H&N evaluation and management of hypopharyngeal carcinoma Flashcards
What risk factors are associated with hypopharyngeal carcinoma?
● Tobacco smoking ● Alcohol use ● Chewing tobacco ● Male sex ● Fifth to seventh decade of life ● Plummer-Vinson syndrome or Patterson-Brown-Kelly syndrome ● Black race
What syndrome with the triad of hypopharyngeal/
esophageal webs, glossitis, and iron deficiency
anemia can cause an increased risk of cervical
esophageal and hypopharyngeal cancer, especially
in nonsmoking women from the United States,
Wales, or Sweden in their third to fifth decade of life?
Plummer-Vinson syndrome
Tumors in which hypopharyngeal subsite(s) are
associated with Plummer-Vinson syndrome?
Postcricoid region
Approximately what percentage of hypopharyn-
geal tumors are squamous cell carcinoma?
95%
Describe three of the most common nonepithelial
tumors that form within the hypopharynx.
● Adenocarcinoma
● Lymphoma
● Sarcoma
Where do adenocarcinomas of the hypopharynx
arise?
Minor salivary glands or ectopic gastric mucosa
What pathologic growth characteristics of hypo-
pharyngeal cancer can make assessment of the
primary tumor challenging?
● Submucosal spread
● Skip lesions
● Multifocal disease
What is the risk of finding a second primary tumor
in a patient with hypopharyngeal cancer?
Up to 18%
What are the most common initial symptoms in patients with hypopharyngeal cancer?
● All stages: Dysphagia, neck mass, sore throat
● Early stage (I/II): Gastroesophageal reflux, sore throat,
dysphagia
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● Advanced stage (III/IV): Neck mass, shortness of breath,
dysphagia, odynophagia, referred otalgia, hemoptysis,
gastroesophageal reflux, hoarseness
Approximately what percentage of hypopharyngeal tumors manifest at advanced stage (stage III– IV)?
70 to 75%
Explain why patients with hypopharyngeal tumors,
particularly those located in the pyriform sinus,
develop referred otalgia.
Sensory fibers from the superior laryngeal nerve (particularly the internal branch) and Arnold nerve both synapse within the jugular ganglion.
Why is in-office flexible endoscopy imperative in
any patient with suspected hypopharyngeal
cancer?
It is essential to evaluate the larynx to assess the presence
of laryngeal invasion, cricoarytenoid joint fixation, and/or
recurrent laryngeal nerve involvement.
During flexible endoscopy, what maneuver can
allow improved visualization of the pyriform sinuses and postcricoid space?
Asking the patient to puff out the cheeks or perform a
Valsalva maneuver
What signs are suggestive of hypopharyngeal
cancer on flexible endoscopy?
● Mucosal fullness ● Ulceration ● Pooling of secretions ● Hyperkeratotic lesions ● Erythematous or friable lesions
Aside from pathologic staging, what diagnostic
imaging modalities are most commonly used for
the workup of hypopharyngeal cancer, and what
advantages do they provide for this subsite in
particular?
● MRI: Staging accuracy is 85%; better at detecting
submucosal spread
● CT with contrast: Best for assessing cartilage and bone
invasion
● PET/CT: Recommended for stage III/IV disease; 10% of
patients have distant metastatic disease; identification of
an unknown primary; primary staging
Note: At minimum, a chest X-ray is recommended to
evaluate pulmonary metastases.
During the workup for hypopharyngeal cancer,
what test is occasionally ordered to work up
second primaries in the esophagus?
Barium swallow (not an imaging modality of choice)
What additional test should be ordered for any patient with hypopharyngeal cancer if the treat-
ment plan includes partial laryngeal surgery or
conservative hypopharyngectomy?
PFTs
Describe T1–3 hypopharyngeal tumor staging
according to the AJCC, 7th edition.
● T1: Limited to one subsite of hypopharynx and/or ≤ 2 cm
● T2: One or more subsites of hypopharynx or an adjacent
site or measures > 2 cm and < 4 cm without fixation of the
hemilarynx
● T3: > 4 cm or with fixation of the hemilarynx or extension
to the esophagus
Describe the criteria for a T4a hypopharyngeal
tumor.
