Adenosquamous carcinoma

Vaginal metastasis of lung cancer: A case report

Lung adenosquamous carcinoma (ASC) is a rare biphasic malignant tumor with squamous cell carcinoma (SCC) and adenocarcinoma (AC) components. ASC is reported to be aggressive; the most common metastatic sites are the regional lymph nodes and surrounding areas. A 46-year-old woman was referred to the emergency department with a persistent dry cough. She underwent fibro-bronchoscopy and was diagnosed with an adenosquamous lung carcinoma. Other than pulmonary and lymphatic findings, a total-body computed tomography (CT) examination highlighted a hypodense formation, of about 9 mm, with a cystic appearance, at the level of the vaginal region. A biopsy performed in the posterior vaginal wall highlighted a vaginal wall flap with subepithelial localization of neoplasia, compatible with the pulmonary ASC. Oncologists took charge of the case and the patient commenced medical therapy with entrectinib. Four months later, she developed dyspnea, and high-resolution CT highlighted an increase in the pathological tissue causing bronchial occlusion. The patient underwent endobronchial stent placement and thereafter restarted therapy with entrectinib, previously stopped because of the new symptoms, and was closely monitored. Apparently only one case of vaginal metastasis from pulmonary tumor has been previously reported, and this is the first report of vaginal metastasis from ASC. Although extremely rare, the presence of such metastasis should be considered in women with suspected vaginal neoformations.

Differences between complex epithelial neoplasms of the ovary and high-grade serous ovarian cancer: a retrospective observational cohort study

BACKGROUND

Complex epithelial neoplasms of the ovary (CENO), an uncommon pathological histotype in ovarian cancer, comprises adenosquamous carcinoma and adenocarcinoma with metaplasia. Owing to the rarity of relevant reports, there are currently no statistics on outcomes based on large samples. Meanwhile high-grade serous ovarian cancer (HGSOC) is the most common histotype in ovarian cancer which has a recognized first-line treatment regimen and poor prognosis. Thus, we aimed to determine the characteristics, prognosis, and independent predictors of survival for CENO, compare them with those of HGSOC and construct prognostic predictive models and nomograms.

METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) database to determine patients diagnosed with CENO or HGSOC from 2000 to 2017. Clinical, demographic, and treatment characteristics were compared between these groups. Propensity score matching, Cox risk regression analysis, Kaplan-Meier survival curves, and the Least Absolute Shrinkage and Selection Operator regression analysis were employed for analyzing the data.

RESULTS

Here, 31,567 patients with HGSOC and 216 patients with CENO between 2000 and 2017 in the SEER database were enrolled. Age < 57 years, unmarried, and early-stage diseases were more common in patients with CENO than in those with HGSOC. Women with CENO were less likely to receive adjuvant chemotherapy (65.7% vs. 79.4%) but more likely to receive radiotherapy (6.0% vs. 0.8%; both p < 0.001) than those with HGSOC. Year of diagnosis, surgery status, number of primary tumors, grade, and FIGO stage were independent prognostic factors for overall and cancer-specific survival in CENO. Overall survival rates were significantly lower for CENO than for more malignant HGSOC.

CONCLUSIONS

In summary, CENO was rare in ovarian cancer, while the year of diagnosis, surgery status, number of primary tumors, grade, and FIGO stage were independent prognostic factors. Compared with other common malignant ovarian tumors, CENO had a poor prognosis. Prognostic predictive models and nomograms had been determined to predict the individual survival rates of patients with CENO. These methods could improve evaluations of survival and therapeutic decisions for patients.

