Laryngeal Dysplasia: To Biopsy or Not?
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CLINICAL REPORT
Laryngeal Dysplasia: To Biopsy or Not? Reshmi Anna Alex1 • Suma Susan Mathews1
•
Roshna Rose Paul1 • Rita Ruby A. Albert1
Received: 9 September 2020 / Accepted: 21 September 2020 Ó Association of Otolaryngologists of India 2020
Abstract A renal transplant recipient with chronic hepatitis B underwent multiple laser excisions over 4 years for laryngeal keratosis. From the initial histopathology reports of mild to moderate dysplasia, a progression to squamous carcinoma was noted over 4 years. This case report highlights the possible role of immunosuppressants and hepatitis virus in the aetiopathogenesis of laryngeal carcinoma. Keywords Dysplasia Keratosis larynx Biopsy Follow up, immunosuppressants
Introduction Laryngeal dysplasia is a premalignant lesion from which laryngeal carcinoma develops [1]. The progression of laryngeal dysplasia to invasive carcinoma varies between 1.7 and 46.3% [2–4]. Therefore early clinical detection, excision biopsy of suspicious lesions and stringent follow up is mandatory. Immunosuppressive states such as post organ transplantation, or chronic infections like hepatitis, Human Immunodeficiency virus (HIV) have a higher chance of developing denovo malignancies [5]. & Suma Susan Mathews [email protected] Reshmi Anna Alex [email protected] Roshna Rose Paul [email protected] Rita Ruby A. Albert [email protected] 1
Case Report A 53 year old renal transplant recipient on immunosuppressants presented with hoarsness for a year. He was also on entecavir for chronic hepatitis B infection and isoniazid prophylaxis for latent pulmonary tuberculosis and had no history of tobacco or alcohol usage. A clinical diagnosis of laryngeal keratosis was made with the flexible laryngoscopic findings of keratotic lesions over the anterior third of both true vocal cords (TVC). Microlaryngeal surgery and excision biopsy was done and histopathology reported as mild to moderate dysplasia. Patient was on regular follow up for the next 4 years with multiple laser excision biopsies done for all clinically suspicious lesions that kept cropping up. The biopsies over the first three years showed mild to moderate dysplasia. However in the fourth year, biopsy of the lesions over the anterior third of both cords involving anterior commissure revealed epithelial hyperplasia with low grade dysplasia (Fig. 1). Five months later excision biopsy of the lesion over the anterior third of both TVC, anterior commissure and subglottis was done (Fig. 2a). The lesion from the TVC revealed a progression to well differentiated squamous cell carcinoma {SCC)} (Fig. 2b), for which he was advised radiotherapy. However after 14 fractions radiotherapy, it had to be discontinued as he developed lobar pneumonia and type 1 respiratory failure. Subsequently he was also diagnosed with interstitial lung disease and the immunosuppressants (prednisolone and azathioprine) were hiked up and advised close monitoring as the dose was to be tapered weekly, with a follow up imaging at the end of two months. The patient h
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