Treatment Outcomes in Patients with Carcinoma In Situ of the Larynx

OBJECTIVE

To compare survival endpoints in patients with laryngeal carcinoma in situ (L-CIS) who received definitive radiotherapy (RT) versus other modalities as first-line treatment and after disease recurrence.

METHODS

This is a retrospective study of patients with L-CIS treated between June 2001 and December 2021. Survival outcomes (recurrence-free (RFS), invasion-free (IFS), laryngectomy-free (LFS), and overall survival (OS)) were compared between patients who had first-line RT versus non-RT modalities and for patients with recurrent disease who underwent second-line RT.

RESULTS

A total of 85 patients with L-CIS were included (73 men [85.9%] and 12 [14.1%] women, median age of 65 [IQR: 55-74] years). Of these, 42 had first-line RT (49.4%) and 43 (50.6%) had non-RT treatment. After median follow-up of 4.8 (IQR: 2.8-9) years, patients in the first-line RT group had improved 2-year (94.2% [95% confidence interval (CI): 86.7-100] versus 41.7% [CI: 29.3-59.5]) and 5-year (90.6% [CI: 80.9-100] versus 27.5% [CI: 16.4-48.2]) RFS relative to non-RT recipients (p < 0.001). OS and IFS were similar between groups. However, patients in the RT group had worse 2-year (94% [CI: 87-100] versus 98% [CI: 93-100]) and 5-year (82% [CI: 68-99] versus 98% [CI: 93-100]; p = 0.013) LFS. All 35 patients with recurrent L-CIS were successfully cured with second-line treatments (12 received RT [34.3%]), and no differences in any survival endpoints were seen in these patients based on first-line and second-line treatments.

CONCLUSION

Although first-line RT for L-CIS led to improved recurrence-free survival compared with other modalities, second-line RT may be a particularly valuable option for recurrent CIS.

LEVEL OF EVIDENCE

3 Laryngoscope, 2024.

Applying Deep Learning with Convolutional Neural Networks to Laryngoscopic Imaging for Automated Segmentation and Classification of Vocal Cord Leukoplakia

Objectives: Vocal cord leukoplakia is clinically described as a white plaque or patch on the vocal cords observed during macroscopic examination, which does not take into account histological features or prognosis. A clinical challenge in managing vocal cord leukoplakia is to assess the potential malignant transformation of the lesion. This study aims to investigate the potential of deep learning (DL) for the simultaneous segmentation and classification of vocal cord leukoplakia using narrow band imaging (NBI) and white light imaging (WLI). The primary objective is to assess the model's accuracy in detecting and classifying lesions, comparing its performance in WLI and NBI. Methods: We applied DL to segment and classify NBI and WLI of vocal cord leukoplakia, and used pathological diagnosis as the gold standard. Results: The DL model autonomously detected lesions with an average intersection-over-union (IoU) >70%. In classification tasks, the model differentiated between lesions in the surgical group with a sensitivity of 93% and a specificity of 94% for WLI, and a sensitivity of 99% and a specificity of 97% for NBI. In addition, the model achieved a mean average precision of 81% in WLI and 92% in NBI, with an IoU threshold >0.5. Conclusions: The model proposed by us is helpful in assisting in accurate diagnosis of vocal cord leukoplakia from NBI and WLI.

NBI Classification Optimization With Morphological Characteristics in Vocal Fold Leukoplakia

Objectives: To investigate the pathological contribution of vocal fold leukoplakia (VFL) of type II in narrow-band imaging (NBI) classification and morphological characteristics to improve pathological prediction. Material and Methods: The 59 VFL patients with type II in 2019 Ni classification in NBI were included. The pathological reports were collected and divided following 2005 WHO Blue Book. Low-risk VFL contained non-, mild, moderate dysplasia, high-risk VFL included severe dysplasia. The morphological classification and laryngoscopic scoring system were employed to evaluate leukoplakia for pathological prediction. Results: The pathologies contained 1 case of leukoplakia with non-dysplasia, 12 of mild dysplasia, 15 of moderate dysplasia, 8 of severe dysplasia, and 23 of carcinoma. The 30 smooth VFL contained 1 non-dysplasia, 12 mild dysplasia, 14 moderate dysplasia, 2 severe dysplasia, and 1 carcinoma. The 29 rough cases included 1 moderate dysplasia, 6 severe dysplasia, and 22 carcinomas. Laryngoscopic scoring system revealed irregular texture, large size, and thick lesion as factors in relationship with high-risk leukoplakia in univariate (P = .002, <.001, <.001) and multivariate (P = .025, .002, .016) analysis, irregular texture was the most accurate predictor of high-risk VFL pathology. Conclusions and Significance: The pathologies of VFL with type II in NBI classification were hard to be predicted. Morphological irregular/rough texture contributed to predict high-risk pathology in leukoplakia.

