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Cancer of the hypopharynx

By

Dr IBRAHIM H. AHMED BarakatM.D.

OtorhinolaryngologyE-mail: salamatuall@yahoo.com

Anatomy of hypopharynx

area extending from : tip of epiglottis to

lower border of cricoid cartilage .

divided into 3 anatomical subsites: pyriform fossa ,

posterior pharyngeal wall, post cricoid area .

Pyriform fossa

Inverted of pharyngeal mucosa .

Superiorly : lateral glosso epiglottic fold .

Apex : meeting of lateral & medial wall inferiorly.

Lateral : Thyroid cartilage. Contiguous with post. pharyngeal wall.

Medially : Aryepiglottic fold & arytenoid cartilage contiguous with post cricoid area .

Posterior pharyngeal wall

Pharyngeal mucosaThe plane of tip of epiglottis

Down to; Cricopharyngeous muscle

Post cricoid area

• Mucosa covering the posterior surface of the cricoid cartilage ,

• extending from the arytenoids superiorly to lower border of cricoid cartilage inferiorly .

The wall of the hypopharynx• An inner mucosa : stratified squamous

epithelium .

• A fibrous layer : of pharyngeal aponerosis .

• A muscular layer : inferior constrictor of the pharynx & distal portion of middle constrictor.

• A layer of fascia : buccopharyngeal fascia .

Blood supply to hypo pharynx

Ascending pharyngeal branch of external carotid a .

Ascending palatine & tonssilar braches of

facial a .

Descending pharyngeal & palatine branches of internal maxillary a .

Lymphatics of hypoharynx

• Upper & mid jugular node .

• Retropharyngeal lymph nodes .

• Node of Rouviere at skull base .

• Prelaryngeal & paratracheal lymph nodes .

Cancer of the hypopharynx

epidemiology

•1.1 per 100,000 per year

etiology

Excessive tobacco use &

alcohol consumption.

Risk factors -chronic alcohol and tobacco use

-older age - family history

-Exposure to polycyclic aromatic hydrocarbons , asbestos , & welding fumes.

-Nutritional deficiencies -Infectious agents especially papilloma virus &

fungi

Diseases associated with hypopharynx ca.

-Plummer Vinson syndrome -esophageal web

-celiac disease -scleroderma

-tylosis

Field cancerization

Tobacco & alcohol contribute to the development of multiple carcinoma

Superficial spreading carcinoma

Areas of in situ carcinoma alternating with sections of micro invasive carcinoma or with foci of frank invasion over a large epithelial field .

Patterns of local spread

Pyriform sinus : paraglottic space .

Lateral & post . Pharyngeal wall . Thyroid gland , cricoid cartilage .

v. c. fixation .

Posterior pharyngeal wall : tonsillar fossa & oropharynx Cervical esophagus. Prevertebral fascia.

Post cricoid area : cricoid cartilage & cervical esoph ,

Pattern of lymphatic spreadPost. Pharyngeal wall:

Pyriform sinus : Post cricoid lesion :

Occult metastasis :

Lymph node groups 60% &Retropharyngeal L. Ns. 44%

L. N. metastasis 75%L. N. metastasis 40%Para tracheal L. N.

50% – 80%

Clinical presentation

Early lesions :

No symptoms . Or vague throat pain .

Advanced lesions :

odynophagia , referred otalgia &

dysphagia

Clinical presentationVague throat pain: Referred otalgia :

Hemoptysis:

Weight loss:

Ptyalism: Palpable neck

lump :

Early lesion. Pyriform fossa tumour.

Large fungating or ulcerated lesion.

Malnutrition . (circumferential lesion ).

Blood tinged ( ulcerated lesion)Direct extension in soft tissue

neck.

Signs of hypopharyneal carcinomaPalpable lump in the neck , in 2/3 of the

extension in soft tissue neck ) .)patientsPooling of saliva , edema & erythema especially near arytenoid . ( apex of pyriform

& post cricoid lesion ). Indirect mirror , tumors of posterior pharyngeal

wall & upper pyriform sinus.

