Systematic esophageal endoscopy screening in patients previously treated for head and neck squamous-cell carcinoma

Routine image-enhanced endoscopic surveillance for metachronous esophageal squamous cell neoplasms in head and neck cancer patients

BACKGROUND

Esophageal squamous cell neoplasms (ESCNs) are common second primary tumors in patients with head and neck cancer. Image-enhanced endoscopy (IEE) with Lugol chromoendoscopy or magnifying narrow-band imaging both increase the detection of early ESCNs. No evidence-based ESCN surveillance program for head and neck cancer patients without a history of synchronous ESCNs exists. We aimed to evaluate the performance of an IEE surveillance program with magnifying narrow-band imaging endoscopy and Lugol chromoendoscopy.

METHODS

From April 2016, we routinely used IEE with magnifying narrow-band imaging and Lugol chromoendoscopy to evaluate patients with head and neck cancer history. All patients who were negative for ESCNs at the first surveillance endoscopy and received at least 2 IEEs through December 2019 were included. Demographic profiles, clinical data, cancer characteristics, IEE results and pathology reports were analyzed.

RESULTS

A total of 178 patients were included. Only 4 patients (2.2%) developed metachronous ESCNs during follow-up, all of whom received curative resection treatment. The interval for the development of metachronous ESCNs was 477 to 717 days. In multivariate Firth logistic regression and Kaplan‒Meier survival curve analysis, Lugol's voiding lesion type C had an increased risk of esophageal cancer development (adjusted odds ratio = 15.71; 95% confidence interval, 1.33-185.87, p = 0.029). Eight patients died during the study period, and none of them had metachronous ESCNs.

CONCLUSIONS

IEE with magnifying narrow-band imaging and Lugol chromoendoscopy is an effective surveillance program in head and neck cancer patients without a history of ESCNs. Annual surveillance can timely detect early ESCNs with low ESCN-related mortality.

Latest Advances in Endoscopic Detection of Oesophageal and Gastric Neoplasia

Endoscopy is the gold standard for the diagnosis of cancers and cancer precursors in the oesophagus and stomach. Early detection of upper GI cancers requires high-quality endoscopy and awareness of the subtle features these lesions carry. Endoscopists performing surveillance of high-risk patients including those with Barrett's oesophagus, previous squamous neoplasia or chronic atrophic gastritis should be familiar with endoscopic features, classification systems and sampling techniques to maximise the detection of early cancer. In this article, we review the current approach to diagnosis of these conditions and the latest advanced imaging and diagnostic techniques.

Screening and surveillance of esophageal cancer by magnifying endoscopy with narrow band imaging improves the survival of hypopharyngeal cancer patients

Introduction

Patients with head and neck cancer may develop a second primary neoplasm (SPN) of the esophagus due to field cancerization. This study investigated the impacts of esophageal cancer screening using magnifying endoscopy with narrow-band imaging (ME-NBI) on the outcomes of hypopharyngeal cancer patients.

Methods

Patients with hypopharyngeal cancer diagnosed from 2008 to 2021 in a tertiary hospital were reviewed retrospectively. Screening and surveillance using ME-NBI examination of the esophagus were divided into three patterns: (1) ME-NBI never performed or more than 6 months after diagnosis of index primary hypopharyngeal cancer, (2) ME-NBI within 6 months only, and (3) ME-NBI within 6 months and regular surveillance.

Results

A total of 261 were reviewed and 21 (8%) patients were in stage I, 20 (8%) in stage II, 27 (10%) in stage III, 116 (44%) in stage IVA, 65 (25%) in stage IVB, and 12 (5%) in stage IVC. Sixty-seven (26%) patients had SPN (50 esophagus, 10 oral cavity, 3 oropharynx, 2 nasopharynx, 1 larynx and 1 lung). Among esophageal SPN, 35 (70%) and 15 (30%) patients developed synchronous and metachronous neoplasia, respectively. In multivariate Cox regression analysis, advanced stages III and IV (compared with stages I and II, HR: 1.86, 1.18-2.95, p=0.008), ME-NBI examination of the esophagus received within 6 months and regular surveillance (HR: 0.53, 0.36-0.78, p=0.001) were independent factors affecting the overall survival of patients with hypopharyngeal cancer.

Discussion

Our findings demonstrated that screening and surveillance of esophageal SPN by ME-NBI improves the survival of patients with hypopharyngeal cancer.

Endoscopic screening of the upper gastrointestinal tract for second primary tumors in patients with head and neck cancer in a Western country

BACKGROUND

Patients with head and neck squamous cell carcinoma (HNSCC) can develop second primary tumors (SPTs) in the esophagus. Endoscopic screening could lead to detection of SPTs at early stages and improve survival.

METHODS

We performed a prospective endoscopic screening study in patients with curably treated HNSCC diagnosed between January 2017-July 2021 in a Western country. Screening was performed synchronously (< 6 months) or metachronously (≥ 6 months) after HNSCC diagnosis. Routine imaging for HNSCC consisted of flexible transnasal endoscopy with positron emission tomography/computed tomography or magnetic resonance imaging, depending on primary HNSCC location. The primary outcome was prevalence of SPTs, defined as presence of esophageal high grade dysplasia or squamous cell carcinoma.

RESULTS

202 patients (mean age 65 years, 80.7 % male) underwent 250 screening endoscopies. HNSCC was located in the oropharynx (31.9 %), hypopharynx (26.9 %), larynx (22.2 %), and oral cavity (18.5 %). Endoscopic screening was performed within 6 months (34.0 %), 6 months to 1 year (8.0 %), 1-2 years (33.6 %), and 2-5 years (24.4 %) after HNSCC diagnosis. We detected 11 SPTs in 10 patients (5.0 %, 95 %CI 2.4 %-8.9 %) during synchronous (6/85) and metachronous (5/165) screening. Most patients had early stage SPTs (90 %) and were treated with curative intent with endoscopic resection (80 %). No SPTs in screened patients were detected with routine imaging for HNSCC before endoscopic screening.

CONCLUSION

In 5 % of patients with HNSCC, an SPT was detected with endoscopic screening. Endoscopic screening should be considered in selected HNSCC patients to detect early stage SPTs, based on highest SPT risk and life expectancy according to HNSCC and comorbidities.

Evaluation of the prevalence of metachronous second primary malignancies in hypopharyngeal carcinoma and their effect on outcomes

Background

To investigate the clinical characteristics of metachronous second primary malignancies (Met‐SPMs) and its impact on prognosis in hypopharyngeal carcinoma (HPC).

Methods

We reviewed 593 newly diagnosed HPC patients without invasive synchronous SPMs (Syn‐SPMs) who were treated in our cancer center between 2009 and 2019. According to the status during follow‐up, patients were classified into three groups: (a) without SPMs (No‐SPMs, n = 440), (b) with tumors in situ in the esophagus or stomach (Tis, n = 80), or (c) with Met‐SPMs (n = 73).

