Surgical management of sinonasal inverted papillomas through endoscopic approach

We defined a standardized approach to surgery of sinonasal inverted papillomas (IP) for adequate and safe resection. A cohort of 65 patients treated from January 1995 to December 2005 at a single institution was retrospectively analyzed (mean follow-up: 28 months; range 1-132). The extension of the tumor was evaluated on clinical findings and computed tomography (CT) scan and/or resonance magnetic imaging (RMI). External and endoscopic surgical approaches were compared according to tumor extension, rate of local recurrence. Univariate analysis was used to review the impact on disease-free survival of factors related to the histopathological findings and the treatment. Endoscopic (alone or combined with transantral approach) and external surgery were used in 46 patients (71%) and 19 patients, respectively. Endoscopic approach (34/46) was performed to control IP in the nasal fossa, the ostiomeatal complex, the sphenoid sinus. It was combined with Caldwell-Luc procedure (12/46) for tumor extent into the lateral part of the maxillary sinus. The mean time for recurrences to occur was 19 months with range of 5-35 months. The rate of local recurrence was 17.6% (6/34) in endoscopic approach alone, 8.3% in endoscopic approach combined with a Caldwell-Luc procedure and 15.8% (3/19) in external approach. Tumor extension, excision with safe margins, associated malignancy or dysplasia have no significant impact on disease-free survival regardless of surgical procedure. On the basis of imaging evaluation and peroperative view of tumor extent, we propose a surgical strategy in which endoscopic approach could be used on the first attempt by trained surgeons. RMI is very useful to determine acute extent of the disease.

Signet-Ring Cell Adenocarcinoma of Sinonasal Tract: An Immunohistochemical Study of the Mucins Profile

Context.—Adenocarcinomas of the sinonasal tract are classified into 4 categories: salivary-type, intestinal-type, nonintestinal-type, and metastatic. Signet-ring cell carcinoma is the rarest form of intestinal-type adenocarcinoma. Only isolated cases have been reported in the literature.

Objective.—To evaluate clinical attributes, morphology, and immunohistochemistry in signet-ring cell carcinoma of the sinonasal tract.

Design.—Seventy-three cases of primary sinonasal adenocarcinomas were retrieved from the files. Only 5 signet-ring cell adenocarcinomas (tumors composed of more than 90% signet-ring cells) were identified. In all cases, clinical data and histologic slides were available and were reviewed. Consecutive tissue sections were immunostained with monoclonal antibodies against MUC2, MUC5AC, MUC5B, MUC6, p53 protein, and MIB-1.

Results.—Four of our 5 patients were woodworkers. They were treated by surgical excision and radiotherapy. Patient follow-up ranged from 11 to 84 months. Three patients presented an unfavorable evolution and died of metastatic spread. Microscopically, the tumors produced abundant mucin deposits, which accumulated in large extracellular pools. Tumor cells were predominantly signet-ring cells floating in the pools of mucin. The mucins profile was MUC2+, MUC5AC+, MUC5B+, and MUC6−. Eighty percent of cells were immunostained by p53 protein antibody and 60% cells with MIB-1 antibody.

Conclusions.—The mucin profile is similar to the profile described in digestive tract adenocarcinoma. It is not useful to differentiate between metastatic adenocarcinoma and primary intestinal-type sinonasal adenocarcinoma. Clinical data and immunochemistry with p53 protein and MIB-1 confirm that sinonasal signet-ring cell carcinoma is a high-grade and aggressive tumor.

