Pitfalls in Sinonasal Pathology Jennifer L. Hunt, MD, MEd Aubrey J. Hough Jr, MD, Endowed Professor of Pathology Chair of Pathology and Laboratory Medicine University of Arkansas for Medical Sciences jhunt2@uams.edu 1
Agenda Inflammatory Conditions Fungal sinusitis Invasive fungal disease Mid-line destructive diseases Epithelial proliferations Low and high grade carcinomas 2
Allergic Fungal Sinusitis 3
Incidence Allergic Fungal Sinusitis 5-10% of chronic sinusitis Gross Polyposis Thick, green mucus Peanut butter consistency 4
Allergic mucus
Allergic Fungal Sinusitis Histopathology Fungus Ball Allergic type mucus Allergic fungal sinusitis 6
Fungus ball 7
Fungus ball 8
Allergic mucus 9
Allergic mucus
Invasive Fungal Sinusitis Classification Acute necrotizing (immunocompromised) Chronic invasive (diabetics) Granulomatous (immunocompetent) Histology Necrosis Vascular invasion Granulomas and giant cells 11
Invasive fungal sinusitis 12
Invasive fungal sinusitis 13
Invasive fungal sinusitis 14
Invasive fungal sinusitis
Invasive fungal sinusitis 16
Treatment of Fungal Disease Non-invasive Surgery to remove mucus Oral then inhaled steroids (up to 1 year) Invasive Complete debridement to viable tissue Intravenous antifungal drugs 17
Pitfalls Midline Destructive Diseases Traumatic Infectious Toxic Inflammatory Neoplastic Physical trauma Bacterial Cocaine Sarcoid Basal cell carcinoma Iatrogenic trauma Mycobacterial Chromium salts Foreign body Squamous cell carcinoma Self-induced Fungal Wegener s Lymphoma Vasculitis Other tumors 18
Wegener s Granulomatosis 19
Clinical Wegener s Granulomatosis C-ANCA Respiratory tract & Kidney Localized vs. systemic disease Histopathology Necrotizing granulomatous inflammation Vasculitis Neutrophilic microabscesses 20
Wegener s 21
Wegener s 22
Wegener s 23
Wegener s, elastic stain 24
Agenda Inflammatory Conditions Fungal sinusitis Invasive fungal disease Mid-line destructive diseases Epithelial proliferations Low and high grade carcinomas 25
Inverted Papilloma 26
Incidence Schneiderian Papilloma Men > women Adult age Clinical Mass lesion, nasal obstruction Three types Inverted, Exophytic, Oncocytic 27
Histology Inverted Papilloma Epithelium >10 cell layers thick Epithelial morphology Transitional Squamous, respiratory, mucinous Transmigrating neutrophils Decreased or absent minor salivary glands 28
Inverted papilloma 29
Inverted papilloma 30
Inverted papilloma
Exophytic Papilloma Location: Septum Histologoy Resembles squamous papilloma of skin Residual goblet cells 32
Exophytic papilloma 33
Exophytic papilloma 34
Oncocytic Schneiderian Papilloma 35
Oncocytic Schneiderian Papilloma Location: Usually lateral nasal wall Histology Oncocytic epithelium Microcysts in epithelium Containing inflammatory debris or mucin 36
Oncocytic schneiderian papilloma 37
Oncocytic schneiderian papilloma 38
Pitfalls Early changes of inverted papilloma Frozen section diagnosis Identifying malignant transformation 39
Schneiderian Papilloma
Schneiderian Papilloma
Malignant Transformation Clinical course Synchronous tumors (61%) Asynchronous tumors (29%) Classification Dysplasia (5-20%) Invasive carcinoma (2-27%) Tumor types: squamous cell carcinoma, schneiderian carcinoma, other 42
Agenda Inflammatory Conditions Fungal sinusitis Invasive fungal disease Mid-line destructive diseases Epithelial proliferations Low and high grade carcinomas 43
Sinonasal Adenocarcinomas 50 40 30 20 10 0 Salivary ITAC Non-ITAC Site % Nasal 40% Ethmoid 30% Maxillary 13% Multiple 18% 44
Clinical Low Grade Non-ITAC: Histology Rare lesion with generally good prognosis Histology Highly variable architecture Papillary, cystadenomatous, tubular Back-to-back glands with no myoepithelial cells Usually no vascular or perineural invasion Cytology Single layer of bland epithelial lining cells Bland nuclei 45
Low grade Adenocarcinoma, non-itac 46 46
Low grade Adenocarcinoma, non-itac 47
Low grade Adenocarcinoma, non-itac 48
Incidence Intestinal Type Adenocarcinoma Rare Men>Women Ethmoid sinus in >80% Clinical Sinonasal symptoms Occupational exposure Wood and leather dust Formaldehyde 49
