Chondrosarcoma of the Larynx Diagnosis With Magnetic Resonance Imaging and Computed Tomography Joseph H. Mishell, MD; Joyce


Schild, MD; Mahmood

\s=b\ Chondrosacomas are

the most comof the larynx. They are generally slow-growing lesions with insidious onset of symptoms. We are presenting a case of chondrosarcoma that recurred 10 years after excision of a presumed chondroma. Computed tomographic and magnetic resonance imaging (MRI) scans were performed. Both studies delineated the lesion nicely. To the best of our knowledge, this is the first report on MRI characteristics of chondrosarcoma of the larynx. A review of the literature regarding the use of computed tomography in the management of chondrosarcoma is presented. The MRI characteristics are discussed and the two scanning modalities are compared. Computed tomography is an excellent study in its ability to demonstrate the extent of the lesion within the laryngeal skeleton. Furthermore, it is more highly sensitive than plain roentgenograms in the detection of calcifications that are highly suggestive of chondrosarcoma. Alternatively, MRI can also demonstrate the lesion within the larynx but it has the added advantage of superior contrast resolution of the tumor and paralaryngeal tissues. When the three-dimensional imaging capacity of MRI is considered as well, MRI seems to be the superior study. (Arch Otolaryngol Head Neck Surg. mon




of the larynx are rare le¬ sions that constitute less than 1% of all laryngeal malignant neoplasms. The most frequent histologie variety is chondrosarcoma.1·2 In a review by Ferlito et al1 in 1984,149 cases of chondro¬ sarcoma were collected from the world literature. Since that time, 10 addi¬ tional cases have been reported.310 Chondrosarcomas of the larynx grow slowly. Symptoms consist of Accepted for publication March 27, 1990. From the Departments of Otolaryngology\p=m-\ Head and Neck Surgery (Drs Mishell and Schild) and Radiology (Dr Mafee), University of Illinois

Chicago. Reprint requests to Department of Otolaryngology\p=m-\Headand Neck Surgery, 1855 W Taylor St, Suite 2.42, Chicago, IL 60612 (Dr Schild). at


Mafee, MD

hoarseness, dyspnea, dysphagia, and cough. While most patients experience symptoms for longer than 6 months, acute airway obstruction can occur as

well."12 In


keeping with its slow after surgical




late. Often the histo¬

logie diagnosis is initially interpreted as benign chondroma, resulting in in¬ adequate treatment with subsequent recurrence.

We report a case of cricoid chondro¬ that recurred 10 years after initial endoscopie removal of a mass initially diagnosed as a chondroma. The recurrent lesion was well delin¬ eated on magnetic resonance imaging (MRI) and computed tomographic (CT) scan. To the best of our knowl¬ edge, this is the first report of the MRI characteristics of laryngeal chondro¬ sarcoma. A review of the literature re¬ garding the imaging of these lesions will be discussed. sarcoma


sile lesion with foci of faint calcifications demonstrated in the posterior cricoid lamina primarily on the right (Figs 1 and 2). The mass protruded into the subglottic space with disruption of the cricoarytenoid joint. Following CT scanning, an MRI was performed on a superconductive 1.5-T imwas

(General Electric) using a special

unremarkable. When seen 1 month after surgery, the patient's airway was patent and he had a serviceable airway. course was

72-year-old man was seen in January 1989, for increasing episodes of choking. The patient had undergone direct laryngoscopy with endoscopie removal of a rightsided subglottic mass diagnosed as a chon¬ droma in August 1978. Postoperatively, mild, nonprogressive hoarseness remained. Examination of his larynx (1989) revealed a smooth, round, red mass below the right arytenoid. Vocal cord motion was present, but there was intermittent incomplete clo¬ sure at the posterior commissure. Upper gastrointestinal roentgenograms were normal. A CT scan was performed (General Electric 9800 Scanner, Milwaukee, Wis) using 3-mm axial sections from the thoracic inlet to the hyoid bone. An expan¬ A


