Personal Experience in Surgical Management of Pulmonary Pleomorphic Carcinoma

Fine-needle aspiration cytology of pleomorphic carcinomas of the lung

Background

Pleomorphic carcinoma (PC) is a rare pulmonary malignancy. Because of its rarity and histological heterogeneity, cytopathologists might suspect PC only rarely on the basis of its cytological specimen. In addition, cytological findings from fine needle aspiration (FNA) specimens have rarely been described. Hence, we investigated the cytological features of FNA in the cases of PC.

Methods

We reviewed 7 FNA specimens of PC. The patients had undergone surgical resection at the Korea Cancer Center Hospital between 2007 and 2011. The cytological features of PC were assessed and compared with the histopathological features of the corresponding surgical specimen. Immunocytochemical analysis with cytokeratin and vimentin was performed on the cell blocks.

Results

The tumor cells were either dispersed or arranged in loose aggregates, and generally lacked any glandular or squamous differentiation. Pleomorphic or spindle shape tumor cells were observed, and mono-, bi-, or multi-nucleated giant cells were frequently observed. The background showed necrosis and contained numerous lymphocytes and neutrophils. Immunocytochemically, the tumor cells were positive for cytokeratin and vimentin.

Conclusions

PC displays characteristic cytological features. It might therefore be possible to make an accurate diagnosis of PC by assessing the degree of nuclear atypia.

Clinical outcomes with perioperative chemotherapy in sarcomatoid carcinomas of the lung

INTRODUCTION

In patients with resected lung cancer, sarcomatoid carcinomas are reputed to carry a worse prognosis. Although generally felt to be chemo-refractory, little data are available about chemotherapy in these patients. We sought to determine the effect of perioperative chemotherapy in patients with completely resected sarcomatoid carcinomas of the lung.

METHODS

We reviewed the pathology reports of 4675 patients consecutively resected at Memorial Sloan-Kettering between 2000 and 2010. Charts and images were reviewed for patients with a histologic diagnosis of sarcomatoid carcinoma. Response to neoadjuvant chemotherapy was assessed radiographically. Kaplan-Meier disease-free probability (DFP) curves were compared for patients who did and did not receive perioperative chemotherapy, stratified by pathological stage.

RESULTS

Of the 4675 patients who underwent an R0 lung cancer resection, 56 (1%) were diagnosed with sarcomatoid carcinomas. Twenty received neoadjuvant and/or adjuvant chemotherapy. Overall radiographic response rate (minor + major) to neoadjuvant chemotherapy was 73% (95% confidence interval 48-90%) in the 15 evaluable patients. The median DFP of patients who received chemotherapy was 34 months versus 12 months in those who did not (p = 0.37). Subset analysis did not reveal a benefit to perioperative chemotherapy in patients with stage Ib-IIa, whereas a benefit was seen in patients with IIb-IIIa disease (p = 0.02).

CONCLUSIONS

Although sarcomatoid carcinomas are felt to be chemo-refractory, our results demonstrate radiographic responses to neoadjuvant chemotherapy and an improvement in DFP in patients with stage IIb-IIIa disease. The use of pathological stage in this analysis may underestimate this benefit. Perioperative chemotherapy should be considered in these patients.

Pulmonary pleomorphic carcinoma mimicking bronchopneumonia in an elderly man

A 77-year-old male smoker presented with fever, cough, and night sweat of 4 weeks' duration. Imaging of the chest revealed a left lung consolidation and a right cavitary lesion. Further investigation with flexible bronchoscopy supported the diagnosis of an infectious/inflammatory process. The patient clinically improved with antibiotics and was discharged. He was readmitted with a similar presentation 2 weeks later; at this time he had new onset of atrial fibrillation and worsening respiratory symptoms. After his heart rate was controlled, he underwent transthoracic needle aspiration and pleural fluid drainage, which again were nondiagnostic. A surgical biopsy was scheduled, but he expired before surgery. Necropsy revealed pulmonary pleomorphic carcinoma with invasion of both the lungs, lymph nodes, pericardium, and myocardium. Clinicians should keep a high index of suspicion for pleomorphic carcinoma in those patients with unusual presentation or progressive or nonresolving pulmonary infiltrates. Early surgical intervention, either for diagnosis or treatment, is imperative due to the aggressive nature of the tumor and the dismal prognosis.