Results

The median follow‐up time for entire cohort (n = 593) was 66.7 months. Met‐SPMs were present in 12.3% of the cohort (73/593). The predominant site of SPMs was esophagus, followed by lung, oral cavity, thyroid, stomach, and oropharynx. In Met‐SPMs group, both index tumor and SPMs were the main causes of death. Tis group exhibited comparable 5‐year overall survival (OS) and disease‐specific survival (DSS) with that of No‐SPMs group. The Met‐SPMs group had similar 5‐year OS rate and better 5‐year DSS rate of 47.3% versus 43.6% (odds ratio [OR], 0.931; 95% confidence interval [CI], 0.681–1.274, p = 0.657) and 66.3% vs. 46.2% (OR, 0.600; 95% CI, 0.402–0.896, p = 0.012), respectively, compared with the No‐SPMs group.

Conclusion

The overall incidence of Met‐SPMs in HPC was 12.3%. The occurrence of Met‐SPMs does not jeopardize the survival outcome of HPC. Routine surveillance of Met‐SPMs was requisite for patients with HPC.

Esophageal cancer: Epidemiology, risk factors and screening

More than 600,000 people are diagnosed with esophageal cancer (EC) every year globally, and the five-year survival rate of EC is less than 20%. Two common histological subtypes of EC, esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC), have great geographical variations in incidence rates. About half of the world's EC was diagnosed in China and a majority of which belong to ESCC. Globally, the overall incidence rate of EC is decreasing. In some high-risk Asian regions, such as China, the incidence rate of ESCC has generally declined, potentially due to economic growth and improvement of diet habits. In some European high-income countries and the United States, the decline is mainly attributed to the decrease in smoking and drinking. The risk factors of EC are not well understood, and the importance of environmental and genetic factors in the pathogenesis is also unclear. The incidence and mortality of advanced EC can be reduced through early diagnosis and screening. White light endoscopy is still the gold standard in the current screening technology. This article reviews the epidemiology, risk factors, and screening strategies of EC in recent years to help researchers determine the most effective management strategies to reduce the risk of EC.

Narrow-band imaging versus Lugol chromoendoscopy for esophageal squamous cell cancer screening in normal endoscopic practice: randomized controlled trial

BACKGROUND

Narrow-band imaging (NBI) is as sensitive as Lugol chromoendoscopy to detect esophageal squamous cell carcinoma (SCC) but its specificity, which appears higher than that of Lugol chromoendoscopy in expert centers, remains to be established in general practice. This study aimed to prove the superiority of NBI specificity over Lugol chromoendoscopy in the detection of esophageal SCC and high grade dysplasia (HGD) in current general practice (including tertiary care centers, local hospitals, and private clinics).

METHODS

This prospective randomized multicenter trial included consecutive patients with previous or current SCC of the upper aerodigestive tract who were scheduled for gastroscopy. Patients were randomly allocated to either the Lugol or NBI group. In the Lugol group, examination with white light and Lugol chromoendoscopy were successively performed. In the NBI group, NBI examination was performed after white-light endoscopy. We compared the diagnostic characteristics of NBI and Lugol chromoendoscopy in a per-patient analysis.

RESULTS

334 patients with history of SCC were included and analyzed (intention-to-treat) from 15 French institutions between March 2011 and December 2015. In per-patient analysis, sensitivity, specificity, positive and negative likelihood values were 100 %, 66.0 %, 21.2 %, and 100 %, respectively, for Lugol chromoendoscopy vs. 100 %, 79.9 %, 37.5 %, and 100 %, respectively, for NBI. Specificity was greater with NBI than with Lugol (P = 0.002).

CONCLUSIONS

As previously demonstrated in expert centers, NBI was more specific than Lugol in current gastroenterology practice for the detection of early SCC, but combined approaches with both NBI and Lugol could improve the detection of squamous neoplasia.

Comprehensive mutational analysis of background mucosa in patients with Lugol-voiding lesions

Somatic mutations including the background mucosa in patients with Lugol-voiding lesions (LVLs) are still not well known. The aim of this study was to evaluate the somatic mutations of the background mucosa in patients with LVLs (Squamous cell carcinoma (SCC), intraepithelial neoplasia (IN), and hyperplasia). Twenty-five patients with LVLs (9 with SCC, 6 with IN, and 10 with hyperplasia) were included. A targeted sequence was performed for LVLs and background mucosa using an esophageal cancer panel. Each mutation was checked whether it was oncogenic or not concerning OncoKB. In LVLs, TP53 was the most dominant mutation (80%). Furthermore, 72% of TP53 mutations was putative drivers. In background mucosa, NOTCH1 was the most dominant mutation (88%) and TP53 was the second most dominant mutation (48%). Furthermore, 73% of TP53 mutations and 8% of NOTCH1 mutations were putative drivers. Putative driver mutations of TP53 had significantly higher allele frequency (AF) in SCC than in IN and hyperplasia. Conversely, putative driver mutations of NOTCH1 did not have a significant accumulation of AF in the progression of carcinogenesis. Furthermore, in SCC, AF of TP53 mutations was significantly higher in LVLs than in background mucosa, but not in IN and hyperplasia. Regarding NOTCH1, a significant difference was not observed between LVLs and background mucosa in each group. The background mucosa in patients with LVLs already had putative driver mutations such as TP53 and NOTCH1. Of these two genes, TP53 mutation could be the main target gene of carcinogenesis in esophageal SCC. Clinical Trials registry: UMIN000034247.

Superiority of NBI endoscopy to PET/CT scan in detecting esophageal cancer among head and neck cancer patients: a retrospective cohort analysis

Background

Second primary cancer of the esophagus is frequent in head and neck patients, especially in high-risk populations, and has a great impact on the prognosis. Although Positron emission tomography (PET)/computed tomography (CT) scan is commonly conducted in head and neck patients, its ability to detect early esophageal cancer is limited. Narrow-band imaging endoscopy is an accurate and convenient technique for esophageal examination. We aimed to compare PET/CT scan and narrow-band imaging endoscopy for the detection of esophageal cancer in head and neck cancer patients.

Methods

From November 2015 to November 2018, all head and neck cancer patients who underwent both PET/CT scan and narrow-band imaging endoscopy at Changhua Christian Hospital were retrospectively enrolled. Descriptive statistics, receiver operating characteristic curve analysis, logistic regression analysis, independent Student’s t-test, and Kaplan–Meier survival analysis were conducted with MedCalc Statistical Software.

Results

A total of 147 subjects were included in the analysis; suspicious esophageal lesions were identified by PET/CT scan in 8 (5.44%) and by narrow-band imaging in 35 (23.81%). The final pathologic diagnoses were esophageal squamous cell carcinoma in 10 and high-grade dysplasia in 5. The respective sensitivity, specificity, and area under the curve for detecting suspicious esophageal lesions were 33.33, 97.73%, and 0.655 for PET/CT scan, and 100.0, 84.85%, and 0.924 for narrow-band imaging endoscopy. Hypopharyngeal or laryngeal location of the primary head and neck cancer was the only risk factor for developing second primary esophageal cancer.

Conclusions

PET/CT scan was inferior to narrow-band imaging endoscopy in detecting second primary esophageal cancer in head and neck cancer patients. In addition to PET/CT scan, narrow-band imaging endoscopy should be considered in head and neck patients at high risk for developing second primary esophageal cancer.

