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Benign Neoplasms and Tumor-Like Lesions 145
a cb
Fig. 8.41a–c. Recurrent/persistent juvenile angiofi broma (JA). SE T1 after contrast administration, coronal plane (a,b); endo-
scopic view (c). a Normal postsurgical MR fi ndings are demonstrated in the fi rst follow-up examination. b Patient did not follow
a regular imaging and clinical follow-up. He presented 3 years after surgery showing a recurrent/persistent lesion at the level of
the pterygoid root (b) with a prevalently exophytic pattern of growth, detectable on endoscopic examination (c)
8.8
Pyogenic Granuloma
(Lobular Capillary Hemangioma)
8.8.1
Defi nition, Epidemiology, Pattern of Growth
First reported in the nineteenth century by Poncet
and Dor (1897) with the term of botryomycoma, pyo-
genic granuloma is a benign, rapidly growing lesion,
characterized by a lobular proliferation of capillaries
(Mills et al. 1980), also known with several other
names (i.e., telangiectatic granuloma, granuloma pedunculatum, infected granuloma). Even though the
term “pyogenic granuloma” is the most commonly
used, it does not address the true nature of the lesion,
which is neither the result of a bacterial infection
nor a true granuloma (El-Sayed and Al-Serhani
1997).
In 1980, the synonym “lobular capillary heman-
gioma” was proposed as an adequate term to indicate a lesion which consists of capillaries arranged
in lobules and separated by a loose connective tissue stroma, often infi ltrated by infl ammatory cells
(Mills et al. 1980).
Lobular capillary hemangioma mainly affects
the female population, with a peak incidence in
the third decade (range: 11–65 years) (Leyden and
Master 1973; El-Sayed and Al-Serhani 1997).
The lesion may involve skin and mucosa, most often
in the oral cavity, where the lips are more frequently
affected (about 38% of patients). Sinonasal localization ranges from 7% to 29%, the anterior portion of
the nasal septum and the turbinates being the most
frequently involved areas (Jafek et al. 1977; Mills
et al. 1980).
The pathogenesis of the lesion is still unclear.
Nasal trauma and hormonal imbalances have been
postulated as possible etiologic factors (Lance et al.
1992). The second hypothesis seems to play a role in
a variant of lobular capillary hemangioma known as
granuloma gravidarum, which usually appears on
the gingival mucosa during pregnancy (Miller et al.
1999).
8.8.2
Treatment Guidelines
The ideal treatment for lobular capillary hemangioma is radical surgery, which in most cases can
be performed through a microendoscopic approach
even in very extensive lesions. Other alternative
treatments (i.e., electrocoagulation, cryotherapy,
Nd:YAG laser) have been successfully employed
(Mayer 1962; Leopard 1975; Powell et al. 1994).
Routine use of preoperative microembolization,
which was suggested to improve bleeding control
in oral lesions (Forman and Goldberg 1990), does
not seem routinely justifi ed for sinonasal localizations.
146
R. Maroldi et al.
8.8.3
Key Information to Be Provided by Imaging
Site, size, and vascularization of the lesion
8.8.4
Imaging Findings
Pyogenic granuloma has no distinctive imaging
features. CT shows a soft tissue density mass with
lobulated contours more commonly arising from
the nasal septum (Simo et al. 1998) (Fig. 8.42). Sinus
opacifi cation can be observed when the mass impairs
any of the mucus drainage pathways. Bony remodeling is usually observed, while bony destruction has
been described in a single case (Lance et al. 1992).
On MR, pyogenic granuloma exhibits intermediate to bright signal on T2 and hypointense signal on
T1 sequences (Fig. 8.43). Relevant enhancement is
observed after either Gd-based or iodine contrast
administration (El-Sayed and Al-Serhani 1997).
Angiography demonstrates the presence of several
arteries converging into the lesion.
