Regular screening of esophageal cancer for 248 newly diagnosed hypopharyngeal squamous cell carcinoma by unsedated transnasal esophagogastroduodenoscopy
Introduction
Hypopharyngeal squamous cell carcinoma (HSCC) is one of the most common head and neck cancers, with the poorest prognosis among primary head and neck cancers. Delayed diagnosis, frequent regional neck lymph node metastasis and distant failure are the main causes of its poor prognosis. Besides, second primary esophageal squamous cell carcinoma (ESCC) are common in patients with HSCC, with the incidence of 10–50% [1], [2], [3], [4], [5], [6], which may be because HSCC and ESCC have the same environmental causative factors including alcohol, cigarette and betel nut [7], [8]. Second primary ESCC significantly leads to poor prognosis despite adequate control of primary HSCC [1], [4], [9]. Therefore, regular screening of the esophagus in HSCC patients at diagnosis is reasonable and has been recommended to detect simultaneous ESCC [1], [10].
For screening purpose, flexible esophagoscopy or esophagogastroduodenoscopy (EGD) is the most effective tool to exclude simultaneous ESCC, especially for small superficial tumors, which are not easily detected by other imaging studies including barium esophagogram, CT, MRI, and PET [1], [5]. However, it is sometimes difficult to use conventional EGD per oral route in patients with locally advanced HSCC or patients with trismus, especially where betel nut chewers are common [11]. Previously, we successfully used small-calibered EGD transnasally to diagnose HSCC and to check the esophagus without conscious sedation at the same time and found 6 simultaneous ESCCs (22%) in 27 newly diagnosed HSCCs [12]. Based on that preliminary experience, unsedated transnasal EGD becomes a regular diagnostic tool for patients with newly diagnosed HSCC, trying to pathologically prove hypopharyngeal cancer and to screen simultaneous ESCC in our hospital. In this paper, we report this prospective experience of unsedated transnasal EGD for diagnosis of 248 newly diagnosed HSCCs and the prevalence of simultaneous esophageal lesions including ESCC, esophageal dysplasia and Lugol voiding lesions (LVLs), and try to find the clinical predictors for simultaneous esophageal lesions and their survival.
Section snippets
Eligible subjects
All patients with suspicious or newly diagnosed HSCC were enrolled in this prospective study to receive transnasal EGD before cancer treatment. Conventional rigid laryngoscopy under general anesthesia was only done within 2 weeks after EGD examination when transnasal EGD did not obtain the adequate tissue for pathological diagnosis of HSCC. The exclusion criteria were prior esophageal resection, hypopharyngeal cancer but not squamous cell carcinoma in nature, recurrent HSCC, other head and neck
Results
Between May 2007 and December 2014, a total of 248 patients with newly diagnosed HSCC, including 241 men and 7 women were enrolled in this study (Table 1). The age ranged from 32 to 89 years, with a mean of 58 years. Two hundred and nineteen tumors (88.3%) were identified in the pyriform sinus, 20 tumors (8%) arose from the posterior hypopharyngeal wall and 5 tumors (2%) were located in postcricoid area. Fifty four HSCCs (21.8%) were classified as T1–T2 and 170 HSCCs (68.5%) were classified as
Discussion
Anatomically, the hypopharynx and esophagus are the continuous structures with the similar mucosal epithelium and both are for food swallow, so that the hypopharynx and esophagus expose to very similar exogenous or endogenous substances and carcinogens. Many epidemiologically case-control or longitudinal follow-up studies have shown that HSCC and ESCC share the same environmental risk factors including alcohol and cigarette in most countries and betel nut besides in Southeast Asia, which cause
Conclusions
About 45% of the 248 patients with newly diagnosed HSCC have simultaneous esophageal lesions, especially heavy alcoholic drinkers and the patients with large neck metastases, which include ESCC in 15% of the patients, esophageal dysplasia without ESCC in another 9% and LVLs without ESCC or esophageal dysplasia in the other 21%, Unsedated transnasal EGD can be the first endoscopic technique for pathological diagnosis of HSCC and screening of simultaneous ESCC during a single session.
