The risk and interval to malignancy of patients with laryngeal dysplasia; a systematic review of case series and meta-analysis

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.

Multi-instance learning based artificial intelligence model to assist vocal fold leukoplakia diagnosis: A multicentre diagnostic study

OBJECTIVE

To develop a multi-instance learning (MIL) based artificial intelligence (AI)-assisted diagnosis models by using laryngoscopic images to differentiate benign and malignant vocal fold leukoplakia (VFL).

METHODS

The AI system was developed, trained and validated on 5362 images of 551 patients from three hospitals. Automated regions of interest (ROI) segmentation algorithm was utilized to construct image-level features. MIL was used to fusion image level results to patient level features, then the extracted features were modeled by seven machine learning algorithms. Finally, we evaluated the image level and patient level results. Additionally, 50 videos of VFL were prospectively gathered to assess the system's real-time diagnostic capabilities. A human-machine comparison database was also constructed to compare the diagnostic performance of otolaryngologists with and without AI assistance.

RESULTS

In internal and external validation sets, the maximum area under the curve (AUC) for image level segmentation models was 0.775 (95 % CI 0.740-0.811) and 0.720 (95 % CI 0.684-0.756), respectively. Utilizing a MIL-based fusion strategy, the AUC at the patient level increased to 0.869 (95 % CI 0.798-0.940) and 0.851 (95 % CI 0.756-0.945). For real-time video diagnosis, the maximum AUC at the patient level reached 0.850 (95 % CI, 0.743-0.957). With AI assistance, the AUC improved from 0.720 (95 % CI 0.682-0.755) to 0.808 (95 % CI 0.775-0.839) for senior otolaryngologists and from 0.647 (95 % CI 0.608-0.686) to 0.807 (95 % CI 0.773-0.837) for junior otolaryngologists.

CONCLUSIONS

The MIL based AI-assisted diagnosis system can significantly improve the diagnostic performance of otolaryngologists for VFL and help to make proper clinical decisions.

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

Treatment experience with and clinicopathological analysis of vocal fold leukoplakia per appearance classification guidance: a cohort of 1442 patients

OBJECTIVE

To analyse the comparative clinical outcomes and clinicopathological significance of vocal fold leukoplakia lesions treated by appearance classification and traditional methods.

METHOD

A total of 1442 vocal fold leukoplakia patients were enrolled. Group A patients were treated according to appearance classification and Group B patients were treated according to traditional methods.

RESULTS

In Group A, 24.4, 14.9 and 60.6 per cent of patients had grade I, II and III dysplasia, respectively. Grade I dysplasia (63.4 per cent) was more than twice as frequent in Group B patients than in Group A patients, while grade II dysplasia (20.4 per cent) and grade III dysplasia (16.2 per cent) were significantly less frequent in Group B patients than in Group A patients (p = 0.000). There was a significant correlation between vocal fold leukoplakia appearance and the degree of dysplasia (p = 0.000). The recurrence and malignant transformation rates (17.6 and 31 per cent, respectively) in Group B were significantly greater than those in Group A (10.8 and 25.9 per cent, respectively) (p = 0.000).

CONCLUSION

Vocal fold leukoplakia appearance classification is useful for guiding treatment decision-making and could help to improve therapeutic accuracy.

I-scan combined with laryngovideostroboscopy for predicting malignancy in vocal fold leukoplakia

OBJECTIVE

This study evaluated vocal fold leukoplakia using i-scan combined with laryngovideostroboscopy for risk assessment prediction.

METHODS

A total of 141 patients with 218 lesions were enrolled in this study. Morphological characteristics of leukoplakia, assessment of the vascular pattern using i-scan, and vocal fold vibratory function were analyzed.

RESULTS

The number of patients with no, mild, moderate, severe dysplasia, and invasive carcinoma were 68, 40, 17, 46 and 47, respectively. The sensitivity of morphological characteristic, vascular pattern, vibratory function and predictive model were 77.4%, 72%, 69.9%, and 82.8%, respectively. Receiver operating characteristic curve analysis of morphological characteristic, vascular pattern, vibratory function and predictive model were 0.771, 0.824, 0.769, and 0.923, respectively. The results of logistic regression analysis showed that rough morphological types, perpendicular vascular pattern, severe decrease and absence of mucosal waves increased the risk of malignancy (OR = 5.531, 4.973, and 16.992, respectively; P < 0.001).

CONCLUSIONS

I-scan combined with laryngovideostroboscopy can improve the differential diagnosis of low-risk and high-risk vocal fold leukoplakia.

Laryngoscopy-based scoring system for the diagnosis of vocal fold leukoplakia

OBJECTIVE

To propose a scoring system based on laryngoscopic characteristics for the differential diagnosis of benign and malignant vocal fold leukoplakia.

METHODS

Laryngoscopic images from 200 vocal fold leukoplakia cases were retrospectively analysed. The laryngoscopic signs of benign and malignant vocal fold leukoplakia were compared, and statistically significant features were assigned and accumulated to establish the leukoplakia finding score.

RESULTS

A total of five indicators associated with malignant vocal fold leukoplakia were included to construct the leukoplakia finding score, with a possible range of 0-10 points. A score of 6 points or more was indicative of a diagnosis of malignant vocal fold leukoplakia. The sensitivity, specificity and accuracy values of the leukoplakia finding score were 93.8 per cent, 83.6 per cent and 86.0 per cent, respectively. The consistency in the leukoplakia finding score obtained by different laryngologists was strong (kappa = 0.809).

CONCLUSION

This scoring system based on laryngoscopic characteristics has high diagnostic value for distinguishing benign and malignant vocal fold leukoplakia.

Vocal fold leukoplakia recurrence risk model

The paper aims to define the variables that elevate the risk of VFL recurrence after adequate primary treatment, and to present the Recurrence Risk Model with practical conclusions to handle pVFL and rVFL. Out of 207 patients with primary vocal fold leukoplakia (pVFL), in 41 (19.8%) recurrent VFL (rVFL) was diagnosed. All patients were assessed by using a trans-nasal flexible video-endoscope using white light, and NBI. The primary measure of our study was to investigate whether morphological features of pVFL in WL, vascular pattern in NBI, and primary histological findings could predict VFL recurrence. To create a model of risk factors, two methods were used: logistic regression and a conditional inference decision tree. The study showed smoking was the factor that significantly and most strongly increased the likelihood of rVFL, as well as the older age groups have a greater odds of rVFL. Types IV, V and VI, according to Ni 2019 classification, were associated with a significantly higher risk of rVFL. The algorithm combining patients' dependent variables and the combination of two classifications improves the predictive value of the presented VFL Recurrence Risk Model.

