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174
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Part 2 Site-Specifi c Indications and Techniques
A
C
Figure 10.2A-C
Setup and Field Arrangement for Conventional
Radiotherapy Technique
Marking of shoulders and palpable nodes facilitates portal
design. e patient is immobilized in a supine position with
the shoulders pulled down to the maximal extent. Lateral
parallel–opposed photon elds are used to treat the primary
tumor and upper and mid neck nodes.
• Superior border: a
t the level of the skull base to include the
upper jugular and parapharyngeal lymphatics.
• Anterior border: 1-cm fallo .
• Posterior border: behind the spinous processes or more
posteriorly in the presence of large nodal mass.
• Inferior border: encompasses primary lesion with margin
(as low as possible while avoiding the shoulders).
A matching anterior portal is used to treat the lower neck
nodes. It may be necessary to use anterior and inferior tilts for
patients with a short neck or because of the inferior extent of
B
the primary tumor or nodal mass. In this case, the supraclavicular fossae are included in the primary portal (see Fig. 9.11).
For boost volume, reduced lateral elds are used as follows:
• Superior and inferior borders: dep
ends on the extent of the
disease; at least include aryepiglottic folds superiorly and
cricoid cartilage inferiorly.
• Anterior border: 1-cm fallo , except when primary lesion
is con ned to the posterior structures where a small strip
of anterior skin may be spared.
• Posterior border: midvertebral bodies, or posterior one
third of vertebral bodies when the primary involves
posterior pharyngeal wall.
Involved upper and midjugular nodes receive boost dose
through lateral elds along with the primary tumor and
lower neck nodes through a reduced anterior portal.
Nodes overlying the spinal cord can receive boost dose
with electron beam(s) or, alternatively, the primary tumor
Chapter 10 Hypopharynx
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175
and ipsilateral node can receive boost dose with oblique photon elds depending on the location of the node(s).
Intensity-Modulated Radiation Therapy Planning
Most patients are now treated with intensity-modulated
radiation therapy (IMRT) to spare parotid function
(Case Study 10-3). e primary tumor and involved
node(s) with a minimum of 1-cm margin constitutes
CTVHD (CTV1). However, because of laryngeal motion, it
is prudent to encompass the majority of the larynx in the
high-dose target volume. CTVID (CTV2) de nes the neck
compartments outside CTVHD with a 2-cm (cranial– caudal)
margin . e remaining nodal levels (II to V) are contoured
Case
Study
10-3
biopsy of which showed squamous cell carcinoma. ere
was no clinical evidence of lymphadenopathy. He received
concurrent radiation and chemotherapy. While bulky disease was seen lling the right pyriform sinus, the disease
had signi cant super cial spread.
A 61-year-old male, presented with sore
throat, mild odynophagia, and weight loss.
Examination revealed an extensive tumor of
the oropharyngeal walls extending into the
right pyriform sinus and postcricoid region,
as CTVED (CTV3). LevelIb on the side of involved node is
included in CTVED.
Dose
Stage I (T1 N0) tumors: 50 Gy in 25 fractions to the initial
target volume and then 16 Gy in 8 fractions to the primary
tumor. For patients treated with IMRT, a dose of 66 Gy is prescribed to CTVHD and 54 Gy to CTVED. An alternative option
is to treat with two sequential plans. e rst delivers 50 Gy
in 25 fractions to CTVHD and CTVED followed by a plan that
delivers 16 Gy in 8 fractions to CTV
Stage II (T2 N0) tumors: hyperfractionated or concomi-
tant boost regimen. Hyperfractionation delivers 55.2 Gy in
A PET-CT simulation was performed to assist in de ning the targets, particularly the inferior extent of disease that
could not be visualized clinically (Fig. 10.3). An axial CT slice
with adjacent fused PET image is shown in Figure10.3A. e
high dose CTV (red) and subclinical target (yellow) are shown
on the CT scan. A more inferior slice through the postcricoid region (Fig. 10.3B) did not demonstrate an increase in
FDG uptake. A high-dose clinical volume was outlined for
boost volume de nition, as this slice was approximately 1 cm
below the identi ed gross target volume.
