Pharyngeal cancer


Published on

  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Pharyngeal cancer

  1. 1. Pharyngeal cancer By Ihab Samy Lecturer of surgical oncology NCI- Cairo University 2014
  2. 2. Nasopharyngeal Carcinoma
  3. 3. Relevant Anatomy • Anteriorly the posterior choanae. • Posteriorly the clivus and the first 2 cervical vertebrae. • Superiorly the floor of the sphenoid. • Inferiorly the level of the free border of the soft palate. • Divided into 3 subsites: 1. The posterosuperior wall 2. The lateral walls 3. The posterosuperior surface of the soft palate.
  4. 4. • The torus tubarius is the opening of the eustachian tube into the lateral nasopharyngeal wall. • The fossa of Rosenmüller is the groove or recess posterior to the torus at the junction between the lateral and posterior walls (Nasopharyngeal carcinoma (NPC) most commonly occurs in this location). • The nasopharynx is an anatomically difficult area to expose surgically. This area is in close proximity to several foramina and associated vital neurovascular structures. These include the foramen ovale, the foramen spinosum, the foramen lacerum, the carotid canal, and the jugular foramen.
  5. 5. • Ho originally described the supraclavicular fossa as a triangular region defined by 3 points: 1. the sternal end of the clavicle 2. the lateral end of the clavicle 3. the point where the neck meets the shoulder. • This area is clinically significant in that any nodal involvement within this triangle is, by definition, an N3 lesion and, therefore, stage IV cancer.
  6. 6. Introduction SSx: • Neck mass (most common initial symptom, 70%). • Serous otitis media from eustachian tube obstruction (second most common presentation, 50%). • Nasal obstruction. • Cranial nerve palsies (abducent nerve most common cranial nerve palsy) Villaret's syndrome • Recurrent epistaxis. • Trismus, headache.
  7. 7. Risk Factors: • Regional distribution (Southern China, Northern Africa, Southeast Asia, Alaska, Greenland). • Epstein-Barr Virus (EBV)  Viral Capsule Antigen (VCA): late antigen, most specific immunological finding in nasopharyngeal cancer • Genetic predisposition (genotypes HLA-A2 and HLA-Bsin2). • Nitosamines (smoked meat and salted fish).
  8. 8. Staging (based on the AJCC Staging) • T1: primary tumor confined to nasopharynx • T2: primary tumor extension into nasal fossa or oropharynx (without parapharyngeal extension [T2a], with parapharyngeal extension [T2b]) • T3: invasion of bony structures or paranasal sinuses • T4: invasion into intracranium, cranial nerves, infratemporal fossa, hypopharynx, or orbit
  9. 9. World Health Organization (WHO) Classification • WHO Type I: Keratinizing Squamous Cell Carcinoma, squamous differentiation, not associated with EBV, worse prognosis, less sensitive to radiation. • WHO II: Nonkeratinizing Squamous Cell Carcinoma, does not demonstrate definite squamous differentiation, associated with EBV, better prognosis, sensitive to radiation • WHO III: Undifferentiated (includes lymphoepitheliomas, anaplastic, and clear cell variants): indistinct cell margins, may have lymphocytic stroma (lymphoepitheliomas), associated with EBV, better prognosis, sensitive to radiation
  10. 10. Other Types: • Lymphoma • Adenocarcinoma • Plasma Cell Myelomas • Cylindromas • Adenocystic Carcinoma • Melanoma • Carcinosarcoma
  11. 11. Diagnostic Tests Diagnosis is made by biopsy of the nasopharyngeal mass. Workup includes the following: • Careful visual examination (by fiberoptic endoscopic examination or examination under anesthesia [EUA]). • Documentation of the size and location of the tumor and neck nodes. • Evaluation of cranial nerve function including neuro-ophthalmological evaluation and audiological evaluation. • Computed tomographic (CT) scan or positron emission tomography (PET)-CT scan. • Magnetic resonance imaging (MRI) to evaluate skull base invasion. • Hemogram. • Chemistry panel. • Epstein-Barr virus titers.
