Lymph node metastasis in thyroid papillary microcarcinoma: a study of 170 patients.

OBJECTIVE: Papillary microcarcinoma of the thyroid has been described as either a normal variant or a serious malignancy. We describe our experience with papillary microcarcinoma and lymph node metastases. METHOD: A total of 685 consecutive total thyroidectomies with central compartment neck dissection were reviewed for papillary microcarcinoma. Association of central compartment lymph node metastases with age, gender, tumour multifocality, bilaterality and extrathyroidal extension was analysed. RESULTS: Out of 170 papillary microcarcinoma cases, multifocality was found in 72 (42.4 per cent), bilaterality in 49 (28.8 per cent) and extrathyroidal extension in 16 (9.4 per cent). In all, 23 patients (13.5 per cent) had lymph node metastases. There was a significant association (p < 0.05) between extrathyroidal extension (but no other tumour characteristics) and lymph node metastases. CONCLUSION: In all, 13.5 per cent of papillary microcarcinomas in our series showed lymph node metastases. Lymph node metastases were associated with extrathyroidal invasion of the papillary microcarcinoma.

Skin metastases in squamous cell carcinoma of the head and neck.

UNLABELLED: Distant metastases in squamous cell carcinoma of the head and neck (SCCHN) are most often to the lung, liver, and bone. SCCHN rarely metastasizes to skin sites. OBJECTIVE: To ascertain the significance of skin metastases (SM) on the prognosis of patients with SCCHN. METHODS: A retrospective review of all patients between 1987 and 1999 with SCCHN was conducted. Patients in whom SM developed were identified. Data pertaining to demographics, primary tumor staging, SM development, and outcome were investigated. RESULTS: In 798 consecutive patients diagnosed with SCCHN between 1987 and 2000, 19 developed SM. The average time of onset of the SM was 17.65 months. The average survival time was 7.2 months after the development of SM. The overall survival time of patients who developed SM from the initial presentation of the primary tumor was 24.85 months. The 1-year survival rate from the time of development of SM was 0%. CONCLUSIONS: Metastasis to skin sites is an uncommon feature of SCCHN. SM may represent the first clinical evidence of impending loco-regional recurrence or distant metastasis. The development of SM is an ominous sign associated with an extremely poor prognosis, similar to the development of distant metastasis at more typical sites. Both the development of SM and survival of patients developing SM are independent of primary tumor stage. Current treatment options of SM are limited in their efficacy.

Analysis of human papillomavirus in schneiderian papillomas as compared to chronic sinusitis and normal nasal mucosa.

Schneiderian papillomas (SPs) are tumours arising from the surface epithelium (schneiderian epithelium) of the nasal cavity and paranasal sinuses. Evidence points toward a viral etiology, specifically human papillomavirus (HPV). Although substantial data indicate HPV as a likely etiology, little is known about the role of HPV in benign nasal pathologies or in normal nasal mucosa. The objective of this study was to characterize the relationship between HPV and SP, chronic sinusitis (CS), and normal nasal mucosa. A case-control study was undertaken, matching patients with SP to patients with CS. Patients with normal nasal mucosa served as a control group. All patients had their tissues analyzed for the presence of various HPV subtypes using line blot assay. A total of 168 patients were identified (74 SP, 74 CS, 20 control). Of these, 70 (41.7%) had detectable deoxyribonucleic acid and 9 of 70 (12.9%) had detectable HPV of subtypes 6, 11, and 16. None had detectable HPV type 18. Significant differences were detected in the presence of HPV in the CS, SP, and control groups, as well as in the presence of low- versus high-risk subtypes among investigation and control groups. Significant differences exist in HPV infectivity among SP, benign nasal pathologies such as CS, and normal nasal mucosa. Human papillomavirus plays an important role, at least in part, in the development of SP, with types 6, 11, and 16 being more pivotal than other types. Line blot assay is a useful technique in identifying HPV in SP.

Unique characteristics of malignant schneiderian papilloma.

