Dr. P. Gullane

Wharton Chair Head & Neck Surgery Professor

Department of Otolaryngology -Head & Neck Surgery University of Toronto

Controversies in The Management of Head and Neck and Thyroid Cancer Royal College of Physicians

London, December 5-6, 2013

Hypopharyngeal Cancer – Chemoradiotherapy or Surgery,

The Debate Continues

Wharton Head and Neck Centre

The Toronto General Hospital

Greetings from Toronto to London

Carcinoma of the hypopharynx

“Carcinoma of the hypopharynx is an awful disease with a terrible prognosis” Randal Weber 2005

Purpose of Presentation

Review Treatment Principles and Options in Hypopharyngeal Carcinoma

Review Options for Pharyngo-Esophageal

reconstruction-A Head and Neck Perspective.

Anatomy of Hypopharynx

Hyoid bone to the inferior border of the cricoid cartilage

3 subsites - Piriform Sinus - Posterior pharyngeal wall - Postcricoid region

Incidence

5-10% of upper aerodigestive cancers

3000 cases/year in U.S.A.

> 95% are squamous cell carcinoma

Age > 50 years

M6:1 F

Frequency of Occurrence • Piriform Sinus - 60-70% - 75% clinical or occult nodes • Posterior pharyngeal wall - 25-33% - 60% clinical or occult nodes • Postcricoid Region - 3-5% - 40% clinical or occult nodes

At Presentation

• 25% Unresectable – palliation • 60% Advanced - organ preservation • 15% Early neoplasms - surgery or irradiation • 65% Nodal metastases at presentation

Diagnostic Evaluation

Clinical Examination • History/physical • Complete head and neck examination - Fiberoptic evaluation and biopsy - Extent of neoplasm-stage - Nodal status, size, site, mobility

Diagnostic Evaluation Imaging • CT/MRI of neck and primary - Cartilage invasion - Lymph node evaluation • Chest x-ray vs CT > 12%

Look for 2nd primary • PET-CT

Diagnostic Evaluation

• Examination under anesthesia and biopsy • Establish extent of neoplasm - Possible tracheostomy

“Role of Panendoscopy” • Prospective study of U. of T. Group - 4 of 154 pts (2.6%) had synchronous primary - Head and Neck 22: 449-455, 2000

CT/PET

MRI/PET/CT

Issues: Value of PET CT: ↑ FDG on the Lt BOT but MR lesion was on the Rt; why↑ FDG @ rectoanal junction

PET CT (3/26/08):

MR (3/26/08): R2A node

Principles of Treatment-Multidisciplinary care

• Radiation Oncologist • Surgical Oncology • Medical Oncologist • Dentist • Speech Pathologist • Oncology Nursing • Nutrition

Treatment Policy • 25% of patients unresectable at presentation • 15% early neoplasms (T1 T2) • 60% advanced T3, T4 (stage III-IV) • “Organ preservation” must be offered to the

patient.

Principles of Treatment • Primary Disease Control • Regional Nodal Control • Preservation of Function

– Speech – Swallowing

Not just organ preservation BUT

Preservation of a functional organ.

Surgical Decisions • Early vs Advanced • Primary vs Salvage

Socioeconomic factors(Hall et al)

Evolution of Organ Preservation Strategies Cancer of the Larynx, Hypopharynx

• 1960’s – Laryngectomy/Pharyngectomy • 1970’s – Laryngectomy alone

Planned radiation with surgery for salvage • 1980’s – Irradiation +/- Chemotherapy (5FU, Mitomycin C) • 1990’s – VA Trial, (Neoadjuvant Chemo/Rad or Laryngectomy) • 2000’s – Adoption of Organ Preservation Approaches. • 1960 2013

100% TL 40% TL Functional Larynx?

Quality of Life?

“I have seen the future and it doesn’t work.” Robert Fulford

Treatment • Early (T1, T2) carcinoma - Piriform sinus - Posterior pharyngeal wall

Laser excision ± neck dissection Partial pharyngectomy + neck (II, III, IV) Primary RT or ChemoRT

• Overall survival @ 3 yrs. – 70%

Problems • Inability to completely resect • Dysphagia • Locoregional recurrence

T2 N0 L. Piriform Fossa Lateral Pharyngotomy

Carcinoma

Transhyoid approach

Study Number of Patients Local Control Laryngeal Preservation 5-Yr Disease Specific

Survival

5-Yr Overall Survival

Open

Laccourreye et al, 1993 (127) 34 (T2) 95% - 56% -

Chevalier et al, 1997 (126) 48 (T1/T2) - - - 47%

(78% T1,

38% T2)

Chung et al, 2013 (136) 58 (T1-T4) - 86.2% 77.6% 78%

TOLS

Steiner et al, 2001 (103) 129 (T1-T4) - - 95% (Stage I/II)

69% (Stage III/IV)

71% (Stage I/II)

47% (Stage III/IV)

Rudert and Hoft et al, 2003

(124)

29 (T1-T4) - 100% - 58% (T1)

48% (T2)

Martin et al, 2008 (142) 172 (T1-T4) 84% (T1)

70% (T2)

75% (T3)

57% (T4a)

- 96% (Stage I/II)

86% (Stage III)

57% (Stage IVa)

68% (Stage I/II)

64% (Stage III)

41% (Stage IVa)

Karatzanis et al, 2010 (143) 119 (T1/T2) 85.4%

90% (T1)

83.1 (T2)

- 72.6%

77.8% (T1)

