Squamous cell carcinoma of the pyriform sinus: a nonrandomized comparison of therapeutic modalities and long-term results

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.

Development and Validation of a Prognostic Nomogram for Hypopharyngeal Carcinoma

Hypopharyngeal squamous-cell carcinoma (HSCC) is a relatively rare head and neck cancer, with great variation in patient outcomes. This study aimed to develop a prognostic nomogram for patients with HSCC. From the Surveillance, Epidemiology, and End Results (SEER) database, we retrieved the clinical data of 2198 patients diagnosed with HSCC between 2010 and 2016. The patients were randomly assigned at a 4:1 ratio to the training set or the validation set. An external validation was performed by a set of 233 patients with locally advanced HSCC treated at our center. A Cox proportional hazards regression model was used to assess the relationship between each variable and overall survival (OS). Cox multivariate regression analysis was performed, and the results were used to develop a prognostic nomogram. The calibration curve and concordance index (C-index) were used to evaluate the accuracy of the prognostic nomogram. With a median overall follow-up time of 41 months (interquartile range: 20 to 61), the median OS for the entire cohort of SEER database was 24 months. The 3-year and 5-year OS rates were 41.3% and 32.5%, respectively. The Cox multivariate regression analysis of the training set showed that age, marital status, race, T stage, N stage, M stage, TNM stage, local treatment, and chemotherapy were correlated with OS. The nomogram showed a superior C-index over TNM stage (training set: 0.718 vs 0.627; validation set: 0.708 vs 0.598; external validation set: 0.709 vs 0.597), and the calibration curve showed a high level of concordance between the predicted OS and the actual OS. The nomogram provides a relatively accurate and applicable prediction of the survival outcome of patients with HSCC.

Long-term outcomes of induction chemotherapy followed by chemoradiotherapy using volumetric-modulated arc therapy as an organ preservation approach in patients with stage IVA-B oropharyngeal or hypopharyngeal cancers

The present study aimed to analyze treatment outcomes after induction chemotherapy followed by chemoradiotherapy (CRT) using volumetric-modulated arc therapy (VMAT) in patients with stage IVA-B oropharyngeal cancer (OPC) or hypopharyngeal cancer (HPC), with long-term observation, including examination of larynx preservation. A total of 60 patients with stage IVA-B OPC or HPC, who underwent induction TPF chemotherapy (a combination regimen consisting of docetaxel, cisplatin, and 5-fluorouracil) followed by CRT using VMAT were analyzed. Overall survival (OS), progression-free survival (PFS), laryngoesophageal dysfunction-free survival (LEDFS), and locoregional control (LRC) were calculated and compared. Univariate and multivariate analyses were performed to determine statistical differences in OS and LEDFS. The median follow-up period at the time of evaluation was 61 months. Twenty-six (43%) patients had OPC and 34 (57%) had HPC. The 5-year OS, PFS, LEDFS, and LRC rates were 57%, 52%, 52%, and 68%, respectively. Response to TPF therapy was the only significant predictive factor of OS and LEDFS in multivariate analyses. Regarding long-term toxicities, grade ≥ 2 late toxicities accounted for 15%. No patients experienced grade ≥ 3 xerostomia, and 5% of all patients developed grade 3 dysphagia. With long-term observation, the OS, PFS, and LEDFS rates were relatively good, and the incidence of late toxicities was low. TPF followed by CRT using VMAT was feasible and more effective in those who responded to induction chemotherapy.

"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.

Surgery is not the only determinant of an outcome in patients with hypopharyngeal carcinoma

BACKGROUND

The aim of this study was to evaluate the outcomes in patients treated for hypopharyngeal carcinoma in a single-center and the importance of considering how patient factors influence outcomes.

METHODS

A retrospective review was conducted on patients who were seen at the Prince of Wales Hospital from 1968 to 2015. Kaplan-Meier and Cox regression analyses were performed for each patient and treatment factor to investigate outcomes of local control, cancer-specific survival (CSS), and ultimate local control.

RESULTS

Three hundred thirty patients were analyzed. Significant multivariate predictors for improved local control and CSS were fitness for surgery, cancer operability, surgery with adjuvant radiotherapy, no treatment interruptions (P < .05). Five-year local control (84%), CSS (50%), and ultimate local control (84%) rates were significantly higher in patients treated surgically with adjuvant radiotherapy, compared to single modality treatment (P < .05).

CONCLUSION

Patient factors influence the outcomes experienced by patients with hypopharyngeal carcinoma.

Prevalence and prognostic impact of synchronous distant metastases in patients with hypopharynx squamous cell carcinomas: a SEER-based study

Background: The prognosis of hypopharynx squamous cell carcinoma (SCC) patients with distant metastasis is poor. We sought to explore prevalence and prognostic impact of synchronous distant metastases among patients with hypopharynx SCC in this study. Methods: Patients with histologically proven hypopharynx SCC were extracted from the Surveillance, Epidemiology and End Results (SEER) database between 2010 and 2014. We examined the relationship between tumor factors and distant metastases using Chi-squared tests and we evaluated the association between survival and different variables using the methods of Kaplan-Meier. Univariate analysis was performed using the log-rank test. Multivariate analyses with the Cox proportional hazards model were used to test the independent significance of the predictors, and two-tailed p-values less than 0.05 were considered statistically significant. Results: We finally identified 1780 patients who were diagnosed with hypopharynx SCC and the most frequent site of distant metastases was lung. Some clinical characteristics, including age, gender, race, histological grade, T classification and N classification were independent risk factors. Higher T or N category, posterior wall of hypopharynx cancers and multiple sites of metastases were associated with poorer overall survival. For cancer-specific survival, elderly patients with higher T category, advanced N category, posterior wall of hypopharynx cancers, multiple sites of metastases and no surgery therapies to the primary tumor were associated with worse survival. Conclusion: This is the first SEER analysis assessing prevalence and prognostic impact of synchronous distant metastases in a large cohort of patients with hypopharynx SCC. Poorer prognosis was associated with elderly patients, higher T category, advanced N category, posterior wall of hypopharynx cancers, no surgery therapies to the primary tumor and more metastatic sites.

