Narrow band imaging during transoral laser surgery for premalignant and early malignant glottic lesions

Rakesh Srivastava

doi:10.4103/2347-8128.182849

ORIGINAL ARTICLE

Year : 2016 | Volume : 4 | Issue : 1 | Page : 35-37

Narrow band imaging during transoral laser surgery for premalignant and early malignant glottic lesions

Rakesh Srivastava
Department of Otolaryngology and Head Neck Surgery, Sushrut Institute of Plastic Surgery and Super Speciality Hospital, Lucknow, Uttar Pradesh, India

Date of Web Publication

23-May-2016

Correspondence Address:
Rakesh Srivastava
Raj ENT Centre and Voice Clinic, 387, Vishal Khand-3, Gomtinagar, Lucknow - 226 010, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2347-8128.182849

Abstract

Introduction: NBI is relatively new optical image enhancement technology. The wavelength is centered on 415 (blue) & 540 nm (green). Blue and green light has different depth of penetration thus highlights mucosa and submucosa. Material and Methods: It is a retrospective study on 45 patients of early premalignant and malignant glottic cancers. Patient undergone preoperative, peroperative and postoperative white light and NBI endoscopy. NBI findings (using Ni etal classification) compared with the histopathological diagnosis. Results: The preoperative distribution of cases on the basis of T-staging using WL/NBI was mild-moderate dysplasia-15, Tis- 4, T1a-16, T1b-8, T2a-2. The peroperative distribution using the same tool changed the distribution with mild-moderate dysplasia-12,Tis-6, T1a-13, T1b-10, T2a-3, T2b-1. Conclusion: The upstaging of disease was noted in all stages of the T-disease using NBI. With the aid of angled telescope peroperatively mapping and staging of the disease is done. Thus it helps in better surgical dissection and results.

Keywords: NBI Larynx, Narrow band imaging, transoral laser

How to cite this article:
Srivastava R. Narrow band imaging during transoral laser surgery for premalignant and early malignant glottic lesions. J Head Neck Physicians Surg 2016;4:35-7

How to cite this URL:
Srivastava R. Narrow band imaging during transoral laser surgery for premalignant and early malignant glottic lesions. J Head Neck Physicians Surg [serial online] 2016 [cited 2021 Jan 25];4:35-7. Available from: https://www.jhnps.org/text.asp?2016/4/1/35/182849

Introduction

Endoscopy was a mainstay for diagnosing any malignancy in the upper aerodigestive tract prior to 2000. The conventional white light (WL) has certain limitations to detect very small lesions. Narrow band imaging (NBI) is relatively new optical technology based on illumination with a narrow band of light wave. The wavelength is centered on 415 (blue light) and 540 nm (green light) and eliminating red light. The lesser wavelength (415 nm, blue light) penetrates superficial mucosal layer and is absorbed by hemoglobin and gives impression of intrapapillary capillary loop while the higher wavelength (540 nm, green light) penetrates deeper accentuate arteriole and venule of submucosa. NBI thus defines microvascular architecture. Muto et al.^[1] first reported the use of NBI with magnifying endoscopy (A240Z, Olympus, Tokyo, Japan) in identifying the superficial squamous cell carcinoma in the head and neck regions. They recognized the advantage of NBI in surveillance of post-radiated esophageal cancers.^[2] Thus, they identified 34 metachronous tumors in oral cavity, oropharynx, and hypopharynx (only five were detectable with WL endoscopy). Muto et al. described the well-demarcated brown dots on NBI as malignant changes.^[3] Watanabe et al.^[4],[5],[6] reported the first use of NBI in the early detection of laryngeal cancers.

The early changes start with alteration in caliber of capillaries. Later, there is widening of microvessels and finally, break in continuity and destruction of physiological microvascular arrangements.

Materials and Methods

This is a retrospective study based on outpatient and surgical records of 45 cases of premalignant and early glottic cancers from March 2014 to April 2015. All the patients underwent preoperative, peroperative, and postoperative assessments using both WL and NBI recording using Olympus CV 170 processor with high-definition television (HDTV) with 4.9 mm flexible video-bronchoscope (charge-coupled device). Pre- and post-operative endoscopies were performed on an outpatient basis under local anesthesia while peroperative endoscopy under general anesthesia (GA) with suspension microlaryngoscopy was performed. NBI assessment and transoral laser surgery (TLS) were performed.

