Pregnancy and malignant neoplasms of the head and neck

This paper, based on a literature review, deals with the occasional development of a head and neck neoplasm in the pregnant woman. This rare event makes for some challenging problems in patient management, insofar as the otolaryngologist is actually responsible for taking care of 2 patients -- the mother and her unborn child. In particular, 4 tumor types have figured prominently among those head and neck tumors arising in pregnant women: cancer of the larynx, cancer of the thyroid, malignant melanomas, and malignant lymphomas of the head and neck. Of these, the most common appear to be melanomas, followed by lymphomas, thyroid carcinomas, and, finally, laryngeal carcinomas. The thyroid tumors, lymphomas, and laryngeal carcinomas do not appear to behave more aggressively in pregnant than in nonpregnant patients; there is, however, some anecdotal evidence to suggest that melanomas in pregnant women may be more aggressive neoplasms than similar-stage tumors in nonpregnant women. One difficulty in treating any of these tumor types in this clinical setting is the limitation that may be imposed on the use of adjuvant therapy by the presence of the unborn child, which may put the attending physicians in the difficult position of balancing less aggressive therapy for the mother against the potential for harming the baby through use of toxic systemic therapy.

Selective lateral neck dissection for laryngeal cancer in the clinically negative neck: is it justified?

Selective lateral neck dissection is a recently-introduced surgical procedure for the treatment of cervical lymph nodes believed to be at risk of metastasis from primary malignant neoplasms of the upper respiratory and digestive tracts. Its value in the management of the clinically negative neck in cancer of the larynx is discussed.

A review of neuroendocrine neoplasms of the larynx: update on diagnosis and treatment

Neuroendocrine neoplasms of the larynx have been divided into those of epithelial or neural origin. The latter consist of paragangliomas while the epithelial origin group can be divided into the typical and atypical carcinoids and small cell neuroendocrine carcinomata, the latter consisting of the oat cell type, the intermediate cell type and the combined cell type. There are now over 500 cases of neuroendocrine neoplasms of the larynx in the literature. The diagnosis is primarily based on light microscopy, and, in some instances, it may be supported by special histochemical studies. It should be confirmed by immunocytochemical and/or ultrastructural investigation. The different biological behaviour of neuroendocrine neoplasms of the larynx makes a specific diagnosis of paramount importance, since treatment depends on diagnostic accuracy. Typical carcinoid is an extremely rare lesion. It is treated preferably by conservative surgery; elective neck dissection is not necessary because of the lack of lymph node metastases at diagnosis. Chemotherapy and/or radiotherapy have not been effective in the limited number of patients treated thus far. Prognosis is excellent with cure following surgery. Atypical carcinoid is the most frequent non-squamous carcinoma of the larynx. The mainstay of treatment is surgery. Elective neck dissection should be performed because of the high likelihood of cervical lymph node metastases. Primary radiation therapy with adjuvant chemotherapy is not indicated. The survival rate is 48 per cent at five years and 30 per cent at 10 years. Although the larynx is one of its most common extrapulmonary sites, small cell neuroendocrine carcinoma is still a rare tumour. Surgical results for this tumour have been disappointing and is reserved for cases of local relapse with no evidence of metastasis. Chemotherapy and radiotherapy currently appear to offer the least disabling and most effective forms of therapy. The two- and five-year survival rates are 16 per cent and five per cent, respectively. Paraneoplastic syndromes have occasionally been reported in association with carcinoid tumours (typical and atypical) and small cell neuroendocrine carcinoma. There have been also rare reports of an elevated neuropeptide serum level. Paraganglioma is the only laryngeal neuroendocrine neoplasm with a female preponderance (3:1). Confusion with atypical carcinoid has led to incorrect diagnosis and inappropriate classification schemes, erroneously suggesting that laryngeal paraganglioma has the potential for aggressive behaviour. Conservative surgery represents the treatment of choice; elective neck dissection is not necessary, and the prognosis is excellent.

Alveolar soft part sarcoma of the head and neck region

Alveolar soft part sarcoma is a soft tissue malignancy most often found in the extremities of young adults; when these tumors arise in the head and neck area, they usually appear in the orbit or the tongue. Their initial behavior is relatively indolent, but over time a sizable number of these tumors recur locally and metastasize; as such, they are best regarded as fully malignant neoplasms. The derivation of these tumors remains uncertain: while some have suggested that these are tumors of muscle origin and others have postulated a neuroendocrine origin, the evidence accumulated to date is conflicting, and so these neoplasms continue to be regarded as tumors of uncertain origin. Surgical excision is the mainstay of therapy.

