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Recurrent Vocal Fold Mass in a Middle-aged Woman

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 45-year-old woman was referred to a tertiary care center for hoarseness. She had a left vocal fold polyp that was removed 2 months earlier at an outside institution, with benign pathology reported. Subsequent stroboscopy revealed a hemorrhagic-appearing polyp (2-3 mm). She was sent for preoperative voice therapy, with plans for excision. However, her voice worsened with therapy, and she returned to the otolaryngology clinic after a few weeks. A larger, 6- to 7-mm, irregular, left vocal fold mass was noted. Preoperative imaging was nonspecific, revealing a small soft-tissue density along the true vocal fold. The patient was taken to the operating room for excision (Figure, A). After the final pathology results were obtained, the patient was taken back to the operating room for cordectomy with negative margins.

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B. Inflammatory myofibroblastic tumor

Inflammatory myofibroblastic tumors (IMTs) are rare, neoplastic lesions that commonly involve the lungs or abdominopelvic region.1,2 Head and neck involvement is very uncommon, with the larynx most frequently affected.3 Laryngeal IMTs has a predilection for the true vocal cords, subglottis, and aryepiglottic folds.2,3 Although persons of any age may be affected, IMTs tend to occur in the fifth decade of life.2 Symptoms are secondary to mass effect, with 74% of patients presenting with hoarseness or dysphonia, dyspnea, dysphagia, globus sensation, otalgia, cough, and stridor.2,3

Laryngeal IMT accounts for less than 1% of all respiratory tract tumors and remains poorly understood.4 The cause of laryngeal IMT has yet to be completely elucidated; however, predisposing factors may include smoking, trauma, infection (Epstein-Barr virus and human herpesvirus-8), and immunologic factors.13 Up to 70% of IMT cases have overexpression of the ALK protein, secondary to genetic abnormalities involving chromosome 2p23, a finding that supports its neoplastic nature.1,4,5 Aberrations in the ALK protein have been demonstrated in several other tumors, including rhabdomyosarcoma, renal cell carcinoma, non–small cell lung cancer, glioblastoma, and its namesake, anaplastic large-cell lymphoma.5

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Article Information

Corresponding Author: Jaime E. Moore, MD, Department of Otolaryngology–Head and Neck Surgery, Virginia Commonwealth University, PO Box 980146, Richmond, VA 23298 (jaime.moore@vcuhealth.org).

Published Online: October 10, 2019. doi:10.1001/jamaoto.2019.2869

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Yan  Q, Hu  XL.  Inflammatory myofibroblastic tumor of the larynx: report of a case and review of the literature.  Int J Clin Exp Pathol. 2015;8(10):13557-13560.PubMedGoogle Scholar
2.
Tay  SY, Balakrishnan  A.  Laryngeal inflammatory myofibroblastic tumor (IMT): a case report and review of the literature.  J Med Case Rep. 2016;10(1):180. doi:10.1186/s13256-016-0967-7PubMedGoogle ScholarCrossref
3.
Do  BA, Varshney  R, Zawawi  F, Levental  M, Caglar  D, Young  J.  Inflammatory myofibroblastic tumor of the larynx-a case report.  J Voice. 2014;28(2):258-261. doi:10.1016/j.jvoice.2013.09.004PubMedGoogle ScholarCrossref
4.
Kieu  MQ, Thottam  PJ, DaCosta  V, Gonzalez-Krellwitz  L, Poulik  JM, Madgy  DN.  Treatment of inflammatory myofibroblastic tumor of the subglottis with KTP laser: a case report.  J Voice. 2014;28(6):841.e1-841.e4. doi:10.1016/j.jvoice.2014.03.016PubMedGoogle ScholarCrossref
5.
Buccoliero  AM, Ghionzoli  M, Castiglione  F,  et al.  Inflammatory myofibroblastic tumor: clinical, morphological, immunohistochemical and molecular features of a pediatric case.  Pathol Res Pract. 2014;210(12):1152-1155. doi:10.1016/j.prp.2014.03.011PubMedGoogle ScholarCrossref
6.
Izadi  F, Ghanbari  H, Azizi  MR, Gasembaglou  S, Manteghi  MJ, Ghanbari  A.  Inflammatory myofibroblastic tumor of the larynx: a case report.  Iran J Otorhinolaryngol. 2016;28(84):79-82.PubMedGoogle Scholar
7.
Butrynski  JE, D’Adamo  DR, Hornick  JL,  et al.  Crizotinib in ALK-rearranged inflammatory myofibroblastic tumor.  N Engl J Med. 2010;363(18):1727-1733. doi:10.1056/NEJMoa1007056PubMedGoogle ScholarCrossref
8.
Lovly  CM, Gupta  A, Lipson  D,  et al.  Inflammatory myofibroblastic tumors harbor multiple potentially actionable kinase fusions.  Cancer Discov. 2014;4(8):889-895. doi:10.1158/2159-8290.CD-14-0377PubMedGoogle ScholarCrossref
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