Squamous cell carcinoma of the hypopharynx--analysis of treatment results

Incidence and complications of hypothyroidism postlaryngectomy: A systematic review and meta-analysis

BACKGROUND

Hypothyroidism is common postlaryngectomy and is associated with laryngectomy-specific complications. The objective of this study is to determine the incidence and predictors of hypothyroidism postlaryngectomy and its associated complications.

METHODS

Systematic review, data extraction, and meta-analyses were performed following the PRISMA protocol. Six databases were searched for studies reporting on postlaryngectomy thyroid status with incidence, risk factors, management, or complications.

RESULTS

Fifty-one studies with 6333 patients were included. The pooled incidence of postlaryngectomy hypothyroidism is 49% (CI 42%-57%). Subgroup analysis showed postlaryngectomy hypothyroidism rates significantly correlated with hemithyroidectomy and radiotherapy. Patients who underwent laryngectomy, hemithyroidectomy, and radiotherapy had a 65% (CI 59%-71%) rate of hypothyroidism; laryngectomy and hemithyroidectomy 46% (CI 33%-60%); laryngectomy and radiotherapy 26% (CI 19%-35%); and laryngectomy alone 11% (CI 4%-27%) (p < 0.001).

CONCLUSIONS

Laryngectomized patients with partial thyroidectomy or radiation therapy are at significant risk of postoperative hypothyroidism. Evidence-based protocols for early detection and (prophylactic) treatment should be established.

Long-Term Survival of Patients After Total Pharyngolaryngoesophagectomy With Gastric Pull-Up Reconstruction for Hypopharyngeal or Laryngeal Cancer Invading Cervical Esophagus

OBJECTIVES

Hypopharyngeal and laryngeal cancers are aggressive and usually diagnosed at advanced stage with esophagus invasion. Total pharyngolaryngoesophagectomy with gastric pull-up reconstruction has been a common surgery for these cancers but long-term outcomes are still questionable. This study aimed to investigate short-term and long-term outcomes of patients who underwent this surgery.

METHODS

Patients with hypopharyngeal or laryngeal cancer invading cervical esophagus who underwent total pharyngolaryngoesphagectomy with gastric pull-up between 2012 and 2016 was included and followed up until 2021. Short-term outcomes were complications and long-term outcomes were overall survival (OS) and disease-free survival (DFS).

RESULTS

Fifty patients were included with a mean age of 60.3 years and 94% were male. Pyriform fossa was the most common primary site of tumor (50%), followed by posterior hypopharyngeal wall (18%) and postcricoid region (18%). Mean operating time, postoperative oral intake and hospital stay was 363.1 ± 43.6 minutes, 8.8 ± 3.6 days and 14.2 ± 3.0 days respectively. Complications occurred in 15 patients (30%) without any in-hospital death. During the follow-up period, 17 patients had recurrence and 35 patients died. Median (95% confidence interval [CI]) OS and DFS time were 30 (21-37) and 30 (19-36) months. Five-year OS and DFS probability (95% CI) were 22.6% (12.8-39.7) and 22.7% (12.9-39.8).

CONCLUSIONS

Total pharyngolaryngoesophagectomy with gastric pull-up is feasible and safe. However, even with curative surgery and multimodal treatment, advanced pharyngeal or laryngeal cancer with cervical esophagus invasion still has poor survival outcome.

A nomogram for predicting occult lymph node metastasis in early hypopharyngeal cancer with cN0

PURPOSE

To explore the risk factors of cervical occult lymph node metastasis (OLNM) in early cN0 hypopharyngeal squamous cell carcinoma (HPSCC), and construct a nomogram model to predict the risk of OLNM in patients with early cN0 HPSCC.

METHODS

78 cases of early (T₁-T₂) HPSCC patients who underwent hypopharyngectomy were retrospectively analyzed. Univariate and multivariate logistic regression analyses were used to determine independent risk factors and a nomogram was constructed according to the results of the multivariate logistic regression analysis. Model performance was assessed by constructing a receiver operating characteristic (ROC) curve, and discriminatory capacity assessed using the area under the curve (AUC). Calibration was completed using a plotted calibration curve accompanied by the Hosmer-Lemeshow test.

RESULTS

Multivariate logistic regression analysis revealed that age (OR 0.928, 95% CI 0.863-0.997), history of drinking (OR 6.668, 95% CI 1.724-25.788), histological differentiation of tumor (OR 7.269, 95% CI 1.000-52.820), depth of invasion (OR 5.046, 95% CI 1.281-19.874) were independent risk factors of OLNM in early cN0 HPSCC. The ROC curve had an AUC of 0.811 (95% CI 0.713-0.909), which implies good discriminate capacity. The calibration curve and the Hosmer-Lemeshow test (P = 0.972) demonstrated good model fitted and high calibration.

CONCLUSION

A nomogram model based on age, drinking history, histological differentiation of tumor, and depth of tumor invasion was successfully developed to predict occult cervical lymph node metastasis in patients with early cN0 hypopharyngeal cancer.

Induction chemotherapy for locally advanced laryngeal and hypopharyngeal cancer: Single institution experience

BACKGROUND

The role of induction chemotherapy (IC) in locally-advanced head and neck squamous cell carcinoma (LAHNSCC) is unclear.

METHODS

A retrospective study of 104 patients with LAHNSCC of the larynx and hypopharynx, treated with IC or up-front chemoradiotherapy (CRT).

RESULTS

Eighty patients received CRT and 24 IC followed by CRT; median follow up was 51.33 months. IC significantly improved median overall survival (OS) in the hypopharyngeal cancer group (64.7 vs 21 months, P = .003); with significant difference in the proportion of complete response at first imaging assessment post definitive CRT; no significant difference in disease free survival (DFS), loco-regional or distant failure in the hypopharyngeal cancer group; or OS and DFS in the laryngeal cancer group. Patients with laryngeal cancer had significantly better median OS than those with hypopharyngeal cancer.

CONCLUSIONS

IC significantly improved complete response rates after CRT, and improved outcomes for patients with locally advanced hypopharyngeal, not laryngeal, cancers.

Impact of tumor dimensions and lymph node density on the survival of patients with hypopharyngeal squamous cell carcinoma

Purpose

To analyze the potential variables affecting the survival of patients undergoing primary surgery for hypopharyngeal squamous cell carcinoma.

