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Immunomorphological evaluation
of cholesteatoma.
Otolaryngol Pol. 2004;58(2):289-95.
Molecular and cellular
mechanisms in chronic otitis media (COM) with cholesteatoma have not
been clearly enough known so far. Investigations on cholesteatoma are
focused on its immunological and morphological status. The authors
presented the results of immunomorphological evaluation of 31 patients
with COM with cholesteatoma, divided into three groups. In the first
group there were 4 patients with congenital cholesteatoma, in the
second group 19 patient with primary acquired cholesteatoma and in the
third group 8 patient with secondary acquired cholesteatoma.
Immunohistochemical investigations were performed using antibodies for
identification the tenascin, S-100 protein, antigens Ki 67, CD 31,
FVIII, HLA-DR, and growth factors TGFbeta1 and EGFR. The immunological
activity was assessed for three types and matrix and perimatrix of
cholesteatoma. High expression of tenascin was proven in the
perimatrix of cholesteatoma and protein S-100 was highly expressed in
the cholesteatoma matrix. Ki 67 antigen was seen rarely and mostly was
present in basal cells of the matrix. The presence of endothelial
cells was proven mainly in the connective and vascular tissue of
perimatrix (CD 31, FVIII). The high expression of HLA-DR in matrix
confirms the presence of Langerhans cells. The presence of growth
factors TGFbeta1 and EGFR was observed in peribasal layer of the
epithelium and keratinocytes of cholesteatoma matrix. Activity of
immunological processes in COM with cholesteatoma confirms their
important role in pathophysiology of chronic otitis media with
cholesteatoma.
Comparative analysis of the
proliferative capacity of cholesteatomas.Acta
Otorrinolaringol Esp. 2000
May;51(4):299-307.
Cholesteatomas of the middle
ear are frequently aggressive and produce bone destruction.
Stimulation of the surrounding inflammatory tissue and autocrine
mechanisms could be responsible for the keratinocytic dysregulation of
cholesteatomas, as well as for abnormal proliferation patterns. The
proliferative capacity of human cholesteatoma of the middle ear was
studied through the kinetics of the epithelial cells of cholesteatomas
and external ear canal. The APAAP method was used to study the
monoclonal antibody MIB-1, which recognizes an antigen of cells in the
division phase. Biopsies taken from the outer ear canal (n = 7)
revealed an MIB-1 level (the ratio of MIB-1 positive cells to all
cells) of 7.6% +/- 2.2%. Cholesteatoma samples (n = 13) showed an
MIB-1 level of 17.4% +/- 8.9%, and heterogeneity of the proliferative
areas. Epithelial invaginations into the surrounding stroma were
characterized by intense mitotic activity. The results confirmed a
statistically significant increase in keratinocytes in the
cholesteatomas, with an MIB-1 level 2.3 times higher than that of
meatal keratinocytes. PCNA, a nuclear proliferation antigen which
expresses the growth phase of cells in normal and tumoral tissue, was
determined in 15 biopsies of meatal skin and 7 specimens of
cholesteatoma in the phase of infection and 8 non-infection. Although
the number of proliferative cells changed depending on the site of the
cholesteatorna, the amount of PCNA-positive cells was significantly
higher in the cholesteatoma (2.5-15, mean 9.3) than in normal skin
(1-2.8, mean 1.5) (p < 0.001). Finally, AgNOR (argyrophyllic nucleolar
organizer regions), which express proliferative activity, were
determined in 12 specimens of meatal skin and in 19 acquired and 2
congenital cholesteatomas. A mean of 3.71 AgNOR dots were counted in
the cholesteatomas and 1.54 dots in meatal skin specimens. The
immunohistological study with three different markers expressing
cellular proliferative capacity showed hyperproliferation associated
with keratinocyte dysregulation in cholesteatoma samples, which could
explain the clinically aggressive and destructive behavior of these
lesions.
Acquired and congenital
cholesteatoma: determination of tumor necrosis factor-alpha,
intercellular adhesion molecule-1, interleukin-1-alpha and lymphocyte
functional antigen-1 in the inflammatory process.ORL
J Otorhinolaryngol Relat Spec. 2000 Sep-Oct;62(5):257-65.
