A Study of Moderately Differentiated Neuroendocrine Carcinomas of the Larynx and an Examination of Non-Neoplastic Larynx Tissue for Neuroendocrine Cells

Non-squamous Cancers of the Larynx

PURPOSE OF REVIEW

Although non-squamous tumors of the larynx are really rare, they may not always be viewed from the same perspective in the multidisciplinary treatment approach once the diagnosis is made. In this review, non-squamous tumors of the larynx and current approaches in treatment will be discussed.

RECENT FINDINGS

When the studies and meta-analyses presented in the last 5 years are evaluated, it is seen that these tumors usually show non-specific symptoms. Due to their submucosal location, the stage of the disease at the time of diagnosis is often advanced. In the literature, treatment may vary in these particular cases. The majority of non-squamous tumors of the larynx includes minor salivary gland tumors, neuroendocrine carcinomas, sarcomas, cartilage tumors, and malignant melanomas. Once treating a patient with these diagnoses, it should be kept in mind that the histopathological subtype is almost as important as the stage of the tumor.

Neuroendocrine Carcinoma of the Larynx and Pharynx: A Clinical and Histopathological Study

Simple Summary

Neuroendocrine carcinomas (NECs) of the head and neck are rare. The presented series of 20 patients with laryngeal and pharyngeal NECs is population-based and one of the largest published to date. We analyzed the treatment results according to the type of therapy and the role of various standard (synaptophysin-chromogranin-CD56, Ki-67, p16, HPV, and EBV) and some novel (INSM1 and PD-L1) neuroendocrine markers or potential prognosticators. The results indicate the following: (1) laryngeal and pharyngeal NECs accounted for 0.43% and 0.17% of the cases in the corresponding tumor groups, respectively; (2) neuroendocrine differentiation can be reliably determined by INSM1 immunohistochemistry; (3) the prognosis was determined by the nodal stage and TNM stage but not by the histological grade (which refers to moderately and poorly differentiated NECs); (4) except in well-differentiated NECs and early-stage (T1-2N0-1) moderately/poorly differentiated NECs, aggressive multimodal therapy is needed; and (5) the p16, HPV, and EBV statuses failed to show any prognostic value.

Abstract

Neuroendocrine carcinomas (NECs) of the head and neck are rare and the experience scanty. The Cancer Registry of Slovenia database was used to identify cases of laryngeal and pharyngeal NECs diagnosed between 1995–2020. Biopsies were analyzed for the expression of standard neuroendocrine markers (synaptophysin, chromogranin, CD56), INSM1, Ki-67, p16, and PD-L1 (using the combined positive score, CPS). In situ hybridization for human papillomavirus (HPV) and Epstein–Barr virus (EBV) was performed. Twenty patients (larynx, 12; pharynx, 8) were identified. One tumor was well differentiated (WD), five were moderately differentiated (MD), and 14 were poorly differentiated (PD). Disease control was achieved solely by surgery in 4/4 MD/PD T1-2N0-1 tumors. Eight patients died of the disease, seven of which were due to distant metastases. All three traditional markers were positive in 11/17 NECs and the INSM1 marker in all 20 tumors. Two of fourteen p16-positive tumors were HPV-positive, but all three nasopharyngeal NECs were EBV-negative. Three tumors had CPSs ≥ 1. In conclusion, INSM1 was confirmed to be a reliable marker of neuroendocrine differentiation. Except in WD and early-stage MD/PD tumors, aggressive multimodal therapy is needed; the optimal systemic therapy remains to be determined. p16, HPV, and EBV seem to bear no prognostic information.

Rare Diseases of Larynx, Trachea and Thyroid

This review article covers data on rare diseases of the larynx, the trachea and the thyroid. In particular, congenital malformations, rare manifestations of inflammatory laryngeal disorders, benign and malignant epithelial as well as non-epithelial tumors, laryngeal and tracheal manifestations of general diseases and, finally, thyroid disorders are discussed. The individual chapters contain an overview of the data situation in the literature, the clinical appearance of each disorder, important key points for diagnosis and therapy and a statement on the prognosis of the disease. Finally, the authors indicate on study registers and self-help groups.

Nomograms Forecasting Long-Term Overall and Cancer Specific Survival of Patients With Head and Neck Neuroendocrine Carcinoma

Background

The purpose of this retrospective analysis was to build and validate nomograms to predict the cancer-specific survival (CSS) and overall survival (OS) of head and neck neuroendocrine carcinoma (HNNEC) patients.