Options of medical treatment and laryngeal function preservation in elderly patients with medial wall pyriform sinus cancer

Objective

To retrospectively investigate the clinical efficacy and larynx preservation of two different treatments: radiotherapy followed by surgery (R+S) and surgery followed by radiotherapy (S+R), in elderly patients with medial wall pyriform sinus cancer.

Materials and methods

Medical records from 48 patients over 70 years old with medial wall pyriform sinus cancer who underwent different treatments between 2001 and 2010 were analyzed. Twenty-one patients underwent radiotherapy first followed by surgery (R+S), and the other 27 patients underwent surgery first followed by radiotherapy (S+R). A Kaplan–Meier method was used to calculate the survival rate.

Results

Overall 3-year and 5-year survival rates were 60.4% and 35.4%, respectively. The 5-year survival rates in R+S group and S+R group were 38.1% and 33.3%, respectively, without a statistically significant difference between the two groups (P>0.05). Also, comparisons of the decannulation rates (64.3% for R+S group vs 50.0% for S+R group) and postoperative complication rates (42.9% for R+S group vs 37.0% for S+R group) between the two groups of patients did not show obvious differences. However, the laryngeal preservation rates in R+S group and S+R group were 66.7% and 37.0%, respectively, with significantly statistical difference between the two groups (P<0.05).

Conclusion

Based on the data analysis of 48 patients, the survival rates of elderly patients who underwent R+S or S+R were comparable, but R+S treatment could improve the laryngeal preservation rate of patients. Further study on large-scale sample pool should be performed to confirm this conclusion.

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.

Definitive Chemoradiotherapy Versus Surgery Followed by Adjuvant Radiotherapy in Resectable Stage III/IV Hypopharyngeal Cancer

Purpose

The purpose of this study is to compare the treatment outcomes for locally advanced resectable hypopharyngeal cancer between organ-preserving chemoradiotherapy (CRT) and surgery followed by radiotherapy (SRT).

Materials and Methods

We reviewed 91 patients with stage III/IV hypopharyngeal squamous cell carcinoma treated with radiotherapy (RT). In the CRT group (n=34), 18 patients were treated with concurrent CRT and 16 patients with induction chemotherapy plus concurrent CRT. In the SRT group (n=57), six patients were treated with total laryngopharyngectomy, 34 patients with total laryngectomy (TL) and partial pharyngectomy (PP), and 17 patients with PP, which were followed by adjuvant radiotherapy (n=41) or CRT (n=16). The median RT dose was 70 Gy for CRT and 59.4 Gy for SRT.

Results

Five-year local control (84.1% vs. 90.9%), and disease-free survival (DFS, 51.0% vs. 52.7%) and overall survival (OS, 58.6% vs. 56.6%) showed no significant difference between the CRT and SRT groups. The functional larynx-preservation rate was higher in the CRT group (88.2% vs. 29.8%). Treatment-related toxicity, requiring surgical intervention, occurred more frequently in the SRT group (37% vs. 12%). In the SRT group, TL resulted in a significantly higher DFS than larynx-sparing surgery (63.9% vs. 26.5%, p=0.027). Treatment outcome of the SRT group improved when only patients with TL were considered (n=40); however, 5-year OS (67.1% vs. 58.6%, p=0.830) and DFS (63.9% vs. 51.0%, p=0.490) did not improve significantly when compared to the CRT group.

Conclusion

Organ preserving CRT provided a treatment outcome that is comparable to SRT for locally advanced hypopharyngeal cancer, while offering an opportunity for functional larynx-preservation and reduced treatment-related toxicity.

Hypopharyngeal cancers requiring reconstruction: a single institute experience

The main objective of this retrospective analysis was to understand the length of stay in hospital, the complication rates and the perioperative mortality after various forms of hypopharyngeal reconstructions. This is a retrospective analysis of hypopharyngeal cancer patients who underwent surgery at the Tata Memorial Hospital, during 2005-2010. Of the total 393 patients, 103 required some form of pharyngeal reconstruction. The mean age of this population was 56 with a male to female ratio of 4:1. The mean hospital stay for all patients was 22 days (mean: 22, median: 15) and 17 % were readmitted for various reasons in the first 30 days after the initial discharge from hospital. The overall perioperative mortality was 10 % (10/103) and majority of these patients (6/10) had GPU as part of treatment. Gastric pull up has a high morbidity especially in patients with low albumin levels and should be used judiciously when needed. A comprehensive analysis of clinical and radiological data is helpful for choosing an ideal reconstruction after hypopharyngeal cancer excision.

