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N a s a l s e p ta l p e d ic u la te c a r c in o m a in s itu :
d if f e r e n tia l d ia g n o s is
Faculdade de Medicilla de ]ulldia{ - Siio Paulo, Brazil
P e d ic u la te d le s io n s o f th e n a s a l c a v itie s a re re la tiv e ly c o m m o n in d a ily p ra c tic e , a n d in c lu d e in fla m m a to ry p o ly p s , b e n ig n tu m o rs (p a p illo m a s b e in g th e m o s t c o m m o n ), m a lig n a n t tu m o rs , a n d s p e c ific p ro c e s s e s , s u c h a s p o ly p o id rh in o s p o rid io s is . T h e a u th o rs d e s c rib e a fe m a le p a tie n t w ith a w a rty , p e d ic u la te d , a n d a s y m p to m a tic le s io n in th e n a s a l s e p ta l m u c o s a . T h e a n a to m o -p a th o lo g ic a l e x a m s h o w e d th is to b e a " c a rc in o m a in s itu ." T h e fe w b ib lio g ra p h ic c ita tio n s re p o rt o n ly a n a s s o c ia tio n b e tw e e n th e tu m o r a n d c o n ta c t w ith w o o d d u s t, s u c h a s o a k , e b o n y a n d b e e c h . T h e p a tie n t w a s n o t e x p o s e d to th e s e e le m e n ts . It is im p o rta n t to e m p h a s iz e th e ro u tin e p e rfo rm a n c e o f a c o m p le te o to la ry n g o lo g ic a l e x a m fo r p a tie n ts s e e k in g o u t s p e c ia lis ts , in o rd e r to d e te c t p o te n tia lly m a lig n a n t le s io n s w h o s e e a rly re m o v a l w o u ld p e rm it a c o m p le te c u re .
U N IT E R M S : N o s e . C a rc in o m a in s itu .
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i n c l i n i c a le d i c u l a t e d l e s i o n s o f t h e n a s a l c a v i t i e so t o l a r y n g o l o g i c a l p r a c t i c e .a r e c o m m o nT h e y m a y a p p e a r i n n a s a l c a v i t i e s a n d p a r a n a s a l s i n u s e s , a n d c a u s e s y m p t o m s s u c h a s n a s a l o b s t r u c t i o n , r h i n o r r e a , e p i s t a x i s , o r n o s y m p t o m s a t a l l . U n f o r t u n a t e l y , t h e m a l i g n a n t l e s i o n s c a n g r o w u n d e t e c t e d a n d b e d i a g n o s e d t o o l a t e , w o r s e n i n g t h e p r o g n o s i s .W e r e p o r t a r a r e c a s e o f m a l i g n a n t t r a n s f o r m a t i o n , f r o m a b e n i g n n a s a l s e p t a l p a p i l l o m a t o a n c a r c i n o m a " i n s i t u ." T h e r e a r e n o e x i s t i n g s c i e n t i f i c r e p o r t s o n t h i s t o p i c , a l t h o u g h t h e r e a r e m a n y r e p o r t s o f
A d re s s fo r c o rre s p o n d e n c e :
E d m ir A m e ric o L o u re m ;o
R u a d o R e tiro ,rJ S l4 2 4 /5 tJ a n d a r, c o n j. 5 3 / 5 4 -A n h a n g a b a u
J u n d ia f/S P - B ra s il - C E P 1 3 2 0 9 -0 0 0
a d e n o c a r c i n o m a s " i n s i t u ." T h e p r i n c i p a l d i a g n o s t i c d i f f e r e n t i a l s a r e e m j J h a z i e d h e r e .