Heterogeneity of tumor immune microenvironment and real-world analysis of immunotherapy efficacy in lung adenosquamous carcinoma

Lung adenosquamous carcinoma (ASC) is an uncommon histological subtype. We aimed to characterize the tumor immune microenvironment (TIME) in lung ASC and estimate patient response to immune checkpoint inhibitors (ICIs), which have never been systematically investigated. In cohort I, we collected 30 ASCs from a single center for analysis of TIME characteristics, including immuno-phenotyping, tumor mutation burden (TMB), T-cell receptor (TCR) repertoires, tumor-infiltrating lymphocytes (TILs), and immune checkpoint expression. Twenty-two (73.3%) patients were EGFR-positive. The TIME was defined by immune-excluded (60%) and immune-desert phenotype (40%). Strikingly, programmed cell death-ligand 1 (PD-L1) and programmed cell death-1 (PD-1) were predominantly expressed in squamous cell carcinoma components (SCCCs) versus adenocarcinoma components (ACCs), where enhanced CD4⁺ FOXP3⁺ regulatory T cell and attenuated CD57⁺ natural killer cell infiltration were present, consistent with a landscape of fewer innate immune cells, more immunosuppressive cells. SCCCs had higher TMB, higher TCR clonality, and lower TCR diversity than ACC. In cohort III, the efficacy of ICI-based therapy was estimated using a real-world data of 46 ASCs from 11 centers. Majority of 46 patients were driver genes negative and unknown mutation status, 18 (39%) and 18 (39%), respectively. The overall objective response rate of 28%, median progression-free survival of 6.0 months (95% confidence interval [CI] 4.3–7.7), and median overall survival of 24.7 months (95% CI 7.2–42.2) were observed in the ICI-based treatment. This work ascertains suppressive TIME in lung ASC and genetic and immuno-heterogeneity between ACCs and SCCCs. Lung ASC patients have a moderate response to ICI-based immunotherapy.

Surgical Options for Resectable Lung Adenosquamous Carcinoma: A Propensity Score-Matched Analysis

Background

Surgery is the primary treatment option for Lung adenosquamous carcinoma (ASC) patients. However, no study compares the benefits of lobectomy and sublobar resection in ASC patients.

Methods

A total of 1379 patients in the Surveillance, epidemiology, and End Results (SEER) database and 466 patients in Shanghai Pulmonary Hospital (SPH) were enrolled. Survival benefits were evaluated after possible confounders were eliminated by propensity score matching (PSM).

Results

After 1:3 PSM, 463 SEER database patients and 244 SPH patients were enrolled. Lobectomy was associated with better overall survival (OS) and disease-free survival (DFS) than sublobar resection for ASC patients (5-year OS of SEER: 46.9% vs. 33.3%, P =0.017; 5-year OS of SPH: 35.0% vs. 16.4%, P =0.002; 5-year DFS of SPH: 29.5% vs. 14.8%, P =0.002). Similar results were observed in stage I patients. Univariate and multivariate Cox regression analyses showed that sublobar resection was an adverse prognostic factor independently (SEER: HR: 1.40, 95%CI: 1.08-1.81, P =0.012; SPH: HR: 1.73, 95%CI: 1.11-2.70, P =0.015). Subgroup analysis showed that all of the ASC patient subtypes tended to benefit more from lobectomy than sublobar resection.

Conclusions

Lobectomy remains the primary option for ASC patients compared to sublobar resection, including stage I.

The histologic phenotype of lung cancers is associated with transcriptomic features rather than genomic characteristics

Histology plays an essential role in therapeutic decision-making for lung cancer patients. However, the molecular determinants of lung cancer histology are largely unknown. We conduct whole-exome sequencing and microarray profiling on 19 micro-dissected tumor regions of different histologic subtypes from 9 patients with lung cancers of mixed histology. A median of 68.9% of point mutations and 83% of copy number aberrations are shared between different histologic components within the same tumors. Furthermore, different histologic components within the tumors demonstrate similar subclonal architecture. On the other hand, transcriptomic profiling reveals shared pathways between the same histologic subtypes from different patients, which is supported by the analyses of the transcriptomic data from 141 cell lines and 343 lung cancers of different histologic subtypes. These data derived from mixed histologic subtypes in the setting of identical genetic background and exposure history support that the histologic fate of lung cancer cells is associated with transcriptomic features rather than the genomic profiles in most tumors.

The molecular determinants of lung cancer histologic subtypes are not well understood. Here the authors analyze lung cancers of mixed histology and find that histologic subtypes are associated with transcriptomic features rather than genomic profiles in most tumors.

