Carcinoid of the larynx: a report of three cases and a review of the literature

Atypical Carcinoid of the Larynx: Case Report

The authors describe a rare case of laryngeal atypical carcinoid. They discuss the histologic pattern of the neoplasm and the differential diagnosis of laryngeal tumors, particularly with oat-cell carcinoma. These tumors represent a spectrum of neoplasms with endocrine differentiation.

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.

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.

Carcinoid tumours of the larynx

The larynx is a rare site of origin of neuroendocrine carcinomas. They can be divided into typical, atypical and small cell tumours on the basis of their histopathological differentiation. The tumour histology and prognosis correlate closely. The typical carcinoid tumours are well differentiated with a benign course. Conservative surgery for local disease is the treatment and is associated with good survival. The atypical carcinoid tumours are poorly differentiated with an aggressive course. Response to radiotherapy and chemotherapy is poor. The treatment of choice is adequate total excision of the lesion with neck dissection if there is clinical evidence of cervical lymphadenopathy and a careful follow-up so as to recognise and treat any metastatic spread. We present two cases with similar history and clinical findings-one typical and the other atypical-and discuss the relevant literature.

Neuroectodermal neoplasms of the head and neck with emphasis on neuroendocrine carcinomas

Tumors exhibiting neuroectodermal differentiation occur throughout the body, and the diverse tissues of the head and neck give rise to a wide assortment of these neoplasms. Neuroectodermal neoplasms may be divided into lesions showing primarily epithelial differentiation (Group I, neuroendocrine carcinomas) and a more diverse group (Group II) of nonepithelial neoplasms. This article reviews these neuroectodermal tumors of the head and neck with emphasis on the neuroendocrine carcinomas and their nomenclature. The author believes that with regard to Group I tumors, the older terminology of carcinoid, atypical carcinoid, and small cell carcinoma should be replaced by subclassifications of well-differentiated, moderately differentiated, and poorly differentiated neuroendocrine carcinoma. The latter category should be further subdivided into small cell and large cell variants. Neuroendocrine carcinomas, particularly the moderately differentiated subtype, are often underdiagnosed in the head and neck region. In the larynx, these tumors are the most common form of nonsquamous carcinoma. Poorly differentiated neuroendocrine carcinoma of small cell type is most common in the salivary glands but can occur elsewhere in the region. The large cell subtype of poorly differentiated neuroendocrine carcinoma has not been well documented in this region. However, the most likely candidate for this tumor category is the so-called sinonasal undifferentiated carcinoma. Group II tumors discussed include olfactory neuroblastoma, malignant melanoma, and Ewing's sarcoma. In addition, differential diagnostic problems related to Group I and II tumors are reviewed in detail. This article reviews and updates our understanding of neuroectodermal neoplasms arising in the head and neck. The focus is on tumors that exclusively involve this region or show a strong predilection to occur here.

A review of neuroendocrine neoplasms of the larynx: update on diagnosis and treatment

Neuroendocrine neoplasms of the larynx have been divided into those of epithelial or neural origin. The latter consist of paragangliomas while the epithelial origin group can be divided into the typical and atypical carcinoids and small cell neuroendocrine carcinomata, the latter consisting of the oat cell type, the intermediate cell type and the combined cell type. There are now over 500 cases of neuroendocrine neoplasms of the larynx in the literature. The diagnosis is primarily based on light microscopy, and, in some instances, it may be supported by special histochemical studies. It should be confirmed by immunocytochemical and/or ultrastructural investigation. The different biological behaviour of neuroendocrine neoplasms of the larynx makes a specific diagnosis of paramount importance, since treatment depends on diagnostic accuracy. Typical carcinoid is an extremely rare lesion. It is treated preferably by conservative surgery; elective neck dissection is not necessary because of the lack of lymph node metastases at diagnosis. Chemotherapy and/or radiotherapy have not been effective in the limited number of patients treated thus far. Prognosis is excellent with cure following surgery. Atypical carcinoid is the most frequent non-squamous carcinoma of the larynx. The mainstay of treatment is surgery. Elective neck dissection should be performed because of the high likelihood of cervical lymph node metastases. Primary radiation therapy with adjuvant chemotherapy is not indicated. The survival rate is 48 per cent at five years and 30 per cent at 10 years. Although the larynx is one of its most common extrapulmonary sites, small cell neuroendocrine carcinoma is still a rare tumour. Surgical results for this tumour have been disappointing and is reserved for cases of local relapse with no evidence of metastasis. Chemotherapy and radiotherapy currently appear to offer the least disabling and most effective forms of therapy. The two- and five-year survival rates are 16 per cent and five per cent, respectively. Paraneoplastic syndromes have occasionally been reported in association with carcinoid tumours (typical and atypical) and small cell neuroendocrine carcinoma. There have been also rare reports of an elevated neuropeptide serum level. Paraganglioma is the only laryngeal neuroendocrine neoplasm with a female preponderance (3:1). Confusion with atypical carcinoid has led to incorrect diagnosis and inappropriate classification schemes, erroneously suggesting that laryngeal paraganglioma has the potential for aggressive behaviour. Conservative surgery represents the treatment of choice; elective neck dissection is not necessary, and the prognosis is excellent.

