Jean Marc Dumollard

High duplication of the internal jugular vein: clinical incidence in the adult and surgical consequences, a report of three clinical cases

Duplication of the internal jugular vein (IJV) is a rare malformation. Three intraoperative cases are reported. In our personal experience, the clinical incidence of the anomaly is approximately 4 per 1,000 unilateral neck dissections. The venous duplication is at a variable height, affecting the superior part of the IJV. The lateral branch of the accessory nerve (XI) always passes medially to the anterior vein and laterally to the posterior vein, between the venous duplication. This is most often unilateral but sometimes bilateral. The IJV may be normal, dilated or ectatic. The discovery of this anatomical variation has practical implications during cervical lymph node clearance, either functional or radical, during oncological surgery necessitating viewing the IJV and its affluents and the lateral branch of the accessory nerve. The embryological explanation suggests a topographical conflict between the development of the IJV and the lateral branch of the accessory nerve. The French version of this article is available in the form of electronic supplementary material and can be obtained by using the Springer LINK server located at http://dx.doi.org/10.1007/s00276-002-0020-yRésuméLa duplication de la veine jugulaire interne (VJI) est une malformation rare. Trois observations per-opératoires sont rapportées. Dans notre expérience personnelle, lincidence clinique de cette anomalie est approximativement de 4 pour 1000 dissections cervicales unilatérales. La duplication veineuse est de hauteur variable, touchant la partie supérieure de la VJI. La branche latérale du nerf accessoire (XI) passe toujours médialement à la veine antérieure, latéralement à la veine postérieure, à travers la duplication veineuse. Celle-ci est le plus souvent unilatérale, parfois bilatérale. La VJI peut être normale, dilatée ou phlébectasique. La découverte de cette variation anatomique a des implications pratiques lors des curages cellulo-ganglionnaires cervicaux, fonctionnels ou radicaux à visée carcinologique, imposant le repérage de la VJI, de ses affluents et de la branche latérale du nerf accessoire. Lexplication embryologique privilégie un «conflit» topographique de développement de la VJI et de la branche latérale du XI.

Descriptive anatomy of the human auditory tube.

The aim of this study was to correlate current morphologic data relating to the lumen of the auditory tube. Four methods were used: dissection under the operating microscope; microendoscopy of the tubal lumen; optical and electron microscope histology; and MR or CT imaging. The auditory tube consists of two unequal cones, a small posterior third, fixed and osseous (protympanum), and a mobile fibrocartilaginous anterior two-thirds, both joined by the tubal isthmus, a short constriction which is pseudosphincteric at endoscopy. The tensor veli palatini muscle (TVPM) and the levator veli palatini muscle (LVPM) are the chief muscles that vary the tubal lumen of the fibrocartilaginous portion, which is collapsed at rest. CT and especially MR imaging allows their observation in static conditions. Serial histologic sections reveal the continuity between the TVPM and the tensor tympani muscle. The main cartilage framing the lumen varies in shape according to the level surveyed. The tubal mucosa is lined with an epithelium combining ciliated and mucus cells, involved in mucociliary drainage and gas exchanges in the auditory tube. These morphologic elements represent a basis for study of tubal physiology and for planning treatment in dysfunctions of the auditory tube.

Atypical presentations of solitary fibrous tumors of the central nervous system: an analysis of unusual clinicopathological and outcome patterns in three new cases with a review of the literature

Central nervous system (CNS) solitary fibrous tumors (SFTs) are rare mesenchymal neoplasms recognized less than a decade ago. Approximately 60 cases of SFT have been reported in the central nervous system. We describe three atypical SFTs of the CNS, two intracranial and one within the spine. One intracranial SFT arose from the sella turcica and expanded into the suprasellar areas. It relapsed twice during the 3 years following partial resection, and the MiB1 labeling index steadily increased without obvious malignant transformation. The second SFT arose from the confluence of the sinuses, widely invaded the lateral sinus and adjacent bones, had a low MiB1 index and has not recurred after 5 years. The intraspinal tumor occurred at T5–T7 in a patient with multiple café-au-lait spots, was predominantly myxoid and developed a second similar lesion at S3–S5 14xa0years later. The MiB1 index was lower in the second tumor. Immunohistochemistry confirmed that all were SFTs. These atypical presentations gave us an opportunity to provide further information about the natural histological course of CNS SFTs.

