0:01

Hi everybody, and thank you for joining us today, uh,

0:04

for lecture number two of Dr.

0:06

McCury. Um, just a reminder, we encourage you

0:09

to turn on your cameras and be ready to ask questions.

0:12

You can ask Dr. McCury directly

0:14

or enter your question into the chat.

0:16

Uh, Dr. McCury, whenever you're ready.

0:20

Yeah. Uh, hey everyone. Let's see.

0:23

We have the usual suspects here. I see. That's good.

0:28

Hey, please. Hey, hey, Andrea. We got, we have gallery.

0:31

I'm at home today,

0:32

so I think hopefully the internet is a little bit faster.

0:35

So, um, so what we're gonna do is, uh,

0:39

we're gonna talk about a simplified approach

0:41

to Cy nasal neoplasms.

0:43

And you know, what I hope to do in this is

0:45

that I'm not gonna cover every single sinus tumor.

0:49

In fact, when I go to the, when I actually go

0:52

to these talks on sinuses

0:54

and they talk about tumors, I'm,

0:56

I'm really paying attention like the first 15 minutes,

0:59

and then afterwards I've completely,

1:02

everything starts looking like everything else.

1:05

And so after a while I'm like, you know,

1:06

they all look like everything else.

1:08

So what I wanna be able to do is

1:11

to give you an approach to this.

1:12

So what, and you'll see as we kind of step through it,

1:15

we'll go, first, we'll go over the anatomy,

1:18

then we'll go over various spread patterns,

1:20

and then we will end the talk about giving you specific

1:23

imaging findings that can allow you to make an,

1:26

an individual a specific diagnosis.

1:28

So, you know, the most common tumor

1:31

to involve the sano nasal cavity is gonna be

1:33

squamous cell carcinoma.

1:35

So if you are looking at a, you know, a sinus, uh, a,

1:40

a sinus C tear in and you see a big mass in an adult, well,

1:44

if you say squamous cell carcinoma, you're gonna be right.

1:46

I mean, if you do the math right here, 97

1:49

to 96% of the time, right?

1:51

Because it is the most common head

1:52

and neck neoplasm, it's a little bit more common in

1:55

males than females.

1:56

And I always hate showing this slide

1:58

because it's in 55 to 65 years old.

2:01

And so I always hate this

2:02

because like on every slide I show,

2:04

these tumors are more common in my demographic.

2:06

So it kind of, kind of gives me the heebie-jeebies.

2:08

But you know, that's just the way it is.

2:11

The location of the squamous cell carcinomas are most

2:14

commonly in the maxillary sinuses, as is seen on the right.

2:17

It's also in the nasal cavity

2:18

and in the ethmoid ear cells as well.

2:22

So, you know,

2:24

squamous cell carcinoma is gonna be the most common tumor.

2:26

Now I'm gonna show this slide

2:27

because the next thing that I want to do is talk about,

2:31

you know, where you should be at the fellowship level.

2:34

So I've sort of, you know, over the last 30 years, I've kind

2:36

of divided head and neck into three levels.

2:38

Number one, like level one of head

2:40

and neck radiology is normal versus abnormal.

2:43

So if you can see something you think that's abnormal, well

2:45

that's pretty good in general, when you look at radiologist

2:47

as a whole, 'cause you're willing to look at this study

2:49

and you see something, the next level is

2:52

to see something abnormal

2:53

and give a, a laundry list of differential diagnosis.

2:56

And the hope is, is that it's a good differential diagnosis.

3:00

And as you gain more experience, you know, you'll,

3:02

you'll be able to focus.

3:04

And so that's why when I read your dictations, you know, I,

3:07

and I hope the feedback is good on those.

3:09

You know, I try to give a pretty comprehensive feedback,

3:12

and if there's something in particular,

3:13

you know, I'll add it.

3:15

But level three is really treatment planning.

3:19

And so what I do when I go to our tumor boards, uh,

3:22

you know, we don't have the largest tumor boards.

3:24

We're not like MD Anderson,

3:25

or we're not seeing 30 patients a week.

3:28

But what we do do is that we always try to sit down

3:31

and go over the actual spread patterns and the,

3:35

and how that affects the surgical approaches.

3:38

So it's a little, sometimes it kind

3:40

of scares me a little bit

3:41

because they really are taking the information I'm saying,

3:43

and they're determining where they should make their cuts.

3:46

They determine what type of flaps their unit gonna use,

3:49

whether they use a graft, so on and so forth.

3:51

So in a way that's sort of level three,

3:53

because what you really wanna do is provide information

3:56

that's going to affect how these patients are treated.

4:00

And I kind of left this up here for a specific reason

4:02

because I know as radiologists, um, you know, we,

4:05

you're probably want to focus on the slide on the left,

4:08

and you don't want to focus on the slide on the right.

4:10

But on the other hand, this is really what we're doing.

4:13

So when it really comes to, uh, cy nasal tumors,

4:18

the majority, and if I go back to this one, you know,

4:20

you can give a laundry list if you want to,

4:22

but my gosh, anyone can see this, say it's abnormal,

4:25

say it's malignancy, it can be easily biopsied.

4:28

But that next level is when you see something like this,

4:31

yeah, you can biopsy it, but how do you get to level two

4:34

and how do you get to level three in particular?

4:36

So when you see squamous cell carcinomas, you have to think

4:39

how the surgeon thinks, but also how the patient thinks.

4:42

So the first thing that we want to comment on is whether

4:45

or not there's intra orbital extension.

4:47

So I try to have this approach when I'm actually, um,

4:51

in interpreting these studies.

4:53

So, you know, you guys can come off

4:55

if anyone wants to come off mute.

4:57

I see gall's off mute and ize is off mute.

5:00

So what's the difference between this approach

5:01

and this approach, gall or, or Belize?

5:03

Do you see that both of these are, are, uh,

5:06

cranial facial approaches

5:07

and they're both lynch incisions

5:08

where they've done a lateral rhinology,

5:11

but what's the difference here versus here?

5:14

Can you tell,

5:20

see how the globe has gone?

5:22

So the globe has been resected.

5:24

So the, there's been an enucleation

5:26

and potential in exenteration, so in a nucleation,

5:29

whereas the globe is removed, whereas an exenteration is

5:32

where all of the orbital contents are resected.

5:35

And you've gotta look at this and

5:35

it is kind of gory to look at.

5:37

I'll, I'll grant you that much.

5:38

But on the other hand, this is real world.

5:40

And the way this decision is made is

5:42

that when you do AAAA mr in particular,

5:46

what you wanna be able to do is comment on whether

5:49

or not there's interorbital extension.

5:52

So in this case, there's no interorbital extension

5:54

because the laminate capricia right here is intact,

5:58

and there's a fat plane between this fat

6:01

and the medial rectus muscle.

6:03

And you can see that the superior BLE is intact as well too.

6:06

So if you say this,

6:08

then these patients can undergo a cranial facial resection

6:11

and the patient can actually save their orbit.

6:15

But on the other hand, here are other types

6:18

of intra orbital extension.

6:21

So in this case, we can see

6:23

that this tumor's extending laterally

6:25

and erodes the laina capricia

6:27

and it's a budding the, the medial aspect

6:30

of the medial rectus muscle.

6:31

So in this case, it's important for us

6:33

to comment on this in general,

6:36

the patients are gonna be consented anyway for an an,

6:39

an enucleation and orbital exenteration.

6:42

But on the other hand, this information is important

6:44

for the surgeon so they can

6:46

appropriately plan their surgery.

6:48

And in this case we can see this, uh, tumor extending

6:51

through the inferior portion of the orbit

6:53

and completely encasing the inferior rectus muscle.

6:56

So these are all two examples of Interorbital extension,

7:01

but it's important for us to say exactly

7:03

what the extension is.

7:04

Is it a budding the muscle, is the fat involved

7:07

or is it actually encasing the muscle?

7:09

So interorbital extension is the first one.

7:12

The second thing that I'll do is I'll sort

7:14

of introduce you again, this is the real world again, about

7:18

how these patients are actually resected.

7:21

So this was a patient that actually, um,

7:23

has a classic cranial facial approach.

