What are the recommendations for a patient consulted for a biopsy of laryngeal cancer?

Recommendations for Laryngeal Cancer Biopsy

Pathological confirmation through biopsy is mandatory for patients with suspected laryngeal cancer. 1 This is the cornerstone of diagnosis and guides subsequent treatment planning.

Diagnostic Workup

Initial Evaluation

• Complete physical examination including neck palpation
• Flexible head and neck fibreoptic endoscopy
• Assessment of performance status, nutritional status, and weight
• Evaluation of speech and swallowing function
• Psychosocial evaluation 1

Laboratory Tests

• Complete blood count
• Liver enzymes
• Serum creatinine
• Albumin
• Coagulation parameters
• Thyroid-stimulating hormone (TSH) 1

Biopsy Procedure

• For laryngeal tumors, biopsy is best carried out using an endoscopic route under general anesthesia 1
• Examination under anesthesia with direct laryngoscopy provides the most valuable information about tumor localization and extent 2
• Microlaryngoscopy allows for precise specimen collection for histopathological examination 2

Imaging Requirements

• Contrast-enhanced CT scan and/or MRI are mandatory to assess the primary tumor, regional lymph nodes, and cartilage invasion 1
• Chest imaging (minimum chest CT) is important to assess for distant metastases in high-risk tumors or second lung primary in heavy smokers 1
• FDG-PET/CT is recommended for:
  • Evaluation of neck response to radiotherapy or chemoradiotherapy 10-12 weeks after treatment
  • Cases of suspected recurrence
  • Work-up of carcinoma of unknown primary 1

Special Considerations

Challenging Cases

• For submucosal laryngeal neoplasms with unsatisfactory laryngoscopy and biopsy results, ultrasound-guided core needle biopsy (US-CNB) can be considered, with 95.8% accuracy for differentiating benign from malignant lesions 3
• Multiple biopsies may be necessary if initial results are negative despite clinical suspicion:
  • A time delay of up to three months in diagnosing cancer does not significantly influence organ preservation and prognosis
  • However, for small tumors, a new representative biopsy should be obtained as quickly as possible to preserve laryngeal function 4

Pathology Assessment

• Squamous cell carcinoma of the head and neck should be classified according to WHO classification 1
• For oropharyngeal tumors, HPV evaluation using p16 immunohistochemistry is mandatory 1
• For neck metastases of unknown origin:
  • p16 status should be assessed
  • If p16-positive, additional specific HPV testing should be performed
  • EBV status should be determined using EBER in situ hybridization 1

Post-Biopsy Management Planning

Early-Stage Disease (T1-T2, N0)

• Treatment options include:
  • Endoscopic removal (preferred for carcinoma in situ)
  • Partial laryngectomy
  • Radiotherapy 1
• Choice depends on anticipated functional outcome, patient preferences, and general medical condition 1
• Most patients with T1-T2 lesions of the glottis and clinically negative cervical nodes do not require routine elective treatment of the neck 1

Advanced Disease

• Multidisciplinary evaluation is essential to determine suitability for larynx-preservation approaches 1
• Options include:
  • Organ-preservation surgery
  • Combined chemotherapy and radiotherapy
  • Radiotherapy alone with surgery reserved for salvage 1
• For selected patients with extensive T3 or large T4a lesions and/or poor pretreatment laryngeal function, total laryngectomy may achieve better survival rates and quality of life 1

Common Pitfalls to Avoid

1. Inadequate sampling: Ensure representative tissue is obtained, as non-representative biopsies may lead to diagnostic delays 4

2. Overlooking submucosal disease: Consider US-CNB for submucosal lesions when standard laryngoscopic biopsy is unsatisfactory 3

3. Delayed diagnosis: When clinical suspicion is high but initial biopsy is negative, proceed with repeat biopsy promptly 4

4. Insufficient imaging: Both CT and MRI have complementary roles; consult with a radiologist specialized in head and neck cancer to determine the most appropriate modality 1

5. Failure to assess cartilage invasion: This is critical for treatment planning, particularly for determining candidacy for larynx-preservation approaches 1, 5

By following these evidence-based recommendations, clinicians can ensure accurate diagnosis and appropriate staging of laryngeal cancer, which are essential for optimal treatment planning and improved patient outcomes.