What is the role of surgery in the management of laryngeal diffuse large B-cell lymphoma (DLBCL) in an adult patient?

Role of Surgery in Laryngeal DLBCL Management

Surgery has no role in the treatment of laryngeal diffuse large B-cell lymphoma beyond obtaining adequate tissue for diagnosis; the disease is treated with systemic chemoimmunotherapy (R-CHOP) with or without radiotherapy, not surgical resection. 1

Surgical Role Limited to Diagnosis Only

The only indication for surgery in laryngeal DLBCL is to obtain sufficient tissue for accurate pathological diagnosis through excisional or incisional biopsy. 1

Diagnostic Biopsy Approach

• Surgical excision biopsy remains the optimal diagnostic method, providing adequate tissue for morphological assessment, immunohistochemistry, and molecular studies 1
• Core needle biopsies or endoscopic biopsies should be reserved only for patients where surgical approach is impractical or carries excessive risk 1
• Fine-needle aspirate should NOT be used as the sole basis for DLBCL diagnosis 1
• Repeated biopsies may be necessary in laryngeal cases when initial samples are insufficient, as diagnosis can be challenging in this anatomic location 2

Critical Diagnostic Requirements

• The biopsy must provide enough material for comprehensive immunohistochemistry including CD20, CD79a, BCL6, CD10, MYC, BCL2, Ki67, and other markers 1
• Ideally, tissue should be sent unfixed to allow flow cytometry and high-quality DNA/RNA extraction 1
• Processing by an experienced haematopathology laboratory with expertise in lymphoma diagnosis is mandatory 1, 3

No Role for Surgical Resection in Treatment

Once diagnosis is established, laryngeal DLBCL is treated as a systemic disease with chemoimmunotherapy, not surgical excision. 2, 4

Standard Treatment Approach

• The standard treatment for laryngeal DLBCL follows the same protocols as nodal DLBCL: R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) for 6-8 cycles 2, 5
• For limited-stage disease (Stage I-II), abbreviated chemotherapy (3-4 cycles of R-CHOP) followed by involved-field radiotherapy is an alternative option 1, 6
• Surgical debulking or resection has no established role and could delay appropriate systemic therapy 2, 4

Treatment Modifications for Laryngeal Site

• Age and comorbidities may necessitate dose adjustments (e.g., R-COP without doxorubicin in elderly patients with cardiac dysfunction), but surgery remains inappropriate 2
• Radiotherapy to the laryngeal site may be incorporated as part of combined-modality therapy in limited-stage disease 2, 6

Common Pitfalls to Avoid

• Do not attempt surgical resection or laryngectomy as primary treatment—this delays curative systemic therapy and does not improve outcomes 2, 4
• Do not accept inadequate biopsy specimens—insufficient tissue leading to diagnostic uncertainty may require repeat procedures 2
• Do not proceed with treatment based on fine-needle aspiration alone—this violates guideline recommendations and risks misdiagnosis 1
• Do not reduce chemotherapy doses unnecessarily—maintaining dose intensity is critical for cure, and growth factor support should be used instead 1, 3