Conflict of interest statement
None declared.
Acknowledgement
“This work was supported in part by the National Science Council of the Republic of China (NSC 98-2314-B-002-046-MY3, 101-2314-B-002-061-MY3, and 102-2628-B-002-033-MY3).”
References (27)
- et al.
Initial staging of squamous cell carcinoma of the oral cavity, larynx and pharynx (excluding nasopharynx). Part 2: Remote extension assessment and exploration for secondary synchronous locations outside of the upper aerodigestive tract. 2012 SFORL guidelines
Eur Ann Otorhinolaryngol Head Neck Dis
(2013) - et al.
Multiple primary tumors in patients diagnosed with hypopharyngeal cancer
Otolaryngol Head Neck Surg
(2003) - et al.
Unsedated transnasal esophagogastroduodenoscopy for the evaluation of dysphagia following treatment for previous primary head neck cancer
Oral Oncol
(2009) - et al.
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)
Gastrointest Endosc
(2009) - et al.
Self-training in unsedated transnasal EGD by endoscopists competent in standard peroral EGD: prospective assessment of the learning curve
Gastrointest Endosc
(2008) - et al.
Clinical significance of intensive endoscopic screening for synchronous esophageal neoplasm in patients with head and neck squamous cell carcinoma
Scand J Gastroenterol
(2014) - et al.
Impact of the early detection of esophageal neoplasms in hypopharyngeal cancer patients treated with concurrent chemoradiotherapy
Asia Pac J Clin Oncol
(2014) - et al.
Prevalence of esophageal cancer during the pretreatment of hypopharyngeal cancer patients: routinely performed esophagogastroduodenoscopy and FDG-PET/CT findings
Acta Oncol
(2012) - et al.
Significance of endoscopic screening and endoscopic resection for esophageal cancer in patients with hypopharyngeal cancer
Jpn J Clin Oncol
(2010) - et al.
Lifetime risk of distinct upper aerodigestive tract cancers and consumption of alcohol, betel and cigarette
Int J Cancer
(2014)
Independent and combined effects of alcohol intake, tobacco smoking and betel quid chewing on the risk of esophageal cancer in Taiwan
Int J Cancer
The impact of second primary malignancies on head and neck cancer survivors: a nationwide cohort study
PLoS ONE
Routine endoscopy for esophageal cancer is suggestive for patients with oral, oropharyngeal and hypopharyngeal cancer
PLoS ONE
Cited by (27)
Second esophageal neoplasms after head and neck index tumor: Incidence, risk factors and prognosis
2023, Acta Otorrinolaringologica EspanolaSquamous Cell Carcinoma of the Esophagus
2022, Gastroenterology Clinics of North AmericaCitation Excerpt :This examination can be followed by a traditional upper endoscopy if suspicious lesions are found. TNE requires no sedation, is well tolerated, is not time-consuming, has good sensitivity and specificity, and can be performed at the point of care by primary care physicians.138,139 However, TNE is not widely available limiting its applicability in the screening setting.
Impact of invasion into cervical esophagus for patients with hypopharyngeal squamous cell carcinoma
2022, Oral OncologyCitation Excerpt :Among head and neck cancer, HypoSCC had been reported with the highest risk of synchronous ESCC.[24,25] It has been reported that the incidence of synchronous ESCC ranged from 10 to 40%.[14,25] Therefore, esophagoscopy has been listed as one of the necessary examinations for patients with newly diagnosed HypoSCC.[13–15]
Screening for Esophageal Squamous Cell Carcinoma
2019, Clinical Gastrointestinal EndoscopyScreening for esophageal squamous cell carcinoma: recent advances
2018, Gastrointestinal EndoscopyCitation Excerpt :Ultrathin transnasal endoscopy (TNE) allows for visualization of the esophagus without sedation, abrogating the risks of sedation and reducing costs. Huang et al44 found TNE to be well-tolerated in over 98% of patients. Wang et al45 demonstrated a reasonable safety profile, with only 2 of 441 patients undergoing TNE having adverse events treated conservatively.
Transnasal esophagoscopy
2018, Dysphagia Evaluation and Management in Otolaryngology