1- Andrea, M.; Dias O. Atlas of rigid and contact endoscopy in microlaryngeal surgery, philadelphia,1995, Lippincott-Raven.2- Andrea,M.; Dias O; Santos A.: “Contact endoscopy during microlaryngeal surgery. A new technique for endoscopic examination of the larinx.” Ann. Otol. Rhinol.Laryngol., 104:333-339, 1995.3- M. Pak, K. To, S. Leung, C.Van Hasselt; In vivo diagnosis of nasopharyngeal carcinoma using contact rhinoscopy, laryngoscope, 111, 1453-1458, August 2001.4-H. Xioaming, M. Haiquiang, D. Manquan, S. Jianyong, S. Yong, L. Kela,L. Xiaoman, H. Tengbo; Examination of Nasofaringeal Epithelium With Contact Endoscopy. Acta Otolaryngol, 121,98-102,2001.

CONTACT ENDOSCOPY ASSESSMENT in NASOPHARYNGEAL CARCINOMA

CONTACT ENDOSCOPY ASSESSMENT in NASOPHARYNGEAL CARCINOMA

Department of Otolaryngology, Voice and Communication Disorders, University of Lisbon, PortugalDepartment of Otolaryngology, Voice and Communication Disorders, University of Lisbon, Portugal

Alberto Santos MD; Andrea Gaspar MD; Joaquim Amaral MD; Carlos Macor MD; Oscar Dias PhD; Mário Andrea PhDAlberto Santos MD; Andrea Gaspar MD; Joaquim Amaral MD; Carlos Macor MD; Oscar Dias PhD; Mário Andrea PhD

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The diagnosis of nasopharynx tumours was improved with the use of rigid and flexible endoscopy. However, the anatomy of this region associated to the exiguity of symptoms difficult the recognition of the disease at an early stage and the promptly identification of recurrence. Contact Endoscopy allows an in vivo and in situ observation of the micro vascular network and superficial cellular layers of the mucosa. Since 1993 (Andrea, Dias) contact endoscopy has been systematically performed in laryngeal diseases. In the following years the technique was naturally used in other ENT territories. The authors report their experience in the nasopharynx mucosa. The objective of this study was to evaluate the importance of contact endoscopy in the diagnosis and follow-up of nasopharyngeal carcinoma.

The diagnosis of nasopharynx tumours was improved with the use of rigid and flexible endoscopy. However, the anatomy of this region associated to the exiguity of symptoms difficult the recognition of the disease at an early stage and the promptly identification of recurrence. Contact Endoscopy allows an in vivo and in situ observation of the micro vascular network and superficial cellular layers of the mucosa. Since 1993 (Andrea, Dias) contact endoscopy has been systematically performed in laryngeal diseases. In the following years the technique was naturally used in other ENT territories. The authors report their experience in the nasopharynx mucosa. The objective of this study was to evaluate the importance of contact endoscopy in the diagnosis and follow-up of nasopharyngeal carcinoma.

The authors performed (since 1998) a double blind study (contact endoscopy/histology) in a population of 41 patients with nasopharyngeal carcinoma (T1=5; T2=18; T3=9; T4=9). A prospective study was also executed: two groups of patients were considered, one to evaluate diagnosis ability: group I- n-46 patients - 41 with clinical and radiological suspicion of carcinoma and a control group of 5 patients without disease. Another to assess the importance in follow up: Group II- n-62 (T1=9; T2=28; T3=10; T4=15) patients with diagnosis of nasopharyngeal carcinoma treated with chemotherapy associated to radiotherapy (nine years follow up).Contact endoscopy was performed through the nose, usually under topical anaesthesia and using a contact rhinoscope Karl Storz 7215 AA and 7215 BA (0º, 30º) after staining the surface of the mucosa with methylene blue (60X, 150X magnification).

The authors performed (since 1998) a double blind study (contact endoscopy/histology) in a population of 41 patients with nasopharyngeal carcinoma (T1=5; T2=18; T3=9; T4=9). A prospective study was also executed: two groups of patients were considered, one to evaluate diagnosis ability: group I- n-46 patients - 41 with clinical and radiological suspicion of carcinoma and a control group of 5 patients without disease. Another to assess the importance in follow up: Group II- n-62 (T1=9; T2=28; T3=10; T4=15) patients with diagnosis of nasopharyngeal carcinoma treated with chemotherapy associated to radiotherapy (nine years follow up).Contact endoscopy was performed through the nose, usually under topical anaesthesia and using a contact rhinoscope Karl Storz 7215 AA and 7215 BA (0º, 30º) after staining the surface of the mucosa with methylene blue (60X, 150X magnification).