Descriptive anatomy of the human auditory tube@@@Anatomie descriptive de la lumière de la trompe auditive adulte humaine

SummaryThe aim of this study was to correlate current morphologic data relating to the lumen of the auditory tube. Four methods were used: dissection under the operating microscope; microendoscopy of the tubal lumen; optical and electron microscope histology; and MR or CT imaging. The auditory tube consists of two unequal cones, a small posterior third, fixed and osseous (protympanum), and a mobile fibrocartilaginous anterior two-thirds, both joined by the tubal isthmus, a short constriction which is pseudosphincteric at endoscopy. The tensor veli palatini muscle (TVPM) and the levator veli palatini muscle (LVPM) are the chief muscles that vary the tubal lumen of the fibrocartilaginous portion, which is collapsed at rest. CT and especially MR imaging allows their observation in static conditions. Serial histologic sections reveal the continuity between the TVPM and the tensor tympani muscle. The main cartilage framing the lumen varies in shape according to the level surveyed. The tubal mucosa is lined with an epithelium combining ciliated and mucus cells, involved in mucociliary drainage and gas exchanges in the auditory tube. These morphologic elements represent a basis for study of tubal physiology and for planning treatment in dysfunctions of the auditory tube.RésuméCe travail a pour but la confrontation des données morphologiques actuelles concernant la lumière de la trompe auditive (tuba auditiva) ou trompe dEustache. 4 méthodes ont été utilisées: la dissection effectuée avec un microscope opératoire, la micro endoscopie de la lumière tubaire, Ihistologie en microscopie optique et électronique, Iimagerie par résonance magnétique nucléaire ou tomodensitométrie. La trompe auditive est faite de deux cônes inégaux, Iun petit (1/3) postérieur, fixe et osseux (protympanum), Iautre plus allongé (2/3), mobile fibro-cartilagineux, réunis tous deux par listhme tubaire, étranglement court, pseudo-sphinctérien en endoscopie. Le muscle tenseur du voile du palais (MTVP) et le muscle élévateur du voile du palais sont les principaux muscles faisant varier la lumière tubaire de la portion fibro-cartilagineuse, colla∼ée au repos. Limagerie en TDM et surtout en IRM permet de les observer de façon statique. Les coupes sériées en histologie révèlent la continuité entre le MTVP et le muscle tenseur du tympan. Le cartilage principal, armature de la lumière a une forme variable suivant la hauteur considérée. La muqueuse tubaire est tapissée dun épithélium associant cellules ciliées et cellules à mucus, participant au drainage muco-ciliaire et aux échanges gazeux de la trompe auditive. Ces éléments morphologiques représentent une base pour létude de la physiologie tubaire, et Iorientation thérapeutique des dysfonctions de la trompe auditive.

Global DNA methylation evaluation: potential complementary marker in differential diagnosis of thyroid neoplasia

The implications of global DNA hypomethylation were recently reported in several models of tumorigenesis. Little is known about this epigenetic event in thyroid neoplasia. The study aimed to evaluate the status of global DNA methylation in several types of thyroid tumors using a monoclonal antibody specific for 5-methylcytidine (5-mc) and to define the diagnosis potential of this marker. 5-mc immunostaining scores were calculated in 17 papillary thyroid carcinomas (PTC), 6 follicular thyroid carcinomas (FTC), 16 follicular adenomas (FA), 19 nodular goiters (NG) and ten Hürthle cells adenomas (HCA). The expression of galectin-3 was also evaluated. Computerized image analysis showed a significant lower level of 5-mc immunostaining in thyroid carcinoma when compared with benign tumors or adjacent normal thyroid parenchyma (P<0.0001). Overall, 5-mc accuracy to distinguish malign from benign thyroid tumors was similar to that of galectin-3 (89% versus 87%, P>0.05). The combination of 5-mc with galectin-3 led to an excellent accuracy level of 96%. Among follicular neoplasia 5-mc accuracy to differentiate malign tumors trends to be higher than galectin-3 one (90% versus 66%, P=0.06). These data stress the necessity of epigenetic events evaluation among thyroid nodules and propose global DNA methylation assessment as a potential diagnostic tool to combine with other valuable markers.

