Hypopharyngeal squamous cell cancer (SCC)

Offer flexible nasoendoscopy/EUA and biopsy to fully assess and accurately document primary tumour extent and characteristic and exclude second primaries.

• For early stage hypopharyngeal cancer offer single modality treatment wherever possible. Where surgery is selected both transoral (Transoral Laser Surgery or Transoral Robotic surgery) and open surgery have a role. Where access permits transoral procedures are preferred due to reduced morbidity. Complete excision aiming for margins 5mm or greater is appropriate.
  
  
• Consider elective dissection of lymph nodes in levels II, III, and IV uni/bilaterally. 

• For loco-regionally advanced disease when multi-modality treatment (surgery then adjuvant (chemo) radiotherapy) is indicated, consider prior to initiating any management:

1. 1. Balance long term control/cure with acute and late morbidity from treatment
   2. Patient suitability and likelihood of completing whole package of treatment
   3. Alternative non-curative options

• Counsel patients carefully on all these factors prior to commencing radical treatment pathway, particularly given poor long term survival rates within this H&N subsite.
  
  
• Organ preservation is not suitable for patients who have functional impairment. Consider primary pharyngolaryngectomy for resectable disease. Assessment of resectablity will comprise endoscopic evaluation under anaesthesia and imaging. Extra-pharyngolaryngeal soft tissue extension with proximity of carotids and relationship to prevertebral fascia are key considerations.
  
  
• In patients with N0 disease offer bilateral selective elective neck dissection (levels II, III, IV) and consider central neck dissection +/- thyroidectomy, especially with piriform fossa apex or post-cricoid/oesophageal involvement.
  
  
• For patients with N+ve disease uncertainty exists regarding extent of lymphadenectomy, thus consider bilateral II-IV neck dissections at least.
  
  
• Most patients will require flap reconstruction. Total pharyngolaryngectomy requires neopharynx reconstruction with a myo- or fasciocutaneous flap, with the majority of published evidence utilising tubed techniques, however alternative reconstructive methods are recognised. There are few differences in outcomes for primary repair using free or pedicled flap techniques; however, free techniques at primary surgery confer the advantage of pedicled backup options in the event of an anastomotic leak. Leaks are common and usually originate at a trifurcation suture line particularly when located at the mobile tongue base. Configure flaps in a way which minimises this risk and its consequences. Stricture formation thought to be related to annular cicatrisation at the junction of neopharynx with oesophagus is common. Reconstructive approaches should seek to reduce the incidence and severity of this complication with consideration given to salivary bypass tube use.
  
  
• Consider primary tracheoesophageal puncture.

Consider prior to initiating any management for salvage:

1. Balance of chance of long term control/cure versus.
2. Likely acute and late morbidity from additional treatment.
3. Likelihood of requiring adjuvant treatment to achieve disease control/cure and patient suitability and likelihood to be offered this depending on patient factors and previous treatment.
4. Alternative non-curative options.

Counsel patients carefully on all these factors prior to commencing salvage treatment pathway.

Salvage surgery is usually undertaken in the context of persistent/recurrent disease after organ preservation treatment.

• Consider salvage neck dissection to the affected nodal basin to patients with N+ve disease who have undergone (chemo)radiotherapy and who have FDG PET-CT residual avidity in neck nodes at 3 months post-treatment, with the primary controlled.
  
  
• Patients with recurrent/persistent resectable disease at the primary site may be considered for salvage surgery in the absence of distant disease. Consider salvage surgery in the event of recurrence taking into account patient factors including age, co-morbidities, and preferences. Anticipate a high complication rate including fistula formation and major haemorrhage. Reconstructive flap surgery is required.
  
  
• Patients with relapse at the primary site as well as regional recurrence have a poor prognosis.
  
  
• Patients with a short disease-free interval have a poor prognosis

For patients not suitable for radical treatment consider debulking and/or discuss tracheostomy in event of airway crisis to elicit patient wishes and assist with advance care planning.