Anatomical and histological study of the deep neck fasciae: does the alar fascia exist?

PURPOSE: The aim of this study was to determine whether the alar fascia is a distinct layer of the deep cervical neck fasciae. The present study also aimed to elucidate the anatomical limits of this fascia. METHODS: Neck dissections of ten adult cadavers were performed, layer by layer, in the retropharyngeal region, under a powered operating microscope. Detailed dissections revealed the anatomical limits of the deep neck fasciae. Histological descriptions were also performed on large tissue samples collected from three cervical dissections. RESULTS: In the ten dissections, three layers of fascia were identified and dissected in the retropharyngeal region: a visceral fascia, a prevertebral fascia and an alar fascia. The alar fascia appeared like a connecting band derivative of the visceral fascia, between both vascular sheaths. It fused completely with the visceral fascia anteriorly at the level of T2 and with the prevertebral fascia posteriorly at the level of C1. No sagittal connection between the visceral fascia and the prevertebral fascia was identified. The stained histological sections confirmed the presence of the visceral and prevertebral fasciae at the oropharyngeal level, with a third intermediate layer closely connected with the visceral fascia. CONCLUSION: The alar fascia is a layer of the cervical neck fascia connected with the visceral fascia from C1 to T2 levels. The anatomical limits of this alar fascia and its relationships with the internal carotid artery are important in the surgical management and the prognosis of deep neck infections and retropharyngeal lymph node metastases.

The anterior commissure of the human larynx revisited.

BACKGROUND: The anterior commissure (AC) of the human larynx is usually understood as an area of the glottis anteriorly situated between the two vocal folds inserting to the thyroid cartilage (TC). The pattern of spread of AC carcinoma could hypothesize that AC could include other structures of the ventral larynx as developmental anatomy could demonstrate. METHODS: Ten adult larynx specimens from donation program cadavers and 15 selected fetal specimens (from 11 to 34 weeks of amenorrhoea) were studied using microdissection and histological serial sections stained with hematoxylin-eosin and reticuline. RESULTS: In adult specimens, internal perichondrium of the TC was easily detached from the entire lateral lamina but not from an intermediate lamina superiorly marked by the superior thyroid notch. On this median band of TC is inserted the ventral connective tissue of the three levels of the larynx: the ventral part of the vocal folds with the anterior macula flava, the Broyle's epiglottic ligament, and the subglottic part of the conoid ligament. In young fetuses (11-12 weeks), intermediate lamina of TC joined at the glottic level but not at the supraglottic level; in fetuses at 22-25 weeks, a meshwork of bundles of connective fibers inserted to the intermediate lamina of TC. In fetuses at 33-34 weeks, organization is practically identical to adult specimens. CONCLUSION: According to the adult anatomical features and the organogenesis, the AC of the human larynx could be anatomically defined ventrally as being made up of the intermediate lamina of TC beneath the superior thyroid notch and dorsally the ventral insertions of vocal folds with macula flava, supraglottic Broyle's ligament, and subglottic conoid ligament leading to a "developmental" AC definition which could better explain specific spreading of AC carcinoma.

Surgical anatomy of the ansa cervicalis nerve: which branch to use for laryngeal reinnervation in humans?

PURPOSE: The aim of this study has been to obtain some data for the selection of which branch of the ansa cervicalis nerve (AC) could be an attractive candidate for a laryngeal reinnervation using AC to recurrent laryngeal nerve (RLN) neurorrhaphy. METHODS: The AC was dissected in ten human head cadavers with an operating microscope. A vagal nerve stimulation was conducted during a bilateral thyroidectomy with normal vocal fold mobility in ten patients using a NIM Medtronic System(®) to record phasic activity within the thyroarytenoid muscle (vocal fold adduction) and one of the infrahyoid muscle (sternothyroid muscle or sternohyoid muscle). RESULTS: Despite reported variations of the roots of AC and location of its loop, the lower portion of the STM and SHM was innervated by a prominent common trunk in 80 % of cases, in a close vicinity of the RLN with an excellent size match to the RLN for a tension-free anastomosis. The STM displays slight but significant electrical activity during vocal fold adduction. CONCLUSION: The common trunk of the SHM and STM is the prime choice for laryngeal reinnervation using AC-RLN non-selective anastomosis. If the main trunk is missing, the branch to the STM can be an attractive candidate.

Morphological and functional asymmetry of the human recurrent laryngeal nerve.

