ORIGINAL RESEARCH |
https://doi.org/10.5005/jp-journals-10023-1261 |
Role of Combination of Palpation, Infiltration, and Image Enhancement in Predicting Margins in Transoral Laser Microlaryngeal Cordectomy Surgery
1-3Department of Voice and Swallowing, Bombay Hospital and Medical Research Center, Mumbai, Maharashtra, India
Corresponding Author: Nupur K Nerurkar, Department of Voice and Swallowing, Bombay Hospital and Medical Research Center, Mumbai, Maharashtra, India, Phone: +91 2222067676, e-mail: nupurkapoor@yahoo.com
Received on: 31 July 2024; Accepted on: 15 October 2024; Published on: 15 November 2024
ABSTRACT
Background: Spectra-A(S) is a part of a novel endoscopic imaging technique based on color tone shift algorithm to increase contrast based mainly on the green (540 nm) and blue (415 nm) light spectral signals designed for the visualization of abnormal microvasculature on the mucosal surface such as intraepithelial papillary capillary loop pattern (IPCL). Transoral laser microlaryngeal cordectomy (TLMC) surgery is performed using a laser with the microscope and the histopathology report is the gold standard in deciding the free margins.
Aim: To assess the accuracy of the combined findings of S light, subepithelial infiltration (I), and palpation (P) of the vocal fold lesion in deciding the margins in TLMC for early glottic cancer, considering the final histopathology report as the gold standard.
Results: Out of a total of 35 study patients, the results of specimen identification protocol (SIP) in deciding free margins were in concordance with the histopathological report (HPR) in 26 patients. Since using a combination of SIP is less resource intensive than frozen section (FS), it may be useful in places where intraoperative FS is not available.
Conclusion: The accuracy of the combined findings of SIP in deciding the margins in TLMC for early glottic cancer was 74%. The gold standard was taken as the final histopathology report.
How to cite this article: Nerurkar NK, Kamath A, Gupta S. Role of Combination of Palpation, Infiltration, and Image Enhancement in Predicting Margins in Transoral Laser Microlaryngeal Cordectomy Surgery. Int J Phonosurg Laryngol 2024;14(2):23-25.
Source of support: Nil
Conflict of interest: Dr National Advisory Board is associated as the National Editorial Board member of this journal and this manuscript was subjected to this journal’s standard review procedures, with this peer review handled independently of this editorial board member and his research group.
Keywords: Early glottic cancer, Palpation, Spectra-A light, Subepithelial infiltration, TLMC.
INTRODUCTION
Spectra-A(S) is an image enhancement system based on color tone shift algorithm to increase contrast for visualization of abnormal microvasculature on the mucosal surface such as intraepithelial capillary loop (IPCL) pattern.1,2
Subepithelial infiltration (I) in vocal fold surgery is used for depth and peripheral margin estimation, hemostasis, and temporary volume increase in the superficial lamina propria (SLP).3,4 Palpation (P) of the vocal fold and lesion may be found to be soft, firm, or hard.
In our study, a combination of specimen identification protocol (SIP) was used to decide the margins for TLMC surgery and was compared with the histopathology report.
MATERIALS AND METHODS
The data was collected from the patients who underwent TLMC surgery at our center in the past 18 months. These were patients where the decision regarding margins had been made using the three parameters of SIP. If on palpation, an area of the vocal fold was found to be hard or firm it was considered positive for pathology. If the vocal fold area was found to be soft on palpation, it was considered negative for pathology. Infiltration was performed using a 27-gauge needle where the tip was inserted into the subepithelial space and 1–2 cc of 1:10,000 saline adrenaline was injected just lateral to the lesion. From the operation theater register, we noted the results of subepithelial infiltration and the presence of a doughnut sign indicating involvement of the ligament or deeper. Finally, the S mode of the image enhancement was used to identify the presence of IPCL and free margins based on the vascular patterns prior to the initiation of surgery and bleeding hampering the vision. The margins taken based on the combined findings of SIP were compared retrospectively with the final histopathology reports of these margins. The data collected was tabulated and analyzed using MS Excel 2007. The findings were tabulated and the accuracy of the combination of SIP in predicting free margins was analyzed.
RESULTS
Our data showed that out of the total 35 patients who underwent TLMC using SIP, a total of 26 patients were true negatives. This suggests that the combination of SIP was able to accurately determine the free margins as confirmed by the final histopathology report in 26 out of 35 patients which gives a concordance of 74.14%. The false negatives were found in 9 patients out of the total 35 where SIP was used to determine a free margin, but this was found to be positive on final histopathology. Thus, the discordance rate was 25.71% (Table 1).
| N = 35 | Margin involved | Margin negative |
|---|---|---|
| SIP used in determining free margins | 9 | 26 |
Figures 1 to 4 are representative figures of the use of white light (WL) and SIP in determining free margins in TLMC.
