Letters to Editor
Ovarian undifferentiated carcinoma resembling giant cell carcinoma of lung
Sir, Giant cell carcinoma (GCC) is a highly aggressive variant of sarcomatoid carcinoma of lung. [1] Morphologically, they are composed of anaplastic and pleomorphic bizarre giant cells. [2] Ovarian tumors with osteoclast type giant cells resembling giant cell tumor of bone are reported.[3,4] However, ovarian carcinoma resembling GCC of lung is extremely rare.[5] We present a rare case of ovarian carcinoma resembling GCC lung. A 49‑year old woman presented at our institution with weight loss of 3‑months duration. On ultrasonography, she had bilateral adenexal masses; left larger than the right side. There was no free fluid in abdomen, liver, spleen, cervix and uterus was normal. Her cervical, endometrial and pouch of Douglas smears were normal. Except raised serum LDH, her biochemical markers were within normal limits. Chest X‑ray was normal. CT abdomen and pelvis revealed bilateral adnexal masses; right side was cystic and measured 5.3 × 3.9 × 3 cm. while the left side measured 13 × 10 × 8 cm. On laprotomy, the frozen section from the left adnexal mass revealed poorly differentiated malignant tumor. Hence, she underwent trans‑abdominal hysterectomy with bilateral salpingo‑oophorectomy along with peritoneal samplings, bilateral pelvic lymph node dissection and omentectomy. The left ovary was adherent to the sigmoid colon and was dissected out. Macroscopically, tumor was cystic haemorrhagic. Right ovary was cystic and was filled with clear fluid. The uterus, tubes and omentum were normal. Microscopically, tumor was composed of solid sheets of cohesive large polygonal cells with abundant pale eosinophilic to clear cytoplasm [Figure 1A] or discohesive pleomorphic mono to multinucleated tumor giant cells along with large number of inflammatory cells [Figure 1B]. The giant cells were large (50‑150 microns), with bizarre nuclear appearance. Occasional giant cells showed emperipolesis of neutrophils [Figure 1C]. Osteoclast types of multi‑nucleated giant cells were not seen. Mitosis was increased. No foci of other tumor types like mucinous or serous carcinomas of ovaries, choriocarcinomas, malignant germ cell tumors, malignant melanomas, angiosarcomas were found. The large cohesive tumor cells showed strong positivity for cytokeratin (AE1/AE3) [Figure 2A, B], vimentin while some of the cells also showed positivity for CD‑15, CD‑10 and Cytokeratin 7. The tumor giant cells showed faint positivity for cytokeratin, strong positivity for Vimentin [Figure 2C, D] and negative reaction to CD‑15, CD‑10 and Cytokeratin 7 but the giant cells showed negative reaction. All the cells showed negative reaction to EMA, CA‑125, PLAP, CD30, HMB45, ER, PR, Cytokeratin‑20, CD31, and CD34. The tumor infiltrated the ovarian capsule but peritoneal samples, right and left pelvic lymph nodes (14 lymph nodes) and omentum were free. The right ovary showed only a simple cyst. The tumor stage at the time of diagnosis was 1C and the patient was started on adjuvant chemotherapy for ovarian carcinoma. However, after five cycles, she developed mucus Indian Journal of Cancer | July–September 2014 | Volume 51 | Issue 3
a
c
b
Figure 1: (a) Ovarian carcinoma showing sheets of cohesive large polygonal cells with eosinophilic or clear cytoplasm accompanied by inflammatory cells (H and E × 40), (b) Ovarian carcinoma showing discohesive large, pleomorphic mono to multinucleated giant cells with bizarre nuclei accompanied by inflammatory cells (H and E × 40), (c) Tumor giant cell showing emperipolesis of neutrophils (H and E × 40)
a
b
c
d
Figure 2: (a) Ovarian carcinoma showing Cyto‑keratin positivity (AE1/AE3) by large cohesive tumor cells (IHC × 20), (b) Tumor giant cells showing faint positive reaction to cytokeratin (IHC × 20), (c) Ovarian carcinoma showing Vimentin positivity by large cohesive tumor cells (IHC × 40), (d) Tumor giant cells showing Vimentin positivity (IHC × 40)
discharge per rectum. CT scan revealed recurrent mass in the pelvis infiltrating the bowel indicating aggressive behavior of the tumor. The patient was started on treatment for refractory epithelial carcinoma. As giant cell tumors have aggressive clinical course, their recognition is important for management of the patients. Urmila Majhi, Kanchan Murhekar, Shirley Sundersingh Department of Pathology, Cancer Institute (WIA), 38, Sardar Patel Road, Chennai, India Correspondence to: Dr. Urmila Majhi, E‑mail: [email protected]
References 1.
Nash AD, Stout AP. Giant cell carcinoma of the lung; Report of 5 cases. Cancer 1958;11:369‑76. 375
Letters to Editor 2. 3. 4. 5.
