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JULY, 1975

A Dramatic Response of Laryngeal Tumor to Radiation Therapy M. TAFRESHI, M.D., Associate Director, Radiology Department, and

N. AKBIYIK, M.D., Assistant Attending Radiotherapist, Radiation Medicine Division, Radiology Department, Queens Hospital Center, Jamaica, New York

The pharynx, larynx and esophagus form an anatomical organ triad which subserves the vital functions of respiration, phonation and deglutition, and consequently a serious situation is created for patients when they are affected by oncological diseases. Carcinoma in one organ frequently invades the others and treatment problems are common to all three. The end results of treatment are best when carcinoma is confined to the larynx; the prognosis for the other sites is poor with present methods of treatment. The hypopharynx is that part of the pharynx which extends from the hyoid bone to the cricoid cartilage at the intervertebral disk between the fifth and sixth cervical vertebrae, where it joins the cervical esophagus.

anteriorly to the larynx and to the trachea, posteriorly to the retropharyngeal tissues and cervical spine, laterally. The disease invades the lateral lobes of the thyroid gland, and carotid sheath and sometimes the recurrent laryngeal nerves are paralyzed. The carci-

CARCINOMA OF THE HYPOPHARYNX

Carcinoma of the hypopharynx may commence in the mucous membranes of the following sites: epiglottis, glosso-epiglottic fold, aryepiglottic fold, pyriform fossa, posterior wall and the posterior cord region. It is not often possible to state the site of origin because the tumor is so extensive when the patient is first seen. 1 The commonest sites are the pyriform fossa, usually in males, and the post-cricoid region, usually in females. 1 Direct extension: The carcinoma spreads superiorly to the nasopharynx and base of the tongue, inferiorly to the cervical esophagus,

true and false cords and subglottic angle. A large soft tissue mass obliterates the air space of the night pyriform sinus and projects into the laryngeal ventricle.

noma spreads widely in the muscles and cartilage of the neck and may affect the skin. Lymph node metastases are frequent and may be bilateral. More than 50% of patients

Vol. 67, No. 4

Laryngeal Tumor

have metastatic lymph nodes when first seen and usually the nodes are fixed.2 Definite diagnosis is made by biopsy, however, determination of the extent of disease is always made by radiographic examination. Usually the radiographic method and findings are: 1. Observation and measurements of the soft tissue spaces in the pharynx and larynx for tumor mass or deformity. 2. Fluoroscopic spot film and cine radiographic study of the air space of the larynx and pharynx during quiet inspiration, phonation and valsalva maneuvers. Tomographic

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mobility and symmetry as well as the integrity of the surrounding anatomy. Filling defects in the pyriform sinuses and valleculae may be visualized.

*..j^~~~~~~~~~~~~~~~~~~~~~~.. . .... .

Fig. 3. Lateral contrast film shows irregular margins of the filling defect of the pyriform sinus.

Plain film study combined with contrast examination and motion maneuvers accurately document alterations in the pharynx and larynx and may be used to study response to radiation therapy.3 ..

Q

Fig. 2. Contrast study shows a large mass preventing filling of the right pyriform sinus and projecting into the laryngeal ventricle.

studies in the AP and lateral projections serve to demonstrate small mass lesions, while fluoroscopy may document abnormal motion. 3. Contrast examination using topical anesthesia and 10cc of oily Dionosil dropped

slowly

over

the-.tongue during quiet inspira-

tion. Contrast outlines the structures of the larynx and pharynx and masses as small as ½/cm stand out in sharp detail. Phonation studies, when the patient says, 'eee~ vividly demonstrate the true cords 9

Fig. 4. Post therapy laryngogram shows complete regression of the tumor mass and smooth, symmetrical margins of the right pyriform sinus.

