A Calcitonin-Producing Neuroendocrine Tumor of the Larynx: A Case Report

A moderately differentiated neuroendocrine carcinoma of the larynx is described. Although the patient had normal serum calcitonin level 36 months before, its level was elevated at the time the neck node was removed. This study supports the hypothesis that a diagnosis of calcitonin-producing neuroendocrine tumor of the larynx with increased plasma calcitonin is possible and should be considered to avoid unnecessary thyroidectomy.

[Effects of protein kinase CK2α on apoptosis and ultrastructure of laryngeal carcinoma cells]

OBJECTIVE

To investigate the effect of protein kinase CK2α on apoptosis and ultrastructure of human laryngeal carcinoma cells and its possible mechanism.

METHODS

The siRNA expression plasmid psiRNA-hH1neo-CK2α specific to protein kinase CK2α and non-specific siRNA expression plasmid psiRNA-hH1neo-cont were transfected into Hep-2 cells respectively by lipofectamine method. Western blot was used to detect the expression of kinase CK2α protein. The apoptotic rate was measured by Annexin V-FITC/PI double-staining. The morphological changes of Hep-2 cells were observed under transmission electron microscope (TEM). The expressions of bcl-2 and Bax protein were measured by Western blot.

RESULTS

The expression of protein kinase CK2α protein significantly decreased in the Hep-2 cells transfected with psiRNA-hH1neo-CK2α (P < 0.01). Compared with the untransfected cells and siRNA-hH1neo-cont transfected group, psiRNA-hH1neo-CK2α transfected group presented with classical ultrastructural features of apoptosis, such as karyopyknosis, chromatic agglutination adjacent to nuclear membrane and apoptotic body. The apoptotic rate of psiRNA-hH1neo-CK2α transfected group was obviously higher than that in untransfected cells and siRNA-hH1neo-cont transfected group (25.66% ± 0.83% vs 3.66% ± 0.43%, 5.18% ± 0.22%, both P < 0.05). Compared with two other groups, the bcl-2 protein expression of psiRNA-hH1neo-CK2α transfected group decreased (0.20 ± 0.09 vs 0.72 ± 0.16, 0.56 ± 0.11, both P < 0.01), the Bax protein expression increased (0.81 ± 0.17 vs 0.26 ± 0.12, 0.33 ± 0.17, both P < 0.01) while the ratio of bcl-2 to Bax decreased (0.25 ± 0.05 vs 2.76 ± 0.21, 1.70 ± 0.22, both P < 0.01).

CONCLUSION

Protein kinase CK2a plays an important role in the apoptosis of human laryngeal carcinoma cells possibly by decreasing bcl-2/Bax. Protein kinase CK2a may provide a potential therapeutic target against human laryngeal carcinoma.

[The cytoskeleton and immigration of laryngeal squamous carcinoma cell affected by Fascin-1 expression]

This study sought to detect the effect of Fascin-1 expression on the cytoskeleton and immigration of laryngeal squamous carcinoma cell. In the experiment, Fascin-1 expression in Hep-2 cells was inhibited by small interfering RNA. The cytoskeleton of Hep-2 cells was observed with the use of laser scanning confocal fluorescence microscope. Millicell insert was applied to detect the immigration of Hep-2 cells in vitro. The results showed that the integrity of cytoskeleton in Hep-2 cells was broken with the down-regulation of Fascin-1 expression and the immigration ability was decreased significantly (P < 0.05). The inhibiting ratio of cell immigration was 44.6 +/- 6.3%. In conclusion, inhibition of Fascin-1 expression in Hep-2 cells could break the integrity of cytoskeleton and decrease the ability of cellular immigration.

Laryngektomia jako postępowanie ratujące u chorych z nasilonym odczynem popromiennym po radioterapii raka krtani

INTRODUCTION

Author discusses problems and treatment principles of patients with massive postradiation injury, who had laryngectomy procedure as a result of insufficience of the farmacological treatment.

MATERIAL AND METHODS

There were 12 patients who were performed laryngectomy as a treatment of massive postradiation injury of the larynx in the period 1975-2005. We suspected presence of persistent neoplasm with postradiation changes. Seven laryngectomies were performed after confirmation of the neoplasm in 1-3 biopsies. Three patients were treated operatively without this confirmation in spite of two biopsies which were negatively, and two patients were treated in this way without biopsies.

RESULTS

Two patients had tomour free postlaryngectomy specimens in the histopathological examinations, and among 10 others the reccurence of the tumour after radiotherapy was present during the post-laryngectomy histopathological examinations. In 7 cases this reccurence was proved with massive postradiation injury in endoscopic biopsies before laryngectomy.

DISCUSSION

Author presents his own problems and presents methods of treatment of the patients with massive postradiation injury of the larynx described in literature.

Ultrastructural evaluation of 585-nm pulsed-dye laser-treated glottal dysplasia

OBJECTIVE/HYPOTHESIS

To describe the ultrastructural changes occurring within pulsed-dye laser (PDL)-treated glottal tissues.

STUDY DESIGN

Prospective.

METHODS

Nine patients presenting with glottal dysplasia requiring biopsy to rule out microinvasive carcinoma were enrolled in this prospective study. At least two samples were obtained in each case: one from a PDL-treated area and another from a non-PDL-treated area (obtained from a nonphonatory region as an internal control). In some cases, a third sample was obtained from the junction between PDL- and non-PDL-treated areas. All samples were examined with light microscopy (H and E stain) and transmission electron microscopy. Observations were made of morphological changes within the epithelium, epithelial/ superficial lamina propria (SLP) junction, and the lamina propria of tissues treated with the PDL. Eight of nine patients were followed for a period of 9-25 months (mean, 18 months) with two recurrences that were retreated with awake-PDL and followed for an additional 8.3 and 9.5 months without recurrence. Vocal fold appearance returned to normal within 3-4 weeks posttreatment.

RESULTS

Intraepithelial desmosome junctions were preferentially destroyed, and regional blood vessels were coagulated. The PDL consistently caused a separation of epithelial cells away from the basement membrane.

