Hyperplastic Laryngeal Lesions Research Articles

Vocal-fold leukoplakia and dysplasia. Mini-review by the French Society of Phoniatrics and Laryngology (SFPL)

Vocal-fold leukoplakia and dysplasia are together designated “epithelial hyperplastic laryngeal lesions” (EHLL). Work-up and follow-up are founded on optical examination with high-definition imaging, stroboscopy and narrow-band imaging. Diagnosis is based on pathology, using the new 2017 WHO classification, dichotomizing “low grade” and “high grade”. Statistically, the risk of cancerous progression is 20% within 5 to 10 years of diagnosis, or more in over-65 year-old males; risk for any given patient, however, is unpredictable. Research focuses on the genetic criteria of the lesion and characterization of the tumoral microenvironment. Treatment is exclusively microsurgical. Resection depth is adjusted according to infiltration. EHLL is a chronic disease, necessitating long-term follow-up, which may be hampered by residual dysphonia and surgical sequelae in the vocal folds. Sequelae need to be minimized by good mastery of microsurgical technique and indications. When they occur, biomaterials such as autologous fat and hyaluronic acid can be useful. Tissue bio-engineering is a promising field.

Polymorphisms of the XRCC3 C722T and the RAD51 G135C genes and the risk of head and neck cancer in a Polish population

Genetic variations in DNA repair genes may affect an individual's susceptibility to head and neck cancer. We performed a case–control study to test the association between head and neck cancer risk and two polymorphisms: the C722 T of the XRCC3 and the G135C of the RAD51 —genes of DNA double strand break (DSB) repair by homologous recombination (HRR). Genotypes were determined by PCR-restriction fragment lenght polymorphism (PCR-RFLP). DNA was isolated from peripheral blood lymphocytes of a group of 288 patients consisting of 97 subjects with precancerous hyperplastic laryngeal lesions (PHLL) and 191 subjects with head and neck squamous cell carcinoma (HNSCC) as well as 353 healthy control donors. We found an association between PHLL and the 722CT (OR 6.67; 95% CI 3.02–14.74) as well as 722 TT (OR 4.65; 95% CI 2.30–9.43) variants of the XRCC3 gene. Similar relation was observed between these genotypes and HNSCC (OR 2.59; 95% CI 1.61–4.16 and OR 5.54; 95% CI 3.22–9.52, respectively). Moreover, we also observed an association between PHLL (OR 6.04; 95% CI 3.69–9.90) and HNSCC (OR 6.04; 95% CI 3.69–9.90) and the135GC variant of the RAD51 gene. The gene–gene interaction between XRCC3 and RAD51 polymorphic variants may contribute to higher prevalence of PHLL. The increased risk of this disease was observed in case of the combination of the 722CT/135GC (OR 3.81; 95% CI 1.55–9.75) as well as the 722 TT/135GC genotypes (OR 5.33; 95% CI 1.96–14.47). The presence of the same genes combinations plays a part in higher probability of HNSCC occurrence (OR 2.42; 95% CI 1.22–4.79 for 722CT/135GC and OR 3.63; 95% CI 1.69–7.76 for 722 TT/135GC). We also found an association between these XRCC3 or RAD51 polymorphic variants and smoking status in PHLL (ORs 2.85–10.28 and 1.82–7.35, respectively) and HNSCC patients (ORs 2.94–13.93 and 1.36–3.94, respectively) as well as alcohol intake among PHLL (ORs 3.44–6.12 and 3.52–8.43, respectively) and HNSCC subjects (ORs 2.71–7.01 and 2.33–4.62, respectively). In conclusion our data showed that the C722 T and the G135C polymorphisms of the XRCC3 and the RAD51 genes might be associated with HNSCC. Finally we suggested that these polymorphisms might be used as predictive factor of precancerous lesion for head and neck cancer in a Polish population.

