ORIGINAL RESEARCH Autofluorescence improves pretreatment mucosal assessment in head and neck cancer patients David Fielding, FRACP, MD, Julienne Agnew, FRACS, David Wright, FRCS, and Robert Hodge, FRACS, Brisbane, Queensland, Australia Sponsorships or competing interests that may be relevant to con- tent are disclosed at the end of this article. ABSTRACT OBJECTIVE: Panendoscopy is used in selected patients with head and neck cancer to detect second primary disease. We hy- pothesized that adding autofluorescence to the bronchoscopy and laryngoscopy part of this procedure could add to the detection of clinically meaningful dysplasias and carcinomas in both the head and neck and bronchus, with resultant change in management. STUDY DESIGN: Prospective observational study on consec- utive patients with head and neck cancer who had panendoscopy prior to surgery. SETTING: Teaching hospital, tertiary referral center. SUBJECTS AND METHODS: All patients had white-light in- spection observed by ENT surgeons, followed by autofluorescence inspection of the head and neck tumor and surrounding area as well as the bronchus. Extra biopsies were taken from regions of abnormal fluorescence where there was no white-light abnormality. RESULTS: Sixty-six patients were studied; mean age 64.9  11 years. As a result of autofluorescence, 33 mucosal biopsies were taken from the head and neck and 37 from the bronchus. Histology included three carcinoma in situ lesions and four severe dysplasias. As a result of these autofluorescence biopsies, change of manage- ment occurred in four patients (6% of the total patients). Standard panendoscopy changed management in five patients. Therefore, standard panendoscopy led to change in management in only 55 percent of cases (CI 21%-86%, P = 0.02), with the rest detected by autofluorescence. CONCLUSION: Adding autofluorescence to panendoscopy in patients with head and neck cancer changed management in a clinically significant number of patients. © 2010 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. P anendoscopy is done prior to definitive treatment in many cases of head and neck cancer. 1 The objectives are to find mucosal disease at other sites within the aerodi- gestive tract and better stage the known primary. 2,3 Patients with head and neck cancer are at risk of such lesions by way of field change disease. 4 Typical yields of standard panen- doscopy for extra sites are three percent. 1,2 Other modali- ties, such as computed tomography (CT) and positron emis- sion tomography (PET)-CT, are performed to look for regional nodal involvement and extra sites of disease else- where in the body. 5,6 At this time, PET has not replaced the need to visually inspect mucosal surfaces. Resolution of PET is 4 to 10 mm on commercially available systems, 7 which is less than the thickness of in situ second primary mucosal tumors. In a recent study by Haele et al, despite the utility of PET in detecting distant second primary disease, the authors concluded that panendoscopy was still required in ruling out second primary disease in early stage head and neck cancer. 8 Despite curative treatment with surgery or chemo-radia- tion, patients can ultimately develop second primary disease in up to 20 percent of cases, with the lung and other sites within the head and neck being the most common sites. 3 Most likely, such patients have, at the time of the original diagnosis, preneoplasia or carcinoma in situ that is not detectable by standard panendoscopy. Autofluorescence is a new form of inspection of mucosal surfaces that improves detection of preneoplasias. 9 Most studies of autofluores- cence have been done in the bronchus. The addition of autofluorescence to white-light bronchoscopy greatly in- creases the yield of in situ carcinomas and high grade dysplasias, even when the standard white-light inspection is done by an experienced technician. By detecting such le- sions early, they can be treated with minimally invasive methods, such as diathermy. 10 A few studies have demonstrated the feasibility of doing autofluorescence in the head and neck region as well. 11,12 Autofluorescence inspection of the oral cavity and larynx is done with a flexible bronchoscope. Alternatively, a rigid laryngoscope can be used. 13 It requires a specific light source and image processor, but no fluorescing drugs are needed. The autofluorescence changes look similar to bron- chial dysplasias and carcinomas. Autofluorescence detec- tion of oral-cavity carcinomas is due to a loss of subepithe- lial stromal fluorescence. 12 Reductions in fluorescence are displayed on a monitor in real time as blue or red, while Received April 29, 2009; revised October 4, 2009; accepted December 9, 2009. Otolaryngology–Head and Neck Surgery (2010) 142, S20-S26 0194-5998/$36.00 © 2010 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2009.12.021