Expression of androgen receptor and prostatic specific markers in salivary duct carcinoma: an immunohistochemical analysis of 13 cases and review of the literature

Recent advances in the diagnostic pathology of salivary carcinomas

This review concentrates on the most important developments since the WHO classification of 2005. In particular, the identification of specific translocations is revolutionising the way salivary tumours are considered and will have a major impact on future diagnostic practice. This is true so far in four malignancies: mammary analogue secretory, mucoepidermoid, adenoid cystic and hyalinising clear cell carcinomas. In each, the gene rearrangement is found in 80 % or more of cases. Two 2014 publications have added further possible candidates with molecular abnormalities to the list (cribriform adenocarcinoma of the tongue and minor salivary glands and epithelial-myoepithelial carcinoma), but these findings have yet to be confirmed by other investigators. The advances in molecular pathology have also allowed re-evaluation of the morphology; for example, it is now realised that the histological spectrum of hyalinising clear cell carcinoma includes intracellular mucin in over half of cases, as well as tumours with only scanty clear cells. In a separate development, it is now proposed that salivary duct carcinoma can be subdivided along molecular lines, in ways analogous to breast cancer, suggesting new therapeutic prospects in an otherwise highly aggressive malignancy.

The oncogenic role of androgen receptors in promoting the growth of oral squamous cell carcinoma cells

OBJECTIVES

The aims of this study were to examine the expression of androgen receptors (AR) in oral squamous cell carcinoma (OSCC) cells and tumors and to determine the role of AR in regulating OSCC cell growth.

MATERIALS AND METHODS

Four OSCC cell lines were used for analyzing AR expression and transcriptional activity. The effects of AR knockdown on the growth and tumorigenicity of OSCC cells were examined. A series of 11 benign, 22 premalignant, and 21 malignant lesions of the oral cavity were used for analyzing AR expression.

RESULTS

OSCC cells expressed AR proteins with differential activities. Stimulation of AR by dihydrotestosterone in OSCC cells caused an increase in cyclin D1 expression and promoted cell growth, whereas treatment with bicalutamide led to decreased cyclin D1 expression and inhibited cell growth. Knockdown of AR expression in OSCC cells resulted in decreased proliferation, increased apoptosis, and inhibited tumorigenicity. Results from immunohistochemical studies showed that AR immunoreactivity was found in 27% (3/11) of benign lesions, while 68% (15/22) of premalignant and 67% (14/21) of malignant lesions showed positive AR staining.

CONCLUSION

Our data suggest that OSCC cells express functional AR proteins which are critical for promoting cell growth and causing malignant disease.

Pleural fluid metastases of salivary duct carcinoma: A case report and review of the literature

Salivary duct carcinoma (SDC) comprises a small proportion of salivary gland tumors; however, it is known to be aggressive with a high rate of metastasis. Although frequent references are made to pulmonary dissemination, metastases in the pleural fluid have not been described. In this article, we report the cytologic features of metastatic SDC in the pleural fluid. The clinical history, cytomorphology and immunohistochemical features used for diagnosis are described. To the best of our knowledge, this is the first case of pleural fluid involvement by salivary duct carcinoma reported in the literature.

[Survival analysis and immunohistochemical study of HER-2 and AR (androgen receptor) expression in salivary duct carcinoma]

BACKGROUND

Because of its low incidence, the clinical characteristics of the salivary duct carcinoma (SDC) based on a statistical analysis with a large number of patients remain to be elucidated, and thus it has been impossible to standardize the optimal treatments of SDC including adjuvant systemic therapy.

AIMS

The present study aimed to determine the prognostic factors along with the clinical outcomes of patients with SDC and to evaluate the expression of several receptor molecules as treatment targets.

METHODS

We performed a statistical analysis and immunohistochemical examination of 16 patients with SDC who had undergone initial treatment in the Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine from 1996 to 2010.

RESULTS

The 3-year disease-free survival (DFS) and cause-specific survival (CSS) rates were 29.2% and 72.7%, respectively. At the time of the analysis, 6 patients are alive without the disease, 2 patients are alive with distant metastasis, whereas 7 patients had died of distant metastasis, and 1 patient had died of another cause (pulmonary embolism). We examined the prognostic value of the clinico-pathological factors such as age, sex, T classification, N classification, clinical stage, primary site, histological pre-existence of pleomorphic adenoma. A univariate analysis revealed that DFS was significantly correlated with age (p = 0.049), T classification (p = 0.018), and clinical stage (p = 0.029), whereas no factor was found to be correlated with CSS. A multivariate analysis demonstrated that age (> or = 61 vs. < or = 60, risk ratio (RR) = 5.423, p = 0.042) and T classification (3, 4 vs. 1, 2, RR = 1.087, p = 0.020) were the independent prognostic factors for DFS. Positive expressions of HER2, ER (estrogen receptor), PR (progesterone receptor), AR (androgen receptor), and MIB-1 (index > 20%) were found in 50%, 6%, 13%, 100%, and 69%, respectively. However, none of them showed significant correlation with survival.

CONCLUSION

Frequent expressions of HER-2 and AR in SDC suggest that these receptors can be suitable molecular targets of systemic therapy for patients with SDC in which distant metastasis seems to be the largest obstacle to improving survival. In order to assess the efficacy of anti-HER-2 therapy and anti-androgen therapy for each receptor-positive SDC, a multi-institutional joint research system should be organized.

An immunohistochemical panel for reliable differentiation of salivary duct carcinoma and mucoepidermoid carcinoma

Salivary duct carcinoma is a highly aggressive salivary gland malignancy that may be misdiagnosed as high-grade mucoepidermoid carcinoma. We utilized tissue microarrays with 78 examples of mucoepidermoid carcinoma and 47 salivary duct carcinomas to evaluate the utility of an immunohistochemical panel consisting of androgen receptor, Her2/neu, p63, and cytokeratin 5/6 in distinguishing these entities. Among all cases in the cohorts, androgen receptor was highly specific for salivary duct carcinoma, while cytokeratin 5/6 and p63 were specific for mucoepidermoid carcinoma. While the rate of unequivocal Her2/neu overexpression among the salivary duct carcinomas was low (8.9 %), discrimination of salivary duct carcinoma was enhanced when this marker was used in combination with androgen receptor due to profound sensitivity. The immunohistochemical panel was particularly efficacious at distinguishing the problematic subset of high-grade mucoepidermoid carcinomas from salivary duct carcinoma. Utilization of this set of immunohistochemical markers allows reliable differentiation of salivary duct and mucoepidermoid carcinoma, a distinction with important prognostic and therapeutic implications.

