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10 slides generated from the cancer page, with a quiz from the open benchmark and speaker notes that cite the sources. Arrow keys move between slides; Print gives one slide per page.
Cancer of the hypopharynx, the funnel behind the voice box, is the head and neck cancer with the worst outlook because it grows silently and spreads to the neck early. Treatment is chemoradiation to keep the larynx where possible, or removal of the larynx and pharynx with reconstruction for the most extensive tumours.
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.
| Setting | Approach | Guideline |
|---|---|---|
| Diagnosis and staging | Panendoscopy with biopsy, CT of the neck and chest, PET-CT for stage III to IV, and assessment of swallowing and nutrition before treatment. | not mapped |
| Early disease (T1 to T2, node-negative) | Radiotherapy alone, or transoral or open partial pharyngectomy in selected small tumours, with treatment of both sides of the neck. | NCCN Category 2A |
| Locally advanced, larynx preservable | Concurrent cisplatin chemoradiation to 70 Gy; induction cisplatin-fluorouracil (EORTC 24891) or docetaxel-cisplatin-fluorouracil followed by radiotherapy in some centres. | NCCN Category 1 (concurrent chemoradiation) |
| Cannot have cisplatin | Cetuximab with radiotherapy (Bonner), or carboplatin-based chemoradiation. | NCCN Category 2A |
| Extensive disease (cartilage destruction, oesophageal extension) or recurrence after radiotherapy | Total laryngopharyngectomy with neck dissection and free-flap or gastric pull-up reconstruction, then postoperative radiotherapy or cisplatin chemoradiation by pathology. | NCCN Category 2A |
| Recurrent or metastatic | Pembrolizumab alone or with platinum-fluorouracil (KEYNOTE-048). | NCCN Category 1 |
| Prevention | Smoking cessation and alcohol reduction; no screening programme exists. | not mapped |