Hypopharyngeal Carcinoma - UCLouvain · Hypopharynx 1 Mar. 2006 Catholic University of Louvain, St-Luc University Hospital Head and Neck Oncology Programme Hypopharyngeal Carcinoma

Hypopharynx 1

Mar. 2006

Catholic University of Louvain, St-Luc University HospitalHead and Neck Oncology Programme

Hypopharyngeal Carcinoma

Hypopharynx 2

Mar. 2006



•• WorkWork--up procedureup procedure

•• TNM stagingTNM staging

•• Primary treatmentPrimary treatment

•• FollowFollow--upup

•• Treatment of recurrent and/or Treatment of recurrent and/or metastaticmetastatic diseasedisease

•• ReferencesReferences

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Clinical evaluation Evidence Option

l complete history of the diseasel weight and weight lossl performance status (Karnofsky / ECOG-WHO)l fiberoptic examination of H&N mucosal neck examinationl drawing of any lesions

Type CType CType CType CType CType C

Std.Std.Std.Std.Std.Std.

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Mar. 2006


Endoscopic evaluation Evidence Option

l endoscopy under general anesthesia with biopsiesof any suspicious site

Type C Std.

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Advanced clinical evaluation Evidence Option

l dental examination by oral surgeonl nutritional assessmentl others (if required)

Type CType CType C

Std.Std.Std.

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Laboratory tests Evidence Option

l hemogram, coagulation tests, liver enzymes, kidney functionl thyroid function: TSH

Type C

Type C

Std.

Std.

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Imaging Evidence Option

l Loco-regional: CT scan (or MRI)1

l Metastatic work-up: chest X-ray, thoracic spiralCT scan

l Additional examination depending on previousfindings

l PET scan

Type CType C

Type C

Type 3

Std.Std.

Std.

Invest.1See guidelines for loco-regional imaging

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Pathologic examination Evidence Option

Standards of the British Royal College ofPathologists (endorsed by EORTC)1

Type C Std.

1See pathology guidelines

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Staging Evidence Option

• TNM classification (6th ed., 2002) • WHO International Classification of Diseases for

Oncology (ICD-O 9 or ICD-O 10)

Type C Type C

Std. Std.

For oropharynx and hypopharynx, T4 is divided into T4A (resectable) anT4B(unresectable) leading to the division of stage IV into stage IVA, stageIVB and stage IVC

Stage IVA T4aN0M0, T4aN1M0, T1N2M0, T2N2M0, T3N2M0, T4aN2MO

Stage IVB T4b any N M0, any T N3 M0

any T N3 M0

Stage IVC any T any N M1

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TNM/AJCC 1997 StagingTNM/AJCC 1997 Staging

• Tx: primary tumor cannot be assessed• T0: no evidence of primary tumor• T1: Tumor limited to one subsite of hypopharynx and ≤ 2 cm• T2: Tumor invades more than one subsites of

hypopharynx or an adjacent site, or > 2cm and ≤ 4 cm without fixation of hemilarynx

• T3: > 4 cm or with fixation of hemilarynx• T4a invades thyroid/cricoid cartilage, hyoid bone, thyroid gland,

esophagus or central compartment soft tissue*• T4b invades prevertebral fascia, encases carotid artery, or invades

mediastinal structures

* Includes prelaryngeal strap muscles and subcutaneous fat

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• N0: no regional node metastasis• Nx: regional nodes cannot be assessed• N1: single ipsilateral node, ≤ 3 cm• N2a: single ipsilateral node, > 3 cm and ≤ 6 cm• N2b: multiple ipsilateral nodes, ≤ 6 cm• N2c: controlateral or bilateral nodes, ≤ 6 cm• N3: node > 6 cm

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•• Mx: DistantMx: Distant metastasis cannot be assessedmetastasis cannot be assessed•• M0: No distantM0: No distant metastasismetastasis•• M1: DistantM1: Distant metastasismetastasis