Zastosowanie klasyfikacji ljubljańskiej do oceny zmian przednowotworowych w krtani

The diagnosis and treatment of laryngeal premalignant lesions has been frustrated because of failure to adequately define the histologic changes that may help in prediction of irreversible neoplastic transformation. To assess the grading of laryngeal hyperplastic epithelial lesion it was used a Ljubljana classification of histologic changes. It was done a retrospective study of 104 laryngeal hyperplastic lesions biopsies that were classified according to the Ljubljana classification comprising benign spinous layer augmentation (simple hyperplasia), benign basal and parabasal layer augmentation (abnormal hyperplasia), alteration of epithelial cells towards malignancy (atypical hyperplasia) and carcinoma in situ. One hundred and four biopsies with preneoplastic changes were reevaluated and classified according to Ljubljana classification. It was found 42 cases (40.4%) which showed simple, 38 (36.5%) abnormal, 21 (20.2%) atypical hyperplasia and 3 (2.9%) carcinoma in situ. Three cases of atypical hyperplasia (2.9% of all investigated cases) and one of abnormal (0.96%) progressed to invasive carcinoma during the observation ranging from 5 to 9 years (median 8.1). None of the cases classified as simple hyperplasia showed progression to malignancy. The Ljubljana classification focuses on the important clinical decision involving benign looking hyperplastic lesion that do not require strict follow-up (simple and abnormal hyperplasia); and "risky" epithelium that require close follow-up with repeated histologic assessment to recognize any malignant progression (atypical hyperplasia); and carcinoma in situ that requires fast and complete treatment. We suggest that the Ljubljana classification may give a reliable assessment of laryngeal hyperplastic epithelial lesions and can help in monitoring all those patients.

Divergent Patterns of Allelic Alterations in Premalignant Laryngeal Lesions Indicate Differences in the Impact of Morphological Grading Characteristics

Objectives: Classic histological grading and molecular genetic analysis of epithelial hyperplastic laryngeal lesions (EHLL) were correlated in an attempt to elucidate, which classic marker reflects best the gradual progression of laryngeal premalignant lesions as determined by an increasing number of molecular genetic aberrations. Methods: Thirty-two EHLL were grouped according to four grades of nuclear atypia, four degrees of epithelial maturation and three groups of overall and suprabasal mitotic activity. Overall and suprabasal proliferative activity were measured by MIB-1 immunostaining and staged according to four levels. Allelic imbalance was determined by PCR using 32 microsatellite loci at nine chromosomal arms. Results: Of the six classic criteria, only progressive mitotic indices correlated with allelic alterations in a remarkable variety of microsatellite markers, especially at chromosome 17p. Conclusion: Using the number of allelic alterations as standard for assessment, this preliminary study gives first evidence that certain morphological criteria could reflect differently the gradual progression of premalignant laryngeal lesions with mitotic index being the most promising marker. Further studies with long-term follow-up are required to prove the predictive value of these criteria in daily practice.

Detection of laryngeal carcinoma and epithelial hyperplastic laryngeal lesions via a rapid-access dysphonia clinic.

Recent government initiatives in the UK have focused on streamlining oncology services by reducing waiting times between urgent referral, assessment and treatment of patients with possible cancer. The performance of the Quick Early Diagnosis Dysphonia Clinic of the Queen Elizabeth Hospital, Birmingham, between May 1997 and April 2001 was reviewed. Of 721 patients reviewed, 123 (17 per cent) had clinically suspicious laryngeal lesions. Thirteen cases of epithelial hyperplastic laryngeal lesions and 27 laryngeal malignancies were diagnosed. There was no statistical link between early cancer detection and assessment within two weeks of referral. However, rapid-access clinics for dysphonia serve an important role in the reassurance and multidisciplinary management of patients with persistent hoarseness. Greater financial commitments are necessary to achieve compliance with objectives for a maximum two-week wait for patients with suspected laryngeal malignancy.

