Proposal for a descriptive guideline of vascular changes in lesions of the vocal folds by the committee on endoscopic laryngeal imaging of the European Laryngological Society

I-scan combined with laryngovideostroboscopy for predicting malignancy in vocal fold leukoplakia

OBJECTIVE

This study evaluated vocal fold leukoplakia using i-scan combined with laryngovideostroboscopy for risk assessment prediction.

METHODS

A total of 141 patients with 218 lesions were enrolled in this study. Morphological characteristics of leukoplakia, assessment of the vascular pattern using i-scan, and vocal fold vibratory function were analyzed.

RESULTS

The number of patients with no, mild, moderate, severe dysplasia, and invasive carcinoma were 68, 40, 17, 46 and 47, respectively. The sensitivity of morphological characteristic, vascular pattern, vibratory function and predictive model were 77.4%, 72%, 69.9%, and 82.8%, respectively. Receiver operating characteristic curve analysis of morphological characteristic, vascular pattern, vibratory function and predictive model were 0.771, 0.824, 0.769, and 0.923, respectively. The results of logistic regression analysis showed that rough morphological types, perpendicular vascular pattern, severe decrease and absence of mucosal waves increased the risk of malignancy (OR = 5.531, 4.973, and 16.992, respectively; P < 0.001).

CONCLUSIONS

I-scan combined with laryngovideostroboscopy can improve the differential diagnosis of low-risk and high-risk vocal fold leukoplakia.

Contact Endoscopic Surface Vascular and Epithelial Morphology in Leukoplakia and Carcinoma of the Vocal Cords: Vascular and morphological changes of vocal folds in leukoplakia and cancer

Purpose Leukoplakia is a macroscopic morphological term for thick white or grey mucosal patches that can represent various histologic diagnostic entities ranging from hyperplasia to malignancy. Aim was the study morphology of the superficial mucosa and microvascular network of the vocal cords in patients with suspected glottic squamous cell carcinoma (SCC) using contact endoscopy (CE). Material and Methods Seventy-nine patients (21 female, 58 male), with a mean age of 57.5 years ± 7.12 (range, 32-73 years), were prospectively enrolled and evaluated. Of these patients, 58 had leukoplakia (Group A/41 males and 17 females, with a mean age of 53.7 years ± 6.65), and 21 (Group B/ 17males and 4 females/ with a mean age of 60.5 years ± 6.04) had malignant lesions (pT1, n = 6; p T2, n = 8; pT3, n = 8; Group B), as proven by the results of the histological examination. Further, 79 non-smokers (control group-group C) were studied. CE imaging findings were classified into five types (I to V) based on the features of the mucosal intra-epithelial capillary loops. CE findings were correlated to the histologic findings. A separate analysis involving smoking status was done. Results The CE-based intraepithelial papillary capillary loop classification score was strongly correlated with the histological findings. Age was strongly associated with both malignancy and bilateral involvement. Smoking habits didn't significantly differ between patients with unilateral and bilateral SCC. Conclusions CE imaging of the vocal cord mucosal capillaries may be useful for the early detection of glottic SCC and pre-cancerous lesions.

Correlation of narrow-band imaging findings using the Ni and European Laryngeal Society classification systems during in-office flexible laryngoscopy with histopathology

OBJECTIVE

This study used the European Laryngeal Society (2016) and Ni (2011 and 2019) classifications for narrow-band imaging and correlated the findings with histopathology.

METHODS

Retrospective analysis was conducted by retrieving data of patients who underwent micro-laryngoscopy for suspicious glottic lesions. The narrow-band imaging findings were classified using both classification systems. Retrieved histopathology report findings were correlated with narrow-band imaging data.

RESULTS

Using the European Laryngeal Society and Ni classifications, 37 (69.8 per cent) and 35 (66 per cent) patients, respectively, were suspected to have malignant lesions. Upon histopathology, 37 (69.8 per cent) lesions were malignant. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy using the European Laryngeal Society classification were 91.9 per cent, 81.3 per cent, 91.9 per cent, 81.3 per cent and 88.7 per cent, and using the Ni classification were 91.9 per cent, 93.8 per cent, 97.1 per cent, 83.3 per cent and 92.5 per cent, respectively.

CONCLUSION

The Ni classification had better specificity and accuracy. The European Laryngeal Society classification is simple to use and may serve as a useful screening tool. For optimum results, both European Laryngeal Society and Ni classifications may be used together, in that order.

Clinical significance of type IV vascularization of laryngeal lesions according to the Ni classification

Background

Scattered, small, dot-like intraepithelial papillary capillary loops (IPCLs) represent type IV epithelial vascularization according to "Ni classification" and are considered to be nonmalignant. According to the European Laryngological Society classification, these loops are malignant vascular changes. This contradiction has high clinical importance; therefore, clarification of the clinical significance of type IV vascularization according to the Ni classification is needed.

Methods

The study was performed between June 2015 and December 2022. All recruited patients (n = 434) were symptomatic, with macroscopic laryngeal lesions (n = 674). Patients were investigated using the enhanced endoscopic methods of narrow band imaging (NBI) and the Storz Professional Image Enhancement System (IMAGE1 S). The microvascular patterns in the lesions were categorized according to Ni classification from 2011 and all lesions were examined histologically.

Results

A total of 674 lesions (434 patients) were investigated using flexible NBI endoscopy and IMAGE1 S endoscopy. Type IV vascularization was recognized in 293/674 (43.5%) lesions. Among these 293 lesions, 178 (60.7%) were benign (chronic laryngitis, hyperplasia, hyperkeratosis, polyps, cysts, granulomas, Reinkeho oedema and recurrent respiratory papillomatosis); 9 (3.1%) were squamous cell carcinoma; 61 (20.8%) were mildly dysplastic, 29 (9.9%) were moderately dysplastic, 14 (4.8%) were severe dysplastic and 2 (0.7%) were carcinoma in situ. The ability to recognize histologically benign lesions in group of nonmalignant vascular pattern according to Ni (vascularization type I-IV) and distinguish them from precancers and malignancies was with accuracy 75.5%, sensitivity 54.4%, specificity 94.4%, positive predictive value 89.6% and negative predictive value 69.9%.

Conclusion

Laryngeal lesions with type IV vascularization as defined by Ni present various histological findings, including precancerous and malignant lesions. Patients with type IV vascularization must be followed carefully and, in case of progression mucosal lesion microlaryngoscopy and excision are indicated.

Vocal fold leukoplakia recurrence risk model

The paper aims to define the variables that elevate the risk of VFL recurrence after adequate primary treatment, and to present the Recurrence Risk Model with practical conclusions to handle pVFL and rVFL. Out of 207 patients with primary vocal fold leukoplakia (pVFL), in 41 (19.8%) recurrent VFL (rVFL) was diagnosed. All patients were assessed by using a trans-nasal flexible video-endoscope using white light, and NBI. The primary measure of our study was to investigate whether morphological features of pVFL in WL, vascular pattern in NBI, and primary histological findings could predict VFL recurrence. To create a model of risk factors, two methods were used: logistic regression and a conditional inference decision tree. The study showed smoking was the factor that significantly and most strongly increased the likelihood of rVFL, as well as the older age groups have a greater odds of rVFL. Types IV, V and VI, according to Ni 2019 classification, were associated with a significantly higher risk of rVFL. The algorithm combining patients' dependent variables and the combination of two classifications improves the predictive value of the presented VFL Recurrence Risk Model.

Comparison of narrow-band imaging with autofluorescence imaging for endoscopic detection of squamous cell carcinoma of the tonsil

PURPOSE

Early detection of mucosal neoplastic lesions is crucial for a patient's prognosis. This has led to the development of effective optical endoscopic diagnostic methods such as narrow band imaging (NBI) and autofluorescence (AFI). Independent of each other, both of these methods were proven useful in the detection of mucosal neoplasias. There are limited reported data comparing both methods for oropharyngeal cancer diagnostics. The aim of the study was to compare NBI and AFI endoscopic visualization of signs in identifying tonsillar squamous cell carcinoma (SCC) and assessing its extent and to determine whether the score was related to the evaluator's experience.

METHODS

Patients with tonsillar SCC underwent endoscopic pharyngeal examination using NBI and AFI. Fiftyseven video sequences of examinations of lesions proven to be SCC were evaluated by three reviewers. The accuracy of determination of lesion extent and visualization of its endoscopic signs of malignancy were evaluated.

RESULTS

Endoscopic visualization of tumour spread was significantly better using AFI than NBI (p = 0.0003). No significant difference was found between NBI and AFI in the visualization of endoscopic malignancy determining signs (p = 0.1405). No significant difference was found among the three reviewers in the visualization of tumour spread and for identifying malignancy-determining signs in NBI endoscopy or AFI endoscopy.

CONCLUSIONS

The results show that AFI obtained better results for assessing the extent of tonsillar cancers than NBI. Both methods were proven to be equal in the visualization of endoscopic malignancy-determining signs. Both are useful even for less experienced evaluators.

