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Transoral robotic resection of unusual spindle cell/pleomorphic lipoma of the larynx
Enrique Cadena-Pineros1, Alfredo Ernesto Romero-Rojas2, Ricardo Guerra3
1 Department of Otorhinolaryngology and Head and Neck, Marly Clinic, Bogotá DC; Department of Otorhinolaryngology, National University of Colombia and National University Hospital of Colombia, Bogotá; Department of Head and Neck, National Cancer Institute, Bogotá, Colombia
2 Department of Pathology, Marly Clinica and National Cancer Institute, Bogotá, Colombia
3 Department of Otorhinolaryngology and Head and Neck, Marly Clinic, Bogotá DC; Department of Otorhinolaryngology, Section of Laryngology, Children's University Hospital of San José, University Foundation of Health Sciences, Bogotá, Colombia
|Date of Submission||18-Nov-2020|
|Date of Decision||16-Feb-2021|
|Date of Acceptance||20-Mar-2021|
|Date of Web Publication||08-Apr-2021|
Calle 50 # 9 – 67, Marly Clinic, Bogotá
Source of Support: None, Conflict of Interest: None
Spindle cell/pleomorphic lipoma (SC/PL) is a subcutaneous mass usually localised on nape, shoulder or upper back. It is a benign lipogenic tumour composed of primitive CD34-positive spindle cells, floret-like multinucleated giant cells and mature adipocytes. Complete surgical excision is the optimal treatment. This unusual tumour in the larynx has only been reported in the medical literature once and was treated surgically by open approach. Actually, transoral robotic surgery (TORS) is most suitable because provides tridimensional magnified view plus a greater mobility with instruments, allowing complete and safe removal of the supraglottic mass, allowing rapid healing and recovery. We present the first case of a SC/PL of larynx managed with TORS. Four hours after surgery, the patient was able to take a soft diet and was discharged 2 h later. The follow-up showed an excellent clinical and functional outcome.
Keywords: Head and neck neoplasm, laryngeal neoplasm, larynx, pleomorphic lipoma, robotic surgical procedures
| ¤ Introduction|| |
The 80% of spindle cell/pleomorphic lipomas (SC/PL) usually present as a solitary, painless, subcutaneous mass in the nape, shoulder or upper back in patients of the fourth and eighth decade of life. The male-to-female ratio is approximately 9:1. Occasionally, these tumours occur in the extremities and trunk. Burkes et al. recently reported the first case of a patient with this tumour in the larynx, and it was managed by anterior transcervical surgical approach. We inform a case of an adult male with a SC/PL of the supraglottic larynx who was successfully treated for us with transoral robotic surgery (TORS). Our literature review suggests that this is the second description of this unusual tumour in the larynx.
| ¤ Case Report|| |
A 63-year-old man with dyspnea in decubitus, sleep apnea, globus sensation, dysphagia and neck fullness, which increased in the past 6 weeks. No history of allergies, tobacco or alcohol use. With a diagnosis of a supraglottic tumour, he was taken twice to unsuccessfully attempt of transoral removal with a suspension laryngoscopy (SL) due to poor vision of tumour-implantation surface and limited range of motion of the instruments through the laryngoscope tube.
Computed tomography scan reported a tumour located on the right aryepiglottic fold, with hypodense and homogeneous low-density areas [Figure 1]a and [Figure 1]b. Flexible fibre-optic laryngoscopy (FFL) detected a large smooth supraglottic tumour that partially obstructed the glottis, with adequate mobility of vocal cords [Figure 1]c.
|Figure 1: Preoperative imaging, computed tomography scan. (a and b) The coronal and axial computed tomography scan confirmed a hypodense mass (yellow arrow) in aryepiglottic fold of the supraglottic larynx. (c) Preoperative flexible fibre-optic laryngoscopy, evidence a giant lipoma. (d and e) Intraoperative view (Imagen obtained using 0° transoral robotic endoscopy), bulky lipoma resting on the right aryepiglottic fold, with a broad base (black arrow). (f) TORS: Cut over tumour base with a 5 mm EndoWrist® monopolar scalpel. Lipo: Lipoma. *epiglottis|
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The da Vinci robotic® (Intuitive Surgical, INC., Sunnyvale, CA, USA) system was docked above the patient's head. The surgical assistant located on the head of the table provides suction and retraction. The Crowe–Davis mouth gag, 8 mm HD telescopic camera 0° and the 5 mm Endo Writs® instruments were used. In surgery was observed the lipoma over the right aryepiglottic fold [Figure 1]d and [Figure 1]e. With the Maryland dissector retraction, a linear cut was easily performed on the base tumour with a monopolar scalpel [Figure 1]f. The docking time and console surgical time were 15 and 4 min, respectively. The patient was immediately extubated, 4 h after was able to take soft diet and was discharged 2 h later. Healing of the wound was uneventful without any signs of infection or fistula.
