|Year : 2019 | Volume
| Issue : 3 | Page : 708-711
Nonkeratinizing squamous cell carcinoma: A rare case report with oral involvement
Rahul Agrawal1, Naresh Kumar2, Kanupriya Gupta1, Nidhi Gupta2
1 Department of Oral Pathology and Microbiology, Faculty of Dental Sciences, IMS, BHU, Varanasi, Uttar Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, IMS, BHU, Varanasi, Uttar Pradesh, India
|Date of Web Publication||29-May-2019|
Dr. Kanupriya Gupta
Faculty of Dental Sciences, IMS, BHU, Varanasi - 221 005, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Transitional cell carcinoma also known as nonkeratinizing carcinoma (NKCa) of sinonasal tract comprises 15%–20% of malignant sinonasal carcinoma. We are reporting the case of 48-year-old male with a history of tooth extraction. A computed tomography was done which showed opacity in the right nasal cavity. Incisional biopsy was taken which revealed NKCa (transitional type). Very few reported cases of this type of malignancy were found. A possible reason could be multiple synonyms such as cylindrical cell carcinoma, Schneiderian carcinoma, and transitional cell carcinoma.
Keywords: Nonkeratinizing carcinoma, sinonasal carcinoma, transitional cell carcinoma
|How to cite this article:|
Agrawal R, Kumar N, Gupta K, Gupta N. Nonkeratinizing squamous cell carcinoma: A rare case report with oral involvement. J Can Res Ther 2019;15:708-11
| > Introduction|| |
Nonkeratinizing carcinoma (NKCa) is a rare malignancy of the nose and paranasal sinuses. The incidence of sinonasal malignancy is approximately 3.5/100,000 population per year. Of this, 15%–20% are NKCa. According to the WHO classification, it has many synonyms including Schneiderian carcinoma, transitional cell carcinoma, cylindrical cell carcinoma, Ringertz carcinoma, and respiratory epithelial carcinoma.
We report a very rare case of NKCa, causing maxillary sinus destruction with extension to and involvement of the oral cavity.
| > Case Report|| |
A 48-year-old man presented with a painful mass in the right posterior maxillary alveolar ridge, symptoms of nasal airway obstruction, and facial enlargement. The patient reported a history of tooth extraction (tooth 15, 16) due to a periapical lesion 15 days back [Figure 1]. The rest of his medical history was unremarkable. Radiographic evaluation including a computed tomography scan revealed a sinonasal mass causing opacification of the right maxillary sinus with destruction of the lateral nasal wall and maxillary sinus floor with anterior and posterior lateral walls [Figure 2] and [Figure 3]. The presumptive diagnosis was aggressive mucocele of the maxillary sinus or malignant tumor. Incisional biopsy was performed and sent for histopathological examination.
|Figure 3: Computed tomography scan showing a sinonasal mass causing opacification of the right maxillary sinus with erosion of the orbital floor, lateral nasal wall, and maxillary sinus floor|
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Hematoxylin and eosin stained sections showed stroma infiltrated by malignant cells forming islands and ribbon-like patterns. The cells displayed large vesicular nuclei with moderate pleomorphism. Some of the cells had 2–3 nucleoli. Mitoses were frequently seen. Bone trabeculae, areas of hemorrhage and necrosis were also present. No evidence of keratinization was seen [Figure 4], [Figure 5], [Figure 6].
The patient was referred to oncology for further treatment.
| > Discussion|| |
NKCa or transitional cell carcinoma of the sinonasal cavity is a rare entity. There are very few reports concerning this type of malignancy. To the best of our knowledge, on literature review, we found only three reported cases of NKCa; Rashid et al. 2011, Prakash and Nishan 2013, Mondal et al. 2015.,, Furthermore, till date, no case with involvement of oral cavity has been reported. According to the WHO classification, it has many synonyms including, Schneiderian carcinoma, cylindrical cell carcinoma, Ringertz carcinoma, and respiratory epithelial carcinoma, as the tumor is composed of malignant proliferating cells derived from the sinonasal respiratory (Schneiderian) epithelium. The name cylindrical cell carcinoma was first coined by Ringertz in 1938, and was recommended as the preferred term by El-Mofty in the WHO classification of 1991.
The WHO classification also lists NKCa as a variant of squamous cell carcinoma (SCC). Microscopically, NKCa is composed of papillary fronds thick ribbons and poly stratified masses of cells that give rise quite often to invaginations of the surface epithelium, which at low magnification may mimic inverted papilloma. The tumor cells are commonly cylindrical and have a tendency to form palisade arrangements perpendicular to the underlying basement membrane. The nuclei are atypical and show increased mitotic activity, as well as abnormal mitotic figures. The pattern of invasion is usually expansive, being characterized by pushing margins with focal infiltration of the stroma. The basement membrane remains in most cases conspicuous, despite stromal infiltration, which should not be regarded as carcinoma in situ. Foci of squamous metaplasia, with transition from cylindrical to squamous epithelium, are not uncommon and when extensive these tumors may be indistinguishable from SCC. This resulted in denominations such as “transitional cell carcinoma” and nonkeratinizing SCC,” which may be confusing, the first because the term transitional has also been applied to carcinomas of the lymphoepithelial type, and the second due to the fact that tumors called “nonkeratinizing SCC” also have foci of keratinization.
The designation of cylindrical cell carcinoma as a synonym, on the other hand, is misleading as it may suggest a relationship to the cylindrical cell papilloma (oncocytic Schneiderian papilloma). The later is microscopically distinct characterized by surface oncocytic columnar and mucus cells and is unrelated to NKCa.
Robin et al. found a difference in the mean age of presentation between men and women in NKCa which was 57.8 and 70.4 years, respectively. They also found a marked contrast in the distribution of sites among the different types of carcinomas. SCCs were seen predominantly in the maxillary antrum; adenocarcinomas were predominantly in the ethmoid while NKCa was more evenly spread. Another observation was that NKCa in men carried a better prognosis than in women where the 5-year survival rates were 40% and 13%, respectively. Other studies have found that it emerges more favorably with the 5-year survival rate of 37.5% compared to SCC of 10% and is more sensitive to radiation but has a greater tendency to local recurrence.
Nasal SCCs rarely metastasize to lymph nodes, and recurrences, when they occur, do so quickly. The advanced local disease worsens the prognosis. Treatment depends on the tumor location and extent. T1 and T2 nasal tumors are treated by surgical resection, while T3 and T4 tumors receive postoperative radiotherapy. Various surgical approaches such as lateral rhinotomy or medial maxillectomy or an en bloc ethmoidectomy are done for superior and lateral nasal cavity carcinomas. Paranasal sinus tumors are managed by radical en bloc surgical resection followed by radiotherapy. Chemotherapy may be used as a neoadjuvant or postoperatively.
Although multimodality therapy does not seem to change the 5-year survival rate, it appears to have improved the local control of tumor. Factors limiting patient survival time are related to local recurrence, nodal metastasis, soft-tissue extension to the palate or nasopharynx, proptosis, and orbital symptoms, as metastases account for approximately 10% of deaths.
| > Conclusion|| |
The intention of this case reported is to alert dentists to include NKCa in the differential diagnosis of maxillary sinus tumors with aggressive behavior, which may extend to the oral cavity or involve the roots of teeth.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]