HSC Section 6 Nov2016 Green Book

The results of office biopsy and their subsequent direct microlaryngoscopy (DML) and biopsy/excision are summarized in Table I. When considered as separate groups, Kendall’s coeffi- cient for each group was all 0.5, indicating “moderate correlation” only. None of these approached statistical sig- nificance ( P 5 0.5). When groups 1 and 2 (i.e., lesions of uncertain significance and premalignant/malignancy) were considered together, the coefficient was 0.64 ( P 5 0.029), indicating “substantial correlation.” For malignant/prema- lignant lesions, the office biopsy analysis was as follows: sensitivity 5 60%, specificity 5 87%, positive predictive val- ue 5 78%, and negative predictive value 5 74%. DISCUSSION Medical decision making, patient counseling, and surgical planning benefit from understanding the nature of a lesion based on patient demographics, clinical his- tory, the physical examination, and cytologic or patho- logic diagnosis. The nature of a laryngeal lesion will affect prioritizing the different surgical goals of the fol- lowing: 1) confidence in a pathologic diagnosis, 2) control of disease, and 3) voice preservation or improvement. See Table II for proposed office biopsy candidacy. While office biopsy increases in popularity, there needs to be further clarification regarding its utility. The results of this study highlight the concern of office biopsy being used as a substitute for traditional DML. The small tissue sample, limited depth past the basement membrane, and ability to sample only portions of a suspicious lesion are known disadvantages to this technique, especially with leukoplakia and lesions that have some degree of dyspla- sia. Serrated or other forceps, however, may favourably influence the sensitivity and specificity of the findings, and appropriate selection of forceps is a major consideration in the management of early laryngeal malignancy by any method. Therefore, just as in the OR under direct laryngo- scopic conditions for which the surgeon would choose the forceps for biopsy carefully, the same considerations must be applied when performing transnasal biopsy. Although it may be acceptable for some screening tests to have a high specificity and lower sensitivity, this is not appropriate for this diagnostic test. Sensitivity for malignancy/premalignancy was only 60%, indicating that it is inadequate as a diagnostic test: clinical suspicion alone in this setting would seem at least equivalent. Only 15% of invasive SCC was identified at office biopsy, and it is evident that any clinically suspicious neoplasm must

TABLE I. Summary of Results.

Accuracy Compared to Final Pathology

Pathology of Missed Diagnosis (False Negatives)

Office Biopsy N 5

Rate of False Negatives%

Office Biopsy Pathology

SCC

4 100.0% N/A

0.0%

Severe

23 17.4% SCC

56.5%

dysplasia/ CIS

Mild–Moderate dysplasia

8.7%

Inflammation only

8.7%

Polyps or nodule

4.3% 4.3%

Keratosis

Mild to

12 25.0% SCC

25.0% Severe dysplasia/CIS 33.3% Polyps or nodule 8.3% Keratosis 8.3% 28.6% Severe dysplasia/CIS 14.3% Polyps or nodule 28.6% Inflammation only 14.3% 12.5% Severe dysplasia/CIS 25.0% Keratosis 12.5% Polyps or nodule 25.0% Papilloma 12.5%

moderate dysplasia

Keratosis without

7 14.3% SCC

dysplasia

Inflammation only

8 12.5% SCC

Polyp/nodule 10 100.0% N/A

0.0%

Papilloma

11 81.8% Inflammation only

9.1%

Other

9.1%

Other benign 6

0.0% SCC

16.7%

Keratosis

33.3% 33.3%

Inflammation only

Papilloma

16.7%

Inadequate 4

N/A SCC

50.0%

Polyp or nodule

50.0%

CIS 5 carcinoma in situ; SCC 5 squamous cell carcinoma.

via the SAS macro MAGREE. Kendall’s coefficients do not treat all misclassifications equally. For instance, Kendall’s coefficients considers the consequences of misclassifying a perfect (rat- ing 5 5) object as bad (rating 5 1) as more serious than misclas- sifying it as very good (rating 5 4). For all statistical analysis, data was analyzed using the SAS System software (SAS Insti- tute, Inc., Cary, NC). RESULTS Seventy-six subjects underwent evaluation with 81 office biopsies with subsequent direct microlaryngoscopy under general anesthesia. The age range of the subjects was 21 to 84 years, with a median age of 62 and a male to female ratio of 5:1. There were 76 laryngeal biopsies and five oropharyngeal biopsies. The oropharynx sub- sites included two for tonsil, two for tongue base, and one for soft palate. There were no complications from any of the office or operative procedures performed.

TABLE II. Candidates for Office Biopsy.

Inclusion

Exclusion

Anatomic limitations for DML

Anticoagulation

Voice less critical

Anterior commissure location

Following a known benign diagnosis

Submucosal lesion

High risk for general anesthesia Lesion associated with obstruction

DML 5 direct microlaryngoscopy.

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