PDF Advances in Surgical Pathology: Colorectal Carcinoma and Tumors of the Vermiform Appendix

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Distinguished 'Read more…. Facebook Twitter Pinterest Linkedin E-mail. Voeg toe Verwijder. Add to cart. Histopathology - Urologic, renal. Andreana Rivera, Hidehiro Takei. Rhonda K. Alberto G. Mitoses are common and apoptotic bodies are often found. The cells are arranged in nests, cords, and sheets and may widely infiltrate the intestinal wall; geographic necrosis and perineural and angiolymphatic invasion are common [ 2 ].

Intense intratumoral or peritumoral lymphocytic infiltrates, lymphocytic infiltrates at the advancing tumor margin and conspicuous "Crohn's-like" lymphoid reactions are common [ 4 ].


Positivity with neuroendocrine immunohistochemical markers is found in approximately one third of cases [ 2 ]. The differential diagnosis of MC includes poorly differentiated colorectal adenocarcinoma, neuroendocrine carcinoma and "lymphoepithelioma-like carcinoma", for which the differential diagnostic features are discussed elsewhere [ 2 ],[ 7 ].

To the best of our knowledge the present case is unique, as concomitant with a wholly viable primary MC tumor, all numerous 11 lymph node metastases were completely necrotic at the time of surgery. Do these findings represent an example of "spontaneous tumor regression"? Criteria for the diagnosis of spontaneous regression were put forward nearly fifty years ago: 1 histologic regression of biopsy proven metastases, 2 radiologic regression of presumed neoplastic disease, and 3 regression of metastatic tumor after therapy considered ineffective [ 8 ].

The first criterion would most closely correspond to the histologic findings we describe. Given its incidence and prevalence, spontaneous regression of colorectal cancer is an extremely rare event, with only 21 cases reported between and according to a major review [ 8 ]. All examples were moderately to poorly differentiated adenocarcinomas of the usual type. Regression almost invariably involved the primary tumor or metastases following removal of the primary tumor.

It should be noted, however, that in several cases where regression of metastatic disease was reported, regression, or not, of the primary tumor was not clearly specified.

Case Reports in Surgery

Numerous hypotheses concerning the mechanism s of tumor regression have been proposed, none conclusive 8. Similarly, we cannot provide a precise explanation for this phenomenon, but the interplay of patient-specific factors and immune-mediated events is likely. Regarding patient factors, there had been no neoadjuvant therapy.

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Causes of local ischemic events such as bowel torsion volvulus or tissue entrapment in an internal hernia or by adhesions were not observed at surgery. However, the patient had several auto immune-mediated diseases hypothyroidism, idiopathic sensory neuronopathy, and pernicious anemia , suggesting heightened activity of her immune system and, perhaps, increased immunosurveillance.

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  6. As the primary tumor was entirely viable, the potential role of the lymph node microenvironment in inducing tumor necrosis is worthy of consideration. One can speculate that tumor antigen processing by lymph node antigen presenting cells APCs may have instigated a localized immunologic response leading to widespread cell necrosis.

    Advances in Surgical Pathology: Colorectal Carcinoma and … ED, 2013 Por Rhonda Yantiss MD

    This would imply, conversely, that the APCs infiltrating and surrounding the primary tumor itself were incapable of instigating such a response: the tumor cells metastatic to the lymph nodes were therefore likely viable. Tumor cell necrosis, formally regarded as a passive phenomenon, is now considered a form of programmed cell death type III PCD [ 9 ]. Whereas apoptosis type II PCD involves the death of individual cells, necrosis involves large cell numbers.

    It is mediated by complex signaling pathways that are activated when, for example, inadequate vascularization leads to ischemia and hypoxia with resulting cell energy deprivation; a variety of anti-cancer drugs also induce necrosis. Tumor cell necrosis in turn further stimulates the immune system: the release of a variety of cytoplasmic molecules to the extracellular space upon loss of cell membrane integrity leads to activation of APCs and macrophages.

    Dendritic cell maturation and T-cell proliferation subsequently occur with optimization of tumor antigen presentation and phagocytosis of dead cells. As such, although the primary initiating event in our case is unknown, we propose that this "lymph node-limited tumor necrosis" may be due to the ability of lymph node specific immune cells to mount a tumor directed immune response. Finally, regarding the patient's polyneuropathy, the development of symptoms before tumor detection and the resolution of symptoms following tumor removal clinically support a paraneoplastic etiology [ 10 ].

    However, no testing for neuro-oncologic antibodies was performed. Paraneoplastic neurological syndromes due to colon cancer are extremely rare, with sensory neuropathy and vasculitis having been described [ 11 ]. Of note, it has been observed that tumors causing paraneoplastic neurologic disorders are often "heavily infiltrated with inflammatory cells" and have a better prognosis than histologically identical tumors with no paraneoplastic neurologic manifestations [ 10 ]. In summary, we present a unique case of medullary colon cancer. The simultaneous occurrence of necrotic lymph node metastases and a viable primary tumor is possibly explained by an immunologic response in the lymph node microenvironment.

    The patient's history of multiple autoimmune diseases raises questions as to the role of her "activated" immune system in responding to the metastases. This case, albeit of morphologic interest, and perhaps representing a form of spontaneous regression, raises important questions relating to the immunologic response to tumor cells instigated within lymph nodes. Set up a giveaway. There's a problem loading this menu right now. Learn more about Amazon Prime. Get fast, free delivery with Amazon Prime. Back to top. Get to Know Us. Amazon Payment Products. English Choose a language for shopping.

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    Intramucosal Carcinoma of the Appendix Arising from Traditional Serrated Adenoma

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