Outcomes of sarcomatoid carcinoma of the lung: a Surveillance, Epidemiology, and End Results Database analysis

BACKGROUND

Sarcomatoid lung carcinomas are unusual, and reports from small single institution case series suggest poor survival rates. We sought to study the clinical characteristics of this form of non-small cell lung cancer using the Surveillance Epidemiology, End Results database.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for respiratory tract malignancies of sarcomatoid histology. The demographic information and oncologic characteristics of this population were examined. A propensity score-matched analysis of patients was performed to test the hypothesis that patients with sarcomatoid cancers undergoing lobectomies perform worse that those with other non-small cell lung cancers.

RESULTS

Of 878,810 patients with lung cancer, only 3,647 patients had a diagnosis of sarcomatoid cancer (0.4%). For the additional analyses of outcomes, only patients with lifetime incidence of a single cancer, known Surveillance, Epidemiology, and End Results historic stage and inpatient reporting were selected (n = 1,921). Demographics, tumor characteristics, and outcomes of these patients were described. Non-small cell lung cancer cohorts (with and without sarcomatoid cancer propensity-matched on age, gender, race, year of diagnosis, grade, and Surveillance, Epidemiology, and End Results historic stage) that underwent lobectomies or pneumonectomies were selected (n = 758). Univariate (hazard ratio, 1.60; 95% confidence interval, 1.31-1.97) and multivariate analysis (hazard ratio, 1.67; 95% confidence interval, 1.36-2.05) revealed a significantly worse overall survival for patients with sarcomatoid cancer compared to matched nonsarcomatoid lung cancer controls.

CONCLUSION

Sarcomatoid cancer is a rare form of lung malignancy with outcomes significantly worse than other forms of non-small cell lung cancer. Novel multimodality treatment strategies are necessary to improve outcomes of this disease.

[Pulmonary sarcomatoid carcinoma: Clinical and prognostic characteristics, a case report]

Sarcomatoid carcinoma is a rare malignancy in the family of non-small-cell lung cancer. They belong to a mixed group of poorly differenciated neoplasia, including sarcomatous cells or sarcomatoid-like cells with giant or spindle cells. We report the case of a 69-year-old man with sarcomatoid carcinoma. We describe the main characteristics of these tumors. Diagnosis is frequently delayed and lesions are locally advanced. The prognostic is poorer than other non-small-cell lung cancer. Chemotherapy is often not efficient.

Clinicopathological characteristics of surgically resected pulmonary pleomorphic carcinoma

OBJECTIVES

Since few large-scale studies of patients with pleomorphic carcinoma have been documented, factors affecting survival after pulmonary resection for pleomorphic carcinoma, as well as its clinicopathological characteristics, are still unknown. For a better understanding of the patients undergoing resection of pulmonary pleomorphic carcinoma, we reviewed our experience with these patients.

METHODS

Between 2002 and 2010, 26 patients with pulmonary pleomorphic carcinoma underwent macroscopically complete pulmonary resections. Various perioperative variables were investigated retrospectively to confirm a role for pulmonary resection and to analyse prognostic factors for overall survival and disease-free survival after lung resection.

RESULTS

Twenty-four patients (92%) were male. Twenty-one patients (81%) were smokers and all of them smoked more than 30 pack-years. In 25 patients (96%), the tumour was located peripherally. Twenty-three of these 25 patients revealed the tumour touching the visceral pleura widely in the preoperative chest computed tomography. In all 26 patients, the tumour was completely resected macroscopically; however, three patients (12%) had microscopically positive surgical margins. Among them, additional irradiation was conducted in two patients and additional surgical resection was performed in one patient. Combined resections were performed in 11 patients (42%), including chest wall resections in 7 patients. Overall survival rate after pulmonary resection was 48% at 5 years. Disease-free survival rate after pulmonary resection was 33% at 5 years. Patients with tumours invading the visceral pleural surface and microscopically positive surgical margin had significantly worse overall survivals (P = 0.048 and 0.037, respectively). However, there were no significant prognostic factors for disease-free survival.

CONCLUSIONS

Despite small number of cases, we found that pleural invasion suggested a worse prognosis for resection of pulmonary pleomorphic carcinoma. Surgical strategy might be constructed to achieve not only macroscopically, but also microscopically complete resection for such large tumours with aggressive nature and peripheral preference.

