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Practical applications of in-office fiberoptic transnasal esophagoscopy in the initial evaluation of patients with squamous cell cancer of the head and neck.

Abstract

We conducted a study to analyze the effectiveness of transnasal esophagoscopy (TNE) as an alternative to operative endoscopy (OE) for the evaluation of primary head and neck cancers and for the surveillance of synchronous esophageal cancers. Our study population was made up of 96 consecutively presenting patients--75 men and 21 women, aged 45 to 88 years (mean: 64)--who were treated at our institution for squamous cell cancer of the head and neck. Of this group, 42 patients had been evaluated with TNE and 54 with OE. More OEs were performed in patients with an unknown primary (26 vs. 3). Incidental findings on TNE included 3 cases of gastritis, 2 cases each of hiatal hernia and esophagitis, 1 case of Barrett esophagus, and 1 inlet patch. No incidental findings were reported during OE. Primary cancers were biopsied by TNE through a port on the endoscope in 4 patients; 2 of these cancers were in the tongue base, 1 in the hypopharynx, and 1 in the aryepiglottic fold. After the initial visit, patients in the TNE group waited significantly fewer days for their endoscopy than did those in the OE group (median: 6.5 vs. 16; p < 0.05). Conversely, patients in the OE group waited significantly fewer days for treatment following endoscopy (median: 12 vs. 20; p < 0.05). However, there was no significant difference between the TNE patients and the OE patients in the total number of days comprising the their entire course of management, from the initial visit to definite treatment (median: 27.5 and 33 days, respectively; p = O. 7). We conclude that TNE is a reasonable alternative to OE for the initial screening for synchronous esophageal cancers in patients with squamous cancers of the head and neck. OE is preferred for the initial workup of unknown primary cancers and for large tongue base cancers. The rate of detection of clinically relevant incidental findings is higher with TNE. Biopsy is possible during TNE for all subsites within the upper aerodigestive tract.

Introduction

The development of in-office fiberoptic transnasal esophagoscopy (TNE) has been a useful technologic advance. We previously reported our experience with TNE in a heterogeneous group of 30 patients and concluded that it is a high-yield diagnostic tool. (1) Others have reported that TNE is useful for esophageal screening in head and neck oncology. (2,3) Indeed, the value of TNE vis-a-vis operative and sedated esophagoscopy has been well established in terms of safety, cost savings, and patient preference. (4,5)

In this article, we describe our experience with using TNE as a substitute for traditional operative endoscopy (OE). We also discuss the clinical applications, pitfalls, and advantages of TNE in head and neck oncology.

Patients and methods

All patients who had presented to our institution from September 2004 through June 2006 with a new diagnosis of squamous cell carcinoma (SCC) involving the mucosal surfaces of the oral cavity, pharynx, or larynx were included in this analysis. The group comprised 96 patients--75 men and 21 women, aged 45 to 88 years (mean: 64); there were no significant differences between the two groups in age or sex. Both TNE and traditional OE were readily available and considered for all patients during the study period. The choice of which to use was based on the surgeon's judgment. The rationale for using TNE was to shorten the amount of time between the initial evaluation and definitive treatment.

We retrospectively reviewed all patient charts. In addition to demographic data, we compiled information on tumor location and TNM category, Eastern Cooperative Oncology Group (ECOG) health status, the reason for performing TNE or OE (e.g., initial endoscopy or biopsy), incidental findings, and procedural complications.

Tumor locations were specified as the oral cavity, oropharynx, hypopharynx, and larynx. We classified as an unknown primary any regionally metastatic SCC with no identifiable source prior to endoscopy. We also documented the date of all patients' initial visit, the date of their endoscopic procedure, and the date of their definitive surgical resection or the first day of chemotherapy or radiation therapy. Our method of TNE is described in our previous report. (1)

Statistical comparisons between the TNE and OE groups were performed with the Student t test, the chi-square (X2) test, and the nonparametric Kruskal-Wallis test. Findings were considered significant at p < 0.05.

Our study was approved by the Institutional Review Board at the Lahey Clinic.

Results

Of the 96 patients, 42 underwent TNE and 54 underwent OE. After the study was closed, all but 3 patients had at least 2 years of follow-up. During that time, no patient was diagnosed with a synchronous (within 6 months of the index cancer) or metachronous cancer of the esophagus.

Clinical characteristics. According to X2 analysis, there were no significant differences between the TNE and OE groups in terms of either tumor category or ECOG health status.