Oncological outcomes and failure patterns of laser cordectomy in recurrent glottic cancer

PURPOSE

Laser cordectomy is a widely accepted treatment modality for selected cases of early glottic cancers, but its role as a salvage treatment remains unclear. We aimed to investigate the oncological outcomes and failure patterns of salvage cordectomy.

MATERIALS AND METHODS

This was a retrospective cohort study of patients who underwent cordectomy for early glottic cancer between 2013 and 2022 at a tertiary referral center. The main outcome measures were overall survival, larynx-preservation rate, tracheostomy dependency rate, and disease-free survival.

RESULTS

A total of 142 patients (mean age: 63 years, interquartile range [IQR]: 45-72, 123[86.9 %] males) were analyzed. There were 38 (26.8 %) recurrences after a mean of 22 months (IQR: 17-26). Among them, 25 (17.6 %) underwent salvage cordectomy, while 13 (9.1 %) received other salvage treatments (11[7.7 %] (chemo)radiotherapy and 2[1.4 %] total laryngectomy). In comparison to the other salvage treatments, salvage cordectomy demonstrated lower tracheostomy rates (0 vs. 31 %, p = 0.05), comparable 5-year disease-free survival (62 % vs. 54 %, p = 0.4), higher 5-year larynx preservation rate (92 % vs. 54 %, p = 0.02), and improved 5-year overall survival rate (84 % vs. 62 %, p = 0.01). Factors associated with salvage cordectomy failure were age >60 years (odds ratio [OR]: 1.3, 95 % confidence interval [CI]: 1.15-1.53), smoking continuation (OR: 3.73, 95 % CI: 3.5-4.4), heavy smoking (OR: 1.24, 95 % CI:1.07-2.15), and pT1b + (OR: 2.26, 95 % CI: 2.1-2.9).

CONCLUSIONS

Salvage cordectomy offers favorable larynx preservation rates and oncological outcomes for recurrent disease amenable to conservative surgery. Smoking, advanced age, and advanced tumor stages are associated with salvage cordectomy failure.

Comparison of non-laser and laser transvenous lead extraction: a systematic review and meta-analysis

AIMS

Transvenous lead extraction (TLE) is performed using non-laser and laser techniques with overall high efficacy and safety. Variation in outcomes between the two approaches does exist with limited comparative evidence in the literature. We sought to compare non-laser and laser TLE in a meta-analysis.

METHODS AND RESULTS

We searched Medline, Embase, Scopus, ClinicalTrials.gov, and CENTRAL databases for TLE studies published between 1991 and 2021. From the included 68 studies, safety and efficacy data were carefully evaluated and extracted. Aggregated cases of outcomes were used to calculate odds ratio (OR), and pooled rates were synthesized from eligible studies to compare non-laser and laser techniques. Subgroup comparison of rotational tool and laser extraction was also performed. Non-laser in comparison with laser had lower procedural mortality (pooled rate 0% vs. 0.1%, P < 0.01), major complications (pooled rate 0.7% vs. 1.7%, P < 0.01), and superior vena cava (SVC) injury (pooled rate 0% vs. 0.5%, P < 0.001), with higher complete success (pooled rate 96.5% vs. 93.8%, P < 0.01). Non-laser comparatively to laser was more likely to achieve clinical [OR 2.16 (1.77-2.63), P < 0.01] and complete [OR 1.87 (1.69-2.08), P < 0.01] success, with a lower procedural mortality risk [OR 1.6 (1.02-2.5), P < 0.05]. In the subgroup analysis, rotational tool compared with laser achieved greater complete success (pooled rate 97.4% vs. 95%, P < 0.01) with lower SVC injury (pooled rate 0% vs. 0.7%, P < 0.01).

CONCLUSION

Non-laser TLE is associated with a better safety and efficacy profile when compared with laser methods. There is a greater risk of SVC injury associated with laser sheath extraction.

Analysis of prognostic factors for vocal fold leukoplakia based on 344 cases at a two-year follow up

OBJECTIVE

To evaluate risk factors for poor prognosis in vocal fold leukoplakia.

METHODS

Clinical data were collected for 344 patients with vocal fold leukoplakia who received surgical treatment in our otolaryngology department from October 2010 to June 2019. Univariate and multivariate logistic regression analyses of the relevant factors were conducted.

RESULTS

Among the 344 patients, 98 exhibited recurrence and 30 underwent a malignant change. Multivariate logistic regression analysis showed that size of the lesion (p = 0.03, odds ratio = 2.14), form of the lesion under white light (p < 0.001), surgical method (p < 0.001, odds ratio = 0.28) and pathological type (p < 0.001) were independent factors that affected the recurrence of vocal fold leukoplakia. In both univariate and multivariate analyses, the sole independent risk factor for malignant transformation of vocal fold leukoplakia was pathological type (p < 0.001).

CONCLUSION

The outlook for vocal fold leukoplakia depends on several clinical factors, especially pathological type. The more severe the pathological type, the more likely it is to recur or become cancerous.

Malignant Transformation and Long-Term Outcome of Oral and Laryngeal Leukoplakia

BACKGROUND

Oral or laryngeal leukoplakia has an increased risk for malignant transformation but the risk of the two anatomical sites has not been compared to each other yet.

MATERIALS AND METHODS

Clinical data of 253 patients with leukoplakia (oral = 221 or laryngeal = 32) enrolled from January 1996 to January 2022 were analyzed. One hundred and seventy underwent biopsy and 83 did not. The mean follow-up time was 148.8 months. Risk factors for the malignant transformation of leukoplakia were identified using Cox proportional hazard models.

