Diagnosis of superficial esophageal cancer and dysplasia using endoscopic screening with a 2% lugol dye solution in patients with head and neck cancer

Endoscopic Screening for Second Primary Tumors of the Esophagus Among Head and Neck Cancer Patients

Malignancies of the head and neck (HN) region and esophagus are among the most common cancers worldwide. Due to exposure to common carcinogens and the theory of field cancerization, HN cancer patients have a high risk of developing second primary tumors (SPTs). In our review of 28 studies with 51,454 HN cancer patients, the prevalence of SPTs was 12%. The HN area is the most common site of SPTs, followed by the lungs and esophagus, and 13% of HN cancer patients have been reported to have esophageal high-grade dysplasia or invasive carcinoma. The prognosis of HN cancer patients with concomitant esophageal SPTs is poor, and therefore identifying esophageal SPTs as early as possible is of paramount importance for risk stratification and to guide the treatment strategy. Image-enhanced endoscopy, especially using narrow-band imaging endoscopy and Lugol’s chromoendoscopy, has been shown to improve the diagnostic performance in detecting esophageal neoplasms at an early stage. Moreover, the early detection and minimally invasive endoscopic treatment of early esophageal neoplasm has been shown to improve the prognosis. Well-designed prospective studies are warranted to establish appropriate treatment and surveillance programs for HN cancer patients with esophageal SPTs.

Alcohol Consumption, ALDH2 Polymorphism as Risk Factors for Upper Aerodigestive Tract Cancer Progression and Prognosis

The upper aerodigestive tract (UADT) is highly susceptible to multiple primary cancers originated from squamous epithelia and constitutes a field of cancerization. Patients with head and neck cancer (head and neck squamous cell carcinoma, HNSCC) are at high risk of developing multiple cancers in the esophagus (esophageal squamous cell carcinoma, ESCC). Conversely, esophageal cancer patients are prone to develop multiple primary tumors in the head and neck region. The East Asian-specific dysfunctional ALDH2*2 missense mutation is a genetic risk factor for UADT cancer. It is not only associated with increased incidences of UADT cancer, but is also implicated in faster cancer progression and poorer prognosis. Alcohol use is a major lifestyle risk factor which causes UADT cancer among ALDH2*2 carriers. The accumulation of the immediate metabolite of alcohol, acetaldehyde, is likely the genotoxic agents that is involved in the process of tumorigenesis. This review summarizes recent publications on the risk and association of ALDH2*2 mutation, alcohol consumption in synchronous, metachronous UADT cancer. Possible molecular mechanisms involved in cancer initiation, progress and prognosis are discussed. The review also highlights a need for precision medicine-based preventive and therapeutic strategies by integrating lifestyle and genetic risk factors, such as alcohol consumption, genotypes of the alcohol metabolizing genes, ADH1B and ALDH2, into a risk assessment model for better screening, surveillance and treatment outcome.

Analysis of Outcomes of Pharyngo-laryngo-esophagectomy and Reconstruction with Longitudinal Comparison in a Single Institution

Advanced hypopharyngeal tumours present complex clinical challenges, and where resection is attempted, there is a requirement for major reconstruction. Despite advances in surgical technique, outcomes remain poor for this patient group, and optimum treatment has yet to be established. We aimed to assess the treatment and outcomes of patients in our institution in the context of previous studies. All patients from 2008 to 2018 who underwent surgical management for hypopharyngeal tumours with pharyngo-laryngo-esophagectomy and flap-based reconstruction were included in the study. Demographic and outcome data were collected, and patient-reported outcomes were solicited from surviving patients using the EORTC QLQ H&N 43 questionnaire. Thirty patients were assessed, in which 12 had gastric pull-ups, 16 had free jejunum flaps, and 2 had free anterolateral thigh flaps. There was a 38% five-year survival rate. Overall, the rates of stricture (10.7%) and fistula (7.1%) were low. The majority of patients (53.6%) returned to a normal diet within three months with a soft or puree diet in 35.7% of patients. Some form of speech was possible in 92.9% of patients. The average questionnaire score for surviving patients was 87.3, with good outcomes related to eating and swallowing, but poorer outcomes for speech and communication. This study showed that outcomes for patients receiving complex reconstruction following hypopharyngeal tumour resection are improving over time. There is still scope for improvement of patient outcomes and refinement of optimum surgical management strategies.

Narrow-band imaging versus Lugol chromoendoscopy for esophageal squamous cell cancer screening in normal endoscopic practice: randomized controlled trial

BACKGROUND

Narrow-band imaging (NBI) is as sensitive as Lugol chromoendoscopy to detect esophageal squamous cell carcinoma (SCC) but its specificity, which appears higher than that of Lugol chromoendoscopy in expert centers, remains to be established in general practice. This study aimed to prove the superiority of NBI specificity over Lugol chromoendoscopy in the detection of esophageal SCC and high grade dysplasia (HGD) in current general practice (including tertiary care centers, local hospitals, and private clinics).