Usmani SZ, Tannenbaum SH, Hegde P. Emperipolesis in giant cell carcinoma of lung. Community Oncol 2010 7;233‑5. Bettinger HF. A giant cell tumor of bone in a pseudomucinous cystadenoma of the ovary. J Obstet Gynaecol Br Emp 1953;60:230‑2. Kherdekar M, Patoria NK. Co‑existing giant cell tumor in a mucinous cystadenoma of the ovary: A case report. Indian J Cancer 1976;13:291‑5. Yasunaga M, Ohishi Y, Nishimura I, Tamiya S, Iwasa A, Takagi E, et al. Ovarian undifferentiated carcinoma resembling giant cell carcinoma of the lung. Pathol Int 2008;58:244‑8.
One more common tumor in an uncommon location: Squamous cell carcinoma on nipple areola complex Sir, The nipple‑areola complex is a very rare site for squamous cell carcinoma (SCC), being the area not a sun exposed region of the body.[1] Authors mentioned that SCC should be considered in the differential diagnosis of a nipple lesion in a patient presenting after radiation therapy. Literature also mentions about radiation induced malignancies following radiotherapy for breast cancer.[2] Other diagnoses to consider include basal Cell Carcinoma, recurrent breast cancer, pagets disease, and radio dermatitis.[1]
Access this article online Quick Response Code:
Website: www.indianjcancer.com DOI: 10.4103/0019-509X.146719 PMID: *****
We noticed cutaneous type of squamous cell carcinoma on the nipple‑areola complex, considering this as a rare entity we presented the case. An 87-year-old female presented with an ulcerating and a fungating growth over the left sided nipple-areola complex. There was no evidence of nipple discharge, previous history for any other risk factor related to this lesion (SCC) was negative. The right sided breast was unremarkable. Excision biopsy was received initially, which showed histopathological findings of a well differentiated squamous cell carcinoma. In view of uncertainty of origin of the tumor, modified radical mastectomy was done, specimen received was of the breast
Figure 1: Nipple‑areola complex showing ulcerating and fungating growth
Figure 2: Cut section of the growth
Figure 3: SCC showing typical keratin pearls (H and E stain)
Figure 4: H and E section of axillary lymph node showing invasion
376
Indian Journal of Cancer | July–September 2014 | Volume 51 | Issue 3
Copyright of Indian Journal of Cancer is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Ovarian undifferentiated carcinoma resembling giant cell carcinoma of lung
Sir, Giant cell carcinoma (GCC) is a highly aggressive variant of sarcomatoid carcinoma of lung. [1] Morphologically, they are composed of anaplastic and pleomorphic bizarre giant cells. [2] Ovarian tumors with osteoclast type giant cells resembling giant cell tumor of bone are reported.[3,4] However, ovarian carcinoma resembling GCC of lung is extremely rare.[5] We present a rare case of ovarian carcinoma resembling GCC lung. A 49‑year old woman presented at our institution with weight loss of 3‑months duration. On ultrasonography, she had bilateral adenexal masses; left larger than the right side. There was no free fluid in abdomen, liver, spleen, cervix and uterus was normal. Her cervical, endometrial and pouch of Douglas smears were normal. Except raised serum LDH, her biochemical markers were within normal limits. Chest X‑ray was normal. CT abdomen and pelvis revealed bilateral adnexal masses; right side was cystic and measured 5.3 × 3.9 × 3 cm. while the left side measured 13 × 10 × 8 cm. On laprotomy, the frozen section from the left adnexal mass revealed poorly differentiated malignant tumor. Hence, she underwent trans‑abdominal hysterectomy with bilateral salpingo‑oophorectomy along with peritoneal samplings, bilateral pelvic lymph node dissection and omentectomy. The left ovary was adherent to the sigmoid colon and was dissected out. Macroscopically, tumor was cystic haemorrhagic. Right ovary was cystic and was filled with clear fluid. The uterus, tubes and omentum were normal. Microscopically, tumor was composed of solid sheets of cohesive large polygonal cells with abundant pale eosinophilic to clear cytoplasm [Figure 1A] or discohesive pleomorphic mono to multinucleated tumor giant cells along with large number of inflammatory cells [Figure 1B]. The giant cells were large (50‑150 microns), with bizarre nuclear appearance. Occasional giant cells showed emperipolesis of neutrophils [Figure 1C]. Osteoclast types of multi‑nucleated giant cells were not seen. Mitosis was increased. No foci of other tumor types like mucinous or serous carcinomas of ovaries, choriocarcinomas, malignant germ cell tumors, malignant melanomas, angiosarcomas were found. The large cohesive tumor cells showed strong positivity