Personal Experience in Surgical Management of Pulmonary Pleomorphic Carcinoma

Autopsy findings in a rare case of pleomorphic carcinoma in a patient on dialysis

Pleomorphic lung cancer is a very rare type of cancer and very few cases have been reported in the literature. We present a case of pleomorphic lung cancer in a patient with history of IgA nephropathy on hemodialysis.

Is Sarcomatoid Lung Cancer Associated With Inferior Overall Survival? A National Cancer Database Analysis

INTRODUCTION

Sarcomatoid lung cancer has mainly been described in case series and single institution reviews. Although often associated with a poor prognosis, the overall survival compared to other forms of nonsmall cell lung cancer (NSCLC) is unknown. We hypothesize that sarcomatoid lung cancers have worse overall survival relative to other forms of NSCLC.

MATERIALS AND METHODS

In this retrospective cohort study, we identified adult patients with nonmetastatic NSCLC from 2004 to 2018 in the National Cancer Database. Patients were categorized by histology as sarcomatoid, adenocarcinoma, or squamous cell carcinoma. We compared clinical and demographic characteristics between the groups. The primary outcome of overall survival was analyzed using Kaplan-Meier analysis. Multivariable Cox analysis was used to analyze factors associated with overall survival in sarcomatoid patients undergoing surgery.

RESULTS

Among 1,259,109 patients with lung cancer, there were 5223 (0.4%) sarcomatoid cancers. Sarcomatoid patients were more likely to be male, of Hispanic ethnicity, have fewer comorbidities, and receive treatment at an academic program. Despite higher cT- and M-stages, patients with sarcomatoid cancer were more likely to undergo surgical resection in multivariate analysis (odds ratio = 1.8 [confidence interval 1.60-2.11]; P < 0.001). Among nonmetastatic patients, overall survival was lower for sarcomatoid cancer relative to other histologies in Kaplan-Meier analysis (median survival sarcomatoid 17.6 mo versus nonsarcomatoid 31.5 mo, P < 0.001).

CONCLUSIONS

This National Cancer Database study confirms the findings of smaller studies that sarcomatoid cancer is associated with inferior overall survival compared to other NSCLCs. Given the inferior prognosis, further studies regarding optimal staging practices are appropriate.

Pembrolizumab combined with anlotinib improves therapeutic efficacy in pulmonary sarcomatoid carcinoma with TMB-H and PD-L1 expression: a case report and literature review

Background

Pulmonary sarcomatoid carcinoma (PSC) is a unique subtype of non-small cell lung cancer (NSCLC) with a high degree of malignancy and poor therapeutic effects. With the widespread use of immune checkpoint inhibitors (ICIs) in recent years, few studies have reported that immunotherapy is effective against PSC. As a multi-target anti-vascular targeting agent, anlotinib showed a better anti-tumor effect in various cancer species. The paper reported the therapeutic and side effects of pembrolizumab combined with anlotinib in a patient with advanced PSC.

Case presentation

This is a 73 year old female patient who underwent thoracoscopy right upper lobectomy and was diagnosed as locally advanced PSC. However, the patient experienced tumor recurrence and metastasis 7 weeks after surgery and was unable to tolerate chemoradiotherapy. Moreover, she detected TP53 mutation and found that tumor mutation burden (TMB) and PD-L1 were high expression. Therefore, the patient received pembrolizumab combined with anlotinib treatment. After 15 cycles of treatment, the tumor significantly shrank with no tumor activity. The evaluation of tumor efficacy is partial response (PR). During the treatment period, she experienced one-degree thyroid-stimulating hormone elevation and two-degree hand-foot syndrome. Pembrolizumab and anlotinib was continued for two years as a maintenance treatment. The patient had a good quality of life and no disease progression was observed. Currently, the patient is still alive without tumor progression and has overall survival exceeding 45 months and toxic side effects were tolerable.

Conclusions

Combining ICIs and anti-angiogenic targeted therapy has brought new hope in treating advanced PSC. Additionally, TMB and PD-L1 expression could be potential predictive biomarkers of the efficacy in advanced PSC with immunotherapy.

Chemotherapy for advanced pulmonary sarcomatoid carcinoma: a population-based propensity score matching study

OBJECTIVES

Pulmonary sarcomatoid carcinoma (PSC) is a rare histological type of non-small cell lung cancer (NSCLC). There are no specific treatment guidelines for PSC. For advanced PSC (stage II-IV), the role of chemotherapy is still controversial. The purpose of this study was to investigate the effect of chemotherapy on the prognosis of advanced PSC.

METHODS

A total of 960 patients with advanced PSC from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2019 were enrolled in this study. To investigate the prognostic factors, the Cox proportional hazard regression model was conducted. A total of 642 cases were obtained after propensity score matching (PSM). The Kaplan‒Meier method was applied to compare overall survival (OS) and cancer-specific survival (CSS).

RESULTS

For all 960 cases included in this study, the Cox proportional hazard model was applied for prognostic analysis. Univariate and multivariate analyses showed that stage, T stage, N stage, M stage, surgery, and chemotherapy were prognostic factors for OS and CSS (P < 0.05). A total of 642 cases were obtained after PSM, with no significant difference between the two groups for all variables. Kaplan‒Meier curves indicated that for OS and CSS, the prognosis was significantly better in the chemotherapy group than in the no-chemotherapy group.

CONCLUSIONS

For advanced PSC, chemotherapy can significantly improve the OS and CSS of patients. Chemotherapy should be an important part of PSC treatment.

Gastrointestinal bleeding due to jejunal metastasis of pleomorphic lung carcinoma: a case report

Gastrointestinal metastasis of pleomorphic lung cancer presents with nonspecific manifestations, leading to delayed diagnosis. Herein, the authors report the case of a 56-year-old patient who presented with gastrointestinal bleeding due to pleomorphic lung carcinoma.

Case presentation

A 56-year-old patient presented to the emergency department with melena. On examination, he was hemodynamically stable. He had a sensitive and mobile mass in the periumbilical region. A thoracoabdominal computed tomography scan showed a mass of the right apical superior lobe measuring 4 cm and a lobulated jejunal mass measuring 10 cm. A percutaneous biopsy of the lung tumor revealed primary pleomorphic lung carcinoma. The authors performed a midline laparotomy and made a bowel resection with an end-to-end anastomosis. The postoperative course was marked by severe nosocomial pneumonia, leading to septic shock and death. The histopathologic examination concluded with a metastatic lesion of pleomorphic lung carcinoma.

Clinical discussion

The authors reported a rare case of jejunal metastasis of pleomorphic lung cancer. Pleomorphic carcinoma of the lung is a rare pathology that accounts for 0.1-0.4% of nonsmall-cell lung cancer. The prognosis is poor. In the presence of gastrointestinal bleeding caused by small bowel metastases of pleomorphic lung cancer, surgery is the treatment of choice.

Conclusions

Small bowel metastasis of pleomorphic lung cancer is rare. Surgical treatment is the treatment of choice. The authors highlight the importance of suspecting gastrointestinal metastases in patients with pleomorphic lung cancer in the presence of nonspecific digestive symptoms.

Clinical analysis of 78 pulmonary sarcomatoid carcinomas with surgical treatment

OBJECTIVE

To evaluate clinical factors influencing the postoperative pulmonary sarcomatoid carcinoma (PSCs) prognosis.

METHODS

We retrospectively evaluated patients with PSCs treated from October 2012 to October 2017. Kaplan-Meier survival curves were calculated using univariable analysis (log-rank test). Univariable/multivariable Cox regression analysis was also performed.

RESULTS

Mixed PSCs were most common (64.10%). Pure PSCs occurred more often with large tumors compared with mixed PSCs. Patients with vs without pleural retraction, respectively, had significantly worse overall survival (OS; 16 vs 23 months) and disease-free survival (DFS; 11 vs 20 months), and patients with airway dissemination had significantly shorter OS (14 vs 21 months) and DFS (11 vs 20 months). Patients with PSC with an adenocarcinoma component had favorable OS. Airway dissemination, pleural retraction, metastatic mediastinal lymph node (LN) number, and pathological tumor-node-metastasis (pTNM) stage were risk factors for short OS. Neither adjuvant chemotherapy nor adjuvant radiotherapy provided a survival advantage. Airway dissemination was an independent prognostic factor (odds ratio, 1.87; 95% confidence interval, 1.04-3.36).

