Pathology Quiz Case 1

Abstract

A 42-YEAR-OLD MAN PRESENTED WITH LEFTsided facial pressure and nasal airway obstruction. Despite a partial response to oral antibiotic therapy, he developed periorbital edema and erythema and was hospitalized. On physical examination, his left eye appeared proptotic. Nasal endoscopy demonstrated a fleshy mass in the left nasal cavity that extended superiorly toward the roof of the ethmoid and obstructed the osteomeatal complex.Computed tomography revealed pansinusitis. Magnetic resonance imaging demonstrated a large soft-tissue mass centered within the left nasal cavity (Figure 1). The mass extended superiorly to the anterior ethmoid air cells and intracranially through the left cribriform plate. Abnormal enhancement was observed along the dura and in the region of the olfactory tracts. An axial T1-weighted postgadolinium image showed that the mass caused severe lateral bowing of the left medial orbital wall, with displacement of the medial rectus and left globe (Figure 2).The patient was treated with intravenous antibiotics and underwent endoscopic biopsy. Microscopically, the biopsy specimen consisted of a submucosal spindle cell proliferation that infiltrated and destroyed the underlying bone. Cellular areas of the tumor exhibited cytologically atypical spindle cells with wavy, elongated nuclei and vague nuclear palisading. Scattered mitoses were also present. Interspersed between the cellular areas were more loose and myxoid areas. Scattered throughout the tumor were relatively large cells with abundant granular eosinophilic cytoplasm occurring singly and as small clusters (Figure 3). Immunohistochemical staining showed that the cells were positive for desmin and myogenin. The spindle cell areas were focally positive for S-100 protein (Figure 4).