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Oncology

HYPOPHARYNGEAL CANCER

 

Anatomy
The region between the oropharynx above (level of the hyoid bone) and the oesophageal inlet below (lower end of the cricoid cartilage)
3 main components to the hypopharynx: pyriform sinus (70% cancers), posterior pharyngeal wall (20%), or post cricoid (10%)

 

Epidemiology
Usually poorly differentiated and presented late (80% stage 3 or 4 at presentation)
95% malignancies are SCC from mucosal epithelium

 

Presentation
Usually asymptomatic until late
Neck mass- 50% present with this, demonstrating that late presentation common
Sore throat- particularly if well localised, associated with referred ear pain on swallowing
Progressive dysphagia- resulting in significant weight loss
Voice change- hoarseness is late symptom indicative of advanced disease
Upper airway obstruction, a late symptom indicating advanced disease.

 

Investigations
MRI neck and staging CT chest
Image prior to biopsy as this will cause oedema and potentially upstage the disease
Rigid panendoscopy and biopsy under GA- assess size of lesion and potential other primaries

 

Staging
T1: Tumor limited to one subsite of the hypopharynx and 2 cm or less in greatest dimension
T2: Tumor invades more than one subsite of the hypopharynx or an adjacent site, or measures more than 2 cm but 4 cm or less in greatest diameter without fixation of hemilarynx
T3: Tumor measures 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, which includes prelaryngeal strap muscles and subcutaneous fat
T4b: Tumor invades prevertebral fascia, encases carotid artery, or involves mediastinal structures

 

Work up
Nutrition: Many are profoundly malnourished. May require NG or PEG feeding prior surgery
Assess performance status

 

Treatment options
Internal Excision
 “Cold steel” or CO2 laser surgery +/- Robotic aided
External Excision: (with or without flap repair)
 Partial pharyngectomy
 Partial pharyngectomy / partial laryngectomy
 Partial pharyngectomy / total laryngectomy
 Total pharyngo-laryngectomy
 Extended pharyngo-laryngectomy

 

Early stage (I and II) disease
Can be treated with equal effectiveness with surgery or radiotherapy
Generally though surgery is performed (provides prognostic info like peri neural spread) that can guide later radiotherapy
All need prophylactic neck dissection as occult metastases in 30%
If primary tumour in midline then do bilateral neck dissection, otherwise do unilateral
Perform SND if N0 and a MRND if N1

 

Late stage (III and IV) disease
Bulky advanced tumours will usually require circumferential or non- circumferential resection with free flap cover
Palliative care may be only choice if too advanced on presentation for surgery

 

Reconstruction
Pectorals major- difficult to tube
Radial forearm free flap- easy to tube
Free jejunal flap
Gastro- omental free flap
Anterolateral thigh free flap
 
Chemoradiotherapy
Don't do if cartilage invasion- need surgery
Chemotherapy adds 7% survival increase to radiotherapy alone
Usually use Cisplatin
Consider tumour bulk reduction with induction chemotherapy prior to definitive radiotherapy
• Give IMRT where to limit the consequences of wide field irradiation to a large volume

 

Palliative care
Radiotherapy for symptom control
Permanent tracheostomy

 

Author: Johno Breeze

Last updated: 16/04/2015