Recurrence and malignant transformation of laryngeal leukoplakia treated with CO2 laser: A systematic review and meta-analysis

BACKGROUND

Laryngeal leukoplakia (LL) is a white lesion with high potential of recurrence and malignant transformation. Currently, CO2 laser has become the primary surgical treatment for LL, and the recurrence and malignant transformation rates after treatment vary widely.

OBJECTIVE

We performed a systematic review and meta-analysis dedicated to evaluating the rates of recurrence and malignant transformation of LL lesions treated with CO2 laser and exploring relevant risk factors for recurrence or malignant transformation.

METHODS

Literature searches were conducted on ProQuest, PubMed, Web of Science, Ovid Medline, Embase, and Cochrane databases. Some articles identified through hand searching were included.

RESULTS

A total of 14 articles and 1462 patients were included in this review. Pooled results showed that the overall recurrence rate was 15%, and the malignant transformation rate was 3%. Subgroup analysis showed that the dysplasia grade was not a significant risk factor for the recurrence and malignant transformation of LL (P > .05).

CONCLUSIONS

The results of this systematic review and meta-analysis suggest that the CO2 laser is a safe and effective surgical instrument for the excision of LL, which yields low rates of recurrence and malignant transformation. The risk factors relevant to recurrence or malignant transformation remain unclear and require further investigation.

Vocal Cord Leukoplakia Classification Using Siamese Network Under Small Samples of White Light Endoscopy Images

OBJECTIVE

Accurate vocal cord leukoplakia classification is instructive for clinical diagnosis and surgical treatment. This article introduces a reliable very deep Siamese network for accurate vocal cord leukoplakia classification.

STUDY DESIGN

A study of a classification network based on a retrospective database.

SETTING

Academic university and hospital.

METHODS

The white light image datasets of vocal cord leukoplakia used in this article were classified into 6 classes: normal tissues, inflammatory keratosis, mild dysplasia, moderate dysplasia, severe dysplasia, and squamous cell carcinoma. The classification performance was assessed by comparing it with 6 classical deep learning models, including AlexNet, VGG Net, Google Inception, ResNet, DenseNet, and Vision Transformer.

RESULTS

Experiments show the superior classification performance of our proposed network compared to state-of-the-art methods. The overall accuracy is 0.9756. The values of sensitivity and specificity are very high as well. The confusion matrix provides information for the 6-class classification task and demonstrates the superiority of our proposed network.

CONCLUSION

Our very deep Siamese network can provide accurate classification results of vocal cord leukoplakia, which facilitates early detection, clinical diagnosis, and surgical treatment. The excellent performance obtained in white light images can reduce the cost for patients, especially those living in developing countries.

Vocal cord leukoplakia classification using deep learning models in white light and narrow band imaging endoscopy images

BACKGROUND

Accurate vocal cord leukoplakia classification is critical for the individualized treatment and early detection of laryngeal cancer. Numerous deep learning techniques have been proposed, but it is unclear how to select one to apply in the laryngeal tasks. This article introduces and reliably evaluates existing deep learning models for vocal cord leukoplakia classification.

METHODS

We created white light and narrow band imaging (NBI) image datasets of vocal cord leukoplakia which were classified into six classes: normal tissues (NT), inflammatory keratosis (IK), mild dysplasia (MiD), moderate dysplasia (MoD), severe dysplasia (SD), and squamous cell carcinoma (SCC). Vocal cord leukoplakia classification was performed using six classical deep learning models, AlexNet, VGG, Google Inception, ResNet, DenseNet, and Vision Transformer.

RESULTS

GoogLeNet (i.e., Google Inception V1), DenseNet-121, and ResNet-152 perform excellent classification. The highest overall accuracy of white light image classification is 0.9583, while the highest overall accuracy of NBI image classification is 0.9478. These three neural networks all provide very high sensitivity, specificity, and precision values.

CONCLUSION

GoogLeNet, ResNet, and DenseNet can provide accurate pathological classification of vocal cord leukoplakia. It facilitates early diagnosis, providing judgment on conservative treatment or surgical treatment of different degrees, and reducing the burden on endoscopists.

