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Squamous Carcinoma of the Hypopharynx T R Helliwell

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Squamous Carcinoma of the Hypopharynx T R Helliwell 81 J Clin Pathol: first published as 10.1136/jcp.56.2.81 on 1 February 2003. Downloaded from Best Practice No 169 Evidence based pathology: squamous carcinoma of the hypopharynx T R Helliwell ............................................................................................................................. J Clin Pathol 2003;56:81–85 This best practice article reviews the published evidence spread of carcinomas of the hypopharynx, and the relevance of pathological features to progno- on the pathology and patterns of spread of carcinomas sis. of the hypopharynx, and the relevance of pathological features to prognosis. Medline (1966–2001) was searched METHODS using a combination of head and neck neoplasms and Published evidence was sought by a search of prognosis, focusing on hypopharynx and pathology. Medline (1966–2001) for papers referring to a Other relevant publications were identified from the combination of head and neck neoplasms and prognosis, focusing on hypopharynx and patho- bibliographies of these papers, and from those obtained logy. Other relevant publications were identified opportunistically. There is relatively little pathological from the bibliographies of these papers, and from literature devoted specifically to squamous carcinomas of papers obtained from opportunistic reading of the hypopharynx and most information comes from large journals. series of patients with head and neck cancers at a range at sites. Lack of consistency in reporting and shifts in RESULTS Epidemiology terminology make comparisons between series difficult. Carcinoma of the hypopharynx is a relatively The most important features determining prognosis are uncommon disease, which has an incidence of less than 1/100 000 of the population, and usually size and extent of local spread of the primary carcinoma http://jcp.bmj.com/ presents in patients aged 60–70 years.2 Carcinoma and extent of involvement of regional lymph nodes. There of the piriform sinuses and posterior pharyngeal is evidence to support the use of the minimum dataset wall occurs mainly in men and is associated with criteria for head and neck carcinomas at this site. Within alcohol and tobacco smoking. Postcricoid carci- noma is more common in women and is the hypopharynx, subsite related differences in aetiology associated with sideropaenic dysphagia and biology may become important. (Paterson–Brown–Kelly syndrome), leading to a .......................................................................... wide variation in geographical incidence, being on September 30, 2021 by guest. Protected copyright. relatively more common in India, Iran, and 3 he hypopharynx is formed by the right and Japan. left piriform sinuses (Latin “pirium” or A review of European cancer registry data “pear”), the posterior pharyngeal wall, and suggests that within the group of patients with T 1 hypopharyngeal carcinoma, there is a higher the postcricoid oesophagus, each of which is This paper is based on a proportion of piriform fossa carcinomas in presentation at a meeting regarded as a subsite of the hypopharynx for on evidence based diagnostic coding. The mucosa is covered by non- France (78%), the Netherlands (63%), and the management of UK (53%) than in other European countries, keratinising stratified squamous epithelium and 4 hypopharyngeal cancer contains mucosal glands, scattered lymphoid such as Germany (18%) and Sweden (5%). organised by the National Changes in incidence, diagnostic fashions, and Otolaryngology Trials aggregates, and a rich lymphatic plexus. Carcino- Office in November 2001. mas arising in the hypopharynx are uncommon referral pathways may have occurred over time, Further details and a full list and are often considered to have a poor prognosis because in 1970 Harrison found 60% of hypopha- of papers and references with a propensity to present with advanced ryngeal carcinomas arising in the postcricoid from this meeting can be 5 primary disease requiring wider resection than region in his practice in London, UK. In the USA obtained from the website and Canada, 65–85% of hypopharyngeal carcino- www.noto.org. carcinomas at other head and neck sites, and with a high risk of nodal metastasis. mas involve the piriform sinuses, 10–20% the Correspondence to: posterior pharyngeal wall, and 5–15% the post- Dr T R Helliwell, cricoid region.6 Department of Pathology, “Carcinomas arising in the hypopharynx Duncan Building, Daulby Part of the apparent variation in prevalence of Street, Liverpool L69 3GA, are uncommon and are often considered to different primary subsites may arise from the UK; [email protected] have a poor prognosis” tendency of carcinomas to involve more than one subsite