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         CASE SNIPPET Year : 2022  |  Volume : 68  |  Issue : 4  |  Page : 249-250

Primary non-Hodgkin's lymphoma of the larynx

NK Nerurkar, A Sarkar
Voice and Swallowing Centre, Bombay Hospital & Medical Research Centre, Mumbai, Maharashtra, India

Date of Submission25-Mar-2022Date of Decision09-May-2022Date of Acceptance02-Jun-2022Date of Web Publication06-Oct-2022

Correspondence Address:
N K Nerurkar
Voice and Swallowing Centre, Bombay Hospital & Medical Research Centre, Mumbai, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jpgm.jpgm_290_22

How to cite this article:
Nerurkar N K, Sarkar A. Primary non-Hodgkin's lymphoma of the larynx. J Postgrad Med 2022;68:249-50

Primary non-Hodgkin's Lymphoma (NHL) of the larynx is rare, accounting for less than 1% of laryngeal neoplasms with fewer than 100 cases reported in the literature.[1] Although NHL usually occurs within lymph nodes, 25% of the cases may arise in normal non-lymphoid tissues.[2] Laryngeal NHL is likely to develop in the supraglottic and ventricular lymphoid collections due to the scarcity of lymphoid tissues in the glottis. We present a case of primary glottic NHL that suffered diagnostic and treatment delays due to the COVID-19 pandemic.

A 62-year-old male complaining of a change in voice and foreign body sensation while swallowing, since one year, was referred to our voice center. He had uncontrolled type-2 diabetes mellitus and routinely used inhaled steroids for bronchial asthma. The patient had been variably treated for bacterial, viral, and fungal laryngitis by four different otolaryngologists earlier. Video laryngostroboscopy revealed irregular red-white patchy lesions over bilateral vocal folds and a large smooth-surfaced bulge in the inter-arytenoid region [Figure 1]a with moderate amplitude of mucosal waves of both vocal folds. Narrow band imaging (NBI) revealed occasional intraepithelial papillary capillary loop (IPCL) pattern/vertical pattern as per the European Laryngeal Society classification[3] of vascularity [Figure 1]b. The patient was advised excision of the lesions, but due to the pandemic-related concerns, he followed up only after eight months. The high-resolution computed tomography neck scan was unremarkable with no involvement of soft tissues or cartilages.

Figure 1: (a) Flexible laryngostroboscopy image revealing irregular red and white patchy lesions over both vocal folds and a smooth surfaced large bulge in the inter-arytenoid region. (b) Flexible laryngoscopy image using NBI light, revealing occasional IPCL pattern/vertical blood vessels. (c) Intraoperative 10 mm 0° telescopic high definition image, revealing red (vascular) and white area over the vocal folds with occasional IPCL pattern. (d) Laser excision of the epithelial lesions of both vocal folds, leaving the anterior commissure untouched

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Intraoperative imaging confirmed red and white areas on both vocal folds [Figure 1]c with occasional IPCLs on Spectra-A imaging. Laser-assisted biopsy of bilateral vocal fold lesions was performed, following subepithelial infiltration, leaving the anterior commissure untouched [Figure 1]d.

Fungal culture reported growth of Aspergillus fumigatus, and mycobacteria growth indicator tube (MGIT) did not reveal the growth of Mycobacterium tuberculosis. Histopathology examination [Figure 2]a and [Figure 2]b suggested atypical lymphoid proliferation in both vocal folds, and immunohistochemistry confirmed NHL with large B-cell type tumor cells expressing CD20, CD30 and MUM-1. Systemic involvement was excluded by whole-body positron emission tomography-computed tomography scan, hepatic and renal function tests. Thereafter, he was advised chemotherapy followed by radiotherapy by the oncologist for the high-grade laryngeal NHL. Upon the latest follow-up (six months after completing treatment), the patient is faring well with a good, serviceable voice.