Impact of phenotype on treatment and prognosis of laryngeal malignancies

An overview of the impact of the phenotype on treatment and prognosis of different laryngeal malignancies is presented.

Giant cell tumor of the larynx

Among the more uncommon tumors that may sometimes be encountered in the laryngeal region is the recently described giant cell tumor of the larynx. This lesion is a true neoplasm, presumably of the fibrohistiocytic series. Histologically, it closely resembles the more familiar true giant cell tumor of long bone. The laryngeal giant cell tumors appear, to date, to be nonmetastasizing lesions; it is possible that they may recur locally if incompletely excised (although this remains to be demonstrated). In view of the rarity of these tumors, a tentative diagnosis of such a neoplasm should always prompt consideration of other (more frequently encountered) differential diagnostic possibilities, including cytologically malignant giant cell-rich tumors such as malignant fibrous histiocytoma and sarcomatoid carcinoma.

Regional and distant metastases in laryngeal and hypopharyngeal sarcomas

Cervical node and distant metastases are the most important prognostic factors in malignant laryngeal neoplasms. Owing to the unusual occurrence of laryngeal sarcomas, the prevalence of their metastases has never been analyzed in detail. We reviewed the laryngeal sarcomas reported in the literature and noticed that both regional and distant metastases are rare events and variable for different histotypes. These observations have obvious therapeutic and prognostic implications.

Wegener's granulomatosis of the head and neck

Among the more puzzling non-neoplastic necrotizing lesions of the head and neck area is Wegener's granulomatosis. This is a condition of unknown cause that may present (in the head and neck area) with ulceration of the nasal septum, sinus mucosa, oral mucosa, or external ear canal, or even destruction of the vocal cord. Diagnosis depends on the pathologic finding of a characteristic inflammatory reaction pattern (which, in its best-developed form, includes necrosis, granulomatous inflammation, and vasculitis) and the serum finding of an elevated antinuclear cytoplasmic antigen. Treatment is principally medical, with the use of powerful immunosuppressive agents. Distinction from other conditions that may mimic Wegener's granulomatosis (such as malignant lymphoma and infections) is of critical importance in constructing an appropriate treatment strategy.

Level I dissection for laryngeal and hypopharyngeal cancer: is it indicated?

Squamous cell carcinoma of the larynx and hypopharynx tends to metastasize frequently to cervical lymph nodes, the location of which depends mainly on the site of the primary lesion. Five anatomical levels of cervical nodes have consequently been defined to standardize the terminology used to describe which lymph node groups are at risk for metastatic spread. Level I includes the submental and submandibular triangles. This review considers the role of these triangles in neck dissection and concludes that, unless there is clear evidence of spread, the inclusion of the level I triangles in the neck dissection is unwarranted since these nodes are not really at risk. There is therefore an important role for selective neck dissection in suitable cases of squamous cell carcinoma of the larynx and hypopharynx.

Hamartoma of the larynx: a critical review of the literature

Hamartoma of the larynx is an extremely rare lesion, and the number of well-documented and acceptable cases is limited. The world literature is critically reviewed in order to develop a more accurate clinicopathological profile of this tumorlike malformation, which has to be differentiated from choristoma, teratoma, and rhabdomyoma, among others. Management consists of local excision, and the prognosis is good.

Synchronous and metachronous multiple primary laryngeal malignancies

The article reviews the literature on synchronous and metachronous multiple primary malignant laryngeal tumors of the same phenotype, of different phenotypes, and of different histogenesis.

Is primary radiotherapy an appropriate option for the treatment of verrucous carcinoma of the head and neck?

The literature on verrucous carcinoma of the head and neck was reviewed to analyse the use of primary radiation therapy in the treatment of this lesion. The results emphasize an overall local control rate of 43.2 per cent, and 6.7 per cent of true anaplastic transformation following irradiation. Diagnosis remains the fundamental problem: without a correct diagnosis of verrucous carcinoma, no correct treatment can be applied.

Basaloid squamous cell carcinoma of the larynx and hypopharynx

Basaloid squamous cell carcinoma (BSCC) is a recently described bimorphic variant of squamous cell carcinoma with distinct morphological and biological features. We describe the clinicopathological findings, along with immunohistochemical and ultrastructural investigations, in 15 new cases of BSCC of the larynx or hypopharynx observed and treated at the otolaryngology department of the University of Padua between 1989 and 1995. The world literature is also reviewed in order to develop a more accurate clinicopathological profile of the tumor. Patient records and histologic slides were reviewed in all of our 15 cases. The patient group consisted of 13 men (86.67%) and 2 women with a mean age of 63.33 years (median 69 years; range 44 to 84 years). Nine patients presented with cervical lymph node metastases. Surgical treatment was the therapy of choice; radiotherapy and chemotherapy have been applied in different combinations. Follow-up was available on all 15 cases. Local recurrence was described in 3 cases. Five of the 9 patients with cervical lymph node metastases developed distant metastases. Distant spread of the tumor without lymph node involvement was observed during follow-up in 4 cases. Nine patients died of disease, 2 are alive with widespread metastases, 2 are alive with no evidence of disease, and 2 have died of other causes. The determined 5-year survival was estimated to be 17.5% by the Kaplan-Meier method. In conclusion, BSCC is a distinctive carcinoma that is important to recognize, because it has a more aggressive biological behavior than conventional squamous cell carcinoma.

