Hypopharyngeal cancer

1. HYPOPHARYNGEAL
CANCER
DR. SATINDER

2. Introduction
Hypopharyngeal cancers arise from the mucosa of
one of the three anatomical subsites of the
hypopharynx.
It is characterised by advanced disease at
presentation mainly because the hypopharynx is a
silent area, allows tumours to grow for a
substantial period of time before symptoms occur.
Hypopharyngeal cancers are relatively rare
neoplasms with unfavourable prognosis among all
cancers.
Aggressive behaviour represented by strong

3. Early occurrence of nodal metastatic
involvement.
Direct invasion of adjacent structures in the
neck and high incidence of distant metastases.
30% of patients have local disease at the time of
diagnosis.
70% have local regional disease.
10% present with distant metastases.

4. Epidemiology
Incidence of less than 1 per 100,000 population.
3%–5% of all head and neck cancers.
Increased incidence in males of over 2.5:100,000 is seen
in India, Brazil, Central and Western Europe.
More common in men than in women.
Peak incidence in the 6th and 7th decades.
Most common site of origin of hypopharyngeal cancer is
the pyriform sinus (66%–75%).
Posterior pharyngeal wall, and postcricoid area (20%–
25%).
In India mainly Bombay and Madras heaving high
incidence.

5. Aetiology
Smoking tobacco.
Chewing tobacco.
Heavy alcohol use.
Eating a diet without enough nutrients.
Having Plummer-Vinson syndrome.
Тobacco and alcohol represent the major risk factors
for the development of hypopharyngeal cancer with
more than 90% of patients presenting with a history of
tobacco use.
There is a significant association with alcohol and

6. • Role of genetic factors- association between
tobacco use and p53 mutations is found in a much
larger percentage of smokers and drinkers.
• The loss of heterozygosity at 9p and abnormalities in
chromosome 11 present.
• Mutations in the p21 gene have also been identified.
• The role of human papilloma virus (HPV) as a
contributing factor to carcinogenesis in head and neck
squamous cell carcinomas.
• Occupational exposures mainly asbestos and
welding fumes.

7. Anatomy

9. Anatomy of the hypopharynx
The hypopharynx is the part of the pharynx
• Hypopharynx extend from C3-C6 cervical vertebrae.
• Superiorly with the oropharynx and is situated
posterior and lateral to the larynx.
• Inferiorly where it narrows and becomes continuous
with the esophagus.
It is divided into three primary anatomic subsites:
1. Pyriform sinuses
2. Postcricoid area
3. Posterior pharyngeal wall

12. Pyrifrom sinuses
•Lies on either sides of larynx.
•Extend from pharyngoepiglottic fold to upper end of
oesophagus.
•The internal laryngeal nerve run submucosally in the
lateral wall of sinus.
•Bounded by-
•Laterally- thyrohyoid membrane and thyroid cartilage.
Medially - aryepiglottic fold, arytenoids, and lateral
aspect
of the cricoid cartilage.Post-cricod area
• It is the part of anterior wall of laryngopharynx.
Posterior pharyngeal wall
•Extends from the level of the hyoid bone to
cricoarytenoid joint.

13. Lymphatic drainage
•Pyriform sinuses- jugulodigastric,
midjugular (level II and III),
and retropharyngeal nodes.
•Posterior pharyngeal wall drain
in lateral retropharyngeal nodes
into deep cervical.
•Post-cricoid area into
retropharyngeal lymph nodes
to the paratracheal,
paraesophageal,
and lower jugular nodes
(level IV and VI).

14. The wall of the hypopharynx is composed of four
layers:
1. An inner mucosal lining of stratified squamous
epithelium over a loose stroma.
2. A fibrous layer of pharyngeal aponeurosis.
3. A muscular layer formed by the inferior
constrictor muscle and, in the upper part by the
distal portion of the middle constrictor.
The most distal fibres of the inferior constrictor
condense into the cricopharyngeus muscle; just
proximal to this muscle on the posterior wall is an
area of relative weakness
known as Killian’s dehiscence.