A nationwide population-based study to access the risk of metachronous esophageal cancers in head and neck cancer survivors

How long esophageal screening should be performed for, and on which sub-groups of head and neck cancer (HNC) survivors, remains uncertain. This retrospective study analyzed data from the Taiwan National Health Insurance Research Database from 1999 to 2013. A total of 68,131 newly- diagnosed HNC patients were enrolled. Subjects who received esophageal endoscopic screening within 6 months after their diagnosis date of index HNC were identified. The incidence trends of secondary primary EC were analyzed using a Cochran-Armitage trend test. Among the 9,707 patients who received index esophageal endoscopy screening, 101 (1.0%) cases of synchronous EC were diagnosed. The 5- and 10-year cumulative incidence rates of metachronous ECs were 1.4% and 2.7%, respectively in those with an initial negative index endoscopic finding. Patients with oropharynx or hypopharynx cancers were at significantly higher risk of developing metachronous ECs compared with those with oral or larynx cancers (10-year incidence rate: 3.3% vs. 0.9%, respectively; hazard ratio: 2.15; 95% confidence intervals: 1.57-2.96). Metachronous EC continues to develop in patients with HNC even at 10-years after treatment for primary HNC. HNC patients, especially those with oropharynx or hypopharynx cancer, may require long-term endoscopic surveillance.

Screening for esophageal squamous cell carcinoma: recent advances

Esophageal squamous cell carcinoma (ESCC) is the most common type of esophageal cancer worldwide, with a high mortality due to advanced stage at diagnosis. Although most common in an area known as the Asian Esophageal Cancer Belt, which extends from the Caspian Sea to northern China, and in parts of Africa, high-risk populations also exist elsewhere in the world. Screening for ESCC has been practiced in a few geographic areas and high-risk populations, with varying levels of success. Esophageal squamous dysplasia is recognized as the precursor lesion for ESCC. Endoscopic screening for ESCC/esophageal squamous dysplasia is expensive and not sufficiently available in many high-risk regions. Recent advances in non-endoscopic screening enhanced by biomarker-based disease detection have raised the prospect of improved accuracy and availability of screening for esophageal squamous dysplasia and early stage ESCC. Development of a cost-effective, accurate, and well-tolerated screening test, if applied in endemic areas and high-risk populations, has the potential to reduce mortality from this deadly disease worldwide. In this review, we summarize recent developments in endoscopic and non-endoscopic screening modalities.

A retrospective study of treatment for curative synchronous double primary cancers of the head and neck and the esophagus

OBJECTIVE

Curative synchronous double primary cancers of the head and neck and the esophagus (CSC-HE) are frequently detected, but a standard treatment remains to be established. We studied the clinical course to explore appropriate treatment strategies.

METHODS

We retrospectively studied consecutive 33 patients who had CSC-HE. The disease stage was classified into 4 groups: group A, early head and neck cancer (HNC) and early esophageal cancer (EC); group B, early HNC and advanced EC; group C, advanced HNC and early EC; and group D, advanced HNC and advanced EC. As induction chemotherapy, the patients received 3 courses of TPF therapy (docetaxel 75mg/m² on day 1, cisplatin 75mg/m² on day 1, and 5-fluorouracil 750mg/m² on days 1-5) at 3-week intervals. The clinical courses and treatment outcomes were studied according to the disease stage of CSC-HE.

RESULTS

The disease stage of CSC-HE was group A in 1 patient (3%), group B in 9 patients (27.3%), group C in 3 patients (9.1%), and group D in 20 patients (60.6%). The median follow-up was 26months, and the 2-year overall survival rate was 67.4%. In groups A, B, and C, the 2-year overall survival rate was 83.3%. In group D, the 2-year overall survival rate was 62.6%. Ten of 20 patients in group D received induction chemotherapy with TPF, and 6 patients were alive and disease free at the time of this writing.

CONCLUSION

The treatment outcomes of patients with CSC-HE were relatively good. TPF induction chemotherapy might be an effective treatment for patients with advanced HNC and advanced EC.

Long-Term Results of Conventional Radiotherapy versus Accelerated Hyperfractionated Radiotherapy versus Concomitant Radiotherapy and Chemotherapy in Locoregionally Advanced Carcinoma of the Oropharynx

AIMS AND BACKGROUND

To compare conventional fractionation (CF) radiation therapy (RT), arm A, versus a split-course accelerated hyperfractionated schedule (S-AHF), arm B, versus CFRT plus concomitant chemotherapy (CT), arm C, in terms of five-year survival and toxicity for squamous cell tumors of the oropharynx.

METHODS AND STUDY DESIGN

Between January 1993 and June 1998, 192 previously untreated patients with stage III and IV oropharyngeal carcinoma (excluding T1N1 and T2N1) were enrolled in a multicenter randomized phase III trial (ORO 93-01). In arms A and C, 66 to 70 Gy in 33 to 35 fractions was administered five days a week for six and a half to seven weeks. In arm B, the dose delivered was 64 to 67.2 Gy in two fractions of 1.6 Gy every day, five days a week, with a planned two-week split at 38.4 Gy. In arm C the CT regimen consisted of three cycles of carboplatin and 5-fluorouracil (CBDCA 75 mg/m2 on days 1 to 4 and 5-FU 1000 mg/m2 i.v. on days 1 to 4 every 28 days).

RESULTS

No statistically significant difference was found in five-year overall survival (P = 0.39): 21% for arm A, 21% for arm B, and 40% for arm C. Similarly, there was no statistically significant difference in terms of five-year relapse-free survival: 15% for arm A, 17% for arm B, and 36% for arm C. There was a slight trend towards better five-year locoregional control (P = 0.07) for the combined arm: patients without locoregional relapse were 48% in arm C, 21% in arm A and 18% in arm B. Locoregional control was significantly better when arm C was compared with arms A and B combined (P = 0.02; arm A+B 20%; arm C 48%). Distant metastases were fairly balanced in the three arms (A: 14; B: 9; C: 11), with a tendency towards more frequent isolated distant metastasis development in arm C (8 of 11 [72%] versus 7 of 23 [30%] in arms A+B). Five-year second-tumor-free survival was 85%. The 13 second tumors were equally distributed and were mainly correlated with tobacco and alcohol consumption (five lung, two esophagus, two oral cavity, one larynx, one pancreas, one hepatocarcinoma, one myeloma). Arm C showed slightly more G3+ late side effects involving subcutaneous tissues and mucosa, although significant late sequelae were relatively uncommon and the mucosal side effects were mostly transient. The occurrence of persistent G3 xerostomia was comparable in the three treatment arms.

CONCLUSIONS

The results obtained with the combination of CT and RT compared with RT alone did not reach statistical significance, but combined treatment almost doubled the five-year overall survival, relapse-free survival and locoregional control rate. Patients with advanced squamous cell carcinomas of the oropharynx who are medically suitable for the combined approach should be treated with a combination of radiotherapy and chemotherapy. The occurrence of second tumors is relatively common in these patients and may contribute substantially to the causes of death.

