Carcinoma of the Hypophatynx: Success and Failure

Mohamed S. Razack, MD, Buffalo, New York

Kumao Sako, MD, Buffalo, New York

Frank C. Marchetta, MD, Buffalo, New York

Peter Calamel, MB, BDS, Buffalo, New York

Vahram Bakamjian, MD, Buffalo, New York Donald P. Shedd, MD, Buffalo, New York

The overall survival figures of squamous cell carci- noma of the hypopharynx have been uniformly poor, with a five year survival rate ranging from 23 to 29 per cent utilizing the present available modalities of treatment [l-4]. In our clinic we are following pa- tients with no evidence of disease who were treated in the past for hypopharyngeal carcinoma with var- ious modalities. A retrospective study was initiated to find out the influence of each modality or combi- nation of modalities of treatment on the survival and recurrence pattern in these patients treated for hy- popharyngeal carcinoma.

Material and Methods

During the fifteen years from January 1957 to December 1971,141 patients were treated for hypopharyngeal car- cinoma at the Department of Head and Neck Surgery at Roswell Park Memorial Institute. Twenty-one patients who died of unrelated causes within three years of treat- ment are excluded, leaving 120 patients for the present study.

In the patients who underwent surgery, all the pathologic specimens were studied for the margins of resection, and node clearance was done in all the patients who had radical neck dissections.

The primary tumor with its extension was fully defined in all patients after a satisfactory endoscopic examination and confirmed on pathologic specimens in patients who were treated by surgery. The TNM clinical staging system for carcinoma of the pharynx as recommended by the American Joint Committee has been followed on all pa- tients. Hypopharynx, as defined by this committee, is an anatomic area extending from just above the level of the tip of the epiglottis to the lower border of the cricoid car- tilage. It is made up of three distinct parts-the pyriform sinus, the postcricoid area, and the posterior pharyngeal wall.

All patients who are alive had a minimum of five years follow-up.

Fromtf~DepMm&ofHeadandNeckSurgerya~~IOncology.RcswellPark Memorial Institute, Buffalo, New York.

Reprint requests should be addressed to WJhMWdS.~.MD.sectii A. Department of Head and Neck Surgery and Oncology, Roswell Park Me- morial Institute. 666 Elm Street, Buffalo, New York 14263.

Presented at the Twenty-Third Annual Meeting of the Society of Head and Neck Surgeons, Hilton Head Island. South Carolina, May 4-7, 1977.

Volume 134, October 1977

Results

Age and Sex Distribution. The age of the patients ranged from thirty-nine to eighty-three years: two patients 31-40 years; nine 41-50; forty-three 51-60; forty-five 61-70; eighteen 71-80; and three 81-90. The tumor was most commonly seen in the 51-70 year old group (88/120, 73.3 per cent). Of the 120 patients in the study, 103 (86 per cent) were male and 17 (14 per cent) female.

Site and Stage of Tumor. Ninety-seven patients (81 per cent) had tumors located in the pyriform sinus, nineteen patients (15 per cent) had primary tumor in the posterior pharyngeal wall, and four patients (4 per cent) had tumor in the postcricoid area. In forty-eight patients (40 per cent) the tumor size was classified as T1 (tumor extending to one anatomic site), in twenty-two (18 per cent) as Tz (tumor extending to the two sites of the hypophar- ynx) , and in fifty (42 per cent) as Te (tumor extending beyond the hypopharynx). In seventeen patients (14 per cent), neck disease was classified as No, in eighty-four patients (70 per cent) as Ni, and in nineteen patients (16 per cent) as Na.

Nine patients (7.5 per cent) were stage I, eight patients (6.5 per cent) were stage II, eighty-four pa- tients (70 per cent) were stage III, and nineteen pa- tients (16 per cent) were stage IV.

Modes of Treatment. Eighty-one patients were treated primarily by surgery. Forty-seven of these eighty-one patients had total laryngectomy, radical neck dissection, and partial pharyngectomy with primary closure of the pharynx. Twenty-seven of the eighty-one patients had total laryngectomy, radical neck dissection, and total circumferential pharyn- gectomy with immediate deltopectoral flap recon- struction. Seven of the eighty-one patients had total laryngopharyngectomy with radical neck dissection, but no immediate reconstructions. They had a large pharyngostoma and a cervical esophagostomy.

