Carcinoma in situ (CIS) is a lesion comprised of “cancer cells,” but with those cells limited to the lining mucosa and without evidence of extension to adjacent structures. In other words, there is no sign of invasion beyond the mucosa. CIS is typically a localized and highly curable precursor to invasive cancer. It is sometimes called intraepithelial carcinoma.
In laryngology, CIS is found primarily on the vocal cords themselves, where a tiny, early lesion can change the quality of the voice. In other locations, CIS would ordinarily be “silent.”
Radiation: Telangiectasia Increases Slowly but is Maximal by 3 Years after End of Radiation
Inflammation with moderate dysplasia (1 of 8)
Hoarseness began 2 years prior to this initial examination photo. This middle aged man has never smoked; has no reflux symptoms, nor has he had any response to empiric reflux therapy. Biopsy shows inflammation with moderate dysplasia. HPV testing was negative. No explanation for this chronic inflammation is ever found. A series of KTP laser treatments of stippled vascular areas and leukoplakia ensues.
Squamous cell carcinoma-in situ (2 of 8)
A year later, similar findings except appearance of a slight anterior commissure inflammatory web. Eventually, after an additional 2 years (5 years after onset of hoarseness) a second biopsy is triggered by aberrant, “corkscrew” capillaries. The diagnosis: squamous cell carcinoma-in situ. Laser excision is typically preferred for well-demarcated early vocal cord cancer, but the diffuse, superficial and bilateral abnormalities suggested radiotherapy instead.
Post radiation (3 of 8)
Six weeks after the end of his 30 radiation treatments, healing of the superficial ulceration (within dotted lines) is underway.
Narrow band light (4 of 8)
Closer view, now under narrow band light: A fine vascular pattern has returned except in the areas bounded by dotted lines.
Regenerated vascular pattern (5 of 8)
Six weeks later (3 months after end of radiotherapy), the superficial ulceration has healed, and voice is very functional. Note the regenerated vascular pattern, and compare with photo 4.
Post-radiation telangiectasias (6 of 8)
“On schedule” a year after the end of successful radiation therapy, post-radiation telangiectasias are becoming evident. Compare progression of these telangiectasias in photos 4, 5, 6, 7, and 8.
Standard light (7 of 8)
Now 3 years from the end of radiotherapy, radiation telangiectasia are “maximal” and stable. Voice remains very good.
Narrow band light (8 of 8)
Same view, under narrow band light.
HPV and Cancer: Types 33 and 45
Hoarse voice (1 of 5)
Chronic hoarseness in a younger woman, diagnosed elsewhere with “nodules.”
Narrow band light (2 of 5)
At closer range, under narrow band light. Note the two distinct vascular patterns: a finer, stippled one of anterior 1/3 and a more coarse and aberrant one on the mid and posterior fold. The pathology report shows invasive carcinoma-in-situ, which was removed using the CO2 laser.
Post excision (3 of 5)
One week after excision of the lesion.
Healed (4 of 5)
After healing, the right fold normalizes remarkably and the patient’s voice sounds normal to her and to the clinician.
"Cured" (5 of 5)
Two years later, laser excision alone (no doubt along with the patient’s immune system) has produced a durable remission/ “cure.”
HPV 31 → Cancer → Cure
Carcinoma in situ (1 of 4)
This man developed hoarseness spontaneously a year before this visit. He had accumulated 30 pack-years as a smoker, but had quit 7 years earlier. Removal of “polyps” elsewhere returned a diagnosis of carcinoma in situ (CIS), the earliest stage in the development of cancer.
HPV subtype 31 (2 of 4)
Under narrow band light, note some unusual “suspicious” capillaries, and the stippled “HPV effect” at the arrow. These findings triggered HPV subtyping and identification of high-risk subtype 31.
Excisions (3 of 4)
After 2 prior excisions elsewhere with positive margins, somewhat aggressive excision was performed in the operating room, attempting to avoid the need for radiotherapy in this fairly young man. The specimen showed severe dysplasia/ CIS, but with negative margins. After some months, voice became very functional.
Seven years later (4 of 4)
Seven years later, at an annual visit, there are no stippled or other abnormal vascular marks. Voice has been very acceptable to the patient, if occasionally faintly husky.