The differential diagnosis should be restricted to
highly vascularized sinonasal masses: hemangioma,
hemangiopericytoma, juvenile angiofi broma, paraganglioma and vascularized metastases (kidney, thy-
ba
Fig. 8.42a,b. Pyogenic granuloma. Plain CT, enhanced VIBE, axial plane. A polypoid mass occupies
the right nasal fossa, indenting the medial maxillary sinus wall. This appears almost completely
demineralized on CT (white arrowheads), whereas MR shows permeation of a residual hypointense
periosteal layer (black arrows). CT density is unremarkable, bright and uniform enhancement is
demonstrated on Gd-DTPA VIBE sequence
a cb
Fig. 8.43a–c. Pyogenic granuloma. Endoscopy (a), TSE T2 (b) on axial plane, enhanced T1 on coronal plane (c). a Endoscopy of
the right nasal fossa shows a pale polypoid mass completely fi lling the inferior meatus and displacing superiorly the inferior
turbinate (IT). NS, nasal septum; MT, middle turbinate. The lobular capillary hemangioma has a hyperintense signal on T2
sequence, it turns around the septum to extend into the contralateral choana. At surgery, the lesion was demonstrated to arise
from posterior nasal septum (arrows). c On the enhanced coronal T1 image a focal irregularity on the right surface of the nasal
septum (arrows) is seen. The inferior turbinate is displaced superiorly (arrowheads)
Benign Neoplasms and Tumor-Like Lesions 147
roid, lung, breast). Unfortunately, among these, exclusively juvenile angiofi broma holds pathognomonic
features (site of origin, presence of intralesional vascular fl ow voids, age, and male sex of patients). As a
consequence, pyogenic granuloma can be suspected
only by matching imaging fi ndings and clinical history (female sex, age in the range 20–40 years, pregnancy, site of origin of the lesion).
8.8.4.1
Diff erential Diagnosis with Cavernous Hemangioma
On CT, cavernous hemangioma may be very diffi cult
to be suspected. Plain study can detect a unilateral
hypodense mass, that may be associated with destruction of the sinusal bony walls, showing poor to mild,
non-homogeneous enhancement (Loh et al. 1994; Kim
et al. 1995; Dufour et al. 2001). On MR, cavernous
hemangioma usually shows intermediate T1 and hyperintense T2 signal, prior to contrast administration
(Fig. 8.44). The enhancement is remarkable. Signal
voids corresponding to enlarged vessels may also be
detected within the lesion. Angiography further defi nes the vascular supply to the mass. Preoperative
embolization has been recommended to prevent uncontrollable hemorrhage (Kilde et al. 2003).
The differential diagnosis includes capillary hemangioma (pyogenic granuloma), hemangioendothelioma, angiosarcoma, and Kaposi’s sarcoma. Most
cavernous hemangiomas arise from the maxillary
sinus (Kul kar ni et al. 1989), while capillary hemangioma more frequently is seen at the nasal septum
(Iwata et al. 2002; Kilde et al. 2003) and is charac-
terized by a dense enhancement on both CT and MR.
Furthermore, adjacent bony structures are usually
remodeled rather than eroded (Dillon et al. 1991).
8.9
Unusual Benign Lesions
A large spectrum of unusual benign lesions taking
origin from minor salivary glands (i.e., pleomorphic
adenoma, monomorphic adenoma) (Compagno and
Wo ng 1977; Cano Cuenca et al. 2000; London et
al. 2002) and soft tissues (i.e., benign fi brous histiocytoma, hemangioma, infl ammatory myofi broblastic tumor, leiomyoma, myxoma, paraganglioma,
schwannoma) (Gregor and Loftus-Coll 1994;
Basak et al. 1998; Soysal et al. 2001; Bloom et al.
2001; Kilde et al. 2003; Cakmak et al. 2003; Ketabchi
et al. 2003) has been reported in the sinonasal tract
(Fig. 8.45).
The predominant symptom is unilateral nasal obstruction, which is mostly related to the presence of
a polypoid or sessile lesion of variable macroscopic
appearance. When the lesion entirely fi lls the nasal
cavity, determination of the site of origin can be very
diffi cult even resorting to endoscopic examination.
Information provided by imaging rarely suggests
the histologic diagnosis, but it is essential to discriminate between liquid vs. solid content of the lesion, together with the degree of vascularization. Moreover,
imaging may detect connection or extension to the
anterior cranial fossa.
Apart from the very rare lesions extending intracranially (Nicolai et al. 1996), benign tumors are
generally amenable with microendoscopic surgery.
