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Case study of well-differentiated carcinoid tumor of the larynx and review of laryngeal neuroendocrine tumors
SPECIAL CASE REPORT SECTION SERGE A. MARTINEZ, MD Case Report Editor
Case study of well-differentiated carcinoid tumor of the larynx and review of laryngeal neuroendocrine tumors LAWRENCE C. MCBRIDE, MD, PAUL D. RIGHI, MD, and PAUL R. KRAKOVITZ, BS, Indianapolis, Indiana
L
aryngeal neuroendocrine neoplasms were first recognized as a distinct clinical and pathologic entity by Goldman et al1 in 1969. Since then, approximately 450 cases have been reported in the English language literature,2 of which only 13 have involved well-differentiated carcinoid tumors. The clinical behavior and overall prognosis associated with these tumors vary widely between the different tumor types. The current World Health Organization classification scheme for neuroendocrine tumors of the larynx is presented in Table 1.3 In this article we describe a rare case of a well-differentiated carcinoid tumor of the larynx and summarize the current literature regarding identification, treatment, and prognosis of these unusual tumors. CASE REPORT A 70-year-old male former cigarette smoker with diabetes went to his local otolaryngologist with right-sided throat pain and hoarseness of several months’ duration. On fiberoptic laryngoscopic examination in the office, a 1.5-cm submucosal mass involving the posterior aspect of the right false vocal cord and the right arytenoid cartilage was seen. Both true vocal cords were mobile. Examination of the neck showed no adenopathy. A biopsy was then performed at the referring hospital, and histopathologic analysis showed an atypical carcinoid tumor. The patient was subsequently referred to Indiana University Medical Center, where fiberoptic examination confirmed a right supraglottic mass (Fig 1). A second review of the pathology slides revealed a carcinoid tumor, with some areas of cellular pleomorphism suggestive of the atypical variant. Further workup findings, including urine cat-
From the Department of Otolaryngology–Head and Neck Surgery, Indiana University (Drs McBride and Righi); and Indiana University School of Medicine (Mr Krakovitz). Reprint requests: Paul D. Righi, MD, Assistant Professor of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Barnhill Dr, Room 0860, Indianapolis, IN 46202-5250. Otolaryngol Head Neck Surg 1999;120:536-9. Copyright © 1999 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/99/$8.00 + 0 23/4/85070 536
echolamine screening, thyroid function tests, complete blood count, and liver function tests, were normal. A CT scan of the neck with contrast demonstrated a well-circumscribed right supraglottic mass directly abutting the arytenoid cartilage. The patient subsequently underwent a right vertical hemilaryngectomy with removal of the involved arytenoid and right selective neck dissection. The right arytenoid cartilage was reconstructed with a portion of the remaining thyroid ala, which was rotated and sutured to the cricoid cartilage. Permanent histopathology of the entire tumor specimen revealed a well-differentiated neuroendocrine tumor characterized by trabeculae and islands of cells with eosinophilic cytoplasm and round, uniform hyperchromatic nuclei without significant pleomorphism (Fig 2). Scattered mitotic figures were present without evidence of invasion of surrounding tissues or blood vessels. The cells stained strongly positive for chromogranin, neuron-specific enolase, and synaptophysin, but there was only weak positive staining for calcitonin. The tumor resection margins were negative on final pathology, and no metastases were identified in the selective neck specimen. The patient’s postoperative course was uncomplicated except for a minor pharyngocutaneous fistula that resolved with conservative treatment. One year after surgery the patient has no difficulty swallowing, and his speech is completely intelligible, although his voice remains mildly hoarse. DISCUSSION Neuroendocrine neoplasms of the larynx are a distinctly uncommon group of tumors that have been categorized into 4 histologic types on the basis of the tissue of origin and the histopathological characteristics of the tumor (Table 1). The clinical behavior of these tumors and outcomes of treatment are directly related to the specific tumor type. Epithelial-origin neuroendocrine tumors of the larynx, such as typical carcinoid, arise from uncommitted epithelial stem cells that are capable of differentiating into multiple cell types. In contrast, neuroendocrine tumors of neural origin (paraganglioma) are derived from paraganglion cells located in proximity to the larynx.4 Histopathologic staining for neurosecretory components is essential in making the diagnosis of a neuroendocrine tumor. As examples, staining for argyrophilic cytoplasmic
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Fig 2. Typical carcinoid tumor of the larynx composed of uniform cells with hyperchromatic nuclei. Note the general lack of mitoses, necrosis, and cellular pleomorphism. Fig 1. Endoscopic view of well-differentiated carcinoid tumor of the right false vocal cord.