Corp, Milwaukee, Wis). A well-defined mass was identified in the posterior cricoid lam¬ ina with displacement of the right arytenoid and early erosion into the postcricoid space. The mass was homogeneous and displayed an intermediate signal inten¬ sity on T,-proton-weigh ted images. On T2weighted images, it was hyperintense (Figs 3 through 5). The patient underwent direct laryngoscopy with biopsy. A red, hard mucosal-covered mass was found in the right subglottic area (Fig 6). Histologie evaluation identi¬ fied the lesion as a low-grade chondrosar¬ coma. Retrospective examination of the bi¬ opsy specimen from 1978 identified the original tumor as a chondrosarcoma. Through a laryngofissure, the tumor was found to correspond to the radiologie find¬ ings with involvement of the right cricoid lamina and cricoarytenoid joint. The poste¬ rior perichondrium of the cricoid was in¬ tact. Excision included the posterior cricoid lamina, the arytenoid, and portions of the right true vocal cord, resulting in a defect that was reconstructed with adjacent mu¬ cosal advancement flaps. The postoperative


terior neck surface coil (Medical Advance


Chondrosarcomas of the larynx oc¬ most commonly in patients in the sixth and seventh decades of life. There is a male predominance of 3 to cur

4:1.1·3·11·12 Chondrosarcoma is essentially a tu¬ mor of hyaline cartilage. The most common site of origin is the cricoid cartilage (70% to 80%), followed by the thyroid cartilage (10% to 20%), and least commonly, the arytenoids and vocal cords. To our knowledge, only two cases arising from the epig¬ lottis, which is elastic cartilage, have been reported.1·9 Hoarseness, dyspnea, and dysphagia are the most common symptoms. The symptoms depend on the degree of anterior or posterior growth. If the tumor extends anteri¬ orly into the lumen of the airway, then

Downloaded From: by a University of Arizona Health Sciences Library User on 05/30/2015

Fig 1.—Left, Computed tomographic (CT) scan showing expansion of the right side of the cricoid cartilage by the tumor mass (T). Note erosion of the posterior aspect of the cricoid (arrow) as well as faint foci of calcification. Right, CT scan obtained with high-resolution bone technique showing the tumor (T) causing erosion and expansion of the cricoid cartilage (arrows).

Fig 2.—Computed tomographic scan showing the erosion of the cricoid cartilage (arrow).

tumor mass

(T) and

Fig 3. Sagittal ,-weighted magnetic resonance imaging scan show¬ ing a large tumor (T) in the region of the posterior cricoid cartilage. The tumor has intermediate signal and is isointense to muscle. Note the arytenoid cartilage (a) and epiglottis (arrow). —

respiratory symptoms will predomi¬ nate. Conversely, if the tumor extends posteriorly into the pharynx, then dys¬ phagia will also be present. Occasion¬ ally, patients will present with a softtissue mass in the neck produced by the tumor bulk.


examinations useful in

the evaluation of these lesions include plain roentgenograms, barium swal¬ low test, and CT scanning. On plain roentgenogram, if the lesion is of suf¬ ficient size, a mass is identified as aris¬ ing from a laryngeal cartilage with intraluminal compromise of the airway. Calcifications are present in 75% to

80% of patients and are highly sug¬ gestive of the diagnosis.1·212 Barium

swallow test is useful in the delinea¬ tion of postcricoid or piriform com¬

pression. Computed tomography has become invaluable in imaging laryngeal chondrosarcomas. In recent years, it has

Downloaded From: by a University of Arizona Health Sciences Library User on 05/30/2015

Fig 4. Left, Proton-weighted magnetic resonance imaging (MRI) scan showing a large tumor (arrows) involving the cricoid cartilage. The tumor is hyperintense to muscle. Note the arytenoid (a) and thyroid cartilage (t). Right, T2-weighted MRI scan showing the tumor (arrows) that appears hyperintense and similar to arytenoid (a) and thyroid (t) cartilages. Note the early invasion of the postcricoid region. —

Fig 5.—Left, Proton-weighted magnetic resonance imaging (MRI) scan showing the tumor (T) involving the cricoid cartilage. Note the left arytenoid cartilage (a). Right, T2-weighted MRI scan showing the tumor (T) with a hyperintense signal. Note the early postcricoid (arrow) invasion and the left arytenoid (a).

