Combined Simultaneous Multiportal Approach via Minimally Invasive Transciliary and Endoscopic Endonasal Approaches for Tumors Invading Both the Skull Base and the Sinonasal Area.

BACKGROUND: A combined transcranial and transfacial approach has long been the gold standard for surgical management of large tumors with sinonasal and skull base involvement. The extended endoscopic endonasal approach for such pathologies has its advantages, but it has flaws as well, such as anatomic limitations and more ponderous skull base reconstruction and thus higher risk of postoperative complications. Our primary technique for surgical treatment of these pathologies has been a combination of transfacial and minimally invasive transciliary supraorbital keyhole approaches. With the aim to further minimize invasiveness, potential complications, and unsatisfactory aesthetic outcomes during surgical treatment of large tumors invading both the sinonasal area and the skull base, we abandoned the transfacial approach and simultaneously combined the transciliary supraorbital keyhole approach with the endoscopic endonasal approach. METHODS: The well-known microscope-assisted minimally invasive approach via a transciliary supraorbital keyhole craniotomy was combined with the endoscopic endonasal approach. RESULTS: Six patients with different histologic types of tumors affecting the sinonasal area and the skull base were operated on. The mean operative time was 3 hours, there were no unexpected intraoperative or postoperative complications, and total tumor removal was achieved in each patient. None of the patients experienced complications associated with the surgery during follow-up. CONCLUSIONS: Our combined simultaneous multiportal approach enables total tumor eradication with reduced operative time and is associated with minimal intraoperative and postoperative complications, low mortality rate, and excellent cosmetic results.

Verrucous Carcinoma of the Vulva: A Case Report and Literature Review.

BACKGROUND Verrucous carcinoma (VC) of the vulva is a variation of squamous carcinoma (SCC). Etiology and treatment of VC are still unclear. CASE REPORT A 50-year-old female visited our clinic with a giant vulvar tumor (8 cm of diameter maximum). Biopsy revealed a suspicious well differentiation squamous cancer. PET/CT (positron emission tomography/computed tomography) scan found suspicious lymph node in bilateral iliac vessel region and bilateral inguinal region. She underwent radical vulvectomy and bilateral inguinal lymph node dissection, and bilateral pelvic lymph node dissection. Pathology turns out to be VC and no lymph nodes involvement. Due to the large defection, vulvar reconstruction was performed 5 weeks later using skin grafts and pudendal thigh flap. This patient was disease free after 12 months follow-up. CONCLUSIONS In patients with VC, a satisfactory biopsy is important and systemic inguinal lymphadenectomy might be omitted. For patients with large defection, flap-based reconstruction is recommended.

Carcinoma verrucoso esofágico: una rara entidad de difícil diagnóstico / Verrucous carcinoma of the esophagus: A rare entity with a difficult diagnosis

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Tumor de Ackerman del pene / Ackerman's tumor of the penis

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Vascularity as assessed by Doppler intraoral ultrasound around the invasion front of tongue cancer is a predictor of pathological grade of malignancy and cervical lymph node metastasis.

OBJECTIVES: To quantitatively evaluate the relationship of vascularity of tongue cancer as demonstrated on intraoral ultrasonography images and tumour thickness with pathological grade of malignancy and the presence of cervical lymph node metastases. METHODS: 18 patients with tongue cancer were enrolled in this retrospective study. Using Doppler ultrasonography images of the invasion front of the cancers along the length of their tumour boundaries, three vascular indexes were analysed quantitatively, namely ratio of blood flow signal area within the cancer to whole tumour area (BAR), blood flow signal number ratio (BNR) and blood flow signal width ratio (BWR). The associations between these three indexes and occurrence of cervical lymph node metastasis and pathological grade of malignancy [Yamamoto-Kohama (YK) classification] were assessed. Furthermore, the relationship between tumour thickness and occurrence of cervical lymph node metastasis was evaluated on B-mode intraoral ultrasonography images. RESULTS: There was no significant association between BAR and tumour thickness or occurrence of cervical lymph node metastasis. The BNRs and BWRs of patients with cervical lymph node metastasis were significantly higher than those of patients without nodal involvement. The BWRs of patients with high-grade malignancy (YK-4C) were significantly higher than those of patients with low-grade malignancy (YK-2 or 3). CONCLUSIONS: BNR and BWR on the invasion front of the tongue cancer are predictors of pathological grade of malignancy and cervical lymph node metastasis.