Table 1. World Health Organization classification of neuroendocrine tumors of the larynx1 Tumors of epithelial origin Typical carcinoid tumor (well-differentiated carcinoid) Atypical carcinoid tumor (malignant carcinoid) Small cell neuroendocrine carcinoma Tumors of neural origin Paraganglioma
granules (neurosecretory granules that have an affinity for silver salts),5 immunohistochemical staining for neuroendocrine markers such as chromogranin and neuron-specific enolase, and documentation of cellular production of hormones like calcitonin and somatostatin have all been used to demonstrate the cell line of these tumors. Although neuroendocrine neoplasms of the larynx contain neurosecretory components capable of producing a paraneoplastic syndrome, active tumor secretion is infrequent.4 In terms of clinical presentation, laryngeal neuroendocrine tumors occur predominantly in men during their sixth decade of life. Presenting symptoms are typical of a laryngeal mass and include dysphagia, odynophagia, globus sensation, and sometimes aspiration. Neuroendocrine tumors of the larynx have a predilection for the supraglottis because this area is rich with neuroendocrine cells. Treatment and prognosis are generally directed by the specific tumor type and will be discussed in the following sections. Typical Carcinoid Typical carcinoid is the least common of the laryngeal neuroendocrine tumors, with to our knowledge, only 13 cases reported in the English language literature. This tumor most
Fig 3. Atypical carcinoid tumor of the larynx characterized by cellular pleomorphism, nuclear atypia, and occasional mitotic figures. (From Wenig BM. Atlas of head and neck pathology. Philadelphia: WB Saunders; 1993. p. 258.)
often appears as a submucosal lesion of the supraglottic larynx, which can be polypoid or sessile and is usually 1 to 2 cm in size. Histologically, the tumor shows organoid formations of cells that are monotonous, with scanty clear or eosinophilic cytoplasm. The defining characteristics of the typical carcinoid tumor are the absence of pleomorphism, necrosis, or invasion, and only rare mitotic figures6-9 (Fig 2).
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Otolaryngology– Head and Neck Surgery April 1999
Fig 4. Small cell carcinoma of the larynx composed of sheets of small, hyperchromatic, undifferentiated cells. Frequent mitoses and necrosis are present. (From Wenig BM. Atlas of head and neck pathology. Philadelphia: WB Saunders; 1993. p. 260.)
Fig 5. Paraganglioma neoplasm that consists primarily of chief cells with round or oval nuclei and abundant cytoplasm surrounded by a small number of sustentacular cells. Note the zellballen arrangement of cells. (From Wenig BM. Atlas of head and neck pathology. Philadelphia: WB Saunders; 1993. p. 152.)
Treatment consists of complete but conservative tumor resection. Elective neck dissection is not indicated because no patient has yet demonstrated cervical metastases. Radiation and chemotherapy are not required for treatment if the tumor is confined to the larynx. Overall prognosis is good for typical carcinoid, with only 1 of 13 reported patients having died of their disease. It should be noted, however, that distant metastases have developed in 4 patients.
