This document presents a case report of a 73-year-old male with a rare small cell neuroendocrine carcinoma arising from the nasal septum. The patient presented with right-sided nasal obstruction, hyponasal speech, and recurrent epistaxis. Imaging showed a mass in the right nasal cavity extending to surrounding areas. The tumour was removed endoscopically and found to be a small cell neuroendocrine carcinoma based on histology and immunohistochemistry. Due to the aggressive nature of this tumour type, the patient received combined chemotherapy and radiation in addition to surgery. At a 10-month follow-up the patient remained free of disease. Small cell neuroendocrine carcinoma of the nasal cavity is an extremely rare and aggressive
Abstract
Background: Olfactory neuroblastoma is a rare malignancy of the nasal cavity.
Methods: We describe a case of radiation-induced olfactory neuroblastoma in a patient with a history of radiation for Graves' ophthalmopathy. We also reviewed the literature and found four other cases of radiation-induced olfactory neuroblastoma reported since 2000, suggesting prior radiotherapy as one risk factor for this disease.
Results: We treated the patient with multimodality treatment consisting of surgery, radiotherapy and chemotherapy (6 cycles of cisplatin/ etoposide). Despite the previously irradiation, treatment was well tolerated without excessive short or long term radiation toxicity. The patient remains in long term remission with no evidence of loco-regional recurrence or systemic metastasis after 12 years of follow-up.
Conclusions: Prior radiotherapy appears to be a risk factor in a handful of cases of this rare malignancy. Although the literature is limited for radiation-related olfactory neuroblastoma, outcomes appear generally poorer for this group but highly variable. With careful patient selection, aggressive multi-modality therapy including post-operative radiotherapy may be feasible.
Abstract
Background: Olfactory neuroblastoma is a rare malignancy of the nasal cavity.
Methods: We describe a case of radiation-induced olfactory neuroblastoma in a patient with a history of radiation for Graves' ophthalmopathy. We also reviewed the literature and found four other cases of radiation-induced olfactory neuroblastoma reported since 2000, suggesting prior radiotherapy as one risk factor for this disease.
Results: We treated the patient with multimodality treatment consisting of surgery, radiotherapy and chemotherapy (6 cycles of cisplatin/ etoposide). Despite the previously irradiation, treatment was well tolerated without excessive short or long term radiation toxicity. The patient remains in long term remission with no evidence of loco-regional recurrence or systemic metastasis after 12 years of follow-up.
Conclusions: Prior radiotherapy appears to be a risk factor in a handful of cases of this rare malignancy. Although the literature is limited for radiation-related olfactory neuroblastoma, outcomes appear generally poorer for this group but highly variable. With careful patient selection, aggressive multi-modality therapy including post-operative radiotherapy may be feasible.
A Sinister Cause for Recurrent Syncope: Metastatic Parapharyngeal Space Tumorasclepiuspdfs
Introduction: Metastasis from oropharyngeal squamous cell carcinoma can occur in the parapharyngeal space (PPS). Syncope is an uncommon presentation of parapharyngeal space tumors. This can occur because of the extrinsic compression or infiltration of the carotid sinus or glossopharyngeal nerve. Aim: This study aims to raise awareness about this rare condition of recurrent syncope secondary to PPS tumor. We aim to share our knowledge of dealing with such a case focusing on clinical presentation, investigations, and multidisciplinary approach to management. Case Presentation: We present a case of a 68-year-old Caucasian male who was admitted to a medical ward with recurrent episodes of syncope. The underlying cause was found to be the extrinsic compression of the left carotid artery from a PPS tumor. The CT scan of the neck raised a suspicion of the left PPS malignancy. It was confirmed on fine-needle aspiration cytology to be a metastatic poorly differentiated squamous cell carcinoma. The patient was managed with best supportive care. Conclusion: In a patient presenting with recurrent syncope, PPS tumor-related carotid sinus or glossopharyngeal nerve involvement should be considered. In our patient, the best supportive care was chosen. However, in select patients, cardiac pacing may be required to prevent recurrent syncope so that curative intent treatment can be started.
