Consistency of histopathological reporting of laryngeal dysplasia. The Scottish Pathology Consistency Group

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.

Predictive factors of frozen section in transoral microlaryngeal surgery for suspicious glottic lesions

OBJECTIVE

Frozen biopsy may guide surgical intraoperative decisions. We evaluated the accuracy of frozen biopsy for diagnosing benign, dysplastic and malignant laryngeal lesions, compared to paraffin section (gold standard).

METHODS

Retrospective review of the charts of all patients presenting with laryngeal lesions suspicious of malignancy, who underwent laryngeal microsurgery with frozen biopsy in our institution, between 2015 and 2020. Results of frozen biopsy and paraffin section examinations were compared.

RESULTS

Among 113 samples of 89 patients, paraffin section diagnosed 23 benign, 31 dysplastic and 59 malignant lesions. The accuracy of the frozen biopsy in identifying dysplasia or malignancy was 80.5% (91/113), and greater for lesions >5 mm (78.8% × 51.5%; p = 0.009). The positive and negative predictive values, sensitivity and specificity were 95.9%, 51.3%, 78.9% and 86.9%, respectively.

CONCLUSIONS

Frozen section is a reliable tool when malignancy is detected, but almost half of benign results exhibit dysplasia or malignancy in paraffin section. Other clinical parameters should be considered in intraoperative decisions to prevent undertreatment.

LEVEL OF EVIDENCE: 4

Recurrence and malignant transformation of laryngeal leukoplakia treated with CO2 laser: A systematic review and meta-analysis

BACKGROUND

Laryngeal leukoplakia (LL) is a white lesion with high potential of recurrence and malignant transformation. Currently, CO2 laser has become the primary surgical treatment for LL, and the recurrence and malignant transformation rates after treatment vary widely.

OBJECTIVE

We performed a systematic review and meta-analysis dedicated to evaluating the rates of recurrence and malignant transformation of LL lesions treated with CO2 laser and exploring relevant risk factors for recurrence or malignant transformation.

METHODS

Literature searches were conducted on ProQuest, PubMed, Web of Science, Ovid Medline, Embase, and Cochrane databases. Some articles identified through hand searching were included.

RESULTS

A total of 14 articles and 1462 patients were included in this review. Pooled results showed that the overall recurrence rate was 15%, and the malignant transformation rate was 3%. Subgroup analysis showed that the dysplasia grade was not a significant risk factor for the recurrence and malignant transformation of LL (P > .05).

CONCLUSIONS

The results of this systematic review and meta-analysis suggest that the CO2 laser is a safe and effective surgical instrument for the excision of LL, which yields low rates of recurrence and malignant transformation. The risk factors relevant to recurrence or malignant transformation remain unclear and require further investigation.

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.

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.

Developing Classifications of Laryngeal Dysplasia: The Historical Basis

During the last 60 years numerous significant attempts have been made to achieve a widely acceptable terminology and histological grading for laryngeal squamous intraepithelial lesions. While dysplasia was included in the pathology of the uterine cervix already in 1953, the term dysplasia was accepted in laryngeal pathology first after the Toronto Centennial Conference on Laryngeal Cancer in 1974. In 1963 Kleinsasser proposed a three-tier classification, and in 1971 Kambic and Lenart proposed a four-tier classification. Since then, four editions of the World Health Organisation (WHO) classification have been proposed (1978, 1991, 2005 and 2017). Several terms such as squamous intraepithelial neoplasia (SIN) and laryngeal intraepithelial neoplasia (LIN) are now being abandoned and replaced by squamous intraepithelial lesions (SIL). The essential change between the 2005 and 2017 WHO classifications is the attempt to induce a simplification from a four- to a two-tier system. The current WHO classification (2017) thus recommends the use of a two-tier system with reasonably clear histopathological criteria for the two groups: low-grade and high-grade dysplasia. Problems with interobserver variability apart, subjectivities and uncertainties remain, but to a lesser degree. Ongoing and additional molecular studies may help to clarify underlying events that will increase our understanding and possibly can facilitate our attempts to obtain an even better classification. The classification needs to be easier for the general pathologist to perform and easier for the clinician to interpret. These two objectives are equally important to provide each patient the best personalised treatment available for squamous intraepithelial lesions.

