Efficacy of Transcutaneous Computed Tomography-Guided Fine Needle Aspiration Biopsy in Patients With Laryngeal Squamous Cell Carcinoma,Probable Failed Radiation Therapy,and Negative Transmucosal Biopsies

For patients with suspected recurrent/persistent laryngeal squamous cell carcinoma (SCC) after external beam radiotherapy (EBRT), routine transmucosal biopsies obtained during direct laryngoscopy may fail to reveal active carcinoma. We evaluated transcutaneous computed tomography-guided fine needle aspiration (CTGFNA) in three consecutive patients who had a persistently fixed true vocal fold after EBRT that had been administered for laryngeal SCC and who had multiple negative transmucosal laryngeal biopsies. All three CTGFNA biopsies were positive, but final pathology confirmed invasive SCC in only one of the three patients. Despite its theoretical advantages, CTGFNA in its present form requires further assessment and/or modification. Laryngoscope, 106:1244-1247, 1996     

The cost-effectiveness of <Superscript>18</Superscript>FDG-PET in selecting patients with suspicion of recurrent laryngeal carcinoma after radiotherapy for direct laryngoscopy

The aim of this study was to estimate the cost-effectiveness of ¹⁸FDG-PET in the selection for direct laryngoscopy in patients with suspicion of recurrent laryngeal carcinoma after radiotherapy. The direct medical costs of 30 patients with suspicion of a recurrence were calculated from the first visit where suspicion was raised until one year after. A conventional strategy, in which all these patients underwent direct laryngoscopy, was compared to an ¹⁸FDG-PET strategy in which only patients with a positive or equivocal ¹⁸FDG-PET underwent direct laryngoscopy. A sensitivity analysis was performed to examine the influence of the type of camera and ‘setting’. The mean costs of an ¹⁸FDG-PET strategy were €399 less than a direct laryngoscopy strategy. The type of camera and setting had no influence. In patients with suspicion for recurrent laryngeal carcinoma after radiotherapy, ¹⁸FDG-PET seems to be effective and less costly in selecting patients for direct laryngoscopy.     

The value of the current diagnostic techniques and fluoro‐18‐deoxyglucose‐positron emission tomography in suspicion of recurrent laryngeal carcinoma after radiotherapy

Introduction. Analysis of the current diagnostic techniques and the potential value of fluoro‐18‐deoxyglucose‐positron emission tomography (FDG‐PET) in patients with suspicion of recurrent laryngeal carcinoma was undertaken. Evaluation of the possibility to prevent unnecessary direct laryngoscopies was also performed. Methods. Retrospective analysis of the data of 158 patients who, between 1986 and 1998, underwent a direct laryngoscopy under narcosis 236 times because of clinical suspicion of recurrent laryngeal carcinoma after radiotherapy. Another group of 27 patients underwent FDG‐PET before direct laryngoscopy. Results. In 45% of 236 laryngoscopies (71% of all patients) a recurrence was diagnosed. The positive and negative predictive value of the different symptoms and examinations are shown in Table 7 . In the other group, all recurrences were shown using FDG‐PET. The sensitivity of FDG‐PET was 100%, the specificity was 83%, the positive predictive value was 50% and the negative predictive value was 100%.

Table 7. Positive and negative predictive value of different symptoms and techniques used to diagnose recurrent laryngeal carcinoma

The enigma of post-radiation oedema and residual or recurrent carcinoma of the larynx and pyriform fossa

Persistence of significant laryngeal oedema following radiotherapy presents the surgeon with a diagnostic dilemma. Though the oedema may represent a prolonged response to irradiation, the possibility of residual carcinoma must be considered. Several authors have commented upon it and have suggested frequent biopsies to prove the presence of residual or recurrent neoplasm (Ward et al., 1975; Lederman, 1970; Calcaterra et al., 1972). Some reluctance to laryngeal biopsy has been exercised to avoid inciting a fulminant perichondritis. However, the difficulty of obtaining a positive biopsy in a post-irradiated case is well known, and repeated negative biopsies do not exclude the presence of a residual tumour. The present paper studies 52 histopathologically proven cases of carcinoma of the larynx and laryngopharynx which had received radiotherapy earlier. These cases underwent salvage radical surgery on clinical suspicion of residual/recurrent tumour, manifested by persistence of significant laryngeal oedema and/or fixation of the larynx. No positive biopsies had been obtained following radiotherapy.     

