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Francis H Gannon

Publications and source records attributed to Francis H Gannon.

At least 19 recordsLinked to original sources
PubMed2005

Skeletal changes in epidermal nevus syndrome: does focal bone disease harbor clues concerning pathogenesis?

Epidermal nevus syndrome (ENS) is a rare, sporadic, congenital disorder of unknown etiology featuring a complex and highly variable phenotype that can include focal or generalized skeletal disease. We describe a young man with ENS manifesting right-sided linear skin lesions, generalized weakness, diffuse osteopenia associated with hypophosphatemic rickets, and distinctive focal bone lesions ipsilateral to the skin findings. Review of the literature concerning ENS-associated skeletal disease suggested such focal bone defects are fibrous dysplasia, but our patient did not have the typical radiographic or histopathologic findings of fibrous dysplasia. Nevertheless, his circulating fibroblast growth factor 23 (FGF-23) level was elevated, likely functioning as a "phosphatonin," yet no activating mutations in GNAS previously reported in fibrous dysplasia or McCune-Albright syndrome were detected in his leukocytes or affected skin. We postulate that the focal skeletal disease, although different than fibrous dysplasia, may be a source of FGF-23 in ENS.

Adolescent↗
PubMed2005

Novel compound enables high-level adenovirus transduction in the absence of an adenovirus-specific receptor.

Viral vectors are extensively used to deliver foreign DNA to cells for applications ranging from basic research to potential clinical therapies. A limiting step in this process is virus uptake and internalization into the target cells, which is mediated by membrane receptors. Although it is possible to modify viral capsid proteins to target the viruses, such procedures are complex and often unsuccessful. Here we present a rapid, inexpensive system for improving transduction of cells, including those that lack receptors for adenovirus fiber proteins. Addition of GeneJammer (Stratagene, La Jolla, CA) during the adenovirus transduction led to a significant increase in both the total number of transduced cells and the level of transgene expression per cell. Studies using cell lines deficient in adenovirus receptors demonstrated that addition of GeneJammer provided a novel cellular entry mechanism for the virus. These findings were tested in a cell-based gene therapy system for the induction of bone, which is contingent on high-level expression of the transgene. Inclusion of GeneJammer in either Ad5BMP2 or Ad5F35BMP2 transduction of a variety of cells demonstrated a correlating increase in bone formation. The results suggest a novel and versatile method for achieving high-level transduction using adenovirus.

Adenoviridae↗
PubMed2005

Repair of the immature and mature craniofacial skeleton with a carbonated calcium phosphate cement: assessment of biocompatibility, osteoconductivity, and remodeling capacity.

BACKGROUND: The apatite compounds used most commonly in craniofacial reconstruction are highly crystalline and biologically inert ceramics. Because their capacity to be replaced by native bone is limited, they have found little application in repair of the growing craniofacial skeleton. Carbonated calcium phosphate cements more closely resemble the mineral phase of bone, thereby offering enhanced bioresorption and osteoconductivity, but their fate in the immature and mature craniofacial skeleton has not been investigated. METHODS: The authors hypothesized that the capacity for cell-mediated remodeling of carbonated calcium phosphate cements is based on (1) their crystallographic and compositional similarity to the mineral phase of bone and (2) the osteogenic capacity of the host. Four noncritical-sized calvarial defects were created in six 3-week-old and six 16-week-old Yorkshire pigs. The defects were repaired with autologous bone, sintered carbonated calcium phosphate cement disks with a higher crystal order, or carbonated calcium phosphate cement (Norian CRS; Synthes Maxillofacial, West Chester, Pa.). The fourth defect was left empty as a control. Specimens were harvested at 30 and 90 days postoperatively. RESULTS: Empty defects healed with dense fibroconnective tissue in all groups. Autologous bone grafts underwent complete remodeling and replacement with woven bone at both time points. Sintered carbonated calcium phosphate disks demonstrated no bony ingrowth or remodeling. In immature animals, carbonated calcium phosphate cement implants were progressively replaced with woven bone through osteoclast-mediated resorption and osteoblast-mediated bone formation. Only minimal remodeling of the carbonated calcium phosphate cement implants was observed in skeletally mature animals. CONCLUSIONS: The results of these experiments suggest that the extent of remodeling of carbonated calcium phosphate cement is dependent on both the composition of the implant itself and the osteogenic capacity of the host and that carbonated calcium phosphate cement may be used successfully for inlay applications in the immature craniofacial skeleton.

