The nature of juvenile nasopharyngeal angiofibroma

Diode Laser Management of Primary Extranasopharyngeal Angiofibroma Presenting as Maxillary Epulis: Report of a Case and Literature Review

Juvenile nasopharyngeal angiofibroma is a rare vascular neoplasm, mostly occurring in adolescent males, and representing 0.05% of all head and neck tumors. Nevertheless, it is usually recognized as the most common benign mesenchymal neoplasm of the nasopharynx. Usually, it originates from the posterolateral wall of the nasopharynx and, although histologically benign, classically shows a locally aggressive behavior with bone destruction as well as spreading through natural foramina and/or fissures to the nasopharynx, nasal and paranasal cavities, spheno-palatine foramen, infratemporal fossa and, very rarely, to the cranial cavity. Extranasopharyngeal angiofibroma is considered a distinct entity due to older age at presentation, different localizations (outside the nasopharyngeal pterygopalatine fossa) and attenuated clinical course. Extranasopharyngeal angiofibroma has been sporadically described in the oral cavity. We report a case of extranasopharyngeal angiofibroma with primary and exclusive involvement of the adherent gingiva of the anterior maxilla, managed by preoperative diode laser trans-mucosal photocoagulation and subsequent surgical removal. The current literature on primary extranasopharyngeal angiofibroma is also reviewed.

Familial Adenomatous Polyposis Syndrome: An Update and Review of Extraintestinal Manifestations

CONTEXT.—

Familial adenomatous polyposis (FAP) is a rare genetic disorder with autosomal dominant inheritance, defined by numerous adenomatous polyps, which inevitably progress to colorectal carcinoma unless detected and managed early. Greater than 70% of patients with this syndrome also develop extraintestinal manifestations, such as multiple osteomas, dental abnormalities, and a variety of other lesions located throughout the body. These manifestations have historically been subcategorized as Gardner syndrome, Turcot syndrome, or gastric adenocarcinoma and proximal polyposis of the stomach. Recent studies, however, correlate the severity of gastrointestinal disease and the prominence of extraintestinal findings to specific mutations within the adenomatous polyposis coli gene (APC), supporting a spectrum of disease as opposed to subcategorization. Advances in immunohistochemical and molecular techniques shed new light on the origin, classification, and progression risk of different entities associated with FAP.

OBJECTIVE.—

To provide a comprehensive clinicopathologic review of neoplastic and nonneoplastic entities associated with FAP syndrome, with emphasis on recent developments in immunohistochemical and molecular profiles of extraintestinal manifestations in the thyroid, skin, soft tissue, bone, central nervous system, liver, and pancreas, and the subsequent changes in classification schemes and risk stratification.

DATA SOURCES.—

This review will be based on peer-reviewed literature and the authors' experiences.

CONCLUSIONS.—

In this review we will provide an update on the clinicopathologic manifestations, immunohistochemical profiles, molecular features, and prognosis of entities seen in FAP, with a focus on routine recognition and appropriate workup of extraintestinal manifestations.

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.

Efficacy and safety of preoperative internal maxillary arterial embolization with gelfoam for nasopharyngeal angiofibroma

PURPOSE

To investigate the efficacy and safety of preoperative internal maxillary arterial embolization with gelfoam particles in patients with nasopharyngeal angiofibroma.

MATERIALS AND METHODS

We retrospectively reviewed a total of 27 consecutive patients with pathologically confirmed nasopharyngeal angiofibroma from August 2006 to September 2018. Of the 27 enrolled patients, 10 patients received surgical excision alone; 17 patients received preoperative internal maxillary arterial embolization followed by surgical excision. Embolic agents were gelfoam particles.

RESULTS

The mean volume of intro-operative blood loss was 385.3 ml in patients with preoperative arterial embolization, which was significantly lower than 1215.0 ml in the patients without preoperative arterial embolization (P < 0.001). The mean surgical time was shorter in patients with preoperative arterial embolization than in the patient without preoperative arterial embolization, but the difference had no statistical significance (205.0 vs 264.5 min, P = 0.064). Neurological complications such as facial palsy or vision loss or hemiplegia were not observed in patients with preoperative arterial embolization.

CONCLUSION

Internal maxillary artery embolization with gelfoam particles suffices to provide an effective and safe adjuvant procedure for surgical excision of nasopharyngeal angiofibroma.

