Accepted Manuscript. Low grade spindle cell sarcoma of the true vocal folds. Samuel R. Barber, Pavel Kopach, Elizabeth M. Genega, Thomas L.

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1 Accepted Manuscript Low grade spindle cell sarcoma of the true vocal folds Samuel R. Barber, Pavel Kopach, Elizabeth M. Genega, Thomas L. Carroll PII: S (17) DOI: /j.xocr Reference: XOCR 45 To appear in: Otolaryngology Case Reports Received Date: 23 August 2017 Revised Date: 17 November 2017 Accepted Date: 27 November 2017 Please cite this article as: Barber SR, Kopach P, Genega EM, Carroll TL, Low grade spindle cell sarcoma of the true vocal folds, Otolaryngology Case Reports (2017), doi: /j.xocr This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

2 Title: Low Grade Spindle Cell Sarcoma of the True Vocal Folds Authors: Samuel R. Barber, MD 1, Pavel Kopach, MD 2, Elizabeth M. Genega, MD 2, Thomas L. Carroll, MD 3 1 Department of Otolaryngology-Head and Neck Surgery, University of Arizona College of Medicine, Tucson, AZ; 2 Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA; 3 Department of Surgery, Division of Otolaryngology, Brigham and Women s Hospital, Boston, MA Formatted for: Otolaryngology Case Reports Keywords: Spindle Cell Sarcoma, Laryngeal Cancer, True Vocal Fold, Soft Tissue Sarcoma, Histopathology Conflict of Interest: None Disclosures: None Word count: 1498 Corresponding Author: Thomas L. Carroll, MD Brigham and Women s Hospital 45 Francis Street ASB-2 Boston, MA Tcarroll@bwh.harvard.edu Phone: Fax:

3 1 Abstract Laryngeal tumors of non-epithelial origin are uncommon. Spindle cell sarcoma specifically of the true vocal fold is exceedingly rare. A comprehensive morphological and immunohistochemical analysis is necessary for diagnosis. Two cases of true vocal fold spindle cell sarcoma are presented. 2

4 INTRODUCTION Most malignancies of the larynx are of epithelial origin, with the most common being squamous cell carcinoma 1,2. Exceedingly rare are spindle cell sarcomas of the larynx, particularly those of the membranous true vocal fold (TVF) 3. In general within head and neck cancers, Spindle cell carcinomas make up 3% and spindle cell sarcomas account for fewer than 1% of all malignant neoplasms in this region with chondrosarcomas being the most common 4. Presented here are two patients with spindle cell sarcoma of the true vocal folds. 2. MATERIALS AND METHODS Both cases were identified using the electronic medical record. IRB exemption was obtained for a retrospective review study design. Histopathology reports were reviewed by multiple pathologists to confirm diagnoses of soft tissue sarcomas. 3. RESULTS 3.1 Case Report 1 A 55 yo male former smoker presented with a known right TVF lesion. He was referred from an outside medical center following biopsy of the lesion in July of The original biopsy report described the histopathology as moderate squamous dysplasia accompanied by moderate chronic inflammation. The patient underwent a microsuspension laryngoscopy (MSL) with KTP laser excisional biopsy of the right vocal fold lesion in January of

5 31 32 Histologic examination of this biopsy revealed a fairly well circumscribed mass composed of a moderate to markedly cellular proliferation of spindle cells within the squamous mucosa; the overlying thin layer of squamous epithelium showed no significant dysplasia. The spindle cells displayed moderate nuclear pleomorphism and mitotic figures were readily apparent (mitotic figures ranged from 6 to 10 per 10 high power fields). Focally the stroma was collagenous. No necrosis or lymphovascular invasion was identified. Immunohistochemical studies were performed revealing the spindle cells were diffusely positive for smooth muscle actin with scattered cells positive for desmin and patchy weak positivity for MDM2 and CDK4. The cells were negative for pankeratin, CAM5.2, AE1, AE3, cytokeratin 5/6, 34βE12, p62, S-100 protein, smooth muscle myosin, CD34, and CD117. Fluorescent in-situ hybridization for MDM2 gene amplification was negative. The lesion was diagnosed as an atypical spindle cell neoplasm best regarded as a low-grade sarcoma. The patient followed up in outpatient clinic monthly with no further surgical or medical treatment necessary. Surveillance continues and there are no signs of tumor recurrence (2 years post). 3.2 Case Report 2 An 86-year-old male with a 60 pack year former smoking history and existing laryngopharyngeal reflux disease presented with a left true vocal fold lesion. He had been previously treated for a right true vocal fold immobility that resolved spontaneously He unexpectedly showed up with significant new hoarseness after 28 months of stable symptoms. The patient underwent MSL with cold excisional biopsy. 4