Animals↗
PubMed2005

Intrauterine fetal constraint induces chondrocyte apoptosis and premature ossification of the cranial base.

BACKGROUND: The spheno-occipital synchondrosis is an important growth center of the craniofacial skeleton and a primary site of malformation in syndromic forms of craniosynostosis. Clinical and laboratory investigations have demonstrated that premature closure of cranial vault sutures in nonsyndromic craniosynostosis is associated with characteristic alterations in cranial base morphology. However, a causal link between premature fusion of calvarial sutures and changes in the cranial base remains elusive. The purpose of these experiments was to test the hypothesis that intrauterine head constraint produces ultrastructural changes in the spheno-occipital synchondroses of fetal mice. METHODS: Fetal constraint was induced through uterine cerclage of six pregnant C57Bl/6 mice on the eighteenth day of gestation. Fetuses were harvested after growing to 24, 48, and 72 hours beyond the normal 20-day gestational period. Between six and nine fetuses were harvested at all time points in both treatment and control groups. The morphology and cell biology of the spheno-occipital synchondroses, in constrained fetuses and unconstrained controls, were examined using hematoxylin and eosin-stained sections. Chondrocyte apoptosis was examined using terminal deoxynucleotidyl transferase-mediated dUDP end-labeling assays and electron microscopy. RESULTS: In nonconstrained animals, the spheno-occipital synchondrosis demonstrated normal architecture and normal chondrocyte morphology at all time points. In contrast, intrauterine constraint resulted in a progressive disruption of the normal cellular architecture of the spheno-occipital synchondrosis over 72 hours, with premature ossification of the synchondrosis. Widespread chondrocyte apoptosis within the synchondrosial growth center was demonstrated by terminal deoxynucleotidyl transferase-mediated dUDP end-labeling assays and electron microscopy. CONCLUSION: These experiments confirm the ability of intrauterine constraint to induce changes in the morphology and cell biology of the cranial base in synostotic fetuses.

Animals↗
PubMed2004

Neonatal lethal osteochondrodysplasia with low serum levels of alkaline phosphatase and osteocalcin.

Neonatal lethal skeletal dysplasias are rare and typically involve thoracic malformations and severe limb shortening. We report on a newborn boy manifesting an osteochondrodysplasia associated with fatal respiratory insufficiency who had normal lung volumes and extremity lengths. His disorder featured aberrant skeletal patterning and defective ossification including a severely osteopenic skull, apparent absence of clavicles, and clefting of the mandible and vertebrae. Serum alkaline phosphatase and osteocalcin levels were markedly low. Biochemical studies suggested parathyroid insufficiency probably from critical illness. Histopathology at autopsy excluded impaired mineralization of skeletal matrix, but endochondral bone formation appeared disorganized with growth plate clustering of chondrocytes in hypertrophic zones and in zones of provisional calcification. Parathyroid glands were not found. Despite features of two distinctive heritable entities, hypophosphatasia and cleidocranial dysplasia, the cumulative findings did not match either condition, and no mutations were found in either the tissue nonspecific ALP isoenzyme or core-binding factor genes, respectively, or in the genes encoding osteocalcin or the osteoblast transcription factor osterix. This patient could represent the extreme of cleidocranial dysplasia (a disorder not always associated with structural mutation in core-binding factor A1), but more likely he defines a unique osteochondrodysplasia disrupting both intramembranous and endochondral bone formation.

Alkaline Phosphatase↗
PubMed2004

Imaging of periosteal osteosarcoma: radiologic-pathologic comparison.