HD.
A
B
Figure 10.3A,B
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Part 2 Site-Specifi c Indications and Techniques
46 fractions to the initial target volume and then 21.6 Gy in
18 fractions (1.2-Gy fractions, twice daily, 6-hour interval);
the spinal cord dose is limited to 44.4 to 45.6 Gy or less, and
uninvolved posterior cervical nodes are supplemented with
2Gy daily to approximately 55 Gy. Concomitant boost delivers 1.8-Gy fractions to 54 Gy in 30 fractions to the initial
target volume and 1.5-Gy fractions to 15 to 18 Gy given as
second daily fractions during the last 2 to 2.5 weeks; the spinal cord dose is limited to 45 Gy or less. For patients treated
with IMRT, one option is to use the concomitant boost schedule, which requires two separate plans. e rst plan delivers
54 Gy in 30 fractions to CTVHD and CTVED, and the second
plan is for 18 Gy in 10 to 12 fractions to CTVHD (given as second daily fractions). An alternative choice is to use one plan
that delivers 70 Gy to CTVHD and 56 Gy to CTVED. Treatment
is given in 35 fractions over 30 treatment days, by delivering
6 fractions a week for 5 weeks with a 6-hour interfraction
interval on the day 2 fractions are delivered.
Stage III and IV tumors: in combination with three cycles
of concurrent cisplatin, radiation is given in conventional 2-Gy
fractions to a dose of 50 Gy to the initial target volume and 70
Gy to the boost volume. Di erential loading may bepreferred
for lateralized lesions with ipsilateral nodal disease only. In
this situation, the dose is speci ed at an isodose line with
maximal allowable dose heterogeneity of ±2.5%. e spinal
cord dose is limited to 45 Gy or less. For patients treated with
IMRT, the commonly prescribed doses are 70 Gy to CTVHD 60
to 63 Gy to CTVID, and 56 to 57 Gy to CTVED, given once daily
in 33 to 35 fractions (Case Studies10-4and10-5).
Postoperative Radiotherapy
e indications, technique, and dose prescriptions are similar to those for supraglottic carcinoma except that the target
volume also encompasses the retropharyngeal nodes. e
superior border of the lateral elds is placed at the level of
the base of skull (Case Study 10-6). For IMRT treatment
planning, CTVHD (CTV1) encompasses the preoperative
tumor bed and involved nodal regions with margin, CTVID
(CTV2) the operative bed, and CTVED (CTV3) the undissected nodal volumes at risk including the retropharyngeal
nodes. e stoma can be delineated as CTVID or CTVED
depending on the risk features. Areas of very high risk (positive margin or extranodal extension) can be delineated separately, to a prescribed higher dose (e.g., 64 to 66 Gy).
Case
Study
10-4
images (Fig. 10.4B,C) showed the right level II node and
the superior aspect of the primary tumor at the vestibule
of the right pyriform sinus and the bulk of the primary
lesion at the level of the mid-pyriform sinus. e inferior
aspect of the node can be seen abutting the anterior aspect
of the sternocleidomastoid muscle. Biopsy of the primary
tumor revealed squamous cell carcinoma. He was staged as
A 53-year-old male presented with a right
upper neck mass and mild sore throat.
Examination revealed a 2.5 cm upper
jugular node and a lesion on the medial wall
of the pyriform sinus (Fig. 10.4A). Axial CT
having a T2 N1 M0 and treated with IMRT with three
cycles of concurrent high-dose cisplatin.
CTVHD (70 Gy) encompassed the primary tumor and
involved node with margins, CTVID (60 Gy) the right posterior neck, and CTVED (56 Gy) the le neck (Fig. 10.4D).
e ipsilateral hypopharyngeal wall down to the cricoid
level was included in CTVHD, right level III nodal region
in CTVID, and le level III, and bilateral level IV, nodes
in CTVED (Fig. 10.4E,F). Figure 10.4G shows the sagittal isodose distribution through the primary tumor. e
patient had good function without evidence of disease
3 years a er completing treatment.
