ENT Flashcards
0
Q
Granulomatous thyroiditis: Hormonal status.
A
Initial phase: T4 and T3 often elevated.
Resolution: Usually euthyroid, but can be hypothyroid.
1
Q
Granulomatous thyroiditis:
A. Age group.
B. Symptoms.
A
A. Middle-aged women.
B. Thyroidal tenderness, fever, sore throat, malaise.
2
Q
Granulomatous thyroiditis: Histology (3).
A
Foreign-body granulomas centered on follicles.
Giant cells with ingested colloid; neutrophils early; mononuclear cells.
Variable fibrosis.
3
Q
Granulomatous thyroiditis vs. sarcoidosis.
A
Sarcoidosis: Granulomas are in the interstitium rather than centered on follicles.
4
Q
Granulomatous thyroiditis vs. fungal thyroiditis.
A
Fungal thyroiditis: Usually acute inflammation with necrosis; granulomas are less frequent.
5
Q
Granulomatous thyroiditis vs. Hashimoto’s thyroiditis.
A
Hashimoto’s thyroiditis:
- Germinal centers.
- Oncocytic change.
6
Q
Granulomatous thyroiditis vs. palpation thyroiditis.
A
Palpation thyroiditis:
- Fewer giant cells and mononuclear cells within thyroid follicles.
- No neutrophils.
7
Q
Hashimoto’s thyroiditis:
A. Geography.
B. Associated HLA types.
A
A. Areas with abundant iodine.
B. DR3, DR5.
8
Q
Hashimoto’s thyroiditis: Associated genetic diseases (3).
A
Turner’s syndrome.
Down’s syndrome.
Familial Alzheimer’s disease.
9
Q
Hashimoto’s thyroiditis: Pitfalls in diagnosis (2).
A
Parasitic nodules may be confused with nodal metastases.
Optically clear nuclei may be overdiagnosed as papillary thyroid carcinoma.
10
Q
Hashimoto’s thyroiditis: Lymphocytes.
A
Mixture of B and T cells.
11
Q
Hashimoto’s thyroiditis vs. nonspecific lymphocytic thyroiditis (3).
A
Nonspecific lymphocytic thyroiditis:
− Fewer germinal centers.
− No oncocytic change.
− Minimal fibrosis.
12
Q
Riedel’s thyroiditis:
A. Age group.
B. Associated fibrosing disorders (3).
A
A. Peak in the fifth decade.
B. Mediastinal fibrosis; retroperitoneal fibrosis; sclerosing cholangitis.
13
Q
Riedel’s thyroiditis: Inflammation.
A
Lymphocytes, plasma cells, neutrophils, histiocytes, eosinophils.
No giant cells, no germinal centers.
14
Q
Riedel’s thyroiditis: Vascular change.
A
“Occlusive phlebitis”: Lymphocytes and plasma cells cause thickened wall and myxoid change.
15
Q
Riedel’s thyroiditis vs. undifferentiated thyroid carcinoma.
A
The carcinoma contains scattered malignant cells; IHC may help.
16
Q
Riedel’s thyroiditis:
A. Treatment.
B. Outcome.
A
A. Corticosteroids or tamoxifen; surgery as needed.
B. Hypothyroidism in half of cases.
17
Q
Graves’ disease: Associated HLA types.
A
DR3, B8.
18
Q
Histology of Graves’ disease:
A. Untreated.
B. After treatment with radioactive iodine.
A
A. Hyperplastic thyroid follicles with decreased colloid; variable lymphocytic inflammation.
B. Nuclear atypia, stromal fibrosis, more colloid.
19
Q
Amyloid goiter:
A. Location of amyloid.
B. Other histologic features (2).
A
A. Around vessels and between thyroid follicles.
B. Squamous metaplasia, secondary atrophy of follicles.
20
Q
Dyshormogenetic goiter: Most common functional defect.
A
Inability to incorporate iodine.
21
Q
Dyshormogenetic goiter: Most commonly associated malignancy.
A
Follicular carcinoma.
22
Q
Dyshormogenetic goiter: Gross appearance.
A
Enlarged, nodular thyroid gland.
23
Q
Dyshormogenetic goiter: Histologic architecture (2).
A
Small follicles contain scant colloid and form clusters that are separated from one another by fibrous bands.
Follicular cells may form papillae.
24
Dyshormogenetic goiter: Cytology.
Often hypercellular and pleomorphic.
25
Thyroglossal-duct cyst:
A. Lining epithelium.
B. Stroma.
A. Respiratory or squamous.
B. Mucus glands and thyroid follicles.
26
Thyroglossal-duct cyst: Most commonly associated malignancy.
Papillary thyroid carcinoma.
27
Causes of finding of ciliated cells on FNA of the thyroid gland (2).
Thyroglossal-duct cyst.
Tracheal aspirate.
28
Branchial-cleft cyst:
A. Anatomic site.
B. Origins (4).
A. Anterolateral neck.
B. 1st, 2nd, 3rd, or 4th branchial pouch.
29
Branchial-cleft cyst: Age group.
Children and young adults.
Unusual in older adults.
30
Branchial-cleft cyst: Lining epithelium.
Squamous, columnar, or ciliated.
Lining may contain mucinous, serous, or sebaceous glands.
31
Branchial-cleft cyst:
A. Stroma.
B. Contents.
A. Lymphoid.
B. Anucleate squames, histiocytes, or cholesterol clefts.
32
Nodal metastasis of SCC mimicking a branchial-cleft cyst: Most common sites of primary tumor.
Tonsils, base of tongue.
33
Nodal metastasis of PTC mimicking a branchial-cleft cyst: Recognition (4).
Nuclear features of papillary thyroid carcinoma.
IHC for TTF-1, thyroglobulin.
Presence of thyroglobulin in FNA fluid.
Presence of thyroid tissue in the lateral neck implies metastasis.
34
Teratoma of the thyroid gland:
A. Basic types (3).
B. How grade is assigned.
A. Benign (mature), immature, malignant.
B. Based on the maturation of the neural component.
35
Teratoma of the thyroid gland: Relevance of age to likelihood of malignancy (2).
Infants: >90% are benign.
Adolescents and adults: Half are malignant.
36
Hyalinizing trabecular tumor: Histologic architecture.
Trabeculae and insulae of cells separated by hyaline bands.
37
Hyalinizing trabecular tumor: Cytology (3).
Large, elongated cells.
Oval nuclei with nuclear grooves and INCIs.
Halo may surround nucleus.
38
Hyalinizing trabecular tumor: Genetics.
Some tumors exhibit rearrangements of RET/PTC gene.
39
Hyalinizing trabecular tumor vs. papillary thyroid carcinoma.
Papillary thyroid carcinoma shows invasive growth.
? Anything else ?
40
Hyalinizing trabecular tumor vs. medullary thyroid carcinoma (2).
Medullary thyroid carcinoma:
- Amyloid may be present.
- Negative for thyroglobulin.
41
Follicular adenoma: Associations (2).
Iodine deficiency.
Cowden's syndrome.
42
Follicular adenoma:
A. Thickness of capsule.
B. Variant that is most prone to infarction after FNA.
A. Thinner than that of follicular carcinoma.
B. Oncocytic variant.
43
Follicular adenoma: Histology of toxic variant.
Mimics that of Graves' disease.
44
Atypical adenoma: Synonym.
Follicular lesion of uncertain malignant potential.
45
Atypical adenoma: Histology (4).
May show necrosis or mitotic activity.
Thickened capsule with partial invasion.
46
Follicular adenoma: Genetics (3).
Aneuploidy (one fourth of cases).
Mutations in RAS.
Rearrangements of PAX8 with PPARγ.
47
Follicular carcinoma: Association.
Iodine deficiency.
48
Follicular carcinoma: Histology of capsular invasion (2).
The tumor must fully penetrate the capsule and not merely be present within the capsule.
Hemorrhage and reactive changes suggest FNA artifact.
49
Follicular carcinoma: Histology of vascular invasion (3).
Vessels must be within or outside the capsule.
There must be at least focal attachment of the tumor to the lining of the vessel.
Some require endothelium on the tumor focus or fibrin deposition.
50
Follicular carcinoma: Genetics (2).
Some cases show
− t(2;3) :: PAX8−PPARγ.
− Mutations of KRAS, NRAS, or HRAS.
