Expression of sex hormone receptors in juvenile angiofibromas and antiproliferative effects of receptor modulators

Can Clinical/ Endocrinal Surrogates Predict Specific Hormone Therapy in Nasopharyngeal Angiofibroma? Current Evidence

Objective: In an attempt to rationalize Hormone therapy (HT) in juvenile nasopharyngeal angiofibroma (JNA) this study intends to investigate the pituitary axis and clinical profile to further establish dominant hormonal-environment based upon secondary sexual characteristics along with other novel possibilities for HT. Design: Prospective observational study. Setting: Tertiary health care centre. Participants: Thirty-three patients were analysed in terms of age, secondary sexual characteristics (SSC), staging, preoperative serum-hormone profile and weight/ volume of excised tumour. Main outcome measures: Serum levels of prolactin, testosterone, oestrogens, progesterone, LH and secondary sexual characteristics. Results: Significant correlation was seen between LH/ testosterone/ estrogen on one hand while LH/ GH/ progesterone on other. LH/ testosterone correlated with age, tumour weight, & almost all SSC. Oestrogen correlated with age, & all SSC (except facial hair/ laryngeal prominence/ deepening of voice). Accordingly, 2 sets of SSC (clinical surrogate markers) defined estrogenic or androgenic predominance in JNA. Conclusions: The clinical surrogates may indirectly reflect corresponding receptor activity (rather than isolated hormone level) and provide a better rationale for selecting a particular HT.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-025-05487-4.

Widespread Distribution of Luteinizing Hormone/Choriogonadotropin Receptor in Human Juvenile Angiofibroma: Implications for a Sex-Specific Nasal Tumor

Juvenile angiofibroma (JA) is a rare, sex-specific, and highly vascularized nasal tumor that almost exclusively affects male adolescents, but its etiology has been controversial. The G protein-coupled hormone receptor LHCGR [luteinizing hormone (LH)/choriogonadotropin (hCG) receptor] represents a promising new candidate for elucidating the underlying mechanisms of sex specificity, pubertal manifestation, and JA progression. We used highly sensitive RNAscope technology, together with immunohistochemistry, to investigate the cellular expression, localization, and distribution of LHCGR in tissue samples from JA patients. Our results provide evidence for LHCGR expression in subsets of cells throughout JA tissue sections, with the majority of LHCGR+ cells located in close vicinity to blood vessels, rendering them susceptible to endocrine LH/hCG signaling, but LHCGR+ cells were also detected in fibrocollagenous stroma. A majority of LHCGR+ cells located near the vascular lumen co-expressed the neural crest stem cell marker CD271. These results are intriguing as both LH and hCG are produced in a time- and sex-dependent manner, and are known to be capable of inducing cell proliferation and angiogenesis. Our results give rise to a new model that suggests endocrine mechanisms involving LHCGR and its ligands, together with autocrine and paracrine signaling, in JA vascularization and cell proliferation.

A Narrative Review of Flutamide in Juvenile Nasopharyngeal Angiofibroma

The detection of androgen receptors within Juvenile Nasopharyngeal Angiofibroma (JNA) has prompted investigation of the role of Flutamide. The aim of this review is to evaluate Flutamide as a possible neo-adjuvant treatment for JNA. Literature searches were conducted using MEDLINE, EMBASE and Web of Science. The Joanna Briggs Institute (JBI) checklist was used to assess risk of bias. The Oxford Centre of Evidence-Based Medicine (OCEBM) Levels of Evidence was used to stratify the evidence level. Literature searches were conducted using MEDLINE, EMBASE and Web of Science. Flutamide as neo-adjuvant treatment potentially causes a reduction in JNA tumor volume by ≥ 25%. Based on the current limited evidence, Flutamide has a limited role in JNA management and further research is required. Its utilization should only follow discussion with the patient, their families, and within the multidisciplinary team.

Endoscopic, endoscopic-assisted and open approaches in the treatment of juvenile angiofibroma: what has been new in the past decade (and 1586 cases)?

PURPOSE

Juvenile angiofibroma (JA) is a benign, but locally invasive tumor of the nasopharynx. Surgical resection of JA is performed through endoscopic (EA), endoscopic-assisted (EAA), or open approaches (OA). The management of these tumors is constantly evolving. We aimed to compare the surgical efficiency and morbidity of EA, EAA, and OA in JA treatment by conducting a systematic review of the literature published over the last 10 years.