PIK3CA mutations and PTEN loss in salivary duct carcinomas

Salivary duct carcinoma (SDC) is an aggressive malignancy that frequently presents at an advanced stage. Mutations/amplification of the gene encoding the p110α catalytic subunit of phosphoinositide 3-kinase (PIK3CA) and/or loss of the phosphatase and tensin homolog (PTEN) are known to activate the phosphoinositide 3-kinase (PI3K) pathway and may represent a therapeutic target. In 7 of 34 SDCs (20.5%) a SNaPshot polymerase chain reaction detected PIK3CA exon 9 [p.E545K (n=3) and p.E542K (n=2)] or exon 20 [p.H1047R (n=2)] mutations. PIK3CA p.E545K mutation was identified in 3 de novo SDCs with conventional morphology. The only case of SDC with anaplastic transformation showed PIK3CA p.H1047R mutation, whereas 1 of 2 PIK3CA p.E542K mutations was identified in SDC arising in a pleomorphic adenoma. None of the 16 tested SDCs showed PIK3CA amplification by fluorescence in situ hybridization. Fluorescence in situ hybridization identified PTEN loss in 8 of 16 tested SDCs (50%) [homozygous deletion (n=3), chromosome 10 monosomy (n=3), hemizygous deletion (n=2)]. Two cases showed both PIK3CA mutation and PTEN loss, suggesting that these events are not mutually exclusive. These findings offer a molecular rationale for therapeutic targeting of the PI3K pathway in patients with SDC.

Definitive treatment of androgen receptor-positive salivary duct carcinoma with androgen deprivation therapy and external beam radiotherapy

BACKGROUND

Salivary duct carcinoma (SDC) is an aggressive malignancy with high recurrence rates. Standard management includes surgical resection followed by adjuvant radiation. Androgen receptor positivity has been described to be present in 40% to 90% of SDCs, and a recent case series showed a benefit to androgen deprivation therapy (ADT) in recurrent or metastatic disease.

METHODS AND RESULTS

We present the case of an 87-year-old woman with a locally advanced androgen receptor-positive parotid SDC treated definitively with ADT and external beam radiotherapy, a regimen modeled after the treatment of prostate cancer. She had a complete response on positron emission tomography (PET)/CT scan and had no evidence of disease 24 months after the completion of treatment.

CONCLUSION

To our knowledge, this case report is the first to describe the use of ADT plus radiation to definitively treat SDC. This regimen could be considered in patients with androgen receptor-positive SDCs who are considered unresectable or who refuse surgery.

Salivary duct carcinoma: new developments--morphological variants including pure in situ high grade lesions; proposed molecular classification

Salivary duct carcinoma (SDC) is an aggressive primary salivary malignancy which microscopically resembles high-grade ductal carcinoma of the breast, with both in situ and invasive patterns. It is typically found in older men, most often in the parotid. It can arise de novo or as the malignant component of carcinoma ex pleomorphic adenoma. SDC is generally a hematoxylin and eosin stain-based diagnosis, with special stains and immunohistochemistry acting mainly in a confirmatory role. Other than epithelial markers, SDC expresses androgen receptors in most cases, with true HER2 positivity seen in about 15 %. Based on these data and analogous to similar schemes in the breast, it is suggested that SDCs can be classified into three main groups: luminal androgen receptor positive, HER2+ and basal phenotype. This may form the basis for prognostic information and new therapeutic possibilities. In addition to the usual type of SDC, a few less common morphological variants have been reported: papillary, micropapillary, mucin-rich, sarcomatoid and oncocytic, as well as pure in situ cases.

A mucin-rich variant of salivary duct carcinoma with a prominent mucinous component, a tumor that mimics mucinous adenocarcinoma

The mucin-rich variant of salivary duct carcinoma (mSDC) is a rare type of salivary duct carcinoma. mSDC usually has both conventional SDC and mucinous adenocarcinoma-like areas. This article describes a first case of mSDC in which 95% of the tumor consisted of a mucinous area without no solid conventional SDC, so that the tumor mimicked mucinous adenocarcinoma. A 55-year-old man was evaluated for a 14 mm mass in the left submandibular gland. The tumor showed that floating tumor nests in a prominent mucinous lake. Some floating tumor nests had focal cribriform pattern with comedo necrosis, and all tumor cells had immunoreactivity for androgen receptor, gross cystic disease fluid protein 15, and Her-2/neu. A diagnosis of mSDC was rendered. mSDC with prominent mucinous component sometimes resembles mucinous adenocarcinoma. Identifying specific histological and immunohistochemical features of floating tumor nests in the mucinous area are important for the diagnosis.

Takahashi R, Nagai T, Yoshida M, Suzuki F, Obikane H, Yamashina M, Matsubayashi J. Immunohistochemical analysis of salivary gland tumors: application for surgical pathology practice

Salivary gland tumors are relatively uncommon and there exists a considerable diagnostic difficulty owing to their diverse histological features in individual lesions and the presence of a number of types and variants, in addition to overlapping histological patterns similar to those observed in different tumor entities. The classification is complex, but is closely relevant to the prognostic and therapeutic aspects. Although hematoxylin-eosin staining is still the gold standard method used for the diagnosis, immunohistochemistry (IHC) can enhance the accuracy and be a helpful tool when in cases to investigate the subjects that cannot be assessed by histological examination, such as the cell nature and differentiation status, cell proliferation, and tumor protein expression. This review depicts on the practical diagnostic utility of IHC in salivary gland tumor pathology under the following issues: assessment of cell differentiation, focusing on neoplastic myoepithelial cells; discrimination of histologically mimic tumor groups; diagnosis of specific tumor types, e.g., pleomorphic adenoma, adenoid cystic carcinoma, and salivary duct carcinoma; and evaluation of malignancy and prognostic factors. IHC plays a limited, even though important, role in the diagnosis of salivary gland tumors, but is often useful to support the histological assessment. However, unfortunately few tumor type-specific markers are still currently available. For these reasons, IHC should be considered a method that can be used to assist the final diagnosis, and its results themselves do not directly indicate a definitive diagnosis.

Salivary gland carcinomas

INTRODUCTION

Salivary gland carcinomas are rare tumours of heterogeneous morphology that require distinctive surgical and adjuvant therapy.

METHODS

Relevant studies were electronically searched in PubMed and reviewed for innovative and important information.

