{"id":44969,"date":"2025-07-02T17:35:00","date_gmt":"2025-07-02T09:35:00","guid":{"rendered":"https:\/\/medicine.nus.edu.sg\/pathweb\/?page_id=44969"},"modified":"2025-08-05T16:25:34","modified_gmt":"2025-08-05T08:25:34","slug":"hn-3","status":"publish","type":"page","link":"https:\/\/medicine.nus.edu.sg\/pathweb\/cytopath\/cyto-mystery-cases\/hn-3\/","title":{"rendered":"Mystery cases &#8211; Head &#038; Neck NOS 3"},"content":{"rendered":"\n<h2>\n\t\tHead and Neck NOS case 3\n\t<\/h2>\n\t<h1>Face swelling<\/h1>\n\t<p><strong>Clinical history:<\/strong>\u00a0A 79-year-old man presented with 2-week history of right temporal swelling associated with worsening vision. MRI shows a lobulated enhancing mass centred in the greater wing of sphenoid measuring 4.9 cm in maximum dimension, and extending into the surrounding soft tissue.\u00a0An FNA of the temporal mass was performed.<\/p>\n\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--label-0\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-0\">Click here for additional clinical history<\/a>\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--icon-0\" tabindex=\"-1\"><i title=\"Expand\">Expand<\/i><\/a>\n\t\t\t\t\t&nbsp;<br \/>\nSerum AFP was grossly elevated at\u00a0900 ng\/ml.\u00a0\n<p>In addition, a non-contrast CT scan showed diffuse nodularity of the liver.\u00a0\u00a0<\/p>\n\t\t\t\t<img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2025\/06\/HN10.jpg\" alt=\"HN10\" itemprop=\"image\" height=\"1440\" width=\"1920\" title=\"HN10\" onerror=\"this.style.display='none'\"  \/>\n\t\t\t\t<img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2025\/06\/HN11.jpg\" alt=\"Head and Neck NOS case 3\" itemprop=\"image\" height=\"1440\" width=\"1920\" title=\"HN11\" onerror=\"this.style.display='none'\"  \/>\n\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--label-0\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-0\">Cytologic findings<\/a>\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--icon-0\" tabindex=\"-1\"><i title=\"Expand\">Expand<\/i><\/a>\n\t\t\t\t\t&nbsp;<br \/>\n<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2025\/06\/HN12.jpg\" alt=\"\" \/>\n<ul>\n<li>Cohesive clusters of polygonal cells forming acini and sometimes vague trabecular structures<\/li>\n<li>Enlarged eccentric or central nuclei<\/li>\n<li>Macronucleoli<\/li>\n<li>Abundant granular cytoplasm<\/li>\n<li>Clean background<\/li>\n<\/ul>\n\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--label-1\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-1\">Differential diagnosis<\/a>\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--icon-1\" tabindex=\"-1\"><i title=\"Expand\">Expand<\/i><\/a>\n\t\t\t\t\t&nbsp;<br \/>\nWithout the clinical history, the initial morphologic differential diagnoses of an acini-forming neoplasm are wide ranging and would include:\n<ol>\n<li>Adenocarcinoma of the thoracic, abdominal or pelvic visceral sites (i.e. prostatic acinar adenocarcinoma, acinar cell carcinoma of the pancreas)<\/li>\n<li>Acini\/follicle forming carcinomas of the head and neck including acinic cell carcinoma of salivary gland tissue, follicular thyroid carcinoma.<\/li>\n<li>Anaplastic meningioma should also be considered owing to the site of the tumour but it should be excluded based on imaging findings<\/li>\n<\/ol>\n<p>Thus, in such an instance, it is helpful to look at clinical investigations, in order to narrow down the differential diagnosis. Important clues to the diagnosis include the grossly elevated AFP and the abnormal finding on liver imaging.<\/p>\n<p>Taking into account the raised AFP and imaging findings, the revised DDx list includes:\u00a0<\/p>\n\u2043 Metastatic hepatocellular carcinoma<br \/>\n\u2043 Germ cell tumour i.e. yolk sac \/ embryonal carcinoma<br \/>\n\u2043 Metastatic prostatic acinar adenocarcinoma<br \/>\n\u2043 Metastatic adenocarcinoma of other visceral sites\n\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--label-2\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-2\">Cell block and histology<\/a>\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--icon-2\" tabindex=\"-1\"><i title=\"Expand\">Expand<\/i><\/a>\n\t\t\t\t\t&nbsp;<br \/>\nThe cell block showed limited amounts of tumour and the following stains were performed:\n<table>\n<tbody>\n<tr>\n<td><img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2025\/06\/HN13.jpg\" alt=\"\" \/><\/td>\n<td><img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2025\/06\/HN14.jpg\" alt=\"\" \/><\/td>\n<\/tr>\n<tr>\n<td><img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2025\/06\/HN15.jpg\" alt=\"\" \/><\/td>\n<td><img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2025\/06\/HN16.jpg\" alt=\"\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Hep Par 1 showed very focal reactivity. Glypican 3 was negative, arguing against the diagnosis of a germ cell tumour (e.g. yolk sac tumour). The possibility of metastatic Hepatocellular carcinoma was considered but the results were not definitive on the cell block.<\/p>\n<p>The mass subsequently resected and the histology is as follows:<\/p>\n<table>\n<tbody>\n<tr>\n<td><img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2025\/06\/HN17.jpg\" alt=\"\" \/><\/td>\n<td><img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2025\/06\/HN18.jpg\" alt=\"\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--label-3\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-3\">Diagnosis<\/a>\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--icon-3\" tabindex=\"-1\"><i title=\"Expand\">Expand<\/i><\/a>\n\t\t\t\t\t&nbsp;<br \/>\n<strong>Metastatic hepatocellular carcinoma<\/strong>\n<p>The difficulty in this case lies in the dominant acinar architecture, presence of vague trabecular structures (noted in retrospect, and more apparent in the cell block than the smears) and absence of endothelial wrapping around the clusters. No bile pigment was identified as well, and this was noted in the cytology report.<\/p>\n<p>Cytomorphologic hallmarks of hepatocellular carcinoma are the presence of trabecular architecture, endothelial wrapping around cell groups and intracytoplasmic bile pigment. Interestingly, the histology sample showed an overwhelming classic sinusoidal-trabecular architecture while the pseudoacinar pattern was only focally noted; the latter being the predominant pattern in the cytology sample.<\/p>\n<p>These sampling issues highlight the importance of rigorous attention to clinical investigations, in particular, where the cytomorphologic features are not fully classical or specific.<\/p>\n\t<p><em>Case writer: Dr Noel Chia<\/em><\/p>\n\n","protected":false},"excerpt":{"rendered":"<p>Head and Neck NOS case 3 Face swelling Clinical history:\u00a0A 79-year-old man presented with 2-week history of right temporal swelling associated with worsening vision. MRI shows a lobulated enhancing mass centred in the greater wing of sphenoid measuring 4.9 cm in maximum dimension, and extending into the surrounding soft tissue.\u00a0An FNA of the temporal mass [&hellip;]<\/p>\n","protected":false},"author":828,"featured_media":0,"parent":44933,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-44969","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>NUS Pathweb<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/cytopath\/cyto-mystery-cases\/hn-3\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:description\" content=\"Head and Neck NOS case 3 Face swelling Clinical history:\u00a0A 79-year-old man presented with 2-week history of right temporal swelling associated with worsening vision. 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