Laryngeal chondrosarcoma: incidence, pathology, biological behavior, and treatment

Functional or radical surgical treatment of laryngeal chondrosarcoma, analysis of survival and prognostic factors: A REFCOR and NetSarc-ResOs multicenter study of 74 cases

INTRODUCTION

Laryngeal chondrosarcoma (LCS) is a rare tumor of slow evolution whose treatment is poorly codified. For a long time, a radical treatment by total laryngectomy (TL) was proposed. More recent studies tend to propose a conservative surgical approach of the larynx. The objective of this study was to compare the overall survival (OS) of total laryngectomized patients (TL+) versus non-laryngectomized patients (TL-). The secondary objectives were to analyse the reoperation free survival (RFS), the total laryngectomy free survival (TLFS) and to identify the preoperative factors leading surgeons to propose TL.

MATERIALS AND METHODS

A retrospective analysis of prospectively collected incident cases from the REFCOR and NetSarc-ResOs multicenter databases between March 1997 and June 2021 was conducted. A propensity score matching analysis was performed to compare the OS of TL+ and TL-patients.

RESULTS

74 patients were included. After propensity score, the 5-year OS of TL+ and TL-patients was comparable (100 %, p = 1). The 5-year RFS rate was 69.2 % (95 % CI [57.5-83.4]) and the 5-year TLFS was 61.7 % (95 % CI [50.4-75.5]). Cricoid involvement greater than 50 % (HR 3.58; IC 95 % [1.61-7.92] p < 0.001), an ASA score of 3 or 4 (HR 5.07; IC 95 % [1.64-15.67] p = 0.009) and involvement of several cartilages (HR 5.26; IC 95 % [1.17-23.6] p = 0.04) are prognostic factors for TL. Dyspnea caused by the tumour is a prognostic factor for reoperation (HR 2.59; IC 95 % [1.04-6.45] p = 0.03).

CONCLUSION

These results demonstrate that conservative treatment should be considered as first-line treatment for laryngeal chondrosarcoma.

Chondrosarcoma of the Thyroid Cartilage Successfully Treated With Partial Resection of the Thyroid Cartilage

Chondrosarcoma of the thyroid cartilage is a sporadic disease with nonspecific clinical presentation. Smooth swelling of the supraglottic area should arouse suspicion of possible pathology. In addition to laryngoceles, which usually do not have a significant impact, otolaryngologists should consider chondrosarcoma of the thyroid cartilage and indicate computed tomography (CT). Late diagnosis leads to worse prognosis, particularly worse voice after more extensive surgery, need for tracheostomy, and worse survival from higher degree chondrosarcomas.

Survival outcomes in laryngeal chondrosarcoma: a systematic review

Laryngeal chondrosarcomas (LCS) are rare lesions that behave as locally aggressive tumours, producing symptoms such as dysphonia, dyspnoea, dysphagia and hoarseness. Different approaches for the treatment of LCS have been described in the literature. The main purpose of this investigation was to find all cases of LCS published to date and analyse management data and survival outcomes. In December 2020, a systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Provider Enrollment, Chain, and Ownership System (PECOS) method including articles published up to this date on different aspects of LCS. The search included the terms larynx, laryngeal, chondrosarcoma. A total of 148 articles were included in this systematic review describing 381 cases of LCS. Dyspnoea was the most reported symptom followed by hoarseness and neck mass sensation. Cricoid cartilage was the most usual location. Survival rate was influenced by both surgical technique (log-rank = 11.7; p = 0.008) and the degree of tumour histologic differentiation (log-rank = 18.3; p = 0.003).

Imaging features of laryngeal chondrosarcomas: A case series and systematic review

BACKGROUND AND PURPOSE

To comprehensively summarize the characteristics of radiological findings of laryngeal conventional chondrosarcomas.

METHODS

We included patients with pathologically proven laryngeal conventional chondrosarcomas with CT and /or MRI, including 41 cases from 31 publications recruited after a systematic review and 14 cases from our institution. Two board-certified radiologists reviewed and evaluated all the radiological images. The relationship between pathological grade and radiological findings was analyzed.

RESULTS

The median long diameter of the lesion was 3.1 cm (range, 1.5-8.5 cm). The most common location was the cricoid (74.5%), followed by the thyroid (12.7%), cricoid and thyroid (7.3%), and arytenoid (5.5%). All lesions showed well-defined margins. Cortical defect/expansion (98.0%), internal low density (89.6%), and calcification (95.8%) with homogeneous and scarce contrast enhancement on contrast-enhanced CT (85.3%) were frequently observed. All cases showed high signal on T2-weighted imaging, low signal on T1-weighted imaging (T1WI), and heterogeneous and mild contrast enhancement on postcontrast T1WI. No significant differences were found between the pathological grades and radiological findings.

CONCLUSIONS

In our summary of comprehensive CT and MRI findings of laryngeal conventional chondrosarcomas, we found that the knowledge of these radiological features may facilitate prompt diagnosis and appropriate management.

Nonepithelial Tumors of the Larynx: Single-Institution 13-Year Review with Radiologic-Pathologic Correlation

Nonepithelial tumors of the larynx are rare and represent a minority of all laryngeal neoplasms. Imaging has an important role in the diagnosis, treatment planning, and surveillance of these entities. However, unfamiliarity with these neoplasms can cause diagnostic difficulties for radiologists, especially because many of the imaging findings are nonspecific. By using a systematic approach based on clinical history, patient age and gender, lesion location, endoscopic results, and specific imaging findings, the differential diagnosis can often be narrowed. These tumors typically affect the submucosal layer, so if a tumor has an intact mucosa at endoscopy, a nonepithelial neoplasm is the most likely diagnosis. Nonepithelial tumors of the larynx can arise from the laryngeal cartilage or muscle or from the surrounding lymphoid tissue or blood vessels. Consequently, imaging findings typically correspond to the specific cell type from which it originated. Recognizing specific features (eg, metaplastic bone formation, macroscopic fat, or enhancement pattern) can often help narrow the differential diagnosis. In addition, identification of noncircumscribed borders of the lesion and invasion of the adjacent structures is key to diagnosis of a malignant process rather than a benign neoplasm. Understanding the pathologic correlation is fundamental to understanding the radiologic manifestations and is ultimately crucial for differentiation of nonepithelial laryngeal neoplasms. Online supplemental material is available for this article. ^©RSNA, 2020.

