298 / 412
be evaluated with direct microlaryngoscopy as possible.
Cohen et al. noted a 33% false negative rate of in-office
flexible laryngeal biopsy; and in their series, CIS on office
biopsy was most often SCC at DML.
5
It should be noted,
however, that when an office biopsy showed a diagnosis
of SCC, it was correlated with the final histologic diagno-
sis in 100% of patients. For patients with a suspected
malignant lesion who are unable to undergo a general
anesthetic, reassurance can be given that a diagnosis of
cancer in the office correlates with a diagnosis of cancer
in OR. The substantial correlation for malignancy/any
degree of dysplasia may be adequate to counsel certain
patients, and early diagnosis with office biopsy may offer
extra confidence in the treatment paradigm, particularly
when multiple treatment options are available. It may
also reduce time to definitive treatment. When a histo-
logic diagnosis of severe dysplasia or CIS in a lesion with
malignant suspicion is added to the diagnostic/staging
capabilities of imaging modalities such as CT scanning,
radiation may be employed with increased confidence of
the clinical diagnosis and stage.
6
Seventy-eight percent of
our patients with severe dysplasia, CIS, or SCC on office
biopsy were counseled appropriately in advance of sur-
gery and underwent microlaryngoscopy with CO2 laser
cordectomy at the time of initial surgical evaluation.
It is an accepted standard of care that mild to mod-
erate dysplasia may be observed, and so it follows that
this diagnosis at office biopsy may reassure the clinician.
However, lesions of uncertain significance have only
moderate correlation to their final pathologic diagnosis.
Mild to moderate dysplasia frequently represents more
sinister disease, and it may be false reassurance to rely
on office biopsy alone. Similar to brush biopsy,
7
a dys-
plastic office biopsy result indicates a need for further
investigation, without providing a definitive diagnosis.
The diagnosis of hyperkeratosis/parakeratosis (path-
ologic correlates of leukoplakia) and inflammation also
frequently correlate with a final histopathologic diagnosis
of malignancy and highlight the limitations on biopsy of
the awake patient with the absence of tactile feedback. It
is well known that potentially malignant and CIS epithe-
lia are associated with pronounced stromal reaction,
8
which is reflected in the 37% of patients with only an
office biopsy of inflammation, however, with severe dys-
plasia/CIS or SCC on final diagnosis. Clinical judgment is
paramount in ensuring that patients with suspected false
negative biopsies undergo DML.
When considering benign lesions such as papilloma
and vocal fold nodules or polyps, office biopsy may play
a more definitive role. A clinical suspicion of papilloma
or polyps/nodules correlated well with final diagnosis.
When clinically indicated, these lesions are appropriate
for office management alone.
In the current environment of financially accounta-
ble medicine, consideration should be given to cost.
Naidu et al.
9
and workers found an average cost saving
of $6,970.56 per patient when office biopsy cost was com-
pared to OR biopsy; however, it is instructive to consider
that any patient who undergoes both office biopsy and
OR biopsy does so at considerable financial burden.
There are limitations to our study, including selection
bias determining the candidacy or need for office biopsy.
In addition, the technique and types of cupped forceps
used were not compared to other approaches. The utility
of serrated forceps or rigid endoscopy with nonflexible for-
ceps should also be considered and may enhance sampling.
The ability to obtain high diagnostic yield biopsies in the
office is also dependent on the experience of the surgeon;
our group obtaining the biopsies has over 5 years experi-
ence with this method. Classification of the severity of dys-
plasia is also variable from different classification systems
and pathologists,
2
which can skew the accuracy of office
biopsies when different grades of dysplasia are considered.
A multicenter study is warranted, especially in the realm
of medical decisionmaking in complex laryngeal lesions, as
well as outcomes of prioritizing disease eradication over
voice outcomes with dysplastic lesions.
CONCLUSION
Our study shows that office biopsy has the highest
utility in clinically benign lesions and those with SCC.
Laryngopharyngeal biopsies have only a moderate corre-
lation with final pathology, although the potential utility
increases in certain clinical scenarios and with careful
choice of forceps. Office biopsy has a tendency to under-
estimate the severity of dysplastic lesions, and any
degree of dysplasia should be considered as potentially
malignant until, as possible, proven otherwise with oper-
ative assessment. However, preoperative patient coun-
seling, surgical planning, and therapy may be positively
impacted by information from office biopsies, comparable
to management of other head and neck neoplasms. For
benign pathology that clinically harbors no suspicion for
malignancy, office biopsy is a safe and viable alternative
to direct microlaryngoscopy and biopsy/excision.
Acknowledgment
We would like to acknowledge Alan Weinberg, MS, for the
statistical analysis, and Laurence T. Blanchard, BA, for
data preparation.
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