Immunohistochemical overexpression of platelet-derived growth factor receptor-beta (PDGFR-β) is associated with PDGFRB gene copy number gain in sarcomatoid non-small-cell lung cancer

Sarcomatoid non-small cell lung cancer (NSCLC) is an uncommon histologic variant that has not been molecularly well-characterized. We conducted immunohistochemical and fluorescence in situ hybridization studies of PDGF-B/PDGFR-b on archived surgically resected specimens and showed high PDGFR-b IHC expression and gene copy number gain. Further studies are warranted to determine whether PDGFR-b is a feasible therapeutic target in this population.

INTRODUCTION

Sarcomatoid non-small cell lung cancer (NSCLC) is an uncommon histologic variant that has not been molecularly well-characterized. We hypothesized that the PDGF-B/PDGF-Rβ pathway may be dysregulated in sarcomatoid lung cancer.

METHODS

We conducted immunohistochemical (IHC) and gene copy number gain studies of PDGF-B/PDGFR-β on archived surgically resected specimens, 43 sarcomatoid NSCLCs and 42 control NSCLCs that were age, gender and stage-matched. Biomarkers were correlated to patient demographics, tumor characteristics, and survival.

RESULTS

Sarcomatoid tumors had higher PDGFR-β IHC expression than control NSCLC (median score 2.69 vs. 1.93; P < 0.0001). No difference was seen between the two groups of PDGF-B IHC expression; and neither PDGF-B nor PDGFR-β IHC levels correlated with gender, age, clinical or pathologic TNM status, or overall survival. PDGFRB gene copy number was evaluated by FISH using three ways: presence of amplification, gene copy number gain, and gene copy ratio between tumor and normal tissue. PDGFRB gene copy number gain was associated with sarcomatoid histology (P = 0.006), lower clinical and pathologic T-stage (P = 0.07, P = 0.048), and higher pathologic N-stage (P = 0.013). Sarcomatoid NSCLC patients (P = 0.006) and female patients (P = 0.03) had higher gene copy ratios above 1.83. Higher PDGFR-β IHC expression in tumor cells was associated with gene copy number gain (P = 0.021) and higher gene copy ratio status (P = 0.005).

CONCLUSION

This is the first study to demonstrate high PDGFR-β IHC expression and gene copy number gain in sarcomatoid NSCLC tumors and suggests that further studies are warranted to determine whether PDGFR-β is a feasible therapeutic target in this population.

[Pleomorphic carcinoma of the lung: a case report]

Pleomorphic carcinoma is a rare malignancy belonging to the family of nonsmall cell lung cancers. A 40-year-old man, a smoker, was hospitalized for thoracic pain and dry cough with a deteriorating general condition. The imaging showed a "drop ball" of both lungs. The pathological evidence was obtained by lung biopsy under scanographic control. The presence of supraclavicular and abdominal nodes classified the tumour as stage IV. The patient received six cycles of first-line chemotherapy associating cisplatin and vinorelbine. However, the disease continued to progress and distant metastases were observed. The patient died 6 months after the diagnosis. Pleomorphic carcinoma is identified by purely histological criteria: the concomitant presence of malignant epithelial and homologous sarcomatoid spindle-cell components. Like the other nonsmall cell lung cancers, the treatment is primarily surgical, and the invasive nature of this tumour makes it very difficult. Pleomorphic carcinoma has a poorer prognosis than conventional nonsmall cell lung cancers despite surgery, irradiation and chemotherapy, because relapse occurs early.

Pleomorphic carcinoma of the lung with high serum beta-human chorionic gonadotropin level and gynecomastia

Although gynecomastia is a well-defined paraneoplastic syndrome in patients with non-small cell lung cancer, the association with pleomorphic carcinoma has not been reported. A 50-yr-old man presented with bilateral gynecomastia and elevated serum beta-human chorionic gonadotropin (βhCG) level. Chest tomography showed a mass in the right middle lobe. Right middle lobectomy and mediastinal lymph node dissection were performed. βhCG levels decreased rapidly after surgery. Histological examination revealed pleomorphic carcinoma with positive immunostaining for βhCG. Serum βhCG levels began to increase gradually on postoperatively 4th month. Computed tomography detected recurrence and chemotherapy was started. After second cycle of chemotherapy, βhCG levels decreased dramatically again and tomography showed regression in mass. Patient died 6 months later due to brain metastasis. βhCG expression may be associated with aggressive clinical course and increased risk of recurrence, also βhCG levels may be used to evaluate therapy response in patients with pleomorphic carcinoma.

