The interpretation of leukoplakia in laryngeal pathology

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.

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.

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.

A new classification of vocal fold leukoplakia by morphological appearance guiding the treatment

OBJECTIVE

To provide a reference for classification and treatment of vocal cords leukoplakia.

METHODS

640 cases of patients with vocal cords leukoplakia were divided into three groups based on the appearances. There were respectively 81 smooth flat lesions, 155 smooth hypertrophy lesions and 13 rough lesions were treated with conservative methods and 26, 153 and 212 cases were resected surgically for biopsy.

RESULTS

A majority of smooth flat leukoplakia lesions were cured by non-operational methods and no atypical hyperplasia. Most of rough lesions were invalid and even progressed treated with conservative therapy and were severe dysplasia or canceration. Although 67.6% smooth hypertrophy lesions were cured or improved by conservative methods and 47% lesions had no or mild dysplasia, over 30% of lesions were still invalid or progressed and over 50% had moderate, severe dysplasia and canceration. By statistical analysis, the appearance of leukoplakia was concordant with pathological changes.

CONCLUSIONS

It is suggested that smooth flat vocal cords leukoplakia could be treated with conservative methods and rough lesions should be resected operationally, while for smooth hypertrophy vocal cords leukoplakia could be first followed-up and then adopt measures based on the appearance changes.

Association of laryngeal cancer with vocal cord leukoplakia and associated risk factors in 1,184 patients diagnosed in otorhinolaryngology practices in Germany

The aim of the present study was to analyze the association between laryngeal cancer and vocal cord leukoplakia in a large nationwide practice database. The study sample included 1,184 patients aged 18-90 years from 113 otorhinolaryngology practices in Germany who were diagnosed with vocal cord leukoplakia between 2007 and 2014. The rates of laryngeal cancer diagnosis within 5 years and the associated risk factors were analyzed. Within 6 months of initial diagnosis of vocal cord leukoplakia, 11% of the patients were diagnosed with laryngeal cancer. Between 7 months and 5 years after the diagnosis of leukoplakia, laryngeal cancer was diagnosed in 7.6% of the patients. Overall, within 5 years of leukoplakia diagnosis, 18.6% of the patients were diagnosed with laryngeal cancer (26.1% of men and 6.3% of women; P<0.001). Moreover, 31.3% of patients aged >65 years, 16.1% of patients aged 50-65 years and 7.6% of patients aged <50 years were diagnosed with laryngeal cancer (P<0.001). Patients aged >65 and those aged 50-65 years had a higher risk of being diagnosed with laryngeal cancer [odds ratio (OR)=4.90 and 2.55, respectively]. Furthermore, the risk of being diagnosed with laryngeal cancer was higher in men compared with that in women (OR=4.09). In the present real-world analysis, the rate of laryngeal cancer underlying vocal cord leukoplakia at first diagnosis appeared to be higher compared with the secondary malignant transformation rate occurring later during the course of the disease. Risk factors for laryngeal cancer included advanced age and male sex.

The usefulness of narrow-band imaging for the diagnosis and treatment of vocal fold leukoplakia

OBJECTIVE

This research was aimed to explore the efficacy of narrow-band imaging (NBI) on distinguishing the degree of dysplasia of vocal fold leukoplakia.

METHODS

Patients were examined by flexible endoscopy, under white light endoscopy (WLE) and NBI. 78 lesions were divided into two groups according to the NBI classification. Group 1: non-dysplasia (ND), including squamous hyperplasia with hyperkeratosis or parakeratosis; Group 2: squamous hyperplasia with mild or moderate dysplasia (MD) or severe dysplasia (SD), or carcinoma in situ (CIS).

RESULTS

The diagnostic accuracy of NBI for Group 1 and Group 2 was 69.70% (23/33) and 95.56% (43/45), respectively, and the kappa index was 0.711 and a p value < .05, which was considered statistically significant.

CONCLUSIONS

The NBI could roughly estimate the degree of dysplasia. Differentiating between ND, MD, SD, and CIS, which may be useful for clinicians on selecting suitable therapies.

Clinicopathological parameters associated with histological background and recurrence after surgical intervention of vocal cord leukoplakia