Laryngeal Dysplasia: Persisting Dilemmas, Disagreements and Unsolved Problems-A Short Review

We present the historical review and current state of the histopathological classifications and terminology of laryngeal precursor lesions. Attention to recent genetic findings is also presented; although in need of additional confirmation, these raise possibility for early detection of patients at risk of dysplasia progression. Although a number of identified genetic alterations with a promising diagnostic and prognostic value are emerging, none of the known genetic alterations can be currently implemented in clinical practice as a completely reliable diagnostic and/or prognostic marker. Regarding the terminology of precursor lesions, dysplasia remains the most frequently used term, but squamous intraepithelial lesion can be used as a synonym as well. Histological findings, in spite of certain degree of subjectivity, remain at present the most reliable method for an accurate diagnosis. The current 2017 WHO classification seems to successfully stratify risk of malignant progression, with a significantly different risk of malignant progression between low-grade dysplasia and high-grade dysplasia. In case of pronounced architectural disorders, severe cellular and nuclear atypias, and an increased number of mitoses, also atypical form, the high-grade dysplasia and carcinoma in situ can be separated. The Slovenian tertiary centers have a policy of surgical removal of high-grade SILs and life-long close follow-up. Radiotherapy is reserved for more pronounced intraepithelial lesions classified as carcinoma in situ and invasive cancer. Such a distinction can facilitate clinical decision to use radiotherapy if complete surgical removal is not possible.

Cytokeratin 19 Immunostain Reduces Variability in Grading Epithelial Dysplasia of the Non-Keratinized Upper Aerodigestive Tract Mucosa

Epithelial dysplasia (ED) grading systems are criticized for low reliability. The effects of diagnostic tests or stains on reducing examiner variability in grading ED of the upper aerodigestive tract have not been investigated. The study aim was to examine the effectiveness of cytokeratin 19 (K19) immunostain on enhancing inter and intraexaminer reliability of ED grading and to reiterate the relation of K19 positivity with epithelial keratinization. The study sample consisted of 122 paraffin blocks that fulfilled the inclusion criteria. Each paraffin block had three sections cut: one immunostained for K19 and two for hematoxylin and eosin stain (H&E). Each examiner graded the study sample in six rounds; three using H&E stain only and three using paired K19-H&E stains. The study examiners were three American-Board certified practicing oral pathologists. The results were analyzed using Krippendorff's alpha, ROC curve, Chi square test and binary logistic regression. Upon the use of paired K19-H&E stains the results showed that the intraexaminer reliability coefficients of grading were improved from 0.70, 0.69, 0.78 to 0.73, 0.88, 0.91 for examiners 1, 2, and 3 respectively. Reliability coefficients for inter-examiners improved from 0.55 to 0.73 (Krippendorff alpha). The accuracy of identifying the diseased cases (high-grade dysplasia) increased from 0.82 to 0.94 (ROC curve). Binary logistic regression revealed that K19 positivity is negatively associated with hyperkeratinization of surface epithelium (P = 0.001). To conclude, for grading non-keratinized epithelial dysplastic lesions of the upper aerodigestive tract, paired K19-H&E stains proved to reduce inter and intra-examiner variability by highlighting the extension of dysplastic epithelial cells within epithelial thickness, thus identifying the involved epithelial third and assigning a more reliable and better reproducible grade.

The White Lesion, Hyperkeratosis, and Dysplasia

Laryngeal mucosal precursor lesions represent a challenging clinical entity. Updated classification systems allow for grade-based categorization. Multiple management options exist, with treatment decisions made jointly by physician and patient and focused on both appropriate lesion treatment and preservation of laryngeal structure and function. Traditional methods include cold steel and CO₂ laser excision, with newer modalities using angiolytic lasers for lesion ablation. Both operating room-based and office-based treatment options exist, and there are advantages and disadvantages to each approach. Research is ongoing to advance the understanding of lesion biology, and to optimize prevention and treatment.

