0:00

I'm really not one for memorizing

0:02

very many grading systems of tumors.

0:05

However, it is useful to look at the Kadish

0:08

system grading of olfactory neuroblastoma in

0:12

order to better inform us of what we should be

0:16

looking for with regard to spread of olfactory

0:20

neuroblastoma, i.e., esthesioneuroblastoma.

0:25

So Group A are those confined to the nasal cavity.

0:27

Group B include not only the nasal

0:30

cavity, but also the paranasal sinuses.

0:33

Group C grow into the skull base and the

0:36

intracranial cavity, and Group D, distant metastases.

0:40

So the important factors here is, is just in

0:42

the nasal cavity, has it spread to the maxillary

0:44

sinus, the ethmoid sinus, is it going into

0:47

the skull base, perineural spread, intracranial

0:49

compartment, and then this is a malignancy,

0:52

do they have distant metastases?

0:55

I mentioned that there was a recent

0:58

upgrade in the World Health Organization

1:01

with regard to sinonasal tumors.

1:04

I've mentioned some of these in passing, but

1:07

you should understand that there are certain

1:10

tumors that are called sinonasal epithelial

1:14

hamartomas, which are benign lesions that

1:17

contain portions of ciliated respiratory

1:20

epithelium, and I mentioned the REAH as a

1:24

respiratory epithelial adenomatoid hamartoma

1:28

as one of these that is the more common.

1:31

These are usually along the olfactory

1:33

cleft and associated, as I mentioned, with

1:36

polyposis, and they may have a little bit of a

1:39

crescent sign around them, reflecting their curved

1:42

linear border.

1:44

I mentioned also the NUT carcinoma.

1:47

This is nuclear protein in testis.

1:49

This is generally a midline tumor

1:52

that can affect the nasal septum.

1:55

They're locally aggressive.

1:56

They may have some mineralization, but

1:58

it's not the same mineralization as that

2:00

chondroid matrix of a chondrosarcoma.

2:04

Now there are other tumors including

2:06

biphenotypic sinonasal sarcomas.

2:09

These are tumors that are characterized

2:11

by avid enhancement and hyperostosis.

2:13

They can occur anywhere in the sinonasal cavity.

2:16

I also mentioned HPV sinonasal carcinomas,

2:20

and the HPV subtype is different than

2:24

the 16, 32 that we typically see in tonsil

2:27

carcinomas and base of the tongue carcinomas.

2:30

These are usually subtype 34, but they may be unique

2:34

tumors, and they by and large have a better prognosis.

2:38

Additionally, I mentioned in talking about

2:40

the sinonasal undifferentiated carcinomas,

2:43

that some of these have been reclassified as

2:46

the SWI/SNF, or SWItch/Sucrose Non-Fermentable related

2:51

matrix-associated actin-dependent

2:55

regulator of chromatin subfamily B tumors.

2:59

So these are replacing some of the

3:03

SMARCB1 tumors, which you see here.

3:06

And these are aggressive tumors,

3:09

may have a calcified matrix, and they may invade the dura.

3:13

And then finally, there are those

3:15

chondro-mesenchymal hamartomas.

3:18

These are what we would've previously called enchondromas

3:21

or chondromas but have been reclassified as well.

3:25

So that about takes us through the

3:27

primary tumors of the sinonasal cavity.

3:31

You should understand that there are

3:34

some tumors that have a predilection for

3:36

metastasizing to the sinonasal cavity.

3:40

The most common of this is kidney carcinoma.

3:43

Kidney carcinoma is often hypervascular.

3:47

It may be hemorrhagic, and that might be one of

3:50

the indicators that this is a metastasis to the

3:54

sinonasal cavity, as opposed to a primary tumor.

3:57

So kidney primaries more common

3:59

than lung and breast and prostate.

4:01

Sometimes we'll have a melanoma

4:03

in the sinonasal cavity, and the patient also has a skin

4:08

cancer, and we question, is that metastatic melanoma

4:12

disease, or is that primary sinonasal melanoma?

4:16

Same thing true with lymphoma.

4:18

You can have primary sinonasal lymphomas,

4:21

or you can have systemic lymphoma with

4:24

metastatic disease to the sinonasal cavity.

4:28

In addition, the sinonasal cavity may be a site where

4:32

myeloma with lytic bone lesions may occur as well.

4:37

Here, for example, is a patient who has a mass

4:40

in the sinonasal cavity associated with bright

4:42

signal on T1-weighted scan that was hemorrhagic.

4:45

This was indeed a renal cell

4:48

carcinoma to the sinonasal cavity.

4:51

This is a patient who has a tumor in

4:53

the maxillary antrum, which is showing

4:56

very avid FDG uptake on the PET scan.

5:00

This was a lymphoma

5:02

of the maxillary antrum, and

5:05

was primary sinonasal lymphoma.

5:08

From the sinonasal cavity, as I mentioned, it's

5:12

relatively unusual to see lymph node spread.

5:15

When we do see lymph node spread, you may see it in

5:18

the level II high jugular chain above the hyoid bone.

5:22

You may see it in the retropharyngeal

5:25

lymphadenopathy, the so-called nodes of Rouvière, or you

5:28

may see submental or submandibular spread of tumor,

5:32

the so-called level I lymphadenopathy.

5:35

With regard to sinonasal lymphatic cancer or

5:39

lymphoma, this is usually diffuse large B-cell

5:44

lymphoma, although you can have your NKT or T-cell

5:49

lymphomas. These tend to occur more commonly

5:52

in the Asian and South American population.