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The Dilemma of Treating Hypopharyngeal Carcinoma: More or Less
Hayes Martin Lecture
William I. Wei, MS, FRCS, FRCSE, FHKAM
Arch Otolaryngol Head Neck Surg. 2002;128:229-232.
ABSTRACT
The optimal therapy for hypopharyngeal carcinoma depends on its staging.
For early-stage disease, radiotherapy and surgery achieve similar results.
Radical surgery followed by radiotherapy is applicable in the management of
patients with advanced-stage disease. Chemoradiation aiming to preserve the
larynx can only be performed for selected patients and in well-equipped institutions.
Thorough understanding of pathological behavior of hypopharyngeal carcinoma,
its submucosal tumor extension, and its high propensity to metastasize to
cervical lymph nodes allows head and neck surgeons to choose optimal surgical
treatment. Lymph node status determines the type of neck dissection required
while location and size of the primary tumor determine the extent of resection
and choice of reconstruction procedure. Adequate tumor extirpation with less
extensive and invasive procedures preserving unaffected normal tissue contribute
to more tumor control and less morbidity.
INTRODUCTION
Over the past few decades, there have been many developments in therapeutic
measures for the management of head and neck malignancies. With better imaging
studies in delineating the extent of tumors with improved modalities for delivering
radiation energy, the results of radiotherapy have shown better local disease
control while leading to less damage of vital head and neck organs. More potent
chemotherapeutic agents are now available and their delivery with radiation
may alter the progress of malignancy. Surgical treatment of malignant diseases
in the head and neck region has also progressed. Understanding the mode of
tumor spread both locally and to cervical nodes allows better surgical treatment
options to be delivered. Precise tumor resection can be performed with a laser
while preserving unaffected nearby organs. Radical resection can also be performed
as we have more effective reconstruction methods, aiming at function and form
restoration. However, contemporary head and neck surgeons face a dilemma when
treating hypopharyngeal carcinomas. A choice has to be made whether (1) to
administer more potent chemotherapeutic agents, or less potent; (2) to target
a wider field around the tumor during radiation therapy, or a narrower field;
or (3) to perform more extensive resection followed by reconstruction, or
less extensive resection.
THERAPEUTIC OPTIONS
Primary Tumor
Therapy for hypopharyngeal carcinoma aims to control the tumor locally
and regionally while improving the chances of a disease-free survival. The
functional outcome following treatment is important and the appropriate therapeutic
measure chosen should be "cost-effective" in that the treatment duration should
be short and the associated morbidity minimal.
Choice of therapy for hypopharyngeal carcinoma depends on the extent
of the disease. In general, stage T1 and T2 tumors with no metastases to cervical
lymph nodes are regarded as early tumors, while T3 and T4 tumors and those
with metastases to the neck glands are recognized as advanced tumors. For
early hypopharyngeal carcinoma, surgical resection of the tumor with an adequate
margin or delivery of external radiotherapy produces good results. The choice
between the 2 treatment modalities depends on the expertise of the treating
physician.
For advanced hypopharyngeal carcinoma, radical resection and reconstruction
followed by postoperative radiotherapy was the standard form of therapy in
the 1970s and 1980s.1-2 The reported
survival rates from different centers worldwide ranged from 20% to 48%.3-5 In recent years, various
studies have shown that with chemoradiation, laryngeal preservation is feasible.6 In patients who responded to chemotherapy and were
given postoperative radiotherapy, 60% had their larynx preserved.7 A laryngeal preservation scheme, however, is only
applicable when the patient responds to chemotherapy and completes the entire
treatment regimen. Patients should be compliant in attending regular follow-up
so that appropriate surgical salvage can be administered in a timely fashion
to avoid mortality. Transoral resection of hypopharyngeal carcinoma with a
carbon dioxide laser has been reported to be effective.8
Although its application is primarily for early diseases, it has been used
for large tumors and initial responses were encouraging. This therapeutic
measure is more effective when the hypopharyngeal carcinoma is exophytic and
not invading the laryngeal skeleton.
Cervical Lymph Nodes
The management of lymph nodes in early hypopharyngeal carcinoma has
remained a challenging problem. For patients with clinically negative necks,
Buckley and MacLennan9 found that 36% of neck
nodes on the side of the primary tumor and 27% of contralateral neck glands
contained a metastatic tumor. Most of tumor-bearing nodes were located in
levels II, III, and IV. For patients with clinical palpable necks nodes on
the side of the primary tumor, disease-positive pathological nodes were present
in 37% in the contralateral neck.