7:26

So in a cranial facial approach,

7:28

what the surgeons do is they, they do a bi coronal flap.

7:31

So they take, make this incision

7:33

and this looking at the head from the top.

7:35

So they actually take the skin

7:37

and they literally peel it inferiorly.

7:39

And so this leaves you the skull.

7:42

So then what they then do is a craniotomy,

7:44

and now they're looking down at the skull

7:45

and they can actually see the frontal sinus.

7:47

So this gives them the approach from the top down.

7:52

Now, so this basically gives their cranial approach.

7:55

Then what they want to do for anterior skull-based tumors is

7:58

that they wanna look from the bottom up.

8:00

And so the way they do that is

8:02

that they do a lateral r otomy and then they open this up,

8:05

and now they have exposure from the bottom

8:08

looking at the top.

8:10

So this is the classic C craniofacial approach.

8:12

So when they're doing this, it's, again,

8:14

it's a very aggressive procedure.

8:16

These are very, very tricky tumors to resect.

8:19

But what they wanna be able to do is, first of all,

8:22

is a patient a candidate.

8:23

So this is an example of a patient that has a tumor,

8:27

a squamous cell carcinoma involving the ethmoid air cells.

8:30

So what they wanna know is whether

8:33

or not there's intracranial involvement.

8:35

So all three of these patients have

8:37

intracranial involvement.

8:39

So if you look at the left here, I want to focus right here.

8:42

Notice how there's a tumor involving the ethmoid air cells

8:45

and extending into the frontal sinus.

8:47

Does everybody see that?

8:49

Now, if you follow the inner cortex

8:50

of the frontal bone down, we can see discontinuity

8:53

of this black line right here.

8:55

And this discontinuity of the black line tells us

8:58

that this tumor's actually eroding the frontal bone.

9:01

Everybody see that? Yes. So that's there.

9:03

So technically this is intracranial involvement,

9:06

but on the other hand, if there's intracranial involvement

9:09

and it's limited to the bone,

9:10

then this can be pretty easily resected

9:12

through classic cranial facial approach.

9:15

Okay? But on the other hand, what type

9:17

of involvement do we see here?

9:18

Do you see this line right here?

9:20

Well, now we see abnormal dural invasion

9:23

or abnormal dural involvement.

9:25

Now, whether or not this is actually due to tumor

9:28

or whether it's due to inflammation,

9:30

remember these tumors have a very robust

9:32

peritumoral inflammation.

9:34

So we don't really know whether this is due to tumor

9:37

or whether it's due to inflammation.

9:39

So in this case, this is not necessarily a contraindication

9:43

to do that c craniofacial approach.

9:46

But what the surgeons have

9:47

to do is once they open up the brain, they have

9:50

to make sure they biopsy the dura

9:52

to make sure there's not dural spread.

9:54

And if there is dural spread there, they're gonna have

9:56

to do a very, very large dur resection.

9:59

But again, clinically, this patient

10:01

with just bone involvement is gonna present very similar

10:03

to this patient with DUR involvement.

10:05

And in this case, what do we see here?

10:08

This is intracranial involvement as well.

10:11

Notice how this tumor is extending posteriorly

10:14

and invades the frontal, the, or I should say overlies

10:18

or likely invades the frontal lobe.

10:20

And when we do the T two weighted images,

10:22

then we can see all of this vasogenic edema.

10:25

So when you see this vasogenic edema associated

10:28

with squamous cell carcinoma,

10:30

this typically indicates brain invasion.

10:32

And if we see this,

10:33

and this is gonna be a contraindication

10:35

at most institutions.

10:37

Now occasionally you can have meningiomas

10:40

that have vasogenic edema.

10:41

That is not a contraindication for resection.

10:44

Oftentimes I'll see it in younger people

10:47

where there's not a lot of CSF and the,

10:49

and the meningioma just tends

10:51

to push on the brain resulting in the edema.

10:53

So in meningiomas it's not necessarily brain invasion.

10:57

And on the other hand, if you have squamous cell carcinoma,

11:00

nine times outta 10, this indicates brain invasion.

11:03

So the take home message on this slide is that all of the,

11:07

these are examples of intercranial involvement.

11:10

Each one of these patients will present

11:12

with the same symptoms.

11:14

The type of intercranial involvement differs.

11:16

One is bone, one is dura, one is brain.

11:19

And our job, when we talk about intercranial involvement to

11:22

that next level, if you win will, is specifically

11:25

describe the type of intrad involvement.

11:30

Now, the next thing that we have to do is to be able

11:32

to talk about perineural spread.

11:35

So when we look at the maxillary sinus,

11:37

here's our maxillary sinus right here.

11:39

And you know that right above the maxillary sinus,

11:42

there's a nerve and this nerve that runs along the roof

11:46

of the sinus, which also is also the floor of the sinus,

11:50

is the second division of the fifth cranial nerve.

11:52

So when you have tumors that involve the maxillary sinus,

11:57

we have to try to determine whether

11:59

or not there's perineural spread.

12:01

Now let me give you the real life scenario. Mm-Hmm.

12:06

Now someone can answer this too.

12:07

So if you guys want to come off mute,

12:09

we can have this a little bit more interactive,

12:10

even though we're like in, in all parts of the world.

12:13

So how does one know already whether

12:16

or not the nerve is involved?

12:18

Any idea when the patients present?

12:25

Anybody,

12:28

There'll be, um, muscle, uh, there'll be, uh,

12:32

in case of mandibular nerve, we'll have, uh,

12:36

difficulty in chewing

12:39

or if any other symptoms. So at

12:41

The max, but the maxillary sign is how do we know

12:44

that the nerve is gonna be involved?

12:47

What symptoms would the patient present

12:49

with? What does V two do?

12:51

Sensory deficit on the face?

12:53

Yeah, they're gonna be numb. Okay.

12:56

So the thing is, is that the, in general, nine times out

13:00

of 10, not all the time,

13:02

but when patients present with squamous cell carcinoma,

13:05

I see this in the clinic on Wednesday,

13:08

sometimes they'll have numbness

13:09

and sometimes they'll have pins and needles,

13:11

but they'll have some type

13:12

of deficit involving the course of V two.

13:15

And you know, when we as radiologists give these talks,

13:17

we say this numbness, well, that's not always the case.

13:19

Sometimes it's just a little bit of pins and needles

13:23

or something involving V two.

13:25

So the bottom line is, is

13:27

that the surgeons are already getting the sense

13:29

that V two is involved.

13:30

So we don't necessarily need to tell them that yes,

13:34

V two is involved anteriorly,

13:36

but what's as important is

13:38

what is the posterior extent of that?

13:40

Because from a surgical standpoint,

13:42

the tumor is gonna spread along V two

13:45

and then it's going to go through the infraorbital foramen,

13:48

and then it's gonna go through this fossa right here.

13:50

So what's the name of the fossa right here?

13:53

The tego Palatine. Palatine fossa, exactly right.

13:57

So V two runs in the roof of the tego palatine fossa.

14:01

Then it runs to this framing right here, which is

14:03

what I, exactly right.

14:07

Then it extends back and involves the ganglion.

14:09

And this ganglion has three names, right?

14:12

It's gian trigeminal and semilunar ganglion.

14:15

It's called three names to it.

14:17

So from a surgical standpoint,

14:20

if this tumor is involving the nerve

14:23

and it's involving the anterior portion

14:25

of the maxillary sinus, well it's still gonna be pretty

14:28

resectable and it's still gonna be pretty curable.

14:31

But on the other hand, once this tumor starts extending back

14:35

and erodes a posterior wall of the maxillary sinus

14:38

and it's in the ergo palatine fossa, well all

14:41

of a sudden it still could be resectable,

14:44

but the prognosis is certainly going to decrease.

14:47

Why? Because when you resect one of these tumors, you want

14:50

to have a clean margin that's at least a centimeter.

14:53

So again, if the tumors involved in the anterior third

14:56

or the anterior two thirds of the maxillary sinus,

14:58

even though it's involving the nerve, it's still curable.

15:01

But what they don't know, just based on the clinical exam,

15:05

is whether or not there's extension in the ter

15:07

palatine fossa.