Fig 6. Endoscopie view of the laryngeal chondrosarcoma. The tumor (T) was submucosal, hard, reddish, and arising from the right posterior cricoid lamina. Notice the endotracheal tube (arrows). —

Downloaded From: by a University of Arizona Health Sciences Library User on 05/30/2015

become the

study of choice, supplant¬

ing plain roentgenograms. It can lo¬ calize the tumor to its specific site of origin within the cartilaginous skele¬ ton as well as demonstrate adjacent structures involved.7 Furthermore, the incidence of calcifications on CT is higher than that of plain roentgeno¬ grams. Despite the extensive size of the tumor in our patient, only faint foci of calcifications were demonstrated on CT (Figs 1, left, and 2). There are several reports in the lit¬ erature concerning the use of CT scan¬ ning in the diagnosis of chondro¬ sarcoma.713·14 Shearer et al7 reported a case of chondrosarcoma of the thyroid ala in a patient presenting with dysp¬ nea and a neck mass. Goiney et al13 re¬ ported a case of a cricoid lesion in a patient presenting with vocal cord pa¬ ralysis. Van Holsbeeck et al15 described a patient with a palpable anterior neck mass with a submucosal lesion. Fish et al16 reported a case of a cricoid chon¬ drosarcoma in a patient who presented with stridor. Marincek et al17 reviewed the cases of 19 patients with chondrogenic tumors. Finally, Zaunbauer and Haertel14 reported their experience with 23 malignant neoplasms of the larynx, including one chondrosarcoma. All of the authors emphasize the ex¬ cellent ability of CT to delineate the

tumor with respect to origin and ex¬ tent and concluded that CT is essential

in the preoperative evaluation of these lesions. Decisions about type and fea¬ sibility of conservation surgery have been greatly helped by CT scanning. To our knowledge, this is the first report of MRI in the diagnosis of laryngeal chondrosarcoma. An expan¬ sile mass involving the cricoid plate was demonstrated by MRI. The signal intensity was homogeneous and inter¬ mediate in proton-weighted images and hyperintense in T2-weighted images (Figs 3 through 5). This signal behavior corresponds to that of the medullary portion of laryngeal carti¬ lage that remains noncalcified. This similarity between the tumor and car¬ tilage is consistent with the former's

cartilaginous origin. When CT imaging is compared with

emerge. Both studies were consistent with one an¬ other and demonstrated the expansile nature of the lesion as well as its

MRI, several features


Additionally, although


chondrosarcomas demonstrate calcifi¬ cations, our particular patient showed only very faint calcifications on CT and none on plain roentgenogram. Calcifi¬ cations on MRI would be expected to display a low signal, mottled appear¬ ance. Our patient demonstrated a ho-

mogeneous signal intensity on both Tr

Trweighted images, which is again consistent with the appearance on CT. Magnetic resonance imaging is a superb modality for the demonstra¬


tion of soft-tissue detail. When CT is compared with MRI, the extent of tu¬ mor infiltration into the surrounding tissue and, especially, the tumor/softtissue interface is seen more clearly on MRI than CT. The treatment for la¬ ryngeal chondrosarcoma is usually conservation surgery, so the exact ex¬ tent and location of the tumor is crit¬ ical information. CONCLUSION While both studies accurately de¬ fined the lesion, MRI was superior for defining the tumor with respect to the surrounding structure in the larynx. Furthermore, while CT can more sen¬ sitively demonstrate calcifications (which is highly suggestive of the di¬ agnosis), the signal behavior of chon¬ drosarcoma on MRI closely follows that of normal, nonossified cartilage. This feature would also be highly sug¬ gestive of a cartilaginous tumor and might be as helpful as calcifications in the differential diagnosis. The combi¬ nation of signal behavior and tissue contrast seen in our patient suggests that MRI is the superior study.

