Aggressive Sinonasal Malignancies eEDE#: eEDE-132 E Supsupin 1, I Alava 2, S Billah 3, E Bonfante 1,...
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Transcript of Aggressive Sinonasal Malignancies eEDE#: eEDE-132 E Supsupin 1, I Alava 2, S Billah 3, E Bonfante 1,...
Aggressive Sinonasal MalignancieseEDE#: eEDE-132
E Supsupin1, I Alava2, S Billah3,
E Bonfante1, Y Weinstock2, S Mukhi4
Institutions:
1 University of Texas Houston Department of Diagnostic & Interventional Imaging, Houston, TX,
2 University of Texas Houston Department of Otorhinolaryngology, Head & Neck Surgery, Houston, TX,
3 University of Texas Houston Department of Pathology, Houston, TX,
4 Michael E. DeBakey VA Medical Center, Houston, TX
Disclosures
None
Introduction Aggressive sinonasal malignancies (ASNM) are
heterogeneous.
Objectives: Correlate imaging features with histopathology Provide an overview of clinical profile and prevailing treatment paradigm
Introduction Aggressive sinonasal malignancies (ASNM) are
heterogeneous.
Objectives: Correlate imaging features with histopathology Provide an overview of prevailing treatment paradigm
Aggressive sinonasal malignancies (ASNM)
Natural killer T-cell lymphomaPlasmablastic lymphoma Sinonasal undifferentiated carcinomaRhabdomyosarcomaOlfactory neuroblastoma (Esthesioneuroblastoma)Sinonasal melanomaSquamous cell carcinoma
23 year-old, healthy man with 1 month of right nasal congestion, pressure, and pain. This was associated with right purulent, nasal discharge and fevers over 1 week.
On his exam he was febrile and his right nasal cavity was occluded with purulent nasal debris and mucosa edema. No neurosensory deficits are noted. Biopsies taken on presentation, started on empiric antibiotics. One week later, further worsening of symptoms including V2 numbness and right palatal cellulitis (circle).
Taken to OR urgently for debridement and biopsies. Biopsies determined to be NK T-Cell Lymphoma.
Natural killer/T-cell lymphoma
Natural killer/T-cell lymphoma
Nasal mass (yellow brackets) on T2 weighted MR (A). Note heterogeneous enhancement on T1 post contrast MRI (C). B – Noncontrast T1 MRI
A B C
Natural killer/T-cell lymphoma
Diffusion restriction (A & B) with increased FDG uptake on PET (C)
BA B C
NK/T cell lymphoma - hypercellular infiltrate composed of NK cells & T-cells with scattered apoptotic debris (black arrow) and a mitotic figure (red arrow) (Hematoxylin & Eosin 60x)
Diffusion restriction correlating with hypercellular infiltrate; also with avid FDG uptake on PET
NK/T-cell lymphoma: imaging-histopathology correlation
Natural killer T-cell lymphomaDWI/ADC Signal intensity Enhancement
Pattern PET
Imaging (+) Diffusion restriction
Intermediate on T1 & T2 WI
Enhancing Avid FDG uptake
Pathology Malignant NK-cells & T- lymphocytes Hypercellularity Mitotic activity Necrosis Angioinvasion
Management Chemo-radiation
Sinonasal undifferentiated carcinoma (SNUC)
61-year-old man with 3 months of progressive right nasal congestion, facial pain, facial pressure and headache, associated with right sided neck swelling. He had no fevers. He presented to the Otolaryngology-Head and Neck Surgery clinic with 1 day of sudden right orbital swelling and ptosis. On examination, he had right periorbital ecchymosis, ptosis, and limited upward gaze. He had no neurosensory deficits. Endoscopy revealed extensive necrotic mass within the nasal cavity into the nasopharynx. Biopsies taken on day of consult proved to be SNUC.
Diffusion restriction (A & B) with increased FDG uptake on PET (C)
Sinonasal undifferentiated carcinoma (SNUC)
A B C
Right naso-ethmoidal mass with orbital invasion. Note heterogeneous enhancement and dural enhancement (arrow). The mass has intermediate to high signal on T2-weighted imaging (circle).
Sinonasal undifferentiated carcinoma (SNUC)
SNUC: imaging-histopathology correlation
NK/T cell lymphoma - hypercellular infiltrate composed of poorly differentiated epithelial cells (Hematoxylin & Eosin 40x)
Diffusion restriction correlating with hypercellular infiltrate; also with avid FDG uptake on PET
Sinonasal undifferentiated carcinoma (SNUC)DWI/ADC Signal intensity Enhancement
Pattern PET
Imaging (+) Diffusion restriction
Intermediate on T1 and intermediate to high on T2
Heterogeneous Avid FDG uptake
Pathology Poorly differentiated epithelial cells Hypercellularity Mitotic activity Necrosis
Management Multimodality (surgery, chemotherapy, radiation)
47 year-old man presented with epistaxis from the left nasal cavity for 2 days. ER treated epistaxis with packing; however within 12 hours the left check and periorbital region began to swell and have tenderness. The patient was taken to OR for biopsy. More workup was conducted and he was also found to have HIV. Pathology was plasmablastic lymphoma.
Plasmablasstic lymphoma
Erosive mass in the left maxillary sinusextending into left nasal cavity. This also extends into the orbit (not shown).
