Avraham Eisbruch, MD

Disclosures

April 10, 2001

Question

What is the best way to treat a 29-year-old woman with a vocal cord mass? The mass is 2 x 1.5 cm; biopsy results are consistent with Hodgkin's disease. There are no other areas of disease. What is appropriate therapy: 2 cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) plus radiation or radiation alone?

Response from Avraham Eisbruch, MD

I performed a MEDLINE search for a case report of Hodgkin's disease in the larynx and did not find any. There are case reports of laryngeal non-Hodgkin's lymphoma, but these tumors were in the glottis. I assume that complete staging, including body CT, bone marrow biopsies, and lab tests are negative. The paucity of lymphatics in the true vocal cords would make the occurrence of a lymphoma in the vocal cords very unlikely. Therefore, I suggest you first send the pathology slides for review to an institution with a reputation in lymphoma pathology, such as the Armed Forces Institute of Pathology at Walter Reed Army Hospital in Washington, DC, or Stanford University.

Rarely, lymphoepithelioma can arise in the larynx and may be mistaken for lymphoma. If the diagnosis of Hodgkin's disease (or non-Hodgkin's lymphoma) is verified by the reviewers, it would be staged as an early extralymphatic disease. It would be helpful to know if it is aggressive disease, such as lymphocyte-depleted or mixed-cellularity Hodgkin's, or intermediate/high-grade non-Hodgkin's. If the histology is aggressive, I would check HIV status because positivity may be associated with unusual presentations of Hodgkin's.[1]

Treatment options include radiation alone, chemotherapy alone, or a combined modality. Radiation alone for a woman with a very favorable Hodgkin's histology would consist of a mantle field, to a dose of 30-36 Gy; chemotherapy alone would consist of 6 cycles of ABVD as a standard therapy. Combining 3 cycles of ABVD chemotherapy and local radiation therapy (approximately 30 Gy to the larynx only) seems to me an appropriate compromise. This way, there would be less dose and extent of radiation, which can be expected to minimize the risk of a future radiation-related secondary cancer as well as the risk of hypothyroidism. The limited number of chemotherapy courses should be well tolerated.

Please keep us posted about the results of the pathology review of this unusual case.

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