Differing characteristics of cartilaginous lesions of the larynx

Introduction

The tissues of the laryngeal region only rarely harbor primary cartilaginous lesions, and squamous cell carcinoma remains the most frequently encountered malignant tumor in this area.

Materials and Methods

We reviewed the salient histological features of cartilaginous laryngeal lesions to provide differential diagnostics and guidelines for distinguishing the benign from the malignant ones.

Results

Cartilaginous neoplasms of the larynx include chondroma and chondrosarcoma. Among the overarching group of all forms of laryngeal sarcoma, chondrosarcoma forms the most common entity in the larynx, followed by rhabdomyosarcoma. Cartilaginous tumors comprise about 0.1%–1% of all laryngeal neoplasms with chondrosarcomas being more frequently encountered than chondromas. Several neoplasms earlier reported as giant-cell tumors of the larynx would most likely, using current terminology, be classified as cases of undifferentiated pleomorphic sarcoma (previously known as malignant fibrous histiocytoma, giant-cell variant) or aneurysmal bone cyst.

Conclusion

When true laryngeal sarcomas do exist, they may prove to be challenging lesions both for the pathologist and the treating clinician. The diagnostic problems are mainly a result of the infrequent exposure of clinicians and diagnosticians to these lesions.

Laryngeal sarcomas: A case series of 5 cases

Primary sarcomas of the larynx are rare and miscellaneous. The most common is chondrosarcoma. Other sarcomas are very rare. Sarcomas can have heterogeneous morphologic features of spindle, small round, epithelioid, pleomorphic and giant cells. Laryngeal sarcomas may mimic carcinomas, lymphomas, small cell carcinoma, mesothelioma and melanoma. This imposes diagnostic challenges for unfamiliar pathologists particularly in small laryngeal biopsies. Our aim was to study the different types of sarcomas that can involve the larynx in our institution, to investigate their diagnostic challenges and potential pitfalls and to find helpful histologic clues to avoid misinterpretation and missed diagnosis. We performed a retrospective review study over 13 years. We retrieved 5 cases of laryngeal sarcomas. They included Kaposi sarcoma, low-grade chondrosarcoma, epithelioid angiosarcoma, polypoid leiomyosarcoma and small cell osteosarcoma. The age range was between 32 and 74 years with an average age of 52 years. The male to female ratio was 3:2. The Kaposi sarcoma and chondrosarcoma were correctly diagnosed. The angiosarcoma was initially missed as recurrent carcinoma. The leiomyosarcoma was initially inferred as polypoid sarcomatoid squamous cell carcinoma. The small cell osteosarcoma initiated the differential diagnosis of high-grade lymphoma, small cell carcinoma, undifferentiated carcinoma, Ewing sarcoma and rhabdomyosarcoma. An implementation of a panel of immunohistochemical markers guided by certain histomorphologic clues was helpful to make the correct diagnosis. Pathologists should be aware of the morphologic spectrum and different growth patterns of laryngeal sarcomas. Immunohistochemistry studies are essential. Correct diagnosis, classification and grading of laryngeal sarcomas are clinically important for the prognosis and appropriate management of patients.

Chondrosarcoma of the Larynx. Case Report and Review of the Literature

Chondrosarcoma of the larynx is a rare tumor; worldwide only about 250-300 cases have been described in the literature. We present a clinical case of laryngeal chondrosarcoma manifesting as a swollen mass of 10 x 7 x 6 cm in the infrahyoid and left lateral cervical region. The patient underwent total laryngectomy, thyroidectomy and bilateral neck dissection. A review of the literature on this disease is also reported.

Role of ancillary techniques in profiling unclassified laryngeal malignancies

Laryngeal biopsies, contrary to biopsies from many other sites of the body, very often contain minute amounts of tumour tissue that may consist of morphologically undifferentiated tumour only. In haematoxylin- and eosin-stained sections, there may be no indicative features of what specific tumour entity that is present. In the larynx, particularly small round cell neoplasms, primary or metastatic, often cause a diagnostic dilemma and where an incorrect diagnosis can induce substantial clinical consequences for the patient (e.g., primary neuroendocrine carcinomas vs metastatic variants, certain sarcomas). If sufficient/representative material has been obtained, the application of immunohistochemistry and/or molecular techniques should in virtually every case reveal the true nature of the malignancy. In cases with sparse amount of material, and therefore a limited number of sections to be cut, a careful and thoughtful stepwise approach is necessary to ascertain a reliable diagnosis, or at least guide the clinician to the most likely diagnoses. With today's advanced and widely available technology with an abundance of markers to discriminate different tumours, the use of the term "undifferentiated" should be largely unnecessary. In the exceptional, and indeed exceedingly rare cases, when a classification is not possible, even after repeat biopsy, we suggest that the laryngeal neoplasm is better termed "unclassified malignant neoplasm" rather than "undifferentiated malignant neoplasm".

