A case of pulmonary pleomorphic carcinoma associated with cystic airspace

Lung cancer associated with a cystic airspace is frequently misdiagnosed or overlooked. Adenocarcinoma, followed by squamous cell carcinoma, is the most typical histologic type of lung cancer connected to a cystic airspace. Here we present the rare case of lung pleomorphic carcinoma associated with a cystic airspace. We encountered a 74-year-old Japanese man diagnosed by computed tomography (CT) as having a nodule outside a cystic airspace in the lung. Several previous CT images showed that the cystic airspace preceded the nodule. Postsurgery, pathology indicated a diagnosis of pleomorphic carcinoma. Since pulmonary pleomorphic carcinomas pursue an aggressive clinical course, their early detection may contribute to an improved prognosis. Our case demonstrated that pleomorphic carcinoma can arise with cystic airspaces. For early diagnosis of those aggressive lung cancers, chest physicians should carefully examine the walls of cystic airspaces on CT.

Metastatic pulmonary pleomorphic carcinoma involving the jejunum: a case report and review of the literature

We present a case report of a pulmonary pleomorphic carcinoma that metastasized to the jejunum in an 80-year-old woman. The patient was admitted to the hospital with symptomatic anemia and melena that had been ongoing for several months. In 2021, non-small cell carcinoma was diagnosed by fine-needle aspiration. In 2022, a computed tomography (CT) scan revealed an enormous mass in the small bowel. The tumor was resected and showed pleomorphic neoplastic cells with giant and spindle cell morphology. These neoplastic cells were positive for thyroid transcription factor 1 (TTF1). Next-generation sequencing of the secondary tumor revealed 97% genomic similarities to the lung tumor and high expression of programmed cell death ligand 1 (PD-L1). The patient may benefit from immune checkpoint therapy.

PIK3CA mutations associated with a poor postoperative prognosis in patients with pulmonary pleomorphic carcinoma: a retrospective cohort study

Background

Pulmonary pleomorphic carcinoma (PPC) is a rare type of non-small cell lung cancer characterized by high malignancy and a poor prognosis. PPC is associated with a high frequency of postoperative relapse, and shows resistance to chemotherapy. The high malignancy of cancers is associated with genomic instability, which is related to mutations of tumor suppressor genes, such as tumor protein p53 (TP53) and ataxia-telangiectasia mutated (ATM). In addition, signaling pathways involving the oncogenes such as phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA) and epidermal growth factor receptor (EGFR) are associated with resistance to chemotherapy. However, the association of PPC with these gene mutations remains unknown. We investigated the impact of TP53, ATM, PIK3CA, and EGFR mutations on the postoperative prognosis of PPC.

Methods

Fifty-five patients with PPC who underwent complete resection were studied. A gene mutation analysis was performed using next-generation sequencing. Postoperative overall survival of patients with gene mutations was evaluated using a multivariable Cox proportional hazards model in which the explanatory variables were the presence of each gene mutation, and the confounding factors were pathological stage and age. The robustness of the results was evaluated by a sensitivity analysis.

Results

The frequencies of pathogenic mutations in TP53, ATM, PIK3CA, and EGFR were 47, 0, 7, and 9%, respectively. A multivariable analysis adjusted for pathological stage and age showed a significant difference for only PIK3CA mutations. The hazard ratio (HR) for overall survival in cases with pathogenic mutations of PIK3CA for wild type or non-pathogenic mutations was 4.5 (95% confidence interval [CI] 1.1–18.8). Likewise, sensitivity analyses adjusted for pathological stage and sex (HR, 7.5; 95% CI 1.7–32.4) and for age and sex (HR, 5.4; 95% CI 1.4–21.7) resulted in similar findings. Although three patients with pathogenic mutations of PIK3CA that recurred postoperatively were treated by chemotherapy or immunotherapy, they survived for less than 2 years.

Conclusions

The postoperative prognosis of PPC with PIK3CA pathogenic mutations is particularly poor. Pathogenic mutations of PIK3CA may be a postoperative prognostic marker. Inhibition of signaling pathways associated with PIK3CA mutations may also be a target for chemotherapy after relapse of PPC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-10176-4.

High programmed death ligand 1 expression in carcinomatous components predicts a poor prognosis in pulmonary pleomorphic carcinoma

PURPOSE

This study reviewed the clinicopathological characteristics and programmed death ligand 1 (PD-L1) expression of 46 patients with pulmonary pleomorphic carcinoma to better understand its clinical behavior and factors affecting the survival.

