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An Official Publication of the Indian Association of Oral and Maxillofacial Pathologists


 
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CASE REPORT - EPITHELIAL MALIGNANCIES  
Year : 2019  |  Volume : 23  |  Issue : 4  |  Page : 87-89
 

Pseudovascular squamous cell carcinoma with eosinophil-rich stroma


Loma Linda University Medical Center, Loma Linda, CA, USA

Date of Submission24-Oct-2018
Date of Acceptance29-Dec-2018
Date of Web Publication22-Feb-2019

Correspondence Address:
Yamil Lopez
Department of Pathology, Loma Linda University Medical Center, 11234 Anderson Street, Room 2516, Loma Linda, CA 92354
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomfp.JOMFP_276_18

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   Abstract 


Pseudovascular squamous cell carcinoma (SCC) is a rare variant of SCC characterized by acantholysis and necrosis with preservation of vascular-like cords and spaces mimicking glands or vascular differentiation. Only three cases of this variant in the oral cavity have been reported in the literature. However, none of these cases were eosinophil-rich, which is considered to be a good prognostic indicator for conventional SCC. We report one case of an eosinophil-rich pseudovascular adenoid SCC in the oral cavity. A 38-year-old previously healthy African-American female presented with an enlarging inner left cheek mass with overlying ulcer of 2 months duration. A computed tomography scan with contrast demonstrated a large irregularly outlined peripherally enhancing mass located between the anterior margin of the ramus of the left mandible and maxilla protruding outward. An incisional biopsy was performed followed by a wide local excision 3 weeks later. She recovered well postoperatively but refused to follow-up chemoradiation therapy. Six months later, she presented with altered mental status secondary to hypercalcemia from bony metastases. She was discharged to a hospice facility as per her family's request. Histologic sections of the specimens revealed a diffuse hypercellular pleomorphic ill-circumscribed lesion with extensive necrosis. The viable areas exhibited slit vascular-like spaces and micropapillary architectural patterns with stromal eosinophilia. Focal small cellular nests with features of SCC were present. Immunohistochemistry displayed positivity for vimentin, p53, AE1/AE3 and CAM 5.2 (focally positive). All tumor cells were negative for desmin and CD34.


Keywords: Adenoid squamous cell carcinoma, eosinophil-rich squamous cell carcinoma, oral cavity squamous cell carcinoma, pseudovascular squamous cell carcinoma


How to cite this article:
Lopez Y. Pseudovascular squamous cell carcinoma with eosinophil-rich stroma. J Oral Maxillofac Pathol 2019;23, Suppl S1:87-9

How to cite this URL:
Lopez Y. Pseudovascular squamous cell carcinoma with eosinophil-rich stroma. J Oral Maxillofac Pathol [serial online] 2019 [cited 2019 May 24];23, Suppl S1:87-9. Available from: http://www.jomfp.in/text.asp?2019/23/4/87/252730





   Introduction Top


Pseudovascular adenoid squamous cell carcinoma (SCC), also known as adenoid SCC or angiosarcoma-like SCC, is a rare variant of SCC characterized by acantholysis and necrosis with the preservation of vascular-like cords and spaces mimicking glands or vascular differentiation. Only three cases of this variant in the oral cavity have been reported in the literature.[1],[2] However, none of these cases were eosinophil-rich, which is considered to be a potential prognostic indicator for conventional SCC.[3],[4] We report one case of an eosinophil-rich pseudovascular adenoid SCC in the oral cavity.


   Case Report Top


Clinical history

A 38-year-old previously healthy African-American female presented with an enlarging inner left cheek mass with overlying ulcer of 2 months duration. A computed tomography scan with contrast demonstrated a large irregularly outlined peripherally enhancing mass located between the anterior margin of the ramus of the left mandible and maxilla protruding outward. An incisional biopsy was performed followed by a wide local excision 3 weeks later. The excision included a composite resection of left buccal mucosa, a left modified radical neck dissection, a left partial maxillectomy, a right anterior thigh flap placement, and a left parotidectomy. A whole-body computed tomography survey demonstrated a 5-mm lingular lung nodule and a 7-mm right hepatic hypodensity. These areas were determined to likely be incidental findings; however, further workup was suggested.

The patient had an unremarkable surgical recovery and was discharged from the hospital 1 week later. An incisional biopsy was performed followed by a wide local excision 3 weeks later. She recovered well postoperatively but refused to follow-up chemoradiation therapy.

Six months later, she presented with altered mental status secondary to hypercalcemia from bony metastases. She was discharged to a hospice facility as per her family's request.

Gross pathology

The excised specimen displayed a pedunculated, exophytic, ulcerated, dark purple mass, appearing to arise from the buccal mucosa. The mass measured 6.0 cm × 5.4 cm × 2.8 cm in greatest dimensions. The cut surface revealed a light tan interior with scattered areas of hemorrhage and necrosis and an infiltrative margin involving the underlying subcutaneous tissue but sparing the overlying skin and adjacent maxillary segment [Figure 1].
Figure 1: Cut surface of ulcerated exophytic mass

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Microscopic examination

Histologic sections of the incisional biopsy specimen revealed a diffuse hypercellular pleomorphic ill-circumscribed lesion with extensive necrosis. The viable areas exhibited slit-like vascular space and micropapillary architectural patterns and focal small cellular nests with features of squamous differentiation. Immunohistochemistry (IHC) displayed positivity for vimentin, p53, AE1/AE3 and CAM 5.2 (focally positive). All tumor cells were negative for desmin and CD34.

