Inflammatory pseudotumor of the nasal cavity

Radiological diagnostic dilemma in a child with small aggressive facial mass, time to increase the differentials: an inflammatory myofibroblastic tumour

A 5-year-old girl with left facial swelling in the medial maxillary region close to the nasal ala was brought by her parents to our head and neck clinic. They have visited other doctors for similar presentation in the last 6 months, which started as redness and swelling, with occasional epiphora. The redness resolved after medical treatment, with slight regression of swelling, although it did not disappear. CT and MRI showed a locally aggressive, small enhancing soft tissue mass involving the left anteromedial maxillary wall, the nasal bone and the orbital floor. The mass involved the bony course of the nasolacrimal duct, which was the aetiology of the epiphora. The head and neck team performed an incisional biopsy through a sublabial approach. Concurrently, a nasolacrimal duct stent was inserted by an ophthalmologist. Histopathology was consistent with inflammatory myofibroblastic tumour with positive stains for CD68, CD163 and anaplastic lymphoma kinase-1. The tumour was excised and presently the patient is on periodic follow-up with head and neck and ophthalmology clinics.

Inflammatory Pseudotumor in the Nasal Cavity and Sinuses: A Case Report and Associated Literature Review

Inflammatory pseudotumor (IP) is a clinically aggressive but histologically benign condition of unknown cause. It rarely appears in the nasal cavity and sinuses. Here, we describe a 24-year-old female with the main symptom of right nasal obstruction. Examinations showed dilation in the right maxillary sinus and a pale neoplasm in the nasal cavity. The neoplasm was completely excised under endoscope. Postoperative pathology showed significant proliferation of plasma cells and lymphocytes, indicating the presence of IP. No recurrence was found during 20 months of follow-up. Only 28 cases (10 males and 18 females, average 41.04 years) have been reported on Pubmed. The main clinical manifestations were nasal obstruction, epistaxis, facial swelling and pain, eyeball protrusion, diplopia, and other ocular symptoms. Inflammatory pseudotumor always erodes the surrounding bone and requires active treatments. Surgery is the optimal option with a good prognosis.

Unusual Nasal Insufficiency in an Infant: What's Behind the Nostril?

OBJECTIVES

Inflammatory myofibroblastic tumor (IMT) is a rare benign lesion, especially in the pediatric age. There are several cases described in pulmonary, digestive and renal localizations, but involvement in head and neck area is infrequent.

METHODS

Case report and review of the literature.

RESULTS

A 1 year and 11 months old child, during 2 months had clinical signs of nasal respiratory insufficiency and epistaxis subsequently developing a purulent rhinorrhea and a sleep apnea. His pediatrician previously requested a sinus and cavum X-ray with the finding of an image compatible with an intranasal mass. Endoscopic resection was performed of the mass with further immunohistochemical analysis showing the result of a lesion compatible with IMT.

CONCLUSIONS

Even though there are very few cases in scientific literature of a tumor with these characteristics in infants, IMT must be present as a differential diagnosis of intranasal masses. The role of the pathologist is essential to reach the definitive diagnosis and the performance of an early surgical treatment decreases aesthetic consequences in this pathology.

Sinonasal Inflammatory Myofibroblastic Tumor with Anaplastic Lymphoma Kinase 1 Rearrangement: Case Study and Literature Review

Inflammatory myofibroblastic tumors (IMTs) are rare mesenchymal tumors initially described in the lung. About half of them exhibit expression of the ALK1 protein, generally resulting from a gene rearrangement. Paranasal sinus IMTs are extremely uncommon, and gene rearrangement of ALK1 is very rare in this localization. A 47-year-old woman presented with rapidly progressive vision loss in her left eye. Clinical and imaging work-up revealed a tumor invading the left ethmoidal and sphenoidal sinuses and extending into the nasal cavity, the orbit and the skull base. Complete tumor resection was performed using an endonasal approach. Pathological examination revealed a paranasal localization of IMT, positive for ALK1 immunostaining. FISH analysis showed an ALK1 gene rearrangement. This case illustrates the local aggressive potential for IMTs. Treatment is primarily surgical, but targeted therapies (crizotinib) might be a solution for ALK1 rearranged cases with a poor prognosis.

An Inflammatory Pseudotumor Arising from Pterygopalatine Fossa with Invasion to the Maxillary Sinus and Orbital Cavity

We report a patient who had an inflammatory pseudotumor (IPT) that invaded to the maxillary sinus and orbital cavity, with the left pterygopalatine fossa as the principal site; this is a very rare case. The patient was an 83-year-old woman who suddenly became aware of impairment in the eyesight and visual field of the left eye. CT images showed a neoplastic lesion that invaded to the maxillary sinus and orbital cavity, with the left pterygopalatine fossa as the principal site, and also showed contrast effects. To obtain a definitive diagnosis from histopathological analysis, the lesion was biopsied, and she was diagnosed as the inflammatory pseudotumor with the immunohistochemical study and multiplex polymerase chain reaction-based clonality assays. The patient had a lymphoid-predominant lesion that responded to radiotherapy but corticosteroids were not effective. It is important to scrutinize the pathology to avoid unnecessary and mutilating surgery.

Inoperable inflammatory myofibroblastic tumour of the para-nasal sinuses and orbit with recurrence responding to methotrexate and prednisolone: a case report

BACKGROUND

Inflammatory myofibroblastic tumour is a rare neoplasm with a potential to behave in a malignant manner. It can occur anywhere in the body, however involvement of the head, especially the para-nasal sinuses is rare.

