Endoscopic screening of the upper gastrointestinal tract for second primary tumors in patients with head and neck cancer in a Western country

Background: Patients with head and neck squamous cell carcinoma (HNSCC) relatively frequent develop second primary tumors (SPTs) in the esophagus. Endoscopic screening could lead to timely detection of SPTs in early stages and therefore improves the survival. Methods: We performed a prospective endoscopic screening study in patients with HNSCC in a Western country. Patients with curably treated HNSCC diagnosed January 2017 to July 2021 were included. Routine imaging for HNSCC consisted of flexible transnasal endoscopy with PET/CT or MRI-scan, depending on primary HNSCC location. Screening was performed synchronously(&lt;6 months) or metachronously (≥6 months) after HNSCC diagnosis. The primary outcome was prevalence of SPTs, defined as presence of esophageal high-grade dysplasia or squamous cell carcinoma. Results: We included 202 patients (81% male, mean age 65 years) and performed 250 screening endoscopies. HNSCC was located in the oropharynx(32%), hypopharynx(26%), larynx(22%), and oral cavity(19%). Endoscopic screening was performed within 6 months(34%), 6 months to 1 year(8%), 1 to 2 years(34%), and 2 to 5 years(24%) after HNSCC diagnosis. We detected 11 SPTs in 10 patients(5.0%, 95%CI: 2.4-8.9%) during synchronous(6/85) and metachronous screening(5/165). Most SPTs were detected in early stages(91%) and treated with curative intent with endoscopic resection(80%). No SPTs in screened patients were detected with routine imaging for HNSCC before endoscopic screening. Conclusion: In 5% of patients with HNSCC, an SPT was detected with endoscopic screening. Endoscopic screening should be considered in a selection of HNSCC patients to detect early-stage SPTs, based on highest SPT-risk and life expectancy depending on HNSCC and comorbidities.</p

Screening for synchronous esophageal second primary tumors in patients with head and neck cancer

Patients with head and neck squamous cell carcinoma (HNSCC) have an increased risk of developing esophageal second primary tumors (ESPTs). We aimed to determine the incidence, stage, and outcome of synchronous ESPTs in patients with HNSCC in a Western population. We performed a prospective, observational, and cohort study. Patients diagnosed with HNSCC in the oropharynx, hypopharynx, any other sub-location in combination with alcohol abuse, or patients with two synchronous HNSCCs, between February 2019 and February 2020 underwent screening esophagogastroduodenoscopy (EGD). ESPT was defined as presence of esophageal squamous cell carcinoma (ESCC) or high grade dysplasia (HGD). Eighty-five patients were included. A lesion suspected for ESPT was detected in 14 of 85 patients, which was pathologically confirmed in five patients (1 ESCC and 4 HGD). The radiotherapy field was extended to the esophagus in two of five patients, HGD was treated with endoscopic resection in three of five patients. None of the ESPTs were detected on MRI and/or CT-scan prior to EGD. Of the remaining nine patients, three had low grade dysplasia on histology whereas the other six patients had benign lesions. Incidence of synchronous ESPT was 5.9% in our cohort of HNSCC patients. All ESPTs were diagnosed at an early stage and treated with curative intent. We recommend that screening for synchronous ESPTs should be considered in a selected group of patients with HNSCC