Morphological and functional asymmetry of the human recurrent laryngeal nerve

PurposeThe aim of the current study was to analyze some parameters that are involved in nerve conduction in the right and left recurrent laryngeal nerves (RLNs) in humans. We have studied two morphological parameters such as the length of the two nerves, and the total intraperineural area (TIPA) from necropsies, and one functional parameter such as the latency of the thyroarytenoid muscle from operated patients.MethodsThe morphological parameters of six white female adult cadavers were analyzed. The RLNs were totally removed on both sides with the vagus nerve from their origin to the entrance in the larynx at the cricothyroid joint. The lengths were measured with the help of a digitalized caliper. Selected sections were obtained from each third of the RLNs for histological analysis. The TIPA was estimated at each selected level using digitized images of nerve sections and a manual micrometer. All the measurements were carried out by specialists in histology. The intraoperative vagal nerve stimulations were conducted using the NIM3 Medtronic® monitoring system (Medtronic Xomed Inc., Jacksonville, FL, USA) in ten adult patients without laryngeal or nervous disease during thyroid gland surgery. The evocated laryngeal electromyography was performed with the Medtronic bipolar needle electrode directly inserted into the thyroarytenoid muscle. The direct vagal nerve stimulation was achieved with the Medtronic stimulation from 0.5 to 1xa0mA. The latency of the thyroarytenoid muscle was recorded on the NIM-response monitor.ResultsThe mean lengths of the left and right RLNs were, respectively, 136.6 and 75.0xa0mm with a mean difference of 61.6xa0mm (range 50–75xa0mm). The quantitative comparison of the TIPA between proximal segments of the left and right RLN showed no significant difference. The distal and proximal TIPA ratio demonstrated differences between the left and right RLN, respectively, 53.76 and 38.88xa0% without any statistical meaning. The comparison of the TIPA of the distal segments of the RLNs showed no significant difference. The intraoperative vagal nerve stimulation (0.5 and 1xa0mA) displayed a mean latency of the right and left thyroarytenoid muscle, respectively, of 3.55–3.68 and 5.90–5.98xa0ms with a mean difference of 2.35–2.30xa0ms (range 1.75–3.30xa0ms).ConclusionIf length and latency asymmetry of the right and left RLNs in humans can be demonstrated, the synchronicity of the vocal folds requiring precise controlled variations within intrinsic laryngeal muscles needs further investigations.

Lamina propria of the human vocal fold: histomorphometric study of collagen fibers

BackgroundSince the seminal work of M. Hirano, which defined the three-layered lamina propria of the human vocal fold, there has been confusion in the labeling of each layer. Recent studies described the composition of fibers and interstitial molecules within the lamina propria leading to various biomechanical properties. However, collagen fibers appear as the most important structure component.MethodsWe used an optical analysis and the picrosirius-polarization method to describe collagen fibers from six adult and two fetal human larynges fixed in formalin and frontally sectioned in the middle part of the vocal fold.ResultsThe deep layer of the lamina propria is the most densely organized band of collagen fibers penetrating the superficial muscle bundles of the vocal muscle. The mean thickness of this layer is about 36% of the lamina propria and shows a network of strongly birefringent fibers (collagen type I and III). The superficial layer of the lamina propria is a narrow band of collagen fibers immediately below the basement membrane of the epithelium. The mean thickness of this layer is about 13% of the lamina propria and shows strong birefringent fibers. The intermediate layer is the less densely organized band between the deep and superficial layers. The mean thickness of this layer is about 51% of the lamina propria and shows clear, green weakly birefringent fibers characterized as collagen type III. The fetal lamina propria contains only a monolayer distribution of loose collagen fibers between the epithelium and the vocal muscle.ConclusionThese results help describe the distribution of collagen fibers within the lamina propria of the human vocal fold and have implications to understand the cover-body theory of voice production both in the adult and newborn.

p16 and p53 expression status in head and neck squamous cell carcinoma: a correlation with histological, histoprognostic and clinical parameters