Evaluation of efficacy and clinical impact of positron emission tomography with 18F fluoro-deoxyglucose (FDG) in patients with suspicion of recurrent laryngeal carcinoma

AimsTo evaluate the efficacy and clinical impact of FDG-PET in patients with suspected recurrent laryngeal carcinomaMaterials and methods15 patients, with suspicion of recurrent laryngeal carcinoma and ambiguous conventional imaging modalities. In all patients a whole body scan was performed with FDG-PET in fasting patients following i.v. administration of 370-444 MBq FDG. The results were confirmed by histology and clinical evolution (follow-up period >12 months)ResultsPrevalence of recurrence was 86.6%. FDG-PET was positive in 13 patients, with confirmation in all cases, and 2 were true negative (TN). Overall sensitivity, specificity, PPV, NPV and accuracy were 100%. FDG-PET changed the modality of treatment in 10 patients (clinical impact 63.3%)ConclusionsFDG-PET has high clinical impact in patients with a suspicion of recurrent laryngeal carcinoma, and should be incorporated to the diagnostic protocols before making a therapy decision     

Direct and indirect autofluorescence laryngoscopy in the diagnosis of laryngeal cancer and its precursor lesions

Autofluorescence endoscopy has proven to facilitate the detection and delineation of precancerous lesions, carcinoma in situ and microinvasive cancer during bronchoscopy. The aim of the present study is to evaluate the diagnostic potential and limitations of this imaging technique applied during direct and indirect laryngoscopy. In a prospective study, 109 patients with suspected precancerous or cancerous lesions were investigated preoperatively by indirect autofluorescence laryngoscopy as well as during microlaryngoscopy. Autofluorescence was induced by filtered blue light (375-440 nm) of a xenon short arc lamp and processed by a CCD camera system (D-light-AF System, Storz, Tuttlingen, Germany). Autofluorescence images were immediately assessed for diagnosis, compared to the direct autofluorescence picture obtained during microlaryngoscopy and compared with pathohistological findings. Comparable to direct autofluorescence images, normal laryngeal mucosa showed a typical green fluorescence signal. Moderate and high epithelial dysplasia, carcinoma in situ, and microinvasive cancer displayed a diminished green fluorescence. False negative results were related to extreme hyperkeratosis. False positive cases showed mild dysplasia with inflammatory reactions or scarring. In 98 cases (90%) we found concordant results. According to our results, the presented technique seems to be a promising diagnostic tool for the early detection of laryngeal cancer and its precursor lesions during direct and indirect laryngoscopy. Scarring, marked hyperkeratosis, and inflammation can limit the predictive value of the method.     

Indirect autofluorescence laryngoscopy in the diagnosis of laryngeal cancer and its precursor lesions

Direct autofluorescence endoscopy of the larynx has proven to facilitate the detection and delineation of precancerous lesions, carcinoma in situ and cancer. The aim of the present study was to evaluate the diagnostic potential and limitations of this imaging technique applied during indirect laryngoscopy. In a prospective study, 116 patients with suspected precancerous or cancerous lesions were investigated preoperatively by indirect autofluorescence laryngoscopy. Autofluorescence was induced by filtered blue light (375–440 nm) of a xenon short-arc lamp and processed by a CCD camera system (D-light-AF System, Storz, Tuttlingen, Germany). Autofluorescence images were immediately assessed for diagnosis, compared to the direct autofluorescence picture obtained during microlaryngoscopy and compared to pathohistological findings. Comparable to direct autofluorescence images, normal laryngeal mucosa showed a typical green fluorescence signal. Moderate and high epithelial dysplasia, carcinoma in situ and cancer displayed a diminished green fluorescence. False negative results were related to extreme hyperkeratosis. False positive cases showed mild dysplasia with inflammatory reactions or scarring. In 103 cases (89%), we found concordant results. According to our results, the presented technique seems to be a promising diagnostic tool for the early detection of laryngeal cancer and its precursor lesions during indirect laryngoscopy. Scarring, marked hyperkeratosis and inflammation can limit the predictive value of the method.This study was presented at the 4th Congress of the European Laryngological Society in Brussels, 5–7 September 2002.     

