Pleomorphic carcinoma showing rapid growth, multiple metastases, and intestinal perforation

Case report: Pulmonary sarcomatoid carcinoma demonstrating rapid growth on follow-up CT

Background

The tumor growth rate and tumor volume doubling time are crucial parameters in diagnosing and managing lung lesions. Pulmonary sarcomatoid carcinoma (PSC) is a unique and highly malignant subtype of lung cancer, with limited documentation on its growth feature. This article aims to address the gap in knowledge regarding a PSC's growth patterns by describing the characteristics of a confirmed case using computed tomography, thereby enhancing the understanding of this rare disease.

Case presentation

A 79-year-old man was transferred to our center presenting with a mild cough, blood-tinged sputum, and a malignant nodule in the left upper lobe. Chest CT revealed a solid nodule in the left upper lobe. A follow-up CT ten days later showed a significant increase in the size of the nodule, accompanied by ground-glass opacity in the surrounding lung. The rapid preoperative growth of the nodule suggested a non-neoplastic lesion, and intraoperative frozen pathology also considered the possibility of tuberculosis. Subsequently, a left upper apical-posterior segment (S1 + 2) resection was performed. Postoperative tumor pathology confirmed the diagnosis of pulmonary sarcomatoid carcinoma with extensive giant cell carcinoma and necrosis. Immunohistochemistry indicated approximately 60% PD-L1 positive and genetic testing revealed a MET mutation. The patient was discharged with oral crizotinib targeted therapy, and his condition remained stable postoperatively. The patient is currently undergoing regular follow-up at our hospital, with no evidence of distant metastasis or recurrence.

Conclusion

Pulmonary sarcomatoid carcinoma can exhibit rapid tumor growth on imaging, and PSC should be considered in the differential diagnosis for lesions that present with a fast growth rate. Timely and appropriate treatment for PSC may lead to a good prognosis.

18F-FDG PET/CT imaging in pulmonary sarcomatoid carcinoma

Background

Pulmonary sarcomatoid carcinoma (PSC) is a rare highly aggressive and poorly differentiated non-small cell carcinoma, and little is known about the information on the usefulness of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT). We investigated the clinical and 18F-FDG PET/CT features of PSC.

Methods

We retrospectively analyzed 25 consecutive PSC patients who had undergone 18F-FDG PET/CT. Demographic data, PET/CT findings before treatment, pathological features, and prognosis in these patients were investigated to define correlates between maximal standard uptake value (SUVmax) and clinicopathological parameters.

Results

From March 2017 to January 2023, twenty-five eligible patients with PSC were identified. There were 23 (92%) men, aged 68.5 ± 8.5 (range 56-90) years. Eighteen (72%) patients had a frequent smoking history. The mean size of PSCs was 59.3 ± 18.6 (range 29-97) mm, and 23 (92%) PSCs were Stage IV tumors. 20 (80%) lesions were located in the upper lung and 19 (76%) cases belonged to the peripheral type. Necrotic foci appeared in 21(84%) tumors. 11 (44%) PSCs invaded the pleura. All PSCs were FDG avid, and the mean of SUVmax was 11.8 ± 5.3 (range 4.8-25.5). Metastases were found on PET/CT in 24(96%) patients. The SUVmax of the lesions ≥ 5cm was higher than that of the lesions < 5cm (p=0.004), and the SUVmax of lesions with TTF-1 expression was higher than those of lesions without TTF-1 expression (p=0.009). All of the 25 primary lesions were considered malignant and confirmative, probable, and possible diagnosis of PSC was made in 2 (8%), 4 (16%), and 5(20%) patients, respectively on PET/CT. PSC was not considered in 14 (56%) patients, in PET/CT. The survival of patients with surgery didn't demonstrate a significantly good prognosis as compared with those without surgery (p=0.675).

Conclusion

All PSCs had obvious FDG avidity. Although imaging diagnosis is still difficult, combined clinical and imaging features more than 40% of primary lesions were considered for the possibility of PSC in our group. Early histopathological diagnosis is necessary to help develop a reasonable regimen.

