Hypopharynx

 || G1 Well differentiated squamous cell carcinoma. G2 Moderatelly differentiated squamous cell carcinoma G3 Poorly differentiated squamous cell carcinoma. G4 Undifferentiated 3 ||
 * Epidemiology: || Pyriform sinus is the most common site for a primary lesion in this region. The ratio of disease in males exceeds females by 2:1. The median age is 50 to 60 years. 1 ||
 * Etiology: || Heavy tobacco use and alcohol consumption are causative factors of cancers of the hypopharynx. Plummer-Vinson syndrome (iron deficiency anemia, inflammation of the tongue, definciency of stomach hydrochloric acid, clubbing of the fingernails) is associated with postcricoid cancer in females. 2 ||
 * Signs & Symptoms: || * Odynophagia (pain on swallowing) is a common presentation. Ipsilateral referred otalgia is also common.
 * Dysphagia is a late symptom.
 * Hoarseness indicates possible laryngeal involvement through mass effect or paralysis of a vocal cord.
 * Fetor oris (bad breath), difficulty in swallowing salia, and dyspnea are advanced manifestations.
 * An isolated cervical mass may be the only presenting symptom. 2 ||
 * Diagnostic Procedures: || * The initial H&P should include indirect laryngoscopy and a flexible endoscopic exaination under topical anesthesia. Posterior pharyngeal wall lesions may be missed during indirect laryngoscopy.
 * Radiologic evaluation includes chest x-ray and CT scan with contrast of the head and neck region, which is helpful in delineating cartilage and bone invasion, as well as extralaryngeal and paraglottic tumor invasion.
 * In most cases, delineating the inferior border of the lesion and involvement of the esophageal inlet requires a barium swallow, including a video to evaluate the hypopharynx and cervical esophagus. 2 ||
 * Histology: || <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">More than 95% of these tumors are squamous cell carcinoma. <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">2 ||
 * Lymph Node Drainage: || <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif;">The lymphatics of the hypopharynx enter the jugulodigastric lymph nodes and upper and middle jugular chain. <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">2 <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif;"> See image below for an example of lymphatics throughout the neck region. <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">3
 * Metastatic Spread: || <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif;">Nodal mets, Lymph, midcervical most commonly are involved. <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">2 ||
 * Grading: || <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif;">Gx Grade of differantion cannot be assessed
 * Staging: || <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif;">AJCC/TNM

T1 Tumor confined to region of origin T2 Extension into adjacent region or site, without fixation of hemilarynx T3 Extension into adjacent region or site, with fixation of hemilarynx T4 Massive tumor invading bone or soft tissues of neck <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">3 <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif;"> || •Extensive locoregional spread of disease •Usual presentation at an advanced stage •Nutritional depletion •Concurrent medical problems conferred by tobacco and alcohol abuse •High incidence of distant mets •Occurence in patients with a predisposition for the development of second malignancies. <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">4 <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">
 * Radiation Side Effects: || <span style="color: #0000ff; font-family: 'Comic Sans MS',cursive; font-size: 110%;">​ <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Complications of Radiation Therapy include mucositis, dermatitis, xerostomia, dysgeusia, soft tissue fibrosis, hypothyroidism, and rarely radionecrosis, pharyngocutaneous fistula, or carotid rupture. <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">6 ||
 * Prognosis:<span style="color: #0000ff; font-family: 'Comic Sans MS',cursive; font-size: 110%;"> || <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Prognosis is poor due to:

Prognostic Factors: -Survivial declines progressively with increasing age. -Women have a significantly higher survival rate than men 3 to 20 years after therapy. -Pathologic findings in pyriform fossa tumors that adversely affect survival include positive surgical margins or tumor persistence in the radiation field after initial definitive therapy. -Aryepiglottic fold and medial wall pyriform fossa tumors are usually smaller and more localized, which leads to higher cure rates than with postcricoid and pharyngeal wall tumors. -The poorest results are seen with pyriform apex, postcricoid, and two- or three- wall tumors. -In pyriform fossa and aryepiglottic fold tumors, metastases reduce the cure rate by 28% and 26% respectively (N0 greater than N+ by 26% to 28%). The presence of extracapsular tumor spread in the cervical lymph nodes and soft tissues of the neck is of paramoount importance in survival. The presence of neck metastases also negatively influences survival. -The size and number of metastases influences survival (higher for N1 than N2 and N3) by an additional 12% to 18%. -Tumor location influences cure rates. The decremental frequency for survival with hypopharyngeal carcinomas at different sites is as follows: pyriform fossa, pharyngeal walls and postcricoid region. -T stage influences survivial as well; most patients present with large tumors (82% are T3 or T4 pyriform sinus cancers). -In pyriform fossa tumors (T1 and T2 exceed T3 and T4 by 28%), there is a significant decrease in cure rates for T3 and T4 disease. <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">2

O <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">verall Survival Table <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">5 <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;"> || <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;"> <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">
 * Treatments:<span style="color: #0000ff; font-family: 'Comic Sans MS',cursive;">​ || ​ <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">Treatment Recommendations (see table below) <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">2 <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">
 * <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">T1 & T2: Surgery or radiation therapy.
 * <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">Large tumors and neck mets: Surgery with adjuvant radiation therapy. <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">2

