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Nasal Cavity Neoplasms: A Pictorial Review
Nasal Cavity Neoplasms: A Pictorial Review Heather Boo, MD, and Jeffery P. Hogg, MD
A pictorial review of nasal cavity neoplasms is provided for the reader to gain or refresh information about these neoplasms. The images provided are to help aid in recognition of the lesions. Retrospective case review of pathologically and clinically proven nasal cavity neoplasms are shown with multiple modalities including computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography/computed tomography (PET/CT) to illustrate the findings and complement a succinct review of this category of disease. Examples include squamous cell cancer, adenoid cystic cancer, esthesioneuroblastoma, inverted papilloma, juvenile nasal angiofibroma, melanoma, lymphoma, sarcoma, and benign nasal histiocytoma.
Consider the nasal cavity as a triangle divided in the middle by the nasal septum. This pyramid opens into the nasal vault, the floor of which is the hard and soft palate. The roof is the cribiform plate, and the lateral walls hold the turbinates. These lateral walls are the functionally most significant part of the nose because the paranasal sinuses drain through them. The superior, middle, and inferior meatus are covered by their respective turbinate. Normal anatomic variations of the turbinates can be seen, including partial aeration (called concha bullosa), and there can be asymmetric enlargement of a turbinate due to normal physiological cycle. The nasal cavity and paranasal sinuses thus aerate and drain the maxillary, frontal, ethmoid, and sphenoid sinuses. The differential diagnoses of nasal masses can be quite extensive as seen in Table 1.1 This pictorial review focuses mainly on examples of primary neoplasms.
From the Department of Radiology, WVU Health Sciences Center, Morgantown, WV. Reprint requests: Heather Boo, MD, Robert C. Byrd Health Sciences Center, Box 9235 HSC, Morgantown, WV 26506. E-mail: hboo@hsc. wvu.edu. Curr Probl Diagn Radiol 2010;39:54-61. © 2010 Mosby, Inc. All rights reserved. 0363-0188/2010/$36.00 ⫹ 0 doi:10.1067/j.cpradiol.2009.07.001
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TABLE 1. Differential diagnosis of nasal masses Primary neoplasms Squamous cell carcinoma Minor salivary gland tumor Inverted papilloma Esthesioneuroblastoma Angiofibroma Lymphoma Rhabdomyosarcoma Osteoma Osteosarcoma Chondrosarcoma Plasmacytoma Meningioma Hemangiopericytoma Secondary neoplasms Paranasal sinus squamous cell carcinoma Meningioma Metastasis Chordoma Lymphoma Infectious or inflammatory masses Inflammatory polyp Antrochoanal polyp Adenoidal hypertrophy Fungal rhinosinusitis Wegener’s granulomatosis Congenital masses Encephalocele Glioma Teratoma Dermoid cyst Epidermoid cyst Idiopathic or acquired masses Fibrous dysplasia Idiopathic midline granuloma Cocaine granuloma
Squamous Cell Carcinoma Squamous cell carcinoma (SCC) comprises 80%-90% of all primary sinonasal malignancies.2 Most of them will occur in the maxillary antrum, followed by the nasal cavity. It is also the most likely tumor to invade this region secondarily. The typical presentation is a male patient over the age of 50. Occupational exposures, cigarette smoking, nickel, and chrome exposure are known risk factors.
Curr Probl Diagn Radiol, March/April 2010
FIG 1. Squamous cell carcinoma. (A) Axial contrast-enhanced computed tomography (CECT) demonstrates a soft-tissue mass in the left nasal cavity with solid enhancement. This distinguishes it from the rim-enhancing masses such as inspissated secretions or a mucocele. The differential for this mass includes undifferentiated carcinoma, lymphoma, inverted papilloma, and even some sarcomas. (B) Axial T2 weighted image (T2WI) shows the mass to be both heterogeneous and hypointense, which is a very important distinguishing feature to differentiate SCC from inflammation, the latter of which will exhibit more T2 shortening.
Bony destruction is common with SCC. In fact, irregular destruction or nonvisualization of an adjacent bone is most commonly SCC. Most patients present later in the disease process such that 80% already will
Curr Probl Diagn Radiol, March/April 2010
FIG 2. Adenoid cystic carcinoma. (A, B) Axial and coronal T2WI show somewhat low signal intensity of the large intranasal mass relating to the degree of necrosis, cellular density, and type of histologic pattern.
have osseous destruction at the time of diagnosis. The patient depicted in Fig 1 is an 80-year-old male with repeated bouts of epistaxis and found to have a lesion on the left turbinate.