PURPOSE: To review the imaging appearance of periosteal osteosarcoma, with pathologic comparison. MATERIALS AND METHODS: Data for 40 pathologically confirmed periosteal osteosarcomas were retrospectively reviewed. Patient demographic data were recorded, and radiographs (n = 40), bone scintigrams (n = 10), angiograms (n = 2), and computed tomographic (CT) (n = 11) and magnetic resonance (MR) (n = 12) images were evaluated for lesion location and size, cortical changes, marrow involvement, and intrinsic characteristics by two musculoskeletal radiologists, with agreement by consensus. Pathology reports were reviewed for presence and predominance of histologic components (fibrous, chondroid, and osteoid), tumor grade, and marrow involvement. RESULTS: There were 25 male (62%) and 15 female (38%) patients with an age range of 10-37 years (average age, 20 years). The most frequent lesion locations were the diaphysis of the tibia (16 patients) or of the femur (15 patients). Radiographs showed a broad-based soft-tissue mass that was attached to the cortex (all patients) and showed cortical thickening (33 patients), cortical scalloping/erosion (37 patients), and/or perpendicular periosteal reaction (38 patients) extending into the soft-tissue mass. Soft-tissue masses were well defined in 91%-100% of cases and surrounded a median of 50%-55% of the cortex. Lesions commonly showed low attenuation at CT (10 patients) and high signal intensity on T2-weighted MR images (10 patients), reflecting the high water content of these largely chondroblastic lesions. Focal areas of adjacent marrow replacement were common at MR imaging (nine patients) but represented reactive changes unless they were in direct continuity with the overlying soft-tissue mass (this was rare, occurring in only one patient, and represented marrow invasion). Review of pathology reports revealed that all lesions contained chondroid tissue, which predominated in 34 patients. CONCLUSION: The radiologic appearance of periosteal osteosarcoma is a broad-based surface soft-tissue mass causing extrinsic erosion of thickened underlying diaphyseal cortex and perpendicular periosteal reaction extending into the soft-tissue component. Reactive marrow changes are commonly seen at MR imaging, but true marrow invasion is rare.

Adolescent↗
PubMed2003

Primitive adult hematopoietic stem cells can function as osteoblast precursors.

Osteoblasts are continually recruited from stem cell pools to maintain bone. Although their immediate precursor is a plastic-adherent mesenchymal stem cell able to generate tissues other than bone, increasing evidence suggests the existence of a more primitive cell that can differentiate to both hematopoietic and mesenchymal cells. We show here that the "side population" (SP) of marrow stem cells, defined by their ability to rapidly expel a DNA-binding dye and to regenerate the hematopoietic compartment, can differentiate to osteoblasts through a mesenchymal intermediate. When transplanted into lethally irradiated mice, single gene-marked murine SP cells reconstituted depleted osteoprogenitor pools, such that a large proportion of the osteogenic cells in the epiphysis of long bone carried the donor SP cell marker. These findings suggest that the developmental capacity of SP cells is not restricted to the hematopoietic lineages but extends to osteogenic differentiation. This property not only elucidates a previously unrecognized step in osteoblast development, but also has intriguing implications for the use of SP cells in clinical orthopedics and stem cell-based disorders of bone.

Animals↗
PubMed2003

Telangiectatic osteosarcoma: radiologic-pathologic comparison.

PURPOSE: To describe the imaging characteristics of a large series of telangiectatic osteosarcomas with pathologic findings for comparison. MATERIALS AND METHODS: The authors retrospectively reviewed 40 pathologically confirmed telangiectatic osteosarcomas. Patient demographics and images from radiography (n = 36), bone scintigraphy (n = 17), angiography (n = 4), computed tomography (CT) (n = 25), and magnetic resonance (MR) imaging (n = 27) were evaluated by three authors in consensus for lesion location, size, and intrinsic characteristics. There were 27 men (68%) and 13 women (32%) in the study, with an age range of 4-83 years (mean age, 24 years). RESULTS: Lesions frequently affected the femur, tibia, and humerus. Radiographs showed geographic bone lysis, a wide zone of transition, and matrix mineralization. CT demonstrated low attenuation, MR demonstrated high signal intensity on T2-weighted images, and both demonstrated hemorrhage, which simulated the appearance of aneurysmal bone cyst. Viable sarcomatous tissue surrounding hemorrhagic and/or necrotic regions was best seen at contrast material-enhanced CT and MR imaging, with thick peripheral, septal, and nodular enhancement in all cases. Subtle matrix mineralization in this viable tissue was best seen at CT. An associated soft-tissue mass was also seen in 19 of 25 cases (76%) at CT and in 24 of 27 cases (89%) at MR imaging. CONCLUSION: CT and MR imaging findings of telangiectatic osteosarcoma often include thick nodular tissue (and matrix mineralization at CT) in a largely hemorrhagic and/or necrotic osseous lesion with an associated soft-tissue mass, which allows distinction from aneurysmal bone cyst.

