Caratterizzazione dei melanomi mucosi: studio del microambiente immunologico e del profilo molecolare per sviluppare terapie mirate

I melanomi mucosi (MM) sono neoplasie rare che originano dai melanociti delle mucose con una patogenesi non correlata alla fotoesposizione solare. Il distretto testa-collo, in particolare il cavo orale e il tratto sinonasale, rappresentano la sede pi\uf9 comune di insorgenza. La prognosi di questa neoplasia \ue8 infausta ed i motivi che possano spiegare questa aggressivit\ue0 sono ancora sconosciuti e richiedono studi di biologia molecolare specifici. \uc8 stata condotta un\u2019analisi retrospettiva su 48 pazienti affetti da MM sinonasale, trattati in due centri italiani di riferimento dal 2000 al 2017. I dati clinici e i fattori prognostici sono stati analizzati. Materiale tissutale adeguato per ogni singolo caso \ue8 stato selezionato negli archivi. \uc8 stata condotta un\u2019analisi immunoistochimica per analizzare il microambiente immunologico dei casi tumorali, utilizzando anticorpi specifici (CD45, CD8, CD3, CD163, CD20, CD66b, BDCA2, CD56, CD274/PD-L1, HLA-DP, DQ, DR. The PD-L1, \u3b2-catenin, e PTEN). Sono state generate delle linee di coltura cellulare e sono state identificate cellule staminali tumorali specifiche. L\u2019analisi mutazionale genetica \ue8 stata condotta utilizzando il sistema Sequenom MassArray ed il sistema il targeted next generation sequencing (NGS). Delezioni/duplicazioni delle regioni cromosomiche 1p, 3, 6 e 8 sono state ricercate utilizzando le sonde SALSA MLPA (Multiplex Ligation-dependent Probe Amplification) P027 Uveal Melanoma. I risultati del presente studio hanno dimostrato che questa neoplasia pu\uf2 essere considerata come un \u201cnoninflammed tumor\u201d con un microambiente immunologico caratterizzato da scarso infiltrato di cellule CD45, CD8 e CD3. Inoltre, l\u2019espressione di PDL-1 \ue8 risultata sempre assente. Questo ambiente immunologico \u201cfreddo\u201d potrebbe spiegare l\u2019efficacia limitata dei protocolli immunoterapici con doppio inibitore di checkpoint immunitario (anti-PD-1/e anti-CTLA4) che sono stati impiegati negli ultimi anni. L\u2019analisi mutazionale ha evidenziato la presenza di mutazioni somatiche nei geni NRAS, KRAS e KIT solo in 14/31 casi. In particolare, non sono state osservate mutazioni di BRAF in nessuno dei casi analizzati, cosa che \ue8 completamente in contrasto con il profilo genetico che classicamente caratterizza i melanomi cutanei. Dal punto di vista genomico, \ue8 stato possibile descrivere un profilo muticromosomico specifico di alterazioni nel numero di copie, caratterizzato da \u201closs\u201d del cromosoma 3p-q, 1p e 8p. Questo profilo, quando presente, \ue8 in grado di identificare un sottogruppo di pazienti caratterizzato da prognosi infausta ed elevato rischio di metastatizzazione precoce. Sebbene questo profilo di alterazioni genomiche non abbia una ricaduta terapeutica specifica al momento attuale, questo risultato potrebbe essere molto utile per aiutare nell\u2019identificazione dei pazienti a prognosi peggiore ed elevato rischio di metastasi che potrebbero essere candidati a forme di trattamento neoadiuvante e/o adiuvante pi\uf9 intensificate. In conclusione, questo studio dimostra come il MM rappresenti un\u2019entit\ue0 tumorale completamente diversa dal melanoma cutaneo dal punto di vista della patogenesi, dell\u2019epidemiologia, del decorso clinico e del profilo genetico-molecolare. Per questo motivo \ue8 importante inquadrare questi pazienti in modo specifico per proporre loro forme di trattamento mirato. A questo proposito, terapie target molecolare con MEK-inhibitors, PI3K-AKT-mTOR inhibitors, CDK4/6 inhibitors, KRASG12C inhibitors, tyrosine kinase inhibitors (Imatinib, Nilotinib, Avapritinib), e multikinase