A 59-year-old man was admitted
in the emergency room after convul-
sions and loss of consciousness.
Computed tomography revealed a
hypodense basi-frontal lesion with a
barely perceptible erosion of the
cribriform plate (Fig. 1). No calcifica-
tions were noted. Complementary
preoperative investigation by MRI
showed a hyperintense T2-weighted
solid mass above the cribriform
Administration of gadolinium indi-
cated a moderate
enhancement and a small bud tissue
developed through the cribriform
plate (Fig. 2). The diagnosis of
meningioma was then made. The
patient underwent a surgical resec-
tion by supra-orbital approach. There
were no post-operative complica-
demonstrated typical features of
was supplemented by radiotherapy.
Unfortunately, a local recurrence
was detected 1 year later (Fig. 3). A
new surgical resection was therefore
undertaken. No evidence of local
recurrence or metastases has been
identified after 2 years of observa-
Esthesioneuroblastoma (ENB) or
olfactory neuroblastoma was initial-
ly described by L. Berger in 1924 (1).
This lesion represents 3% of all nasal
tumors and occurs between ages 3
and 79, with a peak at age 10 and age
40 and occurring predominantly in
males (1-2). The typical localization is
under the cribriform plate. In fact,
the lesion arises from sensory cells
in the olfactory mucosa which is
plate. These erosions are not always
easily visible. Enhancement is usual-
ly moderate after CA perfusion.
Cystic component is sometimes
reported. This may help to differenti-
ate ENB and meningioma when the
infringement is located above the
cribriform plate. “Dural tail” is diffi-
cult to distinguish of meningeal infil-
tration. Finally, it is well known that
meningiomas can cause hyperosto-
sis by osteoblastic reaction. Bone
erosion is rare with meningiomas,
except in very aggressive cases.
Differential diagnosis must include
other regional tumors like epider-
moid carcinoma, adenocarcinoma,
lymphoma, metastasis of melanoma
or hemangiopericitoma. The final
diagnosis is histological in most
Hyams has proposed to differenti-
ate low and high-grade ENB. He has
shown in a retrospective series of
49 patients that the 5-year survival is
influenced by the grade: 80% for the
low grade and 40% for the high (3).
However, this distinction is often
difficult to appreciate, as reported in
the literature (4-5). In 1992, Dulguerov
located in the most superior part of
the nasal cavity. These cells originate
in the neural crest and differentiate
into olfactory elements. Many arti-
cles in the literature present ENB as
a “site specific” tumor developing
first in the superior nasal cavity,
turbinates, ethmoid. Maxillary sinus-
es, orbital cavities, and anterior cere-
bral fossa are occasionally affected.
In our patient, the location of the
ENB was very unusual, causing ini-
tial diagnostic confusion.
By CT or MRI, the choice of sagit-
tal and coronal planes is important
to estimate the development of ENB
into the superior nasal cavity and/or
the anterior cerebral fossa. CT may
show calcifications in the lesion.
These are not constant nor are they
specific. Bone erosions are also
described, including the cribriform
JBR–BTR, 2012, 95: 89-91.
UNUSUAL INITIAL DEVELOPMENT OF AN ESTHESIONEUROBLASTOMA
ABOVE THE CRIBRIFORM PLATE
G. Mazzamuto, P . Bosschaert1
Esthesioneuroblastoma is a rare tumor localized in the superior part of the nasal cavity. Extension in the anterior
cerebral fossa is sometimes observed. As we discovered in our patient, the location of the tumor above the cribriform
plate was very unusual and meningioma was suspected. Features and prognosis are discussed below.
Key-word: Nose, neoplasms.
From: 1. Department of Radiology, Clinique St-Pierre, Ottignies, Belgium.
Address for correspondence: Dr P . Bosschaert, M.D., Department of Radiology, Clinique
St-Pierre, Ottignies, Av. Reine Fabiola 9, B-1340 Ottignies, Belgium.
Fig. 1. — Sagittal (A) and coronal (B) CT slices showing a slight erosion of the cribri-
form plate and the integrity of the superior nasal cavity (white arrow).
and Calcaterra (6) proposed a TNM
classification based on CT and MR
imaging findings (Table I). This clas-
sification differs from that usually
used for carcinomas of the nasal
cavity and paranasal sinuses by the
Cancer (7). This is due to the great
importance given to the extension of
the tumor above the cribriform plate
which involves difficulties in pro-
In most studies, the long term sur-
vival varies between 50% and
80% (8). The prognosis is usually
determined by the initial stage.