The molecular and cellular
factors resulting in the pathologic features of acquired and
congenital cholesteatomas are not completely known. Recently,
proinflammatory cytokines like interleukin-1 alpha (IL-1 alpha) and
tumor necrosis factor-alpha (TNF-alpha) have been shown to induce bone
resorption, in vitro. To elucidate the key molecules involved in bone
resorption and cell infiltration associated with cholesteatoma, we
examined the in vivo levels of IL-1 alpha and TNF-alpha, intercellular
adhesion molecule-1 (ICAM-1) and lymphocyte functional antigen-1
(LFA-1) in acquired and congenital cholesteatomas, by reverse
transcriptase-polymerase chain reaction, immunohistochemistry, and
ELISA. Increased levels of IL-1 and TNF-alpha were detected in both
types of cholesteatomas as compared to normal skin. Increased ICAM-1
expression and LFA-1+ cells were detected in acquired but not
congenital cholesteatoma. Strong correlation was detected between TNF-alpha
and bone resorption in both types of cholesteatoma, and between TNF-alpha
and ICAM, TNF-alpha and severity of infection, or cell infiltration in
acquired cholesteatoma. No correlation existed between various
parameters and IL-1 alpha. These results suggest that TNF-alpha may
play a crucial role in the pathogenesis of both acquired and
congenital cholesteatomas by regulating bone resorption and cell
infiltration.
Intracranial extension of
acquired aural cholesteatoma.Laryngoscope.
2000 May;110(5 Pt 1):761-72.
OBJECTIVE: Cholesteatoma of
the petrous bone extending into the intracranial region is an unusual
occurrence. Most cases have been attributed to secondary extension of
a primary epidermal blastomatous malformation of the temporal bone
into the middle or posterior fossae. Within the past two and a half
decades, intracranial extension of acquired aural cholesteatoma has
been recognized as a likely alternative to this mechanism. Recent
literature has rejoined this observation by considering both primary
and secondary cholesteatoma of the petrous bone as a single group,
petrosal cholesteatoma. The present study is presented to analyze the
clinical presentation, imaging findings, and surgical treatment of six
patients with acquired aural cholesteatoma extending into the
intracranial region. Findings in this study are compared with the
extant literature on congenital and acquired cholesteatoma of the
petrous bone. This study proposes that petrosal cholesteatoma is a
valid anatomical construct; however, the pathogenesis of petrosal
cholesteatoma is still important in understanding the clinical
presentation and management of cholesteatoma that extends beyond the
usual confines of the middle ear and mastoid. STUDY DESIGN:
Retrospective case review conducted at a tertiary referral center.
METHODS: From 1985 to 1999, 477 patients were surgically treated for
acquired aural cholesteatoma. Patients with intracranial extension of
cholesteatoma were studied. Clinical presentation, imaging studies,
operative findings, surgical treatment, and postoperative results were
evaluated. RESULTS: Six cases in a series of 477 patients with
acquired aural cholesteatoma had intracranial extension of disease. In
this series, the most frequent pathway for intracranial extension was
supralabyrinthine through the supratubal recess into the middle
cranial fossa. A less frequent pathway was via the retrofacial air
cells into the posterior cranial fossa. Surgical access for removal of
intracranial cholesteatoma was accomplished through several approaches
including translabyrinthine, transcochlear, retrolabyrinthine, and
middle cranial fossa. In two patients who had reoperation for possible
residual disease, one was free of residual disease and one was found
to have residual cholesteatoma in the region of the horizontal facial
nerve. CONCLUSION: Acquired aural cholesteatoma can extend into either
the middle or posterior cranial fossae. In this study, cholesteatoma
extended into the middle fossa through the supratubal recess along the
labyrinthine facial nerve and into or above the internal auditory
canal. A less frequent path is through the retrofacial air cells into
the posterior fossa. Intracranial acquired cholesteatoma is generally
small and presents with complaints related to underlying otitis media
rather than the neurological deficits that are often associated with
primary petrous bone cholesteatoma. While computed tomography and
magnetic resonance imaging are both required to differentiate
congenital petrous cholesteatoma from other lesions of the petrous
bone, computed tomography of the temporal bone is usually sufficient
to diagnosis and define intracranial extension of acquired aural
cholesteatoma. These lesions can be completely excised rather than
exteriorized.
Increased numbers of mast
cells in human middle ear cholesteatomas: implications for treatment.Am
J Otol. 1998 May;19(3):266-72.
