Caso 8. Tumoración del espacio parafaríngeo / Case 8. Tumours of the parapharyngeal space

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Solución del caso 8. Tumoración del espacio parafaríngeo / Solution to case 8. Tumor of the parapharyngeal space

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Salvage surgery for locoregional recurrences of advanced pharyngolaryngeal squamous cell carcinoma after organ preservation failure.

Organ preservation treatment for advanced head and neck squamous cell carcinoma is associated with poor outcomes due to locoregional recurrences. Salvage surgery is the main therapeutic option for some of these patients. The aim of this study was to analyse the results of salvage surgery for advanced pharyngolaryngeal squamous cell carcinoma previously treated with radiochemotherapy. We performed a retrospective study on 38 patients (36 men, 2 women). The median age at diagnosis was 60 years with a mean follow-up period of 49.8 months. Recurrences were diagnosed at a mean of 395 days after finalising organ preservation treatment. Patients went under different salvage surgeries, including 22 total laryngectomies, 6 partial laryngectomies (3 transoral laser surgeries and 3 opened surgeries), 8 functional neck dissections and 2 tongue base surgeries. Nineteen patients had no postoperative complications after a mean hospital stay of 2 weeks. However, 5 patients died of significant recurrent bleedings. There were 4 salivary fistulas that responded to conservative management, while 7 patients had important pharyngostomas that required reconstruction with either regional or free flaps. The mean hospital stay was of 61.60 days for all patients. Five-year overall survival from diagnosis, overall survival after salvage surgery and survival after salvage surgery were 44.20, 37.90 and 45.70%, respectively. In summary, we conclude that salvage surgery is an optimal treatment for pharyngolaryngeal and regional recurrences and provides improvement in locoregional control and survival, despite the severe complications.

[Impact of FDG-PET in therapeutic management of patients with suspected recurrence of head and neck cancer]. / Impacto de la PET-FDG sobre el manejo terapéutico de pacientes con sospecha de recurrencia tumoral por cánceres de cabeza y cuello.

OBJECTIVE: This study aims to evaluate the impact of Positron Emission Tomography on therapeutic decisions in patients with suspicion of recurrence of head and neck cancers. MATERIAL AND METHODS: The diagnostic and therapeutic impact of FDG-PET was evaluated in 59 of 60 studies performed in a sample of 54 patients. The impact was graded on five levels (high, moderate, low, no impact and negative impact) following the Hicks et al. classification modified by us. RESULTS: The FDG-PET impact was high in 28 studies (47.46 %), moderate in 7 (11.86 %), low in 20 (33.90 %), no impact in 3 (5.09 %) and finally negative impact in 1 study (1.69 %). CONCLUSIONS: FDG-PET is useful in the management of patients in 59.32 % of the studies with indeterminate physical examination and conventional imaging tests. This paper supplies new data since we did not find any studies showing statistical results on therapeutic impact of FDG-PET in head and neck cancers in a systematic review of the literature made by our group.

Comparación entre la PET 18F-FDG y las técnicas de imagen convencionales (TACy RMN) en el diagnóstico de sospecha de recurrencia de tumores de cabeza y cuello / Comparison between 18F-FDG PET and conventional imaging techniques (CT SCAN and MRI) in the diagnosis of head and neck tumor suspicion of recurrence

Objetivo: El propósito de este estudio fue evaluar los resultados obtenidos con la Tomografía por Emisión de Positrones (PET) y con los métodos de imagen anatómicos convencionales (TAC y RMN), en el diagnóstico de sospecha de recurrencia tumoral en cánceres de cabeza y cuello. Pacientes y métodos: Se revisaron retrospectivamente 30 pacientes con sospecha de recidiva tumoral por cánceres de cabeza y cuello, a los que les fueron realizados 34 estudios PET. Las imágenes fueron obtenidas en el Instituto PET de Madrid. Se interpretaron mediante análisis visual y semicuantitativo. La confirmación de los resultados se hizo por seguimiento clínico, respuesta a tratamiento o estudio histológico. Resultados: La sensibilidad y especificidad de la PET fueron 95,6% y 81,8% respectivamente, mientras que para la TAC/RMN fueron de 65% y 80%. Conclusiones: Podemos concluir que la PET aporta mejores resultados que las técnicas de imagen convencionales en la detección de recurrencia tumoral