Tumor site. With respect to procedures according to tumor site, significantly more TNEs than OEs were performed in patients with a tumor of the oral cavity (24 vs. 2, p < 0.05, [chi square] test), and significantly more OEs than TNEs were performed in patients with an unknown primary (26 vs. 3, p < 0.05, [chi square] test). Of the remaining sites, 16 patients had oropharyngeal cancer (7 TNE and 90E; all of these cancers were located in the tongue base), 3 patients had hypopharyngeal SCC (2 TNE and 10E), and 22 patients had laryngeal SCC (6 TNE and 16 OE) (table 1).

Incidental findings. Incidental findings reported during TNE included 3 cases of gastritis, two cases each of hiatal hernia and esophagitis (including Candida esophagitis), 1 case of Barrett esophagus, and 1 inlet patch. No incidental findings were reported during OE.

Complications. No procedural complications occurred in either group.

Biopsies. In the 42 TNE cases, 4 primary cancers were biopsied through a port on the endoscope; 2 of these cancers were in the tongue base, 1 in the hypopharynx, and 1 in the aryepiglottic fold (figure). Of the remaining cases, 30 biopsies were performed as an in-office procedure, and 8 were performed at a referring institution.

In 30 of the 54 OE cases, either the primary cancer was biopsied or directed biopsies were performed in search of the primary. The remaining 24 patients either had an accessible tumor for an in-office biopsy or had their biopsy performed at the referring institution.

Timing of events. Overall, a median of 10 days elapsed between the initial visit and endoscopy (table 2). Patients in the TNE group waited significantly fewer days for their endoscopy than did those in the OE group (median: 6.5 vs. 16; p < 0.05, Kruskal-Wallis test). A total of 29 of the 42 TNE patients did not undergo their TNE the same day as their office visit because they had not fasted for 6 hours per our office protocol or because they simply preferred not to. The 13 patients who underwent same-day TNE far outnumbered the 2 patients who underwent same-day OE (both of these OE patients required emergency treatment to secure their airway).

In terms of the number of days from endoscopy to definitive treatment, information was available on only 78 of the 96 patients--32 of the 42 TNE patients and 46 of the 54 OE patients (table 2). Accurate treatment start dates for 18 patients could not be determined because 8 patients delayed their treatment beyond the prescribed date, 7 patients received treatment at another facility, and 3 patients were lost to follow-up.

Patients in the OE group waited significantly fewer days for treatment following endoscopy than did those in the TNE group (median: 12 vs. 20; p < 0.05, Kruskal-Wallis test), chiefly because 20 of them underwent definitive surgery the same day as their surveillance endoscopy (table 2).

There was no significant difference between the TNE patients and the OE patients in the total number of days comprising their entire course of management, from the initial visit to definite treatment (median: 27.5 and 33 days, respectively; p = 0.7, Kruskal-Wallis test). When data on the 20 OE patients who received their treatment the same day as their endoscopy were excluded from the analysis (leaving 32 TNE patients and 26 OE patients), the number of days between the initial visit and treatment remained statistically not significant (median: 28 vs. 36; p > 0.05, Kruskal-Wallis test).

Discussion

We found that TNE is a safe and reliable alternative to OE for the initial workup of patients with SCC of the head and neck. OE was still preferred for the workup of unknown primary cancers because it allows for directed biopsies and/or tonsillectomy. Our study demonstrated the high diagnostic yield of TNE with regard to incidental gastric and esophageal pathology. TNE was useful for obtaining tissue for histology at sites throughout the upper aerodigestive tract, including the base of the tongue, hypopharynx, and larynx.

Since TNE can be performed quickly and easily as an outpatient procedure, we expected to find that patients would undergo TNE and definitive therapy much more quickly than did the patients evaluated by OE. And while the ease of scheduling and performing TNE did result in significantly fewer days from the initial visit to endoscopy, there was no such significantly shorter interval between endoscopy and definitive therapy. This finding is likely attributable to the fact that OE was often performed just prior to the definitive surgical procedure while the patient remained under the same dose of general anesthesia. One would expect that TNE patients whose definitive treatment consists of radiation therapy would experience a much shorter interval between endoscopy and treatment.

Although TNE was useful for SCCs in most sites, it does have its limitations. For example, assessing the extent of the contiguous spread of tongue base cancers can be difficult without manual manipulation with a rigid scope or by palpation. This is particularly true for larger tumors that obscure the surrounding landmarks such as the vallecula and epiglottis. Six of the 7 tongue base cancers that were evaluated by TNE were small (category T1 or T2). OE is preferred for cases of advanced cancer because it allows for direct tissue manipulation, thereby facilitating the assessment of spread to contiguous structures. Also, OE is preferred over TNE for directed biopsies and/or tonsillectomy.

