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

Impact of cervical lymph node metastasis on transoral surgery for hypopharyngeal squamous cell carcinoma: A retrospective multicenter study

BACKGROUND

Hypopharyngeal carcinoma is likely to spread to the lymph nodes, but there is no established strategy for management in transoral surgery.

METHODS

We compared oncologic and functional outcomes in a retrospective multicenter study of patients who underwent transoral surgery for hypopharyngeal carcinoma between 2015 and 2021.

RESULTS

Two-hundred and thirty-two patients were included. Comparing patients with and without adjuvant radiotherapy, 3-year regional recurrence-free survival (RRFS) was not significantly different in pN2b and pN2c, but was significantly worse in pN3b without adjuvant radiotherapy. In patients without neck dissection, the 3-year RRFS was 85.6%, 76.8%, and 70.0% for T1, T2, and T3 primary lesions, respectively, and was significantly worse for T2 or higher (p = 0.035).

CONCLUSIONS

In the absence of extracapsular invasion, regional control did not deteriorate without adjuvant therapy. If prophylactic neck dissection is not performed, careful follow-up is necessary if the primary lesion is T2 or greater.

Oncological and functional outcomes of partial or total laryngopharyngectomy for hypopharyngeal cancer with thyroid or cricoid cartilage invasion

BACKGROUND

Patients with cartilage invasion in hypopharyngeal squamous cell carcinoma (HPSCC) would benefit from partial laryngopharyngectomy (PLP).

AIMS/OBJECTIVES

The purpose of this study was to examine the treatment outcomes of PLP for HPSCC with cartilage invasion, with a focus on the oncological safety and the function preservation.

MATERIALS AND METHODS

We performed a retrospective review of 28 patients with HPSCC with thyroid or cricoid cartilage invasion who had undergone upfront surgery and were followed for more than one year between 1993 and 2019.

RESULTS

Twelve patients treated with PLP (42.9%) and 16 patients treated with total laryngopharyngectomy (TLP) for cartilage invasion in HPSCC were identified. There was no significant difference in recurrence between the PLP group (7/12, 58.3%) and the TLP group (8/16, 50.0%) (p = .718). PLP was not associated with decreased five-year disease free survival (p = .662) or disease specific survival (p = .883) rates compared to TLP. Nine patients receiving PLP could be decannulated and retained intelligible speech (9/12, 75%). Gastrostomy tubes were placed in the PLP group (5/12, 42.9%) and TLP group (1/16, 6.2%) (p = .057).

CONCLUSIONS AND SIGNIFICANCE

PLP appears to be a feasible option for the treatment of thyroid or cricoid cartilage invasion in HPSCC.

Efficacy of Larynx Preservation Surgery and Multimodal Adjuvant Therapy for Hypopharyngeal Cancer: A Case Series Study

Background: Larynx preservation surgery (LPS) combined with multimodal adjuvant therapy (MAT) is re-emerging as treatment option for hypopharyngeal cancer (HPC). This study aims to explore the survival and functional outcome of this combined approach. Methods: This is a retrospective cohort study. Selected patients with primary HPC treated by LPS and MAT at two large Beijing medical centers between 2005 and 2019 were included. In addition to LPS, patients received one or more of the following treatments: preoperative induction chemotherapy, postoperative intensity-modulated radiotherapy, chemotherapy, or targeted therapy. Results: In total, 64 patients were included (62 were men, and median age was 57.5 years). The disease in most patients was in stage III (28.1%) or IV (56.3%), or in stage T2 (34.4%) or T3 (45.3%), based on the TNM scale. Across all patients, the rate of overall survival (OS) was 60.7% at 3 yr and 47.3% at 5 yr. OS was significantly higher for patients with stage I or II disease than for those with stage III or IV disease (HR 8.64, 95% CI 3.69-20.2, log-rank P = .010). Decannulation was successful in 55 patients (85.9%), and swallowing function was satisfactory (stage 0-III, on Functional Outcome Swallowing Scale) for 50 (78.1%). Median Voice Handicap Index-10 score on voice performance was 19 (range 4-40), and median Functional Assessment of Cancer Therapy-General Questionnaire score for QoL was 75 (range 16-105). Conclusions: LPS and MAT can provide satisfactory oncologic control and good functional outcomes for selected patients with HPC, especially those with stage I or II disease.

