Recurrence and its avoidance in juvenile angiofibroma

Case studies in the surgical management of pediatric nasal airway obstruction

The authors present two case studies on pediatric nasal obstruction that highlight the consequences of a delayed diagnosis and the complexities of managing obstructed lesions in children.

[Safe extirpating of AFJ after preoperative tumor obliteration with tissue adhesive glue]

The purpose of this work is to present the method of operating juvenile nasopharyngeal angiofibroma with the use of preoperative obliteration with tissue adhesive glue (Histoacryl). Authors described the case of 15 years old patient, who was admitted to ENT Department because of epistaxis, nasal obturation and returning headaches. To explain this problem, the routine diagnostics CT and angio-CT scan was applicated. Angiography confirmed well vascularized tumor supplied from facial and palatine arteries. Therapy based on the obliteration of tumor vessels with the glue-tissue was applied. As the next step the tumour was surgically extirpated. The application of this method gave a very good, simply bloodless operation effects. It allows a very good, simple and fully precise tumor extirpation. The extirpation of AFJ which is a highly vascularized tumor with the previous obliteration of the supplying vessels is a safe procedure and results in complete removal of the tumour.

Juvenile Nasopharyngeal Angiofibroma: Spontaneous Resolution

Juvenile nasopharyngeal angiofibroma is a rare, benign tumor that occurs most often in adolescent males. Common practice is to excise the tumor with open or endoscopic surgery. We report the case of a 17-year-old male who presented in 1995 with a mass filling the left posterior nasal cavity. A diagnosis of juvenile nasopharyngeal angiofibroma was obtained with computed tomography and magnetic resonance imaging. The patient elected to have no treatment. On annual scans, the lesion changed little until 1998, when it began to gradually decrease in size. Although it is not well proven, the natural history of these tumors seems to be regression over time. This case supports the argument that a policy of watchful waiting with regular imaging studies may postpone or eliminate the need for surgery and its attendant risks.

[Transpalatal approach for juvenile angiofibroma]

INTRODUCTION

Juvenile nasopharyngeal angiofibromas (JNA) are highly vascular, locally invasive tumours which originate in the sphenopalatine foramen. Several surgical approaches are described for this tumour. The aim of this study was to evaluate the transpalatal approach for juvenile angiofibroma.

MATERIAL AND METHODS

In a group of 22 patients with JNA transpalatal approach was employed. A retrospective patients notes review was done. Extension of tumour, complications of surgery and recurrences were analyzed.

RESULTS

In 17 patients the tumour was confined to the nasal cavity and the nasopharynx. In 5 patients the tumour invaded the sphenoid sinus. No complications were observed after surgery. Two (9%) patients had recurrence.

CONCLUSION

Transpalatal approach is best suited to small tumours (Andrews grade I and II) limited to the nasopharynx, nasal cavity and sphenoid sinus.

Genetic alterations in juvenile nasopharyngeal angiofibromas

Juvenile nasopharyngeal angiofibroma (JNA) is a rare benign neoplasm of the nasopharynx that accounts for 0.5% of all head and neck tumors. Although histologically benign in appearance, JNAs are locally aggressive and destructive, spreading from the nasal cavity to the nasopharynx, paranasal sinuses, and orbit skull base with intracranial extension. The gender selectivity of JNA and the relatively young age at diagnosis suggest hormone-dependent development. Hormonal disorders have been reported in patients with JNA, and androgen and estrogen receptors have been identified in tumor tissue; however, a hormonal influence on JNA is controversial. Recent studies have attempted to further delineate the pathogenesis of JNA through analysis of genetic and molecular changes. Understanding of the molecular mechanisms involved in JNA might improve prevention, prognosis, and treatment of this tumor. In this review, we discuss published studies addressing the possible molecular pathways that might be involved in the development of JNA.

Juvenile nasopharyngeal angiofibroma: Evaluation and surgical management of advanced disease

Objective

Evaluate preoperative imaging in predicting operative stage. Describe the outcomes in surgically treated juvenile nasopharyngeal angiofibroma (JNA) with the influence of middle cranial fossa, carotid, or dural involvement on recurrence.