METHODS

Data of patients with pulmonary pleomorphic carcinomas resected in our institution were retrospectively reviewed. The tumors were classified as carcinomatous or sarcomatous according to the tissue components. Pathological characteristics were evaluated on hematoxylin and eosin-stained sections. The percentages of tumor cells with membrane staining for PD-L1 in carcinomatous and sarcomatous components were determined.

RESULTS

We reviewed data of 46 patients (41 males, 5 females; median age 70.5 years old, range 36-83 years old). Most patients with pulmonary pleomorphic carcinoma expressed PD-L1 (80.4%), and the proportion of PD-L1 expression in tumor cells was significantly higher in sarcomatous components than in carcinomatous components. In univariable analyses, high p-stage (III), necrosis on pathological findings, and high PD-L1 expression in carcinomatous components (≥ 50%) were poor prognostic factors for the overall survival. In multivariable analyses, high PD-L1 expression in carcinomatous components was significantly associated with a poor prognosis after surgery.

CONCLUSIONS

High PD-L1 expression in carcinomatous components was significantly associated with a poor prognosis after surgery.

Case report: Postoperative abdominal recurrence of pulmonary pleomorphic carcinoma showed a dramatic response to S-1 after pembrolizumab

The patient was an 80-year-old woman with combined pulmonary fibrosis and emphysema. She was diagnosed with pulmonary pleomorphic carcinoma in the right upper lobe, which relapsed 18 months after the operation. Computed tomography showed a mass in contact with the posterior wall of the lower part of the stomach. The patient was treated with two cycles of pembrolizumab, but the disease progressed. She was treated with S-1 as second-line therapy, resulting in tumor-shrinking after two cycles. Progression was not observed over the next twelve months. We report a rare case involving S-1 after immune checkpoint inhibitor treatment.

Transformation From Adenocarcinoma to Pleomorphic Carcinoma as an Acquired Resistance to Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors

Pulmonary pleomorphic carcinoma is a very rare histological type of primary lung cancer, and usually provides aggressive clinical courses. A 65-year-old Japanese woman was diagnosed by transbronchial biopsy of the primary tumor as c-stage IV (cT4N3M1b) of adenocarcinoma harboring L858R point mutation in the exon 21 of epidermal growth factor receptor (EGFR). She received EGFR tyrosine kinase inhibitors (TKIs) (gefitinib and erlotinib) and subsequently cytotoxic chemotherapies. Gefitinib achieved partial response, but was switched to erlotinib due to elevated serum aspartate transaminase. After resistance to EGFR-TKIs, the second transbronchial re-biopsy revealed pulmonary pleomorphic carcinoma. Both carcinomatous and sarcomatous components retained the L858R mutation, but did not acquire T790M mutation. This case suggested that the histological transformation to pulmonary pleomorphic carcinoma may be one of mechanisms of drug resistance to EGFR-TKIs.

A case of hyperprogressive disease following atezolizumab therapy for pulmonary pleomorphic carcinoma with epidermal growth factor receptor mutation

A 66-year old man with non-smoking history was diagnosed with pulmonary pleomorphic carcinoma of the right lower lobe. The carcinoma metastasized to the brain, lungs, pleura, and mediastinal lymph nodes. It was positive for epidermal growth factor receptor (EGFR) L858R mutation, and tumor cells highly expressed programmed death-ligand 1(PD-L1). Atezolizumab was initiated as the fourth treatment. After three days, he developed cardiac tamponade and immediately underwent pericardial drainage. Computed tomography showed bilateral ground-glass opacity (GGO), significant worsening of multiple lung metastases, and increased size of metastatic lesions. Newly developed metastasis was noted in the lung, and the patient's respiratory condition rapidly deteriorated. He died of respiratory failure on day 13 after atezolizumab administration. The autopsy showed widespread metastasis in all lobes of the bilateral lungs, cardiac tamponade due to carcinomatous pericarditis, carcinomatous lymphangiopathy, and multiple lung metastases, which were thought to be comprehensively the cause of death. These symptoms suggested hyperprogressive disease (HPD). Hence, we report the first case of HPD following atezolizumab therapy for pulmonary pleomorphic carcinoma with EGFR mutation.

