The pathology of neck dissection in cancer of the larynx

Cancer of the larynx is a common problem in a head and neck oncological surgical practice; as such, pathology departments supporting such surgical practices will examine cervical lymph node dissection specimens with some frequency. Issues to be settled among pathologists and surgeons include--How precise an anatomic dissection of the specimen is called for? What histological features of the specimen will be of most use to the clinicians who are devising a course of postoperative therapy for the patient? What sorts of methods are needed to identify the maximum number of micrometastases which may be lurking within the lymph nodes of the specimen? Is there a role for routine application of special techniques--such as immunohistochemistry or molecular biology--in the analysis of these specimens? While the answers to these questions are likely to vary somewhat from one center to another, patients are best served when these questions are discussed amongst the respective physicians before surgical procedures are undertaken, rather than after the fact.

Classification and terminology of neck dissections

With the proliferation of operations designed to treat cervical metastatic nodal disease, it has become ever apparent for the need to more clearly and precisely communicate the location of the metastatic cervical nodes and the specific surgery performed. To this end, this paper reviews the variety of operations and the resultant confusing terminology that has emerged over the past five decades. It is suggested that a simplified technology be used that specifically describes the nodal levels dissected, the relevant nonlymphatic structures removed, and those structures that are preserved. It is also suggested that the new imaging-based nodal classification be used to standardize the definition of the nodal levels. It is hoped that this approach will eliminate many of the often confusing and nondescriptive terms and there by facilitate better inter-physician and inter-institutional communication.

The role of partial laryngeal resection in current management of laryngeal cancer: a collective review

A spectrum of treatment plans and surgical procedures is available for management of early and moderately advanced laryngeal cancer. While the approach of chemotherapy and irradiation, or irradiation alone, followed by total laryngectomy for failure is often employed in practice by present day clinicians, the options of conventional conservation surgery (CCS), transoral endoscopic laser surgery (TLS) and supracricoid partial laryngectomy (SCPL) provide a wide choice of treatments that may help attain the goal of cure with preservation of laryngeal function and integrity of the airway. While CCS has been supplanted for many early-stage lesions by TLS and for more advanced stages by SCPL, centres throughout the world have reported favourable results with CCS, which is often modified to include resection of more extensive tumours than was previously possible. During the past decade a number of extended CCS procedures have been developed for management of glottic tumours involving both vocal cords and the anterior commissure, the paraglottic space and with vocal cord fixation, and for supraglottic tumours involving the glottis or hypopharynx. TLS has proved an effective, minimally invasive and functionally satisfactory procedure for management of suitable T1 and T2 glottic cancers, and stage I-III supraglottic cancers. The procedure may be effectively employed in combination with neck dissection and postoperative radiotherapy when necessary, particularly for moderately advanced supraglottic carcinomas. SCPL has proven effective in management of glottic and supraglottic cancers of all stages, even with involvement of paraglottic space and thyroid cartilage, provided at least one arytenoid unit can be preserved with clear margins. Invasion of cricoid cartilage is the most significant limitation for this procedure. All three surgical approaches have been employed for irradiation failure, but with greatly increased failure and complication rates compared with the results of treatment of non-irradiated patients. Thus a decision to treat laryngeal cancer initially with irradiation may preclude a satisfactory result from partial laryngectomy should radiation fail. The treatment of laryngeal cancer should be individualized according to the size and extent of the tumour, the age and physical condition of the patient, and the skill and experience of the surgeon with various treatment modalities and surgical procedures.

Pathologic detection of occult metastases in regional lymph nodes in patients with head and neck cancer

Squamous carcinomas of the head and neck region are exceedingly common problems in the routine practice of head and neck tumour surgery. Well-defined treatment protocols have evolved to manage patients afflicted with such tumours. This article explores the role of the hospital pathologist in the detection of occult metastases. The conventional approach to evaluation of cervical nodes from a neck dissection is reviewed, and then the potential utility of more recently developed diagnostic approaches (such as immunohistochemistry and polymerase chain reaction) is explored.

