Yale University EliScholar – A Digital Platform for Scholarly Publishing at Yale Yale Medicine Thesis Digital Library School of Medicine 1987 A retrospective comparison of tumor recurrence and patient survival after treatment with preoperative radiation therapy and surgery, or surgery and postoperative radiation therapy for squamous cell carcinoma of the pyriform sinus and hypopharynx Jesse George Wardlow Jr. Yale University Follow this and additional works at: http://elischolar.library.yale.edu/ymtdl Recommended Citation Wardlow, Jesse George Jr., "A retrospective comparison of tumor recurrence and patient survival after treatment with preoperative radiation therapy and surgery, or surgery and postoperative radiation therapy for squamous cell carcinoma of the pyriform sinus and hypopharynx" (1987). Yale Medicine Thesis Digital Library. 3284. http://elischolar.library.yale.edu/ymtdl/3284 This Open Access Thesis is brought to you for free and open access by the School of Medicine at EliScholar – A Digital Platform for Scholarly Publishing at Yale. It has been accepted for inclusion in Yale Medicine Thesis Digital Library by an authorized administrator of EliScholar – A Digital Platform for Scholarly Publishing at Yale. For more information, please contact [email protected]. A RETROSPECTIVE COMPARISON OF Permission for photocopying or microfilming of purpose of individual scholarly consultation or reference is hereby granted by the author. This permission is not to be interpreted as affecting publication of this work, or otherwise placing it in the public domain, and the author reserves all rights of ownership guaranteed under common law protection of unpublished manuscripts. (Signature of author) (Printed name) (Date) Digitized by the Internet Archive in 2017 with funding from The National Endowment for the Humanities and the Arcadia Fund https://archive.org/details/retrospectivecomOOward A RETROSPECTIVE COMPARISON OF TUMOR RECURRENCE AND PATIENT SURVIVAL AFTER TREATMENT WITH PREOPERATIVE RADIATION THERAPY AND SURGERY, OR SURGERY AND POSTOPERATIVE RADIATION THERAPY FOR SQUAMOUS CELL CARCINOMA OF THE PYRIFORM SINUS AND HYPOPHARYNX A thesis submitted to the Yale School of Medicine in partial fulfillment of the requirements for the degree of Doctor of Medicine Jesse George Wardlow, Jr 1987' (Med Lib 4Ya l&v l TABLE OF CONTENTS Page I. ABSTRACT . iii-iv II. INTRODUCTION.1-4 III. EMBRYOLOGY AND ANATOMY.5-19 IV. REVIEW OF THE LITERATURE.20-61 Tumor Staging at Presentation.20-22 Treatment of Primary Tumor with Radiation.23-30 Treatment of Primary Tumor with Surgery. .31-34 Treatment of Cervical Lymph Nodes.35-46 Combination Therapy.47-61 V. MATERIALS AND METHODS.62-67 Patient Population.62-65 Treatment.66-68 VI. RESULTS.69-72 VII. DISCUSSION.73-75 VIII. REFERENCES.76-80 IX. APPENDICE . A. Types of Modified Neck Dissection. 81 ii ABSTRACT Since 1973, patients with advanced tumors (Stage III and IV) of the pyriform sinus and hypopharynx have been consistently treated with surgery and postoperative radiation therapy by the Yale Section of Otolaryngology. This study will investigate whether this form of combined therapy provides more patients with longer disease-free survival than preoperative radiation therapy and surgery which patients received prior to 1973. Charts of 86 patients with advanced tumors of the pyriform sinus and hypopharynx treated by the Yale Section of Otolaryngology with combination therapy between January 1963 and December 1984 were reviewed. Fifty-nine patients were included in the study. The results of this review showed a 45 percent two-year and a 24 percent five-year disease-free i i i survival among patients receiving preoperative radiation therapy. In the preoperative radiation therapy group, there were two perioperative deaths due to carotid rupture. Other treatment complications included fistula formation, abscess, and pulmonary infiltrate. In the surgery and postoperative radiation therapy group, there was a 37 percent two-year disease-free survival and a 17 percent five-year disease-free survival. The difference in survival between the two treatment groups did not achieve significance using the chi-square test. These results agree with the results published in the literature which show no consistent advantage for either mode of combination therapy. These data show postoperative radiation therapy provides little hope for increasing disease-free survival over preoperative radiation therapy, although it is technically more practical providing a better surgical field with fewer perioperative mortalities. i v INTRODUCTION The pyriform sinuses (aka pyriform fossa or recesses) are located adjacent to the glottis and behind the thyroid cartilage ala. They are the recesses through which solids and liquids are channeled into the esophagus. The 1980 American Joint Committee on Cancer (AJC) places the pyriform sinus in the region of the hypopharynx, which includes the pyriform sinus, posterior cricoid area ( p o st c r i c o id ) and posterior hypophary ngeal wall.'