Spindle-cell carcinoma of the upper aerodigestive tract mucosa. An immunohistologic and ultrastructural study of 18 biphasic tumors and comparison with seven monophasic spindle-cell tumors

Spindle Cell Carcinoma of Buccal Mucosa: An Unusual Presentation of Squamous Cell Carcinoma

Oral squamous cell carcinoma (OSCC) is the most common carcinoma in the H&N (head and neck) region, in which squamous cells show variability in differentiation like basaloid, glandular, and spindle cells. Spindle cell carcinoma (SpCC) is an unusual variant of SCC that is aggressive in nature and has the ability to recur and metastasize. The presence of malignant mesenchymal and squamous epithelial cells gives it a biphasic nature. So, we present a case of SpCC of buccal mucosa in a 45-year-old male who had an ulcerated growth on his left buccal mucosa that had been present for two years.

Prognostic significance of head and neck spindle cell carcinoma

BACKGROUND

Our study investigates the prognostic significance of spindle cell histology on overall survival (OS) of conventional head and neck squamous cell carcinoma (HNSCC).

METHODS

The 2004 to 2017 National Cancer Database was queried for patients with head and neck spindle cell carcinoma (HNSpCC) (n = 1572) or HNSCC (n = 242 697) of the oral cavity, major salivary glands, sinonasal tract, oropharynx, hypopharynx, and larynx treated with curative intent.

RESULTS

Patients with HNSpCC presented more frequently with higher-grade tumors and cN0 disease than those with HNSCC (p < 0.001). In the oral cavity, the HR for death for SpCC compared with SCC was 1.33 (p < 0.001). In the oropharynx, the HR for death for SpCC compared with SCC was 1.47 (p = 0.028).

CONCLUSIONS

After adjusting for patient, tumor, and treatment characteristics, SpCC histology had an independent adverse prognostic effect on OS in the oral cavity and oropharynx. SpCC histology does not necessarily portend poorer survival in all HNSCC.

LEVEL OF EVIDENCE: 4

Maxillary Sarcomatoid Carcinoma with Rhabdo-Myosarcomatous Dedifferentiation: a Clinic-Pathological Emphasis

Spindle cell carcinoma or sarcomatoid carcinoma (SC) has been recently defined as a monoclonal dedifferentiated form of conventional squamous cell carcinoma (SCC) and termed as spindle cell (sarcomatoid) squamous carcinoma as per the current World Health Organization (WHO) classification. Although the frequency of SC of the breast, larynx, esophagus, and lungs has been reported, the frequency of oral SC with rhabdo-myosarcomatous dedifferentiation of the maxilla is unknown yet because of the less number of reported cases. Microscopic features of spindle cell carcinoma resemble many benign and malignant oral lesions. Therefore, a careful depiction with the help of routine hematoxylin and eosin along with immunohistochemistry using appropriate markers is necessary to diagnose spindle cell carcinoma. SC is itself a rare entity accounting for <1% of SCC; however, rhabdo-myosarcomatous dedifferentiation is exceptional; therefore, our aim is to highlight this extremely rare entity. This article focuses on SC with rhabdo-myosarcomatous dedifferentiation; other than rhabdomyosarcoma, with an emphasis on strategies to resolve the diagnostic dilemmas these tumors may present.

Clinicopathologic features and outcome of head and neck mucosal spindle cell squamous cell carcinoma

Spindle cell squamous cell carcinoma (SpC-SCC) is rare, accounting for 0.4-4% of head and neck (HN) SCCs. Better understanding of HN SpC-SCC clinicopathologic characteristics, especially features that predict outcome, is needed. We present a clinicopathologic review of 71 HN mucosal SpC-SCC from three tertiary centers. The patient population showed a median age of 63 years (range 20-91), slight male predominance (M:F = 1.6:1), and a preponderance of smokers/ex-smokers (45/71, 64%). Most lesions involved oral cavity (42/71, 59%), especially oral tongue (n = 18), and larynx (n = 20, 28%). Polypoid/exophytic growth and surface ulceration were seen in 60% and 86% of cases, respectively. Histologically, most tumors showed sarcoma-like pattern (65/70, 93%), the remaining exhibiting granulation tissue-like or fibromatosis-like patterns, and 5 lesions showed osteosarcomatous/chondrosarcomatous elements. Most tumors (53/71, 74%) showed a conventional SCC (C-SCC) component, keratinizing (86%) or non-keratinizing/basaloid (14%). Nodal metastases, seen in 22 (31%) of resection specimens, showed SpC-SCC and/or C-SCC histomorphology. By immunohistochemistry, 76% of lesions showed immunoreactivity for keratin and 62/60% of lesions were p40/p63 positive. Ki-67 proliferation index ranged from 5 to 70%. Follow-up was available on 69 patients, median of 1.1 years from the time of SpC-SCC diagnosis. The 3-, 5-, and 10-year disease-specific survival (DSS) was 62, 37, and 12%, respectively. AJCC pN stage was an independent prognostic factor for DSS and distant metastasis-free survival (DMFS), whereas the presence of C-SCC was independently associated with improved DMFS. HN SpC-SCC is rare and might be diagnostically challenging. AJCC pN stage and co-existing C-SCC component appear to be prognostically relevant.

