Path. Res. Pract. 188, 729-735 (1992)

Superficial Extending Carcinoma (SEC) of the Larynx and Hypopharynx 1 A. Carbone and R. Volpe Division of Pathology, Istituto Nazionale di Ricovero e Cura a Carattere Scientifico, Centro di Riferimento Oncologico, Aviano, Italy

L. Barzan Division of Otolaryngology of the Pordenone General Hospital, Pordenone, Italy

SUMMARY In this study the histopathological features of an underestimated arehitectural variety of infiltrating squamous celf carcinoma of the larynx and hypopharynx, operationally termed as "superficial extending carcinoma", are described. Pathologically, the superficial extending eareinoma is a poorlylmoderately differentiated infiltrating squamous eell carcinoma showing an entirely or predominant superficial type ofgrowth; deep infiltration was eonfined to the mucosa or limited to a few underlying glandular andlor museular laryngopharyngeal structures, regardless of the presenee of lymph node metastasis or lymph vessel invasion. As defined above, the superficial extending carcinoma may be regarded, from a pathologie point of view, as a laryngopharyngeal counterpart to "superfieial esophageal carcinoma". Studying aseries of88 whole organs seriaily sectioned laryngopharyngectomy speeimens, we found that 6 out of 61 primary laryngeal carcinomas (9.8%) mzd 6 out of 26 primary hypopharyngeal carcinomas (23%) showed the peeuliar arehitectural features of the superficial extending carcinoma. In 6 eases (2 laryngeal and 4 hypopharyngeal) the tumor was entirely intramucosal 01' early infiltrated the underlying muscle or gland structures. In the remaining 6 eases (4laryngeal and 2 hypopharyngeal tumor) a superficial extending carcinoma was found to be associated with a deeply infiltrating squamous ceil carcinoma of the "elassie" type. Features useful to histopathologie diagl10sis of superficial extending carcinoma and to its differentation from preneoplastie and other neoplastie lesions of the laryngopharyngeal mucosa are emphasized. The possible association of superficial extending carcinoma with multiple synehronous and metaehronous neoplastie lesions in the upper aerodigestive tract and the frequent underestimation of its real extension may have importallt clinieal implieatiolls.

Introduction

111e occurrence of infiltrating tumors with a predominantly superficial type of growth has been pathologicaHy 1 This work was supported in part by a grant of the Italian Association on Cancer Research (AIRC), Milan.

© 1992 by Gustav Fischer Verlag, Stuttgart

recognized in various organs such as the stomach, esophagus and skin. These weH-defined entities, for wh ich terms as "~arly gastric cancer" 18, "superficial esophageal carcinoma" 11, and "superficial spreading melanoma"4, respectively, have been coined, are known to be associated with distinctive clinical and prognostic features 4, 11, 16, 18. By using whole organ section techniques, a special architectural variety of infiltrating squamous ceH carcino0344-0338/92/0188-0729$3.50/0

730 . A. Carbone, R. Volpe and L Barzan

ma (seC), operationally termed as "superficial extending carcinoma" (SEC), was recently identified in the hypopharynx and larynx2,2o. SEC was pathologically defined as a poorly/moderately differentiated infiltrating sec with an entirely or predominant superficialtype of growth; deep infiltration was confined to the mucosa or limited to a few underlying glandular andlor muscular laryngopharyngeal structures, regardless of the presence of lymph node metastases or lymph vessel invasion. In some ca ses a deeply infiltrating sec of the "classic" type coexisted with a SEC. As defined above, SEC may be regarded, from a pathologie point of view, as a laryngopharyngeal counterpart to "superficial esophageal carcinoma" or "early gastric cancer". On the other hand, the clinical relevance of this entity as weH as its prognostic significance remain uncertain, due to the low number of cases investigated so far. Moreover, the relationships between the clinical definition of "early laryngeal cancer"8, 9 and the broad spectrum of pathologie lesions, including SEC, which under this definition may be

comprised, need to be clarified. This study has the aim to further define the histopathological features of this underestimated variety of infiltrating sec of the larynx and hypopharynx, drawing attention to the differential diagnoses and the possible clinical irnplications related to its precise recognition. Material and Methods From March 1985 to September 1988, 88 consecutive specimens obtained from patients with laryngo-pharyngeal carcinomas were collected and routinely evaluated using a whole organ sections technique developed in the Division of Pathology at the Centro Riferimento Oncologico of Aviano, Italy21. Eighty-two patients were males and 6 were fern ales, their median age was 60 years (range 41-80). Ninety-three tumors were seen in these 88 patients, five of the patients having two synchronous lesions (one patient had 2 supraglottic tumors, 1 patients had a laryngeal and an oropharyngeal tumor, 1 patient had 2 hypopharyngeal tumors, 1 patient