PURPOSE: The aim of the current study was to analyze some parameters that are involved in nerve conduction in the right and left recurrent laryngeal nerves (RLNs) in humans. We have studied two morphological parameters such as the length of the two nerves, and the total intraperineural area (TIPA) from necropsies, and one functional parameter such as the latency of the thyroarytenoid muscle from operated patients. METHODS: The morphological parameters of six white female adult cadavers were analyzed. The RLNs were totally removed on both sides with the vagus nerve from their origin to the entrance in the larynx at the cricothyroid joint. The lengths were measured with the help of a digitalized caliper. Selected sections were obtained from each third of the RLNs for histological analysis. The TIPA was estimated at each selected level using digitized images of nerve sections and a manual micrometer. All the measurements were carried out by specialists in histology. The intraoperative vagal nerve stimulations were conducted using the NIM3 Medtronic(®) monitoring system (Medtronic Xomed Inc., Jacksonville, FL, USA) in ten adult patients without laryngeal or nervous disease during thyroid gland surgery. The evocated laryngeal electromyography was performed with the Medtronic bipolar needle electrode directly inserted into the thyroarytenoid muscle. The direct vagal nerve stimulation was achieved with the Medtronic stimulation from 0.5 to 1 mA. The latency of the thyroarytenoid muscle was recorded on the NIM-response monitor. RESULTS: The mean lengths of the left and right RLNs were, respectively, 136.6 and 75.0 mm with a mean difference of 61.6 mm (range 50-75 mm). The quantitative comparison of the TIPA between proximal segments of the left and right RLN showed no significant difference. The distal and proximal TIPA ratio demonstrated differences between the left and right RLN, respectively, 53.76 and 38.88 % without any statistical meaning. The comparison of the TIPA of the distal segments of the RLNs showed no significant difference. The intraoperative vagal nerve stimulation (0.5 and 1 mA) displayed a mean latency of the right and left thyroarytenoid muscle, respectively, of 3.55-3.68 and 5.90-5.98 ms with a mean difference of 2.35-2.30 ms (range 1.75-3.30 ms). CONCLUSION: If length and latency asymmetry of the right and left RLNs in humans can be demonstrated, the synchronicity of the vocal folds requiring precise controlled variations within intrinsic laryngeal muscles needs further investigations.

Lethal human herpesvirus-6 encephalitis after cord blood transplant.

Clinical, biological, pathological, and imaging findings were all suggestive of lethal human herpesvirus-6-associated encephalitis in a 61-year-old man who had undergone a cord blood transplant. The neuropathological findings of this unusual autopsy case and the pathogenesis of this infection in immunocompromised patients are discussed.

Toxoplasmosis with hemophagocytic syndrome after bone marrow transplantation: diagnosis at autopsy.

Toxoplasmosis is a rare but well recognized opportunistic infection that can occur after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Besides encephalitis, other common presentations of Toxoplasma gondii infection are interstitial pneumonitis and myocarditis. Because of its non-specific clinical and biological signs and its lethal outcome, toxoplasmosis is often misdiagnosed and only revealed at autopsy. We report a case of a postmortem diagnosis of disseminated toxoplasmosis associated with hemophagocytic syndrome, which underlines the value of necropsy in cases of death after transplantation. We also discuss clinical presentations and risk factors that lead to toxoplasmosis in allo-HSCT recipients.

[Values of the autopsy in the university hospitals illustrated by the casuistry]. / Intérêts de l'autopsie hospitalière illustrés par la casuistique.

PURPOSE: Clinical autopsy rate have been declining since the 1950s, but it remains a useful investigation tool. METHODS AND RESULTS: Through six examples of our experience, we underline its interest for clinical, didactic and public health purposes. CONCLUSIONS: We try to understand the reasons for its decline and, as demonstrated, it can be attributed to a number of factors. These need to be addressed in order to reassert the status of the autopsy as an investigation and audit tool which is crucial to the future effectiveness of modern medicine.

[Parotid gland masses: diagnostic value of MR imaging with histopathologic correlations]. / Morphologie IRM des tuméfactions de la glande parotide. Corrélations histopathologiques.

BACKGROUND AND PURPOSE: The purpose of our study has been to describe the pre-operatively MR Imaging appearance of masses in the parotid gland which may be sources of clinical and radiological confusion. METHODS: Sixty-eight adults patients with a parotid mass (39 female, 29 male) has been prospectively investigated. T1-weighted, T2-weighted, diffusion-weighted and contrast-enhanced dynamic MR images were performed by using a 1.5 or 1 T MR Imaging unit (Philips Gyroscan Intera 1.5 T. Siemens Expert 1 T). All patients underwent a parotidectomy with histopathologic analysis. RESULTS-CONCLUSIONS: In case of pleomorphic adenoma (N=30) MR imaging sensibility, specificity and accuracy were respectively 87.5, 80.5 and 83%. In case of Warthin tumors (N=13) the same values were respectively 45.5, 93 and 85%. In case of malignant tumors (N=13) theses values were respectively 71, 89 and 87%. Our routine MR Imaging study appears excellent not only for assessing the type and extent of benign salivary gland tumors and the relationship to adjacent structures, but also for determining whether the tumor is benign or malignant.