Methods

A total of 493 HNNEC patients were selected from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2015, and 74 HNNEC patients were collected from the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital (HCH) between 2008 and 2020. Patients from SEER were randomly assigned into training (N=345) and internal validation (N=148) groups, and the independent data group (N=74) from HCH was used for external validation. Independent prognostic factors were collected using an input method in a Cox regression model, and they were then included in nomograms to predict 3-, 5-, and 10-year CSS and OS rates of HNNEC patients. Finally, we evaluated the internal and external validity of the nomograms using the consistency index, while assessing their prediction accuracy using calibration curves. A receiver operating curve (ROC) was also used to measure the performance of the survival models.

Results

The 3-, 5-, and 10-year nomograms of this analysis demonstrated that M classification had the largest influence on CSS and OS of HNNEC, followed by the AJCC stage, N stage, age at diagnosis, sex/gender, radiation therapy, and marital status. The training validation C-indexes for the CSS and OS models were 0.739 and 0.713, respectively. Those for the internal validation group were 0.726 and 0.703, respectively, and for the external validation group were 0.765 and 0.709, respectively. The area under the ROC curve (AUC) of 3-, 5-, and 10-year CSS and OS models were 0.81, 0.82, 0.82, and 0.78, 0.81, and 0.82, respectively. The C-indexes were all higher than 0.7, indicating the high accuracy ability of our model's survival prediction.

Conclusions

In this study, prognosis nomograms in HNNEC patients were constructed to predict CSS and OS for the first time. Clinicians can identify patients' survival risk better and help patients understand their survival prognosis for the next 3, 5, and 10 years more clearly by using these nomograms.

Laryngeal Neuroendocrine Tumor With Elevated Serum Calcitonin: A Diagnostic and Therapeutic Challenge. Case Report and Review of Literature

Introduction: Laryngeal neuroendocrine neoplasms (NENs) are a rare group of NENs of the neck, which commonly show immunostaining for calcitonin. Laryngeal NENs with calcitonin hypersecretion and lymph node metastases represent a diagnostic and therapeutic challenge, which should be included in the differential diagnosis of medullary thyroid carcinoma (MTC). We report a complex case of laryngeal NEN with calcitonin hypersecretion and a review of the literature. Case Presentation: A 59-year-old man presented with dysphagia, dyspnea, and lateral cervical mass; he was a smoker. At first imaging, a laryngeal lesion with lateral cervical lymphadenopathies was found, and it resulted as a moderately differentiated neuroendocrine tumor (G2), Ki67 = 5%, positive for calcitonin. Increased levels of serum calcitonin (50 pg/ml) were found. The patient started somatostatin analogs for lesions positivity to somatostatin receptor-based imaging. After 5 months, the disease progressed at 18F-fluorodeoxyglucose (¹⁸F-FDG) PET-CT, and also new painful cutaneous lesions occurred. Considering high serum levels of calcitonin, differential diagnosis with MTC was required. Patient performed a thyroid color Doppler ultrasound, nodule fine needle aspiration, calcitonin dosage in fine needle washout fluid, and a calcium gluconate stimulation test. After multidisciplinary evaluation, we decided to perform a total thyroidectomy associated with lateral cervical lymphadenectomy and resection of skin metastases. No MTC was found. Two of the five resected lymph nodes, left upper parathyroid, and skin lesions were metastases of NEN G2, positive for calcitonin. After 2 months, new painful skin lesions occurred, and a target therapy with everolimus 10 mg/day was started. After 6 months of therapy, partial metabolic response with a reduction of 53.7% of radiotracer uptake at primary tumor was detected together with an improvement of patient's quality of life. Conclusions: The present case is the seventh described in the literature of laryngeal NEN associated with elevated serum calcitonin levels and the first case with parathyroid metastasis, suggesting the importance of a correct differential diagnosis between MTC and calcitonin-secreting laryngeal NEN, using an integrated approach of biochemistry and advanced imaging. This is also the first time that somatostatin analogs and then everolimus were used in this setting, resulting in clinical and partial metabolic response.

Well-differentiated Neuroendocrine Carcinoma of the Larynx: Confusion of Terminology and Uncertainty of Early Studies

Well-differentiated neuroendocrine carcinoma (also known as "carcinoid") of the larynx is an exceedingly rare tumor that has an epithelial origin. These tumors are malignant and have a low, but definite, risk of metastasis. Although it can be challenging, this tumor should be differentiated from moderately differentiated neuroendocrine carcinoma (also known as "atypical carcinoid"). The clinical and pathologic features of this tumor, as well as treatment and prognosis, are reviewed in detail.