Study Design

Retrospective cohort of surgically treated patients with JNA.

Subjects and Methods

Eighty-five patients from a regional Italian referral center were assessed for recurrence, radiologic, and operative staging. High risk areas involved were recorded at surgery.

Results

Recurrence for advanced disease (IIIb+) was 18.2% (6 of 33) and 15.3% (13 of 85) overall. Preoperative staging poorly correlated with operative stage ( P = 0.15). No single high risk area was predictive for recurrence, but the absence of any risk factor was associated with a favorable outcome ( P < 0.01).

Conclusion

Dural involvement by tumor is rare and imaging may overstage disease. Anterior access, endoscopic or open, is sufficient to address intracranial involvement. When an open approach is used, a midface degloving technique affords excellent exposure even for advanced disease. Lateral approaches with their associated morbidity can be reserved for selected recurrent disease.

MANAGEMENT OF INVASIVE JUVENILE NASOPHARYNGEAL ANGIOFIBROMAS

OBJECTIVE

Juvenile nasopharyngeal angiofibromas involving the cranial base and intracranial compartment are challenging tumors. We reviewed our experience of these tumors and analyzed the efficacy of a multimodality management.

METHODS

Between 1981 and 2000, 15 extensive juvenile nasopharyngeal angiofibromas (Fisch Grade III or IV) were treated at our institution. The mean age of the patients was 14.5 years, and the mean interval between the first symptom and diagnosis was 12.9 months. Initial management included preoperative embolization of the external carotid artery feeders, followed by tumor removal. A maxillofacial procedure was performed in eight cases, a combination of maxillofacial and neurosurgical approach was performed in four cases, and a neurosurgical cranial base approach was performed in three cases.

RESULTS

Total removal after the initial procedure was obtained in eight patients. Subtotal removal justified additional surgery in one case, gamma knife radiosurgery in two cases, and fractionated irradiation in four cases. True recurrences were observed in four cases at a mean interval of 37 months (range, 24–46 mo) and required tailored multimodality management. No cases of perioperative death were observed. One patient underwent hemiparesis after embolization in the early period of our experience. Permanent facial numbness was reported in four cases, moderate cosmetic problems were reported in three cases, and hyposmia was reported in three cases. Except for one patient who was lost to follow-up at 18 months, 12 patients were free of disease and two patients were free of tumor progression. All patients had normal or near-normal daily life at the last check-up, with a median follow-up period of 108 months (mean, 117 mo; range, 91–252 mo).

CONCLUSION

Extensive juvenile nasopharyngeal angiofibromas are efficiently managed with a multimodal protocol in which preoperative embolization is followed by optimal surgical removal using various transcranial or transfacial approaches. Adjunctive gamma knife radiosurgery is a valuable option for intracavernous residual tumor. Our protocol offers long-term cure with acceptable morbidity.

[Angiographic evaluation and embolization of juvenile nasopharyngeal angiofibroma]

OBJECTIVE

In juvenile nasopharyngeal angiofibroma (JNA), analysis of tumor extension and blood supply is useful for controlling intraoperative bleeding and helps in determining the appropriate surgical approach. The purpose of this study was to evaluate angiographic findings and the efficacy and benefits of preoperative embolization of JNA.

PATIENTS AND METHODS

Twenty-one male patients with JNA (mean age 13.3 years) were included in this study. The tumors were embolized with particles of gel foam. Surgical removal was achieved through transantral approach (n=2), lateral rhinotomy (n=13), midfacial degloving (n=4), and endonasally (n=2).

RESULTS

The blood supply was exclusively homolateral in 18 patients, deriving mainly from the external carotid artery, and bilateral in three. There were no connections between the branches of the internal and external carotid arteries. Intratumoral embolization was achieved in all patients. No major complications occurred. Mean blood loss during surgery was 560 ml. The recurrence rate was 14%.