51
Follicular carcinoma: Metastasis.
Hematogenous, most often to lung and bone.
52
WHAFFT.
Worrisome histologic alterations following FNA of thyroid.
53
Papillary thyroid carcinoma: Nuclear features that are essential to diagnosis (3).
Hypochromasia.
Grooves.
Pseudoinclusions.
54
Metastasis of papillary thyroid carcinoma to regional lymph nodes:
A. Incidence.
B. Effect on prognosis.
A. Occurs in about half of cases.
B. Does not affect long-term prognosis.
55
Papillary thyroid carcinoma: Appearance of metastasis to lymph node.
Tumor cells may appear flattened.
56
Papillary thyroid microcarcinoma:
A. Frequent location.
B. Frequent histology.
A. Subcapsular.
B. Scar-like.
57
Papillary thyroid carcinoma, diffuse sclerosing variant: Location.
Often diffusely involves both lobes of the gland.
58
Papillary thyroid carcinoma, diffuse sclerosing variant: Histology (4).
Extensive fibrosis.
Squamous metaplasia.
Psammoma bodies.
Lymphocytic infiltrate.
59
Papillary thyroid carcinoma, diffuse sclerosing variant: Behavior.
Often metastasizes to cervical lymph nodes and to lungs, due to increased lymphovascular invasion.
60
Papillary thyroid carcinoma, oncocytic variant: Histology (3).
Cells resemble Hürthle cells but have nuclear features of classic PTC.
Nuclear overlap may be absent due to abundance of cytoplasm.
Lymphoid stroma may be present.
61
Papillary thyroid carcinoma, tall-cell variant: Histology.
Cells are three times as tall as they are wide and have basal nuclei.
62
Papillary thyroid carcinoma, columnar-cell variant: Histology (3).
Cells contain basal cytoplasmic vacuoles and show squamous metaplasia.
Nuclei are pseudostratified and luminal.
63
Papillary thyroid carcinoma, tall-cell and columnar variants: Shared morphology (3).
Often . . .
− Large.
− Extend beyond thyroid gland.
− Invade vessels.
64
Papillary thyroid carcinoma: Genetics.
Point mutation in exon 15 of BRAF.
Rearrangements of RET with many other genes.
Rearrangements of TRK with many other genes.
65
Papillary thyroid carcinoma: Relevance of genetics to histology.
Mutations of NRAS are seen in the follicular variant.
66
Papillary thyroid carcinoma: Relevance of genetics to therapy.
Tumors with mutations in BRAF and/or RET may respond to inhibitors of tyrosine kinases.
67
Medullary thyroid carcinoma: Relative frequency of sporadic and hereditary cases.
Sporadic: 80%.
Hereditary: 20%.
68
Medullary thyroid carcinoma: Incidence of nodal metastasis at presentation.
About 50%.
69
Medullary thyroid carcinoma: Tumor markers.
Calcitonin: Postoperative monitoring.
CEA: Usually elevated only in late, progressive disease.
70
Medullary thyroid carcinoma: Diseases associated with hereditary tumors (3).
Familial medullary thyroid carcinoma: No other endocrine abnormalities.
MEN IIA and MEN IIB.
71
MEN IIA and MEN IIB: Tumors.
Medullary thyroid carcinoma: Often multiple.
Pheochromocytoma; parathyroid adenoma or hyperplasia.
MEN IIB: Mucosal and ocular ganglioneuromas also.
72
Medullary thyroid carcinoma: Hereditary type with the best prognosis.
Familial medullary thyroid carcinoma (non-MEN).
73
Medullary thyroid carcinoma: Location in the thyroid gland.
Upper and middle third of lobes.
74
Medullary thyroid carcinoma: Shapes of tumor cells.
Round, polygonal, spindled, plasmacytoid.
75
Medullary thyroid carcinoma: Nuclear features (3).
Pseudoinclusions or grooves.
"Salt-and-pepper" chromatin.
Binucleation is common.
76
Medullary thyroid carcinoma: Stromal contents (3).
Amyloid in 80% of cases; may induce foreign-body reaction.
Calcifications.
Psammoma bodies (rare).
77
Medullary thyroid carcinoma: Histologic features suggesting germline mutation (2).
Bilaterality.
Presence of C-cell hyperplasia.
78
Medullary thyroid carcinoma: Immunohistochemistry (4,1,1).
Positive: Calcitonin, synaptophysin, chromogranin, CEA.
Usually positive: TTF-1.
Negative: Thyroglobulin.
79
Medullary thyroid carcinoma: Genetics (2).
Hereditary cases: Germline mutation in RET.
Sporadic cases: 20-80% have mutated RET.
80
Medullary thyroid carcinoma vs. reactive hyperplasia of C cells.
Reactive hyperplasia:
- Fewer C cells.
- No fibrosis.
81
Nodular hyperplasia of C cells: Histology.
Nodules contain >50 C cells.
No fibrosis, no infiltration.
Identified on H and E stain and confirmed by IHC.
82
Poorly differentiated thyroid carcinoma:
A. Former name.
B. Cell of origin.
A. Insular carcinoma.
B. The follicular cell; may arise from follicular carcinoma or papillary thyroid carcinoma.
83
Poorly differentiated thyroid carcinoma: Gross pathology (2).
Usually large (>5 cm) and invasive of soft tissues.
84
Poorly differentiated thyroid carcinoma: Histology (2).
Nests (insulae) of cells with high N:C ratio.
May show convoluted nuclei, necrosis, or mitotic activity (>3 per 10 hpf).
85
Poorly differentiated thyroid carcinoma: Immunohistochemistry (2,2,1).
Positive: PAX8, cytokeratin.
Variable: Thyroglobulin, TTF-1.
Negative: Calcitonin.
86
Carcinoma showing thymus-like elements:
A. Age group.
B. Prognosis.
A. Fifth decade.
B. Metastasis in one third of cases.
87
Carcinoma showing thymus-like elements:
A. Histology.
B. Immunohistochemistry.
A. Moderately pleomorphic cells form sheets and nests with dense fibrosis.
B. Positive for CD5; negative for TTF-1, thyroglobulin, calcitonin.
88
Spindle-cell tumor with thymus-like elements: Age group.
Second and third decades.
89
Spindle-cell tumor with thymus-like elements:
A. Histology.
B. Immunohistochemistry.
A. Well-circumscribed biphasic tumor of spindled and epithelial cells forming glands, tubules, and sheets.
B. Negative: TTF-1, thyroglobulin, calcitonin.
90
Undifferentiated thyroid carcinoma:
A. Synonyms (2).
B. Cell of origin.
C. Prognosis.
A. Anaplastic carcinoma, pleomorphic carcinoma.
B. Follicular cell; most tumors arise from a preexisting thyroid carcinoma.
C. Death in 6 months.
91
Undifferentiated thyroid carcinoma: Histologic patterns (3).
Squamoid.
Spindle-cell.
Giant-cell.
92
Undifferentiated thyroid carcinoma: Histology of squamoid pattern.
Resembles non-keratinizing SCC, albeit rarely with squamous pearls.
93
Undifferentiated thyroid carcinoma: Histology of spindle-cell pattern (2).
Resembles a sarcoma.
Most likely of the three patterns to contain heterologous elements.
94
Undifferentiated thyroid carcinoma: Histology of giant-cell pattern.
Highly pleomorphic (anaplastic); usually solid growth.
95
Undifferentiated thyroid carcinoma: Immunohistochemistry.
Positive: Cytokeratin, EMA, vimentin.
Variable: Thyroglobulin, TTF-1.
96
Undifferentiated thyroid carcinoma: Genetics.
Strong association with mutations in TP53.
97
Undifferentiated thyroid carcinoma: Important items in the differential diagnosis (4).
Medullary carcinoma: Calcitonin, amyloid.
Sarcoma: Cytokeratin negative.
Lymphoma: CD45 positive.
Metastatic carcinoma.
98
Thyroid lymphoma: Most common type overall.
Diffuse large B-cell lymphoma.
99
Thyroid lymphoma: Most common Hodgkin's type.
Nodular sclerosis.
100
Thyroid lymphoma vs. thyroiditis and Graves' disease (3).
Thyroid lymphoma:
− Atypical lymphoid cells.
− Expansion or effacement of germinal centers.