METHODS

This prospective randomized multicenter trial included consecutive patients with previous or current SCC of the upper aerodigestive tract who were scheduled for gastroscopy. Patients were randomly allocated to either the Lugol or NBI group. In the Lugol group, examination with white light and Lugol chromoendoscopy were successively performed. In the NBI group, NBI examination was performed after white-light endoscopy. We compared the diagnostic characteristics of NBI and Lugol chromoendoscopy in a per-patient analysis.

RESULTS

334 patients with history of SCC were included and analyzed (intention-to-treat) from 15 French institutions between March 2011 and December 2015. In per-patient analysis, sensitivity, specificity, positive and negative likelihood values were 100 %, 66.0 %, 21.2 %, and 100 %, respectively, for Lugol chromoendoscopy vs. 100 %, 79.9 %, 37.5 %, and 100 %, respectively, for NBI. Specificity was greater with NBI than with Lugol (P = 0.002).

CONCLUSIONS

As previously demonstrated in expert centers, NBI was more specific than Lugol in current gastroenterology practice for the detection of early SCC, but combined approaches with both NBI and Lugol could improve the detection of squamous neoplasia.

Composition and consistence of the bacterial microbiome in upper, middle and lower esophagus before and after Lugol's iodine staining in the esophagus cancer screening

BACKGROUND

Esophageal bacteria, as the integral composition of human ecosystem, have been reported to be associated with esophageal lesions. However, few studies focus on microbial compositions in different esophageal segments, especially after Lugol's iodine staining (LIS) in the endoscopic examination for the screening of esophageal cancer. We aim to investigate the composition of the bacterial microbiome in upper, middle and lower esophagus and if LIS would affect the detection of bacteria.

METHODS

A total of 141 fasting samples including the upper, middle and lower esophagus from 27 participants were collected by brushing the mucosal surface of the esophagus before (Eso) and after (Lug) LIS. Bacterial V3-V4 region of 16S rRNA gene was amplified and sequenced by Illumina's sequencing platform.

RESULTS

The top six abundant bacterial phyla taxa among three locations from both Eso and Lug groups were Proteobacteria, Firmicutes, Bacteroidetes, Actinobacteria, Fusobacteria and TM7. In terms of genera, the bacterium in three locations from two groups was all characterized by a highest relative abundance of Streptococcus. Bacteria diversity and the relative abundance between Eso and Lug were comparable (p > .05). Bacteria diversity was consistent in different esophageal locations within the individual.

CONCLUSION

The bacterial microbiome in healthy esophagus are highly diverse and consistent even among three physiological sites at all clades. Lugol's iodine staining would not change local microenvironment in term of microbial composition. These findings provide an essential baseline for future studies investigating local and systemic bacterial microbiome and esophageal diseases.

Chromoendoscopy: role in modern endoscopic imaging

Detection of early gastrointestinal tract malignancy can be challenging on white light endoscopy especially as lesions can be subtle and inconspicuous. With the advent of electronic chromoendoscopy technologies, lesions which have already been detected can be quickly and "conveniently" characterised. This review will discuss some of the indications and modern applications of chromoendoscopy in various conditions including Barrett's oesophagus, oesophageal squamous cell carcinoma, early gastric cancer, inflammatory bowel disease and neoplastic colonic lesions. In carefully selected situations, chromoendoscopy could still be a useful adjunct to white light endoscopy in day-to-day clinical practice.

Early detection of esophageal second primary tumors using Lugol chromoendoscopy in patients with head and neck cancer: A systematic review and meta-analysis

Background

Early detection of esophageal secondary primary tumors (SPTs) in head and neck squamous cell carcinoma (HNSCC) patients could increase patient survival. The purpose of this study was to determine the diagnostic yield of esophageal SPTs using Lugol chromoendoscopy.

Methods

A systematic review of all available databases was performed to find all Lugol chromoendoscopy screening studies.

Results

Fifteen studies with a total of 3386 patients were included. The average yield of esophageal‐SPTs in patients with HNSCC was 15%. The prevalence was the highest for patients with an index hypopharyngeal (28%) or oropharyngeal (14%) tumor. The esophageal‐SPTs were classified as high‐grade dysplasia in 49% of the cases and as invasive carcinoma's in 51%.

Conclusion

Our results show that 15% of the patients with HNSCC that underwent Lugol chromoendoscopy were diagnosed with an esophageal‐SPT. Based on these results there is enough evidence to perform Lugol chromoendoscopy, especially in an Asian patient population.

