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Oncocytoma of the nasal septum: A rare cause of epistaxis
Oncocytoma of the nasal septum: A rare cause of epistaxis ABDUL LATIF HAMDAN, MD, GHASSAN KAHWAGI, MD, FIRAS FARHAT, MD, and AYMAN TAWII, MD, New York, New York
Oncocytoma is a rare tumor of glandular tissue that occurs predominantly in major salivary glands. The term oncocytoma was first introduced by Jaffe et al in 1932 to refer to adenolymphoma, shortly after McFarland described a rare adenoma composed of oncocytes in 1927.1 These tumors have been reported to occur in endocrine glands (mainly the thyroid gland), liver, kidney, esophagus, trachea, and virtually anywhere along the seromucous lining of the respiratory tract. The nasal cavity is a rare site of primary occurrence of oncocytoma, with only few cases being reported in the literature.2 We describe a rare case of oncocytoma of the nasal septum in a 33-year-old man and provide a brief review of oncocytoma of the nasal cavity. The histologic features and clinical behavior of these tumors are discussed. CASE REPORT A 33-year-old man presented with a 1-year history of a mass in the right nasal cavity felt over the septum. The patient reported 1 episode of epistaxis 1 month earlier. He had no history of trauma to the nose, nasal obstruction, or symptoms of allergy or sinusitis. On examination, he was found to have a small lesion, 0.7 × 0.7 cm, over the right anterior aspect of the nasal septum in the little’s area. The mass was soft and nodular. The patient underwent local excision of the lesion with deep margins to
From the Departments of Otolaryngology–HNS (Drs Hamdan, Kahwagi, and Farhat) and Laboratory Medicine (Dr Tawil), American University of Beirut Medical Center. Reprint requests: Abdel Latif Hamdan, MD, Department of Otolaryngogogy–HNS, c/o AUB New York Office, 850 Third Ave, New York, NY 10022; e-mail, hb03@ aub.edu.1b Otolaryngol Head Neck Surg 2002;126:440-1. Copyright © 2002 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2002/$35.00 + 0 23/4/123925 doi:10.1067/mhn.2002.123925
440
include the perichondrium. Histologic examination revealed an oncocytoma. It was a well-circumscribed tumor growing in the lamina propria with an intact overlying surface epithelium (Fig 1A). The tumor was composed of large epithelial cells with eosinophilic granular cytoplasm and centrally placed bland nuclei. Tumor cells were arranged in nests and acinar structures supported by thin, highly vascularized connective tissue (Fig 1B). The results of immunohistochemical stains showed the tumor cells to be positive for cytokeratin and negative for vimentin, actin, desmin, S-100 protein, thyroglobulin, and α-fetoprotein. DISCUSSION Oncocytoma is a term that describes a tumor composed of epithelial cells or myoepithelial cells with abundant granular eosinophilic cytoplasm. The peculiar appearance of these cells (called oncocytes) is due to large numbers of mitochondria in their cytoplasm as demonstrated on electron microscopy.3 The term onkocyte, derived from the Greek word onkousthai, which means “swollen,” was first applied by Hamperl in 1931 to cells that constitute what we now consider to be oncocytoma.2 The distinguishing feature of oncocytic metaplasia (ie, the differentiation of a cell into an oncocyte) is that it occurs in epithelial cells of different origins but all cells look alike. There is a loss of all signs of organ-specific differentiation, making it impossible at times to differentiate between an oncocyte of a salivary gland from that of a thyroid gland.3 This transformation of a cell into an oncocyte does not impair its ability to divide and is transferred to the daughter cell, making it capable of becoming the site of hyperplasia and neoplasia, both benign and malignant. Most oncocytomas are benign, but there have been reports of malignant cases in the literature. The malignant forms are difficult to recognize microscopically because they may not differ much from the benign forms.
