Unusual T- and T/NK- cell non-Hodgkin's lymphoma of the larynx: a diagnostic challenge for clinicians and pathologists

Post-treatment sequelae and management of primary laryngeal NK/T-cell lymphoma: A case report

OUTCOME OBJECTIVES

METHODS: Case Report, April 2016.

RESULTS

A 27-year-old female presented with a three-week history of flu-like symptoms including sore throat, myalgia and insidious nasal congestion. Her hospital course was complicated by pancytopenia, extensive GI bleed of unknown origin and fever. Radiographic studies revealed multifocal centrilobular ground-glass lung nodules, splenomegaly, frontal and paranasal sinus opacification and mucosal thickening and inflammatory process of false and true vocal cords with concentric multi-level narrowing. Extensive rheumatologic, hematologic and infectious workup failed to demonstrate an etiology. Flexible laryngoscopic and bronchoscopic examinations with biopsies exhibited a diffuse supraglottic and glottic exophytic, "heaped-up" infiltration; limited vocal cord motion; and airway narrowing to 3 mm. Pathology yielded NK/T-Cell lymphoma with PET/CT confirming nasopharyngeal and laryngeal involvement sparing the brain and other distant structures. During treatment, the patient's airway became increasingly compromised requiring tracheostomy. Flexible laryngoscopic examination after four rounds of SMILE (dexamethasone, methotrexate, ifosfamide, l-asparaginase, and etoposide) chemotherapy and subsequent radiotherapy with 50 Gy in 25 fractions revealed complete glottic stenosis with alteration of the laryngeal anatomy and a pin-hole aperture seen posteriorly through the tracheostomy. Two dilation procedures performed one month apart, improved her airway considerably which allowed for successful decannulation. She continues to be disease-free post treatment but has persistent supraglottic and glottic scar and has developed tracheal stenosis at her tracheostomal site.

CONCLUSIONS

NK/T-Cell lymphoma of the larynx has been rarely described. Herein, we describe the sequalae of treatment and the requisite airway management.

[A rare endolaryngeal tumor]

We report the case of a 65-year-old woman who presented with a dysphonia. ENT tomography and laryngoscopy showed an endolaryngeal tumoral lesion extended to the right supraglottis. Biopsy of the lesion revealed dense lymphoid infiltrate in the lamina propria, without necrosis or ulceration of the mucosa. The infiltrate showed many CD3+, CD5+, CD4+, CD8+ lymphocytes and plasmocytes. Larger lymphoid cells with cytologic atypia expressed CD56 and cytotoxicity markers such as TIA1 and granzyme B. In situ hybridization for EBV revealed numerous positive cells. The diagnosis of extranodal NK/T cell lymphoma was proposed. The primary laryngeal localization of this disease is exceptionally rare. Heavy admixture of inflammatory cells may mimic inflammatory process and delay the diagnosis.

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.

Primary NK/T-cell lymphoma of the larynx

Laryngeal extranodal non-Hodgkin lymphoma is uncommon, accounting for less than 1% of all laryngeal neoplasms; the B-cell phenotype is predominant. Lymphomas outside the nasal cavity are rare and highly aggressive. We present a case of primary natural killer T-cell (NK/T-cell) lymphoma of the larynx that arose in a 45-year-old man. Because only a limited amount of data is available on laryngeal NK/T-cell lymphoma, the mainstay of treatment remains unclear, although some data suggest that radiotherapy alone is the best option. Our patient was treated with chemotherapy and radiotherapy, and he remained in remission 2 years later.

Primary laryngeal lymphoma: report of 3 cases and review of the literature

BACKGROUND

Extranodal lymphomas limited to the larynx are rare, accounting for less than 1% of all laryngeal neoplasms. The aim of this study was to report the experience of our department in the management of these aggressive lesions, as they require special diagnostic and therapeutic attention.

METHODS

The case records of 3 patients with the diagnosis of lymphoma involving the larynx were retrospectively reviewed.

