Screening examination for superficial carcinoma of the head and neck following endoscopic resection for esophageal carcinoma

We read with great interest the article by Katada et al. on the use of narrow-band imaging combined with magnifying endoscopy (NBI-ME) for detecting superficial squamous cell carcinoma (SCC) of the head and neck in patients with esophageal SCC [1]. They enrolled 112 patients with a current or previous diagnosis of esophageal SCC in a prospective screening study conducted over a period of 2 years. All patients underwent endoscopic screening of the head and neck by NBI-ME, and 15 patients (13 %) were found to have superficial SCC of the head and neck (three lesions in the oral cavity, four lesions in the oropharynx, and nine lesions in the hypopharynx).

We have also retrospectively evaluated the recent outcome of screening examination for superficial SCC of the head and neck in patients who had undergone endoscopic resection for esophageal SCC. Between April 2002 and March 2009, 173 patients with esophageal SCC underwent endoscopic resection (endoscopic mucosal resection [EMR] or endoscopic submucosal dissection [ESD]) at Hokkaido University Hospital. A total of 30 patients who had synchronous or prior head and neck cancer were excluded from the screening examination. The remaining 143 patients were enrolled for retrospective evaluation.

Following endoscopic resection, we performed follow-up endoscopy with Lugol dye staining at 3 months, 6 months, and 1 year. The hypopharynx, oropharynx, larynx, and oral cavity were also carefully observed by endoscopic examination. Subsequently, follow-up endoscopy with Lugol dye staining was performed annually. Physical examination and laryngoscopy were performed by an experienced otolaryngologist annually. After May 2007, we used NBI-ME for endoscopic screening.

Among the 143 patients, 14 (10 %) were found to have superficial SCC of the head and neck during the follow-up term (median term of 37 months). Nine had hypopharyngeal cancer (two had double lesions in the hypopharynx), four had laryngeal cancer of the epiglottis, and one had oropharyngeal cancer. Among them, two with laryngeal cancer of the epiglottis underwent radiotherapy, and 12 with tumors that were detected by endoscopic examination in an early stage underwent endoscopic resection [2] [3]. Six of the patients who underwent resection had histologically confirmed shallow invasion of the subepithelium (the remaining six patients having carcinoma in situ). None of those six patients wished to undergo open surgery or adjuvant chemoradiotherapy in spite of an explanation of the risk of cancer metastasis, and they were observed to assess the outcome.

It should be noted that among the 14 patients who were found to have superficial SCC of the head and neck, four (29 %) had tumors at the anterior part of the epiglottis. Because this site is not usually observed by gastrointestinal endoscopy, two of the cases were found in a rather advanced stage; from these two cases we learned the necessity of careful endoscopic observation at the anterior part of the epiglottis. Tumors in the other two patients were found at an early stage and were treatable by ESD. Katada et al. reported a high detection rate for superficial SCC of the head and neck in their screening study during a 2-year period; however, they found no laryngeal cancer. Images from a patient in our present study, who was found to have early laryngeal carcinoma of the epiglottis by follow-up endoscopic examination, are presented in [Fig. 1]. The patient was treated by ESD and achieved complete remission.

Fig. 1 The anterior part of the epiglottis of an 80-year-old man who previously underwent endoscopic submucosal dissection for esophageal carcinoma. a Narrow-band imaging combined with magnifying endoscopy showed a well-demarcated brownish area. A biopsy specimen obtained from the lesion was histologically diagnosed as squamous cell carcinoma. b Appearance after complete resection of the lesion by endoscopic submucosal dissection. The subepithelial layer under the lesion was clearly visible after resection. c Photomicrograph of the resected specimen showing carcinoma invading the subepithelial layer to a depth of 550 µm (hematoxylin and eosin × 200). Adequate subepithelial tissue and a complete vertical margin were obtained.

In the United States, laryngeal cancer accounts for about 26 % of all head and neck cancer cases [4], and a review of the National Cancer Data Base (NCDB) showed that 32 % of laryngeal cancer cases in the United States were laryngeal SCC of the supraglottis [5]. Thus, laryngeal cancer of the epiglottis is not a rare tumor.

The anterior part of the epiglottis has an anatomically narrow space and is difficult to observe carefully in gastrointestinal endoscopy or laryngoscopy. Detection of early-stage laryngeal carcinoma at this site is difficult. We emphasize that finding superficial SCC of the head and neck including the anterior part of the epiglottis is the business of gastrointestinal endoscopists who can perform an examination using high-performance video endoscopy such as NBI-ME. Patients who undergo endoscopic resection for esophageal SCC have an increased risk of SCC of the head and neck and should therefore be closely observed in order to maintain a good prognosis and quality of life.

Competing interests: None

References

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