Small cell undifferentiated carcinoma of the larynx

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.

Bone marrow metastases from small cell cancer of the head and neck

BACKGROUND

Primary small cell carcinoma of the head and neck is rare. Although the larynx is the most prevalent site of head and neck small cell carcinoma (SCC), this report will concentrate on SCC of the major salivary glands and paranasal sinuses. In all, 33 cases of paranasal sinus and 43 cases of major salivary gland SCC have been reported in the literature.

METHODS

We report two patients, one with submandibular gland SCC and the other with maxillary sinus SCC. A literature review of all known paranasal sinus and major salivary gland SCC with inclusion of data from these two new cases is undertaken. Discussion of all past and present cases concentrates on sites of metastasis, treatment, and survival.

RESULTS

Paranasal sinus SCCs predominantly arise from the nasal cavity, whereas the parotid gland is the primary site in three fourths of major salivary gland SCCs. One half of major salivary gland and three fourths of paranasal sinus SCCs have only local disease at presentation. Both patients in this report developed bone marrow metastases, a feature heretofore not observed in SCC from these primary sites. The patient with maxillary sinus SCC developed the syndrome of inappropriate antidiuretic hormone (SIADH).

CONCLUSION

The paranasal sinus and major salivary glands are rare primary sites for SCCs. Long-term survival with local therapy in patients with local disease can occur, but in patients with metastatic disease survival mirrors metastatic pulmonary SCC.

Moderately differentiated neuroendocrine carcinoma of the larynx. A clinicopathologic study of 54 cases

Fifty-four cases of primary laryngeal moderately differentiated neuroendocrine carcinoma from the Armed Forces Institute of Pathology Otolaryngic Tumor Registry (AFIP-OTR) are reported. The tumors most often present in men in their sixth and seventh decades of life and are heralded by an array of symptoms, the most frequent being hoarseness. The primary site was most often the supraglottic larynx. The investigation has included light-microscopic, histochemical, immunocytochemical, and electron microscopic analyses which support expression of both neuroendocrine and epithelial differentiation. Conservative surgery alone can be utilized if early identification of the tumor and complete surgical removal are assured. The follow-up of the patients reveals 62% as remaining tumor-free after surgical extirpation over periods ranging from 1 month to 16 years (median: 3 years, 9 months). Factors adversely affecting prognosis include metastatic disease at initial presentation, incomplete surgical removal, and vascular or lymphatic invasion. There was no correlation between tumor size, morphologic pattern, mitoses or necrosis, and survival. Sixty-eight percent of the patients gave a history of long-term cigarette smoking. The classification and pathogenesis of these neoplasms remains the focus of much speculation. They are suggested as arising from the cells of the dispersed neuroendocrine system (DNES). However, a more uniform and descriptive nomenclature is necessary. This study resolves this and other issues along with a presentation of clinicopathologic data of the tumor entity.

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.

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.

Extrapulmonary oat cell carcinoma

Primary extrapulmonary tumors with histologic features indistinguishable from bronchogenic oat cell carcinoma are appearing with increasing frequency in the literature. These tumors have been described in the esophagus, stomach, pancreas, larynx, hypopharynx, salivary glands, nasal cavity and paranasal sinuses, thymus, small and large bowel, uterine cervix, endometrium, breast, prostate, urinary bladder, and skin. It is now widely believed that oat cell carcinoma is a poorly differentiated counterpart of carcinoid tumor and that both originate from an endocrine cell system. In this article, the authors review all cases of extrapulmonary oat cell carcinomas, which they were able to find in the English literature, and report personally studied examples of these tumors, occurring in the esophagus, stomach and urinary bladder. A closely related, if not identical, tumor arising in the skin is also described. It is emphasized that a wider recognition of these tumors is likely to lead to their more frequent diagnosis and possible treatment.