Moderately advanced local disease: Invades thyroid/cricoid cartilage, hyoid bone, thyroid gland, or central compartment soft tissue (prelaryngeal strap muscles and subcutaneous fat)
Describe the criteria for a T4b hypopharyngeal
tumor.
Very advanced local disease: Invades prevertebral fascia,
encases carotid artery, or involves mediastinal structures
Which head and neck aerodigestive tract primary
site has the lowest 5-year survival rate?
Hypopharynx (20 to 47%)
What is the most common cause of mortality in
patients with hypopharyngeal cancer?
● Locoregional recurrence
● Distant metastases (bone, lungs, liver), second primary
tumors, comorbid disease
What clinical factors are associated with poor
prognosis in hypopharyngeal cancer?
● Increasing age
● Male sex
● Black ethnicity
● Poor performance status (ECOG or Karnofsky)
● Traditional risk factors for head and neck cancer
What tumor specific factors are associated with
improved prognosis in hypopharyngeal cancer?
● Primary tumor located on the aryepiglottic fold or medial
wall of the pyriform sinus
● Low T or N stage, early overall stage
● Smaller primary tumor volume
Describe the adverse features highlighted by the
NCCN ( 2013) for hypopharyngeal cancer.
● Extracapsular nodal spread ● Positive surgical margins ● pT3 or pT4 ● N2 or N3 nodal disease ● Perineural invasion ● Vascular embolism
What primary treatment modalities does the
NCCN (2013) recommend for the management of
most T1N0 and select T2N0 (not requiring total
laryngectomy) tumors?
● Definitive radiation therapy
● Partial laryngopharyngectomy (open or endoscopic) with
ipsilateral or bilateral neck dissection as indicated
● No adverse features → surveillance
● Extracapsular spread ± positive margin → chemoradiation
therapy
● Positive margins → re-excision or radiation therapy
● Other risk features → radiation therapy ± chemotherapy
● Multimodality clinic trials
What primary treatment modalities does the
NCCN (2013) recommend for the management of selected T2N0 (those requiring total laryngec-
tomy), T1N + , T2–3 any N (if total laryngectomy is required)?
● Induction chemotherapy
● Complete response → radiation therapy ± chemotherapy
● Partial response → chemoradiation therapy
● < partial response → surgery
● No adverse features → radiation therapy
● Extracapsular spread ± positive margin → chemoradiation
therapy
● Other risk features → radiation therapy ± chemotherapy
● Laryngopharyngectomy + neck dissection (includes level
VI)
● No adverse features → surveillance
● Extracapsular spread ± positive margin → chemoradiation
therapy
● Other risk features → radiation therapy ± chemotherapy
● Concurrent chemoradiation therapy (cisplatin)
● Multimodality clinical trial
What are the options available for managing T4a (any N) hypopharyngeal tumors according to the
NCCN (2013)?
● Surgery + neck dissection (preferred) → adjuvant radia-
tion therapy ± chemotherapy
● Induction chemotherapy
○ Complete response → radiation therapy ± chemotherapy
○ Partial response → chemoradiation therapy
○ < Partial response → surgical salvage + neck dissection
as indicated → radiation therapy ± chemotherapy
● Concurrent chemoradiation therapy
● Multimodality clinical trials
What levels should be addressed in an elective
neck dissection for hypopharyngeal cancer?
Select neck dissection levels II–IV with inclusion of level VI in
pyriform apex tumors and retropharyngeal lymph nodes in
pharyngeal wall tumors
For patients undergoing surgical treatment for
hypopharyngeal squamous cell carcinoma, what is
the recommended extent of therapeutic neck
dissection of the clinically N + ipsilateral neck?
Comprehensive neck dissection including levels I-V and
inclusion of level VI with pyriform apex tumors and retropharyngeal lymph nodes with pharyngeal wall tumors
What are the most common surgical approaches
used for the management of hypopharyngeal
tumors?
