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Benign sinonasal neoplasms and tumor-like lesions

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1 Benign sinonasal neoplasms and tumor-like lesions
Prof.Alena Skálová, MD,PhD Charles University, Faculty of Medicine, Plzen, Czech Republic EScoP Belgrade 2011, 7-9th April, 2011, Belgrade, Serbia

2 Anatomy of nasal cavity and sinonasal region

3 Benign lesions of sinonasal region
Sinonasal polyps Sinonasal hamartomatous and teratoid lesions Benign epithelial neoplasms Papillomas Salivary gland-type adenomas Benign sinonasal soft tissue neoplasms

4 Sinonasal polyps Most sinonasal polyps are of allergic origin
consist largely of myxoid edematous tissue with pseudocysts containing eosinophilic proteinaceous material and inflammatory cells heavy infiltration by eosinophils marked thickening of basement membranes goblet cell metaplasia

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6 Antrochoanal angiomatoid polyp

7 Antrochoanal angiomatoid polyp
3-6% of all patients with nasal polyps Usually solitary, at any age, most in young adults Removed by curretage, recurrences- 25% Clinical symptoms nasal obstruction, epistaxis susceptible to vascular injury Origin within sinus, passage through constrictive ostia- characteristic vascular changes AC angiomatoidní polyp představuje asi 3-6% konvenčních nosních polypů, až ve ¼ případů recidivy po neúplném odstranění. Angiomatoidní změny nejsou specifické pouze pro antro-choanální polypy, ale jsou proně charakteristické, AC polypy jsou velmi vulverabilní k ischemii

8 Angiomatoid nasal polyps
arising from inflammatory nasal polyps are benign lesions with frequent recurrences may become partially or extensively infarcted which results in hemorrhage, necrosis and erosion of the surrounding tissues including the skeletal bones histological resemblance to various benign and malignant tumors Heffner DK. Sinonasal angiosarcoma? Not likely (a brief description of infarcted nasal polyps). Ann Diagnostic Pathology 2010: 14:

9 Histology Early angiomatoid vascular changes
Hyperemia, congestion, early hemorhagic necrosis, interstitial edema Late angiomatoid vascular changes Congestion with organizing vascular thrombi, neovascularization (granulation tissue), fibrosis, ulcerations, necrosis Pseudosarcomatous stromal cell change-pitfall Mikroskopický vzhled závisí na stáří (stadiu) polypu. V časné fázi je patrná hyperemie s dilatací cév, extravazace erytrocytů s počínající nekrozou a edémem intersticia polypu. Později v chronické fázi angiomatoidních změn nachází reparativní zánět podobný tvorbě granulační tkáně s neovaskularizací a proliferací fibroblastů ve spodině ulcerace. V cévách často nacházíme trombozy s více nebo méně patrnou organizací. Ve stromatu polypu progreduje fibroza.

10 Ulceration, granulation tissue, bood vessel proliferation

11 Dilated blood vessels, granulation tissue
Polyp je tvořený hojně vaskularizovanou tkání s dilatovanými cévami, kvúli nimž je často zaměnován za juvenilní angiofibrom Dilated blood vessels, granulation tissue

12 Increased cellularity around blood vessels

13 Thrombosis with organisation

14 Hemorrhage, extravasation of RBCs

15 aktin ASMA

16 Angiomatoid nasal polyps (ANP)
45 cases of ANP were retrieved from consultation registry in Pilsen 32 men and 13 women Sites included nasal septum (14/41) antrum Highmori (12/41), ethmoid sinuses (5/41) lateral wall of nasal cavity (5/41), sphenoid sinus (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).

17 Angiomatoid nasal polyps (ANP)
X-ray or computed tomography scans were performed in 19 cases and bone erosions/deviations occurred in 4 cases of them Initial diagnoses submitted by referring pathologists angiofibroma 32%, hemangioma 24%, hemangiopericytoma 16%, angiosarcoma 12%, pyogenic granuloma and hemangio-endotelioma, both at 8% None of the patients died of the disease and there has been no progression in any patient 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).

18 Sinonasal hamartomatous and teratoid lesions

19 Hamartomas of respiratory tract
Rare tumor like lesions of sinonasal mucosa and nasopharynx Respiratory epithelial adenomatoid hamartoma (REAH) Seromucinous hamartoma nasal chondromesenchymal hamartoma Mixed chondro-osseous REAH Wenig BM, Heffner DK. Respiratory epithelial adenomatoid hamartomas of the sinonasal tract and nasopharynx: a clinicopathologic study of 31 cases. Ann Otol Rhinol Laryngol 1995:104:

20 Seromucinous (glandular) hamartomas
polypoid lesions characterized by epithelial proliferations of small glands, acini, and tubules growing haphazaradly in clusters and lobules devoid of myoepithelial cells Weinreb I, et al. Seromucinous hamartomas: a clinicopathological study of a sinonasal glandular lesion lacking myoepithelial cells. Histopathology 2009:54:

21 Seromucinous hamartoma of sinonasal tract
Uncommon, under-reported entity Residual lobular architecture, bland morphology Absence of epithelial tufting, papillae, back-to back glands Absence of invasion Spectrum with REAH and low-grade sinonasal adenocarcinoma Jo 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:

22 Spectrum from seromucinous hamartoma to REAH
Weinreb et al: Histopathology 2009

23 Respiratory epithelial adenomatoid hamartoma (REAH)

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30 Differential diagnosis of sinonasal hamartomas
Low-grade sinonasal adenocarcinoma LG tubulo-papillary adenocarcinoma Schneiderian benign papilloma Oncocytic variant Salivary gland type adenoma

31 Sinonasal adenocarcinomas (SNAC)
uncommon malignancies that show a variety of growth patterns classified as intestinal and non-intestinal types, the latter subclassified as low grade and high grade

32 slowly growing tumour- of nasal mucosa, filling the middle meatus,
72-yr old man presented with sinonasal mucosal polyps nasal obstruction and recurrent attacks of chronic hyperplastic rhinitis for at least 5 years slowly growing tumour- of nasal mucosa, filling the middle meatus tumour 2.5 cm in diameter was removed by curettage in small fragments 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 hyperplastic rhinitis for at least 5 years

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35 Sinonasal adenocarcinomas (SNAC)
Recently, some cases of low-grade sinonasal adenocarcinomas associated with REAH were reported possibly implicating REAH as a precursor lesion for at least a subset of 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:

36 29 LG sinonasal adenocarcinoma reviwed
6 of them associated with REAH REAH may be precursor of LG sinonasal adenoca

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38 Benign epithelial neoplasms
Papillomas Salivary gland-type adenomas

39 Sinonasal papillomas Squamous cell papilloma Schneiderian papilloma
Exophytic Inverted oncocytic

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41 Benign sinonasal soft tissue neoplasms


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