An Algorithmic Immunohistochemical Approach to Define Tumor Type and Assign Site of Origin

Immunohistochemistry represents an indispensable complement to an epidemiology and morphology-driven approach to tumor diagnosis and site of origin assignment. This review reflects the state of my current practice, based on 15-years' experience in Pathology and a deep-dive into the literature, always striving to be better equipped to answer the age old questions, "What is it, and where is it from?" The tables and figures in this manuscript are the ones I "pull up on the computer" when I am teaching at the microscope and turn to myself when I am (frequently) stuck. This field is so exciting because I firmly believe that, through the application of next-generation immunohistochemistry, we can provide better answers than ever before. Specific topics covered in this review include (1) broad tumor classification and associated screening markers; (2) the role of cancer epidemiology in determining pretest probability; (3) broad-spectrum epithelial markers; (4) noncanonical expression of broad tumor class screening markers; (5) a morphologic pattern-based approach to poorly to undifferentiated malignant neoplasms; (6) a morphologic and immunohistochemical approach to define 4 main carcinoma types; (7) CK7/CK20 coordinate expression; (8) added value of semiquantitative immunohistochemical stain assessment; algorithmic immunohistochemical approaches to (9) "garden variety" adenocarcinomas presenting in the liver, (10) large polygonal cell adenocarcinomas, (11) the distinction of primary surface ovarian epithelial tumors with mucinous features from metastasis, (12) tumors presenting at alternative anatomic sites, (13) squamous cell carcinoma versus urothelial carcinoma, and neuroendocrine neoplasms, including (14) the distinction of pheochromocytoma/paraganglioma from well-differentiated neuroendocrine tumor, site of origin assignment in (15) well-differentiated neuroendocrine tumor and (16) poorly differentiated neuroendocrine carcinoma, and (17) the distinction of well-differentiated neuroendocrine tumor G3 from poorly differentiated neuroendocrine carcinoma; it concludes with (18) a discussion of diagnostic considerations in the broad-spectrum keratin/CD45/S-100-"triple-negative" neoplasm.

Carcinosarcoma of the ampulla of Vater

Carcinosarcomas, are very rare tumors in gastrointestinal tract, and at the ampulla of Vater location, are extremely uncommon. They are also called spindle cell carcinomas or sarcomatoid carcinomas. These tumors have an aggressive clinical course with frequent metastasis. We report the case of a male patient of 64 y.o with anemia and jaundice, and a diagnosis of carcinosarcoma of the ampulla of Vater.

Detection of micro-metastases by flow cytometry in lymph nodes from patients with penile cancer

Background

The tumor draining lymph node concept was first described in penile cancer for staging. Immunohistochemistry and histopathology evaluations are routinely used in clinical practice to examine lymph nodes for metastasis. However, these methods are time-consuming with low diagnostic accuracy and micro-metastases might be missed. In this study, we aim to evaluate detection of metastatic cells in draining lymph nodes by flow cytometry.

Methods

To assess the sensitivity of micro-metastasis detection by FACS (Fluorescence-activated cell sorting), HeLa cells were titrated into Peripheral blood mononuclear cells (PBMCs) and expression of pan-cytokeratin AE1/AE3 was analyzed. Single cell suspensions were separately prepared from 10 regional lymph nodes obtained from 5 patients with invasive penile cancer undergoing radical surgery and lymph node dissection. Lymph node dereived cells were examined for cell surface expression of EpCAM, E-cadherin and intracellular expression of pan-cytokeratin AE1/AE3 by FACS.

Results

Ten lymph nodes from 5 penile cancer patients were investigated in a head-to-head comparison between FACS and pathology examination of sections. All metastatic lymph nodes verified by pathology examination were also identified by FACS. Two additional lymph nodes with micro-metastases were diagnosed by FACS only.

Conclusions

FACS analyses of pan-cytokeratin AE1/AE3 stained single cells from tumor draining lymph nodes can be used to detect micro-metastases in patients with penile cancer patients.

Sarcomatoid Carcinoma: A Clinicopathological Profile of Two Cases with Diagnostic Emphasis

Sarcomatoid carcinoma (SC) is an unusual and aggressive variant of squamous cell carcinoma, which frequently recurs and metastasizes, and is associated with poor survival rate. For this reason, its accurate diagnosis is very important. It is considered to be a biphasic tumor made up of epithelial as well as spindle cell component, but of epithelial origin. The diagnosis often represents a clinicopathologic challenge, and immunohistochemistry plays a key role in the histopathological diagnosis. The reported cases in oral cavity are limited. Here, we present two cases of SC where the use of immunohistochemistry allowed us to achieve a conclusive diagnosis.

Laryngeal Dysplasia, Squamous Cell Carcinoma, and Variants

Squamous cell carcinoma (SCC) is a malignant epithelial tumor showing evidence of squamous differentiation. It is the most common malignancy of the larynx, with several variants (verrucous, exophytic or papillary, spindle-cell, basaloid, acantholytic, adenosquamous) recognized, with well-established precursor lesions. Dysplasia is now separated into only low-grade and high-grade categories. Each SCC variant has unique cytomorphologic features and histologic differential diagnoses that are important to consider, as management and outcomes are different.

Huge Carcinosarcoma of the Endolarynx: a Rare Tumour with Unusual Presentation

Carcinosarcoma or sarcomatoid carcinoma is a highly malignant variant of squamous cell carcinoma, which comprises 2 to 3 % of all laryngeal cancer. It is considered to be a biphasic tumour, composed of a squamous cell carcinoma (in situ or invasive) and spindle cell carcinoma with sarcomatous appearance. We present a case of huge carcinosarcoma of larynx in a 34 year-old male who developed severe stridor and dysphagia. The diagnosis was confirmed histopathologically, hence the disease was treated through total laryngectomy followed by adjuvant chemotherapy and radiotherapy. The patient is well and hearty for the past one and a half years.