CONCLUSIONS

The PDL allowed for both a surgical and a nonsurgical multimodality method for treatment of precancerous lesions with minimal effects on the SLP.

Large cell neuroendocrine carcinoma of the larynx: a case report and a review of the classification of this neoplasm

This report describes a case of large cell neuroendocrine carcinoma (LCNEC) of the larynx. A 74 year old man who presented with otalgia underwent direct laryngoscopy with biopsy, which revealed an invasive poorly differentiated carcinoma. Laryngectomy with bilateral neck dissections revealed invasion of the pre-epiglottic space by the tumour, with metastases to bilateral lymph nodes (AJCC T3N2c). The tumour was characterised by large cells with vesicular chromatin and prominent nucleoli. The cells were arranged in organoid and trabecular patterns with a background of extensive necrosis and numerous mitotic figures. Immunohistochemical and ultrastructural analyses confirmed the neuroendocrine nature of the tumour. Metastatic disease was present in the liver, and the patient died within weeks of surgery. LCNEC carcinoma is a rare tumour of the larynx. Recognition at this site is essential so that proper patient management can be initiated.

Leiomyosarcoma of the larynx: critical analysis of the diagnostic role played by immunohistochemistry

Laryngeal leiomyosarcoma (LMS) is definitely considered a rare occurrence: our exhaustive literature review disclosed to date only 45 cases (including the new case we have reported). The morphological diagnosis of laryngeal LMS may be problematic on conventional light microscopy especially in small laryngeal specimens. In the past, LMSs of the larynx were frequently confused with other spindle-cell malignant tumors. Nowadays, immunohistochemical investigations are considered necessary to distinguishing LMS from other spindle-cell tumors. On immunostaining, LMS is usually positive for muscle-specific actin and negative for cytokeratins and epithelial membrane antigen. In most cases, immunohistochemical study allows reliable diagnosis of LMS, but it can produce ambiguous or inconclusive results when the tumor cells lack specific immunohistochemical reactivity. In these controversial cases, LMS diagnosis has to be substantiated by electron microscopy. Distinguishing laryngeal LMS from other spindle-cell malignancies plays a role not only in academic interest. Confusion in the diagnosis of a spindle-cell laryngeal malignancy could result in inappropriate clinical management and inadequate treatment.

The nuclear localization of NFkappaB and p53 is positively correlated with HPV16 E7 level in laryngeal squamous cell carcinoma

The interaction between the HPV (human papilloma virus) 16 E7 and other cell growth factors, such as p53 and NFkappaB in laryngeal cancer is not clearly understood. The aim of this study was to examine the expression of these three proteins in tumor and non-tumor laryngeal tissues from patients with laryngeal squamous cell carcinoma. These three proteins were dominantly expressed in the nucleus and their levels were higher in the tumor tissue than in the non-tumor tissue, although the comparison between the tumor and non-tumor tissues of p53 staining did not reach significance. The intensity of the nuclear stain of E7 and p53 was stronger than that of p65, a subunit of NFkappaB. Correlation analysis revealed that there was a positive relationship between the level of HPV16 E7 and the expression of p65. The correlation between E7 and p53 was also significant, although to a lesser degree. The finding of nuclear localization of p65 suggests that NFkappaB is constantly activated in the laryngeal cancer cells, whereas the sequestration of p53 in the nucleus may represent a mutated form of p53, which is probably inactivated by HPV16 oncoproteins. In conclusion, this study suggests that the nuclear localization of NFkappaB and p53 may play a role in the development of human laryngeal squamous cell carcinoma infected with HPV16.

[Evaluation of the ultrastructure of the vocal folds mucosa in patients with presbyphonia]

Ultrastructure of the vocal folds mucosa was evaluated in 50 elderly patients. Study material included larynx specimens obtained from autopsy and postoperative material after the total laryngectomy due to the cancer of recessus piriformis with unchanged vocal folds. The ultrastructure of tunica mucosa was evaluated by means of the transmission electron microscopy with the use of Opton 900-PC microscope. In the control group the multilayer flat epithelium was found with the folded basal membrane, a large number of pericytes, scarce collagenous fibers in the stroma. The voice disturbances which occur during presbyphonia are conditioned by morphological changes in the epithelium, the basal membrane and the stroma of the vocal folds mucosa. Destruction of the epithelium cells with the enhanced vacuolar degeneration and enlarged intercellular spaces indicated oedemic character of presbyphonia. An increased number of collagenous fibers, vacuolar degeneration of fibroblasts with enlarged granular endoplasmic reticulum and an increased number of blood vessels in the stroma suggested an atrophic form of presbyphonia.

Primary adenocarcinoma of the arytenoid: an ultrastructural study

Primary adenocarcinoma of the larynx is a rare neoplasm that tends to spread to both regional lymph nodes and distant sites. A case of primary adenocarcinoma of the arytenoid in a 74-year-old man is presented. The tumor was evaluated by light and electron microscopy. A high percentage of intranuclear pseudoinclusions (more than 20% of the neoplastic cells) was a peculiar characteristic of the tumor. To the best of our knowledge, such a feature has not been reported previously and should be considered a hallmark of more aggressive behavior.

Laryngeal chondrosarcoma with regard to the ultrastructure

Most common among the laryngeal sarcomas is the chondrosarcoma. The difficulties in differentiation between benign and malignant behavior of cartilaginous tumors are responsible for the danger of misinterpretation of chondrosarcoma as chondroma. A case of a laryngeal chondrosarcoma is presented examined by light and electron microscopy to determine if the ultrastructure of chondrosarcoma could be helpful in the correct diagnosis. The cells and their formation play a more important role than the extracellular matrix in the differentiation of tumor's behavior. As special criterias of malignancy by electron microscopy are the presence of dominant mitochondria, fat vacuoles, dilated rough endoplasmatic reticulum and the irregular shape of chondrocytes. The knowledge of the ultrastructure of chondrosarcomas may be helpful to distinguish between a benign chondroma and low-grade chondrosarcoma, especially when only small tumor biopsies are valuable.

