Investing nasal papillomas symptoms
Such tumors have been referred to by a variety of names, including colonic-type adenocarcinomas, mucinous adenocarcinomas, heterotopic tumors with intestinal mucous membrane, enteric-type adenocarcinomas, papillary adenocarcinomas, or nonspecific adenocarcinomas. The term that has currently emerged as the most preferred is intestinal-type adenocarcinoma ITAC. Etiology Although ITACs are uncommon, they have generated interest not only because of their unusual histologic appearance but also, epidemiologically, as a result of their association with occupational exposure to wood and, occasionally, leather dust 95 , 96 , 97 , 98 , 99 , , , , , , , , , , The tumor came into prominence in the s when Hadfield astutely observed an increased incidence of adenocarcinomas of the sinonasal tract among woodworkers employed in the furniture industry of Oxfordshire and Buckinghamshire, England.
It soon became apparent that the risk for developing ITAC was not limited to these geographic areas but also involved woodworkers in many other countries 98 , 99 , , , , , , , In a review of patients with sinonasal malignant tumors from 17 countries, Mohtashamipur et al.
The risk for developing ITAC in the furniture worker exposed to wood dust is 70— times that of the nonwoodworker 95 , The inhaled particles are concentrated in the anterior portion of the nasal septum and middle turbinate, where they induce cuboidal or squamous metaplasia with impairment of the mucociliary clearance mechanism , This results in prolonged mucosal contact of the dust. The carcinogen in wood dust still has not been identified. The average interval from first dust exposure to the appearance of ITAC is 40 years range, 7—69 years The length of dust exposure has been highly variable.
This, however, seems to be a singular experience. The length of dust exposure in other studies has ranged from 5 to 55 years The risk for ITAC does not appear to decrease for at least 15 years maybe more after termination of occupational exposure Although the majority of tumors associated with wood dust exposure are ITACs, there is also an increased incidence of squamous cell carcinomas, especially among woodworkers in Japan Interestingly, in contrast with ITACs, which are associated with hard wood exposure, squamous cell carcinomas and undifferentiated carcinomas are more common in individuals exposed to dust from soft woods pine and spruce , It has also been suggested that workers with an occupational exposure to wood dust may also be at risk for developing other malignancies.
There may be differences between the two. The male predominance is probably related to the fact that very few women are employed as woodworkers. The average age at diagnosis for both types is about 58 years range, 12—86 years. Although almost all ITACs occur in the sinonasal tract, they are not unique to this site. Spiro et al. Lopez and Perez have also reported another case in the pharynx.
The most common presenting symptom is unilateral nasal obstruction, followed by epistaxis and purulent or clear rhinorrhea 92 , , , , , , Cervical lymph node and distant metastases are rarely present at the time of initial presentation. On physical exam, the tumors are polypoid, papillary, or nodular and dark red, gray-white, or pink-gray. Most are friable. Some are ulcerated and hemorrhagic, whereas others are mucoid. Barnes has described one patient with an advanced tumor of the maxillary sinus that was associated with a pretreatment borderline abnormal serum level of carcinoembryonic antigen.
Whether this laboratory test has any role in monitoring the course of the disease is uncertain. Radiography Radiologic studies are essential in determining the extent of disease and the operative approach. Early lesions will show only a soft tissue mass with little, if any, evidence of bone destruction. Other tumors may be associated with considerable osteodestruction and invasion of contiguous structures such as the orbit and cranial cavity. A few may even involve the contralateral sinonasal tract.
As the tumor enlarges, it may interfere with drainage of nearby sinuses. The ensuing obstructive sinusitis then may interfere with optimal preoperative evaluation and staging. The one proposed by Kleinsasser and Schroeder, however, seems to be gaining acceptance for its ease of use, reproducibility, and clinical correlation According to them, ITACs can be subclassified into four categories: papillary tubular cylinder cell PTCC , alveolar goblet cell, signet ring cell, and transitional.
The columnar cells may be polarized, with their long axes perpendicular to the basement membrane, or stratified and crowded. These cells have pink cytoplasm and round to oval nuclei that vary from vesicular to hyperchromatic, with or without nucleoli. In some tumors, goblet cells are found admixed with columnar cells in a ratio similar to that seen in the intestine.
In others, the fronds may be covered exclusively by columnar or goblet cells. Mitoses may or may not be prominent. FIGURE 8 Full size image Although some papillary tumors are clearly invasive, others remain noninvasive in situ over a broad front much like papillary urothelial carcinoma in situ of the urinary bladder.
