REV.CHIM.(Bucharest) 67No. 7 2016 http:www.revistadechimie.ro 1327The Use of Methylene Blue in Assessing Disease Free Margins During [631622]

REV.CHIM.(Bucharest) ♦67♦No. 7 ♦2016 http://www.revistadechimie.ro 1327The Use of Methylene Blue in Assessing Disease Free Margins During
CO2 LASER Assisted Direct Laryngoscopy for Glottis Cancer
DRAGOS CRISTIAN STEFANESCU1, OCTAVIAN CEACHIR2,3, VIOREL ZAINEA2,3, MURA HAINAROSIE2, CATALINA PIETROSANU2*,
IRINA GABRIELA IONITA2, RAZVAN HAINAROSIE2,3
1 Gen. Dr. Aviator Victor Anastasiu Institute of Aeronautical and Spatial Medicine, 88th Mircea Vulcanescu Str., 010825, Bucharest,
Romania
2 Carol Davila University of Medicine and Pharmacy, 8th Eroii Sanitari Blvd., 050474, Bucharest, Romania
3 Prof. Dr. D. Hociota Institute of Phonoaudiology and Functional ENT Surgery, 21st Mihail Cioranu Str., 050751, Bucharest,
Romania
The main treatment in cases of T1 and T2 laryngeal carcinoma is represented by CO2 LASER resection of
the lesion under direct micro laryngoscopy. This type of minimally invasive surgical treatment will provide
the surgeon with the ability to completely resect the lesion and the patient can be released from the hospital
the next day. The CO2 LASER resection of the lesion must be performed in such manner in which we can
obtain disease free margins after resection of the tumor. The aim of the present paper is to evaluate the
utility of methilene blue staining associated with videocontact endoscopy in obtaining disease free margins
after CO2 LASER resection of the lesion.
Keywords: methilene blue, vocal fold carcinoma, contact endoscopy
Laryngeal cancer represents approximately 3% of the
total cancers in males and approximately 40% of the head
and neck cancers. Despite all efforts, it remains a majorhealth problem [1], with deep social and economic
implications. The main symptom of laryngeal carcinoma
is dysphonia. The diagnosis of the lesion is based on thevisualization the lesion thru endoscopic examination
(flexible nasoendoscopy, rigid endoscopy) under white and
Narrow Band Imaging (NBI) light. Under general anesthesiathe surgeon will examine the larynx under direct
microlaryngoscopy (a metallic laryngoscope is introduced
thru the mouth of the patient down to the level of the vocalfolds). A biopsy must be performed in order to confirm the
neoplasm of the vocal fold. CO
2 LASER resection of the
lesion is performed with the goal of obtaining disease freemargins.
Romania is on the fifth place on the chart of European
countries concerning the incidence (6.8:100,000) andmortality (4.1:100,000) of laryngeal cancer. The carcinoma
of the larynx is the second most frequent neoplastic
process of the airways in both international and nationalstatistics, after lung cancer. Due to the large number of
subjects that present habitual risk factors (tobacco, alcohol
consumption), it represents a major problem of publichealth [2].
The endoscopic CO
2 LASER assisted micro
laryngoscopy is aiming for total resection [3], addressinglesions that are classified T1 to T2 according to the TNM
international classification. These type of techniques, that
are suitable only for certain carefully selected cases [4],are performed under microscopic control, while visualizing
the lesion in white light.
The purpose of this paper is to critically analyze the
method of contact endosocpy using methilene blue in vivo
coloration [5-7] compared with the results of frozen section
and to establish it’s capacity in tracing the limit of thetumoral resection and obtaining disease free margins of
the resection specimens.
*
email: [anonimizat]; Tel.: 0723627405Experimental part
We conducted this study in two medical centers, The
Institute of Phonoaudiology and Functional ENT SurgeryProf. Dr. Dorin Hociota and The Institute of Aeronautical
and Spatial Medicine
Gen. Dr. Aviator Victor Anastasiu .
