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Poorly differentiated sinonasal squamous cell carcinoma

Case contributed by Ryan Thibodeau
Diagnosis certain

Presentation

History of chronic rhinosinusitis.

Patient Data

Age: 75 years
Gender: Male

There is a heterogeneously enhancing mass centered within the ethmoid air cells, eccentric toward the left, measuring approximately 5.6 x 3.1 x 4.3 cm (AP x TV x CC). This 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, predominately om the left. 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 (left greater than right). 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. There is moderate mucosal thickening of the left maxillary sinus. There are retention cysts about the alveolar recesses of the maxillary sinuses. The tumor involves the right lateral wall of the nasal cavity without definitive extension into the right orbit.

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 are mildly enlarged bilateral level Ib lymph nodes measuring up to 1.3 cm in length. These could be reactive or possibly related to nodal metastases.

Other findings include bilateral lens replacements and an old lacunar infarct of the pons on the right side. There is mild diffuse cerebral volume loss. There are scattered foci of T2/FLAIR hyperintensities within the cerebral white matter, which are nonspecific but most likely related to mild chronic microangiopathic changes in this age group.

Case Discussion

This a case of poorly differentiated invasive squamous cell carcinoma. Gross pathologic examination of specimens ranging from 0.2 x 0.1 x 0.1 cm to 0.8 x 0.4 x 0.2 cm revealed soft, tan tissues. Histopathologic examination of the tumor specimen stained positively for P16 and negatively for EBER. Histopathologic examination demonstrated poorly differentiated sinonasal tissue that was highlighted by immunohistochemistry for p16 and negative for EBER.

The patient's tumor was deemed unresectable with a tumor stage of T4b, thus the patient was recommended to begin chemotherapy and radiation therapy, with possible future endoscopic debulking.

Co-author:
Mason Soeder

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