Ultrasonography guided fine needle aspiration cytology in patients with laryngo-hypopharyngeal lesions

IntroductionLaryngeal lesions are usually evaluated by microlaryngoscopy/direct laryngoscopy under anaesthesia for disease mapping and tissue diagnosis. However patients with anticipated airway compromise due to laryngeal mass may require either a protective tracheotomy or emergency tracheotomy to secure the airway. To minimise risk of unplanned tracheotomy and expedite the diagnosis we performed ultrasound-guided transcutaneous fine needle aspiration cytology.ObjectiveTo evaluate the feasibility and performance of ultrasound-guided transcutaneous fine needle aspiration cytology of suspicious/recurrent laryngo-hypopharyngeal masses.MethodsFine needle aspiration cytology was performed under ultrasound guidance. Twenty- four patients were recruited, of which 17 had a pure laryngeal lesion; 6 patients had laryngo-pharyngeal, and one patient had a base tongue lesion with supra-glottis extension.ResultsOut of 24 patients, 21 had positive cytology for squamous cell carcinoma, 2 patients had non-diagnostic cytology (atypical cells) and the other had inadequate tissue for definitive diagnosis. Patients with negative and inconclusive cytology underwent direct laryngoscopy biopsy, which was positive for squamous malignancy. All patients tolerated the procedure well and no adverse events were noted.ConclusionAlthough direct laryngoscopy remains the standard of care in evaluation of laryngo-hypopharyngeal lesions, this pilot study has shown that ultrasound-guided transcutaneous fine needle aspiration cytology was feasible as an out-patient procedure, employing safe and sensitive technique enabling rapid diagnosis and avoiding the need for direct laryngoscopy under GA for tissue diagnosis.     

The enigma of post-radiation edema and recurrent or residual carcinoma of the larynx

Persistence of significant edema of the larynx beyond six months after completion of radiotherapy presents the lavyngologist with a diagnostic dilemma. Review of the results of 43 cases demonstrated a high incidence of residual or recurrent carcinoma. Based upon this experience earlier and frequent laryngeal biopsies are recommended for these cases.     

Ploidy status and the response of T1 glottic carcinoma to radiotherapy

Flow cytometric DNA ploidy measurements were performed on formalin fixed paraffin embedded tumour specimens from patients with a T₁ glottic laryngeal carcinoma in order to evaluate the role of DNA content in relation to local control. From 1980 to 1987, a consecutive series of 90 patients with a T₁ glottic laryngeal carcinoma were treated by radiotherapy with curative intent. Biopsies from 44 of these patients were readily available for DNA flow cytometry. In this group aneuploidy was associated with a significantly higher risk (P= 0.018) of local recurrence within 2 years after completion of radiotherapy (38% vs. 9% in the diploid group).     

Laryngoscopy in neonates and infants: Experience with the flexible fiberoptic bronchoscope

A small flexible fiberoptic bronchoscope was used for laryngeal examination in a series of neonates and infants; 104 laryngoscopies were performed in 59 patients. A high yield of diagnostic information was obtained in both postextubation patients and patients presenting with upper airway obstruction. No major complications were observed. This technique is useful in the evaluation of neonates and infants with potential upper airway problems.     

Clinical contribution to ultrasound diagnosis of the larynx (echolaryngography)

This paper outlines sonographic indications in laryngeal diseases in adults, based on our ultrasonic technique for diagnosis of the larynx. Here, findings may be investigated that in combination with the indirect laryngoscopy and endoscopic techniques such as computer tomography and magnetic resonance imaging may contribute towards the differential diagnosis of laryngeal disease. The diagnostic possibilities of echolaryngography in inflammatory diseases, where an indirect laryngoscopy is either impossible or difficult, (e.g. epiglottitis), are presented. Additionally, sonographic findings in laryngeal paralysis (e.g. paralysis of the recurrent laryngeal nerve after strumectomy) in both benign and malignant tumours are discussed. Empirical data from 14 patients with laryngeal carcinoma are presented.     

p53,c-myc,nm23癌基因蛋白在喉复发癌的表达及其意义

目的：研究p53,c-myc,nm23癌基因蛋白的表达与喉癌复发的关系，对预后作出估计。方法：回顾分析喉癌手术标本574例，术后随访3年，确诊术后复发56例。正常喉对照标本39例。标本制成组织芯片，采用免疫组化SABC法对芯片标本进行染色。结果：p53,nm23、c-myc在喉癌组织中有表达，其阳性率各有不同，其中c-myc在喉癌复发组的表达明显增强，与未复发组的表达差异有极显著性意义（P＜0．01）；而nm23在喉癌复发组的表达明显减弱，与未复发组的表达差异有极显著性意义（P＜0．01）。p53在喉癌复发组与复发组的表达差异无显著性意义（P＞0．05）。c-myc的表达与喉癌复呈正相关，nm23癌基因蛋白的表达与喉癌复发呈负相关。结论：c-myc,nm23癌基因蛋白的表达可作为预测喉癌术后复发的指标。     

