Squamous cell carcinoma in situ at oropharyngeal and hypopharyngeal mucosal sites

Position statement of the World Endoscopy Organization: Role of endoscopy in screening, diagnosis, and treatment of esophageal superficial squamous neoplasiaia

Esophageal squamous cell carcinoma (ESCC) remains a significant global health challenge, being the sixth leading cause of cancer mortality with pronounced geographic variability. The incidence rates range from 125 per 100,000 in northern China to 1-1.5 per 100,000 in the United States, driven by environmental and lifestyle factors such as tobacco and alcohol use, dietary habits, and pollution. Major modifiable risk factors include tobacco and alcohol consumption, with a synergistic risk increase when combined. Nonmodifiable risk factors include previous diagnoses of head and neck squamous cell carcinoma (H&N SCC), achalasia, and prior radiotherapy. Prevention strategies must be tailored to specific regional burdens to efficiently allocate medical and financial resources. Gastrointestinal endoscopy is crucial in reducing ESCC burden through early detection and characterization of neoplastic changes, such as high-grade dysplasia. Early diagnosis significantly improves survival rates, while endoscopic resection of noninvasive dysplasia can prevent ESCC onset, reducing treatment burden for advanced disease. Postresection surveillance can detect high-risk metachronous lesions. Despite these benefits, endoscopic prevention faces challenges, including the lack of high-level evidence supporting its efficacy, opportunity costs, the need for specialized training and techniques, and the requirement for advanced technology investments. This Position Statement from the World Endoscopy Organization (WEO) aims to address these challenges, supplying recommendations for the exploitation of endoscopic resources regarding the possible role of screening, quality, and training for the detection, characterization, resection, and surveillance of ESCC.

Comparative analyses of short- and long-term outcomes between endoscopic submucosal dissection and endoscopic laryngo-pharyngeal surgery for superficial pharyngeal carcinomas

Objectives

Endoscopic treatment of superficial pharyngeal carcinomas includes endoscopic submucosal dissection (ESD; usually performed by endoscopists), and endoscopic laryngo-pharyngeal surgery (ELPS; primarily performed by otolaryngologists). Few studies have compared the efficacy of the two techniques in treating superficial pharyngeal carcinomas. In this study, we compared the outcomes of these two techniques to determine the advantages.

Methods

We retrospectively examined the short- and long-term outcomes of 93 consecutive patients with superficial pharyngeal carcinoma who either underwent an ESD or ELPS between August 2008 and December 2021.

Results

There were 35 lesions among 29 patients and 93 lesions among 71 patients in the ESD and ELPS groups, respectively. The ELPS group had a significantly shorter procedure time (121.2 ± 97.4 min vs. 54.7 ± 40.2 min, p<0.01), greater procedure speed (0.10 ± 0.06 min/min vs. 0.30 ± 0.23 min/min, p<0.01), and less laryngeal edema than that of the ESD group. There were no significant differences in the 3-year overall, relapse-free, or disease-specific survival rates between the two groups. Intervention with ESD during ELPS was most commonly required when it was difficult to secure the visual field.

Conclusions

There were no differences in batch resection rates or long-term prognoses between the two groups; nevertheless, the ELPS group had a shorter treatment time and less laryngeal edema than the ESD group. However, the treatment of narrow areas, such as the esophageal inlet patch, is a technical limitation of ELPS; thus, ELPS should be combined with ESD techniques.

Impact of HPV status on oropharyngeal cancer detection via gastrointestinal endoscopy: a retrospective study

BACKGROUND

Gastrointestinal endoscopy (GIE) performed by gastroenterologists is essential for the early detection of pharyngeal cancer. Human papillomavirus (HPV) is a significant cause of oropharyngeal squamous cell carcinoma (OPSCC). However, the prevalence of HPV-related OPSCC detected by GIE remains unclear.

AIM

This study aims to evaluate the differences in detection rates, patient characteristics, and treatment approaches between HPV-positive and HPV-negative OPSCCs, with a focus on the role of GIE in early diagnosis.

METHODS

We retrospectively analyzed 207 OPSCCs from 2018 to 2022, where HPV infection was diagnosed by p16 immunohistochemistry. We compared detection modalities and evaluated the proportion of lesions detected by GIE in both p16-positive and p16-negative cases.

RESULTS

Out of the 207 patients, 92 (44.4%) were p16-positive. p16-positive cases had significantly lower rates of alcohol use, smoking, and history of esophageal or head/neck squamous cell carcinoma (all p < 0.001). Only 4.3% of p16-positive cases were detected by GIE, compared to 44.3% of p16-negative cases (p < 0.001). In addition, p16-positive patients were often diagnosed at advanced stages and underwent transoral resection less frequently (2.2% vs. 31.3%, p < 0.001). In cT1 cases, GIE and laryngoscopy revealed that p16-positive lesions were typically protruding and white to normal-colored, while p16-negative lesions were predominantly flat and erythematous.

CONCLUSIONS

HPV-related OPSCC cases are rarely detected by GIE, and few cases are treated with minimally invasive transoral resection. These findings highlight the need for enhanced detection strategies for HPV-positive OPSCC.

Comparison of White Light With Narrow Band Imaging Using Flexible Laryngoscopy for the Detection of Local Recurrences After (Chemo)Radiation for Pharyngeal or Laryngeal Cancer: A Randomised Controlled Trial

OBJECTIVES

Early detection of local recurrences in patients with head and neck squamous cell carcinoma (HNSCC) is crucial for long-term survival. Aim of this study was to compare white light (WL) imaging with narrow band imaging (NBI) during flexible laryngoscopy for detection of local recurrences and evaluate the effects on clinical outcome in patients with HNSCC treated with radiotherapy ± chemotherapy ((C)RT).

DESIGN

Prospective randomised controlled trial.

SETTING

Tertiary head and neck oncologic center.

PARTICIPANTS

257 patients without residual disease after (C)RT were randomised in a WL group (n = 120) or WL-NBI group (n = 137) and followed for 24 months.

MAIN OUTCOME MEASURES

Local recurrence rate and overall survival, disease-specific survival, disease-free survival and local recurrence-free survival were compared between both groups.

RESULTS

Detection rate of local recurrences was the same in both groups: 11.7% in WL-NBI and 10.0% in WL (p > 0.05). Overall survival (WL: 88.3%, WL-NBI: 87.6%), disease-specific survival (WL: 86.7%, NBI: 83.9%), disease-free survival (WL: 85.0%, WL-NBI: 83.2%) and local recurrence-free survival (WL: 90.0%, WL-NBI: 89.1%) showed no superiority in the WL-NBI group (p > 0.05).

CONCLUSIONS

Local recurrence rates are relatively low in the first 24 months after (C)RT for HNSCC. WL-NBI did not improve the detection of local recurrences nor the survival compared to WL.

TRIAL REGISTRATION

This randomised clinical trial was registered at the research register UMCG with the number 201500918.

Narrow-Band Imaging in Head and Neck Carcinomas: A Systematic Review and Meta-Analysis

OBJECTIVE

The purpose of this study was to assess the diagnostic performance of narrow-band imaging (NBI) in monitoring patients with head and neck carcinomas posttreatment and to compare it with that of white light endoscopy (WLE).

DATA SOURCES

PubMed, Embase, Web of Science (WOS), Cochrane Library, China Biology Medicine disc (CBM disc), China National Knowledge Internet (CNKI), Wanfang Data, China Science and Technology Journal Database (CSTJ), Chinese Clinical Trial Register.

REVIEW METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), literature published before July 2024 was searched. Patients who underwent surgery, radiotherapy (RT), or chemo-RT for head and neck carcinomas with posttreatment follow-up using NBI were analyzed. The main outcomes were sensitivity, specificity, and diagnostic odds ratio (DOR) for NBI and WLE in posttreatment follow-up.

RESULTS

The sensitivity, specificity, and DOR for NBI and WLE in posttreatment follow-up for head and neck carcinomas were 95% (95% confidence interval [CI]: 88%-98%), 96% (95% CI: 92%-98%), 433 (95% CI: 120-1560) and 72% (95% CI: 49%-87%), 72% (95% CI: 4%-99%), 7 (95% CI: 0-191). Additionally, the area under the curve (AUC) values for NBI and WLE were 0.99 (95% CI: 0.97-0.99) and 0.75 (95% CI: 0.71-0.79), respectively. The number of lesions and patients, treatment modality, follow-up time, disease, and endoscopic system might be sources of heterogeneity.

CONCLUSION

Compared to WLE, NBI demonstrated superior diagnostic performance in follow-up patients with head and neck carcinoma posttreatment. NBI offers technical support and a clinical foundation for early detection of head and neck carcinoma recurrence.

LEVEL OF EVIDENCE

NA Laryngoscope, 135:34-44, 2025.

Narrow-band imaging to enhance intraneural dissection in head and neck schwannoma surgery: a quantitative evaluation

OBJECTIVE

The objective of this study was to assess the utility of narrow-band imaging (NBI) for improving intraneural dissection during gross total resection of head and neck schwannoma. Specifically, we aimed to quantitatively evaluate whether NBI can enhance the identification of pseudocapsule and true capsule within the tumor.