Pretreatment pathologic prognostic factors in head and neck squamous cell carcinoma

Squamous carcinomas of the head and neck region are a common problem for the otolaryngologist; surgeons are obliged to draw together disparate lines of evidence-from physical examination, pathology, and radiology-to plan optimal therapy for their patients. This article explores some of the ways in which pathologic analysis of a biopsy specimen in the past (determination of extent of invasion and degree of differentiation), present (including an analysis of the pattern of infiltration and the tumor' s DNA content), and, perhaps, the future (possibilities including cytogenetics and analysis of discrete steps in the cell cycle) plays a role in this process.

Syndrome of inappropriate antidiuretic hormone secretion associated with head neck cancers: review of the literature

In a minority of patients with malignant tumors, signs and symptoms develop that cannot be explained on the basis of the mass effect produced by the primary tumor or its metastases, or production of a hormone normally associated with the tissue type that has given rise to the malignant tumor; these peculiar symptom complexes are known as paraneoplastic syndromes, and may be divided into endocrinologic, dermatologic, hematologic, neurologic, and osteoarticular manifestations. In the head and neck region in particular, the syndrome of inappropriate antidiuretic hormone production (SIADH, or Schwartz-Bartter syndrome) is a well-recognized form of paraneoplastic syndrome that may accompany head and neck malignancies. Most of such tumors are squamous carcinomas, with lesser numbers of olfactory neuroblastomas, small cell neuroendocrine carcinomas, adenoid cystic carcinomas, and undifferentiated carcinomas; sarcoma was reported in only a single instance. The lesions associated with the development of SIADH have most often been located in the oral cavity, and less often in the larynx, nasopharynx, hypopharynx, nasal cavity, maxillary sinus, parapharyngeal space, salivary glands, and oropharynx. Key features of SIADH include serum hypo-osmolality; an unexpectedly high urinary specific gravity; an absence of edema or dehydration; normal adrenal, thyroid, and renal function; hyponatremia; and an elevation of plasma vasopressin.

Role of DNA measurements of head and neck tumors

The measurement of DNA ploidy has been used as a tool to try to determine the prognosis of many neoplasms. DNA ploidy can be determined by flow cytometry or image analysis of a tumor. In squamous carcinomas of the head and neck, a poorer prognosis has been associated with nondiploid tumors. Similar results have been obtained from studies of salivary gland neoplasms. The role of DNA ploidy as a provider of independent information has yet to be determined. With rarer head and neck tumors, measurement of tumor ploidy has yet to be established as a valuable adjunct to routine light microscopic study.

Barrier between the supraglottis and the glottis: myth or reality?

Controversial opinions on the existence of a "barrier" between the supraglottic and glottic regions of the larynx are reported. Even if the two areas have different embryological derivations, there is no anatomic evidence of a "barrier" that could prevent supraglottic cancer from extending downward to the glottis. Numerous adequate pathologic studies, including whole organ sections, confirm that for advanced cancers, anatomic compartments delimiting the spread of the neoplastic process from the supraglottis to the glottis do not exist. Therefore, supraglottic laryngectomy should be performed not on the basis of embryological considerations, but on the basis of the actual extension of the neoplastic lesion.

Human immunodeficiency virus-1 infection of the lymphoid tissues of Waldeyer's ring

Human immunodeficiency virus-1 (HIV-1) infection is a fatal retroviral infection that may first present clinically as enlargement of the lymphoid tissues of Waldeyer's ring. These tissues are a major site of viral replication. The presence of the virus in these tissues causes a unique constellation of diagnostic histopathologic features, including florid follicular hyperplasia, follicle lysis, and productively HIV-1-infected multinucleated giant cells of probable dendritic cell origin. Serologic evaluation is confirmatory of HIV infection. With the recent advances in antiretroviral chemotherapy, the early institution of which may significantly prolong life and disease-free interval, the recognition of the clinical and pathologic parameters of HIV-related enlargement of Waldeyer's ring tissues is essential.

