Difference between revisions of "An introduction to head and neck pathology"

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'''Head and neck pathology''' is squamous cell carcinoma and weird stuff.  The [[thyroid]] is dealt with in its own article, as is pathology of the [[salivary gland]].
This article is '''an introduction to head and neck pathology'''. Most of head and neck pathology is squamous cell carcinoma and its variants.   
 
The [[thyroid gland]] is dealt with in its own article, as is pathology of the [[salivary gland]].


Cytopathology of the head and neck is dealt with in a separate article called ''[[head and neck cytopathology]]''.
Cytopathology of the head and neck is dealt with in a separate article called ''[[head and neck cytopathology]]''.
=Anatomy=
[[Image:Blausen_0872_UpperRespiratorySystem.png|thumb|Head and neck anatomy (BruceBlaus/WC).]]
*Oropharynx - includes: tonsil, tonsillar pillar, base of tongue, soft palate.<ref>URL: [https://www.cancer.org/cancer/oral-cavity-and-oropharyngeal-cancer/about/what-is-oral-cavity-cancer.html https://www.cancer.org/cancer/oral-cavity-and-oropharyngeal-cancer/about/what-is-oral-cavity-cancer.html]. Accessed on: 1 April 2021.</ref><ref>URL: [http://www.headandneckcancerguide.org/teens/cancer-basics/explore-cancer-types/throat-cancer/oropharyngeal-cancer/soft-palate-cancer/ http://www.headandneckcancerguide.org/teens/cancer-basics/explore-cancer-types/throat-cancer/oropharyngeal-cancer/soft-palate-cancer/]. Accessed on: 15 November 2016.</ref>
*Oral cavity - includes floor of mouth, bucca, anterior 2/3 of tongue,<ref>URL: [http://www.headandneckcancerguide.org/teens/cancer-basics/explore-cancer-types/oral-cancers/tongue-cancer/ http://www.headandneckcancerguide.org/teens/cancer-basics/explore-cancer-types/oral-cancers/tongue-cancer/]. Accessed on: 15 November 2016.</ref> lips, [[hard palate]], upper & lower alveolar ridge, retromolar trigone.<ref>URL: [http://www.headandneckcancerguide.org/teens/cancer-basics/explore-cancer-types/oral-cancers/oromandibular-cancer/ http://www.headandneckcancerguide.org/teens/cancer-basics/explore-cancer-types/oral-cancers/oromandibular-cancer/]. Accessed on: 15 November 2016.</ref>
*Laryngopharynx.
*Nasopharynx.


=Clinical=
=Clinical=
Common lesions:<ref name=Ref_PBoD780>{{Ref PBoD|780}}</ref>
Common lesions:<ref name=Ref_PBoD780>{{Ref PBoD|780}}</ref>
*Leukoplakia.
*[[Leukoplakia]].
**Homogeneous.
**Homogeneous.
**Non-homogeneous.
**Non-homogeneous.
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==Leukoplakia==
==Leukoplakia==
:''[[Hairy leukoplakia]] is dealt with in a separate section''
:''[[Hairy leukoplakia]] is dealt with in a separate section''.
 
:''The typical [[benign leukoplakia]] is dealt with in a separate section''.
===General===
{{Main|Leukoplakia}}
*Non-specific clinical finding - may be benign ''or'' malignant.
*Associated with tobacco use.<ref name=pmid11336117>{{Cite journal  | last1 = Bánóczy | first1 = J. | last2 = Gintner | first2 = Z. | last3 = Dombi | first3 = C. | title = Tobacco use and oral leukoplakia. | journal = J Dent Educ | volume = 65 | issue = 4 | pages = 322-7 | month = Apr | year = 2001 | doi =  | PMID = 11336117 }}</ref>
 
Risk of malignancy:
*In twos series ~13% were associated with an invasive lesion.<ref name=pmid19953947>{{Cite journal  | last1 = Lan | first1 = AX. | last2 = Guan | first2 = XB. | last3 = Sun | first3 = Z. | title = [Analysis of risk factors for carcinogenesis of oral leukoplakia]. | journal = Zhonghua Kou Qiang Yi Xue Za Zhi | volume = 44 | issue = 6 | pages = 327-31 | month = Jun | year = 2009 | doi =  | PMID = 19953947 }}</ref><ref name=pmid16545712>{{Cite journal  | last1 = Lee | first1 = JJ. | last2 = Hung | first2 = HC. | last3 = Cheng | first3 = SJ. | last4 = Chen | first4 = YJ. | last5 = Chiang | first5 = CP. | last6 = Liu | first6 = BY. | last7 = Jeng | first7 = JH. | last8 = Chang | first8 = HH. | last9 = Kuo | first9 = YS. | title = Carcinoma and dysplasia in oral leukoplakias in Taiwan: prevalence and risk factors. | journal = Oral Surg Oral Med Oral Pathol Oral Radiol Endod | volume = 101 | issue = 4 | pages = 472-80 | month = Apr | year = 2006 | doi = 10.1016/j.tripleo.2005.07.024 | PMID = 16545712 }}</ref>
*Non-homogenous leukoplakia has a greater risk of malignancy than homogenous.<ref name=pmid16545712/>
*Location matters - floor of mouth and ventral tongue lesions higher risk for malignancy.<ref name=pmid7548621>{{Cite journal  | last1 = Sciubba | first1 = JJ. | title = Oral leukoplakia. | journal = Crit Rev Oral Biol Med | volume = 6 | issue = 2 | pages = 147-60 | month =  | year = 1995 | doi =  | PMID = 7548621 | URL = http://cro.sagepub.com/content/6/2/147.long }}</ref>
 
===Gross===
*White lesion - may be subdivided:
**Non-homogenous.
**Homogenous.
 
===Microscopic===
Features:<ref name=Ref_PBoD780>{{Ref PBoD|780}}</ref>
*Often associated with epithelial thickening ([[hyperkeratosis]], acanthosis).
 
DDx:
*Food debris.
*[[Oral candidiasis]].
*[[Lichen planus]].
*Benign alveolar ridge keratosis (oral [[lichen simplex chronicus]]).<ref name=pmid18158926>{{Cite journal  | last1 = Natarajan | first1 = E. | last2 = Woo | first2 = SB. | title = Benign alveolar ridge keratosis (oral lichen simplex chronicus): A distinct clinicopathologic entity. | journal = J Am Acad Dermatol | volume = 58 | issue = 1 | pages = 151-7 | month = Jan | year = 2008 | doi = 10.1016/j.jaad.2007.07.011 | PMID = 18158926 }}</ref>
*[[Squamous cell carcinoma of the head and neck]].
*Others - see ''[[Dermatopathology#Leukoplakia]]''.


==Erythroplakia==
==Erythroplakia==
===General===
===General===
*Non-specific clinical finding - may be benign or malignant.
*Non-specific clinical finding - may be benign or [[malignant]].
*Strong association with non-keratinizing squamous lesions (invasive and dysplastic).
*Strong association with non-keratinizing squamous lesions (invasive and dysplastic).


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==Oral==
==Oral==
{{Main|Oral pathology}}
Infectious:
*[[Hairy leukoplakia]].
*[[Oral candidiasis]].
Other:
*[[Pemphigus vulgaris]].
*[[Pemphigus vulgaris]].
Vascular:
*[[Pyogenic granuloma]].
*[[Pyogenic granuloma]].


Infectious:
Pigmentation:
*[[Hairy leukoplakia]].
*Focal:
*[[Oral candidiasis]].
**[[Amalgam tattoo]].
**[[Melanocytic lesions]].
***[[Melanotic macule]].
***[[Blue nevus]].
***[[Malignant melanoma]]
*Diffuse
**[[Peutz-Jeghers syndrome]].
**[[Addison's disease]].


==Nasal cavity/nose==
==Nasal cavity/nose==
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===Cystic lesions - overview===
===Cystic lesions - overview===
Lateral cystic lesions:
Lateral cystic lesions:
*[[Brachial cleft cyst]].
*[[Branchial cleft cyst]].
*[[Cystic hygroma]].
*[[Cystic hygroma]].


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==Thyroglossal duct cyst==
==Thyroglossal duct cyst==
===General===
{{Main|Thyroglossal duct cyst}}
*Congenital.
*Midline.
 