RESULTS

In the oral or laryngeal group, the rate of cancer was 21.7% and 50% (p = 0.002), respectively. The 10-year estimated malignant transformation was 15.1% and 42% (p < 0.0001), respectively. The laryngeal group had an increased risk of malignant transformation (p < 0.0001). The 5-year estimated survival with leukoplakia-associated cancer for the oral or laryngeal group was 40.9% and 61.1% (p = 0.337), respectively. Independent predictors of malignant transformation in the oral group were dysplasia and the grade of dysplasia of the leukoplakia, and in the laryngeal group, dysplasia had a significant impact. The malignant transformation rate was low for oral patients without biopsy or with no dysplasia, 3.9% and 5.1%, respectively. The malignant transformation occurred over 10 years.

CONCLUSIONS

Patients with dysplastic leukoplakia have an increased risk of malignant transformation, but the risk is higher with laryngeal than with oral leukoplakia. There is no significant difference between the groups regarding survival with leukoplakia-associated cancer. Oral patients with no dysplastic lesions have a low risk of malignant transformation. A complete excision and long-term follow up are suggested for high-risk patients to diagnose cancer in an early stage and to control late (over 10 years) malignant events.

Office-Based Blue Laser Therapy for Vocal Fold Leukoplakia: A Preliminary Report of 12 Cases

Objective

To report the efficacy of office-based blue laser therapy for vocal fold leukoplakia.

Study Design

A retrospective case series.

Setting

A tertiary care center.

Methods

A retrospective chart review of patients with vocal fold leukoplakia who underwent office-based blue laser therapy between July 2019 and October 2022 was conducted. The video recordings of their laryngeal examination and their voice evaluation were analyzed before and after surgical intervention.

Results

A total of 10 patients, eight with unilateral disease and 2 with bilateral disease, were included in this study. In total, 12 vocal folds with leukoplakia were treated. Nine had a single session and 3 had 2 sessions due to incomplete regression of the lesion after the first laser therapy session. Following treatment, 9 regressed completely (75%) and 3 regressed partially (25%). The mean Voice Handicap Index-10 (VHI-10) score decreased significantly from 15.4 ± 12.9 preoperatively to 3.8 ± 2.86 after surgery (p = .023). There was a statistically significant decrease in the means of grade, roughness, breathiness, asthenia, and strain (p < .05). There was also a statistically significant decrease in the jitter and shimmer percent (p = .008 and p = .048, respectively) and a significant increase in the maximum phonation time from 9.63 ± 3.83 to 13.54 ± 5.92 seconds (p = .039).

Conclusion

This preliminary study indicates that office-based blue laser therapy is an effective treatment modality for vocal fold leukoplakia.

Dysplastic Lesions of the Larynx

There have been many advancements in the clinical and histologic diagnosis of laryngeal dysplasia (LD), but diagnosis still necessitates invasive histologic evaluation. Furthermore, despite improved histologic identification of dysplastic lesions, the exact details of pathophysiologic progression and the risk of malignant transformation is still uncertain. These unknowns create a barrier to establishing an ideal grading and classification system, which prevents the establishment of a precise and consistent treatment paradigm. Identifying these gaps in knowledge serves to highlight where further studies are warranted, ideally focusing on a better understanding of the biological behavior of LD. This would ultimately allow for the creation of a reliable grading and classification system and for the formalization of management and treatment guidelines for LD.

Inferior Surface Leukoplakia of Vocal Folds: Risk of Recurrence: A Preliminary Study

OBJECTIVES

This study aimed to identify vocal fold leukoplakia (VFL) lesions on the inferior surface as a risk factor for recurrence.

METHODS

This was a retrospective study with data collected from 2001 to 2018. The study comprised 37 patients with VFL, divided into the nonrecurrent and recurrent groups. We examined the clinicopathological characteristics and the surgical procedures performed in each patient.

RESULTS

Among the 37 patients, 15 (40.5%) had residual (3) or recurrent (12) VFL. Of those patients with and without recurrence, 8 of 12 (66.7%) and 6 of 22 (27.3%), respectively, had inferior surface lesions of the vocal fold at the initial operation (P = .036). Recurrences were significantly higher in patients with inferior surface lesions. Other evaluated factors did not show significance for recurrence.

CONCLUSION

The presence of VFL lesions on the inferior surface is a significant risk factor for recurrence.

A 6-Year Retrospective Study of the Demographics of Glottic Keratosis in a Tertiary Care Voice Centre

Since Keratosis may be accompanied with severe dysplasia or malignancy; early management of this condition is of essence. However, since this condition has a high rate of recurrence the surgical dilemma remains as to how frequently the surgeries should be performed and what should be the factors to guide this decision. The objectives of our study are to attempt to understand the demographics of laryngeal keratosis and its behaviour pattern including the potential to recur, disease upstaging and malignant transformation. This is a 6-year retrospective study of patients presenting to a Voice and Swallowing Centre. All patients had been operated upon and confirmed to have keratosis with or without cancer. The medical records and stroboscopy videos were reviewed for details such as age, gender, history of smoking, laterality of lesion, location of lesion on the vocal fold, recurrence with any disease upstaging or malignant transformation. In the case of recurrence of lesion the histopathology of the recurrence was compared with the primary histopathology. Chi square test & Fisher's exact test was used for comparison of proportions between two groups. A total of 71 patients were included in the study, 88% were males. Recurrence was seen in 20 patients (28%), 14 with benign recurrence and 6 with malignant. Rate of recurrence when the primary keratosis had been benign was 30.7 and 20.6% when the primary keratosis had been associated with malignancy. A majority of patients with glottic keratosis were males and all that underwent malignant transformation were males. The rate of postoperative recurrence when the primary keratosis had been benign was higher than when it had been keratosis associated with malignancy. This may indicate the need for aggressive surgical management for benign keratosis.

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.

Narrative Review of Classification Systems Describing Laryngeal Vascularity Using Advanced Endoscopic Imaging

Endoscopic methods are critical in the early diagnosis of mucosal lesions of the head and neck. In recent years, new examination methods and classification systems have been developed and introduced into clinical practice. All of these new techniques target the notion of optical biopsy, which tries to assess the nature of the lesion before histology examination. Many methods suffer from interpretation issues due to subjective interpretation of the findings. Therefore, multiple classification systems have been developed to assist the proper interpretation of mucosal findings and reduce the error rate. They provide various perspectives on the assessment and interpretation of mucosa changes. This article provides a comprehensive and critical view of the available classification systems as well as their advantages and disadvantages.