Two different patients with pulmonary pleomorphic carcinoma response to PD-1 inhibitor plus anlotinib

Pulmonary pleomorphic carcinoma (PPC) is a rare and highly malignant subtype of non-small-cell lung cancer (NSCLC), and chemotherapy and radiotherapy are insensitive. Some clinical trials have shown that targetable driver gene mutations, such as EGFR, ALK or BRAF, have rarely been detected in PPC patients, but the incidence of MET exon 14 mutations is more frequent. For these patients with driver gene mutations, corresponding molecular targeted therapy may be valid. In addition, limited cases have suggested that immunotherapy may be effective for PPC without sensitising EGFR or ALK alterations, but the efficacy in patients with other driver mutations remains unclear. Herein, we reported two PPC patients with different targetable gene mutations who both responded dramatically to the PD-1 inhibitor camrelizumab combined with the oral anti-angiogenic drug anlotinib: one harbouring a BRAF V600E mutation with positive PD-L1 expression, few tumour-infiltrating lymphocytes (TILs) and abundant tumour blood vessels; and the other exhibiting a MET exon 14 skipping mutation with PD-L1 overexpression, scattered TILs and abundant tumour blood vessels. Our findings suggest that PD-1 inhibitor combined with anlotinib may be a potential treatment for PPC patients, and abundant tumour vessels should be investigated as a possible therapeutic biomarker.

Prognostic impact of the tumor immune microenvironment in pulmonary pleomorphic carcinoma

INTRODUCTION

Pulmonary pleomorphic carcinoma (PC) is a rare non-small cell lung carcinoma (NSCLC) and is characterized by sarcomatoid and NSCLC components. This study aimed to characterize the association between immune microenvironmental factors and clinicopathological characteristics of PC.

METHODS

Eighty consecutive PC patients who had undergone complete surgical resection were enrolled. We calculated the immunohistochemical staining scores for E-cadherin, vimentin, programmed death ligand 1 (PD-L1), and carbonic anhydrase IX in cancer cells and counted the numbers of CD204-positive tumor-associated macrophages (TAMs) and Foxp3-, CD8-, and CD20-positive tumor-infiltrating lymphocytes (TILs). We also examined the association between these scores and the prognostic outcomes.

RESULTS

The staining score for PD-L1 in cancer cells and the number of CD204-positive TAMs in the sarcomatoid component were significantly higher than those in the NSCLC component; E-cadherin score in the sarcomatoid component was significantly lower. Patients with high PD-L1 expression in the NSCLC component had significantly longer overall survival (OS) and recurrence-free survival (RFS) than those with low PD-L1 expression in the NSCLC component (OS: p = 0.001, RFS: p = 0.038). Multivariate analysis revealed that high PD-L1 expression in the NSCLC component was an independent favorable prognostic factor for OS (p = 0.018), whereas high PD-L1 expression in the sarcomatoid component was not. The number of CD8-positive TILs was significantly higher in the high PD-L1 expression group than in the low expression group (NSCLC components: p < 0.001).

CONCLUSION

High PD-L1 expression in the NSCLC component may be associated with a favorable prognostic value in pulmonary PC.

Outstanding clinical efficacy of PD-1/PD-L1 inhibitors for pulmonary pleomorphic carcinoma

BACKGROUND

We evaluated programmed death ligand 1 (PD-L1) expression and efficacy of PD-1/PD-L1 inhibitors in patients with pulmonary pleomorphic carcinoma (PC).

METHODS

We created two cohorts of patients diagnosed with pulmonary PC from 2016 to 2019, PD-L1 expression and programmed death 1 (PD-1)/PD-L1 inhibitor efficacy cohorts. The PD-L1 expression cohort included all patients evaluated for PD-L1 expression, irrespective of PD-1/PD-L1 inhibitor therapy. High PD-L1 expression was defined as ≥50% positive tumour cells (TC) for 22C3, ≥25% for SP263 or ≥10%/5% TC/immune cell (IC) for SP142. The PD-1/PD-L1 efficacy cohort included patients treated with PD-1/PD-L1 inhibitors, irrespective of PD-L1 tests.

RESULTS

One hundred twenty-five of 175 patients diagnosed with pulmonary PCs were included in the PD-L1 expression cohort. Among them, 112 patients (89.6%) had PD-L1-positive (≥1%) tumours and 100 (80.0%) had tumours with high PD-L1 expression. A total of 49 patients were included in the efficacy cohort: 40 received pembrolizumab, 7 nivolumab and 2 atezolizumab. The objective response rate was 49.0%, with a median progression-free survival (PFS) of 7.2 months and a median overall survival of 22.2 months. In the efficacy cohort, high PD-L1 expression (n = 41) was associated with longer PFS (median: 7.2 versus 1.5 months, hazard ratio [HR]: 0.53 [0.22-1.29], p = 0.16) and overall survival (median: 22.2 versus 3.5, HR: 0.21 [0.08-0.57], p = 0.001) than low/negative/unknown PD-L1 expression (n = 8).