Neuroendocrine Tumors of the Head and Neck: A Selected Review with Emphasis on Terminology

Virtually every variant of neuroendocrine neoplasia can occur, at least rarely, in the head and neck region. This review focuses on the terminology surrounding neuroendocrine carcinomas of the larynx and their distinction from morphologically similar but biologically distinctive neoplasms. It is suggested that rare typical laryngeal carcinoids be labeled as such. There is little evidence that these lesions are part of a morphologic continuum. In contrast, more common "carcinoid-like" carcinomas, previously referred to as "atypical carcinoids" are more appropriately labeled as "moderately differentiated neuroendocrine carcinomas." These neoplasms should, in turn, be distinguished from "small cell neuroendocrine carcinomas," although these latter two neoplasms do represent a morphologic and behavioral spectrum. Light microscopic and immunohistochemical features distinguishing neuroendocrine carcinomas of the larynx from paraganglioma, metastatic medullary carcinoma, malignant melanoma, and basaloid squamous cell carcinoma are presented. The second portion of this review outlines the clinicopathologic features of two head and neck neoplasms exhibiting varying degrees of neuroendocrine differentiation. Olfactory neuroblastomas have well-developed neuroendocrine differentiation, almost invariably arise from the olfactory mucosa, typically exhibit low-grade cytologic features, and may have protracted clinical course with an approximately 50% overall 5-yr survival. In contrast, sinonasal undifferentiated carcinoma is a microscopically high-grade neoplasm with minimal, abortive neuroendocrine features, a highly aggressive clinical course, and virtually 100% mortality. They can arise throughout the sinonasal region.

Well-differentiated (oncocytoid) neuroendocrine carcinoma of the larynx with multiple skin metastases: a brief report

A 63-year-old woman presented with a history of increasing dysphagia of about two weeks duration. Laryngoscopy revealed a nonulcerated supraglottic epitheliomatous lesion that morphologically appeared well-differentiated and distinctly oncocytoid. Although the tumour lacked any criteria for malignancy such as cellular atypia, pleomorphism or necroses, it recurred twice after primary surgery and later gave rise to multiple painful skin metastases. The diagnosis of an oncocytoid differentiated neuroendocrine carcinoma of the larynx (laryngeal carcinoid) was made. Misinterpretation of laryngeal carcinoids is common, but can be avoided if one is familiar with this rare variant of laryngeal neoplasms.

Neuroendocrine carcinomas of the larynx

The clinical and histopathological characteristics of seven cases of Moderately Differentiated Neuroendocrine Carcinomas (MDNEC) and two cases of Poorly Differentiated Neuroendocrine Carcinomas (PDNEC) have been reviewed. The tumours arose in the supraglottis of predominantly elderly men. Two cases had raised levels of urinary 5-hydroxy-indole-acetic acid at presentation but no case developed the carcinoid syndrome. PDNEC were histologically identical to the oat cell type carcinoma of the bronchus and were associated with an extremely aggressive clinical course with both patients dying of widespread metastases within one month of registration. MDNEC also metastasized frequently with four of seven cases dying with widespread disease. The tumours have previously been reported as not being radiosensitive; however three cases remain free of disease following biopsy and radiotherapy alone. The place of radiotherapy in the management of these tumours is discussed.

Neuroendocrine tumors of the larynx

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

Carcinoid tumours of the larynx: report of two cases

Carcinoid tumour of the larynx is extremely rare. The increasing number of these lesions reported is due to the application of ultrastructural and immunological methods in the diagnosis. Two new cases of this malignant neoplasm are presented and discussed with particular reference to the difficulty in distinguishing carcinoids from other tumours of the larynx. The accurate pathological identification of the tumour is essential for treatment and prognosis.

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.

Carcinoid (neuroendocrine carcinoma) of the larynx

Carcinoid of the larynx is a rare aggressive malignancy with few long-term survivors. Three cases of laryngeal carcinoid treated at the University of Michigan and 23 cases reported previously are reviewed. The clinical behavior, patterns of metastasis, and response to therapy were analyzed to determine optimal therapeutic evaluation and treatment strategies. Patient survival did not correlate with clinically evident regional adenopathy, length of symptoms, extent of laryngeal surgery, or retrospective staging according to American Joint Committee guidelines on cancer of the larynx (AJC-1980). Distant metastatic spread occurred frequently and was the most common cause of death. Surgical therapy is currently the only effective treatment for primary or recurrent disease. Future treatment regimens must address distant spread of tumor.

Carcinoid tumor of the larynx: the role of conservative therapy

Carcinoid tumors of the larynx are an extremely rare condition, universally malignant, and unresponsive to radiation and chemotherapy. Just over 20 cases have been reported in the literature to date. Treatment is adequate surgical excision. The number of these tumors reported should increase due to the use of electron microscopy and immunohistologic techniques in making the diagnosis. This paper illustrates the role of conservative laryngeal surgery, when appropriate, as an effective form of therapy. The basic pathologic diagnostic criteria are illustrated.