Lewis James S, Chernock Rebecca D, Haynes Wesley, El-Mofty Samir K
Departments of *Pathology and Immunology †Otolaryngology Head and Neck Surgery ‡Radiation Oncology, Washington University in St Louis, St Louis, MO.
Am J Surg Pathol. 2015 May;39(5):714-21. doi: 10.1097/PAS.0000000000000390.
The sinonasal tract harbors several different types of papillomas, some of which can progress to carcinoma. The most frequent among these are inverted and oncocytic Schneiderian papillomas. The rates of progression are somewhat controversial but are approximately 5% to 10% and are almost invariably described in the literature as in situ or invasive squamous cell carcinoma. Other carcinoma types, such as mucoepidermoid and sinonasal undifferentiated carcinoma, have also been described. Almost all of the described patterns of malignancy involve frank carcinoma with overtly dysplastic nuclear features, lack of cell maturation, and increased mitotic activity. Some squamous cell carcinomas, particularly nonkeratinizing, can grow in a papillary pattern, appearing to only line the surface epithelium, but they are cytologically overtly malignant throughout. In this case report, however, we describe a novel, human papillomavirus-negative, papillary carcinoma, which presented as a left nasal and maxillary sinus exophytic and inverted-appearing, papillomatous mass with very bland cytomorphology. The initial features were not typical for any defined Schneiderian papilloma but were also not clearly diagnostic of papillary carcinoma. The tumor recurred >10 times over 18 years despite extensive surgical resection including orbital exenteration. The tumor retained a bland appearance throughout the patient's entire clinical course, but did develop a pushing pattern of stromal invasion, increased mitotic activity, vesicular nuclei with prominent nucleoli, lymph node metastases, and eventually overwhelming local recurrence and nodal metastases, resulting in death. This tumor seems best characterized as a low-grade papillary Schneiderian carcinoma and appears to represent a novel type of sinonasal carcinoma.
鼻窦道存在几种不同类型的乳头状瘤，其中一些可进展为癌。其中最常见的是内翻性和嗜酸性细胞性施奈德乳头状瘤。其进展率存在一定争议，但约为5%至10%，且几乎在文献中均被描述为原位或浸润性鳞状细胞癌。其他癌类型，如黏液表皮样癌和鼻窦未分化癌，也有相关报道。几乎所有已描述的恶性模式均涉及具有明显发育异常核特征、缺乏细胞成熟和有丝分裂活性增加的典型癌。一些鳞状细胞癌，尤其是非角化型，可呈乳头状生长模式，似乎仅衬于表面上皮，但在细胞学上始终具有明显的恶性特征。然而，在本病例报告中，我们描述了一种新型的、人乳头瘤病毒阴性的乳头状癌，其表现为左鼻和上颌窦外生性且呈内翻状的乳头状肿物，细胞形态非常温和。其初始特征既不符合任何明确的施奈德乳头状瘤，也未明确诊断为乳头状癌。尽管进行了包括眶内容摘除术在内的广泛手术切除，但该肿瘤在18年内复发超过10次。在患者的整个临床过程中，肿瘤始终保持温和外观，但确实出现了推挤式的间质浸润模式、有丝分裂活性增加、核呈泡状且核仁突出、淋巴结转移，最终出现严重的局部复发和淋巴结转移，导致患者死亡。这种肿瘤似乎最适合被描述为低级别乳头状施奈德癌，并且似乎代表了一种新型的鼻窦癌。