Functional organ preservation in laryngeal and hypopharyngeal cancer

The principles of open versus laser microsurgical approaches for partial resections of the larynx are described, oncologic as well as functional results discussed and corresponding outcomes following primary radiotherapy are opposed. Over the last decade, the endoscopic partial resection of the larynx has developed to an accepted approach in the treatment of early glottic and supraglottic carcinomas thus leading to a remarkable decline in the use of open surgery. Comparing the various surgical approaches of laryngeal partial resections, the oncological outcome of the patients, as far as survival and organ preservation are concerned, are comparable, whereas functional results of the endoscopic procedures are superior with less morbidity. The surgical procedures put together, are all superior to radiotherapy concerning organ preservation. Transoral laser microsurgery has been used successfully for vocal cord carcinomas with impaired mobility or fixation of the vocal cord, supraglottic carcinomas with infiltration of the pre- and/or paraglottic space as well as for selected hypopharyngeal carcinomas. It has been well documented that laser microsurgery achieves good oncological as well as functional results with reasonable morbidity. However, patients with those tumours have been successfully treated by open partial resections of the larynx at medical centres with appropriate expertise. The initially enthusiastic assessment of study results concerning the efficacy of various protocols of chemoradiation with the intent of organ preservation for laryngeal and hypopharyngeal carcinomas are judged more cautious, today, due to recent reports of rather high rates of late toxicity complications.

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.

A useful procedure for observing the cervical esophagus via the hypopharynx

OBJECTIVE

The aim of the study was to evaluate upper gastrointestinal endoscopy with movable over tube (i.e., the movable over tube method) for observing the hypopharynx to cervical esophagus, for use in treatment, and to determine its safety.

METHODS

The study population consisted of 28 patients (23 men, 5 women; a mean age of 66.6 years old; age range of 50-80 years old). The patients consisted of nine cases of globus sensation, eight cases of hypopharyngeal cancer (post-chemoradiotherapy), three cases of hypopharyngeal cancer (untreated), two cases of hoarseness, two cases of unknown primary carcinoma, two cases of foreign body, one case of esophageal cancer, and one case of dysphagia. We used upper gastrointestinal endoscopy with movable over tube to examine the hypopharynx to the cervical esophagus in subjects.

RESULTS

With the movable over tube method, which was performed under pharyngeal surface anesthesia and an infusion of diazepam (5-10mg/kg body weight), one could observe from the hypopharynx to cervical esophagus without any blind spots. There were no complications after the examination.

CONCLUSIONS

The results suggest that the movable over tube method is an easy, useful, and safe method to observe the region from the hypopharynx to the cervical esophagus.

Voice and swallowing after laryngopharyngectomy and free ileocolic flap reconstruction for hypopharyngeal cancer

Sixteen patients with hypopharyngeal carcinoma who underwent laryngopharyngectomy had immediate reconstruction with a free ileocolic flap to restore voice and swallowing. All patients had satisfactory voice production and swallowing in the early postoperative stage. Maintaining adequate tension and decreasing redundancy of the transferred colon prevented food pooling and provided smooth, rapid swallowing. A wedge resection of the subserosa of the ileocecal valve to increase the intraluminal pressure helped prevent food reflux and provide good phonation. Although this modified technique yielded good initial results, both voice and swallowing deteriorated after concurrent chemoradiotherapy, possibly because of radiation injury to the transferred bowel.

Prognostic relevance of volumetric analysis in tumour specimens of hypopharyngeal cancer

OBJECTIVE

The purpose of this study was to investigate the prognostic relevance of the tumour specimen's volume in patients with squamous cell cancers of the hypopharynx.

DESIGN

Tumour specimens of 67 patients treated primarily with surgery were evaluated, prospectively. Pathologic tumour volume was described as the product of the three longest diameters of the tumour in cubic millimeters (mm(3)). Statistical analysis was performed to determine the relation of pathologic tumour volume to pTNM stages as well as to patients' survival. This study has been approved by our institutional review board.

RESULTS

Pathologic tumour volume was significantly associated with pT (P = 0.006) and pN (P = 0.01). The univariate evaluation of tumour variables showed pathologic tumour volume (P = 0.01) and pN (P = 0.04) as the only parameters which were significantly associated with overall survival. Entering these variables in a Cox regression model, pathologic tumour volume had the most impact on overall survival (P = 0.03). Most important thereby is the fact that we could distinguish within the pN0 group between the more and the less favourable cases.

CONCLUSION

Pathologic tumour volume could be an essential prognostic indicator and the inclusion of this parameter in future clinical trials is recommended.

Prognostic factors for hypopharyngeal cancer: a univariate and multivariate study of 142 cases

CONCLUSIONS

Reduction of distant metastases is essential for better survival. Effective adjuvant chemotherapy should be developed for patients with advanced primary disease (T>2) as well as for patients with advanced nodal status (N>0 or PLN>2).

OBJECTIVES

The aim of this study was to identify prognostic factors for hypopharyngeal cancer.

PATIENTS AND METHODS

In all, 142 previously untreated patients were analyzed retrospectively; 75% of the cases were stage III or IV. Surgical resection was administered as primary treatment to 116 of the patients (82%), while 26 patients (18%) underwent primary radiotherapy.

RESULTS

The cause-specific 5-year actuarial survival was 46.3%. Distant metastases were the most frequent (23%) cause of failure, followed by local recurrence (15%), and regional recurrence (13%). Cox's regression analysis showed that the significant factors affecting cause-specific survival were N classification, T classification, number of pathological lymph node metastases (PLN), lymphatic invasion, and positive surgical margin. Similarly, T classification and PLN affected distant metastases.

