Angiomatoid change in polyps of the nasal and paranasal regions: an underrecognized and commonly misdiagnosed lesion—report of 45 cases

A Patient With Submerged Sinonasal Angiosarcoma After Resection of Underlying Organizing Hematoma

A 30-year-old female patient with facial pain diagnosed as organizing hematoma of maxillary sinus by biopsy and imaging studies, and subsequently tumor was resected via an endoscope-assisted midfacial degloving approach. The tumor was histopathologically confirmed as organizing hematoma. In 3-week follow-up, asymptomatic emerging mass was observed at the same site, and needed a revision endoscopic resection. On pathologic examination, a low-grade angiosarcoma was identified, not organizing hematoma. After postoperative radiotherapy, she has been a status of no evidence of disease. This report emphasizes that complete and delicate resection of sinonasal tumor should be made to prevent recurrence and submerged malignant potential.

Organized Hematoma: An Analysis of 84 Cases with Emphasis on Difficult Prediction and Favorable Management

OBJECTIVE

To characterize features of organized hematoma (OH) that may cause considerable diagnostic difficulties.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary medical center.

SUBJECTS AND METHODS

Eighty-four patients with pathologically confirmed OH over a 10-year period were retrospectively reviewed for clinical features, imaging findings, pathologic characteristics, and treatment modalities.

RESULTS

This study included 39 males and 45 females who presented with frequent epistaxis and nasal obstruction. There were 62 (74%) patients >40 years old (mean, 50; range, 9-81). OH mainly originated in the maxillary sinus (n = 82) or nasal cavity (n = 2) unilaterally, and most were expansile masses (n = 73) that extended into nasal cavity (n = 71) or choanae (n = 17). Several lesions were locally aggressive and simulated a malignant process that involved the ethmoid sinus (n = 22), orbit (n = 11), pterygopalatine fossa (n = 16), infratemporal fossa (n = 9), cheek (n = 3), and hard palate (n = 3). Internal architecture on computed tomography (CT) scans showed OH with expansile remodeling of the maxillary wall (82.1%) and smooth bony destruction (70.2%), whereas T2-weighted magnetic resonance (MR) images showed inhomogeneity with a notable hypointense peripheral rim in all lesions. CT and MR contrast-enhanced images revealed patchy heterogeneous enhancement that could be interpreted according to histopathologic findings of hemorrhage and neovascularization. OH was successfully removed with endoscopic surgery, although 5 cases recurred.

CONCLUSIONS

OH can be successfully treated by endoscopic surgery. CT and MR examination provide characteristic findings for prediction and careful surgical planning.

Nasal Cavity and Paranasal Sinuses

The nasal cavity and paranasal sinuses occupy the top of the upper respiratory tract and form pneumatic spaces connected with the atmosphere. They are located immediately beneath the base of the cranium, where crucial vital structures are harbored. From this region, very much exposed to airborne agents, arise some of the more complex and rare benign and malignant lesions seen in humans, whose difficulties in interpretation make this remarkable territory one of the most challenging in the practice of surgical pathology.

Contents of this chapter cover inflammations and infections, polyps and pseudotumors, fungal and midfacial destructive granulomatous lesions, as well as benign, borderline, and malignant neoplasms. Among the neoplasms, emphasis is made on those entities characteristic or even unique for the sinonasal region, such as Schneiderian papillomas, glomangiopericytoma, intestinal- and non-intestinal-type adenocarcinomas, olfactory neuroblastoma, nasal-type NK-/T-cell lymphoma, and teratocarcinosarcoma. Moreover, recently recognized entities involving this territory, i.e., HPV-related non-keratinizing carcinoma, NUT carcinoma, and SMARCB1-deficient basaloid carcinoma, are also discussed in the light of their specific molecular findings. Furthermore, the text is accompanied by numerous classical and recent references, several tables, and 100 illustrations.