Nomograms predicting prognosis for locally advanced hypopharyngeal squamous cell carcinoma

PURPOSE

This study aimed to construct nomograms to predict the overall survival (OS) and cancer-specific survival (CSS) for patients with locally advanced hypopharyngeal squamous cell carcinoma (HSCC).

METHODS

864 patients with locally advanced HSCC during 2010-2015 from the surveillance, epidemiology and end results (SEER) database were selected. After classifying continuous data by risk, Cox regression analyses were applied to detect significant independent prognostic factors, with which nomograms were established. To evaluate the value of nomograms, concordance index (C-index), area under the receiver-operating characteristic (ROC) curve (AUC), calibration curves, and decision curve analysis (DCA), Kaplan-Meier analysis was adopted. The efficacy of surgery in different risk groups was also studied to figure out people who can benefit from surgery.

RESULTS

A total of 864 locally advanced HSCC patients were randomized into the training cohort (n = 608) and the validation cohort (n = 256). Age, race, tumor size, T stage, N stage, primary site, radiotherapy, and chemotherapy were independent prognostic factors for OS and CSS (except race) and formed the nomograms. The nomograms revealed satisfied performance in C-index, AUC, DCA, and calibration curves, and prevailed over American Joint Committee on Cancer (AJCC) TNM staging system in predicting OS and CSS. After risk stratification, patients of low-risk group resulted in the best outcomes. Patients in moderate-risk may benefit from surgery.

CONCLUSIONS

Convenient and well-calibrated nomograms to predict OS and CSS for III/IVA/IVB-stage HSCC patients were set up and assessed and may do a favor to make clinical decisions.

Use of Supraclavicular Flap by End to Side Technique in Pharyngeal SCC: A Case Report and Review of Literature

Objectives

In recent years, conservation laryngeal surgeries, including partial pharyngectomy, have been introduced as an alternative procedure for selected cases of hypopharyngeal squamous cell carcinoma (HSCC). Reconstruction of these defects presents a considerable challenge for the surgeon after partial pharyngectomy due to its circumferential nature. In this case report, we represent the innovative "End to side" technique to reconstruct hypopharyngeal defect using the rolled supraclavicular flap after laryngeal-preserving partial pharyngectomy.

Methods and Results

A 70-year-old female presented with a history of progressive dysphagia and odynophagia. The evaluations revealed a T3N0M0 SCC of pyriform sinus. The mass was successfully resected through partial pharyngectomy, and the hypopharyngeal defect reconstruction was achieved using the rolled supraclavicular flap via the "End to side" technique. The patient was discharged after decannulation on day 10. The 3-week barium swallow was performed with no evidence of anastomotic leakage, and the oral feeding was started after NG tube removal. At week 5, complete movement of the true vocal cord on the one side and good phonation and deglutition was observed. There was no evidence of recurrence after 1 year.

Conclusions

Laryngeal-preserving partial pharyngectomy and hypopharyngeal reconstruction with the rolled supraclavicular flap via the "End to side" technique could lead to good oncological and functional outcomes in selected cases of pyriform sinus.

Oncological and Functional Outcomes of Larynx-preserving Surgery for Hypopharyngeal Cancer: A Comparison with Definitive Radiation-based Treatment

Purpose

Larynx-preserving surgery (LPS) have recently gained popularity and achieved comparable oncologic outcomes to conventional radical surgery for localized hypopharyngeal cancer (HPC). In the current study, the role of LPS has been assessed thoroughly in comparison with upfront radiation therapy (RT).

Materials and Methods

We retrospectively reviewed 185 candidates for LPS with cT1–2 disease; 59 patients underwent upfront LPS while 126 patients received upfront RT, respectively. Oncological and functional outcomes were investigated and compared.

