eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Head & Neck Surgery
Postcricoid Area, Malignant Tumors: Treatment
Updated: Jun 28, 2006
Treatment
Medical Therapy
Treatment for postcricoid cancer has undergone a transformation similar to that of the laryngopharyngeal area as a whole. Lately, researchers have sought ways to avoid the perceived morbidity of total laryngectomy. Many centers are relinquishing the primary surgery�postoperative radiation approach for an organ-preservation protocol. The scientific rationale for this model received support from a large US Department of Veterans Affairs laryngeal-preservation trial. This was a randomized study of more than 330 patients who received cisplatin and 5-fluorouracil chemotherapy delivered in a neoadjuvant setting. Patients with at least a partial response (>50%) also received radiation treatment. Nonresponders underwent total laryngectomy and postoperative radiation therapy. Overall survival rates for both methods were similar, and two thirds of survivors retained their larynx.
The European Organization for Research and Treatment of Cancer performed a similar trial for the hypopharynx, with stricter chemotherapy-response criteria. Only complete responders proceeded directly to radiation, while incomplete responders received total laryngectomy and partial or total pharyngectomy. Again, no significant survival difference was noted, and 42% of survivors retained their larynx.
To evaluate the effect of chemotherapy, a French group randomized a group of patients who had pyriform sinus cancer. The 2 arms of the study were neoadjuvant chemotherapy followed by radiation (regardless of tumor response) and standard surgery followed by postoperative radiation. Results showed that survival rates in the chemotherapy arm were almost half those of the surgical arm, suggesting that chemotherapy did not treat cancer, but that it acted mostly as a selection tool for cancers that would respond well to radiation.
The University of Florida treats T1 and favorable T2 tumors 6cc or less with hyperfractionated radiation to a total tumor dose of 74 Gy. T3-T4 and/or N2-N3 tumors often receive concomitant chemotherapy (if patient health status allows) or primary surgical management followed by postoperative radiation therapy. IMRT using the concomitant boost technique may be advantageous to irradiate postcricoid carcinomas in patients with a low-lying larynx and a short neck.
Surgical Therapy
Surgical excision followed by postoperative radiation is the treatment of choice for cancers not amenable to a conservation protocol (ie, tumors destroying cartilage, tumors too bulky for control with primary radiation). Some patients, if their functional disability is significant, choose this route even with smaller tumors, and a total laryngectomy offers improved swallowing and, rarely, improved vocalization. The minimum operation recommended is a total laryngectomy and partial pharyngectomy with a central (level 6) node dissection.
The hypopharynx is special in that studies show extensive submucosal spread of tumor and even skip lesions in this region. For these reasons, the surgeon must be more aggressive and obtain wider margins than in other areas of the head and neck. If the tumor is staged as a T2 or higher, perform a neck dissection (usually bilaterally because the postcricoid area is a midline structure that can send metastases to either side of the neck). The extent of neck dissection is debated widely and depends on various factors, including primary tumor extent and nodal metastases. Most commonly, perform a bilateral lateral neck dissection (level 2-4) with the inclusion of level 6. Often, a primary tracheoesophageal puncture is placed to allow early feeding via a Levine tube and eventual voice restoration.
Reconstruction of the resultant defect varies widely and depends on the extent of resection of the hypopharyngeal mucosa (see Image 2). Because these tumors often manifest late in their course, total laryngopharyngectomies are common. For small lesions in which only a small amount of mucosa is resected, primary closure may be attempted. If this procedure fails, several options are available, provided a 2-cm wide (or wider) strip of mucosa remains in continuity with the cervical esophagus. The most common closure for this defect is the pectoralis major musculocutaneous rotational flap, with the skin paddle facing into the lumen of the hypopharynx (see Images 3-4).
If a smaller strip of mucosa remains or if the pectoralis flap cannot be used, the next most common reconstruction is the radial forearm fasciocutaneous free flap. Advantages of this procedure include increased tissue pliability (because of decreased muscle bulk) and greater positioning ease (because the flap is not tethered by a muscular pedicle). Unfortunately, this procedure increases the operative time and hospital course. Some studies suggest that the tubed forearm flap yields better swallowing results than the partially tubed pectoralis rotational flap.