15. Clinical presentation
•Early hypopharyngeal cancers-mild, nonspecific sore
throat or vague discomfort on swallowing.
•Predominating symptoms are those related to the
locoregional disease spread including
• Sore throat -Typically, pain is unilateral and well
localized.
• Odynophagia
• Dysphagia
• Weight loss
• A mass in the neck
• Poor dentition and halitosis

16. •Hoarseness: This indicates either involvement of the
recurrent laryngeal nerve, which runs deep to the
anterior wall of the pyriform sinus, or direct invasion of
the larynx.
•A “hot potato” voice may be due to the involvement of
the base of the tongue.
•Approximately 50% of patients present with palpable
neck lymphadenopathy

17. •Otalgia: Referred pain to the ear is mediated by branches of the
tenth cranial nerve . Invasion of the laryngeal nerve causes
spread of neuropathic impulses to the auricular nerve (sensory to
posterior external auditory canal and back of pinna).
Patient presented with hoarseness and otalgia. On MRI, there was a
bulky left pyriform sinus tumor with an area of gadolinium enhancement extending to the
carotid sheath. This T4 tumor was unresectable, and the patient was treated with
chemoradiation. Despite a good response to chemoradiotherapy, the evaluation for
progressive neck pain 4 months later revealed a bulky recurrence in the left neck.
Note tumor (white arrows) surrounding the carotid artery (black arrow).

18. Patient presenting with hoarseness and dysphagia.
CT scan demonstrates bulky right pyriform sinus tumor (white arrows) eroding through
thyroid cartilage, with displacement of supraglottic airway. A total laryngectomy would
have been required, because the patient placed a high value on retaining the ability to
talk, chemoradiotherapy was chosen.

19. Patient presenting with hoarseness and dysphagia. CT scan
Demonstrated bulky right pyriform sinus tumor eroding through thyroid cartilage, with
displacement of supraglottic airway. Total laryngectomy would have been required,
because the patient placed a high value on retaining the ability to talk,
chemoradiotherapy was chosen. Following chemoradiotherapy, note persistent fullness
in tumor bed. Endoscopy revealed edema and scarring, but the biopsy was negative for
tumor. Continued vigilance is needed in this situation.

20. Routes of primary tumour spread
•Hypopharyngeal cancers, particularly those arising in
the postcricoid area, have a strong tendency for
extensive submucosal spread.
•Pyriform sinus cancers-
Lateral -thyroid cartilage spread
Medial - aryepiglottic folds and arytenoids,
preepiglottic and paraglottic space and
intrinsic laryngeal muscles that results in a
loss of vocal cord mobility.
Superior- extension beyond the lateral
pharyngoepiglottic fold into the vallecula can involve the
base of the tongue. Inferior -extension beyond the apex
can involve the thyroid gland.

21. A large right piriform fossa
carcinoma

22. Postcricoid tumours
• Tending to grow circumferentially frequently involve the
cricoid cartilage, arytenoids and intrinsic laryngeal
muscles with resultant vocal cord fixation.
•The inferior tumour spread can lead to invasion of
cervical
esophagus and trachea.
In figure. A large
postcricoid carcinoma
extending into the
cervical oesophagus with
a skip lesion 4 em from
the advancing
tumour edge (arrow).

23. Posterior pharyngeal wall tumours
The tumour usually involves adjacent areas when first
diagnosed and almost always involves the posterior wall
of the oropharynx
Superiorly to the base of the tonsil
Laterally to the oropharyngeal wall
Inferiorly in to the postcricoid region and cervical
oesophagus.
• As the tumour enlarges and bulges into the pharynx it
typically.
•Invasion of the prevertebral fascia occurs late.
•Retropharyngeal space, and may spread laterally to
involve both piriform sinuses.

24. Regional metastases
• Metastases in the neck lymph nodes are already present in
appro. 70% of patients at the time of presentation with levels II
and III being the most frequently affected sites.
• Paratracheal and Paraesophageal nodes (level VI) are most
commonly present in patients with cancers in the postcricoid
area.
• Retropharyngeal lymph node metastases are most frequently
present in patients with cancers of the posterior pharyngeal wall
and the postcricoid area.
•Up to 80 percent of patients with carcinoma of the posterior
pharyngeal wall will have neck node metastases at presentation.

25. A patient presenting with a large right neck
mass (an N3 node) due to an ipsilateral piriform
fossa cancer.

26. •In patients with clinically positive neck, the incidence of
bilateral occult lymph node metastases is at least 50%
•Hypopharyngeal cancers include retropharyngeal and
parapharyngeal nodes paratracheal nodes and
mediastinal
nodes.
•Advanced stage at presentation and its involvement or
extension to cross the midline, the risk of contralateral
metastases is high, with histological identification of
tumour in more than 20% of cases treated surgically.
Distant metastases
• At the time of clinical diagnosis distant metastatic 17%.
• Approximately half of the recurrences was distant
metastatic disease.
• The most common site for distant metastases is the
lung, liver, bones and brain.