Contact Endoscopy - Narrow Band Imaging (CE-NBI) data set for laryngeal lesion assessment

The endoscopic examination of subepithelial vascular patterns within the vocal fold is crucial for clinicians seeking to distinguish between benign lesions and laryngeal cancer. Among innovative techniques, Contact Endoscopy combined with Narrow Band Imaging (CE-NBI) offers real-time visualization of these vascular structures. Despite the advent of CE-NBI, concerns have arisen regarding the subjective interpretation of its images. As a result, several computer-based solutions have been developed to address this issue. This study introduces the CE-NBI data set, the first publicly accessible data set that features enhanced and magnified visualizations of subepithelial blood vessels within the vocal fold. This data set encompasses 11144 images from 210 adult patients with pathological vocal fold conditions, where CE-NBI images are annotated using three distinct label categories. The data set has proven invaluable for numerous clinical assessments geared toward diagnosing laryngeal cancer using Optical Biopsy. Furthermore, given its versatility for various image analysis tasks, we have devised and implemented diverse image classification scenarios using Machine Learning (ML) approaches to address critical clinical challenges in assessing laryngeal lesions.

Surgical Outcome of Potassium-Titanyl-Phosphate (KTP) Laser Photocoagulation for Vocal Fold Vascular Lesions

INTRODUCTION

Laser technology is used in microscopic direct laryngeal surgery for a variety of indications. Lasers are categorized broadly as photoangiolytic or cutting/ablating lasers, based on the chromophores that absorb their energy. Photoangiolytic lasers such as the 532 nm Potassium-Titanyl-Phosphate (KTP) laser are absorbed selectively by the chromophore hemoglobin, facilitating controlled intravascular coagulation, with preservation of the overlying epithelium and adjacent tissue. Efficacy of the KTP laser has been demonstrated for incision, coagulation, and ablation in vocal fold (VF) surgery.

OBJECTIVE

The purpose of the present study was to examine surgical outcomes following KTP laser photocoagulation for the management of VF vascular lesions.

METHODS

Adult patients with sufficient data who had undergone KTP laser photocoagulation in the operating room for the treatment of VF vascular lesions were included in this retrospective study. Strobovideolaryngoscopy (SVL) video footage from all preoperative visits and all available postoperative visits was compiled and de-identified. Patients were followed up at days 1-7, 8-14, 30-60, and greater than 60 days after surgery. Three blinded physician evaluators reviewed and evaluated the SVL footage independently for postoperative outcome parameters. Postoperative SVL video footage was evaluated on a 5-point scale for surgical success (surgical objective score; 1 = failure and 5 = complete success). The average surgical objective score was 4.36, 4.04, 4.25, and 4.46 (out of 5) at postoperative visits 1-4, respectively.

RESULTS

There were 60 cases (19 male and 41 female) included in the retrospective cohort. The average age was 42.42 ± 15.51 (range = 18-74). Fifty-one-point six seven percent of subjects were professional voice users (singers, teachers, public speakers, and others). All subjects were diagnosed preoperatively with VF vascular malformations and had undergone pulsed KTP laser photocoagulation. There were 40 bilateral cases and 20 unilateral cases, for a total of 100 VFs included in the study. Vascular malformation recurrence was identified in 3.00% and 10.00% of subjects at the third and fourth postoperative visits, retrospectively. The formation of new vascular malformations was identified in 0.00%, 1.00%, 6.00%, and 7.00% of subjects at postoperative visits 1-4, respectively.

CONCLUSION

KTP laser photocoagulation is highly effective for the management of vocal fold vascular lesions. Presence of hemorrhage or edema does not affect the long-term surgical outcome. In relatively few cases, vascular lesion recurrence or formation of new vascular lesions may occur.

Recurrent laryngeal papillomatosis: multimodal therapeutic strategies. Literature review and multicentre retrospective study

Objectives

Recurrent respiratory papillomatosis (RRP) is a benign, rare disease caused by Human Papilloma Virus (HPV) that can be divided into juvenile and adult forms. The course of the disease is variable, but is usually more aggressive in the juvenile form. The standard surgical treatment is represented by CO2 laser resection, although photoangiolytic lasers represent a valid alternative. Adjuvant therapies have been proposed for disease control in case of frequent surgical resections or spreading into the lower airways. In recent years, the development of immunotherapy led to the use of bevacizumab either intratumorally or intravenously, but the most promising therapeutic development is represented by HPV vaccination. This paper aims to present a narrative review of the literature and the experience of three different University Centres in the treatment of RRP.

Methods

A retrospective analysis of the clinical charts of all patients affected by laryngeal papillomatosis and treated in three different University Centres between 2002 and 2022 was performed. The following parameters were collected: sex, age at first evaluation, sites of larynx involved, HPV type, type of first surgical treatment, presence and number of recurrences, surgical treatment of recurrences, adjuvant therapies, side effects and status at last follow-up.

Results

Seventy-eight patients were available for evaluation. Of these, 88% had adult onset RRP (Ao-RRP) and 12% juvenile onset RRP (Jo-RRP). The glottis was the most frequently involved subsite; all patients were submitted to surgical resection with CO2 laser under general anaesthesia. Recurrences appeared in 79% of the patients, the patients who did not recur were all adults. The mean number of recurrences was 9 (range 1-110). Recurrences were more frequent in children (M = 20; range 2-110) than adults (M = 5; range 1-21). Thirty-two (52%) of the 62 patients who recurred were re-treated with CO2 laser under general anaesthesia, while office-based treatment with a photoangiolytic laser was preferred in the remaining 30 (48%) patients. Adjuvant treatments were applied in 26 patients. The analysis of the course of the disease showed that in the 9 patients with Jo-RRP, 6 (67%) were free of lesions at the last follow-up, while the other 3 (33%) had papillomas. Of the 69 patients with Ao-RRP, 53 (77%) were alive and free of disease at the last visit, 14 (21%) were alive with disease, 1 (1%) was lost at follow-up and 1 (1%) died for other disease. Severe side effects were not observed except for 2 patients, who developed posterior glottic stenosis.

Conclusions

Our results confirmed the literature review. RRP is a potentially aggressive disease, especially in juvenile onset. Surgical resection is still first-line treatment, but in case of multiple recurrences the use of adjuvant therapies must be taken into consideration.

Dysplastic Lesions of the Larynx

There have been many advancements in the clinical and histologic diagnosis of laryngeal dysplasia (LD), but diagnosis still necessitates invasive histologic evaluation. Furthermore, despite improved histologic identification of dysplastic lesions, the exact details of pathophysiologic progression and the risk of malignant transformation is still uncertain. These unknowns create a barrier to establishing an ideal grading and classification system, which prevents the establishment of a precise and consistent treatment paradigm. Identifying these gaps in knowledge serves to highlight where further studies are warranted, ideally focusing on a better understanding of the biological behavior of LD. This would ultimately allow for the creation of a reliable grading and classification system and for the formalization of management and treatment guidelines for LD.

Evolution of mucosal vasculature after radiotherapy of T1 vocal cord cancer: a pilot study

PURPOSE

Narrow-band imaging is the state of the art in the diagnosis of mucosal lesions of the vocal cords. It is also used in the follow-up of patients after surgical therapy. Unfortunately, if a patient has received radiotherapy the follow-up is much more difficult. Radiation induces inflammatory changes in the mucosa, which lead to changes in the vascular architecture and thus affect the results of the examination. The dynamics and time dependence of vascular changes after radiotherapy have not yet been described. The purpose of this study is to describe the evolution of the vascular pattern in vocal cords after primary radiotherapy for glottic cancer.

METHODS

This was a retrospective cohort study. Each patient underwent NBI videolaryngoscopy and was followed every 3 months.

RESULTS

The tumor-related mucosal changes diminished at 3 months after radiotherapy. Afterward, growth of new longitudinal vasculature was observed and significantly slowed after 9 months. No perpendicular vasculature or tumor recurrence was observed during the course of the study.

CONCLUSIONS

According to our data, we can conclude that post-radiation mucosal vasculature changes are only longitudinal.

The Comparison of Narrow Band Imaging, White Light Laryngoscopy and Videolaryngostroboscopy in the Evaluation of Benign Vocal Fold Lesions

BACKGROUND

The aim of the study was comparing the diagnostic role of the white light (WL) endoscopy, video laryngostroboscopy (VLS), and narrow-band imaging (NBI) in the evaluation of the benign vocal fold lesions.

MATERIAL AND METHODS

From March 2018 to June 2019, a total of 118 cases were enrolled in this study. Ninety-eight patients were suspected with vocal fold nodules, cysts, polyps, and sulcus vocalis and 20 patients without a history of dysphonia. Each patient was examined by WL, VLS, and NBI endoscopy. Recorded images and videos were analyzed and scored by three otorhinolaryngologists who had at least 3 years of experience in phoniatrics field. The evaluation results were compared between the methods and the physicians.

RESULTS

A total of 118 cases were grouped by their confirmed diagnosis, vocal fold nodules (n = 28), vocal fold cyst (n = 24), vocal fold polyp (n = 9), and sulcus vocalis (n = 37). When the correct diagnosis rates of the physicians were compared, the statistical significance was found between the physicians in the WL and VLS method (P= 0.014, P= 0.027). No statistically significant difference was found among physicians in NBI method (P = 0.368). The difference between the diagnostic methods was found to be statistically significant in reaching the accurate diagnosis for benign vocal fold lesions (P< 0.001). While the difference between NBI-WL and VLS-WL was statistically significant (P< 0.001 and P< 0.001). The difference between NBI-VLS was not statistically significant while evaluating the vocal fold nodules, cysts, and sulcus vocalis separately (P= 0.102, P = 0.026, P = 0.157). Otherwise, it was statistically significant (P= 0.002) while evaluating total benign lesions in the study. The difference between NBI-VLS combination and VLS, NBI-VLS combination and VLS-WL combination were statistically significant (P< 0.001 and P= 0.001).