Efficacy of narrow-band imaging in detecting early esophageal cancer and risk factors for its occurrence

OBJECTIVE

The aim of this study is to evaluate the efficacy of narrow-band imaging (NBI) in the detecting early esophageal cancer and precancerous lesions and to investigate the risk factors for its occurrence.

METHODS

The esophagus was examined with ordinary endoscopy, NBI, and iodine staining. All the lesions were confirmed by histopathologically as the gold standard; NBI and intrapapillary capillary scale (IPCL) scale were compared with pathologic diagnosis. The accuracy, sensitivity, specificity, positive and negative predictive values (PPV, NPV) were calculated. Subgroup analysis was performed between the elderly vs. younger group, and head and neck squamous cell cancer (HNSCC) vs. non-HNSCC patients.

RESULTS

Ninety lesions were detected with ordinary endoscopy, 108 with NBI, and 120 with iodine staining. All esophageal cancers were detected both by NBI and by iodine staining. Accuracy, sensitivity, and specificity for esophageal cancer and precancerous lesion were 67.8%, 58.1%, and 76.6%; 92%, 89.7%, and 96%; 93.4%, 93.4%, and 93.2%, respectively. NBI endoscopy and iodine staining were superior to ordinary endoscopy for detecting esophageal cancer and precancerous lesions (p < 0.05). NBI showed better detection of esophageal neoplasms in the elderly patients (p < 0.001). The incidence of multiple squamous cell cancers (SCCs) was significantly higher in non-elderly group (p = 0.009). NBI can also detect more esophageal neoplastic lesions in patients with head and neck cancers (p = 0.003).

CONCLUSIONS

NBI endoscopy appears as effective as Lugol staining to detect and screen the early esophageal cancer. NBI shows better detection of esophageal neoplasms in the elderly patients. The incidence of multiple SCCs was much higher in non-elderly patients.

Endoscopic screening for synchronous esophageal neoplasia among patients with incident head and neck cancer: Prevalence, risk factors, and outcomes

Esophageal squamous-cell neoplasia (ESCN) is a common second primary neoplasia found in patients with head-and-neck squamous-cell carcinoma (HNSCC). This study sought to identify the risk factors for synchronous ESCN and how they influence survival in HNSCC patient. Eight hundred and fifteen incident HNSCC patients were prospectively recruited for endoscopy screening for ESCN using white-light imaging, narrow-band imaging, Lugol chromoendoscopy, and pathological confirmation. Associated lifestyle and clinicopathological data were collected. The interquartile follow-up period cutoffs were 11.3, 20.5 and 34.9 months. 124 patients (15.2%) were diagnosed as having synchronous ESCN (66 low-grade dysplasia, 29 high-grade dysplasia, and 29 esophageal squamous-cell carcinoma). Consumption of alcohol, but not betel nut or cigarette, was significantly associated with the presence of synchronous ESCN (adjusted odds ratio [aOR] = 7.1 and 10.9 for former and current drinkers, respectively). There was an interaction between cumulative dose of alcohol consumption and alcohol flushing response on the development of ESCN. High-dose drinkers with flush response were 16.9 times more likely to have esophageal high-grade dysplasia/SCC than non-drinkers. Compared with oral cavity cancer patients, those with hypopharyngeal, laryngeal and oropharyngeal cancer were 6.8, 4.6 and 2.8 times more likely to have esophageal high-grade dysplasia/SCC. HNSCC patients with synchronous ESCN had lower overall survival than those without (p < 0.0001). In conclusion, surveillance of ESCN is strongly recommended for the high-risk subpopulation of HNSCC patients, especially drinkers who have a flush response to alcohol, and those with distant metastasis of index cancer and cancers in hypopharynx, oropharynx and larynx.

Early squamous neoplasia of the esophagus: The endoscopic approach to diagnosis and management

Considerable focus has been placed on esophageal adenocarcinoma in the last 10 years because of its rising incidence in the West. However, squamous cell cancer (SCC) continues to be the most common type of esophageal cancer in the rest of the world. The detection of esophageal SCC (ESCC) in its early stages can lead to early endoscopic resection and cure. The increased incidence of ESCC in high-risk groups, such as patients with head and neck squamous cancers, highlights the need for screening programs. Lugol's iodine chromoendoscopy remains the gold standard technique in detecting early ESCC, however, safer techniques such as electronic enhancement or virtual chromoendoscopy would be ideal. In addition to early detection, these new "push-button" technological advancements can help characterize early ESCC, thereby further aiding the diagnostic accuracy and facilitating resection. Endoscopic resection (ER) of early ESCC with negligible risk of lymph node metastases has been widely accepted as an effective therapeutic strategy because it offers similar success rates when compared to esophagectomy, but carries lesser morbidity and mortality. Endoscopic submucosal dissection (ESD) is the preferred technique of ER in lesions larger than 15 mm because it provides higher rates of en bloc resections and lower local recurrence rates when compared to endoscopic mucosal resection (EMR).

Surveillance of patients at high-risk of squamous cell esophageal cancer

Currently curative treatment for esophageal squamous cell cancer (ESCC) is possible only in patients with early-stage, usually asymptomatic disease. In Western countries, where the incidence of ESCC is relatively low, a screening of asymptomatic, average-risk population is untenable. In order to detect early-stage ESCC or its precursor lesions it is important to identify high-risk patients and consider endoscopic surveillance in these groups. These high-risk groups include patients after curative treatment for head and neck cancer, previous endoscopic resection of ESCC, caustic injury, and patients with tylosis or achalasia. This paper discuss the evidence and proposed method of endoscopy surveillance of these high-risk patients.

Clinical significance of early detection of esophageal cancer in patients with head and neck cancer

Background/Aims

The efficacy of surveillance for esophageal squamous cell neoplasia (ESCN) in patients with head and neck squamous cell carcinoma (HNSCC) remains controversial. Our study aimed to provide clinical data concerning the necessity of surveillance for detecting early ESCN in patients with HNSCC.

Methods

We retrospectively reviewed the data from 714 patients who were pathologically confirmed as having HNSCC (n=236 oral cavity cancers, 137 oropharyngeal cancers, 87 hypopharyngeal cancers, and 254 laryngeal cancers).

Results

Of 714 patients, during a median follow-up of 31 months, 48 ESCNs (37 synchronous and 11 metachronous) were detected in 36 patients (5%). Fifteen synchronous lesions (40.3%) were early ESCN, whereas nine metachronous lesions (81.8%) were early ESCN. The 3-year survival rates of HNSCC only and HNSCC combined with ESCN were 71.2% and 48.2%, respectively (p<0.001). Among 36 patients with ESCN, the 3-year survival rates for early and advanced ESCN were 77.7% and 21.7%, respectively (p=0.01). In the multivariate analysis, alcohol consumption and hypopharyngeal cancer were significant factors associated with the development of ESCN.

Conclusions

HN-SCC patients with early ESCN were similar in prognosis with patients without ESCN, in contrast to patients with advanced ESCN. Therefore, surveillance for the early detection of ESCN in patients with HNSCC, especially in alcohol drinkers and those with hypopharyngeal cancer, is warranted.

