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
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Hypopharyngeal Cancer – Chemoradiotherapy or Surgery, The ... patrick Gullane...Surgical management of carcinoma of the hypopharynx and cervical esophagus: analysis of 209 cases.
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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
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
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
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
• 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