Structural biology of intraepithelial neuroendocrine cells in the larynx: Literature review

Current knowledge of laryngeal neuroendocrine cells in man and other vertebrates is reviewed. Particular attention is paid to differences in the distribution of neuroendocrine cells between squamous and respiratory laryngeal mucosa, foetal versus post-natal spatial arrangements, relation to the laryngeal cavity and nerve fibres, and immunoreactivities of these cells. Methodological deficiencies and gaps in knowledge are outlined. Comparisons with neuroendocrine cells in lung and gut are drawn, caution with regard to existing histogenetic models of laryngeal neuroendocrine neoplasia is advised and lines of future research are suggested.

How phenotype guides management of the neuroendocrine carcinomas of the larynx

Objective

This review aimed to critically analyse data pertaining to the clinical presentation and treatment of neuroendocrine carcinomas of the larynx.

Method

A PubMed search was performed using the term ‘neuroendocrine carcinoma’. English-language articles on neuroendocrine carcinoma of the larynx were reviewed in detail.

Results and conclusion

While many historical classifications have been proposed, in contemporary practice these tumours are sub-classified into four subtypes: carcinoid, atypical carcinoid, small cell neuroendocrine carcinoma and large cell neuroendocrine carcinoma. These tumours exhibit a wide range of biological behaviour, ranging from the extremely aggressive nature of small and large cell neuroendocrine carcinomas, which usually have a fatal prognosis, to the less aggressive course of carcinoid tumours. In small and large cell neuroendocrine carcinomas, a combination of irradiation and chemotherapy is indicated, while carcinoid and atypical carcinoid tumour management entails conservation surgery.

Neuroendocrine Carcinomas of the Larynx and Head and Neck: Challenges in Classification and Grading

Primary neuroendocrine carcinomas (NECs) of the larynx and head and neck are an uncommon and heterogeneous group of neoplasms categorized by the 2017 WHO Classification of Head and Neck Tumors as: (a) well-differentiated (WD-NEC), (b) moderately-differentiated (MD-NEC), and (c) poorly-differentiated (PD-NEC) with small cell and large cell types. The classification incorporates elements of differentiation and grading and closely correlates to the 5-year disease specific survival of 100, 52.8, 19.3 and 15.3% for each diagnostic category. These survival rates are based on historical data limited by the previous lack of standard pathologic diagnostic criteria. The classification has de-emphasized the use of the terms "carcinoid" and "atypical carcinoid" as diagnostic categories. The adoption of uniform pathologic criteria for the classification of NECs of the head and neck should enable the design of high quality studies in order to understand the molecular alterations of these neoplasms.

Differential Diagnosis in Neuroendocrine Neoplasms of the Larynx

The differential diagnosis of neuroendocrine neoplasms of the larynx is broad and includes lesions of epithelial, mesenchymal, and neuroectodermal origin. These lesions have overlapping clinical and pathologic aspects and must be carefully considered in the differential diagnosis of laryngeal neoplasms. The prognosis and treatment are also different among these tumor types, which necessitates making these distinctions clinically. The current literature was reviewed to provide updated information regarding the epithelial-derived tumors, including carcinoid, atypical carcinoid, small cell neuroendocrine carcinomas, large cell neuroendocrine carcinoma, and squamous cell carcinoma with neuroendocrine component. These tumors are compared and contrasted with non-epithelial-derived tumors such as paraganglioma and nonmucosal tumors, such as medullary thyroid carcinoma. The morphologic and cytologic features are discussed, along with helpful immunohistochemical and ancillary investigations.