− Neoplastic lymphocytes infiltrate thyroid follicles.
101
Thyroid lymphoma: Putative origin of plasmacytoma.
MALT lymphoma with plasmacytic differentiation.
102
Metastases to the thyroid gland: Most common origins (6).
Melanoma.
Breast.
Lung.
Kidney.
Gastrointestinal tract.
Head and neck (mostly SCC).
103
Parathyroid cyst: Function.
Only a minority cause hyperparathyroidism.
104
Histology of parathyroid cyst:
A. Lining.
B. Wall.
A. Cells are flat or cuboidal and have basal nuclei and clear cytoplasm.
B. Fibrous.
105
Parathyroid cyst: Origin.
Some arise from degenerated adenoma or area of hyperplasia.
106
Parathyroid cyst: Ancillary studies (2).
PTH is positive by IHC and in cyst fluid.
107
Parathyroid cyst vs. cyst of the 3rd pharyngeal pouch.
Cyst of the 3rd pharyngeal pouch contains both parathyroid and thymic tissue.
108
Parathyroid hyperplasia:
A. Number of enlarged glands.
B. Relationship to hyperparathyroidism.
A. More than one; usually all 4.
B. Causes about 15% of cases of hyperparathyroidism.
109
Chemical findings in hyperparathyroidism:
A. Primary.
B. Secondary.
A. High calcium and low phosphate; high PTH.
B. Low calcium and high phosphate (due to renal failure); high PTH.
110
Parathyroid hyperplasia in MEN syndromes:
A. Which syndromes?
B. Which cells?
A. MEN I, MEN IIA, and MEN IIB.
B. Chief cells.
111
Parathyroid hyperplasia: Normal weight of parathyroid gland.
Up to 40 mg.
112
Histology of parathyroid hyperplasia:
A. Cells.
B. Growth patterns.
C. Stroma.
A. Chief cells, oncocytic cells, transitional cells, clear cells, or mixed.
B. Solid, glandlike, or in cords.
C. Decreased fat (decreased within cells also).
113
MEN syndromes: Genes and their locations.
MEN I: Gene for menin on 11q.
MEN IIA and IIB: RET on 10q.
114
Parathyroid hyperplasia vs. parathyroid adenoma (2).
Parathyroid adenoma:
− More likely when only one gland is enlarged.
− Rim of compressed normal parathyroid tissue.
115
Parathyroid hyperplasia: Treatment.
Excision of 3½ parathyroid glands.
116
Parathyroid adenoma:
A. Cell of origin.
B. Atypical anatomic sites (3).
A. The chief cell.
B. Intrathyroidal, mediastinal, retroesophageal.
117
Parathyroid adenoma: Relationship to hyperparathyroidism.
Accounts for about 80% of cases of hyperparathyroidism.
118
Parathyroid adenoma: Inherited syndromes.
MEN I, MEN IIA, MEN IIB.
Hyperparathyroidism−jaw tumor syndrome.
119
Parathyroid adenoma: Typical weight.
More than 300 mg.
120
Parathyroid adenoma:
A. Mitotic rate.
B. Growth patterns (4).
A. Usually absent; never high.
B. Solid, nested, glandlike, or pseudopapillary.
121
Parathyroid adenoma: Contents of cystic structures.
PAS-positive fluid.
122
Parathyroid adenoma: Features of atypical adenoma (2).
Thickened capsule.
Thick fibrous bands.
No invasion of vessels or of adjacent structures.
123
Hyperparathyroidism−jaw tumor syndrome.
A. Gene, location, product.
B. Histology of parathyroid adenoma.
A. HRPT2, 1q25, parafibromin.
B. Often cystic.
124
Parathyroid adenoma: IHC.
Positive: Cytokeratin, PTH, chromogranin.
125
Parathyroid adenoma: Genetics (2).
Loss of 11q.
Rearrangement of cyclin D1 (PRAD1).
126
Parathyroid adenoma: Age-related possible mimic.
Oncocytic nodule.
127
Parathyroid carcinoma:
A. Age group.
B. Degree of hypercalcemia.
A. 45-55 years: 10 years younger than for adenoma.
B. Usually marked: Higher than for adenoma.
128
Parathyroid carcinoma: Mean weight.
6 grams.
129
Parathyroid carcinoma: Intraoperative appearance (2).
Invades adjacent structures.
Usually no nodal disease.
130
Histology of parathyroid carcinoma:
A. Cells (2).
B. Other possible features (3).
A. Usually show only mild or moderate pleomorphism; only 50% show mitotic activity.
B. Thicker capsule than in adenoma, thick fibrous bands, necrosis.
131
Histology of parathyroid carcinoma: Findings diagnostic of malignancy (2).
Extension into adjacent structures.
Vascular invasion.
132
Histology of parathyroid carcinoma: Definition of vascular invasion.
Tumor cells are attached to the inside of a vessel located outside the main mass.
133
Parathyroid carcinoma: Genetics (2).
Loss of 13q (region of RB and BRCA2).
Mutation of HRPT2.
134
Parathyroid carcinoma: Immunohistochemistry (2).
Positive: Cytokeratin, chromogranin.
Loss of parafibromin may indicate mutation in HRPT2.
135
Parathyroid carcinoma: Metastasis (3).
To cervical lymph nodes, lung, liver, typically occurring late.
136
Metastases to the parathyroid glands: Most common origins (5).
Breast.
Skin.
Lung.
Soft tissue.
Leukemia.
137
Infectious sialadenitis: Causes.
Viruses.
Gram-positive cocci.
Gram-negative bacteria.
138
Chronic sialadenitis: Rheumatological association.
Rheumatoid arthritis.
139
Necrotizing sialometaplasia: Histology (3).
Coagulative necrosis of acini.
Squamous metaplasia.
Pseudoepitheliomatous hyperplasia of overlying mucosa.
140
Necrotizing sialometaplasia: Site.
Any site; palate is the most common.
141
Benign lymphoepithelial lesion: Histology (3).
Epimyoepithelial islands.
Background lymphoid infiltrate.
Intercellular hyaline matter.
142
Lymphocytes in benign lymphoepithelial lesion:
A. In the epimyoepithelial islands.
B. In the background.
A. Monocytoid B cells.
B. Mainly T cells.
143
Benign lymphoepithelial lesion vs. lymphoma (3).
Lymphoma:
− Large aggregates of monocytoid B cells.
− Extension into adjacent fat and connective tissue.
− Monoclonality by IHC.
144
Lymphoepithelial cyst: Sites and origins (2).
Parotid gland: Remnant of branchial apparatus.
Lymph node: Cystic formation in nests of intranodal salivary-gland tissue.
145
Lymphoepithelial cyst: Infectious association.
HIV: Cysts are often bilateral.
146
Histology of lymphoepithelial cyst: Typical (3).
Multilocular.
Glandular and squamous lining.
Hyperplastic lymphoid follicles with germinal centers.
147
Histology of lymphoepithelial cyst: HIV infection.
Multifocal.
Florid lymphoid hyperplasia.
148
Salivary-duct cyst:
A. Site.
B. Etiology.
A. Mainly parotid gland.
B. Ductal obstruction.
149
Salivary-duct cyst: Histology (3).
Squamous lining.
Densely fibrous wall.
Surrounding inflammation and parenchymal atrophy.
150
Mucocele vs. mucus-retention cyst.
A. Mucocele: Younger patients; extravasation of salivary fluid; no epithelial lining.
B. Mucus-retention cyst: Any age; type of salivary-duct cyst; epithelial lining.
151
Most common benign tumor of salivary origin.
Pleomorphic adenoma.
152
Most common tumor of salivary glands in children.
Pleomorphic adenoma.
153
Pleomorphic adenoma: Most common sites (4).
Parotid gland.
Palate.
Upper lip.
Buccal mucosa.
154
Pleomorphic adenoma: Most common associated tumor.
Warthin's tumor.
155
Pleomorphic adenoma: Effect on facial nerve.
May compress it (resulting in facial paralysis), but does not invade it.
156
Pleomorphic adenoma: Capsule.
Usually present, but less often in
− Tumors of minor salivary glands.
− Tumors of the myxoid type.
157
Pleomorphic adenoma: Possible features of the mesenchymal component (4).
Myxoid, hyaline, cartilaginous, or osseous differentiation.
