Patient satisfaction with expanded polytetrafluoroethylene (Softform) implants to the perioral region.

OBJECTIVE: To assess clinical results in patients undergoing implantation of expanded polytetrafluoroethylene (Softform) for perioral enhancement (melolabial fold, melomental fold, upper lip, and lower lip). DESIGN: Fifty patients had undergone Softform implantation by a single surgeon. A retrospective telephone survey (25 questions) was conducted. Of 50 patients, 38 (76%) were contacted. The mean interval between the procedure and survey was 22.7 months (range, 2-40 months). Responses were submitted for statistical analysis. A pathological review was performed on specimens removed from 2 patients. RESULTS: Two patients (4%) developed postoperative infections that resolved with use of oral antibiotics; 5 patients (10%) requested repositioning owing to dissatisfaction with placement; and 5 patients (10%) requested implant removal. Composite scores indicated that patients were "slightly" satisfied with the procedure outcome. Of the 38 patients contacted, 24 (63%) would undergo additional implants and 20 (53%) would recommend the procedure to others. Results were not significantly influenced by site, size, or history of prior augmentation procedures. Histologic review indicated that implants elicit a chronic inflammatory reaction and that blood vessels infiltrate the porous walls of the implant. CONCLUSION: With proper patient selection, Softform represents a potential option for those individuals considering perioral enhancement.

Laryngeal verrucous carcinoma: a clinicopathologic study and detection of human papillomavirus using polymerase chain reaction.

Laryngeal verrucous carcinoma (LVC) is a rare, well-differentiated variant of squamous carcinoma with a low malignant potential. Human papillomavirus (HPV)-16 DNA has been identified in a small number of LVC and an etiologic relationship has been suggested. A correlative clinical and molecular pathological study was performed in order to determine the prevalence and typing of HPV DNA in LVC. Possible associations between patient and tumor subsets, and the presence of HPV DNA were also investigated. Formalin-fixed, paraffin-embedded tissue samples from 29 patients with LVC were examined by polymerase chain reaction (PCR) using DNA primers specific for HPV types 6b/11, 16, and 18. Overall, HPV DNA was detected in 13 (45%) of the cases. Of these, HPV-16 DNA, HPV-18 DNA, and both HPV-16 DNA and HPV-18 DNA were detected in 4 (14% overall; 31% of positive cases), 4, and 5 (17% overall; 38% of positive cases), respectively. HPV-6b/11 DNA was not detected in any LVCs. In 16 cases, no HPV DNA was detected. There was a trend toward HPV DNA detection in higher stage tumors. HPV DNA detection was unrelated to patient age, tumor site, or radiotherapeutic responsiveness. The detection of HPV DNA in 45% of LVCs suggests an association between the presence of HPV-16 DNA and HPV-18 DNA, and some LVCs.

Accuracy of pathologic diagnosis in thyroid lesions.

Although there is much literature devoted to the role that fine-needle biopsy plays in the management of the thyroid mass, only a handful of studies deal with the diagnostic accuracy of the frozen section and final paraffin section of thyroid lesions. Fine-needle biopsy results, frozen-section diagnoses, final paraffin-section diagnoses, and panel review diagnoses were recorded for 137 consecutive patients who underwent thyroidectomy procedures. The overall accuracy of fine-needle biopsy, frozen-section, and paraffin-section diagnoses was 81%, 87%, and 94%, respectively. The high positive predictive value and specificity of both the fine-needle and frozen-section modalities suggests that intraoperative pathology consultation, given that the preoperative needle aspirate is positive for malignant neoplasia, can offer little further in the treatment of the patient. Statistical analysis of the accuracy of the three modalities suggests strategies for accurate treatment of the thyroid nodule.

Hyoid bone involvement by squamous cell carcinoma: clinical and pathological features.

The incidence of hyoid bone involvement by neoplasia is undetermined, despite its importance in hyoid-preserving surgery. Eleven (1.46%) of 755 whole-organ laryngeal specimens examined demonstrated hyoid bone infiltration. These included 6 cases originating from the larynx, 3 from the vallecula, and 1 case each from the pyriform fossa and tongue base. Clinically, vallecular involvement was helpful in determining hyoid invasion; however, computed tomography (CT) was disappointing. The greater cornu was the sole site of invasion in six cases. Ten of 11 cases were secondary to direct tumor spread. All carcinomas were advanced, with variable differentiation. Vascular and neural invasion was a prominent feature. Hyoid bone invasion is rare, and associated with a poor prognosis. Hyoid bone preservation is feasible in a majority of patients.

