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Acinic cell carcinoma of the maxillary sinus
Ioannis Dimitrakopoulos, Nicolaos Lazaridis, Ekaterini Triantafillidou Department of Oral and Maxillofacial Surgery, Dentistry School, Aristotle University of
ThessaloNki, Thessaloniki,Greece
A case report L Dimitrakopoulos, N. Lazaridis, E. Triantafillidou: Acinic cell carcinoma o f the maxillary sinus. A case report. Int. J. Oral Maxillofac. Surg. 1992," 21." 350-351. © M u n k s g a a r d 1992
Abstract. A case of acinic cell c a r c i n o m a o f the maxillary sinus is presented. As can be assumed f r o m the n u m b e r of r e p o r t e d cases, this is a n u n c o m m o n site for this t u m o r to occur.
Acinic cell c a r c i n o m a (ACC) is a n unc o m m o n salivary gland tumor, comprising approximately 2.5% of all salivary gland n e o p l a s m s 1°. It m o s t frequently arises in the p a r o t i d gland, representing 7-15% o f all p a r o t i d m a l i g n a n t tumors, while occurrence in other m a j o r or min o r salivary glands has been r e p o r t e d to be 0 . 4 - - 1 . 8 % 7,8 . The t u m o r occurs m o r e often in females, a n d the peak incidence
Fig. 1. Occipito-mental radiograph showing soft-tissue mass obliterating left antrum.
Fig. 2. Axial CT scan showing tumor filling left maxillary sinus with erosion of antral wall.
Key words: acinic cell carcinoma; maxillary sinus. Accepted for publication 14 July 1992
Case report
(CT) examination demonstrated a soft-tissue mass completely filling the left maxillary sinus (Figs. 1 and 2). Erosion of the antral walls, with extension of the lesion into the left nasal cavity, pterygomaxillary space, and subperiosteally in the cheek, was also noted (Fig. 2). CT examination of the neck revealed no evidence of metastatic disease. A biopsy from the tuberosity indicated the diagnosis of acinic cell carcinoma. Routine laboratory data showed no abnormalities. CT of the chest and upper abdomen was normal, excluding any metastases of lungs and liver. The patient underwent a subtotal maxillectomy by a Weber-Ferguson incision. The floor of the orbit was explored and a part was resected, but the eye was left, since frozen section of the orbital content revealed no tumor. The posterior bony resection was made through the pterygopalatine fissure, not including the pterygoid process. A small area of erosion through the posterior wall of the antrum was noted. Three layers of human lyophilized dura were cut and sutured into the orbital defect. The entire cavity was
A 65-year-old man was referred to our hospital, complaining of a swelling and intermittent pain of the left maxilla that had been present for about 2 months. The patient had noted diplopia on downward gaze for the last 2 weeks. Examination showed facial asymmetry caused by expansion of the anterolateral wall of the left maxillary sinus associated with slight exophthalmos and infraorbital nerve paresthesia. Visual acuity and globe movements were normal. Oral examination revealed a painless swelling on the labial aspect of the maxillary left canine and premolar region. The teeth were not displaced, mobile, or tender to percussion and responded to electric pulp test. The buccal cortex of the maxillary tuberosity was thin and penetrated in one area, but the overlying mucosa was intact and normal in color and consistency. Regional lymph nodes were not enlarged. Radiographic and computed tomographic
Fig. 3a. Histologic section showing basophilic cells arranged in acinar groups and small, irregular, fluid-filled spaces among basophilic tumor cells (HE x 100). b. High-power view of tumor, showing uniform cuboidal or low columnar cells enclosing cavities of varying sizes (HE x 400).
is in the fifth decade 5,8,9. A l t h o u g h the t u m o r is of low-grade m a l i g n a n c y a n d generally associated with good initial prognosis, late recurrence a n d m e t a stasis in cervical l y m p h nodes as well as in d i s t a n t sites, including bone, lung, a n d brain, are well k n o w n 3,5J°. There are reports in the literature o f the t u m o r occurring in ectopic salivary tissue (mandible) a n d extraoral m i n o r salivary glands (nasal cavity), b u t such cases are rare. F L O O D et al. 1 presented a case of a central acinic cell c a r c i n o m a o f the m a n d i b l e a n d reviewed three cases t h a t h a d previously been reported. T h e tum o r has also been reported to arise in the nasal cavity 8, p a r a n a s a l sinuses 3, a n d cervical l y m p h nodes 1. A case o f a n extensive maxillary sinus i n v o l v e m e n t is presented.