Adolescent↗
PubMed2003

Stromal cells of fibrodysplasia ossificans progressiva lesions express smooth muscle lineage markers and the osteogenic transcription factor Runx2/Cbfa-1: clues to a vascular origin of heterotopic ossification?

Fibrodysplasia ossificans progressiva (FOP) is a rare heritable genetic disorder, which is characterized pathologically by sporadic episodes of explosive growth of mesenchymal cells in skeletal muscle followed by cellular differentiation to heterotopic bone through an endochondral process. This study examined the histological origin and differentiation state of stromal cells in early FOP lesions and investigated the association between the phenotype of these FOP cells and bone formation. Interestingly, FOP lesional stromal cells were found to display characteristics of the smooth muscle (SM) cell lineage and are therefore potentially of vascular origin. These cells co-express multiple SM lineage markers along with multiple proteins associated with bone formation including the obligate osteogenic transcription factor Runx2/Cbfa-1. It is hypothesized that the stromal cells of early FOP lesions may be locally recruited vascular cells or cells of the bone marrow stroma and that these cells maintain the potential (given the correct environmental stimuli) to differentiate along an endochondral ossification pathway.

Biopsy↗
PubMed2003

Malignant giant cell tumor of the sphenoid.

Malignant giant cell tumors (MGCTs) of the sphenoid sinus are extremely rare neoplasms. They are challenging to diagnose and difficult to treat because of their skull base location. To the best of our knowledge, we report the first case of a primary MGCT of the sphenoid arising in a patient with Paget's disease. A 77-year-old man presented with epistaxis and a history of Paget's disease. There was normal cranial nerve function although radiographic images disclosed a large mass centered in the sphenoid sinus and extending into the ethmoid and maxillary sinuses. Excisional biopsy revealed a MGCT composed of a cellular stroma with increased mitotic activity and necrosis with giant cells present throughout. Additional therapy was declined and the patient died with disease 7 months later. Because of their rarity, no treatment guidelines exist for the management of MGCTs of the sphenoid. We discuss both the diagnostic and therapeutic considerations based on a review of the pertinent literature.

Aged↗
PubMed2003

Reconstruction of the immature craniofacial skeleton with a carbonated calcium phosphate bone cement: interaction with bioresorbable mesh.

Calcium phosphate cements have been recently introduced for use in craniofacial reconstruction. In the clinical setting, however, pulsations of the underlying brain and dura may interfere with the crystallization of these cements, thereby rendering their use in cranioplasty problematic. To circumvent such problems, many clinicians have interposed synthetic resorbable plates or mesh between the dura and the cement. At the present time, however, little is known about the influence of such materials or their breakdown products on the fate of calcium phosphate cements. The specific aim of this project was to evaluate the biocompatibility, osteoconductivity, and remodeling capacity of a calcium phosphate cement after implantation into experimental calvarial defects when combined with a resorbable mesh underlay. Four 10-mm diameter full-thickness calvarial defects (two frontal, two parietal) were created in each of six 3-week-old Yorkshire pigs. The defects were treated as follows: 1) empty control, 2) macroporous polylactic acid (70/30 L/DL polylactic acid [PLA]) mesh, 3) Norian CRS calcium phosphate cement, and 4) Norian CRS over PLA mesh underlay. Animals were divided into two groups. Half of the animals were killed 30 days after surgery, and half were killed 180 days after surgery, and the graft recipient sites were examined histologically. At 30 days, minimal bone ingrowth was observed in untreated calvarial defects or in those that were treated with PLA plates alone. Defects treated with the cement alone demonstrated a modest amount of new woven bone deposition, primarily at the periphery of the implants. Defects treated with calcium phosphate cement over PLA mesh underlays were characterized by remodeling and woven bone deposition at 30 days, with complete or near-complete osseous bridging of the ectocranial implant surfaces. Progressive bone ingrowth was noted in all defects at 180 days, with near-complete replacement of all Norian CRS implants by host bone. The PLA mesh remained incompletely resorbed at 180 days. No inflammatory response to the implants was observed at either time point. Calcium phosphate cement may be safely used for craniofacial reconstruction in the presence of PLA implants without compromise to its biocompatibility, osteoconductivity, or remodeling capacity.

Absorbable Implants↗
PubMed2003

Mesenchymal chondrosarcoma of the sinonasal tract: a clinicopathological study of 13 cases with a review of the literature.