METHODS

Nine schwannoma surgery cases conducted between February 2018 and October 2022 were retrospectively analyzed. The surgical procedures followed established principles with a specific focus on utilizing NBI to distinguish between the pseudocapsule and true capsule. Intraneural dissection was performed by searching for a tumor surface with a fascicle-free window, followed by longitudinal incision of the pseudocapsule. NBI was used to distinguish between the pseudocapsule and true capsule. Surgical views were captured under both white light (WL) illumination and NBI for further analysis. The brightness and contrast of the pseudocapsule and true capsule were quantitatively measured using ImageJ and were compared.

RESULTS

Under NBI, the pseudocapsule consistently appeared greenish-gray, whereas the true capsule exhibited a white appearance. Quantitative analysis revealed a statistically significant difference (p < 0.0001) in brightness between the pseudocapsule (mean grayscale value 52.1, 95%CI; 46.4-75.3) and true tumor capsule (mean grayscale value 120.8, 95%CI; 155.7-109.0) under NBI. Conversely, there was no statistically significant difference in the brightness of these structures under WL (p = 0.2067). NBI also showed significantly higher contrast between the two structures than did WL (contrast 73.6, 95%CI; 53.1-89.5 vs. 30.9, 95%CI; 1.0-47.5, p = 0.0034). Further spectral analysis revealed that the most substantial difference in brightness between the pseudocapsule and the true tumor capsule was observed in the red spectrum, with a difference in brightness of -0.6 (95%CI; -16.8-14.8) under WL and 83.5 (95%CI; 50.3-100.0) under NBI (p < 0.0001).

CONCLUSION

NBI proved to be a valuable tool for enhancing the identification of pseudocapsule and true capsule during intraneural dissection in head and neck schwannoma surgery. The improved contrast and membrane visibility offered by NBI might have the potential to reduce postoperative neurological deficits and improve surgical outcomes. Further research is warranted to validate our findings and explore the broader applications of NBI in schwannoma surgery.

Imaging Modalities for Head and Neck Cancer: Present and Future

Several imaging modalities are utilized in the diagnosis, treatment, and surveillance of head and neck cancer. First-line imaging remains computed tomography (CT); however, MRI, PET with CT (PET/CT), and ultrasound are often used. In the last decade, several new imaging modalities have been developed that have the potential to improve early detection, modify treatment, decrease treatment morbidity, and augment surveillance. Among these, molecular imaging, lymph node mapping, and adjustments to endoscopic techniques are promising. The present review focuses on existing imaging, novel techniques, and the recent changes to imaging practices within the field.

NBI Classification Optimization With Morphological Characteristics in Vocal Fold Leukoplakia

Objectives: To investigate the pathological contribution of vocal fold leukoplakia (VFL) of type II in narrow-band imaging (NBI) classification and morphological characteristics to improve pathological prediction. Material and Methods: The 59 VFL patients with type II in 2019 Ni classification in NBI were included. The pathological reports were collected and divided following 2005 WHO Blue Book. Low-risk VFL contained non-, mild, moderate dysplasia, high-risk VFL included severe dysplasia. The morphological classification and laryngoscopic scoring system were employed to evaluate leukoplakia for pathological prediction. Results: The pathologies contained 1 case of leukoplakia with non-dysplasia, 12 of mild dysplasia, 15 of moderate dysplasia, 8 of severe dysplasia, and 23 of carcinoma. The 30 smooth VFL contained 1 non-dysplasia, 12 mild dysplasia, 14 moderate dysplasia, 2 severe dysplasia, and 1 carcinoma. The 29 rough cases included 1 moderate dysplasia, 6 severe dysplasia, and 22 carcinomas. Laryngoscopic scoring system revealed irregular texture, large size, and thick lesion as factors in relationship with high-risk leukoplakia in univariate (P = .002, <.001, <.001) and multivariate (P = .025, .002, .016) analysis, irregular texture was the most accurate predictor of high-risk VFL pathology. Conclusions and Significance: The pathologies of VFL with type II in NBI classification were hard to be predicted. Morphological irregular/rough texture contributed to predict high-risk pathology in leukoplakia.

Significance of P53-Binding Protein 1 as a Novel Molecular Histological Marker for Hypopharyngeal Squamous Neoplasms

The DNA damage response protein p53-binding protein 1 (53BP1) accumulates and forms foci at double-strand DNA breaks, indicating the extent of DNA instability. However, the potential role of 53BP1 as a molecular biomarker for hypopharyngeal squamous cell carcinoma (HPSCC) diagnosis remains unknown. Here, we evaluated the potential of immunofluorescence-based analysis of 53BP1 expression to differentiate the histology of hypopharyngeal neoplasms. A total of 125 lesions from 39 surgically or endoscopically resected specimens from patients with HPSCC was histologically evaluated. 53BP1 expression in the nucleus was examined using immunofluorescence. The number of 53BP1 nuclear foci increased with the progression from non-tumorous to low-grade dysplasia, high-grade dysplasia, and squamous cell carcinoma. Unstable 53BP1 expression served as an independent factor for distinguishing lesions that required intervention. Colocalization of 53BP1 foci in proliferating cells, as assessed by Ki67, was increased in tumors ≥ 1000 µm in depth compared to those <1000 µm in depth at the tumor surface. Hence, the expression patterns of nuclear 53BP1 foci were associated with the progression of hypopharyngeal neoplasms. These findings suggest that 53BP1 could serve as an ancillary marker to support histological diagnosis and predict the factors that influence prognosis in patients with HPSCC.

Safety and outcome of three-dimensional transoral videolaryngoscopic surgery

BACKGROUND

Transoral videolaryngoscopic surgery (TOVS) is widely used in Japan, and conventional two-dimensional (2D) endoscopic methods have been established. Three-dimensional (3D) endoscopic surgery offers superior distance perception because it provides stereoscopic views. Recently, we have developed 3D endoscopy for TOVS (3D TOVS).

METHODS

This study included 46 patients with pharyngeal cancer who underwent 3D TOVS. The perioperative complications and survival curves were retrospectively analyzed.

RESULTS

One patient with oropharyngeal cancer who underwent neck dissection and transoral resection simultaneously experienced postoperative hemorrhage of the neck. Another patient with oropharyngeal cancer underwent hemostasis for postoperative pharyngeal hemorrhage. There was one case of aspiration pneumonia. One patient developed cervical lymph node recurrence; however, there was no local recurrence or primary mortality. The 2-year overall survival, disease-specific survival, local control rates, locoregional control rate, and invasive disease-free survival were 90.9%, 100%, 100%, 97.4%, and 79.9%, respectively.

CONCLUSIONS

Three-dimensional endoscopy can be safely applied to TOVS.

Accuracy of Narrow-Band Imaging-Guided Histopathology and Ki-67 Index in Head and Neck Carcinoma

As per Globocan 2012, every year the incidence of head and neck cancer is 683235/1000000 with a mortality of around 375665/1000000 thus being the sixth cause of cancer death throughout the world. Head and neck cancer includes cancer of the nasopharynx, oropharynx, hypopharynx, larynx, and oral cavity. Early diagnosis of head and neck cancer is very challenging, hence detecting mucosal lesions at an early stage decreases mortality thereby improving overall survival, disease-free survival, and quality of life. Out of different diagnostic modalities, narrow-band imaging (NBI) combined with endoscopic techniques can provide a promising diagnostic tool in detecting early lesions of head and neck cancer. Numerous studies have shown that Ki-67 is a good prognostic marker in oral cancers. Our study aims to evaluate the diagnostic accuracy of NBI and combine the Ki-67 index to diagnose head and neck cancer.

Materials and Methods

All patients were first examined under white light and then under NBI endoscopy, and a biopsy was obtained from suspected lesions and sent for histopathological examination (HPE) and Ki-67 index.

Results

Eighty patients were examined out of which, 68 patients having lesions in the oral cavity, oropharynx, larynx, and hypopharynx were examined. The rate of detecting cancerous lesion by white light and NBI were respectively 92% and 100% for oral cavity lesions, 69% and 100% for oropharyngeal lesions, 38% and 100% for hypopharyngeal lesions, and 37% and 100% for laryngeal carcinoma. However, we have found no significant difference in detecting T2-T4 tumors. Hence, we concluded that NBI mode can be a significantly better diagnostic tool than white light mode in detecting early mucosal cancer in head and neck cancer.

Conclusion

We have concluded that NBI combined with Ki-67 estimation is a very promising tool that helps in the early diagnosis of mucosal lesions in head and and neck cancer.

Efficacy of endoscopic surveillance for pharyngeal mucosa during endoscopic resection for pharyngeal carcinoma: a multicenter prospective study

INTRODUCTION

Since patients with pharyngeal squamous cell carcinoma (SCC) often have multiple pharyngeal lesions, evaluation of pharyngeal lesions before endoscopic resection (ER) is important. However, detailed endoscopic observation of the entire pharyngeal mucosa under conscious sedation is difficult. We examined the usefulness of endoscopic surveillance with narrow band imaging (NBI) and lugol staining for detection of pharyngeal sublesions during ER for pharyngeal SCC under general anesthesia (endoscopic surveillance during treatment; ESDT).

METHODS

From January 2021 through June 2022, we examined 78 patients who were diagnosed with superficial pharyngeal SCC and underwent ER. They underwent the ESDT and for patients who were diagnosed with new lesions of pharyngeal SCC or high-grade dysplasia (HGD) that were not detected in the endoscopic examination before treatment, ER were performed simultaneously for new lesions and the main lesions. The primary endpoint of this study was the detection rate of new lesions of pharyngeal SCC or HGD in the ESDT.