Sarcomatoid neoplasms of the lung and pleura

Sarcomatoid neoplasms of the lung and pleura are rare tumors that present a complex differential diagnosis, making them challenging for surgical pathologists. In the lung, the main tumors are the sarcomatoid carcinomas, including pleomorphic carcinoma, spindle cell carcinoma, giant cell carcinoma, carcinosarcoma, and pulmonary blastoma. They are characterized by histologic heterogeneity; molecular data support their origin from a pluripotent stem cell that undergoes neoplastic transformation with divergent epithelial and sarcomatous differentiation. Diagnosis is difficult in small biopsy specimens and typically requires a resection specimen. Despite the presence of sarcomatoid features, these tumors are classified as lung carcinomas. Pulmonary blastomas must be distinguished from pleuropulmonary blastomas, which are a unique type of thoracic sarcoma typically occurring in young children. In the pleura, the main tumors to consider are the sarcomatoid and desmoplastic types of malignant mesothelioma, solitary fibrous tumor, and desmoid tumor. While light microscopy is sufficient to diagnose most of these tumors, immunohistochemistry can be useful in selected settings. In particular, it can aid to confirm epithelial differentiation in spindle cell carcinomas and the presence of rhabdomyosarcoma in sarcomatoid carcinomas, mesotheliomas, or pleuropulmonary blastomas. For sarcomatoid and desmoplastic mesothelioma, keratin is the most useful stain because it can highlight invasive growth and mesothelial markers are positive in only the minority of cases. Clinical and radiologic correlation is needed to separate some pleomorphic carcinomas with pleural involvement from sarcomatoid malignant mesothelioma, since these poorly differentiated tumors may not express the usual immunohistochemical markers for carcinoma or mesothelioma.

Clinical characteristics of pleomorphic carcinoma of the lung

BACKGROUND

Pleomorphic carcinoma of the lung is a malignant epithelial tumor that contains carcinomatous and sarcomatoid components. Due to its rarity, few studies have been reported, and its clinical and pathological characteristics remain unclear.

METHOD

We retrospectively investigated 22 cases of pleomorphic carcinoma of the lung.

RESULTS

Fifteen cases were diagnosed by surgical resection, 4 by autopsy, and 3 by transbronchial biopsy. Nineteen patients were male and 3 were female, and their mean age at diagnosis was 68.3 years (+/-10.1). Eighteen were current- or ex-smokers with substantial smoking histories (mean 46.4 pack-years). Sixteen patients had symptoms: hemoptysis and cough were commonly seen. Chest computed tomography (CT) findings revealed that the tumors were quite large (mean diameter 45.3+/-21.9mm; range 14-110mm), and 21 tumors were peripherally located. Positron emission tomography with 18-fluorodeoxy-glucose (FDG-PET) was performed in 12 patients, and the Standardized Uptake Value (SUV) tended to be high (9.44+/-4.98). In the 15 patients who underwent surgical resection, recurrence was common; systemic metastases were also frequently found. Patients who had received surgical treatment with proper follow-up care survived longer than those who did not undergo surgery. Responses to chemotherapy were generally poor, although 1 patient exhibited partial response to gefitinib.

CONCLUSIONS

Pulmonary pleomorphic carcinoma has strong malignant potential with frequent distant metastases, as has already been reported. However, this study demonstrated that surgical treatment and appropriate follow-up therapy might result in better prognoses.