Mucosal Injection of the Silicon Phthalocyanine Pc 4 in a Rabbit Model-A Pilot Study

OBJECTIVE

The silicon phthalocyanine Pc 4 is a photosensitizing agent previously shown to be a promising treatment for cutaneous neoplasms using photodynamic therapy (PDT). Based on prior preclinical studies, we believe Pc 4-PDT has potential as a targeted treatment of human recurrent respiratory papillomatosis or laryngeal leukoplakia by direct injection into mucosal surfaces.

METHODS

This was a proof-of-concept pilot study assessing direct mucosal injection of Pc 4 into buccal and vocal fold mucosae in a rabbit model. Five New Zealand white rabbits underwent tattooing of bilateral buccal mucosae to delineate injection sites, followed by submucosal injections of control and Pc 4 solutions. Rabbits were monitored for post-injection tolerance. Punch biopsies were obtained from injected mucosa and assessed histopathologically. Once the buccal mucosa was found to be tolerant, vocal folds of three rabbits were injected. The rabbits were then sacrificed, and laryngeal tissue was assessed histopathologically.

RESULTS

All rabbits tolerated injection of Pc 4 and control solutions into buccal mucosa with no evidence of gross visual inflammatory changes and no changes in behavior or masticatory function. Histopathologic analysis of Pc 4 injected buccal and control mucosal tissue revealed mild focal histological changes and no stigmata of diffuse inflammatory reactions. The histopathologic analysis of Pc 4 injected into laryngeal tissue revealed similar findings with addition of mild eosinophilia in one sample.

CONCLUSION

Direct mucosal injection of Pc 4 in rabbit buccal and vocal fold mucosae appears to be well tolerated with no gross inflammatory changes, and only mild histopathologic inflammatory changes observed.

LEVEL OF EVIDENCE

NA Laryngoscope, 2024.

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.

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.

Preliminary Correlation of the Immunoexpression of Cathepsin B and E-Cadherin Proteins in Vocal Fold Leukoplakia

OBJECTIVES

Early identification of vocal fold leukoplakia (VFL), which has a risk of progressing to malignant transformation, remains a controversial topic. The identification of biological markers for diagnosing these lesions would lead to a more effective treatment. We aimed to analyze the immunoexpression of cathepsin B and E-cadherin in VFL and correlate it with clinical and epidemiological data and disease prognosis.

METHODS

Thirty-two patients with VFL treated with microsurgery were retrospectively evaluated. The patients were distributed according to the histological results into Group A (low grade) and Group B (high grade). The expression of markers was quantitatively determined as per their staining intensity and tissue distribution using ImageLab. The index of expression (IE) of each marker was correlated with tobacco and alcohol consumption, signs of laryngopharyngeal reflux, and local recurrence of the lesion.

RESULTS

The correlation between the IE of markers and variables within the two groups (A and B) demonstrated that patients in Group B with local recurrence had a higher IE of cathepsin B. When all patients (A + B) were included, the same analysis demonstrated that the IE of cathepsin B was higher among smokers and patients who did not show signs of reflux and that the IE of E-cadherin was higher only in patients with recurrence.

CONCLUSION

Patients with moderate to severe dysplasia and carcinoma in situ who smoked as well as had a high IE of cathepsin B were more prone to local recurrence. Regardless of the type of histological lesion, patients with signs of laryngopharyngeal reflux had a lower IE of cathepsin B. The IE of E-cadherin was higher among patients with VFL who relapsed after initial treatment.

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.

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.