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 precursor lesions: Interrater and intrarater reliability of histopathological assessment

OBJECTIVE

The World Health Organization classification (WHOC) 2017 of low-grade versus high-grade laryngeal dysplasia recently replaced the previous WHOC 2005 of mild, moderate, and severe dysplasia and carcinoma in situ. Our objectives were to compare the interrater agreement of the WHOC 2017 with that of the WHOC 2005 and to test the intra-rater agreement of the WHOC 2005.

METHODS

Two expert head and neck pathologists rated 211 tissue samples that were initially diagnosed with laryngeal precursor lesions. The samples were rated twice according to the WHOC 2005 and once according to the WHOC 2017; estimates of interrater and intrarater agreements were calculated with kappa statistics.

RESULTS

The crude intrarater agreements using the WHOC 2005 were 0.93 for rater 1 and 0.62 for rater 2. The corresponding unweighted kappa values were 0.90 (95% confidence interval [CI], 0.86-0.95) for rater 1 and 0.43 (95% CI, 0.35-0.54) for rater 2, whereas the standard linear weighted kappa values were 0.93 (95% CI, 0.90-0.97) for rater 1 and 0.60 (95% CI, 0.53-0.69) for rater 2. The crude interrater agreement for the WHOC 2005 was 0.57, with a corresponding unweighted kappa value 0.38 (95% CI, 0.31-0.48) and a standard linear weighted kappa value 0.52 (95% CI, 0.42-0.60). The crude interrater agreement for the WHOC 2017 was 0.83, with a corresponding unweighted kappa value 0.45 (95% CI, 0.31-0.59) and a standard linear weighted kappa value 0.46 (95% CI, 0.30-0.60).

CONCLUSION

Our results indicate difficulties in providing reliable diagnosis of laryngeal precursor lesions, even with experienced head and neck pathologists and the application of a newly revised classification system.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:2375-2379, 2018.

[Reconstruction of the examination of the laryngeal carcinoma of Emperor Frederick III by Rudolf Virchow]

Rudolf Virchow is one of the founders of modern pathology, and many of his ideas on inflammatory and neoplastic diseases are still valid today. Even for Virchow, determination of malignancy was not always easy. As an example, the laryngeal disease of Crown Prince Frederick William, the later Emperor Frederick III, is presented.The clinical findings at the beginning of the disease were suggestive of a carcinoma, though an inflammatory lesion was also discussed. Several attempts were made to remove the lesion bioptically, but local recurrences occurred and the first tissue samples were not examined histopathologically. Since laryngeal tumour operations had a high mortality at that time, histopathologic examinations were made in order to decide for or against an operation. The samples taken after pre-treatment did not meet Virchow's criteria for determining a carcinoma. Contrary to the present concept of a carcinoma in situ-carcinoma sequence, Virchow's concept was based on the assumption that carcinomas are not derived from the epithelium, but arise from a mesenchymal-epithelial transformation from the connective tissue. The clinical suspicion of a laryngeal carcinoma was confirmed only shortly before the patient's death and later by a post-mortem examination.The question repeatedly asked is whether Virchow should have diagnosed a carcinoma at the beginning of the disease. The answer has been the same for more than a hundred years: the clinician is dissatisfied with the histopathological diagnosis, so the pathologist is to blame.

Update from the 4th Edition of the World Health Organization Classification of Head and Neck Tumours: What is New in the 2017 WHO Blue Book for Tumours of the Hypopharynx, Larynx, Trachea and Parapharyngeal Space