Background: This study aimed to assess the results obtained with the positron emission tomography (PET) and conventional anatomic imaging methods (CT scan and MRI) in the diagnosis of suspicion of tumor recurrence in head and neck cancers. Methods: Thirty patients with suspicion of tumor recurrence due to head and neck cancers were reviewed retrospectively. Consequently, 34 PET studies were performed. The images were obtained in the PET Institute of Madrid. They were interpreted by visual and semiquantitative analysis. The results were confirmed with clinical followup, response to treatment or with histological studies in some cases. Results: Sensitivity and specificity of the PET were 95.6% and 81.8% respectively, while it was 65% and 80% for the CT scan/MRI. Conclusions: We can conclude that PET provides better results than conventional imaging techniques in the detection of head and neck cancer recurrence

[Treatment of early glottic carcinoma with transoral laser CO2]. / Tratamiento del cáncer glótico precoz con cirugía transoral láser CO2.

OBJECTIVE: We present our outcome in the treatment of 125 patients with malignant glottic lesions between 1992 and 2003 in a retrospective study. PATIENT AND METHODS: We analyze 125 cases of patients, with previously untreated carcinoma of the larynx with histological diagnosis, treated with Transoral Laser Microresection. We will pay special attention to those tumors involving the Anterior Commissure. We will also analyze several parameters related to the post and intraoperatory histopathological report, in order to decide adjuvant therapies. We will also analyze the technique indications, complications, hospital length of stay, oncologic and functional outcomes, survival and follow up of recurrences. OUTCOMES AND CONCLUSION: Transoral laser microresection is an effective and functional preserving procedure, and nowadays the base of the treatment of early glottic carcinoma. Anterior Commissure involvement is a prognostic factor. Sometimes complementary therapies are needed based on by the histopathological report.

[Temporal bone chondroblastoma. A clinical case and literature review]. / Condroblastoma de hueso temporal. Caso clínico y revisión de la literatura.

We report a clinical case of a 31 year old male with a left temporal painful mass of six months evolution. After radiologic diagnosis, intraoperatory biopsy and surgical removal, the anatomopathological result confirmed the histology of chondroblatoma, with a satisfactory postoperative evolution. The chondroblastoma is a benign bone tumor typically located in the epiphysis of long bones and the temporal bone is an excepcional location as we have verified through a literature review.

Tratamiento del cáncer glótico precoz con cirugía transoral láser CO2 / Treatment of early glottic carcinoma with transoral laser CO2

Objetivo: Estudio retrospectivo (1992-2003) de cánceres glóticos en estadio precoz tratados con cirugía transoral láser CO2. Material y métodos: Se estudian 125 casos de pacientes no previamente tratados, con diagnóstico histológico de carcinoma, tratados mediante Resección Transoral Láser CO2. Prestaremos especial atención a la afectación de la comisura anterior. También se analizarán aspectos referentes al informe anatómico de la pieza quirúrgica y su importancia intra y postoperatoria a la hora de realizar tratamientos complementarios. Analizamos las indicaciones de la técnica, las complicaciones, la estancia media, los resultados funcionales y oncológicos, la supervivencia y realizamos seguimiento de las recidivas. Resultados y Conclusiones: La técnica Láser es efectiva, conservadora de la función, y la base del tratamiento del carcinoma precoz de cuerda vocal. La afectación comisural influye en el pronóstico. Ocasionalmente pueden ser necesarios tratamientos complementarios en base al informe patológico postoperatorio

Objective: We present our outcome in the treatment of 125 patients with malignant glottic lesions between 1992 and 2003 in a retrospective study. Patient and methods: We analyze 125 cases of patients, with previously untreated carcinoma of the larynx with histological diagnosis, treated with Transoral Laser Microresection. We will pay special attention to those tumors involving the Anterior Commissure. We will also analyze several parameters related to the post and intraoperatory histopathological report, in order to decide adjuvant therapies. We will also analyze the technique indications, complications, hospital length of stay, oncologic and functional outcomes, survival and follow up of recurrences. Outcomes and conclusion: Transoral laser microresection is an effective and functional preserving procedure, and nowadays the base of the treatment of early glottic carcinoma. Anterior Commissure involvement is a prognostic factor. Sometimes complementary therapies are needed based on by the histopathological report