● Laryngeal conservation approach (T1, T2, and some T3
tumors):
● Partial pharyngectomy: Lateral pharyngotomy, partial
pharyngectomy via lateral pharyngeal approach, anterior
transhyoid pharyngotomy
● Partial laryngopharyngectomy
● Supracricoid hemilaryngectomy
● Transoral laser microsurgery
● Total laryngectomy with partial/total pharyngectomy (T3,
T4)
● Total pharyngo-laryngo-esophagectomy (T4)
An open partial pharyngectomy can be considered
in patients with T1 or T2 hypopharyngeal tumors
of the pyriform sinus. What are the contra-
indications to this procedure?
● Tumor extension to more than one wall of the pyriform
sinus
● Involvement of the pyriform apex
● Involvement of the larynx including the medial wall of the
pyriform sinus
An open partial laryngopharyngectomy combines a classic hemilaryngectomy with a partial pha-
ryngectomy and is used for what specific hypo-
pharyngeal tumors?
Medial wall pyriform sinus tumors
What are the advantages of transoral laser microsurgery and endoscopic resection of hypopharyngeal tumors when compared with open approaches?
● No tracheostomy ● No reconstruction ● Preservation of the suprahyoid musculature improving postoperative swallowing ● Earlier return to an oral diet ● Shorter hospital stay
What is the surgical treatment of choice for most T3 and T4 hypopharyngeal squamous cell carcinomas?
Total laryngectomy with partial or total pharyngectomy
with neck dissection as indicated by clinical nodal disease
What are the contraindications for conservation
laryngeal surgery in patients with hypopharyngeal
malignancy?
● Thyroid or cricoid cartilage invasion
● Pyriform apex involvement
● Postcricoid region involvement
● Impaired vocal cord mobility
What is the recommended definitive radiation
therapy for primary hypopharyngeal cancer and gross lymphadenopathy according to the NCCN
(2013)?
● Conventional fractionation: 66 to 74 Gy, daily (Monday
through Friday) for 7 weeks
● Altered fractionation:
○ Accelerated: 6 fractions/week, 66 to 74 Gy to gross
disease, 44 to 64 Gy to subclinical disease
○ Concomitant boost accelerated radiation therapy:
72 Gy/6 weeks with a boost given as a second daily
dose for the last 12 days of treatment
○ Hyperfractionation: 81.6 Gy, twice daily (Monday
through Friday) for 6 weeks
What dose of radiation is generally recommended
for subclinical hypopharyngeal nodal disease when
given as definitive management?
44 to 64 Gy
What dose of radiation is recommended for
hypopharyngeal cancer when given as primary
concomitant chemoradiation?
Conventional fractionation:
● Gross disease: ≥ 70 Gy
● Subclinical disease: 44 to 64 Gy
What does the NCCN (2013) recommend for
adjuvant radiation therapy after primary surgical
intervention for hypopharyngeal cancer?
Conventional fractionation: 60 to 66 Gy to the primary and
gross nodal disease, 44 to 64 Gy to occult nodal disease for
6 weeks
What chemotherapy regimen is recommended for concurrent chemoradiation therapy in hypopharyngeal squamous cell carcinoma?
Cisplatin: 100 mg/m2 every 3 weeks in three doses
What chemotherapy regimen is recommended for induction chemotherapy in patients with hypopharyngeal cancer?
Cisplatin and 5-FU (up to three cycles)
What is the reconstruction of choice after an open conservation procedure for an early stage hypo-
pharyngeal tumor?
Primary closure. Exception is for endoscopic tumor resection → healing by secondary intention
What are the reconstructive options for circumferential defects of the hypopharynx?
● Tubed fasciocutaneous free flap
● Gastric transposition (gastric “pull-up”)
● Colonic transposition
● Jejunal free flap
In terms of function, what are the differences
between chemoradiation (organ sparing) therapy
and surgery with adjuvant radiation therapy for
hypopharyngeal cancer?
Although data are sparse, there are no studies that have
shown a clear advantage in terms of function for one
treatment algorithm over the other. Eating, aesthetics, and
speech are comparable in most studies.
What factors correlate with higher complication
rate in patients with hypopharyngeal cancer
treated with laser excision?
Surgeon inexperience
Tumor size
Diagnosis of diabetes mellitus
What are the most common complications associated with CO2 laser excision of hypopharyngeal carcinoma?
● Hemorrhage (8% in one series)
● Pneumonia (6%)
● Fistula (1%)
● Less commonly local infection and dyspnea