Porocarcinoma of the nose- reconstructed with seagull flap
Authors:Balasubramaniam, Ramanandham, Pradeep, Sivakumar, Kalpa Pandya
Int J Biol Med Res. 2024; 15(1): 7760-7763
https://www.biomedscidirect.com/2847/porocarcinoma-of-the-nose-reconstructed-with-seagull-flap
Abstract: Of all the cutaneous tumours, the reported incidence of porocarcinoma is as low as 0.005-0.01%. Very few cases of porocarcinoma of the nose have been described in English literature. Median forehead flap, also known as seagull flap is an excellent reconstruction modality for the nasal defect. We describe here an interesting case of porocarcinoma of the dorsum of the nose which was reconstructed in the first stage using a seagull flap providing the patient with a pleasing nasal profile.
Porocarcinoma of the nose- reconstructed with seagull flap
Authors:Balasubramaniam, Ramanandham, Pradeep, Sivakumar, Kalpa Pandya
Int J Biol Med Res. 2024; 15(1): 7760-7763
https://www.biomedscidirect.com/2847/porocarcinoma-of-the-nose-reconstructed-with-seagull-flap
Metastasis of Neck Node with Unknown Primary Himanshu Soni
carcinoma of unknown Primary accounts for 5%-10% of all tumours. 3–5% of head and neck cancers presented as cervical squamous cell carcinomas of unknown primary
Skull Metastasis From Papillary Thyroid Carcinoma : Case Report and Literatur...komalicarol
Although papillary thyroid carcinoma is a relatively common form of malignancy, metastatic spread to the skull
is exceptional. Here, we report a case of papillary thyroid carcinoma revealed by frontal skull metastasis.
Skull Metastasis from Papillary Thyroid Carcinoma: Case Report and Literature...semualkaira
Although papillary thyroid carcinoma is a relatively common form of malignancy, metastatic spread to the skull
is exceptional. Here, we report a case of papillary thyroid carcinoma revealed by frontal skull metastasis.
Pleomorphic adenoma of the buccal salivary glandPrashant Munde
Salivary gland swellings can result from tumors, an inflammatory process
or cysts. It can sometimes be difficult to establish; whether pathology arises
from the salivary gland itself or adjacent structures. Neoplasms of the salivary
glands account for less than 1% of all tumors, 3–5% of all head and neck
tumors and benign pleomorphic adenoma (PA) of minor salivary glands arising
de novo is very rare. PA is the most common tumor of the salivary gland. While
the majority arises from the parotid gland, only a small percentage arises from
the buccal minor salivary gland. A case of PA of minor salivary glands in the
buccal mucosa in a 70‑year‑old female is discussed. It includes review of
literature, clinical features, histopathology, radiological findings and treatment
of the tumor; with emphasis on diagnosis.
Reversible hearing loss after 3D video-assisted marsupialization of several ...Michel Triffaux
Case report
Very few pediatric cases of arachnoid cyst of ponto-cerebellar angle are desribed in the literature. Only 4 are
described with hearing loss. It is a pathology which poses especially a problem of early diagnosis. In this paper
we describe the management of a 16-year-old patient with an arachnoid cyst of the cerebellopontine angle with
an isolated auditory deficit that was treated surgically. The follow up was marked by a Full recovery of hearing
after surgical treatment. Arachnoid cyst of the cerebellopontine angle is rare in the pediatric population, early
surgical management help to increase the chances of recovery.
Cervical Sympathetic chain ganglioneuroma : case report and review of literatureiosrphr_editor
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
Laryngeal NK/T-cell Lymphoma: A Report of a Rare Case with Unusual Locationasclepiuspdfs
Extranodal NK/T-cell lymphoma (ENKL) is a rare type of non-Hodgkin lymphoma, and involvement of the larynx is an even rarer entity. We present a case of 23-year-old woman presenting with several weeks of respiratory distress and hoarseness. Bronchoscopy showed severely stenosed glottis and subglottis with multiple 1–2 mm pink-colored nodules over the false vocal cords and vallecula. Histology revealed unremarkable squamous mucosa with underlying diffuse proliferation of atypical lymphoid cells in a necrotic background. The atypical lymphoid cells were positive for CD2, CD3, CD56, CD30, and EBER with high Ki-67 proliferative activity. The overall findings were consistent with extranodal NK/T cell lymphoma of the larynx. The diagnosis of ENKL can be challenging due to the non-specific clinical presentation and relatively unusual localization. In the setting of inflammation of mucosa, neoplastic NK/T cells may be masked by secondary reactive inflammatory cells or intense necrosis. Therefore, a diagnosis of ENKL is frequently dependent on a series of immunohistochemical and molecular studies.
