Prediction of lymph-node metastasis and lymphatic invasion of superficial pharyngeal cancer on narrow band imaging with magnifying endoscopy.

OBJECTIVE: We studied factors related to lymphatic invasion and lymph-node metastasis in patients with superficial pharyngeal cancer who underwent transoral surgery. METHODS: The study group comprised 67 patients with superficial pharyngeal cancer (92 lesions) in whom squamous cell carcinoma was histopathologically diagnosed. The primary endpoint was clinicopathological findings according to the presence or absence of lymph-node metastasis, lymphatic invasion, or both. The secondary endpoints were (1) endoscopic findings according to the presence or absence of subepithelial invasion and (2) tumor thickness according to the endoscopic findings. RESULTS: Lymph-node metastasis, lymphatic invasion, or both were related to the white light findings of the main macroscopic type (p = 0.006), the NBI magnifying endoscopy findings of the classification of type B vessels (p = 0.005) and avascular area (AVA) (p = 0.003), and the histopathological findings of subepithelial invasion (p = 0.027), solitary nests (p = 0.013), venous invasion (p = 0.003), and tumor thickness (p = 0.028). The white light findings of white coat (p = 0.027), main macroscopic type (p = 0.005), and protruding type (p = 0.027) and the NBI magnifying endoscopy findings of the classification of type B vessels (p = 0.0002) were significantly related to subepithelial invasion. Tumor thickness was significantly related to the white light findings of white coat (p = 0.0002), main macroscopic type (p < 0.0001), protruding type (p < 0.0001), and mixed type (p = 0.017) and the NBI magnifying endoscopy findings of the classification of type B vessels (p < 0.0001) and AVA (p = 0.005). CONCLUSION: Detailed assessment by means of NBI magnifying endoscopy at the time of transoral surgery may contribute to the prediction of lymphatic invasion and lymph-node metastasis in patients with superficial pharyngeal cancer.

Usefulness of narrow band imaging with magnifying endoscopy for the differential diagnosis of cancerous and noncancerous laryngeal lesions.

BACKGROUND: We evaluated the accuracy of endoscopic findings observed by narrow band imaging (NBI) combined with magnifying gastrointestinal endoscopy (GIE) for the differential diagnosis of cancerous and noncancerous laryngeal lesions. METHODS: A total of 166 vocal cord lesions for which good images were obtained on NBI with magnifying GIE were evaluated with respect to the following 6 variables: macroscopic type, tumor location, color, white coat, keratinization, and abnormal microvessels. RESULTS: Multivariate analysis showed that white coat (odds ratio [OR], 2.95, P = 0.05), keratosis (OR, 3.14, P = 0.02) and abnormal microvessels (OR, 31.1, P < 0.0001) were significantly related to laryngeal cancer. In the diagnosis of laryngeal cancer, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of abnormal microvessels were 84.4%, 88.6%, 91%, 80.5%, and 86.1%, respectively. CONCLUSION: The abnormal microvessels on NBI combined with magnifying GIE are useful for the differential diagnosis of laryngeal lesions.

A retrospective study of treatment for curative synchronous double primary cancers of the head and neck and the esophagus.

OBJECTIVE: Curative synchronous double primary cancers of the head and neck and the esophagus (CSC-HE) are frequently detected, but a standard treatment remains to be established. We studied the clinical course to explore appropriate treatment strategies. METHODS: We retrospectively studied consecutive 33 patients who had CSC-HE. The disease stage was classified into 4 groups: group A, early head and neck cancer (HNC) and early esophageal cancer (EC); group B, early HNC and advanced EC; group C, advanced HNC and early EC; and group D, advanced HNC and advanced EC. As induction chemotherapy, the patients received 3 courses of TPF therapy (docetaxel 75mg/m2 on day 1, cisplatin 75mg/m2 on day 1, and 5-fluorouracil 750mg/m2 on days 1-5) at 3-week intervals. The clinical courses and treatment outcomes were studied according to the disease stage of CSC-HE. RESULTS: The disease stage of CSC-HE was group A in 1 patient (3%), group B in 9 patients (27.3%), group C in 3 patients (9.1%), and group D in 20 patients (60.6%). The median follow-up was 26months, and the 2-year overall survival rate was 67.4%. In groups A, B, and C, the 2-year overall survival rate was 83.3%. In group D, the 2-year overall survival rate was 62.6%. Ten of 20 patients in group D received induction chemotherapy with TPF, and 6 patients were alive and disease free at the time of this writing. CONCLUSION: The treatment outcomes of patients with CSC-HE were relatively good. TPF induction chemotherapy might be an effective treatment for patients with advanced HNC and advanced EC.