Genetic heterogeneity of EGFR mutation in pleomorphic carcinoma of the lung: response to gefitinib and clinical outcome

Somatic epidermal growth factor receptor (EGFR) mutations in exons 19 and 21 have been found in non-small cell lung cancer (NSCLC) and are associated with the therapeutic response to gefitinib in patients with advanced NSCLC. We report a case of pleomorphic carcinoma of the lung with different EGFR mutations. Prior to gefitinib treatment, an exon 19 deletion of EGFR mutation was positive in the specimens obtained from pleural effusion and left cervical lymph node, histologically proven to be adenocarcinoma. However, the response to gefitinib was poor and the patient died of progressive disease 4 months after the initiation of gefitinib therapy. Postmortem examination revealed the major histological component to be of the sarcomatoid or pleomorphic type with scant mixed adenocarcinoma, resulting in a histological diagnosis of pleomorphic carcinoma of the lung. Although the adenocarcinomatous tissue was still positive for exon 19 deletion of EGFR mutation alone, sarcomatous components had both the exons 19 deletion and 20 T790M mutation concomitantly, thought to be a gefitinib resistance mutation. Pulmonary pleomorphic carcinoma is a rare NSCLC composed of biphasic and heterogeneous malignant cell populations. The present case suggested that expression of different EGFR mutations is related to the biphasic histological appearance in pulmonary pleomorphic carcinoma.

Review article: pulmonary sarcomatoid carcinomas: a practical overview

Pulmonary sarcomatoid carcinomas (PSCs) are currently defined as poorly differentiated non-small-cell carcinomas containing a component with sarcoma or sarcoma-like (spindle and/or giant cell) features. They consist of 5 major histological variants, namely pleomorphic carcinoma, spindle cell carcinoma, giant cell carcinoma, carcinosarcoma, and pulmonary blastoma. The segregation of PSCs into a distinct clinicopathologic entity seems justified on the basis of morphologic, behavioral, and genotypic/phenotypic attributes. As a group, PSCs generally run an aggressive clinical course and may cause major difficulties in the differential diagnosis with other primary and secondary malignancies of the lung. At present, PSCs are believed to represent a family of carcinomas "in transition," in which diverse pathways of clonal evolution account for histological differences of a common ancestor lesion. The sarcomatous or sarcomatoid component of these tumors is thought to derive from carcinoma cells during the progression of carcinogenesis through the activation of an epithelial-mesenchymal transition program leading to sarcomatous transformation or metaplasia (conversion paradigm). Conceivably, targeting the epithelial-mesenchymal transition program could become a valid therapeutic strategy for these life-threatening tumors, whose sensitivity to current medical manipulation is disappointing.

Pleomorphic carcinoma of the lung: clinicopathologic characteristics of 70 cases

Pleomorphic carcinoma (PC) of the lung is rare, and it is classified as a subtype of sarcomatoid carcinoma of the lung in the World Health Organization histologic classification of lung tumors. In this study, 70 cases of PC surgically resected were reviewed to identify its clinicopathologic characteristics. There were 57 men and 13 women, and their mean age was 66 years (range: 29 to 80 y). Sixty-eight tumors contained identifiable epithelial components, and the other 2 consisted of spindle cells and giant cells alone. An adenocarcinoma component was found in 34 cases, a squamous cell carcinoma component in 13, and a large cell carcinoma component in 40. The overall survival rate and disease-free survival rate were 36.6% and 40.7%, respectively, and both rates were significantly lower than for other nonsmall cell lung carcinomas. When the PC patients were divided into 3 groups according to the predominant epithelial component, an adenocarcinoma group, squamous cell carcinoma group, and large cell carcinoma group, there were no significant differences in the overall survival rate and median survival time between the 3 groups. Univariate analysis revealed that advanced stage (stage III), mediastinal lymph node metastasis, lymphatic permeation, and histologically diagnosed massive coagulation necrosis (>25% of the tumor) predicted poorer disease-free survival. Multivariate analysis showed that massive necrosis alone was an independent prognostic factor. We concluded that PC should be considered as an aggressive disease and massive necrosis should be routinely reported and used as a factor in clinical assessments.