Morbidity and Volumetric Progression in Juvenile Nasopharyngeal Angiofibroma in a Long-Term Follow-Up

Objective  We compare the open and transnasal approaches for the excision of juvenile nasopharyngeal angiofibromas regarding the rate of morbidity, and residual tumor and its symptomatic recurrence over time. In addition, we present volumetric measurements of juvenile nasopharyngeal angiofibromas over time. Methods  All surgically treated patients of our institution were reviewed back to 1969 for type of surgery, residual tumor by magnetic resonance imaging (MRI)-based volumetry, recurrence, and morbidity. We performed a prospective clinical and radiological follow-up on reachable patients. Results  In total, 40 patients were retrievable from our records. We were able to follow up on 13 patients after a mean of 15.7 years since surgery (range: 1-47 years). Patients operated by the open approach had a higher rate of postoperative complications and thus a higher morbidity than endoscopic patients (4/4 vs 3/9; p  = 0.007), although tumor sizes were equal among groups ( p  = 0.12). Persisting tumor was noted in 3/4 and 4/9 ( p  = 0.56) patients, respectively. The corresponding mean volumes of residual tumors were 16.2 ± 14.4 cm ³ and 10.8 ± 6.6 cm ³ ( p  = 0.27). No progression could be noted in endoscopically treated patients ( p  = 0.24, mean time between scans 2 years). Conclusions  Our analysis shows that the endoscopic approach results in less morbidity. The open approach does not guarantee freedom from persisting tumor tissue. Age seems to be a most important risk factor for the conversion of an asymptomatic persistence into a symptomatic recurrence.

Nasopharyngeal angiofibroma in an elderly female patient: A rare case report

'Juvenile' nasopharyngeal angiofibroma, which accounts for <1% of all head and neck neoplasms, occurs predominantly in males between 10 and 18 years of age. The small number of patients older than 30 years confirms that presentation after this age is exceptional. Only rare cases of nasopharyngeal angiofibroma in female patients have been documented to date, and some authors believe that sex chromosome studies are indicated in such cases. The pathogenesis of nasopharyngeal angiofibroma remains unknown, but it has been hypothesized that it is a testosterone-dependent tumor. We herein report a particularly rare case of a 68-year-old woman diagnosed with nasopharyngeal angiofibroma and describe the diagnostic and therapeutic workup. This case describes, to the best of our knowledge, the oldest patient reported in the literature.

Human Papilloma virus in Juvenile Nasopharyngeal Angiofibroma: possible recent trend

BACKGROUND

Juvenile nasopharyngeal angiofibroma (JNA) has witnessed a four-fold increase in the incidence at our facility in the current decade as compared to the 1980s. With high global incidence of human pappilloma virus (HPV) related oropharyngeal cancer in India, we hypothesize its implication in JNA as it has not yet been reported.

METHODS

Clinico-Surgical variables of 6 patients of JNA were included for correlation and their tissue samples were subjected to western blotting (WB), polymerase chain reaction and immunoflorescence to demonstrate a definite association with HPV. In addition 6 control samples (adenoids) underwent WB analysis.

OBSERVATIONS

A universal presence of HPV with JNA is novel 'discovery' and has suggested a possibility of a definite association. Only a single case suggested weak infection. None of the controls suggested infection, thus ruling out the presence of HPV in nasopharynx of normal population.

INTERPRETATION

With the dawn of this definite association, no specific conclusions can yet be drawn but a whole plethora of questions have emerged with our novel 'discovery'.

Tissue Maturation during the Growth of Juvenile Nasopharyngeal Angiofibroma

Juvenile nasopharyngeal angiofibroma involves a specific age group and changes from vascular tissue to fibrous tissue. The goal of this study was to investigate the correlation among tumor extension, the histologic characteristics of the tumor, and the patient's age. We performed a prospective study of 43 male patients with untreated juvenile nasopharyngeal angiofibroma (average age, 15.42 years). We correlated the patient's age with the extension of the tumor (analyzing the computed tomographic scan) and the immunohistologic characteristics of the tumor (morphological and morphometric analysis of the central portion of the tumor, the sphenopalatine foramen region). We observed that the larger the tumor, the smaller the number of vessels and cells, but the larger the fibrous component and the higher the grade of maturation of the tissue. The patient's age was not correlated with tumor extension or the histologic characteristics of the tumor. However, the grade of maturation of the tissue in the region of the sphenopalatine foramen was higher in larger tumors.

[Juvenile nasopharyngeal angiofibroma with orbital extension]

CLINICAL CASE

The case is presented of a 21 year-old male with a history of left proptosis and diplopia of two weeks of onset. The MRI showed an ethmoid-orbital vascular lesion with anterior skull base invasion and orbital extension. Biopsy of the ethmoid confirmed fibrovascular tissue, which supported the diagnosis of angiofibroma.

