Inflammatory Myofibroblastic Tumor of the Vocal Cord Mimicking Vocal Polyp / 대한이비인후과학회지

Inflammatory myofibroblastic tumor (IMT) is an uncommon benign fibroinflammatory mass that is composed of myofibroblastic spindle cells with acute and chronic inflammatory cells. IMT may arise within numerous organs such as lung, intestine, orbit and paranasal sinuses. However, IMT of the larynx is extremely rare. IMT can have systemic manifestations including fever of unknown origin, anemia, thrombocytosis and elevated erythrocyte sedimentation rate. The treatment of IMT is complete excision, but in some cases, additional therapy such as chemotherapy or radiotherapy may be required. Recently, we experienced a case of IMT which was originated from the right true vocal cord and mimicking the vocal polyp. So, we report this case with a review of the literature.

Metastatic Renal Cell Carcinoma in the Nasal Cavity and Mouth Floor / 대한이비인후과학회지

Renal cell carcinoma (RCC) has a high incidence of metastasis to any location in the body. This tumor metastasizes to the head and neck region in 15% of cases, whereas metastasis to the sinonasal area or to the mouth floor is rare. None of the cases of the RCC that are metastatic to both sites (sinonasal area and mouth floor) has been previously described. Recently, we experienced a case of metastatic RCC involving the nasal cavity and the mouth floor that were managed by local excision and postoperative radiotherapy. Because of its unpredictable clinical behavior, a long term follow-up is essential for early detection of recurrent or residual lesion of RCC.

Multiple Primary Malignancies in the Head and Neck: A Clinical Review of 70 Patients / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Recent advances in medical management, along with increased life span, have contributed to the increased opportunity for detecting multiple primary malignancy (MPM). The purpose of this study was to evaluate the incidence and clinical characteristics of MPM in the head and neck region. SUBJECTS AND METHOD: We reviewed retrospectively the medical records of 984 patients with malignant tumors of head and neck who had been diagnosed histopathologically and treated between August 1985 to July 2005. RESULTS: Seventy patients (7.11%) were diagnosed as having MPM (double, n=66 ; triple, n=4). This group consisted of 67 men and 3 women (p<0.01). Twenty-five patients (36%) had synchronous double primary malignancy (SDPM) and 45 patients (64%) had metachronous double primary malignancy (MDPM). The hypopharynx was the most frequently involved site of the index tumor. The most common index tumors were squamous cell carcinoma histopathologically. Second primary malignancies were found in esophagus, stomach and lung. Fifty-five patients were found with first primary malignancy in head and neck, and 25 were with second primary malignancy. The patients with first and second primary malignancy in head and neck were 10 cases. The prognosis of SDPM (average of survival 11.1 months) was very poor. Patients with MPM have high cigarettes smoking and alcohol drinking habit. CONCLUSION: Patients with head and neck malignancies will require careful follow up for prevention, early detection, and the treatment of second primary malignancy.

Effect of Macrolide on the MUC4 Gene Expression in Human Airway Epithelial Cells / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Mucin gene expression and mucin secretion are highly increased by inflammatory airway diseases such as asthma, chronic bronchitis and rhinosinusitis. Macrolide antibiotics is considered one of the effective drugs inhibiting mucus secretion for chronic bronchitis and rhinosinusitis with nasal polyp. However, the anti-secretory effect of macrolide is not clear. This study was designed to investigate whether macrolide can suppress interleukin-1beta (IL-1beta)-induced MUC4 gene expression and mucin secretion in the cultured human nasal polyp epithelial cells and NCI-H292 epithelial cells. SUBJECTS AND METHOD: Nasal polyps were obtained from 20 patients with chronic rhinosinusitis with nasal polyp during endoscopic sinus surgery. We observed the effect of roxithromycin on the IL-1beta-induced MUC4 gene and mucin secretion by reverse transcriptase-polymerase chain reaction (RT-PCR) with enzyme-linked immunosorbent assay (ELISA) method. RESULTS: Roxithromycin attenuated the IL-1beta-induced MUC4 mRNA expression and mucin secretion with a dose dependent pattern in both of the cultured human nasal polyp epithelial cells and NCI-H292 epithelial cells. CONCLUSION: This result suggests that roxithromycin may be considered as an effective anti-hypersecretory agent for its down-regulation of the MUC4 gene.

