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  Table of Contents    
CASE REPORT  
Year : 2013  |  Volume : 56  |  Issue : 4  |  Page : 416-418
Primary gastric adenosquamous carcinoma in an Indian male


1 Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India
2 Department of Histopathology, Sir Ganga Ram Hospital, New Delhi, India

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Date of Web Publication18-Jan-2014
 

   Abstract 

Adenosquamous carcinoma (ASC) of the stomach is a very rare tumor comprising less than 0.5% of all stomach malignancies. Here, we report a case of a 37-year-old male, who presented with upper gastrointestinal bleeding in the form of hematemesis and malena. A subtotal gastrectomy was done in view of massive uncontrolled bleed. Histology showed evidence of ASC of the body and antrum with metastasis to the liver, perigastric lymph nodes and peritoneal and pleural cavity.

Keywords: Adenosquamous, malignant ulcer, stomach cancer, tumor

How to cite this article:
Bansal RK, Sharma P, Kaur R, Arora A. Primary gastric adenosquamous carcinoma in an Indian male. Indian J Pathol Microbiol 2013;56:416-8

How to cite this URL:
Bansal RK, Sharma P, Kaur R, Arora A. Primary gastric adenosquamous carcinoma in an Indian male. Indian J Pathol Microbiol [serial online] 2013 [cited 2019 Dec 7];56:416-8. Available from: http://www.ijpmonline.org/text.asp?2013/56/4/416/125357



   Introduction Top


Adenosquamous carcinoma (ASC) and pure squamous cell carcinomas (SCCs) occurring in the stomach are rare entities. ASC is a mixed neoplasia (gland-like and squamous) and the incidence of these tumors collectively varies between 0.04% and 0.7% with a male:Female ratio of approximately 4:1. [1],[2],[3],[4] ASC is characterized by more aggressive clinicopathological features and carries a poorer prognosis than typical gastric adenocarcinomas. [4] Intestinal-type adenocarcinomas may present with variable areas of squamous differentiation. However for ASC diagnosis, it has been established that the squamous component should be present in more than 25% of the tumoral sample. The origin of these tumors has been of considerable debate. The prognosis for ASC is usually worse than the intestinal-type carcinoma; despite its major biological determinant is the adenocarcinoma component.


   Case Report Top


This paper reports a case of a 37-year-old male patient who presented with abdominal pain in the epigastric region for which he was taking regular analgesic and admitted in the emergency ward with hematemesis and malena since 2 days. Complete hemogram revealed hemoglobin of 6.8 g/dl and a microcytic, hypochromic anemia. The total leukocyte count, platelet counts and kidney functions tests were unremarkable. An upper gastrointestinal endoscopy revealed a large ulcer in the antrum and body of the stomach [Figure 1]a. Multiple biopsies were taken from the various areas of the ulcer, which was suggestive of well differentiated adenocarcinoma. Computed tomography of abdomen reveled irregular wall thickening along the lesser curvature of stomach with necrotic perigastric and peripancreatic lymph nodes, enlarged reteoperitoneal lymph nodes [Figure 1]b. Endoscopic ultrasound fine needle aspiration of perigastric node suggests the possibility of neuroendocrine tumor or well differentiated adenocarcinoma and immunohistochemistry (IHC) was advised. Meanwhile patient again developed massive hematemesis and underwent palliative distal gastrectomy. During operation 4 cm × 6 cm lesion at distal body and antrum along the lesser curvature infiltrating left lobe of the liver was present. A surface nodule in the right lobe of liver and in falciform ligament was also found. Multiple enlarged lymph nodes in porta and perigastric along with moderate ascites were also seen. Pathological specimen of subtotal gastrectomy along with the growth (size 4 cm × 6 cm) showed that the cut surface of ulcerated growth was grey white, firm and involving most of the gastric parenchyma and infiltrating full thickness of the wall. On microscopic examination, there was poorly differentiated adenocarcinoma stomach with large area of squamoid differentiation [Figure 2]a and b. Tumor was infiltrating full thickness of gastric wall. There was marked lymphovascular and perineural infiltration [Figure 2]c. The squamous cell component of the tumor was about 30-40% [Figure 3]a and b and the rest was adenocarcinoma [Figure 3]c and d. Both components were moderate to poorly differentiated. Immunohistochemical staining was performed, which revealed p63-positivity for squamous component [Figure 4]a and carcino-embryonic antigen positivity for adenocarcinoma component [Figure 4]b. IHC with synaptophysin was performed for neuroendocrine differentiation, which was negative. IHC for p63 was performed retrospectively on the original biopsy, which came out to be negative. Distal resected end and radial margin were involved by the tumor and proximal margins and free edge of the greater omentum was free of tumor. The changes in the uninvolved stomach were of mild chronic gastritis. There were no intestinal metaplasia or Helicobacter pylori in the uninvolved stomach. The liver nodule showed extensive tumor infiltration by adenocarcinoma component. Ascites and pleural effusion, which he developed during the hospital stay were sent for malignant cells and found consistent with metastatic poorly differentiated adenocarcinoma in both the fluids. Patient had a very rapid deteriorating course and died during the hospital stay.
Figure 1: (a) Endoscopy image showing large ulcer in body and antrum, (b) contrast enhanced computed tomography abdomen showing irregular wall thickening along lesser curvature of stomach with necroti c perigastric and peripancreati c lymph nodes, enlarged reteoperitoneal lymph nodes