70% (T2)

-

Outcomes of Partial Conservation Surgery in Hypopharyngeal Cancer

Treatment

• Advanced T3, T4 carcinoma – Concurrent Chemo-radiation – Hyperfractionated RT – Laryngopharyngectomy and Adjuvant RT or

ChemoRT

MACH-NC outcome by site

Study Number of

Patients

Stage/Site Local Control Regional Control Laryngeal

Preservation

5-Yr Disease

Specific Survival

5-Yr Overall

Survival

Lefebvre et al,

1996

194 (100 pts in ICT

arm)

T2-T4, N0-N3/ PS,

AEF

17% 23% 35% 25% 30%

Bensadoun et al,

2006

163 (20 Hyp

tumors in CRT arm)

T3, T4, N0-N3 - - - 44.5% (2 yrs) 37.8% (2 yrs)

Lefebvre et al,

2009

450 T2-T4, N0-N2 (231

Hyp)

- - 30.5% ICT Arm

36.2% CRT Arm

- 48.5% ICT Arm

51.9% CRT Arm

Prades et al, 2010 71 T3 PS - - 68% ICT Arm

92% CRT Arm

(2 yrs)

36% ICT Arm

41% CRT Arm

(2 yrs)

-

Lefebvre et al,

2012

194 (100 pts in ICT

arm)

T2-T4, N0-N3/ PS,

AEF

- - 62.5% (10 yrs) 26.97% (10 yrs) 13.1% (10 yrs)

Lefebvre et al,

2013

Phase II

116 (ICT + CRT vs

ICT + BRT)

Stage II, III, IVa (69

Hyp)

95% ICT+CRT

93% ICT+BRT

(3 months)

Randomized Trials of Chemoradiation Therapy in Hypopharyngeal Cancer.

Surgery & Radiation Therapy for Carcinoma of the Hypopharynx

S + RT (n=132)

• Locoregional Control 61% • 5 yr OS 30% • 5 yr DFS 41% Kraus DH, Zeleksky MJ, et al, Otolaryngol

Head Neck Surg 116: 637-31, 1997

Is Pharyngolaryngectomy Palliative?

• Shah J. Carcinoma of the hypopharynx. Am J Surg. 1976;132:439 » 1950 - 1970: 301 untreated patients » Overall 5YS 26% » Early stage (T1N0) > 43% 5YS

• Spiro R. Gastric transposition for head and neck cancer. A Critical update. Am J Surg. 1991;162:348

» 1973 - 1990: 120 patients » Overall 5YS 27% (hypo 32% > cerv esoph 21%)

• Wei W. Currant status of pharyngolaryngo-esophagectomy and pharyngogastric anastomosis

» 1966 - 1995: 317 patients » 1979: 5YS 18% » 1995: 5YS 25%

Outcome in 41 patients of Gastric Transposition

• Goldberg M. Freeman J. Gullane PJ. Patterson GA. Todd TR. McShane D. Transhiatal esophagectomy with gastric transposition for pharyngolaryngeal malignant disease. J Thor Cardiovasc Surg. 97(3):327-33, 1989

– 41 patients (21 prior high dose RT)

– Mortality 20%

– Morbidity 46%

– Fistula 22%

– Mean LOS 31 days

– Overall 35% 2YS

Triboulet JP. Surgical management of carcinoma of the hypopharynx and cervical esophagus: analysis of 209 cases.

Arch Surg. 136:1164, 2001

Surgical Salvage Following Irradiation ± Chemotherapy

Problems - Extent of recurrence - neck only - neck & primary - Hostile wound - High fistula rate - Need for flap repair

The Ideal Reconstruction after Laryngopharyngectomy

• Single stage procedure. • Restore gastrointestinal continuity. • Low or minimal surgical

morbidity/mortality. • Low rate of distal stenosis. • Allow the development of functional

fistula speech. • Minimal technical/surgical expertise. • Ability to discharge the patient early.

Menu of Options in Reconstruction

Reconstruction Swallowing Speech Morbidity

Gastric Transposition

++++ + ++++

Jejunum ++ + ++

Gastro-omental ++++ +++ ++

Anterolateral Thigh

+++ ++ +

Forearm +++ ++ +

Current Treatment Philosophy

For Total Laryngopharyngectomy Avoid Gastric Transposition In high performance patients with no previous

laparatomy-Gastro-Omental Flap In poor performance patients-Anterolateral thigh flap with

salivary stent

Algorithm of Pharyngeal Reconstruction in an Era of Organ Preservation 2010

Circumferential Defect

Primary Surgery

Thigh Thickness

Radial Forearm Anterolateral Thigh

Salvage Surgery

Initial Therapy

Standard Radiotherapy

Chemoradiation/ high dose altered

fractionation

Performance

Gastro-Omental Flap

Poor

Adequate

Summary Management of Carcinoma of the Hypopharynx

Primary Disease Control and Organ Preservation in appropriate patients

Management of the Neck and Regional Control Aggressive use of complex reconstructive techniques

in concurrent chemoradiation failure patients

Treatment of Hypopharyngeal Carcinoma-PMH approach

Small Primary Tumors Primary surgery(laser or partial pharyngectomy) + Neck

Management + Post-op RT vs Primary RT or Concurrent Extensive Tumors-T4a Primary Laryngopharyngectomy + Postop RT vs

Concurrent ChemoRT and Salvage Unresectable Concurrent ChemoRT or Clinical Trial

University Health Network

Thank you