Contact endoscopy during microlaryngeal surgery: a new technique for endoscopic examination of the larynx

By means of a microcolpohysteroscope during microlaryngoscopy, the cells of superficial layers of the vocal cord epithelium, previously stained with methylene blue, were observed in vivo and in situ. Several parameters were evaluated: regularity of the epithelium, dimensions and color of the nucleus, nucleus-cytoplasm ratio, nucleus and cytoplasm contours, and presence of the nucleolus, mitosis, cytoplasmic inclusions, keratosis, and koilocytes, among others. The normal squamous epithelium of the vocal cord has a homogeneous cell arrangement, with a spheroid and isochromic nucleus, and a uniform nucleus-cytoplasm ratio. Specific cellular epithelial patterns in different disorders were observed, namely, chronic laryngitis, keratosis, dysplasia, papilloma, and malignant tumor. The present study on contact endoscopy during microlaryngeal surgery reports our first results with this original technique, performed in 68 patients.

Laryngeal mucosal malignant melanoma. A clinicopathologic, immunohistochemical, and ultrastructural study of four patients and a review of the literature

BACKGROUND

Primary laryngeal mucosal malignant melanomas are uncommon tumors that morphologically are readily confused with more common types of laryngeal cancer.

METHODS

Four cases of primary laryngeal mucosal malignant melanoma were identified from the files of the Otolaryngic Tumor Registry-Armed Forces Institute of Pathology. Clinical records were available for all four cases. Paraffin blocks or unstained slides were available for three of the four cases. The light microscopic features were evaluated in all cases. Immunohistochemistry was performed in three cases; electron microscopic analysis was performed in two cases. Follow-up data was available in three of the four cases.

RESULTS

The patients were all males and ranged in age from 35 to 84 years. The clinical presentations included hoarseness, hemoptysis, dysphagia, and airway obstruction, with complaints ranging from 1 to 8 months. The sites of involvement included the supraglottic larynx and the right true vocal cord. A history of cutaneous melanoma or of a melanoma of another site was not reported for any of the patients. Histologically, the tumors were invasive and composed of a pleomorphic epithelioid cell population of malignant cells. Malignant spindle-shaped cell could also be identified. The presence of melanin was identifiable by light microscopy in two cases; Fontana stains confirmed the presence of melanin in the other two. The immunohistochemical findings showed diffuse immunoreactivity with S-100 protein and HMB-45. There was no immunoreactivity with cytokeratin. The specimen of one patient demonstrated focal immunoreactivity with chromogranin. Electron microscopic features included the presence of premalonosomes or melanosomes. Total laryngectomy was the treatment of choice supplemented with radiotherapy. Follow-up information was available for three patients and all three died of metastatic disease within 36 months of diagnosis. Metastasis occurred to the brain, lungs, spine, and regional lymph nodes. The fourth patient was lost to follow-up.

CONCLUSIONS

Laryngeal mucosal malignant melanoma is an uncommon neoplasm that clinically and pathologically simulates more conventional types of laryngeal cancers. The light microscopic, immunohistochemical, and electron microscopic findings confirm the diagnosis. Aggressive management is indicated, as these tumors disseminate widely and are rapidly fatal.

[Primary microcytoma of the larynx. Case report, ultrastructural study and review of the literature]

Oat cell carcinoma of the larynx is a rare tumor. A throughout search of the literature revealed only 80 cases; the first case in literature was reported by Olofsson in 1972. The tumor often presents in the sixth and seventh decades of life and appears to be highly aggressive and metastases develop early. We have had the opportunity to study ultrastructurally a small cell carcinoma of oat cell type arising in the larynx.