sis than the typical carcinoid variant. Metastatic disease develops in approximately 45% of patients. The 5-year survival rate approximates 50%, and 10-year survival rate is only 30%. Radiation and chemotherapy are of questionable value as therapeutic modalities except in metastatic disease. The size of the primary tumor is important prognostically in that patients with tumors greater than 1 cm demonstrate twice the mortality rate (44% vs 23%).8-10
Atypical Carcinoid
Small Cell Neuroendocrine Carcinoma
Atypical carcinoid of the larynx is the most common laryngeal neuroendocrine tumor, with approximately 200 documented cases in the literature. On gross examination, this lesion appears similar to the typical variant. The vast majority of atypical carcinoid tumors are also supraglottic in origin. Although 75% of patients with atypical carcinoid have a positive smoking history, a causative link is uncertain. Histologically, atypical carcinoid shows cellular pleomorphism, nuclear atypia including hyperchromasia, necrosis, more than rare mitotic figures, and often, vascular invasion (Fig 3).8-10 Treatment of atypical carcinoid of the larynx involves aggressive surgical resection, modified neck dissection, and surveillance for metastatic disease. Atypical laryngeal carcinoid is more aggressive and portends a much poorer progno-
Small cell cancer of the larynx is the second most prevalent type of neuroendocrine tumor of the larynx, with approximately 125 cases reported in the English language literature. Patients with this tumor commonly have cervical or distant metastases at presentation. The histologic appearance of small cell carcinoma of the larynx is similar to that of small cell lung carcinoma. Microscopically, this tumor appears as either sheets or cords of small, hyperchromatic, undifferentiated cells. Scant cytoplasm, frequent mitoses, necrosis, and vascular/lymphatic invasion are observed (Fig 4).8,11-13 Small cell neuroendocrine carcinomas of the larynx have an extremely poor prognosis similar to that of pulmonary small cell carcinoma; 75% of patients die within 18 months of diagnosis, and the 5-year survival rate is abysmal at 5%.
Otolaryngology– Head and Neck Surgery Volume 120 Number 4
Chemotherapy and local irradiation form the basis of treatment. Surgical resection is not indicated.8,11-13
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surgery plays a significant role in management of these lesions. The prognosis for these unusual laryngeal neoplasms ranges from favorable to poor depending on the specific tumor type.
Paraganglioma Paragangliomas comprise the final type of neuroendocrine laryngeal tumor. Unlike carcinoid tumors, there is a female preponderance (3:1). The clinical and pathologic hallmark of these lesions is their vascularity. Paragangliomas of the larynx generally arise in direct approximation to the superior laryngeal artery as it enters the larynx because of an embryologic rest of paraganglion cells located in that region. Branches from the superior laryngeal artery evolve into the main blood supply for the tumor. Histologically, this tumor is composed of noninvasive chief and sustentacular cells in a “zellballen” (small clusters or cords) arrangement. These cell types are separated by a prominent fibrovascular stroma. Sustentacular cells are spindle shaped and few in number, whereas chief cells are numerous and have an abundant eosinophilic cytoplasm that can be vacuolated. Mitoses are rare (Fig 5). The only true criteria for the unusual malignant paraganglioma are invasion of surrounding tissues and metastases.14 Treatment of paraganglioma of the larynx involves complete surgical resection. Patients’ clinical courses tend to be favorable, with eradication of local disease being the central issue. Preoperative angiography is useful, and embolization may be necessary. Routine neck dissection is not indicated, and metastasis is very rare (3%). Overall, prognosis with surgical treatment is excellent.14 CONCLUSION Neuroendocrine tumors of the larynx are a rare group of neoplasms that require accurate diagnosis because of their varied clinical behavior and response to treatment. In general,