APUD cells of the larynx

Argyrophil cells and melanocytes were sought with Grimelius' and Fontana-Masson's techniques in 43 specimens of laryngeal mucosa. In 7 cases, melanocytes were found in the squamous epithelium: in only 2 cases, rare argyrophil cells were found in the respiratory epithelium. The demonstration of argyrophil cells in the laryngeal mucosa constitutes the anatomic rationale for the insurgence of carcinoids and oat-cell carcinomas at this site.

Primary anaplastic small cell (oat cell) carcinoma of the larynx. Review of the literature and report of 18 cases

Anaplastic small cell (oat cell) carcinoma is a neoplasm commonly arising in the lungs. However, it may also occur, though rarely, in the larynx. A series of 43 cases is presented (ten cases from the Armed Forces Institute of Pathology, eight from the Department of Otolaryngology of the Padua University, and 25 from the literature). The tumor often presents in the sixth and seventh decades of life and appears to be highly aggressive, and metastases develop early. The most common presenting symptom is hoarseness. As in pulmonary small cell carcinoma, prognosis is poor and does not seem to depend upon therapeutic modalities, tumor location or the extent of initial local disease. The tumor seems to derive from the Kulchitsky cell present not only in the bronchial mucosa but also in the laryngeal lining. Like pulmonary anaplastic small cell carcinoma, small cell carcinoma of the larynx should be treated with systemic chemotherapy and radiotherapy. The association of small cell carcinoma with squamous carcinoma of the larynx is also reported and problems connected with the histogenesis of this mixed tumor are discussed.

Small cell undifferentiated carcinoma of the larynx. Report of two patients and review of 13 additional cases

Two patients with small cell undifferentiated carcinoma of the larynx (SCUCL) are described and 13 additional well-documented cases are reviewed. SCUCL affects middle-aged and elderly smokers and has a 2:1 male predominance. Half the patients presented with cervical metastases, an additional 43% developed regional metastases, and 71% ultimately had distant metastases. Thyroid gland involvement occurred in 29% of cases. Ten of fourteen patients had died of their neoplasms (mean survival, 7.8 months). One was living with unresectable tumor. Three were clinically disease-free, 30, 15, and six months, respectively, after diagnosis. Following initial therapy, six patients had recurrent or persistent local tumor or regional metastases. None of them received both total laryngectomy and ipsilateral cervical lymphadenectomy. Four of the six patients had radiation, suggesting that radiotherapy was not always effective in the control of local or regional disease when used in lieu of more extensive surgery. Three patients received chemotherapy, in addition to other modes of treatment, and their mean survival compared favorably with the overall group. The tumor from one of the patients contained a squamous component, and, ultrastructurally, both neoplasms had squamous and neuroendocrine features.

A malignant carcinoid tumour of the supraglottic larynx

A rare case of carcinoid tumour of the laryngeal surface of the epiglottis in a 49-year-old woman is presented. This is the fourth report of this tumour in the world literature. The clinical features, and the light and electron microscopical appearances are discussed. The literature and the relationship to other carcinoid tumours is reviewed. Based on this and previously reported cases, recommendations are made as to management.

Primary oat cell carcinoma of the larynx: a case history and literature review

A case of primary oat cell carcinoma of the larynx is described and the literature reviewed. The origin of this rare tumor and the natural history of the disease are discussed. The different treatment modalities carried out so far are described.

Double primary synchronous and metachronous cancer of the larynx and hypopharynx with dissimilar histology. Five case reports and review of the literature

Five cases of double primary synchronous and metachronous cancers of the larynx and hypopharynx with dissimilar histology encountered at the Section of Pathology of the Department of Otolaryngology of Padua University from 1966 through 1979 are reported. The pathogenesis of these double primary malignancies is discussed, and in particular stress is laid on the perhaps not purely coincidental association of squamous cell and oat cell carcinoma of the larynx and hypopharynx. Furthermore, a thorough review of the literature is made on the reported cases of two primary simultaneous or metachronous malignancies of the larynx and hypopharynx of different histological type.