Introduction

Thanks to instrumental advances and accumulation of understandings of endoscopic features of early oropharyngeal neoplasia, we often encounter diminutive pharyngeal lesions. However, whether follow-up is permissible or therapeutic intervention is preferable for these lesions is uncertain. Accurate endoscopic diagnosis is pivotal for the decision-making process. This study aimed to assess the accuracy of endoscopic diagnosis for pharyngeal microlesions.

Aims & Methods

We evaluated pre-treatment endoscopic images of 121 lesions 3 mm or less in that pharyngeal neoplasia was endoscopically diagnosed with magnifying narrow-band imaging observation and resected by cold forceps biopsy. Two endoscopists, one with over 15 years of experience and another with 5 to 10 years (study A), made endoscopic diagnosis of each image and categorized the images into non-dysplasia, low-grade dysplasia, or squamous cell carcinoma (SCC)/high-grade dysplasia, and the accuracy of the endoscopic diagnosis was evaluated with the pathological findings of resected tissues. To assess interrater agreement, another physician joined to each experience group (study B), and the kappa coefficient was calculated.

Results

In study A, the overall accuracy rate of the endoscopic diagnosis was 60.7%. However, for SCC/high-grade dysplasia, the sensitivity was 12.5% (95% confidence interval [CI]: 3.5-29.0), specificity was 94.3% (95% CI: 90.2-97.0), positive predictive value was 25.0% (95% CI: 7.3-52.4), and negative predictive value was 87.6% (95% CI: 82.6-91.6). Nearly 90% of malignant or high-grade dysplastic lesion were not correctly diagnosed by endoscopic observation even with magnifying narrow-band imaging. Although the concordance rate between study A and B was low (κ coefficient 0.07, 95% CI: -0.15-0.30), study B also exhibited low sensitivity (31.2%, 95% CI: 16.1-50.0), specificity (83.3%, 95% CI: 77.6-88.1), positive predictive value (22.2%, 95% CI: 11.2-37.1), and negative predictive value (88.8%, 95% CI: 83.6-92.9) for SCC/high-grade dysplasia.

Conclusion

The accuracy of endoscopic diagnosis of diminutive malignant pharyngeal lesions was very low regardless of proficiency of endoscopist. Thus, given that such diminutive lesions can be resected with minimally invasive cold forceps biopsy, proactive excision for diagnostic treatment is recommended.

Introduction

Recent improvements in endoscopic diagnostic techniques have made it possible to detect early-stage superficial laryngopharyngeal cancer, and endoscopic resection has become one of the standard treatments in Japan1). However, it is not fully known to what extent endoscopic treatment alone is curative.

Aims & Methods

To clarify the relationship between depth and lymph node metastasis in superficial laryngopharyngeal cancer. From August 1996 to April 2023, we experienced 501 cases of 810 lesions of superficial laryngopharyngeal cancer. Of these, 396 cases with 652 lesions (462 in the hypopharynx, 149 in the oropharynx, and 41 in the larynx) that were resected orally without prior treatment and followed for more than 1 year were included to investigate the relationship between depth and late lymph node metastasis.