The pathobiology of salivary gland. I. Growth and development of rat submandibular gland organoids cultured in a collagen gel matrix.

Fragments of rat submandibular gland (organoids) which maintained the topological organization of the parent tissue were cultured in a three-dimensional collagen gel matrix for up to 30 days. At 48 h, vigorous peripheral outgrowth had occurred around each organoid. This was accompanied by central necrosis and the bridging of adjacent organoids. By day 5, large cyst-like spaces occupied the centre of many organoids. Bromodeoxyuridine labelling indicated that a considerable proportion of the lining cells were proliferating. Organoid growth peaked at between 5 and 10 days. Thereafter, the number of viable colonies and proliferating cells declined. Addition of isoproterenol after 24 h culture resulted in marked morphological alterations, with earlier and more prolific outgrowth and a greater tendency for organoids to flatten and grow out over the surface of the gel with squamous differentiation. Ultrastructurally, nuclear and cytoplasmic features of isoproterenol-treated and untreated cultures were similar. The secretory granules and extensive rough endoplasmic reticulum of terminal tubule cells, evident in organoids immediately after isolation, were infrequent after 24 h and absent by 48 h. Similar alterations occurred in the few acinar cells, so by 5 days the cultures were composed entirely of a uniform population of primitive, dedifferentiated cells. Further uses of this culture systems will include the study of diseases and disorders of the salivary glands as well as normal growth and differentiation pathways.

Myoepithelioma--new concepts of histology and classification: a light and electron microscopic study.

Based on histological, immunohistochemical, and ultrastructural studies, it is now apparent that the modified myoepithelial cell component of pleomorphic adenomas has a considerable range of cytological features. We reasoned that myoepitheliomas could be tumors with a similar spectrum of neoplastic myoepithelium but lacking the ductal element displayed in pleomorphic adenomas. A review of available salivary gland tumors identified 40 examples based on this definition. Architecturally, these myoepitheliomas displayed either nonmyxoid (solid), myxoid (pleomorphic adenoma-like), reticular (canalicularlike), or mixed growth patterns, while cytologically the lesions were composed of spindle-type (32.5%), hyaline-type (7.5%), epithelial-type (45.0%), clear-type (2.5%), or mixed-type (12.5%) tumor cells. Electron microscopy was carried out on eight examples and detailed immunohistochemistry on two methanol-fixed cases. As a result of the current review of myoepitheliomas and the description of similar lesions in the literature, it is our contention that salivary gland myoepitheliomas are not as rare as has been purported.

Ultrastructural contributions to the study of morphological differentiation in malignant mixed (pleomorphic) tumors of salivary gland.

Ultrastructural studies of pleomorphic adenoma have shown a coordinated differentiation of luminal epithelial and modified myoepithelial cells with the latter cells related to processes resulting in the myxochondroid stroma. Five examples of various histologic types of malignant mixed tumor of parotid origin were examined by electron microscopy to see if underlying patterns of tumor cell differentiation and organization matched those of pleomorphic adenoma. Whether they were intracapsular tumors (with or without identifiable pleomorphic adenoma), carcinomas ex pleomorphic adenoma, or a true malignant mixed tumor, all lesions had cell types and organizations either identical to those in pleomorphic adenoma or, as in less-differentiated examples, displayed features suggesting origin from luminal cells, myoepithelial cells, or both. Even the chondroid cells in the true malignant mixed tumor expressed ultrastructural features indicating their epithelial derivation. On the basis of these findings, some alterations to the classification and terminology of the subtypes of malignant mixed tumor are suggested.

T3N0M0 glottic carcinoma--a pathologic analysis of 41 patients treated surgically following radiotherapy.

