Program in Leukoplakia and Pre-malignant Vocal Fold Changes
The program in leukoplakia and pre-malignant vocal fold changes reflects the many challenges of a vocal lesion that is evolving to cancer. Led by Kenneth W. Altman MD, PhD, aspects of the pathogenesis and physiology are investigated, along with predisposition and optimal management strategies.
Over the course of every otolaryngologist’s career they’re involved with evaluating hoarseness and encounter surface changes to the vocal folds. Sometimes indistinguishable from stagnant mucus or scar on office laryngoscopy, leukoplakia is a category of epithelial lesions that run a spectrum from benign thickening (keratosis) to carcinoma-in-situ or microinvasive carcinoma. Leukoplakia can arise from the same etiologies as cancer, including caustic carcinogens such as tobacco smoke, Human papilloma virus infection (HPV), laryngopharyngeal reflux (LPR), and genetic predisposition. The challenge is to determine the risk factors for malignancy, recognize when the lesion is suspicious, and properly assess the need for surgical intervention while conserving voice function. Figure 1 shows the larynx of a 55 year-old man with a 3 month history of hoarseness, and a mound of white debris on the right vocal fold (shown on the left). This turned out to be benign keratosis overlying a right vocal cyst. Figure 2 shows the vocal folds of a 62 year-old man with a 4-month history of hoarseness, revealing a bilateral bed of erythematous vocal folds and exophytic epithelium. Pathology revealed microinvasive squamous cell carcinoma.
At the Eugen Grabscheid Voice Center, we’re using high-definition imaging modalities in the office, such as digital laryngostroboscopy with variable spectrum light sources to identify the nature of this broad array of leukoplakic lesions. There are roles for office-based biopsy in some patients, and surgical evaluation with microlaryngoscopy and targeted microflap full-thickness excisions help properly stage the extent of disease while determining the best treatment options for voice preservation. Pre-malignant lesions can be successfully reversed with our comprehensive approach to the evaluation and management of gastroesophageal reflux and LPR, as well as new office-based treatments using the pulsed-dye laser. We also employ state-of-the-art surgical tools for near-margin vocal cordectomies in early-invasive disease, and have a host of surgical and non-surgical rehabilitation options as well. Overall, since leukoplakia has a greater than 65% chance of showing at least some dysplasia, we recommend proper evaluation of the disease and risk factors in all patients. Current investigations include:
- The physiologic microenvironment that permits development of cancer, and ways to manipulate decreased recurrence, in collaboration with Andrew Sikora MD, PhD and Julio Aguirre-Ghiso, PhD
- Early detection using intra-operative high-resolution microendoscopy (HRME), in collaboration with Brett Miles MD, DMD and Andrew Sikora MD, PhD
- Optimal voice outcomes from surgery, balancing disease control with severity of dysplasia (pre-malignant changes)