Neck nodes in hypopharyngeal carcinoma require some form of treatment
even though they may not be clinically detectable. If surgery is used for
the treatment of the primary tumor, selective neck dissection for levels II,
III, and IV lymph nodes should be performed; if radiotherapy is used, the
radiation field should cover the neck. For clinically positive neck nodes,
radical neck dissection on the side of the lesion is the recommended treatment
and should be performed with resection of the primary tumor. A selective neck
dissection of levels II, III, and IV lymph nodes of the contralateral neck
should be considered when the primary tumor extends toward the midline.
CONCEPTS OF SURGICAL RESECTION FOR THE PRIMARY TUMOR
For the majority of advanced hypopharyngeal carcinomas, radical resection
of the primary tumor with neck dissection, followed by postoperative radiotherapy,
offers a good chance of eradicating the disease.5
A frequently asked question regarding radical resection of the primary tumor
is whether jejunum or stomach is preferred for reconstruction. This could
be answered by going back to basic principles.
The hypopharynx is a cylindrical muscular tube extending from the oropharynx
to the esophagus with the larynx as the anterior wall. The lumen of this vascular
tube is wider in the upper region. Curative resection aims to remove the primary
tumor with an adequate margin, in a 3-dimensional sense, with clearing of
the regional draining lymph nodes. The subsequent reconstruction aims to restore
the continuity of the alimentary tract and the procedure with lowest morbidity
should be chosen. The reconstruction decision method should only be taken
when adequate resection of the primary tumor has been performed. When a partial
pharyngectomy is performed, the defect can be reconstructed with a myocutaneous
flap. When a circumferential pharyngectomy is performed, the defect can be
reconstructed with a free jejunal graft. Following pharyngectomy and esophagectomy,
the stomach might be used for reconstruction. With this plan of management,
our clinical data reported of the 1980s showed a hospital mortality of approximately
9.2% and a local recurrence rate of 14% (Table 1).10
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Table 1. Surgical Treatment Results for Hypopharyngeal Carcinoma, 1983-1990
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The ultimate goal of surgery is to resect enough tumor to effect an
adequate curative resection while removing as little normal tissue as possible,
aiming to reduce mortality and morbidity. This optimal balance can only be
achieved when the surgeon appreciates the pathological behavior of the malignancy.
This behavior in hypopharyngeal carcinoma includes the early and high propensity
of metastasis to the cervical lymph nodes and the extensive submucosal tumor
spread. Submucosal tumor extension must be taken into account during surgery
so that adequate tumor extirpation can be achieved. The distance of submucosal
tumor extension along the longitudinal axis of the hypopharynx, as reported
from different centers, ranges from 10 mm to 20 mm.11-13
To investigate the incidence of submucosal tumor extension in 3 dimensions,
a whole specimen step serial sectioning study was conducted in the early 1990s.
Findings showed that submucosal tumor extension was present in 60% of specimens
and the distance of submucosal spread was greatest in the inferior aspect,
followed by the lateral direction, and then superiorly. On inspecting the
specimens macroscopically, the submucosal tumor extension could be divided
into 3 types. Type 1 were submucosal extensions that had a grossly evident
tumor front. Type 2 submucosal extensions were not obvious macroscopically,
while type 3 included the skipped lesions, ie, the submucosal tumor was separated
from the primary tumor with a bridge of normal mucosa. Most type 2 lesions
were seen in patients who had previous radiation therapy and surgery was performed
for salvage purposes. The distance of submucosal extensions were also more
extensive in this group of patients.10
Other findings included the invasion of thyroid cartilage in 55% of
the specimen and 30% of the thyroid gland. A radial margin of clearance of
over 1 mm has been shown to affect survival, as this implies that the tumor
can be removed clearly from the prevertebral muscle.10
Therefore, based on our results, we recommend that the resection margin in
patients without previous radiation be 15 mm superiorly, 30 mm inferiorly,
and 20 mm laterally. For patients with previous radiation, it should be 20
mm, 40 mm, and 30 mm, respectively. The deep margin under both circumstances
should be greater than 1 mm.
We have used these measurements as our guideline for appropriate resection
margins when performing resections for hypopharyngeal carcinoma. With the
evaluation of the tumor extent before the operation and at the time of resection,
adequate resection of the hypopharynx is performed. Patients who had no preoperative
radiotherapy will be given radiation after operation. Tumor-free margins were
further confirmed by frozen section during operation and appropriate reconstruction
followed. When a partial pharyngectomy was performed for tumor extirpation,
the pharyngeal defect was reconstructed with a patched pectoralis major myocutaneous
flap. When adequate tumor resection resulted in a circumferential pharyngeal
defect, a segment of jejunum was transferred to the neck for reconstruction.
The jejunal vessels were joined to the neck vessels using microvascular techniques.