METHODS

A systematic review of the English literature on surgical cases of JA published between 2012 and 2022 was performed. Eligible articles were analyzed for individual patient data (IPD) and aggregate patient data (APD). The primary predictor variable was the surgical approach. The primary outcome variable was recurrence rate.

RESULTS

The search retrieved 75 articles reporting 1586 JA surgical cases; 129 in IPD, and 1457 in APD data sets. Within the IPD data set, recurrence rates were significantly lower in cases completed by EA than that by OA (p < 0.05). There was no significant difference in recurrence rates between the EA and EAA groups (p > 0.05). EAA had a lower recurrence rate than that of OA (p < 0.05). For the APD data set, the recurrence rate following EA was significantly lower than that following OA (p < 0.05). There was no significant difference in recurrence between the EA and EAA groups (p > 0.05), and between the EAA and OA groups (p > 0.05).

CONCLUSIONS

EA represents the method of choice for mild and moderately advanced JA. EAA and OA still play important roles in the treatment of advanced-stage JA.

Management of Vulvovaginal Cellular Angiofibroma: A Single-Center Experience

Objective

The study aimed to explore the clinical characteristics, treatment, and prognosis of cellular angiofibroma in females.

Methods

We performed a retrospective study in patients with vulvovaginal cellular angiofibroma treated at Peking Union Medical College Hospital between August 2012 and October 2021.

Results

Eight patients were included in our study, with 7 cases of vulvar tumors and 1 case of vaginal stump tumors. The median age at diagnosis was 47.5 years (range, 38–83 years). The tumors were found incidentally in two patients (2/8, 25.00%) without specific history before diagnosis surgery. Of the other six patients, the median history from onset of the mass to diagnosis was 5.5 years (range, 3–14 years). Complete excision was performed in all 8 patients. According to histopathologic examination, the median tumor size was 3.4 cm (range, 1.7–11 cm). As the tumor size increased, both the operation time and postoperative length of stay increased. Gonadotrophin releasing hormone agonist was used in one case to minimize the size of the tumor, obtaining satisfactory results. Up to the last follow-up, no evidence of relapse was found in all 8 patients.

Conclusions

For vulvovaginal cellular angiofibroma, the mainstay of treatment remains surgical resection without residual tumor if possible; inadvertent urinary system injury and rectum injury should be avoided to the utmost; and enough attention should be paid to hemostasis to avoid hematoma after surgery. Before surgery, hormone receptor modulators may be considered to minimize the size of the tumor to reduce the surgery-associated risk.

Neural Crest Stem Cells in Juvenile Angiofibromas

The etiology of juvenile angiofibroma (JA) has been a controversial topic for more than 160 years. Numerous theories have been proposed to explain this rare benign neoplasm arising predominately in adolescent males, focusing mainly on either the vascular or fibrous component. To assess our hypothesis of JA’s being a malformation arising from neural crest cells/remnants of the first branchial arch plexus, we performed immunohistochemical analyses of neural crest stem cells (NCSC) and epithelial-mesenchymal transition (EMT) candidates. Immunoexpression of the NCSC marker CD271^p75 was observed in all investigated JA’s (n = 22), mainly around the pathological vessels. Close to CD271^p75-positive cells, high MMP3-staining was also observed. Additionally, from one JA with sufficient material, RT-qPCR identified differences in the expression pattern of PDGFRβ, MMP2 and MMP3 in MACS^®-separated CD271^p75positive vs. CD271^p75 negative cell fractions. Our results, together with the consideration of the literature, provide evidence that JA’s represent a malformation within the first branchial arch artery/plexus remnants deriving from NCSC. This theory would explain the typical site of tumor origin as well as the characteristic tumor blood supply, whereas the process of EMT provides an explanation for the vascular and fibrous tumor component.

[Current perspectives on imaging and treatment of juvenile angiofibromas : A review]

CLINICAL ISSUE

Juvenile angiofibroma is a benign tumor, whose surgical treatment may be complicated due to intraoperative hemorrhage. The tumors appear as well circumscribed, reddish masses, which often extend into the complete nasal cavity and nasopharynx.