Electric Bioimpedance Sensing for the Detection of Head and Neck Squamous Cell Carcinoma

The early detection of head and neck squamous cell carcinoma (HNSCC) is essential to improve patient prognosis and enable organ and function preservation treatments. The objective of this study is to assess the feasibility of using electrical bioimpedance (EBI) sensing technology to detect HNSCC tissue. A prospective study was carried out analyzing tissue from 46 patients undergoing surgery for HNSCC. The goal was the correct identification of pathologic tissue using a novel needle-based EBI sensing device and AI-based classifiers. Considering the data from the overall patient cohort, the system achieved accuracies between 0.67 and 0.93 when tested on tissues from the mucosa, skin, muscle, lymph node, and cartilage. Furthermore, when considering a patient-specific setting, the accuracy range increased to values between 0.82 and 0.95. This indicates that more reliable results may be achieved when considering a tissue-specific and patient-specific tissue assessment approach. Overall, this study shows that EBI sensing may be a reliable technology to distinguish pathologic from healthy tissue in the head and neck region. This observation supports the continuation of this research on the clinical use of EBI-based devices for early detection and margin assessment of HNSCC.

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.

Diagnostic Yield of Office-Based Laryngeal Biopsy in Patients With Leukoplakia; A Case Study With Review of the Literature

OBJECTIVE

To review the authors experience in un-sedated office-based biopsies of patients with vocal fold leukoplakia and to review the literature.

MATERIAL AND METHOD

A retrospective review of 29 patients was conducted.

RESULTS

A total of 41 office-based procedures were performed (eight patients had bilateral vocal fold lesions and four patients had the procedure performed twice). In 26 out of the 41 biopsies, the pathology revealed benign lesion. In eight cases, the pathology showed dysplasia (four high-grade and four low-grade). Seven biopsies revealed squamous cell carcinoma. Five patients underwent suspension micro-laryngoscopy for definitive diagnosis. Four of whom had a change in their diagnosis.

CONCLUSION

Un-sedated office-based biopsy of vocal fold leukoplakia is an alternative to suspension microlaryngoscopy in case of carcinoma or nonmalignant lesions.

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.

Defining the Performance of Clinician's Ability to Screen for Laryngeal Mass From Voice

OBJECTIVE

Defining a clinician's ability to perceptually identify mass from voice will inform the feasibility, design priorities, and performance standards for tools developed to screen for laryngeal mass from voice. This study defined clinician ability of and examined the impact of expertise on screening for laryngeal mass from voice.

STUDY DESIGN

Task comparison study between experts and nonexperts rating voices for the probability of a laryngeal mass.

SETTING

Online, remote.

METHODS

Experts (voice-focused speech-language pathologists and otolaryngologists) and nonexperts (general medicine providers) rated 5-s/i/voice samples (with pathology defined by laryngoscopy) for the probability of laryngeal mass via an online survey. The intraclass correlation coefficient (ICC) estimated interrater and intrarater reliability. Diagnostic performance metrics were calculated. A linear mixed effects model examined the impact of expertise and pathology on ratings.

RESULTS

Forty clinicians (21 experts and 19 nonexperts) evaluated 344 voice samples. Experts outperformed nonexperts, with a higher area under the curve (70% vs 61%), sensitivity (49% vs 36%), and specificity (83% vs 77%) (all comparisons p < .05). Interrater reliability was fair for experts and poor for nonexperts (ICC: 0.48 vs 0.34), while intrarater reliability was excellent and good, respectively (ICC: 0.9 and 0.6). The main effects of expertise and underlying pathology were significant in the linear model (p < .001).

CONCLUSION

Clinicians demonstrate inadequate performance screening for laryngeal mass from voice to use auditory perception for dysphonia triage. Experts' superior performance indicates that there is acoustic information in a voice that may be utilized to detect laryngeal mass based on voice.

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.

