Clear cell adenocarcinoma of the colon: A case report and review of literature

Colonic de novo Clear Cell Adenocarcinoma of Intestinal-Type: A Case Report and Review of the Literature

Colorectal clear cell adenocarcinomas are rare tumors. They can be divided into two types: intestinal- and Müllerian-type. Most intestinal-type clear cell adenocarcinomas show a composite morphology, and most early-stage (T1) intestinal-type clear cell adenocarcinomas have an adenoma component. We report an additional early-stage (T1) colonic clear cell adenocarcinoma that was a de novo adenocarcinoma without any adenoma component. It had a pure morphology and the smallest size (0.6 cm) ever reported. Immunohistochemical results demonstrated an intestinal phenotype (KRT20+, KRT7-, CEA+, and CDX2+). Periodic acid-schiff and alcian blue stains were both negative, which demonstrated decrease in mucin expression in the clear tumor cells. Enteroblastic differentiation was observed in a few colorectal clear cell adenocarcinomas in the literature, while it had not been observed in the present tumor. The tumor did not have deep submucosal invasion and cancer embolus, endoscopic submucosal dissection with regular follow-up was an appropriate treatment for the patient. Due to the rarity and diversity of primary colorectal clear cell adenocarcinomas, the cause of clear cytoplasm change and the impact on patient prognosis remain unknown. Accumulating evidence indicates that clear cell adenocarcinomas of intestinal-type is a histological variant of colorectal adenocarcinoma.

Mucinous Adenocarcinoma of the Colon with Clear Cell Component: A Case Report and Literature Review

Clear cell adenocarcinomas of the colon are defined as a subtype of colorectal adenocarcinoma with clear cell morphology. A 65-year old man was admitted to a Gastroenterology Department for diagnostic evaluation of a tumor in the sigmoid colon found on CT. There, the patient developed complete bowel obstruction and was operated urgently, where intraoperatively, a large tumor in the sigmoid fixated to the lateral abdominal wall was revealed. A subtotal colectomy was performed. Histopathological analysis of the surgical specimen was conducted. The immunohistochemistry staining was positive for CEA, CDX2, and CD20 and negative for CK7, CD10, MUC2, AFP, and PAS staining. Mismatch repair protein testing was negative. The pathological diagnosis was mucinous carcinoma with a clear cell component which bears an extremely low incidence that has been scarcely reported in literature. This stresses the need for more case reports like ours to be published.

Early stage clear cell adenocarcinoma coexisting with tubular adenoma and adenoma with clear cell change in the colon

Primary clear cell adenocarcinoma (CCA) of the colorectum is rare. We report a case of a 57-year-old man with early-stage CCA with conventional tubular adenoma and tubular adenoma with clear cell change in the transverse colon, diagnosed with image-enhanced endoscopy. The tumor was then treated with endoscopic submucosal dissection. The endoscopic findings characteristic of clear cell adenoma/adenocarcinoma could not be identified. Therefore, similar diagnostic tools as for conventional colorectal adenoma/cancer were considered. The pathogenesis of the clear cell change was unknown, but it might appear with the progression of the malignancy.

Incidental morphological findings in colorectal adenomas

Owing to a sharp increase in the frequency of diagnosis of colorectal adenomas in the current era of population screening, distinctive morphological features are increasingly being observed. These may present diagnostic challenges and cause clinical management issues. Paneth cell metaplasia is a more common occurrence, but the incidence rates of squamous metaplasia, clear cell metaplasia, osseous metaplasia, neuroendocrine differentiation and signet‐ring cell‐like lesion are low, and they can be seen in <1% of colorectal adenomas. Their histomorphological characteristics are quite unique; ancillary studies are not very helpful and often not needed. In this review, we give an overview and describe the potential clinical consequences of such incidental and special morphological findings in colorectal adenomas.