CONCLUSION

This study showed that NBI assessments have similar accuracy and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to VLS and have a higher value than WL endoscopy in reaching the diagnosis for benign vocal fold lesions. Therefore, NBI can be accepted as a promising approach to identify benign laryngeal lesions due to its optical properties.

Narrative Review of Classification Systems Describing Laryngeal Vascularity Using Advanced Endoscopic Imaging

Endoscopic methods are critical in the early diagnosis of mucosal lesions of the head and neck. In recent years, new examination methods and classification systems have been developed and introduced into clinical practice. All of these new techniques target the notion of optical biopsy, which tries to assess the nature of the lesion before histology examination. Many methods suffer from interpretation issues due to subjective interpretation of the findings. Therefore, multiple classification systems have been developed to assist the proper interpretation of mucosal findings and reduce the error rate. They provide various perspectives on the assessment and interpretation of mucosa changes. This article provides a comprehensive and critical view of the available classification systems as well as their advantages and disadvantages.

Role of Narrow Band Imaging in Laryngeal Lesions: A Prospective Study from Southern India

To assess the utility of Narrow Band Imaging (NBI) as a diagnostic tool in evaluating laryngeal pathology in patients presenting with hoarseness. Study design: Prospective cross sectional diagnostic study. Methods: 200 patients with voice change were recruited and laryngeal findings documented with high definition flexible endoscopy with both white light and narrow band light and the representative still images recorded for analysis. The NBI intraepithelial papillary capillary loop (IPCL) patterns was compared with the histopathology report. Of the 200 patients evaluated, 84 lesions were biopsied which included both benign and malignant lesions. The sensitivity obtained was 73.3% [54.1-87.7% with 95% CI] and the specificity was 87% [75.1-94.6% with 95% CI] for detecting malignant lesions. NBI can be considered as a useful diagnostic tool in evaluating laryngeal pathology and can be used to detect early premalignant and malignant lesions.

NBI and Laryngeal Papillomatosis: A Diagnostic Challenge: A Systematic Review

Highlights

Abstract

Narrow-band imaging (NBI) represents a valid aid in laryngeal squamous cell carcinoma (LSCC) diagnosis for detecting vascular changes. However, LSCC and laryngeal papillomatosis (LP) show similar vascular patterns that may lead to misdiagnosis and improper treatment. This review aims to deepen this NBI limit in order to stress a careful preoperative evaluation of laryngeal lesions. The research was carried out on PubMed, Web of Science and Scopus databases using specific keywords. The topic of research was assessed by these parameters: accuracy, sensitivity, specificity, and positive and negative predictive values. This review included only five articles: they demonstrated that NBI is better than white-light endoscopy in detecting LSCC and LP. They also reported that LP is frequently mistaken for LSCC, resulting in high rates of false positives using NBI. This is the first review that emphasized this NBI limitation in distinguishing between LP and LSCC in cases of a type V pattern of intraepithelial papillary capillary loop. Although NBI application increased the rate of early cancer detection, LP reduces NBI accuracy. This drawback may lead to misdiagnosis and improper treatment. Our advice is to be careful in cases of type V pattern on NBI and to research LP epithelial and clinical features because it could be a pitfall.

Surgical Outcome of Low-Power-Density Blue Laser for Vascular Lesions of the Vocal Fold

Photoangiolytic lasers such as the 532-nm potassium-titanyl-phosphate (KTP) and the novel 445-nm blue laser (introduced into the United States in 2020) are absorbed selectively by hemoglobin, permitting targeted ablation of vascular structures such as vascular malformations of the vocal fold (VF). Previously, we reported the high rate of success of KTP laser photocoagulation for VF vascular lesions. Compared with other photoangiolytic lasers, blue laser has the highest absorption in hemoglobin, and therefore it can be operated at lower power densities to minimize thermal injury to adjacent tissue.

OBJECTIVE

The purpose of this study was to determine the efficacy and safety of blue laser for treatment of VF vascular lesions using low power densities, and to compare outcomes of blue laser with those of KTP laser.

METHODS

Adult voice patients who underwent blue laser treatment of VF vascular lesions in the operating room at the lowest power densities that appeared clinically to cause the effect desired were included in this retrospective study. Baseline lesion characteristics and postoperative outcomes were assessed with a model that we had described previously. Postoperative outcomes were compared to those of previously reported KTP laser.

RESULTS

Thirty-one subjects (54 VFs treated) underwent blue laser vaporization of VF vascular lesions (average age was 40.63 ± 17.51). Data were compared to those of 66 subjects (100 VFs) who had undergone KTP laser vaporization of VF vascular lesions. There were no significant differences in subject demographics, past medical or surgical history, or preoperative location or severity of vascular lesions. Surgical success for blue laser at the low power densities used was 3.74 ± 0.50, 3.55 ± 0.94, 3.90 ± 0.94, and 3.70 ± 1.11 (out of 5) at postoperative visits 1-4, respectively. Surgical objective score was significantly greater following KTP laser at every postoperative visit. Treatment with KTP laser resulted in significantly greater generalized postoperative edema, and blue laser resulted in significantly greater localized edema at postoperative visits one and two. At visit three and four, there are no significant differences. VF stiffness following blue laser was 2.41 ± 0.67, 1.91 ± 0.69, 1.33 ± 0.47, and 1.10 ± 0.18 (out of 4) at postoperative visits 1-4, respectively. Postoperative VF stiffness did not differ significantly from KTP laser. Postoperative hemorrhage severity after blue laser was 1.79 ± 0.54, 1.59 ± 0.48, 1.15 ± 0.25, and 1.14 ± 0.26 (out of 4) at postoperative visits 1-4, respectively. Blue laser resulted in significantly less VF hemorrhage than KTP laser at the first (1.79 ± 0.54 versus 2.26 ± 0.83) and second (1.59 ± 0.48 versus 1.98 ± 0.72) postoperative visits. Vascular lesions treated with low-power-density blue laser were significantly more likely to recur than those treated with KTP laser (40.74% versus 10.00%). New vascular malformations were significantly more likely to form after blue laser than KTP (24.07% versus 6.00%). Subjects treated with low-power-density blue laser were significantly more likely to undergo repeat surgery than those treated with KTP (31.48% versus 14.00%). Significant predictors for the need for repeat blue laser included lesion recurrence, a lower surgical objective score at the third or fourth postoperative visit and a higher baseline lesion severity grade.

CONCLUSION

Blue laser is an effective tool for the surgical management of VF vascular lesions. Although overall surgical success ratings were inferior to KTP laser at the power densities used, the severity of postoperative edema and VF hemorrhage were significantly less with blue laser. Re-evaluation of blue laser using higher power densities is in progress.

Videomics of the Upper Aero-Digestive Tract Cancer: Deep Learning Applied to White Light and Narrow Band Imaging for Automatic Segmentation of Endoscopic Images

Introduction

Narrow Band Imaging (NBI) is an endoscopic visualization technique useful for upper aero-digestive tract (UADT) cancer detection and margins evaluation. However, NBI analysis is strongly operator-dependent and requires high expertise, thus limiting its wider implementation. Recently, artificial intelligence (AI) has demonstrated potential for applications in UADT videoendoscopy. Among AI methods, deep learning algorithms, and especially convolutional neural networks (CNNs), are particularly suitable for delineating cancers on videoendoscopy. This study is aimed to develop a CNN for automatic semantic segmentation of UADT cancer on endoscopic images.

Materials and Methods

A dataset of white light and NBI videoframes of laryngeal squamous cell carcinoma (LSCC) was collected and manually annotated. A novel DL segmentation model (SegMENT) was designed. SegMENT relies on DeepLabV3+ CNN architecture, modified using Xception as a backbone and incorporating ensemble features from other CNNs. The performance of SegMENT was compared to state-of-the-art CNNs (UNet, ResUNet, and DeepLabv3). SegMENT was then validated on two external datasets of NBI images of oropharyngeal (OPSCC) and oral cavity SCC (OSCC) obtained from a previously published study. The impact of in-domain transfer learning through an ensemble technique was evaluated on the external datasets.

Results

219 LSCC patients were retrospectively included in the study. A total of 683 videoframes composed the LSCC dataset, while the external validation cohorts of OPSCC and OCSCC contained 116 and 102 images. On the LSCC dataset, SegMENT outperformed the other DL models, obtaining the following median values: 0.68 intersection over union (IoU), 0.81 dice similarity coefficient (DSC), 0.95 recall, 0.78 precision, 0.97 accuracy. For the OCSCC and OPSCC datasets, results were superior compared to previously published data: the median performance metrics were, respectively, improved as follows: DSC=10.3% and 11.9%, recall=15.0% and 5.1%, precision=17.0% and 14.7%, accuracy=4.1% and 10.3%.

Conclusion

SegMENT achieved promising performances, showing that automatic tumor segmentation in endoscopic images is feasible even within the highly heterogeneous and complex UADT environment. SegMENT outperformed the previously published results on the external validation cohorts. The model demonstrated potential for improved detection of early tumors, more precise biopsies, and better selection of resection margins.

Correlating intraepithelial papillary capillary loops of vocal cord leukoplakia with histopathology

BACKGROUND

The pathology of vocal fold leukoplakia (VFL) was hard to predict before surgery.

OBJECTIVES

To investigate the correlation of intraepithelial papillary capillary loops (IPCLs) with the malignant transformation in VFL.