False negative conventional histology of lymph nodes in patients with head and neck cancer

Lymph node micrometastases in patients with head and neck cancer found node-negative by clinical examination and conventional histology may be discovered with additional sectioning of the lymph nodes, by immunohistochemistry and by molecular biology.

Hyalinizing trabecular adenoma of the thyroid diagnosed by fine-needle aspiration biopsy

Two cases of hyalinizing trabecular adenoma of the thyroid are presented. The diagnosis was established on initial assessment by fine-needle aspiration biopsy. Histologic evaluation of the surgical specimens confirmed the diagnosis of hyalinizing trabecular adenoma.

Paraneoplastic syndromes in patients with laryngeal and hypopharyngeal cancers

Paraneoplastic syndromes are systemic, nonmetastatic manifestations associated with a variety of malignant neoplasms and occurring in a minority of cancer patients. Paraneoplastic syndromes in association with cancers of the larynx and hypopharynx are considered rare. The world literature is reviewed, dividing paraneoplastic syndromes into 4 main groups, ie, cutaneous (acanthosis nigricans, Bazex's syndrome, Bowen's disease, bullous pemphigoid, dermatomyositis, pruritus, Sweet's syndrome, yellow nail syndrome, and tylosis), endocrine (carcinoid syndrome, adrenocorticotropic hormone syndrome, Schwartz-Bartter syndrome, hypercalcemia), hematologic (Trousseau's syndrome), and neurologic (cerebellar degeneration, Eaton-Lambert myasthenic syndrome). A paraneoplastic syndrome may precede the clinical manifestations of a persistent or recurrent tumor or of asymptomatic metastases, and its onset may even, in a minority of cases, be the presenting sign of a malignancy. Otolaryngologists and head and neck surgeons should have a knowledge of the paraneoplastic syndromes in order to facilitate their detection of malignancies or recurrences.

Bilateral secondary syphilis of the tonsil

A patient with bilateral tonsillar enlargement secondary to syphilis is presented. Clinical appearance, histological findings and serological tests permitted a correct diagnosis to be obtained, ruling out the suspicion of cancer.

Micrometastases: have they an impact on prognosis?

Current routine histopathologic methods may fail in detecting lymph node micrometastases, while the introduction of newer, sensitive techniques, such as immunohistochemistry and molecular analysis, can improve their detection. The literature reveals that the presence of micrometastases has clinical and prognostic implications.

Review of sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) of head and neck

The entity known as sinus histiocytosis with massive lymphadenopathy (SHML), or Rosai-Dorfman disease (RD disease), is an uncommon benign proliferation of hematopoietic and fibrous tissue that often presents in the head and neck region. Its initial manifestations most often include a roughly symmetric, painless, bilateral cervical adenopathy, although extranodal disease may develop in a minority of patients. The key histologic feature of SHML is the presence of various numbers of large, pale histiocytic cells that contain within their cellular borders apparently engulfed lymphocytes ("emperipolesis"); these distinctive large, pale cells - RD cells - are S-100 protein-positive by immunostaining and so differ from ordinary histiocytes. Despite its sometimes impressive clinical presentation, SHML is a benign and self-limited disease, whose treatment is aimed largely at controlling its local manifestations (most often by surgical therapy). The microscopic differential diagnosis, particularly in extranodal disease, is at times challenging and can include Langerhans' cell histiocytosis, Hodgkin's disease, non-Hodgkin's lymphoma, metastatic carcinoma, and metastatic malignant melanoma.

Histiocytic necrotizing lymphadenitis (Kikuchi-Fujimoto disease) diagnosed by fine needle aspiration biopsy

A case of histiocytic necrotizing lymphadenitis involving a right submandibular lymph node is described in a 14-year-old Caucasian boy. The diagnosis was established on initial assessment by fine needle aspiration biopsy. Excisional biopsy, performed because the lymph node enlargement failed to regress, confirmed the cytological findings.