Vocal Folds Leukoplakia: The Efficacy of Vitamin A in the Initial Treatment

Introduction  Laryngeal leukoplakia corresponds to a white lesion in the mucosa developed by the deposit of keratin in the epithelium, potentiated by chronic smoking. It is considered a preneoplastic lesion. Surgery is the most adopted treatment; however, non-surgical treatment is advocated by some authors. Objective  To evaluate the effectiveness of vitamin A in the management of vocal fold leukoplakia. Methods  Patients with videolaryngoscopy diagnosis of vocal fold leukoplakia were selected. The endoscopic images were photographed and with the aid of the ImageJ software (National Institutes of Health, Bethesda, MD, USA), the proportion of the size of the leukoplakia was calculated. Eligible patients were prescribed 50,000U of vitamin A, twice daily for 2 months, at which point videolaryngostroboscopy was repeated for comparative analysis between pre and posttreatment. The efficacy of the treatment was classified as: outcome I - complete improvement of the lesion, outcome II - partial improvement, and outcome III - no difference or increased lesion size. Results  Fifteen patients (eight women, seven men) were included, six of whom had bilateral lesions. Smoking was reported in 86.8% of patients. Complete improvement of the lesion was found in 7 cases (33.4%, outcome I), partial improvement in 6 (28.6%, outcome II), and worsening of the injury in 8 (38.1%, outcome III). Of the latter, 6 underwent microsurgery; histopathology indicated absence of dysplasia in 3, and mild dysplasia in 3. Conclusions  In this study, the treatment with vitamin A at a dose of 100,000 IU daily for 2 months was effective in reducing the laryngeal leukoplakia size in 62% of cases.

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.

Videolaryngoendoscopic and Stroboscopic Evaluation in Predicting the Malignancy Risk of Vocal Fold Leukoplakia

Background: Vocal fold leukoplakia (VFL), despite our knowledge of its etiopathogenetic factors, and the development of laryngeal visualization, remains a diagnostic and therapeutic challenge. Objective: This research aimed to explore the efficacy of clinical and morphological feature identification in videolaryngoendoscopy (VLE) using a three-tier classification, and videolaryngostroboscopy (VLS) in predicting the risk of VFL malignant transformation. Material and Methods: We examined 98 patients with VFL by flexible endoscopy under VLE and VLS. Morphological characteristics of 123 lesions including the surface, margin, and texture were assessed; then, VFL was subdivided into three types: I—flat and smooth, II—elevated and smooth, and III—rough. Based on the histopathological findings, 76 (61.79%) lesions were classified as low- and 47 (38.21%) lesions as high-grade dysplasia. Results: The inter-rater agreement between two raters evaluating the VFL in VLE was almost perfect (Cohen’s kappa = 0.826; p < 0.00; 95%CI 0.748−0.904). In ROC curve analysis, the AUC difference between Rater I and Rater II was 0.024 (0.726 vs. 0.702). In multivariate analysis, high-risk VFL was positively related to unilateral plaque localization (p = 0.003), the type III VLE classification (p = 0.013), absence of a mucosal wave (p = 0.034), and a positive history of alcohol consumption (p = 0.047). In ROC analysis, VLE had an AUC of 0.726, with a high sensitivity of 95.7% and low specificity of 40.8%. The NPV was high, at 93.9%; however, the PPV was low, at 50%. The proposed logistic regression model including features significant in multivariate analysis showed lower sensitivity (80.9% vs. 95.7%) and lower NPV (86.2% vs. 93.9%); however, the specificity and PPV were improved (73.7% vs. 40.8% and 65.5% vs. 50.0%, respectively). Conclusions: The combination of clinical history with endoscopic (plaque morphology) and stroboscopic examination (mucosal wave assessment) can fairly estimate the degree of dysplasia in VFL and thus is recommended for use in clinical settings. The findings of this study can be used to guide the decision regarding immediate biopsy or watchful waiting.

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.

Vocal Outcome After Cordectomy by Transoral CO2 Laser Microsurgery in Patients With Laryngeal Intraepithelial Neoplasia and Non-neoplastic Lesions

OBJECTIVES

This study investigates vocal outcome after cordectomy by transoral CO2 laser microsurgery (TLM-cordectomy) in patients with laryngeal intra-epithelial neoplasia (LIN) or non-neoplastic lesions (NNL), for improved individual patient advice and potential adjustment of national treatment strategy by which patients suspected to have glottic LIN or T1a cancer are offered TLM-cordectomy, without prior biopsy.

STUDY DESIGN

Prospective, longitudinal, quasi-experimental time series.

