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

Head & Neck Case Review 2021-02

Head & Neck Case Review

February, 2021

History

A 65 year-old male with no significant past medical history presents with fatigue, difficulty swallowing, and voice changes for several months duration. CT scan showed an 8 cm left-sided neck mass. The patient underwent left hemithyroidectomy and parathyroidectomy. CT imaging, H&E sections, and immunostains of the mass are shown.

Images

Quiz

Q1. All of the following are characteristic features of this tumor, EXCEPT:

  • A. Invasive growth involving adjacent structures
  • B. Vascular and/or perineural invasion
  • C. Nodular growth pattern with broad bands of fibrous connective tissue
  • D. Rare recurrence after resection

Q2. CDC73 mutation is the molecular driver in the pathogenesis of this tumor.

  • A. True
  • B. False

Diagnosis

Contributor

Mitra Mehrad, MD
Assistant Professor
Department of Pathology, Microbiology and Immunology
Vanderbilt University Medical Center, Nashville, TN

Head & Neck Case Review 2021-01

Head & Neck Case Review

January, 2021

History

An 80-year-old female with a history of squamous cell carcinoma of the tongue that was treated by hemiglossectomy presented a year later with a tender right neck mass. A right radical neck dissection was performed, consisting predominantly of matted cervical lymph nodes with necrosis. In addition, Level IB contained a 3.0 cm well circumscribed, firm, tan-pink mass, shown below.

Images

Quiz

Q1. The histologic features are consistent with:

  • A. Sjogren syndrome
  • B. Atypical lymphoproliferative disorder
  • C. Chronic sclerosing sialadenitis
  • D. Chronic sialadenitis
  • E. Castleman disease

Q2. Which statement is TRUE about this disease?

  • A. It is considered an IgG4-related disease.
  • B. Fine needle aspiration of salivary gland can be diagnostic.
  • C. It can result from compression by an adjacent tumor.
  • D. Obliterative phlebitis is a characteristic feature.
  • E. Lymphoepithelial lesions are characteristic features.

Diagnosis

Contributors

  1. F. Zahra Aly, M.D., Ph.D., Clinical Associate Professor, Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine
  2. Saja Alramadhan, BDS, PGY-3 Resident, Department of Oral and Maxillofacial Pathology, University of Florida College of Dentistry
  3. Nada Al Qaysi, MD, PGY-4 Resident, Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine

Head & Neck Case Review 2020-12

Head & Neck Case Review

December, 2020

History

A boy presented to the pediatric otolaryngology clinic with a chief concern of mass in his left neck of several months’ duration.  He was also experiencing mild intermittent pain. There was no lymphadenopathy. Pre-operative imaging studies identified an intraparotid nodule.  A superficial parotidectomy was performed. H&E sections of the nodule are shown.

Images

Quiz

Q1. Which gene is most likely to harbor an alteration in this patient’s tumor?

  • A. MAML2
  • B. NR4A3
  • C. PLAG1
  • D. PTEN

Q2. This tumor type is associated with a considerable rate of recurrence.

  • A. True
  • B. False

Diagnosis

Contributor

Jiancong Liang, MD PhD
Assistant Professor
Department of Pathology, Microbiology and Immunology
Vanderbilt University Medical Center, Nashville, TN

Head & Neck Case Review 2020-11

Head & Neck Case Review

November, 2020

History

A 58-year-old woman presented to her physician with a chief concern of mass of her anterior neck, of several years’ duration.  She was also experiencing dysphagia and hoarseness.  Review of her medical history revealed no medical conditions or medications.  The patient had smoked cigarettes for many years.  The mass was firm to palpation.  It was centered in the thyroid gland and was fixed to underlying anatomic structures, per radiographic evaluation.  At the time of presentation, the patient was euthyroid.  A total thyroidectomy was performed, with suspicion for a malignant process.

Images

Quiz

Q1.

  1. Given the histologic findings, which additional laboratory test would be most beneficial in evaluation of this patient?
  • A. PTH
  • B. RET status
  • C. Serum IgG4
  • D. Serum thyroglobulin

Q2. What is the vascular alteration characteristic of this disease process?

  • A. Vasculitis
  • B. Superior vena cava syndrome
  • C. Thrombosis
  • D. Occlusive phlebitis

Diagnosis

Contributors

Anne C. McLean-Holden, DMD, MS: Emory University Hospital, Atlanta, GA

Justin A. Bishop, MD: University of Texas Southwestern Medical Center, Dallas, TX

Head & Neck Case Review 2020-10

Head & Neck Case Review

October, 2020

History

A middle-aged man presented with a palpable neck mass and was found to have a complex 8.5 cm mass arising from the left thyroid lobe. He had no notable past medical history and no history of radiation exposure. The patient underwent hemithyroidectomy, with negative margins. Following resection, staging PET/CT/ultrasound did not demonstrate any other lesions.

Two months after hemithyroidectomy, the patient developed neck and supraclavicular swelling. PET/CT demonstrated a mass in the surgical bed extending into the mediastinum, as well as nodules in the contralateral platysma, sternocleidomastoid muscle, and supraclavicular region. A fine needle aspiration was performed of a palpable supraclavicular nodule. Images from the supraclavicular fine needle aspiration and thyroid resection are shown.

Images

Quiz

Q1. Which genetic alteration has been associated with this tumor?

  • A. BRAF V600E mutation
  • B. DICER1 mutation
  • C. RET-PTC3 fusion
  • D. Isochromosome 12p
  • E. PIK3CA mutation

Q2. Tumors occurring in infants and children generally have a favorable prognosis.

  • A. True
  • B. False

Diagnosis

Contributor

Margaret Compton, MD
Assistant Professor
Department of Pathology, Microbiology and Immunology
Vanderbilt University Medical Center, Nashville, TN