Acinic cell carcinoma of the antrum covered with a split-thickness skin graft. Histologic examination showed that the tumor was poorly encapsulated and composed of round or polyhedral cells with a very characteristic basophilic granular cytoplasm and small hyperchromatic nuclei. These cells were arranged in sheets with focal acinar formation separated by narrow bands of dense fibrous connective tissue. In some areas, uniform cuboidal and low columnar cells were arranged in a ductlike pattern. Irregular spaces with fluid accumulation and microcystic structures of varying size were also seen (Fig. 3). Discussion
Cases of A C C arising in minor salivary glands of the upper respiratory tract are extremely rare. To our knowledge, only one case arising from the respiratory mucosa of paranasal sinuses has previously been reported 3. That case occurred in the anterior ethmoids and maxillary antrum with extension into the nasal cavity 3. SPIRO et al. 8 reported 67 cases of ACC, among them one case which presumably arose from minor salivary glands of the nasal cavity. Several authors, in an effort to explain the origin of such central maxillary gland tumors, have suggested that these lesions may arise within ectopic glandular tissue, occurring either in the oral and antral mucosa or in the jaws, and subsequently invading centrally 2'4. MA-
RANO • KENTON 4 emphasized t h a t in view of the m a n y minor salivary glands within the maxillary antral lining, many central salivary tumors may originate from these glands. In the case presented, the tumor had filled up the left maxillary sinus, resulting in expansion and erosion of the antral walls, and it had extended into the orbit, nasal cavity, pterygomaxillary space, and subperiosteally in the cheek. The treatment of choice for A C C is wide surgical excision 3'6'8-1°. Radiotherapy does not appear to be effective 5'6'9. Long-term studies indicate that patients with A C C have a relatively good prognosis (over 80% recover) on the basis of 5-year follow-up; however, a significant number of individuals will probably die 15-20 years after initial treatmentS,6,8,10.
References 1. FLOOD TR, MAHARAJABB, MACDONALD
DG, GIPd DD. Central acinic cell carcinoma of the mandible: report of a case. Br J Oral Maxillofac Surg 1991: 29: 26-8. 2. GINGEL JC, BECKERMANT, LEVY BA, SNIDER LA. Central mucoepidermoid carcinoma. Oral Surg 1984: 57: 436-40. 3. MANACE ED, GOLDMANJL. Acinic cell carcinoma of the paranasal sinuses. Laryngoscope 1971: 81: 1072-82. 4. MARANOPD, K~NTON SH. Central muc-
351
oepidermoid carcinoma arising in a maxillary odontogenic cyst. J Oral Surg 1974: 32: 915-19. 5. MmLAR BG, JOHNSONPA, LEOPARDPJ. Bilateral acinic cell carcinoma of the parotid. Br J Oral Maxillofac Surg 1989: 27: 192-7. 6. PERZINKH, LWOLSXVA. Acinic cell carcinoma arising in salivary glands. A clinicopathologic study. Cancer 1979: 44: 1434-57. 7. SAITOK, MICHI K, TACHIKAWAA. Acinic cell carcinoma in salivary gland of the palate. Int J Oral Maxillofac Surg 1989: 18: 168-9. 8. SPmo PH, Huvos AG, STRONGEW. Acinic cell carcinoma of salivary origin. A clinicopathologic study of 67 cases. Cancer 1978: 41: 924-35. 9. TUFFIN JR, DANIEL F, DAVI~SAS, TYRRELL CJ. Acinic cell carcinoma - Plymouth's experience with postoperative radical radiotherapy. Br J Oral Maxillofac Surg 1989: 27: 186-91. 10. WATSONPH, SUTHERLANGR, DIOCEEM, SIMA AE Acinic cell carcinoma metastatic to the brain: case report and ultrastructural study. Head Neck Surg 1987: 10: 118-23. Address: Dr Ioannis Dimitrakopoulos Department of Oral and Maxillofacial Surgery Dentistry School Aristotle University of Thessaloniki 54006 Thessaloniki Greece
Acinic cell carcinoma of the maxillary sinus
Ioannis Dimitrakopoulos, Nicolaos Lazaridis, Ekaterini Triantafillidou Department of Oral and Maxillofacial Surgery, Dentistry School, Aristotle University of
ThessaloNki, Thessaloniki,Greece
A case report L Dimitrakopoulos, N. Lazaridis, E. Triantafillidou: Acinic cell carcinoma o f the maxillary sinus. A case report. Int. J. Oral Maxillofac. Surg. 1992," 21." 350-351. © M u n k s g a a r d 1992
Abstract. A case of acinic cell c a r c i n o m a o f the maxillary sinus is presented. As can be assumed f r o m the n u m b e r of r e p o r t e d cases, this is a n u n c o m m o n site for this t u m o r to occur.