RESULTS

Fifteen of the 78 patients were diagnosed as having undetected new pharyngeal lesions in the ESDT and 10 (12.8%) (95% CI 6.9-22.2%) were histopathologically confirmed to have new lesions of pharyngeal SCC or HGD. Among the 13 lesions of SCC or HGD, 8 were found by NBI observation; however, 5 were undetectable using NBI but detectable by lugol staining. All of the 13 lesions had endoscopic findings of pink color sign on lugol staining.

CONCLUSIONS

Endoscopic surveillance for pharyngeal sublesions during ER for pharyngeal SCC is feasible and useful.

Efficacy and safety of the water pressure method for endoscopic submucosal dissection in superficial pharyngeal cancer

Background and study aims Superficial pharyngeal cancers can be cured with transoral surgery (TOS), which preserves organ function and quality of life. Pharyngeal endoscopic submucosal dissection (ESD) is challenging to perform because of limited maneuverability and complex anatomical features. The water pressure method (WPM) is useful for natural traction techniques during ESD and is potentially useful for pharyngeal ESD. This study aimed to investigate the short-term outcomes of WPM-ESD for pharyngeal lesions. Patients and methods Therapeutic outcomes of patients who underwent WPM-ESD for pharyngeal lesions at Keio University between May 2019 and February 2022 were retrospectively analyzed. Results Twenty-one pharyngeal lesions treated with WPM-ESD were analyzed. Three lesions were located in the oropharynx and 18 in the hypopharynx. All ESD procedures were performed under general anesthesia. The endoscopic en bloc resection rate was 100%. The median procedure time was 15 minutes (range 4-45 minutes). All patients were successfully extubated on the day of ESD. No serious adverse events (AEs) related to WPM-ESDs were observed. None of the patients required nasogastric intubation, percutaneous endoscopic gastrostomy, or tracheotomy. The median fasting time and hospital stay were 2 days (range 2-5 days) and 6 days (range 6-10 days), respectively. All the histological results indicated squamous cell carcinoma. The complete histologic resection rate was 76.2%. Conclusions WPM-ESD achieved a high en bloc resection rate and short procedure time without serious AEs. Thus, it may be a useful treatment for pharyngeal lesions.

Artificial intelligence-based diagnosis of the depth of laryngopharyngeal cancer

OBJECTIVE

Transoral surgery (TOS) is a widely used treatment for laryngopharyngeal cancer. There are some difficult cases of setting the extent of resection in TOS, particularly in setting the vertical margins. However, positive vertical margins require additional treatment. Further, excessive resection should be avoided as it increases the risk of bleeding as a postoperative complication and may lead to decreased quality of life, such as dysphagia. Considering these issues, determining the extent of resection in TOS is an important consideration. In this study, we investigated the possibility of accurately diagnosing the depth of laryngopharyngeal cancer using radiomics, an image analysis method based on artificial intelligence (AI).

METHODS

We included esophagogastroduodenoscopic images of 95 lesions that were pathologically diagnosed as squamous cell carcinoma (SCC) and treated with transoral surgery at our institution between August 2009 and April 2020. Of the 95 lesions, 54 were SCC in situ, and 41 were SCC. Radiomics analysis was performed on 95 upper gastrointestinal endoscopic NBI images of these lesions to evaluate their diagnostic performance for the presence of subepithelial invasion. The lesions in the endoscopic images were manually delineated, and the accuracy, sensitivity, specificity, and area under the curve (AUC) were evaluated from the features obtained using least absolute shrinkage and selection operator analysis. In addition, the results were compared with the depth predictions made by skilled endoscopists.

RESULTS

In the Radiomics study, the average cross-validation was 0.833. The mean AUC for cross-validation calculated from the receiver operating characteristic curve was 0.868. These results were equivalent to those of the diagnosis made by a skilled endoscopist.

CONCLUSION

The diagnosis of laryngopharyngeal cancer depth using radiomics analysis has potential clinical applications. We plan to use it in actual surgery in the future and prospectively study whether it can be used for diagnosis.

Swallowing Function and Quality of Life in Patients Treated With Transoral Videolaryngoscopic Surgery for Pharyngolaryngeal Cancer

BACKGROUND

It is controversial whether transoral resection for early pharyngolaryngeal cancer preserves swallowing function and quality of life. We investigated swallowing function and quality of life before and after transoral videolaryngoscopic surgery (TOVS).

METHODS

Seventy-three patients with pharyngolaryngeal cancer who underwent TOVS between July 2012 and July 2022 were enrolled in this prospective analysis. The Hyodo score and European Organization for Research and Treatment of Cancer Quality of Life Questionnaires were recorded preoperatively and at three, six, and 12 months postoperatively, in addition to the postoperative functional outcome swallowing scale (FOSS) at six months postoperatively.

RESULTS

Although most patients could consume food orally without restrictions with a preferable FOSS score, 23 patients showed impaired Hyodo scores. Age ≥65 years significantly predicted impaired swallowing. Sub-scores of the impaired patient group showed worsening for the glottal closure reflex when the endoscope touched the epiglottis or arytenoid, as well as a reduction in the extent of pharyngeal clearance following the ingestion of blue-dyed water.

CONCLUSION

After TOVS, swallowing function is generally well preserved. Elderly patients, especially those with laryngeal hypoesthesia and poor clearance, are at risk of swallowing dysfunction.

Diagnostic Performance of a Novel Ultra-Thin Endoscopy under Narrow-Band Imaging for Superficial Squamous Cell Carcinoma of the Pharynx and Esophagus

This study aimed to evaluate the diagnostic utility of the ultra-thin endoscope (UTE) for superficial squamous cell carcinoma (SSCC) compared to magnifying endoscopy (ME) under narrow-band imaging. Participants underwent endoscopic examination, and images of pharyngeal and esophageal SCCs, as along with suspicious SSCC lesions, were collected using UTE and ME on the same day. Three image catalogs (UTE, ME-1, and ME-2) were created and reviewed by three expert endoscopists. ME-1 and ME-2 contained the same endoscopic images. The primary endpoint was the intra-observer agreement for diagnosing SCC. Eighty-six lesions (SCC = thirty-nine, non-SCC = forty-seven) in 43 participants were identified. The kappa values for the intra-observer agreement between UTE and ME-1 vs. the control (ME-1 vs. ME-2) were 0.74 vs. 0.84, 0.63 vs. 0.76, and 0.79 vs. 0.88, respectively. The accuracies for diagnosing SCC by UTE and ME-1 were 87.2% vs. 86.0%, 78.0% vs. 73,2%, and 75.6 vs. 82.6%, respectively, with no significant differences (p > 0.05). The rates of lesions that were diagnosed with confidence by UTE and ME-1 were 30.2% vs. 27.9%, 55.8% vs. 62.8%, and 58.1% vs. 55.8%, respectively. UTE demonstrates substantial diagnostic performance for SSCC in the pharynx and esophagus.

Local recurrence and metachronous multiple cancers after transoral nonrobotic surgery for pharyngeal and laryngeal squamous cell carcinoma: A retrospective multicenter study

BACKGROUND

Late laryngopharyngeal cancers after transoral surgery include not only local recurrences but also metachronous multiple cancers.

METHODS

We compared clinical information, surgical outcomes, and late laryngopharyngeal cancers in patients who underwent transoral nonrobotic surgery for laryngopharyngeal squamous cell carcinoma without lymph node metastases between 2015 and 2021 in a multicenter retrospective study.

RESULTS

Four hundred and fifty-seven patients were included. Positive surgical margins were found in 121 patients (26.5%). Twenty-two patients (4.8%) received additional treatment. Positive horizontal margins of invasive carcinoma (p = 0.003) and positive horizontal margins of carcinoma in situ only (p = 0.032) were independent risk factors for local recurrence, and prior radiotherapy (p = 0.001) for metachronous multiple cancers. Local control was significantly worse without additional treatment (p = 0.049), but there was no significant difference in survival.

CONCLUSIONS

Patients with positive margins had an increased frequency of local recurrence, but salvage therapy was effective.

A comparison of the efficacy of narrow band imaging and contact endoscopy in an early diagnosis of squamous malignancies of the upper aerodigestive tract

Background

This study aims to compare the efficacy of narrow band imaging (NBI) endoscopy and contact endoscopy in early diagnosis of squamous malignancies of upper aerodigestive tract.

Methods

This study was of 18 months duration, sample size 50, and carried out at tertiary care hospital. The patients were subjected initially to NBI endoscopy followed by contact endoscopy. Thereafter, the lesion was biopsied and subjected to histopathological examination as is done routinely. The images obtained were analyzed based on criteria proposed by earlier studies and compared with histopathological examination as gold standard.

Results

The sensitivity, specificity, and negative predictive values of NBI in early diagnosis of squamous malignancies of upper aerodigestive tract were high and better than contact endoscopy.

Conclusion

Endoscopic NBI is a noninvasive and promising tool used for in vivo differentiation between malignant and nonmalignant lesions of upper aerodigestive tract by using morphology of mucosal capillaries and is more efficacious than contact endoscopy. It can be employed as part of routine ENT examination in outpatient departments; however, it has got a learning curve associated with it.

