 |
|
Symptom-Directed Selective Endoscopy
Long-term Efficacy
Michael S. Benninger, MD;
Afser Shariff, MD;
Kathleen Blazoff, RN, CNP
Arch Otolaryngol Head Neck Surg. 2001;127:770-773.
ABSTRACT
| |
Background Synchronous primary neoplasms have been encountered in some patients
with mucosal squamous cell carcinoma of the head and neck. Routine panendoscopy
along with various radiological tests have been advocated to identify these
potential tumors. In 1993, we originally described symptom-directed, selective
endoscopy as an efficient and cost-effective means to evaluate patients to
identify synchronous primary neoplasms.
Objective To review the ultimate success rate of symptom-directed, selective endoscopy
in that initial cohort of patients and the success of the program longitudinally
in clinical practice over the intervening 6 years.
Patients and Methods The status of the original 100 patients who participated in the selective
endoscopy study were reviewed at least 6 months after the original procedure.
A statistically significant random sample of 101 subsequent patients who had
at least 6 months' follow-up or until their death were reviewed.
Results No additional primary, mucosal head and neck, esophageal, or pulmonary
cancers were identified in the surviving original cohort of patients suggesting
that the selective endoscopy identified all synchronous tumors. Sixteen metachronous
primary cancers were identified between 12 and 70 months after the initital
evaluation. Eight synchronous primary cancers were identified in the new cohort
using symptom-directed evaluation, direct laryngopharyngoscopy, and chest
x-ray films. No additional tumors were detected within 6 months.
Conclusion Symptom-directed, selective endoscopy seems to be an effective alternative
to routine panendoscopy in identifying synchronous primary cancers.
INTRODUCTION
PATIENTS WITH squamous cell carcinomas (SCCs) of the head and neck have
been found to have an associated synchronous primary upper aerodigestive tract
malignant neoplasm in many cases with synchronous tumors being identified
in 1% to 17% of these patients.1-5
It is believed that these tumors occur because of the chronic irritant exposure
of the mucosa of the pharynx, larynx, esophagus, and tracheobronchial tree.
In an effort to identify these neoplasms, routine endoscopic assessment including
direct laryngoscopy, esophagoscopy, and bronchoscopy (triple endoscopy) has
been recommended by many authors.1-2,6-7
Additional evaluations such as a barium swallow esophagogram, bronchial washings,
and various laboratory tests have also been recommended.1, 5
These recommendations are based on the desire to identify and manage these
synchronous neoplasms with a goal of improving outcome and survival.
In 1993, we suggested that symptoms could be used to direct the subsequent
endoscopic evaluations, decrease potential morbidity, and reduce the costs
of the evaluations.5 Esophagoscopy was recommended
if patients had symptoms of true dysphagia (not just a globus sensation),
odynophagia, or noncardiac chest pain. Bronchoscopy was recommended for symptoms
of chronic cough, hemoptysis, shortness of breath, or stridor. That study
showed that symptom-directed esophagscopy and bronchoscopy along with direct
or indirect laryngopharyngoscopy and a chest x-ray film could identify second
primary tumors without the need for mandatory triple endoscopy. Because some
patients are initially seen with silent pharyngeal tumors, direct laryngopharyngoscopy
was recommended in all patients, although the potential for office-based videolaryngopharyngoscopy
was considered. Bronchial washings were not valuable and, therefore, were
not recommended. That study also suggested that further research and long-term
evaluations may be needed to strengthen the recommendations.5
This study evaluated the long-term results and survival of the original
cohort of patients5 to identify if there was
any evidence of missed second primary tumors, assessed the frequency of metachronous
neoplasms, and analyzed the success of the selective endoscopic recommendations
in the intervening years to determine if this approach failed to identify
any subsequent second primary tumors.
PATIENTS, MATERIALS, AND METHODS
The medical records of the original cohort of 100 patients were retrospectively
reviewed. Variables evaluated included the following: disease status, ultimate
survival and outcome, potential missed second primary tumors, recurrences,
and metachronous cancers. A separate cohort of 101 randomly sampled, statistically
significant patients were also retrospectively evaluated. These patients were
drawn from an average of 150 new head and neck cancer evaluations per year.