Potentials and pitfalls of gold-silica nanoshell as the exogenous contrast agent for optical diagnosis of cancers: a numerical parametric study

For nanoshell-assisted optical detection of cancers, gold shell, silica core (gold-silica) nanoshells are engineered to be the exogenous contrast agent. This work has performed systematic numerical parametric study to investigate the nonlinear dependences of the hemisphere diffuse reflectance on gold-silica nanoshells, laser irradiance, and hosting biology tissue. Planar phantom based tissue models have been constructed as platforms for study. The radiant transport equation (RTE) has been applied to mathematically describe the interactions among laser lights, hosting tissues, and hosted nanoshells. The diffuse reflectance signal under various combinations of parametric conditions has been computed and analyzed. Parametric parameters whose effects on the diffuse reflectance signal have been investigated are: (1) optical properties of a nanoshell generic, (2) nanoshell volume fraction, which is an indicator of nanoshell accumulation in the target tissue site, (3) the width of irradiating laser beam, and (4) thickness of the tissue slab. Seven nanoshell generics have been tested as the exogenous contrast agent including the R[50, 10] (radius of silica core is 50 nm and thickness of gold shell is 10 nm), R[55, 25], R[40, 15], R[40, 40], R[104, 23], R[75, 40] and R[154, 24] nanoshells. It has been found the R[55, 25] nanoshell works best as the exogenous contrast agent, the R[75, 40] and R[104, 23] nanoshells show good potentials as well while the R[50, 10] and R[40, 15] nanoshells should be avoided for diagnostic usage. The practice of neglecting the absorption characteristic of the exogenous contrast agent, which is quite common among the bio-nano community, has been proven to end up with an over-prediction of the effectiveness of the exogenous contrast agent. Such practice therefore is not well justified and should be avoided in future research. Interactions among laser lights, the tissue and nanoshells are highly nonlinear, demonstrated by that nanoshell generics with totally different optical properties might have similar effects on the diffuse reflectance signal and vice versa. Prior to any bench experiment, preliminary numerical investigation as this work has showcased is highly recommended.

Detection of Second Primary Malignancies of the Esophagus and Hypophraynx in Oral Squamous Cell Carcinoma Patients

Objective

To assess the usefulness of modified esophagogastroduodenoscopy (EGD) for the detection of second primary malignancies of the esophagus or hypopharynx in patients with oral squamous cell carcinoma and determine the association between the oral lesion subsite and esophageal or hypopharyngeal lesion occurrence.

Study Design

Retrospective review.

Methods

In total, 166 patients with oral squamous cell carcinoma without any established symptoms of esophageal or hypopharyngeal squamous cell carcinoma underwent modified EGD based on the Valsalva maneuver and U-turn method, image-enhanced endoscopy, and chromoendoscopy using Lugol's iodine for diagnosis. All suspected lesions were biopsied to determine the clinical stages and duplication rates. Odds ratios for the occurrence of duplicate lesions according to the oral lesion subsite were determined.

Results

In total, 37 esophageal and 16 hypopharyngeal lesions were detected. According to the Union for International Cancer Control/American Joint Committee on Cancer classification (2009), 75.7% and 5.4% esophageal lesions were classified as stage IA and IB, respectively, and 50% and 18.8% hypopharyngeal lesions as stage II and stage I, respectively. Approximately 59.1% and 50% esophageal and hypopharyngeal lesions, respectively, were successfully treated by endoscopic resection. Oral lesions involving the floor of the mouth were more frequently accompanied by second primary malignancies of the esophagus or hypopharynx.

Conclusions

Modified EGD is an effective noninvasive technique for early diagnosis and treatment of second primary malignancies of the esophagus and hypopharynx in patients with oral squamous cell carcinoma. In particular, patients with floor of the mouth lesions need close monitoring for hypopharyngeal and esophageal lesions.

Level of Evidence

3b.

Long-Term Results of Conventional Radiotherapy versus Accelerated Hyperfractionated Radiotherapy versus Concomitant Radiotherapy and Chemotherapy in Locoregionally Advanced Carcinoma of the Oropharynx

AIMS AND BACKGROUND

To compare conventional fractionation (CF) radiation therapy (RT), arm A, versus a split-course accelerated hyperfractionated schedule (S-AHF), arm B, versus CFRT plus concomitant chemotherapy (CT), arm C, in terms of five-year survival and toxicity for squamous cell tumors of the oropharynx.

METHODS AND STUDY DESIGN

Between January 1993 and June 1998, 192 previously untreated patients with stage III and IV oropharyngeal carcinoma (excluding T1N1 and T2N1) were enrolled in a multicenter randomized phase III trial (ORO 93-01). In arms A and C, 66 to 70 Gy in 33 to 35 fractions was administered five days a week for six and a half to seven weeks. In arm B, the dose delivered was 64 to 67.2 Gy in two fractions of 1.6 Gy every day, five days a week, with a planned two-week split at 38.4 Gy. In arm C the CT regimen consisted of three cycles of carboplatin and 5-fluorouracil (CBDCA 75 mg/m2 on days 1 to 4 and 5-FU 1000 mg/m2 i.v. on days 1 to 4 every 28 days).

