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


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


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)


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).


SNUC: imaging-histopathology correlation

NK/T cell lymphoma - hypercellular infiltrate composed of poorly differentiated epithelial cells (Hematoxylin & Eosin 40x)


Sinonasal undifferentiated carcinoma (SNUC)DWI/ADC Signal intensity Enhancement

Pattern PET


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)


Plasmablastic lymphomaDWI/ADC Signal intensity Enhancement

Pattern PET


Intermediate on T1 & T2 WI


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)


RhabdomyosarcomaDWI/ADC Signal

intensity Enhanceme

ntPattern

PET


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)


Squamous cell carcinomaDWI/ADC Signal

intensityEnhanceme

ntPattern

PET


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


Intermediate


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)


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.


Signal intensity Enhancement

Pattern

PET

Imaging May have areas of T1 shortening; may have low signal on T2 from paramagnetic effects of blood products


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.

aggressive sinonasal malignancies eede#: eede-132 e supsupin 1, i alava 2, s billah 3, e bonfante 1,...

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