Basosquamous carcinoma of the supraglottic larynx with sudden death from asphyxia.
BASOSQUAMOUS CARCINOMA is a poorly differentiated squamous cell carcinoma with distinctive histologic features. We describe a hypopharyngeal basosquamous carcinoma that became large with only subtle symptoms before causing the patient's sudden and unexpected death.
The deceased was a 51-year-old black woman who had a history of intravenous drug abuse and who had been jailed in a federal correctional institution for several years for a drug offense. She had a 2 pack-per-day smoking history for more than 20 years, and her medical history included asthma, hemorrhoids, and a hysterectomy in 1984. In late March 2000, she went to a clinic complaining of a 1-month history of a sore throat with accompanying hoarseness and episodes of choking while eating and sleeping. She was noted by the examiner to have a "raspy" tone to her voice, but physical examination was unremarkable except for vague throat tenderness. After being treated symptomatically for 2 months, she suddenly had shortness of breath and collapsed in a bathroom. Mouth-to-mouth resuscitation was attempted by bystanders. On arrival of nursing personnel, no pulse or spontaneous breathing was noted. Multiple attempts at intubation en route to an emergency room were unsuccessful. Attempted intubation at the emergency ro om was also unsuccessful, and she was pronounced dead soon after arrival. At the hospital emergency room, an apparent laryngeal obstruction was noted during the intubation attempt.
At autopsy, the patient was noted to be well nourished and well developed. No injuries were present. Examination of the hypopharynx showed a 4 x 3 x 3 cm polypoid tan neoplasm on the epiglottis with a broad-based pedicle 0.3 cm in length (Figs 1 and 2). This tumor had functioned as a ball valve, prolapsing into the opening of the larynx, causing obstruction and death by asphyxia. On section, the tumor was uniformly tan-grey with tiny speckled areas of tan-yellow. No hemorrhage in the tumor was noted. Microscopically, the tumor was composed of nests of malignant cells invading through a fibrous background. In the tumor nests, peripheral palisading of nuclei was present (Fig 3). Central necrosis of tumor nests was prominent (Fig 4). The malignant cells exhibited a wide range of appearance, varying from spindly cells with abundant lightly eosinophilic cytoplasm to small cells with round nuclei and scanty cytoplasm. Residual surface squamous dysplasia was seen.
Basosquamous (basaloid squamous) carcinoma is a poorly differentiated squamous cell carcinoma showing evidence of squamous differentiation as well as elements with a more primitive appearance. The latter may appear as nests of basal-type cells with scanty cytoplasm, central comedonecrosis, and peripheral palisading. Spaces may be present containing material that is positive on PAS staining, and spindle cells may be present, sometimes with associated osteoclast-like giant cells. Wain et al (1) first recognized basosquamous carcinoma in tumors arising in the tongue, hypopharnyx, and larynx. It is believed to behave more aggressively than the usual squamous cell carcinoma. (2)
The supraglottic larynx, including the epiglottis, forms the anterior wall of the hypopharynx. (3) With routine clinical examination, direct visualization of the hypopharynx is limited to the tip of the epiglottis, at best.(4) Satisfactory evaluation of the supraglottic area requires laryngoscopy. Apparently because of resistance to invasion from the underlying cartilage of the epiglottis, typically, malignant neoplasms of this area have an exophytic appearance. (5) As in our case, these tumors can sometimes become large without discovery Neoplasia of the hypopharynx can be totally asymptomatic or exhibit a variety of symptoms. (6,7) Otalgia without identifiable cause and dysphagia are both characteristic of supraglottic tumors. Inspiratory stridor may be present, though tumors of this area rarely produce hoarseness unless they are extensive. Pain from invasion and fixation may produce a muffled "hot potato" voice. A "scratchy" or "sharp" sore throat and a cough due to overflow of secretions may also be pres ent.
