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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4518_Библиотеки_им_академика_М_И_Перельмана
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Chapter 12
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Head andNeck Pathology
CalebJ.Fan, AndreyFilimonov, LuciaS.Olarte, KellyMagliocca,
andFredY.Lin
Pearls
• Papillary carcinoma features the formation of papillae and unique nuclear fea-
tures like “orphan Annie eye” nuclei and psammoma bodies.
• Melanoma is characterized by melanin pigment and is S100+, HMB 45+, Melan
A+ (melanocytic antigen), Tyrosinase+.
• Vestibular Schwanommas show two coexisting histologic patterns present
(Antoni A and Antoni B) with areas of characteristic perivascular hyalinization.
C. J. Fan (*) · F. Y. Lin
Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at the
Mount Sinai Hospital, New York, NY, USA
e-mail: fred.lin@mountsinai.org
A. Filimonov
Department of Otolaryngology, Head and Neck Surgery, Icahn School of Medicine at the
Mount Sinai Hospital, New York, NY, USA
e-mail: Andrey.limonov@mountsinai.org
L. S. Olarte
Surgery, Division of Otolaryngology– Head and Neck Surgery, Cedars Sinai Medical Center,
Los Angeles, CA, USA
e-mail: lucia@drolarte.com
K. Magliocca
Department of Pathology, Emory University Hospital Midtown– Pathology,
Atlanta, GA, USA
e-mail: kmagliocca@emory.edu
© Springer Nature Switzerland AG 2023
F. Y. Lin, Z. M. Patel (eds.), ENT Board Prep,
https://doi.org/10.1007/978-3-031-26048-3_12
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C. J. Fan et al.
Larynx
Nodule/Polyp (Fig.12.1a, b)
• Nodules: Bilateral, usually on the true vocal cord, middle third, less than
0.5cm in size
• Polyps: Unilateral, usually anterior 1/2 true cord, up to 3cm in size
• Smooth, rounded, sessile, or pedunculated excrescences
• Covered by squamous epithelium, can be keratotic/hyperplastic
• Subepithelial edema, vascular or myxoid stromal changes
Contact Ulcer (Fig.12.2)
• Aka: contact granuloma
• Polypoid, ulcerated lesion with associated granulation tissue and inammation
• Benign reactive epithelial response, usually bilateral
• Ulcerative lesion (active) and hyperplastic squamous epithelium (healing/
reactive)
• Associated brinoid necrosis, ± scattered multinucleated giant cells
• Connective tissue: granulation tissue, radiating dilated vascular pattern, promi-
nent enlarged reactive broblasts
Histoplasmosis (Fig.12.3)
• Histiocytic and lymphoplasmacytic inammatory inltrate
• May not have well-formed granuloma formation
• In the larynx can occur as the primary upper aerodigestive tract presentation or a
component of active pulmonary histoplasmosis
ab
Fig. 12.1 (a) Laryngeal nodule: Hyperplastic surface epithelium with normal maturation.
Basophilic and hyalinized stroma. (b) Laryngeal polyp: Surface epithelium with normal maturation. Edematous stroma with increased vascularity
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Fig. 12.2 Contact ulcer: Surface ulceration with radiating vascular channels within granulation tissue
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Fig. 12.3 Histoplasmosis: intracellular fungal organisms (arrow, including inset)
• Intracellular organisms
– Very small, 2–4 μm in size, oval yeast forms with pale capsular halo
– Difcult to see on hematoxylin and eosin stain (H&E)
• Fungal stain: Gomori’s methenamine silver (GMS) will highlight
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C. J. Fan et al.
Adult-Type Rhabdomyoma (Fig.12.4)
• Benign mesenchymal neoplasm with skeletal muscle differentiation
• Median age 60 years; male-female ratio 3:1
• Rarely, laryngeal adult-type rhabdomyoma associated with Birt-Hogg-Dubé
syndrome
• Large, polygonal, eosinophilic, and clear cells, pink brillar cytoplasm
• Granular-appearing cross-striations or crystals common
• Multiple small round nuclei, centrally or peripherally placed in cell
• Vacuolated cytoplasm due to glycogen content
– Results in “spider-web” formations, i.e., pink intracellular strands
• Special stains: phosphotungstic-acid hematoxylin (PTAH) stain: shows striations
of myoid differentiation
Laryngeal Papillomatosis (Fig.12.5)
• Most common benign epithelial neoplasm of the larynx/trachea, composed of
papillary fronds or nger-like projections of stratied squamous epithelium with
brovascular cores (arrows).
• Associated with HPV (most commonly low risk types 6/11, rarely HPV
16/18 seen).
• Tends to occur where ciliated/respiratory epithelium and squamous epithelium
juxtaposed.
• Mild cytologic atypia common, can have minor areas of keratinization.
Fig. 12.4 Adult-type rhabdomyoma: Glycogen results in clear cell change and development of
“spider webs” (long arrow). Granular appearance of eosinophilic muscle cells (short arrow)
a b
a
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– Extensive keratinization and/or high-grade dysplasia in bulky papillary epi-
thelial proliferation requires exclusion of papillary SCC.
• Koilocytotic changes can be seen (arrows).
Granular Cell Tumor (Fig.12.6)
• Benign neuroectodermal tumor
• Pseudoepitheliomatous hyperplasia of overlying squamous epithelium in
25–50% cases, unencapsulated
• Large, polygonal cells with granular eosinophilic cytoplasm (lysosomes)
• Nuclei small round, centrally placed
• Ancillary testing (special stains and IHC):
– PAS (periodic acid-Schiff) +, Diastase resistant (lysosomes appear red).
