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 resultsx, 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. © 2010 Wiley Periodicals, Inc. Head Neck, 2012Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90087/1/21613_ftp.pd

Flap reconstruction of the hypopharynx: a defect orientated approach

The present retrospective analysis evaluated the outcomes of different flap reconstructions for several hypopharyngeal defects in 136 patients who underwent hypopharyngeal reconstruction with a free or pedicled flap after excision of pharyngeal or laryngeal carcinoma.Functional and oncological outcome were the main measures. Nine patients had a type I-a hypopharyngeal defect (partial with larynx preserved), 33 type I-b (partial without larynx preserved), 85 type II (circumferential), 5 type III (extensive superior) and 4 vertical hemipharyngolaryngectomy. The flaps used to reconstruct these defects were pectoralis major (n = 34), free radial forearm (n = 25), jejunum (n = 72), pedicled latissimus dorsi (n = 2), sternocleidomastoid (n = 1), lateral thigh (n = 1) and deltopectoral (n = 1). Twelve defects (9%) needed a secondary flap reconstruction. Surgical and medical complications were seen in 29% and 8% of patients, respectively; 18% of patients developed a fistula. No difference in complication rate or admission days was found for pre-operative versus no previous radiotherapy, type of defect or free versus pedicled flap. After 12 months follow-up, 38% of patients had a tracheo-oesophageal voice prosthesis, in 82% a fully oral diet was obtained and the average body weight gain was 0.9 kg. Five-year overall and disease-specific survival rates were 35% and 49%, respectively, while local and regional control rates were 65% and 91%, respectively. Considering these results, a defect orientated approach may be helpful for deciding which flap should be used for reconstruction of the hypopharynx. An algorithm is proposed with similar functional and oncological outcomes for the different groups. The choice of flap should be based on expected morbidity and functional outcome

Uloga slobodnih režnjeva u rekonstrukciji defekta tipa II hipofarinksa

There are several options for hypopharyngeal reconstruction depending on defect size. Reconstructive options include primary closure, local flaps, regional axial flaps or regional intestinal flaps, and free flap transfer with skin or intestinal free flaps. The preferred method of reconstruction should minimize early postoperative complications that prolong hospital stay and/or become life threatening, ensure early restoration of function and decrease donor site morbidity. The purpose of this study was to evaluate functional outcomes of different flap reconstruction methods in type II hypopharyngeal defects. In this non-randomized retrospective cohort study, data on 31 (27 male and four female) patients were collected over a 10-year period of single institution type II hypopharyngeal defect reconstructions. The following measures of functional outcome were extracted from patient medical histories: postoperative complications (flap failure, fistula formation, donor site related complications), hospital stay in days and swallowing function after 14 days, 1 month and 6 months. There were nine patients in the radial forearm free flap (RFFF) reconstruction group, seven in the jejunum reconstruction group, and 15 in the gastric tube reconstruction group. In the RFFF group, three patients experienced flap failure; in the jejunal transfer group, no donor site morbidity was observed; whereas three patients from the gastric tube reconstruction group had minor abdominal skin wound dehiscence. Out of the 3 different reconstructive methods, RFFF was most likely to fail. The mean duration of hospital stay was 22.6 days, being shortest in the RFFF group. There were no significant differences in early postoperative swallowing function among the groups. The choice of flap used for hypopharynx reconstruction should be driven by donor site factors and functional outcomes. When assessing type II hypopharyngeal defect reconstruction results, the findings of this study suggest that free jejunal flaps and gastric tubes offer superior functional results in comparison with RFFFs.Postoji niz metoda za rekonstrukciju hipofarinksa, a odabir ovisi o veličini defekta sluznice. Metode rekonstrukcije uključuju primarno zatvaranje, lokalne režnjeve, regionalne aksijalne režnjeve, regionalne režnjeve probavnog sustava i slobodne režnjeve koji sadrže kožu ili sluznicu probavnog sustava. Optimalna metoda rekonstrukcije trebala bi biti praćena minimalnim poslijeoperacijskim komplikacijama koje ako nastaju produljuju broj dana provedenih u bolnici, i trebala bi uključivati brz oporavak funkcije. Cilj ove nerandomizirane retrospektivne studije bio je prikazati rezultate rekonstrukcija bolesnika s defektom hipofarinksa tipa II. U razdobolju od 10 godina u Klinici za otorinolaringologiju i kirurgiju glave i vrata, KBC “Sestre milosrdnice” operiran je 31 bolesnik (27 muškaraca i četiri žene). Za procjenu ishoda rekonstrukcije upotrebljene su sljedeće mjere: rane poslijeoperacijske komplikacije (propadanje režnja, postojanje fistule, komplikacije donorskog mjesta), duljina boravka u bolnici i procjena funkcije gutanja nakon 14 dana, jednog mjeseca i šest mjeseci. Bolesnici su podijeljeni u sljedeće skupine: devet bolesnika s radijalnim režnjem (RFFF), sedam bolesnika s režnjem jejunuma i 15 bolesnika s tzv. gastric tube rekonstrukcijom. U tri bolesnika skupine RFFF režanj je propao; u skupini s režnjem jejunuma nije bilo komplikacija donorskog mjesta, dok su u skupini s gastric tube rekonstrukcijom tri bolesnika imala manju dehiscijenciju rane trbušnog zida. Od tri uspoređivane rekonstrukcijske metode bolesnici u skupini RFFF imali su najveći broj komplikacija. Prosječna duljina boravka u bolnici iznosila je 22,6 dana, s najkraćim boravkom u skupini RFFF. Nije nađeno razlika u ranoj gluticijskoj funkciji između uspoređivanih skupina. Odabir pojedine metode rekonstrukcije trebao bi ovisiti o opsegu resekcije, općem stanju bolesnika, donorskom mjestu i očekivanoj funkciji. Naši rezultati upućuju na superiornost rekonstrukcije upotrebom “jejunalnog režnja” i gastric tube rekonstrukcije u usporedbi s radijalnim režnjem

