Endoscopic screening for upper aerodigestive tract cancer in alcoholics using wide visualization of the pharynx and esophageal iodine staining procedures

Background : Squamous cell carcinoma of the oro-/hypo-pharynx (SCCP) is easily treated with endoscopic or endoscope-guided mucosectomy if detected at an early superficial stage with endoscopic screening. However, superficial SCCP is often overlooked because of the anatomical structures of the pharynx that create blind spots during regular endoscopic procedures. Thus it is important to develop procedures for widening and improving the endoscopic field of view of the pharynx for early precise detection of pharyngeal SCC. Methods : The subjects consisted of 599 Japanese alcoholic men (≥*40 years) who consecutively underwent cancer screening that used endoscopy combined with oropharyngolaryngeal inspection and esophageal iodine staining. We applied procedures for wide visualization of pharynx to the patients. First, after endoscopic inspection of the oral cavity, the patients were asked to bow their head deeply in the left lateral position, and then we put our hand on back of patient's head and pushed it forward by one span of our hand (approximately 20 cm). Then they were asked to lift up the chin as far as possible with the occipital point fixed by our thumb (lateral sniffing position). When inspecting the hypopharynx we asked them to say "E" and to hold their breath at full inspiration (Valsalva's maneuver). The extent of the view of hypopharyngeal opening was classified into 4 categories (very good, good, fairly good, and poor). Results : The wide endoscopic view of the pharynx was obtained in a series of the procedures (very good, 58% ; good, 18% ; fairly good, 19% ; and poor, 5%). Oral or pharyngeal SCC was detected in 8 patients (3 hypopharyngeal SCC ; 2 oropharyngeal ; 1 oropharyngeal and hypopharyngeal ; 1 tongue and hypopharyngeal ; and 1 oral floor). All the lesions were the flat or slightly elevated type. Hypopharyngeal SCCs had invaded up to the subepithelial layer in 4 patients, and all the other SCCs were intraepithelial SCCs. All the SCCPs were detected in those patients whose extent of hypopharyngeal opening was determined to be very good (4/7) or good (3/7). Esophageal SCCs were detected in 19 patients, and the SCCs were intraepithelial cancer in 10 patients, had invaded up to the proper mucosal layer in 3 and up to the submucosa in 3, and into proper muscular layer or deeper in 3. Conclusions : The procedure for wide visualization of the pharynx provided an excellent endoscopic field of view of pharynx and was useful to detect the very early superficial type of SCCP. Routine application of these procedures in endoscopic screening of these high risk individuals will yield an extremely high rate of detection of SCCs in the oral cavity and pharynx as well as the esophagus.