Hypopharyngeal cancer

Hypopharyngeal cancers are usually squamous cell carcinomas (SCCs) that has the worst prognosis among the head and neck cancers. Overall, 5-year survival rate remains poor despite recent improvements in diagnostic imaging, radiation and chemotherapy, and improved surgical techniques. Hypopharyngeal cancers tend to present with advanced primary disease, and nodal metastasis is highly likely. The most important features determining prognosis are the size and extent of local spread of the primary carcinoma and the extent of involvement of regional lymph nodes. Distant metastasis at presentation is more common in hypopharyngeal cancers than in other head and neck cancers. Poor survival rate is partly due to emergence of second primary cancers but also to development of distant metastasis. Contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) remain the mainstay of initial radiological evaluation of hypopharyngeal cancer. Imaging usually results in upstaging of the tumor at presentation. Meticulous evaluation of the extent of the primary tumor with attention to spread to the subsites of the hypopharynx, larynx, and cartilage invasion are necessary for accurate staging. After surgery and radiation therapy, it is difficult with CT and MR to differentiate residual and recurrent tumor from edema and scarring. Fluorine 18-fluoro-deoxy-glucose -positron emission tomography (FDG-PET) has high sensitivity in detection of occult, residual, and recurrent tumors but has low specificity. Combined PET and CT increase specificity and are increasingly being used to image posttreatment cases. Other newer imaging modalities such as diffusion-weighted imaging (DWI), MR spectroscopy, and MRI with superparamagnetic iron oxide (SPIO) contrast agent are reported to be useful and should be used more widely in difficult cases.

Clinicopathologic significance of CD105 expression in squamous cell carcinoma of the hypopharynx

BACKGROUND

Induction of angiogenesis is a key process in tumor growth and metastasis. We studied the CD105 (endoglin) and vascular endothelial growth factor (VEGF) in hypopharyngeal cancer to evaluate their clinicopathologic significance.

METHODS

Seventy-three patients who underwent complete excision of hypopharyngeal cancer were included in this study. Clinicopathologic data were collected retrospectively. Immunohistochemical analysis was performed with antibodies of CD105 and VEGF. Positive-stained microvessels for CD105 were counted on hot spots of tumors. The staining intensity for VEGF was also evaluated.

RESULTS

High expression of CD105 correlated significantly with positive nodal metastasis (p < .001) and TNM stage (p < .01). High expression of VEGF correlated significantly with advanced tumor (T) classification (p < .01). The overall 5-year survival rate was worse in patients with higher CD105 expression (p < .001), advanced TNM stage (p < .01), advanced T classification (p < .01), and positive nodal metastasis (p < .001). Furthermore, Cox regression analysis revealed that CD105 expression in microvessels of tumor tissue, advanced T classification, and nodal status were independent factors for survival.

CONCLUSION

Our results suggest that expression of CD105 is a useful predictive prognostic factor in hypopharyngeal cancer.

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.

Squamous cell carcinoma of the oropharynx and hypopharynx

Oropharyngeal and hypopharyngeal squamous cell carcinomas require an interdisciplinary approach to manage patients appropriately. Tumor stage and histology, functional outcome, and patient comorbidities are important factors to consider. Various surgical approaches as well as chemotherapy and radiation therapy alone or in combination remain the mainstay of therapy.

[Hypopharyngeal squamous cell carcinoma: retrospective study of 149 patients]

PURPOSE

Hypopharyngeal squamous cell carcinoma is associated to one of the most unfavorable prognosis among the cancers of the head and neck. The purpose of this study is to analyze its therapeutic modalities in the Salah-Azaïz Institute (Tunis) and to compare their results.

PATIENTS AND METHOD

This retrospective study concerns 271 hypopharyngeal squamous cell carcinomas, compiled in the Carcinologic Surgery Department of Head and Neck of the Salah-Azaïz Institute over a period of 25 years (from 1977 to 2002). The average age of the patients was of 56 years; sex-ratio was on average of 1.2 (man/woman). The indication of a curative treatment was initially retained for 149 (55%) patients, who were the only ones retained for the analysis of results.

RESULTS

We retained the indication of a protocol including surgery and postoperating radiotherapy for 26.2% of the patients. Postoperation mortality rate was 5.1%; the operating rate of morbidity was 46.2%. For 13.5% of the patients, postoperating radiotherapy was permanently interrupted because of a gradual deterioration of the patients' health in the course of treatment. We retained the indication of exclusive radiotherapy for 59.7% of the patients. The average age was of 56 years and the sex-ratio of 1.2. The external radiotherapy was conventional. Radiotherapy had to be permanently interrupted in progress in 32.6% of cases on account of an deterioration of the patients' health; the rate of morbidity of the radiotherapy was 33.3%. We indicated a protocol of conservation of organ with induction chemotherapy for 21 patients (14.1%). The average age was of 53 years (28-65 years) and sex-ratio (man/woman) of 0.5. The global survival was 25.5% at one year, 18.1% at two years, 11.4% at three years and 7.4% at five years. All the patients selected for chemotherapy died in the course of treatment. The rates of survival in two and five years according to protocols surgery-radiotherapy and exclusive radiotherapy were respectively: 21.5 and 12%, and 18.3 and 10%. The difference between the rates of survival of this two protocols is not significant (P =0.08).

CONCLUSION

Although the induction chemotherapy entails a particularly high death rate in our series, the association surgery-radiotherapy and the exclusive radiotherapy seem to be similarly efficient for the treatment of the hypopharyngeal carcinoma.

[Regional failure of hypopharyngeal squamous cell carcinoma]

PURPOSE

Lymph nodes and distant metastases contribute to the poor prognosis of hypopharyngeal squamous cell carcinoma. The purpose of this study is to estimate the frequency, mode and prognosis factors related to regional and distant metastasis.

PATIENTS AND METHOD

The authors' report is based on a retrospective study concerning 271 hypopharyngeal squamous cell carcinoma, compiled in the service of Surgery of Head and Neck Cancers of the Salah-Azaïz Institute (1977-2002). Frequency and histoclinical characters of cervical and distant metastases have been assessed, as well as their prognosis factors among 155 patients treated in a curative purpose.

