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.