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A 4 5 - y e a r o l d h o u s e w i f e , w i t h o t o l o g i c a l c o m p l a i n t s a n d n o p r i o r h i s t o r y o f a n y s i g n i f i c a n t i l l n e s s e s , w a s e x a m i n e d a t o u r o f f i c e . A c o m p l e t e o t o l a r y n g o l o g i c a l e x a m w a s n o r m a l . S o m e m o n t h s l a t e r , d u r i n g a r o u t i n e e x a m , a n a n t e r i o r r h i n o s c o p y w i t h a n a s a l s p e c u l u m r e v e a l e d a p e d i c u l a t e d l e s i o n i n t h e n a s a l s e p t a l m u c o s a , a b o u t 6 m l i n d i a m e t e r , g r a y i n c o l o r , w a r t - l i k e a p p e a r a n c e , a n d n o u l c e r a t i o n . T h i s l e s i o n w a s t o t a l l y a s y m p t o m a t i c , w i t h n o b l e e d i n g o r p a i n .
T h i s i n n e r n o s e l e s i o n w a s s u b m i t t e d t o t o t a l s u r g i c a l e x t i r p a t i o n u n d e r t o p i c a l a n e s t h e s i a , a n d t h e p a t h o l o g i s t 's e x a m s h o w e d i t t o b e a c a r c i n o m a " i n s i t u ."
S a o P a u lo M e d ic a l J o u rn a l/R P M 1 1 4 (4 ): 1 2 1 6 -1 2 1 9 , 1 9 9 6 L O U R E N < ;:O , E A & C O S T A , L .H .C . - N a s a l s e p ta l p e d ic u la te c a rc in o m a
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Figure 1 -Polypoid lesion w ith thick, stratified pavim entous epithelium (x40;H &E).
HISTOLOGICAL FINDINGS
H is to lo g ic a l s lic e s o f th e b lo c k s h o w e d a p o ly p o id le s io n o f th e n a s a l s e p ta l m u c o s a . T h e s tra tifie d , p a v im e n to u s e p ith e liu m w a s th ic k , a n d h ig h ly c e llu la r w ith a la c k o f m a tu ra tio n , c h a ra c te riz in g s e v e re d y s p la s ia , a n d , th e re fo re , a c a rc in o m a " in s itu ." T h ro u g h o u t th e th ic k n e s s o f th e e p h ite liu m w e c o u ld s e e c e lls w ith h ig h ly -c o lo re d n u c le i, fe w a n d irre g u la r m ito tic fig u re s , c h a ra c te riz in g c e llu la r re s tle s s n e s s , o r ra th e r, c y to lo g ic a ty p ia . T h e b a s a l m e m b ra n e w a s in ta c t, a n d in th e s tro m a w e c o u ld s e e a m ild c h ro n ic lin fo p la s m o c ita ry in fla m m a to ry in filtra te a n d v a s c u la r p ro life ra tio n . T h is w a s a tru e p a p illo m a , w ith a ty p ia s , a n d c o n s e q u e n tly , a p re c a n c e ro u s le s io n .
DISCUSSION
T h e b a s a l m e m b ra n e s e p a ra te s th e n a s a l e p ith e liu m fro m th e c o riu m , a n d th is m e m b ra n e is fo rm e d b y th e a s s o c ia tio n o f b a s a l la m in a (p ro d u c e d b y e p ith e lia l c e lls ), . g ly c o p ro te in s , re tic u la r fib e rs a n d p ro te in s . T h e b a s a l m e m b ra n e is th e m o s t im p o rta n t la n d m a rk in th e c la s s ific a tio n o f e p ith e liu m tu m o rs . A tu m o r is c la s s ifie d a s " in s itu " w h e n th e n e o p la s tic c e lls d o n o t g o b e y o n d th is m e m b ra n e . If th e re is n o c o riu m in v a s io n , th e p ro g n o s is is g e n e ra lly g o o d (if th e le s io n is c o m p le te ly e x tirp a te d ). I
In th e d iffe re n tia l d ia g n o s is o f n a s a l c a v ity p e d ic u la te d le s io n s , w e c a n c ite th e in fla m m a to ry p o ly p s , tu m o ra l le s io n s (b e n ig n a n d m a lig n a n t), a n d th e s p e c ific p a th o lo g ie s .