27. Differentials
Differential diagnoses include the following:
Hodgkin Disease
Lymphoma, Non-Hodgkin
Pharyngitis, Bacterial
Pharyngitis, Viral
Plasmacytoma, Extramedullary

28. Diagnosis
1.Complete head and neck examination, including
inspection, palpation, and indirect or fiberoptic
examination.
2.Flexible fiberoptic endoscopic examination is
important to attempt to localize and stage the primary
tumor.
3.Endoscopy easily reveal tumours arising in the upper
pyriform sinus and the posterior pharyngeal wall.
4.Typical findings of hypopharyngeal cancer include
• mucosal ulceration
• pooling of the saliva in the pyriform fossa
• edema of the arytenoids
• fixation of the cricoarytenoid joint
• true vocal cords, or both.

29. 5. The neck should be examined in a systematic fashion.
Any lymph nodes should be assessed with regard to size,
location, and mobility. On neck examination, loss of the grating
sensation (laryngeal crepitus) of the laryngeal cartilages over
the prevertebral tissues may indicate deep pharyngeal wall
involvement.
•Oral examination
• The hypopharynx is not visible directly, but other regional pathologies, including the
synchronous oral cavity or oropharyngeal tumors, might be seen.
• Asymmetry of tonsillar pillars can be a clue to a tumor invading the
palatopharyngeus muscle at insertion to the inferior constrictor muscle.
•Larynx and pharynx examinations
• The mirror examination is the quickest and simplest screening tool, but it cannot
reveal lower pyriform sinus or postcricoid lesions. Fiberoptic laryngoscopy is the
examination of choice.
• During the flexible laryngoscopy, the assessment of vocal cord mobility or fixation is
important for staging purposes.
• Findings include mass lesions, hyperkeratotic or erythematous mucosal lesions,
ulcerations, and vocal cord paralysis.

30. Neck examination
•Examine and document the size, location, and number
of palpable lymph nodes in all cervical and
supraclavicular node-bearing areas.
•Palpate and wiggle the larynx from side to side.
Tenderness suggests invasion, while loss of normal
tracheal crepitus suggests invasion of prevertebral
tissue or a large postcricoid tumor.
Head examination
•Assess cranial nerve function.
•Assess jaw mobility. Trismus suggests invasion of
pterygoid muscles.
•Areas of mass lesions or tenderness are suggestive of
regional metastases.

31. Serial endoscopic images of endoscopic submucosal dissection procedure for
the removal of an early hypopharyngeal cancer showing a 10×8 mm sized,
slightly elevated lesion with surface irregularity and hyperemia on the left
pyriform sinus (A), markings around the lesion with a needle knife (B),
circumferential mucosal incision and submucosal dissection with an hook and
IT knife (C), and artificial ulcer after complete en-bloc resection (D).

32. General examination for distant metastases
and comorbidities
1. A complete blood count
2. Liver function tests
3. Renal function tests
4. Chest x-ray films may demonstrate metastases,
synchronous lesions, or effusions suggesting
metastases to pleura or lymphatic obstruction.
5.CVS examination
6.USG Abdomen Hepatomegaly
7.General neurologic examination
8.Perform a peripheral lymph node examination to
assess for possible distant lymph node metastases.

33. Imaging studies
1.Chest x-ray films
2. Barium study
3. CT scan or MRI of oral cavity and neck.
4.The contrast-enhanced CT scan is typically used as
the initial imaging modality to assess local tumor
extent and evaluate lymph nodes. Perform a CT scan
of the head and neck with contrast to assist with
delineation of cartilage and bone invasion, lymph node
metastasis, and extralaryngeal invasion. As a single
modality, this is generally more useful for staging
hypopharyngeal cancers.
5. MRI is most often used to study lesions that suggest
submucosal spread toward the esophagus on CT
scans.
6. PET scan(FDG-PET)-evaluation of locally advanced

34. Advantages and disadvantages of computed
tomography (CT) and magnetic resonance
imaging (MRI) in the
evaluation of hypopharyngeal tumours
CT SCAN MRI
Planes of
investigation
2 3
Assessment
bone/cartilage
Good poor
Differentiate
tumour from
oedema
Poor Good
Radiation hazard mild none

35. 6. FDG-PET may
• Improve pretreatment staging
• Identification of an occult primary site,
• Estimation of treatment response, and
• Differentiation of early recurrence from scar tissue.
• Integrated PET/CT overcomes poor anatomic
localization of PET together with the morphologic
data revealed by CT.
• PET/CT is helpful
• In locating and localizing occult primary and regional
disease
• Differentiating between malignant disease and
posttreatment changes.
7 Abdominal CT scan
8 Bone scan

36. Diagnostic procedures
1.Fine-needle aspiration
2.Core biopsy
3.Biopsy of primary tumour site
4.Panendoscopy
Histologic findings
• More than 95% of hypopharyngeal malignancies are squamous
cell carcinomas
• less than 60% are keratinizing,
• 33% are nonkeratinizing, and
• Rest all are usually poorly differentiated.
• Uncommon histologic types include adenocarcinoma,
lymphoma, and sarcoma.

