Meningioma in the internal auditory canal

A case is presented of an entirely intracanalicular meningioma in a 48-year-old woman that was excised via a conventional translabyrinthine approach to the internal auditory canal (IAC). Pre-operative magnetic resonance imaging (MRI) suggested that the tumour was a vestibular schwannoma (VS). Histological examination confirmed the intra-operative impression that the tumour was a meningioma. Although VS is by far the commonest intracanalicular tumour, the differential diagnosis includes meningioma. MRI is unable to distinguish between these two entities when the tumour is located entirely in the internal auditory canal.     

Prognostic relevance of volumetric analysis in tumour specimens of hypopharyngeal cancer.

OBJECTIVE: The purpose of this study was to investigate the prognostic relevance of the tumour specimen's volume in patients with squamous cell cancers of the hypopharynx. DESIGN: Tumour specimens of 67 patients treated primarily with surgery were evaluated, prospectively. Pathologic tumour volume was described as the product of the three longest diameters of the tumour in cubic millimeters (mm(3)). Statistical analysis was performed to determine the relation of pathologic tumour volume to pTNM stages as well as to patients' survival. This study has been approved by our institutional review board. RESULTS: Pathologic tumour volume was significantly associated with pT (P = 0.006) and pN (P = 0.01). The univariate evaluation of tumour variables showed pathologic tumour volume (P = 0.01) and pN (P = 0.04) as the only parameters which were significantly associated with overall survival. Entering these variables in a Cox regression model, pathologic tumour volume had the most impact on overall survival (P = 0.03). Most important thereby is the fact that we could distinguish within the pN0 group between the more and the less favourable cases. CONCLUSION: Pathologic tumour volume could be an essential prognostic indicator and the inclusion of this parameter in future clinical trials is recommended.     

Scintigraphic evaluation of glomus tumours

The current investigations of choice for a suspected glomus tumour are either direct or indirect angiography to include digital subtraction followed by computerized tomography (CT) or magnetic resonance imaging (MRI) or, if available, CT and MRI with gadolinium alone. Although these modalities confirm the diagnosis and give anatomical information to facilitate accurate staging, they do not provide functional data. The use of radionuclide scintigraphy can add an extra physiological dimension to glomus tumour imaging. Iodine-131/123 metaiodobenzylguanidine (MIBG) is a tumour imaging agent which has been used to diagnose head and neck neuroendocrine tumours to include paragangliomata and medullary carcinoma of the thyroid (MCT). However, it is expensive and the new head and neck tumour imaging agent technetium-99 m (Tc99m) (v) dimercaptosuccinic acid (DMSA) has superceded it as the imaging agent of choice to evaluate MCT. We report a patient with a glomus jugulare tumour which was evaluated with I131/I123-MIBG and Tc99m (v) DMSA. The tumour was functional and is the first reported case exhibiting positive accumulation of both I131-MIBG and Tc99m (v) DMSA. The patient was subsequently treated with a therapeutic dose of I131-MIBG. The significance of these results is discussed.     

The emerging role of trans-oral robotic surgery for the detection of the primary tumour site in patients with head-neck unknown primary cancers: A meta-analysis

The identification of the site in head neck unknown primary (HNUP) tumour is of utmost importance to help select best treatment while decreasing treatment-related morbidity and mortality. The primary purpose of this study is to demonstrate that TORS may be a valuable tool in detecting primary tumour. Studies were systematically searched in the PubMed, EMBASE, the Cochrane Library and CENTRAL electronic databases. A total of 12 selected studies (349 patients) were analyzed. The primary tumour detection and positive surgical margins rates were 70.8% and 19.4%, respectively. The rate of HPV-related tumour was 71.3%. The primary tumour was mainly in base of tongue (64%).In conclusion, TORS seems to be an effective surgical approach both in terms of detection of primary tumour site and in terms of therapeutic perspective for HNUP. In particular, a subset of HPV-related tumours might benefits all advantages from this surgical modality.     