RESULTS

Recent insights in genetic alterations like chromosomal aberrations, expression of receptor tyrosine kinases, malfunction of tumour suppressor genes or DNA promoter methylations increased the knowledge about aetiology and pathogenesis. New histological subtypes are recognised, and a three-tiered grading system seems reasonable. Ultrasound remains the basic diagnostic imaging procedure. New developments comprise the diffusion-weighed magnetic resonance imaging, while fluorodeoxyglucose positron emission tomography/computed tomography shows good diagnostic accuracy in detecting distant metastases and local recurrence. Fine-needle aspiration cytology helps in differentiating a neoplasia from a non-neoplastic lesion while being unreliable in recognising malignancy. In contrast, additional core needle biopsy and/or intraoperative frozen section diagnosis increase the accuracy in diagnosing a malignant lesion. Conservative parotid surgery with nerve monitoring remains state-of-the-art. Free flaps or musculoaponeurotic flaps are proposed for prevention of Frey's syndrome. As parotid cancer often shows skip metastases, complete ipsilateral neck dissection (level I-V) is indicated particularly in high-grade lesions. Adjuvant radio(chemo)therapy increases local tumour control, whereas overall survival is not necessarily improved. Current results of systemic chemotherapy or targeted therapy in advanced tumour stages are disappointing.

CONCLUSION

Despite several developments, salivary gland carcinomas remain a heterogeneous group of tumours challenging both pathologists and clinicians.

Invasive salivary duct carcinoma ex pleomorphic adenoma of the parotid gland: a teaching case giving rise to the genuine diagnostic difficulty on an inadequate cytology specimen

A history of a recent rapid increase in long-standing swelling mass was presented in the right parotid gland of an 85-year-old male. The inadequate cytologic specimens contained few small clusters of three-dimensional malignant epithelial cells having hyperchromatic pleomorphic nuclei and prominent nucleoli, adjacent to a cluster of benign monomorphic myoepithelial cells. We first interpreted it merely as an adenocarcinoma, not otherwise specified. A radical parotidectomy was performed, and gross examination revealed an encapsulated and firm tumor lesion, looking grayish-blue to yellowish-white, focally associated with extracapsular invasion. On microscopic examination, the tumor was predominantly composed of a proliferation of highly atypical epithelial cells having abundant eosinophilic cytoplasm, often arranged in a Roman-bridge appearance with foci of comedo necrosis, alternating with extensive infiltration to adjacent stroma in a trabecular or alveolar fashion with severe vessel permeation. Within the background of pleomorphic adenoma, the carcinoma cells sometimes replaced ductal luminal cells while retaining an intact-like myoepithelial layer. Therefore, we finally made a diagnosis of invasive salivary duct carcinoma ex pleomorphic adenoma. We should be aware that owing to its characteristic features, cytopathologists might be able to determine correct diagnosis, based on multiple and adequate samplings.

VIRTUAL SLIDES

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/2126158270695815.

Management and outcome of salivary duct carcinoma in major salivary glands

Salivary duct carcinoma (SDC) is a rare and aggressive malignancy with poor prognosis. Its histomorphology is distinctly reminiscent of the ductal carcinoma of the breast. We reviewed the treatment and outcome of SDCs at a single tertiary care centre. Twenty-five cases of SDC of major salivary gland origin, diagnosed and treated at the Department of Otolaryngology, Head and Neck Surgery, Helsinki University Central Hospital, Helsinki, Finland, during a 14-year period from 1997 to 2011, were reviewed retrospectively. Survival outcome was analyzed for 18 patients with a minimum follow-up of 24 months. There were 16 male (64 %) and 9 female (36 %) patients with a median age of 61 years (range 36-82 years). The majority of the cases occurred in the parotid gland (n = 21, 84 %) followed by the submandibular gland (n = 4, 16 %). The primary treatment consisted of surgical resection in all cases and 17 (68 %) patients also underwent neck dissection. Most of the patients (n = 18, 72 %) were treated with postoperative radiotherapy. Seven patients (28 %) had a disease recurrence within a median follow-up time of 15 months (range 3-27 months). In the group (n = 18) with a minimum follow-up time of 24 months, the 2- and 5-year overall and disease-specific survival rates were 66, 41 % and 75, 55 %, respectively. These results confirm the aggressive nature of SDCs in major salivary glands. Diagnostics and management of these tumours need to be centralized in experienced surgical Head and Neck Oncology Centres, and new treatment strategies should be investigated.

Common Malignant Salivary Gland Epithelial Tumors

Malignant salivary gland epithelial tumors are histologically diverse with at least 24 recognized distinct entities. In general, malignant tumors account for 15% to 30% of parotid tumors, 40% to 45% of submandibular tumors, 70% to 90% of sublingual tumors, and 50% of minor salivary tumors. Common malignancies include mucoepidermoid carcinoma, adenoid cystic carcinoma, acinic cell carcinoma, salivary duct carcinoma, carcinoma ex pleomorphic adenoma, polymorphous lowgrade adenocarcinoma, and myoepithelial carcinoma. Each tumor type has its own unique histologic variants and prognostic pathologic features, and only mucoepidermoid carcinomas have a formalized grading system. The molecular pathogenesis of certain tumors, such as mucoepidermoid carcinoma and adenoid cystic carcinoma, has recently begun to be elucidated.

Metastasis of occult prostatic carcinoma to the sphenoid sinus: report of a rare case and a review of the literature

We present a case (55-year-old) with a metastasis to the sphenoid sinus from an occult prostatic adenocarcinoma as the first evidence of disease. The patient's symptoms were progressive left-sided headache of a few months duration and a 2-week history of blurred vision with diplopia. Clinical examination revealed a left cranial nerve III palsy and ptosis. A computed tomography scan showed a 2 cm large, well delineated soft tissue lesion involving the left sphenoid sinus and extending to the left cavernous sinus with sclerosis of the adjacent sphenoid bone. Histological and immunohistochemical examinations revealed a poorly differentiated adenocarcinoma that was positive for prostate specific antigen (PSA) and broad-spectrum cytokeratins (Cam 5.2). Subsequent urological examination confirmed a locally advanced prostatic carcinoma with significantly increased serum-PSA (4,561 μg/l) and bone scintigraphy showed widespread metastasis.

