Poorly differentiated sinonasal squamous cell carcinoma

Case contributed by Ryan Thibodeau
Diagnosis certain


Left face pain and sinus congestion.

Patient Data

Age: 70 years
Gender: Female

There is an aggressive soft tissue mass centered within the ethmoid sinuses, left greater than right. There is destruction of the septae within the ethmoid air cells and destruction of the horizontal plate of the ethmoid. There is involvement of the middle and superior turbinates bilaterally, left greater than right. There is destruction of the bilateral medial orbital walls. There is extension to the left medial canthus, medial and superior extraconal space and intraconal space. The left globe is displaced laterally and anteriorly, resulting in mild proptosis. There is a small soft tissue component in the right medial extraconal space. There is destruction of the anterior cranial fossa, with small intracranial component. There is no destructive changes of the foramen rotundum, pterygoid canal, or foramen ovale. There is no evidence of perineural spread.

There is complete opacification of the bilateral frontal sinuses.

There is of a heterogeneously enhancing mass centered within the ethmoid air cells, eccentric toward the left which erodes through the left lamina papyracea and extends into the extraconal left orbit anteriorly extending into the medial canthal region with involvement of the left nasolacrimal duct and possibly the lacrimal sac. Anteriorly, the mass erodes through the nasal bridge, frontal processes of the maxilla on the left side, and upper nasal bones, more so on the left side. Additionally, the tumor involves the superior and middle turbinates, more so on the left side. Superiorly, the tumor extends through the cribriform plate intracranially to about the frontal lobes of the brain, more so on the left side. Along the superior margin, there are small cystic components of the tumor. There is mild associated mass effect upon the anteroinferior left frontal lobe gyrus rectus and medial gyrus. There is some superimposed edema in the left gyrus rectus and medial orbital gyrus, which could be related to the mass effect or possibly pial tumor invasion. The tumor also extends into the frontal sinuses, more so on the left side. There is associated severe mucosal thickening and fluid filling the right frontal sinus. There is moderate to severe mucosal thickening of the left frontal sinus.

The tumor involves the right lateral wall of the nasal cavity without definitive extension into the right orbit. There are bilateral lens replacements.

There is some dural enhancement along the anterior frontal convexities, particularly along the anterior cranial fossa. This could be related to dural tumor involvement or dural reaction.

There is an old lacunar infarct of the pons on the right side. Otherwise, there is no diffusion evidence of an acute infarct. There is no evidence of parenchymal hemorrhage on the SWAN sequence. There is mild diffuse cerebral volume loss.

There is moderate mucosal thickening of the left maxillary sinus. There are retention cysts about the alveolar recesses of the maxillary sinuses.

There are mildly enlarged bilateral level Ib lymph nodes. These could be reactive or possibly related to nodal metastases.

Case Discussion

This is a case of a poorly differentiated squamous cell carcinoma. Gross pathologic examination revealed aggregates of irregular, grey, friable soft tissue admixed with membranous pink tissue and hard osseous tissue. The tumor specimens varied in size from 0.5 x 0.3 x 0.2 cm to 3.5 x 2.5 x 1.6 cm. Histopathologic examination demonstrated poorly differentiated keratinizing sinonasal tissue that was highlighted by immunohistochemistry for p16.

Patient initially did well post-operatively but failed to arrive for her 1-week postoperative appointment at the outpatient clinic. She was unable to receive transportation from her nursing home. 5 weeks postoperatively, the patient required a second operation due to dehiscence of the wound in the left cheek and skull defect from her original paramedian forehead flap. She was also found to have a questionable positive margin in the anterior nasal septum which required further tissue removal. The patient underwent a combination of chemotherapy and radiation therapy after the initial operation. A large neurocutaneous fistula was closed two years after her initial surgery with no complications. Patient continues to undergo removal of nasal crusting for oncologic surveillance.

Mason Soeder

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