The lesions were classified on the basis of classification given by Ni et al.^[7] using microvascular patterns in superficial mucosal lesions. The lesions were later compared with histopathological diagnosis separately in case of bilateral lesions. The lesions were also classified on the basis of surface such as smooth, rough, keratotic, and ulcerative or proliferative and also on basis of tumor spread – unilateral/both cords, involvement of anterior commissure (AC)/posterior commissure, ventricle, ventricular folds [Figure 1].

Figure 1: (a) White light-preoperative (Ant. comm. involvement doubtful), (b) NBI-preoperative(Ant.comm. involvement evident)

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Results

The average age of the patients was 45 years with male predominance (41 males and 4 females). Of 45 patients, ten had no past history of tobacco and alcohol intake. The average duration of gap between preoperative assessment and TLS was 10 days. The tumors were staged using the Union for International Cancer Control (tumor node metastasis classification). Thirteen patients with doubtful involvement of AC, paraglottic, and supraglottic extent were referred for 64-slice high-resolution computed tomography scan (contrast-enhanced).

Premalignant lesions of the larynx are based on histopathological characteristics. There are various grades of lesion, namely, Grade 1 presenting as hyperplasia or keratosis with or without mild dysplasia, Grade 2 with moderate dysplasia, and Grade 3 where the dysplasia is severe (carcinoma in situ).^[8],[9]

The preoperative distribution of cases on the basis of T-staging using WL/NBI was mild-moderate dysplasia-15, Tis-4, T1a-16, T1b-8, T2a-2.

The peroperative distribution using the same tool changed the distribution with mild-moderate dysplasia-12, Tis-6, T1a-13, T1b-10, T2a-3, T2b-1. The upstaging was noted in all stages of the T-disease; thus, the type of endoscopic cordectomy also changed [Figure 2].

Figure 2: Pre- and per-operative distributions of cases

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All the patients had undergone different types of laser cordectomies depending on depth, extend of invasion, and site of involvement. The distribution of laser cordectomies is Type I-13 (+1 from Type-1b), Type II-6, Type III-8, Type IV-7, Type Va-9, and TypeVb-3 [Figure 3].

Figure 3: Types of laser cordectomies

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Discussion

NBI (suspension microlaryngoscopy under GA) with HDTV improved the definition of margins of the primary tumor and thus staging the tumor peroperatively. It helped to modify the surgical planning and therapeutic approach.

Ugumori et al.^[10] compared that the images taken with high-definition WL endoscopy were able to identified neoplastic and nonneoplastic lesions in only 10% of cases and microvascular irregularities in only 27% of cases while the NBI identified these in 63% and 94% of cases.

There is a definite shift to higher stage in early glottic cancers from unilateral to bilateral and from T1 stage to T2a stage [Figure 4] and [Figure 5]. This shift brings change in peroperative plan and functional results, especially the vocal outcomes. In India where the frozen section facilities are not readily available at all major centers, this new optical enhancement technology helps in defining the margins and tumor mapping.

Figure 4: (a) Preoperative-white light in office, (b) preoprative NBI in office

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Figure 5: (a) Preoperative-white light in OR, (b) preoperative-NBI (Upstaging) in OR

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Malignancies of larynx constitute 30% of all head and neck cancers. In India where the cancer detection and diagnosis are late, NBI is useful diagnostic tool and is of great help in early detection of head and neck cancers. Early detection helps in organ preservation techniques of the larynx. It has been used in screening, surveillance of head and neck cancers, and also in cases of unknown primary.^[11],[12] It clearly delineates between normal and abnormal mucosal pattern, thus helps in preoperative target biopsy for very early suspicious neoplastic lesions.

The European Laryngological Society recommendations for the follow-up patients treated with laryngeal cancers in their statement 21 states that flexible nasopharyngolaryngoscopy integrated with NBI is accurate clinical tool in follow-up of laryngeal cancers treated with any surgical or nonsurgical modality.^[13]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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