Superficial Pharyngeal Cancer Research Articles

Observation of the Pharynx to the Cervical Esophagus Using Trans-nasal Endoscopy with Image-enhanced Endoscopy for Early Detection of Head and Neck Cancers

Introduction: We started endoscopic treatment for superficial pharyngeal cancer in 1996, and thus far, 97 lesions of 77 cases of superficial head and neck cancer have been detected using trans-oral endoscopy. However, some areas are difficult to observe with trans-oral endoscopy because of the gag reflex. We have therefore applied transnasal endoscopy for observing of the pharynx to the cervical esophagus. Methods: To avoid overlooking cancers located at the floor of the mouth, soft palate and uvula, we first observe the oral cavity. After administering local anesthesia to the nose without sedation, the endoscope is inserted through the nose. When the tip of the endoscope reaches caudal to the uvula, the patient opens his or her mouth wide, sticks the tongue forward as far as possible and makes a makes a vocalization like “ayyy”. The endoscopist then makes the endoscope take a U-turn and observes the oropharynx, particularly radix linguae. To examine the hypopharynx and the orifice of the esophagus, the patient is asked to blow hard and puff their cheeks while the mouth remains closed. This approach provides a much better view of the orifice of the esophagus than is possible with trans-oral endoscopy with deep sedation. Results: In this study, we detected 22 superficial cancers of the oral cavity. Previous efforts to detect such cancers using trans-oral endoscopy have failed. In addition, we were never able to detect early cancers located at base of tongue in the past, but since implementing the intra-oropharyngeal U-turn method, we have detected more than 10 cases. We were also never able to detect early cancers located at the pharyngoesophageal junction in the past, but since implementing the modified Valsalva maneuver, we have detected more than 20 cases. Between 2008 and 2016, a total of 164 cases of 227 lesions of superficial head and neck cancer were detected by trans-nasal endoscopy, which is more than twice as many as were detected with conventional screening. Mucosal redness, white deposits or loss of a normal vascular pattern and proliferation of vascular pattern such as small dots or salmon roe with a close-up view of it are important characteristics to diagnose superficial pharyngeal cancer. Moreover, a brownish area using image-enhanced endoscopy is useful for early diagnosis. With adequate extension of the pharyngeal mucosa using the Valsalva maneuver, observing the protruded areas should prove useful for diagnosing the depth of invasion. Conclusions: Observing the pharynx to the cervical esophagus using trans-nasal endoscopy with imageenhanced endoscopy is useful for early detection of head and neck cancers.

Efficacy of double-scope endoscopic submucosal dissection and long-term outcomes of endoscopic resection for superficial pharyngeal cancer.

Owing to increased awareness and use of narrow-band imaging, there are more opportunities to treat superficial pharyngeal cancer (SPC). The present study aimed to describe the short- and long-term outcomes of endoscopic resection (ER) for SPC. This study included 166 consecutive SPC in 113 patients treated during 2006 to 2013 at one referral cancer center. In the first period, we treated patients using endoscopic mucosal resection (EMR), in the second period using conventional ESD (cESD) and in the recent period using double-scope ESD (dsESD), which involves a second thin endoscope for assistance to produce traction. Median follow-up period was 30months. All lesions were diagnosed as squamous cell carcinoma. Complete resection rate of cESD and dsESD procedures was 56.4% and 82.3% (P<0.01), and local recurrence rate was 2.6% and 0.0%, respectively. Procedure duration was significantly shorter for dsESD than for cESD (P<0.05). Four cases of recurrent lymph node (LN) metastasis were observed; however, all patients with LN metastases survived to a 48-month median interval after neck dissection. Risk factors for LN metastasis included subepithelium invasion, tumor thickness >1000μm, droplet infiltration, and lymphovascular invasion. Overall survival rate after 5years was 79.5%; no patients died of SPC. Cumulative rate of metachronous SPC after 5years was 46.5%. ER for SPC is a feasible and effective treatment, although metachronous SPC occurred frequently. For the technique of ER, dsESD was effective.

Gastrointestinal Endoscopy-Assisted Minimally Invasive Surgery for Superficial Cancer of the Uvula.