CONCLUSION

Pure PSCs were more likely with large tumors compared with mixed PSCs. Airway dissemination, pleural retraction, and metastatic mediastinal LN number were associated with OS. Airway dissemination was an independent prognostic factor.

Omega-6 Polyunsaturated Fatty Acids Enhance Tumor Aggressiveness in Experimental Lung Cancer Model: Important Role of Oxylipins

Lung cancer is currently the leading cause of cancer death worldwide; it is often diagnosed at an advanced stage and bears poor prognosis. It has been shown that diet is an important environmental factor that contributes to the risk and mortality of several types of cancers. Intake of ω-3 and ω-6 PUFAs plays an important role in cancer risk and progression. Current Western populations have high consumption of ω-6 PUFAs with a ratio of ω-6/ω-3 PUFAs at 15:1 to 16.7:1 This high consumption of ω-6 PUFAs is related to increased cancer risk and progression. However, whether a diet rich in ω-6 PUFAs can contribute to tumor aggressiveness has not been well investigated. We used a murine model of pulmonary squamous cell carcinoma to study the aggressiveness of tumors in mice fed with a diet rich in ω-6 PUFAs and its relationship with oxylipins. Our results shown that the mice fed a diet rich in ω-6 showed a marked increase in proliferation, angiogenesis and pro-inflammatory markers and decreased expression of pro-apoptotic proteins in their tumors. Oxylipin profiling revealed an upregulation of various pro-tumoral oxylipins including PGs, HETEs, DiHETrEs and HODEs. These results demonstrate for the first time that high intake of ω-6 PUFAs in the diet enhances the malignancy of tumor cells by histological changes on tumor dedifferentiation and increases cell proliferation, angiogenesis, pro-inflammatory oxylipins and molecular aggressiveness targets such as NF-κB p65, YY1, COX-2 and TGF-β.

Adjuvant chemotherapy for pulmonary sarcomatoid carcinoma: A retrospective analysis of the National Cancer Database

OBJECTIVES

Pulmonary sarcomatoid carcinoma (PSC) is a rarely occurring variant of non-small cell lung cancer with sarcoma-like features. Compared with traditional non-small cell lung cancer, PSC patients typically present later and have poorer prognoses, irrespective of stage. The standard of care is resection, but guidelines for the use of adjuvant chemotherapy have not been established. To advance the development of evidence-based management algorithms for PSC after resection, a statistical analysis on a nationwide representative sample of patients was performed.

METHODS

A retrospective cohort study was performed by querying the National Cancer Database for patients with a diagnosis of PSC between 2004 and 2015. Patients who received complete anatomical resection with or without adjuvant chemotherapy were included. Multivariable regression was used to detect factors associated with the receipt of adjuvant chemotherapy. Multivariable Cox regression of overall survival and Kaplan-Meier survival analysis on propensity-matched groups was conducted to study the association between adjuvant chemotherapy and prognosis.

RESULTS

We included 1497 patients with PSC in the final analysis. Factors associated with receiving adjuvant chemotherapy were age, histology, and receipt of adjuvant radiation. The results of multivariable Cox analysis and Kaplan-Meier analysis on propensity matched groups yielded similar trends: adjuvant chemotherapy was associated with improved 5-year overall survival for stage II and III disease, but not for stage I disease.

CONCLUSIONS

Multiple factors are associated with receipt of adjuvant chemotherapy for PSC, and this treatment appears to be associated with improved survival in stage II and stage III, but not stage I patients.

Clinicopathological characteristics, survival outcomes and prognostic factors in pleomorphic carcinoma: a SEER population-based study

Background

Pulmonary pleomorphic carcinoma (PPC) is a rare tumor, and it usually has an aggressive clinical course and poor prognosis. We aim to analyze the clinicopathological features, management and prognostic factors of pulmonary pleomorphic carcinoma.

Patients and methods

Using the surveillance, epidemiology, and end results (SEER) database, we identified 461 patients of pulmonary pleomorphic carcinoma from 2004 to 2014 including clinicopathological characteristics, treatment modalities and outcome data.

Results

The mean age of all PPC patients was 66 years and 58% of the patients were male. Most patients (80%) were white people, 53% were found in the right lung, and lesions were mostly observed in upper lobe (56%). The median overall survival was 9 months and overall 1-, 3- and 5-year survival rate was 45%, 29%, 23%. In Kaplan–Meier analysis, age, marital status, tumor primary site, gender, laterality, SEER summary stage, chemotherapy and surgery were associated with overall survival. Patients received surgery or chemotherapy had a better OS for patients with PPC. Multivariate Cox analysis revealed that SEER summary stage, age, surgery and chemotherapy were found to be independently associated with the OS. Surgery could significantly prolong survival in patients with localized stage and regional stage (HR = 0.120, 95% CI 0.038–0.383, p < 0.001; HR = 0.351, 95% CI 0.212–0.582, p < 0.001) while it did not have great impact on survival in patients with distant stage (p = 0.192). Chemotherapy decreased risk of death by 46% (HR = 0.544, 95% CI 0.393–0.752, p < 0.001) for patients with distant stage, whereas chemotherapy did not confer survival benefits to patients with localized stage and regional stage. But radiation did not have great impact on survival of patients with different stages in this study.

Conclusions

PPC mostly occurred in white people, with a median age of 66 years, and men were more susceptible to this disease. The SEER summary stage, age, surgery and chemotherapy were independently associated with prognosis. Surgery should be considered for the PPC patients with localized stage or regional stage, and chemotherapy should be recommended for the treatment of patients with distant stage.

Ringed fluorodeoxyglucose uptake predicted poor prognosis after resection of pulmonary pleomorphic carcinoma

Background

Pulmonary pleomorphic carcinoma (PPC) is a relatively rare and poorly differentiated non-small cell carcinoma. This study aimed to investigate the clinicopathological features including programmed cell death ligand 1 (PD-L1) expression status in patients with PPC who underwent curative resection.

Methods

We retrospectively studied 29 consecutive patients who had undergone anatomical lung resections for PPC. Perioperative and pathological variables, including radiological findings, were investigated to define prognostic factors.

Results

Overall survival (OS) rates were 71.8% at 1 year and 60.0% at 5 years. Disease-free survival (DFS) rates were 54.8% at 1 year and 43.6% at 5 years. Univariate analysis revealed that ringed fluorodeoxyglucose (FDG) uptake on positron emission tomography/computed tomography (PET/CT) (p = 0.003), a cavity in the tumor on CT (p = 0.004), and tumor size (> 40 mm) (p = 0.014) were poor prognostic factors for OS. Regarding DFS, ringed FDG uptake (p = 0.002), a cavity on CT (p < 0.001), tumor size (p = 0.007), and pleural invasion (p = 0.014) were poor prognostic factors. PD-L1 expression was not a prognostic factor.

Conclusion

This study showed for the first time that ringed FDG uptake on PET/CT is a poor prognostic factor of PPC. PD-L1 expression status was not related to the prognosis.

Trial registration The study was approved by the Kobe City Medical Center General Hospital’s ethics board (No. 20112) on August 20, 2020.

The importance of medical treatment before surgery in pleomorphic carcinoma of the lung: A case series study

Introduction and importance

Pleomorphic carcinoma of the lung is a rare malignant epithelial tumor. Due to its rarity, its clinicopathological characteristics are not clear, and there is no defined therapeutic path for this type of tumor.

Case presentation

We retrospectively analyzed the medical and pathological reports of 8 patients who underwent surgical resection for pleomorphic carcinoma between 2007 and 2010.