Chondrosarcoma of the Larynx: Presentation of a Case and Review of the Literature

Chondrosarcoma of the larynx is a rare tumor of the upper respiratory tract that originates from cartilaginous tissue. The cricoid cartilage is the most frequent site of onset at the larynx. The diagnosis is not always easy, given the tumor's slow growth rate, the aspecificity of the symptoms, and the low degree of malignancy with which most cases present and which often causes it to be mistaken for a chondroma. A case is presented of a 61-year-old woman with a chondrosarcoma of the larynx, grade 2, originating from the cricoid cartilage and measuring about 3 cm in diameter. The patient underwent extirpation of the tumor together with the cricoid cartilage, with a successive thyrotracheal anastomosis because she refused a total laryngectomy, which would have been the indicated intervention on the basis of the extent and grade of the neoplasm. At 6 years from surgery, the patient is in a good state of health with good laryngeal function and without recurrence of the disease. This fact confirms that the surgical approach to chondrosarcoma of the larynx can in most cases be conservative, reserving demolitive surgery for the more aggressive forms, for tumors of greater extent, and for recurrences. In fact, good laryngeal function and therefore a good quality of life can be maintained even for long periods of time.

Primary chondrosarcoma of the thyroid cartilage: Surgery-based management of a rare case

In this study, we present a case of a 52-year-old male with a chondrosarcoma of the left lamina of the thyroid cartilage. Pre-operative evaluations detected typical calcifications and delineated the extent of the tumor. The patient underwent a total laryngectomy to ensure the complete resection of the tumor. The tumor was histopathologically found to consist of chondrocytes in a hyaline cartilage matrix. The patient's post-operative course has been successful apart from the permanent tracheostomy. Herien, we discuss the methods and rationales for the diagnosis and management of and recovery from this rare tumor, and also provide a review of the literature.

Recurrent chondrosarcoma of the larynx: A case report and literature review

BACKGROUND

Laryngeal chondrosarcoma (LCS) is a rare laryngeal tumor that most commonly originates from the cricoid cartilage. The current trend for treatment of low-grade LCS is function-sparing surgical option with negative margins.

CASE SUMMARY

We reported here a case of a 63-year-old male patient with a 3-month history of progressive hoarseness and throat pain. The patient had undergone surgical resection of a laryngeal mass 2 years prior. A supracricoid partial laryngectomy was performed this time. Histological examination supported the diagnosis of low-grade chondrosarcoma. Three years later, the radiological and clinical findings showed no evidence of recurrence.

CONCLUSION

Currently, total laryngectomy is preferred for patients with recurrent low-grade LCS. However, the literature review and our case suggest that a second function-preserving procedure may be a reasonable choice for recurrent LCS.

Laryngeal chondrosarcoma: A systematic review of 592 cases

OBJECTIVES/HYPOTHESIS

Laryngeal chondrosarcomas are rare entities that arise from the cartilaginous structures of the larynx, including the cricoid, thyroid cartilage, epiglottis, and arytenoid cartilages. These tumors represent a minority of malignancies involving the larynx and can be mistaken for benign pathologies. The treatment has historically been surgical excision, often by total laryngectomy. This review investigates treatment modalities and patient outcomes.

STUDY DESIGN

Systematic review using PubMed/MEDLINE and EMBASE database.

METHODS

The databases were used to identify articles reporting cases of chondrosarcomas occurring exclusively in the larynx. Variables analyzed included patient demographics, presenting symptoms, grade, therapeutic approach, patient outcomes, and follow-up.

RESULTS

Five hundred and ninety-two cases were identified. The average age reported was 62.5 years. There was a 3:1 male to female ratio. The most common surgical approach was local excision in 178 cases, followed by total laryngectomy in 174 cases. Nonsurgical treatment such as radiotherapy and chemotherapy was only used in 0.8% and 0.2%, respectively. Disease-specific survival rates for 1, 5, 10, and 20 years were 97.7%, 91.4%, 81.8%, and 68.0%, respectively, with no differences when comparing 5-year survival rates for location, grade, and therapy.

CONCLUSION

Laryngeal chondrosarcomas are rare with a good prognosis. Various surgical approaches exist, with no difference noted in 5-year survival outcomes. Nonsurgical approaches were rarely used for these lesions.

LEVEL OF EVIDENCE

N/A. Laryngoscope, 2016 127:430-439, 2017.

Hemicricoidectomy as the primary diagnosis and treatment for cricoid chondrosarcomas

OBJECTIVES/HYPOTHESIS

The objective was to present a new approach for the diagnosis and treatment of chondrosarcoma involving the cricoid cartilage. The technique involved an extramucosal resection of the ipsilateral half of the involved cricoid cartilage, providing enough tissue to be sent for pathological study, and resulted in good laryngeal function without jeopardizing patients' long-term survival.

STUDY DESIGN

Retrospective study.

METHODS

A retrospective study of eight patients who underwent hemicricoidectomy for cricoid chondrosarcoma was performed at the Center for Voice Disorders, Wake Forest University (Winston-Salem, NC). One patient was a woman and seven were men. The mean age at diagnosis was 64 years (age range, 53-72 y).

RESULTS

All patients had a low-grade tumor. Primary treatment included hemicricoidectomy in all cases. In six (75%) of the patients, tracheotomy was required at the initial surgery. The mean time for decannulation was 3.2 months (range, 5 d-1 y). In four cases a second procedure was required because of recurrence. The second procedure included two total laryngectomies and two endoscopic carbon dioxide laser excisions. The mean follow-up time was 3 years (range, 2 mo-10 y). At the time of writing, six patients were alive without recurrence, one patient was alive with disease; and one patient had died of unrelated causes.

CONCLUSION

The authors recommended unilateral hemicricoidectomy as the diagnosis and treatment of choice. This procedure allows sufficient tissue for histological study and provides good long-term breathing and phonatory function without compromising long-term survival. This procedure is appropriate for patients with 1) mobility of one vocal fold, 2) dysphonia or aphonia, and 3) an adequate subglottic airway.

Chondrosarcoma of the arytenoids- a rare laryngeal malignancy

Even though laryngeal malignancies are the most frequent primary malignancies of the upper aero digestive tract except for oral cavity cancers, laryngeal chondrosarcomas are rare tumors, constituting less than 1% of all laryngeal tumors. We present a rare case of chondrosarcoma arising from the right arytenoid cartilage with sub glottic extension. The mode of presentation and management of the case is presented along with a review of the literature.