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Figure 2: (a) Poorly diff erenti ated adenocarcinoma with large areas of squamoid diff erenti ati on (H and E, ×40), (b) poorly diff erenti ated adenocarcinoma with large areas of squamoid diff erenti ati on (H and
E, ×100), (c) poorly diff erenti ated adenocarcinoma with large areas of squamoid diff erenti ati on (H and E, ×200)


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Figure 3: (a) Photomicrograph showing squamous component of adenosquamous carcinoma (H and E, ×100), (b) higher magnifi cati on of squamous component (H and E, ×400), (c) areas of adenocarcinoma (H and E, ×100), (d) higher magnifi cati on showing areas of adenocarcinoma (H and E, ×400)

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Figure 4: (a) Squamous component, positive for p63 (immunohistochemistry, ×100), (b) adenocarcinoma component, positive for carcino-embyonic antigen (immunohistochemistry, ×100)

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   Discussion Top


ASCs of the stomach are rare entities with some studies showing the incidence of 0.5% or less of all gastric carcinomas. [1],[2],[3] The present tumor consisted of a mixture of adenocarcinoma and SCC and gradual transition between the two was present. Thus, the present tumor was not collision tumors, but true ASCs. Pure SCC of the stomach is extremely rare. The ASC is very aggressive and most cases are found in the late stage with lymph node metastasis, liver metastasis and peritoneal dissemination. [2],[5],[6],[7] Studies of large series also reported poor prognosis of ASC of the stomach and our patients behaved in the same way. [8] Peritoneal metastasis is one of the main factors for the dismal prognosis; the 5-year survival rate is approximately 10% and the median survival time is only 12 months. [2]

The origin of SCC components in primary gastric carcinoma are thought to arise from: (i) Foci of heterotopic squamous epithelia in the gastric mucosa; (ii) metaplastic benign squamous gastric epithelia; (iii) totipotent stem cells of the gastric mucosa; (iv) endothelial cells differentiated toward squamous elements; and (v) squamous metaplasia in a pre-existing adenocarcinoma. [9],[10] Saito et al.[10] suggest that although SCC components are derived from adenocarcinoma, SCC components can differentiate into tumor cells with completely different characteristics or into those resemble pure SCC. [9]

In a study by Lee et al.[9] the expression of p53, p16 and retinoblastoma (RB) proteins and their clinicopathologic correlation were investigated in 15 cases of primary gastric ASC and two cases of SCC of the stomach. The altered expression of p53 correlated with the advanced stage, but did not correlate with the depth of invasion, lymph node metastasis or recurrence. The altered expression of p16 and RB proteins did not correlate with any of the above clinico-pathologic factors. They concluded that the three tumor suppressor gene products shares the same pattern suggests that squamous and adenocarcinoma components in the stomach originate from the same or a genetically related clone. In another study by Kim et al.[5] comparing the clinicopathological features and differences of p53 and Ki-67 expression in ASC and SCC of the stomach the authors found that over expression of p53 was seen in 63% of cases and their survival was poor when compared to the p53-negative group. The mean Ki-67 labeling index was 70 ± 21%, and was not associated with p53 staining. The authors concluded that the ASC show p53 protein over expression and high Ki-67 labeling index, which might be related to poor prognosis.

