Benign sinonasal neoplasms and tumor-

like lesions

Prof.Alena Skálová, MD,PhDCharles University, Faculty of

Medicine, Plzen, Czech Republic

EScoP Belgrade 2011, 7-9th April, 2011, Belgrade, Serbia

Anatomy of nasal cavity and sinonasal region

Benign lesions of sinonasal Benign lesions of sinonasal regionregion

Sinonasal polypsSinonasal polyps Sinonasal hamartomatous and Sinonasal hamartomatous and

teratoid lesionsteratoid lesions Benign epithelial neoplasmsBenign epithelial neoplasms

PapillomasPapillomas Salivary gland-type adenomasSalivary gland-type adenomas

Benign sinonasal soft tissue Benign sinonasal soft tissue neoplasmsneoplasms

Sinonasal polypsSinonasal polyps

Most sinonasal polyps are of allergic originMost sinonasal polyps are of allergic origin consist largely of myxoid edematous tissue consist largely of myxoid edematous tissue

with pseudocysts containing eosinophilic with pseudocysts containing eosinophilic proteinaceous material and inflammatory proteinaceous material and inflammatory cellscells

heavy infiltration by eosinophilsheavy infiltration by eosinophils marked thickening of basement marked thickening of basement

membranesmembranes goblet cell metaplasiagoblet cell metaplasia

Antrochoanal angiomatoid polyp

Antrochoanal angiomatoid Antrochoanal angiomatoid polyppolyp

3-6% of all patients with nasal polyps3-6% of all patients with nasal polyps Usually solitary, at any age, most in young Usually solitary, at any age, most in young

adultsadults Removed by curretage, recurrences- 25%Removed by curretage, recurrences- 25% Clinical symptoms Clinical symptoms

nasal obstruction, epistaxisnasal obstruction, epistaxis susceptible to vascular injurysusceptible to vascular injury

Origin within sinus, passage through constrictive Origin within sinus, passage through constrictive ostia- ostia- characteristic vascular changescharacteristic vascular changes

Angiomatoid nasal polypsAngiomatoid nasal polyps

arising from inflammatory nasal polyps are arising from inflammatory nasal polyps are benign lesions with frequent recurrencesbenign lesions with frequent recurrences

may become partially or extensively may become partially or extensively infarctedinfarcted

which results in hemorrhage, necrosis and which results in hemorrhage, necrosis and erosion of the surrounding tissues including erosion of the surrounding tissues including the skeletal bonesthe skeletal bones

histological resemblance to various benign histological resemblance to various benign and malignant tumors and malignant tumors

Heffner DK. Sinonasal angiosarcoma? Not likely (a brief descriptionof infarcted nasal polyps). Ann Diagnostic Pathology 2010: 14: 233-234.

HistologyHistology

Early angiomatoid vascular changesEarly angiomatoid vascular changes Hyperemia, congestion, early Hyperemia, congestion, early

hemorhagic necrosis, interstitial edemahemorhagic necrosis, interstitial edema Late angiomatoid vascular changesLate angiomatoid vascular changes

Congestion with organizing vascular Congestion with organizing vascular thrombi, neovascularization (granulation thrombi, neovascularization (granulation tissue), fibrosis, ulcerations, necrosis tissue), fibrosis, ulcerations, necrosis

Pseudosarcomatous stromal cell Pseudosarcomatous stromal cell change-pitfallchange-pitfall

Ulceration, granulation tissue, bood vessel proliferation

Dilated blood vessels, granulation tissue

Increased cellularity around blood vessels

Thrombosis with organisation

Hemorrhage, extravasation of RBCs

ASMA

Angiomatoid nasal polypsAngiomatoid nasal polyps (ANP)(ANP)

4545 cases of ANP were retrieved from cases of ANP were retrieved from consultation registry in Pilsen consultation registry in Pilsen 32 men and 13 women32 men and 13 women

Sites includedSites included nasal septum (14/41)nasal septum (14/41) antrum Highmori (12/41), ethmoid sinuses (5/41) antrum Highmori (12/41), ethmoid sinuses (5/41)

lateral wall of nasal cavity (5/41), sphenoid sinus lateral wall of nasal cavity (5/41), sphenoid sinus (1/41), and non-specific nasal cavity (4/41)(1/41), and non-specific nasal cavity (4/41)

Hadravsky L, Skalova A, Michal M. Angiomatoid nasal polyp: often

misdiagnosed and little known lesion. Report of 45 cases. Modern Pathology 2011: 24: 278A (Abstract).

Angiomatoid nasal polypsAngiomatoid nasal polyps (ANP)(ANP)

X-ray or computed tomography scans were X-ray or computed tomography scans were performed in 19 cases and bone performed in 19 cases and bone erosions/deviations occurred in 4 cases of themerosions/deviations occurred in 4 cases of them

Initial diagnoses submitted by referring Initial diagnoses submitted by referring pathologists pathologists angiofibroma 32%, hemangioma 24%, angiofibroma 32%, hemangioma 24%,

hemangiopericytoma 16%, angiosarcoma 12%, hemangiopericytoma 16%, angiosarcoma 12%, pyogenic granuloma and hemangio-endotelioma, both at pyogenic granuloma and hemangio-endotelioma, both at 8%8%

None of the patients died of the disease and None of the patients died of the disease and there has been no progression in any patientthere has been no progression in any patient

Recurrence was recorded in 30% (9/30)Recurrence was recorded in 30% (9/30)Hadravsky L, Skalova A, Michal M. Angiomatoid nasal polyp: often misdiagnosed and little known lesion. Report of 45 cases. Modern Pathology 2011: 24: 278A (Abstract).