Chapter 3 "Tumours of the hypopharynx, larynx, trachea, and parapharyngeal space" of the World Health Organization (WHO) Blue Book 2017 "Classification of Head and Neck Tumours" shows a shortened list of entities, especially due to reducing the number of benign and malignant soft tissue tumours, malignant melanoma and some others, which are transferred to more frequently affected regions of the head and neck. The basic concept of the new edition is to assimilate all advances concerning the discussed tumours in a shorter framework, appropriate for daily work. The main emphasis is on the most frequent lesions and tumors originating from the covering squamous epithelium. Laryngeal and hypopharyngeal conventional squamous cell carcinoma (CSCC), its variants and precursor lesions, occupy a major part of the chapter. New data on etiopathogenesis, with the focus on human papillomavirus (HPV) infection, are discussed in relation to the entities of the squamous epithelium. Although only a small fraction of these lesions are HPV-related, further studies are required for evaluation of the potential prognostic and therapeutic benefit of mRNA HPV determination. In contrast to earlier data, laryngeal and hypopharyngeal verrucous SCC, spindle cell SCC and basaloid SCC are not anymore considered as HPV-related tumours. New data on the pathogenesis of spindle cell SCC exhibiting divergent differentiation by epithelial-mesenchymal transition, are also briefly discussed. The most important innovation is brought by the section on precursor lesions, in which a unified two-tier classification, consisting of low- and high-grade dysplasia, is introduced. The proposed two-tier system can also be transformed into a three-tier classification for treatment purposes, with a distinction between carcinoma in situ and high-grade dysplasia. The reviewed morphological criteria of the proposed system are based on the amended Ljubljana classification. The section on laryngeal neuroendocrine carcinomas (NEC) represents a considerable improvement in terminology and classification. NEC are divided into well-, moderate- and poorly-differentiated neuroendocrine carcinoma. The latter is additionally divided into small cell NEC and large cell NEC (LCNEC). It is of extreme importance that LCNEC, which was associated in the WHO 2005 edition with atypical carcinoid/moderately differentiated neuroendocrine carcinoma, grade II, has now been transferred into the group of poorly differentiated NEC, grade III, displaying a specific morphology and poorer prognosis.

Laryngeal Squamous Intraepithelial Lesions: An Updated Review on Etiology, Classification, Molecular Changes, and Treatment

Laryngeal carcinogenesis is a multistep process, characterized by an accumulation of genetic changes associated with architectural and cytologic alterations, ranging from squamous hyperplasia to carcinoma in situ and encompassed by the terminology of squamous intraepithelial lesions (SILs). The etiology, classification, genetic changes, and malignant progression of these lesions are reviewed. Tobacco remains the principal etiological factor with gastroesophageal reflux disease recently considered as a possible factor. In contrast, there is little evidence that microbiological agents, especially human papillomavirus infection, are frequently involved in laryngeal carcinogenesis and probably <10% of SILs are driven by biologically active human papillomavirus infection. Light microscopy, despite a degree of subjectivity, remains the mainstay of accurate diagnosis, prognosis, and guidance for a patient's treatment. The currently used classifications, the dysplasia system, squamous intraepithelial neoplasia, and the Ljubljana classification, reflect different standpoints on this important topic. The modified Ljubljana classification, with good interobserver agreement, could be considered as a proposal for a unified classification of laryngeal SILs. This review also briefly discusses recently discovered genetic changes, such as CDKN2A and CTNNB1 genes, and chromosome instability of chromosomes 1 and 7; however, none of these can at present improve histologic diagnosis. Malignant progression of precursor lesions varies from 2% to 74%, according to different studies. Cold-steel microinstruments, CO2 laser, and radiotherapy are used to treat the different grades of precursor lesions. There is as yet no worldwide agreement on the treatment of high-grade lesions and carcinoma in situ.

Laryngeal Papillomatosis Associated Dysplasia in the Adult Population

Objectives:

The objectives were to determine the prevalence of laryngeal dysplasia and associated human papilloma virus (HPV) subtypes in adult patients, 18 years or older, suffering from laryngeal papillomatosis at a tertiary care institution.

Study Design:

Retrospective cohort study.

Methods:

Patients with biopsy proven laryngeal papillomatosis were identified via chart review. All available pathology specimens were reviewed by a dedicated head and neck pathologist to confirm/refute the diagnosis of laryngeal dysplasia, and grade the level of dysplasia. Interrater agreement was compared using cross-tabulation methods. Specimens identified to be positive for dysplasia underwent further testing via in situ hybridization for low-risk (6/11) or high-risk (16/18) HPV subtypes.