RESULTS

No statistically significant difference was found in five-year overall survival (P = 0.39): 21% for arm A, 21% for arm B, and 40% for arm C. Similarly, there was no statistically significant difference in terms of five-year relapse-free survival: 15% for arm A, 17% for arm B, and 36% for arm C. There was a slight trend towards better five-year locoregional control (P = 0.07) for the combined arm: patients without locoregional relapse were 48% in arm C, 21% in arm A and 18% in arm B. Locoregional control was significantly better when arm C was compared with arms A and B combined (P = 0.02; arm A+B 20%; arm C 48%). Distant metastases were fairly balanced in the three arms (A: 14; B: 9; C: 11), with a tendency towards more frequent isolated distant metastasis development in arm C (8 of 11 [72%] versus 7 of 23 [30%] in arms A+B). Five-year second-tumor-free survival was 85%. The 13 second tumors were equally distributed and were mainly correlated with tobacco and alcohol consumption (five lung, two esophagus, two oral cavity, one larynx, one pancreas, one hepatocarcinoma, one myeloma). Arm C showed slightly more G3+ late side effects involving subcutaneous tissues and mucosa, although significant late sequelae were relatively uncommon and the mucosal side effects were mostly transient. The occurrence of persistent G3 xerostomia was comparable in the three treatment arms.

CONCLUSIONS

The results obtained with the combination of CT and RT compared with RT alone did not reach statistical significance, but combined treatment almost doubled the five-year overall survival, relapse-free survival and locoregional control rate. Patients with advanced squamous cell carcinomas of the oropharynx who are medically suitable for the combined approach should be treated with a combination of radiotherapy and chemotherapy. The occurrence of second tumors is relatively common in these patients and may contribute substantially to the causes of death.

Surveillance of patients at high-risk of squamous cell esophageal cancer

Currently curative treatment for esophageal squamous cell cancer (ESCC) is possible only in patients with early-stage, usually asymptomatic disease. In Western countries, where the incidence of ESCC is relatively low, a screening of asymptomatic, average-risk population is untenable. In order to detect early-stage ESCC or its precursor lesions it is important to identify high-risk patients and consider endoscopic surveillance in these groups. These high-risk groups include patients after curative treatment for head and neck cancer, previous endoscopic resection of ESCC, caustic injury, and patients with tylosis or achalasia. This paper discuss the evidence and proposed method of endoscopy surveillance of these high-risk patients.

Revisiting the gastric pull-up for pharyngoesophageal reconstruction: A systematic review and meta-analysis of mortality and morbidity

Gastric pull-up (GPU) is among the oldest techniques for reconstructing the pharyngoesophageal junction following cancer resection. This review examines morbidity and mortality rates following GPU pharyngoesophageal junction reconstruction from 1959 until present: 77 studies, 2,705 patients. The odds of mortality, anastomotic complications, and other complications decreased by 37.2% (95%CI = 28.0-45.3%; P < 0.0001), 8.0% (95%CI = -2.1 to 17.1%; P = 0.12), 21.0% (95%CI 3.5-35.2%; P = 0.021) per decade respectively. J. Surg. Oncol. 2016;114:907-914. © 2016 Wiley Periodicals, Inc.

Routine endoscopy for esophageal cancer is suggestive for patients with oral, oropharyngeal and hypopharyngeal cancer

Background

This study attempted to reveal the incidence and risk of synchronous and metachronous esophageal cancer in subjects with oral, oropharyngeal and hypopharyngeal cancer based on a population-wide database in Taiwan.

Methods

We retrieved data for this cross-sectional study from the Taiwanese Longitudinal Health Insurance Database 2000. The study group included 2,965 subjects who had received their first-time diagnosis of oral/oropharyngeal/hypopharyngeal cancer in 2002∼2009. We assigned the date of their first diagnosis of oral/oropharyngeal/hypopharyngeal cancer as the index date. We also randomly retrieved 29,650 comparison subjects matched with the study subjects in terms of gender and age group. We assigned their first medical utilization that occurred in the index year as the index date for the comparison group. We further performed a conditional logistic regression to investigate the association between esophageal cancer and oral cancer.

Results

Results showed that prevalences of esophageal cancer within 3 months before and after the index date were respectively 2.19% and 0.04% for the study and comparison groups. A conditional logistic regression revealed that the odds ratio (OR) of esophageal cancer for subjects with oral/oropharyngeal/hypopharyngeal cancer was 55.33 (95% confidence interval (CI): 29.86∼102.52) compared to comparison subjects. Furthermore, compared to comparison subjects, ORs for esophageal cancer were respectively 18.41 (95% CI: 8.50–39.85), 40.49 (95% CI: 15.11∼108.64), and 240.96 (95% CI: 125.49–462.69) for study subjects with a malignancy of the oral cavity, oropharynx, and hypopharynx.

Conclusion

We concluded that there were relatively high chances for synchronous and metachronous esophageal cancers being detected through panendoscopy in patients with oral, oropharyngeal, and hypopharyngeal cancers. The routine use of panendoscopy in such patients should be encouraged with a higher priority.

Effectiveness of unsedated transnasal endoscopy with white-light, flexible spectral imaging color enhancement, and lugol staining for esophageal cancer screening in high-risk patients

BACKGROUND AND AIMS

Transnasal endoscopy (TNE) has been proposed to screen for esophageal squamous cell cancer (ESCC) in Asia. This study aimed to assess the feasibility and tolerance of Brazilian patients to undergo unsedated TNE for screening, the prevalence of ESCC in this population, and the effectiveness of white-light endoscopy (WLE) and digital chromoendoscopy [flexible spectral imaging color enhancement (FICE)] to diagnose esophageal neoplasia.