Cutaneous and Subcutaneous Metastases From Atypical Laryngeal Carcinoids: Case Report and Review of the Literature

The incidence of cutaneous and subcutaneous metastases from atypical laryngeal carcinoids is approximately 20%. However, the pathogenesis and natural history of, and prognostic factors for, the condition remain poorly understood. We reported a 54-year-old female presented with cutaneous and subcutaneous metastases from atypical laryngeal carcinoid. Laryngoscopy revealed a 0.5 × 1.5-cm reddish mass on the laryngeal surface of the epiglottis. Under general anesthesia, a biopsy sample was obtained via suspension laryngoscopy. Routine pathology revealed atypical laryngeal carcinoid. Immunohistochemical staining of the sections of primary tumor was positive for cytokeratin, chromogranin A, synaptophysin, hypoxia-inducible factor-1α, P53, and CD56. GLUT-1, p-Akt, and PI3K were negative. The Ki-67 index was 15%. Supraglottic laryngectomy and selective right-neck dissection were performed. After 6 months, the patient complained of pain in the right wall of the chest; multiple cutaneous and subcutaneous nodules were evident at that site and in the abdomen. An abdominal nodule was biopsied and pathology revealed that the atypical metastatic carcinoid had metastasized to both cutaneous and subcutaneous areas of the abdomen. Chemotherapy was then prescribed. Currently, the intrathecal drug delivery system remains in place. No local recurrence has been detected. Furthermore, we systematically reviewed clinical manifestations of the disease, pathogenesis, prognostic factors, and treatment. The metastasis rate (cutaneous and subcutaneous) was approximately 12.2%. Thirty patients (62.5%) with cutaneous and subcutaneous metastases exhibited contemporaneous lymph node invasion. The 3-, 5-, and 10-year survival rates were 44.0%, 22.0%, and 13.0%, respectively. The prognosis of patients with atypical laryngeal carcinoids was poor. Relevant prognostic factors included the level of p53, human papilloma virus status, certain hypoxic markers, and distant metastasis. No optimal treatment for such metastases has yet been defined.

[A Case of Oropharyngeal Large Cell Neuroendocrine Carcinoma]

The large cell neuroendocrine carcinoma (LCNEC) of the lung was first reported in detail by Travis et al. in 1991. Extrapulmonary LCNEC rarely occurs, and only 22 cases have been reported in the head and neck mucosal regions. Today LCNEC of the larynx is contained in the moderately differentiated/Grade 2 category. However some authors advocate that LCNEC of the larynx should be separated from this category because of the difference in the clinical manifestations and pathological features. Standard treatment for head and neck mucosal LCNEC (M-LCNEC) has not been confirmed. However we suggested the efficacy of postoperative chemotherapy for M-LCNEC. This report describes a case of an LCNEC of the oropharynx. The patient was a 64-year-old man. We treated him with surgery and chemoradiotherapy. He has been disease-free for 36 months after adjuvant-chemotherapy.

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.

Large cell neuroendocrine carcinoma of the head and neck

Large cell neuroendocrine carcinoma is a poorly differentiated neuroendocrine carcinoma that usually occurs in the lung. Although rare in the head and neck, salivary and mucosal subtypes are recognized. This article describes their characteristic light microscopic and immunohistochemical features and highlights the importance of accurate diagnosis, management and prognostic implications.

Terminology and classification of neuroendocrine neoplasms of the larynx

OBJECTIVES

To review the history and literature on neuroendocrine neoplasms of the larynx and discuss the terminology and classification of these tumors.

STUDY DESIGN

Contemporary review.

METHODS

Published journal articles identified through PubMed and conference proceedings were reviewed.

RESULTS

Neuroendocrine neoplasms of the larynx include both epithelial (carcinomas) and neural-type lesions (paragangliomas).The nomenclature of these tumors has changed quite a bit over time, but recently, clearer categories have emerged that are biologically meaningful. They can overlap clinically and histologically so that segregation into the clinically relevant subtypes can be difficult, but it is extremely important to do so as they have a wide range of behaviors going from benign to rapidly fatal.

CONCLUSIONS

Neuroendocrine neoplasms of the larynx can be clearly categorized into the five tumor types: typical carcinoid, atypical carcinoid, small cell neuroendocrine carcinoma, large cell neuroendocrine carcinoma, and paraganglioma. These have concrete biologic and clinical significance and clearly dictate patient treatment.

