Combined endoscopic and transoral resection of a high-staged juvenile nasopharyngeal angiofibroma: A pictorial essay

Juvenile Nasopharyngeal Angiofibroma: A Series of 96 Surgical Cases

Introduction  Juvenile nasopharyngeal angiofibroma (JNA) is a benign vascularized tumor that affects almost exclusively male adolescents. Surgery is the treatment of choice for JNA. Objectives  The present study is a 42-year retrospective review of a series of JNA cases treated surgically without previous embolization. Methods  The present is a retrospective, descriptive study based on medical records of 96 patients with JNA who underwent microscopic or endoscopic excision without previous embolization from 1978 to 2020 in a single institution. The patients were categorized according to the Andrews et al. stage, and data were collected on age, gender, tumor staging, surgical approach, affected side, and outcome. Results  All patients were male, with an average age of 17 years. The predominant tumor stage consisted of type II, with 52.1%. A total of 33.3% of the patients were submitted to the microscopic technique and 66.7%, to the endonasal technique. The rate of intraoperative blood transfusion was of 17.7%. Conclusion  The present study reinforces that resection of JNA in various stages is viable without previous artery embolization.

[Surgical approach of transnasal endoscopic resection of benign lesions in the paramedian lateral skull base]

Objective:To investigate the surgical approach of transnasal endoscopic resection of benign lesions in the paramedian lateral skull base. Methods:Retrospectively analyze 40 cases of the clinical data of patients with benign lesions of the skull base from August 2018 to February 2021 with transnasal endoscopic surgery, including 9 cases of cholesteatoma, 6 cases of hemangioma, 1 case of hemangiopericytoma, 6 cases of schwannoma, 15 cases of sphenoid sinus lateral crypt meningocele and cerebrospinal fluid leak, 3 cases of nasopharyngeal carcinoma bone inflammation after radiotherapy. All patients underwent transnasal endoscopic surgery, and different surgical approaches were selected according to the lesion location. Results:The total resection rate was 100% in 40 patients. One patient had cerebrospinal fluid rhinorrhea, which was cured after repair. During the follow-up period of 3-30 months, 39 patients had different degrees of numbness in the maxillary or mandibular region, and the numbness disappeared from 2 weeks to 6 months; one patient with schwannoma still had numbness on one side of the upper lip one year after surgery. Conclusion:Transnasal endoscopic resection of benign lesions in the paramedian skull base has a high surgical safety and cure rate. The surgical approach selection mainly focuses on the pterygoid process and extends to the periphery. The shortest and least damaging approach should be selected according to the lesion location, and the endoscopic approach should also be selected according to the surgeon's expertise.

Neural Crest Stem Cells in Juvenile Angiofibromas

The etiology of juvenile angiofibroma (JA) has been a controversial topic for more than 160 years. Numerous theories have been proposed to explain this rare benign neoplasm arising predominately in adolescent males, focusing mainly on either the vascular or fibrous component. To assess our hypothesis of JA’s being a malformation arising from neural crest cells/remnants of the first branchial arch plexus, we performed immunohistochemical analyses of neural crest stem cells (NCSC) and epithelial-mesenchymal transition (EMT) candidates. Immunoexpression of the NCSC marker CD271^p75 was observed in all investigated JA’s (n = 22), mainly around the pathological vessels. Close to CD271^p75-positive cells, high MMP3-staining was also observed. Additionally, from one JA with sufficient material, RT-qPCR identified differences in the expression pattern of PDGFRβ, MMP2 and MMP3 in MACS^®-separated CD271^p75positive vs. CD271^p75 negative cell fractions. Our results, together with the consideration of the literature, provide evidence that JA’s represent a malformation within the first branchial arch artery/plexus remnants deriving from NCSC. This theory would explain the typical site of tumor origin as well as the characteristic tumor blood supply, whereas the process of EMT provides an explanation for the vascular and fibrous tumor component.