Impacto de la PET-FDG sobre el manejo terapéutico de pacientes con sospecha de recurrencia tumoral por cánceres de cabeza y cuello / Impact of FDG-PET in therapeutic management of patients with suspected recurrence of head and neck cancer

Objetivo. El propósito de este estudio es evaluar el impacto de la tomografía por emisión de positrones (PET) sobre las decisiones terapéuticas en pacientes con sospecha de recidiva tumoral de cánceres de cabeza y cuello. Material y métodos. El impacto diagnóstico y terapéutico de la PET-FDG fue evaluado en 59 de los 60 estudios llevados a cabo en una muestra de 54 pacientes. La gradación del impacto se hizo en 4 niveles (alto, moderado, bajo, no impacto e impacto negativo), siguiendo la clasificación de Hicks et al modificada por nosotros. Resultados. El impacto de la PET con 18F-fluorodeoxiglucosa (PET-FDG) fue alto en 28 estudios (47,46 %), moderado en 7 (11,86 %), bajo en 20 (33,90 %), no impacto en 3 (5,09 %) y finalmente impacto negativo en un estudio (1,69 %). Conclusiones. La PET-FDG es útil en el manejo de pacientes en el 59,32 % de los estudios con exploración física y pruebas de imagen convencionales indeterminadas. Este trabajo aporta datos novedosos, ya que en una revisión sistemática de la literatura realizada por nuestro equipo, no encontramos estudios que mostraran resultados estadísticos sobre el impacto de la PET-FDG en cánceres de cabeza y cuello

Objective. This study aims to evaluate the impact of Positron Emission Tomography on therapeutic decisions in patients with suspicion of recurrence of head and neck cancers. Material and methods. The diagnostic and therapeutic impact of FDG-PET was evaluated in 59 of 60 studies performed in a sample of 54 patients. The impact was graded on five levels (high, moderate, low, no impact and negative impact) following the Hicks et al. classification modified by us. Results. The FDG-PET impact was high in 28 studies (47.46 %), moderate in 7 (11.86 %), low in 20 (33.90 %), no impact in 3 (5.09 %) and finally negative impact in 1 study (1.69 %). Conclusions. FDG-PET is useful in the management of patients in 59.32 % of the studies with indeterminate physical examination and conventional imaging tests. This paper supplies new data since we did not find any studies showing statistical results on therapeutic impact of FDG-PET in head and neck cancers in a systematic review of the literature made by our group

Condroblastoma de hueso temporal. Caso clínico y revisión de la literatura / Temporal bone chondroblastoma. A clinical case and literature review

Presentamos el caso clínico de un paciente de 31 años de edad que consulta por una tumoración dolorosa en región temporal izquierda de seis meses de evolución. Tras su examen radiológico, biopsia intraoperatoria y exéresis quirúrgica se confirma el diagnóstico de condroblastoma, con una evolución clínica postoperatoria satisfactoria. El condroblastoma es un tumor benigno que asienta preferentemente en las epífisis de los huesos largos de las extremidades, cuya localización en hueso temporal es excepcional como constatamos al realizar una revisión bibliográfica de esta patología

We report a clinical case of a 31 year old male with a left temporal painful mass of six months evolution. After radiologic diagnosis, intraoperatory biopsy and surgical removal, the anatomopathological result confirmed the histology of chondroblatoma, with a satisfactory postoperative evolution. The chondroblastoma is a benign bone tumor typically located in the epiphysis of long bones and the temporal bone is an excepcional location as we have verified through a literature review

[Comparison between 18F-FDG PET and conventional imaging techniques (CT SCAN and MRI) in the diagnosis of head and neck tumor suspicion of recurrence]. / Comparación entre la PET 18F-FDG y las técnicas de imagen convencionales (TAC y RMN) en el diagnóstico de sospecha de recurrencia de tumores de cabeza y cuello.

BACKGROUND: This study aimed to assess the results obtained with the positron emission tomography (PET) and conventional anatomic imaging methods (CT scan and MRI) in the diagnosis of suspicion of tumor recurrence in head and neck cancers. METHODS: Thirty patients with suspicion of tumor recurrence due to head and neck cancers were reviewed retrospectively. Consequently, 34 PET studies were performed. The images were obtained in the PET Institute of Madrid. They were interpreted by visual and semiquantitative analysis. The results were confirmed with clinical follow-up, response to treatment or with histological studies in some cases. RESULTS: Sensitivity and specificity of the PET were 95.6% and 81.8% respectively, while it was 65% and 80% for the CT scan/MRI. CONCLUSIONS: We can conclude that PET provides better results than conventional imaging techniques in the detection of head and neck cancer recurrence.