DISCUSSION

It is a benign neoplasm with local characteristics of malignancy due to its ability to invade adjacent areas. In this case, the debut presented with manifestations of orbital extension. A broad and multidisciplinary approach is needed in order to improve prognosis.

The presence of tumor-infiltrating IL-17-producing cells in juvenile nasopharyngeal angiofibroma tumor microenvironment is a poor prognostic factor

BACKGROUND

Although juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor histologically, it demonstrates aggressive propensity of locally destructive growth causing bone erosion. The patients with JNA remain high recurrence rate after surgical excision. Th17 cells secrete the proinflammatory cytokine interleukin-17 (IL-17), and play an important role in carcinogenesis and tumor progression. So far, no studies have focused on the significance of IL-17-producing cells in the JNA tumor microenvironment. The current study was designed to investigate the localization and level of tumor-infiltrating IL-17-producing cells in JNA microenvironment. The presence and number of IL-17-producing cells were further analyzed for a possible association with clinicopathological features and disease outcome.

MATERIALS AND METHODS

Immunohistochemistry was used to analyze the expression of IL-17 in a tissue microarray from 70 patients with JNA and 10 control subjects. Correlations between the levels of IL-17 expression and clinicopathologic variables, as well as tumor recurrence, were assessed.

RESULTS

In vessels, the IL-17-producing cells were identified in pericytes and irregular smooth muscle cells, but the matured vascular endothelial cells showed no IL-17 reactivity. The expression of IL-17 in stromal cells was concentrated in the less differentiated and plump cells that contained a central hypochromatic nucleus and single small nucleolus. Chi-square test showed that tumor stage (p=0.09), operation history (p=0.828), operation approach (p=0.159), and volume of intraoperative hemorrhage (p=0.352) were not associated with the expression of IL-17 in JNA patients. However, intratumoral IL-17-producing cells were negatively associated with patient's age (p=0.004). Furthermore, we found that patients with extensive infiltration of IL-17-producing cells had significantly higher recurrence rates than those with less infiltration of IL-17-producing cells (p=0.028). Log rank analysis showed that JNA patients with high levels of IL-17 had significantly shorter disease free survival (DFS) than those with low levels of IL-17 (p=0.004). Univariate Cox regression analysis suggested that IL-17 and patient's age were significantly associated with DFS. Multivariate analysis indicated that high infiltration with IL-17-producing cells was associated with poor DFS. Of all clinicopathological features, IL-17 level was an independent factor predicting the patient's prognosis.

CONCLUSION

In JNA patients, a high level of IL-17-producing cells was negatively associated with patient's age. Patients with extensive infiltration of IL-17-producing cells had significantly higher tumor recurrence rates. High infiltration of IL-17-producing cells in JNA microenvironment is an independent poor prognostic factor for shorter disease-free survival. Future studies further focusing on the role of IL-17 may provide more promising therapeutic methods for extensive JNA tumors.

Invasive growth patterns of juvenile nasopharyngeal angiofibroma: radiological imaging and clinical implications

Juvenile nasopharyngeal angiofibroma is a benign lesion with locally aggressive nature. Knowledge of its typical growth patterns is crucial for precise preoperative staging and adequate preoperative patient counseling. This pictorial essay focuses on characteristic radiological features and paths of invasive growth of this rare tumor. Also, the impact of accurate preoperative evaluation of tumor extensions on surgical planning and results of treatment are discussed.

Immunohistochemistry in diagnosis of extranasopharyngeal angiofibroma originating from nasal cavity: case presentation and review of the literature

Angiofibromas are rare vascular tumors which originate predominantly in the nasopharynx and occur typically in male adolescents. Extranasopharyngeal sites such as nasal cavity and paranasal sinuses are less frequent. This review article was undertaken to evaluate the incidence, clinical features and management of extranasopharyngeal angiofibromas originating exclusivelly from nasal cavity structures. Our focus of interest was to evaluate the significance of immunohistochemical analysis in diagnosis of such extremely rare neoplasms. In the PubMed and Google Search, we found only 39 cases of nasal angifibroma, 27 males and 12 females from 1980 to 2012. The most prevalent site of origin was nasal septum, followed by inferior and middle turbinate. The commonest symptoms were nasal obstruction and epistaxis. Nasal angiofibromas are clinically distinct from nasopharyneal angiofibromas and can therefore be misdiagnosed. The differential diagnosis includes other vascular lesions, such as lobular capillary hemangioma and sinonasal-type hemangiopericytoma. Although immunohistochemistry is not necessary for differentiation between angiofibroma and capillary hemangioma, that diagnostic procedure may be helpful in distinction from sinonasal hemangiopericytoma. As an ilustration for immunohistochemical analysis, we presented a case of an elderly woman with tumor arising from the middle turbinate, diagnosed as angiofibroma. The staining was positive for CD34, CD31, factor VIII, vimentin and smooth muscle alpha-actin, and negative for desmin.