[Giant aneurysm of the right coronary artery]. / Anévrysme pseudotumoral de l'artère coronaire droite.

INTRODUCTION: Giant coronary aneurysms are rare and often confused with cardiac tumours. OBSERVATION: We report a new case of this type of aneurysm occurring on the right coronary artery revealed by a cardiac congestion. COMMENTS: These aneurysms can be due to inflammatory diseases or dysplasia. But in these pseudotumoral forms, atherosclerosis is the main aetiology. The diagnosis and treatment require surgery and histological examination.

Infracentimetric cervical lymph node metastasis in head and neck squamous cell carcinoma: Incidence and prognostic value.

OBJECTIVES: Supracentimetric cervical lymph node metastasis is classically a poor prognostic factor for locoregional recurrence and survival in head and neck cancer. Causality, however, is more controversial for infracentimetric cervical lymph node metastases. The objective of this study was to evaluate the incidence and prognostic value of infracentimetric lymph node metastasis. MATERIALS AND METHODS: Two hundred and forty-three neck dissections from 150 head and neck cancer patients were analyzed. A single pathologist exhaustively inventoried the number and size of all adenopathies in the surgical specimen. RESULTS: Cervical lymph node metastases were infracentimetric in 38% of cases, with 72% extracapsular spread (versus 91% for supracentimetric adenopathies; P<0.01). Infracentimetric metastases were more often associated with other cervical lymph node metastases (mean 5.3 versus 3.9; P=0.14). Fifty three percent of specimens showed only supracentimetric metastases (versus 13% infracentimetric metastases; P<0.01). Disease-specific and failure-free survival were lower in case of infracentimetric metastasis, associated with supracentimetric metastasis or not, than in case of macrometastasis only. CONCLUSION: Infracentimetric cervical lymph node metastasis is a factor of poor prognosis, and may represent a different, more aggressive lymphatic process. We suggest complete neck dissection by the surgeon and meticulous analysis by the pathologist, the results of which guide complementary therapy. Close surveillance of recurrence is also recommended.

Anterior laryngeal commissure: Histopathologic data from supracricoid partial laryngectomy.

OBJECTIVES: To analyze histopathologic invasion of the anterior laryngeal commissure on surgical specimens from patients operated on for stage-2 squamous-cell carcinoma managed by supracricoid partial laryngectomy (SCL). PATIENTS AND METHODS: Twenty-five patients with previously untreated stage-2 squamous-cell carcinoma were selected. Preoperative endoscopy confirmed anterior commissure involvement; CT found no cartilage lysis. SCL was performed in all cases: 15 anterior frontal SCLs with epiglottoplasty, 8 with cricohyoidepiglottopexy, and 2 with cricohyoidopexy. Histopathology analyzed resection margins (< 1 mm, 1-5 mm, > 5 mm), cartilage extension and vascular embolism. Mean time to observation was 18 months (range, 12-36 months). RESULTS: Resection margins were < 1 mm in 7 cases (28%), 1-5 mm in 9 and > 5 mm in 9 patients. Vascular emboli were found in 15 patients (60%). Twenty patients were free of medial thyroid cartilage involvement; 5 showed cartilage extension (20%), restricted to the internal cortical layer in 4 cases (stage T3) and transfixing in 1 (stage T4a). Mucosal extension appeared non-predictive of cartilage invasion. The T4a patient showed local laryngeal recurrence at 12 months. CONCLUSIONS: In laryngeal commissure squamous-cell carcinoma, SCL enables pathologic analysis of the entire anterior commissure as organogenetically defined: medial thyroid wing, in which the three laryngeal regions are inserted. Microscopic cartilage invasion is poorly predicted by mucosal extension, and may affect 20% of initially T2 patients.

Surgical management of hyperthyroidism.

