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.

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

Oral lesions

Clinical:[1]

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

Pyogenic granuloma

General

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

Gross

Features:[2]

  • Erythematous.
  • Hemorrhagic.

Microscopic

Features:[3]

  • Vascular.
  • Peduncular lesion.

DDx:

  • Capillary hemangioma.

Hairy leukoplakia

Features:[4]

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

Gross:

  • White confluent patches (icing sugar).

Microscopic

Features:[5]

  • Hyperkeratosis (thicker stratum corneum).[6]
  • Acanthosis (thicker stratum spinosum).[7]
  • "Balloon cells" in upper stratum spinosum - perinuclear clearing.

Plummer-Vinson syndrome

Triad:[2]

  • 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:[4]

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

Tonsillar lymphangiomatous polyps

Features:[8]

  • Polyp with lymph channels.

Pharyngeal carcinoma/nasopharyngeal carcinoma

  • 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:

Classification

SCC is subdivided by the WHO into:[11]

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

Histology of SCC

Features:[12]

  • KT subtype:
    • Keratinization & intercellular bridges through-out most of the malignant lesion.
  • UT:
    • Non-distinct borders/syncytial pattern.
    • Nucleoli.
  • NT:
    • Well-defined cell borders.

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

Microscopy

Invasive cancer look for:

  • 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:[14]

  • 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.[15]
  • 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

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

Features:

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

Image:

Olfactory neuroblastoma

  • AKA esthesioneuroblastoma.

Microscopic

Features:

  • Small round (blue) cell tumour.

Rathke cleft cyst

Microscopic

Features:

  • Lined by cuboidal or columnar epithelial +occasional goblet cells.[16]
  • +/-Squamous metaplasia.

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

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).

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.
  • Ameloblastoma.

Nasal polyps

DDx (benign - multiple):[19]

  • 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.[20]
    • 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.[19]

Treatment

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

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 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.
  3. ↑ 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.
  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. 777. ISBN 0-7216-0187-1.
  5. ↑ URL: http://www.pathologyoutlines.com/oralcavity.html#hairyleukoplakia.
  6. ↑ URL: http://www.emedicine.com/asp/dictionary.asp?keyword=hyperkeratosis.
  7. ↑ URL: http://www.emedicine.com/asp/dictionary.asp?keyword=acanthosis.
  8. ↑ http://www.nature.com/modpathol/journal/v13/n10/full/3880208a.html
  9. ↑ S. Raphael
  10. ↑ S. Raphael
  11. ↑ Sternberg P.975.
  12. ↑ Sternberg P.975.
  13. ↑ 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.
  14. ↑ URL: http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675%2806%2970297-2. Accessed on: March 9, 2010.
  15. ↑ URL: http://www.biomedcentral.com/1471-2407/6/146. Accessed on: March 9, 2010.
  16. ↑ URL: http://www.endotext.org/neuroendo/neuroendo3/neuroendo3.html. Accessed on: 27 May 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. ↑ 19.0 19.1 http://emedicine.medscape.com/article/994274-overview
  20. ↑ http://emedicine.medscape.com/article/333492-overview

External links

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