Primary adenosquamous carcinoma of the liver which produces granulocyte-colony-stimulating factor and parathyroid hormone related protein: association with leukocytosis and hypercalcemia

Unresectable primary hepatic adenosquamous carcinoma successfully treated with systemic and transcatheter hepatic arterial injection chemotherapies followed by conversion surgery: a case report and literature review

Background

Primary hepatic adenosquamous carcinoma (ASC) is a type of tumor that has the features of both adenocarcinoma and squamous cell carcinoma (SCC). The prognosis for patients with ASC is poor, as the chemotherapy has been ineffective so far.

Case presentation

Here, we report a case of a 62-year-old male patient who presented with high fever. The tumor marker levels were high, and abdominal dynamic computed tomography showed a liver tumor and distant lymph node metastases. Upon further investigation, needle biopsy of the liver tumor showed a primary hepatic SCC. Because the SCC was unresectable, the patient was treated with tegafur/gimeracil/oteracil (S-1) and transcatheter hepatic arterial injection (TAI) of cisplatin. After chemotherapy, a surgical resection performed on the remaining liver tumor, made the patient cancer-free. After the operation, the liver tumor was confirmed as primary hepatic ASC. Subsequently, the patient was administered postoperative adjuvant chemotherapy, which prevented its recurrence.

Conclusions

Due to the lack of an effective treatment for primary hepatic ASC, its prognosis is poor. Here, we suggest that a chemotherapy combination of 5-fluorouracil (S-1) and cisplatin along with conversion surgery might be an effective way for treating primary hepatic ASC. Our experience from this case shall be valuable to clinicians around the world involved in the treatment of primary hepatic ASC.

Usefulness of 18F-fluorodeoxyglucose positron emission tomography for assessment of tumorviability after resection of granulocyte-colony-stimulating-factor -Producing cholangiocarcinoma-a case report

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Surgical case of Granulocyte-Colony-Stimulating-Factor -Producing Cholangiocarcinoma is limited.

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¹⁸F-fluorodeoxyglucose positron emission tomography is reported to be useful in diagnosis.

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¹⁸F-fluorodeoxyglucose uptake in bone marrow is characteristic in this disease.

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We used FDG uptake not only diagnosis but assessing tumor viability and determining the surgical indication after postoperative recurrence.

Introduction and importance

Granulocyte colony-stimulating factor (G-CSF)-producing intrahepatic cholangiocarcinoma is rare. Surgical cases with postoperative clinical course have rarely been reported.

Case presentation

A 63-year-old woman complained upper abdominal pain. Computed tomography (CT) showed intrahepatic mass measuring 9 × 9 × 9 cm in the left lateral segment. ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET) showed high uptake by the tumor, with diffuse uptake in the bone marrow. An extended left lobectomy was performed to achieve complete resection. Histopathological examination showed poorly differentiated adenocarcinoma with no lymph node metastasis. Immunohistochemical analysis revealed that tumor cells produced G-CSF. After chemotherapy with S-1 regimen at 10 months after the operation, CT and FDG-PET detected lymph node metastasis in the peri-duodenal area and left kidney metastasis, with no FDG uptake in the bone marrow. Serum G-CSF was normal. Combination chemotherapy with gemcitabine plus cisplatin was administered, and, 12 months after liver resection, metastases were enlarged and FDG uptake in the bone marrow was detected again. Serum G-CSF was elevated at 71.6 pg/mL. The patient was enrolled in a clinical trial of chemotherapy with another regimen and was alive at 19 months after liver resection.

Clinical discussion

Because of rapid progression, rapid diagnosis and resection are important. FDG uptake in the bone marrow is characteristic in G-CSF producing tumor. In this case, FDG uptake in the bone marrow reappeared after the enlargement of recurrent lesions, followed by tumor enlargement.

Conclusion

FDG-PET was useful for differential diagnosis and to assess tumor viability and determine the surgical indication.