Several repair options are available for total laryngopharyngectomy defects. Historically, the Wookey flap was used to restore pharyngeal-esophageal continuity. The procedure consists of internalizing the cervical skin and, through multiple operations, tubing this skin and reconnecting the gullet. Disadvantages include multiple operations and high fistula and stricture rates.
The Wookey flap was replaced by the Bakamjian flap, which uses the rotated deltopectoral fasciocutaneous flap pedicled on the first 3 perforators from the internal mammary system. This method also requires several operations, and, while more reliable than the Wookey flap, it tends to stricture at the distal anastomosis. The tubed pectoralis major flap based on the thoracoacromial artery eventually displaced the Bakamjian flap because this is a one-stage procedure using a very reliable flap with a lower failure rate. The major disadvantage of this flap is the difficulty of completely tubing the skin, subcutaneous fat, and muscle from the chest, especially in women and large individuals.
The advent of free tissue transfer techniques allows a more customized and functional reconstruction in a single stage. The 2 most common are the radial forearm fasciocutaneous flap based on the radial artery and the jejunal free flap based on a mesenteric artery (see Images 5-6). Each has advantages and disadvantages. The jejunum is part of the alimentary tract; thus, it is already lubricated and tubed, eliminating the need for a vertical suture line. However, entering the abdomen to harvest the flap creates an ileus and further slows the recovery process. The forearm flap is more reliable but must undergo metaplasia to a more respiratory-type mucosa, and it needs a vertical suture line to complete the tube. The stricture rate is low for each flap.
For individuals who simply reject the procedure, who are poor candidates for free flaps (because of an inability to tolerate extended general anesthesia or because of vascular problems), or who have tumor extending to the cervical esophagus, the correct reconstructive procedure becomes the gastric pull-up. This entails a mediastinal dissection, complete removal of the esophagus, and passage of the stomach into the neck via the posterior mediastinum (see Image 7). This procedure can be performed from an open abdominal approach or endoscopically (see Image 8). The risks include proximal necrosis of the stomach (with resultant separation), dumping syndrome into the duodenum, and uncontrolled reflux into the neopharynx.
Preoperative Details
Obtain a full oncologic workup to include a complete history, physical examination, head and neck examination, and review of systems. The full workup then includes a CBC count, Chem-7, blood type and screen, chest radiograph, ECG, CT scan, and interventions indicated based on the review of systems. If a radial forearm flap is a reasonable option, perform an Allen test on each arm. A bowel preparation is often used if a jejunal free flap or gastric pull-up is planned. If possible, present the patient's case at a tumor board forum to receive input from all involved physicians. Ensure that voice therapists counsel the patient preoperatively to assist in the transition to alaryngeal speech and to address the difficulties of learning to swallow again. Finally, after the patient has received a full explanation of the procedure, obtain signed consent.
Intraoperative Details
Intubate the supine patient. Prepare the patient with povidone-iodine (Betadine) scrub, and paint to include the lower ears, upper lip, and neck (along the edge of the trapezius). Always prepare the chest in case a pectoralis flap is needed, and include a thigh for a potential split-thickness skin graft. Prepare other areas (eg, forearm, abdomen) if those flaps are planned. Alert the anesthetist that the airway circuit will be changed once the trachea is entered.
Incision
The most common type of access is a U-shaped "apron" flap extending from one mastoid process to the other and crossing the midline approximately 2 cm above the sternal notch. Then, complete the neck dissections in standard fashion. Generally, lateral neck dissections are performed; the submandibular area is not removed, and the sternocleidomastoid muscle, the spinal accessory nerve, and internal jugular vein are all left in the patient. This results in the removal of lymph nodes from levels 2-4.
Tumor removal
Remove attachments of the inferior and middle pharyngeal constrictors to the thyroid cartilage to skeletonize the larynx. Partially free the pyriform mucosa from the thyroid ala. Next, mobilize the hyoid bone by removing all suprahyoid attachments down to the hyoepiglottic ligament. Remove the soft tissues down to the trachea; the thyroid gland can be included or excluded from this dissection. Resect the tumor if it encroaches on a lobe of the thyroid gland. If oncologically possible, preserve at least a portion of thyroid and parathyroid glands. Establish the airway by incision into the larynx, and transfer the anesthesia circuit. Place a Deaver retractor into the mouth, and pass it to the vallecula, which has been inspected previously to ensure an absence of tumor.
