Hypopahryngeal Cancer
The hypopharynx
is situated behind the voice box. The upper part communicates with
the oropharynx and the lower part forms the entrance of the food
pipe (oesophagus). Because the hypopharynx is behind the voice box,
the front wall of the hypopharynx is actually the back wall for
the voice box covered by mucosa (known as post cricoid area). On
either side of the front wall, are the funnel shaped pyriform sinuses
directing food down towards the oesophagus.
Hypopharynx
include:
- Post
cricoid area
- Pyriform
sinuses
- Posterior
pharyngeal wall
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Risk
Factors:
Incidence of
hypopharyngeal cancers is much less compared to the laryngeal cancers
and is nearly always squamous cancers. Approximately 80% of cancers
occur in men. This is because smoking and alcohol abuse are common
among men.
Clinical
presentation:
Unfortunately
hypopharyngeal tumours produce few symptoms until they are advanced.
They may cause:
- Sore throat
- Ear pain
- Voice change
- Pain or difficulty
in swallowing
- Appreacnce
of a lump in the neck
- Feeling of
food sticking in the throat.
Atleast 70%
of hypopharyngeal cancer arise in the pyriform sinus. Diffuse local
spread is common and is due to tumour extension underneath the mucosal
lining. Abundant lymphatic drainage results in a higher incidence
of spread to lymphnode than other head and neck tumours. At presentation,
70-80% of the patients with hypopharyngeal cancers have a lump in
the neck; in half of these patients lymphnode metastases is the
presenting complaint. Bilateral metastases are seen in only 10%
of the patients with pyriform sinus cancers but in 60% of those
with postcricoid tumours. The hypopharynx will be examined by the
ENT surgeon with a help of small mirrors or fibreoptic endoscope.
The flexible fibreoptic hypopharyngoscopy can be done as an out
patient procedure under local anesthesia by passing a thin endoscope
through the nose into the pharynx.
If something
suspicious is seen, then the next step is doing endoscopy under
general anesthesia. If some area looks abnormal, then biopsy is
done from that area.
If the neck
nodes are enlarged, fine needle aspiration is done for cytological
examination (FNAC) by the pathologist to rule out metastatic carcinoma.
If cancer is found, the doctor will need to know the extent of the
disease. This is called staging. In most cases, the most important
factor in considering treatment options is the stage of the disease.
The stage is based on the size of the tumour, as well as whether
or not the cancer has spread (metastasized) and where it has spread.
To obtain more information about the location and extent of the
cancer, the doctor may perform the following investigations.
- CT scan of
neck
- X-ray/CT
scan of chest
- Ultrasound
of liver
- Barium swallow
Treatment:
The three main
types of treatment for these cancers are surgery, radiation and
chemotherapy. Most of these cancers will need surgery and /or radiotherapy.
Chemotherapy is usually given when the cancer has spread too far
to be treated with surgery and radiotherapy. It is also given before
or along with radiation with goal of preserving the voice box.
Radiation:
Since surgical treatment for hypopharyngeal cancer involves removal
of voice box, radiotherapy has been the ideal treatment for small
tumours. Radiotherapy is most commonly used after surgery to kill
cancer cells that are not visible during surgery. In some cases
when the tumour is extensive and cure is not possible, radiotherapy
is given for easing symptoms like pain, bleeding and swallowing.
Surgery:
With small tumours, a number of conservative surgical procedures
are available viz
- Partial pharyngectomy
- Partial laryngopharyngectomy
- Near total
laryngectomy
All these procedures
are designed to preserve the natural voice by preserving the voice
box, fully or partly. With large tumours, surgical removal of the
voice box along with the tumour becomes inevitable.
Total
laryngopharyngectomy:
In this, the
continuity between the pharynx and oesophagus is lost. This is reconstructed
in a number of ways. The latest technique is to use a small portion
of the small intestine (Jejunum). The blood supply tot his segment
of the transposed intestine is reestablished in the neck by connecting
its blood vessels to the blood vessels in the neck using microsurgical
techniques.
In cases where
the tumour extends into the food pipe (oesophagus), total laryngopharyngo
oesophagectomy is done. The stomach is brought to neck and connected
to the pharynx.
When the voice
box is removed, the patient will no longer have normal speech. This
doesn’t mean that speech is lost and there are ways to talk
without larynx.
Further information
about Alaryngeal Speech can be obtained in the section for cancer
of larynx.
Questions patients should ask before deciding about the
treatment:
1. What are
my treatment options?
2. What are the risks and benefits for each of my treatment options?
3. How will treatment affect my everyday activity? How long?
4. How often will I need to return?
5. Has my doctor explained various surgical options to my satisfaction?
6. Has a surgeon who has expertise with removal of cancer, as
well as, with reconstruction seen me? Have I seen by a surgeon,
radiation oncologist, prosthodontist and dentist?
7. Do I know all I need to know about prostheses and prosthetic
techniques?
8. How often has the surgeon performed the kind of surgery he
is recommending?
9. What will the surgical site look like after healing?
10. Will my appearance and physical capabilities be affected?
If so how?
11. Should I consider combination therapy (both surgery and radiation
therapy)?
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