Pathology Quiz Case 2

Abstract

A 78-YEAR-OLD WOMAN PRESENTED WITH A 9-year history of hoarseness, which had substantially progressed in the 12 months before presentation. Her medical history was remarkable for gastroesophageal reflux, which had been treated with Nissen fundoplication 2 years earlier. The results of a Bravo pH study performed 1 year earlier were negative. The patient had a 50 pack-year smoking history and had stopped using tobacco 9 years ago. Her vocal quality was strained and harsh, with normal frequency and significantly reduced pitch. Videostroboscopy revealed edematous, ambercolored mucosa of the false vocal cords, aryepiglottic folds, and arytenoids (Figure 1). The true vocal folds were mobile but with irregular mucosal thickening. A vibratory mucosal wave was not visualized owing to diffusely edematous false vocal cords. There were no ulcerative lesions; however, there was evidence of cobblestoning and redundancy of the interarytenoid mucosa. There also was a small amount of anterior webbing. Direct microlaryngoscopy with biopsy was recommended. Hematoxylin-eosin staining of the supraglottic and glottic larynx biopsy specimens revealed amorphous eosinophilic material beneath respiratory mucosa, which demonstrated squamous metaplasia (Figure 2). Congo red staining showed diffuse, muted, red, extracellular aggregates. Application of polarized light elicited birefringent deposits (Figure 3). Immunoperoxidase stains showed focal aggregates of CD20-positive B lymphocytes and CD3and CD43-positive T lymphocytes. A few scattered and -positive mature plasma cells were observed on and in situ hybridization. What is your diagnosis?