What is the management strategy for high-grade squamous intraepithelial neoplasia (HSIL) of the left vocal cord in a 59-year-old patient with a history of chronic smoking?

Management of High-Grade Squamous Intraepithelial Neoplasia of the Left Vocal Cord

This 59-year-old chronic smoker with high-grade squamous intraepithelial neoplasia (HSIL) of the left vocal cord requires excisional biopsy as the primary treatment, with complete cessation of smoking and indefinite surveillance, as HSIL of the larynx represents part of the sequential continuum toward invasive squamous cell carcinoma in the aerodigestive tract. 1

Primary Treatment Approach

Excisional biopsy is the preferred treatment for HSIL of the vocal cord because it serves dual purposes: definitive histological diagnosis and potential cure of the lesion. 1 This approach is superior to ablative techniques because:

• It allows complete pathological assessment to rule out occult invasive cancer or microinvasive disease that may be present but undetected on initial biopsy 1
• It provides adequate margins for histological evaluation, which is critical for determining need for additional therapy 1
• It offers excellent prognosis for both voice preservation and survival when performed for carcinoma in situ and microinvasive cancer of the larynx 1

Risk Stratification Based on Pathology

The natural history of laryngeal dysplasia shows significant progression risk in chronic smokers:

• High-grade dysplasia and carcinoma in situ progress to invasive cancer in a substantial proportion of untreated cases 2
• Progression rates for severe dysplasia/CIS range from 17% to 69% depending on patient population and follow-up duration 2
• This patient's smoking history significantly elevates risk, as chronic smokers with aerodigestive dysplasia show progression rates approaching 60% 2

Management Algorithm Based on Excisional Biopsy Results

If Margins Are Clear (Negative)

• Proceed with surveillance protocol (detailed below) 1
• No immediate additional surgery required 1

If Margins Are Inadequate or Positive

Two treatment options exist, with choice depending on voice preservation priority:

1. Re-excision is the preferred approach for most patients, offering another opportunity for complete removal with clear margins 1

2. Radiotherapy should be reserved only for cases where voice conservation is paramount, as it represents definitive treatment but with potential long-term voice quality implications 1

Critical Smoking Cessation Counseling

Smoking cessation is mandatory but does not eliminate progression risk. 1 The patient must understand:

• Cessation does not remove the potential for disease progression, as the carcinogenic changes are already established 1
• Continued smoking dramatically increases risk of both local recurrence and development of synchronous lesions elsewhere in the aerodigestive tract 2
• This is a field cancerization process, meaning the entire aerodigestive mucosa remains at risk 2

Surveillance Protocol

Indefinite surveillance is required regardless of treatment success. 1 The surveillance strategy should include:

• Regular laryngoscopic examinations to detect recurrence or new lesions 1
• Biopsy of any suspicious areas during follow-up, as these lesions can recur locally 1
• Monitoring of the entire aerodigestive tract, given the field cancerization effect in chronic smokers with prior aerodigestive dysplasia 2

The highest recurrence risk occurs:

• Within the first 6 months post-treatment 3
• Between 22-24 months, with dramatically lower rates during months 7-21 3

Important Clinical Caveats

Do not assume regression will occur. While some preinvasive lesions may regress (54% regression rate reported for various grades of dysplasia), 2 high-grade lesions in chronic smokers have substantial progression risk that mandates active treatment rather than observation. 2

Biopsy itself may disrupt lesions, potentially affecting natural history assessment, but this does not change the treatment imperative for HSIL. 2

Age is a risk factor for recurrence, with increasing age independently associated with 1.6-fold per decade increase in recurrence risk. 3

Prognosis

Excisional biopsy of HSIL and microinvasive cancer of the larynx offers excellent prognosis for both voice preservation and survival when margins are adequate. 1 However, this patient remains at elevated risk for:

• Local recurrence requiring repeat intervention 1, 3
• Development of invasive laryngeal cancer if inadequately treated or lost to follow-up 2
• Synchronous or metachronous lesions elsewhere in the aerodigestive tract given smoking history 2