Surgery <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">Radiation Therapy <span style="color: #0000ff; font-family: 'Comic Sans MS',cursive;"> || <span style="color: #0000ff; display: block; font-family: Arial,Helvetica,sans-serif; text-align: left; vertical-align: super;"> ||
 * <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">Performed if there is transglottic extension, cartilage invasion, vocal fold paralysis, pyriform apex invasion, postcricoid invasion, and extension beyond the laryngeal framework.
 * <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">In almost all cases, an ipsilateral neck dissection is performed followed by radiation therapy.
 * <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">A partial laryngopharyngectomy and neck dissection can be performed for small lesions that meet certain constraints. For tumors that do not meet the constraints, either a total laryngopharyngectomy or total laryngectomy and partial pharyngectomy with reconstruction with neck dissection are performed. <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">2
 * <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">Pre-operative: Fields extend from base of skull and mastoid to supraclavicular lymph nodes. The fields include the anterior and posterior cervical lymph node chains, larynx, pharynx, and neck. For pyriform sinus cancers that extend into the oropharynx, fields should include the retropharyngeal nodes. Doses are 45-50 Gy.
 * <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">Post-operative: Fields (opposed laterals and anterior field) include the primary tumor, upper and lower cervical lymph nodes, and the tracheostoma. After 46 Gy, an anterior spinal cord shield is used. A total dose of 60-66 Gy is given.
 * <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">Alone: Fields include the nasopharynx, oropharynx, hypopharynx, and upper esophagus using opposed laterals and an anterior field. Total dose of 60 Gy. A boost dose of 10-15 Gy is given to the gross tumor and grossly involved nodes. <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">2
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Please see image below for the field borders for hypoharynx. <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">7
 * TD5/5: || <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">The organs at risk in the fields can include the brachial plexus, glottic larynx, parotid gland (one or both), the spinal cord and thyroid. Please see the table below for the TD5/5 information. Traditional TD5/5 doses are highlighted in red. <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">6
 * Treatment Planning Photos: || <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Digitally Reconstructed Radiographs (DRR) of Hypopharynx. <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">8 <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">

<span style="color: #0000ff; display: block; font-family: Arial,Helvetica,sans-serif; text-align: center;">

<span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">

<span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;"> || 1. Rubin, P. //<span style="font-family: Arial,Helvetica,sans-serif;">Clinical Oncology - A multidisciplinary approach for physicians and students, 8th //<span style="font-family: Arial,Helvetica,sans-serif;"> ed: 432-3. Philadephia, PA: W.B. Saunders Company, 2001. 2. Chao KS, Perez CA, Brady, LW. //<span style="font-family: Arial,Helvetica,sans-serif;">Radiation Oncology - Management Decisions, 2nd ed: 255-263. //<span style="font-family: Arial,Helvetica,sans-serif;"> Philadelphia, PA: Lippincott, Williams & Wilkins, 2002. 3. Washington CM, Leaver D, eds. //<span style="font-family: Arial,Helvetica,sans-serif;">Principles and Practice of Radiation Therapy, 2 // <span style="font-family: Arial,Helvetica,sans-serif;">nd ed: 693-709. Philadelphia, PA: Mosby Inc, 2004. 4. Lenards, N. //<span style="font-family: Arial,Helvetica,sans-serif;">Fundamentals of Clinical Oncology for Medical Dosimetrists. //<span style="font-family: Arial,Helvetica,sans-serif;">Course content - Hypopharynx, Slide 3. December, 2009. 5. Hansen Ek, Schrechter NR. Cancer of the Larynx and Hypoharynx. In: Hansen EK, Roach M. //<span style="font-family: Arial,Helvetica,sans-serif;">Handbook of Evidence-based Radiation Oncology, //<span style="font-family: Arial,Helvetica,sans-serif;"> 1st ed: 115-123. New York, NY: Springer, 2007. 6. MedPhysFiles. Compiled and distributed by Childress, N. <span style="font-family: Arial,Helvetica,sans-serif;">@http://www.medphysfiles.com/index.php?name=Downloads&file=details&id=4 <span style="font-family: Arial,Helvetica,sans-serif;">. Accessed June 9, 2009. 7. Lenards, N. //<span style="font-family: Arial,Helvetica,sans-serif;">Fundamentals of Clinical Oncology for Medical Dosimetrists. ​ //<span style="font-family: Arial,Helvetica,sans-serif;"> Course content - Hypopharynx, Slide 8. December, 2009. 8. Digitally Reconstructed Radiographs courtesy of Ginnie Dea, RT(T), Alta Bates Summit Comprehensive Cancer Center.
 * || <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">[[image:HypopLPO_rev.png width="280" height="288" align="left" caption="Hypopharynx-LPO"]] ||
 * <span style="font-family: Arial,Helvetica,sans-serif;">References **<span style="font-family: Arial,Helvetica,sans-serif;">

Ginnie is bright blue. Bridget is green. Sheri is brown. Zack is purple.