Beta 2-microglobulin in squamous cell carcinomas of the head and neck and in tumours heterotransplanted into nude athymic mice

Beta 2-microglobulin (beta 2m) is a small polypeptide, related to the immunoglobulins and present on nucleated cells as part of the strong transplantation antigens. Elevated plasma levels have been recorded in patients with various malignant diseases. Human beta 2m has also been detected immunohistochemically in carcinomas transplanted into nude mice, and in the plasma of tumour-bearing mice. In the present study the occurrence of human beta 2m was studied in the plasma of 26 patients with squamous cell carcinoma (SCC) of the head and neck and in six heterotransplanted carcinoma lines. Extractable beta 2m was measured in seven SCC of the head and neck and in the six heterotransplanted tumour lines. Immunohistochemically detectable beta 2m was studied in 20 SCC and in six heterotransplanted tumour lines. Only 3 of 26 patients (12%) had elevated p-beta 2m levels. Stage IV tumours seemed to have more p-beta 2m (though within the normal range) than did less advanced tumours. There was no correlation between the total amount of extractable beta 2m in the patients' tumours and p-beta 2m. However, there was an association between the concentration of beta 2m in the tumours and p-beta 2m. Human beta 2m could be detected in the plasma of mice with tumours from all tumour lines, and there was a tendency toward an association between tumour size and p-beta 2m. The ratio of p-beta 2m/tumour volume differed between the tumour lines. Tumour volume doubling time (DT) was determined for the various tumour lines, and there was a correlation between DT and beta 2m concentration of the tumours.(ABSTRACT TRUNCATED AT 250 WORDS)     

Growth of xenografted head and neck cancer in nude mice pre-treated with whole body irradiation.

In an attempt to enhance the primary acceptance rate of human squamous cell carcinoma of the head and neck (HNSCC), nude mice (BALB/c) were given whole body irradiation (WBI) prior to heterotransplantation of tumour specimens. A total of 27 fresh HNSCC biopsies were transplanted, with a take rate of 15%. No difference in primary tumour acceptance rate was found between irradiated and non-irradiated mice. Only one of the accepted tumours established growth both in irradiated and non-irradiated mice. In a second experiment, three previously established tumour lines of HNSCC were re-transplanted to irradiated and non-irradiated mice. As compared with non-irradiated mice, the growth rate was lower in all tumours transplanted to irradiated mice, the difference being statistically significant in two out of the three tumour lines. The results of the study show that attempted immunosuppression by WBI of nude mice prior to tumour implantation does not improve the growth conditions of HNSCC. These findings further emphasise the complexity of the transplantation barrier against human tumour xenografts in nude mice.     

False-positive magnetic resonance image in the diagnosis of small acoustic neuroma

A patient presented with sudden hearing loss on her first visit to our department. Gadolinium-DTPA-enhanced magnetic resonance imaging (MRI) of the posterior cranial fossa portrayed an intracanalicular tumour image (2-3 mm), and the pure tone average (PTA) and speech discrimination score (SDS) values were 65 dB and 60 per cent, respectively. Surgical intervention to remove the suspected tumour was scheduled by the translabyrinthine approach. Intracanalicular observations by the retrolabyrinthine approach revealed limited oedema on the inferior vestibular nerve with vascular dilation. The tumour image disappeared two years after the operation. Surgical findings and the post-operative course advocate that gadolinium-DTPA-enriched MRI image of an intracanalicular lesion such as arachnoiditis might produce a false-positive result.     

Endolymphatic sac tumours: surgical management

BACKGROUND: Endolymphatic sac tumours (ELSTs) have been known as an individual tumour entity only since 1984. ELSTs may occur either solitarily and sporadically or as a hereditary manifestation associated with von Hippel-Lindau (VHL) disease. The latter association was first observed in 1992 and confirmed by molecular genetic analysis of the VHL gene. No consensual diagnostic and treatment strategy of ELST exists at present. METHODS: Based on imaging criteria in computed tomography, magnetic resonance imaging (MRI), and magnetic resonance angiography, we developed a staging system to classify ELST in a series of seven consecutive patients in an attempt to custom-tailor the surgical approach. Type A referred to tumours that were locally confined without temporal bone erosion or infiltration of the dura (n = 2); type B tumours showed evidence of bone infiltration of the osseous labyrinth and sensorineural hearing loss (n = 2); and in type C, the tumour further invaded the sigmoid sinus and jugular bulb (n = 3). Two patients suffered from VHL disease. RESULTS: In all patients, the tumour was completely removed. Stage-adapted surgical approaches included various transpetrosal procedures, from the translabyrinthine to the infratemporal approaches. The functional integrity of the facial nerve was maintained in all tumour stages, whereas the vestibulocochlear nerve could be preserved only in patients with type A tumours. Follow-up MRI demonstrated no local tumour recurrence during a postoperative observation period ranging from 4 to 38 months. CONCLUSION: Stage-based surgical strategy enables the complete removal of ELST with minor morbidity. Transmastoid approaches are most efficient for resection of the tumour matrix to prevent local recurrence.     

