Sarcomatoid (spindle cell) carcinoma of the pancreas: A case report and review of the literature

Undifferentiated sarcomatoid carcinoma of the pancreas-a single-institution experience with 23 cases

BACKGROUND

The clinical course and surgical outcomes of undifferentiated sarcomatoid carcinoma of the pancreas (USCP) remain poorly characterized owing to its rarity. This study aimed to describe the histology, clinicopathologic features, perioperative outcomes, and overall survival (OS) of 23 resected USCP patients.

METHODS

We retrospectively described the histology, clinicopathologic features, perioperative outcomes and OS of patients who underwent pancreatectomy with a final diagnosis of USCP in a single institution.

RESULTS

A total of 23 patients were included in this study. Twelve patients were male, the median age at diagnosis was 61.5 ± 13.0 years (range: 35-89). Patients with USCP had no specific symptoms and characteristic imaging findings. The R0 resection was achieved in 21 cases. The En bloc resection and reconstruction of mesenteric-portal axis was undertaken in 9 patients. There were no deaths attributed to perioperative complications in this study. The intraoperative tumor-draining lymph nodes (TDLNs) dissection was undergone in 14 patients. The 1-, 3- and 5-year survival rates were 43.5%, 4.8% and 4.8% in the whole study, the median survival was 9.0 months. Only 1 patient had survived more than 5 years and was still alive at last follow-up. The presence of distant metastasis (p = 0.004) and the presence of pathologically confirmed mesenteric-portal axis invasion (p = 0.007) was independently associated with poor OS.

CONCLUSIONS

USCP was a rare subgroup of pancreatic malignancies with a bleak prognosis. To make a diagnose of USCP by imaging was quite difficult because of the absence of specific manifestations. Accurate diagnosis depended on pathological biopsy, and the IHC profile of USCP was mainly characterized by co-expression of epithelial and mesenchymal markers. A large proportion of patients have an early demise, especially for patients with distant metastasis and pathologically confirmed mesenteric-portal axis invasion. Long-term survival after radical resection of USCPs remains rare.

Pancreatic carcinosarcoma: An orthogonal analysis

BACKGROUND

Pancreatic carcinosarcoma is a rare subtype of pancreatic cancer. There are no consensus guidelines regarding its treatment. The current study is an orthogonal analysis of multiple datasets to evaluate prognostic features.

METHODS

A modified Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 systematic review was performed for reported cases of pancreatic carcinosarcoma. All cases of pancreatic carcinosarcoma in the National Cancer Database were identified for analysis. Analyses were compared to previously published data from the Surveillance, Epidemiology, and End Results database to increase validity.

RESULTS

Seventy-one cases of pancreatic carcinosarcoma were reported in the literature. Reports of pancreatic carcinosarcoma increased over time (P = .0075). Tumor size >5.0 cm, metastatic disease, and relapse were associated with decreased disease-specific survival (all log-rank P < .05). Ninety-nine cases of pancreatic carcinosarcoma were analyzed within the National Cancer Database. Pancreatic carcinosarcoma incidence increased over time (P = .0371). Resection + chemotherapy, pathologic lymph node examination, and treatment at an academic center were associated with improved overall survival (all log-rank P < .05), whereas harboring ≥2 positive lymph nodes was associated with decreased overall survival (log-rank P = .0171). Within a multivariable model adjusting for age, sex, comorbid disease, and disease stage, resection + chemotherapy was associated with a decreased hazard of death (hazard ratio .036; confidence Interval .004-.298; P = .0022). Published data from the Surveillance, Epidemiology, and End Results database supported the current analysis regarding the incidence of pancreatic carcinosarcoma, resection, lymph node evaluation, and the impact of metastatic disease.

CONCLUSION

Pancreatic carcinosarcoma is exceedingly rare, with a poor prognosis. Long-term survival is possible with curative resection in the absence of relapse. The number of positive lymph nodes appears to impact prognosis.

