Answer for BIR CoW 06 Jun 2021
Inverted papilloma
Findings
Ill-defined T2 / FLAIR iso to hyperintense lesion noted involving the left nasal cavity causing deviation of nasal septum towards right side, which shows restricted diffusion with low ADC values. The lesion extends superiorly to involve the left ethmoid sinus, posteriorly through choana involve the nasopharynx. The lesion causes obstruction of the left middle and superior meatus which leads to stasis of mucosal secretions of sphenoid and left maxillary sinuses. No evidence of intraconal/intraorbital extension noted. Mucosal thickening noted in the right maxillary sinus and ethmoid sinus. On contrast administration , the lesion shows avid heterogenous enhancement. Fluid noted in left mastoid air cells.
Discussion
Nasal papillomas are uncommon, accounting for only 0.4-4.7% of all sinonasal tumors. Most recent pathologic descriptions of nasal papillomas refer to distinct forms: namely, fungiform papilloma, inverted papilloma, and cylindric cell papilloma Inverted papilloma is a benign epithelial neoplasm of the sinonasal cavity that has a significant malignant potential. Inverted papillomas most often affect patients from 40 to 70 years old and occur two to four times more often in men than in women . The common symptoms are epistaxis, rhinorrhea, nasal obstruction, anosmia, sinusitis, facial pain, and frontal headache. The cause is uncertain On gross examination, inverted papilloma appears as a mucosal polypoid lesion . Most arise from the lateral wall of the nasal cavity and sometimes extend centrifugally into maxillary or ethmoidal sinuses Diagnostic imaging helps to identify a sinonasal mass as likely caused by inverted papilloma, when a polypoid morphology can be identified and the mass seems to arise on the lateral nasal wall. Imaging is also used to establish the extent of inverted papilloma and possibly to anticipate an associated malignancy. A convoluted cerebriform gross morphology was noted on T2- or contrast-enhanced T1-weighted images or both On fast spin-echo T2-weighted images this pattern consisted of striations of high signal intensity and other striations that were thinner and closer to fat in signal intensity. Correlating with gross histologic sections, the thinner lower signal-intensity striations were considered to correspond to the higher cellular metaplastic epithelium and the thicker higher signal-intensity striations to the less cellular edematous stroma . On contrast-enhanced T1-weighted images, it seems that less-enhancing metaplastic squamous epithelium, well-enhancing stroma, and the gaps between these folds of tissue combined, like multiple strands, to create this convoluted cerebriform pattern . According to the pathology literature, the stroma of inverted papilloma ranges from compact and fibrous to edematous and loosely fibrous. This range means that the signal intensity or enhancement pattern of the stroma might vary considerably . Whereas constituency of the convolutions might vary internally, the overall cerebriform morphology, in this series, remained a constant feature of isolated inverted papilloma.
REFERENCES :
1. Michaels L, Young M. Histogenesis of papillomas of the nose and paranasal sinuses. Arch Pathol Lab Med 1995; 119:821-826 [Medline] [Google Scholar]
2. Som PM, Brandwein M. Tumors and tumorlike conditions: sinonasal cavities—inflammatory diseases, tumors, fractures, and postoperative findings. In: Som PM, Cutin HD, eds. Head and neck imaging, 2nd ed. St. Louis: Mosby, 1996:185-262 [Google Scholar]
3. Michaels L. Benign mucosal tumors of the nose and paranasal sinuses. Semin Diagn Pathol 1996; 13:113-117 [Medline] [Google Scholar]
4. Yousem DM, Fellows DW, Kennedy DW, Bolger WE, Kashima H, Zinreich SJ. Inverted papilloma: evaluation with MR imaging. Radiology 1992; 185:501-505 [Crossref] [Medline] [Google Scholar]
5. Barnes L, Verbin RS, Gnepp DR. Diseases of the nose, paranasal sinuses, and nasopharynx. In: Barnes L, ed. Surgical pathology of the head and neck, vol. 1. New York: Marcel Dekker,1985:403-451 [Google Scholar]
Findings
Ill-defined T2 / FLAIR iso to hyperintense lesion noted involving the left nasal cavity causing deviation of nasal septum towards right side, which shows restricted diffusion with low ADC values. The lesion extends superiorly to involve the left ethmoid sinus, posteriorly through choana involve the nasopharynx. The lesion causes obstruction of the left middle and superior meatus which leads to stasis of mucosal secretions of sphenoid and left maxillary sinuses. No evidence of intraconal/intraorbital extension noted. Mucosal thickening noted in the right maxillary sinus and ethmoid sinus. On contrast administration , the lesion shows avid heterogenous enhancement. Fluid noted in left mastoid air cells.