at diagnosis; therefore, the allocation of a Accepted for publication 12 September 2002 This paper reviews the published evidence of carcinoma to a putative site of origin may be an ....................... the nature on the pathology and patterns of inexact science. Michaels7 noted that 60% of cases www.jclinpath.com 82 Helliwell involved more than one site and usually all three areas are affected, with the piriform sinuses alone involved in 32%. Table 1 Distribution of nodal metastases J Clin Pathol: first published as 10.1136/jcp.56.2.81 on 1 February 2003. Downloaded from Pathological node assessment Macroscopic pathology of the primary carcinoma (% cases with positive nodes) Knowledge of the pathology and spread of hypopharyngeal First author Clinical node carcinoma has come from elegant studies of whole organ (ref) assessment Level II Level III Level IV sections5 7–9 which have been confirmed by imaging studies.1 Jones27 All patients 70% 23% 5% Because hypopharyngeal tumours tend to present at a 28 relatively late stage, the early pattern of spread is more Candela N0 15% 8% 0% N+ 72% 72% 47% difficult to define than at some other head and neck sites. Hypopharyngeal carcinomas are most often flat plaques Shah26 N0 75% 75% 0% with raised edges, and superficial ulceration. The carcinomas N+ 78% 75% 47% show a tendency for multisite involvement within the hypopharynx and extend into adjacent mucosal areas. The more extensive, multisite carcinomas tend to show superficial mucosal invasion and to be undifferentiated.3 The carcinomas tend to spread within the mucosa, beneath intact epithelium, Pathology of nodal metastases for an average of 10 mm in the piriform sinus and 5 mm in the Nodal metastasis is more common for hypopharyngeal postcricoid region.58 Tumours spread through the muscle of primary carcinomas than for some other head and neck sites, the hypopharyngeal wall in most cases but the laryngeal car- although the frequency and pattern of metastasis varies tilages resist invasion and are only invaded in a minority of according to the hypopharyngeal subsite.21 Delayed regional cases.7 metastasis (more than two years after diagnosis) is more Superior spread of piriform sinus carcinomas often involves common for patients with piriform sinus carcinoma (31%) the lateral wall of the oropharynx and the base of the tongue. than for patients with postcricoid (18%), supraglottic (16%), Carcinomas of the piriform sinuses, particularly those involv- or glottic (6%) carcinomas.22 ing the medial wall, spread anteriorly into the supraglottic and Even small (T1–2) piriform sinus carcinomas are associated glottic larynx. Once the paraglottic space is involved, the with nodal spread at presentation10 and there is a high tumour may spread outside the larynx through the cricothy- (> 50%) chance of occult nodal metastasis.23 24 Bilateral meta- roid membrane. Vocal cord fixation may result from involve- static disease is common, and even in patients with a clinically ment of the crico–arytenoid joint, invasion of the posterior N0 neck, 56% of ipsilateral and 47% of contralateral neck dis- crico–thyroid muscle, or involvement of the recurrent laryn- sections contain positive nodes.25 geal nerve.10–12 Piriform sinus carcinomas spread most often to level II Posterior hypopharyngeal wall tumours tend to be exo- nodes, with level III and IV nodes being involved particularly 12 phytic and are often large (80% > 5 cm) at presentation, in clinically node positive patients (table 1). Eleven per cent of 13 extending into the posterior oropharyngeal wall. Postcricoid piriform fossa carcinomas have metastases in the supracla- carcinomas tend to grow anteriorly to involve the posterior vicular nodes or posterior triangle.26 crico–arytenoid muscle, and may extend into the trachea Tumours of the posterior pharyngeal wall may also spread through the cricoid cartilage or inferiorly to involve the to retropharyngeal nodes in 40% of patients.29 Postcricoid car- 5 oesophagus and trachea. cinomas spread to mid and lower cervical nodes and paratra- http://jcp.bmj.com/ The thyroid gland is often involved by hypopharyngeal car- cheal nodes, and have a lower incidence (30%) of nodal cinoma because of the proximity of the upper lobes to the lat- metastasis than other hypopharyngeal carcinomas.27 Eighteen eral wall of the hypopharynx. Thyroid invasion is a poor prog- per cent of patients have bilateral cervical node metastases.6 14 nostic factor. Only one paper specifically looks at the prognostic import- Microscopic pathology of the primary carcinoma ance of extracapsular spread from nodal metastases in hypopharyngeal carcinoma. The relative risk for recurrence of In situ carcinoma is often seen adjacent to invasive squamous neck disease is greater if the nodes are more than 3 cm in carcinoma and, although there have been no studies of
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