Hypoharynx

These symptoms or signs should be discussed with a doctor, especially if they are persistent or get worse. [2] When detected early, hypopharyngeal cancer can often be treated successfully while preserving the function of the hypopharynx. [2] A specific blood test will be given that detects hypopharyngeal cancer. Several tests, including blood and urine tests, may be done to help determine the diagnosis and learn more about the disease. [2] || Pyriform fossa tumors travel along mucosal surfaces to include nearby structures like false vocal folds and larynx by way of the paraglottic space, for example. Originating from other areas, hypopharyngeal cancers can invade thyroid cartilage and cricoid cartilage. After invading these structures, spread can travel through muscle tissue up to the base of scull and through the vagus, glossopharyngeal, and sympathetic nerves. [3] Postcriciod tumors invade cricoid cartilage into muscle and onto esophageal tissues. [3] Lymph node metastases are common due to good drainage in the area. With increased nodal metastases, survival decreases while complications increase. ||
 * **Epidemiolgy:** || * The hypopharynx is the most inferior part of the pharynx meeting the esophagus and trachea.[1]
 * 65% of tumors occur in the pyriform fossa.[1]
 * 35% of tumors occur in postcricoid and hypopharyngeal wall.
 * The most commonly involved lymph nodes are the midcervical lymph nodes.
 * 95% of tumors are squamous cell carcinoma, originating in lining of the pharynx and hypopharynx.
 * Women have higher survival rates of 3 to 20 years.
 * There is a higher occurrence in males than females. ||
 * **Etiology:** || * Tobacco and heavy use of alcohol increase risk of hypopharyngeal cancer
 * Poor diets low in iron and other essential vitamins.
 * Plummer-Vinson syndrome increase risk of hypopharyngeal cancer[1]
 * Survival rates decline with age. ||
 * **Signs & Symptoms:** || There are several signs and symptoms that are presented for hypopharyngeal cancer; however most of these symptoms do not always show in patients. Some of the signs and symptoms that are presented are:
 * Hoarseness or change in voice (often an early symptom) that does not go away within two weeks
 * An enlarged lymph node or a lump in the neck
 * Airway obstruction, difficulty breathing, and noisy breathing
 * Persistent sore throat or a feeling that something is caught in the throat
 * Persistent difficulty in swallowing
 * Ear pain
 * Chronic bad breath
 * Choking
 * Unexplained weight loss
 * Fatigue
 * Dyspnea and stridor
 * Ipsilateral otalgia
 * Dysphagia
 * Odynophagia
 * Chronic cough
 * Hemoptysis [2]
 * **Diagnostic Procedures:** || Diagnostic procedures that are done to conclude hypopharyngeal cancer are through a larngoscopy.[2] Another way is through X-ray/barium swallow. [2] An x-ray will be taken of the structures inside of your body, using a small amount of radiation. [2] Sometimes, the patient will be asked to swallow barium, which coats the mouth and throat, to enhance the image on the x-ray (called a barium swallow). [2] A barium swallow is used to identify abnormalities along the throat and esophagus. [2] A special type of barium swallow, called a modified barium swallow, may be needed to evaluate difficulties with swallowing. Additionally, a dentist may take extensive x-rays of the teeth, mandible (jawbone), and maxilla (upper jaw), including a panorex (panoramic view). [2] If there are signs of cancer, the doctor may recommend a computed tomography (CT) scan. [2] Furthermore, magnetic resonance imaging (MRI) is also used as a way to diagnosis hypopharyngeal cancer. An MRI uses magnetic fields, not x-rays, to produce detailed images of soft tissue, such as the tonsils and the base of the tongue. [2] Last but not least, a bone scan can also be used. [2] A bone scan uses a radioactive tracer to look at the inside of the bones. The tracer is injected into a patient’s vein. It collects in areas of the bone and is detected by a special camera. Healthy bone appears gray to the camera, and areas of injury, such as those caused by cancer, appear dark. In head and neck cancer, bone scans are recommended if there are signs of bone metastasis. After these diagnostic tests are done, the doctor will review all of the results with the patient. If the diagnosis is cancer, these results also help the doctor describe the cancer; this is called first steps to take after a diagnosis of cancer [2]. ||
 * **Histology:** || 95% or more of hypopharyngeal tumors are squamous cell carcinoma.[3] ||
 * **Lymph node drainage:** || Hypopharygeal drainage goes to the juglodigastric lymph node and upper and middle jugular chain. Spinal accessory nodes and retropharyngeal lymph nodes also drain this area. [3] ||
 * **Metastatic spread:** || Hypopharynx tumors can metastasize to different areas depending on the point of origin. In the United States, 65% of hypopharynx tumors occur in pyriform fossa, 20% in the postcricoid, and 10- 15% in the hypopharyngeal wall. [3]
 * **Grading:** || **GX**: The grade cannot be evaluated.
 * G1 ** : The cells look more like normal tissue (well differentiated).
 * G2 ** : The cells are only moderately differentiated.
 * G3 ** : The cells don't resemble normal tissue (poorly differentiated).
 * Recurrent ** : Cancer that comes back after treatment. If there is a recurrence, they may need to re-stage. [2] ||
 * **Staging:** || //** PRIMARY TUMOR: **//
 * TX: ** The primary tumor cannot be evaluated.
 * TO: ** No evidence of a tumor is found.
 * TIS: ** Carcinoma in situ. An early cancer where the cancer cells are only in one layer of tissue.
 * T1: ** The tumor is small, not larger than 2 centimeters (cm), and is limited to a single site in the lower throat.
 * T2: ** The tumor involves more than one site in the lower throat, but does not touch the voice box, or a tumor that measures larger than 2 cm, but not larger than 4 cm.
 * T3: ** The tumor is larger than 4 cm. or has spread to the larynx.
 * T4a: ** The tumor has spread into nearby structures, such as the thyroid, the arteries that carry blood to the brain, or the esophagus.
 * T4b: ** The tumor has spread to the prevertebral fascia, encases the arteries, or involves mediastinal structures.

