No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Malignant Neoplasms of Surface Epithelium
Abstract
Squamous cell carcinoma, although rare, is the commonest malignant neoplasm of the nasal vestibule, which is a region covered by modified hair-bearing skin. The other two important malignant neoplasms of the skin, malignant melanoma and basal cell carcinoma, also occur here, but with less frequency.
By the end of this chapter, the reader will:
BACKGROUND
Basaloid squamous cell carcinoma (BSCC) is a high grade, aggressive variant of squamous cell carcinoma with a predilection for the larynx, hypopharynx, tonsils, and base of the tongue. To the authors' knowledge, BSCC originating in the nasal cavity and paranasal sinuses rarely has been reported.METHODS
Fourteen cases of BSCC involving the nasal cavity and paranasal sinuses were identified in the files of the Otolaryngic-Head and Neck Pathology Tumor Registry of the Armed Forces Institute of Pathology from 1975–1997. Clinical records and follow-up were available in all cases. Paraffin blocks were available for histochemical and immunohistochemical studies in all cases.RESULTSThere were 7 females and 7 males, ages 32–86 years (median, 66.5 years; mean, 62 years). The patients presented primarily with a mass lesion and unilateral nasal obstruction. In nine patients the tumor was confined to the nasal cavity. In three patients the tumor involved the sinuses alone and in two patients the tumor involved the nasal cavity and paranasal sinuses. Histologically, the tumors were widely invasive with a variety of growth patterns, including lobular, solid, trabecular, cribriform, and fascicular. The neoplastic infiltrate included predominantly pleomorphic, basaloid-appearing cells with hyperchromatic nuclei, inconspicuous to prominent nucleoli, and a variable amount of eosinophilic to clear-appearing cytoplasm. Mitotic figures, including atypical forms, were readily apparent as was necrosis (individual cell and comedo-type). Foci of squamous differentiation were limited in extent but were found in all cases and included squamous whorls, individual cell keratinization, and intercellular bridges. Intraepithelial dysplasia, carcinoma in situ, or invasive squamous carcinoma was present in all cases. Other histologic features included intercellular stromal hyalinization and peripheral nuclear palisading. In two cases, neural-type rosettes were found. Immunoreactivity for a variety of epithelial markers including cytokeratin (AE1/AE3/LP34), CAM 5.2, 34βE12, CK7, and epithelial membrane antigen was present in all cases. Variable reactivity was present with vimentin, actins (smooth muscle and muscle specific), neuron specific enolase, S-100 protein, glial fibrillary acidic protein, CK20, carcinoembryonic antigen, Leu7, and Ewing's marker. Chromogranin, synaptophysin, neurofibrillary protein, leukocyte common antigen, HMB-45, desmin, and Epstein–Barr virus latent membrane protein were absent. Surgical resection was the treatment of choice. Eight patients had recurrent or persistent tumor and metastatic disease occurred in five patients. At last follow-up, 7 patients (50%) had died of disease with a median survival of 12 months from the time of diagnosis and 3 patients were alive with disease over periods ranging from 8 months-5 years. Of the 4 remaining patients, 2 were alive without disease at 1 month and 5 years, respectively, 1 patient was lost to follow-up with no evidence of tumor at 3 years, and 1 patient had died of unrelated causes with no evidence of disease.CONCLUSIONS
Sinonasal BSCC is a histologically distinct variant of squamous cell Cancer 1999;85:841–54. © 1999 American Cancer Society.
Cancer in the paranasal sinuses and nasal cavities in a relatively rare tumor disease, with an annual incidence of about one case per 100,000 inhabitants in Europe and the United States.1 The majority of these tumors start in the mucous membrane of the maxillary antrum or the ethmoid labyrinth. A few cases originate from the nasal cavities, while primary cancers in the sphenoid and frontal sinuses are extremely rare. The age-specific incidence of the disease continuously increases with age; it is predominately a disease of the middle aged and aging.
The only known etiologic factor of some importance in antral carcinoma is chronic sinusitis. Long-standing sinusitis causes a squamous cell metaplasia of the respiratory epithelium, which probably is the origin of most antral cancers. Some patients have a long history with signs of chronic sinusitis, prior to the signs of progressive tumor.
Squamous cell carcinoma is the most frequent
Biopsy specimens from nasal mucosa of 30 nickel-exposed individuals and 6 controls were analysed by atomic absorption spectrophotometry to determine the content of nickel, copper, cobalt, zinc and iron. Timm's sulphide silver staining method was used for visualizing heavy metals in cryostat sections of biopsy material from each individual. The purpose of the investigation was to study the sulphide silver staining pattern in nasal mucosa of nickel-exposed individuals and controls, and to establish whether variations in heavy metal concentrations, especially nickel, affect the histochemical pattern in the mucosa. No consistent differences were found in the histochemical pattern between biopsies with high and low concentrations of nickel or any of the other metals. Some difference in epithelial types between specimens from the nickel-exposed group and the control group was seen, but the staining pattern was quite similar for corresponding epithelial types in the two groups. Two nasal carcinomas from nickel workers were virtually unstained with the sulphide silver staining method.
The present report is a pilot study. The results indicate that nickel-exposed individuals develop histo-logical changes that may be precancerous.
The experience with 40 consecutive cases of cancer of the nasal cavity seen over a period of 15 years is presented. Males outnumbered females in a ratio or 5 to 3. Age ranged from 35 to 88 years, and the median age was 67 years. Epidermoid carcinoma accounted for 78% of the cases. Smoking from early age was a noticeable habit among these patients. The median length of smoking history was 51 years. Most lesions were diagnosed in an advanced stage of the disease, 58% of the cases being T3 lesions. Regional lymph nodes metastases were infrequent; only 12% of the patients presented nodes on admission; another 5% developed metastatic nodes during the follow-up period. An overall 5-year survival of 56% was obtained. The survival of cases with T1N0 lesions was 91%. Radiation therapy was the treatment of choice employed in 85% of the cases. A 5-year survival of 50% was obtained in these patients. Irradiation offers an additional means of salvaging recurrences after surgery. The special characteristics of tumors of the nasal cavity merit the evaluation of such lesions separately from tumors of the paranasal sinuses.