Treatment:
*Surgical excision (with piece of hyoid bone).
 
===Microscopic===
Features:
*Cyst.
**Lining:
***Squamous or respiratory epithelium.
***Cyst contents: debris.
*+/-Thyroid gland.
*+/-Granulomatous inflammation (phagocytosis of debris).
 
Images:
*[http://150.59.224.157/pathology/system/data/image_data/117116921705.jpg TDC (150.59.224.157)].<ref>URL: [http://150.59.224.157/pathology/index.php?now_position=1&first_category_id=2&second_category_id=19 http://150.59.224.157/pathology/index.php?now_position=1&first_category_id=2&second_category_id=19]. Accessed on: 4 February 2011.</ref>
*[http://150.59.224.157/pathology/system/data/image_data/117116931536.jpg TDC - thyroid gland (150.59.224.157)].


==Branchial cleft cyst==
==Branchial cleft cyst==
*[[AKA]] ''branchial cleft remnant''.
*[[AKA]] ''branchial cleft remnant''.
===General===
{{Main|Branchial cleft cyst}}
*Benign congenital thingy in the lateral neck.<ref>URL: [http://www.childrenshospital.org/az/Site663/mainpageS663P0.html http://www.childrenshospital.org/az/Site663/mainpageS663P0.html]. Accessed on: 15 March 2011.</ref>
*Most common cystic neck lesion in young adults.<ref name=pmid19593684>{{Cite journal  | last1 = Pietarinen-Runtti | first1 = P. | last2 = Apajalahti | first2 = S. | last3 = Robinson | first3 = S. | last4 = Passador-Santos | first4 = F. | last5 = Leivo | first5 = I. | last6 = Mäkitie | first6 = AA. | title = Cystic neck lesions: clinical, radiological and differential diagnostic considerations. | journal = Acta Otolaryngol | volume = 130 | issue = 2 | pages = 300-4 | month = Feb | year = 2010 | doi = 10.3109/00016480903127450 | PMID = 19593684 }}</ref>
*Treatment: excision.
 
===Gross===
*Lateral neck mass.
 
Image - clinical:
*[http://medical-dictionary.thefreedictionary.com/_/viewer.aspx?path=mosby&name=500051-fx23.jpg Branchial cleft cyst (thefreedictionary.com)].
 
===Microscopic===
Features:
*Cystic space lined by squamous epithelium - usually.
**+/-Inflammation.
*Connective tissue:
**+/-Adipose tissue.
**+/-Cartilage.
**+/-Bone.
**+/-Muscle.
 
DDx:
*Cystic [[squamous cell carcinoma]] - may be deceptively benign appearing.<ref name=pmid19593684>{{Cite journal  | last1 = Pietarinen-Runtti | first1 = P. | last2 = Apajalahti | first2 = S. | last3 = Robinson | first3 = S. | last4 = Passador-Santos | first4 = F. | last5 = Leivo | first5 = I. | last6 = Mäkitie | first6 = AA. | title = Cystic neck lesions: clinical, radiological and differential diagnostic considerations. | journal = Acta Otolaryngol | volume = 130 | issue = 2 | pages = 300-4 | month = Feb | year = 2010 | doi = 10.3109/00016480903127450 | PMID = 19593684 }}</ref>
 
Image:
*[http://www.pathology.med.ohio-state.edu/residents/InternalGate/Area51/ResidentSlideCollection/images%2FB403.jpg Branchial cleft cyst (med.ohio-state.edu)].<ref>URL: [http://www.pathology.med.ohio-state.edu/residents/InternalGate/Area51/ResidentSlideCollection/RSLdx.asp http://www.pathology.med.ohio-state.edu/residents/InternalGate/Area51/ResidentSlideCollection/RSLdx.asp]. Accessed on: 15 March 2011.</ref>
 
===IHC===
*p16 -ve.
**May be done to exclude a [[HPV-associated head and neck squamous cell carcinoma]].
*Ki-67 low.


==Benign lymphoepithelial lesion==
==Benign lymphoepithelial lesion==
*[[AKA]] ''benign lymphoepithelial cyst''
*[[AKA]] ''benign lymphoepithelial cyst''
 
{{Main|Benign lymphoepithelial lesion}}
===General===
*Usually parotid gland.
*Associated with autoimmune disease, e.g. [[Sjoegren disease]], may not remain benign.<ref name=pmid12058269>{{Cite journal  | last1 = Goto | first1 = TK. | last2 = Shimizu | first2 = M. | last3 = Kobayashi | first3 = I. | last4 = Chikui | first4 = T. | last5 = Kanda | first5 = S. | last6 = Toshitani | first6 = K. | last7 = Shiratsuchi | first7 = Y. | last8 = Yoshida | first8 = K. | title = Lymphoepithelial lesion of the parotid gland. | journal = Dentomaxillofac Radiol | volume = 31 | issue = 3 | pages = 198-203 | month = May | year = 2002 | doi = 10.1038/sj/dmfr/4600690 | PMID = 12058269 }}</ref>
 
===Microscopic===
Features:
*Lymphocytes.
*Ductal epithelial cells.<ref name=pmid12761623>{{Cite journal  | last1 = Metwaly | first1 = H. | last2 = Cheng | first2 = J. | last3 = Ida-Yonemochi | first3 = H. | last4 = Ohshiro | first4 = K. | last5 = Jen | first5 = KY. | last6 = Liu | first6 = AR. | last7 = Saku | first7 = T. | title = Vascular endothelial cell participation in formation of lymphoepithelial lesions (epi-myoepithelial islands) in lymphoepithelial sialadenitis (benign lymphoepithelial lesion). | journal = Virchows Arch | volume = 443 | issue = 1 | pages = 17-27 | month = Jul | year = 2003 | doi = 10.1007/s00428-003-0824-0 | PMID = 12761623 }}</ref>
 
Note:
*'''Must''' rule-out (MALT) [[MALT lymphoma|lymphoma]].
 
===IHC===
*CD20, CD3 -- mixed population.
*Kappa ~ lambda.


=Other benign=
=Other benign=
==Vocal cord nodule==
==Vocal cord nodule==
===General===
*Benign.
*[[AKA]] ''singer's nodule''.
*[[AKA]] ''singer's nodule''.
*Etiology: overuse, mechanical trauma (?).
*[[AKA]] ''vocal cord polyp''.
 
{{Main|Vocal cord nodule}}
===Microscopic===
Features:<ref>URL: [http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675%2806%2970310-2 http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675%2806%2970310-2]. Accessed on: 4 February 2011.</ref>
*Early:
*#Edema.
*#Fibroblasts proliferation.
*Late:
*#Subepithelial hyaline / stromal hyaline.
*#Blood vessels - dilated.
 
Notes:
*No inflammation.
 
DDx:<ref>{{Ref HaNP|9}}</ref>
*[[Amyloidosis]].
*[[Granular cell tumour]].
*Spindle cell [[squamous cell carcinoma of the head and neck|squamous cell carcinoma]].
*Myxoma.
*Ductal-type cyst.
 
Images:
*[http://commons.wikimedia.org/wiki/File:Laryngeal_nodule_(1).jpg?uselang=en Laryngeal nodule - low mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Laryngeal_nodule_(2).jpg?uselang=en Laryngeal nodule (WC)].
 
===Sign out===
<pre>
VOCAL CORD LESION, EXCISION:
- STRATIFIED SQUAMOUS EPITHELIUM WITH PARAKERATOSIS AND SUBEPITHELIAL
  HYALINE MATERIAL, CONSISTENT WITH WITH VOCAL CORD NODULE OR POLYP.
- NEGATIVE FOR MALIGNANCY.
</pre>


==Squamous papilloma==
==Squamous papilloma==
:''Laryngeal papilloma'' redirects here.
:Caruncle lesion is dealt with in ''[[papilloma of the caruncle]]''.
===General===
:The lesion in the [[esophagus]] is dealt with in ''[[squamous papilloma of the esophagus]]''.
*Benign.
{{Main|Squamous papilloma}}
*Typically related to [[HPV]] 6 and HPV 11.
 
===Gross===
Features:<ref name=Ref_HaNP33>{{Ref HaNP|33}}</ref>
*Exophytic mass.
 