Evaluation of the primary tumour and the metastatic lymph node with or without extracapsular spread by means of argyrophillic nucleolar regions (AgNOR)

Though TNM staging is the most popular clinical system for defining the prognosis of Head and Neck Squamous Cell Carcinoma (HNSCC), different clinical trials of the tumours with the same TNM stage have caused doubts about this system. Extra Capsular Spread (ECS) in a metastatic lymph node is one of the recently defined prognostic factors in HNSCC. The hypothesis of this study was to assess the relationship between the primary tumour of laryngeal and oral cavity squamous cell carcinoma and the metastatic lymph nodes with and without ECS. The argyrophillic Nucleolar Organiser Regions (AgNOR) count was used as an index of the grade of malignancy of the neoplastic tissue. As a result, significantly higher AgNOR counts were obtained in the metastatic lymph nodes with ECS than in the primary tumours, while the lowest AgNOR counts were found in the metastatic lymph nodes without ECS. However, when primary tumours of the metastatic lymph nodes with ECS and the primary tumours of the metastatic lymph nodes without ECS were compared, no significant difference was found.

Immunoelectron microscopical identification of the c-erbB-2 oncoprotein in patients with laryngeal squamous cell carcinoma

The peroxidase-antiperoxidase (PAP) method was used for localization of the c-erbB-2 oncoprotein at the electron microscopical level in 15 patients with laryngeal squamous cell carcinoma. It was found that c-erbB-2 oncoprotein was present in 7 of 15 samples. Electron microscopical examination revealed expression of the c-erbB-2 oncoprotein both on the membrane of individual cells and in the cytoplasm. In 5 of the 7 cases of positive labeling, it was observed only on the plasma membrane of cells whereas in 2 cases, there was also cytoplasmic staining. Reaction product was associated with endoplasmic reticulum, and the nuclear envelope and was scattered throughout the cytoplasm on ribosomes. Control incubations using normal rabbit serum instead of the primary antibody showed no labeling. A significant correlation between c-erbB-2 oncoprotein and pathological characteristics such as nodal status and histological grade was not found.

Sarcomatoid carcinomas of the upper aerodigestive tracts

Sarcomatoid carcinoma of the upper aerodigestive tract continues to be one of the most difficult diagnostic challenges for surgical pathologists. Histogenesis has been settled in favor of a divergent (mesenchymal) differentiation of a carcinoma, most often a squamous cell carcinoma. Finding the carcinoma and/or its immunohistochemical marker in the metaplastic cells establishes the diagnosis. There are, however, lesions that can simulate sarcomatoid carcinomas to varying degrees, and in which neither a definable carcinoma nor immunohistochemical evidence of one can be found. Such lesions fall into several categories: 1. benign reactive lesions, 2. inflammatory myofibroblastic tumors, 3. sarcomas, usually low-grade, 4. atypical pseudosarcomatous proliferation. The clinicopathologic considerations of sarcomatoid carcinomas are presented in this context and include immunohistochemical findings, prognostic factors, and biologic course.

Immunogold labelling of PCNA and Ki-67 antigen at the ultrastructural level in laryngeal squamous cell carcinoma and its correlation with lymph node metastasis and histological grade

Streptavidin-gold was used for the immunolocalization of PCNA and Ki-67 antigen at the ultrastructural level with a postembedding technique in biopsies of 15 patients with laryngeal squamous cell carcinoma. Positive immunoelectron staining was obtained in 9 cases for PCNA (60%) and in 8 cases for Ki-67 (53%). PCNA was predominantly found in heterochromatin of the nucleus of laryngeal carcinoma cells in a granular pattern. Positivity for PCNA was not found in nucleoli. In 4 cases, positive staining was observed both in nucleus and cytoplasm. In the cytoplasm, it was found to be present on the endoplasmic reticulum and on ribosomes throughout the cytoplasm. Ki-67 antigen was localized in the nucleus where it was associated with heterochromatin and euchromatin. It was also observed in nucleoli in all cases. Cytoplasmic localization of Ki-67 antigen was similar to that of PCNA. All 8 cases that were positive for Ki-67 were also positive for PCNA. Control incubations did not result in labelling with steptavidin-gold particles for both antigens. A significant correlation between PCNA and Ki-67 expression in association with pathological characteristics such as nodal status and histological grade was not found. Our data indicate that Ki-67 antigen staining correlates with PCNA labelling, whereas a relationship between proliferation markers and tumour progression was not found.

Specific changes of chromatin structure in nuclei of normal epithelium adjacent to laryngeal squamous cell carcinoma. A preliminary study of 82 cases

The aim of this study was to confirm the existence of specific nuclear texture feature alterations of histologically normal epithelial borders nearby invasive laryngeal cancer (NC). Paraffin sections of NC and of chronic inflammations unrelated to cancer (CI) were analysed for nuclear texture and for integrated optical density (IOD-index) and were compared to normal epithelium of patients without evidence of cancer (NE). Several discriminant functions based on nuclear texture features were trained to separate different subgroups. As the most important result, specific nuclear texture feature shifts were only found in NC with high-density lymphocytic stroma infiltrate (NC+). Classification of nuclei of NE versus NC+ was correct in 70%. The same classifier was correct in only 58% when nuclei of NE were classified versus CI. We also found lower values of IOD-Index within the NC+ group when compared to NE (p < 0.001).

[Studies on localization of laryngeal carcinoma associated antigen by immunoelectromicroscopy]

OBJECTIVE

To study the localization of laryngeal carcinoma associated antigen (LCAA) in the carcinoma tissue.

METHODS

Ninety cases of laryngeal carcinoma and 14 cases of laryngeal precancerous lesion and 10 cases of normal laryngeal mucosa were detected with three strains of monoclonal antibodies LC9, LC11, LC12 by immunochemistry. The positive sections of laryngeal carcinoma were observed under light microscope and electromicroscopy.