One hundred one patients were originally assessed to determine the success
of identification of second primary cancers. A minimum follow-up of 6 months
or death from disease before 6 months was required to have the success of
the evaluations determined. The medical records of these 101 patients were
evaluated for original evaluations performed, disease status, ultimate survival
and outcome, length of follow-up, potentially missed second primary tumors,
recurrences, and metachronous tumors.
RESULTS
No new laryngopharyngeal, pulmonary, or esophageal tumors were identified
in the original group of patients within 6 months of the original endoscopies
and evaluations. This would suggest that the endoscopic assessment and chest
x-ray films identified all second primary tumors. These patients have had
an average follow-up of 38 months (follow-up range, 2-131 months). The average
follow-up for the 52 patients who were alive at the last office visit or contact
was 53 months (range, 5-131 months). Only 1 of these patients were followed
up for less than 6 months and only 5 for less than 12 months. Overall, 10
patients were followed up for less than 6 months—8 either died of disease
(6 patients) or died of unrelated causes (2 patients). One patient never returned
for treatment after the original assessment and 1 was lost to follow-up after
4 months.
Thirty-one patients developed a recurrence; 16 were local recurrences,
8 were locoregional, 1 was regional only, 2 were local metestatic, and 3 developed
locoregional metastatic recurrences. Six patients had persistence of their
disease after the initial treatment. Fourteen patients were subsequently found
to have developed a metachronous cancer, with 11 being in the upper aerodigestive
tract (Table 1). The average time
to the identification of a metachronous primary tumor was 29.9 months (range,
12-70 months). None was identified in the first year after the initial evaluation.
|
|
|
|
Table 1. Metachronous Cancers in Original 100 Patients
|
|
|
Fifty-two patients were alive with no evidence of disease; 1 was alive
with disease; 32 had died of their primary, secondary, or metachronous cancer;
12 died with no evidence of disease; and 3 had less than 1 year follow-up
where final status could not be assessed. Of the 11 patients who were originally
identified with a second primary cancer, 3 were alive with no evidence of
disease, 4 had died of disease, and 4 died with no evidence of disease.
Following the original study, 101 patients from an average of 150 new
head and neck cancer evaluations per year were randomly sampled from patients
undergoing selective endoscopic evaluations. Qualifying patients had at least
6 months of follow-up evaluation or had died of disease. The sites of tumors
for the 101 patients were larynx, 56 patients; oropharynx, 19; hypopharynx,
11; oral cavity, 9; nasopharynx, 3; and unkown primary with neck metastases,
3. The tumor stage, nodal status, and disease stage at presentation are noted
in Table 2.
|
|
|
|
Table 2. Primary Tumor, Nodal Status, and Stage at Presentation of
Second Cohort of 101 Patients
|
|
|
All patients underwent direct laryngopharyngoscopies and chest x-ray
films as part of their initial evaluation. Eight of the chest x-ray films
had an abnormality that might suggest cancer. Three pulmonary second primary
tumors were identified. No esophograms were performed. Twenty symptom-directed
esophagoscopies were performed; no esophageal cancers were identified. Seven
symptom-directed bronchoscopies were performed with 1 being positive for cancer.
The positive result was in a patient who had already been identified as having
a mass by chest x-ray film.
Six synchronous second primary cancers were identified in the upper
aerodigestive tract; 2 epiglottic tumors that were symptomatic, 1 asymptomatic
hypopharynx cancer; and 3 lung cancers (1 that was symptomatic). In addition,
an adenocarcinoma of the colon and a non-Hodgkin lymphoma were discovered.
A total of 19 synchronous cancers were discovered in 18 patients (9.5%) from
a total of 201 patients from the prior and present studies. The sites of the
total synchronous primary tumors are listed in Table 3. All 3 esophageal tumors were symptomatic. While all 5 pulmonary
tumors were identified by routine chest x-ray screening, only 1 (20%) was
symptomatic. In neither cohort of patients was there evidence of a second
primary pulmonary tumor being identified within 6 months with a normal initial
chest x-ray film. Eight (73%) of the 11 head and neck cancers were symptomatic,
with all 3 asymptomatic tumors being identified in the hypopharynx.
|
|
|
|
Table 3. Synchronous Primary Cancers in 201 Patients
|
|
|
The 101 patients have been followed up for an average of 27 months (follow-up
range, 3-75 months). Patients who were alive at their last encounter were
followed up for an average of 32.9 months (follow-up range, 7-72 months) while
those who died were followed up for an average of 13.5 months (follow-up range,
2-39 months). There have been no missed second primary tumors identified.