[Cancer of the parotid gland]. / Tumores malignos de la glándula parótida.

OBJECTIVE: To review our experience and results in the diagnosis and treatment of a low incidence pathology such as the cancer of the parotid gland. METHODS: The study reviewed 40 patients with malignant tumors of the parotid gland treated between 1991 and 2002 in our hospital. It was used the staging system TNM (American Joint Committee on Cancer 1997). RESULTS: The most common histological type in our series is the squamous cell carcinoma, in general unilateral and in the superficial lobe. Rapid tumor enlargement, fixation to the skin, cervical lymphadenopathy, pain and facial palsy are malignancy clinical findings. We obtained a 56% 5-year global survival rate, with a 68% for stages I and II, and 43% for stages III and IV. CONCLUSIONS: This pathology has a low incidence but high mortality. The staging and histological type are important prognostic factors. The surgery is the election treatment, associated with neck disection or radiotherapy.

Tumores malignos de la glándula parótida / Cancer of the parotid gland

Objetivo: Revisar la experiencia y resultados de nuestro hospital en el diagnóstico y tratamiento de una patología con una baja incidencia como son los tumores malignos de la glándula parótida. Material y método: Realizamos un estudio retrospectivo de 40 pacientes tratados de tumores malignos de la glándula parotídea entre los años 1991 y 2002 en nuestro hospital. El sistema de estadiaje utilizado fue el TNM, según la clasificación de la American Joint Committee on Cancer (1997). Resultados: El tipo histológico más frecuente en nuestra serie es el carcinoma epidermoide, presentándose generalmente como una tumoración unilateral y en el 90% de los casos en el lóbulo superficial de la glándula. La presencia de un crecimiento rápido, dureza y fijación a los elementos adyacentes y la piel, adenopatías regionales, dolor o parálisis facial están íntimamente relacionados con el grado de malignidad. La supervivencia global de los tumores malignos de parótida en nuestro estudio fue del 56% a los 5 años, con un 68% para los tumores en estadio I y II y un 43% para los de estadio III y IV. Conclusiones: Esta patología tiene una incidencia baja, pero de alta mortalidad. La histología y el estadio tienen un importante valor pronóstico. La cirugía es el tratamiento de elección, con vaciamiento cervical o radioterapia complementaria

Objective: To review our experience and results in the diagnosis and treatment of a low incidence pathology such as the cancer of the parotid gland. Methods: The study reviewed 40 patients with malignant tumors of the parotid gland treated between 1991 and 2002 in our hospital. It was used the staging system TNM (American Joint Committee on Cancer 1997). Results: The most common histological type in our series is the squamous cell carcinoma, in general unilateral and in the superficial lobe. Rapid tumor enlargement, fixation to the skin, cervical lymphadenopathy, pain and facial palsy are malignancy clinical findings. We obtained a 56% 5-year global survival rate, with a 68% for stages I and II, and 43% for stages III and IV. Conclusions: This pathology has a low incidence but high mortality. The staging and histological type are important prognostic factors. The surgery is the election treatment, associated with neck disection or radiotherapy

[Primitive neuroectodermal tumor/extraosseus Ewing sarcoma of the temporal bone]. / Tumor neuroectodérmico primitivo periférico/sarcoma de Ewing extraóseo del hueso temporal.

The term primitive neuroectodermal tumor (PNET) should be included in the differential diagnosis of small round blue cell tumors, which come from the neural crest and explain their neuroectodermal character. This is one of the most indifferentiated histological types of malignant tumors. In the PNET family, we high light the Ewing's Sarcoma, that is frecuently located in bony sites and has a less frequent localization in soft tissues. We focus on one atypic case of PNET/Extraosseus Ewing's Sarcoma that involves the external auditory canal and infiltrates the temporal bone. Surgery followed by postoperative chemotherapy and radiation offers the best local control of the disease.

