Leon Barnes

Cystosarcoma phyllodes: a clinicopathologic analysis of 42 cases.

A retrospective clinicopathologic evaluation of 42 patients with cystosarcoma phyllodes was undertaken to determine if tumor size, contour, degree of stromal atypia and mitotic activity were reliable indicators of clinical behavior. Excluding size, the latter three determinants showed a positive correlation with prognosis and served as the basis of a classification in which 18 benign, 5 borderline and 19 malignant cystosarcomas were diagnosed. The tumors occurred in women averaging 44.3 years of age who most often presented with a palpable occasionally painful mass with a median diameter of 5 cm. Excision or simple mastectomy were the more frequent forms of therapy. Local recurrences were experienced by 6 patients and occurred in all 3 categories of tumor. Only malignant neoplasms developed systemic metastases which was observed in 4 patients 3 of which have died. One borderline tumor recurred 14 times and eventually proved fatal as a result of contiguous pulmonary involvement. A plea is made to label the stroma of malignant cystosarcomas as to the cell(s) of origin so future investigators may evaluate the effect of various soft tissue patterns on prognosis.

Prognostic factors in mobile tongue and floor of mouth carcinoma

This study identifies significant prognostic factors in squamous cell carcinomas of the anterior tongue and floor of mouth. It is clear that the TMN staging system does not account for other important variables that affect tumor prognosis. Tumor thickness and the presence of perineural invasion and intralymphatic tumor emboli should be examined in all resected tumors. Tumor thickness, tumor size, and perineural invasion all have an impact on survival and must be considered in treatment plans. Tumors measuring between 2 mm and 3 mm may or may not have metastases and further evaluation of this group needs to be done. Most importantly, the data in this study supports a multiinstitutional prospective evaluation of pathology specimens. Precise guidelines must be established for handling of the specimen, which must then be evaluated for the variables mentioned above. In this way, more definitive conclusions can be reached in the management of tumors of the antierior tongue and floor of mouth.

Intestinal-type adenocarcinoma of the nasal cavity and paranasal sinuses

Intestinal-type adenocarcinoma (ITAC) of the nasal cavity and paranasal sinuses may occur sporadically or as an occupational-related hazard, especially in cases of wood dust exposure. The clinical and pathologic features of 17 cases of sporadic-type ITAC are presented and compared to those among woodworkers. Both groups are analyzed collectively to define further the biological spectrum of this rare neoplasm. Histologically, five variants of ITAC were recognized: papillary, colonic, solid, mucinous, and mixed. The nine men and eight women in this series ranged from 31 to 80 years of age. Eight tumors originated in the maxillary sinus, seven in the nasal cavity, and two in the ethmoid sinus. Unilateral nasal obstruction and epistaxis, averaging 6.8 months in duration, were the most common symptoms. At least four of the patients are known to have died of their disease. In contrast, ITAC in woodworkers occurs primarily in men, originates almost exclusively in the nasal cavity or ethmoid sinus, and has a better prognosis. Data pooled from 213 cases of ITAC indicate that 53% of patients have experienced local recurrences following therapy, 8% (range 0-22%) have developed cervical lymph node and 13% (range 0-29%) distant metastases, and 60% have died of their disease. Of those dying, 80% did so within 3 years of diagnosis (range 1 month to 9.1 years).

Molecular analysis to demonstrate that odontogenic keratocysts are neoplastic.

