The impact of laryngeal dysplasia on the development of laryngeal squamous cell carcinoma

Malignant Transformation of Dysplastic Vocal Fold Lesions: A Systematic Review and Meta-Analysis

Importance

The reported rates of malignant transformation of dysplastic laryngeal lesions are highly variable, as is time to malignant degeneration.

Objective

To evaluate the rate of and time to malignant transformation of dysplastic laryngeal lesions based on the World Health Organization (WHO) dysplasia classification system.

Data Sources

PubMed, MEDLINE, Embase, CINAHL, CENTRAL, and Cochrane Reviews were searched from the date of database inception to June 8, 2023.

Study Selection

English-language articles assessing the rate of malignant transformation using the 2005 WHO dysplasia classification system were included in this systematic review and meta-analysis.

Data Extraction and Synthesis

The study was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data extraction was performed by 2 independent investigators. Study quality was assessed using a validated quality tool. When possible, data were pooled using random-effects meta-analysis.

Main Outcome Measures

The primary outcome measure was the malignant transformation rate in each laryngeal dysplasia category. Secondary outcome measure was the time interval over which malignant transformation had occurred.

Results

A total of 5585 records were screened, 61 full texts were assessed, and 18 retrospective cohort studies with 3243 participants were included in the final review. The weighted pooled mean malignant transformation rates of mildly, moderately, and severely dysplastic lesions were 10.9%, 23.3%, and 30.5%, respectively. Malignant transformation rate of nondysplastic laryngeal lesions was 4.5%. Moderately and severely dysplastic lesions had significantly higher odds of malignant transformation compared with mildly dysplastic lesions (moderate: odds ratio [OR], 2.90 [95% CI, 2.06-4.09]; I2 = 0%; severe: OR, 3.42 [95% CI, 2.11-5.52]; I2 = 40%). Lesions without dysplasia had a significantly lower odds of malignant transformation compared with lesions with mild dysplasia (OR, 0.48; 95% CI, 0.28-0.81; I2 = 0%). The overall mean time to malignant transformation was 28.8 months (range, 22.0-35.6 months) for all dysplasia grades.

Conclusion and Relevance

This systematic review and meta-analysis found that the rate of malignant transformation increased with the grade of laryngeal dysplasia. Moderately dysplastic lesions were more likely to undergo malignant degeneration compared with mildly dysplastic lesions.

Clinical significance of type IV vascularization of laryngeal lesions according to the Ni classification

Background

Scattered, small, dot-like intraepithelial papillary capillary loops (IPCLs) represent type IV epithelial vascularization according to "Ni classification" and are considered to be nonmalignant. According to the European Laryngological Society classification, these loops are malignant vascular changes. This contradiction has high clinical importance; therefore, clarification of the clinical significance of type IV vascularization according to the Ni classification is needed.

Methods

The study was performed between June 2015 and December 2022. All recruited patients (n = 434) were symptomatic, with macroscopic laryngeal lesions (n = 674). Patients were investigated using the enhanced endoscopic methods of narrow band imaging (NBI) and the Storz Professional Image Enhancement System (IMAGE1 S). The microvascular patterns in the lesions were categorized according to Ni classification from 2011 and all lesions were examined histologically.

Results

A total of 674 lesions (434 patients) were investigated using flexible NBI endoscopy and IMAGE1 S endoscopy. Type IV vascularization was recognized in 293/674 (43.5%) lesions. Among these 293 lesions, 178 (60.7%) were benign (chronic laryngitis, hyperplasia, hyperkeratosis, polyps, cysts, granulomas, Reinkeho oedema and recurrent respiratory papillomatosis); 9 (3.1%) were squamous cell carcinoma; 61 (20.8%) were mildly dysplastic, 29 (9.9%) were moderately dysplastic, 14 (4.8%) were severe dysplastic and 2 (0.7%) were carcinoma in situ. The ability to recognize histologically benign lesions in group of nonmalignant vascular pattern according to Ni (vascularization type I-IV) and distinguish them from precancers and malignancies was with accuracy 75.5%, sensitivity 54.4%, specificity 94.4%, positive predictive value 89.6% and negative predictive value 69.9%.

Conclusion

Laryngeal lesions with type IV vascularization as defined by Ni present various histological findings, including precancerous and malignant lesions. Patients with type IV vascularization must be followed carefully and, in case of progression mucosal lesion microlaryngoscopy and excision are indicated.

Prognostic Role of the Initial Grade of Dysplasia on Premalignant Vocal Fold Lesions

PURPOSE

The main objective of this study was to analyze the prognostic role of the initial grade of dysplasia on the progression to SCC.

STUDY DESIGN

Retrospective cohort.