37. Staging
Primary tumour (T)
TX: Primary tumour cannot be assessed
T0: No evidence of primary tumour
Tis: Carcinoma in situ
T1: Tumour limited to one subsite of hypopharynx and/or 2 cm or
less in greatest dimension
T2: Tumour invades more than one subsite of hypopharynx or an
adjacent site, or measures more than 2 cm, but not more than 4
cm in greatest dimension without fixation of hemilarynx
T3: Tumour more than 4 cm in greatest dimension or with fixation
of hemilarynx or extension to esophagus
T4a: Moderately advanced local disease. Tumour invades
thyroid/cricoid cartilage, hyoid bone, thyroid gland, or central
compartment soft tissue*
T4b: Very advanced local disease. Tumour invades prevertebral
fascia, encases carotid artery, or involves mediastinal structures

38. American Joint Committee on Cancer (AJCC) TNM
classification of hypopharyngeal cancer

39. Regional lymph nodes (N)
Nx: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in
greatest dimension
N2: Metastasis in a single ipsilateral lymph node, more than 3 cm
but not more than 6 cm in greatest dimension; or in multiple
ipsilateral lymph nodes, not more than 6 cm in greatest
dimension; or in bilateral or contralateral lymph nodes, not more
than 6 cm in greatest dimension
N2a: Metastasis in a single ipsilateral lymph node more than 3 cm
but not more than 6 cm in greatest dimension
N2b: Metastasis in multiple ipsilateral lymph nodes, not more than
6 cm in greatest dimension
N2c: Metastasis in bilateral or contralateral lymph nodes,
not more than 6 cm in greatest dimension
N3: Metastasis in a lymph node, more than 6 cm in greatest
dimension

40. Distant metastasis (M)
M0: No distant metastasis
M1: Distant metastasis
Anatomic stage/prognostic groups
0: Tis N0 M0
I: T1 N0 M0
II: T2 N0 M0
III: T3 N0 M0, T1-T3 N1 M0
IVA: T4a N0 M0, T4a N1 M0, T1-T3 N2 M0, T4a N2
M0
IVB: Any N M0, Any T N3 M0
IVC: Any T Any N M1
American Joint Committee on Cancer (AJCC) TNM
classification of hypopharyngeal cancer

41. Risk of nodal disease based on T stage is as follows:
T1 - Risk of nodal disease 60%
T2 - Risk of nodal disease 60-70%
T3 - Risk of nodal disease 84%
T4 - Risk of nodal disease 84%

42. Treatment of hypopharyngeal cancer
1.Early hypopharyngeal carcinoma
• Surgical excision neck dissection(s) (endoscopic (CO2) or
open surgery)
• Conservation surgery bilateral selective neck dissection
postoperative radiotherapy chemotherapy
• Concurrent chemoradiotherapy to primary site and both necks
• Radiotherapy alone – where significant co-morbidity prevents
the above options.
2. Locally advanced hypopharyngeal carcinoma
• Concurrent chemobioradiotherapy to primary and neck
• Radical surgery; pharyngolaryngectomy reconstruction
bilateral selective or modified neck dissection, with
postoperative chemoradiotherapy.

43. Classification of surgery on the
hypopharynx.
Classification
Internal excision CO2 laser or ‘cold steel’
External excision (with or
without flap repair)
Partial pharyngectomy
Partial pharyngectomy/partial
laryngectomy
Partial pharyngectomy/total
laryngectomy
Total pharyngolaryngectomy
Extended
pharyngolaryngectomy

44. Radiation Therapy and Combined Therapy
Indications for radiotherapy include the following:
•Definitive treatment
•Resectable cancer for organ preservation
•Adequate function of the laryngopharynx
•Unresectable cancer
1. Cancer that involves the prevertebral fascia
2. Cancer that encases the carotid artery
Indications for postoperative radiotherapy include the
following:
•Primary indications
1. Positive or close margins (< 5 mm)
2. T4 tumors
3. Invasion of cartilage, bone, or soft tissues by the primary tumor
•Neck indications
1. Two or more lymph nodes with metastasis
2. Extracapsular extension

