Masafumi Okuda

Observation of the Pharynx to the Cervical Esophagus Using Transnasal Endoscopy with Blue Laser Imaging

Background In 2014, the new transnasal endoscopy with Blue laser Imaging (BLI) has been developed. Aim We present the usefulness of the observation of from the pharynx to the cervical esophagus using transnasal endoscopy with BLI. Patients and Methods This study was conducted between June 2014 and October 2014. During this period, 70 consecutive patients (60 men, 10 women; mean age 67.9 years old) with esophageal or head and neck cancer underwent endoscopic screening at the orophar‐ ynx and hypopharynx by transnasal endoscopy with BLI system We performed this endoscopic observation from oral cavity to pharynx before inserting into the cervical esophagus.The visibility of subsites of the hypopharynx and the orifice of the esophagus was evaluated. The extent of the view of hypopharyngeal opening was classified into 3 categories (excellent, good, poor). Then, the diagnostic accuracy of transnasal endoscopy with BLI system was estimated. Our screening is as follows. First, the patient is asked to bow their head deeply in the left lateral position. We put a hand on the back of the patient’s head and push it forward. The patient is then asked to lift the chin as far as possible. In order to inspect the oral cavity, we insert an endoscope without a mouthpiece. After observation of the oral cavity, the endoscope was inserted through the nose. When the tip of the endoscope reached caudal to the uvula, the patient opened his mouth wide, stuck his tongue forward as much as possible and made a vocal sound like “ayyy”. The endoscopist caused the endoscope to U-turn and observed the oropharynx, in particular the radix linguae (Intra© 2015 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. oropharyngeal U-turn method). For examination of the hypopharynx and the orifice of the esophagus, the patient is asked to blow hard and puff their cheeks while the mouth remains closed (Trumpet maneuver). Results 8 elderly cases were excluded because they could not perform the adequate ballooning. Finally, 62 cases were investigated. The ballooning the pyriform sinus and posterior wall not only allows accurate assessment of the stretched pharyngeal mucosa but also gives a view of postcricoid subsite and the orifice of the esophagus. The wide endoscopic view of the pharynx was obtained in a series of the procedures (excellent=53/62, 85.4%; good=7/52, 4.5%; and poor=2/62, 7.6%). Among 70 patients, 6 superficial lesions (8.6%) at the oropharynx(n=1) and hypopharynx (n=5) were discovered with BLI system. Mucosal redness, a pale thickened mucosa, white deposits or loss of a normal vascular pattern, well demarcated areas covered with scattered dots are important characteristics to diagnose superficial carcinoma. Conclusion The more progress achieved in transnasal endoscopy rapidly in the last few years, it can improve for observing the blind area using trans-oral endoscopy, therefore the trans-nasal endoscope will be a standard tool for the screening of the upper gastrointestinal tract in the near future.

Histological study of the thin membranous structure made of dense connective tissue around the esophagus in the upper mediastinum

BackgroundThe structure of the fascia in upper mediastinum has already been reported from gross anatomical viewpoints by Sarrazin. But it is necessary to understand meticulous anatomy for thoracoscopic or mediastinoscopic surgery. So herein, we investigate histologically the thin membranous structure made of dense connective tissues.MethodsSemi-sequential transverse sections of the mediastinum were obtained from three cadavers. Hematoxylin and eosin staining, Elastica van Gieson staining, and Masson trichrome staining were performed to identify the presence and location of the thin membranous structure made of dense connective tissues.ResultsThe “visceral sheath” and “vascular sheath,” as previously described by Sarrazin, were observed histologically. These two thin membranous structures do not surround the esophagus and trachea cylindrically. In addition, the “visceral sheath” on the right side of the upper mediastinum was unclear in comparison to the left side. The “visceral sheath” (on the left side) gradually became unclear, and seemed to almost disappear; the esophagus was found to be very close to the thoracic duct on the caudal side of the bifurcation of the trachea. Although the left recurrent nerve was located inside the “visceral sheath” in all cadavers, the left recurrent nerve lymph nodes were located inside the “visceral sheath” in cadaver 1 and between the “visceral sheath” and “vascular sheath” in cadaver 3.ConclusionThe “visceral sheath” around the esophagus in the upper mediastinum was histologically demonstrated; however, the findings were not constant.

Asymptomatic marginal zone lymphoma of mucosa-associated lymphoid tissue in the hypopharynx, detected with esophagogastroduodenoscopy

Abstract Mucosa-associated lymphoid tissue (MALT) lymphoma is a type of lymphoma that commonly originates in the gastrointestinal (GI) tract, and in rare instances may also occur in the head and neck region. In this report, we present a case of early stage, primary asymptomatic MALT lymphoma of the hypopharynx as detected by esophagogastroduodenoscopy (EGD). A 73-year-old man underwent EGD for an examination of the upper GI tract. At the left pyriform sinus, a swollen irregular mucosa was detected. Biopsy specimens confirmed histologically prominent proliferation of lymphocytes in the epithelium. Immunohistochemical analysis showed that the neoplastic lymphocytes were positive for CD20 and negative for CD3. Based on the other imaging studies, we diagnosed the lesion as a localized MALT lymphoma of the hypopharynx at Stage IA. In total, 46 Gy of radiotherapy was administered to the lesion. In the subsequent 5 years after the treatment, there have been no signs of recurrence.