Publication Trends of Research on Head and Neck Squamous Cell Carcinoma During 2002 to 2022: A 20-Year Bibliometric Study

BACKGROUND

Head and neck squamous cell carcinoma (HNSCC) is the sixth most common cancer worldwide. Our study attempted to analyze the research trends in HNSCC and compare contributions from different countries, institutions, journals, and authors.

MATERIALS AND METHODS

The authors extracted publications in this field from 2002 to 2022 from the Web of Science database. Microsoft Excel and VOSviewer were performed to collect data on publication numbers, analyze publication trends, and visualize relevant results.

RESULTS

A total of 1903 publications were screened. In the past 20 years, the United States contributed the most publications and citations in the HNSCC research. China ranked second in the number of publications. The Ophthalmic Plastic and Reconstructive Surgery was the most productive journal concerning HNSCC. ESMAELIB of the University of Texas System and ROSENTHAL EL of Stanford University had published the most publications in this field. Keywords were categorized into 3 clusters: basic study, clinical feature study, and treatment-related study. The keywords "reflectance confocal microscopy", "raman-spectroscopy", and "confocal laser endomicroscopy" were most frequently emerged in the recent years. Management-related research has been recognized as a potential focus in the HNSCC.

Necessity of pharyngeal anesthesia during transoral gastrointestinal endoscopy: a randomized clinical trial

BACKGROUND/AIMS

The necessity for pharyngeal anesthesia during upper gastrointestinal endoscopy is controversial. This study aimed to compare the observation ability with and without pharyngeal anesthesia under midazolam sedation.

METHODS

This prospective, single-blinded, randomized study included 500 patients who underwent transoral upper gastrointestinal endoscopy under intravenous midazolam sedation. Patients were randomly allocated to pharyngeal anesthesia: PA+ or PA- groups (250 patients/group). The endoscopists obtained 10 images of the oropharynx and hypopharynx. The primary outcome was the non-inferiority of the PA- group in terms of the pharyngeal observation success rate.

RESULTS

The pharyngeal observation success rates in the pharyngeal anesthesia with and without (PA+ and PA-) groups were 84.0% and 72.0%, respectively. The PA- group was inferior (p=0.707, non-inferiority) to the PA+ group in terms of observable parts (8.33 vs. 8.86, p=0.006), time (67.2 vs. 58.2 seconds, p=0.001), and pain (1.21±2.37 vs. 0.68±1.78, p=0.004, 0-10 point visual analog scale). Suitable quality images of the posterior wall of the oropharynx, vocal fold, and pyriform sinus were inferior in the PA- group. Subgroup analysis showed a higher sedation level (Ramsay score ≥5) with almost no differences in the pharyngeal observation success rate between the groups.

CONCLUSION

Non-pharyngeal anesthesia showed no non-inferiority in pharyngeal observation ability. Pharyngeal anesthesia may improve pharyngeal observation ability in the hypopharynx and reduce pain. However, deeper anesthesia may reduce this difference.

Rare case of endometrial vascular dystrophy: Three case reports

RATIONALE

Endometrial vascular dystrophy refers to abnormal vessels that are very tortuous, dilated, and sometimes thrombosed. Endometrial vascular dystrophy is rare under hysteroscopy.

PATIENT

All three patients had a history of abnormal uterine bleeding. The duration of vaginal bleeding ranged from 1 month to 2 years. There was no history of unusual diseases, alcohol or drug abuse, or genetic history.

DIAGNOSES

Endometrial vascular dystrophy.

INTERVENTION

Three patients underwent hysteroscopy and curettage under intravenous general anesthesia. Pathological examination showed secretory endometrium, with one case coexisting with endometrial polyps.

OUTCOMES

No recurrence was found during postoperative follow-up at 12 months.

LESSONS

Endometrial vascular dystrophy is a rare hysteroscopy phenomenon shown in the secretory endometrium. We believe that it was a capillary loop with different manifestations.

Clinical outcome of endoscopic-assisted transoral surgery for superficial cancer of pharyngo-esophageal junction

BACKGROUND

Endoscopic-assisted transoral surgery (TOS) for superficial cancer of the pharyngo-esophageal junction (PEJ) is risk of stricture, and therapeutic outcomes are unclear. This study aimed to evaluate clinical outcomes of endoscopic-assisted TOS for superficial PEJ cancers.

METHODS

We retrospectively compared clinical outcomes of endoscopic-assisted TOS for superficial PEJ cancers (group A) and of other sites in the hypopharynx (group B).

RESULTS

The group A comprised 12 lesions in 12 patients, and group B comprised 198 lesions in 146 patients. Group A and group B exhibited en bloc resection rates of 100% and 99%. Median operative times were 82 and 37 min (p < 0.001). The frequency of stricture and local recurrence in group A was significantly higher in group B (42% vs. 1%, p < 0.001; 25% vs. 6%, p = 0.036). All adverse events could be managed with conservative treatments.

CONCLUSIONS

Endoscopic-assisted TOS is not ideal for treating superficial PEJ cancers compared to other sites.

Artificial Intelligence in Head and Neck Cancer: A Systematic Review of Systematic Reviews

INTRODUCTION

Several studies have emphasized the potential of artificial intelligence (AI) and its subfields, such as machine learning (ML), as emerging and feasible approaches to optimize patient care in oncology. As a result, clinicians and decision-makers are faced with a plethora of reviews regarding the state of the art of applications of AI for head and neck cancer (HNC) management. This article provides an analysis of systematic reviews on the current status, and of the limitations of the application of AI/ML as adjunctive decision-making tools in HNC management.

METHODS

Electronic databases (PubMed, Medline via Ovid, Scopus, and Web of Science) were searched from inception until November 30, 2022. The study selection, searching and screening processes, inclusion, and exclusion criteria followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. A risk of bias assessment was conducted using a tailored and modified version of the Assessment of Systematic Review (AMSTAR-2) tool and quality assessment using the Risk of Bias in Systematic Reviews (ROBIS) guidelines.

RESULTS

Of the 137 search hits retrieved, 17 fulfilled the inclusion criteria. This analysis of systematic reviews revealed that the application of AI/ML as a decision aid in HNC management can be thematized as follows: (1) detection of precancerous and cancerous lesions within histopathologic slides; (2) prediction of the histopathologic nature of a given lesion from various sources of medical imaging; (3) prognostication; (4) extraction of pathological findings from imaging; and (5) different applications in radiation oncology. In addition, the challenges in implementation of AI/ML models for clinical evaluations include the lack of standardized methodological guidelines for the collection of clinical images, development of these models, reporting of their performance, external validation procedures, and regulatory frameworks.

CONCLUSION

At present, there is a paucity of evidence to suggest the adoption of these models in clinical practice due to the aforementioned limitations. Therefore, this manuscript highlights the need for development of standardized guidelines to facilitate the adoption and implementation of these models in the daily clinical practice. In addition, adequately powered, prospective, randomized controlled trials are urgently needed to further assess the potential of AI/ML models in real-world clinical settings for the management of HNC.

Salvage transoral videolaryngoscopic surgery for post-irradiation recurrence of hypopharyngeal carcinoma

Background

Transoral salvage surgery has the potential to preserve a patient's quality of life. Therefore, we investigated the outcomes, safety, and risk factors for postoperative complications of salvage transoral videolaryngoscopic surgery (TOVS) for recurrent hypopharyngeal carcinoma after radiotherapy (RT) or chemoradiotherapy (CRT).

Methods

This retrospective analysis enrolled patients with hypopharyngeal cancer who had a history of RT or CRT and underwent TOVS from January 2008 to June 2021. The factors related to postoperative complications, postoperative swallowing functions and survival rates were analyzed.

Results

Seven patients (36.8%) of the 19 patients developed complications. Severe dysphagia was the primary complication, and post-cricoid resection was a complication risk factor. The FOSS score was significantly lower in the salvage treatment group. The survival rates were: 3-year overall survival: 94.4%; disease-specific survival: 94.4%; 5-year overall survival: 62.3%; and disease-specific survival: 86.6%.

Conclusions

Salvage TOVS for hypopharyngeal cancer was feasible, and oncologically and functionally reasonable. Level of Evidence: 2b.

Narrow Band Imaging Technology: Role in the Detection of Recurrent Laryngeal and Hypopharyngeal Cancers Post-radiotherapy

To assess the diagnostic accuracy of NBI endoscopy for the diagnosis of early recurrent laryngeal and hypopharyngeal cancers after radiotherapy. The study was conducted over a period of two and a half years from June 2019 to February 2022 and included 123 post-RT patients with laryngeal and hypopharyngeal cancers. The patients were planned for endoscopy with white light and narrow-band imaging. The biopsy was carried out in NBI suspected lesions and sent for histopathological examination. The pathologist was blinded to the outcome of NBI and WLE results to eliminate observer bias. The age group most commonly affected in our study was 40-50 years. Out of the 123 patients, 106 were males and 17 were females. The overall Sensitivity, Specificity, Positive predictive value and Negative predictive value of NBI for malignant lesions were 90.6%, 99%, 95.2% and 98% respectively. NBI Technology is a first-rate diagnostic tool that can help in diagnosing early recurrent cancer lesions, especially after RT, in which the recurrence is otherwise difficult to differentiate from post-radiotherapy oedema. This technology can significantly reduce the rates of failure to detect cancers in early stages.