Delivery to lysosomes in the human carcinoma cell line HEp-2 involves an actin filament-facilitated fusion between mature endosomes and preexisting lysosomes

We have addressed the following question: what is the mechanism behind the delivery of internalized molecules from mature endosomes to lysosomes in HEp-2 cells, and which role does the cytoskeleton play in this process? Quantitative electron microscopy and immunogold labeling revealed that whereas the cytoskeleton was not of importance for endosome maturation, actin filaments facilitated fusion of mature endosomes with preexisting lysosomes. Delivery to lysosomal degradation was not dependent on protein synthesis as determined biochemically, but was reduced by cytochalasin D. Observations made by electron microscopy as well as by video microscopy of living cells showed that the concerted action of actin filaments and microtubules was responsible for the random distribution and movement of endocytic organelles throughout the cell. Actin microfilaments, however, seem to facilitate perinuclear clustering and frequent fusion of mature endosomes and lysosomes, while microtubules play a role in preventing formation of large lysosome aggregates by separating endosomes and lysosomes and moving them toward the cell periphery. Taken together, our data suggest that delivery of internalized molecules to lysosomal proteolysis takes place by fusion of mature endosomes with preexisting lysosomes and that actin microfilaments somehow facilitate this step.

Integrin expression in head and neck cancers

Neoplastic transformation results in rearrangement of the cell membrane with a breakdown of the regular expression of adhesion molecules such as integrins. A relationship may exist between the intensity of this alteration, and the form it takes, and a tumour's ability to metastatise. We studied this possibility by investigating the epithelial integrin expression of 35 head and neck squamous cell carcinomas. Two types of positivity were observed: one associated with tumours with a better prognostic index, the other with those characterized by greater malignancy.

[Laryngeal neuroendocrine carcinoma. Report of a clinical case]

A case of neuroendocrine small cell carcinoma is described in a 79 year-old male. This tumor is an unusual laryngeal carcinoma (the incidence is slightly lower than 1% of all carcinomas) with an aggressive biological behaviour. This work analyzes its clinical, pathological, therapeutical and evolutive aspects, and compare this case to those reported in the literature.

Rhabdomyoma of the larynx: a review of the literature with a summary of previously described cases of rhabdomyoma of the larynx and a report of a new case

A review of extracardial rhabdomyomas of the larynx reported in the literature is presented. A new case is added (the largest described yet). The diagnosis was based on routine histological and immunohistological staining, and electron microscopy. The extracardial rhabdomyomas were divided into three types according to histopathological findings: (i) adult; (ii) foetal cellular type; and (iii) foetal myxoid. There are 23 well-documented cases (including this case) of extracardial rhabdomyomas of the larynx; 15 of the adult type, four of the foetal myxoid type and four of the foetal cellular type. The differential diagnosis and the requisite diagnostic procedure is discussed. The tumour is benign. The treatment is surgical excision. Although rare, its existence should be kept in mind in the differential diagnosis of laryngeal tumours.

Over-expression of tumour suppressor gene p53 in laryngeal squamous cell carcinomas and its prognostic significance

p53 is a nuclear phosphoprotein which acts as a tumour suppressor factor, regulating cell growth and division. Mutations in the p53 gene appear to be the most common genetic alterations in human cancer. The aim of this study was to investigate p53 expression in laryngeal squamous cell carcinomas and to assess its role as a marker of prognostic significance. Using immunohistochemical staining techniques, a series of laryngeal carcinomas (n = 87) were examined for expression of the mutant form of p53 phosphoprotein using the monoclonal antibody PAB 1801. p53 over-expression was noted in 50 biopsies of laryngeal carcinomas (57.5%) but not in any of the non-neoplastic laryngeal mucosa which were used as the control. There was no statistical correlation between p53 immunoreactivity and the clinicopathological parameters of the cancers including: site of tumour, TNM staging, differentiation grading and tumour recurrence. These findings indicate that p53 expression is strongly associated with carcinoma cells and not with normal cells in the larynx. However, p53 expression is probably unrelated to the biological aggressiveness of these tumours.