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

BACKGROUND

Predilection of juvenile angiofibromas in adolescent boys has prompted the hypothesis of hormone-dependent tumor growth. However, knowledge on expression and function of sex hormone receptors in juvenile angiofibromas is still sparse and inconsistent.

METHODS

Transcript and protein expression of sex hormone receptors in juvenile angiofibromas was studied by quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) and immunohistology/fluorescence. A bromodeoxyuridine assay was used to assess the antiproliferative effects of flutamide (androgen receptor antagonist) and tamoxifen (estrogen receptor modulator).

RESULTS

Significantly increased transcript levels were observed for androgen receptor, estrogen receptor α, follicle-stimulating hormone receptor, and luteinizing hormone receptor in juvenile angiofibromas versus the stroma of nasal mucosa. Estrogen receptor β and progesterone receptor mRNA levels were low and similar for both tissues. Estrogen receptor α protein was detected in juvenile angiofibroma tumors and mesenchymal cell lines. Flutamide and tamoxifen inhibited proliferation of cultured juvenile angiofibroma mesenchymal cells.

CONCLUSION

These findings contribute to the understanding of juvenile angiofibroma pathophysiology and offer novel therapeutic options.

Treatment and prognosis of nasopharyngeal angiofibroma involving the eye and optic nerve

OBJECTIVE

To discuss the minimally invasive treatment and prognosis of juvenile nasopharyngeal angiofibroma involving the eye and optic nerve.

METHODS

Retrospective analysis of clinical data for 18 large juvenile nasopharyngeal angiofibromas, with reports of three typical cases.

RESULTS

The tumour invaded the orbit, eye, optic nerve and optic chiasm in 18, 9, 8 and 5 patients, respectively. Twelve patients were cured after surgery, with the affected eye and vision essentially returning to normal. In six patients, tumour residue was found in the middle cranial fossa; two of these six did not return for follow up. Four patients underwent radiotherapy; all four regained placement of the eye in a normal or near-normal position. One of these four patients regained normal visual acuity, two experienced no improvement in visual acuity, and one became blind.

CONCLUSION

In patients with this tumour, surgery may return the eye to the normal position and may restore visual acuity if the optic fundus, macula, retina and optic nerve are only mildly affected. Modern radiotherapy can treat the intracranial residue effectively. A combined approach via the antrum, infratemporal fossa and nasal cavity, using a Caldwell-Luc incision, provides minimally invasive surgical access.

Biological distinctions between juvenile nasopharyngeal angiofibroma and vascular malformation: an immunohistochemical study

The exact nature of juvenile nasopharyngeal angiofibroma (JNA) is still in dispute. In recent years, the main controversy of its nature has focused on hemangioma and vascular malformation. In this study, the immunolocalization of vascular endothelial growth factor (VEGF), VEGF receptor-1/fms-like tyrosine kinase-1 (VEGFR-1/Flt-1), VEGF receptor-2/fetal liver kinase-1 (VEGFR-2/Flk-1), proliferating cell nuclear antigen (PCNA), and CD34 was investigated in 28 cases of JNA and 20 cases of orbital cavernous hemangiomas (OCH). The immunostaining levels of VEGF, Flt-1, and Flk-1 were higher and more frequent in vascular endothelial cells of JNA than those of OCH (p<0.05). The average microvessel density (MVD) marked by CD34 in JNA was (49.3 ± 9.1)/HPF (high power field), which was higher than OCH (29.1 ± 6.7)/HPF (p<0.05). Immunoreactivity of PCNA was localized in both endothelial and stromal cell components of JNA, but was predominantly seen in the stromal cells. However, no PCNA immunoreactivity was identified in any of the stromal and endothelial cells in cases of OCH. The immunostaining levels of CD34, VEGF, Flt-1, Flk-1, and PCNA in JNA were higher than those in OCH. These data support the view that JNA has biological characteristics of an angiogenic histogenetic tumor. In the future, anti-angiogenic therapy may represent a novel treatment strategy for JNA.

Management of juvenile nasopharyngeal angiofibroma: a five year retrospective study

Juvenile nasopharyngeal angiofibroma is a pathologically benign yet locally aggressive and destructive vascular lesion of head and neck region typically affecting adolescent boys. The present article is a retrospective study of surgically treated patients of juvenile nasopharyngeal angiofibroma over a period of 5 years. The study discusses about most common presenting complaints, correlation of preoperative radiological and intraoperative staging and factors affecting recurrence of juvenile nasopharyngeal angiofibroma.