Neoadjuvant therapy for sarcomatoid carcinoma of the pancreas: a case report and review of the literature

BACKGROUND

Sarcomatoid carcinoma of the pancreas (SCP) is a rare type of malignant pancreatic neoplasm, and its prognosis is even worse than that of conventional pancreatic ductal adenocarcinoma (PDAC). Currently, there is no standard regimen for treating SCP, and the impact of systemic therapy on the survival of patients with SCP has not been well defined.

CASE PRESENTATION

Herein, we report a 38-year-old Asian man diagnosed of local unresectable SCP with supraclavicular lymph node metastasis, radical excision after camrelizumab and anlotinib therapy, which resulted in a remarkable reduction in the size of primary tumor and complete remission of the metastatic lymph node.

CONCLUSIONS

This is the first report of the use of immunotherapy and anti-angiogenesis therapy in a patient with SCP, which provides optimistic data to support the synergistic effect.

Cytologic, histologic, and molecular features of pancreatic sarcomatoid undifferentiated carcinoma with heterologous osteosarcomatous transformation

Fine-needle aspiration (FNA) is a minimally invasive and effective modality to diagnose pancreatic ductal adenocarcinoma. However, some histologic subtypes of ductal adenocarcinoma are rarely encountered and challenging to diagnose on FNA/small biopsies. To date, cytohistologic features of pancreatic sarcomatoid undifferentiated carcinoma with heterologous elements have not been thoroughly described. An 83-year-old man with lower back pain was found to have an incidental pancreatic neck mass. FNA biopsy of the mass showed rare markedly atypical, large, pleomorphic cells in a background of abundant calcifications/bone formation without areas of conventional adenocarcinoma. A diagnosis of "Malignant neoplasm with osteosarcomatous differentiation" was rendered on the FNA specimen. Subsequently, a Whipple resection revealed a 4.1 cm lobulated, calcified pancreatic mass. Microscopic examination showed a heavily calcified/ossified mass with adjacent areas of a highly cellular malignant spindle cell proliferation and admixed large, pleomorphic tumor cells; no background conventional adenocarcinoma was identified. Cytokeratin immunostains MNF116 and CK19 were positive in a large subset of the malignant spindle cells, and AE1.3/CAM5.2 showed patchy weak staining. Molecular testing revealed mutations in KRAS, TP53, BRCA2, NTRK3, EPHA2, MYD88, and CBL. No reportable fusions were detected. The final diagnosis was "Sarcomatoid undifferentiated carcinoma with heterologous elements (osteosarcomatous differentiation)." Definitive diagnosis of extremely rare subtypes of ductal adenocarcinoma is challenging on FNA biopsies. In this case, cytologic evaluation was helpful in making an early diagnosis of a malignant neoplasm with highly unusual features, prompting appropriate triage and early surgical resection of a sarcomatoid undifferentiated carcinoma with prominent osteosarcomatous differentiation.

Sarcomatoid carcinoma of the pancreas — a rare tumor with an uncommon presentation and course: A case report and review of literature

BACKGROUND

Sarcomatoid carcinoma of the pancreas (SCP) is a rare type of pancreatic neoplasm, and only a few cases have been described in the literature. Histologically, it is composed mostly of atypical spindle cells with apparent sarcomatous features.

CASE SUMMARY

This is a report of a 61-year-old Chilean woman who underwent medical investigation for acute abdominal pain. Computed tomography identified a solid tumor in the tail of the pancreas with features suspicious of malignancy. En-bloc distal pancreatectomy and splenectomy were performed to excise the tumor. Histopathology and immunohistochemistry were confirmatory of sarcomatoid carcinoma with lymphovascular invasion. After surgery, the patient did not receive chemotherapy. Previous studies indicate a poor prognosis for this type of malignancy. However, our patient has survived for 35 mo with no recurrence to date.

CONCLUSION

The case presented herein is a patient with an SCP with a rare presentation and long-term survival after surgery despite not receiving adjuvant chemotherapy.