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TreatmentTreatment ofof HypopharyngealHypopharyngeal wallwall / / postcricoid area tumorpostcricoid area tumor

NONO

FollowFollow--upup

SelectiveSelectivebilateralbilateral ND ND

±±RxThRxTh

EndoscopicEndoscopic LaserLasermicroexcision microexcision

((selectedselected T1 N0)T1 N0)

RxThRxTh

N0N0

UniUni-- ororbilateralbilateral NDND

SalvageSalvage surgerysurgery+ Neck dissection+ Neck dissection

NeckNeckdissectiondissection

FollowFollow--upup

FollowFollow--upupFollowFollow--upup

T1 T1 -- T2T2

PrimaryPrimary control ?control ?YESYES

NONOYESYES

PrimaryPrimary control ?control ?

ResidualResidual neckneck diseasedisease

N1N1 ≥≥N2N2

YESYES NONO

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TreatmentTreatment of of pyriform pyriform sinus sinus tumorstumors

RxTh RxTh ± ND ± ND Partial Partial PharyngoPharyngo--

laryngectomy laryngectomy + uni+ uni-- or or bilateralbilateral

NDND

EndoscopicEndoscopic LaserLaserMicroexcisionMicroexcision

((SelectedSelected T1 N0)T1 N0)+ ND ± + ND ± RxThRxTh

PostopPostopRxThRxTh FollowFollow--upup

FollowFollow--upup

T1 T1 -- T2T2

Candidate for conservationCandidate for conservation surgerysurgery

indication for postindication for post--op RxThop RxTh

YESYES NONO

Yes NoNo

FollowFollow--upup

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TreatmentTreatment ofof HypopharyngealHypopharyngeal tumorstumors

ThyroidThyroid cartilagecartilageintact orintact or moderately invadedmoderately invaded

ExtendedExtended partialpartialPharyngolaryngectomyPharyngolaryngectomy

+ free+ free flapflap++ bilateralbilateral NDND

Locally advanced RxThLocally advanced RxThprotocol protocol ± ND± ND

FollowFollow--upup

+ + PostPost--opop. . RxThRxTh

TotalTotalPharyngolaryngectomyPharyngolaryngectomy ±±

EsophagectomyEsophagectomy+ + bilateral bilateral NDND

ThyroidThyroid//cricoidcricoid cartilagecartilage massively massively invaded Tumor extending beyondinvaded Tumor extending beyond

thethe pharyngolarynxpharyngolarynx

+ + PostPost--opop..RxThRxTh

FollowFollow--upup

RecurrenceRecurrence

Candidate for conservationCandidate for conservation surgerysurgery ??

YESYES NONO

T3 T3 -- T4T4

Salvage Salvage surgerysurgery

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Primary treatment: general strategy: hypopharyngealwall/postcricoid area carcinoma

Evidence Option

l T1, N0-N1, M0-RxTh (T+N bilateral)-Endoscopic laser excision + ND (bilateral) ± RxTh1

l T2, N0-N1, M0-“moderately advanced” RxTh protocol (T+N bilateral) ± ND2

l T1-T2, ≥ N2a, M0-“locally advanced” RxTh protocol (T+N bilateral) ± ND2

l T3-T4, any N, M0-“locally advanced” RxTh protocol (T+N bilateral) ± ND2

-total pharyngolaryngectomy ± cervical oesophagectomy + bilateral ND + RxTh1

Type 3Type 3

Type 3

Type 3

Type 3

Type 3

Std.Std.

Std.

Std.

Std.

Std.