REFERENCES 1. Goldman NC, Hood CI, Singleton GT. Carcinoid of the larynx. Arch Otolaryngol 1969;90:90-3. 2. Gripp FM, Risse EKJ, Leverstein H, et al. Neuroendocrine neoplasms of the larynx. Eur Arch Otorhinolaryngol 1995;252:280-6. 3. Shanmugaratnan K, Sobin LH, Barnes L, et al. Histological typing of tumors of the upper respiratory tract. International histological classification of tumors. 2nd ed. New York: SpringerVerlag; 1991. 4. Ferlito A, Rosai J. Terminology and classification of neuroendocrine neoplasms of the larynx. ORL J Otorhinolaryngol Relat Spec 1991;53:185-7. 5. Robbins SL. Pathologic basis of disease. 4th ed. Philadelphia: WB Saunders; 1993. p. 555, 727, 818-20. 6. El-Naggar AK, Batsakis JG. Carcinoid tumor of the larynx. ORL J Otorhinolaryngol Relat Spec 1991;53:188-93. 7. Schmidt U, Metz KA, Schrador M, et al. Well-differentiated (oncocytoid) neuroendocrine carcinoma of the larynx with multiple skin metastasis: a brief report. J Laryngol Otol 1994;108: 272-4. 8. Moisa II, Silver CE. Treatment of neuroendocrine neoplasms of the larynx. ORL J Otorhinolaryngol Relat Spec 1991;53:259-64. 9. Patterson SD, Yarington CT. Carcinoid tumor of the larynx: the role of conservative therapy. Ann Otol Rhinol Laryngol 1987;96: 12-4. 10. Woodruff JM, Senie RT. Atypical carcinoid tumor of the larynx: a critical review of the literature. ORL J Otorhinolaryngol Relat Spec 1991;53:194-209. 11. Googe PB, Ferry JA, Bhan AK, et al. A comparison of paraganglioma, carcinoid tumor, and small-cell carcinoma of the larynx. Arch Pathol Lab Med 1988;112:809-15. 12. Overholt SM, Donovan DT, Schwartz MR, et al. Neuroendocrine neoplasms of the larynx. Laryngoscope 1995;105:789-94. 13. Batsakis JG, El-Nagger AK, Luna MA. Pathology consultation: neuroendocrine tumors of larynx. Ann Otol Rhinol Laryngol 1992;101:710-4. 14. Wenig BM. Atlas of head and neck pathology. 1st ed. Philadelphia: WB Saunders; 1993. p. 152-260.
International Meeting on Otology
The International Meeting on Otology of the Jean Causse Ear Clinic will be held June 5, 1999, at the Jean Causse Ear Clinic, Béziers, France. The preliminary program includes “Current Topics” and “Ossiculoplasty: Indications, Problems, and Technical Choices.” Simultaneous translation from French to English and English to French will be available for the round tables and conferences. For further information, contact Robert Vincent, MD, Jean Causse Ear Clinic, Traverse de Béziers, 34440 Colombiers, France; phone, 33-4-67-35-62-62; fax, 33-467-35-62-00.
Case study of well-differentiated carcinoid tumor of the larynx and review of laryngeal neuroendocrine tumors LAWRENCE C. MCBRIDE, MD, PAUL D. RIGHI, MD, and PAUL R. KRAKOVITZ, BS, Indianapolis, Indiana
L
aryngeal neuroendocrine neoplasms were first recognized as a distinct clinical and pathologic entity by Goldman et al1 in 1969. Since then, approximately 450 cases have been reported in the English language literature,2 of which only 13 have involved well-differentiated carcinoid tumors. The clinical behavior and overall prognosis associated with these tumors vary widely between the different tumor types. The current World Health Organization classification scheme for neuroendocrine tumors of the larynx is presented in Table 1.3 In this article we describe a rare case of a well-differentiated carcinoid tumor of the larynx and summarize the current literature regarding identification, treatment, and prognosis of these unusual tumors. CASE REPORT A 70-year-old male former cigarette smoker with diabetes went to his local otolaryngologist with right-sided throat pain and hoarseness of several months’ duration. On fiberoptic laryngoscopic examination in the office, a 1.5-cm submucosal mass involving the posterior aspect of the right false vocal cord and the right arytenoid cartilage was seen. Both true vocal cords were mobile. Examination of the neck showed no adenopathy. A biopsy was then performed at the referring hospital, and histopathologic analysis showed an atypical carcinoid tumor. The patient was subsequently referred to Indiana University Medical Center, where fiberoptic examination confirmed a right supraglottic mass (Fig 1). A second review of the pathology slides revealed a carcinoid tumor, with some areas of cellular pleomorphism suggestive of the atypical variant. Further workup findings, including urine cat-
From the Department of Otolaryngology–Head and Neck Surgery, Indiana University (Drs McBride and Righi); and Indiana University School of Medicine (Mr Krakovitz). Reprint requests: Paul D. Righi, MD, Assistant Professor of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Barnhill Dr, Room 0860, Indianapolis, IN 46202-5250. Otolaryngol Head Neck Surg 1999;120:536-9. Copyright © 1999 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/99/$8.00 + 0 23/4/85070 536
