carcinoma of hypopharynx

1. Carcinoma of Hypopharynx
Dr. Krishna Koirala
MBBS, MS (ENT-HNS)
2019-02-25

2. Surgical Anatomy of hypopharynx
• Lowermost and 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
– Pyriform Fossa
– Postcricoid area (Pharyngo-oesophageal junction)
– Posterior pharyngeal wall

3. Anatomic extent of hypopharynx

5. • Marginal area:
– Aryepiglottic folds that separate the endolarynx
from medial wall of pyriform sinus bilaterally
– Tumors behave aggressively like hypopharyngeal
cancer

6. Characteristics of Hypopharyngeal cancers
• Late presentation (77.3% manifest with stage III / IV)
• Higher tendency to submucosal extension into esophagus
• Higher incidence of distant metastases
– At the time of diagnosis : 30% have local disease, 60%
locoregional disease, and 10% distant metastases
• Neck node metastasis
– Pyriform sinus : 65-85%
– Posterior pharyngeal wall : 10 -20%
– Postcricoid area : 5-15%

7. Routes of spread of tumors of pyriform fossa

8. Risk Factors
• Plummer Vinson syndrome: Paterson-Brown Kelly
Syndrome, Sideropenic dysphagia
• Alcohol
• Tobacco
• Second primary malignancies (4-8%)
• Chronic irritation from gastroesophageal reflux

9. Clinical Presentation
• Relatively silent than other head and neck cancers
• Average duration of symptoms before presentation :
2-4 mths
• Dysphagia
– Persistent and progressive
– For solids
– Food ‘sticks’ on swallowing

10. • Pain
– Usually lateralized & prominent on swallowing
– May radiate to ipsilateral ear
– Aggravated by eating hot & spicy foods
– Requires investigation in >2-3 weeks
• Hoarseness
– In association with dysphagia/otalgia
– Coarse, raspy, breathy or diplophonic voice

11. • 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

12. 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

13. Ca of postcricoid region Ca of medial wall of L pyriform sinus

14. Ca Rt pyriform sinus with
extention to larynx
Localized tumour of medial wall of R
pyriform sinus

15. Ca R pyriform sinus with transglottic invasion

16. Investigations

17. Hematological
• CBC (Vit B12 & folate)
• Iron stores
• Urea & electrolytes
• LFT
• Serum calcium
• TFT

18. Radiological
• CT scan or MRI before endoscopic evaluation and 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

19. Bulky right pyriform sinus tumor

20. • Barium swallow
– To assess tumor length and rule out primary tumor of
esophagus
– To assess tumor mobility on vertebral column during
deglutition
• PET scan
– Initial assessment in locally advanced disease
– Nodal involvement
– Suspicion of metastatic disease
– Evaluation of an unknown primary site

21. • Abdominal CT scan : rule out liver metastases
• Bone scan : rule out bone metastases
• Triple endoscopy (Panendoscopy)
– Laryngoscopy, bronchoscopy and esophagoscopy
– Used to assist in defining the extent of the tumour
and its histopathology

22. 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

23. Staging of regional lymph nodes
• NX: Regional lymph nodes cannot be assessed
• N0: No regional lymph node metastasis
• N1: Metastasis in a single ipsilateral node ( ≤3 cm at its
greatest dimension)
• N2: Metastasis 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

24. Staging for distant metastasis
• M0: No distant metastasis
• M1: Distant metastasis (eg, lung, mediastinal lymph nodes,
skeletal, hepatic)

25. Stage grouping
Stage Grouping
Stage 0 TIS N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III
T3 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

26. Staging

27. Treatment planning
Important determinants involved
Tumour factors:
Anatomical subsite of tumour origin
Clinical stage
Histological grade
Patient factors:
General condition
Nutritional status
Immune competence
External factors:
Differences in treatment centers
Availability of expertise
Ethnic considerations
Other social factors

28. • Ultimate goals of treatment
– Control of cancer
– Preservation of speech and normal swallowing
– Avoidance of a tracheostomy
• Advanced disease with pharyngolaryngectomy
– Re-establishing anatomic continuity of alimentary
tract
– Restoration of ability to swallow as soon as
possible

29. • Current treatment modalities
– Full course irradiation with surgical salvage
– Surgery alone
– Combination of irradiation therapy with surgery
– Chemotherapy (before surgery or irradiation or in
combination)

30. Curative treatment of hypopharyngeal cancers
Pyriform sinus
Posterior
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

31. Pyriform fossa tumors
• Lesions not extending to apex of fossa, post cricoid
region or posterior wall resected preserving the larynx
• Lesion involving lateral wall of fossa : Partial
pharyngectomy with resection of upper thyroid ala
• Medial wall and hemilarynx resectable by near total
laryngectomy

32. Postcricoid tumors
• Few small tumors <5cm : radical radiotherapy
• Larger recurrent tumours: total laryngopharyngectomy
• Extension into esophagus: esophagectomy

33. 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

34. The neck
• 60% pyriform tumours have +ve neck nodes
• 30-40% uninvolved neck have occult disease
• Treatment determined individually by the stage of
primary and neck

35. • Superficial primary tumor of posterior pharyngeal wall
or lateral wall of pyriform fossa
– Excised orally or with/without use of laser or
through transhyoid pharyngotomy
• Primary tumours of pyriform sinus with limited
extension to adjacent sites of larynx
– Partial laryngopharyngectomy
Surgical treatment

36. • 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

37. Surgical options
Procedure T stage Reconstruction
Partial pharyngectomy T1 , T2 Primary closure
Partial laryngopharyngectomy T1,T2,T3 Regional or free flap
Supracricoid Hemilaryngectomy T1,T2,T3 Primary Closure
Endoscopic CO2 laser resection
T1,T2(possible
T3,T4)
Secondary intention
Total laryngectomy with partial-total
pharyngectomy
T3,T4
Primary closure vs
regional or free flap
Total
pharyngolaryngoesophagectomy
T4 Gastric pull-up

38. Radiation Therapy
• Used as a single modality therapy limited to early
lesions (T1, selected T2)
• Exophytic lesions limited to medial wall of pyriform
sinus
• Elderly, debilitated, advanced lesion refusing surgery
• For palliative treatment

39. Indications for radiotherapy
• Definitive treatment
– Resectable cancer
• Organ preservation
• Adequate function of the laryngopharynx
– Unresectable cancer
• Cancer that involves the prevertebral fascia
and encases the carotid artery

40. 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