Head and Neck Pathology by IHC001

Head and Neck Presentation delivered by: Kavita Singhal Presentation prepared by: Gillian Hall

Head and Neck Summary  Special stains / immunos  Syndromes  Tumours most commonly but not uniquely encountered in the head and neck  Sinonasal tract  Head and Neck  Minimum Datasets / cancer questions  Oral cavity / hypopharynx / larynx

Question 1 Special stains / immunos

 Q1: Identify the special stain / immunochemical antibody which would aid in diagnosis for each case:

 CD1a  S-100  CD68  Synaptophysin  Ziehl Neelson

CD45 DPAS p16 EBV ISH GFAP

 1. A 37 year old female presents with a polyp on the tongue which is excised. The H and E stained section shows sheets of plump polygonal cells with abundant eosinophilic granular cytoplasm filling the lamina propria. Options: CD1a S-100 CD68 Synaptophysin Ziehl Neelson

CD45 DPAS p16 EBV ISH GFAP

Granular cell tumour Differential diagnosis of lumps and bumps on tongue  Fibroepithelial polyp  Chronic oral candidiasis  Viral wart  Minor salivary gland tumour  SCC  Granular cell tumour

Granular cell tumour Previous names include granular cell myoblastoma Most common non-epithelial benign tumour 50% of Head and Neck Cases Tongue, larynx Schwannian origin S100 positive

Granular cell tumour Infiltrative growth pattern Eccentric small bland nuclei Abundant granular cytoplasm Indistinct cell boundaries Pseudoepitheliomatous hyperplasia

S-100

 2. A 75 year old female undergoes incisional biopsy of a mixed red and white plaque on the tongue. There is some irregular pseudoepitheliomatous hyperplasia of the epithelium and mild atypia. Aggregates of neutrophils are readily detected in the surface parakeratin. Options:

CD1a S-100 CD68 Synaptophysin Ziehl Neelson

CD45 DPAS p16 EBV ISH GFAP

Pseudooepitheliomatous hyperplasia Chronic hyperplastic candidiasis Psoriasiform hyperplasia Plasma cells Neutrophilic microabscesses PAS or PASD to look for hyphae Usually some reactive keratinocyte atypia and often overcalled dysplasia

PAS

Similar appearances seen in benign migratory stomatitis aka geographic tongue No candida will be found Psoriasiform hyperplasia +++ neutrophilic abscesses

 3. A 30 year old male undergoes biopsy of a white patch on the lateral border of the tongue. Histological examination shows parakeratosis and a band-like layer of cells with clear cytoplasm in the upper stratum spinosum.

Options:

CD1a S-100 CD68 Synaptophysin Ziehl Neelson

CD45 DPAS p16 EBV ISH GFAP

Hairy leukoplakia Classical histological appearances Often candida +++ but lack of inflammation Band of clear cells classical Should confirm diagnosis by EBV immuno’ or ISH Pathognomonic of HIV

EBV IHC

 4. A 45 year old oriental male presents with an enlarged cervical lymph node and on pan-endoscopy is found to have a mass in the nasopharynx.

Options:

CD1a S-100 CD68 Synaptophysin Ziehl Neelson

CD45 DPAS p16 EBV ISH GFAP

Nasopharyngeal carcinoma Aetiological factors: race, genetic, environmental (diet), EBV Around 70% present with lymphadenopathy Subtypes Keratinising SCC Non-keratinising SCC Undifferentiated (with lymphoid stroma)

Nasopharyngeal carcinoma Non-keratinising and undifferentiated types EBV associated Radiosensitive

 5. An 8 year old male presents with premature loosening of deciduous molars on the lower left side and an osteolytic lesion is seen on plain X-ray. Curettings show sheets of mononuclear cells with oval nuclei admixed with clusters of eosinophils. Options:

CD1a S-100 CD68 Synaptophysin Ziehl Neelson

CD45 DPAS p16 EBV ISH GFAP

Langerhan’s cell histiocytosis Childhood mainly Head and Neck: middle ear and jaw Osteolytic punched out lesions Unifocal, multifocal Oval reniform nuclei with grooves or folds Eosinophils CD1a (also S-100 positive) DD: other histiocytic proliferations, HL

Question 2 Syndromes

 Many syndromes present with signs in the head and neck region. Match the syndrome to the clinical description:          

Neurofibromatosis type 2 Fanconi’s anaemia Gardners syndrome Down’s syndrome Albrights syndrome (McCune-Albright) Osteogenesis imperfecta Gorlin Goltz syndrome MEN2b Cowdens syndrome Plummer-Vinson syndrome