Impact of endoscopic surveillance on mortality of metachronous esophageal and head and neck cancer after esophageal endoscopic resection

BACKGROUND AND AIM

As more superficial esophageal cancer (EC) patients are being treated with endoscopic resection (ER), it is important to understand the outcomes, including survival data, of patients who develop metachronous EC and head and neck cancer (HNC). We aimed to evaluate the long-term surveillance and survival outcomes of metachronous EC and HNC after esophageal ER.

METHODS

This study included 627 patients who underwent ER of superficial esophageal squamous cell carcinoma from 2008 to 2016 and were generally followed by annual or biannual esophagogastroduodenoscopy up to 2019 at Osaka International Cancer Institute. Data on metachronous cancer development and causes of death were collected from an integrated database of hospital-based cancer registry and Vital Statistics of Japan.

RESULTS

During a median (range) follow-up period of 67.4 (3.8-142.7) months, 230 patients (36.7%) developed 500 metachronous ECs and 126 patients (20.1%) developed 239 metachronous HNCs, post-ER of index EC. The 3-year, 5-year, and 7-year cumulative incidences were 25.8%, 36.0%, and 43.6% for metachronous EC and 10.9%, 16.0%, and 26.9% for metachronous HNC, respectively. No patients died of metachronous EC, and only seven patients (1.1%) died of metachronous HNC. The 3-year, 5-year, and 7-year disease-specific survival rates were 99.8%, 99.6%, and 98.6%, respectively.

CONCLUSIONS

The incidences of metachronous EC and HNC increase with time over 5 years after esophageal ER; therefore, surveillance endoscopy should be continued over 5 years. Endoscopic surveillance is useful for survivors after esophageal ER given the high incidence and extremely low mortality of metachronous EC and HNC.

A Prospective Study to Evaluate the Role of Narrow Band Imaging and Toludine Blue in the Screening of Premalignant and Malignant Lesions of the Oral Cavity in a Tertiary Referral Centre

In India cancer patients come at a very advanced stage with many of them being crossed the stage of resection. A wide range of non invasive techniques like toludine blue staining, methylene blue staining, Narrow band imaging have been developed for the early detection of malignant and premalignant lesions in the mucosa including oral cavity and gastrointestinal tract. However it is difficult for the clinicians to decide which diagnostic tool is most appropriate and useful for screening, resulting in failure to pick up the lesions at an early stage. Various online journals have been reviewed and no journal was found to support this point. This study here by describes Toludine blue and narrow-band imaging (NBI), diagnostic tools already proven independently as a useful screening method in many fields, and demonstrate its usefulness in the early detection of premalignant and malignant lesions of the oral cavity, as reported by previous studies in the otolaryngologic literature and compare both screening tools which has not been done till now. This study was done in a tertiary referral centre in middle India from March 2018 to August 2019 in order to evaluate the role of different screening tools (NBI and Toludine blue).44 patients with suspicious oral cavity lesions (premalignant and malignant) who had given consent for both NBI and toludine blue screening techniques were selected from the suspected (premalignant and malignant lesions) who had visited the OPD during the study period. Patients with proven malignancy were excluded from the study. A detailed history of the patient taken and standard Ear, nose, throat, oral cavity and neck examination of patient carried out. After subjecting the patients to screening tools like NBI and toludine blue, the efficacy of these techniques in helping us to take a representative biopsy was evaluated. In present study the sensitivity (to correctly identify all patients with disease), specificity (to correctly reject healthy patients without disease) of older technique toludine blue in detecting premalignant lesion was 66.6%, 87.8% while for NBI was 66.6%, 95%. For malignant lesion sensitivity and specificity of toludine blue was 94.3%, 100%, while the same for NBI was 100%, 88.8% respectively. Both NBI and toludine blue staining can be adopted for screening and the accurate detection of biopsy site and in the follow up of premalignant lesions to look for malignant transformation. Time tested is Toludine blue which is cheap and easily available. But being a better tool and having an upper hand in evaluating the lesions, NBI should be made available in all the secondary and tertiary care centres as a screening method.

Outcomes of Endoscopic Submucosal Dissection for Treatment of Superficial Pharyngeal Cancers: Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Studies evaluating the role of endoscopic submucosal dissection (ESD) in the management of superficial pharyngeal cancers have reported promising results. This meta-analysis evaluates the efficacy and safety of ESD in the management of superficial pharyngeal cancers.

METHODS

We reviewed several databases from inception to September 03, 2020, to identify studies evaluating the efficacy and safety of ESD in the management of superficial pharyngeal cancers. Our outcomes of interest were en bloc resection rate, complete resection rate, adverse events, and rates of local recurrence. Pooled rates with 95% confidence intervals (CI) for all outcomes were calculated using random-effect model. Heterogeneity was assessed by I² statistic. We assessed publication bias by using funnel plots and Egger's test. We conducted meta-regression analysis to explore heterogeneity in analyses.

RESULTS

Ten studies were included in analyses. All studies were from Asia. Pooled rates (95% CI) for en bloc resection and complete resection were 94% (87%, 97%) and 72% (62%, 80%), respectively. The pooled rates (95% CI) for adverse events and local recurrence were 10% (5%, 17%) and 1.9% (0.9%, 4%), respectively. Most of the analyses were limited by substantial heterogeneity. On meta-regression analysis, the heterogeneity was explained by size of tumor and histology. Funnel plots and Egger's test showed no evidence of publication bias.

CONCLUSIONS

This meta-analysis including studies from Asian countries demonstrated that ESD is an efficacious and safe option in the management of superficial pharyngeal cancers. More studies and studies from Western countries are needed to further validate these findings.

Intraoperative In Vivo Imaging Modalities in Head and Neck Cancer Surgical Margin Delineation: A Systematic Review

Surgical margin status is one of the strongest prognosticators in predicting patient outcomes in head and neck cancer, yet head and neck surgeons continue to face challenges in the accurate detection of these margins with the current standard of care. Novel intraoperative imaging modalities have demonstrated great promise for potentially increasing the accuracy and efficiency in surgical margin delineation. In this current study, we collated and analyzed various intraoperative imaging modalities utilized in head and neck cancer to evaluate their use in discriminating malignant from healthy tissues. The authors conducted a systematic database search through PubMed/Medline, Web of Science, and EBSCOhost (CINAHL). Study screening and data extraction were performed and verified by the authors, and more studies were added through handsearching. Here, intraoperative imaging modalities are described, including optical coherence tomography, narrow band imaging, autofluorescence, and fluorescent-tagged probe techniques. Available sensitivities and specificities in delineating cancerous from healthy tissues ranged from 83.0% to 100.0% and 79.2% to 100.0%, respectively, across the different imaging modalities. Many of these initial studies are in small sample sizes, with methodological differences that preclude more extensive quantitative comparison. Thus, there is impetus for future larger studies examining and comparing the efficacy of these intraoperative imaging technologies.

A comparative study of demarcation line diagnostic performance between non-magnifying observation with white light and non-magnifying observation with narrow-band light for early gastric cancer

BACKGROUND AND AIMS

With the improvement in endoscopic equipment functions, narrow-band imaging (NBI) for endoscopic observation of the stomach, which is an organ with a large lumen, is now feasible. Studies evaluating the NBI utility without magnifying endoscopy to diagnose the invasion extent for the demarcation line identification in early gastric cancer have not been reported. This study aimed to investigate the demarcation line diagnostic performance of NBI in early gastric cancer compared to that of white-light imaging (WLI) using prospectively collected consecutive specimens from early gastric cancer patients.

METHODS

Thirty consecutive lesions were collected from patients who underwent endoscopic submucosal dissection for early gastric cancer. Next, 30 NBI and 30 WLI images, each with the same degree of gastric wall extension, angle, and layout for one lesion, were selected, and a total of 60 images were prepared for testing. The early gastric cancer invasion ranges in the endoscopic images was plotted using the web-developed software, and 264 independent endoscopists, unaware of the diagnosis, performed the web tests, with the concordance rates between the ranges of responses. After estimating the actual early gastric cancer invasion ranges, the NBI and WLI results were compared.

RESULTS

The concordance rates for NBI and WLI images were 43.1% (95% confidence interval [CI] 42.5-43.7%) and 37.2% (95% CI 36.6-37.7%), respectively, showing that the concordance rate for NBI was significantly higher than that for WLI.

CONCLUSION

This study suggested that NBI was more useful for identifying demarcation lines than WLI.

Effects of steroid use for stenosis prevention after endoscopic submucosal dissection for cervical esophageal cancer

BACKGROUND AND AIM

Esophageal stenosis is a serious complication after endoscopic submucosal dissection (ESD) for thoracic esophageal cancer (TEC), and steroid has been applied for stenosis prevention. However, the rate of stenosis and effect of steroid for ESD of cervical esophageal cancer (CEC) remain unknown. The aim was to clarify the rate and managements of post-ESD stenosis for CEC.

METHODS

A total of 325 lesions with 272 patients who underwent ESD for esophageal cancers were enrolled and were divided to the CEC group (43 lesions) or the TEC group (282 lesions). Patient characteristics, clinicopathological features, procedure-related outcomes of esophageal ESD, stenosis rate and clinical outcome of steroid use cases were evaluated.

