In this study, we evaluated the potential of induction chemotherapy as an indicator of the management of advanced hypopharyngeal carcinoma with cervical oesophageal invasion. Seventy percent of patients with hypopharyngeal carcinoma are diagnosed at an advanced stage (7). Advanced hypopharyngeal carcinoma can spread submucosally and tends to invade the cervical oesophagus (8). Between February 2003 and November 2016, we treated approximately 800 patients who were diagnosed with hypopharyngeal carcinoma, including 75 patients with lesions involving the cervical oesophagus, which accounted for approximately 9.38% of all hypopharyngeal carcinomas. In this study, the 3- and 5-year OS rates of all patients were 20.59% and 5.88%, respectively. These findings were similar to those reported in a previous study of hypopharyngeal and oesophageal carcinoma (5).
Surgery remains the main treatment strategy for advanced hypopharyngeal carcinoma with cervical oesophageal invasion. Surgical treatment mainly comprises primary tumour excision, cervical lymph node dissection, and reconstruction of the pharynx and digestive tract, the latter of which is the biggest challenge. In recent years, there have been several reports of post-operative repair and reconstruction (9, 10). In this study, reconstruction of the pharynx and digestive tract was primarily performed using one of the three methods described previously (9, 11, 12). For unilateral pyriform sinus carcinomas where the lesion invades the oesophageal inlet and does not reach the circumference of the cavity of the oesophageal canal, but infiltrates downward for up to 2–3 cm, it is possible to repair the residual hypopharyngeal mucosa and upper oesophageal mucosa using a pectoralis major myocutaneous flap. For large pyriform sinus and posterior pharyngeal wall carcinomas that span the midline with an infiltration depth of 2–3 cm, the digestive tract can be repaired by residual laryngeal anastomosis instead of hypopharyngeal-oesophageal anastomosis. For annular tumours with an infiltration depth of >2–3 cm from the inlet of the oesophagus, total esophagectomy can be performed, and the oesophagus can be replaced by a gastric lift or free jejunum/colon.
Induction chemotherapy, or neoadjuvant chemotherapy as it is also known, refers to the chemotherapy administered before surgery or radiotherapy, which can reduce the tumour load in a short period of time. Induction chemotherapy has been widely used in clinical practice in recent years. Commonly used regimens include TPF and platinum plus fluorouracil, with the former being significantly more effective than the latter (13). Induction chemotherapy can reduce the tumour volume and maximise the retention of organ function (14). It also facilitates screening to determine which patients are likely to respond to treatment with either radiotherapy or concurrent chemoradiotherapy. For unresponsive patients, surgical treatment is preferred. Induction chemotherapy allows for a more individualised, standardised, and precise treatment of advanced hypopharyngeal carcinoma (15).
Our results show that, before 2010, patients were mainly treated surgically, and the treatment methods were relatively simple. With an increase in the number of related studies and advancements in treatment modalities, therapeutic options since 2010 have no longer been dominated by surgery, and adjuvant management methods, such as chemotherapy and radiotherapy, have been used.
The differences in 3- and 5-year OS rates between Groups A and B were not statistically significant. However, the laryngeal and oesophageal retention rates were significantly higher in Group A than in Group B. The laryngeal and oesophageal retention rates are important indicators of the quality of survival in patients with hypopharyngeal and oesophageal carcinoma. We used induction chemotherapy to screen for sensitive patients in whom radiotherapy/concurrent chemoradiotherapy was administered. The OS rate of these patients was not affected. However, their quality of life was improved. Surgical treatment was not delayed in patients unresponsive to induction chemotherapy. In some patients, the tumour size was reduced, which can improve the response to surgery and post-operative adjuvant therapy. This can also serve as an effective treatment. We found that there was no significant difference in the incidence of post-operative complications between the two groups, indicating that induction chemotherapy did not increase the incidence of surgical complications. Surgery is the main treatment for advanced hypopharyngeal carcinoma, and patients who undergo surgery tend to have a longer OS. However, surgical resection is extensive, the post-operative quality of life is poor, and the incidence of post-operative complications is high.
This study has several limitations. First, patients were randomly divided into groups to ensure balance and comparability and to reduce selection bias. Multiple follow-up methods were employed to avoid loss of patients or no response. However, some selection bias (e.g. prevalence-incidence bias) remained. Secondly, in the univariate analysis, no statistically significant differences in OS rates were observed between the two groups, regardless of age, sex, anatomical subregion, the degree of differentiation, the presence or absence of cervical lymph node metastasis, smoking status, or alcohol consumption. This could be due to the small number of patients included in this study. Further studies with larger sample sizes are needed to determine the relevance of factors influencing survival.