Poorly differentiated sinonasal squamous cell carcinoma

Case contributed by Ryan Thibodeau
Diagnosis certain


Headache/face pain. Rule out abscess or orbital cellulitis.

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 a heterogeneous enhancing 3.7 x 4.8 x 3.9 cm (AP x TRV x CC) mass centered about the left ethmoid sinuses that is primarily isointense on T1 and T2/FLAIR sequences. The mass invades through the left lamina papyracea into the left orbit, surrounding the left medial rectus muscle and pushes the intraorbital optic nerve laterally. There is left orbital proptosis.

On coronal enhanced T1 images, there is epidural enhancing tumor below the medial frontal lobes particularly the left. This tracks along the inferior aspect of the anterior interhemispheric falx. This tumor deposition measures a 2.2 cm transversely by approximately 9 mm cranio-caudally and it generates edema inferior medial frontal lobes. On coronal T1 images the tumor extends inferiorly surrounding the left middle turbinate and the superior turbinates but does not involve the inferior turbinate. There is enhancing material in the zygomatic recess of the right maxillary sinus, measuring 2.6 cm anteroposteriorly and 2.6 cm transversely.

Mucosal thickening in the medial left maxillary sinus.

Tumor also slightly invades through the right lamina papyracea (9 mm defect) with no effect upon the optic nerve or extraocular muscles.

Tumor invades into the frontal sinus and extends through the cribriform plate. The majority of the frontal sinus is fluid-filled in part due to obstruction but there may be tumor within the midline. There is mild increased T2 FLAIR signal in the inferior medial frontal lobes consistent with edema likely due to tumor invasion of the epidural space.

Case Discussion

This is a poorly differentiated squamous cell carcinoma. Gross pathologic examination revealed an aggregate of soft, friable tan/pink tissue fragments. Histopathologically, the tissue demonstrated marked areas of necrotic and inflamed tissue. There were rare atypical epithelioid cells with marked degeneration that were highlighted by p40 and cytokeratin AE1/AE3. Sections demonstrated a high grade poorly differentiated carcinoma with foci of non-keratinizing squamous differentiation. This was supported by the presence of foci of maturation in the nests and ribbons of tumor from a basaloid periphery toward central cells with abundant abundant eosinophilic to clear cytoplasm with discrete cell borders. The diagnosis of invasive squamous carcinoma was supported by the finding of tumor cells in the specimen with extensive staining with immunohistochemical stains p40, p63, and CK5/6. Locoregional nodes were positive for poorly differentiated squamous cell carcinoma.

Mason Soeder

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