15:09

And in this particular case, we can actually see, see

15:12

how this nerve right here,

15:13

this is V two running in frame and rotunda.

15:16

So if I had to do, um, go from one side

15:19

to the opposite side,

15:20

this is V two right here involving frame and rotunda,

15:23

and this is the normal V two on the left side.

15:25

On the right side, this is the nerve of the videon canal,

15:28

and this is the normal nerve of the videon canal.

15:31

So once it gets back into the central skull base involving

15:34

framer rotunda, in general,

15:35

these patients are not gonna be treated

15:37

primarily with surgery.

15:39

And oftentimes they'll be treated, treated with chemotherapy

15:42

and radiation therapy.

15:44

So that's what I mean about, you know, getting to

15:46

that next level of head and neck radiology.

15:48

You know, we need to be able to identify in information

15:52

that's gonna directly affect how these patients are treated.

15:57

So let me stop there. What we did,

15:58

what we just did right now is that we went over the anatomy

16:00

and we talked about certain things

16:02

that you should include on in our, in your report.

16:05

And in a way, you know, you can look at this as,

16:07

um, you know, checklist.

16:09

You can look at it as a standardized report.

16:11

You can call it, call it whatever Lexi,

16:13

whatever nomenclature you want.

16:15

But there, are there any questions at all

16:17

regarding the first, uh, first 20 minutes or so?

16:20

15 minutes, I should say.

16:26

Hi, I have a question. Sure.

16:28

Um, with regards to perineural spread, like you said, um,

16:32

you follow the course of the nerve

16:33

and if there is perineural spread,

16:35

then obviously you won't be able

16:36

to get clear margins in surgery.

16:38

So, uh, radiologically speaking, how would you,

16:41

how would you see perineural spread?

16:43

Is this just thickening of the nerve enhancement

16:45

of the nerve or any other subtle sign that you might be able

16:49

to see if there's not actually the tumor

16:52

that goes into the type of pe fossa,

16:54

but just spread along the nerve?

16:56

Yeah, no, it's a good question. So just one clarification.

16:58

Even if you have car neural spread, it's still possible

17:01

to get clean margins.

17:03

It just depends on where the spread is.

17:05

So in this case, this peroneal spread actually extended into

17:09

the central skull base.

17:10

So as a result, then they would have

17:12

a hard time getting that.

17:14

But let's say if that peroneal spread was involved in the

17:16

anterior two thirds of the maxillary sinus,

17:19

then it's possible to go ahead

17:21

and completely do a, a clean resection.

17:23

So, you know, so the bottom line is that you can still have,

17:27

uh, uh, uh, clean margins with perineural spread.

17:31

So what are the findings that you look for?

17:33

Well, in early perineural spread, what you'll do,

17:36

and I have an example of this I think in another talk, is

17:39

that the earliest findings of perineural spread, do you see

17:43

where my arrow is right here?

17:45

Yeah. So that's the nerve of the vian canal.

17:48

So the first thing you'll see in the earliest findings in

17:51

perineural spread, and you know, with the leap of faith,

17:54

you can almost see a little dot right there.

17:56

It's not the best example,

17:58

but the earliest findings,

17:59

what you'll see is you can see this dot right here

18:01

that's surrounded by this enhancing neurovascular plexus.

18:05

So sometimes what you'll see is this little dot get larger

18:09

and replacement here of the fat.

18:11

The second thing that you can see is

18:13

asymmetrical enhancement.

18:15

So for instance, I'm sure you've seen cases

18:17

of bell's palsy, right?

18:19

So in Bell's palsy

18:21

what you'll see is asymmetrical enhancement of the nerve.

18:23

So technically that's not perineural spread,

18:26

but it is a neuritis, so it's actually involving the nerve.

18:29

So that's the second stage.

18:31

You'll just see this enhancement with actually

18:34

early enhancement.

18:36

The next thing you'll see enlargement of the nerve.

18:38

So in really severe cases of Bell's palsy,

18:40

you can see the nerve enlarge.

18:42

And in this particular case,

18:43

we can actually see, oops, sorry about that.

18:46

You can actually see the, uh, not only the loss

18:50

of the fat enlargement of the nerve enhancement

18:53

of the nerve, and now we can see actually expansion

18:55

of the frame and on the right then compared to the left.

18:59

So just yesterday, I think, actually I think we had a,

19:03

we had office hours yesterday.

19:05

I haven't had a chance to download it, but right

19:08

before you guys, I have a, I do, I work with the RS NA

19:11

for their global learning center.

19:13

And um, so I'd read out with the fellows from Tanzania,

19:17

and I remember it's, it kind

19:18

of reminds me the way India was like 30 years ago,

19:21

when I would go to India,

19:22

we would see all these massive cases

19:24

of the very advanced disease, but

19:26

because the healthcare has gotten better in India

19:29

and you're imaging earlier, we don't see as much.

19:31

But in Tanzania, you know, you still see these crazy cases.

19:35

So yesterday I actually saw a case of diffuse

19:37

and enlargement of the inferior alveolar nerve in a patient

19:40

with probably squamous cell carcinoma lymphoma

19:44

that extended all the way from the mental frame

19:46

and all the way back to the jaw.

19:48

And you can literally see that whole nerve canal,

19:50

the bony canal enlarged.

19:52

So that's on my to-do list.

19:54

So I'll start making some cases

19:55

and hopefully I'll show that to you.

19:57

So that's a long answer to a short question,

19:59

but does, did I answer it?

20:02

Absolutely. Thank you. Okay.

20:03

It's the last time you'll ask a question

20:06

for going on so long.

20:08

Any other questions that you have?

20:12

So what is the, the, uh, criteria

20:14

for ation versus manipulation?

20:19

Uh, that's a great question. That's a great question.

20:22

Um, for squamous cell carcinoma,

20:24

I'm not a hundred percent sure in general for exenteration,

20:29

if for in general for squamous cells,

20:31

they'll do an exenteration.

20:32

So they'll take out the muscles and the globe, right?

20:36

Because if it's involving the orbit,

20:37

they have to take it out.

20:39

But if you have somebody like a retinoblastoma

20:41

or if you have someone that has a really bad infection

20:44

of the eye, you'll probably see this sometimes.

20:47

Or if you have trauma, the eye,

20:48

then they'll do it in nucleation

20:50

and then they'll put in a prosthesis.

20:52

So I think in general, it's a really good question.

20:54

I'll have to ask my, um, ENT colleagues.

20:56

I think if you're dealing with neoplasms in general,

20:59

you're gonna do an exenteration.

21:01

But if you're doing, doing, uh, you have to, if you have

21:04

to remove the globe for maybe infectious causes

21:07

or traumatic causes, um,

21:09

or degenerative causes,

21:10

then you're more likely doing a nucleation.

21:16

Great questions. Anything else? No.

21:22

All right. All right.

21:24

So now what I want you to do is that if you want to,

21:27

you can take a, go off mute if you want to.

21:29

'cause the next one's gonna be a little bit in,

21:31

in a way you'll see where we're going with this anyway.

21:33

So anyway, squamous cell carcinoma is

21:35

the most common one, right?

21:37

So now we have a mass right here

21:39

that's involving the left nasal cavity.

21:41

And we have another mass

21:42

that's involving the left maxillary sinus.

21:45

So if an adult, if an adult comes in

21:47

and you see something like this,

21:49

what do you think the second most likely, uh,

21:52

tumor's gonna be to involve the, the, um, the CY nasal area

21:59

Lymphoma?

22:01

Uh, good lymphoma. Excellent.

22:03

So lymphomas are the second most likely tumor

22:06

to involve the Sano nasal cavity.

22:08

Who got that one right? Was that Andrea or Nia or,

22:11

or gallery wasn't an it was Nia good for you?

22:14

Alright. Um, the, so the second most likely is lymphoma.

22:19

Majority of these are T-cell le uh, T-cell lymphoma.

22:22

So they're non-Hodgkin's lymphoma,

22:24

but specifically T-cell, they're associated

22:27

with Epstein-Barr virus and they're more common in Asians.

22:31

The incidences in males are a little bit

22:33

more common in females.