Kimura's disease of the intraparotid lymph nodes: fine needle aspiration biopsy findings

A case of Kimura's disease involving two intraparotid lymph nodes is described in a 16-year-old Caucasian boy presenting with a painless swelling of the right parotid gland. A preoperative diagnosis of Kimura's disease was made on the basis of fine-needle aspiration biopsy (FNAB) and was confirmed by histological evaluation of the surgical specimen. FNAB is a safe and accurate procedure that can be used in the outpatient setting to enable a prompt preliminary diagnosis.

Management of the clinically negative cervical lymph nodes in patients with non-conventional squamous carcinoma of the larynx

This paper discusses the indications for neck dissection in those patients with laryngeal tumours which prove to be, on pathologic examination, not conventional squamous carcinomas but rather fall into the category either of one of the uncommon histological subtypes of carcinoma, or another type of unusual histological variant of laryngeal malignancy, a mesenchymal tumour. It appears as though these unusual laryngeal malignancies may manifest both biological behaviours and propensities to metastasize to regional lymph nodes that differ from those of the more commonly encountered conventional squamous carcinomas of the larynx. This heterogeneous group of tumours accounts for about 10 per cent of all malignant tumours of the larynx.

Laryngeal malignant neoplasms in children and adolescents

An exhaustive literature review of the last two decades discloses 47 laryngeal malignant neoplasms in children and adolescents. The most frequent malignant neoplasm is the embryonal variant of rhabdomyosarcoma. The timely diagnosis of a laryngeal neoplasm depends on maintaining a high index of suspicion in a patient with progressive airway obstruction, dysphagia or dysphonia, and conducting an efficient work-up-including magnetic resonance imaging and direct laryngoscopy under general anesthesia in association with bronchoscopy-in order to define the extent of the lesion, rule out multiple lesions, establish and maintain an airway, and perform a biopsy of the tumor. The authors observed that several risk factors, such as previous radiation therapy for juvenile laryngeal papillomatosis, intrauterine exposure to ionizing radiation, chemical carcinogens, smoking or tobacco exposure were lacking in those patients with a detailed clinical history. Probably, cancer of the larynx in these unusual patients is the final result of an interaction of immunological and genetic factors. The choice of therapy depends on several factors, including the clinical stage at presentation, histological type and potential radio-chemosensitivity of the tumor.

Basaloid squamous cell carcinoma of oral cavity and oropharynx

Basaloid squamous cell carcinoma is a variant of squamous cell carcinoma with distinctive histological and immunohistochemical characteristics and aggressive behaviour involving predominantly the upper aerodigestive tract. We describe the clinicopathological findings, along with immunohistochemical investigations, in 5 new cases with carcinoma localized in oral cavity and oropharynx.

A review of heterotopia and associated salivary gland neoplasms of the head and neck

Salivary tissue neoplasms may involve normal, accessory and heterotopic salivary gland tissue. A case of Warthin's tumour originating from heterotopic salivary gland tissue of the upper neck is reported. The radioactive uptake of 131I, evidenced in the neck mass in its pre-diagnostic assessment, suggested a diagnosis of cervical node involvement from a primary malignant thyroid neoplasm. A critical review of the literature on heterotopic salivary gland tissue neoplasms of the head and neck is also presented.

Sinonasal malignant lymphomas: a distinct clinicopathological category

Sinonasal lymphomas represent a distinct subset of extranodal head and neck lymphomas. While sinonasal lymphomas are relatively rare in Western countries, in Asian populations they are the second most frequent group of extranodal lymphomas, after gastrointestinal lymphomas. With advances in immunohistochemistry, these lymphomas have been separated into B-cell, T-cell, and most recently into natural killer (NK) cell phenotypes. The B-cell phenotype is typically located in the paranasal sinuses and has a slight predominance in Western countries. The T/NK-cell phenotype is the most common in Asian and South American countries. These tumors are typically located in the nasal cavity and have an aggressive, angioinvasive growth pattern that often results in necrosis and bony erosion. Thus, sinonasal lymphomas have been included in the past with other destructive malignant and benign lesions under the descriptive and nonspecific name lethal midline granuloma. Patients are classically in the sixth to eighth decades, with a 2:1 male-to-female ratio. The prognosis is generally better than that of nodal-based lymphomas of similar histologic grade. Treatment is a combination of local irradiation and chemotherapy with an anthracycline-based regimen.

