[Morphology and histochemistry of lymphatic vessels of the upper aerodigestive tract: a clinically oriented study]

Sentinel lymph node biopsy in malignant melanoma of the head and neck

BACKGROUND

The aim of this retrospective study was to investigate sentinel lymph node biopsy in patients with head and neck melanoma.

MATERIALS AND METHODS

Patients who underwent SLNB between 2010 and 2016 were comprised. Epidemiological, radiological, and surgical data were collected and compared to histological findings. Patients who underwent primary complete lymph node dissection were excluded.

RESULTS

74 patients underwent SLNB during this period. The most common tumor localizations were the cheek (20.4%) and ears (20.4%). Overall, 256 sentinel lymph nodes (SLN) were detected and removed, most frequently in Robbins-levels IIA and IIB as well as in the surrounding of the parotid gland. 12.3% of the SLN showed a microscopic or macroscopic metastasis. In preoperative imaging all lymph nodes with macroscopic metastasis were described as suspect but only 4 of 11 lymph nodes with microscopic metastases were described as such.

CONCLUSIONS

SLNB is an especially good procedure for the diagnosis of microscopically metastases as disease status is an important diagnostic and prognostic factor in early-stage melanoma patients. However, due to the complex lymphatic system in head and neck melanoma, a short follow-up interval is necessary in order to prevent delayed diagnosis of a nodal recurrence due to a false-negative SLN.

Diversity of treatment of T2N0 glottic cancer of the larynx: lessons to learn from epidemiological cancer registry data

CONCLUSION

Neither elective selective neck dissection nor any conservative treatment option in pT2cN0 glottic cancer showed a significant advantage on survival. This should be the basis for future treatment standardization. Obligatory documentation of the R status and cause of death in the cancer registries will improve the data interpretation in the future.

OBJECTIVES

Optimal adjuvant treatment of pT2cN0 glottic cancer is not well defined. The impact of neck dissection or radio(chemo)therapy for better outcome is unknown.

METHODS

In a retrospective cancer registry study we analyzed the survival of 73 patients with pT2cN0 glottic cancer in Thuringia, Germany, treated surgically between 1996 and 2005.

RESULTS

In all, 35 patients had undergone elective neck dissection, the remaining 38 patients had not. Histopathology revealed occult lymph node metastasis in three patients. Adjuvant radiotherapy was delivered to 17 patients and radiochemotherapy to 4. Overall, 52 patients received an adjuvant treatment. The 5-year recurrence-free survival rate was 60.8% and the 5-year overall survival rate was 56.5%. Multivariate but not univariate analysis revealed age >62 years (p = 0.05) and neck dissection (p = 0.033) as significant negative risk factors for tumor recurrence. Looking at overall survival, the site of primary surgery and radiotherapy were significant univariate risk factors, whereas multivariate analysis did not reveal any independent risk factor. No adjuvant treatment or combinations of adjuvant treatment resulted in better recurrence-free or overall survival (p = 0.253; p = 0.279).

[Functional anatomy of the larynx from clinical points of view: part II: Laryngeal mucous membrane, blood supply, innervation, lymphatic drainage, age-related changes]

Diseases of the larynx are of concern not only for ear, nose, and throat physicians and phoniatricians but also for other clinicians who treat the larynx either conservatively or surgically, including speech therapists, pediatricians, anesthetists, oncologists, pulmonologists, radiologists, and general practitioners. Based on today's state of knowledge and taking into account our own research results of the last years as well as clinical points of view, the present contribution gives a short overview of the anatomy and physiology of the larynx. Part 2 discusses the functional anatomy of the laryngeal mucous membrane (glycoconjugates, mucins, trefoil factor family peptides, antimicrobial substances, larynx-associated lymphoid tissue), the vascular supply, innervation, and lymphatic drainage, as well as age-related laryngeal changes and their effects on swallowing, breathing, and phonation.