Figure 2: Low- (a) and high-power (b) histopathology images suggestive of sheets of medium and large lymphoid cells with scanty cytoplasm and mildly convoluted, mitotically active nuclei, containing prominent nucleoli suggestive of NHL. Immunohistochemistry confirmed NHL with large B-cell type tumor cells expressing CD20, CD30 and MUM-1

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Primary laryngeal NHL is reported more frequently in men in a ratio of 3.4:1.[4] Clinical appearance may be as non-ulcerated submucosal masses occurring commonly in the supraglottis, particularly the aryepiglottic folds that are known to have a rich lymphatic network.[4] Involvement of supraglottis is likely to cause ventricular phonation resulting in a change in voice. The laryngoscopy appearance resulted in the patient receiving treatment for fungal laryngitis and reflux at various centers. Both long-term uncontrolled diabetes mellitus and steroid use lead to an immunocompromised state, which may aid in pathogenesis of lympho-proliferative disorders like NHL. There is growing evidence linking insulin and insulin-like growth factor- 1 (IGF-I) to cell proliferation, lack of apoptosis in cells and cell metastasis phenomena involved in the development and progression of malignancies.[5]

Prior to surgery, anesthetic management was carefully planned. We used a 5.5 mm size laser-safe cuffed micro-laryngeal endotracheal tube to secure the airway and prevent leakage of anesthetic gas or oxygen while providing ventilation. Endotracheal tube cuff was filled with methylene blue tinted saline to alert in case of rupture of cuff. When using the laser, inspired oxygen concentration was reduced to <30%, and nitrous oxide was discontinued. CO2 laser microflap excision of the glottic lesions was performed using acublade in scanning mode, ensuring that the anterior commissure remains untouched. In case of the inter-arytenoid lesion, tissue was excised unilaterally to prevent cicatrization and posterior glottic webbing.

Treatment of NHL includes radiation and/or chemotherapy and/or immunotherapy depending upon the histological grade of lesion. Rituximab and CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen is usually the standard treatment choice for diffuse large B-cell NHL. Laryngeal NHL patients with T-cell type have a worse prognosis than those with B-cell lymphoma.[4] In the present patient, the B-cell type expressed CD30 positivity which is rare. Hu et al.[6] have reported in 2013 that CD30 expression identifies a novel subgroup of diffuse large B-cell lymphoma patients with superior clinical outcomes. Although the prognosis of localized B-cell type laryngeal NHL is favorable, life-long follow-up is indicated for early detection of recurrence.

Declaration of patient consent

The authors certify that appropriate patient consent was obtained.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

 :: References 
1.Andriychuk A, Kristensen BW. Non-Hodgkin lymphoma of the larynx. Ugeskr Laeger 2010;172:2901-2.  
    2.Ansell SM, Habermann TM, Hoyer JD, Strickler JG, Chen MG, McDonald TJ. Primary laryngeal lymphoma. Laryngoscope 1997;107:1502-6.  
    3.Arens C, Piazza C, Andrea M, Dikkers FG, Robin EA, Gi TP, et al. Proposal for a descriptive guideline of vascular changes in lesions of the vocal folds by the committee on endoscopic laryngeal imaging of the European Laryngological Society. Eur Arch Otorhinolaryngol 2016;273:1207-14.  
    4.Sataloff RT, Hawkshaw MJ, Hamdan A. Non-Laryngeal Cancer and Voice. United States: Plural Publishing Incorporated; 2020. 180-89 p.  
    5.Mitri J, Castillo J, Pittas AG. Diabetes and risk of non-Hodgkin's lymphoma- A meta-analysis of observational studies. Diab Care 2008;31:2391-97.  
    6.Hu S, Xu-Monette ZY, Balasubramanyam A, Manyam GC, Visco C, Tzankov A, et al. CD30 expression defines a novel subgroup of diffuse large B-cell lymphoma with favorable prognosis and distinct gene expression signature: A report from the International DLBCL Rituximab-CHOP Consortium Program Study. Blood 2013;121:2715-24.  
    
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