Patients and methods

Between August 2007 and December 2016, 93 patients with primary hypopharyngeal squamous cell carcinomas undergoing radical surgery at Fudan University Shanghai Cancer Center were reviewed. The clinicopathological features were analyzed retrospectively. The optimal cutoff values were determined based on the receiver operating characteristic curve analysis. Pearson correlation coefficients were used to assess the correlations between variables. The Kaplan–Meier and Cox proportional hazard methods were used to evaluate the impact of variables on overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS).

Results

Cox multivariate analysis revealed that a depth of invasion (DOI) ≥ 4.3 mm was correlated with inferior OS (P=0.045), DSS (P=0.046), and DFS (P=0.046). A primary tumor volume (PTV) ≥0.36 mL was related to poor OS (P=0.018), DSS (P=0.026), and DFS (P=0.036). A lymph node density (LND) ≥0.07 was also associated with worse OS (P=0.014) and DSS (P=0.045). Moreover, additional prognostic value was observed in the combined use of PTV and LND.

Conclusion

The DOI, PTV, and LND obtained from the surgical specimens could provide additional valuable information for prognostic stratification and allowed the more appropriate selection of suitable candidates for more aggressive adjuvant therapy.

Combined Surgery and Radiation Therapy for Squamous Cell Carcinoma of the Hypopharynx

Squamous cell carcinoma of the hypopharynx remains a highly lethal disease. This article documents our experience with 132 patients undergoing surgical management of squamous cell carcinoma of the hypopharynx, of whom 80% received postoperative radiation therapy. Local-regional control was obtained in 61% of the patients. Five-year overall and disease-free survival rates were 30% and 41%, respectively. Prognosis was better in patients with limited disease: local disease permitting larynx-sparing surgery, N0/N1 clinical neck, and stage I/II/III disease. Cancer of the hypopharynx remains an aggressive entity associated with poor prognosis. Novel strategies stressing improved local-regional control with prevention of distant metastasis are warranted.

Prognostic impact of perineural invasion in hypopharyngeal squamous cell carcinoma

OBJECTIVES

The aim of this study was to evaluate the role of PNI in HPSCC.

METHODS

The medical records of 105 patients who underwent surgery-based treatment for HPSCC were reviewed. Clinicopathologic parameters including disease-specific survival were correlated with PNI.

RESULTS

PNI was identified in 27 of the 105 (25.7%) cases of HPSCC. Correlation analysis demonstrated that PNI in HPSCC was significantly correlated with pN classification (10.3% in N0/N1 vs 34.8% in N2/N3, p = 0.006). Patients with PNI had decreased 5-year disease-specific survival with borderline significance (p = 0.065). In a sub-set of 31 patients who did not receive post-operative radiotherapy, PNI was determined to be a significant prognostic predictor (p = 0.033). In multivariate analysis, extracapsular invasion was the only independent prognostic factor for disease-specific survival (p = 0.001).

CONCLUSION

Perineural invasion (PNI) should be considered an independent predictor for cervical lymph node involvement. PNI status in primary hypopharyngeal squamous cell carcinoma (HPSCC) specimens should be considered in decisions concerning adjuvant radiotherapy.

Delayed reconstruction of the upper digestive tract in a patient following total pharyngolaryngectomy with resection of the cervical oesophagus

Carcinoma of the hypopharynx is an uncommon disease, with an annual incidence of approximately 1 in 100,000. Post-cricoid carcinoma is more common in women and is not usually associated with tobacco and alcohol abuse. Reconstruction of large pharyngeal defects following surgery for squamous cell carcinoma is complex and often requires microvascular free tissue transfer to achieve the best oncological and functional outcomes. The most common complications of such procedures include fistulas and strictures of the neopharynx. Here, we describe a case of a female patient admitted to the Head and Neck Department at our hospital to undergo delayed reconstruction following pharyngolaryngectomy and removal of the cervical oesophagus. Several complications occurred during post-operative care, including stricture and skin dehiscence. At present, the patient is able to swallow saliva and is currently being prepared to return to a normal diet.

Alternative treatment option for hypopharyngeal cancer: clinical outcomes after conservative laryngeal surgery with partial pharyngectomy

CONCLUSION

The oncological and functional outcomes of hypopharyngeal cancer after conservative laryngeal surgery are fairly acceptable, making this a reasonable initial treatment option for selected patients.

OBJECTIVE

The purpose of this study was to assess the clinical outcomes of patients with hypopharyngeal squamous cell carcinoma (SCC) treated with conservative laryngeal surgery with partial pharyngectomy.

METHODS

Fifty-eight patients with hypopharyngeal SCC who underwent laryngeal preservation surgery were enrolled. The tumors were classified as cT1 in 5 (8.6%) patients, cT2 in 35 (60.3%), cT3 in 14 (24.1%), and cT4a in 4 (6.9%) patients.

RESULTS

Surgical outcomes: 5-year overall and disease-specific survival rates were 78% and 77.6%. Recurrent disease developed in 13 patients (22.4%). Multivariate analysis revealed that level VI metastasis confirmed by histopathological analysis, close (< 5 mm) histologic margin, advanced N stage, and posterior pharyngeal wall tumor were independent factors associated with poor disease-specific survival. Functional outcomes: 50 patients (86.2%) could obtain all their nutritional needs orally. Eight patients needed the assistance of a percutaneous endoscopic gastrostomy tube. Oral re-alimentation was achieved within a mean of 26.1 days after surgery. Fifty-one patients (87.9%) could be decannulated after a mean of 43.8 days postoperatively.

Role of surgery in the management of head and neck cancer: a contemporary view of the data in the era of organ preservation

OBJECTIVE

Review of the literature on the role of surgery in the management of head and neck cancer in the era of organ preservation.

METHOD

Literature search based on the essential practice guidelines set out by the US National Comprehensive Cancer Network.

RESULTS

Despite the increasing popularity of non-surgical treatment options, the surgeon remains a key figure in the multidisciplinary head and neck cancer team, along with the radiation oncologist, the medical oncologist and the speech and swallowing therapist. Even when organ preservation is successful, early and late toxicity may cause serious complications, including laryngeal dysfunction with a 'frozen larynx'. When organ preservation fails, salvage surgery is often associated with increased complications and reduced survival.

