Successful recovery from a subclavicular ulcer caused by lenvatinib for thyroid cancer: a case report.

BACKGROUND: There are currently no effective therapeutic methods for locally recurrent, metastatic, or progressive radioactive iodine (RAI)-refractory differentiated thyroid cancer. However, multitargeted tyrosine kinase inhibitors (TKIs) such as lenvatinib or sorafenib have been approved for patients with RAI-refractory differentiated thyroid cancer as a second targeted therapy, and these agents can prolong patient survival. However, several cases have been reported that TKIs have caused fatal complications such as fistula formation or bleeding. CASE PRESENTATION: We report a case of a 53-year-old woman, who underwent repeated neck dissections and RAI therapy after total thyroidectomy in an outside hospital. Pathology revealed a papillary carcinoma of the tall cell variant. Locoregional recurrence was not under control; therefore, she visited our hospital. Although surgery was performed for locoregional recurrences three times in our hospital, they were not under control and distant metastases were found in the lung and bone a year later. Therefore, although sorafenib was initiated, the locoregional recurrence progressed 6 months later and computed tomography (CT) showed a 7-cm mass in the right subclavicular lesion. Lenvatinib was started at a dose of 24 mg daily. However, although tumor was rapidly reduced, an ulcer occurred in the right subclavicular lesion and was gradually increasing in size. The pulsation of subclavicular artery was found in the deep portion of the ulcer. Therefore, a pectoralis major myocutaneous flap was transplanted to cover the ulcer. Lenvatinib was an antiangiogetic TKI; therefore, it was preoperatively discontinued for 8 days and postoperatively for 12 days. The postoperative course was uneventful. CONCLUSIONS: Fistula formation or bleeding is known to be a severe side effect of antiangiogenic TKIs such as lenvatinib or sorafenib. There is a possibility that severe complications can occur when initiating TKIs in patients whose tumor has invaded into the skin, vessels, trachea, esophagus, and other areas. Therefore, it is necessary to use antiangiogenic TKIs very carefully. It is important to determine the appropriate time to start TKIs; however, there is no established protocol for this, and it is a problem that needs urgent attention.

Endoscopic laryngo-pharyngeal surgery for superficial laryngo-pharyngeal cancer.

BACKGROUND AND STUDY AIMS: Narrow band imaging (NBI) combined with magnifying endoscopy enables us to detect superficial laryngo-pharyngeal cancers, which are difficult to detect by standard endoscopy. Endoscopic laryngo-pharyngeal surgery (ELPS) is a technique developed to treat such lesions and the purpose of this study is to evaluate the usefulness of ELPS for superficial laryngo-pharyngeal cancer. PATIENTS AND METHODS: Seventy five consecutive patients with 104 fresh superficial laryngo-pharyngeal cancers are included in this study. Under general anesthesia, a specially-designed curved laryngoscope was inserted to create a working space in the pharyngeal lumen. A magnifying endoscope was inserted transorally to visualize the field and a head & neck surgeon dissected the lesion using the combination of the orally-inserted curved grasping forceps and electrosurgical needle knife in both hands. The safely, functional outcomes, and oncologic outcomes of ELPS were evaluated retrospectively. RESULTS: Median operation time per lesion was 35 min. Post-operative bleeding occurred in 3 cases and temporal subcutaneous emphysema occurred in 10 cases. No vocal fold impairment occurred after surgery. The median fasting period was 2 days and all patients except one have a normal diet with no limitations. Local recurrence occurred in 1 case, and the 3-year overall survival rate and the 3-year disease specific survival rate was 90% and 100%, respectively. CONCLUSIONS: ELPS is a hybrid of head and neck surgery and gastrointestinal endoscopic treatment, and enjoys the merit of both procedures. ELPS makes it possible to perform minimally-invasive surgery, preserving both the swallowing and phonation functions.

Magnifying endoscope with NBI to predict the depth of invasion in laryngo-pharyngeal cancer.