Fig. 1. Patient 6, "Pure" intramucosal laryngeal SEC. - A: Laryngectomy specimen: a flat, whitish, granular-Iooking lesions with poody defined margins involves the entire left ventricular fold and rcaches the arythenoid region and the posterior quarter of the tme vocal cord. - Band C: Consecutive whole organ histologie sections at supraglottic level of the specimen shown in Fig. A: the tumor had an entirely intramucosal growth and superficially spreads along the left ventricuJar fold. Gland structures between the laryngeal saccule (curved arrow) and the mucosal surface are not involved. Maximal tumor extension is shown in Fig. B; ipsilateral lymph node metastases were recorded in this patient (see Table 1). (TC: thyroid cartilage; A: arytenoid cartilage, arrowhead: petiole of the epiglottis).

Laryngopharyngeal SEC . 731 had a hypopharyngeal and an oropharyngeal tumor, while the remaining patient had a supraglottic and a hypopharyngeal tumor). Eighty-nine were primary tumors (61 laryngeal, 26 hypopharyngeal and 2 oropharyngeal), while 4 were recurrent lesions (2 laryngeal and 2 hypopharyngeal, respectively). As for the histological type, all but one of the tumors were squamous cell carcinomas: the remaining lesion was an undifferentiated carcinoma not otherwise specified. Microscopically, 12 primary tumors shared the peculiar architectural features previously described for the superficial extending carcinoma (SEC) of the hypopharynx and larynx 2,2o; these cases were the object of the present study.

Results

A preferentially superficial type of growth was found in 6 outof 61 primary laryngeal carcinomas (9.8 %) and in 6 out of 26 primary hypopharyngeal carcinomas (23 %). The main clinical and pathological features of these cases are shown in Table 1. The specific locations of SEC were the ventricular folds (5 cases) and the vocal cord (1 case) within the larynx, and the retrocricoid area (2 cases), the pyriform sinus (3 cases) and the aryepiglottic fold (1 case) within the hypopharynx.

Table 1. Main clinical and pathological features of 12 cases of superficial extending carcinoma of the larynx and hypopharynx No. Age/sex

Clinical evaluation

Site

1

55/F

UI lesion, impaired VCM; VFs synchronous tumor of the PPW. Tl (larynx); Tl (pharynx); NO

2

70/M

3

52/M

UI lesion, impaired VCM; T2 VFs NO I lesion, impaired VCM; Tl N1 VF

4

65/M

5

53/M

6

61/M

7

53/M

8

59/M

UV lesion, impaired VCM; T2 N2b

9

41/M

10

60/M

UV lesion, fixed VC; T4 (PEF PS extension suspected) N1 UV lesion with infiltrating mar- PS gins, impaired mobility of the tongue, normal VCM; T4 (oropharynx) N2c

11

52/M

UV lesion, normal VCM; T2 N2b

PS

12

58/M

UV lesion, normal VCM; T2 NO

RCA

UI lesion, impaired VCM; T2 NO UV lesion, fixed VCs; T3 NO

VF VCs

Microvegetating lesion, impaired VF VCM; Tl N1 UI lesion, normal VCM; T2 RCA N2a AEF

Extension

Histology

DI-SCC + SEC (larynx); DI-SCC with associated areas of CIS (hypopharynx); pT3 (larynx) pTl (pharynx); N1; G2/3 E, PES, PGS, DI-SCC (Ieft VF) + SEC TC (right VF); pT3 NO; G2/3 "Pure" intramucosal SEC; E pTl N2c; G3 E, AEFs DI-SCC (E) + SEC (VF, AEFs); pTl NO; G2 PGS, TC, AEF, DI-SCC (Ieft VC) + SEC C,IG (right VC and pharyngeal surface of the left AEF); pT4 NO; GlIG3 "Pure" intramucosal SEC; VC, E pTl N1; G3 PS, AEF SEC with early submucosal infiltration; pT2 N3; G3 VCs, AEF, E, PES

