9.

Treatment of locally advanced hypopharyngeal cancer

Staging	Patient classification 1	Patient classification 2	Level I expert recommendation	Level II expert recommendation
Patients not suitable for surgery: poor physical condition, reject opreration for various reasons, or heavy tumor burden. Patients not appropriate for cisplatin treatment: age >70 years, performance status (PS) >2, loss of hearing, renal dysfunction (creatinine clearance <50 mL/min), or > level 1 neuropathy ( 15).
T1−2N1−3/ T3 any N	Patients suitable for surgery	Patients suitable cisplatin treatment	Surgery (1) (class 2A evidence) Radiation therapy + cisplatin (4-6) (class 1A evidence) Induction chemotherapy → radiation therapy alone (7,8) (class 1A evidence)	Radiation therapy + cetuximab (9,10) (class 1B evidence) Induction chemotherapy → radiation therapy + cetuximab (11) (class 2A evidence)
		Patients not suitable for cisplatin treatment	Surgery (1) (class 2A evidence)	Radiation therapy + cetuximab (9,10) (class 1B evidence) Radiation therapy alone (1) (class 2A evidence)
	Patients not suitable for surgery	Patients suitable for cisplatin treatment	Radiation therapy + cisplatin (4-6) (class 1A evidence) Induction chemotherapy → radiation therapy alone (12-14) (class 1B evidence)	Radiation therapy + cetuximab (9,10) (class 1B evidence)
		Patients not suitable for cisplatin treatment	Radiation therapy alone (1) (class 2A evidence)	Radiation therapy + cetuximab (9,10) (class 1B evidence)
T4 with different N	Surgery candidates	—	Surgery (1) (category 2A)	—
	Patients unfit for surgery	Appropriate for cisplatin treatment	Radiation therapy + cisplatin (4-6) (category 1A) Induction chemotherapy →RT (12-14) (category 1B)	Radiation therapy + cetuximab (9,10) (category1B)
		Not appropriate for cisplatin treatment	Radiation therapy (1) (category 2A)	Radiation therapy + cetuximab (9,10) (category 1B)