Discussion
Nasal papillomas are uncommon, accounting for only 0.4-4.7% of all sinonasal tumors. Most recent pathologic descriptions of nasal papillomas refer to distinct forms: namely, fungiform papilloma, inverted papilloma, and cylindric cell papilloma Inverted papilloma is a benign epithelial neoplasm of the sinonasal cavity that has a significant malignant potential. Inverted papillomas most often affect patients from 40 to 70 years old and occur two to four times more often in men than in women . The common symptoms are epistaxis, rhinorrhea, nasal obstruction, anosmia, sinusitis, facial pain, and frontal headache. The cause is uncertain On gross examination, inverted papilloma appears as a mucosal polypoid lesion . Most arise from the lateral wall of the nasal cavity and sometimes extend centrifugally into maxillary or ethmoidal sinuses Diagnostic imaging helps to identify a sinonasal mass as likely caused by inverted papilloma, when a polypoid morphology can be identified and the mass seems to arise on the lateral nasal wall. Imaging is also used to establish the extent of inverted papilloma and possibly to anticipate an associated malignancy. A convoluted cerebriform gross morphology was noted on T2- or contrast-enhanced T1-weighted images or both On fast spin-echo T2-weighted images this pattern consisted of striations of high signal intensity and other striations that were thinner and closer to fat in signal intensity. Correlating with gross histologic sections, the thinner lower signal-intensity striations were considered to correspond to the higher cellular metaplastic epithelium and the thicker higher signal-intensity striations to the less cellular edematous stroma . On contrast-enhanced T1-weighted images, it seems that less-enhancing metaplastic squamous epithelium, well-enhancing stroma, and the gaps between these folds of tissue combined, like multiple strands, to create this convoluted cerebriform pattern . According to the pathology literature, the stroma of inverted papilloma ranges from compact and fibrous to edematous and loosely fibrous. This range means that the signal intensity or enhancement pattern of the stroma might vary considerably . Whereas constituency of the convolutions might vary internally, the overall cerebriform morphology, in this series, remained a constant feature of isolated inverted papilloma.
REFERENCES :
1. Michaels L, Young M. Histogenesis of papillomas of the nose and paranasal sinuses. Arch Pathol Lab Med 1995; 119:821-826 [Medline] [Google Scholar]
2. Som PM, Brandwein M. Tumors and tumorlike conditions: sinonasal cavities—inflammatory diseases, tumors, fractures, and postoperative findings. In: Som PM, Cutin HD, eds. Head and neck imaging, 2nd ed. St. Louis: Mosby, 1996:185-262 [Google Scholar]
3. Michaels L. Benign mucosal tumors of the nose and paranasal sinuses. Semin Diagn Pathol 1996; 13:113-117 [Medline] [Google Scholar]
4. Yousem DM, Fellows DW, Kennedy DW, Bolger WE, Kashima H, Zinreich SJ. Inverted papilloma: evaluation with MR imaging. Radiology 1992; 185:501-505 [Crossref] [Medline] [Google Scholar]
5. Barnes L, Verbin RS, Gnepp DR. Diseases of the nose, paranasal sinuses, and nasopharynx. In: Barnes L, ed. Surgical pathology of the head and neck, vol. 1. New York: Marcel Dekker,1985:403-451 [Google Scholar]
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!