EPIDEMIOLOGY AND BIOSTATISTICS (case report)Farah Adriana
In epidemiology, case reports are defined as singular reports on one individual patient. In our presentation, we explain about a case report titled Schwannoma with Chondroid Metaplasia of the External Auditory Canal.
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
An Unusual Presentation of Squamous Cell Carcinoma of Bilateral Temporal Bones by Titas Kar in Experiments in Rhinology & Otolaryngology
Squamous cell carcinoma of temporal bone is a rare entity, comprising of a very small percentage of all head neck tumours, mostly occurring in aged population. Bilateral presentation of tumours in both temporal bones is extremely rare and only a few cases have been reported. We report a case of bilateral squamous cell carcinoma of both temporal bones in a young adult male patient who presented very late.
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Similar to Carcinoma neuroendocrino del setto un rarissimo tumore nasale (20)
Artroplastica totale del ginocchio per il trattamento dell'osteoartrite del g...
Carcinoma neuroendocrino del setto un rarissimo tumore nasale
1. ACTA oTorhinolAryngologiCA iTAliCA 2010;30:EPUB December 29, 2010
Case report
Neuroendocrine carcinoma arising from
the septum. A very rare nasal tumour
Carcinoma neuroendocrino del setto: un rarissimo tumore nasale
E. Iacovou, a. chrysovErgIs, a. ElEfthErIadou1, I. yIotakIs, d. kandIloros
department of otolaryngology, hippokration hospital, university of athens; 1 department of otolaryngology,
general hospital of rethymnon, greece
SUmmAry
The case is presented of a 73-year-old male with a history of right-sided nasal obstruction, hyponasal speech and three episodes of recur-
rent epistaxis. on examination, there was a tumour in the right nasal cavity. Computed tomography showed a mass in the right nasal cavity
extending to the right maxillary sinus, ethmoidal cells and right sphenoid sinus. The patient underwent a functional endoscopic removal
of the tumour. Biopsy revealed a small cell neuroendocrine carcinoma. This is an extremely rare tumour of the nasal cavity and sinuses.
Because of the aggressive behaviour of this tumour, he was also treated with combined chemotherapy and radiation. Ten months later, he
remains free of disease.
KEy worDS: Nasal cavity • Sinuses • Malignant tumours • Small cell neuroendocrine carcinoma
riASSUnTo
Viene presentato il caso di un uomo di 73 anni con una storia di ostruzione nasale destra persistente, rinolalia chiusa, e tre episodi di
epistassi ricorrente. All’esame obiettivo, era presente una neoformazione della fossa nasale destra. La tomografia computerizzata ha
B
evidenziato la presenza di una massa della cavità nasale destra estesa al seno mascellare, alle cellule etmoidali e al seno sferoidale omola-
terali. Il paziente è stato sottoposto a rimozione della massa nasale per via endoscopica. L’esame istologico ha evidenziato un carcinoma
neuroendocrino a piccole cellule, che rappresenta un tumore estremamente raro delle fosse nasali. A causa del comportamento aggressivo
di tale tumore, è stato necessario eseguire un trattamento combinato radio-chemioterapico. Il paziente è libero da malattia a dieci mesi
dall’esordio.
