Immunohistological comparison of the World Health Organization (WHO) and Ljubljana classifications on the grading of preneoplastic lesions of the larynx

Comparison of the prognoses of laryngeal preneoplastic lesions based on Ljubljana and World Health Organization classifications

BACKGROUND

The aim of this study is to evaluate the prognosis of patients with laryngeal preneoplastic lesions based on Ljubljana classification (LC), Revised LC, World Health Organization Dysplasia System (WHO-DS) 2005 and WHO-DS 2017.

METHODS

Patients diagnosed with a laryngeal preneoplastic lesion in our clinic between 2005 and 2018 were included in the study. Biopsy preparations of patients were reexamined by the pathology unit and classified based on LC, Revised LC, WHODS 2005, and WHO-DS 2017. Patients with carcinoma were identified during follow-up. The prognosis of preneoplastic lesions was statistically analyzed based on carcinoma development and duration using these four different classifications.

RESULTS

Carcinoma developed in 16 of 142 patients after repeated biopsy. The risk for carcinoma development was found to be more statistically significant in atypical hyperplasia than in squamous cell hyperplasia and basal-parabasal cell hyperplasia according to LC (p: 0.027 and 0.035), no statistically significant difference was observed between squamous and basal-parabasal cell hyperplasia and CIS groups. The risk of carcinoma development was more statistically significant in high-grade squamous intraepithelial lesion (SIL) than in low-grade SIL according to revised LC (p: 0.04); in severe hyperplasia than in other groups according to WHO-DS 2005; and in highgrade dysplasia than in low-grade dysplasia according to WHO-DS 2017 (p: 0.013). The Cox regression analysis demonstrated that the risk of developing carcinoma statistically increased with age in all classifications, independent of the severity of dysplasia (p < 0.01). According to Cox regression analysis, there was no effect of sex on carcinoma development.

DISCUSSION

: In revised classifications, such as the revised LC and WHO-DS 2017, it is seen that facilitating clinical use is achieved by reducing the number of subgroups by combining the subgroups that do not statistically differ in terms of carcinoma development.

Precursor Lesions of the Vocal Cord: a Study on the Diagnostic Role of Histomorphology, Histometry and Ki-67 Proliferation

The precise typing of precursor lesions of squamous cell carcinoma of vocal cord is of vital importance since it determines the line of therapy and prognosis. The aim of the present study is to evaluate the possible value of the types of dyskeratosis, histometry and cell proliferation rate in discriminating these lesions. The present retrospective study was based on 145 patients, classified according to the updated 2017 WHO system and included: Low-grade dysplasia (24 cases), high -grade dysplasia (53 cases), carcinoma insitu (33 cases) and microinvasive carcinomas (35 cases). Cell proliferation was assessed by immunoreactivity to Ki-67. For histometry and quantitation of Ki-67 proliferation rate, an image analysis system was used (Leica LAS, Wetzlar, Germany). Epithelial pearls (cell nests) were commonly observed in microinvasive carcinoma (82.9%) than high-grade dysplasia (5.9%). The median epithelial thickness, as well as, proliferation rate showed a significant increase according to the grade of the lesion. It is concluded that dyskeratosis pattern, histometry and Ki-67proliferation rate are valuable parameters to characterize precursor lesions. The presence of epithelial pearls, thickness > 450 μm and Ki-67 > 40% denote high risk lesions that require adequate excision and/or radiotherapy.

Laryngeal Dysplasia, Squamous Cell Carcinoma, and Variants

Squamous cell carcinoma (SCC) is a malignant epithelial tumor showing evidence of squamous differentiation. It is the most common malignancy of the larynx, with several variants (verrucous, exophytic or papillary, spindle-cell, basaloid, acantholytic, adenosquamous) recognized, with well-established precursor lesions. Dysplasia is now separated into only low-grade and high-grade categories. Each SCC variant has unique cytomorphologic features and histologic differential diagnoses that are important to consider, as management and outcomes are different.