Surgical total resection is sometimes
impossible. Local recurrences are
frequent and mostly intra-cranial, by
meningeal or parenchymal exten-
sion. The largest study which was
90JBR–BTR, 2012, 95 (2)
Fig. 2. — Axial FLAIR (A) and T1-weighted MR acquisition after gadolinium administration, with sagittal (B) and coronal (C) recon-
structions, showing the ENB (asterisk) above the cribriform plate and surrounding edema. Enhancement is moderate to intense.
A small extension along the nasal septum is present (white arrow).
Fig. 3. — MR examination realized 1 year later, with sagittal (A) and coronal (B) T1-
weighted slices, demonstrating a local recurrence of ENB.
Table I. — TNM classification of Dulguerov and Calcaterra.
T1 Tumor involving the nasal cavity and/or paranasal sinuses (excluding the sphenoid), sparing the
most superior ethmoidal cells
Tumor involving the nasal cavity and/or paranasal sinuses (including the sphenoid), with extension
to – or erosion of – the cribiform plate
Tumor extending into the orbit or protruding into the anterior cranial fossa, with / without dural
Tumor involving the brain
No cervical lymph node metastasis
Any form of cervical lymph node metastasis
published by Duguerov and Allal
shows a local rate of 29% (9). Distant
recurrences are lung, liver, bone, but
also meningeal or cerebro-spinal in
10%-25% of cases according to
authors. The primary treatment for
ENB is surgery followed by radio-
therapy. A collaborative team of
experienced medical and surgical
specialists including neurosurgeons
and otorhinolaryngologists is crucial
to define the best treatment for each
patient. To date, there is no evidence
as to the effectiveness of chemother-
In conclusion, an extra-axial tumor
centered on the cribriform plate
should include the diagnosis of ENB
although this lesion is less frequent
than meningioma, and knowing that
most of ENB have an intranasal
development. The diagnosis is often
difficult and is histological in many
ence 1970-1990. Laryngoscope, 1992,
7. TNM - 7thedition, 2009 – UICC/AJCC -
Wiley and Sons Publishers
8. Jethanamest D.,
Sikora A.G., Kutler D.I.: Esthesio -
neuroblastoma: a population-based
analysis of survival and prognostic
factors. Arch Otolaryngol Head Neck
Surg, 2007, 133: 276-80.
9. Dulguerov P ., Allal A.S.: Nasal and
paranasal sinus carcinoma: how can
we continue to make progress? Curr
Opin Otolaryngol Head Neck Surg
Review, 2006, 14: 67-72.
10. Bassoulet J., Bourhis J., Cosnard G.
et al.: Esthésioneuroblastome olfactif:
étude clinique, radiologique, anato-
mopathologique et thérapeutique: à
propos de trois observations. J Eur
Radiother, 1988, 9: 159-166.
11. Benfari G., Fusconi M., Ciofalo A. et
al.: Radiotherapy alone for local
tumor control in esthesioneuroblas-
toma. Acta Otorhinolaryngol Ital,
2008, 28: 292-297.
1. Broich G., Pagliari A., Ottaviani F .:
Esthesioneuroblastoma: a general
review of the cases published since
the discovery of the tumor in 1924.
Anticancer Res, 1997, 17: 2683-2706.
2. Dulguerov P ., Allal A.S., Calcaterra T.C.:
Esthesioneuri blastoma: a meta-analy-
sis and review. Lancet Oncol, 2001, 2:
3. Hyams V.J.: Olfactory neuroblastoma
– Tumors of the upper respiratory
tract and ear. Armed Forces Institute
of Pathology, 1988, 240-248.
4. Gaye P .M., Mesbah L., Kanouni L. et
al.: Esthesioblastome olfactif: expe-
rience de l’institut d’oncologie de
Rabat et revue de la literature. J Afr
Cancer, 2010, 2: 36-40.
5. Kadish S., Goodman G., Wang S.S.:
Olfactory neuroblastoma: a clinical
analysis of 17 cases. Cancer, 1976, 37:
6. Dulguerov P.,
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ESTHESIONEUROBLASTOMA ABOVE THE CRIBRIFORM PLATE — MAZZAMUTO et al91