inhibitors (Regorafenib) potrebbero essere proposte per questi pazienti, in base al loro stato mutazionale. Inoltre, trattamenti immunoterapici combinati con inibitori di doppio check point immunitario (anti-CTLA-4 e anti-PD-1) potrebbero essere usati per questi pazienti sia nel setting neoadiuvante che come forma di trattamento adiuvante.Mucosal melanoma (MM) is a highly aggressive and rare form of melanoma arising from mucosal melanocytes with a pathogenesis unrelated to sun exposure. Head and neck, in particular the oral cavity and the sinonasal tract (SN), represent the most common MM sites. MM outcome is very poor and the reasons behind this aggressive clinical behavior are only partially understood. A retrospective review of 48 patients treated for sinonasal tract mucosal melanoma in two Italian tertiary care referral centres (University of Insubria, Varese, and University of Brescia) from 2000 to 2017 was performed. Clinical data, survival outcomes and prognostic factors have been fully analyzed. Tissue blocks were retrieved from Institutional archives. Immunohistochemical evaluation of the immunological tumor microenvironment was performed by testing different antibodies, such as CD45, CD8, CD3, CD163, CD20, CD66b, BDCA2, CD56, CD274/PD-L1, HLA-DP, DQ, DR. The PD-L1, \u3b2-catenin, and PTEN immunostaining were also performed. Cell lines were generated and cancer stem cells were identified. Gene mutation analysis was performed both using Sequenom MassArray system and targeted next generation sequencing (NGS) analysis. Deletions/duplications analysis of regions in chromosomes 1p, 3, 6 and 8 was performed using SALSA MLPA (Multiplex Ligation-dependent Probe Amplification) probemix P027 Uveal Melanoma. We found that MM is a noninflammed tumor with an immune contexture poor of CD45, CD8 and CD3 positive cells. In addition to the scarce immune infiltration, PDL-1 expression is almost absent in MM. This \u201ccold\u201d immune contexture may explain the limited efficacy of immunotherapy, even in the form of double immune checkpoint inhibitor anti-PD-1/anti-CTLA4, which has been observed in MM patients. When considering the molecular landscape of MM, we found somatic mutations only in 14/31 cases, mainly involving NRAS, KRAS and KIT. No BRAF mutations were found, in contrast with the genetic fingerprint of cutaneous melanoma. From genomic viewpoint, we described a multichromosome copy number aberration signature characterized by chromosome 3p-q losses together with 1p loss and 8p loss, which is associated with poor prognosis and early systemic metastasization risk. Although this genomic signature at present does not have a direct therapeutic implication, it may be useful in identifying patients at high risk for early dissemination of disease and poor prognosis, who might benefit from intensification of systemic treatments in neoadjuvant or adjuvant setting. In conclusion, we found that MM should be considered as clinical entity significantly different from cutaneous melanoma with regard to its pathogenesis, epidemiology, clinical characteristics and genetic-molecular fingerprint. As such, it is important to evaluate these patients as a separate subset in order to give patients realistic expectations for their disease course and to propose them specific forms of treatment. In this regards, in well selected cases, target-therapies with MEK-inhibitors, PI3K-AKT-mTOR inhibitors, CDK4/6 inhibitors, KRASG12C inhibitors, tyrosine kinase inhibitors (Imatinib, Nilotinib, Avapritinib), and multikinase inhibitors (Regorafenib) should be considered, based on the molecular profile. In addition, immunotherapy with double immune check points inhibitors (anti-CTLA-4 and anti-PD-1) might be used in selected cases both in neoadjuvant and adjuvant setting