158
Pleomorphic adenoma: Main variants (2).
Cellular: Mostly epithelial.
Myxoid: Mostly myxochondromatous.
159
Pleomorphic adenoma: Genetics (2).
Clonal chromosomal rearrangements of
− 8q12.
− 12q13-15.
160
Pleomorphic adenoma vs. polymorphous low-grade adenocarcinoma (3).
Polymorphous low-grade adenocarcinoma:
− Perineural growth.
− Infiltration of adjacent tissues.
− Tubules or cords of cells at the periphery.
161
Myoepithelioma: Variants (3).
Spindle-cell.
Plasmacytoid.
Epithelioid.
162
Myoepithelioma, spindle-cell variant: Histology (2).
Interlacing fascicles of uniform, elongated spindle cells.
Minimal, myxoid stroma.
163
Myoepithelioma, plasmacytoid variant: Histology.
Cells are plasmacytoid.
Most common variant.
164
Myoepithelioma, epithelioid variant: Histology (3).
Epithelioid cells with round to oval vesicular nuclei and inconspicuous nucleoli.
Occasional microcystic areas.
Myxoid or hyaline stroma.
165
Myoepithelioma vs. myoepithelial carcinoma (3).
Myoepithelial carcinoma:
− Infiltrative borders.
− Cellular pleomorphism.
− Possible perineural or vascular invasion.
166
Myoepithelioma: Type that may be confused with metastatic renal-cell carcinoma.
Clear-cell myoepithelioma lacks the prominent vascular of RCC.
167
Second most common benign tumor of the salivary glands.
Warthin's tumor.
168
Warthin's tumor: Gross pathology.
Finely nodular and papillary surface.
Brown, turbid fluid in cystic spaces.
169
Warthin's tumor vs. oncocytoma.
Oncocytoma:
− Usually solid.
− No lymphoid component.
170
Warthin's tumor: Atypical site.
Within an intra-parotid lymph node.
171
Warthin's tumor: Associated tumors (2).
Rare association with
− Mucoepidermoid carcinoma.
− Oncocytic carcinoma.
172
Oncocytoma:
A. Gross pathology.
B. Nucleus.
A. Red-brown tumor with a central scar.
B. Contains large nucleolus.
173
Oncocytoma: Histologic variations (2).
Clear cells.
Cystic areas.
174
Oncocytoma: Electron microscopy.
Many mitochondria.
175
Oncocytoma: Special stain.
PAS highlights cellular glycogen.
176
Oncocytoma: Treatment.
Excision.
Avoid radiotherapy.
177
Oncocytoma vs. Warthin's tumor.
Warthin's tumor:
− Papillae.
− Lymphoid stroma.
− Squamous metaplasia (sometimes).
178
Congenital polycystic disease:
A. Definition.
B. Histology.
A. Congenital malformation of the ductal system.
B. Many apocrine-lined cysts filled with spheroliths.
180
Salivary-gland cystadenoma: Sites.
Parotid gland, minor salivary glands.
181
Salivary-gland cystadenoma vs. intraductal papilloma.
Intraductal papilloma:
− Unicystic.
− More epithelial proliferation.
182
Salivary-gland cystadenoma vs. low-grade papillary cystadenocarcinoma.
Cystadenocarcinoma: Infiltration of adjacent tissue.
183
Hemangioma of the salivary gland:
A. Epidemiology.
B. Basic types.
A. 80% of tumors occur in females.
B. Capillary and cavernous.
184
Hemangioma of the salivary gland: Juvenile vs. adult.
Juvenile type: More cellular; smaller vascular spaces; more mitotic activity.
Such findings in an adult hemangioma should raise suspicion for malignancy.
185
Basal-cell adenoma:
A. Age group.
B. Focality.
A. Sixth and seventh decades.
B. May be multifocal if membranous subtype.
186
Basal-cell adenoma: Histology (2).
Monotonous (monomorphic adenoma) proliferation of basal cells without the myxochondromatous stroma of mixed tumors.
Squamous differentiation can occur.
187
Basal-cell adenoma: Subtypes (4).
Solid: Resembles BCC.
Membranous: Resembles cylindroma.
Trabecular: Interlacing narrow bands of basaloid cells.
Tubular: Many small lumens.
188
Basal-cell adenoma vs. pleomorphic adenoma.
Pleomorphic adenoma:
- Myxochondromatous stroma.
- No sharp interface between epithelial and stromal elements.
188
Basal-cell adenoma vs. basal-cell adenocarcinoma.
Basal-cell adenocarcinoma: Infiltrative growth, even with bland cytology.
189
Canalicular adenoma: Site.
Mainly upper lip.
190
Canalicular adenoma: Histology.
Thin (2 cells thick) cords that often form small cystic spaces.
Loose stroma.
191
Sebaceous lymphadenoma: Histology (2).
Sebaceous islands; cysts lined by various types of epithelium.
Densely lymphoid stroma, sometimes with germinal centers.
192
Sebaceous adenoma: Histology (2).
Squamous and/or sebaceous islands or ducts.
Fibrous stroma.
193
Adenoid-cystic carcinoma: Sites.
May occur in any salivary gland.
Most common malignant tumor of the submandibular gland.
194
Adenoid-cystic carcinoma: Possible presenting complication.
Paralysis of the facial nerve.
195
Adenoid-cystic carcinoma: Gross pathology (2).
Falsely appears well circumscribed.
Tends to grow along nerves.
196
Adenoid-cystic carcinoma: Cellular components (2).
Ductal epithelial cells.
Myoepithelial cells.
197
Adenoid-cystic carcinoma: Major patterns of growth (3).
Cribriform (most common).
Tubular.
Solid.
198
Adenoid-cystic carcinoma, solid pattern: Cytology.
More pleomorphism than in other types.
More mitotic figures.
More necrosis.
199
Adenoid-cystic carcinoma, solid pattern: How to distinguish from other basaloid tumors.
Look for areas of cribriform and/or tubular growth.
200
Adenoid-cystic carcinoma: Immunohistochemistry.
Positive:
− p63 (myoepithelial cells).
− CD117 (not specific).
201
Adenoid-cystic carcinoma vs. polymorphous low-grade adenocarcinoma.
PLGA:
− Very rarely involves major salivary glands.
− Cribriform architecture like that of AdCC is uncommon.
− Dual-cell population is not as conspicuous.
202
Acinic-cell carcinoma: Patterns of growth (4).
Solid, microcystic: Most common.
Papillary-cystic.
Follicular.
203
Acinic-cell carcinoma: Cytology (3).
Sheets of cells with coarsely granular or vacuolar cytoplasm.
Minimal cytologic atypia.
Variable mitotic activity.
204
Acinic-cell carcinoma: Special stain.
Tumor cell are PAS positive and diastase resistant.
205
Acinic-cell carcinoma: Predictors of aggressive behavior (7).
```
Stromal hyalinization.
Cytologic atypia.
High mitotic rate.
Large size.
Infiltrative borders.
Neural invasion.
Necrosis.
```
206
Acinic-cell carcinoma: Predictors of favorable outcome (4).
Tumor in minor salivary gland.
Encapsulation.
Lack of vascular invasion.
Lymphocyte-rich stroma.
207
Mammary-analogue secretory tumor: Definition.
Salivary-gland tumor with translocation involving ETV6.
208
Mammary-analogue secretory tumor: Histology.
Apocrine-like cells forming microcysts or sheets.
Bland, vesicular nuclei.
209
Mammary-analogue secretory tumor:
A. Immunohistochemistry.
B. Special stain.
A. Positive: S100 (not specific), mammaglobin.
B. PAS negative.
210
Mammary-analogue secretory tumor: Translocation.
t(12;15)(p13;q25) :: ETV6−NTRK3.
211
Polymorphous low-grade adenocarcinoma:
A. Site.
B. Epidemiology.
A. Minor salivary glands, esp. at the junction between the hard and soft palates.
B. Twice as common in females.
212
Polymorphous low-grade adenocarcinoma: Clinical appearance.
Rarely ulcerated.
213
Polymorphous low-grade adenocarcinoma: Cytology.
Bland; rare mitotic figures and necrosis.
214
Polymorphous low-grade adenocarcinoma: Stroma.
Collagenous or hyalinized.
215
Polymorphous low-grade adenocarcinoma: Architecture.
