Abstract
Background: The endoscopic appearance of glottic erythroleukoplakias is non-predictive of their histopathology, potentially ranging from keratosis to invasive squamous cell carcinoma (SCC). The aim of this study was to assess a comprehensive workup for the one-step diagnosis and treatment of mid-cord erythroleukoplakias, using CO2 laser excisional biopsy. Methods: We evaluated 147 untreated patients affected by 155 mid-cord erythroleukoplakias submitted to excisional biopsy by subepithelial (Type I) or subligamental cordectomy (Type II), across two academic institutions. Patients were evaluated by preoperative videolaryngostroboscopy, pre- and intraoperative videoendoscopy with biologic endoscopy (narrow band imaging, NBI, or the Storz professional image enhancement system, SPIES), either with or without intraoperative saline infusion into the Reinke’s space. Adequacy of treatment was the primary outcome. Results: The histopathologic diagnosis was keratosis in 26 (17%) cases, squamous intraepithelial neoplasia (SIN1-2) in 47 (30%), carcinoma in situ in 21 (14%), and SCC in 61 (39%) patients. The adequacy of treatment across the entire cohort was 89%. The intraoperative saline infusion procedure, facing not clearly suspicious lesions, raised the adequacy of treatment from 60% to 90% (p = 0.006). Conclusions: Excisional biopsy by Type I–II cordectomies, after a comprehensive diagnostic workup, should be accepted as an adequate and cost-effective treatment of unilateral mid-cord glottic erythroleukoplakias.
Highlights
The diagnosis and treatment of premalignant and early malignant glottic lesions are still challenging due to the need for correct one-step diagnosis and treatment by excisional biopsy, which aims for the best compromise between oncological radicality and satisfactory vocal outcomes
A retrospective study was carried out, enrolling 147 previously untreated patients, 139 (94.5%) of whom were affected by unilateral mid-cord erythroleukoplakias, and 8 (5.5%), by bilateral mid-cord lesions without involvement of the anterior commissure, who underwent a total of 155 excisional biopsies by transoral CO2 laser microsurgery (CO2 TOLMS according to the ELS nomenclature [14])
The extent of the resection was graded according to the ELS classification as subepithelial (Type I) and subligamental (Type II) cordectomies [4,5]
Summary
The diagnosis and treatment of premalignant and early malignant glottic lesions (arising, in most cases, as leuko- or erythroleukoplakias) are still challenging due to the need for correct one-step diagnosis and treatment by excisional biopsy, which aims for the best compromise between oncological radicality and satisfactory vocal outcomes. Multiple incisional biopsies may cause undue damage and fibrosis to the multi-layered and delicate microanatomy of the vocal cord [3], forcing the surgeon to subsequently perform a wider and deeper resection, in terms of transmuscular cordectomy (Type III according to the European Laryngological Society (ELS) classification [4]), in order to excise the tumor and surrounding cicatricial tissues. In such a scarred vocal cord scenario, all the sophisticated diagnostic techniques described would become useless or, at least, greatly hampered [5,6].
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