Results

Following LPS, safe margin (≥ 5 mm) was achieved in 37.3% of patients. Overall, better clinical outcomes at 5 years were achieved following upfront LPS than those following upfront RT: overall survival (OS) (72.7% vs. 59.0%, p=0.045), disease-free survival (DFS) (59.8% vs. 45.0%, p=0.039), and functional laryngeal preservation (100% vs. 89.7%, p=0.010). Although similar outcomes were observed in patients with cT1 disease, better 5-year DFS was achieved following upfront LPS in patients with cT2 disease (57.0% vs. 36.4%, p=0.023) by virtue of better local control. Despite frequent cN2–3 disease in upfront LPS group, comparable outcomes were observed between upfront RT and LPS group. However, multivariable analyses revealed that performance status and double primary cancer diagnosed within 6 months of HPC diagnosis affected OS significantly, while treatment modality per se did not.

Conclusion

Although upfront LPS could provide better local control than upfront RT in patients with cT2 disease, overall outcomes were comparable following either modality. Treatment selection of larynx-preserving approach for HPC should be individualized based on tumor and patient factors.

Tumor dimension-dependent microscopic extensions of hypopharyngeal cancer: Therapeutic implications for larynx-preserving hypopharyngectomy

INTRODUCTION

Hypopharyngeal cancer (HPC) is well characterized by the early submucosal spread of cancer cells into adjacent subsites of the hypopharynx and deep tissues, advocating a wide extent of treatment. However, the microscopic extensions (ME) from gross tumors, according to the primary tumor dimensions, has not been reported in detail.

METHODS

We included patients who underwent upfront curative surgery, and retrospectively reviewed pathology specimens from 45 HPC cases. The distance of the MEs, defined as tumor infiltration beyond the gross tumor border on the submucosal and deep sides, was measured. We analyzed potential correlations between MEs and various physical tumor factors.

RESULTS

A rough linear correlation between the submucosal ME and the maximal diameter of tumors was found (p < .001, r²  = 0.225). Deep MEs did not correlate with tumor physical factors. However, the MEs differed significantly by the T status (p = .033 and .015 in submucosal and deep sides). In T1-2 tumors, the submucosal MEs were less than 0.5 cm, whereas those of T3-4 tumors were 1.5-2.0 cm.

CONCLUSION

In HPC, local MEs beyond the gross tumor border correlated with primary tumor T status. Our findings support that the surgical safety margin for HPC can be adjusted according to tumor dimension.

Predicting Factors for Oncological and Functional Outcome in Hypopharyngeal Cancer

OBJECTIVES/HYPOTHESIS

Hypopharyngeal squamous cell carcinoma (SCC) is a rare but aggressive malignancy, with low survival rates and high incidence of tumor and treatment-related morbidity. This study aims to analyze the long-term oncologic and functional outcomes of a large cohort of patients and to determine prognostic factors.

STUDY DESIGN

Retrospective cohort study.

METHODS

The records of all patients diagnosed with hypopharyngeal SCC and treated with curative intent at our tertiary referral center were reviewed. Patient and initial disease characteristics, features, and complications of primary treatment, recurrence patterns, and corresponding treatments and the oncologic and functional long-term outcome were determined.

RESULTS

For a total of 179 patients, primary radiotherapy (RT) was the predominant treatment modality (78%), whereas 22% underwent primary surgery. The median, 2-year, and 5-year overall survival (OS) for the study cohort were 47 months, 64% and 43%. The median survival after first and second relapse was 7 and 6 months, respectively. The 2 and 5-year relapse-free survival (RFS) was 52% and 36%. The median RFS after first relapse and salvage treatment was 9 months. A nodal status of ≥cN2 (HR = 1.89, CI:1.21-3.05, P < .005) and any other primary tumor localization than pyriform sinus (HR = 1.60, CI: 1.04-2.42, P < .05) were identified as independent risk factors for shorter OS and RFS. Regarding functional outcome, the 2- and 5-year laryngectomy-free-survival was 55% and 37%, respectively.