Results

Endoscopic classification of the treated lesions was 81 lesions of type 0-Ⅰ(protruded type), 164 lesions of type 0-IIa(elevated type), 391 lesions of type 0-IIb(flat type), and 16 lesions of type 0-IIc (depressed type). Type 0-IIb was the most frequent.
Histopathologically evaluated 174 cases of intraepithelial carcinoma with 249 lesions showed no metastasis. On the other hand, of the 403 lesions in 295 cases of subepithelial invasive cancer (T1, tumor size less than 2cm: 213 lesions, T2, tumor size 2-4cm or smaller: 159 lesions, T3, tumor size greater than 4cm: 31 lesions), 30 lesions in 28 cases(9.5%) had later lymph node metastasis. Two of 305 lesions (0.65%) with tumor thickness less than 1000 μm were positive for metastasis. By size, 1 of 178 lesions in T1(0.6%), 1 of 111 lesions(0.9%) in T2, and 0 of 16 lesions in T3 were positive for metastasis. On the other hand, 28 of 98 lesions (28.6%) with tumor thickness greater than 1000 μm were positive for metastasis. By size, 6 of 35 lesions in T1(17.1%), 17 of 48 lesions(35.4%) in T2, and 5 of 15 lesions(33.3%) in T3 were positive for metastasis. The frequency of lymph node metastasis by endoscopic type was 20 of 81 lesions(24.7%) for type 0-I, 8 of 164 lesions (4.9%) for type 0-IIa, 1 of 391 lesions(0.25%) for type 0-IIb, and 1 of 16 lesions (6.25%) for type 0-IIc, metastasis was seen more frequently in type 0-I. The observation of brownish areas and brown dots with Image Enhanced Endoscopy is useful for detecting early-stage cancer. When examining the depth of the disease, the Valsalva method is recommended to focus on type 0-I lesions with a thickness of 1 mm or more and a well-stretched pharyngeal mucosa.

Conclusion

Superficial carcinomas with a thickness greater than 1 mm should be noted for late lymph node metastasis.

References

1) Watanabe A, Taniguchi M, Kimura Y, et al. Synopsis of transoral endoscopic laryngopharyngeal surgery for superficial pharyngeal cancers. Head Neck 2017; 39: 1779-1787

Disclosure

The authors have no financial conflicts of interest disclose concerning the study.

Introduction

Recent advances in high definition endoscopy have increased the diagnostic accuracy for superficial non- ampullary duodenal epithelial tumors (SNADETs). Appropriate endoscopic categorization of these tumors as low grade adenoma (LGA)/high grade adenoma (HGA)/adenocarcinoma (AC) is of extreme importance to plan appropriate management. We report the accuracy and feasibility of a novel ‘Simple Scoring System’ (SSS) for SNADETs to differentiate LGA from HGA/AC.​

Aims & Methods

The aim of this prospective study was to evaluate the accuracy of SSS for diagnosis of SNADETs and to assess the feasibility of its understanding and usage among beginner and expert gastroenterologists. SSS includes four sections which are evaluated and scored: 1. Tumor diameter (10-20mm: +1, >20mm: +2); 2. Color on white light imaging (redness: +1); the presence/absence of irregular surface pattern by magnifying endoscopy using narrow band imaging (ME-NBI) (Present: +1); 4. The presence/absence of irregular vascular pattern on ME- NBI (Present: +1). The score is on a 5-point scale. A score of 3 or more is diagnosed as HGA/AC. Study 1: 319 SNADETs were preoperatively evaluated with SSS from June 2019 to February 2022 and were compared with postoperative pathological results. Diagnostic accuracy according to histological type (gastric, intestinal, or mixed gastrointestinal) was also evaluated. Study 2: Diagnostic accuracy of 20 lesions (10 LGA and 10 HGA/AC lesions) selected randomly were compared before and after a lecture on SSS for 26 expert and beginner gastroenterologists in 7 hospitals. Experts were defined as those with minimum 5 years of endoscopic experience and 3 years of experience with magnifying endoscopy. A total of 4 images of each lesion (white light imaging; indigo carmine; ME-NBI distant view; ME-NBI near view) were presented for evaluation. T test was used to analyze the pre and post lecture outcomes.

Results

Study 1: The overall diagnostic accuracy was 258/319 (80.8%), sensitivity 80.7%, and specificity 81.2%. Diagnostic accuracy for each tissue type was 83.3% for gastric type, 80.3% for intestinal type, and 100% for mixed type. Study 2: The mean diagnostic accuracy before and after the lecture changed from 71% to 79% overall, 70% to 81% for HGA/AC, 72% to 78% for LGA. Diagnostic accuracy of both experts (13) and beginners (13) improved significantly (p value expert: <0.01, beginner: <0.01) after the lecture.

Conclusion

SSS can be understood and used easily. It is an accurate method to diagnose SNADETs endoscopically.