Low-Grade Cribriform Cystadenocarcinoma of the Parotid Gland: A Neoplasm With Favorable Prognosis, Distinct From Salivary Duct Carcinoma

Low-grade cribriform cystadenocarcinoma of salivary glands is a recently described rare tumor with favorable prognosis. This study reports the case of 50-year-old woman with swelling lasting for 9 months in the right parotideomasseteric area. Grossly, the tumor was well circumscribed and dominated by cystic space. Microscopically, the neoplasm consisted of well-demarcated islets, some of them cystically dilated. The architecture of islets varied from solid to cribriform and micropapillary without comedo-type necroses. The tumor cells featured no significant cytologic atypia. Immunohistochemically, luminal cells showed expression of cytokeratins (CK), CK7, CK18, and S100 protein. In addition, immunostains for CK5/6, CK14, p63 protein, and smooth muscle actin displayed a continuous rim of myoepithelial cells around all tumor nests. In contrast, detection of CK20, hormonal receptors (androgen, estrogen, and progesterone), epidermal growth factor receptor and Her-2/neu oncoprotein was negative. The patient is free of disease for 2 years. The relationship between low-grade cribriform cystadenocarcinoma and salivary duct carcinoma is discussed.

[Primary ductal adenocarcinoma near the orbit]

The case of a 59-year-old patient is described who presented with a left-sided pressure sensation in the left orbit and exophthalmus with a proud bulbus. The limited bulbus motility led to double vision. A preoperative MRI showed a space-occupying lesion in the left medial orbit. The morphological and immunohistochemical findings led to the diagnosis of a primary ductal carcinoma resembling salivary duct carcinoma (SDC). The tumor could be removed without compromising the eye. The patient suffers no side-effects or recurrences 12 months later.

Expression of mitotic checkpoint proteins BUB1B and MAD2L1 in salivary duct carcinomas

OBJECTIVE

Defects in the mitotic checkpoint lead to aneuploidy and might facilitate tumorigenesis. However, the ploidy status in salivary duct carcinoma (SDC) has been reported to play limited role in prediction of prognosis. Thus, we need more reliable markers to reflect the rapid tumor progression in SDCs. We aimed here to investigate the expression of mitotic checkpoint proteins benzimidazole 1 homolog beta (BUB1B) and mitosis arrest-deficient 2 like 1 (MAD2L1) in SDCs and to determine their possible role as surrogate prognostic markers.

METHODS

We analyzed the clinical courses, pathologic findings and immunohistochemical profiles of mitotic checkpoint proteins (BUB1B and MAD2L1) in 27 pathologically confirmed SDCs. The expression status of BUB1B and MAD2L1 was compared with clinicopathologic factors and other molecular markers, such as TGF-beta, c-erb-B2, androgen receptor, vascular endothelial growth factor, and epidermal growth factor receptor, for prognostic significance.

RESULTS

High BUB1B expression was detected in 25.9% of subjects, and high MAD2L1 expression was in 55.6% of subjects. However, survival analysis revealed that mitotic checkpoint expression did not have prognostic significance in SDCs, nor did the other studied markers. Rather, the clinical variable of N classification at diagnosis (in N+ status, hazard ratio 5.19, 95% CI 1.26-21.32 for disease-free survival and hazard ratio 7.18, 95% CI 1.09-46.99 for overall survival) was strongly associated with survival and prognosis based on the Cox proportional hazard model.

CONCLUSIONS

Mitotic checkpoint proteins appeared to play a limited role in predicting prognosis in SDCs. Further study is required to elucidate the exact role of mitotic checkpoint proteins in SDCs.

Update on selected salivary gland neoplasms

CONTEXT

Malignancies of the salivary gland are uncommon and account for 0.3% of all malignancies. In addition to their rarity, diagnosing these tumors can be challenging given the histologic overlap among various subtypes, their morphologic heterogeneity, and the recent recognition of new entities.

OBJECTIVE

To provide an overview of 4 salivary gland malignancies that we often see in consultation, with a focus on essential diagnostic features and the importance of reporting pertinent diagnostic information to ensure appropriate clinical management.

DATA SOURCES

Review of the literature, supplemented by the personal experience of the authors, which is based on their respective institutional experiences and consultation services.

CONCLUSIONS

When diagnosing carcinoma ex pleomorphic adenoma, pathologists must report several important pieces of information to allow for optimal clinical management. In addition to histologic subtype, the degree of differentiation as well as the degree of invasion, if any, must be reported because all have prognostic relevance. Polymorphous low-grade adenocarcinoma can be a challenging diagnosis on biopsy specimens. Evaluation of the tumor periphery and nuclear features should lead to the correct diagnosis in most cases. Salivary duct carcinoma is an aggressive malignancy characterized by histologic resemblance to breast carcinoma, high-grade cytologic features, and expression of androgen receptor. Benign and malignant myoepithelial neoplasms have a broad morphologic spectrum, and immunohistochemistry is important in reaching the correct diagnosis.

Dedifferentiated Epithelial-Myoepithelial Carcinoma of the Parotid Gland With Aberrant Expression of Prostate Specific Antigen: A Case Report

This report describes a rare case of dedifferentiated epithelial—myoepithelial carcinoma (EMCa) of the parotid gland. The tumor had 2 distinct components; a well-differentiated EMCa comprising of ductal and myoepithelial cells with low nuclear grade and low proliferation index. The second component showed a completely different morphology comprising of sheets and clusters of poorly differentiated cells with high nuclear grade and proliferative activity. The dedifferentiation was associated with an accelerated clinical course. Dedifferentiated EMCa is extremely rare with only 8 cases reported in the English literature. An unusual feature, hitherto not described in this tumor is the aberrant expression of prostate-specific antigen in the dedifferentiated component. In male patients, this may cause diagnostic confusion with metastatic prostate carcinoma.

Salivary duct carcinoma in situ of the parotid gland

AIMS

To describe three cases of purely in situ salivary duct carcinoma, so as better to define the entity.

METHODS AND RESULTS

Three primary tumours of the parotid gland are presented, in each case composed of cysts and ducts and lined by high nuclear grade epithelial cells. All parts of each tumour were surrounded by a myoepithelial cell rim and there was no evidence of invasion. The tumour cells expressed immunohistochemical markers seen in invasive salivary duct carcinoma of usual (high-grade) type. In two cases the androgen receptor (AR) reaction was strong, but there was no immunohistochemical expression of HER2 protein or gene amplification by in situ hybridization. In the remaining case, fewer nuclei stained for AR, but both HER2 protein and gene amplification were demonstrated.

CONCLUSIONS

Salivary duct carcinoma in situ is morphologically similar to breast ductal carcinoma in situ and, although our cases are few, salivary duct carcinoma in situ can possibly be subdivided into luminal and non-luminal cell types, as can analogous mammary neoplasms. The present study cannot determine whether low-grade cribriform cystadenocarcinoma, architecturally similar but immunohistochemically different, is part of the spectrum of salivary duct carcinoma in situ, or whether it represents a separate entity.