PURPOSE: To ascertain the characteristics unique to malignant schneiderian papilloma (MSP). METHODS: A case-control study of all schneiderian papilloma (SP) patients treated between 1978 and 1997 was conducted. Comparison was made between patients with MSP and patients with benign SP (BSP). RESULTS: A diagnosis of SP was made in 72 patients. Malignant changes, all of them the inverted papilloma subtype, were found in 8 of these patients. Three were diagnosed carcinoma in situ, and 5 were defined as invasive squamous cell carcinoma. At presentation, the MSP patients had significantly larger tumor spread into the ethmoid and sphenoid sinuses. The recurrence rate was significantly lower in SP patients treated with extensive surgical procedures. An association was found between the presence of malignant lesions and positive smoking history, subjective awareness of a nasal mass, and ethmoid and sphenoid sinus involvement. Also, histologic multicentricity was a feature more often seen in MSP than BSP and was a significant correlate with malignancy. CONCLUSION: The physician evaluating a patient with SP should be aware of the features described and of their possible association with a malignant lesion.

Occult cervical metastases: immunoperoxidase analysis of the pathologically negative neck.

OBJECTIVES: The purpose of this study is to better estimate the true incidence of occult regional metastases associated with stage I and II squamous cell carcinoma of the oral cavity. The clinical and prognostic significance of micrometastatic disease discovered by cytokeratin immunoperoxidase reactivity in the previously pathologically N0 neck is also evaluated. METHODS: Forty patients treated between 1985 and 1996 with T1 or T2 squamous cell carcinoma of the lip and oral cavity were studied. All had primary surgical treatment including functional neck dissection. No metastases were demonstrated on hematoxylin and eosin microscopy. All specimens were reexamined with immunoperoxidase staining for cytokeratin. RESULTS: Five percent of patients had micrometastatic disease. Retrospective analysis of patients with a minimum follow-up of 2 years has failed to show a statistically significant association between a positive cytokeratin analysis and poor locoregional control or overall survival. CONCLUSIONS: Results suggest that the true incidence of occult metastases with carcinoma of the oral cavity is significantly higher than previously documented. However, the prognostic significance of these findings remains unclear.

Sinonasal schneiderian papilloma.

OBJECTIVE: Schneiderian papilloma of the paranasal sinuses is a locally aggressive benign epithelial tumour with malignant potential. METHOD: A retrospective analysis of 72 patients as seen at our institution from 1978 to 1997 was conducted. RESULTS: The most frequent symptoms at time of presentation were nasal obstruction, presence of a nasal mass, and nasal discharge. The most common sites of involvement were the maxillary antrum (58.3%), lateral nasal wall (41.7%) and ethmoid sinus (37.5%). Histologic examination confirmed all 72 instances of schneiderian papilloma, with 55/72 (76.4%) being of the inverted type, 13/72 (18.1%) being the fungiform type, and 4/72 (5.5%) being the cylindrical type. An associated malignancy or potential premalignant condition was present in 15 patients (20.8%), with 8 (11.1%) exhibiting dysplastic changes, 4 patients (5.5%) found to have carcinoma in situ, and 3 patients (4.2%) found to have invasive carcinoma. Conservative surgical excision was performed in 37 (51.4%) with more radical surgery, including lateral rhinotomy and medial maxillectomy performed in 35 (48.6%) patients. Recurrence was seen in 17/37 (45.9%) patients treated conservatively compared to 0/35 (0.0%) patients treated aggressively. CONCLUSIONS: Our results indicate that more aggressive surgery is associated with a more definitive treatment and significantly less recurrence and, as such, is the management of choice in cases of schneiderian papilloma. Furthermore, our results indicate the need for long-term follow-up, and the applicability of sinus endoscopy in doing so.

Overexpression of p53 protein does not predict local-regional control or survival in patients with early-stage squamous cell carcinoma of the glottic larynx treated with radiotherapy.