Laryngeal Dysplasia: To Biopsy or Not?

A renal transplant recipient with chronic hepatitis B underwent multiple laser excisions over 4 years for laryngeal keratosis. From the initial histopathology reports of mild to moderate dysplasia, a progression to squamous carcinoma was noted over 4 years. This case report highlights the possible role of immunosuppressants and hepatitis virus in the aetiopathogenesis of laryngeal carcinoma.

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.

Malignant Transformation in Glottic Dysplasia Treated With Photoangiolytic LASER - A Systematic Review and Meta-analysis

OBJECTIVE

This systematic review and meta-analysis seeks to characterize the rate of malignant progression among patients with laryngeal dysplasia treated with photoangiolytic laser and compare to prior systematic reviews of conventional surgical approaches.

METHODS

OVIDMedline, Pubmed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Google Scholar were searched, including terms related to patients with vocal fold dysplasia who were treated by angiolytic laser ablation. Some articles already known to authors or identified through hand searching were included.

RESULTS

Six articles with 155 cases were included. Two studies used potassium titanyl phosphate exclusively, one solely used the pulsed dye laser, and three studies utilized both laser types during the study period. The pooled overall mean of malignant progression for patients with laryngeal dysplasia treated with photoangiolytic laser was 12%, as calculated by conducting a meta-analysis of single arm proportion.

CONCLUSION

Laryngeal dysplasia is a premalignant lesion which confers a risk of progression to malignancy. After biopsy to establish the diagnosis there are multiple surgical techniques available for treatment with the goal of lesion eradication and voice preservation. In our review, there is a low malignant transformation rate for patients treated via with photoangiolytic laser.

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.

Update from the 5th Edition of the World Health Organization Classification of Head and Neck Tumors: Hypopharynx, Larynx, Trachea and Parapharyngeal Space

In this article, we review the chapter on tumors of the larynx, hypopharynx, trachea and parapharyngeal space in the new edition of the WHO book, focusing on the new developments in comparison to the previous edition. Squamous cell carcinoma (SCC) and its variants are by far the most common malignancies at these locations, with very limited new insights. The most important is the introduction of new targeted treatment-checkpoint inhibitors, with a new task for pathologists, who may help to predict the response to treatment by analyzing the expression of targeted proteins in biopsy samples. Precancerous lesions remain a controversial topic and, similarly to other organs, it is acceptable to use the terms "dysplasia" or "squamous intraepithelial lesion" (SIL), but there is a slight difference between low-grade dysplasia and low-grade SIL: in the former, mild atypia must be present, while the latter also includes hyperplastic epithelium without atypia. Two approaches have been proposed: a two-tiered system with low- and high-grade dysplasia/SIL and a three-tiered system with an additional category, carcinoma in situ. We are still searching for reliable diagnostic markers to surpass the subjectivity in biopsy diagnosis, with a few potential candidate markers on the horizon, e.g., stem cell markers. Other tumors are rare at these locations, e.g., hematolymphoid, neuroendocrine and salivary gland neoplasms, and are no longer included in Chapter 3. They must be diagnosed according to criteria described in specific chapters. The same holds true for soft tissue tumors, with the exception of cartilaginous neoplasms, which are still included in Chapter 3.

In vivo detection of head and neck tumors by hyperspectral imaging combined with deep learning methods

Currently, there are no fast and accurate screening methods available for head and neck cancer, the eighth most common tumor entity. For this study, we used hyperspectral imaging, an imaging technique for quantitative and objective surface analysis, combined with deep learning methods for automated tissue classification. As part of a prospective clinical observational study, hyperspectral datasets of laryngeal, hypopharyngeal and oropharyngeal mucosa were recorded in 98 patients before surgery in vivo. We established an automated data interpretation pathway that can classify the tissue into healthy and tumorous using convolutional neural networks with 2D spatial or 3D spatio-spectral convolutions combined with a state-of-the-art Densenet architecture. Using 24 patients for testing, our 3D spatio-spectral Densenet classification method achieves an average accuracy of 81%, a sensitivity of 83% and a specificity of 79%.

Polymorphisms of acetaldehyde dehydrogenase 2 and alcohol dehydrogenase 1B on the malignant transformation of vocal cord leukoplakia: A Chinese cohort

Severe dysplasia of vocal cord leukoplakia (VCL) is more likely to occur in laryngeal carcinoma. Alcohol dehydrogenase and acetaldehyde dehydrogenase are both important enzymes in alcohol metabolism. This study aimed to investigate the incidence rate of malignant transformation in patients with VCL and the role of drinking habits and ALDH2 and ADH1B genetic polymorphisms in the malignant transformation of VCL. From January 2007 to January 2017, 136 cases of VCL were included in this retrospective analysis. Information on medical history, alcohol and tobacco consumption habits, ALDH2 and ADH1B genotypes, gastroesophageal reflux, and clinical pathological characteristics of VCL was collected. As a result, patients had a median follow-up of 9.6 years (interquartile range: 7.5-12.5 years). Twenty-three of 136 VCL patients finally developed laryngeal carcinoma, resulting in a cumulative malignant transformation rate of 16.9%. Cox regression analysis demonstrated that the independent risk factors for the malignant transformation of VCL included age over 60 years (hazard ratio [HR]: 13.872, p < 0.001), ALDH2 *2 allele status (HR: 9.694, p < 0.001), alcohol (HR: 10.011, p < 0.001) and tobacco (HR: 8.869, p < 0.001) exposure after operation, and drinking frequency (HR: 2.178, p = 0.016). Therefore, among patients over 60 years old, an ALDH2-inactivating mutation and excessive ethanol and tobacco consumption are potential contributors to the malignant transformation of VCL.

Decrement of prognostic nutrition index in laryngeal diseases: from precancerous lesion to squamous cell carcinoma

BACKGROUND

Malnutrition and systemic inflammatory response have been confirmed to be important risk factors for various cancers.

