Published ahead of print on September 3, 2008
doi: 10.3174/ajnr.A1264
American Journal of Neuroradiology 30:428-430, February 2009
© 2009 American Society of Neuroradiology
Case Report
HEAD & NECK
High Uptake in Schneiderian Papillomas of the Maxillary Sinus on Positron-Emission Tomography Using Fluorodeoxyglucose
F.Y. Lina,
E.M. Gendena,b,
W.L. Lawsona,
P. Somc and
L. Kostakogluc
a Department of Otolaryngology–Head and Neck Surgery, Mount Sinai School of Medicine, New York, NY
b Head and Neck Cancer Center, Mount Sinai School of Medicine, New York, NY
c Department of Radiology, Mount Sinai School of Medicine, New York, NY
Please address correspondence to Fred Y. Lin, MD, Department of Otolaryngology–Head and Neck Surgery, Mount Sinai School of Medicine, One Gustave L. Levy Pl, Box 1189, New York, NY 10029; e-mail: fred.lin{at}mssm.edu
SUMMARY: Schneiderian papillomas are benign tumors of the nasal
cavity and paranasal sinuses often asymptomatic in their early
stages. We report a case of a maxillary sinus oncocytic schneiderian
papilloma first detected by positron-emission tomography by
using fluorodeoxyglucose (FDG). Schneiderian papillomas demonstrate
increased FDG uptake, similar to that of other oncocytic tumors,
making it important for otolaryngologists and radiologists to
realize that high uptake of FDG does not necessarily indicate
a malignant lesion.
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Introduction
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Positron-emission tomography (PET) using fluorodeoxyglucose
(FDG) combined with CT (FDG-PET/CT) offers the advantage of
integrating morphologic and metabolic data at 1 single session.
In head and neck cancer, FDG-PET/CT has been shown to be of
particular use in tumor staging and restaging. Furthermore,
it provides a superior definition of lesion location and the
extent of disease, given the complex anatomy and the presence
of physiologic FDG uptake in normal structures.
1-4 However,
FDG is not specific to malignant processes and can also accumulate
in benign conditions such as infectious processes and benign
tumors that exhibit an increased rate of glycolysis.
5,6 Thus,
it is of prime importance to recognize false-positive lesions
for an accurate interpretation of FDG-PET/CT at both the initial
staging and restaging. In this article, we report a case of
a maxillary sinus oncocytic schneiderian papilloma in a patient
with squamous cell cancer of the head and neck, whose detection
by FDG-PET led to a subsequent histopathologic confirmation.
We also review the clinical characteristics of this benign tumor.
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Case Report
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A 70-year-old man presented with ear pain, odynophagia, and
hoarseness for 6 months. The patient was without any other significant
medical history and denied any symptoms of nasal drainage or
obstruction, facial pain, or headaches. On physical examination,
the patient was found to have enlarged lymph nodes in level
II, and on fiber optic nasolaryngoscopy, a large right pyriform
sinus mass with fixation of the right vocal cord was observed.
The patient was subsequently referred for a PET/CT study for
further evaluation of the extent of disease. PET/CT imaging
demonstrated a large hypopharyngeal soft-tissue mass as well
as 2 large hypermetabolic right-sided level II lymph nodes.
Additionally, an unexpected soft-tissue mass was detected within
the wall of the right maxillary sinus (
Figs 1 and
2), which
demonstrated significantly increased FDG uptake (maximum standard
uptake value [SUVmax], 28.0), which was highly suggestive of
a malignant process, probably of a metastatic nature. A month
later, the patient was brought to the operating room for panendoscopy,
biopsy of the hypopharyngeal mass, and a right Caldwell-Luc
operation with excisional biopsy of the maxillary sinus mass.
Histopathology revealed the hypopharyngeal mass to be a poorly
differentiated squamous cell carcinoma. Most interesting, the
maxillary sinus mass was histologically proved to be a sinonasal
oncocytic schneiderian papilloma. On the basis of these findings,
the patient's disease was staged as a T3N2bM0 hypopharyngeal
carcinoma. The patient subsequently underwent chemotherapy and
hyperfractionated radiation therapy for the hypopharyngeal squamous
cell carcinoma followed by a selective neck dissection. He responded
well to therapy with no evidence of disease after a follow-up
of 8 months, which included repeat PET/CT and diagnostic CT
studies. The patient is currently without a recurrence of his
maxillary sinus papilloma.