Narrow-Band Imaging Magnifying Endoscopy versus Lugol Chromoendoscopy with Pink-Color Sign Assessment in the Diagnosis of Superficial Esophageal Squamous Neoplasms: A Randomised Noninferiority Trial

Previous studies have shown the high diagnostic accuracy of narrow-band imaging magnifying endoscopy (NBI-ME) and Lugol chromoendoscopy with pink-color sign assessment (LCE-PS) for superficial esophageal squamous cell carcinoma (SESCC). However, there has been no controlled trial comparing these two diagnostic techniques. We conducted a randomized noninferiority trial to compare the diagnostic accuracy of NBI-ME and LCE-PS. We recruited patients with, or with a history of, squamous cell carcinoma in the head and neck region or in the esophagus. They were randomly assigned to either NBI-ME or LCE-PS. When lesions > 5 mm in diameter were found as brownish areas on NBI or as Lugol-voiding lesions (LVL), they were evaluated to determine whether they are SESCC on the basis of the findings of NBI-ME or PS in the LVL. NBI-ME and LCE-PS were completed in 147 patients each. There was no significant difference in all diagnostic values between the two techniques. Compared with LCE-PS, NBI-ME showed a significantly shorter examination time but a larger number of misdiagnosed lesions especially in patients with many irregularly shaped multiform LVLs. Compared with LCE-PS, NBI-ME might be similarly accurate and less invasive, but less reliable in patients with many LVLs, in the diagnosis of SESCC.

Use of transnasal endoscopy for screening of esophageal squamous cell carcinoma in high-risk patients: yield rate, completion rate, and safety

BACKGROUND

Patients with head and neck squamous cell carcinoma are at high risk for synchronous and/or metachronous esophageal cancer. The present study aimed to evaluate the feasibility and safety of unsedated transnasal endoscopy (TNE) for screening these high-risk patients.

PATIENTS AND METHODS

Consecutive high-risk patients including patients with suspicious or diagnosed head and neck cancer or patients with alarming symptoms received screening TNE. All endoscopic procedures, including sequential conventional white-light, narrow-band imaging, and Lugol chromoendoscopy, were done without sedation. All suspicious lesions in the esophagus were biopsied for histological evaluation. The completion rate, procedure time, and significant adverse events of all endoscopic procedures were recorded and analyzed.

RESULTS

From May 2007 to August 2011, a total of 500 TNE were carried out in 441 high-risk patients. Among them, 294 patients (66.7%) had diagnosed head and neck squamous cellcarcinoma, and most were hypopharyngeal cancer (n = 186). Esophageal squamous cell carcinomas and high-grade intraepithelial neoplasms were detected in 10.1% and 7.3%, respectively, of the cases. Completion rate of TNE in head and neck cancer was 96.7%; tumor obstruction and stenosis of anastomosis site were the main reasons for incomplete procedures. Mean duration of the endoscopic procedure was 14.6 min. One patient had post-endoscopic epistaxis while another patient had post-biopsy hemoptysis, both of whom were treated conservatively. No procedure-related mortality or significant morbidity occurred.

CONCLUSION

Unsedated TNE is safe and feasible for screening synchronous or metachronous esophageal neoplasms in high-risk patients, especially those with head and neck cancer.

Perspectives on narrow-band imaging endoscopy for superficial squamous neoplasms of the orohypopharynx and esophagus

BACKGROUND AND AIM

Narrow-band imaging (NBI) is widely available and over the last decade has been applied as a detection and characterization technique for superficial neoplasms of the aerodigestive tract. The aims of the present study were to systematically review clinical trials of NBI endoscopy and to investigate an upgraded NBI system using a novel endoscope for superficial squamous neoplasms in the orohypopharynx and esophagus.

METHODS

Studies on the diagnostic use of NBI endoscopy for superficial squamous neoplasms in the orohypopharynx and esophagus were retrieved from MEDLINE and PubMed and reviewed. An upgraded NBI system using a novel endoscope was investigated with our clinical cases.

RESULTS

In many clinical trials, NBI endoscopy with or without magnification had high diagnostic value for superficial squamousneoplasms in the orohypopharynx and esophagus. An upgraded NBI system can produce a significantly brighter endoscopic view than conventional endoscopes with high-quality magnified images that could be used to diagnose superficial squamous neoplasms.

CONCLUSIONS

NBI endoscopy with or without magnification has diagnostic utility for superficial squamous neoplasms in the orohypopharynx and esophagus. The upgraded NBI endoscopic system is expected to facilitate the use of NBI and magnifying endoscopic diagnosis.

(18)F-FDG PET/CT surveillance at 3-6 and 12 months for detection of recurrence and second primary cancer in patients with head and neck squamous cell carcinoma

Background:

Early detection of recurrence of head and neck squamous cell carcinoma (HNSCC), which is often obscured by surgical or radiotherapy-induced tissue distortion, is essential for proper patient management.

Methods:

A total of 143 consecutive patients with previously untreated HNSCC were evaluated by whole-body fluorine 18-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) and regular clinical follow-up after curative treatment. The ¹⁸F-FDG PET/CT was performed ∼3–6 and 12 months after treatment and findings suspicious for recurrence or SPC were confirmed using histopathology.

Results:

The sensitivities of 3–6- and 12-month PET/CT scans at patient level were 96% and 93%, respectively, and those of regular clinical follow-up were 11% and 19%, respectively (McNemar test, P<0.001). In patients with no clinical suspicion, PET/CT detected 95% and 91% of recurrent patients at 3–6 and 12 months, respectively. The sensitivity of PET/CT for the identification of SPC was 29% and 80% at 3–6 and 12 months, respectively. A positive interpretation of PET/CT was significantly associated with poor overall survival (log-rank test, P<0.001).

Conclusion:

The ¹⁸F-FDG PET/CT surveillance is beneficial for the detection of recurrence that may be missed by regular follow-up physical and endoscopic examinations of the head and neck area after curative treatment for HNSCC.

Second primary malignancies in head and neck cancer patients: high prevalence of curable-stage disease

BACKGROUND AND PURPOSE

Patients treated for squamous cell carcinoma of the head and neck (HNSCC) carry a high risk of second primary malignancies (SPM). Recently, computed tomography (CT) of the chest was shown to significantly decrease the risk of death due to bronchial carcinoma (BC) in a cohort of smokers whose risk of BC is increased but might be lower than that of patients previously treated for HNSCC. Thus, the present study evaluated the potential benefit of CT and other examinations in the detection of SPM in HNSCC patients.

PATIENTS AND METHODS

Between July 2008 and November 2011, 118 participants underwent a prospective, systematic examination for SPM (13 women, 105 men, median age 62 years). All patients had been previously treated for HNSCC and showed no recurrence or distant metastases at the time of the study start. CT scans, ear-nose-throat endoscopy, and endoscopy of the esophagus and stomach were performed.

RESULTS

Overall, 33 suspicious findings were clarified by additional investigations. In all, 26 SPM were confirmed in 21 of 118 patients (18%; 10 lung, 7 HNSCC, 3 gastrointestinal, 1 renal). Eighteen of these 21 patients (86%) underwent therapy with curative intent.

