Squamous cell carcinoma with prominent myxoid stroma

Squamous Cell Carcinoma With Prominent Myxoid Stroma MARIO P. FOSCHINI, MD, EZIO FULCHERI, MD, PATRIZIA BARACCHINI, BSc, CIAUDIO CECCARELLI, BSc, CHRISTINE M. BEllS, BSc, AND VINCENZO EUSEBI, MD Three cases of a squamous cell carcinoma oid stroma are reported. presented polypoid

as a lump

man and Bl-year-old

woman,

was immersed

stances. In addition immunocytochemical

respectively.

in abundant

to occasional

The

squamous

evidence of high-weight extracellular

with histologically

mucosubstances

taken into consideration,

similar

and it has been

newly described

entity showing

be distinguished

from numerous

abundant benign

has been

suggested

that this

myxoid

stroma has to

and malignant

soft tissue tumors. HUM PATHOL 21:859-865. Saunders

tissue. The diflesions

0

myxoid

1990 by W.B.

Company.

Extracellular mucosubstances (EMU) are present in several tumors of different nature and histogenesis. When EMU are epithelial in nature and are constituted b,y glycoproteins, the term “mucoid stroma” is “myxoid stroma” is attributed adopted.’ In contrast, to those neoplastic conditions having a large amount of mucopolysaccharides of mesenchymal nature in their stroma. ’ Adenocarcinomas arising in various organs may be characterized by neoplastlc cells floating in a mucoid stroma. Similarly, there is a wide spectrum of benign and malignant soft tissue tumors in which the myxoid stroma is a prominent feature.” Myxoid stroma present in carcinomatous proliferation has not been well documented in the literature. We present here an ultrastructural, histochemical and immunologic study of three cases of squamous cell carcinoma with prominent myxoid stroma. Their differential diagnosis with other histologically similar tumors is discussed.

Cases 1 and

according

to

CASE HISTORIES See Table 2 for details. Case 1 The patient, a 70-year-old woman, complained of a nodule located in the upper outer quadrant of the right breast. far from the skin surface, present for 2 years. A frozen section of the nodule was interpreted as “unusual mucoid carcinoma.” Consequently, a mastectomy was performed with lower axillary dissection. Local radiotherapy followed. The patient did not experience metastases and is alive and well after 3 years. Macroscopically the nodule was pink-grayish in color, firm in consistency, had irregular margins. and measured 2 cm in its greatest axis. The remaining breast was normal; the five axillar); lymph nodes examined were free of metastases.

Case 2

MATERIALS AND METHODS stitute of Pathology

was performed

et al,*,” using the streptavidinbiotin-peroxidase complex (Detek I-hrp, Signal Generating System, Lot. n. TCI; Enzo Biochemicals Inc, New York, NY) instead of the avidin-biotin-peroxidase complex. The antisera used, together with their dilutions, are reported in Table 1. Positive controls were stained in each batch of slides. Negative controls were obtained by substituting the specific antisera. Case I was studied ultrastructurally: blocks were fixed in 3% glutaraldehyde for 3 hours, postfixed in 1%I OsO,, dehydrated, and embedded in araldite. Ultrathin sections were stained with uranyl acetate and lead citrate.

attachment un-

to be similar to those seen in connective diagnosis

Immunohistochemistry the method of Hsu

keratin present in

microscopy.

The

mucosub-

pearls, it displayed

der

ferential

as

carcinomatous

extracellular

cells and, in one case, desmosomal

electraIn

had

and cervix uteri in a 65-year-old

the neoplastic proved

been seen in consultation by one of’ us (V.E.). In all cases formalin-fixed paraffin-embedded tissues from the entire lesions were available: 5 pm-serial sections were stained with hematoxylin and eosin (H&E), Alcian blue pH 1” and pH 2.5.1 high iron diamine (HID)j prior to and after digestion with testicular hyaluronidase” and sialidase,’ and periodic acid-Schiff (PAS) following diastase digestion.

myx-

woman

in the breast, the other two presented

lesions of the larynx

component

with a prominent

One case in a ‘IO-year-old

A G-year-old man presented with a short history of dysphonia. He had been a moderate smoker until 9 years previous to presentation. Upon performing a laryngoscopy, a small polyp of the right vocal chord was found. The lesion measured 0.8 cm in its greatest axis. Physical examination of the patient failed to reveal metastases. He is alive and well 27 months later.

