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