Pyriform Sinus

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The pyriform sinus is the most common site of squa-mous cell carcinoma in the hypopharynx. The incidence of palpable lymph node metastasis is high at 75 percent. Upward of 10 to 14 percent of such patients will have bilateral or contralateral nodal disease.

Early stage disease, T1 and early T2 lesions with exophytic low bulk lesions, can be effectively treated with primary radiation therapy or surgery.

T1 lesions can be treated with radiation administered with conventional fractionation at 180 cGy to a dosage of 7,000 cGy. Likewise, larger volume T1 and selected T2 lesions can be treated with accelerated fractionation with a delayed concomitant boost to a dosage of 7,000 cGy to the primary lesion and lymphadenopathy. A larynx compensator is used to improve the dose homogeneity to that region. Comprehensive nodal irradiation is necessary in view of the high incidence of lymph node metastasis. 5,000 to 5,400 cGy is administered for elective nodal irradiation; 6,000 cGy is administered for clinically palpable lymphadenopathy, with subsequent neck dissection planned approximately 6 weeks after treatment. Such patients with advanced disease by virtue of the adenopathy would also be administered cisplatin chemotherapy concurrently. Mendenhall and colleagues51,52 report local control rates of 88 percent for T1 and 80 percent for T2 lesions treated with radiation therapy alone. However, it should be noted that some feel that only exophytic, small lesions of the membranous portion of the pyriform sinus can be reliably treated with radiation and this should be considered in the therapeutic decision. Surgical salvage of radiation failure may be possible, however it may be associated with an increased complication rate.

Conservation surgery for T1 and T2 lesions can be considered as well and is associated with local control rates of 96 percent.53 Various surgical procedures have been used based on the location and size of the lesion and include supracricoid hemilaryngopharyn-gectomy and a partial laryngopharyngectomy. Postoperative radiation therapy may be indicated particularly for large T2 lesions and with nodal metastasis.

Advanced disease, stage T3 and T4, can be treated with a larynx preservation approach using chemotherapy and radiation when the extent of the primary disease would require a total laryngectomy. An EORTC54 study consisted of patients with locally advanced hypopharyngeal carcinoma limited to the pyriform sinus or hypopharyngeal aspect of the aryepiglottic fold. They were randomized to either receive standard surgery (total laryngectomy, partial pharyngectomy, neck dissection) and postoperative radiation therapy (5,000 to 7,000 cGy at 200 cGy/fraction) versus induction chemotherapy with

Figure 21-6. Patient with a T2N2cM0 squamous cell carcinoma of the base of tongue. He was treated with external beam radiation therapy to the primary area and regional lymph nodes to a dosage of 5,400 cGy, and 5,000 cGy to the low anterior neck nodes. Subsequently a bilateral neck dissection was performed showing no pathologic evidence of metastatic disease. At the same surgery, he underwent a temporary afterloaded interstitial implant (A). Lateral film after the procedure shows the orientation of the catheters with the implants in place (B).

Figure 21-6. Patient with a T2N2cM0 squamous cell carcinoma of the base of tongue. He was treated with external beam radiation therapy to the primary area and regional lymph nodes to a dosage of 5,400 cGy, and 5,000 cGy to the low anterior neck nodes. Subsequently a bilateral neck dissection was performed showing no pathologic evidence of metastatic disease. At the same surgery, he underwent a temporary afterloaded interstitial implant (A). Lateral film after the procedure shows the orientation of the catheters with the implants in place (B).

Figure 21-7. A and S, Patient with a T3N2CM0 squamous cell carcinoma of the base of the tongue. He was treated with cisplatin chemotherapy on day 1 and 22 concurrent with accelerated fractionation radiotherapy with a delayed concomitant boost to the sites of tumor to a dosage of 7000 cGy.

cisplatin + 5FU for up to 3 cycles and radiation therapy (7,000 cGy at 200 cGy/fraction) for those who achieve a complete clinical response at the primary site. Those with less than a complete response at the primary site underwent standard surgery and postoperative radiation therapy. Results revealed a 3-year survival of 57 percent with chemotherapy-radiation therapy versus 43 percent with the surgery-radiation therapy arm; however the survival advantage was not maintained at 5 years. The 3-year disease-free survival with a functional larynx was 64 percent in those patients with a complete response to induction chemotherapy. Zelefsky and colleagues55 reported on the Memorial Sloan-Kettering Cancer Center experience and found that the survival was comparable between patients treated with chemotherapy-radiation therapy and those who underwent standard surgery with postoperative radiation therapy for advanced hypopharyngeal cancers.

At Memorial Sloan-Kettering Cancer Center, we would administer cisplatin on days 1 and 22, concurrent with radiation therapy using accelerated fractionation with a concomitant boost to the primary lesion and lymphadenopathy to a dosage of 7,000 cGy. 5,000 to 5,400 cGy would be administered for elective nodal irradiation. Surgery is saved for salvage.

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