CONCLUSION

PD-1/PD-L1 inhibitors show outstanding efficacy for pulmonary PCs, and this is possibly attributable to high PD-L1 expression in these tumours.

Prognostic Significance of Tumor Immunity in Surgically Resected Pulmonary Pleomorphic Carcinoma

BACKGROUND

Pulmonary pleomorphic carcinoma (PPC) is a rare aggressive neoplasm, with dismal prognosis. Whether tumor immunity is associated with the progressive biological behavior of PPC remains unclear. The purpose of this study was to examine the prognostic significance of tumor immunity-related markers such as programmed death-1 ligand (PD-L1) and CD4⁺ or CD8⁺ tumor-infiltrating lymphocytes (TILs) in patients with surgically resected PPC.

PATIENTS AND METHODS

Ninety-nine patients with surgically resected PPC were assessed by immunohistochemistry. The expression of PD-L1, CD4, and CD8 was examined in specimens of the resected tumors.

RESULTS

PD-L1 was highly expressed in 61% (60/99) of lesions and high expression of CD4 and CD8 was identified in 42% (42/99) and 51% (51/99) of lesions, respectively. There was no relationship between the expression PD-L1 and the numbers of CD4⁺ or CD8⁺ TILs. The expression of PD-L1 was not identified as a significant prognostic marker; however, a low number of CD4⁺ TILs was identified as an independent marker for predicting a worse outcome after surgical resection of PPC, especially in patients with an epithelial component of adenocarcinoma or early stage of disease. By univariate analysis, a low number of CD8⁺ TILs was found to be a significant prognostic marker linked to poor overall survival in patients with non-adenocarcinoma components.

CONCLUSION

A low number of CD4⁺ TILs is an independent marker for predicting a favorable prognosis after surgical resection in patients with PPC, especially in patients with adenocarcinoma components or early stage of disease.

Single pembrolizumab treatment causing profound durable response in a patient with pulmonary pleomorphic carcinoma

We report a case of a 73-year-old man diagnosed with pulmonary pleomorphic carcinoma who showed profound durable response after a single treatment with pembrolizumab. The patient underwent a diagnostic workup in our hospital due to a hoarseness of voice. Chest computed tomography revealed a massive pulmonary tumor in the left upper lobe and multiple nodules in the both lung fields. Histological examination of a transbronchial lung biopsy specimen revealed pulmonary pleomorphic carcinoma. First-line treatment with pembrolizumab was discontinued after a single administration due to treatment-related pneumonitis. However, durable response has been observed over 17 months to date.

A case of pulmonary pleomorphic carcinoma with malignant phenotypes induced by ZEB1-associated epithelial-mesenchymal transition

A 60-year-old man was admitted to our hospital with non-small cell lung cancer (NSCLC). Imaging and pathological studies revealed NSCLC, not otherwise specified (NOS), at clinical stage T3N1M0 stage IIIA. We started radiotherapy alone because of obstructive pneumonia and end-stage renal disease, but the tumors progressed rapidly and resulted in death due to air obstruction by pharyngeal metastasis. The cancer was diagnosed as pleomorphic carcinoma in an autopsy. Viable lung tumor cells, which were resistant to radiotherapy, and the pharyngeal metastasis had mesenchymal phenotypes and expressed ZEB1 but not SNAI1. These observations indicated that ZEB1-associated epithelial-mesenchymal transition has malignant features including resistance to radiotherapy and aggressive metastatic potential. ZEB1-associated EMT may be an important mechanism to understand the pathophysiology of pleomorphic carcinoma.

Successful Treatment of Pulmonary Pleomorphic Carcinoma with Nivolumab: A Case Report

Pulmonary pleomorphic carcinoma (PPC) has a poor prognosis due to the poor results of treatment with systemic chemotherapy. We report the case of a 73-year-old woman with PPC who showed a favorable response to nivolumab. As first-line treatment for postoperative recurrence, she received carboplatin and nanoparticle albumin-bound paclitaxel. However, 12 months later, a new metastatic lymph node appeared. Nivolumab was administered as second-line treatment, and the patient showed a favorable prolonged response. The effects of treatment of PPC with nivolumab seem promising. The results of a future prospective study are expected to identify indicators for the treatment of PPC.