Colorectal adenocarcinoma with enteroblastic differentiation: a clinicopathological study of five cases

AIMS

Colorectal adenocarcinoma with enteroblastic differentiation (CAED) is a rare malignancy, and its clinicopathological characteristics have not yet been fully elucidated. This study aimed to elucidate the clinicopathological features of CAED through immunostaining of enteroblastic lineage markers alpha-fetoprotein (AFP), glypican-3 (GPC3), and spalt-like transcription factor 4 (SALL4).

METHODS AND RESULTS

We identified five CAED cases (0.3%) from 1666 colorectal carcinomas, analysed the clinicopathological characteristics and performed immunostaining for AFP, GPC3 and SALL4. Three patients were male and two were female. All cases were located in the sigmoid colon or rectum. Histologically, all cases showed adenocarcinoma composed of cuboidal or columnar cells, with clear cytoplasm resembling the primitive gut; one case exhibited a partial hepatoid pattern. The depth of invasion was T2 and T3 in two and three cases, respectively. Lymphatic/venous invasion was found in all cases (100%), lymph node metastases in four of five cases (80%) and distant metastases in three of five cases (60%) (liver, two cases; lung, one case). Two patients died as a result of their disease during follow-up. Immunohistochemically, SALL4 and GPC3 were each positive in four of five cases, whereas one case with a hepatoid component was positive for AFP. All three CAED cases with distant metastases were GPC3-positive.

CONCLUSIONS

CAED was frequently located in the sigmoid colon or rectum, showed aggressive behaviour, such as lymph node metastasis and distant metastasis, and had a dismal prognosis. In addition, CAED was immunoreactive to AFP, GPC3 or SALL4, indicating that these markers may be characteristic of CAED.

Colon adenoma and adenocarcinoma with clear cell components - two case reports

Background

Diagnoses reflect clear cell morphologies when tumor cells have clear cytoplasm in many organs, and the nature of such clear cells is typically identified. Colorectal tubular adenoma or adenocarcinoma, conversely, rarely show clear cells, the reason for which remains uncertain. We report 2 colon tumors with clear cell components (Case 1: adenoma; Case 2: adenocarcinoma) and investigate the nature of the clear cells.

Case presentation

Case 1 was a 75-year-old man with a superficial elevated polyp detected in the rectum for whom endoscopic submucosal dissection was performed. Microscopically, 10% of the tumor showed dysplastic columnar epithelium with clear cytoplasm forming tubular structures accompanied by conventional tubular adenoma. Case 2 was a 58-year-old man with a pedunculated polyp found in his sigmoid colon for which polypectomy was performed. Microscopically, 90% of the tumor showed dysplastic columnar epithelium with clear cytoplasm forming fused glands or cribriform structures adjacent to the ordinal tubular adenocarcinoma. In both cases, clear and ordinary tumor cells were negative for CK7 and positive for CK20 and CDX2, consistent with findings of colorectal origin. Different results were found for CEA and CD10 staining. CEA was positive on the luminal side of the conventional area in contrast diffuse cytoplasmic staining of the clear cell area in both cases. CD10 was only positive for the clear cell component of case 2. The clear cell components were negative for Periodic acid-Schiff (PAS), Alcian blue, and mucicarmine staining and AFP immunohistochemistry. An ultrastructural examination found multiple cytoplasmic lipid-like vacuoles in the clear cell component that were predominantly negative for adipophilin by immunoelectron microscopy.

Conclusions

We investigated tubular adenoma and tubular adenocarcinoma with clear cell components. The accompanying conventional tubular adenoma or adenocarcinoma cells helped us to evaluate the atypia of the clear cells. Diffuse cytoplasmic staining of CEA and CD10 suggested that the clear cell component might harbor malignant potential. We were unable to verify the well-known causes of clear cytoplasm, such as an accumulation of glycogen, lipid, or mucin and enteroblastic differentiation. The causes of clear cells in the colorectal region remain uncertain; however, possible explanations include autolysis and carbohydrate elution.

