FLEX October 2023

15314995, 2017, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/lary.26263 by Karuna Dewan - Ochsner Medical Foundation - New Orleans - USA , Wiley Online Library on [21/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

TABLE I. Lesion Area by NBI and WL Drawn on a Schematic Vocal Fold Image.

Average Lesion Area byWL 6 SD, mm 2

Average Lesion Area by NBI 6 SD, mm 2

Observer

Difference (95% CI)

P

38.7 6 25.5 41.1 6 21.5 19.4 6 11.6 22.6 6 15.6 28.0 6 13.1 18.8 6 10.0 28.1 6 19.3

36.9 6 21.2 44.5 6 21.3 21.4 6 12.5 25. 8 6 18.3 31.1 6 15.5 20.8 6 9.8 29.9 6 18.9

2 0.23 ( 1 4.82, 2 5.29) 1 4.52 ( 1 8.96, 1 0.86) 1 1.97 ( 1 5.51, 2 1.55) 1 3.14 ( 1 6.72, 2 0.44) 1 2.86 ( 1 8.54, 2 2.82) 1 2.16 ( 1 5.17, 2 0.83) 1 2.41 ( 1 4.05, 1 0.76)

1

.927

2 3

.046 .266

4

.84

5 6

.312 .153

Total average

.04

Difference 5 (area by NBI) 2 (area by WL). Probability value was calculated by paired t test. CI 5 confidence interval; NBI 5 narrow band imaging; SD 5 standard deviation; WL 5 white light.

byWL ( P 5 .007). Regarding recognition of carcinoma, NBI was more sensitive compared to WL: 58.6% and 48.7%, res pectively. However, NBI was less specific: 61.2% compared with 76.1%, respectively. The performance measurements for identification of carcinoma by NBI and WL are summarized in Table III. DISCUSSION Under NBI conditions, premalignant or malignant glottic lesions appeared larger compared to that seen using WL. This study is the first to highlight this phe nomenon, documented by five of six independent blinded otolaryngologists. Moreover, there was more suspicion of malignancy using NBI and with a higher sensitivity thanWL. There are two possible explanations for lesions to be perceived as larger in NBI. First, the lesions are truly larger. NBI enhances vascular abnormalities and keratin. When these changes are vague, as in the tumor perimeter, the human eye may not detect them under WL imaging but can clearly see them by NBI. Therefore, it is possible that NBI enables us to see the true dimensions and boundaries of a lesion, which is larger than previously thought. Second, there might be some size overestimation related to optical illusions. Because the human brain is not used to this new modality and different colors, it per ceives and estimates the lesion to be larger than it really is. As the authors of this study, we believe that the major contribution to the increase in the estimated size using NBI is related to an improved detection of subtle changes at the periphery of the lesions. Further studies are needed to resolve this subject.

of the VF size, 45.1% were estimated between one-third and two-thirds, and 27.1% were estimated to be more than two-thirds. With NBI, the estimations were 21.1%, 45.1%, and 33.8%, respectively. The kappa value for the agreement between the WL and NBI size estimations was 0.49. Most of the lesions (66.9%) were estimated by the observers to be in the same size category whether pre sented by NBI or by WL; 22.6% of the lesions were esti mated to be larger by NBI, compared to 10.5% that were estimated as larger by WL. In cases of disagreement, the McNemar test showed homogeneity of a trend to estimate the lesions as larger by NBI ( P 5 .007). Estimation of Lesions’ Pathology When asked to estimate the pathological diagnosis by a multiple choice question, the observers tended to assess more lesions as “invasive carcinoma” when using NBI relative to WL: 44.7% versus 33.8%, respectively ( P 5 .001). Analyzing the results for each observer sepa rately, this tendency was also demonstrated in five of the six observers. In most of the cases (64.6%), there was agreement regarding lesion malignancy whether NBI or WL was presented. When there was a discrepan cy, the estimated pathology was “invasive carcinoma” in 24.3% for NBI, compared with 11.1% for WL ( P 5 .034). The 21 lesions with final pathology reports of “invasive carcinoma” were presented to the six observers (a total of 126 lesion presentations). NBI indicated “invasive carcinoma” in 53.9% of lesions compared to 45.2% when using WL ( P 5 .166). In the remaining 24 lesions, the final pathology was not “invasive carcinoma” (altogether 144 lesion presenta tions). In 37.5% of cases, the lesions were mistakenly estimat ed to be invasive carcinoma using NBI, compared with 22.9%

TABLE II. Average Distance From Anatomic Locations by NBI and WL Lesion Drawings on a Schematic Vocal Fold Image.

Lesion Distance by WL 6 SD, mm

Lesion Distance by NBI 6 SD, mm

Difference (95%CI)

Anatomic Location

P

2.9 6 3.1 1.5 6 2.8

2.4 6 3.3 1.3 6 2.7

Vocal process

0.6 (0.2, 1.0)

0.002

0.2 ( 2 0.05, 0.5)

Anterior commissure

0.104

Difference 5 (distance by WL) 2 (distance by NBI). Probability value was calculated by paired t test. CI 5 confidence interval; NBI 5 narrow band imaging; SD 5 standard deviation; WL 5 white light.

Laryngoscope 127: April 2017

Shoffel-Havakuk et al.: NBI Preoperative Detection of Malignancy 897