Immunohistochemical evaluation of androgen receptor, HER-2/neu, and p53 in benign pleomorphic adenomas

CONTEXT

Immunohistochemical stains for androgen receptor (AR), HER-2/neu, and p53 are used as diagnostic markers associated with malignancy in several histologic types of salivary gland tumors. These markers may be useful in differentiating pleomorphic adenoma with cytologic atypia from intracapsular carcinoma ex pleomorphic adenoma (CXPA), as these tumors are often difficult to distinguish on the basis of morphology alone.

OBJECTIVE

To determine whether AR, HER-2/neu, and p53 expression can be seen in entirely benign pleomorphic adenomas.

DESIGN

Androgen receptor, HER-2/neu, and p53 immunoreactivity was assessed in 41 histologically and clinically benign pleomorphic adenomas.

RESULTS

A total of 3 of 41 pleomorphic adenomas exhibited multifocal areas with moderate staining for HER-2/ neu and AR. The positive staining was mainly confined to the epithelial component, where the ductal epithelium showed no cytologic atypia. Immunoreactivity for p53 was observed in the epithelial component of 5 of 41 cases, none of which stained for HER-2/neu and AR. Mean mitotic rate and Ki-67 index were 1 per 10 high-powered fields and 2.7% in HER-2/neu- and AR-positive cases and 1 per 10 high-powered fields and 2.2% in p53-positive cases.

CONCLUSIONS

HER-2/neu, AR, and p53 are expressed in a subset of histologically and clinically benign pleomorphic adenomas. These markers cannot be used to reliably predict early carcinomatous transformation in pleomorphic adenoma.

Cribriform carcinoma of the gallbladder: a clinicopathologic study of 7 cases

Carcinomas of the gallbladder are morphologically heterogeneous. Some are similar or mimic carcinomas that commonly arise in other organs and therefore can be confused with metastatic lesions. We report here the clinicopathologic features of 7 cribriform carcinomas of the gallbladder that resemble cribriform carcinomas of the breast. Five patients were women and 2 men whose ages ranged from 31 to 72 years (average age 57 y). These 7 patients were younger than those with conventional adenocarcinomas of the gallbladder (average age for males 71 y and average age for females 72 y). Five patients had cholelithiasis. The youngest patient, a 31-year-old woman, had no gallstones. Instead, she had an osteosarcoma removed from her distal femur, 4 years before. Although the osteosarcoma in this patient may be coincidental, a true association could not be entirely excluded. None of the 4 cribriform carcinomas of the gallbladder tested showed immunoreactivity for estrogen and progesterone receptors. Three patients with high nuclear grade cribriform carcinomas died as a result of the tumor which infiltrated the liver by direct extension; 3 patients with low nuclear grade cribriform carcinomas confined to the gallbladder wall survived 4 to 7 years after cholecystectomy and 1 patient was lost to follow-up. In conclusion, this study provides support to previous observations that a small proportion of gallbladder carcinomas display an unusual but predominant cribriform pattern similar to that of some invasive breast carcinomas. In contrast to mammary cribriform carcinomas, those arising in the gallbladder occur in individuals usually with gallstones, may coexist with skeletal osteosarcoma, lack estrogen and progesterone receptors, and behave aggressively like conventional adenocarcinomas of the gallbladder.

Prognostic values of pathologic findings and hypoxia markers in 21 patients with salivary duct carcinoma

BACKGROUND

Salivary duct carcinoma (SDC) is associated with aggressive clinical behavior.

METHODS

We examined the prognostic values of clinicopathologic variables and hypoxia biomarker expression in 21 patients with SDC treated by resection with/without neck dissection and radiotherapy. Tissue microarrays constructed from tumor blocks were stained with monoclonal antibodies to hypoxia-inducible factor (HIF)-1alpha, HIF-2alpha, carbonic anhydrase-9, glucose transporter-1, and erythropoietin receptor. Locoregional control and survival rates were calculated by the Kaplan-Meier method and prognostic factors were calculated from uni- and multivariate analyses.

RESULTS

The cervical nodal metastasis rate was 67% at initial diagnosis and the distant metastasis rate was 71% during follow-up. The only significant predictor of distant metastasis was nodal metastasis (P = 0.006). Actuarial 5-year locoregional control, distant metastasis-free survival, and overall survival rates were 57%, 40%, and 44%. Multivariate analysis showed that lymphovascular and perineural invasion and radiotherapy were independent predictors of overall survival (P < 0.025). None of the hypoxia biomarkers, however, was a significant predictor of locoregional control, distant metastasis, or survival.

CONCLUSIONS

Lymphovascular and perineural invasion, but not hypoxia biomarkers, were significant prognostic factors for patients with SDC.

Salivary gland cancers: current treatments, molecular characteristics and new therapies

Salivary gland cancers are relatively rare and quite diverse. Current therapy relies on local ablation. There are few large clinical trials or randomized trials to guide treatment, especially for metastatic disease. This article reviews the epidemiology, staging, molecular characteristics, and treatment evidence for the most common types of salivary cancers and suggests potential future diagnostic and treatment directions. Progress in understanding the molecular and cell biology of salivary gland cancers may lead to the development of targeted therapies in these rare tumors. Multidisciplinary and multi-institutional collaborative studies are needed to help improve survival in salivary gland cancers.

Her-2/neu expression in salivary duct carcinoma: an immunohistochemical and chromogenic in situ hybridization study

Salivary duct carcinoma (SDC) shares significant morphologic and immunophenotypic overlap with ductal carcinoma of the breast, including HER-2/neu expression. Previous studies have detected HER-2/neu at the protein level in SDCs; however, no study, to date, has assayed whether this expression is related to gene amplification detected by chromogenic in situ hybridization (CISH). Formalin-fixed, paraffin-embedded tissue sections from 12 previously diagnosed SDCs were evaluated by immunohistochemistry (IHC) and CISH for HER-2/neu status. Result concordance was seen in all 12 cases. A total of 4 SDCs were positive by IHC; all 4 cases showed amplification with CISH. The remaining 8 cases were negative by IHC and showed no gene amplification with CISH. SDCs in this study show HER-2/neu overexpression on both the protein and gene levels in approximately 30% of cases. These findings suggest a role may exist for Herceptin (trastuzumab) based therapy in some SDC patients.

Salivary duct carcinoma: a clinical and histologic review with implications for trastuzumab therapy

BACKGROUND

Salivary duct carcinoma (SDC) is an aggressive tumor of the head and neck with a poor prognosis. The objective was to study SDC and recommend the use of trastuzumab as adjuvant therapy.

METHODS

A retrospective chart review of patients seen between 1993 and 2006 was performed. Tumor specimens were examined for HER-2 protein overexpression via immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) methods.