A
Figure 10.4A,B
B
Chapter 10 Hypopharynx
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177
C
E
D
F
G
Figure 10.4C-G
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Part 2 Site-Specifi c Indications and Techniques
Case
Study
10-5
scan revealed tumor extension into the neck (Fig. 10.5A).
ere were multiple ipsilateral lymph nodes. Biopsy of the
primary tumor showed squamous cell carcinoma. Stage: T4
N2b M0.
Due to marginal renal function, he received three
cycles of carboplatin and paclitaxel with good response.
He was subsequently treated with IMRT and concurrent
weekly paclitaxel. Figure 10.5B shows CTVHD (70 Gy—red)
encompassing the prechemotherapy tumor extent with
A 69-year-old man, with a history of heavy
tobacco and alcohol consumption, presented
with a large right neck mass.
Examination showed a large primary
tumor of the right pyriform sinus. PET-CT
1-cm margin, CTVID (63 Gy—blue) de ning the uninvolved
ipsilateral level V nodes, and CTVED (57 Gy—yellow) covering the uninvolved contralateral neck nodes at the level
of the mid pyriform sinus. A fourth volume (orange) was
delineated to prescribe a dose of 66 Gy to the anterior tissues and the mid-posterior hypopharynx due to the extensive neck involvement. e red circle over the vertebral
body is a dosimetric reference point. Figures 10.5C–E show
isodose distributions through the isocenter on axial, sagittal, and coronal views. Isodose distributions on axial slices
at the level of the retropharyngeal nodes (Fig. 10.5F) and
low level IV nodes (Fig. 10.5G) are also displayed. Two
years a er completion of therapy, he remained free of disease, ate a near normal diet, and had normal speech.
A
C
Figure 10.5A-D
B
D
Chapter 10 Hypopharynx
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179
E
G
Figure 10.5E-G
Case
Study
10-6
ately di erentiated squamous cell carcinoma. Because of
the weight loss and near obstruction of the larynx, a gastrostomy tube was placed and tracheostomy performed. He
subsequently underwent total laryngectomy, partial pharyngectomy, and bilateral neck dissections. e defect was
repaired with a radial forearm gra . Histologic examination revealed a carcinoma of the le pyriform sinus invading the le aryepiglottic fold and thyroid cartilage. ere
A 61-year-old man presented with several
months of le otalgia and weight loss. Examination showed a large mass lling the le pyriform sinus, invading medially into the larynx.
Biopsy of the primary tumor revealed moder-
F
was perineural and lymph-vascular space invasion. Two
of twenty- ve nodes recovered from the le neck dissection contained metastatic disease without extracapsular
extension. Stage: pT4 N2b M0. He received postoperative
radiation.
Figure 10.6A shows treatment began with large
parallel–opposed elds that were progressively reduced
a er 42 and 56 Gy to administer a total of 60 Gy to the
high-risk regions. Figure 10.6B shows an isodose distribution through the central axis. e posterior cervical
strips were supplemented with 12 MeV electrons to 56 Gy.
Amatching anterior eld was used to treat the low neck
and stoma to 50 Gy.
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Part 2 Site-Specifi c Indications and Techniques
A B
Figure 10.6A,B
Background Data
Table 10.1
Institution
University of Florida T1 (23) 85
University of Texas M.D. T1 (19) 89
Anderson Cancer Center
Massachusetts General
Hospital
Japan (10 institutions)
a
Includes all hypopharyngeal sites (69% of patients had pyriform sinus
tumors).
b
Includes all hypopharyngeal sites (70% of patients had pyriform sinus
tumors).
c
Crude local control rate.