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PArolE ChiAvE: Fosse nasali • Seni paranasali • Tumori maligni • Carcinoma neuroendocrino a piccole cellule
Acta Otorhinolaryngol Ital 2010;30:EPUB December 29, 2010
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Introduction to their behavioural differences in relation to metastasis
and local spread. Also SnEC shows similar clinical and
Primary small cell neuroendocrine carcinoma (SnEC) of morphological features to olfactory neuroblastoma (onB)
the nasal cavity and sinuses is an extremely rare tumour and and must also be distinguished from this tumour.
difficult to diagnose by conventional methods of histologi- The diagnosis of SnEC of the head and neck region is
cal examination. not many cases are reported in the litera- based on the recognition of the typical neuroendocrine ar-
ture and thus analysis of the cases is not an easy procedure. chitecture and morphology and on the immunohistochem-
ray Chowdhuri first described SnEC as a differentiated ical confirmation of neuroendocrine differentiation.
histological entity in the paranasal sinuses in 1965 1. in the world health organization (who) classification
By 2000, 154 incident cases of primary SnEC (interna- of endocrine tumours, SnECs are subdivided into well-
tional Statistical Classification of Diseases and related differentiated tumours, well-differentiated carcinomas,
health Problems) with histological confirmation had been and poorly differentiated carcinomas depending on their
identified. A crude incidence rate of 0.73 SnEC cases per histopathological and biological characteristics.
100,000 inhabitants was estimated using the 2001 Census no specific treatment exists, at present, for neuroendo-
data for the denominator (1.19 per 100,000 among men crine tumours of the head and neck region, and despite
and 0.30 per 100,000 among women). the improved histological classification they are mostly
Although these tumours exhibit morphological features treated as conventional squamous cell carcinomas or, less
similar to those of anaplastic small cell carcinomas of the often, as small cell carcinomas of the lung 2.
lung and, at first, were thought to arise from the lung, they in this article, a rare case of SnEC, arising from the nasal
are now considered to be completely different entities due septum, and its management are presented.
1
2. E. iacovou et al.
Case report
A 73-year-old man presented at the EnT department of
hippokration general hospital with a long-standing his-
tory of right-sided nasal obstruction, hyponasal speech
and three episodes of recurrent epistaxis.
Physical examination revealed an exophytic tumour mass of
the right nasal cavity. Colour of the mucosa over the growth
varied from white to pink. There were no obvious, palpa-
tive lymph nodes and no distant metastasis was found.
The computed tomography (CT) scan that was carried out
showed a mass of the right nasal cavity extending to the right
maxillary sinus, ethmoidal cells and right sphenoid sinus.
general examination revealed that the patient was mod-
erately built and nourished, with normal gait and satisfac-
tory vital signs. Fig. 2. Positive synaptophysin immunoreactions in neoplastic cells.
From his past medical history, he had hypertension and
diabetes mellitus. The patient denied smoking, drinking immunophenotypic examination showed staining for
and exposure to radiation or environmental irritants. synaptophysin (Fig. 2), CD56 and Ki67 (+90%) (Fig. 3),
Functional endoscopic sinus surgery was used in order to while no staining appeared for cytokeratin (CK) AE1/
remove the mass. Upon surgery, a large tumour of the right AE3, carcinoembryonic antigen (CEA), CK34bE12, leu-
B
nasal cavity was revealed adjacent to the posterior part of
the nasal septum and medial wall of the right maxillary si-
nus, invading the middle nasal turbinate. The tumour was
kocyte (lCA) or chromogranin. immunohistochemical
reaction for thyroid transcription factor-1 (TTF-1) was
not necessary because of thorough examination of thyroid
translucent and polypoid in structure (Fig. 1). During the and lung by CT scan.
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operation, repeated biopsies were taken and were found The post-operative course was uneventful. Due to the ag-
to be positive for malignancy. Debulking of the tumour gressive behaviour of this tumour, combined chemothera-
carried out in order to define the site of origin, showed py and radiation were also performed. Close follow-up 10
that the tumour arose from the posterior-superior part of months after treatment, through endoscopic examination
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the septum. Therefore, complete excision of the mass was did not reveal any sign of local recurrence.
performed and intra-operative biopsies revealed that the
margins of the excision were without signs of disease.
The final histological examination showed a small cell Discussion
neuroendocrine carcinoma with poor differentiation. The Small cell carcinoma is a very rare and aggressive tumour
tumour was extremely cellular and composed of sheets or of the sinonasal tract. histologically, it is undistinguishable
nests of small cells. The shape and size of cells were simi- from the anaplastic small cell carcinoma of the lung. They
lar and regular with small amounts of cytoplasm, round both exhibit similar morphological features, as described
nuclei, and high mitotic rate. vascular structures and foci by Koss et al. 3. They are both solid tumours composed of
of necrosis were also present. sheets, nests and cords of small to intermediate-sized cells
Fig. 1. Intra-operative endoscopic image of the tumour. Fig. 3. Positive Ki67 immunoreaction in neoplastic cells (90%).