CONCLUSION

There is a definite need to apply more rigorous standards to the use of organ preservation strategies, and to re-evaluate the role of surgery in head and neck cancer treatment.

Neck and mediastinal node dissection in pharyngolaryngeal tumors

INTRODUCTION

The present study sought to determine the necessity and prognostic impact of superior mediastinum (SM) dissection in advanced upper aerodigestive tract squamous cell carcinoma (SCC).

METHODS

A retrospective review was made of the records of 31 patients who had undergone (pharyngo-) laryngectomy for advanced SCC. Statistical analysis examined correlations between the presence of SM lymph node metastasis and clinical factors, with a significance threshold of P<0.05.

RESULTS

Positive cervical and/or SM lymph nodes were found in 20 cases, including six with isolated positive SM nodes. Positive SM nodes were found in none of the patients with laryngeal SCC, versus six of the 13 patients with hypopharyngeal SCC, where they were associated with tumors greater than 35 mm. Presence of paratracheal lymph node metastasis showed a strong but not statistically significant association with the primary site (larynx vs. hypopharynx: P=0.08).

CONCLUSIONS

In the present series, advanced laryngeal carcinoma was never associated with positive SM nodes, whereas advanced hypopharyngeal carcinoma showed a trend in favor of paratracheal lymph node involvement.

Reconstructive options after total laryngectomy with subtotal or circumferential hypopharyngectomy and cervical esophagectomy

PURPOSE OF REVIEW

The present review is focused on the main reconstructive options currently used after partial or circumferential resection of the hypopharynx and cervical esophagus. The advantages and disadvantages of pectoralis major myocutaneous (PMMC) pedicled flap, fasciocutaneous free flaps as radial forearm and anterolateral thigh (ALT), and visceral free grafts like jejunum and gastro-omental are overviewed.

RECENT FINDINGS

For partial hypopharyngeal defects with limited extension to the cervical esophagus, no specific pedicled or free flap is deemed superior over others: the patient's body habitus and surgeon's preference remain the most important factors affecting the reconstructive choice. In contrast, after circumferential hypopharyngectomy, pharyngocutaneous fistula (PCF) and stricture rates of PMMC are higher than those obtained by free flaps. In the most recent series applying ALT and jejunum, PCF and stricture occurrence is comparable, whereas reduced mortality, overall complication rate, and donor-site morbidity of ALT and its better swallowing and speech outcomes have contributed to make this option progressively more popular. On the other hand, gastro-omental seems to offer an unparalleled amount of highly vascularized tissue to manage the difficult situation of salvage surgery after chemoradiation, even though complication rates remain not negligible and this technique has not been widely adopted.

SUMMARY

The reconstructive armamentarium of head and neck surgeons involved in hypopharyngeal and cervical esophagus reconstruction should encompass every option described herein in order to appropriately deal with specific clinical needs and patient requirements. However, fasciocutaneous free flaps (especially ALT) seem to play an ever greater role in restoration of pharyngoesophageal continuity.

Role of larynx-preserving partial hypopharyngectomy with and without postoperative radiotherapy for squamous cell carcinoma of the hypopharynx

The purpose of this study was to examine the treatment outcomes of larynx-preserving partial hypopharyngectomies for hypopharyngeal carcinoma. Forty-three patients underwent partial hypopharyngectomy and reconstruction using faciocutaneous free flaps with and without postoperative radiotherapy between 1998 and 2009. Primary tumor sites were pyriform sinus in 35 and posterior pharyngeal wall in 8 patients. Thirty patients received postoperative radiotherapy. The 5-year overall and disease-specific survival rates were 63% and 67%, respectively. A significant positive correlation was found between pathologic N stage and primary site and disease-specific survival rates (N0/N1 stage; 93% vs. N2/N3 stage; 43%, p<0.001 and pyriform sinus; 80% vs. posterior pharyngeal wall; 29%, p=0.012, respectively). Recurrences occurred in 15 (35%) patients. Among them, two patients were successfully rescued. Primary partial hypopharyngectomy with laryngeal preservation can be achieved with favorable oncologic outcomes. Factors that affected prognosis were advanced stage neck disease and posterior pharyngeal wall carcinoma.

Impact of combination therapy on disease free survival in hypopharynx cancer

OBJECTIVE

To evaluate the disease-free survival in hypopharyngeal tumors submitted to postoperative radiotherapy.

METHODS

we retrospectively studied 174 patients with the following distribution: two cases of stage I, four stage II, 46 stage III and 122 stage IV. Regarding gender, 163 were male and 11 female; mean age was 56 years. All patients underwent pharyngolaryngectomy; neck dissections were radical in 206 and selective in 16. One hundred six patients underwent postoperative radiotherapy, with a mean dose of 58.2 Gy.

RESULTS

Histological examination showed two cases of stage pT1, 15 stage pT2, 100 stage pT3 and 57 stage pT4. As for lymph nodes, 25 patients had no involvement (pN0); 149 presented with lymph node invasion (pN +). Five-year disease-free survival was 40% and the overall survival was 28%. According to the results of histological examination, five-year disease-free survival was 75% in clinical stage III versus 28% in IV.

CONCLUSION

The initial manifestation of squamous cell carcinoma of the hypopharynx happens in advanced stages (III and IV), with superior five-year disease-free survival in clinical stage III.

Concurrent radiochemotherapy in advanced hypopharyngeal cancer

Background

Concurrent platinum-based radiochemotherapy has been recommended as a standard of care in patients with locally advanced squamous cell head and neck carcinomas. Unfortunately, there is a lack of level one evidence on best treatment approach for advanced hypopharyngeal cancer. This report aims to summarize the results of our study on concurrent radiochemotherapy in patients with advanced hypopharyngeal cancer.

Methods

A retrospective analysis of 41 patients with stage III-IV hypopharyngeal cancer was performed. All patients were treated with three dimensional conformal radiotherapy and received 70 Gy in 35 fractions (2 Gy per fraction, 5 fractions per week). In dependence of the period when radiotherapy was realized, two different treatment techniques were used. Concurrent chemotherapy consisted of cisplatin 30 mg/m² given on a weekly basis.