Correlation between microvascular characteristics and the expression of MVD, IGF-1 and STAT3 in the development of colonic polyps carcinogenesis

The aim of the present study was to investigate the correlation between vascular characteristics under narrow band imaging (NBI) and the expression of angiogenic factors of colorectal carcinoma and adenoma, and to evaluate the feasibility of NBI in vivo visualizing angiogenesis. Patients with colorectal polyps, which were pathologically confirmed as early carcinoma and adenoma, were recruited and examined by NBI. The vascular pattern was classified into type I (invisible or faintly visible vasculature), type II (clearly visible microvasculature that is regularly arranged in a round, oval honeycomb-like pattern) and type III (clearly visible microvasculature that is irregularly arranged in size and caliber or has irregular winding). Immunohistochemical staining was performed by cluster of differentiation (CD)34, insulin-like growth factor (IGF)-1 and signal transducer and activator of transcription 3 (STAT3). The histological results were compared with the vascular pattern under NBI. Overall, 64 sites (15 adenocarcinomas, 29 adenomas and 20 normal) from 58 patients were recruited in the study and examined by NBI. A higher proportion of adenomas (82.1%, 23/28) and adenocarcinomas (66.7%, 10/15) had vascular patterns II and III, respectively. The expression of microvessel density (MVD)-CD34 and IGF-1 in normal mucosa compared with adenomas and adenocarcinomas was significantly different (P<0.0001 and P=0.0062, respectively). MVD-CD34, IGF-1 and STAT3 expression in the sites displayed with vascular patterns I, II, and III was different significantly (P<0.0001, P=0.0010 and P=0.0055, respectively). The spearman correlation coefficient between NBI vascular pattern and MVD-CD34, IGF-1 and STAT3 expression was 0.67, 0.41 and 0.40, respectively. In conclusion, vascular-pattern analysis and the use of an NBI system may be a promising tool for evaluating angiogenesis of colorectal lesions in real-time endoscopy.

Correlation Between Clinical Diagnosis and Pathological Diagnosis in Laryngeal Lesions

OBJECTIVES

To evaluate the degree of agreement between the clinical and the pathological diagnosis in patients undergoing laryngeal microsurgery due to epithelial or edematous lesions of the vocal folds.

STUDY DESIGN

This is a retrospective study.

METHODS

The study was developed in the ear, nose, and throat clinic of a tertiary hospital, through chart review. We included all patients who underwent microsurgery of the larynx, whose videolaryngoscopic tests showed vocal fold lesions, from January 2003 to August 2014. During the study period, we identified 48 patients with epithelial and edematous lesions. The patients were divided into two groups. In group A, patients with edematous lesions with clinical diagnosis of polyps and Reinke edema were included. Group B comprised patients with epithelial lesions, as leukoplakic injuries. A correlation between histopathological findings and clinical hypothesis between these two groups of lesions was performed.

RESULTS

In group B, there was agreement in 88.9% of cases between the clinical and pathological diagnosis. In group A, compatibility occurred in only 46.4% of cases. We observed a statistically significant difference between the compatibility of the clinical and pathological diagnosis just in edematous lesions (P = 0.029).

CONCLUSIONS

The study showed the limitation of the pathological examination on edematous laryngeal lesions. On the other hand, on the epithelial lesions, there was more agreement between those diagnosis.

Morphometric analysis of Ki-67 and p16 expression in laryngeal precursor lesions

Laryngeal precursor lesions represent areas of altered epithelium with an increased likelihood for progression to squamous cell carcinoma. The exact molecular mechanisms of malignant transformation of laryngeal mucosa are not completely clear, but are certainly due to deregulation of cell proliferation. To assess the potential value of the p16 and Ki-67 as markers of malignant progression, we undertook a retrospective immunohistochemical and morphometric analysis on biopsy specimens from patients with precancerous lesions in the larynx. Morphometric analysis of samples stained with p16 antibody showed epithelial cell positivity in 29 (100 %) of samples with simple hyperplasia, 31 (100 %) samples with basal/parabasal cell hyperplasia, 23 (88 %) samples with atypical hyperplasia and 20 (95 %) samples with in situ carcinoma. There was a significant difference in percentage of p16-positive cells between samples with simple hyperplasia and samples with in situ carcinoma. Morphometric analysis of samples stained with Ki-67 antibody showed epithelial cell positivity in 27 (93 %) of samples with simple hyperplasia, 30 (97 %) samples with basal/parabasal cell hyperplasia, 26 (100 %) samples with atypical hyperplasia and 18 (86 %) samples with in situ carcinoma. There was a significant difference not only in the percentage of Ki-67-positive cells between samples with simple hyperplasia and samples with in situ carcinoma, but also between samples with simple and basal/parabasal cell hyperplasia. Laryngeal epithelial precursor lesions show significantly opposite patterns in p16 and Ki-67 immunopositivity. Simple hyperplasia on average shows 12 % of Ki-67-positive cells and 46 % of p16-positive cells. In situ carcinoma on average shows 23 % of Ki-67-positive cells and 36 % of p16-positive cells.