Functional outcomes and complications after salvage total laryngectomy for residual, recurrent, and second primary squamous cell carcinoma of the larynx and hypopharynx : a multicenter retrospective cohort study

Background/Purpose: We analyzed complications and functional outcomes and aimed at identifying prognostic factors for functional outcomes and complications in patients who underwent salvage total laryngectomy (STL) for residual, recurrent, and second primary squamous cell carcinoma (SCC) of the larynx and hypopharynx after initial (chemo)radiation. Methods: Retrospective cohort study of patients who underwent STL in four major Belgian reference hospitals between 2002 and 2018. Prognostic factors for functional outcomes and complications were identified with uni- and multivariable analysis. Results: A total of 405 patients were included in the final analysis. STL was performed for residual tumor (40.2%), local recurrence (40.5%), or second primary laryngeal or hypopharyngeal SCC (19.4%). Early postoperative complications were experienced by 34.2% of patients: postoperative hemorrhage occurred in 5.4%, wound infection in 16.2%, and clinical pharyngocutaneous fistula (PCF) in 25.5% of patients. Early readmission proved necessary in 15.1% of cases, most often due to late PCF development (72.2%). Patients achieved total peroral intake in 94.2% of cases. However, subjective dysphagia was reported by 31.3% of patients during follow-up. Functional speech, defined as functional communication by speech without additional aids, was reported in 86.7% of cases and was most often achieved by tracheo-esophageal puncture (TEP) (94.1%). In a multivariable model, lower preoperative hemoglobin (<12.5 g/dl) was identified as an independent prognostic factor for higher overall complication rate. No risk factors were found significant for clinical fistula formation. Vascularized tissue augmentation did not significantly prevent clinical PCF. Patients with positive section margins, patients initially treated with surgery combined with adjuvant RT (vs. radiotherapy alone), and those developing PCF after STL were less likely to achieve total peroral intake. Postoperative dysphagia proved more likely in patients who developed a PCF postoperatively, and less likely in patients who underwent STL without partial pharyngectomy and in patients with myocutaneous pectoralis major (PM) flap reconstruction, compared to muscle onlay PM flap. Achieving postoperative functional speech proved most likely in patients with smaller tumors (lower pT classification) and free section margins. Conclusion: Substantial complication rates and favorable functional outcomes are reported after STL

Partial pharyngolaryngectomy with infrahyoid flap: Our experience

Aim: We evaluated a cohort of advanced hypopharyngeal squamous cell carcinoma, treated with conservative surgery, reconstruction with infrahyoid flap and radio-chemotherapy. Methods: We used partial pharyngo-laryngectomy and radio-chemotherapy to treat fifty-seven patients with stage III–IV hypopharyngeal SCC from November 1994 to December 2011. Clinical examination and speech therapy evaluation were used for estimation of laryngeal function. Results: All patients received a partial pharyngo-laryngectomy. All patients underwent neck dissection; 56 patients received bilateral neck dissection. Reconstruction was achieved by infra-hyoid flap. Five-year overall and disease-specific survival rates were 54.4% and 61.4%, respectively. Successful laryngeal function preservation with complete five-year remission was achieved in 44% of the patients. Conclusion: Selected even if advanced carcinomas of the hypopharynx maybe treated with partial pharyngo-laryngectomy with reconstruction with pedicled flap. Both oncological and functional results showed a good outcome