OBJECTIVES/HYPOTHESIS: Mesenchymal chondrosarcoma of the sinonasal tract is a rare, malignant tumor of extraskeletal origin. Isolated cases have been reported in the English literature, with no large series evaluating the clinicopathological aspects of these tumors. STUDY DESIGN: Retrospective review. METHODS: Thirteen patients with sinonasal mesenchymal chondrosarcoma were retrieved from the Otorhinolaryngologic-Head and Neck Registry of the Armed Forces Institute of Pathology. RESULTS: Nine women and 4 men (age range, 11 to 83 y; mean age, 38.8 y) presented with nasal obstruction (n = 8), epistaxis (n = 7), or mass effect (n = 4), or a combination of these. No patients reported prior head and neck irradiation. The maxillary sinus was the most common site of involvement (n = 9), followed by the ethmoid sinuses (n = 7) and the nasal cavity (n = 5). Tumors had an overall mean size of 5.1 cm. Microscopically, the tumors displayed a small, blue, round cell morphology appearance arranged in a hemangiopericytoma-like pattern with foci of cartilaginous matrix. All cases were managed by surgery with adjuvant radiation therapy (n = 4) and/or chemotherapy (n = 3). The overall mean survival was 12.1 years, although five of six patients who developed local recurrences died of disease (mean survival, 6.5 y). Six patients were alive and disease free (mean survival, 17.3 y), and two patients were lost to follow-up. CONCLUSIONS: Mesenchymal chondrosarcoma of the sinonasal tract is an aggressive tumor with a predilection for young women. The pattern of growth and scarcity of cartilaginous matrix result in frequent misdiagnosis. Recurrence develops in approximately one-third of patients and seems to predict a poor prognosis. Aggressive, exenterative surgery combined with adjuvant therapy appears to yield the best clinical outcome.

Adolescent↗
PubMed2002

Use of a chimeric adenovirus vector enhances BMP2 production and bone formation.

Recombinant adenoviral vectors have potential for the treatment of a variety of musculoskeletal defects and such gene therapy systems have been a recent research focus in orthopedic surgery. In studies reported here, two different adenovirus vectors have been compared for their ability to transduce human bone marrow mesenchymal stem cells (hBM-MSCs) and elicit bone formation in vivo. Vectors consisted either of standard adenovirus type 5 (Ad5) vector or a chimeric adenovirus type 5 vector that contains an adenovirus type 35 fiber (Ad5F35), which has been recently demonstrated to bestow a different cellular tropism, and a complete cDNA encoding human bone morphogenetic 2 (BMP2). Studies were also conducted to compare the transduction efficiency of these vectors using enhanced green fluorescent protein (GFP). hBM-MSCs transduced with Ad5F35 vectors had higher levels of transgene expression than those transduced with Ad5 vectors. The results also demonstrate that hBM-MSCs lack the coxsackie-adenovirus receptor (CAR), which is responsible for cellular adsorption of Ad5. Therefore, the data suggest that Ad5 virus adsorption to hBM-MSCs is inefficient. Ad5BMP2- or Ad5F35BMP2-transduced hBM-MSCs were also compared in an in vivo heterotopic bone formation assay. Mineralized bone was radiologically identified only in muscle that received the Ad5F35BMP2 transduced hBM-MSCs. In summary, Ad5F35BMP2 can efficiently transduce hBM-MSCs leading to enhanced bone formation in vivo.

Adenoviridae↗
PubMed2002

Chondrosarcoma of the larynx: a clinicopathologic study of 111 cases with a review of the literature.