Follow-up Alive, 29 mo; .5 mo later metachronous DI-SCC of the BT. Alive, 26 mo Alive, 18 mo Alive, 10 mo Alive, 6 mo

Alive, 2 mo

Alive, 50 mo; 17 mo later metachronous esophageal DI-SCC PS, RCA, IAF SEC with early submucosal Alive,45 mo infiltration; Associated CIS of the opposite PS; pT2 N2c; G3 AEF, IAF, PGS, DI-SCC (AEF, E) + SEC Dead with disease, 9 E, RCA (PS); pT3 N2c; G3 mo "Pure" intramucosal SEC; Alive, 7 mo synchronous DI-SCC of the glossoepiglottic area; pTl; G3 (hypopharynx); pT4; G1/2 (oropharynx); pN2c "Pure" intramucosal SEC; Alive, 5 mo synchronous DI-SCC of the opposite (left) PS and microinvasive SCC of the tip of the E pT3 (left PS) pTl (right PS, E) N2c; G3 SP, AEF DI-SCC (RCA) + SEC Alive,4 mo (RCA, PS, AEF) and associated areas of CIS; pT2 N2c; G3

UI: ulcero-infiltrating; VCM: vocal cord mobility; VC: vocal cord; RCA: retrocricoid area; PS: pyriform sinus; AEF: aryepiglottic fold; SEC: superficial extending carcinoma; DI-SCC: Deeply infiltrating squamous cell carcinoma; UV: ulcero-vegetating; IAF: interarytenoid fold; CIS: carcinoma in situ; BT: base of the tongue; PEF: pharyngoepiglottic fold; PGS: paraglottic space; E: epiglottis; PPW: posterior pharyngeal wall; VF: ventricular fold; PES: preepiglottic space; TC: thyroid cartilage; I: infiltrating; IG: hypoglottic level; C: cricoid cartilage.

732 . A. Carbone, R. Volpe and L. Barzan

In 4 cases (21aryngeal- 3.3 % - and 2 hypopharyngeal tumors - 7.7%) the lesion consisted of an intramucosal SEC without invasion of the underlying structures ("Pure" intramucosal SEC, see Figs. 1 and 2); two other hypopharyngeal tumors (7.7 %) early infiltrated the undedying muscle or gland structures (see Fig. 3A). In the remaining 6 cases (41aryngeal~ 6.6 % -and 2 hypoharyngeal tumors7.7 %) a SEC was found to be associated with a deeply infiltrating carcinoma (of the "classic" type) (see Fig.

The superficial extending component of the latter group showed pathological features similar to those of the other SECs; thus, they are described together. Grossly, the lesion was flat, whitish, with granularlooking or micropapillary areas and poody defined mar-

3B).

Fig. 2. Patient 3, "Pure" intramueosallaryngeal SEC. - A and B: Conseeutive whole organ histologie seetions at supraglottie level: the tumor shows an entirely superficial growth Iimited to the lamina propria and invoIves thc anterior half of thc Icft ventricular fold; bilaterallymph node metastases were reeorded in this patient (see table 1) (A: arythenoids; TC: thyroid cartilage; arrows: laryngeal saccules). - C: a partieular of the lesion illustrated in A and B showing a poorly differentiated squamous eell careinoma with a'complete, but limited in depth, basaloid-like infiltrative growth.

Fig. 3. A: Patient 7, SEC of the hypopharynx with early submucosal infiltration. Whole organ histologie section at supraglottie level demonstrates an infiltrating tumor involving the entire retroerieoid region (darker areas) with limited growth in depth. A strong inflammatory reaetion (uniformly grey areas) surrounds the neoplastie growth. Mieroseopieally, the underlying interarythenoid muscle was not involved. - B: Patient 12, SEC of the retroerieoid area assoeiated with a deeply infiltrating squamous cell earcinoma of the pharyngeal surfaee of the right aryepiglottie fold (see table 1). Whole organ histologie seetioll at glottie level shows the "pure" intramucosal SEC associated eomponent of this tumor. (A: arythenoid; TC: thyroid eartilage; arrows: laryngeal saeeules, asterisk: interarythenoid muscle).

