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Hypopharyngeal
malignancy
And its management
By drtbalu
drtbalu
www.drtbalu.co.in
1/1/2009
Hypopharyngeal malignancy
By
Posteriorly the Hypopharynx is separated from the prevertebral fascia (this fascia
covers the prevertebral muscles) by a thin layer of areolar tissue. This potential
space is known as retropharyngeal space.
1. The constrictor muscles are thin, especially the superior constrictor. Hence
there is very little resistance to tumor spread via this area.
2. At the junction of inferior constrictor and cricopharyngeas muscle there is
another area of weakness (Killian’s dehiscence).
3. In the lateral pharyngeal wall, where the middle and inferior constrictors
join just below the hyoid bone, there is another weak area.
4. The lateral pharyngeal wall contains the thyrohyoid membrane, through
which the superior laryngeal vessels traverse. This area may facilitate direct
lateral extension of the tumor.
Marginal area: This is formed by aryepiglottic folds bilaterally and bridges the
larynx and Hypopharynx. This area is usually considered to be part of Supraglottis.
Nerve supply: The sensory nerve supply to Hypopharynx is via the internal branch
of the superior laryngeal nerve which runs along the anterior wall of pyriform fossa.
Referred Otalgia from Hypopharyngeal growth is due to this nerve.
Etiology:
1. Smoking
2. Alcohol consumption
3. Combination of smoking and alcohol consumption multiplicative
4. Post cricoid and esophageal cancers may be influenced by dietary factors
5. Exposure to welding fumes
6. Radiation exposure
7. Exposure to polycyclic hydrocarbons
8. Deficiency of DNA repair mechanisms commonly associated with Xeroderma
pigmentosa, Bloom’s syndrome, and Fanconi anaemia may predispose to
Hypopharyngeal malignancy.
It is a potential space that lies on either side of the larynx. They are two in number.
It is shaped like a pyramid with the base pointing above and the apex below. They
belong to the Hypopharyngeal area of the pharynx. It has two parts; the shallow
upper part and a deeper lower part.
Boundaries: The pyriform fossa is bounded laterally by the mucosa covering the
lamina of the thyroid cartilage. Medially it is bounded by the aryepiglottic fold and
arytenoid cartilages above and the cricoid cartilage below. Superiorly it is bounded
by the lateral glosso epiglottic fold (Pharyngoepiglottic fold), inferiorly it continues
with the oesophagus.
Features of pyriform fossa:
1. In early stages of pyriform fossa growth, patients rarely seek help because it
just presents with sticky sensation in the throat. Depending on the rate of
progression of growth, Dysphagia may eventually occur. Dysphagia initially
starts off for solid foods and eventually the patient finds it difficult to
swallow even liquids.
2. Hoarseness of voice: Possibly due to secondary laryngeal invasion /
involvement of recurrent laryngeal nerve due to post cricoid extension.
3. Neck masses due to nodal metastasis. Hypopharynx is richly supplied with
lymphatics, hence early metastasis to cervical nodes is common.
4. Odynophagia is also one of the presenting features of pyriform fossa growth.
5. Patients are usually under nourished because of Dysphagia
6. Referred Otalgia
7. Unusual symptom can occur rarely in pyriform fossa tumors
8. Since pyriform fossa is a distensible space, the tumor will have to enlarge to a
large size to become symptomatic.
1. The tumor may spread medially to involve the larynx. The vocal cord may
become fixed due to involvement of cricoarytenoid muscles.
2. Lesions in lateral pyriform fossa may spread over the mucosal surface and
extend superiorly along the lateral pharyngeal wall.
3. They may grow posteriorly to involve the posterior wall of Hypopharynx and
may even reach the opposite pyriform fossa (Horse shoe growth).
4. Tumors of lateral wall of pyriform fossa may exit laterally through
thyrohyoid membrane, presenting itself as a lateral neck mass. This should
be differentiated from cervical neck node metastasis.
Figure showing routes of spread from pyriform fossa
Thyroid gland may be involved if the tumor spreads directly through the thyroid
cartilage, or from the tumor exiting the larynx through the thyrocricoid membrane
more posteriorly.
Post cricoid growth:
Anatomy: Post cricoid region includes mucosa and submucosa extending from the
inferior aspect of arytenoids to the bottom of cricoid cartilage.
Post cricoid tumors account for nearly 20% of Hypopharyngeal malignancy. This
area may be commonly involved by tumors spreading from the apex of pyriform
fossa, or it may be a separate lesion on its own. Tumors involving this area may
remain asymptomatic until they become extremely large compromising swallowing.
Tumors of post cricoid area are prone for circumferential growth.
