Management Of Nonepidermoid Cancer Of The Larynx

Non-Squamous Cell Carcinoma of the Larynx: A State-of-the-Art Review

(1) Background: Non-squamous cell laryngeal carcinoma includes endothelial tumors, such as minor salivary gland tumors, lymphoepithelial tumors, neuroendocrine tumors, soft and hard tissue sarcomas, and malignant melanomas. (2) Methods: A state-of-the-art review using the MEDLINE/PUBMED, Google Scholar, Ovid Medline, Embase, and Scopus electronic databases was performed. (3) Conclusions: In order to optimize overall treatment outcomes, a multidisciplinary, patient-centered approach to the management of non-SCC of the larynx must be adopted universally; a national or international registry on non-SCC laryngeal cancer can be useful to improve understanding about the behavior of this kind of tumor.

Next-Generation Sequencing as an Auxiliary Tool in Pediatric Laryngeal Lymphoma Diagnosis

Lymphomatous involvement of the larynx is a rare entity. We present a case of atypical laryngotracheitis as the initial manifestation of non-Hodgkin's lymphoma in a pediatric patient. The diagnosis was aided through the use of microbial cell-free DNA (mcfDNA) testing, which detected the presence of Epstein-Barr virus in the patient's plasma. This enabled the consideration of an Epstein-Barr virus-related lymphoproliferative process, leading to additional workup and the final diagnosis of lymphoma. To our knowledge, this is the first case of mcfDNA testing leading not simply to an infectious organism, but further to a new oncologic diagnosis. Plasma mcfDNA testing has the potential to inform clinical practice beyond classic infectious disease manifestations. In this article, we review both the possible future applications and the areas of further investigation that remain.

Neuroendocrine Carcinomas of the Upper Airways: A Small Case Series with Histopathological Considerations

Neuroendocrine carcinomas are rare tumors. In the head and neck region they are most common in the larynx, where they represent 0.5-1% of epithelial cancers. Diagnosis requires the recognition of the typical neuroendocrine architecture and morphology and the immunohistochemical confirmation of neuroendocrine differentiation. In the 1991 WHO classification laryngeal neuroendocrine carcinomas have been divided into carcinoids, atypical carcinoids, small cell carcinomas and paragangliomas. Atypical carcinoids in the head and neck region usually show an aggressive behavior analogous to poorly differentiated carcinomas, and are resistant to chemo- and radiotherapy. For this reason, it was recently proposed to change their designation to “moderately differentiated neuroendocrine carcinomas”.

We present the clinical and histopathological features of 2 moderately differentiated neuroendocrine carcinomas of the larynx, one large cell poorly differentiated neuroendocrine carcinoma of the oropharynx, and one small cell carcinoma of the minor salivary glands of the tongue. The patient with small cell carcinoma was free from disease 26 months after radical surgery, while the other patients showed liver, lung and bone metastases 18, 26 and 24 months after the diagnosis despite radical surgery or concomitant intra-arterial chemotherapy and radiotherapy.

Individual participant data meta-analysis of primary laryngeal lymphoma: Focusing on the clinical characteristics and prognosis

OBJECTIVES/HYPOTHESIS

Primary lymphoma of the larynx is rare. The symptoms are ambiguous and nonspecific, and confirmation of the diagnosis is often difficult. To better understand the clinical characteristics of this distressing disease, we performed an individual participant data meta-analysis focusing on the diagnoses and treatment outcomes.

STUDY DESIGN

Systematic review article.

METHODS

A literature search of the MEDLINE, Embase, and Cochrane library databases was conducted using the following Medical Subject Headings and keywords: "primary," "lymphoma," "cancer," and "larynx." The individual data of 57 patients from 41 articles were selected based on the inclusion criteria for the analysis.

RESULTS

The mean age of the 57 patients at the time of diagnosis was 53.9 ± 18 years, and there was a preponderance of male patients (male:female = 35:22). The mean follow-up was 33.2 ± 40.5 months. The most common symptom was hoarseness (70.2%). Extension of the lymphoma was found in the supraglottic larynx (63.2%). B-symptoms were noted in only 14.0% of patients. The treatment method and disease extent were not significant factors. The significant prognostic factors were the biopsy frequency (P = .000), B-symptoms (P = .032), and cell type (P < .001).