Tumor neuroectodérmico primitivo periférico/ sarcoma de Ewing extraóseo del hueso temporal / Primitive neuroectodermal tumor/Extraosseus Ewing Sarcoma of the temporal bone

El término tumor neuroectodérmico primitivo (PNET) se incluye dentro de un grupo de neoplasias formado por "células redondas azules de pequeño tamaño" que derivan de la cresta neural y de ahí su carácter neuroectodérmico. Es uno de los tipos histológicos más indiferenciados de tumores malignos. Dentro de esta familia de tumores destaca el Sarcoma de Ewing, que aparece fundamentalmente en estructuras óseas, disminuyendo su probabilidad en estructuras extraóseas. Presentamos un caso atípico de pPNET/Sarcoma de Ewing extraóseo que ocupaba el CAE e infiltraba el hueso temporal. Para el control de la enfermedad, el enfoque preferido es la cirugía más radioquimioterapia

The term primitive neuroectodermal tumor (PNET) should be included in the differential diagnosis of small round blue cell tumors, which come from the neural crest and explain their neuroectodermal character. This is one of the most indifferentiated histological types of malignant tumors. In the PNET family, we high light the Ewing´s Sarcoma, that is frecuently located in bony sites and has a less frequent localization in soft tissues. We focus on one atypic case of PNET/ Extraosseus Ewing´s Sarcoma that involves the external auditory canal and infiltrates the temporal bone. Surgery followed by postoperative chemotherapy and radiation offers the best local control of the disease

Tumores malignos del conducto auditivo externo y oído medio / Malignant tumours of the external auditory canal and of the middle ear

Objetivos: Revisar la experiencia de nuestro Centro en el tratamiento de una patología tan poco frecuente como son los tumores del CAE y oído medio. Material y métodos: Se realiza una revisión de 36 pacientes con tumores malignos del oído medio y CAE tratados en el servicio de nuestro hospital en el período de 1977-2000, excluyendo los tumores de pabellón, tumores metastásicos y sarcomas. El sistema de estadiaje utilizado es el propuesto por el M.D. Anderson. Resultados: El tipo histológico más frecuente en nuestra serie es el carcinoma epidermoide, presentándose en el 100 por ciento de los casos con otorrea y dolor como primer síntoma en el momento de la consulta. La combinación de cirugía y radioterapia obtuvo una tasa de supervivencia a los 5 años del 41 por ciento. Conclusiones: Esta patología precisa para la realización de un diagnóstico precoz un alto índice de sospecha clínica. El correcto estadiaje clínico tiene un importante valor pronóstico (AU)

OBJECTIVES: To review our experience and results in the treatment of a low incidence pathology such as the malignant ear tumors. METHODS: The study reviewed 36 patients with malignant tumors of the EAC and middle ear treated between 1977 and 2000 in our hospital, excluding cancer of the pinna, metastatic tumours and sarcomas. It was used the staging system proposed by the M.D. Anderson. RESULTS: The most common histological type in our series is the squamous cell carcinoma, and the otorrhea and pain are the primary symptoms in 100% of patients. Surgery combined with radiotherapy obtained a 41% 5-year survival rate. CONCLUSIONS: The staging system is an important prognostic factor and it is important an early diagnosis to achieve a better therapeutical result (AU)

[Idiopathic recurrent facial palsy]. / Parálisis facial recidivante idiopática.

We report a 34 year old female patient with six episodes of idiopathic right facial palsy, all of wich had total recovery. Idiopathic recurrent facial palsy is a rare entity, with a few cases in the literature. Recurrent facial palsy is usually in the setting of a family history and have both autosomal dominant and recessive inheritance or in the setting of hypertension and diabetes. A review of the literature does not report a previous case with six episodes.

[Geniculate ganglion tumors. Therapeutic and reconstructive management]. / Tumores del ganglio geniculado. Manejo terapéutico y reconstructivo.