Chondrosarcoma of the Arytenoid Cartilage: A Case Report and Review of the Literature

We report the case of a 56-year-old black woman with a locally aggressive chondrosarcoma at an unusual tumor site: the right arytenoid cartilage. The tumor extended from the superior pole of the right arytenoid cartilage to the soft-tissue areas of the right aiyepiglottic fold, piriform sinus, and interarytenoid area. We undertook a conservative surgical approach by performing an endoscopic transoral CO2 laser resection, a right arytenoidectomy with wide soft-tissue margins, and a tracheotomy in anticipation of postoperative edema. Surgical exploration revealed that the tumor extended into the cricoid cartilage. Histopathology demonstrated a low-grade chondrosarcoma of the conventional variant. Clear margins were obtained by staged procedures. Chondrosarcomas of the larynx typically exhibit low-grade histopathology, and affected patients have a low incidence of metastasis and a good prognosis. Even so, these tumors can present diagnostic and therapeutic challenges. Surgical resection provides adequate airway protection and sound oncologic safety while preserving speech and swallowing, and these should be the surgeon's goals in this setting. Options include open laryngofissure, thyrotomy, organ preservation with partial laryngectomy, and endoscopic laser resection.

Chondrosarcoma of the hyoid bone

Chondrosarcoma of the head and neck is relatively rare. We report the sixth case known to us in which the chondrosarcoma had originated in the hyoid bone. The patient, a 66-year-old man, underwent surgery. The resected tumour was a 5 cm encapsulated lesion composed of lobulated, firm, gray-white tissue. Histologically it showed mature chondrocytes without capsular invasion. There was high cellularity and a few binucleated chondrocytes. Although the tumour grade was prognostic significance, our literature review of the five other cases suggests that the location of the primary lesion and the adequacy of its resection to be more important. Our patient continues to do well 15 months post-operatively. However, long-term follow-up is essential as recurrences have been reported even after eight or 10 years.

Subtotale Krikoidresektion als primäre Therapie eines hochdifferenzierten Chondrosarkoms des Ringknorpels

Chondrosarcomas of the larynx are rare malignant tumors usually diagnosed with significant delay due to their nonspecific symptoms. We report a 50-year-old male presenting with progressive dyspnea. Indirect laryngoscopy revealed a subglottic stenosis. The cricoid cartilage was shown on CT to be massively damaged. Histologic differentiation between chondroma and highly differentiated chondrosarcoma was very difficult. Therefore, an organ-preserving treatment concept using partial cricoid resection and staged endoscopic arytenoidectomy was chosen. Total laryngectomy and permanent tracheostomy could be avoided. Due to the risk of recurrence, early follow-up with endoscopy and CT is mandatory.

[Chondrosarcoma of the cricoid]

OBJECTIVE

Chondrosarcoma of the larynx is a rare neoplasm generally observed on the cricoid. The purpose of this study was to define the most appropriate surgical management depending on tumor extension and histological grade.

PATIENTS AND METHODS

Three males and one female were treated for chondrosarcoma of the cricoid between 1990 and 2003 in the Ear, Nose and Throat department in Tours, France. There were three grade I tumors and one grade II tumor. Tumor resection by thyrotomy was performed in two patients, total laryngectomy in one and laser desobstruction in one.

RESULTS

The patient who underwent total laryngectomy remained in complete remission at five years. Among the two patients who had thyrotomy, one remained in remission at three years and the other experienced recurrence at four years and underwent a second operation. He died five years later due to another disease. Total follow-up was nine years. The patient treated by laser therapy achieved stabilization at twelve months.

CONCLUSION

Computed tomography and histological grading enable choosing the best surgical procedure. Partial laryngeal surgery is indicated for small or low-grade chondrosarcomas. For large or high-grade tumors, total laryngectomy must be performed. In the event of patient refusal, laser desobstruction can provide clinical stabilization.

[Clear cell chondrosarcoma of the larynx. A rare tumor in an uncommon location]

Clear cell chondrosarcoma is a rare bone tumor of low malignancy. It constitutes only 2% of all chondrosarcomas and shows a particular predilection for the epiphyses of long bones. So far, there have only been three cases of clear cell chondrosarcoma of the larynx published in the literature. We report the case of a 46 year old man who suffered from slowly worsening dyspnoea. Diagnostic evaluation revealed a directly subglottic stenosis of the larynx, narrowing the lumen to 1/3. When we tried to resect the stenosis via splitting the ring cartilage from outside, tumorous infiltration of the whole ring cartilage was found. Extended biopsies were taken and histology revealed a clear cell chondrosarcoma. The therapy of choice for this tumor is wide surgical resection. Additional radio- and/or chemotherapy are not recommended. Therefore, the patient underwent laryngectomy. Histologically, the clear cell chondrosarcoma can be easily confused with the highly malignant osteosarcoma or the conventional chondrosarcoma, both requiring more aggressive treatment. Thus, clear cell chondrosarcoma should be kept in mind and, when necessary, a reference histology by a bone tumor register should be requested.

Chondrosarcome laryngé

Chondrosarcoma is a malignant tumor relatively rare on the larynx, and raises diagnostic and therapeutic difficulties. Its diagnosis often requires the recourse to a radiological, endoscopic and anatomopathologic confrontation. Its treatment is exclusively surgical. It is based on broad excision sometimes mutilating and requires in this kind of localization a multidisciplinary collaboration between ORL, vascular surgeon and radiotherapy. In the light of a new very conclusive observation and data of the literature, we wanted to give a progress report on the clinical and therapeutic positions of the various authors.

