Skip Navigation

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (1)
Right arrow Request Permissions
Google Scholar
Right arrow Articles by Nakayama, H.
Right arrow Articles by Enzan, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Nakayama, H.
Right arrow Articles by Enzan, H.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

Japanese Journal of Clinical Oncology Pages 427-432

Metaplastic Shadow Cells in Rectal Adenocarcinoma: Report of a Case with Immunohistochemical Study
Introduction
Case Report
   Pathological Findings
   Macroscopic Findings
   Microscopic Findings
   Immunohistochemical Analysis
Discussion
Acknowledgments
References
Metaplastic Shadow Cells in Rectal Adenocarcinoma: Report of a Case with Immunohistochemical Study

Metaplastic Shadow Cells in Rectal Adenocarcinoma: Report of a Case with Immunohistochemical Study

Hirofumi Nakayama1, Atsuo Kimura2, Tsuneo Okumichi2, Eriko Miyazaki1, Hiroki Kajihara3, Hideaki Enzan1

1First Department of Pathology, Kochi Medical School, Kochi, 2Department of Surgery, Yoshijima Hospital, Hiroshima, 3Laboratory of Pathology, Institute of Health Sciences, Hiroshima University School of Medicine, Hiroshima, Japan

We report a case of adenocarcinoma of the rectum with foci of metaplastic shadow cells. The patient was a 65 year old man with anemia. Macroscopically the tumor was an ordinary rectal cancer. Microscopically, in addition to the features of moderately differentiated adenocarcinoma invading the subserosa, islands of shadow cells in tumor nests were detected in both primary and one of three pericolic metastatic lymph node lesions. Neoplastic glandular cells showed gradual transition to shadow cells. An antibody specific for high-molecular-weight cytokeratins reacted with the shadow cells and intermediate zone epithelial cells surrounding them, but no CEA, low-molecular-weight cytokeratins or cyclin D1 was detectable in them. Cytokeratin 14 was expressed only in the transitional zone epithelial cells. The intermediate zone epithelial cells were regarded as metaplastic squamous cells, from which the shadow cells were derived. The patient died of multiple liver metastases nine and a half months after surgery. To our knowledge, this is the first report of an immunohistochemical study of rectal adenocarcinoma containing shadow cells not only in the primary lesion but also in a metastatic lymph node.

Key words: adenocarcinoma - rectum - shadow cells - squamous metaplasia

INTRODUCTION

Adenocarcinomas of the colorectum are malignant tumors arising from the crypt epithelium (1). Ordinarily the histological type is moderately to well differentiated adenocarcinoma (1). Nevertheless, many primary adenosquamous carcinomas and pure squamous cell carcinomas have been reported and some of them have been subjected to extensive clinicopathological study (2-4). Squamous cell carcinoma of the colorectum appears to be comparable with adenocarcinoma of the colorectum in terms of clinical behavior (5), but adenosquamous carcinoma in the colorectum tends to be more aggressive, the squamous component showing the greater metastatic potential (2,5).

In the present report we describe a case of rectal adenocarcinoma containing foci of metaplastic shadow cells. Apart from this single case, we have found only two other similar examples in the English literature (6).

CASE REPORT

A 65 year old man with anemia was admitted to the Department of Surgery, Yoshijima Hospital, Hiroshima, on May 30, 1994. A barium enema study demonstrated narrowing of the rectum and a colonoscopic examination revealed a large ulcerative lesion in the rectum above the peritoneal reflection, suggesting advanced rectal cancer. The preoperative serum level of CEA, 1.6 ng/ml, was within normal limits (normal range: <2.5 ng/ml, by radioimmunoassay). A biopsy specimen revealed features of moderately differentiated adenocarcinoma. Low anterior resection was performed on June 10, 1994, and the patient was discharged on July 5, 1994. However, a radiological and ultrasonographical examination revealed multiple liver metastases and the patient was re-admitted on January 27, 1995. The patient's serum CEA level rose to 31.4 ng/ml (normal range: <5.0 ng/ml, by enzyme immunoassay). The patient died of hepatic failure on March 24, 1995. Neither autopsy nor necropsy was performed. The patient's serum level of SCC, a tumor marker specific for squamous cell carcinoma (7), was not measured.

Pathological Findings

Macroscopic Findings

The resected rectal tumor, measuring 4.5 ×; 4.0 ×; 1.0 cm, was a well circumscribed elevated tumor with central ulceration (Fig. 1). The cut surfaces of this tumor showed subserosal invasion and pericolic lymph node metastases (Fig. 2).