Variable architectural patterns, including cribriform.
However, cribriform structures mimicking those of adenoid-cystic carcinoma are rare.
216
Polymorphous low-grade adenocarcinoma: Infiltration (3).
Infiltrates soft tissues, sometimes bone.
Tendency toward perineural invasion.
Vascular invasion is less frequent.
217
Most common malignant tumor of the salivary glands in
A. Adults.
B. Children.
Both: Mucoepidermoid carcinoma.
218
Mucoepidermoid carcinoma: Clinical presentation.
Usually as a solitary painless mass.
Facial nerve involved in some cases.
219
Mucoepidermoid carcinoma: Associations (2).
Radiation.
Warthin's tumor.
220
Mucoepidermoid carcinoma: Cells that line the cysts.
Mucous cells (mostly) and epidermoid cells.
221
Mucoepidermoid carcinoma: Morphology of most common cell type.
Intermediate cells are basaloid or appear less squamoid than the epidermoid cells.
222
Mucoepidermoid carcinoma: Clear cells (2).
Usually a minor component.
Contain glycogen rather than mucus.
223
Mucoepidermoid carcinoma: Grading.
1 (Low): Mostly cystic; focal cellular proliferation.
2 (Intermediate): Addition of invasive features.
3 (High): Solid; high-grade cytology.
224
Mucoepidermoid carcinoma: Translocation.
t(11;19) :: MAML−CTRC1.
225
Mucoepidermoid carcinoma vs. cystadenocarcinoma.
Cystadenocarcinoma:
- Fewer types of cells make up the cystic structures.
- Epidermoid cells are uncommon.
226
Mucoepidermoid carcinoma vs. necrotizing sialometaplasia (3).
Necrotizing sialometaplasia:
− Islands of cells have smooth outlines and a lobular distribution like that of normal salivary acini.
− No cysts.
− No intermediate-type cells.
227
Epidermoid-cell-rich mucoepidermoid carcinoma vs. squamous-cell carcinoma.
Squamous-cell carcinoma:
− More keratinization.
− No mucin in tumor cells.
228
High-grade mucoepidermoid carcinoma: Metastasis.
To lung, bones, brain.
229
Epithelial-myoepithelial carcinoma: Grade.
Low.
230
Epithelial-myoepithelial carcinoma: Cells.
Myoepithelial cells: More numerous; polygonal or spindle-shaped; clear cytoplasm.
Ductal: Cuboidal; eosinophilic cytoplasm.
231
Epithelial-myoepithelial carcinoma: Histology (3).
Myoepithelial cells surround ductal structures or form sheets or nests.
Fibrous bands may surround lobules of tumor.
Variable stroma.
232
Epithelial-myoepithelial carcinoma: Infiltration.
Occasional infiltration of soft tissues and perineural invasion.
233
Epithelial-myoepithelial carcinoma: Myoepithelial stains (3).
S100, p63, calponin.
234
Epithelial-myoepithelial carcinoma vs. adenoid-cystic carcinoma.
Adenoid-cystic carcinoma:
− Classic cribriform structures.
− Ductal cells are more basaloid and less conspicuous.
235
Epithelial-myoepithelial carcinoma: Histologic predictors of prognosis.
Histology has not been found to predict prognosis.
236
Carcinoma of salivary ducts:
A. Age group.
B. Clinical presentation.
A. Can affect young adults, but peak is in the 5th and 6th decades.
B. Rapidly enlarging mass that may involve the facial nerve.
237
Carcinoma of salivary ducts: Histology.
Resembles ductal carcinoma of the breast.
238
Carcinoma of salivary ducts: Immunohistochemistry (3).
Androgen receptor: Most cases.
EFGR: About half.
HER-2 is overexpressed in some cases.
239
Carcinoma of salivary ducts vs. salivary-gland adenocarcinoma, NOS.
Salivary-gland adenocarcinoma, NOS, lacks morphologic criteria of typical carcinomas of the salivary gland.
240
Carcinoma of salivary ducts vs. metastasis.
Metastatic carcinoma from breast or prostate: Clinical history may be required.
241
Carcinoma ex pleomorphic adenoma: Diagnosis.
Must contain areas of benign mixed tumor.
242
Carcinoma ex pleomorphic adenoma: Histology of the malignant component.
Resembles salivary-gland adenocarcinoma, NOS.
High-grade nuclei and many mitotic figures.
243
Carcinoma ex pleomorphic adenoma: Infiltration (3).
May remain within capsule: Known as encapsulated mixed tumor, noninvasive mixed tumor, or mixed tumor in situ.
May breach capsule and infiltrate adjacent soft tissue.
May invade vessels and surround nerves.
244
Carcinoma ex pleomorphic adenoma: Prognosis (2).
Encapsulated tumors: Same prognosis as that of benign mixed tumor.
Invasive tumors: Distant metastasis can occur.
245
Carcinoma ex pleomorphic adenoma vs. carcinosarcoma.
Carcinosarcoma: The mesenchymal component is also malignant.
246
Carcinosarcoma of the salivary gland: Histology of the sarcomatous component (2).
Usually predominates.
Usually chondrosarcoma, but other types of sarcoma have been reported.
247
Carcinosarcoma of the salivary gland: Histology of the carcinomatous component.
Most often high-grade ductal adenocarcinoma, but other types of carcinoma have been reported.
248
Metastatic carcinosarcoma of the salivary gland:
A. Route.
B. Site.
A. Hematogenous.
B. Most often to the lungs.
249
Metastatic carcinosarcoma of the salivary gland: Histology.
Sarcomatous; the carcinomatous component may also be present.
250
Small-cell (undifferentiated) neuroendocrine carcinoma of the salivary gland: Clinical presentation.
Rapidly growing, painless mass.
251
Small-cell neuroendocrine carcinoma of the salivary gland vs. metastatic small-cell neuroendocrine carcinoma of the lung.
Similar histology.
Salivary tumor is negative for TTF-1 by IHC.
252
Lymphoepithelial carcinoma of the salivary gland:
A. Epidemiology.
B. Association.
A. More common in natives of the Far North.
B. EBV.
253
Lymphoepithelial carcinoma of the salivary gland:
A. Epithelial component.
B. Lymphoid component.
A. Undifferentiated malignant cells with vesicular nuclei and pink cytoplasm; may resemble amelanotic melanoma.
B. Benign; dense infiltrate; may form germinal centers.
254
Lymphoepithelial carcinoma of the salivary gland: Ancillary studies (3).
ISH for genomes of EBV.
IgA anti-VCA.
IgG anti-EBNA.
255
Lymphoepithelial carcinoma of the salivary gland vs. large-cell undifferentiated carcinoma.
Large-cell undifferentiated carcinoma: No lymphoid stroma.
256
Lymphoepithelial carcinoma of the salivary gland vs. metastatic nasopharyngeal carcinoma.
Requires clinical correlation.
257
Lymphoma of the salivary gland: Most common origin of primary tumors.
De novo, i.e. not arising from a benign lymphoid process.
258
Lymphoma of the salivary gland: Frequent association in young men.
HIV.
259
Lymphoma of the salivary gland: Most common types (2).
Follicular lymphoma.
Diffuse large B-cell lymphoma.
260
Metastasis to the salivary glands: Most common origins (5).
SCC of head and neck.
Malignant melanoma.
Carcinomas of lung, kidney, breast.
261
Undifferentiated tumors of the base of the skull: Most helpful immunohistochemical markers (4).
Cytokeratin.
Synaptophysin.
Desmin.
Melanocytic marker.
262
Ewing's sarcoma / PNET: Positive immunohistochemical markers (2).
CD99.
Synaptophysin / chromogranin.
263
Which type of rhabdomyosarcoma can be positive for cytokeratin?
Alveolar rhabdomyosarcoma.
264
Sinusitis: Most frequently involved sinus.
Maxillary.
265
Chronic sinusitis: Important complication.
Mucocele (pseudocyst) may be mistaken clinically for a malignancy.
266
Allergic fungal sinusitis: Agents (3).
Aspergillus spp.
Curvularia spp.
Dematiaceous fungi.
267
Allergic fungal sinusitis: Gross pathology.
Thick secretion that resembles putty or clay.
268
Allergic fungal sinusitis: Histology.
"Tidal wave" layering of mucus and eosinophils.
