Treatment with laser CO2 cordectomy and clinical implications in management of mild and moderate laryngeal precancerosis

Abstract

All the classification of precancerous lesions are based on the progression of specific histopathological characteristics, which in turn considers the grade of epithelial hyperplasia and dysplasia, nevertheless the transformation of laryngeal keratosis into carcinoma occurs through progressive modifications of normal epithelium in keratosis without dysplasia, to the point of degenerating into carcinoma in situ. The treatment of laringeal precancerosis has not yet defined a gold standard: according to some authors, a simple excision biopsy may be sufficient, others, instead, perform the stripping of the involved vocal cord, while others yet perform vaporization by means of CO2 laser. The aim of this paper is to evaluate and possibly validate the treatment of mild and moderate laryngeal dysplasia (LIN1-2) by CO2 laser, with particular attention to oncological and functional results. Fifty-eight patients (44 males and 14 females, mean age 54.3 years) affected by mild and moderate dysplasia (32 LIN I and 26 LIN II) diagnosed by a bioptic exam, were treated by performing a CO2 laser cordectomy (following the European Society of Laryngology's criteria). Before surgery to the patients was given a questionnaire to identify primary risk factors such as smoking, alcohol use and gastroesophageal reflux, were also handed a Vocal Performance Questionnaire. In all patients was performed a pH measurement over a 24-h period, a voice evaluation using a Kay digital Strobe 920. 84% of patients were smokers; the presence of reflux was reported in 11 patients (19%). The 32 LIN1 cases treated with type I cordectomy determined four recurrences (12.4%), of which two LIN1, one LIN2 and one carcinoma in situ. Of the 26 LIN2 cases examined, the 12 treated with type 1 cordectomy generated 1 recurrence alone with the presence of an invasive carcinoma (T1a) (8.3%), while no recurrences were reported in the group of 14 LIN2 cases treated with type II cordectomy. 93.1% (54/58) of cases showed a complete closing of the glottal plane over time. Considering the results in terms of disease control, and functional outcomes, our experience suggests subepithelial cordectomy (ELS I) for LIN 1 and subligament cordectomy (ELS II) for LIN 1 recurrences; therefore we suggest subligament cordectomy (ELS II) in LIN 2 cases.

Management of laryngeal precancerous lesions

“…As reported by several study, the recurrence of a dysplastic lesion ranges between 9.5 and 46.4%, and the type of treatment was not determinant to the final results [8,[15][16][17][18] (Table 3). The excision biopsy alone does not seem to present higher recurrence rates compared to simple cord stripping or type 1 cordectomy [16].…”

“…The theory of the transformation of laryngeal keratosis into carcinoma, which occurs through progressive modifications of normal epithelium in keratosis without dysplasia, or the point of degenerating into carcinoma in situ, is confirmed by epidemiological data and the tendency to relapse to a more advanced stage of dysplasia [8]. The concept of pre-invasive lesion has more correctly replaced that of precancerous lesion.…”

“…In 90% of cases carcinomas develop from precancerous epithelial lesions [8]. Prompt treatment after an early diagnosis is capable to prevent the development of an invasive neoplasm and the consequent recourse to more invasive laryngeal surgery [3,9].…”

The impact of laryngeal biopsy on voice outcomes: a pilot study

“…Post biopsy, however, comparison of the patient data to the control group, revealed that some perceptual and acoustic changes had occurred, with some parameters no longer significantly different to the control group performance. As such, it may be suggested that these small shifts in function may be due to the removal of tumour tissue as supported by some authors [14][15][16].…”

“…The biopsy, an important key step in the initial diagnostic process for laryngeal cancer, can occur using a variety of techniques and is dependent upon lesion characteristics (superficial versus invasive versus exophytic), location of the lesion and individual surgeon skill and preferences [1,14,15]. For glottic tumours, the endoscopic excisional biopsy is favourably reported since it has the dual purpose in that it is both diagnostic and optimises therapeutic outcomes in a single procedure [14,16,17].…”