2
3. neuroendocrine carcinoma arising from the septum
with high nucleo/cytoplasmic ratio, hyperchromatic nuclei gesting loco-regional invasion have been reported, such
with absent or occasional basophilic nucleoli. They also as local pain and anosmia. Cervical node metastasis has
have a high mitotic rate with frequent abnormal mitotic also been described 10.
figures, necrosis and haemorrhage. They are both char- radiographically, the tumour always involves the nasal cav-
acterized by the presence of electron-dense, membrane ity and multiple paranasal sinuses 11. in our case, the mass
bound, neurosecretory granules 4. Differential diagnosis of the right nasal cavity extended to the right maxillary si-
must include other malignant tumours such as lymphoma, nus, ethmoidal cells and right sphenoid sinus. CT scan can
rhabdomyosarcoma, undifferentiated nasopharyngeal car- help to diagnose the malignant nature of the tumour, as it
cinoma, and undifferentiated sinonasal carcinoma. can reveal the presence of an osteolytic lesion. magnetic
of great importance is to distinguish SnEC from onB. resonance imaging (mri) with T1, T2 using i.v. gadolinium
Their relationship remains confusing and controversial. improves differentiation between inflammatory reaction, tu-
hyams et al. 5 proposed a histological grading for onBs mour and liquid retention; mri also identifies the anatomi-
based on their degree of cellular and architectural dif- cal relationship between the tumour and the meninges.
ferentiation. in most cases, SnEC should be readily dis- little is known about the management of these tumours.
tinguished from low-grade onB. Sinonasal SnEC lacks Different therapeutic approaches have been used over
lobular architecture, fibrovascular septa, neurofibrillary time. in the 1980s, surgery followed by radiotherapy was
stroma, and does not contain neural or olfactory rosettes. preferred by the Authors of the largest study 10 and has also
The anaplastic cells of SnEC have neglible cytoplasm, been recommended more recently 12. in the late 1990s, the
high nucleo/cytoplasmic ratio, round or oval dense hy- combination of chemotherapy and radiotherapy, with or
perchromatic nuclei, numerous mitotic figures, and apop- without surgery was shown to have promising results, for
B
totic cells accompanied by extensive areas of necrosis.
in contrast, the cells of low-grade onBs show moderate
amounts of cytoplasm, round nuclei, low nucleo/cytoplas-
mic ratio, and low mitotic activity. necrosis is uncommon
neuroblastoma and SnECs of the nasal and paranasal cav-
ities. A retrospective study by E. Babin et al. 13 suggests
the use of the same protocol that was proposed in the 35th
Congress of the French Cervico-facial Carginological So-
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in low-grade onBs 6. high-grade onBs 5 6 show marked ciety (november 2003) and is presented in Figure 4.
