Head & Neck Case Review 2023-12

Head & Neck Case Review

December, 2023

History

A 64-year-old male presents with a left sided neck mass that he had noticed one month ago. On ultrasonographic examination, the mass was 4.3 x 3.3 x 2.2 cm with heterogeneous appearance. An ultrasound guided needle biopsy was performed and displayed malignant cells compatible with metastatic squamous cell carcinoma.  A p16 immunostain was strongly positive, high risk human papillomavirus (HPV) E6/E7 mRNA in-situ hybridization was equivocal. A follow up 18F-fluorodeoxyglucose (FDG) PET/CT showed uptake in the left cervical level II lymph node, and symmetric mild uptake in bilateral palatine tonsils. A transoral robotic tonsillectomy and base of tongue resection was performed to localize the site of primary. A firm fibrotic area was noted in the left tonsil on palpation and cut surface.  A representative frozen section was taken:

Images

Quiz

1. Which of the following is most likely representative of the finding on frozen section?

  • A. Hamartoma
  • B. Teratoma
  • C. Choristoma
  • D. Pleomorphic adenoma

2. What is the most common cartilage producing parapharyngeal space tumor?

  • A. Pleomorphic adenoma
  • B. Teratoma
  • C. Chondroma
  • D. Chondrosarcoma

Diagnosis

Contributors

John Grove, DO
Resident Physician, Department of Anatomic & Clinical Pathology
University of Pittsburgh Medical Center

Raja R. Seethala, MD
Professor of Pathology and Otolaryngology
University of Pittsburgh Medical Center

Head & Neck Case Review 2023-01

Head & Neck Case Review

January, 2023

History

A 61-year-old female presents with an enlarging mass along the left angle of the mandible and pre-auricular area. A contrast-enhanced CT scan of the neck shows a heterogeneous, irregular left preauricular mass involving the parotid gland and invading into facial skin.

Images

Quiz

1. Which of the following immunohistochemical stains is MOST likely to be positive in this carcinoma?

  • A. p40
  • B. Androgen receptor
  • C. S-100 protein
  • D. Estrogen receptor

2. Which of the following is TRUE?

  • A: This carcinoma is most likely to arise in the minor salivary glands.
  • B: This carcinoma only arises as carcinoma ex pleomorphic adenoma.
  • C: This carcinoma is most common in female patients.
  • D: This carcinoma can show ERBB2 gene amplification.

Diagnosis

Contributors

Stephanie Hart, MD
PGY-1, Department of Pathology, Microbiology and Immunology
Vanderbilt University Medical Center

James S. Lewis Jr. MD
Professor
Associate Director of Surgical Pathology
President, North American Society of Head and Neck Pathology
Vanderbilt University Medical Center

Head & Neck Case Review 2022-09

Head & Neck Case Review

September, 2022

History

A 72-year-old female presents with hoarseness of voice and dysphagia. A 3.2 x 1.9 x 2.7 cm heterogenous nodule in the left neck adjacent to the submandibular gland is noted on ultrasound. An ultrasound guided core needle biopsy is performed.

Images

Link to Virtual Slide HERE!

Quiz

1. Which of the following is TRUE?

  • A. These tumors are defined by PAX8::GLIS3 gene rearrangements.
  • B. These tumors are typically driven by mutations in the succinate dehydrogenase complex.
  • C. Sclerosis is a key feature to predict aggressive (i.e. metastatic) potential.
  • D. They often show low and high molecular weight cytokeratin expression.

2. TRUE or FALSE: 10% of these tumors are familial/inherited.

Diagnosis

Contributors

Grayson Cole, DDS
PGY-3 Oral Pathology Resident
University of Pittsburgh School of Dental Medicine
University of Pittsburgh Medical Center

Raja R. Seethala, MD
Professor of Pathology and Otolaryngology
University of Pittsburgh Medical Center

Head & Neck Case Review 2022-08

Head & Neck Case Review

August, 2022

History

A 36-year-old man presented with left eyelid drooping for one year along with progressively worsening headaches, blurry vision and diplopia for the prior month. A CT scan of the head showed a mass in the left maxillary sinus measuring 5.5 x 4.4 x 3.3 cm with bony destruction of the maxillary sinus walls and extension into the soft tissues of the posterior left orbit. The clinical and radiographic findings were highly suspicious for malignancy. A biopsy of the mass was subsequently performed. Representative CT scan radiographic images of the mass along with images of the surgical pathology are shown below.