Can dual-energy CT improve the assessment of tumor margins in oral cancer?

OBJECTIVES: The aim was to investigate the image quality of dual-energy computed-tomography (DECT) compared to single-energy images at 80 kV and 140 kV in oral tumors. MATERIALS AND METHODS: Forty patients underwent a contrast-enhanced DECT scan on a definition flash-CT. Four reconstructions (80 kV, 140 kV, mixed (M), and optimum-contrast (OC)) were assessed by four blinded readers for subjective image quality (10-point scale/10=best). For objective quality assessment, linear attenuation measurements (line density profiles (LDP)) were positioned at the tumor margin, and the difference between minimum and maximum was calculated. Signal-to-noise ratios (SNR) were measured in the tongue. RESULTS: The mean image quality for all readers was 5.1±0.3, 8.4±0.3, 8.1±0.2, and 8.3±0.2 for the 140 kV, 80 kV, M, and OC, respectively (P<001 between 140 kV and all others). The mean difference between the minimum and maximum within the LDP was 139.4±59.0, 65.7±29.5, 105.1±46.5, and 118.7±59.4 for the 80 kV, 140 kV, M, and OC, respectively (P<001). The SNR for the tongue was 3.8±2.1, 3.8±2.1, 4.2±2.4, and 4.1±2.3 for the 80 kV, 140 kV, M, and OC, respectively. DISCUSSION: DECT of oral tumors offers high image quality, with subjectively rated image quality and attenuation contrast at the tumor margin similar to that of 80 kV; DECT, however, provides a significantly higher SNR compared to 80 kV.

Linitis-like squamous esophageal cancer diagnosed by endoscopic ultrasonography-guided fine-needle aspiration cytology: report of two cases.

Endoscopic ultrasonography-guided fine-needle aspiration cytology (EUS-FNA) may provide full-thickness biopsies, adequate for cytology and histology. In the present case report, we describe the first cases of a rare well-differentiated squamous esophageal carcinoma (verrucous esophageal cancer), finally diagnosed by EUS-FNA using a large FNA needle after several upper endoscopies with biopsies negative for malignancy. In this report, we highlight the usefulness of this procedure and EUS features in the diagnosis of suspicious esophageal lesions with negative endoscopic biopsies for malignancy.

Bilateral fungiform papilloma with synchronous verrucous carcinoma of the nasal septum: a rare presentation and a literature review.

AIM: Fungiform papillomas are benign mucosal neoplasms presenting as a unilateral exophytic mass involving the anterior portion of the nasal septum. In this study, we present an exceptional case of a bilateral fungiform papilloma with a synchronous verrucous carcinoma of the nasal septum. MATERIAL AND METHODS: A case study with a review of the literature concerning malignant changes in fungiform papilloma. RESULTS: The general consensus in most of the literature is that malignant change in fungiform papilloma is exceptional. Our patient is probably the third reported case of verrucous carcinoma of the nasal septum, and the first report of a bilateral fungiform papilloma with a synchronous verrucous carcinoma. The tumour was subjected to complete surgical removal in the first instance. There was no recurrence at follow up seven months after surgery. CONCLUSION: Although fungiform papillomas are generally not premalignant, occasional malignant transformation may occur. Thus, they must be managed with the utmost cautiousness.

Verrucous carcinoma of the esophagus: a rare variant of squamous cell carcinoma for which a preoperative diagnosis can be a difficult one to make.