Interobserver variability of laryngeal mucosal premalignant lesions: a histopathological evaluation

The objective of this study is to measure interobserver variability in the classification of laryngeal mucosal premalignant lesions by reassessing the histopathology of previously diagnosed cases and to determine the possible therapeutic consequences of disagreement among observers. Histopathological assessment of 110 laryngeal mucosal premalignant lesions was done by three pathologists. Each slide had to be classified according to the World Health Organization, Squamous Intraepithelial Neoplasia, and the Ljubljana Squamous Intraepithelial Lesions systems. After the independent assessment, a joint meeting took place. To assess the relation between histopathological grading and subsequent clinical management, we created a two- and a three-grade system besides one comprising all options. For all analyses, the SAS/STAT statistical software was used. The highest unweighted κ-values concerning the all-options system are observed for the Squamous Intraepithelial Neoplasia classification (0.28, 95% confidence interval 0.23-0.33), followed by the World Health Organization and Ljubljana classifications. For the two-grade system the Ljubljana classification shows the highest unweighted κ-values (0.50, 95%, 0.39-0.61), followed by the World Health Organization and Squamous Intraepithelial Neoplasia classifications. For the three-grade system, the unweighted κ-values are similar. The implementation of weighted κ-values led to higher scores within all three classification systems, although these did not exceed 0.55 (moderate agreement). Given the high level of consensus, simultaneous pathological assessment may be said to provide added value in comparison with independent assessment. In the current study, no clear tendency is observed in favor of any one classification system. The proposed three-grade system could be an improved histopathological tool because it is easier to correlate with clinical decision making and because it yields better unweighted κ-values and proportions of concordance than the all-options system. Furthermore, clinical management could benefit from assessment by more than one pathologist in suspected cases of dysplasia or carcinoma.

Inter-observer agreement in laryngeal pre-neoplastic lesions

In this series, laryngeal preneoplastic lesions were evaluated by the classifications of the World Health Organization (WHOC), Ljubljana (LC) and squamous intraepithelial neoplasia (SINC) by multiple observers. The inter-observer agreement (IA) by WHOC for laryngeal lesions had been previously evaluated, but to the best of our knowledge, there are no data for LC and SINC. H&E stained slides from 42 laryngeal biopsies were evaluated by fourteen participants according to WHOC and LC, and SINC was additionally applied by 6. The results were analyzed statistically. The diagnoses which were favored by most participants for each case, according to WHOC, were as follows: squamous cell hyperplasia (n = 5; 12%), mild dysplasia (n = 11; 26.2%), moderate dysplasia (n = 12; 28.6%), severe dysplasia (n = 7; 16.7%), carcinoma in situ (n = 5; 12%), and invasive squamous cell carcinoma (n = 2; 4.8%). There was a significant difference between the participants for all three classifications; some participants gave lower or higher scores than the others. The mean correlation coefficients (MCC) of the participants were higher for WHOC compared to LC (0.55 ± 0.15 and 0.48 ± 0.14, respectively). The mean linear-weighted kappa (wKappa) values of participants were not significantly different (0.42 ± 0.10, 0.41 ± 0.12 and 0.37 ± 0.07 for WHOC, LC and SINC, respectively). The kappa values in this series are in agreement with those in previous literature for WHOC, and the similar results obtained for LC and SINC are novel findings. Although the MCC of WHOC was higher, as the wkappa was not significantly different, the findings in this series are not in favor of any of the classifications for better IA for pre-neoplastic laryngeal lesions.

ProEx C Stain Analysis in Recurrent Respiratory Papillomatosis

Objectives:

We evaluated the presence and pattern of ProEx C stain, a marker for the proliferative capacity of cells, in laryngeal tissues, including benign, malignant, and recurrent respiratory papilloma (RRP) specimens, and compared it to hematoxylin and eosin staining for the presence of dysplasia.

Methods:

We performed a retrospective study with chart review.