Otolaryngology– Head and Neck Surgery Volume 126 Number 4
Acceptable criteria for malignancy were stated by Gray et al1 as distant metastasis; local lymph node metastasis; perineural, intravascular, or lymphatic invasion; and frequent mitosis and cellular pleomorphism with invasion and destruction of adjacent structures. Oncocytic cells may be present in many organs and represent a form of regression, degeneration, or “burnout” of a cell with loss of its specific function. They are rare before the age of 20 years and are more common in elderly men.3 Oncocytomas may arise anywhere from the seromucous gland of the upper aerodigestive system, but it is unusual for them to appear outside the endocrine organs and major salivary glands. The nasal cavity is a rare site of occurrence, with only a few cases reported in the literature.2,4 The usual symptoms are epistaxis, nasal obstruction, rhinorhea, and the feeling of a nasal mass. Oncocytomas can occur anywhere in the nasal cavity, ranging from the nasal septum to the lateral nasal wall. Their clinical behavior cannot be predicted on the basis of their morphologic or biologic characteristics. They rarely have a capsule and may exhibit either a benign or a locally aggressive behavior with metastasis.4,5 In our patient, the tumor had a benign course with no invasion to the contiguous structures. Oncocytoma of the nasal cavity is a rarely encountered tumor. When diagnosed, proper assessment of the behavior of the lesion may direct the extent of resection and plan for further management.
HANDAN et al
441
A
REFERENCES
1. Gray SR, Cornog JL Jr, Sook IS. Oncocytic neoplasms of salivary glands: a report of fifteen cases including two malignant oncocytomas. Cancer 1976;38:1306-17. 2. Mahmoud NA. Malignant oncocytoma of the nasal cavity. J Laryngol Otol 1979;93:729-34. 3. Hamperl H. Benign and malignant oncocytoma. Cancer 1962;15:1019-27. 4. Comin CE, Dini M, Lo Russo G. Oncocytoma of the nasal cavity: report of a case and review of the literature. J Laryngol Otol 1997;111:671-3. 5. Nayak DR, Pillai S, Balakrishnan R et al. Malignant oncocytoma of the nasal cavity: a case report. Am J Otolaryngol 1999;20:323-327.
B Fig 1. A, Section showing the interface between the tumor (arrow) and adjacent lamina propria. The overlying epithelium is intact (hematoxylin-eosin stain, original magnification ×40). B, Section at higher magnification showing tumor cells (oncocytes) with uniform bland nuclei and prominent granular cytoplasm (hematoxylineosin stain, original magnification ×400).
Oncocytoma is a rare tumor of glandular tissue that occurs predominantly in major salivary glands. The term oncocytoma was first introduced by Jaffe et al in 1932 to refer to adenolymphoma, shortly after McFarland described a rare adenoma composed of oncocytes in 1927.1 These tumors have been reported to occur in endocrine glands (mainly the thyroid gland), liver, kidney, esophagus, trachea, and virtually anywhere along the seromucous lining of the respiratory tract. The nasal cavity is a rare site of primary occurrence of oncocytoma, with only few cases being reported in the literature.2 We describe a rare case of oncocytoma of the nasal septum in a 33-year-old man and provide a brief review of oncocytoma of the nasal cavity. The histologic features and clinical behavior of these tumors are discussed. CASE REPORT A 33-year-old man presented with a 1-year history of a mass in the right nasal cavity felt over the septum. The patient reported 1 episode of epistaxis 1 month earlier. He had no history of trauma to the nose, nasal obstruction, or symptoms of allergy or sinusitis. On examination, he was found to have a small lesion, 0.7 × 0.7 cm, over the right anterior aspect of the nasal septum in the little’s area. The mass was soft and nodular. The patient underwent local excision of the lesion with deep margins to
From the Departments of Otolaryngology–HNS (Drs Hamdan, Kahwagi, and Farhat) and Laboratory Medicine (Dr Tawil), American University of Beirut Medical Center. Reprint requests: Abdel Latif Hamdan, MD, Department of Otolaryngogogy–HNS, c/o AUB New York Office, 850 Third Ave, New York, NY 10022; e-mail, hb03@ aub.edu.1b Otolaryngol Head Neck Surg 2002;126:440-1. Copyright © 2002 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2002/$35.00 + 0 23/4/123925 doi:10.1067/mhn.2002.123925
440