PATIENTS AND METHODS

This was a diagnostic test study that enrolled patients with head and neck squamous cell cancer (HNSCC) referred to ESCC screening. Patients' tolerance was rated by a numeric pain intensity scale. Interventions included unsedated TNE with WLE and FICE examination of the esophagus, in a tandem manner with blinded operators, followed by lugol chromoscopy. Performance of WLE and FICE for neoplasia detection was compared with the reference standard (lugol chromoscopy plus histology).

RESULTS

A total of 106 patients were recruited. TNE was feasible in 99.1%, and 92% of the patients rated the discomfort as absent or minimal. Thirteen ESCC were detected (12.3%), with 10 early cancers (77%). The tests showed an excellent performance and there was no difference between WLE (sensitivity 92.3%, specificity 98.9%, accuracy 98.1%, area under curve 0.995) and FICE (sensitivity 100%, specificity 98.9%, accuracy 99%, area under curve 0.956) for esophageal neoplasia detection.

CONCLUSIONS

Unsedated TNE is a feasible, well accepted, and efficient diagnostic tool for the screening of ESCC. The elevated rate of esophageal neoplasia strengthens the recommendations to screen patients with HNSCC. The yields of WLE and FICE were similar for ESCC detection.

Narrow-band imaging without magnification for detecting early esophageal squamous cell carcinoma

AIM: To compare narrow-band imaging (NBI) without image magnification, and chromoendoscopy with Lugol’s solution for detecting high-grade dysplasia and intramucosal esophageal squamous cell carcinoma (SCC) in patients with head and neck cancer.

METHODS: This was a prospective observational study of 129 patients with primary head and neck tumors consecutively referred to the Gastrointestinal Endoscopy Unit of Hospital das Clínicas, São Paulo University Medical School, Brazil, between August 2006 and February 2007. Conventional examinations with NBI and Lugol chromoendoscopy were consecutively performed, and the discovered lesions were mapped, recorded and sent for biopsy. The results of the three methods were compared regarding sensitivity, specificity, accuracy, positive predictive value, negative predictive value, positive likelihood value and negative likelihood value.

RESULTS: Of the 129 patients, nine (7%) were diagnosed with SCC, 5 of which were in situ and 4 which were intramucosal. All carcinomas were detected through NBI and Lugol chromoendoscopy. Only 4 lesions were diagnosed through conventional examination, all of which were larger than 10 mm.

CONCLUSION: NBI technology with optical filters has high sensitivity and high negative predictive value for detecting superficial esophageal SCC, and produces results comparable to those obtained with 2.5% Lugol chromoendoscopy.

Second primary tumors in patients with head and neck cancer

This is a review on second primary tumors in patients with head and neck cancer. These patients have a high risk of developing other cancers simultaneously or subsequently. The incidence of multiple primary tumors in this population can be as high as 27%. Recurrences are the most common cause of treatment failure within the first 2 years of follow-up. After the third year the diagnosis of a second primary tumor becomes the most important cause of morbimortality in head and neck cancer patients, especially in those treated for cancers early diagnosed. Most second primary tumors occur in the upper aerodigestive tract (40%-59%), lung (31%-37.5%), and esophagus (9%-44%). Patients who develop second primary tumor have a significant reduction of survival expectancy.

Usefulness of magnifying endoscopy for iodine-unstained lesions in a high-risk esophageal cancer population

AIM: To investigate the usefulness of magnified observations of iodine-unstained esophageal lesions in the histological diagnosis of esophageal mucosa abnormalities, in high-risk esophageal cancer groups.

METHODS: The subjects included 38 patients who had at least one of the four criteria known to be high-risk factors for esophageal cancer. Following endoscopic observation, magnified observations were performed on iodine-unstained lesions of the esophagus. The total number of lesions was 43. These lesions were classified as type A (clear papilla), type B (fused papilla), and type C (non-visible papilla) according to the findings. Tissue biopsy was then carried out. Finally the histological findings were graded in terms of histological factors, and their relationships were compared.

RESULTS: Of the 43 lesions, 11 were type A, 17 were type B, and 15 were type C under magnifying endoscopy. Histological findings such as inflammatory cell infiltration and basal cell hyperplasia were significantly increased in type B and type C lesions compared with type A lesions (P < 0.05). Low-grade esophageal dysplasia was apparent in 1 (9%) of 11 type A lesions, in 3 (18%) of 17 type B lesions, and in 6 (40%) of 15 type C lesions, with the highest rate in type C.

CONCLUSION: Magnified observations of the esophagus, classified by papillary aspects using magnifying endoscopy of iodine-unstained lesions in high-risk esophageal cancer groups, are considered useful in estimating dysplasia and inflammation of esophageal mucosa.