Figure 1. Resected rectal tumor, measuring 4.5 × 4.0 × 1.0 cm, showing ulceration with raised everted edges.


Figure 2. Cut surfaces of the tumor. The tumor invades the subserosa and shows pericolic lymph node metastases.

Microscopic Findings

In the primary tumor, the predominant histologic features were those of moderately differentiated adenocarcinoma. The neoplastic cells had vesicular nuclei and showed irregular tubular structures including a cribriform pattern (Fig. 3). In both the primary and one of three pericolic metastatic lymph node lesions, islands of shadow cells were detected in tumor nests. The neoplastic cells showed a gradual transition to shadow cells (Fig. 4). Intermediate zone epithelial cells generally had abundant amphophilic cytoplasm and relatively regular nuclei (Fig. 4). The shadow cells had eosinophilic cytoplasm, a central, unstained shadow at the site of the lost nucleus and well defined borders (Figs 4 to 8). However, neither trichohyaline granules nor keratohyaline granules were detected. Clusters of shadow cells were also seen in the fibrous stroma unaccompanied by any other carcinoma cells (Fig. 5), but often with foreign body giant cells (Fig. 6) or foamy cells (Fig. 7). Venous involvement was seen in the primary rectal lesion. Seventeen regional lymph nodes including seven pericolic lymph nodes were submitted for histopathological examination. Four (three pericolic and one regional) of these lymph nodes contained metastatic carcinoma. In one of the three pericolic lymph nodes with metastasis a larger nodule, measuring 1.5 × 1.5 cm and composed mainly of shadow cells, was seen (Fig. 8). However, calcification was not seen in association with the shadow cells. Hair bulbs were not detected anywhere in the primary or metastatic tumors.


Figure 3. Neoplastic glandular epithelia showing a predominantly tubular and cribriform pattern.


Figure 4. Gradual transition of neoplastic glandular epithelia to the shadow cells. Intermediate zone epithelial cells have abundant eosinophilic or amphophilic cytoplasm and relatively regular nuclei (arrowheads). The shadow cells have eosinophilic cytoplasm and unstained shadows at the site of lost nuclei (arrows).


Figure 5. Shadow cells directly attached to the stroma.


Figure 6. Shadow cell nest surrounded by foreign body giant cells.


Figure 7. Shadow cell nest surrounded by foamy cells.


Figure 8. Large nodule composed of shadow cells in one lymph node metastatic lesion.

Immunohistochemical Analysis

To elucidate the nature of the shadow cells and the transitional intermediate epithelial cells facing them, we performed immunohistochemical staining. The antibodies used are listed in Table 1 and the results are summarized in Table 2. The neoplastic glandular cells were positive for CEA and low-molecular-weight cytokeratins (CKL) (Fig. 9), and a small number of their nuclei showed positive immunostaining for cyclin D1. However, the neoplastic glandular cells were negative for cytokeratin 14 (CK14). On the other hand, the intermediate zone epithelial cells adjacent to the shadow cells expressed high-molecular-weight cytokeratins (CKH) and CK14 (Fig. 9). The shadow cells were positive for CKH (Fig. 9) but negative for CK14. CKL and CEA were not expressed in the shadow cells or the transitional intermediate epithelial cells. We were unable to detect p53 protein in either the primary or metastatic tumors using the antibody CM-1.

. Immunostaining for CKL, CK14 and CKH. (a) Neoplastic glandular cells are positive for CKL. (b) Intermediate zone epithelial cells directly surrounding the shadow cells show immunoreactivity for CK14. (c) The shadow cells express CKH.

Table 1 . Results of immunohistochemical analysis in the present case
Antibody Specificity Source
CAM5.2 Cytokeratins 8, 18, and 19 (low-molecular- weight cytokeratins: CKL) Nippon Becton Dickinson Tokyo
C34903 Cytokeratins 1, 5, 10, and 11 (high-molecular- weight CKs: CKH) Enzo Biochemicals, New York, NY
LL002 Cytokeratin 14 Novocastra, Newcastle, United Kingdom
II-7 CEA DAKO Japan, Kyoto
CM1* p53 Novocastra, Newcastle, United Kingdom
P2D11F11 Cyclin D1 Novocastra, Newcastle, United Kingdom
*This antibody is a rabbit polyclocal antibody and all the others are mouse monoclonal antibodies.

