Staging and reporting of

carcinoma Hypopharynx
Presenter: Dr. Samanvitha Gode
Relevant anatomy
Carcinoma hypopharynx
• Location:
- Most common – pyriform sinus (60 to 85%) followed by posterior
pharyngeal wall (10 to 20 %) and rarely post cricoid region (5 to 15 %).

• Sex
• Histology
• Second primary carcinoma - esophagus (27%) and lung (6.34%).
Imaging protocol:
Desirable Minimal imaging method
 CECT HEAD &NECK
• Topogram- Supine head to toe direction.
• Coverage-Cover from above base skull down to aortic arch. Hands should be by the side of patient;
voluntary shoulder pull-down as much as possible.
• Quiet breathing; refrain from coughing or swallowing
• Scan Type-Helical KV/MAs/Rotation
• Time-120KV/200MAs/0.8 -1sec (Depends on scanner slice)
• Pitch 0.8 to 1.5
• Display Field of view – 25 cm, 16-20cm for larynx
• IV contrast (Nonionic iodinated) with Iodine concentration- 300/350 mg/mL Inject 80 ml with flow rate 2.5
to 3.5 ml/sec; scan delay 40 seconds
• Slice thickness - Acquire scans with 2.5 or 5 mm slice thickness; preferably retro reconstruct at
0.625/0.75mm or 1.25 mm respectively.
• Scan plane- For larynx, scan plane should be parallel to hyoid bone for an optimal study. Dental amalgam
can seriously degrade image quality in patients with tumors of the oral cavity. This can be corrected by
scanning with a tilted CT gantry or with an open mouth.
• Algorithms - acquire both bone and soft tissue algorithms (study bone in bone algorithm images*)
• *Bone algorithm sequences particularly useful for nasopharynx, oral cavity and larynx-hypopharynx to
study base skull, mandible and laryngeal cartilages respectively.
 Staging hypopharyngeal carcinoma
• TNM – 8th edition by American Joint Committee on Cancer, which is used for staging starting
January 1, 2018.
• Primary tumour (T)
• TX: primary tumour cannot be assessed
• Tis: carcinoma in situ
• T1:
• tumour limited to one subsite of hypopharynx (left or right pyriform sinuses, posterior hypopharyngeal
wall, or postcricoid region), and/or
• tumour ≤2 cm in greatest dimension
• T2:
• tumour extends into adjacent subsite of hypopharynx or adjacent site (larynx,oropharynx), and/or
• tumour >2 cm and ≤4 cm without fixation of hemilarynx
• T3:
• tumour >4 cm, or
• clinical fixation of hemilarynx, or
• extension to oesophageal mucosa
• T4: moderately advanced and very advanced local disease
• T4a: moderately advanced local disease in which tumour invades one or more of the
following:
• Thyroid cartilage
• Cricoid cartilage
• Hyoid bone
• Thyroid gland
• oesophageal muscle
• central compartment soft tissue (prelaryngeal strap muscles and subcutaneous fat)
• T4b: very advanced local disease in which tumour encases carotid artery or invades one
or more of the following:
• Mediastinal structures
• Prevertebral fascia

Changes since prior edition:

Since the 7th edition, the T3 criterion of oesophageal invasion has been split into oesophageal
mucosa involvement (T3) and oesophageal muscle (T4).
Cervical lymph node staging
 Clinical nodal status Pathological nodal status

NX cannot be assessed cannot be assessed

N0 no regional node metastases no regional node metastases

N1 metastasis in single ipsilateral node, ≤3 cm, and no metastasis in single ipsilateral