Metastasis to the stomach: a systematic review

Background: This study reviews the literature on gastric metastases (GM) in terms of diagnosis, treatment, and outcomes. The goal of this study was to provide clinicians with a reliable and beneficial source to understand gastric metastases arising from various primary tumors and to present the growing literature in an easily accessible form. Methods: Articles published in English language from implementation of MEDLINE and Cochrane databases until May 2022 were considered for the systematic review. Articles other than English language, letters to the editor, posters, and clinical images were excluded. Hematogenous and lymphogenic metastases were included whereas direct tumoral invasion and seeding were excluded. Articles and abstracts were analyzed and last selection was done after cross-referencing and by use of defined eligibility criteria. Results: In total 1,521 publications were identified and 170 articles were finally included totaling 186 patients with GM. The median age of patients was 62 years. Gynecologic cancer was the most common cancer type causing GM (67 patients), followed by lung cancer (33 patients), renal cancer (20 patients), and melanoma (19 patients). One of the main treatment methods performed for metastasis was resection surgery (n=62), sometimes combined with chemotherapy (ChT) or immunotherapy. ChT was the other most used treatment method (n=78). Also, immunotherapy was amongst the most preferred treatment options after surgery and ChT (n=10). Conclusions: As 172 case reports were screened in the systematic review from different journals, heterogeneity was inevitable. Some articles missed important information such as complete follow-up or clinical information. Moreover, since all of the included articles were case reports quality assessment could not be performed. Among 172 case reports reviewed, resection surgery was performed the most and was sometimes combined with ChT and immunotherapy. Further research about what type of treatment has the best outcomes for patients with gastric metastases is needed.

Sarcomatoid Carcinoma of the Lung With Gastrointestinal Metastasis Causing Small Intestinal Obstruction: A Rare Case of Acute Surgical Emergency

Pulmonary sarcomatoid carcinomas (PSCA) are a rare subset of Non-Squamous-Cell Lung Carcinoma (NSCLC), the most common pathological subtype of lung cancers which are the most common malignancy in the world. These rarest of rare tumours may have gastrointestinal metastasis and present as an acute abdominal surgical emergency with bowel obstruction or bleeding, as in our patient, who did not have a diagnosis of lung cancer till then. Use of novel immunohistochemistry markers like thyroid transcription factor-1 (TTF-1) may help diagnose the site of the primary tumour with accuracy in this clinical setting. Further evaluation of these patients with positron emission tomography (PET) scans helps determine the tumour burden and degree of dissemination. The aim of this article is to emphasize this rare presentation which may be unsuspected as a cause of bowel obstruction by surgical teams on the acute surgical take due to its rarity. It is vital that nihilism is avoided in these patients as a subset of these patients can still be offered curative metastectomy and treatment of the primary tumour with reasonable outcomes.

Cytokine Release Syndrome and Immune-Related Pneumonitis Associated With Tumor Progression in a Pulmonary Pleomorphic Carcinoma Treated With Nivolumab Plus Ipilimumab Treatment: A Case Report

Effective control of severe immune-related adverse events, including cytokine release syndrome (CRS), is essential for the success of immunotherapy. We present a case of a granulocyte colony-stimulating factor–producing pleomorphic lung carcinoma treated with nivolumab plus ipilimumab which developed CRS and severe immune-related pneumonitis. The effect of immunotherapy was heterogeneous; gastric metastasis was eliminated, but the pulmonary lesion had primary resistance. Steroid and tocilizumab were successful in controlling CRS, but additional infliximab was necessary to control pneumonitis. To control immune-related adverse events, it is important to choose immunosuppressive agents to the specific target organ and inflammatory cells.

Duodenal Metastasis of Pulmonary Pleomorphic Carcinoma: A Case Report

Pulmonary pleomorphic carcinoma (PPC) is a rare subtype of lung sarcomatoid carcinoma that has a poor prognosis, and no standard therapy has been established. Here, we report the case of a 74-year-old man with PCC who showed rare duodenal metastasis. He was referred to our hospital with a mass shadow in the right lung. The patient was diagnosed with PPC clinical stage II B on the basis of immunohistochemical staining from bronchoscopy, and the tumor proportion score of programmed death-ligand 1 was 80%. He did not want any treatment. A year and a half later, progressive anemia was detected. The primary tumor was stable; however, abdominal computed tomography and esophagogastroduodenoscopy revealed a duodenal tumor with stenosis. He was diagnosed with duodenal metastasis from PPC, and he underwent gastrojejunal bypass surgery to prevent bowel obstruction. After surgery, he received pembrolizumab for chemotherapy. However, owing to the progression of peritoneum dissemination, he died 2 months later due to the onset of melena.