High level of galectin-1 expression is a negative prognostic predictor of recurrence in laryngeal squamous cell carcinomas

Monitoring of gene-expression profiles is assumed to refine tumor characterization of laryngeal squamous cell carcinomas (LSCCs) with a therapeutic perspective. This is especially expected for adhesion/growth-regulatory effectors such as galectins, a class of endogenous lectins. Using computer-assisted microscopy, we investigated the prognostic value contributed by the quantitative determination of the immunohistochemical levels of expression of galectin-1, -3 and -7 in a series of 62 LSCCs including 42 low- and 20 high-stage LSCCs. As galectin-1 may have a key role leading to a tumor escape from immune surveillance, we also investigated whether or not the level of galectin-1 expression correlated with lymphocyte infiltration in LSCCs. The immunohistochemical determination of expression of galectin-1 is of prognostic value in human squamous laryngeal cancers. LSCCs that display high levels of galectin-1 have worse prognoses than laryngeal cancers with low levels of galectin-1 expression. Elevation of galectin-1 levels in laryngeal cancers can contribute to the process of tumor immune escape by killing the activated T-cells and other protumoral activities such as promoting motility or activity of oncogenic H-Ras proteins. The quantitative determination of galectin-1 in LSCCs is an independent prognostic marker when opposed to TNM staging. It has the potential to identify patients unlikely to benefit from T-cell-mediated immunotherapy, although the definitive effector function from its pro- and antitumoral activity profile has not been delineated.

Proposal for revision of the European Laryngological Society classification of endoscopic cordectomies

A classification of laryngeal endoscopic cordectomies, which included eight different types, was first proposed by the European Laryngological Society in 2000. The purpose of this proposal of classification was an attempt to reach better consensus amongst clinicians and agree on uniformity in reporting the extent and depth of resection of cordectomy procedures, to allow relevant comparisons within the literature when presenting/publishing the results of surgery, and to recommend the use of guidelines to allow for reproducibility amongst practicing laryngologists. A total of 24 article citations of this classification have been found through the science citation index, as well as 3 book chapters on larynx cancer surgery, confirming its acceptance. However, on reflection, and with the passage of time, lesions originating at the anterior commissure have not been clearly described and, for that reason, a new endoscopic cordectomy (type VI) for cancers of the anterior commissure, which have extended or not to one or both of the vocal folds, without infiltration of the thyroid cartilage is now being proposed by the European Laryngological Society Committee on Nomenclature to revise and complete the initially reported classification.

Respiratory epithelial adenomatoid hamartomas of the sinonasal tract

We report the clinicopathologic features of two cases of respiratory epithelial adenomatoid harmartoma (REAH) of the sinonasal tract. Hamartomas are rare in the nasal cavity. Histologically, these lesions were characterized by a glandular proliferation lined by ciliated respiratory epithelium originated from the surface epithelium. The two patients were evaluated by a gastroenterologist to assess intestine colocalization. The treatment was a complete surgical resection through limited approach. We should be aware of this entity as a differential diagnosis for inverted papilloma and well-differenciated adenocarcinoma. Fine histopathological analysis is necessary to avoid aggressive surgery for this benign lesion.

[Organ preservation surgery in pharyngolaryngeal cancer]

Organ preservation surgery is a reasonable name for these types of techniques because it accurately describes the postoperative outcome, which is preservation of the quintessential laryngeal functions: swallowing, respiration without a permanent stoma and speech. In response to the common use of total laryngectomy, the non-surgical approaches have often been referred to as organ preservation strategies. In many institutions, it appears that there are organ preservation strategies and then there is surgery. In our opinion there are both non surgical organ preservation strategies and surgical organ preservation strategies. The key is that in both approaches the goal is to spare the functions of the larynx. In both, the work-ups are very important to analyse 3-dimensional extent of the lesion by nasofibroscopy (laryngeal mobilities), endoscopy and radiology. Organ preservation surgical approach allowed to save the use of radiotherapy for the management of various metachronous second primary tumours.

Galectin 7 (p53-Induced Gene 1): A New Prognostic Predictor of Recurrence and Survival in Stage IV Hypopharyngeal Cancer

BACKGROUND

Eighty percent of hypopharyngeal squamous cell carcinoma patients have advanced stages (III and IV) of the disease, and biological markers are required to predict high-risk head and neck squamous cell carcinoma patients in need of highly aggressive treatments after surgery to improve the survival rate. We analyzed the potential prognostic value of galectin 7 in a series of 81 stage IV hypopharyngeal SCCs because galectin 7 is an emerging marker involved in the epidermal development of pluristratified epithelia and in epidermal cell migration.