Clinical significance of visceral pleural and lymphovascular invasion in surgically resected adenosquamous lung cancer

OBJECTIVES

The aim of this study was to assess the relationship between visceral pleural invasion (VPI), lymphovascular invasion (LVI) and other clinicopathological characteristics and their prognostic impact on surgically resected adenosquamous carcinoma (ASC).

METHODS

We retrospectively reviewed 256 patients with radically resected ASC between January 2010 and December 2015. Patients were divided into 2 groups: those with VPI and those with LVI. The effects of VPI and LVI on disease-free survival and overall survival were evaluated, further stratified by tumour size and lymph node status.

RESULTS

Finally, 213 patients with ASC were enrolled in our study. VPI was correlated with tumour location (P < 0.001), pT stage (P < 0.001) and pN stage (P = 0.012). LVI was related to age (P = 0.005) and pN stage (P = 0.003). Both VPI and LVI were adverse prognostic factors for disease-free survival (P = 0.008, P = 0.028) and overall survival (P = 0.005, P = 0.009) using the Kaplan-Meier method. In multivariable analysis only, VPI was an independent risk factor for disease-free survival [hazard ratio (HR) 0.61, 95% confidence interval (CI) 0.42-0.87; false discovery rate, adjusted P = 0.020] and overall survival (HR 0.60, 95% CI 0.42-0.86; false discovery rate, adjusted P = 0.017). When the prognostic value of VPI was stratified by tumour size and lymph node status, we observed that only patients with VPI in tumours ≤4 cm and patients with N0 status had a worse prognosis than those without visceral invasion (P < 0.05).

CONCLUSIONS

VPI and LVI were poor prognostic factors in patients with ASC, but only VPI was an independent factor for survival, especially in patients with tumours ≤4 cm and pN0 status.

An Uncommon Lung Neoplasm in a Young Patient: Diagnostic Challenges

Patient: Female, 29-year-old

Final Diagnosis: Lung adenosquamous carcinoma

Symptoms: Cough • Low back pain • night sweats • thoracic pain • weight loss

Medication: —

Clinical Procedure: Chemotherapy • CT-scan • fiberoptic bronchoscopy • radiotherapy • transbronchial biopsy

Specialty: Oncology • Pulmonology

Primary Adenosquamous Cell Carcinoma of the Ileum in a Dog

A 9-year-old male, castrated Chihuahua was examined because of a 7-day history of intermittent vomiting. A mass in the small intestine was identified on abdominal radiography and ultrasonography. Laparotomy revealed a mass lesion originating in the ileum, and surgical resection was performed. The mass was histologically diagnosed as adenosquamous cell carcinoma. Chemotherapy with carboplatin was initiated, but the dog was suspected to have experienced recurrence 13 months after surgery and died 3 months later. To our knowledge, this is the first case report to describe the clinical course of adenosquamous cell carcinoma in the small intestine of a dog.

Tumor Location and Survival Outcomes in Lung Adenosquamous Carcinoma: A Propensity Score Matched Analysis

Background

There is little information in the literature available on lung adenosquamous carcinoma (LASC). The association between tumor location and survival outcomes in LASC is poorly understood. Our study was designed to probe the effect of tumor location on survival outcomes of LASC.

Material/Methods

Patients with LASC between 2004 and 2015 were identified using the Surveillance, Epidemiology and End Results (SEER) databases. The patients were divided into 2 groups, a main bronchus group and a peripheral group, according to their primary sites. The Propensity Score Matching (PSM) method was used to reduce possible bias between groups. The primary endpoints were overall survival (OS) and cancer-specific survival (CSS).

Results

A total of 3176 patients, afflicted with LASC between 2004 and 2015, were extracted from the SEER databases. Of these, 212 patients were found to be eligible for analysis after a propensity 1: 1 nearest neighbor matched analysis. After PSM, multivariate Cox regression analysis showed that primary site, American Joint Committee on Cancer (AJCC) stage, T stage and surgery were independent predictors of LASC in both OS and CSS. Kaplan-Meier survival analysis showed that patients with LASC located in a peripheral site had better survival outcomes than those with LASC located in the main bronchus. In subgroup analysis, the advantages of tumor located in a peripheral site were more pronounced in female patients and AJCC stage I patients.