Previous studies reported that endoscopic resection is effective for the treatment of superficial pharyngeal cancers, as for digestive tract cancers. However, the optimal treatment for superficial cancer of the uvula has not been established because of the rarity of this condition. We present two male patients in their 70s with superficial cancer of the uvula, detected with upper gastrointestinal endoscopy. Both patients underwent surgical resection of the uvula under general anesthesia. The extent of the lesions was determined by means of gastrointestinal endoscopy by using magnifying observation with narrow-band imaging, enabling the performance of minimally invasive surgery. Endoscopic submucosal dissection was performed to achieve en bloc resection of the intramucosal carcinoma that had infiltrated the area adjacent to the uvula. Gastrointestinal endoscopists should carefully examine the laryngopharynx to avoid missing superficial cancers. Our minimally invasive treatment for superficial cancer of the uvula had favorable postoperative outcomes, and prevented postoperative loss of breathing, swallowing, and articulation functions.

Endoscopic submucosal dissection as minimally invasive treatment for superficial pharyngeal cancer: a phase II study (with video)

Although endoscopic submucosal dissection (ESD) has been applied for superficial pharyngeal cancer, no prospective trials have been reported. To investigate the efficacy and safety of ESD for superficial pharyngeal cancer, we conducted a prospective phase II trial. Fifty-four patients with 73 lesions were enrolled from September 2010 to August 2014, and ESD was performed. The primary endpoint was the complete resection rate. Secondary endpoints were safety, recurrence-free survival, overall survival, and incidence of metachronous pharyngeal cancer. Fifty-four patients had stage 0-III cancer: stage 0, n = 22; stage I, n = 14; stage II, n = 17; and stage III, n = 1. The en bloc resection rate was 100%, and the complete resection rate was 79.5% (58/73 lesions; 95% confidence interval, 68%-88%). No serious adverse events related to ESD were encountered. Four patients required nasogastric intubation and feeding. No patients required percutaneous endoscopic gastrostomy and tracheotomy. Swallowing, speech, and airway functions were preserved in all patients. One of the 54 patients died of an unrelated illness. Median follow-up was 27 months (range 6-55 months). Local cervical lymph node metastasis was observed in 1 patient, and the case was salvaged successfully with lymph node dissection. The 3-year overall and recurrence-free survival rates were 97.7% and 98.1%, respectively. Cumulative development of multiple cancers of the pharynx at 3 years was 18.4%. ESD appears to be a safe and effective minimally invasive treatment in patients with superficial pharyngeal cancer. ( UMIN000003623.).

Utility of magnifying endoscopy with narrow band imaging in determining the invasion depth of superficial pharyngeal cancer

Magnifying endoscopy with narrow band imaging (ME-NBI) is useful to diagnose invasion depth of superficial esophageal cancer. The purpose of this study was to evaluate the utility of ME-NBI of superficial pharyngeal cancer. Between April 2008 and June 2012, 146 lesions in 104 patients who underwent ME-NBI and en bloc resection were retrospectively analyzed. Based on magnifying endoscopic classification, proposed by the Japan Esophageal Society, microvasculature type was classified into B1, B2, and B3. B1 alone, B2, and B3 were observed in 128, 14, and 4 lesions, respectively. The frequency of subepithelial cancer were 20.3% (26 of 128), 78.6% (11 of 14), and 100% (4 of 4), respectively (p < .05). Mean invasion distance were 650 μm, 720.0 μm, and 2256.5 μm. Positive and negative predictive value for diagnosing subepithelial cancer based on the presence of B2 or B3 was 83.3% (15 of 18) and 79.7% (102 of 128). ME-NBI is useful to determining invasion depth of superficial pharyngeal cancer.

