Carcinosarcomas of the larynx: systematic review of the literature of a rare nosologic entity

Purpose

Carcinosarcoma, also known as Spindle Cell Carcinoma (SpCC), is a rare type of malignant tumor. Generally, this type of pathology occurs in the urogenital tract, the gastrointestinal tract, respiratory tract and mammary gland; in the larynx, SpCC represents only 2–3% of all malignancies. Due to its rarity, there is currently no generally acceptable treatment guideline for this disease. The aim of this study was to systematically review the literature of SpCC of larynx and report epidemiologic, clinicopathologic and main therapeutic approaches for this entity.

Methods

A systematic literature review was performed using MEDLINE, EMBASE, PubMed and Scopus databases. For this review, the results were extrapolated in the period between January 1990 to September 2020. Data extraction was performed using a standard registry database. The clinical and pathological staging were recalculated according to the Eight Edition of AJCC Cancer Staging Manual and statistical analyses were performed using SPSS Version 25.0.

Results

A total of 111 patients affected by laryngeal carcinosarcoma were included. From our review arises that surgery is the main treatment for primary laryngeal carcinosarcoma. In this way, various techniques such as minimally invasive laryngoscopy excision, laser CO2 cordectomy, partial laryngectomy (vertical and horizontal) and total laryngectomy. The role of radiotherapy is still controversial. The overall survival (OS) for T1 stage tumor at 5 years of follow-up is 82.9%, the OS for T2 and T3 tumor is 74% and 73.4%. The OS at 5 years of follow-up is 91.7% for supraglottic tumor, 69.3% for glottic tumor and 50% for transglottic site. Subglottic site is described in only 2 cases [12–13], so the OS at 5 years is not statistically significant. The 5-year overall survival in patients without lymph nodes involvement (N0) is 90.2%, 66.7% and 50%, respectively, for N1 and N2 lesions.

Conclusion

Primary laryngeal carcinosarcoma is a very rare malignancy. There are no clear guidelines in the management but in the literature, surgery is described as the best modality of therapy; radiation only can be a reasonable alternative with controversial efficacy. The most important prognostic factor is the nodal metastasis.

Multimodality Treatment Options and Outcomes of Laryngeal Carcinosarcoma: A Clinical Analysis of a Rare Tumor from a Single Hospital

Primary laryngeal carcinosarcoma is a rare type of malignancies, and the standard therapeutic protocol for its treatment has yet to be established. This retrospective study analyzed the clinical and pathological characteristics, risk factors, treatment options, and prognosis of 13 patients with primary laryngeal carcinosarcomas. This case series included 11 males and 2 females with an age range from 32 to 78 years at diagnosis. The initial clinical symptoms included hoarseness, dyspnea, and foreign body sensation in the throat. The primary tumor sites were at the glottis, supraglottis, and larynx. All these patients were active or passive smokers, and more than half of them were alcohol addictive. The surgical treatment for laryngeal carcinosarcomas included CO2 laser surgery in seven cases, partial laryngectomy and neck dissection in three cases, and total laryngectomy and neck dissection in three cases. Among them, seven cases received postoperative radiotherapy. After follow-up with a mean of 31.15-month, four cases died. Primary laryngeal carcinosarcoma is a rare but more aggressive malignancy. Contralateral lymph node metastasis can occur at the early stage of this disease. A treatment combining surgery and postoperative radiotherapy is strongly recommended.

True hypopharyngeal carcinosarcoma: a case report and literature review

Objective

Carcinosarcoma consists of carcinomatous and sarcomatous tissues and is an aggressive malignant tumor. It is rarely reported in the hypopharynx.

Methods

A 72-year-old man presented with dysphagia and dyspnea. Laryngoscopy, computed tomography (CT), and ¹⁸F-fluorodeoxyglucose positron emission tomography/CT (¹⁸F-FDG PET/CT) showed a neoplasm on the left posterior hypopharyngeal wall. The patient underwent bilateral neck dissection and excision of the hypopharyngeal cancer followed by postoperative radiation therapy.

