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Year : 2019  |  Volume : 15  |  Issue : 3  |  Page : 708-711

Nonkeratinizing squamous cell carcinoma: A rare case report with oral involvement

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 Publication29-May-2019

Correspondence Address:
Dr. Kanupriya Gupta
Faculty of Dental Sciences, IMS, BHU, Varanasi - 221 005, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_501_17

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 > Abstract 

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

How to cite this URL:
Agrawal R, Kumar N, Gupta K, Gupta N. Nonkeratinizing squamous cell carcinoma: A rare case report with oral involvement. J Can Res Ther [serial online] 2019 [cited 2021 Nov 27];15:708-11. Available from: https://www.cancerjournal.net/text.asp?2019/15/3/708/244465

 > Introduction Top

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.[1] 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.[2]

We report a very rare case of NKCa, causing maxillary sinus destruction with extension to and involvement of the oral cavity.

 > Case Report Top

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 1: Intraoral view of lesion

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Figure 2: Thee-dimensional computed tomography scan of the lesion

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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].
Figure 4: H and E stained sections scanner view (4 x)

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Figure 5: H and E stained sections low power view (10 x)

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Figure 6: H and E stained sections high power view (40 x)

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The patient was referred to oncology for further treatment.

 > Discussion Top

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.[3],[4],[5] 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,[6] as the tumor is composed of malignant proliferating cells derived from the sinonasal respiratory (Schneiderian) epithelium.[7] The name cylindrical cell carcinoma was first coined by Ringertz in 1938,[6] and was recommended as the preferred term by El-Mofty in the WHO classification of 1991.[8]

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.[9]

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.[9]

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.[10] 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.[11]

Nasal SCCs rarely metastasize to lymph nodes, and recurrences, when they occur, do so quickly. The advanced local disease worsens the prognosis.[12] 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.[5]

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 Top

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.

 > References Top

Muir CS, Nectoux J. Descriptive epidemiology of malignant neoplasms of nose, nasal cavities, middle ear and accessory sinuses. Clin Otolaryngol Allied Sci 1980;5:195-211.  Back to cited text no. 1
Pilch BZ, Bouquot J, Thompson LD. Squamous cell carcinoma. In: Barnes L, Eveson JW, Reichart P, Sidransky D, editors. World Health Organization Classifcation of Tumors. Pathology and Genetics of Head and Neck Tumors. Lyon: IARC Press; 2005. p. 15-7.  Back to cited text no. 2
Rashid NH, Pauzi SH, Tan GC, Husain S, Yunus MR, Gendeh BS. Non keratinizing carcinoma of the sinonasal tract: A diagnosis of confusing nomenclature. Phillip J Otolaryngol Head Neck Surg 2011;26:21-4.  Back to cited text no. 3
Prakash SB, Nishan. A rare malignancy of sinonasal tract- transitional cell carcinoma: A case report. J Evol Med Dent Sci 2013;2:6946-50.  Back to cited text no. 4
Mondal M, Dey A, Bandopadhyay J, Banerjee D. Transitional cell carcinoma of the sinonasal tract. A rare entity. Clin Cancer Investig J 2015;4:50-3.  Back to cited text no. 5
  [Full text]  
Ringertz N. Pathology of malignant tumors arising in the nasal and paranasal cavities and maxilla. Acta Otolaryngol Suppl 1938;27:31-42.  Back to cited text no. 6
Shanmugaratnam K. WHO Histological Typing of Tumors of the Upper Respiratory Tract and Ear. 2nd ed. Berlin, New York: Springer, Heidelberg; 1991. p. 3.  Back to cited text no. 7
El-Mofty SK, Lu DW. Prevalence of high-risk human papillomavirus DNA in nonkeratinizing (cylindrical cell) carcinoma of the sinonasal tract: A distinct clinicopathologic and molecular disease entity. Am J Surg Pathol 2005;29:1367-72.  Back to cited text no. 8
Zarbo RJ, Torres FX, Gomez J. Nasal cavity and paranasal sinuses: Embryology, anatomy, histology and pathology. In: Pilch BZ, editor. Head and Neck Surgical Pathology. Philadelphia: Lippincott Williams & Wilkins; 2000. p. 80-156.  Back to cited text no. 9
Robin PE, Powell DJ, Stansbie JM. Carcinoma of the nasal cavity and paranasal sinuses: Incidence and presentation of different histological types. Clin Otolaryngol Allied Sci 1979;4:431-56.  Back to cited text no. 10
Friedmann I, Osborn DA. Carcinoma of the surface epithelium. In: Freidmann I, editor. Pathology of Granulomas and Neoplasms of the Nose and Paranasal Sinuses. Edinburgh: Churchill Livingstone; 1982. p. 118-82.  Back to cited text no. 11
Barnes L, Eveson JW, Reichart P, Sidransky D, editors. Pathology and Genetics Head and Neck Tumours. World Health Organization Classification of Tumours. Lyon: IARC Press; 2005.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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