Intestinal Type Adenocarcinoma Histopathology: Resembles GI tumors IHC CDX2 positive CK20 positive CK 7 positive (most cases) 50
Intestinal type adenocarcinoma 51
Intestinal type adenocarcinoma 52 52
ITAC, CDX2 ITAC, CK20 53
Sinonasal Undifferentiated Carcinoma Clinical Rare and very aggressive tumors Histopathology Undifferentiated tumor cells Mitoses and necrosis Vascular invasion and adjacent structures Immunohistochemistry Positive for Cytokeratin Rarely positive for NSE 54
SNUC, H&E 55
SNUC, H&E 56
SNUC, H&E 57
SNUC, H&E 58
SNUC, CAM5.2 59
Differential Diagnosis Melanoma Ewings/PNET Rhabdomyosarcoma NUT midline carcinoma Lymphoepithelial carcinoma Lymphoma Neuroendocrine carcinoma 60
Work-Up of High Grade Tumor Cytokeratin stains Neuroendocrine stains S100 HMB45 CD99 Myogenin Desmin Lymphoma markers 61
Summary Inflammatory Conditions Fungal sinus disease Mid-line destructive diseases Epithelial proliferations Low and high grade carcinomas 62
Head and Neck Lesions Every Pathologist Should Know Jennifer L. Hunt, MD, MEd Aubrey J. Hough Jr, MD, Endowed Professor of Pathology Chair of Pathology and Laboratory Medicine University of Arkansas for Medical Sciences jhunt2@uams.edu 63
Agenda Differential diagnosis for cysts in the neck Differential diagnosis for neuroendocrine tumors (sinonasal and beyond) 64
Neck Cysts Differential diagnosis for cysts in the neck Benign developmental cysts Metastatic cystic squamous cell carcinoma 65
Clinical Branchial Cleft Cyst Relatively common Usually in children and young adults Asymptomatic mass lesion Draining sinus Variable location 66
Auditory canal Palatine tonsil II I 1 External auditory meatus Parathyroid (inferior) Thymus Parathyroid (superior) Ultimobranchial body IV III 2 3 4 Branchial pouches Pharyngeal grooves (clefts) 67
Branchial Cleft Cysts Type Location Lining Special features First Arch (type 1 and type 2) Second Arch Third and Fourth Arches Near the ear Tract in supratonsillar fossa Cyst in the low anterolateral neck Tract in pyriform sinus Cyst at anterior border of SCM Keratinized squamous Squamous and/or respiratory Lymphoid stroma Squamous and/or respiratory Lymphoid stroma Cartilage can be seen in type 2 95% are this type <1% Can present with suppurative thyroiditis 68
Branchial Cleft 69
Branchial Cleft 70
Branchial Cleft 71
Differential Diagnosis Thyroglossal duct cyst Thymic cyst Metastatic cystic squamous cell carcinoma 72
Thyroglossal duct cyst 73
Thymic cyst 74
Clinical Cystic Metastasis Mass lesion in upper to mid-level neck 3.9 cm average size Male >> Female Average age: 54 75
Gross Cystic Metastasis Well circumscribed Thick capsule Multilocular Thick purulent or gumous material 76
Histology Cystic Metastasis Ribbon like epithelium Thickness of tonsillar type epithelium Can have endophytic or exophytic areas Cytology Moderate N:C ratio No maturation Bland appearance 77
Cystic Metastatic Squamous Carcinoma
Cystic Metastatic Squamous Carcinoma
Cystic Metastatic Squamous Carcinoma 80
Controversies Branchiogenic carcinoma vs. metastatic squamous carcinoma Bland metastasis vs. branchial cleft cyst 81
Differentiating Features Feature Metastasis Branchial cleft cyst Gross Cyst contents Unilocular Keratin Debris Multilocular Clear fluid Lining Dysplastic Respiratory & squamous Age Older Younger 82
Carcinoma in Branchial Cleft Cyst Diagnostic Criteria Anatomy Anterior to the sternocleidomastoid Between the tragus and the clavicle Association with sinus tract Histology Benign branchial cleft tissue Carcinoma with transition from benign to dysplastic and malignant epithelium Clinical course No primary tumor identified Minimum of five-year follow-up period 83
Clinical Metastatic Cystic Carcinoma May be first presenting symptom Primary tumor may be extremely small 64% come from the tonsil or tongue base Other sites include larynx and nasopharynx 84
Tonsil and Tongue Base SCC Oropharynx: >50% of tumors are positive for HPV HPV in cystic lymph node metastases Between 50 and 80% will be positive when originating from an oropharyngeal site Desai PC, Exp Mol Pathol, 87:94, 2009 Goldenberg D, Head Neck, 30:898, 2008 85
