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OJHAS Vol. 9, Issue 3:
(Jul - Sep, 2010) |
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| Pitfalls
in Cytodiagnosis of Pleomorphic Adenoma of the Nasal Septum - A
Rare Case Report |
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Abhishek MG, Assistant Professor, Department
of Pathology,
Vijayshankar S Assistant Professor, Department of Pathology,
Amitha Krishnappa, Assistant Professor Department of Pathology,
Adichunchanagiri Institute of Medical Sciences, BG Nagara, Bellur cross, Mandya district, Karnataka, India. |
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Address For Correspondence |
Assistant Professor,
Department
of Pathology,
Adichunchanagiri Institute of Medical Sciences,
B.G.Nagara, Bellur cross,
Mandya district, Karnataka, India.
E-mail:
drmgabhishek@gmail.com |
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Abhishek MG, Vijayshankar S, Krishnappa A. Pitfalls
in Cytodiagnosis of Pleomorphic Adenoma of the Nasal Septum - A
Rare Case Report. Online J Health Allied Scs.
2010;9(3):17 |
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Submitted: Aug 18, 2010;
Accepted:
Sep 15, 2010; Published: Oct 15, 2010 |
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| Abstract: |
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Pleomorphic
adenoma is the most common benign mixed tumor of major salivary gland.
Ectopic occurrence of pleomorphic adenoma are seen in minor salivary
glands of pharynx, trachea, larynx and very rarely in nasal septum.
We report a case of 40 year old female who presented with right sided
nasal mass and mild nasal obstruction since six months. Cytologically
a possibility of pleomorphic adenoma was made which was confirmed by
histopathological study. We present this case due to 1) rarity in the
nasal septum 2) pitfalls at cytology due to abundance (predominance)
of myoepithelial cells and scanty or even absent mesenchymal component
and 3) under reporting in English literature to the best of our knowledge.
Key Words: Pleomorphic adenoma; Nasal septum; Fine needle aspiration cytology
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A 40 year
old female presented with the complaint of right sided nasal mass and
minimal nasal obstruction since six months. Clinical examination revealed
a firm swelling on the right side of the nose. Rhinoscopy showed a pink
white globular firm mass with smooth surface arising from the nasal
septum. Clinically the possibilities of haemangioma or chordoma were
considered. The patient was subjected for FNAC.
On Examination
revealed a pink-white firm mass arising from the right side of nasal
cavity measuring 1.5x1.0 cm (Figure 1). Aspiration was performed twice
from different sites which yielded scanty blood mixed whitish material.
Cytology showed moderately cellular smears comprising of predominantly
epithelial component arranged in pseudo papillary pattern. acini,
ducts and in singles (Figure 2), against the background showing
scanty mesenchymal stroma characteristic of fibrillary chondromyxoid
appearance. Thus the possibility of pleomorphic adenoma was suggested.
The mass was excised under local anaesthesia and sent for histopathologic
examination which confirmed the diagnosis of pleomorphic adenoma.(Figure
3)
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Figure1: Rhinoscopy showing
a pink white globular firm mass with smooth surface arising from
the nasal septum |
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Figure2:
Photomicrograph shows cellular smear comprising of predominantly epithelial
cells in psuedopapillary pattern, clusters and in singles (Geimsa stain, X 100) |
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Figure3:
Photomicrograph shows tumour cells in cords, tubules, sheets intermingled
with scant myxoid stroma. (Haematoxylin and Eosin, X 450). |
Pleomorphic
adenoma is a common benign mixed salivary gland tumor arising most commonly
from Parotid (80%).1 Incidence of pleomorphic adenoma in nasal septum
is only 3%1 It occurs more commonly in
females between third & sixth decade of life.