Stem cell-related proteins C-KIT, C-MYC and BMI-1 in juvenile nasopharyngeal angiofibroma--do they have a role?

Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular tumour, occurring almost exclusively in adolescent males. Histogenesis of JNA remains unclear, two optional theories proposing either fibrous or vascular tissue as the tissue of origin. Stem cell-related proteins have been discussed to possibly participate in the growth of these tumours. In our study, we reviewed retrospective clinicopathological data of 26 JNA patients. By immunohistochemistry, we investigated the cellular distribution and expression levels of stem cell-related proteins C-KIT, C-MYC and BMI-1 and their correlation with cell and vessel density of the tumour. Contrary to earlier reports, we detected C-KIT expression in addition to stromal cells also in endothelial cells. The C-KIT expression was more dominant in slit vessels than large vessels. A significant correlation was found between endothelial immunoexpression of C-KIT and cellular density of the tumour. C-MYC and BMI-1 expression was detected in stromal cells only. Due to our finding of C-KIT expression in both stromal and endothelial cells and the strong correlation between the endothelial C-KIT expression and cellular density, we suggest that, besides the stromal tissue, the vascular component might take part in the neoplastic growth of JNA.

The changing surgical management of juvenile nasopharyngeal angiofibroma

The management of juvenile nasopharyngeal angiofibroma (JNA) has changed during the last decades but it still continues to be a challenge for the multidisciplinary head and neck surgical team. The aim of this study was to review the used treatment approach and outcome of JNA in a single institution series of 27 patients diagnosed and treated during the years 1970-2009. All patients were male, with the median age of 17 years (range 11-33 years). Surgery was used as the primary treatment in every case. Surgical approaches varied, transpalatal approach (N = 14) being the most common approach used in this series. During the last decade various other techniques were applied, including endoscopic (N = 3) resection. Two patients were additionally treated with antiangiogenic agents and one patient with stereotactic radiotherapy. The primary recurrence rate was 37% and it seemed to correlate with vascular density of tumour and the surgical approach used. We suggest that the management of JNA should be planned by an experienced head and neck surgeon, as part of a multidisciplinary team, preferably in a tertiary referral setting, and the recent development of the available therapies should be taken into account to minimise the risk of recurrence.

Lacrimal hyposecretion: a surgical complication of juvenile nasopharyngeal angiofibroma

PURPOSE

The aim of this study was to evaluate lacrimal hyposecretion in the surgical management of juvenile nasopharyngeal angiofibroma (JNA) and discuss how to prevent and treat this expected surgical complication.

MATERIALS AND METHODS

Six cases of JNA were extirpated surgically in the last 3 years in our department. The clinical signs, results of the total tear secretion test (Schirmer I test), imaging studies, surgical findings, and pathologic changes in these cases are reviewed retrospectively.

RESULTS

Three of the 6 cases developed an irritated dry eye on the affected side postoperatively as a result of lacrimal hyposecretion, caused by damage to or partial removal of the pterygopalatine ganglion and vidian nerve. On follow-up for 1 to at least 2 years, the clinical signs disappeared in 2 cases, whereas there was no improvement in 1 case.

CONCLUSIONS

If a JNA originates near the pterygopalatine foramen adjacent to the pterygopalatine ganglion and vidian nerve, these may be damaged or partially removed intraoperatively. The consequent lacrimal hyposecretion can be a temporary or permanent complication.

SIGNIFICANCE

A few reports have described lacrimal hyposecretion as a surgical complication of JNA; there have been no articles reporting the prognosis of this complication or the related pathologic findings of the involved pterygopalatine ganglions. Prevention of this complication remains a clinical challenge.

Epstein-Barr virus and human herpes virus-8 are not associated with juvenile nasopharyngeal angiofibroma

BACKGROUND

Nasopharyngeal angiofibroma (also known as juvenile nasopharyngeal angiofibroma) is a rare fibroblastic tumor with a vascular component that occurs in the nasopharynx and posterolateral nasal wall of adolescent boys. The etiology of nasopharyngeal angiofibroma remains elusive. This investigation was undertaken to determine if human herpes simplex virus-8 and Epstein-Barr virus are possible etiologic viruses and to determine if they have any association with the age of the patient and/or the proliferative state of the lesion.

MATERIALS AND METHODS

Formalin fixed, routinely processed, and paraffin embedded surgical specimens of 15 angiofibromas were submitted to PCR for EBV and HHV-8, while in situ hybridization was also employed for EBV. Immunohistochemical analysis for ki-67 was performed using MIB immunostaining.