Two patients had a history of adenocarcinoma of the lungs. Two patients developed
metachronous upper aerodigestive tract malignant neoplasms during the follow-up
period; a nasopharyngeal carcinoma at 38 months, and an SCC of the lip at
43 months. Seven patients developed metastatic SCCs. Five of these were in
the lungs at an average of 27 months after initial evaluation and 2 in the
liver at an average of 23 months. For the 201 patients evaluated, a total
of 16 metachronous upper aerodigestive tract cancers (7.9%) and 3 other tumors
were identified. Because many of these patients have had a short follow-up,
it can be expected that this rate would likely increase over time.
The status of the 101 patients from the most recent cohort of patients
showed that 75 are alive with no evidence of disease at an average follow-up
of 33.8 months and 3 patients are alive with disease at an average of 11 months.
Sixteen patients have died of disease at an average of 14.7 months and 7 patients
have died with no evidence of disease at an average of 10.3 months.
COMMENT
Synchronous primary cancers are identified in the upper aerodigestive
tract in 1% to 17% of the patients with SCCs of the head and neck.1-2 Our present studies suggest that this
occurs in 8% to 9% of individuals. It can be suggested that this occurs because
of the field cancerization effect from chronic exposure to cancer-causing
agents, principally tobacco and alcohol exposure, and perhaps in individuals
with a genetic predisposition. The development of second primary tumors is
frequent enough to warrant further investigation. Traditional teaching has
suggested that a thorough search for these secondary tumors should include
a chest x-ray film, bronchoscopy, esophagoscopy, and laryngoscopy (triple
endoscopy). Other studies such as a barium swallow esophagogram and various
laboratory tests have also been recommended. The principles of these approaches
are to attempt to identify early tumors, some of which may be asymptomatic
to treat promptly and perhaps affect the ultimate outcome.
Some studies indicate that asymptomatic tumors can be identified through
routine endoscopy.6-7 Whether
this is the case has not been made clear. The definition of asymptomatic is
not always firmly established, or has there been established diagnostic protocols
for defining the subsequent evaluations. Our studies indicate that there are
asymptomatic pharyngeal and pulmonary tumors. Although no asymptomatic esophageal
tumors were identified, the numbers were small. Anecdotally, we are unaware
of any unidentified esophageal tumors since we have initiated our selective
evaluations. The clinical influence of identifying asymptomatic tumors has
also been undetermined. "No study has yet examined whether patients with synchronous
pulmonary or esophageal tumors have increased survival if their tumors are
detected with routine endoscopy when asymptomatic instead of later, when symptomatic."8(p1208) It is interesting that despite a multiple-year
history of many articles supporting triple endoscopy, there is still very
wide geographic variability in the number of procedures performed. Deleyiannis
et al8 used the National Cancer Institute's
Surveillance, Epidemiology, and End Results Program to assess the frequency
to which esophagoscopy and bronchoscopy are being used in the United States
to evaluate patients with head and neck cancer. They found wide geographic
variation with esophagoscopy being performed in 12.9% to 39.8% and bronchoscopy
in 6.9% to 32.6% of patients with local disease, depending on the part of
the country where the patient presented. These numbers increased from 22.2%
to 59.7% for esophagoscopy and 12.8% to 50.7% in patients with regional cancers.8 The only 2 factors that were found to be associated
with variations in the rates of these procedures were where a patient was
treated geographically in the country and whether they had local vs regional
disease. Despite the infrequency of endoscopies being performed in some areas
of the country, they found that patients who underwent esophagoscopy or bronchoscopy
did not have statistically significant differences in survival.8
The role of esophageal evaluation is unclear. Despite our study showing
no asymptomatic esophageal tumors, there have been studies that have shown
that endoscopy may identify asymptomatic tumors.6-7
There are some risks and morbidity associated with esophagoscopy including
discomfort, perforation, and even death; although in skilled hands these risks
would be expected to be minimal. The costs associated with esophagoscopy is
related to anaesthesia, operative costs, and surgeon fees. If done at the
time of direct laryngoscopy, these costs would also be low. Because of these
low costs and risks, some have advocated that esophagoscopy be performed in
those patients who would otherwise require direct operative laryngoscopy.9 With the possibility of performing videolaryngopharyngoscopy
in an office potentially obviating the need for operative direct laryngoscopy,10 the routine performance of esophagoscopy would be
more costly and associated with greater risks. The bottom line is that there
is a lack of adequate data.9 Given the findings
of our study and the failure to show increased survival benefit in the large
National Cancer Institute's Surveillance, Epidemiology, and End Results Program
study,8 we believe that symptom-directed selective
endoscopy is a reasonable option for screening for secondary esophageal cancers.