Pepsin Increases the Proliferation of Vocal Cord Leukoplakia Epithelial Cells by Inducing Autophagy

OBJECTIVE

To investigate the role of H+ /K+ ATPase in the proliferation of pepsin-induced vocal cord leukoplakia (VCL) cells.

STUDY DESIGN

Translation research.

SETTING

Affiliated Hospital of University.

METHODS

Immunohistochemistry was used to detect pepsin, H+ /K+ ATPase (ATP4A and ATP4B subunits) in VCL cells with varying degrees of dysplasia. After primary cultures of VCL cells had been established, the effects of acidified pepsin on the proliferation, autophagy, and H+ /K+ -ATPase distribution of VCL cells were investigated.

RESULTS

The levels of pepsin, ATP4A, and ATP4B were significantly higher in VCL tissue with moderate-to-severe dysplasia than in normal tissue (p < .05); these levels gradually increased according to dysplasia severity. The expression levels of ATP4A and ATP4B were significantly correlated with the amount of pepsin in VCL cells (p < .01). Acidified pepsin enhanced the levels of proliferation and autophagy in human VCL epithelial cells. The cloning- and autophagy-promoting effects of acidified pepsin on VCL cells were partially reversed by pantoprazole; these effects were completely blocked by the autophagy inhibitor chloroquine. Finally, acidified pepsin promoted the colocalization of H+ /K+ -ATPase and lysosomes in VCL cells; it also mediated lysosome acidification.

CONCLUSION

Pepsin and H+ /K+ -ATPase may contribute to the progression of VCL. Specifically, acidified pepsin may regulate lysosome acidification by promoting lysosomal localization of H+ /K+ -ATPase.

Polymorphisms of acetaldehyde dehydrogenase 2 and alcohol dehydrogenase 1B on the malignant transformation of vocal cord leukoplakia: A Chinese cohort

Severe dysplasia of vocal cord leukoplakia (VCL) is more likely to occur in laryngeal carcinoma. Alcohol dehydrogenase and acetaldehyde dehydrogenase are both important enzymes in alcohol metabolism. This study aimed to investigate the incidence rate of malignant transformation in patients with VCL and the role of drinking habits and ALDH2 and ADH1B genetic polymorphisms in the malignant transformation of VCL. From January 2007 to January 2017, 136 cases of VCL were included in this retrospective analysis. Information on medical history, alcohol and tobacco consumption habits, ALDH2 and ADH1B genotypes, gastroesophageal reflux, and clinical pathological characteristics of VCL was collected. As a result, patients had a median follow-up of 9.6 years (interquartile range: 7.5-12.5 years). Twenty-three of 136 VCL patients finally developed laryngeal carcinoma, resulting in a cumulative malignant transformation rate of 16.9%. Cox regression analysis demonstrated that the independent risk factors for the malignant transformation of VCL included age over 60 years (hazard ratio [HR]: 13.872, p < 0.001), ALDH2 *2 allele status (HR: 9.694, p < 0.001), alcohol (HR: 10.011, p < 0.001) and tobacco (HR: 8.869, p < 0.001) exposure after operation, and drinking frequency (HR: 2.178, p = 0.016). Therefore, among patients over 60 years old, an ALDH2-inactivating mutation and excessive ethanol and tobacco consumption are potential contributors to the malignant transformation of VCL.

[Risk prediction and malignant transformation in vocal cord leukoplakia based on electronic laryngoscope]