RESULTS

The histopathological diagnosis revealed 1 case of marginal zone lymphoma mucosa-associated lymphoid tissue type, 1 case of T-lymphoblastic lymphoma, and 1 case of a rare coexistence of in situ squamous cell carcinoma with an isolated intravascular (angioimmunoblastic) lymphoma of peripheral T-cell origin. Details of the presentation, diagnostic procedures, treatment, and outcome of these patients were presented.

CONCLUSIONS

Primary laryngeal lymphoma is a rare entity. Early symptoms are subtle and nonspecific, and confirmation of the diagnosis is often difficult. Because of the rarity of this tumor type, the optimal management remains controversial and it seems that should be managed not as a distinct disease entity but as an unusual presentation of non-Hodgkin lymphoma, according to the recent treatment trends.

Extranodal NK/T-cell lymphoma, nasal type

Extranodal NK/T-cell lymphoma, nasal type (ENKTCL), previously known as lethal midline granuloma is a distinct clinico-pathological entity associated with Epstein-Barr virus that typically causes destruction of the midface, palatal and orbital walls. In addition, ENKTCL can involve the skin, soft tissue, testes, gastrointestinal and upper respiratory tract. ENKTCL neoplastic cells express some T-cell associated antigens, most commonly CD2 and cytoplasmic CD3epsilon and, in favour of an NK-cell origin, CD56. Early stage disease may respond to radiotherapy alone, however late stage disease does not respond well to any available therapies. Overall, patients with ENKTCL have a cumulative probability of survival at 5 years ranging from 37.9% to 45.3%.

Primary Laryngeal Lymphoma: Case Report

Extranodal laryngeal lymphoma is extremely rare. We report a case of primary laryngeal lymphoma in a 76-year-old man who had presented with a 7-week history of progressive hoarseness. Laryngoscopy revealed asymmetry of the right false vocal fold. Pathology of a deep biopsy specimen identified a malignant, diffuse, CD20-positive, B-cell lymphoma. The stage IE lymphoma completely resolved after treatment with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) and rituximab. Despite its relative rarity, the consequences of a missed diagnosis warrant vigilance for this type of laryngeal tumor.

Extranodal lymphomas of the head and neck

Malignant lymphomas represent approximately 5% of all malignant neoplasms of the head and neck and may involve nodal or extranodal sites. Nodal head and neck lymphomas are similar to other nodal sites and are not further reviewed here. The head and neck region is the second most frequent anatomical site of extranodal lymphomas (after the gastrointestinal tract). Most are non-Hodgkin's lymphomas of B-cell lineage, and overall diffuse large B-cell lymphoma is the most common type. Hodgkin's lymphoma rarely occurs in extranodal sites. Other hematologic neoplasms that commonly involve extranodal sites of the head and neck are also discussed. In this review, we begin by discussing lymphomas involving the head and neck according to anatomical site. Then we discuss specifically the pathological findings of extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue, plasmablastic lymphoma, extramedullary plasmacytoma, and extranodal natural killer/T-cell lymphoma of nasal type.

[Hodgkin and Non-Hodgkin lymphomas in otorhinolaryngology]

Lymphomas of the head and neck arise in lymph nodes and extranodal areas as Waldeyer ring, nasal cavity, thyroid gland and salivary glands. Though anatomically in close proximity, lymphomas presenting at the ENT area have different clinical characteristics if they are Hodgkin or Non-Hodgkin. We included 31 patients with the diagnosis of lymphoma and diagnosed in our Department between 1999 and 2002. We studied all the different variables that differentiate Hodgkin and Non-Hodgkin's lymphoma. Both types of lymphoma usually present as a cervical mass. Non-Hodgkin lymphoma have extranodal involvement more frequently and also a more advance disease at diagnosis. It is important to include the lymphoma in the differential diagnosis of any cervical mass or ENT lesion.