Different histopathology and prognosis characterise the human papillomavirus (HPV)-related oropharyngeal tumours, but squamous cell carcinomas (SCC) of other localisations have not been exhaustively studied. Tissues from 120 patients with a head and neck SCC were studied for the expression of p16 and p53, and the Brandwein-Gensler (BG) histological risk assessment model. p16 positivity and p53 normal expression were significantly correlated with non-smoking, an earlier T stage and a non-keratinising morphology. The BG risk score was not associated with p16 or p53 expression; p16 expression was associated with a lymphocytic T-cytotoxic response. BG risk score was significantly correlated with overall survival and progression-free survival, while neither p16 nor p53 expression were associated with prognosis. p16 and p53 expression are associated with the histological subtype and the T stage even in non-oropharyngeal-restricted tumours. The BG risk score is not correlated with p16 or p53 and retains its power in non-site-specific SCCs.

Descriptive anatomy of the cricoarytenoid articulation: application to articular dynamics in carcinology.

The descriptive anatomy of the cricoarytenoid articulation provides an essential foundation for understanding disorders of mobility of the larynx, especially in carcinology. Thirteen formaline-preserved anatomic specimens of the adult larynx were studied and 4 pathologic larynges with loss of mobility due to a malignant tumor. The cricoid and arytenoid articular surfaces showed major intra- and inter-individual variations, causing dynamic asymmetry at the glottic level. They were joined by a connective-elastic articular capsule bounding a cavity, characterized by a peudo-meniscal synovial ridge and deep peripheral blind recesses, indicative of great articular mobility. The cricoarytenoid ligament shares in stabilizing the articulation. The posterior cricoarytenoid m. (abductor) and the lateral cricoarytenoid m. (adductor) have a motor innervation derived from the inferior laryngeal nerve, which forms an endolaryngeal arch with a ventral concavity, in contact with the lateral articular recess. The cricoarytenoid articulation thus appears as a diarthrosis possessing three degrees of liberty during movements of glottic abduction and adduction an antero-posterior rocking movement, an antero-medial shift of the arytenoid on the cricoid, and a less marked axial rotation. Histological study of the cricoarytenoid articulation where mobility was reduced by carcinomatous infiltration showed that each articular component may be affected (muscles, cartilage, capsule, nerve), and that several components may be involved simultaneously to a minimal degree. The therapeutic implications are important, particularly in conservative laryngeal surgery.

Prognostic impact of immune microenvironment in laryngeal and pharyngeal squamous cell carcinoma: Immune cell subtypes, immuno-suppressive pathways and clinicopathologic characteristics

Background Immune system affects prognosis of various malignancies. Anti-immune pathways like PD-L1 and CTLA4 are used by the tumor to overcome immune system and they serve as immunotherapy targets. The immune microenvironment of head-and-neck squamous cell carcinoma (SCCHN) has not been sufficiently studied. Patients and Methods 152 SCCHN were immunohistochemically studied for the expression of CD3, CD8, CD57, CD4, granzyme b, CD20, CD163, S100, PD-L1, CTLA4 and CXCR4. Results CD3, CD8, CD57 and stromal S100 higher density is a good prognostic factor (p=0.02, 0.01, 0.02, 0.03 respectively). CTLA4 tumor expression is a poor prognostic factor (p=0.05). The rest immune cells do not affect prognosis. CD3 and CD8 density does not correlate with clinicopathological factors or p16/p53 expression, while CD57 and CD4 higher density is associated with the absence of distant metastases (p=0.03 and 0.07, respectively). Higher CD20 and S100 density is associated with lower T stage (p=0.04 and 0.03, respectively). PD-L1 expression is higher in CD3, CD8, and CD163 infiltrated tumors and in histologically more aggressive tumors. Response to neoadjuvant chemotherapy is better in highly CD3 infiltrated tumors and in tumors with less intraepithelial macrophages. Conclusion Rich T-lympocytic and dendritic cell response is a good prognostic factor in SCCHN, whereas tumors expressing CTLA4 show poor prognosis. PDL1 expression does not affect prognosis, but it is expressed in histologically more aggressive tumors and in T-cells rich tumors. Response to induction chemotherapy is better in tumors less infiltrated by macrophages and mostly infiltrated by T cells.