===Microscopic===
Features:<ref name=Ref_HaNP33>{{Ref HaNP|33}}</ref>
*Branching papillae.
**Papilla = nipple-like projection with a fibrovascular core.
*Basal cell hyperplasia.
*Koilocytes.
 
Note:
*The threshold for dysplasia is somewhat higher in the [[head and neck pathology|head and neck]] than in the [[uterine cervix]].
 
DDx:
*[[Squamous cell carcinoma of the head and neck]] - verrucous, papillary and exophytic subtypes.
*[[Verruca vulgaris]] - have granular layer, hyperkeratosis and parakeratosis.<ref name=Ref_HaNP246>{{Ref HaNP|426}}</ref>
*[[Oral condyloma]] - broader projections with a blunted appearance.<ref name=Ref_HaNP246>{{Ref HaNP|426}}</ref>
 
Images:
*[http://www.webpathology.com/image.asp?case=170&n=1 Laryngeal papilloma - low mag. (webpathology.com)].
*[http://www.webpathology.com/image.asp?case=170&n=2 Laryngeal papilloma - high mag. (webpathology.com)].
*[http://ars.els-cdn.com/content/image/1-s2.0-S1875918111001450-gr2a.jpg Low-grade squamous dysplasia (els-cdn.com)].<ref name=pmid10502732>{{Cite journal  | last1 = Hedström | first1 = J. | last2 = Grenman | first2 = R. | last3 = Ramsay | first3 = H. | last4 = Finne | first4 = P. | last5 = Lundin | first5 = J. | last6 = Haglund | first6 = C. | last7 = Alfthan | first7 = H. | last8 = Stenman | first8 = UH. | title = Concentration of free hCGbeta subunit in serum as a prognostic marker for squamous-cell carcinoma of the oral cavity and oropharynx. | journal = Int J Cancer | volume = 84 | issue = 5 | pages = 525-8 | month = Oct | year = 1999 | doi =  | PMID = 10502732 | URL = http://www.sciencedirect.com/science/article/pii/S1875918111001450 }}</ref>
 
===Sign out===
<pre>
LARYNGEAL LESION ("LARYNGEAL PAPILLOMA"), RIGHT, BIOPSY:
- SQUAMOUS PAPILLOMA.
</pre>
 
====Not definite====
<pre>
TONGUE PAPULE, RIGHT, BIOPSY:
- SQUAMOUS EPITHELIUM WITH PARAKERATOSIS AND VERY SCANT STROMA WITH FEATURES
SUGGESTIVE OF A SQUAMOUS PAPILLOMA.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
</pre>
 
====Dysplastic====
<pre>
LARYNGEAL LESION ("LARYNGEAL PAPILLOMA"), LEFT, BIOPSY:
- SQUAMOUS PAPILLOMA WITH LOW-GRADE DYSPLASIA.
- NEGATIVE FOR HIGH-GRADE DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
- CLOSE FOLLOW-UP IS RECOMMENDED.
</pre>
 
====Micro====
The sections show fibrovascular cores covered by stratified squamous epithelium with basal cell hyperplasia and edema.  Scattered lymphocytes are present in the epithelium.  No mitotic activity is appreciated.  There is no significant nuclear atypia.
Dyskeratotic cells are seen focally. Parakeratosis is present. Koilocytes are not apparent.
 
====Low-grade dysplasia====
The sections show fibrovascular cores covered by stratified squamous epithelium.  Scattered lymphocytes are present in the epithelium.  Rare mitotic activity is appreciated in the lower third of the epithelium.  Mild nuclear atypia (hyperchromasia and mild nuclear enlargement in the lower third of the epithelium) is present.
Dyskeratotic cells are seen focally. Parakeratosis is present. Koilocytes are seen focally.


==Pemphigus vulgaris==
==Pemphigus vulgaris==
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*[[AKA]] ''pemphigus''.
*[[AKA]] ''pemphigus''.
**Should not be confused with ''[[bullous pemphigoid]]'' (which is less serious).
**Should not be confused with ''[[bullous pemphigoid]]'' (which is less serious).
===General===
*May lead to blindness.
*Oral lesion is classically: ''first to show & last to go''.
**Oral lesions usually precede the skin lesions.
Etiology:
*Autoimmune disease.
**Antibodies against: desmoglein 1, desmoglein 3.
===Microscopic===
Features:<ref>{{Ref PBoD8|1193}}</ref>
*Suprabasilar blistering.
DDx: [[Hailey-Hailey disease]].


==Pyogenic granuloma==
==Pyogenic granuloma==
*[[AKA]] ''lobular capillary hemangioma''.<ref name=pmid21839350>{{Cite journal  | last1 = Baglin | first1 = AC. | title = [Vascular tumors and pseudotumors. Pyogenic granuloma (lobular capillary hemangioma)]. | journal = Ann Pathol | volume = 31 | issue = 4 | pages = 266-70 | month = Aug | year = 2011 | doi = 10.1016/j.annpat.2011.05.014 | PMID = 21839350 }}</ref>
*[[AKA]] ''lobular capillary hemangioma''.<ref name=pmid21839350>{{Cite journal  | last1 = Baglin | first1 = AC. | title = [Vascular tumors and pseudotumors. Pyogenic granuloma (lobular capillary hemangioma)]. | journal = Ann Pathol | volume = 31 | issue = 4 | pages = 266-70 | month = Aug | year = 2011 | doi = 10.1016/j.annpat.2011.05.014 | PMID = 21839350 }}</ref>
===General===
{{Main|Lobular capillary hemangioma}}
*Sometimes ''pregnancy tumour''.
*Seen in children, young adults, pregnant women.
 
Clinical:
*May grow quickly - clinically suspicious for a malignancy.
 
Notes:
*[[no truth in names|Name of entity is a misnomer]]:
**Not pyogenic, i.e. infectious.
**Not [[granuloma|granulomatous]].
*The WMSP advocates the name ''lobular capillary hemangioma''.<ref name=Ref_WMSP12>{{Ref WMSP|12}}</ref>
 
===Gross===
Features:<ref name=Ref_PBoD776>{{Ref PBoD|776}}</ref>
*Erythematous.
*Hemorrhagic.
 
Usually location:<ref name=Ref_WMSP12>{{Ref WMSP|12}}</ref>
*Lips.
*[[Tongue]].
*Gingiva.
 
===Microscopic===
Features:<ref name=Ref_PBoD775>{{Ref PBoD|775}}</ref>
*Polypoid ''or'' peduculated.
*Vascular, i.e. many blood vessels, with plump endothelium.
*Usu. thinned epithelium<ref>URL: [http://basicpathology-histopathology.blogspot.com/2009/10/head-and-neck-oral-cavity-reactive_3282.html http://basicpathology-histopathology.blogspot.com/2009/10/head-and-neck-oral-cavity-reactive_3282.html]. Accessed on: 2 February 2011.</ref> or ulcerated.<ref name=Ref_WMSP12>{{Ref WMSP|12}}</ref>
*Lobular arrangement of vascular (seen at low power).<ref>S. Sade. 8 September 2011.</ref>
 
DDx:
*[[Capillary hemangioma]].
*[[Myopericytoma]] (???).
*[[Bacillary angiomatosis]].<ref name=pmid16310070>{{Cite journal  | last1 = Levy | first1 = I. | last2 = Rolain | first2 = JM. | last3 = Lepidi | first3 = H. | last4 = Raoult | first4 = D. | last5 = Feinmesser | first5 = M. | last6 = Lapidoth | first6 = M. | last7 = Ben-Amitai | first7 = D. | title = Is pyogenic granuloma associated with Bartonella infection? | journal = J Am Acad Dermatol | volume = 53 | issue = 6 | pages = 1065-6 | month = Dec | year = 2005 | doi = 10.1016/j.jaad.2005.08.046 | PMID = 16310070 }}</ref>
 
Why it is not...
*[[Glomus tumour]] - cookie cutter arrangement of cells.
 
====Image====
<gallery>
Image:SkinTumors-PB061062.JPG | Pyogenic granuloma. (WC)
</gallery>
www:
*[http://www.sciencephoto.com/images/download_lo_res.html?id=670066054 Pyogenic granuloma (sciencephoto.com)].
 
===IHC===
Features - positive for vascular markers:<ref name=Ref_WMSP12>{{Ref WMSP|12}}</ref>
*CD34 +ve.
*CD31 +ve.
*Factor VIII +ve.
 