6 54 55 Histopathology of this biopsy reported a polypoid fragment of malignant spindle cell neoplasm consistent with low-grade sarcoma. There were neoplastic cells, ranging in size from small spindle cells to rare giant multinucleated tumor cells with increased mitotic count (Approximately 2-3 mitosis per high power field). The surface squamous epithelium was ulcerated and moderate dysplasia was identified where the surface epithelium was intact. Immunohistochemical stains revealed positive staining of tumor cells for Vimentin, P53, and focally for SMA and CD68. The tumor cells were negative for Pankeratin, Cam5.2, CK34BE12, Myogenin, CD34, Myoglobin, P63, P16, S100, Desmin, SMMyosin, CD45, CD20, CD3, CD57, HMB45, CD31, Mart1, GFAP, Synaptophysin, HPV and EBV. The stain for CD138 was non contributory. The stain for Ki-67 showed a proliferation rate of 20%. The stain for PHH3 highlighted mitotic figures (up to 2-3 mitosis per high power field). The patient underwent follow up MSL with KTP laser assisted excisional biopsy for margin clearance in the same area of the right TVF. The pathology showed no residual malignant spindle cell neoplasm however squamous mucosa with focal ulceration, lamina propria fibrosis and focal moderate squamous dysplasia in the posterior margin was observed. No evidence of recurrent or persistent neoplasm has been identified on follow up surveillance laryngoscopies over 2 years DISCUSSION 76 5

7 77 78 Compared to the incidence of spindle cell carcinomas, low-grade spindle cell sarcomas of the membranous true vocal folds are extraordinarily unique. However, discriminating between these two tumors is often difficult due to the mixed histologic features of lesions with spindle cells. One reason is due to the lack of epithelial differentiation by immunohistochemistry. In this scenario, not all pathologists will unanimously agree upon a diagnosis. Secondly, the overlap of features is so similar that many histologic descriptions contain both words. Many spindle cell carcinomas are described as pseudosarcoma, carcinosarcoma, sarcomatoid carcinoma, or pseudosarcomatous carcinoma 1. Morphologically, the differential diagnosis for spindle cell lesions can be divided into monomorphic, pleomorphic, and biphasic categories 4. Spindle cell carcinomas demonstrate a biphasic morphology, with both epithelial squamous carcinoma in-situ or with invasion, along with subepithelial spindle cell sarcomatous lesions 1,2. In our first case, the squamous epithelium was preserved, demonstrating an isolated soft tissue lesion. The tissue specimen was a well-circumscribed nodule of spindle cells with pleomorphic nuclei, which were ovoid or tapering with mild atypia and occasional mitotic figures. The most common pleomorphic malignancies are malignant melanoma and spindle cell squamous carcinoma 4, which add to the confusion in proper diagnosis. The second case had an ulcerated epithelium with moderate dysplasia seen at the edges of the ulcer. Immunohistochemical staining did not show evidence of a carcinomatous contribution to the lesion and on re-biopsy no residual malignant spindle cell neoplasm 98 was found. 6

8 Following pleomorphic morphology, immunophenotyping is performed to determine the cell lineage. In ruling out spindle cell carcinoma, pankeratin, cytokeratin /6, and AE1/3 were all negative 2. In ruling out malignant melanoma, S-100 was negative. The lack of any inflammatory cells rules out the possibility of pleomorphic spindle cell sarcoma (formerly malignant fibrous histiocytoma) and inflammatory myofibroblastic tumor 2. Positive staining of SMA, desmin, and caldesmon are found in leiomyosarcoma. However, no distinct smooth muscle histologic features were present, which are necessary for the diagnosis 5. Furthermore, since these positive results occur in multiple soft tissue origins, it is not possible to clearly identify from which cell type the tumor came. The histogenesis of spindle cell carcinoma has not been resolved. Nevertheless, mounting molecular evidence suggests that spindle cell carcinoma is a monoclonal epithelial neoplasm with a mesenchymal differentiation, rather than a collision tumor, or biphasic derivation, or "pseudosarcoma 6-8. The etiology of spindle cell sarcoma itself is rather mysterious. Viral causes for sarcoma include HHV8 for Kaposi sarcoma 3. For some sarcomas, genetics plays a role in predisposition for disease. Neurofibromatosis type I is associated with malignant nerve sheath tumors, and Li-Fraumeni syndrome patients have higher chances of sarcomas from bone, skeletal muscle, and fibrosarcomas 3,9. One interesting topic worth noting is the correlation of soft tissue sarcomas with previous surgical trauma. In a study by Dijkstra et al, five patients developed sarcomas in the location of previous surgical scars 9. This may be pertinent to the current report s second case Unfortunately, much is unknown about rare tumors when it comes to prognosis and treatment. As a malignancy, sarcomas have the potential for growth, recurrence, 7

