What is the management of leukoplakia, dysplasia, and carcinoma in situ of the glottis?

Management of Leukoplakia, Dysplasia, and Carcinoma in Situ of the Glottis

For glottic leukoplakia, dysplasia, and carcinoma in situ, endoscopic removal (stripping or laser excision) is the preferred first-line treatment due to excellent cure rates and voice preservation, with radiation therapy as an effective alternative when surgery is not ideal. 1

Diagnostic Approach

• All suspicious lesions require biopsy for histopathological confirmation
• Multidisciplinary consultation is critical due to potential impact on speech and swallowing function 1
• Staging should determine:
  • Extent of lesion
  • Vocal cord mobility
  • Presence of regional metastases (rare in early glottic lesions)

Treatment Algorithm by Pathology

Leukoplakia

• Initial management:
  • Biopsy to rule out dysplasia or malignancy
  • If no dysplasia: observation or endoscopic removal
  • Elimination of risk factors (tobacco, alcohol) is essential 2

Mild to Moderate Dysplasia

• Primary treatment:
  • Endoscopic excision/stripping (preferred)
  • Close surveillance after treatment
  • Repeat excision for recurrent lesions 3, 4

Severe Dysplasia

• Primary treatment:
  • Endoscopic excision with possible laser resection/ablation
  • More aggressive surveillance schedule
  • Consider radiation therapy for extensive lesions or recurrences 3, 4

Carcinoma in Situ

• Primary treatment options:

  • Endoscopic removal (stripping, laser) - preferred first option
  • Radiation therapy (51 Gy in 20 fractions over 4 weeks) - excellent alternative 1, 5

• Outcomes:

  • Endoscopic removal: Higher recurrence rate (up to 52% in some studies) but 100% salvage rate with subsequent treatment 6
  • Radiation therapy: 5-year local control rate of 98% with minimal complications 5

Treatment Selection Factors

1. Lesion characteristics:

   • Size and extent
   • Location within glottis
   • Unifocal vs. multifocal

2. Patient factors:

   • Voice quality requirements
   • Reliability for follow-up
   • General medical condition
   • Patient preference 1

3. Technical considerations:

   • For superficial lesions on free edge of vocal cord: endoscopic excision provides excellent voice outcomes
   • For indistinct lesions or those with widespread abnormal mucosa: radiation therapy may be preferred 1

Follow-up Protocol

• Regular laryngoscopic examinations
• More frequent follow-up for higher-grade lesions
• Surveillance for:
  • Local recurrence
  • Development of invasive cancer
  • Second primary tumors (24% of patients may develop subsequent malignancies) 5

Important Considerations and Pitfalls

• Voice preservation: Both treatment modalities can preserve voice, but outcomes may differ based on lesion extent and location
• Recurrence management: Recurrence after endoscopic removal can be successfully salvaged with either repeat excision or radiation therapy 6
• Second primary risk: Patients require long-term surveillance not only for recurrence but also for development of second primaries in the upper aerodigestive tract 5
• Alternative therapies: Photodynamic therapy may be considered for extensive lesions or when surgery is contraindicated, though evidence is stronger for oral rather than glottic lesions 2

Advanced Treatment Options for Recurrent Disease

• Repeated endoscopic excision
• Radiation therapy (if not previously used)
• More extensive surgical procedures for persistent/recurrent disease
• Combined modality approaches for resistant cases 1, 3

By following this management approach, excellent outcomes can be achieved with 5-year local control rates exceeding 95% for carcinoma in situ and preservation of laryngeal function in the vast majority of patients 5, 6.