Primary combined small cell carcinoma of the larynx

Collision Tumour of Combined Neuroendocrine and Squamous Cell Carcinoma of Nasal Cavity and Paranasal Sinus- Case Report and Review of Literature

Background

There have been many disputes about the definition, diagnosis, therapy, and prognosis of collision tumours.

Case Summary

We describe a rare patient with a collision tumour consisting of high-grade neuroendocrine carcinoma (NEC) and squamous cell carcinoma (SCC) in the right nasal cavity and paranasal sinus. She received surgery, concurrent chemoradiotherapy, and then two cycles of palliative chemotherapy. Follow-up at 26 months after diagnosis showed that this patient experienced a complete response with no signs of recurrence or metastasis. A literature review of previous 27 cases diagnosed with collision tumour of NEC and SCC in the head and neck was also undertaken.

Conclusion

It is highly challenging to manage collision tumours because these are two morphologically and etiologically distinct tumours. Well-designed multimodality therapy including surgery and chemoradiotherapy might lead to a long survival in these patients.

Primary small cell thyroid carcinoma combined with poorly differentiated thyroid carcinoma, evidence for a common origin: A case report

Primary small cell thyroid carcinomas are extremely rare and there is still debate about their classification as a distinct disease entity. The present case report reports a small cell carcinoma (SCC) combined with poorly differentiated thyroid carcinoma (PDTC) in a 34 year old man. The tumor consisted of ~80% PDTC and ~20% SCC. The PDTC component was positive for cytokeratin and thyroid transcription factor-1 (TTF-1), and negative for calcitonin, chromogranin and synaptophysin. The SCC component was positive for synaptophysin and CD56, and negative for calcitonin, chromogranin and TTF-1. Seven months after thyroid surgery, two new lung nodules were detected. Histologically and immunohistochemically, the lung tumors were similar to the SCC component of the thyroid carcinoma. The mutational status of cancer-related genes was assessed using targeted next-generation sequencing in both the thyroid and lung, which identified similar genetic alterations. The histogenesis of SCC was evaluated through NGS analysis of the two cancer components.

Primary Combined Small-Cell and Squamous Cell Carcinoma of the Supraglottis: Case Report and Literature Review

Combined small-cell carcinoma and squamous cell carcinoma of the larynx is an exquisitely rare and underreported primary tumor the head and neck region, with an English literature review revealing only 17 documented cases. There is limited information on how best to treat these patients oncologically, given the low number of reported cases. A subset of the reported cases also detail a unique local spread of this combined carcinoma, further obscuring the clinical picture of these patients. Here, we detail an 18th case, with nodal metastasis of only one component of the primary tumor, and discuss the published literature surrounding this etiology.

Collision tumor of squamous cell carcinoma and neuroendocrine carcinoma in the head and neck: A case report

BACKGROUND

There are many disputes about the definition, diagnosis, therapy, and prognosis of collision tumors.

CASE SUMMARY

We describe a rare patient with a collision tumor consisting of neuroendocrine carcinoma (NEC) and squamous cell carcinoma (SCC) in the nasal cavity and paranasal sinus. She received operation, concurrent chemoradiotherapy, and then two cycles of palliative chemotherapy. Follow-up at 12 mo after diagnosis showed that this patient experienced a complete response with no signs of recurrence or metastasis. A literature review of previous 26 cases diagnosed with collision tumor of NEC and SCC in the head and neck was also undertaken.

CONCLUSION

It is challenging to manage collision tumors because there are two morphologically and etiologically distinct tumors. Well-designed multimodality therapy including surgery and chemoradiotherapy might lead to a long survival in these patients.