Examination of the excisional specimen revealed similar morphology with more developed pseudovascular cystic areas with stromal eosinophilia [Figure 2] and [Figure 3]. IHC displayed positivity for AE1/AE3 and lack of E-cadherin and CD34 expression [Figure 4] and [Figure 5]. Focal areas of conventional SCC architecture were present at radial edges of the tumor.
Figure 2: Pseudovascular architecture with prominent acantholysis mimicking vascular channels

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Figure 3: Stromal eosinophils intermixed with poorly differentiated tumor cells

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Figure 4: Immunostain for AE1/AE3 demonstrating positivity in tumor cells

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Figure 5: Immunostain for CD34 demonstrating lack of antigen in tumor cells

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Metastatic tumor was present in four of 35 examined left cervical lymph nodes with the largest metastases measuring 1.5 cm and displaying extracapsular extension. The stromal eosinophilia was also present within the metastatic foci.

Procedure

Histology

The incisional biopsy and resection specimens were evaluated via standard grossing protocols. Subsequently, sections were fixed with buffered formalin, embedded in paraffin, cut 4 mm thick and stained with H&E.

Immunohistochemistry

IHC stains were performed for CD34, vimentin, CAM 5.2, AE1/AE3, desmin and P53. Before immunostaining, the slides were deparaffinized, hydrated and then incubated with anti-CD34 (Ventana, Tucson, AZ, 10 mg/ml), anti-p53 (Ventana, 3 mg/ml), anti-CAM 5.2 (Cell, Rocklin, California, 32.5 mg/ml) and anti-AE1/AE3 (Ventana, 5 mg/ml). All slides were counterstained with H&E.


   Discussion Top


Pseudovascular SCC is an uncommon variant of SCC which must not be mistaken for angiosarcoma. The difference in management is substantial for these two entities and highlights the need for an accurate diagnosis. With thorough sampling and microscopic examination, these tumors usually retain a focus of conventional SCC,[1] which can greatly assist this diagnostic dilemma. If further confirmation is necessary, then IHC with keratins and vascular antigens can be used to display the tumor classification.

The possibility of E-cadherin loss in the pathogenesis of this pseudovascular SCC has been suggested in two previous cases.[1] This loss of E-cadherin was also noted in our case and further supports the notion that loss of tumor cell adhesion and subsequent acantholysis may result in a pseudovascular appearance of SCC.

The prognostic significance of tumor-associated eosinophilia (TAE) in conventional head and neck SCC (HNSCC) has had mixed results in the literature. In one study, TAE was found to suggest favorable prognosis.[3] However, subsequent studies of TAE in HNSCC have found either unfavorable prognosis[4] or no statistical significance.[5],[6]

In our case, it is difficult to determine and clinical significance of TAE due to the lack of postoperative therapy and subsequent rapid clinical decline. Since our case is an uncommon variant of SCC, it is possible that the noted TAE could play a prognostic role in the behavior of this entity. However, more study of this is needed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Zidar N, Gale N, Zupevc A, Dovsak D. Pseudovascular adenoid squamous-cell carcinoma of the oral cavity – A report of two cases. J Clin Pathol 2006;59:1206-8.  Back to cited text no. 1
    
2.
Vidyavathi K, Prasad C, Kumar HM, Deo R. Pseudovascular adenoid squamous cell carcinoma of oral cavity: A mimicker of angiosarcoma. J Oral Maxillofac Pathol 2012;16:288-90.  Back to cited text no. 2
  [Full text]  
3.
Dorta RG, Landman G, Kowalski LP, Lauris JR, Latorre MR, Oliveira DT, et al. Tumour-associated tissue eosinophilia as a prognostic factor in oral squamous cell carcinomas. Histopathology 2002;41:152-7.  Back to cited text no. 3
    
4.
Alrawi SJ, Tan D, Stoler DL, Dayton M, Anderson GR, Mojica P, et al. Tissue eosinophilic infiltration: A useful marker for assessing stromal invasion, survival and locoregional recurrence in head and neck squamous neoplasia. Cancer J 2005;11:217-25.  Back to cited text no. 4
    
5.
Ercan I, Cakir B, Başak T, Ozdemir T, Sayin I, Turgut S, et al. Prognostic significance of stromal eosinophilic infiltration in cancer of the larynx. Otolaryngol Head Neck Surg 2005;132:869-73.  Back to cited text no. 5
    
6.
Tadbir AA, Ashraf MJ, Sardari Y. Prognostic significance of stromal eosinophilic infiltration in oral squamous cell carcinoma. J Craniofac Surg 2009;20:287-9.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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