Laryngopharyngeal SEC . 733

gins (see Fig. 1A). Ulceration and a clearly infiltrating or vegetating growth was observed only in cases associated with a deeply infiltrating tumor. On cut surface, the superficial type of growth of the lesion was frequently clollded becallse of the strong stromal reaction surrounding the tumor margins. Microscopically, SECor SEC associated with an infiltrating "classic" SCC were poorly (11 cases) or moderately (1 case) differentiated SCC (see Fig. 4A); in all cases the entire lesion showed an invasive growth through the basal membrane into the lamina propria with apredominant, extensive, lateral spread limited to the mllcosa (see Figs. 1 to 3). In other words, SEC was alesion entirely constituted by an infiltrating SCC invading the fllll thickness between the ep ithelial lining and the underlying muscle or gland structures; in SEC cases with extension to the llnderlying gland or muscle structures, infiltration was restricted to a few microscopic foci. A moderate to intense stromal inflammatory rcaction was observed at the tumor-host

interface in all cases. Areas of dysplasia and/or carcinoma in siru (CIS) were frequently observed at the edges of SEC lesions as weil as in othcr sites of the laryngopharyngeal mucosa (sec Fig. 4B) . Foci of CIS were also found near thc excision margins in 1 SEC of the hypopharynx. Lymph node metastases were obscrvcd in 9 of 12 patients. Interestingly, lymph vessel invasion and lymph nodc metastases wcrc fOllnd in four patients with "pure" intramucosal SEC. Multifocallesions were observed in 3 cases, whereas in 3 other ca ses synchronolls primary tumors wcrc found in different pharyngeal sites (see Table 1). Metachronous lesions were recorded in 2/12 patients with SEC (16.7%) and in 7/76 patients (9.2 %) with "classic" deeply infiltrating SCc. On clinical and radiological CT examination these cases did not show distinctive features, appearing as deeply infiltrating lesions or extension areas of an associated "classic" deeply infiltrating SCc.

Fig.4. Patient 6, "Pure" intra.mucosallaryngeal SEC. Both microphotographs are particular of the lesion sho wn in fig. 1. The tumor appears as a poorty differentiated squamous cell carcinoma infiltrating the lamina propria (A). Areas of dysplas ia and carcinoma in situ are present at the edge of the tumor (B).

734 . A. Carbone, R. Volpe and L. Barzan

Discussion Using a whole organ serial sections technique21 in the routine pathological examination of laryngopharyngectomy specimens, we found that 6 or 9.8 % of primary laryngeal carcinomas and 6 or 23 % of primary hypopharyngeal carcinomas met the pathologic criteria for the diagnosis of SECZ,2o. A pure intramucosal SEC or a SEC with early infiltration of the underlying muscle or gland structures was observed in 3.3 % and in 15.4 % of primary laryngeal and hypopharyngeal carcinomas, respectively, whereas a SEC was found to be associated with a "classic" deeply infiltrating SCC in about 7 % of primary carcinomas observed in each of the two anatomical sites considered. In a 'previous study of 242 ca ses of carcinoma of the hypopharynx uniformly studied using whole organ sections, an overall frequency of 10.7 % of SECs was observed 2; 9.1 % of cases were "pure" intramucosal SEC or SEC with early infiltration of the underlying muscle or gland structures, whereas in 1.7 % of the ca ses a SEC was found to be associated with a "classic" deeply infiltrating SCC. The slight differences we found in the incidence of hypopharyngeal SEC may be due to the different pathological approach: we microscopically analyzed the entire specimen while in the cited study only 7 codified sections were taken. From our results and previous studies2,20 a fairly consistent histopathological picture of laryngopharyngeal SEC emerges; it consisted of a poorly/moderately differentiated infiltrating SCC with a clearly invasive growth through the basal membrane into the lamina propria, an entire or predominant, extensive, lateral spread limited to the mucosa, and invasion of the underlying laryngopharyngeal structures restricted, when present, to a few microscopic foci. Multicentric lesions, areas of dysplasialCIS or a "classic" deeply infiltrating SCC may be found associated or coexistent with a SEC. The pathological definition of SEC is not influenced by the occurrence of lymph vessel invasion or lymph node metastases: we observed lymph node metastases in two patients with "pure" intramucosallaryngeal SEC only. HistologicaIly, SEC may be easily separated from intraepithelial neoplastic lesions of the laryngopharyngeal mucosa 1,3,5-7,10,12,14,23 (dysplasia andlor CIS) for the presence of a clear invasion through the basal membrane into the lamina propria. The lesion that may be easily confused with a SEC is microinvasive carcinoma. The latter is mostly an intraepithelial carcinoma with only rare foci of stromal invasion7,15 )Vhereas SEC is alesion entirely constituted of an infiltraring SCC invading the full thickness between the epithelial lining and the underlying muscle or gland structures. In SEC, areas of intraepithelial neoplasia are frequently found, but they are observed as a minimal component in marginal fields of the lesion or in different laryngopharyngeal sites. An exophytic growth, weIl-circumscribed, pushing margins, high degree oLceIlular differentiation, and a nonmetastatic behaviour 13 are distinguishig features of verru-