STANDARD RADIOLOGICAL METHODS

Diagnosis is based on computed tomography (CT) and magnetic resonance imaging (MRI) with angiography to identify supplying blood vessels.

STANDARD TREATMENT

Open resection.

INNOVATION IN TREATMENT

The endoscopic endonasal resection is the therapy of choice and may be combined with open surgery after endovascular embolization. Radiation or hormone therapy are alternatives for patients with very advanced tumors or high surgical morbidity. Depending on location and age of the patients, residual tumors after surgery can be watched only or treated with radiotherapy.

PERFORMANCE

Preoperative endovascular embolization lowers intraoperative blood loss by about 70%, induces tumor shrinkage, and facilitates resection. The endonasal approach will lower the peri- and postoperative morbidity.

RECOMMENDATION

An endonasal approach combined with preoperative endovascular embolization should be preferred over open resection, but requires expertise as well as modern endoscopy and navigation equipment. MRI follow-ups should be performed regularly until after puberty. Recurrence after puberty is very uncommon.

Early Postoperative Magnetic Resonance in the Diagnosis of Persistent Juvenile Angiofibroma

OBJECTIVES/HYPOTHESIS

Despite improvements in the treatment of juvenile angiofibroma (JA), the rate of persistence (pJA) is still not negligible. In the present study, we assessed the value of early postoperative magnetic resonance imaging (MRI) in depicting unintentional pJAs and designed a MRI-driven decisional flow-chart for pJA management and follow-up.

STUDY DESIGN

Observational study.

METHODS

Patients undergoing early postoperative MRI after endoscopic resection of JA in the Unit of Otorhinolaryngology - ASST Spedali Civili, University of Brescia from 2007 to 2017 were enrolled. MRI was defined as negative or positive based on defined radiological criteria. The diagnostic performance of MRI was evaluated.

RESULTS

The analysis included 26 patients, with a mean age of 16.5 years (range, 11-25). Early MRI was negative for pJA in 21 (80.8%) patients and positive in five (19.2%). No patient with a negative finding was found positive at subsequent follow-up MRIs. The accuracy of a positive finding was confirmed by pathologic examination (three cases) or follow-up MRIs (two cases). The diagnostic performance of MRI was excellent with sensitivity and specificity of 100%. An MRI-driven flow-chart for pJA management and follow-up was designed.

CONCLUSIONS

Early postoperative MRI demonstrated a high diagnostic accuracy in the detection of unintentional pJA. Our MRI-driven strategy and decisional flow-chart could aid in the decision-making process in the management of pJA and definition of postoperative surveillance.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2436-E2441, 2021.

The Genetic and Molecular Determinants of Juvenile Nasopharyngeal Angiofibroma: A Systematic Review

Objective:

Juvenile nasopharyngeal angiofibroma (JNA) is a rare vascular tumor of unknown etiology. Studies investigating the molecular and genetic determinants of JNA are limited by small sample size and inconsistent approaches. The purpose of this study is to examine all eligible JNA studies in aggregate, applying qualitative analysis to highlight areas of particular relevance, including potential targets for therapeutic intervention.

Methods:

The PubMed, MEDLINE, Embase, Web of Science, Cochrane, and CINAHL databases were screened with inclusion and exclusion criteria applied to all citations. Manuscripts investigating the genetic determinants, histopathogenesis, and heritability of juvenile nasopharyngeal angiofibroma were included. Non-English studies, case reports, and articles focusing on clinical management without original data were excluded. Full text articles were obtained. A qualitative synthesis of data was performed.

Results:

A total of 59 articles met criteria for inclusion. These were divided into 6 categories based on the primary topic or target discussed, (1) steroid hormone receptors, (2) chromosomal abnormalities, (3) growth factors, (4) genetic targets, (5) molecular targets, (6) Wnt cell signaling, and (7) studies that overlapped multiple of the aforementioned categories. Although relatively low n values prevent definitive conclusions to be drawn, a predominance of certain molecular targets such as vascular endothelial growth factor (VEGF) and Wnt/β-catenin pathway intermediaries is apparent.

