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Presented by William Westra, M.D. and prepared by Rui Zheng, M.D., Ph.D.
Case 3: 50 year-old man with a destructive mass in his sinonasal tract.
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1. Question
Week 446: Case 3
50 year-old man with a destructive mass in his sinonasal tractimages/1alex/08092010case3image1.jpg
images/1alex/08092010case3image2.jpg
images/1alex/08092010case3image3.jpgCorrect
Answer: Adenoid cystic carcinoma, solid type
Histology: The maxillary bone is infiltrated by large nests of basaloid cells. Necrosis with cystic degeneration is a common finding in the center of the expanding tumor lobules. The basaloid cells have a high N:C ratio, prominent nucleoli, and a brisk mitotic rate. The solid proliferations are interrupted by small pseudoglandular structures filled with a grayish blue material. Focally, these pseudoglandular spaces are well developed and impart a more classic cribriforming pattern.
Discussion: Adenoid cystic carcinoma is one of the more common types of salivary gland carcinoma. Most adenoid cystic carcinomas arise in the parotid and submandibular glands, but they can also originate from seromucinous glands anywhere along the upper respiratory tract including the sinonasal tract. The cribriform pattern is the hallmark morphologic finding of adenoid cystic carcinoma. The tumor cells are arranged around sharply punched-out holes, imparting a “swiss cheese”-like appearance. These holes, or cysts, are not true glandular spaces. Instead, they are lined by myoepithelial cells and filled with matrix ground substance. Duct epithelial cells are also present, and they form true glandular spaces. The formation of cysts and ducts is not a conspicuous finding in these solid areas, and the cells may exhibit appreciable pleomorphism, mitotic activity, and even necrosis.
In the solid pattern, the tumor cells grow as large nests and sheets. The solid variant of ACC may cause some diagnostic confusion, especially in its distinction from other basaloid neoplasms composed of dark basaloid cells growing in solid nests. A thorough microscopic examination of the tumor can usually establish the diagnosis without the need for ancillary diagnostic studies such as immunohistochemistry. The solid variant of ACC seldom occurs as a pure variant. Instead, thorough tumor sampling will usually disclose a component of classic cribriform growth. This variant is also important to recognize from a prognostic perspective. Solid growth of poorly differentiated cells with necrosis and a high mitotic rate portends a more explosive course, and has been associated with early metastases and poor survival even at five years.
Incorrect
Answer: Adenoid cystic carcinoma, solid type
Histology: The maxillary bone is infiltrated by large nests of basaloid cells. Necrosis with cystic degeneration is a common finding in the center of the expanding tumor lobules. The basaloid cells have a high N:C ratio, prominent nucleoli, and a brisk mitotic rate. The solid proliferations are interrupted by small pseudoglandular structures filled with a grayish blue material. Focally, these pseudoglandular spaces are well developed and impart a more classic cribriforming pattern.
Discussion: Adenoid cystic carcinoma is one of the more common types of salivary gland carcinoma. Most adenoid cystic carcinomas arise in the parotid and submandibular glands, but they can also originate from seromucinous glands anywhere along the upper respiratory tract including the sinonasal tract. The cribriform pattern is the hallmark morphologic finding of adenoid cystic carcinoma. The tumor cells are arranged around sharply punched-out holes, imparting a “swiss cheese”-like appearance. These holes, or cysts, are not true glandular spaces. Instead, they are lined by myoepithelial cells and filled with matrix ground substance. Duct epithelial cells are also present, and they form true glandular spaces. The formation of cysts and ducts is not a conspicuous finding in these solid areas, and the cells may exhibit appreciable pleomorphism, mitotic activity, and even necrosis.
In the solid pattern, the tumor cells grow as large nests and sheets. The solid variant of ACC may cause some diagnostic confusion, especially in its distinction from other basaloid neoplasms composed of dark basaloid cells growing in solid nests. A thorough microscopic examination of the tumor can usually establish the diagnosis without the need for ancillary diagnostic studies such as immunohistochemistry. The solid variant of ACC seldom occurs as a pure variant. Instead, thorough tumor sampling will usually disclose a component of classic cribriform growth. This variant is also important to recognize from a prognostic perspective. Solid growth of poorly differentiated cells with necrosis and a high mitotic rate portends a more explosive course, and has been associated with early metastases and poor survival even at five years.
