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Original Investigation |

Rigid Esophagoscopy for Head and Neck Cancer Staging and the Incidence of Synchronous Esophageal Malignant Neoplasms

Patrick O. McGarey Jr, MD1; Ashli K. O’Rourke, MD2; Scott R. Owen, MD3; David C. Shonka Jr, MD1; James F. Reibel, MD1; Paul A. Levine, MD1; Mark J. Jameson, MD, PhD1
[+] Author Affiliations
1Division of Head and Neck Oncologic and Microvascular Surgery, Department of Otolaryngology–Head and Neck Surgery, University of Virginia Health System, Charlottesville
2Evelyn Trammell Institute for Voice and Swallowing, Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston
3Department of Otolaryngology–Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City
JAMA Otolaryngol Head Neck Surg. 2016;142(1):40-45. doi:10.1001/jamaoto.2015.2815.
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Importance  Rigid esophagoscopy (RE) was once an essential part of the evaluation of patients with head and neck squamous cell carcinoma (HNSCC) due to the high likelihood of identifying a synchronous malignant neoplasm in the esophagus. Given recent advances in imaging and endoscopic techniques and changes in the incidence of esophageal cancer, the current role for RE in HNSCC staging is unclear.

Objective  To analyze the current role of RE in evaluating patients with HNSCC, and to determine the incidence of synchronous esophageal malignant neoplasms in patients with HNSCC.

Design, Setting, and Participants  In this retrospective study performed at an academic tertiary care center, 582 patients were studied who had undergone RE for HNSCC staging from July 1, 2004, through October 31, 2012. To assess the incidence of synchronous esophageal malignant neoplasms, a literature review was performed, and the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) data set was queried.

Main Outcomes and Measures  The primary outcome measure was the incidence of synchronous esophageal malignant neoplasms, as measured by retrospective review at our institution, SEER data set analysis, and literature review. Secondary outcome measures were RE complications and nonmalignant findings during RE.

Results  A total of 601 staging REs were performed in 582 patients. The mean age was 60.2 years and 454 (78.0%) were men. There were 9 complications (1.5%), including 1 esophageal perforation (0.2%). Rigid esophagoscopy was aborted in 50 cases. Of the 551 completed REs, no abnormal findings were noted in 523 patients (94.9%), and nonmalignant pathologic findings were identified in 28 patients (5.1%). No synchronous primary esophageal carcinomas were detected. The incidence of synchronous esophageal malignant neoplasms found on screening endoscopy based on literature review and on SEER data set analysis was very low and has decreased from 1980 to 2010 in North America. The incidence reported in South America and Asia was relatively high.

Conclusions and Relevance  Rigid esophagoscopy is safe, but the utility is low for cancer staging and for detection of nonmalignant esophageal disease. Review of the literature and analysis of a large national cancer data set indicate that the incidence of synchronous esophageal malignant neoplasms in patients with HNSCC is low and has been decreasing during the past 3 decades. Thus, screening esophagoscopy should be limited to patients with HNSCC who are at high risk for synchronous esophageal malignant neoplasms.

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Figure 1.
Annual and Decade Incidence of Synchronous Esophageal Malignant Neoplasms in Patients With Head and Neck Squamous Cell Carcinoma (HNSCC)

Incidences are based on the National Cancer Institute’s Surveillance, Epidemiology, and End Results 9 registry, 1973-2009.

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Figure 2.
Incidence of Synchronous Esophageal Malignant Neoplasms Detected by Staging Endoscopy

Incidence of synchronous esophageal malignant neoplasms in patients with index head and neck squamous cell carcinoma detected on staging flexible or rigid esophagoscopy based on literature review, 1979-2014. Results are stratified by studies that examined patients from North America and the World (excluding North America). Exponential line of best fit for North America values is shown.

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