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

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)

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

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

38. Benign epithelial neoplasms
Papillomas Salivary gland-type adenomas

39. Sinonasal papillomas Squamous cell papilloma Schneiderian papilloma
Exophytic
Inverted
oncocytic

41. Benign sinonasal soft tissue neoplasms