Clinical evaluation -complete history of the disease

- weight and weight loss -performance status

- fiberoptic examination of H&N mucosa

-neck examination -drawing of any lesions

Complete examination of the head and neck Includes examination

• oral cavity,• pharynx, • indirect laryngoscopy.• fiberoptic examination of the larynx and pharynx

.

The examination

status of the dentition,the status of the airway,

vocal cord mobility ,laryngeal crepitus ,

tumor extension to:

- the medial, anterior and lateral wall of the pyriform sinus

- the posterior pharyngeal wall or to the post cricoid region .

Palpation of the neck bilaterally , Recording

- the location (Group or Level I - VI), -size,

- mobility , - relationship of the node(s) to adjacent

structures .

The staging of the primary and of the cervical lymph nodes must be documented

Imaging Studies:

•Chest radiographs, PA and lateral

To rule out

(1) A synchronous pulmonary tumor,(2) Acute or chronic pulmonary

disease (3) Metastatic tumor.

imagingExtent , synchronous tumour. Thickness , invasion ,

Lymph node metastasis. Soft tissue details & fat planes, Tissue edema & tumor extention. Viability of a tumor.

Residual , recurrent tumor afterRadiotherapy.

barium swallowC T scan

M R I

P E T

Fig.1Contrast-enhanced spiral CT images. a. Axial image during quiet breathing shows subtle soft tissue thickening in the apex of the right pyriform sinus (arrow; compare to opposite side); there is some evidence of subtle infiltration or displacement of the paraglottic space fat (arrowhead).

b. Axial image obtained during modified Valsalva maneuver. The right pyriform sinus expands somewhat less than the opposite side; the mucosal irregularity produced by the cancer is now better visible (arrowheads). Squamous cell

carcinoma .

Fig.2Unenhanced spiral CT images in a patient with a large laryngohypopharyngeal carcinoma. No contrast medium was injected because of renal failure. a. Axial image at the level of the cricoid cartilage. Soft tissue thickening is seen in the retrocricoidal hypopharynx (arrow) and also beyond the thyroid cartilage, beneath the thyroid gland (arrowheads). Extensive sclerosis of the cricoid arch and inferior part of the thyroid lamina is seen at the left side

b. Axial image at the glottic level. Thickening of the left vocal cord, with infiltration of the left paraglottic space (compare to opposite side). The mass is also seen in the apex of the pyriform sinus (arrow), extending underneath the pharyngeal constrictor muscle posterolaterally from the thyroid lamina (arrowheads). Note again

sclerosis of the left thyroid lamina and left arytenoid .

c. Axial image through the lower supraglottis. Large tumour mass in the left pyriform sinus (arrows), extending into the left paraglottic space (arrowheads).

d. Axial image just above the thyroid cartilage. The hypopharyngeal tumour mass bulges into the soft tissues of the neck (arrows); the carotid artery (asterisk) has not yet been affected. Infiltration of the upper paraglottic space (arrowhead). Pathological examination revealed squamous cell carcinoma and confirmed the described soft tissue infiltration, but no neoplastic cartilage invasion was

found .

Laboratory Tests: • Preoperative tests according to institutional guidelines. • Pulmonary function and arterial blood gases in the patients with COPD or who are candidates for partial laryngo-pharyngectomy. • Baseline liver function tests (optional).

.EXAMINATION UNDER ANESTHESIA AND BIOPSY:

To assess the superior and inferior limits of the tumor, its relationship to the apex of the pyriform sinus, the lateral pharyngeal wall, tonsillar fossa, base of tongue, the postcricoid region, the opposite pyriform sinus, and direct involvement of the larynx. To rule out the existence of other primary tumors in the aerodigestive tract.

EXAMINATION UNDER ANESTHESIA AND BIOPSY:

•To assess the mobility of the tumor over the prevertebral fascia.

•In patients with advanced primary disease and airway impairment, the examination under anesthesia may require a tracheostomy to secure the airway. If this is necessary, the examination may be performed in conjunction with the definitive surgical procedure.