Endoscopic laser management of supraglottic cancer

Current concepts of endoscopic management of supraglottic cancer are an extension of precepts fostered by Jackson. The current approach has been facilitated by a half century of technological developments: the surgical microscope, the CO2 laser, improved laryngoscopes, and general endotracheal anesthesia. Selected small-volume cancers can be curatively resected, whereas excisional biopsy can be performed on larger neoplasms. With this cost effective minimally-invasive surgical approach, there is less disturbance of normal tissue, thereby minimizing morbidity rate and hospitalization. If the transoral excision is inadequate, radiotherapy can not be depended on to eradicate known residual disease. Endoscopic resection of supraglottic cancer should not alter the surgeon's standard management of the neck.

Detection of human papillomavirus in laryngeal lesions by in situ hybridization

Human papillomavirus (HPV) is associated with human neoplasms of squamous epithelium. Squamous papillomas and verrucous carcinomas are two types of squamous neoplasms of the larynx that present difficult problems in differential diagnosis. Using in situ hybridization with biotinylated DNA probes, we examined benign squamous papillomas and verrucous squamous carcinomas of the larynx for the presence of HPV. Forty-two biopsy specimens from 18 patients with laryngeal papillomas and 11 biopsy specimens from seven patients with verrucous carcinomas were obtained from the files of Pennsylvania Hospital, Philadelphia, PA. Tissue sections were hybridized with an HPV DNA cocktail. The HPV-positive cases then were subtyped further with DNA probes specific for HPV subtypes 6/11, 16/18, and 31/33/35. All benign squamous papillomas (42 of 42) were positive for HPV subtype 6/11. None of the verrucous carcinomas contained demonstrable HPV (none of 11). Some of the squamous papillomas were recurrences, which shows the persistence of the virus. These results indicate that laryngeal papillomas may be related to HPV, but verrucous carcinomas are not.

Morphological and histochemical study of human submucosal laryngeal glands

BACKGROUND

The respiratory submucosal glands are a major source of secretions in the airway. Human submucosal laryngeal glands have been scarcely studied, with no works existing about their ultrastructure and histochemistry.

METHODS

Samples of epiglottis, ventricle, false vocal folds and true vocal folds were fixed in 10% buffered formalin for histochemical study with conventional and carbohydrate lectin histochemistry. Other samples were fixed in 2.5% glutaraldehyde and conventionally processed for transmission electron microscopy.

RESULTS

The human submucosal laryngeal glands are composed of serious tubules; mucous tubules; collector duct; and final portion of this duct. The serous cells showed sialosulphomucins and affinity for WGA and Con-A lectins. With a previous treatment with neuraminidase, they also labelled with PNA. The mucous cells contained sialosulphomucins and showed affinity for WGA and DBA lectins in the samples proceeding from blood group A, and for WGA, UEA-I and LTA with those from blood group O. Ultrastructurally, the serous cells presented a wide variety of granules, cells in which seromucous granules predominated. The mucous cells presented larger-sized granules which were very electron-lucent. The collector duct was composed of mitochondria-rich cells and basal cells. A cell which we have termed "intermediate" was identified in the transition zone between the mucous tubules and the collector duct, and in the final portion of the collector duct. It had morphological characteristics as if it were a transition between a goblet cell and collector duct cell. Some nerve endings with cholinergic and peptidergic vesicles were found among the myoepithelial cells.

CONCLUSIONS

These glands presented some histological differences from the bronchial glands, the mucous secretion was related to the blood group antigens, and the serous cells showed a wide variability in their secretory granules, many of them being of a seromucous type.

[Sphenoidal metastasis of laryngeal carcinoma]

Metastatic tumors to the nose and paranasal sinuses are very uncommon and metastases to the sphenoid sinus are exceedingly rare. The most common tumor sites from which sphenoid metastases arise are the kidney and the lung. Distant metastases from laryngeal carcinoma are rare, the most common sites being the lungs, skeletal system, and liver. We report a patient with a supraglottic laryngeal carcinoma who had metastases to the sphenoid sinus. The management of this entity is described and cases reported in the literature are reviewed.