METHODS

The immunohistochemical expression of galectin 7 was determined on a series of 81 stage IV hypopharyngeal SCCs and was compared with that of galectins 1 and 3.

RESULTS

High levels of galectin 7 expression were associated with rapid recurrence rates and dismal prognoses in these 81 stage IV hypopharyngeal SCCs, a feature not observed with galectin 3 and one observed weakly, if at all, with galectin 1.

CONCLUSIONS

These data suggest that the immunohistochemical determination of galectin 7 expression in the case of high-risk hypopharyngeal cancers is a meaningful tool to identify patients who should benefit from aggressive postsurgical adjuvant therapy after surgery, including not only radiotherapy, but also chemotherapy.

Local recurrence after CO2 laser cordectomy for early glottic carcinoma

OBJECTIVES

To point out prognosis factors of local recurrence after endoscopic cordectomies for Tis, T1a, T1b, and T2 glottic squamous cell carcinomas.

STUDY DESIGN

A cohort of 110 patients treated from January 1990 to December 2000 at a single institution was retrospectively analyzed: 21 had Tis, 76 T1a, 7 T1b, and 6 T2 (mean follow-up 42 mo; range 1-160 mo).

METHODS

The depth and extension of the excision were graded according to the European Laryngological Society Classification. Univariate analysis was used to review the impact on disease-free survival of factors related to the host, the tumor, and the treatment.

RESULTS

According to the Kaplan-Meier method, the 5 year overall survival and the disease-free survival were 87% and 75%, respectively. The rates of cause-specific survival, ultimate local control with laser alone, and laryngeal preservation were 97%, 84%, and 90%, respectively. Univariate analysis by the log rank test revealed that vocal muscle infiltration (P = .001) and subglottic involvement (P = .02) have a significant impact on disease-free survival. Of the 22 patients with local recurrence (17 T1a, 1 T1b, and 4 T2), 9 were managed with total laryngectomy, 5 with partial laryngectomy, 4 with further laser cordectomy, 2 with radiotherapy, and 2 had no curative treatment.

CONCLUSION

Transoral laser surgery for early glottic carcinoma is a valid alternative to radiotherapy and partial laryngectomy in terms of oncologic results. It offers low morbidity and excellent retreatment options in case of local failure. Careful patient selection for laser surgery is essential to secure good results.

Clinical outcome in patients with high-grade internal carotid artery stenosis after irradiation

The authors followed up 41 consecutive patients (21 symptomatic) with internal carotid artery stenosis > or =70% and previous neck irradiation. After 28 months, 15 patients (36.6%) had died, five (12.2%) had had an ischemic stroke, and 15 (36.6%) had a new malignancy. Having a new malignancy was the only independent predictor of death. The major risk for patients with ICA stenosis > or =70% and previous neck irradiation is malignancy, not stroke.

Évolution périopératoire du statut nutritionnel en chirurgie carcinologique des voies aérodigestives supérieures. Étude prospective et descriptive

AIM OF THE STUDY

To assess the perioperative evolution of the nutritional status of head and neck surgical patients.

DESIGN

Prospective, descriptive case series.

PATIENTS AND METHODS

Fifty-four patients candidates for total or partial laryngectomy for malignancy of the neck tract without a past of neck surgery. The nutritional status of all patients hospitalized for total pharyngolaryngectomy, total or partial laryngectomy was assessed by 1) clinical parameters including weight (W), weight variation (WV, percentage of loss), Body Mass Index (BMI), triceps skin fold measurement (T), midarm circumference (M), and 2) biological parameters such as serum albumin (SA), transthyretin (TTR), lymphocytes (Ly). These parameters were noted at the time of diagnostic laryngoscopy (T1), the day before surgery (T2), and 10 days afterward (T3) when patients were authorized to eat normally. All patients had enteral nutrition (EN) support (35 kcal/kg/day) starting at D1 and for 10 days afterward. Only complete data per patient were analyzed.