Endoscopic Resection of Sinonasal Malignant Tumors / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Endoscopic surgery largely replaced the traditional external approach in the treatment of sinonasal inflammatory diseases and most benign tumors. However, there is much debate about its applicability to resection of sinosal malignancy. In this study, we demonstrate the efficacy of the endonasal endoscopic approach in the treatment of highly selected sinonasal malignant tumors. SUBJECTS AND METHOD: We retrospectively reviewed the medical records and radiologic findings of 11 patients who had underwent transnasal endoscopic excision for sinonasal malignancy from 1998 to 2003. All patients were treated with curative intent. RESULTS: The mean age was 60.6 (31-75 years) years and the mean follow-up period was 69 months (52-112 months). Eight cases consisted of T1 and three cases were T2. The pathologic diagnosis was malignant melanoma (4 cases), plasmacytoma (2 cases), adenoid cystic carcinoma, olfactory neuroblastoma, cylindrical cell carcinoma, squamous cell carcinoma and neuroendocrine carcinoma. In ten cases, the tumor was removed by transnasal endoscopic excision with adequate free margin of normal mucosa. In one case, Caldwell-Luc operation was combined with the endoscopic excision. During the follow-up, only one case of malignant melanoma had recurred at the lateral neck and retropharyngeal lymph node, but the other ten cases have kept up well without recurrence of primary tumor and significant complication. CONCLUSION: Considering oncological results and surgery-related morbidities, transnasal endoscopic resection can be used as a good modality in the highly selected early T stage of sinonasal malignancies.

The Detection of Epstein-Barr Virus and Expression of bcl-2 and p53 Proteins in the Extranodal Malignant Lymphoma of the Head and Neck / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Although the cause of the malignant lymphoma has not been understood entirely, viruses and oncogenes have been implicated as probable causative factors. Particularly, Epstein-Barr virus (EBV), the over-expression of bcl-2 and the mutant p53 seem to be closely related to lymphomatogenesis. The purpose of this study was to investigate the relationship between EBV, bcl-2 and p53 proteins in the development of human extranodal malignant lymphoma in the head and neck. SUBJECTS AND METHOD: Specimens were obtained from 40 patients diagnosed as the extranodal malignant lymphoma in the head and neck region. Paraffin-embedded tumor tissues were analyzed by in situ hybridization for Epstein-Barr virus encoded RNA(EBER) and by immunohistochemical technique for bcl-2 and p53 proteins. RESULTS: In EBER and bcl-2 protein-positive group, there were no significant differences in the pathologic types. However, the angiocentric lymphoma type (85.7%) and the peripheral T cell lymphoma unspecified large cell type (83.3%) were identified significantly in the p53 protein positive group (p0.05). CONCLUSION: These results suggest that EBV, bcl-2 and p53 protein play a role in the tumorigenesis of the human extranodal malignant lymphoma, independently.

Cavernous Hemangioma of the External Auditory Canal: A Case Report / 대한이비인후과학회지

Hemangiomas are common benign neoplasms that frequently involve regions of the head and neck. However, cavernous hemangioma is extremely rare in the external auditory canal. We recently experienced a 46-year-old man with a cavernous hemangioma of the external auditory canal without invasion into the tympanic membrane. It was excised en bloc without significant bleeding. This case report represents the seventh such lesion reported in the literature and the first to be seen in Korea. The clinical presentation and surgical management are discussed with a review of the literature.

Bilateral Submandibular Gland Aplasia: A Case Report / 대한이비인후과학회지

The formation of the salivary glands begins between the 6th and the 12th week of development of the embryo. The submandibular gland develops from the endoderm of the floor of the mouth and begins forming later than the parotid gland. The congenital absence of major salivary glands is uncommon; aplasia of both submadibular glands, in particular, is extremely rare. It's major symptoms are dryness of the mouth, dysphagia and dental caries. The diagnosis of aplasia of the salivary glands should be achieved by imaging methods such as technetium-99m pertechnetate radionuclide scan, ultrasonography, sialography or computerized tomography. We report with relative literature on the case of a 50 year old woman suffering from dryness of the mouth due to aplasia of both submandibular glands.

