A 32 year old man who had recurrent episodes of epistaxis was seen in the ENT outpatient clinic. Flexible endoscopy revealed deviation of the nasal septum to the left. Arising from the posterior end of the left nasal septum was a pedunculated well-circumscribed lesion. Magnetic resonance imaging revealed no other abnormalities. At operation, a lobulated solid mass was seen. The mucosa anterior to the mass had become detached. The underlying bone was removed but did not look involved. Postoperative recovery was uneventful and he was discharged the next day. The lesion was suspected to be a haemangioma. Previous episodes of epistaxis were treated with silver nitrate cautery. The patient has no significant past medical history. He is a non-smoker, was not on any regular medication and had no relevant occupational history. Subsequently, the patient had two further operations. Firstly, removal of the posterior aspect of the nasal septum was performed four months after removal of this mass. Secondly, a biopsy of the nostril was undertaken. The former revealed mucosal fragments incorporating seromucinous glands with intervening chronic inflammation of the stroma but no evidence of residual adenocarcinoma. The latter showed inflammatory granulation tissue around suture granulomata from previous surgery. Since initial presentation over two years ago, the patient remains free of recurrence or metastatic disease and does not have any lesions in his lungs or thyroid gland.
Macroscopically, two yellow-white polypoid fragments of tissue, measuring 10 and 4 mm in maximum dimension were received. Histologically, these fragments were partly covered by focally ulcerated squamous epithelium. The underlying stroma was infiltrated by a neoplasm with a complex papillary and tubular configuration, lined by moderately dysplastic pale columnar epithelium with intervening spindle shaped cells(Figure and ).
Low Power photomicrograph (×40) of this entity: low-grade non-intestinal tubulopapillary adenocarcinoma of the sinonasal tract with overlying surface squamous epithelium.
High power photomicrograph (×250): complex tubules and papillae lined by mild/moderately dysplastic pale columnar cells.
Immunohistochemical labelling revealed diffuse positivity with antibodies to EMA, CAM 5.2, CK 7, CK 19 and TTF-1 (Figure ). The cells were negative with CK 20, CEA, S-100 protein, thyroglobulin, SMA and p63. The appearances were consistent with a low-grade, non-intestinal type sinonasal tubulopapillary adenocarcinoma.
Immunohistochemical nuclear positivity for thyroid transcription factor 1 (TTF-1).