Papillary squamous cell carcinoma versus verrucous squamous cell carcinoma of the head and neck

Papillary squamous cell carcinoma and verrucous squamous cell carcinoma of the head and neck may be confused. The clinicopathological profile of the two neoplasms is presented and the differential diagnosis is discussed. A correct diagnosis is imperative in order to institute the most appropriate treatment.

Laryngeal pathology in the acquired immunodeficiency syndrome: diagnostic and therapeutic dilemmas

The acquired immunodeficiency syndrome has produced a growing population of patients who, because of their associated immune system compromise, are prone to opportunistic infections and neoplastic diseases. The larynx, with its relatively inaccessible yet critical anatomic location, is a site in which these processes can produce clinical dilemmas, with respect to diagnosis as well as to therapy. By presenting 4 cases involving unusual laryngeal problems in patients infected with the human immunodeficiency virus (HIV), we emphasize these inherent diagnostic and therapeutic problems. Otolaryngologists must be familiar with the many diagnostic possibilities and therapeutic alternatives when HIV-infected patients present with laryngeal complaints.

AIDS-related plasmablastic lymphomas of the oral cavity and jaws: a diagnostic dilemma

Acquired immunodeficiency syndrome (AIDS)-related non-Hodgkin's lymphomas are highly pleomorphic in their clinical, pathological, and biological features. Recent investigations have led to the identification of a particular type of AIDS-related non-Hodgkin's lymphomas presenting in the oral cavity and jaws. This novel category of AIDS-related non-Hodgkin's lymphomas derives from B-cells and has been defined as plasmablastic lymphoma on the basis of its morphological and immunophenotypic features. Clinically, AIDS-related plasmablastic lymphoma is generally limited to the oral cavity at the time of diagnosis, although extension to distant sites frequently occurs at a later stage. Histologically, AIDS-related plasmablastic lymphoma is composed of a monomorphic and cohesive pattern of plasmablasts with basophilic cytoplasm. Phenotypically, AIDS-related plasmablastic lymphoma fails to express the most common B-cell-associated surface antigens, whereas it consistently expresses high levels of plasma cell-associated markers, including VS38c and CD138/syndecan-1. For the purpose of differential diagnosis, the morphological and immunophenotypic peculiarities of AIDS-related plasmablastic lymphoma clearly distinguish these lymphomas from other categories of AIDS-related non-Hodgkin's lymphomas, as well as from undifferentiated large cell carcinomas.

Synovial sarcoma of the larynx and hypopharynx

Synovial sarcoma represents a mesenchymal malignancy of unknown histogenesis that most often occurs in the lower limbs of young adults. The head and neck region is a relatively rare location, in which the hypopharynx and larynx are, respectively, the most and least often affected anatomic sites. Histologically, synovial sarcomas are classified into monophasic and biphasic variants. Immunohistochemistry plays a major part in the differential diagnosis, enabling the demonstration of epithelial differentiation. Both monophasic and biphasic synovial sarcomas are characterized cytogenetically by the reciprocal translocation t(X;18)(p11.2;q11.2) between chromosomes X and 18. Two cases of synovial sarcoma arising in the larynx and in the hypopharynx and in which cytogenetic analysis detected a diagnostic t(X;18) chromosome aberration are reported here.

Selective lateral neck dissection for laryngeal cancer with limited metastatic disease: is it indicated?

The most important prognostic factor in cancer of the larynx is the presence of cervical metastatic disease, which is the most common type of recurrence in such patients. Because micrometastases cannot be detected pre-operatively at present, selective lateral neck dissection is increasingly recommended as the standard treatment for patients with a clinically negative neck in order to reduce the recurrence rate. In cases of N+ disease, selective lateral neck dissection can be as valid as modified radical neck dissection, providing patients have only limited, occult metastatic disease.