We enrolled in our study 43 patients with histo-
pathological T1 (12 patients) and T2 (31 patients)
confirmed vocal fold carcinoma. The age of the patients
was between 49 and 74 year old. The patients groupconsisted of 36 males and 7 women. Cervical and thoracic
computer tomography was performed before CO
2 LASER
resection.
The surgery was performed under general anesthesia
with oral intubation. The laryngoscopy metallic tube is
inserted trans orally and the glottis plan is exposed.
We performed video contact endoscopic after staining
the vocal fold with methylene blue. We cleaned the vocal
fold’s surface with saline solution and after that with aceticacid 1%. Afterwards, we stained the surface of the vocal
fold with 1% methylene blue and we waited for 5 min. The
vocal fold was cleaned with saline solution and the surfaceof the vocal fold was then dried.
Video contact endoscopy was first imagined to asses
morphological modifications at the level of the cellular field.It was designed to evaluate premalignant and early
malignancies of the vocal fold, but the results did not match
the optimism of the authors regarding the method.
We consider that observing the vascular network of the
vocal fold using video contact endoscopy will provide us
with more information about the margins of the tumor. Weperformed video contact endoscopy and by reading the
vascular network modifications we tried to establish the
real limits of the tumor, correlated with the image obtainedafter methylene blue staining. The result, an in vivo
Fig. 1. Chemical
formula of
methilene blue.

http://www.revistadechimie.ro REV.CHIM.(Bucharest) ♦67♦No. 7 ♦2016 1328microscopic image, could then be studied. In our study,
we used a 8715 A Karl Storz contact endoscopy rod with
an angle of 00 and a high resolution camera, necessary for
assessing the finest details [8].
CO2 LASER resection of the tumor was performed using
the tumor limits traced by video contact endoscopy. Frozensection were then sent to the histopathology department.
If the margins of the tumor were not disease free, further
resection was performed. All specimens were send to thehistopathology department and the resection margins
were analyzed.
Results and discussions
The histological specimens were oriented according to
the position of the tumor on the vocal fold.
From each resection specimen we have studied 6
resection margins. We found that 92% of the resection
margins were disease free, when compared with theparaffin histological results. The correlation between frozen
section and paraffin section after hystopathological
examination was 98.3%.
These results allowed us to conclude that the methylene
blue staining video contact endoscopy is a valuable method
of practical importance, allowing the surgeon to trace tumormargins before performing CO
2 LASER resection of the
vocal fold carcinoma.
In another paper was studied the utility of the Toluidine
Blue staining test in assessing disease free resection
margins during the transversal approach of oral carcinomas
[9].
Conclusions
Methylene blue video contact endoscopy is a valuable
tool in assessing disease free resection margins when
performing CO2 LASER assisted micro laryngoscopy.
The methylene blue coloration with contact endoscopy
at the level of the vocal fold is a minimally invasive and
cheap endoscopic technique. However, for the time being,
the endoscopic exam with a 00 rigid rod after methylene
blue coloration can not replace the frozen section, that
provide the surgeon a better correlation with paraffin
histological findings. Further developments of theFig. 2. Normal vascular network of the vocal
fold in contact endoscopy 60X magnification
Fig. 3. V ascular network of the vocal fold
carcinoma in contact endoscopy 60X magnification
methylene blue staining test contact endoscopy test will
increase the correlation with the paraffin test results, but
we must keep in mind that this test does not replace thehistopathological result.
Also, there is a learning curve for the ENT surgeon, that
must learn to interpret alone the aspect of the vascularnetwork.
Another aspect that we must keep in mind are the high
costs associated with this method. The instrumentsnecessary for contact endoscopy have a high price (rigid
contact endoscopes, high resolution video camera),
however, once the acquisitions have been made, the costof the disposables is low.
In centers where frozen sections are not available, the
methylene blue staining video contact endoscopy test canbe used to asses the free disease margins of the vocal fold
carcinoma. We consider this method to be a reliable one,
increasing the safety and efficiency of the procedure withminimal risks for the patient.
Acknowledgement: all authors have contributed equally to this paper.
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Manuscript received: 23.04.2016