55
Minor Salivary Gland Tumor: Adenoid Cystic Adenoid cystic cancer is the most common histologic subtype of the minor salivary gland tumors.2,3 Other subtypes include mucoepidermoid carcinoma, adenocarcinoma, and undifferentiated carcinoma. Contrast should always be used in the imaging evaluation to check for perineural spread; sometimes nerve pain or numbness is the presenting complaint. Anatomic location may predict cell type (eg, adenocarcinoma is more likely to arise in the ethmoid air cells), and adenoid cystic is most likely to occur in the oral cavity. These tumors are slow growing, but relentless, and distal metastases are most common to the lungs (Fig 2).
Esthesioneuroblastoma Anatomically, the most common site of origin is high in the nasal vault from the olfactory epithelium, most of which is located at the cribiform plate. Esthesioneuroblastoma has 2 peaks of incidence: the first in young men and the second between the ages of 50 and 60 years.2,4 Clinical complaints include nasal pressure, headache, nasal discharge, and inability to breathe through the nose or smell. Treatment is a combined approach of surgery and radiation (Fig 3).
Inverted Papilloma The inverted papilloma is the most common type of papilloma. Though benign, approximately 15% of inverted papillomas harbor a squamous cell carcinoma. Anatomically, the most common site of origin is the lateral nasal wall. Like esthesioneuroblastoma, it can cross the cribiform plate quite aggressively. The extent of the mass determines the staging (Fig 4 and Table 2).
Juvenile Nasopharyngeal Angiofibroma The classic clinical presentation is a teenage male presenting with nasal obstruction and epistaxis. Juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor with a propensity to bleed. It often shows aggressive spread through the skull base foramina. Preoperative embolization can be performed to reduce blood loss. The tumor is staged based on extent of spread as outlined in Table 3 (Fig 5).
56
FIG 3. Esthesioneuroblastoma. (A) Sagittal post contrast T1 weighted image (T1WI) showing a large nasal mass extending through the ethmoid sinuses with subsequent intracranial extension. There is avid enhancement due to the highly vascular nature of the mass. The frontal lobe is displaced upward. (B) Coronal T2WI shows an intermediate to hyperintense mass inferior to the cribiform plate. (C) Coronal T1WI showing the same mass that is hypointense on T1WI.
Curr Probl Diagn Radiol, March/April 2010
TABLE 2. Staging of inverted papilloma I. Limited to the nasal cavity II. Limited to the ethmoid sinuses and medial and superior portions of the maxillary sinuses III. Extension into the lateral and inferior aspects of the maxillary sinuses or extension into the frontal or sphenoid sinuses TABLE 3. Staging of JNA IA. Tumor limited to posterior nares or nasopharyngeal vault IB. Extension into 1 or more paranasal sinus IIA. Minimal lateral extension through sphenopalatine foramen into medial pterygomaxillary fossa IIB. Full occupation of pterygomaxillary fossa, displacing posterior wall of antrum forward; superior extension eroding orbital bones IIC. Extension through pterygomaxillary fossa into cheek and temporal fossa III. Intracranial extension
Pterygomaxillary/ pterygopalatine fossa
Sphenopalatine foramen
A
FIG 4. Inverted papilloma. (A) A nonspecific mass filling the ethmoid air cells and a portion of the left sphenoid sinus on axial non-enhanced computed tomography (NECT) is identified. It also disrupts the lamina papyracea. This is consistent with stage IV. (B) Axial NECT with a mass of the left lateral nasal wall, which has disrupted the lamina papyracea and invades the left orbit. Because it has spread outside the nasal cavity and sinuses, this is stage IV. (C) Coronal NECT shows a left nasal and maxillary lesion thought to be an inverted papilloma but biopsy showed a benign polyp. Despite imaging characteristics, neoplastic features may still overlap and diagnosis on imaging alone is difficult.
Curr Probl Diagn Radiol, March/April 2010
B FIG 5. Juvenile nasopharyngeal angiofibroma. (A) Post contrast coronal CT showing marked enhancement of a highly vascular mass extending in the pterygopalatine fossa. (B) Post contrast coronal T2WI shows flow voids due to the highly vascular nature, termed a “salt and pepper” appearance.
