27 Head and Neck Pathology Flashcards
Describe the presentation of Herpes in the oral cavity
- 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
What is the test for Herpes?
Tzanck test (swab ulcer and smear on slide)
What histology is observed in Herpes of the oral cavity?
- “3 Ms”:
- Multinucleation
- Molding (conformity of adjacent cell nuclei to one another)
- Margination (chromatin “marginated” near the edge of the cell)
What is the most common fungal infection? What are some common causes?
- Candidiasis/Thrush
- Causes:
- Dentures
- Diabetes mellitus
- Steroids/prolonged antibiotics
- Immunosuppression (AIDS, transplant, chemo)
Describe the appearance of candidiasis
White plaque-like pseudomembrane
**scrapes off (erythematous base below)
What stain is used for candidiasis?
GMS silver stain
**Observe fungal hyphae superficially attached to the underlying mucosa
What is the most common cancer of the oral cavity/larynx? What is its etiology/risk factors?
- 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)
Contrast leukoplakia and erythroplakia
- 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
What is epithelial dysplasia?
Progressive proliferation, loss of polarity, and increased mitotic figures of the immature (basal) cells
Where does squamous cell carcinoma often occur in the oral cavity? What is the prognosis?
- 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
How does a patient present with squamous cell carcinoma of the larynx?
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)
What is the treatment and prognosis for squamous cell carcinoma of the larynx?
- Treatment:
- surgery (laryngectomy)
- radiation
- 5 year survival:
- stage 1= 70%
- stage 4= 30%
What are the two major variants of squamous cell carcinoma?
Classic keratinizing and HPV associated non-keratinizing
What feature of a squamous cell carcinoma is very likely to increase recurrence of the tumor even after resection?
“Perineural” involvement (aka when the tumor grows around nerves)
What is Waldeyer’s ring?
- 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)
Describe HPV-associated squamous cell carcinoma
- 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
What is seen histologically in HPV-associated squamous cell carcinoma?
- no keratinization
- sheets/strips of cohesive cells with basaloid morphology
- nuclear atypia
- increased mytotic activity
- +/- necrosis
What is rinosinusitis? What is a possible complication?
- 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
What are 2 examples of malignant tumors of the nasal cavity?
Olfactory neuroblastoma and nasopharyngeal carcinoma
Describe olfactory neuroblastoma
- arises in superior/lateral mucosa of the nose
- median age= 50 years
- symptoms= epistaxis (nose bleed), nasal obstruction, headache
What is seen microscopically in olfactory neuroblastoma?
- 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
Contrast pseudorosettes versus rosettes
- “homer wright” pseudorosettes= no lumen
- “flexner-wintersteiner” rosettes= lumen
- both common in low grade olfactory neuroblastoma
What is the prognosis of olfactory neuroblastoma?
- locally invasive
- metastasizes widely (to local lymph nodes and lungs)
- 5 year survival= 50-70%
What are some etiologic factors for nasopharyngeal carcinoma?
- EBV infection
- Environment (fish diet, smoking)
- common in northern Africa, China, SE Asia
- rare in US
- Hereditary (some consistent molecular abnormalities)
What are three main types of nasopharyngeal carcinoma?
- keratinizing squamous cell
- non-keratinizing squamous cell (HPV associated)
- lymphoepithelial carcinoma (a type of undifferentiated non-keratinizing squamous cell; EBV associated)
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
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
What are the major salivary glands and the type of saliva they secrete?
- Parotid gland (on the side of the face)
- Serous
- Submandibular gland
- Mixed, mainly serous
- Sublingual gland (midline, under tongue)
- Mainly mucinous
What are the minor salivary glands?
Innumerable, distributed throughout the mucosa of the oral cavity (lips, gingiva, cheek, hard/soft palates, tonge, tonsils, oropharynx)
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)
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
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%)
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)
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)
Describe a warthin tumor
- most common bilateral salivary gland tumor
- 2nd most common overall
- restricted to parotid gland
- M>F
- associated with smoking
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
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
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
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
What is commonly seen on histology in adenoid cystic carcinoma?
- perineural invasion (envelopes nerves; locally aggressive)
- cribriform architecture (“like swiss-cheese”)
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
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!)
Describe the gross and micro appearance of a branchial cleft cyst
- gross= thin walled, filled with “cheesy” mucoid material
- micro= squamous lining, numerous lymphocytes
