General Principles and Management
Tim J. Kruser
Nitin A. Pagedar
Henry T. Hoffman
Paul M. Harari
INTRODUCTION
Cancers of the hypopharynx and the cervical esophagus share a number of overlapping features with regard to risk factors, epidemiology, management, and treatment outcomes. The anatomy of this region is served by a rich lymphatic network; therefore, presentation with nodal metastases is commonplace. In addition, patients with hypopharynx and cervical esophageal tumors frequently present with advanced-stage disease and harbor medical comorbidities that may limit the feasibility of delivering aggressive cancer care. Therefore, despite therapeutic advances in recent years, oncologic outcomes in these tumors remain relatively poor. Although organ-preservation surgery may be feasible in selected early-stage tumors, surgical management more commonly requires radical surgery such as laryngopharyngectomy or pharyngolaryngoesophagectomy. These procedures result in significant functional impairment, as well as cosmetic changes, and therefore tumors of the hypopharynx and the cervical esophagus are commonly managed with radiation or chemoradiation in an effort to control tumor while preserving organ function.
Cancers of the hypopharynx and the cervical esophagus are commonly considered together, as they share many features, and tumor frequently extends from one anatomic region into the other. Cancers of the hypopharynx accounted for 5.2% of upper aerodigestive malignancies from 2000 to 2008.1 Similarly, cervical esophageal cancer is rare, with only 2 % to 10% of esophageal carcinomas occurring in the cervical location.2 In a recent world-wide study of >4,500 esophagectomy patients, upper esophageal tumors accounted for only 4.1% of the cohort.3 The relative rarity of these tumors lends itself to grouping them together in order to effectively study epidemiology, management strategies, and outcomes. However, randomized control studies specific to tumors of the hypopharynx and/or the cervical esophagus are rare; studies of these cancers are often retrospective, incorporating heterogeneous management strategies spanning many years, and in some cases decades. The relative rarity of these tumors leads to a paucity of large-scale clinical trials data with which to base treatment guidelines.
Cancers of the hypopharynx and the cervical esophagus are commonly associated with tobacco use.4,5 In addition, patients are typically elderly, with dysphagia and weight loss as a result of their tumor burden and/or a poor baseline diet.5,6 These matters complicate management decisions and delivery of effective therapy. Given the complexity of these tumors, the surrounding structures, and frequent patient comorbidities, management of patients warrants multidisciplinary management with evaluation by head and neck, reconstructive, and thoracic surgeons, medical oncologists, radiation oncologists, speech/swallow therapists, nutritionists, and social workers. Despite advances in the treatment of hypopharyngeal and cervical esophageal cancer, the overall outcome in these patients remains poor. Efforts to improve cure rates and reduce treatment-related morbidity, including the incorporation of molecularly targeted agents, remain vital for the future.
Incidence, Etiology, and Epidemiology
In the United States, cancer of the hypopharynx and cervical esophagus account for <10% of the tumors of the upper aerodigestive tract.7 Approximately 1,800 cases of hypopharyngeal cancers are diagnosed each year in the United States.8 Tumors of the cervical esophagus account for 5.3% of all esophageal cancers,7 which equates to roughly 900 of the nearly 17,000 esophageal cancer cases per year in the United States.9 Squamous cell carcinoma (SCC) accounts for 95% of cancers in the hypopharynx and cervical esophagus, and the causative factors for SCC in these locations are shared.
The mean age of patients presenting with hypopharyngeal cancer is 65, with three-fourth of cases occurring in men. More than 90% of patients will report a tobacco history.10 Alcohol consumption potentiates the carcinogenic effects of cigarette smoke; in combination, heavy tobacco and alcohol users are at
up to 100 times elevated risk of developing tumors in the upper aerodigestive tract as compared with nonsmoking, nondrinking individuals. In addition to potentiating the effects of tobacco, a moderate to high consumption of alcohol can put nonsmoking individuals at a higher risk for hypopharyngeal and cervical esophageal cancers (Table 19.1).7,11 Alcohol appears to have a stronger neoplastic effect in the hypopharynx than in the larynx, and dark liquor may carry a higher risk than light liquor.12 In addition to tobacco and alcohol, gastroesophageal reflux, obesity, and achalasia can lead to higher rates of esophageal cancer.
up to 100 times elevated risk of developing tumors in the upper aerodigestive tract as compared with nonsmoking, nondrinking individuals. In addition to potentiating the effects of tobacco, a moderate to high consumption of alcohol can put nonsmoking individuals at a higher risk for hypopharyngeal and cervical esophageal cancers (Table 19.1).7,11 Alcohol appears to have a stronger neoplastic effect in the hypopharynx than in the larynx, and dark liquor may carry a higher risk than light liquor.12 In addition to tobacco and alcohol, gastroesophageal reflux, obesity, and achalasia can lead to higher rates of esophageal cancer.
TABLE 19.1 Odds Ratios for Oral and Pharyngeal Cancers Associated with Alcohol Consumption. Odds Ratios (or) Adjusted for Smoking, Age, and Race | ||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| ||||||||||||||||||||||||||||||||||||||||
As tobacco and alcohol are the major causative agents for tumors of the hypopharynx and cervical esophagus, field cancerization is a common phenomenon in these patients. The wide mucosal exposure to carcinogens results in a field of diseased mucosa characterized by high-grade dysplasia, giving rise to the index hypopharyngeal or cervical esophageal tumor. Therefore, these patients have high rates of synchronous and/or metachronous upper aerodigestive primary tumors. Approximately 10% of patients may be found to have synchronous primary tumors,13 and up to 20% will develop a metachronous second primary tumor. Hypopharyngeal cancer patients have a worse overall survival than other malignancies of the head and neck due to the tendency for advanced disease at presentation.10 In addition, even among survivors of the initial presenting lesion, survivorship is poorer in the following years; the fact that metachronous malignancies are more common in these patients than in other head and neck squamous cell carcinoma (HNSCC) patients contributes to this observation (Fig. 19-1). Counseling patients on smoking cessation can diminish treatment-related side effects, can minimize the risk of subsequent malignancies of the upper aerodigestive tract, and should be emphasized during the initial evaluation of these patients.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