MATERIALS AND METHODS

The IPCLs in 90 patients were classified according to 2019 Ni classification. Type I-III represented to non- to moderate dysplasia in pathology being viewed as 'benign leukoplasia', type IV-VI represented to severe dysplasia/cancer in situ, cancerization being viewed as 'malignant leukoplasia'. The corresponding relationship of IPCLs with pathology was calculated.

RESULTS

Forty-one cases were classified as type I-III, the consistency of type I-III with pathology was 61.0%, with 100.0% of type I, 47.1% of type II and 30.0% of type III. 49 cases were classified as type IV-VI, all were 'malignant leukoplasia', the consistency of type IV-VI and pathology was 100.0%. The accuracy of type I-III, IV-VI to predict pathology were 61.0, 100.0%. The sensitivity, specificity, accuracy, positive predictive value, negative predictive value of Ni classification corresponding to 'benign/malignant leukoplasia' was 75.8, 100.0, 82.2, 100.0, 60.0%, respectively.

CONCLUSIONS AND SIGNIFICANCE

IPCLs of type IV-VI in vocal cord leukoplasia had a close correlation with pathology. The degree of dysplasia was underestimated in type II and type III.

Leukoplakia: An Invasive Cancer Hidden within the Vocal Folds. A Multivariate Analysis of Risk Factors

Introduction

Discerning the preoperative nature of vocal fold leukoplakia (VFL) with a substantial degree of certainty is fundamental, seeing that the histological diagnosis of VFL includes a wide spectrum of pathology and there is no consensus on an appropriate treatment strategy or frequency of surveillance. The goal of our study was to establish a clear schedule of the diagnostics and decision-making in which the timing and necessity of surgical intervention are crucial to not miss this cancer hidden underneath the white plaque.

Material and Methods

We define a schedule as a combination of procedures (white light and Narrow Band Imaging diagnostic tools), methods of evaluating the results (a combination of multiple image classifications in white light and Narrow Band Imaging), and taking into account patient-related risk factors, precise lesion location, and morphology. A total number of 259 patients with 296 vocal folds affected by leukoplakia were enrolled in the study. All patients were assessed for three classifications, in detail according to Ni 2019 and ELS 2015 for Narrow Band Imaging and according to Chen 2019 for white light. In 41 of the 296 folds (13.9%), the VFL specimens in the final histology revealed invasive cancer. We compared the results from the classifications to the final histology results.

Results

The results showed that the classifications and evaluations of the involvement of anterior commissure improve the clinical utility of these classifications and showed improved diagnostic performance. The AUC of this model was the highest (0.973) with the highest sensitivity, specificity, PPV, and NPV (90.2%, 89%, 56.9%, and 98.3%, respectively).

Conclusion

The schedule that combines white light and Narrow Band Imaging, with a combination of the two classifications, improves the specificity and predictive value, especially of anterior commissure involvement.

Deep Convolution Neural Network for Laryngeal Cancer Classification on Contact Endoscopy-Narrow Band Imaging

(1) Background: Contact Endoscopy (CE) and Narrow Band Imaging (NBI) are optical imaging modalities that can provide enhanced and magnified visualization of the superficial vascular networks in the laryngeal mucosa. The similarity of vascular structures between benign and malignant lesions causes a challenge in the visual assessment of CE-NBI images. The main objective of this study is to use Deep Convolutional Neural Networks (DCNN) for the automatic classification of CE-NBI images into benign and malignant groups with minimal human intervention. (2) Methods: A pretrained Res-Net50 model combined with the cut-off-layer technique was selected as the DCNN architecture. A dataset of 8181 CE-NBI images was used during the fine-tuning process in three experiments where several models were generated and validated. The accuracy, sensitivity, and specificity were calculated as the performance metrics in each validation and testing scenario. (3) Results: Out of a total of 72 trained and tested models in all experiments, Model 5 showed high performance. This model is considerably smaller than the full ResNet50 architecture and achieved the testing accuracy of 0.835 on the unseen data during the last experiment. (4) Conclusion: The proposed fine-tuned ResNet50 model showed a high performance to classify CE-NBI images into the benign and malignant groups and has the potential to be part of an assisted system for automatic laryngeal cancer detection.

Deep Learning Applied to White Light and Narrow Band Imaging Videolaryngoscopy: Toward Real-Time Laryngeal Cancer Detection

OBJECTIVES

To assess a new application of artificial intelligence for real-time detection of laryngeal squamous cell carcinoma (LSCC) in both white light (WL) and narrow-band imaging (NBI) videolaryngoscopies based on the You-Only-Look-Once (YOLO) deep learning convolutional neural network (CNN).

STUDY DESIGN

Experimental study with retrospective data.

METHODS

Recorded videos of LSCC were retrospectively collected from in-office transnasal videoendoscopies and intraoperative rigid endoscopies. LSCC videoframes were extracted for training, validation, and testing of various YOLO models. Different techniques were used to enhance the image analysis: contrast limited adaptive histogram equalization, data augmentation techniques, and test time augmentation (TTA). The best-performing model was used to assess the automatic detection of LSCC in six videolaryngoscopies.

RESULTS

Two hundred and nineteen patients were retrospectively enrolled. A total of 624 LSCC videoframes were extracted. The YOLO models were trained after random distribution of images into a training set (82.6%), validation set (8.2%), and testing set (9.2%). Among the various models, the ensemble algorithm (YOLOv5s with YOLOv5m-TTA) achieved the best LSCC detection results, with performance metrics in par with the results reported by other state-of-the-art detection models: 0.66 Precision (positive predicted value), 0.62 Recall (sensitivity), and 0.63 mean Average Precision at 0.5 intersection over union. Tests on the six videolaryngoscopies demonstrated an average computation time per videoframe of 0.026 seconds. Three demonstration videos are provided.

CONCLUSION

This study identified a suitable CNN model for LSCC detection in WL and NBI videolaryngoscopies. Detection performances are highly promising. The limited complexity and quick computational times for LSCC detection make this model ideal for real-time processing.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

The Narrow Band Imaging as an essential complement to White Light Endoscopy in Recurrent Respiratory Papillomatosis diagnostics and follow-up process

The aim of the study is to discuss the role of NBI imaging in upper respiratory papillomatosis (RRP). In the available literature on the subject, as of 2009, there have been 117 publications on NBI imaging focusing on the diagnosis of the upper respiratory and digestive tract, especially the larynx. They discuss the following diagnostic and therapeutic problems: identifying an abnormal vascular pattern within the mucosa, differentiating benign and malignant lesions, assessing the nature of lesions under the leukoplakia plaque, pre-operative definition of laryngeal cancer margins, supporting laser procedures to obtain safe margins, postoperative monitoring after cancer treatment, detecting second simultaneous and metachronic neoplasms and primary tumors in the case of metastases from an unknown primary site. Few reports have been devoted to the assessment of the extent and recurrence of RRP. Due to its recurrent nature, this pathology deserves special attention as it requires multiple inspections and manipulation within the larynx. It also applies to the pediatric population, where there should be no margin for underestimating or overestimating changes, because any suspicion of recurrence results in subsequent general anesthesia. Hence the attempt to define an unambiguous picture of RRP recurrence and the criteria for referring for subsequent surgical treatment.

Hemoglobin Absorption Spectral Imaging (H.A.S.I.): a novel optical staining technique for microlaryngoscopy

PURPOSE

Optical image enhancement techniques are widely used in endoscopy to improve the visualization of blood vessels for diagnostic and therapeutic purposes. These techniques are monitor-based and therefore not available for direct microscopy. In this study, a novel optical microscope filter, Hemoglobin absorption spectral imaging (H.A.S.I.) was tested for use in microlaryngoscopy.

METHODS

A novel dichroic filter was designed to improve contrast in small blood vessels by highlighting transmission in the spectrum range of hemoglobin absorption maxima. A surgical microscope equipped with the novel H.A.S.I. filter was installed in one operating room in our institution. 68 consecutive patients referred to our ENT department for endoscopy were examined using white light and the novel H.A.S.I. filter during microlaryngoscopy. Surgeons described the blood vessels of the vocal cords using a classification chart and assessed for suspected malignancy using both white light and H.A.S.I.

RESULTS

77 consecutive microlaryngoscopies were performed on 68 patients. 142 vocal cords were visualized in microlaryngoscopy and the blood vessels classified according to the chart. With white light, 152 blood vessel characteristics were documented and 157 with H.A.S.I. Notably, pathologies like benign horizontal blood vessel changes, leukoplakia, and vertical blood vessel changes like dots and loops were seen more frequently with H.A.S.I. Finally, seven lesions were treated by transoral laser microsurgery (TLM) with H.A.S.I. to test the practicability of the method for microlaryngoscopic laser surgery.

CONCLUSION

This is the first study describing H.A.S.I. as an optical staining method for microlaryngoscopy. In our experience, the method was practical and improved the evaluation of vocal cord blood vessels. In some cases, the use of H.A.S.I. led to a change in diagnosis and treatment. Also, H.A.S.I. was found to be helpful in microlaryngeal laser surgery for demarcating resection margins. This is, to our knowledge, the first optical staining method integrated into a surgical microscope and can be conveniently used during microlaryngeal laser surgery and does not require further equipment.

[Contact endoscopy with narrow-band imaging for detection of perpendicular vascular changes in benign, dysplastic, and malignant lesions of the vocal folds]

BACKGROUND

Perpendicular vascular changes (PVC) are markers of tumor-induced neoangiogenesis at the vocal folds. Contact endoscopy with narrow-band imaging (CE-NBI) allows a detailed analysis of such vascular changes.