retrieved from the files of the Inof the University of Bologna; case 3 has

2 were

From the IFtituti di Anatomia ed Istologia Patologica. Univer$II~ di Bologna e di <:enova, Italy; and Dipartimento di Patologia Sperimentale. Universiti di Bologna, Italy. Accepted tor publication December 1. 1989. Supported 1)) grants from MPI 40% and WC%, ,md CiYR XX.OCl66244. and I!SL 23 Imola. Ku? word\: m\xoid str-oma. squamous cell carcinoma. breast, larynx. cervix uteri. Address correspondenceand reprint requests to Vincenzo Eusebi, MD, Istituto di Anatomia ed Istologia Patologica. Universiti di Bologna. Ospedale Bellaria, Via Altura 3, 4013 Bologna, Italy. 0 1990 by W.B. Saunders Company. 0046-X 177/90/2 1ox-00 13$5.00/0

Case 3 A 6 1-year-old woman presented to the General Hospital in Prato, (Tuscany, Italy) with vaginal bleeding. A colposcopy showed her to have a cervical polvp, which was removed. Following the diagnosis of malignant myxoid tumour, the patient underwent hysterectomy and bilateral salpingo-oophorectomy. Regional lymph nodes were also

859

Volume 21, No. 8 (August 1990)

HUMAN PATHOLOGY TABLE

lmmunohistochemistty Dilution

Antisera M Keratin

1.

EAB 903

M Keratin EAB 902 P Epithelial Membrane

Source

1:1,500

Ortho Diagnostic (Milan, Italy) Ortho Diagnostic Kindly given by

1:1,500 1:6,000

Antigen M Vimentin

1:200

P Desmin P S-100 Protein

1:300 1:3,600

System System

Dr. Sloane (London, England) Dakopatts (Copenhagen, Denmark) Dakopatts Dakopatts

Notes: P, polyclonal; M, monoclonal. removed. A computed tomography scan and an osseous scintigraphy did not reveal metastases. She is alive and well after 6.5 years. Macroscopically, the uterus and ovaries appeared normal in size and shape. The cervix showed a polypoid lesion of 1.4 cm in length, protruding from the posterior lip. The polypoid structure appeared soft in consistency and yellowish in color.

.. ‘i*

?

.

..

HISTOLOGY As the three cases had the same histologic appearance, they will be described together. Microscopically, the bulk of the lesions was composed of plexiform chords of neoplastic cells variously anastomosing and floating in an abundant EMU where a delicate meshwork of capillaries was present (Fig 1). In occasional areas typical squamous pearls were seen (Figs 2 and 3). These were most evident in case 1. Most of the cells had strongly eosinophilic cytoplasm and a centrally placed nucleus (Fig 4). Nuclei were round-to-ovoid in shape, and one to two nucleoli were clearly evident. Numerous single cells were fusiform or polygonal in shape, and appeared to float by themselves in the EMU (Fig 5). Neither signet ring cells nor neoplastic elements showing intracytoplasmic lumina were seen. In case 2 the laryngeal mucosa overlying the tumor contained squamous carcinoma, apparently in situ. In case 1 rare mucous filled cysts were present. The cyst walls were lined by neoplastic elements, and in the lumina occasional round neoplastic cells with eosinophilic cytoplasm were present. In this same case the myxoid areas gradually merged with solid areas composed of neoplastic spindle cells, reminiscent of a fibrosarcoma-like pattern. Necrosis TABLE2.

FIGURE 1. Case 3: plexiform chords of neoplastic cells appear to float in abundant EMU [H&E stain; magnification x 100).

was absent in all cases. Mitotic ratio was high (Fig 6) in cases 1 and 2 (7 per 10 high-power fields (hpf) in case 1; 6 per 10 hpf in case 2; 2 per 10 hpf in case 3). In no case was there evidence of lymphatic or blood vessel invasion. Histochemistry See Table 3 for details. Histochemical reactions were scored as follows: - when negative; +iwhen focal stain was obtained; + when the stain was diffuse but weak; and + + when the stain was diffuse and strong. Case Histories

Case No.

Age/Sex

1

70/F

Breast

Nodule

2cm

SM LD R

2

65/M

Larynx

PO’YP

0.8 cm

P

2.3, AW

3

61/F

Uterine, cervix

PO’YP

1.4 cm

HO LD

6.5, AW

Site

Abbreviations: AW, alive and well; HO, hysterectomy radiotherapy; SM, simple mastectomy.

Presentation

and bilateral oophorectomy;

860

Size

Treatment

LD, lymph node dissection;

Follow-up Years

3, AW

P, polypectomy;

R.