Since most of the aforementioned lesions share the
same epidemiologic, clinical and radiologic profi le,
as well as the same treatment guidelines, only pleomorphic adenoma, schwannoma, leiomyoma, and
paraganglioma, which are more frequently observed
in the sinonasal tract, will be discussed in detail.
Fig. 8.44. Cavernous hemangioma. TSE T2 fat-sat coronal
plane. In the right nasal fossa a large hemangioma extends
deeply into the maxillary sinus (black arrows) and displaces
the nasal septum contralaterally (white arrows)
8.9.1
Pleomorphic Adenoma (Mixed Tumor)
With more than 100 cases reported in the literature (Compagno and Won g 1977; Freeman et al.
148
R. Maroldi et al.
a
c d
Fig. 8.45a–d. Myofi broblastic infl ammatory tumor. TSE T2 (a) and enhanced T1 (b) on coronal
plane. a On left side, the ethmoid is occupied by an hypointense mass (asterisk) abutting the
adjacent lamina papyracea. Extensive thickening of the nasal septum due to spread of lesion is
demonstrated (arrows). Retained secretions within frontal sinus are characterized by bright signal. b Posteriorly, the mass shows intermediate signal intensity (white arrows), it causes blockage
of left maxillary sinus. On the opposite side, the maxillary sinus is partially fi lled by signal intensity consistent with lesion (1). Thickening of anterior infraorbital canal is present (2). c Same
level as (a) after Gd-DTPA: non-homogeneous enhancement of the left ethmoid (asterisk) and
septal lesions is shown. Effacement of intraorbital fat is also present (arrows). d Same level as (b)
after Gd-DTPA: enhancement of the lesion extending into right maxillary sinus is demonstrated
(1). Compared to the left side (3), the right infraorbital nerve presents perineural thickening
and enhancement (2). Focal interruption of hypointense periosteal/bony layer (arrowhead) of
the left fovea is associated with enhanced thickened dura (4)
b
1990; Prager et al. 1991; Liao and Chong 1993;
Wakami et al. 1996; Golz et al. 1997; Jassar et al.
1999; Makeieff et al. 1999; Fa co n et al. 2002), pleomorphic adenoma is the most common benign tumor of the sinonasal tract after osteoma and inverted
papilloma. Histologically, the neoplasm displays a
pleomorphic architecture, being made up of lumi-
nal-type ductal epithelial cells, myoepithelial cells
and tissue of mucoid, myxoid, or chondroid appearance (Shanmugaratnam 1991). Most pleomorphic
adenomas take origin from major salivary glands,
whereas only about 10% affect minor salivary glands,
more commonly of the hard and soft palate (Prager
et al. 1991; Liao and Chong 1993). The tumor may
Benign Neoplasms and Tumor-Like Lesions 149
rarely occur in other sites such as the lacrimal gland,
larynx, pharynx, sinonasal tract, and trachea. Data
from two major reviews of patients with pleomorphic adenoma of the sinonasal area (Compagno and
Wo ng 1977; Wakami et al. 1996) clearly identify the
nasal septum as the most frequently affected site, followed by the maxillary sinus. Pleomorphic adenoma
usually affects patients in the fi fth decade of life, with
a slight female predominance. At present, no one of
the histogenetic hypotheses (i.e., misplaced embryogenic ectodermal epithelial cells, residual of the vomeronasal organ, fully developed salivary gland tissue)
postulated to explain the origin of the lesion from
the nasal septum is fully accepted (Stevenson 1932;
Matthew et al. 1944; Evans and Cruickshank
1970). Strangely enough, fewer minor salivary glands
are present in the septal submucosa than in other
sinonasal anatomic areas (Wa l l a c e et al. 1990).
A recurrence rate of 10% after surgical treatment
has been specifi cally reported for sinonasal localizations by Compagno and Wo n g (1977). According to
the authors, this low recurrence rate might be related
to the histologic profi le of sinonasal pleomorphic
adenoma, which presents more cells and less myxoid
stroma than the major salivary gland counterpart.
Distant metastases and malignant degeneration have
been rarely observed (Freeman et al. 1990; Cho et
al. 1995).
