Successful treatment for hypopharyngeal cancer in a patient with superficial esophageal cancer by endoscopic submucosal dissection

A 68-year-old man with a history of laryngectomy for laryngeal cancer 3 years earlier was diagnosed with superficial esophageal squamous cell carcinoma (ESCC). In addition, a slightly elevated lesion (1.6 cm) was detected synchronously in the posterior wall of the hypopharynx ([Fig. 1 ] a). Using a narrow-band imaging (NBI) system with magnifying endoscopy (GIF TYPE H260Z; Olympus), this lesion displayed a clearly demarcated brownish area ([Fig. 1 ] b) and the intrapapillary capillary loop (IPCL), which was advocated by Inoue et al. [1], took on irregular shapes ([Fig. 1 ] c). For treatment of the hypopharyngeal lesion, endoscopic submucosal dissection (ESD) was performed under general anesthesia followed by subtotal esophagectomy. A mucosal incision was made with the flex knife and the subepithelial tissue was cut with a hook knife. Macroscopic examination of the resected specimen (3.5 × 3.0 cm) revealed cancer spread over an area of 1.7 × 1.3 cm ([Fig. 2 ] a). Histologically, noninvasive squamous cell carcinoma was limited to the epithelial layers without either vessels or lymphatic infiltration, and both horizontal and vertical margins were sufficient ([Fig. 2 ] b). Immunohistochemistry revealed that p53-positive cells were widespread in the outer basal cell layer ([Fig. 2 ] c). This observation led to a diagnosis of squamous cell carcinoma of the hypopharynx, not a dysplastic lesion or regenerative changes.

Fig. 1 Upper endoscopic findings for the hypopharynx. a A slightly elevated lesion with fine granular changes and absence of continuity with blood vessels, approximately 1.6 cm in diameter, was detected synchronously in the posterior wall of the hypopharynx. b With the narrow band imaging (NBI) system, this lesion displayed a clearly demarcated brownish area. c Using the NBI system with a magnifying endoscope, the intrapapillary capillary loop took on irregular shapes including dilation, tortuosity, caliber change, and meandering. These observations suggested that the lesion would have malignant potential.

Fig. 2 Macroscopic and pathologic findings. a The resected specimen measured 3.5 × 3.0 cm and macroscopically, resected margins were almost optimal circumferentially (× 1). The extent of cancer spread was schematically drawn using yellow color lines, and measured 1.7 × 1.3 cm. b Histologic findings revealed noninvasive, moderately differentiated squamous cell carcinoma limited to the lamina propria mucosae without vessel or lymphatic infiltration. In addition, both horizontal and vertical margins were sufficient (× 20). c Immunohistochemistry revealed p53-positive cells were randomly widespread in the outer basal cell layer (× 200).

One of the hallmarks of ESCC is synchronous or metachronous tumors arising in the head and neck [2]. An NBI system with magnifying endoscopy is useful for acquiring valuable information about small lesions of the hypopharynx [3], and ESD is a more favorable method than endoscopic mucosal resection for early-stage hypopharyngeal cancer located in anatomically complex areas [4]. In conclusion, an NBI system with magnifying endoscopy has increased the chance of early detection of hypopharyngeal cancer, and ESD would be the optimal method of treatment at least for early-stage hypopharyngeal cancer.

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References

• 1 Kumagai Y, Inoue H, Nagai K. et al . Magnifying endoscopy, stereoscopic microscopy, and the microvascular architecture of superficial esophageal carcinoma.  Endoscopy. 2002;  34 369-375
• 2 Motoyama S, Saito R, Kitamura M, Ogawa J. Outcomes of active operation during intensive followup for second primary malignancy after esophagectomy for thoracic squamous cell esophageal carcinoma.  J Am Coll Surg. 2003;  197 914-920
• 3 Muto M, Nakane M, Katada C. et al . Squamous cell carcinoma in situ at oropharyngeal and hypopharyngeal mucosal sites.  Cancer. 2004;  101 1375-1381
• 4 Shimizu Y, Yamamoto J, Kato M. et al . Endoscopic submucosal dissection for treatment of early stage hypopharyngeal carcinoma.  Gastrointest Endosc. 2006;  64 255-259; discussion 260 – 252