Secondary prevention of esophageal squamous cell carcinoma in areas where smoking, alcohol, and betel quid chewing are prevalent

Esophageal cancer is ranked as the sixth most common cause of cancer death worldwide and has a substantial effect on public health. In contrast to adenocarcinoma arising from Barrett's esophagus in Western countries, the major disease phenotype in the Asia-Pacific region is esophageal squamous cell carcinoma which is attributed to the prevalence of smoking, alcohol, and betel quid chewing. Despite a multidisciplinary approach to treating esophageal cancer, the outcome remains poor. Moreover, field cancerization reveals that esophageal squamous cell carcinoma is closely linked with the development of head and neck cancers that further sub-optimize the treatment of patients. Therefore, preventive strategies are of paramount importance to improve the prognosis of this dismal disease. Since obstacles exist for primary prevention via risk factor elimination, the current rationale for esophageal cancer prevention is to identify high-risk groups at earlier stages of the disease, and encourage them to get a confirmatory diagnosis, prompt treatment, and intensive surveillance for secondary prevention. Novel biomarkers for identifying specific at-risk populations are under extensive investigation. Advances in image-enhanced endoscopy do not just substantially improve our ability to identify small precancerous or cancerous foci, but can also accurately predict their invasiveness. Research input from the basic sciences should be translated into preventive measures in order to decrease the disease burden of esophageal cancer.

Transnasal endoscopy with narrow-band imaging and Lugol staining to screen patients with head and neck cancer whose condition limits oral intubation with standard endoscope (with video)

BACKGROUND

Early detection of esophageal cancer in patients with head and neck cancers may alter treatment planning and improve survival. However, standard endoscopic screening is not feasible for some patients with tumor-related airway compromise or postirradiation trismus.

OBJECTIVE

To evaluate a novel, sequential approach by integrating ultrathin endoscopy with narrow-band imaging and Lugol chromoendoscopy.

DESIGN

Cross-sectional study.

SETTING

Single center in Taiwan.

PATIENTS

Forty-four consecutive patients with transoral difficulty screened for synchronous or metachronous esophageal cancer.

MAIN OUTCOME MEASUREMENTS

Sensitivity, specificity, and accuracy in the detection of mucosal high-grade neoplasia or invasive cancer.

RESULTS

Fifty-four endoscopic interpretations were obtained, and 11 mucosal high-grade neoplasia and 7 invasive cancers were confirmed by histology. The mean examination time was 19.4 minutes (range 7.9-35.2 minutes), and all patients tolerated the procedure well. Sensitivity, specificity, and accuracy (with 95% CI) were 55.6% (95% CI, 33.5%-75.6%), 97.2% (95% CI, 85.8%-99.3%), and 83.3% (95% CI, 71.2%-90.9%), respectively, for standard endoscopy; 88.9% (95% CI, 66.9%-96.6%), 97.2% (95% CI, 85.8%-99.3%), and 94.4% (95% CI, 84.9%-97.9%), respectively, with the adjunct of narrow-band imaging; and 88.9% (95% CI, 66.9%-96.6%), 72.2% (95% CI, 55.9%-84.1%), and 77.8% (95% CI, 64.9%-86.8%), respectively, with the adjunct of Lugol chromoendoscopy. When we integrated all interpretations on the basis of the sequential approach, the estimated probability of false-negative findings was 1.2% (95% CI, 0.1%-4.6%).

LIMITATIONS

Inherent shortcomings of ultrathin endoscopy, such as its resolution, light source, and lack of magnification.

CONCLUSIONS

The use of ultrathin endoscopy in a sequential approach for multimodal detection is feasible in patients with transoral difficulty and substantially increases the detection rate of synchronous or metachronous neoplasms.

Novel imaging modalities in the detection of oesophageal neoplasia

The prognosis of oesophageal neoplasia is dependent on the stage of the disease at the time of detection. Early lesions have an excellent prognosis in contrast to more advanced stages that usually have a dismal prognosis. Therefore, the early detection of these lesions is of the utmost importance. In recent years, several new techniques have been introduced to improve the endoscopic detection of early lesions. The most important improvement, in general, has been the introduction of high-resolution/high-definition endoscopy into daily clinical practice. The value of superimposing techniques such as chromoendoscopy, narrow band imaging and computed virtual chromoendoscopy onto high-resolution/high-definition endoscopy will have to be proven in randomised cross-over trials comparing these techniques with standard techniques. Important future adjuncts to white-light endoscopy serving as 'red-flag' techniques for the detection of early neoplasia may be broad field functional imaging techniques such as video autofluorescence endoscopy. In addition, real-time histopathology during endoscopy has become possible with endocytoscopy and confocal endomicroscopy. The clinical value of these techniques needs to be ascertained in the coming years.

American Gastroenterological Association (AGA) Institute technology assessment on image-enhanced endoscopy

This document presents the official recommendations of the American Gastroenterological Association (AGA) Institute Technology Assessment on "Image-Enhanced Endoscopy." It was approved by the Clinical Practice and Economics Committee on August 3, 2007, and by the AGA Institute Governing Board September 27, 2007.