RESULTS

The positive rates of LCAA were dramatically higher than that in normal epithelial and precancerous tissues (P < 0.01). The results showed that the mixed monoclonal antibody had tissue specificity. The MLC associated antigens only distributed in cell membranes and/or cytoplasm. No cell nucleus was stained.

CONCLUSION

The LCAA is mainly located in cell membranous structure. This study may provide morphological basis for immunoimaging diagnosis and targeting chemotherapy by application of laryngeal carcinoma McAb.

Immuno-ultrastructural localization of p53 protein in patients with laryngeal carcinoma

Protein p53 was localized ultrastructurally with 5 nm gold-streptavidin particles in cells of laryngeal carcinoma embedded in Epon 815. Postembedding technique to study p53 protein was used. Protein p53 was found predominantly in nucleus of the cells but the label was also observed in cytoplasm of the cells. Five of 15 samples from patients with laryngeal carcinoma showed positive labeling for p53, (33.3% of all examined samples). Controls of tumor cells incubation with normal mouse serum showed no labeling with gold streptavidin particles.

[Ultrastructural pathologic research on the adult laryngeal papilloma]

In this paper, the ultrastructural features of laryngeal papillomas of 9 cases of adult patients were investigated by means of SEM. It showed that the polypoid surface of the papilloma is easily recognized; the surface cells are covered by microvilli of different size and shape; and the epithelium is bordered by an irregular and continuous basement membrane. In some areas, there is pseudopodium of basal cells stretching into connective tissue. The structure of interface between basement membrane and connective tissue varies with aggravation of tumor cell atypia. The significant variation of structural of basement membrane and semidesmosomes suggests the possibility of malignant change.

[Retrospective analysis of selected tumor markers (p53, PCNA, Ki67; DNA ploidy) and ultrastructure in patients with larynx carcinomas]

A comparison was made of the staining intensities of selected immunohistochemical proliferating antigens (p53, PCNA, Ki67), DNA flow-cytometry and ultrastructures of neoplastic cells from 120 cases of laryngeal cancers. Clinically very advanced tumors were in the majority (T3, 43%; T4, 18%). A 5-grade scale was adopted to evaluate the level of immunohistochemical staining of the carcinoma cell nuclei. Positive staining was obtained in 70% for p53, 57% for Ki67 and 80% for PCNA. Sixty-two percent of the cases were DNA-diploid and 38% DNA-aneuploid. The DNA-diploid carcinomas were accompanied by enlargement of the cell nuclei, preservation of wide margins of nuclear heterochromatin, enlargements of the nuclear areas and increases in the number of nuclei. In the aneuploid-polyploid cancers the nuclei had a substantial polymorphism, with large cleaved nuclei showing significant variations in size and having a nuclear envelope. A frequent finding was euchromatization of chromatin. Dense chromatin appeared in the form of small clumps spread over the whole area of these irregular nuclei. Enlargement and activation of nucleoli were found. There was a positive (chi-square) correlation between T- and N-stage and immunohistochemical staining. There was also a positive correlation in staining intensity between p53, Ki67 and PCNA markers and strong correlation between these markers for proliferative activity and the degree of aggressiveness of a tumor.

Atypical carcinoid tumor of the larynx: an immunohistochemical, ultrastructural, and flow cytometric analysis

The clinicopathologic features, including a detailed immunohistochemical, ultrastructural, and flow cytometric analysis, are described in three cases of atypical carcinoid tumor of the larynx. All patients had metastatic disease within cervical lymph nodes at presentation and eventually developed distant metastases. Special stains revealed focal intracytoplasmic mucin accumulation, and immunohistochemistry showed the tumors to be positive for CAM 5.2, CEA, chromogranin A, and calcitonin. In two cases, double-staining techniques revealed occasional cells that stained for both mucin and chromogranin A. The histochemical and immunohistochemical findings in these two cases were confirmed at the ultrastructural level, with most tumor cells containing many neurosecretory granules. Smaller numbers of cells contained mucin vacuoles and, in occasional cells, both mucin and neuroendocrine granules were identified. The three tumors exhibited positive staining with D07 (anti-p53), and flow cytometric analysis revealed DNA aneuploidy and polyploidy. The double-staining and ultrastructural features indicate that laryngeal atypical carcinoid qualifies for the designation of true amphicrine carcinoma. Further study is necessary to determine whether mutation of the p53 gene is important in the evolution of laryngeal neuroendocrine tumors and whether DNA aneuploidy or polyploidy identifies a subset of these tumors with a poor prognosis.

Clinicopathological consultation. Lymphoepithelial carcinoma of the larynx hypopharynx, and trachea

Lymphoepithelial carcinoma of the larynx, hypopharynx, and trachea is a rare neoplasm composed of large, poorly differentiated, nonkeratinized cells intermingled with small nonneoplastic lymphocytes and plasma cells. It is histologically similar to its more common counterpart occurring in the nasopharynx. In contrast to nasopharyngeal carcinoma, most cases have not been associated with Epstein-Barr virus (EBV), although rare cases have been reported to be EBV-positive. The diagnosis often requires immunohistochemistry or electron microscopy for confirmation. The neoplasm seems to behave in a fashion reminiscent of nasopharyngeal carcinoma. Lymph node metastasis occurs in the majority of patients, and eventual visceral dissemination occurs in one fourth. Radiotherapy is the main treatment for the primary tumor and regional metastases, but chemotherapy is indicated for more advanced disease. The initial stage is the primary determinant of prognosis. Death from disease occurs in about one third of patients.

[Parapharyngeal carcinoma of the larynx: current clinical and pathological aspects and reports of a clinical case]

Schwannomas (neurilemmomas) are benign tumors of the nerve sheath arising from the Schwann cells in the neural sheath of cranial and spinal nerves. The most frequent sites are the peripheral nerves of the head and neck and the flexor surfaces of the upper extremities. Parapharyngeal schwannomas are rare, which makes them interesting for ear, nose and throat specialists. A new case of schwannoma of the parapharyngeal space is reported. Our experience with the clinical management and surgical treatment of cervical schwannomas is discussed and the literature is reviewed.

