Rare histologic types of rectal cancer: A monocentric cases series report.

PURPOSE: There is paucity of data on rectal cancer with uncommon histologic types. The objective was to describe managements of care and outcomes in patients with rectal cancer of histologic types other than adenocarcinoma. MATERIAL AND METHODS: This monoinstitutional retrospective study included all patients with rectal cancer undergoing rectal radiotherapy. RESULTS: From 2004 to 2015, 744 patients were treated for rectal cancer, and ten had a histologic type other than adenocarcinoma. The median age was 60.7 years (range: 34.6-80.4 years). Histologic types were neuroendocrine (four), adenosquamous (one), undifferentiated with large cell (one), clear cell (one), anaplastic with small cell (one), signet ring cell (one) and adenocarcinoma with choriocarcinomatous differentiation (one). Four patients were initially diagnosed with a stage IV rectal cancer, and two ultimately became metastatic. Six patients underwent surgery, with four neoadjuvant chemoradiotherapies. None experienced complete response and two had incomplete resections. First-line and concomitant chemotherapies were adapted to histology results, mainly with etoposide and platinum salts for neuroendocrine and small cells tumours. Four patients experienced progression before first line treatments were achieved. Median progression free survival and overall survival were 3.8 and 10.1 months respectively. Two patients were long survivors (22 and 54.7 months, both still alive). All other died of rectal cancer. CONCLUSION: The present study highlights the rarity and the specificities of uncommon histologic types of rectal cancer. We report the real-life management and outcome of rare histologic types of rectal cancers, with dismal prognosis of stage IV tumours. We also report that treatments were adapted to histology.

Assessment of cellular adequacy of fine needle aspiration biopsy for small solid renal tumors.

OBJECTIVE: Our aim was to evaluate the performance of fine needle aspiration (FNA) as a method for obtaining cellular material for the tissue diagnosis of small solid renal tumours. METHODS: Fifty-five patients with a small solid renal tumour (4 cm or smaller) underwent a FNA biopsy under computed tomography guidance. Direct smears and rinse of needle with Cytolyt® were prepared. The cellular adequacy was divided into three groups: satisfactory cellular material, scant cellular material and noncellular material. RESULTS: Postoperative pathological diagnosis showed 35 clear cell carcinomas, 10 papillary carcinomas, four chromophobe carcinomas, four oncocytomas, one adenoma and one metastatic carcinoma. A total of 21 (38.2%) FNA biopsies belonged to noncellular group. For clear cell carcinomas, the cellularity of satisfactory cellular group, scant cellular group and noncellular group was, respectively, seven (20.0%), nine (25.7%) and 19 (54.3%). Of the 10 papillary carcinomas, nine (90%) and all four chromophobe carcinomas (100%) had satisfactory cellular materials. The percentages of noncellular group among clear cell carcinoma, papillary carcinoma and chromophobe carcinoma were significantly different (P = 0.0020). Fifteen tumours were 2 cm or smaller and 40 tumours were larger than 2 cm. No significant difference was found in the percentage of noncellular material for the tumours 2 cm or less (40.0%) and for the tumours larger than 2 cm (37.5%; P > 0.05). CONCLUSIONS: The cellularity of FNA biopsy of small solid renal masses might correlate with the subtype of renal cancers. FNA biopsy was an effective method of tissue sampling for papillary and chromophobe renal carcinomas.

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.

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.

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.

Thyroid nodule surgery: predictive diagnostic value of fine-needle aspiration cytology and frozen section.