II- MATERIAL AND METHODSII- MATERIAL AND METHODS

I- INTRODUCTIONI- INTRODUCTION

Several cellular and vascular parameters could be assessed: nucleus shape, dimensions and staining, nuclei/cytoplasm ratio, the presence of abnormal mitosis and nucleoli. The major vascular characteristics are vascular network regularity, and circulatory kinetics. Regarding these parameters it was possible to establish normal and pathological patterns. Normal pattern (Fig. 1) is characterized by the presence of normal ciliated epithelium especially in the nasopharynx lateral wall. In some regions with heavier exposure to airflow the mucosa may be covered only by squamous epithelium, such as the posterior wall of the nasopharynx. The excretory duct of the glands can also be observed, especially at the lateral wall and over the torus tubarius. In contact endoscopy, carcinoma presents (Fig 2,3) with an heterogeneous cellular pattern (anysokariosis, dischromasia). The higher magnification (150x) allows the observation of typical hyperchromatic nucleus with increased and irregular dimensions and shape. Thenuclei/cytoplasm ratio is increased and variable. Sometimes the nucleus appears to fill the entire cell with almost no cytoplasm, forming groups of malignant sincytial cells. Prominent nucleoli and abnormal mitosis can also be seen. The diagnosis of carcinoma also has to take into account vascular parameters. In cases of difficult access to cellular pattern as in some ulcerated lesions, submucosal or hemorrhagic lesions the vascular assessment (Fig.2 c,d) can be extremely important to the diagnosis. The normal vascular architecture is disturbed showing a completely irregular arrangement of the vessels, with an atypical shape, increased diameter, wall ectasies, thrombosis, an irregular kinetic of the blood cells and an extreme vascular fragility. In 39 patients the diagnosis was coincident with histology. In 2 cases of carcinoma the diagnosis could not be achieved by contact endoscopy due to mucosal fragility and bleeding.

Several cellular and vascular parameters could be assessed: nucleus shape, dimensions and staining, nuclei/cytoplasm ratio, the presence of abnormal mitosis and nucleoli. The major vascular characteristics are vascular network regularity, and circulatory kinetics. Regarding these parameters it was possible to establish normal and pathological patterns. Normal pattern (Fig. 1) is characterized by the presence of normal ciliated epithelium especially in the nasopharynx lateral wall. In some regions with heavier exposure to airflow the mucosa may be covered only by squamous epithelium, such as the posterior wall of the nasopharynx. The excretory duct of the glands can also be observed, especially at the lateral wall and over the torus tubarius. In contact endoscopy, carcinoma presents (Fig 2,3) with an heterogeneous cellular pattern (anysokariosis, dischromasia). The higher magnification (150x) allows the observation of typical hyperchromatic nucleus with increased and irregular dimensions and shape. Thenuclei/cytoplasm ratio is increased and variable. Sometimes the nucleus appears to fill the entire cell with almost no cytoplasm, forming groups of malignant sincytial cells. Prominent nucleoli and abnormal mitosis can also be seen. The diagnosis of carcinoma also has to take into account vascular parameters. In cases of difficult access to cellular pattern as in some ulcerated lesions, submucosal or hemorrhagic lesions the vascular assessment (Fig.2 c,d) can be extremely important to the diagnosis. The normal vascular architecture is disturbed showing a completely irregular arrangement of the vessels, with an atypical shape, increased diameter, wall ectasies, thrombosis, an irregular kinetic of the blood cells and an extreme vascular fragility. In 39 patients the diagnosis was coincident with histology. In 2 cases of carcinoma the diagnosis could not be achieved by contact endoscopy due to mucosal fragility and bleeding.

Contact endoscopy is a non-invasive technique performed in vivo and in real time which has a high potential for early diagnosis of nasopharyngeal carcinoma. Contact endoscopyallows the detection of atypical cells and abnormal vascularization areas, helping diagnosis and permitting the selection of suspicious areas to biopsy. In our opinion Contact Endoscopy has also an important role in follow up because can promote, not just a regular macroscopic observation but also an easy and frequent microscopic control allowing an earliest detection of recurrence.

Contact endoscopy is a non-invasive technique performed in vivo and in real time which has a high potential for early diagnosis of nasopharyngeal carcinoma. Contact endoscopyallows the detection of atypical cells and abnormal vascularization areas, helping diagnosis and permitting the selection of suspicious areas to biopsy. In our opinion Contact Endoscopy has also an important role in follow up because can promote, not just a regular macroscopic observation but also an easy and frequent microscopic control allowing an earliest detection of recurrence.

Fig. 1: Contact EndoscopyA- Ciliated epithelium (60X), columnar cells with visible bundles of cilia (lateral wall). B- Gland Ostium, lateral wall of the nasopharynx(150X).

Fig. 1: Contact EndoscopyA- Ciliated epithelium (60X), columnar cells with visible bundles of cilia (lateral wall). B- Gland Ostium, lateral wall of the nasopharynx(150X).