Table 2 . Results of immunohistochemical analysis in the present case
Cell types CKL CKH CK14 CEA p53 cyclin D1
Neoplastic glandular + - - + - +
(focal)
Intermediate zone - + + - - -
epithelial
Shadow - + - - - -
+, positive; -, negative

DISCUSSION

Shadow cells, also referred to as ghost cells, are cornified cells that, when stained in section by hematoxylin-eosin, appear as pale eosinophilic cells with distinct borders with poorly stained round zones in their centers, i.e., shadows or ghosts of nuclei (karyolysis), resulting from faulty attempts to form hair shafts (8). Shadow cells have been described as occurring not only in pilomatricoma but also in basal cell carcinoma (9), trichoepithelioma (conventional and desmoplastic types) (8), mixed tumors of the skin (8,10), adnexal carcinoma (10), intracranial dermoid cyst (11), endometrial adenocarcinoma with squamous metaplasia (12,13), ovarian adenocarcinoma with squamous metaplasia (13), atypical endometrial hyperplasia with squamous metaplasia (6), colonic adenocarcinoma with squamous metaplasia (6), pilomatricoma of the testicle (14) and transitional cell carcinoma of the urinary bladder (15). As shown in Table 3, only two cases of colonic adenocarcinoma containing shadow cells appear to have been described hitherto in the literature (6) and, furthermore, there have been no reports of immunohistochemical studies.

In the present case, epithelial cells adjacent to the shadow cells showed transition to neoplastic glandular cells and a positive immunoreaction for CK14, but did not express CKL or CEA. Generally, CK14 is expressed in the cytoplasm of squamous epithelium and myoepithelial cells but not in that of glandular epithelium (16). In fact, the neoplastic glandular cells in the present study were negative for CK14. The antibody C34903 against CKH reacts with all squamous and ductal epithelium and stains carcinoma as much as squamous cell carcinoma and adenocarcinoma of ductal origin (e.g., breast, pancreas). In the present study, both the transitional zone epithelial cells and the shadow cells were reactive with C34903 but the neoplastic glandular cells were not. CAM5.2 recognizes CK8 and CK18, which are not expressed in stratified squamous epithelium and some squamous cell carcinomas. One report has described that CAM5.2 also detects CK19 (17). It is said that cyclin D1 expression represents a common feature of malignancies of diverse histogenesis (18). In the present case, the neoplastic glandular cells showed immunostaining for cyclin D1, whereas the intermediate zone epithelial cells around the shadow cells did not. These results strongly suggest that the intermediate zone epithelial cells were metaplastic squamous cells, from which the shadow cells had developed. Although one report has maintained that shadow cells serve as an important clue to follicular differentiation (8), those in the present case were not surrounded by matrix cells. In addition, calcification was not seen in association with the shadow cells. Therefore, we could not regard the shadow cells as evidence of matrix differentiation in the present tumor.

Table 3 . Reported cases of colorectal adenocarcinoma containing foci of shadow cells
Investigators Age Sex Site Tumor extension
Zamecnik et al. (6) 63 M Sigmoid
colon		 Locally extensive and
inoperable tumor without
distant metastasis (clinically)
Zamecnik et al. (6) 58 M ND Infiltration of deep submucosa
without metastasis
Present case 65 M Rectum Infiltration of deep subserosa
with lymph node metastasis
M, male; ND, not described.

Interestingly, peritoneal keratin granulomas, composed of ghost squamous cell fragments and foreign body-type giant cells with few or no viable carcinoma cells, have no association with the prognosis of patients with adenocarcinoma of the uterus or ovary showing squamous differentiation (12,13).

Judging from reports on uterine and ovarian carcinomas (11,12), the present type of colorectal adenocarcinoma may appear comparable with ordinary adenocarcinoma. To elucidate the prognostic significance of the shadow cells in adenocarcinoma of the colorectum, accumulation of similar cases and clinicopathological studies is needed.

Acknowledgments

The authors are grateful to Prof. Paul D. Andrew, Division of Physical Therapy, Institute of Health Sciences, Hiroshima University School of Medicine, for reading through the manuscript, and Mr Chitoshi Hidaka, Clinical Laboratory Department, Yoshijima Hospital, Hiroshima and Mr Masatoshi Shirota, Medical Research Center, Kochi Medical School, for excellent technical assistance.