include the perichondrium. Histologic examination revealed an oncocytoma. It was a well-circumscribed tumor growing in the lamina propria with an intact overlying surface epithelium (Fig 1A). The tumor was composed of large epithelial cells with eosinophilic granular cytoplasm and centrally placed bland nuclei. Tumor cells were arranged in nests and acinar structures supported by thin, highly vascularized connective tissue (Fig 1B). The results of immunohistochemical stains showed the tumor cells to be positive for cytokeratin and negative for vimentin, actin, desmin, S-100 protein, thyroglobulin, and α-fetoprotein. DISCUSSION Oncocytoma is a term that describes a tumor composed of epithelial cells or myoepithelial cells with abundant granular eosinophilic cytoplasm. The peculiar appearance of these cells (called oncocytes) is due to large numbers of mitochondria in their cytoplasm as demonstrated on electron microscopy.3 The term onkocyte, derived from the Greek word onkousthai, which means “swollen,” was first applied by Hamperl in 1931 to cells that constitute what we now consider to be oncocytoma.2 The distinguishing feature of oncocytic metaplasia (ie, the differentiation of a cell into an oncocyte) is that it occurs in epithelial cells of different origins but all cells look alike. There is a loss of all signs of organ-specific differentiation, making it impossible at times to differentiate between an oncocyte of a salivary gland from that of a thyroid gland.3 This transformation of a cell into an oncocyte does not impair its ability to divide and is transferred to the daughter cell, making it capable of becoming the site of hyperplasia and neoplasia, both benign and malignant. Most oncocytomas are benign, but there have been reports of malignant cases in the literature. The malignant forms are difficult to recognize microscopically because they may not differ much from the benign forms.
Otolaryngology– Head and Neck Surgery Volume 126 Number 4
Acceptable criteria for malignancy were stated by Gray et al1 as distant metastasis; local lymph node metastasis; perineural, intravascular, or lymphatic invasion; and frequent mitosis and cellular pleomorphism with invasion and destruction of adjacent structures. Oncocytic cells may be present in many organs and represent a form of regression, degeneration, or “burnout” of a cell with loss of its specific function. They are rare before the age of 20 years and are more common in elderly men.3 Oncocytomas may arise anywhere from the seromucous gland of the upper aerodigestive system, but it is unusual for them to appear outside the endocrine organs and major salivary glands. The nasal cavity is a rare site of occurrence, with only a few cases reported in the literature.2,4 The usual symptoms are epistaxis, nasal obstruction, rhinorhea, and the feeling of a nasal mass. Oncocytomas can occur anywhere in the nasal cavity, ranging from the nasal septum to the lateral nasal wall. Their clinical behavior cannot be predicted on the basis of their morphologic or biologic characteristics. They rarely have a capsule and may exhibit either a benign or a locally aggressive behavior with metastasis.4,5 In our patient, the tumor had a benign course with no invasion to the contiguous structures. Oncocytoma of the nasal cavity is a rarely encountered tumor. When diagnosed, proper assessment of the behavior of the lesion may direct the extent of resection and plan for further management.
HANDAN et al
441
A
REFERENCES
1. Gray SR, Cornog JL Jr, Sook IS. Oncocytic neoplasms of salivary glands: a report of fifteen cases including two malignant oncocytomas. Cancer 1976;38:1306-17. 2. Mahmoud NA. Malignant oncocytoma of the nasal cavity. J Laryngol Otol 1979;93:729-34. 3. Hamperl H. Benign and malignant oncocytoma. Cancer 1962;15:1019-27. 4. Comin CE, Dini M, Lo Russo G. Oncocytoma of the nasal cavity: report of a case and review of the literature. J Laryngol Otol 1997;111:671-3. 5. Nayak DR, Pillai S, Balakrishnan R et al. Malignant oncocytoma of the nasal cavity: a case report. Am J Otolaryngol 1999;20:323-327.
B Fig 1. A, Section showing the interface between the tumor (arrow) and adjacent lamina propria. The overlying epithelium is intact (hematoxylin-eosin stain, original magnification ×40). B, Section at higher magnification showing tumor cells (oncocytes) with uniform bland nuclei and prominent granular cytoplasm (hematoxylineosin stain, original magnification ×400).