57
FIG 6. Melanoma. (A) Axial T1WI shows right-sided septal mucosal thickening. Low signal intensity reflects a special type called amelanotic melanoma: tumors may contain variable amounts of melanin. (B) Axial post contrast T1WI reveals enhancement of the soft tissues near the right nasal septum and nare beyond that of normal mucosal tissue. (C) Axial positron emission tomography/computed tomography (PET/ CT) shows abnormal glucose metabolic activity diffusely along the right septal mucosal surface, which can be termed melanosis.
58
FIG 7. Lymphoma. (A) Axial CECT shows a nonspecific homogeneous soft-tissue mass in the right nasal cavity with extension into the subcutaneous tissues below the right orbit. (B) An axial PET/CT shows corresponding hypermetabolic activity in the mass.
Curr Probl Diagn Radiol, March/April 2010
FIG 8. Chondrosarcoma. (A) Axial CECT shows heterogeneous enhancement pattern due to cartilage, mucoid tissue, or necrosis. (B) Axial NECT shows characteristic whorls of calcification that is highly suggestive of the diagnosis. (C) Coronal T2WI shows inflammatory edema within the right frontal temporal lobe. Chondroid matrix is usually bright on T2 because of its water content. (D) Axial T1WI shows a lobulated heterogeneous mass with intracranial and intraorbital extension.
Curr Probl Diagn Radiol, March/April 2010
59
Melanoma Nasal malignant melanoma is a rare and aggressive cancer with a very poor outcome. The most common site for nasal malignant melanoma is the nasal septum. Treatment at this time is aggressive surgical wide resection. Metastasis is frequently due to the rich lymphatic and vascular supply inherent to this region. Positron emission tomography/computed tomography (PET/CT) is used to identify and stage distant metastases (Fig 6).5
Lymphoma Nearly all nasopharyngeal lymphomas are non-Hodgkin’s type and most of these in the western United States are of B-cell origin, as in the illustrated case.6 The most common presentation is nasal obstruction, but a painless mass has also been reported as being common. This patient was a 77-year-old female with a painless mobile lump for at least the past year. Pathology is the primary mode for definitive diagnosis and cell type, but anatomic location can sometimes be a predictor. For example, B-cell tends to prefer maxillary sinus origins, whereas T-cell prefers midline/septum. The prognosis is much worse for nasal lymphomas than lymphoma at other sites, but B-cell has more favorable prognosis than T-cell (Fig 7).7
Chondrosarcoma Nasal sarcoma is extremely rare. Chondrosarcoma is the most common subtype, although under 10% of all chondrosarcomas will appear in the sinonasal region (mostly long bones and pelvis).8 Usually this tumor arises from the cartilaginous portion of the septum and presents as a painless mass. If neglected, it can become large enough to cause mass effect and invade surrounding structures. The treatment is surgical. Death occurs mostly due to skull base invasion. Metastatic disease would be uncommon (Fig 8).
Alveolar Soft Part Sarcoma This extremely rare tumor comprises less than 0.1% of sarcomas in the head and neck, and under 1% of all sarcomas.6 The most common group affected seems to be young females. Forty-one percent will involve the orbit when discovered in the head and neck. Alveolar soft part sarcoma progresses very slowly. The most common site of metastasis is in the lung. The treatment is surgical wide excision (Fig 9).
60
FIG 9. Alveolar soft part sarcoma. (A) Coronal CECT shows a heterogeneous soft-tissue expansile mass centered about the left nasal cavity with superior extension into the left ethmoid sinuses with destruction of the adjacent lamina papyracea. Mass effect is exerted on the otherwise uninvolved medial rectus muscle. (B) Coronal PET/CT shows abnormal hypermetabolic glucose activity within a left-sided sinonasal mass. There is invasion through the left lamina papyracea and through the floor of the left anterior cranial fossa.
