From the Guidelines
A tumor in the pyriform sinus is classified as a hypopharyngeal cancer, specifically as squamous cell carcinoma, which is the most common type of hypopharyngeal cancer, accounting for approximately 60-70% of all hypopharyngeal malignancies. The pyriform sinus is a pear-shaped recess on either side of the laryngeal inlet, forming part of the hypopharynx. Due to their location, these tumors often remain asymptomatic until they reach an advanced stage, which contributes to their generally poor prognosis. Patients typically present with symptoms such as dysphagia (difficulty swallowing), odynophagia (painful swallowing), referred otalgia (ear pain), hoarseness, or a neck mass.
Classification and Staging
The staging of head and neck cancer, including hypopharyngeal cancer, is based on the TNM system, which takes into account the size and extent of the primary tumor (T), the presence and extent of lymph node metastases (N), and the presence of distant metastases (M) 1. According to the seventh AJCC classification, T4 tumors are subdivided into T4a moderately advanced and T4b very advanced, and stage IV is subdivided into stages IVa and IVb accordingly, and stage IVc for metastatic disease.
Treatment Approaches
Treatment approaches for pyriform sinus tumors depend on the stage but usually involve a combination of surgery, radiation therapy, and chemotherapy. Early detection is crucial for improving outcomes, though unfortunately many pyriform sinus tumors are diagnosed at advanced stages due to their hidden location and initially subtle symptoms. A multidisciplinary treatment schedule should be established in all cases, with consideration of the patient’s nutritional status and dental rehabilitation before radiotherapy 1.
Recent Guidelines
Recent guidelines, such as the ACR Appropriateness Criteria for staging and post-therapy assessment of head and neck cancer, emphasize the importance of accurate staging and follow-up imaging for the detection of recurrent disease 1. The approach to staging and posttreatment imaging varies and depends on the anatomic site and pathology, with a comprehensive evaluation of adenopathy and assessment for distant metastases.
Key Considerations
Key considerations in the management of pyriform sinus tumors include the size and extent of the primary tumor, the presence and extent of lymph node metastases, and the presence of distant metastases. The decision of which procedure to employ is based on, among other things, the size of the tumor, whether it is medial or lateral, fixed or not fixed, and exophytic or invasive 1.
From the Research
Classification of Tumors in the Pyriform Sinus
- The classification of tumors in the pyriform sinus is typically based on the location and extent of the tumor, as well as the presence of lymph node metastases 2, 3.
- Tumors can be classified into different stages, with stage I and II being early-stage tumors and stage III and IV being more advanced tumors 3, 4.
- The pyriform sinus can be subdivided into three groups: one-wall lesions, medial-wall lesions, and two- or three-wall lesions, each with different treatment options and outcomes 2.
Treatment Options
- Treatment options for tumors in the pyriform sinus include surgery, radiation therapy, and combined therapy 2, 3, 5.
- Conservation surgery and definitive radiotherapy are considered available treatment modalities for patients presenting with stage T1 and T2 pyriform sinus carcinomas without clinical evidence of neck lymph node metastases 4.
- Elective neck dissection or elective neck irradiation is considered mandatory due to the high risk of occult metastatic nodal disease even in the earliest stage of pyriform sinus cancer 4.
Outcomes
- The cumulative survival rate at 5,10,15, and 20 years was 56%, 35%, 31%, and 20%, respectively, in one study 2.
- The 3 and 5 year survival rates for all patients were 59.1% and 41.4%, respectively, in another study 3.
- The use of a new suturing technique, called end to side technique, has been shown to result in good short-term and long-term outcomes in patients with SCC of the pyriform sinus apex 6.