Results

The median age was 52 years (range 29-70). Stage IV disease was recognized in 73.2% of the patients. Complete response rates at the primary site and at the metastatic neck lymph nodes were 68.3% and 36.6%, respectively. A complete composite response was present in 27 patients (65.9%). Median follow-up was 13 months (range 7-36). Distant metastases as initial failure occurred in 7 patients (46.7%). The 2-year local relapse-free survival and regional relapse-free survival rates were 55.2% and 75.8%, respectively. The 2-year locoregional relapse-free survival rate was 51.3%. The 2-year disease-free survival and overall survival rates were 29.3% and 32.8%, respectively. Confluent mucositis was developed in 46.3% of patients. Leucopenia grade 1 was the most frequent hematological toxicity. The median weight loss at the end of treatment was 12% (range 5-21). The worst grade of late toxicity was most commonly pronounced in the skin and in the subcutaneous tissue.

Conclusions

Based on unsatisfactory results in our study we suggest that the use of sequential radiochemotherapy or chemotherapy given concomitantly with altered fractionation radiotherapy with the implementation of intensity-modulated radiotherapy as radiotherapy technique could represent treatment approaches able to improve outcome in patients with advanced hypopharyngeal cancer.

The impact of paratracheal lymph node metastasis in squamous cell carcinoma of the hypopharynx

The aim of this study was to analyze the prevalence and prognostic importance of paratracheal lymph nodes in squamous cell carcinoma of the hypopharynx. A retrospective review of 64 previously untreated patients with squamous cell carcinoma (SCC) of the hypopharynx that underwent surgery was performed. Ipsilateral paratracheal lymph node metastases occurred in 22% (14 out of 64) and the mean number of paratracheal lymph nodes dissected per side was 2.3 (range 1–6). Contralateral paratracheal lymph node metastases were present in 2% (1 out of 42). Sixty-seven percent with postcricoid SCC and 22% with pyriform sinus SCC developed clinical node-positive ipsilateral paratracheal lymph node metastases, whereas 11% with posterior pharyngeal wall SCC developed paratracheal metastases. There was a significant correlation between paratracheal lymph node metastasis and cervical metastasis (p = 0.005), and the primary tumor site (postcricoid, 57.1%; pyriform sinus, 20.0%; posterior pharyngeal wall, 8.3%) (p = 0.039). Patients with no evidence of paratracheal lymph node metastasis may have a survival benefit (5-year disease-specific survival rate, 60 vs. 29%). However, this result did not reach statistical significance (p = 0.071). The patients with SCC of the postcricoid and/or pyriform sinus were at risk for ipsilateral paratracheal lymph node metastasis; furthermore, patients with paratracheal node metastasis had a high frequency of cervical metastasis and a poorer prognosis. Therefore, routine ipsilateral paratracheal node dissection is recommended during the surgical treatment of patients with SCC of the postcricoid and/or pyriform sinus with clinical node metastases.

Free jejunal graft for reconstruction of defects in the hypopharynx and cervical esophagus following the cancer resections

OBJECTIVES

The reconstruction of esophagus defects after hypopharyngeal and cervical esophageal carcinoma resection is an ongoing problem. The objective of this article was to investigate the techniques of the free jejunal graft for the reconstruction of hypopharyngeal and cervical esophagus and discuss the outcome related to the procedures.

SUBJECTS AND METHODS

From July of 2005 to December 2007, seven patients with hypopharyngeal and cervical esophageal cancer underwent free jejunal graft reconstruction of the hypopharyngeal and cervical esophagus. Their clinical data were retrospectively analyzed. All patients received postoperative radiotherapy and were followed up for 7-24 months.

RESULTS

Despite the multistep and time-consuming procedure, free jejunal graft survival was 100%. Operation-induced complications did not occur in six patients. One patient developed pharyngeal fistula.

CONCLUSION

The present experience supports the use of free jejunal grafts in reconstruction of the hypopharyngeal and cervical esophagus defects after exenteration of the central compartment of the neck. A high successful rate with low incidence of complications in reconstruction of the hypopharyngeal and cervical esophagus was obtained in this study.

Management of the patients with hypopharyngeal cancer: eight-year experience of Miyagi Cancer Center in Japan

The aim of this study is to evaluate the results of treatment for hypopharyngeal cancer and indicate the future prospect of the treatment. Seventy-four patients with squamous cell carcinoma of the hypopharynx admitted to Miyagi Cancer Center from 1993 through 2000 are reviewed. Sixty-four patients received radical treatment, and 10 patients received palliative treatment or no treatment. The cancer was advanced (stages III and IV) in 82% of all the patients. The overall 5-year survival rate of all the patients was 38%. The overall 5-year survival rate of 64 patients received radical treatment was 43%. The ten patients who received palliative treatment or no treatment died of cancer within 16 months. Fifty-two out of the 74 patients underwent neck dissection for the neck lymph node involvement; forty of the 52 patients underwent ipsilateral neck dissection and 12 underwent bilateral neck dissection. Four out of the 40 patients, who underwent ipsilateral neck dissection alone, developed late contralateral regional recurrence but were successfully treated by contralateral neck dissection at the time of recurrence. Twenty-three out of 74 patients had multiple primary cancers synchronously or metachronously (31%). Cause of the death of six patients out of 74 patients was confirmed to be primary cancers other than hypopharyngeal cancer, as judged by physicians in other department or other hospitals. Most of the patients died due to distant metastasis from hypopharyngeal cancer or other primary cancers. We therefore conclude that contralateral elective neck dissection which is frequently chosen for the treatment of hypopharyngeal cancer surgery is unnecessary. Even if locoregional control is accomplished, distant metastasis or multiple primary cancers emerge and make prognosis poor. To improve the prognosis, we should develop some strategy against hypopharyngeal cancer for each patient. New strategies including chemoprevention and surgery against distant metasistasis are necessary.

Reconstruction after resection of hypopharyngeal carcinoma: Comparison of the postoperative complications and oncologic results of different methods

BACKGROUND

Radical surgery followed by radiotherapy plays an important role in the treatment of patients with hypopharyngeal cancer. However, there is no general consensus as to which is the best method of reconstruction after surgical resection.

METHODS

We retrospectively reviewed the records of 91 patients who underwent radical surgery and reconstruction. Postoperative complications and oncologic results of the different reconstructive methods were compared.