Magnifying Endoscopy with Narrow Band Imaging to Determine the Extent of Resection in Transoral Robotic Surgery of Oropharyngeal Cancer

Transoral robotic surgery (TORS) is a less invasive treatment that is becoming popular all over the world. One of the most important factors for achieving success in TORS is the ability to determine the extent of resection during the procedure as the extent of resection in the laryngopharynx not only affects oncological outcomes but also directly affects swallowing and voice functions. Magnifying endoscopy with narrow band imaging (ME-NBI) is an innovative optical technology that provides high-resolution images and is useful in detecting early superficial pharyngeal cancers, which are difficult to detect by standard endoscopy. A 55-year-old male with superficial oropharyngeal cancer has been successfully treated by combining MB-NBI with TORS and MB-NBI was useful in determining the extent of resection. ME-NBI with TORS will make it possible to achieve a higher ratio of minimally invasive treatment in pharyngeal cancer.

Pharyngeal Cancer Surveillance Using Narrow Band Imaging during Conventional Upper Gastrointestinal Endoscopy

Background: Recent studies have suggested that narrow band imaging (NBI) is useful for detecting superficial pharyngeal cancer. Nevertheless, pharyngeal observation is not a routine practice during upper gastrointestinal (GI) endoscopy. Two aims of this study were to evaluate the feasibility of pharyngeal observation during upper GI endoscopy and to determine the prevalence of pharyngeal cancer in asymptomatic high-risk patients. Methods: Fifty-year-old or older asymptomatic males with smoking and drinking habits were prospectively recruited as a pharyngeal cancer high-risk group. A total of 224 high-risk patients underwent pharyngeal observation using NBI before conventional upper GI endoscopy. The feasibility of pharyngeal examination without sedation was assessed by a questionnaire for the first 60 participants. Results: The median time for pharyngeal observation was 1.7 min. The questionnaire demonstrated 88% of participants thought the pharyngeal examination acceptable. The NBI examination identified 5 superficial pharyngeal cancers (2 Tis and 3 T1) in 224 high-risk patients; the prevalence of pharyngeal cancer in this group was 2.2%. Three of the 5 patients had a concurrent or past history of esophageal squamous cell carcinoma (ESCC). Conclusions: Pharyngeal observation using NBI during upper GI endoscopy is well tolerated and recommended for all high-risk patients, particularly those with a history of ESCC.

Sa1456 Characteristics of Esphageal Achalasia in Patients Treated With Per-Oral Endoscopic Myotomy

synchronous esophageal cancer, and 8 had a history of radiotherapy for pharyngeal cancer. Histologically, 127 lesions were carcinoma in situ, 50 showed invasion to the subepithelial layer, and 8 were finally diagnosed as high-grade intraepithelial neoplasia. Mean maximum tumor size was 20.2 mm (range 1-84 mm), lymphovascular involvement was observed in 5 patients, negative lateral margins were detected in 163 lesions (88%), and negative vertical margins were present in 183 lesions (99%). Treatment-related adverse events were observed in three cases: subcutaneous emphysema in two cases and aspiration pneumonia in one case. Cases improved with conservative medical management. There were no severe events or treatment-related deaths. Tracheostomy prior to ESD was performed in 6 patients, and extubation one day after ESD as a result of fear of laryngeal edema was performed in 41 patients. There were no remarkable events after extubation. Mean follow-up period was 920 days. Although local recurrence developed in one case at the primary site, it was treated by ESD. Synchronous lymph node metastasis was detected in one case and lymph node metastasis in the neck during follow-up developed in two cases. No other recurrent findings were detected in these three patients after cervical lymph node dissection. There were no deaths due to primary pharyngeal cancer, however, 8 patients died of other causes. The three-year-survival rate was 95.7%, and the five-year-survival rate was 84.3%. Conclusions: ESD for superficial pharyngeal cancer is a safe and feasible treatment option. No severe adverse events occurred and the average prognosis was extremely good.