HYPOTHESIS: Because many of
the biologic phenomena in which mast cells are involved also are
observed in human cholesteatoma pathology, the authors hypothesized
that mast cells may play a role in this disease. The first test of
this hypothesis is to determine whether there are an increased number
of mast cells associated with cholesteatomas. BACKGROUND: The
molecular and cellular defects that result in the pathologic features
observed in acquired and congenital cholesteatomas are unknown. One
common feature of cholesteatoma pathogenesis is the presence of
bacteria and a numerous inflammatory cytokines expressed by host
inflammatory cells. The interactions between inflammatory cells and
cholesteatoma epithelium could result in the induction of other
aberrant biologic features of cholesteatomas. Thus, it is critical to
the understanding of the pathogenesis of cholesteatomas to define the
specific role of each cell type involved in this disease. Connective
tissue mast cells have a complex retinue of functions mediated via the
secretion of a variety of cytokines and proteinases, and many of the
biologic phenomena in which mast cells are involved also are observed
in cholesteatoma pathology. METHODS: The authors evaluated by
immunohistochemistry 36 cholesteatomas of all types (e.g., primary and
secondary acquired, recurrent, and congenital) and 23 specimens of
normal tissues (e.g., tympanic membrane, canal wall skin, and
postauricular skin) for the expression of tryptase, a mast
cell-specific protease. RESULTS: Cholesteatomas showed approximately
threefold to sevenfold increase in the concentration of mast cells
when compared with that of normal tissues. In addition, 19-34% of the
mast cells were found within the suprabasal layers of the squamous
epithelium of cholesteatoma subgroups, a phenomenon observed only in
grossly inflamed tympanic membrane specimens, but not in other control
tissues including minimally inflamed tympanic membranes. CONCLUSIONS:
The authors conclude from these data that mast cells may represent a
previously unrecognized host inflammatory cell, which plays an
important role in the development of one or more traits of
cholesteatoma pathology.
Cholesteatoma: a molecular and
cellular puzzle.Am J Otol.1998 Jan;19(1):7-19.
HYPOTHESIS: There are at least
three possible molecular models of cholesteatoma pathogenesis.
Cholesteatoma may arise as a result of 1) the induction of a
preneoplastic or neoplastic transformation event; 2) a defective
wound-healing process; and/or 3) a pathologic collision of the host
inflammatory response, normal middle ear epithelium, and a bacterial
infection. BACKGROUND: There have been a number of speculations
concerning the factors that foster the development of cholesteatoma.
Before resolving the molecular basis for the pathogenesis of
cholesteatomas, it is important to present and test plausible models
that could explain how a cholesteatoma becomes invasive, migratory,
hyperproliferative, aggressive, and recidivistic. METHODS: The authors
evaluated by various techniques (e.g., immunohistochemistry, flow
cytometry, and image analysis) a large number of cholesteatomas of all
types (e.g., primary and secondary acquired, recurrent, and
congenital) and a range of normal tissues (tympanic membrane, canal
wall skin, and postauricular skin) for the expression of various
proteins (e.g., p53, ectopeptidases, tryptase) and for the presence of
DNA aneuploidy. RESULTS AND CONCLUSIONS: The authors' published and
unpublished studies to date support several suppositions concerning
the pathology of cholesteatomas. First, cholesteatoma epithelium
behaves more like a wound-healing process than a neoplasm. The
available evidence to date does not indicate that cholesteatomas have
inherent genetic instability, a critical feature of all malignant
lesions. Second, the induction of hyperproliferative cells in all
layers of the cholesteatoma epidermis implicates a potential
idiopathic response to both internal events as well as external
stimuli in the form of cytokines released by infiltrating inflammatory
cells. Third, the presence of bacteria may provide a critical link
between the cholesteatoma and the host, which prevents the
cholesteatoma epithelium from terminating specific differentiation
programs and returning to a quiescent state in which it becomes
minimally proliferative, nonmigratory, and noninvasive. Fourth, none
of our data suggest that there are any obvious molecular or cellular
differences among the various types of cholesteatomas (e.g., primary
and secondary acquired, recidivistic, and congenital). Continued
research should delineate the precise molecular and cellular
dysfunction involved in the pathogenesis of cholesteatomas and how
this knowledge can be useful in the clinical management of
cholesteatomas.
Expression of p53 protein in human
middle ear cholesteatomas: pathogenetic implications.Am
J Otol.1998 Jan;19(1):30-6.
BACKGROUND: Cholesteatoma is a
destructive lesion of the middle ear or mastoid process or both. The
molecular and cellular defects that result in the clinical hallmarks
of acquired and congenital cholesteatomas, namely invasion, migration,
uncoordinated proliferation, altered differentiation, aggressiveness,
and recidivism, are unknown. Determining the existence of defects in
the normal biology, biochemistry, and genetic complement of the major
cellular constituents comprising a cholesteatoma (i.e., fibroblasts
and keratinocytes) is critical to the understanding of the
pathogenesis of cholesteatomas. It has been speculated that the
development of human cholesteatomas is due, in part, to the altered
control of cellular proliferation, which tilts the balance toward the
aggressive, invasive growth of squamous epithelium within the middle
ear. However, whether this altered control is due to defects in the
mechanisms and underlying genes that control proliferation, or to
cytokines released from infiltrating inflammatory cells, or to some
other mechanism is unknown. The nuclear phosphoprotein p53 tumor
suppressor gene plays a critical regulatory role in cell cycle control
and apoptosis. In the current article, the authors have analyzed
congenital, primary and secondary acquired, and recurrent
cholesteatomas for the altered expression of p53 and Ki-67, a marker
of active proliferation. METHODS: p53 and Ki-67 expression was
determined by immunohistochemical assays using specific monoclonal
antibodies. RESULTS: The authors' results indicate that p53 is
elevated 9- to 20-fold in all cholesteatomas when compared to the
expression of p53 in normal postauricular skin or tympanic membrane.
