J Med Dent Sci 2015； 62： 19－24
Original Article Risk factors for cervical lymph node metastasis in superficial head and neck squamous cell carcinoma Toru Sasaki, MD1, 2), Seiji Kishimoto, MD, PhD1), Kazuyoshi Kawabata, MD2), Yukiko Sato, DDS, PhD3) and Tomohiro Tsuchida, MD, PhD4)
1) Department of Head and Neck Surgery, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan 2) Division of Head and Neck, Cancer Institute Hospital, Japanese Foundation of Cancer Research, Tokyo, Japan 3) Department of Pathology, Cancer Institute, Japanese Foundation of Cancer Research, Tokyo, Japan 4) Division of Endoscopy, Cancer Institute Hospital, Japanese Foundation of Cancer Research, Tokyo, Japan
Introduction: The necessity of transoral surgery for head and neck carcinoma is increasing, but its indications for the treatment of superficial head and neck carcinomas have not yet been established. This study was intended to help establish the standard indications for transoral surgery and additional therapy in patients with superficial head and neck carcinoma. Methods: Sixty-two patients with 83 superficial head and neck carcinoma underwent transoral tumor resection at the Cancer Institute Hospital between June 2006 and September 2011. We measured the tumor size and thickness, examined the gross appearance, permeation of vessels, and droplet infiltration, and analyzed the correlations between each parameter. Results: Sessile type of tumor on gross appearance showed a significantly higher incidence of thickness ≥1000 µm than the other types. Tumor thickness ≥1000 µm was associated with higher incidences of permeation of vessels, droplet infiltration, and cervical lymph node metastasis. Conclusions: In superficial head and neck carcinoma, if the endoscopic gross appearance is the sessile type, tumor thickness is likely to be ≥1000 µm and risk of cervical lymph node Corresponding Author: Toru Sasaki, MD Division of Head and Neck, Cancer Institute Hospital, 3-10-6, Ariake, Koto-ku, Tokyo, 135-8550, Japan. Tel: +81-3-3520-0111 Fax: +81-3-3570-0343 E-mail: [email protected] Received September 30, 2014；Accepted January 8, 2015
metastasis is increased. Key words: Superficial head and neck carcinoma; transoral surgery; permeation of vessels; droplet infiltration; gross appearance Introduction The conventional therapy for early head and neck carcinoma is radiotherapy. However, some cases can no longer undergo radiotherapy because of previous radiotherapy for other head and neck carcinomas. Furthermore, radiotherapy is associated with problems, such as delayed radiation injury and radiation-induced cancer. Recent innovations in endoscopic devices like narrow-band imaging (NBI) have made it possible to 1-3 detect superficial head and neck carcinomas. Transoral surgery has been undergoing development as a minimally invasive, function-preserving surgery for superficial head and neck carcinoma. Since 2006 at our institute, endoscopic mucosal resection (EMR) has been applied for superficial head and neck carcinoma. The EMR is an effective treatment for superficial esophageal carcinoma, gastric carcinoma, and colorectal carcinoma. In these regions of the digestive tract, the indications for EMR and additional therapy are decided based on the depth of tumor invasion and permeation of vessels (PV). 4-6 However, the indications for transoral surgery for superficial head and neck carcinoma have yet to be established. The present study examined the relationship between