Images

Quiz

1. To qualify as chronic invasive fungal rhinosinusitis (CIFR), symptoms must be present for at least:

  • A. 4 weeks
  • B. 8 weeks
  • C. 12 weeks
  • D. 26 weeks

2. Which of the following histopathologic features is seen in chronic granulomatous invasive fungal rhinosinusitis (CGIFR)?

  • A. Submucosal edema
  • B. Extensive fibrosis
  • C. Angioinvasive fungal hyphae
  • D. Well-formed granulomas with discrete rimming by mature lymphocytes
  • E. None of the above

Diagnosis

Contributors

George de Castro, BS, Medical Student
MD Program
Vanderbilt University School of Medicine

James Lewis Jr., MD
Department of Pathology, Microbiology, and Immunology
Vanderbilt University Medical Center

Head & Neck Case Review 2022-06

Head & Neck Case Review

June, 2022

History

A 61-year-old female presented with a lesion on the right maxillary gingiva. Clinical examination revealed an ulcerated and endophytic lesion with associated leukoerythroplakia, involving the right maxillary gingiva and the adjacent soft tissue with noticeable bone loss. No lymphadenopathy was noted. An incisional biopsy was performed.

Images

Quiz

1. The histologic features are suggestive of:

  • A. Malignant melanoma
  • B. Squamous cell carcinoma
  • C. Traumatic ulcerative granuloma with stromal eosinophilia
  • D. Granulomatosis with polyangiitis
  • E. Langerhans cell histiocytosis

2. True or False: The prognostic role of eosinophilic infiltration in this disease is still unknown

  • True
  • False

Diagnosis

Contributor

Saja Alramadhan, BDS, OMFP
Fellow, Department of Oral and Maxillofacial Pathology
University of Florida College of Dentistry

Head & Neck Case Review 2021-12

Head & Neck Case Review

December, 2021

History

An elderly man presented with a maxillary sinus mass. Physical exam showed softness of the right hard palate and a nasal endoscopy showed a mass extending into the right maxillary sinus. A CT and MRI showed a mass within the right maxillary sinus with bowing of the medial maxillary wall and cortical breakthrough of the posterior wall. The mass demonstrated extension into the fat of the right masticator space and involvement of the right maxilla.  A biopsy of the mass was performed. Representative imaging of the mass along with H&E stained sections and immunohistochemical stains of the biopsy are shown.

Images

Quiz

  1. Which of the following best characterizes the process shown?
  • A. Clusters of benign remnant epithelial cell rests
  • B. A reactive inflammatory process disrupting normal epithelial elements
  • C. A malignant epithelial process
  • D. A malignant process derived from embryologic remnants

2. What is the immunohistochemical stain shown in the last image?

  • A. p63
  • B. Brachyury
  • C. SOX-10
  • D. WT1

Diagnosis

Contributor

Troy Hutchens, MD, PhD
Head & Neck Surgical Pathology Fellow
Department of Pathology & Immunology
Washington University School of Medicine

Head & Neck Case Review 2021-10

Head & Neck Case Review

October, 2021

History

An adult woman with a significant smoking history presented to the emergency department with chronic unilateral otalgia and worsening odynophagia causing decreased appetite and weight loss. The patient denied fevers or B symptoms. Physical exam demonstrated a firm, exophytic, non-ulcerated mass in the palatine tonsil. CT scan showed a tonsillar mass with bilateral lymphadenopathy throughout the neck. The patient underwent bilateral tonsillectomy.

Images

Quiz

Q1. What is the diagnosis?

  • A. Extramedullary plasmacytoma
  • B. Systemic lupus erythematosus
  • C. T. pallidum infection
  • D. Granulomatosis with polyangiitis

Q2. What is the most specific confirmatory test?