The free jejunal graft used for reconstruction has been shown to tolerate
postoperative radiotherapy if required.14
When the hypopharyngeal tumor extends inferiorly to affect the cervical
esophagus, tumor extirpation to achieve an adequate lower resection margin
will include the removal of the esophagus. The resection will become a pharyngolaryngoesophagectomy
and reconstruction can be achieved with mobilization of the stomach to the
neck for a pharyngogastric anastomosis. This is a 1-stage operation, removing
the organs that might harbor malignant disease; there is only 1 anastomosis.
The procedures of resection and reconstruction, however, traverse 3-body compartments,
delivering significant trauma to patients who are frequently elderly, chronic
smokers, drinkers, and nutritionally deprived. Whenever there is a complication,
the associated morbidity may become significant and lead to hospital mortality.15 The operation, however, when successfully performed,
will invariably relieve distressing dysphagia and long-term functional results
will be acceptable.16
This operation has been performed on 317 patients in the Department
of Surgery at Queen Mary Hospital, University of Hong Kong Medical Centre,
China, from 1966 to 1995.17 The operation was
performed for extensive laryngeal carcinoma in the early years, and recently
has been primarily for patients with carcinoma arising from the lower hypopharynx
and cervical esophagus. The operation is performed with the patient in a supine
position. While resection of the primary tumor in the neck, with or without
radical neck dissection, is performed, a second surgical team simultaneously
prepares the stomach in the abdomen. The esophagus is mobilized transhiatally
by blunt dissection and removed with the primary tumor and neck dissection
specimen. The stomach is then brought up to the neck through the orthotopic
route and anastomosed to the oropharynx. When the cervical esophagus extends
to affect the trachea, a manubrium resection can be performed to allow resection
of the trachea at a lower level and a terminal tracheostome can be constructed
over the anterior chest wall.
Since we began performing this operation, hospital mortality has decreased
from 31% to 9% and anastomotic leakage rate has been reduced to 9% from 22%.
Reports from more than 10 patients published over the last 30 years indicate
that overall hospital mortality is approximately 16%.17
Reported complication rates are approximately 60% and most complications are
minor. Major complications associated with this operation are vascular injuries
and damage to the posterior tracheal wall. When blunt dissection of the esophagus
tears a small artery, it usually contracts and does not give rise to serious
problems. The bleeding, however, can be severe when the azygos vein is damaged
during blunt dissection. Under these circumstances, immediate thoracotomy
is necessary for hemostasis. Injury to the upper part of the posterior tracheal
wall can be repaired through the neck while a torn posterior tracheal wall
in lower trachea has to be repaired immediately with a thoracotomy. Accidental
leakage at the pyrolomyotomy site can be closed with a loop of jejunum.18
Improved outcomes associated with the operation may be the result of
patient selection, prompt management of the complications, and some modifications
in surgical technique. Instead of blunt dissection of the esophagus, endoscopic
mobilization under thoracoscope has been used in recent years.19
Precise ligation of vessels and sharp dissection of tissue have also been
performed under direct vision. Furthermore, to reduce tension at the pharygngogastric
anastomosis, apart from removing shoulder support and mobilizing the posterior
pharyngeal wall up to the nasopharynx, the incision over the anterior wall
of the stomach should be done in a "T" shape fashion. This moves the anterior
gastric wall toward the lateral aspect where tissue tension is the greatest.
The lowered wound over the anterior wall of the stomach can still meet the
mobile tongue base. Despite all these technical modifications, the surgical
insult of this operation is significant and should only be performed for adequate
tumor extirpation, not for the convenience of using the stomach for reconstruction.
For patients with small leakages at the pharyngogastric anastomosis,
conservative management can be used successfully. For any substantial leakage,
early construction of a pharyngostome is essential to prevent further contamination
of the neck wound and mediastinum. The stomach wall should be everted to suture
to the neck skin. When the inflammation subsides, the pharyngostome can be
closed with a pectoralis major myocutaneous flap at a second stage.
For the past decade, we have managed hypopharyngeal carcinoma surgically
with the concepts presented. We resect adequately and then reconstruct using
the procedure associated with the lowest morbidity. Our results have shown
improvement over time. Mortality and morbidity have been reduced and, more
important, local tumor control has improved (Table 2). These results suggest that surgery and postoperative radiotherapy
have been effective. The survival rate, however, has remained unchanged as
patients developed distant metastasis and second primary tumors for which
prompt salvage may not be applicable (Table
3).
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Table 2. Surgical Treatment Results for Hypopharyngeal Carcinoma, 1993-2000
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Table 3. Compared Results of Radical Surgery for Hypopharyngeal Carcinoma*
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In summary, for early hypopharyngeal carcinoma and for some patients
with advanced disease, we are doing less while curing more. For those requiring
resection, less but adequate tumor extirpation followed by appropriate reconstruction
leads to more favorable outcomes.
AUTHOR INFORMATION
Accepted for publication December 5, 2001.
This study was presented as the 2001 Hayes Martin Lecture at the annual
meeting of the American Head and Neck Society, Palm Desert, Calif, May 15,
2001.