Adapted from Rabbani A, et al. Defi nitive radiotherapy for T1-T2 squamous
cell carcinoma of the pyriform sinus. Int J Radiat Oncol Biol Phys
2008;72:351; Garden AS, et al. Early squamous cell carcinoma of the
hypopharynx: outcomes of treatment with radiation alone to the primary
disease. Head Neck 1996;18:317; Wang CC. Carcinoma of the hypopharynx.
In: Radiotherapy of head and neck neoplasms. New York, NY: Wiley-Liss,
1997:212; and Nakamura K. et al. Multi-institutional analysis of early
squamous cell carcinoma of the hypopharynx. Int J Radiat Oncol Biol Phys
2006;65:1045.
Local Control of Radiation for Early
(T1 To T2) Squamous Cell Carcinoma of
the Pyriform Sinus (Literature Review)
Stage (No.
Patients)
5-yr Actuarial
Control (%)
T2 (100) 85
a
T2 (63) 70
T1 (24)
T2 (51)
b
T1 (39)
T2 (76)
74
76
85
68
c
Table 10.2
Distribution of Initial Failures in Patients
with Early Stage (T1 To T2) Carcinoma of
the Hypopharynx Treated with Radiation
Therapy
Type of Recurrence
T1
(n = 58)
T2
(n = 139)
Total
(n = 197)
Primary relapse (P) 8 32 40
Nodal recurrence (N) 3 11 16
P + N 0 7 7
P + D 1 0 1
N + D 0 5 5
P + N + D 0 1 1
Distant metastasis (D) 3 8 10
Failure above clavicles
12 (21%) 50 (36%) 62 (31%)
without D
Total failures 15 (26%) 58 (42%) 73 (37%)
Modifi ed from Garden AS, et al. Early squamous cell carcinoma of the
hypopharynx: outcomes of treatment with radiation alone to the primary
disease. Head Neck 1996;18:317 and Nakamura K. et al. Multi-institutional
analysis of early squamous cell carcinoma of the hypopharynx. Int J Radiat
Oncol Biol Phys 2006;65:1045.
Chapter 10 Hypopharynx
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181
Table 10.3
Stage No. of Patients
T1–T2
N0
N1b
N3
Total
T3
N0
N1b
N2b
N3
Total
Overall total 434 119 (27) 70 (16) 40 (9) 229/434 (53)
Minimal follow-up 2 years.
P, primary; N, node; P + N, primary + node.
Modifi ed from Bataini, et al. Int J Radiat Oncol Biol Phys 1982;8:1277.
Table 10.4
Type of Complications No. of Patients
Death related to therapy
Total 11/434 (2.5%)
Hemorrhage 7
Cachexia 2
Asphyxia due to laryngeal edema 1
Aspiration pneumonia 1
Major but nonfatal (in 114 patients alive at 3 yr):
Total 12/114 (11%)
Tracheostomy 6
Gastrostomy 1
Tracheostomy + gastrostomy 1
Soft tissue necrosis (treated
conservatively)
Modifi ed from Bataini, et al. Int J Radiat Oncol Biol Phys 1982;8:1277.
Cancer of the Pyriform Sinus Treated by Radical Radiotherapy: Loco-Regional Failures According to
Stage of Primary and Nodal Disease
Recurrences
P: No. (%) P + N: No. (%) N: No. (%) Total: No. (%)
33
21
36
90
90
105
9
140
344
Cancer of the Pyriform Sinus Treated
by Radical Radiotherapy: Radiotherapy
Complications in 434 Patients
10
6
7
23 (26)
27
30
5
34
96 (28)
—
1
5
6 (7)
6
15
—
42
64 (19)
—
2
9
11 (12)
3
11
6/9
15
29 (8)
setting, the combination of conventional radiation fractionation(70 Gy in 35 fractions over 7 weeks) with cisplatin
2
(100mg/m
given on days, 1, 22, and 43 of radiotherapy) is rec-
10/33 (33)
9/21 (43)
21/36 (58)
40/90 (44)
36/90 (40)
56/105 (53)
91/140 (65)
189/344 (55)
ommended. Neck dissection is indicated in patients who have
residual neck mass 6 to 10 weeks a er completion of therapy.