RESULTS

Reconstruction with gastric pull-up had the lowest pharyngocutaneous (PC) fistula (0%) and pharyngoesophageal (PE) stenosis rates (0%). However, the overall postoperative complication rate was high (64%). Laryngotracheal flap (LTF) reconstruction had relatively lower rates of PC fistula (3%), PE stenosis (10%), and overall complications (22%). The introduction of the LTF technique significantly decreased postoperative complications from 71% to 30% (p = .0001), with similar tumor control and survival.

CONCLUSIONS

Hypopharyngeal reconstruction with an LTF is a simple and effective method. The chance of using a complex flap is decreased. The postoperative complications are reduced, and the oncologic results are satisfactory.

Enhancement of chemotherapeutic drug-induced apoptosis by a cyclooxygenase-2 inhibitor in hypopharyngeal carcinoma cells

Our previous study demonstrated that cyclooxygenase-2 (COX-2) was overexpressed in human hypopharyngeal carcinoma. In this study, we tested the effect of a specific COX-2 inhibitor, NS398, on proliferation of hypopharyngeal cancer cells. Our results indicated that NS398 inhibited growth of hypopharyngeal cancer cells and this inhibition is associated with induction of G1 growth arrest. Western blot analysis showed that expression of G1 cyclins or cyclin-dependent kinases (CDKs) was not changed by NS398. On the contrary, NS398 significantly increased expression of CDK inhibitors p21(Waf1) and p27(Kip1). We also found that treatment of NS398 alone could not induce significant apoptosis in hypopharyngeal cancer cells. However, NS398 potently augmented chemotherapeutic drug-induced apoptosis. Caspase activation and DNA fragmentation were clearly detected in cancer cells pretreated with NS398 followed by chemotherapeutic drugs. Collectively, our results suggest that COX-2 inhibitors may suppress proliferation of hypopharyngeal cancer cells via induction of G1 growth arrest and may be useful in combination with chemotherapeutic drugs for the treatment of hypopharyngeal carcinoma.

Carcinoma of the hypopharynx

Despite advances in surgical and nonsurgical treatment, overall survival rates for patients who have hypopharyngeal carcinoma have not improved,and this disease still has a poor prognosis. The best results are obtained with multimodality therapy. but at best, two thirds of patients are palliated rather than cured of disease. Radical surgery with postoperative radiation therapy remains the standard of care. Organ preservation strategies have not been as successful in hypopharyngeal cancer as for cancers of other head and neck sites. Chemoradiation is an effective alternative method of aggressive treatment but may be associated with significant dysfunction of the end organ when preservation is possible. Because of poor long-term survival rates, local control remains the most important factor in planning treatment, to provide meaningful palliation and best possible quality of life.

Clinical outcome following total laryngectomy for cancer

BACKGROUND

Patients with advanced cancers of the larynx and hypopharynx have been treated with total laryngectomy at the Department of Head and Neck Surgery, Royal Prince Alfred Hospital, Sydney in the past. Increasingly, these patients are being managed with organ-sparing protocols using chemo-therapy and radiotherapy. The aim of the present study was to review complication, recurrence and survival rates following total laryngectomy.

METHODS

Patients who had total laryngectomy for squamous carcinomas of the larynx or hypopharynx between 1987 and 1998 and whose clinicopathological data had been prospectively accessioned onto the computerized database of the Department of Head and Neck Surgery, Royal Prince Alfred Hospital, were reviewed. Patients whose laryngectomy was a salvage procedure for failed previous treatment were included.

RESULTS

A total of 147 patients met the inclusion criteria for the study, including 128 men and 19 women with a median age of 63 years. Primary cancers involved the larynx in 90 patients and hypopharynx in 57. There were 30 patients who had recurrent (n = 24) or persistent disease (n = 6) after previous treatment with radiotherapy (26 larynx cases and four hypopharynx cases). Pharyngo-cutaneous fistulas occurred in 26 cases (17.7%) and, using multivariate analysis, the incidence did not correlate with T stage, previous treatment or concomitant neck dissection. Local control rates were 86% for the larynx and 77% for the hypo-pharynx groups and neck control was 84% and 75%, respectively. Five-year survival for the larynx cancer group was 67% and this was significantly influenced by T stage and clinical and pathological N stage. Survival in the hypopharynx group was 37% at 5 years and this did not significantly correlate with T or N stage. There was a non-significant trend to improved survival among previously treated patients whose laryngectomy was a salvage procedure.

CONCLUSION

Patients with cancer of the larynx had a significantly better survival following total laryngectomy than patients with hypopharyngeal cancer. Those whose laryngectomy was carried out as a salvage procedure following failed previous treatment did not have a worse outcome than previously untreated patients.

[Reconstruction after total circular pharyngolaryngectomy: comparison between gastric interposition and free jejunal flap]

AIM OF THE STUDY

To elucidate hospital mortality, morbidity and actuarial survival rates of patients with carcinoma of the hypopharynx and cervical oesophagus and to identify the technique of choice for reconstruction after pharyngolaryngectomy.

PATIENTS AND METHODS

We reviewed the records of 209 patients who underwent total pharyngolaryngectomy between May 1982 and January 2000. The majority of patients had advanced cancer: hypopharyngeal in 131 cases and cervical oesophageal in 78 cases. Follow-up was complete for all patients. Chi 2 and log rank tests were used, with a limit of significance of 5%.

RESULTS

The postoperative mortality and morbidity rates were 4.8% and 38.3%, respectively. Alimentary continuity was achieved using the stomach (127 patients), colon (5 patients), or free jejunal autograft (77 patients). The 1-year and 5-year survival rates were 62% and 24%, respectively. There was no significant difference with regard to the survival between gastric transposition and free jejunal autograft, but there were fewer complications in the gastric pull-up group with regard to the respiratory complications (33% vs 47.0%, p < 0.05), local recurrences (15.8% vs 33.8%, p = 0.004) and survival without dysphagia (76% vs 89%, p < 10(-5)).

CONCLUSION

Surgical ablation is a viable option for advanced hypopharyngeal and cervical oesophageal neoplasms, and stomach interposition is the preferred method of reconstruction.

Radial clearance in resection of hypopharyngeal cancer: an independent prognostic factor

BACKGROUND

The depth of infiltration of tumor is of particular relevance in hypopharyngeal cancers, because most of them are seen late, and extensive infiltration into the muscle wall and the cartilage are not uncommon.