RESULTS

None of the tumors were positive for HHV-8. The PCR technique produced a false positive reaction in five cases, with all cases non-reactive with EBV-ISH. The age of the patients did not show correlation with the Ki-67 labeling index.

CONCLUSION

Angiofibroma does not appear to be associated with either HHV-8 or EBV, thereby excluding these viruses as potential etiologic agents. The lack of a correlation between the proliferative index and the age of the patient suggests the proposed puberty induced, testosterone-dependent tumor growth may not play a significant role in tumor development.

Radiofrequency-induced thermotherapy of nasopharyngeal angiofibroma and immunohistochemical analysis of vessel proliferation: a case report

Introduction

Nasopharyngeal angiofibroma presents with symptoms of nasal obstruction and epistaxis. The treatment of choice is embolization followed by surgery.

Case presentation

A 52-year-old man underwent surgery for nasopharyngeal angiofibroma after adjuvant radiofrequency-induced thermotherapy. To the best of the authors' knowledge, this is the first case of angiofibroma with clinical follow-up after thermocoagulation therapy supported by quantitative, double immunohistochemistry. We found this case of angiofibroma to be of interest owing to the presentation of symptoms leading to biopsy, the pathohistological observations obtained with synchronous Ki67/cluster of differentiation 34 and Ki67/smooth muscle actin immunohistochemistry and high pericyte proliferation.

Conclusion

Coagulation of angiofibroma vessels followed by acquisition of a thick mantle of pericytes in a patient with a nasopharyngeal growth suggests that radiofrequency-induced thermotherapy could be a useful, palliative therapy for bleeding nasopharyngeal angiofibroma, supporting vessel maturation prior to surgical tumor removal.

Juvenile nasopharyngeal angiofibroma: an immunohistochemical characterisation of the stromal cell

AIMS

Juvenile nasopharyngeal angiofibroma (JNA) is a rare tumour occurring almost exclusively in young adult males. Although histologically benign, it can be locally aggressive with a significant recurrence rate. The finding of activating beta-catenin gene mutations in the stromal cells indicates these are the neoplastic cells and supports the association of JNA and familial adenomatous polyposis (FAP). Previous immunohistochemical studies have demonstrated a null or focal myoepithelial immunophenotype in the stromal cells. Recently, expression of several growth factors and oncoproteins including CD117 (c-kit) in the stromal cells has been demonstrated. Our objective is to evaluate the immunohistochemical phenotype of the stromal cell of JNA, particularly within the proliferative zone of the tumour, by application of antibodies against MNF116, CAM5.2, S-100, CD31, CD34, CD99, CD68, vimentin, EMA, SMA, desmin, calponin, Bcl-2 and (CD117) c-kit in a series of 54 cases.

METHODS

A routine immunohistochemical protocol was applied to representative paraffin sections of 54 JNAs collected from the Port Moresby General Hospital, Papua New Guinea, and Princess Alexandra and Royal Brisbane Hospitals, Queensland, Australia. Immunoexpression of each antigen was assessed in the stromal cells and the vessels.

RESULTS

The majority of stromal cells in more than half of the cases demonstrated no staining with any of the 14 antibodies other than vimentin. Of 54 cases, 22 contained a microvascular component (usually peripherally located and indicating the active growth front of the tumour) in which the stromal cells demonstrated a hybrid immunophenotype with both smooth muscle and endothelial differentiation. c-kit was negative in all cases.

CONCLUSIONS

The majority of stromal cells have an undifferentiated immunophenotype with no evidence of epithelial, myoid, endothelial or other lineage specific differentiation. In the microvascular component the stromal cells appear able to show smooth muscle or endothelial differentiation. No c-kit expression was identified.

Nasopharyngeal angiofibroma with intracellular accumulation of SPARC – a hypothesis (SPARC in nasopharyngeal angiofibroma)

Nasopharyngeal angiofibroma is a histologically benign tumor composed of stroma and vessels. The vascular component of the lesion is prone to bleeding and responsible for its clinical "malignancy". Some nasopharyngeal angiofibromas are resistant to surgical therapy because of extensive growth and occasionally bone destruction. It has been shown that molecular factors supporting residual tissue after incomplete surgery might be targeted with pharmacotherapy as a cell based therapy. Because the cell of origin of nasopharyngeal angiofibroma is not recognized yet, it would be of interest to discuss molecule(s) relevant to all the cell components of the growth. Such molecule(s) may also regulate bone homing of the tumor. We propose that in nasopharyngeal angiofibroma the molecule responding to the cues mentioned above is SPARC (secreted protein acidic rich in cystein). We discuss SPARC-enabling formation of molecular complexes important for the angiogenic events and present nasopharyngeal angiofibroma as a hyperplastic angiogenic machinery or a "soil" without "seed". Therapeutic targeting of SPARC in nasopharyngeal angiofibroma would be targeting of a molecule at the roots of cooperation between stromatogenesis and angiogenesis, coexpressed with Ki67 in the vascular compartment. Considering the intracellular accumulation of SPARC, the benefit of (anti) SPARC therapy in nasopharyngeal angiofibroma is yet to be proved.