Clinical discussion

Eight patients were analyzed (7 males and 1 female, mean age 60). All patients underwent CT scans, and the average diameter of the nodules was 56 mm. Four patients were also investigated with FDG-PET with hypermetabolic activity in all four cases. In four patients, the carcinomatous component was adenocarcinoma (all with sarcomatoid component of spindle cell and giant cell carcinoma), although in two patients, it was squamous cell carcinoma (one with spindle cell and one with giant cell). In the two remaining patients, one showed a non-small cell carcinoma with giant cell carcinoma, and the other was a non-small cell carcinoma and squamous cell carcinoma with spindle and giant cell carcinoma. All cases were treated with surgical resection. Only two patients underwent neoadjuvant chemotherapy. At the time of data analysis, only one patient treated with neoadjuvant chemotherapy was alive.

Conclusion

The prognosis for these patients with a diagnosis of pleomorphic carcinoma undergoing surgery is generally better than those not treated with surgical resection, however the survival remains poor. Although with low number of patients, our research would suggest to consider neoadjuvant chemotherapy an appropriate approach for improving the outcomes before surgery.

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Pleomorphic carcinoma of the lung

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Rare malignant epithelial tumor

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Clinicopathological characteristics unclear

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Not defined therapeutic path

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Neoadiuvant chemotherapy improves the prognosis.

Survival Analysis and Prediction Model for Pulmonary Sarcomatoid Carcinoma Based on SEER Database

Objective

This study aimed to investigate the incidence of the pulmonary sarcomatoid carcinoma (PSC), to compare the clinical characteristics and overall survival (OS) of patients with PSC and those with other non-small-cell lung cancer (oNSCLC), so as to analyze the factors affecting the OS of patients with PSC and construct a nomogram prediction model.

Methods

Data of patients with PSC and those with oNSCLC diagnosed between 2004 and 2015 from the Surveillance, Epidemiology, and End Results database were collected. The age-adjusted incidence of PSC was calculated. The characteristics of patients with PSC and those with oNSCLC were compared, then the patients were matched 1:2 for further survival analysis. Patients with PSC were randomly divided into training set and testing set with a ratio of 7:3. The Cox proportional hazards model was used to identify the covariates associated with the OS. Significant covariates were used to construct the nomogram, and the C-index was calculated to measure the discrimination ability. The accuracy of the nomogram was compared with the tumor–node–metastasis (TNM) clinical stage, and the corresponding area under the curve was achieved.

Results

A total of 1049 patients with PSC were enrolled, the incidence of PSC was slowly decreased from 0.120/100,000 in 2004 to 0.092/100,000 in 2015. Before PSM, 793 PSC patients and 191356 oNSCLC patients were identified, the proportion of male, younger patients (<65 years), grade IV, TNM clinical stage IV was higher in the PSC. The patients with PSC had significantly poorer OS compared with those with oNSCLC. After PSM, PSC still had an extremely inferior prognosis. Age, sex, TNM clinical stage, chemotherapy, radiotherapy, and surgery were independent factors for OS. Next, a nomogram was established based on these factors, and the C-indexs were 0.775 and 0.790 for the training and testing set, respectively. Moreover, the nomogram model indicated a more comprehensive and accurate prediction than the TNM clinical stage.

Conclusions

The incidence of PSC was slowly decreased. PSC had a significantly poor prognosis compared with oNSCLC. The nomogram constructed in this study accurately predicted the prognosis of PSC, performed better than the TNM clinical stage.

Prognostic value of PET parameters in patients with pleomorphic lung cancer: Results from a single institution

OBJECTIVES

Pleomorphic lung carcinoma (PLC) is a rare histotype of non-small cell lung cancer (NSCLC) characterized by aggressive clinical course, poor response to therapy and poor prognosis. Therefore, aim of our study is to analyze with 18F-FDG PET/CT a subset of patients affected by PLC to evaluate their metabolic characteristics in terms of SUVmax, MTV and TLG, in order to correlate them with overall survival (OS) and disease-free survival (DFS).

MATERIAL AND METHODS

We retrospectively analyzed 49 consecutive patients with histologically defined PLC occurred to our Institution between 2003 and 2014. All patients underwent F18-FDG PET-CT before surgery and primary tumor was automatically segmented using an isocontour threshold method. SUV threshold for tumor segmentation was defined as the 41 % of lesion SUVmax. Total volume of the segmented VOI (MTV, centimeters cubed) and average SUV (SUVavg, grams per milliliter) in the segmented VOI were measured.

RESULTS

In our population men were significantly more affected than women (42:7). According to Youden criteria, SUVmax, MTV41 and TLG41 best cut-off values to predict 2-year mortality were, 18.95, 27.89 and 290.45, respectively, with TLG41 showing best specificity (85 %) and positive predictive value (82.4 %). As concerning 2-year recurrence, SUVmax, MTV41 and TLG41 best cut-off values were 10.08, 27.89 and 134.85, with SUVmax showing best sensitivity (96.7 %) and negative predictive value (85.7 %). ROC curves confirmed that SUVmax, MTV41 and TLG41 were equally accurate to predict 2-year mortality and 2-year recurrence in our population.

CONCLUSION

Metabolic biomarkers such as SUVmax, MTV and TLG can be used as a prognostic index for disease progression, recurrence and death in patients with PLC, independently from other clinical/pathological prognostic elements.

Combination of Pembrolizumab With Platinum-containing Chemotherapy for Pleomorphic Carcinoma of the Lung

BACKGROUND/AIM

Pleomorphic carcinoma of the lung is a rare, highly malignant subtype of lung cancer, with a more aggressive clinical course compared with other types of non-small-cell lung cancer (NSCLC). Platinum-containing chemotherapy has been the standard therapy for patients with NSCLC and pembrolizumab is one of the novel and reliable agents for these patients.

CASE REPORT

We herein report the case of a 60-year-old man with advanced chemo-naïve pleomorphic carcinoma of the lung who was successfully treated with a combination of pembrolizumab with platinum-containing chemotherapy.

CONCLUSION

In the absence of definitive clinical trials, which are unlikely to be performed due to the rarity of this tumor, our case demonstrates the potential utility of the combination of pembrolizumab with platinum-containing chemotherapy. Our result also suggest that this combination of therapy may be key to the treatment of pleomorphic carcinoma of the lung.

An 86-Year-Old Woman Presenting With 2 Weeks of Worsening Dyspnea and Cough

CASE PRESENTATION

An 86-year-old Singaporean Malay woman with no known respiratory condition presented with 2 weeks of progressively worsening dyspnea, cough, and pleuritic chest pain. There was a positive sick contact and recent long-distance travel to Norway. However, further history revealed her symptoms presented even prior to her overseas trip. Red flag symptoms of hemoptysis, loss of appetite/weight, and risk factors such as smoking/occupational exposure, and personal and familial history of cancer were absent.

Clinicopathological characteristics and prognostic factors of pulmonary sarcomatoid carcinoma: a large population analysis

BACKGROUND

This study was conducted to identify the clinicopathological characteristics and survival outcomes of pulmonary sarcomatoid carcinoma (PSC), and to compare prognostic factors between elderly (≥65 years) and non-elderly (<65 years) patients.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was used to identify patients diagnosed with PSC between 2004 and 2016. The Kaplan-Meier method was used for overall survival (OS) and cancer-specific survival (CSS) analysis. The Cox proportional hazards model was used to detect independent prognostic factors. A propensity score matched (PSM) analysis was conducted to compare OS and CSS in elderly versus non-elderly PSC patients.

RESULTS

A total of 1,039 eligible cases were identified, with a median follow-up of 6 months. The 5-year OS and CSS rates were 12.3% and 18.7%, respectively, and the median survival was 6 months. Multivariate analysis revealed that female (HR =0.750, P<0.004), surgery (HR =0.484, P<0.001), chemotherapy (HR =0.504, P<0.001), and radiation (HR =0.801, P=0.041) were independent favorable prognostic factors. There was a significant difference in the OS and CSS rates between elderly and non-elderly patients after PSM (P=0.007 and P=0.017, respectively). In multivariate analysis, the predictors for OS in the elderly patients were gender, tumor stage, and chemotherapy, whereas in the non-elderly patients, the predictors were tumor stage, chemotherapy, and surgery.