RESULTS

39.1% of the tumours were classified N0, 24.4% N1, 10.7% N2 and 25.8% N3 (UICC 2002). The cervical nodal invasion was significantly more frequent for the classified tumors T3T4 than for the T1T2 (for pyriform sinus, postcricoid esophagus, posterior wall, and total hypopharynx, respectively : P =0.001, P =0.007, P =0.047 and P =0.0005). A cervical lymphatic evidement was preferred in thirty two patients. Among N0, 46.9% were N+; The frequencies of the capsular effraction were not significantly different for the N0N1 from for the N2N3 (P =0.11). The two and five years survival rates were respectively 32.5 and 20.5% for N0, and 10.9% and zero for N3. The survival differences after two and five years between the N0N1 and the N2N3 were significant (P =0.04). A regional failure was noticed for 18.5% of the patients. The tumoral site did not influence significantly the rate of nodal failure (P =0.98), neither the clinical status N (P =0.34). Capsular effraction was a significant factor for the regional failure (P =0.007). Distant metastasis significantly occurred more frequently among the patients initially classified N2N3 than those classified N0N1 (P =0.03), and in case of capsular effraction (P =0.0009).

CONCLUSION

Hypopharyngeal squamous cell carcinoma has a high rate of lymph nodes metastasis, correlated to the local extension, and a high rate of occult nodal metastasis. Lymph node clinical status does not seem to have influenced the patients survival; however, capsular effraction constitutes a major prognosis factor of regional failure and distant metastasis. Distant metastases are frequent, particularly in case of wide local and regional tumoral extension.

CT determination of lymphocytic infiltration around head and neck squamous cell carcinomas may be a predictor of lymph node metastases

The histological detection of a peritumoral lymphocytic infiltration (PLI) and a sharp tumor border in patients with squamous cell carcinoma (SCC) of the larynx, pharynx or oral cavity is inversely correlated with the development of cervical lymph node metastases and is therefore a favorable prognostic factor. However, preoperative biopsies are often too small for an evaluation of these tumor features. Here, we examined retrospectively whether elevation of peritumoral density values as determined by contrast-enhanced computed tomography (CT) correlates with PLI and the presence of cervical lymph node metastases. A total of 40 patients with primarily resected SCC were studied (pT1=8, pT2=13, pT3=9, pT4=10); 25 patients were pN-positive. All tumors were histologically analyzed regarding PLI (present or not) and the tumor border (sharp or infiltrating). Based on standardized CT examinations (90 ml contrast agent at 1.5 ml/s), repeated region-of-interest (ROI)-based peritumoral density measurements were obtained. Correlations between CT density, PLI, tumor border and metastatic involvement of regional lymph nodes were statistically evaluated. CT densities were significantly higher (P<0.001) in patients with PLI and sharp tumor borders than in patients without PLI and patients with infiltrating tumor borders. Moreover, the presence of PLI, sharp tumor borders and elevated peritumoral CT densities were each correlated with the absence of lymph node metastases (P<0.001). An elevation of peritumoral CT densities is linked to PLI and sharp tumor borders on histology and a lower risk to develop lymph node metastases. For a patient-adapted therapy, these relations have to be prospectively evaluated regarding their prognostic relevance.

The clinicopathological significance of p53 and p21 expression in squamous cell carcinoma of hypopharyngeal cancer

To evaluate the roles of p53 and p21 expression in the squamous cell carcinoma of hypopharyngeal cancer, we performed the immunohistochemical studies in 58 patients with hypopharyngeal cancer. We found significant correlation between a high expression of p53 and a histological grade of well differentiation, advanced tumor (T) and TNM stage. Furthermore, low expression of p21 correlated significantly with advanced TNM stage and positive nodal status. Cox's regression analysis revealed tumor stage and nodal status were the only prognostic factors for survival. Therefore, we concluded that p53 and p21 are useful markers in predicting some clinicopathological features in hypopharyngeal cancer.

Primary laryngopharyngeal reconstruction using pectoralis major myocutaneous flaps - Our experience

Twenty-one eases of laryngectomy/laryngopharyngectomy that required primary reconstruction with P. M. M. C flaps at the Division of Surgical Oncology, Regional Cancer Centre, Triyandrum were studied retrospectively from July 1995 to December 2090 and compared with the in cases where primary closure of the neopharynx was done.Four of the 21 cases developed post operative pharyngocutaneous fistulae PCF(I9%) which healed Complefely within an average period of I week compared to 4 PCFs (40%) after primary closure. (n=10), where the average healing time was 12.5 days, with I recurrence. The average duration of Onset of fistula was relatively earlier in cases that required primary closure (II days) compared to those cases where P. M. M. C flap was used for reconstruction (12.5 days). All complications were Wound related and managed conservatively.

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.

acp Best Practice No 169. Evidence based pathology: squamous carcinoma of the hypopharynx

This best practice article reviews the published evidence on the pathology and patterns of spread of carcinomas of the hypopharynx, and the relevance of pathological features to prognosis. Medline (1966-2001) was searched using a combination of head and neck neoplasms and prognosis, focusing on hypopharynx and pathology. Other relevant publications were identified from the bibliographies of these papers, and from those obtained opportunistically. There is relatively little pathological literature devoted specifically to squamous carcinomas of the hypopharynx and most information comes from large series of patients with head and neck cancers at a range at sites. Lack of consistency in reporting and shifts in terminology make comparisons between series difficult. The most important features determining prognosis are size and extent of local spread of the primary carcinoma and extent of involvement of regional lymph nodes. There is evidence to support the use of the minimum dataset criteria for head and neck carcinomas at this site. Within the hypopharynx, subsite related differences in aetiology and biology may become important.