Results:

Of the 85 subjects identified to have laryngeal papillomatosis, 24(28%) demonstrated laryngeal dysplasia. There was good interrater agreement on the presence of dysplasia; however, there was only fair agreement on the grade of dysplasia. Of the pathology specimens tested for HPV subtype, the majority of patients (62%) were positive for HPV 6/11, including all high-grade dysplasia patients. Three (12%) dysplasia specimens were negative for both high- and low-risk HPV subtypes.

Conclusions:

We found a 28% prevalence of dysplasia in our patient population with the majority of patients positive for low-risk HPV subtypes indicating that high-risk HPV subtypes do not predispose laryngeal papilloma patients to dysplasia.

Current views and perspectives on classification of squamous intraepithelial lesions of the head and neck

The current state in the field of classifying oral and laryngeal precursor lesions, as proposed in the WHO 2005 Blue Book is not ideal. The results of various inter-observer studies have shown that the currently used grading systems, with different basic concepts and different terminology, cannot continue to be reliably used in the future. The different etiology of cervical and head and neck precursor lesions requires a classification designed to cater to the specificities of the head and neck region. Trying to harmonize different classifications of the oral and laryngeal precursor lesions, we have proposed four crucial steps to set up a unified classification of squamous intraepithelial lesions (SILs): (a) the classification should contain two grades, low-grade and high-grade lesions and, specifically for the larynx, an additional grade-carcinoma in situ (CIS) which must be separated from high-grade laryngeal SILs; (b) the terminology should be unified; our preference is for the term SIL over squamous intraepithelial neoplasia; (c) all leading morphological criteria for low- and high-grade lesions, as well as for CIS, should be clearly defined; (d) agreement between clinicians and pathologists should be achieved on the most appropriate choice of treatment of different grades of SILs in separate head and neck areas.

Diagnostic Variability of Laryngeal Premalignant Lesions

Objective

This study was to analyze the interobserver histopathological variability and carcinoma transformation of laryngeal premalignant lesions.

Study Design

A historical cohort study.

Setting

Department of Pathology, Beijing TongRen Hospital, Capital Medical University, Beijing, China.

Subjects and Methods

κ-statistics analysis was performed to estimate interobserver histopathological variability among pathologists by reassessment of 237 cases with laryngeal premalignant lesion according to 2005 WHO classification system. A retrospective follow-up of 237 patients over 8-year duration was carried out, and the carcinoma transformation of laryngeal premalignant lesions was analyzed using Kaplan-Meier survival curve estimation.

Results

κ-values of 0.5989 concerning interobserver variability indicated a moderate agreement among 3 pathologists. Major source of intergrade diagnostic disagreement between the original and the consensus diagnoses involved 2 grade pairs, namely, mild and moderate dysplasia, severe dysplasia, and carcinoma in situ. In addition, follow-up study showed that 20 of 237 (8.44%) laryngeal premalignant lesion cases developed into invasive carcinoma. Carcinoma transformation in severe dysplasia group exhibited a similar risk compared to that in carcinoma in situ group ( P = .232).

Conclusion

Severe dysplasia shows the same carcinoma transformation potential as the carcinoma in situ does. Clinically, more attention to severe dysplasia is needed in comparison with mild and moderate dysplasia.

Expression of cancer/testis (CT) antigens in squamous cell carcinoma of the head and neck: evaluation as markers of squamous dysplasia

Cancer/testis (CT) antigens, normally only expressed in germ cells of adult testis, can be activated in malignancy as tumor-specific antigens. The potential value of CT antigens as biomarkers in the evaluation of mucosal squamous precursor lesions of the head and neck has not been investigated. The expression of 8 CT antigens (MAGE-A, GAGE, NY-ESO-1, CT7, CT10, SAGE1, CT45 and NXF2) in 76 cases of invasive head and neck squamous cell carcinoma (SCC) was evaluated immunohistochemically. 65 mucosal biopsies of squamous dysplasia and 55 squamous papillomas with dysplasia were analyzed for 6 CT antigens, using an antibody cocktail. Of invasive SCC, 66% (50/76) expressed at least one CT antigen, most commonly MAGE-A (47%). Among the biopsies, only 1 of 55 squamous papillomas was CT-positive, whereas 8 of 65 (12%) squamous dysplasia lesions were CT-positive. These 8 CT-positive biopsies were from 6 patients, 3 of which had concurrent or subsequent SCC. CT antigens are frequently expressed in head and neck SCC; however, there was no difference in the clinicopathological characteristics or behavior of CT-positive tumors compared to CT-negative tumors. The usefulness of CT antigens as positive predictors for SCC in squamous dysplasia biopsies remains to be determined by long-term follow-up in larger cohorts.