for cytokeratin (AE1/AE3) [Figure 2A, B], vimentin while some of the cells also showed positivity for CD‑15, CD‑10 and Cytokeratin 7. The tumor giant cells showed faint positivity for cytokeratin, strong positivity for Vimentin [Figure 2C, D] and negative reaction to CD‑15, CD‑10 and Cytokeratin 7 but the giant cells showed negative reaction. All the cells showed negative reaction to EMA, CA‑125, PLAP, CD30, HMB45, ER, PR, Cytokeratin‑20, CD31, and CD34. The tumor infiltrated the ovarian capsule but peritoneal samples, right and left pelvic lymph nodes (14 lymph nodes) and omentum were free. The right ovary showed only a simple cyst. The tumor stage at the time of diagnosis was 1C and the patient was started on adjuvant chemotherapy for ovarian carcinoma. However, after five cycles, she developed mucus Indian Journal of Cancer | July–September 2014 | Volume 51 | Issue 3
a
c
b
Figure 1: (a) Ovarian carcinoma showing sheets of cohesive large polygonal cells with eosinophilic or clear cytoplasm accompanied by inflammatory cells (H and E × 40), (b) Ovarian carcinoma showing discohesive large, pleomorphic mono to multinucleated giant cells with bizarre nuclei accompanied by inflammatory cells (H and E × 40), (c) Tumor giant cell showing emperipolesis of neutrophils (H and E × 40)
a
b
c
d
Figure 2: (a) Ovarian carcinoma showing Cyto‑keratin positivity (AE1/AE3) by large cohesive tumor cells (IHC × 20), (b) Tumor giant cells showing faint positive reaction to cytokeratin (IHC × 20), (c) Ovarian carcinoma showing Vimentin positivity by large cohesive tumor cells (IHC × 40), (d) Tumor giant cells showing Vimentin positivity (IHC × 40)
discharge per rectum. CT scan revealed recurrent mass in the pelvis infiltrating the bowel indicating aggressive behavior of the tumor. The patient was started on treatment for refractory epithelial carcinoma. As giant cell tumors have aggressive clinical course, their recognition is important for management of the patients. Urmila Majhi, Kanchan Murhekar, Shirley Sundersingh Department of Pathology, Cancer Institute (WIA), 38, Sardar Patel Road, Chennai, India Correspondence to: Dr. Urmila Majhi, E‑mail: [email protected]
References 1.
Nash AD, Stout AP. Giant cell carcinoma of the lung; Report of 5 cases. Cancer 1958;11:369‑76. 375
Letters to Editor 2. 3. 4. 5.
Usmani SZ, Tannenbaum SH, Hegde P. Emperipolesis in giant cell carcinoma of lung. Community Oncol 2010 7;233‑5. Bettinger HF. A giant cell tumor of bone in a pseudomucinous cystadenoma of the ovary. J Obstet Gynaecol Br Emp 1953;60:230‑2. Kherdekar M, Patoria NK. Co‑existing giant cell tumor in a mucinous cystadenoma of the ovary: A case report. Indian J Cancer 1976;13:291‑5. Yasunaga M, Ohishi Y, Nishimura I, Tamiya S, Iwasa A, Takagi E, et al. Ovarian undifferentiated carcinoma resembling giant cell carcinoma of the lung. Pathol Int 2008;58:244‑8.
One more common tumor in an uncommon location: Squamous cell carcinoma on nipple areola complex Sir, The nipple‑areola complex is a very rare site for squamous cell carcinoma (SCC), being the area not a sun exposed region of the body.[1] Authors mentioned that SCC should be considered in the differential diagnosis of a nipple lesion in a patient presenting after radiation therapy. Literature also mentions about radiation induced malignancies following radiotherapy for breast cancer.[2] Other diagnoses to consider include basal Cell Carcinoma, recurrent breast cancer, pagets disease, and radio dermatitis.[1]
Access this article online Quick Response Code:
Website: www.indianjcancer.com DOI: 10.4103/0019-509X.146719 PMID: *****
We noticed cutaneous type of squamous cell carcinoma on the nipple‑areola complex, considering this as a rare entity we presented the case. An 87-year-old female presented with an ulcerating and a fungating growth over the left sided nipple-areola complex. There was no evidence of nipple discharge, previous history for any other risk factor related to this lesion (SCC) was negative. The right sided breast was unremarkable. Excision biopsy was received initially, which showed histopathological findings of a well differentiated squamous cell carcinoma. In view of uncertainty of origin of the tumor, modified radical mastectomy was done, specimen received was of the breast
Figure 1: Nipple‑areola complex showing ulcerating and fungating growth
Figure 2: Cut section of the growth
Figure 3: SCC showing typical keratin pearls (H and E stain)
Figure 4: H and E section of axillary lymph node showing invasion
376
Indian Journal of Cancer | July–September 2014 | Volume 51 | Issue 3
Copyright of Indian Journal of Cancer is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
