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

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==Pharyngeal/nasopharyngeal specimens==
==Pharyngeal/nasopharyngeal specimens==
*Specimens may be challenging to interpret as there is normally an abundance of lymphoid cells.
*Specimens may be challenging to interpret as there is normally an abundance of lymphoid cells.
*Malignant tissue can look benign.<ref>S. Raphael. December 2008.</ref>.
*Malignant tissue can look benign.<ref>S. Raphael. December 2008.</ref>
*May be difficult to differentiate from other malignancies.
*May be difficult to differentiate from other malignancies.


Revision as of 06:15, 14 November 2010

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.

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

Clinical

Oral lesions

DDx:[1]

  • Leukoplakia.
    • Unidentified white lesion.
    • More worrisome than erythroplakia.
    • Often assoc. with epithelial thickening (hyperkeratosis, acanthosis).
  • Erythroplakia.
    • Unidentified red lesion.
    • Often erosion.

Benign

Rathke cleft cyst

General

Radiology:

  • Typically no calcifications.[2]

Radiologic DDx:[2]

Microscopic

Features:

  • Lined by cuboidal or columnar epithelial +occasional goblet cells.[3]
  • +/-Squamous metaplasia.

Image: Rathke's cleft cyst (endotext.org).

Pemphigus vulgaris

General

  • AKA pemphigus.
    • Should not be confused with bullous pemphigoid (which is less serious).
  • 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: desmoglein 1, desmoglein 3.

Pyogenic granuloma

General

  • Sometimes pregnancy tumour.
  • Seen in children, young adults, pregnant women.

Gross

Features:[4]

  • Erythematous.
  • Hemorrhagic.

Microscopic

Features:[5]

  • Vascular.
  • Peduncular lesion.

DDx:

  • Capillary hemangioma.

Hairy leukoplakia

Features:[6]

  • Oral lesion.
  • Often on tongue.
  • Thought to be caused by EBV.

Gross:

  • White confluent patches (icing sugar).

Microscopic

Features:[7]

  • Hyperkeratosis (thicker stratum corneum).[8]
  • Acanthosis (thicker stratum spinosum).[9]
  • "Balloon cells" in upper stratum spinosum - perinuclear clearing.

Plummer-Vinson syndrome

Triad:[4]

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

Oral candidiasis

  • Fungus.
  • May be associated with immunodeficiency, e.g. AIDS, organ transplant/immunosuppression.

Forms:[6]

  • Pseudomembranous (thrush).
  • Erythematous.
  • Hyperplastic.

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:

  • Keratocystic odontogenic tumour.
  • Radicular cyst.
  • Dentigerous cyst.
  • Ameloblastoma.
  • Adenomatoid odontogenic tumour.
  • Ameloblastic fibroma.
  • Odontogenic myxoma.

Pharyngeal/nasopharyngeal specimens

  • Specimens may be challenging to interpret as there is normally an abundance of lymphoid cells.
  • Malignant tissue can look benign.[10]
  • 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:

Nasopharyngeal carcinoma

General

  • "Nasopharyngeal carcinoma" is the name of an entity - it is not a descriptive term.
  • Strong association of EBV.

Microscopic

Features:[12]

  • Prominent lymphoid component - key feature.
  • Features of squamous cell carcinoma:
    • Cohesive cells with:
      • Abundant dense eosinophilic cytoplasm.
      • Central nuclei with small/indistinct nucleoli.

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 cell carcinoma

General

  • Most common tumour of the head & neck.

Microscopic

Classification

SCC is subdivided by the WHO into:[13]

  • Keratinizing type (KT).
    • Worst prognosis.
  • Undifferentiated type (UT).
    • Intermediate prognosis.
    • EBV association.
  • Nonkeratinizing type (NT).
    • Good prognosis.
    • EBV association.

Features based on classification:[13]

  • 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:

Overview of subtypes

There are several subtypes:[15]

  • 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.[16]
  • Typically poor prognosis.

Features:

  • Need keratinization. (???)

DDx:

  • Neuroendocrine tumour.

Lymphoepithelial (squamous cell) carcinoma

  • Rare.
  • +/-EBV.

Small cell anaplastic carcinoma

  • Rare.

DDx:

  • Metastatic small cell carcinoma of the lung.

Granular cell tumour

General

  • May mimic (well-differentiated) squamous cell carcinoma - histopathologically.
  • Usually a benign tumour.

Microscopic

Features:

  • Large polygonal cells with abundant (eosinophilic) granular cytoplasm.

Image:

Olfactory neuroblastoma

General

  • AKA esthesioneuroblastoma.
  • Prognosis: poor. (???)

Microscopic

Features:

  • Small round (blue) cell tumour.

Craniopharyngioma

General

  • Develop from remains of Rathke's pouch or squamous epithelial cell rests.[17]

Comes in several flavours:[17]

  • Adamantinomatous type.
  • Squamous papillary type.

Radiology:[17]

  • Calcified.
  • Solid & cystic.

Microscopic

Features:[18]

  • Well-circumscribed or pseudoinvasive border.
  • Squamoid appearance - papillary arch.

Image: Craniopharyngioma - micrograph (lmp.ualbera.ca).

Nasopharyngeal angiofibroma

General

  • AKA juvenile nasopharyngeal angiofibroma.
  • Classical adolescent males with recurrent nose bleeds.