Conclusions

Tumor location may have an impact on the survival outcomes of patients with LASC. Patients with LASC located in a peripheral site had better survival outcomes than patients with LASC located in the main bronchus, particularly in female patients and AJCC stage I patients.

Development and validation of a nomogram for predicting cancer-specific survival of surgical resected stage I-II adenosquamous carcinoma of the lung

OBJECTIVES

Primary lung adenosquamous carcinoma (ASC) is a rare cancer subtype and has a poor prognosis. The prognostic factors for resected early-stage ASC remain unclear. We aimed to develop a nomogram to predict lung cancer-specific survival (LCSS) of patients undergoing surgical resection for stage I-II ASC.

METHODS

Data of patients undergoing resection for stage I-II ASC and diagnosed between 2004-2015 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. All the included patients were randomized at a 7:3 ratio into a training and a validation cohort. We selected and integrated significant prognostic factors based on competing for risk regression to build a nomogram. The performance of the nomogram was evaluated using Harrell's concordance index (C-index) and calibration plots.

RESULTS

A total of 988 patients (530 men and 458 women) undergoing surgical resection for stage I-II ASC were identified and randomized into a training (692, 70%) cohort and a validation cohort (296, 30%). The baseline characteristics were similar in the training and validation cohorts. Age, T stage, N stage, and the number of examined lymph nodes were independent prognostic factors for LCSS and were used in the nomogram. The calibration plots showed that the 3- and 5-year LCSS probabilities were consistent between the nomogram prediction and the actual observation. The C-index of the nomogram was 0.671 (95%CI: 0.618-0.724) and 0.635 (95%CI: 0.557-0.713) in the training cohort and validation cohort, respectively. We developed a risk classification system based on the nomogram to stratify patients into high- and low-risk of cancer-specific death groups. Patients with a similar risk shared similar prognostic prediction regardless of the stage category and patients with the same risk shared similar prognoses despite the different stage category.

CONCLUSIONS

We developed a competing risk nomogram to reliably predict cancer-specific survival of patients undergoing surgical resection for stage I-II ASC. The nomogram might be a useful tool to identify patients undergoing surgical resection for ASC who could be suitable candidates for adjuvant chemotherapy.

Genomic origin and EGFR-TKI treatments of pulmonary adenosquamous carcinoma

BACKGROUND

Adenosquamous carcinoma (ASC) of the lung is a heterogeneous disease that is composed of both adenocarcinoma components (ACC) and squamous cell carcinoma components (SCCC). Their genomic profile, genetic origin, and clinical management remain controversial.

PATIENTS AND METHODS

Resected ASC and metastatic tumor in regional lymph nodes (LNs) were collected. The ACC and SCCC were separated by microdissection of primary tumor. The 1021 cancer-related genes were evaluated by next-generation sequencing independently in ACC and SCCC and LNs. Shared and private alterations in the two components were investigated. In addition, genomic profiles of independent cohorts of adenocarcinomas and squamous cell carcinomas were examined for comparison. We have also carried out a retrospective study of ASCs with known EGFR mutation status from 11 hospitals in China for their clinical outcomes.

RESULTS

The most frequent alterations in 28 surgically resected ASCs include EGFR (79%), TP53 (68%), MAP3K1 (14%) mutations, EGFR amplifications (32%), and MDM2 amplifications (18%). Twenty-seven patients (96%) had shared variations between ACC and SCCC, and pure SCCC metastases were not found in metastatic LNs among these patients. Only one patient with geographically separated ACC and SCCC had no shared mutations. Inter-component heterogeneity was a common genetic event of ACC and SCCC. The genomic profile of ASC was similar to that of 170 adenocarcinomas, but different from that of 62 squamous cell carcinomas. The incidence of EGFR mutations in the retrospective analysis of 517 ASCs was 51.8%. Among the 129 EGFR-positive patients who received EGFR-TKIs, the objective response rate was 56.6% and the median progression-free survival was 10.1 months (95% confidence interval: 9.0-11.2).