MYXOID SQUAMOUS CARCINOMA (Foschin et al)

FIGURE 3. Case 1. At higher power squamous pearl appears surrounded by dissociated single neoplastic elements (H8& stain; magnification x 350.1

FIGURE 2. Case 1. In one area typical squamous pearls appear within the myxoid stroma. (H&E stain; magnification x 100.)

lmmunohistochemistry The IEMu-rich stroma stained intensely with Alcian blue pH 1 and HID. In more detail case 1 revealed a prevalence of carboxylated (+) and sulphated (-t + ) mucopolysaccharides, the amount of which was decreased by hyaluronidase digestion, whereas it was not modified by sialidase digestion. Case 2 revealed carboxylated ( + ) and sulphated (+ ) mucopolysaccharides in greater amounts. By hyaluronidase digestion sulphated mucopolysaccharides were com.pletely removed, whereas they were not modified by sialidase digestion. Case 3 revealed a mixture of mucopolysaccharides and glycoproteins. The stroma contained carboxylated ( +) and a lesser quantity of sulphated ( + / - ) mucopolysaccharides. After hyaluronidase digestion mucopolysaccharides were slightly decreased, whereas after sialidase digestion they were slightly increased, thus confirming the presence of sialic acid masking sulphated mucopolysaccharides. Use of the PAS method, both prior to and after diastase digestion, did not reveal staining. None of the neoplastic cells stained with PAS or Alcian blue pH 2.5.

The antikeratin antibody EAB 903, specific to cytokeratins no. 1, 5, 10, and I 1,i” intensely stained the cytoplasm of most of the neoplastic cells in all cases (Fig 7). Positivity was also shown by antivimentin antibody. S-100 antiserum was localized in some cells of case 2. Anti-low weight keratin antibody EAB 902 specific to cytokeratin no. 8”’ and anti-epithelial membrane antigen (EMA) failed to reveal any positivitv in the three cases. Electron Microscopy Electron microscopy (EM) performed in case 1 revealed two types of neoplastic cells. One type (Fig 8) was mainly arranged in nests, was elongated or round in shape, and had a large irregular nucleus. Chromatin in these cells was finely dispersed and mostly condensed at the periphery of the nuclei. The cytoplasm contained numerous tonoftlaments and was rich in endoplasmic reticulum. The cytoplasmic borders were irregular showing a pseudomicrovillous surface. Occasional desmosomes were present. Some of the neoplastic cells were adherent to each other while 861

HUMAN PATHOLOGY

Volume 21, No. 8 (August 1990)

FIGURE 4 Case 1. The neoplastic elements show eosinophilic cytoplasm with centrally placed nuclei. (H&E stain; magnification x 100; inset, magnification x 250.)

FIGURE 6. Case 2. Several mitotic figures are displayed by the neoplastic elements (H&E stain; magnification x 350.)

others appeared separated by obvious intercellular spaces. The other type of cell (Fig 9) appeared polygonal in shape with an irregular nucleus. These elements appeared to float in an amorphous substance

in which dissociated collagenous fibers were present. The cytoplasm of these elements contained occasional tonofibrils, abundant ergastoplasmic reticulum, and dilated cisternae where an amorphous material was

FIGURE 5. Case 2. Fusiform or polygonal neoplastic elements are dissociated by abundant EMU. (H&E stain; (left] magnificaftan x 100; (right) magnification x 550.)

MYXOID SQUAMOUS CARClNOfvlA (Foschini et al)

TABLE3.

Histochemistry Hyaluronidase

Detection Methods

I

HID

HID

AB

HID

AB

+

++

+I-

+i-

++

+I-

+ +

+ +I-

_ +I-

+ it-

+ ++

ii-

.a

(:ase I (:ase 9 (Zase 3

Abbreviations: AB 1, Alcian pH 2.5; HID. high iron diamine. Notes: -- . no positive stain; stnin: + +, strong diffuse stain.

present. abundant

Sialidase

Collagenous extracellular

blue

pH

1: .4B 2.5. Alcian

_

blue

+/- , focal stain; + , weak diffuse

fibers appeared dissociated amorphous substance.

by

DISCUSWN All three tumors were characterized by squamous cell carcinomas (KC) where neoplastic elements floalted in a sulphated mucopolysaccharide rich stroma. O’ccasional squamous pearls were visible in all cases. Admittedly, these were more obvious in case 1, while in cases 2 and 3 squamous pearls were found only after a prolonged search. Case 2 demonstrated in situ carcinoma in the overlying mucosa. EM features in case 1 and immunohistochemistry of all cases were also #consistent with the squamous nature of the tumors. Hligh weight keratins, which have been described to be mainly expressed by squamous epithelial, I” were selectively localized in all three cases. In addition, in case 1 cytoplasmic tonofilaments and desmosomes observed at EM level are features consistent with squamous differentiation. The histochemically detected EMU composing the stroma of the three cases appeared to be of mesenchymal nature. Carboxylated and sulphated mucopolysaccharides were present in significative amounts; in no case was epithelial glycoprotein found. Therefore, it ap-

