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Clinical Challenge
June 2017

Slow-Growing Infiltrative Sinonasal Mass

Author Affiliations
  • 1Florida State University College of Medicine, Tallahassee
  • 2Department of Otolaryngology, University of Florida, Gainesville
  • 3Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville
JAMA Otolaryngol Head Neck Surg. 2017;143(6):625-626. doi:10.1001/jamaoto.2016.3693

A man in his 50s was referred for a 6-month history of swelling involving the nasal bridge and right eye, accompanied by intermittent ipsilateral epistaxis. His medical history was notable for allergic rhinitis and well-controlled type 2 diabetes mellitus. The prior biopsy diagnosis from the area of swelling was inflammatory nasal polyp. Physical examination revealed tenderness to palpation over the right nasal bridge and mild right proptosis. Flexible and rigid nasal endoscopy demonstrated a right-sided exophytic mass visible between the middle turbinate and nasal septum. Computed tomography showed a large, right-sided mass centered in the ethmoid sinus with expansion into the anterior skull base, anterior cribriform plate, and right medial orbit. Magnetic resonance imaging showed vascularity in the lesion and early intracranial involvement with transdural spread but no evidence of invasion into the meninges or brain. The patient was taken for surgery, and findings from intraoperative frozen section analysis were consistent with a spindle cell neoplasm. Definitive skull base resection of the mass was deferred until final pathological diagnosis was obtained, given the morbidity with skull base resection. The final pathology report showed an infiltrative, low-grade, malignant spindle cell neoplasm with immunoreactivity for BCL2 protein and neural marker, S-100 protein, and focal immunoreactivity for smooth muscle markers SMA and HHF35 (Figure). Cytoplasmic immunoreactivity for β-catenin was noted, and nonreactive immunostains included CD31, CD34, epithelial membrane antigen (EMA), and CD99. In addition, there was minimal mitotic activity, and no tumoral necrosis was present. There was no regional or distant metastasis, and TNM staging was cT4N0M0.

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