Charcot-Leyden crystals sometimes.
Hyphae are uncommon.
269
Myospherulosis: Etiology.
Packing the nose with petrolatum.
270
Myospherulosis:
A. Histology.
B. Importance.
A. Large spaces that contain brown spherules representing altered erythrocytes.
B. Spherules may be confused with Prototheca.
271
Rhinoscleroma:
A. Etiology.
B. Geography.
A. Klebsiella rhinoscleromatis.
B. Central America, India.
272
Rhinoscleroma: Histology (2).
Lymphoplasmacytic infiltrate.
Foamy macrophages (Mikulicz cells) filled with bacteria.
273
Rhinosporidiosis: Agent.
Rhinosporidium seeberi.
274
Rhinosporidiosis: Histology.
Spherules (300 μm) containing endospores (2-9 μm).
Dense lymphoplasmacytic infiltrate.
275
Rhinosporidiosis: Special stains (3).
PAS, GMS, mucicarmine.
276
Nasal polyp: Associations in children.
Cystic fibrosis.
Hurler's syndrome.
277
Nasal polyp: Histology (4).
Respiratory epithelium.
Thickened basement membrane.
Myxoid stroma containing inflammatory cells.
Vascular proliferation sometimes.
277
Respiratory epithelial adenomatous hamartoma: Age group.
Sixth decade.
278
Respiratory epithelial adenomatous hamartoma: Histology.
Adenoma-like proliferation of pseudostratified, ciliated glands.
Thick basement membrane surrounds glands.
Some glands show connection to the surface.
279
Glial heterotopia:
A. Definition.
B. Variant histology.
A. Mature glial tissue without connection to the CNS.
B. Gemistocytic change in astrocytes.
280
Nasopharyngeal angiofibroma: Site.
Posterolateral wall or roof of the nasopharynx or posterior nasal cavity.
281
Nasopharyngeal angiofibroma: Stromal cells (2).
Stellate or spindled.
Many mast cells.
282
Nasopharyngeal angiofibroma: Immunohistochemistry (3).
Positive:
- β-Catenin (nuclear).
- Androgen receptor.
- Vascular markers.
283
Nasopharyngeal angiofibroma vs. hemangiopericytoma.
Hemangiopericytoma: Stromal cells are positive for smooth-muscle actin.
284
Nasopharyngeal angiofibroma vs. solitary fibrous tumor.
Solitary fibrous tumor: Stromal cells are positive for CD34.
285
Nasopharyngeal angiofibroma: Prognosis.
Malignant transformation rarely occurs.
286
Nasopharyngeal lobular capillary hemangioma: Site.
Nasal cavity, frequently the septum.
287
Sinonasal papilloma: Epidemiology.
Twice as common in men.
288
Sinonasal papilloma:
A. Most common type.
B. Least common type.
A. Inverted papilloma.
B. Cylindrical-cell papilloma.
289
Sinonasal papilloma: Possible microbiological association.
HPV types 6 and 11.
290
Inverted sinonasal papilloma: Sites (2).
Lateral nasal wall.
Paranasal sinuses.
291
Inverted sinonasal papilloma: Histology.
Deeply invaginated nests of benign squamous epithelium.
Intact basement membrane.
Intraepithelial microabscesses.
292
Exophytic sinonasal papilloma:
A. Synonym.
B. Site.
A. Fungiform papilloma.
B. Nasal septum.
293
Exophytic sinonasal papilloma: Histology.
Nonkeratinized squamous or transitional epithelium lines true papillae.
294
Cylindrical-cell sinonasal papilloma:
A. Synonym.
B. Sites (2).
A. Oncocytic papilloma.
B. Lateral nasal wall; paranasal sinuses.
295
Cylindrical-cell sinonasal papilloma: Histology.
Similar to that of inverted papilloma, but may be either endophytic or exophytic.
296
Sinonasal papilloma: Prognosis.
Malignant transformation is most likely in inverted (10-15%) and cylindrical-cell types.
Dysplasia, if seen, should be graded.
297
Sinonasal squamous-cell carcinoma: Sites (3).
Maxillary sinus.
Nasal cavity.
Ethmoid sinus.
298
Sinonasal squamous-cell carcinoma: Risk factors (5).
Smoking.
Ni, Cr, Ra.
Isopropanol.
299
Sinonasal squamous-cell carcinoma: Subtypes.
Conventional SCC.
Verrucous, basaloid, spindle-cell carcinomas.
300
NUT midline carcinoma: Histology.
High-grade undifferentiated cells and areas of necrosis.
Widely infiltrative and destructive.
301
NUT midline carcinoma:
A. Immunohistochemistry.
B. Genetics.
A. Positive: NUT (nuclear protein in testis).
B. Rearrangement involving NUT gene on 15q14.
302
NUT midline carcinoma: Prognosis.
Death in 7 months.
303
Sinonasal undifferentiated carcinoma: Epidemiology.
Three times more common in males.
304
Sinonasal undifferentiated carcinoma: Histology.
Sheets, trabeculae, or nests of cells.
Extensive necrosis.
305
Sinonasal undifferentiated carcinoma: Cytology.
Undifferentiated cells with a high N:C ratio and a single prominent nucleolus.
Many mitotic figures.
306
Sinonasal undifferentiated carcinoma: Immunohistochemistry.
Positive: Pancytokeratin, CK 7.
Negative: CK 5/6.
Rare: Focal synaptophysin / chromogranin.
307
Sinonasal undifferentiated carcinoma vs. nasopharyngeal carcinoma.
Nasopharyngeal carcinoma:
− Lymphoid infiltrate (absent in SNUC).
− Often positive for EBV.
308
Sinonasal undifferentiated carcinoma: Prognosis.
Death within 2 years.
309
Nasopharyngeal carcinoma, keratinizing type:
A. Association with EBV.
B. Epidemiology.
C. Prognosis.
A. Weaker.
B. Older patients.
C. Worse.
310
Nasopharyngeal carcinoma, keratinizing type: Histology.
It is a keratinizing squamous-cell carcinoma.
311
Nasopharyngeal carcinoma, non-keratinizing type:
A. Association with EBV.
B. Most common clinical presentation.
A. Stronger.
B. Unilateral cervical lymphadenopathy.
312
Nasopharyngeal carcinoma, non-keratinizing type:
A. Epidemiology.
B. Geography.
A. Three times more common in males.
B. Southeast Asia, North Africa.
313
Nasopharyngeal carcinoma, non-keratinizing type: Environmental risk factors (4).
Nitrosamines.
Salted fish.
Smoking.
Formaldehyde.
314
Nasopharyngeal carcinoma, non-keratinizing type: Histologic subtypes.
Undifferentiated (lymphoepithelial carcinoma).
Non-keratinizing SCC.
315
Nasopharyngeal carcinoma, non-keratinizing SCC: Histology.
Resembles non-keratinizing SCC in other sites.
Desmoplastic stroma.
316
Nasopharyngeal carcinoma, undifferentiated: Growth patterns.
Regaud's type: Well-defined tumor nests in fibrous stroma.
Schminke's type: Sheets of cells obscured by lymphoid infiltrate.
317
Nasopharyngeal carcinoma, undifferentiated: Cytology (3).
Vesicular nuclei, large nucleolus.
Many mitotic figures.
Necrosis may be extensive.
318
Nasopharyngeal carcinoma, undifferentiated: Inflammatory component.
Usually lymphoid, but eosinophils can predominate.
319
Nasopharyngeal carcinoma, undifferentiated: Stroma.
Usually not desmoplastic.
May contain amyloid.
320
Nasopharyngeal carcinoma: Immunohistochemistry.
Positive: CK 5/6, 34βE12.
321
Detection of EBV in nasopharyngeal carcinoma:
A. Best method.
B. Presumptive method.
A. ISH for Epstein-Barr−encoded RNA (EBER).
B. IgA anti-VCA or IgG anti-EA.
322
Nasopharyngeal carcinoma: Treatment.
Radiation:
- Chemotherapy may be added.
- Keratinizing SCC is less responsive.
323
Sinonasal adenocarcinoma: Sites (2).
Nasal cavity, sinuses.
324
Sinonasal adenocarcinoma: Histologic types (3).
Enteric.
Non-enteric.
Salivary.