CONCLUSIONS

In this large cohort with long-term follow-up, any other primary tumor localization than pyriform sinus and a nodal status of ≥cN2 were identified as risk factors for reduced OS and RFS.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1543-E1549, 2021.

"End to Side Technique": More organ preservation with less morbidity in patients with pyriform sinus apex SCC

INTRODUCTION

Hypopharyngeal squamous cell carcinoma (SCC) is rare, but highly aggressive. Due to the advanced stage of this cancer at the time of diagnosis, radical surgery with reconstruction of pharynx is the standard care with high morbidity and mortality rate. A safer partial pharyngectomy could also be used for invasive hypopharyngeal cancer. In this study, we investigated the short and long-term outcomes in patients with SCC of the pyriform sinus apex undergoing standard partial pharyngectomy using a new suturing technique, called end to side technique.

METHODS

This case series was performed on 8 patients with SCC of the pyriform sinus apex at the otorhinolaryngology clinic. All participants underwent standard partial pharyngectomy using "end to side technique". Post-operative evaluations included 6 and 12 months CT scan and 1-year barium swallow.

RESULTS

Of 8 patients, 7 were male (87.5%) and 1 was female (12.5%) with a mean age of 60 years old. All patients were diagnosed at stage III of hypopharyngeal cancer and cervical lymph node involvement was reported in 3 patients (37.5%). Tumor margins were negative in all patients. Fistula was reported in 2 patients (25%) which was managed using conservative treatments.

CONCLUSIONS

According to our study, the standard partial pharyngectomy with end to side technique is a safe and feasible method for the surgical resection of the squamous cell carcinoma of the pyriform sinus apex with good short-term and long-term outcomes.

Long-term oncological and functional outcomes of induction chemotherapy followed by (chemo)radiotherapy vs definitive chemoradiotherapy vs surgery-based therapy in locally advanced stage III/IV hypopharyngeal cancer: Multicenter review of 266 cases

OBJECTIVE

The aim of this study was to evaluate the treatment outcomes for stage III/IV locally advanced hypopharyngeal squamous cell carcinoma (SCC), comparing induction chemotherapy followed by (chemo)radiotherapy (ICT), definitive chemoradiotherapy (CRT) and surgery-based therapy (SRT).

SUBJECTS AND METHODS

Two hundred sixty-six patients with stage III/IV locally advanced hypopharyngeal squamous cell carcinoma (SCC) who underwent ICT (n = 74), CRT (n = 53) or SRT (n = 139) from 1997 through 2014 at the Seoul National University Hospital (n = 127) and the Hallym University Medical Center (n = 139) were enrolled in the study. All surgical procedures in the SRT group were performed by a single surgeon to eliminate surgeon bias.

RESULTS

The 5-year disease-free survival (DFS) and overall survival (OS) of all patients (n = 266) were 59.4% and 44%, respectively. The 5-year DFS rates after salvage treatment were 52.7% for ICT, 52.8% for CRT and 65.5% for SRT (p = 0.194). The OS rates were 44.6% for ICT, 39.6% for CRT and 45.3% for SRT group (p = 0.106). The salvage rates were 12.5% for ICT, 15.6% for CRT and 3.8% for SRT group. The final laryngeal preservation rate was significantly lower in the SRT group (44.6%) than in the ICT (71.6%) or CRT (71.7%) groups. All major postoperative complications were significantly higher in the salvage surgery group.

CONCLUSION

Treatment outcomes in the ICT and CRT groups were comparable to that of the SRT group for stage III/IV hypopharyngeal SCC. However, the relatively low chance of cure and high risk of complications should be taken into account when considering salvage surgery.

Oncological and Functional Evaluation of Open Conservation Surgery for Hypopharyngeal Cancer with/without Reconstruction

Objectives

Oncological and functional results of open conservation surgery for hypopharyngeal cancer have been desired.

