Case 2:
A 39-year-old female, never-smoker, with a history of squamous cell carcinoma in situ of the right true vocal cord, longstanding Crohn’s disease, and gastroesophageal reflux presented with a cough and sore throat. The prior right vocal cord lesion had been treated with microlaryngoscopy and KTP laser excision by an outside otolaryngologist seven months earlier. The pathology was consistent with SCC in situ with negative margins. Her Crohn’s disease has been difficult to control with oral involvement and prior requirement for multiple immunosuppressants and steroids, including most recently the systemic biologic ustekinumab (Stelara®). Gastroenterology planned to switch the patient to vedolizumab (Entyvio®) in place of ustekinumab given ongoing uncontrolled GI symptoms and the presence of the head and neck neoplasm. Vedolizumab is a more gastrointestinal-selective agent, with less systemic immunosuppression.
At presentation she reported a number of laryngeal symptoms including constant cough, hoarseness, and sore throat, without shortness of breath. On nasopharyngolaryngoscopy, a mass of the right anterior/mid true cord was observed. The entire vocal fold was noted to be edematous and erythematous, but vocal cord mobility was normal. There were no palpable cervical lymph nodes. The patient was counseled on the need for tissue biopsy of the concerning vocal cord lesion.
Microdirect laryngoscopy with biopsy of the right vocal cord mass was performed in late January 2020. The lesion involved the right anterior vocal cord without involvement of the anterior commissure, very limited involvement of the inferior aspect of the vocal cord and suspicion for possible early infraglottic extension. The lesion was noted to be partly submucosal, very firm, and adherent to the underlying muscle/ligament (Fig. 2). Pathology was positive for invasive, well-differentiated, keratinizing SCC. She was therefore diagnosed with a stage I (cT1aN0M0) SCC of the right vocal fold.
At this point, COVID-19 had entered our institution. Standard of care options would normally include open or endoscopic cordectomy or definitive radiotherapy. Radiation Oncology favored primary surgical resection over radiotherapy given the risk of increased radiation toxicity in a patient with active Crohn’s disease with oral cavity involvement, the risk of exposure to SARS-CoV-2 from other patients and healthcare providers during a typical 28-fraction (six-week) course of radiotherapy, which would have corresponded to the predicted peak surge in COVID-19 cases in our region, and her young age and hypothetical risk of secondary malignancy. After discussion of the risks and benefits of the different options with the patient and in collaboration with our multidisciplinary team, she decided to undergo laser cordectomy.
In order to minimize aerosolization, the procedure was done with sharp (cold) technique instead of laser. It was felt that an outpatient procedure was preferable with avoidance of open partial laryngectomy with imbrication and tracheostomy. At the time of surgery, the tumor was considerably more extensive in terms of infraglottic spread than had been anticipated and had likely progressed over a very short interval since the original diagnosis. She was discharged after surgery and instructed to take oral hydroxychloroquine (Plaquenil) 400 mg twice daily on day one, then 200 mg twice daily for four days per an Infectious Disease consultant. Final pathology revealed a keratinizing, well differentiated, invasive squamous cell carcinoma of the right vocal cord with negative but close margins, and was pathologically staged as T2a. Tumor board consensus was to follow her by telemedicine for the next several weeks and have her return for an in-person visit after the anticipated viral infection “surge” in our community, and if she were to recur, consideration of radiotherapy or supracricoid partial laryngectomy. At this time, the patient is recovering well post-operatively, with her care being coordinated via telemedicine.