Chondrosarcomas of the larynx are rare tumors accounting for about 0.5% of all laryngeal primary tumors. A total of 111 laryngeal chondrosarcoma cases, diagnosed between 1970 and 1997, were retrieved from the Otorhinolaryngic-Head & Neck Tumor Registry of the Armed Forces Institute of Pathology. There was a 3.6:1 male/female ratio of patients 25-91 years of age (mean, 64.4 years). Patients presented most frequently with hoarseness (n = 72 patients) present for a mean of 28.2 months. The majority of tumors involved the cricoid cartilage (n = 77) with a mean size of 3.5 cm. All tumors were invasive and malignant by radiology and/or histology (into bone within the ossified laryngeal cartilages in 52 tumors). Most tumors were low-grade lesions: grade 1 (n = 51), grade 2 (n = 54); there were six grade 3 tumors. An associated benign chondroma with (n = 41 tumors) or without ischemia (n = 24 tumors) was noted. All patients had surgery and five had radiation therapy. Wide excision or voice-sparing surgery was used in 73 patients, whereas 37 patients had a laryngectomy. Recurrences occurred in 20 (18%) patients, 10 of whom underwent salvage laryngectomy. At the last follow-up, 102 patients had no evidence of disease (alive or dead, mean 11.2 years) and five patients had evidence of disease (alive, one patient, 6.5 years; dead, four patients, mean 6.4 years). The six patients with high-grade chondrosarcoma were all without disease at the last follow-up (mean, 15.1 years). There was no difference in clinical outcome based on grade (p = 0.210), location (p = 0.078), or treatment (p = 0.607) but was worse for patients with a myxoid-type chondrosarcoma (p = 0.044). Primary laryngeal chondrosarcomas are typically low- to moderate-grade lesions involving the cricoid cartilage, frequently associated with a chondroma. They usually portend an excellent overall long-term prognosis with initial conservative voice-sparing surgery.

Adult↗
PubMed2002

Repair of the immature craniofacial skeleton with a calcium phosphate cement: quantitative assessment of craniofacial growth.

The potential for growth restriction has limited the use of alloplastic materials for reconstruction of the growing craniofacial skeleton. A calcium phosphate cement that has been introduced recently for craniofacial reconstruction crystallizes in situ into a substance that resembles more closely the mineral phase of bone, thereby offering the potential for enhanced bioresorption and osteoconductivity. The purpose of these experiments was to assess quantitatively craniofacial growth after reconstruction of frontal craniectomy defects in skeletally immature animals with this calcium phosphate bone mineral substitute. To simulate the calvarial defects that result from unilateral fronto-orbital advancement procedures, unilateral frontal bone flaps were removed in 3-week-old female Yorkshire piglets. The bone flaps were trimmed medially and posteriorly, and were then reattached to the supraorbital ridge. The resulting 5-mm gap between the frontal bone flap and the native bone was either filled with Norian CRS bone cement (N = 3) or left empty (N = 3). After 90 days, the animals were killed and the skulls were harvested and cleared. Direct craniometric measurements were performed on the prepared dry skulls to assess craniofacial growth in all dimensions. Extensive remodeling was observed within defects treated with the calcium phosphate cement, with complete or near-complete replacement of the cement by host bone, resulting in a solid bony union. Direct craniometric measurements revealed no differences in craniofacial growth in any dimension between the operated and unoperated sides of the cranium in either group. These studies demonstrate that craniofacial growth is not restricted after reconstruction of frontal craniectomy defects with carbonated calcium phosphate cement in skeletally immature animals. The remodeling capacity of this material offers promise for its safe use in reconstruction of the growing calvarium.

Animals↗
PubMed2002

Dedifferentiated chondrosarcomas of the larynx: a report of two cases and review of the literature.

OBJECTIVE: To analyze the long-term clinical outcome of dedifferentiated chondrosarcoma or chondrosarcoma with additional malignant mesenchymal component (CAMMC) of the larynx and compare the results with those of axial chondrosarcomas. STUDY DESIGN/METHODS: Two patients with CAMMC of the larynx (0.03%) were retrospectively identified within the archives of the Armed Forces Institute of Pathology between 1970 and 2001. We compared the clinical and histologic features of these two cases with those reported in the English literature (Medline 1966-2001) (Table I). RESULTS: Patient no. 1 was a 67-year-old man who presented with a 12-month history of hoarseness and was found to have a 4-cm mass involving the cricoid cartilage. Enucleation was performed and histologically demonstrated a dedifferentiated chondrosarcoma. Without additional intervention, the patient died after 136 months without evidence of disease. Patient no. 2 was a 41-year-old man who also presented with a 12-month history of hoarseness and dysphagia and was found to have a 5-cm mass involving the cricoid cartilage. A total laryngectomy was performed for the dedifferentiated chondrosarcoma. He is alive without evidence of disease at last contact (91 mo). CONCLUSION: CAMMC of the larynx are rare tumors but have a better prognosis than their axial counterparts (mean, 6 mo). Initial voice-sparing surgery can be followed with more aggressive surgery if recurrences develop.

Adult↗