Concurrent combination of irradiation and immune checkpoint inhibitor for recurrent pleomorphic carcinoma of the lung

We report the case of a 49-year-old patient who developed brain, sternal, and spine metastases almost simultaneously after the radical resection of a yp-T4N0M0 pulmonary pleomorphic carcinoma of the right upper lobe following induction chemotherapy. The left occipital brain metastasis was surgically removed and followed by radiation therapy. The sternal and vertebral metastases were treated with radiation therapy. Concurrently, the immune checkpoint inhibitor nivolumab was administered. After 12 cycles of nivolumab, the two bone metastases were well-controlled. However, the brain metastasis recurred and was surgically removed again. We were able to investigate the tumor-infiltrating lymphocytes in brain metastases resected before and after radio-immunotherapy. The results revealed the increased number of CD8- and CD68-positive cells after the combined therapy compared with before the therapy. In addition, the high-level expression of program death-ligand 1 was maintained in the brain metastasis.

Breast metastasis of pulmonary pleomorphic carcinoma: a case report

BACKGROUND

Lung cancer rarely metastasizes to the breast, and breast metastasis of pulmonary pleomorphic carcinoma has not been previously reported.

CASE PRESENTATION

The patient was a 66-year-old woman who became aware of a mass in the right breast and visited a physician. She was referred to our department for close examination, upon which she was diagnosed with double cancer (right breast cancer and left lung cancer). Needle biopsy findings for the mammary tumor were similar to those for the lung biopsy specimen, but spindle cell or metaplastic carcinoma were possibilities. The initial diagnosis was primary breast cancer. Left upper lobectomy and lymph node dissection were performed for left lung cancer. Both the lung and mammary tumors grew rapidly during the wait for surgery. The white blood cell count was within the normal range at the first examination, but was markedly increased and remained at a high level after surgery for lung cancer. Preoperative chemotherapy was initially planned for the mammary tumor, but surgical treatment was selected in consideration of the clinical course, and right mastectomy and full thickness skin graft were performed. However, the disease rapidly aggravated and the patient died 5 months after the first examination.

CONCLUSION

The final diagnosis was pulmonary pleomorphic carcinoma with metastasis to the breast on postoperative histopathological examination. We describe this case as the first reported example of breast metastasis of pulmonary pleomorphic carcinoma.

The Successful Treatment of Pulmonary Pleomorphic Carcinoma with Pembrolizumab: A Case Report

Pulmonary pleomorphic carcinomas are rare malignant tumors, and no standard treatments have been established. We herein report the successful treatment of a patient with pulmonary pleomorphic carcinoma with pembrolizumab. A 51-year-old man who was a current smoker presented to our hospital due to dyspnea and hemosputum. Chest X-ray showed right-sided pneumothorax with pleural effusion; chest tube drainage was therefore performed. Computed tomography after chest tube drainage showed a cavitary nodule in the right upper lobe and right hilar and bilateral mediastinal lymphadenopathy. Surgery was performed for the diagnosis and treatment. He was eventually diagnosed with pulmonary pleomorphic carcinoma corresponding to clinical stage IVB (cT2aN2M1c [PLE, ADR, HEP]). The giant cells strongly expressed programmed death ligand-1, and the tumor proportion score was more than 50%. Therefore, pembrolizumab was introduced as the first-line therapy. After 3 cycles of pembrolizumab, his right hilar and bilateral mediastinal lymphadenopathy and pleural dissemination notably decreased. Pembrolizumab might be an effective therapy for pulmonary pleomorphic carcinoma.

Clinicopathological factors influenced the prognosis of surgically resected pulmonary pleomorphic carcinoma

BACKGROUND

Pulmonary pleomorphic carcinoma has made an unfavorable prognosis because of its properties of resisting radiation and chemotherapy, and its aggressive growth. The correlation between clinicopathological factors and prognosis about pulmonary pleomorphic carcinoma patients who received its surgical resection has not been clearly identified.

METHODS

We retrospectively investigated the clinical records of 24 pulmonary pleomorphic carcinoma patients who had a surgical resection from January 2004 to December 2013 at our institute. We examined the correlation between their clinicopathological factors and therapeutic effects including their prognosis.

RESULTS

The median follow up time was 2.3 years. The 5-year survival was 54.7% and the 5-year progression free survival was 52.4%. In comparison with other tissue types of lung cancer, the prognosis was not so poor even taking into consideration the survival curve including several progression stages. We analyzed the 21 clinicopathological factors in order to clarify the factors connected with the prognosis and disease progression. As a result, we found that both vascular invasion evaluated by immunohistochemistry and lymph node metastasis were connected closely with the overall survival. We found another strong link between the tissue type of epithelial components, vascular invasion evaluated by immunohistochemistry and lymph nodal metastasis with the progression free survival.

CONCLUSIONS

Pulmonary pleomorphic carcinoma patients with lymph node metastasis and vascular invasion had worse prognosis after their surgical resections. We have to find an effective chemotherapeutic drug or molecular targeted drug.