Microscopic

Features:[19]

  • Fibroblastic cells with plump (near cuboidal) nuclei.
  • Fibrous stroma.
  • Abundant capillaries.

Image: Angiofibroma (WP).

Nasal Polyps

Overview

DDx (benign - multiple):[20]

  • Autoimmune/idiopathic:
    • Asthma.
    • Allergic rhinitis.
    • Churg-Strauss syndrome (AKA allergic granulomatous angiitis) - considered a type of Polyarteritis nodosa (PAN).
      • Features: asthma, eosinophilia, granulomatous inflammation, necrotizing systemic vasculitis, and necrotizing glomerulonephritis.[21]
    • 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 carcinomas.
  • Sarcomas.
  • Hemangioma.
  • Papilloma.
  • Other.

Epidemiology

  • More commonly assoc. with nonallergic conditions.[20]

Treatment

  • Recurrent polyps: Functional endoscopic sinus surgery (FESS).

Allergic nasal polyp

General

  • People with allergies.

Gross

  • Polypoid mass - several millimetres to centimetres in size.

Microscopic

Features:[22]

  • Normal respiratory epithelium.
  • Stroma with:
    • Edema.
    • Eosinophils.
    • +/-Other inflammatory cells (plasma cells, lymphocytes, neutrophils).

Tonsillar lymphangiomatous polyp

Microscopic

Features:[23]

  • Polyp with lymph channels.

Schneiderian papilloma

General

  • AKA Schneiderian polyp.
  • Lumpers vs. splitters debate about whether it is one entity or three.[24]

Subclassification:[24]

  • Inverted - most common ~60-65%.
  • Fungiform - less common ~ 30-35%.
  • Oncocytic - least common ~5%.

Microscopic

Inverted papilloma

Features:[24]

  • Well-demarcated epithelial islands in the stroma.
  • +/-Neutrophils.
  • +/-Surface keratinization.

Notes:

  • May mimic invasive SCC.

Images:

See also

References

  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.
  2. ↑ 2.0 2.1 URL: http://emedicine.medscape.com/article/343629-overview. Accessed on: 14 November 2010.
  3. ↑ URL: http://www.endotext.org/neuroendo/neuroendo3/neuroendo3.html. Accessed on: 27 May 2010.
  4. ↑ 4.0 4.1 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. 776. ISBN 0-7216-0187-1.
  5. ↑ 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. 775. ISBN 0-7216-0187-1.
  6. ↑ 6.0 6.1 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. 777. ISBN 0-7216-0187-1.
  7. ↑ URL: http://www.pathologyoutlines.com/oralcavity.html#hairyleukoplakia.
  8. ↑ URL: http://www.emedicine.com/asp/dictionary.asp?keyword=hyperkeratosis.
  9. ↑ URL: http://www.emedicine.com/asp/dictionary.asp?keyword=acanthosis.
  10. ↑ S. Raphael. December 2008.
  11. ↑ S. Raphael
  12. ↑ Klatt, Edward C. (2006). Robbins and Cotran Atlas of Pathology (1st ed.). Saunders. pp. 145. ISBN 978-1416002741.
  13. ↑ 13.0 13.1 Mills, Stacey E; Carter, Darryl; Greenson, Joel K; Oberman, Harold A; Reuter, Victor E (2004). Sternberg's Diagnostic Surgical Pathology (4th ed.). Lippincott Williams & Wilkins. pp. 975. ISBN 978-0781740517.
  14. ↑ Wenig BM (March 2002). "Squamous cell carcinoma of the upper aerodigestive tract: precursors and problematic variants". Mod. Pathol. 15 (3): 229–54. doi:10.1038/modpathol.3880520. PMID 11904340. http://www.nature.com/modpathol/journal/v15/n3/pdf/3880520a.pdf.
  15. ↑ URL: http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675%2806%2970297-2. Accessed on: March 9, 2010.
  16. ↑ URL: http://www.biomedcentral.com/1471-2407/6/146. Accessed on: March 9, 2010.
  17. ↑ 17.0 17.1 17.2 Garnett, MR.; Puget, S.; Grill, J.; Sainte-Rose, C. (2007). "Craniopharyngioma.". Orphanet J Rare Dis 2: 18. doi:10.1186/1750-1172-2-18. PMID 17425791.
  18. ↑ Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 184. ISBN 978-0470519035.
  19. ↑ Klatt, Edward C. (2006). Robbins and Cotran Atlas of Pathology (1st ed.). Saunders. pp. 144. ISBN 978-1416002741.
  20. ↑ 20.0 20.1 http://emedicine.medscape.com/article/994274-overview
  21. ↑ http://emedicine.medscape.com/article/333492-overview
  22. ↑ Klatt, Edward C. (2006). Robbins and Cotran Atlas of Pathology (1st ed.). Saunders. pp. 144. ISBN 978-1416002741.
  23. ↑ http://www.nature.com/modpathol/journal/v13/n10/full/3880208a.html
  24. ↑ 24.0 24.1 24.2 Barnes L (March 2002). "Schneiderian papillomas and nonsalivary glandular neoplasms of the head and neck". Mod. Pathol. 15 (3): 279–97. doi:10.1038/modpathol.3880524. PMID 11904343. http://www.nature.com/modpathol/journal/v15/n3/full/3880524a.html.

External links

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