Fibrous Histiocytoma Fibrous histiocytoma is a rare tumor with nonspecific imaging features that can be benign or malignant. It
Curr Probl Diagn Radiol, March/April 2010
FIG 10. Fibrous histiocytoma. (A) Coronal NECT shows a soft-tissue mass expanding the left nasal cavity extending to the cribiform plate. (B) Axial unenhanced T1WI shows the mass isointense to brain. The nasal septum is deviated to the right. (C) Axial unenhanced T2WI shows the mass isointense to brain. The higher signal within the left maxillary antrum is a result of obstruction of the osteomeatal unit.
can be found in many locations within the body. The benign form usually occurs in the diaphysis or in the pelvis. The malignant form usually occurs within soft tissues, and the adjacent bone is rarely involved. Indeed, it is extremely rare to have the benign type occur in the head and neck and even more rare for it to occur within the sinonasal cavity (Fig 10).7
REFERENCES 1. Allbery S, Chaljub G, Cho NL, et al. MR imaging of nasal masses. Radiographics 1995;15:1311-27. 2. Grossman RI, Yousem DM. Sinonasal disease. In: Neuroradiology the Requisites. Philadelphia, PA: Mosby, 2003. p. 611-38. 3. Nguyen Ba D. Sinonasal malignant melanoma with diffuse carcinomatosis: Initial PET/CT staging and follow-up CT/MR imaging. Radiol Case Rep 2008;3:1311-27.
Curr Probl Diagn Radiol, March/April 2010
4. Toma P, Granata C, Rossi A, et al. Multimodality imaging of Hodgkin’s disease and non-Hodgkin’s lymphomas in children. Radiographics 2007;27:1335-54. 5. Nakamura K, Uehara S, Omagari J, et al. Primary nonHodgkin’s lymphoma of the sinonasal cavities: Correlation of CT evaluation with clinical outcome. Radiology 1997;204: 431-5. 6. Chen CC, Hsu L, Hecht J, et al. Bimaxillary chondrosarcoma: Clinical, radiologic, and histologic correlation. AJNR Am J Neuroradiol 2002;23:667-70. 7. Kim HS, Lee HK, Weon YC, et al. Alveolar soft-part sarcoma of the head and neck: Clinical imaging features in five cases. AJNR Am J Neuroradiol 2005;26:1331-5. 8. Shrier DA, Wang AR, Patel U, et al. Benign fibrous histiocytoma of the nasal cavity in a newborn: MR and CT findings. AJNR Am J Neuroradiol 1998;19:1166-8.
61
A pictorial review of nasal cavity neoplasms is provided for the reader to gain or refresh information about these neoplasms. The images provided are to help aid in recognition of the lesions. Retrospective case review of pathologically and clinically proven nasal cavity neoplasms are shown with multiple modalities including computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography/computed tomography (PET/CT) to illustrate the findings and complement a succinct review of this category of disease. Examples include squamous cell cancer, adenoid cystic cancer, esthesioneuroblastoma, inverted papilloma, juvenile nasal angiofibroma, melanoma, lymphoma, sarcoma, and benign nasal histiocytoma.
Consider the nasal cavity as a triangle divided in the middle by the nasal septum. This pyramid opens into the nasal vault, the floor of which is the hard and soft palate. The roof is the cribiform plate, and the lateral walls hold the turbinates. These lateral walls are the functionally most significant part of the nose because the paranasal sinuses drain through them. The superior, middle, and inferior meatus are covered by their respective turbinate. Normal anatomic variations of the turbinates can be seen, including partial aeration (called concha bullosa), and there can be asymmetric enlargement of a turbinate due to normal physiological cycle. The nasal cavity and paranasal sinuses thus aerate and drain the maxillary, frontal, ethmoid, and sphenoid sinuses. The differential diagnoses of nasal masses can be quite extensive as seen in Table 1.1 This pictorial review focuses mainly on examples of primary neoplasms.
