27 Head and Neck Pathology Flashcards
1
Q
Describe the presentation of Herpes in the oral cavity
A
- HSV type I, transmission person to person
- Virus persists in the dormant state (asymptomatic)
- Reactivation results in vesicles:
- intraepithelial edema -> clear fluid -> rupture -> ulcer
- multinucleated cells with intranuclear viral inclusions
2
Q
What is the test for Herpes?
A
Tzanck test (swab ulcer and smear on slide)
3
Q
What histology is observed in Herpes of the oral cavity?
A
- “3 Ms”:
- Multinucleation
- Molding (conformity of adjacent cell nuclei to one another)
- Margination (chromatin “marginated” near the edge of the cell)
4
Q
What is the most common fungal infection? What are some common causes?
A
- Candidiasis/Thrush
- Causes:
- Dentures
- Diabetes mellitus
- Steroids/prolonged antibiotics
- Immunosuppression (AIDS, transplant, chemo)
5
Q
Describe the appearance of candidiasis
A
White plaque-like pseudomembrane
**scrapes off (erythematous base below)
6
Q
What stain is used for candidiasis?
A
GMS silver stain
**Observe fungal hyphae superficially attached to the underlying mucosa
7
Q
What is the most common cancer of the oral cavity/larynx? What is its etiology/risk factors?
A
- 95% of cancers are squamous cell carcinoma
- 50-70 years old
- M>F
- Risk factors:
- tobacco and alcohol (synergistic if both)
- family history
- HPV infection (especially 16 and 18)
- Leukoplakia (rare) and erythroplakia (common)
8
Q
Contrast leukoplakia and erythroplakia
A
- leukoplakia
- white patch caused by epidermal thickening/hyperkeratosis
- CANNOT be scraped off (unlike thrush)
- occasionally associated with epithelial dysplasia
- 5-25% risk of maligancy
- erythroplakia
- red granular area (may or may not be elevated)
- poorly defined boundaries
- usually associated with epithelial dysplasia
- ~50% risk of maligancy
9
Q
What is epithelial dysplasia?
A
Progressive proliferation, loss of polarity, and increased mitotic figures of the immature (basal) cells
10
Q
Where does squamous cell carcinoma often occur in the oral cavity? What is the prognosis?
A
- most occur on the tongue and floor of the mouth
- also on gingiva, hard/soft palates, dorsal tongue, mucosa
- prognosis much better when found in early stages
- common metastasis to lymph nodes, lung, liver, and bone
11
Q
How does a patient present with squamous cell carcinoma of the larynx?
A
Differs depending on location:
- Glottis/true vocal cords= hoarseness
- most common location of laryngeal carcinoma (thicker epithelium and more damage)
- diagnosed earlier because of symptoms
- Supraglottic or infraglottic= asymptomatic
- diagnosed at later stages (symptoms not until mass spreads and causes hemoptysis, dysphagia, etc)
12
Q
What is the treatment and prognosis for squamous cell carcinoma of the larynx?
A
- Treatment:
- surgery (laryngectomy)
- radiation
- 5 year survival:
- stage 1= 70%
- stage 4= 30%
13
Q
What are the two major variants of squamous cell carcinoma?
A
Classic keratinizing and HPV associated non-keratinizing
14
Q
What feature of a squamous cell carcinoma is very likely to increase recurrence of the tumor even after resection?
A
“Perineural” involvement (aka when the tumor grows around nerves)
15
Q
What is Waldeyer’s ring?
A
- Tonsillar type lymphoid tissue “ring” in the back of the mouth composed of:
- palatine tonsils
- base of tongue
- adenoids
- HPV-associated squamous cell carcinoma likes to infect Waldeyer’s ring (increased permeability due to lymphatic function)
16
Q
Describe HPV-associated squamous cell carcinoma
A
- occurs in the oropharynx/tonsils
- common serotypes= HPV 16 and 18
- p16 positive IHC staining
- HPV proteins E6 and E7 inactivate p53 and Rb (tumor suppressors)
- frequently metastasizes to neck lymph nodes early in disease
17
Q
What is seen histologically in HPV-associated squamous cell carcinoma?
A
- no keratinization
- sheets/strips of cohesive cells with basaloid morphology
- nuclear atypia
- increased mytotic activity
- +/- necrosis
18
Q
What is rinosinusitis? What is a possible complication?
A
- viral (common cold), allergic, or obstructive process (e.g. deviated septum)
- edematous nasal mucosa/enlarged turbinates on gross examination
- microscopy= mixed inflammatory infiltrate, edema, thickened basement membrane
- complication= nasal polyps
19
Q
What are 2 examples of malignant tumors of the nasal cavity?
A
Olfactory neuroblastoma and nasopharyngeal carcinoma
20
Q
Describe olfactory neuroblastoma
A
- arises in superior/lateral mucosa of the nose
- median age= 50 years
- symptoms= epistaxis (nose bleed), nasal obstruction, headache
21
Q
What is seen microscopically in olfactory neuroblastoma?
A
- Composed of uniform cells with round nuclei, scant cytoplasm, “salt and pepper” chromatin
- EM= neurosecretory granules
- IHC= neuroendocrine markers (synaptophysin and chromogranin)
- “rosette” formation common in low grade
22
Q
Contrast pseudorosettes versus rosettes
A
- “homer wright” pseudorosettes= no lumen
- “flexner-wintersteiner” rosettes= lumen
- both common in low grade olfactory neuroblastoma
23
Q
What is the prognosis of olfactory neuroblastoma?