RESULTS

More patients in the CEC group received preventive steroid treatment compared to the TEC group (37.2% vs 14.5%, P = 0.001). The rate of post-ESD stenosis tended to be higher in the CEC group (11.6%) than in the TEC group (6.7%). For cases of 3/4 ≤ of circumference, local injection with oral steroid had lower stenosis rate than local injection only in both groups (CEC 40% vs 100%, TEC 30.7% vs 56.3%). More sessions and longer duration of dilation were needed to release the stenosis in the CEC group (20 times vs. 5 times, P = 0.015; 196 days vs. 55 days, P = 0.043).

CONCLUSION

The post-ESD stenosis rate of CEC tended to be higher than that of TEC. More intensive preventive measures for post-ESD stenosis may be needed for CEC than TEC.

[The application of NBI endoscopy in finding concealed primary lesions of misdiagnosis of oropharyngeal cancer]

Objective:The aim of this study is to analyze the application value of NBI endoscopy in finding the concealed primary lesions of misdiagnosis of oropharyngeal cancer. Methods:The clinical data of patients with missed oropharyngeal cancer treated in the Department of Otolaryngology Head and neck surgery, the Second Affiliated Hospital of Xi'an Jiaotong University from May 2018 to June 2021, were retrospectively studied, and the missed diagnosis was also analyzed combined with results of NBI endoscopy. Results:In 31 cases of misdiagnosis of oropharyngeal cancer patients, including 25 males and 6 females, there was no significant difference in age, BMI index, course of disease and TNM stage （P> 0.05）, and the pharyngeal or cervical symptoms were the first clinical manifestations of them, containing pharyngeal pain in 17 cases（54.8%） , pharyngeal foreign body sensation in 4 cases（12.9%） and unilateral cervical mass in 10 cases （32.3%）. No laryngoscopy was performed （21 cases） or no primary lesion was found by laryngoscopy （10 cases） at initial diagnosis. Among them, "inflammatory lesions" were given anti-inflammatory treatment with ineffective results or surgical resection was explored for suspicious lesions （17 cases）, or imaging examination （9 cases, including 6 cases with CT and MRI, 3 cases with PET-CT） and cervical lymph node biopsy （5 cases） were carried out for further diagnosis. According to these results, they were given ordinary laryngoscope （2 cases） or NBI endoscopy （29 cases） subsequently, finally they were confirmed as oropharyngeal squamous cellcarcinoma after localized biopsy at the suspicious lesions, indicating that the accuracy of NBI endoscopy in finding the concealed primary lesions of oropharyngeal cancer （93.55%） is significantly higher than that of ordinary electronic laryngoscope （6.45%）（χ²=43.613, P<0.01）. Conclusion:NBI endoscopy has unique advantages in finding oropharyngeal cancer in concealed parts such as tonsil, root of tongue, soft palate and lateral wall of oropharynx, which could reduce misdiagnosis of oropharyngeal cancer.

Second primary malignancies in patients with clinical T1bN0 esophageal squamous cell carcinoma after definitive therapies: supplementary analysis of the JCOG trial: JCOG0502

BACKGROUND

Previous studies have suggested that patients with esophageal squamous cell carcinoma (ESCC) are still at a high risk of developing second primary malignancies (SPMs) after definitive therapies. We evaluated the development of SPMs and explored its risk factors in patients with clinical T1bN0 ESCC.

METHODS

JCOG0502 prospectively compared esophagectomy with definitive chemo-radiotherapy for clinical T1bN0 ESCC. Here, we reviewed all JCOG0502 patients' data for SPMs and investigated the risk factors for SPMs using uni-variable and multivariable analyses by Fine and Gray model.

RESULTS

Among 379 enrolled patients, 213 underwent esophagectomy and 166 received chemo-radiotherapy. Patient characteristics were male (85%); median age [63 (range 41-75) years; location of the primary tumor (upper/middle/lower thoracic esophagus, 11%/63%/27%, respectively]; alcohol consumption history (79%); smoking history (66%); prevalence of no/several/many/unknown Lugol-voiding lesions (LVLs) (45%/36%/8%/11%, respectively). In a median follow-up of 7.1 years, 118 SPMs occurred in 99 (26%) patients. Cumulative incidences of SPMs after 3, 5, and 10 years were 9%, 15%, and 36%, respectively. The most common primary tumor sites were the head and neck (35%), stomach (20%) and lungs (14%). In multivariable analyses, compared to no LVLs, several LVLs [hazard ratio (HR) 2.24, 95% confidential interval (CI) 1.32-3.81] and many LVLs (HR 2.88, 95% CI 1.27-6.52) were significantly associated with the development of SPMs. Sixteen patients died due to the SPMs.

CONCLUSION

The incidence of SPMs was high. The presence of LVLs, which was a predictive factor for SPMs, may be useful for surveillance planning.

Demarcation of early esophageal squamous cell carcinoma during endoscopic submucosal dissection: A comparison study between Lugol's iodine staining and narrow-band imaging

Lugol's iodine staining (LIS) and narrow-band imaging (NBI) are currently the most common methods applied in demarcating early esophageal squamous cell carcinoma (EESCCs) during endoscopic submucosal dissection. The purpose of the present study was to investigate the effects on clinical outcomes in comparison between LIS and NBI for the demarcation of EESCCs during endoscopic submucosal dissection.This was a single-center, retrospective, cohort study. A total of 172 patients were involved. 109 patients received demarcation of the lesion by LIS and 63 patients by NBI. Data on baseline characteristics, clinical outcomes and follow-up information were collected for analyses.The mean diameter of the lesions was 3.9 ± 1.5 cm. R0 resection rate was 89.5%. The rate of total and in-hospital adverse events was 25.6% and 9.3%. The cumulative recurrence rate was 2.9% and 3-year disease-specific survival rate was 98.3%. Compared to patients of the LIS group, patients of the NBI group showed significantly shorter procedure time (44.8 ± 32.2 v.s.57.0 ± 40.6, P = .044), lower rate of using of scopolamine butylbromide (19.0% vs 35.8%, P = 0.021), reduced number of clips used (1.3 ± 1.2  vs 1.8 ± 1.5, P = .017) and alleviated discomfort evaluated by visual analog system score after operation (4.7 ± 0.8 vs 5.5 ± 1.0, P < .001). There was no significant difference of R0 resection rate, margin status, adverse events, cumulative recurrence rate and 3-year disease-specific survival rate between the two groups.Demarcation of EESCCs by NBI could achieve comparable accuracy and clinical outcomes with more convenience and safety compared with demarcation by LIS.

Effect of adding magnifying BLI, magnifying NBI, and iodine staining to white light imaging in diagnosis of early esophageal cancer

Background and study aims  We investigated the effect of adding magnifying blue laser imaging (BLI), magnifying narrow-band imaging (NBI), and iodine staining to white light imaging in diagnosis of early esophageal squamous cell carcinoma (EESCC) in high-risk patients. Patients and methods  Between May 2013 and March 2016, two parallel prospective cohorts of patients received either primary WLI followed by NBI-magnifying endoscopy (ME) or primary WLI followed by BLI-ME, were studied. At the end of screening, both groups underwent iodine staining. The percentage of patients with newly detected esophageal malignant lesions in each group and the diagnostic ability of image-enhanced endoscopy (IEE)-ME were evaluated. Results  There are 258 patients assigned to the NBI-ME group and 254 patients assigned to the BLI-ME group. The percentage of patients with one or more malignant lesions detected in the WLI + NBI-ME examination was similar in the WLI + BLI-ME examination (15 of 258 patients or 5.81 % vs. 14 of 254 patients or 5.51 %). However, four of 19 lesions in the NBI-ME group and six of 21 lesions in the BLI-ME group were overlooked and were detected by iodine staining. NBI-ME and BLI-ME showed similar accuracy in differentiation of cancerous lesions from non-cancerous lesions in diagnosis of EESCC (NBI/BLI: sensitivity, 87.5/89.5; specificity, 78.9/76.6; accuracy, 80.8/79.5; positive predictive value, 53.8/53.1; negative predictive value, 95.7/96.1). Conclusions  Both NBI and BLI were useful for detection of EESCC. However, because some lesions were overlooked by even NBI and BLI, high-risk patients may benefit from use of iodine staining during endoscopic screening of EESCC (UMIN000023596).

Narrow band imaging in early diagnosis of laryngopharyngeal malignant and premalignant lesions

OBJECTIVES

(1) To assess the diagnostic accuracy of narrow-band imaging (NBI) in the assessment of benign, premalignant, and malignant vocal fold lesions. (2) To evaluate the diagnostic value of NBI in detection of recurrence in upper aero-digestive tract malignancy.

METHODS

This was a prospective, observational study done between December 2018- November 2019 in the Department of Otolaryngology. One hundred six patients of suspected benign, premalignant, malignant lesions of larynx and hypopharynx along with recurrence cases of upper aerodigestive tract malignancy who have completed chemoradiation therapy. All patients were subjected to white light endoscopy (WLE), NBI, and biopsy for histopathological diagnosis. In WLE, laryngeal lesions were classified into three types: malignant, suspected malignant, and benign. NBI images were classified into 5 types based on the intrapapillary capillary loop (IPCL) patterns: Type I-IV were considered benign and Type V lesion was considered malignant. At the end, WLE and NBI findings were correlated with histopathological reports.