echolamine screening, thyroid function tests, complete blood count, and liver function tests, were normal. A CT scan of the neck with contrast demonstrated a well-circumscribed right supraglottic mass directly abutting the arytenoid cartilage. The patient subsequently underwent a right vertical hemilaryngectomy with removal of the involved arytenoid and right selective neck dissection. The right arytenoid cartilage was reconstructed with a portion of the remaining thyroid ala, which was rotated and sutured to the cricoid cartilage. Permanent histopathology of the entire tumor specimen revealed a well-differentiated neuroendocrine tumor characterized by trabeculae and islands of cells with eosinophilic cytoplasm and round, uniform hyperchromatic nuclei without significant pleomorphism (Fig 2). Scattered mitotic figures were present without evidence of invasion of surrounding tissues or blood vessels. The cells stained strongly positive for chromogranin, neuron-specific enolase, and synaptophysin, but there was only weak positive staining for calcitonin. The tumor resection margins were negative on final pathology, and no metastases were identified in the selective neck specimen. The patient’s postoperative course was uncomplicated except for a minor pharyngocutaneous fistula that resolved with conservative treatment. One year after surgery the patient has no difficulty swallowing, and his speech is completely intelligible, although his voice remains mildly hoarse. DISCUSSION Neuroendocrine neoplasms of the larynx are a distinctly uncommon group of tumors that have been categorized into 4 histologic types on the basis of the tissue of origin and the histopathological characteristics of the tumor (Table 1). The clinical behavior of these tumors and outcomes of treatment are directly related to the specific tumor type. Epithelial-origin neuroendocrine tumors of the larynx, such as typical carcinoid, arise from uncommitted epithelial stem cells that are capable of differentiating into multiple cell types. In contrast, neuroendocrine tumors of neural origin (paraganglioma) are derived from paraganglion cells located in proximity to the larynx.4 Histopathologic staining for neurosecretory components is essential in making the diagnosis of a neuroendocrine tumor. As examples, staining for argyrophilic cytoplasmic
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Fig 2. Typical carcinoid tumor of the larynx composed of uniform cells with hyperchromatic nuclei. Note the general lack of mitoses, necrosis, and cellular pleomorphism. Fig 1. Endoscopic view of well-differentiated carcinoid tumor of the right false vocal cord.
Table 1. World Health Organization classification of neuroendocrine tumors of the larynx1 Tumors of epithelial origin Typical carcinoid tumor (well-differentiated carcinoid) Atypical carcinoid tumor (malignant carcinoid) Small cell neuroendocrine carcinoma Tumors of neural origin Paraganglioma
granules (neurosecretory granules that have an affinity for silver salts),5 immunohistochemical staining for neuroendocrine markers such as chromogranin and neuron-specific enolase, and documentation of cellular production of hormones like calcitonin and somatostatin have all been used to demonstrate the cell line of these tumors. Although neuroendocrine neoplasms of the larynx contain neurosecretory components capable of producing a paraneoplastic syndrome, active tumor secretion is infrequent.4 In terms of clinical presentation, laryngeal neuroendocrine tumors occur predominantly in men during their sixth decade of life. Presenting symptoms are typical of a laryngeal mass and include dysphagia, odynophagia, globus sensation, and sometimes aspiration. Neuroendocrine tumors of the larynx have a predilection for the supraglottis because this area is rich with neuroendocrine cells. Treatment and prognosis are generally directed by the specific tumor type and will be discussed in the following sections. Typical Carcinoid Typical carcinoid is the least common of the laryngeal neuroendocrine tumors, with to our knowledge, only 13 cases reported in the English language literature. This tumor most
Fig 3. Atypical carcinoid tumor of the larynx characterized by cellular pleomorphism, nuclear atypia, and occasional mitotic figures. (From Wenig BM. Atlas of head and neck pathology. Philadelphia: WB Saunders; 1993. p. 258.)
often appears as a submucosal lesion of the supraglottic larynx, which can be polypoid or sessile and is usually 1 to 2 cm in size. Histologically, the tumor shows organoid formations of cells that are monotonous, with scanty clear or eosinophilic cytoplasm. The defining characteristics of the typical carcinoid tumor are the absence of pleomorphism, necrosis, or invasion, and only rare mitotic figures6-9 (Fig 2).