References 1. Ferlito A, Nicolai P, Montaguti A, Cecchetto A, Pennelli N. Chondrosarcoma of the larynx: review of the literature and report of three cases. Am J Otolaryngol. 1984;5:350-359. 2. Batsakis JG, Raymond AK. Cartilage tumors of the larynx. South Med J. 1988;81:481-484. 3. Neis PR, McMahon MF, Norris CW. Cartilaginous tumors of the trachea and larynx. Ann Otol Rhinol Laryngol. 1989;98:31-36. 4. Eriksen HE, Greisen O, Hjorth L. Chondrosarcoma of the larynx. ORL J Otorhinolaryngol Relat Spec. 1986;48:270-274. 5. Webber PA, Hussain SSM, Radcliffe GJ. Cartilaginous neoplasms of the head and neck (a report on four cases). J Laryngol Otol. 1986;

100:615-619. 6. Leonetti JP, Collins SL, Jablokow V, Lewy R. Laryngeal chondrosarcoma as a late-appearing paralysis. Otolaryngol Head Neck Surg.

1987;97:391-395. 7. Shearer JE, Goldberg AL, Lupetin AR, Rothfus WE. Chondrosarcoma of the larynx: report of

a case with characteristic computed tomography findings. J Comput Assist Tomog. 1988:12;292-294. 8. Poole AG, Hall R. Chondrosarcoma of the larynx: a case report and review of the literature. Aust N Z JSurg. 1986;56:281-284. 9. Kasanzew M, John DG, Newman P, Lesser TJH, Thomas PL. Chondrosarcoma of the epiglottis. J Laryngol Otol. 1988;102:374-377. 10. Tiwari RM, Snow GB, Balm AJM, Gerritsen GJ, Vos W, Bosma A. Cartilagenous tumours of the larynx. J Laryngol Otol. 1987;101:266-275. 11. Cantrell RW, Reibel JF, Jahrsdoerfer RA, Johns ME. Conservative surgical treatment of chondrosarcoma of the larynx. Ann Otol Rhinol Laryngol. 1980;89:567-571. 12. Lavertu P, Tucker HM. Chondrosarcoma of

the larynx: case report and management philosopy. Ann Otol Rhinol Laryngol. 1984;93:452\x=req-\ 456. 13. Goiney RC, Martyn JB, Nichols DM, Ostrow DN. CT diagnosis of laryngeal cricoid chondrosarcoma. J Can Assoc Radiol. 1984;35:404-405. 14. Zaunbauer W, Haertel M. Computer tomographic diagnosis of maligant tumors of the larynx. Fortschr Geb Rontgenstr Nuklearmed.


15. Van Holsbeeck

MT, Stessens RC, Oyen RH,

et al. CT diagnosis of larynx chondrosarcoma. Eur

J Radiol. 1985;5:297-299. 16. Fish B, Nussbaum M, Smulewicz JJ. Chondrosarcoma of larynx: computed tomographic study. N Y State J Med. 1982;82:216-218. 17. Marincek B, von Gumppenberg S, Triller J, Robotti G. Computed tomography of chondro-



Radiologe. 1984;24:211-216.

Editorial Footnote The authors conclude that MRI is supe¬ rior to CT scan in the diagnosis of laryngeal chondrosarcoma. Our reviewers believed that while their views should be published, additional observations would be necessary to verify this conclusion. The fundamental issue frequently comes down to the cost of

diagnostic studies and whether the infor¬ mation generated is worth the price. Be¬ cause there was already a "ballpark" diag¬ nosis and CT scan could provide additional important information for surgical plan¬

ning, what was gained in terms of better patient treatment? We are moving into an

of patient treatment guidelines and clinical indicators, and it is important that we make recommendations of this type era


Bryon J. Bailey, MD Chief Editor

Downloaded From: by a University of Arizona Health Sciences Library User on 05/30/2015

Chondrosarcoma of the larynx. Diagnosis with magnetic resonance imaging and computed tomography.

Chondrosarcomas are the most common sarcomas of the larynx. They are generally slow-growing lesions with insidious onset of symptoms. We are presentin...
7MB Sizes 0 Downloads 0 Views