Does cellular senescence play an important role in the prognosis of sarcomatoid carcinoma of the pancreas?

Aim

Sarcomatoid carcinoma of the pancreas (SCP) is an extremely rare and aggressive disease with poor prognosis. We have already reported a rare case of SCP with long-term survival. In the present article, we investigate the underlying mechanisms of patient’s long-term survival from the point of view of cellular senescence which was examined in three SCP cases, including our reported case, using immunohistochemical analysis.

Findings

The expressions of cellular senescence marker were observed in the sarcomatous component of the patient with long-term survival but not observed in the other patients with short- term survival. Thus, we can speculate that cellular senescence might play an important role in the reduction of the cell proliferative and metastatic activities of sarcomatous cells, leading to long-term patient survival.

Sarcomatoid carcinoma of the pancreas with rare long-term survival: a case report

BACKGROUND

Sarcomatoid carcinoma of the pancreas (SCP) tends to have similar or even worse prognosis than that of conventional pancreatic ductal adenocarcinoma. The clinical and pathological features of SCP remain poorly characterized owing to its rarity.

CASE PRESENTATION

A 58-year-old man was admitted to our hospital with the chief complaints of upper abdominal pain and weight loss. Abdominal contrast computed tomography revealed a 5-cm low-density mass in the pancreatic body. Magnetic resonance cholangiopancreatography revealed an obstruction of the main pancreatic duct and a dilation of the distal main pancreatic duct. Based on the clinicoradiological findings, pancreatic body cancer was suspected, and the distal pancreatectomy was performed. A pathological examination revealed that the tumor was composed of an area of invasive ductal adenocarcinoma and an area of sarcomatous spindle-shaped cells; the latter component predominated. The spindle cells were immunohistochemically positive for both cytokeratin and vimentin, and thus, a pathological diagnosis of SCP was made. In addition, immunohistochemical analysis suggested the sarcomatous component might be derived from the adenocarcinoma component via the process of epithelial-mesenchymal transition. After the operation, the patient received 6 months of chemotherapy with gemcitabine. At 10 years after the operation, the patient is alive with no recurrence.

CONCLUSIONS

The current case study presented a SCP patient with long-term survival after the operation. It was worth noting that the sarcomatous component of the tumor pathologically showed lower MIB-1 labeling index compared with those in previously reported SCP cases, which might account for the long-term survival of the patient.

Pancreatic sarcomatoid carcinoma: CT, MRI, and 18F-FDG PET/CT features

AIM

To investigate computed tomography (CT), magnetic resonance imaging (MRI), and combined 2-[¹⁸F]-fluoro-2-deoxy-d-glucose (¹⁸F-FDG) positron-emission tomography (PET)/CT features of pancreatic sarcomatoid carcinoma (PSC).

MATERIALS AND METHODS

The hospital database was searched retrospectively for the patients with PSC confirmed at histopathology after surgery. Ten patients who underwent unenhanced and enhanced CT (n=4), unenhanced and enhanced MRI (n=2), ¹⁸F-FDG PET/CT (n=2), and both enhanced CT and ¹⁸F-FDG PET/CT (n=2) were enrolled. Two patients underwent additional delayed PET/CT. The maximum standardised uptake value (SUVmax) was measured on PET/CT images.

RESULTS

Eleven lesions were detected in 10 patients. Solid and cystic components (n=6), intratumoural haemorrhage (n=1), nodular calcification (n=2), main pancreatic duct dilatation resulted from lesion obstruction (n=5) or compression (n=3), cholangiectasis (n=5), vascular and peripheral organ invasion (n=5 and 6, respectively), hepatic and lymphatic metastases (n=4 and 2, respectively) were detected. All five lesions in four patients who underwent PET/CT showed intense FDG uptake on PET/CT with SUVmax (16, range 10.9-21.1). Increase of FDG uptake (SUVmax = 18.9, 20.1, and 27.3, respectively) was revealed on the delayed scan of three lesions in two patients.

