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DR HANIA NAVEED
NORMAL ANATOMY
CONTD
NORMAL HISTOLOGY
CASE NO 1
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DIAGNOSIS
NASAL GLIOMA Malformed tumor like condition affecting infants Sub-cutaneous masses at the base of nose or intranasal polyps GFAP +ve Other causes: Encephaloceles (associated bony defects) Chondromesenchymal hamartoma
CASE NO 2
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SINONASAL PAPILLOMA
Types: exophytic, inverted, oncocytic M/E: squamous/transitional/respiratory type epithelium. Intraepithelial neutrophils, microcysts, thin basement membrane HPV 6 AND 11 association
Type Exophytic
Inverted
Endophytic nests (more than a few inverted nests qualify for inverted)
Oncocytic/ cylindrical
Exophytic and endophytic nests of cells, oncocytic cells in less than 6-8 layers
NASAL POLYPS
<20yrs
Neuroblastoma,
>20 yrs
Neuroblastoma,
CASE NO 3
50-year-old man with a nasal mass arising from the lateral nasal wall
MICROSCOPY
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DIAGNOSIS
ONCOCYTIC PAPILLOMA
Infectious
Spirochetes
Inflammatory
Wegener
Sarcoidosis
Wegener's granulomatosis
WEGENERS GRANULOMATOSIS
Diagnostic
Leukocytoclastic
vasculitis, granulomas, necrosis + involvement of lung OR kidney 2/3 microscopic features + involvement of lung AND kidney
Probable
2/3
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Suggestive
1/3
microscopic features+ lung and kidney involvement microscopic features + lung or kidney involvement microscopic features + kidney and lung involvement
Suspicious
1/3
Non specific
No
Rhinoscleroma
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D/D:
LEPROSY
Mucormycosis
Aspergillus
CASE NO 3
DIAGNOSIS
SINONASAL CARCINOMA
SINONASAL CARCINOMA
within nose - usually vestibule and lateral wall; rarely septum; sinus - usually ethmoid, rare in frontal sinus Risk factors: nickel refiners, woodworkers Usually HPV and EBV negative
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Acantholytic squamous cell carcinoma Adenosquamous carcinoma Basaloid squamous cell carcinoma Papillary squamous cell carcinoma Spindle cell squamous cell carcinoma Verrucous carcinoma
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To label a tumor as keratinizing squamous cell carcinoma there should be histologic evidence of squamous differentiation
Keratin
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Subtypes of squamous carcinoma should be recognized and listed. Basaloid squamous cell carcinomas tend to present with more extensive disease but are also more radiosensitive than conventional squamous cell carcinomas. In this histologic grading scheme, 3 histologic grades are suggested, as follows: Grade 1 Well differentiated = Low-grade Grade 2 Moderately differentiated = Intermediategrade Grade 3 Poorly differentiated = High-grade Grade X Cannot be assessed
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When a tumor manifests more than 1 grade of differentiation, the surgical report must designate both the highest and the most prevalent tumor grades.
CASE NO 4
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GLANDULAR HAMARTOMA
CASE NO 5
DIAGNOSIS
MUCINOUS ADENOCARCINOMA
ADENOCARCINOMA
10% of sinonasal malignancies Usually middle turbinate or ethmoid sinus Divided into:
Intestinal-type
Salivary
gland type
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Intestinal type adenocarcinoma Strong association with woodworking industry Spectrum of appearance Well differentiated tumors: resembles the normal intestinal mucosa (goblet,paneth,argentaffin,well formed villi and muscularis mucosa) Less differentiated tumors: solid sheets of neoplastic cells having only scattered glandular lumen CK20, CDX-2, MUC2 +ve Molecular genetic studies indicate frequent mutations in K-RAS and TP53
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Non-intestinal adenocarcinoma Not immunoreactive for colonic markers Usually low grade and can be misdiagnosed as adenoma or papilloma Grading into low and high grade is based on:
marked
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Low grade adenocarcinoma should be distinguished from the intestinal type adenocarcinoma because of the aggressive clinical course of the latter. The distinction is based on
Nuclear
CASE NO 6
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CASE NO 7
61yrs old woman presented with long standing bilateral nasal polyps SLIDE
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CASE NO 8
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For the majority of salivary gland carcinomas there is only a single histologic grade and classification alone determines the histologic grade (eg, acinic cell carcinoma is a histologically low-grade carcinoma; salivary duct carcinoma is a histologically high-grade carcinoma). In some carcinomas, histologic grading may be based on growth pattern, such as in adenoid cystic carcinoma, for which a histologic high-grade variant has been recognized based on the percentage of solid growth. Those adenoid cystic carcinomas showing 30% or greater of solid growth pattern are considered to be histologically high-grade carcinomas
CASE NO 9
Highly aggressive epithelial malignancies composed of nests, lobules or sheets of atypical cells with a high mitotic rate, necrosis and apoptosis. Minimal or no evidence of:
neuroendocrine
differentiation (i.e. no Homer Wright rosettes, no fibrillary background, no ganglion-like cells) no squamous or glandular differentiation no dense lymphoplasmacytic infiltrate
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Immunohistochemistry: Positive stains: CK7, CK8, CK19,Ki-67, NSE, EMA Negative stains: CK 5/6, CK13, EBV, PLAP, CEA, S100, EBER1, chromogranin, Synaptophysin D/D:
Olfactory neuroblastoma Nasopharyngeal undifferentiated carcinoma (syncytial growth of cells with uniform nuclei with vesicular chromatin in inflammatory stroma) Small cell carcinoma Lymphoma Melanoma Rhabdomyosarcoma
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In children and young adults particularly, SNUC should be distinguished from NUT midline carcinomas which are characterized by translocations that involve the nuclear protein in testis (NUT).