 1. A 21 year old male who on a routine dental X-ray was found to have bilateral multilocular jaw cysts and also on further examination, a pearly plaque with central telangiectasia on the forehead          

Odontogenic keratocyst Officially now a tumour (WHO 2005) In syndrome: multiple and earlier onset than sporadic and greater tendency to recur Is the only odontogenic cyst to keratinize Basal cell palisading and corrugated surface typical Satellite and daughter cysts more prevalent in syndromic patients

 2. A 60 year old female with long standing dysphagia and anaemia undergoes pharyngo-laryngectomy for a post-cricoid (hypopharyngeal) squamous cell carcinoma          

Soft tissue in continuity ND

SMG

Upper aerodigestive tract SCC  Mostly associated with alcohol / tobacco  Nasopharyngeal already mentioned  Small proportion of patients never smokers and little to moderate alcohol intake  Fanconi anaemia  Other inherited disorders of DNA repair  Check it’s not pseudoepitheliomatous hyperplasia in a v young patient!!!  Plummer Vinson associated with post-cricoid ca (30-70% at this site have syndrome)

 3. An 8 year old boy with multiple mucosal polyps especially around the lips and a fixed thyroid mass which is reported as probably malignant on cytology          

MEN 2b Adrenal phaeochromocytoma Medullary carcinoma of thyroid Multiple mucosal neuromas Marfanoid bodies AD –RET mutation

 4. A 9 year old female with pigmented skin lesions, early onset of puberty and a painless unilateral swelling of the maxilla along with radiological abnormalities of the ribs and right femur.          

Albright’s syndrome / fibrous dysplasia Expansion and replacement of bone by cellular fibroblastic tissue in which irregular trabeculae of woven bone are deposited Tend to lack osteoblastic rimming and lesional bone merges with adjacent normal bone Syndrome = polyostotic fibrous dysplasia + café au lait pigmentation + endocrinopathy

Question 3 Tumours most commonly but not uniquely encountered in the head and neck

 Tumours most commonly (but not uniquely) encountered in the head and neck          

Granular cell tumour Adenomatoid odontogenic tumour Adenoid cystic carcinoma Acinic cell carcinoma Squamous cell carcinoma Ameloblastoma Myoepithelioma Polymorphous low grade adenocarcinoma Mucoepidermoid carcinoma Pleomorphic adenoma

 1. A 36 year old female with a multilocular radiolucency of the left body of mandible. Histology shows islands of epithelium composed of loosely cohesive cells centrally with peripheral palisading and reverse polarity          

Ameloblastoma Most common odontogenic tumour (exc odontoma which is hamartomatous) Wide age range Benign but locally aggressive Classical histological appearances Peripheral palisading Reverse polarity Central stellate reticulum-like cells

Stellate reticulum like cells

Ameloblast like cells

 2. A 45 year old male has a biopsy of the floor of mouth swelling which consists of cribriform islands of angular basaloid cells arranged around gland like spaces filled with homogenous eosinophilic or basophilic material.          

Adenoid cystic carcinoma Wide age range Slow growing with tendency for perineural spread Tubular, cribriform and solid patterns 2 cell populations: ductal cells and abluminal myoepithelial cells Cytologically bland, angular and dense chromatin

Adenoid cystic carcinoma Cribriform pattern: multiple punched out holes “pseudocysts” Contain dense eosinophilic basement membrane-like material or bluish mucopolysaccharides Perineural invasion +++ 5 yr survival good, 20 yrs <10% Lung metastases seen later in course

 3. A palatal biopsy from a 15 year old female showing lobular islands of cytologically bland polygonal cells with distinct cell boundaries admixed with scattered mucous / goblet cells.          

Mucoepidermoid carcinoma Wide age range and most common malignant salivary gland tumour in adolescents and children 3 types of cells Epidermoid cells Mucous cells Intermediate cells Clear cells

Mucoepidermoid carcinoma Grading Cystic change Necrosis Neural invasion Anaplasia >4 mitoses / 10 hpf

Mucoepidermoid carcinoma Low grade can be well circumscribed Often a nesting pattern Sometimes lymphoid stroma

 4. A multinodular submandibular tumour which has rather variable appearances including cellular areas containing ductal structures, sheets and strands of hyaline plasmacytoid cells, all embedded in a loose myxoid stroma.          