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Fig 4. Small cell carcinoma of the larynx composed of sheets of small, hyperchromatic, undifferentiated cells. Frequent mitoses and necrosis are present. (From Wenig BM. Atlas of head and neck pathology. Philadelphia: WB Saunders; 1993. p. 260.)
Fig 5. Paraganglioma neoplasm that consists primarily of chief cells with round or oval nuclei and abundant cytoplasm surrounded by a small number of sustentacular cells. Note the zellballen arrangement of cells. (From Wenig BM. Atlas of head and neck pathology. Philadelphia: WB Saunders; 1993. p. 152.)
Treatment consists of complete but conservative tumor resection. Elective neck dissection is not indicated because no patient has yet demonstrated cervical metastases. Radiation and chemotherapy are not required for treatment if the tumor is confined to the larynx. Overall prognosis is good for typical carcinoid, with only 1 of 13 reported patients having died of their disease. It should be noted, however, that distant metastases have developed in 4 patients.
sis than the typical carcinoid variant. Metastatic disease develops in approximately 45% of patients. The 5-year survival rate approximates 50%, and 10-year survival rate is only 30%. Radiation and chemotherapy are of questionable value as therapeutic modalities except in metastatic disease. The size of the primary tumor is important prognostically in that patients with tumors greater than 1 cm demonstrate twice the mortality rate (44% vs 23%).8-10
Atypical Carcinoid
Small Cell Neuroendocrine Carcinoma
Atypical carcinoid of the larynx is the most common laryngeal neuroendocrine tumor, with approximately 200 documented cases in the literature. On gross examination, this lesion appears similar to the typical variant. The vast majority of atypical carcinoid tumors are also supraglottic in origin. Although 75% of patients with atypical carcinoid have a positive smoking history, a causative link is uncertain. Histologically, atypical carcinoid shows cellular pleomorphism, nuclear atypia including hyperchromasia, necrosis, more than rare mitotic figures, and often, vascular invasion (Fig 3).8-10 Treatment of atypical carcinoid of the larynx involves aggressive surgical resection, modified neck dissection, and surveillance for metastatic disease. Atypical laryngeal carcinoid is more aggressive and portends a much poorer progno-
Small cell cancer of the larynx is the second most prevalent type of neuroendocrine tumor of the larynx, with approximately 125 cases reported in the English language literature. Patients with this tumor commonly have cervical or distant metastases at presentation. The histologic appearance of small cell carcinoma of the larynx is similar to that of small cell lung carcinoma. Microscopically, this tumor appears as either sheets or cords of small, hyperchromatic, undifferentiated cells. Scant cytoplasm, frequent mitoses, necrosis, and vascular/lymphatic invasion are observed (Fig 4).8,11-13 Small cell neuroendocrine carcinomas of the larynx have an extremely poor prognosis similar to that of pulmonary small cell carcinoma; 75% of patients die within 18 months of diagnosis, and the 5-year survival rate is abysmal at 5%.
Otolaryngology– Head and Neck Surgery Volume 120 Number 4
Chemotherapy and local irradiation form the basis of treatment. Surgical resection is not indicated.8,11-13
MCBRIDE et al
539
surgery plays a significant role in management of these lesions. The prognosis for these unusual laryngeal neoplasms ranges from favorable to poor depending on the specific tumor type.