We present five cases of patients diagnosed of a facial nerve tumoral lesion localised at the Geniculate Ganglion and all of which underwent surgical resection. The initial symptoms were in four cases of peripheral facial nerve paralysis and in the fifth case facial paresis. Two trans-mastoid extralabyrinthine approaches were performed and one through a combined path (middle fossa and trans-mastoid) with reconstruction of the facial nerve through a termino-terminal graft. In the fourth case, an approach through fossa media was done, and did not include nerve reconstruction but palliative treatment with a palpebral gold plaque. In the fifth case, a modified trans-labyrinthine approach with facial-hypoglossus termino-terminal anastomosis. Histological diagnosis was 3 neurinomas and 2 hemangiomas. Of the termino-terminal grafts two managed a functional Grade III of the House-Brackmann classification. The third one sustained a Grade VI and therefore a suspension with temporal muscle was carried out. The patient with facial-hypoglossus anastomosis is in a functional Grade IV. Geniculate ganglion tumors are in their majority benign and their treatment is the total resection of the tumor. Nerve reconstruction can be primary or deferred with the aid of a nerve graft or anastomosis, being necessary palliative techniques when resection is not possible.

Parálisis facial recidivante idiopática / Idiopathic recurrent facial palsy

Presentamos el caso de una paciente de 34 años que presenta en seis ocasiones parálisis facial periférica idiopática derecha, con recuperación total en todos los casos. La parálisis facial recidivante idiopática es una rara entidad, poco descrita en la literatura. Las parálisis recidivantes suelen estar asociadas a casos familiares relacionados con herencia autosómica tanto dominante como recesiva o a casos relacionados con hipertensión y diabetes. El hecho de que se produzca en seis ocasiones, sin asociación familiar es excepcional en la literatura (AU)

We report a 34 year old female patient with six episodes of idiopathic right facial palsy, all of wich had total recovery. Idiopathic recurrent facial palsy is a rare entity, with a few cases in the literature. Recurrent facial palsy is usually in the setting of a family history and have both autosomal dominant and recessive inheritance or in the setting of hypertension and diabetes. A review of the literature does not report a previous case with six episodes (AU)

Tumores del ganglio geniculado. Manejo terapéutico y reconstructivo / Geniculate ganglion tumors. Therapeutic and reconstructive management

Presentamos cinco casos de pacientes diagnosticados de una lesión tumoral del nervio facial localizada en la región del ganglio geniculado a los cuales se practicó cirugía de exéresis. La clínica inicial fue en cuatro de los casos parálisis facial periférica de larga evolución y en el quinto paresia facial. Se realizaron dos abordajes transmastoideos extralaberínticos y uno por vía combinada (fosa media y transmastoidea) con reconstrucción del nervio facial mediante injerto termino-terminal. En el cuarto caso, un abordaje por fosa media, no se incluyó reconstrucción nerviosa sino tratamiento paliativo con placa de oro palpebral. En el quinto, un abordaje translaberíntico modificado, se hizo anastomosis termino-lateral hipogloso-facial. El diagnóstico histológico fue de 3 neurinomas y 2 hemangiomas. Funcionalmente 2 de los injertos termino-terminales lograron grado III de la clasificación de House-Brackmann. El tercero mantuvo grado VI por lo que se realizó suspensión con músculo temporal. El paciente con anastomosis hipoglosofacial está en grado funcional IV. Los tumores del ganglio geniculado son en su mayoría de histología benigna y su tratamiento es la exéresis completa. La reconstrucción nerviosa puede ser primaria o diferida ayudándose de injerto nervioso o anastomosis, siendo necesarias las técnicas paliativas cuando ésta no es posible (AU)

We present five cases of patients diagnosed of a facial nerve tumoral lesion localised at the Geniculate Ganglion and all of which underwent surgical resection. The initial symptoms were in four cases of peripheral facial nerve paralysis and in the fifth case facial paresis. Two trans-mastoid extralabyrinthine approaches were performed and one through a combined path (middle fossa and trans-mastoid) with reconstruction of the facial nerve through a termino-terminal graft. In the fourth case, an approach through fossa media was done, and did not include nerve reconstruction but palliative treatment with a palpebral gold plaque. In the fifth case, a modified trans-labyrinthine approach with facial-hypoglossus termino-terminal anastomosis. Histological diagnosis was 3 neurinomas and 2 hemangiomas. Of the termino-terminal grafts two managed a functional Grade III of the House-Brackmann classification. The third one sustained a Grade VI and therefore a suspension with temporal muscle was carried out. The patient with facial-hypoglossus anastomosis is in a functional Grade IV. Geniculate ganglion tumors are in their majority benign and their treatment is the total resection of the tumor. Nerve reconstruction can be primary or deferred with the aid of a nerve graft or anastomosis, being necessary palliative techniques when resection is not possible (AU)