CASE NO 10
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CASE NO 11
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PLASMABLASTIC LYMPHOMA
CASE NO 12
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HMB45
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CASE NO 13
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MENINGIOMA
CASE NO 14
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GLOMANGIOPERICYTOMA
CASE NO 15
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DIAGNOSIS
Alveolar rhabdomyosarcoma
CASE NO 16
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CASE NO 17
A 40 year woman with nasal sinus congestion had a CT scan, which showed a mass. Endoscopy showed friable nasal tissue. A biopsy was obtained.
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Keratin
CD20
CD3
CD56
EBV
TIA
DIAGNOSIS
Highly associated with EBV Characterized by small to medium sized to large transformed cells showing angioinvasion Necrosis is nearly always present. EBER positive (imp to differentiate with reactive lymphoid infiltrate and other CD56+ve lymphoma)
OLFACTORY NEUROBLASTOMA
Also called esthesioneuroblastoma Rare, malignant neuroectodermal tumor thought to arise from olfactory membrane Gross: red-gray, highly vascular, polypoid mass of soft tissue Micro: nests or sheets of uniform small cells with scant cytoplasm, round nuclei with indistinct nuclear membrane and punctuate chromatin, no/indistinct nucleoli; mild to moderate nuclear pleomorphism; prominent fibrillary or reticular background, variable mitotic figures; variable Homer Wright rosettes, ganglion cells and tumor cell melanin; necrosis is poor prognostic factor
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Positive stains: neuron-specific enolase (strong), synaptophysin (strong), chromogranin, occasional GFAP and keratin Negative stains: EWS-FL1, CD99, EMA, desmin
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DD:
Lymphoma
Ewing/PNET Plasmacytoma
Rhabdomyosarcoma
Small
cell carcinoma
NASOPHARYNGAL CARCINOMA
78-90% of malignant neoplasm in this region are non-glandular. Strongly associated with EBV infection for undifferentiated and nonkeratinizing subtypes Micro:
keratinizing
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SQUAMOUS CELL CARCINOMA (K) Squamous differentiation Adenoid or acantholytic forms NON-KERATINIZING CARCINOMA Lacks the microscopic evidence of squamous differentiation Pavement stone pattern and well defined cell margins Variable number of inflammatory cells in stroma
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UNDIFFERENTIATED CARCINOMA (LYMPHOEPITHELIOMA) Syncytial pattern Uniform cells with ovoid, vesicular nuclei, indistinct cell borders Inflammatory cells rich in lymphocytes REGAUD PATTERN: well defined cells nests and cords separated by inflammation SCHMINKE PATTERN: diffuse inflammatory cells permeate cell nests causing isolation of carcinoma cells within lymphoid background D/D: EMA, CK and LCA (lymphoma)
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In the revised W.H.O. the distinction between undifferentiated and differentiated nonkeratinizing nasopharyngeal carcinomas is no longer necessary since sub-classification is of no prognostic or therapeutic significance.
CASE NO
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NUT MIDLINE CARCINOMA NMC is defined by translocations involving the NUT gene at 15q14 The most common (75%) translocation is t(15;19) Consistent reactivity to cytokeratins and p63 Surprisingly, CD34 expression, rare in carcinomas, is seen in about half of cases. Melanoma markers, neuroendocrine markers, muscle markers) are consistently negative. The gold standard for the diagnosis of NMC is FISH
THANKU
CASE NO
49 y.o. male with a 2.5 cm nasal mass NON K SCC Sections show an ulcerated polypoid tumor that is composed of basaloid appearing tumor cells with a predominantly inverted growth pattern. Focal keratinization is also noted. Immunostains for cytokeratin, p16 and p63 are strongly and diffusely positive.
CASE NO
67 y.o. female patient with a right nasopharyngeal mass The biopsy shows a malignant neoplasm composed of tumor cells that have scant cytoplasm, round to oval nuclei with open chromatin and small inconspicuous nucleoli that are infiltrated by small lymphocytes. The mitotic rate is high. Immunostains demonstrate that the tumor cells are cytokeratin positive (AE1/AE3), while chromogranin and p16 are negative.
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