Mixed Neuroendocrine-Nonneuroendocrine Neoplasms (MiNENs): Unifying the Concept of a Heterogeneous Group of Neoplasms

The wide application of immunohistochemistry to the study of tumors has led to the recognition that epithelial neoplasms composed of both a neuroendocrine and nonneuroendocrine component are not as rare as traditionally believed. It has been recommended that mixed neuroendocrine-nonneuroendocrine epithelial neoplasms are classified as only those in which either component represents at least 30 % of the lesion but this cutoff has not been universally accepted. Moreover, since their pathogenetic and clinical features are still unclear, mixed neuroendocrine-nonneuroendocrine epithelial neoplasms are not included as a separate clinicopathological entity in most WHO classifications, although they have been observed in virtually all organs. In the WHO classification of digestive tumors, mixed neuroendocrine-nonneuroendocrine neoplasm is considered a specific type and is defined as mixed adenoneuroendocrine carcinoma, a definition that has not been accepted for other organs. In fact, this term does not adequately convey the morphological and biological heterogeneity of digestive mixed neoplasms and has created some misunderstanding among both pathologists and clinicians. In the present study, we have reviewed the literature on mixed neuroendocrine-nonneuroendocrine epithelial neoplasms reported in the pituitary, thyroid, nasal cavity, larynx, lung, digestive system, urinary system, male and female genital organs, and skin to give the reader an overview of the most important clinicopathological features and morphological criteria for diagnosing each entity. We also propose to use the term "mixed neuroendocrine-nonneuroendocrine neoplasm (MiNEN)" to define and to unify the concept of this heterogeneous group of neoplasms, which show different characteristics mainly depending on the type of neuroendocrine and nonneuroendocrine components.

Primary combined small and squamous cell carcinoma of the hypopharynx: A case report

We herein report a very rare case of combined small-cell carcinoma (SmCC) of the hypopharynx, with a squamous cell carcinoma (SqCC) element. A 74-year-old man presented with a 3-month history of throat pain and hoarseness. On hypopharyngoscopy, a tumor was identified in the right anterior wall of the piriform sinus and, following examination of a biopsy sample, the lesion was diagnosed as SqCC. Total laryngectomy with bilateral neck dissection was performed and the malignancy was diagnosed as combined SmCC. One month after surgery, concomitant chemoradiotherapy with cisplatin and etoposide was administered. Immunohistochemically, the SmCC element was positive for CD56 and Ki-67 (50.2%), whereas the SqCC element was positive for cytokeratin 34βE12 and Ki-67 (47.5%). Furthermore, the SmCC element was positive for KIT and platelet-derived growth factor α (PDGFRα), while the SqCC element was positive for epidermal growth factor receptor (EGFR) and PDGFRα. By genetic analysis, a silent mutation in the PDGFRα gene was recognized. The expression of KIT, PDGFRα and EGFR in this case provided evidence that combined SmCC may be a candidate for molecular-targeted therapy, although further investigations are required.

Lingual hamartoma associated with a cleft palate in a newborn

A hamartoma is a benign malformation of native tissue that may occur in any area of the body. Hamartoma of the tongue is a rare developmental lesion. We describe the case of a pendulant lingual hamartoma in a 2-day-old girl that had not been identified on prenatal ultrasonography. We also review the utility of prenatal imaging options, the role of preoperative imaging, the mechanical relationship between lingual hamartoma and cleft palate, the histopathology of this tumor, surgical treatment, and emergency airway management.

[Laryngeal Atypical Carcinoid Combined with Squamous Cell Carcinoma: A Case Report]

The primary laryngeal atypical carcinoid is relatively rare, and the tumor combined with other histologic types including squamous cell carcinoma is extremely rare. We experienced a case which was complicated with atypical carcinoid and squamous cell carcinoma. A 79 years old man complaining of sputum was admitted to Hiroshima City Hospital. A tumor was seen in over the right glottis and the right vocal fold was fixed. Squamous cell carcinoma was diagnosed based on a biopsy harvested under laryngoscopy. Imaging studies (CT, MRI) were done. The primary tumor was in the right aryepiglottic fold, and one swollen lymph node was found in level 2 (right side). Based on the findings, the stage was T3N1M0. We performed a total laryngectomy and right neck dissection. Atypical carcinoid and squamous cell carcinoma were detected in the same tumor. There were two lymph node metastases, both of which were atypical carcinoid metastases. Postoperative irradiation was provided. It is now 4 years since the operation, but the patient lives without relapse and metastasis of this disease.

Clinical recommendations on the treatment of neuroendocrine carcinoma of the larynx: A meta-analysis of 436 reported cases

BACKGROUND

Current recommendations on the treatment of neuroendocrine carcinoma of the larynx (NCL) are based on anecdotal evidence. With this meta-analysis, our purpose was to provide clinicians with more substantiated guidelines in order to improve the treatment outcome of the patients affected with NCL.