AIMS: Hyperthyroidism includes several clinical and histopathological situations. Surgery is commonly indicated after failure of medical treatment. The aim of this study was to analyze the indications and complications of surgery as well as endocrine results. MATERIALS AND METHODS: Patients operated on for hyperthyroidism between 2004 and 2012 were included in a retrospective study. Total thyroidectomy was performed for Graves' disease, toxic multinodular goiter and amiodarone-associated thyrotoxicosis; patients with toxic nodule underwent hemithyroidectomy. Pathologic analysis assessed surgical specimens; postoperative complications and resolution of hyperthyroidism were noted. RESULTS: Two hundred patients from 15 to 83 years old were included. One hundred and eighty-eight underwent primary surgery and 12 were re-operated for recurrent goiter (6 with subtotal thyroidectomy for multinodular goiter 25 years previously; 6 with hemithyroidectomy for solitary nodule 15 years previously). Eighty-two patients suffered from toxic multinodular goiter, 78 from Graves' disease, 35 from solitary toxic nodules and 5 from amiodarone-associated thyrotoxicosis. Fourteen papillary carcinomas (including 11 papillary microcarcinomas) and 34 healthy parathyroid glands (17%) were identified in the pathological specimens. Postoperative complications comprised 4% permanent recurrent laryngeal nerve palsy (1 year follow-up), 9% hematoma requiring surgical revision, and 3% definitive hypocalcemia. Normalization of thyroid hormone levels was observed in 198 patients. Two recurrences occurred due to incomplete resection (1 case of Graves' disease and 1 intrathoracic toxic goiter that occurred respectively 18 and 5 months after resection). Postoperative complications were more frequent in multinodular goiter (23%) than in Graves' disease (13%) (ns: P>0.05). CONCLUSION: Surgical management of hyperthyroidism enables good endocrinal control if surgery is complete. Patients need to be fully informed of all possible postoperative complications that could occur, especially vocal ones. Long-term follow-up is necessary to detect recurrence, which can occur more than 20 years after partial thyroidectomy surgery. Surgery allows early diagnosis of 12.5% of papillary carcinomas.

In situ immunohistochemical study of Bcl-2 and heat shock proteins in human corneal endothelial cells during corneal storage.

AIM: To investigate the expression of Bcl-2 and heat shock proteins (HSPs), which are known to increase cell survival, in human corneal endothelial cells (HCECs) of corneas stored in organ culture. METHODS: 32 paired corneas were randomly assigned to either a short or a long storage time. The flat mounts of endothelium were examined after immunostaining with monoclonal antibodies to Bcl-2 and HSP 27, 60, 70, and 90. RESULTS: HCECs expressed generally all the proteins studied. Bcl-2 expression was weaker in the long stored corneas (p=0.035). There was no relation between immunostaining, age, sex, or death to culture time. Frequently some Descemet membranes carried negative cells preferentially located in folds and exhibiting morphological changes consistent with swelling cells corresponding to early stages of apoptosis. CONCLUSION: Expression of these cytoprotective proteins reflects the high level of HCEC resistance to stresses induced by organ culture. The decreased immunostaining of Bcl-2 in the long storage group could act in cellular loss currently observed with storage time. The negativity of Bcl-2 and HSP labelling in corneal folding may be related to apoptosis.

Mechanisms of staurosporine induced apoptosis in a human corneal endothelial cell line.

BACKGROUND: Apoptosis very probably plays a key part in endothelial cell loss during corneal storage in organ culture as well as hypothermic storage. However, the mechanisms underlying endothelial apoptosis are poorly understood. The response of a human corneal endothelial cell (HCEC) line to staurosporine, a known inducer of apoptosis, was investigated to gain insights into the intracellular modulators that participate in endothelial cell death. METHODS: Immortalised HCECs were studied after 3, 6, 12, and 24 hours of incubation with 0.2 micro M staurosporine. Cell shedding was monitored. Hoechst 33342 fluorescent DNA staining combined with propidium iodide was used for apoptosis/necrosis quantification and morphological examination. The caspase-3 active form was assessed using western blot, proteolytic activity detection, and immunocytochemistry. The cleaved form of poly(ADP-ribose) polymerase (PARP) was assessed using immunocytochemistry and western blot. The ultrastructural features of cells were screened after 12 hours with staurosporine or vehicle. RESULTS: The specific apoptotic nature of staurosporine induced HCEC death was confirmed. The ultrastructural features of staurosporine treated cells were typical of apoptosis. HCEC shedding and DNA condensation increased with time. Caspase-3 activity was detected as early as 3 hours after exposure with staurosporine, peaking at 12 hours of incubation. The presence of cleaved PARP after 3 hours confirmed caspase-3 activation. CONCLUSIONS: These data suggest strongly that HCEC cell death induced by staurosporine is apoptosis. The main consequence of HCEC apoptosis is shedding. Staurosporine induced apoptosis of endothelial cells involves activation of caspase-3, and could be a useful model to study strategies of cell death inhibition.

Value of two mortality assessment techniques for organ cultured corneal endothelium: trypan blue versus TUNEL technique.