Large sinonasal mass with diffusion restriction (A & B) with increased FDG uptake on PET (C)
Plasmablastic lymphoma
A B C
Large sinonasal mass with orbital invasion (arrow) and extension into the masticator space. The mass is avidly enhancing (circle). Intermediate signal on T2-weighted imaging
Plasmablastic lymphoma
Plasmablastic lymphoma: imaging-histopathology correlation
Plasmablastic lymphoma - hypercellular infiltrate composed of intermediate to large sized atypical lymphocytes with plasmablastic morphology, scattered apoptotic debris (red arrows), & a mitotic figure (black arrow) (Hematoxylin & Eosin 60x)
Diffusion restriction correlating with hypercellular infiltrate; also with avid FDG uptake on PET
Plasmablastic lymphomaDWI/ADC Signal intensity Enhancement
Pattern PET
Imaging (+) Diffusion restriction
Intermediate on T1 & T2 WI
Enhancing Avid FDG uptake
Pathology Intermediate to large sized atypical B-lymphocytes Hypercellularity Mitotic activity Necrosis
Management Chemo-radiation
17 year-old healthy man with 3 weeks of rapid left nasal obstruction, orbital edema followed by severe proptosis and diplopia. Exam was positive for severe left sided proptosis, cheek swelling, and inability to close eyelid. No neurosensory deficits. Endoscopy was positive for mass pushing out from orbit and maxillary sinus into nasal cavity. Taken to OR for decompression and biopsies. Final pathology is rhabdomyosarcoma.
Rhabdomyosarcoma
Rhabdomyosarcoma
Invasion of the orbit and marked orbital proptosis: clinical – imaging correlation
Large sinonasal mass with diffusion restriction (A & B) with increased FDG uptake on PET (C)
Rhabdomyosarcoma
A B C
Large sinonasal mass with orbital invasion (arrow) and extension into the masticator space. The mass is avidly but heterogeneously enhancing. Note skull base extension and dural enhancement (arrow). Intermediate signal on T2-weighted imaging (circle)
Rhabdomyosarcoma
Rhabdomyosarcoma: imaging-histopathology correlation
Alveolar rhabdomyosarcoma, solid variant: hypercellular infiltrate composed of rhabdomyoblasts with a mitotic figure (arrow) (Hematoxylin & Eosin 60x)
Diffusion restriction correlating with hypercellular infiltrate; also with avid FDG uptake on PET
RhabdomyosarcomaDWI/ADC Signal
intensity Enhanceme
ntPattern
PET
Imaging (+) Diffusion restriction
High signal on T2
Strongly enhancing
Avid FDG uptake
Pathology Rhabdomyoblasts in solid & alveolar patterns Hypercellularity Mitotic activity Necrosis
Management
Multimodality (chemotherapy, radiation, surgery)
Large, expansile nasal mass with diffusion restriction (A & B) with avid FDG uptake on PET (C)
Squamous cell carcinoma
A B C
Large, expansile nasal mass extending into and obliterating the nasopharynx. The mass is avidly but heterogeneously enhancing (bracket). Intermediate signal on T2-weighted imaging with areas of hyperintensity(arrows)
Squamous cell carcinoma
Squamous cell carcinoma: imaging-histopathology correlation
Squamous cell carcinoma: hypercellular infiltrate composed of poorly differentiated squamous cells. A mitotic figure is shown in the center (arrow) (Hematoxylin & Eosin 60x)
Diffusion restriction correlating with hypercellular infiltrate; also with avid FDG uptake on PET
Squamous cell carcinomaDWI/ADC Signal
intensityEnhanceme
ntPattern
PET
Imaging (+) Diffusion restriction
Intermediate to slightly high on T2
Slight hetero-geneous
Avid FDG uptake
Pathology Poorly differentiated squamous cells Hypercellularity Mitotic activity Necrosis
Management
Surgical, followed radiation therapy
Olfactory neuroblastoma with skull base and intracranial invasion
Photomicrograph showing tumor cells with vesicularnucleus with nucleoli & moderate amount of cytoplasm(H&E X 400)
Olfactory neuroblastoma: imaging-histopathology correlation
Histopath image from: Vidya MN, Shivakumar S, Biswas S, Vijay Shankar S. Olfactory Neuroblastoma: Diagnostic Difficulty. Online J HealthAllied Scs. 2010;9(4):18URL: http://www.ojhas.org/issue36/2010-4-18.htm
Mildly restricted diffusion (bracket) and increased FDG uptake on PET (circle)
Olfactory neuroblastoma(Esthesioneuroblastoma)
DWI/ADC Signal intensity on
T2 WI
Enhancement
Pattern
PET
Imaging (+) Diffusion restriction
Intermediate
Enhancing Avid FDG uptake
Pathology Intermediate sized tumor cells with neuroendocrine differentiation
Homer-Write rosettes Hypercellularity Mitotic activity Necrosis
Management
En-bloc resection, postoperative radiation; multimodality in advanced stages
Sinonasal malignant melanoma
Increased FDG uptake on PET (red circle) and areas of T1 shortening (melanocytic) [arrows]; the lesion is enhancing (blue circle)
Sinonasal malignant melanoma
Histologically, the tumor is composed of solid sheets of neoplastic cells with extensive necrosis.
Case from: http://moon.ouhsc.edu/kfung/JTY1/Com07/Com704-1-Diss.htm
A 59 year-old man with a maxillary mass.Lichao Zhao, M.D., Ph.D., Cheng Z. Liu, M.D., Ph.D., Kar-Ming Fung, M.D., Ph.D. Department of Pathology, University of Oklahoma, Oklahoma City, OK.
Sinonasal malignant melanoma
Signal intensity Enhancement
Pattern
PET
Imaging May have areas of T1 shortening; may have low signal on T2 from paramagnetic effects of blood products
Enhancing Avid FDG uptake
Pathology Hypercellular infiltrate of melanocytes Mitotic activity Necrosis Bone invasion
Management
Radical surgery with palliative radiation
Summary Examples of aggressive sinonasal malignancies
(ASNM) are illustrated.
Imaging-histopathologic correlation and overview of prevailing treatment paradigm are provided.