Results

Immunohistochemistry revealed carcinomatous cells with membrane positivity for cytokeratin, glucose transporter-1 (GLUT-1), phosphoinositide-3 kinase (PI3K), hypoxia-inducible factor-1α (HIF-1α), and hexokinase-II as well as sarcomatous cells with membrane positivity for smooth muscle actin, GLUT-1, HIF-1α, and PI3K. Histopathology and immunohistochemistry revealed a true carcinosarcoma of the hypopharynx (pT3N0M0, Stage III).

Conclusions

Thorough immunohistochemistry is required for a correct diagnosis of hypopharyngeal carcinosarcoma. ¹⁸F-FDG PET/CT may help to distinguish hypopharyngeal carcinosarcoma from benign tumors.

[Sarcomatoid carcinoma of larynx. A histological challenge?]

INTRODUCTION

Sarcomatoid carcinoma can occur in any part of the body; in the head and neck it occurs most frequently in the major salivary glands, with only about 1% of cases found in the larynx. As it has both epithelial and mesenchymal components, there are many theories concerning its origin and it can prove a diagnostic challenge.

CASE REPORT

A 76 year old male smoker presented with dysphonia. Vocal cord injury was found on examination but no lymphadenopathy or metastases were present. Laryngeal microsurgery was performed with complete excision of the lesion. Histopathology showed it to be a carcinosarcoma which showed intense and diffuse positivity for vimentin and focal positivity for AE1-AE3, CK5 and p63. The patient underwent radiotherapy as complementary treatment.

DISCUSSION

Sarcomatoid carcinoma usually presents with obstructive symptoms such as dysphonia. Prognosis depends on the stage and the presence or not of metastases. Both epithelial markers EMA, cytokeratin (AE1-AE3), epithelial membrane antigen, Ki 67 and mesenchymal markers such as vimentin, desmin, S-100 may be positive in these tumours. Recommended treatment for T2-T1 stages is an excisional biopsy which can be followed by adjuvant radiotherapy; radiotherapy alone has also been successful. T3-T4 stages can be treated with local excision, partial laryngectomy or total laryngectomy with subsequent ganglion emptying and concomitant radio and chemotherapy.

Outcomes and patterns of failure of sarcomatoid carcinoma of the larynx: The Mayo Clinic experience

OBJECTIVES/HYPOTHESIS

Sarcomatoid carcinoma is a rare variant of squamous cell carcinoma of the head and neck. No consensus exists on its management. Our aim was to present our outcomes.

STUDY DESIGN

Retrospective study. Median follow-up 45 months.

METHODS

There were 38 patients with pathologically confirmed sarcomatoid carcinoma of the larynx treated at the Mayo Clinic from 1990 to 2014. Statistical analysis of overall survival (OS), progression-free survival (PFS), and local control (LC) were conducted using the Kaplan-Meier method.

RESULTS

The majority of patients were elderly males (92%) with a smoking history (74%) presenting with early-stage disease (71%). Surgery alone was the primary treatment in 27 patients (71%). Nine patients (25%) were treated with adjuvant radiation due to initial stage or high-risk pathologic features. Median radiation dose to the primary/surgical bed was 65 Gy (range, 60.3-75.0 Gy). A total of 15 patients (39%) had tumor recurrence, majority being local (n = 12). Sixty percent (n = 9) had multiple local recurrences. Five-year OS, PFS, and LC were 63%, 46%, and 72%, respectively. Subgroup analysis by stage I versus higher stages (II-IV) showed an OS of 80% versus 43% (P = .030), PFS of 65% versus 18% (P = .003), and LC of 84% versus 57% (P = .039).

CONCLUSIONS

Sarcomatoid carcinoma of the larynx is rare, and frequently presents at an early stage in older men with history of smoking. Based on our outcomes and patterns of failure, it appears early-stage tumors are treated appropriately with single-modality therapy, whereas more advanced tumors require multimodality therapy. Validation in a larger cohort is warranted.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:373-377, 2018.

Endoscopic CO(2) Laser Horizontal Partial Laryngectomy in Larynx Carcinosarcoma

Background. Carcinosarcoma is an extremely rare malignant neoplasm, with both a malignant epithelial and mesenchymal component, that rarely affects the larynx. Aim. Aim of this paper is to describe the case of a patient affected by a larynx carcinosarcoma treated by endoscopic horizontal partial laryngectomy with CO(2) laser and particularly discuss the histogenetic hypothesis as well as the possible treatment modalities of this rare lesion. Methods. Case report and literature review. Discussion and Conclusion. Still little is known about the biology of carcinosarcoma and there is still no consensus in the literature on the treatment of these tumors. Endoscopic horizontal partial laryngectomy could represent another treatment option in selected cases.