Objective:To investigate the predictive risk factors of vocal fold leukoplakia under electronic laryngoscope and influential factors of malignancy. Methods:A total of 163 cases with vocal cord leukoplakia were analyzed retrospectively. The relationship between the clinical features, including site, size, whether involving the anterior commissure, morphology and pathological grade were analyzed. Then the associations with malignant transformation in vocal cord leukoplakia were evaluated by using multiple Logistic regression analysis. Results:There were one side lesions in 96 cases（58.9%）, and bilateral vocal cord lesions in 67 cases（41.1%）. The vocal cord leukoplakia with extension less than half of the vocal cord was observed in 135 cases（82.8%） and beyond half of the vocal cord was seen in 28 cases（17.1%）. Lesions involving the anterior commissure were 42 cases（25.8%）, without involving the anterior commissure were 121 cases（74.2%）. According to morphological features, 82 patients（50.3%） had a superficial type, followed by exophytic type（n=65, 39.9%）, and ulcerative type（n=16, 9.8%）. The pathological type included squamous epithelial simple hyperplasia in 65 cases（39.9%）, mild hyperplasia in 44 cases（27.0%）, moderate hyperplasia in 31 cases（19.0%）, severe hyperplasia and carcinoma in situ in 23 cases（14.1%）. 140 cases（85.9%） were in low risk group, and 23 cases（14.1%） were in high risk group. The site of the vocal fold leukoplakia was not associated with the pathological grade（P>0.05）, whether the vocal fold leukoplakia range exceeds 1/2 of the total length of the vocal fold, and whether involving the anterior commissure were associated with the pathological grade（both P<0.05）. There were statistically significant differences between the pathological grade and the morphological type（P<0.01）. Ten cases developed larynx cancer, the ratio of malignant transformation was 6.1%. The multiple Logistic regression showed that whether involving the anterior commissure and histopathological classification were the risk factors of malignant transformation in vocal cord eukoplakia. Conclusion:The pathological results of vocal cord leukoplakia can be predicted by laryngoscopy features. Involving of the anterior commissure and histopathological classification are the risk factors of malignant transformation in vocal cord leukoplakia.

Readability of Online Materials Related to Vocal Cord Leukoplakia

Objectives

To assess readability and understandability of online materials for vocal cord leukoplakia.

Study Design

Review of online materials.

Setting

Academic medical center.

Methods

A Google search of "vocal cord leukoplakia" was performed, and the first 50 websites were considered for analysis. Readability was measured by the Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), and Simple Measure of Gobbledygook (SMOG). Understandability and actionability were assessed by 2 independent reviewers with the PEMAT-P (Patient Education Materials Assessment Tool for Printable Materials). Unpaired t tests compared scores between sites aimed at physicians and those at patients, and a Cohen's kappa was calculated to measure interrater reliability.

Results

Twenty-two websites (17 patient oriented, 5 physician oriented) met inclusion criteria. For the entire cohort, FRES, FKGL, and SMOG scores (mean ± SD) were 36.90 ± 20.65, 12.96 ± 3.28, and 15.65 ± 3.57, respectively, indicating that materials were difficult to read at a >12th-grade level. PEMAT-P understandability and actionability scores were 73.65% ± 7.05% and 13.63% ± 22.47%. Statistically, patient-oriented sites were more easily read than physician-oriented sites (P < .02 for each of the FRES, FKGL, and SMOG comparisons); there were no differences in understandability or actionability scores between these categories of sites.

Conclusion

Online materials for vocal cord leukoplakia are written at a level more advanced than what is recommended for patient education materials. Awareness of the current ways that these online materials are failing our patients may lead to improved education materials in the future.

[The research of prognosis and evaluation of vocal leukoplakia by narrow band image endoscope]

Objective:To explore the ability of narrowband imaging to predict the nature of leukoplakia of the vocal cords Method:In 46 patients with leukoplakia of the vocal cords, laryngoscopy was performed simultaneously with white light and narrow-band imaging modes. Type the images and compare with the postoperative pathological results. The receiver operating characteristic curve and the area under the curve are used to judge the diagnostic accuracy of different examination methods. Result:The AUC in white light mode is 0.642, which predicts the sensitivity of early vocal cord cancer is 41.67%, and the specificity is 97.06%; For NBI mode, the AUC is 0.896（P<0.05） and its sensitivity and specificity is 58.33% and 97.06%, respectively. Conclusion:Compared with white light mode, NBI mode is more sensitive and accurate in identification of benign and malignant vocal cord lesions.

[Clinical diagnosis and treatment of 157 cases of vocal leukoplakia]

Objective:To study the clinical characteristics and common etiology of vocal cord leukoplakia, and explore the treatment principle. Method:One hundred and fifty-seven patients with vocal cord leukoplakia were recruited in this study. They were assessed by routine laryngoscope, narrow band imaging （NBI）, stroboscope, reflux finding score （RFs） and reflux symptom index （RSI）, and given conservative treatment （smoking cessation, alcohol, acid suppression, sound cessation, etc.） and/or surgical treatment. Result:Among 157 patients with leukoplakia of vocal cord, 109 （69.4%） had basically improved or cured after conservative treatment. Forty-eight cases underwent operation. The postoperative pathological diagnosis was mild dysplasia in 2 cases （1.3%）, moderate dysplasia in 15 cases （9.6%）, severe dysplasia or carcinoma in situ in 19 cases （12.1%）, and invasive carcinoma in 12 cases （7.6%）. Conclusion:NBI and stroboscopic laryngoscopy showed that most of the leukoplakia of vocal cord was non-malignant in nature, which was not in accordance with the indication of operation. Conservative treatment is effective. Biopsy or operation was indicated in only a few patients. Moreover, most of the patients are accompanied by laryngopharyngeal reflux, and the treatment of acid suppression is effective.