Condrossarcoma laríngeo: relato de caso e revisão de literatura

Os tumores cartilaginosos da laringe são extremamente raros e correspondem a aproximadamente 1% dos tumores que acometem este órgão. Menos que 0,1% destes tumores correspondem aos condrossarcomas. Os condromas e os condrossarcomas de baixo grau são os mais freqüentemente encontrados e 70-75% destes tumores localizam-se na face laríngea da lâmina posterior da cartilagem cricóidea. O diagnóstico do condrossarcoma da laringe pode ser esquecido devido a sua baixa ocorrência e sua forma indolente de crescimento. A apresentação clínica é variada e diretamente dependente do tamanho e localização do tumor: estridor, cornagem, dispnéia, disfagia ou massa cervical são os sinais mais freqüentes. O objetivo deste estudo é apresentar um caso incomum de condrossarcoma laríngeo de origem na cartilagem tireóidea, discutindo o quadro clínico, o diagnóstico, tratamento e os fatores prognósticos.

Laryngeal chondroma presenting as a laryngopyocele

The abnormal dilatation of saccules in direct communication with the laryngeal lumen is termed laryngocele. A simple laryngocele is an air-filled dilatation of the saccule and is mostly asymptomatic. When the neck of the laryngocele is obstructed, the laryngocele becomes filled with mucus. If a mucus-filled laryngocele is infected, it is called a laryngopyocele. The etiology of laryngoceles is not well understood. However, there is an association between laryngoceles and carcinoma of the supraglottic larynx. The main reasons are probably obstruction and mucosal retention of the saccule, increasing intralaryngeal pressure due to airway obstruction or abnormal contraction of the involved laryngeal muscles due to tumoral spreading. We present a patient with laryngopyocele that arose because of a laryngeal chondroma.

Cricoid Chondrosarcoma Presenting as Arytenoid Hypertelorism

BACKGROUND

Arytenoid hypertelorism (arytenoid cartilages spaced too widely apart) appears to be the most common initial recognizable physical finding of cricoid chondrosarcoma. Nine cases from the Center for Voice Disorders are presented. With arytenoid hypertelorism caused by cricoid chondrosarcoma, usually the posterior larynx is open. In fact, patients with arytenoid hypertelorism caused by cricoid chondrosarcoma may be aphonic even though the anterior membranous vocal folds make contact during attempted phonation.

METHODS

Between 1991 and 2002, nine patients were diagnosed with cricoid chondrosarcoma. Patients' charts and video examinations were retrospectively evaluated for symptoms and the presence of arytenoid hypertelorism on endoscopic evaluation. Two were women, and seven were men, with a mean age of 70 (range 53-72) years at diagnosis.

RESULTS

Eight (88%) patients had aphonia or dysphonia caused by arytenoid hypertelorism as their presenting symptom. Six were diagnosed after failed medialization laryngoplasty or other laryngeal rehabilitation surgery. All nine patients had a low-grade tumor. The initial treatment in eight patients was hemicricoidectomy, and one patient had a total laryngectomy. In four cases, a second procedure was needed 1 to 6 years later because of recurrence. Seven patients are alive without clinically significant disease; one is alive with moderate disease, and one has died from an unrelated cause.

CONCLUSIONS

Severely dysphonic, elderly patients presenting with arytenoid hypertelorism of unknown cause should be evaluated by fiberoptic laryngoscopy and by computed tomography scan to rule out cricoid chondrosarcoma. Because these tumors behave so benignly, the authors recommend conservative surgery (unilateral hemicricoidectomy) as the diagnostic/treatment modality of choice.

Dedifferentiated chondrosarcoma of the larynx

Dedifferentiated chondrosarcoma is an uncommon malignant cartilaginous neoplasm of bone characterized by the presence of a malignant spindle cell neoplasm associated with a low- or medium-grade chondrosarcoma. Origin of this tumor in the cartilagenous framework of the larynx is very rare. A 60-year-old male with a 2-year history of hoarseness and dyspnea was examined while presenting in acute airway distress. Direct laryngoscopy revealed a mass of the right side of the larynx. Histopathologic examination revealed a malignant cartilaginous tumor with a malignant spindle cell component. We report a case of dedifferentiated chondrosarcoma arising in the thyroid cartilage. This, to our knowledge, is the eleventh fully documented case of this neoplasm arising in the larynx.

Chondroma and chondrosarcoma of the larynx

PURPOSE OF REVIEW

The purpose of this review is to give a detailed description of chondroma and chondrosarcoma of the larynx and to put into perspective new findings from recent literature.

RECENT FINDINGS

Recent findings indicate that chondroma and chondrosarcoma of the larynx are closely related, either synchronously (areas of both tumor types within the same lesion) or metachronously (malignant transformation of chondroma over time). It is questioned whether the grading of Lichtenstein and Jaffe, and Evans et al. should be used in the larynx, because these grading systems were designed for chondrosarcoma of the long bones. Chondrosarcomas of the larynx seems to behave more like chondrosarcomas of the phalanx, because they too hardly ever metastasize or cause tumor-related deaths. Both CT and MRI play an important role in the workup of these tumors, but they cannot be used to differentiate between both tumor types. No new treatment modalities have emerged recently and surgery is still the treatment of choice. Tracheal autotransplantation may play an increasing role in the treatment of cricoid tumors because it allows for wide resection and optimal revalidation.

SUMMARY

It is now firmly established that metastasis in chondrosarcoma is a poor prognostic sign, but is very rare. Without metastasis the prognosis is excellent. Cartilaginous tumors of the larynx are rare. Clinical, radiologic and pathologic characteristics of these tumors are described and a review of treatment modalities is presented. Wide excision with clear margins is usually indicated. The authors recommend that the management of cartilaginous tumors of the larynx be multidisciplinary and centralized in dedicated referral centers.