Results:

A total of 26 specimens (9 benign, 7 malignant, 10 RRP) representing 21 patients were stained. ProEx C stained positive in the nuclei of laryngeal tissue, consistent with its localization in cervical cytology specimens. Seven of 9 benign and 7 of 10 RRP specimens stained positive. The benign specimens were mostly polyps. The malignant specimens were either well or moderately differentiated squamous cell carcinoma, and they stained strongly and diffusely. In benign and RRP specimens, the basal layer typically stained positive. Other areas of epithelium stained weakly in benign specimens and variably in RRP specimens. Current analysis of hematoxylin and eosin—stained RRP specimens revealed that 30% of specimens had at least moderate dysplasia and 80% exhibited viral changes (koilocytosis).

Conclusions:

ProEx C is a clean and reliable stain in laryngeal tissue, and stains positive in RRP. This study could not definitively correlate positive ProEx C staining in areas of greater dysplasia, although a trend was observed. Further studies are necessary to determine whether ProEx C can be used in triage of cases of clinically aggressive RRP for closer follow-up or frequent operative intervention.

Grading systems in head and neck dysplasia: their prognostic value, weaknesses and utility

BACKGROUND

Grading of dysplasia, including head and neck lesions, continues to be a hotly debated subject. It is subjective and lacks intra- and inter-observer reproducibility due to the insufficiency of validated morphological criteria and the biological nature of dysplasia. Moreover, due to the absence of a consensus, several systems are currently employed.

OBJECTIVES

The aims of this review are to: 1) Highlight the significance of dysplasia and the importance of a valid method for assessing precursor lesions of the head and neck. 2) Review the different histopathological classification systems for grading intraepithelial lesions of the head and neck. 3) Discuss and review quality requirements for these grading systems.

CONCLUSION

Regarding the different classification systems, data concerning the WHO classification system are the most available in current literature. There is no simple relationship or overlapping between the classification systems. Further studies should be done to see whether other systems have advantages above the current WHO system and to discover indications that could lead to an universal classification system for intraepithelial lesions of the head and neck.

Dysplasia of the upper aerodigestive tract squamous epithelium

Dysplasia of the oral, laryngeal and oropharyngeal stratified squamous epithelia is a microscopically defined change that may occur in clinically identifiable lesions including erythroplakia, leukoplakia and erythroleukoplakia, lesions that convey a heightened risk for carcinomatous progression. Dysplastic lesions have been classified microscopically according to degree of cytologic atypia and changes in architectural patterns, usually on a three part or four part gradation scale. Vocal cord epithelial lesions are graded according to either the Ljubljana or the World Health Organization (WHO) system whereas oral dysplasias are generally classified according to WHO criteria. Cytologically atypical cells are considered to represent precancerous changes predicting an increase risk for carcinomatous transformation. Inter- and intra-rater reliability studies among pathologists have disclosed low correlation coefficients for four part grading systems, whereas improved agreement is achieved (kappa correlation values) using the Ljubljana systems. Evidence forwarded by some studies supports the prognostic value of progressively severe dysplastic changes for carcinomatous transformation; however, some studies indicate that the presence of a clinically defined lesion without microscopic evidence of dysplasia also connotes increased risk for carcinomatous transformation. Loss of heterozygosity (LOH) at 3p and 9p microsatellite domains, DNA ploidy analysis and nuclear image analyses may have predictive value as molecular and histomorphological biomarkers.

[Application of Ljubljana classification in laryngeal precancerous lesions]

The diagnosis and treatment of laryngeal premalignant lesions has been frustrated because of failure to adequately define the histologic changes that may help in prediction of irreversible neoplastic transformation. To assess the grading of laryngeal hyperplastic epithelial lesion it was used a Ljubljana classification of histologic changes. It was done a retrospective study of 104 laryngeal hyperplastic lesions biopsies that were classified according to the Ljubljana classification comprising benign spinous layer augmentation (simple hyperplasia), benign basal and parabasal layer augmentation (abnormal hyperplasia), alteration of epithelial cells towards malignancy (atypical hyperplasia) and carcinoma in situ. One hundred and four biopsies with preneoplastic changes were reevaluated and classified according to Ljubljana classification. It was found 42 cases (40.4%) which showed simple, 38 (36.5%) abnormal, 21 (20.2%) atypical hyperplasia and 3 (2.9%) carcinoma in situ. Three cases of atypical hyperplasia (2.9% of all investigated cases) and one of abnormal (0.96%) progressed to invasive carcinoma during the observation ranging from 5 to 9 years (median 8.1). None of the cases classified as simple hyperplasia showed progression to malignancy. The Ljubljana classification focuses on the important clinical decision involving benign looking hyperplastic lesion that do not require strict follow-up (simple and abnormal hyperplasia); and "risky" epithelium that require close follow-up with repeated histologic assessment to recognize any malignant progression (atypical hyperplasia); and carcinoma in situ that requires fast and complete treatment. We suggest that the Ljubljana classification may give a reliable assessment of laryngeal hyperplastic epithelial lesions and can help in monitoring all those patients.