The main differential diagnosis histologically usually consists of adenoid cystic carcinoma and small-cell undifferentiated carcinoma. (8) Review of the English language literature since 1966 yielded only five reports of adults with benign neoplasms (excluding papillomas) of the hypopharynx and supraglottic larynx causing sudden death, (9-13) and one report of a malignant lymphoma of the hypopharynx. (14) The present case is the only reported case of laryngeal carcinoma causing sudden death. This report emphasizes the importance of a high clinical index of suspicion and early laryngoscopy in patients with possible hypopharyngeal neoplasia.
Acknowledgments. We thank William Chang, MD (Department of Pathology, West Virginia University, Morgantown) and Ho-Huang Chang, MD (Department of Pathology, Charleston Area Medical Center, Charleston, WV) for advice and technical assistance.
(1.) Wain SL, Kier R, Vollmer RT, et al: Basaloid-squamous carcinoma of the tongue, hypopharynx, and larynx: report of 10 cases. Hum Pathol 1986;17:1158-1166
(2.) Ferlito A, Rinaldo A, Altavilla G, et al: Basaloid squamous cell carcinoma of the larynx and hypopharynx. Ann Otol Rhinol Laryngol 1997;106:1024-1035
(3.) Barrett LH (ed): Gary's Anatomy. Edinburgh, Churchill-Livingstone, 38th Ed, 1995, p 1637
(4.) DeGowin RL (ed): DeGowin's and DeGowin's Diagnostic Examination. NewYork, McGraw-Hill, 6th Ed, 1994, p 166
(5.) Castellanos PF, Spector JG, Kaiser TN: Tumors of the larynx and laryngopharynx. Otorhinolaryngology--Head and Neck Surgery, Baltimore, Williams & Wilkins Go, 15th Ed, 1996, pp 594-595
(6.) Sasaki CT, Carlson RD: Malignant neoplasms of the larynx. Otolaryngology--Head and Neck Surgery. Cummings cw, Fredrickson J, Harker L, et al (eds). St. Louis, Mosby Year Book Go, 2nd Ed, 1993, p 1927
(7.) Stringer SP: Neoplasms and cysts of larynx and cervical esophagus. Otolaryngology--Head and Neck Surgery. Meyerhoff WL, Rice DH (eds). Philadelphia, WB Saunders Go, 1992, p 740
(8.) Barnes L, Ferlito A, Altavilla G, et al: Basaloid squamous cell carcinoma of the head and neck: clinicopathological features and differential diagnosis. Ann Otol Rhinol Laryngol 1996; 105:75-82
(9.) Allen Ms Jr, Talbot WH: Sudden death due to regurgitation of a pedunculated esophageal lipoma. J Thorac Cardiovasc Surg 1967; 54:756-758
(10.) Peacock JA, Salem SR, Beckelr SM: Sudden asphyxial death due to an esophageal leiomyoma. Am J Forensic Med Pathol 1985; 6:159-161
(11.) Fyfe B, Mittleman RE: Hypopharyngeal lipoma as a cause for sudden asphxial death. Am J Forensic Med Pathol 1991; 12:82-84
(12.) Taff ML, Schwartz IS, Boglioli LR: Sudden asphyxial death due to a prolapsed esophageal fibrolipoma. Am J Forensic Med Pathol 1991; 12:85-88
(13.) Gardner PM, Jentzen JM, Komorowski RA, et al: Asphyxial death caused by a laryngeal schwannoma: a case report. J Laryngol Otol 1997; 111:1171-1173
(14.) Connely SC, Hogan JM, Bredin CP: Sudden death from primary B-cell non-Hodgkin's lymphoma of the larynx. Respir Med 1991; 85:77-79
RELATED ARTICLE: KEY POINTS
* We describe the pathology of basosquamous carcinoma.
* The clinical presentation of carcinoma of supraglottic larynx is discussed.
* Clinicians need to have a high clinical index of suspicion.
From the Office of the Chief Medical Examiner, Charleston, WV.
Reprint requests to Robert C. Belding, MD, 246 Mercer St, Beckley, WV 25801.