CONCLUSIONS

From an analysis of larynx lymphoma patients, accurate biopsy, the presence of B-symptoms, and the cell type of the lymphoma are important to the prognosis. However, the treatment method was not effective in predicting the prognosis.

LEVEL OF EVIDENCE

NA.

Malignant melanoma metastatic to the larynx: a case report

Malignant melanoma of the larynx is a rare cancer that can appear as a primary tumor or as a metastasis from a cutaneous head and neck primary. To the best of our knowledge, only 60 cases of primary laryngeal melanoma have been reported in the world literature. Melanomas metastatic to the larynx are even more rare, as only 24 cases have been previously reported. Survival is poor, and recurrence is uncommon. We describe a new case of a malignant melanoma metastatic to the larynx, which represents the first such case in Iran.

Imaging characteristics of primary laryngeal lymphoma

BACKGROUND AND PURPOSE

The larynx is a rare site for primary NHL. Fewer than 100 cases have been reported in the literature, with the largest imaging review involving only 4 patients. We describe the findings of laryngeal lymphoma on CT, PET, and MR imaging and identify features that may distinguish laryngeal lymphoma from the far more common laryngeal squamous cell carcinoma.

MATERIALS AND METHODS

Multi-institutional retrospective chart review revealed 20 patients with histopathologically proved laryngeal lymphoma. Pretreatment CT, PET, and MR images were reviewed by a head and neck radiologist, focusing on extent of tumor, cervical lymph node involvement, and enhancement patterns.

RESULTS

Patients ranged from 30 to 90 years of age with a mean of 63 years at the time of initial diagnosis and a 2:1 female predominance. The average tumor size was 37 +/- 19 mm. In all patients, laryngeal lymphoma involved the supraglottis but also extended into the glottis (65%) and hypopharynx (60%). The subglottis was less frequently involved (35%). Laryngeal cartilage invasion and cervical lymphadenopathy were each seen in 20% of patients. Lymphoma was consistently FDG-avid (100%) and usually enhanced uniformly with iodinated contrast (73%). Necrosis and calcification were not seen in any cases.

CONCLUSIONS

Although laryngeal lymphoma is rare, particular imaging features suggest this diagnosis. A large uniformly enhancing supraglottic tumor without central necrosis and without cervical lymphadenopathy is a characteristic finding of lymphoma. Similar to squamous cell carcinoma, lymphoma may extend into the subglottis, pharynx, and laryngeal cartilages.

Neuroendocrine Carcinoma of the Jugular Foramen

We describe what might have been the first reported case of a neuroendocrine carcinoma of the jugular foramen. A 50-year-old woman presented with progressive left-sided sensorineural hearing loss, vertigo, pulsatile tinnitus, headaches, and ataxia. Magnetic resonance imaging revealed a 4-cm left-sided jugular foramen tumor. The patient underwent near-total resection of the tumor. Despite lower cranial nerve preservation, postoperative paralysis of cranial nerves IX and X occurred, and vocal fold medialization was performed 5 days later. The final pathologic diagnosis was neuroendocrine carcinoma. The patient was treated with concurrent chemotherapy and intensity-modulated radiation therapy. This article will discuss the pathologic features and the management of jugular foramen tumors, along with the differential diagnosis of these rare tumors.

Solitary extramedullary plasmacytoma of the canine larynx

An 11-year-old, female, spayed cocker spaniel was presented with dysphonia caused by a solitary laryngeal mass. Excisional biopsy was performed, and a diagnosis of plasmacytoma was made on the basis of histological examination. Further investigations showed no signs of systemic involvement. Coarse fractionated radiation therapy failed to control the tumour. Therapy was successfully instituted with a conventional combination chemotherapy protocol over a period of 14 months. The dog remains disease free 30 months after diagnosis. Most solitary, extramedullary plasmacytomas in dogs arise in the gastrointestinal tract, with fewer reports in other sites. The larynx is an uncommon sight of involvement in any species, and to the authors' knowledge, this is the first report of this tumour type in the canine larynx. In contrast to the therapeutic benefits reported in humans, the combination of surgery and radiation therapy was unsuccessful in this case, although sustained remission was gained following chemotherapy.