METHODS

The resected specimens of hypopharyngeal cancers were studied with whole-organ step-serial sectioning. The extent of infiltration into the thickness of the wall and the radial clearance were carefully documented. These parameters were correlated with the tumor recurrence and survival rates.

RESULTS

Most patients with hypopharyngeal cancer had a minimal radial margin; the radial clearance was <1 mm in 56% of the patients. Despite such a minimal margin, the local recurrence rate was only 19% and occurred mainly in the upper and lower resection margins. Radial clearance was an independent prognostic factor for overall survival, disease-free survival, and nodal recurrence-free survival on multivariate analysis.

CONCLUSION

Radial clearance is an important independent prognostic factor, and it is recommended to be included in the routine pathologic reporting of the resected specimen in hypopharyngeal cancer.

Clinicopathological significance of p16 gene expression in the surgical treatment of head and neck squamous cell carcinomas

AIMS

To evaluate the clinicopathological significance of p16 expression in the surgical management of squamous cell carcinomas of the oral cavity, oropharynx, hypopharynx, and larynx.

METHOD

p16 expression in 225 head and neck squamous cell carcinomas (HNSCCs) was studied using an immunohistochemical method and paraffin wax embedded tumour tissues. Associations between p16 expression and clinicopathological features were investigated.

RESULTS

Decreased p16 expression was found in 48% of the tumours. There was a higher frequency of decreased p16 expression in tumours of the larynx compared with those from the pharynx and oral cavity. There was a significant correlation between decreased p16 expression and more advanced T stage. There was no significant correlation between p16 expression and sex, age, tumour grade, nodal metastasis, recurrence, or survival.

CONCLUSION

There was a high frequency of downregulation of p16 expression in HNSCC. Tumours of the larynx had a significantly higher frequency of weak p16 expression compared with tumours of the oral cavity and pharynx. Downregulation of p16 contributed to cellular proliferation, resulting locally in a more advanced tumour. It had no prognostic significance for nodal metastasis and survival.

Overexpression of cyclo-oxygenase 2 in squamous cell carcinoma of the hypopharynx

Upregulation of cyclo-oxygenase 2 (COX-2) expression is frequently found in a variety of human cancers. In this study, we examined COX-2 expression in squamous cell carcinoma of the hypopharynx. COX-2 messenger RNA (mRNA) analyzed by reverse-transcription polymerase chain reaction was detected in 87% (20 of 23) of tumor tissues. Expression of COX-2 protein was examined by Western blot analysis. COX-2 protein levels were increased in tumor tissues and correlated with the expression level of mRNA. Immunohistochemical study was performed to detect the subcellular localization of COX-2. Our results showed that COX-2 was predominantly detected in cancer cells, and the staining pattern was cytoplasmic. Several histologically normal adjacent tissues obtained from these patients were also investigated. We found that COX-2 mRNA was detectable in these tissues. However, COX-2 mRNA and protein levels were lower in these tissues than in tumor specimens. In contrast, COX-2 mRNA and protein levels in normal oral mucosa obtained from healthy volunteers were very low or undetectable. The frequency of COX-2 overexpression was significantly higher in the N1-N3 group than in the N0 group. These results suggest that overexpression of COX-2 is linked with increased lymphatic invasion in hypopharyngeal carcinoma. Collectively, these results suggest that overexpression of COX-2 is a frequent phenomenon in hypopharyngeal carcinoma and may play a role in tumorigenesis of this cancer.

Hypopharyngeal squamous cell carcinoma--treatment results in 138 consecutively admitted patients

The aim of this study was to evaluate the results of the initial and salvage treatment for hypopharyngeal carcinoma. The study was conducted in 1963 to 1991 and included 138 patients (38 females (28%) and 100 males (73%)). Most of the tumours originated in the piriform sinus (86%). Tumour stage distribution was T1: 20%, T2: 27%, T3: 37% and T4: 17% and nodal stage distribution was N0: 45%, N1: 25%, N2: 10%, and N3: 20%. Primary treatment was delivered with curative intent in 124 out of 138 cases (90%). Treatment failure was noted in 98 patients, with 55% recurrence in T-position, 39% in N-position, and 14% at distant metastases sites. Salvage surgery was successful in 9 out of 32 patients. The overall 5-year locoregional tumour control, cause-specific and overall survival rates were 20%, 25% and 19%, respectively. Univariate actuarial analysis showed that T- and N-stage, clinical stage, tumour size and well-differentiated tumours were significant prognostic parameters. A Cox multivariate analysis showed that only the T- and N-stages were independent prognostic factors. In conclusion, the prognosis for advanced hypopharyngeal carcinoma is extremely poor and the meagre results with conventional radiotherapy alone indicate that other treatment modalities should be introduced in the management of this disease.

Multicentricity in pharyngoesophageal tumors: argument for total pharyngolaryngoesophagectomy and gastric transposition

BACKGROUND

Pharyngoesophageal tumors pose a challenge to surgical management, and there is controversy in the literature as to the best procedure to be used. Advantages and disadvantages are mentioned for total pharyngolaryngoesophagectomy and gastric transposition (PLE&GT), free jejunal transplants, and free forearm flaps. One of the arguments for PLE&GT is the persistence or subsequent occurrence of multiple primaries in a field cancerization region. Multiple tumors in the head and neck/esophagus/lung axis have been reported. However, despite extensive investigation, there is little information on specific multicentricity in patients treated with PLE&GT for pharyngolaryngoesophageal carcinomas.

METHODS

A clinicopathological study was undertaken in 35 consecutive patients who underwent PLE&GT for pharyngoesophageal cancer to evaluate synchronicity, multicentricity, and metachronicity. Only in situ and invasive carcinomas were considered. The findings were compared with the reports in the literature.

RESULTS

Thirty-eight tumors were diagnosed preoperatively, with the main indications for PLE&GT being tumors located in the esophagus or hypopharynx (32 patients) and larynx (three patients). After the surgical treatment, 21 patients had single primaries (60%) and 14 (40%) had 25 multiple primaries in addition to their main primaries (total of 60 tumors in the whole group). Synchronous, previous metachronous and subsequent metachronous carcinomas occurred in 26%, 17%, and 8.5% of the instances, respectively. Twenty of the 25 multicentric carcinomas were invasive (80%). Either the main primaries or the multicentric carcinomas were located in the esophagus or hypopharynx (91.5% and 60%, respectively). Other sites included the larynx, oropharynx, oral cavity, and lung.