In modern clinical practice, most esophagoscopies are performed with large-caliber endoscopes and sedation. Otolaryngologists have relinquished much of our clinical hold on esophagoscopy to gastroenterologists and their large scopes. However, with the advent of TNE, esophagoscopy is moving back into mainstream otolaryngology practice, as gastroenterologists have been slow to adopt this new technology. It is likely that otolaryngologists embraced TNE because of its many similarities to fiberoptic laryngoscopy. Still, any new technique or device is subject to enthusiastic overuse, and TNE is no exception.

Our initial experience with TNE showed that it is a high-yield diagnostic tool when used for a variety of indications. In our earlier review of 30 TNEs, we found that nearly 50% of patients had an incidental finding, including esophagitis and Barrett esophagus (the two most common diagnoses). (1) Now we rarely perform rigid esophagoscopy, reserving it (1) to examine patients with head and neck cancer who are already undergoing direct laryngoscopy for biopsy and/or to assess the extent of the primary cancer, (2) to perform surveillance the day of surgery in patients who have a biopsy-proven cancer, and (3) to search for an unknown primary. This makes sense given that the diagnostic value of TNE is reported to be equivalent to that of rigid endoscopy in terms of detecting synchronous cancers. (3)

In our experience, described in our previous report, we had not incorporated biopsy with TNE. (1) We have since done so, as is reflected in our experience reported here. This ability allows us to expand the indications for TNE in head and neck oncology. This is especially relevant in cases of laryngeal pathology where palpation or manual manipulation of tissue is not generally needed to determine the extent of tumor.

Although we detected no synchronous primary cancers in our patients, the need for surveillance endoscopy is clear based on several population studies and metaanalyses. (6,8) Newer modalities such as F18-fluorodeoxyglucose-positron-emission tomography (FDG-PET) and FDG-PET with computed tomography have been reported to detect synchronous cancers with sufficient sensitivity to make panendoscopy unnecessary? However, in more recent and better controlled studies, investigators have disputed this finding, contending that FDG-PET cannot detect early cancers because most synchronous cancers present early (i.e., categoryT1). (10) As a result, these investigators argue that FDG-PET yields many false-negative findings, and therefore endoscopy should remain the standard of care. (10)

Overall, synchronous primary cancers occur in approximately 2% of patients with head and neck cancer, usually in the upper aerodigestive tract. (11) Approximately 10% of these occur within the esophagus, and most of them are found in association with a cancer involving the hypopharynx and in patients with a history of high alcohol consumption. (8,12,13) Most second neoplasms, while still occurring within the upper aerodigestive tract, are metachronous, and they usually occur within 2 years of the diagnosis of the index cancer.

Although we limited our study to the use of TNE in the initial workup, using it for episodic routine surveillance within the first 2 years after diagnosis of the index cancer maybe beneficial. (14) In-office evaluation for synchronous primary cancers with TNE usually does not involve routine bronchoscopy. The inclusion of bronchoscopy in the workup (i.e., triple endoscopy) is controversial in patients with a normal chest CT because the detection rate for an endobronchial synchronous cancer is on the order of less the 1%. (13) We do not routinely per form bronchoscopy, even on our patients who are undergoing OE.

In conclusion, we find that TNE is a reasonable alternative to OE for the initial screening for synchronous esophageal cancers in patients with SCC of the head and neck. At our clinic, OE is preferred for the initial workup of unknown primary cancers and large tongue base cancers. The detection rate of clinically relevant incidental findings is higher with TNE than with OE. Biopsy is possible during TNE at all subsites within the upper aerodigestive tract.

Acknowledgment

The authors gratefully acknowledge the assistance of Joanne Bilmazes in collecting and organizing the data.

References

(1.) Andrus JG, Dolan RW, Anderson TD. Transnasal esophagoscopy: A high-yield diagnostic tool. Laryngoscope 2005; 115(6):993-6.

(2.) Postma GN, Cohen IT, Belafsky PC, et al. Transnasal esophagoscopy: Revisited (over 700 consecutive cases). Laryngoscope 2005; 115(2): 321-3.

(3.) Postma GN, Bach KK, Belafsky PC, Koufman JA. The role of transnasal esophagoscopy in head and neck oncology. Laryngoscope 2002; 112(12):2242-3.

(4.) Sharma A, Price T, Mierzwa K, et al. Transnasal flexible laryngooesophagoscopy: An evaluation of the patient's experience. J Laryngol Otol 2006;120(1):24-31.