===Sign out===
<pre>
TONGUE, LEFT LATERAL, BIOPSY:
- LOBULAR CAPILLARY HEMANGIOMA (PYOGENIC GRANULOMA).</pre>
 
====Micro====
The sections shows a pendunculated vascular lesion with small capillaries arranged in a lobular fashion. The endothelial cells of the lesion show no atypia.  The overlying acanthotic epidermis has hyperkeratosis and hypergranulosis, and is focally ulcerated and impetiginized. There is no significant keratocyte atypia. No melanocytic nests are seen. The dermis has a mild perivascular lymphoplasmacytic infiltrate. The lesion is excised in the plane of section.


==Plummer-Vinson syndrome==
==Plummer-Vinson syndrome==
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==Rhinoscleroma==
==Rhinoscleroma==
===General===
{{Main|Rhinoscleroma}}
*Caused by ''Klebsiella rhinoscleromatis''.
*Nose involved +95% of the time.<ref name=pmid17359555>{{Cite journal  | last1 = Chan | first1 = TV. | last2 = Spiegel | first2 = JH. | title = Klebsiella rhinoscleromatis of the membranous nasal septum. | journal = J Laryngol Otol | volume = 121 | issue = 10 | pages = 998-1002 | month = Oct | year = 2007 | doi = 10.1017/S0022215107006421 | PMID = 17359555 }}</ref>
 
===Gross===
*Nasal mass - may be deforming.
 
Image:
*[http://commons.wikimedia.org/wiki/File:Wolkowitsch1.jpg Rhinoscleroma (WC)].
 
===Microscopic===
Features:<ref>URL: [http://www.brown.edu/Courses/Digital_Path/systemic_path/hn/rhinoscleroma2.html http://www.brown.edu/Courses/Digital_Path/systemic_path/hn/rhinoscleroma2.html]. Accessed on: 18 January 2012.</ref>
*Macrophages - clear-to-foamy cytoplasm.
*Lymphocytes.
*Plasma cells.
 
DDx:
*[[Rosai-Dorfman disease]].
 
Images:
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Rhinoscleroma_-_intermed_mag.jpg Rhinoscleroma - intermed. mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Rhinoscleroma_-_very_high_mag.jpg Rhinoscleroma - very high mag. (WC)].
*www:
**[http://www.brown.edu/Courses/Digital_Path/systemic_path/hn/rhinoscleroma2.html Rhinoscleroma (brown.edu)].
**[http://www.jameswpattersonmd.com/images/pages/rhinoscleroma_mic324.jpg Rhinoscleroma (jameswpattersonmd.com)].<ref>URL: [http://www.jameswpattersonmd.com/case_studies/index.cfm?CFID=387434 http://www.jameswpattersonmd.com/case_studies/index.cfm?CFID=387434]. Accessed on: 21 February 2012.</ref>
 
===Stains===
*Warthin-Starry stain +ve (rod-shaped organisms).
*[[Dieterle stain]] +ve (rod-shaped organisms).


=Neoplasms=
=Neoplasms=
Line 407: Line 156:


Work-up of negative H&E Bx differs by site:
Work-up of negative H&E Bx differs by site:
*Sunnybrook:<ref>S. Raphael. December 2008.</ref>
*One large hospital:
**[[LMWK]] ([[CAM5.2]]).  
**LMWK (CAM5.2).  
**[[pankeratin]] ([[AE1/AE3]]).
**Pankeratin ([[AE1/AE3]]).
*UHN.
*Another large hospital:
**Nothing.
**Nothing.


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==Human papillomavirus-associated head and neck squamous cell carcinoma==
==Human papillomavirus-associated head and neck squamous cell carcinoma==
*Abbreviated ''HPV-HNSCC''.
*Abbreviated ''HPV-HNSCC''.
===General===
{{Main|Human papillomavirus-associated head and neck squamous cell carcinoma}}
*Tumours associated with high risk HPV, typically [[HPV]] 16.<ref name=pmid22001331 >{{Cite journal  | last1 = Wang | first1 = XI. | last2 = Thomas | first2 = J. | last3 = Zhang | first3 = S. | title = Changing trends in human papillomavirus-associated head and neck squamous cell carcinoma. | journal = Ann Diagn Pathol | volume = 16 | issue = 1 | pages = 7-12 | month = Jan | year = 2012 | doi = 10.1016/j.anndiagpath.2011.07.003 | PMID = 22001331 }}</ref>
**Thought to be different that tumours driven by [[alcohol]] and [[smoking|tobacco]] use.<ref name=pmid21769577>{{Cite journal  | last1 = Wittekindt | first1 = C. | last2 = Wagner | first2 = S. | last3 = Klussmann | first3 = JP. | title = [HPV-associated head and neck cancer. The basics of molecular and translational research]. | journal = HNO | volume = 59 | issue = 9 | pages = 885-92 | month = Sep | year = 2011 | doi = 10.1007/s00106-011-2357-1 | PMID = 21769577 }}</ref>
***Patients tend to be male and slightly younger - risk thought to be due to sexual practices.<ref name=pmid22046680>{{Cite journal  | last1 = Vourexakis | first1 = Z. | last2 = Dulguerov | first2 = P. | title = [HPV associated head and neck cancers]. | journal = Rev Med Suisse | volume = 7 | issue = 311 | pages = 1919-22 | month = Oct | year = 2011 | doi =  | PMID = 22046680 }}</ref>
*Lesions more radiosensitive and usually have a better prognosis.<ref name=pmid22001331/>
 
===Gross===
Classic locations:
*Tonsil and base of tongue<ref name=pmid21752613/> (palatine tonsil, lingual tonsil, oropharynx).
 
Note:
*Memory device:
**Where the tip of the [[penis]] goes when someone is ''deep throating''.
 
===Microscopic===
Features:<ref name=pmid20596971>{{Cite journal  | last1 = Chernock | first1 = RD. | last2 = El-Mofty | first2 = SK. | last3 = Thorstad | first3 = WL. | last4 = Parvin | first4 = CA. | last5 = Lewis | first5 = JS. | title = HPV-related nonkeratinizing squamous cell carcinoma of the oropharynx: utility of microscopic features in predicting patient outcome. | journal = Head Neck Pathol | volume = 3 | issue = 3 | pages = 186-94 | month = Sep | year = 2009 | doi = 10.1007/s12105-009-0126-1 | PMID = 20596971 | PMC = 2811624 | URL = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2811624/?tool=pubmed }}</ref>
*Typically non-keratinizing squamous cell carcinoma.
 
DDx:
*HPV-negative squamous cell carcinoma.
 
Images:
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2811624/figure/Fig1/ HPV NK SCC (nih.gov)].
 
===IHC===
*p16 +ve.<ref name=pmid21752613>{{Cite journal  | last1 = Heath | first1 = S. | last2 = Willis | first2 = V. | last3 = Allan | first3 = K. | last4 = Purdie | first4 = K. | last5 = Harwood | first5 = C. | last6 = Shields | first6 = P. | last7 = Simcock | first7 = R. | last8 = Williams | first8 = T. | last9 = Gilbert | first9 = DC. | title = Clinically significant human papilloma virus in squamous cell carcinoma of the head and neck in UK practice. | journal = Clin Oncol (R Coll Radiol) | volume = 24 | issue = 1 | pages = e18-23 | month = Feb | year = 2012 | doi = 10.1016/j.clon.2011.05.007 | PMID = 21752613 }}</ref>
*EBER -ve.


==Sinonasal undifferentiated carcinoma==
==Sinonasal undifferentiated carcinoma==
*Abbreviated ''SNUC''
*Abbreviated ''SNUC''.
 