OBJECTIVES/HYPOTHESIS: To examine if macroscopic classification with a magnifying gastrointestinal endoscope with narrow band imaging (ME-NBI) is useful in predicting pathological depth of tumor invasion in laryngo-pharyngeal cancer. STUDY DESIGN: Retrospective study. METHODS: Preoperative endoscopy reports and postoperative pathological reports on 139 laryngo-pharyngeal cancer lesions were retrospectively reviewed, and the association between macroscopic findings in the lesions and the depth of tumor invasion was analyzed statistically. RESULTS: The ratios of lesions macroscopically classified as 0-I (superficial and protruding), 0-IIa (slightly elevated), 0-IIb (true flat), 0-IIc (slightly depressed), and 0-III (superficial and excavated) in the preoperative endoscopy reports were 3%, 25%, 71%, 1%, and 0%, respectively. Regarding the depth of tumor invasion in the postoperative pathological reports, the ratios of lesions classified as EP (carcinoma in situ), SEP (tumor invades subepithelial layer), and MP (tumor invades muscularis propria) were 73%, 26%, and 1%, respectively. The ratios of subepithelial invasion or muscular invasion in 0-I, 0-IIa, and 0-IIb were 100%, 54%, and 14%, respectively, and showed significant difference (P < 0.0001). Only one of 139 lesions invaded the muscular propria. CONCLUSIONS: This study is the first one to show that macroscopic findings by ME-NBI predict the depth of tumor invasion in superficial laryngo-pharyngeal cancer. It was indicated that there is a little chance of muscular invasion if the lesion is endoscopically diagnosed as 0-I or 0-II. A new T stage classification based on the depth of tumor invasion may be needed in order to adapt the classification to include transoral surgery. LEVEL OF EVIDENCE: 4.

Magnifying endoscopy with narrow band imaging to determine the extent of resection in transoral robotic surgery of oropharyngeal cancer.

Transoral robotic surgery (TORS) is a less invasive treatment that is becoming popular all over the world. One of the most important factors for achieving success in TORS is the ability to determine the extent of resection during the procedure as the extent of resection in the laryngopharynx not only affects oncological outcomes but also directly affects swallowing and voice functions. Magnifying endoscopy with narrow band imaging (ME-NBI) is an innovative optical technology that provides high-resolution images and is useful in detecting early superficial pharyngeal cancers, which are difficult to detect by standard endoscopy. A 55-year-old male with superficial oropharyngeal cancer has been successfully treated by combining MB-NBI with TORS and MB-NBI was useful in determining the extent of resection. ME-NBI with TORS will make it possible to achieve a higher ratio of minimally invasive treatment in pharyngeal cancer.

Usefulness of narrow-band imaging for detecting the primary tumor site in patients with primary unknown cervical lymph node metastasis.

OBJECTIVE: We sometimes experienced patients with primary unknown cervical lymph node metastasis. In such cases, if computed tomography, magnetic resonance imaging, laryngoscopy and gastrointestinal endoscopy cannot detect a primary site, there is no other effective method to identify a possible primary tumor. We investigated whether narrow-band imaging can detect a possible primary tumor in such. METHODS: Forty-six patients with primary unknown cervical lymph node metastasis were surveyed about primary tumors, from January 2003 to December 2006. All cervical lymph nodes were histologically proved to be squamous cell carcinoma by fine-needle aspiration cytology. Narrow-band imaging combined with magnifying endoscopy was used to identify the primary site in the head and neck region and cervical esophagus. Histological analysis was performed for all suspicious lesions by a biopsy specimen. RESULTS: Twenty-six lesions were suspected to be cancerous lesions by narrow-band imaging in the head and neck region. Sixteen lesions in 16 (35%, 16/46) patients were squamous cell carcinoma. Ten lesions were located in the hypopharynx and the remaining six lesions were located in the oropharynx. White light endoscopy could not point out any lesion. CONCLUSIONS: Narrow-band imaging endoscopy can detect possible primary cancer in patients with primary unknown cervical lymph node metastasis.

Prospective study of early detection of pharyngeal superficial carcinoma with the narrowband imaging laryngoscope.

BACKGROUND: The newly developed narrowband imaging (NBI) gastrointestinal endoscope makes possible the detection of superficial carcinoma in the oropharynx and hypopharynx, which is difficult with the conventional laryngoscope. Here, we investigated whether the combined use of laryngoscope with NBI allows the detection of superficial carcinoma in this region. METHODS: A total of 51 superficial, histologically confirmed lesions in 29 patients were studied. The quality of visualization of superficial carcinoma in the oropharynx and hypopharynx using the NBI-equipped laryngoscope was evaluated in comparison with the results by conventional laryngoscopy. RESULTS: The NBI laryngoscope provided better detection of the irregular microvascular pattern of carcinoma than the conventional laryngoscope (p <.05) and better visualization of the demarcation line (p <.05), and thus significantly better visualization of the lesions. CONCLUSION: The NBI laryngoscope may play an important role in the diagnosis and treatment of superficial carcinoma in the oropharynx and hypopharynx.