CONCLUSIONS

PSCs were more commonly ill-defined solid cystic masses, which caused pancreatic duct obstruction/compression without pancreatic parenchymal atrophy, and these masses on PET/CT showed high FDG uptake on both initial and delayed PET/CT.

A Comparison of the Pathological Types of Undifferentiated Carcinoma of the Pancreas

OBJECTIVES

This study aimed to identify the detailed clinicopathological features of undifferentiated carcinoma of the pancreas (UCP).

METHODS

We investigated clinical, imaging features and the prognoses of 261 patients; 8 were our patients, and the remainder were identified by searching English-language articles in PubMed.

RESULTS

We classified patients with UCP into 3 types based on pathological findings: osteoclast-like giant cell-associated carcinoma, pleomorphic cell carcinoma (PLC), and spindle cell carcinoma. There were no remarkable differences in clinical, radiological features between these 3 types. However, PLCs were significantly more likely to be unresectable than were the other 2 types (P < 0.001). Patients with osteoclast-like giant cell-associated carcinoma achieved the best overall survival (OS) rates (P < 0.001), whereas those with spindle cell carcinoma had significantly longer OS rates than did those with PLC (P = 0.004). These OS patterns were maintained when considering only those patients who underwent resection. Patients with PLC had both lower curative resection and high lymph node metastasis rates (P = 0.029, P = 0.023). Patients who underwent resection had more favorable prognoses than did those who did not.

CONCLUSIONS

Surgery is the first choice for resectable UCP. Pleomorphic cell carcinoma is particularly malignant; postoperative treatment should be introduced immediately.

Early Stage Anaplastic Sarcomatoid Carcinoma of The Pancreas, A Case Report

BACKGROUND Anaplastic sarcomatoid carcinoma of the pancreas (ASCP) is a rare variant of pancreatic malignancies. It is a high-grade epithelial carcinoma predominated with spindle cells. CASE REPORT We report a case of a 65-year-old patient who presented with early stage, ampullary mass indicating malignancy, and who subsequently underwent pancreatoduodenectomy. Histopathology and immunohistochemistry were confirmatory for anaplastic, grade IV sarcomatoid adenocarcinoma arising from the head of the pancreas. CONCLUSIONS To our knowledge, this is a rare presentation with few cases reported in the literature.

Sarcomatoid carcinoma of the pancreas: A case report

BACKGROUND

Sarcomatoid carcinoma of the pancreas (SCP) is a rare and aggressive epithelial tumor that has both epithelial and mesenchymal features. It is characterized by sarcomatous elements with evidence of epithelial differentiation. And the term “sarcomatoid carcinoma” is often confused with “carcinosarcoma”.

CASE SUMMARY

We present a case of SCP with lymph node metastasis in a 59-year-old male patient. He had experienced darkening of the urine, scleral icterus, and fatigue for 4 weeks. Computed tomography and magnetic resonance imaging revealed a mass in the pancreatic head, and laboratory tests revealed elevated serum bilirubin levels. The patient underwent pancreaticoduodenectomy after biliary decompression. Histologically, spindle cells with marked nuclear atypia and brisk mitotic activity arranged in a storiform or fascicular pattern were present in the bulk of the tumor. Immunohistochemical analysis found that the spindle cells exhibited strong diffuse positivity for epithelial markers, indicative of epithelial differentiation. Accordingly, the pathologic diagnosis of the pancreatic neoplasm was SCP.

CONCLUSION

Although sarcomatoid carcinomas and carcinosarcomas have different pathologic features, both have epithelial origin.

