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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
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Anatomy of nasal cavity and sinonasal region
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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
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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
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Antrochoanal angiomatoid polyp
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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
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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.
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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
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Ulceration, granulation tissue, bood vessel proliferation
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Dilated blood vessels, granulation tissue
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Increased cellularity around blood vessels
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Thrombosis with organisation
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Hemorrhage, extravasation of RBCs
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ASMA
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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).
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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).
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Sinonasal hamartomatous Sinonasal hamartomatous and teratoid lesionsand teratoid lesions
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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.
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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.
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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.
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Spectrum from seromucinoushamartoma to REAH
Weinreb et al: Histopathology 2009
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Respiratory epithelial adenomatoid hamartoma (REAH)
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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
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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
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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
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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.
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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
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Benign epithelial Benign epithelial neoplasmsneoplasms
PapillomasPapillomasSalivary gland-type adenomasSalivary gland-type adenomas
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Sinonasal papillomasSinonasal papillomas
Squamous cell papillomaSquamous cell papilloma Schneiderian papillomaSchneiderian papilloma
ExophyticExophytic InvertedInverted oncocyticoncocytic
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Benign sinonasal soft Benign sinonasal soft tissue neoplasmstissue neoplasms