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Keywords:

  • head and neck cancer;
  • hypopharyngeal cancer;
  • radiotherapy;
  • surgery

The goals of treatment for squamous cell carcinoma of the head and neck include eradication of the cancer, minimizing the risk of treatment complications, and optimizing quality of life. Endpoints that are useful to evaluate the efficacy of treatment include overall survival, cause-specific survival, locoregional control, distant metastasis-free survival, severe complications, and quality of life. Although overall survival is a crude endpoint, it is the least subject to interpretation biases of the investigator. Hall and coworkers have demonstrated that there was no difference in overall survival or cause-specific survival after surgery with or without adjuvant radiotherapy (RT) compared with definitive RT in a large population-based study of patients treated for squamous cell carcinoma of the hypopharynx.1 The data were analyzed using 3 techniques: a restricted cohort study, a matched-case study, and a natural experiment study. All 3 methods failed to reveal a survival difference, regardless of extent of disease. These observations are consistent with our institutional experience treating patients with T3 glottic carcinomas; overall and cause-specific survival rates after laryngectomy were similar to those observed after definitive RT.2 In addition, there were no differences in the rates of locoregional control or severe complications.

So, if there is no survival advantage associated with surgery, why not treat all patients with definitive RT and add concomitant chemotherapy for those with stage III-IV disease? The majority of patients present with locally advanced cancers that would necessitate a total laryngectomy, if surgery were to be performed, and only 20% to 25% of patients would be rehabilitated with tracheoesopharyngeal puncture.3 In addition, patients with locoregionally advanced disease would receive concomitant chemoradiation, and this has been associated with a further improvement in overall survival compared with definitive RT alone.4-6

Of course, the reason to treat some patients surgically is that additional endpoints are important; these include locoregional control, complications, and quality of life.1 Although the rates of local control are relatively high after definitive RT for T1-T3 pharyngeal wall cancers and low-volume T1-T2 pyriform sinus carcinomas, the likelihood of a local recurrence is fairly high for T3-T4 pyriform sinus lesions.7, 8 In addition, as tumor volume increases, the probability of a functionless larynx increases in those patients whose tumor is locally controlled.9 Although response to induction chemotherapy could be used to select patients with unfavorable cancers for definitive chemoradiation, we have found that tumor volume may be as good a predictor and has no associated morbidity or additional cost.9-11 Patients treated with definitive RT for hypopharyngeal cancers are probably more likely to have severe long-term swallowing dysfunction after definitive RT, necessitating a permanent gastrostomy, than those irradiated for cancers arising in the oropharynx and larynx.12-16 Patient who develop a local recurrence have about a 30% to 35% risk of a pharyngocutaneous fistula after a salvage laryngectomy. Thus, patients who are likely to recur locally after definitive RT, or have a poor functional outcome if locally controlled, are probably better treated initially with surgery and postoperative RT.

Our current philosophy is to treat patients with T1 and low-volume (<6-7 mL) exophytic T2 pyriform sinus carcinomas with definitive RT; concomitant cisplatin is added for those who are lymph node-positive. All patients with pharyngeal wall carcinomas are treated with definitive RT alone or combined with concomitant chemotherapy. Although one could argue that patients with T4 pharyngeal wall carcinomas would have a better outcome if treated surgically, most would have tumors that are incompletely resectable and are treated with definitive RT by default. Patients who are lymph node-positive undergo a computed tomographic scan 4 weeks after completing RT and undergo a planned neck dissection if the likelihood of residual regional discourse exceeds 5%.17, 18 Patients with high-volume T2, T3, and T4 cancers of the pyriform sinus have a low likelihood of cure with a good functional outcome after definitive RT and are usually treated with surgery and postoperative RT. Patients with postcricoid carcinomas are treated using the same paradigm as that used for those with pyriform sinus cancers.

Conflict of Interest Disclosures

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  3. References

The authors made no disclosures.

References

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  2. Conflict of Interest Disclosures
  3. References