Functional treatment of a large laryngeal chondrosarcoma by tracheal autotransplantation

Chondrosarcoma of the cricoid cartilage poses difficult therapeutic challenges. The tumor necessitates resection of parts of the cricoid cartilage with a resulting defect that is difficult to repair. We wanted to improve the functional outcome after resection of a lateralized chondrosarcoma by applying the technique of tracheal autotransplantation. The technique involves a 2-stage procedure, because the trachea needs at least 2 weeks for revascularization. Tracheal revascularization is the first stage, and is accomplished by wrapping the trachea in vascularized fascia (radial forearm). The second stage, performed after 14 days, consists of a hemilaryngectomy with tracheal autotransplantation. A case of a large unilateral chondrosarcoma of the cricoid cartilage with involvement of 1 cricoarytenoid joint is reported. The tumor was removed by hemicricohemilaryngectomy. After 2 weeks of tracheal revascularization, the cervical trachea was used to repair the laryngeal defect. The tumor was completely resected, and all laryngeal functions (swallowing, voice, respiration without tracheostomy) were restored. The patient remains tumor-free after a follow-up period of 3 years. Tracheal autotransplantation improves the functional treatment of lateralized chondrosarcomas of the cricoid cartilage.

Chondrosarcoma of the larynx: a clinicopathologic study of 111 cases with a review of the literature

Chondrosarcomas of the larynx are rare tumors accounting for about 0.5% of all laryngeal primary tumors. A total of 111 laryngeal chondrosarcoma cases, diagnosed between 1970 and 1997, were retrieved from the Otorhinolaryngic-Head & Neck Tumor Registry of the Armed Forces Institute of Pathology. There was a 3.6:1 male/female ratio of patients 25-91 years of age (mean, 64.4 years). Patients presented most frequently with hoarseness (n = 72 patients) present for a mean of 28.2 months. The majority of tumors involved the cricoid cartilage (n = 77) with a mean size of 3.5 cm. All tumors were invasive and malignant by radiology and/or histology (into bone within the ossified laryngeal cartilages in 52 tumors). Most tumors were low-grade lesions: grade 1 (n = 51), grade 2 (n = 54); there were six grade 3 tumors. An associated benign chondroma with (n = 41 tumors) or without ischemia (n = 24 tumors) was noted. All patients had surgery and five had radiation therapy. Wide excision or voice-sparing surgery was used in 73 patients, whereas 37 patients had a laryngectomy. Recurrences occurred in 20 (18%) patients, 10 of whom underwent salvage laryngectomy. At the last follow-up, 102 patients had no evidence of disease (alive or dead, mean 11.2 years) and five patients had evidence of disease (alive, one patient, 6.5 years; dead, four patients, mean 6.4 years). The six patients with high-grade chondrosarcoma were all without disease at the last follow-up (mean, 15.1 years). There was no difference in clinical outcome based on grade (p = 0.210), location (p = 0.078), or treatment (p = 0.607) but was worse for patients with a myxoid-type chondrosarcoma (p = 0.044). Primary laryngeal chondrosarcomas are typically low- to moderate-grade lesions involving the cricoid cartilage, frequently associated with a chondroma. They usually portend an excellent overall long-term prognosis with initial conservative voice-sparing surgery.

Clear cell chondrosarcoma of the larynx: a case report of a rare histologic variant in an uncommon localization

The authors describe a clear cell chondrosarcoma of the larynx. The clear cell type is a rare variant of chondrosarcoma that only twice has been reported in this localization. The light-microscopic diagnosis of the actual case was confirmed by immunohistochemical results, in particular by positive staining for S-100 protein and collagen type II, and ultrastructural findings. Loss of heterozygosity analysis demonstrated allelic loss at 9p22 and 18q21, but neither in the region of the Rb gene on chromosome 13q nor at the p53 locus on chromosome 17p where allelic loss has already been reported in chondrosarcomas. Furthermore, our molecular genetic investigations revealed a methylation of the cell cycle control gene p16, which is localized on chromosome 9p. This characteristic has been recorded previously only in high-grade chondrosarcomas. Mutations in the exons of p16, alterations of the putative tumor suppressor gene MMAC1/PTEN on chromosome 10q, or an amplification of the cyclin D1 gene (CCND1) on 11q13, which were found to be changed in other studies of chondrosarcomas, could not be demonstrated here.

Tumores cartilaginosos da laringe

Introdução: Os tumores cartilaginosos da laringe são raros, sendo a cartilagem cricóide a mais acometida. A raridade desses tumores tem como conseqüência experiência limitada e, portanto, o conhecimento a respeito destas neoplasias apresenta pontos obscuros. Objetivo: Apresentar os resultados cirúrgicos bem como o seguimento a longo prazo de 6 pacientes com tumores cartilaginosos da laringe, 4 condrossarcomas de baixa malignidade e 2 condromas. Forma de estudo: Retrospectivo não randomizado. Material e método: Cinco dos tumores acometiam a cartilagem cricóide e 1 a tireóide. Os pacientes foram submetidos a laringectomia parcial (4) e total (2), com seguimento de 6 a 30 anos (média-19,5 anos). Resultados: Nenhum dos pacientes apresentou metástase ou morte relacionada ao tumor. A sobrevida alcançada por 5 anos foi de 100% e a por 20 anos, 67%, sendo a comorbidade responsável por tal decréscimo. Conclusões: Nossos resultados reforçam o conceito de que a laringectomia conservadora seja a modalidade ideal de tratamento, reservando a ressecção total para tumores extensos ou casos de recorrência. Há indícios de que 5 anos pode não ser tempo suficiente para observar recorrência no condrossarcoma de baixo grau de malignidade.

Chondrosarcoma of the Larynx: A Therapeutic Challenge

The diagnosis of laryngeal chondrosarcoma is likely to be missed because of its infrequent occurrence and its indolent pattern of growth. A 53-year-old woman came to our service with an 18-year history of hoarseness and increasing dyspnea. She had been previously documented as having left vocal fold paralysis and a bulging laryngeal mass. Computed tomography revealed the presence of a large calcified tumor that had caused a deformity of the larynx and an erosion of the arytenoid and cricoid cartilages. Direct laryngoscopy detected a large supraglottic mass with a normal-appearing mucosa. Total excision of the tumor was achieved through a lateral neck incision that spared the larynx. This case emphasizes the importance of a high index of suspicion for laryngeal chondrosarcoma in a patient who has unexplained vocal fold paralysis and a submucosal subglottic mass. Every effort should be made to take a conservative surgical approach that preserves laryngeal function when possible.