Verrucous carcinoma of the esophagus is an extremely rare entity. It is associated with severe epithelial hyperplasia and parakeratosis of the epithelial layers. Superficial biopsies are usually falsely negative for malignant cells, as the biopsied mucosa usually demonstrates the hyperplastic epithelium. The tumor spread is through submucosal and paraesophageal infiltration. Endoscopically, verrucous carcinoma appears as a wartlike, exophytic lesion, hence the name verrucous. The diagnosis can be difficult to make, even after repeated endoscopic biopsies. We report a rare case of verrucous carcinoma of the esophagus in a 45-year-old man whose final pathologic diagnosis was confirmed only after an Ivor-Lewis esophagectomy was performed.

Verrucous carcinoma of the foot affecting the bone: utility of the computed tomography scanner.

Verrucous Carcinoma (VC) of the foot often affects deep structures such as tendons, muscles or bone. The complete removal of the tumor is essential to avoid recurrences. Radiological studies should be performed before surgical planning in order to determine the extent of the tumor. A 54-year-old man presented with a VC of the foot. Magnetic resonance imaging (MRI) demonstrated a soft-tissue mass affecting the plantar aponeurosis and the sole muscles, without evidence of bone invasion. Computed tomography (CT) showed a lytic area with cortical disruption in the fourth metatarsal neck. A transmetatarsal amputation was performed. Histopathological examination confirmed the bone invasion. MRI is considered the imaging technique of choice in studying VC of the foot. Computed tomography is superior to MRI in determining minimum changes in the cortical bone related to tumor invasion. We conclude that when MRI images are not conclusive, CT scan is a good alternative to determine incipient bone invasion.

Combined ultrasound and magnetic resonance imaging findings on cervical verrucous carcinoma with endometrial invasion: a case report.

BACKGROUND: Cervical verrucous carcinoma is a rare form of cervical cancer. Very few reports present the correlation between diagnostic images and clinicopathologic findings. CASE: A 50-year-old woman was treated with laser ablation for cervical condyloma 6 years prior to her presentation with progressive vaginal bleeding and a foul-smelling discharge at our clinics in August 2004. Biopsy of the cervical mass was compatible with pathologic features of condyloma acuminata. Ultrasonography with color Doppler revealed a 5.9x4.1-cm, hyperechogenic mass with a honeycomb appearance in the lower uterine corpus and hypervascularization of the tumor with resistance indexes ranging from 0.41 to 0.47. Magnetic resonance imaging (MRI) showed that the tumor had a homogeneous intensity on T1-weighted images and heterogeneous intensity on T2-weighted images. After administration of contrast medium, the tumor exhibited a lower signal intensity than did the surrounding cervical stroma. A human papillomavirus test was positive for types 11 and 53. Combined with the clinicopathologic findings, verrucous carcinoma of the cervix, stage Ib2, was suspected and the patient underwent radical hysterectomy and bilateral pelvic lymph node dissection. The final pathology report proved the impression of malignancy. The patient had an uneventful postoperative course, and no disease recurred during 1 year of follow-up. CONCLUSION: The diagnosis of cervical verrucous carcinoma requires a good clinical and pathologic correlation. Nevertheless, detailed imaging studies, such as ultrasound and MRI, as in our case, may provide valuable presurgical information for treatment.

[Oral verrucous carcinoma]. / Le carcinome verruqueux oral.

Verrucous carcinoma is a rare, low-grade, well-differentiated form of squamous cell carcinoma seen on skin and mucosa. It is a slow-growing and locally aggressive tumor whose standard treatment is surgery. A case of strongly invasive oral verrucous carcinoma is presented with the medical history. The differential diagnosis of this neoplasm is difficult and requires clinic and pathologic data confrontation. In this paper, the importance of knowing the malignant potential of this lesion is stressed. Indeed, in 20% of verrucous carcinoma, foci of squamous cell carcinoma can be found. A review of literature and a differential diagnosis of verrucous carcinoma are presented.