*' Each pyriform sinus is shaped like an inverted horn or pyramid, as described in a recent article by T. Sasaki: The pyriform sinus or recess (is) defined as the space which extends from the pharyngoepiglottic fold (superiorly), to the entrance of the esophagus (interiorly). Laterally, the sinus is bounded by the inner aspect of the thyroid cartilage and medially is bounded by the arytenoepiglottic fold and mouth of the esophagus.^ Anatomically this is a very confined region which is difficult to assess on physical examination or by 2 clinical inspection in the clinic. The apex of the pyriform sinus is subject to thorough indirect mirror examination only by the most skillful of examiners. The walls of the pyriform sinus are often only partially open when viewed from above. Direct laryngoscopy performed under general anesthesia could provide information on the horizontal extent of tumor, but is unable to accurately ascertain the extent of submucosal infiltration or soft tissue invasion. Radiologically, contrast laryngography had been the diagnostic procedure of choice in the 1960s. Contrast laryngography was unable to provide information to evaluate the extent of tumor invasion. In the 1970s, Computed Axial Tomography (CT-Scan) was shown to be a superior method of radiologic evaluation, able to accurately determine the vertical extent of tumor and the degree and presence of cervical adenopathy. Cartilagenous invasion can be detected, although it can be difficult to accurately determine due to irregular ossification of the laryngeal framework. Ossification of the cartilagenous framework can be mistaken for tumor invasion of cartilage on CT-Scan. Misleading results have also been found 3 using the CT-Scan to evaluate soft tissue invasion by tumor specifically, over estimation of tumor size due to associated edematous changes, inflammation, and 4 — 6 mass effect of tumor. Magnetic Resonance Imaging (MRI) utilizing surface coil technology seems to hold the promise of detailed studies of submucosal tissue and deep tissue planes in this region. MRI may improve the ability of the surgeon, in cooperation with the radiologist, to preoperatively assess the degree of tumor extension and infiltration into the cartilagenous laryngeal framework and tumor 4 — 6 invasion of the soft tissues of the neck. On physical exam the loss of thyroid crepitations or fullness behind the thyrohyoid or cricohyoid membrane may be an indication of malignant disease which is already well advanced. Tumors in this region often do not produce symptoms until late in their course. By the time they become clinically apparent, they may have become quite large with extensive invasion and infiltration. One-third of patients initially present with dysphagia secondary to mass obstruction. The ominous appearance of firm cervical nodes unresponsive to antibiotic therapy is the first clinical sign of malignancy in 20-25 percent of patients. Vocal changes such as 4 hoarseness may occur late or not at all; "hot potatoe voice" may signify infiltration of the base of the tongue. Other late symptoms include weight loss, foul breath, and general disability.^ Recently the advent of flexible fiberoptic endoscopy of the oropharyngeal region has allowed for improved direct visualization of the region with a permanent record made on video tape. This technological innovation may permit earlier diagnosis of these tumors. The advanced stage of these tumors at presentation has historically lead to a very dismal prognosis. Mattox (1985) in a review article reported that 60-75% of hypopharyngeal tumors occur in the pyriform sinus and most published series report 20-30 percent five-year survival. Nodal metastases reduce survival by one-half and are present in 50-80 percent of cases of hypopharyngea1 carcinoma, although 25 percent of the time they are clinically occult.^ Sites of tumor origin in the pyriform sinus include the apex, medial wall, lateral wall and g aryepiglottic fold. EMBRYOLOGY AND ANATOMY OF THE HYPOPHARYNX The structures of the pharyngeal region arise from the branchial arches and clefts whose most active development takes place between the fourth and twelfth weeks of gestation. The laryngotracheal ridge appears during the fourth week caudal to the fourth pharyngeal pouch. Furrows develop on either side of this ridge which progressively deepen and eventually join to form the laryngotracheal tube. The cranial end of this tube forms the primitive laryngeal aditus (slit) (Figure 1). Hast describes