1 see guidelines for post-operative radiotherapy2 see guidelines for post-radiotherapy ND (slide 24)

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Primary treatment: general strategy: pyriform sinus carcinoma Evidence Option

l T1, N0-N1, M0-partial laryngopharyngectomy + bilateral ND (unilateral for lateral wall tumor) ± RxTh1

-good pulmonary fonction-apex non-invaded

-RxTh ± ND2

-non fitted for surgery-not suitable for conservative surgery (e.g. apex invaded)

-endoscopic laser surgery + bilateral ND (unilateral for lateral wall tumor) ± RxTh1

-very selected tumor easily exposedl T2, N0-N1, M0

-partial laryngopharyngectomy + bilateral ND± RxTh1


-RxTh ± ND2

-non fitted for surgery-not suitable for conservative surgery (e.g. apex invaded)

Type 3

Type 3

Type 3

Type 3

Type 3

Std.

Std.

Std.

Std.

Std.


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Mar. 2006


Primary treatment: general strategy:pyriform sinus carcinoma Evidence Option

l T1-T2, ≥ N2a, M0-“locally advanced” RxTh protocol (T+N bilateral) ± ND2

-partial laryngopharyngectomy + bilateral ND (unilateral for lateral wall tumor) ± RxTh1


l T3, N0-N1, M0-“locally advanced” RxTh protocol (T+N bilateral) ± ND2

-extended hemilaryngopharyngectomy (Urken) + bilateral ND + RxTh1

-total laryngopharyngectomy + bilateral ND + RxTh1

l T3, > N2a, M0 - T4, any N, M0-“locally advanced” RxTh protocol (T+N bilateral) ± ND2

-total laryngopharyngectomy + bilateral ND + RxTh1

Type 3Type 3

Type 3Type 3

Type 3

Type 3Type 3

Std.Std.

Std.Std.

Std.

Std.Std.


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Mar. 2006


Primary treatment: surgical procedure of the “N” site Evidence Option

l N site:- N0: bilateral selective ND (II-IV)1

- N1: homolateral MRND + controlateral selective ND- N2a-b: homolateral MRND or RND + controlateral

selective ND (or MRND)- N2c: bilateral MRND (or RND + MRND)- N3: homolateral RND + controlateral SND

Type CType CType C

Type CType C

Std.Std.Std.

Std.Std.

1see clinical target volume for the nodes

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Primary treatment: RxTh regimen Evidence Option

l Target volumesT: CTV = GTV + margin according to anatomical barriersN: see table on node levels according to T site

l Technique-conformal radiotherapy-IMRT radiotherapy

l Dose / fractionation / treatment timel Early stage:1

-prophylactic dose: 50 Gy,-therapeutic dose: 66-70 Gy, 2 Gy daily

l "moderately advanced"2 / "locally advanced"3 stage-on protocol: GORTEC 99-02 / IMCL CP02-9815-off protocol: moderately accelerated regimen (concomitant boost)

l post-operative RxTh-dose: 60-64 Gy, 2 Gy daily4

Type 3Type 3

Type CType C

-Type 1

Type 2

Std.Invest.

Std.Std.

Invest.Std.

Std.1T1 N0-N12T2 N0-N13any T N2a-N34See guidelines for post-operative radiotherapy

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Mar. 2006

Catholic University of Louvain, St-Luc University HospitalHead and Neck Oncology ProgrammeTarget Volumes: Target Volumes: hypopharynxhypopharynx

Level of evidence : type 3 / option : standardLevel of evidence : type 3 / option : standardStage Ipsilateral neck Controlateral neck

N0 II1-III-IV +RP for post. II1-III-IV + RP for post. pharyngeal wall T + VI for pirif. pharyngeal wall T + VI

sinus or esophageal extension for esophageal extension

N1-N2a-N2b Ib-II-III-IV-V +RP + VI for II1-III-IV + RP for post. pirif. sinus or esophageal pharyngeal wall T + VI

extension for esophageal extension

N2c According to N stage on According to N stage oneach side of the neck each side of the neck