CONCLUSIONS

The PSC patients in our study had poor survival outcomes. Comprehensive treatment, including surgery, chemotherapy, and radiotherapy, could improve patient prognosis. Elderly patients had different clinicopathological characteristics, compared to non-elderly patients.

Pulmonary pleomorphic carcinoma presenting as undifferentiated non-small cell carcinoma with giant cells: A case report and review of literature

Pulmonary pleomorphic carcinoma (PPC) is a poorly differentiated non-small cell lung carcinoma, including squamous cell carcinoma, adenocarcinoma, or undifferentiated non-small cell lung carcinoma with at least 10% spindle and/or giant cells. Here, we report a case of PPC showing undifferentiated non-small cell lung carcinoma with giant cells. A 71-year-old man with dyspnea underwent right lobectomy because of a mass in the right upper lobe of the lung. A 5.0 × 3.0 × 1.5 cm-sized tumor was identified; microscopically, the tumor composed of undifferentiated large sized tumor cells admixed with syncytial tumor giant cells and emperipoletic giant cells. Immunohistochemically, the tumor cells were reactive for pan-cytokeratin, but negative for P40, thyroid transcription factor 1 (TTF-1), and vimentin. The tumor cells were also positive for 3 clones of programmed death-ligand 1 (PD-L1). The clinical and histologic findings supported the diagnosis of an undifferentiated non-small cell lung carcinoma with giant cells, which is a subtype of pulmonary pleomorphic carcinoma. Unfortunately, after surgery, multifocal lymph node metastasis was identified in radiologic examination. Only palliative chemotherapy was administered to the patient, although he was indicated for immunochemotherapy. Pulmonary pleomorphic carcinoma is known to have a poor prognosis, even in early stages of the disease, therefore, we should be careful in the diagnosis to ensure optimal treatment.

Prognostic factors for sarcomatoid carcinomas of lung: A single-centre experience

Background:

Although lung sarcomatoid carcinomas (LSCa) arised from the epithelial tissue, they have very distinctive features than other non-small cell lung carcinomas in terms of histopathology and survival. It constitutes 0.1%–0.4% of all lung cancers. The aim of our study is to evaluate the survival analysis of LSCa in a single thoracic surgery clinic and to determine the prognostic factors.

Materials and Methods:

It was a retrospective cohort study. After the approval of the local ethics committee, a total of 34 patients who were operated in our department between January 2010 and December 2018, whose pathologies were reported as sarcomatoid carcinoma was included in the study. The patients were analyzed by age, gender, presence of necrosis in the histopathological examination, tumor stage, tumor diameter, and tumor location.

Results:

There were 28 males and 6 females. The median age was 60 years (range: 36–80 years). The median survival was 42 months (32.6–52.2 months), and the 5-year overall survival was 33.6%. Significantly negative prognostic factors were tumor diameter and tumor stage (P = 0.003 and 0.001, respectively). Median disease-free interval (DFI) was 38 months (27.3–49.1 months), and 5-year DFI was 32.6%.

Conclusion:

LSCa are highly heterogeneous epithelial malignancies, and it has worse survival than other epithelial cancers. Relatively, satisfactory results can be obtained in these tumors with surgical treatment.

Approaches to Tumor Classification in Pulmonary Sarcomatoid Carcinoma

Pulmonary sarcomatoid carcinoma (PSC) is a heterogeneous category of primary lung cancer accounting from 0.3% to 3% of all primary lung malignancies. According to the most recent 2015 World Health Organization (WHO) classification, PSC includes several different variants of malignant epithelial tumors (carcinomas) histologically mimicking sarcomas showing or entirely lacking a conventional component of non-small cell lung cancer (NSCLC). Thus, this rare subheading of lung neoplasms includes pleomorphic carcinoma, spindle cell carcinoma, giant cell carcinoma, pulmonary blastoma, and carcinosarcoma. A diagnosis of PSC may be suspected on small biopsy or cytology, but commonly requires a surgical resection to reach a conclusive definition. The majority of patients with PSC consists of elderly, smoking men with a large, peripheral mass characterized by well-defined margins. However, presentation with a central, polypoid endobronchial lesion is well-documented, particularly in pleomorphic carcinoma and carcinosarcoma showing a squamous cell carcinoma component. As expected, PSC may pose diagnostic problems and immunohistochemistry is largely used when pathologists deal these tumors in routine practice. Indeed, PSC tends to overexpress molecules associated with the epithelial-to-mesenchymal transition, such as vimentin, but the panel of immunostains also includes epithelial markers (cytokeratins, EMA), TTF-1, p40 and negative markers (e.g., melanocytic, mesothelial and sarcoma-related primary antibodies). Although rare, PSC has increased their interest among oncologist community for different reasons: a. identification of the epithelial-to-mesenchymal phenomenon as a major mechanism of secondary resistance to tyrosine kinase inhibitors; b. over-expression of PD-L1 and effective treatment with immunotherapy; c. identification of c-MET exon 14 skipping mutation representing an effective target to crizotinib and other specific inhibitors. In this review, the feasibility of the diagnosis of PSC, its differential diagnosis and novel molecular findings characterizing this group of lung tumor are discussed.

Pleomorphic carcinoma of the lung: from thin-walled cavity to solid tumor

Pulmonary pleomorphic carcinoma accounts for less than 1% of all lung malignancies. It is more aggressive than other forms of non-small cell lung cancer, and usually presented as a solid mass on computed tomography scan. However, a thin-walled lung cavity is more suggestive of a benign lesion in generally. Here we encountered a 39-year-old woman, who had been found a thin-walled cavity in her lung occasionally, whose chest computed tomography initially presented as a thin-walled lung cavity which was considered to be a benign lung cyst, became a solid tumor after 3 years. Then she underwent video-assisted thoracoscopic left lower lobectomy and lymphadenectomy, postoperative pathological examination demonstrated the diagnosis of pleomorphic carcinoma.

Perioperative chemotherapy is not associated with improved survival in stage I pleomorphic lung cancer

OBJECTIVES

Pulmonary pleomorphic carcinoma represents an understudied, rare, and aggressive histologic subtype of non-small cell lung cancer. Better understanding of rare disease subtypes allows for improved individualization of patient care. This study aimed to evaluate current trends in treatment and survival of pleomorphic carcinoma.

METHODS

The National Cancer Database was used to identify patients with staged, pleomorphic carcinoma and adenocarcinoma between 2004 and 2015. Patient characteristics and treatments were compared using χ² tests. Cox proportional hazard models examined survival by stage after controlling for confounders. Propensity score matched Kaplan-Meier curves estimated survivor functions stratified by stage. Differences in survival following treatment for stage I pleomorphic carcinoma with surgery alone versus surgery plus chemotherapy were compared with Cox proportional hazard models and Kaplan-Meier survival curves.

RESULTS

One thousand four hundred eight patients with pleomorphic carcinoma and 607,561 patients with adenocarcinoma were identified. Pleomorphic carcinoma accounted for 0.1% of all non-small cell lung cancers. Pleomorphic disease had poorer overall 5-year survival compared with adenocarcinoma for stages I through IV (49.4% vs 59.1%, 34.5% vs 43.8%, 16.9% vs 28.4%, and 5.7% vs 7.8%, respectively; P < .0047 for all). Perioperative chemotherapy was used more frequently for pleomorphic disease (17.5% vs 6.1%; P < .001). For stage I pleomorphic cancer, treatment with surgery alone (n = 253) and surgery with chemotherapy (n = 57) had overall 5-year survival rates of 55.2% and 53.7%, respectively, and were not significantly different (P = .2868).

CONCLUSIONS

Pulmonary pleomorphic carcinoma is rare and aggressive, with worse survival when compared with adenocarcinoma. Perioperative chemotherapy has not demonstrated significant survival benefits in stage I pleomorphic cancer.

