S2093 Case Report of Hypopharyngeal Extraesophageal Cancer Incidentally First Visualized and Diagnosed at Esophagogastroduodenoscopy With Tumor Mass Biopsies

Abstract

INTRODUCTION: A gastroenterologist standardly concentrates on examining the esophagus, stomach, and duodenum at esophagogstroduodenoscopy (EGD), while an otolaryngologist concentrates on examination of the hypopharynx, vocal chords, and larynx during flexible laryngoscopy. Therefore, a laryngologist is almost always the first to diagnose hypopharyngeal cancer by laryngoscopy with biopsies. However, the gastroenterologist gets a fleeting look at hypopharyngeal structures during EGD. A case is reported of a gastroenterologist incidentally diagnosing hypopharyngeal (extraesophageal) cancer during EGD. CASE DESCRIPTION/METHODS: A 68-year-old female, with a 50-pack-year history of smoking cigarettes, long history of alcoholism, and no known GERD presented with 10 weeks of dysphagia to solids and liquids associated with 10-kg-involuntary weight loss during 6 weeks. Physical examination revealed cachexia (BMI = 16.0 Kg/m2), and temporal and intercostal muscle wasting. The hemoglobin level was 13.6 g/dl. Routine liver function tests were within normal limits. EGD performed by gastroenterology revealed mild antral gastritis, and an endoscopically normal esophagus and duodenum. During endoscopic extubation, a friable 2.0-cm-wide exophytic left arytenoid/hypopharyngeal (extraesophageal) mass, with overlying exudate that was not obstructing the airway or esophagus was identified and biopsied (Figure 1). Pathologic analysis of these biopsies revealed moderately well-differentiated invasive squamous cell carcinoma (Figure 2), which was confirmed by positive immunohistochemistry for p40, and p16 (not illustrated), which are markers for squamous cell cancer. Neck CT scan revealed a 2.5-cm-wide hypopharyngeal mass (Figure 3). Positive emission tomography scan showed the same hypopharyngeal mass. After undergoing prophylactic PEG placement, the patient received daily radiation to the hypopharynx and bilateral neck area for a total of 70 gy during 7 weeks, with concurrent chemotherapy with 3 rounds of cisplatin. Follow-up neck CT 6 months later showed near complete resolution of tumor bulk. DISCUSSION: This work shows that a gastroenterologist can incidentally diagnose major hypopharyngeal lesions during EGD, and successfully diagnose hypopharyngeal cancer by endoscopic biopsies. Gastroenterologists may avoid biopsying lesions next to the vocal chord due to the risks of inducing laryngospasm. Incidental diagnosis during EGD by gastroenterologists may reduce medical costs and improve patient prognosis by earlier cancer detection.Figure 1.: Image obtained during esophagogastroduodenoscopy showing a 2.0 cm wide hypopharyngeal mass, not obstructing the vocal chords which are seen distally.Figure 2.: Medium power photomicrograph of hematoxylin & eosin (H&E) stained section of endoscopic biopsies of hypopharyngeal mass shows non-keratinizing squamous cell carcinoma (arrows), with tumors cells showing high nuclear-to-cytoplasmic ratio, high-grade, pleomorphic cytologic features, and having intimately associated lymphoplasmocytic infiltrates.Figure 3.: Axial view image of CT scan of the neck with IV contrast showing a heterogeneously enhancing mass (arrow) in the supraglottic region, arising from the left aryepiglottic fold, measuring 2.5 × 1.8 cm.