Forty-one patients undergoing surgery for recurrent or residual tumour following radical radiotherapy for T3N0M0 glottic carcinoma had their larynges evaluated pathologically by whole organ laryngeal sectioning. All patients had been staged initially as T3N0M0 glottic carcinoma and treated according to a protocol of radical radiotherapy (50-55 Gy in 4-5 weeks) with surgery reserved for radiation failure. Seventeen of the 41 patients died as a result of locoregional or distant recurrence or complications following surgery. Twenty-four patients were either alive or dead with intercurrent disease. Pathologic staging demonstrated 58% of these tumours to be rpT4, 29% rpT3 and the remainder rpT0-2. The incidence of major cartilage invasion, vascular or perineural invasion, and subglottic extension greater than 15 mm was more frequent in patients with locoregional recurrence than in patients without recurrence. The presence of these pathologic features had a positive predictive value of 0.78 in relation to probability of locoregional failure. In addition, there was a significant difference in the frequency of these pathologic features between patients with and without locoregional recurrence (P less than 0.001). The frequency of positive margins (19%) and pattern of involvement are described. The incidence of occult nodes (0%) in patients undergoing neck dissection is presented. The frequency (23%) and pattern of osteo-chondroradionecrosis are also described. The patterns of growth and spread observed were similar to those described previously. The importance of performing wide surgical resections in patients with recurrence following radiotherapy is emphasized.

Primary thyroid thymoma: a distinct clinicopathologic entity.

A 51-year-old man presented with a paratracheal tumor. He had undergone resection of a thyroid tumor 15 years previously; at that time, the histologic diagnosis had been anaplastic carcinoma. When the tumor recurred, the presumptive clinical diagnosis was medullary thyroid carcinoma. Histologic examination revealed a poorly differentiated epithelial tumor with immunoreactivity for keratins, carcinoembryonic antigen, and, focally, S-100 protein. The tumor was negative for calcitonin and thyroglobulin. There were scattered lymphocytes and plasma cells. Ultrastructural examination showed elongated epithelial cells with prominent desmosomes and bundles of cytoplasmic tonofilaments but no secretory granules; amyloid was not present ultrastructurally or histochemically. The characteristic ultrastructural and immunocytochemical features and the clinical behavior of this tumor verify the existence of primary thyroid thymoma. This new primary thyroid neoplasm is of clinical importance, considering the more benign behavior of primary thyroid thymoma than of other tumors in the differential diagnosis of this lesion.

T3N0M0 glottic carcinoma--a failure analysis.

There is at present considerable controversy regarding the appropriate management of a patient who presents with a T3N0M0 glottic carcinoma. This paper presents the results for 141 patients presenting clinically with T3N0M0 glottic carcinoma between 1964 and 1981 and treated with primary radiotherapy reserving surgery for residual or recurrent disease. The actuarial survival for the entire group of patients was 50.5% at 5 yr; 28% of the patients died of glottic cancer. The local relapse-free rate achieved with radiotherapy was higher in female patients (68%) than male patients (41%) (P = 0.04); the local relapse-free rate was higher in males 60 yr of age or older (46%) than in males 59 yr of age or younger (31%) (P = 0.02). Involvement of all three laryngeal regions and initial tracheotomy were associated with a high primary failure rate. Fifty-nine per cent of patients alive at 5 yr retained and intact and functioning larynx. The time up until diagnosis of recurrence and the number of endoscopies required to establish recurrent or residual disease were all assessed with respect to their effects on survival and were shown to have no significant impact. Methods of improving the results of treatment for those patients with a high primary failure rate following radiotherapy are discussed.

Polymorphous low-grade adenocarcinoma: a case report with ultrastructural findings.

A specimen of a polymorphous low-grade adenocarcinoma of minor salivary gland origin in the nose, originally diagnosed as an adenoid cystic carcinoma, was examined by electron microscopy. The tumor cells forming narrow, anastomosing trabecular cords in histologic sections were almost exclusively well-differentiated myoepithelial cells when examined with the electron microscope. Adenoidal regions within and between the columns of tumor cells resulted from the production of excessive amounts of basal lamina and glycosaminoglycans. In one focal region, glandular lumina were formed within the trabecular cords and more solid regions of the tumor. By both immunohistochemistry (anticytokeratins and anti-S 100 protein) and electron microscopy, transitions from the principal tumor cells comprising the trabecular cords (myoepithelial cells) to luminal epithelial cells could be detected. Since the patient is free of recurrence or metastases 7 years after limited surgical resection of the tumor, the designation of polymorphous low-grade adenocarcinoma seems quite appropriate.

Characterization of epimyoepithelial islands in benign lymphoepithelial lesions of major salivary gland: an immunohistochemical and ultrastructural study.

