Is panendoscopy a necessary staging procedure in patients with lacking risk factors and oral squamous cell carcinoma?

ObjectivesRoutine panendoscopy is used to detect synchronous malignancies of the upper aerodigestive tract in staging of oral squamous cell carcinoma. The goal of this study was to investigate the occurrence of synchronous malignancies at time of diagnosis using panendoscopy. To challenge the role of panendoscopy as inherent part of routine staging procedures, we were especially interested in low risk patients.Materials and methodsRetrospectively, a cohort of 484 patients with pathologically confirmed diagnosis of primary oral and oropharyngeal squamous cell carcinoma was investigated. Electronically recorded findings of in-house conducted panendoscopy were retrieved and evaluated for the occurrence of pathological changes of the mucosa. In case of synchronous malignancies, findings were correlated to preoperative radiographic imaging. Patients were classified as high or low risk. Patients with lacking risk factors (no smoking, no drinking in history) were defined as low risk patients.ResultsOverall, we detected three synchronous malignancies of the upper aerodigestive tract (3/484; 0.6%). Two non-small cell lung cancers were detected in patients with a smoking history of 60 pack years. One esophageal carcinoma in situ was detected in a patient with reported alcohol consumption. No synchronous malignancy was detected in patients without risk factors and no malignancy was previously detected by diagnostic imaging.ConclusionPre-treatment panendoscopy can reveal synchronous malignancies of the upper aerodigestive tract in patients with primary oral squamous cell carcinoma. Risk stratification of patients can avoid unnecessarily conducted panendoscopy in patients without risk factors. This may lead to a higher cost-efficacy in public health system, less treatment-related complications and earlier treatment initiation.     

Panendoscopy and simultaneous primary tumours in patients presenting with early carcinoma of the mobile tongue

Many patients who present with primary malignant disease of the head and neck are examined under anaesthesia to see if they have synchronous tumours. Although previous studies have attempted to establish whether this is either efficient or cost-effective, the patients included tended to include heterogeneous index sites as well as newly-diagnosed and previously-diagnosed tumours. Seventy-four patients who presented with newly-diagnosed early carcinoma of the mobile tongue (T1 N0 / T2 N0) were studied. None had any symptoms of other upper aerodigestive tract disease and all had panendoscopy including bronchoscopy and oesophagoscopy. Only three had serious abnormalities, of which two were synchronous carcinomas. In no patient did the findings of the panendoscopy influence definitive treatment of the index tumour.Although there was no morbidity associated with panendoscopy among these patients, the routine use of panendoscopy we conclude that it is not warranted.     

Panendoscopy and synchronous second primary tumors in head and neck cancer patients

Endoscopy techniques are used to diagnose and to determine the extent and exact location of malignancies in the head and neck region, bronchial tree and esophagus. Panendoscopy is used to find the primary tumor in the case of metastatic disease from unknown primaries or to detect a simultaneous second primary tumor at the time of diagnosis of a malignancy in the upper aerodigestive tract (UADT). The value of panendoscopy has been debated lately because of the relatively small proportion of malignant findings and because of the lack of convincing data concerning its effect on survival rates. However, despite the relatively low proportion of positive findings, their significance is often crucial for the individual patient. The significant number of late metachronous, second primaries, especially in the lungs, also emphasizes the importance of follow-up endoscopies. This study consists of 203 consecutive patients with squamous cell cancer (SCC) of the upper aerodigestive tract who underwent panendoscopy in Turku University Central Hospital as part of the initial diagnostic workup from 1992–1999. Eight patients with synchronous second primaries were found to represent a prevalence of 3.9%, and in addition, 19 patients with metachronous tumors were diagnosed. In the case reports we illustrate the importance of some of these findings.     

Gastroduodenoscopy: a routine examination of 2,800 patients before laparoscopic cholecystectomy

Background Unrecognized gastric and duodenal peptic ulcer is a common cause of epigastric pains for patients with cholelithiasis qualified for laparoscopic cholecystectomy. Undiagnosed gastric or duodenal ulcer may be the cause of persistent pains after cholecystectomy. The purpose of the study was to assess the value of a routine preoperative panendoscopy for qualifying patients to undergo laparoscopic cholecystectomy. Methods The study enrolled 2,800 patients treated for cholelithiasis from May 1993 to December 2002. Endoscopic examination was performed for all treated patients 1 to 4 days before their operations. Results Preoperative endoscopy showed pathologic changes in the stomach or duodenum in 1,187 (42%) of 2,800 patients qualified for laparoscopic cholecystectomy. Gastric ulcer was found in 179 patients (6.4%) duodenal ulcer in 127 patients (4.5%), gastritis in 735 patients (26.3%), polyps in 143 patients (5.1%), and cancer in 3 patients (0.1%). The surgery was postponed for patients with ulcer, and antiulcer treatment was started. In 16 patients, the symptoms associated with cholelithiasis subsided after healing of the ulcer. Cholelithiasis in these patients was asymptomatic, and a cholecystectomy was not performed. Conclusions Panendoscopy should be a routine examination performed for each patient qualified to undergo laparoscopic cholecystectomy. For some patients with asymptomatic cholelithiasis, pain in fact is caused by peptic ulcer.     