20
J Med Dent Sci
T. Sasaki et al.
each parameter, namely gross appearance of the tumor, tumor size, tumor thickness, and PV. Furthermore, it was intended to help in the establishment of the s tandard indi cations for tran so ra l surge ry and additional therapy in patients with superficial head and neck carcinoma. Materials and methods The recent introduction of magnifying gastrointestinal endoscopy with NBI for head and neck region has allowed the detection of superficial carcinoma in the pharynx and larynx. Therefore, superficial head and neck cancers often refer to superficial lesions of pharynx and larynx. In this study, the superficial head and neck cancer was defined as the superficial lesions of the pharynx and larynx. Hence, 62 patients (60 men, 2 women) with a total of 83 lesions underwent transoral tumor resection based on a diagnosis of superficial head and neck squamous cell carcinoma at the Cancer Institute Hospital in Japan between June 2006 and September 2011. They were followed-up for more than one year after the surgery. Among the 83 lesions, 71 were hypopharyngeal carcinoma (pyriform sinus, 58; posterior wall, 9; postcricoid, 4), 6 were oropharyngeal carcinoma (base of tongue, 1; posterior wall, 4; vallecula, 1), and 6 were laryngeal carcinoma (arytenoid, 5; epiglottis, 1) (Table1). Mean age at diagnosis was 65.0 years (range, 41–84 years). Median duration of follow-up was 40.0 months (range, 13–79 months). Tumor thickness and size were measured as shown in Figure1. Median tumor thickness Table 1. Clinical characteristics, treatment profiles, and pathologic status of lesions Abbreviations: EMR-C, endoscopic mucosal resection with cap-fitting endoscope; ESD, endoscopic submucosal dissection; ELPS, endoscopic laryngo-pharyngeal surgery
FIGURE 1.
②
①
① Tumor thickness ② Tumor size
①
Tumor Epithelium Subepithelial layer
②㻌
①㻌
Figure 1. Methods for measuring tumor thickness and size
was 500 µm (range, 170–7000 µm). Median tumor size was 15 mm (range, 4–55 mm). All lesions were N0M0. Gross appearance was classified into 3 types according to the General Rules for Clinical Studies on Head and th Neck Cancer 5 Edition: protruding (0-I); flat (0-II); or depressed (0-III). Protruding type was further classified into 2 subtypes: pedunculated type (0-Ip) or sessile type (0-Is). Flat type was also further classified into 3 subtypes: slightly elevated (0-IIa); flat (0-IIb); or slightly depressed (0-IIc). Eleven lesions were type 0-Is, 34 were type 0-IIa, 37 were type 0-IIb, and only 1 was type 0-IIc. No type 0-Ip or type III lesion was encountered (Table 1). The treatment methods comprised of EMR with capfitting endoscope (EMR-C)7 for 40 lesions, endoscopic submucosal dissection (ESD) 8 for 38 lesions, and endoscopic laryngo-pharyngeal surgery (ELPS)9 for 5 lesions (Table 1). The EMR-C and ESD are well-known techniques for superficial esophageal, gastric, and colon cancers. These procedures for pharyngeal lesions were done with the patients under general anesthesia in a supine position. In EMRC, a small plastic cap with a snare was attached to the tip of the endoscope. The lesion was suctioned into the cap. The snare closed at the base of the aspirated lesion, and the lesion was then resected electrosurgically. In ESD, mucosal incision was performed on the circumference of the lesion. The lesion was dissected at the submucosal layer. The ELPS is a transoral surgical technique using a curved laryngoscope. Superficial lesions were resected directly with the use of a flexible endoscope. After transoral surgery, each patient underwent both surveillance clinical examination and laryngoscopy at least every 3 months. A CT or ultrasound scan was also
Risk factors for lymph node metastasis in superficial HNSCC
carried out every 6 months to detect any lymph node metastasis. We measured the tumor size, tumor thickness, and PV; wherein, all of which are considered risk factors for lymph node metastasis (LNM). Tumors were measured as shown in Figure 1. We also checked for droplet infiltration (DI), which is a risk factor for LNM from esophageal carcinoma (Figure 2). The DI is defined as an isolated single cancer cell or cluster of cancer cells scattered beyond the tumor margin at the invasive front.10, 11 This represents a similar pathological feature to tumor budding in colorectal adenocarcinoma. FIGURE 2.