RESULTS

Of the 7 patients with SDC, 57% had tumors arising in the parotid gland, the majority having facial nerve paralysis, 71% with nodal disease, and 43% having recurrence. All samples were HER-2 positive on IHC. Three patients had FISH-positive tumors, recurrent disease, and received trastuzumab therapy; 1 of the 3 died after 20 months and a second has shown disappearance of metastatic disease.

CONCLUSIONS

Trastuzumab is effective in treating HER-2-positive breast cancer. Given immunohistochemical similarities between SDC and ductal carcinoma of the breast, patients with FISH-positive HER-2/neu SDC should be considered for trastuzumab therapy.

Differential expression of hormonal and growth factor receptors in salivary duct carcinomas: biologic significance and potential role in therapeutic stratification of patients

Salivary duct carcinoma (SDC), a rare malignancy, manifests remarkable morphologic and biologic resemblance to high-grade mammary ductal carcinoma. We contend that, similar to mammary ductal carcinoma, hormones and growth factors may play a role in SDCs. Our aim was to determine the incidence and clinical significance of the expression of several hormone and growth factor receptors and evaluate their potential in therapeutic stratification of SDC patients in the largest cohort studied to date. Eighty-four archived tumor tissue blocks were analyzed immunohistochemically for expression of estrogen receptor-beta (ERbeta), androgen receptor (AR), and proline, glutamic acid, and leucine-rich protein-1 and growth factor receptors HER-2 and epidermal growth factor receptor. The results were correlated with available pathologic, demographic, and clinical data from 59 of 84 cases. Proline, glutamic acid, and leucine-rich protein-1, ERbeta, and AR were expressed individually in 94% (71/76), 73% (57/80), and 67% (56/84) of SDCs, respectively, and coexpressed in 45% (34/75). AR was expressed significantly more often in SDCs of men than in SDCs of women [79% (35/57) vs. 33% (9/27), P<0.001]. Epidermal growth factor receptor and HER-2 were overexpressed individually in 48% (40/83) and 25% (21/84), respectively, and co-overexpressed in 12% (10/83). Survival decreased significantly in patients with lymph node metastasis (P=0.002) and positive surgical margins (P=0.006). Lack of ERbeta expression correlated with increased local and regional recurrence (P=0.05 and P=0.002, respectively). Together, these results indicate that (a) ERbeta down-regulation is associated with adverse clinical features, (b) lymph node and surgical margin status are significant survival factors, and (c) the differential expression of these hormones and growth factor receptors may assist in triaging patients with SDC for novel therapies.

Distinguishing prostatic from colorectal adenocarcinoma on biopsy samples: the role of morphology and immunohistochemistry

CONTEXT

Poorly differentiated carcinoma on prostate or colorectal biopsy can occasionally present a diagnostic challenge in determining tumor source especially in locally advanced colorectal carcinoma (CRCa) or prostate carcinoma (PCa). Such determination can affect prognosis and therapy.

OBJECTIVE

To evaluate the role of morphology and immunohistochemistry in the previously mentioned setting.

DESIGN

Surgical pathology and consultation records. Hematoxylin-eosin sections were reviewed in 16 cases (11 PCa, 5 CRCa). Immunohistochemistry for 9 markers was performed in 15 cases.

RESULTS

Dirty necrosis, seen in 5 (100%) of 5 CRCa and 2 (18%) of 11 PCa cases, and the presence of columnar cells with basal nuclei, seen in 5 (100%) of 5 CRCa and 1 (9%) of 11 PCa cases, appear to be the most useful morphologic parameters. Immunohistochemistry confirmed the value of prostate-specific antigen (PSA), CDX2, cytokeratin (CK) 20, and beta-catenin in the differential of CRCa (0% PSA+, 60% CDX2+, 80% CK20+, and 100% beta-catenin+) versus PCa (80% PSA+, 0% CDX2+, 10% CK20+, and 0% beta-catenin+). P501S had a similar sensitivity as PSA in detecting PCa (80%). Two (20%) of 10 PCa cases were positive for 1 of the 2 markers but not the other. P501S was negative in all 5 cases of CRCa.

CONCLUSIONS

P501S is a useful marker in this setting when included together with PSA, CDX2, CK20, and beta-catenin. P501S labels a subset of PCa cases that are negative for PSA. Dirty necrosis and/or columnar cells with basal nuclei could also be of help.

Tubulo-squamous Polyp

We report 10 cases of a morphologically distinct vaginal polyp which has hitherto not been characterized. The polyps occurred in women aged 39 to 78 years (most were postmenopausal) and were from 1.0 to 3.0 cm. Most of whose location is known to us were in the upper vagina. Histologically, all the polyps were remarkably similar and composed of well-circumscribed expansile nests of epithelial cells embedded in a hypocellular fibrous stroma. The epithelial elements, which were morphologically bland, were predominantly glycogenated or nonglycogenated squamous in type but small tubules were present at the periphery of some of the nests in all cases. Some of the squamous nests exhibited central necrosis with or without calcification and, in 3 cases, some contained keratin pearls. In 3 cases, a few tubules unassociated with squamous elements were present. In 3 of 4 cases tested, the cells lining the tubules were positive with prostatic acid phosphatase and in 2 of 4 with prostate-specific antigen. The epithelial elements reacted with broad-spectrum cytokeratins and cytokeratin 7 but the mesenchymal component was negative. The squamous elements were estrogen receptor positive and the mesenchymal component estrogen and progesterone receptor positive. The histologic features of this polyp, which we term "tubulo-squamous polyp of the vagina," are constant and distinctive and differ from other polyps and from mixed tumor of the vagina. Several cases reported in the literature as vaginal mixed tumor or Brenner tumor are likely examples of this entity. Possible theories of histogenesis include a Mullerian origin, derivation from mesonephric remnants or derivation from urogenital sinus-derived epithelium. Positive staining in some cases with prostatic acid phosphatase and prostate-specific antigen raises the possibility of ectopic prostatic tissue, although the overall appearance is different from that entity, or derivation from paraurethral Skene glands, the female equivalent of prostatic glands in the male.