If feasible, enter the pharynx on the side opposite the tumor. Cut through the pharyngeal mucosa to expose the tip of the retractor. Under direct visualization, perform pharyngeal cuts around the larynx. This step may include a circumferential or partial pharyngectomy. Remove the larynx by cutting through the back wall of the trachea at the previous incision site. Remove the tumor, achieving a pharyngeal mucosa margin of at least 3 cm.
Reconstruction
If primary closure can be performed, use a running Connell stitch. This stitch is designed to invert the mucosa for a watertight seal. If a strip of mucosa is left in continuity (cranial-caudal), a musculocutaneous pectoralis major flap can be tunneled into the neck, and closure can be performed by suturing the mucosa to the skin paddle. If only a small strip of mucosa remains or if a total pharyngectomy has been performed, a tubed radial forearm free flap can be placed. The authors usually suture the vertical limb while the flap is still pedicled in the forearm. If a total pharyngectomy had been planned, the authors prefer a jejunal flap for reconstruction.
A second team concomitantly harvests the free flap while the resection nears completion. Then, bring the tubed forearm or jejunum flap into the neck and suture the posterior aspect of the superior and inferior anastomosis to the pharyngeal mucosa with interrupted 3-0 polyglycolic sutures. Place the anterior sutures followed by anastomosis of the vascular pedicles. Allow up to a 3- or 4-hour period of ischemia for the jejunal and forearm flaps, respectively. Copiously irrigate the site, and bring down the skin flaps while maturing the tracheostoma with 3-0 monofilament sutures.
Postoperative Details
The first postsurgical night usually entails intensive care unit admission, especially with free-flap reconstructions. The authors monitor the free flap every 4 hours for 3 days with a pinprick using a 25-gauge needle (see Complications). Incline the head of the bed 30�, and obtain vital signs hourly. After the first night, transfer the patient to a step-down unit with nurses specifically trained in the care of patients with airway issues. Continue antibiotic coverage while drains are in place.
Airway
If the underlying pulmonary system allows, extubate at the end of surgery without placing a stent in the tracheostoma. Deliver cool mist via a face tent positioned over the stoma, and add oxygen to keep oxygen saturation above 90%. Commence suctioning every 2-4 hours and as needed.
Nutrition
Begin tube feeding on postoperative day 1 unless the abdomen has been entered for a gastric pull-up or a jejunal free flap, in which case hold feeding until the ileus has resolved. (Food is then delivered via jejunostomy tube.) Stenting of the closure by a feeding tube is unnecessary for either primary approximation of the hypopharynx or flap-assisted closure; thus, the authors use the primary tracheoesophageal puncture site or a gastrostomy tube. The authors rarely use a nasogastric tube. Usually, start oral feeding on postoperative day 6 or 7, provided no serious complication (eg, pharyngocutaneous fistula, flap failure) has occurred. Perform a barium swallow before the initiation of oral alimentation in patients who have received a free flap (see Image 9).
Pain control
Initially, administer morphine via nursing assessment or, if feasible, by patient-controlled analgesia. Switch to oxycodone elixir as soon as enteral feeding has begun; reserve morphine for breakthrough pain.
Drain management
Leave drains until output decreases to 15 mL in 8 hours or until drains have been in for 1 week. The authors are conservative in leaving drains, especially in patients who have received a free flap.
Discharge
Approve patients for discharge when they can perform daily living activities (eg, bathing, toiletry) and can ingest and tolerate sufficient nutrient energy. Generally, this means oral feeding has begun. Occasionally, the feeding tube must be continued, usually due to fistula formation. In addition, uncontrolled infection must be absent. These conditions are usually met at approximately postoperative day 7-10 in patients who have not been irradiated.
Follow-up
Follow-up depends on the type of closure used to repair the neopharynx. Home nursing affords patients an early discharge while maintaining medical oversight. A home nurse also may assist with the management of wounds and tracheostoma. If a free flap has been used, normally schedule the first clinic visit at postoperative day 7-14, depending on postoperative complications.