325
Sinonasal adenocarcinoma, enteric type:
A. Histogenesis.
B. Risk factors.
A. Respiratory epithelium.
B. Woodworking, leather, some chemicals.
326
Sinonasal adenocarcinoma, enteric type: Histology.
Intermediate- or high-grade tumor resembling colonic adenocarcinoma.
May contain intestinal metaplasia without atypia.
327
Sinonasal adenocarcinoma, enteric type: Immunohistochemistry.
Positive: Cytokeratin; often CDX2 (nuclear).
Tumors gain colonic-type markers (e.g. CK20) as they come to resemble the colon histologically.
328
Sinonasal adenocarcinoma, enteric type, vs. metastatic colonic carcinoma.
Requires clinical correlation.
329
Sinonasal adenocarcinoma, enteric type: Mutated genes.
RAS, TP53.
330
Sinonasal adenocarcinoma, non-enteric type:
A. Histogenesis.
B. Risk factors.
A. Seromucinous glands.
B. None known.
331
Sinonasal adenocarcinoma, non-enteric type, low-grade: Histology.
Bland tumor resembling benign seromucinous glands.
Back-to-back glands, or papillary formations.
332
Sinonasal adenocarcinoma, non-enteric type, high-grade: Histology.
More solid growth.
More pleomorphism.
More mitotic activity.
More necrosis.
333
Sinonasal adenocarcinoma, non-enteric type: Immunohistochemistry.
Positive: CK7.
Variable: S100.
334
Sinonasal adenocarcinoma, salivary type: Histology.
Identical to tumors arising from the salivary glands.
Adenoid-cystic carcinoma in the most common.
335
Sinonasal adenocarcinoma, salivary type: Immunohistochemistry.
Positive: CK7.
Variable: S100.
336
Nasopharyngeal papillary adenocarcinoma:
A. Age group.
B. Prognosis.
A. Children and adults.
B. Cured by resection.
337
Nasopharyngeal papillary adenocarcinoma:
A. Histology.
B. IHC.
A. Nuclei resemble those of papillary thyroid carcinoma.
B. Positive for TTF-1; negative for thyroglobulin.
338
Teratocarcinoma: Histology.
Composite malignancy of several lineages, including carcinoma, neuroblastoma, sarcoma, and sometimes germ-cell tumor.
339
Olfactory neuroblastoma: Age group.
Peaks at 15 years and 55 years.
340
Olfactory neuroblastoma: Histology (3).
Small round blue cells form rosettes (Homer Wright and Flexner-Wintersteiner).
Fibrillary stroma.
May contain ganglion cells.
341
Olfactory neuroblastoma: Immunohistochemistry (3).
Positive: Neuroendocrine markers.
Variable: Cytokeratin.
S100 highlights sustentacular cells.
342
Olfactory neuroblastoma: Electron microscopy.
Dense-core neurosecretory granules.
343
Olfactory neuroblastoma: Sites of metastases.
Cervical lymph nodes, lung.
344
Most common sarcoma of the head and neck:
A. In children.
B. In adults.
A. Embryonal rhabdomyosarcoma.
B. Alveolar rhabdomyosarcoma.
345
Embryonal rhabdomyosarcoma: Subtypes (2).
Botryoid.
Spindled.
346
Embryonal rhabdomyosarcoma, botryoid subtype: Histology (2).
Small blue cells in abundant myxoid stroma.
Subepithelial "cambium" layer consisting of more compacted cells.
347
Embryonal rhabdomyosarcoma, spindled subtype: Histology (3).
Fairly uniformed spindled cells.
Rare rhabdoid cells.
Occasional rhabdomyoblasts.
348
Embryonal rhabdomyosarcoma: Mutation.
Loss of heterozygosity in 11p.
349
Alveolar rhabdomyosarcoma: Typical histology (3).
Nests of incohesive small round blue cells.
Many mitotic figures.
Fibrous stroma.
350
Alveolar rhabdomyosarcoma: Variant histology (2).
Solid pattern.
Clear cells.
351
Alveolar rhabdomyosarcoma: Mutations (2).
t(2;13) :: PAX3−FKHR.
t(1;13) :: PAX7−FKHR.
352
Rhabdomyosarcoma: Aberrant expression of IHC markers (2).
Alveolar rhabdomyosarcoma:
- Cytokeratin (up to 50%).
- Neuroendocrine markers.
353
Sinonasal melanoma: Histologic clue to diagnosis.
Melanocytes located at the base of the respiratory epithelium or exhibiting pagetoid spread.
354
Sinonasal melanoma: Mutations (2).
In contrast to melanoma of the skin:
- Mutation of CD117.
- Infrequent mutation of BRAF.
355
Western sinonasal lymphomas: Most common type.
Diffuse large B-cell lymphoma.
356
Non-Western sinonasal lymphomas:
A. Most common type.
B. Gender predilection.
A. NK/T-cell lymphoma, angiocentric.
B. Three times more common in males.
357
NK/T-cell lymphoma, angiocentric: Histology (3).
Small and medium-sized cells.
Prominent necrosis, karyorrhexis, inflammation.
Vascular invasion and angiocentricity.
358
NK/T-cell lymphoma, angiocentric: IHC (3,2).
Positive: CD2, CD43, CD56.
Negative: CD3, CD57.
359
NK/T-cell lymphoma, angiocentric: Additional study.
ISH for EBV.
360
Metastases to the sinonasal region: Most common sources (3).
Kidney.
Melanoma.
Breast.
361
Leukoplakia: Sites of greatest risk for dysplasia.
Floor of mouth.
Ventrolateral aspect of tongue.
Labial mucosa.
362
Oral squamous papilloma: HPV types (6).
2, 4, 6, 11, 13, 32.
363
Oral squamous papilloma: Associated syndrome.
Cowden's syndrome.
364
Oral squamous papilloma vs. condyloma acuminatum (2).
Condyloma acuminatum:
- More conspicuous HPV effect.
- Broader papillary fronds.
365
Squamous-cell carcinoma of the oropharynx:
A. Most common site.
B. Clinical presentation.
A. Tonsil.
B. Neck mass in 30%; dysphagia, sore throat, otalgia.
367
Oral Kaposi's sarcoma: Most common site.
The palate.
368
Peripheral giant-cell granuloma: Histology.
Granulation tissue with
- Giant cells.
- Acute and chronic inflammation.
- Metaplastic bone sometimes.
369
Granular-cell tumor: Granules.
Lysosomes.
370
Periapical cyst:
A. Synonym.
B. Sites.
A. Radicular cyst.
B. Maxillary incisors, mandibular molars.
371
Periapical cyst: Radiography.
Round or flask-shaped radiolucency with a radiopaque margin.
372
Periapical cyst: Histology (3).
Lined by stratified squamous epithelium that is chronically inflamed.
Cholesterol clefts.
Rushton (hyaline) bodies in 10% of cases.
373
Periapical cyst vs. odontogenic keratocyst.
Odontogenic keratocyst: No inflammation.
374
Dentigerous cyst: Site.
Third molars (most often).
Encases the crown of an unerupted tooth.
375
Dentigerous cyst: Radiography.
Unilocular radiolucency.
376
Dentigerous cyst: Histology.
Lined by stratified squamous epithelium that is uninflamed (unless infected).
377
Odontogenic keratocyst:
A. Synonym.
B. Sites.
A. Keratocystic odontogenic tumor.
B. Posterior mandible, posterior maxilla.
378
Odontogenic keratocyst: Radiography.
Unilocular or multilocular radiolucency.
379
Odontogenic keratocyst: Histology.
Lined by stratified squamous epithelium that has
- No inflammation.
- A corrugated surface.
- Palisaded basal cells.
380
Odontogenic keratocyst: Associated syndrome.
Nevoid-basal-cell-carcinoma (Gorlin's) syndrome.
381
Ameloblastoma:
A. Most common site.
B. Associations (2).
A. Posterior mandible.
B. Impacted 3rd molars; odontogenic keratocyst.
382
Ameloblastoma: Radiography.
Multilocular, "soap-bubble" radiolucency.
383
Ameloblastoma: Clinicopathologic forms (3).
Unicystic, multicystic: Younger patients.
Peripheral: Older patients, extraosseous.
384
Ameloblastoma, follicular pattern: Histology.
Nests of epithelial cells with reverse polarity (nuclei away from the basement membrane).