Histological examination of biopsy shows usefulness in the diagnosis of vocal cord leukoplakia; however, in considerable amount of cases, the examination cannot provide definitive diagnosis of malignancy from benign conditions such as hyperplasia and dysplasia. The present work therefore was aimed to identify clinicopathological factors and molecular markers predictive of recurrence and malignant transformation of vocal cord leukoplakia.Clinical data of 555 cases of vocal cord leukoplakia enrolled from July 1999 to June 2014 were analyzed. The cohort consisted of keratosis (n = 137), hyperplasia (n = 139), dysplasia (n = 177), and primary (n = 10) and invasive (n = 46) carcinoma. Correlations between patients' backgrounds, clinicopathological factors, molecular markers (p53, p16, Ki67, cytokeratin, and proliferating cell nuclear antigen), and histology backgrounds were examined using by Pearson Chi-squared or Fisher exact test. Reflux symptom index (RSI) and reflux finding score (RFS) before and after treatment were compared using Wilcoxon signed-rank test. Risk factors for disease recurrence were identified using Cox proportional hazards models of multivariate analysis. Time to recurrence was analyzed using log-rank test of Kaplan-Meier method.In the present cohort, alcohol drinking was found associated with GRBAS grade (P = .0258) and the site (P = .0298) of leukoplakia. For the different disease types, chief complaint (P = .0179), GRBAS grade (P = .0101), mucosal wave (P < .0001), and molecular markers p53 (P < .0001) and Ki67 (P < .0001) were identified as correlates. RSI and RFS were significantly lowered by surgical intervention. A single side of leukoplakia was predictive of a lower risk of recurrence (odds ratio, 0.378; 95% confidence interval, 0.197-0.723; P = .0033). Absence of mucosal wave was associated with a shorter time-to-recurrence (P = .0357).The present work identified clinicopathological factors and molecular markers associated with the different histology of vocal cord leukoplakia, and also the prognostic factor for the low risk of recurrence after surgery.

The role of narrow-band imaging (NBI) endoscopy in optical biopsy of vocal cord leukoplakia

The aim of this study was to investigate whether observing microvascular changes by narrow-band imaging (NBI) endoscopy in the area surrounding leukoplakia is sufficient for discriminating between benign and malignant patterns of vocal cord leukoplakia. A total of 282 patients were investigated using white-light high-definition TV laryngoscopy and NBI endoscopy from 6/2013 to 8/2015, and 63 patients with a primary case of laryngeal leukoplakia were enrolled. Patients were divided into two groups based on leukoplakia with surrounding malignant intraepithelial papillary capillary loops (group I; 26/63) and leukoplakia with a surrounding benign vascular network (group II; 37/63), both by NBI endoscopy. All 63 patients were evaluated by blinded histological examination, and results were compared with NBI optical biopsy. Carcinoma in situ or invasive squamous cell carcinoma was confirmed in 22/26 cases (84.6 %) in group I. Hyperkeratosis or low-grade dysplasia was confirmed histologically in 31/37 (83.8 %) and squamous cell carcinoma in 2/37 (5.4 %) cases in group II. Accordance of NBI endoscopy and histopathological features of vocal cord leukoplakia lesions was statistically significant (kappa index 0.77, p < 0.001), with a sensitivity of 88.0 % (95 % CI 67.8-97.5 %) and specificity of 89.5 % (95 % CI 71.2-97.1 %). NBI is convenient for improving evaluation of laryngeal leukoplakias based on optic prehistological diagnosis. The close accordance between NBI features and histological results suggests that a negative NBI endoscopy may be an indication for long-term endoscopy follow-up without histological evaluation.

Positive therapy of andrographolide in vocal fold leukoplakia

PURPOSE

Vocal fold leukoplakia is a premalignant precursor of squamous cell carcinoma. Although many efforts have been contributed to therapy of this disease, none exhibits a satisfactory result. The aims of this study were to investigate the effectiveness and feasibility of andrographolide therapy in vocal fold leukoplakia and to explore the preliminary mechanism underlying.

MATERIALS AND METHODS

Forty-one eligible patients were enrolled in the study. The patients were treated for 10-minute exposures of 5 ml (25mg/ml) andrographolide injection aerosols twice a day, and 2 weeks was considered as one treatment course. Electronic laryngoscope was used to observe the condition of vocal fold leukoplakia during the treatment. Every patient received one or two treatment courses, and the follow-up was carried out for 12 months. Toxic reactions of treatments were evaluated on the basis of the standards of the United States MD Anderson Cancer Center. Moreover, laryngeal carcinoma cell line Hep2 was applied to explore the mechanism of effect of andrographolide. Anti-proliferative effect on Hep2, cell nuclear morphology, express of mitogen-activated protein kinases (MAPK) and pro-apoptotic protein were detected after andrographolide treatment.

RESULTS

We found that andrographolide exhibited significant curative effects on treatments, which were accompanied by thinning of the lesion of leukoplakia, reduction in the whitish surface area, and return of pink or red epithelium. A complete response up to 85% was observed, and no toxic side effect events occurred during the study. No patient with a complete response had a recurrence in the follow-up. Moreover, cellular experiments in Hep2 indicated that andrographolide activated MAPK pathway and caspase cascade, and finally induced apoptosis in laryngeal carcinoma cell.

CONCLUSIONS

The advantages of andrographolide are connected with minimally invasive and localized character of the treatment and no damage of collagenous tissue structures, which are more convenient and less painful for patients. These results suggest that andrographolide treatment is a viable strategy for curing vocal fold leukoplakia.

Oral premalignant lesions: from the pathological viewpoint

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