METHODS

This study was performed in the Otorhinolaryngology Department of a tertiary hospital center from January 2010 to December 2020. Every patient submitted to a microlaryngoscopy during this period with a histology of dysplasia on the first biopsy was included.

RESULTS

A total of 112 patients were included and median follow-up was 24 months (range 1-120 months). Mean age at diagnosis was 59.71 (+/- 12.03) and 88 patients were male (78.6%). Initial grade of dysplasia was mild on 60 patients (53.6%), moderate on 24 (21.4%), severe on 18 (16.1%), and carcinoma in situ in 10 (8.9%). Overall, 25 patients (21.4%) developed invasive squamous cell carcinoma (SCC) and 15 (13.4%) died during follow-up. On an adjusted 5 year's progression free survival analysis, considering gender, age, dysplasia grade, tobacco and alcohol consumption, the initial grade of dysplasia was the only factor significantly associated with progression to carcinoma (P = .047). When compared to mild dysplasia, moderate dysplasia had a Hazard Ratio (HR) of 0.81 (95%CI 0.21-3.22); severe dysplasia had a HR of 1.76 (95%CI 0.59-5.30) and carcinoma in situ had a HR of 4.25 (95%CI 1.44-12.59).

CONCLUSION

The initial dysplasia grade seems to be the most important prognostic factor regarding progression to SCC in patients with premalignant vocal fold disease.

Laryngeal dysplasia: a 10-year review of rates of progression to invasive carcinoma and treatment-specific outcomes in a regional ENT department in Northern Ireland

Background

Laryngeal dysplasia represents a complex pre-malignant condition characterised by a spectrum of mucosal changes, with a reported malignant transformation rate from dysplasia to invasive carcinoma of 14.0 per cent.

Objective

To identify whether increasing glottic dysplasia severity is associated with higher local malignant transformation rates or adverse clinical outcomes.

Methods

This retrospective cohort study identified 125 patients with any histopathological grade of glottic dysplasia over a 10-year period who were followed up for a standardised 10-year period.

Results

The malignant transformation rate was 21.8 per cent over 10 years, demonstrating a statistically significant greater risk with increasing dysplasia severity. The mean time to transformation was 52 months, with time to transformation statistically associated with increasing dysplasia severity. Rapid progression to carcinoma within 12 months occurred in 40 per cent of cases, and 58 per cent of subsequently diagnosed laryngeal squamous cell carcinomas were tumour stage T1.

Conclusion

Laryngeal dysplasia carries a significant malignant potential, appearing greatest within 12 months of diagnosis and with increasing severity of dysplasia.

Laryngeal dysplasia: Oncological outcomes in a large cohort of patients treated in a tertiary comprehensive cancer centre

PURPOSE

Laryngeal dysplasia represents a series of precancerous lesions, observed as laryngeal leukoplakia. General agreement has been lacking for their management and treatment ranging from simple biopsy to complete excision with cold blade/laser. In this work, we aim at providing the oncological outcomes of patients affected by laryngeal dysplasia, treated with a single modality, and at identifying clinical parameters predictive of malignant transformation.

MATERIALS AND METHODS

We performed a retrospective analysis of patients treated with transoral laser microsurgery between January 2005 and December 2015 in a tertiary comprehensive cancer centre. Data were collected about smoke and alcohol habits, site of the laryngeal lesion, surgical outcomes and progression to invasive squamous cell carcinoma.

RESULTS

The grade of dysplasia, margins' status and smoke habit were not associated with a significantly worse DFS and a higher risk of invasive SCC. We identified three parameters (supraglottic involvement, multifocality and history of more than one recurrence of dysplasia) that have a significant prognostic value.

CONCLUSIONS

On the base of these clinical parameters, a more intensive follow-up might be warranted for high-risk patients.

European Laryngological Society position paper on laryngeal dysplasia Part II: diagnosis, treatment, and follow-up

PURPOSE OF REVIEW

To give an overview of the current knowledge regarding the diagnosis, treatment, and follow-up of laryngeal dysplasia (LD) and to highlight the contributions of recent literature. The diagnosis of LD largely relies on endoscopic procedures and on histopathology. Diagnostic efficiency of endoscopy may be improved using videolaryngostroboscopy (VLS) and bioendoscopic tools such as Narrow Band Imaging (NBI) or Storz Professional Image Enhancement System (SPIES). Current histological classifications are not powerful enough to clearly predict the risk to carcinoma evolution and technical issues such as sampling error, variation in epithelial thickness and inflammation hamper pathological examination. Almost all dysplasia grading systems are effective in different ways. The 2017 World Health Organization (WHO) system should prove to be an improvement as it is slightly more reproducible and easier for the non-specialist pathologist to apply. To optimize treatment decisions, surgeons should know how their pathologist grades samples and preferably audit their transformation rates locally. Whether carcinoma in situ should be used as part of such classification remains contentious and pathologists should agree with their clinicians whether they find this additional grade useful in treatment decisions. Recently, different studies have defined the possible utility of different biomarkers in risk classification. The main treatment modality for LD is represented by transoral laser microsurgery. Radiotherapy may be indicated in specific circumstances such as multiple recurrence or wide-field lesions. Medical treatment currently does not have a significant role in the management of LD. Follow-up for patients treated with LD is a fundamental part of their care and investigations may be supported by the same techniques used during diagnosis (VLS and NBI/SPIES).