Diagnostic Value and Pathological Correlation of Narrow Band Imaging Classification in Laryngeal Lesions

OBJECTIVES

To explore the diagnostic value and pathological correlation of narrow band imaging (NBI) classification in laryngeal lesions.

METHODS

A total of 112 patients (123 lesions) with laryngeal lesions from July 2018 to May 2019 were selected in this study. All patients were examined by NBI and white light imaging endoscopy. The NBI endoscopy was applied to classify the observed lesion sites according to intraepithelial papillary capillary loop pattern. The gold standard of diagnosis was pathological results. To evaluate the consistency of NBI classification and pathological results.

RESULTS

The sensitivity, specificity, positive predictive value, and negative predictive value of the diagnosis for benign, precancerous, and malignant lesions under the NBI endoscopy were 90.91%, 81.19%, 74.07%, 85.42%; 41.67%, 92.93%, 58.82%, 86.79%; and 93.51%, 65.22%, 91.14%, 68.18%, respectively. There was a high consistency between NBI classification and pathological results (κ = 0.679, P < .001).

CONCLUSIONS

The NBI classification can improve the accuracy of the diagnosis of laryngeal lesions. It is important for early diagnosis and treatment of vocal cord leukoplakia and laryngeal cancer.

[The progress of narrow band imaging endoscopy in diagnosis of vocal cord leukoplakia]

SummaryThe appearances of vocal cord leukoplakia are largely identical in the macroscopic examination even though the pathological character may differ. This makes it difficult for physicians to evaluate the extent of dysplasia of vocal cord leukoplakia and detect the occurrence of canceration using the conventional laryngoscopy, which might result in overtreatment or undertreatment of vocal cord leukoplakia in different patients. Therefore, an accurate preoperative assessment of the pathological character of vocal cord leukoplakia shows clinical significance in the selection of an appropriate treatment plan and predicting the prognosis of a patient. Recent studies have found that narrow band imaging（NBI） endoscopy can facilitate the early and differential diagnosis of head and neck cancers by observing the intraepithelial papillary capillary loop（IPCL） patterns at the mucosal surfaces. In this paper, the recent progress of NBI endoscopy in the diagnosis of vocal cord leukoplakia is reviewed.

[Clinical treatment of benign vocal cord lesions with occult vocal cord sulcus]

Objective:To discuss the correlation of benign vocal cord lesions with occult vocal cord sulcus and the treatment of benign vocal cord lesions with occult vocal cord sulcus, through the analysis of surgical data, preoperative voice evaluation data and postoperative follow-up data of patients.Method:The data from 377 patients of benign vocal cord lesions with concealed vocal cord sulcus admitted to Beijing Tongren Hospital from 2005 to 2016 were reviewed. The follow-up time was more than half a year after surgery.Result:About 2.9% of the benign lesions of the vocal cords were associated with occult vocal cords sulcus,of which 61.27% were bilateral vocal cords sulcus,22.55% was right vocal cords sulcus,and 16.18% was left vocal cord sulcus.Of the patients with bilateral vocal fold sulcus,64.5% had benign vocal cord lesions and 35.5% had unilateral vocal cord benign lesions.Of the patients with unilateral vocal fold,73.97% were associated with ipsilateral vocal cord benign lesions, and 26.03% were associated with contralateral vocal cord lesions.In the 531 sides of the vocal cords sulcus,183 sides of vocal fold sulcus typeⅠwere not treated. The 332 sides of vocal fold sulcus type Ⅱ were treated with removed lesions of the vocal cords and microdissection of vocal cord adhesion.The 16 sides of vocal fold sulcus type Ⅲ were treated with removed lesions of the vocal cords,local tamponaded of autogenous abdominal fascia and microsutured to close the wound. There were 9 cases with 11 sides of vocal fold sulcus combined with the mucous bridge.The satisfactory rate of sound improvement was 80.37% in half a year after the operation.Postoperative fundamental frequency,jitter,shimmer and maximum phonation time were significantly improved compared with preoperative.Conclusion:The occurrence of benign vocal cord lesions may be related to occult vocal fold sulcus.Simultaneous treatment of benign vocal cord lesions with occult vocal cord sulcus can achieve satisfactory voice improvement.Therefore, we should pay attention to the treatment of vocal fold sulcus in the diagnosis and treatment of benign vocal cord diseases.