A High PD-L1 Expression in Pulmonary Pleomorphic Carcinoma Correlates with Parietal-pleural Invasion and Might Predict a Poor Prognosis

Objective Pleomorphic carcinoma (PC) is a rare pulmonary epithelial malignant tumor with a poor prognosis. The objective of the present study was to investigate the programmed death-ligand 1 (PD-L1) expression in PC and its correlation between the clinicopathological factors and prognosis. Methods Clinical and pathological data of 35 patients with surgically resected PC encountered from 2002 to 2016 at our institution were collected. The PD-L1 expression on tumor cells was evaluated via immunohistochemistry (clone 22C3). We examined the correlation between the PD-L1 expression and patients' clinicopathological factors and their prognosis. Results A high PD-L1 expression (≥50%) was seen in 21 (60%) patients, and parietal-pleural invasion was significantly correlated with a high PD-L1 expression (p=0.012). The 5-year overall survival and relapse-free survival were 68.2% and 43.2%, respectively. Tumor size ≥50 mm (p=0.021), lymph node metastasis (p=0.023), and a high PD-L1 expression (p=0.047) were correlated with a short relapse-free survival. Since lymph node metastasis was an independent risk factor of a poor overall survival (p=0.012), patients with a high PD-L1 expression also tended to have a worse overall survival than those with low levels (p=0.081). Conclusion A high PD-L1 expression is frequently seen in PC. The PD-L1 expression is associated with parietal-pleural invasion and might indicate a poor prognosis.

Perioperative change in neutrophil-to-lymphocyte ratio (NLR) is a prognostic factor in patients with completely resected primary pulmonary sarcomatoid carcinoma

Background

There has been controversy regarding prognostic factors for surgically resected primary pulmonary sarcomatoid carcinoma (PSC). Recently, several studies have shown that neutrophil-to-lymphocyte ratio (NLR) was a prognostic factor for various types of cancers from multiple organs. Therefore, we performed this study to evaluate whether NLR is related to prognosis after complete surgical resection of primary PSC.

Methods

From Oct. 2003 to Sep. 2015, a total of 50 patients underwent surgical resection for primary PSC. After excluding patients with any history of other malignancy and incompletely resected cases, a total of 37 patients were included, and data were retrospectively collected and analyzed. Change in postoperative NLR and the initial NLR (ΔNLR) was calculated from the perioperative complete blood count (CBC) results.

Results

Mean age of the cohort was 62.2±1.9 years, and 31 patients (83.8%) were male. Twenty patients (54.1%) were revealed as pN0. Overall 5-year survival rate was 50.3%. Seventeen patients (45.9%) had locoregional or distant metastases. Univariate survival analysis revealed age >70, ΔNLR >17 as risk factors for overall survival (P=0.009, 0.005) and disease-free survival (P=0.036, 0.018). Multivariate Cox-regression analysis revealed age >70 and ΔNLR >17 as independent risk factors for overall survival and ΔNLR >17 as the only independent risk factor for the disease-free survival.

Conclusions

In patients with completely resected primary PSC, perioperative ΔNLR had a significant effect on the overall survival and disease-free survival. Older age was also an independent risk factor for overall survival.

Pulmonary sarcomatoid carcinoma: an analysis of a rare cancer from the Surveillance, Epidemiology, and End Results database

OBJECTIVES

Pulmonary sarcomatoid carcinoma (PSC) is a rare malignant neoplasm that accounts for a small percentage of non-small-cell lung carcinoma (NSCLC). At least 10% of PSCs has a spindle and/or giant cell component, which is often associated with a poor prognosis. We reviewed the Surveillance, Epidemiology, and End Results (SEER) database for the clinicopathological characteristics and surgical outcomes of PSCs.

METHODS

The SEER database (1973-2013) was queried for PSC. A comparison between PSC and other NSCLC patients was performed. Cox regression for overall survival (OS) and logistic regression for node-positive predictors were performed. A propensity-matched (1:2) analysis (including age, gender, grade and stage) among surgically treated cases was done to compare OS in PSC versus other NSCLCs.

RESULTS

A total of 955 899 NSCLC patients were identified; of these, 4987 patients had been diagnosed with PSC (0.52%). Men represented 60.9% of cases, with a median age of 68 years. The median size of the tumour was 5 cm and 3.5 cm in PSCs and NSCLCs, respectively (P < 0.001). PSC patients had significantly less Stage I, more high-grade tumours, advanced T stage, N+ disease and M1 disease (P < 0.001). In the PSC cohort, the most significant predictor of N+ disease on multivariate analysis was advanced T stage (P < 0.001). Predictors of OS in Stages I/II PSC on multivariate analysis were advanced age [P < 0.001, hazard ratio (HR) = 1.03], male gender (P = 0.024, HR = 1.25), carcinosarcoma (P = 0.002, HR = 1.76), grade (P = 0.033, HR = 1.81), T stage (P = 0.003, HR = 1.75), N status (P = 0.001, HR = 1.90) and surgical resection (P < 0.001, HR = 0.58). Among matched surgically resected cohorts, a poorer prognosis for OS was evident in PSCs in early stages (I/II) than in other NSCLCs (P = 0.009).

CONCLUSIONS

PSC patients present with more advanced stage and with worse survival outcomes than other NSCLC patients. While surgical resection conveys a survival advantage in PSC, this group represents a population at a high risk for relapse and should be evaluated for novel adjuvant therapies.

Pulmonary Sarcomatoid Carcinomas: A Review

Pulmonary sarcomatoid carcinomas belong to a group of neoplasms that remain incompletely understood. They are rare tumors of the bronchopulmonary system that incorporate a wide range of neoplasms that by definition contain a sarcomatoid component characterized by spindle or giant cells. Such classification has led to a heterogenous tumor category that includes neoplasms with different clinical, morphologic, and prognostic features. To date, the histopathologic diagnosis of pulmonary sarcomatoid carcinomas does not require the use of ancillary testing and is based on light microscopic criteria alone. However, with recent advances in immunohistochemical and molecular methods, it is becoming increasingly clear that pulmonary sarcomatoid carcinomas represent poorly differentiated or "dedifferentiated" variants of conventional non-small cell carcinomas with similar immunophenotype and molecular signatures. This review summarizes the latest insights and concepts of these unusual tumors and outlines future directions with emphasis on tumor classification and patient management.

Clinicopathological characteristics and prognosis of pulmonary pleomorphic carcinoma: a population-based retrospective study using SEER data

Background

Pulmonary pleomorphic carcinoma (PPC) is a rare malignancy; unique clinicopathological characteristics and prognosis have not been described.

Methods

PPC patient information collected in the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2014 were extracted, evaluated, and compared with NSCLC patient data. Overall survival (OS) was evaluated by the Kaplan-Meier method. Univariate analysis (UVA) and multivariate analysis (MVA) by the Cox proportional hazards regression identified risk factors that predicted OS and the results were used to construct a nomogram to predict 1-, 3-, and 5-year OS in PPC patients.

Results

A total of 309 patients diagnosed with PPC were identified among the records of 320,510 NSCLC patients. The median age was 66 (IQR, 57-75) years, 59.2% were men, 79.3% were White, 63.9% had upper lobe tumors, 77.0% were poorly differentiated, and 38.0% were AJCC stage IV. Median OS was 9 (95% CI: 6.69-11.31) months and 5-year OS was 25.1% (95% CI: 23.6-26.6%). PPC patients had significantly larger and less differentiated tumors, a higher rate of radical surgical resection, less N+ disease, and fewer distant metastases (P<0.001) than NSCLC patients. UVA and MVA identified age, T stage, M stage, surgery, and chemotherapy as independent risk factors. The nomogram had a calibration index of 0.798.

Conclusions

PPC had distinct clinicopathological characteristics. Age, T stage, M stage, surgery and chemotherapy were independently associated with OS. The nomogram accurately predicted 1-, 3- and 5-year OS.

Sarcomatoid Carcinoma of the Lung: The Mayo Clinic Experience in 127 Patients

BACKGROUND

Pulmonary sarcomatoid carcinoma (PSC) is an unusual form of non-small-cell lung cancer (NSCLC). Because of its rarity and heterogeneity, the treatment and prognosis of PSC have not been clearly described.