The Supplementary Diagnostic Power of Selected Immunohistochemical, Molecular Genetic and Infective Parameters in Epithelial Hyperplastic Laryngeal Lesions

Objectives: MIB-1 and p53 protein expression, loss of heterozygosity (LOH), microsatellite instability (MSI) of di- and mononucleotide repeats, and HPV status were tested for their potential to characterize different stages of epithelial hyperplastic laryngeal lesions (EHLL). Methods: Thirty-two EHLL were reclassified according to the Ljubljana classification into simple (SH), abnormal (AbH), atypical hyperplasia (AtH) and carcinoma in situ, and investigated by immunohistochemical methods, PCR and direct sequencing analysis. Results: MIB-1 increased with progressive grades of EHLL, whereas p53 protein expression was distinctive only between SH and AbH. LOH showed increasing frequency with grades of the lesions, but the distribution of altered loci (9p, 9q, 10q, 11q, 17p) was not qualified to differentiate between the stages. MSI was detected in SH, AbH and AtH without clear correlation to histopathological grading. HPV infection occurred mostly in SH and AbH (both: 66.7%). Conclusion: MIB-1 labeling and allelic loss could assist histopathological diagnosis in the entire spectrum of EHLL, whereas the MSI results point to a genetic instability of the laryngeal mucosa in general and are therefore not helpful in the distinction of different stages of EHLL. However, future molecular genetic analyses should consider more late events of laryngeal carcinogenesis to improve their diagnostic potential. Furthermore, our results indicate that nonrisky and risky EHLL could probably be caused by different exogenous factors.

The Ljubljana classification of epithelial hyperplastic laryngeal lesions: a morphometric evaluation of nuclear pleomorphism

Epithelial hyperplastic laryngeal lesions (EHLL) are associated, with a varying degree of "epithelial risk"- to develop invasive carcinoma. Several classifications have been proposed but none has received a total agreement. The 1999 Ljubljana classification distinguished four grades: simple, abnormal and atypical hyperplasia and in situ carcinoma (ISC). The first two grades are considered benign lesions; the ISC is the malignant lesion, while the atypical hyperplasia is considered a "risky lesion". This is characterized by alterations of epithelial cells towards malignancy, but not to the extent to be found in carcinoma cells. Such characteristics refer to cytomorphological (e.g., nuclear hyperchromatism, nucleoli, increased nuclear/cytoplasmic ratio) and architectural (e.g. stratification, orientation, maturation) features. In the Ljubljana scheme, nuclear pleomorphism is one of the most important features. We wanted to improve the importance of nuclear pleomorphism in the basal cells layer in different classes of EHLL using morphometrical analysis. We studied 8 cases of simple hyperplasia, 10 of abnormal hyperplasia, 10 of atypical hyperplasia and 8 of ISC using the software SAM (Shape Analytical Morphometry). The results were submitted to univariate statistical analysis. Nuclear dimensions (maximum diameter, perimeter and area) showed a progressive increase from simple to atypical hyperplasias to ISC, while abnormal hyperplasia showed the lowest values. On the contrary, analytical parameters related to nuclear contour irregularities and asymmetries showed their highest values in abnormal hyperplasia nuclei. There were no significant differences between atypical hyperplasia and ISC, while it was possible to differentiate abnormal hyperplasia from the others. In conclusion basal nuclei of atypical hyperplasia and ISC are similar so that other cytological and morphological architectural parameters are necessary to distinguish the two lesions. Abnormal hyperplasia seems to be the biological category of 'proliferative " benign laryngeal epithelium; simple hyperplasia refers to "stable" - irritative epithelium.

EPITHELIAL HYPERPLASTIC LARYNGEAL LESIONS: AN OVERVIEW OF RESEARCH WORK IN SLOVENIA AND FURTHER PROSPECTS DEDICATED TO THE MEMORY OF PROFESSOR VINKO KAMBIČ

