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

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.

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.

"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.

Modified Infrahyoid Myocutaneous Flap for Laryngopharyngeal Reconstruction

The laryngopharyngeal reconstruction in patients with pyriform sinus carcinoma continues to be a challenge for surgeons. In this article, we describe our experience with laryngopharyngeal reconstruction in patients with pyriform sinus carcinoma using the modified infrahyoid myocutaneous flap (IHMCF). The modified incision design for the modified IHMCF and clinical outcomes are also detailed here. Between January 2012 and February 2018, 10 patients with hypopharyngeal squamous cell carcinoma who underwent laryngopharyngeal reconstruction using the modified IHMCF after hemicricolaryngopharyngectomy were included in this study. The drainage vessels of the modified IHMCF, oncological outcomes, and functional reservation of the larynx were recorded. All of the flaps survived well. No flap necrosis or other major complications occurred during follow-up. None of the patients remained on nasogastric feeding for more than 4 weeks postoperatively. The follow-up period ranged from 12 to 73 months (mean, 36 months). In our series, 6 patients were successfully decannulated and 5 had received radiation therapy. We roughly assessed the speech and swallowing functions, and the outcomes seemed acceptable in all of the patients after surgery. Laryngoscopic examination showed that the modified IHMCF survived well and the new glottis provided excellent function and good ventilation results. In our experience, the modified IHMCF is a safe and viable procedure that can serve as a valid alternative to free flaps and the pectoralis major myocutaneous flap to reconstruct laryngopharyngeal defects.

Open-neck organ preservation surgery for hypopharyngeal cancer: indications, techniques, limits, and outcomes

PURPOSE OF REVIEW

To appraise the practice and role of open-neck organ preserving surgery for hypopharyngeal squamous cell carcinoma and to update the current indications, techniques, limits, and outcomes.

RECENT FINDINGS

The role of primary surgery for hypopharyngeal carcinoma has shifted over the past two decades to primary nonsurgical management with the use of induction or concurrent chemoradiotherapy. The preferred and most suitable tumours for open-neck surgery are the small-volume T stage diseases, with small to medium-volume neck metastases, however such patients are exceedingly rare. Nonetheless, more advanced tumours with cartilage invasion, vocal cord paralysis, or located at piriform apex and postcricoid area, previously unsuitable for open-neck organ preserving surgery, can now be excised and repaired, minimizing morbidity and improving quality of patients' life. Much of this surgical progress has been developed by innovative surgeons using free tissue transfer, accurate placement surgery, reconstruction of a neoglottis, and perfecting the pharyngoesophageal anastomosis. Current practice of open-neck organ preserving surgery for hypopharyngeal carcinoma has been mainly reported in Asia: Korea, Taiwan, Japan, and China.

SUMMARY

There are some patients who are deemed unsuitable and/or unwilling for current treatment by nonsurgical approaches, and open-neck organ preserving laryngopharyngeal surgery may be a more suitable alternative than selecting a 'lesser or modified' chemo or bioradiotherapy regimen, resulting in a prolonged quantity and quality of life.

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.

[Laryngeal conservative surgery in patients candidates for combined treatment with chemo-radiotherapy]

BACKGROUND

The standard of care for advanced-stage laryngeal cancer is combined treatment (chemo-radiotherapy). However, the complications with this treatment are not few, mainly in swallowing. Conservative laryngeal surgery remains an effective alternative for cancer control without the complications of chemo-radiotherapy.

MATERIAL AND METHODS

Retrospective study was conducted on patients with laryngeal cancer cT3, cN0 with paraglottic infiltration, fixation of the vocal cord, minimal invasion of the hyo-thyroepiglottic space, but with normal arytenoid mobility and no sub-glottic extension, were treated with subtotal supracricoid laryngectomy. Complications, sequels of treatment, and local recurrence were evaluated. Bronchial aspiration was studied with radioactive swallow.

RESULTS

There were 25 patients, 22 with negative surgical margins, one had tumour contact with the surgical margins, and 2 were positive. Two patients received postoperative radiotherapy. The mean decannulation was 15 days and removal of nasogastric tube 25 days. During the mean follow-up of 26 months, none of the patients had tumour recurrence or required conversion to total laryngectomy. In all patients swallowing has been normal and none required permanent or temporary tracheotomy or definitive gastrostomy. The voice is considered intelligible in all patients. Radioactive swallow showed aspiration in 15/25 patients, with none being clinically relevant. There were postoperative complications in 5 patients, and 4 patients required re-intervention but no conversion to total laryngectomy.

CONCLUSION

Conservative surgery is an effective surgical-alternative to chemo-radiotherapy in patients with locally advanced laryngeal cancer, providing oncological control, acceptable complications and minimal sequels. Although most patients have aspiration, this does not affect functional status.