Laryngopharyngectomy with reconstruction

A wide range of reconstructive options allows the ablative surgeon to resect tumors completely with wide margins. Wide resection is especially important because of the rich lymphatic drainage and submucosal spread seen with carcinomas in the hypopharyngeal area. Postoperative stenosis can be a difficult, recurring problem if the neopharynx does not have enough tissue incorporated into the closure. Therefore, most laryngopharyngectomy procedures benefit from the addition of transposed tissue, either pedicled or using free tissue transfer microvascular techniques. Often the location of the tumor is a major factor in determining which reconstruction is best for the patient. Minimizing the donor-site morbidity must be carefully considered, also.

Human leukocyte antigens and prognosis in patients with head and neck cancer: results of a prospective follow-up study

BACKGROUND

Prognostic information is essential for optimal treatment of patients with head and neck cancer. We studied the relationship of class I and class II human leukocyte antigens (HLA) on prognosis in patients with head and neck cancer.

METHODS

HLA-A, -B, -C and -DR antigens were determined in 209 patients with squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx. The patients were subjected to follow-up investigations for a period of 5 years.

RESULTS

Five-year survival rates in relation to tumor stage varied between 86% for stage I tumors and 28% for stage IV tumors (P <.0001, log-rank trend test). The EBA-A11 antigen showed a significant negative correlation with survival. While the 5-year survival of 124 HELA-A11-negative patients was 58%, none of the 17 HLA-A11-positive patients survived 5 years (P = .0002). A significant negative correlation with survival was also observed for HLA-DR6. While the 5-year survival rate of 106 HLA-DR6-negative patients was 60%, it was only 40% in 35 HLA-DR6-positive patients (P = .0313).

CONCLUSIONS

If the findings of our study can be confirmed, HLA-A11 and HLA-DR6 might become clinically important supplemental prognostic markers in head and neck cancer.

Avaliação dos resultados da cirurgia conservadora do câncer da laringe

OBJETIVO: Avaliar retrospectivamente os resultados de pacientes submetidos a laringectomias parciais por carcinoma epidermóide de laringe no serviço do HMCP. MÉTODOS: Dos doentes estudados, 28 eram do sexo masculino (93,5%) e dois do feminino (6,5%) com idade variável de 42 a 66 anos, com média de 58 anos. Em relação ao procedimento cirúrgico, este foi variável, dependendo do local da extensão tumoral e do estádio. A técnica mais utilizada foi a laringectomia frontolateral em 12 pacientes (40%), seguido pela laringectomia vertical em oito (26,6%), laringectomia supraglótica em quatro (13,3%), laringectomia supracricóidea em quatro (13,3%), laringectomia near-total em um (3,3%) e cordectomia em um (3,3%). RESULTADOS: Na avaliação pós-operatória precoce, três pacientes (10%) apresentaram complicações evidenciadas por fístula faringocutâneas em dois, com boa evolução após tratamento conservador, e pneumotórax no paciente restante com boa evolução após drenagem do tórax. No que se refere à avaliação da deglutição, cinco pacientes (16,6%) apresentaram dificuldade de ingestão oral devido a aspirações recorrentes com tempo variável de 45 a 180 dias (média - 65 dias), o que obrigou a um paciente ser submetido à totalização da laringectomia devido a pneumonias recorrentes. Na avaliação tardia, de seis a 125 meses e média de 29 meses, quatro pacientes (13,3%) apresentaram recidiva locorregional, sendo dois submetidos à laringectomia vertical, um à frontolateral e o restante à supracricóidea. Em todos foram realizadas totalização e/ou radioterapia, e dois evoluíram a óbito pela doença. Vinte e quatro pacientes (84%) apresentaram preservação da voz. CONCLUSÃO: Assim, os autores concluem que a cirurgia conservadora da laringe proporciona bom controle da doença e com sobrevida aceitável, já que 90% dos pacientes estudados estão vivos e sem doença até o final da avaliação. Além disso, apresentam melhor qualidade de vida já que a maioria dos pacientes demonstrou voz e ingestão oral bem satisfatórias.

Cervical node metastasis in Carcinoma of Pyriform Sinus: A prospective analysis of prevalence and distribution

The present study included 28 cases of carcinoma of pyriform sinus admitted in ENT ward of SMS Hospital in year 2000. The present work has been undertaken to analyse the prevalence and distribution of cervical lymph node metastases in cases of Pyriform sinus carcinoma, to compare the incidence and distribution of lymph node metastasis in medial vs lateral wall pyriform sinus carcinoma and to review the case of pyriform sinus carcinoma in reference to symptoms, clinical features and histopathological tumor staging.Most of the patients were in 6(th) decade of life. Sex incidence observed was male 93% and female 7% Histological variety was moderately differentiated squamous cell carcinoma (46.5%) which differs from the previous studies reporting the commonest variety to be poorly differentiated squamous cell carcinoma.It was observed in this series that 60% cases were of malignancy medial wall of pyriform fossa and 40% cases were of both lateral and medial wall. In contrast to previous studies which suggested that chances of contralateral cervical metastases was more with carcinoma involving medial wall of pyriform sinus, we observed equal incidence of contralateral node metastases in both group of pyriform sinus carcinoma case.In the present study 75% cases presented to us with T(4) stage. Though there were 4 cases of T(1) tumor in present series but none were in TNM stage I or II. This indicates that there is essentially no difference in the risk of lymph node metastases by T-stage.

Advanced hypopharyngeal carcinoma treatment results according to treatment modalities

BACKGROUND

The purpose of this retrospective study is to compare the treatment results of locally advanced hypopharyngeal carcinoma according to treatment modalities.