Once the acute healing process is completed, patients often receive radiation treatments, if not previously administered. Thereafter, follow up every 4-6 weeks the first year, every 8-10 weeks the second year, every 12 weeks the third year, and then annually. Obtain a CT scan at 6 months, sometimes at 1 year, and then only as symptoms indicate. If a tracheoesophageal puncture has been performed, insert the prosthesis after 2 weeks and commence speech therapy.
Complications
Intraoperative
Several complications can occur intraoperatively. They can be divided into technical and nontechnical problems. Nontechnical complications relate to general anesthesia and include malignant hyperthermia, vascular embolus, and diabetes insipidus. Technical complications include excessive hemorrhage, incomplete tumor removal, loss of airway, and excessive operating time.
Postoperative
The most common serious complication is pharyngocutaneous fistula. This usually results from a technical error in suturing the pharynx (with or without a flap), from leaving tumor at the margin, or from radiated tissue with poor blood supply (predisposed to necrose at the distal tip). Fistulas occur in approximately 10-15% of cases. Conservative management yields more satisfactory results than covering the fistula with more tissue. The authors' approach medullizes the fistula from the carotids by opening the tissues further in this direction and then packing the opening with quarter-inch gauze. Over the next few weeks, granulation tissue forms and slowly closes the fistula.
One of the more serious preventable problems is loss of airway. This occurs by mucous plugging, crusting over from the tissue edges, or foreign bodies lodging in the upper airway. Loss of airway can be avoided with attentive nursing care and by strategically placing susceptible patients in rooms near the nursing station.
Carotid blowout is often fatal problem and occurs after the carotid artery is exposed to saliva for some time. Emergent management includes holding pressure over the wound, establishing 2 large-bore intravenous lines, and ordering replacement volume or blood—all while transporting the patient to the operating room. Ligate the carotid as far inferior as possible, then rotate it in a vascularized flap to cover the stump. Attempt to divert the saliva, but the tissues are generally friable and hold sutures poorly. This complication is rare with newer reconstructive techniques.
A chylous fistula can occur but is related to neck dissection. (Essentially, the thin-walled lymph system suffers violation without recognition during surgery.) For output of less than 500 mL/d, place a pressure dressing and change the tube feeding to a medium-weight triglyceride solution. For greater outputs, institute total parenteral nutrition. If drainage fails to slow, then reexplore the wound and oversew the area. Additionally, rotate a muscular pedicled flap from the scalenes to give a second-layer closure to the area.
Flap failure is always possible because of an insufficiency in the arterial or venous pedicle. For free flaps, the problem usually lies in a thrombus formation at the venous anastomosis. Rarely, compression or clotting occurs in the arterial system, leading to insufficient blood flow to the flap. With either case, most major centers achieve a success rate of 93-96%. Maintain vigilant flap inspection during the first 72 hours, when most complications occur. Check flaps every 4 hours during this critical period using the pinprick method (ie, a 25-gauge needle used to express blood from the flap).
Bright red arterial blood indicates a normal system, whereas venous blood indicates early venous pedicle obstruction. No bleeding suggests a backup that halts all ingress of blood. Another method uses Doppler signals (internally or externally) to check flow in the vascular pedicle. Immediately upon discovering the problem, perform emergent exploration and revision of the anastomosis. Approximately 50% of such flaps can be salvaged with an emergent operation.
Various postoperative medical conditions, influenced by patient health state and operation duration, may occur. Fever in the immediate postoperative course is usually due to atelectasis of the lungs, but this may progress to pneumonia. Also, deep venous thromboses may occur, possibly leading to pulmonary emboli. To reduce this possibility, leave compression boots on the patient. Early ambulation helps prevent both problems.
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Further Reading
Keywords
malignant tumors of the postcricoid area, hypopharyngeal carcinoma, hypopharynx cancer, hypopharyngeal cancer, hypopharynx cancer, head and neck cancer, head and neck carcinoma, postcricoid cancer, post-cricoid cancer, postcricoid carcinoma, post-cricoid carcinoma, hypopharyngeal tumor, hypopharynx tumor, hypopharyngeal malignancy, postcricoid malignancy, Plummer-Vinson syndrome, Paterson-Brown-Kelly syndrome, squamous cell carcinoma, SCC, head and neck squamous cell carcinoma, head and neck SCC