  12. 12. Treatment • Stage I Nasopharyngeal Cancer: High-dose radiation therapy to the primary tumor site and prophylactic radiation therapy to the nodal drainage. • Stage II Nasopharyngeal Cancer: 1. Chemoradiation therapy followed by adjuvant chemotherapy. 2. High-dose radiation therapy to the primary tumor site and prophylactic radiation therapy to the nodal drainage.
  13. 13. • Stage III & IV Nasopharyngeal Cancer: 1. Combined chemoradiation therapy 2. Combined chemoradiation therapy followed by adjuvant chemotherapy. 3. Altered fractionation radiation therapy. 4. Neck dissection may be indicated for persistent or recurrent nodes if the primary tumor site is controlled.
  14. 14. Surgical approaches • Transnasal – maxillary: 1. Lateral Rhinotomy. 2. LeForte’s I osteotomy. 3. Extended Subtotal maxillectomy. • Sublabial midfacial degloving • Transpalatal • Transfacial-maxillary swing • Mandibular swing • Infratemporal
  15. 15. Prognosis prognostic factors adversely influencing outcome of treatment include the following: • Large tumor size. • A higher tumor (T) stage. • The presence of involved neck nodes. • Age. • World Health Organization (WHO) grade I. • Long interval between biopsy and initiation of radiation therapy. • Diminished immune function at diagnosis. • Incomplete excision of involved neck nodes. • Pregnancy during treatment. • Locoregional relapse. • High-titer antibodies to virus capsid antigen and early antigen, especially of high IgA class that persist after therapy.
  16. 16. Oropharyngeal cancer
  17. 17. Surgical anatomy • The junction of the soft palate and hard palate superiorly • The circumvallate papillae of the tongue anteriorly • The hyoid bone inferiorly. • The subsites of the oropharynx: the soft palate, base of tongue, tonsillar fossa and pillars, and a portion of the posterior pharyngeal wall.
  18. 18. • Squamous cell carcinoma being by far the most common histologic type. • The most important causative factors are prolonged tobacco and alcohol exposure.
  19. 19. Potential fascial spaces • The retropharyngeal space • the parapharyngeal space When invasion does occur, tumors may spread into these potential spaces.
  20. 20. Presentation • Older than 45 years of age • Throat discomfort. • Odynophagia • Otalgia • Trismus, dysphagia, and dysarthria may develop with deeper invasion. • Bleeding, aspiration, airway obstruction, and weight loss (Late). • Neck mass (45% to 78% of patients with oropharyngeal primaries may present with cervical adenopathy at the time of diagnosis)
  21. 21. Base of tongue • Sore throat is the most common presenting symptom. • Difficult to visualize, and submucosal lesions are common. • Digital palpation of the tongue base in patients with persistent sore throat is thus critical in making a proper diagnosis. • Presents at an advanced stage with high rates of cervical and distant metastasis.
  22. 22. • The overall survival rate as low as 20%. • More aggressive SCC than oral tongue (high grade). • Cervical lymph node metastasis is high. • Almost 20% present with bilateral cervical metastases secondary to the rich lymphatic system of the base of tongue. • Levels II, III, and IV are mostly involved
  23. 23. Soft palate • 15% of cancers of the soft palate are found during routine physical examination. • The most common chief complaint is odynophagia. • Visible and symptomatic earlier than other cancers of the oropharynx. • Cervical lymph node metastases ranges from 2% to 45%. Bilateral in 5% to 15% of patients • Primary lymphatic drainage to level II
  24. 24. Tonsil • The most common sites of carcinoma of the oropharynx, contributing 75% to 80% of all oropharyngeal cancers. • Odynophagia or dysphagia (60-80%). • Cervical adenopathy (15-30%). • Otalgia or bleeding. • Posterior and deep extension may involve the pterygoid musculature causing significant pain and trismus
  25. 25. • Often presents with involvement of the anterior tonsillar pillar. • Spread anteriorly or medially to involve the retromolar trigone, buccal, and tongue base mucosa. • The lingual nerve, inferior alveolar nerve, glossopharyngeal nerve, and mandible may become involved just deep to the anterior tonsillar pillar. • Cervical metastasis (66% - 76%) regions II, III, and IV.