Pleomorphic adenoma  Pleomorphic refers to variety of cells and architectural patterns not to cytomorphology  The most common benign tumour  Tumours of minor glands can be non or poorly encapsulated  Ductal / luminal cells and abluminal myoepithelial population  Myoepithelial population often most prominent

Pleomorphic adenoma Myoepithelial cells Hyaline plasmacytoid Clear Spindled Epithelioid

Pleomorphic adenoma Stroma Myxoid Chondroid Hyalinised Fibrous (Bone)

Pleomorphic adenoma Bosselated multinodular growth Malignant transformation

CHONDROID

MYXOID

PLASMACYTOID CELLS

 5. A well defined parotid gland tumour, reported as probably benign by the radiologist, composed of sheets of plump cells with voluminous basophilic granular cytoplasm with a smaller population of clear cells and focal areas of papillary cystic architectural change          

Acinic cell carcinoma 90% parotid Low grade tumour, usually fairly well circumscribed Lymphoid stroma Variable histological appearances and rarity account for difficult in diagnosis in many cases

Acinic cell carcinoma In it’s simplest form Sheets of large polygonal cells with abundant granular basophilic cytoplasm, small eccentric nuclei with even chromatin pattern

Often nested organoid pattern

Acinic cell carcinoma  Other cell types Clear cells Non-specific glandular cells Hobnail cells Vacuolated

 Architectural arrangements Solid Papillary cystic Microcystic Follicular

Question 4 Sinonasal tract

Sinonasal lesions: select one of the following:           

Tuberculosis Wegener’s granulomatosis Capillary haemangioma Nasopharyngeal angiofibroma Haemangiopericytoma Malignant melanoma Intestinal type adenocarcinoma Mucocele NK/T cell lymphoma Sinonasal undifferentiated carcinoma Olfactory neuroblastoma

 1. A 50 year old female with a polypoid mass in the roof of the nasal fossa comprising lobular sheets of small blue round cells embedded in a fibrillary background and with occasional rosettes.           

Olfactory neuroblastoma 3rd – 4th decade Lobules of small blue round cells 60-70% have a fibrillary stroma Rosettes: Homer - Wright or Flexner – Wintersteiner Neuroendocrine markers + Cytokeratins – S-100 scattered + cells at periphery of lobules

Olfactory neuroblastoma Differential diagnosis Small cell carcinoma SNUC Rhabdomyosarcoma ES / PNET Melanoma Lymphoma

 2. A 14 year old male also with a polypoid mass in the roof of the nasal fossa composed of variable sized vessels embedded in a variably cellular and collagenised fibroblastic stroma with stellate shaped fibroblasts a notable feature           

Juvenile nasopharyngeal angiofibroma Exclusively seen in males 10-25 yrs Androgen receptor positive Collagenised vascular stroma containing numerous irregularly shaped blood vessels Spindle and stellate shaped cells

 3. A 57 year old carpenter presents with nasal discharge and obstruction. Curettings comprise mucinous material containing glandular structures and papillary strands of columnar cells showing cytological atypia and frequent mitoses           

Intestinal type adenocarcinoma Classification of sinonasal malignancy Keratinising squamous cell carcinoma Non-keratinising (transitional) squamous cell carcinoma Sinonasal undifferentiated carcinoma Low grade adenocarcinoma Intestinal type adenocarcinoma Malignant melanoma

ITAC Aetiological factors: occupational wood and nickel workers Well differentiated looks virtually like normal colonic mucosa Papillary-tubular patterns, back to back glands with atypia Essentially range of features seen in colonic adenoca CK7+/- CK20 + can be CDX2 positive

 4. Crusting and ulceration of the nasal septum, altered renal function in a 39 year old female. A biopsy from the nasal cavity is largely necrotic but in viable areas, some non-caseating granulomata containing multinucleated giant cells are seen.           

Wegener’s granulomatosis Systemic vasculitis and necrotising granulomatosis Upper and lower respiratory tracts and kidneys cANCA positive Triad Necrosis Vasculitis Granulomatosis

Wegener’s granulomatosis Mixed acute on chronic inflammation with neutrophilic microabscesses Eosinophils Giant cells unassociated with granulomas Geographic necrosis

 5. A 52 year old male also with crusting and ulceration of the nasal mucosa but with no other systemic symptoms. The biopsy shows geographic ulceration with sheets of small, medium and large cells present in viable areas which frequently invade vessel walls.           