CONCLUSION

The examinations revealed a high prevalence of curable stage SPM in HNSCC patients. Adapting a surveillance scheme including a chest CT is recommended.

Second cancer incidence, risk factor, and specific mortality in head and neck squamous cell carcinoma

OBJECTIVE

Second primary malignancies (SPMs) are common in patients with head and neck squamous cell carcinoma (HNSCC) and have a negative impact on their survival. This study aimed to evaluate risk factors for SPM occurrence and cause-specific mortality in Asian HNSCC patients.

STUDY DESIGN

A retrospective cohort study.

SETTING

University teaching hospital.

SUBJECTS

Nine hundred and thirty-seven patients without previous cancer history who were treated between 2000 and 2009 and followed for at least 2 years.

METHODS

Confirmation of SPMs was performed by histopathology. The cumulative probability of a SPM among survivors of index HNSCC was calculated using a competing risk model. Univariate and multivariate analyses were utilized to determine factors predictive of SPM occurrence and cause-specific mortality.

RESULTS

Of 937 patients, cumulative incidence of SPMs was 7.2% at 0 to 6 months (synchronous), 17.9% at 5 years, and 23.1% at 10 years after index tumor diagnosis. In multivariate analyses, old age (>60 years) (P = .002), hypopharyngeal index tumor site (P = .001), and heavy drinker (P = .001) were independently associated with the development of SPMs, and hypopharyngeal index tumor site were independent variables for SPM-specific survival (P < .001). Cumulative incidence function of SPM-specific mortality according to index tumor sites was significantly higher in the hypopharynx than other sites (P = .011).

CONCLUSION

Elderly patients, hypopharyngeal index cancer patients, or heavy drinkers may require careful surveillance for the development of SPMs. Our results may help identify and properly manage Asian patients at high risk of SPMs.

Endoscopic resection of hypopharyngeal squamous cell carcinoma

Hypopharyngeal cancers are often diagnosed at an advanced stage and have a poor prognosis. Even when they are diagnosed at an operable stage, surgery often results in substantial morbidity and decreased patients' quality of life. Although the endoscopic diagnosis of early hypopharyngeal cancer is difficult, recent developments in advanced imaging endoscopy have enabled easier diagnosis of these lesions. Endoscopic resection of early hypopharyngeal cancer is a potential minimally invasive treatment that can preserve the function and quality of life of patients. Reports of this procedure are limited, however. We report a case of hypopharygeal cancer treated with endoscopic resection.

A comparative study of isolated and metachronous oesophageal squamous cell carcinoma with antecedent upper aerodigestive tract cancer

OBJECTIVES

Metachronous oesophageal squamous cell carcinoma (OSCC) has been increasing in long-term survivors of upper aerodigestive tract (UADT) cancers in recent years, but the treatment of such cases is not well established. The aim of this study was to compare the prognosis between patients with metachronous OSCC who had antecedent UADT cancers and patients with isolated OSCC.

METHODS

From January 1995 to December 2009, we retrospectively compared the data from 84 patients with metachronous OSCC who had antecedent UADT cancers (metachronous group) with the data from 527 patients with isolated OSCC (isolated group) according to their treatment modalities at Kaohsiung Chang Gung Memorial Hospital.

RESULTS

Overall, the metachronous group had significantly (P = 0.03) worse overall survival than the isolated group. For patients receiving surgery or preoperative chemoradiotherapy followed by surgery, the overall survival rates and incidence of postoperative complications were not significantly different. For patients receiving definite chemoradiotherapy or radiotherapy alone, the metachronous group had significantly (P = 0.02) inferior overall survival compared with the isolated group.

CONCLUSIONS

Offering a radical approach for the treatment of patients with metachronous OSCC who had antecedent UADT cancers is justifiable, with survival rates similar to those of patients with isolated OSCC.

Upper gastrointestinal tract cancers as double-cancers in elderly patients with oral squamous cell carcinoma

Against a background of a rapidly aging society, the number of patients with oral cancers in Japan is increasing yearly. The number of double-cancers with oral cancer as the first malignancy is also reportedly on the rise. Esophageal and gastric cancers are the most common second malignancies. At our institution, our policy is to proactively perform upper gastrointestinal (GI) fiberscopy (GIF) in patients with oral cancer. In anticipation of a probable further increase in the number of patients with double-cancers consisting of oral and GI tract malignancies, we retrospectively analyzed the occurrence of upper GI tract cancers in patients with oral squamous cell carcinoma (OSCC). The cohort consisted of 171 patients in whom OSCC had been diagnosed and who had undergone upper GIF between March 1996 and August 2008. Multivariate analysis was performed. Upper GIF identified 8 patients (7 men, 1 woman, totaling 4.7% of 171 patients) with double-cancer in the upper GI tract. One patient had a triple malignancy consisting of oral, esophageal and gastric cancers. Seven patients had esophageal cancer, while two had gastric cancer. An age of over 65 years was significantly higher in patients with double-cancers including esophageal cancer than in patients without esophageal cancer (OR=10.454, 95% CI=1.143-95.621). None of the other analyzed patient factors (sex, smoking habit, drinking habit, site of OSCC, TNM classification, staging results) showed a significant difference. These results indicate that, when treating elderly patients with oral cancers, physicians need to devise suitable treatment plans which take into account the possibility of upper GI tract cancer, particularly esophageal cancer, as a double-cancer.

Prevalence of esophageal cancer during the pretreatment of hypopharyngeal cancer patients: routinely performed esophagogastroduodenoscopy and FDG-PET/CT findings

BACKGROUND

The prevalence of esophageal cancer accompanied by hypopharyngeal cancer (HPC) is high and increasing rapidly in Asia. The purpose of this prospective study was to evaluate the prevalence of esophageal cancer during the pretreatment of HPC patients who were routinely examined using esophagogastroduodenoscopy (EGD) and 18F-fluorodeoxyglucose/computed tomography (FDG-PET/CT) and to discuss the utility of these examinations.

MATERIAL AND METHODS

Between September 2005 and September 2010, 33 patients with newly diagnosed HPC (all with squamous cell carcinoma) underwent EGD (after a conventional endoscopy, iodine staining was performed) and FDG-PET/CT examinations. We evaluated the prevalence of esophageal cancer among HPC patients according to the EGD findings and determined the sensitivity of FDG-PET/CT for the detection of esophageal primary tumors for each clinical T classification.

RESULTS

In 17 of the 33 patients (51.5%), 29 biopsy-proven esophageal squamous cell carcinomas were diagnosed using EGD. In eight of the 17 (47.1%) patients, two or more esophageal cancer lesions were diagnosed. Twenty-four of the 29 (82.8%) lesions were superficial esophageal cancers, and the remaining five (17.2%) lesions were advanced esophageal cancers. In six of the 29 (20.7%) esophageal cancer lesions that were detected using FDG-PET/CT, only one of the 29 (3.4%) lesions was evaluated as being equivocal; the remaining 22 (75.9%) lesions were not detected. The distribution of the clinical T classifications detected using FDG-PET/CT was as follows: T1a, 0/21 (0%); T1b, 1/3 (33%); and T3, 5/5 (100%).

