Reply to Eken and Eken

We thank Drs. Eken and Eken for their interest in our article and for raising a question about endoscopic submucosal dissection (ESD) for superficial supraglottic squamous cell carcinoma (SCC) at an early stage. They raise interesting points.

First, lymph node metastasis after ESD is an important prognostic factor. However, is there a high incidence of lymph node metastasis in clinical T1N0M0 supraglottic SCC cases with successful locoregional control after ESD? For supraglottic carcinoma, tumor size and depth are not clearly included, and vocal cord mobility is only mentioned in the TNM classification of the International Union Against Cancer (UICC) [1]. That is a problem for superficial laryngeal carcinoma because lymph node or distant metastases are strongly related to subepithelial and more vertical invasion into veins and lymph vessels. Redaelli et al. [2] reported that the incidence of occult lymph node metastasis was 0 % in patients in the pT1 category. In addition, the American Society of Clinical Oncology (ASCO) recommends that all patients with T1 or T2 laryngeal carcinoma be initially treated with intent to preserve the larynx, because laryngectomy, especially total laryngectomy, results in sequelae such as loss of voice, permanent tracheostoma, social isolation, job loss, and depression [3]. Our patient did not want additional treatment. Moreover, compared with usual T1 cases the stage of this tumor was extremely close to Tis, because this case showed only microinvasion and no vascular invasion. We consider that the incidence of metastasis is low without invasion into veins and lymph vessels if, as in our case, the T-stage is Tis (carcinoma in situ) or T1 (a stage with very slight invasion of the tumor to the subepithelial layer). At 1 month, 3 months, and then every 6 months after endoscopic mucosal resection (EMR), we performed follow-up endoscopy. Qualified otolaryngologists also routinely performed physical examination, CT scan, and laryngoscopy. We have strictly performed follow-up in cooperation with otolaryngologists.

In many previous studies on metastasis of supraglottic carcinoma, stage Tis cases were not investigated [4] [5] [6]. According to a review of the National Cancer Data Base, there were only 170 (0.3 %) patients with TisN0M0 tumors among about 50 700 patients with supraglottic carcinoma diagnosed between 1985 and 2001 in the United States [7]; and a review of a comprehensive registry of head and neck cancer in Japan (1988 – 1999) by the Japan Society for Head and Neck Cancer revealed that there were only two patients with tumors diagnosed as Tis among 1151 patients with supraglottic cancer [8]. There remain the problems that supraglottic carcinoma usually has an unfavorable prognosis because it is often diagnosed at an advanced stage – there are no remarkable symptoms at an early stage, especially in the case of superficial lesions. However, most endoscopists know that the number of cases of head and neck cancer detected at an early stage has been increasing in recent years owing to surveillance of patients at high risk of esophageal, head, and neck cancers [9] [10] [11]. Moreover, magnifying endoscopy and narrow-band imaging (NBI) allow accurate evaluation of head and neck cancers [11] [12] [13], and the EMR/ESD technique enables complete en-bloc resection in these cases together with preservation of the laryngopharynx [10] [11] [14].

However, there are still many problems concerning additional treatment with curative purpose after EMR/ESD, such as additional neck dissection, chemotherapy, and (concurrent chemo-)radiotherapy. Including in the case that we described, we have performed treatment in cooperation with otolaryngologists in patients with early-stage head and neck cancer, and we would not have succeeded without these cooperative partnerships with the otolaryngologists. Endoscopists and otolaryngologists should cooperate in treatment, follow-up, and accumulation of information on superficial cancers of the head and neck.

Competing interests: None

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