Anatomical definition of the subglottic region

BACKGROUND

Due to laryngeal neoplasia, as well as infectious and autoimmune diseases, the subglottic region is of great clinical relevance. However, descriptions of the subglottic structures are inconsistent. The aim of our study was to present a precise analysis of the subglottic region and derive functional and clinical conclusions.

METHODS

Histological, histochemical and immunohistochemical investigations as well as scanning electron microscopy were performed and combined with injection techniques applied to the subglottic region of the larynges of 33 body donors.

RESULTS

The three-dimensional extensions of the subglottic region were newly defined: the inferior arcuate line of the vocal cord was defined as the cranial border. The lower margin of the cricoid is the caudal border. Craniolaterally, the elastic cone and, further caudally, the cricoid form the border. Therefore, the definition presented comprises heretofore unnamed ventral and dorsal parts of the lower larynx. The subglottic region can be described as cylindrical, becoming smaller in the cranial direction, following the elastic cone. The ventral boundary is formed by the median part of the cricothyroid ligament (ligamentum conicum), the dorsal part by the cricoid cartilage. The walls of the subglottis are divided into three or four layers composed of collagenous and elastic fibres in which seromucous glands are embedded. Subglottic blood vessels including a tight subepithelial capillary plexus were delineated.

CONCLUSION

The new definition of the subglottic extensions presented is helpful and essential for precise laryngeal tumour classification. The results indicate that the boundaries are unlikely to counteract tumour progression in the subglottis. Furthermore, the findings suggest that these structures contribute to temperature regulation of breath, protection against inflammation as well as breath frequency and depth-dependent mucus secretion.

Functional anatomy of the lymphatic drainage system of the upper aerodigestive tract and its role in metastasis of squamous cell carcinoma

BACKGROUND

Although there is a significant understanding of the vascular anatomy of the upper aerodigestive tract (UADT), there is less detailed knowledge of the architecture and drainage patterns of the lymphatic system. Detailed knowledge of the lymphatic system is critical for understanding the role of sentinal node identification in the management of different cancers.

METHODS

We have combined microscopic techniques with in vivo and in vitro lymphographic studies to survey the architecture and drainage patterns of the lymphatic system of the UADT in 850 organ specimens.

RESULTS

These studies show an interaction of superficial and deep lymphatic networks that vary in density but have a constant distribution characterized by predictable patterns of lymph drainage into the regional lymph nodes.

CONCLUSIONS

Detailed knowledge of the lymphatic system of the UADT contributes to a better understanding of the patterns of metastatic spread of carcinomas of the UADT and provides a strong rationale for the practice of sentinel node identification in the management of these tumors.

Expression of 5'-nucleotidase and alkaline phosphatase in human aqueous drainage channels

PURPOSE

Lymphatic vessels and blood vessels can be distinguished histochemically by their expression of 5'-nucleotidase and alkaline phosphatase. The aim of this study was to compare the expression of these enzymes in human aqueous drainage channels with that seen in lymphatics and blood vessels.

METHODS

Histological sections from the angular regions of human eyes were prepared both by enzyme histochemical and immunohistochemical methods to analyse 5'-nucleotidase and alkaline phosphatase expression. In some of these eyes, Indian ink-stained gelatin was injected into Schlemm's canal and the suprachoroidal space to facilitate the identification of aqueous drainage routes.

RESULTS

There was no expression of 5'-nucleotidase in the endothelium of aqueous drainage channels. Ocular blood vessels were characterized by strong expression of alkaline phosphatase, whereas the cellular lining of Schlemm's canal, the collector channels, the aqueous veins and a scleral channel from the suprachoroidal space showed significantly weaker expression or no expression at all.

CONCLUSION

The study failed to show a histochemical similarity between lymphatics and human aqueous drainage channels, as no expression of 5'-nucleotidase could be found in any part of the aqueous outflow pathway. The endothelium of aqueous drainage channels also differed from normal blood vessels by a much weaker expression of alkaline phosphatase. This makes a histochemical distinction between aqueous veins and scleral veins possible.