Diagnostic and reporting issues of preneoplastic polyps of the large intestine with early carcinoma

Premalignant polyps of the large intestine are common specimens in surgical pathology. They consist of several different subtypes identifiable by histological criteria that are associated with different molecular characteristics and with the development of different types of colorectal carcinoma. The most common of these is the conventional adenoma, which most commonly leads to carcinomas with a low degree of methylation (CIMP-L) that are microsatellite stable. In Lynch syndrome patients these polyps lead to CIMP-L carcinomas that are microsatellite instable. The second most common is the sessile serrated adenoma, which leads to carcinomas with a high degree of methylation (CIMP-H) that may be either microsatellite stable or instable. The least common premalignant polyp is the traditional serrated adenoma, which can lead to either CIMP-L or CIMP-H carcinomas, most often microsatellite stable. This paper will review the histological features of these lesions, discuss problems in diagnosis and discuss the role of histology in management.

Early stage clear cell adenocarcinoma of the colon examined in detail with image-enhanced endoscopy: a case report

Primary clear cell adenocarcinoma (CCA) of the colorectum is a rare tumor. We report on a 48-year-old man with early stage CCA in the descending colon who underwent detailed examination with image-enhanced endoscopy, such as magnifying endoscopy with narrow-band imaging and crystal violet staining. The tumor was treated successfully with endoscopic mucosal resection at our hospital.

Clear cell colorectal carcinoma: Time to clarify diagnosis

Primary clear cell colorectal carcinoma (CCC) is a very rare entity accounting for only 35 cases reported in the Literature. CCC is neither classified as a distinct entity nor is it defined as a CRC variant because its ontogeny remains unclear. Most of the reported CCC were found in the distal colon in patients with a mean age of 56 years. Histologically, clear cell change is the main morphologic feature and may present in a "pure" form, composed exclusively of clear cells, or in a "composite" form, admixed with other morphologically different components. It is possible to distinguish two biologically different types of CCC, with different clinical-pathologic features, therapeutic management and diagnostic criteria: a) Intestinal CCC consisting of an aggressive neoplasm, affecting mainly adult men, characterized by an intestinal-type immunoprofile (CK20+, CK7-, CEA+, CDX-2+) and b) Müllerian CCC consisting of an indolent carcinoma of the sigmoid-rectum, affecting young women, characterized by a different (CK7+, CK20-, CEA-, CA125 +) immunoprofile. Considerable diagnostic difficulties can arise in distinguishing CCC and primary or secondary clear cell neoplasms, such as metastases from renal carcinoma, lower urinary tract, female genital tract, adrenal gland, mesothelioma, melanoma and primary intestinal PEComa. In this paper we review the Literature with two additional cases in order to define the diagnostic criteria of CCC.

Primary clear cell adenocarcinoma of the colon presenting as a huge extracolic mass: A case report

A primary clear cell adenocarcinoma of the colon is a rare oncologic entity. The current study presents a case of such a tumor in the transverse colon of a 26-year-old male, and describes the computed tomography features of the neoplasm. The tumor appeared as an extensive extracolic mass, which displaced the loop of the small bowel and pancreas, and invaded the spleen. A laparotomy was performed and a huge mass measuring 12 cm maximally was revealed, arising from the transverse colon close to the left colonic flexure, with invasion of the spleen. The tumor and the spleen were resected concurrently. Histopathological examination of the excised mass revealed features of clear cell adenocarcinoma. A primary clear cell adenocarcinoma of the colon is a rare tumor, with only 13 cases reported in the English literature at present. The present case is reported here due to its rarity.

Clear cell adenocarcinoma of the colon: a case report and review of the literature