CONCLUSIONS

The ACC and SCCC share a monoclonal origin, a majority with genetically inter-component heterogeneity. ASC may represent a subtype of adenocarcinoma with EGFR mutation being the most common genomic anomaly and sharing similar efficacy to EGFR TKI.

Adenosquamous carcinoma of the lung

Adenosquamous carcinoma of the lung (ASC), a relatively rare subtype of non-small-cell lung cancer, is defined as a malignancy containing components of lung adenocarcinoma (ADC) and lung squamous cell carcinoma (SCC). Although ASC has biological characteristics of ADC and SCC, it is not by any means a simple hybrid of two components above. It is extremely difficult to diagnose preoperatively; pathology of surgically resected gross specimen is the most effective means for adequate diagnosis of ASC. Platinum-based postoperative adjuvant chemotherapy for at least four cycles can significantly improve the survival in stage III patients with ASC. Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) such as erlotinib and gefitinib can be the effective therapeutic strategies for advanced EGFR-mutant ASC. The studies of crizotinib in the treatment of patients with ASC are very limited. Immune checkpoint blockade therapy may be a potential treatment choice for ASC patients.

Clinicopathological characteristics and survival outcomes in adenosquamous carcinoma of the lung: a population-based study from the SEER database

Adenosquamous carcinoma (ASC) of the lung is an unusual histology type in non-small-cell lung cancers. Due to its rarity, the clinicopathological characteristics and survival outcomes of the lung ASC are incompletely understood. We used the Surveillance, Epidemiology, and End Results (SEER) database to enroll 203,208 eligible patients, including 4,245 ASC, 124,253 adenocarcinoma (ADC) and 74,710 squamous cell carcinoma (SCC) patients. To date, this is the largest cohort in a study for ASC of the lung. With regard to age, sex, race, year of diagnosis, tumor size and SEER stage, ASC was intermediate between ADC and SCC. However, compared with ADC and SCC patients, ASC patients presented with a higher tumor grade and lower prevalence of nodal metastasis. More ASC patients underwent surgery and a lower proportion underwent radiation treatment and chemotherapy. Kaplan-Meier analysis showed that ASC patients had a better prognosis than ADC and SCC patients, but stratified analysis showed that the prognosis of ASC patients was worse than that of ADC and SCC patients in surgery and non-surgery subgroup. Multivariate analysis further confirmed that the ASC histology type was a risk factor for poor prognosis with respect to ADC and SCC. Using the propensity score matching to 1:1 match ASC with ADC or SCC, we found that ASC patients had worse survival than ADC and SCC patients. Subgroup analysis further demonstrated that ASC was a more aggressive histology type with a worse prognosis. These results provided a deep understanding of ASC, which contributed to better clinical diagnosis and treatment.

Characteristics of lymph node metastasis in resected adenosquamous lung cancer

The aim of this study was to retrospectively analyze the clinical data of resected adenosquamous lung cancer (ASLC) and to explore the influencing factors and clinicopathological characteristics of the metastasis lymph nodes. A total of 1156 consecutive patients with surgically resected lung cancer from January 2009 to June 2014 were studied. Fifty-four previously diagnosed ASLC patients were re-evaluated by experienced pathologists. IHC and H&E staining were employed to examine the primary focus and metastasis lymph nodes. The relationship between lymph node metastasis and clinicopathological characteristics of ASLC patients was then analyzed and the pathological type of metastasis lymph node was also determined. Forty-nine cases of typical ASLC were included in the study. Of the 49 ASLC patients, 26 cases presented lymph node metastasis. Lymph node metastasis was not associated with gender, smoking, tumor distribution, histological type of primary focus, and preoperative CEA level, but was associated with age ≥ 65 (P < .05) and tumor size ≥ 3 cm (P < .05). Lymph node metastasis adenocarcinoma was the main type in ASLC patients, and was related to the age and tumor size of the primary focus. Further large sample studies are necessary to identify influencing factors and clinicopathological characteristics of metastasis lymph nodes.