Treatment Option Overview
Hypopharyngeal cancer usually does not give rise to symptoms until late in the course of the disease. Because of this and the high incidence of early metastasis, survival rates for carcinoma of the hypopharynx are perhaps the lowest of all cancer sites in the head and neck.
No single therapeutic regimen offers a clear-cut superior survival advantage over other regimens. Although the literature highlights various therapeutic options, few reports present any valid comparative studies. The ultimate therapeutic choice will depend on a careful review of each individual case, paying attention to the staging of the neoplasm, the general physical condition of the patient, the emotional status of the patient, the experience of the treating team, and the available treatment facilities.[1,2]
Except for very early stage (T1) cancers of this region, treatment has primarily been surgery, usually followed with postoperative radiation therapy (PORT). Some early stage (T1 and T2), low-volume, exophytic pyriform sinus carcinomas have been successfully treated with radiation alone.[3-5] Single-modality therapy of advanced-stage hypopharyngeal cancer, with either surgery or radiation therapy, has resulted in consistently poor survival.[6-8] Combined-modality treatment should be considered for patients who present with stage III or stage IV disease.[4,6,9,10] When used in conjunction with surgery, radiation therapy is typically administered postoperatively. Alternative strategies using neoadjuvant chemotherapy and radiation therapy may increase the chance for local control in selected advanced presentations to a level approaching that of resection and PORT. In addition, combined chemotherapy and radiation therapy may offer better tumor control with organ preservation than does radiation therapy alone.[11-13] Patients with stage III and advanced resectable stage IV cancer should be considered for a larynx preservation approach including neoadjuvant chemotherapy and radiation therapy.[14-16]
A review of published clinical results of radical radiation therapy for head and neck cancer suggests a significant loss of local control when the administration of radiation therapy was prolonged; therefore, lengthening of standard treatment schedules should be avoided whenever possible.[17,18] Chronic pulmonary and hepatic diseases related to excessive tobacco and alcohol use are common in patients with head and neck cancer; recognition of these comorbidities is essential to the formulation of an appropriate treatment plan. Patients who smoke during radiation therapy appear to have lower response rates and shorter survival durations than those who do not; consequently, patients should be counseled to stop smoking before beginning radiation therapy. Accumulating evidence has demonstrated a high incidence (i.e., >30%–40%) of hypothyroidism in patients who have received external-beam radiation therapy to the entire thyroid gland or to the pituitary gland. Thyroid function testing of patients should be considered prior to therapy and as part of posttreatment follow-up.[20,21]References
- Thawley SE, Panje WR, Batsakis JG, et al., eds.: Comprehensive Management of Head and Neck Tumors. 2nd ed. Philadelphia, Pa: WB Saunders, 1999.
- Murthy AK, Galinsky D, Hendrickson FR: Hypopharynx. In: Laramore GE, ed.: Radiation Therapy of Head and Neck Cancer. Berlin: Springer-Verlag, 1989, pp 107-24.
- Pameijer FA, Mancuso AA, Mendenhall WM, et al.: Evaluation of pretreatment computed tomography as a predictor of local control in T1/T2 pyriform sinus carcinoma treated with definitive radiotherapy. Head Neck 20 (2): 159-68, 1998. [PUBMED Abstract]
- Hinerman RW, Amdur RJ, Mendenhall WM, et al.: Hypopharyngeal carcinoma. Curr Treat Options Oncol 3 (1): 41-9, 2002. [PUBMED Abstract]
- Mendenhall WM, Parsons JT, Stringer SP, et al.: Radiotherapy alone or combined with neck dissection for T1-T2 carcinoma of the pyriform sinus: an alternative to conservation surgery. Int J Radiat Oncol Biol Phys 27 (5): 1017-27, 1993. [PUBMED Abstract]
- Mendenhall WM, Werning JW, Pfister DG: Treatment of head and neck cancer. In: DeVita VT Jr, Lawrence TS, Rosenberg SA: Cancer: Principles and Practice of Oncology. 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2011, pp 729-80.
- Godballe C, Jørgensen K, Hansen O, et al.: Hypopharyngeal cancer: results of treatment based on radiation therapy and salvage surgery. Laryngoscope 112 (5): 834-8, 2002. [PUBMED Abstract]
- Johansen LV, Grau C, Overgaard J: Hypopharyngeal squamous cell carcinoma--treatment results in 138 consecutively admitted patients. Acta Oncol 39 (4): 529-36, 2000. [PUBMED Abstract]
- Spector JG, Sessions DG, Emami B, et al.: Squamous cell carcinoma of the pyriform sinus: a nonrandomized comparison of therapeutic modalities and long-term results. Laryngoscope 105 (4 Pt 1): 397-406, 1995. [PUBMED Abstract]
- Jones AS, Stell PM: Squamous carcinoma of the posterior pharyngeal wall. Clin Otolaryngol 16 (5): 462-5, 1991. [PUBMED Abstract]
- Brizel DM, Albers ME, Fisher SR, et al.: Hyperfractionated irradiation with or without concurrent chemotherapy for locally advanced head and neck cancer. N Engl J Med 338 (25): 1798-804, 1998. [PUBMED Abstract]
- Samant S, Kumar P, Wan J, et al.: Concomitant radiation therapy and targeted cisplatin chemotherapy for the treatment of advanced pyriform sinus carcinoma: disease control and preservation of organ function. Head Neck 21 (7): 595-601, 1999. [PUBMED Abstract]
- Jeremic B, Shibamoto Y, Milicic B, et al.: Hyperfractionated radiation therapy with or without concurrent low-dose daily cisplatin in locally advanced squamous cell carcinoma of the head and neck: a prospective randomized trial. J Clin Oncol 18 (7): 1458-64, 2000. [PUBMED Abstract]
- Lefebvre JL, Chevalier D, Luboinski B, et al.: Larynx preservation in pyriform sinus cancer: preliminary results of a European Organization for Research and Treatment of Cancer phase III trial. EORTC Head and Neck Cancer Cooperative Group. J Natl Cancer Inst 88 (13): 890-9, 1996. [PUBMED Abstract]
- Kim S, Wu HG, Heo DS, et al.: Advanced hypopharyngeal carcinoma treatment results according to treatment modalities. Head Neck 23 (9): 713-7, 2001. [PUBMED Abstract]
- Okamoto M, Takahashi H, Yao K, et al.: Clinical impact of using chemoradiotherapy as a primary treatment for hypopharyngeal cancer. Acta Otolaryngol Suppl (547): 11-4, 2002. [PUBMED Abstract]
- Fowler JF, Lindstrom MJ: Loss of local control with prolongation in radiotherapy. Int J Radiat Oncol Biol Phys 23 (2): 457-67, 1992. [PUBMED Abstract]
- Hansen O, Overgaard J, Hansen HS, et al.: Importance of overall treatment time for the outcome of radiotherapy of advanced head and neck carcinoma: dependency on tumor differentiation. Radiother Oncol 43 (1): 47-51, 1997. [PUBMED Abstract]
- Browman GP, Wong G, Hodson I, et al.: Influence of cigarette smoking on the efficacy of radiation therapy in head and neck cancer. N Engl J Med 328 (3): 159-63, 1993. [PUBMED Abstract]
- Turner SL, Tiver KW, Boyages SC: Thyroid dysfunction following radiotherapy for head and neck cancer. Int J Radiat Oncol Biol Phys 31 (2): 279-83, 1995. [PUBMED Abstract]
- Constine LS: What else don't we know about the late effects of radiation in patients treated for head and neck cancer? Int J Radiat Oncol Biol Phys 31 (2): 427-9, 1995. [PUBMED Abstract]