Methods

We performed a chart review of 33 patients with hypopharyngeal cancer who underwent open conservation surgery. Oncological and functional results were evaluated in surgery with primary closure (Group A) and surgery with reconstruction (Group B). Postoperative functions were evaluated by interval to resumption of oral intake, Functional Outcome Swallowing Scale (FOSS) and Communication Scale (CS).

Results

Five-year disease-specific and overall cumulative survival rates by Kaplan-Meier method for all cases were 95.7% and 82.3%, respectively. Duration from surgery to full oral intake was 12 days in Group A and 14 days in Group B. FOSS rates were 83.3 in Group A and 95.5 in Group B. CS was 0 in both groups.

Conclusion

Oncological and functional results of open conservation surgery were comparable to those with transoral surgery and chemo/radiotherapy. Our technique represents a reliable treatment for hypopharyngeal cancer.

Manoeuvres to Improve Endoscopic Visualization of Hypopharynx

The more progress achieved in endoscopy, the more superficial cancers in head and neck region have been diagnosed. There are, however, some areas difficult to observe, particularly the hypopharynx, due to closure of this space. Examination of hypopharynx form an essential part of head and neck examination especially in the suspected malignancies as well as in the cases with unknown primary. As the flexible fiber-optic nasopharyngolaryngoscopy forms an essential part of examination of hypopharynx, the present study aims to evaluate the effectiveness of various manoeuvres devised to aid in better visualization of the hypopharynx. The present prospective study is an observation carried out on 30 patients, which had been followed up for hypopharyngeal or laryngeal disease, in the OPD of the department of Otorhinolaryngology and head and neck surgery in Gandhi Medical College and associated hospital, Bhopal, M.P. In the present study, authors compared the visibility of subsites of hypopharynx in 30 patients undergoing trans nasal flexible fibre optic endoscopy in normal seated position and with head torsion, valsalva manoeuvre and the Killian position. The authors concluded that the above mentioned manoeuvres facilitated the visualization of the entire circumference of the hypopharynx during endoscopic examination, are non invasive and easy to perform and so should be included as a part of routine examination while performing flexible fibre optic endoscopy.

Comparison of Clinical and Functional Outcomes Using Pectoralis Major and Cutaneous Free Flaps for Hypopharyngeal Squamous Cell Carcinoma

Background

The purpose of this study was to compare postoperative morbidities and functional outcomes of pectoralis major myocutaneous (PMMC) flap and cutaneous free flap reconstruction approaches in hypopharyngeal squamous cell carcinoma patients.

Methods

We retrospectively reviewed records from 99 patients who underwent hypopharyngeal reconstruction with a cutaneous free flap (n=85) or PMMC flap (n=14) between 1995 and 2013. Morbidity was classified into hospitalization, medical, or flap-related complications. Functional outcomes were classified into oral re-alimentation and decannulation time.

Results

The overall flap-related complication rate was higher in the PMMC flap group (n=8, 57.1%; P=0.019), but the medical morbidity rate was higher in the cutaneous free flap group (n=68, 80%; P=0.006). The rate of pneumonia was higher in the cutaneous free flap group (n=48, 56.5%; P=0.020). Pulmonary premorbidity was the variable most significantly associated with pneumonia (odds ratio=3.012, P=0.012). There was no statistically significant difference in oral re-alimentation and decannulation time between the two groups.

Conclusions

Although the functional superiority of free flaps has been reported in many studies, our results do not support this hypothesis. One limitation of our study is the relatively smaller flap size and fewer PMMC flap cases compared with the cutaneous free flap group. The low postoperative medical morbidity incidence rate in the PMMC flap group was clinically significant; however, the free flap group had more flap-related complications. Thus, PMMC flaps should be considered a viable option, especially for patients with pulmonary premorbidities.