The role of palliative chemotherapy for advanced pulmonary pleomorphic carcinoma

Pulmonary pleomorphic carcinoma is an uncommon malignant tumor of the lung, which has the dual cell components of spindle or giant cells and epithelial cells. The objective of this study was to investigate the clinical course and efficacy of palliative chemotherapy in patients with advanced pulmonary pleomorphic carcinoma. Twelve patients were diagnosed with advanced pulmonary pleomorphic carcinoma and received palliative chemotherapy from February 2000 to December 2007. Among the 12 patients, five patients received gemcitabine/cisplatin, three patients received gemcitabine/carboplatin, two patients received paclitaxel/carboplatin, one patient received paclitaxel/cisplatin, and one patient received docetaxel/cisplatin as first-line chemotherapy. The median patient's age was 62 (range, 32-72 years). Among the 12 patients, nine patients had relapsed disease after curative resection and three patients had metastatic disease at the initial presentation. After treatment with first-line palliative chemotherapy, seven patients (58%) had progressive disease, three patients (25%) had stable disease, and only two patients (17%) had a partial response. The median overall survival from the day of initiation of first-line chemotherapy was only 8 months (95% CI, 6-10) with median follow-up of 26 months. These results showed the dismal prognosis and the poor response to chemotherapy of advanced pulmonary pleomorphic carcinoma. Further studies are needed to investigate whether the current strategy of palliative chemotherapy for the treatment of advanced pulmonary pleomorphic carcinoma can be justified or not. Moreover, additional novel treatment approaches are required.

Giant cell lung carcinoma in a man with acquired immunodeficiency syndrome

A 66-year-old man, who was discovered to have human immunodeficiency virus (HIV) infection 22 months previously and was treated with highly active antiretroviral (HAART) therapy, developed giant cell carcinoma of the lung. In English literature, this is the first case of such cell type of lung cancer during HAART therapy. Since giant cell carcinoma of the lung occurs mainly in elderly men who smoke heavily, there may not be a possibility that the HIV or HAART was causative in our patient.

Pulmonary Sarcomatous Tumors

Context.—Sarcomatous pulmonary neoplasms are a rare and diagnostically challenging group of tumors. Primary pulmonary sarcomas must be distinguished from the more frequent occurrence of sarcoma metastatic to the lung, primary pulmonary sarcomatoid carcinoma, and diffuse malignant mesothelioma involving the lung. In current practice, the general availability of ancillary diagnostic techniques, such as immunohistochemistry and molecular analysis, can reliably classify many sarcomatoid lesions.

Objective.—To review the literature and report on additional primary material about the application of immunohistochemistry and molecular analysis in the differential diagnosis pulmonary sarcomatous neoplasms.

Data Sources.—Literature review of relevant articles indexed in PubMed (National Library of Medicine) between 1961 and 2007 and primary material from the author's institution.

Conclusions.—This review discusses specific criteria for the diagnosis of primary lung sarcomas and offers a practical approach to excluding other sarcoma-like lesions involving the lung. The pathologist has an essential role in evaluating these tumors and will often be the first to suggest an unusual, alternative diagnosis, which may have significant implications for patient care, therapy, and prognosis.

Palliative chemotherapy for pulmonary pleomorphic carcinoma

Pulmonary pleomorphic carcinoma is a rare tumor of the lung, which is believed to spread at an early stage and to have an aggressive clinical course. The efficacy of chemotherapy for advanced pulmonary pleomorphic carcinoma has not been defined. The objective of this study was to evaluate the efficacy of palliative chemotherapy for pulmonary pleomorphic carcinoma. Thirteen consecutive patients who received palliative chemotherapy for advanced pulmonary pleomorphic carcinoma were investigated. All 13 patients were treated using chemotherapy regimens known to be active for the treatment of advanced non-small cell lung cancer (NSCLC). Eleven patients (85%) had progressive disease and two (15%) had stable disease after first-line chemotherapy. No patient achieved an objective response (objective response rate, 0%; 95% confidence interval, 0-23%). Of the 13, eight were given second-line chemotherapy, and all had progressive disease after second-line chemotherapy (objective response rate, 0%; 95% CI, 0-32%). Median overall survival from the initiation of first-line palliative chemotherapy was only 5 months (range, 2-12) with a median follow-up of 16 months. Advanced pulmonary pleomorphic carcinoma showed poor response to chemotherapy regimens that provide active treatment for NSCLC. Novel treatment approaches are required for pulmonary pleomorphic carcinoma.

Sarcomatoid carcinoma of the lung: a predictor of poor prognosis

BACKGROUND

Sarcomatoid cancer (SARC) of the lung is a rare histologic type of non-small cell lung cancer (NSCLC). Although believed to be associated with poor prognosis, its effect on survival and recurrence has not been well defined. Our goal was to determine the prognostic significance of SARC histology in patients undergoing pulmonary resection.

METHODS

We retrospectively evaluated all patients who underwent pulmonary resection for NSCLC during a 20-year period at the University of Texas MD Anderson Cancer Center and compared recurrence and survival rates of patients with SARC with a cohort of patients with typical NSCLC. To account for known prognostic factors such as smoking status, age, gender, pathologic stage, and adjuvant therapy, we used one-to-one matching based on propensity scores.