The binary oral dysplasia grading system: validity testing and suggested improvement

OBJECTIVES

A binary system is reputed to be superior to the World Health Organization (WHO) system in grading oral dysplasia. We aimed to validate its reproducibility and prognostic ability and examine whether it could be improved.

STUDY DESIGN

Three pathologists graded 141 oral epithelial dysplasia biopsies with the use of both systems. Observer variability and prognostic ability were assessed with the use of kappa and logistic regression models.

RESULTS

The binary system showed superior agreement to the WHO system (multirater kappa 0.59 vs. 0.49, respectively) but similar prognostic ability (odds ratio [OR] 4.59 [P = .014] vs. OR 2.25 [P = .02], respectively). Adding smoking and alcohol slightly improved the prognostic ability of both systems (OR 5.10 vs. OR 2.42, respectively). Our new binary system with a refined diagnostic threshold demonstrated a slightly greater prognostic ability and improved ability to differentiate between high- and low-risk moderate dysplasia cases.

CONCLUSIONS

The binary system has similar prognostic ability but superior reproducibility compared with the WHO system. Prognostication is improved still further by using a new threshold.

Alterations in the immunoexpression of galectins-1, -3 and -7 between different grades of oral epithelial dysplasia

INTRODUCTION

Oral epithelial dysplasia (OED) is a potentially malignant lesion characterized by a combination of cytological and architectural anomalies, which are essential for its diagnosis. Galectins are proteins that participate in cell cycle, adhesion and differentiation, apoptosis, and immune responses, as well as in cancer development and progression.

MATERIALS AND METHODS

The aim of this study was to analyze the immunohistochemical expression of galectins-1, -3, and -7 in the OED (21 low risk and 29 high risk) and normal oral mucosa (NOM). The binary grading system was used.

RESULTS

Galectin-1 was expressed in the middle/lower third in most OED cases. Nuclear/cytoplasmic staining was observed in most low-risk and high-risk OEDs. All cases of NOM were negative for galectin-1. Galectin-3 was expressed in the middle/lower third in most low-risk cases. Nuclear/cytoplasmic staining was noted in most low-risk and high-risk OEDs. Middle/lower third and in membrane staining was detected in four cases of NOM for galectin-3. Galectin-7 was expressed in the upper/middle third in most of OED cases. Nuclear/cytoplasmic staining predominated in low-risk and high-risk OEDs. Galectin-7 was detected in four cases of NOM, all of them presenting staining in the upper/middle third and in the membrane.

CONCLUSION

The differences in the immunoexpression of galactin-1, -3, and -7 between different grades of OEDs suggest the involvement of this protein in the progression of dysplasias.

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.

Oral premalignant lesions: from the pathological viewpoint

Under the widely used World Health Organization (WHO) classification for the pathological diagnosis of oral premalignant lesions, dysplasia, which is graded as mild, moderate or severe, and carcinoma in situ (CIS), which is a non-invasive carcinoma, are classified as precursor lesions of oral squamous cell carcinoma. Since the first edition (Wahi et al. International histological classification of tumours no. 4, WHO, Geneva, 1971), the criterion for CIS--that all epithelial layers are replaced by atypical cells--has remained unchanged. However, this dysplasia-carcinoma sequence theory was introduced from the viewpoint of pathological changes in the uterine cervix: in contrast, almost all premalignant lesions and CIS of the oral mucosa show superficial maturation and differentiation. Based on this recognition, the squamous intraepithelial neoplasia (SIN) classification and Ljubljana classification were included in WHO's latest edition published in 2005. Although the WHO classification is commonly used in Japan, recent developments in oral oncology have promoted modifications of the classification used in this country. In 2005, the Working Group of the Japan Society for Oral Tumours advocated iodine staining and proposed a modified SIN system, and in 2007, the Working Committee of the Japanese Society for Oral Pathology (JSOP) reported a new CIS (JSOP) definition that included differentiated-type CIS. In 2010, based on these studies, a new entity--oral intraepithelial neoplasia (OIN)--was included in the first edition of General Rules for Clinical and Pathological Studies on Oral Cancer. In this review, we focus on the OIN/CIS (JSOP) new classification of premalignant lesions in oral mucosa, which further advances the concept of SIN.

