Primary Treatment of T1-T2 Hypopharyngeal Cancer: Changing Paradigms

There has been a general shift in the treatment of hypopharyngeal cancer from open surgical techniques (either radical or partial "organ" preserving) toward non-surgi cal "organ preserving" strategies (radiotherapy [RT] or chemoradiotherapy [CRT]) and minimally invasive transoral laser microsurgery (TLM) or transoral robotic surgery (TORS). Oncologic outcomes reported are comparable whatever modality is chosen, but better functional outcomes are observed in the RT/CRT and TLM/TORS-treated patients. Because of the high rate of second primary malignancies, which influences overall survival, one could favor an up-front transoral surgical procedure as a primary treatment modality for early hypoharyngeal carcinoma, leaving the (chemo)radiotherapeutic option open for treatment of a likely later emerging second primary. However, the TLM and TORS studies report a high rate of adjuvant irradiation-based treatment for close or positive margin excisions. Concerning post-treatment functionality, both RT/CRT and TLM/TORS yield satisfactory results, especially when compared to the open surgical procedures, but it remains unclear which of these options will result in the long-term best laryngopharyngeal functional outcome. There is a need for multi-institutional randomized controlled trials comparing the long term oncologic and functional outcomes of up-front minimal invasive transoral surgery with/without adjuvant treatment, to a primary non-surgical organ preservation treatment.