OBJECTIVE

This work intends to evaluate the potential of CE-NBI for diagnosis of benign, dysplastic, and malignant lesions of the vocal folds. In addition, it should be determined whether CE-NBI offers an additional benefit in detecting PVC compared to white-light endoscopy (WLE) and NBI alone.

MATERIALS AND METHODS

Three examiners evaluated histologically verified cases of benign, dysplastic, and malignant lesions of the larynx in WLE, NBI, and CE-NBI (n = 60). In each mode, they examined the lesion for PVC and assessed the lesion's dignity. The proportion of lesions with detected PVC, the statistical measures of performance in detecting high-grade dysplasia and carcinoma, and the interrater variability for each mode were calculated.

RESULTS

CE-NBI proved superior to the other investigated diagnostic methods in terms of detecting PVC and in terms of sensitivity and accuracy in the diagnosis of high-grade dysplasia and carcinoma. A clear association of such pathologies with PVC was seen.

CONCLUSION

CE-NBI detects PVC more frequently and reliably than the other methods investigated. The association of these vascular patterns to high-grade dysplasia and vocal fold carcinomas could be confirmed. Compared to WLE and NBI endoscopy, the diagnostic quality for detecting high-grade dysplasia and carcinoma is increased. Thus, CE-NBI can improve endoscopic differentiation between benign and malignant lesions of the vocal folds by enhancing the detection of PVC.

An overview of the current clinical status of optical imaging in head and neck cancer with a focus on Narrow Band imaging and fluorescence optical imaging

Early and accurate identification of head and neck squamous cell carcinoma (HNSCC) is important to improve treatment outcomes and prognosis. New optical imaging techniques may assist in both the diagnostic process as well as in the operative setting by real-time visualization and delineation of tumor. Narrow Band Imaging (NBI) is an endoscopic technique that uses blue and green light to enhance mucosal and submucosal blood vessels, leading to better detection of (pre)malignant lesions showing aberrant blood vessel patterns. Fluorescence optical imaging makes use of near-infrared fluorescent agents to visualize and delineate HNSCC, resulting in fewer positive surgical margins. Targeted fluorescent agents, such as fluorophores conjugated to antibodies, show the most promising results. The aim of this review is: (1) to provide the clinical head and neck surgeon an overview of the current clinical status of various optical imaging techniques in head and neck cancer; (2) to provide an in-depth review of NBI and fluorescence optical imaging, as these techniques have the highest potential for clinical implementation; and (3) to describe future improvements and developments within the field of these two techniques.

Narrow-band imaging combined with salivary pepsin to diagnose patients with laryngopharyngeal reflux

BACKGROUND

Laryngopharyngeal reflux (LPR) is a prevalent disease in the ENT outpatient department. Methods of LPR diagnosis differ much. Narrow-band imaging (NBI) and Salivary pepsin-level measurements have been considered as totally new ways for the diagnosis of LPR in recent years.

AIM

We aimed to identify the specific manifestation of LPR and assess the correlation between NBI views and pepsin levels in LPR diagnosing.

MATERIALS AND METHODS

130 Patients enrolled in our study were divided into LPR group and non-LPR group according to the scores of RSI and RFS. All individuals received endoscopic NBI tests and salivary pepsin measurements. NBI views of the larynx were divided into four grades based on the existing descriptive guidelines and our clinical observations, and the correlation between NBI grading and salivary pepsin levels was calculated.

RESULTS

NBI grading and pepsin levels are significantly correlated with RFS/RSI scores. The diagnostic concentration of salivary pepsin was 33 ng/ml. There was a significant correlation between NBI grading and salivary levels.

CONCLUSIONS AND SIGNIFICANCE

NBI grading system was proved to provide a better diagnostic value in the diagnosis of LPR. There was a possibility that a combination of these two methods might increase the diagnostic accuracy of this disease.

The role of NBI with flexible video-endoscope in the follow-up of head and neck cancer patients: a prospective study

PURPOSE

Narrow band imaging (NBI) enhances mucosal vasculature and could help in the identification of recurrences. We assessed the effectiveness of NBI with flexible video-endoscope in the early detection of recurrence after treatment of head and neck squamous cell carcinoma, its diagnostic advantage over high-definition white-light (HD WL) endoscopy, also in relation to recurrence site, and the influence of previous radiotherapy (RT) or chemotherapy (CT). Moreover, we investigated the association between index tumor site and the risk of developing recurrence, and the relation between index tumor site and recurrence site.

METHODS

From January 2018 to November 2020, 160 patients previously treated with surgery and/or RT ± CT were evaluated using NBI with flexible video-endoscope. Sensitivity, specificity, positive/negative predictive value, and accuracy were calculated for NBI and HD WL, and compared using the McNemar test. The Fisher exact test was used to compare the other associations investigated.

RESULTS

The difference between NBI and HD WL sensitivity was statistically significant (p < 0.001). The NBI diagnostic advantage was 62.5%, highest in the hypopharynx (p = 0.05), and was not influenced by previous RT or CT (p = 0.49). Index tumor site statistically related with recurrence site (p < 0.001), but not with the risk of developing recurrence (p = 0.81).

CONCLUSION

NBI with flexible video-endoscope could represent a valid option to detect recurrence early during the follow-up, especially in a difficult-to-visualize site such as the hypopharynx.

Evaluation of laryngeal vascular changes with image1 s enhancement system in reference to the European laryngological society guideline

OBJECTIVES

To assess the feasibility of using Image1 S™ endoscopic enhancement system for discrimination of the vascular patterns in laryngeal lesions.

DESIGN

Forty patients presenting with benign, dysplastic and malignant laryngeal lesions were examined with Image1 S system. The vascular patterns were classified by a group of authors according to the European Laryngological Society (ELS) guideline, as perpendicular or longitudinal, in all lesions. The relationship between the vascular patterns and the pathological results was statistically analysed. Endoscopic images of the lesions were evaluated through an online survey by a group of otolaryngologists with different levels of clinical expertise and asked them to choose a diagnosis and a vascular pattern. The vascular pattern evaluations of the participants were compared to the authors' evaluations to determine the interobserver reliability. The final diagnostic judgements of the participants were compared with the definitive histopathological diagnoses.

SETTING

Tertiary university hospital.

PARTICIPANTS

Forty patients with laryngeal lesions and thirty otolaryngologists with different clinical experience levels.

MAIN OUTCOME MEASURES

The study evaluates the usefulness of the Image1 S system for the detecting the vascular patterns associated with benign, dysplastic, and malignant lesions and measures the level of accuracy and inter observer agreement in detecting the final histopathology.

RESULTS

Histopathological examination diagnosed 12 patients as benign, 12 dysplastic and 16 malignant. Using Image1 S, the vascular patterns were longitudinal in 11 lesions, perpendicular in 28 lesions and undetectable in 1 lesion. With white light, longitudinal pattern was observed in 14 lesions, perpendicular in 21 lesions and undetectable in 5 lesions. The correlation between the vascularisation pattern and the pathological diagnosis was found to be significant (p < .001). The qualitative evaluation of the vascular patterns by the two groups of observers showed significant reliability (κ = 0.63, p < .001). The agreement with the final diagnoses was also significant (κ = 0.56, p < .001).

CONCLUSIONS

Image1 S endoscopic enhancement system with spectral modes provides an improved visibility of the vascular patterns defined by the ELS in laryngeal lesions. ELS classification can reliably distinguish benign lesions from suspected ones and can be applied even by less-experienced clinicians but the final diagnosis needs experience and should be confirmed with histopathology.

Diagnosis of Laryngeal Pemphigus Vulgaris Can Be Facilitated Using Advanced Endoscopic Methods

Background: Isolated laryngeal pemphigus vulgaris (LPV) is rare; however, early diagnosis is crucial in determining its course and prognosis. This paper aims to describe mucosal vascular changes typical for LPV using advanced endoscopic methods, which include Narrow Band Imaging (NBI), IMAGE1-S video-endoscopy and enhanced contact endoscopy (ECE). Materials and Methods: Retrospective analysis of all laryngeal mucosal lesion examined using advanced endoscopic methods during 2018-2020 at tertiary hospital was performed. Results: Videolaryngoscopy examination records of 278 patients with laryngeal mucosal lesions were analyzed; three of them were diagnosed with LPV. Epithelial vascularization of LPV included specific pattern. Intraepithelial papillary capillary loops were symmetrically stratified and were organized into "contour-like lines". This specific vascularization associated with LPV were different from other laryngeal mucosal pathologies. Conclusions: Using advanced endoscopic methods supports early diagnosis of LPV and accelerate the diagnosis and treatment.