1. Present late
2. Carries poor prognosis as nutritional status of the patient is compromised
3. This area is very rich in lymphatics and vascular network making metastasis
as the order of the day
4. Very common in females (tends to affect them very early in their life)
Etiology:
Diagnosis:
Indirect laryngoscopy is one way of examining the larynx and its surrounding
structures. It will give a rough idea about the size and extent of the tumor mass.
CT scans:
1. CT scans are useful in delineating tumor extent.
2. It also helps in assessing tumor involvement of thyroid cartilage.
3. It helps to evaluate cricoid cartilage invasion.
4. Tongue base involvement.
5. Cervical nodal metastasis can be clearly assessed.
6. Contrast CT help in accurate assessment of nodal metastasis.
Histology:
The staging system used is derived from the American Joint Committee on Cancer.
This was updated in 2002.
Primary tumor:
(Subsites include pyriform fossa, postcricoid area, and posterior pharyngeal wall)
Regional Nodes:
N2a: Metastasis to a single ipsilateral node (size more than 3 cm and less than 6
cm in the greatest dimension)
N2b: Metastasis to multiple ipsilateral nodes but none of them more than 6cm in
the greatest dimension
N2c: Metastasis to bilateral nodes / contralateral nodes (none of them more than
6 cm in the greatest dimension)
N3: Metastasis to cervical node (size more than 6cm in the greatest dimension)
Distant metastasis:
o T3, N0, M0
o T1, N1, M0
o T2, N1, M0
o T3, N1, M0
Stage IVA
o T4a, N0, M0
o T4a, N1, M0
o T1, N2, M0
o T2, N2, M0
o T3, N2, M0
o T4a, N2, M0
Stage IVB
o T4b, any N, M0
o Any T, N3, M0
Stage IVC - Any T, any N, M1
Biopsy from the lesion should be taken at multiple sites along the edge of the mass.
Stage III Surgery and post op Surgery and post op RT Surgery and post op RT
RT
Stage IV Surgery and post op Surgery and post op RT Surgery and post op RT
RT
Inclusion criteria for primary radiotherapy:
If a tumor does not fulfill these criteria, then the patient should be submitted to
surgery if age and general condition are favorable.
It should also be accepted that radiotherapy when used for small volume disease is
an excellent form of radical therapy. It has also the added advantage of avoiding
laryngectomy.
The total prescribed doses used for primary radiotherapy are 70-72 Gy. Prescribed
doses for postoperative regimens are 60-66 Gy, depending on the pathologic margin
status. The dose per fraction in head and neck tumors should be 200 cGy when daily
radiotherapy is used alone. Dose reductions to 180 cGy or less (ie, 120 cGy twice a
day) can be used if the fractionation schedule is altered or radiation is combined
with chemotherapy. When IMRT is used, these doses can be delivered by
sequentially reducing the volume of irradiation, as has been done with traditional
nonconformal techniques. With this serial cone-down technique, more conventional
radiotherapy doses per fraction are used.
Radiotherapy regimens:
Partial Laryngopharyngectomy:
Tumors that arise from the medial wall of pyriform fossa with limited extension to
the aryepiglottic folds can be managed by this procedure. Invasion of thyroid
cartilage is a contraindication for this surgical procedure.
Procedure:
Total pharyngolaryngectomy:
Procedure:
1. The larynx and pharynx are mobilized by dissection medial to the carotid
sheath on each side
2. The superior thyroid pedicle are identified and divided on both sides.
3. Inferior thyroid artery on the side of the tumor is also divided.
4. In case of post cricoid tumors both lobes of thyroid gland should be excised
in continuity with the primary mass
5. Trachea is divided at the level of 4th tracheal ring and a permanent
tracheostome is fashioned.
6. Upper end of oesophagus is palpated to identify the lower end of the tumor.
7. Three cm below the palpated point vicryl stay sutures are placed through
esophageal muscular wall and the esophagus is divided immediately below it.
8. Pharynx is divided at its upper end.
9. Wound is washed, and hemostasis is obtained.
10. Pharyngeal repair may be completed by using a free jejunal transfer
Block neck dissection can be resorted to for clearing involved neck nodes.
Because of its size and frequent association with enlarged nodes, tumors of posterior
pharyngeal wall do not do well with radiotherapy.
Procedure:
1. Age: The survival rate usually declines as the age increases. However, 50%
or more of the patients who present when younger than 40 years (1-3%) have
stage IV disease.
2. Sex: Women usually present with earlier-stage disease and have a higher
survival rate after therapy.
3. Karnofsky performance score: Patients with a poor Karnofsky performance
score (KPS) usually have poorer outcome due to weight loss, cachexia,
malnutrition, and anemia.
4. Tumor-related factors that influence prognosis include the following: