Comparison of Efficacy, Safety, and Cost-Effectiveness of In-Office Cup Forcep Biopsies Versus Operating Room Biopsies for Laryngopharyngeal Tumors

doi:10.1016/j.jvoice.2011.10.003

Journal of Voice

Volume 26, Issue 5, September 2012, Pages 604-606

Presented at the Eastern Section Meeting of the American Laryngological, Rhinological, and Otological Society, Inc., Boston, Massachusetts, January 2008.

https://doi.org/10.1016/j.jvoice.2011.10.003 Get rights and content

Summary

Objective

To compare the diagnostic yield, safety, and cost of biopsies of laryngopharyngeal tumor performed in an office setting with those performed in the operating room (OR) under general anesthesia.

Study Design

This was a retrospective review of patients’ records at Boston Medical Center from 2006 to 2008.

Methods

In-office biopsies were performed using flexible digital videolaryngoscopy with cup forcep biopsies taken via the working channel in patients in whom cancer was strongly suspected. Patients whose in-office biopsies were nondiagnostic or suspected to be falsely negative were taken to the OR for biopsy under general anesthesia and served as the control group.

Results

Twelve patients fit the selection criteria and had in-office biopsies attempted. One patient could not tolerate the in-office biopsy. Seven of the 11 in-office biopsies performed were diagnostic for squamous cell carcinoma. The average cost (facility and professional otolaryngology charges) for an in-office biopsy was $2053.91. Five of these patients required further biopsy in the OR at an average cost (charges for surgeon, OR, anesthesia, and recovery room) of $9024.47. There were no significant complications reported for any of the procedures.

Conclusions

In patients with strongly suspected laryngopharyngeal cancer, in-office cup forcep biopsies were 64% diagnostic. When compared with the OR, in-office cup biopsies of laryngopharyngeal tumor are safe and considerably more cost-effective. Although 36% of patients required operative biopsies, the cost would have been considerably higher in this cohort if all patients had gone to the OR for biopsies.

Introduction

Laryngeal tumors are gaining prevalence in today’s society with approximately 24 180 new cases diagnosed among men in 2007. Worldwide, laryngeal tumors are the 11th most common type of cancer among men and the second most prevalent head and neck cancer.¹ Furthermore, the number of estimated annual deaths resulting from some form of laryngeal cancer is approximately 3660 for both men and women.² As with any other cancer, early detection is the key to its eradication.³ This also promotes increased survival and preservation of laryngeal function.⁴

Detection starts with a history and physical examination to directly inspect a suspicious mass. Imaging, such as computer-assisted tomography scan, is also useful for characterizing a suspected laryngopharyngeal tumor.⁵ Most importantly, tissue samples are needed to make the definitive diagnosis. Biopsies have traditionally been done in the operating room (OR) with patients under general anesthesia because of difficulty in assessing this anatomic site in an awake patient. Benefits of this approach include the consistent ability to gain access to this anatomic site without patient movement and define the extent of disease along mucosal surfaces that may not be apparent during the awake examination (ie, hypopharynx). Drawbacks to biopsies under general anesthesia include the risk of anesthesia, scheduling hassles, and higher costs.

Recent technologic advances make performing biopsies of laryngopharyngeal tumors in an awake patient easier. Digital cameras located in the distal end of flexible nasolaryngoscopes (distal chip scopes) offer superior image quality of the older fiber-optic endoscopes. In addition, these distal chip scopes are available with an instrument port that allows the passage of a biopsy device (cup forceps or brush). The advantages of this approach include avoidance of general anesthesia, easier scheduling, and reduced cost. Drawbacks are the inability to distend the laryngopharyngeal space to visualize all the mucosal edges of the tumor, the need for a cooperative patient, and not being able to biopsy as deeply as when in the OR.

The purpose of this study was to compare the diagnostic yield, safety, and cost of biopsies of laryngopharyngeal tumors performed in an office setting with those performed in the OR under general anesthesia.

Section snippets

Methods

This study is a retrospective institutional review board review of charts from Boston Medical Center of patients who were examined for laryngopharyngeal tumors between 2006 and 2008. Specific anatomic subsites of interest were the tongue base, posterior pharyngeal wall of oro- and hypopharynx, supraglottis, and glottis. Patients were excluded if they were younger than 18 years. Office biopsies were done using an Olympus channeled flexible nasolaryngoscope (ENF Type V2; Olympus Medical Systems,

Results

Twelve patient charts met the selection criteria of this study. The average age was 62.5 years. There were eight men and four women in this patient cohort. Six patients had tumors of the glottis (vocal folds), three had supraglottic tumors, and the remaining three tumors were pharyngeal (hypopharynx, tongue base, and posterior pharyngeal wall) (Table 1).

One patient was not able to tolerate the in-office biopsy and underwent an operative biopsy instead. Eleven in-office biopsies were

Discussion

With improved technology, many medical procedures are shifting from the OR to the clinic.6, 7 Traditionally, patients with suspected tumors of the laryngopharynx have gone to surgery for a biopsy because this anatomic area is difficult to access in an awake patient.⁸ With the improved image quality of distal chip scopes (flexible nasolaryngoscopes with digital cameras located in the tip), clinicians are better able to visualize these tumors in the clinic setting. When these scopes contain

Conclusion

When laryngopharyngeal tumors were fully visualized in the clinic, in-office (unsedated) biopsies and cancer staging were performed safely, with a diagnostic yield of 64% in our series of 11 patients. Exophytic tumors and those whose surface is perpendicular to the endoscope, rather than tangential, are easier to biopsy in the clinic setting. In-office biopsies were significantly cheaper than those performed in the OR ($2053.91 and $9024.47, respectively).

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Comparison of Efficacy, Safety, and Cost-Effectiveness of In-Office Cup Forcep Biopsies Versus Operating Room Biopsies for Laryngopharyngeal Tumors

Summary

Objective

Study Design

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

Otolaryngol Clin North Am

Otolaryngol Clin North Am

Otolaryngol Head Neck Surg

Eur Urol

Cancer Facts and Figures, 2007