METHODS

A structured literature search for all research concerning NCL was performed against the MEDLINE and EMBASE databases. Available data was normalized, pooled, and statistically analyzed.

RESULTS

Four hundred thirty-six cases of NCL were extracted from 182 studies, of which 23 were typical carcinoid, 163 were atypical carcinoid, 183 were small-cell neuroendocrine carcinoma, 29 were large-cell neuroendocrine carcinoma, and 38 were unspecified carcinoid tumors. The 5-year disease-specific survival (DSS) was 100% for typical carcinoid, 53% for atypical carcinoid, 19% for small-cell neuroendocrine carcinoma, and 15% for large-cell neuroendocrine carcinoma (p < .001). Patients with an atypical carcinoid treated with surgery had better DSS than those treated with radiotherapy (60% vs 54%; p = .035). Postoperative radiotherapy did not result in better DSS in atypical carcinoid. Patients with an atypical carcinoid, not undergoing surgical treatment of the neck, developed isolated regional recurrence in 30% of cases (p = .001). Radiochemotherapy yielded the best DSS for small-cell neuroendocrine carcinoma compared to other modalities (31% vs 13%; p = .001).

CONCLUSION

Typical carcinoid can be treated by local excision alone. Atypical carcinoids do not seem to respond well to radiotherapy and are best managed through radical surgical excision in combination with elective neck dissection. Patients with small-cell neuroendocrine carcinoma or large-cell neuroendocrine carcinoma seem to benefit most from chemoradiotherapy.

Combined small cell and squamous cell carcinoma of the larynx

A case of combined small cell and squamous cell carcinoma of the larynx in a male patient in the sixth decade of life is reported. The etiopathogenesis of this combined tumor remains unclear; however, a number of hypotheses were proposed in the past including the pivotal role of Kulchitsky, squamous cells and the glandular cells. The gene mutations may also play an important role in laryngeal carcinogenesis. This unusual type of laryngeal combined carcinoma has previously been reported worldwide in only 17 cases. This is an extremely rare tumor the histological nature of which makes the diagnosis more complicated than in other types of laryngeal cancers. The diagnosis of this carcinoma is based on light microscopy and should be supported by immunohistochemical studies. In our case, the tumor was growing in the left pyriform sinus. Metastatic neck lymph nodes were found on the left side, but no distant metastases were observed. Microscopic sections revealed a combined tumor composed of small cell carcinoma neuroendocrine type and non-keratinizing squamous cell carcinoma. Positive reaction to p16, bcl-2, thyroid transcription factor 1, synaptophysin and chromogranin A in the small cell neuroendocrine type carcinoma component was observed. The cells from squamous cell carcinoma component showed positive reaction to p63, high-molecular-weight cytokeratin and cytokeratin 5/6.

Combined small cell carcinoma of the hypopharynx

We report an extremely rare case of combined small cell carcinoma (combined SmCC) of the hypopharynx. A 73-year-old male presented with multiple left neck swellings for 1 month. A tumorous lesion was found in the left pyriform sinus, and biopsy revealed that the lesion was squamous cell carcinoma (SqCC). Surgery was performed and pathological examination led to a diagnosis as combined SmCC, composed of SqCC and small cell carcinoma (SmCC). One month after surgery, a contrast-CT indicated metastases to the cervical lymph node (LN), mediastinum and liver. We performed 5 courses of chemotherapy with the use of cisplatin (CDDP) and irinotecan (CPT-11). The patient temporarily showed a favorable response to the chemotherapy; however, eventually he died of regrowth of the tumor. Combined SmCC is a disease with a poor prognosis. Although biopsy sometimes fails to detect the SmCC component, intensive diagnosis and treatment are necessary.

Primary, combined, atypical carcinoid and squamous cell carcinoma of the larynx: a new variety of composite tumour

OBJECTIVE

We report the first case of a laryngeal composite tumour consisting of a squamous cell carcinoma combined with an atypical carcinoid.

METHODS

Case report and review of the literature concerning laryngeal composite tumours.