  • A. c-ANCA
  • B. Flow cytometry, serum protein electrophoresis and bone marrow biopsy
  • C. Direct immunofluorescence
  • D. Serum RPR and VDRL
  • E. Serum RPR and FTA-ABS

Diagnosis

Contributors

Igor Damasceno Vidal, MD, PGY-2 resident
Pathology Residency Program
University of Alabama at Birmingham School of Medicine

Manuel Lora Gonzalez, MD, Assistant Professor
Department of Pathology
University of Alabama at Birmingham Hospital & School of Medicine

Head & Neck Case Review 2021-07

Head & Neck Case Review

July, 2021

History

A 50-year-old man presents with a 6-month history of a left tongue lesion which was biopsied. Characteristic H&E stained sections and one immunostain are shown.

Images

Quiz

Q1. Which of the following is true regarding this lesion?

  • A. It is the result of a proliferation of histiocytes.
  • B. The lesional cells are filled with PAS+, diastase resistant granules.
  • C. The overlying mucosal process is characteristic of basal cell carcinoma.
  • D. Leukoplakia and erythroplakia are precursors of this lesion.

Q2. Which immunohistochemical stain is used to help diagnose this lesion and is shown here?

  • A. CK5/6
  • B. SOX10
  • C. S100
  • D. Desmin

Diagnosis

Contributor

Qiuying Shi, MD, MS (Assistant Professor, Lead author)
Oluwaseun Ogunbona, MD, PhD (PGY3 resident)
Department of Pathology
Emory University Hospital Midtown
Emory University School of Medicine, Atlanta, GA

Head & Neck Case Review 2021-06

Head & Neck Case Review

June, 2021

History

A 44-year-old woman presented with a 2-month history of right mandibular pain and mild swelling. Recent developments included paresthesia along the lip and right side of the chin. A cone beam CT study showed irregular resorption of bone including erosion of the buccal cortex. Representative axial and coronal slices of the mass along with the H&E stained sections and immunostains of the biopsied tissue are shown.

Images

Quiz

Q1. What is the characteristic genetic event in this tumor in children?

  • A. PAX 3/7-FOX01 gene fusion
  • B. FGFR4, RAS, AKT pathway mutations
  • C. PTEN hypermethylation
  • D. NCOR2 or VGLL2 gene fusion

Q2. Which one of the following is a morphologic variant of this tumor?

  • A. Sclerosing
  • B. Embryonal
  • C. Pleomorphic
  • D. Alveolar

Diagnosis

Contributor

Yeshwant B. Rawal, BDS, MDS, MS
Professor, Department of Surgical Sciences
Marquette University School of Dentistry, Milwaukee, WI

Head & Neck Case Review 2021-04

Head & Neck Case Review

April, 2021

History

A 68-year-old African American male presented with a nontender mass under his tongue for 2 weeks. He had dysarthria because of compromised tongue movement. He denied pain, bleeding, dysphagia, loss of appetite, weight changes, and shortness of breath. There was no history of prior swelling, trauma, or oral cavity surgeries. Clinical examination revealed a mobile, solid, non-tender, oval-shaped right sublingual mass (3.0 x 2.0 cm). No notable cervical adenopathy was found.

CT scan showed a well-circumscribed, oblong shaped hyperdense mass (4.1 x 2.5 x 4.0 cm) situated within the floor of mouth/right sublingual gland with mild mass effect upon the midline intrinsic tongue musculature. No calcification or sialolith were identified. There was no surrounding inflammation or cervical lymphadenopathy. Excision of the mass was performed.

Images

Quiz

Q1. Which genetic alteration is associated with this tumor?

  • A. SS18-SSX1/SSX2/SSX4 fusion
  • B. EWSR1-FLI1 fusion
  • C. NAB2-STAT6 fusion
  • D. PLAG1 rearrangement

Q2. Histologic features of the tumor always predict outcome in these patients.

  • A. True
  • B. False

Diagnosis

Contributors

Shajia Ansari, MD
Resident
Pathology and Immunology
Baylor College of Medicine
Houston, TX US

Syeling Lai, MD
Associate Professor
Pathology and Immunology
Baylor College of Medicine
Houston, TX US