[Malignant fibrohistiocytoma in otorhinolaryngology. Review of two cases]

Fibrohistiocytomas are soft-tissue tumors of histiocytic origin that have a variety of histological patterns. Although cases of malignant fibrohisticytoma (MFH) of the head and neck have been reported with increasing frequency in recent years, they can be considered rare. However, they probably are more frequent than thought because of the different designations that the disease has received and confusion among clinicians and pathologists regarding these tumors. We report two cases of MFH of the tonsil and larynx, respectively. The histopathological diagnostic criteria, therapeutic indications, and prognosis evaluation are described.

[Ultrastructural study of tumor infiltrating lymphocyte in tissues of laryngeal squamous cell carcinoma]

By transmission electron microscopy tumor infiltrating lymphocyte (TIL) in laryngeal squamous cell carcinoma tissues of 14 cases was studied. The results showed that the infiltrating lymphocyte in varying degrees eristed in laryngeal squamous cell carcinoma tissues. Most of them were present in a motionless state, and the others showed the feature of activated metrocyte and closely contracted with cancer cells and resulted in distinct morphological changes both the cancer cells and themselves. Therefore, this study provided an important morphological evidence for TIL as killer and inhibiter to the growth of cancer cells.

[Expression of proto-oncogene bcl-2 in squamous cell carcinoma of the larynx]

Apoptosis, or programmed cell death, is responsible for deleting cells in normal tissues to maintain homeostasis after DNA damage. Apoptosis has several physiological inhibitors, one of the most important being the proto-oncogene bcl-2. An immunohistochemical study was made of bcl-2 expression in 25 squamous cell carcinomas of the larynx, in laryngeal mucosa distant from the primary neoplasm, and in lymph node metastases. The relationship between bcl-2 expression and various clinical and pathological parameters was investigated. Bcl-2 was detected in 40% of primary tumors and in 71% of lymph node metastases; it seems to be a late event in laryngeal malignant transformation. We found no statistical association between bcl-2 expression and most of the clinical and pathological parameters examined. Only tumor differentiation was related to bcl-2 expression, bcl-2 positive tumors being moderately or poorly differentiated (p < 0.02).

[Granular cell tumor of the larynx]

Granular cell tumor is an unusual growth of probably neuroectodermal histogenesis, first reported by Abrikossoff in 1926 with the name of myoblastoma. Of the about 1200 cases reported since, the 50 percent were found in the head and neck. Of second mentioned 10 percent had a laryngeal sitting. A case of glottic granular cell tumor surgically removed with free borders is presented. Bibliographical review.

[Scanning electron microscopic observation of the three-dimensional structure of laryngeal carcinoma using freeze-cracking method]

OBJECTIVE

To investigate the relation between the morphology and the biological characteristics of laryngeal carcinoma.

METHODS

The freeze-cracking method was used to examine 126 specimens of the larynx under scanning electron microscope (SEM). The specimens were obtained from 12 patients suffering from laryngeal cancer and 4 patients with normal larynx.

RESULTS

(1) In the normal larynx, the squamous-cell epithelium showed marked keratinization and the intracellular bridges were clear and regular. (2) In areas adjacent to cancer, the structure of the squamous-cell epithlium could be identified, but the cells were deranged and paramorphic. (3) There were two types in the marginal area of the carcinoma. Along the areas adjacent to cancer, infiltrating lymphocytes were usually observed and the surface of the lymphocytes had many leading lamella.

CONCLUSION

The results indicate that the three-dimensional observation with SEM using the freeze-cracking technique is helpful for studying the relation between morphology and biologic characteristics of laryngeal carcinoma.

Macromolecular synthesis and ultrastructural changes induced in human larynx carcinoma cells following photodynamic therapy in vitro

Human larynx carcinoma cells (HEp2) were sensitized with different concentrations of Hematoporphyrin and irradiated with a He-Ne laser at different fluences. The degree of PDT-effects were estimated by two parameters: a) macromolecular synthesis and b) observations using electron microscopy. All experiments were evaluated after 68 hr at 37 degrees C. The results showed that PDT exposure of HEp2 cells is characterized by: 1) inhibition of macromolecular synthesis and 2) different cellular and subcellular lesions. Summing up, these studies indicate the existence of a strong correlation between different PDT exposures and the degree of biochemical and ultrastructural changes in human larynx carcinoma cells in vitro.

Prognostic significance of epidermal growth factor receptor in laryngeal squamous cell carcinoma

Epidermal growth factor receptor (EGFR) content was determined by a radioligand receptor assay in 140 primary laryngeal squamous cell carcinomas (median value of 8.4 fmol mg-1 protein, range 0-169.9 fmol mg-1 protein). Cox univariate regression analysis using EGFR as a continuous variable showed that EGFR levels are directly associated with the risk of death (chi 2 = 14.56, P-value = 0.0001) and relapse (chi 2 = 7.77, P-value = 0.0053). A significant relationship between EGFR status and survival was observed at the different arbitrary cut-off values chosen (8, 16 and 20 fmol mg-1 protein). The cut-off value of 20 fmol mg-1 protein was the best prognostic discriminator. In fact, the 5 year survival was 81% for patients with EGFR- tumours compared with 25% for patients with EGFR+ tumours (P < 0.0001). The 5 year relapse-free survival was 77% for patients with EGFR- tumours compared with 24% for patients with EGFR+ tumours (P < 0.010). When clinicopathological parameters and EGFR status were examined in the multivariate analysis, T classification and EGFR status retained an independent prognostic value. In this study we demonstrated that high EGFR levels single out patients with poor prognosis in laryngeal cancer.