Head and neck Langerhans cell histiocytosis

Among the potential sites of involvement by Langerhans cell histiocytosis (LCH), the head and neck region is the most commonly cited. Though principally a pediatric disease, LCH can affect any age group. It can be unifocal (skeletal) or multifocal (skeletal and/or visceral); it appears as though the presence of visceral lesions is more common in the youngest patients, and may be associated in some with a rapidly progressive course resulting in death. Head and neck manifestations may mimic such varied entities as eczema, otitis media, osteomyelitis, and cholesteatoma. Current approaches to therapy are less aggressive than they were in the past, and are particularly intended to monitor for and treat any complicating secondary infections (which may develop in the youngest patients with multifocal disease including visceral involvement). The prognosis is very good for unifocal skeletal system disease, and poor for multifocal disease with involvement of tissues other than bone.

Clinicopathological consultation. Lymphoepithelial carcinoma of the larynx hypopharynx, and trachea

Lymphoepithelial carcinoma of the larynx, hypopharynx, and trachea is a rare neoplasm composed of large, poorly differentiated, nonkeratinized cells intermingled with small nonneoplastic lymphocytes and plasma cells. It is histologically similar to its more common counterpart occurring in the nasopharynx. In contrast to nasopharyngeal carcinoma, most cases have not been associated with Epstein-Barr virus (EBV), although rare cases have been reported to be EBV-positive. The diagnosis often requires immunohistochemistry or electron microscopy for confirmation. The neoplasm seems to behave in a fashion reminiscent of nasopharyngeal carcinoma. Lymph node metastasis occurs in the majority of patients, and eventual visceral dissemination occurs in one fourth. Radiotherapy is the main treatment for the primary tumor and regional metastases, but chemotherapy is indicated for more advanced disease. The initial stage is the primary determinant of prognosis. Death from disease occurs in about one third of patients.

Nasopharyngeal carcinoma, with emphasis on its relationship to Epstein-Barr virus

Nasopharyngeal carcinoma (NPC) is an epithelial tumor with a distinct geographic distribution and characteristic histologic appearance. It is rare in Europe and North America, but it is among the most common cancers in southern China. Genetic predisposition, environmental factors, and Epstein-Barr virus (EBV) all have been associated with the pathogenesis of this tumor. There is an increasing body of evidence that among all these factors, EBV appears to be the strongest and most consistently related factor. According to the current sensitive in situ hybridization methods for the detection of EBV-encoded small RNAs (EBER), almost 100% of cases of NPC, irrespective of their histologic subtypes, have demonstrable EBERs in the nuclei of the tumor cells. In this review paper, we discuss the predisposing genetic and environmental factors and the role of EBV in the pathogenesis of this tumor with particular emphasis on the role of EBV.

Yolk sac tumors (endodermal sinus tumors) of the extracranial head and neck regions

Yolk sac tumors (or endodermal sinus tumors) are rare neoplasms of germ cell origin that have been reported in gonadal sites (testis and ovary). Extragonadal yolk sac tumors are uncommonly seen, and in particular, they are rare in the extracranial head and neck regions; we found 27 well-documented cases in the English-language literature. We discuss their clinical and pathologic features.

Clinicopathological consultation. Ear cholesteatoma versus cholesterol granuloma

Cholesteatoma and cholesterol granuloma of the ear are two different pathologic conditions that have often been confused in the past, and even in the present, in the literature. The features differentiating the two lesions are presented.

Squamous neoplastic component in unconventional squamous cell carcinomas of the larynx

Both otolaryngologists and surgical pathologists are involved in the diagnosis and treatment of lesions of the larynx that are best diagnosed as invasive squamous cell carcinomas of some specified degree of differentiation, not further subclassified (that is, conventional squamous cell carcinomas). On occasion, however, a patient will present with an invasive tumor that on histologic examination diverges from the expected pattern of a squamous cell carcinoma of the usual type and so raises the question of proper classification (on the part of the pathologist) and, following classification, a consideration of the prognostic and therapeutic implications of such a classification (on the part of the clinician). While some of these unconventional squamous cell carcinomas are rather indolent lesions (as, for example, the hybrid verrucous squamous cell carcinoma), others behave in a fashion similar to conventional squamous cell carcinomas (such as the adenoid squamous cell carcinomas), and yet others seem to behave more aggressively than do conventional squamous cell carcinomas of a similar size and stage (examples include the basaloid squamous cell carcinomas and adenosquamous carcinomas). Finally, the possibility exists within the larynx, as elsewhere in the body, that a nonepithelial lesion such as malignant melanoma may mimic a tumor more commonly encountered in that vicinity- namely, a squamous cell carcinoma- and so receive inappropriate treatment if such mimicry is not recognized.