22:34

They oftentimes present with bulky soft tissue masses.

22:37

And again, you can see various enhancement.

22:40

Now, Sami cell car, excuse me, lymphoma is associated

22:44

with um, peroneal spread too.

22:46

So remember, squamous cell carcinomas can give you

22:48

perineural spread as can lymphomas.

22:51

So one thing about a lymphoma, the purpose of this slide is

22:54

to really demonstrate the heterogeneity.

22:57

So here we can see this intermediate T two signal here,

23:00

it's low T two signal in this case pre contrast

23:04

and post contrast we can see different types of enhancement.

23:07

The one on the right is a little bit more enhancing.

23:09

The one on the left is not as enhancing.

23:12

So again, you can have a fair amount

23:14

of variability in the in the appearance.

23:18

Another example, uh, what can you suggest is lymphoma.

23:22

Well, what I tend to use, and it doesn't always work,

23:26

but on the other hand, if I see a soft tissue mass

23:28

and there's not a lot of bone erosion

23:31

and maybe a little bit more expansion,

23:33

then I start thinking about lymphoma.

23:35

Now I could still have a low grade squamous cell carcinoma

23:38

or other things like that,

23:40

but the fact that it's a second most common tumor,

23:42

if I see something like this

23:44

that's a little bit more insinuating

23:46

and does not have a lot

23:48

of bone erosion than I can, I can suggest it.

23:51

And this case on the right, this,

23:52

there's actually a finding here that this one I, one

23:55

of the few I actually got, right,

23:57

so this was an example of lymphoma.

24:00

But can anyone tell me why?

24:03

Um, finding here about what kind

24:07

of tipped me off that it was lymphoma.

24:09

So you can look at it and I'll tell you the story.

24:12

This is back when I did neurointerventional.

24:14

So I came in for an angiogram in the middle of the night.

24:16

It was like two in the morning

24:18

and again, they were having trouble getting the patient

24:20

down, which is normal.

24:21

So you didn't have to come in, then you wait

24:23

for like a couple hours for the patient down.

24:25

So I decided to read a couple of cases

24:27

'cause I had to read it the next day anyway,

24:29

so I opened this case, it was literally two in the morning

24:32

and I saw this mass right here involving

24:34

this, the sphenoid sinus.

24:36

So this is a contrast enhanced T one weighted image.

24:38

Okay, so does anybody see anything else

24:42

that would suggest the diagnosis of, of um, lymphoma?

24:47

Why it would suggest it was lymphoma?

24:50

And I want you to concentrate on the colvis,

24:56

See how the colvis is involved, right?

24:59

So you can see this posterior margin right here,

25:02

the sphenoid sinus and this posterior margin,

25:04

the sphenoid sinus.

25:05

But when we talk about lymphoma

25:07

and leukemia, I sort of transitioned

25:09

to using the term hematopoietic disorders.

25:12

So if you look at the WHO classification for head

25:15

and neck tumors, it kind

25:16

of used the terminology hematopoietic

25:18

or lymphoproliferative disorders.

25:21

So lymphoproliferative disorders mean sort

25:23

of lymphoma leukemia.

25:25

And as a result they do have a tendency

25:28

to involve the bone marrow in areas

25:31

where it actually gen generates lymphoid cells,

25:34

lymphatic cells, leukemia cells, et cetera.

25:36

So it was this finding right here,

25:38

this involvement in the marrow

25:40

diffuse involvement in the marrow.

25:41

So not really aggressive

25:42

but more replacement that kind of suggested that,

25:45

that we were dealing with lymphoma.

25:47

So that's, these are some tips that I've learned over time

25:50

to try to help me separate one from the other.

25:53

It doesn't always work,

25:54

but in general, you know, it can be pretty helpful.

25:57

Okay. Okay, so the third one.

26:01

So now we have this patient that has

26:05

this mass involving the right maxillary sinus.

26:09

And what are the yellow arrows pointing at

26:14

And rot them?

26:17

Good? Yeah. So what about them?

26:18

You can speak up a little bit.

26:21

So there is uh, enhancing soft tissue along the right uh,

26:26

uh, V two nerve as well as the nerve of radi.

26:30

Yeah, so we have this aggressive mass involving the right

26:32

maxillary sinus extending back into the tegal

26:35

palatine fossa.

26:36

And I don't know if Nia is still on or not, um,

26:39

but this is the case that I was looking for earlier.

26:42

So if you look at the left hand side,

26:45

this is the normal vian nerve

26:47

and you can see the enhancing plexus

26:49

and see where, where my arrow is right now.

26:51

That arrow is actually on the nerve.

26:54

Now if you look at the right side, notice

26:57

how this vascular plexus is a faced

26:59

and you see where the tip of my arrow is right here.

27:02

See how this nerve is enlarged on the right,

27:04

then compare it to the left.

27:06

So this is that second sign of early perineural spread

27:10

where there's enlargement of the nerve.

27:12

And then this is a third sign

27:14

where now we have diffuse enhancement of the nerve.

27:16

So the case that I showed earlier, remember that big nerve

27:20

that was completely enlarged, that's like the latest sign

27:23

of perineural spread.

27:25

So in this one, if you will, there are three,

27:27

there are three ways of finding it.

27:29

Number one is just enlargement.

27:30

The nerve number two is enhanced,

27:32

but number three is an enlargement of the canal.

27:35

So if you see a cyto nasal mass like this

27:38

and you have multiple nerves that are being involved,

27:42

then what do you think about?

27:44

And then I see exactly the third most likely tumor

27:49

to involve the cy nasal cavity is gonna be a a

27:52

minor salivary gland tumor.

27:53

So minor salivary gland tumors that have propensity

27:57

for perineural spread.

27:58

You mentioned already adenoid cystic is number one,

28:01

but number two you can also have muco

28:03

epidermoids as well too.

28:05

But in general, adenoid cystic carcinoma, um,

28:07

in minor salivary gland tumors are the third most common

28:10

tumor to involve the sano nasal cavity.

28:14

Now these are all examples of adenoid cystic carcinomas.

28:18

I don't want to give you the impression

28:20

that they're all associated with perineural spread

28:23

at minor salivary gland tumors account for up to 10%

28:27

of all malignancies.

28:28

They tend to be slow growing.

28:30

They have a perineural uh,

28:32

spread pattern in approximately uh, 60%

28:35

and they are associated with this thing which is called NAM.

28:39

So back when I was your age I learned about NCAM,

28:42

but now we've now refined this as CD 56.

28:46

So you know, I don't know, I cannot keep up

28:48

with all the genomics

28:49

and the proteomics and things like that.

28:51

Every time I look they've taken this disease

28:53

that I've called one thing, it still looks the same,

28:56

but now there's associated with a specific uh, marker.

29:00

So you know, it's now it's CD 56.

29:03

Um, you there are associated with various skip lesion

29:07

and this is maybe what was donia was talking about before.

29:10

It's, it's well known that once you have perineural spread,

29:14

especially in adenoid cystic carcinomas,

29:16

the perineural spread isn't necessarily continuous,

29:19

but you can have perineural spread, then a normal component,

29:22

then another perineural spread, normal component, et cetera.

29:26

So those are what are referred to as skipped lesions.

29:29

So in this particular case,

29:30

this was an adenoid cystic carcinoma involving the ethmoid

29:34

sinus and the sphenoid sinus.

29:36

And on the left hand side,

29:38

look at all the spread right here.

29:39

This is actually retrograde perineural spread involving the

29:42

facial nerve and compare the left side here

29:45

and compare it to the right side.

29:46

See on the right side here, that's sort

29:48

of normal enhancement.

29:50

And on the left hand side we can see this diffuse

29:52

thickening and enhancement.

29:54

So that's perineural spread.

29:57

Alright, any questions so far?

30:02

Doing all right? Yes. All right.

30:06

Okay, so here's the, here's the next one.

30:11

So this is a patient that has a, uh,

30:13

mass involving the left nasal cavity

30:18

and it has a certain internal characteristic to it.

30:25

And when we look at CT scan, we have a little bit of, uh,

30:28

internal sclerosis to it.

30:31

So any uh, any ideas of what this could be?