Histopathological diagnoses were compiled for 100 sinonasal cancers and 259 lung cancers in nickel refinery workers, including cases from Wales, Canada, and Norway. The sinonasal cancers comprised squamous cell carcinomas (48 percent), anaplastic and undifferentiated carcinomas (39 percent), adenocarcinomas (6 percent), transitional cell carcinomas (3 percent), and other malignant tumors (4 percent). The lung tumors comprised squamous cell carcinomas (67 percent), anaplastic, small cell, and oat cell carcinomas (15 percent), adenocarcinomas (8 percent), large cell carcinomas (3 percent), other malignant tumors (1 percent), and cancers not otherwise specified (6 percent). Possible selection bias in these data cannot be excluded, since the histological diagnoses represent 63 percent, 68 percent, and 100 percent of cases of sinonasal cancer and 24 percent, 47 percent, and 86 percent of cases of lung cancer in the Welsh, Canadian, and Norwegian workers. This study suggests that (a) the sinonasal cancers in nickel refinery workers conformed to the usual distribution of histological types observed in the general population (in contrast to the predilection for adenocarcinomas in wood workers), and (b) the lung cancers in nickel-refinery workers showed preponderance of squamous cell carcinomas and deficit of adenocarcinomas, compared to prevalent proportions of these neoplasms, possibly reflecting the paucity of women in the cohorts and temporal trends during the six decades in which the tumors were diagnosed.
In a series of 180 malignant tumours in the paranasal sinuses and nasal cavity the largest groups comprised 90 epidermoid carcinomas, 25 adenocarcinomas, and 19 adenocystic carcinomas. The epidermoid carcinomas were classified according to various proposed methods. The planned treatment schedule for carcinoma was 57 to 60 Gy in 30 fractions over 42 days, followed 8 to 12 weeks later by radical surgery. In the group of 80 patients with epidermoid carcinomas treated with radical intention, the 5-year corrected survival was 42 per cent. The prognosis has been analysed against a number of parameters, and it is found that sex, tumour size, and histologic score are important but neither totally independent nor evenly distributed parameters.
Of 624 cases of carcinoma of the nasal cavity and paranasal sinuses the presence or absence of metastasis to the regional nodes or to distant sites was recorded. Regional nodes were involved in 14.3 per cent, varying according to site and histological type. Disseminated metastases were found in 1.6 per cent. The prognosis for those with involved nodes was severely reduced, and for those with distant metastases it was negligible. This bleak outlook should be considered when treatment is being planned.
We reviewed our experience with sinonasal malignancies, which comprise less than 1% of all cancers, in order to determine the spectrum of disease and outcome after treatment. The medical records of 48 patients with sinonasal malignancies treated between 1990-1997 were reviewed for epidemiologic characteristics, tumor location and histology, treatment modalities, and tumor recurrence. Mean age was 58.5 years and 46% were male. Multiple sites of origin were common, including maxillary sinus (83%), ethmoid sinus (35%), and nasal cavity (40%). The histologic spectrum included squamous cell carcinoma (46%), adenoid cystic carcinoma (6%), and miscellaneous others (48%). Treatment included surgery and adjuvant radiotherapy (XRT) (58%), surgery alone (27%), XRT and chemotherapy (6%), surgery and chemotherapy (4%), and XRT alone (4%). Mean follow-up was 15 months (range 2-58). Recurrence was evident in nine patients (19%), 3 (33%) of whom had prior treatment before presenting to HUP. Of the six who recurred after initial treatment at HUP, five (83.3%) were treated with surgery and XRT and one (16.7%) was treated with surgery alone. Of the three that recurred after undergoing attempts at salvage (prior treatment and then treatment at HUP), one had received surgery alone followed by surgery and XRT, one had surgery and XRT followed by surgery and one had XRT followed by surgery alone. Our experience reveals surgery and XRT to be the modality of choice, particularly for advanced tumors, whereas surgery alone may be sufficient for small, well localized tumors. Neoadjuvant chemotherapy may offer improved local control; the future role of endoscopic surgery warrants further investigation.
Sixty patients were treated with radiation therapy alone (56 patients) or followed by surgery (4 patients) between 1970 and 1995 for squamous cell carcinoma of the nasal vestibule.
Local control rates at five years after irradiation alone in 56 patients were: T1-T2, 94%; T4, 71%; and overall, 85%. Multivariate analysis revealed that tumor size and bone invasion significantly influenced local control. All four patients with extensive T4 tumors treated with radiation therapy plus surgery were cured. Cause-specific survival rates at five years for 56 patients treated with radiation therapy alone were: T1-T2, 94%; T4, 86%; and overall, 91%. Multivariate analysis revealed that bone invasion and tumor size adversely influenced cause-specific survival. No patient treated with irradiation alone experienced a major complication, compared with three of four patients who underwent irradiation and surgery.
Radiation therapy results in a high cure rate with good cosmesis. Patients with extensive T4 cancers have an improved chance of cure with radiation and surgery but more complications.
Histological typing of tumors of the upper respiratory tract and ear
- K Shanmugaratnam
The management of carcinoma of the nasal vestibule
- A R Kagan
- H Nussbaum
- A Rao
- AR Kagan
Histopathology of sinonasal and lung cancers in nickel refinery workers
- F W Sunderman
- L C Morgan
- A Andersen
- FW Sunderman Jr