Sinonasal NK/T cell lymphoma Broad morphological spectrum Polymorphic with atypical lymphoid cells Plus background of other cells (neuts eos) Pale to clear cytoplasm Angioinvasion Geographic necrosis CD56, variable for T cell markers (CD2) EBV related

Biopsy findings for the nasopharynx prior to radiotherapy.

a, Proliferation of small to large, pleomorphic lymphoma cells b, Lymphoma cells are invading a vein (arrows) c, Positive reactions for UCHL-1 are evident on the cytoplasmic membranes of lymphoma cells d, Expression of EBER1 in nuclei of lymphoma cells (EBER in situ hybridization,)

Questions 5-10 Head and Neck Minimum Datasets / cancer questions

Question 5 Lymph nodes lying deep to sternocleidomastoid at a level bounded superiorly by omohyoid muscle and inferiorly by the clavicle are located in anatomical level IIa IIb III IV V

Terminology of node groups Six major anatomical groups (levels) of lymph nodes are described. Level I: nodes of the submandibular and submental triangles. Levels II, III and IV: nodes of the upper, middle, and lower jugular chain. These nodes lie deep to the upper, middle and lower thirds of the sternocleidomastoid muscle respectively. The point at which the omohyoid muscle crosses deep to the sternocleidomastoid muscle is a useful landmark separating levels III and IV. Level IV extends from the omohyoid muscle to the clavicle. Level V: nodes of the posterior triangle, behind the posterior border of the sternocleidomastoid muscle. Level VI: nodes of the anterior compartment, around the midline visceral structures of the neck from the hyoid bone to the suprasternal notch.

Imaging studies may subclassify node levels II and V. It is not suggested that this should be part of routine pathological practice but if separate groups are submitted, e.g. IIA and IIB, this should be noted in the pathology report.

Lymph nodes lying deep to sternocleidomastoid at a level bounded superiorly by omohyoid muscle and inferiorly by the clavicle are located in anatomical level IIa IIb III IV V

Question 6  A tumour resected from the postero-lateral part of the tongue is seen to be composed of lobules of atypical cells with a high n:c ratio showing peripheral palisading, a thickened basement membrane and focal evidence of keratinisation. Cystic spaces containing mucoid material are seen and there is high grade dysplasia of the surface epithelium. There is also comedo type necrosis within larger islands. This is a: Adenosquamous squamous cell carcinoma Adenoid cystic carcinoma Adenoid / acantholytic squamous cell carcinoma Basaloid squamous cell carcinoma Moderately differentiated squamous cell carcinoma

 A tumour resected from the postero-lateral part of the tongue is seen to be composed of lobules of atypical cells with a high n:c ratio showing peripheral palisading, a thickened basement membrane and focal evidence of keratinisation. Cystic spaces containing mucoid material are seen and there is high grade dysplasia of the surface epithelium. There is also comedo type necrosis within larger islands. This is a: Adenosquamous squamous cell carcinoma Adenoid cystic carcinoma Adenoid / acantholytic squamous cell carcinoma Basaloid squamous cell carcinoma Moderately differentiated squamous cell carcinoma

Question 7  A resected squamous cell carcinoma of mandibular alveolus with a diameter of 22mm and depth of 7mm shows superficial erosion of the cortex of the mandible but not full thickness loss of cortical plate. This is most appropriately graded: pT1 pT2 pT3 pT4 pT4a

 A resected squamous cell carcinoma of mandibular alveolus with a diameter of 22mm and depth of 7mm shows superficial erosion of the cortex of the mandible but not full thickness loss of cortical plate. This is most appropriately graded: pT1 pT2 pT3 pT4 pT4a

Question 8  Which of the following statements is true: High risk HPV can cause squamous cell carcinoma at any site in the head and neck HPV associated tumours are well differentiated HPV associated tumours have a better prognosis and are more sensitive to non surgical therapy than nonHPV tumours HPV is a rare cause of head and neck cancer HPV associated tumours present with large primaries and rarely metastasize to cervical lymph nodes

HPV associated SCC almost exclusively in oropharynx i.e. tonsil and base of tongue

PARANASAL SINUSES

NASAL CAVITY

NASOPHARYNX ORAL CAVITY

OROPHARYNX

PHARYNX

HYPOPHARYNX

SALIVARY GLANDS

TRACHEA

LARYNX

OESOPHAGUS

 As a proportion of H&N ca (US) 1973 – 18% 2004 – 31%

 Incidence of tonsil cancer England  1997 n=281  2007 n=703

 HPV as an aetiological agent first proposed in 1983  HPV + oropharyngeal ca is a different entity Patient demographics and clinical presentation Histological grading Response to chemoradiotherapy Clinical outcome

 HPV 16  Thought currently that around 60% of oropharyngeal SCC are HPV associated