45. Chemotherapy, Radiation Therapy, and Combined
Therapy
Managementbased on stage, as follows:
1. T1/T2 - Radiotherapy alone (commonly 66-70 Gy) or surgery
(possibly with postoperative irradiation, depending on the
pathology findings). Larynx preservation therapy is typically
possible and is strongly favored.
2. T3/T4 (resectable) - Partial or total laryngopharyngectomy,
neck dissection, postoperative radiotherapy, or radiotherapy
alone with altered fractionation or concurrent
chemoradiotherapy or participation in prospective clinical trials.
3. Unresectable or medically unstable - (1) Radiotherapy alone
with altered fractionation or concurrent chemoradiotherapy or
(2) participation in prospective clinical trials including the study
of induction chemotherapy

46. NCCN Guidelines Hypophyarnx

50. Surgical therapy
1. Partial laryngopharyngectomy (PLP) for tumors of
the medial pyriform sinus
2. Near-total laryngopharyngectomy
3. Total laryngopharyngectomy
4. Total laryngopharyngectomy with esophagectomy
5. Extended total laryngectomy for tumors of the
pyriform sinus

51. Total laryngopharyngectomy
Lateral view of tumor cuts for
laryngopharyngectomy.

52. The tendency for submucosal spread of advanced hypopharyngeal tumors
mandates wide margins, and primary closure is often not possible. These
procedures often require free tissue transfer for closure.
Extended total laryngectomy for tumors of the
pyriform sinus

53. Chemotherapeutic agent
1. Cisplatin (Platinol)
2. Fluorouracil Paclitaxel (Taxol)
3. Methotrexate (Folex, Rheumatrex)
4. Docetaxel (Taxotere
5. Cetuximab (Erbitux)
6. Leucovorin (Folinic Acid,
Wellcovorin)

54. Stage I Hypopharyngeal Cancer
Treatment of stage 1 hypopharyngeal cancer may include the following:
1. Laryngopharyngectomy and nec disections with or without high-dose
radiation therapy to the lymph nodes of the neck.
2. Partial laryngopharyngectomy with or without high-dose radiation therapy to
the lymph nodes on both sides of the neck.
Stage II Hypopharyngeal Cancer
Treatment of stage II hypopharyngeal cancer may include the following:
1. Laryngopharyngectomy and neck dissection. High-dose radiation therapy to
the lymph nodes of the neck may be given before or after surgery.
2. Partial laryngopharyngectomy. High-dose radiation therapy to the lymph
nodes of the neck may be given before or after surgery.
3. Chemotherapy given during or after radiation therapy or after surgery.
4. A clinical trial of chemotherapy followed by radiation therapy or surgery.

55. Stage III Hypopharyngeal Cancer
Treatment of stage III hypopharyngeal cancer may include the following:
1. Radiation therapy before or after surgery.
2. Chemotherapy given during or after radiation therapy or after surgery.
3. A clinical trial of chemotherapy followed by surgery and/or radiation
therapy.
4. A clinical trial of chemotherapy given at the same time as radiation therapy.
5. A clinical trial of surgery followed by chemotherapy given at the same time
as radiation therapy.
Stage IV Hypopharyngeal Cancer
Treatment of stage IV hypopharyngeal cancer that can be treated with
surgery may include the following:
1. Radiation therapy before or after surgery.
2. A clinical trial of chemotherapy followed by surgery and/or radiation
therapy.
3. A clinical trial of surgery followed by chemotherapy given at the same
time as radiation therapy.

56. Surgical treatment and follow-up of stage IV hypopharyngeal
cancer is complex and is ideally overseen by a team of specialists
with experience and expertise in treating this type of cancer. If all
or part of the hypopharynx is removed, the patient may need
plastic surgery and other special help with breathing, eating, and
talking.
Treatment of stage IV hypopharyngeal cancer that cannot be
treated with surgery may include the following:
1. Radiation therapy.
2. Chemotherapy given at the same time as radiation therapy.
3. A clinical trial of radiation therapy with chemotherapy.

57. 1. Radiation therapy alone.
2. Concurrent chemoradiation.
3. Induction chemotherapy
followed by radiation
4. therapy alone.
5. Induction chemotherapy
followed by concurrent
chemoradiation.
6. Postoperative concurrent
chemoradiation.
Radiation Therapy

58. THANK
YOU