PURPOSE: Nonfunctional or mutated p53 protein (m-p53) is found in a myriad of solid tumors in humans. m-p53 is believed to confer radioresistance through inhibition of radiation-induced apoptosis. This study was carried out to determine if the overexpression of p53 in squamous cell carcinomas (SCC) of the glottic larynx treated with radiation therapy alone carried a poorer prognosis than normal wild-type p53 (w-p53) and could, therefore, be used as a marker of radioresistance in glottic SCC. METHODS & MATERIALS: Eighty-six patients with early-stage glottic SCC (64 T1N0, 25 T2N0 by TMN stage) treated with contemporary radiotherapy techniques to doses of 50-70 Gy were analyzed. Aberrant p53 protein was detected by immunohistochemical (IHC) staining on archival tissue samples containing original tumor specimens. Analysis of prognostic factors and treatment outcome to expression of p53 was performed. All patients were carefully selected to have comparable sites of disease, histology, early-stage disease, and treatment delivered, thus increasing the power of this study by controlling for other independent factors affecting outcome. RESULTS: Sixty percent of patients demonstrated overexpression of p53 in tissue samples. Accumulation of p53 was not predictive of tumor grade, stage, or smoking status prior to diagnosis. p53 status was not predictive of treatment outcome parameters including local-regional failure rate and disease-free survival rate. Factors significantly affecting treatment outcome were stage and dose of radiotherapy in T2 patients (50 Gy vs. > 62 Gy). CONCLUSION: m-p53 protein detected by IHC staining was not predictive as a prognostic factor for clinical outcome following radiation therapy for early-stage glottic SCC. This is in general agreement with other recently published studies of laryngeal carcinoma patients treated with radiation or surgery. At the present time, p53 status should not be used as a marker for prognosis and clinical outcome in laryngeal SCC.

Glottic microinvasive carcinoma: is it different from carcinoma in situ?

OBJECTIVE: To determine the impact of different treatment modalities on the outcome of microinvasive carcinoma. DESIGN: Retrospective review of patients presenting between 1976 and 1990. SETTING: Fifteen patients with microinvasive carcinoma (MIC) of the glottic larynx treated at McGill University teaching hospitals. METHODS: All patients had MIC involving the glottis confirmed pathologically. Nine patients (60%) had right vocal cord involvement, four (27%) had left vocal cord involvement, and two (13%) had involvement of both cords. Five patients (33%) were treated by stripping(S), three patients (20%) by stripping and radiotherapy (S + RT), and six patients (40%) by radiotherapy (RT) alone as the primary treatment. Only one patient underwent hemilaryngectomy. RESULTS: With a median follow-up time of 63 months (range 20-208 months), the 15-year actuarial survival rate is 100% for all patients. CONCLUSIONS: Surgery alone, RT alone, or S + RT is equally effective in treating MIC of the glottic larynx; however, single-modality therapy is preferred. The choice of treatment modality should be individualized for each patient.

Carcinoma in situ of the glottic larynx: excision or irradiation?

BACKGROUND: The management of glottic carcinoma in situ (CIS) is controversial, with vocal cord stripping (S) generally accepted as the standard treatment, and radiotherapy (RT) as an alternative. We present our experience with 34 patients treated by either stripping or RT. METHODS: ++Between 1974 and 1990, 34 patients with CIS of the glottic larynx larynx were treated at McGill University teaching hospitals. The median age at diagnosis was 67 years, with a male:female ratio of 6:1. All patients had CIS involving the glottis and the pathology was reviewed on all patients. Twenty-one patients were treated by S and 13 patients by RT as the primary treatment. RESULTS: With a median follow-up of 96 months (25-209 months), the 15-year actuarial survival rate is 95% for all patients, with 100% and 87% survival rates for S and RT groups, respectively (p = 0.25). One patient in the RT group developed a subglottic invasive squamous cell carcinoma. On the other hand, 11 patients in the S group developed recurrence and were treated by repeat S (6 patients) or RT (5 patients), with a salvage rate of 100%. CONCLUSION: Although most patients with CIS of the glottis are traditionally treated with vocal cord S, RT is effective in terms of freedom from recurrence; it is an attractive option and should be considered in patients with lesions recurring after stripping as well as in those whose follow-up presents a problem.

Intraparotid facial nerve schwannoma.

Intraparotid facial nerve schwannomas have been documented sporadically throughout the medical literature. These benign tumours of neurogenic origin should be considered in the differential diagnosis of parotid region masses. A case report is presented, followed by a brief literature review and discussion of appropriate diagnostic and treatment modalities.

Sarcomatoid carcinoma of the head and neck.