OBJECTIVE

To compare pretreatment prognostic nutrition index (PNI) among patients with laryngeal squamous cell carcinoma (LSCC), laryngeal precancerous lesion (LPL) and laryngeal benign lesion (LBL).

METHODS

A total of 253 male patients with laryngeal lesions were divided into LBL, LPL with low risk (LPL (l)), LPL with high risk (LPL(h)), LSCC (i), LSCC (ii) and LSCC (iii) groups according to their histopathological findings and the TNM staging system. PNI and other clinical parameters were calculated. Kruskal-Wallis, Mann-Whitney U or Chi-square or Fisher's exact test were used for comparison of different parameters among groups. Logistic regression was performed to estimate the odds ratios (OR) and the corresponding 95% confidence intervals (CI).

RESULTS

The PNI in the LSCC group was significantly lower than those of the LBL and LPL groups (p = .013 and p = .004, respectively), and decreased from LPL(l) to LSCC (iii) (from 53.97 ± 3.69 to 50.02 ± 4.75). LPL patients with lower PNI values had a higher risk of LSCC, the OR was 0.91 (95% CI: 0.84, 0.97) for a one-unit decrease.

CONCLUSIONS

PNI could be a simple and reproducible marker for predicting the severity of laryngeal diseases.

Supporting the use of adjuvant radiotherapy in recurrent pleomorphic adenoma of the parotid

BACKGROUND

The use of adjuvant radiotherapy remains controversial in the treatment of recurrent pleomorphic adenomas.

AIMS/OBJECTIVES

The aim of this study was to provide the highest level of evidence possible by performing a systematic review and meta-analysis of the literature.

MATERIAL AND METHODS

We searched the English-language literature between 1985 and 2019.Inclusion criteria included any study on the treatment and outcome of recurrent pleomorphic adenomas. Exclusion criteria included the use of radiotherapy for residual tumors, case reports, and pleomorphic adenomas not arising from the parotid.

RESULTS

A total of 522 abstracts were studied, data analyzed from 14 studies, on a total of 697 patients. When the data werepooled, the overall risk of further recurrence was 21%. In studies where surgery alone was undertaken this increased to 26% and decreased to 10% in those receiving adjuvant radiotherapy (p = .000). There were 21 recurrences in 159 patients in the radiotherapy group, and 151 recurrences out of 538 patients in the surgery group (p < .0001).

CONCLUSIONS

These data support the use of radiotherapy to decrease the risk of re-recurrence in recurrent pleomorphic adenoma.

SIGNIFICANCE

This study is the highest level of evidence currently available in guiding management of recurrent pleomorphic adenoma.

Management of Laryngeal Dysplasia and Early Invasive Cancer

OPINION STATEMENT

Dysplasia and early laryngeal cancer lie on a spectrum of cellular changes. These start with early changes to the cells including epithelial hyperplasia and expand to dysplasia, squamous cell carcinoma in situ and finally developing in to invasive cancer. Dysplasia can range from low to high grade, with each being treated in a different manner. Treatment options are typically determined by where the dysplasia/invasive cancer lie on this spectrum along with the site within the larynx. Hyperkeratosis, mild dysplasia and moderate dysplasia typically involve primary endoscopic excision. Severe dysplasia and squamous cell carcinoma in situ involve primary endoscopic resection with the addition of possible laser resection and/or ablation. At this stage, surgery will be followed by close surveillance. Finally, early laryngeal cancer such as T1 and T2 lesions is typically more involved. Treatment depends on the site and degree of involvement of the structures, along with spread to surrounding structures. Typical treatment options of more involved early laryngeal cancer can range from radiation therapy, endoscopic transoral laser resection, endoscopic transoral robotic resection to open resection. Often times, my choice of treatment will be aimed at voice preservation but patient preference will also play a role in the decision making between treatment modalities. Chemotherapy and immunotherapy are typically not used in early stage laryngeal cancer.

Laryngoscopic characteristics related to the risk of cancerization of vocal cord leukoplakia

BACKGROUND

The diagnosis of vocal cord leukoplakia mainly relies on laryngoscopy. The morphology of vocal cord leukoplakia under laryngoscope is closely related to the pathological nature of leukoplakia. The specific manifestations associated with high-risk vocal cord leukoplakia remain to be explored.

OBJECTIVE

To investigate the characteristics of low-risk and high-risk vocal cord leukoplakia under conventional white light imaging (WLI) laryngoscopy and its correlations with narrow band imaging (NBI) laryngoscopy.

METHODS

One hundred and seventy-five cases of vocal cord leukoplakia were divided into low-risk and high-risk groups. The characteristics of low-risk and high-risk vocal cord leukoplakia under WLI laryngoscopy and its correlations with NBI laryngoscopy were analyzed.

RESULTS

Logistic regression analysis showed that thickness and hyperemia were independent factors (p < .05). Hyperemia had a strong consistency with the visualization of spots under NBI laryngoscopy (kappa = 0.758). The sign of hyperemia and the NBI classification had equivalent diagnostic efficacy for predicting the risk of cancerization of vocal cord leukoplakia.

CONCLUSION

The sign of hyperemia under WLI laryngoscopy is significantly correlated with the visualized spots under NBI laryngoscopy. Hyperemia is an important feature for predicting malignant potential of vocal cord leukoplakia.