21
primarily due to superficial head and neck carcinoma was noted. Eight patients died due to other malignancies, and 1 patient died due to other disease without malignancy (Table 1). Figure 3 shows the correlations between tumor size and thickness and PV. Comparing the tumor thickness
Original Article Risk factors for cervical lymph node metastasis in superficial head and neck squamous cell carcinoma Toru Sasaki, MD1, 2), Seiji Kishimoto, MD, PhD1), Kazuyoshi Kawabata, MD2), Yukiko Sato, DDS, PhD3) and Tomohiro Tsuchida, MD, PhD4)
1) Department of Head and Neck Surgery, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan 2) Division of Head and Neck, Cancer Institute Hospital, Japanese Foundation of Cancer Research, Tokyo, Japan 3) Department of Pathology, Cancer Institute, Japanese Foundation of Cancer Research, Tokyo, Japan 4) Division of Endoscopy, Cancer Institute Hospital, Japanese Foundation of Cancer Research, Tokyo, Japan
Introduction: The necessity of transoral surgery for head and neck carcinoma is increasing, but its indications for the treatment of superficial head and neck carcinomas have not yet been established. This study was intended to help establish the standard indications for transoral surgery and additional therapy in patients with superficial head and neck carcinoma. Methods: Sixty-two patients with 83 superficial head and neck carcinoma underwent transoral tumor resection at the Cancer Institute Hospital between June 2006 and September 2011. We measured the tumor size and thickness, examined the gross appearance, permeation of vessels, and droplet infiltration, and analyzed the correlations between each parameter. Results: Sessile type of tumor on gross appearance showed a significantly higher incidence of thickness ≥1000 µm than the other types. Tumor thickness ≥1000 µm was associated with higher incidences of permeation of vessels, droplet infiltration, and cervical lymph node metastasis. Conclusions: In superficial head and neck carcinoma, if the endoscopic gross appearance is the sessile type, tumor thickness is likely to be ≥1000 µm and risk of cervical lymph node Corresponding Author: Toru Sasaki, MD Division of Head and Neck, Cancer Institute Hospital, 3-10-6, Ariake, Koto-ku, Tokyo, 135-8550, Japan. Tel: +81-3-3520-0111 Fax: +81-3-3570-0343 E-mail: [email protected] Received September 30, 2014；Accepted January 8, 2015
metastasis is increased. Key words: Superficial head and neck carcinoma; transoral surgery; permeation of vessels; droplet infiltration; gross appearance Introduction The conventional therapy for early head and neck carcinoma is radiotherapy. However, some cases can no longer undergo radiotherapy because of previous radiotherapy for other head and neck carcinomas. Furthermore, radiotherapy is associated with problems, such as delayed radiation injury and radiation-induced cancer. Recent innovations in endoscopic devices like narrow-band imaging (NBI) have made it possible to 1-3 detect superficial head and neck carcinomas. Transoral surgery has been undergoing development as a minimally invasive, function-preserving surgery for superficial head and neck carcinoma. Since 2006 at our institute, endoscopic mucosal resection (EMR) has been applied for superficial head and neck carcinoma. The EMR is an effective treatment for superficial esophageal carcinoma, gastric carcinoma, and colorectal carcinoma. In these regions of the digestive tract, the indications for EMR and additional therapy are decided based on the depth of tumor invasion and permeation of vessels (PV). 4-6 However, the indications for transoral surgery for superficial head and neck carcinoma have yet to be established. The present study examined the relationship between