Diagrammatic recording of head and neck tumours1

The increasing demands of clinical audit have resulted in the need for accurate data collection. The use of tumour maps allows standardization of the records of patients with head and neck cancer, which facilitates collation of data in multicentre studies and makes interdepartmental comparisons more meaningful. The aim of this study was to develop an improved standard set of tumour maps for recording the stage of head and neck tumours. A review of the existing tumour diagrams was performed to identify those anatomical areas that are not adequately represented or where ambiguity exists. The areas where improvements could be made were identified as: (1) the anterior commissure of the larynx; (2) axial and sagittal views of the larynx; (3) the pyriform fossa and cervical oesophagus; (4) the oropharynx and vallecula; (5) the nasal cavity and paranasal sinuses; and (6) cervical nodal involvement. A new set of tumour maps is presented in an attempt to correct some of the limitations of the existing diagrams.     

Interdigitating dendritic cell sarcoma of the parotid gland

Interdigitating dendritic cell sarcomas (IDCSs) are extremely uncommon tumours that arise predominantly in lymphoid tissue. We report a case of an IDCS arising in the parotid gland of a 73-year-old man. Clinically, a primary salivary gland tumour was suspected but fine needle aspiration cytology suggested a soft tissue tumour. A diagnosis of IDCS was made on histopathological examination of the resection specimen, with subsequent confirmation by electron microscopy. Given the extreme rarity of this tumour at this site, it is unlikely to be a common diagnostic problem, but the importance of multiple diagnostic modalities is emphasized. The findings of cytology, histology, immunohistochemistry and electron microscopy have not previously been described together in a single case report of this tumour.     

Pleomorphic adenoma of the nasal cavity: a case arising from the wall of the maxillary sinus

INTRODUCTION: Pleomorphic adenoma is a common and benign tumour, originating from sero-mucous glands. Location in the nasal cavity and particularly on the medial wall of the maxillary sinus is very rare. PATIENTS AND METHODS: One patient with a pleomorphic adenoma of the nasal cavity and a review of literature are reported in order to describe the diagnostic and therapeutic management of this tumour. RESULTS: A 63-year-old woman was referred to our institution for evaluation of an unilateral nasal tumour. Clinical and radiological studies revealed an intra-nasal tumour, slightly lytic in nature, arising from the mucosa of the medial wall of the maxillary sinus. More than 2 years after complete excision of the tumour using an endoscopic procedure, the nasal cavity was free of tumour. DISCUSSION: Pleomorphic adenoma of the nasal cavity is a rare and benign tumour, usually presenting as a unilateral nasal tumour. Prognosis of this tumour is mainly linked to recurrences in cases of incomplete resection and to possible metastasis, such as an eventual malignant evolution. The gold standard treatment is complete surgical resection. After a complete imaging study for patient selection (CT scan and MRI), endonasal endoscopic surgery seems to be a reliable therapeutic treatment. CONCLUSION: Intra-nasal pleomorphic adenoma originates from nasal seromucous glands. Radiological study reveals a slightly lytic tumour developed from the septum of the medial wall of the maxillary sinus. Resecton can be performed with endoscopic endonasal surgery as long as the orbital bony framework and the ethmoidal roof are free of tumour. Whatever technique is employed, long term follow-up has to be used to detect any recurrence.     

Prognosis in laryngeal carcinoma: host factors

A personal series of 1171 patients with a laryngeal tumour seen in a 27-year period from 1962 to 1988 is reported. Of these patients, 763 were previously untreated and had a histologically proved squamous cell carcinoma. The interaction between the host factors (age, sex and general condition) and other tumour factors, and the effect of the host factors on survival were analysed. The maximum age incidence was the same in the two sexes but performance status (general condition) declined with increasing age. There was no relation between age and site or histological grade of the tumour. However, the incidence of T3-T4 tumours increased up to the seventh decade and then declined again. Age was not a significant predictor of survival when allowance was made for patients who were untreated, or who had died of intercurrent disease or a second primary tumour. Men were more likely to have a glottic tumour: these tumours presented at an earlier stage and were likely to be well differentiated, mainly because glottic T1 carcinoma is almost exclusively a male disease. When individual sites are examined the crude survival for supraglottic tumours in women is better than that in men because of a higher death rate from other diseases and other tumours in men. Sex had no other effect on survival. Good performance status was associated with lower T-stage but not quite significantly so. It was not associated with any other tumour parameters. Performance status significantly affected survival of treated patients, probably indicating that general condition affects the patient's ability to resist his tumour.     