Vocal Fold Leukoplakia: Which of the Classifications of White Light and Narrow Band Imaging Most Accurately Predicts Laryngeal Cancer Transformation? Proposition for a Diagnostic Algorithm

The management of Vocal Fold Leukoplakia (VFL) remains problematic. There is no consensus on the indications or the timing for surgery. The objective was to select the most accurate classification for predicting low- and high-risk VFL in White Light Imaging (WLI) and Narrow Band Imaging (NBI) and to establish a diagnostic algorithm with a timely referral for treatment. A total of 259 VFL patients were included in the study; 186 lesions were classified as low-grade and 110 as high-grade dysplasia. The results of WLI acc. to the two-tier and the three-tier Chen 2019 classifications and NBI classifications: ELS, Ni 2011, and Ni 2019 with different cut-off points were compared with the pathological examination (HP). In WLI, the greatest agreement was obtained between type 3 of the three-tier classification and high-grade dysplasia (accuracy, specificity, and PPV: 80.4%, 92.0%, and 81.5%, respectively). Assessing VFL periphery in NBI, cut-off point 5 (Ni 2011 type V) demonstrated a higher accuracy, specificity, and PPV than 4 (83.1%, 93.6%, 85.5% and 77.4%, 74.9%, and 65.4%, respectively). In NBI, we observed higher accuracy, sensitivity, and PPV (84.1%, 93.0%, 85.2% vs. 80.7%, 81.3% and 71.3%, respectively) for cut-off point 5 (Ni 2019 type V and VI) in comparison to the cut-off point 4 group (type IV, V, and VI) (80.7%, 81.3%, 71.3%, respectively), and a higher kappa value (0.68 vs. 0.58) was obtained. We have shown that both the plaque image and the microvascular pattern on the leukoplakia periphery are critical in the diagnosis of high-risk VFL. The most accurate predictor of VFL malignant transformation in WLI is type 3 according to the Chen 2019 classification, while in NBI type V and VI according to the Ni 2019 classification.

The Efficiency of (videolaryngo)stroboscopy in Detecting T1a Glottic Carcinoma and Its Preliminary Stages

OBJECTIVE

The efficiency of laryngovideostroboscopy (LVS) in detecting premalignancies of the vocal fold and early glottic cancer was determined in a prospective monocentric study. In addition, the recovery rate of the mucosal membrane on the vocal fold after surgical intervention was determined by LVS.

METHODS

We included 159 patients with a leukoplakia of the vocal folds and 50 healthy controls. Clinicopathological data and LVS characteristics (amplitude, mucosal wave, nonvibratory segment, glottic closure, phase symmetry, periodicity) at the lesion site were obtained and compared with the histopathological results. LVS parameters were recorded before cordectomy and in a 12-month follow-up interval. Patients who had prior laryngosurgery, radiotherapy, or laryngeal scarring were excluded.

RESULTS

Absent or greatly reduced mucosal waves were found in all patients with an invasive carcinoma, in 94% with a severe intraepithelial neoplasia (SIN III), in 38% with a moderate squamous intraepithelial neoplasia (SIN II), in 32% with a mild squamous intraepithelial neoplasia (SIN I), and in 23% with a hyperkeratosis without dysplasia. The sensitivity and specificity of LVS in predicting an invasive carcinoma based on the absence or reduction of mucosal waves was 0.96 and 0.90, respectively. Following surgical intervention, the recovery rate of the mucosal wave and amplitude was 12% in the invasive carcinoma group, 36% in the SIN III group and up to 80% for both these parameters in the SIN I, SIN II, and hyperkeratosis groups.

CONCLUSION

LVS is a valid tool to identify early glottic carcinoma and its high risk premalignancy carcinoma in situ (CIS). Even when there is no definitive differentiation between SIN I and II, the invasive character of a CIS and an invasive glottic carcinoma can be identified. Especially strobosopic signs of abnormal amplitude and/or mucosal waves, particularly phoniatric halt, are an early indication for a CIS or an invasive carcinoma.

Association between Laryngopharyngeal Reflux and Vocal Fold Leukoplakia

INTRODUCTION

Vocal fold leukoplakia (VFL) has a risk of malignant transformation, and the underlying mechanisms are currently unrecognized. Some clinical evidence has indicated that laryngopharyngeal reflux (LPR) probably plays a critical role.

OBJECTIVE

To explore the risk factors associated with the occurrence of VFL and to investigate the importance of LPR in VFL and its different pathological types using 24-h multichannel intraluminal impedance-pH monitoring.

MATERIALS AND METHODS

Eighty-one patients with VFL and 27 healthy volunteers were recruited. General information and LPR parameters were analyzed.

RESULTS

The monitoring showed that 35.8% (29/81) of patients had acidic LPR and that 43.2% (35/81) had weakly acidic LPR. Heavy drinking (odds ratio = 4.004, p = 0.037) and acidic LPR (odds ratio = 4.471, p = 0.029) were independent risk factors for the occurrence of VFL. Acidic LPR showed a strong correlation with the Reflux Finding Score (p < 0.05) in patients suspected of having LPR based on the scale score. Meanwhile, weakly acidic LPR parameters increased with the severity of pathological degrees which were higher in high-grade dysplasia (p < 0.05).

CONCLUSION

Our study confirms the importance of LPR in VFL. Heavy drinking patients with VFL, particularly those with acidic LPR, should undergo intensive treatment. Meanwhile, weakly acidic LPR may play a critical role in the pathological changes in VFL.

Circulating immune parameters-based nomogram for predicting malignancy in laryngeal neoplasm

BACKGROUND

Malignancy prediction remains important to preoperative diagnosis and postoperative follow-up in laryngeal neoplasm.

AIM

To evaluate the circulating immune population and develop a nomogram for prediction of malignancy in patients with laryngeal neoplasm.

METHODS

A primary cohort of 156 patients was divided into laryngeal benign lesion, premalignant lesion and malignant lesion groups. Peripheral blood from patients was measured by blood routine test and flow cytometry. A nomogram was developed and applied to a validation cohort containing 55 consecutive patients.

RESULTS

Age, gender and seven circulating immune parameters exhibited significant differences between laryngeal benign lesion and premalignant lesion. The nomogram incorporated predictors, including gender, age, smoke index, proportions of monocytes, CD8+ T cells, CD4+ T cells, B cells and CD4/CD8+ T cell ratio. It showed good discrimination between laryngeal premalignant lesion and malignant lesion, with a C-index of 0.844 for the primary cohort. Application of this nomogram in the validation cohort (C-index, 0.804) still had good discrimination and good calibration. Decision curve analysis revealed that the nomogram was clinically useful.

CONCLUSION

This novel nomogram, incorporating both clinical risk factors and circulating immune parameters, could be appropriately applied in preoperative individualized prediction of malignancy in patients with laryngeal neoplasm.