A Study for the Effect of Stellate Ganglion Block on Herpes Zoster Oticus / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES : Facial palsy of herpes zoster oticus has rapid onset, is usually severe in degree, and poorer in prognosis than Bell's palsy. In the past, herpes zoster oticus has usually been treated with acyclovir and steroid, but recently, applying stellate ganglion block for herpes zoster oticus has been recognized as an additional treatment that may improve facial palsy. This study was designed to evaluate the effect of stellate ganglion block on herpes zoster oticus. Subjects and METHOD : We reviewed retrospectively the medical records of 30 patients with herpes zoster oticus who were treated with acyclovir, steroid and stellate ganglion block between January 1995 and December 2004. The follow-up period was at least over than 6 months. RESULTS : All patients suffered from otalgia, vesicle, and facial palsy. The average degree of House-Brackmann classification on admission was 3.26 in the complete recovery patients and 4.61 in the incomplete recovery patients. Seventeen patients were completely recovered from facial palsy (56.7%), and 13 showed residual facial palsy 13 patients(43.3%). The poor prognosis may be related with early onset of facial palsy, high degree of House-Brackmann classification on admission and high degenerative ratio on electroneurography of facial nerve. CONCLUSION : The additional treatment of stellate ganglion block in herpes zoster oticus may not be effective on improving the complete recovery rate and prognosis.

Detection of Cyclin D1 Protein in Inflammation, Dysplasia and Carcinoma of the Laryngeal Mucosa / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Cyclin D1 is one of the proteins regulating G1-S transition in the cell cycle and is considered to play an important role in subsequent mitotic division. So it is a candidate of a proto-oncogene implicated in the pathogenesis of several human tumor types, including laryngeal squamous cell carcinomas. The purpose of this study was to investigate the development of tumorigenesis and clinicopathologic means of cyclin D1 protein in squamous cell carcinoma of the larynx. SUBJECTS AND METHOD: Sixty two patients, who have been treated with benign lesion (keratosis and chronic inflammation), dysplasia or squamous cell carcinoma of the larynx from March 1994 to December 1996 were investigated for this purpose. cyclin D1 protein was detected by immunohistochemical technique in the paraffin embedded tissues. RESULTS: The expression of cyclin D1 protein was detected in 6 out of 11 cases (54.5%) in benign lesion, 3 out of 5 cases (60.0%) in mild to moderate dysplasia, 12 out of 18 cases (66.7%) in severe dysplasia and carcinoma in situ, and 36 out of 44 cases (81.8%) in invasive squamous cell carcinoma of the larynx. Of these, the expression of cyclin D1 protein in invasive squamous cell carcinoma was the highest positive rate, and there was significant difference (p0.05). CONCLUSION: Cyclin D1 protein may be considered to play an important role in the development of the tumorigenesis in invasive squamous cell carcinoma of the larynx.

Injury of the Medial Rectus Muscle by Using a Microdebrider During Endoscopic Sinus Surgery : A Case Report / 영남의대학술지

A microdebrider is increasingly used in endoscopic sinus surgery. Although it has many advantages over conventional instruments, it has been associated with severe complications. We treated a case of rupture of the left medial rectus muscle after use of a microdebrider during endoscopic sinus surgery in a 50 year-old female patient who complained of binocular diplopia and exotropia. The patient showed marked limitation on adduction and about 40 prism diopters of left exodeviation. The orbital computed tomography showed a bony defect at the left medial orbital wall, and injury of the medial rectus muscle. The exodeviation was corrected after ophthalmologic surgery. We report a case of the rupture of the medial rectus muscle after use of a microdebrider during endoscopic sinus surgery and review the medical literature.