Vocal Fold Leukoplakia: Which of the Classifications of White Light and Narrow Band Imaging Most Accurately Predicts Laryngeal Cancer Transformation? Proposition for a Diagnostic Algorithm

The management of Vocal Fold Leukoplakia (VFL) remains problematic. There is no consensus on the indications or the timing for surgery. The objective was to select the most accurate classification for predicting low- and high-risk VFL in White Light Imaging (WLI) and Narrow Band Imaging (NBI) and to establish a diagnostic algorithm with a timely referral for treatment. A total of 259 VFL patients were included in the study; 186 lesions were classified as low-grade and 110 as high-grade dysplasia. The results of WLI acc. to the two-tier and the three-tier Chen 2019 classifications and NBI classifications: ELS, Ni 2011, and Ni 2019 with different cut-off points were compared with the pathological examination (HP). In WLI, the greatest agreement was obtained between type 3 of the three-tier classification and high-grade dysplasia (accuracy, specificity, and PPV: 80.4%, 92.0%, and 81.5%, respectively). Assessing VFL periphery in NBI, cut-off point 5 (Ni 2011 type V) demonstrated a higher accuracy, specificity, and PPV than 4 (83.1%, 93.6%, 85.5% and 77.4%, 74.9%, and 65.4%, respectively). In NBI, we observed higher accuracy, sensitivity, and PPV (84.1%, 93.0%, 85.2% vs. 80.7%, 81.3% and 71.3%, respectively) for cut-off point 5 (Ni 2019 type V and VI) in comparison to the cut-off point 4 group (type IV, V, and VI) (80.7%, 81.3%, 71.3%, respectively), and a higher kappa value (0.68 vs. 0.58) was obtained. We have shown that both the plaque image and the microvascular pattern on the leukoplakia periphery are critical in the diagnosis of high-risk VFL. The most accurate predictor of VFL malignant transformation in WLI is type 3 according to the Chen 2019 classification, while in NBI type V and VI according to the Ni 2019 classification.

Detecting Aspiration During FEES with Narrow Band Imaging in a Clinical Setting

The use of narrow band imaging (NBI) during flexible endoscopic evaluation of swallowing (FEES) is recognised as an emerging technology to improve the contrast of the test fluid during endoscopic dysphagia evaluation. This study tested the hypothesis that the use of NBI in FEES would improve the detection of laryngeal penetration and aspiration in patients with unilateral vocal fold paralysis/paresis (UVFP), a typically difficult population in which to detect the presence of aspiration with FEES. Twenty-one consecutive outpatients with UVFP were evaluated with FEES using white light (WL) and NBI under 150 test conditions (75 WL & 75 NBI). Three speech pathologists, highly experienced in FEES using WL but novices to using NBI, rated laryngeal penetration and aspiration for green dyed thin fluid (5 ml and 90 ml) and mildly thick fluid (5 ml) milk, and were compared to two raters more experienced in using NBI during FEES. Laryngeal penetration and aspiration were significantly higher for larger volumes (90 ml) (p < 0.05). With NBI-naïve raters, there was a trend towards lower intra-rater and inter-rater reliability compared to WL on all bolus trials reaching significance on mildly thick fluid (p < 0.01). There was lower rater confidence when using NBI compared to WL in NBI-naïve raters to detect aspiration (p < 0.01). Sensitivity was lower regardless of NBI experience; 80.77-84.21% with WL compared to 46.15-50.00% with NBI. Findings indicate that the improved contrast of a dyed opaque milk trial under WL may negate the potential benefits of using NBI to increase the contrast of the test fluid and supports the use of an opaque test fluid such as milk. NBI may also not be as useful to clinicians with no experience with the altered light condition, and can result in lower sensitivity in even the experienced user.

Diagnostic Value of Narrow Band Imaging in Visualization of Pathological Lesions in Larynx and Hypopharynx

INTRODUCTION

Narrow Band Imaging (NBI) is an endoscopic optical imaging enhancement technology that improves the contrast of mucosal surface texture and enhances visualization of mucosal and submucosal vasculature. Due to its properties, it can visualize suspected malignant or precancerous lesions earlier than conventional white light endoscopy. The aim of this study was to analyze the benefit of NBI in visualization of precancerous and malignant lesions in preoperative and intraoperative diagnostics and correlation with histopathologic results.

METHODS

A total of 589 patients with suspicious laryngeal or hypopharyngeal lesion were investigated using conventional white light endoscopy (WLE) and NBI endoscopy with high-definition TV (HDTV NBI) from 10/2013 to 12/2019. Patients were divided into two groups based on pre-operative NBI examination (group A, 345 patients) and intraoperative NBI examination (group B, 244 patients). All suspicious lesions were graded to 5 types of Ni classification and correlated with histopathologic results. The SPSS version 8.0.4 statistical software package was used for statistical analysis. In diagnosing premalignant and malignant lesions sensitivity, specificity, positive predictive value, and negative predictive value were calculated.

RESULTS

The agreement between NBI endoscopy and histopathological analysis in group A was statistically significant (Қ = 0.76, p < 0.001), with a sensitivity of 86.2% (95% IS: 65.4-95.2) and specificity of 90.9% (95% IS: 70.6-94.1). Moreover, in group B was proven almost perfect agreement between NBI and histopathological analysis (Қ = 0.8461, p < 0.001), with a sensitivity of 84.0% (95% IS: 60.2-92.4) and specificity of 96.0% (95% IS: 87.0-99.2).

CONCLUSIONS

Based on our results, NBI using the Ni classification has great potential in improving diagnosis of precancerous and malignant lesions and correlates strongly with histopathologic results. It serves as a useful adjunct to white light endoscopy in the diagnosis of laryngeal and hypopharyngeal lesions, especially using HDTV NBI.

Deep Learning for Automatic Segmentation of Oral and Oropharyngeal Cancer Using Narrow Band Imaging: Preliminary Experience in a Clinical Perspective

Introduction

Fully convoluted neural networks (FCNN) applied to video-analysis are of particular interest in the field of head and neck oncology, given that endoscopic examination is a crucial step in diagnosis, staging, and follow-up of patients affected by upper aero-digestive tract cancers. The aim of this study was to test FCNN-based methods for semantic segmentation of squamous cell carcinoma (SCC) of the oral cavity (OC) and oropharynx (OP).

Materials and Methods

Two datasets were retrieved from the institutional registry of a tertiary academic hospital analyzing 34 and 45 NBI endoscopic videos of OC and OP lesions, respectively. The dataset referring to the OC was composed of 110 frames, while 116 frames composed the OP dataset. Three FCNNs (U-Net, U-Net 3, and ResNet) were investigated to segment the neoplastic images. FCNNs performance was evaluated for each tested network and compared to the gold standard, represented by the manual annotation performed by expert clinicians.

Results

For FCNN-based segmentation of the OC dataset, the best results in terms of Dice Similarity Coefficient (Dsc) were achieved by ResNet with 5(×2) blocks and 16 filters, with a median value of 0.6559. In FCNN-based segmentation for the OP dataset, the best results in terms of Dsc were achieved by ResNet with 4(×2) blocks and 16 filters, with a median value of 0.7603. All tested FCNNs presented very high values of variance, leading to very low values of minima for all metrics evaluated.

Conclusions

FCNNs have promising potential in the analysis and segmentation of OC and OP video-endoscopic images. All tested FCNN architectures demonstrated satisfying outcomes in terms of diagnostic accuracy. The inference time of the processing networks were particularly short, ranging between 14 and 115 ms, thus showing the possibility for real-time application.

Narrow-Band Imaging in oncologic otorhinolaryngology: State of the art

OBJECTIVES

To describe the diagnostic performance of Narrow Band Imaging (NBI) combined with White Light Imaging (WLI) in the diagnosis of mucosal lesions at each location of the upper aerodigestive tract, for detection of primary tumor in case of carcinoma of unknown primary, for determination of intraoperative resection margins, and to describe its main diagnostic pitfalls.

MATERIAL AND METHODS

A PubMed search was carried out according to the PRISMA method.

RESULTS

Four hundred and seventy-seven articles published between 2007 and 2020 were identified, 133 of which met the study inclusion criteria and were assessed.

CONCLUSION

The current literature seems to support the use of NBI in diagnosis and/or follow-up of (pre-)malignant head & neck tumors, and in the determination of intraoperative resection margins.

Validation of the European Laryngological Society classification of glottic vascular changes as seen by narrow band imaging in the optical biopsy setting

Purpose

In 2016, the European Laryngological Society (ELS) proposed a classification for vascular changes occurring in glottic lesions as visible by narrow band imaging (NBI), based on the dichotomic distinction between longitudinal vessels (not suspicious) and perpendicular ones (suspicious). The aim of our study was to validate this classification assessing the interobserver agreement and diagnostic test performance in detecting the final histopathology.

Methods

A retrospective study was carried out by reviewing clinical charts, preoperative videos, and final pathologic diagnosis of patients submitted to transoral microsurgery for laryngeal lesions in two Italian referral centers. In each institution, two physicians, independently re-assessed each case applying the ELS classification.

Results

The cohort was composed of 707 patients. The pathologic report showed benign lesions in 208 (29.5%) cases, papillomatosis in 34 (4.8%), squamous intraepithelial neoplasia (SIN) up to carcinoma in situ in 200 (28.2%), and squamous cell carcinoma (SCC) in 265 (37.5%). The interobserver agreement was extremely high in both institutions (k = 0.954, p < 0.001 and k = 0.880, p < 0.001). Considering the diagnostic performance for identification of at least SIN or SCC, the sensitivity was 0.804 and 0.902, the specificity 0.793 and 0.581, the positive predictive value 0.882 and 0.564, and the negative predictive value 0.678 and 0.908, respectively.

Conclusion

The ELS classification for NBI vascular changes of glottic lesions is a highly reliable tool whose systematic use allows a better diagnostic evaluation of suspicious laryngeal lesions, reliably distinguishing benign ones from those with a diagnosis of papillomatosis, SIN or SCC, thus paving the way towards confirmation of the optical biopsy concept.