Undifferentiated large cell/rhabdoid carcinoma presenting in the intestines of patients with concurrent or recent non-small cell lung cancer (NSCLC): clinicopathologic and molecular analysis of 14 cases indicates an unusual pattern of dedifferentiated metastases

Undifferentiated carcinoma metastatic to the bowel is uncommon in surgical pathology practice and might be confused with primary gastrointestinal carcinoma, melanoma, lymphoma, and others. We present 14 cases of uni- (n = 9) or multifocal (n = 5) undifferentiated large cell/rhabdoid carcinoma presenting in the bowel of patients with concurrent (n = 9) or recent (diagnosed 1 to 25 months earlier; median, 4) non-small cell lung cancer (NSCLC). Patients were 6 females and 8 males, aged 52 to 85 years. Primary NSCLC was verified histologically in 10 cases and by imaging in 4. The undifferentiated histology was present in the lung biopsy in 4/10 patients (as sole pattern in 3 and combined with adenocarcinoma in 1) and was limited to the intestinal metastases in the remainder. PDL1 was strongly expressed in 7/9 cases (CPS: 41 to 100). Loss of at least one SWI/SNF subunit was detected in 7/13 cases (54%). SMARCA2 loss (n = 6) was most frequent and was combined with SMARCA4 loss in one case. PBRM1 loss was observed in one tumor. Successful molecular testing of 11 cases revealed BRAF mutations in 4 (3 were non-V600E variants), KRAS mutations in 3, and wildtype in 4. None had EGFR mutations. Analysis of 4 paired samples revealed concordant KRAS (2) and BRAF (1) mutations or wildtype (1). Our study indicates that undifferentiated carcinoma within the intestines of patients with concurrent/recent NSCLC represents dedifferentiated metastasis from the NSCLC. Recognition of this unusual presentation is cardinal to avoid misdiagnosis with inappropriate therapeutic and prognostic implications.

Clinicopathological features and differential diagnosis of gastrofibromatosis-like undifferentiated carcinoma

Objective

To study the clinicopathological features and differential diagnosis of gastrofibromatosis-like undifferentiated carcinoma (GFLUC).

Methods

Three patients with GFLUC underwent histological and immunophenotypic analyses and fluorescence in situ hybridization to detect human epidermal growth factor receptor (HER2) gene amplification.

Results

Among the three patients (2 male [36 and 44 years old], 1 female [58 years old]), two had lesions in the gastric body and one had lesions in the gastric antrum. Histological analysis revealed mixtures of aggressive fibromatosis and undifferentiated carcinoma in all three cases. Highly invasive fibromatous tissue, consisting of fibroblasts, proliferating myofibroblasts, and collagenous fibrous tissues, accounted for >90% of the tumor, with undifferentiated cancerous tissue accounting for <10% scattered in the gaps within the invasive fibromatous tissue, with no glandular ducts or nests. Immunophenotypic analysis showed that the undifferentiated cancerous cells were positive for pan-cytokeratin, CDX2, villin, and p53, while the cytoplasm of invasive fibromatous cells was positive for vimentin, β-catenin, and smooth muscle actin. No HER2 gene amplification was detected.

Conclusions

Unlike other gastric carcinomas, GFLUC shows specific histological, biological, and immunophenotypic characteristics.

