Radiotherapy for Locoregionally Advanced Hypopharyngeal Cancer by onetwo3

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									    Radiotherapy for Locoregionally Advanced
     Hypopharyngeal Cancer: the Treatment
                 Consideration
Case Number: RT2009 – 13 (M)

Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor

Purpose: to present a case of locoregionally advanced hypopharyngeal cancer;
to discuss the treatment consideration.

Scenario: You are radiotherapy (RT) Intent Doctor/Special Nurse/Resident Doctor,
and you are assigned to evaluate the following patient before visiting of your RT
attending physician. Please review the following description carefully; your RT
attending physician will visit this patient later and discuss with you after your review.

Case Presentation:
      This 36–year-old male patient, 沈 OO, was referred to us for radiotherapy assessment for
‘This 36 y/o male had hypopharyngeal ca T4bN3M0 diagnosed at 林口長庚 hospital in 97/05.
Since the patient live in 南投, the patient referred to our hospital for further management. We
sincerely need your expertise opinion for CCRT evaluation. Thank you truly!’.
      S:
           1. In 2007/11, he started to suffer from sore throat and right lateral neck pain.
           2. In 2008/05, unresectable hypopharyngeal carcinoma was told at LMC.
           3. In 2008/06, he came to our hospital for further management due to home location.
           4. On 2008/06/21, you visit this patient in the ward.

           Histories: NDKA, history of smoking and drinking, no major medical disease history.
           Review of systems: neck pain, neck swelling, mild discomfort at the tracheostomy site.

     O:
          1. General Condition: ECOG: 1-2, ambulatory status, speech: slurred (due to tracheostomy
          in place)
          2. Physical Examinations:
             (1). HEENT & SCF: biltateral neck Lns, right more than left, multiple; N3 LNs on the
             right neck; tracheostomy in place
             (2). Others: neg.
          3. ***Pathology in 2008/05, hypopharynx tumor biopsy, right, at LMC: moderatedly
          differentiated squamous cell carcinoma.
          4. Images:
             (1). CXR in 2008/06: on tracheostomy in place; right neck mass (+); no active lung
             lesions on both lung fields.
             (2). Whole body PET/CT in 2008/05, at LMC: hypopharyngeal cancer with bilateral
             level II-IV LNs; without distant metastases.
             (3). H&N MRI in 2008/05, at LMC: no result available at visiting
             (4). ABD sono and bone scan in 2008/05, at LMC: negative
          5. Others: no other image studies available at visiting
Key Image(s):

Fig. 1. CXR




Fig. 2. Panel A. HN CT




Fig. 2. Panel B. HN CT
Questions & Discussions:
(Please answer the following questions commented from your RT attending
    physician.)

    Q1: What are your findings/interpretations for the above key image(s)?


    Q2: What is your clinical cancer stage, according to the AJCC 2006, for this
       case?


    Q3: What is your pathologic cancer stage, according to the AJCC 2006, for
       this case?


    Q4: What are your Oncology Diagnosis and/or other Assessments for this
       case?


    Q5: What is your Oncology Plan for this case?


    Q6: What is your Radiotherapy Plan for this case?
       (Please reply with the following form: Indication/Contraindication, Goal, Target &
       Volume, Technique, and Dose & Fractionation.)


    Q7: Please denote the neck LN classification.


    Q8: Please denote the retropharyngeal LNs.


    Q9: Please denote the neck LN involved rates in patients with
hypopharyngeal cancers.


    Q10: Please denote the general treatment guide for hypopharynx cancers.
Questions & Discussions: (with potential answers)
(Please answer the following questions commented from your RT attending
    physician.)

    Q1: What are your findings/interpretations for the above key image(s)?
    A1: As described in the last attached page.


    Q2: What is your clinical cancer stage, according to the AJCC 2006, for this
       case?
    A2: cT4bN3M0, stage IVB (AJCC 2006)

    Q3: What is your pathologic cancer stage, according to the AJCC 2006, for
       this case?
    A3: No pathology stage can be defined in this case.

    Q4: What are your Oncology Diagnosis and/or other Assessments for this
       case?
    A4:
       1. Oncology Diagnosis: Squamous cell carcinoma, moderately differentiated, of the
    hypopharynx, right pyriform sinus with cross-midline invasion, 5.2 cm, with bilateral neck
    nodes, right > left, cT4bN3M0, stage IVB (2008/05, AJCC 2006)
       2. CCRT is indicated for this patient with the following indicators:
          (1). Primary unresectable disease of cT4bN3M0, stage IVB
      3. RT treatment goal: potentially curative


    Q5: What is your Oncology Plan for this case?
    A5: Suggest: definitive CCRT


    Q6: What is your Radiotherapy Plan for this case?
       (Please reply with the following form: Indication/Contraindication, Goal, Target &
       Volume, Technique, and Dose & Fractionation.)
    A6: RT Plan may be designed as the following one:
         (1). Indication: unresectable cT4bN3M0, stage IVB disease
         (2). Goal: potentially curative in definitive CCRT setting
         (3). Target & Volume: hypopharyngeal primary tumor and bilateral necks
         (4). Technique: IMRT
         (5). Dose & Fractionation: 7200-7560 cGy in 40-42 fractions to the gross tumor; 5940
         cGy in 33 fractions to the secondary target regions; 5040 cGy in 28 fractions to the
         elective irradiated region.

    Q7: Please denote the neck LN classification.
    A7:
    As the following figure. --- Adapted from [AJCC 2006].
    Q8: Please denote the retropharyngeal LNs.
    A8:
    As the following figure. --- adapted from [AJCC 2006].




    Q9: Please denote the neck LN involved rates in patients with
hypopharyngeal cancers.
    A9:
    As the following figure. --- adapted from [2008 Perez]
   Q10: Please denote the general treatment guide for hypopharynx cancers.
   A10:
   As the following table. --- adapted from [2008 Perez].




Further Readings & References: NCCN 2009 & 2008 Perez & AJCC
2006
                                                           Radiation Oncologist
                                                          Hon-Yi Lin 2009/01/31
Key Image(s): (with marked)

Fig. 1. CXR
                              Fig. 1. CXR shows the right neck
                              soft-tissue mass with size more than 5
                              cm (as the white arrow); the preventive
                              tracheostomy in place (as the long black
                              arrow); a dilated stomach in place (as
                              the short black arrow).




Fig. 2. Panel A. HN CT
                              Fig. 2. Panel A. Multiple
                              contrast-enhanced tumor masses
                              over the CT image at the level of
                              hypopharynx region, mainly on the
                              right neck (as the short white
                              arrows) with a small residual upper
                              airway lumen (as the long white
                              arrow); a NG tube in place (as the
                              black arrow); two small LNs over
                              the left neck (as the white arrow
                              heads).




Fig. 2. Panel B. HN CT
                              Fig. 2. Panel B. the primary tumor
                              over the hypopharynx region with
                              circular soft-tissue thickness and
                              mild contrast enhanced (as the long
                              white arrows); multiple enlargement
                              LNs over bilateral neck with central
                              necrosis pattern (as the short white
                              arrows).

								
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