Benign sinonasal neoplasms and tumor-like lesions

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

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: 233-234.

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

10. Ulceration, granulation tissue, bood vessel proliferation

11. Dilated blood vessels, granulation tissue

12. Increased cellularity around blood vessels

13. Thrombosis with organisation

14. Hemorrhage, extravasation of RBCs

15. 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 1995:104:639-645.

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 2009:54:205-213.

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 2009:33:401-408.

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. 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 2009:33:401-408.

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

38. Benign epithelial neoplasms PapillomasSalivary gland-type adenomas

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

41. Benign sinonasal soft tissue neoplasms