30:40

What's

30:40

That in? What inverted

30:41

Papillo.

30:43

Inverted papilloma. And why do you say that?

30:48

Um, I, I'm not sure,

30:50

but I feel there's some sed form pattern

30:55

that is seen in the middle in mochi,

30:58

Right? Yeah, inverted

30:59

papilloma, exactly right.

31:01

So when you look at inverted papilloma is what we see

31:04

is this cerebral form or cauliflower appearance to this.

31:08

And in general, the bone is actually intact.

31:11

So how I suggest the diagnosis

31:14

of inverted papilloma is I look for primary cy nasal mass,

31:18

I see this enhancement,

31:20

but when I look in here, I can see the cerebral four mass

31:23

that's not associated with the aggressive bone erosion.

31:27

Now could this be an early squamous cell carcinoma?

31:29

A hundred percent. Could this be minor salivary gland?

31:32

A hundred percent. Could it be lymphoma? Absolutely.

31:35

But what I look for is if I see the cerebral form pattern

31:38

without bone erosion

31:40

and then I actually see this dystrophy calcification,

31:43

then I start to think of inverted papilloma.

31:46

So the reason these inverted papillomas have these cerebral

31:49

form appearance, here's the gross appearance

31:51

of an inverted papillo.

31:53

You can see this papillary or fron like,

31:55

or some people have called it brain-like appearance.

31:59

Um, histologically it's comprised of what we referred to

32:02

as schneiderian papilloma.

32:04

Unfortunately the incidences in males is equal to females.

32:07

And again, there I am, I'm that in that demographic again

32:10

between 40 and 70.

32:11

So, um, it has this classic endo fitted growth pattern

32:15

and about 10 to 15% may have concurrent squamous

32:19

cell carcinomas.

32:21

So here's another typical example of inverted papilloma.

32:24

They typically involve our unilateral, they have

32:28

that cerebral form appearance to it.

32:29

And again, on contrast enhanced study,

32:32

we can see this nice fron like appearance.

32:36

Now occasionally inverted papillomas

32:39

can de differentiate into squamous cell carcinomas.

32:43

So one of, I remember I went to, uh, ASH

32:46

and r um, about, uh, it was, I think it was last,

32:49

I think it was last year, but the year before.

32:51

And um, there was a, at their quiz they said, uh, for

32:56

I think it was like final jeopardy in our quiz

32:58

case or something like that.

32:59

And they showed a case and it said one

33:01

biopsy, two pathologies.

33:04

And they showed a case of a patient that had this a similar

33:08

to this, an aggressive mass

33:10

involving the nasal cavity extended to the sphenoid sinus.

33:15

And so the answer was inverted papillo

33:18

with squamous cell carcinoma.

33:20

So this was a actually a path proven example

33:23

of an inverted papillo

33:25

that de differentiated into a squamous cell carcinoma.

33:28

This is another example as well too.

33:30

And with the leap of faith, you can actually almost see this

33:33

papillary cerebra form component

33:35

and then you see a more aggressive component.

33:37

Another example here, a more more

33:39

of a cerebra form pattern here,

33:41

but then a different component.

33:42

I'm probably reading too much into this,

33:45

but the point is, is just remember that about 10 to 15%

33:48

of inverted papillo will undergo de differentiation

33:52

it squamous cell carcinoma.

33:53

So it's always up to the, um, pathologist to make sure

33:57

and the ENT surgeons to closely look at the biopsies

34:01

to make sure there's not two pathologies.

34:05

Okay? So number one,

34:07

squamous cell carcinoma is gonna be number

34:08

one, it's most common.

34:09

Lymphoma is the second.

34:11

It's gonna be having a non-specific pattern.

34:13

If you see perineural spread, you have to think

34:15

of minor salivary gland tumors.

34:17

And then if you see something that's fron like,

34:20

or with in intratumoral calcifications, you think

34:22

of inverted papillo.

34:25

Okay, what about this case?

34:27

So this is a, AAAA patient that had this

34:30

and it wa what's the one question you need to,

34:34

to ask yourself when you see a case like this?

34:39

So someone shows you a sinal nasal mass,

34:41

what are some questions you should be asking

34:43

regarding history, uh, to help you come up

34:46

with the correct diagnosis?

34:47

What's the number one thing you should ask

34:52

Patient H That's exactly right.

34:55

And if the age, if it's a child, then you have to think

34:57

of rhabdomyosarcoma.

34:59

So you know, if I told you

35:00

that this was a middle-aged male like myself,

35:02

then it's probably gonna be squamous cell or lymphoma.

35:05

But on the other hand, if you say it's a child,

35:07

then it's going to be rhabdomyosarcoma.

35:10

So again, I, this is in great generalizations

35:13

because I can show basically any tumor can occur anywhere.

35:17

It can look like anything.

35:18

But if you've just played the percentages,

35:20

the most likely uh, soft tissue malignancy in the head

35:24

and neck is going to be rhabdo my sarcoma.

35:27

So the incidences, um, uh, is,

35:30

is typically occurs less than five years.

35:32

And there is the second incident that's been reported,

35:35

a second peak, if you will, between 30 and 40 years old.

35:39

Most commonly involves the orbit followed

35:41

by the nasopharynx.

35:42

It can involve the middle ear and the skull base

35:45

and it can also involve the sino nasal cavities.

35:48

So rhabdo, myosis sarcomas are very

35:50

aggressive tumors as we know.

35:51

This just demonstrates the decrease, uh,

35:55

ADC values here involving in nasal cavity.

35:58

And this sagal images,

35:59

this demonstrates this very aggressive mass

36:01

that's extending retrograde

36:03

and erodes the anterior skull base.

36:06

Okay, so how about this one

36:19

H? What is the age?

36:24

Yeah, how old is the patient? Okay. Alright, good one.

36:27

It's uh, 16

36:31

Juvenile.

36:32

Yeah. Yeah. So you have to ask, what's the next question?

36:35

Age and the gender, right? Yeah, yeah, exactly right.

36:40

And the answer is juvenile angio fi. That's exactly right.

36:43

So when you look at juvenile an neurofibromas, you know,

36:46

this is sort of the characteristic appearance of this.

36:48

So this involves, so here's the voo zla,

36:52

I dunno if you guys follow European football

36:54

or we call it American soccer.

36:56

This is the voo zla.

36:57

So the voo zla is, it has a little opening right here

37:02

where you blow into.

37:03

So what's the name of this foramen right here?

37:05

Anybody remember the name of it's between the sphenoid bone

37:08

and this little bone right here called the palatine bone.

37:10

So what's the name of that? Foramen

37:13

Sen Palatine.

37:15

Exactly. Seno Palatine foramen.

37:16

If you go laterally, you're in this fossa right here.

37:19

So what's the name of the fossa here?

37:22

Tego Palatine, I think Tego Palatine fossa.

37:25

And as you go back more laterally, you're in a fissure

37:27

and what's the name of the fissure right here?

37:30

Tego. Maxillary Fis

37:31

Magary. Exactly, exactly.

37:32

37:33

So to me, in the way that I think this looks like a big vla.

37:36

So the opening of the speed of seno palatine foramen,

37:40

tego palatine fossa and then tego maxillary fisher.

37:44

So juvenile angio fibromas we've always taught

37:47

that involves a tegal palatine fossa.

37:49

But one thing that I've learned over time is

37:51

that the majority of jfs actually arise in the nasal cavity.

37:55

So I remember there were a couple of cases back that

37:57

that I thought were probably he angios

38:00

or some other hypervascular polyps

38:03

that the pathologist came back and said it's AJAF.

38:06

And I remember I ran up and down, I screamed

38:08

and I shouted, I said it can't be

38:09

because it's not involving the terrigal palatine fossa

38:13

so and so.

38:14

I said I wanna see the pathology,

38:16

which is probably a big mistake

38:18

'cause I can't look at a pathology.

38:19

I just remember blew his bag.

38:21

So it's quite possible

38:22

that pathologist was playing a joke on me.

38:24

I think he showed me something

38:25

and for all I know is it may have been a rat

38:27

testes, I have no idea.

38:29

But he told me it was a juvenile angio fibroma.

38:31

So I sort of had to believe him.