Acinic cell c a r c i n o m a (ACC) is a n unc o m m o n salivary gland tumor, comprising approximately 2.5% of all salivary gland n e o p l a s m s 1°. It m o s t frequently arises in the p a r o t i d gland, representing 7-15% o f all p a r o t i d m a l i g n a n t tumors, while occurrence in other m a j o r or min o r salivary glands has been r e p o r t e d to be 0 . 4 - - 1 . 8 % 7,8 . The t u m o r occurs m o r e often in females, a n d the peak incidence
Fig. 1. Occipito-mental radiograph showing soft-tissue mass obliterating left antrum.
Fig. 2. Axial CT scan showing tumor filling left maxillary sinus with erosion of antral wall.
Key words: acinic cell carcinoma; maxillary sinus. Accepted for publication 14 July 1992
Case report
(CT) examination demonstrated a soft-tissue mass completely filling the left maxillary sinus (Figs. 1 and 2). Erosion of the antral walls, with extension of the lesion into the left nasal cavity, pterygomaxillary space, and subperiosteally in the cheek, was also noted (Fig. 2). CT examination of the neck revealed no evidence of metastatic disease. A biopsy from the tuberosity indicated the diagnosis of acinic cell carcinoma. Routine laboratory data showed no abnormalities. CT of the chest and upper abdomen was normal, excluding any metastases of lungs and liver. The patient underwent a subtotal maxillectomy by a Weber-Ferguson incision. The floor of the orbit was explored and a part was resected, but the eye was left, since frozen section of the orbital content revealed no tumor. The posterior bony resection was made through the pterygopalatine fissure, not including the pterygoid process. A small area of erosion through the posterior wall of the antrum was noted. Three layers of human lyophilized dura were cut and sutured into the orbital defect. The entire cavity was
A 65-year-old man was referred to our hospital, complaining of a swelling and intermittent pain of the left maxilla that had been present for about 2 months. The patient had noted diplopia on downward gaze for the last 2 weeks. Examination showed facial asymmetry caused by expansion of the anterolateral wall of the left maxillary sinus associated with slight exophthalmos and infraorbital nerve paresthesia. Visual acuity and globe movements were normal. Oral examination revealed a painless swelling on the labial aspect of the maxillary left canine and premolar region. The teeth were not displaced, mobile, or tender to percussion and responded to electric pulp test. The buccal cortex of the maxillary tuberosity was thin and penetrated in one area, but the overlying mucosa was intact and normal in color and consistency. Regional lymph nodes were not enlarged. Radiographic and computed tomographic
Fig. 3a. Histologic section showing basophilic cells arranged in acinar groups and small, irregular, fluid-filled spaces among basophilic tumor cells (HE x 100). b. High-power view of tumor, showing uniform cuboidal or low columnar cells enclosing cavities of varying sizes (HE x 400).
is in the fifth decade 5,8,9. A l t h o u g h the t u m o r is of low-grade m a l i g n a n c y a n d generally associated with good initial prognosis, late recurrence a n d m e t a stasis in cervical l y m p h nodes as well as in d i s t a n t sites, including bone, lung, a n d brain, are well k n o w n 3,5J°. There are reports in the literature o f the t u m o r occurring in ectopic salivary tissue (mandible) a n d extraoral m i n o r salivary glands (nasal cavity), b u t such cases are rare. F L O O D et al. 1 presented a case of a central acinic cell c a r c i n o m a o f the m a n d i b l e a n d reviewed three cases t h a t h a d previously been reported. T h e tum o r has also been reported to arise in the nasal cavity 8, p a r a n a s a l sinuses 3, a n d cervical l y m p h nodes 1. A case o f a n extensive maxillary sinus i n v o l v e m e n t is presented.