Squamous cell carcinoma of the upper aerodigestive tract: dysplasia and select variants

Upper aerodigestive tract (UADT) mucosal premalignant lesions include non-keratinizing and keratinizing intraepithelial dysplasia. The keratinizing type of intraepithelial dysplasia represents the majority of UADT dysplasias. Historically, grading of UADT dysplasias has followed a three tier system to include mild, moderate and severe dysplasia. Recent recommendations have introduced a two tier grading scheme to including low-grade (ie, mild dysplasia) and high-grade (moderate and severe dysplasia/carcinoma in situ) providing for better consensus among pathologists in the interpretation of such dysplastic lesions. Squamous cell carcinoma is the most common malignant neoplasm of the UADT. Several variants of squamous cell carcinoma are recognized among which the more common types include papillary squamous cell carcinoma, verrucous carcinoma, spindle cell squamous cell carcinoma (sarcomatoid carcinoma) and basaloid squamous cell carcinoma. Each of these variants of squamous cell carcinoma poses diagnostic challenges and each correlates to specific therapy and prognosis. This review details the proposed update in the grading of UADT dysplasia to a two-tiered system as well as providing the key diagnostic features for select variants of squamous cell carcinoma.

Primary adrenal sarcomatoid carcinoma metastatic to the lung: Case report and review of the literature

Adrenal sarcomatoid carcinoma is a rare adrenal carcinoma. To the best of our knowledge, only 11 cases have been reported since 1987. Adrenal sarcomatoid carcinoma presents a diagnostic challenge due to its atypical symptoms and histological patterns. At the time of diagnosis, a large percentage of patients are already at the metastatic stage and succumb within a few months. The present study reports a case of a 59-year-old man presenting with asthenia and weight loss with adrenal sarcomatoid carcinoma metastatic to the lung. A computed tomography (CT) scan and ultrasonography of the patient's abdomen suggested a large homogeneous mass in the right adrenal gland, and a CT scan of his chest suggested lung metastasis. Right adrenalectomy was performed. Histological examination revealed that the tumor was composed of sarcomatous and carcinomatous differentiation elements. Immunohistochemical examination revealed tumor cell positivity for vimentin and cytokeratin. At the 6-month follow-up the patient exhibited no disease progression and refused further proposed treatment. The patient was alive at the time of writing the current report. The present case report additionally reviews the literature, for the purpose of raising awareness of these rare lesions and assisting in achieving accurate diagnoses and effective treatment.

Carcinosarcoma of the bile duct: a case report and review of literature

Carcinosarcomas of the bile ducts are very rare tumors consisting of both epithelial and mesenchymal elements. We report a case of bile duct carcinosarcoma and its clinical, radiological and pathological features and a brief review on this rare condition.

Nasal Cavity and Paranasal Sinuses

The nasal cavity and paranasal sinuses occupy the top of the upper respiratory tract and form pneumatic spaces connected with the atmosphere. They are located immediately beneath the base of the cranium, where crucial vital structures are harbored. From this region, very much exposed to airborne agents, arise some of the more complex and rare benign and malignant lesions seen in humans, whose difficulties in interpretation make this remarkable territory one of the most challenging in the practice of surgical pathology.

Contents of this chapter cover inflammations and infections, polyps and pseudotumors, fungal and midfacial destructive granulomatous lesions, as well as benign, borderline, and malignant neoplasms. Among the neoplasms, emphasis is made on those entities characteristic or even unique for the sinonasal region, such as Schneiderian papillomas, glomangiopericytoma, intestinal- and non-intestinal-type adenocarcinomas, olfactory neuroblastoma, nasal-type NK-/T-cell lymphoma, and teratocarcinosarcoma. Moreover, recently recognized entities involving this territory, i.e., HPV-related non-keratinizing carcinoma, NUT carcinoma, and SMARCB1-deficient basaloid carcinoma, are also discussed in the light of their specific molecular findings. Furthermore, the text is accompanied by numerous classical and recent references, several tables, and 100 illustrations.

Anti-Hu Antibody Associated Paraneoplastic Cerebellar Degeneration in Head and Neck Cancer

Background

Paraneoplastic syndromes are most frequently associated with small cell lung carcinoma, hematologic and gynecologic malignancies while reports in head and neck cancer are rare.

Case presentation

We present the case of a 60-year old female patient who developed paraneoplastic cerebellar degeneration upon locoregional recurrence of a poorly differentiated spindle cell carcinoma of the nasal cavity and paranasal sinus. The neurological symptoms, especially ataxia, stabilized after resection of tumor recurrence and concomitant chemoradiotherapy whereas anti-Hu-antibodies remained positive. Despite the unfavorable prognosis of paraneoplastic neurological disorders associated with onconeural antibodies, the patient achieved long-standing stabilization of neurological symptoms.

Conclusion

We report the first patient with anti-Hu antibodies and paraneoplastic cerebellar degeneration associated with a spindle cell carcinoma of the head and neck. We recommend that evaluation of neurological symptoms in patients with this tumor entity should also include paraneoplastic syndromes as differential diagnoses and suggest early extensive screening for onconeural antibodies.

Spindle cell carcinoma of the mandible: Clinicopathological and immunohistochemical characteristics

Spindle cell carcinoma, a rare variant of squamous cell carcinoma, has propensity to occur in the upper aero digestive tract, including the oral mucosa. In this oral pathology communication, we report the occurrence of this neoplasm in the left mandible as a large fleshy growth with destruction of bone in a 73-year-old Afro-Trinidadian female. The distinction of this tumor from other malignant spindle cell mesenchymal tumors is important. Selective sampling of this specimen for possible transitional areas of squamous and spindle cell appearance, immunohistochemical staining for cytokeratin, vimentin, and S-100 protein are helpful in establishing the diagnosis. According to the patient's insistence, debulking of the tumor was performed under general anesthesia. Eight months later the patient succumbed to the disease.

Disease-Specific Survival with Spindle Cell Carcinoma of the Head and Neck

Objectives

(1) Determine factors influencing survival in patients diagnosed with spindle cell carcinoma (SpCC), a rare variant of head and neck squamous cell carcinoma (SCC). (2) Compare survival of patients with SpCC to those with conventional SCC.

Study Design

Retrospective cohort study.

Setting

Surveillance, Epidemiology, and End Results 18 database (years 2004-2009).