RESULTS

Primary laryngeal carcinoma is the most common malignancy of the upper aerodigestive tract. The vast majority are of the squamous cell type. Primary neuroendocrine neoplasms represent a rare, heterogeneous subset of laryngeal malignancies, comprising typical carcinoid, atypical carcinoid, small cell carcinoma and paraganglioma. Primary combined neuroendocrine and squamous cell carcinoma of the larynx is even more rarely encountered, with only 14 publications of this so-called composite tumour to date. In each case, the neuroendocrine component has been small cell carcinoma.

CONCLUSION

The treatment of primary neoplasms comprising more than one histological type is tailored to the most biologically aggressive tumour. Accurate diagnosis of the histological nature of laryngeal composite tumours is imperative to ensure optimal therapy.

The pathology of extrapulmonary small cell carcinoma

Extrapulmonary small cell carcinomas (EPSCCs) are uncommon malignant neoplasms with a reported incidence of 0.1% to 0.4% in the United States. Since their first description in 1930, they have been seen in nearly every organ system. Like their more common pulmonary counterparts, EPSCCs are thought to arise from a multipotential stem cell. However, there is recent molecular evidence that small cell elements may arise as a late-stage phenomenon in the genetic progression of more organ-typical carcinomas. The morphologic, immunohistochemical, and ultrastructural features are similar to those described in pulmonary small cell carcinomas (PSCCs). The differential diagnosis of EPSCC includes PSCC, other neuroendocrine tumors, small round blue cell tumors, metastatic melanoma, lymphoma, and poorly differentiated non-small cell carcinomas. Molecular alterations reported to occur in EPSCCs include abnormalities described in PSCC and changes found in carcinomas more typically encountered in the organ from which they arise. In this article we discuss the pathology of EPSCC with a review of theories of histogenesis, sites of occurrence, diagnostic features, differential diagnosis, molecular alterations, and clinical behavior.

Small cell carcinoma of the head and neck: a review

Small cell carcinoma (SCC) has become recognized as a distinct, though relatively infrequent, clinical pathology that occurs in multiple sites throughout the head and neck. Excluding cases that are considered to arise from skin, SCC in the head and neck has been found to develop in nearly all structures associated with the upper aerodigestive tract. Among the head and neck sites, the frequency of SCC is greatest in the larynx, with salivary glands and the sinonasal region comprising the other principle areas of origin. Controversy exist as to whether SCC can develop as a distinct entity in the thyroid, with most tumors that previously would have been considered as SCC now found to be lymphomas or variant forms of other types of thyroid malignancy. While there seems to be some differences among tumors arising from the various subsites, in general all SCC that originate in the head and neck have a tendency for aggressive local invasion and a strong propensity for both regional and distant metastasis. Treatment may include surgical resection, radiotherapy, chemotherapy, or some combination of these modalities. Due to the infrequency of these tumors, it is very unlikely that any large, controlled study will ever be done. For this reason, recommendations for treatment of SCC arising in the head and neck are based primarily on retrospective data from various small case series and on comparative data for treatment of SCC of bronchogenic and other extrapulmonary origin. Although patients with truly limited local disease may enjoy some prolonged survival, most patients with this tumor do poorly despite all current attempts at treatment.

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.

Primary combined squamous and small cell carcinoma of the larynx: Report of two cases and discussion of treatment modalities

Combined small cell carcinoma (SMCC) of the larynx consists of SMCC admixed with a component of squamous cell carcinoma or adenocarcinoma. These tumors are very rare and, to date, only a few cases have been fully described. This points out the lack of information available about the correct management of these patients. Here, we describe two additional cases of combined SMCC of the larynx that illustrate the difficulties that we can encounter to diagnose correctly these patients and, by consequence, to treat them adequately.

Primary combined squamous and small cell carcinoma of the larynx: a case report and review of the literature

Primary laryngeal carcinomas comprise approximately 2% to 5% of all malignancies worldwide. Of these laryngeal carcinomas, approximately 99% are primary squamous cell carcinomas. During the past 30 years, about 160 cases of primary small cell carcinoma of the larynx have been reported. Combined primary squamous and small cell carcinoma of the larynx, the so-called composite tumor of the larynx, is even more rare, with only 13 published cases to date. Although the major risk factors for developing these composite tumors of the larynx are thought to be similar to other more common neoplasms of the larynx, such as squamous cell carcinoma, the treatment and prognosis are different. We report an additional case of combined small cell carcinoma of the larynx and discuss the histogenesis of this unusual neoplasm.

