Oesophageal squamous cell carcinoma (ESCC) increases the relative risk of developing head and neck cancer by up to 34.9-fold (1). This association is explained by the field cancerization phenomenon, in which the entire epithelial surface of the upper aerodigestive tract becomes susceptible to malignant transformation after chronic exposure to shared carcinogens such as alcohol and tobacco. Consequently, multiple synchronous or metachronous squamous cell carcinomas may arise throughout this region (2). Despite their clinical relevance, pharyngeal cancers are frequently missed on standard white-light endoscopy. Even with advances such as magnification and digital chromoendoscopy, early detection remains challenging, and many cases continue to be diagnosed at advanced stages (3–6).
Early identification of superficial pharyngeal cancers enables curative resection, improving survival and reducing the long-term functional consequences associated with advanced disease and its treatments, including swallowing and voice impairments (6). Endoscopic submucosal dissection (ESD) has emerged as a minimally invasive, organ-preserving, and safe therapeutic option with excellent outcomes and low complication rates (3–6). Although well established for early gastric, rectal, and colonic tumors, its use for superficial pharyngeal cancers is relatively recent. Most evidence originates from Asian centers, and limited global exposure may be hindering widespread familiarity and adoption of this promising technique (4,7).
We describe the case of a 71-year-old male patient with a history of oesophageal squamous cell carcinoma (ESCC) who had previously undergone subtotal esophagectomy. During follow-up endoscopy, and considering the field cancerization theory, a meticulous examination of the oral cavity and upper gastrointestinal tract was performed. On the right wall of the hypopharynx, an extremely subtle flat area with only minimal erythema was noted so discreet that it was barely visible on white-light endoscopy. Under NBI chromoendoscopy, this area showed mildly brownish, raising suspicion. The biopsy, confirmed high-grade dysplasia. After multidisciplinary discussion with the head and neck surgeon, ESD was indicated.
First, the patient was anesthetized with orotracheal intubation, and no accessory device for laryngeal elevation was required. During the procedure, the lesion margins were difficult to identify, making 1.25% Lugol chromoendoscopy necessary to clearly delineate the affected area, revealing a flat lesion of approximately 40 x 20 mm. Circumferential marking and the submucosal dissection was performed using the OriseTMProKnife. Submucosal lifting with 6% hydroxyethyl starch and indigo carmine was then carried out, followed by submucosal dissection. Near the end of the procedure, the clip-with-line traction technique was employed to enhance lesion exposure and facilitate submucosal dissection. Complete en bloc resection of the lesion was successfully achieved. The procedure was completed in approximately 40 minutes.
The lesion was successfully resected en bloc using ESD, without intraprocedural or postprocedural adverse events. Histopathological evaluation confirmed in situ squamous cell carcinoma, with both lateral and deep margins free of neoplasia. No lymphovascular invasion was detected. The patient recovered uneventfully. Food intake was resumed on day 1 post-ESD, and the patient was discharged on day 2 post-ESD. Endoscopic follow-up was scheduled at 6 months after the procedure (not done yet).
This case illustrates the importance of meticulous oral cavity and pharynx evaluation in patients with a history of ESCC, given their high risk of developing secondary neoplasia due to field cancerization. Even minimal subtle pharyngeal lesions may correspond to early carcinoma and can be easily missed on white-light endoscopy. Adjunctive imaging techniques significantly enhance lesion detection and margin delineation. Wider adoption of systematic screening protocols and pharyngeal ESD in Western centres could improve early detection rates and survival, while preserving laryngeal function in this population.