METHODS

Consecutively included patients (n = 155) with LIN (n = 84) or NNL (n = 71) who underwent voice assessments before and after TLM-cordectomy. The multi-dimensional voice assessment protocol comprised voice and speech range profiles, aerodynamics, acoustic analysis, self-evaluated voice handicap, and perceptual auditory voice ratings.

RESULTS

Median follow-up time was 195 (range 50-1121) days for patients with LIN and 193 (range 69-1294) days for patients with NNL. Statistically significant changes, LIN: in voice handicap index (VHI) and breathiness after TLM-cordectomy. Statistically significant changes, NNL: voice range profile (voice range area, intensity range, and frequency range) and VHI after TLM-cordectomy. All group-wise changes were to less disordered voices. Previous smokers had the largest decreases in VHI and breathiness. Patients with baseline VHI scores >65 had smaller increases in VHI, however 13-19% of the patients had increases in VHI above the clinically relevant threshold after TLM-cordectomy.

CONCLUSION

Overall, TLM-cordectomy in patients with LIN and NNL improved vocal outcome and our study thus supports the current Danish treatment strategy and improves the basis for proper patient advice. Multi-dimensional voice assessment is suggested preoperatively and six-nine months postoperatively, with focus on individual vocal differences and voice demands.

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.

Genetic polymorphisms and protein levels in vocal fold leukoplakia: a systematic review

Vocal fold leukoplakia (VFL) has a risk of malignant transformation. Therefore, patients can have symptoms such as dysphonia, vocal strain, difficulty breathing, and dysphagia. Additionally, there is a genetic predisposition that can be associated with genetic polymorphisms. We aimed to evaluate the influence of genetic polymorphisms and protein levels in the etiology of VFL. Our study followed the PRISMA checklist and was registered on PROSPERO database. The questions were: "Are genetic polymorphisms involved in the etiology of VFL? Are protein levels altered in patients with VFL?". Eligibility criteria were case control studies that compared the presence of polymorphisms or/and protein levels of subjects diagnosed with VFL and healthy controls. Of the 905 articles retrieved, five articles with a total of 1038 participants were included in this study. The C allele of the single nucleotide polymorphisms (SNP)-819 T/C IL-10, A allele of the SNP -592 A/C IL-10, CT genotype of the SNP rs11886868 C/T BCL11A, GG genotype of the SNP rs4671393 A/G BCL11A, LL genotype, and L allele of (GT)n repeat polymorphisms of the HO-1 were risk factors for VFL development. Nevertheless, there was a lack of association between VFL and the -1082 A/G IL-10, rs14024 CK-1, and -309 T/G Mdm2 SNPs. The concentrations of the MDM2, BCL11A, and HO-1 proteins were modified, while IL-10 levels were normally expressed in these subjects. In conclusion, most markers evaluated in this review could be potential indicators to develop effective therapies, avoiding a malignant transformation of the lesion.

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.

Leukoplakia: An Invasive Cancer Hidden within the Vocal Folds. A Multivariate Analysis of Risk Factors

Introduction

Discerning the preoperative nature of vocal fold leukoplakia (VFL) with a substantial degree of certainty is fundamental, seeing that the histological diagnosis of VFL includes a wide spectrum of pathology and there is no consensus on an appropriate treatment strategy or frequency of surveillance. The goal of our study was to establish a clear schedule of the diagnostics and decision-making in which the timing and necessity of surgical intervention are crucial to not miss this cancer hidden underneath the white plaque.

Material and Methods

We define a schedule as a combination of procedures (white light and Narrow Band Imaging diagnostic tools), methods of evaluating the results (a combination of multiple image classifications in white light and Narrow Band Imaging), and taking into account patient-related risk factors, precise lesion location, and morphology. A total number of 259 patients with 296 vocal folds affected by leukoplakia were enrolled in the study. All patients were assessed for three classifications, in detail according to Ni 2019 and ELS 2015 for Narrow Band Imaging and according to Chen 2019 for white light. In 41 of the 296 folds (13.9%), the VFL specimens in the final histology revealed invasive cancer. We compared the results from the classifications to the final histology results.

