Primary and salvage (hypo)pharyngectomy: Analysis and outcome

BACKGROUND: Surgery for squamous cell carcinoma (SCC) arising or extending to the hypopharynx is generally reserved for advanced disease or salvage. The prognosis of patients requiring pharyngectomy is poor, and the perioperative morbidity is significant. The aim of the present study is to describe the disease-related and treatment-related outcomes of patients undergoing primary and salvage pharyngectomy for cancer of the hypopharynx and larynx over a 10-year period from a single institution. METHODS: We retrospectively reviewed 138 partial and circumferential pharyngectomies performed at a tertiary referral center between 1992 and 2002. There were 31 females and 107 males. The median age was 62 years (range, 27-81 years), and mean follow-up was 3.6 years. Salvage pharyngectomy for radiation failure was performed in 72 patients (52%), and in 66 patients (48%) pharyngectomy was performed as the primary treatment. RESULTS: The 5-year overall survival rate after salvage pharyngectomy was 31% and after primary pharyngectomy was 38%. The 5-year disease-specific survival (DSS) for salvage was 40% and after primary surgery was 45%. The 5-year local and regional control rates for salvage pharyngectomy were 71% and 70%, respectively, and for primary pharyngectomy were 79% and 67%, respectively. The perioperative mortality rate was 3.6%, and the combined morbidity rate was 70%. Postoperative hypocalcemia developed in 44% of patients, a pharyngocutaneous fistula developed in 31% of patients, and the long-term stricture rate was 15%. Variables adversely affecting DSS on univariate analysis were nodal metastases (p = .044), extracapsular spread (ECS) (p = .006), poorly differentiated tumors (p = .015), lymphovascular invasion (p = .042), and positive tumor margins (p = .026). ECS (p = .023) was the only independent prognostic variable on multivariable analysis; however, there was a trend toward significance for nodal metastases (p = .064) and tumor differentiation (p = .079). CONCLUSION: This study demonstrates that both salvage pharyngectomy and primary surgery for advanced disease are viable options with high locoregional control. However, this represents a high-risk group in terms of both operative morbidity and survival. Patients with nodal metastases, ECS, and poorly differentiated tumors are likely to succumb to their disease and should be selected for adjuvant therapy when possible.     

Improved survival in patients with head and neck cancer in the 1990s

It is generally felt amongst the medical profession and the lay public that cancer is being treated more successfully than in the past. This is certainly true for childhood malignancies and leukaemia but evidence that significantly improved survival is occurring in the common solid tumours is lacking. Since 1963 the University of Liverpool Department of Otolaryngology/Head and Neck Surgery has collected data on all patients with head and neck tumours presenting to the department. The present study investigates patients with histologically proven squamous cell carcinoma of the four main sites: larynx, hypopharynx, oral cavity and orophyarnx. From 1963 until the end of 1989, 2738 patients were seen by the department and from 1990 a further 717 patients have been seen. Since 1990 patients have tended to be in better general physical condition but, on the other hand, have tended to have more advanced disease at the primary site. The department has latterly tended to see fewer laryngeal cancers and more cancers of the oropharynx. Significantly fewer patients have presented with neck node metastases. Multiple logistic regression suggests that the most significant difference between the two groups is the great reduction in neck node recurrence rates in the group of patients seen since 1990 (P = 0.0001). The recurrence of tumours at the primary site since 1990 has been 35% compared with 41% before 1990, and recurrence in the neck nodes since 1990 has been 12%, compared with 15% before 1990. These differences are significant (P = 0.0141 and P = 0.0494, respectively). When studying survival in the 1960s, 1970s and 1980s, the 5-year cure rate was 50%, whereas since 1990 the figure has risen to 60% tumour-specific 5-year survival—a significant difference. A similar effect was noted in observed survival. This improvement in cure rate occurred for all four main sites. The results were confirmed by Cox’s proportional hazards model where year of treatment was highly significantly associated with improved survival (P = 0.0001). It has been demonstrated that locoregional recurrence has improved since 1990 and this is reflected in improved survival figures. Although there are differences in the parameters of tumours referred before 1990 and since 1990, multivariate analysis suggests that the improvement in neck node recurrence rates may be responsible for this improved survival rate. Multivariate analysis for survival also suggests that the improvement in cure rates is independent of compounding variables and dependent on the year of presentation of the tumour. This improved survival may be related to factors, such as the administration of radical postoperative radiotherapy.     