Occasionally, advanced tumors (T4) are treated with
surgery and postoperative radiotherapy. Carcinoma of the
postcricoid region is very rare and is usually treated with
surgery with or without postoperative radiotherapy.
Primary Radiotherapy
Target Volume
e initial target volume encompasses the primary with at
least 2- to 3-cm margins (of note is that submucosal spread
can be extensive) and level II to V and retropharyngeal nodes
(Case Study 10-7). e boost volume encompasses primary
tumor and involved nodes with 1- to 2-cm margins.
4
IMRT target volumes are similar to those described for
pyriform sinus cancers. CTVHD should, however, include
3 to 5 mm of the anterior vertebral bodies even without
demonstrable bone invasion. CTVID is o en more generous, 2 to 3cm in the cranial and caudal dimensions, because
POSTERIOR HYPOPHARYNGEAL
WALL
of the risk of submucosal lymphatic spread through the
retropharyngeal space.
Treatment Strategy
Primary radiotherapy is preferred for T1 to T2 tumors. Combination of radiation with chemotherapy is the treatment of
choice for T3 or N2 to N3 tumors. Outside protocol study
Setup and Field Arrangement for Conventional
Radiotherapy T
echnique
Marking of palpable nodes and shoulders facilitates portal
design. e patient is immobilized in a supine position with
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Part 2 Site-Specifi c Indications and Techniques
a thermoplastic mask with the shoulders pulled down as far
as possible. Lateral parallel–opposed photon elds are used
for treatment of the primary tumor and upper neck nodes
(see Case Study 10-7).
• Superior border: a
geal lymphatics and upper jugular nodes.
• Anterior border: at least 2 cm anterior to the known
extent of the tumor, but when feasible short of fallo
anteriorly.
• Posterior border: just behind the spinous processes or more
posteriorly in the presence of large nodal masses. A er
o -cord reduction, the posterior portal margin is at the
posterior one third of vertebral bodies to include the retropharyngeal nodes and provide margin for the posterior
pharyngeal wall.
• Inferior border: encompasses primary lesion with 3-cm or
greater margin when possible.
An anterior appositional portal is used for treating lower
neck nodes. It may be necessary to use anterior and inferior tilts for patients with a short neck or because of the
t the base of skull to cover parapharyn-
inferior extent of the primary tumor or nodal mass. In this
case, the supraclavicular fossae are included in the primary portal.
For boost volume, the lateral elds are reduced:
• Superior and inferior borders: depends on extent of the
primary tumor.
• Anterior border: short of fallo .
• Posterior border: posterior one third of vertebral bodies.
Involved level II and III nodes are encompassed in lateral
elds and lower neck nodes in a reduced anterior portal.
Nodes overlying the spinal cord can be boosted with
electron beam(s) or, alternatively, the primary tumor and
ipsilateral node can be boosted with oblique photon elds.
Intensity-Modulated Radiation Therapy Planning
IMRT is best suited for treating tumors extending to the para
vertebral region without overdosing the spinal cord because
this technique can produce a horseshoe-shaped isodose distribution. e patient is immobilized in a supine position
with an extended thermoplastic mask. in-cut computed
Case
Study
10-7
pable neck nodes. A CT scan con rmed the physical ndings and in addition showed some thickening of the le
aryepiglottic fold. Biopsy showed moderately di erentiated
squamous cell carcinoma. Stage: T2 N0 M0. is patient
received radiotherapy with a hyperfractionation schedule.