Clear cell adenocarcinoma of the colon has been described scarcely in the literature. It affects elderly men more commonly than women and usually appears in the left side of the colon. A Hispanic 41-year-old female came to the emergency room with abdominal pain, vomiting, and distension. Physical exam revealed generalized tenderness without peritoneal signs. Laboratory data was unremarkable. A CT scan showed an apple-core lesion in the distal colon. A flexible sigmoidoscopy revealed an obstructive mass that made further evaluation impossible. Exploratory surgery revealed a hard mass obstructing the descending colon, which was resected. Histopathology analysis with immunohistochemistry staining was positive for cytokeratin 20, cytokeratin 10, CDX2, and villin, while it was negative for cytokeratin 7, RCC, vimentin, and CD31. These results confirmed the clear cell variant of the adenocarcinoma. Clear cell adenocarcinomas usually arise from the kidneys and Müllerian organs. Immunohistochemistry is crucial for establishing the origin of these neoplastic cells. A cytokeratin 20+/7− with positive CDX2 is highly specific and sensitive for intestinal neoplastic origin. The main treatment has been surgery alone with moderately good results. More research and information about this malignancy is needed, especially in regard to prognosis and in order to provide the best treatment option.

Clear cell change in colonic tubular adenoma and corresponding colonic clear cell adenocarcinoma is associated with an altered mucin core protein profile

Clear cell change is seen in <1% of colonic tubular adenomas (TAs) and remains incompletely characterized. Associated adenocarcinomas can also demonstrate a clear cell phenotype. Eleven TAs with at least focal clear cell change with or without associated invasive adenocarcinoma, from 10 patients were studied. The lesions were stained with periodic acid-Schiff (PAS)/PAS-diastase and immunolabeled with antibodies to MUC2, MUC5AC, MUC6, CK7, CK20, and CDX2. Eight of 11 (77%) TAs with clear cell change had focal to extensive high-grade dysplasia. Two were associated with invasive clear cell adenocarcinoma. The adenomas and adenocarcinomas ranged from 0.5 to 3.5 cm. PAS/PAS-diastase stains showed minimal PAS(+) material in the clear cells. On immunohistochemical studies, the clear cells had decreased MUC2 labeling compared with the surrounding conventional adenoma in 9 of 11 (88%) cases, including the 2 clear cell adenocarcinomas. In 3 of the 11 lesions, the background TA showed at least focal MUC5 immunoreactivity, their associated clear cell area had decreased MUC5 labeling in all 3 cases. No immunoreactivity to MUC6 was observed in the background TAs and clear cells in all cases. Compared with background TA, both increased and decreased expression of CK7, CK20 (in quantity), and CDX2 (in intensity) were observed in the clear cells of TAs and adenocarcinomas. One of the clear cell adenocarcinomas was CK20, CK7, CDX2 and the other was CK20, CK7, CDX2-focal positive. Thus, although the clear cells have different MUC protein profiles than the background adenomatous epithelium, invasive clear cell adenocarcinomas retained the typical CK20(+)/CK7(-) profile of conventional adenocarcinomas. Our results indicate that clear cell adenocarcinomas can be primary to the colorectum with identifiable precursors. Awareness of them and their immunoprofile allows distinction from clear cell lesions from other sites.

Perivascular epithelioid cell neoplasm of the colon

A 17-year-old female presented with rectal bleeding from an ulcerated sigmoid mass in 1994. Initial pathological evaluation revealed a rare clear cell neoplasm of the colon, possibly originating from kidneys, adrenals, lung or a gynecologic source as a metastatic lesion. Extensive imaging studies were negative, and over the next 15 years, she remained well with no recurrence. The original resected neoplasm was reviewed and re-classified as a perivascular epithelioid cell neoplasm (PEComa). Although the long-term natural history of PEComas requires definition, increased clinical and pathological awareness should lead to increased recognition of an apparently rare type of colonic neoplasm that likely occurs more often than is currently appreciated.

Clear cell adenocarcinoma of the colon is a unique morphological variant of intestinal carcinoma: Case report with molecular analysis

Here we report a new case of clear cell adenocarcinoma (CCA) of the colon in a 54-year-old Caucasian man. Despite of the previous reported cases, the lesion was located in the right colon and was not associated with the conventional adenoma. We performed immunohistochemical and molecular analyses in order to explore whether the CCA had the molecular features generally associated with conventional colorectal carcinoma. The immunohistochemical and molecular analyses showed that the different morphology of CCA does not reflect a distinct biological entity but only an unusual morphological variant of intestinal carcinoma.