OBJECTIVES: The authors analyse the predictive diagnostic accuracy of fine-needle aspiration cytology (FNAC) and frozen section examination in adult patients operated for thyroid nodules. PATIENTS AND METHODS: The same pathologist performed macroscopic and cytological examination, followed by frozen section examination on each operative specimen. FNAC results were classified into three groups: benign, malignant or suspicious of malignancy. Frozen section examination was also classified into three categories: benign, malignant or suspicious of malignancy when not all criteria of malignancy were present. RESULTS: One hundred and sixty-six (82%) of the 202 patients included in the study were females. Patients had a mean age of 51 years. Thyroid carcinoma was diagnosed on final pathology in 22% of women and 25% of men. FNAC results were benign in 85% of cases, malignant in 9% of cases and atypical or suspicious in 6% of cases, with a specificity of more than 99% and a sensitivity, including and excluding microcarcinomas, of 36% and 48%, respectively. The diagnostic accuracy of FNAC was 84% and 89%, after excluding micro-carcinomas. Frozen section was benign in 85% of cases, malignant in 13% of cases and suspicious in 2% of cases, with a specificity of more than 99% and a sensitivity, including and excluding microcarcinomas, of 56% and 68%, respectively. The diagnostic accuracy of frozen section was 89% and 90%, after excluding microcarcinomas. The diagnostic accuracy of the combination of the two examinations was 94% after excluding microcarcinomas. CONCLUSION: FNAC and frozen section have a comparable predictive diagnostic accuracy. Frozen section is requested by the surgeon not only on the basis of preoperative FNAC, especially when it is suspicious, or even indeterminate, but also in the light of the macroscopic surgical findings.

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.

[Clinicopathological study and immunohistochemical expression of CA9 in cystic multilocular renal cell carcinomas]. / Étude anatomoclinique et de l'expression immuno-histochimique de CA9 dans les carcinomes kystiques multiloculaires du rein.

OBJECTIVE: Multilocular cystic renal cell carcinoma has been considered as a distinct subtype of clear cell renal cell carcinoma according to 2004 WHO classification. CA9 has proven to be a diagnostic and prognostic marker for clear cell renal cell carcinoma, but the study has been limited to solid tumors. The aim of this article was to analyse the clinical features of multilocular cystic renal cell carcinoma with focus on CA9 expression. PATIENTS AND METHODS: Nine multilocular cystic renal cell carcinomas were found. Their age was from 33 to 74 years old with a median of 54 years. There were five men and four women. The computerized tomography was analyzed. There were three total nephrectomies and six partial nephrectomies. The follow-up ranged from five to 102 months with a median 56 months. Immunohistochemical staining was performed on surgical samples to detect CA9 expression. RESULTS: There were seven pT1a, one pT1b and one pT2; four grade 1 and five grade 2. The Bosniak classification was: one B2F, six B3 and two B4. In CT examination, all tumors showed a hypodense mass. Seven out of nine showed multiple intern septa, more or less thick and vascularized with an enhancement after injection of contrast. No metastasis or relapse was found during follow-up. Eight out of nine multilocular cystic renal cell carcinomas expressed strongly CA9. CONCLUSION: Multilocular cystic renal cell carcinoma was a low malignant tumor with a good prognosis. The diagnostic criteria based on the WHO classification 2004 should be adopted in routine. CA9 could be a new diagnostic marker for this tumor.

Poloxamines for deswelling of organ-cultured corneas.

BACKGROUND: Poloxamines are amphiphilic tetrofunctional block copolymers composed of four polyoxyethylene-polyoxypropylene arms joined to a central ethylene diamine bridge. Their safe profile allows diverse pharmaceutical and biomedical applications. AIM: To assess their use for corneal deswelling using a porcine model of organ culture (OC). METHODS: Five poloxamines (T90R4, T904, T908, T1107 and T1307) were dissolved in a standard commercial OC medium (control) to reach 350 mosm kg(-1). In vitro cytotoxicity was tested using MTT assay on human corneal epithelial and endothelial cell (EC) lines and on primary human corneal fibroblasts. Paired porcine corneas stored in OC for 3 days were assigned for 48 h to a poloxamine medium or to a standard deswelling medium containing 5% dextran T500. Corneal EC density, morphometry, mortality, stromal thickness and transparency were evaluated before and after deswelling. Post-deswelling, EC viability/mortality was determined using a fluorescent live/dead assay. RESULTS: Besides similar corneal thickness reduction and transparency improvement, T908, T1107 and T1307 decreased EC loss (5.4 ± 1.7% vs. 9.9 ± 2.6% in controls (p < 0.001)) and mortality, improved EC morphometry and reduced endothelial lesions compared to dextran. CONCLUSION: On this porcine model, poloxamines T908, T1107 and T1307 appear as good candidates to replace dextran for the deswelling. Experiments on human corneas are now necessary to confirm their efficiency and safety profile in OC.

