Haina Rosie 8 17 [631614]

http://www.revistadechimie.ro REV.CHIM.(Bucharest) ♦68♦No. 8 ♦2017 1768Disease Free Margins Assessment Using Enhanced Methylene Blue
Video Contact Endoscopy with SPIES Filters in Vocal Fold Malignancies
RAZVAN HAINAROSIE1,2, VIOREL ZAINEA1,2, MURA HAINAROSIE1, CATALINA PIETROSANU1*, IRINA IONITA1
1 Carol Davila University of Medicine and Pharmacy, 8th Eroii Sanitari Blvd., 050474, Bucharest, Romania
2 Prof. Dr. D. Hociota Institute of Phonoaudiology and Functional ENT Surgery, 21st Mihail Cioranu Str., 050751, Bucharest,
Romania
Vocal fold carcinomas represent a pathology that has an important incidence. Recent studies showed that
70% of the dysplastic lesions can skip the phases of mild and severe dysplasia directly to carcinoma. For that
reason early detection of a malignancy of the vocal fold is mandatory. If the lesion is discovered in an early
stage it must be aggressively treated using CO2 LASER surgery and disease free margins must be obtained.
Because frozen sections are not always available in all medical centers we are proposing a new protocol to
assess disease free margins during CO2 LASER assisted laryngoscopy. Methylene blue contact endoscopy
is not a new method, as it was introduced in laryngology by professors Oscar Diaz and Mario Andreea in
1994. We are proposing a protocol designed to assess disease free margins using an enhanced video
contact endoscopy with SPIES software filters. The SPIES filters technology is a relatively new technology
proposed by Karl Storz in 2013. A critical analysis of the method will be done comparing the results with
paraffin histopathology exam.
Keywords: methylene blue, vocal fold carcinoma, contact endoscopy, SPIES filters, disease free
Video contact endoscopy is not a new method in
laryngology, where it was introduced in 1994 by twoprofessors Mario Andreea and Oscar Diaz [1-3]. In The
Institute of Phonoaudiology and Functional ENT Surgery
we started using this method in 1997. First the methodwas designed to detect early malignancies on the vocal
fold. Great focus was on the cellular field modifications,
such as: uniformity of the cellular field, the ratio betweenthe nucleus and cytoplasm, size and shape of the cell and
nuclear abnormalities.
The cellular abnormalities can only be identified using
150X video contact endoscope and it is necessary at least
a 3-5 years learning curve for a surgeon to learn to read
and to interpret the cellular field’s modifications.
Surgery with oncological safety limits offers a better
long-term survival. Thus the relapse rate decreases, as well
as the risk of distant metastasis. Unfavorable evolution isassociated with the need to use multiple lines of
oncological treatment with a wide range of immediate
and remote side effects [4,5].
In 2008 we proposed during the European Congress of
Laryngology in Barcelona [6] a new approach using
methylene blue video contact endoscopy. We wanted tomove the focus from the abnormalities of the cellular field
to the pattern of the superficial vascular network. We have
done that having in mind that a 1 mm malignant tumorwill start to produce endothelial growth factor in order to
get more vessels and nutrients needed for the accelerated
development of the tumor [7-10]. That will lead to vascularnetwork pattern modifications that can be easily identified
by the surgeon. Also, new types of delivery systems for
cytotoxic drugs have been deviced for unresectable lesionsin the oral cavity and for other local tumor therapies [11,
12]. The results can also be correlated with complex
oncological investigations. New serum markersare being tested in order to establish the existence of
mucosal damages and tumor angiogenesis [13].
* email: catapietrosanu@gmail.com; Phone: 0723627405 All authors have contributed equally to this p aper.So far, the methylene blue videocontact endoscopy
enhanced with other light filters, like NBI (Narrow Band
Imaging) has shown promising results [14].
Experimental part
The study was performed in The Prof. Dr. Dorin Hociota
Institute of Phonoaudiology and Functional ENT Surgery.
We enrolled in our study 32 patients with confirmed
malignant lesion of the vocal fold in stages T1 and T2b.The age of the patients was between 39 and 68 year old.
The patients group consisted of 24 males and 8 females.
The patients were enrolled in the study after performingtrans nasal flexible endoscopy using white and Narrow
Band Imaging light.
The surgery was performed under general anesthesia
with oral intubation. The glottis plan was exposed using a
medium Kleissaser laryngoscope.
Rigid endoscopy was performed using white and SPIES
filtered light. We used all SPIES filters, but according to our
earlier studies concerning the SPIES filters we have taken
into account only the filters CHROMA and SPECTRA B.
First, a methylene blue video contact endoscopy was
performed using normal light, after which the enhancing
SPIES filters and a combination between these filters wasused, respecting the following protocol (only CHROMA and
SPECTRA B).
Fig. 1. Chemical formula of methilene blue