•Esophagoscopy is performed to evaluate extension into the post cricoid region or cervical esophagus.

•Bronchoscopy if indicated by clinical or radiographic findings.

Consultations:

•Radiation therapy

In anticipation of possible need for post-operative radiation therapy or to use radiation therapy as a definitive primary modality of treatment in early stage tumors.

Consultations:

•Dental

To assess the status of the teeth and make recommendations considering that radiation therapy may be indicated. The evaluating dentist should be versed in the effects of radiotherapy on dentition. This evaluation should be done with knowledge of the treatment portals planned for the radiotherapy.

Consultations:

•Speech pathology

For pre-operative counseling regarding possible post-operative speech and swallowing rehabilitation.

managementSurgery and radiotherapy employed alone or in combination . Recently , induction

chemotherapy in combination with radiation &

surgery has been used aiming to :

-Increase loco regional control. -decrease systemic metastasis.

-prolong survival. -preserving a functioning larynx .

Surgical treatment

1 – partial larygopharyngectomy. 2 – posterior pharyngeal wall resection.

3 – total laryngectomy with partial pharyngectomy .

4 – total laryngopharyngectomy. 5 – total laryngopharyngoesophagectomy.

Surgical procedure Indications -small pyriform sinus tumour not affecting its

apex or base of tongue , with mobile v .cords.

-advanced pyriform sinus tumour involves its apex ,post cricoid mucosa , laryngeal

framework , with paralysed hemi larynx.

-1ry closure if defect is < 1/3 circumference. -radial forearm free flap or pectoralis major

myocutanous flap if defect is > 50% circumference

-partial laryngopharyngectomy :

-total laryngectomy with partial pharyngectomy:

-Reconstruction:

-:

Surgical management continue.

Surgical procedure

-Total larengopharyngectomy:

-Reconstruction:

•Total laryngopharyngoesophagectomy

-Reconstruction:

-Resection of post. Pharyngeal wall ca.-Reconstruction

indications

-Post cricoid & cervical esophageal lesions.

- A free segment of jejunum, - Radial forearm free flap.

-Lesion extends to lower cervical esophagus ,or upper thoracic esophagus.

-Mobilization of the stomach & transposition into the neck .

-A small superficial upper or lower post. Phary. wall lesion.

-Split thickness skin graft for ( limited excion ),or

-Radial forearm mictovascular free flap ( (large resection ) .

Management of the neck

No neck : elective neck dissection , clearing level 1 , 2 , 3 .

N +ve neck : comprehensive neck dissection .

Role of radiotherapy

Radiotherapy is usually utilized in conjunction with surgery except :

-Superficial lesions confined to pyriform sinus with normal vocal cord.

-posterior pharyngeal wall tumours .

Multimodality therapy

Induction chemotherapy with 2 to 3 cycle of cisplatin – based chemotherapy gives complete response rates of up to 60% with no improvement in survival over convential treatment of surgery with post operative

radiotherapy .

Postoperative Care includes:

•Hospitalization for 7-14 days. •Intensive care unit, as needed. •Tube feedings until oral alimentation is reestablished. •Low pressure suction to the drains. •Removal of the drains when 24 hour output is less than 30-50 cc. •Tracheostomy or stoma care. •Sutures removed from the neck on the 7-10 postoperative day. •consult a home-visiting nursing service (optional) •Speech therapy and physical therapy, as needed

Postoperative Care includes:

•For patients undergoing a laryngeal sparing procedure or partial laryngectomy, a modified barium swallow may be appropriate prior to initiating oral alimentation, to rule out significant aspiration. •May require discharge with tracheotomy tube and feeding tube in place. Adequate training of patient and support personnel is needed before discharge can safely be effected. Ensure that a portable suction machine is available to the patient

عليك} .... الله فضل وكان تعلم تكن لم ما وعلمكالنساء { : 113عظيما

DR , IBRAHIM HABIBThank you