METHODS AND MATERIALS

We retrospectively evaluated all patients with a diagnosis of PSC from 1997 to 2015 at the Mayo Clinic (Rochester, MN). The clinical characteristics, treatment details, and outcomes were collected. The survival rates of the PSC patients were compared with those for other subtypes of NSCLC. We used propensity score matching to minimize the bias resulting from to imbalanced comparison groups.

RESULTS

The study included 127 PSC patients. The median age at diagnosis was 68 years (range, 32-89 years), most of whom were men (61%) and smokers (82%). The clinical stage was I, II, III, and IV in 15.9%, 20.6%, 22.2%, and 41.3%, respectively. The median survival time was 9.9 months (95% confidence interval [CI], 7.6-12.6 months). The 1-, 2-, and 5-year survival rates were 42%, 23%, and 15%, respectively. Most patients received multimodality treatment. Of the 3 patients who received neoadjuvant chemotherapy, a partial response was demonstrated in 2. Twenty-five patients who underwent palliative chemotherapy were evaluated for tumor response: 52% experienced progression, 40% stable disease, 8.0% a partial response, and 0% a complete response. Multivariate analysis showed T stage, M stage, and treatment with surgery plus neoadjuvant chemotherapy or surgery plus adjuvant therapy were independent prognostic factors (P < .05). In matched analysis, multivariate models revealed worse overall survival for PSC compared with adenocarcinoma (hazard ratio, 2.38; 95% CI, 1.61-2.53) and squamous cell carcinoma (hazard ratio, 2.20; 95% CI, 1.44-2.34).

CONCLUSION

We found the outcome of PSC to be significantly worse than that of adenocarcinoma and squamous cell carcinoma. Neoadjuvant or adjuvant chemotherapy, in addition to surgical resection, should be considered.

Treatment of Lung Carcinosarcoma and Other Rare Histologic Subtypes of Non-small Cell Lung Cancer

OPINION STATEMENT

Lung carcinosarcoma (PCS) and other histological subtypes of non-small cell lung cancer, such as primary pulmonary lymphoma (PPL), pulmonary carcinoid (PC), and primary pulmonary lymphoepithelioma-like carcinoma (LELC), are rare. For their low incidence, the diagnosis and treatment are still controversial. Some patients only need surgery, while others may need chemotherapy, radiotherapy, or targeted therapy. In this paper, we retrospectively reviewed the literature of some rare histological subtype of NSCLC for the recent 20 years, and try to get some conclusions.

Characteristics and Prognostic Analysis of 69 Patients With Pulmonary Sarcomatoid Carcinoma

BACKGROUND

Pulmonary sarcomatoid carcinoma (PSC) is a rare malignancy.

METHODS

A total of 69 patients with PSC treated at a single institution in southern China with long-term follow-up were evaluated in this study. We analyzed the clinical characteristics, immunohistochemical profiles, epidermal growth factor receptor mutation status, K-RAS mutation status, treatments, and prognosis.

RESULTS

PSC mainly occurred in young male patients with a history of smoking. Most patients received multimodality treatments and the majority had early-stage disease. The median survival time was 19.1 months, and the 5-year survival rate was 17.4%. The patients without distant metastasis, with normal or higher body mass index (≥18.5), with normal hemoglobin, with smaller tumor size (≤4 cm), and those who received complete resection had significantly better overall survival (P<0.05). The patients with pleomorphic carcinoma had much worse prognosis. In a Cox regression model, M stage, pathology, and having received a complete resection were independent prognostic factors (P<0.05).

CONCLUSIONS

PSC is a unique lung malignancy with poor prognosis. Patients receiving complete resection had better prognosis, likely a reflection of early-stage disease. Neither neoadjuvant nor adjuvant chemotherapy improved patient survival for those with early-stage disease. The retrospective design and small sample size limited the generalizability. Future multicenter collaborations may be necessary to determine the optimal treatment.

Local and systemic immunity predict survival in patients with pulmonary sarcomatoid carcinoma

Pulmonary sarcomatoid cancer (PSC) is a rare, aggressive subtype of non-small cell lung cancer, and measures of local and systemic immunity as biomarkers are incompletely known. We performed this study to characterize the leukocyte composition within the tumor, stroma, and peripheral blood in patients with PSC and correlated our findings with overall survival. Tissue from 30 patients diagnosed with PSC was evaluated by IHC for the presence of CD3⁺, CD14⁺, and CD19⁺ cells and PD-L1 expression. A lymphocyte-to-monocyte ratio (LMR) was calculated for the tumor microenvironment (TME) and peripheral blood. Survival analyses were performed based on IHC scores or groups defined by receiver operating characteristic curve cutoffs. CD3⁺ and CD14⁺ cells were found throughout the TME. CD19⁺ cells were almost exclusive to the stroma and correlated with superior overall survival (HR 0.40, 95% CI 0.21-0.72, p = 0.003). Most patients expressed PD-L1 on the tumor and/or the infiltrating immune cells, but neither the presence nor PD-L1 expression level impacted survival. A more prolific immune infiltration of the TME was associated with improved survival (HR 0.82, 95% CI 0.70-0.98, p = 0.029). PSC patients with a TME LMR ≥1.2 had a median survival of 1598 versus 488 days for a TME LMR <1.2 (p = 0.010). In the peripheral blood, an LMR ≥2.3 was associated with improved median survival (1579 vs. 332 days, p < 0.001). Our data demonstrate multiple measures of the local and systemic immunity are associated with patient survival in PSC.

Pulmonary pleomorphic carcinoma: A case report and review of the literature

RATIONALE

Pleomorphic carcinoma (PC) is a rare malignancy of the lung. It has a dual-cell component of spindle and/or giant cells, and of epithelial cells.

PATIENT CONCERNS AND DIAGNOSES

We presented a case of PC. A 69-year-old healthy asymptomatic woman who was occasionally found an abnormal shadow on her chest X-rays. A computerized tomography scan showed a mass located in the left lingular lobe and the percutaneous lung biopsy pathology confirmed sarcomatoid cancer.

INTERVENTIONS AND OUTCOMES

The patient underwent pneumonectomy. A diagnosis of PC was confirmed after surgery through immunohistochemistry. The pathological stage was T2aN0M0 (Ib). Due to the patient's refusal, adjuvant chemotherapy was not taken and she has been living disease free for 12 months after the surgery.

LESSONS

PC of the lung represents a rare pathological entity. Surgical resection remains the cornerstone of the treatment and may offer the possibility of long-time survival in early-stage patients. More cases of PC should be reported to establish an optimal management.

Clinicopathological factors influenced the prognosis of surgically resected pulmonary pleomorphic carcinoma

BACKGROUND

Pulmonary pleomorphic carcinoma has made an unfavorable prognosis because of its properties of resisting radiation and chemotherapy, and its aggressive growth. The correlation between clinicopathological factors and prognosis about pulmonary pleomorphic carcinoma patients who received its surgical resection has not been clearly identified.

METHODS

We retrospectively investigated the clinical records of 24 pulmonary pleomorphic carcinoma patients who had a surgical resection from January 2004 to December 2013 at our institute. We examined the correlation between their clinicopathological factors and therapeutic effects including their prognosis.

RESULTS

The median follow up time was 2.3 years. The 5-year survival was 54.7% and the 5-year progression free survival was 52.4%. In comparison with other tissue types of lung cancer, the prognosis was not so poor even taking into consideration the survival curve including several progression stages. We analyzed the 21 clinicopathological factors in order to clarify the factors connected with the prognosis and disease progression. As a result, we found that both vascular invasion evaluated by immunohistochemistry and lymph node metastasis were connected closely with the overall survival. We found another strong link between the tissue type of epithelial components, vascular invasion evaluated by immunohistochemistry and lymph nodal metastasis with the progression free survival.

CONCLUSIONS

Pulmonary pleomorphic carcinoma patients with lymph node metastasis and vascular invasion had worse prognosis after their surgical resections. We have to find an effective chemotherapeutic drug or molecular targeted drug.