  26. 26. Posterior and lateral oropharyngeal walls • Frequently presents at an advanced stage. • 78% of these cancers presented at a size greater than 5 cm. • Extend either superiorly to the nasopharynx or inferiorly to the hypopharynx. • Dysphagia (66%) and odynophagia (62%) • Weight loss, neck pain, and hoarseness. • Initial presentation of a neck mass was reported in 20% of patients.
  27. 27. Evaluation and staging • Size and mobility of the lesion. • Trismus or decreased mobility of the tongue is a sign of invasion of the pterygomaxillary space or deep tongue muscles. • Cranial nerves V, VII, XI, X, and XII examination. • The number and size of lymph nodes.
  28. 28. • MRI is useful for evaluating soft tissue involvement, particularly of the tongue base and the parapharyngeal space. • CT is useful in evaluating invasion of bone of the skull base or mandible. • EUA  staging and tissue Bx.
  29. 29. Staging (American Joint Committee on Cancer staging for oropharyngeal carcinoma) • TX Primary tumor cannot be assessed • T0 No evidence of primary tumor • Tis Carcinoma in situ • T1 Tumor =2cm in greatest dimension • T2 Tumor >2cm but not more than 4cm in greatest dimension • T3 Tumor >4cm in greatest dimension or extension to lingual surface of the epiglottis • T4a Moderately advanced, local disease.Tumor invades the larynx, deep/extrinsic muscle of the tongue, medial pterygoid, hard palate, or mandible • T4b Very advanced, local disease.Tumor invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, or skull base or encases the carotid artery
  30. 30. Management • An argument can be made against primary surgical therapy for oropharyngeal cancers. • Even early-stage carcinomas are at risk for regional lymph node metastases. • Traditional neck dissections often fail to address retropharyngeal and parapharyngeal lymphatics. • High risk of bilateral neck disease
  31. 31. • Because of these issues and the morbidity of surgical resection of the oropharynx, there has been an overall trend toward primary therapy with radiation or chemoradiation therapy, especially for advanced disease. • Single-modality therapy with radiation or surgery can achieve similar locoregional control for early and intermediate cancers, with radiotherapy generally yielding better functional outcomes. • Many institutions therefore recommend radiation therapy for early-stage disease and chemoradiation therapy for intermediate- and advanced-stage disease.
  32. 32. Surgical approaches • Reserved for patients who have failed primary radiation or chemoradiation or not candidates for such therapy. • The key factor in any approach is adequate exposure. • Generally, all approaches are accompanied by a neck dissection and a tracheostomy.
  33. 33. Transoral approach • The simplest, NO scars but poor exposure. • Success depends on the size and location of the tumor. • Preferred method for excising smaller lesions of the soft palate, posterior pharyngeal wall, tonsil and anterior pillar, and uvula. • Recently, transoral laser approaches have been described for treatment of small lesions of the base of tongue
  34. 34. Transcervical/Visor Flap • May be considered for large tumors of the base of tongue or tonsil • Access oropharynx from a transoral incision of the floor of the mouth • Preserves mandibular integrity • Poor exposure, chin numbness
  35. 35. Mandibular swing approach • Wide exposure of the entire oropharynx. • Mandible should not be involved. • Mandibular osteotomies are performed anterior to the mental foramen, preserving the sensory innervation of the lip and chin. • The floor of mouth is released along with the lateralized mandibular segment, while preserving the lingual nerve in its course if uninvolved.
  36. 36. Mandibulectomy • For oropharyngeal cancers that involve the mandible, composite resection of the mandible and oropharynx may be required. • This resection is achieved with by lip-splitting or a visor flap incision. • Approached laterally or medially with a lip-splitting incision (mandibular swing) • Provides excellent exposure, easier soft tissue closure. • Risk of malocclusion and plate extrusion.