The article, dedicated to the memory of Professor Vinko Kambic, provides a review of research work on epithelial hyperplastic laryngeal lesions (EHLL) in Slovenia. It is largely thanks to Professor Kambic, who recognized the importance of these challenging problems in laryngology more than three decades ago and studied them systematically throughout his long professional career. His views on etiology, histomorphologic classification with terminological problems and modalities of treatment of EHLL, have been published worldwide, internationally accepted and supported by the European Society of Pathology. Among his greatest achievements, an original histologic grading system of EHLL, the Kambic-Lenart classification, has to be highlighted. The classification, which was further supplemented by the members of the Working group on EHLL of the European Society of Pathology in 1997 and renamed the Ljubljana classification, was devised to cater to specific laryngeal issues. This grading system has been found to be more precise for daily diagnostic work than other classifications and provides data closely correlated to the biological behaviour of the lesions. The results confirm that the central focus of the Ljubljana classification is atypical (or risky) epithelium. For practical purposes, the Ljubljana classification has been based solely on pathohistological criteria of traditional light microscopy. However, for diagnostically difficult cases and when the biological behaviour of recurrent precancerous lesions is to be assessed, additional sophisticated techniques can be of help. Professor Kambic’s team of collaborators owes him a debt of sincere thanks for his long years of teaching, watchful guidance of scientific work, and sincere friendship. With the deepest sense of appreciation for what Professor Kambic did for the development, progress and international recognition of the entire research work of EHLL in Slovenia, we will certainly continue to follow his scientific guidance and his visions of the future. It is hoped that we will make further contributions to the continuing discussions on the pathogenesis and grading of EHLL, based on the future findings of molecular pathology, and that these discoveries will eventually lead to the worldwide acceptance of the Ljubljana classification grading system.

The Ljubljana classification: a practical strategy for the diagnosis of laryngeal precancerous lesions.

There is no internationally accepted classification of epithelial hyperplastic laryngeal lesions (EHLL). The majority of current classifications follow criteria similar to those commonly used for cervical epithelial lesions. However, the different etiology of laryngeal cancer and its particular clinical and histologic features necessitate a grading system more appropriate to this region. The Ljubljana classification of EHLL was devised in 1971 to cater to this requirement. Detailed criteria for histologic grading in this classification were formulated by a working group on EHLL of the European Society of Pathology in 1999. The system recognizes four grades: simple and abnormal hyperplasia are benign categories; atypical hyperplasia ("risky" epithelium) is potentially malignant, and carcinoma in situ actually malignant. The main features by which the proposed grading system differs from other classifications are: 1. the distinction between benign and potentially malignant lesions; 2. the positive separation of carcinoma in situ from atypical hyperplasia; 3. the lack of prognostic significance for any surface keratin layer. The eventual outcome of EHLL patients so graded justifies the proposal for separating the lesions into a benign group, showing malignant transformation in only 0.9% of cases, from a potentially malignant group showing malignant transformation in 11% of cases. For diagnostically difficult cases, supplementary techniques such as those using morphometry, immunohistochemical and molecular biology are advised to improve the accuracy of diagnosis and predictions of their biological behavior.

Clinical applicability of the Ljubljana classification of epithelial hyperplastic laryngeal lesions.

The diagnosis, prognosis, and choice of treatment of various laryngeal lesions depends almost entirely on the interpretation of changes in the covering epithelium. These abnormalities, referred to as epithelial hyperplastic laryngeal lesions, have been graded according to the Ljubljana classification into simple, abnormal and atypical (risky epithelium) hyperplasia and carcinoma in situ. The aim of this study was to evaluate the clinical applicability and prognostic value of this classification and to determine the incidence of malignant transformation. A retrospective clinical-pathological analysis was performed in a series of 4167 patients with 4574 biopsies, treated from 1979 to 1994. Simple (benign prickle cell) hyperplasia was the predominant grade in nodules, polyps, Reinke's oedema, granulomas, and papillomas, accounting for 37.6-68.6% of cases. In chronic laryngitis, abnormal (benign basal cell) hyperplasia was predominant with 43.9% of cases. Atypical ('risky') hyperplasia was observed almost exclusively in patients with chronic laryngitis (16.1%) and papillomas (10.1%), and only exceptionally in patients with vocal cord nodules (0.9%) and Reinke's oedema (0.3%). The percentage of malignant transformation in atypical hyperplasia was 11.6% (13/112 patients in 2-12 years), while in simple and abnormal hyperplasia, it was 0.3% (8/2920 patients in 1.5-11 years). The data support the concept of the Ljubljana classification dividing epithelial hyperplastic laryngeal lesions into benign (simple and abnormal hyperplasia), potentially malignant (atypical hyperplasia) lesions and carcinoma in situ.

