Head and Neck Preetha Chengot
Case 1
• PAROTID TUMOUR FEMALE 26yrs
• Circumscribed tumour • Solid sheets of large polygonal cells, abundant finely granular eosinophilic cytoplasm • Pools of extracellular mucin and colloid-like eosinophilic secretions, macro and microcystic spaces • Papillary areas • Plump polygonal cells, vesicular nuclei • Few mitoses • Scalloping and hobnail-like cell areas
• Mammary analogue secretory carcinoma
• t(12,15) translocation • Same as mesoblastic nephroma and infantile fibrosarcoma • S-100 positive • DD acinic cell ca, mucoepidermoid ca • Low grade • Males as well as females
• Prior to 2010 = acinic cell carcinoma
Case 2
• MALE, 56 YRS, DYSPHAGIA AND LUMP IN PHARYNX
Case 2 • Mucoepidermoid carcinoma • • • •
Low grade Epidermoid, clear and mucous cells Part solid, part cystic Lymphoid stroma
Case 2 • MEC grading – – – – –
Intracystic component <20% Neural invasion Necrosis >4 / 10 hpf Anaplasia
Case 3
• FEMALE, 21 YRS, LUMP IN FLOOR OF MOUTH
Case 3 • Pseudocyst lined by compressed rim of foamy macrophges
• Extravasation mucocele
Case 4 • FEMALE, 48 YRS, DYSPHAGIA, THICKENING OF PHARYNGEAL WALL ON IMAGING
Case 4 • Infiltrative tumour • Large polygonal cells with ++ granular cytoplasm • Eccentric bland nuclei
• Granular cell tumour
Case 5 • CYST ASSOCIATED WITH UNERUPTED LOWER WISDOM TOOTH, FEMALE 16 YRS
Case 5 • Largely uninflamed fibrous capsule • Non-specific squamous epithelial lining • No keratinisation • Location + histology = dentigerous cyst
Common odontogenic cysts / cystic tumours and differential diagnosis • Radicular cyst • Dentigerous cyst • Odontogenic keratocyst (Keratocystic odontogenic tumour WHO 2005) • Ameloblastoma
Case 6 • NASAL POLYP, MALE 28 YRS
Case 6 • Laminated mucin • Degenerate eosinophils • Charcot-Leyden crystals • Allergic fungal sinusitis
Case 7 • BLOCK FROM MAXILLECTOMY SPECIMEN, FEMALE 62 YRS
Case 7 • SCC and Grade I follicular type non Hodgkin B cell lymphoma
bcl-2
Case 8 • 46 YRS MALE, NASAL POLYPS AND DISCHARGE
Case 8 • Epithelial lesion in-keeping with inverted papilloma • Stromal inflammatory lesion – – – –
Granulomata Necrosis Vasculitis Background mixed inflammation including eosinophils
Case 8 • Differential diagnosis – Churg Strauss disease – Wegeners granulomatosis ( Granulomatosis with polyangitis)
Case 8 • • • • •
Wegener’s Polymorphous infiltrate Vasculitis Necrosis Isolated multinucleated giant cells • Poorly formed granulomas • Negative cultures / stains for microbes • C-ANCA
• Churg Strauss • Aka allergic granulomatosis and vasculitis • Multisystem disease also • Blood eosinophilia • Polymorphous infiltrate dominated by eosinophils • Granulomas • Vasculitis • Giant cells in vessel walls • Eosinophilic microabsesses • ANCA levels +/- (does not differentiate)
Case 9 • 38 YRS FEMALE, CYST ASSOCIATED WITH UNERUPTED WISDOM TOOTH
Case 9 • Basal cell palisading • Corrugated parakeratosis
• Focal inflammation – loss of above and “non-specific” features • Odontogenic keratocyst
Case 9 • WHO 2005 Keratocystic odontogenic tumour • Consistent loss of PTCH tumour suppressor gene • Tendency for recurrence
Case 10 • EXCISION OF TUMOUR TONGUE / FLOOR OF MOUTH, 66Y FEMALE
Mucosal melanoma • Diagnosis straightforward
Mucosal melanoma • Oral pigmented patches • Usually – – – –
Melanotic macules Smokers melanosis Amalgam tattoos Naevi rare
Case 11 • NUMBNESS OF FACE (DISTRIBUTION OF INFRAORBITAL NERVE) BIOPSY FROM INFRATEMPORAL FOSSA
Case 11 • Deposition of hyalinised eosinophilic material in stroma • Congo red • +++
Case 11 • Consider type • ? Assoc with plasma cell dyscrasia – Kappa and lambda check plasma cells at edge of lesion • Systemic investigations for AL ? Myeloma • AA / hereditary • IHC
Case 12 • LUMP IN PAROTID, MALE 55 YRS
Case 12 • Acinic cell carcinoma – Lymphoid stroma (also seen in mucoepidermoid)
Case 12 • Cell types – – – – –
Serous acinar Hobnail Vacuolated Non-specific glandular clear
• Architectural patterns – – – –
Solid Papillary cystic Microcystic follicular
Case 12 • High grade transformation a possibility
Case 13 • LUMP IN PAROTID, MALE 69 YRS
Case 13 • Warthin’s tumour • Multifocality and bilaterality sometimes a feature
• Association with smoking
Case 14 • LUMP IN NECK, FEMALE, 42 YRS
Case 14 • • • •
Nests of cells Vascular Large vessels in background Sustentacular cells
• Paraganglioma • “Carotid body tumour”