HPV and Tumor Characteristics HPV Positive Demographics 5 years younger Non-smokers/non-drinkers HPV Negative Typical ages Tobacco and alcohol Site Tonsil & Tongue base All locations Histology Genetics Non-keratinizing, basaloid, and lymphoepithelial p53 inactivated by E6 Rb inactivated by E7 p16 over-expressed Keratinizing SCC p53 inactivated by mutation Rb inactivated by cyclin D1 amplification Inactivation of p16 86
HPV Detection Methods In situ hybridization DNA based either multiplexed or single type probes RNA based transcriptionally active virus Polymerase chain reaction Other methods Hybrid capture (cytology samples) p16 immunohistochemistry 87
H&E HPV ISH p16 IHC
p16 Immunohistochemistry Excellent surrogate marker for HPV p16 staining should be strong and diffuse 89
Why test for HPV? Diagnostic marker (cystic metastases) Prognostic marker To select therapeutic approaches De-escalation therapy 90
Agenda Differential diagnosis for cysts in the neck Differential diagnosis for neuroendocrine tumors in the sinonasal cavity Olfactory neuroblastoma Neuroendocrine carcinoma Paraganglioma Ectopic pituitary lesions 91
Olfactory Neuroblastoma 92
Incidence Olfactory Neuroblastoma Relatively rare (2% of sinonasal tumors) Broad age range Clinical Peaks in 2 nd and 6 th decades Sinonasal symptoms: nasal obstruction, epistaxis, non-specific symptoms Usually arises in the upper nasal cavity (superior nasal concha, upper septum, roof of nose, cribriform plate) 93
Olfactory Neuroblastoma Histopathology Small to medium sized cells in nests Minimal pleomorphism Rosettes Homer Wright: Central fibrillary material Up to 50% Flexner-Wintersteiner: True lumen Rare Neuropil Grading: Hyam s Grading system 94
Olfactory neuroblastoma 95
Olfactory neuroblastoma, Homer Wright rosettes 96
Olfactory neuroblastoma, Flexner-Wintersteiner rosettes 97
Olfactory Neuroblastoma Immunohistochemistry Synpatophysin, chromogranin positive S100 with sustentacular pattern CAM5.2 occasionally positive 98
Olfactory neuroblastoma, Synaptophysin 99
Olfactory neuroblastoma, S100 stain 100
Olfactory neuroblastoma with divergent differentiation
Olfactory neuroblastoma with divergent differentiation, S100
Olfactory neuroblastoma with divergent differentiation Synaptophysin Cytokeratin
Neuroendocrine Carcinomas Nomenclature Carcinoid Atypical carcinoid Neuroendocrine carcinoma, small cell type Neuroendocrine carcinoma, large cell type 104
Neuroendocrine Carcinoma, large cell type Incidence Rare tumor Locations: Throughout the head and neck Histology Solid sheets, ribbons, or trabeculae Large cells with coarse chromatin and nucleoli Necrosis and mitoses IHC Chromogranin, syaptophysin, NSE Cytokeratin 105
Neuroendocrine carcinoma 106
Neuroendocrine carcinoma 107
Neuroendocrine carcinoma, synaptophysin
Incidence Paraganglioma Adrenal (pheochromocytoma) >> extra-adrenal Head and Neck Clinical Originate from carotid body (most), middle ear, and vagal body Mass lesion, pulsatile Usually not functional in the head and neck 109
Histology Paraganglioma Neuroendocrine chromaffin cells Supporting sustentacular cells 110
Paraganglioma 111
Paraganglioma Immunohistochemistry Neuroendocrine chromaffin cells Chromogranin, Synaptophysin Negative for cytokeratins Supporting sustentacular cells S100 positive 112
Paraganglioma S100 113
Paraganglioma Hereditary Von Hippel Lindau MEN syndromes Neurofibromatosis Familial paragangliomatosis 114
Clinical Ectopic Pituitary Occur along the embryological migration and invagination pathway of Rathke s Pouch Distinguish radiologically, clinically and surgically from invasive pituitary adenoma Broad age range; most common in 6 th decade Frequently mis-diagnosed 115
Pathology Ectopic Pituitary Bland appearing neuroendocrine lesion Hormones: FSH, LH, GH, TSH, ACTH, PRL, Calcitonin 116
Ectopic pituitary adenoma
Ectopic pituitary adenoma, ACTH
Summary Cystic lesions in the neck Branchial cleft cyst Thyroglossal duct and thymic cysts Cystic metastasis from squamous carcinoma HPV associated SCC Neuroendocrine tumors Olfactory neuroblastoma Neuroendocrine carcinoma, large cell type Paraganglioma Ectopic pituitary 119