Pathologic Findings and Long-Term Results After Surgical Treatment for Pulmonary Sarcomatoid Tumors: A Multicenter Analysis

BACKGROUND

Pulmonary sarcomatoid carcinoma (PSC) is a very rare subtype of non-small cell lung cancer (NSCLC). The aim of this study was to clarify the pathologic characteristics and long-term survival after surgical treatment in patients with PSC.

METHODS

From January 2003 to December 2013, we retrospectively reviewed the clinical findings, surgical notes, and pathologic and follow-up data from 148 consecutive patients who underwent curative resection for PSC in 5 institutions. The Kaplan-Meier method, log-rank test, and Cox regression analysis were used.

RESULTS

Mean age and male to female ratio were 66.6 ± 9.9 years and 120:28, respectively. Surgical resection (pneumonectomy in 8 patients, bilobectomy in 132 patients, and sublobar resection in 8 patients) was complete in 142 cases (96%). At pathologic evaluation, 36 patients (24%) had stage I, 69 patients (47%) had stage II, 33 patients (22%) had stage III, and 10 patients (7%) had stage IV disease. A "biphasic tumor" (PSC with an NSCLC component) was observed in 77 patients (52%). We detected a high rate of vascular emboli in the surgical specimens (overall, 68%; 57% in pathologic stage I tumors), whereas lymphatic emboli were found in 30% of cases (5% of pathologic stage I tumors). Overall median and 5-year long-term survival (LTS) was 19 months and 12.6% (LTS, 16.3% in pathologic stage I), respectively. Distant recurrences frequently occurred after surgical treatment (81%), even in pathologic stage I tumors that underwent R0 resection (62%). Multivariable survival analysis identified R+ resection (hazard ratio [HR],12.3; 95% confidence interval [CI], 3.67-41.28; p < 0.0001), advanced pathologic stage (HR, 5.75; 95% CI, 2.55-12.98; p < 0.0001), and the presence of vascular emboli (HR, 1.67; 95% CI, 1.05-2.67; p = 0.0327) as independent negative prognostic factors.

CONCLUSIONS

PSCs have very aggressive behavior and high metastatic potential even in early stages. R+ resection, pathologic TNM status, and the presence of vascular emboli are independent prognostic factors.

Pulmonary Sarcomatoid Carcinoma: An Analysis of the National Cancer Data Base

INTRODUCTION

Pulmonary sarcomatoid carcinoma (PSC) is a grouping of 5 rare non-small-cell lung cancer (NSCLC) subtypes. We studied the clinical characteristics and outcomes of PSC utilizing the National Cancer Data Base (NCDB), an oncology outcomes database.

METHODS

The NCDB lung cancer database was queried from 1998 to 2011 for PSC using ICD-O-3 codes. Data were extracted for patient demographics, tumor pathology, treatment, and outcomes. Overall survival (OS) data were available for patients diagnosed from 1998 to 2006 and comorbidity data from 2003 to 2011. Univariate association with covariates between PSC and other forms of NSCLC was assessed by the chi-square test or ANOVA, as appropriate.

RESULTS

Of the 1,547,531 NSCLC patients in the NCDB from 1998 to 2011, 7965 were identified with PSC (0.5%). PSC patients had a median age of 70 years, 59% were men, and 89% were white. At presentation, 18% had American Joint Committee on Cancer stage I disease, 10% stage II, 24% stage III, and 48% stage IV. The median OS for stage I-II PSC was 16.9 months, 5.8 months for stage III, and 5.4 months for stage IV. There was a higher risk of death on multivariate analysis for PSC patients compared to other histologic subtypes of NSCLC in all patients (hazard ratio = 1.34 (95% confidence interval, 1.20-1.48) P < .001) and in propensity score-matched subsets (hazard ratio = 1.34; 95% confidence interval, 1.15-1.56; P < .001).

CONCLUSION

PSC is a rare histologic subtype of NSCLC, accounting for 0.5% of all lung cancers. The disease of patients with PSC has aggressive clinical characteristics and an inferior survival outcome relative to other histologic subtypes of NSCLC.

Pemetrexed and bevacizumab-containing chemotherapy for pleomorphic carcinoma of the lung

Pleomorphic carcinoma of the lung is a rare, highly malignant subtype of lung cancer, with a more aggressive clinical course compared with other types of non-small-cell lung cancer (NSCLC). Pemetrexed and bevacizumab are currently evaluated as two of the most reliable chemotherapeutic drugs for advanced NSCLC. We herein report a case of a 68- and a 46-year-old man with recurrent and chemo-naïve pleomorphic carcinoma of the lung, respectively, who were treated with a combination of carboplatin, pemetrexed and bevacizumab. The overall survival after the initiation of chemotherapy was 30 and 8 months, respectively. These cases exhibited a relatively long-term survival with chemotherapy. In the absence of definitive clinical trials, which are unlikely to be performed due to the rarity of this tumor, our cases demonstrated the potential utility of pemetrexed- and bevacizumab-containing chemotherapy. Our results also suggested that pemetrexed-containing chemotherapy may be key to the treatment of pleomorphic carcinoma of the lung.

[Pulmonary sarcomatoid carcinoma]

Pulmonary sarcomatoid carcinomas are a rare group of tumors accounting for about one percent of non-small cell lung carcinoma (NSCLC). In 2015, the World Health Organization classification united under this name all the carcinomas with sarcomatous-like component with spindle cell or giant cell appearance, or associated with a sarcomatous component sometimes heterologous. There are five subtypes: pleomorphic carcinoma, spindle cell carcinoma, giant cell carcinoma, carcinosarcoma and pulmonary blastoma. Clinical characteristics are not specific from the other subtypes of NSCLC. Epithelial to mesenchymal transition pathway may play a key role. Patients, usually tobacco smokers, are frequently symptomatic. Tumors are voluminous more often peripherical than central, with strong fixation on FDG TEP CT. Distant metastases are frequent with atypical visceral locations. These tumors have poorer prognosis than the other NSCLC subtypes because of great aggressivity, and frequent chemoresistance. Here we present pathological description and a review of literature with molecular features in order to better describe these tumors and perhaps introduce new therapeutics.

[Clinical Characteristics and Prognostic Analysis of 38 Patients with Pulmonary Sarcomatoid Carcinoma]

BACKGROUND AND OBJECTIVE

Pulmonary sarcomatoid carcinoma is a rare histologic subtype of non-small cell lung cancer. The effective treatment for this disease has not well defined due to its extremely low morbidity. This study explores the clinicopathological characteristics and prognosis of 38 patients with PSC, so as to provide some clues for its diagnosis and treatment.

METHODS

The study enrolled 38 patients with PSC that were diagnosed with histology or cytology in our hospital between January 2000 and December 2013. We retrospectively analyzed general clinical characteristics, smoking history, tumor size, TNM staging, pathology, immunohistochemistry, diagnostic method, treatment and prognosis. We used SPSS 19.0 statistical software and Kaplan-Meier method to analyze our data.

RESULTS

Patients in this study were aged from 26 to 76 years old (the median age was 57.5 years old). Among all of them, the male to female ratio was 4:1, and 81.6% of patients had smoking history. Cough and hemoptysis were the most common primary symptoms. The median survival was 21 months, while one-year survival rate, three-year survival rate and five-year survival rate were 68.4%, 31.6% and 18.4% respectively. Tumor size, TNM staging, distant metastasis and surgery therapy were associated with the prognosis of patients.

CONCLUSIONS

Patients with PSC present with no special symptoms generally. According to our study, factors that affect patients' prognosis include tumor size, TNM staging, distant metastasis and surgery. Complete resection is the key treatment for PSC patients, but comprehensive chemoradiotherapy needs further exploration in evidence-based medicine. Biological target therapy may give new insight into treatment for PSC.
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Pulmonary pleomorphic carcinoma with rapid progression

We describe a case of pleomorphic carcinoma showing a recurrent tumor with massive hemorrhage and myxoid change in the chest wall 2 months after complete resection. Whereas specimens from the initial surgery revealed both adenosquamous carcinoma and sarcomatous elements, the recurrent tumor predominantly consisted of a sarcomatous element. The recurrent tumor had stronger immunoreactivity for mesenchymal markers than the primary tumor, indicating that the sarcomatous element had more malignant potential than the epithelial element.