Subjects and Methods

Among patients receiving treatment for a single primary in the oral cavity, oropharynx, hypopharynx, or larynx, 118 subjects with SpCC and 18,298 subjects with SCC were identified with complete data for the variables of age, sex, grade, tumor size, stage group, and TNM stage. Disease-specific survival curves were compared. Univariate and multivariate analyses were used to examine the effects of each factor on survival over all sites and within each of 3 sites.

Results

Univariate analysis of the combination of the 3 anatomic subsites showed survival with SpCC was worse than with conventional SCC ( P < .001). Three-year disease-specific survival with SpCC was 49.5%, and 5-year disease-specific survival was 40.2%. Compared with conventional SCC, survival was worse for SpCC of the oral cavity ( P < .001) and oropharynx ( P < .001) but no different for the larynx and hypopharynx site ( P = .15). Multivariate analysis identified age ( P = .02), tumor size ( P = .006), and M stage ( P < .001) as the only variables significantly affecting survival with SpCC. All variables significantly affected survival with conventional SCC.

Conclusions

Spindle cell carcinoma carries a worse prognosis than SCC. Larger tumor size, older age, and metastatic disease portend worse survival with SpCC of the head and neck.

Characterization of Spontaneous Mammary Tumors in Domestic Djungarian Hamsters (Phodopus sungorus)

Mammary tumors that spontaneously occurred in domestic Djungarian hamsters ( Phodopus sungorus) were histologically examined. Forty-five mammary tumors included 14 adenomas, 18 adenocarcinomas, 1 lipid-rich carcinoma, 2 adenoacanthomas, 2 malignant adenomyoepitheliomas, 1 benign mixed tumor, and 7 “balloon cell” carcinosarcomas. The latter 4 types were newly recognized neoplasms in Djungarian hamsters. The relatively high incidence of spontaneous mammary carcinosarcomas in domestic Djungarian hamsters is intriguing. Carcinosarcomas exhibited anomalous histological features made up of a mixture of glandular cells, polygonal cells (including “balloon cells”), and sarcomatous spindle cells in varying proportions. Transitional features from glandular cells to polygonal cells and subsequently to sarcomatous spindle cells were observed. Using immunohistochemistry, we observed that glandular cells exhibited an epithelial phenotype (cytokeratin(+)/vimentin(–)), spindle cells exhibited a mesenchymal phenotype (cytokeratin(–)/vimentin(+)), and polygonal cells exhibited an intermediate phenotype (cytokeratin(+)/vimentin(+)). Reduction or loss of β-catenin expression and gain of S100A4 expression were observed in polygonal and spindle cells. The polygonal cell population included a varying number of characteristic cells that were expanded by large intracytoplasmic vacuoles. Electron microscopy revealed that these “balloon cells” had large cytoplasmic lumens lined by microvilli. These observations suggest that epithelial-mesenchymal transition may account for the pathogenesis of mammary carcinosarcomas in Djungarian hamsters.

Rhabdomyoblastic Differentiation in Head and Neck Malignancies Other Than Rhabdomyosarcoma

Rhabdomyosarcoma is a relatively common soft tissue sarcoma that frequently affects children and adolescents and may involve the head and neck. Rhabdomyosarcoma is defined by skeletal muscle differentiation which can be suggested by routine histology and confirmed by immunohistochemistry for the skeletal muscle-specific markers myogenin or myoD1. At the same time, it must be remembered that when it comes to head and neck malignancies, skeletal muscle differentiation is not limited to rhabdomyosarcoma. A lack of awareness of this phenomenon could lead to misdiagnosis and, subsequently, inappropriate therapeutic interventions. This review focuses on malignant neoplasms of the head and neck other than rhabdomyosarcoma that may exhibit rhabdomyoblastic differentiation, with an emphasis on strategies to resolve the diagnostic dilemmas these tumors may present. Axiomatically, no primary central nervous system tumors will be discussed.

Sarcomatoid (spindle cell) carcinoma of tongue: a report of two cases

Sarcomatoid Carcinoma (SC) is an unusual and aggressive variant of squamous cell carcinoma, which frequently recurs and metastasizes; for this reason, the right diagnosis is very important. It is considered to be a biphasic tumor made up of cells from squamous and spindle cells carcinoma with a sarcomatous aspect, but of epithelial origin. The diagnosis often represents a clinical-pathological challenge where the study with immunohistochemical technique (IHC) is key to the histopathological diagnosis. The reported cases related to oral mucosa are limited. In this work we present two SC cases where the use of IHC allowed us to achieve a conclusive diagnosis.

Epidermal Growth Factor Receptor Expression in Spindle Cell Carcinomas of the Head and Neck

Spindle cell carcinoma (SpCC) is an uncommon head and neck squamous cell carcinoma (SCC) variant consisting of spindled and/or pleomorphic cells with epithelial differentiation. Epidermal growth factor receptor (EGFR) is expressed by >90 % of conventional SCC, and high level expression is associated with a poorer prognosis. Anti-EGFR therapies are commonly used to treat head and neck SCC. However, no studies have evaluated EGFR expression in SpCC. Cases of SpCC were retrieved from department files. The diagnosis required either a biphasic lesion with a squamous neoplastic component, or a purely spindle cell or pleomorphic tumor with immunohistochemical positivity for epithelial markers. EGFR immunohistochemistry was performed and was quantified in quartiles. Medical records were reviewed for clinical follow up information. EGFR was expressed in 21/30 (70 %) cases, including in the squamous component in 18/19 (95 %) and the spindle cell component in only 12/30 (40 %). Where the spindle cell component was positive, the intensity and distribution were lower than for the squamous component. Recurrent tumors were predominantly (80-90 %) of the spindle cell component, and had low (or absent) EGFR expression. Kaplan-Meier survival analysis showed no statistically significant differences in overall or disease free survival between the EGFR expressing and non-expressing groups (p = 0.414 and 0.19, respectively). SpCCs of the head and neck have a poor prognosis, and markedly reduced EGFR expression. EGFR-specific therapies may not be ideal for SpCC patients, which may lack EGFR expression, but further studies are needed.