In fla m m a to ry p o ly p s c a n o rig in a te fro m a n a lle rg ic a n d /o r in fe c tio u s p ro c e s s . T h e y c a n a p p e a r a s s m o o th , in tra n a s a l p e d ic u la te d m a s s e s , e d e m a to u s , w ith a p a le o r h y p e re m ic s u rfa c e . H is to lo g ic a lly , th e re is a v a ria b le in fla m m a to ry in filtra te a n d h y p e rp la s ia in th e c o n ju n c tiv e tis s u e . G e n e ra lly lo c a te d in th e m e d iu m m e a tu s , a n d fre q u e n tly c o e x is tin g w ith c h ro n ic s in u s p ro b le m s , th e y o fte n p re s e n t s y m p to m s lik e o b s tru c tio n , itc h in g , s n e e z in g a n d rh in o rre a .
A m o n g b e n ig n tu m o rs , p a p illo m a s a re th e m o s t c o m m o n . T h e y h a v e a w a rt-lik e fo rm , a n d b le e d e a s ily . T h e y a re le s s fre q u e n t th a n th e in fla m m a to ry p o ly p s , o c c u rrin g m o re c o m m o n ly in m a le s , a n d u n ila te ra lly . H is to lo g ic a lly , th e y h a v e a n e p ith e lia l n a tu re , a n d c a n d e g e n e ra te a n d la te r b e c o m e m a lig n a n t. T h e is o la te d p la s m o c ito m a c a n o rig in a te d fro m ly m p h o id tis s u e . T h e n e o p la s tic e p ith e lia l c e lls a re u s u a lly s q u a m o u s , b u t m a y b e c u b o id a l, c o lu n m n a r, o r c ilia te d . P ro life ra tio n o f b a s a l c e lls is u s u a lly p re s e n t, a n d m ic ro s c o p ic m u c o u s c y s ts a re fre q u e n t in th e in te rio r o f th e e p ith e liu m .
T h e s u p p o rtin g c o riu m is e d e m a to u s , a n d it c o n ta in s v a ry in g a m o u n ts o f c h ro n ic in tla m m a to ry c e lls , in c lu d in g e o s in o p h ils . M o s t p a p illo m a s a re e x o p h y tic , w ith a c e n tra l c o re o f c o n n e c tiv e tis s u e a n d a re u s u a lly lo c a te d o n th e n a s a l s e p tu m . T h o s e th a t o n th e la te ra l w a lls a re m o re fre q u e n tly in v e rte d p a p illo m a s , c h a ra c te riz e d b y a d o w n w a rd p ro l i fe ra tio n o f th e e p i th e l i u m in to th e
u n d e rly in g c o riu m ; a p a tte rn w h ic h m a y e a s ily b e c o n fu s e d w ith w e ll-d iffe re n tia te d s q u a m o u s c a rc in o m a . R a re ly d o s q u a m o u s c a rc in o m a s (a b o u t 1 -3 p e rc e n t) a ris e fro m re c u rre n t n a s a l p a p illo m a s .2
T h e n a s a l v e s tib u lu m k e ra to tic p a p illo m a is a b e n ig n le s io n w h ic h a ris e s o n th e v e s tib u la r s k in s u rfa c e , o r a t th e m u c o c u ta n e o u s ju n c tio n o f th e s e p tu m , a n d s u p p o s e d ly re s u lts fro m re p e a te d tra u m a . It is a w a rty g ro w th , c h a ra c te riz e d m ic ro s -c o p i-c a lly b y h y p e rk e ra to s is , p a p illo m a to s is a n d a c a n th o s is .4
A m o n g th e s p e c ific d is e a s e s , th e m o s t c o m m o n is rh in o s p o -rid io s is . It m a n ife s ts a s a p o ly p o id
LO U R EN <;O , E.A. & C O STA, L.H .C . - N asal septal pediculate carcinom a in situ: differential diagnosis
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~ ::> m ~ ~ ~ ~ ~ ;o ..1 ; " 'm ff::'? -tm m % m * t~ ~ ~ W lli~ p :~ ~ $ ill~ ~ r;.W ::'$ :t:~ ~ r.« < ::;~ ~ -::~ ~ M :" ~ ~ ~ r~ ~ ~ := ::::;ry ~ im m r::::'l:m r~ ~ jm r~ W iW " t~ m ;.~ ~ 1 rt.~ = fft~ IillW ~ ~
Figure 3-Intact basal m em brane and corium show ing a m ild chronic linfoplasm ocitary inflam m atory infiltrate and vascular proliferation (x400;H & E ).