Sarcomatoid carcinoma of the pancreas: A case report and review of the literature

Sarcomatoid carcinoma (SC) is an extremely rare and complicated malignant neoplasm that consists of both malignant epithelial components and atypical spindle cells that express an epithelial phenotype. The presents study reported a case of SC of the pancreas (SCP), along with a brief review of the literature. A 63‑year‑old man was admitted to The Second Hospital of Jilin University hospital with complaints of epigastralgia and jaundice of one month in duration. Based on preoperative laboratory blood tests and radiography, a mass at the distal common bile duct was suspected. Intraoperative examination discovered a 2.5x2x1.8‑cm mass in the pancreatic head, with invasion of the distal bile duct. Pancreaticoduodectomy was performed. Histopathology and immunohistochemistry of the specimen confirmed the diagnosis of SCP. The patient succumbed 18 months after surgery due to multiple hepatic metastases.

High-grade malignant pancreatic neoplasm with sarcomatoid features

Sarcomatoid carcinoma is a rare and aggressive form that occur at diverse locations in the body such as upper respiratory tract, upper and lower digestive tracts, genitourinary tract, breast and thyroid glands. However, its occurrence in pancreas has been rarely reported. Sarcomatoid carcinoma of pancreas (SCP) is a high-grade epithelial malignancy composed predominantly of spindle cells often having features suggestive of epithelial derivation without features indicative of a specific line of mesenchymal differentiation. Its pathogenesis has not been elucidated. Microscopically, SCP comprises mostly anaplastic cells and is strikingly sarcoma-like in appearance. Confirmation of this disease is often based on the pathological diagnosis. We report a case that was incidentally found after a CT was done for worsening chronic back pain and the patient was found to have a pancreatic mass and a liver lesion. Endoscopic ultrasound (EUS)-guided liver biopsy revealed high grade malignant pancreatic neoplasm with sarcomatoid features. Further CT chest revealed bilateral lung nodules and PET scan revealed prominent bony metastases within vertebral bodies at L1, L2, and L3. The patient refused definitive treatment and succumbed to illness within 3 months.

Pancreatic Extraskeletal Osteosarcoma Metastasizing to the Scalp

Extraskeletal osteosarcoma (ESOS) is a rare mesenchymal soft-tissue neoplasm that accounts for approximately 1% of all soft-tissue sarcomas. Over 70% of these malignant tumor progress to local recurrence and metastasis. It commonly metastasizes to the lungs, lymph nodes, bone, and skin and has a poor survival outcome. Cutaneous metastasis is exceedingly rare and known to be a sign of widespread metastases. We present a 57-year-old woman who presented with a rapidly growing protuberant mass on the scalp that was finally diagnosed as metastatic ESOS from a primary pancreatic ESOS. To our knowledge, there has been no reported case of pancreatic ESOS metastasizing to the scalp.

Undifferentiated carcinoma of the pancreas with osteoclast-like giant cells reported in an asymptomatic patient: a rare case and literature review

Undifferentiated carcinoma of the pancreas with osteoclast-like giant cells (UC-OGC) is a rare and poorly described pancreatic malignancy. It is comprised of mononuclear, pleomorphic, and undifferentiated cells as well as osteoclast-like giant cells (OGC’s). It constitutes less than 1% of pancreatic non-endocrine neoplasia and is twice as likely to occur in females as in males. Its histopathologic properties remain poorly understood. It is suspected that UC-OGC is of epithelial origin that can then transition to mesenchymal elements. As part of this study, we describe a case of a malignant pancreatic neoplasm that was discovered in a 69-year old patient as an incidental finding. We also provide an overview of previously published data to highlight UC-OGC’s clinical and pathologic features.