20
J Med Dent Sci
T. Sasaki et al.
each parameter, namely gross appearance of the tumor, tumor size, tumor thickness, and PV. Furthermore, it was intended to help in the establishment of the s tandard indi cations for tran so ra l surge ry and additional therapy in patients with superficial head and neck carcinoma. Materials and methods The recent introduction of magnifying gastrointestinal endoscopy with NBI for head and neck region has allowed the detection of superficial carcinoma in the pharynx and larynx. Therefore, superficial head and neck cancers often refer to superficial lesions of pharynx and larynx. In this study, the superficial head and neck cancer was defined as the superficial lesions of the pharynx and larynx. Hence, 62 patients (60 men, 2 women) with a total of 83 lesions underwent transoral tumor resection based on a diagnosis of superficial head and neck squamous cell carcinoma at the Cancer Institute Hospital in Japan between June 2006 and September 2011. They were followed-up for more than one year after the surgery. Among the 83 lesions, 71 were hypopharyngeal carcinoma (pyriform sinus, 58; posterior wall, 9; postcricoid, 4), 6 were oropharyngeal carcinoma (base of tongue, 1; posterior wall, 4; vallecula, 1), and 6 were laryngeal carcinoma (arytenoid, 5; epiglottis, 1) (Table1). Mean age at diagnosis was 65.0 years (range, 41–84 years). Median duration of follow-up was 40.0 months (range, 13–79 months). Tumor thickness and size were measured as shown in Figure1. Median tumor thickness Table 1. Clinical characteristics, treatment profiles, and pathologic status of lesions Abbreviations: EMR-C, endoscopic mucosal resection with cap-fitting endoscope; ESD, endoscopic submucosal dissection; ELPS, endoscopic laryngo-pharyngeal surgery
FIGURE 1.
②
①
① Tumor thickness ② Tumor size
①
Tumor Epithelium Subepithelial layer
②㻌
①㻌
Figure 1. Methods for measuring tumor thickness and size
was 500 µm (range, 170–7000 µm). Median tumor size was 15 mm (range, 4–55 mm). All lesions were N0M0. Gross appearance was classified into 3 types according to the General Rules for Clinical Studies on Head and th Neck Cancer 5 Edition: protruding (0-I); flat (0-II); or depressed (0-III). Protruding type was further classified into 2 subtypes: pedunculated type (0-Ip) or sessile type (0-Is). Flat type was also further classified into 3 subtypes: slightly elevated (0-IIa); flat (0-IIb); or slightly depressed (0-IIc). Eleven lesions were type 0-Is, 34 were type 0-IIa, 37 were type 0-IIb, and only 1 was type 0-IIc. No type 0-Ip or type III lesion was encountered (Table 1). The treatment methods comprised of EMR with capfitting endoscope (EMR-C)7 for 40 lesions, endoscopic submucosal dissection (ESD) 8 for 38 lesions, and endoscopic laryngo-pharyngeal surgery (ELPS)9 for 5 lesions (Table 1). The EMR-C and ESD are well-known techniques for superficial esophageal, gastric, and colon cancers. These procedures for pharyngeal lesions were done with the patients under general anesthesia in a supine position. In EMRC, a small plastic cap with a snare was attached to the tip of the endoscope. The lesion was suctioned into the cap. The snare closed at the base of the aspirated lesion, and the lesion was then resected electrosurgically. In ESD, mucosal incision was performed on the circumference of the lesion. The lesion was dissected at the submucosal layer. The ELPS is a transoral surgical technique using a curved laryngoscope. Superficial lesions were resected directly with the use of a flexible endoscope. After transoral surgery, each patient underwent both surveillance clinical examination and laryngoscopy at least every 3 months. A CT or ultrasound scan was also
Risk factors for lymph node metastasis in superficial HNSCC
carried out every 6 months to detect any lymph node metastasis. We measured the tumor size, tumor thickness, and PV; wherein, all of which are considered risk factors for lymph node metastasis (LNM). Tumors were measured as shown in Figure 1. We also checked for droplet infiltration (DI), which is a risk factor for LNM from esophageal carcinoma (Figure 2). The DI is defined as an isolated single cancer cell or cluster of cancer cells scattered beyond the tumor margin at the invasive front.10, 11 This represents a similar pathological feature to tumor budding in colorectal adenocarcinoma. FIGURE 2.
21
primarily due to superficial head and neck carcinoma was noted. Eight patients died due to other malignancies, and 1 patient died due to other disease without malignancy (Table 1). Figure 3 shows the correlations between tumor size and thickness and PV. Comparing the tumor thickness