{{Main|Sinonasal undifferentiated carcinoma}}
===General===
*Aggressive/poor prognosis.
**In the past, survival was measured in months.<ref name=pmid17170968>{{Cite journal  | last1 = Pitman | first1 = KT. | last2 = Costantino | first2 = PD. | last3 = Lassen | first3 = LF. | title = Sinonasal undifferentiated carcinoma: current trends in treatment. | journal = Skull Base Surg | volume = 5 | issue = 4 | pages = 269-72 | month =  | year = 1995 | doi =  | PMID = 17170968 | PMC = 1656535 | url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1656535/ }}</ref>
**With (aggressive) combined modality treatment, the overall five-year survival is approximately 75%.<ref name=pmid22476411>{{Cite journal  | last1 = Al-Mamgani | first1 = A. | last2 = van Rooij | first2 = P. | last3 = Mehilal | first3 = R. | last4 = Tans | first4 = L. | last5 = Levendag | first5 = PC. | title = Combined-modality treatment improved outcome in sinonasal undifferentiated carcinoma: single-institutional experience of 21 patients and review of the literature. | journal = Eur Arch Otorhinolaryngol | volume =  | issue =  | pages =  | month = Apr | year = 2012 | doi = 10.1007/s00405-012-2008-5 | PMID = 22476411 }}</ref>
 
===Microscopic===
Features:<ref name=Ref_WMSP38>{{Ref WMSP|38}}</ref>
*Architecture: nested, trabecular or lobular.
*Distinct cellular borders.
*Small-to-moderate cytoplasm.
*+/-Distinct nucleoli.
*Tumour cell size variable (small to large).
 
Note:
*Glandular and squamous differentiation are absent by definition.<ref name=pmid11904342/>
 
Images:
*www:
**[http://www.nature.com/modpathol/journal/v15/n3/fig_tab/3880522f7.html SNUC (nature.com)].<ref name=pmid11904342>{{Cite journal  | last1 = Mills | first1 = SE. | title = Neuroectodermal neoplasms of the head and neck with emphasis on neuroendocrine carcinomas. | journal = Mod Pathol | volume = 15 | issue = 3 | pages = 264-78 | month = Mar | year = 2002 | doi = 10.1038/modpathol.3880522 | PMID = 11904342 | URL = http://dx.doi.org/10.1038/modpathol.3880522 }}</ref>
**[http://www.pathologypics.com/PictView.aspx?ID=244 SNUC (pathologypics.com)].
**[http://www.pathologypics.com/PictView.aspx?ID=249 SNUC (pathologypics.com)].
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Sinonasal_undifferentiated_carcinoma_-_low_mag.jpg SNUC - low mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Sinonasal_undifferentiated_carcinoma_-_high_mag.jpg SNUC - high mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Sinonasal_undifferentiated_carcinoma_-_very_high_mag.jpg SNUC - very high mag. (WC)].
 
===IHC===
Features:<ref name=Ref_WMSP38>{{Ref WMSP|38}}</ref>
*Pankeratin +ve.
*EMA +ve.
*CK7 +ve.
*CK5/6 -ve.
 
Others:
*NSE +ve/-ve.
*Chromogranin A -ve.
*Synaptophysin -ve.
*p63 +ve/-ve.<ref name=pmid21805120>{{Cite journal  | last1 = Wadsworth | first1 = B. | last2 = Bumpous | first2 = JM. | last3 = Martin | first3 = AW. | last4 = Nowacki | first4 = MR. | last5 = Jenson | first5 = AB. | last6 = Farghaly | first6 = H. | title = Expression of p16 in sinonasal undifferentiated carcinoma (SNUC) without associated human papillomavirus (HPV). | journal = Head Neck Pathol | volume = 5 | issue = 4 | pages = 349-54 | month = Dec | year = 2011 | doi = 10.1007/s12105-011-0285-8 | PMID = 21805120 | PMC = 3210220 | URL = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3210220/ }}</ref>


==Nasopharyngeal carcinoma==
==Nasopharyngeal carcinoma==
*Abbreviated ''NPC''.
*Abbreviated ''NPC''.
===General===
{{Main|Nasopharyngeal carcinoma}}
*"Nasopharyngeal carcinoma" is the name of an entity - it is not a descriptive term.
*Strong association with [[Epstein-Barr virus]] (EBV).
 
Note:
*A morphologically identical tumour elsewhere is called ''[[lymphoepithelioma-like carcinoma]]''.
 
===Gross===
*Nasopharynx - as the name would suggest.
 
===Microscopic===
Features:<ref name=Ref_Klatt145>{{Ref Klatt|145}}</ref>
*Prominent lymphoid component - '''key feature'''.
*Features of squamous cell carcinoma:
**Cohesive cells with:
***Abundant dense eosinophilic cytoplasm.
***Central nuclei +/- small/indistinct nucleoli.
 
Images:
*[http://en.wikipedia.org/wiki/File:Lymphoepithelioma_met_to_LN_4.jpg Nasopharyngeal carcinoma - in a LN - low mag. (WP)].
*[http://commons.wikimedia.org/wiki/File:Lymphoepithelioma_met_to_LN_6.jpg Nasopharyngeal carcinoma - in a LN - intermed. mag. (WC)].
*[http://en.wikipedia.org/wiki/File:Lymphoepithelioma_met_to_LN_2.jpg Nasopharyngeal carcinoma - in a LN - high mag. (WP)].
 
====Histologic subclassification====
World Health Classification (2005) for NPC:<ref name=Ref_WMSP39>{{Ref WMSP|39}}</ref>
{| class="wikitable"
! Type
! Histology
! Description
! EBV
! Prevalence
! Prognosis
|-
| 1
| keratinizing SCC
| graded poorly-well-diff.
| -ve
| ?
| bad
|-
| 2a
| nonkeratinizing carcinoma, differentiated
| well def. cell borders & tumour nest borders, mimics appearance of [[UCC]]
| +ve
| ?
| good
|-
| 2b
| nonkeratinizing carcinoma, undifferentiated
| sheets/syncytial, vescicular nuclei, prominent nucleoli, pink cytoplasm
| ?
| most common
| ?
|-
| 3
| basaloid SCC
| mimics BCC - see [[basaloid SCC]]
| ?
| least common
| ?
|}
 
How to remember ''KNUB'':
*'''K'''eratinizing, '''N'''on-keratinizing diff., non-keratinizing '''U'''ndiff., '''B'''asaloid SCC.
 
===IHC===
*EBER +ve.
*p16 -ve.<ref name=pmid9546345>{{cite journal |author=Gulley ML, Nicholls JM, Schneider BG, Amin MB, Ro JY, Geradts J |title=Nasopharyngeal carcinomas frequently lack the p16/MTS1 tumor suppressor protein but consistently express the retinoblastoma gene product |journal=Am. J. Pathol. |volume=152 |issue=4 |pages=865–9 |year=1998 |month=April |pmid=9546345 |pmc=1858242 |doi= |url=}}</ref>
 
Notes:
*[[HPV-associated head and neck squamous cell carcinoma]]s are p16 +ve.<ref name=pmid21484924>{{Cite journal  | last1 = Singhi | first1 = AD. | last2 = Califano | first2 = J. | last3 = Westra | first3 = WH. | title = High-risk human papillomavirus in nasopharyngeal carcinoma. | journal = Head Neck | volume = 34 | issue = 2 | pages = 213-8 | month = Feb | year = 2012 | doi = 10.1002/hed.21714 | PMID = 21484924 }}</ref>


==Squamous lesions==
==Squamous lesions==
Line 576: Line 191:


==Squamous dysplasia of the head and neck==
==Squamous dysplasia of the head and neck==
===General===
{{Main|Squamous dysplasia of the head and neck}}
*Similar to squamous dysplasia elsewhere.
 
===Sign out===
<pre>
PHARYNGEAL WALL, POSTERIOR, BIOPSY:
- SQUAMOUS MUCOSA WITH MILD SQUAMOUS DYSPLASIA.
- NEGATIVE FOR MALIGNANCY.
</pre>


==Squamous cell carcinoma of the head and neck==
==Squamous cell carcinoma of the head and neck==
{{Main|Squamous cell carcinoma}}
{{Main|Squamous cell carcinoma of the head and neck}}
===General===
*Most common malignant tumour of the head & neck.
*Most common spindle cell tumour of the head & neck.
 
===Microscopic===
====Classification====
SCC is subdivided by the WHO into:<ref name=Ref_Sternberg4_975>{{Ref Sternberg4|975}}</ref>
*Keratinizing type (KT).
**Worst prognosis.
*Undifferentiated type (UT).
**Intermediate prognosis.
**EBV association.
*Nonkeratinizing type (NT).
**Good prognosis.
**EBV association.
 