Figure 10.7 shows lateral elds designed to encompass the primary tumor and the majority of neck nodes
while sparing a strip of anterior skin. e posterior border
of the o -cord and boost portals at the level of the primary
tumor was close to the posterior edge of the vertebral bodies to cover the lesion adequately. Supraclavicular nodes
were treated with an anterior appositional photon eld.
e primary tumor received 76.6 Gy in 7weeks (55.2Gy
in 46 fractions for 4.6 weeks + 21.6 Gy in 18fractions
for 2 weeks); uninvolved upper and midjugular nodes
received 55.2 Gy in 4.6weeks and uninvolved posterior
cervical nodes 54 Gy in 5 weeks. Supraclavicular nodes
received 50 Gy in ve fractions for 5 weeks. Physical
examination 6 months a er radiotherapy revealed fullness of the le pyriform sinus. Biopsy of this area showed
squamous cell carcinoma. He underwent total laryngopharyngectomy with le modi ed neck dissection and
A 68-year-old man had a 1-year history of
dysphagia. Mirror examination revealed a mass
in the le lateral and posterior hypopharyngeal walls. e medial wall and apex of the
pyriform sinus were free. ere were no pal-
pharyngeal reconstruction with jejunal free ap. Second
local recurrence occurred 5 months a er surgery, and he
died of uncontrolled local disease.
Figure 10.7
Chapter 10 Hypopharynx
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183
tomography (CT) scans are obtained in treatment position. Clinical target volumes (CTVs), as described for pyriform sinus carcinomas above, are outlined for dosimetric
planning.
Dose
T1 tumors: 50 G
then 16 Gy in 8 fractions to the primary tumor.
T2 tumors: hyperfractionated or concomitant boost
regimen. Hyperfractionation delivers 55.2 Gy in 46 fractions
to the initial target volume and then 21.6 Gy in 18 fractions
(1.2-Gy fractions, twice daily, 6-hour interval); the spinal
cord dose is limited to 44.4 to 45.6 Gy or less, and uninvolved
posterior cervical nodes are supplemented with 2 Gy daily
to approximately 55 Gy. Concomitant boost delivers 1.8-Gy
fractions to 54 Gy in 30 fractions to the initial target volume
and 1.5-Gy fractions to 15 to 18 Gy given as second daily
fractions during the last 2 to 2.5 weeks; the spinal cord dose
is limited to 45 Gy or less.
Positive nodes, frequently present, receive doses
appropriate for the size and the fractionation schedule
Case
Study
10-8
invading the preverterbral muscles (Fig. 10.8B) with le
retropharyngeal adenopathy (Fig. 10.8C). He underwent
total pharyngolaryngectomy and bilateral neck dissections
including resection of the retropharyngeal space followed
y in 25 fractions to the initial target volume
A 60-year-old man presented with dysphagia
and was found to have biopsy proven squamous
cell carcinoma of the posterior hypopharynx
(Fig. 10.8A). Axial CT slices show disease (red
arrows) in the posterior hypopharyngeal wall
used, for example, 66 to 70 Gy in 2-Gy fractions, 69 to
72 Gy with concomitant boost, or 74.4 to 79.2 Gy with
hyperfractionation.
T3 tumors: in combination with three cycles of concurrent cisplatin, radiation is given in the conventional 2-Gy
fractions to a dose of 50 Gy to the initial target volume and
70 Gy to the boost volume. e spinal cord dose is limited to
45 Gy or less.
Regimens for IMRT are similar to that described for
pyriform sinus tumors.
Postoperative Radiotherapy
Indications and technique for postoperative radiotherapy are
similar to those for pyriform sinus cancer with the exception
that the posterior border of the o -cord and boost elds are
brought closer to the posterior edge of the vertebral bodies
to ensure good coverage of the prevertebral and paravertebral tissues (see Case Study 10-8). CTVHD should, however, include 3 to 5 mm of the anterior vertebral bodies even
without demonstrable bone invasion.
by a tubed anterolateral thigh free ap reconstruction.
Histologic examination revealed a 7-cm primary tumor, ve
positive nodes in the right neck and eight positive nodes in
the le neck, as well as disease in the retropharyngeal space.
He was treated with concurrent cisplatin and IMRT delivering 60Gy in 30 fractions to CTVHD. Figure 10.8 D–F show
representative isodose distribution on axial, sagittal, and
coronal views through isocenter. He developed lung metastasis without local-regional relapse <1 year from diagnosis.
A
Figure 10.8A,B
B
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