  37. 37. Suprahyoid approach • Most appropriate for small neoplasms of the midline base of tongue. • Entering the pharynx above the hyoid bone into the vallecula. • The tumor is excised inferiorly to superiorly.
  38. 38. The lateral pharyngotomy approach • The pharynx is entered between the hypoglossal and superior laryngeal nerves. • A rather limited view of the tongue base can be improved by extending into a suprahyoid approach, thus giving an excellent view of the base of tongue and pharyngeal walls. • Inadequate for lesions extending superiorly to the tonsillar fossa or retromolar trigone region.
  39. 39. • The transcervical transpharyngeal approaches have the advantage of minimally disrupting existing functional anatomy while providing adequate exposure for selected posterior oropharyngeal tumors. • They may be combined, if necessary, for exposure but require some experience to be used effectively.
  40. 40. Reconstruction of the oropharynx • Objective of reconstruction is to restore functional speech and swallowing while providing an adequate airway. • Primary closure, is reserved for small defects where minimal tethering will be created, such as early lesions of the base of tongue where transpharyngeal approaches have been employed. • Skin grafting is usually limited to lesions along the posterior and lateral pharyngeal wall where a bolster can be placed.
  41. 41. • The pectoralis major myocutaneous flap is extremely reliable and provides sufficient bulk to fill major defects of the oropharynx. • Other pedicled flaps described for reconstruction of the oropharynx include the latissimus dorsi flap and the trapezius myocutaneous flap. • Pedicled flaps work best where mobility and sensation are less critical, such as in the tonsil and lateral pharyngeal regions.
  42. 42. • Microvascular free tissue transfer including The radial forearm flap, based on the radial artery, provides a thin, pliable, and possibly sensate reconstructive option; and The lateral arm flap, based on the posterior radial collateral artery, is another option for reconstruction of the oropharynx. • These flaps are most effectively used in tongue base and palatal defects where mobility is essential to function. • Bony microvascular free tissue may be used such as the fibular or scapular osteofasciocutaneous free flap if mandibulectomy is needed.
  43. 43. Chemoradiation therapy • Several prospective, randomized studies provide strong data demonstrating a statistically significant improvement in locoregional control and a strong trend for improved overall survival with concomitant chemoradiation therapy over radiation therapy alone for patients with advanced oropharyngeal carcinoma. • Better regional and distant tumor control.
  44. 44. Hypopharyngeal carcinoma
  45. 45. Surgical anatomy • Extends from the level of the hyoid bone to the esophageal inlet. • It is intimately associated with the larynx, surrounding its posterior and lateral borders. • The subsites of the hypopharynx include the pyriform sinus, the posterior pharyngeal wall, and the postcricoid region. • The superior aspect of the pyriform sinus is surrounded by the thyrohyoid membrane through which the internal branch of the superior laryngeal nerve passes.
  46. 46. • Sensory portions of this nerve synapse along with sensory nerves of the external auditory canal (Arnold’s nerve) leading to symptoms of referred otalgia. • The postcricoid region lies posterior to the arytenoid cartilages and cricoid ring, terminating at the junction between the pharynx and esophagus. • The posterior pharyngeal wall of the hypopharynx begins at the level of the hyoid bone continuing also to the pharyngoesophageal junction.
  47. 47. • Has a muscular wall consisting of the middle and inferior constrictor muscles. • The retropharyngeal space posterior to the hypopharynx, which contains lymphatics and loose areolar tissue, separates the visceral compartment of the neck from the prevertebral muscles with their overlying prevertebral fascia. • The hypopharynx has a rich lymphatic supply with its major lymphatic drainage pattern to the jugular chain and retropharyngeal lymph nodes and the node of Rouviere.
  48. 48. Introduction • Cancers of the hypopharynx are uncommon, representing only about 0.5% of all malignancies. • Most cancers of the hypopharynx are squamous cell carcinoma in histology. • Have a strong association with alcohol and tobacco abuse and, more recently, with chronic reflux disease.