CONTEXT Odontogenic keratocysts (OKCs) are unique odontogenic lesions that have the potential to behave aggressively, that can recur, and that can be associated with the nevoid basal cell carcinoma syndrome. Whether they are developmental or neoplastic continues to be debated. OBJECTIVES To identify loss of heterozygosity of tumor suppressor genes in OKCs and to suggest a pathogenetic origin for these lesions. DESIGN We examined 10 OKCs for loss of heterozygosity of tumor suppressor genes, using a microdissection and semiquantitative genotyping analysis. The genes analyzed included 10 common tumor suppressor genes, as well as the PTCH gene, which is mutated in nevoid basal cell carcinoma syndrome. RESULTS Loss of heterozygosity was seen in 7 of 10 cases, with a frequency between 11% and 80% of the genes studied. The genes that exhibited the most frequent allelic losses were p16, p53, PTCH, and MCC (75%, 66%, 60%, and 60%, respectively). Daughter cysts were associated with a higher frequency of allelic loss (P =.02), but epithelial budding was not. CONCLUSIONS Our study indicates that a significant number of OKCs show clonal loss of heterozygosity of common tumor suppressor genes. The finding of clonal deletion mutations of genomic DNA in these cysts supports the hypothesis that they are neoplastic rather than developmental in origin.

A review of neuroendocrine neoplasms of the larynx: update on diagnosis and treatment.

Neuroendocrine neoplasms of the larynx have been divided into those of epithelial or neural origin. The latter consist of paragangliomas while the epithelial origin group can be divided into the typical and atypical carcinoids and small cell neuroendocrine carcinomata, the latter consisting of the oat cell type, the intermediate cell type and the combined cell type. There are now over 500 cases of neuroendocrine neoplasms of the larynx in the literature. The diagnosis is primarily based on light microscopy, and, in some instances, it may be supported by special histochemical studies. It should be confirmed by immunocytochemical and/or ultrastructural investigation. The different biological behaviour of neuroendocrine neoplasms of the larynx makes a specific diagnosis of paramount importance, since treatment depends on diagnostic accuracy. Typical carcinoid is an extremely rare lesion. It is treated preferably by conservative surgery; elective neck dissection is not necessary because of the lack of lymph node metastases at diagnosis. Chemotherapy and/or radiotherapy have not been effective in the limited number of patients treated thus far. Prognosis is excellent with cure following surgery. Atypical carcinoid is the most frequent non-squamous carcinoma of the larynx. The mainstay of treatment is surgery. Elective neck dissection should be performed because of the high likelihood of cervical lymph node metastases. Primary radiation therapy with adjuvant chemotherapy is not indicated. The survival rate is 48 per cent at five years and 30 per cent at 10 years. Although the larynx is one of its most common extrapulmonary sites, small cell neuroendocrine carcinoma is still a rare tumour. Surgical results for this tumour have been disappointing and is reserved for cases of local relapse with no evidence of metastasis. Chemotherapy and radiotherapy currently appear to offer the least disabling and most effective forms of therapy. The two- and five-year survival rates are 16 per cent and five per cent, respectively. Paraneoplastic syndromes have occasionally been reported in association with carcinoid tumours (typical and atypical) and small cell neuroendocrine carcinoma. There have been also rare reports of an elevated neuropeptide serum level. Paraganglioma is the only laryngeal neuroendocrine neoplasm with a female preponderance (3:1). Confusion with atypical carcinoid has led to incorrect diagnosis and inappropriate classification schemes, erroneously suggesting that laryngeal paraganglioma has the potential for aggressive behaviour. Conservative surgery represents the treatment of choice; elective neck dissection is not necessary, and the prognosis is excellent.

Geographic variation in allergic fungal rhinosinusitis

Allergic fungal rhinosinusitis (AFRS) has a worldwide distribution. This survey of 20 otolaryngologic practices throughout the United States confirmed a variation in the frequency of AFRS relative to endoscopic sinus procedures performed for all other diagnoses. The highest incidence occurred in Memphis, Tennessee at 23%, with three other southern practices reporting a frequency of at least 10%. In the northern locations the frequency ranged from 0 to 4%. No correlation with mould counts was demonstrated, possibly because of incomplete mould data relative to most of the surgical locations.

Surgical margins in head and neck cancer: a contemporary review.