Primary radiotherapy for squamous cell carcinoma of the pyriform sinus

The objective of this study is to report the long-term outcomes of primary radiotherapy (RT) for patients with T1-T2 squamous cell carcinomas (SCC) of the pyriform sinus. Between November 1964 and March 2008, 135 patients with T1-T2 pyriform sinus SCC were treated with primary RT at the University of Florida. Adjuvant chemotherapy was employed in 21 patients (16 %) and 62 patients (46 %) underwent a planned neck dissection. Median follow-up was 3.5 years (range 0.2-24.7 years); median follow-up on living patients was 8.3 years (range 3.8-24.0 years). The 5-year outcomes were as follows: local control, 85 %; regional control, 81 %; local-regional control, 71 %; distant metastasis-free survival, 76 %; cause-specific survival, 62 %; and overall survival, 38 %. The 5-year local control rate was 88 % for T1 cancers and 84 % for those with T2 SCCs (p = 0.5429). Sixteen patients (12 %) experienced severe late complications. Primary RT results in a high probability of cure with a relatively modest risk of severe late complications for patients with T1-T2 SCCs of the pyriform sinus.

A new option for hypopharyngeal reconstruction with transverse cervical artery perforator flap: a case report

We report a case of a 61-year-old man with T2N2M0 hypopharyngeal carcinoma. In this case, the right vertical hemipharyngolaryngectomy (VHPL) and the right radical neck dissection were performed. At the same time, flap was taken from the superficial branch of transverse cervical artery for hypopharyngeal reconstruction. Postoperative wound healed smoothly. The patient resumed normal oral intake and was free of the tracheal tube at the 12th and 15th days after surgery, respectively. The superficial branch of transverse cervical artery flap is a new option to successfully reconstruct hypopharynx and has many advantages, such as no additional incision, a thin shape, local transfer, and a reliable blood supply.

Novel laryngoscopic strategies to improve evaluation of the site and extent of primary hypopharyngeal tumours

Objective:

To investigate different strategies for displaying the hypopharynx and oesophageal entrance during laryngoscopy for hypopharyngeal cancer.

Patients and methods:

A total of 113 patients with hypopharyngeal cancer underwent laryngoscopy prior to surgery. The hypopharynx was displayed by: (1) pulling the anterior cervical skin; (2) having the patient perform the Valsalva balloon-blowing manoeuvre; and (3) injecting oxygen through the biopsy channel to expose the oesophageal entrance. The effect of these methods on visualisation of primary tumour size and extent was assessed.

Results:

During pronunciation of the letter ‘e', the hypopharynx was displayed in only 33 patients (29.2 per cent); with anterior cervical skin traction plus the balloon-blowing manoeuvre, the hypopharynx was displayed in 106 patients (93.8 per cent; p < 0.001). The combined strategy was superior especially when judging the extent of posterior pharyngeal wall and postcricoid invasion. Oesophageal entrance involvement was visible in 33 patients upon injecting oxygen through the laryngoscopic biopsy channel, and in 25 patients during radiological examination; laryngoscopy was superior to radiological examination in determining the extent of oesophageal entrance invasion (p = 0.003).

Conclusion:

Adequate laryngoscopic display of the hypopharynx could increase the accuracy of pre-treatment hypopharyngeal cancer staging.

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.

Definitive radiation therapy for squamous cell carcinoma of the pharyngeal wall

PURPOSE

To analyze the results of definitive radiation therapy (RT) for squamous cell carcinoma of the pharyngeal wall.

METHODS AND MATERIALS

Between 1964 and 2009, 170 patients were treated with definitive RT; all living patients had a 1.7-year minimum follow-up.

RESULTS

The 5-year rates of local control and ultimate local control were the following: T1, 93% and 93%; T2, 84% and 91%; T3, 60% and 62%; and T4, 44% and 44%. Multivariate analysis revealed stage I-II tumors, female gender, and altered fractionation were associated with improved local-regional control. The 5-year cause-specific and overall survival rates were the following: I, 88% and 50%; II, 89% and 57%; III, 49% and 31%; IV, 35% and 21%; and overall, 50% and 31%, respectively. Fatal complications occurred in 9 patients (5%).

CONCLUSIONS

Local-regional control and survival are related to extent of disease and treatment technique. Although outcomes have improved in recent years, the morbidity of treatment is significant and a substantial proportion of patients die due to cancer.