Ultrastructure of the lamina propria of the human vocal fold

We studied three-dimensional arrangement of collagen fibers and elastic fibers in the human vocal fold by scanning electron microscopy after digesting cellular elements and collagen fibers with formic acid treatment and cellular elements and elastic fibers with 10% sodium hydroxide. The superficial layer consisted of clusters of collagen fibers and fine elastic fibers running straight or coiled. The intermediate layer consisted of thick bundles of collagen and elastic fibers running longitudinally and fine coiled elastic fibers. The deep layer consisted of coil elastic fibers and dense collagen bundles. Collagen fibers may have a role of maintaining the organization of vocal folds even during vibration, and elastic fibers act to rapidly restore the vocal folds to their original form. We also studied the distribution of oxytalan fibers in vocal folds by aldehyde-fucusin staining. Oxytalan fibers were distributed throughout the connective tissue of the vocal folds, and a large number of fibers was present just under the epithelial basement membrane and around the muscle fibers. If these fibers are damaged and lose their functions, vibration of the vocal folds will be impaired.

[Laryngeal cancer and angiogenesis]

Angiogenesis is required for the growth of solid tumors which, in avascular condition, are limited to 2-3 mm3 volume. The switch to the angiogenic phenotype allows new vessels to converge upon the tumor, growth to proceed at an exponential rate and metastasis diffusion. The evaluation of tumoral angiogenesis has been proposed to be an independent prognostic marker of behaviour of some solid tumors: it has been demonstrated that, in some types of carcinoma (breast, prostate, lung, etc...), an intense vascular proliferation correlates with the aggressiveness of the disease. However in malignant melanomas and colorectal carcinomas, there are conflicting results on the correlation between angiogenesis and the progression of the cancer. There are also conflicting data on the role of microvessels count (MC) in the management of head and neck cancer. Despite a large number of studies, at the present, there are not biological or molecular markers available to predict consistently the outcome of the patients with laryngeal squamous cell carcinoma (LSCC). In fact the prognosis of this tumor has been mainly based, up to now, on a number of clinico-pathological parameters, especially localization, tumor extent and nodal involvement. The aim of this study has been to compare MC inside LSCC with disease free survival, grading, pT, pN and pathological stage. We investigated the relevance of the number of microvessels in the peritumoral stroma of 68 LSCC (only Caucasian males, age 35-70 years), classified according to UICC/1987 randomly selected (33 classified in clinical stage I e II and 35 in clinical stage III-IV). All patients have been surgically treated and pN + cases have been also submitted to radiotherapy. The follow-up was 60-84 months. The vascular density was assessed according to Horak et Al. with an immunohistochemical method using JC70 monoclonal antibody (CD31; Dako, Astrup, Denmark). Univariate analysis showed that MC, pT, pN, Pathological Stage and grading were correlated with the disease-free survival. A MC < 120/mm2 was predictive for a high survival index; in contrast a MC > 150 mm2 were associated with relapse. Furthermore, multivariate analysis demonstrated that MC was the only independent predictor for the disease free survival. Our findings demonstrate that in LSCC, MC is the first measurable biological parameter which is significant for evaluating the disease free-survival. Therefore, MC in LSCC is crucial in the prognosis and in the choice of a more aggressive management of the disease, including the possible treatment with antiangiogenic compound.

Laryngeal lymphoma derived from mucosa-associated lymphoid tissue

Extranodal lymphomas account for as many as 40% of non-Hodgkin's lymphomas, and most arise in the gastrointestinal tract, but other mucosal organs may be involved, especially the upper aerodigestive tract. Low-grade B-cell lymphomas arising in the gastrointestinal tract and other mucosae have been found to recapitulate the structure and cytologic features of mucosa-associated lymphoid tissue (MALT). Histologically low-grade MALT lymphomas are characterized by centrocyte-like B-cells with a phenotype similar to that of so-called marginal zone B-cells. Tumors evolving from MALT are generally rare among lymphomas of the upper aerodigestive tract, but a few cases of laryngeal lymphomas derived from MALT have been reported. Primary MALT lymphoma of the larynx should always be considered in tumors with histopathologic features of low-grade B-cell lymphoma, or so-called pseudolymphoma.

Immunohistochemical characterization of benign laryngeal lesions

It has been proposed that laryngeal nodules and polyps represent injury to the basement membrane zone of the vocal fold. Repeated trauma from shearing forces produced by excessive or abusive phonation leads to basement membrane zone disruption and thickening. This thickening, along with poorly understood vascular changes, creates the characteristic clinical appearance of the vocal nodule or polyp. As such, to better understand vocal fold nodules it is imperative to characterize the extracellular matrix in this area of injury. Secondary to the small size and relatively acellular nature of these lesions, hematoxylin and eosin (H & E) preparations of histologic material are unsatisfying. A previous study examined this area with immunohistochemical techniques to better characterize its contents. The report, however, contained little information with regard to the clinical appearance of the lesions prior to excision. Therefore, we were prompted to review histologic material from 31 patients who underwent microsurgical excision of 41 benign lesions, vocal nodules (4), polyps (19), polypoid corditis (4), and cysts (14) with immunohistochemical techniques to characterize the patterns of fibronectin and collagen type IV within these lesions. Normal human vocal folds were stained for control. All material was correlated with the H & E preparations and the clinical diagnosis. Collagen type IV and fibronectin appeared present in relatively abnormal patterns in the areas adjacent to the lesion. This study validates earlier results. In addition, correlation with clinical data allows association of immunohistochemical staining patterns with clinical diagnosis.