Huge nasopharyngeal angiofibroma with intracranial extension: change in the dura mater and choice of surgical management

We aimed to review (1) the imaging changes in the dura mater in cases of huge, lobulated juvenile nasopharyngeal angiofibroma, and (2) the choice of surgical management.

Imaging from four cases of juvenile nasopharyngeal angiofibroma showed extrapharyngeal extension of the tumour. The sphenoid sinus, sella turcica and clivus were extensively eroded, and the tumour had spread deep into the cranial fossa. In three cases, intracranial exploration was performed to treat the intracranial tumour lobule. Subsequently, the tumours were removed using extracranial approaches. No perforation of the dura mater was found in these three cases, although the dura mater in the superior orbital fissure was congested, haemorrhagic and solid. Pre-operative imaging for two cases (i.e. the first operation for one and the second operation for the other) revealed no dura mater perforation. A transantral approach via a midfacial degloving incision was used to remove these tumours completely.

We conclude that change in the dura mater is a crucial indication for the choice of management. If the dura mater is intact, a transantral approach via a midfacial degloving incision may remove the tumour successfully.

Steroid hormone receptor expression in nasopharyngeal angiofibromas. Consistent expression of estrogen receptor beta

Nasopharyngeal angiofibroma is an uncommon tumor arising in adolescent males, suggesting that the tumor may be hormonally responsive. Previous studies have found androgen receptor (AR) expression but variable expression of estrogen receptor (ER). The recently described ss receptor for estrogen has not been analyzed in angiofibroma. We analyzed 13 cases of nasal angiofibroma by immunohistochemical analysis for the presence of ARs, progesterone receptors (PR), and ER-a and ER-ss. All 13 cases were positive for ER-ss, in stromal pericytic and endothelial cells, and 12 of 13 stained strongly. Five cases were positive for AR in stromal cells, most staining weakly, and with no staining in endothelial or pericytic cells. None of the cases displayed staining for ER-a or PR. The findings confirm that nasopharyngeal angiofibromas express ER and suggest that new modulators of ER-ss activity may provide an alternative therapy for these lesions.

Proliferation, angiogenesis and hormonal markers in juvenile nasopharyngeal angiofibroma

OBJECTIVES

Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular and locally invasive tumor that exclusively affects male adolescents. Sex hormones are first discussed to clarify the etiology of JNA. Recently with the advances in the field of cell biology angiogenetic markers, proliferation markers and growth factors are investigated to identify the molecular basis of JNA as all neoplasm. In this study we tried to evaluate the expression of proliferation, angiogenesis and hormonal markers in JNA.

METHODS

Immunohistochemical analysis were performed on paraffin-embedded 27 JNA samples which were obtained from the patients operated at University of Hacettepe Department of Otorhinolaryngology, a tertiary care center. Estrogen receptor (ER), progesterone receptor (PR), proliferating cell nuclear antigen (PCNA), vascular endothelial growth factor (VEGF) and transforming growth factor beta (TGF-beta) specific antibodies were used and evaluated by light microscopy

RESULTS

Two of 27 cases were ER positive. Nine of 27 cases were positive for PR. All of the cases were stained with PCNA. Twenty-four of 27 cases stained with VEGF. TGF-beta was positive in 14 of 27 cases. All recurrent cases were stained with PCNA and VEGF; just three of them were stained with TGF-beta.

CONCLUSIONS

Hormonal markers ER and PR did not seem to play a role in pathogenesis of JNA. PCNA, VEGF and TGF-beta may play a role in the pathogenesis of JNA by promoting angiogenesis and proliferation, but this role did not seem to have a relation with hormonal markers.

Tissue maturation correlating to clinical manifestations in juvenile angiofibroma

OBJECTIVES

Juvenile nasopharyngeal angiofibroma is a rare benign tumor that affects young male patients and shows a characteristic development from its origin. It is not a true neoplasm, but shows features of vascular processes, developing into a more fibrous condition. The aim of this study was to correlate the clinical manifestations and the histologic findings of the tumor.

METHODS

Thirty-six patients without previous treatment were studied. We correlated the incidence and duration of the clinical manifestations (nasal obstruction, epistaxis, nasal and/or pharyngeal tumor, and facial deformity) and morphometric histologic analyses of the central region of the tumor (number, caliber, and presence of muscle cells in the vessel wall, and tissue maturity and cellularity).