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Fig 1. Volumetric FDG-PET image demonstrates increased uptake in the supraglottic/hypopharyngeal region consistent with the primary tumor (gray arrow). Additionally noted are multiple foci of FDG uptake in right-sided cervical lymph nodes, consistent with metastatic disease. There is an additional focus of intense uptake in the region of the maxilla, suggestive of metastatic disease (black arrow; Fig 2). Faint and symmetric uptake in the midline is consistent with physiologic uptake in the vocal cords.
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Fig 2. Fusion (A), PET (B), and axial CT (C) images demonstrate a focus of intensely increased FDG uptake (arrow) corresponding to a soft-tissue attenuation projecting off the epithelial surface of the right maxillary sinus, highly suggestive of a malignant process. However, histopathologic examination revealed this mass to be a schneiderian papilloma.
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Discussion
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Schneiderian papillomas are benign tumors of the nasal cavity
and paranasal sinuses and are often asymptomatic in their early
stages. Hyams
7 described 3 histologic types of sinonasal papillomas:
inverted papillomas, fungiform papillomas, and cylindrical cell
papillomas. Inverted papillomas, unlike normal papillomas, are
derived from the inversion of the neoplastic epithelium into
underlying stroma instead of proliferating outward. Fungiform
papillomas are exophytic with a thin central core of connective
tissue, which is most consistent with the common concept of
papillomas. Cylindrical papillomas, which were later described
by Barnes and Bedetti
8 as oncocytic schneiderian papillomas,
are characterized by proliferating multilayered columnar cells
with typical involvement of the maxillary sinus or in conjunction
with the lateral wall of the nasal cavity or ethmoid sinus.
Oncocytic schneiderian papillomas are the rarest of the 3 variants, affecting males and females equally, with a propensity for local recurrence (33%–40%) and malignant transformation (4%–17%).7-9 Patients presenting with the disease typically offer nonspecific complaints with the most common being nasal obstruction, rhinorrhea, headache and facial pain or hyposmia and, rarely, tinnitus, sensorineural hearing loss, and diplopia.10 Symptoms often last between 0 and 72 months, with an average of 24 months, though Eggers et al10 showed that many patients are often asymptomatic at diagnosis.
Although there are no specific radiologic findings of schneiderian papillomas, typical findings on plain radiographs or CT are a unilateral opacification in the maxillary sinus or a mass in the nasal fossa, with occasional thinning or destruction of the bony walls.10 CT is the current technique of choice; however, due to its poor soft-tissue contrast, tumor cannot be differentiated from retained secretions or inflammation.10 FDG-PET, on the other hand, can image areas of increased glucose metabolism that appear to be linked with malignancy, though it is not tumor-specific, with uptake being involved in both tumor cells and nonneoplastic cells such as fibroblasts and neutrophils.11
Ninomiya et al11 studied 22 patients with suggestion of malignant tumors in the nasal cavity and paranasal sinuses, with results showing malignant tumors having a higher uptake of FDG than those of benign origin. FDG-PET depicted squamous cell carcinoma with high SUV significantly greater than that of normal tissue and benign lesions. However, oncocytic tumors such as Warthin tumors, oncocytomas, and oncocytic papillomas have been observed with high SUVs, despite being benign tumors.12-14 The etiology of increased FDG uptake is poorly understood, though it is hypothesized that oncocytic tumors possess a high number of mitochondria causing increased metabolism and an increased uptake of metabolites such as FDG.15
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Conclusions
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FDG-PET has been increasingly used in routine clinical applications
for head and neck carcinomas at both initial presentation and
follow-up for detection of possible recurrence. It offers a
technique of imaging that uses both metabolic and morphologic
data, allowing better characterization and localization of tumors.
However, increased FDG uptake is not solely limited to malignant
lesions. As we report here, schneiderian papillomas, which are
rare benign tumors of the nasal cavity and paranasal sinuses,
demonstrate significantly increased FDG uptake, similar to that
of other oncocytic tumors such as Warthin tumors and oncocytomas.
It is important that otolaryngologists and radiologists alike
be aware that high uptake of FDG does not necessarily confer
a malignant etiology. Thus, these tumors should be included
in the differential diagnosis to avoid false readings at both
staging and restaging for better patient management.
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References
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Received May 25, 2008;
accepted after revision June 21, 2008.
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Introduction