Adenosquamous carcinoma of the nasal cavity.

[FIGURE 1 OMITTED]

Adenosquamous carcinoma of the nose and paranasal sinuses is rare, as only 7 cases have been reported in the literature. (1-3) We report a case of adenosquamous carcinoma of the nasal cavity with a unique presentation that was managed endoscopically.

A 54-year-old woman presented to our office with a 5-week history of right-sided nasal obstruction, discharge, and occasional epistaxis. She believed that her symptoms might have been caused by an insect that had flown into her nose and might have become lodged there. She reported no history of any nasal symptoms prior to that incident. She had no allergies or sinus problems, and she was otherwise completely healthy.

Physical examination revealed no insect in the patient's nose. It did reveal, however, that a soft, friable, polypoid mass was filling the right nasal cavity and pushing the septum to the left. No lymphadenopathy in the neck was seen. The patient had already undergone computed tomography (CT) of the sinuses. CT confirmed the presence of a soft-tissue mass that had completely filled the right nasal cavity and had pushed the septum significantly to the left (figure 1). No evidence of invasion and no bony destruction of the ethmoid sinuses or cribriform plate were seen on CT, and the nasopharynx appeared to be free of disease.

The patient was taken to the operating room and put under general anesthesia, and a full endoscopic examination of the nasal cavity confirmed that a large, polypoid, soft, friable mass filled the right nasal cavity. The mass was not attached in any way to the nasal septum, middle turbinate, or lateral nasal wall. Instead, it was attached to the cribriform plate and the sphenoethmoid recess by a stalk. The mass was confined strictly to the nasal cavity and did not extend to the nasopharynx. The middle meatus appeared to be free of disease.

Analysis of a large frozen-section biopsy specimen revealed that the mass was a malignant tumor composed of small, round cells. Because the rest of the mass was bleeding quite profusely, it was removed completely with a microdebrider. Subsequent inspection of the nasal cavity demonstrated an intact septum and lateral wall and an intact cribriform plate. We decided to conclude our procedure pending final pathologic findings.

Microscopic analysis revealed that the polypoid tumor was composed of cells with gland-forming pleomorphic nuclei (figure 2). Mitotic figures were abundant. There were areas composed of sheets of keratinizing squamous cells with pleomorphic nuclei. Mucin stains were positive. These findings were compatible with a diagnosis of a moderately differentiated adenosquamous carcinoma.

Magnetic resonance imaging (MRI) of the head, neck, and paranasal sinuses and positron-emission tomography were performed postoperatively. Neither detected any signs of residual or additional disease. The patient was then treated with a course of radiotherapy localized to the area of the cribriform plate to eradicate any remaining microscopic foci of disease. At follow-up 6 months later, she was doing well and exhibited no signs of recurrent disease on physical examination and imaging studies.

All of the previously reported cases of adenosquamous carcinoma of the nose and paranasal sinuses involved large, extensive, and destructive tumors that required aggressive surgery along with chemotherapy and radiotherapy. (1-3) To the best of our knowledge, ours is the first reported case that involved an adenosquamous carcinoma that was strictly confined to the nasal cavity and did not involve any bony structure in the nose or the sinuses. It is also the only case that was treated solely via an endoscopic approach. Since there was no postoperative evidence of gross disease in the nose or paranasal sinuses, we believe that a more radical and aggressive surgical intervention was not warranted in this case. However, the patient will be monitored closely for any sign of recurrence. Although we agree that most cases of adenosquamous carcinoma of the nose and paranasal sinuses require aggressive surgical and adjuvant therapy, our case demonstrates that it may be possible to successfully treat noninvasive tumors endoscopically.

[FIGURE 2 OMITTED]

The differential diagnosis of adenosquamous carcinoma includes squamous cell carcinoma and mucoepidermoid carcinoma. (2) The evaluation of a patient with a nasal tumor should include a careful history and physical examination, particularly a complete nasal and nasopharyngeal endoscopy. CT of the nose and paranasal sinuses is necessary for evaluating the extent of the tumor and any sinus or skull-base invasion and bony destruction. MRI may sometimes be needed to better evaluate possible intracranial involvement.

Acknowledgment

The authors thank Michelle Grillis, DO, of the Department of Pathology at Memorial Hospital in Fremont, Ohio, for her help in the preparation of this manuscript.

References

(1.) Gerughty RM, Hennigar GR, Brown FM. Adenosquamous carcinoma of the nasal, oral and laryngeal cavities: A clinicopathologic survey of ten cases. Cancer 1968;22(6):1140-55.

(2.) Minic AJ, Stajcic Z. Adenosquamous carcinoma of the inferior turbinate: A case report. J Oral Maxillofac Surg 1994;52(7):764-7.

(3.) Ogawa T. A clinico-pathologic study of adenocarcinomas of the nasal cavity and paranasal sinuses [in Japanese]. Nippon Jibiinkoka Gakkai Kaiho 1989;92(3):317-33.

Shai Y. Shinhar, MD; Christina L. Heckathorn, DO From the Department of Otolaryngology, Memorial Hospital, Fremont, Ohio.