FIGURE 7. Most of the neoplastic cells appear imlmunoreactive with antihigh-weight keratin. (Avidin-biotin complex peroxidase stain; (left) Case 1, magnification x 100; (right) Case 2, magnification x 100.)

pears that the three cases studied all show a mucopolysaccharide pattern of the stroma similar to that seen in soft tissue tumors with myxoid features.2211 Sarcomatoid carcinomas with focal EMU rich stroma have been occasionally mentioned in the literature. Sporadic cases have been reported in the upper respiratory and digestive tract,12.‘? mucous membrane of the head and neck,‘” breast,‘j,‘” skin,*“.17 and the kidney. In Nevertheless, in no case has a systematic histochemical evaluation of staining characteristics of stromal component been performed. In the breast, cystosarcoma phyllodes (CP) may show squamous metaplasia of the epithelium and a fibrosarcoma-like stroma with focal myxoid and edematous appearance. I9 These features can mimic the appearance shown by XC with myxoid stroma. Nevertheless, the epithelial-lined glandular channels of CP with the characteristic double layer of cells, together with the lack of atypicality in the squamous metaplasia, allow an easy distinction between the two entities. Mucoepidermoid carcinoma with intense squamous metaplasia can be distinguished from SCC with myxoid stroma on the basis of the glandular structures and epithelial mucins which characterize the former.20.“1 Diffuse squamous metaplasia in mucoid carcinoma of the breast seems unlikely in case 1 as no intra- or extracellular epithelial glycoproteins typical of mucoid carcinomas22 were seen. Laryngeal tumors composed of eosinophilic cells immersed in EMU might suggest t.he diagnosis of chordoma. In contrast to chordomas, case 2 did not show any physaliphorous cells arranged in an organoid pattern. In addition, EMA and S-100 protein were not localized in case 2, while these have been seen in chordomas.23J’ Furthermore, the presence of squamous pearls easily distinguishes the tumor in case 2 from myxoid chondrosarcoma which occasionally affects the larynx.“”

HUMAN PATHOLOGY

Volume 21, No. 8 (August 1990)

FIGURE 8. Case 1. Small clumps of cells having elongated nucleus with finely dispersed chromatin. mostly condensed at the periphery. The cytoplasm contains numerous tonofilaments. The neoplastic elements appear detached from one another and the cytoplasmic borders are irregular, showing a pseudomicrovillous surface. (EM; magnification x 20,000.)

Case 3 presented as a small cervical polyp. Benign polyps with atypical stromal cells immersed in a myxoid stroma which occur in the lower genital tract*” can mimic SCC with myxoid stroma. The immunologic demonstration of keratin positivity in our case distinguished it from those benign polypoid lesions. Botryoid rhabdomyosarcoma,” leiomyoangiomyxoma of the pelvis,“” sarcoma,2H aggressive and mixed tumors of the vagina,“O although sharing the same type of stromal carbohydrates with case 3, can be easily distinguished as they do not show any other features observed in the latter, including kera-

tin positivity. Sarcomatoid carcinomas, primarily located in the uterine cervix, were reported by Steeper, et al in 198331 ; none of their four cases showed myxoid stroma. All the present cases seem to have a favorable prognosis. Admittedly, the follow-up of the patients (from 3 to 6.5 years, mean 4.1 years) is relatively short; nevertheless, this could be related to the presence of high amounts of EMU, which, as reported in mucoid carcinomas of the breast’” and myxoid liposarcoma of soft tissues,*’ appears protective. Further studies are needed to investigate this. The purpose of this paper was to report three cases of myxoid

FIGURE 9. Case 1. The other type of cell is polygonal in shape, and has an irregular nucleus. The cytoplasm contains occasional tonofibrils, abundant ergastoplasmic reticulum, and dilated cisternae. (EM; magnification x 12500.)

MYXOID SQUAMOUS CARCINOMA (Foschini et al)

SCC which should be considered in the differential diagnosis of tumors having abundant extracellular mumsubstances. ,4~kllo71llrd~1~~111. Dr R. R. Millis is thanked for critically evaluated the manuscript. Acknowledgment to Mirna Montanari f’or secretarial help.

having is due

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