The interesting case -- case number 61

A 58-year-old patient presented after having undergone radiation therapy, afterloading therapy and chemotherapy of a T4 nasopharynx carcinoma. On the basis of the MRI findings, local tumour recurrence was suspected. The samples taken from the nasopharynx and the left maxillary sinus confirmed this diagnosis. Neuroradiological imaging showed that the tumour extended into the area around the left skull base and also revealed an irregular formation located in the left temporal flap. Therefore not only tumour resection (Fisch approach type C) but also a temporal craniotomy was indicated in order to determine the degree of intracerebral tumour extension. The dura mater, which had been intact, was intraoperatively opened and revealed vital brain tissue, i. e. tumour infiltration had not reached the brain. It was concluded that the radiological findings probably indicated a postradiogenic necrosis of the temporal flap. The presented case illustrates the rare differential diagnostic procedure carried out in a patient with radiogenic necrosis while taking into account the possibility of local tumour infiltration into the brain parenchyma.     

Merkel-cell tumor associated with a spinocelluar epithelioma. Apropos a case report

One case of Merkel cell carcinoma is reported in a 71 years-old woman. Lately treated by surgical excision (14 years after the occurrence of the tumour), this tumour was already associated with inguinal lymph node metastases. Its evolution was lethal within 3 months after local recurrence, cutaneous and visceral (lung, liver) metastases. This tumour, characteristic histologically and ultrastructurally (secretory granules), was accompanied by an infiltrative epidermoid carcinoma. This association and the presence of cytokeratin in tumoral Merkel cells are arguments for the common origin of keratinocytes and neuroendocrine Merkel cells from a common young epithelial cell.     

Role of alcohol and smoking in diagnostic delay of head and neck cancer patients

CONCLUSIONS: This study shows that heavy drinking is a risk factor for prolonged delay in presenting with head and neck cancer and for presenting with a large tumour in the head and neck region. Excessive smoking is only a risk factor for being diagnosed with a large tumour, although there is a weak association between smoking and prolonged diagnostic delay. OBJECTIVE: It is reasonable to assume that prolonged delay in presenting with head and neck cancer is associated with an advanced stage of cancer at diagnosis. In this study we analysed the effects of drinking and smoking habits on diagnostic delay and the T stage of the tumour at diagnosis. MATERIAL AND METHODS: A total of 427 patients with newly diagnosed head and neck carcinomas were eligible for this study. Of these, 306 (72%) actually participated: 134 (77%) with an oral tumour; 117 (69%) with a larynx tumour; and 55 (65%) with a pharynx tumour. Diagnostic delay was defined as a period of >30 days between the appearance of the first tumour-related symptoms and the first visit to a physician. T3 4 tumours were defined as advanced tumours. Drinking behaviour was classified into three types: light (0 2 drinks/day); moderate (3 4 drinks/day); and heavy ( >4 drinks/day). Smoking habits were classified into 4 types: never; stopped; light (0 20 cigarettes/day); and heavy (>20 cigarettes/day). RESULTS: Logistic regression showed that there were significantly more heavy than light drinkers [p = 0.04; odds ratio (OR) 1.8; 95% CI 1.0-3.1] in the delay group than in the non-delay group. Light smokers showed a tendency towards prolonged delay (p = 0.06; OR 2.2; 95% CI 1.0-5.0). Both heavy drinking (p = 0.01; OR 2.0; 95% CI 1.2-3.6) and heavy smoking (p = 0.03; OR 3.1; 95% CI 1.1-8.4) were risk factors for a patient to be diagnosed with a large tumour.     

Schwannoma of the larynx: case report

Neurogenous tumours of the larynx are extremely uncommon. We present a rare case of schwannoma of the larynx. Clinical findings are presented together with computed tomography (CT) and magnetic resonance images. The tumour was located in the right aryepiglottic fold of the larynx. CT showed a well defined and hypodense mass extending from the right aryepiglottic fold to the right vocal cord. The patient underwent an excision of the mass through a lateral thyrotomy and the tumour was completely removed. The diagnosis and treatment of this tumour are discussed. Received: 11 May 2000 / Accepted: 5 September 2000     

Koilocytosis in oral squamous cell carcinoma: what does it mean?

OBJECTIVES: (1) To determine the prognosis of patients with squamous cell carcinoma (SCC) of the oral cavity and (2) to determine whether a relationship exists between koilocytosis and tumour grade, stage, and prognosis in these patients. METHODS: Retrospective study of patients with SCC of the oral cavity at McGill University in the last 5 years followed by a pathology review of available cases. The data extracted were age at diagnosis, risk factors, tumour stage and grade, koilocytosis, treatment, and outcome. Deoxyribonucleic acid (DNA) extraction was done, followed by polymerase chain reaction (PCR) to detect the presence of human papillomavirus (HPV). RESULTS: One hundred ninety-nine patients were identified. There was an overall 13% mortality rate over the follow-up period of 5 years. Pathology material was available for 146 patients. Koilocytosis was found in 67% of patients. More specifically, koilocytosis was present in 67.2% of well-differentiated lesions, 65.2% of moderately differentiated lesions, and 68.4% of poorly differentiated lesions. Koilocytosis was evenly distributed among tumour stages (I, 73%; II, 68%; III, 68%; IV, 69%). PCR was positive in only one sample. CONCLUSION: Mortality rates in this series are similar to those published in the literature. There is a high prevalence of koilocytosis in SCC of the oral cavity, which appears to be associated with better tumour differentiation and poorly differentiated equally and also evenly distributed among tumour. Because HPV is negative, we do not know if koilocytosis is a marker of HPV. We could not determine the relationship between HPV and prognosis.     