METHODS

Seventy-three patients with locally advanced hypopharyngeal carcinoma treated at the Department of Therapeutic Radiology, Seoul National University Hospital, between August 1979 and July 1997 were retrospectively analyzed. Twenty-three patients were treated with radiotherapy (RT) alone, 18 patients were treated with surgery and postoperative RT, and 32 patients were treated with neoadjuvant chemotherapy (CTx) and RT. Median follow-up period was 28 months.

RESULTS

The overall 5-year survival rates were 15.7% for the RT alone group, 46.8% for surgery and postoperative RT group, and 43.0% for neoadjuvant CTx and RT group. The 5-year disease-free survival rates were 13.9%, 47.4%, and 30.7%, respectively. Surgery and postoperative RT or neoadjuvant CTx and RT showed superiority over RT alone in terms of both overall survival and disease-free survival rates. No significant differences were found in overall and disease-free survival rates between the surgery and postoperative RT group and neoadjuvant CTx and RT group (p =.15, p =.13). In the neoadjuvant CTx and RT group, 12 patients (38%) retained their larynx more than 5 years.

CONCLUSION

Neoadjuvant CTx and RT is an effective strategy to achieve organ preservation without compromising the survival of patients with locally advanced hypopharyngeal carcinoma.

Delayed regional metastases, distant metastases, and second primary malignancies in squamous cell carcinomas of the larynx and hypopharynx

OBJECTIVE

To determine the impact of delayed regional metastases, distant metastases, and second primary tumors on the therapeutic outcomes in squamous cell carcinomas of the larynx and hypopharynx.

STUDY DESIGN

Chart review and statistical analysis.

METHODS

A retrospective tumor registry analysis was made of patients with squamous cell carcinomas of the larynx and hypopharynx who were treated with curative intent in the Department of Otolaryngology-Head and Neck Surgery and the Radiation Oncology Center of the Washington University School of Medicine (St. Louis, MO) between January 1971 and December 1991 and developed delayed regional metastases (2 y after treatment), distant metastases, and second primary malignancies.

RESULTS

In 2550 patients, the mean age (59.8 y), sex (8.5 male patients and 1 female patient), and tumor differentiation did not affect the incidence of delayed distant, regional, or second primary malignancies. The overall incidence of delayed regional metastases was 12.4% (317/2550 patients); distant metastases, 8.5% (217/2550); and second primary tumors, 8.9% (228/2550), with a 5-year disease-specific survival of 41%, 6.4%, and 35%, respectively. Second primary malignancies were not statistically related to the origin of the primary tumor, tumor staging, or delayed regional and distant metastases (P =.98). Delayed regional metastases and distant metastases were related to advanced primary disease (T4 stage), lymph node metastases (node positive [N+]), tumor location (hypopharynx), and locoregional tumor recurrence (P < or =.028). Advanced regional metastases at initial diagnosis (N2 and N3 disease) increased the incidence of delayed and distant metastases threefold (P =.017). These two metastatic parameters were significantly greater in hypopharyngeal tumors than in laryngeal tumors (P =.037). The incidences of delayed regional metastases by anatomical location of the primary tumor were as follows: glottic, 4.4%; supraglottic, 16%; subglottic, 11.5%; aryepiglottic fold, 21.9%; pyriform sinus, 31.1%; and posterior hypopharyngeal wall, 18.5%. The incidences of distant metastases were as follows: glottic, 4%; supraglottic, 3.7%; subglottic, 14%; aryepiglottic fold, 16%; pyriform fossa, 17.2%; and posterior hypopharyngeal wall, 17.6%. Seventeen hypopharyngeal tumors (2%) presented with M1 disease. Delayed regional metastases to the ipsilateral treated neck had a significantly worse survival prognosis than delayed metastases to the contralateral nontreated neck (P =.001).

CONCLUSIONS

Conclusions are as follows: 1) The incidence of second primary tumors is independent from the primary tumor staging and distant and delayed regional metastases. The highest incidence occurred in patient groups with the highest disease-free survival rates (P =.0378). 2) Highest incidence of delayed and distant metastases occurred in hypopharyngeal tumors and was three times greater than in laryngeal cancers (P =.028). 3) Salvage therapeutic rates were poor for delayed metastases to the ipsilateral treated nodes and distant metastases as compared with contralateral neck metastases and second primary tumors (P =.001). 4) Delayed and distant lymph node metastases were significantly higher in advanced primary disease (T4 stage), locoregional recurrences, and regional disease (N2 and N3) (P =.028) in both the larynx and hypopharynx. 5) The higher incidence of delayed and distant metastatic disease was related to more advanced initial tumor presentation in hypopharyngeal cancer as compared with laryngeal cancer (P =.039). 6) Incidence of distant metastases was greatest between 1.5 and 6 years after initial treatment with a mean incidence being less than or equal to 3.2 years.

Organ preservation by transoral laser microsurgery in piriform sinus carcinoma

OBJECTIVE

To determine the effectiveness of organ-preserving CO2 laser microsurgery for the treatment of piriform sinus carcinoma.

METHODS

A retrospective review of 129 previously untreated patients undergoing CO2 laser microsurgery for the treatment of squamous cell carcinomas of the piriform sinus from 1981 to December 1996 was undertaken. The intention was complete tumor removal by preserving functionally important structures of the larynx. Distribution of tumors (Union Internationale Contre le Cancer/American Joint Committee on Cancer, 1992) was 24 cases with pT1, 74 with pT2, 17 with pT3, and 14 with pT4 disease. Node status was positive in 68% of patients. Seventy-five percent of patients had stage III or IV disease. Forty-two percent of the patients were treated solely with surgery, and 58% had surgery and postoperative radiotherapy. The median follow-up interval was 44 months.