先天性第四鳃裂畸形的诊断和治疗

目的 探讨先天性第四鳃裂畸形(congenital fourth branchial anomaly,CFBA)的解剖学特点、临床表现、诊断和外科处理原则.方法 回顾性分析8例CFBA患者的临床资料,年龄27～300个月(中位年龄114个月);男4例,女4例;初治3例,复发5例;病变均位于左颈,其中囊肿型1例,窦道型3例(均为内瘘口),瘘管型4例;3例表现为急性甲状腺炎,4例表现为颈深部脓肿,1例表现为颈部肿块.结果 术前检查包括食管吞钡8例次、直接喉镜4例次、CT 5例次、MRI 5例次.急性期患者采取充分引流、控制感染;静止期患者行病灶完整切除+喉返神经解剖+甲状腺腺叶部分切除,对复发病例采用择区性颈清扫术根除瘢痕、炎性肉芽和病变组织.术后1例患者切口局部感染,经换药后愈合;1例患者出现暂时性声带麻痹,1个月后完全恢复.患者随访13～42个月,中位随访时间21个月,未见复发.结论 CFBA走行与喉返神经和甲状腺关系密切.食管吞钡、直接喉镜检查最具诊断价值,CT和MRI有助于明确诊断.治疗原则为感染静止期行喉返神经解剖和甲状腺腺叶部分切除,必要时切除部分甲状软骨翼板以减少并发症和预防复发,复发病例可采用择区性颈清扫术治疗.     

Indirect fluorescence laryngoscopy in the diagnosis of precancerous and cancerous laryngeal lesions

Indirect fluorescence endoscopy of the larynx has proven to facilitate the detection and delineation of precancerous and cancerous lesion. The different methods are easy to handle and can be performed on an outpatient basis. Early diagnosis of laryngeal cancer and its precursor lesions is simplified. The aim of the present study is to compare indirect autofluorescence laryngoscopy to 5-ALA-induced PPIX fluorescence laryngoscopy. In a prospective study, 56 patients with suspected precancerous or cancerous lesions were primarily investigated by indirect autofluorescence laryngoscopy. In a second step 5-ALA-NaCl (0.6%) was topically applied to the larynx by inhalation, and indirect fluorescence laryngoscopy repeated 2 h after application. Autofluorescence as well as 5-ALA-induced fluorescence was induced by filtered light (375–440 nm) of a xenon short arc lamp and processed by a CCD camera system (D-light-AF System, Storz, Tuttlingen, Germany). White-light and fluorescence images were digitally recorded, immediately assessed for diagnosis and finally compared to pathohistological findings. Inconspicuous laryngeal mucosa presented a typical green fluorescence signal in autofluorescence endoscopy, which turned blue during 5-ALA-laryngoscopy. Precancerous and cancerous lesions displayed a loss of autofluorescence in autofluorescence endoscopy whereas increased protoporphyrin IX fluorescence could be observed in 5-ALA laryngoscopy. Both imaging techniques were suitable to distinguish benign from precancerous or cancerous lesions. In contrast PPIX fluorescence was easily recognized in scarred vocal folds. According to our results, both non-invasive fluorescence imaging techniques are useful in the early diagnosis of laryngeal cancer. Moreover autofluorescence can be used immediately without drug application and possible side effects. 5-ALA-induced fluorescence seems to be more suited for diagnostic examination of mucosal lesions in recurrent precancerous and cancerous lesions after surgery.     

Assessment of dendritic cell number and radiosensitivity in laryngeal tumours

Objectives: Radiotherapy is one of the principal treatment modalities for many types of head and neck tumour; what effects the dendritic cell (DC) population may have on treatment outcome have not been critically evaluated in laryngeal cancer. Design: Retrospective, case‐controlled study using immunohistochemistry to investigate the presence of S‐100 positive DC in pre‐treatment, archival biopsy tissue of early stage laryngeal cancers. Setting: Patients with laryngeal cancer treated with radiotherapy in Head and Neck Departments in England. Participants: Patients diagnosed with early stage laryngeal cancer, treated with single modality radiotherapy with curative intent. Radioresistant tumours (n = 22), defined as recurrent tumours within 12 months of therapy. Radiosensitive tumours (n = 22), defined as no recurrence with a minimum follow‐up of 36 months. Main outcome measures: Density of S‐100 staining DC on three ×200 magnified microscopic fields. Results: DC were present in approximately equal numbers in both radioresistant and radiosensitive laryngeal tumour pre‐treatment biopsies and therefore density did not correlate with radiotherapy treatment outcome (P = 0.420). Conclusion: There is no intrinsic deficiency in DC number in radioresistant laryngeal tumours meaning that such tumours could potentially benefit from vaccination strategies that enhance the specific anti‐tumour immune response.     