Synovial sarcoma of the larynx treated by supraglottic laryngectomy: case report and literature review

We describe a case of synovial sarcoma of the larynx, and we discuss the use of fluorescence in situ hybridization (FISH) in confirming the diagnosis. The patient was a 21-year-old woman who presented with a recurrence of a previously resected supraglottic tumor of the aryepiglottic folds. A horizontal supraglottic laryngectomy was performed, and the 0.5-cm tumor was resected. Histopathologic study suggested that it was a biphasic malignant tumor compatible with a synovial sarcoma. The diagnosis of synovial sarcoma was confirmed by FISH immunohistochemistry with the use of an SYT break-apart probe. The patient recovered satisfactorily, but at follow-up 5 years and 4 months later, tumoral activity was evident in the left side of the neck. A biopsy found that 5 lymph nodes contained a metastasis of the synovial sarcoma. Again, a bilateral neck dissection was performed, and it revealed that 16 of 16 right-side nodes and 36 of 36 left-side nodes were negative. Two months later, the patient received 46 Gy of radiotherapy in 23 sessions. She remained free of disease during 2 more years of follow-up. Synovial sarcoma of the larynx is a rare entity. Organ preservation seems to be indicated in these cases. The histologic diagnosis may be difficult. In this case, the identification of a genetic mutation corroborated the diagnosis.

True carcinosarcoma of the larynx

OBJECTIVE

To explore the diagnosis and treatment of carcinosarcoma of the larynx.

METHODS

Clinical information, including presentation, pathology, treatment and outcome, was obtained from a review of patient charts.

RESULTS

Seven male patients were confirmed pathologically to have had carcinosarcoma between 2003 and 2009 in our hospital. All patients underwent surgery: four total laryngectomies, two vertical partial laryngectomies, and one supracricoid partial laryngectomy-cricohyoidopexy. The mean follow up was 40.6 months. At the time of writing, six patients were alive and being followed; two of these suffered regional metastasis to the cervical lymphatic nodes and underwent radical neck dissection. One patient died of multiple distant metastases 60 months post-operatively.

CONCLUSION

Carcinosarcoma of the larynx describes a biphasic tumour showing both carcinomatous and sarcomatous differentiation. It is extraordinarily rare and prone to metastasise to the cervical lymph nodes. Complete surgical resection of laryngeal primary lesions with wide margins and suitable neck dissection of cervical nodes is reasonable therapy.

Clinical outcome of window partial laryngectomy for stage T2-3 glottic laryngeal carcinoma

OBJECTIVE

To investigate the operative impact and therapeutic value of window partial laryngectomy for the treatment of stage T2-3 glottic laryngeal carcinoma.

METHODS

From October 2000 to December 2006, window partial laryngectomy and laryngeal reconstruction were performed on 48 appropriately selected patients with stage T2-3 glottic laryngeal carcinomas. Twenty-nine males and 19 females were included. Before the operation and in the sixth month after the operation, degree of hoarseness, vocal fold mobility and symmetry, glottal width during quiet breathing, degree of glottal closure during phonating, respiratory function, and swallowing function were surveyed. In addition, tumor recurrence and metastasis and patient survival time were monitored.

RESULTS

With the exception of vocal fold mobility (P=0.343), there were significant differences between the two treatment groups in all areas that were investigated, including degree of hoarseness (all P<0.01), vocal fold symmetry (P=0.000), glottal width during quiet breathing (P=0.001), degree of glottal closure during phonating (P=0.001), and respiratory function (P=0.001). Swallowing function was not influenced (P=0.310). There was recurrence in one case (2.1%), cervical lymph node metastasis in one case, and hepatic metastasis in one case. The 3- and 5-year overall survival rates were 96.9% and 88.9%, respectively.

CONCLUSIONS

This study showed that window partial laryngectomy was successful for treating properly selected stage T2-3 glottic laryngeal carcinoma. This operation was effective for reducing surgical invasion and facilitated the resumption of respiratory and vocal function.