[The anterior commissure of the larynx in the subperichondral functional surgery of the glottic plane: critical evaluation on the basis of a serial section study in normal and neoplastic laryngeal specimens]

It is a well-known fact that the clinical growth of laryngeal cancer varies according to the site of its origin. A number of macro and microscopy studies have attempted to explain the various routes it follows in spreading. The anatomical features of the anterior commissure, the conus elasticus and posterior commissure condition the direction and extent of tumour spreading as do the blood supply in the glottis and the distribution of mucous glands in the glottis and subglottis. Of the various regions of the larynx, the anterior commissure has provided perhaps the greatest challenge to investigators in that its boundaries as well as its morphology are still not clear. The possible spreading of glottic cancers exceeding these anatomic structures is very difficult to evaluate using two dimensional picture given by laryngoscopy as well as the images provided by TC and NMR which justifies a different behavior of same stage. Therefore these elements, in addition to the absence of a universally accepted clinical definition of the boundaries of AC, justify the diagnostic, pathologic, and therapeutic problems linked to AC carcinoma. Eight normal adult larynges were studied by microdissection and serial section after fixation in 10 percent formalin followed by decalcification. These specimens were dissected according to the stages of "evisceratio laryngis" performed in our Department for the treatment of T1a, T1b tumors. Our observations confirm that the island located at the anterior insertion of the thyroarytenoid muscle, easy reached during subperichondral dissection, cannot be identified with the so-called tendon described by Broyles. The specimens shown circumstantiate the fact that this fibrous-cartilagineous island act as a barrier and that when the neoplasia does start to spread into this segment, this fibrous area forces it to spread mainly along the surface. Our observations were confirmed by histologic examination of 6 surgical specimens after "evisceratio laryngis" performed on T1a, T1b tumors. Clinical positive results in subjects treated employing "evisceratio laryngis" appear to further confirm of our interpretation to these morphological observations.

Cytokeratin and vimentin expression in normal epithelium and benign lesions of the vocal cords

The expression of cytokeratins and vimentin was studied immunohistochemically in normal epithelium and 12 benign lesions of the vocal cord with the use of a broad panel of monoclonal antibodies against cytokeratins and vimentin. Histology showed that the various lesions contained hyperkeratotic, hyperplastic and atrophic epithelium, irrespective of their clinical appearance. Especially the Ck profile of the (hyper)keratotic lesions was changed in comparison with the native epithelium. Increased expression of the keratinization marker Ck 10 was associated with decreased expression of the stratification markers Cks 4 and 13. Expression of the basal cell marker Ck 14 and hyperproliferation-associated Cks 16 and 17 was increased in all the benign lesions, except in atrophic epithelium. These expression patterns differ from those observed in malignant epithelial lesions. The latter show a marked expression of simple cell Cks and vimentin and more pronounced expression of hyperproliferation-associated markers than the benign lesions.

[The use of x-ray microanalysis and transmission microscopy in studies of the chemical composition and ultrastructure of the microregions of precancerous tissues of the larynx]

The authors have presented the results of studies concerning the changes of chemical composition and ultrastructure of tissue microregions at patients with laryngeal precancerous states. Microanalytical studies were made using X-ray JEOL JSM 35 microprobe analyser. The chemical composition of laryngeal precancerous tissue taken from the patients and a control group was estimated. The results of studies were verified using X-ray PHILIPS XL-30 microanalyser. Studies of tissue ultrastructure changes were conducted using JOEL JEM 100 XC transmission microscope. Some heavy metals like, lead, cadmium, nickel, iron, copper and caesium were found in the tissue from larynx precancerous state. Further more, in analysed biologic material there were noticed various degenerative changes within stratified squamous epithelium.

[Paraganglioma of the larynx]

A rare case of a large paraganglioma of larynx was presented. The whole tumor was removed by partial laryngectomy.

[Diagnostic and prognostic value of p53 oncogene and the selected neoplastic markers (Ki67, PCNA, DNA ploidy) of the ultrastructure in patients with laryngeal cancer]

A comparison was performed of staining intensity of immunohistochemical proliferating antigens (p53, PCNA, Ki67), DNA flow cytometry and ultrastructure of the carcinoma cells in 120 cases of laryngeal cancer. Clinically very advanced tumors were in majority (T3 - 43%, T4 - 18%). A 5 graded scale was adapted to evaluate the level of immunohistochemical staining of the carcinoma cell nuclei. A positive staining was obtained in 70% for p53, 57% for Ki67 and in 80(2/3) for PCNA. 62% of the cases were DNA diploid and 38% DNA aneuploid. The DNA diploid carcinomas were accompanied by the enlargement of the cell nuclei, preserving of the nuclei's wide margins of heterochromatine, enlargement of the nuclear area and increase of the number of nuclei. In the aneuploid-polyploid cancer the nuclei had a substantial polymorphism with large cleaved nuclei and with significant variation in size, and with nuclear envelope. A frequent finding was euchromatization of chromatine. Dense chromatine appeared in the form of small clumps spread over the whole area of these irregular nuclei. Enlargement and activation of nucleoli occurred. There was a positive correlation (Chi-square) between T- and N-stage and immunohistochemical staining. There was also a positive correlation in staining intensity between p53, Ki67 and PCNA. There is also strong correlation between these markers of proliferative activity and the degree of aggressiveness of the tumour.

[p53 oncogene in the laryngeal cancer]

Cancer is a genetic disease and the development of the techniques of molecular biology in recent 10 years contributed to the new understanding of neoplasmatic process. The mutations of gene p53 became one of the most common abnormality in human cancer. The aim of this research was to mark oncoprotein p53 in 120 cases of larynx cancer and the correlation of its appearance with clinical and histopathological parameters. The evaluate the degree of immunohistochemical staining of cell nuclei a 5 degree scale was adopted. The positive staining of cell nuclei was observed in 70% of cases. Positive correlations based on a chi-square test was observed between p53 and T and N as well as between p53 and the degree of histological differentiation.

[A case of the laryngeal fibroma]

The authors describe a case of very rare neoplasm fibroma proper in the region subglottic of larynx. Operative treatment by tracheostomy, thyroidotomy and complete extirpation of the tumor.