//** NODES: **//
 * NX: ** The regional lymph nodes cannot be evaluated.
 * NO: ** There is no evidence of cancer in the regional nodes.
 * N1: ** The cancer has spread to a single node on the same side as the primary tumor, and the cancer found in the node is 3 cm. or smaller.
 * N2: ** Describes any of the following conditions:
 * N2a: ** The cancer has spread to a single lymph node on the same side as the primary tumor and is largerthan 3 cm, but not larger than 6 cm.
 * N2b: ** The cancer has spread to more than 1 lymph node on the same side as the primary tumor, and none measure larger than 6 cm.
 * N2c: ** The cancer has spread to more than 1 lymph node on either side of the body, and none measure larger than 6 cm.
 * N3: ** The cancer found in the lymph nodes is larger than 6 cm.

//** METASTATIC SPREAD: **//
 * MX: ** Distant metastasis cannot be evaluated.
 * MO: ** The cancer has not spread to other parts of the body.
 * M1: ** The cancer has spread to other parts of the body.

//** STAGING: **// -redness or skin irritation -swelling -dry mouth -thickened saliva from damage to salivary glands (can be temporary or permanent) -bone pain -fatigue -mouth sores -sore throat -dental problems if not taken care of before treatment -change in voice -taste changes [2] ||
 * Stage 0: ** Describes a carcinoma in situ (Tis), with no spread to lymph nodes (NO) or distant metastasis (MO).
 * Stage I: ** Describes a small tumor (T1), with no spread to lymph nodes (NO) or distant metastasis (M0).
 * Stage II: ** Describes a tumor with some spread to nearby areas (T2), but has no spread to lymph nodes (N0) or to distant parts of the body (M0).
 * Stage III: ** Describes any larger tumor (T3), with no spread to reagional lymph nodes (N0) or metastasis (M0), or a smaller tumor (T1, T2) that has spread to regional lymph nodes (N1) but has no sign of distant metastasis (M0).
 * Stage IVA: ** Describes any invasive tumor (T4a), with either no lymph node involvement (N0) or spread to only a single same-sided lymph node (N1), but no metastasis (M0). It is also used for any tumor (any T) with more significant spread to the lymph nodes (N2), but no metastasis (M0).
 * Stage IVB: ** Describes any cancer (any T) with extensive spread to lymph nodes (N3), but no metastasis (M0). For laryngeal cancer, it is also used for a very advanced localized tumor (T4b), wuth or without lymph node involvement (any N), but no metastasis (M0).
 * Stage IVC: ** Indicates there is evidence of distant spread (any T, any N, M1). [2] ||
 * **Radiation side effects:** || Some side effects after radiation therapy are:
 * **Prognosis:** || Unfortunately, most patients with hypopharyngeal cancer present with advanced stage disease. Usually, more than 50% of patients diagnosed, present with palpable cervical lymph nodes. Overall, only around 25% of patients survive five years. Prognosis decreases with age and women have a higher survival rate of 3-20 years after treatment. [3] ||
 * **Treatments:** || Combined modality treatment is often used. Surgery can be used alone for conservation with small lesions. A partial laryngopharyngectomy and neck dissection can be performed if the lesion is confined. Otherwise, a total laryngopharyngectomy or total laryngectomy and partial pharyngectomy with reconstruction can be done. This involves neck dissection as well. Radiation can be given pre or postoperative. Preoperative irradiation is delivered to the larynx, pharynx and neck, whereas radiation alone includes the nasopharynx, oropharynx, hypopharynx, and upper cervical esophagus. [1]

__ Radiation Treatment Techniques __ Large fields are typically treated to 45 Gy, and then reduced off the spinal cord. Smaller fields are continued to 65-70 Gy. It is important to ensure the shoulders are pulled down and out of the treatment fields. Figure 1: Typical lateral and anterior photon portals for hypopharyngeal cancer [4] Figure 2: Radiation portals for a patient with a large pharyngeal lesion.

Lateral fields: Extend from base of the skull and mastoid to the supraclavicular lymph nodes. Encompass the anterior and posterior cervical lymph node chains. Doses commonly used are 45-50 Gy.
 * Preoperative Irradiation **

Lateral fields: Include primary tumor from base of the skull. Anterior field: Encompass lower neck to the tracheostoma and lower cervical lymph nodes. Doses commonly used are 63 Gy. After initial 46 Gy, a spinal cord shield is used. Figure 3: Radiation portals for hypopharyngeal cancer.
 * Postoperative Irradiation **

Opposed laterals and anterior field: Include the nasopharynx, oropharynx, hypopharynx and upper cervical esophagus. Doses commonly used are 60 Gy, including a boost of 10-15 Gy given to the gross tumor volume for a total dose of 70-75 Gy. [1] || Table 1: dose limits [5] ||
 * Irradiation Alone **
 * **TD 5/5:** || TD 5/5:
 * **References:** || ===== =====

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2. Laryngeal and Hypopharyngeal Cancer. Oncologist-approved cancer information from the American Society of Clinical Oncology. December 2011. Available at: []. Accessed: May 22, 2012. =====

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5. Marks L.B, Yorke ED, Jackson A, et al. Use of Normal Tissue Complication Probability Models in the Clinic. //Int J Radiat Oncol Biol Phys.// 2010;76(3):S10-S19. doi: 10.1016/j.ijrobp.2009.07.1754. ===== || Back to Week 1