Palatovaginal (pharyngeal) artery: clinical implication and surgical experience

The palatovaginal or pharyngeal artery is a small branch of the internal maxillary artery supplying the nasopharynx. Bleeding from this artery is exceptional and only one case of traumatic epistaxis from this artery has been reported previously. We report a case of a 66-year-old male presenting with right recurrent posterior epistaxis. Endoscopic dissection of the pterygopalatine fossa and direct visualization of the palatosphenoidal canal permitted to identify the origin of bleeding, and coagulation of the pharyngeal artery solved the epistaxis. Although rare, intractable posterior epistaxis may arise from the pharyngeal artery. The anatomical knowledge of this artery and of the palatosphenoidal canal is of outmost importance in endoscopic transpterygoid and nasopharyngeal procedures, to identify the vidian canal, evaluate nasopharyngeal cancer spread in the pterygopalatine fossa, reduce bleeding during surgery of the nasopharynx, and harvest adequately the pedicle of the nasoseptal flap

Sinonasal mucosal melanoma: Molecular profile and therapeutic implications from a series of 32 cases

BACKGROUND: Primary sinonasal mucosal melanomas are aggressive tumors with a poor clinical control by current treatments, raising the urgent need of novel strategies. METHODS: By fluorescence in situ hybridization (FISH), direct sequencing, and immunohistochemistry, we investigate the spectrum of molecular abnormalities in a cohort of 32 cases of primary sinonasal mucosal melanomas. RESULTS: We found that all primary sinonasal mucosal melanomas lack BRAF V600E mutation; in addition, they are characterized by somatic mutations of NRAS (22%) and KIT (12.5%), together with amplification of RREB1 (100%) and loss of MYB (76%). The large majority of cases showed KIT protein expression (96.9%). Among tumor suppressor genes, primary sinonasal mucosal melanomas showed loss of PTEN (48.1%) and p16/INK4a (55.2%). All tested cases showed expression of pAkt and pErk, suggesting a combined activation of PI3K/Akt and RAS-mitogen-activated protein kinase (MAPK) pathways. CONCLUSIONS: This molecular fingerprint strongly argues against the clinical efficacy of BRAF-inhibitors, but could candidate primary sinonasal mucosal melanomas to therapeutic strategies targeting RAS and KIT mutations or inhibiting PI3K-Akt-mTOR pathway

Social Perception of Reconstruction following Orbital Exenteration

Background: Orbital exenteration, the removal of the entire globe, eyelids, and orbital content, is indicated in extensive neoplastic disease involving the orbital region. Although a functional reconstruction of orbital exenteration defects is mandatory, aesthetic concerns need to be considered. Facial disfigurement following reconstructive surgery often leads to great discomfort and social retirement, which can limit social interaction. The aim of this study was to explore how the society perceives the aspect of patients who underwent orbital exenteration and subsequent reconstruction, comparing two different types of reconstruction: standard anterolateral thigh (ALT) or "sandwich" fascial ALT (SALT) free flap. Methods: An online survey was created based on four questions regarding the perception of reconstruction (discomfort at looking at that patient, perception of unhealthiness, hypothesis of social life impairment, etc); five possible answers were provided, ranging from "completely" to "not at all." The survey was administered to the general population and to medical students. Results: In total, 255 people participated to the survey (130 medical students and 125 people of the general population); a total of 245 surveys were considered eligible (10 were incomplete and then discharged). Statistical significance was found (P < 0.001) regarding the better overall appearance of the SALT group over the ALT one. Conclusions: After analysis, the surgical outcome after SALT reconstruction has been found to be less disruptive in both groups, due to a reduced scar burden and a more pleasant orbital pocket. Our results encourage more research in the field of postexenteration reconstruction to achieve more aesthetic and social acceptability

Emergency endovascular treatment of cavernous internal carotid artery acute bleeding with flow diverter stent: a single-center experience

Background and objective To describe our single-center experience in the treatment of cavernous internal carotid artery (ICA) acute bleeding with flow diverter stent (FDS), as a single endovascular procedure or combined with an endoscopic endonasal approach. Methods We analyze a case series of 5 patients with cavernous ICA acute bleeding, i.e., 3 iatrogenic, 1 post-traumatic, and 1 erosive neoplastic. After an immediate nasal packing to temporarily bleeding control, patients underwent digital subtraction angiography (DSA) to identify the site of the ICA injury. A concomitant balloon occlusion test (BOT) was performed, to exclude post-occlusive ischemic neurological damage. An FDS was placed with parallel intravenous infusion of abciximab in 3 cases and tirofiban in 2 cases. In two patients, an innovative "sandwich technique" combining the endovascular reconstruction with an extracranial intrasphenoidal cavernous ICA resurfacing with autologous flaps or grafts by endoscopic endonasal approach was performed. Results No patient had periprocedural ischemic-hemorrhagic complications. All patients had a regular clinical evolution, without general complications or new onset of focal neurological deficits. No further bleeding occurred in 3 patients, while 2 cases experienced a mild rebleeding in a period ranging from 5 to 15 days after the endovascular procedure. In these two cases, we proceeded with an endoscopic endonasal procedure to resurface the exposed ICA wall in the sphenoid sinus. Conclusions Although the treatment of choice for cavernous ICA acute bleeding remains the occlusion of the injured vessel, in cases of poor hemodynamic compensation at the BTO, the endovascular FDS emergency placement can be effective. A combined endoscopic endonasal technique to support the extracranial side of the vessel using autologous flaps or grafts can be performed to prevent the risk of rebleeding