[Ultrastructure and pathogenesis of vocal nodules on the vocal cords]

Controlled electron microscopy of the epithelium in voice lesions revealed: thickening and destruction of basement membrane, reduplication of the lamina densa, near absence of normal hemidesmosomes and anchoring fibrils, abundant electro-dense vesicles at the basal cell pole (discharging through the cell membrane), abundant mitochondria, euchromatin and nucleolar prominence. These histologic phenomena suggest that the basal cell layer responds to trauma to its anchorages with metabolic hyperactivity. Therefore the traumatic mechanism should be considered as damaging to the basement membrane.

[Chondrosarcoma of the larynx. Needle biopsy diagnosis by computed tomography]

Chondrosarcoma of the larynx is the most frequent sarcoma at this site. The growth rate is very slow, so that the first symptoms, dyspnea and hoarseness, may be insidious. Chondrosarcomas are usually of low-grade malignance and rarely metasize. Surgical resection is the treatment of choice. We present a case of diagnostic FNA using computed tomography.

Fibrous neoplasms of the adult larynx

Fibrous neoplasms of the adult larynx are uncommon and can be benign, locally aggressive, or malignant. From January 1, 1987 to December 31, 1991, 189 adult patients underwent partial or total laryngectomy for laryngeal neoplasms at the University of Texas Southwestern Medical Center-affiliated hospitals. During this period, three (1.6%) patients were treated for fibrous neoplasms of the larynx. All three lesions arose in the true vocal fold. In one patient, a local recurrence within 6 months following partial laryngeal resection necessitated total laryngectomy. All three patients are alive and disease-free 1 to 4 years following definitive surgery. We present these cases and discuss computed tomographic (CT), histopathologic, and electron microscopic (EM) findings. Based on this experience, surgical treatment of these lesions is recommended, the extent of which is guided by clinical, radiologic, and pathologic evaluation.

DNA content of head and neck squamous carcinoma by flow and image cytometry

OBJECTIVE

To compare the measurement of quantitative DNA in squamous cell carcinoma of the head and neck by flow cytometry and image cytometry.

DESIGN

Comparison of image cytometry to the more commonly used flow cytometry using paraffin-embedded tissues.

SETTING

University of California, Davis Medical Center, Sacramento. A 472-bed university teaching hospital.

PATIENTS

Records of 26 patients with squamous cell carcinoma of the tongue, base of tongue, and larynx were obtained from the case files of an otolaryngologist-head and neck surgeon. They were reviewed for staging and follow-up.

RESULTS

We demonstrated a 96% concordance rate between the methods. A solitary discrepant case was aneuploid by image cytometry and diploid by flow cytometry. The specimen involved tumor infiltrated by lymphocytes that may have masked the aneuploid population to measurement by flow cytometry. Quantitative DNA analysis correlated moderately well with tumor grade, tumor stage, and patient outcome with a minimum of 6 years of follow-up. All patients with diploid tumors were long-term survivors.

CONCLUSIONS

Both methods provide accurate quantitative DNA analyses in squamous cell carcinoma of the head and neck. The methods are highly correlative and yield similar predictive data regarding tumor behavior and prognosis.

[Simultaneous laryngeal carcinomas: a case report and review of literature]

The high incidence of second primary malignant neoplasms in patients under treatment for head and neck tumors has been well documented in literature. In these cases the second primary reappears still in the upper aero-digestive tract or in distant organs (lung, esophagus, stomach, skin,....). The Authors report a case of a male, 64 year old patient, a moderate drinker and smoker, with two distinct simultaneous laryngeal malignant neoplasms. One tumor, which arose on the laryngeal face of the epiglottis, was a verrucous carcinoma (Ackerman's tumor); the other neoplasm, on the right vocal cord, was a well differentiated squamous cell carcinoma. Microlaryngeal examinations and TC-scans revealed a normal, uninvolved right false vocal cord and the Morgagni's ventricle. After surgical therapy, serial laryngeal samples were removed and underwent immunohistochemical studies. Microscopic examination revealed that the anterior commissure, the pre-epiglottic and paraglottic spaces were intact, furthermore, monoclonal antibody studies proved that the two simultaneous laryngeal cancers were independent. In the discussion the Authors report some clinical considerations, a review of literature concerning multiple simultaneous laryngeal tumours and emphasize the concept of "field cancerization", first described with regard to the oral cavity by Slaughter.