ASCs usually invade deep into the muscular layer, present with venous and lymphatic invasion and tend to be diagnosed later, in more advanced stages. Its biological behavior is usually determined by the adenocarcinoma component. In our patient also the ASC was extending to his serosa, with nodal and hepatic metastasis (T3N1M1) and also with lymphatic and venous invasion with malignant cells present in ascitic and pleural fluid. It is interesting that the present case showed metastases of adenocarcinoma but not SCC in ascitic and pleural fluid as well as in metastatic lymph node. Thus, it seems that the biologic behaviors may be determined by adenocarcinoma element in ASC of the stomach. If that holds true then the degree of differentiation of the adenocarcinoma component may have important prognostic implications as well. Although much more studies of such cases are required. Mean age of presentation in patients with ASC is usually 70-80 years, [9],[10] however, our was a young patient who presented with hematemesis as the first presentation. Definite therapy for this tumor still has not shown any optimistic results as these patients usually present at a very advanced stage and had rapid downhill course. Study by Saito et al.[10] tried fluoropyrimidine based therapy with poor results. It has been reported that S-1 monotherapy improves survival times compared with control therapy; however, the survival rate remains very poor. [2],[11],[12]

To conclude, ASC is a rare tumor of the stomach that usually presents at advanced stage with poor response to chemotherapy agents.

 
   References Top

1.Straus R, Heschel S, Fortmann DJ. Primary adenosquamous carcinoma of the stomach. A case report and review. Cancer 1969;24:985-95.  Back to cited text no. 1
    
2.Ebi M, Shimura T, Yamada S, Hirata Y, Tsukamoto H, Okamoto Y, et al. A patient with gastric adenosquamous carcinoma with intraperitoneal free cancer cells who remained recurrence-free with postoperative S-1 chemotherapy. Intern Med 2012;51:3125-9.  Back to cited text no. 2
    
3.Boswell JT, Helwig EB. Squamous cell carcinoma and adenoacanthoma of the stomach. A clinicopathologic study. Cancer 1965;18:181-92.  Back to cited text no. 3
    
4.Mori M, Iwashita A, Enjoji M. Adenosquamous carcinoma of the stomach. A clinicopathologic analysis of 28 cases. Cancer 1986;57:333-9.  Back to cited text no. 4
    
5.Kim YS, Heo WS, Chae KH, Gang YS, Jung JH, Kim SH, et al. Clinicopathological features and differences of p53 and Ki-67 expression in adenosquamous and squamous cell carcinomas of the stomach. Korean J Gastroenterol 2006;47:425-31.  Back to cited text no. 5
    
6.Blázquez S, Raventós A, Díaz ML, García-Fontgivell JF, Martínez S, Sirvent JJ. Adenosquamous gastric carcinoma in Caucasian patient. Rev Esp Enferm Dig 2005;97:211-2.  Back to cited text no. 6
    
7.Toyota N, Minagi S, Takeuchi T, Sadamitsu N. Adenosquamous carcinoma of the stomach associated with separate early gastric cancer (type IIc). J Gastroenterol 1996;31:105-8.  Back to cited text no. 7
    
8.Aoki Y, Tabuse K, Wada M, Katsumi M, Uda H. Primary adenosquamous carcinoma of the stomach: Experience of 11 cases and its clinical analysis. Gastroenterol Jpn 1978;13:140-5.  Back to cited text no. 8
    
9.Lee WA, Woo DK, Kim YI, Kim WH. p53, p16 and RB expression in adenosquamous and squamous cell carcinomas of the stomach. Pathol Res Pract 1999;195:747-52.  Back to cited text no. 9
    
10.Saito S, Hosoya Y, Morishima K, Ui T, Haruta H, Kurashina K, et al. A clinicopathological and immunohistochemical study of gastric cancer with squamous cell carcinoma components: A clinically aggressive tumor. J Dig Dis 2012;13:407-13.  Back to cited text no. 10
    
11.Osugi H, Takada N, Takemura M, Kaseno S, Lee S, Ueno M, et al. Oral fluoropyrimidine anticancer drug TS-1 for gastric cancer patients with peritoneal dissemination. Oncol Rep 2002;9:811-5.  Back to cited text no. 11
    
12.Fujitani K, Tsujinaka T, Hirao M. Feasibility study of S-1 for resectable gastric cancer with peritoneal seeding. Hepatogastroenterology 2003;50:889-92.  Back to cited text no. 12
    

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Correspondence Address:
Anil Arora
Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi - 110 060
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.125357

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