CONCLUSION

Preoperative angiographic evaluation and embolization of JNA are important tools for planning surgical approach. Embolization reduces significantly the intraoperative blood loss, minimizes the need of blood transfusion, and makes resection easier.

An audit of nasopharyngeal fibromas

BACKGROUND

Nasopharyngeal angiofibroma (NA) is a vascular tumor of the nasopharynx of young males which presents rarely. Our aim was to analyse outcome and prognostic factors of a case series of NA.

MATERIALS AND METHODS

We conducted a retrospective study of patients with diagnosis of NA treated at a single institution from 1981 to 2003. We evaluated clinical, radiological and therapeutic data for recurrence- and disease-free survival-associated prognostic factors. Bi- and multivariate analyses were performed.

RESULTS

Fifty-four males with NA constitute our study group. Age varied from 12 to 35 years (mean, 18.5 years; standard deviation [SD], 4.9). There were 18 recurrences; localization in nasopharynx, nasal fossae or maxillary antrum was not associated with recurrences. Invasion to pterygomaxillary fossae, to infratemporal fossae or to skull base and/or intracranial extension were associated with recurrences in two of 14, in five of 12, and in 11 of 18 cases, respectively. Tumors < or >or=6 cm were associated with zero and with 18 recurrences, respectively (p<0.01). Multivariate analyses conferred statistical significance (p<0.01) to a model including patterns of extension, tumor size in pterygomaxillary or anterior infratemporal fossa invasion, and surgical margins.

CONCLUSION

Recurrence factors for NA are defined and consequently treatment design is suggested. Endoscopic approaches could be considered in patients with minor lateral extensions, while wide surgical approaches are indicated in invasive cases. Radiotherapy could be applied alone or combined with surgery for extensive intracranial involvement.

Endoscopic sinus surgery for the treatment of vascular tumors

BACKGROUND

This study points out the effectiveness of the endoscopic approach for the treatment of vascular lesions such as angiofibroma, hemangioma, and hemangiopericytoma involving the nose and paranasal sinuses.

METHODS

We performed a retrospective study at an academic tertiary referral center. Thirteen patients, diagnosed with vascular tumors of the nose and paranasal sinuses were treated endoscopically between February 1996 and July 2003. All patients underwent endonasal endoscopic surgery. Preoperative angiography with embolization was performed in all but two cases.

RESULTS

The follow-up of this series varied from 6 to 75 months (mean, 23 months); only one recurrence (8%) was observed in the juvenile angiofibroma group encountered 20 months postoperatively. This recurrence was again treated endoscopically. The average intraoperative blood loss for the removal of the juvenile angiofibroma group was 300 mL and it was 100 mL for the other vascular tumors.

CONCLUSION

Endoscopic treatment alone is an effective approach for the removal of selected cases of vascular tumors. Even in the presence of a lesion with limited intracranial extension, the tumor still may be amenable to an endoscopic approach alone. On the contrary, this is not true if the intracranial extension receives feeding vessels from the internal carotid arterial system.

Management Dilemmas in the Treatment and Follow-Up of Advanced Juvenile Nasopharyngeal Angiofibroma

Advanced juvenile nasopharyngeal angiofibroma (JNA) (i.e. disease with intracranial extension) is reportedly uncommon. The optimum management form of such a clinical situation currently remains controversial. This review, of the recent English published literature, discusses the common JNA classification systems advocated, shows the advantages and disadvantages of surgical approaches used (both open, endoscopic or combined), and re-evaluates the current role of radiotherapy (for initial management or treatment of residual/recurrent disease). We also discuss the typical presentation of these patients, the role of pre-operative embolization, as well as surgical techniques to minimize recurrence, and advocate a post-treatment follow-up protocol.

Staging and surgical approaches in large juvenile angiofibroma--study of 95 cases

INTRODUCTION

Surgery has been the treatment of choice for juvenile nasopharyngeal angiofibroma (JNA) and selection of proper surgical approach depends primarily upon the extensions of the tumor. Minimal external deformity/surgical scar without affecting growth pattern of facial skeleton of patient along with extensions of JNA were the basis of selecting surgical approach in present study.