The other common sites are palate, pharynx, larynx, trachea, rarely
the nasal septum.2 Clinically it appears as a solitary
painless, slow growing nodule. Pleomorphic adenoma of nasal septum
was reported for the first time in 1929 by Denker and Kahler.3 According
to Spirro et al(1973) common site for pleomorphic adenoma in nasal
cavity is on four square cartilage of nasal septum. Nasal septum
is an unusual site for the occurrence because majority of minor serous
and mucinous glands are located in the lateral wall.4
At present there are two theories that explain the origin of septal
pleomorphic adenoma, one being that it arises from the Jacobson’s
organ or vomeronasal organ, an epithelial lined 6mm duct in the septal
cartilage, which normaly degenerates during early foetal life and the
other being that it may arise from misplaced embryonic epithelial cells
from the mucous membrane of the septum.6
At histopathology
most of the pleomorphic adenoma have biphasic component comprising of
epithelial/myoepithelial and fibromyxoid, chondroid stroma, but usually wide
variations in the morphologic spectrum have been reported, varying
from large epithelial types to large stromal types. This wide spectrum
of morphological variations is a major source of pitfall or error
in cytological interpretations. Predominance of epithelial cells in
FNAC leads to a mistaken diagnosis of monomorphic adenoma, myoepithelioma
and adenoid cytic carcinoma. If myxoid material is predominant with
scant or absent epithelial cells it may be erroneously diagnosed as
retention cyst, while presence of many metaplastic cells with scant
mucoid material may lead to mistaken diagnosis of mucoepidermoid
carcinoma.8
Pleomorphic
adenoma in the nasal septum is unique in that, these neoplasms have
predominant epithelial component, the stromal component being insconspicuous7
making cytological diagnosis difficult.
Hence predominance
of benign epithelial cells in the aspirate should caution a pathologist
to consider pleomorphic adenoma as a differential diagnosis in evaluating
nasal cavity masses, thereby preventing aggressive treatment and local
recurrences.
Although
excision is the main stay of treatment and majority behave in a benign
fashion, 50% of pleomorphic adenoma in nasal septum have local recurrences.
Hence follow up is must.
Pleomorphic
adenoma of nasal septum is very rare. At FNAC, high epithelial and absent
stromal component adds to the diagnostic dilemma. Cytologic diagnosis
of Pleomorphic adenoma in a nasal lesion is a challenge since it lacks
typical bimodal cell components, especially the mesenchymal one. Hence
in conclusion, inspite of the rarity of occurrence in the nasal cavity,
pleomorphic adenoma should always be considered as a differential diagnosis
while evaluating nasal cavity lesions. A careful search for the characteristic
chondromyxoid fibrillary stroma would clinch the diagnosis.
English Literature
search regarding cytologic diagnosis of nasal septal pleomorphic adenoma
did not reveal any reports so far to the best of our knowledge. Hence
our case could be the first report describing the cytological
features of nasal septal pleomorphic adenoma.
- Faissal M, Leila E, Asma EK, Hicham J, Nabila N, Nezha J et al. Giant
pleomorphic adenoma of the nasal fossae. FrORL. 2007;92:309-311.
- Batsakis, J. G. Tumors of the Head and Neck: Clinical and Pathological
Consideration. 2nd ed. Baltimore: Williams & Wilkins. 1984. pp 76-99
- Denker A, Kahler O. Handush der Hals. Nasen ohrenheilkunde 1929;5:202
- Patrocinio TG, Patrocinio JA, Patrocinio LG. Nasal Pleomorphic Adenoma:
Resection Via Degloving. Int Arch Otolaryngol. 2006;10
- Swamy KVN, Gowda BVC. A Clinical study of benign tumors of Nose and
Paranasal sinuses. Indian J Otolaryngol Head Neck Surg 2004;56(4):265-268
- Sen S, Saha S, Basu N. Pleomorphic adenoma of Nasal septum. Indian J
Otolaryngol Head Neck Surg 2005;57(2):163-165
- Gana P, Masterson L. Pleomorphic adenoma of the nasal septum: a case
report. J Med Case Reports. 2008 Nov 17;2:349
- Verma K, Kapila K. Role of Fine needle aspiration cytology in diagnosis
of pleomorphic adenomas. Cytopathology 2002;13:121-127.
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