9 and metastasis. Two classification systems for soft tissue sarcomas include the United States National Cancer Institute (NCI) and the French Federation Nationale des Centres de Lutte Contre le Cancer (FFNCLCC) 5. According to the WHO, the FFNCLCC classification system was shown to predict prognosis in unknown sarcomas best; however, there is currently no prognostic value for rare soft tissue sarcomas 5. Solely one other case similar to this one could be found in a search of the current literature. Fruth, et al, reported a 77 yo male with a recurrent vocal fold polyp of the middle third of the right vocal cord 10. The lesions were resected each time, with pathology progressively transforming from dysplastic tissue to a low-grade spindle cell sarcoma. After each resection, the tumor relapsed at a faster rate, despite excision with complete margins. This patient s last tissue samples stained positive for Ki-67 in up to 15% of cells, and demonstrated pleomorphic nuclei with occasional rough endoplasmic reticulum. An overall diagnosis of a FRCC grade II spindle cell sarcoma, NOS was given. Without significant prevalence in the literature for laryngeal spindle cell sarcomas, treatment paradigms have no established guidelines in this anatomic location. In our case report, the excision was performed via endoscopic microsurgery with narrow margins using cold knife and/or KTP laser. Close margins were employed to preserve voice in the setting of close follow up using chip tip flexible laryngoscopes, light filter technology and stroboscopy to identify any early changes that might suggest recurrence. Without these office tools, a wider margin may be prudent and the patient should be included in the treatment discussion when close margins are considered and/or voice loss is possible. The histologic diagnosis of sarcoma versus carcinoma is important, 8

10 since spindle cell carcinoma often involves metastases to local lymph nodes 5. No neck dissection was indicated for sarcoma; therefore, close clinical follow-up as described was prudent. 5. CONCLUSION Spindle cell sarcoma of the true vocal fold is a rare tumor. The differential diagnosis can be difficult without immunohistochemistry. Therefore, a comprehensive morphological and immunohistochemical analysis is necessary. 9

11 References 1. Miyahara H, Tsuruta Y, Yane K, Ogawa Y. Spindle cell carcinoma of the larynx. Auris, nasus, larynx 2004; 31: Volker HU, Scheich M, Holler Set al. Differential diagnosis of laryngeal spindle cell carcinoma and inflammatory myofibroblastic tumor--report of two cases with similar morphology. Diagnostic pathology 2007; 2:1. 3. Fisher C. Spindle Cell Sarcomas. Surgical Pathology Clinics 2011; 4: Anderson CE, Al-Nafussi A. Spindle cell lesions of the head and neck: an overview and diagnostic approach. Diagnostic Histopathology 2009; 15: Barnes L, Eveson, John W., Reichart, Peter, Sidransky, David. World Health Organization Classification of Tumours. Pathology And Genetics of Tumours of Soft Tissue and Bone. Lyon: IARC Press, Thompson L, Chang B, Barsky SH. Monoclonal origins of malignant mixed tumors (carcinosarcomas). Evidence for a divergent histogenesis. Am J Surg Pathol 1996; 20: Torenbeek R, Hermsen MA, Meijer GA, Baak JP, Meijer CJ. Analysis by comparative genomic hybridization of epithelial and spindle cell components in sarcomatoid carcinoma and carcinosarcoma: histogenetic aspects. J Pathol 1999; 189: Lewis JE, Olsen KD, Sebo TJ. Spindle cell carcinoma of the larynx: review of 26 cases including DNA content and immunohistochemistry. Human pathology 1997; 28: Dijkstra MD, Balm AJ, Gregor RT, Hilgers FJ, Loftus BM. Soft tissue sarcomas of the head and neck associated with surgical trauma. The Journal of laryngology and otology 1995; 109: Fruth K, Hansen T, Katenkamp D, Mann W, Lippert BM. Recurrence of a laryngeal spindle cell sarcoma with a transformation into a higher grade of malignancy. Auris, nasus, larynx 2009; 36:

12 Figure legends Figure 1 (Case 1): 1A: Squamous epithelium with underlying spindle cell proliferation (H&E, x40). 1B: Neoplastic cells with moderate nuclear pleomorphism and readily apparent mitotic figures (arrows) (H&E, x400). Figure 2 (Case 2) 2A: Spindle cell proliferation with a small fragment of overly squamous epithelium (right upper corner); nuclear pleomorphism apparent at low magnification (H&E, x40). 2B: Pleomorphic tumor cells with a mitotic figure in the center (arrow) (H&E, x400). Figure 3 (Case 1) 3A Intraoperative view of the glottis prior to resection using a 0 degree endoscope for visualization. The Right TVF sarcoma involved the anterior commissure. 3B Intraoperative view of the anterior commissure following resection using a 30 degree endoscope for visualization. Gross, total resection of the lesion was achieved. 3C: Two year post-operative results obtained via flexible endoscopy during outpatient follow-up appointment. Abducted vocal folds are seen with a smooth Right TVF and blunting of the anterior commissure. 11

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