Figure 2 -T hick, stratified pavim entous epithelium , highly cellular, and w ith colored nuclei and a few and irregular m itotic figures, characteristics of a lack of m aturation (x100;H & E ).
in c r e a s e th e in c id e n c e o f n a s o s in u s a l c a r c in o m a s b y 5 0 0 tim e s .3 .4 O u r p a tie n t h a d n o t b e e n e x p o s e d to a n y o f th e s e e le m e n ts .
I t is im p o r ta n t to e m p h a s iz e th a t o to la r y n g o lo g ic a l e x a m s m u s t b e th o r o u g h a n d a c c u r a te f o r a ll p a tie n ts c o n s u ltin g s p e c ia lis ts , e s p e c ia lly f o r th e e a r ly d e te c tio n o f p o te n tia lly m a lig n a n t le s io n s , w h o s e e a r ly r e m o v a l c a n le a d to a c o m p le te c u r e .
f o r m , a n d its d ia g n o s is is c o n f ir m e d b y th e h is to lo g ic a l f in d in g o f th e e th io lo g ic a l a g e n t, R h in o s p o r id iu m s e e b e r i.
B e n ig n a n d m a lig n a n t g la n d u la r n e o p la s m s a r e q u ite u n c o m m o n in th e n a s a l c a v ity a n d p a r a n a s a l s in u s e s . T h e a d e n o c a r c in o m a s a c c o u n t f o r o n ly 4 - 8 p e r c e n t o f n a s a l a n d p a r a n a s a l s in u s c a r c in o m a s . T h e y a r e f o u n d m o r e f r e q u e n tly in m a le s , a n d in th e f if th d e c a d e o f lif e . T h e s e tu m o r s c a n o r ig in a te f r o m th e s u r f a c e o f th e r e s p ir a to r y e p ith e liu m , o r f r o m g la n d s lo c a te d in th e e p ith e liu m . W e f o u n d m a n y r e p o r ts o f n a s a l s e p ta l p le o m o r -f ic a d e n o m a , s o m e tim e s m a q u e -r a d in g a s a c a r c in o m a .3,4
T h e e x p r e s s io n a d e n o c a r -c in o m a " in s itu " is c o n tr o v e r s ia l. P a th o lo g is ts h a v e g iv e n p r e f e r e n c e to th e te r m " p r e c o c io u s a d e n o c a r -c in o m a ." T h e y a r e c o m p o s e d o f g la n d s c o a te d w ith a ty p ic a l c e lls , w ith in th e c o r iu m , w ith n o in f iltr a tio n o f th e b a s a l m e m b r a n e .
