Hypopharyngeal cancer

Hypopharyngeal squamous cell carcinoma arises in the pyriform sinuses, the posterior pharyngeal wall or the postcricoid region, the mucosa-lined funnel between the oropharynx and the oesophagus that wraps around the back of the larynx. It causes few symptoms until it is large: a sore throat, pain referred to the ear, difficulty swallowing and, most often, a lump in the neck, so most patients present with stage III or IV disease, and many are malnourished. Tobacco and alcohol are the causes, and a second primary in the oesophagus or lung is common enough that panendoscopy is part of staging.

The landmark trial is EORTC 24891, reported by Lefebvre in 1996, which compared induction cisplatin and fluorouracil followed by radiotherapy in responders with total laryngectomy and partial pharyngectomy followed by radiotherapy: survival was no different and a proportion of survivors in the chemotherapy arm kept a working larynx, establishing larynx preservation as a legitimate aim. Concurrent cisplatin chemoradiation, shown in RTOG 91-11 to preserve the larynx best in laryngeal cancer, became the usual organ-preserving approach for hypopharyngeal cancer too, with cetuximab and radiotherapy (Bonner, which included hypopharyngeal tumours) for patients who cannot have cisplatin.

Tumours that have destroyed the laryngeal cartilage, fixed the vocal cords or extended into the cervical oesophagus, and those that recur after chemoradiation, are treated by laryngopharyngectomy, reconstructed with a free jejunal, anterolateral thigh or radial forearm flap, or a gastric pull-up when the oesophagus is involved, followed by postoperative radiotherapy or chemoradiation for extranodal extension or positive margins. Recurrent or metastatic disease is treated as for other head and neck squamous cell carcinoma with pembrolizumab-based therapy. Smoking cessation, nutritional support and swallowing rehabilitation are part of every plan.