38:33

But over time, you know, we did write a paper on this

38:37

and the majority of jfs arise in this little vascular plexus

38:41

right here, which is just at the seno palatine frame.

38:43

And so the earliest ones are gonna arise here.

38:46

It's only when they're late do they actually make this

38:48

little u-turn and then extend into the tegal palatine fossa.

38:53

So the classic thing is

38:54

that you're gonna have anterior displacement

38:56

of the posterior wall of the maxillary sinus.

38:59

Now advanced juvenile angio fibromas.

39:01

And you sort of see this right here, it

39:04

actually can't erode the central skull base.

39:06

But in general, if you took this big mass right here

39:09

and if this was a rhabdomyosarcoma, you're going have a heck

39:13

of a lot more bone erosion.

39:16

So these are ex, one of these is a juvenile angio fibroin.

39:20

One of this is a rhabdomyosarcoma.

39:22

Can you say which one is which?

39:27

The left is

39:32

Right here. Why do you

39:33

say that?

39:35

Because of the flow voids in the right,

39:38

Exactly right. So

39:39

there are no flow voids here

39:40

and there are flow voids here.

39:42

So if you see the flow voids,

39:43

and that's a juvenile angio fibroma.

39:46

And the reason why it's important is

39:48

because I'm sure you've done your readings

39:49

and you know that juvenile angio fibromas present with

39:52

what they present with epistaxis, right?

39:55

And they present with nasal stuffiness. Well guess what?

39:58

Guess what? Juvenile an guess

40:01

what rhabdo my sarcomas present with, they present

40:03

with epistaxis and they present with nasal stuffiness.

40:06

So the bottom line clinically, it's hard

40:08

to differentiate one from the other.

40:11

So if you say that the, this is a juvenile angio fibroma,

40:14

then they're not gonna biopsy this,

40:16

but they're gonna do some type of,

40:18

in general non-invasive vascular studies.

40:21

If you say that this is a rhabdo, my sarcoma

40:24

or a squamous cell carcinoma,

40:25

they're gonna biopsy this to prove it.

40:28

But on the other hand, if you say

40:29

that this is a rhabdomyosarcoma, you get it wrong,

40:33

then the surgeons are gonna biopsy it

40:35

and you're gonna have a big problem, right?

40:36

Because the kid's gonna start bleeding in their office.

40:39

So that's why it is important

40:41

to understand the different differentiating feature feature.

40:44

So here we can see the multiple flow voids on the left,

40:47

no flow voids and rhabdo sarcoma.

40:49

In this case we can see the aggressive bone destruction.

40:52

And in this particular case, in a juvenile angio fibroma,

40:56

we can see anterior displacement of the posterior wall

40:59

of the maxillary sinus.

41:00

So these are the differentiating features, flow voids,

41:03

aggressive bone erosion.

41:05

And that's why it's important to understand why, uh,

41:08

you need to understand why you need to understand those uh,

41:11

distinguishing features.

41:14

So any questions on these?

41:18

Um, I have a question.

41:19

So if you were to be reporting on a CT scan

41:22

of a young male boy who has a mass in this location

41:26

and you're trying to decide whether it's an angio fibroma

41:30

or a rhabdo, my sarcoma

41:31

and you can't see any obvious bone restriction,

41:34

so would you be confident in,

41:36

in calling it one over the other

41:38

or would you, you would recommend MRI to T flow lights?

41:42

Yeah, I, that's a great question.

41:44

I, we would either do an MR

41:45

or if I'm not sure I would do CT angio.

41:49

Okay, If I do a CT angio then you can see the

41:52

hypervascular enhancement that happens all the time.

41:54

So that's great question. Yeah.

41:57

So we know that juvenile angio fibromas a rise in

41:59

adolescent men, right?

42:01

Adolescent boys I should say. Right?

42:03

So gallery gani

42:04

and Andre, what's the upper age limit of an adolescent male?

42:10

1518 maybe. No,

42:14

My Wife said two

42:16

so I'm just, that was a joke.

42:19

All right, you guys are no fun. It's a very funny joke.

42:23

All right. Okay, so we'll go to the next one.

42:27

Okay, so now you see someone comes in like this, all right.

42:33

Oh, all right. What's the diagnosis?

42:37

Neuroblast? Yeah, exactly. Anesthesia neuroblastoma.

42:40

So this is the classical appearance

42:42

of an anesthesia neuroblastoma.

42:44

This is the reason why you have anesthesia neuroblastomas is

42:47

that they arise from the first cranial nerve

42:49

and the first cranial nerve runs along the floor

42:52

of the anterior cranial fossa.

42:54

It then dropped these little neural als

42:56

that provide sensory innervation to the nasal cavity.

42:59

So the reason why you have this figure eight appearance is

43:03

because anesthesia neuroblastomas are sometimes called

43:05

olfactory groove neuroblastomas that they're not,

43:08

I don't think they're really neuroblastomas per se,

43:10

but that's sort of what they're referred to.

43:13

So the reason why you have this figure eight appearance is

43:16

that you'll have this tumor growing all the way along the

43:18

neuro fibers and the nerve.

43:20

And right here at the anterior cranial fossa,

43:23

you see this little waist right here.

43:24

So that's why you have this figure eight

43:26

or this dumbbell shaped appearance.

43:29

So on the right hand side we can see the classic

43:31

dumbbell shaped appearance.

43:33

Now what's been also described in neuro uh, uh,

43:36

olfactory groove neuroblastomas

43:38

or anesthesia neuroblastomas is you have these

43:40

peritumoral cysts.

43:41

And I remember when this was described,

43:43

I think it was a late 1990s there, early 2000.

43:46

You know, all of a sudden it was supposed

43:48

to be pathognomonic for an uh, uh,

43:50

for anesthesia neuroblastoma.

43:52

That's not the case at all.

43:53

'cause I've seen meningiomas have this.

43:55

I've seen, uh, squamous cell carcinomas.

43:58

But on the other hand, if you do have a mass right there

44:00

that's centered in the superior nasal cavity

44:02

and you do see this, this little peritumoral cyst,

44:06

well you can suggest the possibility

44:08

of an anesthesia neuroblastoma.

44:10

So it's not pathognomonic,

44:12

but it can be somewhat confirmatory if you,

44:15

if you see this in um, association

44:17

with this mass involve in the nasal cavity.

44:21

So these are the other appearances,

44:23

probably the more common appearances

44:25

of a seizure neuroblastomas.

44:27

This is one that happened

44:28

to be involved the right maxillary sinus.

44:30

Again, after a while, this looks like the same, you know,

44:33

these were all recurrences involving

44:35

anesthesia neuroblastomas.

44:37

This just demonstrates its recurrence involving superior

44:40

portion of the nasal cavity.

44:42

And this just highlights that

44:45

and we'll discuss this next Thursday is on lymph nodes is

44:48

that the primary echelon drainage

44:51

of the nasal cavity actually goes

44:52

to the retro pharyngeal lymph nodes.

44:54

So anytime that you are looking

44:55

for tumors involved in the nasal cavities,

44:58

make sure you always assess the retro

45:00

pharyngeal lymph nodes.

45:03

Okay, so juvenile rhabdomyosarcoma, a child

45:07

juvenile angios, adolescent males

45:10

AEs neuroblastomas is the figure eight appearance.

45:15

Okay, what about this one? So this is a non-contrast mr.

45:21

And this is a non-contrast ct.

45:25

So what do you think about this case?

45:27

There's it's finding here.

45:28

You can come to the right diagnosis.

45:34

Oma

45:39

Myelo sarcoma.

45:42

ILO sarcoma. Good talk. I'll give you a hint.

45:44

And this is a non-contrast T one, right?

45:47

Mm-Hmm And the mass right here

45:50

and there's no, no contrast.

45:52

What is this? What signal is this?

45:55

Is it melanoma? Maybe

45:57

It's melanoma. Exactly

45:58

right. This is melanoma.

45:59

So the melanoma, remember what's right on T one you have

46:02

gadolinium, you have blood, you have melanin, right?

46:05

So if you are looking at cy nasal mass

46:07

and you see the high T one signal,

46:09

then you can suggest it's melanoma.