Knowledge of the processes leading to the development of epimyoepithelial islands bears on histogenetic and morphogentic processes in salivary gland tumors. Immunohistochemical and ultrastructural investigations of the cellular composition of epimyoepithelial islands were carried out on three examples of benign lymphoepithelial lesions with varying histologic features. The monoclonal anti-keratin antibody 312C8-1, which specifically decorates myoepithelial cells of the normal salivary gland, also stains the myoepithelial cells surrounding residual acini and intercalated ducts in benign lymphoepithelial lesions and the cell population of epimyoepithelial islands, with the exception of persisting luminal epithelial cells. Ultrastructurally, the myoepithelial cells of involuting acini and ducts and the modified myoepithelial cells of epimyoepithelial islands, identified in both locations by the monoclonal antibody 312C8-1, show an increasing complement of tonofilament bundles. In addition, persisting lumens (often distended with lymphocytes) and definite luminal epithelial cells can be seen in electron micrographs of some epimyoepithelial islands. The designation for this characteristic epithelial feature of benign lymphoepithelial lesions is therefore appropriate.

Lipid degeneration in pheochromocytomas mimicking adrenal cortical tumors.

A case of bilateral adrenal pheochromocytomas with unusual morphologic features is reported in a 27-year-old man with a family history of von Hippel-Lindau disease. In both glands, the medulla was replaced by neoplasms with two distinct gross and microscopic appearances. There was typical pheochromocytoma in areas of dusky red tissue. The yellow nodules noted on gross examination were microscopically composed of large cells with vacuolated cytoplasm. Fat stains confirmed the presence of lipid in these areas. Immunohistochemistry revealed positivity for neuron-specific enolase and chromogranin in the cytoplasm of pheochromocytes, as well as in the perinuclear cytoplasm and processes of cells scattered in the yellow nodules. Ultrastructural examination of the yellow lesions showed characteristics of pheochromocytoma and an extensive accumulation of lipid. Although gross and light-microscopic examination of the yellow tissue suggested adrenal cortical nodules, immunohistochemistry and electon microscopy elucidated lipid degeneration within pheochromocytoma, a finding not previously described.

Ultrastructural morphology and cellular differentiation in acinic cell carcinoma.

Acinic cell carcinomas, in some instances, contain a component of intercalated duct cells. However, the manner in which this element is integrated within the more obvious acinar cells, as well as the role neoplastic intercalated duct cells play in determining morphologic patterns in acinic cell tumors, has not been fully investigated. Ultrastructural study and immunostaining with antibodies to cytokeratins and to S-100 protein carried out in nine cases of parotid acinic cell carcinoma suggest two basic differentiation patterns. In three cases, the lesions were essentially composed of acinar cells (with variation in the number and form of secretory granules), and one of these tumors was unique in having ultrastructural evidence of differentiated myoepithelial cells. In the second group of six cases, there was light microscopic, ultrastructural, and immunohistochemical evidence of a significant component of intercalated duct cells. By means of both immunostaining (intercalated ducts were positive for keratin and S-100 protein; acinar cells were negative for both antigens) and electron microscopy, flattened-to-cuboidal intercalated duct cells were noted to enclose and, presumably, to be involved in the formation of microcystic spaces. Acinic cell carcinomas with a more solid growth pattern contained groups of intercalated duct cells positive for keratin and S-100 protein. Ultrastructurally, these cells were organized into well-formed ducts related to nests of acinar cells. Acinic cell carcinoma is another class of salivary gland tumor in which there can be an integrated proliferation of intercalated duct and acinar cells and, infrequently, of myoepithelial cells, all organized in a simulation of the intercalated duct-acinar unit of the normal salivary gland.

Diffuse epithelial mesothelioma: a review of the ultrastructural spectrum.

Traditionally, diffuse epithelial mesotheliomas are mainly identified at the ultrastructural level by the numerous, long, wavy-appearing surface microvilli. By electron microscopy of a series of diffuse mesotheliomas of varying subtype (epithelial, biphasic, sarcomatous, and poorly differentiated), it can be demonstrated that the differentiation of this specialized surface organelle is quite variable even in well-differentiated lesions. The presence of only a few, scattered, short microvilli does not exclude a diagnosis of epithelial mesothelioma, particularly if historical, surgical, and radiologic findings support this diagnostic conclusion. Indeed, even the complete absence of surface microvilli is compatible with a diagnosis of diffuse epithelial mesothelioma. It is important to become aware of the spectrum of tumor cell differentiation in serosal tumors, as all of the fine structural diagnostic criteria in mesotheliomas are expressed to varying degrees in individual cases.