8.9.1.1
Imaging Findings
Sinonasal pleomorphic adenoma generally appears
as a well-defi ned soft tissue mass, most commonly
arising from the nasal septum (Pisani et al. 1998)
(Fig. 8.46). Bone destruction is unexpected, unless
malignant transformation has occurred (Yi ota ki s
et al. 2001b). Ossifi cation has been described in an
isolated report (Lee et al. 1992).
As for lesions arising in more typical sites (such
as the parotid gland), MR fi ndings consist of T2 hyperintensity, low to intermediate T1 signal and nonhomogeneous enhancement (Yio tak is et al. 2001b;
Unlu et al. 2003).
Nonetheless, none of the above-mentioned features support a defi nitive diagnosis.
8.9.2
Schwannoma
According to the WHO classifi cation (Shanmugaratnam 1991), schwannoma is a benign tumor
taking origin from Schwann cells. Even though this
tumor has been in the past indicated with other
synonyms such as neurilemmoma, neurinoma, neurolemmoma, neuroma, perineural fi broblastoma,
peripheral fi bromatosis, peripheral glioma and
schwannoglioma, schwannoma nowadays is universally considered the most adequate term. From a
macroscopic standpoint, schwannomas are well encapsulated, gelatinous, or cystic lesions.
Schwannoma frequently occurs in the head and
neck area (25%–45%), but only about 4% of the lesions involve the sinonasal tract (Yo u n i s et al. 1991;
Donnelly et al. 1992). In this region, the ethmoid
complex is the more frequently affected site, followed
by the maxillary sinus, nasal septum, and sphenoid
Fig. 8.46a,b. Pleomorphic adenoma. Plain CT on axial (a) and coronal plane (b). Non-homoge-
neous soft tissue mass centered on the anterior part of the septum and occupying both nasal
vestibules. Both displacement and erosion of the septum are demonstrated (arrows). (Courtesy of
Castelnuovo, MD and Di Giulio, MD, Pavia, Italy)
ba
150
R. Maroldi et al.
sinus (Berlucchi et al. 2000). Most cases occur between the second and fi fth decade of life (range: 6–
78 years); there is no specifi c association with sex or
race (Higo et al. 1993). Even though some schwannomas of the sinonasal tract are associated with Von
Recklinghausen’s disease, the neoplasm usually occurs in the solitary form (Oi et al. 1993).
The risk of malignant transformation is very
low; however an increase in patients affected by Von
Recklinghausen’s disease (about 10%–15% of cases)
has been observed (Butugan et al. 1993).
8.9.2.1
Imaging Findings
CT and MR appearance of sinonasal schwannomas is
rather nonspecifi c. Remodeling and interruption of
adjacent bony structures are frequent fi ndings, which
may be present alone or in association (Fujiyoshi
et al. 1997) (Fig. 8.47). MR fi ndings refl ect the histologic features of the lesion. In detail, the prevalence
of Antoni A component (highly cellular) results in
intermediate signal on both T1 and T2. On the other
hand, whenever an Antoni B pattern is predominant,
schwannomas exhibit a more cystic appearance. In
fact, in these cases, T2 hyperintensity is observed,
due to the presence of intercellular loose myxoid
stroma. Contrast uptake is variable and often nonhomogeneous (Bando et al. 1992; Sarioglu et al.
2002, Cakmak et al. 2003; Quesada et al. 2003). No
enhancement is observed in cystic areas of Antoni
B schwannomas (Sarioglu et al. 2002). Intracranial
extension has been reported in few cases (Fujiyoshi
et al. 1997).
8.9.3
Leiomyoma
Leiomyoma is a benign myogenic neoplasm which
may sporadically occur in the sinonasal area
(Zijlker and Vis se r 1989; Nal l et al. 1997). From
the histological standpoint, it is classifi ed into the
following subtypes: vascular, nonvascular, and epithelioid, also known as leiomyoblastoma (Batsakis
1978). In the former type, the lesion seems to arise
from vessel walls. In the second type, neoplastic cells
are generally spindle-shaped and associated with
lengthened blunt-ended nuclei and eosinophilic cytoplasm. In the epithelioid form, the cells are round
or polygonal, with clear or eosinophilic cytoplasm
(Shanmugaratnam 1991).
ba
Fig. 8.47a–c. Benign schwannoma. Plain CT (a),
SE T2 (b), Gd-DTPA SE T1(c), coronal plane. A
soft tissue mass occupies the left nasal fossa. Mild
displacement of the nasal septum is observed, in
the absence of bone destruction. Bright contrast
enhancement might refl ect the relative preva-
c
lence of Antoni A component in the histology of
the lesion
Benign Neoplasms and Tumor-Like Lesions 151
Hachisuga et al. (1984), in a large series of 562
patients affected by leiomyoma, observed only fi ve
cases of sinonasal involvement. Nicolai et al. (1996),
in a review of the literature, identifi ed about 30 instances of well-documented sinonasal leiomyomas.