RESULTS

The diagnostic accuracy of NBI in diagnosing benign, premalignant, and malignant lesions is significantly better than WLE. The sensitivity of NBI in detecting malignant lesions is significantly greater than WLE. NBI has proved to be of great value in identifying lesions that could be missed by WLE alone, as combined sensitivity of NBI and WLE is significantly higher than WLE alone.

CONCLUSION

NBI is an excellent technique for early detection of laryngopharyngeal malignancies with significantly higher sensitivity than WLE alone.

In Vivo Imaging-Based Techniques for Early Diagnosis of Oral Potentially Malignant Disorders-Systematic Review and Meta-Analysis

Objectives: Oral potentially malignant disorders (OPMDs) are lesions that may undergo malignant transformation to oral cancer. The early diagnosis and surveillance of OPMDs reduce the morbidity and mortality of patients. Diagnostic techniques based on medical images analysis have been developed to diagnose clinical conditions. This systematic review and meta-analysis aimed to evaluate the efficacy of imaging-based techniques compared to the gold standard of histopathology to assess their ability to correctly identify the presence of OPMDs. Design: Literature searches of free text and MeSH terms were performed using MedLine (PubMed), Scopus, Google Scholar, and the Cochrane Library (from 2000 to 30 June 2020). The keywords used in the search strategy were: (“oral screening devices” or “autofluorescence” or “chemiluminescence” or “optical imaging” or “imaging technique”) and (“oral dysplasia” or “oral malignant lesions” or “oral precancerosis”). Results: The search strategy identified 1282 potential articles. After analyzing the results and applying the eligibility criteria, the remaining 43 papers were included in the qualitative synthesis, and 34 of these were included in the meta-analysis. Conclusions: None of the analyzed techniques based on assessing oral images can replace the biopsy. Further studies are needed to explore the role of techniques-based imaging analysis to identify an early noninvasive screening method.

Transoral Endoscopic Examination of the Oropharynx With Tongue Protrusion, Phonation, and Open Mouth

BACKGROUND/AIM

We examined the diagnostic performance of the tongue protrusion with phonation and open mouth (TOPPOM) method for visualizing structures of the oropharynx.

PATIENTS AND METHODS

Transoral endoscopy was performed on 20 healthy participants to evaluate 12 oropharynx subsites under three conditions: open mouth (OM), phonation with open mouth (POM), and TOPPOM. Each subsite was scored from 0 to 2 depending on subsite visualization, and the scores were summed. Images of subsite-adjacent mucosa were similarly scored.

RESULTS

The total scores were significantly higher for TOPPOM than for POM and for POM than for OM. Such scores were observed for both the palatine arches, both palatine tonsils, the left lingual tonsillar sulcus, and the vallecula.

CONCLUSION

TOPPOM enables visualization of the oropharynx through transoral endoscopic examination, and TOPPOM with conventional transnasal endoscopy may enable early detection of oropharyngeal carcinomas and lesions and improve the performance of pre- and post-treatment evaluations.

Texture and Color Enhancement Imaging Increases Color Changes and Improves Visibility for Squamous Cell Carcinoma Suspicious Lesions in the Pharynx and Esophagus

Texture and color enhancement imaging (TXI) has been developed as an image-enhanced endoscopy technology. TXI mode2 enhances texture and brightness, and TXI mode1 also enhances color. This study aims to assess the color differences in squamous cell carcinoma (SCC) suspicious lesions in the pharynx and esophagus using white light imaging (WLI), TXI mode1, TXI mode2, and narrow-band imaging (NBI). A total of 59 SCC suspicious lesions from 30 patients were analyzed. The color differences (ΔE) between the lesion and the surrounding mucosa were calculated for each modality. The color value was assessed using the Commission Internationale d’Eclairage L*a*b* color space. The visibility of the lesion in each modality was evaluated and compared to that in the WLI by six endoscopists. The mean ΔE values in the WLI, TXI mode1, TXI mode2, and NBI were 11.6; 18.6; 14.3; and 17.2, respectively, and the ΔE values of TXI mode1, TXI mode2, and NBI were significantly higher than those of the WLI (p < 0.001). No lesions had worse visibility, and 62.5% (37/59) had improved visibility, as assessed by more than half of the endoscopists in TXI mode1. TXI mode1 can enhance color changes and improve the visibility of SCC suspicious lesions in the pharynx and esophagus, compared to WLI.

Tumor detection with transoral use of flexible endoscopy for unknown primary head and neck cancer

OBJECTIVES

With the advent of new optical technologies, early pharyngolaryngeal cancerous lesions can be better visualized. Although the conventional transnasal approach offers great views of the hypopharynx and larynx, the visualization of the oropharynx and palatine tonsils is limited. Through the transoral insertion of a flexible video-laryngoscope, direct views of the oropharynx and oral cavity can be obtained. Thus, transoral examination may contribute to primary detection of cancers of unknown primary (CUP).

METHODS

Eighty-five CUP patients from Tokai University were included retrospectively in this study, from 2006 to 2017. Starting in 2010, we employed the transoral examination in addition to our conventional method. The primary detection rates were compared before and after 2010. Oropharyngeal primaries were further analyzed for tumor subsite and p16 status.

RESULTS

The overall primary detection rate did not improve with the addition of transoral examination. However, greater numbers of oropharyngeal primaries were detected. The oropharyngeal lesions detected by transoral examination were mainly p16 positive, located on the palatine tonsil.

CONCLUSION

Transoral examination is a noninvasive, easy method to adopt in an outpatient setting, and a promising technique to improve tumor detection in this era of human papillomavirus-associated head and neck cancers.

LEVEL OF EVIDENCE

3.

Endoscopic near-infrared photoimmunotherapy in an orthotopic head and neck cancer model

Near-infrared photoimmunotherapy (NIR-PIT) is a cell selective cancer therapy that uses an antibody-photoabsorber (IRDye700DX, IR700) conjugate (APC) and NIR light. NIR-PIT targeting epidermal growth factor receptor (EGFR) in head and neck cancer (HNC) was conditionally approved in Japan in 2020. APC-bound tumors can be detected using endoscopic fluorescence imaging, whereas NIR light can be delivered using endoscopic fiber optics. The aims of this study were: (1) to assess the feasibility of endoscopic NIR-PIT in an orthotopic HNC model using a CD44-expressing MOC2-luc cell line; and (2) to evaluate quantitative fluorescence endoscopic imaging prior to and during NIR-PIT. The results were compared in 3 experimental groups: (1) untreated controls, (2) APC injection without light exposure (APC-IV), and (3) APC injection followed by NIR light exposure (NIR-PIT). APC injected groups showed significantly higher fluorescence signals for IR700 compared with the control group prior to therapeutic NIR light exposure, and the fluorescence signal significantly decreased in the NIR-PIT group after light exposure. After treatment, the NIR-PIT group showed significantly attenuated bioluminescence compared with the control and the APC-IV groups. Histology demonstrated diffuse necrotic death of the cancer cells in the NIR-PIT group alone. In conclusion, endoscopically delivered light combined with quantitative fluorescence imaging can be used to "see and treat" HNC. This method could also be applied to other types of cancer approachable with endoscopy.

The role of NBI with flexible video-endoscope in the follow-up of head and neck cancer patients: a prospective study

PURPOSE

Narrow band imaging (NBI) enhances mucosal vasculature and could help in the identification of recurrences. We assessed the effectiveness of NBI with flexible video-endoscope in the early detection of recurrence after treatment of head and neck squamous cell carcinoma, its diagnostic advantage over high-definition white-light (HD WL) endoscopy, also in relation to recurrence site, and the influence of previous radiotherapy (RT) or chemotherapy (CT). Moreover, we investigated the association between index tumor site and the risk of developing recurrence, and the relation between index tumor site and recurrence site.

METHODS

From January 2018 to November 2020, 160 patients previously treated with surgery and/or RT ± CT were evaluated using NBI with flexible video-endoscope. Sensitivity, specificity, positive/negative predictive value, and accuracy were calculated for NBI and HD WL, and compared using the McNemar test. The Fisher exact test was used to compare the other associations investigated.

RESULTS

The difference between NBI and HD WL sensitivity was statistically significant (p < 0.001). The NBI diagnostic advantage was 62.5%, highest in the hypopharynx (p = 0.05), and was not influenced by previous RT or CT (p = 0.49). Index tumor site statistically related with recurrence site (p < 0.001), but not with the risk of developing recurrence (p = 0.81).

CONCLUSION

NBI with flexible video-endoscope could represent a valid option to detect recurrence early during the follow-up, especially in a difficult-to-visualize site such as the hypopharynx.

Efficacy and safety of cold forceps biopsy for diminutive pharyngeal neoplasms: Single-center, prospective pilot study

BACKGROUND

Management of diminutive pharyngeal neoplasms is controversial. Thus, we conducted a single-center, prospective pilot study to investigate the efficacy and safety of endoscopic excision with cold forceps biopsy (CFB) of these lesions.