(5.) Amin MR, Postma GN, Setzen M, Koufman JA. Transnasal esophagoscopy: A position statement from the American Bronchoesophagological Association (ABEA). Otolaryngol Head Neck Surg 2008; 138(4):411-14.

(6.) Leon X, Quer M, Diez S, et al. Second neoplasm in patients with head and neck cancer. Head Neck 1999;21(3):204-10.

(7.) Muto M, Takahashi M, Ohtsu A, et al. Risk of multiple squamous cell carcinomas both in the esophagus and the head and neck region. Carcinogenesis 2005;26(5):1008-12.

(8.) Raghavan U, Quraishi S, Bradley PJ. Multiple primary tumors in patients diagnosed with hypopharyngeal cancer. Otolaryngol Head Neck Surg 2003;128(3):419-25.

(9.) Stokkel MP, Moons KG, ten Broek FW, et al. 18F-fluorodeoxyglucose dual-head positron emission tomography as a procedure for detecting simultaneous primary tumors in cases of head and neck cancer. Cancer 1999;86(11):2370-7.

(10.) Suzuki H, Hasegawa Y, Terada A, et al. Limitations of FDG-PET and FDG-PET with computed tomography for detecting synchronous cancer in pharyngeal cancer. Arch Otolaryngol Head Neck Surg 2008;134(11):1191-5.

(11.) Rennemo E, Zatterstrom U, Boysen M. Synchronous second primary tumors in 2,016 head and neck cancer patients: Role of symptom-directed panendoscopy. Laryngoscope 2011;121(2):304-9.

(12.) Tanabe H, Yokota K, Shibata N, et al. Alcohol consumption as a major risk factor in the development of early esophageal cancer in patients with head and neck cancer. Intern Med 2001;40(8):692-6.

(13.) Guardiola E, Pivot X, Dassonville O, et al. Is routine triple endoscopy for head and neck carcinoma patients necessary in light of a negative chest computed tomography scan? Cancer 2004;101(9):2028-33.

(14.) Haughey BH, Gates GA, Arfken CL, Harvey I. Meta-analysis of second malignant tumors in head and neck cancer: The case for an endoscopic screening protocol. Ann Otol Rhinol Laryngol 1992;101 (2 Pt 1):105-12.

Robert W. Dolan, MD; Timothy D. Anderson, MD

From the Department of Otolaryngology-Head and Neck Surgery, Lahey Clinic, Burlington, Mass.

Corresponding author: Robert W. Dolan, MD, Department of Otolaryngology-Head and Neck Surgery, Lahey Clinic, 41 Mall Rd., Burlington, MA 01805. Email: Robert.w.dolan@lahey.org

Table 1. Distribution of tumors by T category, ECOG score, and site

                          Oral   Tongue               Unknown
                         cavity   base   HPX  Larynx  primary  Total

THE group, n               24      7      2     6        3      42
  TNM T category 1 or 2    17      6      1     3       --      27
  TNM T category 3 or 4    7       1      1     3       --      12

  ECOG score 0 or 1        24      6      2     5        3      40
  ECOG score 2 or 3        0       1      0     1        0       2

OE group, n                2       9      1     16      26      54
  TNM T category 1 or 2    0       5      0     9       --      14
  TNM T category 3 or 4    2       4      1     7       --      14

  ECOG score 0 or 1        2       8      1     12      25      48
  ECOG score 2 or 3        0       1      0     4        1       6

Key: HPX = hypopharynx; THE = transnasal endoscopy; ECOG = Eastern
Cooperative Oncology Group health status; OE = operative endoscopy.

Table 2. Number of elapsed days between the initial visit, endoscopy,
and treatment (N = 96)

                       Total             THE               OE

                               Days, n, median (range)

Initial visit to    10 (0 to 27)    6.5 (0 to 14)     16 (0 to 27)
  endoscopy           (n = 96)         (n = 42)         (n = 54)
Endoscopy to        14 (0 to 31)    20 (9.5 to 31)    12 (0 to 23)
  treatment           (n = 78)         (n = 32)         (n = 46)
Initial visit to   29.5 (3 to 78)   27.5 (3 to 78)   33 (19 to 77)
treatment             (n = 78)         (n = 32)         (n = 46)

                   Significance *

Initial visit to      p < 0.05
  endoscopy
Endoscopy to          p < 0.05
  treatment
Initial visit to      p = 0.7
treatment

* Kruskal-Wallis test.
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Title Annotation:ORIGINAL ARTICLE
Author:Dolan, Robert W.; Anderson, Timothy D.
Publication:Ear, Nose and Throat Journal
Article Type:Report
Date:Sep 1, 2013
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