Het 'buried bumper'-syndroom:Een complicatie van PEG-sondes

AchtergrondBij patiënten met een percutane endoscopische gastrostomie(PEG)-sonde kan het inwendige fixatieplaatje (de ‘bumper’) in de maagwand of nog dieper migreren en overgroeid raken met maagslijmvlies. Dit leidt tot het ‘buried bumper’-syndroom.CasusOnze patiënte kreeg tweeëneenhalf jaar na plaatsing van een PEG-sonde last van progressieve pijn ter hoogte van de insteekopening en lekkage van sondevoeding. De PEG-sonde was in de laatste 3 maanden niet ‘gedompeld en gedraaid’ (daarbij wordt de sonde een paar centimeter in het maaglumen geschoven en onderwijl om zijn as gedraaid). Bij gastroscopie bleek de bumper volledig vergroeid te zijn. Na klieven van het maagslijmvlies ter plaatse van de bumper kon deze worden gemobiliseerd en de sonde worden verwijderd.ConclusieHet buried-bumpersyndroom is een ernstige complicatie na plaatsing van een PEG-sonde. Vroege herkenning is belangrijk en in vrijwel alle gevallen is endoscopische therapie noodzakelijk. Dagelijks ‘dompelen en draaien’ voorkomt dat de bumper overgroeid raakt met maagslijmvlies. Met adequate voorlichting over het belang van dagelijks ‘dompelen en draaien’ moet ernaar gestreefd worden deze complicatie zoveel mogelijk te voorkomen.InleidingPercutane endoscopische gastrostomie (PEG) is een endoscopisch geleide procedure waarbij een permanente voedingssonde door de buikwand in de maag wordt geplaatst De sonde wordt gefixeerd met een inwendig fixatieplaatje in de maag en een uitwendig fixatieplaatje op de huid (figuur 1).Het zogenoemde ‘buried bumper’-syndroom (BBS) is een langetermijncomplicatie waarbij het inwendige fixatieplaatje van de sonde geleidelijk migreert door de maagwand en daarbij door maagslijmvlies overgroeid raakt. In dit artikel laten wij zien hoe deze potentieel ernstige complicatie te behandelen en – nog belangrijker – te voorkómen is

MRI-based pre- and postprandial flow in the mesenteric vasculature of patients with suspected chronic mesenteric ischemia

Purpose: The physiological increase of mesenteric blood flow after a meal is impaired in patients with occlusive chronic mesenteric ischemia (CMI). This principle could be used to develop a highly desired diagnostic test assessing the sufficiency of the collateral mesenteric circulation. This study assesses the potential to identify CMI patients using two-dimensional time-resolved phase-contrast magnetic resonance imaging (2D PC-MRI) flow measurements. Method: This prospective cohort study included patients with suspected CMI, based on: typical history, imaging, and functional testing. Cardiac gated 2D PC-MRI flow measurements (expressed as ml/min/kg) were performed in mesenteric arteries and veins during inspiration and expiration, after six hours of fasting and 20, 30, and 40 min after a meal challenge with a high caloric drink. Results: Flow measurements were obtained in 19 patients: 8 CMI and 11 non-CMI. CMI patients showed a significantly smaller increase in postprandial blood flow in the superior mesenteric artery (SMA) at 30 and 40 min (30 min CMI 1.27(0.12–2.44) vs. non-CMI 7.82(6.28–10.90); 40 min CMI 0.30(-0.26–3.16) vs. non-CMI 7.94(6.32–10.90)) and a lower total arterial flow at 40 min (CMI 3.21(-0.72–5.05) vs. non-CMI 9.31(5.58–13.83)). Repeated flow measurements showed normalization of impaired postprandial venous flow after mesenteric artery stenting in one patient. Conclusions: The significantly lower increase in postprandial mesenteric blood flow in CMI patients confirms the promise of mesenteric blood flow measurements, before and 30–40 min after a meal, as a future diagnostic test to identify CMI patients among patients with a high clinical suspicion of CMI and mesenteric artery stenosis

Recommendations for endoscopic surveillance after esophageal atresia repair in adults