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.

Neuroendocrine tumors of the larynx

A review of the international literature has revealed 68 paragangliomas, 42 large cell, and 74 small cell tumors of the larynx. Paragangliomas are usually benign, although malignant cases have been reported. Large cell tumors are malignancies associated with a high incidence of early cervical metastasis. Small cell tumors are aggressive cancers characterized by early, diffuse metastatic disease. All three neoplasms demonstrate a propensity for the supraglottic larynx. While surgery remains the treatment of choice for paragangliomas and large cell cancers, small cell cancers are best treated by radiotherapy and chemotherapy. The determinate 5-year survival for patients with paragangliomas, large cell, and small cell cancers is 60%, 34%, and 14%, respectively. While representing distinct clinical entities, these neoplasms demonstrate similar ultrastructural and histochemical features and should be classified as neuroendocrine tumors of the larynx (NETL). A comprehensive analysis of these laryngeal tumors is presented herein. Their clinical behavior and management options are reviewed and a scheme for their nomenclature and classification is proposed.

Malignant laryngeal epithelial tumors and lymph node involvement: therapeutic and prognostic considerations

The relationship among various malignant epithelial tumors of the larynx, with or without their respective lymph node and visceral metastases, is discussed. The tumors considered include squamous cell carcinoma, verrucous squamous cell carcinoma, spindle cell squamous carcinoma, small cell carcinoma, atypical carcinoma, mucoepidermoid carcinoma, adenoid cystic carcinoma, and primary malignant melanoma. Other, rarer, malignant epithelial neoplasms of the larynx are only mentioned. The choice of therapy should be determined by tumor stage, oncotype, and patient status.

Diagnosis and treatment of small cell carcinoma of the larynx: a critical review

Small cell carcinoma of the larynx is an uncommon neuroendocrine tumor with particular pathologic, therapeutic, and prognostic connotations. The first case of this lesion was observed in Canada in 1972. Fourteen cases of small cell carcinoma of the larynx were observed in the Ear, Nose, and Throat Department of Padua University in a series of 3,284 primary and secondary laryngeal and hypopharyngeal malignant neoplasms. This number constitutes the largest collection from a single institution in the literature and brings the total recorded cases to 66. The tumor is thought to arise from the argyrophilic Kulchitsky cells normally found in laryngeal mucosa. The diagnosis is based on the light microscopic appearance of the neoplasm and can be confirmed by electron microscopy. The differential diagnosis must be made from carcinoid, atypical carcinoid, small cell squamous carcinoma, small cell ductal carcinoma, lymphoma, mycosis fungoides, and metastatic lung small cell cancer. Systemic chemotherapy with radiation therapy is the accepted manner of treatment today. The survival of the patients treated with these modalities may be significantly improved, and some patients may be cured.

Small cell carcinoma of the head and neck

Treatment methods for patients with small cell carcinoma of the head and neck are changing. Increasing clinical experience with these tumors and a better appreciation of patterns of recurrence, the need for thorough tumor staging, and the importance of chemotherapy as a form of primary therapy have contributed to these changes. Current concepts regarding small cell carcinoma arising in the head and neck are reviewed. Reported results of treatment for a variety of head and neck sites and site-specific relapse rates are summarized. New cases of small cell carcinoma arising in the hypopharynx, paranasal sinus, and from an unknown primary are added to the reported experience in the literature.

Long-term survival in response to combined chemotherapy and radiotherapy in laryngeal small cell carcinoma

Fourteen patients with small cell carcinoma of the larynx are studied. This represents the largest series, from a single institution, reported in the literature. This neoplasm is usually highly aggressive and the prognosis very poor, but, in our experience, combined chemo- and radiotherapy can significantly improve the clinical course of the disease. Three of six patients who received this combined modality treatment are still clinically disease-free more than six years after the initial diagnosis.