Squamous cell carcinoma variants of the upper aerodigestive tract: a comprehensive review with a focus on genetic alterations

CONTEXT

Squamous cell carcinoma of the upper aerodigestive tract is a heterogenous entity. Although conventional squamous cell carcinomas are easily recognized, the morphologic variants of squamous cell carcinoma can present a diagnostic challenge. Familiarity with these variants is necessary because many are associated with unique risk factors and are characterized by specific molecular alterations (eg, nuclear protein in testis midline carcinomas). Perhaps the most important distinction is in identifying viral-related from nonviral-related carcinomas. The accurate diagnosis of these variants is necessary for prognostic and therapeutic reasons.

OBJECTIVES

To provide a clinicopathologic overview and summary of the molecular alterations of the common squamous cell carcinoma variants, including verrucous, spindle cell, acantholytic, adenosquamous, basaloid, and papillary squamous cell carcinoma, as well as nuclear protein in testis midline carcinoma, and to discuss the distinguishing features of human papillomavirus- and Epstein-Barr virus-related squamous cell carcinomas.

DATA SOURCES

Published peer-reviewed literature.

CONCLUSIONS

Familiarity with squamous cell carcinoma variants is essential for proper diagnosis and to guide appropriate clinical management. Further insight into the molecular alterations underlying those variants may lead to alterations in existing treatment approaches and to evolution of novel treatment modalities.

Use of p40 and p63 immunohistochemistry and human papillomavirus testing as ancillary tools for the recognition of head and neck sarcomatoid carcinoma and its distinction from benign and malignant mesenchymal processes

Sarcomatoid carcinoma (SC) is a variant of head and neck squamous cell carcinoma characterized by a prominent and sometimes exclusive spindle cell component. Distinction from a sarcoma or reactive stroma can be problematic, particularly in cases in which the conventional component is not obvious. The value of immunohistochemistry is limited because of the loss of cytokeratin expression in a sizable percentage of cases. Staining for p63 can enhance detection of epithelial differentiation, but its usefulness is offset by expression in various soft tissue proliferations. Staining for p40--a squamous-specific isoform of p63--could potentially improve diagnostic accuracy. Immunohistochemistry for pancytokeratin, p63, and p40 was performed on 37 head and neck SCs, 201 soft tissue neoplasms, and 40 reactive stromal proliferations. The SCs were also stained for p16 in the event that some of the tumors were human papillomavirus (HPV) related. HPV in situ hybridization was performed on p16-positive cases. Twenty-three of 37 (62%) SCs were positive for pancytokeratin, 23 of 37 (62%) were positive for p63, and 20 of 37 (54%) were positive for p40. Compared with p63, p40 staining was less likely to be observed in soft tissue tumors (5% vs. 30%) and reactive stromal proliferations (0% vs. 30%). HPV16 was detected in 3 of 10 (30%) SCs of the oropharynx but in none of the nonoropharyngeal SCs. p40 staining does not improve the sensitivity for diagnosing SC, but it does diminish the risk of misdiagnosing a sarcoma or reactive stroma as SC. The presence of a sarcomatoid variant of HPV-related oropharyngeal cancer points to HPV testing as a useful diagnostic tool for atypical spindle cell proliferations of the oropharynx.

Spindle cell carcinoma of the larynx presenting as a vocal fold cyst

Spindle cell carcinoma (SPCC) is a rare, malignant variant of squamous cell carcinoma (SCC), which shows biphasic proliferation of the conventional SCC component and malignant spindle shape cells with sarcomatous appearance. We present two cases of SPCC of the true vocal fold that presented as a benign appearing subepithelial mass. We discuss the patient presentation, voice assessment, surgical treatment, and a review of the literature.

Spindle cell carcinoma of the nasal cavity

Spindle cell carcinoma (SpCC) is a unique variant of squamous cell carcinoma (SCC). SpCC confined to the nasal cavity is extremely rare, with only one case having been previously reported. We present a case report of nasal cavity SpCC and review the literature on this rare entity. A 29-year-old male presented with intermittent epistaxis from the left nasal cavity. On physical examination, the patient had an ulcerated mass in the left nasal vestibule and a biopsy showed a proliferation of spindle and epitheliod cells. The patient underwent wide local excision of the mass via a lateral alotomy approach and reconstruction with a composite conchal bowl skin and cartilage graft. Histologically, the mass had dyplastic squamous epithelium and spindle-shaped cells admixed with epitheliod cells. Immunohistochemistry was only positive for pancytokeratin AE1/AE3 and vimentin. Six months after surgery, the patient continues to have no evidence of disease. On literature review, only one previous case of SpCC confined to the nasal cavity was identified. We present a rare case of nasal cavity SpCC. No definite treatment protocol exists for this unique entity, but we believe that this tumor should primarily be treated with aggressive, wide local excision. Adjuvant radiation and/or chemotherapy have also been used anecdotally.