Results

The results showed that the classifications and evaluations of the involvement of anterior commissure improve the clinical utility of these classifications and showed improved diagnostic performance. The AUC of this model was the highest (0.973) with the highest sensitivity, specificity, PPV, and NPV (90.2%, 89%, 56.9%, and 98.3%, respectively).

Conclusion

The schedule that combines white light and Narrow Band Imaging, with a combination of the two classifications, improves the specificity and predictive value, especially of anterior commissure involvement.

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.

Cancer of the Larynx and Hypopharynx

The Radiation Therapy Oncology Group 91-11 trial and US Veterans Affairs trial revolutionized the way locally advanced laryngeal cancers are treated. Adjuvant therapies exist aimed toward laryngeal preservation using docetaxel, cisplatin, and fluorouracil. Cetuximab is a cornerstone of treatment due to the large role of epidermal growth factor receptor in laryngeal and hypopharyngeal carcinomas. In addition, the immune system is vital in the prevention of recurrence, and various immunomodulators against programmed cell death receptor 1 are being investigated. Multidisciplinary management of the patient with laryngeal and hypopharyngeal is key, as many vital functions are affected by this devastating disease.

Malignant Transformation Rate of Non-reactive Oral Hyperkeratoses Suggests an Early Dysplastic Phenotype

The presence of epithelial dysplasia (ED) in oral leukoplakia is the single most important predictor of malignant transformation (MT). The majority of leukoplakias, however, do not show evidence of ED and yet MT of these lesions is well-recognized. These lesions have been referred to as "hyperkeratosis/hyperplasia, no dysplasia," "keratosis of unknown significance" and "hyperkeratosis, not reactive (HkNR)." This study evaluates the MT rate of such leukoplakias. A literature review was performed to identify cohort studies on leukoplakias where (1) there was a recorded histopathologic diagnosis, (2) cases of "hyperkeratosis/hyperplasia, no dysplasia" comprised part of the cohort, and (3) follow-up information was available. There were 9,358 leukoplakias, of which 28.5% exhibited ED while 37.7% consisted of HkNR. Follow-up ranged from 15 to 73 months. The incidence of MT in leukoplakia exhibiting HkNR was 4.9%, compared to 15.3% for ED. Among oral squamous cell carcinomas (SCC) with previously biopsied, site-specific precursor lesions, 55.7% arose from ED/carcinoma in situ and 28.0% arose from HkNR. Leukoplakia exhibiting HkNR has a substantial MT rate, similar to that of mild ED, and must be recognized and managed appropriately to reduce oral SCC incidence.

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.

Cigarette smoke-induced changes in the murine vocal folds: a Raman spectroscopic observation

Raman spectroscopic methods are being projected as novel tools to study the early invisible molecular level changes in a label-free manner. In the present study, we have used Raman spectroscopy to explore the earliest biochemical changes in murine vocal folds in response to time-bound cigarette smoke exposure. Mice were exposed to cigarette smoke for 2 or 4-weeks through a customized smoke inhalation system. The larynx was collected and initial evaluations using standard methods of analysis such as histopathology and immunofluorescence was performed. Concurrent unstained sections were used for Raman imaging. Two common pathological features of vocal fold disorders including alterations in collagen content and epithelial hypercellularity, or hyperplasia, were observed. The mean spectra, principal component analysis, and Raman mapping also revealed differences in the collagen content and hypercellularity in the smoke exposed tissues. The differences in 2-week exposed tissues were found to be more prominent as compared to 4-week. This was attributed to adaptive responses and the already reported biphasic effects, which suggest that collagen synthesis is significantly reduced at higher cigarette smoke concentrations. Overall findings of the study are supportive of the prospective application of Raman imaging in monitoring changes due to cigarette smoke in the vocal folds.

Glottic Keratosis: Significance and Identification of Laryngoscopic Findings

Objective

Glottic keratosis poses a challenge because a decision to biopsy must weigh the likelihood of dysplasia and cancer against the voice outcome after biopsy. We determined the significance of laryngoscopic findings and agreement among clinicians to identify those specific findings.

Study Design

Retrospective case-control study.

Setting

Tertiary care university hospital.