Contribution of narrow band imaging in delineation of laryngopharyngeal superficial cancer spread: a prospective study

PURPOSE

The aim of this study was to assess the performance of Narrow Band Imaging (NBI) added to White Light (WL) in the delineation of laryngopharyngeal superficial cancer spread during office-based transnasal flexible endoscopy.

METHODS

This bi-centric prospective study was conducted between October 2014 and December 2017. We included consecutive patients with laryngopharyngeal malignant tumors. Transnasal flexible endoscopy was performed by two endoscopists who were blinded to each other's assessments and who examined each patient independently. The first endoscopist only performed a WL examination, while the second endoscopist carried out both WL and NBI. The extent of tumor involvement was reported based on predefined anatomical sub-units. Biopsies in NBI + /WL- sub-units were subsequently performed during panendoscopy.

RESULTS

Eighty-four patients were included in the study. A total of 72 NBI + /WL- sub-units were sampled in 38 patients, and 37 of the biopsies were positive (51.4%): 16 for invasive carcinoma, 17 for high-grade dysplasia/carcinoma in situ and 4 for low-grade dysplasia. Ultimately, 26.2% of patients had at least one positive biopsy in an NBI + /WL- sub-unit and, therefore, a better tumor delineation. The clinical T stage was upgraded in 4.8% of cases examined.

CONCLUSION

Adding NBI to WL imaging during transnasal flexible endoscopy in patients presenting with laryngopharyngeal pre-malignant or malignant lesions improves the delineation of superficial cancer spread, thereby leading to better adapted treatments. Clinicaltrials.gov registration number: NCT02035735.

NBI utility in oncologic surgery: An organ by organ review

The main aims of the oncologic surgeon should be an early tumor diagnosis, complete surgical resection, and a careful post-treatment follow-up to ensure a prompt diagnosis of recurrence. Radiologic and endoscopic methods have been traditionally used for these purposes, but their accuracy might sometimes be suboptimal. Technological improvements could help the clinician during the diagnostic and therapeutic management of tumors. Narrow band imaging (NBI) belongs to optical image techniques, and uses light characteristics to enhance tissue vascularization. Because neoangiogenesis is a fundamental step during carcinogenesis, NBI could be useful in the diagnostic and therapeutic workup of tumors. Since its introduction in 2001, NBI use has rapidly spread in different oncologic specialties with clear advantages. There is an active interest in this topic as demonstrated by the thriving literature. It is unavoidable for clinicians to gain in-depth knowledge about the application of NBI to their specific field, losing the overall view on the topic. However, by looking at other fields of application, clinicians could find ideas to improve NBI use in their own specialty. The aim of this review is to summarize the existing literature on NBI use in oncology, with the aim of providing the state of the art: we present an overview on NBI fields of application, results, and possible future improvements in the different specialties.

The Impact of Narrow-band Imaging on the Pre- and Intra- operative Assessments of Neoplastic and Preneoplastic Laryngeal Lesions. A Systematic Review

Introduction  Narrow-band imaging is an endoscopic diagnostic tool that, focusing on superficial vascular changes, is useful to detect suspicious laryngeal lesions, enabling their complete excision with safe and tailored resection margins.

Objectives  To analyze the applications and benefits of narrow-band imaging in detecting premalignant and malignant laryngeal lesions through a comparison with white-light endoscopy.

Data Synthesis  A literature search was performed in the PubMed, Scopus and Web of Science databases using strict keywords. Then, two authors independently analyzed the articles, read the titles and abstracts, and read completely only the relevant studies according to certain eligibility criteria. In total, 14 articles have been included in the present review; the sensitivity, specificity, positive and negative predictive values, and accuracy of pre- and/or intraoperative narrow-band imaging were analyzed. The analysis showed that narrow-band imaging is better than white-light endoscopy in terms of sensitivity, specificity, positive and negative predictive values, and accuracy regarding the ability to identify cancer and/or precancerous laryngeal lesions. Moreover, the intraoperative performance of narrow-band imaging resulted more effective than the in-office performance.

Conclusion  Narrow-band imaging is an effective diagnostic tool to detect premalignant and malignant laryngeal lesions and to define proper resection margins. Moreover, narrow-band imaging is useful in cases of leukoplakia that may cover a possible malignant lesion and that cannot be easily assessed with white-light endoscopy. Finally, a shared, simple and practical classification of laryngeal lesions, such as that of the European Laryngological Society, is required to identify a shared lesion management strategy.

Key Points

European Laryngological Society position paper on laryngeal dysplasia Part II: diagnosis, treatment, and follow-up

PURPOSE OF REVIEW

To give an overview of the current knowledge regarding the diagnosis, treatment, and follow-up of laryngeal dysplasia (LD) and to highlight the contributions of recent literature. The diagnosis of LD largely relies on endoscopic procedures and on histopathology. Diagnostic efficiency of endoscopy may be improved using videolaryngostroboscopy (VLS) and bioendoscopic tools such as Narrow Band Imaging (NBI) or Storz Professional Image Enhancement System (SPIES). Current histological classifications are not powerful enough to clearly predict the risk to carcinoma evolution and technical issues such as sampling error, variation in epithelial thickness and inflammation hamper pathological examination. Almost all dysplasia grading systems are effective in different ways. The 2017 World Health Organization (WHO) system should prove to be an improvement as it is slightly more reproducible and easier for the non-specialist pathologist to apply. To optimize treatment decisions, surgeons should know how their pathologist grades samples and preferably audit their transformation rates locally. Whether carcinoma in situ should be used as part of such classification remains contentious and pathologists should agree with their clinicians whether they find this additional grade useful in treatment decisions. Recently, different studies have defined the possible utility of different biomarkers in risk classification. The main treatment modality for LD is represented by transoral laser microsurgery. Radiotherapy may be indicated in specific circumstances such as multiple recurrence or wide-field lesions. Medical treatment currently does not have a significant role in the management of LD. Follow-up for patients treated with LD is a fundamental part of their care and investigations may be supported by the same techniques used during diagnosis (VLS and NBI/SPIES).

Juvenile recurrent respiratory papillomatosis treated with combined erlotinib and celecoxib: Initial report

Recurrent respiratory papillomatosis (RRP) is a chronic disease caused by human papillomavirus (HPV). RRP is a clinical challenge because of the high recurrence rate, poor surgery response, extension to tracheobronchial tree and because of the risk of malignancy in some cases. There is no consensus on which adjuvant therapy is better for those patients with highly recurrent course. Because papilloma cells overexpress the epidermal growth factor receptor (EGFR), together with an increased expression of COX-2 and prostaglandin E2, the combination of erlotinib and celecoxib seems plausible, and could be proposed for patients with poor response to previous lines of treatment.

The usefulness of the narrow band imaging (NBI) in decision-making process regarding second look procedure (SL) in laryngeal cancer follow-up after transoral laser microsurgery

Background

The prognostic value of positive surgical margins after transoral laser microsurgery (TOLM) is still under debate. In case of positive superficial margins, some experts recommend a second-look surgery (SL) and some recommend wait and watch approach with close observation. Narrow band imaging (NBI) is an advanced imaging system used to enhance visualization of mucosal vascular pattern. In laryngology, NBI is used to improve the detection of premalignant, dysplastic and malignant lesions.

Aim

To assess the usefulness of NBI imaging in guiding clinical decision making regarding follow-up plan and SL after TOLM.

Materials and methods

A prospective cohort of 127 patients was divided into three groups based on the histology results and NBI vascular pattern of the mucosa. Group A (24/127, 18.90%) consisted of patients with suspicious vascular pattern in NBI or/and with positive deep margin. Group B (52/127, 40.94%) consisted of patients with positive or uncertain superficial margins and non-suspicious vascular pattern in NBI. Group C (51/127, 40.15%) had non-suspicious vascular NBI pattern and all negative margins.

Results

After the first TOLM procedure, 9/24 (37.5%) patients had positive deep margins, 1/24 (4.2%) had uncertain deep margin and 1/24 patient (4.2%) had both positive deep margin and suspicious vascular pattern in NBI. The remaining 13 cases in Group A had a suspicious NBI finding only during the first follow-up. All of the 24 patients (Group A) underwent a second look surgery. The final histology after SL showed squamous cell carcinoma in 10/24 (41.7%) patients. All 10 patients had suspicious vascular pattern in NBI and one patient had both a positive deep margins after the first TOLM and positive NBI finding. None of Group B and C subjects developed an early recurrence.

Conclusions

Our study provides evidence that NBI imaging will be a useful adjunct to margin status after TOLM and will facilitate clinical decision-making regarding performing the SL in patients with positive or uncertain superficial surgical margins in the first TOLM procedure. However, additional investigation with more subjects is required at this time to further validate this technique and change the standard of care.