References

1. Fenoglio-Preiser CE, Pascal RR, Perzin KL. Adenocarcinoma. In: Hartmann WH, Sobin LH, editors. Atlas of Tumor Pathology, Second Series, Fascicle 27 `Tumor of the Intestines'. Washington DC: Armed Forces Institute of Pathology, 1990:175-250.

2. Cerezo L, Alvararez M, Edwards W, Price G. Adenosquamous carcinoma of the colon. Dis Colon Rectum 1985;28:597-603.

3. Comer TP, Beahrs OH, Dockerty MB. Primary squamous cell carcinoma and adenoacanthoma of the colon. Cancer 1971;28:1111-7.

4. Crissman JD. Adenosquamous and squamous cell carcinoma of the colon. Am J Surg Pathol 1978;2:47-54.

5. Morson BC, Dawson IMP, Day DW, Jass JR, Price AB, Williams GT, editors. Morson's and Dawson's Gastrointestinal Pathology, 3rd ed. Oxford: Blackwell Science, 1992.

6. Zamecnik M, Michal M. Shadow cell differentiation in tumors of the colon and uterus. Zentralbl Pathol 1995;140:421-6.

7. Kato H, Torigoe T. Radioimmunoassay for tumor antigen of human cervical squamous cell carcinoma. Cancer 1977;40:1621-8.

8. Jackobson M, Ackerman BA. `Shadow' cells as clues to follicular differentiation. Am J Dermatopathol 1987;9:51-7.

9. Aloi FG, Molinero A, Pippione M. Basal cell epithelioma with matrical differentiation. Am J Dermatopathol 1988;10:509-13.

10. LeBoit PE, Parslow TG, Choy SH. Hair matrix differentiation occurrence in lesions other than pilomatricoma. Am J Dermatopathol 1987;9:399-405.

11. Hitchcock MG, Ellington KS, Friedman AH, Provenzale JM, McLendon RE. Shadow cells in an intracranial dermoid cyst. Arch Pathol Lab Med 1995;119:371-3.

12. Chen KTK, Kostich ND, Rosai J. Peritoneal foreign body granulomas to keratin in uterine adenoacanthoma. Arch Pathol Lab Med 1978;102:174-7.

13. Kim KR, Scully RE. Peritoneal keratin granulomas with carcinomas of endometrium and ovary and atypical polypoid adenomyoma of endometrium. Am J Surg Pathol 1990;14:925-32.

14. Minkowitz G, Lee M, Mikowitz S. Pilomatricoma of the testicle. Arch Pathol Lab Med 1995;119:96-9.

15. Zamecnik M, Michal M. Shadow cells in extracutaenous lesions [Letter]. Arch Pathol Lab Med 1995;119:426-8.

16. Tseng SCG, Jarvinen MJ, Nelson WG, Huang JW, Woodcock-Mitchell J, Sun TT. Correlation of specific keratins with different types of epithelial differentiation: monoclonal antibody studies. Cell 1982;30:361-72.

17. Makin CA, Borrow LG, Bodmer WF. Monoclonal antibody to cytokeratin for use in routine histopathology. J Clin Pathol 1984;37:975-83.

18. Bartkova J, Lukas J, Strauss M, Bartek J. Cyclin D1 oncoprotein aberrantly accumulates in malignancies of diverse histogenesis. Oncogene 1995;40:775-8.

Received March 4, 1997; accepted June 20, 1997
For reprints and all correspondence: Hirofumi Nakayama, First Department of Pathology, Kochi Medical School, Kohasu, Okoh-cho, Nankoku, Kochi 783, Japan
Abbreviations: CEA, carcinoembryonic antigen; CK, cytokeratin; CKL, low-molecular-weight cytokeratins; CKH, high-molecular-weight cytokeratins.

This page is run by Oxford University Press, Great Clarendon Street, Oxford OX2 6DP, as part of the OUP Journals
Comments and feedback: www-admin{at}oup.co.uk
Last modification: 19 May 1998
Copyright© Japanese Journal of Clinical Oncology, 1997.
This page is run by Oxford University Press, Great Clarendon Street, Oxford OX2 6DP, as part of the OUP Journals
Comments and feedback: www-admin{at}oup.co.uk
Last modification: 19 May 1998
Copyright© Japanese Journal of Clinical Oncology, 1997.
Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?



This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (1)
Right arrow Request Permissions
Google Scholar
Right arrow Articles by Nakayama, H.
Right arrow Articles by Enzan, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Nakayama, H.
Right arrow Articles by Enzan, H.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?