[Problems and advantages of autopsy in the case of out-of-hospital childhood death: report of 2 cases]. / Difficultés et intérêt de l'autopsie dans le cas de décès d'enfant hors établissement de santé : à propos de 2 observations.

In France, the number of deaths remains high in the pediatric population. These deaths are rarely subject to a scientific or forensic autopsy. However, this medical act appears necessary to answer the many private and public questions (public health, prevention, judicial, or even institutional) that can arise. Two pediatric clinical observations raising these questions in the context of a household accident are presented. In the first one, the death led to the establishment of a forensic obstacle to the burial and a forensic autopsy. The autopsy results provided answers, both to the relatives and to the court. The second concerns a deceased child managed within the protocol for sudden infant death syndrome. The autopsy was not authorized by the parents and no answer on the causes of death could be determined. These 2 observations underline the importance and utility of this medical act.

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.

Rupture of the left ventricle due to blunt trauma--a pediatric case study and literature review.

Tamponade due to rupture of the chambers of the heart, in particular the left ventricle, after blunt thoracic trauma is described only sparsely in the literature. Most cases involve multiple thoracic trauma following motor vehicle accidents. We present the case study of a five-year old victim of a household accident, in which two concrete basins apparently fell on him. He died rapidly, despite attempted resuscitation. The autopsy showed essentially a hemorrhagic extravasation of the diaphragm and mediastinum, hemopericardium, and massive damage to the apex of the left ventricle. Pathological exam confirmed the traumatic origin of the cardiac rupture, with no underlying pathology. We will discuss the mechanisms described in the literature that result in such lesions, the mechanism which we believe most probable in this case, and the importance of background information. In our case study, lack of specific information concerning the accident prevents a definitive conclusion of the exact mechanism that caused this massive trauma particularly due to the fact that the external examination couldn't find any lesion in favor of a thoracic or abdominal traumatism. To our knowledge, in context of a household accident, such an isolated lesion causing almost immediate death has not previously been described in the literature.

Macroscopic, histological and toxicological aspects of early Gammarus pulex scavenging.

Two cases of scavenging postmortem freshwater shrimps (Gammarus pulex) are presented. We report the two first illustrated observations of cutaneous postmortem injuries inflicted by a G. pulex population, a small freshwater crustacean, on two non putrefied drowning victims, and we describe their particular histological features and their potential in forensic investigations.

[Benefit of a prolonged adjuvant treatment with temozolomide for the management of patients with glioblastoma]. / Intérêt d'un traitement d'entretien prolongé par témozolomide dans la prise en charge des patients atteints d'un glioblastome.

PURPOSE: Temozolomide has significantly improved the outcome of patients with glioblastoma. However, the optimal duration of continuation treatment after chemoradiation remains uncertain. This retrospective analysis aims at assessing the feasibility, the tolerance, and the potential benefit of prolonging adjuvant temozolomide more than six months, which is the reference protocol. PATIENTS AND METHODS: Forty-six patients were included in the analysis. Median age at diagnosis was 61 years old (range 40 to 77). Forty-five patients received a conformal external beam radiation with concurrent temozolomide-based chemotherapy. Then, 37 patients received adjuvant chemotherapy with temozolomide. The treatment was continued until progression or toxicity. RESULTS: During the adjuvant phase, no treatment discontinuation for toxicity was necessary. Eight patients required dose adaptation because of toxicity. Thirty-two patients presented tumor progression during the adjuvant phase. Overall median survival was 12.3 months (range 11-13.2 months) and progression-free survival (PFS) was 7.6 months (range 5.6-9.6 months). CONCLUSION: These results suggest feasibility of delivering temozolomide beyond the six months of the standard protocol, with mild toxicity and survival data at least comparable to those from literature. Prospective assessments are ongoing.