Feasibility of a “resect and watch” strategy with endoscopic resection for superficial pharyngeal cancer

After endoscopic resection (ER) for superficial pharyngeal cancer (SPC), additional treatments such as radical surgical resection or radiation therapy may be needed in cases of possible incomplete resection. However, the benefit of prophylactic additional treatment is unclear. To evaluate the feasibility of a "resect and watch" strategy with ER for SPC. Retrospective, single-center cohort study. Tertiary cancer center. A total of 32 patients with 47 SPCs were eligible. A "resect and watch" strategy of initial ER and observation until development of secondary diseases, including local recurrence, neck lymph node metastasis (LNM), and metachronous pharyngeal cancer. Complications, tumor recurrence, development of metachronous pharyngeal cancer, overall survival, and cause-specific survival. There were no severe complications related to ER. Median length of follow-up was 43 months (range, 7-76 months). Cumulative development of secondary diseases at 5 years was 44% (95% CI, 24.5%-63.8%). Local recurrence (N = 4) and neck LNM (N = 5) were successfully treated by local resection (2 partial surgical resections and 2 additional ERs) and neck dissection, respectively. Metachronous pharyngeal cancers (N = 6) were completely removed by ER. The overall survival and cause-specific survival rates at 5 years were 84.4% (95% CI, 70.0%-98.8%) and 100%, respectively. No patient needed radical surgery as an additional therapy. Thus, the larynx and its function were preserved in all patients. Retrospective nature, single-center setting, relatively small sample size. A "resect and watch" strategy with ER for SPC is feasible and rational.

Clinical outcomes of endoscopic mucosal resection and endoscopic submucosal dissection as a transoral treatment for superficial pharyngeal cancer

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been introduced for the treatment of superficial pharyngeal cancer. Sixty superficial pharyngeal cancers in 45 patients were treated by EMR or ESD. Resectability and curability, complications, and survival were analyzed retrospectively. The en bloc resection and curative resection rate were higher with ESD (100; 81.6%) than with EMR (59; 50%). In subgroup analysis with regard to tumor size ≤ 10 mm, both resection rates were comparative. All the patients had preserved larynx and swallowing, speech, and airway function. Two of the 45 patients died of other diseases, local recurrence was observed in 4 of 18 patients with noncurative resection with a median observation period of 38 months. No recurrence was observed in patients with curative resection. ESD or EMR for superficial pharyngeal cancer is minimally invasive treatment and lesions larger than 10 mm should be referred for ESD.

A new technique for pharyngeal endoscopic submucosal dissection: peroral countertraction (with video)

Endoscopic submucosal dissection (ESD) can be used to perform resections en bloc for early-stage GI tumors. Pharyngeal ESD is less invasive, but technically difficult. Therefore, innovations to safely and easily perform this procedure are needed. The aim of this study was to evaluate ESD under peroral countertraction, a new traction system for improving subepithelial cutting line visualization, compared with conventional ESD. Retrospective study. Toranomon Hospital, Tokyo, Japan. A total of 93 patients (140 lesions) with superficial pharyngeal cancers treated with ESD were enrolled. ESD under peroral countertraction or conventional ESD. En bloc resection rate, size of the tumor, and procedure time. All lesions were resected en bloc by using this technique. The mean longest lesion size was 23.4 mm in the peroral countertraction group and 18.1 mm in the conventional group (P = .038). The mean procedure time did not differ between the 2 groups. Subcutaneous emphysema as an adverse event was observed in the conventional ESD group. No treatment-related adverse events occurred in the peroral countertraction group. Retrospective comparison. ESD under peroral countertraction is easier and appears to be safer for completely removing superficial mesopharyngeal and hypopharyngeal cancers.

Superficial pharyngeal cancer can be diagnosed in the West

Superficial pharyngeal cancer can be diagnosed in the West

Submucosal Dissection for Superficial Pharyngeal Cancer

Objective: We have previously reported that narrow band imaging (NBI) combined with magnifying endoscopy is useful in detecting early superficial pharyngeal cancers, which are difficult to detect with a standard endoscopy. In this study, we investigated the usefulness of submucosal dissection for such superficial lesions of pharyngeal cancer retrospectively. Method: Fifty patients with superficial pharyngeal cancer were treated since September 2007. Under general anesthesia, a curved laryngoscope was inserted trans-orally, the extent of the lesion was determined by the NBI endoscope, and the lesion was dissected with an orally inserted curved electric knife. Results: Tracheostomy was performed in 5 cases, which had synchronous multiple lesions in the hypopharynx. Regarding adverse effects, postoperative bleeding occurred in one case, which needed emergency tracheostomy. With a median follow-up period of 20 months, metachronous multiple laryngo-pharyngeal cancer occurred in 4 cases and recurrence occurred in 2 cases. All the metachronous cancer cases and the recurrent case were controlled with additional endoscopic submucosal dissection. The cause-specific survival rates at 2 years were 100%. All the patients retained their pharynx and their speaking, breathing, and swallowing functions. Conclusion: Endoscopic submucosal dissection for early pharyngeal cancer allows excellent survival and preservation of swallowing and voice functions. Early detection of superficial pharyngeal cancer with narrow band imaging technology and treatment with endoscopic submucosal dissection can be a new treatment strategy for head and neck cancer.

