The hypopharynx is continued inferiorly with the cervical oesophagus and is situated post-laterally to the larynx with which it has a close relationship, enfolding almost 180° of it. Internally it is made up of mucosa, it does not have any cartilage or bone scaffold but only a muscular layer that forms the outer structure. Ninety-five percent of cancer cases in this region develop from the cells of the mucosal surface in the form of squamous cell carcinomas.

STAFF

At the IEO hypopharynx cancer is treated by a multidisciplinary team consisting of specialists in:

• Otolaryngology - Head and Neck Surgery
• Urogenital and Head and Neck Tumors Medical Treatment
• New Drugs and Early Drug Development for Innovative Therapies
• Department of Pathology and Laboratory Medicine
• Department of Medical Imaging and Radiation Sciences

The risk factors of hypopharynx cancer are alcohol and tobacco abuse; the combination of these two factors increases the risk of hypopharyngeal cancer exponentially. Men, especially in the age range between 50 and 60, are more frequently affected. When present, throat cancer symptoms are the sense of an external body in the throat, pain on swallowing, bad breath, stabbing pain to the ear, the presence of spots of blood in the saliva. In more advanced stages, throat cancer symptoms may be associated with changes in the voice, difficulty breathing, or swelling in the neck due to a metastatic lymph node which can often be the first sign of throat cancer. Diagnosis is made via a clinical and instrumental evaluation (fibre-optic video) of the throat cancer in the clinic. It can be confirmed histologically by performing a biopsy of the throat cancer under general anaesthesia. Additional diagnostic tests such as CT, or magnetic resonance of the facial skeleton and neck, and PET complete staging to define in detail the spread of the throat cancer before proposing the treatment, which in general depends on the stage.

Good standards for prevention

• Adopting a healthy lifestyle, not smoking and limiting alcohol intake.
• Adopting a few precautions in eating habits: eating fruit, vegetables, and foods rich in carotenoids, such as tomatoes, carrots, sweet and spicy peppers, pumpkin, apricots, herbs (probable evidence).
• Keeping a careful eye on oral hygiene.
• Not underestimating any injury of the mouth although small or painless (nodules, small ulcers, white or red patches, growths).
• After the age of 60 in subjects with risk factors, examination of the oral cavity and pharyngeal-laryngeal district is recommended.
• Undergoing regular visits, if already affected in the past by a carcinoma of the head and neck region.

The most common symptoms and signs are small ulcers of the lip or mouth, a white or red spot in the oral mucosa, frequent epistaxis (nosebleeds), nasal respiratory obstruction, hoarseness, persistent sore throat, feeling of closed ears, pain radiating to the ear, blood in sputum, difficulty chewing, swallowing or breathing, numbness of the tongue, painless and persistent swelling in the neck. The durability of these disorders should be considered as an alarm bell; if they have not resolved spontaneously or with treatment within 3 weeks, a specialist should be consulted.

The first approach to treatment is essential. Cure is the main goal, and is considered as important as the quality of life and functionality of the treated organs, such as the voice, language, swallowing, taste and breathing. IEO provides patients with a multidisciplinary team dedicated to diagnosis, treatment and rehabilitation.

Innovative and minimally invasive therapies: over the years the Division has developed some original techniques and minimally invasive approaches to improve the oncological and functional results of interventions, so that patients have more therapeutic options with less surgical impact. Some of these therapies are available only here in IEO.

Surgery: our head and neck surgeons perform the highest number of operations for malignant tumours each year than any other center in Italy (AGENAS data). Moreover, for more than 20 years we have been conveying the message of Prof Veronesi, that is, "the minimum effective therapy" also for head and neck lesions. We were the first in Italy to offer conservative thyroid surgery, with over 15 years of experience in hemi-thyroidectomy even for malignant tumours. We were among the first to perform endoscopic conservative surgery of the larynx with over 250 procedures a year, we were pioneers in functional tongue surgery allowing a near normal post-op quality of life. Finally, for over 20 years we have been performing very delicate salivary gland surgery. This is the only recognised head and neck surgery department in Italy.

TORS (Transoral Robotic Surgery): we were the first in Italy and among the first in the world to use robotic surgery for oropharyngeal and parapharyngeal lesions, managing to treat many patients with conservative surgery with minimally invasive access for parapharyngeal masses and neoplasms of the tonsillar region, ensuring a lower impact of this surgery[1]

TLM (Transoral Laser Microsurgery) the Division has extensive experience in laser microsurgery of early laryngeal neoplasms, avoiding radiotherapy, which can eventually be proposed at later date if necessary[2]

 USGTCB (US-guided transcutaneous tru-cut biopsy) : USGTCB biopsy of laryngeal and the base of the tongue masses is an original technique developed at the IEO over 12 years ago that allows for a minimally invasive diagnosis avoiding general anaesthesia and tracheotomy

THE VALUE OF A MULTIDISCIPLINARY TEAM

Our multidisciplinary team is dedicated to the diagnosis, treatment and rehabilitation of patients with tumors of the head and neck, and to the study of these diseases. Our team includes over thirty oncology professionals with expertise in various specialties, such as ENT, maxillofacial surgery, emergency surgery, plastic-reconstructive surgery, radiotherapy, medical oncology, radiology, pathology, nuclear medicine, nutrition, physiotherapy, endocrinology, dentistry, voice therapy, speech therapy, psychology, and biology.