Long-term follow-up of cartilaginous tumors of the larynx

BACKGROUND

Cartilaginous tumors of the larynx are uncommon. A literature review disclosed approximately 250 cases since 1816; the cricoid cartilage is the most common site. The rarity of these tumors has made for limited experience and, as a consequence, our knowledge is incomplete.

OBJECTIVE

To report surgical results as well as long-term follow-up on 6 patients with cartilaginous tumors of the larynx.

DESIGN

A 28-year retrospective study with the patients followed-up from 6 to 28 years (average, 17.8 years).

METHODS

Six adult white male patients with cartilaginous tumors of the larynx: 4 low-grade chondrosarcoma (1 of the thyroid and 3 of the cricoid) and 2 chondroma of the cricoid. Surgical treatment included total laryngectomy of the thyroid and 1 of the cricoid chondrosarcoma, and conservation surgery of the other 4 cricoid tumors: the 2 patients with chondrosarcoma had total resection of the cricoid cartilage with thyrotracheal anastomosis, and the 2 patients with chondroma had local tumor resection using a laryngofissure approach.

RESULTS

The margins of the specimen were negative for tumor in the 6 patients. On follow-up, none of the patients had regional or distant metastasis or tumor-related death. One of the patients with cricoid chondrosarcoma developed recurrence 8 years after conservation surgery, and required a total laryngectomy for salvage. Survival rate tumor-free at 5 years was 100% and at 10 years 67%, co-morbidity being responsible for the decrease in survival rate.

CONCLUSIONS

Based on this small series of patients, the long-term follow-up of benign and low-grade malignant tumors suggests that the surgical approach and prognosis does not depend on histologic distinction and, importantly, underdiagnosed malignancy on tumor sampling and recurrent chondrosarcoma, managed with salvage surgery, have no adverse impact on patient survival. Total resection of the cricoid cartilage with thyrotracheal anastomosis over a stent proved an alternative surgical technique in chondrosarcoma who otherwise would have been treated by total laryngectomy.

Laryngeal chondrosarcoma: a 24-year experience at the Royal National Throat, Nose and Ear Hospital

This paper presents a review of the experience of 12 patients with chondrosarcoma of the larynx treated at The Royal National Throat, Nose and Ear Hospital, London, over the last 24 years. This represents the largest European series and the third largest in the world. Chondrosarcoma is the most frequent non-epithelial malignant tumor of the larynx, with 83.3% of cases arising from the cricoid cartilage in our series. We have shown that deep wedge biopsy with a CO2 laser, aided by computerized tomography scanning, gives the most reliable diagnosis. Laryngeal chondrosarcoma is characterized by indolent growth, a potential for local recurrence and, infrequently, by metastases. The treatment details of our patients are discussed. Adequate partial resection is often successful and use of CO2 laser as the initial treatment in five of these cases is presented.

Fine-needle aspiration of dedifferentiated chondrosarcoma of the larynx

We present a case of dedifferentiated chondrosarcoma of the larynx in which the dedifferentiated component was initially diagnosed by fine-needle aspiration (FNA). The patient was a 74-yr-old man who presented with difficulty breathing and an anterior neck mass. A CT scan demonstrated a 4.5-cm cartilaginous lesion involving the left thyroid cartilage, with an anterior soft-tissue component. Nine years prior, the patient had an incomplete resection of a low-grade chondrosarcoma at the same site. FNA was performed on the current lesion, demonstrating a high-grade spindle-cell sarcoma with a storiform pattern. The cytomorphology together with immunocytochemistry and electron microscopy were diagnostic of malignant fibrous histiocytoma (MFH), and synthesis of the clinical, radiographic, and cytomorphologic features resulted in a diagnosis of dedifferentiated chondrosarcoma. The cytologic diagnosis was histologically confirmed by laryngectomy. Although rare, dedifferentiated chondrosarcoma should be included in the differential diagnosis of high-grade sarcomas of bone and cartilage assessed by FNA.

Chondroid tumors of the larynx: computed tomography findings

PURPOSE

Chondromas and chondrosarcomas of the larynx are rare cartilaginous tumors making up less than 1% of all laryngeal tumors. Patients typically present with symptoms of hoarseness, dysphagia, or dyspnea. The most common location in the larynx for these tumors is the cricoid cartilage. Radiographically, these lesions are typically hypodense, well-circumscribed masses containing mottled calcifications with smooth walls centered within the cartilage.

MATERIALS AND METHODS

We present 6 cases of chondroid tumors of the larynx.

RESULTS

One patient had a chondroma, 4 patients had low-grade chondrosarcomas, and 1 patient had an intermediate-grade chondrosarcoma. Two partial laryngeal resections and 4 total laryngectomies were performed.

CONCLUSIONS

In most cases of chondroma or chondrosarcoma of the larynx, conservative surgery should be attempted, but total laryngectomy may be required for large or recurrent lesions.

Management of the clinically negative cervical lymph nodes in patients with non-conventional squamous carcinoma of the larynx

This paper discusses the indications for neck dissection in those patients with laryngeal tumours which prove to be, on pathologic examination, not conventional squamous carcinomas but rather fall into the category either of one of the uncommon histological subtypes of carcinoma, or another type of unusual histological variant of laryngeal malignancy, a mesenchymal tumour. It appears as though these unusual laryngeal malignancies may manifest both biological behaviours and propensities to metastasize to regional lymph nodes that differ from those of the more commonly encountered conventional squamous carcinomas of the larynx. This heterogeneous group of tumours accounts for about 10 per cent of all malignant tumours of the larynx.