Endoscopic-assisted transorbital surgery: Where do we stand on the scott’s parabola? personal considerations after a 10-year experience

Transorbital approaches are genuinely versatile surgical routes which show interesting potentials in skull base surgery. Given their "new" trajectory, they can be a very useful adjunct to traditional routes, even being a valid alternative to them in some cases, and add valuable opportunities in selected patients. Indications are constantly expanding, and currently include selected intraorbital, skull base and even intra-axial lesions, both benign and malignant. Given their relatively recent development and thus unfamiliarity among the skull base community, achieving adequate proficiency needs not only a personalized training and knowledge but also, above all, an adequate case volume and a dedicated setting. Current, but mostly future, applications should be selected by genetic, omics and biological features and applied in the context of a truly multidisciplinary environment

Impact of the COVID-19 pandemic on paediatric otolaryngology: a nationwide study

Objective: The COVID-19 pandemic profoundly modified the work routine in healthcare; however, its impact on the field of paediatric otorhinolaryngology (ORL) has been rarely investigated. The aim of this study was to assess the impact of COVID-19 on paediatric ORL. Methods: A questionnaire was developed by the Young Otolaryngologists of the Italian Society of ORL-Head and Neck Surgery (GOS). The questionnaire consisted of 26 questions related to workplace and personal paediatric ORL activities. The link was advertised on the official social media platforms and sent by e-mail to 469 Italian otolaryngologists. Results: The questionnaire was completed by 118 responders. During the pandemic, the main reduction was observed for surgical activity (78.8%), followed by outpatient service (16.9%). The conditions that were mostly impacted by a delayed diagnosis were respiratory infections in 45.8% of cases and sensorineural hearing loss in 37.3% of cases. Conclusions: Paediatric ORL was highly impacted by the COVID-19 pandemic, with a significant reduction of surgical and outpatient activities and a delay in time-sensitive diagnosis. Therefore, the implementation of new strategies, such as telemedicine, is recommended

Nasoseptal flap with extended pedicle dissection based on the maxillary artery: Clinical series of 55 cases

: Nasoseptal flap with extended pedicle dissection is a low morbidity and high success rate flap. It is a flap that can be applied to reconstruct a wide range of ipsilateral skull base defects

A functional gene expression analysis in epithelial sinonasal cancer: Biology and clinical relevance behind three histological subtypes

Epithelial sinonasal cancers (SNCs) are rare diseases with overlapping morphological features and a dismal prognosis. We aimed to investigate the expression differences among the histological subtypes for discerning their molecular characteristics. We selected 47 SNCs: (i) 21 nonkeratinizing squamous cell carcinomas (NKSCCs), (ii) 13 sinonasal neuroendocrine cancers (SNECs), and (iii) 13 sinonasal undifferentiated cancers (SNUCs). Gene expression profiling was performed by DASL (cDNA-mediated annealing, selection, extension, and ligation) microarray analysis with internal validation by quantitative RT-PCR (RT-qPCR). Relevant molecular patterns were uncovered by sparse partial-least squares discriminant analysis (sPLS-DA), microenvironment cell type (xCell), CIBERSORT, and gene set enrichment (GSEA) analyses. The first two sPLS-DA components stratified samples by histological subtypes. xCell highlighted increased expression of immune components (CD8 + effector memory cells, in SNUC) and \u201cother cells\u201d: keratinocytes and neurons in NKSCC and SNEC, respectively. Pathway enrichment was observed in NKSCC (six gene sets, proliferation related), SNEC (one gene set, pancreatic \u3b2-cells), and SNUC (twenty gene sets, some of them immune-system related). Major neuroendocrine involvement was observed in all the SNEC samples. Our high-throughput analysis revealed a good diagnostic ability to differentiate NKSCC, SNEC, and SNUC, but indicated that the neuroendocrine pathway, typical and pathognomonic of SNEC is also present at lower expression levels in the other two histological subtypes. The different and specific profiles may be exploited for elucidating their biology and could help to identify prognostic and therapeutic opportunities