Endoscopic detection of early upper GI cancers

The detection of early-stage neoplastic lesions in the upper GI tract is associated with improved survival and the potential for complete endoscopic resection that is minimally invasive and less morbid than surgery. Despite technological advances in standard white-light endoscopy, the ability of the endoscopist to reliably detect dysplastic and early cancerous changes in the upper GI tract remains limited. In conditions such as Barrett's oesophagus, practice guidelines recommend periodic endoscopic surveillance with multiple biopsies, a methodology that is hindered by random sampling error, inconsistent histopathological interpretation, and delay in diagnosis. Early detection may be enhanced by several promising diagnostic modalities such as chromoendoscopy, magnification endoscopy, and optical spectroscopic/imaging techniques, as these modalities offer the potential to identify in real-time lesions that are inconspicuous under conventional endoscopy. The combination of novel diagnostic techniques and local endoscopic therapies will provide the endoscopist with much needed tools that can considerably enhance the detection and management of early stage lesions in the upper GI tract.

Optically tunable nanoparticle contrast agents for early cancer detection: model-based analysis of gold nanoshells

Many optical diagnostic approaches rely on changes in scattering and absorption properties to generate optical contrast between normal and diseased tissue. Recently, there has been increasing interest in using exogenous agents to enhance this intrinsic contrast with particular emphasis on the development for targeting specific molecular features of disease. Gold nanoshells are a class of core-shell nanoparticles with an extremely tunable peak optical resonance ranging from the near-UV to the mid-IR wavelengths. Using current chemistries, nanoshells of a wide variety of core and shell sizes can easily be fabricated to scatter and/or absorb light with optical cross sections often several times larger than the geometric cross section. Using gold nanoshells of different size and optical parameters, we employ Monte Carlo models to predict the effect of varying concentrations of nanoshells on tissue reflectance. The models demonstrate the importance of absorption from the nanoshells on remitted signals even when the optical extinction is dominated by scattering. Furthermore, because of the strong optical response of nanoshells, a considerable change in reflectance is observed with only a very small concentration of nanoshells. Characterizing the optical behavior of gold nanoshells in tissue will aid in developing nanoshells as contrast agents for optical diagnostics.

Chemoradiation therapy with or without salvage surgery for early squamous cell carcinoma of the hypopharynx

PURPOSE

Early squamous cell carcinoma of the hypopharynx is a rare clinical entity. Our objective was to analyze the outcome of patients with early hypopharyngeal cancer treated with curative radiotherapy or the combination of preoperative radiotherapy with surgery.

METHODS AND MATERIALS

Forty-three patients with Stage I-II hypopharyngeal cancer were initially treated with 30-40 Gy of irradiation with or without chemotherapy. Thirty-two patients (74.4%) who demonstrated a complete response continued to receive further radiotherapy, with a median total dose of 61.2 Gy. Eleven other patients (25.6%) received surgery.

RESULTS

Local control with laryngeal voice preservation was achieved in 8 (88.9%) of 9 patients with Stage I disease, and in 23 (67.6%) of 34 patients with Stage II disease. The overall and disease-specific 5-year survival rates for all patients were 70.4% and 89.5%, respectively. The disease-specific survival rates according to the T-category were 100% for patients with T1 disease and 87.2% for patients with T2 disease (p = 0.32). Twenty patients (46.5%) had synchronous or metachronous cancers. Four patients died of hypopharyngeal cancer, and 5 died of second-primary esophageal cancer.

CONCLUSIONS

A majority of patients with early hypopharyngeal cancer was curable. However, second malignancies influenced the overall outcome of patients with early hypopharyngeal cancer.

Impact of hiatal hernia on histological pattern of non-erosive reflux disease

BACKGROUND

Hiatus hernia (HH) has major pathophysiological effects favoring gastroesophageal reflux and hence contributing to esophageal mucosa injury, especially in patients with severe gastroesophageal disease. However, prospective studies investigating the impact of HH on the esophageal mucosa in non-erosive reflux disease (NERD) are lacking. This study evaluated the association between the presence of (HH) and the histological findings in symptomatic patients with NERD.

METHODS

Fifty consecutive patients with gastroesophageal reflux disease (GERD) were enrolled. After conventional endoscopy, Lugol solution was applied and biopsy specimens were obtained. Histological parameters including basal zone hyperplasia, papillary length and cellular infiltration were evaluated. The chi-square test with Yates' correlation was used for comparing discrete parameters between groups. However, Fisher's exact probability test was used where the expected frequencies were lower than 5. Wilcoxon's test for unpaired samples was preferred in cases of semi-quantitative parameters.

RESULTS

The presence of HH along with more severe findings (0.01 <P < 0.05) was confirmed in 18 patients. NERD was observed in 29 (58%) patients. Basal zone hyperplasia and loss of glycogen accompanied HH in all cases, and the correlation was significant in NERD (P < 0.001). The remaining histological patterns were similar between erosive reflux disease and NERD in the presence of HH.

CONCLUSION

The presence of HH is correlated with more severe endoscopy findings, and predisposes for severe histological abnormality in cases of NERD.