The neoplasm usually affects subjects between the
fi fth and sixth decade of life, with a slight predominance for females.
The rarity of such a lesion in the sinonasal tract
may be explained by the paucity of vascular smooth
muscle fi bers, which are considered the elements of
origin (Batsakis 1978; Mccaffrey et al. 1978; ).
According to other theories, the lesion could stem
from aberrant undifferentiated mesenchymal cells or
from piloerector or sweat gland muscles (Batsakis
1978; Barr et al. 1990).
8.9.3.1
Imaging Findings
Both the lack of specifi city of CT or MR fi ndings
and the extreme rarity of sinonasal leiomyoma make
an imaging based diagnosis nearly impossible. As an
aggressive pattern of growth has sometimes been described for this benign lesion – including bone destruction and orbit encroachment (Harcourt and
Gallimori 1993; Trott et al. 1994) – the main role
of imaging is to precisely defi ne the deep extension
of the lesion.
mately 30 cases reported in the literature (Ketabchi
et al. 2003). In this area, the lesion more frequently
involves the ethmoid and the middle turbinate; furthermore, there is a slight predominance in females
and in the fi fth decade of life (Ketabchi et al. 2003).
As in other anatomic sites, paraganglioma of the sinonasal tract may display an aggressive behavior and an
infi ltrating growth pattern (Welkoborsky et al. 2000).
According to a recent review of the literature (Ketabchi
et al. 2003), six patients with paraganglioma of the sinonasal tract presented distant or regional metastases.
Increased mitotic fi gures, necrosis, vascular invasion,
aneuploidy and a high proliferation rate may be important indicators for identifying lesions with a potentially
aggressive biological behavior (Shanmugaratnam
1991; Welkoborsky et al. 2000)
8.9.4.1
Imaging Findings
Sinonasal paragangliomas exhibit no distinctive imaging feature. On both CT and MR sinonasal paragangliomas appear as markedly enhancing lesions;
bone destruction can be observed (Myssiorek 2001)
(Fig. 8.48). The differential diagnosis is therefore restricted to highly vascularized lesions, such as lobular capillary hemangioma, hemangiopericytoma,
schwannoma, and metastases (particularly from kidney, breast, and thyroid cancer).
8.9.4
Paraganglioma
Paraganglioma is a benign neoplasm made up of cells
originating from the neural crest and later migrating
together with ganglionic cells of the autonomic nervous system. Histologically, the lesion is characterized
by nests of epithelioid cells (Zellballen), surrounded by
a capillary network (Shanmugaratnam 1991). Other
terms such as glomus tumor, chemodectoma and apudoma have been used, but at present paraganglioma
is the recommended name. Paragangliomas are commonly divided into adrenal (i.e., pheochromocy tomas)
and extra-adrenal in relation to the site of origin. The
latter group includes cervicofacial paragangliomas,
which rarely secrete catecholamines and therefore are
classifi ed as non-chromaffi n. Most cases take origin in
the temporal bone (glomus jugulare and glomus tympanicum), above the bifurcation of the carotid artery
(carotid body), and from the nodose ganglion (glomus
intravagale) (Lack et al. 1977), whereas localization in
the sinonasal tract is exceedingly rare, with approxi-
Fig. 8.48. Paraganglioma. Gd-DTPA SE T1 on sagittal plane.
Brightly enhancing ethmoid lesion eroding the anterior cranial
fossa fl oor. Note encroachment of the hyperintense signal of the
dura (arrows), indicating intradural extension. The lesion also
invades both the frontal and sphenoid sinus (arrowheads)
152
R. Maroldi et al.
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