Eleven patients treated by surgery were failures of radiation therapy given elsewhere. Three of these eleven patients had total laryngectomy, radical neck dissection, and partial pharyngectomy with primary

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Razack et al

pharyngeal closure. Three others had a total laryn- gopharyngectomy with no immediate reconstruction. The remaining five had total laryngopharyngectomy with immediate deltopectoral flap reconstruction.

Twenty-eight patients were treated with radiation therapy alone. These patients were in either very poor general condition or had far advanced disease in the form of fixed neck mass.

Four of the eighty-one surgical patients had mi- croscopic tumor at the margins of resection and re- ceived a full course of radiation therapy in the im- mediate postoperative period.

Forty of fifty-seven surgically treated patients received radiation therapy only after a local recur- rence was proved. These patients received 5,000 to 6,000 r in five to six weeks. In seventeen surgical failure patients, radiation therapy was not given because these patients had widespread metastases below the clavicle in addition to the local recur- rence.

Mortality. Two patients died in the immediate postoperative period (within 30 days of surgery) for a mortality rate of 1.8 per cent (2/110). One patient died due to common carotid artery rupture (on postoperative day 28) and the other died due to septic shock and congestive cardiac failure after pharyngeal fistula.

Survival and Recurrence Rates. Of the eighty-one patients treated with surgery alone, nine had stage I, eight stage II, and sixty-four stage III disease. Twenty of eighty-one patients (24.5 per cent) treated with surgery alone were alive with no evidence of disease for five or more years. Three of these twenty patients were stage I (3/g), four were stage II (4/8), and thirteen were stage III (13/64). In the thirteen patients with stage III disease, only three patients had three or more positive neck nodes.

Of four patients (1 stage I, 1 stage III) who had a full course of postoperative radiation therapy, be- cause the pathologic specimen showed microscopic disease at the margins of resection, two (50 per cent) (1 stage I, 1 stage III) were alive for five or more years. During the follow-up of the remaining fifty-seven patients (5 stage I, 4 stage II, 48 stage III) who were treated with surgery alone and developed recur-

TABLE I Survival according to Clinical Stage

stage Total

I 9 II 8 III 84 IV 19

Total 120

No Evidence Died of of Disease Disease

7 (77%) 2 5 (63%) 3

21 (25%) 63 1(5%) 18

34 86

rences, thirty-four patients (59.6 per cent) (4 stage I, 3 stage II, 27 stage III) developed recurrences within six months, and in twenty-two patients (38.5 per cent) (1 stage I, 1 stage II, 20 stage III) the re- currences were documented during the first year after surgery. In one patient (stage III) widespread metastases were noted two years after surgery. In seventeen of fifty-seven patients (29.8 per cent), the recurrent disease was evident both above and below the clavicle, representing a widespread metastatic pattern. These patients were unsuitable for radiation therapy and all were dead of disease within six months of documentation of recurrences.

Forty patients who had recurrence after operation (4 stage I, 3 stage II, 33 stage III) were treated with radiation therapy, receiving 5,000 to 6,000 r in five to six weeks. Eight patients (3 stage I, 1 stage II, and 4 stage III) responded well to radiation therapy and are alive with no evidence of disease for five or more years. In all these eight patients radiation therapy was given for recurrences noted within six months of surgery. The remaining thirty-two patients died with disease within two years after recurrences were proved.

Eleven patients (9 stage III, 2 stage IV) who were treated with radiation therapy elsewhere were seen here with recurrent disease. All had evidence of re- current disease in the hypopharynx and in only four patients was disease also evident in the neck. Three of the eleven patients (27.27 per cent) could be sal- vaged by surgery and these patients were alive with no evidence of disease for five or more years. Eight were dead with disease within one year of surgery.

Twenty-eight patients (11 stage III, 17 stage IV) were treated with radiation therapy alone. Only one of twenty-eight, a stage III patient, survived for five years. In sixteen of twenty-seven patients (59 per cent) recurrences were noted within six months, and in eleven of twenty-seven patients (41 per cent) re- currences were noted within one year of radiation therapy. Nineteen of twenty-seven patients (70 per cent) were dead with disease within one year of therapy and eight of twenty-seven (30 per cent) were dead within eighteen months of therapy.

The overall five year survival in this entire group is 28.3 per cent (34/120). (Table I.)