Features based on classification:<ref name=Ref_Sternberg4_975>{{Ref Sternberg4|975}}</ref>
*KT subtype:
**Keratinization & intercellular bridges through-out most of the malignant lesion.
*UT:
**Non-distinct borders/syncytial pattern.
**Nucleoli.
*NT:
**Well-defined cell borders.
 
====Invasion====
Features:
*Eosinophilia.
*Extra large nuclei/bizarre nuclei.
*Inflammation (lymphocytes, plasma cells).
*Long rete ridges.
*Numerous beeds/blobs of epithelial cells that seem unlikely to be rete ridges.
 
Pitfalls:
*Tangential cuts.
**If you can trace the squamous cells from a gland to the surface it is less likely to be invasive cancer.
 
Notes on invasion:
*Nice review paper by ''Wenig''.<ref name=pmid11904340>{{cite journal |author=Wenig BM |title=Squamous cell carcinoma of the upper aerodigestive tract: precursors and problematic variants |journal=Mod. Pathol. |volume=15 |issue=3 |pages=229–54 |year=2002 |month=March |pmid=11904340 |doi=10.1038/modpathol.3880520 |url=http://www.nature.com/modpathol/journal/v15/n3/pdf/3880520a.pdf}}</ref>
*See ''[[SCC of the cervix versus CIN III]]''.
 
Image(s):
*[http://commons.wikimedia.org/wiki/File:Oral_cancer_(1)_squamous_cell_carcinoma_histopathology.jpg?uselang=de Invasive oral SCC (WC)].
 
===Overview of subtypes===
There are several subtypes:<ref>URL: [http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675%2806%2970297-2 http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675%2806%2970297-2]. Accessed on: March 9, 2010.</ref>
*Basaloid - poor prognosis, usu. diagnosed by recognition of typical SCC.
*Warty (Condylomatous).
*Verrucous - good prognosis, rare.
*Papillary.
*Lymphoepithelial, rare.
*Spindle cell, a common spindle cell lesion of the H&N.
 
====Verrucous squamous cell carcinoma====
Features:
*Exophytic growth.
*Well-differentiated.
*"Glassy" appearance.
*Pushing border.
 
DDx: papilloma.
 
====Spindle cell squamous carcinoma====
*Key to diagnosis is finding a component of conventional squamous cell carcinoma.
 
IHC:
*Typically keratin -ve.
*p63 +ve.
 
DDx:
*Spindle cell [[melanoma]].
*Mesenchymal neoplasm.
 
====Basaloid squamous cell carcinoma====
*May mimic ''[[adenoid cystic carcinoma]]''.
*Classically base of tongue.<ref>URL: [http://www.biomedcentral.com/1471-2407/6/146 http://www.biomedcentral.com/1471-2407/6/146]. Accessed on: March 9, 2010.</ref>
*Typically poor prognosis.
 
Features:
*Need keratinization. (???)
 
DDx:
*Neuroendocrine tumour.
 
====Lymphoepithelial (squamous cell) carcinoma====
*Rare.
*+/-EBV.


==Small cell anaplastic carcinoma==
==Small cell anaplastic carcinoma==
Line 684: Line 204:
==Granular cell tumour==
==Granular cell tumour==
{{Main|Granular cell tumour}}
{{Main|Granular cell tumour}}
===General===
*May mimic (well-differentiated) squamous cell carcinoma - histopathologically.
**There is a well-described phenomenon called ''[[pseudoepitheliomatous hyperplasia]]''.<ref name=pmid16487362>{{cite journal |author=Abu-Eid R, Landini G |title=Morphometrical differences between pseudo-epitheliomatous hyperplasia in granular cell tumours and squamous cell carcinomas |journal=Histopathology |volume=48 |issue=4 |pages=407–16 |year=2006 |month=March |pmid=16487362 |doi=10.1111/j.1365-2559.2006.02350.x |url=}}</ref>
*Usually a benign tumour.
===Microscopic===
Features:
*Large polygonal cells with abundant (eosinophilic) granular cytoplasm.
Image:
*[http://commons.wikimedia.org/wiki/File:Granular_cell_tumor_%283%29_skin.jpg Granular cell tumour (WC)].


==Olfactory neuroblastoma==
==Olfactory neuroblastoma==
:See also: ''[[neuroblastoma]]''.
:See also: ''[[neuroblastoma]]''.
*[[AKA]] ''esthesioneuroblastoma''.
*[[AKA]] ''esthesioneuroblastoma''.
===General===
{{Main|Olfactory neuroblastoma}}
Epidemiology:<ref name=pmid20596981/>
*Prognosis: poor.
*Wide age range with bimodal distribution - teens and 60s.
*No sex predilection.
 
Clinical presentation:<ref name=pmid20596981>{{Cite journal  | last1 = Thompson | first1 = LD. | title = Olfactory neuroblastoma. | journal = Head Neck Pathol | volume = 3 | issue = 3 | pages = 252-9 | month = Sep | year = 2009 | doi = 10.1007/s12105-009-0125-2 | PMID = 20596981 | PMC = 2811627 | URL = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2811627/?tool=pubmed }}</ref>
*Nasal obstruction ~ 70%.
*Epistaxis ~ 50%.
*Anosmia.
*Headache.
 
===Gross===
*Arises from olfactory mucosa - upper nasal cavity.<ref name=Ref_WMSP41>{{Ref WMSP|41}}</ref>
 
===Microscopic===
Features:<ref name=pmid20596981/>
*[[Small round cell tumour|Small round (blue) cell tumour]] with:
**Stippled chromatin.
**High NC ratio.
*+/-Flexner-Wintersteiner [[rosette]] - rosette with empty centre (donut hole).
*+/-Fibrillary, eosinophilic material (neuropil-like).<ref name=Ref_WMSP41>{{Ref WMSP|41}}</ref>
 
DDx:
*[[Lymphoma]].
*[[Small cell carcinoma]].
*Other [[small round cell tumours]].
*Basaloid squamous carcinoma.{{fact}}
 
Images:
*[http://path.upmc.edu/cases/case467/images/fig02.jpg Olfactory neuroblastoma - crappy image (upmc.edu)].<ref>URL: [http://path.upmc.edu/cases/case467.html http://path.upmc.edu/cases/case467.html]. Accessed on: 21 January 2012.</ref>
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2811627/figure/Fig6/ Olfactory neuroblastoma (nih.gov)].<ref name=pmid20596981/>
 
===IHC===
*S100:
**Sustentacular cells +ve.
**Small round cells -ve.
*Neuroendocrine markers +ve (CD56, synaptophysin).
 
Others:
*CD45 -ve (r/o [[lymphoma]]).
*AE1/AE3 usu. -ve (r/o carcinoma).
*CAM5.2 usu. -ve -- up to 35% +ve.<ref name=Ref_WMSP41>{{Ref WMSP|41}}</ref>


==Craniopharyngioma==
==Craniopharyngioma==
Line 751: Line 218:
:See also: ''[[Angiofibroma]]''.
:See also: ''[[Angiofibroma]]''.
*[[AKA]] ''juvenile nasopharyngeal angiofibroma''.
*[[AKA]] ''juvenile nasopharyngeal angiofibroma''.
===General===
{{Main|Nasopharyngeal angiofibroma}}
*Classically adolescent males with recurrent nose bleeds.
 
===Microscopic===
Features:<ref name=Ref_Klatt144>{{Ref Klatt|144}}</ref>
*Fibroblastic cells with plump (near cuboidal) nuclei.
*Fibrous stroma.
*Abundant capillaries.