T h e m u c in o u s a d e n o c a r -c in o m a m a y b e p a p illa r y o r s o lid . M o s t o f th e p a p illa r y tu m o r s a r e m o d e r a te ly o r w e ll d if f e -r e n tia te d , a n d s o m e o f th e m c o n ta in ' c y s tic s tr u c tu r e s . H is to lo g ic a lly , th e s e tu m o r s o f te n r e s e m b le c o lo n ic c a r c i-n o m a s . T h e y a r e lo c a lly a g g r e s -s iv e , b u t s e ld o m m e ta s ta s iz e , a lth o u g h m a n y p a tie n ts d ie f r o m J o c a l e x te n s io n o r d is s e m in a tio n o f th e tu m o r . T h e r e is a h ig h e r p r o p o r tio n o f w o o d w o r k e r s e x p o s e d to b e e c h , o a k , a n d
e b o n y d u s t a m o n g p a tie n ts w ith a d e n o c a r c in o m a o f th e n o s e a n d p a r a n a s a l s i n u s e s , th a n in th e g e n e r a l p o p u la tio n . I t h a s b e e n d is c u s s e d th a t th e c a r c in o g e n ic e f f e c t is d u e to th e m ix e d e x p o s u r e to b o th w o o d d u s t a n d o th e r c h e m ic a ls u s e d in w o o d w o r k in g , s u c h a s : p r e s e r v a tiv e s ; v a r n is h e s ; s o lv e n ts ; a n d o th e r s a g e n ts lik e f o r m a ld e h y d e , c h r o m i u m , th o r o tr a s t, i s o p r o p h y I
a lc o h o l, n ic k e l, s m o k e , a n d e th y l- a lc o h o l. T h e s e a g e n ts
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RESUMO
L e s o e s p e d ic u la d a s d a s c a v id a d e s n a s a is s a o re la tiv a m e n te c o m u n s n a p rc H ic a o to rrin o la rin g o l6 g ic a d ia ria , e n tre e la s o s p 6 1 ip o s in fla m a t6 rio s , o s tu m o re s b e n ig n o s , tu m o re s m a lig n o s e p ro c e s s o s e s p e c ffic o s , c o m o a rin o s p o rid io s e . O s a u to re s d e s c re v e m u m a p a c ie n te , d o la r, p o rta d o ra d e u m a le s a o v e rru c o s a e p e d ic u la d a a s s in to m a tic a n a m u c o s a d o s e p to n a s a l. 0 e x a m e a n a to m o -p a to l6 g ic o m o s tro u tra ta r-s e d e u m "c a rc in o m a in s itu ". A s c ita y o e s b ib lio g ra fic a s s a o p o u c o n u m e ro s a s e s o m e n te re p o rta m c o n c o m it€ m c ia e n tre a d e n o c a rc in o m a s in s itu e 0c o n ta to c o m p 6 d e m a d e ira (fa ia , e b a n o e c a rv a lh o ).
E
im p o rta n te e n fa tiz a r a im p o rt€ m c ia d a re a liz a y a o d o e x a m e o to rrin o la rin g o l6 g ic o c o m p le to , ro tin e ira m e n te , e m to d o s o s p a c ie n te s q u e p ro c u ra m 0e s p e c ia lis ta , e s p e c ific a m e n te n a d e te c y a o d e le s o e s p o te n c ia lm e n te m a lig n a s , c u ja re m o y a o p re c o c e p e rm ite c u ra c o m p le ta .REFERENCES
l. A c h e n s o n E D , H a d fie ld E H , M a c B e th R G . C a rc in o m a o f
th e n a s a l c a v ity a n d a c e s s o ry s in u s e s in w o o d w o rk e rs . L a n c e t
1 9 6 7 ;1 :3 1 1 -2 .
2 . J u n q u e ira L C , C a rn e iro 1 . In : H is to lo g ia B a s ic a , 6 th E d ., R io
d e J a n e iro : G u a n a b a ra , 1 9 8 5 :3 4 3 -8 .
3 . K le in s a s s e r 0 , S c h o ro e d e r H G , M a y e r-B rix , 1 . P re in v a s iv e
s ta g e s o f a d e n o c a rc i n o m a o f th e n o s e a fte r e x p o s u re to w o o d
d u s t. E u r A rc h O to rh in o la ry n g o l 1 9 9 1 ;2 4 8 (4 ):2 2 2 -9 .
4 . L ia o B S , H ils in g e r J r. R L , C h o n g E . S e p ta l p le o m o rp h ic
a d e n o m a m a s q u e ra d in g a s s q u a m o u s c e ll c a rc in o m a . E N T
J o u rn a l 1 9 9 3 ;7 2 (1 2 ):7 8 1 -2 .
L O U R E N < ;O , E .A . & C O S T A , L .H .C . - N a s a l s e p ta l p e d ic u la te c a rc in o m a in s itu : d iffe re n tia l d ia g n o s is