Corresponding author and reprints: William I. Wei, MS, FRCS, FRCSE,
FHKAM, Department of Surgery, University of Hong Kong Medical Centre, Queen
Mary Hospital, Pokfulam Road, Hong Kong Special Administrative Region, China
(e-mail: hrmswwi{at}hkucc.hku.hk).
From the Department of Surgery, University of Hong Kong Medical Centre,
Queen Mary Hospital, China.
REFERENCES
| |
1. Arriagada R, Eschwege F, Cachin Y, Richard JM. The value of combining radiotherapy with surgery in the treatment of
hypopharyngeal and laryngeal cancers. Cancer. 1983;51:1819-1825.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
2. Mirimanoff RO, Wang CC, Doppke KP. Combined surgery and postoperative radiation therapy for advanced laryngeal
and hypopharyngeal carcinomas. Int J Radiat Oncol Biol Phys. 1985;11:499-504.
WEB OF SCIENCE
| PUBMED
3. Johansen LV, Grau C, Overgaard J. Hypopharyngeal squamous cell carcinoma—treatment results in 138
consecutively admitted patients. Acta Oncol. 2000;39:529-536.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
4. Stoeckli SJ, Pawlik AB, Lipp M, Huber A, Schmid S. Salvage surgery after failure of nonsurgical therapy for carcinoma
of the larynx and hypopharynx. Arch Otolaryngol Head Neck Surg. 2000;126:1473-1477.
FREE FULL TEXT
5. Hoffman HT, Karnell LH, Shah JP, et al. Hypopharyngeal cancer patient care evaluation. Laryngoscope. 1997;107:1005-1017.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
6. Zelefsky MJ, Kraus DH, Pfister DG, et al. Combined chemotherapy and radiotherapy versus surgery and postoperative
radiotherapy for advanced hypopharyngeal cancer. Head Neck. 1996;18:405-411.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
7. Adelstein DJ, Saxton JP, Lavertu PI, et al. A phase III randomized trial comparing concurrent chemotherapy and
radiotherapy with radiotherapy alone in resectable stage III and IV squamous
cell head and neck cancer: preliminary results. Head Neck. 1997;19:567-575.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
8. Steiner W, Ambrosch P, Hess CF, Kron M. Organ preservation by transoral laser microsurgery in piriform sinus
carcinoma. Otolaryngol Head Neck Surg. 2001;124:58-67.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
9. Buckley JG, MacLennan K. Cervical node metastases in laryngeal and hypopharyngeal cancer: a
prospective analysis of prevalence and distribution. Head Neck. 2000;22:380-385.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
10. Ho CM, Ng WF, Lam KH, Wei WI, Yuen PW. Submucosal tumor extension in hypopharyngeal cancer. Arch Otolaryngol Head Neck Surg. 1997;123:959-965.
FREE FULL TEXT
11. Hiroto I, Nomura Y, Sueyoshi K, Mitsuhashi S, Ichikawa A, Kurokawa H. Pathological studies relating to neoplasms of the hypopharynx and the
cervical esophagus. Kurume Med J. 1969;16:127-133.
PUBMED
12. Harrison DFN. Pathology of hypopharyngeal cancer in relation to surgical management. J Laryngol Otol. 1970;84:349-366.
PUBMED
13. Davidge-Pitts KJ, Mannel A. Pharyngolaryngectomy with extrathoracic esophagectomy. Head Neck Surg. 1983;6:571-574.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
14. Wei WI, Lam LK, Yuen PW, Kwong D, Chan KW. Mucosal changes of the free jejunal graft in response to radiotherapy. Am J Surg. 1998;175:44-46.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
15. Lam KH, Choi TK, Wei WI, Lau WF, Wong J. Present status of pharyngogastric anastomosis following pharyngolaryngo-oesophagectomy. Br J Surg. 1987;74:122-125.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
16. Wei WI, Lam KH, Choi S, Wong J. Late problems after pharyngolaryngoesophagectomy and pharyngogastric
anastomosis for cancer of the larynx and hypopharynx. Am J Surg. 1984;148:509-513.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
17. Wei WI, Lam LK, Yuen PW, Wong J. Current status of pharyngolaryngoesophagectomy and pharyngogastric
anastomosis. Head Neck. 1998;20:240-244.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
18. Wei WI, Lam KH, Lau WF, Choi TK, Wong J. Salvageable mediastinal problems in pharyngolaryngo-esophagectomy and
pharyngogastric anastomosis. Head Neck. 1988;10(suppl):S60-S68.
19. Law SYK, Fok M, Wei WI, et al. Thoracoscopic esophageal mobilization for pharyngolaryngoesophagectomy. Ann Thorac Surg. 2000;70:418-422.
FREE FULL TEXT
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