BACKGROUND: Endoscopic surveillance of adults with esophageal atresia is advocated, but the optimal surveillance strategy remains uncertain. This study aimed to provide recommendations on appropriate starting age and intervals of endoscopic surveillance in adults with esophageal atresia. METHODS: Participants underwent standardized upper endoscopies with biopsies. Surveillance intervals of 3-5 years were applied, depending on age and histopathological results. Patient's age and time to development of (pre)malignant lesions were calculated. RESULTS: A total of 271 patients with esophageal atresia (55% male; median age at baseline endoscopy 26.7 (range 15.6-68.5) years; colon interposition n = 17) were included. Barrett's esophagus was found in 19 (7%) patients (median age 32.3 (17.8-56.0) years at diagnosis). Youngest patient with a clinically relevant Barrett's esophagus was 20.9 years. Follow-up endoscopies were performed in 108 patients (40%; median follow-up time 4.6 years). During surveillance, four patients developed Barrett's esophagus but no dysplasia or cancer was found. One 45-year-old woman with a colon interposition developed an adenoma with high-grade dysplasia which was radically removed. Two new cases of esophageal carcinoma were diagnosed in patients (55 and 66 years old) who were not under surveillance. One of them had been curatively treated for esophageal carcinoma 13 years ago. CONCLUSIONS: This study shows that endoscopic screening of patients with esophageal atresia, including those with a colon interposition, can be started at 20 years of age. Up to the age of 40 years a surveillance interval of 10 years appeared to be safe. Endoscopic surveillance may also be warranted for patients after curative esophageal cancer treatment

Predictive value of endoscopic esophageal findings for residual esophageal cancer after neoadjuvant chemoradiotherapy

Background Endoscopic evaluation of the esophageal mucosa may play a role in an active surveillance strategy after neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer. This study investigated the yield of endoscopic findings for detection of residual disease. Methods Patients from the multicenter preSANO cohort, who underwent nCRT followed by surgery for esophageal or junctional cancer, were included. Upper endoscopy was performed 6 and 12 weeks after nCRT. Patients with residual disease at 6 weeks underwent immediate surgery. Endoscopic records were reviewed for presence of stenosis, suspicion of residual tumor, scar tissue, and ulceration. Presence and type of endoscopic findings were compared with outcome of the resection specimen. Results 118 of 156 patients (76%) had residual disease in the resection specimen. Endoscopic suspicion of residual tumor was significantly associated with presence of residual disease. At 6 weeks, 40/112 patients with residual disease and 4/33 patients with complete response had endoscopic suspicion of residual tumor (36% vs. 12%; P =0.01), while this was reported in 16/73 and 0/28 patients, respectively, at 12 weeks (22% vs. 0%; P <0.01). Positive predictive value of endoscopic suspicion of residual tumor was 91% at 6 weeks and 100% at 12 weeks. Endoscopic findings of non-passable stenosis, passable stenosis, scar tissue, or ulceration were not associated with residual disease. Conclusions Endoscopic suspicion of residual tumor was the only endoscopic finding associated with residual disease. Based on its positive predictive value, this endoscopic finding may contribute to the diagnostic strategy used in active surveillance

Predictive value of endoscopic esophageal findings for residual esophageal cancer after neoadjuvant chemoradiotherapy

Background Endoscopic evaluation of the esophageal mucosa may play a role in an active surveillance strategy after neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer. This study investigated the yield of endoscopic findings for detection of residual disease. Methods Patients from the multicenter preSANO cohort, who underwent nCRT followed by surgery for esophageal or junctional cancer, were included. Upper endoscopy was performed 6 and 12 weeks after nCRT. Patients with residual disease at 6 weeks underwent immediate surgery. Endoscopic records were reviewed for presence of stenosis, suspicion of residual tumor, scar tissue, and ulceration. Presence and type of endoscopic findings were compared with outcome of the resection specimen. Results 118 of 156 patients (76%) had residual disease in the resection specimen. Endoscopic suspicion of residual tumor was significantly associated with presence of residual disease. At 6 weeks, 40/112 patients with residual disease and 4/33 patients with complete response had endoscopic suspicion of residual tumor (36% vs. 12%; P =0.01), while this was reported in 16/73 and 0/28 patients, respectively, at 12 weeks (22% vs. 0%; P <0.01). Positive predictive value of endoscopic suspicion of residual tumor was 91% at 6 weeks and 100% at 12 weeks. Endoscopic findings of non-passable stenosis, passable stenosis, scar tissue, or ulceration were not associated with residual disease. Conclusions Endoscopic suspicion of residual tumor was the only endoscopic finding associated with residual disease. Based on its positive predictive value, this endoscopic finding may contribute to the diagnostic strategy used in active surveillance