From the Department of Radiology, WVU Health Sciences Center, Morgantown, WV. Reprint requests: Heather Boo, MD, Robert C. Byrd Health Sciences Center, Box 9235 HSC, Morgantown, WV 26506. E-mail: hboo@hsc. wvu.edu. Curr Probl Diagn Radiol 2010;39:54-61. © 2010 Mosby, Inc. All rights reserved. 0363-0188/2010/$36.00 ⫹ 0 doi:10.1067/j.cpradiol.2009.07.001
54
TABLE 1. Differential diagnosis of nasal masses Primary neoplasms Squamous cell carcinoma Minor salivary gland tumor Inverted papilloma Esthesioneuroblastoma Angiofibroma Lymphoma Rhabdomyosarcoma Osteoma Osteosarcoma Chondrosarcoma Plasmacytoma Meningioma Hemangiopericytoma Secondary neoplasms Paranasal sinus squamous cell carcinoma Meningioma Metastasis Chordoma Lymphoma Infectious or inflammatory masses Inflammatory polyp Antrochoanal polyp Adenoidal hypertrophy Fungal rhinosinusitis Wegener’s granulomatosis Congenital masses Encephalocele Glioma Teratoma Dermoid cyst Epidermoid cyst Idiopathic or acquired masses Fibrous dysplasia Idiopathic midline granuloma Cocaine granuloma
Squamous Cell Carcinoma Squamous cell carcinoma (SCC) comprises 80%-90% of all primary sinonasal malignancies.2 Most of them will occur in the maxillary antrum, followed by the nasal cavity. It is also the most likely tumor to invade this region secondarily. The typical presentation is a male patient over the age of 50. Occupational exposures, cigarette smoking, nickel, and chrome exposure are known risk factors.
Curr Probl Diagn Radiol, March/April 2010
FIG 1. Squamous cell carcinoma. (A) Axial contrast-enhanced computed tomography (CECT) demonstrates a soft-tissue mass in the left nasal cavity with solid enhancement. This distinguishes it from the rim-enhancing masses such as inspissated secretions or a mucocele. The differential for this mass includes undifferentiated carcinoma, lymphoma, inverted papilloma, and even some sarcomas. (B) Axial T2 weighted image (T2WI) shows the mass to be both heterogeneous and hypointense, which is a very important distinguishing feature to differentiate SCC from inflammation, the latter of which will exhibit more T2 shortening.
Bony destruction is common with SCC. In fact, irregular destruction or nonvisualization of an adjacent bone is most commonly SCC. Most patients present later in the disease process such that 80% already will
Curr Probl Diagn Radiol, March/April 2010
FIG 2. Adenoid cystic carcinoma. (A, B) Axial and coronal T2WI show somewhat low signal intensity of the large intranasal mass relating to the degree of necrosis, cellular density, and type of histologic pattern.
have osseous destruction at the time of diagnosis. The patient depicted in Fig 1 is an 80-year-old male with repeated bouts of epistaxis and found to have a lesion on the left turbinate.
55
Minor Salivary Gland Tumor: Adenoid Cystic Adenoid cystic cancer is the most common histologic subtype of the minor salivary gland tumors.2,3 Other subtypes include mucoepidermoid carcinoma, adenocarcinoma, and undifferentiated carcinoma. Contrast should always be used in the imaging evaluation to check for perineural spread; sometimes nerve pain or numbness is the presenting complaint. Anatomic location may predict cell type (eg, adenocarcinoma is more likely to arise in the ethmoid air cells), and adenoid cystic is most likely to occur in the oral cavity. These tumors are slow growing, but relentless, and distal metastases are most common to the lungs (Fig 2).
Esthesioneuroblastoma Anatomically, the most common site of origin is high in the nasal vault from the olfactory epithelium, most of which is located at the cribiform plate. Esthesioneuroblastoma has 2 peaks of incidence: the first in young men and the second between the ages of 50 and 60 years.2,4 Clinical complaints include nasal pressure, headache, nasal discharge, and inability to breathe through the nose or smell. Treatment is a combined approach of surgery and radiation (Fig 3).
Inverted Papilloma The inverted papilloma is the most common type of papilloma. Though benign, approximately 15% of inverted papillomas harbor a squamous cell carcinoma. Anatomically, the most common site of origin is the lateral nasal wall. Like esthesioneuroblastoma, it can cross the cribiform plate quite aggressively. The extent of the mass determines the staging (Fig 4 and Table 2).
Juvenile Nasopharyngeal Angiofibroma The classic clinical presentation is a teenage male presenting with nasal obstruction and epistaxis. Juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor with a propensity to bleed. It often shows aggressive spread through the skull base foramina. Preoperative embolization can be performed to reduce blood loss. The tumor is staged based on extent of spread as outlined in Table 3 (Fig 5).