Laryngeal Squamous Cell Carcinomas are Commonly Associated With Differentiated Squamous Intraepithelial Neoplasia With or Without an Admixture With Usual Type of Squamous Intraepithelial Neoplasia: Clinical and Pathologic Significance

BACKGROUND

Differentiated squamous intraepithelial neoplasia (dSIN) is a pathway in the development of invasive squamous cell carcinoma (SCC) distinct from the usual-type squamous intraepithelial neoplasia (uSIN) and has not been described in the larynx.

MATERIALS AND METHODS

Sixty-nine consecutive cases of SCC were identified which included 25 dSIN, 13 uSIN, and 31 mixed dSIN+usual-like SIN (u-like SIN) cases.

RESULTS

dSIN was characterized by atypical squamous cells limited to the basal/parabasal layers and u-like SIN was characterized by cytologic atypia limited to less than full thickness. Despite the lack of neoplastic involvement of the full thickness of the epithelium, these types of SIN were commonly connected with invasive carcinoma. Prior biopsies demonstrating only dSIN, without the underlying invasive SCC, were underdiagnosed in 2 cases. Because of the frequent keratinization, u-like SIN likely represents the "keratinized dysplasia" and shows changes suggestive of dSIN with upward spread of neoplastic cells into the upper layer of the epithelium.

CONCLUSIONS

Laryngeal dSIN represents an important but under recognized pathway of invasive SCC development. As moderate dysplasia of uSIN type are not associated with invasive SCC, labeling u-like SIN as dysplasia of grade 2 or 3 likely leads to the controversies in the current grading systems in the upper aerodigestive system and causes confusion for clinicians.

Laryngeal inflammatory response to smoke and vape in a murine model

PURPOSE

To build a murine model for tobacco smoke and electronic cigarette vapor exposure to characterize the inflammatory and immune responses in the larynx.

MATERIALS AND METHODS

In this pilot study, twenty-four wild-type C57BL/6 mice were divided into four groups: smoke, vapor with nicotine, vapor without nicotine, and air only. Following daily exposure for 4 months, larynges were dissected and processed with cytokine detection arrays. Each laryngeal cytokine level between the four different groups was analyzed statistically by using statistical analysis software (SAS) to calculate the analysis of variance (ANOVA).

RESULTS

IL-4 was the only cytokine found to achieve statistically significant different levels in this study, with elevated levels of IL-4 in the tobacco smoke and vapor with nicotine groups compared to the levels found in the vapor without nicotine and air only groups (p = 0.0418). While statistically non-significant, prominent findings revealed up-regulation of TGF-β2 and TGF-β3 in the smoke group, but near-normal levels of TGF-β2 and TGF-β3 and suppression of IL-10 in the vapor groups (p > 0.05).

CONCLUSION

The potential utility of the murine model is established for studying the inflammatory and immune effects of tobacco smoke and vapor on the mammalian larynx. IL-4 levels in mice larynges were significantly elevated in the tobacco smoke and vapor with nicotine groups.

Outcomes of Treating Early Glottic Neoplasms With a Potassium Titanyl Phosphate Laser

Objectives:

The aim of this study was to assess the outcome of treating glottic dysplasia and early squamous cell carcinoma (SCC) with potassium titanyl phosphate (KTP) photoangiolytic laser ablation.

Methods:

Patient demographics, comorbidities, and tumor characteristics were recorded. Perceptual, patient-reported, and objective voice outcomes were assessed. Use of treatment modalities in addition to the KTP laser, development of locoregional or metastatic SCC, and overall survival were recorded.

Results:

There were 23 patients with glottic dysplasia and 18 patients with glottic SCC. Mean age at treatment was 69 years. Most patients (95%) were male. Posttreatment fundamental frequency fell from 132 ± 35 to 116 ± 24 Hz ( P = .03). Overall, 61% of patients achieved a normal voice. There was a learning-curve, and most treatment failures occurred in the first half of the series. Five-year KTP-only disease-control rates were 87.1% and 53.5% for dysplasia and malignancy, respectively. Five-year overall survival was 56%, with no laryngectomies or deaths due to SCC.

Conclusions:

Ablating dysplasia and early glottic cancer using a KTP laser is a viable treatment option. It has a learning curve and a failure rate but, in this series, no ultimate loss of oncologic control. Its introduction into clinical practice should be managed carefully in the context of multidisciplinary cancer care.