[A Pediatric Case of Retropharyngeal Abscess Causing Multiple Instances of Cranial Nerve Palsy].

Deep neck abscesses are relatively rare in children compared with adults. Diagnosis can be difficult in pediatric patients because of the various clinical symptoms, therefore, it is important to correctly understand the pathology. We report herein on a rare pediatric case of a deep neck abscess that caused multiple instances of cranial nerve palsy. The patient was a 7-year-old boy who, despite treatment by a local physician for fever, swelling of the left neck and neck pain, developed torticollis, dysarthria, dysphagia and hoarseness and consequently consulted our department. We observed palsy associated with the IX, X, and XII left cranial nerves and a retropharyngeal abscess was diagnosed based on the computed tomography findings. The patient was hospitalized and underwent conservative treatment, and on day 21 of hospitalization, the patient was discharged after his symptoms had eased and the size of the abscess had reduced. We believe that palsy of the cranial nerves in the present case occurred as a result of pressure being applied to the cranial nerves in the carotid space due to an abscess in the retropharyngeal space.

One hundred supracricoid laryngectomies with cricohyoidoepiglottopexy: do we achieve better local control?

OBJECTIVE: Supracricoid laryngectomy with cricohyoidoepiglottopexy has been known to be able to cope with tumor excisions with minimal margins. Extended resection may result in a limited margin and may impair the prognosis. We conducted a clinicopathologic analysis of local recurrence in supracricoid laryngectomy with cricohyoidoepiglottopexy patients. METHODS: Between 1997 and 2013, 100 patients with glottic cancers underwent supracricoid laryngectomy with cricohyoidoepiglottopexy. The clinicopathologic findings were evaluated. We also analyzed: (i) cancer-specific and overall survival rates, (ii) the correlation between locoregional recurrence and overall survival, (iii) T staging and larynx preservation rates and (iv) previous radiation history and larynx preservation rates. RESULTS: Local recurrence was recognized in eight of the 100 patients (8%); all were initially staged as T3 or T4. Recurrence was identified in the submucosal regions of the ipsilateral arytenoid and/or infraglottis. Six patients were salvaged by completion total laryngectomy except two. Cancer-specific survival at 5 years was 93%; overall survival at 5 years was 89%. There was no significant difference between overall survival and locoregional recurrence. There was a significant difference between larynx preservation in T1-2 and T3-4 patients. There was no significant difference between larynx preservation and the previous radiation therapy status. CONCLUSIONS: Our experience convinced us of the clinical potential of supracricoid laryngectomy with cricohyoidoepiglottopexy as one of the effective options for functional larynx preservation. Supracricoid laryngectomy with cricohyoidoepiglottopexy is the most suitable for unfavorable T2 and T3a cases and is applicable for appropriately selected radiation-failed patients. Thorough pre-operative evaluation, proper surgical techniques and careful follow-up are prerequisites for the success of supracricoid laryngectomy with cricohyoidoepiglottopexy.

Clinical outcomes of 849 laryngeal cancers treated in the past 40 years: are we succeeding?