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C- Normal squamous epithelium. A- (60x) Polyhedral cells with a round dark blue nuclei and a light blue cytoplasm compose the squamous epithelium. Note the homogeneity and regularity of the cellular pattern, made by nucleus with regular and similar dimensions, shape, staining, limits and nuclei/cytoplasm ratio.D- The higher magnification (150X) allows a better characterization of the nuclei (dimensions, shape, staining, limits), cytoplasm and nuclei/cytoplasm ratio (posterior wall).

C- Normal squamous epithelium. A- (60x) Polyhedral cells with a round dark blue nuclei and a light blue cytoplasm compose the squamous epithelium. Note the homogeneity and regularity of the cellular pattern, made by nucleus with regular and similar dimensions, shape, staining, limits and nuclei/cytoplasm ratio.D- The higher magnification (150X) allows a better characterization of the nuclei (dimensions, shape, staining, limits), cytoplasm and nuclei/cytoplasm ratio (posterior wall).

C DFig. 2: Nasopharyngeal carcinoma. A-Tumoral cellular pattern (60X), heterogeneity made by diskariosis and dischromasia. B- Nuclear abnormalities in size, shape and colour. The nucleus/cytoplasm ratio is increased and variable. Prominent nucleoli and abnormal mitosis can be observed. C- Carcinoma vascular pattern (60X) the micro vascular architecture is completely disturbed. D-Disturbed architecture of the micro vascular network made by fragile neovessels, abnormal size and shape with ectasis, thrombosis and irregularities of the red blood cells circulation.

Fig. 2: Nasopharyngeal carcinoma. A-Tumoral cellular pattern (60X), heterogeneity made by diskariosis and dischromasia. B- Nuclear abnormalities in size, shape and colour. The nucleus/cytoplasm ratio is increased and variable. Prominent nucleoli and abnormal mitosis can be observed. C- Carcinoma vascular pattern (60X) the micro vascular architecture is completely disturbed. D-Disturbed architecture of the micro vascular network made by fragile neovessels, abnormal size and shape with ectasis, thrombosis and irregularities of the red blood cells circulation.

During follow-up (1998-2007) there were 12 local recurrences in our population (n=62). In 11 cases, Contact Endoscopy allowed a guided biopsy of the lesion and in 1 case, in which there was no clinical suspicion of recurrence, CE showed a suspicious microscopic area that was confirmed as recurrence by histology. In all cases, no second biopsy was needed.Concerning the patients with no recurrence, micro vascular pattern remained abnormal in all cases, although in different degrees. The post-radiotherapy vascular pattern is basically composed by the existence of neo vascularizationobserved as an increase of the density of the vessels which present a distribution less linear then the normal but without wall ectasies or thrombosis as in tumour pattern (Fig 4,5). The circulation of the blood cells is not disturbed and vascular fragility is minimal when compared with carcinoma pattern. The typical cellular pattern in the first 3 years after treatment is characterized by metaplasia and keratosis. In the following years, the period of recovering to normal epithelium, in our population, was variable, and in a few cases (n=8) never achieved.

During follow-up (1998-2007) there were 12 local recurrences in our population (n=62). In 11 cases, Contact Endoscopy allowed a guided biopsy of the lesion and in 1 case, in which there was no clinical suspicion of recurrence, CE showed a suspicious microscopic area that was confirmed as recurrence by histology. In all cases, no second biopsy was needed.Concerning the patients with no recurrence, micro vascular pattern remained abnormal in all cases, although in different degrees. The post-radiotherapy vascular pattern is basically composed by the existence of neo vascularizationobserved as an increase of the density of the vessels which present a distribution less linear then the normal but without wall ectasies or thrombosis as in tumour pattern (Fig 4,5). The circulation of the blood cells is not disturbed and vascular fragility is minimal when compared with carcinoma pattern. The typical cellular pattern in the first 3 years after treatment is characterized by metaplasia and keratosis. In the following years, the period of recovering to normal epithelium, in our population, was variable, and in a few cases (n=8) never achieved.

Fig.5: Post. Radiotherapy vascular pattern: The general architecture is abnormal but regular, with an increased density of the vessels. There are no ectasis, thrombosis or important irregularities of the blood circulation

Fig.5: Post. Radiotherapy vascular pattern: The general architecture is abnormal but regular, with an increased density of the vessels. There are no ectasis, thrombosis or important irregularities of the blood circulation

Fig.4: Nasopharyngeal normal vascular pattern observed by contact endoscopy (no stainning).

Fig.4: Nasopharyngeal normal vascular pattern observed by contact endoscopy (no stainning).

Fig.3: A (60x) and B (150x): Schminck pattern, syncicial formations made by large cells with an increased nuclei and a small cytoplasm C- Islands of atypical cells can be seen in a normal cilliated epithelium. Fig.3: A (60x) and B (150x): Schminck pattern, syncicial formations made by large cells with an increased nuclei and a small cytoplasm C- Islands of atypical cells can be seen in a normal cilliated epithelium.

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