Sinonazal mukozal melanom

Özet

Sinonazal mukozal melanom, sıklıkla nazal kavite mukozasında başlayan nadir ve agresif melanom alt tipidir. İntravenöz kontrastlı BT, kitle merkezini ve kemik yayılımını gösterir; MR yumuşak doku sınırlarını ve melaninle ilişkili sinyal özelliklerini tamamlayabilir. Sık rastlanan amelanotik formlar nedeniyle makroskopik görünüm tanıyı kesinleştirmez; doğru sınıflandırma için histopatoloji ve immunohistokimya gereklidir. Erken evre veya derin anatomik bölgelerde başlayan küçük lezyonlar erişim zorluğu nedeniyle gecikebilir ve nonspesifik inflamasyonla karıştırılarak önemsiz bulunabilir.

Faz ve pencere

Kontrastsız tanısal

Kontrastsız ince kesit görüntüde nazal kavite ya da sinüs içinde yumuşak doku kitlesi ve kemik remodeling/destrüksiyonu değerlendirilir; BT dansitesi melanin içeriğini güvenilir biçimde göstermez.

Kontrastlı tanısal

Kontrastlı BT veya MR ile tümörün uzanımı ve komşu yumuşak doku tutulumu değerlendurulür; ancak kontrastlanma paterni melanom için özgün değildir. Boyanma tek başına melanom tanısı koydurmaz.

Önerilen pencereler: Yumuşak doku (G 400 / M 40), Kemik (G 1800 / M 400).

BT bulguları

• Lateral nazal duvar, septum veya konka mukozasında polipoid ya da infiltratif yumuşak doku kitlesi.
• Maksiller sinüs veya etmoid hücrelerde ikincil dolum ve ostium tıkanması.
• Komşu kemikte düzgün bası remodelingi veya düzensiz destrüktif erozyon.
• Melanin içeren tümörlerde MR T1-weighted sekanslarda hipersignal, T2-weighted sekanslarda hipsignal görülür; BT dansitesi ise melanin varlığına dair güvenilir bir belirteç değildir.
• Kontrast sonrası solid komponentte heterojen ya da belirgin boyanma.
• Orbita medial duvarı, kribriform plak veya pterigopalatin fossaya doğru uzanım.
• Servikal lenf nodları veya uzak hastalık değerlendirmesi için boyun ve sistemik evreleme görüntülemesi gereksinimi.

Normalde

Karşı burun boşluğunun normal hava kolonları ve kemik yapısı ile kıyaslanması, tek taraflı tıkanıklık veya erozyon şüphesini artırmalıdır. Tek taraflı kitlenin köken yeri ve kemik/komşu doku uzanımı, karşı tarafa kıyasla ve çok planar rekonstrüksiyonlarla detaylı olarak incelenmelidir.

Ayırıcı tanı

Sinonazal lenfoma

diğer kötü huylu tümörlerin aksine, komşu kemikte yıkım yerine yeniden şekillenme (remodeling) yapabilir.

Skuamöz hücreli karsinom

belirgin kemik destrüksiyonu ve sinüs/lateral duvar merkezli kitle yapabilir.

Lobüler kapiller hemanjiom

çoğunlukla septum veya konka kökenli, iyi sınırlı ve belirgin boyanan küçük nodüldür.

İnvaziv fungal sinüzit (mükormikozis)

derin immün baskılanma, nekrotik eskar, kemik erozyonu ve perinerural yayılım ile ayrılır.

Olfaktör nöroblastom (estesiyonöroblastom)

olfaktör oluk ve kribriform plak merkezli üst nazal kavite kitlesidir.

Tuzaklar

• Melanin içeren tümörün BT'de mutlaka hiperdens olacağını varsayma; amelanotik lezyonlar sıradan yumuşak doku yoğunluğunda olabilir.
• Melanin içeriği BT dansitesiyle güvenilir şekilde saptanamaz; pigmente lezyonların tanısında ve uzanımının değerlendirmesinde MR görüntülemenin rolü kritiktir.
• Polipoid görünüm melanomu dışlamaz; tek taraflı kitlede başlangıç mukozası ve kemik etkisini belirt.

Kendini dene

1. Tek taraflı, kontrastlanan nazal kitle BT'de sıradan yumuşak doku yoğunluğunda; pigment görünümü yok. Pigment görünümü olmaması sinonazal melanomu dışlar mı?

   • Melanom dışlanamaz
   • Melanom kesin dışlanır
   • Yalnız osteom düşünülür
   • Bu görünüm antrolittir
   Cevabı göster

   Melanom dışlanamaz. Sinonazal melanom amelanotik olabilir; BT yoğunluğu histolojik melanin varlığını güvenilir biçimde belirlemez.

2. Septumdan köken alan küçük, belirgin kontrastlanan lobüle kitle ve kemik yıkımı yok. Sinonazal melanomun ayırıcı tanısında yer alan tümörlerden biri hangisidir?

   • Benign septal vasküler proliferasyon
   • Estesiyonöroblastom
   • Osteosarkom
   • Mukosel
   Cevabı göster

   Benign septal vasküler proliferasyon. Septum kökenli, iyi sınırlı ve belirgin boyanan küçük lezyon benign damar kökenli proliferasyonu destekler; olfaktör nöroblastom ise genellikle üst nazal kavite ve kribriform plak kökenlidir.

Kaynaklar

Bu sayfadaki 35 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 12 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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