CONCLUSIONS

The prevalence of esophageal cancer during the pretreatment of HPC patients was 51.5%; this prevalence was higher than that in previous reports. We believe that the increasing proportion of superficial lesions (82.8%) detected using iodine staining and EGD may have led to the relatively high prevalence. FDG-PET/CT detected only 20.7% of the esophageal cancers, although FDG-PET/CT is capable of detecting unexpected primary malignant tumors other than esophageal cancer.

Screening for oesophageal cancer

Oesophageal cancer is a global health problem with high mortality due to the advanced nature of the disease at presentation; therefore, detection at an early stage significantly improves outcome. Oesophageal squamous-cell cancer is preceded by dysplasia and oesophageal adenocarcinoma is preceded by Barrett's oesophagus, which progresses to cancer via intermediate dysplastic stages. Screening to detect these preneoplastic lesions has the potential to substantially reduce mortality and morbidity. However, the risks and benefits of such programmes to individuals and to society need to be carefully weighed. Endoscopic screening is invasive, costly and error prone owing to sampling bias and the subjective diagnosis of dysplasia. Non-endoscopic cell-sampling methods are less invasive and more cost effective than endoscopy, but the sensitivity and specificity of cytological assessment of atypia has been disappointing. The use of biomarkers to analyse samples collected using pan-oesophageal cell-collection devices may improve diagnostic accuracy; however, further work is required to confirm this. The psychological and economic implications of screening as well as the feasibility of implementing such programmes must also be considered.

Head and neck oncology--2010, part II

Part II this article reviewed the current state of the art in head and neck oncology. These include very important and stimulating new areas of interest including the marked acceptance of chemoradiation in favor of surgery in patients with cancer of the head and neck. The concept of HPV as a cause of cancer of the oropharynx is relatively new and very important in the epidemiology of these tumors. New modalities such as PET CT scanning and robotic surgery are discussed and appear to be very important in management of cancer of the head and neck. Endoscopic endonasal skull base surgery is another new high technology contribution to the field of head and neck surgery as is the use of endoscopic assisted thyroid surgery. These and other new concepts are discussed in this manuscript.

Multiple primary malignant tumors of upper gastrointestinal tract: A novel role of 18F-FDG PET/CT

AIM: To evaluate the capacity of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) for detecting multiple primary cancer of upper gastrointestinal (UGI) tract.

METHODS: Fifteen patients (12 without cancer histories and 3 with histories of upper GI tract cancer) were investigated due to the suspicion of primary cancer of UGI tract on X-ray barium meal and CT scan. Subsequent whole body ¹⁸F-FDG PET/CT scan was carried out for initial staging or restaging. All the patients were finally confirmed by endoscopic biopsy or surgery. The detection rate of multiple primary malignant cancers was calculated based on ¹⁸F-FDG PET/CT and endoscopic examinations.

RESULTS: ¹⁸F-FDG PET/CT scan was positive in 32 suspicious lesions, 30/32 were true positive primary lesions, and 2/32 were false positive. In 15 suspicious lesions with negative ¹⁸F-FDG PET/CT scan, 12/15 were true negative and 3/15 were false negative. Among the 15 patients, 12 patients had 29 primary synchronous tumors confirmed by pathology, including 8 cases of esophageal cancers accompanied with gastric cancer and 4 of hypopharynx cancers with esophageal cancer. The other 3 patients had 4 new primary metachronous tumors, which were multiple primary esophageal cancers. PET/CT imaging detected local lymph node metastases in 11 patients. Both local lymph node metastases and distant metastases were detected in 4 patients. On a per-primary lesion basis, the sensitivity, specificity, accuracy, negative predictive value and positive predictive value of ¹⁸F-FDG PET/CT for detecting multiple primary cancer of UGI tract were 90.9%, 85.7%, 89.4%, 80% and 93.7%, respectively.

CONCLUSION: The whole body ¹⁸F-FDG PET/CT may play an important role in evaluating the multiple primary malignant tumors of UGI tract cancer.

Searching for metachronous tumours in patients with head and neck cancer: the ideal protocol!

PURPOSE OF REVIEW

As treatment changes in the management of head and neck cancer, patients are reportedly living longer; therefore, their death may be due to comorbidity, metastatic disease or the development of a metachronous second primary tumour (MSPT). This review describes recent developments in the identification of MSPTs of head and neck cancer, oesophagus and lung, and suggests/recommends an 'ideal surveillance protocol'.

RECENT FINDINGS

The rate of MSPT development ranges between 6 and 9% annually for life. Improved accuracy in the detection of mucosal asymptomatic premalignant and early cancer has been enhanced by incorporating fluorescence spectroscopy in addition to modern flexible endoscopic techniques in the outpatient setting. Newer imaging has replaced old techniques (chest radiograph, barium swallow, etc.) by using radiotracer PET-computed tomography to detect local tumour activity. Further advances are anticipated in optical diagnostics and the incorporation of radiopharmaceuticals with labelled antibodies to enhance PET imaging, thus making tumour identification more accurate. Genetic classification of head and neck cancer has already identified high-risk patient groups, thereby allowing expensive tumour screening techniques to be used selectively and specifically. Patients who continue to smoke and abuse alcohol must be helped and encouraged to quit.

SUMMARY

It is now possible to review traditional follow-up policy for treated head and neck cancer patients, to encourage the implementation of an evidence-based surveillance protocol, to identify only patients who are at high-risk of developing a MSPT, to incorporate modern targeted expensive tumour screening and to allow treatment of early cancer and effective treatment, thereby improving patients' quality of life and increasing survival.

Clinical manifestation of esophageal carcinosarcoma: a Taiwan experience

Carcinosarcoma of the esophagus is a rare neoplasm with both carcinomatous and sarcomatous components. This study aimed to investigate its clinicopathologic features and endoscopic characteristics. The data of patients diagnosed to have esophageal carcinosarcoma pathologically in the past 30 years (January 1976-December 2007) were reviewed. Of 3318 cases of esophageal malignancy, 12 were diagnosed as esophageal carcinosarcoma, with an incidence of 0.36%. All of the cases were male with a mean age of 62.3 years. Of the 12 tumors, 8 were polypoid type, and 4 were ulcerative type. In the endoscopic ultrasonography examination, the tumors show heterogeneous hypoechoic lesions with irregular outer margins and internal multicystic components. Four patients (33.3%) had previous head and neck squamous cell carcinoma that occurred metachronously. This is the first report about the characteristics of esophageal carcinosarcoma under endoscopic ultrasonography examination. The relationship between esophageal carcinosarcomas and head and neck cancer needs further investigation.

Characteristics of esophageal squamous cell carcinomas and lugol-voiding lesions in patients with head and neck squamous cell carcinoma

BACKGROUND

The relationship between esophageal squamous cell carcinoma (ESCC) and Lugol-voiding lesions (LVLs) in patients with head and neck squamous cell carcinoma (HNSCC) is unclear.

AIM

To investigate the characteristics of ESCC and the relationship between ESCC and LVLs in patients with HNSCC.