cous carcinoma that may be useful in separating this entity from SEC. The presence of laryngeal structures that act as temporary barrier for the neoplastic growth 17 could make a false feature of SEC in an otherwise "classic" deeply infiltrating SCc. This may be true especially for the vocal cords, where muscular fibers are weIl represented. Attention must be paid to vocal muscle infiltration, invariably weIl represented in "classic" infiltrating SCC, and to the presence of involvement of deeply laryngeal structures whenever the lesion spreads in other laryngeal sites. Interestingly, all of the laryngeal "pure" intramucosal SEC we observed were "Iarge" neoplastic lesions located at supraglottic level, where invasion of the laryngeal fat spaces is commonly observed I7,19. FinaIly, all the above mentioned histopathologic lesions, including SEC and "classic" deeply infiltrating SCC, must not be confused with the term "early laryngeal cancer" (ELC), which is a clinical definition distinguishing a tumor limited to one site of glottic or supraglottic levels with preserved cordal mobility8,9; therefore, this weIl-established clinical definition does not suggest a precise histopathological entity. So me clinical implications may be drawn from our data and previously reported studies on SEC2,2o: 1) multicentric and synchronous or metachronous neoplastic lesions of the upper aero-digestive tract (UADT) are frequently observed in patients with SEC. In our overall series three out of 5 patients with multiple synchronous tumors in the UADT were in the SEC group (see Material and Methods and T able 1); besides, patients with SEC showed a high er frequency of metachronous tumors of the UADT in comparison with patients with "classic" deeply infiltrating SCC (16.7% vs 9.2 %). Since cancers of these regions may be the expression of a generalized and progressive transformation of the surface epithelium22, 23, microscopic evidence of a carcinoma with an entire or associated superficial growth may alert the clinician to the higher risk of associated synchronous or metachronous tumors in the UADT. 2) Since SEC may be detected at microscopic level alone, unexpected local recurrence of an apparently weIl defined infiltrating carcinoma may be due to an associated but not grossly recognized SEC, as previously suggested2. Thus, especially in hypopharyngeal tumors, thepossibility of a SEC must be considered in evaluating frozen sections of margins of excision. In conclusion, using a standardized pathological approach to laryngeal and hypopharyngeal carcinomas, a distinct variety of SCC, with a preferential superficial type of growth - SEC -, may be observed in these sites. The low number of cases investigated and the short foIlow-up of the patients does not permit any firm conclusion on the prognostic significance of SEC; besides, its collocation as a distinct biological stage in the sequence dysplasia-deeply infiltrating ("classic") carcinoma may be only speculated 20,23. However, its possible association with multiple synchronous and metachronous neoplastic lesions in the UADT and the frequent underestimation of its real extension may have important clinical implications. A