Images:
==Biphenotypic sinonasal sarcoma==
*[http://commons.wikimedia.org/wiki/File:Nasopharyngeal_angiofibroma_-_intermed_mag.jpg Nasopharyngeal angiofibroma - intermed. mag. (WC)].
*[[AKA]] ''low grade sinonasal sarcoma with neural and myogenic features''.
*[http://commons.wikimedia.org/wiki/File:Nasopharyngeal_angiofibroma_-_2_-_high_mag.jpg Nasopharyngeal angiofibroma - high mag. (WC)].
{{Main|Biphenotypic sinonasal sarcoma}}


=Nasal polyps=
=Nasal polyps=
==Overview==
{{Main|Nasal polyps}}
DDx (benign - multiple):<ref name=emedicine994274>URL: [http://emedicine.medscape.com/article/994274-overview http://emedicine.medscape.com/article/994274-overview]. Accessed on: 16 March 2011.</ref>
*Autoimmune/idiopathic:
**Asthma.
**Allergic rhinitis.
**[[Churg-Strauss syndrome]] (AKA ''allergic granulomatous angiitis'').
***Features: [[asthma]], eosinophilia, granulomatous inflammation, necrotizing systemic [[vasculitis]], and necrotizing glomerulonephritis.<ref name=emedicine333492>[http://emedicine.medscape.com/article/333492-overview http://emedicine.medscape.com/article/333492-overview]</ref>
**Nonallergic rhinitis with eosinophilia syndrome (NARES).
*Infectious:
**Fungal infection (with allergic component - ''AFS'' = allergic fungal sinusitis).
**Chronic rhinosinusitis.
*Genetic:
**Primary ciliary dyskinesia.
**[[Cystic fibrosis]].
*Associations:
**Alcohol intolerance ~ 50%.
**Aspirin intolerance - upto ~ 25%.
*Tumours:
**Juvenile [[nasopharyngeal angiofibroma]] - young males.
**[[Nasopharyngeal carcinoma]]s.
**[[Sarcoma]]s.
**[[Hemangioma]].
**[[Schneiderian papilloma]].
**Other.
 
Memory devices:
*''GAIT'' = '''G'''enetic, '''A'''llergic/idiopathic, '''I'''nfectious, '''T'''umours.
*Allergic causes '''A'''s - '''a'''llergic, '''a'''sthma, '''a'''llergic granulomatous angiitis (Churg-Strauss syndrome), non'''a'''llergic rhinitis with eosinophilia.
 
===Epidemiology===
*More commonly assoc. with nonallergic conditions.<ref name=emedicine994274/>
 
===Treatment===
*Recurrent polyps: functional endoscopic sinus surgery (FESS).
 
==Inflammatory polyps with neutrophils==
===General===
*Histologic findings are non-specific; DDx includes:<ref name=emedicine994274dx>URL: [http://emedicine.medscape.com/article/994274-diagnosis http://emedicine.medscape.com/article/994274-diagnosis]. Accessed on: 16 March 2011.</ref>
**[[Cystic fibrosis]].
**Primary ciliary dyskinesia syndrome.
**Young syndrome
 
===Microscopic===
Features:
*Neutrophil predominant.
*Edema.
*+/-Mucus-impaction (dilated glands with mucus).
**Suggestive of cystic fibrosis.<ref name=pmid15554502>{{cite journal |author=Beju D, Meek WD, Kramer JC |title=The ultrastructure of the nasal polyps in patients with and without cystic fibrosis |journal=J. Submicrosc. Cytol. Pathol. |volume=36 |issue=2 |pages=155–65 |year=2004 |month=April |pmid=15554502 |doi= |url=}}</ref>
 
===Sign out===
<pre>
A. Nasal sinus tissue, right, excision:
- Inflamed edematous sinonasal mucosa with abundant neutrophils.
- Negative for malignancy.
 
B. Nasal sinus tissue, left, excision:
- Inflamed edematous sinonasal mucosa with abundant neutrophils and fragments of bone.
- Negative for malignancy.
</pre>
 
==Allergic nasal polyp==
===General===
*People with allergies.
**Same type of polyps seen in those without allergies.<ref name=pmid8441521>{{Cite journal  | last1 = Davidsson | first1 = A. | last2 = Hellquist | first2 = HB. | title = The so-called 'allergic' nasal polyp. | journal = ORL J Otorhinolaryngol Relat Spec | volume = 55 | issue = 1 | pages = 30-5 | month =  | year = 1993 | doi =  | PMID = 8441521 }}</ref>
 
===Gross===
*Polypoid mass - several millimetres to centimetres in size.
**Translucent.{{fact}}
 
===Microscopic===
Features:<ref>{{Ref Klatt|144}}</ref>
*Normal respiratory epithelium.
*Stroma with:
**Edema.
**Eosinophils.
**+/-Other inflammatory cells (plasma cells, lymphocytes, neutrophils).
 
DDx:
*Inflammatory nasal polyp with abundant neutrophils.
*[[Vasculitis]].
**[[Wegener's granulomatosis]].
**[[Churg-Strauss syndrome]].
 
===Sign out===
<pre>
A. Nasal sinus tissue, right, excision:
- Inflamed edematous sinonasal mucosa with abundant eosinophils.
- Negative for malignancy.
 
B. Nasal sinus tissue, left, excision:
- Inflamed edematous sinonasal mucosa with abundant eosinophils and fragments of bone.
- Negative for malignancy.
</pre>
 
 
<pre>
A. NASAL SINUS TISSUE, RIGHT, EXCISION:
- INFLAMED EDEMATOUS SINONASAL MUCOSA WITH ABUNDANT EOSINOPHILS.
- NEGATIVE FOR MALIGNANCY.
 
B. NASAL SINUS TISSUE, LEFT, EXCISION:
- INFLAMED EDEMATOUS SINONASAL MUCOSA WITH ABUNDANT EOSINOPHILS AND FRAGMENTS OF BONE.
- NEGATIVE FOR MALIGNANCY.
</pre>
 
==Tonsillar lymphangiomatous polyp==
===Microscopic===
Features:<ref>http://www.nature.com/modpathol/journal/v13/n10/full/3880208a.html</ref>
*Polyp with lymph channels.
 
==Schneiderian papilloma==
*[[AKA]] ''Schneiderian polyp''.
*[[AKA]] ''sinonasal papilloma''.<ref>URL: [http://emedicine.medscape.com/article/862677-overview http://emedicine.medscape.com/article/862677-overview]. Accessed on: 19 November 2011.</ref>
===General===
*Lumpers vs. splitters debate about whether it is one entity or three.<ref name=pmid11904343>{{cite journal |author=Barnes L |title=Schneiderian papillomas and nonsalivary glandular neoplasms of the head and neck |journal=Mod. Pathol. |volume=15 |issue=3 |pages=279–97 |year=2002 |month=March |pmid=11904343 |doi=10.1038/modpathol.3880524 |url=http://www.nature.com/modpathol/journal/v15/n3/full/3880524a.html}}</ref>
 
[http://www.nature.com/modpathol/journal/v15/n3/fig_tab/3880524t1.html#figure-title Subclassification]:<ref name=pmid11904343/>
*Inverted (Schneiderian) - most common ~60-65%.
*Fungiform (Schneiderian) - less common ~30-35%.
*Oncocytic (Schneiderian) - least common ~5%.
====Inverted====
*[[AKA]] ''[[inverted papilloma]]''.<ref name=pmid8189990>{{Cite journal  | last1 = Vrabec | first1 = DP. | title = The inverted Schneiderian papilloma: a 25-year study. | journal = Laryngoscope | volume = 104 | issue = 5 Pt 1 | pages = 582-605 | month = May | year = 1994 | doi =  | PMID = 8189990 }}</ref>
*Usually lateral wall (as the septum as little soft tissue to grow into).<ref name=pmid11904343/>
*May transform to carcinoma.
 
====Fungiform====
*[[AKA]] exophytic papilloma, [[AKA]] septal papilloma.<ref name=pmid11904343/>
*Low risk of malignant transformation.
 
====Oncocytic====
*[[AKA]] ''cylindrical cell papilloma''.<ref>{{Cite journal  | last1 = Bravo Domínguez | first1 = O. | last2 = Vela Cortina | first2 = M. | last3 = Ramírez Ruiz | first3 = RD. | last4 = Ros Vergara | first4 = A. | last5 = Dinarés Jaumeandreu | first5 = D. | last6 = Encina Ruiz | first6 = L. | last7 = Arias Cuchí | first7 = G. | last8 = Ardíaca Bosch | first8 = MC. | last9 = Cánovas Robles | first9 = E. | title = [Oncocytic schneiderian papilloma. A case report]. | journal = An Otorrinolaringol Ibero Am | volume = 32 | issue = 2 | pages = 115-23 | month =  | year = 2005 | doi =  | PMID = 15929584 }}</ref>
*Lateral nasal wall.<ref name=pmid11904343/>
 
===Microscopic===
====Inverted Schneiderian papilloma====
Features:<ref name=pmid11904343/>
*Well-demarcated epithelial islands in the stroma.
*Squamous +/-surface keratinization ''or'' respiratory type epithelium (with cilia).
*+/-Neutrophils.
*+/-Goblet cells.
 