METHODS

Between 2003 and 2006, 157 patients with primary HNSCC underwent Lugol chromoendoscopy at the Hiroshima University Hospital, Hiroshima, Japan. Of the patients, 135 were followed up for more than 6 months. We retrospectively analyzed the incidence of synchronous and metachronous ESCC and cumulative proportions of patients without metachronous ESCC with or without multiple LVLs.

RESULTS

Synchronous and metachronous ESCC were detected in 17 of 157 (10.8%) and 9 of 135 (6.7%) patients, respectively. The incidence of synchronous and metachronous ESCC was significantly higher in patients with LVLs compared with the incidence in those without LVLs [13 of 32 (40.6%) vs. 4 of 125 (3.2%), P<0.0001 and 8 of 19 (42.1%) vs. 1 of 116 (0.9%), P<0.0001, respectively]. Cumulative proportions of patients without metachronous ESCC were significantly lower in patients with multiple LVLs compared with that in those without multiple LVLs (P<0.0001).

CONCLUSIONS

Patients who had HNSCC, especially those with multiple LVLs in the esophagus, should be followed with close endoscopic observation with Lugol chromoendoscopy.

Narrow-band imaging endoscopy with magnification is useful for detecting metachronous superficial pharyngeal cancer in patients with esophageal squamous cell carcinoma

BACKGROUND AND AIMS

Head and neck cancers, especially pharyngeal cancers, as well as esophageal cancers frequently coexist either synchronously or metachronously, but most cases of pharyngeal cancer are detected at an advanced stage resulting in poor prognosis. The aim of this study is to evaluate the effectiveness of using narrow-band imaging (NBI) endoscopy with magnification for early detection of pharyngeal cancer on patients following their treatment for esophageal squamous cell carcinoma (SCC).

METHODS

This case series was conducted at the National Cancer Center Hospital in Tokyo between April and October 2005 and included 424 consecutive patients for surveillance endoscopy who had previously undergone chemoradiotherapy (CRT) and/or surgery for esophageal SCC. Observation of the pharyngeal region was randomly conducted on 91 patients using NBI endoscopy with magnification (NBI group) and 333 patients using conventional white light endoscopy (control group).

RESULTS

The detection rate for pharyngeal cancer was significantly higher using NBI endoscopy with magnification (10.9%; 10/91) compared with conventional endoscopy (1.2%; 4/333) (P < 0.0001). In particular, the detection rate in CRT patients was significantly higher in the NBI group (12.9%; 7/54) than the control group (0.5%; 1/191) (P < 0.0001). In addition, diagnostic sensitivity, specificity, accuracy, positive predictive value and negative predictive value for the NBI group were 100% (10/10), 97.5% (79/81), 97.8% (89/91), 83.3% (10/12) and 100% (79/79), respectively.

CONCLUSION

NBI endoscopy with magnification is a promising technique for detecting superficial pharyngeal cancer at an early stage in patients previously treated for esophageal SCC.

Detection of metachronous esophageal squamous carcinoma in patients with head and neck cancer with use of transnasal esophagoscopy

BACKGROUND

The use of transnasal esophagoscopy was examined for detecting metachronous esophageal squamous carcinoma in patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

In all, 398 transnasal esophagoscopies were performed in 293 previously treated patients with HNSCC between December 2007 and January 2009.

RESULTS

Metachronous esophageal squamous carcinoma was detected in 15 (5.1%) patients. The prevalence rate was 15.9% (7/44) in patients with hypopharyngeal cancer, significantly higher than the 8.3% (2/24) with laryngeal, 7.1% (3/42) with oropharyngeal, and 1.6% (3/183) with oral cancer (p = .001). The stage distributions of esophageal squamous carcinoma were I-II in 12 (80%) and III-IV in 3 (20%) patients. Subsequently, curative strategies were performed in 13 (87%) patients.

CONCLUSIONS

Transnasal esophagoscopy can be used as a routine survey technique in patients with HNSCC to detect metachronous esophageal squamous carcinoma, especially in those with hypopharyngeal cancer.

Transnasal endoscopy with narrow-band imaging and Lugol staining to screen patients with head and neck cancer whose condition limits oral intubation with standard endoscope (with video)

BACKGROUND

Early detection of esophageal cancer in patients with head and neck cancers may alter treatment planning and improve survival. However, standard endoscopic screening is not feasible for some patients with tumor-related airway compromise or postirradiation trismus.

OBJECTIVE

To evaluate a novel, sequential approach by integrating ultrathin endoscopy with narrow-band imaging and Lugol chromoendoscopy.

DESIGN

Cross-sectional study.

SETTING

Single center in Taiwan.

PATIENTS

Forty-four consecutive patients with transoral difficulty screened for synchronous or metachronous esophageal cancer.

MAIN OUTCOME MEASUREMENTS

Sensitivity, specificity, and accuracy in the detection of mucosal high-grade neoplasia or invasive cancer.

RESULTS

Fifty-four endoscopic interpretations were obtained, and 11 mucosal high-grade neoplasia and 7 invasive cancers were confirmed by histology. The mean examination time was 19.4 minutes (range 7.9-35.2 minutes), and all patients tolerated the procedure well. Sensitivity, specificity, and accuracy (with 95% CI) were 55.6% (95% CI, 33.5%-75.6%), 97.2% (95% CI, 85.8%-99.3%), and 83.3% (95% CI, 71.2%-90.9%), respectively, for standard endoscopy; 88.9% (95% CI, 66.9%-96.6%), 97.2% (95% CI, 85.8%-99.3%), and 94.4% (95% CI, 84.9%-97.9%), respectively, with the adjunct of narrow-band imaging; and 88.9% (95% CI, 66.9%-96.6%), 72.2% (95% CI, 55.9%-84.1%), and 77.8% (95% CI, 64.9%-86.8%), respectively, with the adjunct of Lugol chromoendoscopy. When we integrated all interpretations on the basis of the sequential approach, the estimated probability of false-negative findings was 1.2% (95% CI, 0.1%-4.6%).

LIMITATIONS

Inherent shortcomings of ultrathin endoscopy, such as its resolution, light source, and lack of magnification.

CONCLUSIONS

The use of ultrathin endoscopy in a sequential approach for multimodal detection is feasible in patients with transoral difficulty and substantially increases the detection rate of synchronous or metachronous neoplasms.

Cribado del carcinoma escamoso de esófago en población de riesgo

Together with adenocarcinoma, epidermoid esophageal carcinoma is the most clinically important neoplasm of the esophagus. Because of the low incidence of epidermoid esophageal carcinoma in the general population, strategies for its early diagnosis are not a priority compared with other neoplasms. However, because survival is low when the disease is diagnosed in symptomatic patients (less than 20% at 5 years), methods for its early diagnosis should be investigated. The use of cytology or Lugol chromoendoscopy in countries with a high incidence of epidermoid carcinoma or in individuals at increased risk (mainly alcoholics and smokers) has allowed early diagnosis and potentially curative treatment, substantially increasing life expectancy in this group of patients. These results should stimulate the evaluation and eventual implementation of programs to achieve early diagnosis and therefore greater survival in patients with epidermoid esophageal carcinoma in Western countries.