Pharyngeal Pouch Carcinoma: Real or Imaginary Risks?

Abstract

Pharyngeal pouch or Zenker's diverticulum presents to the otolaryngologist with symptoms of dysphagia. As supported by the published literature, the condition is more frequently seen in Northern Europe, especially the United Kingdom, than elsewhere in the world. The cause of the reported increased incidence in the United Kingdom is not known, but may be dietary. Surgical management is the treatment of choice and is directed at the cricopharyngeus muscle by either an external or an internal approach. There is a real risk of carcinoma or carcinoma in situ developing in a treated or untreated pharyngeal pouch. Excision of the pouch sac is recommended in younger patients, less than 65 years, and in patients who have a large pouch. If endoscopic diverticulotomy is performed, then long-term patient symptom follow-up is to be advocated.

Current management in pharyngeal pouch surgery by UK otorhinolaryngologists

“…The main predisposing factor is thought to be chronic inflammation of the pouch lining over many years, secondary to food retention. 23 The reported incidence varies widely but larger series have reported an incidence of 0. have been encountered by UK otolaryngologists with one surgeon reporting 5 cases. The diagnosis is often made at surgery, when cleaning of the pouch and careful examination with an oesophagoscope or Hopkins rod should be performed prior to any definitive surgical procedure..…”

“…However, cases of carcinoma in situ or small carcinomas may not be detected radiologically or by endoscopic examination. In a recent review by Bradley et al 23 two cases of carcinoma in situ were reported. Both of these had not been suspected clinically or found on endoscopy and the diagnosis was established by histopathological examination.…”

“…However, despite the lack of firm evidence, it would be reasonable to argue that patients should be informed of the potential risk of carcinoma development in a pouch years later (albeit a very small risk) if it is not excised at the first presentation. It is for this reason that Bradley et al 23 proposed that patients less than 65 years of age should undergo excision of the pouch with a long cricopharyngeal myotomy and pathological examination of the pouch. Long-term follow-up should be considered in these cases and endoscopic examination of the whole oesophagus should be undertaken if symptoms persist or recur.…”

“…Long-term follow-up should be considered in these cases and endoscopic examination of the whole oesophagus should be undertaken if symptoms persist or recur. 23 Assessment of treatment outcome can be made clinically. There is no role for postoperative contrast studies as they bear little correlation to symptoms; lax mucosa that remains following endoscopic stapling, for example, may appear to be a residual pouch in an asymptomatic patient.…”

Flexible endoscopic and surgical management of Zenker's diverticulum

“…Squamous cell carcinoma in a ZD was first reported by Pitt in 1896 [64], with an estimated incidence of 0.4-1.5% [65][66][67][68]. There should be a high index of suspicion for development of a cancer within a ZD in the presence of alarm Review symptoms, which include neck pain, hemoptysis or hematemesis, an increase in the severity of dysphagia, regurgitation and malnutrition [65].…”