MATERIAL AND METHODS

The medical records of 95 patients with histologically proven large JNA who underwent treatment in our institution between 1992 and 2002 were reviewed retrospectively. Inclusion criterion-Stage II, III, IV JNA, minimum available follow up of 2 years. Exclusion criterion-Stage I JNA, follow up of less than 2 years. Lazy S incision was used and combined transmaxillary and transpalatal removal of angiofibroma was done in most of the cases.

RESULTS

Complete removal of JNA was achieved in 78 (82%) cases in single surgery. Residual tumor was found in 17 (18%) cases.

CONCLUSIONS

Infratemporal, pterygopalatine, orbital and intracranial extensions of JNA (Stage IIIa and IIIb) can be removed by combined transpalatal and transmaxillary approach by Lazy S incision without producing any facial asymmetry or cosmetic defect. Conservative lateral infratemporal approach (type D1 approach) is required in very large lateral extensions or where JNA is extending intracranially through foramen ovale. Staged fronto-temporal craniotomy should be done in Stage IVa tumors (large intracranial extensions). In Stage IVb tumors (invading cavernous sinus), usually residual tumor remains which should be followed subsequently.

Surgical approaches for nasopharyngeal angiofibroma: comparative analysis and current trends

This study presents a comparative analysis of current surgical approaches for the treatment of nasopharyngeal angiofibroma, including extension of tumors, postoperative morbidity, complications, and recurrence rate. Twenty-four patients who underwent surgery with the diagnosis of juvenile nasopharyngeal angiofibroma at our department between 1993 and 2003 were retrospectively reviewed according to their clinical presentation, surgical approaches, and prognosis. Radkowski staging scale was used for staging tumors. The transpalatal approach was used in 10 patients before 1999 with tumor stages between Ia and IIa. Transpalatal fistula was encountered in one. Nine patients underwent transnasal endoscopic surgery after 1999 with tumor stages between Ia and IIIa. Lateral rhinotomy in four patients and a degloving approach in one patient were used with tumor stages between IIa and IIIa; postoperative nasal crusting was the most annoying problem in these groups. Recurrent tumor was seen in only one patient who had undergone the transpalatal approach in the 12- to 56-month follow-up period. In this regard, the transnasal endoscopic approach can be used successfully in place of the transpalatal approach due to the former's lesser surgical morbidity and wide lateral exposure of the field in patients with nasopharyngeal angiofibroma. Also, many patients who underwent lateral rhinotomy for the removal of stage IIa, IIb, and IIIa tumors can successfully be treated using the transnasal endoscopic approach. In tumors that extend, infratemporal fossa lateral rhinotomy and degloving approaches provide the optimal exposure but have higher potential for morbidity than does transnasal endoscopic surgery.

Endoscopic surgery for juvenile nasopharyngeal angiofibroma: where are the limits?

PURPOSE OF REVIEW

This article will examine recent publications on the endoscopic management of juvenile nasopharyngeal angiofibromas.

RECENT FINDINGS

The use of an endoscopic approach to resect small juvenile nasopharyngeal angiofibromas is supported by excellent results from a number of operative series published in recent years. Large juvenile nasopharyngeal angiofibromas continue to present a considerable surgical challenge, with most being resected by traditional open approaches. However, the results achieved after the endoscopic resection of large tumours have been reported for a small number of cases. This review focuses on the outcome of these cases, which would seem to compare favourably to open series, and the advances in instrumentation and techniques, that facilitate the endoscopic removal of large juvenile nasopharyngeal angiofibromas.

SUMMARY

Improvements in preoperative assessment and preparation, operative technique, and instrumentation potentially enable the endoscopic removal of most juvenile nasopharyngeal angiofibromas.