RESULTS

Eighty-seven percent of patients were controlled locally. Neck recurrences occurred in 14.0% of patients, metachronous distant metastases with locoregional control in 6.2%, and second primary tumors in 18.6%. Twenty percent of patients died of TNM-related deaths. The 5-year overall Kaplan-Meier survival rate was 71% for stages I and II and 47% for stages III and IV disease; the 5-year recurrence-free survival rates were 95% and 69%, respectively.

CONCLUSION

A comparatively low local recurrence rate, a high recurrence-free survival rate, and the avoidance of laryngectomy favor function-preserving surgery of piriform sinus carcinomas.

Reconstruction of the pharynx and cervical esophagus using ileocolic free autograft

BACKGROUND

Advanced stage hypopharyngeal cancer is commonly treated by surgery and radiotherapy. This report presents a technique using ileocolic free autograft as a single-stage procedure for voice and swallowing rehabilitation after pharyngolaryngoesophagectomy.

METHODS

Digestive tract restoration is obtained by using the cecum and ascending colon, while the last ileal loop, protected by the ileocecal valve for food and liquid inhalation, is anastomized to the cervical trachea. After abdominal harvesting, the ileocolic complex is transected, transposed, and then revascularized in the cervical field.

RESULTS

Six patients underwent this operation successfully with recovery of swallowing function and vocal performance within a short period of time, varying from 18 to 38 days.

CONCLUSION

On the basis of achieved results, the ileocolic free autograft can be considered a good option for pharyngoesophageal reconstruction, offering as it does an immediate restoration of swallowing and voice function.

Surgical management of head and neck cancer

Head and neck cancer surgery continues to evolve through the years and undergo improvement and refinement. In this article, the current state of head and neck cancer surgery is summarized in a site-by-site basis. The most important developments include organ-sparing surgery and microvascular free-tissue transfer for reconstruction.

Contralateral hemilaryngotracheal flap reconstruction of the hypopharynx in pyriform carcinoma resection

OBJECTIVES

To simplify the approach and reconstruction for advanced hypopharyngeal cancer, a modified technique-laryngotracheal fissure approach and laryngotracheal flap reconstruction--is presented.

STUDY DESIGN

Prospective.

METHODS

From August 1991 to December 1995, 44 consecutive patients with advanced hypopharyngeal cancer, mostly involving pyriform sinus, were operated on with this technique. The functional and oncologic results and complications were evaluated.

RESULTS

Reconstruction was completed by using the laryngotracheal flap in 75% of patients, while the other 25% required additional patch-on pectoralis major myocutaneous flaps. Pharyngoesophageal stenosis occurred in one patient after radiotherapy and pharyngocutaneous fistula was noted in two. No local recurrence was noted. Seven cervical metastases developed in the follow-up period and six over the contralateral neck not treated surgically. The 5-year Kaplan-Meier disease-free survival was 46.8%.

CONCLUSIONS

The authors' experience indicates that this is a simplified, radical treatment for most advanced hypopharyngeal cancer, with high applicability, good oncologic results, and low complication.

Squamous cell carcinomas of the aryepiglottic fold: therapeutic results and long-term follow-up

Three hundred fifteen patients with squamous cell carcinomas involving the aryepiglottic (A-E) folds were treated between January 1964 and December 1991. The age ranged from 39 to 87 years (mean, 62.4 years; median, 61.3 years) and the male-to-female ratio was 5:1 (54 women and 261 men). Symptom duration prior to diagnosis was 4.8 months. Eighty percent of patients had T3 and T4 lesions and 56.3% had neck metastases at presentation. Six patients (1.8%) had distant metastases and were excluded from this study. Clinically the tumors presented as either exophytic infiltrating lesions which were confined to the A-E fold (n = 57) or mucosally spreading tumors which extended to the lateral supraglottis or pyriform sinus (n = 258). Prior to 1978 preoperative radiation (3000 to 5000 cGy) was used. Higher doses of postoperative radiation (5000 to 6000+ cGy) were used thereafter. After 1982 the use of myocutaneous flaps for closure of partial laryngopharyngectomy defects was routine. Almost all N0 neck disease was treated by radiation or surgery. Combined therapy was used in N1-N3 disease. One quarter of the patients had single-modality therapy (25.7%; 81 patients) with a cumulative 5-year disease-free survival of 53%. The remainder of the patients (n = 234) had combined therapy with a cumulative 5-year survival of 67.2%. The latter group had 163 conservation surgeries and 121 total laryngectomy resections. The 5-year disease-free survival for preoperative radiation with surgery (68%) and postoperative radiation with surgery (64%) was similar. Those treated by radiation alone had a 34% 5-year disease-free survival and those treated with surgery alone had a 61% 5-year disease-free survival. The cumulative locoregional control rate was 77%. The cumulative disease-free survival at 5, 10, 15, and 20 years is 66%, 57%, 55%, and 55%, respectively. Infiltrating tumors had a better disease-free survival (by more than 10%) than spreading tumors. The 5-year survival rates were separated well by clinical stages of tumors. In patients with T1 tumors the 5-year survival was 87%; in those with T2 tumors, 80%; in those with T3 tumors, 78%; and in those with T4 tumors, 41%. The survival rate was greater in those with N0 tumors than in those with N+ tumors by 25% and greater in those with N1 tumors than in those with N2 + N3 tumors by an additional 18%. The overall complication rate was 26% and in 7.7% these were fatal.(ABSTRACT TRUNCATED AT 400 WORDS)