Rare living hypopharyngeal foreign body

BACKGROUND: This is a case report about a rare hypopharyngeal foreign body causing dysphagia, dyspnea, and hemoptysis as well as melena: an ingested leech. The patient was in this condition for more than 1 week. METHODS: The ingested leech, attached to the right piriform fossa partially obstructing the larynx, had to be removed under general anesthesia. RESULTS: After removal, no further symptoms occurred. The leech was identified as the species Theromyzon tessulatum. CONCLUSIONS: Human infestation of a leech in the upper aerodigestive tract is a very rare condition in urban areas. The current literature is reviewed and the diagnostic approach as well as therapeutic options are discussed.     

Management of Post-cricoid carcinoma

This paper discusses the results of treatment of post-cricoid carcinoma based on a personal series of 141 patients. The following conclusions can be drawn: small tumours with no clinical evidence of cervical lymph node metastasis should almost certainly be treated with radiotherapy, which gives a 5-year survival of approximately 35%. Surgery for recurrent disease after radiotherapy is fraught with complications, and satisfactory salvage is seldom possible. Surgery for larger tumours and those associated with neck node metastases has a lower (20%) 5-year survival with a high incidence of complications. The main problem after pharyngolaryngectomy is replacement of the pharynx. There is no evidence that any one of the methods in common use (skin flaps, transposition of the colon or stomach) is superior to any other.     

喉咽部滑膜肉瘤的临床特征

目的　探讨喉咽部滑膜肉瘤的临床特征。方法　通过复习文献并对 1例喉咽部滑膜肉瘤患者的临床资料进行分析。结果　该病例治疗结束后随访 6个月无复发。结论　喉咽部滑膜肉瘤是头颈部罕见的软组织恶性肿瘤。其诊断除根据临床表现外 ,主要依靠病理学检查。治疗采用以手术为主的综合治疗。预后受多种因素影响。     

Head and Neck Cancer: Global Burden and Regional Trends in India

The actual burden of head and neck cancer in India is much greater than reflected through the existingliterature and hence can be regarded as a ‘tip of iceberg’ situation. This has further been evident by the recentreports of ‘Net-based Atlas of Cancer in India’. South-east Asia is likely to face sharp increases of over 75% inthe number of cancer deaths in 2020 as compared to 2000. Since the percentage increase of Indian populationhas been nearly twice that of the world in last 15 years there is a likelihood of increase in cancer burden with thesame proportion. The distribution of population based cancer registries is grossly uneven with certain importantparts of the country being not represented at all and hence the current cancer burden is not reflected by registrydata. However, the pathetic situation of health care system in major parts of the country as also emphasizedby the World Bank, is not suitable to provide anywhere near accurate data on cancer burden. Head and neckcancer (including thyroid lesions) is third most common malignancy seen in both the sexes across the globe butis the commonest malignancy encountered in Indian males. Also oral cavity cancer is the most prevalent typeamongst the males and one of the highest across the globe. This article reviews the latest global and nationalsituation with an especial emphasis on head and neck cancer. Furthermore this review focuses on burden indifferent sub sites at national and global levels.     

Current management strategy of hypopharyngeal carcinoma

Objectives

Squamous cell carcinoma (SCC) of the hypopharynx represents a distinct clinical entity among other cancers of the head and neck region. Despite recent advances in chemoradiotherapy, surgery remains the preferred therapeutic option for locally advanced disease and salvage for failure after chemo-radiotherapy. In this article, several aspects of surgical and non-surgical approaches in the management of hypopharyngeal cancer are discussed.

Methods

A search in pubmed was made for publications with regard to the management of hypopharyngeal carcinoma.

Results

In early-staged hypopharyngeal cancer, the overall and disease-specific survival rates after organ-preserving radiotherapy is comparable to that after surgery. However, for advanced staged disease, the results initial surgery with post-operative adjuvant radiotherapy was superior to chemoradiotherapy alone. The incidence of occult nodal metastasis is found to be more than 20%. Selective neck dissection removing cervical lymph node level II–IV is the procedure of choice for patients with clinically N0 neck. Contralateral nodal clearance may also be considered in tumors involving the medial wall of the pyriform recess, post-crioid region or the posterior wall, and those with ipsilateral palpable nodal metastasis and clinical stage IV disease. Transoral robotic surgery (TORS) has the potential value as the minimally invasive procedure for the management of carcinoma of the hypopharynx.

Conclusions

The treatment strategy for carcinoma of the hypopharynx has been evolving with time. Organ preserving chemoradiotherapy has been the treatment of choice for early stage disease, with surgical resection and reconstruction reserved for advanced and recurrent tumors.