The surgical specimen showed a yellowish, discoid, well-encapsulated lesion with a gelatinous texture measuring 4.0 cm × 2.5 cm × 2.0 cm [Figure 2]a. It was diagnosed SC/PL showing a neoplastic lesion with lobular architecture, few fat cells, spindle cells with stubby nuclei, surrounded by collagen fibres, and myxoid matrix mixed with rounded cells with radially nuclei in a 'floret-like' pattern and immunoreactivity for CD34. No anaplasia, mitoses or necrosis, were identified, malignancy, a SC/PL was diagnosed [Figure 2]b and [Figure 2]c. Follow-up with FFL 13 months after surgery, revealed an aryepiglottic fold with small hypertrophic tissue and no evidence of residual o recurrent lipoma. At this time, the patient had no specific complaints [Figure 2]d.
|Figure 2: (a) Surgical specimen was a well-encapsulated tumour 4 cm × 2.5 cm × 2.0 cm. (b) Admixture of mature adipose tissue and pleomorphic multinucleated cells, so-called floret-like giant cells (Floret giant cells are highlighted by black arrows) (H and E, ×40). (c) immunohistochemical study shows CD34+ spindle and pleomorphic cells (×40). (d) Flexible fibre-optic laryngoscopy, 13 postoperative months: Aryepiglottic fold has a small hypertrophic tissue and no evidence of residual o recurrent lipoma (black arrow)|
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| ¤ Discussion|| |
Enzinger was the first to mention the Spindle cell lipoma, then reported the pleomorphic lipoma characterised by hallmark floret-like multinucleated giant cells., Posteriorly, Van Treeck described the SC/PL. SC/PL represents 1.5% of all adiposity tumours, occurring in older men and is a type of benign lipogenic tumour composed of primitive CD34-positive spindle cells, pleomorphic multinucleated cells, so-called floret-like giant cells and mature adipocytes., This tumour has 12% of recurrence after incomplete resection, even after long-free intervals. Total excision of the tumour is the treatment of choice, either by the open or transoral approached. TORS, has advantages over open traditional approaches among others, no tracheostomy, close exposition of the operative field, tremor-free wristed instruments, three-dimensional view, which allows operation through narrow areas, making a safe and efficient surgery that's allows total block resection.
Burkes et al. reported the first case of SC/PL in the larynx treated by through transcervical approach, the patient was kept intubated in surgical intensive care unit for 1 day and was discharged 2 days later. Our patient had two failed previous attempts for transoral resection with a SL due to inadequate exposure of the tumour-implantation surface.
Instead, we used a Crowe–Davis mouth gag that provides an excellent view of the operative field, allowing a TORS with a short surgical time and with great three-dimensional view. He was discharged 6 h after surgery. Intubation, tracheostomy or suspension of diet was not necessary. The follow-up showed an excellent clinical and functional result.
| ¤ Conclusion|| |
SC/PL of the larynx is a very rare benign lipogenic tumour, in which conservative local excision is considered sufficient, but incomplete resection may lead to recurrence., TORS showed to be an excellent option on its own, as it can overcome the restrictions of conventional transoral and transcervical approaches. It provides an enlarged three-dimensional view plus a wide range of motion of the instruments, allowing complete tumour resection, with quick recovery and healing.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| ¤ References|| |
Van Treeck BJ, Fritchie KJ. Updates in spindle cell/pleomorphic lipomas. Semin Diagn Pathol 2019;36:105-11.
Burkes JN, Campos L, Williams FC, Kim RY. Laryngeal spindle cell/pleomorphic lipoma: A case report. An in-depth review of the adipocytic tumors. J Oral Maxillofac Surg 2019;77:1401-10.
Enzinger FM, Harvey DA. Spindle cell lipoma. Cancer 1975;36:1852-9.
Shmookler BM, Enzinger FM. Pleomorphic lipoma: A benign tumor simulating liposarcoma. A clinicopathologic analysis of 48 cases. Cancer 1981;47:126-33.
Chan JY, Richmon JD. Transoral robotic surgery (TORS) for benign pharyngeal lesions. Otolaryngol Clin N Am 2014;47:407-13.
[Figure 1], [Figure 2]