Carcinosarcoma of the Pancreas: Case Report With Comprehensive Literature Review

Carcinosarcomas are rare biphasic neoplasms with distinct malignant epithelial and mesenchymal components. Most commonly, carcinosarcomas arise in the uterus as malignant mixed müllerian tumors, but also infrequently appear in other organs such as the ovaries and breast, the prostate and urinary tract, the lungs, or in the gastrointestinal system, among others. Pancreatic carcinosarcomas are exceedingly rare; only a few cases are reported in the English literature. Their pathogenesis remains to be fully clarified. We present here the case of a pancreatic carcinosarcoma with evidence for monoclonality via determination of Kras mutational status after microdissection and suggest a common origin of the 2 tumor components. Comprehensive review of the available literature allows the conclusion that most pancreatic carcinosarcomas appear to be of monoclonal origin and seem to have arisen from a carcinoma via metaplastic transformation of 1 part or subclone of the tumor, probably by epithelial-mesenchymal transition. All reported patients were treated with surgery. Adjuvant therapy, if administered, consisted predominantly of gemcitabine. Prognosis for this neoplasm occurs to be similar or even worse compared with classic pancreatic ductal adenocarcinoma. Despite the lack of evidence-based recommendations for its treatment, resection should be performed, if possible.

Long-term survival after resection of sarcomatoid carcinoma of the pancreas: an updated experience

BACKGROUND

Sarcomatoid carcinoma of the pancreas (SCP) is a rare histologic subtype of undifferentiated pancreatic carcinoma. Historically, this has been associated with a worse overall prognosis than adenocarcinoma. However, the clinical course and surgical outcomes of SCP remain poorly characterized owing to its rarity.

METHODS

A single-institution, prospectively maintained database was queried for patients who underwent pancreatic resection with a final diagnosis of SCP. We describe their histology, clinicopathologic features, and perioperative outcomes. Survival data are highlighted, and common traits of long-term survivors are examined.

RESULTS

Over a 25-year period, 7009 patents underwent pancreatic resection at our institution. Eight (0.11%) were diagnosed with SCP on final histopathology. R0 resection was achieved in six patients (75%). Four patients had early recurrence leading to death (<3 months). Two (25%) experienced long-term survival (>5 years), with the longest surviving nearly 16 years despite the presence of lymph node metastasis. There were no deaths attributed to perioperative complications. Both long-term survivors had disease in the body/tail of the pancreas and received adjuvant radiotherapy. One also received adjuvant gemcitabine-based chemotherapy.

CONCLUSIONS

SCP is a rarely appreciated subset of pancreatic malignancy that does not necessarily portend to a uniformly dismal prognosis. Although some have rapid recurrence and an early demise, long-term survival may be possible. Future studies are needed to better define the cohort with potential for long-term survival so that aggressive therapies may be tailored appropriately in this patient subset.

Manifestation of osteoblastic phenotypes in the sarcomatous component of epithelial carcinoma and sarcomatoid carcinoma

Epithelial carcinomas occasionally have sarcomatous components that consist primarily of spindle and cuboidal cells, which often resemble osteoblasts. Sarcomatoid carcinomas consist of similar cells. Recent studies have characterized these phenomena as a manifestation of epithelial-mesenchymal transition in carcinoma cells, but the mesenchymal phenotypes that manifest in sarcomatous cells of epithelial carcinomas are not well understood. Here, we examined the expression profiles of four osteoblastic differentiation biomarkers in the sarcomatous components of multiple carcinoma types, including five renal clear cell, four breast invasive ductal, two esophageal, one maxillary squamous cell, three larynx, three lung, one liver, and one skin sarcomatoid carcinoma. Expression was analyzed by immunohistochemistry using antibodies against cell adhesion molecule 1, a member of the IgCAM superfamily, osterix transcription factor (Osterix), cluster of differentiation 151, a transmembrane 4 superfamily member, and alkaline phosphatase. Immunostaining intensity was rated in scale 0 (negative), 0.5 (weak), and 1 (strong) for each marker, and the four scale values were summed to calculate osteoblastic scores. In all, 10 cases had a osteoblastic score ≥3, and all of these 10 cases were cell adhesion molecule 1- and Osterix-positive. Eight and five of the nine samples with a osteoblastic score <3 were negative for cell adhesion molecule 1 ( p < 0.0001) and Osterix ( p = 0.006), respectively. The other markers showed no statistical significance. These results indicate that osteoblastic differentiation can occur in carcinoma cells and that cell adhesion molecule 1 could be a useful marker for identifying this phenomenon in carcinoma tissues.