extranodal extension (ENE(−)) node, ≤3 cm, and no extranodal
extension (ENE(−))
N2 N2a – metastasis in single ipsilateral node, >3 cm and ≤6 N2a - metastasis in single ipsilateral
cm, and ENE(−) node, >3 cm and ≤6 cm, and
N2b - metastasis in multiple ipsilateral nodes, all ≤6 cm, ENE(−); or metastasis in single
and ENE(−) ipsilateral node, ≤3 cm, and ENE(+)
N2c - metastasis in bilateral or contralateral nodes, all ≤6 N2b - metastasis in multiple
cm, and ENE(−) ipsilateral nodes, all ≤6 cm, and
ENE(−)
N2c - metastasis in bilateral or
contralateral nodes, all ≤6 cm, and
ENE(−)
N3 N3a - metastasis in a node, >6 cm,
and ENE(−)
N3b - metastasis in a node with
clinically overt ENE(+) (ENEc)
N3a - metastasis in a node, >6 cm,
and ENE(−)
N3b - metastasis in single ipsilateral
node, >3 cm, and ENE(+); or
multiple ipsilateral, contralateral, or
bilateral nodes any with ENE(+); or
single contralateral node of any size
and ENE(+)
Distant metastasis (M)
• cM0: no evidence of metastases
• cM1: distant metastasis
• pM1: distant metastasis, microscopically confirmed
Stage groups
• Stage 0
• Tis, N0, M0
• Stage I
• T1, N0, M0
• Stage II
• T2, N0, M0
• Stage III
• T3, N0, M0
• [T1, T2, T3], N1, M0
• Stage IVA
• T4a, [N0, N1], M0
• [T1, T2, T3, T4a], N2, M0
• Stage IVB
• [Any T], N3, M0
• T4b, [Any N], M0
• Stage IVC
• [Any T], [Any N], M1
T4a
T4b
 Reporting checklist
• Pre-treatment:
1. Primary site:
Hypopharynx
1. Lesion epicenter:
2. Laterality : right/ left/ crossing midline
3. Measurement _ x _ x _cm
4. Further Spread to adjacent regions
• Paraglottic space
• Preepiglottic space
• Tongue base mucosa
• Extrinsic Tongue muscles
• Cricoid cartilage • Arytenoid cartilage • Thyroid cartilage – intact/ sclerosis/ inner cortex erosion/ inner & outer cortex erosion
• Extralaryngeal spread (ELS) – Absent/ present
• Strap muscle invasion
• Inavsion of Trachea/ Thyroid gland/ Esophagus/ rest of mediastinum
• Prevertebral fascia/ Retropharyngeal space invasion
• Internal carotid artery– free/ invaded
• Internal jugular vein– free/ invaded
2. Nodal status:
• Look at drainage area for nodes with abnormal features
• Look at nodes at other sites
I. Abnormal nodes
o Ipsilateral (midline nodes are considered ipsilateral)– levels, number, size &abnormal
features (necrosis & extranodal spread, shape & margins , increased enhancement,
clustering)
o Contralateral - levels, number , size & abnormal features 19
o if extranodal spread +ve – mention
a) Circumferential contact with artery ( internal or common carotid artery) - < 180 ° /
> 180 ° and < 270 ° / > 270 °
b) Invasion/ adherence of node to internal jugular vein (IJV) or tumour thrombus in
IJV
c) Relation with muscles-- sternocleidomastoid or strap muscles.
II. Reactive/ benign nodes – levels and normal features qualifying as benign.
III. Equivocal nodes – levels, features
• Impression:
1. Mention brief extent of primary tumour
2. Describe location and number of abnormal nodes.
3. Mention location of reactive and equivocal nodes separately.
4. In abnormal nodes with extranodal spread, mention structures
invaded, particularly vessels
• Post treatment:
Structured report (common elements):

A. CT / MRI study dated:

B. Previous study : available / not available(mention which study-
CT/MRI) and If available : date
C. Clinical Indication & Previous treatment :
D. Legend: Describe Procedure & any special maneovers
Post treatment imaging
 References:
1. Saito, Naoko; Nadgir, Rohini N.; Nakahira, Mitsuhiko; Takahashi, Masahiro; Uchino, Akira; Kimura,
Fumiko; Truong, Minh Tam; Sakai, Osamu (2012). Posttreatment CT and MR Imaging in Head and
Neck Cancer: What the Radiologist Needs to Know. RadioGraphics, 32(5), 1261–
1282. doi:10.1148/rg.325115160.
2. Nilendu C Purandare et al, Post-treatment appearances, pitfalls, and patterns of failure in head
and neck cancer on FDG PET/CT imaging, Indian journal of nuclear medicine, 10.4103/0972-
3919.136564.
3. Huang, Y. , Liang, Y. , Zhao, W. . Hypopharyngeal Cancer: Staging, Diagnosis, and Therapy. In: Zhou,
X. , Zhang, Z. , editors. Pharynx - Diagnosis and Treatment [Internet]. London: IntechOpen; 2021
[cited 2022Nov03].https://www.intechopen.com/chapters/76452 doi: 10.5772/intechopen.97462.
THANK YOU