An 82-year-old Caucasian lady known to suffer from ischaemic heart disease, hypertension, and mild renal impairment was admitted to hospital in November 2010 complaining of a 3-month history of increasing facial pain and difficulty breathing. She had previously undergone surgery for a complicated diverticular abscess two years prior to this presentation and this had resulted in a defunctioning colostomy. Physical examination showed no lymphadenopathy or organomegaly. Indirect laryngoscopy showed a mass at the base of the tongue, involving the epiglottis and causing airway obstruction. The patient underwent an emergency tracheostomy to secure the airway. Investigations showed a white blood count of 11.3 × 109/L, haemoglobin of 104 g/L, platelets of 296 × 109/L, and a normal serum lactate dehydrogenase level of 209 U/L. Staging with computed tomography only confirmed disease in the laryngeal area () and did not show any thoracic, abdominal, or pelvic lymphadenopathy. Bone marrow aspiration and biopsy showed no evidence of bone marrow involvement.\nBiopsy of the laryngeal mass showed that the mucosa and submucosa were infiltrated by large atypical lymphoid cells with irregular nuclear outlines and multiple prominent nucleoli. The cells were positive for CD45 and CD20 and negative for CD3 and bcl2 on immunohistochemistry (). These findings were consistent with a diagnosis of diffuse large B-cell (high-grade) non-Hodgkin lymphoma of the larynx, stage IE, with an R-IPI score of 1 (age > 60, ECOG 0–2, normal LDH of 209 U/L, 0-1 extranodal sites, and stage I/II disease).\nThe patient was administered three cycles of R-CEOP (rituximab, cyclophosphamide, etoposide, vincristine, and prednisone) followed by involved field radiotherapy. Anthracyclines were avoided in view of a decreased left ventricular ejection fraction of 40% on echocardiography performed at diagnosis.\nThe first cycle of chemotherapy was complicated by an acute coronary syndrome, from which the patient recovered with supportive care. The tracheostomy was removed following the second cycle of cytotoxics and the patient remains alive and well 5 years later.
A 60-year-old Caucasian female presented with a 2-month history of progressive dysphagia, hoarseness, and globus sensation, accompanied by a 10-pound weight loss over this period. At time of presentation, she also reported exertional dyspnea. She denied nausea, vomiting, fever, hemoptysis, or hematemesis. Her only other medical comorbidity was hypertension, which was well controlled. She denied smoking, drinking, or related family history of malignancy.\nA CT neck with contrast revealed a large sessile, isointense mass on the laryngeal surface of epiglottis measuring 4.7 cm in its greatest dimension, with no submucosal extension or cervical lymphadenopathy (see ).\nThe patient was subsequently referred to the otolaryngology service for further evaluation. On examination she had a muffled voice and minimal inspiratory stridor without respiratory distress. On palpation, she had normal external laryngeal landmarks and no palpable neck masses. Using a tongue depressor, a large mass could be seen in the oropharynx behind the upper edge of epiglottis. Flexible fiberoptic examination confirmed an exophytic mass in oropharynx that was sessile to the laryngeal surface of the epiglottis and occupied most of the oropharynx. Just beyond the mass, the hypopharynx and laryngeal inlet were normal in appearance (see ).\nA transoral biopsy of the mass was conducted under local anesthesia, since it was easily visualized through her mouth and the mass was stable without glottis obstruction. The biopsy revealed an unusual B-cell lymphoma subtype (see ), based on immunostaining and in situ hybridization ().\nCT of chest, abdomen, and pelvis was negative for additional lymphadenopathy. Bone marrow aspiration and biopsy showed no evidence of bone marrow involvement. These findings were consistent with a diagnosis of diffuse large B-cell (high grade; also she has intermingled low grade areas) non-Hodgkin lymphoma of the larynx, stage IE, with an R-IPI score of 1 (age > 60, ECOG 0–2, normal LDH of 209 U/L, 0-1 extranodal sites, and stage I/II disease). The patient was subsequently treated with definitive chemotherapy and radiation.\nShe was given three cycles of R-CEOP (rituximab, cyclophosphamide, etoposide, vincristine, and prednisone) followed by involved field radiotherapy to the neck with 40 Gy radiation. The patient was seen in clinic 8 weeks later with complete resolution of dysphonia and dysphagia. Repeat fiberoptic examination demonstrated complete resolution of the epiglottic mass without evidence of recurrent or residual tumor. She was seen again four months later with normal voice and remained disease free on examination (). Her PET scan 3 months after treatment was negative.