28 Hypopharyngeal Cancer

Peter E. Andersen and Douglas Reh

Primary malignant tumors of the hypopharynx are uncommon, representing only a small fraction of the total cancers diagnosed in the United States. The American Cancer Society (ACS) estimated 8600 new diagnoses of cancer of the pharynx in the United States in 2002, with 2100 deaths from pharyngeal cancer in that same period.1 Because the ACS figures include cases of nasopharyngeal and oropharyngeal as well as hypopharyngeal cancers, these figures are an upper limit of the magnitude of the problem, and actual incidence is, of course, less. Hypopharyngeal cancer is closely associated with laryngeal cancer in terms of its anatomical location as well as its risk factors. These include principally tobacco and alcohol use. Although many different types of malignant tumors can arise within the anatomical boundaries of the hypopharynx, the vast majority of hypopharyngeal cancers are squamous carcinoma. This discussion will focus solely on this histologic type.

The pyriform sinus is the most common site of malignancy in the hypopharynx, followed by the posterior pharyngeal wall and postcricoid region. The most common presenting symptoms in a patient with hypopharyngeal cancer include the presence of a neck mass, throat pain, ipsilateral otalgia, dysphagia, and hoarseness.² Because of the rich lymphatics in this region, there is early spread of the disease to regional lymph nodes. An estimated two thirds of patients have palpable lymph node metastasis on initial evaluation, and almost half of the clinically N₀ patients will be found to have occult cervical lymph node metastasis if elective neck dissection is performed.³ Because of the propensity for regional nodal metastasis, high stage at presentation is common, with ~80% of patients presenting with stage III or IV disease.⁴ The most common sites of nodal metastasis are to the jugular chain of nodes,³ although the retropharyngeal, paratracheal, parapharyngeal, and paraesophageal nodes may also be involved. Survival rates in patients with hypopharyngeal cancers tend to be poor. The disease-free 5-year survival rate has been estimated at 56% in patients with pyriform sinus cancer and 30% in those with cancer of the posterior wall of the hypopharynx.⁵

Initial treatment for hypopharyngeal cancer is beyond the scope of the current discussion; however, it should be noted that multiple methods often are employed to treat hypopharyngeal cancer. Hypopharyngeal cancers have a high risk of recurrence after initial therapy. This has been attributed to the high rate of submucosal extension, including extension into the thyroid cartilage and surrounding tissue. Small-stage lesions or lesions that occur in patients who are unsuitable for more aggressive treatment are often treated with radiotherapy alone. Radiotherapy alone has been reported by Stoeckli et al to have a recurrence rate as high as 59%.⁶ Commonly, patients with cancer of the hypopharynx are treated with combined therapy, either surgical resection followed by radiation therapy or combinations of chemotherapy and radiation therapy given sequentially or simultaneously. Most patients with hypopharyngeal cancer undergo some combination of surgical resection, reconstruction, and radiotherapy/chemotherapy. Conservation surgery may be indicated for T1 and T2 cancers in which the pyriform sinus is solely involved above the apical region. This includes partial laryngopharyngectomy. Supracricoid and hemicricoid laryngopharyngectomy have also been described. These patients also have an extremely high incidence of neck disease; consequently, planned neck dissections are an important part of their surgery.⁷

Evaluation and Work-up of Patients with Recurrent Hypopharyngeal Cancer

Because of the high rates of recurrence in patients treated for hypopharyngeal cancer, salvage surgery and treatment have become an increasingly important aspect in the management of these patients. The remainder of our discussion will focus on the evaluation, work-up, and treatment of patients with recurrent hypopharyngeal cancer.

The aforementioned high recurrence rates necessitate careful follow-up after initial treatment. Consequently, patients are usually monitored very closely through serial examinations. The presenting symptoms in patients with recurrence are essentially the same as those of patients with new-onset hypopharyngeal cancer. The presence of a neck mass is the most common complaint and may be accompanied by throat pain, ipsilateral otalgia, dysphagia, odynophagia, and hoarseness. These and other symptoms should be monitored in patients who are being followed after their initial treatment for hypopharyngeal cancer.

Patients being referred for suspicion of a recurrence need a full and detailed history and physical examination. The history should focus on a careful analysis of the patient’s symptoms. These can be useful in determining the location and extent of the tumor and the patient’s functional status. The past medical history should focus on the location and size of the original tumor, as well as the extent of any neck disease. The consulting head and neck surgeon must know the initial treatment course. These are principally either surgery, radiation, combination surgery and radiation, or concurrent versus sequential chemo- and radiation therapy. If the patient underwent surgical resection of the initial tumor, it is important to obtain the operative note to get details regarding the approach, findings at the time of surgery (including extent of the tumor), and techniques used in the tumor’s excision. Treatment of any neck disease is also important. This will be essential in determining the treatment options for this patient’s recurrence. If the patient underwent radiation therapy, it is also important to obtain the details of the radiation therapy. This includes overall dose, port size, and the time to failure after completion of the therapy. Obviously, these details will be most easily obtainable from the records of the previous treatment rather than from the patient. Those patients who have had a recurrence within a year of their primary radiotherapy are much less likely to be able to be radiated for their recurrence. If the patient underwent chemotherapy, it is important to establish which chemotherapeutic regimens were used. This will be important, not only in determining what can be used for the treatment of the recurrence but also in establishing any comorbidities that may have been caused by the initial therapy. These include renal impairment caused by cisplatin or peripheral neuropathy caused by both cisplatin and docetaxel.

Careful attention should be paid to understanding the patient’s other underlying comorbid conditions. Diseases such as diabetes, coronary artery disease, chronic obstructive pulmonary disease (COPD), and liver disease can significantly impact a patient’s outcome in terms of the existing cancer, as well as the patient’s response and morbidity to treatment. This information will help in determining ideal treatment options. A careful review of the patient’s medications is also important. Certain medications, such as steroids, can significantly impact a patient’s outcome, especially in terms of his or her recovery from surgery. Establishing overall performance status for a patient is another important component of the medical history. This includes an understanding of the patient’s daily functional status, social support, and overall health. It determines the level of medical and social care that the patient will need, both during and after treatment (Table 28.1).⁸ Overall nutritional status is another essential piece of information. If a surgery is being planned, the patient’s nutritional status must be ascertained and any steps must be taken to maximize their overall nutrition prior to surgery and/or any other form of treatment for the cancer.

A detailed review of systems should also be performed as part of the consultation. This may help to establish symptoms consistent with distant metastasis, which will affect treatment decisions.

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