Spindle cell carcinomas of the head and neck rarely harbor transcriptionally-active human papillomavirus

Spindle cell carcinoma is an uncommon variant of squamous cell carcinoma characterized by spindled or pleomorphic cells which appear to be a true sarcoma but are actually epithelial. Some head and neck squamous cell carcinoma variants can be human papillomavirus (HPV)-related and have improved outcomes. We sought to determine if spindle cell carcinomas are associated with transcriptionally-active HPV. Cases of spindle cell carcinoma were retrieved from department files. Transcriptionally-active HPV was determined by mRNA in situ hybridization for high risk HPV E6 and E7 transcripts and by a surrogate marker, p16 immunohistochemistry, with a 50% staining cutoff. RT-PCR for high risk HPV mRNA was performed on the cases that were technical failures by in situ hybridization. Medical records and follow up information were retrieved for all patients. Of 31 cases, 5 were from the oropharynx, 12 from the oral cavity, and 14 from the larynx or hypopharynx. One purely spindled oral cavity spindle cell carcinoma was HPV positive. It was also diffusely positive for p16. Another laryngeal spindle cell carcinoma was HPV positive in both the squamous and spindle cell components, but was negative for p16. None of the five oropharyngeal spindle cell carcinomas were positive for p16 or HPV RNA. The HPV positive patients both presented at high stage (IV) and died with disease within 2 years of diagnosis. The majority of spindle cell carcinomas of the head and neck, including those arising in the oropharynx, are not related to transcriptionally active HPV. Although the number of cases is too small for any definitive conclusions, for the rare HPV positive spindle cell carcinoma cases, positive viral status does not appear to confer any prognostic benefit.

Primary adrenocortical sarcomatoid carcinoma: Report of a case

We report the case of a 72-year-old man with a right adrenocortical mass who had undergone complete tumour excision with the adrenal gland and around adipose tissue. Pathologic examination led to a final diagnosis of primary sarcomatoid carcinoma of the right adrenal gland. The patient was without recurrence at the one year follow-up. To our knowledge, this is the first case in China and the second reported case in English published studies.

Spindle cell carcinoma of the larynx with rhabdomyoblastic heterologous element: a rare form of divergent differentiation

Spindle cell (sarcomatoid) carcinoma of the larynx is a rare subtype of squamous cell carcinoma that shows a prominent spindle cell component with a mesenchymal phenotype. Heterologous elements may be seen in these spindled areas and usually consist of osteosarcomatous or chondrosarcomatous differentiation. We describe an unusual spindle cell carcinoma of the vocal cord in a 68-year-old male which demonstrated rhabdomyosarcomatous differentiation as confirmed by desmin and myogenin immunoreactivity. Thus rhabdomyosarcomatous differentiation adds to the phenotypic spectrum of spindle cell carcinomas of the larynx and should be considered before invoking a diagnosis of true rhabdomyosarcoma of the larynx.

Undifferentiated carcinoma of the common bile duct with intraductal tumor thrombi: report of a case

We report a case of undifferentiated carcinoma of the common bile duct with intraductal tumor thrombi. A 73-year-old man presented with general malaise. Abdominal computed tomography and magnetic resonance imaging revealed a mass in the distal common bile duct, accompanied by dilatation of the intra- and extrahepatic bile ducts. The patient underwent pancreaticoduodenectomy with regional lymphadenectomy. Gross examination revealed that the distal common bile duct was obstructed by an elastic hard mass, 3.2 × 2.6 cm, accompanied by intraductal tumor thrombi. Microscopically, the nodule was well defined and composed of atypical large tumor cells with bizarre nuclei and little cytoplasm. Immunohistochemically, the tumor cells were diffusely positive for cytokeratin-7 and CAM5.2, but negative for CD56, chromogranin A, and synaptophysin. Thus, a histological diagnosis of undifferentiated carcinoma of the common bile duct was made. The patient recovered uneventfully and has remained free of any signs of recurrence for 18 months since the operation. Undifferentiated carcinomas of the extrahepatic bile duct can be detected early, with the chance of a good prognosis; however, because their biologic growth behavior is still considered aggressive, careful observation after surgery and the initiation of multidisciplinary treatment against recurrence are necessary.

N-cadherin expression is correlated with metastasis of spindle cell carcinoma of head and neck region

Spindle cell carcinoma (SpCC) is a biphasic tumor composed of conventional squamous cell carcinoma and a malignant spindle cell component. SpCC expresses both epithelial and mesenchymal markers by immunohistochemical analysis. There is mounting evidence for sarcomatoid transformation from the epithelial component, supporting the theory that SpCC is a monoclonal neoplasm originating from a stem cell giving rise to both components. The loss of E-cadherin and the gain of N-cadherin expression are known as the "cadherin switching". Cadherin switching is a major hallmark of epithelial-mesenchymal transition (EMT). EMT is a crucial process in cancer progression providing cancer cells with the ability to escape from the primary focus, to invade stromal tissues, and to migrate to distant regions. Although E-cadherin down-regulation is well known in various cancers, there are a few studies on N-cadherin expression in cancer. Here, therefore, we investigated N-cadherin expression in the progression of head and neck SpCC. First, we examined cadherin switching in our established SpCC cell lines, SpCC-1 and SpCC-2. SpCC-1 and SpCC-2 cells were spindle in shape and showed cadherin switching. Moreover, we examined N-cadherin expression in 15 SpCC cases by immunohistochemistry. Although N-cadherin expression was not observed in non-neoplastic squamous epithelium, high expression of N-cadherin was observed in 10 of 15 SpCC cases. Interestingly, 6 of 7 SpCC cases with metastasis showed high expression of N-cadherin. In conclusion, our findings suggest that N-cadherin may play an important role in metastasis of SpCC in addition to the pathogenesis of SpCC of the head and neck.