Carcinoma ex pleomorphic adenoma of the salivary gland: an immunohistochemical study

The proliferative activity of the tumor cells and the expression of tumor-associated genes and sex steroid hormone receptors were investigated immunohistochemically in ten cases of carcinoma ex pleomorphic adenoma (Ca-ex-PA) of the salivary glands. These were analyzed in benign and malignant components separately, and then were compared with ten cases of the other malignant tumors [adenocarcinomas, not otherwise specified (ACN) and salivary duct carcinomas (SDC)] and ten cases of pleomorphic adenomas (PA). The results obtained in this study were as follows: (1) malignant component of Ca-ex-PA showed a higher incidence of PCNA and Ki67 than benign component of Ca-ex-PA. A significant difference between benign component of Ca-ex-PA and PA was not observed. (2) A significant difference in the incidence of p53, c-erbB-2, EGFR overexpression was observed only between malignant component of Ca-ex-PA and benign component of Ca-ex-PA. (3) The incidence of PCNA, Ki67, p53, c-erbB-2 overexpression in malignant component of Ca-ex-PA showed the highest data among the four groups. These results suggest that Ca-ex-PA acquired the particular biological behavior in contrast to the other salivary neoplasms in the long-standing process while PA undergoes malignant transformation.

Rak przewodowy gruczołów ślinowych (salivary duct carcinoma) – charakterystyka kliniczna i patologiczna 5 przypadków

The 5 cases of salivary duct carcinoma (SDC); very rare, but distinct group of highly malignant salivary gland tumor are presented, and difficulties with pathological and clinical diagnosis is discussed. The SDC developed in single cases in parotid salivary gland, submandibular salivary and in mucosa of maxillary sinus, pyriform fossa and oral cavity (check). In 3 cases the second malignant tumor was present--synchronously (SDC + pleomorphic adenoma in parotid gland; SDC + squamous cell carcinoma in hypopharynx) or metachroneously (squamous cell carcinoma of upper lip followed by SDC). In one case the high levels of PSA suggesting of metastases from unknown primary within the prostate gland, or PSA expression related to SDC was observed. The four patients received radical treatment - surgical resection followed by radiotherapy; in one case only palliative treatment was applied, due to patient's poor general condition and high advancement of the primary disease. The observation ranged from 10 to 77 months (average time--31 months). The one patient died 13 months after diagnosis and palliative treatment. The three patients are alive with distant metastases to the lung and bones (77, 38 and 18 months after primary treatment was completed). Only one patient with 10 months observation after treatment is living without symptoms of recurrence or metastases.

Androgen receptor expression in metastatic adenocarcinoma in females favors a breast primary

Background

The differential diagnosis of metastatic mammary adenocarcinoma and adenocarcinomas from other primary sites can be challenging, particularly in tumors that are poorly differentiated and negative for Estrogen/Progesterone receptors (ER/PR). With progression of disease, Androgen receptors (AR) are preserved with higher frequency than ER/PR in metastatic mammary carcinoma. This study was undertaken to evaluate the diagnostic significance of AR expression in adenocarcinoma of breast and other morphologically similar adenocarcinomas.

Design

Formalin-fixed paraffin-embedded tissue sections of 113 primary adenocarcinoma of various sites [breast (34, all females), lung (23, M- 6, F-17), colon (9, M-2, F-7), stomach (6, M-4, F-2), liver and bile duct (11, M-5, F-6), pancreas (7, M-2, F-5), ovary (10), endometrium (7), and cervix (6)] were immunostained with monoclonal antibody for AR. Except for well differentiated lobular carcinoma of breast (5) and bronchoalveolar carcinoma of lung (10), majority of the tumors were moderately to poorly differentiated. Tumors immunoreactive for ≥ 10% of nuclei were considered AR positive. However, AR immunoreactivity in the cytoplasm only was also recorded.

Results

56% (19/34) mammary carcinoma and 20% (2/10) adenocarcinoma of ovary were positive for AR. Remaining 69 adenocarcinomas did not show nuclear immunoreactivity for AR in ≥ 10% nuclei; however, 52% (36/69) showed variable cytoplasmic immunoreactivity.

Conclusion

Significant proportion of mammary carcinomas and some ovarian carcinomas express AR in the nuclei of more than 10% tumor cells. If metastatic tumor with unknown primary in a female is AR positive, breast and ovary are the most likely primary sites. Cytoplasmic immunoreactivity alone without nuclear immunoreactivity for AR was non-specific for this differential diagnosis.

Systemic therapy in the palliative management of advanced salivary gland cancers

Cancers of the salivary glands are unusual lesions that vary widely in their histologic appearance and molecular characteristics. Likewise, there is a wide spectrum of biologic behavior, ranging from low-grade, minimally invasive tumors, to highly lethal malignancies. There are few data on the role of systemic therapies in the management of these cancers, and chemotherapy is generally reserved for the palliative management of advanced disease that is not amenable to local therapies such as surgery and/or radiation. The majority of patients for whom systemic therapy is considered will have either adenoid cystic carcinoma, mucoepidermoid carcinoma, or high-grade adenocarcinoma. This article will review the available literature regarding the use of palliative chemotherapy for patients with advanced salivary gland cancer of these histologies, with an emphasis on the potential role of targeted agents. There is a need for a determined, coordinated effort to conduct high-quality clinical trials in patients with these rare cancers.

Immunoreactivity for Sex Steroid Hormone Receptors in Pulmonary Hamartomas

Sex steroid hormone [ie, estrogen (ER), progesterone (PgR), and androgen (AR)] receptors have been identified previously in normal salivary glands and, more variably, in salivary gland and salivary gland-type tumors. No data are available, however, on their expression in pulmonary hamartoma, a benign biphasic tumor consisting of reactive epithelial cells and neoplastic fibromyxoid stroma, cartilage and fat, which shares some morphologic, immunophenotypic, and genotypic features to pleomorphic adenoma of major salivary glands. Thirty pulmonary hamartomas (15 in male patients and 15 in age-matched female patients), were evaluated for ER, PgR, and AR immunoreactivity, and also for mesenchymal, epithelial, and myoepithelial markers, in the fibromyxoid, epithelial, and chondroid components. ER immunoreactivity was encountered in 90% of hamartomas, PgRs in 90%, and ARs in 53% (P<0.001), but not in normal lung tissues. ARs were confined to males (P<0.001), with a marginal prevalence in the fibromyxoid component (P=0.067). PgRs and ERs were instead present in both sex, with the former being restricted to the fibromyxoid stromal component (P<0.001) and the latter preferentially located in epithelial cells (P=0.107). In most cases, fibromyxoid stroma and spindle cells surrounding the chondroid foci displayed simultaneous immunoreactivity for ERs, PgRs, and ARs, along with immunoreactivity for vimentin, S-100 protein, glial fibrillary acid protein, smooth muscle actin, and calponin but lack of staining for cytokeratins. This profile is consistent with an incomplete myoepithelial differentiation of the receptor-expressing mesenchymal cells. In conclusion, sex steroid hormone receptor expression is a nonrandom event in pulmonary hamartoma, and may be related to the development and growth of this tumor.