Neuroendocrine neoplasms of the larynx: Advances in identification, understanding, and management

While 85-90% of laryngeal malignancies prove to be squamous carcinomas, the second most common tumour type found in the laryngeal region will prove to be a member of the family of neuroendocrine tumours. Laryngeal carcinoid tumours have a capacity for metastasis, and so are more aggressive tumours than their light microscopic features might imply--5-year survival rates are in the vicinity of 50%. Laryngeal atypical carcinoid tumours are lesions with a well-recognized capacity for local recurrence as well as metastasis, with a 5-year survival of just under 50%. Laryngeal small cell neuroendocrine carcinomas are particularly aggressive tumours, with a 5-year survival of no more than 5-10%. Laryngeal paragangliomas are lesions without any real capacity for metastasizing. Surgical excision is the mainstay of treatment of carcinoid tumours, atypical carcinoid tumours, and paragangliomas. Small cell neuroendocrine carcinomas are chiefly treated by way of radiation and chemotherapy; the role of adjuvant therapy in the treatment of atypical carcinoid tumours remains to be established.

Salivary gland carcinoma of the larynx

BACKGROUND

Salivary gland carcinomas of the larynx are rare, and account for < 1% of laryngeal malignancy. The purpose of this study is to review our management experience of salivary gland carcinomas of the larynx in Taipei Veterans General Hospital and to compare it with other major existing series.

METHODS

From 1981 to 2000, 11 patients with laryngeal salivary gland carcinomas treated in Taipei Veterans General Hospital were included in this study. Their demographic data, treatment modalities, survival, and failure pattern, obtained by review of medical records, were analyzed.

RESULTS

All 11 patients were male. Median follow-up period was 95 months (range, 18-181 months). The 5-year overall survival rate of all patients was 71%, and the 5-year disease-specific survival rate was 83%.

CONCLUSION

The mainstay treatment of laryngeal salivary gland carcinomas in these cases was surgery or surgery with postoperative radiotherapy. The survival rate was satisfactory and similar to that of squamous cell carcinoma of the larynx.

Sarcomas of the head and neck region

PURPOSE OF REVIEW

This review discusses the classification, etiology, diagnosis, evaluation, treatment, and prognosis of sarcoma of the head and neck region.

RECENT FINDINGS

Sarcomas account for less than 1% of all malignancies in the United States with only 5 to 15% of these sarcomas occurring in the head and neck region. However, about 1 in 3 pediatric sarcomas will occur in the head and neck region. Occasionally, these tumors are associated with genetic syndromes or previous radiation exposures, but, most commonly, no clear etiology exists. Pathologic classification is critical to the ultimate treatment and prognosis of sarcoma of the head and neck. Osteosarcoma, rhabdomyosarcoma, malignant fibrous histiocytoma, and angiosarcoma are the most common types of sarcoma to occur in the head and neck region; however, up to 20% of head and neck sarcomas will remain unclassified. Surgery has been central to the management of these malignancies with some exceptions in the pediatric population. Adjuvant chemotherapy is being utilized and/or studied for most high-grade sarcomas and adjuvant radiotherapy is important for disease control in high-grade soft-tissue sarcomas. Prognosis is clearly related to tumor grade and margin status.

SUMMARY

Sarcomas of the head and neck region are rare malignancies often without a clear etiology. Expert pathologic review and classification is critical, as are quality imaging and multidisciplinary management.