Sarcomatoid (spindle cell) carcinoma of the head and neck mucosal region: a clinicopathologic review of 103 cases from a tertiary referral cancer centre

Sarcomatoid carcinomas are biphasic tumors proven to be monoclonal dedifferentiated forms of conventional squamous carcinomas. This study evaluates their clinicopathologic characteristics in head and neck mucosal sites and the problems in distinguishing them from other spindle cell tumors. A total of 103 cases with a confirmed diagnosis of sarcomatoid carcinoma accessioned in the pathology department of a tertiary referral cancer centre over a period of 7 years (2004-2010) were studied. An algorithm used for their diagnosis is presented. Ages of the patients were 22-90 years (median 53 years), and male:female ratio was 3.7:1. Site distribution was oral cavity (n = 65, 63.1%), larynx (18, 17.5%), oropharynx/hypopharynx (12, 10.7%), maxilla (6, 5.8%) and metastatic nodes (2, 1.9%). A large number of patients (95%) presented with a mass lesion of less than 1 year duration. Histopathologically, epithelial differentiation was evident on morphology in 48 (46.6%) cases, only on IHC in 34 (33%) cases, and in 21 (20.4%) no epithelial differentiation was seen. Typically, tumors were polypoidal (92, 89.3%) and ulcerated (95, 92.2%) with cells arranged predominantly in fascicles (59, 57.3%) or storiform pattern (17, 16.5%) amidst collagenous (50, 48.5%) or myxoid matrix (35, 34%). Anaplasia (2+/3+) and mitosis >10 per 10 HPF were noted in 96 (93.2%) cases. IHC was done in 82 cases; 55 (66.7%) showed positivity for epithelial markers with aberrant expression of mesenchymal markers in 43 (41.7%). Diagnosis of sarcomatoid squamous carcinoma is challenging because of overlapping histopathological features with other spindle cell tumors. Understanding their clinicopathologic characteristics facilitates their diagnosis and appropriate clinical management.

A case of oral multiple primary cancer including Spindle Cell Carcinoma

Spindle Cell Carcinoma (SPCC) is a relatively rare tumour that is classified as a subtype of squamous cell carcinoma (SCC). Histologically, SPCC is composed of a SCC region and epithelium-derived spindle cells with mesenchymal differentiation. We encountered an interesting case of multiple cancer including SPCC. A histopathologically atypical papillary lesion was found 13 years before our initial examination. Multiple verrucous leukoplakia later developed in the oral mucosa, for which an oral vitamin A derivative (a retinoid) was intermittently administered. Multiple cancer including SPCC subsequently developed in the lower gingiva. We investigated the case histologically and immunohistologically based on the concept of field cancerization.

Cytology of head and neck squamous cell carcinoma variants

The most common diagnosis rendered with head and neck fine needle aspiration (FNA) biopsy is metastatic squamous cell carcinoma (SCC). While most cases of metastatic SCC pose little diagnostic difficulty, the diagnosis of metastatic histologic variants of SCC, often coupled with less common etiologies, can be more problematic. This manuscript reviews the clinicopathologic features of the histologic variants of upper aerodigestive tract SCC (verrucous, papillary, spindle cell, undifferentiated, acantholytic, and basaloid) and uncommon etiologies of head and neck SCC (human papillomavirus, Epstein-Barr Virus, and NUT midline carcinomas). Particular attention is paid to the cytologic features of these lesions. Differential diagnoses and the use of ancillary testing are discussed.

Nasenhöhle und Nasennebenhöhlen

Die Gesichtsmitte (der Bezirk zwischen Oberlippe und Stirn) entwickelt sich zwischen der 4. und 8. Schwangerschaftswoche. [ 220] Der Stirnfortsatz bildet sich währen der 4. postovulatorischen Woche, aus ihm gehen die oberen und mittleren Anteile des Gesichts hervor. Die Oberkiefer- und Nasenwülste entwickeln sich unterhalb des Stirnfortsatzes. Am Ende der 4. Woche bilden zwei oberflächliche Verdickungen der Nasenwülste die Riechplakoden, die ektodermaler Herkunft sind und aus denen der Epithelbelag der Nasenhöhle und Nasennebenhöhlen hervorgeht. Die Plakoden stülpen sich ein und bilden die Riechgruben, aus denen die vorderen Choanen (Nasenlöcher) und weniger oberflächlich die primitiven hinteren Choanen entstehen. Die medialen Nasen- und Stirnfortsätze bilden das Nasenseptum, die Stirnknochen, Nasenknochen, die Siebbeinzellen- Komplexe und die oberen Schneidezähne. Die lateralen Nasen- und Oberkieferfortsätze vereinigen sich zur Bildung des Philtrum und der Columella. Das knorpelige Nasenskelet bildet sich während der 7. und 8. postovulatorischen Woche tief unterhalb der Nasen- und Stirnbeinknochen aus dem Chondrocranium. Die Nasennebenhöhlen entwickeln sich in der 6. Fetalwoche aus den lateralen Nasenwänden, und ihr Wachstum setzt sich nach der Geburt während des gesamten Kindes- und Jugendalters fort.

Spindle cell lesions--neoplastic or non-neoplastic?: spindle cell carcinoma and other atypical spindle cell lesions of the head and neck

One challenging feature of head and neck pathology is that a dizzying array of spindle cell lesions occur here ranging all the way from reactive to malignant and very aggressive. This makes accurate diagnosis critical. At mucosal sites, the most important of these is spindle cell carcinoma (SpCC). Most SpCC are overtly malignant, and the differential diagnosis then includes a number of different malignant spindle cell neoplasms. However, there are several benign or even non-neoplastic lesions that can sometimes be difficult to discern from SpCC. The pathologic and clinical features can resolve this differential diagnosis. This review will focus on the clinical and diagnostic features of SpCC and the select non-neoplastic or benign lesions which are occasionally hard to distinguish from it.

Spindle cell carcinoma of the palatine tonsil: report of a diagnostic pitfall and literature review

Spindle cell carcinomas of the tonsil are very rare tumors. We present an additional case that occurred in a 58-year-old woman. She presented with a tumor of the right tonsil. Histologic sections of tonsillar biopsies suggested that this tumor was a squamous cell carcinoma. She underwent a transoral resection of the right oropharynx. The final diagnosis was spindle cell carcinoma. We emphasize the difficulties in diagnosing this type of tumor and discuss therapeutic approaches to this rare tumor, which shows little response to radiotherapy; the literature is reviewed. We offer this case study in an effort to increase awareness of this rare malignancy.