Proliferation, angiogenesis and hormonal markers in juvenile nasopharyngeal angiofibroma

OBJECTIVES

Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular and locally invasive tumor that exclusively affects male adolescents. Sex hormones are first discussed to clarify the etiology of JNA. Recently with the advances in the field of cell biology angiogenetic markers, proliferation markers and growth factors are investigated to identify the molecular basis of JNA as all neoplasm. In this study we tried to evaluate the expression of proliferation, angiogenesis and hormonal markers in JNA.

METHODS

Immunohistochemical analysis were performed on paraffin-embedded 27 JNA samples which were obtained from the patients operated at University of Hacettepe Department of Otorhinolaryngology, a tertiary care center. Estrogen receptor (ER), progesterone receptor (PR), proliferating cell nuclear antigen (PCNA), vascular endothelial growth factor (VEGF) and transforming growth factor beta (TGF-beta) specific antibodies were used and evaluated by light microscopy

RESULTS

Two of 27 cases were ER positive. Nine of 27 cases were positive for PR. All of the cases were stained with PCNA. Twenty-four of 27 cases stained with VEGF. TGF-beta was positive in 14 of 27 cases. All recurrent cases were stained with PCNA and VEGF; just three of them were stained with TGF-beta.

CONCLUSIONS

Hormonal markers ER and PR did not seem to play a role in pathogenesis of JNA. PCNA, VEGF and TGF-beta may play a role in the pathogenesis of JNA by promoting angiogenesis and proliferation, but this role did not seem to have a relation with hormonal markers.

Endoscopic versus Traditional Approaches for Excision of Juvenile Nasopharyngeal Angiofibroma

OBJECTIVES

Juvenile nasopharyngeal angiofibroma (JNA) is an uncommon neoplasm originating in the nasopharynx. The purpose of this study was to determine whether endoscopic approaches had been effective without increasing intraoperative blood loss, length of hospital stay, complications, and rate of recurrence as compared with traditional surgical approaches.

STUDY DESIGN

Retrospective chart review to compare outcomes in six consecutive patients who underwent endoscopic resection with outcomes of traditional external excision of JNA at Mayo Clinic between 1975 and 2004.

METHODS

The medical records of patients who underwent either endoscopic or external surgical resection of JNA were reviewed retrospectively. The main outcome measures were intraoperative blood loss, length of hospital stay, complications, and recurrence. We review the reasons why we developed our current endoscopic approach to resection and highlight some of the obstacles we have encountered.

RESULTS

We identified 65 patients treated for JNA during the studied interval. Their mean age was 15 (range 6-35) years. Six consecutive patients underwent successful resection of JNA by way of an endoscopic approach since 2001. Compared with the conventional surgery group, the endoscopic group had less intraoperative blood loss (225 vs. 1,250 mL), a lower occurrence of complications (1 patient vs. > or = 30 patients), shorter length of hospital stay (2 vs. 5 days), and lower rate of recurrence (0% vs. 24%).

CONCLUSION

Endoscopic removal of JNA tumor appears to be safe and effective. Recurrence was not appreciably affected by approach.

Angiofibroma: an outcome review of conventional surgical approaches

Juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor of the nasopharynx, and for its treatment, many surgical approaches have been recommended. However, selecting the appropriate one for the tumor in an advanced stage is still controversial. In this study, we evaluate the rate of recurrence of JNA and its relationship to the preoperative stage as well as various surgical approaches. Thirty-seven patients with pathologically proven JNA were retrospectively analyzed. For each patient, data were obtained regarding the primary extension, various surgical approaches and rate of recurrence. Seven patients were in stage III with intracranial extensions. Two of these patients had symptomatic recurrence that needed surgery. Three of them were disease free, and in two cases residues were demonstrated that were asymptomatic and were chosen only to be observed. Among different surgical approaches used, the transpalatal resulted in 1 recurrence out of 14 patients treated with this approach when the lesion was limited to the nasal cavity, nasopharynx and paranasal sinuses (stage I). No recurrence was observed with the use of this approach with lesions with minimal extension to the pterygopalatine fossa (stage IIA). But among three patients with intracranial extension who were treated with this approach, two resulted in symptomatic recurrence; however, using the Lefort I surgical technique, no evidence of recurrence was observed in the two patients in stage III who were treated with this approach. Involvement of the orbit, middle cranial fossa and base of the pterygoid by the primary JNA results in a higher incident of recurrent tumor. Among different surgical techniques, the lowest recurrence rate is seen either in the transpalatal approach when the tumor is limited to the nasopharynx with extension to the nasal cavity or paranasal sinuses or with the Lefort I approach when skull base invasion is present.