Case 14 • IHC – positive for neuroendocrine markers – Negative for cytokeratins – S-100 positive for sustentacular cells
Case 14 • 10% familial • Assoc with phaeochromocytoma / MEN
• Cellular pleomorphism not a feature of malignancy • Differential diagnosis includes metastatic medullary ca of thyroid
Case 15 • EPISTAXIS, NUMBNESS OF CHEEK AND PROPTOSIS, 60 YRS MALE
Case 15 • Small blue round cell tumours nasal cavity – – – – – – – – – –
Sinonasal undiff carcinoma (SNUC) Olfactory neuroblastoma Basaloid SCC Neuroendocrine (small cell) Rhabdo ES/PNET Lymphoma Melanoma Small cell osteosarcoma G3 adenoid cystic carcinoma
Case 15 • • • • • •
Cytokeratins (high and low mw) CD56, synaptophysin, chomogranin Melanoma markers CD45 (CD20, CD56, T markers) CD99 Skeletal muscle (desmin, MyoD1)
Case 15 • CK ++ • Everything else -
• SNUC
NUT midline carcinoma • t(15,19) • Poorly differentiated carcinomas of UADT, particularly sinonasal region • Genetically defined disease and therefore does not arise from one organ • Very poor prognosis – virtually all patients die of disease and usually within 1 year • Monomorphic clonal appearance +/- keratinisation
Case 16 • EPISTAXIS, BIOPSY OF MASS, UPPER PART OF NASAL CAVITY, MALE 16 YRS
CASE 16 • • • •
Nasopharyngeal angiofibroma Only seen in males, almost all <25 Posteriolateral nasal cavity Hormonally driven – androgen receptor positive • FAP association
Case 17 • LARGE CYSTIC LESION POSTERIOR MANDIBLE, FEMALE 71 YRS
Case 17 • Ameloblastoma
Case 18 • PALATAL SWELLING, FEMALE 28 YRS
PLGA vs ACC In common • Tubular and cribriform architecture • Perineural invasion • Infiltrative growth • Lack of cytological atypia • Mucoid / hyaline stroma
Distinct features • Additional architectural patterns (PLGA) • Single cell population (PLGA) vs dual population (ACC) • Nuclei: pale, round,vesicular (PLGA); angular, hyperchromatic (ACC)
Back to back ducts / tubules form cribriform areas
Indian filing, hyaline stroma, pale, washed out nuclei
Targetoid perineural invasion
Nuclear features and cytological uniformity, mucoid stroma
Case 19 • MALE, WOODWORKER, 56Y, NASAL MASS, OBSTRUCTION AND BLEEDING
• CK7 focally positive • CK20 and CDX-2 strongly and diffusely positive • Intestinal type adenocarcinoma
ITAC • Hardwood dust, leather, nickel exposure • Well diff can resemble normal colonic mucosa • Infrequent lymph node metastasis • 5 year survival poor and correlates with grade
Case 20 • NASAL TUMOUR, MALE 34 YRS
Case 20 • Focal keratinisation • Small area of conventional SCC • Dysplasia • Basaloid SCC • ? NUT midline ca
Case 21 • CYST FROM APEX OF NON VITAL INCISOR TOOTH
Case 21 • Radicular cyst • Inflammation • Location • Epithelium
Case 22 • LYMPH NODE POST AURICULAR AREA, FEMALE 19 YRS
Case 22 • Triad – Follicular hyperplasia – Peri or intra follicular non-caseating granulomata – Seams of monocytoid B cells
Case 22 • Toxoplasmosis lymphadenitis
Case 23 • LYMPH NODE FROM NECK, 22 YRS FEMALE
Case 23 • Necrotising lymphadenitis • Karyorrhectic debris • Absence of neutrophils • Large blasts and histocytes at edge of necrotic areas
Case 23 • Kikuchi’s lymphadentitis
Case 24 • PAROTID SWELLING, MALE 55 YRS
Case 24 • Pleomorphic adenoma with ossification and atypia
• In situ carcinoma ex pleomorphic adenoma
Case 25 • PAROTID SWELLING, MALE 79 YRS
CD5
CD23
Cyclin D1
IHC • CD5, bcl-2, CD79a, CD23 positive • CD3, CD10 and cyclin D1 negative
Case 25 • Warthin’s tumour and small lymphocytic lymphoma ( CLL)
Case 26 • LUMP ON GUM, FEMALE 46 YRS
Case 26 • Peripheral ameloblastoma • Diff diagnosis – BCC – Minor salivary gland tumour
Case 27 • SUBMANDIBULAR SWELLING PRESENT FOR SOME TIME, SUDDENLY ENLARGED, MALE 49 YRS
Case 27 • Carcinoma ex pleomorphic adenoma • Carcinoma often – High grade – Adenoca NOS – Can be any type of malignant sal gland tumour – hybrid
Case 28 • WHITE PATCH BUCCAL MUCOSA, SMOKER, MALE 39 YRS
Case 28 • “Interface” inflammatory pattern • Lichenoid mucositis – lichen planus or lichenoid reaction
• Drugs / dental materials esp amalgam
Case 29 • WHITE PATCH BUCCAL MUCOSA, SMOKER, MALE 57 YRS
Case 29 • Chronic hyperplastic candidosis • Test tube shaped / psoriasiform epithelial hyperplasia • Neutrophilic subcorneal microabscesses
Case 30 • 45 M, PREVIOUS MULTIPLE EXCISIONS OF NASAL TUMOUR, FURTHER RESECTION
Case 30 • Features of benign inverted papilloma predominantly • Small areas showing malignant transformation into SCC • Transformation rates 7% with increasing risk with recurrences