Notes:
*May mimic invasive SCC.
 
Images:
*[http://path.upmc.edu/cases/case32.html Inverted papilloma & verrucous carcinoma (upmc.edu)].
*[http://commons.wikimedia.org/wiki/File:Sinonasal_papilloma_-_very_low_mag.jpg Schneiderian papilloma - very low mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Sinonasal_papilloma_-_cropped_-_very_high_mag.jpg Schneiderian papilloma - very high mag. (WC)].
 
====Fungiform Schneiderian papilloma====
Features:
*Exophytic growth pattern - '''key feature'''.
 
====Oncocytic Schneiderian papilloma====
Features:
*Oncocytes - '''key feature'''.
*Exophytic or endophytic growth pattern.


=See also=
=See also=

Latest revision as of 17:37, 4 March 2022

This article is an introduction to head and neck pathology. Most of head and neck pathology is squamous cell carcinoma and its variants.

The thyroid gland is dealt with in its own article, as is pathology of the salivary gland.

Cytopathology of the head and neck is dealt with in a separate article called head and neck cytopathology.

Anatomy

Head and neck anatomy (BruceBlaus/WC).
  • Oropharynx - includes: tonsil, tonsillar pillar, base of tongue, soft palate.[1][2]
  • Oral cavity - includes floor of mouth, bucca, anterior 2/3 of tongue,[3] lips, hard palate, upper & lower alveolar ridge, retromolar trigone.[4]
  • Laryngopharynx.
  • Nasopharynx.

Clinical

Common lesions:[5]

  • Leukoplakia.
    • Homogeneous.
    • Non-homogeneous.
  • Erythroplakia - more worrisome for cancer than leukoplakia.

Leukoplakia

Hairy leukoplakia is dealt with in a separate section.
The typical benign leukoplakia is dealt with in a separate section.
Main article: Leukoplakia

Erythroplakia

General

  • Non-specific clinical finding - may be benign or malignant.
  • Strong association with non-keratinizing squamous lesions (invasive and dysplastic).

Microscopic

Features:[5]

  • Unidentified red lesion.
  • Often erosion.

Overview

Cysts

Larynx

Oral

Main article: Oral pathology

Infectious:

Other:

Vascular:

Pigmentation:

Nasal cavity/nose

Benign cystic lesions

Cytology dealt with in Head and neck cytopathology.

Cystic lesions - overview

Lateral cystic lesions:

Medial cystic lesions:

Lateral & medial lesions:

Rathke cleft cyst

Main article: Rathke cleft cyst
  • Arises from intermediate lobe - embryonic remnant.
  • Benign cystic lesion without calcification.
  • Related to craniopharyngioma.

Thyroglossal duct cyst

Main article: Thyroglossal duct cyst

Branchial cleft cyst

  • AKA branchial cleft remnant.
Main article: Branchial cleft cyst

Benign lymphoepithelial lesion

  • AKA benign lymphoepithelial cyst
Main article: Benign lymphoepithelial lesion

Other benign

Vocal cord nodule

  • AKA singer's nodule.
  • AKA vocal cord polyp.
Main article: Vocal cord nodule

Squamous papilloma

Caruncle lesion is dealt with in papilloma of the caruncle.
The lesion in the esophagus is dealt with in squamous papilloma of the esophagus.
Main article: Squamous papilloma

Pemphigus vulgaris

Main article: Pemphigus vulgaris

Pyogenic granuloma

  • AKA lobular capillary hemangioma.[7]
Main article: Lobular capillary hemangioma

Plummer-Vinson syndrome

Triad:[8]

  • Iron-deficiency anemia.
  • Glossitis.
  • Esophageal dysphagia (usually related to webs).

Rhinoscleroma

Main article: Rhinoscleroma

Neoplasms

Odontogenic tumours and cysts

Main article: Odontogenic tumours and cysts

This is a rather large topic and dealt with in a separate article.

It includes:

Pharyngeal/nasopharyngeal specimens

  • Specimens may be challenging to interpret as there is normally an abundance of lymphoid cells.
  • Malignant tissue can look benign.[9]
  • May be difficult to differentiate from other malignancies.

Histology

  • Upper airway distant from areas with friction: respiratory type epithelium.

Work-up of negative H&E Bx differs by site:

  • One large hospital:
    • LMWK (CAM5.2).
    • Pankeratin (AE1/AE3).
  • Another large hospital:
    • Nothing.

Laryngeal neoplasms

Main article: Laryngeal carcinoma

These are dealt with in a separate article.

Human papillomavirus-associated head and neck squamous cell carcinoma

  • Abbreviated HPV-HNSCC.
Main article: Human papillomavirus-associated head and neck squamous cell carcinoma

Sinonasal undifferentiated carcinoma

  • Abbreviated SNUC.
Main article: Sinonasal undifferentiated carcinoma

Nasopharyngeal carcinoma

  • Abbreviated NPC.
Main article: Nasopharyngeal carcinoma

Squamous lesions

  • Premalignant lesions
    • Mild dysplasia.
      • Low risk of progression to invasive lesions.
    • Moderate dysplasia.
    • Severe dysplasia/carcinoma in situ (CIS).
      • Histologically severe dysplasia and CIS cannot be differentiated reliably; ergo, there can be considered the same thing.
      • Severe dysplasia is not a necessary intermediate for cancer, i.e. invasive squamous cell carcinoma may be present with moderate dysplasia.
  • Invasive squamous cell carcinoma (SCC).
    • "Microinvasive" squamous cell carcinoma - term should be avoided as there is no concenus on what it means.
    • There are several subtypes of SCC.

Squamous dysplasia of the head and neck

Main article: Squamous dysplasia of the head and neck

Squamous cell carcinoma of the head and neck

Main article: Squamous cell carcinoma of the head and neck

Small cell anaplastic carcinoma

  • Rare.

DDx:

Granular cell tumour

Main article: Granular cell tumour

Olfactory neuroblastoma

See also: neuroblastoma.
  • AKA esthesioneuroblastoma.
Main article: Olfactory neuroblastoma

Craniopharyngioma

Main article: Craniopharyngioma
  • Cystic lesion +/- calcifications +/-squamous nests.
  • Related to Rathke cleft cyst.

Nasopharyngeal angiofibroma

See also: Angiofibroma.
  • AKA juvenile nasopharyngeal angiofibroma.
Main article: Nasopharyngeal angiofibroma

Biphenotypic sinonasal sarcoma

  • AKA low grade sinonasal sarcoma with neural and myogenic features.
Main article: Biphenotypic sinonasal sarcoma

Nasal polyps

Main article: Nasal polyps

See also

References

  1. ↑ URL: https://www.cancer.org/cancer/oral-cavity-and-oropharyngeal-cancer/about/what-is-oral-cavity-cancer.html. Accessed on: 1 April 2021.
  2. ↑ URL: http://www.headandneckcancerguide.org/teens/cancer-basics/explore-cancer-types/throat-cancer/oropharyngeal-cancer/soft-palate-cancer/. Accessed on: 15 November 2016.
  3. ↑ URL: http://www.headandneckcancerguide.org/teens/cancer-basics/explore-cancer-types/oral-cancers/tongue-cancer/. Accessed on: 15 November 2016.
  4. ↑ URL: http://www.headandneckcancerguide.org/teens/cancer-basics/explore-cancer-types/oral-cancers/oromandibular-cancer/. Accessed on: 15 November 2016.
  5. ↑ 5.0 5.1 Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 780. ISBN 0-7216-0187-1.
  6. ↑ Penner, CR.; Thompson, L. (Dec 2003). "Nasal glial heterotopia: a clinicopathologic and immunophenotypic analysis of 10 cases with a review of the literature.". Ann Diagn Pathol 7 (6): 354-9. PMID 15018118.
  7. ↑ Baglin, AC. (Aug 2011). "[Vascular tumors and pseudotumors. Pyogenic granuloma (lobular capillary hemangioma)].". Ann Pathol 31 (4): 266-70. doi:10.1016/j.annpat.2011.05.014. PMID 21839350.
  8. ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 776. ISBN 0-7216-0187-1.
  9. ↑ S. Raphael. December 2008.

External links

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