CONCLUSION

The incidence of multicentric tumors in patients with pharyngoesophageal carcinomas may favor total PLE&GT as the procedure of choice, because it includes all the condemned upper pharyngolaryngoesophageal mucosa.

Survival and functional results of Pearson's near-total laryngectomy for larynx and pyriform sinus carcinoma

BACKGROUND

Current treatment for most T3 and T4 transglottic and pyriform sinus carcinomas is total laryngectomy or total laryngectomy with partial pharyngectomy. Voice rehabilitation usually requires the use of a tracheoesophageal puncture (TEP). Pearson's near-total laryngectomy (NTL) is an option for voice preservation in selected cases with no invasion of the interarythenoid space and limited invasion of the subglottis. The purpose of this study is to report the functional and survival results of 42 consecutive patients who underwent NTL from 1988 to 1995. Patients and Methods The patients were 40 men and two women, with a median age of 58 years. All patients had squamous cell carcinoma. There were 37 larynx and five pyriform sinus tumors. T3 stage tumor represented 85.7% of the cases.

RESULTS

There were complications in 13 patients (28.9%). Vocal quality was considered good in 83.3% of the cases. To date, eight patients presented tumor recurrences: two local, two in the neck, and four distant. The 5-year actuarial overall survival rates were of 81.7% in larynx carcinoma and 66.6% in pyriform sinus carcinoma.

CONCLUSIONS

In selected transglottic and pyriform sinus carcinomas, NTL can be carried out with acceptable morbidity and a high potential of voice preservation and tumor control.

A third decade's experience with the gastric pull-up operation for hypopharyngeal carcinoma: changing patterns of use

Gastric transposition has been used extensively in this department since 1965 for reconstruction following pharyngolaryngoesophagectomy (PLO). A previous report by Harrison and Thompson in 1986 detailed our experience with 101 cases dating back to 1965. Here we review our experience between 1986-1996. Medical records of 41 cases were examined. The primary site and stage of tumour and associated lymph nodes, patient demographics, complications, in-patient mortality and survival as demonstrated by the Kaplan-Meier method were recorded. Gastric transposition is now used for more extensive tumours: 70 per cent T4 (83 per cent pathologically T4) compared to 21 per cent in the previous report. A high proportion of 'radiation failures' remains (54 per cent). The in-hospital mortality has fallen from 11 per cent to seven per cent. The five-year-survival calculated using the Kaplan-Meier method is 11 per cent. This procedure is increasingly being used as a palliative procedure aiming to restore swallowing in the relatively young patient who has very extensive hypopharyngeal carcinoma. Long-term survival rates specific to this operation have fallen. This is attributed to patient selection for the procedure with the vast majority having disease extending into bone, cartilage or soft tissues (T4). The defect created by the resection of less extensive tumours are now increasingly reconstructed with jejunal free flaps and musculocutaneous flaps.

Reconstructive techniques currently used following resection of hypopharyngeal carcinoma

There is no general consensus as to the best method of reconstruction following total laryngopharyngectomy for hypopharyngeal carcinoma. The aim of this study is to attempt to establish the current practice amongst British ENT Consultants and to ascertain the reasons for their choice of reconstructive technique. An anonymous questionnaire was sent to 546 consultants in the UK and the results of 363 (66.5 per cent) were analysed. One hundred and twenty-eight (35.3 per cent) consultants replied that they performed surgery for hypopharyngeal carcinoma. Sixty-five (50.8 per cent) performed a stomach pull-up procedure, 23 (18 per cent) used a jejunal free flap, 36 (28.1 per cent) used both and four (3.1 per cent) used other techniques. In the stomach pull-up group, the main reasons given for their choice were because there was no lower resection margin (48 out of 65) and because of tradition in the way they were trained (37 out of 65). In the group using the jejunal free flap, lower morbidity (18 out of 23) and mortality (14 out of 23) were the main reasons for their choice. The questionnaire also found that amongst the 60 consultants who would consider using a jejunal free flap, the majority (39) aimed for a lower clearance margin of 2-4 cm, while 17 aimed for > 4 cm clearance. This study provides a good indication of the current practice in the UK of reconstruction following resection for hypopharyngeal carcinoma. It appears that the stomach pull-up remains the most commonly used method of reconstruction, but the jejunal free flap is becoming increasingly more popular because of its lower morbidity and mortality.

Intraoperative brachytherapy, laryngopharyngoesophagectomy, and gastric transposition for patients with recurrent hypopharyngeal and cervical esophageal carcinoma

OBJECTIVE

To evaluate the role of laryngopharyngoesophagectomy (LPE), intraoperative 125I brachytherapy (IOBT), and gastric transposition (GT) in patients with recurrent carcinoma involving the hypopharynx, or cervical esophagus.

METHODS

Between 1988 and 1994 a total of 21 patients were managed with LPE/IOBT/GT. All patients had documentation of recurrent disease at the hypopharynx or cervical esophagus and had previously been treated with external-beam radiation (EBRT) to a total median dose of 60 Gy. Median age was 67 years, with 17 male patients and four female. IOBT was performed in all cases with permanent 125I implantation. Medical records were retrospectively reviewed. Overall survival, local control, and complications were evaluated. Median follow-up was 6 months.

RESULTS

The median activity of 125I was 36 mCi, with a median dose of 80 Gy to the region at risk. Fifteen patients had lymph node dissections performed in conjunction with LPE, and 10 patients had nodal involvement on pathologic examination. Margins were microscopically positive in nine patients, and lymphvascular space invasion noted in 13. Actuarial survival at 1 and 3 years was 32% and 14%, respectively, with patients alive and with local control at 6, 24, 36, and 48 months (negative margins). Actuarial local control at 1 and 3 years was 63%. Complications included fistula in five patients, facial edema in four, protracted facial pain in two, cervical abscess in one, and mucosal hemorrhage in one.

CONCLUSION

Patients with recurrent carcinoma of the hypopharynx or cervical esophagus after EBRT have an extremely poor prognosis. LPE, IOBT, and GT may provide very good local control for all candidates and prolonged survival for a small percentage of patients with an acceptable risk profile.