Differential diagnosis of laryngeal spindle cell carcinoma and inflammatory myofibroblastic tumor--report of two cases with similar morphology

Background

Spindle cell tumors of the larynx are rare. In some cases, the dignity is difficult to determine. We report two cases of laryngeal spindle cell tumors.

Case presentation

Case 1 is a spindle cell carcinoma (SPC) in a 55 year-old male patient and case 2 an inflammatory myofibroblastic tumor (IMT) in a 34 year-old female patient. A comprehensive morphological and immunohistochemical analysis was done. Both tumors arose at the vocal folds. Magnified laryngoscopy showed polypoid tumors. After resection, conventional histological investigation revealed spindle cell lesions with similar morphology. We found ulceration, mild atypia, and myxoid stroma. Before immunohistochemistry, the dignity was uncertain. Immunohistochemical investigations led to diagnosis of two distinct tumors with different biological behaviour. Both expressed vimentin. Furthermore, the SPC was positive for pan-cytokeratin AE1/3, CK5/6, and smooth-muscle actin, whereas the IMT reacted with antibodies against ALK-1, and EMA. The proliferation (Ki67) was up to 80% in SPC and 10% in IMT. Other stainings with antibodies against p53, p21, Cyclin D1, or Rb did not result in additional information. After resection, the patient with SPC is free of disease for seven months. The IMT recurred three months after first surgery, but no relapses were found eight months after resurgery.

Conclusion

Differential diagnosis can be difficult without immunohistochemistry. Therefore, a comprehensive morphological and immunohistochemical analysis is necessary, but markers of cell cycle (apart from the assessment of proliferation) do not help.

Establishment and characterization of a spindle cell squamous carcinoma cell line

BACKGROUND

Spindle cell squamous carcinoma (SCSC) is a rare and peculiar biphasic malignant neoplasm that occurs mainly in the upper aerodigestive tract. It consists of sarcomatoid proliferation of pleomorphic spindle-shaped cells and squamous cell carcinoma.

METHODS

Here, we established a SCSC cell line from a tumour arisen in gingiva. We characterized the feature of a SCSC cell line by immunohistochemistry. To know the biological feature, we examined the cell growth, invasiveness and epithelial-mesenchymal transition markers of a SCSC cell line in comparison with oral squamous cell carcinoma (OSCC) cell lines.

RESULTS

By immunohistochemical analyses, the primary tumour expressed cytokeratin and vimentin, indicating carcinosarcoma-like characters. This tumour also showed overexpression of p53 protein. Cultured SCSC cells resulted in bypass of crisis and maintenance over passage 100. The established SCSC cell line was spindle-shaped and showed identical immunohistochemical characters to those of primary tumour cells. Similar to the primary tumour, the cell line showed p53 overexpression and had p53 mutation at codon 132: AAG (lys)-->AAT (asp). The SCSC cell line grew slower than two other OSCC cell lines (MSCC-1 and HSC-2), whereas SCSC cells had remarkable invasiveness in comparison with these cell lines. Moreover, SCSC cells expressed wnt-5a and vimentin mRNA at high levels, but did not express E-cadherin mRNA. This expression pattern of the markers was similar to that of mesenchymal cells, not of epithelial cells.

CONCLUSION

In the present study, we newly established a SCSC cell line with strong invasiveness. This is the first report on the establishment of SCSC cell line. The SCSC cell line can be a useful cell model for the study to know the cytodifferentiation and nature of SCSC.

Spindle cell carcinoma of the oral cavity and oropharynx: factors affecting outcome

BACKGROUND

Spindle cell carcinoma (SpCC) is considered to be a rare variant of squamous cell carcinoma (SCC). The behavior of such tumors is unclear. The aim of this study was to elucidate the treatment and outcome of oral and oropharyngeal SpCC.

METHODS

All the medical records of patients with the diagnosis of SpCC in the oral cavity and oropharynx in our hospital from 1994 to 2005 were reviewed. The clinical features, treatments and survival of the patients were evaluated.

RESULTS

Within the 11-year study period, 18 patients were diagnosed with oral and oropharyngeal SpCC. There were 3 cases of AJCC (American Joint Committee on Cancer) stage I, 3 of stage II, 2 of stage III, 9 of stage IV, and 1 case without definite staging. Twelve patients died of their diseases. The median overall survival time was 8.89 months. The 1-year overall survival rate was 36.7% and the 3-year overall survival rate was 27.5%. In the early stage group, the 1-year and 3-year survival rates were both 100%. In the late stage group, the 1-year survival rate was 9%, and the 3-year survival rate was 0%. The factors influencing overall survival were tumor grade, lymph nodes, metastasis, stage, vascular invasion and distant recurrence. A high local recurrence rate (73.3%) and distant metastasis rate (33.3%) were observed.

CONCLUSION

The behavior of SpCC seems to be more aggressive than that of SCC at a similar stage. Setting wider safety margins (> 2 cm) during surgical intervention is suggested. In the case of locoregional recurrence, salvage operation showed some benefit. Seeking an effective chemotherapy protocol is important for the control of distant recurrence.

Sarcomatoid carcinoma of the parotid gland with apparent metastasis of epidermoid elements to cervical lymph nodes

A case of sarcomatoid carcinoma of the parotid gland is described in a 47-year-old male. Despite radical surgery and postoperative chemoradiation therapy, a distant metastasis occurred 1 month after treatment. The primary site was composed of well-differentiated squamous cell carcinoma intermingled with spindle-shaped malignant mesenchymal cells. Immunohistochemical studies showed that keratin was present in both epithelial cells and spindle cells, whereas vimentin was present in spindle cells and absent in epithelial cells. Two lymph nodes were metastasized by the epidermoid component. The origin of the sarcomatoid component and the differential diagnosis from malignant mixed tumours are discussed.