Nasal cavity, paranasal sinuses, nasopharynx
Sinonasal carcinoma
Intestinal type adenocarcinoma (ITAC)

Author: Abul Ala Syed Rifat Mannan, M.D. (see Authors page)
Editor: Songyang Yuan, M.D., Ph.D.

Revised: 4 October 2018, last major update October 2013

Copyright: (c) 2004-2018, PathologyOutlines.com, Inc.

PubMed Search: Intestinal type adenocarcinoma nasal

Cite this page: Mannan, A.A.S.R. Intestinal type adenocarcinoma (ITAC). PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/nasalintestinaladeno.html. Accessed October 22nd, 2018.
Definition / general
  • Primary sinonasal epithelial malignancy that histologically resembles intestinal adenoma or adenocarcinoma
  • #2 most common type of sinonasal adenocarcinoma after adenoid cystic carcinoma
Terminology
  • ITAC is also known as colonic type adenocarcinoma or enteric type adenocarcinoma
Epidemiology
Sites
  • Ethmoid sinus is most common location (40%), followed by nasal cavity (25%) and maxillary antrum (20%) (Head Neck Pathol 2007;1:38)
  • Cases related to industrial wood dust exposure show predilection for ethmoid sinus
  • Sporadic tumors are more common in maxillary antrum
  • In nasal cavities, inferior and middle turbinates are the preferred sites
Clinical features
  • Unilateral nasal obstruction, rhinorrhea, epistaxis are common presentations
  • Advanced tumors may cause pain, neurologic disturbances, exophthalmos, visual impairment
Diagnosis
  • CT and MRI are used for diagnosing early lesions, defining disease extent and detecting early recurrences
Prognostic factors
  • Locally aggressive with ~50% local recurrence
  • Locoregional / distant metastasis occurs in 10 - 20% cases
  • 5 year cumulative survival rate is ~40%
  • Histologic subtype bears prognostic significance
    • Papillary subtype is associated with 80% survival at 5 years, while mucinous and solid subtypes carry poor prognosis (Hum Pathol 1999;30:1140)
  • HRAS mutation, chromogranin expression and HER2 / c-erbB-2 expression are associated with aggressive behavior (Cancer 1999;86:255)
  • There is no significant prognostic difference between occupational and sporadic tumors
Treatment
  • Adequate surgical removal
  • Postoperative radiotherapy for advanced cases
Gross description
  • Irregular exophytic tan, pink mass bulging into nasal cavity or paranasal sinuses, often with necrotic and friable appearance
  • Some lesions are gelatinous
Microscopic (histologic) description
  • Two major histologic classifications for ITAC:
    • Barnes classification recognizes 5 categories:
    • Kleinasser and Schroeder subdivides ITAC into 4 categories:
      • Papillary tubular cylinder cell types I - III (I - well differentiated, II - moderately differentiated and III - poorly differentiated)
      • Alveolar goblet type
      • Signet ring type
      • Transitional type (Arch Otorhinolaryngol 1988;245:1)
  • Papillary and colonic types are most common histologic types
  • Papillary type: predominantly papillary growth pattern with tubular elements
  • Colonic type: tubuloglandular architecture with minor papillary elements; neoplastic cells have palisaded hyperchromatic nuclei and a few goblet cells
  • Solid type: poorly differentiated; trabecular and solid proliferation of neoplastic cells
  • Mucinous: mucin laden neoplastic glands or tumor cell clusters within pools of extracellular mucin
  • Mixed: variable admixture of two or more subtypes
  • Goblet cells, paneth cells and argentaffin cells may be found in all subtypes
  • Exceptionally well differentiated ITAC may resemble normal small intestinal mucosa with well formed villi and muscularis mucosae
Microscopic (histologic) images

Images hosted on other servers:

Colonic and papillary types

Colonic type

Colonic type

Papillary pattern

Papillary tubular cylinder cell I

Papillary tubular cylinder cell II


Various images

Mucinous pattern

Alveolar goblet cell

Various subtypes


CK7-

Focal CK7+

Diffuse nuclear CDX2+

Various stains


Other diagnoses for comparison:

Intestinal metaplasia of nasal mucosa

Low grade nonintestinal adenocarcinoma

Tubulopapillary low grade (nonintestinal) adenocarcinoma

Positive stains
Molecular / cytogenetics description
  • Frequent KRAS and p53 mutations
  • Tumors with occupational exposure to wood dust show p53, p14 ARF, p16 INK4a gene deregulation
  • EGFR alterations also reported (Cell Oncol (Dordr) 2012;35:443)
Differential diagnosis
  • Low grade sinonasal adenocarcinoma: usually not associated with wood dust exposure; "clean" background, may have papillary / tubular architecture; more glandular, less papillary, few columnar / goblet cells
  • Metastasis from colonic adenocarcinoma: rare but most important differential; usually CEA+, CK7-, chromogranin-; clinical features and colonoscopy are helpful
  • Papillary sinusitis: may have abundant mucinous material but has short and blunt papillae with clean background; thick and hyalinized basement membrane; ciliated surface cells; prominent eosinophils and no significant cytological atypia