Acinic cell carcinoma of the antrum covered with a split-thickness skin graft. Histologic examination showed that the tumor was poorly encapsulated and composed of round or polyhedral cells with a very characteristic basophilic granular cytoplasm and small hyperchromatic nuclei. These cells were arranged in sheets with focal acinar formation separated by narrow bands of dense fibrous connective tissue. In some areas, uniform cuboidal and low columnar cells were arranged in a ductlike pattern. Irregular spaces with fluid accumulation and microcystic structures of varying size were also seen (Fig. 3). Discussion
Cases of A C C arising in minor salivary glands of the upper respiratory tract are extremely rare. To our knowledge, only one case arising from the respiratory mucosa of paranasal sinuses has previously been reported 3. That case occurred in the anterior ethmoids and maxillary antrum with extension into the nasal cavity 3. SPIRO et al. 8 reported 67 cases of ACC, among them one case which presumably arose from minor salivary glands of the nasal cavity. Several authors, in an effort to explain the origin of such central maxillary gland tumors, have suggested that these lesions may arise within ectopic glandular tissue, occurring either in the oral and antral mucosa or in the jaws, and subsequently invading centrally 2'4. MA-
RANO • KENTON 4 emphasized t h a t in view of the m a n y minor salivary glands within the maxillary antral lining, many central salivary tumors may originate from these glands. In the case presented, the tumor had filled up the left maxillary sinus, resulting in expansion and erosion of the antral walls, and it had extended into the orbit, nasal cavity, pterygomaxillary space, and subperiosteally in the cheek. The treatment of choice for A C C is wide surgical excision 3'6'8-1°. Radiotherapy does not appear to be effective 5'6'9. Long-term studies indicate that patients with A C C have a relatively good prognosis (over 80% recover) on the basis of 5-year follow-up; however, a significant number of individuals will probably die 15-20 years after initial treatmentS,6,8,10.
References 1. FLOOD TR, MAHARAJABB, MACDONALD
DG, GIPd DD. Central acinic cell carcinoma of the mandible: report of a case. Br J Oral Maxillofac Surg 1991: 29: 26-8. 2. GINGEL JC, BECKERMANT, LEVY BA, SNIDER LA. Central mucoepidermoid carcinoma. Oral Surg 1984: 57: 436-40. 3. MANACE ED, GOLDMANJL. Acinic cell carcinoma of the paranasal sinuses. Laryngoscope 1971: 81: 1072-82. 4. MARANOPD, K~NTON SH. Central muc-
351
oepidermoid carcinoma arising in a maxillary odontogenic cyst. J Oral Surg 1974: 32: 915-19. 5. MmLAR BG, JOHNSONPA, LEOPARDPJ. Bilateral acinic cell carcinoma of the parotid. Br J Oral Maxillofac Surg 1989: 27: 192-7. 6. PERZINKH, LWOLSXVA. Acinic cell carcinoma arising in salivary glands. A clinicopathologic study. Cancer 1979: 44: 1434-57. 7. SAITOK, MICHI K, TACHIKAWAA. Acinic cell carcinoma in salivary gland of the palate. Int J Oral Maxillofac Surg 1989: 18: 168-9. 8. SPmo PH, Huvos AG, STRONGEW. Acinic cell carcinoma of salivary origin. A clinicopathologic study of 67 cases. Cancer 1978: 41: 924-35. 9. TUFFIN JR, DANIEL F, DAVI~SAS, TYRRELL CJ. Acinic cell carcinoma - Plymouth's experience with postoperative radical radiotherapy. Br J Oral Maxillofac Surg 1989: 27: 186-91. 10. WATSONPH, SUTHERLANGR, DIOCEEM, SIMA AE Acinic cell carcinoma metastatic to the brain: case report and ultrastructural study. Head Neck Surg 1987: 10: 118-23. Address: Dr Ioannis Dimitrakopoulos Department of Oral and Maxillofacial Surgery Dentistry School Aristotle University of Thessaloniki 54006 Thessaloniki Greece