Fig. 1: White light image of a vascular lesion of the left vocal fold
Fig. 2: Spectra-A image of the same lesion revealing IPCL/vertical blood vessel pattern over the lesion suggestive of malignant changes
Fig. 3: On palpation, the lesion and vocal fold were soft to firm
Fig. 4: Subepithelial infiltration with saline: adrenaline (1:10,000) reveals an absence of doughnut effect suggesting uninvolved vocal ligament
DISCUSSION
Narrow band imaging (NBI) is a novel technique used in the detection of the laryngeal carcinoma in endoscopy.5,6 It enhances the potential of diagnosis by highlighting the superficial mucosal vessels. NBI consists of light of different wavelengths which peak at 415 nm (blue spectrum) and 540 nm (green spectrum).7-9 These spectrums of wavelengths are absorbed easily by hemoglobin, resulting in contrast images of superficial and deeper vessels. When the combination of these two wavelengths is used, they provide an extremely high-contrast image of the tissue surface being examined and give us additional information regarding the vasculature of the tissue and the presence of IPCL which aids in deciding the further line of management.10-13 However, one limitation of NBI is that it cannot be used with the microscope currently. However, the Storz professional image enhancement system (SPIES) camera is compatible with the microscope and permits for the use of S during microscopic laser surgery. TLMC surgery is performed for early glottic cancer with the aid of a laser under microscopic magnification.14-16
Patients with glottic malignancy usually present early to the physician due to the development of hoarseness and have a good prognosis due to the combined factors or early-stage disease and poor vascularity.17 Narrow margins are accepted as oncologically safe for early glottic cancer.17-19 Since there is a fine line between oncological safety and residual disease an intraoperative frozen section (FS) evaluation aids in confirming the adequacy of the surgical margin and also holds a medicolegal significance.17,20 However, this facility is not present at all hospitals. Furthermore, the specimen may be too small for the thicker cuts of frozen sectioning occasionally.17 In the study done by Nerurkar et al.,17 the accuracy of FS in laser laryngeal surgery was reported to be 95.1%. In the study done by Remacle et al.18 of 97 patients, the accuracy of FS was 94.8%. Ocak et al.21 in their study stated the accuracy was 94.04%. Despite the high accuracy rate, there are certain limitations to FS that have to be borne in mind such as extra time of anesthesia for the patient, thicker tissue cuts as compared to routine histopathology and formation of artifacts. Furthermore, a close collaboration between the operating surgeon and pathologist is essential for accurate diagnosis and to overcome the limitations of FS.
The study done by Garofolo et al.22 has assessed the pre- and intraoperative use of high definition-NBI endoscopically which proved to be an essential tool in evaluating the neoplastic margins and which reduced the occurrence of positive margins after TLM. They reported the positive superficial margins intraoperatively were 3.6% as compared to the 23.7% in the control group of patients treated with WL. In the study done by Campo et al.23 using NBI, a significant reduction of superficial positive margins was observed with improved clinical outcomes. The Klimza et al.7 study reported the use of intraoperative NBI on a sample size of 44 patients, which showed clear margins in definitive histology, giving a sensitivity, specificity, and accuracy to be 100, 0.0, and 85.7%, respectively.
Similarly, Piersiala et al.8 with a sample size of 98 where intraoperative WL and NBI were used provided negative margins in all patients, as well as helped identify lesions invisible in WL in 10 patients (10.2%) which needed further sampling.
Another study by Piazza et al.9 where the NBI and high-definition television were used in evaluation of oral and oropharyngeal squamous cell cancer, proved the sensitivity, specificity, positive, and negative predictive values and accuracy to be 96, 100, 100, 93, and 97%, respectively. However, NBI can be used in the setup only with the endoscope to determine the margins involved prior to TLMC surgery and not with a microscope.
In our study, we used the SPIES, specifically spectra-A to define the margins for a TLMC surgery along with palpation and infiltration. The accuracy of the combination of SIP in predicting the margins for patients undergoing TLMC was found to be 74% and holds significance in centers with no facility for frozen sectioning.
CONCLUSION
The combination of SIP may be used to decide the margins for TLMC with an accuracy of 74.1% in centers where FS facility is not available. The gold standard remains the final histopathology report.
ORCID
Nupur K Nerurkar https://orcid.org/0000-0002-4127-1590
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