46:12

And on the CT scan, if it's non-contrast

46:14

and you see the high attenuation,

46:16

then again you can suggest it's melanoma.

46:18

So these are all examples MR. And CT of melanoma.

46:23

So melanomas arise from neural crest cells.

46:26

Again, I hate this 50 to seven years, 50 to seven years old.

46:30

They're primary lesions that arise in the nasal cavity

46:33

and they're usually unifocal.

46:35

They oftentimes, and this is just something

46:37

that I've learned in my quote unquote experience,

46:40

melanomas to me in general.

46:42

Um, it's they don't erode bone early when they get really

46:47

big then I've seen the bone erosion.

46:49

But I've seen lots of cases of melanoma

46:51

that grow and grow and grow.

46:53

They present late because they don't erode the bone

46:57

and they'll present with like nasal stuffiness.

46:59

So in general for me, I'll start thinking about melanoma.

47:02

If someone presents with a large nasal mass

47:05

and that bone is intact,

47:06

but the confirmatory findings are the high signal on T one.

47:11

So this is a fat suppressed T one weighted image.

47:13

You can see the high signal here in the melanin.

47:16

And then also the high attenuation here on a CT scan.

47:19

If I see those then I think a melanoma, right?

47:25

So you see how we're building our thing, right?

47:27

By the end of this you're gonna have, you know, a, a a,

47:32

an approach or at least give you 13

47:35

masses involved in the cy nasal cavity.

47:37

It's not gonna include the a hundred,

47:39

but I would suggest that after, if you remember these 12

47:42

or 13 things, that'll get you 99% of the cases

47:45

that you'll see in the head and neck.

47:48

Mm-Hmm. And this wasn't really old skin, you know.

47:52

So this was a patient

47:53

that has this mass involved in the maxillary sinus.

47:56

And I show this for a specific reason.

47:58

I think I got this case when I was,

48:00

I think I was at University of North Carolina

48:02

or something, this is like 30 years ago.

48:04

But again, sometimes I like the old cases

48:07

'cause I like to tell the stories behind it.

48:08

You know, life's about storytelling, right?

48:10

So this was a child at that time

48:14

that ended up having these tumors involving the globes

48:18

and these were the original what we used

48:20

to call port films back in the old days.

48:23

So this patient had,

48:24

what do you think this patient had involving his globes?

48:27

You can sort of see it there.

48:28

There's one here and there's one there

48:31

Bla Retinoblastoma.

48:33

So this is the old days when you used

48:35

to treat these patients with high dose radiation therapy

48:38

and there was really no way to try to lower the dose.

48:40

There was no really chemotherapy at the time,

48:42

but they just got treated with really high

48:44

dose radiation therapy.

48:46

And then about 30 years later he presents

48:48

with this large cy nasal mass.

48:51

So what do you think the diagnosis is?

49:00

Lymphoma radiation in sarcoma.

49:03

Ah, Garry. So it's radiation associated sarcoma.

49:07

So one time I said radiation induced sarcoma

49:10

and my radiation oncologist got very mad at me

49:13

and I said, why are you so mad at me?

49:15

He said, well Dr. Mukherjee as radiation oncologist

49:19

we cure tumors, we don't create tumors.

49:22

So ever since then I've already said radiation

49:24

associated sarcomas.

49:27

So these are rare complications following radiation therapy.

49:31

And in order to make the diagnosis they have

49:33

to be located in the irradiated field.

49:35

So the dose has to be in general above 6,000.

49:39

They also have to occur uh,

49:41

after the treatment is completed.

49:43

And typically, uh, after four years I believe is the cutoff

49:47

and the most of 'em occur really much more after four years.

49:51

They have to be histologically distinct from the tumor

49:55

and the radiation therapy is felt

49:56

to cause specific genetic mutations.

49:58

So P 53, rb mic, et cetera.

50:02

So these are all examples of radiation associated sarcoma.

50:05

So this was a sarcoma that was uh,

50:08

associated involving the right maxillary sinus.

50:11

This was another sarcoma involving the right masticator

50:14

space and this was an osteosarcoma here.

50:17

In fact, with the leap of faith,

50:18

you can actually see this sunburst appearance

50:20

involving the mandible.

50:22

So these are all radiation associated sarcomas

50:25

and the way you can suggest that diagnosis,

50:28

if you know the patient has has a sarco

50:31

and hast previously been radiated

50:33

and you have to make sure they weren't radiated

50:35

for a sarcoma, typically, again it has

50:37

to be histologically distinct.

50:40

Okay? Okay, what about this one?

50:45

I just saw a case like this Similarly, I'll tell you,

50:47

I got back from, I think I got back from Budapest actually

50:50

Andre, I think I was either visiting you guys

50:52

or I was in Tanzania and I show up to our head

50:55

and neck tumor board and the surgeon says, ah, Dr.

50:58

Mukerjee, I said, hello, how are you?

51:00

He had that little twinkle in his eye.

51:02

He says, I've got a case for you

51:04

that I bet you'll get 'cause you're so smart.

51:08

And it was a case like this that I completely missed it.

51:11

So I kind of looked like an idiot.

51:13

But on the other hand, this was a case

51:15

that I'd seen about 10 years ago

51:17

and it's involved in Cy nasal region

51:20

and you can actually make the diagnosis, if you look at a

51:25

specific finding,

51:27

and I'll give you a hint, it's this finding right here.

51:34

So see how there's a mass here involved in the nasal cavity.

51:36

But what are we seeing here that's involving the brain?

51:45

What would you call that?

51:51

Dural involvement? Dural, okay,

51:53

it's dural enhancement, right?

51:55

Yeah. So forget if you didn't see this

51:58

thing in the nasal cavity.

51:59

You just saw the dural enhancement

52:00

and you saw this in the cerebellar pontine angle,

52:03

or this is in the anterior skull base.

52:05

Then what would you call this mening? That's exactly right.

52:09

This was a meningioma that's involving.

52:12

So we tend to forget about meningiomas

52:14

because you know, meningiomas we think

52:16

are intracranial lesions.

52:17

But just realized meningiomas involved with durra,

52:20

and I haven't shown you a case of this,

52:22

but I remember back when I was a fellow,

52:25

I actually biopsied the ator space mass

52:28

and the masticator space mass came back to be meningioma.

52:31

I'm like, what in the world?

52:32

And again, I got all p****d off at the pathologist,

52:34

but you know what, what am I gonna do?

52:37

But I've seen several cases of this

52:38

because sometimes you'll have meningiomas

52:41

that are involved in the middle cranial fossa

52:43

and yes they can extend superiorly,

52:45

but on occasion they can extend inferiorly

52:47

and involve the masticator space.

52:49

So the case that they showed me, um, this summer, um,

52:54

when I looked at it, you know, it was already operated on,

52:58

but what I missed was the dural enhancement.

53:01

So if I do see something in the superior nasal cavity,

53:03

and I also see this dural enhancement,

53:06

I always include meningioma in my differential diagnosis.

53:10

So these are all examples of meningiomas.

53:13

These are all in general, as you know, slow.

53:16

Oops, sorry about that. They're slow growing lesions.

53:18

I'm trying to move your face outta the way. There we go.

53:21

Slow growing lesions.

53:23

Um, and the way that we can suggest the diagnosis is to look

53:27

for the dural enhancement.

53:28

Or again, you can see this bone erosion, excuse me,

53:32

this new bone formation, this sclerotic bone right here.

53:35

So in the old days, the reason why I remember this is

53:38

that in the, when I was um, resident, you know, we,

53:42

we were using cts but we were just starting to do Mrs

53:46

and I still remember my attending showing me the way they

53:49

used to make diagnosis of meningiomas.

53:51

And we would look for a plain film

53:53

and we would look for hyperos posis.

53:56

So the hyperos posis was this new bone formation.

53:59

We used to call it blistering.

54:01

So in a way, this bone formation right here is analogous to

54:06

that blistering that we would see on the plain films.

54:08

So if I do see something like this in the cy nasal area,

54:12

then I start thinking about meningiomas.

54:14

In fact, that one case that I was telling you about,

54:16

it had the dur enhancement

54:18

and it also had the blistering as well too.