Large cell neuroendocrine carcinoma of the larynx: definition of an entity

Laryngeal atypical carcinoids (AC/moderately-differentiated neuroendocrine carcinoma) are associated with moderately aggressive clinical behavior; however, a subset of tumors classified as AC have much greater aggressive potential. These tumors fulfill the proposed diagnostic criteria for pulmonary large cell neuroendocrine carcinoma, albeit in the larynx. In the current WHO classification, laryngeal large cell neuroendocrine carcinomas (LCNEC) are classified as variants of AC, whereas pulmonary LCNEC are classified as poorly-differentiated neuroendocrine carcinomas. Reported outcomes for pulmonary tumors support the separate classification of LCNEC. Five and ten year survival rates for pulmonary AC are 61-73, and 35-59%, respectively, while the 5-year survival rate for pulmonary LCNEC is as low as 30%. By extension, we postulate that the biologic potential of laryngeal LCNEC is similar to that of small-cell carcinoma (poorly-differentiated neuroendocrine carcinoma), and as such, warrants reclassification. The files of Barnes Jewish Hospital/Washington University were searched for the term "neuroendocrine" and the anatomic subsite larynx. Neuroendocrine carcinoma cases were evaluated using the WHO definitions for pulmonary AC and LCNEC; small cell carcinoma was excluded. Cases were also solicited from the larger head and neck pathology community. A literature search was also performed for cases of laryngeal neuroendocrine carcinoma, and cases which could be clearly classified as LCNEC by this scheme were captured as well. Six new cases plus four reported cases were identified which fulfill the WHO criteria for pulmonary LCNEC (eight men and two women). Nine patients presented at stage IV and 88% died of disease (DOD), 75 and 100% of these at 2 and 3 years, respectively. Laryngeal LCNEC is a rare entity, distinct from AC. We recommend that laryngeal tumors fulfilling WHO criteria for pulmonary LCNEC not be classified as variants of AC, but as variants of small cell carcinoma (poorly-differentiated neuroendocrine carcinoma) as they are associated with poorer outcome.

Moderately differentiated neuroendocrine carcinoma of the larynx

Neuroendocrine neoplasm of the larynx is a morphologically heterogeneous group of tumors. This unusual neoplasm includes the four different type of tumors. Paraganglioma is the best-known neural origin tumor. The epithelial origin tumor is further divided based on the degree of differentiation into well, moderately, and poorly differentiated carcinoma. The diverse biological behavior of neuroendocrine neoplasm of larynx makes an accurate diagnosis of paramount importance, since treatment depends on diagnostic accuracy. The diagnosis is based primarily on light microscopy, and immunohistochemical and/or ultrastructural investigations are needed to diagnose correctly. The mainstay of treatment of moderately differentiated neuroendocrine carcinoma of the larynx is surgery. Elective neck treatment should be performed considering the high likelihood of cervical lymph node metastases. The 5-yr survival rate approximates 50%, and 10-yr survival rate is only 30%.

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.

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.

Neuroendocrine carcinoma of supraglottis - A case report

Neuroendocrine carcinoma of the larynx is a rare entity constituting about 0.6% of all laryngeal malignancies. An interesting case of neuroendocrine carcinoma of supraglottis in a 70 year old lady is being reported.

The spectrum of endocrinocarcinomas of the larynx

The authors discuss the terminology, classification, pathology, diagnosis, treatment and prognosis of the endocrinocarcinomas of the larynx.

Moderately Differentiated Neuroendocrine Carcinoma (Atypical Carcinoid) of the Larynx: A Clinically Aggressive Tumor

OBJECTIVES

To evaluate the presentation, treatment, and outcome of a small series of patients with moderately differentiated neuroendocrine carcinoma (MDNC) of the larynx seen at one institution and to provide information on this uncommon laryngeal malignancy for therapeutic decision making.

STUDY DESIGN

Retrospective analysis of medical records. Cases were identified from databases maintained by the medical informatics and pathology departments.

METHODS

Patient, tumor, treatment, and outcome data were collected from medical records. Main outcome measures were recurrence, overall and disease-specific survival, and cause of death.

RESULTS

Eleven patients (6 males; 5 females) seen between 1990 and 2003 had sufficient documentation for further evaluation. Patients presented with dysphagia, throat pain, or hoarseness, and all tumors arose in the supraglottis. Eight of 11 patients gave a history of cigarette use. Of the 10 patients treated with curative intent, 7 who recurred all died with disease. The average disease-free interval was 54 months, with a range of 2 to 101 months. The overall and disease-specific survival was 64 and 54 months, respectively. Nine patients were alive 3 years after diagnosis. No correlations with age, stage at presentation, or initial treatment modality and outcome (recurrence or survival) were found.

CONCLUSIONS

Laryngeal MDNC is an aggressive malignancy with frequent regional and distant metastases. Although surgical resection is usually recommended, patients did respond to radiation and chemotherapy, suggesting a combined approach may be indicated. Aggressive initial therapy is needed because development of recurrence portends a poor outcome.