  49. 49. Clinical presentation • Sore throat • Dysphagia • Otalgia • Hoarseness • Neck mass (25%) • 70% of patients will have palpable adenopathy on initial examination [
  50. 50. Evaluation and staging • Indirect pharyngolaryngoscopy (Tumors of the posterior wall or upper pyriform sinus). • Flexible fiberoptic examination • Edema, erythema, pooling of secretions, and loss of laryngeal crepitus are important signs of hypopharyngeal carcinoma. • Vocal cord invasion with limited mobility is a sign of extensive disease.
  51. 51. • Palpation of the neck is necessary for evaluation of lymphadenopathy. • Direct laryngoscopy, esophagoscopy, and biopsy under general anesthesia to facilitate accurate evaluation and staging as well as allowing identification of possible synchronous tumors. • CT and MRI scans are important for further evaluation of the primary site (eg, for laryngeal cartilage erosion) as well as evaluation for the presence of cervical lymphadenopathy.
  52. 52. American Joint Committee on Cancer staging for hypopharyngeal carcinoma • T1 Tumor limited to one subsite of hypopharynx and 2 cm or less in greatest dimension • T2 Tumor invades more than one subsite of hypopharynx or an adjacent site, or measures more than 2 cm but not more than 4 cm in greatest diameter without fixation of hemilarynx • T3 Tumor more than 4 cm in greatest dimension or with fixation of hemilarynx • T4a Tumor invades thyroid/cricoid cartilage, hyoid bone, thyroid gland, esophagus, or central compartment soft tissue • T4b Tumor invades prevertebral fascia, encases carotid artery, or involves mediastinal structures.
  53. 53. Treatment
  54. 54. Surgery The mainstay of treatment in advanced cancer of the hypopharynx remains surgery followed by radiation therapy • Patient’s performance status. • Extent of disease. • Laryngeal involvement. • Presence of lymph node metastasis. Only very select patients with tumors of the hypopharynx are amenable to conservation laryngeal surgery.
  55. 55. Contraindications to conservation laryngeal surgery: • Thyroid cartilage invasion. • Involvement of the apex of the pyriform sinus. • Involvement of the postcricoid region. • Impairment of vocal cord motion. Lesions of the postcricoid region, laryngectomy is almost always required.
  56. 56. • Total laryngectomy with partial or total pharyngectomy followed by postoperative radiation therapy are the most common surgical procedures performed for advanced squamous cell carcinoma of the hypopharynx • Preservation of the larynx has been reported to be possible in less than 50% of Small T1 and T2 tumors arising from the medial wall of the pyriform sinus. • Elective neck dissection should be performed at the time of surgery because of the high incidence of bilateral occult cervical metastasis + Rouviere’s node
  57. 57. Surgical reconstruction • Primary closure or skin grafting may be used for small defects (Posterior pharyngeal wall lesions). • The pectoralis major myocutaneous flap or radial forearm free flap may be used for reconstruction of subtotal hypopharyngeal defects. • After total laryngopharyngectomy, a free jejunal flap or a tubed radial forearm free flap provides an excellent method of reconstruction
  58. 58. • In a total laryngopharyngectomy defect where the distal esophageal stump lies inferior to the sternal notch, gastric interposition may be required. 1. Major abdominal surgery. 2. Extensive mediastinal dissection. 3. Operative morbidity is nearly 50%. 4. Mortality rates have been reported to reach 10%.
  59. 59. Chemotherapy and radiation therapy • Early-stage disease  Radiation therapy results comparable to conservation surgical treatment. • Advanced disease  Radiation therapy alone was inferior to surgery combined with postoperative radiation therapy.
  60. 60. • An organ-preservation protocol using chemotherapy is another option for improving results of therapy for advanced disease. • Induction chemotherapy followed by definitive radiation therapy, reserving surgery for salvage. • Tumor response to chemotherapy may need to be taken into account before radiation therapy is chosen instead of surgery.
  61. 61. • The overall prognosis for patients with squamous cell carcinoma of the hypopharynx is poor because most of these patients present at an advanced stage, and many patients succumb to distant disease. Overall, • Patients with late-stage hypopharyngeal carcinoma treated with curative intent have a 5-year survival of approximately 35%.
  62. 62. Thank you