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 regionCa 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 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 0TISN0M0 Stage IT1N0M0 Stage IIT2N0M0 Stage III T3N0M0 T1,T2,T3N1M0 Stage IVA T4N0M0 T4N1M0 Any TN2M0 Stage IVBAny TN3M0 Stage IVCAny TAny NM1 Adopted from the AJCC staging manual. 6 th 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 ProcedureT stageReconstruction Partial pharyngectomyT1, T2Primary closure Partial laryngopharyngectomyT1,T2,T3Regional or free flap Supracricoid HemilaryngectomyT1,T2,T3Primary 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 T4Gastric 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