The role of bronchoscopy is more speculative. Since many pulmonary and
tracheobronchial tree tumors are likely to be either asymptomatic or associated
with nonspecific symptoms, some pulmonary evaluation is warranted. In our
initial study, bronchial washings were not found to be valuable having both
low sensitivity and specificity.5 In neither
of our studies was bronchoscopy found to be of valuable. Only 1 patient with
pulmonary cancer had an abnormal bronchoscopy, and that tumor was suspected
after identification on a chest x-ray film. On the premise that true tracheal
neoplasms are rare, in addition with most secondary respiratory primary cancers
being found in the lungs or bronchial tree and because we advocate routine
chest x-ray film, bonchoscopic assessment would seem to add little value in
ruling out second primary tumors. To perform bronchoscopy on symptomatic patients
still seems reasonable despite the expected low yield, but routine bonchoscopy
in asymptomatic patients is probably unnecessary. The questions regarding
the roles of other imaging techniques such as computed tomographic or magnetic
resonance imaging scans was not addressed in this study, although this may
be found to be important in the future.
We do believe that a thorough evaluation of the laryngopharynx should
be accomplished in all patients, since second primary tumors are most common
in these areas and may on occasion be asymptomatic. This could be performed
in the following setting: (1) when accurate staging is desired, (2) when difficult
to obtain biopsy specimens are needed such as from the larynx or hypopharynx,
(3) during planned excision of the primary cancer, or (4) when symptom-directed
esophagoscopy or bronchoscopy is planned. In skilled hands, a complete evaluation
can be performed with office-based videolaryngopharyngoscopy.10
Our initial study suggested the cost-effectiveness of symptom-directed evaluations
and is consistent with the findings of others.5, 11
Given the results of this long-term follow-up study, the consideration of
performing symptom-directed esophagoscopy and bronchoscopy along with a complete
evaluation of the laryngopharynx and a chest x-ray film seems justified. Two
unanswered questions remain: whether a few select patients will have asymptomatic
cancers that are missed by these selective evaluations, and if so, will their
ultimate outcome be affected? Further study is necessary to provide the data
needed to definitively answer these questions.
Our studies revealed that metachronous primary tumors occurred in 7.9%
of patients, despite a short follow-up in some patients. Ultimate metachronous
cancer rates would be expected to be higher, consistent with other reports.12 Metachronous cancers likely occur secondary to the
field cancerization effect suggested with synchronous tumors. With these frequent
occurrences of metachronous cancers, long-term observation and screening is
important and is recommended. Although the evaluation of metachronous cancers
was not explored in these studies, a selective approach with routine evaluation
of the laryngopharynx with periodic chest x-ray films and symptom-directed
selective bronchoscopies and esophagoscopies would seem to be an appropriate
surveillance method.
CONCLUSIONS
Symptom-directed selective endoscopy along with chest x-ray films and
a complete examination of the laryngopharynx by direct or indirect laryngopharyngoscopy
is a reasonable alternative to mandatory triple endoscopy in identifying second
primary tumors in patients with head and neck SCCs. The role of bronchoscopy
in the presence of advancing appropriate radiological evaluation of the chest
and lungs is questioned.
AUTHOR INFORMATION
Accepted for publication April 6, 2001.