N3 I-II-III-IV-V +RP + VI (pirif. II1-III-IV + RP for post. sinus or esoph. ext) ± adjacent pharyngeal wall T + VI structures according to clinical for esophageal extension

and radiological data1level IIb could be omitted for N0 patients

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StdStd..Type 3Type 3•• PlannedPlanned ND (SND, RMND, RND or ND (SND, RMND, RND or extendedextended ND) 2ND) 2--3 3 monthsmonths afterafter completioncompletion ofof RxThRxTh in patients in patients withwith aacontrolledcontrolled primaryprimary site site andand in case of in case of residualresidual or or suspected suspected

residualresidual, , resectableresectable N N diseasedisease irrespectiveirrespective ofof thethe initial N initial N stagestage

OptionOptionEvidenceEvidencePrimary treatment: neck dissection following a primary radiotherapy

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•• Treatment of recurrent and/orTreatment of recurrent and/or metastaticmetastatic diseasedisease


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Follow-up Evidence Option

l Clinical examination-fiberoptic examination and neck palpation every 2 months (first 2 years), every 6 months (3rd-5th year), then every year (> 5 years)-dental examination every 6 months

l Imaging-chest X-ray every year

l Laboratory tests-thyroid function (TSH) every year

l Evolution of late toxicity (EORTC/RTOG) scale

Type C

Type C

Type C

Type CType C

Std.

Std.

Std.

Std.Std.

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Salvage treatment for recurrent disease: general principle

Treatment will depend on:l Site and extension (rTNM stage)l Previous treatment(s)l Performance statusl Patient wishes

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Salvage treatment for recurrent disease Evidence Option

l anyT-N0-M0-surgery ± RxTh1

-RxTh1 / brachyth (T < 3 cm)-chemotherapy

l T0-anyN-M0-ND ± RxTh1

-RxTh1

-chemotherapyl AnyT-anyN-M0

-surgery ± RxTh1

-chemotherapy-best supportive care

l Metastasis-chemotherapy-best supportive care

Type CType CType C

Type CType CType C

Type CType CType C

Type CType C

Std.Indiv.Indiv.

Std.Std.

Indiv.

Std.Indiv.Indiv.

Std.Std.

1depending on previous radiotherapy ; see guidelines for post-operative radiotherapy

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ReferencesReferences• AJCC Cancer Staging Manual / American Joint Committee on Cancer. 5 th edition Lippincott-Raven eds, 1997.• Chevalier D, Watelet JB, Darras JA, Piquet JJ.Supraglottic hemilaryngopharyngectomy plus radiation for the treatment of early lateral margin and pyriform sinus carcinoma.Head Neck. 1997;19(1):1-5• Dubois JB, Guerrier B, Di Ruggiero JM, Pourquier H.Cancer of the piriform sinus: treatment by radiation therapy alone and with surgery. Radiology. 1986;160(3):831-6.• El Badawi SA, Goepfert H, Fletcher GH, Herson J, Oswald MJ.Squamous cell carcinoma of the pyriformsinus.Laryngoscope. 1982;92(4):357-64.• Garden AS, Morrison WH, Clayman GL, Ang KK, Peters LJ. Early squamous cell carcinoma of the hypopharynx: outcomes of treatment with radiation alone to the primary disease. Head Neck. 1996;18(4):317-22.• Kramer S, Gelber RD, Snow JB, Marcial VA, Lowry LD, Davis LW, Chandler R.Combined radiation therapy and surgery in the management of advanced head and neck cancer: final report of study 73-03 of the Radiation Therapy Oncology Group.Head Neck Surg. 1987;10(1):19-30.• Laccourreye O, Merite-Drancy A, Brasnu D, Chabardes E, Cauchois R, Menard M,Laccourreye H. Supracricoid hemilaryngopharyngectomy in selected pyriform sinus carcinoma staged as T2. Laryngoscope. 1993;103(12):1373-9.• Lefebvre JL, Chevalier D, Luboinski B, Kirkpatrick A, Collette L, Sahmoud T. Larynx preservation in pyriform sinus cancer: preliminary results of a European Organization for Research and Treatment of Cancer phase III trial. EORTC Head and Neck Cancer Cooperative Group. J Natl Cancer Inst. 1996;88(13):890-9.• Mendenhall WM, Parsons JT, Devine JW, Cassisi NJ, Million RR. Squamous cell carcinoma of the pyriform sinus treated with surgery and/or radiotherapy. Head Neck Surg. 1987;10(2):88-92.• Mendenhall WM, Parsons JT, Stringer SP, Cassisi NJ, Million RR. Radiotherapy alone or combined with neck dissection for T1-T2 carcinoma of the pyriform sinus: an alternative to conservation surgery. Int J Radiat Oncol Biol Phys. 1993;27(5):1017-27. • Nguyen TD, Malissard L, Eschwege F, Panis X, Hoffstetter S, Jung GM, Bachaud JM, Prevost B, Quint R, Chaplain G, et al.Radiothérapie postopératoire dans les cancers du sinus pyriforme. Work of the "Groupe radiotherapie de la Federation nationale des centres de lutte contre le cancer. Bull Cancer Radiother. 1995;82:318-25.