Clinicopathological parameters associated with histological background and recurrence after surgical intervention of vocal cord leukoplakia

Histological examination of biopsy shows usefulness in the diagnosis of vocal cord leukoplakia; however, in considerable amount of cases, the examination cannot provide definitive diagnosis of malignancy from benign conditions such as hyperplasia and dysplasia. The present work therefore was aimed to identify clinicopathological factors and molecular markers predictive of recurrence and malignant transformation of vocal cord leukoplakia.Clinical data of 555 cases of vocal cord leukoplakia enrolled from July 1999 to June 2014 were analyzed. The cohort consisted of keratosis (n = 137), hyperplasia (n = 139), dysplasia (n = 177), and primary (n = 10) and invasive (n = 46) carcinoma. Correlations between patients' backgrounds, clinicopathological factors, molecular markers (p53, p16, Ki67, cytokeratin, and proliferating cell nuclear antigen), and histology backgrounds were examined using by Pearson Chi-squared or Fisher exact test. Reflux symptom index (RSI) and reflux finding score (RFS) before and after treatment were compared using Wilcoxon signed-rank test. Risk factors for disease recurrence were identified using Cox proportional hazards models of multivariate analysis. Time to recurrence was analyzed using log-rank test of Kaplan-Meier method.In the present cohort, alcohol drinking was found associated with GRBAS grade (P = .0258) and the site (P = .0298) of leukoplakia. For the different disease types, chief complaint (P = .0179), GRBAS grade (P = .0101), mucosal wave (P < .0001), and molecular markers p53 (P < .0001) and Ki67 (P < .0001) were identified as correlates. RSI and RFS were significantly lowered by surgical intervention. A single side of leukoplakia was predictive of a lower risk of recurrence (odds ratio, 0.378; 95% confidence interval, 0.197-0.723; P = .0033). Absence of mucosal wave was associated with a shorter time-to-recurrence (P = .0357).The present work identified clinicopathological factors and molecular markers associated with the different histology of vocal cord leukoplakia, and also the prognostic factor for the low risk of recurrence after surgery.

Association of the microsatellite (GT)n repeat polymorphisms of the HO-1 gene promoter and corresponding serum levels with the risk of laryngeal squamous cell carcinoma

CONCLUSION

Long (GT)n repeat polymorphisms in the heme oxygenase-1 (HO-1) gene promoter and decreased serum HO-1 levels are associated with a higher susceptibility to laryngeal squamous cell carcinoma (LSCC).

OBJECTIVE

In this case-control study, the association of HO-1 microsatellite (GT)n repeat polymorphisms and serum levels with the risk of LSCC was investigated.

METHODS

A total of 142 LSCC patients, 54 vocal leukoplakia patients and 98 healthy controls, were examined for (GT)n polymorphisms by sequencing, and the serum HO-1 levels were detected in a sub-set from participants above by ELISA.

RESULTS

Compared with the controls, the LSCC group had significantly higher frequencies of L-allele (> 29 repeats) and L-allele carriers (p < 0.001, OR = 2.037 and p = 0.005, OR = 2.152, respectively). The frequencies of lymph node metastasis and of moderate or poor differentiation were significantly higher in L-allele carriers compared to non-L-allele carriers (p < 0.05). Significantly lower serum HO-1 levels were detected in LSCC patients (p < 0.001), and patients with lower serum HO-1 levels had more advanced cancer stage and a higher lymph node metastasis rate (p < 0.05). Furthermore, the L-allele carriers had lower serum HO-1 concentrations compared with the non-L-allele carriers (p = 0.019).