RESULTS

The duration of nasal obstruction, the presence of nasal and/or pharyngeal tumor, and facial deformity were significantly correlated with the number of vessels, the tissue maturation, and the cellularity of the tumor. Epistaxis showed a strong correlation with the presence of muscle fibers in the vessels.

CONCLUSIONS

There are correlations between the duration of the clinical manifestations and histologic maturation in the central portion of the tumor.

Nasopharyngeal angiofibroma in an elderly woman

"Juvenile" nasopharyngeal angiofibroma is a locally aggressive, yet histologically benign, vascular neoplasm. This neoplasm accounts for less than 0.5% of neoplasms of the head and neck and occurs almost exclusively in adolescent males. We report a rare case of a 64-year-old woman with a red lobulated mass in the right nostril, diagnosed as nasopharyngeal angiofibroma on postoperative histopathologic and immunohistochemical analysis.

Estrogen receptor beta expression in vascular neoplasia: an analysis of 53 benign and malignant cases

The importance of estrogen in vascular neoplasia is suggested by a predilection for women and a tendency for rapid growth during pregnancy. Although early experiments using radioligand assays demonstrated estrogen receptor (ER) expression, these findings were not confirmed by subsequent immunohistochemical studies which were performed with antibodies raised against ER alpha. A newly discovered estrogen receptor subtype, ER beta, has not been previously characterized in vascular lesions. In order to verify the expression of estrogen receptors in vascular neoplasms as well as to clarify the inconsistency between radioligand and early immunohistochemical studies, we examined a series of 53 benign and malignant vascular neoplasms for ER beta expression. All of the subtypes of vascular neoplasia examined had nuclear expression of ER beta. The majority of cases (94%) displayed 2+ to 3+ staining. The discrepancy between radioligand studies and previous immunohistochemical studies is attributable to the use of antibodies raised against ER alpha, which is not expressed in vascular lesions, and not ER beta, which is broadly expressed in both benign and malignant vascular neoplasms. Although ER beta may be of limited diagnostic use in vascular neoplasia due to its broad expression, the potential exists for a therapeutic approach using ER agonists.

Orbital involvement in juvenile nasopharyngeal angiofibroma: prevalence and treatment

PURPOSE

To assess the prevalence of orbital invasion by juvenile nasoangiofibroma and to discuss its surgical treatment.

METHODS

A retrospective review of the medical records and tomographic scans of a case series of 19 patients with juvenile nasoangiofibroma was performed. All scans were reviewed by a radiologist and an orbital surgeon. The presence of the tumor was assessed in the pterygopalatine fossa, nasal cavity, nasopharynx, paranasal sinuses, inferior orbital fissure, orbit, and middle cranial fossa.

RESULTS

The most common structures invaded were pterygopalatine fossa (100%), nasal cavity (94.7%), sphenoid sinus (84.2%), and nasopharynx (73.7%). The orbit was invaded in 6 (31.6%) patients. In 5 of these patients, the tumor extended in the orbit through the inferior orbital fissure. Four patients with orbital invasion were successfully operated with the Le Fort I approach.

CONCLUSIONS

Orbital involvement is relatively common in the setting of juvenile nasoangiofibroma extension. The main route of orbital invasion is the inferior orbital fissure. The Le Fort I osteotomy is an adequate approach for managing juvenile nasoangiofibroma when it invades the orbit.

Relaxation of imprinting of IGFII gene in juvenile nasopharyngeal angiofibromas

IGFII and H19 genes are expressed only from one allele due to genomic imprinting, biallelic expression (loss of imprinting) being associated with the tumorigenic process of different types of tumors. The mechanism responsible for genomic imprinting is not yet determined, although DNA methylation has been considered the main genetic event for an imprinted mark. In the current study, the authors analyzed the imprinting status and expression levels of the IGFII and H19 genes in 27 cases of Juvenile Nasopharyngeal Angiofibroma (JNA) using RFLPs, RT-PCR, and Southern and Northern Blots. The authors found that four out of eight informative cases (50%) for ApaI/IFGII polymorphism showed biallelic expression of IFGII whereas none of the nine informative cases for the polymorphism showed biallelic expression of the H19 gene. Overexpression of IFGII was observed in 8 out of 22 cases (36.4%), and 7 out of 19 cases (36.8%) showed H19 overexpression. Hypomethylation was found only in the H19 gene in six out of eight cases analyzed. Therefore, our results demonstrate that alterations in the IFGII/H19 imprinted region occur in JNA.