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Carcinoma of Hypopharynx
Dr. Krishna Koirala
Surgical Anatomy• Lowermost & Longest of 3 segments of pharynx• Extends from the oropharynx to cervical esophagus• Superior extent
– Level of hyoid bone/ epiglottic tip/floor of the vallecula
• Inferior extent– Lower border of cricoid
• Anatomical subsites– The pyriform Fossa– The postcricoid area (Pharyngo-oesophageal junction)– Posterior pharyngeal wall
Anatomic extent of hypopharynx
• Marginal area:
– Aryepiglottic folds that separates the endolarynx
from medial wall of pyriform sinus bilaterally
– Tumors behave aggressively like hypopharyngeal
cancer
Characteristics of Hypopharyngeal Tumors
• Late presentation (77.3% manifest with stage III & IV)
• At the time of diagnosis : 30% of patients have local disease, 60% local regional disease, and 10% distant metastases
• Tendency to submucosal extension into esophagus
• Higher incidence of distant metastases
• Subsites:
– Pyriform sinus : 65-85% , Posterior pharyngeal wall : 10 -20% , Postcricoid area : 5-15%
Routes of spread of tumours of the piriform fossa
Risk Factors• Plummer Vinson syndrome: In females– Paterson-Brown Kelly Syndrome,
Sideropenic dysphagia
• Alcohol
• Tobacco
• Second primary malignancies (4-8%)
• Chronic irritation from gastroesophageal reflux
Clinical Presentation• Relatively silent than other head and neck
cancers
• Average duration of symptoms before presentation : 2-4 mths
• Dysphagia
– Persistent & progressive
– For solids
– Food ‘sticks’ on swallowing
• Pain
– Usually lateralized & prominent on swallowing
–May radiate to ipsilateral ear
– Aggravated by eating (of hot & spicy food)
– Requires investigation in >2-3 weeks
• Hoarseness
– In association with dysphagia/otalgia
– Coarse, raspy, breathy or diplophonic voice
• Neck mass
–Nodal metastasis or direct extension through thyrohyoid membrane
• Hemoptysis
– Unusual
– Pyriform sinus or posterior pharyngeal wall tumor
• Weight loss
– Present in late stage disease
Examination• Typical findings in Hypopharynx /larynx
–Mucosal ulceration
– Pooling of the saliva in the pyriform fossa (Chevalier Jackson’s sign)
– Edema of the arytenoids
– Fixation of the cricoarytenoid joint, true vocal cords, or both
Ca of postcricoid region Ca of medial wall of L pyriform sinus
Ca Rt pyriform sinus with extention to larynx
Localized tumour of medial wall of R pyriform sinus
Ca R pyriform sinus with transglottic invasion
Investigations
Hematological •CBC (Vit B12 & folate)
•Iron stores
•Urea & electrolytes
•LFT
•Serum calcium
•TFT
Radiological• CT scan or MRI before endoscopic evaluation &
biopsy• Specific uses of imaging– To assess extent of primary tumour, relation with
larynx and extension– To exclude second primary / distant metastases– Presence / absence of cartilage invasion– To assess the neck– To assess stomach prior to gastric transposition for
reconstruction– To confirm/refute presence of pharyngeal pouch
Bulky right pyriform sinus tumor
• Barium swallow– To assess tumor length and rule out primary
tumor of esophagus
– To assess tumor mobility on vertebral column during deglutition
• PET scan
– In initial assessment in locally advanced disease,
nodal involvement, suspicion of metastatic
disease, or for evaluation of an unknown primary
site
• Abdominal CT scan : rule out liver
metastases
• Bone scan : rule out bone metastases
Endoscopy and Biopsy
• Triple endoscopy (Panendoscopy)
– Laryngoscopy, bronchoscopy and esophagoscopy
– Used to assist in defining the extent of the
tumour and its histopathology
Staging of primary hypopharyngeal tumors (AJCC)• TX: Primary tumor cannot be assessed • T0: No evidence of primary tumor • TIS: Carcinoma in situ • T1: Limited to one subsite of the hypopharynx and ≤ 2
cm• T2: Involves more than one subsite of the
hypopharynx or an adjacent site or is >2 cm but not larger than 4 cm at its greatest diameter without fixation of the hemilarynx
• T3: Tumor is larger than 4 cm or involves fixation of the hemilarynx
• T4a: Tumor invades the thyroid/cricoid cartilage, hyoid bone, thyroid gland, esophagus, or central compartment soft tissues, including prelaryngeal strap muscles and subcutaneous fat
• T4b: Tumor invades the prevertebral fascia, encases the carotid artery, or involves mediastinal structures
Staging of regional lymph nodes • NX: Regional lymph nodes cannot be assessed• N0: No regional lymph node metastasis• N1: Metastasis is found in a single ipsilateral node
( ≤3 cm at its greatest dimension)• N2: Metastasis is found in a single ipsilateral lymph
node (>3 cm but <6 cm in greatest dimension) or in multiple ipsilateral lymph nodes none >6 cm at greatest dimension– N2a : Metastasis in a single ipsilateral lymph node
(>3 cm but <6 cm at its greatest dimension) – N2b : Metastasis in multiple ipsilateral lymph
nodes (none >6 cm at greatest dimension) – N2c : Metastasis in bilateral or contralateral lymph