– S100+, SOX10+(neural differentiation).
– CD68 highlights cytoplasmic granules (lysosomes).
Fig. 12.5 Laryngeal papillomatosis: (a) Low magnication of papillary silhouette. Fibrovascular
cores support hyperplastic papillary squamous epithelium (arrows). (b) Koilocytosis, mild cellular
and nuclear variability (arrows)
Fig. 12.6 Granular cell
tumor: (a)
Pseudoepitheliomatous
(“pseudocarcinomatous”)
hyperplasia present in area
overlying granular cell
tumor (inset). (b)
Syncytium of large
eosinophilic cells with
granular cytoplasm
b
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C. J. Fan et al.
Squamous Cell Carcinoma (SCC) (Figs.12.7, 12.8, 12.9, 12.10,
12.11, and 12.12)
• Conventional SCC most commonly encountered type
• Multiple variants possible
Fig. 12.7 Squamous-cell carcinoma: Malignant epithelial proliferation forming keratin pearls
inltrating connective tissue
Fig. 12.8. Carcinoma cuniculatum: Well-differentiated squamous carcinoma variant with endophytic and cystic, burrowing appearance (arrows) into underlying tissues
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Fig. 12.9 Basaloid squamous cell carcinoma. Lobular basaloid tumor nests with comedonecrosis
arranged in compact jigsaw puzzle-like arrangement
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Fig. 12.10 Papillary squamous cell carcinoma: low magnication of papillary silhouette. Similar
to “celery or cauliower bunches” cut in cross-section. Inset, high magnication of pleomorphism
in tumor
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Fig. 12.11 Spindle-cell carcinoma: Atypical spindled cells in a collagenized stroma
C. J. Fan et al.
Fig. 12.12 Verrucous carcinoma: Warty surface silhouette of the well-differentiated neoplasm
with broad pushing invasion into the lamina below the level of the surrounding epithelium,
approaching skeletal muscle (compare distance between epithelium and muscle, highlighted by
paired arrows)
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Conventional SCC (Keratinizing Type) (Fig.12.7)
• Keratinization, keratin pearls, and/or presence of intercellular bridges and
“glassy” cytoplasm supportive of squamous differentiation.
• At interface of tumor and regional stromal tissue, stroma may show desmoplastic
reaction.
– Desmoplasia: pale blue-appearing extracellular matrix deposition with vari-
able degree of inammation adjacent to tumor nests
– helpful in recognizing and supporting “invasion”
• Inltrating tumor appearance variable: large cohesive nests, small inltrative
irregular nests and single cells.
• Grading (well, moderately, poorly): considers tumor similarity to normal squa-
mous epithelium.
Carcinoma Cuniculatum (CC) (Fig.12.8)
• Exceedingly bland, well-differentiated variant of SCC.
• Characterized by complex cystic, endophytic “rabbit-burrow” growth into under-
lying stroma.
• Partial/biopsy sampling of CC may be interpreted as reactive squamous epithe-
lium, epidermoid cyst, stula tract, and/or abscess.
• CC and verrucous carcinoma (VC) are both bland, well-differentiated keratiniz-
ing SCC variants but are distinguished by endophytic growth (CC) vs exophytic
growth (VC).
Basaloid SCC (Fig.12.9)
• Prominent basaloid (“blue”) H&E appearance, high nuclear to cytoplasmic ratio,
solid tumor lobules with basal palisading, central comedonecrosis
• Excess myxoid or hyaline matrix surrounds tumor nests, contributes to jigsaw
puzzle appearance
• Tumor cells monotonous in some tumors, but quite pleomorphic with vesicular
chromatin and prominent nucleoli in others
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C. J. Fan et al.
Papillary SCC (Fig.12.10)
• Variant of SCC with low magnication appearance of cut “celery stalks.”
• Complex exophytic, papillary fronds composed of abnormal squamous
epithelium:
– Commonly non-keratinizing epithelium
– Lack of epithelial maturation
– Increased and-or variable nuclear to cytoplasmic ratios, pleomorphism
– Abnormal mitotic gures, usually throughout the epithelial thickness
• Exophytic tumor extensions project into multiple planes but upon biopsy.
• In a subset, block-like p16 expression is seen along with high-risk RNA HPV in
situ hybridization, although nding remains of uncertain clinical signicance in
the larynx.
Spindle Cell Carcinoma (Fig.12.11)
• Variant of SCC with a microscopic spindle cell “sarcomatoid” pattern
• Exophytic polypoid lesions, often ulcerated, with surface brinoid necrosis
• Areas of overlying epithelial dysplasia and proximity to mucosa-based site favor
consideration of spindle cell carcinoma over a diagnosis of a true sarcoma
• Dense cellularity, more cellular than reactive lesions
– Arranged in fascicular or storiform, cartwheel pattern
Verrucous Carcinoma (Fig.12.12)
• Well-differentiated variant of SCC.
• Associated with tobacco, no denitive HPV association.
• Uniform squamous cells with little atypia.
• Epithelial cells show densely eosinophilic cytoplasm, i.e., “glassy.”
• Limited mitotic gures, conned to basal and parabasal layers.
• Marked surface parakeratinization, church spire-like or steeple-like projections,
and parakeratin crypts/invaginations.
• Dysplastic nuclei, irregular breakaway nests of inltration/invasion, and desmo-
plasia indicates conventional SCC.Terminology could then include:
– Hybrid verrucous + conventional
– Invasive well-differentiated SCCA with verrucous features.
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