Conclusions:

Although the etiology of JNA remains elusive, contemporary molecular genetic investigation holds promise for risk stratification and could form the basis of a modernized staging system. A multicenter clinical registry and linked tissue bank would further promote the search for JNA specific biomarkers.

Nasal juvenile angiofibroma: Current perspectives with emphasis on management

Juvenile angiofibroma is an uncommon, benign, locally aggressive vascular tumor. It is found almost exclusively in young men. Common presenting symptoms include nasal obstruction and epistaxis. More advanced tumors may present with facial swelling and visual or neurological disturbances. The evaluation of patients with juvenile angiofibroma relies on diagnostic imaging. Preoperative biopsy is not recommended. The mainstay of treatment is resection combined with preoperative embolization. Endoscopic surgery is the approach of choice in early stages, whereas, in advanced stages, open or endoscopic approaches are feasible in expert hands. Postoperative radiotherapy (RT) or stereotactic radiosurgery seem valuable in long-term control of juvenile angiofibroma, particularly those that extend to anatomically critical areas unsuitable for complete resection. Chemotherapy and hormone therapy are ineffective. The purpose of the present review was to update current aspects of knowledge related to this rare and challenging disease. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1033-1045, 2017.

Adjunctive Treatment in Juvenile Nasopharyngeal Angiofibroma: How Should We Approach Recurrence?

A recent case of advanced, recurrent juvenile nasopharyngeal angiofibroma (JNA) at our institution has highlighted the limited evidence regarding adjunctive treatment. We present the case of a 10-year-old boy who is the first to undergo multiple-staged surgical resections alongside vincristine treatment. We performed a review of the literature analyzing the roles of radiation therapy, cytotoxic drugs, and novel targeted agents in JNA relapse. Small cohort studies suggest radiotherapy and flutamide are the most rational treatment options for residual and recurrent JNA. Our review highlights the need for further research into the management of primary and recurrent JNA.

Mesenchymal-endothelial transition in juvenile angiofibroma?

CONCLUSION

Mesenchymal-endothelial transition is proposed for juvenile angiofibromas (JAs). Propranolol might be an interesting new medical option in JA treatment, as it reduces mesenchymal cell growth and decreases the number of CD31-positive cells in vitro.

OBJECTIVE

Juvenile angiofibromas (JAs) are rare fibro-vascular tumors affecting almost exclusively adolescent males. Based on morphological aspects of irregularly configured vascular spaces and clinical features, JAs have been proposed to represent a vascular malformation. In general, mesenchymal-endothelial transition has been noted as an important process in tumorigenesis as well as in embryonal development.

METHODS

The study analyzed effects of vascular endothelial growth factor (VEGF)/basic fibroblast growth factor (bFGF) and propranolol on endothelial differentiation (CD31+) of cultured JA cells and their expression of angiogenic growth factors using aortic ring assay and enzyme-linked immunosorbent assay.

RESULTS

Following VEGF/bFGF supplement to cultured mesenchymal cells, an average of 4.47% (± 2.35%) CD31-positive cells were found (p < 0.001). Propranolol addition reduced the number of CD31-positive cells and inhibited mesenchymal cell growth. The aortic ring assay and ELISA investigation indicated no increased angiogenic growth factor secretion from cultured JA mesenchymal cells.

Expression of vascular endothelial growth factor in Juvenile Angiofibroma

OBJECTIVE

To examine Juvenile Angiofibroma (JA) tissue for expression of vascular endothelial growth factor (VEGF), and to explore its relationship with puberty status, stage, recurrence and the intraoperative blood loss.

METHODS

Retrospective cohort study of 36 histologically proven cases of JA. Minimum follow up period was 3 years. VEGF expression on tumor cells assessed by immunohistochemistry and graded on two criteria--percentage of cells expressing positivity and the intensity of positivity. These two parameters assessed for impact on puberty status, stage, recurrence, and blood loss.

RESULTS

VEGF expression noted on the tumor endothelial cells in 36/36, and on the tumor stromal cells in 34/36. The percentage of cells expressing VEGF and the intensity of expression were not significantly related to puberty status, tumor stage, recurrence, or intra-operative blood loss (p values 0.3-1.0).

CONCLUSION

VEGF expression is near universal in JA. Such expression is independent of puberty status and stage, and does not impact on intra operative blood loss and recurrence.