Hypopharyngeal Cancer Flashcards
Boundaries of the hypopharynx
Hyoid bone to inferior border of the cricoid cartilage
Lies behind and around the larynx
What is the m/c site of hypopharyngeal CA?
Piriform sinus
Hypopharyngeal CA subsites
- Piriform sinus (65-75%)
- Posterior pharyngeal wall
- Postcricoid region (rare, <5%)
What is T4a HP CA?
Moderately advanced local dz, invasion of
- thyroid/cricoid cartilage
- hyoid
- thyroid gland
- central compartment soft tissue
What is T4b HP CA?
Very advanced local dz, invasion of
- prevertebral fascia
- carotid encasement
- mediastinal involvement
What are skip lesions?
Tumors of the HP may extend submucosally resulting in skip lesions
MAN of early HP CA (T1 or T2)
- Single modality Rx:
- -RT (incl both necks) w/ salvage surgery
- -Excision w/ postop RT
- Neck MAN:
- -Elective RT to b/l necks w/ primary
- -Elective IPSI ND w/ primary excision
MAN of advanced HP CA (T3 or T4)
- Multimodality Rx:
- -Chemo/RT w/ salvage surgery for poor response
- Neck MAN:
- -Elective RT to b/l necks
Options of surgery for HP CA
- Partial laryngopharyngectomy
- Combined suprahyoid and lateral pharyngectomy
- TL w/ partial pharyngectomy
- Esophagectomy
- Wookey procedure (turned-in cervical skin flaps)
When do you consider a partial laryngopharyngectomy?
Early T1-T2 piriform CA if tumor involves primarily the medial wall and > 1.5 cm clear from apex
When to perform combined suprahyoid and lateral pharyngectomy?
For early T1-T2 posterior cricopharyngeal wall CA
Includes removal of lateral 1/3 of thyroid cartilage
When to perform TL with partial pharyngectomy?
Most postcricoid primaries
Advanced HP dz
Recurrence
Radiation failures
Complications of gastric pull-up recon
- Anastamosis breakdown/leak (10-37%)
- Abdominal complications
- Cardiopulm complications
- Hypocalcemia
- Tracheobronchial injury
Imp epidemiology of HP CA
- Rare (<5% of HNC)
- 76% male
- 90% smokers
- 77% p/w stage III/IV dz
- 64-90% p/w nodal dz, 40% w/ b/l nodes
- 60% have systemic mets at presentation or f/u
- 5 yr dz survival 33%
What would be an advantage of getting an MRI in a pt w/ HP CA?
-MRI is good to look for invasion of prevertebral fascia
T1 HP CA
Limited to 1 subsite AND <2cm
T2 HP CA
More than 1 subsite or 2-4 cm
T3 HP CA
Fixation of hemilarynx or > 4 cm
What is the Tx for early stage dz (Stage I-II)?
-RT usu (Primary RT is comparable to surgery)
What is the Tx for late stage dz (Stage III-IV)?
- Primary RT is inferior to surg + adjuvant RT
- Chemo/RT is comparable to surg + adjuvant RT
Salvage rates after chemo/RT
25%
- Increases survival from 3.8 to 14 months
- Inc morbidity (fistula rate 75%)
Lymphatic drainage of HP?
- Jugulodigastric nodes (II-IV), sometimes V
- RP nodes (esp posterior pharyngeal wall)
- Inferiorly - paratracheal/paraesophageal nodes
- BILATERAL DRAINAGE COMMON
How should you treat the necks?
- In the 34% of pts who p/w N0 necks, 41% will have occult mets so treat both necks (maybe just IPSI neck for T1 lesions)
- If there is nodal dz, treat both necks
- N0 –> II-IV
- N+ –> I-V
What are the radical open surgeries available for T3-T4 lesions?
- Total laryngopharyngectomy (lesions involving > 2/3 circum of pharynx)
- TL, partial pharyngectomy
Recon
- Pedicled myocutaneous flaps (DP, pec)
- Gastric pullup transposition
- Free flaps (RFFF, ALT, jejunal)
What are the main problems with jejunal free flaps
- Wet voice
- Hypocalcemia
What are the partial open surgeries available for T1-T2 lesions?
Partial pharyngectomy
- Lateral pharyngectomy (cut small part of thyroid lamina)
- Trans-thyroid pharyngotomy
- Trans-hyoid pharyngotomy
- Median labiomandibular glossotomy
May need to combine w/ partial laryngectomy to get margin