However, there is no concomitant increase in Ki-67 expression in
cholesteatomas. CONCLUSIONS: These data indicate a defect in
cholesteatomas in the mechanisms that p53 engages (i.e., cell cycle
control or apoptosis or both). In addition, these data further suggest
that there is no intrinsic difference between any clinicopathologic
group of cholesteatomas, at least with respect to p53-expression and,
presumably, p53 function.
Differences in
dendritic cells in congenital and acquired cholesteatomas.
Laryngoscope.1993 Nov;103 (11 Pt 1):1214-7.
Cholesteatomas
are histologically benign, though biologically invasive lesions that
arise from the migration of squamous epithelium of the ear. Acquired
cholesteatomas usually arise in an antigenically active environment,
i.e., a chronically and/or recurrently inflamed middle ear. In
contrast, congenital cholesteatomas occur in an uninflamed
environment. The potential role of dendritic cells (DCs) in the
evolution of this lesion has not been thoroughly studied. By staining
for S-100 protein, the authors evaluated the presence and distribution
of DCs in cholesteatomas. Sixteen cases of cholesteatomas diagnosed
from 1987 to 1989 were selected for this study. The formalin-fixed,
paraffin-embedded sections were processed by a standard avidin-biotin
peroxidase-antiperoxidase method for S-100 protein and for leukocyte
common antigen (LCA). The presence and distribution of S-100
protein-positive DCs was evaluated and compared to canal wall skin.
DCs were present in all cases. Nine acquired cholesteatomas had 5 to
16 epithelial DCs per high-power field (HPF). Seven congenital
cholesteatomas were examined. Four with isolated congenital pearl-like
cholesteatomas had 1 to 3/HPF epithelial DCs. In contrast, the three
inflamed congenital cholesteatomas had 6 to 12/HPF DCs. The control
uninflamed canal wall skin had only 1 to 3/HPF DCs. All DCs were LCA
negative, as expected.
Retraction pockets and attic
cholesteatomas.Acta
Otorhinolaryngol Belg. 1980;34(1):62-84.
An attic cholesteatoma is
defined as an epidermoid cyst found in the attic. This is
differentiated from an infected retraction pocket of the pars tensa or
a retraction pocket cholesteatoma. Stratified squamous epithelium may
also be present in the middle ear as other clinical or pathological
entities, such as metaplastic islands of the mucosa in chronic ears
with central perforations. Histological examination of 22 temporal
bones with attic cholesteatomas has shown them to reside mainly medial
to the ossicular chain. This explains the difficulty they have in
self-cleansing, as well as the ensuing secondary infection. When a
similar process occurs lateral to the ossicles, a self-cleansing
nature's atticotomy may be formed. The aetiology of an attic
epidermoid cyst, i.e., an attic cholesteatoma, is usually considered
to be an invasive retraction from the external ear. However, it is
difficult to accept invasion of external canal skin into the upper
medial attic. This is especially so in the face of such biological
phenomena as epithelial contact inhibition, or the invariable outward
migration of stratified squamous epithelium from the edges of
retraction pockets as well as from cholesteatoma perforations. Also,
large cholesteatomas usually present themselves from the "beginning"
simultaneously with their perforations; no documentation of an
evolving process from a pre-existing perforation exists at present.
Marginal perforations, which have later evolved into attic
cholesteatomas have so far not been documented. On the other hand,
retraction pockets of the pars tensa or pars flaccida associated with
some middle ear negative pressure do occur, however, it is yet to be
shown that such retractions can reach the medial part of the ossicular
chain and form epidermoid-like cysts there. Therefore, the possibility
that an attic cholesteatoma often arises primarily in the attic and
presents itself secondarily in the external canal as a "perforated"
epidermoid cyst, is to be considered. The possibility that a
congenital rest is responsible for such an epidermoid cyst has often
been put forward, but evidence that such rests actually exist has not
yet been presented. The frequency with which cholesteatoma sacs found
in the attic show mucosal cells as part of their lining, suggests a
metaplastic phenomenon. This means that the epithelial cells of the
middle ear lining may have changed from mucosal into keratinizing
cells (or even vice versa). Metaplastic changes of mucosas into
keratinizing epithelium occur very frequently in the bronchi, nose,
ears and genitourinary system. Attic epidermoid cysts may, therefore,
be seen as an analogous formation to glandular cysts in the attic --
the latter being very frequently seen in there in chronically infected
ears. Such "organ" formations (glands or epidermoid cysts) may arise
when their respective cells (forming mucus or keratin) grow in the
midst of connective tissue rather than on the surface...
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