The occurrence of plasma cell granuloma of the larynx appears to be unusual. Review of the literature revealed only two previously reported cases. We present an additional case of plasma cell granuloma of the larynx. The diagnosis was made by histological and immunohistochemical examinations. The tumour was successfully treated by radiation therap

Becker, Minerva

Beer, Karl

Läng, Hubert

Zbären, Peter

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The Journal of Laryngology and OtologySeptember 1995, Vol. 109, pp. 895-898Pathology in FocusPlasma cell granuloma of the supraglottic larynxPETER ZBAREN, M.D.*, HUBERT LANG, M.D.f, KARL BEER, M.D.J, MINERVA BECKER, M.D.**AbstractThe occurrence of plasma cell granuloma of the larynx appears to be unusual. Review of the literature revealedonly two previously reported cases. We present an additional case of plasma cell granuloma of the larynx. Thediagnosis was made by histological and immunohistochemical examinations. The tumour was successfullytreated by radiation therapy.Key words: Laryngeal neoplasms; Granuloma, plasma cellIntroductionPlasma cells are the secretory form of B-lymphocytescharacterized by the presence of abundant protein-synthesizing equipment in the cytoplasm.Plasma cell tumours of the head and neck are classified(Batsakis, 1983) as follows: (1) multiple myeloma; (2)solitary plasmacytoma of the bone; (3) extramedullaryplasmacytoma (localized or disseminated form); (4) plasmacell granuloma.Plasma cell granuloma is a rare benign tumour-likelesion affecting people of all ages, found most frequently inthe lungs (Bahadori and Liebow, 1973; Mandelbaum et al.,1981; Monzon et al, 1982) and the oral cavity (Warson andPreis, 1969; Batsakis, 1983). Other affected organs haveincluded the abdomen (Issacson et al., 1978; Pisciotto et al,1978), nasopharynx and maxillary sinus (Guillemin et al,1989), thyroid (Rockford et al., 1984), mediastium (Hutch-ins and Eggleston, 1979) and liver (Pack and Baker, 1953).We found only two cases of plasma cell granuloma of thelarynx described in the medical literature (Albizzati et al.,1988; Fradis et al, 1988).We present the clinical and pathological findings of anadditional case of plasma cell granuloma of the larynx.Case reportA 57-year-old man was admitted with a 10-monthhistory of dysphagia, hoarseness and a sensation of alump in his throat. The patient was otherwise healthy withno significant past medical history. He had had no chronicENT infections. Clinical ENT examination revealed adiffuse submucosal swelling of the epiglottis with extensioninto the valleculae and right aryepiglottic fold (Figure 1).No regional lymph nodes could be palpated. Generalphysical examination, routine clinical laboratory data and achest X-ray were normal. MRI examination showed a largetumour originating in the epiglottis with extension to thevalleculae and the pre-epiglottic space (Figure 2). Directmicroscopic laryngoscopy was performed under generalanaesthesia and deep biopsies were taken from thetumour.PathologyAll biopsy specimens taken from the tumour-like lesionshowed identical histomorphological features. The cellulartissue showed a predominance of mature plasma cellsdevoid of atypia, standing out against a background ofsmall lymphocytes, histiocytes/macrophages, polymorpho-nuclear leucocytes, vessels and loose connective tissue(Figure 3). The overlying squamous epithelium wasmoderately infiltrated by lymphocytes and plasma cells.Russell bodies and amyloid were not observed. Immuno-histochemical reactions with antibodies directed against Kand \ light chains revealed polyclonality of the plasma cellpopulation (Figure 4a and b).FIG. 1Endoscopic view of the thickened epiglottis. Intubation tube isseen.From the Departments of Otorhinolaryngology, HeadRadiology**, Inselspital, CH-3000 Bern, Switzerland.Accepted publication: 15 May 1995.and Neck Surgery*, Pathologyt, Radio-Oncology^ and Diagnostic895https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100131627Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 30 May 2017 