12 March 2008 – Case of the Week #112
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We thank Dr. Paul Mellen, East Central Indiana Pathologists and Dr. Crystal L Rose, Ball Memorial Hospital, both in Muncie, Indiana (USA) for contributing this case and much of the discussion. To contribute a Case of the Week, email [email protected] with the clinical history, your diagnosis and microscopic images in JPG, GIF or TIFF format (send as attachments, we will shrink if necessary). Please include any other images (gross, immunostains, etc.) that may be helpful or interesting. We will write the discussion (unless you want to), list you as the contributor, and send you $35 (US dollars) for your time after we send out the case. Please only send cases with a definitive diagnosis, and preferably that are out of the ordinary.
Case of the Week #112
A 76 year old man presented with a chief complaint of a globus (round mass) sensation in the throat. The patient denied dysphagia, pain, infection or aspiration. His history is significant for a prior thyroid lobectomy with a 1 mm papillary carcinoma. At nasopharyngoscopy, an asymmetric, granular and friable right nasopharyngeal mucosal lesion was noted, that was thought to represent an infectious process. The lesion was unchanged over several months. A punch biopsy was performed.
A thyroglobulin immunostain was negative.
What is your diagnosis?
Warthin’s tumor of the nasopharynx
This Warthin's tumor (papillary cystadenoma lymphomatosum) shows the usual glandular and cystic tumor lined by an inner double layer of oncocytic epithelium with a lymphoid cuff.
Warthin's tumor is almost exclusively found in the parotid salivary gland, and comprises 10% of all parotid gland tumors. It usually occurs in men, with a peak incidence in the seventh decade of life (Elsevier: Head and Neck Pathology, 2006, pages 309-12). It is associated with cigarette smoking, and there is controversy whether it is neoplastic or reactive. Molecular studies indicate it is not clonal (Hum Path 2000; 31:1377, Mod Path 2005;18:964), although cases with coexisting mucoepidermoid carcinoma are associated with t(11;19) and the CRTC1/MAML2 fusion transcript (Genes Chromosomes Cancer 2008;47:309)
Warthin's tumors have been found in the oral cavity, larynx, and cervical lymph nodes (Auris Nasus Larynx 2004;31:293). It rarely is multifocal. Nasopharyngeal Warthin's tumor is exceedingly rare. The finding of extra-parotid Warthin's tumor in areas prone to acute and chronic inflammation has continued to fuel the debate whether this entity is a true neoplasm or reactive (Otolaryngology-Head and Neck Surgery 1999;120:942). The differential diagnosis in the head and neck region includes the Warthin-like variant of papillary thyroid carcinoma, which has similar histology plus papillary nuclear features (see topic in Thyroid Chapter).
Surgical excision is almost always curative, although it rarely recurs. It may be associated with other benign or malignant tumors.
Dr. Peter Hillsamer provided clinical information.
Nat Pernick, M.D., President
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Bingham Farms, Michigan (USA) 48025
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