Early detection in head and neck cancer - current state and future perspectives

Survival and quality of life in head and neck cancer are directly linked to the size of the primary tumor at first detection. In order to achieve substantial gain at these issues, both, primary prevention and secondary prevention, which is early detection of malignant lesions at a small size, have to be improved. So far, there is not only a lack in the necessary infrastructure not only in Germany, but rather worldwide, but additionally the techniques developed so far for early detection have a significance and specificity too low as to warrant safe implementation for screening programs. However, the advancements recently achieved in endoscopy and in quantitative analysis of hypocellular specimens open new perspectives for secondary prevention. Chromoendoscopy and narrow band imaging (NBI) pinpoint suspicious lesions more easily, confocal endomicroscopy and optical coherence tomography obtain optical sections through those lesions, and hyperspectral imaging classifies lesions according to characteristic spectral signatures. These techniques therefore obtain optical biopsies. Once a "bloody" biopsy has been taken, the plethora of parameters that can be quantified objectively has been increased and could be the basis for an objective and quantitative classification of epithelial lesions (multiparametric cytometry, quantitative histology). Finally, cytomics and proteomics approaches, and lab-on-the-chip technology might help to identify patients at high-risk. Sensitivity and specificity of these approaches have to be validated, yet, and some techniques have to be adapted for the specific conditions for early detection of head and neck cancer. On this background it has to be stated that it is still a long way to go until a population based screening for head and neck cancer is available. The recent results of screening for cancer of the prostate and breast highlight the difficulties implemented in such a task.

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.

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.

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.

The diagnostic concordance of actinic keratosis and squamous cell carcinoma

Diagnostic concordance of intraepithelial malignancy is generally only fair. Because the diagnosis of actinic keratosis (AK) and squamous cell carcinoma (SCC) is not uniform and because such terms are not consonant with the nomenclature of other human epithelial malignancies, nomenclature revisions have been attempted. One hundred dermatopathologists were solicited to review 15 tissue sections representing a spectrum of varying thickness epidermal malignancy and to choose either AK or SCC as the diagnosis. Among the 77 participating dermatopathologists, intraclass correlation was high for what was perceived as AK, SCC, and their differentiation. Development of a two-tiered diagnostic system that retains our present diagnostic capabilities, but better fits the pathobiology of superficial epidermal malignancy is suggested. Davis DA, Donahue JP, Bost JE, Horn TD. The diagnostic concordance of actinic keratosis and squamous cell carcinoma.

Size, shape, structure, and direction of angiogenesis in laryngeal tumour development

AIMS

Angiogenesis and vessel organisation in laryngeal tumour development and progression were examined to determine characteristics of biological and clinical relevance.

METHODS

Automated quantitative image analysis was performed on 1451 factor VIII (FVIII) associated blood vessels with regard to occurrence, structure, size, shape, and staining intensity, in addition to vessel direction.

RESULTS

Vessel numbers were increased in preneoplastic states and severe dysplasia, in addition to squamous cell carcinomas, being greater in poorly differentiated carcinomas. Small regular vessels predominated in benign conditions and large, irregular vessels in malignant neoplasms. Vessel distribution was related to degree of differentiation in squamous cell carcinomas, with circumferential angiogenesis occurring in well differentiated neoplasms, directional angiogenesis in moderately differentiated tumours, and aberrant angiogenesis in less well differentiated neoplasms. Alterations in vessel shape increased significantly with increasing degree of malignancy. Comparing the characteristics of individual vessels showed vessel shape abnormalities and the intensity of FVIII staining to increase with vessel size.