Chromosomes 7,17 Polysomies and Overexpression of Epidermal Growth Factor Receptor and p53 Protein in Epithelial Hyperplastic Laryngeal Lesions

Purpose: To visualize directly a sequence of genetic changes underlying the entire spectrum of epithelial hyperplastic laryngeal lesions (EHLL) and laryngeal cancer by the use of non-isotopic in situ hybridization (ISH) for chromosomes 7 and 17 in correlation with overexpression of p53 protein and epidermal growth factor receptor (EGFR). The specific aim was to compare the results and prognostic significance between the two types of EHLL: isolated, mainly atypical hyperplasia or risky epithelium, and EHLL associated with squamous cell carcinoma (SCC). Patients and Methods: 59 tissue specimens of EHLL obtained from 34 patients, graded according to the Ljubljana classification into simple (SH), abnormal (AbH) and atypical hyperplasia (AtH), and carcinoma in situ (CIS) were included in the study. Non-fluorescent ISH for chromosomes 7 and 17 was performed by biotinylated α-satellite DNA probes. Immunohistochemical staining for EGFR and p53 protein was analyzed on the same tissue samples. Results: Polysomy for both chromosomes increased in correlation with progressive grades of EHLL. The most important finding was the statistically significant difference in chromosome copy numbers between the isolated AtH and AtH associated with SCC. Overexpression of EGFR and p53 protein was found in 61 (36/59) and 52% (31/59) of cases, respectively. The immunoreactivity for both markers increased with the grade of lesions, but the staining pattern was not so uniform in isolated EHLL. On the other hand, the immunoreactivity was expressed more constantly in EHLL adjacent to SCC. Conclusions: Numerical changes in chromosomes 7 and 17 might be associated with an upregulation of EGFR and p53 genes, and could contribute to critical events in laryngeal carcinogenesis. For daily practice, the cytogenetic and immunohistochemical analyses could be of assistance in distinguishing between low- and high-risk groups of AtH. However, the isolated forms of atypical hyperplasia need considerable further study by evaluating genetic changes with the described methods regarding their ultimate transformation to carcinoma.

Criteria for grading in the Ljubljana classification of epithelial hyperplastic laryngeal lesions. A study by members of the Working Group on Epithelial Hyperplastic Laryngeal Lesions of the European Society of Pathology.

To validate histological criteria for the grading of epithelial hyperplastic laryngeal lesions (EHHL) (dysplastic laryngeal lesions), we used a system that had been devised and tested in Ljubljana, Slovenia over many years and was felt to be more appropriate to laryngeal pathology than is the commonly-used model of intraepithelial neoplasia in the cervix. Vocal cord biopsies of 45 patients with a broad spectrum of EHLL were reviewed. Detailed histological criteria were formulated for each of the four grades of EHLL in the Ljubljana classification, comprising simple hyperplasia (benign spinous layer augmentation), abnormal hyperplasia (benign basal and parabasal layer augmentation), atypical hyperplasia (risky for malignancy) and carcinoma in situ (actually malignant, but without invasion). Using these criteria a high degree of concordance of histological diagnoses of grading levels for the Ljubljana classification was achieved between the pathologists of the Working Group. The system was found to be more precise for routine diagnostic work than the others in vogue. The different grades of the Ljubljana classification correspond to significantly different levels yielded in each grade by the semiobjective methods of quantitative morphometry and immunohistochemistry.