Orbital involvement in juvenile nasopharyngeal angiofibroma: prevalence and treatment

PURPOSE

To assess the prevalence of orbital invasion by juvenile nasoangiofibroma and to discuss its surgical treatment.

METHODS

A retrospective review of the medical records and tomographic scans of a case series of 19 patients with juvenile nasoangiofibroma was performed. All scans were reviewed by a radiologist and an orbital surgeon. The presence of the tumor was assessed in the pterygopalatine fossa, nasal cavity, nasopharynx, paranasal sinuses, inferior orbital fissure, orbit, and middle cranial fossa.

RESULTS

The most common structures invaded were pterygopalatine fossa (100%), nasal cavity (94.7%), sphenoid sinus (84.2%), and nasopharynx (73.7%). The orbit was invaded in 6 (31.6%) patients. In 5 of these patients, the tumor extended in the orbit through the inferior orbital fissure. Four patients with orbital invasion were successfully operated with the Le Fort I approach.

CONCLUSIONS

Orbital involvement is relatively common in the setting of juvenile nasoangiofibroma extension. The main route of orbital invasion is the inferior orbital fissure. The Le Fort I osteotomy is an adequate approach for managing juvenile nasoangiofibroma when it invades the orbit.

Endoscopic surgery in treatment of juvenile nasopharyngeal angiofibroma

OBJECTIVES

Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular and locally invasive tumor with a high incidence of persistence and recurrence. The classical treatment of this tumor is surgery and/or radiotherapy. Use of endoscopic techniques seems to be on the rise in treatment of these lesions. We tried to explore the roles and limits of endoscopic surgery alone or with classical surgical techniques in treatment of these tumors.

METHODS

Retrospective case review was conducted at a tertiary referral center. Twelve patients were treated for nasopharyngeal angiofibroma using endoscopic approach between 1998-2002. The staging, average blood loss during surgery, residual, and/or recurrent tumor were evaluated.

RESULTS

Eight of these patients (8/12) were up to stage IIC according to Radkowski staging. This group of patients has an average blood loss of 1000 ml and were followed for at least 6 months. We did not encounter any residual or recurrent tumor in this group. Four patients (4/12) had minimal intracranial extension, were staged IIIA, and had an average blood loss of 1500 ml during surgery. Two of these patients had minimal residual tumor around the cavernous sinus, but showed no progression of disease over a follow-up of 2 years with MRI. Two patients had no residual or recurrent tumor over a follow-up of 6 months.

CONCLUSION

This data suggests that endoscopic surgery can be used in the treatment of JNA even with minimal intracranial extension with minimal morbidity and low recurrence rate.

Endoscopic surgery for juvenile angiofibroma: when and how

OBJECTIVES/HYPOTHESIS

In recent years, the indications for endoscopic surgery of the sinonasal tract, originally introduced for the treatment of inflammatory diseases, have been expanded to include selected cases of benign and malignant neoplastic lesions. The aim of the present study was to establish the efficacy of endoscopic surgery in the management of small and intermediate-sized juvenile angiofibromas.

STUDY DESIGN

Retrospective study.

METHODS

We reviewed the clinical records and the preoperative and postoperative imaging studies of 15 patients with juvenile angiofibroma who were treated with an endoscopic approach after embolization in the period from January 1994 to April 2000. All patients were prospectively followed by endoscopic and magnetic resonance imaging evaluations performed at regular intervals (every 4 months during the first year and, subsequently, every 6 months).