Well-differentiated (oncocytoid) neuroendocrine carcinoma of the larynx with multiple skin metastases: a brief report

A 63-year-old woman presented with a history of increasing dysphagia of about two weeks duration. Laryngoscopy revealed a nonulcerated supraglottic epitheliomatous lesion that morphologically appeared well-differentiated and distinctly oncocytoid. Although the tumour lacked any criteria for malignancy such as cellular atypia, pleomorphism or necroses, it recurred twice after primary surgery and later gave rise to multiple painful skin metastases. The diagnosis of an oncocytoid differentiated neuroendocrine carcinoma of the larynx (laryngeal carcinoid) was made. Misinterpretation of laryngeal carcinoids is common, but can be avoided if one is familiar with this rare variant of laryngeal neoplasms.

Ultrastructure of the ganglion on human internal laryngeal nerve

There is now definite evidence for the presence of a macroscopic ganglion on the human internal laryngeal nerve, with the distribution of its post-ganglionic fibres to the glands in the saccule and to the glands at the root of epiglottis in the vicinity of the opening of the saccule. This ganglion could be identified as early as 14 weeks in human foetal larynx, which contains immature neurons. Seven ganglia, dissected from human laryngectomy specimens and resected for carcinoma larynx, were studied by electron microscopy. Ultrastructurally, the neurons and the synaptic terminals had both small, round, luscent vesicles and dense core vesicles. Symmetrical, asymmetrical and electrical synaptic complexes were noted. A few neurons revealed degenerative changes suggestive of axotomy. The location of the ganglion on the internal laryngeal nerve, a branch of nervus vagus, and ultrastructural demonstration of large and small dense core vesicles and small luscent vesicles in the neurons of this ganglion, lead us to believe that the ganglion is parasympathetic in nature.

Nucleolar organizer regions activity in lymphocytes of patients with laryngeal carcinoma

The activity of nucleolar organizer regions (Ag-NORs) and the frequency of NOR associations in chromosomes of phytohemagglutinin-stimulated lymphocytes from 12 patients with laryngeal carcinoma and 12 healthy subjects were studied using the gelatine silver staining technique. This study was undertaken to examine whether any disease associated changes occur in NOR activity. A lower mean number of Ag-NORs per metaphase (t test, 0.05 > p > 0.02) was found in patients compared to controls. This difference was not due to any specific group of acrocentric chromosomes (D or G). The mean number of NOR associations per metaphase was also found to be markedly lower (t test, 0.01 > p > 0.001) in patients than in controls. This difference was principally due to the significant decrease in the associations between 2 chromosomes (t test, 0.02 > p > 0.01), and in particular to the decrease in the D-G type associations (t test, 0.05 > p > 0.02). These findings are discussed in relation to existing data on the nucleolar activity of lymphocytes in a variety of solid tumours and leukemias.