Preservation of the Larynx in Laryngeal and Hypopharyngeal Cancer

In the last decade the primary treatment of laryngeal and hypopharyngeal cancer was shifted towards organ preservation, i.e. preservation of the larynx. The treatment of laryngeal cancer was changed from standard radiotherapy towards hyperfractionated radiotherapy. Hypopharyngeal cancer is nowadays mostly treated with a combination of chemotherapy and radiotherapy instead of primary surgery. Therefore, the greatest shift in treatment protocols found was for hypopharyngeal cancer. The goal of this thesis was in the first place to find out whether recurrent laryngeal cancer can be treated with preservation of the larynx and the consequences of organ preservation for the function of the “new” organ. The second goal of this thesis was to find out which treatment protocols are used in the Netherlands for hypopharyngeal cancer. Also, to find the consequences of chemoradiation protocols for surgical treatment of recurrent hypopharyngeal cancer. Chapter I is a general introduction of laryngeal and hypopharyngeal cancer. The incidences of laryngeal and hypopharyngeal cancer are mentioned. Furthermore, the biggest risk factors, being smoking and alcohol, are described. Especially, the effect of tobacco smoke on the development of laryngeal and hypopharyngeal cancer is described. Tobacco smoke contains several substances, which can cause mutations in genes. The mutations deregulate several enzyme systems and cell regulation systems, which cause degeneration of squamous cell epithelium. An overview of the other chapters of this thesis is given. In Chapter II two partial laryngectomy techniques are described. The oncological and functional results of the endoscopic CO2 laser and the frontolateral partial laryngectomy for the treatment of the recurrent glottic laryngeal cancer are described. The indications of both techniques are mentioned. Both techniques have good oncological results and less functional problems were found. With the CO2 laser 44-58% of the patients are cured with preservation of the larynx; with the frontolateral partial laryngectomy 71% was cured. It is important to realize that in case of a new recurrence, a total laryngectomy can be performed without an extra risk of failure for therapy. Both partial laryngectomy techniques, CO2 laser and frontolateral partial laryngectomy, are good treatment modalities for recurrent glottic laryngeal cancer. However, the indications for the different techniques are important and should be followed strictly. In chapter III the functional and oncological results of the third partial laryngectomy technique, cricohyoidoepiglottopexy (CHEP), is described. With the CHEP 79% of the patients are cured with preservation of the larynx. In eight patients a Flexible Endoscopic Evaluation of Swallowing (FEES) was performed to objectify problems swallowing. In none of the patients aspiration was found. Before and after the operation the voice was recorded and judged. After the operation the voice is worst. However, most patients are satisfied with there voice. The CHEP appears oncologically safe and functional for the treatment of recurrent glottic laryngeal cancer in selected patients. In chapter IV was investigated whether the quality of life is different after a partial laryngectomy versus a total laryngectomy for recurrent laryngeal carcinomas after radiotherapy. Also the voice of both groups of patients was judged. The quality of life was investigated with the EORTC Quality of Life Questionnaire (QLQ) – C30 Dutch version 3.0 and the EORTC – H & N 35 questionnaire. The only difference found was smell and taste related. The voice was judged with the Voice Handicap Index. No differences between the two groups were found. There are no big differences in quality of life after treatment with a partial or a total laryngectomy. This is mainly caused by the unexpected good quality of life after a total laryngectomy. In chapter V the treatment of hypopharyngeal cancer in the Netherlands is described. The treatment of hypopharyngeal cancer in the period 1985 – 1994 was investigated. The biggest group of patients was treated with radiotherapy alone or with combined radiotherapy and surgery. The overall 5-year disease-free survival after treatment with curative intention was 32%. The disease-free survival is better after combined surgery and radiotherapy. In chapter VI, the complications after salvage surgery in patients prior treated with radiotherapy alone or chemoradiation is described. The post-operative complication rate is significantly higher (92% vs. 50%) in the chemoradiation group. The most frequent complication found was a pharygocutaneous fistula. The quality of life, after a longer post-operative period, showed a significant difference in social functioning in disadvantage of the chemoradiation group. In the general discussion (chapter VII) the found results are discussed. The most important conclusion is that there is place for organ preservation therapy, but we must remain critical of indications and side effects of organ preservation protocols while we should realize that quality of life after total laryngectomy are not as poor as we might sometimes think

Surgical Alternatives in the Therapy of Hypopharyngeal Tumours of Various Locations - 30 Years (1986-2018) of Experience at the Department of Otorhinolaryngology, Head, and Neck Surgery, University of Szeged, Hungary

Background and Aim: The authors present advances in the surgical management of hypopharyngeal tumours in Hungary, specifically at the department of otorhinolaryngology and Head-Neck Surgery, Faculty of Medicine, University of Szeged. Resective and function-preserving surgical interventions performed via open operation are described separately. Indications for external exploration and the endoscopic-microscopic approach are also detailed, and the surgical repertoire used in the management of hypopharyngeal tumours at the department is presented. Results: At the department of Otorhinolaryngology, Head, and Neck Surgery, University of Szeged we have experienced a continuous increase in the number of hypopharyngeal tumours since the 1980s. It is not only the increased incidence that we have noted but the tumours are also getting more advanced. When focusing on the surgical management of hypopharyngeal tumours, we aim to achieve radical removal as well as retain certain functions, such as the ability of speech, which is an important aspect of the quality of life. Conclusion: Resection of hypopharyngeal tumors with laser increases the risk of recurrence, therefore it is only considered safe in some selected cases. Laryngoscopic assess and the straight line of CO2 laser determines the direction of laser line, which makes it difficult for surgeon to evaluate the involvement of deeper tissues. However, if the indications are closely observed, laser surgery is a potential alternative to surgical intervention in the treatment of small hypopharyngeal tumors