at 18:54:27, subject to the Cambridge Core terms of use, available at896 P. ZBAREN, H. LANG, K. BEER, M. BECKER&MFIG. 2Axial Trweighted spin echo sequence obtained after intrave-nous administration of Gd-DTPA. A large soft tissue masswith minimal contrast enhancement is seen at the level of theepiglottis (arrowheads). The tumour has invaded the vallecu-lae (arrows) and led to near total obstruction of the airway.Treatment (radiation therapy)The patient was treated with parallel opposed Cobalt 60fields (daily dose 170 cGy (ICRU point); weekly dose 750cGy). After 2900 cGy (17 fractions) the tumour was stillthe same size: only after 3400 cGy did the tumour slowlybegin to shrink. The total dose given in 30 fractions over 44days was 5100 cGy. Clinically complete remission was firstseen 19 weeks after initiation of radiation therapy.The patient was followed-up for 15 months without anyfurther symptoms or evidence of recurrence (Figure 5).DiscussionThe aetiology of plasma cell granuloma is unknown. It isassumed to be of infectious origin (Scully et al., 1982).Bahadori and Liebow (1973) have suggested a hypersensi-tivity reaction. In our case, no chronic ENT infection wasknown. In the past, the lesion has been referred to byvarious names including xanthoma, histiocytoma, xantho-matous pseudotumour, fibrous xanthoma, reflecting thepredominant morphological component of the lesion(Scully et al., 1982). The designation of plasma cellgranuloma was preferred by Bahadori and Leibow(1973). The majority of the lesions that they describehave mature plasma cells as the predominant cellularcomponent.The histological features are characterized by polyclonalinfiltration of plasma cells mixed with lymphocytes,histiocytes, neutrophils, and/or macrophages. The plasmacells show no cytological abnormalities and are usuallyconcentrated in areas surrounded by well vascularizedconnective tissue. Russell bodies and amyloid may bepresent (Shanmugaratnam, 1978; Batsakis, 1983).The diagnosis is made by histological and immunohis-tochemical studies. The differential diagnosis must bemade from monoclonal neoplastic lesions, such as multiplemyeloma and solitary plasmocytoma, a tumour which islikewise a rare neoplasm of the larynx (Zbaren andFIG. 3Fairly dense cellular infiltrate with a predominance of matureplasma cells, standing out against a background of smalllymphocytes and histiocytes/macrophages. Some plasma cellsand lymphocytes are present in the overlying squamousepithelium. (H & E; X 350).Zimmermann, 1994). The differentiation between mono-clonal and polyclonal infiltration is carried out byimmunohistochemical techniques determining the intracel-lular immunoglobulins.The standard treatment for plasma cell granuloma isusually surgery (Bahadori and Liebow, 1973; Mandelbaumet al., 1981). In cases where the lesion is locally aggressiveand surgically unresectable or resectable with majormorbidity, radiation therapy can be an effective alternative(Hoover et al., 1977; Imperato et al.. 1986).The lesion of our patient was localized in the epiglottiswith extension to the valleculae and right aryepiglotticfold, indicating the need for a supraglottic laryngectomywith resection of a part of the tongue base. We thoughtthat such a procedure was not justified and we choseconservative treatment using radiation therapy in spite ofthe fact that recurrences have been described afterradiation therapy (Mehta et al, 1980; Guillemin et al.,1989).The two plasma cell granulomas of the larynx describedin the literature (Albizzati et al., 1988; Fradis et al.. 1988)have been both successfully treated with steroids, but theyseem to have been much smaller in size than ours. Onepatient was followed-up for a period of one year, the otherfor two years without recurrence. Our patient, treated withradiation therapy has been followed-up for more than oneyear without recurrence.https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100131627Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 30 May 2017 at 18:54:27, subject to the Cambridge Core terms of use, available atPATHOLOGY IN FOCUSFIG. 