Postępowanie w stanach przedrakowych krtani – dylematy i znaki zapytania

BACKGROUND

Development of the laryngeal squamous cell carcinoma is taking place on the base of well-documented precancerous lesions. In histological examination precancerous lesions show dysplasia which may be reversible. The quick and proper diagnosis allows for applying the adequate and successful treatment.

AIM

Aim of the study was to evaluate the incidence of precancerous lesions of the larynx, their potential to evolve in relation to grade of dysplasia and discuss the pathologic findings.

MATERIAL AND METHOD

Retrospective analysis of histopathological documentation and ambulatory cards gathered in ENT Department between 1994-2003 was performed. The 173 patients with dysplasia and carcinoma in situ of vocal cord were analyzed.

RESULTS

The 2719 directoscopies were performed in 10 year period. Two out of 117 patients with moderate and 5 out of 27 with severe dysplasia were treated for laryngeal cancer during the follow up period. Out of these 117 patients the group of 46 patients was chosen, in whom more then 2 microlaryngoscopies were performed (more then 3 in 71,7%) with mean follow up period 4,2 years (from 4 month to 10 years). This group of 45 males and 1 female with dysplasia was carefully analyzed. The mean age was 59,6. Hoarseness from 2 weeks to 20 years (mean 17,5 month) was observed, but most often the patients were seen by the doctor in 2 month duration of complaints. The time between first presentation in Outpatient Department and direct laryngoscopy was from 1 day to 1,5 year, but as routine 2 week period was established. In 10 cases the up-grading of dysplasia was observed. The pathologic findigs were presented.

CONCLUSIONS

Quick, adequate (sensitive, specific) diagnostics of premalignancy in the glottis allows for effective and not humiliating treatment (phonosurgery, laser, partial laryngectomy). The rigid schedule of precancerous patient's treatment and follow-up should be drowning. The further diagnostic directions should attempt to find more sensitive methods than the routine histological examination for the assessment of the dysplastic lesions, allowing better evaluation of the risk for cancer development.

Why oral histopathology suffers inter-observer variability on grading oral epithelial dysplasia: an attempt to understand the sources of variation

The present study attempted to assess the reasons behind the inter-observer variation in grading oral epithelial dysplasia (OED). Three oral pathologists and one general pathologist examined 68 histological slides of OED lesions of variable grade for scoring the presence of each individual characteristic of the architecture and cytology changes that were established by the 2005 WHO classification. The assigned features in each case were correlated with clinical outcomes to understand which features are more commonly associated with malignant transformation. Interestingly, for all individual characteristics, the pairwise inter-examiner and group kappa values ranged from poor to moderate. It appeared that for each characteristic separately there was much dissension. Despite these observations, comparing these data with that from our previous paper on the same slides showed that the inter-observer agreement on the degree of dysplasia either by using the new binary system of "low-risk" or "high-risk" or by using the 2005 WHO classification turned out to be better than the agreement on the individual characteristics of architecture and cytology changes. Certain features show significant association with the clinical outcomes. In the discussion, some explanations to help understanding the sources of variation in grading OED are put forward. In conclusion, grading dysplasia is not an exact science and pathologists are doing their best to reach optimal results. Improvement in the standard of the histopathology reporting of OED lesions could be achieved by consideration of several issues. Of these, there is need for a universal definition of the architectural and cytological features that are the basis of any OED grading process. A minimum dataset for reporting OED lesions should be set up. Also, the use of a consensus scoring process between two or more observers should be encouraged as this would improve inter-observer agreement.