RESULTS

24 patients were excluded. During the 21 days [7-53] preoperative period (T1-T2), WV was (6.6% [-8,1-+20.0] [T2] vs. 4.7% [-12,9-+20.0] [T1], p<0.05) without difference in T and M. In the postoperative period (T2-T3), all parameters worsened, except T, with: WV (8.2% [-8,1-+20.0] [T3], p<0.05 vs T2), M (27.4 cm [20.0-37.0] [T3] vs 28.3 cm [20.5-39.0] [T2], p<0.05) et TTR (0.21 mg/l [0.09-0.36] [T3] vs. 0.27 mg/l [0.08-0.45] [T2], p<0.05). BMI was 22.9 [15.2-36.7] (T1) vs 22.9 [15.2-35.3] (T2), NS and 22.1 [15.0-34.9] (T3), p<0.05 vs (T2).

CONCLUSION

The nutritional status in malignancy head and neck surgical patients seems to be best assessed by loss weight. It worsened mainly during the postoperative period even if a well-conducted EN was performed as defined by the French consensus conference.

Sub-cellular distribution of endothelin signaling pathway components in ventricular myocytes and heart: lack of preformed caveolar signalosomes

Stimulation of endothelin receptors (ETRs) leads to activation of the extracellular signal-regulated protein kinase (ERK) cascade. It is unclear whether compartmentalization to lipid rafts is necessary for proper endothelin signaling, as methodologies employed to isolate and study caveolae involve detergent extraction, which may induce aggregation of membrane-associated proteins. The present study was to determine if components of the endothelin-1 (ET-1) pathway leading to ERK activation localize to caveolae and constitute preformed signalosomes. Microsomes were prepared from intact ventricular myocardium, in the absence of detergents, and fractionated by differential and sucrose-density gradient centrifugation to determine if caveolins and components of the ETRs post-receptor signaling cascade were in vesicles having similar physical properties. Confocal fluorescence microscopy, followed by digital deconvolution, was employed to determine if the signaling proteins colocalized with caveolin within intact, freshly isolated adult myocytes. With the exception of ET(A)Rs, proteins from the ET-1 pathway copurified in part or entirely (Galpha(11)), with caveolin-1 and caveolin-3. In contrast, with the exception of Galpha(q/11), Galpha(i3) and Gbeta G-protein subunits, most of the proteins studied showed little colocalization with caveolin-3. Thus, although components of the ET-1 signaling pathway may exist in vesicles having similar characteristics to vesicles containing caveolin, these proteins did not associate with caveolae in intact myocytes. The lack of detectable colocalization of caveolin-3 with proteins within the endothelin post-receptor signaling system in intact myocytes argues against the presence of a preformed, caveolae-associated signalosome.

Histologic structure and development of the laryngeal macula flava

The laryngeal maculae flavae (MF) have been previously described as cellular condensations at the extremities of the vocal cords, but the exact nature and role of the MF are unknown. The purpose of this study is a histomorphological analysis of the nature and development of the MF in human vocal cords, from the beginning of fetal life to adulthood. Eighty-six larynges, from the fetus at 12 weeks of amenorrhea (WA) to adulthood, were collected from autopsies and studied by light microscopy with hematoxylin and eosin, orcein, and Alcian blue staining and pS 100 immunostaining. Our observations allowed us to separate the fetal development of the MF into 4 periods. The first corresponds to the appearance of the posterior MF between 13 and 15 WA. In the second period, the anterior MF appeared between 16 and 18 WA, allowing definition of the intermacular space. Fibrous structures, composed of collagen and elastic fibers, of the MF and intermacular space developed between 20 and 33 WA. The last period, from 33 WA to birth, corresponded to a maturation of these structures. In adults, the histologic structure of the MF presented a concentric peripheral fibrous layer associated with a central cellular component. Structural analysis of the MF concludes in favor of the chondroid nature of the macular cell. These observations bring into question the current knowledge on the MF. From these observations, the role of the MF in the developing vocal cord is discussed.