Diagnosis, treatment and results of malignant skull base tumours

BACKGROUND: Malignant tumours of the cranial base are rare and present usually in advanced tumour stage due to the lack of early clinical symptoms. PATIENTS AND METHODS: Sixty patients with malignant tumours infiltrating the skull base were treated at the Department of Otorhinolaryngology Head and Neck Surgery, University of Würzburg between 1987 and 1999. Most of the tumours (n = 51) originated from the nose or paranasal sinuses, the epipharynx, the outer ear canal or the middle ear. Seven tumours were malignant brain tumours infiltrating the bony structures of the skull base or originated from the cranial base itself. Two patients suffered from metastases of an adenocarcinoma of the prostata. The histological diagnosis was confirmed in 53 patients preoperatively and in seven patients during tumour resection. Squamous cell carcinoma (n = 24), adenocarcinoma (n = 10) and sarcoma (n = 7) were the most common histologies found. RESULTS: A radical en bloc resection of the tumour was only possible in 26 out of 60 cases. A surgical tumour reduction with postoperative radiation therapy was performed in seven patients as a palliative approach. Eight patients underwent a combined radio- and chemotherapy according to the histological diagnosis. Primary radiotherapy was the treatment of choice in eleven patients, where the tumours were located in the central area of the cranial base. Palliative radiotherapy or solely medical pain control were applied to eight patients who presented either with distant metastases or an advanced tumour growth. The mean postoperative survival following radical surgery was 48 months and after primary radiotherapy 27 months. DISCUSSION: A statistical analysis of the results is not applicable due to the great variety of the disease concerning the histological diagnosis, the tumour size and the location as well as the small number of patients.     

Primary tumour volume: important predictor of outcome for T3- and T4-staged nasopharyngeal carcinoma

OBJECTIVE: To investigate the relationship between primary tumour volumes and treatment outcomes within T3- and T4-staged nasopharyngeal carcinoma. DESIGN: Retrospective study. SETTING: Tertiary care centre. METHODS: Forty newly diagnosed T3-staged patients and 36 newly diagnosed T4-staged patients participated in the study. MAIN OUTCOME MEASURES: Computed tomography-derived primary tumour volume was obtained from the summation of areas technique. The probabilities of achieving tumour control and patient survival were estimated using the product-limit method of Kaplan and Meier. The log rank test was used to examine significance. RESULTS: In T3-staged nasopharyngeal carcinoma, the median primary tumour volume was 29.6 mL, with a range from 8.0 to 131.8 mL. After segregating the primary tumour volume into two subgroups (< 30 mL, > 30 mL), large primary tumour volume was associated with a significantly poorer disease-specific survival (p = .0001). In T4-staged cases, the median primary tumour volume was 54.07 mL, with a range from 6.7 to 223.1 mL. After segregating the primary tumour volume into two subgroups (< 60 mL, > 60 mL), larger primary tumour volume was associated with a significantly poorer disease-specific survival (p = .0022). CONCLUSION: Within the same T3- and T4-staged nasopharyngeal carcinoma, the primary tumour volume represented an important prognostic factor. To improve the treatment outcome of T3- and T4-staged nasopharyngeal carcinoma with large primary tumour volumes, more aggressive treatment is needed.     

Reversible hyposmia caused by intracranial tumour

Two patients with hyposmia caused by an intracranial tumour recovered olfactory functions after craniotomy. The first case was a 68-year-old male with a tumour metastasized from the lung to the right frontal lobe. The second case was a 75-year-old male with meningioma of the right frontal lobe. Results of T & T olfactometry and venous olfaction tests also indicated suspected central hyposmia. Magnetic resonance imaging (MRI) indicated compression of the frontal lobe by intracranial tumour. Pressure on the olfactory centre located in the frontal lobe produced hyposmia. Decompression of the frontal lobe by craniotomy improved the sense of smell. Therefore, some cases of olfactory disturbance caused by intracranial tumour may be reversible if they are the result of simple compression of the olfactory centre.