Atypisches Karzinoid des Larynx

Background

With an incidence of over 90%, squamous carcinomas are the most frequent laryngeal malignancies. Laryngeal neuroendocrine tumors appear only in approximately 1%. These are aggressive tumours with a high rate of metastases. To date, no diagnosis or treatment guidelines have been established for this entity.

Case report

We describe the case of a 63-year-old man complaining of dysphagia and intermittent hoarseness. Initial laryngoscopy showed a tumour at the laryngeal epiglottic surface. Staging demonstrated an atypical carcinoid tumour with local lymph-node metastasis. At 24 months following revision surgery with safety distance, elective bilateral neck dissection and adjuvant radiotherapy the patient is free of complaints and recurrence.

Conclusion

In atypical carcinoid tumours total resection as well as bilateral neck dissection should be performed, even in cN0 cases. In the presence of cervical lymph node metastases adjuvant radiotherapy is indicated.     

The significance of arytenoid edema following radiotherapy of laryngeal carcinoma with respect to residual and recurrent tumour

We sometimes experience patients with persistent or progressive arytenoid edema, among which residual or recurrent cancer is often accompanied. Because it is difficult to distinguish tumour rest or recurrence from normal tissue sequelae in the early period after irradiation, it is important to know both the contributing factors for arytenoid edema, and the incidence of residual or recurrent tumours in patients with postirradiation laryngeal edema. We therefore reviewed the charts of 67 patients with early laryngeal carcinoma who had received a curative dose of irradiation in the last 5 years. Fourteen patients (20.9%) had moderate or severe laryngeal edema persisting for or developing at more than 3 months after completion of a course of definitive radiotherapy. The incidence was highest in supraglottic T₂ disease, followed by glottic T₂ tumour. Of the 14 patients with edema, six (42.9%) had persistent or recurrent disease. The primary disease was uncontrolled in 18 patients, 17 of whom received successful salvage surgery. In patients without residual tumours, the edema was usually moderate and resolved within a year, although four patients had chronic edema lasting more than a year after treatment. All four had supraglottic T₂ lesions and received 70 Gy of X-ray. We also reviewed, for sake of comparison, the records of 38 patients treated with radiotherapy at doses of more than 40 Gy between l975 and 1980, when endoscopic microsurgery for laryngeal cancer was introduced as a primary part of treatment. The incidence of persistent or late developed edema over the period, though not significant, was 36.8%: nearly twice that of the last 5 years. Microscopic endolaryngeal surgical procedures seem to have been a causal factor for edema in this period.     

Early detection of recurrent hypopharyngeal cancer after radiotherapy by utilizing narrow-band imaging--report of a case

Narrow-band Imaging (NBI) is a novel optical technique in which the diagnostic capability of endoscopes in characterizing tissue is enhanced by the use of narrow-bandwidth filters in the video endoscope system. We report a case of early recurrence of hypopharyngeal cancer after radical radiotherapy which was detected by laryngoscopy using NBI. A 66-year-old man with right pyriform sinus cancer was treated by radical radiotherapy in March 2004. Twenty months later, laryngoscopy using NBI revealed an abnormal lesion in the right pyriform sinus, visualized as scattered brownish dots, which highly suggestive of a malignant lesion. After obtaining written informed consent from the patient, endoscopic mucosal resection of the lesion was performed. Histological examination of the resected specimen revealed a squamous cell carcinoma in situ. The patient did not need any additional therapy. Laryngoscopy using NBI appears to have good potential to detect early stage local tumor recurrence after radical radiotherapy.     

Laryngeal involvement in patients with active pulmonary tuberculosis

The aim of this study was to determine the incidence of laryngeal tuberculosis (LT) among patients with active pulmonary tuberculosis. A total of 319 patients under treatment for pulmonary tuberculosis were subjected to laryngoscopy. Five patients (1.5%) with LT were identified. Odynophagia was the most common complaint, followed by alteration in voice. The larynx returned to its normal appearance in 3–8 months (average 18 weeks) by antituberculous medication. Physicians dealing with pulmonary tuberculosis should keep in mind that symptoms of laryngeal involvement may be minor, and laryngoscopy should always be performed when laryngeal involvement is suspected in order to isolate highly infectious patients. Response to antituberculous medication is usually late in LT and diagnosis by “wait and watch” policy will cause a significant delay in the diagnosis of a possible larynx carcinoma.