Subcloning and characterization of highly metastatic cells derived from human esophageal squamous cell carcinoma KYSE150 cells by in vivo selection

Esophageal cancer is the eighth most common cancer and the sixth most common cause of cancer-related deaths worldwide. Despite the research progress in understanding the disease, the mechanism underlying the metastasis is still unclear. Here, we successfully generated a highly metastatic cell subline, designated as KYSE150-LuM, derived from an esophageal squamous cell carcinoma cell line (KYSE150) by in vivo selection. To elucidate the mechanisms driving metastasis, we characterized the gene expression differences between LuM cells and parent KYSE150 cells. IL-6, IL-1β, and LCN2, previously associated with tumor growth and metastasis, were up-regulated in LuM cells. Recent studies on cancer have increasingly focused on the tumor microenvironment, from which these cytokines are released. The fact that these three cytokines (IL-6, IL-1β, LCN2) were up-regulated in LuM cells indicates that these highly metastatic cells obtained through in vivo selection will be a useful resource for further studies on elucidating the mechanisms underlying the tumor microenvironment which is associated with cytokine-related tumor growth and metastasis. Moreover, LuM cells could disseminate to the lung in shorter period of time in vivo, indicating their utility for in vivo experiments of metastasis and new therapeutic targets in a shorter period of time than currently possible.

Observation of the Pharynx to the Cervical Esophagus Using Trans-nasal Endoscopy with Image-enhanced Endoscopy for Early Detection of Head and Neck Cancers

Introduction: We started endoscopic treatment for superficial pharyngeal cancer in 1996, and thus far, 97 lesions of 77 cases of superficial head and neck cancer have been detected using trans-oral endoscopy. However, some areas are difficult to observe with trans-oral endoscopy because of the gag reflex. We have therefore applied transnasal endoscopy for observing of the pharynx to the cervical esophagus. Methods: To avoid overlooking cancers located at the floor of the mouth, soft palate and uvula, we first observe the oral cavity. After administering local anesthesia to the nose without sedation, the endoscope is inserted through the nose. When the tip of the endoscope reaches caudal to the uvula, the patient opens his or her mouth wide, sticks the tongue forward as far as possible and makes a makes a vocalization like “ayyy”. The endoscopist then makes the endoscope take a U-turn and observes the oropharynx, particularly radix linguae. To examine the hypopharynx and the orifice of the esophagus, the patient is asked to blow hard and puff their cheeks while the mouth remains closed. This approach provides a much better view of the orifice of the esophagus than is possible with trans-oral endoscopy with deep sedation. Results: In this study, we detected 22 superficial cancers of the oral cavity. Previous efforts to detect such cancers using trans-oral endoscopy have failed. In addition, we were never able to detect early cancers located at base of tongue in the past, but since implementing the intra-oropharyngeal U-turn method, we have detected more than 10 cases. We were also never able to detect early cancers located at the pharyngoesophageal junction in the past, but since implementing the modified Valsalva maneuver, we have detected more than 20 cases. Between 2008 and 2016, a total of 164 cases of 227 lesions of superficial head and neck cancer were detected by trans-nasal endoscopy, which is more than twice as many as were detected with conventional screening. Mucosal redness, white deposits or loss of a normal vascular pattern and proliferation of vascular pattern such as small dots or salmon roe with a close-up view of it are important characteristics to diagnose superficial pharyngeal cancer. Moreover, a brownish area using image-enhanced endoscopy is useful for early diagnosis. With adequate extension of the pharyngeal mucosa using the Valsalva maneuver, observing the protruded areas should prove useful for diagnosing the depth of invasion. Conclusions: Observing the pharynx to the cervical esophagus using trans-nasal endoscopy with imageenhanced endoscopy is useful for early detection of head and neck cancers.

A Mediastinoscopic Approach With Bilateral Cervicopneumomediastinum in Radical Thoracic Esophagectomy

We previously reported the performance of “mediastinoscopic esophagectomy with lymph node dissection” (MELD) under pneumomediastinum using a transcervical and transhiatal approach, as a method of r...

Case of Superficial Cancer Located at the Pharyngoesophageal Junction Which Was Dissected by Endoscopic Laryngopharyngeal Surgery Combined with Endoscopic Submucosal Dissection

Aims. In order to determine the indications of transoral surgery for a tumor located at the pharyngoesophageal junction, the trumpet maneuver with transnasal endoscopy was used. Its efficacy is reported here. Material and Methods. An 88-year-old woman complaining of dysphagia, diagnosed with cervical esophageal cancer, and hoping to preserve her voice and swallowing function was admitted to our hospital. Conventional endoscopy showed that the tumor had invaded the hypopharynx. When inspecting the hypopharynx and the orifice of the esophagus, we asked the patient to blow hard and puff her cheeks with her mouth closed (trumpet maneuver). After the trumpet maneuver, the pharyngeal mucosa was stretched out. The pedicle of the tumor arose from the left-anterior wall of the pharyngoesophageal junction, so we decided to perform endoscopic resection. Result. Under general anesthesia, the curved laryngoscope made it possible to view the whole hypopharynx, including the apex of the piriform sinus and the orifice of the esophagus. The cervical esophageal cancer was pulled up to the hypopharynx. Under collaboration between a head and neck surgeon and an endoscopist, the tumor was resected en bloc by endoscopic laryngopharyngeal surgery combined with endoscopic submucosal dissection. Conclusion. Transnasal endoscopy using the trumpet maneuver is useful for a precise diagnosis of the pharyngoesophageal junction. Close collaboration between head and neck surgeons and endoscopists can provide good results in treating tumors of the pharyngoesophageal junction.