Transoral Resection of the Pharyngeal and Laryngeal Cancers

Objective: Evaluate the efficacy and safety of the transoral en bloc resection of superficial pharyngeal and laryngeal cancers. Transoral tumor resection is one option of minimally invasive surgery. Method: From 2008 to 2010, 34 lesions (from 31 patients) were resected transorally under microscope with monopolar cautery. Results: Twenty-four hypopharyngeal, 4 oropharyngeal, and 6 laryngeal cancers were operated on using this method. Operation field was widely exposed with wide caliber scope or extending laryngoscope. Bimanual procedure under microscope enabled us to achieve en bloc resection. Radical neck dissection was done simultaneously in one case. Local control rate was 97%. No postoperative dyspnea or dysphagia was observed. Two-thirds of the patients had no symptoms, which were detected by screening of the esophageal cancer patients. Narrow Band Imaging (NBI) system was very useful for detection of the superficial lesions. Conclusion: Transoral robotic surgery is now applied for minimally invasive surgery, which is not applicable yet in Japan. Our technique of en bloc resection can be easily introduced and was effective in maintaining the quality of life after treatment.

Long-term outcome of transoral organ-preserving pharyngeal endoscopic resection for superficial pharyngeal cancer

Early detection of pharyngeal cancer has been difficult. We reported that narrow-band imaging (NBI) endoscopy can detect superficial pharyngeal cancer, and these lesions can be treated endoscopically. To assess the safety and long-term efficacy of transoral organ-preserving pharyngeal endoscopic resection (TOPER) for superficial pharyngeal cancer. Retrospective 2-center cohort study. The study included 104 consecutive patients with superficial pharyngeal cancer. TOPER with the patients under general anesthesia. Safety of the procedure, long-term survival, clinical outcome. A total of 148 consecutive lesions were resected in 104 patients. There was no severe adverse event. Temporary tracheostomy was required in 17 patients (16%) to prevent airway obstruction. The median fasting period and hospital stay after TOPER were 2 days (range 1-20 days) and 8 days (range 3-58 days), respectively. Ninety-six patients (92%) had no local recurrence or distant metastases. Local recurrence at the primary site developed in 6 patients, but all were resolved by repeat TOPER. With a median follow-up period of 43 months (range 3-96 months), the overall survival rate at 5 years was 71% (95% CI, 59-82). Cause-specific survival rate at 5 years was 97% (95% CI, 93-100). The cumulative development rate of multiple cancers in pharyngeal mucosal sites at 5 years was 22% (95% CI, 12-33). The pharynx was preserved in all patients, and they experienced no loss of function. Retrospective design. Peroral endoscopic resection of superficial pharyngeal cancer is a feasible and effective treatment with curative intent.

Long-term Outcome of Endoscopic Mucosal Resection for Superfi cial Pharyngeal Cancers

Long-term Outcome of Endoscopic Mucosal Resection for Superfi cial Pharyngeal Cancers

Narrow‐band imaging endoscopy with magnification is useful for detecting metachronous superficial pharyngeal cancer in patients with esophageal squamous cell carcinoma