Hypopharyngeal squamous cell carcinoma producing both granulocyte colony-stimulating factor and parathyroid hormone-related protein

A 57-year-old woman was admitted to Hokkaido University Hospital because of dysphagia. Laryngoscopy indicated hypopharyngeal tumor histologically diagnosed as squamous cell carcinoma (SCC). A combination of radiotherapy and chemotherapy was performed for 2 months, and the hypopharyngeal lesion completely regressed. After 4 months, fever, anorexia, and malaise appeared, and chest X-ray and CT indicated two large tumors in the right lung. Transbroncheal lung biopsy (TBLB) specimens were diagnosed as SCC. Laboratory data showed high levels of serum granulocyte colony-stimulating factor (G-CSF) and parathyroid hormone-related protein (PTHrP). Subsequently, positron emission tomography (PET) showed multiple metastases to several organs including the liver, spine, skull, and thigh. Two months after readmission, the patient died with no success of chemotherapy. At autopsy, the lung tumor was clearly positive for both G-CSF and PTHrP on immunohistostaining. Retrospectively, examination showed that the primary pharyngeal tumor was focally positive for these two cytokines. Thus, a certain population of hypopharyngeal cancer producing G-CSF and PTHrP, spread to various organs and contributed to the rapid progression and poor prognosis. This case is presented with a discussion of several other cases in the literature.

Unusual combination of paraneoplastic manifestations in a patient with metastatic gastrointestinal stromal tumor (GIST)

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Activating mutations in tyrosine kinase receptors KIT or platelet-derived growth factor receptor alpha (PDGFRA) are the main mechanisms causing the disease. Patients generally present with non-specific symptoms, while a number of tumors are discovered incidentally and may be metastatic at the time of diagnosis. Aggressive GISTs have a defined pattern of metastasis to the liver or throughout the abdomen, or both. Though GISTs rarely present systemic or isolated paraneoplastic reactions, a few cases have been reported in the literature. We present the case of a 54-year-old patient with metastatic GIST at diagnosis and the emergence of paraneoplastic manifestations during follow-up.

Carcinosarcoma of the liver producing granulocyte-colony stimulating factor

An autopsy case of carcinosarcoma of the liver producing granulocyte-colony stimulating factor (G-CSF) is reported. The patient, a 74-year-old Japanese man, presented with multiple liver masses. His serum G-CSF was elevated to 286 pg/mL and a marked leukocytosis of 19 100/microL was observed. The patient had a rapidly aggravated clinical course and died 57 days after admission. Autopsy revealed a liver carcinosarcoma composed both of hepatocellular carcinoma (HCC) and sarcomatous elements immunoreactive with alpha-smooth muscle actin and desmin. Immunohistochemistry revealed positive staining of G-CSF in the cytoplasm of HCC, whereas none of the spindle cells was positively stained. Production of G-CSF was also confirmed by enzyme-linked immunosorbent assay, using the frozen tumor tissue taken at the autopsy. Similar to the majority of G-CSF-producing tumors in the literature, only the epithelial elements of the present case were immunopositive for G-CSF. Although a monoclonal origin of carcinosarcomas has generally been proposed, heterologous differentiation from a single clone might lead to the production of G-CSF only in the epithelial element in the present case. It is suggested that G-CSF was associated with the high-grade transformation of the epithelial elements, as well as the reported phenomenon of conventional HCC producing G-CSF.

Laryngeal squamous cell carcinoma with ectopic production of granulocyte colony-stimulating factor and parathyroid hormone-related protein

It is known that malignant tumors occasionally produce hormone-like substances. However, they rarely produce two or more kinds of hormonal factors simultaneously. We describe the clinical, biochemical, and immunohistochemical findings in a patient with squamous cell carcinoma of the larynx associated with leukocytosis and hypercalcemia, without bone metastasis. The serum granulocyte colony-stimulating factor (G-CSF) level was 222 pg/ml (normal, < 38 pg/ml), and decreased to 15 pg/ml after surgery. The serum parathyroid hormone-related protein (PTHrP) level was 5.6 pmol/l (normal, < 0.5 pmol/l), and this also decreased, to less than 0.5 pmol/l. G-CSF and PTHrP increased again with tumor recurrence. The production of G-CSF from the tumor was confirmed by immunohistochemical staining with monoclonal antibody against human recombinant G-CSF. The tumor was revealed to produce both G-CSF and PTHrP. In this article, we describe this very rare case of primary squamous cell carcinoma of the head and neck with the simultaneous ectopic production of more than one hormone-like substance.