BACKGROUND: Sarcomatoid carcinoma (SC) of the upper aerodigestive tract is a rare malignancy of which the diagnosis, optimum treatment, and prognosis remain controversial. A series of 17 patients with SC is presented, along with an analysis of potential prognostic factors, outcome following treatment, and patterns of failure. MATERIALS AND METHODS: Hospital charts and pathology material were reviewed in all cases. The end points chosen were overall survival (OS), disease-free survival, and local control above the clavicles. RESULTS: There were 15 male and 2 female patients with a median age of 70 years. With a median follow-up length of 29 months, the median survival time was 32 months with an actuarial survival of 72% and 42% at 2 and 5 years, respectively. CONCLUSION: All recurrences were detected within 30 months from diagnosis. There was an OS advantage for patients with early-stage disease, patients with extralaryngeal presentations, and patients treated with surgery.

Pregnancy complicated by medulloblastoma with metastases to the placenta.

BACKGROUND: Maternal malignancy may complicate as many as one in 1000 pregnancies. Rarely, the tumor may metastasize to the products of conception. We here describe a case of medulloblastoma metastatic to the placenta. CASE: A 21-year-old woman who had previously undergone resection of a posterior fossa medulloblastoma was admitted at 20 weeks' gestation complaining of low back pain. Investigation revealed medulloblastoma metastatic to the bone marrow. The pregnancy was prolonged to 29 weeks' gestation, at which time she was delivered by cesarean. The postoperative course was complicated by coagulopathy, massive bleeding, and pneumonia leading to death. Autopsy showed medulloblastoma metastatic to the bone marrow and placenta. CONCLUSION: Primary intracranial neoplasms may metastasize to the products of conception. The dramatic course of the disease in this patient may suggest that medulloblastoma is responsive to hormonal therapy.

Trisomy 22 and facioauriculovertebral (Goldenhar) sequence.

We report on an infant girl born with complete trisomy 22 and left hemifacial microsomia, ear anomaly, and limbal and epibulbar complex choristoma. Trisomy 22 was confirmed by prometaphase chromosome analysis and in situ hybridization. This patient extends the list of chromosome abnormalities associated with apparent Golenhar sequence and emphasizes the importance of chromosome analysis in the investigation of patients with this condition. A detailed ophthalmopathological investigation is reported.

Fourth branchial cleft cyst.

Remnants of the fourth branchial arch are uncommon clinical entities. They may present in either the neck or chest in association with aortic arch development. They are encountered more frequently in younger individuals as an asymptomatic left-sided neck mass, recurrent neck abscess or suppurative thyroiditis. In view of the rarity of this lesion, we thought it worthwhile to present the case of a 25-year-old female with a diagnosed fourth branchial cleft cyst in her left lower neck. The embryology and management of these cases is discussed.

Spindle cell myoepithelioma of the nasal cavity.

Minor salivary gland neoplasms with mesenchymal-like features are uncommon in the sinonasal tract. We herein report a case of spindle cell myoepithelioma of the nasal cavity in a 69-year-old woman who presented with a rapidly expanding tumor accompanied by episodes of epistaxis. Although initially considered as a mesenchymal neoplasm, ultrastructural and immunophenotypical characterization demonstrated its myoepithelial nature. In the sinonasal setting, this unusual neoplasm may be confused with soft tissue tumors showing spindle cell or myxoid features. Staining for cytokeratin is found to be the most useful adjunct to diagnosis.

Triploidy arising from a first meiotic non-disjunction in a mother carrying a reciprocal translocation.

We report on a 22 year old mother, a carrier of a 6;14 balanced reciprocal translocation, who aborted a triploid conceptus carrying a similar translocation. We showed the maternal origin of this triploidy, after non-disjunction at meiosis I. The phenotypic expression as a non-molar pregnancy, the contribution of the maternal translocation, and possible aetiological factors of triploidy are discussed.

Multifocal cytomegalovirus-associated hepatic lesions simulating metastases in AIDS.

Fatty infiltration of the liver has been described in association with a large number of systemic conditions. The authors describe a case of multifocal fatty infiltration simulating metastatic disease. The patient had acquired immunodeficiency syndrome and pathologically proved cytomegalovirus hepatitis. To the authors' knowledge, neither entity has been described in association with this radiologic finding.