HSC Section 6 Nov2016 Green Book

In addition, the technique and types of cupped forceps used were not compared to other approaches. The utility of serrated forceps or rigid endoscopy with nonflexible for- ceps should also be considered and may enhance sampling. The ability to obtain high diagnostic yield biopsies in the office is also dependent on the experience of the surgeon; our group obtaining the biopsies has over 5 years experi- ence with this method. Classification of the severity of dys- plasia is also variable from different classification systems and pathologists, 2 which can skew the accuracy of office biopsies when different grades of dysplasia are considered. A multicenter study is warranted, especially in the realm of medical decisionmaking in complex laryngeal lesions, as well as outcomes of prioritizing disease eradication over voice outcomes with dysplastic lesions. CONCLUSION Our study shows that office biopsy has the highest utility in clinically benign lesions and those with SCC. Laryngopharyngeal biopsies have only a moderate corre- lation with final pathology, although the potential utility increases in certain clinical scenarios and with careful choice of forceps. Office biopsy has a tendency to under- estimate the severity of dysplastic lesions, and any degree of dysplasia should be considered as potentially malignant until, as possible, proven otherwise with oper- ative assessment. However, preoperative patient coun- seling, surgical planning, and therapy may be positively impacted by information from office biopsies, comparable to management of other head and neck neoplasms. For benign pathology that clinically harbors no suspicion for malignancy, office biopsy is a safe and viable alternative to direct microlaryngoscopy and biopsy/excision. Acknowledgment We would like to acknowledge Alan Weinberg, MS, for the statistical analysis, and Laurence T. Blanchard, BA, for data preparation. BIBLIOGRAPHY 1. Eller R, Ginsburg M, Lurie D, Heman-Ackah Y, Lyons K, Sataloff R. Flexi- ble laryngoscopy: a comparison of fiber optic and distal chip technolo- gies. Part 1: vocal fold masses. J Voice 2008;22:746–750. 2. Rosen CA, Amin MR, Sulica L, et al. Advances in office-based diagnosis and treatment in laryngology. Laryngoscope 2009;119(suppl 2):S185–S212. 3. Zhang HK, Liu HG. Is severe dysplasia the same lesion as carcinoma in situ? 10-Year follow-up of laryngeal precancerous lesions. Acta Otolaryn- gol 2012;132:325–328. 4. Rees CJ, Postma GN, Koufman JA. Cost savings of unsedated office-based laser surgery for laryngeal papillomas. Ann Otol Rhinol Laryngol 2007; 116:45–48. 5. Cohen JT, Safadi A, Fliss DM, Gil Z, Horowitz G. Reliability of a trans- nasal flexible fiberoptic in-office laryngeal biopsy. JAMA Otolaryngol Head Neck Surg 2013;139:341–345. 6. Chu MM, Kositwattanarerk A, Lee DJ, et al. FDG PET with contrast- enhanced CT: a critical imaging tool for laryngeal carcinoma. Radio- graphics 2010;30:1353–1372. 7. Nichols ML, Quinn FB, Jr, Schnadig VJ, et al. Interobserver variability in the interpretation of brush cytologic studies from head and neck lesions. Arch Otolaryngol Head Neck Surg 1991;117:1350–1355. 8. Hellquist H, Cardesa A, Gale N, Kambic V, Michaels L. Criteria for grading in the Ljubljana classification of epithelial hyperplastic laryngeal lesions. A study by members of the Working Group on Epithelial Hyperplastic Lesions of the European Society of Pathology. Histopathology 1999;34:226–233. 9. Naidu N, Noordzij JP, Samin A, Jalisi S, Grillone GA. Comparison of effi- cacy, safety, and cost-effectiveness of in-office cup forcep biopsies versus operating room biopsies for laryngopharyngeal tumours. J Voice 2012; 26:604–606.

be evaluated with direct microlaryngoscopy as possible. Cohen et al. noted a 33% false negative rate of in-office flexible laryngeal biopsy; and in their series, CIS on office biopsy was most often SCC at DML. 5 It should be noted, however, that when an office biopsy showed a diagnosis of SCC, it was correlated with the final histologic diagno- sis in 100% of patients. For patients with a suspected malignant lesion who are unable to undergo a general anesthetic, reassurance can be given that a diagnosis of cancer in the office correlates with a diagnosis of cancer in OR. The substantial correlation for malignancy/any degree of dysplasia may be adequate to counsel certain patients, and early diagnosis with office biopsy may offer extra confidence in the treatment paradigm, particularly when multiple treatment options are available. It may also reduce time to definitive treatment. When a histo- logic diagnosis of severe dysplasia or CIS in a lesion with malignant suspicion is added to the diagnostic/staging capabilities of imaging modalities such as CT scanning, radiation may be employed with increased confidence of the clinical diagnosis and stage. 6 Seventy-eight percent of our patients with severe dysplasia, CIS, or SCC on office biopsy were counseled appropriately in advance of sur- gery and underwent microlaryngoscopy with CO2 laser cordectomy at the time of initial surgical evaluation. It is an accepted standard of care that mild to mod- erate dysplasia may be observed, and so it follows that this diagnosis at office biopsy may reassure the clinician. However, lesions of uncertain significance have only moderate correlation to their final pathologic diagnosis. Mild to moderate dysplasia frequently represents more sinister disease, and it may be false reassurance to rely on office biopsy alone. Similar to brush biopsy, 7 a dys- plastic office biopsy result indicates a need for further investigation, without providing a definitive diagnosis. The diagnosis of hyperkeratosis/parakeratosis (path- ologic correlates of leukoplakia) and inflammation also frequently correlate with a final histopathologic diagnosis of malignancy and highlight the limitations on biopsy of the awake patient with the absence of tactile feedback. It is well known that potentially malignant and CIS epithe- lia are associated with pronounced stromal reaction, 8 which is reflected in the 37% of patients with only an office biopsy of inflammation, however, with severe dys- plasia/CIS or SCC on final diagnosis. Clinical judgment is paramount in ensuring that patients with suspected false negative biopsies undergo DML. When considering benign lesions such as papilloma and vocal fold nodules or polyps, office biopsy may play a more definitive role. A clinical suspicion of papilloma or polyps/nodules correlated well with final diagnosis. When clinically indicated, these lesions are appropriate for office management alone. In the current environment of financially accounta- ble medicine, consideration should be given to cost. Naidu et al. 9 and workers found an average cost saving of $6,970.56 per patient when office biopsy cost was com- pared to OR biopsy; however, it is instructive to consider that any patient who undergoes both office biopsy and OR biopsy does so at considerable financial burden. There are limitations to our study, including selection bias determining the candidacy or need for office biopsy.

Laryngoscope 125: April 2015

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

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