56
FIG 3. Esthesioneuroblastoma. (A) Sagittal post contrast T1 weighted image (T1WI) showing a large nasal mass extending through the ethmoid sinuses with subsequent intracranial extension. There is avid enhancement due to the highly vascular nature of the mass. The frontal lobe is displaced upward. (B) Coronal T2WI shows an intermediate to hyperintense mass inferior to the cribiform plate. (C) Coronal T1WI showing the same mass that is hypointense on T1WI.
Curr Probl Diagn Radiol, March/April 2010
TABLE 2. Staging of inverted papilloma I. Limited to the nasal cavity II. Limited to the ethmoid sinuses and medial and superior portions of the maxillary sinuses III. Extension into the lateral and inferior aspects of the maxillary sinuses or extension into the frontal or sphenoid sinuses TABLE 3. Staging of JNA IA. Tumor limited to posterior nares or nasopharyngeal vault IB. Extension into 1 or more paranasal sinus IIA. Minimal lateral extension through sphenopalatine foramen into medial pterygomaxillary fossa IIB. Full occupation of pterygomaxillary fossa, displacing posterior wall of antrum forward; superior extension eroding orbital bones IIC. Extension through pterygomaxillary fossa into cheek and temporal fossa III. Intracranial extension
Pterygomaxillary/ pterygopalatine fossa
Sphenopalatine foramen
A
FIG 4. Inverted papilloma. (A) A nonspecific mass filling the ethmoid air cells and a portion of the left sphenoid sinus on axial non-enhanced computed tomography (NECT) is identified. It also disrupts the lamina papyracea. This is consistent with stage IV. (B) Axial NECT with a mass of the left lateral nasal wall, which has disrupted the lamina papyracea and invades the left orbit. Because it has spread outside the nasal cavity and sinuses, this is stage IV. (C) Coronal NECT shows a left nasal and maxillary lesion thought to be an inverted papilloma but biopsy showed a benign polyp. Despite imaging characteristics, neoplastic features may still overlap and diagnosis on imaging alone is difficult.
Curr Probl Diagn Radiol, March/April 2010
B FIG 5. Juvenile nasopharyngeal angiofibroma. (A) Post contrast coronal CT showing marked enhancement of a highly vascular mass extending in the pterygopalatine fossa. (B) Post contrast coronal T2WI shows flow voids due to the highly vascular nature, termed a “salt and pepper” appearance.
57
FIG 6. Melanoma. (A) Axial T1WI shows right-sided septal mucosal thickening. Low signal intensity reflects a special type called amelanotic melanoma: tumors may contain variable amounts of melanin. (B) Axial post contrast T1WI reveals enhancement of the soft tissues near the right nasal septum and nare beyond that of normal mucosal tissue. (C) Axial positron emission tomography/computed tomography (PET/ CT) shows abnormal glucose metabolic activity diffusely along the right septal mucosal surface, which can be termed melanosis.
58
FIG 7. Lymphoma. (A) Axial CECT shows a nonspecific homogeneous soft-tissue mass in the right nasal cavity with extension into the subcutaneous tissues below the right orbit. (B) An axial PET/CT shows corresponding hypermetabolic activity in the mass.
Curr Probl Diagn Radiol, March/April 2010
FIG 8. Chondrosarcoma. (A) Axial CECT shows heterogeneous enhancement pattern due to cartilage, mucoid tissue, or necrosis. (B) Axial NECT shows characteristic whorls of calcification that is highly suggestive of the diagnosis. (C) Coronal T2WI shows inflammatory edema within the right frontal temporal lobe. Chondroid matrix is usually bright on T2 because of its water content. (D) Axial T1WI shows a lobulated heterogeneous mass with intracranial and intraorbital extension.