OBJECTIVE: We analyzed the clinical outcomes of 849 laryngeal cancers treated in the past 40 years, which overlapped with the era of the global treatment shift. METHODS: To compare the chronological outcomes, patients were divided into four groups according to their registration year as 1972-82, 1983-92, 1993-2002 and 2003-12; treatment trends, larynx preservation rate and overall survival rate were compared. RESULTS: There were 104, 173, 253 and 319 patients registered in 1972-82, 1983-92, 1993-2002 and 2003-12, respectively. Five-year overall survival rates were 74, 76.5, 75.6 and 82.2% in 1972-82, 1983-92, 1993-2002 and 2003-12, respectively. The five-year larynx preservation rates were 65.5, 75.7, 75.4 and 80.9% in 1972-82, 1983-92, 1993-2002 and 2003-12, respectively. CONCLUSIONS: The number of patients treated at our institute increased, and the overall survival and larynx preservation rates exhibited favorable improvements over the past four decades. In the analysis of nonsurgical options, S1 combined radiotherapy showed superiority over concurrent chemoradiotherapy and radiotherapy in larynx preservation, and S1 combined radiotherapy, concurrent chemoradiotherapy and Tegafur Uracil combined radiotherapy showed superiority over radiotherapy in overall survival. In nonsurgical approaches, proper case selection is the key to success and may be much more important than pursuing radiotherapy dose escalation. In the analysis of surgical options, laser and supracricoid laryngectomy with cricohyoidoepiglottopexy contributed to larynx preservation in early- and intermediate-stage cancers, respectively. Supracricoid laryngectomy with cricohyoidoepiglottopexy demonstrated overall survival not worse than total laryngectomy, which is the prerequisite treatment basis for larynx preservation options. We must make extra efforts in pursuing an ideal balance between nonsurgical and surgical larynx preservation options.

A clinical study of transoral pharyngectomies to treat superficial hypopharyngeal cancers.

BACKGROUND: For years, it has been a major interest for surgeons and oncologists to develop a novel technique to detect hypopharyngeal cancers at an early stage and to treat the lesions in a less invasive manner. The advent of the narrow band imaging system combined endoscopy and various endoscopic approaches shed light on the new era of the minimum invasive management of superficial cancers in hypopharyngeal regions. METHODS: Three endoscopic approaches, endoscopic mucosal resection, endoscopic submucosal dissection and endoscopic laryngopharyngeal surgery, were chronologically introduced at our institute. In this study, we focused on the clinical outcomes, advantages and limitations of each procedure. RESULTS: A total of 30 patients (42 procedures) received transoral pharyngectomies between June 2006 and May 2012. Tracheotomy was performed in 9 of 42 (21%) patients. Three patients developed local recurrence and were subsequently controlled by additional transoral pharyngectomies. The 2- and 5-year local control rates were 92.8 and 83.5%. The 2- and 5-year overall survival rates were 82.1%. CONCLUSIONS: Endoscopic mucosal resection, endoscopic submucosal dissection and endoscopic laryngopharyngeal surgery-transoral pharyngectomies are useful procedures for treating superficial hypopharyngeal cancers. Endoscopic mucosal resection manifested the least invasiveness and may be beneficial for resecting small superficial lesions, endoscopic submucosal dissection may be advantageous for patients with difficult laryngopharyngeal exposure and endoscopic laryngopharyngeal surgery has shown the optimal effectiveness and minimal complications and can be applied to most of the hypopharyngeal sub-sites. All three procedures require a high level of technical skill and close collaboration between otolaryngologists and gastroenterologists.

Clinical outcome of supracricoid laryngectomy with cricohyoidoepiglottopexy: radiation failure versus previously untreated patients.