Docetaxel and Cisplatin Combination Chemotherapy in Patients with Advanced Head and Neck Cancer / 영남의대학술지

BACKGROUND: Head and neck cancer is curable at early stages with local-regional therapy. However, most patients are diagnosed with advanced stage disease that requires combination therapy. The aim of this study was to determine the efficacy of docetaxel and cisplatin combination chemotherapy, in patients with advanced head and neck cancer by evaluating the response, survival and organ preservation rates. MATERIALS AND METHODS: We reviewed retrospectively the medical records of 39 patients with advanced head and neck cancer who received docetaxel and cisplatin combination chemotherapy from March 2000 to July 2004. RESULTS: The average age of the 39 patients was 53.4 (range 30 to 73 years) years and the most common primary site was the hypopharynx (23.0%). There were 36 patients who had stage IV disease and three patients with stage III disease. The overall response rate was 76.9% (30/39), including 12 complete responses (30.8%) and 18 partial responses (46.1%). The response rate based on the primary cancer and neck metastasis was 74.4% and 69.3%; the differences were not significant. Among 16 patients with laryngeal and hypopharyngeal cancer, 13 (81.2%) had their larynx preserved after chemotherapy followed by radiotherapy and a survival rate of 61.5%; three patients (18.8%) received a total laryngectomy and had a survival rate of 66.7%. The overall survival rate from the start of chemotherapy was 56.4% with a median survival of 30 months. The common toxicities observed were alopecia, vomiting, diarrhea, hepatotoxicity and anemia but they were all generally manageable. CONCLUSION: Docetaxel and cisplatin combination chemotherapy is an effective regimen with a relatively high response rate and acceptable toxicity

Docetaxel and Cisplatin Combination Chemotherapy in Patients with Advanced Head and Neck Cancer / 영남의대학술지

BACKGROUND: Head and neck cancer is curable at early stages with local-regional therapy. However, most patients are diagnosed with advanced stage disease that requires combination therapy. The aim of this study was to determine the efficacy of docetaxel and cisplatin combination chemotherapy, in patients with advanced head and neck cancer by evaluating the response, survival and organ preservation rates. MATERIALS AND METHODS: We reviewed retrospectively the medical records of 39 patients with advanced head and neck cancer who received docetaxel and cisplatin combination chemotherapy from March 2000 to July 2004. RESULTS: The average age of the 39 patients was 53.4 (range 30 to 73 years) years and the most common primary site was the hypopharynx (23.0%). There were 36 patients who had stage IV disease and three patients with stage III disease. The overall response rate was 76.9% (30/39), including 12 complete responses (30.8%) and 18 partial responses (46.1%). The response rate based on the primary cancer and neck metastasis was 74.4% and 69.3%; the differences were not significant. Among 16 patients with laryngeal and hypopharyngeal cancer, 13 (81.2%) had their larynx preserved after chemotherapy followed by radiotherapy and a survival rate of 61.5%; three patients (18.8%) received a total laryngectomy and had a survival rate of 66.7%. The overall survival rate from the start of chemotherapy was 56.4% with a median survival of 30 months. The common toxicities observed were alopecia, vomiting, diarrhea, hepatotoxicity and anemia but they were all generally manageable. CONCLUSION: Docetaxel and cisplatin combination chemotherapy is an effective regimen with a relatively high response rate and acceptable toxicity

Transnasal Endoscopic Reconstruction of Medial Orbital Wall Fracture / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Before introducing transnasal endoscopic sinus surgery, surgical repair of the blowout fracture includes the transorbital approach with an external incision and/or the maxilloethmoidal approach. The advantages of the transnasal endoscopic technique include magnified direct visualization and easy access to the medial orbital walls. Gelfoam is a slowly absorbable material and is rigid enough to provide support where Silastic sheet is to be placed. The purpose of this study was to evaluate outcomes of transnasal endoscopic reconstruction with Gelfoam and Silastic sheet of medial orbital wall fracture. SUBJECTS AND METHOD: This study was a retrospective analysis 27 patients who underwent transnasal endoscopic reduction of blowout fracture from February 1999 to April 2004. The follow-up period was at least over than 12 months. RESULTS: The study population included 18 males and 9 female patients ranging from 13 to 54 years (mean, 33.3 years) of age. Twenty of 23 patients with diplopia showed a complete improvement of diplopia and 3 patients showed an incomplete improvement. All of 13 patients with limitation of ocular movement and 2 patients with enophthalmos revealed a complete resolution of their symptoms. There were no significant complications in all patients although ocular pain and epiphora were observed temporally after operation. CONCLUSION: Transnasal endoscopic reconstruction with Gelfoam and Silastic sheet for medial orbital wall fracture is a very successful technique that does not accompany major complications and has definite cosmetic advantage of causing no external scarring.