Circumferential pharyngolaryngectomy with total esophagectomy for locally advanced carcinomas

BACKGROUND

Forty-nine cases of circumferential pharyngolaryngectomy with total esophagectomy (PLTE) done between 1982 and 1996 were studied retrospectively. These procedures were performed for advanced squamous cell tumors of the superior esophageal sphincter (n = 23), for hypopharyngeal tumors with synchronous esophageal carcinoma (n = 15), and for hypopharyngeal tumors extensively invading the cervical esophagus (n = 11).

METHODS

Ninety-six percent of the patients had T3-4 lesions, and it was impossible to use a free jejunal graft reconstruction. Patients underwent primary surgery in 70% of the cases, and salvage surgery (after failure of chemoradiotherapy) in 30%. In most patients, esophagectomy was performed without thoracotomy (n = 45). Resection was curative (R0) in 70% of the cases, in spite of lymph node invasion in 94%. Reconstruction of the digestive tract was achieved with the stomach in 33 patients (67%) or with the colon in 16 patients (33%).

RESULTS

Before 1989, postoperative mortality was high, was correlated with the high frequency of palliative surgery, and resulted in unsatisfactory survival results (overall 5-year survival rate of 7%). After 1989, as a result of better selection of patients and appropriate training of our team, postoperative mortality decreased from 33% to 10%, R1-2 resections decreased from 39% to 26%, and a 3-year overall survival rate of 28% was obtained for the last 25 patients, all of whom were able to eat without difficulty. These results are superior to the survival rates and functional results obtained with radiochemotherapy alone for such advanced tumors, even though the voice is preserved with radiochemotherapy alone.

CONCLUSIONS

PLTE for advanced pharyngeal or cervical esophageal tumors is the best treatment currently available, but it is indicated only in very selected cases: when it is technically impossible to perform reconstruction with a free jejunal graft after circumferential pharyngolaryngectomy; as primary surgery, rather than as salvage surgery following chemoradiotherapy; after careful preoperative morphologic and endoscopic assessment of the extent of the tumor; and in patients able to tolerate a thoracotomy for an esophagectomy with lymphadenectomy. Selection according to these guidelines should improve results.

Cyclin-D1-gene amplification is a more potent prognostic factor than its protein over-expression in human head-and-neck squamous-cell carcinoma

To evaluate the prognostic significance of cyclin D1 protein/gene expressions in human head-and-neck squamous-cell carcinoma (HNSCC), we examined amplification of the cyclin-D1 gene (CCND1) by the differential PCR method and over-expression of cyclin-D1 protein by immunohistochemistry in 45 paraffin-embedded sections from HNSCC. Amplification of CCND1 was found in 10 (22%) cases and over-expression of cyclin D1 was found in 24 (53%) cases. CCND1 amplification was also found in 3 (25%) of 12 cases of dysplastic lesions adjacent to HNSCC. The overall 5-year survival of patients with CCND1 amplification or with protein over-production was significantly lower than that of patients without (p < 0.0001 and p < 0.05, respectively). However, with multivariate analysis, only amplification of CCND1 retained an independent prognostic value (p = 0.0018). These suggest that CCND1 amplification occurs at early stages of HNSCC tumorigenesis and is a more useful prognostic factor than over-expression of cyclin D1 in HNSCC.

Cyclin D1 overexpression in primary hypopharyngeal carcinomas

BACKGROUND

Hypopharyngeal squamous cell carcinomas (HPCS) are associated with an extremely poor prognosis. Generally, conventional clinicopathologic factors have only limited value as prognostic factors for this malignancy. It is therefore clinically important to identify new prognostic factors that accurately reflect the biologic aggressiveness of this malignancy. The amplification and overexpression of the cyclin D1 protooncogene have been reported in a variety of malignancies, and are thought to be related to tumor progression. Based on this phenomenon, the authors immunohistochemically evaluated overexpression of the cyclin D1 gene in 42 cases of primary HPCS. In addition, the immunohistochemical staining of the proliferation marker MIB-1 (Ki-67 antibody) was also performed.

METHODS

Formalin fixed, paraffin embedded biopsy specimens obtained prior to treatment were examined. Cyclin D1 and Ki-67 were detected using monoclonal antibodies by means of the streptavidin-biotin method. The relationship between cyclin D1 overexpression and the stage, histologic grade, presence of lymph node metastases, proliferation index, and survival was then statistically analyzed. The correlation between the proliferation index, other clinicopathologic factors, and survival was also evaluated.

RESULTS

Twenty-three (54.8%) HPCS specimens showed a 20% or greater immunoreactivity for cyclin D1. Cyclin D1 overexpression was related to cervical lymph node metastases (P = 0.037) but not to clinical stage, histologic grade, or the proliferation index. Cyclin D1 negative tumors were associated with a significantly better prognosis (P = 0.023), particularly in patients who underwent multimodality treatment. Finally, the MIB-1 labeling index showed no correlation with either the clinicopathologic parameters or overall survival.

CONCLUSIONS

Based on these findings, cyclin D1 immunohistochemical staining is considered to be useful, not only as a prognostic factor for HPCS, but also as a means of determining the optimum treatment for each individual patient. Conversely, the MIB-1 labeling index appears to have no clinical significance in HPCS.

Factors influencing contralateral metastasis and prognosis from pyriform sinus carcinoma

BACKGROUND

The presence of neck metastasis reduces the probability of regional control and survival. The purpose of this study is to identify risk factors for contralateral neck metastasis in a series of 218 patients with pyriform sinus carcinoma.

PATIENTS AND METHODS

Tumor stages were: 31 T1-T2, 187 T3-T4, 40 N0, 174 N1-N3, and 4 NX. A total of 182 patients (83%) had metastatic lymph nodes (23 in the contralateral neck).

RESULTS

Thirty-five patients presented neck recurrences (27 in contralateral undissected neck). Logistic regression identified T and N stages, epilarynx and posterior pharyngeal wall involvement, hemilarynx fixation, and ipsilateral level 1 metastasis as important predictors of contralateral metastasis. Five-year survival rates were 41% (pN0), 23% (contralateral pN0), and 31% (contralateral positive nodes).

CONCLUSIONS

The contralateral side of the neck was the most common site of recurrence. A lateral neck dissection is advisable for the contralateral side of the neck for high-risk patients.