nuclear anaplasia and high mitotic activity accompanied Although it has no significant effect on tumour growth, bi-
by prominent necrosis. They also retain the lobular archi- otherapy with somatostatin analogues and/or interferon-α
tecture of well-differentiated tumours, and foci of neuro- is recommended both for well-differentiated and function-
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fibrillary stroma with rosette formation are usually identi- ing tumours. on the other hand, chemotherapy, usually
fied 7. These findings are absent in SnEC. Furthermore, with cisplatin and etoposide is effective in the treatment
prominent nucleoli are not found in SnEC. of tumours with poor differentiation grade and high pro-
immunohistochemistry has not been consistently used to
distinguish these two entities. SnEC lacks the S-100-pos-
SNEC of nasal and paranasal cavity
itive cells seen at the periphery of the cell nests of onB
and is negative for nF 6. SnEC usually shows staining
with AE1:AE3 or Cam 5.2 antibodies, which is uncom- Chemotherapy CE = 2 cycles separated by 15-day interval
Cisplatin 33 mg/m2/j for 3 days
mon in onB 6 7. Etoposide 100 mg/m2/j for 3 days
So far, no study appears to have been presented specifically
investigating the immunohistochemical features of these
tumours. Strong staining with synaptophysin and CD56 Evaluation of efficiency by imagery
(Response is the reduction of tumour volume compared with
nerve cell adhesion molecule has been reported and weak pre-treatment volume)
staining with chromogranin A and CAm 5.2/AE-1 as ap-
pears also in our case 8. Perez-ordonez et al. showed strong
Response > 50% Response < 50% with tumour
staining for CAm 5.2 or AE1:AE3 in a series of 6 patients. resection possible or Response < 50%
Expression of neuroendocrine markers, such as nSE, syn- with tumour resection impossible
aptophysin, and chromogranin, although positive in all
cases, was variable and may be weak with individual mark- Surgery on T and N if N > 0
ers, particularly synaptophysin 9. This pattern of staining is
similar to that found in pulmonary small cell carcinoma. Radiotherapy 68 Gy Radiotherapy 68 Gy
Clinical manifestations and behaviour of small cell neu-
roendocrine carcinoma do not differ from other tumours of Evaluation of efficiency by imagery Evaluation of efficiency by imagery
the sinonasal tract. it usually presents with epistaxis, nasal
obstruction, followed by ophthalmic signs (exophthalmos,
Chemotherapy CE Chemotherapy CE
visual acuity trouble and limitation of eye mobility) due
to orbital involvement. less frequently, other signs sug- Fig. 4. Protocol of the French Cervico-facial Carcinological Society.
3
4. E. iacovou et al.
liferation rate. Currently, the most used therapeutic op- tic factors, such as invasion of the lamina cribosa, have been
tions are: surgery, radiotherapy and chemotherapy as we discussed 10. The ectopic hormone syndrome is a predictor of
performed in our case, endoscopic removal of the tumour bad prognosis and increased mortality of pulmonary SnEC
with margins free of disease followed by adjuvant radio- patients because of the higher risk of cerebral metastasis. The
therapy and chemotherapy. endocrine syndrome also seems to negatively affect the prog-
novel therapies, new pharmacological formulations and nosis in cases of head and neck SnEC 17. other factors, such
more selective somatostatin analogues are now under clinical as size of the tumour and number of mitoses, show no cor-
investigation for the treatment of neuroendocrine tumours 14. relation with recurrence, metastasis or survival 10. Because of
Extra-pulmonary small cell carcinoma is usually a fatal dis- the small number of cases in the literature, no conclusions or
ease with a 13% 5-year survival rate 15. in the same retrospec- therapeutic recommendations can be made. however, there
tive study of 20 patients 13, recurrences and metastasis have is the need for a multidisciplinary treatment approach com-
been reported to occur after three years in 70% of the patients bining surgery, radiotherapy and chemotherapy.
and 4 out of 5 patients in the combined experience of Koss et in conclusion, sinonasal small cell neuroendocrine carci-
al. 3 and weiss et al. 16 died of disease after a follow-up rang- noma is a very rare neoplasm with an aggressive clinical
ing from 8 months to 2 years. 80% of patients suffering from behaviour and poor prognosis. it exhibits similar mor-
relapses or metastasis within the first two years. The median phological and immunohistochemical features to those of
survival time was between two and three years. Common anaplastic small cell carcinoma of the lung. it must be
metastatic locations are brain, lungs, bones and skin. Four out distinguished from olfactory neuroblastoma. The use of
of 6 patients, in the above-mentioned series of Perez-ordonez
B current diagnostic ancillary techniques such as, electron
et al. 9 had recurrent disease or died after a mean follow-up of microscopy and immunohistochemistry can be helpful in
37 months. in a study carried out by the mayo Clinic 15, the studying the morphological and biological characteristics
median overall survival of 14 patients with primary head and of the tumour. There are no treatment protocols. however,
neck tumours was only 14.5 months. Unfavourable prognos- a combined therapy is advantageous.
U
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5
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received: november 9, 2009 - Accepted: march 14, 2010
Address for correspondence: Anna Eleftheriadou, mD PhD, Po
Box 269, 74100, rethymnon, Kreta, greece. E-mail: aegika@ya-
hoo.gr
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