DAFE autofluorescence assessment of oral cavity, larynx and bronchus in head and neck cancer patients

Head and neck (H&N) cancer patients have a high incidence of local field change as well as second primary lung tumours. We have applied the Wolf Diagnostic Autofluorescence Endoscopy (DAFE) system in a novel way, combining autofluorescence evaluation of both H&N region and bronchial. New H&N cases as well as “old” cases with symptoms were included. The DAFE procedure was done separate to panendoscopy. The H&N region was examined first; images were recorded of the known primary with reference to subsequent resection margins, as well as of adjacent mucosa inspecting for additional abnormal sites. Then autofluorescence bronchoscopy was performed. Changes in management were only on the basis of histology taken because of abnormal autofluorescence. One hundred and seven cases were referred, including 96 new cases and 11 old cases. Autofluorescence examination of H&N detected sites which led to change of management in 11 patients. This included additional sites in nine patients (which then either had extra surgery or radiotherapy as a result) and wider resection margins were made possible in two patients. In the bronchus there were 21 significant lesions in 16 patients. Immediate management change occurred in one invasive cancer, two microinvasive carcinomas and three carcinomas in situ (in four patients). There were 15 sites of severe and moderate dysplasia in 12 patients. None of these bronchoscopic lesions were detectable on CT chest. Therefore, overall an immediate change in management occurred in 15 of 107 patients (14% of patients). This combined procedure yielded a significant number of lesions particularly as a simple addition to preoperative work-up in new H&N cancer cases.     

Panendoscopy as a screening procedure for simultaneous primary tumors in head and neck cancer

Head and neck cancer is often associated with second primary neoplasms. These cancers most commonly involve other regions of the head and neck, esophagus, and lung. The majority of cases are also squamous cell carcinomas. In view of this rather frequent occurrence of multiple primary cancers and how they adversely affect the patient's survival, it becomes imperative to analyze how the clinician can intervene effectively. One such approach is to detect multiple primaries as early as possible. As such, panendoscopy as a part of the tumor-staging procedure has been advocated by many investigators to search for simultaneous second primary malignant neoplasms in patients presenting with head and neck cancer. In a 24-month period, data were gathered from 127 consecutive patients referred to University Hospital, Ghent with previously untreated, squamous cell carcinomas of the head and neck. One hundred-eighteen patients underwent an endoscopic examination under general anesthesia, during which 4 simultaneous second primary tumors were found in 3 patients. This represents an incidence of 3.4% of simultaneous second primary neoplasms. The results for the different parts of the endoscopy are discussed and compared with literature findings. Guidelines are given for the initial evaluation of the head and neck cancer patient.     

Clinical significance of panendoscopy in initial staging of oral squamous cell carcinoma and detection of synchronous second malignancies of the upper aerodigestive tract — Insights from a retrospective population-based cohort study

The aim of this study was to examine the prevalence of synchronous upper aerodigestive tract (UAT) tumors within oral squamous cell carcinoma (OSCC) patients, and to specify distinct risk groups who benefit from panendoscopy.Definite clinical and pathohistological characteristics, as well as overall and recurrence-free survival (OAS and RFS, respectively) of OSCC patients with and without synchronous second UAT tumors, carcinomas in situ, or higher-grade dysplasia/metaplasia, were evaluated based on a retrospective population-based cohort study, including alignment with cancer registry data.Out of 727 included OSCC patients, 465 cases (64.0%) received panendoscopy. Among these, 18 UAT tumors were detected, all of which were linked to patients with a positive history of nicotine abuse. Every synchronous UAT tumor was revealed by panendoscopy, which, analyzed as an independent staging procedure, was accompanied by a low complication rate (1.7%). When illuminating the impact of a second UAT tumor in OSCC patients, survival analysis revealed reduced 5-year OAS (63.9% vs 43.5%, p = 0.010) and RFS (57.1% vs 32.4%, p = 0.016) for patients with a second oncology diagnosis of the UAT.Within the limitations of the study, it seems that panendoscopy should be performed in the majority of patients suffering from OSCC, because most of them have a history of smoking and drinking, which correlates with an increased risk of developing synchronous UAT tumors.