Adequate resection margins are critical to the treatment decisions and prognosis of patients with head and neck squamous cell carcinoma (HNSCC). However, there are numerous controversies regarding reporting and interpretation of the status of resection margins. Fundamental issues relating to the basic definition of margin adequacy, uniform reporting standards for margins, optimal method of specimen dissection, and the role of intraoperative frozen section evaluation, all require further clarification and standardization. Future horizons for margin surveillance offer the possible use of novel methods such as “molecular margins” and contact microscopic endoscopy, However, the limitations of these approaches need to be understood. The goal of this review was to evaluate these issues to define a more rational, standardized approach for achieving resection margin adequacy for patients with HNSCC undergoing curative resection.

Salivary duct carcinoma

Salivary duct carcinoma (SDC) is a highly malignant tumor that is histologically similar to ductal carcinoma of the breast. This article presents the clinicopathologic features of 15 patients with SDC arising in the salivary glands. The majority of patients were male and aged 65 years or older. The tumor was most often located in the parotid gland. Pain, facial palsy, and presence of calcification in the CT scan were diagnostic features suggestive of SDC. Histologically, 27% of the tumors arose from pre-existing pleomorphic adenoma. Perineural and lymphatic invasion were common findings. There was an extensive cervical lymph node involvement (73%). Distant metastasis was the most common cause of failure. Although SDC exhibits an unpredictable clinical course, total parotidectomy with neck dissection and adjunctive radiation therapy appear to be appropriate for local and regional control of this aggressive neoplasm.

Basaloid squamous cell carcinoma of the head and neck: Clinicopathological features and differential diagnosis

Basaloid squamous cell carcinoma is a recently recognized variant of squamous cell carcinoma. The lesion is histologically distinctive and manifests a predilection for the supraglottis, pyriform sinus, and tongue base. The immunohistochemical profile is discussed. The differential diagnoses include adenoid cystic carcinoma, small cell neuroendocrine carcinoma, basal cell adenocarcinoma, adenosquamous carcinoma, squamous cell carcinoma, spindle cell squamous carcinoma, mucoepidermoid carcinoma, and adenoid squamous cell carcinoma. Basaloid squamous cell carcinoma is a biologically high-grade tumor with a propensity for nodal as well as systemic metastases. It is a morphologic and phenotypic entity with a separate prognostic significance.

Basaloid squamous cell carcinoma of the head and neck: A clinicopathologic and flow cytometric study of 10 new cases with review of the English literature

INTRODUCTION We describe the clinicopathologic and flow cytometric features of 10 cases of basaloid squamous cell carcinoma (BSCC) of the head and neck to determine if DNA ploidy is a useful prognostic indicator. We also provide a review of 80 cases previously reported in the English language literature. MATERIALS AND METHODS The 10 cases were obtained from the surgical pathology files of Presbyterian University Hospital and The Eye and Ear Institute, Pittsburgh, PA (1987-1991). In all 10 cases, the microscopic slides and clinical data were reviewed. Flow cytometry was performed using the Hedley technique and formalin-fixed, paraffin-embedded tissue. RESULTS The mean age of patients with BSCC was 64 years (range, 49 to 75 years). Tumor involved the base of tongue (n = 5), hypopharynx-epiglottis (n = 3), and tonsil (n = 1). One case presented with cervical lymph node metastasis from an unknown primary site. Histologically, BSCC showed a biphasic pattern with basaloid-squamous elements, comedonecrosis, stromal hyalinization, surface dysplasia, and an in situ and/or invasive squamous cell carcinoma component. Flow cytometry revealed six diploid and four aneuploid tumors. Five of six patients with diploid and all four patients with aneuploid tumors developed early regional and/or distant metastases. Of the two patients who died of disease, one had a diploid and the other an aneuploid tumor. CONCLUSION Our study reaffirms the predilection of BSCC for the base of tongue, pyriform sinus, and supraglottic larynx, and its aggressive biologic behavior with a high incidence of cervical lymph node metastasis (64%), distant spread (44%), and death from disease (38% mortality at 17 months median follow-up). However, in contrast to previous reports, tumor ploidy by flow cytometry provided no additional prognostic information beyond that supplied by routine histologic evaluation.