OBJECTIVE: A history of radiation therapy is known to be a major risk factor promoting post-surgical complications. By comparing the clinical outcomes of supracricoid laryngectomy with cricohyoidoepiglottopexy (SCL-CHEP) in irradiated and non-irradiated patients, we investigated the usefulness of salvage SCL-CHEP. METHODS: 73 patients who received SCL-CHEP between 1997 and 2010 (30 had received radiation therapy preoperatively and 43 had not). Staging error, wound infection, accuracy of surgical margin determination, acquired laryngeal function, and prognosis were compared between the two groups. RESULTS: Staging error occurred in 6/30 (20%) irradiated and 14/43 (33%) non-irradiated patients. An intraoperative margin study demonstrated a dysplastic or positive margin in 15/30 (50%) irradiated and 13/43 (30%) non-irradiated patients. Wound infection developed in 12/30 (40%) irradiated and 7/43 (16%) non-irradiated patients (P<0.05). Delayed wound infection was identified in four patients with a radiation dose over 65Gy. Swallowing function (ability to eat in public) was acquired in 28/30 (93%) irradiated and 39/43 (91%) non-irradiated patients. Five-year larynx preservation rates were 94% in irradiated and 91% in non-irradiated patients. Five-year overall survival rates were 81% in irradiated and 87% in non-irradiated patients. CONCLUSIONS: Risk of infection was significantly higher in irradiated patients; delayed infection should be appropriately managed. Functional and oncological results were stable regardless of radiation history. We encourage head and neck surgeons to take reasonable risks in performing salvage SCL-CHEP.

Buccal fat augmentation for insufficient neoglottal closure after supracricoid laryngectomy with cricohyoidoepiglottopexy.

OBJECTIVE: Supracricoid laryngectomy with Cricohyoidoepiglottopexy (SCL-CHEP) is a functional organ preservation surgery for laryngeal cancers. Post-operative laryngeal function is generally promising. Some patients, however, cannot attain satisfactory functional results because of an excessively wide neoglottis resulting in an insufficient neoglottal closure. Autologous buccal fat augmentation was conducted to correct the insufficiency. PATIENTS AND METHODS: Two patients underwent intervention. Under general anesthesia, autologous fat was harvested from the buccal fat pad. Fat tissue was injected into the widest plane of the neoglottis under direct laryngoscopy; a navigation system was incorporated to identify the responsible site. Acoustic, aerodynamic, and perceptual analyses along with videofluoroscopic swallowing study and screening questionnaires were used for functional evaluation. RESULTS: A total of 0.8ml (Case 1) and 0.7ml (Case 2) of fat tissues were injected into the submucosal space of the responsible sites. Both patients experienced functional improvement subjectively after augmentation; psychological parameters for voice and swallowing also improved. CONCLUSIONS: Buccal fat augmentation to correct insufficient neoglottal closure after SCL-CHEP was technically feasible. A navigation system was helpful for confirmation. Fat absorption occurred and one third of the volume remained at 3 and 6 months. Although, vocal measurements remained unchanged, psychological parameters for voice and swallowing improved.

Usefulness and pitfall of Narrow band imaging combined with magnifying endoscopy for detecting an unknown head and neck primary site with cervical lymph node metastasis.

OBJECTIVE: Cervical nodal metastasis from clinically undetectable primary squamous cell carcinoma (SCC) accounts for 1-2% of head and neck malignancies. We retrospectively evaluate the ability of Narrow band imaging combined with magnifying endoscopy (NBI-ME) to detect the primary sites of superficial SCC in the head and neck region. METHODS: This was a report of 11 patients. We performed with NBI-ME to detect unknown primary sites in the head and neck. RESULTS: Among 11 patients, primary sites were detected in eight. Primary sites were detected in the head and neck in 6 (54.5%) of 11 patients on NBI-ME, all 6 primary lesions were a flat lesion. Two patients in whom primary lesions could not be detected on NBI-ME, one had submucosal tumor like lesion, the other featured by a detectable primary lesion 19 months after neck dissection. CONCLUSION: NBI-ME can be recommended as an essential procedure for the detection of primary lesions in patients with primary unknown cervical lymph node metastasis.

Laminin-5 immunohistochemical mapping for analysis of local extension in hypopharyngeal cancer: A preliminary report.