Methods

Adults with glottic keratosis with preoperative office laryngoscopies were included. Preoperative videostroboscopies were reviewed by a blinded reviewer. Multivariable logistic regression was used to examine the correlation between laryngoscopic appearance of glottic keratosis and presence or absence of high-grade dysplasia or carcinoma on biopsies. Consensus among head and neck cancer surgeons to detect specific laryngoscopic findings was evaluated by presenting representative laryngoscopies to a blinded cohort. Interrater reliability was calculated using Fleiss’s κ.

Results

Sixty glottic keratotic lesions met inclusion criteria. On logistic regression, both erythroplakia and aberrant microvasculature like vascular speckling were significantly associated with high-grade dysplasia and carcinoma, P = .002 and P = .03, respectively. Interrater reliability among clinicians to identify erythroplakia and aberrant microvasculature was minimal, κ = 0.35 and κ = 0.29, respectively. Interrater reliability was improved with the use of virtual chromoendoscopy.

Conclusion

The presence of erythroplakia and aberrant microvasculature in glottic keratosis is associated with the presence of high-grade dysplasia or carcinoma. Virtual chromoendoscopy can be used to improve reliability for detecting erythroplakia and vascular speckling, and this is a potential area for practice-based learning. Clinicians should identify and consider immediate diagnostic biopsy of suspicious glottic keratosis.

Role of Narrow Band Imaging Endoscopy in Preoperative Evaluation of Laryngeal Leukoplakia: A Review of the Literature

INTRODUCTION

Leukoplakia is a precancerous lesion considered to be within the spectrum of histopathological results from parakeratosis, through stages of dysplasia to invasive cancer. Narrow band imaging (NBI) endoscopy has been introduced to improve early diagnosis of benign and malignant laryngeal lesions. The aim of this literature review was to evaluate the accuracy of preoperative evaluation of vocal fold leukoplakia with NBI endoscopy in comparison with histology.

METHODS

A systematic review of the literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using 3 different databases: PubMed, Embase, and Scopus. The included articles in the systematic review were identified combining each of the following terms: "narrow band imaging" OR "NBI," [AND] with each of these terms: "laryngeal leukoplakia," OR "vocal fold leukoplakia," OR "vocal cord leukoplakia."

RESULTS

The articles that fully met the inclusion criteria were 5 case series, conducted between January 2010 and February 2018, and published between 2017 and 2019. The selected articles included 312 patients (86% males and 14% females), affected by 382 vocal cord leukoplakia, evaluated with NBI endoscopy and that underwent surgical microlaryngoscopy with biopsy. Based on the studies included in the review, accuracy of NBI in predicting malignancy within leukoplakia ranged from 81% to 97.8%, demonstrating to be an accurate method to predict the risk of malignant transformation of vocal fold leukoplakia.

CONCLUSION

Narrow band imaging can help otolaryngologists in the decision-making process on the necessity to perform a biopsy and transoral surgery or long-term follow-up. Larger studies are necessary to confirm the high association of NBI evaluation of the epithelium surrounding the leukoplakia with the histological diagnosis.

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.

Correlation of Clinical and Pathological Diagnosis and Inflammatory Markers for Patients Undergoing Laryngeal Microsurgery

BACKGROUND

The purpose of this study was to investigate the rate of concordance between indirect- and direct laryngoscopy and final pathology in patients undergoing laryngeal microsurgery.

STUDY DESIGN

Retrospective case study.

METHODS

This study was conducted in the Otolaryngology clinic of a tertiary center between January 2017 and June 2020. Archives records of 432 patients, who underwent laryngeal microsurgery because of benign and premalignant lesions or malignancy, were examined. The patients were divided into three subgroups according to pathology results: benign lesions, premalignant lesions, and malignancies.

RESULTS

There were 400 laryngeal lesions from 385 patients, that met the inclusion and exclusion criteria, 307 (79.7%) were male and 78 were (20.3%) female. The average age of patients was 52.88 ± 13.21 years. The most common diagnosis was polyp (34.25%) followed by squamous cell carcinoma (27.75%) and Reinke's edema (8.25%) according to final pathology. For the benign laryngeal lesions, a high correlation level was observed regarding the compatibility of the indirect- and direct laryngoscopy diagnosis, and final pathology (P < 0.001). The laryngeal premalignant lesions and malignancies were significantly more common in older age and male gender (P <0.001). Similarly, smoking usage was more frequent in patients with premalignant lesions and malignancy (P <0.001). The neutrophil count, neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, neutrophil to platelet ratio as well as CRP value were significantly higher in malignancy group (P <0.05). On the other hand, lymphocyte ratio was smaller in the malignancy group compared with the benign and premalignant lesions, and this difference was significant (P = 0.016).