BACKGROUND/AIM: It is known that trypan blue staining is not a good predictor of loss of corneal endothelial cells (ECs) during organ culture. As it is primarily an indicator of membrane integrity, it would also not be expected to identify ECs undergoing apoptosis. The aim of this study was to determine the ability of the in situ TdT dUTP mediated nick end labelling (TUNEL) technique to detect cell death in the corneal endothelium caused by apoptosis during organ culture, compared with conventional vital staining with trypan blue. METHODS: 31 human corneas were organ cultured at 31C for 3-35 days. Staurosporine was used to induce apoptosis in five control corneas. The endothelium was assessed by trypan blue and by the in situ TUNEL technique. The percentages of trypan and TUNEL positive ECs were compared. Their links with sex, donor age, time from donor death and organ culture, initial and final EC density and cell loss were studied. RESULTS: TUNEL stained ECs were observed in all corneas. TUNEL positive ECs were mostly located either in corneal folds or at the periphery of corneal folds showing central shedding. The mean percentage of cell death at the end of storage, assessed by the trypan blue technique, was 1.47% (SD 2.63, range 0.03-12); assessed by the TUNEL technique it was 12.7% (SD 16.4 range 0.6-65.5). There was a significant correlation between the two techniques (r = 0.7, p<0.001). The percentage of TUNEL stained ECs was correlated negatively with EC density at the end of storage (r = -0.47, p <0.005) and positively with percentage EC loss during storage (r = 0.46, p < 0.05). CONCLUSION: This study demonstrates that organ cultured corneas systematically carry non-viable ECs that are implicated in cell death by apoptosis and go undetected when trypan blue staining is used. Because the in situ TUNEL assay detects earlier events in the cell death process than does trypan blue, it should be used to quantify endothelial viability, especially for experiments with new storage media.

Interest of PS100 assay when (99m)Tc sestamibi scintigraphy failed to identify lymph node metastases of melanoma.

The study evaluated the contribution of serum PS100 assay to the detection of lymph node metastases during the follow-up of patients previously treated for a malignant melanoma, in addition to (99m)Tc sestamibi (MIBI) scintigraphy and investigation for gene MDR1, in order to detect chemoresistance phenomena. The study included 37 patients with a clinically questionable lymph node around basin lymphatic areas of the previously surgically-treated malignant melanoma. The sensitivity and specificity of PS100 assay were 91% and 86.5%, respectively. The sensitivity and specificity of MIBI scintigraphy were 95% and 85%, respectively. Overexpression of gene MDR1 was observed in six cases. In the event of negative scintigraphic findings, the concomitant analysis of PS100 levels and the scintigraphic result enabled the metastatic MDR+ patients to be distinguished from the non-metastatic patients. PS100 assay may therefore be proposed for the follow-up of malignant melanoma.

An immunohistochemical study of the simultaneous expression of bcl-2 and p53 oncoproteins in epithelial tumors of the colon and rectum.

OBJECTIVE: Bcl-2 and p53 genes may participate in a common pathway for regulation of apoptosis. The aims of this study were (1) to study the immunohistochemical expression of the bcl-2 oncoprotein in colorectal tumors, (2) to correlate it with that of p53 protein overexpression, and (3) to compare it with histopathologic prognostic factors, such as TNM classification and grade. DESIGN: Prospective study of expression of bcl-2 and p53 oncogenes in colorectal tumors. We examined 6 colorectal hyperplastic polyps, 33 adenomas, and 61 carcinomas. SETTING: Regional academic medical center. METHODS: An immunohistochemical study with bcl-2 and p53 antibodies was performed on frozen sections of colorectal tumors. The levels of bcl-2 and p53 expression were evaluated using a semiquantitative grading system. Two-color immunohistochemistry was performed to examine the intracellular colocalization of bcl-2 and p53 in all tumors with a strong positivity for both antigens. RESULTS: Bcl-2 was expressed in 28 (85%) of the 33 adenomas, whereas p53 was expressed in only one adenoma, which had areas of in situ carcinoma. Bcl-2 and p53 were each expressed in 43 (70.4%) of the 61 carcinomas. Thirty-one (50%) of the colorectal carcinomas coexpressed the two oncoproteins. There was no correlation between the number of cells expressing bcl-2 and the number expressing p53 in a given carcinoma. No correlation was observed between the expression of bcl-2 or p53 and the established prognostic factor. CONCLUSION: Abnormal bcl-2 oncoprotein expression appears earlier than p53 accumulation in colorectal carcinogenesis. This study suggests that there is more than one sequence and mechanism of bcl-2 and p53 gene deregulation in colorectal carcinomas.