A few are rather bland cytologically and may resemble a villous adenoma or even normal intestinal mucosa, yet are locally aggressive and destructive. The PTCC II moderately differentiated, also known as the colonic type is composed of well to moderately differentiated glands and more closely resembles adenocarcinoma of the large intestine than does any of the other variants Fig. At times, one may also see cystic glandular spaces with intracystic papillary projections.
FIGURE 9 Full size image The PTCC III poorly differentiated, also know as the solid type is composed of a diffuse proliferation of smaller, more cuboidal cells with amphophilic to pink cytoplasm, occasionally with mucin droplets, and round, vesicular nuclei, often with nucleoli. There is little attempt at gland formation. FIGURE 10 Full size image The signet ring variant also known as mucinous type is composed of small groups or isolated signet ring cells floating in pools of mucus.
No strips of epithelium are apparent. The transitional cell type also known as mixed type is composed of two or more of the preceding growth patterns. ITAC, regardless of histologic type, may contain Paneth and enterochromaffin cells as well as a muscularis mucosa. The enterochromaffin cells may express a variety of peptides, including gastrin, glucagon, serotonin, cholecystokinin, and leu-enkephalin 93 , , Although Schmid et al.
If they do transform, the transformation is usually to one of the more aggressive types. On the basis of the work of Cheng and Leblond and of Kirkland, it has been suggested that multidirectional differentiation of a common stem cell could account for the variety of cells Paneth, endocrine, absorptive, goblet observed in ITAC 94 , , The stem cell, either by direct transformation or by induction of adjacent mesenchyme, might also give rise to the muscularis mucosa noted in a few tumors.
The similarity of ITAC to intestinal tumors extends beyond the light-microscopic to the ultrastructural and, to some extent, the immunohistochemical level 93 , 94 , , Batsakis et al. These structures are thought to be important in identifying tumors of intestinal epithelium or tumors arising from metaplastic intestinal-type epithelium. The immunohistochemical profile of ITAC is discussed in the next section of this article. Wu et al. Differential Diagnosis The differential diagnosis includes a metastasis from a gastrointestinal carcinoma, papillary rhinosinusitis, and papillary adenocarcinoma of the nasopharynx.
Metastases to the nasal cavity and paranasal sinuses from a primary adenocarcinoma of the gastrointestinal tract are not common , In a study of 82 tumors metastatic to the maxilla, nose and paranasal sinuses, Bernstein et al. The maxillary, ethmoid, and frontal sinuses and nasal cavity were involved in descending order. In some of these patients, the head and neck metastasis was the initial manifestation of an otherwise clinically occult carcinoma.
For this reason, examination of the gastrointestinal tract in all patients with ITAC, especially the PTCC II colonic variant, would seem prudent, although in the absence of relevant signs and symptoms, such studies will generally prove negative. Immunohistochemical stains for chromogranin, neuron-specific enolase NSE , and carcinoembryonic antigen CEA may offer some limited help in distinguishing ITAC from metastatic colorectal adenocarcinoma.
Because ITACs tend to contain more endocrine cells than colorectal adenocarcinomas, they will usually show a more diffuse and stronger intensity when stained for chromogranin and NSE In contrast, colorectal adenocarcinomas are diffusely and strongly positive for CEA, whereas ITACs tend to show only focal, weak reactivity Staining for cytokeratin 7 is also helpful in distinguishing ITAC from metastatic adenocarcinoma of the colon ITAC is consistently positive for this marker, whereas adenocarcinoma of the colon is negative.
Sinusitis, at times, may have a papillary configuration, but in these instances, the papillae are short and blunt and not highly branched, as one sees in some ITACs. P-ITAC, in contrast to PACN, occurs primarily in the nasal cavity and paranasal sinuses and is often not invariably associated with an occupational exposure to wood dust.
P-ITAC also tends to be less glandular and more papillary. Rather than cuboidal cells, the papillae are covered by tall columnar and goblet cells, the latter of which are sparse to absent in PACN. Such cells are not seen in PACP. Last, PACP tends to be associated with a hemorrhagic, inflammatory background and often recurs after therapy.
Tumor necrosis with sepsis is often a problem and may be life threatening. Perez et al. Treatment consists of surgical excision using a lateral rhinotomy or, at times, even a cranial base approach. The use of radiotherapy is dictated by the extent and resectability of the tumor. An elective neck dissection is not warranted. Prognosis depends on the histologic type, degree of differentiation, stage of the disease, and the adequacy of resection margins.
PTCC I has the best prognosis. It may recur but rarely metastasizes. The other types are more virulent, with a greater propensity for dissemination. Over the course of time, a few tumors may change from one histologic type into another. This may be an ominous finding, signaling a tumor with increased aggressiveness.