Sarcomas of the head and neck

With the exception of pediatric RMS, soft tissue sarcomas only rarely arise in the head and neck region. Soft tissue sarcomas include a diverse array of histologic types because of the variety of mesenchymal tissues from which they originate. The combination of infrequent occurrence, varied pathologic features, and the many potential sites of presentation makes these tumors a challenge for the head and neck oncologist and underscore the need for review by a pathologist experienced with soft tissue tumors. Classification schemes that group sarcomas according to grade have been helpful in providing prognostic information. Although local control of the primary tumor is critical to successful treatment of both high- and low-grade lesions, the high rate of distant metastases in high-grade tumors supports the role of combined modality therapy. Compared with other types of head and neck neoplasms, such as squamous cell carcinoma, soft tissue sarcomas have low rates of regional metastases. Surgery generally has been recommended as the primary method of treatment for achieving local control, except in those high-grade tumors arising in sites not amenable to resection. Exceptions to this principle include RMSs of the orbit, paranasal sinuses, and masticator space in children; these are usually treated with radiotherapy and combined multiagent chemotherapy, thereby avoiding the functional and cosmetic impact of surgery. Also, extensive angiosarcomas of the scalp should be treated with multimodality therapy combining surgery and wide-field radiation therapy in an attempt to achieve local control. Adjuvant radiotherapy is generally recommended for high-grade sarcomas, large tumors, close or positive surgical margins, and certain histologic variants. Systemic chemotherapy is recommended for those tumors with a significant risk of distant metastases. Increasingly, neoadjuvant chemotherapy is being used to determine responsiveness to chemotherapy, which can help physicians select patients who may benefit from systemic postoperative therapy. Traditional predictors of treatment failure for soft tissue sarcomas include larger tumor size, high-grade histology, and positive surgical margins. The advent of more advanced reconstructive techniques, including free tissue transfer, has made more aggressive surgical resection of these tumors possible. Nevertheless, a considerable number of ancillary support staff are critical to the patient's postoperative rehabilitation and eventual return to a satisfactory level of function and quality of life. In the future, the discovery of the molecular pathogenesis of specific tumor types, such as the cytogenetic findings in synovial sarcoma, will improve physicians' prognostic abilities and selection of patients who are most likely to benefit from emerging adjuvant therapies.

Solitary plasmacytosis of the larynx in a patient with non-Hodgkin's lymphoma

Solitary plasmacytosis of the larynx is a clinically unusual event. It may cause hoarseness or airway obstruction and usually needs surgical excision. Plasmacytosis is distinguished from extramedullary plasmacytoma (EMP) in that the latter primarily involves the head and neck and needs more intensive therapy such as radiotherapy. Many reports have described the histopathology and immunohistochemistry of EMP of the larynx; however, no literature in English has described solitary plasmacytosis of the larynx. We report a 44-year-old female patient with non-Hodgkin's lymphoma and systemic lupus erythromatosus with Sjögren's syndrome. She complained of 1-year period of hoarseness that became exacerbated in the most recent 3 weeks. A wide-base and smooth-surface mass at the left supraglottic area was noted by direct laryngoscope. Computed tomography scan revealed a well-defined radiopaque mass. The histopathology of a specimen excised by carbon dioxide laser-assisted laryngomicrosurgery was interpreted initially as plasmacytoma. Immunohistochemical staining for kappa and lambda light chains demonstrated polyclonal plasma cells, and the definitive diagnosis was plasmacytosis. After 6 months follow-up, the subjective quality of her voice improved. Laryngoscopic examination revealed no evidence of recurrence.

Laryngeal chondrosarcoma: a 24-year experience at the Royal National Throat, Nose and Ear Hospital

This paper presents a review of the experience of 12 patients with chondrosarcoma of the larynx treated at The Royal National Throat, Nose and Ear Hospital, London, over the last 24 years. This represents the largest European series and the third largest in the world. Chondrosarcoma is the most frequent non-epithelial malignant tumor of the larynx, with 83.3% of cases arising from the cricoid cartilage in our series. We have shown that deep wedge biopsy with a CO2 laser, aided by computerized tomography scanning, gives the most reliable diagnosis. Laryngeal chondrosarcoma is characterized by indolent growth, a potential for local recurrence and, infrequently, by metastases. The treatment details of our patients are discussed. Adequate partial resection is often successful and use of CO2 laser as the initial treatment in five of these cases is presented.

Chondroid tumors of the larynx: computed tomography findings

PURPOSE

Chondromas and chondrosarcomas of the larynx are rare cartilaginous tumors making up less than 1% of all laryngeal tumors. Patients typically present with symptoms of hoarseness, dysphagia, or dyspnea. The most common location in the larynx for these tumors is the cricoid cartilage. Radiographically, these lesions are typically hypodense, well-circumscribed masses containing mottled calcifications with smooth walls centered within the cartilage.

MATERIALS AND METHODS

We present 6 cases of chondroid tumors of the larynx.

RESULTS

One patient had a chondroma, 4 patients had low-grade chondrosarcomas, and 1 patient had an intermediate-grade chondrosarcoma. Two partial laryngeal resections and 4 total laryngectomies were performed.

CONCLUSIONS

In most cases of chondroma or chondrosarcoma of the larynx, conservative surgery should be attempted, but total laryngectomy may be required for large or recurrent lesions.