Activation and Abnormalities of Cell Cycle Regulating Factor in Head and Neck Squamous Cell Carcinoma Cell Lines: Abnormal Expression of CDKN2 Gene in Laryngeal Squamous Cell Carcinoma / 영남의대학술지

BACKGROUND: Cyclin-dependent kinase (CDK) inhibitors are family of molecules that regulate the cell cycle. The CDKN2, a CDK4 inhibitor, also called p16, has been implicated in human tumorigenesis. The CDKN2 inhibits the cyclin/CDK complexes which regulate the transition from G1 to S phase of cell cycle. There is a previous report that homozygous deletion of CDKN2 region on chromosome 9p21 was detected frequently in astrocytoma, glioma and osteosarcoma, less frequently in lung cancer, leukemia and ovarian cancer, but not detected in colon cancer and neuroblastoma. However, little is known about the relationship between CDKN2 and laryngeal cancer. Therefore this study was initiated to investigate the role of CDKN2 in human laryngeal squamous cell carcinoma development. MATERIALS AND METHODS: We used 5 human laryngeal carcinoma cell lines whether they have deletions or losses of CDKN2 gene expression by DNA-PCR or RT-PCR, respectively. We examined 8 fresh frozen human laryngeal cancer tissues to detect the loss of heterozygosity (LOH) of CDKN2. PCR was performed by using microsatellite markers of short arm of human chromosome 9 (D9S126, D9S144, D9S156, D9S161, D9S162, D9S166, D9S171, D9S200 and D9SIFNA). For informative cases, allelic loss was scored if the signal of one allele was significantly decreased in tumor DNA when compared to the same allele in normal DNA. RESULTS: The CDKN2 DNA deletion was observed in 3 cell lines. The CDKN2 mRNA expression was observed in only one cell line, which was very weak. LOH was detected in 7 cases (87.5%). CONCLUSION: These results suggest that CDKN2 plays a role in the carcinogenesis of human laryngeal squamous cell carcinoma.

Evaluation of Computed Tomography and Magnetic Resonance Imaging of Sinonasal Inverted Papilloma / 영남의대학술지

BACKGROUND: Computed tomography (CT) is commonly used to evaluate the degree of sinus involvement in cases of inverted papilloma (IP). However, CT cannot differentiate tumor from adjacent inflammatory mucosa or retained secretions. By contrast, magnetic resonance imaging (MRI) has been reported to be useful in distinguishing IP from paranasal sinusitis. This study investigated whether preoperative assessment with MRI and CT accurately predict the extent of IP. MATERIALS AND METHODS: CT and MRI were retrospectively reviewed in 9 cases of IP. Patients were categorized into stages based on CT and MRI findings, according to the staging system proposed by Krouse. The involvement of IP in each sinus was also assessed. RESULTS: Differentiation of IP from inflammatory disease may be more successful in routine cases where the inflammatory mucosa has low signal intensity on T1-weighted images and very high signal intensity on T2-weighted images. CT imaging could not differentiate tumor from adjacent inflammatory mucosa or retained secretions. CONCLUSION: Preoperative MRI of IP can predict the location and extent of the tumor involvement in the paranasal sinuses and sometimes predicts malignant changes.

Clinical Characteristics and Prognostic Factors of Nasopharyngeal Cancer / 영남의대학술지

BACKGROUND: Nasopharyngeal cancer is a rare disease with a relatively poor prognosis because it tends to be diagnosed at an advanced stage. The aim of this study was to establish the clinical characteristics of nasopharyngeal cancer. MATERIALS AND METHODS: The medical records of 54 patients with nasopharyngeal cancer from January 1993 to December 2002 were reviewed retrospectively. Forty one cases were male (75.9%) and thirteen were female (24.1%). The average age was of 46.9 (range 16 to 78 years) years. The majority of patients (79.6%) were diagnosed in the advanced stage. The most common complaints were a neck mass (55.5%) and the WHO type III (53.7%) was the most frequent histological type. RESULTS: The cumulative survival rate for a 5-year period was 46.5% and the T stage, N stage, pathologic type, and clinical stage were not significantly related to the survival rate. Sixteen of 54 (31.5%) cases presented with a distant metastasis of the bone, lung, brain, spine, and liver, and six cases (11.1%) presented with a locoregional recurrence. CONCLUSION: TNM staging is not appropriate for predicting survival rate of nasopharyngeal carcinoma patients. Therefore, a newer staging system, which includes new factors, is needed to predict the prognosis.