Nucleolar organizer regions in glottic carcinomas: comparison of DNA cytofluorometry and clinicopathological analysis

The significance of nucleolar organizer regions (NORs) and nuclear DNA content in 73 glottic carcinomas was assessed for proliferative activity and tumor progression. NORs stained with silver colloid were counted, and nuclear DNA content was assayed by cytofluorometry. The cytofluorometric study demonstrated that the percentage of tumors with aneuploidy tended to increase as histological differentiation decreased. Survival rates of patients with diploid and aneuploid tumors were not significantly different. AgNOR staining revealed that mean AgNOR numbers rose as histological differentiation of tumors decreased. Moreover, as T and N categories and stages showed advancing malignancy, mean AgNOR numbers tended to rise. However, there was no significant difference in survival rates between tumors with low and with high AgNOR counts. These studies indicate that while AgNOR staining is better than DNA cytofluorometry for determining histological differentiation of glottic carcinoma, neither is of prognostic value at the present time.

Grading of precancerous laryngeal lesions by multiparameter image analysis at separate epithelial layers

In order to detect early precancerous changes which do not involve the whole thickness of the epithelium, we used a novel image analysing program based on an IBAS system (Kontron, Germany) to determine nuclear DNA content (NC) as well as average nuclear area (NA) and variation of nuclear area (VA), in the entire epithelium and in three sublayers, parabasal, intermediate, and superficial. DNA aneuploidy was found in only half of the cases classified as 'high-grade' (HG) lesions, comprising carcinoma in situ (CIS) and severe epithelial dysplasias (EDIII), and was chiefly demonstrable in the parabasal third of the epithelium. The other lesions were DNA euploid. HG lesions showed highly significant increases of NA and VA at the lower levels of the epithelium when compared with 'low-grade' (LG) lesions comprising moderate and mild epithelial dysplasias (EDII and EDI). Our data show that the combination of multiparameter image analysis with conventional morphology assists in the objective grading of precancerous lesions and permits the reliable detection of high-grade lesions.

Langerhans cells in normal and pathological vocal cord mucosa

The Langerhans cells in samples of histologically normal and pathological vocal cord mucosa were counted after identification using S-100 polyclonal antibody. Langerhans cells were commonly seen in vocal cord polyp epithelium but were infrequent in normal cord mucosa. They were also identified in samples of squamous carcinoma, severe dysplasia and chronic inflammation.

[Moderately differentiated neuroendocrine carcinoma of the larynx]

We present a case of moderately differentiated neuroendocrine carcinoma of the larynx. These tumors represent 0.6% of all laryngeal carcinomas. Histological diagnosis requires the use of immunohistochemical methods, the tumoral cells presenting positivity for epithelial markers (cytokeratin) and neuroendocrine markers (chromogranin). Clinically, their location is supraglottic and they affect mainly males between the 6th-7th decades of life. The prognosis is better than that of squamous carcinoma or adenocarcinoma. The differential diagnosis must be made with granular cell tumor and paragangliomas.

DNA index, cellular proliferative activity and nucleolar organizer regions in cancers of the larynx

The DNA index, expression of cell-cycle-related proteins--proliferating cell nuclear antigen (PCNA, cyclin) and Ki-67--and the content of silver-binding nucleolar organizer regions (AgNORs) were evaluated in 30 unselected consecutive primary squamous cell carcinomas of the larynx. Results were compared and subsequently related to histological grading, lymph node status, pT category, and pathological stage. DNA content was non-diploid in 9 cases (30%). Mean AgNOR counts per tumor ranged from 2.52 to 8.76. PCNA and Ki-67 expressions were similar in 10 cases (33%). In the remaining cases, PCNA-positive cells usually outnumbered Ki-67-positive cells. No significant correlation was found among DNA index, PCNA and Ki-67 expressions, and AgNOR counts. Although there was a positive trend when Ki-67 was compared with histological grading, findings were not statistically significant. In contrast, a significant correlation was found between DNA index and lymph node status (P = 0.035), with a higher incidence of neck node metastases in non-diploid tumors. These data suggest that tumor ploidy can be correlated with lymph node spread in laryngeal squamous cell carcinoma and might be used as an additional prognostic factor when planning treatment.

Sarcomatoid carcinoma: an ultrastructural study with light microscopic and immunohistochemical correlation of 10 cases from various anatomic sites

The histogenesis of sarcomatoid carcinoma has been an intriguing topic for pathologists for many years, and considerable evidence has accumulated in the fields of tissue culture, electron microscopy, and immunohistochemistry to support the concept that the sarcomatous cells derive by way of "divergent differentiation" (metaplasia) from the carcinomatous elements. We have studied a group of 10 cases of these tumors from various organs, using detailed ultrastructural analysis as well as light microscopic and immunohistochemical correlation. We found that there is an ultrastructural spectrum of differentiation from epithelial to mesenchymal type features and that the malignant spindle cells may be purely epithelial (3 cases), purely mesenchymal (3 cases), or a mixture of both (4 cases). Furthermore, individual cells may show biphasia, having desmosomes and tonofibrils as well as well developed rough endoplasmic reticulum and filaments with dense bodies. Electron microscopic and immunohistochemical results do not always correlate, illustrating the prudence of using several keratin antibodies, including wide-spectrum ones, and of performing electron microscopic examination on these tumors.

Neuroendocrine neoplasms of the larynx. Importance of the correct diagnosis and differences between atypical carcinoid tumors and small-cell neuroendocrine carcinoma

Findings in the present study have confirmed that the diagnosis of neuroendocrine tumors of the larynx (NETL) requires that a panel of neuroendocrine markers and electron microscopy be performed. This means that the clinician must be aware of the clinical presentations of such patients and should send fresh biopsy specimens to the clinical laboratory for optimal tissue studies. As shown in this study, the possibility of misdiagnosis of an atypical carcinoid tumor (ACT) is rather high. In establishing a diagnosis, a part of the material should be fixed for conventional histology, a part for immunohistochemistry and a part for electron microscopy. The correct diagnosis of NETL is obviously of great importance for subsequent treatment and prognosis. Patients with the diagnosis of ACT of the larynx require surgical treatment. Our findings also show that small-cell neuroendocrine carcinomas of the larynx should be considered to be a disseminated disease at initial presentation. A metastatic workup is necessary, but radical surgical procedures should be avoided. The combination of radiotherapy and chemotherapy is always indicated.