HSC Section 6 Nov2016 Green Book

Reprinted by permission of Laryngoscope. 2015; 125(4):909-912.

The Laryngoscope V C 2014 The American Laryngological, Rhinological and Otological Society, Inc.

The Utility of Office-Based Biopsy for Laryngopharyngeal Lesions: Comparison with Surgical Evaluation

Amanda L. Richards, MBBS, FRACS; Manikandan Sugumaran, MD; Jonathan E. Aviv, MD; Peak Woo, MD; Kenneth W. Altman, MD, PhD

Objectives/Hypothesis: Advances in flexible endoscopy with working-channel biopsy forceps have led to excellent visu- alization of laryngopharyngeal lesions with capability for in-office awake biopsy. Potential benefits include prompt diagnosis without risk of general anesthesia, preoperative counseling, and avoiding an anesthetic should the lesion return benign. We evaluate the accuracy of these biopsies in order to determine their role and diagnostic value. Study Design: Retrospective chart review. Methods: Medical records were reviewed from January 1, 2010, through July 31, 2013, of patients who underwent office-based current procedural terminology code 31576 and were taken to the operating room for direct microlaryngoscopy with biopsy/excision. Clinical diagnoses and pathology reports were reviewed. For statistical analysis, we considered three groups: 1) malignant and premalignant, 2) lesions of uncertain significance, and 3) benign lesions. Results: In the study period, 76 patients with an office biopsy had a clinical picture to warrant direct microlaryngo- scopy and biopsy/excision. Kendall’s coefficient for each group indicated moderate correlation only. When groups 1 and 2 were considered together, there was a substantial and statistically significant correlation. For malignant and premalignant lesions, the office biopsy analysis was as follows: sensitivity 5 60%, specificity 5 87%, positive predictive value 5 78%, and negative predictive value 5 74%. Conclusion: Office biopsy may offer early direction and avoid operative intervention in some cases; however, for sus- pected dysplastic or malignant lesions, direct microlaryngoscopy should be the standard of care to ensure adequate full- thickness sampling and staging. For benign pathology, office biopsy is a safe and viable alternative to direct microlaryngo- scopy and biopsy/excision. Key Words: Office biopsy, lesion, leukoplakia, dysplasia, microlaryngoscopy, medical decision making. Level of Evidence: 4. Laryngoscope , 125:909–912, 2015

INTRODUCTION Advances in flexible laryngoscopy, imaging technol- ogy, instrument miniaturization, and changes to proce- dure reimbursement have led to an increase in office- based management in laryngology. Since the introduc- tion of the fiber optic laryngoscope in 1976, there have been steady advances in the quality of lighting and imaging for office laryngeal examinations from fiber optic to distal chip endoscopes. 1 Also, adaptations in the design of the flexible scopes have allowed for the use of a side channel port or disposable sheath for passage of a cupped laryngeal biopsy forceps. 2 The combination of these forceps with optimal imaging has provided an From the Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine, Mount Sinai Hospital, New York, New York, U.S.A. Editor’s Note: This Manuscript was accepted for publication October 7, 2014. Dr. Aviv is shareholder in Vision Sciences. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Kenneth W. Altman, MD, PhD, FACS, Professor and Vice Chair for Clinical Affairs, Director, The Institute for Voice and Swallowing at BCM, Bobby R. Alford Department of Otolaryn- gology - HNS, Baylor College of Medicine, 6501 Fannin Street, Room NA 102, Houston, TX 77030. E-mail: Kenneth.Altman@bcm.edu

option to obtain tissue for pathology during an outpa- tient office visit with topical anesthesia. Traditionally, these patients would require a visit to the operating room (OR) with general anesthesia for a direct microlar- yngoscopy and biopsy or excision of the lesion. However, regardless of technique, all biopsies need to provide a representative sample of the lesion to demonstrate cell morphology. In addition, sample depth is also important, particularly in cases of dysplasia for which deeper levels may determine a different diagnosis and prognosis. 3 There are a proposed number of conditions for which office biopsy alone has been proposed as suffi- cient: 1) confirmed diagnosis of carcinoma when clini- cally suspected; 2) complete excision of a lesion at the time of office biopsy; 3) benign pathology and resolution of the lesion with treatment; 4) evidence for keratosis, papilloma, or mild dysplasia with stable clinical exami- nation; and 5) the risks of surgical evaluation with gen- eral anesthesia outweigh the potential diagnostic or therapeutic benefits of the procedure. Potential benefits include the following: 1) avoiding the risk of general anesthesia, 2) reduced duration from clinical suspicion to histologic confirmation, 3) negating patient anatomic limitations, and 4) avoiding the costs of general anesthe- sia and the OR. 4

DOI: 10.1002/lary.25005

Laryngoscope 125: April 2015

Richards et al.: Office-Based Biopsy for Laryngopharyngeal Lesions

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