The Role of Keratin-8 and Keratin-18 Polymorphisms and Protein Levels in the Occurrence and Progression of Vocal Leukoplakia

OBJECTIVE

This study aimed to evaluate the association between the single-nucleotide polymorphism (SNP) and tissue protein level of keratin-8/18 and the occurrence and progression of vocal leukoplakia.

METHODS

The case-control study enrolled 158 patients with vocal leukoplakia, 326 patients with laryngeal squamous cell carcinoma (LSCC), and 268 healthy controls, which were tested for genotype analysis with keratin-8 and keratin-18 gene polymorphisms using pyrosequencing. The tissue protein expression levels of keratin-8 and keratin-18 were evaluated using immunohistochemistry.

RESULTS

The keratin-8 SNP RS1907671 showed an obvious increased risk for vocal leukoplakia (OR 1.56, p = 0.002), while the other SNPs (RS2035875, RS2035878, RS4300473) were tested as protective factors for vocal leukoplakia and LSCC (OR <1, p < 0.05). In keratin-18 SNP test, both RS2070876 and RS2638526 polymorphisms demonstrated decreased risks for vocal leukoplakia and LSCC (OR <1, p < 0.05). The protein levels of keratin-8 and keratin-18 in vocal leukoplakia group were significantly higher than those of the LSCC group (p < 0.05).

CONCLUSIONS

Keratin-8 and keratin-18 polymorphisms and protein levels are associated with the occurrence and progression of vocal leukoplakia.

Contribution of narrow band imaging in delineation of laryngopharyngeal superficial cancer spread: a prospective study

PURPOSE

The aim of this study was to assess the performance of Narrow Band Imaging (NBI) added to White Light (WL) in the delineation of laryngopharyngeal superficial cancer spread during office-based transnasal flexible endoscopy.

METHODS

This bi-centric prospective study was conducted between October 2014 and December 2017. We included consecutive patients with laryngopharyngeal malignant tumors. Transnasal flexible endoscopy was performed by two endoscopists who were blinded to each other's assessments and who examined each patient independently. The first endoscopist only performed a WL examination, while the second endoscopist carried out both WL and NBI. The extent of tumor involvement was reported based on predefined anatomical sub-units. Biopsies in NBI + /WL- sub-units were subsequently performed during panendoscopy.

RESULTS

Eighty-four patients were included in the study. A total of 72 NBI + /WL- sub-units were sampled in 38 patients, and 37 of the biopsies were positive (51.4%): 16 for invasive carcinoma, 17 for high-grade dysplasia/carcinoma in situ and 4 for low-grade dysplasia. Ultimately, 26.2% of patients had at least one positive biopsy in an NBI + /WL- sub-unit and, therefore, a better tumor delineation. The clinical T stage was upgraded in 4.8% of cases examined.

CONCLUSION

Adding NBI to WL imaging during transnasal flexible endoscopy in patients presenting with laryngopharyngeal pre-malignant or malignant lesions improves the delineation of superficial cancer spread, thereby leading to better adapted treatments. Clinicaltrials.gov registration number: NCT02035735.

Laryngeal Leukoplakia: State of the Art Review

Objective

This state-of-the-art article reviews the epidemiology, diagnosis, and management of vocal fold leukoplakia, with focus on recent advances. It focuses on the clinical challenges that otolaryngologists face balancing both oncological efficacy and functional outcomes in leukoplakia and presents the current philosophies and techniques to consider when managing such patients.

Data Sources

PubMed/MEDLINE.

Review Methods

We conducted a detailed review of publications related to vocal cord and laryngeal leukoplakia, dysplasia, hyperkeratosis, leukoplakia endoscopy, and leukoplakia management focusing specifically on oncologic outcomes, voice preservation, current and emerging diagnosis, and management techniques.

Conclusions

There has been a paradigm shift away from performing “vocal cord stripping” procedures that can cause irreversible hoarseness toward voice preservation surgery while achieving comparable oncologic control. Surgical technical and instrumental developments have been designed to maximally treat superficial disease while preserving underling vibratory mucosa. Recent improvements in histopathological grading systems and advances in biomarker classification may allow for improved oncologic risk stratification. Furthermore, improvements in endoscopic imaging capabilities and contact endoscopy are currently being studied for their potential diagnostic significance.

Implications for Practice

To optimally manage vocal fold leukoplakia, the otolaryngologist should become familiar with the oncologic implications of the disease and the importance of obtaining pathologic diagnosis to rule out malignancy. In addition, the surgeon should maintain surgical techniques and knowledge of available instruments and lasers that can assist in surgical management while prioritizing the preservation of vibratory tissue and voice quality. Finally, the surgeon and the patient should understand the clinical importance of routine endoscopic surveillance.

Effect of a training course on the diagnosis of vocal fold leukoplakia by narrow-band imaging

OBJECTIVE

To investigate the value of narrow-band imaging training for differentiating between benign and malignant vocal fold leukoplakia.

METHOD

Thirty cases of vocal fold leukoplakia were selected.

RESULTS

Narrow-band imaging endoscopy training had a significant positive effect on the specificity of the differential diagnosis of vocal fold leukoplakia. In addition, the consistency of diagnostic typing of vocal fold leukoplakia by narrow-band imaging improved to 'moderate agreement' following the combination of types I and II and the combination of types IV, V and VI in the typing of vocal fold leukoplakia.

CONCLUSION

The narrow-band imaging training course may improve the ability of laryngologists to diagnose vocal fold leukoplakia. The new endoscopic diagnostic classification by narrow-band imaging needs to be further simplified to facilitate clinical application.

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).

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.

Grading systems of oral cavity pre-malignancy: a systematic review and meta-analysis

PURPOSE

Oral potentially malignant disorders (OPMDs) may have varying degrees of oral epithelial dysplasia (OED). Traditional grading schemes separate OED into three-tiers (mild, moderate, and severe). Alternatively, a binary grading system has been previously proposed that stratifies OED into low-risk and high-risk categories based on a quantitative threshold of dysplastic pathologic characteristics. This systematic review evaluates the predictive value of a binary OED grading system and examines agreement between pathologists.