RESULTS

The study included 63 SARC patients and 1133 NSCLC patients with complete data. Propensity score matching identified 63 NSCLC patients that were similar to the 63 SARC patients from known clinical factors. The 5-year survival for SARC patients was 24.5% compared with 46.3% for NSCLC patients (p = 0.01); median time to recurrence was 11.3 months and 61.4 months, respectively (p = 0.001).

CONCLUSIONS

Compared with other histologic subtypes, SARC behaves in an aggressive fashion. These tumors are frequently symptomatic, are locally advanced, and have higher rates of recurrence. Future investigation of novel treatment approaches is warranted. Nonsurgical treatment modalities may be appropriate for patients with clinically advanced disease.

Sarcomatoid lung cancer (spindle/giant cells): An aggressive disease?

OBJECTIVE

We investigated the clinical, surgical, and pathologic features of sarcomatoid lung carcinomas with spindle/giant cells, giving special attention to the prognostic behavior of these rare tumors.

METHODS

Surgical specimens from 39 patients (29 men and 10 women; mean age, 61 years) were examined by means of light microscopy. Preoperative and postoperative data were collected, and survival was calculated by using the Kaplan-Meier method.

RESULTS

Nineteen patients were diagnosed with cancer preoperatively. Only one sarcomatoid tumor had been diagnosed. Presenting symptoms were noted in 85% of patients, and complete resection was achieved in 37 tumors. Postoperative pTNM staging: T2/T3/T4, 22/15/2; N0/N1/N2, 28/8/3; 15 stage IB, 14 stage IIB, 7 stage IIIA, 2 stage IIIB, and 1 stage IV. Histopathologic analysis revealed necrosis in 90% of the tumors (34 pleomorphic, 3 spindle cell, and 2 giant cell carcinomas). During follow-up (median, 24 months), 21 patients died of disease recurrence, and 3 died of postoperative complications. The 5-year survival rate (33%; median, 11 months) was negatively influenced by large tumors (7.5% survival for > or =7 cm vs 56% for <7 cm, P = .0026). The disease-free interval was significant for patients who relapsed (0% for disease-free interval <6 months vs 33% for disease-free interval > or =6 months, P = .0019).

CONCLUSIONS

A highly heterogeneous group, spindle/giant cell lung carcinomas tend to be symptomatic, peripheral, and necrotic. Preoperative diagnosis is difficult. Most patients in our study relapsed and died the first year after surgical intervention. Surgical intervention can permit long-term survival, but adjuvant therapy warrants consideration because of the aggressive nature of these tumors.

Pleomorphic carcinoma of the lung: A surgical outcome

OBJECTIVES

Pleomorphic carcinoma of the lung, a rare malignant disease with a dual-cell component of spindle and/or giant cells, and of epithelial cells, was defined in the World Health Organization classification updated in 1999. Reported prognoses are heterogeneous, and optimal treatment remains undefined.

METHODS

Data were retrospectively examined for 45 consecutive patients (41 men and 4 women) who had undergone surgical resection for pulmonary pleomorphic carcinoma.

RESULTS

Sarcomatous elements were as follows: 23 spindle cell types (51.1%), 11 giant cell types (24.4%), and 11 combined spindle and giant cell types (24.4%). Epithelial components were adenocarcinoma in 25 (55.6%) patients, squamous cell carcinoma in 8 (17.8%) patients, and large call carcinoma in 12 (26.7%) patients. Nodal status was classified as pN0 disease in 28 (62.2%) patients, pN1 disease in 5 (11.1%) patients, and pN2 disease in 12 (26.7%) patients. Even patients with pN0 disease frequently manifested vascular invasion (16/28 [57.1%]). Five-year overall survival and disease-free survival were 39.2% and 47.1%, respectively. Although the subtype of epithelial components, as well as sarcomatous elements, did not affect prognosis, overall survival (P = .02) and disease-free survival (P = .002) in patients with pN1/N2 disease were significantly worse than those in patients with pN0 disease. Most recurrences occurred at distant sites (14/20 [70.0%]), and recurrence within 6 months after resection was found in 10 patients (10/20 [50.0%]). Moreover, median survival time after confirmation of initial relapse was 2.6 months.