Sentinel node detection in N0 cancer of the pharynx and larynx

Neck lymph node status is the most important factor for prognosis in head and neck squamous cell carcinoma. Sentinel node detection reliably predicts the lymph node status in melanoma and breast cancer patients. This study evaluates the predictive value of sentinel node detection in 50 patients suffering from pharyngeal and laryngeal carcinomas with a N0 neck as assessed by ultrasound imaging. Following 99m-Technetium nanocolloid injection in the perimeter of the tumour intraoperative sentinel node detection was performed during lymph node dissection. Postoperatively the histological results of the sentinel nodes were compared with the excised neck dissection specimen. Identification of sentinel nodes was successful in all 50 patients with a sensitivity of 89%. In eight cases the sentinel node showed nodal disease (pN1). In 41 patients the sentinel node was tumour negative reflecting the correct neck lymph node status (pN0). We observed one false-negative result. In this case the sentinel node was free of tumour, whereas a neighbouring lymph node contained a lymph node metastasis (pN1). Although we have shown, that skipping of nodal basins can occur, this technique still reliably identifies the sentinel nodes of patients with squamous cell carcinoma of the pharynx and larynx. Future studies must show, if sentinel node detection is suitable to limit the extent of lymph node dissection in clinically N0 necks of patients suffering from pharyngeal and laryngeal squamous cell carcinoma.

Value of sentinel lymphonodectomy in head and neck cancer patients without evidence of lymphogenic metastatic disease

OBJECTIVE

Only few communications deal with the value of sentinel node (SN) biopsy for head and neck squamous cell carcinoma (HNSCC). Based on the results of 38 investigated patients with clinically N0-neck the feasibility of SN biopsy in HNSCC is critically discussed.

PATIENTS AND METHODS

Thirty-eight previously untreated patients with clinically N0-neck were staged by intraoperative SN biopsy. After intraoperative identification of the hottest node (SN(1)) and further less tracer accumulating lymph nodes (SN(2), SN(3)), patients were treated by different types of neck dissection (ND), adjusted to the location and extent of the primary tumour. Postoperatively the histologic results of the SN(1-3) and the entire ND specimen were compared.

RESULTS

The stage of cervical metastatic disease was demonstrated by a disease-free SN(1) in 32 patients. In five patients an isolated metastasis could be proven in the intraoperatively identified SN(1), while in the remaining patient an isolated metastasis was found in the SN(2).

CONCLUSION

Intraoperative SN biopsy seems to be valuable for the detection of occult lymph node metastases in HNSCC. This method might help to limit the extent of ipsilateral ND, if used as an intraoperative staging procedure to investigate the first draining tracer accumulating lymph nodes (SN(1-3)).

Lymphangioma of large intestine: report of ten cases with endoscopic and pathologic correlation

BACKGROUND

Lymphangioma of the intestinal tracts is extremely rare and usually presents as a sessile or pedunculated polyp. The cause of these gross morphologic differences is unknown. The aim of this study was to investigate the characteristic histopathology of the colonic lymphangiomas in comparison with their endoscopic findings.

METHODS

Ten colonic lymphangiomas, diagnosed and resected endoscopically between 1992 and 1999, were microscopically examined and immunohistochemically stained with CD31, CD34, Factor VIII-related antigen, and smooth muscle actin.

RESULTS

The characteristic endoscopic finding was a transparent, fluctuating sessile (7 cases) or pedunculated (3 cases) polypoid mass with the color of normal colonic mucosa. Proliferative and dilated lymphatic tumor vessels were found in the colonic mucosa as well as in the submucosa in seven cases. In three pedunculated lymphangiomas, dilated lymphatics were exclusively restricted to the submucosa. The endothelial lining cells stained positively for both CD31 and Factor VIII-related antigen in all 10 cases tested, but most cases were negative for CD34.

CONCLUSION

A pedicle does not exclude the endoscopic diagnosis of lymphangioma and there is a close correlation between its presence and histologic submucosal localization of dilated lymphatic vessels.