CASE PRESENTATION

A 33-year-old South Asian male presented with coryzal symptoms including a persistent cough with an asymmetrical swelling of the left side of the face. Imaging revealed a mass lesion involving the para-nasal sinuses eroding into the orbit. Histology and the clinical picture were compatible with inflammatory myofibroblastic tumour. As curative excision of the tumour was not feasible, medical management was offered. Despite early features of remission to glucocorticoids, tapering resulted in recurrence. Hence combination therapy with glucocorticoids and methotrexate was commenced with dramatic reduction of tumour burden and the patient has been in remission to date.

CONCLUSION

Inflammatory myofibroblastic tumour has the potential to behave in a malignant manner. Medical management with chemotherapy, glucocorticoids and non-steroidal anti-inflammatory drugs though effective, do not have a uniform response pattern. Surgically unresectable inflammatory myofibroblastic tumour above neck should be treated aggressively with combination regimens. Combination of prednisolone with methotrexate has been shown to have good outcome.

Inflammatory myofibroblastic tumors of the nasal cavity and paranasal sinus: a clinicopathologic study of 25 cases and review of the literature

Inflammatory myofibroblastic tumor (IMT) is rare in nasal cavity and paranasal sinus. The aim of this study was to describe the clinicopathological features of sinonasal IMT and analyze the relationship between the clinicopathological features and the prognosis. A retrospective study of 25 IMT patients between 2001 and 2012 was performed. Data on clinical features, treatment, and follow-up were recorded. The histological characters were observed. Overall survival (OS) and event-free survival (EFS) were estimated using the Kaplan-Meier method. Clinically, the most common symptoms were nasal obstruction, facial pain, and toothache. Twenty patients received follow-ups 6-120 months after initial diagnosis. Fifteen (75 %) developed recurrence 1 or more times. One patient had left cervical lymph node metastasis (5 %). Five patients died of the tumor (25 %). Histologically, the IMTs composed of bland spindle cells admixed with a prominent infiltrate of plasma cells and lymphocytes and showed obvious atypia in recurrent cases. Histology with necrosis, mitosis (≥1/10 HPF), ganglion-like cells, histological pattern I or II and relapse (≥4 times) was significantly associated with poor OS and EFS. IMT of the nasal cavity and paranasal sinuses exhibits relatively bland histologic appearances, but can shows strongly aggressive behavior and relatively poor outcomes. Multiple relapse, necrosis, frequent mitosis, the presence of ganglion-like cells, and histological pattern might be associated with poor clinical outcomes.

Transcatheter arterial embolisation for paediatric inflammatory pseudotumour of the maxillary sinus

BACKGROUND

Inflammatory pseudotumours are mostly seen in the lung, and occasionally in the head and neck region including the sinonasal area. Reported treatment modalities comprise corticosteroid treatment, surgical excision and radiotherapy. The latter option is required because wide surgical resection may be difficult for head and neck lesions, especially in children. However, clinicians should be aware of the risk of late-onset side effects of radiotherapy in children.

CASE REPORT

We present a two-year-old girl with a massive inflammatory pseudotumour of the maxillary sinus. Transcatheter arterial embolisation was performed, and the lesion was successfully managed without additional therapy. There was no evidence of recurrence over the next five years.

CONCLUSION

This is the first report presenting the utility of arterial embolisation for inflammatory pseudotumour.

Anaplastic lymphoma kinase expression and prognosis in inflammatory myofibroblastic tumours of the maxillary sinus

Inflammatory myofibroblastic tumours (IMT) of the nasal cavity and nasal sinus are rare and, although over 50 cases have been reported in the English-language literature, their precise aetiology and biological behaviour have not been elucidated. Recent studies suggest that anaplastic lymphoma kinase (ALK)-positive tumours have a very low risk of metastasis, but ALK reactivity does not appear to correlate with recurrence. Between March 2002 and December 2008, we encountered three cases of maxillary sinus IMT and investigated them to determine the clinicopathological course, prognosis and immunohistochemical expression of ALK. Two of the patients died < 13 months after the initial diagnosis and the third had multiple recurrences. All three cases were immunohisto chemically negative for ALK expression. IMT of the sino-nasal tract is rare and may undergo malignant transformation in a minority of cases. The three cases manifested progressive extension with bone destruction and multiple recurrences, and two cases had a fatal outcome and one case had high recurrence.

Sphenoid wing inflammatory pseudotumor mimicking a clinoidal meningioma: case report and review of the literature

BACKGROUND

Inflammatory pseudotumor is a nonneoplastic process of unknown etiology most frequently involving the lungs and orbits. Primary intracranial inflammatory pseudotumors are exceptionally rare. The authors report a rare case of clinoidal inflammatory pseudotumor mimicking a medial sphenoid wing meningioma.

CASE DESCRIPTION

A 24-year-old woman presented with visual diminution and proptosis in the left eye for one and a half years. Imaging revealed a medial sphenoid wing mass, which was surgically decompressed. Histopathology confirmed the diagnosis of inflammatory pseudotumor after which she was treated with steroids. The patient is doing well at 3 months' follow-up with resolution of proptosis and no further diminution of vision.

CONCLUSION

Inflammatory pseudotumors can mimic a malignant tumor both radiologically and clinically. The treatment options consist of surgery, high-dose steroids, irradiation, and chemotherapeutic agents with variable therapeutic response. Intracranial involvement due to inflammatory pseudotumor is exceptionally rare. The importance of recognizing and appropriately diagnosing this rare intracranial pathology lies in prognostication and avoidance of overzealous treatment.