A Case of Pulmonary Pleomorphic Carcinoma With Renal Metastasis

A 62-year-old man was referred to our hospital for an axillary mass. Computed tomography (CT) revealed a right axillary tumor and a left renal tumor. Needle biopsies of lung tumor and renal tumor were performed, but a definite diagnosis was impossible. Because his performance status worsened and the lung tumor grew day by day, chemotherapy with gemcitabine and cisplatin was started without definite diagnosis. However, the chemotherapy could not be continued because of interstitial pneumonia and the patient died because of the progression of disease. The final histopathologic diagnosis was pulmonary pleomorphic carcinoma based on immunohistochemical staining.

Clinical significance of the 'not otherwise specified' subtype in candidates for resectable non-small cell lung cancer

The histological subtype of non-small-cell lung cancer (NSCLC) is a significant factor when selecting treatment strategies. However, cases are occasionally encountered that are diagnosed as ‘not otherwise specified’ (NOS) prior to surgery, due to an uncertain histological subtype. The present study investigated the prognostic significance of the NOS subtype for patients with resectable NSCLC. Between 2001 and 2011, 1,913 patients were diagnosed with NSCLC using transbronchial biopsy and underwent surgical resection at two facilities in Japan. Of these patients, 151 (7.9%) were pre-operatively diagnosed with NSCLC-NOS (NOS group) and the remainder had confirmed histological subtypes (confirmed group). The present study compared the clinicopathological features and prognoses of these groups. Analyses of resected specimens revealed that pleomorphic cell carcinoma, large cell neuroendocrine cell carcinoma, large cell carcinoma and adenosquamous carcinoma were significantly more common in the NOS group than in the confirmed group (P<0.001, P=0.002, P=0.019 and P=0.014, respectively). The five-year survival rate was significantly poorer in the NOS group (60.5 vs. 67.1%; P=0.010), particularly for stage I disease (70.8 vs. 80.7%; P=0.007). The results of a multivariate analysis of overall survival indicated that NOS was a significant independent prognostic factor (hazard ratio, 1.40; 95% confidence interval, 1.02–1.86; P=0.041). These results indicated that pre-operative NOS was significantly associated with poorer survival, including for stage I disease. In conjunction with other clinicopathological parameters, NOS can be a useful prognostic factor when deciding on a treatment strategy for NSCLC.

Surgical treatment for pulmonary pleomorphic carcinoma: A retrospective study of 60 patients

BACKGROUND

Pleomorphic carcinoma is a rare epithelial malignant tumor. Because the clinical characteristics and behavior of the disease remain unclear, we investigated the clinicopathological findings and prognosis of 60 patients with pleomorphic carcinoma.

METHODS

The clinicopathological characteristics of 60 cases of pulmonary pleomorphic carcinoma identified between 1999 and 2011 were studied. Of these, 55 patients had peripheral disease and five had central disease. The tumor size in all patients was 1-9.5 cm (mean, 5.8 ± 4.5 cm), while 30 had lesions with a diameter larger than 5 cm. All patients underwent pulmonary resection.

RESULTS

There were no in-hospital deaths. The three and five year survival rates of all patients were 47.2% and 25.6%, respectively. The three and five year survival rates were 57.3% and 32.5% for N0 patients, and 25.4% and 17.1% for N1-2 patients, respectively. Overall survival was significantly different between the radical resection and incomplete resection groups. Multivariate Cox regression analyses of overall survival for all 60 patients indicated that radical resection (P= 0.041), tumor node metastasis (TNM) stage (P= 0.044), and nodal status (P= 0.029) were significant independent prognostic factors.

CONCLUSION

Pleomorphic carcinoma is a rare type of lung cancer. In our study, pleomorphic carcinoma of the lung was often found as a peripherally located large mass and was associated with a poor prognosis. Radical resection, TNM stage and nodal status were significant independent prognostic factors.

[Sarcomatoid carcinoma of the lung: retrospective study of 28 cases]

INTRODUCTION

Sarcomatoid carcinoma (SC) of the lung is defined by the World Health Organization as poorly differentiated non-small cell carcinoma that contains a component of sarcoma or sarcoma-like elements. It represents an overall continuum of epithelial and mesenchymal differentiation. Five subtypes are recognized: pleomorphic carcinoma, spindle cell carcinoma, giant cell carcinoma, carcinosarcoma, and pulmonary blastoma. The diagnosis is pathological and requires a good sampling of the tumor.

PATIENTS AND METHODS

Twenty-eight cases of primary sarcomatoid carcinoma, diagnosed between 1993 and 2010, were reviewed retrospectively, noting the clinicopathological characteristics.

RESULTS

The patient population consisted of 25 males and 3 females with mean age of 62.9 years (48-75 years). The symptomatology was dominated by respiratory symptoms. Imaging features showed a pulmonary mass invading pleura or thoracic wall in 5 cases. The diagnosis was made in all cases on histological examination. These 28 tumors were divided as below: into 19 pleomorphic carcinomas, 4 giant cell carcinomas, 1 spindle cell carcinoma and 4 carcinosarcomas. Twenty-seven tumors were treated surgically. Associated treatments were neoadjuvant (3 cases) or adjuvant chemotherapy (1 case) and preoperative radiotherapy (5 cases). Deaths occurred in 7 patients. Twenty-two patients were lost to follow up.

CONCLUSION

These tumors are frequently symptomatic, are locally advanced, and have higher rates of recurrence. Its prognosis is worse than that of other non-small cell lung cancer.

Long-term complete response in a patient with disseminated pulmonary pleomorphic carcinoma induced by cisplatin and gemcitabine

A 47-year-old man was referred to our department due to multiple metastases in the lungs and liver with pleural dissemination six weeks after undergoing curative surgery for lung pleomorphic carcinoma. He received two regimens of chemotherapy, both of which resulted in disease progression. Considering his good general condition, he was treated with cisplatin plus gemcitabine (GP). The metastatic lesions exhibited a complete response after six courses of GP, and the patient has remained free from recurrence for over six years. An immunohistochemical analysis revealed that the tumor was highly expressive of gemcitabine transporter human equilibrative nucleoside transporter 1, thus suggesting a high sensitivity to gemcitabine.

Intussusception caused by intestinal metastasis from lung pleomorphic carcinoma

Intussusception is the second most common abdominal emergency in children. On the contrary, it is rare in adults. Most of adult intussusceptions are caused by definable structural lesions, and about half of these lesions are malignant. However, intussusception caused by gastrointestinal metastasis from lung pleomorphic carcinoma is extremely rare, and only a few case reports have been published thus far. We present a rare case of gastrointestinal metastasis from lung pleomorphic carcinoma causing jejuno-jejunal and colon-colonic intussusceptions, and review the previously 3 published cases. Intussusceptions caused by gastrointestinal metastases should always be considered in the differential diagnosis of patients with lung pleomorphic carcinoma presenting with gastrointestinal symptoms. Metastasis-related intussusception is a poor prognostic indicator in patients with pleomorphic carcinoma, regardless of the treatment.

[Should elevated beta-HCG levels be an exclusion criteria in clinical trials? A case report of paraneoplastic secretion associated with lung adenocarcinoma]

We report the case of a 55-year-old woman with pulmonary adenocarcinoma and bone metastases who was diagnosed with paraneoplastic secretion of the beta subunit of human chorionic gonadotropin (beta-HCG) while being screened for inclusion in a clinical trial. Immunohistochemistry analysis of a bone biopsy revealed strong staining of cancer cells with anti-beta HCG antibodies. Serial measurements of circulating Beta HCG seemed to be influenced by antineoplastic treatments, although they were not strictly associated with tumour evolution assessed by CT scans. Little is known about paraneoplastic secretion of beta HCG, although it has been found in 12% to 24% of non-small cell lung cancers. Usefulness of serial measurements of beta HCG for monitoring NSCLC has yet to be demonstrated, but its use as a criterion for inclusion in clinical trials needs to be questioned.