Head and neck cancers, especially pharyngeal cancers, as well as esophageal cancers frequently coexist either synchronously or metachronously, but most cases of pharyngeal cancer are detected at an advanced stage resulting in poor prognosis. The aim of this study is to evaluate the effectiveness of using narrow-band imaging (NBI) endoscopy with magnification for early detection of pharyngeal cancer on patients following their treatment for esophageal squamous cell carcinoma (SCC). This case series was conducted at the National Cancer Center Hospital in Tokyo between April and October 2005 and included 424 consecutive patients for surveillance endoscopy who had previously undergone chemoradiotherapy (CRT) and/or surgery for esophageal SCC. Observation of the pharyngeal region was randomly conducted on 91 patients using NBI endoscopy with magnification (NBI group) and 333 patients using conventional white light endoscopy (control group). The detection rate for pharyngeal cancer was significantly higher using NBI endoscopy with magnification (10.9%; 10/91) compared with conventional endoscopy (1.2%; 4/333) (P < 0.0001). In particular, the detection rate in CRT patients was significantly higher in the NBI group (12.9%; 7/54) than the control group (0.5%; 1/191) (P < 0.0001). In addition, diagnostic sensitivity, specificity, accuracy, positive predictive value and negative predictive value for the NBI group were 100% (10/10), 97.5% (79/81), 97.8% (89/91), 83.3% (10/12) and 100% (79/79), respectively. NBI endoscopy with magnification is a promising technique for detecting superficial pharyngeal cancer at an early stage in patients previously treated for esophageal SCC.

Feasibility of endoscopic mucosal resection for superficial pharyngeal cancer: a minimally invasive treatment

New diagnostic techniques have recently been developed so detection of superficial pharyngeal cancer is dramatically increasing and endoscopic mucosal resection (EMR) can now be performed on an experimental basis. The aim of this study was to clarify the effectiveness of EMR for superficial pharyngeal cancer. Between 2004 and 2007, 31 patients with 37 pharyngeal lesions underwent EMR at our hospital. EMR using a cap-fitted endoscope (EMR-C) was used on 34 lesions and strip biopsies on the remaining three. We retrospectively assessed the effectiveness of those procedures in treating superficial pharyngeal cancer. Median procedure time was 45 minutes (range 20 - 180 minutes) and median hospital stay was 7 days (range 4 - 12 days). Regarding complications, one patient experienced laryngeal edema, one suffered aspiration pneumonia, and two sustained dermatitis around the mouth caused by Lugol staining. Histologically, 18 lesions were confirmed as carcinoma in situ and the other 19 lesions demonstrated microinvasion of the subepithelial tissue with lymphatic invasion in one case. During the median follow-up period of 40 months (range 21 - 62 months), two patients received radiotherapy and two patients underwent an additional EMR because of recurrent tumors. Five other patients developed metachronous superficial pharyngeal cancers, but all those lesions were resected primarily by EMR while two of the study's 31 patients died from esophageal cancer. None of the remaining 20 patients experienced any recurrent or metachronous tumors during their follow-up periods. Our results indicated that EMR was a safe, effective, and minimally invasive treatment for superficial pharyngeal cancer.

A New Field of Endoscopic Treatment, Superficial Pharyngeal Cancer: A Case Series of 115 Superficial Cancers

A New Field of Endoscopic Treatment, Superficial Pharyngeal Cancer: A Case Series of 115 Superficial Cancers

Endoscopic diagnosis of pharyngeal carcinoma by NBI

Head and neck cancer, especially pharyngeal cancer, frequently co-exist with esophageal cancer, but pharyngeal cancer has proven difficult to detect in such cases before its progression to an advanced stage. Several recent reports have indicated that narrow-band imaging (NBI) endoscopy with magnification is able to improve the detection of superficial pharyngeal cancer. NBI is a relatively new optical technology based on limiting the depth of light penetration into the mucosa. The recognition of these lesions is dramatically improved and the microvascular structure of the mucosal surface is significantly enhanced by NBI. As a result, NBI enables more accurate diagnosis and increases the detection rate of superficial pharyngeal cancer. This particular field has only been developed in recent years, however, and there are still a number of problems that need to be addressed in the future. It will be necessary to accumulate and evaluate resected specimens and follow up patients in order to establish the appropriate criteria for curative endoscopic treatment in these patients. The ease in using NBI in combination with this new diagnostic concept based on microvascular changes makes NBI suitable for worldwide use in the future.