Laryngopharyngeal SEC . 735

precise pathological recogmtlOn of this entity and its distinction from the usual "classic" deeply infiltrating laryngopharyngeal see might per mit an appropriate evaluation of its prognostic significance. References 1 Bridger GP, Nassar VH (1971) Carcinoma in situ involving the laryngeal mucus glands. Arch Otolaryngol 94: 389-400 2 Carbone A, Micheau C, Bosq], Caillaud]M, Vandenbrouck C (1983) Superficial extending carcinoma of the hypopharynx: Report of 26 cases of an underestimated carcinoma. Laryngoscope 93: 1600-1606 3 Carbone A, Volpe R, Santi L (1984) Lesioni preneoplastiche deI cavo orale, faringe e laringe. Concetti istopatologici. Argomenti di Oncologia 5: 313-317 4 Clark WH, From L, Bernardino EA, Mihm MC (1969) The histogenesis and biologie behavior of primary human malignant melanoma of the skin. Cancer Res 29: 705 -726 5 Crissman]D (1982) Laryngeal keratosis preceding laryngeal carcinoma. Areport of four ca ses. Arch Otolaryngol 108: 445-448 6 Crissman ]D (1985) Histopathologie diagnosis of early cancers. In: Chretien PB,]ohns ME, Shedd DP, Strong EW, Wards PH (Eds) Head and Neck Cancer, Vol. 1: 134-140. BC Decker, Philadelphia 7 Crissman]D (1986) Intraepithelial neoplasia of the larynx. Arch Otolaryngol Head Neck Surg 112: 522-528 g DeSanto LW (1982) The options in early laryngeal carcinoma. N Engl] Med 1: 910-912 9 DeSanto LW (1985) Treatment options in early cancers of the larynx. in: Chretien PB, lohns ME, Shedd DP, Strong EW, Wards PH (Eds) Head and Neck Cancer, Vol. 1: 202-206. BC Decker, Philadelphia 10 Elman A], Goodman M, Wang CC, Pilch B, Busse] (1979) In situ carcinoma of the vocal cords. Cancer 43: 2422-2428 11 Endo M, Yamada A, Ide H, et al. (1980) Early cancer of the esophagus: diagnosis and c1inical evaluation. Int Adv Surg Oncol 3: 49-71

12 Ferlito A (1976) Histological c1assification of larynx and hypopharynx cancers and their c1inical implications. Acta Otolaryngol (Suppl) 342: 1-88 13 Ferlito A (1985) Diagnosis and treatment of verrucolls squamous cell carcinoma of the larynx: a critical review. Ann Otol Rhinol Laryngol 94: 575-579 14 Friedmann I, Piris F (1986) Neoplasms of the larynx. In: W StC Symmers General (Ed) Systemic Pathology (Nose, Throat and Ear), Vol. 1, 3rd: 210-228. Churchill Livingstone, Edinburgh-London-Melbourne-New York 15 Gillis TM, Incze], Strong MS, Vaughan CW, Simpson GT (1983) Natural history and management of keratosis, atypia, carcinoma in situ, and microinvasive cancer of the larynx. Am ] Surg 146: 512-516 16 Grigioni WF, Alampi G, Bondi A, Biasco G, Santini D, Miglioli M (1980) Retrospective studies of early gastric cancer in a high incidence area of haly. Histopathol 4: 533-545 17 Micheau C, Luboinski B, Sancho H, Cachin Y (1976) Modes of invasion of cancer of the larynx. A statistical, histological, and radioclinical analysis of 120 cases. Cancer 38: 346-360 18 Murakami T (1973) Pathomorphological diagnosis. Definition and gross c1assification of early gastric cancer. GANN Mon Cancer Res 11: 53-55 19 Olofsson], Van NostrandAW (1973) Growth and spreadof laryngeal and hypopharyngeal carcinoma with reflections on the effect of preoperative irradiation. 139 cases studied by whole organ serial sectioning. Acta Otolaryngol (Suppl) 308: 1-84 20 Sulfaro S, Volpc R, Barzan L, Querin F, Lutman M, Comoretro R, Carbone A (1988) Superficial extending carcinoma of the larynx. Laryngoscope 98: 1127-1132 21 Sulfaro S, Volpe R, Miniutti C, Barzan L, Comoretto R, Carbone A (1989) A method for routine approach to laryngeal and hypopharyngeal surgical specimens by whole organ sections in the horizontal plane. Path Res Pract 184: 248-254 22 Weaver A (1985) Early cancer of the head and neck: diagnostic considerations. In: Chretien PB, lohns ME, Shedd DP, Strong EW, Wards PH (Eds) Head and Neck Cancer. Voll: 131-134. BC Decker, Philadelphia 23 Zarbo R], Crissman ]D (1988) The surgical pathology of head and neck cancer. Seminars in Oncology 15: 10-19

Received ]uly 12, 1990 . Accepted in revised form ]uly 15, 1991

Key words: Superficial extending carcinoma - Laryngeal cancer - Whole organ section technique Dr. Antonino Carbone, Division of Pathology, Centro di Riferimento Oncologico, via Pedemontana Occidentale, Aviano 1-33081, haly