Laryngeal Mid-Cord Erythroleukoplakias: How to Modulate the Transoral CO2 Laser Excisional Biopsy

Background: The endoscopic appearance of glottic erythroleukoplakias is non-predictive of their histopathology, potentially ranging from keratosis to invasive squamous cell carcinoma (SCC). The aim of this study was to assess a comprehensive workup for the one-step diagnosis and treatment of mid-cord erythroleukoplakias, using CO₂ laser excisional biopsy. Methods: We evaluated 147 untreated patients affected by 155 mid-cord erythroleukoplakias submitted to excisional biopsy by subepithelial (Type I) or subligamental cordectomy (Type II), across two academic institutions. Patients were evaluated by preoperative videolaryngostroboscopy, pre- and intraoperative videoendoscopy with biologic endoscopy (narrow band imaging, NBI, or the Storz professional image enhancement system, SPIES), either with or without intraoperative saline infusion into the Reinke’s space. Adequacy of treatment was the primary outcome. Results: The histopathologic diagnosis was keratosis in 26 (17%) cases, squamous intraepithelial neoplasia (SIN1-2) in 47 (30%), carcinoma in situ in 21 (14%), and SCC in 61 (39%) patients. The adequacy of treatment across the entire cohort was 89%. The intraoperative saline infusion procedure, facing not clearly suspicious lesions, raised the adequacy of treatment from 60% to 90% (p = 0.006). Conclusions: Excisional biopsy by Type I–II cordectomies, after a comprehensive diagnostic workup, should be accepted as an adequate and cost-effective treatment of unilateral mid-cord glottic erythroleukoplakias.

The value of narrowband imaging using the Ni classification in the diagnosis of laryngeal cancer

INTRODUCTION

Narrowband imaging (NBI) is a special endoscopic optical enhancement setting allowing better visualization of mucosal microvasculature compared to white light endoscopy. This study evaluates the validity of NBI using the Ni classification in the detection and differentiation of severe dysplasia (SD) and glottic squamous cell carcinoma (SCC).

METHODS

Patients with suspicious vocal cord lesions underwent conventional white light endoscopy followed by clinically indicated biopsy. At the same time, NBI images were obtained and graded independently. Lesions were graded from I to V according to the Ni classification and compared to histopathological findings.

RESULTS

Fifty-two patients were included in this study (40 SCC and 12 SD). The sensitivity and specificity of NBI in diagnosing laryngeal cancer was 95.0% (CI, 83.9%-99.4%) and 83.3% (CI, 51.6%-97.9%), respectively. The negative likelihood ratio was 0.06. Higher Ni grades correlated very strongly with more advanced disease.

CONCLUSIONS

NBI using the Ni classification is a sensitive diagnostic tool for the detection and differentiation of early neoplastic and preneoplastic glottic lesions. As higher Ni classification correlates strongly with advanced disease, it serves as a useful adjunct to white light endoscopy in the diagnosis of laryngeal cancer.Level of Evidence: Level IV.

Laryngeal Lesion Classification Based on Vascular Patterns in Contact Endoscopy and Narrow Band Imaging: Manual Versus Automatic Approach

Longitudinal and perpendicular changes in the vocal fold’s blood vessels are associated with the development of benign and malignant laryngeal lesions. The combination of Contact Endoscopy (CE) and Narrow Band Imaging (NBI) can provide intraoperative real-time visualization of the vascular changes in the laryngeal mucosa. However, the visual evaluation of vascular patterns in CE-NBI images is challenging and highly depends on the clinicians’ experience. The current study aims to evaluate and compare the performance of a manual and an automatic approach for laryngeal lesion’s classification based on vascular patterns in CE-NBI images. In the manual approach, six observers visually evaluated a series of CE+NBI images that belong to a patient and then classified the patient as benign or malignant. For the automatic classification, an algorithm based on characterizing the level of the vessel’s disorder in combination with four supervised classifiers was used to classify CE-NBI images. The results showed that the manual approach’s subjective evaluation could be reduced by using a computer-based approach. Moreover, the automatic approach showed the potential to work as an assistant system in case of disagreements among clinicians and to reduce the manual approach’s misclassification issue.

KTP Laser Treatment of Early Glottic Cancer: A Multi-Institutional Retrospective Study

OBJECTIVES

The primary objectives were to report oncologic outcomes of transoral laser microsurgery with potassium-titanyl-phosphate (KTP) laser (TLM-KTP) ablation of early glottic cancer (EGC). The secondary objectives were to report vocal outcomes and to analyze factors that might influence outcomes.

METHODS

A multi-institutional, retrospective analysis of consecutive patients treated for T1 or T2 glottic squamous cell carcinoma undergoing TLM-KTP ablation with at least 2 years of follow-up was performed. Patients with prior radiation or surgery for laryngeal disease were excluded.

PRIMARY OUTCOME MEASURES INCLUDED

surgical failures requiring radiation or laryngectomy, disease-specific survival (DSS), and overall survival (OS). Secondary outcome measures included: pre- and postoperative Voice Handicap Index-10 (VHI-10) scores. The effects of smoking status, stage, and anterior commissure involvement on outcomes were analyzed.

RESULTS

Overall 88 patients met inclusion criteria (83% male, 79.5% current or former smokers). Mean age was 68 (standard deviation (SD): 12). Mean follow-up was 39.5 months (SD: 15.3). Staging included 50 T1a, 21 T1b, and 20 T2 tumors, including three metachronous second primaries. Radiation and/or laryngectomy avoidance was achieved in 87/88 (98.9%) of patients, inclusive of 24 patients requiring KTP re-treatments. Two patients had biopsy-proven recurrence (2.3%), but only 21 of 24 re-treated patients received a formal biopsy. No patients died from laryngeal cancer. DSS and OS were 100% and 92.3%, respectively. The mean VHI-10 scores were 19.3 preoperatively, 3.8 at 6-months postop, and 3.8 at 2-years postop. Smokers had a longer interval to re-treatment (P = .03), patients with T2 lesions had a shorter interval to re-treatment (0.02), and patients with T2 lesions presented with worse initial VHI-10 scores (0.002).

CONCLUSIONS

A multi-institutional, retrospective case series of TLM-KTP ablation of EGC demonstrated excellent oncologic outcomes when close surveillance and proactive re-treatments were utilized. Disease-specific survival, overall survival, and vocal function were excellent. Additional studies are necessary to further analyze the merits and risks of this treatment approach.

A Preliminary Study on Automatic Characterization and Classification of Vascular Patterns of Contact Endoscopy Images

The structure and organization of blood vessels in the vocal fold go through changes during the advancement from healthy to benign and further on to malignant stages. Contact Endoscopy (CE) is an optical technique providing real-time information related to the vascular structure of laryngeal mucosa. However, this technique comes with subjectivity in the interpretation of vascular patterns. In this study, a novel automated approach is proposed for vessel pattern charac-terization and classification of larynx CE + Narrow Band Imaging (NBI) images. This method is mainly based on the computation of indicators related to the level of disorder of vessels. 12 features were extracted from the indicators and were fed into two supervised classifiers. Linear Support Vector Machine (SVM) and K-Nearest Neighbor (KNN) showed an accuracy of 95.76% and 93.92% for vascular patterns and 86.04% and 82.23% for larynx histopathologies classification, respectively. These promising results show that the proposed method can potentially solve the subjectivity issues of CE.

Interrater variation of vascular classifications used in enhanced laryngeal contact endoscopy

PURPOSE

Combined use of contact endoscopy (CE) and Narrow Band Imaging (NBI, Olympus^®) is suggested for the visualization of specific vascular changes indicative of glottic neoplasia. We investigated the interrater reliability and agreement in 3 recognized classification systems of vascular changes applied to images from CE + NBI in patients suspected for glottic neoplasia.

METHODS

Six experienced head and neck surgeons familiar with NBI rated 120 images obtained by CE + NBI by 3 classification systems of vascular changes as suggested by Ni et al. (N-C), Puxeddu et al. (P-C), and the European Laryngological Society (ELS-C). Three raters were experienced in CE, and three raters had only limited experience with CE. Crude agreement and Fleiss' kappa with 95% confidence interval were estimated for all 6 raters, and for the 2 levels of expertise for each original classification system and for dichotomized versions of the N-C and the P-C based on suggested neoplastic potential.

RESULTS

The interrater crude agreement and the corresponding kappa values for the ELS-C were good and significantly higher than those for the N-C and P-C for all raters, irrespective of the level of experience with CE (p < 0.0001). There were no significant differences between the N-C and the P-C (p = 0.16). Kappa was considerably improved for both the N-C and the P-C to a level not different from the ELS-C (p = 0.21-0.71) when their 5 original categories were pooled into dichotomized classifications.

CONCLUSION

Difficulties in reliably classifying vascular changes in CE + NBI are evident. Two-tier classification systems are the most reliable.

Ni endoscopic classification for Storz Professional Image Enhancement System (SPIES) endoscopy in the detection of upper aerodigestive tract (UADT) tumours

The diagnostic procedure for upper aerodigestive tract (UADT) tumours is by white light endoscopy (WLE) combined with biopsy. However, WLE has difficulty identifying minute epithelial changes which hinders early diagnosis. Storz Professional Image Enhancement System (SPIES) is designed to enhance the visualization of microvasculature on the mucosal surface and detect any epithelial changes. In this study, we aimed to evaluate the use of Ni endoscopic classification with SPIES endoscopy in the detection of UADT tumours. Fifty-nine patients with suspected UADT tumours underwent WLE followed by SPIES endoscopy. All the tumours were biopsied and sent for histopathological examination (HPE). The kappa index (κ) was used to evaluate the agreement between the methods. The level of agreement between SPIES using Ni classification and HPE showed almost perfect agreement as compared to moderate agreement between WLE and HPE. The sensitivity and specificity for WLE and HPE were 77.5% and 84.2% respectively with positive predictive value (PPV) of 91.2% and negative predictive value (NPV) of 64%. The sensitivity and specificity for SPIES endoscopy using Ni classification and HPE were 97.5% and 94.7% respectively with PPV of 97.5% and NPV of 94.7%. SPIES endoscopy using Ni classification is a valid tool for earlier tumour detection.