The quiet revolution. Techniques of cell biology applied to tissue diagnosis.

In the past decade many of the techniques of cell biology developed in the research laboratory have been applied to tissue diagnosis. Increasing use of electron microscopy has allowed ready differentiation of many neoplasms with an identical appearance under the light microscope. The identification of highly specific antigenic substances in individual cells using monoclonal antibodies in the immunoperoxidase technique has allowed a degree of diagnostic accuracy not previously available in tissue diagnosis. Recent efforts have been directed at more accurately predicting biological behavior on the basis of cellular characteristics. Techniques being introduced include morphometry (computer-assisted image analysis), cytophotometry (measurement of cellular DNA content), flow cytometry (analysis of cells in suspension for DNA content and other physical and chemical properties), scanning electron microscopy, and cytogenetics (the study of cellular chromosomes).

Verrucous carcinoma (Ackerman's tumor) of the larynx: diagnostic and therapeutic considerations.

Verrucous carcinoma (Ackerman's tumor) is a low-grade malignant lesion with distinct clinical and pathologic features, distinguishing it from other well-differentiated squamous cell carcinomas. Much of the confusion surrounding its natural history, response to therapy, and anaplastic transformation may be ascribed to the failure of critically reviewing accepted diagnostic criteria. A series of 44 patients with verrucous carcinoma of the larynx is presented, 18 of these being updated results of previously reported patients. Ackerman's tumor, although not radioresistant, seems less radiosensitive than ordinary squamous cell carcinoma. The tumor's rounded, pushing margins and inability to metastasize would seem to favor endoscopic removal, saving partial laryngectomy procedures for those lesions that cannot be managed endoscopically. Extensive lesions that would require total laryngectomy for complete removal of the tumor should be treated by primary radiotherapy. It is our belief that total laryngectomy should only be performed in large lesions that fail to respond to radiotherapy and whenever medical considerations preclude partial laryngectomy procedures.

Prognostic significance of thyroid gland involvement in laryngeal carcinoma.

We reviewed 173 laryngeal specimens that included thyroid tissue received from patients undergoing laryngectomy between 1966 and 1980 for evidence of thyroid gland invasion. Twenty-three (14%) of the larynges demonstrated thyroid involvement. In 15 specimens, involvement of the thyroid gland was by direct extension, and in eight the thyroid was involved metastatically. The survival in this group of patients was poor, with 18 patients dying of their disease within three years. Subglottic extension of 10 mm or greater was noted in 21 of 23 patients, and local recurrence was noted in 15 of 18 patients dying of their disease. The importance of removing one or both lobes of the thyroid gland in advanced laryngeal cancer is restated, and a surgically aggressive approach to the paratracheal nodes is recommended in patients with extensive subglottic involvement.

Basal cell adenoma with myoepithelial cell-derived "stroma": a new major salivary gland tumor entity.

The light microscopic, immunohistochemical, and ultrastructural features of a unique variant of tubular-trabecular basal cell adenoma are described. The unusual feature of the six examples reported is the richly cellular "stroma" composed of spindle cells coursing between the anastomosing cords of epithelial tumor cells. Immunohistochemistry of all six cases and electron microscopy of two examples illustrated the biphasic differentiation of the epithelial portion of this form of basal cell adenoma, with a central core of duct luminal cells bordered on either side by one or more layers of modified myoepithelial cells. By light microscopy, the features and arrangement of cells in "stromal" regions of this tumor convey a fibroblastic derivation. However, this population of cells stains strongly for S-100 protein, ultrastructurally displays excessive external lamina production, intercellular junctions, and a growth pattern unlike fibroblasts, and is involved in the formation of extracellular mucinous materials. Such aspects indicate a second population of neoplastic myoepithelial cells in this tumor. Thus, this form of tubular-trabecular basal cell adenoma displays tricellular differentiation and, perhaps, may be considered either a hybrid basal cell adenoma and myoepithelioma or a cellular pleomorphic adenoma.