Multivesicular bodies in HEp-2 cells are maturing endosomes

Conventional fluorescence microscopy of fixed HEp-2 cells as well as video microscopy of living cells incubated with transferrin-Texas Red (Tf-TxR) for < 60 min revealed distinct punctuate endosomal structures. Quantitative ultrastructural analysis using horseradish peroxidase (HRP) and cationized gold as tracers showed that spherical multivesicular bodies (MVBs) were the predominant endocytic compartments in HEp-2 cells and that MVBs within 60 to 90 min matured into lysosomes still containing internal vesicles. The number of labeled MVBs increased continuously from 2.5 min to 30 min of tracer incubation. However, when the cells were pulsed for 5 min followed by 10 or 25 min chases, the number of labeled MVBs corresponded to that obtained after 5 min of continuous incubation. The diameter of labeled MVBs was largely constant with time, but the number of internal MVB vesicles increased. Thus, early or newly formed MVBs contained few internal vesicles, whereas late MVBs, that is to say, MVBs that have existed for some period of time, contained numerous internal vesicles, and finally a mixture of membranous material or myelin figures and vesicles. It is thus in principle possible to distinguish between early and late MVBs in HEp-2 cells on the basis of morphology. However, the difference in number of internal vesicles applies only to the entire MVB population; after only 2.5 to 5 min of incubation, MVBs with numerous internal vesicles could also be reached by internalized tracer. Concomitant with the gradual changes in morphology, the MVBs also showed a characteristic change in content of marker proteins as detected by immunogold labeling on ultracryosections. Hence, early MVBs with relatively few internal vesicles and typically reached by internalized tracers within 5 min contained transferrin receptors (TfRs). By contrast, MVBs with many internal vesicles and labeled after 60 min of incubation contained mannose-phosphate receptors (MPRs), and the MVBs with distinct membranous material or myelin figures in addition to the internal vesicles were enriched in the lysosome membrane protein lamp-1. Thus, there seems to be a gradual maturation of MVBs in HEp-2 cells.

Ultrastructural changes of the basement membrane zone in benign lesions of the vocal folds

The basement membrane zone (BMZ) of the epithelium of the vocal folds was investigated electron microscopically in 10 patients suffering from various benign lesions and in 3 controls. Various defects were observed: a thickening by deposition of electron dense material, a loss of normal architecture, and a near absence of normal hemidesmosomes and anchoring fibers. Beside these previously reported phenomena, many vesicles carrying electron dense material were found near the plasma membrane. The vesicles were observed at various stages of fusion with the plasma membrane, on the other side of which their content was discharged. In the cytoplasm an increase of mitochondria was seen. The amount of condensed chromatin decreased while the nucleoli increased in comparison with the controls. These observations are suggestive of a hyperactivity of the basal cells of the epithelium in response to vibratory stress.

A clinico-pathological classification of laryngeal paraganglioma

A case of metastatic laryngeal paraganglioma is presented. We have reviewed the current world literature on this entity and thereby identified two apparently distinct types of this rare lesion (type I and type II). The histopathological features are unhelpful in discriminating these two types and this is instead based on clinico-epidemiological differences. The latter are annotated and discussed with respect to prognosis and management. A true estimate of the frequence of type II (potentially malignant) awaits the utilization of the recent improvements in diagnostic techniques.

DNA content and histologic growth pattern correlate with prognosis in patients with advanced squamous cell carcinoma of the larynx. The Department of Veterans Affairs Cooperative Laryngeal Cancer Study Group

BACKGROUND

Alterations in DNA content, nuclear morphologic characteristics, and histologic grading have been associated with prognosis in several types of solid malignant neoplasms.

METHODS

To determine the potential usefulness of these factors in predicting tumor behavior in patients with laryngeal squamous cell carcinoma, tumor specimens from 88 previously untreated patients with Stage III or IV cancers were studied. The DNA content and nuclear area (NA) were measured for individual nuclei of each tumor with the use of Azure A-stained frozen sections. An adjusted DNA index (aDI) for each patient was calculated from the slope of the linear regression analysis of nuclear DNA index on NA. Hematoxylin and eosinstained sections were examined and graded systematically for histologic growth pattern. All patients were enrolled in a prospective clinical trial and had laryngectomy and postoperative radiation therapy.

RESULTS

The disease-free survival length was longer and the relapse rates were lower in patients with a low aDI (P less than 0.005) and with tumors exhibiting low-grade growth patterns (P less than 0.001).

CONCLUSIONS

These parameters were independent of staging variables and were better predictors of tumor relapse than traditional clinical staging classifications.