Successful salvage endoscopic mucosal resection for residual superficial hypopharyngeal carcinoma after chemoradiotherapy, with long-term survival

We have read with great interest the article by Yano et al. [1] on the utility of salvage endoscopic mucosal resection (EMR) in esophageal carcinoma patients with local failure after definitive chemoradiotherapy, and also the article by Iizuka et al. [2] on the safety of endoscopic submucosal dissection (ESD) and the efficacy of elevation of the larynx for treatment of early mesopharyngeal and hypopharyngeal carcinoma. Yano and colleagues reported that 5-year survival rates following salvage EMR were 67.5 % (T1, n = 11) and 30.0 % (T3/T4, n = 10). Their data show that salvage EMR is not inferior to salvage esophagectomy for recurrent or residual esophageal carcinoma after definitive chemoradiotherapy [3], in terms of curative treatment effect and long-term survival, if the lesions are superficial without lymph node and distant metastasis. Iizuka and colleagues attempted ESD with elevation of the larynx with the objective of improving the efficiency and effectiveness of endoscopic treatment for pharyngeal lesions. In order to perform this technique with adequate intraoperative and postoperative management and without serious complications, cooperation between endoscopists and otolaryngologists is necessary. We have also always performed treatment in cooperation with otolaryngologists for cases of early-stage head and neck cancer. Patients with primary superficial laryngopharyngeal carcinoma at an early stage have been curatively treated by EMR and ESD with such cooperation, especially in Japan [2] [4] [5] [6]. However, the utility of salvage EMR or ESD for residual superficial laryngopharyngeal carcinoma after definitive chemoradiotherapy is unclear. Here we describe for the first time a case of long-term survival following successful treatment with salvage EMR for residual superficial hypopharyngeal carcinoma after definitive chemoradiotherapy, in cooperation with otolaryngologists, and we discuss the utility of salvage EMR in this context.

A 75-year-old man was admitted to Hokkaido University Hospital for treatment of a hypopharyngeal lesion. Initially, a hypopharyngeal tumor of about 3 cm in size was found in the right piriform fossa ([Fig. 1 a]) and was diagnosed as hypopharyngeal squamous cell carcinoma without metastatic lesions (T2 N0 M0) at the Department of Otolaryngology. He was treated with concurrent chemoradiotherapy, involving 66 Gy irradiation (33 fractions of 2 Gy) together with 4 infusions of docetaxel (10 mg/m²). At 3 months after chemoradiotherapy, the tumor was prominently reduced but remained. Endoscopic examination revealed a 8 × 7-mm, round, elevated lesion with a furry white surface on the right piriform fossa ([Fig. 1 b, c]). The surface was reddish-granular with easy bleeding and without any ulceration after removal of the furry white plaque. The histopathological diagnosis of a biopsy specimen was viable squamous cell carcinoma. A whole-body computed tomography (CT) scan demonstrated no lymphadenopathy or distant metastases. Based on these findings, a diagnosis of hypopharyngeal carcinoma without metastatic lesions (T1 N0 M0) was made.

Fig. 1 a Reversed laryngoscopic view before chemoradiotherapy. A protruding hypopharyngeal carcinoma occupied the right piriform fossa. b Endoscopic view after chemoradiotherapy. The residual lesion had a furry white plaque. c After removal of the furry white plaque, a superficial protruding lesion was visible.

As a result of consultation with otolaryngologists and after informed consent had been obtained from the patient, salvage EMR was carried out for a complete cure of the hypopharyngeal carcinoma. EMR using a transparent cap and a snare (EMR-C method [7]) was performed with the patient under general anesthesia. To delineate the margins of the lesion, 1.5 % iodine staining was used before resection. EMR was successfully performed without complications ([Fig. 2 a]). Histopathologic examination of the resected specimen showed that squamous cell carcinoma had invaded the subepithelial layer ([Fig. 2 b, c]). The margins of the resected specimen were tumor-free histologically, and there was no invasion into veins or lymph vessels. The final diagnosis was T1 N0 M0.

We performed follow-up endoscopy at 1 month, 3 months, and then every 6 months after EMR. Specialist otolaryngologists also routinely carried out a physical examination, CT scan, and laryngoscopy. There has been no recurrence or occurrence of metastatic lesions after EMR during a follow-up period of 5 years and 6 months ([Fig. 2 d]).

Fig. 2 a Appearance after complete resection of the residual lesion by endoscopic mucosal resection with a transparent cap-fitted device (EMR-C). The subepithelial layer under the tumor was clearly visible after resection. b Macroscopic image of the resected specimen. c Photomicrograph of the EMR specimen, showing the residual lesion elevated from the epithelial mucosa and with slight invasion into the subepithelial layer without vascular invasion; complete resection of lateral and vertical margins was confirmed (hematoxylin and eosin [H&E] stain). d Endoscopic view of the hypopharynx after salvage EMR. There has been no recurrence after EMR during a follow-up period of 5 years and 6 months.

According to data from the Surveillance, Epidemiology, and End Results (SEER) registry, the incidence of hypopharyngeal carcinoma in elderly people is high, and the 5-year survival rates for patients with head and neck cancer are extremely low [8]. However, recent efforts by gastrointestinal endoscopists have enabled detection of laryngeal and pharyngeal cancer at an early stage, especially in Japan [4] [9]. Additionally, EMR and ESD have been used for treatment of early-stage head and neck cancers because of their minimal invasiveness and because laryngopharyngeal functions are preserved. For some primary superficial laryngopharyngeal carcinomas at an early stage, use of the EMR/ESD technique, in cooperation with otolaryngologists for treatment and follow-up enables complete en bloc resection, accurate histological evaluation, and locoregional control.

In this report, we describe for the first time long-term survival in a patient successfully treated with salvage EMR for residual superficial hypopharyngeal carcinoma after chemoradiotherapy. The next definitive treatment could only have been total laryngopharyngectomy for salvage. However, the patient was of advanced age and did not want to undergo a surgical operation. Total laryngopharyngectomy is very invasive and results in notable deterioration of the patient’s quality of life, including loss of voice and permanent tracheostoma [10] [11]. In addition, laryngopharyngectomy after failed chemoradiotherapy has a risk of severe complications [12]. In the present case, it was expected that EMR would be difficult because of fibrosis after the chemoradiotherapy, but in fact EMR was done successfully without any trouble. However, salvage EMR must be performed carefully with attention to possible perforation and bleeding.

For recurrent or residual esophageal carcinoma after definitive chemoradiotherapy, salvage EMR/ESD is one of the curative treatment options if the lesions are superficial and without lymph node and distant metastases [1] [13]. As in the present case, if the recurrent or residual lesion is superficial with no lymphadenopathy and no distant metastasis, we consider salvage EMR/ESD to be one of the curative treatment options for hypopharyngeal carcinoma, with, of course, the informed consent of the patient. In addition, the EMR/ESD method enables an en bloc resected specimen to be obtained and therefore accurate histological evaluation.

In this case, salvage for the patient was successfully done after consultation with us because otolaryngologists at our hospital were well informed about the utility of EMR for hypopharyngeal carcinoma. Although therapy for residual hypopharyngeal carcinoma after chemoradiotherapy is usually discussed and decided by only otolaryngologists, we consider that it is important to make them aware of the utility of EMR in this context.

Competing interests: None

References

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