The Role of a Gastroenterologist in Detection of a Hypopharyngeal Cancer: A Case Report

Abstract

Introduction: Current guidelines do not recommend routine oropharyngeal evaluation on esophagogastroduodenoscopy (EGD). We present a case of hypopharyngeal cancer missed on two consecutive EGDs.Figure: Hypopharyngeal mass as seen during the EGD.Case: A 71-year-old male with history of prostate cancer status post radiation therapy presented with complaints of globus sensation, and gradually worsening dysphagia and odynophagia to solids and liquids for 2 months. He denied food regurgitation, heartburn, hematemesis, melena, allergies, weight loss, smoking or alcohol consumption. An EGD was performed which showed LA grade D esophagitis, small hiatal hernia and a duodenal bulb ulcer. He was started on high dose proton-pump inhibitors. Biopsies were negative for H. pylori. A repeat EGD after 2 months showed good resolution of esophagitis and well healed duodenal ulcers, as well as esophageal biopsies were negative for eosinophilic esophagitis. The patient's dysphagia persisted and further work up with an esophagram and a motility study were unrevealing. A third EGD was performed for attempted impedance evaluation to assess for association of reflux symptoms. Upon insertion of the endoscope in the hypopharynx, a 2cm friable, non-ulcerated hypopharyngeal mass was observed. Results of the biopsies revealed invasive poorly differentiated squamous cell carcinoma. A direct laryngoscopy confirmed the mass was originating from the post-cricoid mucosa, posterior to the arytenoids without arytenoidal mucosal involvement. A PET/CT scan was done and the tumor was classified as T1N0M0. Patient received radiation therapy with resolution of symptoms. Discussion: Hypopharyngeal cancers (HPC) are aggressive with majority diagnosed at advanced AJCC stages III or IV. Diagnosis of HPC at earlier stages might improve survival outcomes. In US, 7 million routine EGDs are performed per year. Oropharyngeal structures are also visible during EGDs. Therefore, EGDs could be a valuable tool in HPC screening, especially in high-risk patients. Currently, there are no guidelines regarding routine evaluation of the oropharyngeal anatomy during EGD. Since prior EGDs had missed the HPC lesion, this case raises several important questions. Should complete visualization of the oropharyngeal structures be part of a routine EGD? Does prolonged oropharyngeal evaluation during EGD raise the aspiration risk? Are there any specific sedation protocols better suited for oropharyngeal evaluation? Further studies are required to answer such questions.