Sarcomatoid carcinoma of the common bile duct: A case report

RATIONALE

Sarcomatoid carcinoma is an extremely rare lesion in the common bile duct (CBD).

PATIENT CONCERNS

We present a case of sarcomatoid carcinoma of the distal CBD in a 51-year-old woman who presented with jaundice and abdominal pain. Whipple's operation was performed successfully. Microscopically, the tumor was a poorly differentiated carcinoma containing a component of sarcoma-like differentiation. The tumor cells displayed spindle-shaped nuclei with occasional mitotic figures. Cytokeratin (CK) 7, CK19, CK18, and pan-CK (AE1/AE3) staining was positive on immunohistochemistry. Vimentin and carcinoembryonic antigen (CEA) staining were also positive.

DIAGNOSES

Sarcomatoid carcinoma of the distal CBD.

INTERVENTIONS

The patient received three cycles of chemotherapy after surgery.

OUTCOMES

The patient has experienced no adverse events in the 3 years post-surgery.

LESSONS

We present here a case report of sarcomatoid carcinoma of the distal CBD. The patient received chemotherapy after surgery, and was event-free for 3 years post-surgery, suggesting a relatively better prognosis, despite the infiltrative pattern of the tumor.

A spindle cell anaplastic pancreatic carcinoma with rhabdoid features following curative resection

Anaplastic pancreatic carcinoma (ANPC) accounts for ~5% of all pancreatic ductal adenocarcinoma cases. Due to its rarity, its clinical features and surgical outcomes remain to be clearly understood. A 74-year-old woman was admitted to Onomichi General Hospital (Onomichi, Japan) in April 2015 without any significant past medical history. Contrast-enhanced computed tomography (CT) revealed a 9.5×8.0 cm tumor in the body and tail of the pancreas. The patient developed acute abdominal pain 3 weeks later and the CT revealed massive abdominal bleeding caused by tumor rupture. The tumor increased in size and reached 12.0×10.0 cm in maximal diameter. The tumor doubling time was estimated to be 13 days. ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/CT confirmed the absence of distant metastasis since FDG accumulation was detected only in the tumor lesion. Emergency distal pancreatectomy and splenectomy were performed. Histologically, the tumor was classified as a spindle cell ANPC with rhabdoid features. The patient succumbed to mortality 8 months following the surgery while undergoing systemic adjuvant chemotherapy for multiple liver metastases. ANPC is difficult to detect in the early stages due to its progressive nature and atypical radiological findings. Long-term survival can be achieved only by curative resection; therefore, surgical resection must be performed whenever possible, even if the chance of long-term survival following surgery is considered dismal. As the present case suggested, spindle cell ANPC with rhabdoid features is highly aggressive and curative-intent resection must not be delayed.

TGF-β Tumor Suppression through a Lethal EMT

TGF-β signaling can be pro-tumorigenic or tumor suppressive. We investigated this duality in pancreatic ductal adenocarcinoma (PDA), which, with other gastrointestinal cancers, exhibits frequent inactivation of the TGF-β mediator Smad4. We show that TGF-β induces an epithelial-mesenchymal transition (EMT), generally considered a pro-tumorigenic event. However, in TGF-β-sensitive PDA cells, EMT becomes lethal by converting TGF-β-induced Sox4 from an enforcer of tumorigenesis into a promoter of apoptosis. This is the result of an EMT-linked remodeling of the cellular transcription factor landscape, including the repression of the gastrointestinal lineage-master regulator Klf5. Klf5 cooperates with Sox4 in oncogenesis and prevents Sox4-induced apoptosis. Smad4 is required for EMT but dispensable for Sox4 induction by TGF-β. TGF-β-induced Sox4 is thus geared to bolster progenitor identity, whereas simultaneous Smad4-dependent EMT strips Sox4 of an essential partner in oncogenesis. Our work demonstrates that TGF-β tumor suppression functions through an EMT-mediated disruption of a lineage-specific transcriptional network.