High-resolution chromoendoscopy in the esophagus

The major role for chromoendoscopy in the esophagus is the identification of premalignant or early cancerous lesions. In combination with high-resolution or magnification endoscopes, chromoendoscopy can potentially increase the diagnostic yield of clinically relevant lesions. Preliminary data have indicated a good correlation of findings using this technique to histopathologic readings. The ultimate goal of chromoendoscopy in combination with high resolution/magnification endoscopy is the determination of histology without obtaining tissue samples. In this article we review the different stains, the technical aspects, and current data in esophageal chromoendoscopy. We summarize possible clinical applications of these techniques and future directions of their use in esophageal diseases.

Videofiberoptic examination of the pharyngoesophageal segment and esophagus in patients after total laryngectomy

BACKGROUND

Posttreatment follow-up in patients with squamous cell carcinoma of the head and neck is critical because of the high risk of recurrence or a new primary tumor. However, in patients who have undergone total laryngectomy, evaluation of the pharyngoesophageal segment (PES) and esophagus is difficult.

METHODS

Sixty patients who had undergone total laryngectomy received a videofiberoptic examination of the PES and esophagus at the OPD office during follow-up.

RESULTS

Satisfactory examination was achieved in 56 (93%) of the patients. Each procedure was completed within 15 minutes. Although only 11 (18%) of the patients were symptomatic at follow-up, 19 patients (34%) had significant findings, including one local recurrence and two secondary esophageal cancers. Patients were asymptomatic in all three cases.

CONCLUSIONS

Videofiberoptic examination is a simple, effective, and relatively noninvasive method that can be performed in the OPD office to evaluate the PES and esophagus in patients after total laryngectomy.

Oesophageal squamous cell neoplasia in head and neck cancer patients: upregulation of COX-2 during carcinogenesis

Patients with (previous) head and neck cancer (HNC) are at high risk for developing second squamous cell cancer of the oesophagus. The role of cyclooxygenase-2 (COX-2) in oesophageal squamous carcinogenesis has not yet been investigated in this high-risk group. Therefore, this study examined COX-2 mRNA and protein expression in oesophageal biopsies and resected tissues of 44 HNC patients. The evaluation covered 55 oesophageal tissue samples (18 invasive oesophageal squamous cell cancers, four high- and eight low-grade dysplasias, 25 normal squamous epithelia) from the 44 patients. mRNA levels of COX-2 were measured by real-time PCR using a LightCycler. COX-2 protein expression was studied immunohistochemically and graded by a staining score. COX-2 mRNA was detected in all samples, and its levels correlated positively with the immunohistochemical staining score (P<0.05). COX-2 expression was upregulated during oesophageal squamous carcinogenesis in HNC patients, that is COX-2 expression increased significantly from normal oesophageal squamous epithelium to low- and high-grade dysplasia and finally to invasive squamous cell cancer (P<0.001). Our findings suggest that COX-2 upregulation contributes to oesophageal squamous carcinogenesis in HNC patients. Prospective studies are needed to evaluate the chemopreventive potential of COX-2 inhibitors in this high-risk group.

Oral cancer research with an emphasis on genomic analysis

Ablative surgery has been a standard procedure for many years, but during the past few years there has been a significant improvement in our understanding of invasion and metastasis in oral cancer. Each procedure has to be planned individually. Before surgery, every attempt must have been made to arrive at a proper diagnosis, including the exact nature and aggressiveness of the tumor and an analysis of the patient's genetic background. These procedures and the prognosis will be discussed.

Endoscopic treatment of early gastroesophageal malignancy

With the routine use of endoscopy, gastroesophageal cancers, which were often diagnosed in the symptomatic and incurable state, are now being diagnosed at earlier stages. Treatment of early-stage upper gastrointestinal cancers has evolved tremendously. Endoscopic therapy has been employed for early-stage lesions in an attempt to avoid the high morbidity and mortality associated with current curative procedures such as esophagectomy. These new endoscopic techniques include endoscopic mucosal resection, photodynamic therapy, electrocoagulation, and laser therapy. Exciting and novel endoscopic therapeutic options in diagnosing and treating early gastroesophageal cancers are the focus of this review.

Screening for oesophageal neoplasia in patients with head and neck cancer

Due to advanced disease at the time of diagnosis the prognosis of oesophageal cancer is generally poor. As mass screening for oesophageal cancer is neither feasible nor reasonable, high-risk groups should be identified and surveilled. The aim of this study was to define the risk of oesophageal cancer in patients with (previous) head and neck cancer. A total of 148 patients with (previous) head and neck cancer were prospectively screened for oesophageal cancer by video-oesophagoscopy and random oesophageal biopsies. Even in a macroscopically normal looking oesophagus, four biopsy specimens were taken every 3 cm throughout the entire length of the squamous oesophagus. Low- or high-grade squamous cell dysplasia was detected histologically in 10 of the 148 patients (6.8%). All but one dysplasias were diagnosed synchronously with the head and neck cancers. In addition, oesophageal squamous cell carcinoma was diagnosed in 11 of the 148 patients (7.4%). Most invasive cancers (63.6%) occurred metachronously. The risk of squamous cell neoplasia of the oesophagus is high in patients with (previous) head and neck cancer. Surveillance is recommended in this high-risk group.