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Presented by Jonathan Epstein, M.D. and prepared by Angelique W. Levi, M.D.
Case 2: 60 year old male with a pleural mass
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1. Question
Week 8: Case 2
60 year old male with a pleural mass
Correct
Answer: Biphasic malignant mesothelioma
Histology: This pleural lesion has a biphasic appearance. In areas, the lesion has a typical morphology of a papillary and tubular adenocarcinoma. Cytologically, the cells appear malignant with areas of necrosis within this epithelial component. Adjacent to the malignant epithelium component is a malignant spindle cell proliferation resembling a malignant fibrous histiocytoma with areas of necrosis. Both the sarcomatous and epithelial component extend into the surrounding adipose tissue.
Discussion: Malignant fibrous tumors would have a similar appearance to the sarcomatous component within the mesothelioma. However, it would lack the malignant epithelial component. Similarly, adenocarcinomas would show a malignant epithelial component yet the associated desmoplastic reaction would not appear cytologically malignant. A carcinosarcoma and biphasic malignant mesothelioma would have a very similar appearance. A biphasic tumor on the pleura in almost all cases represents malignant mesothelioma rather than metastatic carcinosarcoma. Distinction between the two can be made immunohistochemically where the epithelial component in a carcinosarcoma is CEA positive in contrast to negative CEA staining in malignant mesotheliomas. Malignant mesotheliomas also strongly express calretinin in contrast to negative or focal weak staining in adenocarcinomas of the lung.
Incorrect
Answer: Biphasic malignant mesothelioma
Histology: This pleural lesion has a biphasic appearance. In areas, the lesion has a typical morphology of a papillary and tubular adenocarcinoma. Cytologically, the cells appear malignant with areas of necrosis within this epithelial component. Adjacent to the malignant epithelium component is a malignant spindle cell proliferation resembling a malignant fibrous histiocytoma with areas of necrosis. Both the sarcomatous and epithelial component extend into the surrounding adipose tissue.
Discussion: Malignant fibrous tumors would have a similar appearance to the sarcomatous component within the mesothelioma. However, it would lack the malignant epithelial component. Similarly, adenocarcinomas would show a malignant epithelial component yet the associated desmoplastic reaction would not appear cytologically malignant. A carcinosarcoma and biphasic malignant mesothelioma would have a very similar appearance. A biphasic tumor on the pleura in almost all cases represents malignant mesothelioma rather than metastatic carcinosarcoma. Distinction between the two can be made immunohistochemically where the epithelial component in a carcinosarcoma is CEA positive in contrast to negative CEA staining in malignant mesotheliomas. Malignant mesotheliomas also strongly express calretinin in contrast to negative or focal weak staining in adenocarcinomas of the lung.