4(a). Dark, stained, mature, plasma cells displaying intracellular K light chains (arrowed). (Avidin-biotin technique, peroxidase;haematoxylin as nuclear counterstain; X 350). (b). A roughly equal proportion of plasma cells with intracellular \ light chains(arrowheads). (Avidin-biotin technique, peroxidase; haematoxylin as nuclear counterstain; x 350).FIG. 5Axial T,-weighted spin echo sequence after intravenousadministration of Gd-DTPA obtained 15 months after radio-therapy showing normal appearance of the epiglottis (arrow-head) and the valleculae (arrows).ReferencesAlbizzati, K. C , Ramesar, R. B., Davis, B. C. (1988) Plasmacell granuloma of the larynx. Journal of Laryngology andOtology 102: 187-189.Bahadori, M., Liebow, A. A. (1973) Plasma cell granulomas ofthe lung. Cancer 31: 191-208.Batsakis, J. G. (1983) Plasma cell tumours of the head andneck. Annals of Otology, Rhinology and Laryngology 92:311-313.Fradis, M., Rosenman, D., Podoshin, L., Ben-David, Y.,Misslevitch, A. (1988) Steroid therapy for plasma cellgranuloma of the larynx. Ear, Nose and Throat Journal 67:558-564.Guillemin, Ph., Guillemin, C, Pelte, M. F., Lehmann, W.(1989) Le granulom plasmocytaire dans la sphere ORL.Problemes Actuels d/Otorhinolaryngologie 13: 358-364.Hoover, S. V., Granston, A. S., Kach, D. F., Hudson, T. R.(1977) Plasma cell granuloma of the lung, response toradiation therapy. Cancer 39: 123-126.Hutchins, G. M., Eggleston, J. C. (1979) Unusual representa-tion of pulmonary inflammatory pseudotumor (plasma cellgranuloma) as oesophageal obstruction. Journal of Gastro-enterology 71: 501-504.Imperato, J. P., Folkman, J. L., Sagerman, R. H., Cassady, J.R. (1986) Treatment of plasma cell granuloma of the lungwith radiation therapy. Cancer 57: 2127-2129.Issacson, P., Buchanan, R., Mepham, B. L. (1978) Plasma cellgranuloma of the stomach. Human Pathology 9: 355-358.Mandelbaum, I., Brashear, R. E., Hull, M. T. (1981) Surgicaltreatment and course of pulmonary pseudotumour (plasmacell granuloma). Journal of Thoracic and CardiovascularSurgery 82: 77-82.https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100131627Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 30 May 2017 at 18:54:27, subject to the Cambridge Core terms of use, available at898 P. ZBAREN, H. LANG, K. BEER, M. BECKERMehta, J., Desphanade, S., Stauffer, J. L., Stanford, R.,Fernandez, E. (1980) Plasma cell granuloma of the lung:endobronchial presentation and absence of response toradiation therapy. Southern Medicine 73: 1198-1201.Monzon, C. M., Gilchrist, G. S., Burgert, E. O., O'Connel, E.J., Telander, R. L., Hoffman, A. D., Li, C. Y. (1982) Plasmacell granuloma of the lung in children. Pediatrics 70:268-273.Pack, G. T., Baker, H. W. (1953) Total right hepaticlobectomy. Annals of Surgery 138: 253-258.Pisciotto, P. T., Gray, G. F., Miller, D. R. (1978) Abdominalplasma cell pseudotumor. Journal of Pediatrics 93: 628-630.Rockford, Y., Under, J., Schenken, J. R. (1984) Plasma cellgranuloma of the thyroid. Human Pathology 18: 848-850.Scully, R. E., Mark, E. J., McNeely, B. U. (1982) Case recordsof the Massachusetts General Hospital. New EnglandJournal of Medicine 202: 596-602.Shanmugaratnam, K. (1978) Histologic Typing of UpperRespiratory Tract Tumours, World Health OrganizationGeneva.Warson, R., Preis, F. A. (1969) New exophytic plasma cellgranuloma of the mandible. Report of a case. Journal ofOral Surgery, Oral Medicine, Oral Pathology 28: 791-794.Zbaren, P., Zimmermann, A. (1994) Solitary plasmacytoma ofthe larynx. Journal of Oto-Rhino-Laryngology and itsRelated Specialities 57: 49-52.Address for correspondence:Dr P. Zbaren,University Clinic of Otorhinolaryngology,Head and Neck Surgery,Inselspital,CH-3000 Bern,Switzerland.https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100131627Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 30 May 2017 at 18:54:27, subject to the Cambridge Core terms of use, available at

Plasma cell granuloma of the supraglottic larynx

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