Sinonasal hamartomatous Sinonasal hamartomatous and teratoid lesionsand teratoid lesions

Hamartomas of respiratory Hamartomas of respiratory tracttract

Rare tumor like lesions of sinonasal Rare tumor like lesions of sinonasal mucosa and nasopharynxmucosa and nasopharynx Respiratory epithelial adenomatoid Respiratory epithelial adenomatoid

hamartoma (REAH)hamartoma (REAH) Seromucinous hamartomaSeromucinous hamartoma nasal chondromesenchymal hamartomanasal chondromesenchymal hamartoma Mixed chondro-osseous REAHMixed chondro-osseous REAH

Wenig BM, Heffner DK. Respiratory epithelial adenomatoid hamartomasof the sinonasal tract and nasopharynx: a clinicopathologic study of 31 cases.Ann Otol Rhinol Laryngol 1995:104:639-645.

Seromucinous (glandular) Seromucinous (glandular) hamartomashamartomas

polypoid lesions characterized by polypoid lesions characterized by epithelial proliferations of small epithelial proliferations of small glands, acini, and tubules growing glands, acini, and tubules growing haphazaradly in clusters and haphazaradly in clusters and lobuleslobules

devoid of myoepithelial cellsdevoid of myoepithelial cells

Weinreb I, et al. Seromucinous hamartomas: a clinicopathological studyof a sinonasal glandular lesion lacking myoepithelial cells.Histopathology 2009:54:205-213.

Seromucinous hamartoma of Seromucinous hamartoma of sinonasal tractsinonasal tract

Uncommon, under-reported entityUncommon, under-reported entity Residual lobular architecture, bland Residual lobular architecture, bland

morphologymorphology Absence of epithelial tufting, papillae, Absence of epithelial tufting, papillae,

back-to back glandsback-to back glands Absence of invasionAbsence of invasion Spectrum with REAH and low-grade Spectrum with REAH and low-grade

sinonasal adenocarcinomasinonasal adenocarcinomaJo VY, Mills SE, Cathro HP, Carlson DL, Stelow EB. Low-grade sinonasal

adenocarcinomas. The association with and distinction from respiratory

epithelial adenomatoid hamartomas and other glandular lesions.

Am J Surg Pathol 2009:33:401-408.

Spectrum from seromucinoushamartoma to REAH

Weinreb et al: Histopathology 2009

Respiratory epithelial adenomatoid hamartoma (REAH)

Differential diagnosis of Differential diagnosis of sinonasal hamartomassinonasal hamartomas

Low-grade sinonasal adenocarcinomaLow-grade sinonasal adenocarcinoma LG tubulo-papillary adenocarcinomaLG tubulo-papillary adenocarcinoma

Schneiderian benign papillomaSchneiderian benign papilloma Oncocytic variantOncocytic variant

Salivary gland type adenomaSalivary gland type adenoma

Sinonasal adenocarcinomas Sinonasal adenocarcinomas (SNAC)(SNAC)

uncommon malignancies that show a uncommon malignancies that show a variety of growth patternsvariety of growth patterns

classified as intestinal and non-classified as intestinal and non-intestinal types, the latter intestinal types, the latter subclassified as low grade and high subclassified as low grade and high gradegrade

Low grade tubulopapillary adenocarcinoma of the nasal cavity in 72-y old man,slowly growing tumour- of nasal mucosa, filling the middle meatus,Presented with nasal obstruction and recurrent attacks of chronic hyperplasticrhinitis for at least 5 years

Sinonasal adenocarcinomas Sinonasal adenocarcinomas (SNAC)(SNAC)

Recently, some cases of low-grade Recently, some cases of low-grade sinonasal adenocarcinomas sinonasal adenocarcinomas associated with REAH were reportedassociated with REAH were reported

possibly implicating REAH as a possibly implicating REAH as a precursor lesion for at least a subset precursor lesion for at least a subset of SNACof SNAC

Jo, et al. Low-grade sinonasal adenocarcinomas. The association with and distinction from respiratory epithelial adenomatoid hamartomas and other glandular lesions. Am J Surg Pathol 2009:33:401-408.

29 LG sinonasal adenocarcinoma 29 LG sinonasal adenocarcinoma reviwedreviwed

6 of them associated with REAH6 of them associated with REAH REAH may be precursor of LG sinonasal REAH may be precursor of LG sinonasal

adenocaadenoca

Benign epithelial Benign epithelial neoplasmsneoplasms

PapillomasPapillomasSalivary gland-type adenomasSalivary gland-type adenomas

Sinonasal papillomasSinonasal papillomas

Squamous cell papillomaSquamous cell papilloma Schneiderian papillomaSchneiderian papilloma

ExophyticExophytic InvertedInverted oncocyticoncocytic

Benign sinonasal soft Benign sinonasal soft tissue neoplasmstissue neoplasms