Level of Evidence:

4.

Correlating laryngoscopic appearance of laryngeal lesions with histopathology

OBJECTIVES/HYPOTHESIS

Meticulous scrutiny of laryngeal lesions with laryngoscopes and microscopes often identify angiogenic activity, one of the hallmarks of neoplastic and preneoplastic lesions. The aim of this study was to determine if there is an association between laryngoscopic appearance and histopathology of laryngeal lesions based on operative biopsies.

STUDY DESIGN

Retrospective case-control study.

METHODS

One hundred forty-four laryngeal biopsies from 92 patients between 2015 and 2017 met inclusion criteria. Cases were patients who had biopsy-proven laryngeal dysplasia or malignancy. Controls were patients who had benign laryngeal pathology. All of the laryngeal lesions had either keratosis or vascular stippling, an indication of angiogenic activity. Medical records, videostroboscopies and operative findings of these patients were reviewed. Multivariable logistic regression was used to examine the correlation between laryngoscopic appearance of laryngeal lesions and presence or absence of dysplasia and invasive carcinoma.

RESULTS

Fifty percent of the 144 laryngeal lesions were classified either as dysplastic or malignant by histopathology. Vascular stippling was present in 31% of all laryngeal lesions. On logistic regression, vascular stippling was significantly associated with dysplastic and malignant lesions (P = .0018). Overall sensitivity and specificity of vascular stippling and the presence of dysplasia and malignancy were 51% and 89%, respectively.

CONCLUSIONS

Laryngoscopic and microscopic appearance of vascular stippling could inform clinicians on diagnostic sampling of suspicious laryngeal lesions that reduces delay in diagnosis. The low sensitivity of vascular stippling underlies the importance of maintaining high clinical suspicion and proceeding to the operating theater for adequate tissue sampling.

LEVEL OF EVIDENCE

3 Laryngoscope, 129:1308-1312, 2019.

Site-specific familial risk and survival of familial and sporadic head and neck cancer

The vast majority of head and neck cancers (HNCs) are sporadic squamous cell carcinomas, smoking and heavy drinking being the main risk factors. However, little is known about the possible role of family history and the importance of inherited factors versus shared environment. We used Swedish population-based registries to study the family history of HNC. In order to estimate the risk for family members to get the same cancer, and the risk for cancer-specific death in patients with a family history of HNC compared with patients without a family history, multivariate Cox proportional hazards analyses were performed. A 1.43-fold increased risk for developing HNC in the first-degree relatives (FDRs) of HNC patients [hazard ratio (HR), 1.43; 95% CI, 1.28-1.61] was found, when compared with relatives of healthy controls. In spouses of patients with HNC, the risk for developing any HNC was moderately increased (HR, 1.25; 95% CI, 1.01-1.53), compared with spouses of healthy controls. In addition, a 1.34-fold increased risk for death of HNC was found in HNC patients with a family history of HNC (HR, 1.34; 95% CI, (1.03-1.73) compared with HNC patients without a family history. We found an increased risk for HNC in relatives and spouses of HNC patients, when compared with family members of healthy controls. This suggests that in addition to inherited factors, shared environmental factors have a significant role in the development of the cancer. Family history of HNC was associated with worse survival in a newly diagnosed HNC patient.

Comparative Study between the Surgeon's Intraoperative Evaluation and Histopathology for Diagnosis of Laryngeal Lesions

Objective. To compare the surgeon's evaluation and histopathology for diagnosis of laryngeal lesions. Material. A clinical survey was distributed to laryngeal surgeons, ENT clinicians, and students in 2013 at the Department of Otorhinolaryngology in Rostock. Participants were asked to anonymously identify laryngeal pathologies and to assess the severity of the lesion starting from hyperplasia and inflammation over moderate dysplasia to early laryngeal cancer. Images of similar clinical laryngeal lesions were demonstrated in a multiple-choice modus to assess the surgeon's intraoperative evaluation. The questionnaires were digitally processed and evaluated. The results were correlated with histopathology and compared between experienced laryngeal surgeons, clinicians inexperienced in laryngeal surgery, and medical students from the Medical Faculty of the University of Rostock. Results. Sensitivity and specificity varied among the various groups, being highest in experienced laryngeal surgeons. In this group, sensitivity, specificity, positive and negative predictive value, and accuracy were 85%, 56%, 44%, 90%, and 65%, respectively. In 4% and 31%, laryngeal disease was underdiagnosed and overdiagnosed, respectively. In this group, Kappa statistics resulted in Kappa 0.32 (P < 0.001). Conclusion. This clinical survey clearly demonstrates that conformity between histopathology and evaluation of the laryngeal lesion depends on the surgeon's experience.