Pulmonary Pleomorphic Carcinoma Mimicking Primary Sarcoma of the Neck: A Case Report and Literature Review

We describe our challenge in diagnosing an unusual and rapidly progressing case of pulmonary pleomorphic carcinoma (PPC)-a rare, poorly differentiated, or undifferentiated non-small-cell carcinoma that can metastasize locally or distantly and has a poor prognosis. Our patient was an elderly man with a one-month history of abdominal pain, anorexia, and weight loss, diagnosed with atrophic gastritis via endoscopy, and treated medically without improvement. A week later, this patient developed pain in the head, neck, and shoulder area, and further examination revealed a thickening of his left neck and shoulder, with no palpable lymph nodes. Computed tomography (CT) of the neck, chest, and abdomen led us to believe that we might be dealing with primary sarcoma of the neck since no lung mass was evident. Further investigation could not be performed because the patient's status deteriorated rapidly. An autopsy revealed that soft tissue in the left neck and the mesentery was invaded by poorly differentiated polymorphic malignant cells, which were also seen in the lung lesion. Immunohistochemically, these malignant cells were all positive for AE1/AE3, CAM5.2, TTF-1, Napsin-A, and Vimentin. The cells were also positive for programmed death-ligand 1 staining with a low level of tumor proportion score (over 1%). The final diagnosis was PPC with metastases to soft tissues in the left neck and the mesentery. A review of previous case reports of PPC revealed that soft tissue is an uncommon site for metastasis, and that our CT findings were rather unusual. We hereby present our case and review of published case reports, with the hope that an awareness of the heterogeneous features of PPC could prompt timely biopsy and histological diagnosis.

18 F-FDG PET/CT imaging of small intestinal metastasis from pulmonary sarcomatoid carcinoma: Brief report and review of the literature

We herein report two cases of small intestinal metastasis from pulmonary sarcomatoid carcinoma (PSC) detected by ¹⁸F‐fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F‐FDG PET/CT). We reviewed the literature on ¹⁸F‐FDG PET/CT features in gastrointestinal metastasis of PSC patients since 1992, and further analyzed the imaging features. According to the literature review, 23 eligible cases were identified from eight studies, and no cases underwent ¹⁸F‐FDG PET/CT imaging. In this study, clinical and PET/CT imaging data of two patients are reported. In our cases, clinical and the CT images of lung masses were not typical, but the uptake of ¹⁸F‐FDG was remarkably high, with SUVmax exceeding 30. Small intestinal metastases may not be related to obstruction, or even the local intestinal cavity may be dilated. Therefore, in PSC patients with mild or without abdominal symptoms, ¹⁸F‐FDG PET/CT imaging could identify intestinal metastasis at a relatively early stage and may be used to determine the preferred biopsy site, or early intervention by surgery.

Key points

¹⁸F‐FDG PET/CT imaging of small intestinal metastasis of PSC has not been previously reported in the literature and here we report the ¹⁸F‐FDG PET/CT features of two cases.

The uptake of ¹⁸F‐FDG was remarkably high in both the primary tumor and metastatic intestinal lesion. ¹⁸F‐FDG PET/CT imaging may therefore be used to determine the preferred biopsy site or early intervention by surgery.

Gastrointestinal metastasis from primary lung cancer. Case series and systematic literature review

Aim of the present study is to report clinical characteristics and outcomes of patients treated in authors' hospital for GI metastasis from primary lung cancer, and to report and analyse the same data concerning patients retrieved from a systematic literature review. We performed a retrospective analysis of prospectively collected data, and a systematic review using the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. Ninety-one patients were included, 5 patients from the authors' hospital and 86 through PubMed database using the keywords "intestinal metastasis" AND "lung cancer". The median time between primary lung cancer diagnosis and GI metastasis diagnosis was 2 months and the median overall survival was 4 months. This group of patients present a poor prognosis and the gold standard treatment is not defined. None of the reported treatments had a significant impact on survival.

Pulmonary pleomorphic carcinoma metastasis to the midfoot

Metastases to the bones in the foot are extremely uncommon, occurring in approximately 0.01% of all metastatic bone disease. We describe a case of an 82-year-old female with a metastatic pulmonary sarcomatoid carcinoma lesion to the midfoot. This rare and aggressive pulmonary malignancy has a poor prognosis. The purpose of the present case report was to highlight the key roles that medical history and biopsy, combined with a multispecialty approach, play in accurately diagnosing and appropriately treating a patient with metastatic bone disease.