Comments

Twenty of eighty-one patients (24.5 per cent) who were treated with surgery alone survived for five or more years. Ten more patients were salvaged by ra- diation therapy given in the immediate postoperative period for microscopic residual disease (2/4 patients) and for local postoperative recurrences (8/40). Thus,

490 The American Journal of Suroerv

Carcinoma of Hypopharynx

TABLE11 NumbercfPatkntswlthNcEvtdancedDlsease at 5 Years according to Cllnlcal Stage and Treatment Mcdalltv

Treatment Clinical Stage

Total No. Modality

Surgery alone Surgery i- RT Surgery and surgery

+ RT Surgery (RT failed) RT alone foalliative)

I II III IV of Patients

3 4 73 20187 415 713 5136 70144 7 5 78 30187

2 7 3177 7 7126

Note: RT = radiation therapy.

in patients who were treated with surgery alone and surgery plus radiation therapy in the immediate postoperative period for microscopic residual disease and for proved postoperative recurrences, the five year survival rate was 37 per cent (30/81). (Table II.) Hence, it appears from this study that radiation therapy given for local postoperative recurrences and in the immediate postoperative period for micro- scopic residual disease is worthwhile and can signif- icantly increase the five year salvage rate. It also appears from the present study that the patients in whom recurrences were documented within six months of surgery and who were treated with radia- tion therapy (8/34 patients) had significantly better salvage rate than those in whom recurrences were noted after six months (O/23). It may be that the patients in whom recurrences were noted six months or more after surgery and received radiation therapy did not do as well in terms of survival because of the presence of occult distant metastases in addition to the local recurrence.

The introduction of radical surgery and radiation therapy when utilized separately or in combination in squamous cell carcinoma of the hypopharynx in the present series gave a relatively poor five year survival figure (34/120, 28 per cent). Seventeen of fifty-seven patients (29.8 per cent) who developed recurrence in the neck or pharynx also had evidence of systemic disease, and other patients who died with disease also had evidence of metastases below the clavicle, in addition to the local recurrence, probably representing a reflection of the high tendency for distant metastases in hypopharyngeal carcinoma. Because of this persistently poor prognosis and the poor survival figures associated with these well ac- cepted modalities of treatment and because of the high incidence of widespread metastases noted in this study, a prospective randomized trial is warranted to study the influence of adjuvant systemic chemo- therapy with and without combination of radiation therapy on the survival of patients with hypopha- ryngeal carcinoma who are treated initially with surgery.

Summary

From January 1957 to December 1971, 141 pa- tients were treated for hypopharyngeal carcinoma. Twenty-one patients who died within three years of treatment with unrelated cause are excluded, leaving 120 patients for the present study with a minimum of five years follow-up. Nine patients were classified stage I, eight stage II, eighty-four stage III, and nineteen stage IV.

Eighty-one patients were treated primarily by radical surgery with (27) or without (54) deltopec- toral flap reconstruction. Twenty of these eighty-one patients (24 per cent) survived for five years.

Four patients had microscopic tumor at margin of resection and received a full course of radiation therapy in the immediate postoperative period. Two of four (50 per cent) survived for five years. Fifty- seven other patients developed recurrences; of these, forty patients could be treated with radiation ther- apy. Eight of forty patients (20 per cent) with post- operative local recurrences and treated with radiation therapy survived five years.

The overall total five year survival by surgery, surgery and immediate postoperative radiation therapy for microscopic residual disease, and surgery and radiation therapy for postsurgical local recur- rence is 37.3 per cent (30/81). Eleven patients were seen here with radiation therapy failures elsewhere that were treated with surgery. Five year survival in this group is 27.27 per cent (3/11). Twenty-eight patients were treated here with radiation therapy alone. These patients were in very poor general condition or had far advanced disease (fixed neck masses). Only one of twenty-eight (3.5 per cent) was alive after five years.

Total five year survivorship was 34 of 120 (28.3 per cent). Seven patients had stage I, five stage II, twenty-one stage III, and one stage IV disease.

From this study it appears that radiation therapy for local postoperative recurrence and in the imme- diate postoperative period for microscopic residual disease is worthwhile and can significantly increase the five year salvage rate.

References

7. Smith RR, Frazell EL, Caulk R. Holinger PH, Russell WO: The American Joint Committee’s proposed method of stage classification and end result repotting applied to 7,320 pharynx cancers. Cancer 76: 7505, 7963.

2. Hanvick RD: Carcinoma of the pyriform sinus. Am J Surg 730: 493, 7975.

3. Marchetta FC, Sako K, Holyoke ED: Squamous cell carcinoma of the pyriform sinus. Am J Surg 7 74: 507, 7967.

4. Shah JP, Shaha AR, Spiro RH, Strong EW: Carcinoma of the hypopharynx. Am J Surg 732: 439, 7976.

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