CONCLUSIONS

Pulmonary pleomorphic carcinoma, which often presented in symptomatic male smokers as a large peripheral lesion, carried a poor prognosis, even when early-stage disease was diagnosed and resected. Distant metastases occurred more frequently and earlier, and the survival after relapse was very short, suggesting that this entity should be considered to have a tremendously aggressive malignant behavior. Further investigation of biologic features of pulmonary pleomorphic carcinoma and therapeutic response is a high-priority issue, so that suitable treatment strategies can be planned.

An immunohistochemical profile of giant cell carcinoma of the larynx

OBJECTIVE

This report describes a case of a 62-year-old male with giant cell carcinoma of the larynx that presented as a neck mass and hoarseness.

METHODS

Case report, review of the world literature, and an immunohistochemical examination.

RESULTS

Extended total laryngectomy and bilateral functional neck dissection were performed. Microscopical examination showed that the tumor was composed of solid masses of anaplastic small cells with hyperchromatic nuclei. There were multinucleated giant cells with huge nuclei, prominent nucleoli, and clear or eosinophylic cytoplasm. The diagnosis of giant cell carcinoma of the larynx was made. An immunohistochemical staining was applied to the case and tumor showed immunoreactivity with cytokeratin 8/18, cytokeratin 18, cytokeratin 19, vimentin, epithelial membrane antigen, S-100, cytokeratin 7 and did not show immunoreactivity with cytokeratin 10, cytokeratin 20, and carcinoembryogenic antigen.

CONCLUSION

Giant cell carcinoma of the larynx is an extremely rare tumor the origin of which is not clearly understood. It is believed to be the counterpart of giant cell carcinoma of the lung in larynx. It is the sixth case reported in English literature and also the first case that is examined immunohistochemically. In conclusion, giant cell carcinoma of the larynx is confirmed to be a specific entity of simple epithelial origin and it is the counterpart of giant cell carcinoma of the lung.

[A rare primary pulmonary tumor: pleomorphic carcinoma]

INTRODUCTION

Pleomorphic carcinoma is a rare malignancy in the family of non-small cell lung cancers.

CASE

This 65-year-old woman, a nonsmoker, was hospitalized for hemoptysis and weight loss. Computed tomography showed a peripheral tumor of the right upper lobe, and the radiography showed signs of malignancy. Pathologic examination of the transparietal biopsy confirmed the tumor diagnosis, classifying it as stage III A. The patient underwent 2 cycles of induction chemotherapy that combined gemcitabine and cisplatin. Disease progression continued, however, and distant metastases were observed. The patient died 4 months after diagnosis.

DISCUSSION

Pleomorphic carcinoma is identified by purely histologic criteria: the concomitant presence of malignant epithelial and homologous sarcomatoid spindle-cell components. Like the other non-small cell lung cancers, treatment is primarily surgical, and the invasive character of this tumor makes it very difficult. Pleomorphic carcinoma has a poorer prognosis than conventional non-small cell lung cancers despite surgery, irradiation and chemotherapy, because relapse occurs early.

Initial presentation of lung sarcomatoid carcinoma as a metastatic lesion in the mandibular gingiva

BACKGROUND

Sarcomatoid carcinoma of the lung is a very rare type of tumor characterized by distant metastasis. However, metastasis to the gingiva is an uncommon event. Occasionally, an oral metastatic lesion may be the preliminary clinical feature observed before the diagnosis of the primary tumor.

METHODS

The clinical features of gingival metastasis as an initial presentation of lung sarcomatoid carcinoma are discussed. A 55-year-old male patient presented with a rapidly growing pedunculated exophytic mass on the gingiva at the left side of the lower jaw. Incisional biopsy was performed.

RESULTS

The histologic and immunohistochemical diagnosis was metastatic carcinoma. To locate the primary tumor, we analyzed the lung lesion by chest computerized tomography (CT) scans and biopsy. The patient was ultimately diagnosed with sarcomatoid carcinoma of the lung with gingival metastasis. Palliative chemotherapy for lung cancer was administered. The gingival lesion disappeared after chemotherapy.

CONCLUSION

Although this case is unusual, periodontists should recognize that gingival masses similar to benign or inflammatory lesions may represent an initial sign of underlying malignant tumors.