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Nonkeratinizing Carcinoma of the Sinonasal Tract: A ... - PSO-HNS

Nonkeratinizing Carcinoma of the Sinonasal Tract: A ... - PSO-HNS

CASE REPORTSPhilippine

CASE REPORTSPhilippine Jo u r n a l Of Ot o l a r y n g o l o g y-He a d An d Ne c k Su r g e r y Vo l. 26 No. 2 Ju ly – De c e m b e r 2011epithelium lining of the nasal cavity and the paranasal sinuses asectodermal in origin. 6 It is derived from nasal placodes that invaginateto form the primitive nasal sacs and ultimately the sinonasal cavitiesand lacrimal apparatus. The posterior boundary of this lining is theposterior choanae although it is continuous with the rest of thenasopharynx which is endodermally-derived i.e. from the foregutrespiratory epithelium. Therefore, the use of the term Schneideriandistinguishes the boundaries of this epithelium and avoids confusionwith any other anatomically-located tumors. 7The WHO classification also lists NKCa as a variant of squamous cellcarcinoma. It is described as a tumor of the sinonasal tract characterizedby a plexiform or ribbon-like growth pattern with occasional mucuscontainingcells. 5 Although identified as nonkeratinizing, there areoften small keratin pearls interspersed within the proliferations andsome may form surface keratin that fills cystic spaces. 5,8In our patient, histopathological examination showed tissue partlylined by respiratory epithelium with the underlying stroma infiltratedby malignant cells forming islands and ribbon-like patterns. The cellsdisplayed large nuclei with moderate pleomorphism, vesicular nucleiand prominent large nuclei. Some of the cells had 2 to 3 nucleoli.Mitoses were frequently seen. Bone trabeculae, areas of haemorrhageand necrosis were also present. No evidence of keratinisation was seen(Figures 2 and 3). Amelanotic mucosal malignant melanoma was ruledout by immunohistochemistry where there was negativity to Melan-A,HMB45 and S100.The ribbon-like invasive architecture and monomorphic nuclearcytology of nonkeratinizing carcinoma may mimic inverted papilloma.Thus, Osborn called inverted papillomas as transitional papillomasand sinonasal nonkeratinizing carcinoma as transitional carcinomas. 2However, the focal keratin pearl formation, increased mitotic activityand nuclear pleomorphism distinguish the nonkeratinizing carcinoma. 8It may be impossible to identify NKCa from a carcinoma-ex-invertedpapilloma characterized by diffuse dysplasia of the epithelium unlessthere is residual, better differentiated underlying inverted papillomapresent. 8 As reported by Robin et al. in 1979 and Svane-Knudsen et al.in 1998, a small percentage of transitional-type carcinomas may arisein pre-existing transitional cell papillomas. 1,9 Most nonkeratinizingcarcinomas are well-differentiated resembling transitional epitheliumreminiscent of urothelium. Some are poorly-differentiated, composinglayers of disordered small anaplastic cells though others showpseudostratified tall cylindrical cells with a basal palisade of columnarcells. 8The designation of cylindrical cell carcinoma as a synonym onthe other hand is misleading as it may suggest a relationship to the(Hematoxylin-Eosin, 40X)Figure 2. Histopathologic section. Hematoxylin and Eosin, low-power view (40X). Respiratoryepithelium with the underlying stroma infiltrated by malignant cells forming islands and ribbon-likepatterns.(Hematoxylin-Eosin, 400X)Figure 3. Histopathologic section. Hematoxylin and Eosin, high-power view (400X). The cells displaylarge nuclei with moderate pleomorphism, vesicular nuclei and prominent large nuclei, some with 2to 3 nucleoli and frequent mitoses. No evidence of keratinisation is seen.cylindrical cell papilloma (oncocytic Schnederian papilloma). The latteris microscopically distinct characterized by surface oncocytic columnarand mucus cells and is unrelated to NKCa. 3The many different terminologies and synonyms that have beenused frequently in the international literature may have lead to someconfusion and perhaps misdocumentation of this rare tumor. In aseries reported by Osborn in 1970 there were 57 cases of transitionalcell carcinomas seen and treated in the Royal National Throat andEar Hospital between 1948 and 1968 accounting for approximately20% of all carcinomas of the nose and sinuses. 2 A review by Robinet al. in 1979 illustrated a series obtained from registrations in theBirmingham Regional Cancer Registry from 1957 to 1972 inclusive ofPhilippine Jo u r n a l Of Ot o l a r y n g o l o g y-He a d An d Ne c k Su r g e r y 23

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