OBJECTIVE: Laminin-5 γ2 chain (LNγ2) plays an important role in cancer differentiation and migration. Using a novel immunohistochemical mapping technique to investigate whole mucosal strips of total laryngopharyngectomy specimens using iodine, H-E, and LNγ2 stainings, we investigated the locoregional behavior of hypopharyngeal cancer. METHODS: Surgical specimens from two patients with pyriform sinus cancer were investigated. Three percent iodine was applied to the tumor-bearing laryngopharynx during surgery and photographed. Stainabilities of H-E and LNγ2 on pathologic sections from all mucosal strips were scored and coordinated with the laryngopharyngeal photograph to illustrate the immunohistochemical map. RESULTS: In both patients, the main tumor of invasive squamous cell carcinoma was circumferentially surrounded by a superficial lesion characterized by high grade intraepithelial neoplasia that remained unstained by iodine. On LNγ2 immunohistochemical mapping, the main tumor was demonstrated by Score 2 staining and the superficial lesion by a stronger Score 3 staining. CONCLUSIONS: The finding of neoplastic cells at the periphery demonstrating a higher potential than the cancer cells at the tumor center is suggestive of impending progression from neoplasia to carcinoma. The current preliminary report suggested morphological evidence of intraepithelial infiltration and lateral invasion in hypopharyngeal cancer.

Clinical significance of positive Delphian node in supracricoid laryngectomy with cricohyoidoepiglottopexy.

OBJECTIVE: A positive Delphian node is known to predict a poor prognosis in laryngeal cancer. To elucidate the clinical significance of positive Delphian node metastasis in supracricoid laryngectomized patients, we conducted a thorough clinical review. METHODS: We reviewed clinical data from 65 patients who underwent supracricoid laryngectomy with cricohyoidoepiglottopexy; in these patients, the Delphian node was examined by frozen section as a routine process. Incidence, positivity rates and clinical impact of the positive Delphian node were analyzed. RESULTS: The presence of the Delphian node was detected in 27 of 65 (41.5%) patients; among these 27 patients, 3 (3/65 = 4.6%) were positive for metastasis. Case 1 (pT3N2b) died of lung metastases 32 months after supracricoid laryngectomy with cricohyoidoepiglottopexy. Case 2 (pT4N2c) underwent conversion to total laryngectomy during supracricoid laryngectomy with cricohyoidoepiglottopexy because of unexpected submucosal lymphatic infiltration; this patient is currently alive with disease 23 months after surgery. Case 3 (T3N1) is currently alive without disease 48 months after surgery. CONCLUSIONS: The positive Delphian node is exclusively encountered in advanced laryngeal cancers and suggests an ominous outcome. Sufficient dissection of the paratracheal and lateral neck nodes is recommended. Delphian node evaluation is advised for all supracricoid laryngectomy surgeries.

Diagnosis of the extent of advanced oropharyngeal and hypopharyngeal cancers by narrow band imaging with magnifying endoscopy.

OBJECTIVES/HYPOTHESIS: Narrow band imaging combined with magnifying endoscopy (NBI-ME) is useful for the detection of superficial cancer in the oropharynx, hypopharynx, and esophagus. We used NBI-ME to evaluate the frequency of superficial cancer spread (SCS) contiguous with advanced oropharyngeal and hypopharyngeal cancers and esophageal cancers. STUDY DESIGN: Retrospective. METHODS: We retrospectively studied 45 patients with oropharyngeal and hypopharyngeal cancer and 44 with esophageal cancer who underwent NBI-ME from October 2006 through April 2009. The following variables were evaluated: 1) the frequency of SCS contiguous with advanced oropharyngeal and hypopharyngeal cancer and esophageal cancer, and 2) the influence of SCS contiguous with advanced oropharyngeal and hypopharyngeal cancer on clinical T category and clinical stage. RESULTS: SCS contiguous with the primary tumor was found in 49% (22/45) of the patients with advanced oropharyngeal and hypopharyngeal cancer and in 52% (23/44) of those with advanced esophageal cancer. When SCS contiguous with the primary tumor was included in the evaluation of tumor size in advanced oropharyngeal and hypopharyngeal cancer, the clinical T category and clinical stage were revised in 20% (9/45) and 4% (2/45) of patients, respectively; SCS was ≤ 2 cm in 64% of cases (14/22) and between >2 cm and ≤ 4 cm in 36% (8/22). CONCLUSIONS: NBI-ME should be included in the pretreatment diagnostic work-up to evaluate lesion extent and decide optimal surgical margins and radiation fields in patients with advanced oropharyngeal and hypopharyngeal cancer.