Long-Term Treatment Outcomes in Endoscopic Management of Sinonasal Benign Tumors / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Recently, rhinologists have increasingly applied their expertise in endoscopic sinus surgery to the resection of sinonasal neoplasms. However, there have not been many reports about long-term follow-up outcomes about endoscopic resection of sinonasal benign tumor. The purpose of this study is to evaluate long-term results of endoscopic management in sinonasal benign tumors. SUBJECTS AND METHOD: We reviewed retrospectively the medical records and radiologic findings of 35 patients with sinonasal benign tumors, who had been treated with transnasal endoscopic resection between January 1995 and December 1999 at Yeungnam University Medical Center and followed over a 5-year. RESULTS: Inverted papilloma (22 cases, 62.8%) was the most common of benign tumor, followed by hemangioma (4 cases), fibrous dysplasia (2 cases), angiofibroma (2 cases), etc. Among of the 22 cases of inverted papilloma, there were 4 cases of T1, 12 of T2 and 6 of T3 according to the Krause staging system. The most common chief complaint was unilaterally nasal obstruction. The mean follow-up period was 6.5 years (5-8 years). There was no major complications, with only one case (4.5%) of recurrent inverted papilloma observed during the following-up period. CONCLUSIONS: The transnasal endoscopic surgical procedure is less aggressive than other methods and except for massively extended cases of sinonasal benign tumors, it is a successful, therapeutic surgical method.

MUC2/5AC Expression and Mucin Secretion through Leukotriene Receptor in Human Airway Epithelial Cells / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Mucin gene expression and mucin production are highly increased during inflammatory airway disorders such as, asthma, chronic bronchitis and sinusitis. Cytokines, lipopolysaccharides and other inflammatory mediators are related with secretion and production of mucin. However, among of inflammatory mediators, the relation of leukotrienes and mucin genes expression is not clear. The aim of this study is to evaluate MUC2/5AC genes expression and mucin secretion through leukotriene receptor in human airway epithelial cells. SUBJECTS AND METHOD: The effect of Leukotriene D4 and leukotriene receptor antagonist, pranlukast hydrate (ONO-1078) on the regulation of MUC2/5AC gene expression and mucin secretion was observed in the human airway NCI-H292 epithelial cells. The mRNA levels of MUC2/5AC and the amount of mucin protein were determined by reverse transcription-polymerase chain reaction (RT-PCR) and immunoassay. RESULTS: Leukotriene D4 upregulated MUC2/5AC gene expression and mucin secretion on a dose dependent pattern. Pranlukast hydrate (ONO-1078, 100 micrometer) downregulated the leukotriene D4-mediated MUC2/5AC gene expression and mucin secretion. CONCLUSION: These results suggest that the leukotriene receptor system is one of the expression mechanisms of MUC2/5AC genes and mucin secretion.

Sinonasal Undifferentiated Carcinoma / 영남의대학술지

Sinonasal Undifferentiated Carcinoma (SNUC) is a very rare, highly aggressive malignant tumor of the nasal cavity and paranasal sinuses. SNUC tends to present with advanced-stage disease, often with intracranial invasion. It requires an aggressive multimodality therapy that includes surgical resection. A cure rate of less than 20% is generally reported in the literature, with most patients dying within 1 year of onset of the disease. Three patients diagnosed as SNUC were treated at the Yeungnam University Medical Center between the years 2000 and 2003 were analyzed retrospectively. All patients presented with the disease very advanced. The three cases were given chemotherapy or chemotherapy with radiotherapy. Two patients died of the disease, surviving only 6 and 11 months following treatment, respectively. We did a follow-up on just the one remaining case with incomplete controlled disease for 27 months. The overall prognosis of SNUC is very poor. We consider that more intensive multimodality therapies are recommended for all patients with SNUC.