A
- locally invasive
- metastasizes widely (to local lymph nodes and lungs)
- 5 year survival= 50-70%
24
Q
What are some etiologic factors for nasopharyngeal carcinoma?
A
- EBV infection
- Environment (fish diet, smoking)
- common in northern Africa, China, SE Asia
- rare in US
- Hereditary (some consistent molecular abnormalities)
25
What are three main types of nasopharyngeal carcinoma?
1. keratinizing squamous cell
2. non-keratinizing squamous cell (HPV associated)
3. lymphoepithelial carcinoma (a type of undifferentiated non-keratinizing squamous cell; EBV associated)
26
Describe lymphoepithelial carcinoma
* a type of _undifferentiated_ non-keratinizing squamous cell **nasopharyngeal carcinoma**
* EBV associated
* positive cytokeratin IHC
* **numerous lymphocytes** between tumor cells obscure the epithelial derivation
27
What is the prognosis for nasopharyngeal carcinoma? What is the treatment?
* grow silently until they become unresectable (invade skull base or brain tissue)
* local regional lymph node involvement and distant metastasis
* 50-70% 3 year survival
* treatment= radiotherapy
28
What are the major salivary glands and the type of saliva they secrete?
* Parotid gland (on the **_s_**ide of the face)
* **_S_**erous
* Submandibular gland
* _Mixed_, mainly serous
* Sublingual gland (**_m_**idline, under tongue)
* Mainly **_m_**ucinous
29
What are the minor salivary glands?
Innumerable, distributed throughout the mucosa of the oral cavity (lips, gingiva, cheek, hard/soft palates, tonge, tonsils, oropharynx)
30
What is sjogren syndrome?
* Autoimmune disease (anti SSB)
* Often in association with other autoimmune diseases (RA, lupus, etc)
* Observe "lymphoepithelial islands" (benign lesions)
* Pathology= lymphocytic infiltration of salivary and lacrimal glands with eventual gland destruction causing:
* xerostomia (dry mouth)
* keratoconjunctivitis (dry eyes)
31
Describe neoplasms of the salivary glands
* \<2% of all human tumors
* 65-80% in _parotid gland_
* 10% in submandibular gland
* remainder in minor salivary glands
* mostly in adults (50-70 yo), possibly malignant when older
* slight female precominance
32
Give examples of benign and malignant neoplasms of the salivary glands
* benign
* pleomorphic adenoma (60%)
* warthin tumor (5-10%)
* malignant
* mucoepidermoid carcinoma (15%)
* adenocarcinoma (10%)
* adenoid cystic carcinoma (5%)
33
Describe a pleomorphic adenoma
* **most common** salivary gland tumor
* wide age range
* 75-85% in the parotid gland
* benign _mixed tumor_
* epithelial cells
* myoepithelial cells
* mesenchymal components (myxoid, hyaline, chondroid)
34
What is the clinical course of a pleomorphic adenoma?
* painless, slow growing
* local recurrence ~4%
* malignant transformation 2-10% (increased likelihood for tumors present longer)
35
Describe a warthin tumor
* most common _bilateral_ salivary gland tumor
* 2nd most common overall
* restricted to parotid gland
* M\>F
* associated with smoking
36
What is the gross and microscopic appearance of a warthin tumor?
* gross= often undergoes papillary cystic change
* microscopy= **bilayered oncocytic epithelial cells** (pink; lots of mitochondria) with **numerous lymphocytes**
37
Describe a mucoepidermoid carcinoma
* most common _malignant_ tumor of the salivary glands
* 50% in parotid, 40% in minor glands
* occurs in both adults and children
* mixture of squamoid, mucous (**intracellular mucin**), and intermediate cells
38
What is the treatment and prognosis of a mucoepidermoid carcinoma?
* treatment= surgical resection + radiation
* low grade tumors
* invade locally
* rarely metastasize
* \>90% 5 year survival
* intermediate/high grade tumors
* recur more frequently
* 30% metastasize
* ~50% 5 year survival
39
Describe an adenoid cystic carcinoma
* 10% of all salivary gland carcinomas
* wide age rande (peak at 50-70 years old)
* major AND minor salivary glands
* wide/radical surgical resection because of common local recurrence
40
What is commonly seen on histology in adenoid cystic carcinoma?
* **perineural invasion** (envelopes nerves; locally aggressive)
* **cribriform architecture** ("like swiss-cheese")
41
What is a thyroglossal duct cyst?
* **midline** developmental cyst that presents \<40 years old
* always connected to the hyoid bone (**moves when swallowing**)
* lined by respiratory or squamous epithelium, **_thyroid tissue in the wall of the cyst_**
42
What is a branchial cleft cyst?
* arises from the 2nd branchial pouch
* 75% of patients 20-40 years old
* laterally placed in the neck along the anterior border of the SCM
* **differential diagnosis= HPV associated squamous cell carcinoma (similar appearance and age range!)**
43
Describe the gross and micro appearance of a branchial cleft cyst
* gross= thin walled, filled with "cheesy" mucoid material
* micro= **squamous lining, numerous lymphocytes**
