Clinically based comments on the proposal for revision of the European Laryngological Society (ELS) classification of endoscopic cordectomies

Abstract

Sir, We read with interest the recent proposal for revision of the ELS classiWcation of endoscopic cordectomies by Remacle et al. [3]. It formally modiWes the previous classiWcation [1], but, in our opinion, there are still some points that should be discussed and reconsidered. At least in our Country, the number of literature citations reported by Remacle et al. [3] surely underestimates the wide diVusion and acceptation of ELS cordectomies’ ClassiWcation. Since its introduction in 2000, in our clinical practice, we have been codifying endoscopic cordectomies according to the ELS Working Committee ClassiWcation [2]. From our viewpoint, this classiWcation deWnitely improved the possibilities of meaningful comparisons between oncological and functional results achieved by diVerent groups of surgeons. Moreover, endoscopic laserassisted cordectomy is often an unlikely reproducible procedure, and following the classiWcation categories may signiWcantly contribute to surgical technique learning. The revised ELS ClassiWcation introduced the type VI cordectomy, indicated for carcinomas originating in the anterior commissure with or without extension to one or both vocal folds with no inWltration of thyroid cartilage. Obviously, this modiWcation is formally reasonable, but probably it does not have a signiWcant impact on ClassiWcation’s structure, because the occurrence of this localization is quite unusual (considering our experience of 200 patients who have undergone laser-assisted cordectomy in Vittorio Veneto Institution since 2001, this occurrence represented approximately 3% of the cases) (Fig. 1). Bradley et al. [1] and Remacle et al. [3] conWrmed that endolaryngeal laserassisted surgical approach to anterior commissure primary carcinoma is still controversial considering that this localization is frequently associated with a transglottic carcinoma extension. Vocal fold carcinomas involving the laryngeal anterior commissure are signiWcantly more frequent: in these cases endoscopic laser surgery is currently a wellcodiWed surgical option (Fig. 2). We completely agree with Remacle et al. [3] who conWrmed that cordectomy type Va deWnition has to be reconsidered because currently it includes simultaneously surgical excision depths and carcinoma extensions signiWcantly heterogeneous. This problem brings to attention the fact that types I to IV cordectomies’ essential criterium is surgical excision’s depth. On the other hand, type V cordectomy sub-classiWcation (a, b, c, d) is based on superWcial excision extension, not considering surgical excision depth. For this reason, a laryngologist might correctly classify as type V cordectomies both a sub-epithelial excision in a severe dysplasia/in situ carcinoma involving most of the glottis (Fig. 3) and a sub-perichondral excision with subtotal glottic evisceration for a T1b glottic carcinoma (Fig. 4). Obviously, the functional outcomes of these diVerent surgical approaches, both classiWed as type V, are usually very diVerent. In clinical practice, in order to correctly evaluate the postoperative results of patients who have undergone type Va cordectomy, we have to evaluate the exact intraoperative description of lesion’s extension and the performed surgery report. In our opinion, there are no reasons to change the original ClassiWcation of cordectomies from type I to IV. On the other hand, the extension to the contralateral vocal fold (or M. Lucioni (&) Department of Otolaryngology, Vittorio Veneto Hospital, via Forlanini 71, 31029 Vittorio Veneto, Italy e-mail: marco.lucioni@alice.it