The integration of various skills can address complex clinical problems, from diagnosis and treatment planning, to the functional recovery (speech, breathing, swallowing) in order to achieve the best results with cancer and adequate quality of life. The team works in harmony and meets on a weekly basis to discuss cases of patients who trust in our structure. They develop comprehensive personalized care plans considering all aspects of treatment and rehabilitation, considering the different treatment options, taking into account the needs of individual patients in accordance with internal, national and international guidelines.

The team, in close collaboration with the Scientific and Health Management Board, monitors the results of treatment and the quality of the performances in real time in order to point out critical issues and identify areas for improvement and development. The multidisciplinary meetings are an opportunity for professional development based on the exchanges in the group, the evidence in the literature, and the critical review and update of guidelines as well as diagnostic and therapeutic approaches. The information obtained from the critical review of the clinical activities, from technological innovations, from the study of the evolution of the cancers treated, and from continuous updating are used to identify open issues and propose research activities. Thanks to this approach, clinical research activities and institutional research projects in collaboration with national and international institutions have been put in place.

Cancers of the hypopharynx

The therapeutic treatment choice depends on various factors such as stage, site of the tumour and general health conditions of the patient. In cases diagnosed at the initial stage, it is possible to intervene with conservative methods such as radiotherapy or - in selected cases - minimally invasive surgical procedures using transoral laser microsurgery. On the contrary, in case of intermediate or advanced stage tumours, treatments combining chemotherapy and radiotherapy or more extensive surgery (total laryngopharyngectomy) need to be used, sometimes followed by post-operative radiotherapy or chemo-radiotherapy. 

Distant metastases of head and neck carcinoma

Distant metastases are defined as tumor spread to other organs. Lung, liver, and bone are the most common sites for hematogenous metastases of head and neck squamous cell carcinoma. The incidence of distant metastasis in head and neck squamous cell carcinoma is low for the general head and neck squamous cell carcinoma population: generally below 5% at presentation. Head and neck squamous cell carcinoma patients with distant metastases are generally candidates for palliative treatment scenarios only, because currently no systemic therapy has curative potential in head and neck squamous cell carcinoma patients with distant disease. Consequently, extensive locoregional treatment is usually considered futile in these patients. Particular attention is paid to our collaboration with CNAO, National Centre of Oncology Hadrontherapy) for Phase II, the clinical trial on radiotherapy boost, using protons (hadron therapy) for locally advanced tumours of the cervical-cephalic region.

Attention to the patient and his quality of life: since 2003, the department has been equipped with a speech therapy service, one of the best in Italy, which deals with the rehabilitation of swallowing, phonation and the articulation of the word. The division also has a dentistry service that deals with the preparation for surgery and postoperative dental rehabilitation. The IEO also has a physiotherapy service for motor and respiratory rehabilitation and a dietician for the management of nutritional aspects.  Pain management and Psychological support services are also offered. A holistic approach which takes care of all the needs of the patient, allowing a more rapid return to normal life.

Clinical nutrition

Stage and location of the disease, anatomical changes resulting from any surgical procedure, and the acute and late toxicity of chemo-radiotherapy are all factors that may contribute to the impairment of swallowing and create deficiency in the oral protein-calorie intake.

Artificial Nutrition (AN) is indicated with cancers that cause a stenosis (narrowing), severe dysphagia (difficulty in eating that contraindicate oral feeding), or where there is evident malnutrition or in the patient who, although feeding through the mouth, takes on a calorie-protein amount <50% of nutritional needs. AN must also be started when you expect a period of severe dysphagia longer than 7 days or inadequate intake (<60% of the nutritional requirements) for at least 10 days.

In patients with cancer of the cervical-facial district, Enteral Nutrition (EN) represents the primary route of choice when the gastrointestinal tract is accessible and functioning. It can be performed via nasogastric tube or via Percutaneous Endoscopic Gastrostomy (PEG) or Jejunostomy Nutrition, in case of expected duration of nutritional support greater than 3-4 weeks. EN is effective in containing the decline in body weight, preventing dehydration and interruptions of the radio-chemotherapy treatment, reducing the frequency and duration of hospitalisations, and improving the quality of life.

 Adequate nutritional support during radiotherapy treatment can reduce the impact and degree of morbidity (mucositis, odynophagia, dysphagia, xerostomia, dysgeusia, nausea, vomiting, and anorexia), minimise weight loss, preserve the nutritional status, improve the quality of life and optimize the situation by speeding up the recovery of the patient at the end of treatment.

The use of early and intensive nutritional counseling and oral caloric supplementation have been shown to increase the protein-calorie oral intake, reduce the extent of body weight loss, and reduce the interruptions of the cancer treatment.

In the presence of a sufficiently safe swallowing, oral feeding (using a diet modified in consistency) is the first choice.