PATIENTS AND METHODS

Thirty-nine lesions endoscopically diagnosed with narrow-band imaging as pharyngeal neoplasms of 3 mm or smaller were excised with CFB using jumbo biopsy forceps (cap diameter 2.8 mm, jaw volume 12.4 mm³ ). The primary outcome was endoscopically determined local remnant/recurrence rate 3 months after CFB. The secondary outcomes were histopathologically determined local remnant/recurrence rate; risk factors associated with the endoscopic remnant/recurrence; and incidence of intraoperative or delayed bleeding and other adverse events.

RESULTS

Histological diagnosis of the 39 CFB-excised lesions were: 11 high-grade dysplasia (28.2%), 22 low-grade dysplasia (56.4%), two basal cell hyperplasia (5.1%) and four atypical squamous epithelium (10.3%).Twenty-seven patients (30 lesions) underwent follow-up endoscopy 3 months after CFB; the endoscopic and pathological local remnant/recurrence rate was 20% (6/30; 95% confidence interval (CI), 7.7-36.6%) and 16.7% (5/30; 95% CI, 5.6-34.7%), respectively. Location of the lesion in the hypopharynx was a significant risk factor associated with the endoscopic local remnant/recurrence (P = 0.049). No significant adverse events occurred.

CONCLUSIONS

Cold forceps biopsy with jumbo biopsy forceps appears to be a safe and effective technique for excising diminutive pharyngeal neoplasms. Although small, the excised lesions may have a remarkably high frequency of high-grade dysplasia. (Clinical trial registration number: UMIN000037980).

Artificial Intelligence-based methods in head and neck cancer diagnosis: an overview

BACKGROUND

This paper reviews recent literature employing Artificial Intelligence/Machine Learning (AI/ML) methods for diagnostic evaluation of head and neck cancers (HNC) using automated image analysis.

METHODS

Electronic database searches using MEDLINE via OVID, EMBASE and Google Scholar were conducted to retrieve articles using AI/ML for diagnostic evaluation of HNC (2009-2020). No restrictions were placed on the AI/ML method or imaging modality used.

RESULTS

In total, 32 articles were identified. HNC sites included oral cavity (n = 16), nasopharynx (n = 3), oropharynx (n = 3), larynx (n = 2), salivary glands (n = 2), sinonasal (n = 1) and in five studies multiple sites were studied. Imaging modalities included histological (n = 9), radiological (n = 8), hyperspectral (n = 6), endoscopic/clinical (n = 5), infrared thermal (n = 1) and optical (n = 1). Clinicopathologic/genomic data were used in two studies. Traditional ML methods were employed in 22 studies (69%), deep learning (DL) in eight studies (25%) and a combination of these methods in two studies (6%).

CONCLUSIONS

There is an increasing volume of studies exploring the role of AI/ML to aid HNC detection using a range of imaging modalities. These methods can achieve high degrees of accuracy that can exceed the abilities of human judgement in making data predictions. Large-scale multi-centric prospective studies are required to aid deployment into clinical practice.

Transoral surgery for superficial head and neck cancer: National Multi-Center Survey in Japan

Head and neck cancers, especially in hypopharynx and oropharynx, are often detected at advanced stage with poor prognosis. Narrow band imaging enables detection of superficial cancers and transoral surgery is performed with curative intent. However, pathological evaluation and real‐world safety and clinical outcomes have not been clearly understood. The aim of this nationwide multicenter study was to investigate the safety and efficacy of transoral surgery for superficial head and neck cancer. We collected the patients with superficial head and neck squamous cell carcinoma who were treated by transoral surgery from 27 hospitals in Japan. Central pathology review was undertaken on all of the resected specimens. The primary objective was effectiveness of transoral surgery, and the secondary objective was safety including incidence and severity of adverse events. Among the 568 patients, a total of 662 lesions were primarily treated by 575 sessions of transoral surgery. The median tumor diameter was 12 mm (range 1–75) endoscopically. Among the lesions, 57.4% were diagnosed as squamous cell carcinoma in situ. The median procedure time was 48 minutes (range 2–357). Adverse events occurred in 12.7%. Life‐threatening complications occurred in 0.5%, but there were no treatment‐related deaths. During a median follow‐up period of 46.1 months (range 1–113), the 3‐year overall survival rate, relapse‐free survival rate, cause‐specific survival rate, and larynx‐preservation survival rate were 88.1%, 84.4%, 99.6%, and 87.5%, respectively. Transoral surgery for superficial head and neck cancer offers effective minimally invasive treatment.

Clinical trials registry number: UMIN000008276.

Clinical Management of Early-Stage Hypopharyngeal Squamous Cell Carcinoma: A Single-Institution Clinical Analysis

OBJECTIVE

Early detection of hypopharyngeal squamous cell carcinoma (SCC) is important for both an improved prognosis and less-invasive treatment. We retrospectively analyzed the detection rates of early hypopharyngeal SCCs according to the evaluation methods and the clinical management of early hypopharyngeal SCCs.

METHODS

Sixty-eight patients with early hypopharyngeal SCC who were diagnosed were reviewed.

RESULTS

The number of early hypopharyngeal cancer patients with asymptomatic or synchronous or metachronous esophageal cancer examined by upper gastrointestinal endoscopy with narrow-band imaging (NBI) was significantly higher than those examined by laryngopharyngeal endoscopy with NBI. The 3-year disease-specific survival rates according to T classification were as follows: Tis, 100%; T1, 100%; T2, 79.8%; and overall, 91.2%, respectively.

CONCLUSIONS

Early-stage hypopharyngeal SCC can be cured by minimally invasive transoral surgery or radiotherapy. Observation of the pharynx using NBI in patients with a history of head and neck cancer, esophageal cancer, gastric cancer, or pharyngeal discomfort is very important, and routinely examining the pharynx with NBI, even in patients undergoing endoscopy for screening purposes, is recommended.

Evaluation of Pharyngeal Background Mucosa in Patients with Superficial Hypopharyngeal Carcinoma

OBJECTIVES/HYPOTHESIS

Transoral surgery (TOS) has become increasingly popular for patients with superficial hypopharyngeal squamous cell carcinoma (SCC). However, the number of patients in whom metachronous multiple SCC of the head and neck (HNSCC) occurs has also increased. In this study, we investigated whether multiple lugol-voiding lesions (LVLs) in the pharyngeal background mucosa observed during TOS would be a biomarker of metachronous HNSCC.

STUDY DESIGN

Retrospective study.

METHODS

We examined 362 patients who underwent TOS for superficial hypopharyngeal carcinoma. Endoscopic images were reviewed in a blinded fashion by two endoscopists. LVLs in the pharyngeal mucosa were graded as follows: A, no lesions; B, 1 to 4 lesions; and C, ≥5 lesions per endoscopic view.

RESULTS

Cumulative incidence curves of secondary HNSCC in the groups of grades A, B, and C revealed 3-year incidence rates of 14.4%, 18.8%, and 29.3%, respectively (P = .001 for A vs. C and P = .002 for B vs. C). Cumulative incidence curves of third HNSCC in the groups of grades A, B. and C revealed 5-year incidence rates of 3.9%, 9.8%, and 19.6%, respectively (P = .001 for A vs. C and P = .006 for B vs. C). Cumulative incidence curves of fourth HNSCC in the groups of grades A, B, and C revealed 7-year incidence rates of 0%, 2.3%, and 13.2%, respectively (P = .025 for A vs. C and P = .009 for B vs. C).

CONCLUSIONS

Multiple LVLs in the pharyngeal mucosa increase the risk of development of metachronous multiple HNSCC.

LEVEL OF EVIDENCE

3 (nonrandomized, controlled cohort/follow-up study) Laryngoscope, 131:2036-2040, 2021.

Validation of the European Laryngological Society classification of glottic vascular changes as seen by narrow band imaging in the optical biopsy setting

Purpose

In 2016, the European Laryngological Society (ELS) proposed a classification for vascular changes occurring in glottic lesions as visible by narrow band imaging (NBI), based on the dichotomic distinction between longitudinal vessels (not suspicious) and perpendicular ones (suspicious). The aim of our study was to validate this classification assessing the interobserver agreement and diagnostic test performance in detecting the final histopathology.

Methods

A retrospective study was carried out by reviewing clinical charts, preoperative videos, and final pathologic diagnosis of patients submitted to transoral microsurgery for laryngeal lesions in two Italian referral centers. In each institution, two physicians, independently re-assessed each case applying the ELS classification.

Results

The cohort was composed of 707 patients. The pathologic report showed benign lesions in 208 (29.5%) cases, papillomatosis in 34 (4.8%), squamous intraepithelial neoplasia (SIN) up to carcinoma in situ in 200 (28.2%), and squamous cell carcinoma (SCC) in 265 (37.5%). The interobserver agreement was extremely high in both institutions (k = 0.954, p < 0.001 and k = 0.880, p < 0.001). Considering the diagnostic performance for identification of at least SIN or SCC, the sensitivity was 0.804 and 0.902, the specificity 0.793 and 0.581, the positive predictive value 0.882 and 0.564, and the negative predictive value 0.678 and 0.908, respectively.

Conclusion

The ELS classification for NBI vascular changes of glottic lesions is a highly reliable tool whose systematic use allows a better diagnostic evaluation of suspicious laryngeal lesions, reliably distinguishing benign ones from those with a diagnosis of papillomatosis, SIN or SCC, thus paving the way towards confirmation of the optical biopsy concept.