nodes (none >6 cm at greatest dimension)• N3: Metastasis in a lymph node larger than 6 cm at its
greatest dimension
Staging for distant metastasis
• M0: No distant metastasis
• M1: Distant metastasis (eg, lung,
mediastinal lymph nodes, skeletal,
hepatic)
Stage groupingStage GroupingStage 0 TIS N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage IIIT3 N0 M0
T1,T2,T3 N1 M0
Stage IVA
T4 N0 M0
T4 N1 M0
Any T N2 M0
Stage IVB Any T N3 M0
Stage IVC Any T Any N M1
Adopted from the AJCC staging manual. 6th edition NY-Springer-Verlag, 2002
Staging
Treatment planningImportant determinants involvedTumour factors:
Anatomical subsite of tumour originClinical stageHistological grade
Patient factors:General conditionNutritional statusImmune competence
External factors:Differences in treatment centersAvailability of expertiseEthnic considerationsOther social factors
• Ultimate goals of treatment
– Control of cancer
– Preservation of function of speech & normal swallowing
– Avoidance of a tracheostomy
• With advanced disease with pharyngolaryngectomy– Re-establishing anatomic continuity of
alimentary tract– Restoration of ability to swallow as soon
as possible
• Current treatment modalities
– Full course irradiation with surgical salvage
– Surgery alone
– Combination of irradiation therapy with surgery
– Prospective protocols with chemotherapy,
before surgery or irradiation or in combination
Curative treatment of hypopharyngeal tumours
Pyriform sinusPosterior
pharyngeal wall
Postcricoid
Stage I (T1,N0)Primary radiotherapy or surgery (PP or PPPL)
Primary radiotherapy or surgery (PP)
Primary radiotherapy or surgery (TLP)
Stage II (T2,N0)
Primary radiotherapy or surgery (PPPL or TLP)
Primary radiotherapy or surgery (PP or TLP)
?Primary radiotherapy or surgery (TLP) and post-op radiotherapy
Stage III (T1-2,N+)
(T3,N0,N+)
Surgery (TLPP or TLP) and post-op radiotherapy
Surgery (PP or TLP) and post-op radiotherapy
Surgery (TLP or TLPO) and post-op radiotherapy
Stage IV (T4,N0,N+)
Surgery (TLPP or TLP) and post-op radiotherapy
Surgery (TLP) and post-op radiotherapy
Surgery (TLPO) and post-op radiotherapy
Pyriform fossa tumors
• Lesions not extending to apex of fossa, post cricoid region or posterior wall may be resected preserving larynx
• Lesion involving lateral wall of fossa :
– Partial pharyngectomy with resection of upper thyroid ala
• Medial wall & hemilarynx resectable by near total laryngectomy
• Advanced tumors have higher chances of locoregional recurrence & distant metastases
Postcricoid tumors
• Few small tumors <5cm treated with
radical radiotherapy alone
• Larger recurrent tumours require total
laryngopharyngectomy
• Extension into esophagus:
esophagectomy
Posterior Pharyngeal wall tumours
• Small lesions
– Radiotherapy or partial pharyngectomy with laryngeal preservation
• Advanced lesions
– Total pharyngolaryngectomy
• Skip lesions or direct extension to esophagus
– Esophagectomy
• Close surgical margins treated with radiotherapy
The neck• 60% pyriform tumours have +ve neck nodes
• 30-40% uninvolved neck have occult
disease
• Treatment determined individually by the
stage of primary & neck
• Superficial primary tumor of post pharyngeal wall or lateral wall of pyriform fossa
– Excised orally or with/out use of laser or through transhyoid pharyngotomy
• Primary tumours of pyriform sinus with limited extension to adjacent sites of larynx
– Partial laryngopharyngectomy
Surgical treatment
• Invasion of postcricoid region, deep invasion
into musculature of base of tongue
– Pharyngectomy with total laryngectomy
• Significant extension into cervical esophagus
– Pharyngolaryngoesophagectomy with
immediate appropriate reconstruction
Surgical optionsProcedure T stage Reconstructi
onPartial pharyngectomy T1 , T2 Primary closurePartial laryngopharyngectomy T1,T2,T3 Regional or free
flapSupracricoid Hemilaryngectomy T1,T2,T3 Primary Closure
Endoscopic CO2 laser resection
T1,T2(possible T3,T4)
Secondary intention
Total laryngectomy with partial-total pharyngectomy
T3,T4Primary closure vs regional or free flap
Total pharyngolaryngoesophagectomy
T4 Gastric pull-up
Radiation Therapy• Used as a single modality therapy
limited to early lesions (T1, selected T2)
• Exophytic lesions limited to medial wall or pyriform sinus
• Elderly, debilitated, advanced lesion who refuse surgery
• For palliative treatment
Indications for radiotherapy
• Definitive treatment
– Resectable cancer for organ preservation
– Adequate function of the laryngopharynx
– Unresectable cancer
• Cancer that involves the prevertebral fascia
• Cancer that encases the carotid artery
Indications for postoperative radiotherapy
• Primary indications – Positive or close margins (<5 mm)
– T4 tumors
– Invasion of cartilage, bone, or soft tissues by the primary tumor
• Neck indications – Two or more lymph nodes with metastasis
– Extracapsular extension