RESULTS

According to a staging system reported in 1989, there were two patients with a type I, nine with a type II, three with a type IIIA, and one with a type IIIB juvenile angiofibroma. Angiography demonstrated that the vascular supply was strictly unilateral in 11 patients and bilateral in 4. Intraoperative blood loss ranged from 80 to 600 mL (mean blood loss, 372 mL). During follow-up (range, 24-93 mo; mean follow-up, 50 mo [SD +/- 19.9 mo]), only one patient presented a residual lesion on magnetic resonance imaging, which was 16 mm in diameter and was detected 24 months after surgery.

CONCLUSIONS

The endoscopic approach is a safe and effective technique that allows removal of small and intermediate-sized juvenile angiofibromas (without extensive involvement of the infratemporal fossa and cavernous sinus) with a low morbidity. Advanced lesions are more appropriately treated by external approaches.

Relaxation of imprinting of IGFII gene in juvenile nasopharyngeal angiofibromas

IGFII and H19 genes are expressed only from one allele due to genomic imprinting, biallelic expression (loss of imprinting) being associated with the tumorigenic process of different types of tumors. The mechanism responsible for genomic imprinting is not yet determined, although DNA methylation has been considered the main genetic event for an imprinted mark. In the current study, the authors analyzed the imprinting status and expression levels of the IGFII and H19 genes in 27 cases of Juvenile Nasopharyngeal Angiofibroma (JNA) using RFLPs, RT-PCR, and Southern and Northern Blots. The authors found that four out of eight informative cases (50%) for ApaI/IFGII polymorphism showed biallelic expression of IFGII whereas none of the nine informative cases for the polymorphism showed biallelic expression of the H19 gene. Overexpression of IFGII was observed in 8 out of 22 cases (36.4%), and 7 out of 19 cases (36.8%) showed H19 overexpression. Hypomethylation was found only in the H19 gene in six out of eight cases analyzed. Therefore, our results demonstrate that alterations in the IFGII/H19 imprinted region occur in JNA.

Juvenile nasopharyngeal angiofibromas: A study of recurrence pattern and role of pre-Operative embolization - 'a decade'S experience'

This study is a retrospective analysis of 30 consecutive cases of Juvenile Nasopharyngeal Angiofibroma (JXA) operated at. Department of Head and Neck Surgery, Kidwai Memorial Institute of Oncology Bangalore, India: la tertiary referral centre) after prior emohilization by an interventional neuro-radiologisl (1996-2002). This study discusses critically the planning of surgical approach, based on anatomico-radiological factors and highlights the efficacy of preoperalive embolization in expediting total re moral of the tumor in 25 out of JO cases with advanced stage JNA.

OBJECTIVES

To analyze the utility of pre-operatire embolisation in surgical extirpation of large JNAs; planning of the surgical approaches based on CT topography of the tumor; to study the various complications of embolisation and surgery associated with JXA & lastly to evaluate the puttern and location of recurrent tumor thus correlating with the original topography.

SETTING

Tertiary care cancer referral centre.

PATIENTS

PATIENTS ranged in age from ')- 24 years. all being males.

INTERVENTIONS

Majority of them were accessed by transfacial surgical approach(26). and in the recent past via midfacial degloving(4) within 4H hours of angioembolisation.

RESULTS

Complete removal of the tumor was achieved in 25 out of 30 cases with advanced stage JNA.Post surgical CT scans revealed tumor residua in 5 individuals, where the tumor was documented in - the temporal fossa 12), para-cavernous sinus region (I), cavernous sinus! I) and pterygo palatine fossa (I). Only the lesion in pterygopalaline fossa was successfully re-i>xcised & this alongwith the recurrence at para-cavernous & cavernous sinus & another were treated with radiotherapy; the 2 cases in the temporal fossa are under observation. The average blood loss during the procedure was 546.60 ml.

CONCLUSIONS

Today, advances in radiologie imaging-complemented by interventional neuro-radiological expertise in angio-embolisation have expedited complète excision with minimal morbidity and acceptable recurrence rate. This study has justified pre-operative embolisation and M currently the standard of care for advanced JXA.