-fetoprotein, and carbohydrate antigen 19-9) were within the respective normal ranges. Esophagogastroduodenoscopy showed a 150-mm (100 mm esophageal side and 50 mm gastric side) type 1 tumor on his EGJ. A histopathological examination of a biopsy specimen revealed well-differentiated tubular adenocarcinoma at the gastric side; however, only necrotic tissue was noted on the esophageal side. Contrast-enhanced computed tomography did not reveal any invasion of the adjacent structures; however, it did show five swollen regional lymph nodes. ¹⁸F-Fluorodeoxyglucose positron emission tomography with computed tomography did not reveal distant metastases. We performed thoracic subtotal esophagectomy, total gastrectomy, and two-field plus left cervical paraesophageal lymphadenectomy. Macroscopically, the lesion consisted of two components: a 7.5-cm type 2 tumor and a 9-cm type 1 tumor at the proximal end of the type 2 tumor. Microscopically, the type 2 tumor showed predominantly solid or cribriform proliferation of tumor cells with clear cytoplasm, which was moderately differentiated adenocarcinoma with enteroblastic-like differentiation. The tumor cells of the adenocarcinoma component had periodic acid-Schiff (PAS)-positive globules and were positive for sal-like protein 4 (SALL 4) and negative for α-fetoprotein (AFP) or human epidermal growth factor receptor type 2 (HER2). The type 1 tumors consisted of the adenocarcinoma-like type 2 tumor and spindle cells (sarcomatous component). Part of the sarcomatous component showed cartilage differentiation. The type 2 and type 1 lesions were continuous lesions. The epicenter of the tumor was located at the EGJ. The adenocarcinoma component was present in 10 of 27 resected lymph nodes. The tumor was diagnosed as carcinosarcoma of the EGJ.

CONCLUSIONS

We report a rare patient with carcinosarcoma of the EGJ wherein the carcinomatous element was adenocarcinoma.

Carcinosarcoma of Stomach Confined to the Mucosa

Carcinosarcoma is a malignant tumor composed of both epithelial and mesenchymal malignant tumor components. A 78-year-old man was transferred to our hospital because of hematemesis and tarry stool. An emergency gastrointestinal endoscopic examination revealed active bleeding from an ulcerative lesion on the posterior wall of the gastric body; endoscopic hemostasis was successfully performed. A gastrointestinal endoscopy performed two months later showed a polypoid lesion at the same place where the ulcer had been. The biopsy specimen was histologically diagnosed as well to moderately differentiated tubular adenocarcinoma. The patient underwent a laparoscopic distal gastrectomy with D2 lymph node dissection under a diagnosis of gastric adenocarcinoma. A 28 × 15 mm polypoid tumor was resected from the gastric body, and was found on microscopic examination to consist of both carcinoma and sarcoma components, showing atypical spindle cells, which were positive for α-smooth muscular actin, calponin, and h-caldesmon, but negative for CD34, CD117 (c-kit), desmin, and dog 1. These findings led to a diagnosis of gastric carcinosarcoma. The tumor was confined to the mucous membrane. Lymph node metastasis was found in one node and contained only the carcinoma component. The postoperative course was uneventful. The patient lived without recurrence for 2 years. Carcinosarcoma of the stomach is a rare tumor with high malignant potential and poor prognosis. Careful follow up is required for early detection of any recurrence.