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ReferencesReferences• Ogura JH, Marks JE, Freeman RB. Results of conservation surgery for cancers of the supraglottis and pyriform sinus. laryngoscope.1980;90(4):591-600.• Parsons JT, Mendenhall WM, Stringer SP, Cassisi NJ, Million RR.Twice-a-day radiotherapy for squamous cell carcinoma of the head and neck: the University of Florida experience.Head Neck. 1993;15(2):87-96.• Plouin-Gaudon, I; Hamoir M, ; Desuter G, ; Rombaux P; Grégoire V; Lengelé B.Organ preservation with surgery plus radiation therapy for selected early and advanced staged pyriform sinus cancer. Am J surg. Submitted for publication. 2001• Pradhan SA. Strategies for voice conservation in cancers of the hypopharynx. Proceedings of the 5th International Conference on Head and Neck Cancer. San francisco 2000 :577-80.• Spector JG, Sessions DG, Emami B, Simpson J, Haughey B, Harvey J, Fredrickson JM. Squamous cell carcinoma of the pyriform sinus: a nonrandomized comparison of therapeutic modalities and long-term results. Laryngoscope. 1995; 105:397-406.• Steiner W, Ambrosch P, Hess CF, Kron M. Organ preservation by trans-oral laser microsurgery in piriform sinus carcinoma. Otolaryngol Head Neck Surg. 2001;124(1):58-67.• Steiner W, Stenglein C, Fietkau R, Sauerbrei W. Therapy of hypo-pharyngeal cancer. Part IV: Long-term results of transoral laser microsurgery of hypopharyngeal cancer. HNO. 1994;42(3):147-56.• Urken ML, Blackwell K, Biller HF. Reconstruction of the laryngopharynx after hemicricoid/hemithyroid cartilage resection. Preliminary functional results.Arch Otolaryngol Head Neck Surg. 1997;123(11):1213-22.• Vandenbrouck C, Eschwege F, De la Rochefordiere A, Sicot H, Mamelle G, Le Ridant AM, Bosq J, Domenge C.Squamous cell carcinoma of the pyriform sinus: retrospective study of 351 cases treated at the Institut Gustave-Roussy. Head Neck Surg. 1987;10(1):4-13.• Vandenbrouck C, Sancho H, Le Fur R, Richard JM, Cachin Y.Results of a randomized clinical trial of preoperative irradiation versus postoperative in treatment of tumors of the hypopharynx. Cancer. 1977;39(4):1445-9.• Wang CC. Twice-daily radiation therapy for head and neck carcinomas.Front Radiat Ther Oncol. 1988;22:93-8.

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Hypopharyngeal Carcinoma - UCLouvain · Hypopharynx 1 Mar. 2006 Catholic University of Louvain, St-Luc University Hospital Head and Neck Oncology Programme Hypopharyngeal Carcinoma