 Other head and neck sites?  3% oral cavity  Detection of virus does not prove it is biologically relevant

Early 2000s

Late 2000s

Base of tongue

58%

84%

Tonsil

68%

93%

 Sweden  HPV16+

Attner et al 2010, Int J Cancer. Nasman et al 2009 Int J Cancer

 Oral cavity ca ↓ 1.85% per year 19732004 (US)

 Oropharyngeal ca ↑ 2-3% per year

 A decade younger than non-HPV SCC (50’s)  Especially males  Often non, ex or minimal smokers and low to moderate alcohol intake  Presentation more often with neck lump rather than primary lesion

 For all cancer sites general principle in pathology that poorer differentiation associated with worse outcome

Poorly differentiated / basaloid SCC

 Oral cavity / hypopharynx / larynx  HPV negative and poorer prognosis than conventional SCC

 Oropharyngeal  If HPV associated, radiosensitive and much better prognosis

Basaloid squamous cell carcinoma of upper aerodigestive tract: a single squamous cell carcinoma subtype of two distinct entities hiding under one histologic pattern. Woolgar et al Eur Arch Otolaryngol 2011

 More radio and chemo sensitive than non-HPV tumours  Apoptosis / cell cycle inhibition pathways intact but switched off

Viral protein E6 inactivates p53 Viral protein E7 inactivates Rb Rb normally held in a complex with E2F E2F when free triggers cell cycle

 p16  If positive HPV ISH or PCR (or both)

 5 year survival data 80-85% HPV + 30-35% HPV –

Independent of the treatment HPV + tobacco users – negative effect on the prognosis

 Which of the following statements is true: High risk HPV can cause squamous cell carcinoma at any site in the head and neck HPV associated tumours are well differentiated HPV associated tumours have a better prognosis and are more sensitive to non surgical therapy than nonHPV tumours HPV is a rare cause of head and neck cancer HPV associated tumours present with large primaries and rarely metastasize to cervical lymph nodes

Question 9  A patient underwent bilateral selective neck dissections at the same time as removal of a floor of mouth SCC. Pathological assessment found 4 positive LNs on the right, largest 35mm and one on the left, diameter 10mm. The pathological stage is: pN1 pN2a pN2b pN2c pN3

Nodal staging            

pN Regional lymph nodes (for all primary sites, except nasopharynx) pNX Nodes cannot be assessed pN0 No nodal metastasis pN0(i+) Isolated tumour cells only (<0.2 mm) pN1(mi) Micrometastasis (2 mm or less) only, in single node pN1 Metastasis in single ipsilateral node 30 mm or less in diameter pN2(mi) Micrometastasis (2 mm or less) only, in multiple or bilateral nodes pN2a Metastasis in single ipsilateral node 31–60 mm diameter pN2b Metastasis in multiple ipsilateral nodes <61 mm diameter pN2c Metastasis in bilateral or contralateral lymph nodes, none more than 60 mm in greatest dimension pN3 Metastasis in lymph node more than 60 mm diameter.

 A patient underwent bilateral selective neck dissections at the same time as removal of a floor of mouth SCC. Pathological assessment found 4 positive LNs on the right, largest 35mm and one on the left, diameter 10mm. The pathological stage is: pN1 pN2a pN2b pN2c pN3

Nodal staging  For nasopharyngeal primary carcinomas:  pN1 Unilateral metastasis <61 mm above the supraclavicular fossa and/or unilateral or  bilateral retropharyngeal metastases  pN2 Bilateral metastases <61 mm above the supraclavicular fossa  pN3 Metastasis in nodes >60 mm or in supraclavicular fossa  pN3a > 60 mm in dimension  pN3b Extension in the supraclavicular fossa.

Question 10 Which of these statements is true for oral SCC: Perineural invasion does not influence prognosis ECS is an important prognosticator and presence implies an aggressive tumour and poor prognosis pT staging is based purely on size criteria A cohesive pattern of invasion is associated with a poor prognosis

Microscopic ECS

Macroscopic ECS

Macro ECS – nerves and vessels

100

Cum Survival

N+

NO ECS

N+

ECS

0 0

Months from operation

Importance of microscopic ECS 100

Green microscopic ECS

Cum Survival (%)

Red gross ECS

0 0

Months from operation

Which of these statements is true for oral SCC: Perineural invasion does not influence prognosis ECS is an important prognosticator and presence implies an aggressive tumour and poor prognosis pT staging is based purely on size criteria A cohesive pattern of invasion is associated with a poor prognosis

Any Questions or Comments ?