Epidemiological and Clinical Relief on Hyperplastic Lesions of the Larynx

Fiorella R, Di Nicola V, Resta L. Epidemiological and clinical relief on hyperplastic lesions of the larynx.Chronic hyperplastic laryngopathies are considered precancerous lesions because of their possible transformation in time into malignant epithelial neoplasia. We studied 130 patients affected by “hyperplastic laryngeal lesions” according to their semeiological characteristics. The lesions affected the vocal cords in 127 cases and in only 3 cases the ventricular bands. All patients underwent microlaryngoscopy while under general anesthesia and were treated by limited excision (37'%1) or total stripping (63%). The histomorphological classification by Kleinsasser (7) was used. The following clinical checks showed that 30 out of 48 patients (62.5%) treated by partial stripping recovered; in 11 the lesion relapsed (23%) and in 7 cases (14.5%) a carcinoma appeared. Of those cases treated by total stripping 65 patients (79%) recovered, 12 (15%) relapsed and 5 (6%) showed carcinoma. In conclusion we noticed the appearance of a malignant lesion after surgery in 12 out of 130 cases (9.2%). The cancerization was about 3 times more frequent in patients with histological results of degree II than in those with degree I (17% vs. 6%). Our study confirms that the laryngeal hyperplastic lesion represents a possible passage to cancer in a limited number of cases (< 10%), but with a triple probability for degree II dysplasia in respect to degree I. The patients affected by dyskeratosis, regardless of type of lesion, need a regular follow-up and immediate radical surgery because of the frequent incidence of relapse.

Problems in Outpatients with Laryngeal Hyperplastic Lesions

Goldman NC. Problems in outpatients with laryngeal hyperplastic lesions.The care of outpatients with epithelial hyperplastic lesions of the larynx presents problems of classification, treatment, continued surveillance and prognosis. One hundred patients who underwent microlaryngoscopy and vocal cord stripping from 1990 through 1995 were studied retrospectively with a follow-up period of 8–156 months. Twenty-eight patients with biopsy proven epithelial hyperplastic lesions were given 21 different pathological diagnoses exclusive of invasive carcinoma following 52 operative microlaryngoscopies. Prognosis was inferred and treatment commenced primarily on the basis of the pathology report. Microlaryngoscopy and stripping with and without the carbon dioxide laser, “watchful waiting”, radiation therapy, and partial laryngectomy were all used as treatment modalities. Controversy remains as of choice of treatment. Encouraging the patient to discontinue smoking is an integral part of treatment; however, most patients continue to smoke. Recent changes in the United States health care delivery system present additional problems in surveillance of the patient.

Local immune response in hyperplastic lesions of the larynx.

A retrospective morphologic and immunohistochemical study of 25 benign and 5 malignant laryngeal hyperplastic lesions was performed concerning a local immune response which might be characteristic and of prognostic value for each particular group of these alterations, using Kambic's classification, especially for precancerous and cancerous lesions. On paraffin and frozen sections, 7 monoclonal antibodies against various leukocytic antigens were used. CD43 and CD45RO T lymphocytes were the predominant cells in the infiltrates, and their frequency increased according to the degree of hyperplastic lesions. Next in frequency were CD4 cells, and a predominance of CD4 over CD8 cells was an obvious finding. The infiltration of CD68-, CD57-, and CD20-positive cells was generally weak. The intensity and composition of the local reaction in all cases of atypical hyperplasias was nearly identical, regardless of their subsequent behaviour. No apparent cytotoxic effects on the epithelial cells, either in precancerous or in cancerous lesions, were observed. Thus, the immunocompetent cells in the epithelial and stromal tissue are most likely not an effective defense in preventing hyperplastic lesions from becoming malignant. It seems that laryngeal hyperplastic lesions do not provoke an essential defense immune response, but the present local inflammatory reaction might be a constituent part of etiologically different inflammations which may lead to unfavorable lesions.

Laryngeal hyperplastic lesions, follow-up study and application of lectins and anticytokeratins for their evaluation

A retrospective study of 878 biopsy specimens from 692 patients with laryngeal hyperplastic aberrations was performed according to the KamW-Lenart classification. Special attention was focused on 88 patients with persistent or recurring disease. In these carcinoma developed in 17 (2.4 %) patients, 12 (1.7 %) of whom had had atypical byperplasia. We therefore propose that the term precancerosis, which so definitely implies cancer, should be replaced with the expression risky epithelium where nothing is determined in advance, but a careful follow-up of the patients is imperative. In particular cases of laryngeal byperplastic lesions, mainly in abnormal and in atypical byperplasias when the tissue specimens are cut tangentially, the exact identification and position of individual epithelial cells is essential. In such cases histochemical and immunohistochemical methods yield more precise evaluation. Lectins and cytokeratins provide good markers of epithelial maturation. These results contribute to a more useful evaluation of laryngeal byperplastic lesions, crucial for the choice of adequate therapy.