Diagnostic utility of immunohistochemistry in morphologically difficult prostate cancer: review of current literature

Varma M & Jasani B (2005) Histopathology47, 1-16 Diagnostic utility of immunohistochemistry in morphologically difficult prostate cancer: review of current literatureImmunohistochemistry is widely used to distinguish prostate cancer from benign mimics and to establish the prostatic origin of poorly differentiated carcinoma. We critically review the recent advances in prostate cancer immunohistochemistry, including the introduction of newer basal cell markers such as p63 and the discovery of the overexpression of alpha-methylacyl coenzyme A racemase (AMACR) in prostate cancer. The description of newer urothelial markers to aid the distinction of prostate cancer from urothelial carcinoma is also presented together with refinements in the quality control of PSA and PSAP immunostaining. Although AMACR is a useful immunohistochemical marker for prostate cancer, it has significant limitations. These limitations are discussed and the need for interpreting AMACR immunoreactivity in the appropriate morphological context and in conjunction with basal call markers is emphasized. We also describe the utility of an immunohistochemical panel composed of PSA, PSAP and high molecular weight cytokeratin for distinguishing poorly differentiated prostate cancer from high-grade urothelial carcinoma. A morphological differential diagnosis based selection of immunohistochemical markers is highlighted as a novel approach in the diagnosis of prostate cancer in routine surgical pathology practice.

Novel estrogen receptor coactivator PELP1/MNAR gene and ERβ expression in salivary duct adenocarcinoma: potential therapeutic targets

Salivary duct carcinoma (SDC) is a high-grade neoplasm with marked morphological resemblance to mammary duct carcinoma. The novel estrogen receptor (ER)-interacting protein and the proline-, glutamic acid-, and leucine-rich protein 1 ( PELP1 ), also called the modulator of nongenomic activity of ER ( MNAR ), have been shown to activate steroid hormone receptors in mammary carcinomas by nongenomic and genomic mechanisms. The expression and the relationship of this gene to the ER status in SDCs are unknown. We investigated the differential expression of the PELP1 / MNAR and the ERs alpha and beta proteins in SDCs, using Western blotting and immunohistochemistry. Western blot analysis of 7 paired normal and tumor specimens showed increased expression of PELP1 / MNAR and ER beta in 3 and 4 of the SDCs, respectively. No detectable expression of ER alpha in any normal or SDC specimens was noted. Immunohistochemical staining performed on 70 SDCs revealed strong expression of PELP1 / MNAR in 51 (73%) and ER beta in 52 (74%) tumors. PELP1 / MNAR and ER beta were coexpressed in 35 (50%), individually in 17 (24.2%), and negative in 18 (25.7%) tumors. PELP1 / MNAR staining was predominantly cytoplasmic whereas ER beta staining was nuclear and occasionally cytoplasmic in tumor cells. Our results indicate that PELP1 / MNAR and ER beta are coexpressed in most SDCs and may play a role in the pathobiology of these tumors.

Salivary duct carcinoma metastatic to inguinal lymph node: A case report of salivary duct carcinoma with distant metastasis diagnosed by fine-needle aspiration

Salivary duct carcinoma (SDC) is a high-grade malignant tumor exhibiting aggressive growth with early regional and distant metastasis. We report a case of SDC in a 53-yr-old male with distant metastasis to an inguinal lymph node. The diagnosis of the primary tumor as well as the metastatic lesion was accomplished by fine-needle aspiration (FNA). Aggressive clinical management appears to be the main therapeutic option for long-term survival. Therefore, establishing an accurate preoperative diagnosis by FNA can have both clinical and prognostic relevance.

Prostatic acid phosphatase is a possible tumor marker for intravascular large B-cell lymphoma

Intravascular large B-cell lymphoma (LBCL) is a rare and aggressive subtype of diffuse LBCL characterized by disseminated intravascular proliferation of neoplastic lymphocytes. Obstruction of blood flow by tumor cells in a variety of organs can cause an array of clinical changes, including alteration of the neural and spinal system and the respiratory system, as well as skin lesions. It is usually very difficult to diagnose intravascular LBCL in a patient simply from clinical symptoms or laboratory examinations. We here document our findings that serum prostatic acid phosphatase levels in both males and a female (2.2-24.0 microg/L) reflect the presence of intravascular LBCL, changing synchronously in response to chemotherapy. To determine whether prostatic acid phosphatase (PAP) might be a useful tumor marker for early diagnosis, we reviewed five intravascular LBCLs. Immunohistochemically, tumor cells in all cases were positive for anti-PAP antibody. The results were further confirmed in one case by Western-blot analysis and in another by the detection of amplified messenger RNA for PAP in microdissected tumor cells, respectively. PAP has not been detected in 17 lymphomas (diffuse LBCL, 8 cases; follicular lymphoma, 3 cases; T-cell lymphoma, 3 cases; Hodgkin lymphoma, 3 cases) by Western blot analyses. We conclude that serum PAP is a useful tumor marker for intravascular LBCL and that it deserves further investigation in this context.

Prostatic adenocarcinoma metastatic to the head and neck and the workup of an unknown epithelioid neoplasm

BACKGROUND

Epithelioid tumors in the head and neck are common and include both primary and metastatic lesions. For metastatic lesions, clinical factors, tumor location, and ancillary immunohistochemical studies must be taken into consideration to help the clinician and the pathologist determine the site of origin. One unusual, but important, primary tumor that can metastasize to the head and neck is carcinoma of the prostate (CAP).

METHODS

The files of the University of Pennsylvania Department of Pathology were searched for cases of metastatic CAP. All slides were examined, and clinical information was obtained from the referring physician's patient charts.

RESULTS

We describe 14 cases of metastatic CAP to the head and neck. Six patients had no history of CAP at the time of biopsy of the head and neck metastasis, and only eight patients had other widespread metastatic disease. Histologically, most of the tumors had epithelioid cells with prominent nucleoli and cribriform, solid, or infiltrating single cell growth patterns. PSA and PSAP immunohistochemical stains were positive in all cases. Seven of 12 patients with known follow-up are alive after radiation or hormonal therapy.

CONCLUSIONS

These results demonstrate a fair prognosis with possible prolonged survival with metastatic CAP to the head and neck after appropriate diagnosis and subsequent hormone and radiation therapy. Given this survival advantage with treatment, it is critical to consider the diagnosis of metastatic CAP when evaluating a metastatic malignant epithelioid tumor in the head and neck of an elderly man.