A case of giant chondrosarcoma of the cricoid cartilage presenting as a superior mediastinal tumour

We report the case of a 73-year-old man operated on for a symptomatic superior mediastinal mass which developed from the cricoid cartilage. Through cervicotomy and partial sternotomy, laryngeal subglottic resection allowed complete removal of the tumour. From pathological examination, a benign chondroma was initially diagnosed without any criterion of malignancy. However, subsequent review of the pathological slides showed the lesion to be a low grade chondrosarcoma with an epithelial quota of spindle cells, responsible for the patient's death. This case illustrates the need for resection of presumed cricoid cartilage chondromas because of their potential mediastinal development and associated malignancies.

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.

Osteosarcoma of the larynx

About 11,600 cases of laryngeal cancer were reported in the United States in 1995, accounting for 1% of all reported cancers. Fewer than 1% of laryngeal cancers are sarcomas, osteosarcoma being the rarest type. Twelve cases of laryngeal osteosarcoma have been cited in the literature. A 47-year-old man presented with hoarseness following a benign vocal polypectomy. The entire larynx appeared swollen, although both vocal folds moved well. Biopsies did not reveal pathologic tissue. Computed tomographic imaging revealed a destructive, expansile lesion of the thyroid cartilage. A computed tomography-guided biopsy of this cartilage revealed a high-grade sarcoma. Laryngeal osteosarcoma was diagnosed following total laryngectomy. Laryngeal osteosarcoma is a highly malignant neoplasm with early hematogenous spread. Survival statistics for peripheral osteosarcoma are poor. Limited experience reveals that a combination of surgery and radiotherapy with adjuvant chemotherapy can offer some palliation. The literature and published cases of laryngeal osteosarcoma are reviewed.

Chondrosarcoma of the larynx: the role of radiotherapy revisited--a case report and review of the literature

BACKGROUND

Experience in the treatment of laryngeal chondrosarcoma is based on about 250 cases reported to date. The standard therapy is conservative surgery. Radiotherapy has universally been regarded as ineffective in the treatment of this disease.

METHODS

A patient with a laryngeal chondrosarcoma was observed for 11 years after radical radiotherapy. The literature on laryngeal chondrosarcoma was critically reviewed, with emphasis placed on radiotherapy.

RESULTS

The review of the literature revealed that experience with radiotherapy of laryngeal chondrosarcoma has been lacking, with fewer than 10 cases with short follow-up documented up to now. Meanwhile, increasing evidence of the efficacy of radiotherapy in the treatment of skeletal chondrosarcoma has emerged. The authors report the first case of chondrosarcoma of the larynx in which radical radiotherapy resulted in a long term remission of more than 10 years.

CONCLUSIONS

Radiotherapy should be considered when radical surgery is not feasible without severe mutilation. It should also be considered for the treatment of residual disease. Laryngectomy should be restricted to salvage treatment when radiotherapy fails. In this study, radiotherapy appeared to be an effective modality in the treatment of low grade laryngeal chondrosarcoma, and these results contrast with the current widespread disapproval of this treatment.

Laryngeal chondrosarcomas: the Mayo Clinic experience

BACKGROUND

Laryngeal chondrosarcomas occur infrequently. Their management is often guided by inferences made from the management of sarcomas arising from more commonly afflicted organs.

METHOD

A retrospective analysis of patients with laryngeal chondrosarcomas treated at the Mayo Clinic between 1959 and 1992 was performed to assess prognostic factors and outcomes after various treatments.

RESULTS

A total of 20 patients received treatment during this time period. All chondrosarcomas were low grade; 19 involved the cricoid cartilage and one arose in the supraglottic larynx. Initial treatment consisted of local excision (often subtotal removal) alone in 12 patients (60%), hemilaryngectomy in 2 (10%), near total laryngectomy in 2 (10%), and total laryngectomy in 4 (20%). Six patients (30%) had local recurrence: five initially had local excision and one had hemilaryngectomy. All local recurrences or tumor progression developed >3 years after initial treatment. Salvage surgery was performed in five of the six patients who had local recurrence, and the other patient was observed. Of the five patients who had salvage surgery, three required another resection because of a second recurrence.

CONCLUSIONS

These results suggest that initial conservative subtotal laryngectomy should be explored further because this treatment may provide long-term voice preservation in most patients, and patients who experience a recurrence after local excision often have been given several years of voice preservation.

Cartilaginous tumors of the larynx: clinicopathologic review of 47 cases

We reviewed the clinical and pathologic features of 47 laryngeal cartilaginous tumors treated at the Mayo Clinic. This represents the largest reported series of these tumors. The patient group consisted of 36 men (77%) and 11 women (mean age, 63 years; range, 44 to 91 years). The tumors included 44 chondrosarcomas, all low-grade, and 3 chondromas. The overall 5-year survival was 90.1%, which did not differ significantly from the expected survival. Laryngectomy was performed as primary treatment for chondrosarcoma in 6 patients. Of the patients with chondrosarcoma, 40% had tumor recurrence or symptomatic tumor progression at an average of 4.5 years after diagnosis. Only 15 of the patients with chondrosarcoma (34%) required total laryngectomy. There were no metastases, and 4 patients died of local disease (all received treatment before 1960). At latest follow-up, 34 patients with chondrosarcoma (77%) were alive without disease or had died of other causes. We conclude that laryngeal chondrosarcoma can be treated with conservative surgery in most cases, both initially and for recurrent disease.

Recurrent chondrosarcoma of the hyoid bone

Chondrosarcoma is a malignant tumor of cartilaginous origin, and the second most common primary malignant bone tumor in the United States. Only approximately 10% of chondrosarcomas occur in the head and neck region, and of these the hyoid bone is a rare site of involvement. This report describes such a case, as well as the radiographic features as seen by CT scan.