CASE REPORT A 67-year old male who was admitted to the hospital because of massive hemoptysis The patient's history dates back

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to several months ago when this first occurred. He was admitted to another hospital where a work-up was to have been done, including bronchoscopy. No etiology was discovered for the hemoptysis. The symptoms persisted and he finally presented himself here where work-up and evaluation were done, including direct laryngoscopy, which revealed a large exophytic tumor mass approximately 1.5-2 inches involving the right pyriform sinus (Figs. 1-3). Examination of the neck revealed movable nodes on the right side varying in size from l /2-31/2 inches. The patient would therefore be classified as a T3N2 carcinoma of the pyriform sinus. The patient also had a history of chronic alcoholism with liver cirrhosis. A lack of coagulation factors would contraindicate radical surgery, along with the fact that the patient and his wife preferred that there be no operation. The patient's biopsy (the right pyriform fossa) revealed poorly differentiated epidermoid carcinoma.

CLINICAL COURSE The patient was treated with extemal radiation therapy utilizing Cobalt 60 teletherapy units in the Queens Hospital Center. According to the decision reached in the Head and Neck Conference, the patient received 7,000 rads tumor dose in seven weeks. The treatment area included the level of the soft palate to the whole neck. Bilateral supraclavicular fossa, as well as the base of the tongue were also included in the treatment fields. Treatment ended on January 3, 1975. At the end of the treatment, indirect laryngoscopic examination of the pyriform sinus revealed complete disappearance of the tumor mass and there were no palpable nodes in the neck.

DISCUSSION

The treatment of carcinoma of the hypopharynx by surgery or by radiotherapy alone gives disappointing results and a poor prognosis because so many patients come with advanced disease and have metastases. Because of the infiltrative nature of these tumors and the extensive areas of necrosis, causing poor oxygenization of the central tumor and frequently superimposed infection,, these lesions are radio-resistant.' Most institutions today obtain best prog-

JULY, 1975

nostic results with a combination of the two treatment modalities, radiotherapy and surgery. 1,4, However, our patient was not a candidate for any type of surgical treatment due to a lack of blood coagulation factors, and his opposition to any surgical approach. We treated the patient with radiation therapy and maintenance chemotherapy to prevent recurrence of disease. Toward the end of the dose of 7,000 rads in seven weeks of radiation therapy with Cobalt 60 teletherapy units, the patient's advanced lesion showed unusual and dramatic response. On indirect laryngoscopic examination, complete disappearance of the tumor mass was noted. The metastatic lymph nodes in the neck also disappeared. LITERATURE CITED

1. RAVEN, R. W. Carcinoma of the Hypopharynx. Amer. J. Roentgenol. Rad. Therapy Nuc. Med., 173, 1974. 2. MOSS, W. T. Radiation Oncology: Rationale, Technique, Results. Mosby, 1973. 3. G. H. FLETCHER and B. S. JING. An Atlas of Tumor Radiology. The Head & Neck, Radiographic Methods of Diagnosis. Second Edit. Year Book Medical Pub., 2: 5-10, 1968 pp. 5-10. 4. S. RAFLA, and J. BOCHETTO, JR. Aggressive Management of Advanced Head & Neck Tumors. Amer. J. Roentgenol. Rad. Therapy Nuc. Med., 608, 1974. 5. J. J. SCHNEIDER, and G. H. FLETCHER, and H. T. BARKLEY, JR. Control by Irradiation Alone of Non-fixed Clinically Positive Lymph Nodes from Squamous Cell Carcinoma of the Oral Cavity, Oropharynx, Supraglottic Larynx & Hypopyarynx. Amer. J. Roentgenol. Rad. Therapy Nuc. Med., 42: 1975.

(Presidents Column, from page 317) rubella vaccine, with 73.9% having been immunized against diphtheria, pertussis, and tetanus. In our communities, approximately 5.6 million of 14 million one to four year-old children are not adequately protected against one or more of these diseases. It is time to remember-and time to act. A large percentage of these children are currently in a health delivery system. Are all the children

you see immunized? Each time you or a member of your staff pulls a child's record, review the immunization status. Polio, measles, rubella and other childhood diseases can be prevented if all of us do our part. The hazard and potential tragedy of waiting and postponing immunization cannot be overemphasized. VERNAL G. CAVE, M.D.

A dramatic response of laryngeal tumor to radiation therapy.

272 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION JULY, 1975 A Dramatic Response of Laryngeal Tumor to Radiation Therapy M. TAFRESHI, M.D., Associate...
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