CONCLUSIONS

Increased angiogenesis was an early event in laryngeal tumour development, with vessel structure, size, and shape related to the tumour growth pattern and behaviour.

Observer variability in the Goseki grouping of gastric adenocarcinoma in resection and biopsy specimens

AIMS

The Goseki grouping of gastric adenocarcinoma has been suggested as a possible prognostic factor. In those centres where it is used, it may be valuable to assess the Goseki grouping of a tumour on the initial diagnostic biopsy as well as on the resection specimen since it may in theory influence management. We examined the robustness of Goseki grouping of gastric adenocarcinoma in representative sections from resection and biopsy specimens in order to assess the consistency of agreement among a group of pathologists.

METHODS

A single representative block from 100 gastric resection specimens was studied using a haematoxylin and eosin and mucin (alcian blue/periodic acid-Schiff) stain. These were circulated in batches to members of a group of 12 pathologists who each completed a simple proforma confirming the presence of carcinoma and assigning a Goseki group. In a second circulation the diagnostic biopsy specimen taken prior to resection was examined in the same way. This allowed comparison of the Goseki group of the biopsy and resection specimens.

RESULTS

In both studies kappa statistics showed good agreement on tubular differentiation of the carcinoma, but only moderate agreement for the intracellular mucin production, resulting in moderate agreement for the final Goseki group. Correlation between the Goseki group assigned on the biopsy and resected specimens was seen in 62% of the cases. However, the reproducibility was low (kappa 0.375).

CONCLUSIONS

The Goseki grouping of resected gastric adenocarcinoma is reproducible and can be used in prognostication. Goseki grouping of biopsy specimens is of limited value in predicting the Goseki group assigned to the resected carcinoma.

Symposium part 2: Should the Bethesda System terminology be used in diagnostic surgical pathology?: Counterpoint

The criteria currently used for grading cervical intraepithelial neoplasia (CIN) are arbitrary and subjective with consequent considerable intra- and interobserver variability. None of the currently used criteria make a clear-cut case for changing terminology. The combination of CIN 2 and CIN 3 into a high-grade lesion is not supported by biologic behavior or HPV typing and leads to overtreatment. The various shifts in nomenclature over the last 50 years through the dysplasia, CIN, and Bethesda systems, although intellectually stimulating, have neither improved diagnostic accuracy nor patient management. On the contrary, they often caused confusion and duplication, leading to the common and ironic practice that several terminologies are now being used in an additive fashion. New diagnostic markers are on the horizon as a result of the rapid development in the areas of genomics and proteomics. It seems likely that specific molecular biomarkers will become available, allowing the consistent and accurate discrimination between those intraepithelial lesions that will ultimately become invasive from the vast majority of lesions that will regress or persist. It is preferable at this time to maintain the current three-tier system, which is well entrenched and accepted around the world, until a novel approach places the classification of cervical precursor lesions on a new and solid footing. Ideally, we will then have a single-tier system identifying reliably those lesions that have the potential to become invasive.

Premalignant lesions of the oral mucosa. A discussion about the place of oral intraepithelial neoplasia (OIN)

Oral precancerous lesions are traditionally classified as leukoplakia, erythroplakia, erythroleukoplakia, and distinguished from precancerous conditions. Major attention is focused on leukoplakia, and no distinction made whether dysplasia is or not present. Malignant transformation is a multistep process that should be approached also from the histological, and not merely from the clinical standpoint. Intraepithelial neoplasia, a notion created for the uterine cervix and already extended to other mucosae, should be adapted to the oral mucosa and used as diagnostic term. OIN (oral intraepithelial neoplasia) is not only a change in terminology, but also a progress in the unifying concept of precursors of squamous cell carcinoma, suppressing the useless discussion between severe dysplasia and carcinoma in situ. Furthermore, grading lesions as low or high grade OIN increases diagnostic consistency. OIN is suspected on three clinical patterns reflecting histological changes: mosaic, irregular keratosis, erythroplakia (or intermediate aspects), but dysplastic mucosa may also appear normal clinically.