Woodworkers seem to have a better prognosis than those individuals with sporadic ITAC. This probably relates to the fact that the woodworker is under heightened surveillance for this tumor and that in this group, the tumors are more often found in the nasal cavity or ethmoid sinus and can therefore be detected earlier by the patient.
In contrast, patients with sporadic tumors are not in early detection programs and have neoplasms that are relatively more common in the maxillary sinus, which are difficult to detect early. Exceptionally, adenocarcinomas may also arise from the mucosa, and when they do, they are typically papillary and are referred to as papillary adenocarcinomas of the nasopharynx , Most present with airway obstruction.
Other less common symptoms include serous otitis media with or without hearing loss and postnasal drip with blood-tinged sputum. Rarely the tumor may be an incidental finding after adenoidectomy. PACN are typically confined to the nasopharynx and, on physical examination, present as exophytic or pedunculated masses with a papillary, nodular, or cauliflower-like appearance.
The tumors range from 0. Regular follow-up is necessary for early detection of recurrence or metastases. The outcome for malignant lesions is relatively poor and associated with late diagnosis, difficult surgical anatomy and a lack of effective adjuvant modalities of treatment Topically applied corticosteroids have a favourable effect on symptoms However, corticosteroids are only helpful in allergic conditions. FESS was the most commonly used surgical intervention Polypectomy and Caldwell-Luc procedure for nasal polyposis are certainly associated with a risk of recurrence.
FESS offers a definite advantage over other procedures and is now the preferred modality Complete surgical resection followed by adjuvant radiotherapy is an effective and safe approach in the treatment of sinonasal cancer and associated with better survival 35 However, radiotherapy was the only mode of treatment offered to patients in our clinic.
Conclusions Sinonasal masses have various differential diagnoses. Malignancy should be distinguished from non-malignant lesions. Benign conditions show a peak during second to fourth decade of life, while malignancy is generally observed only after the 4th decade. Polyps are the most common benign lesion, while squamous cell carcinoma is the most common malignant tumour of the sinonasal tract. Nasal obstruction is the most common symptom. Medical management is often not adequate and has a limited role.
Surgery is the treatment of choice for benign lesions, while a combination of surgery and radiotherapy is helpful in malignant conditions. Acknowledgements We are thankful to Dr. Shinde, Professor and Head, Department of Otorhinolaryngology, for his guidance and encouragement. We are also thankful to Pravara Medical Trust, Loni, Maharashtra, India for providing permission and lending support to the project. References 1. Clinicopathological study of sinonasal masses.
Bangladesh J Otorhinolaryngol. Harley EH. Pediatric congenital nasal masses. Ear Nose Throat J. Valencia MP, Castillo M. Congenital and acquired lesions of the nasal septum: a practical guide for differential diagnosis. Radio Graphics. Prevalence of asthma, aspirin intolerance, nasal polyposis and chronic obstructive pulmonary disease in a population-based study.
Int J Epidemiol. Histological study of polypoidal lesions in the nasal cavity. Indian J Otolaryngol. Nasal polyps-histopathological spectrum. Economic Survey The textbook of preventive and social medicine. Shanmugaratnam K, Sobin LH. Histological typing of upper respiratory tract tumors. International Histological Typing of Tumors.
Geneva, Switzerland: World Health Organization; Histological typing of tumours of the upper respiratory tract and ear. Berlin: Springer-Verlag; Clinicopathological study of non-neoplastic lesions of nasal cavity and paranasal sinuses. Indian J Pathol Microbiol. Clinico-pathological profile of sinonasal masses: an experience in national ear care center Kaduna, Nigeria.
BMC Research Notes. Nasal polyposis: from pathogenesis to treatment, an update. Inflamm Allergy Drug Targets. Nasal polyps - Histopathologic spectrum. Overview of nasal masses. J Inst Med. Human nasal rhinosporidiosis: an Italian case report. Diagnostic Pathology. Arseculeratne SN. Recent advances in rhinosporidiosis and Rhinosporidium seeberi. Indian J Med Microbiol.
Rhinoscleroma of the sinusesa. Cavernous hemangioma of the nasal bones: an alternative management option. J Laryngol Otol. Cavernous haemangioma of the left nasal cavity. Acta Otorhinolaryngol Ital. Hemangioma of the nasal cavity: a clinicopathological study. Auris Nasus Larynx. HPV infections in benign and malignant sinonasal lesions. J Clin Pathol. Schneiderian papillomas. World health organization classification of tumors.
Lyon: Pathology of the Head and Neck Tumors. Inverted sinonasal papilloma: a molecular genetic appraisal of its putative status as a precursor to squamous cell carcinoma.
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