Curr Probl Diagn Radiol, March/April 2010
59
Melanoma Nasal malignant melanoma is a rare and aggressive cancer with a very poor outcome. The most common site for nasal malignant melanoma is the nasal septum. Treatment at this time is aggressive surgical wide resection. Metastasis is frequently due to the rich lymphatic and vascular supply inherent to this region. Positron emission tomography/computed tomography (PET/CT) is used to identify and stage distant metastases (Fig 6).5
Lymphoma Nearly all nasopharyngeal lymphomas are non-Hodgkin’s type and most of these in the western United States are of B-cell origin, as in the illustrated case.6 The most common presentation is nasal obstruction, but a painless mass has also been reported as being common. This patient was a 77-year-old female with a painless mobile lump for at least the past year. Pathology is the primary mode for definitive diagnosis and cell type, but anatomic location can sometimes be a predictor. For example, B-cell tends to prefer maxillary sinus origins, whereas T-cell prefers midline/septum. The prognosis is much worse for nasal lymphomas than lymphoma at other sites, but B-cell has more favorable prognosis than T-cell (Fig 7).7
Chondrosarcoma Nasal sarcoma is extremely rare. Chondrosarcoma is the most common subtype, although under 10% of all chondrosarcomas will appear in the sinonasal region (mostly long bones and pelvis).8 Usually this tumor arises from the cartilaginous portion of the septum and presents as a painless mass. If neglected, it can become large enough to cause mass effect and invade surrounding structures. The treatment is surgical. Death occurs mostly due to skull base invasion. Metastatic disease would be uncommon (Fig 8).
Alveolar Soft Part Sarcoma This extremely rare tumor comprises less than 0.1% of sarcomas in the head and neck, and under 1% of all sarcomas.6 The most common group affected seems to be young females. Forty-one percent will involve the orbit when discovered in the head and neck. Alveolar soft part sarcoma progresses very slowly. The most common site of metastasis is in the lung. The treatment is surgical wide excision (Fig 9).
60
FIG 9. Alveolar soft part sarcoma. (A) Coronal CECT shows a heterogeneous soft-tissue expansile mass centered about the left nasal cavity with superior extension into the left ethmoid sinuses with destruction of the adjacent lamina papyracea. Mass effect is exerted on the otherwise uninvolved medial rectus muscle. (B) Coronal PET/CT shows abnormal hypermetabolic glucose activity within a left-sided sinonasal mass. There is invasion through the left lamina papyracea and through the floor of the left anterior cranial fossa.
Fibrous Histiocytoma Fibrous histiocytoma is a rare tumor with nonspecific imaging features that can be benign or malignant. It
Curr Probl Diagn Radiol, March/April 2010
FIG 10. Fibrous histiocytoma. (A) Coronal NECT shows a soft-tissue mass expanding the left nasal cavity extending to the cribiform plate. (B) Axial unenhanced T1WI shows the mass isointense to brain. The nasal septum is deviated to the right. (C) Axial unenhanced T2WI shows the mass isointense to brain. The higher signal within the left maxillary antrum is a result of obstruction of the osteomeatal unit.
can be found in many locations within the body. The benign form usually occurs in the diaphysis or in the pelvis. The malignant form usually occurs within soft tissues, and the adjacent bone is rarely involved. Indeed, it is extremely rare to have the benign type occur in the head and neck and even more rare for it to occur within the sinonasal cavity (Fig 10).7
REFERENCES 1. Allbery S, Chaljub G, Cho NL, et al. MR imaging of nasal masses. Radiographics 1995;15:1311-27. 2. Grossman RI, Yousem DM. Sinonasal disease. In: Neuroradiology the Requisites. Philadelphia, PA: Mosby, 2003. p. 611-38. 3. Nguyen Ba D. Sinonasal malignant melanoma with diffuse carcinomatosis: Initial PET/CT staging and follow-up CT/MR imaging. Radiol Case Rep 2008;3:1311-27.
Curr Probl Diagn Radiol, March/April 2010
4. Toma P, Granata C, Rossi A, et al. Multimodality imaging of Hodgkin’s disease and non-Hodgkin’s lymphomas in children. Radiographics 2007;27:1335-54. 5. Nakamura K, Uehara S, Omagari J, et al. Primary nonHodgkin’s lymphoma of the sinonasal cavities: Correlation of CT evaluation with clinical outcome. Radiology 1997;204: 431-5. 6. Chen CC, Hsu L, Hecht J, et al. Bimaxillary chondrosarcoma: Clinical, radiologic, and histologic correlation. AJNR Am J Neuroradiol 2002;23:667-70. 7. Kim HS, Lee HK, Weon YC, et al. Alveolar soft-part sarcoma of the head and neck: Clinical imaging features in five cases. AJNR Am J Neuroradiol 2005;26:1331-5. 8. Shrier DA, Wang AR, Patel U, et al. Benign fibrous histiocytoma of the nasal cavity in a newborn: MR and CT findings. AJNR Am J Neuroradiol 1998;19:1166-8.
61