REV.CHIM.(Bucharest) ♦68♦No. 8 ♦2017 http://www.revistadechimie.ro 1769We used the 0 degree 60X magnification contact
endoscopy laryngoscope [15]. First we obtainedinformation concerning the normal vocal fold and then the
vocal fold with the lesion was evaluated. A virtual map
with the resection was designed using the information fromthe methylene blue video contact endoscopy in white light
(fig. 2).
A second resection virtual map was designed using the
information obtained using the enhanced methylene blue
video contact endoscopy with SPIES filters (fig. 3 and fig.
4).
The resection of the lesion was performed as in the
virtual map obtained with white light. Multiple biopsieswere performed. In the second step the resection plan
continued according to the virtual plans obtained using the
SPIES enhanced methylene blue video contact endoscopy.Again, multiple biopsies were sent for pathologic
examination.
We performed ELS II to ELS V type cordectomy as
indicated in table 1.
The percentage of disease free margins was analyzed
comparing the numbers obtained from the virtual resectionmap designed using methylene blue contact endoscopy
and from the virtual map using the enhanced methylene
blue video contact endoscopy using CHROMA and SPECTRAB SPIES filters.Results and discussions
Comparing the virtual map for disease free margins
under white light and SPIES enhanced methylene blueendoscopy we obtained the results shown in Table 2.
Both types of methylene blue SPIES enhanced video
contact endoscopy provide a better percentage of diseasefree margins compared to the normal microscopic virtual
resection map.
SPIES software filters enhanced methylene blue video
contact endoscopy provides the surgeon the ability to obtain
more accurate disease free margins when performing the
resection of the tumor. The CHROMA filter provides a goodpercentage of disease free margins, the false positive
results are relatively high, but the false negative numbers
are at an acceptably low value compared to the classicmicroscopic resection plan. The SPECTRA B filter provides
the best numbers as far as disease free margins are
concerned, with a high value of false positives and lowfalse negatives.
Conclusions
SPIES software filter enhancing of the methylene blue
contact endoscopy using CHROMA and SPECTRA B filters
will provide an increased number of disease free marginscompared to the classic microscopic resection plan or even
to the methylene blue contact endoscopy plan using white
light.
Fig. 2. Virtual map with the resection
plan obtained from the methylene blue
video contact endoscopy with white
lightFig. 3. Virtual map with the resection
plan obtained from the methylene blue
video contact endoscopy enhanced
with CHROMA SPIES filterFig. 4 Virtual map with the resection
plan obtained from the methylene
blue video contact endoscopy
enhanced with SPECTRA B SPIES filter
Table 2
RESULTS OF THE COMPARISON BETWEEN THE VIRTUAL MAP FOR DISEASE FREE MARGINS UNDER WHITE LIGHT AND SPIES ENHANCED
METHYLENE BLUE ENDOSCOPY
Table 1
ELS II TO ELS V
CORDECTOMIES IN OUR
PATIENT GROUP

http://www.revistadechimie.ro REV.CHIM.(Bucharest) ♦68♦No. 8 ♦2017 1770Both CHROMA and SPECTRA B filters provide an
important percentage of false positives that will lead to a
more extensive resection plan than it is necessary, but wethink that the most important thing is the low false positive
results concerning the disease free margins obtained in
our study.
We have been using the SPIES filters technology for 1,5
year, so we are at the beginning of our learning curve. As in
all other areas, we consider that the more experienced wewill get, the better results we will achieve.
Frozen sections remain the gold standard in assessing
disease free margins, but these are not available in allcenters at all time. In that cases we consider that SPIES
enhanced methylene blue video contact endoscopy is a
viable alternative to frozen sections.
Still the video contact endoscopy system and the SPIES
capable high definition camera are expensive state of the
art technologies that need a learning curve in order toachieve good results.
The main disadvantage of the so-called
optical biopsies
is that we do not have any information about the depth of
the lesion, but they remain a viable alternative, still in need
of further research.
.
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Manuscript received: 29.05.2017