Current trends in initial management of hypopharyngeal cancer: the declining use of open surgery

Squamous cell carcinoma of the hypopharynx represents a distinct clinical entity. Most patients present with significant comorbidities and advanced-stage disease. The overall survival is relatively poor because of high rates of regional and distant metastasis at presentation or early in the course of the disease. A multidisciplinary approach is crucial in the overall management of these patients to achieve the best results and maintain or improve functional results. Traditionally, operable hypopharyngeal cancer has been treated by total (occasionally partial) laryngectomy and partial or circumferential pharyngectomy, followed by reconstruction and postoperative radiotherapy in most cases. Efforts to preserve speech and swallowing function in the surgical treatment of hypopharyngeal (and laryngeal) cancer have resulted in a declining use of total laryngopharyngectomy and improved reconstructive efforts, including microvascular free tissue transfer. There are many surgical, as well as nonsurgical, options available for organ and function preservation, which report equally effective tumor control and survival. The selection of appropriate treatment is of crucial importance in the achievement of optimal results for these patients. In this article, several aspects of surgical and nonsurgical approaches in the treatment of hypopharyngeal cancer are discussed. Future studies must be carefully designed within clearly defined populations and use uniform terminology and standardized functional assessment and declare appropriate patient or disease endpoints. These studies should focus on improvement of results, without increasing patient morbidity. In this respect, technical improvements in radiotherapy such as intensity-modulated radiotherapy, advances in supportive care, and incorporation of newer systemic agents such as targeted therapy, are relevant developments.     

Human papillomavirus DNA in head and neck squamous cell carcinomas in the Free State,South Africa

Human papillomaviruses (HPVs) have been associated with a subset of head and neck squamous cell carcinomas (HNSCCs). The aim of this study was to determine the prevalence of HPV DNA in archived formalin-fixed paraffin-embedded tissue from patients with histologically confirmed HNSCCs in a South African cohort. A nested PCR was used for the detection of HPV DNA targeting the L1 gene. Positive samples were confirmed using an in-house hemi-nested PCR targeting the E6 gene and genotyped by sequence determination of amplicons. HPV DNA was detected in 57/780 (7.3%) samples, with the highest prevalence being in the sinonasal tract (16.0%) and oropharynx (10.8%). HPV16 was the most frequently detected type, being found in 26/57 (45.6%) positive samples. The prevalence of HPV DNA in HNSCCs found in this study was lower than that found in developed countries     

带蒂胸大肌岛状肌皮瓣在晚期下咽癌手术中的应用

报道了60例晚期下咽癌术后,利用胸大肌岛状肌皮瓣移植、修复与重建下咽及颈段食道。通过分析手术操作优、缺点及术中注意事项等,认为应用带蒂胸大肌岛状肌皮瓣具有其它皮瓣不具备的优点,操作简便易行,效果满意。     

Carcinoma of the posterior wall of the hypopharynx: surgical treatment with larynx preservation

IntroductionPosterior pharyngeal wall is the most rare subsite for hypopharyngeal carcinomas. Because of its rarity, there are few studies published in the literature specifically concerning posterior pharyngeal wall carcinoma.ObjectivesTo report our functional results in patients with the carcinoma of the posterior wall of the hypopharynx after surgical treatment by resection via a lateral or infrahyoid pharyngotomy approach, with the preservation of the larynx and reconstruction with a radial forearm free flap.MethodsThe study included 10 patients who underwent surgery for a carcinoma of the posterior wall of the hypopharynx over a 6 year period. The associated postoperative morbidity was investigated and functional results were analyzed.ResultsNine patients had T3 lesions and one patient had a T2 lesion. The preferred approach to access the hypopharynx was a lateral pharyngotomy in 5 patients and lateral pharyngotomy combined with infrahyoid pharyngotomy in 5 patients with superior extension to oropharynx. The pharyngeal defects were reconstructed successfully with radial forearm free flaps. Four patients received adjuvant radiotherapy only, and 4 patients with N2b and N2c neck diseases received adjuvant chemoradiotherapy. The mean duration of hospitalization was 15.6 days (range, 10–21 days). All patients achieved oral intake in a median time of 74 days (range, 15–180). Decannulation was achieved in all patients and the median time for decannulation was 90 (range, 21–300 days). The mean followup duration was 38.3 months (range, 10–71 months) and 8 patients survived. One patient died due to regional recurrence in the retropharyngeal lymph nodes and 1 patient died due to systemic metastasis.ConclusionPrimary surgery is still a very effective treatment modality for the carcinoma of the posterior wall of the hypopharynx and does not permanently compromise the swallowing and laryngeal functions if pharyngeal reconstruction is performed with a free flap.     

Carcinoma of the hypopharynx results of primary radical radiation therapy

The results of radiation therapy as applied to patients with squamous cell carcinoma of the hypopharynx seen during the period 1972–1976 at the Princess Margaret Hospital are presented. Approximately $\text{2}\text{3}$ of the patient population presented with disease involving the regional lymph nodes or with systemic metastases. Ninety percent ($\text{127}\text{141}$) of all patients registered were treated primarily with radiation therapy with surgery reserved for the management of residual or recurrent disease only. Seventy-seven percent ($\text{98}\text{127}$) of those who received radiation therapy were treated with radical intent. The uncorrected actuarial 5 year survival rate for those patients treated radically was 19%. Five year actuarial survival rates by the UICC TNM (1974) staging system, showed that nodal disease was the most significant determinant of survival. Five year survival rates were as follows: N₀ 36%; N₁ 20%; N₂N₃0%. When considered within each nodal category the survival of the combined T₁T₂ group was not significantly different from the T₃ category. Forty-five percent of those patients who failed with local or regional disease had an attempt at salvage surgery. Of these, $\text{6}\text{24}$ ultimately achieved local and regional control. Comparisons with other series in the literature are discussed and reasons for differences in published results are considered.     

Loss of HOP tumour suppressor expression in head and neck squamous cell carcinoma

We report that homeodomain-only protein (HOP) is expressed in the suprabasal layer of normal upper aerodigestive tract epithelium and expression strongly decreases in hypopharyngeal carcinoma. Interestingly, HOP has very recently been shown to be a tumour suppressor involved in differentiation, suggesting that HOP may have a similar role in head and neck squamous cell carcinoma (HNSSC).     

Reconstruction with radial forearm flaps after ablative surgery for hypopharyngeal cancer

BACKGROUND: Patients afflicted with advanced hypopharyngeal cancer must contend with both potentially poor survival prognosis and a compromised quality of remaining life. After extensive ablative surgery, it is imperative to use a reliable, low morbidity reconstructive strategy that will allow for an expedient reconstitution of speech and swallowing. METHODS: Retrospective review of the records of 28 patients who underwent pharyngoesophageal reconstruction with radial forearm free flaps (RFFF) between 1996 and 2001 by a single surgeon (RE). Analysis was confined to patients requiring complete tubulation of the RFFF. Perioperative mortality, morbidity, and functional evaluation based on the parameters of speech and swallowing were analyzed. RESULTS: Completely tubulated RFFF were required in 25 patients. There was 100% RFFF survival with no perioperative mortalities. The median hospital stay was 8.0 days. All patients acquired a reconstitution of oral alimentation; median time to swallowing was 18.0 days. Fourteen of 16 patients (93%) were able to rely on TEP speech as their main modality of communication. Two patients (8%) had early fistulas develop, and 5 (20%) had late fistulas develop. Nine patients (36%) required mechanical dilatation; five of the nine patients required only one dilatation. CONCLUSION: Review of our experience has confirmed the reliability and excellent functional outcome associated with this flap.