Presented in part at the annual meeting of the American Head and Neck
Society, Fifth International Conference on Head and Neck Cancer, San Francisco,
Calif, July 29-August 2, 2000.
We acknowledge Richard Nichols, MD, for his collaboration on the first
cohort of patients. We also thank medical student Jaswinder Sandhu for compiling
part of the data.
Corresponding author: Michael S. Benninger, MD, Department of Otolarynology–Head
and Neck Surgery, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202
(e-mail: Mbenning{at}HFHS.org).
From the Department of Otolarynology–Head and Neck Surgery, Henry
Ford Hospital, Detroit, Mich.
REFERENCES
| |
1. McGuirt WF. Panendoscopy as a screening examination for simultaneous primary tumors
in head and neck cancer: a prospective sequential study and review of the
literature. Laryngoscope. 1982;92:569-576.
ISI
| PUBMED
2. Masaki N, Hashimoto T, Ikeda H, Inoue T, Kozuka T. Multiple primary malignancies in patients with head and neck cancer. Jpn J Clin Oncol. 1987;17:303-307.
FREE FULL TEXT
3. Licciardello JT, Spitz MR, Hong WK. Multiple primary cancer in patients with cancer of the head and neck:
second cancer of the head and neck, esophagus, and lung. Int J Radiat Oncol Biol Phys. 1989;17:467-476.
ISI
| PUBMED
4. Silvestri F, Bussani R, Cosatti C, Bosatra A. High-relative risk of a second pulmonary cancer in patients affected
by laryngeal cancer: differences by specific site of occurrence and lung cancer
histotype. Laryngoscope. 1994;104:222-225.
ISI
| PUBMED
5. Benninger MS, Enrique RR, Nichols RD. Symptom-directed selective endoscopy and cost containment for evaluation
of head and neck cancers. Head Neck. 1993;15:532-536.
ISI
| PUBMED
6. McGuirt WF, Matthews B, Koufman JA. Multiple simultaneous tumors in patients with head and neck cancer:
a prospective, sequential panendoscopic study. Cancer. 1982;50:1195-1199.
FULL TEXT
|
ISI
| PUBMED
7. Leipzig B, Zelmer JE, Klug D for the Panendoscopy Study Group. The role of endoscopy in evaluating patients with head and
neck cancer:
a multi-institutional prospective study. Arch Otolaryngol. 1985;111:589-594.
FREE FULL TEXT
8. Deleyiannis FW, Weymuller EA Jr, Garcia I, Potosky AL. Geographic variation in the utilization of esophagoscopy and bonchoscopy
in head and neck cancer. Arch Otolaryngol Head Neck Surg. 1997;123:1203-1210.
FREE FULL TEXT
9. Deleyiannis FW, Weymuller EA Jr. Screening patients with head and neck cancer for esopaghageal cancer:
a lack of adequate data. Arch Otolaryngol Head Neck Surg. 1998;124:933.
FREE FULL TEXT
10. Bastian RW, Collins SL, Kaniff T, Matz G. Indirect videolaryngoscopy versus direct endoscopy for larynx and pharynx
cancer staging toward the elimination of preliminary direct laryngoscopy. Ann Otol Rhinol Laryngol. 1989;98:693-698.
ISI
| PUBMED
11. Shaha AR, Hoover EL, Marti J, Krespi Y. Is routine triple endoscopy cost-effective in head and neck cancer? Am J Surg. 1988;155:750-753.
FULL TEXT
|
ISI
| PUBMED
12. de Visscher AV, Manni JJ. Routine long-term follow-up in patients treated with curative intent
for squamous cell carcinoma of the larynx, pharynx, and oral cavity: does
it make sense? Arch Otolaryngol Head Neck Surg. 1994;120:934-939.
FREE FULL TEXT
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
RELATED ARTICLE
Archives of Otolaryngology–Head & Neck Surgery Reader's Choice: Continuing Medical Education
Arch Otolaryngol Head Neck Surg. 2001;127(7):889-890.
FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Prediction of Simultaneous Esophageal Lesions in Head and Neck Squamous Cell Carcinoma: A Multivariate Analysis
Chow et al.
Arch Otolaryngol Head Neck Surg 2009;135:882-885.
ABSTRACT
| FULL TEXT
|
