71 y/o M with 100 pack-year smoking history presented with Stage IVA (T4aN0M0) SCC of the L pyriform sinus with extension to the posterior pharyngeal wall and invasion of thyroid cartilage.


He was treated with definitive chemoradiation using IMRT and concurrent cisplatin. The primary tumor received 70 Gy in 35 fractions over 6 weeks. The high risk elective neck LN including bilateral levels III, IV, V and VI received 63 Gy and the low risk elective neck LN including bilateral level II, lateral RP (VIIa) and retrostyloid space (VIIb), and low level IV, received 56 Gy during this time.

  • Cover levels II-IV and lateral RP nodes bilaterally for all HPX tumors. Level V can be included with low added morbidity.
  • Add level VI if a) pyriform sinus apex is involved, b) advanced T stage, c) post-cricoid primary, or d) N+ neck.
  • Definitive RT dose and coverage (per Eisbruch et al Sem Rad Onc 2002):
    • CTV70 = GTV plus 0-5mm. Fraction size ≤2Gy/day due to late toxicity risk.
    • CTV60-63 = high risk subclinical disease including parapharyngeal tissue cranially through NPX and caudally 2 cm below cricoid cartilage due to propensity for submucosal spread (Ho CM et al Head Neck 1993) shows 1cm sup, 2cm lat/inf, 2.5cm medial); include posterior pharyngeal wall and ipsilateral hemilarynx for pyriform sinus and lateral pharyngeal wall primaries (CTV P); include LN levels at high risk (CTV N).
    • CTV56 = include low risk LN levels (ie level II, lateral RP).
  • IMRT preferred for increased LRC per Mok G et al Head Neck 2015.

  • EORTC 24891 showed larynx preservation is a reasonable option for locally advanced hypopharynx cancer.