METHODS

This meta-analysis queried 4 databases (PubMed, Ovid-MEDLINE, Cochrane, and SCOPUS) and includes 4 studies evaluating binary OED grading systems. Meta-analysis of proportions and correlations was performed to pool malignant transformation rates (MTR), risk of malignant transformation between OED categories, and measures of interobserver agreement.

RESULTS

Pooled analysis of 629 lesions from 4 different studies found a six-time increased odds of malignant transformation in high-risk lesions over low-risk lesions [odds ratio (OR) 6.14, 95% 1.18-15.38]. Reported ORs ranged from 2.8 to 22.4. The overall MTR was 26.8%, with the high-risk and low-risk lesions having MTRs of 57.9% (95% CI 0.386-0.723) and 12.7% (95% CI - 0.210 to 0.438), respectively. Pooled unweighted interobserver kappa values for the binary grading system and three-tiered system were 0.693 (95% CI 0.640-0.740) and 0.388 (95% CI 0.195-0.552), respectively.

CONCLUSION

Binary grading of OED into low-risk and high-risk categories may effectively determine malignant potential, with improved interobserver agreement over three-tiered grading. Improved grading schemes of OED may help guide management (watchful waiting vs. excision) of these OPMDs.

Incidence and malignant transformation of glottic precursor lesions in Denmark

Objectives: Glottic precursor lesion (GPL) is a well-known premalignant condition, but the existing knowledge of incidence and malignant potential is based on subpopulation studies. In this first, nationwide study we report data from all verified cases of GPL in Denmark during a 10-year period with focus on incidence and malignant transformation of GPL.Methods: Patients were identified by a search for GPL in the time period from 01.01.2000 to 31.12.2009 using the Danish Pathology Data Base, Patobank, which is a nationwide source of all cyto- and histopathological data obtained in Denmark. Data were validated and supplemented by medical chart review.Results: A 10-year national cohort of 965 patients (median age 60 years, male-female ratio 2:1) with histologically verified GPL was analyzed. The overall malignant transformation rate was 18.3% (mild dysplasia 7.7%, moderate dysplasia 19.8%, severe dysplasia 28.5%, and carcinoma in situ 40.3%) with a median progression time of 29 months. Eighty-eight percent of patients were active or former smokers. A significantly larger proportion of male patients (24.1%) experienced malignant transformation compared to females (6.6%) (p < .001).Conclusion: This nationwide population-based study of GPL patients confirmed a stable incidence of GPL in Denmark from January 2000 to December 2009 and a considerable malignant potential, correlated to the grading of GPL according to the World Health Organization classification of laryngeal precursor lesions from 2005, WHOC2005. The recent update, WHOC2017, of low-grade versus high-grade lesions may thus contain less nuanced prognostic information than WHOC2005.Level of evidence: 2b retrospective cohort study.

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.

Risk factors associated with severe recurrent respiratory papillomatosis

Background

Objectives

Methods

Results

Conclusion

Value of pre- and intraoperative diagnostic methods in suspected glottic neoplasia

PURPOSE

To evaluate the individual and combined ability of videostroboscopy (VS), high-speed digital imaging (HSDI), enhanced endoscopy (EE) and saline infusion (SI) to predict neoplasia, defined as glottic precursor lesion (GPL) or T1a glottic cancer, in patients suspected for glottic neoplasia.

METHODS

A nationwide prospective cohort study of patients treated by cordectomy for suspected GPL or T1a glottic cancer from August 1st 2016 to October 31st 2018 was conducted in the five Danish University Departments of Head and Neck surgery. Sensitivity, specificity, negative and positive predictive values, and area under Receiver Operating Curves (AUC-ROC) were calculated with 95% confidence intervals with respect to the histological diagnosis. Logistic regression with an imputation model for missing data was applied.

RESULTS

261 patients aged 34-91 years participated; 79 (30.3%) with non-neoplasia (i.e., inflammation, papilloma, hyperkeratosis) and 182 (69.7%) neoplasia, hereof 95 (36.4%) with GPL and 87 (33.3%) with T1a glottic cancer. Data from 188 VS, 60 HSDI, 100 preoperative EE, 209 intraoperative EE, and 234 SI were analyzed. In the complete case analysis the AUC-ROC of each diagnostic test was low, but increased when the tests were combined and especially if the combination included EE. However, multinomial logistic regression with imputation showed significant association (p < 0.05) only between age, male gender, and perpendicular vasculature in intraoperative EE, and the endpoint neoplasia.

CONCLUSIONS

Intraoperative EE was the most accurate diagnostic method in detecting neoplasia. The prediction ability of methods applied preoperatively was more limited, but improved when test modalities were combined.

Clinical Implications of Carcinoma In Situ in Sinonasal Inverted Papilloma

Objective

Sinonasal inverted papilloma (IP) is a typically benign sinonasal tumor with a tendency to recur and the potential for malignant transformation. Varying degrees of dysplasia may be present, of which carcinoma in situ (CIS) is most advanced. We hereby describe the biological and clinical behavior of IP with CIS (IPwCIS).

Study Design

Retrospective cohort.

Setting

Tertiary academic referral center.

Subjects and Methods

Patients who underwent surgical resection for IP between 2002 and 2017. Pertinent clinical data were obtained, and all IPwCIS cases were histologically confirmed.

Results

In total, 37 of 215 cases (17.2%) were identified with IPwCIS. Mean age was 57 years and 86.5% of patients were male. Median follow-up was 82 months, and the recurrence rate was 27%. The maxillary sinus was the most common primary site (37.8%) and 14 tumors (37.8%) demonstrated multifocal attachment, which was associated with recurrence (odds ratio [OR], 9.7; 95% confidence interval [CI], 1.4-112.8; P = .028). IPwCIS was also associated with multiple recurrences (OR, 2.71; 95% CI, 1.246-5.814; P = .021). Most patients were treated with surgery alone (89.1%) and 4 patients received adjuvant radiotherapy (8.1%). Only 1 patient (2.7%) demonstrated malignant transformation after definitive surgery.

Conclusions

IPwCIS represents the most severe degree of dysplasia prior to malignant transformation and is associated with higher recurrence rate and multifocal involvement but low rate of conversion to invasive carcinoma. The need for adjuvant therapy remains controversial, and further research into the etiology of the disease is warranted.