CONCLUSION

Our study demonstrated a high rate of agreement between the clinical diagnosis and pathology results in patients with benign laryngeal lesions, in contrast to premalignant lesions and malignancies. Also, the neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, neutrophil to platelet ratio as well as CRP were shown to be increased in patients with laryngeal malignancies.

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).

European Laryngological Society position paper on laryngeal dysplasia Part I: aetiology and pathological classification

Purpose of review

To give an overview of the current knowledge regarding the aetiology, epidemiology, and classification of laryngeal dysplasia (LD) and to highlight the contributions of recent literature. As most cases of dysplasia occur at the glottic level and data on diagnosis and management are almost exclusively from this location, laryngeal dysplasia in this position paper is taken to be synonymous with dysplasia of the vocal folds.

Summary

LD has long been recognized as a precursor lesion to laryngeal squamous cell carcinoma (SCC). Tobacco and alcohol consumption are the two single most important etiological factors for the development of LD. There is currently insufficient evidence to support a role of reflux. Although varying levels of human papillomavirus have been identified in LD, its causal role is still uncertain, and there are data suggesting that it may be limited. Dysplasia has a varying presentation including leukoplakia, erythroleukoplakia, mucosal reddening or thickening with exophytic, “tumor-like” alterations. About 50% of leukoplakic lesions will contain some form of dysplasia. It has become clear that the traditionally accepted molecular pathways to cancer, involving accumulated mutations in a specific order, do not apply to LD. Although the molecular nature of the progression of LD to SCC is still unclear, it can be concluded that the risk of malignant transformation does rise with increasing grade of dysplasia, but not predictably so. Consequently, grading systems are inherently troubled by the weak correlation between the degree of the dysplasia and the risk of malignant transformation. The best data on LD grading and outcomes come from the Ljubljana group, forming the basis for the World Health Organization classification published in 2017.

Biomarkers for Malignant Potential in Vocal Fold Leukoplakia: A State of the Art Review

OBJECTIVE

To explore biomarkers that are candidates for understanding potential degeneration to malignancy of vocal fold leukoplakia (VFL), with the goal of guiding future diagnostic and treatment recommendations.

DATA SOURCES

PubMed and Medline search engines.

REVIEW METHODS

A systematic review was conducted by searching the following key words: vocal fold or laryngeal, coupled with leukoplakia or dysplasia, and combined with the term prognostic markers. We collated the biomarkers and their significance, followed by observing the power of their evidence by assessing the quality of the studies according to guidelines of tumor marker prognostic studies (REMARK).

CONCLUSIONS

Prognostic biomarkers in the 16 studies are generally divided into 3 categories according to their biological roles: proliferation (Ki-67, CK-1 RS14024 SNP), cell cycle control (P53, p16, cyclin D1, p57kip2, interleukin-10 [IL-10], miR-10a, and miR-34c), cell adhesion, and invasion (neutrophil-to-lymphocyte ratio, OPN/CD44v6 axis, MMP-1, vascular endothelial growth factor A, MMP-9, serpin peptidase inhibitor 1, plasminogen activator, CTNN/B1, β-catenin, NANOG, HERG1). The prognostic use of these biomarkers is limited due to the variable methodologies, study design, assay methods, and statistical analysis performed.

IMPLICATIONS FOR PRACTICE

Prognostic factors in vocal fold leukoplakia have important clinical implications regarding the potential for malignant degeneration. Although further study is needed, the currently available evidence suggests that p53, p16, cyclin D1, IL-10, NLR, OPN and CD44v6, CTNNB1, and CTTN and FAK might be of particular interest in determining prognosis of VFL as related to malignancy. Future, large, well-designed, prospective studies are expected to determine the prognostic power of these biomarkers before their implementation in routine clinical practice.