Paraganglioma Paragangliomas comprise the final type of neuroendocrine laryngeal tumor. Unlike carcinoid tumors, there is a female preponderance (3:1). The clinical and pathologic hallmark of these lesions is their vascularity. Paragangliomas of the larynx generally arise in direct approximation to the superior laryngeal artery as it enters the larynx because of an embryologic rest of paraganglion cells located in that region. Branches from the superior laryngeal artery evolve into the main blood supply for the tumor. Histologically, this tumor is composed of noninvasive chief and sustentacular cells in a “zellballen” (small clusters or cords) arrangement. These cell types are separated by a prominent fibrovascular stroma. Sustentacular cells are spindle shaped and few in number, whereas chief cells are numerous and have an abundant eosinophilic cytoplasm that can be vacuolated. Mitoses are rare (Fig 5). The only true criteria for the unusual malignant paraganglioma are invasion of surrounding tissues and metastases.14 Treatment of paraganglioma of the larynx involves complete surgical resection. Patients’ clinical courses tend to be favorable, with eradication of local disease being the central issue. Preoperative angiography is useful, and embolization may be necessary. Routine neck dissection is not indicated, and metastasis is very rare (3%). Overall, prognosis with surgical treatment is excellent.14 CONCLUSION Neuroendocrine tumors of the larynx are a rare group of neoplasms that require accurate diagnosis because of their varied clinical behavior and response to treatment. In general,
REFERENCES 1. Goldman NC, Hood CI, Singleton GT. Carcinoid of the larynx. Arch Otolaryngol 1969;90:90-3. 2. Gripp FM, Risse EKJ, Leverstein H, et al. Neuroendocrine neoplasms of the larynx. Eur Arch Otorhinolaryngol 1995;252:280-6. 3. Shanmugaratnan K, Sobin LH, Barnes L, et al. Histological typing of tumors of the upper respiratory tract. International histological classification of tumors. 2nd ed. New York: SpringerVerlag; 1991. 4. Ferlito A, Rosai J. Terminology and classification of neuroendocrine neoplasms of the larynx. ORL J Otorhinolaryngol Relat Spec 1991;53:185-7. 5. Robbins SL. Pathologic basis of disease. 4th ed. Philadelphia: WB Saunders; 1993. p. 555, 727, 818-20. 6. El-Naggar AK, Batsakis JG. Carcinoid tumor of the larynx. ORL J Otorhinolaryngol Relat Spec 1991;53:188-93. 7. Schmidt U, Metz KA, Schrador M, et al. Well-differentiated (oncocytoid) neuroendocrine carcinoma of the larynx with multiple skin metastasis: a brief report. J Laryngol Otol 1994;108: 272-4. 8. Moisa II, Silver CE. Treatment of neuroendocrine neoplasms of the larynx. ORL J Otorhinolaryngol Relat Spec 1991;53:259-64. 9. Patterson SD, Yarington CT. Carcinoid tumor of the larynx: the role of conservative therapy. Ann Otol Rhinol Laryngol 1987;96: 12-4. 10. Woodruff JM, Senie RT. Atypical carcinoid tumor of the larynx: a critical review of the literature. ORL J Otorhinolaryngol Relat Spec 1991;53:194-209. 11. Googe PB, Ferry JA, Bhan AK, et al. A comparison of paraganglioma, carcinoid tumor, and small-cell carcinoma of the larynx. Arch Pathol Lab Med 1988;112:809-15. 12. Overholt SM, Donovan DT, Schwartz MR, et al. Neuroendocrine neoplasms of the larynx. Laryngoscope 1995;105:789-94. 13. Batsakis JG, El-Nagger AK, Luna MA. Pathology consultation: neuroendocrine tumors of larynx. Ann Otol Rhinol Laryngol 1992;101:710-4. 14. Wenig BM. Atlas of head and neck pathology. 1st ed. Philadelphia: WB Saunders; 1993. p. 152-260.
International Meeting on Otology
The International Meeting on Otology of the Jean Causse Ear Clinic will be held June 5, 1999, at the Jean Causse Ear Clinic, Béziers, France. The preliminary program includes “Current Topics” and “Ossiculoplasty: Indications, Problems, and Technical Choices.” Simultaneous translation from French to English and English to French will be available for the round tables and conferences. For further information, contact Robert Vincent, MD, Jean Causse Ear Clinic, Traverse de Béziers, 34440 Colombiers, France; phone, 33-4-67-35-62-62; fax, 33-467-35-62-00.