Centers of nests contain loose stellate epithelium and microcysts.
385
Ameloblastoma, plexiform pattern: Histology.
Cytologically similar to the follicular pattern, but arranged in anastomosing cords.
386
Ameloblastoma, acanthomatous pattern: Histology.
Follicular nests with squamous metaplasia.
387
Ameloblastoma, desmoplastic pattern: Histology.
Dense stroma that may contain osteoid.
388
Ameloblastoma: Relevance of histology to prognosis (2).
Presence or absence of infiltration is the most important prognostic factor.
Histologic pattern does not matter.
389
Ameloblastic fibroma: Histology.
Benign mixed tumor with epithelial (odontogenic) and mesenchymal (dental papilla−like) components.
390
Calcifying epithelial odontogenic tumor:
A. Synonym.
B. Most common site.
A. Pindborg's tumor.
B. Posterior mandible.
391
Calcifying epithelial odontogenic tumor:
A. Association.
B. Radiography.
A. Impacted tooth (half of cases).
B. Poorly demarcated, multilocular radiolucency that contains granular opacities.
392
Calcifying epithelial odontogenic tumor: Cytology (3).
Polyhedral cells with much pink cytoplasm and intercellular bridges.
Pleomorphic nuclei with large nucleoli.
No mitosis, necrosis, or inflammation.
393
Calcifying epithelial odontogenic tumor: Stroma (3).
Concentric calcifications (Liesegang's rings).
Amyloid-like matter.
Little fibrosis.
394
Adenomatoid odontogenic tumor:
A. Age group.
B. Most common site.
A. Second decade.
B. Maxilla; anterior portions of jaws, esp. canines.
395
Adenomatoid odontogenic tumor: Radiography.
Well-defined radiolucency with or without an impacted tooth.
396
Adenomatoid odontogenic tumor: Histology (4).
Thick fibrous capsule.
Odontogenic epithelium forms sheets, strands, and duct-like structures.
Little fibrous stroma.
Small calcifications.
397
Cementoblastoma: Most common sites.
Mandibular 1st molar and premolars.
398
Cementoblastoma: Radiography.
Well-defined radiopacity attached to the tooth root and surrounded by a thin radiolucent zone.
399
Cementoblastoma: Histology (3).
Thick trabeculae of mineralized osteoid-like tissue displaying cementoblastic rimming.
Loose fibrovascular tissue between the trabeculae.
Radiating columns of uncalcified matrix at the periphery.
400
Chondrosarcoma of the jaw: Most common sites.
Maxilla.
Base of skull.
401
Chondrosarcoma: Histologic subtypes (3).
Conventional.
Mesenchymal.
Dedifferentiated.
402
Chondrosarcoma, conventional subtype: Histology.
Invasive lobules of cartilage.
Mild to severe atypia.
403
Chondrosarcoma, conventional subtype: Criteria of a grade 3 lesion.
Peripheral spindling
- or -
More than 2 mitotic figures per 10 hpf.
404
Chondrosarcoma, mesenchymal subtype: Histology.
Two components:
− Clearly recognizable hyaline cartilage.
− Small round blue cells.
405
Chondrosarcoma, dedifferentiated subtype: Histology.
Two components:
− Conventional chondrosarcoma (often grade 1).
− High-grade spindle cells or epithelioid cells.
406
Chondrosarcoma vs. chondroblastic osteosarcoma.
Chondroblastic osteosarcoma:
− Lacelike osteoid.
− Atypical osteoblasts.
407
Chondrosarcoma, grade 1 vs. enchondroma (3).
Enchondroma:
− Less cellular.
− No binucleate chondrocytes.
− No necrosis.
408
Chondrosarcoma vs. chondroid chordoma (2).
Chondroid chordoma:
− Contains foci of conventional chordoma in addition to chondroid areas.
− Expresses cytokeratin, EMA, Brachyury marker.
409
Chondrosarcoma: Relevance of grade to metastasis (3).
Grade 1: Very few tumors metastasize.
Grade 3: About 70% metastasize.
A metastasis is often of higher grade than the primary tumor.
410
Osteosarcoma of the jaw: Associations (3).
Radiation, fibrous dysplasia, Paget's disease.
Most cases arise de novo.
411
Osteosarcoma of the jaw:
A. Age group.
B. Locations within the bone.
A. Third and fourth decades.
B. Medullary, periosteal.
412
Osteosarcoma of the jaw: Radiography.
Radiolucent or radiopaque.
Sunburst pattern is classic.
413
Osteosarcoma of the jaw: Most common histologic type.
Chondroblastic: Malignant-appearing chondroid areas with focal deposition of malignant osteoid.
414
Osteosarcoma of the jaw: Less common histologic types (3).
Fibroblastic: Resembles fibrosarcoma or MFH but contains focal osteoid.
Osteoblastic: Predominance of malignant, lacelike, variably mineralized osteoid.
Telangiectatic: Resembles aneurysmal bone cyst but consists of very pleomorphic cells.
415
Osteosarcoma of the jaw vs. ossifying fibroma:
Ossifying fibroma:
− Bland cells.
− Radiologically and histologically well circumscribed.
416
Oral squamous-cell carcinoma, HIV-associated: Most common sites (2).
Oropharynx.
Tonsils.
417
HPV in squamous-cell carcinoma of the oropharynx:
A. Frequency.
B. Prognosis.
A. 30-70% of tumors.
B. Better; more responsive to radiation.
418
Oral squamous-cell carcinoma: Genetics (2).
Overexpression of TP53 in 30-50% of cases.
Non-diploid tumors are more aggressive.
419
Oral verrucous carcinoma: Most common sites (2).
Buccal mucosa.
Gingiva.
420
Oral verrucous carcinoma: Risk factor.
Chaw.
421
Metastases to the oral cavity: Most common primary sites.
Lung.
Kidney, breast, skin.
422
Laryngeal nodule: Synonyms (2).
Vocal-cord nodule.
Singer's nodule.
423
Laryngeal nodule: Most common site.
Anterior third of the vocal cord.
424
Laryngeal nodule: Histology.
Covering: Stratified squamous epithelium.
Stroma: Collagenous and vascular (telangiectatic form) or edematous (gelatinous form).
425
Laryngeal nodule: Possible confounding histologic features (2).
Florid papillary endothelial hyperplasia.
Amyloid-like matter.
426
Contact ulcer of the vocal cord: Typical site.
Posterior commissure of the vocal cord.
427
Contact ulcer of the vocal cord: Histology.
Exuberant granulation tissue, with ulceration of the overlying squamous epithelium.
428
Laryngeal amyloidosis:
A. Most common site.
B. Typical composition.
A. False cords.
B. Immunoglobulin light chains.
429
Laryngeal papilloma: Clinical types.
Juvenile: Typically multiple; often recurs.
Adult: Typically solitary; infrequently recurs.
430
Laryngeal papilloma: HPV types.
6, 11.
431
Laryngeal papilloma: Risk factors for malignancy (3).
Dysplasia.
Previous irradiation.
Solitary lesion.
432
Squamous cell carcinoma of the larynx: Association with HPV.
Present in less than 5 percent of cases.
433
Squamous cell carcinoma of the larynx: Sites.
Glottic (esp. anterior vocal cord): Most common.
Supraglottic.
Subglottic.
434
Squamous cell carcinoma of the larynx: Subtypes (5).
Keratinizing.
Non-keratinizing.
Verrucous.
Basaloid.
Spindle-cell (sarcomatoid).
435
Squamous cell carcinoma of the larynx: Relevance of site to prognosis.
Glottic: Best.
Supraglottic.
Subglottic: Worst.
436
Squamous cell carcinoma of the larynx: Relevance of subtype to clinical behavior (2).
Non-keratinizing: Tends to spread along mucosal surface.
Basaloid: Typically poor prognosis.
437
Neuroendocrine tumors of the larynx: Types.
Carcinoid.
Atypical carcinoid.
Neuroendocrine carcinoma.
438
Atypical carcinoid of the larynx:
A. Frequency.
B. Definition.
A. More common than typical carcinoid.
B. 2-10 mitotic figures per 10 hpf or small foci of necrosis.
439
Carcinomas of the trachea: Most common (2).
Squamous-cell carcinoma: Lower third.
Adenoid-cystic carcinoma: Upper third.