54:20

And unfortunately I wasn't smart enough to learn,

54:22

but the next time I see that,

54:23

I know I'm gonna make the right diagnosis.

54:25

So those are two little things from my, um, mistakes

54:28

that maybe can, can help you in the future.

54:32

All right, so meningioma,

54:33

how can we make the diagnosis typically involve in superior

54:37

nasal cavity involves a skull base

54:39

and you could have a dural tail.

54:42

Okay, what about this one?

54:44

The key thing here is that this is a non-contrast ct.

54:47

And again, it's a bit of an older case,

54:49

but I remember the history on this

54:51

'cause this presented to our head

54:52

and neck tumor board when I was at UNC.

54:55

So we looked at this and again the key thing was a

54:58

non-contrast ct.

54:59

So what do you think

55:04

Fungal?

55:06

What's that? I can't hear you speak up.

55:12

A fungal ball or

55:15

Fungal ball. That's a

55:16

good thought. That's a good thought.

55:17

But it's dense. So that is a very good thought.

55:20

In general, you would have a little bit more low attenuation

55:23

within it and a fungal ball should be sitting in a sea

55:26

of mucosal thickening.

55:29

That's a good thought. Are these blood products

55:32

or why is it, are these,

55:34

could it be like blood products within it or,

55:37

Uh, it's a little bit too dense

55:38

for blood products, but it's a good thought.

55:40

You're getting warmer. The thing is, is this, uh,

55:44

the key thing to ask you when you see something this dense,

55:48

is it due to something in the sinus

55:50

or is it actually the sinus itself?

55:57

So this was a fibro osseous lesion.

55:59

This was actually bone formation.

56:02

So this is what we more typically see.

56:04

So one thing that I learned in my fellowship years ago

56:08

was if I see a bony lesion right here,

56:10

I just call 'em fiber osseous lesions

56:12

because I kind of give it to the pathologist

56:14

and they can determine what to call it.

56:17

So you could have a lot of overlapping features.

56:19

I think we would all make the diagnosis here, right?

56:21

This is fibrous dysplasia.

56:24

This is an osteo involving the frontal sinuses.

56:27

And this was an ossifying fibroma.

56:29

So you know, if you see something like this

56:31

with the speckles, you can maybe suggest a diagnosis

56:34

of an ossifying fibroma.

56:35

But again, for me, you know, I'll just call it

56:39

fibro osseous lesion.

56:40

Then I'll let the path, uh, the dental pathologist,

56:43

'cause they're the real experts on these, determine

56:45

what the actual diagnosis is.

56:48

Now here's the classical example of fibrous pl dysplasia.

56:52

This is the typical woven bone.

56:54

You could have monotonic, fibrous dysplasia

56:57

or polyostotic if it's polyostotic, it's a mune Albright.

57:02

And then if you have fibrous dysplasia,

57:04

that's predominantly involving the mandible in the face

57:07

and anybody know what you would call this,

57:08

it sort of looks like an angel.

57:12

Quin. What's that?

57:15

Starts with a Cism. Thatcherism, exactly right.

57:20

This is the, the chair root face that's associated

57:22

with this fibrous dysplasia.

57:27

All right. And then the last one, oops, sorry about that.

57:30

Here's this fibrous dysplasia, and this was chondra sarcoma.

57:34

So sometimes it can be, I hard to I to differentiate these.

57:38

So this is all bony,

57:40

but this is a soft tissue

57:41

that has these rings and circles in it.

57:43

Okay. But what do you think this was, this is the last case,

57:47

and again, I remember this case so well.

57:50

This is when I was getting at UNC.

57:52

They presented this case and I thought I was a hotshot head

57:55

and neck radiologist, and I gave this beautiful differential

57:59

diagnosis and I was completely wrong.

58:02

So I looked at this and I said, there's this bony mass

58:05

that's arising from the inferior turbinate.

58:07

You know, this could be a little osteo,

58:10

it could be an enchroma,

58:12

it could be a low grade chondro sarcoma,

58:14

it could be a low grade osteosarcoma.

58:17

Um, a great differential diagnosis. So what do you think?

58:22

And I learned a very important lesson from this.

58:24

What do you think? This, this is

58:29

Foreign body.

58:30

Yeah, it was foreign body. Yeah,

58:31

That's what I'm saying. Yeah.

58:32

This, this was an eraser. Yeah.

58:35

So what ended up happening is

58:37

that they took the patient in the operating room

58:39

and they took it out and it was a calcified eraser.

58:42

So when they cut it open, there was an eraser.

58:43

Then I remember they asked him

58:45

and said, how'd you get an eraser?

58:46

And, you know, he said, oh, back when I was like 20 years

58:49

ago, I was in school

58:50

and I had an eraser at the tip of my pencil that I lost it.

58:53

I could never find it. And so that was true.

58:58

So one thing I learned about was anytime

59:01

that I see something weird that's located in a cavity

59:06

that communicates with the outside body, I always have

59:10

to include foreign body in my differential diagnosis.

59:14

So, you know, what we have learned so far is that, you know,

59:17

we went over number one, we went over the anatomy.

59:20

The second thing is we went over the checklist.

59:23

So if we do have tumors involved in the cyto nasal

59:25

cavity, remember those checklist.

59:27

But just to go over one more time, it's about 12

59:30

or 13 things here,

59:31

and this will get you through probably 99% of things, is

59:34

that, remember squamous cell carcinoma is number one.

59:37

Lymphoma. It's non-specific.

59:40

If you have perineural spread, think

59:42

of minor salivary gland tumors.

59:44

A unilateral mass that's fron like and has calcifications.

59:47

Think of an inverted, I should say inverting.

59:50

It's inverted papilloma in a child rhabdomyosarcoma,

59:55

adolescent male juvenile angio fibromas

59:58

with the upper age limit of being 17 or 18.

60:00

Okay, not 62.

60:02

If you have something that's a figure eight appearance,

60:05

think of anesthesia neuroblastomas.

60:07

If you have high T one signal

60:09

or a little bit of high attenuation on ct.

60:11

Think melanoma, prior radiation therapy.

60:15

Think of radiation associated.

60:17

Now, radiation induced radiation associated sarcomas.

60:21

If you have something involving the skull base

60:23

or the dural tail, think of meningiomas,

60:25

ground glass appearance, fibrous dysplasia

60:28

or fiber osseous lesions.

60:30

And then finally, you know, always remember foreign bodies,

60:33

um, and always, you know, look at the history.

60:35

So I can stop right there. Thank you very much.

60:38

I'm happy to take any questions.

60:49

No question. I have question. Yeah,

60:50

Yeah.

60:51

Also, is there, uh, any way to differentiate between, uh,

60:55

signon SMUs and sign carcinoma on imaging?

61:00

Um, good question. Uh, not really. Not really.

61:04

Um, there is a specific type of adenocarcinoma

61:07

that involves a cy nasal region

61:09

that doesn't enhance as much.

61:11

Um, and I'm blanking on the specific name of it,

61:13

but there is, I think it's called an intestinal variant

61:16

of an adenocarcinoma.

61:18

Um, and that's supposed to enhance less than a,

61:22

a typical squamous cell carcinoma.

61:24

Yeah, I remember with squamous cell carcinomas,

61:26

you can have, they're all types of, of, of those things.

61:29

Um, but in general, you can't differentiate between the two.

61:31

But, um, the, the ad, the intestinal type

61:35

of adenocarcinoma tends to enhance a little bit less,

61:38

but in general, it's non-specific.

61:49

All right, you guys have a great day. Thanks for attending.

61:53

Um, we will see you, uh, I think next Thursday.

61:56

I think next Thursday we're gonna have a talk on lymph

61:58

nodes, and then you'll be getting a,

62:01

you'll be getting a memo

62:02

because if you wanna plan ahead next Friday, um,

62:07

I'll be giving a talk on, um, sinuses again,

62:10

but a different talk on sinuses.

62:12

Great. Yes. Thank you very much.

62:14

It was really, really good. Alright.

62:16

Thank you. Take care.

62:17

Thank you. Thank you everybody. Have a good day. Bye-Bye.