P R E S E N T E D B Y

S e r e n e M a r i a

P h a r m D 5 t h Y e a r

R e g N o : 1 1 Q 1 6 0 4

K a r a v a l i C o l l e g e O f P h a r m a c y

Case Presentation On Pyriform Fossa Carcinoma

Carcinoma Of Left Pyriform Fossa

Definition

It is the cancer ofPyriform Fossa whichis a part ofhypopharynx that liepartly to each side ofthe larynx.( pearshape )

D y s p h a g i a

S o r e t h r o a t

O d y n o p h a g i a

N e c k m a s s

C h a n g e i n v o i c e

We i g h t l o s s

p a i n i n e a r s

O b s t r u c t i o n

Signs and Symptoms

Long t e rm exposu r e o f c a r c i n ogens ( t o bac c o and e t h ano l ) c a usesp r o g r e s s i v e c e l l u l a r d y s r e gu l a t i o n by a l t e r a t i o n o f t umo r s upp r e s s o rgenes ( t p 53 ) , amp l i f i c a t i o n o f p r o t o on c ogenes ( c y c l i n d1 ) , a nddamage t o r e gu l a t o r y f a c t o r s ( t r a n s f o rm i n g g r ow t h f a c t o r –be t aand r e t i n o i c a c i d r e cep t o r s ) , u l t ima t e l y l e a ds t o abno rma l c e l lg r ow t h .

The p r og r e s s i o n f r om no rma l mucosa t o c an c e r c o r r e l a t e s w i t ha c c umu l a t i o n o f g ene t i c a bno rma l i t i e s

Pathophysiology

Alcohol and tobacco use

Genetic factors

Deficient DNA repair mechanism

Human papilloma virus

Chronic irritation of pharynx

Eating a diet without enough nutrients.

Etiology and risk factors

L o c a l a n d p h y s i c a l e x a m i n a t i o n o f t h r o a t

B a r i u m e s o p h a g o g r a m

l a r y n g o s c o p y

B i o p s y

C T s c a n

M R I

P E T s c a n

H i s t o l o g i c a l s t u d i e s

Diagnosis

CT images

PET –CT IMAGES

TreatmentsFour types of standard treatment are used:

•Surgery

•Pharyngectomy and

•laryngopharyngectomy

•Radiation therapy

•Chemotherapy

•5-FU

•Cisplatin

•Paclitaxel

•Methotrexate

•Docetaxel

•Cetuximab

•Radiation therapy &Chemotherapy

Patient details

A 58 years old male patient was admitted in

radiotherapy ward in Fr. Muller’s Hospital with

c/o - pain while swallowing saliva since 1 month.

DOA : 8/12/15

HOPI

Patient was apparently normal one month back, when he developed pain while swallowing . Pain was insidious in onset and gradually progressive.Patient even experienced pain while swallowing saliva.

No H/O food being stuck in the back of throat . No H/O weight loss or loss of appetite.

No H/O voice change , dysphagia or breathing difficulty .

Family historyNothing significant

Personnel history:Diet, sleep and appetite - normalBowel and bladder habits - normalH/O Beedi smoking and alcohol consumption since 30

years, stopped 1 month back.

Past medical history :-.

No H/O medical co- morbidities

General examination

Pallor : -ve Cyanosis: -ve

Icterus : -ve Clubbing: -ve

Left level 3 lymph nodes ( +) 1.5*2 cm in size. Soft to firm ,

mobile & non tender.

PR : 72bpm BP : 110/ 70 mmHg

TEMP : 98.6°C RR : 16 /mt

Physical examination

• proliferative growth (+) involving left Pyriform fossa extending to

the left AE (aryepiglotottic) fold ,

• pooling of secretions present

• vocal cords can not be visualized

• base of tongue normal

Systemic examination

CVS : S1 & S2 +VE

RS : No added sounds

PA : Soft , non tender , No organomegaly

CNS : No neurological defects

Cardiorespiratory report

observation : patient was conscious , oriented and nourished.

O/E

mild crepts present all over lung field

decreased entry of air in upper and middle BL lung field

decreased ROM (range of motion) of jaws and neck

Lab investigation

Blood group A+

Hb 16.5

PLATELETS 171000

TC 9400

DC N-59, L-28, E-2, M-1

SGPT/SGOT 18/23

Na 145 meq/L

K 3.14 meq/L

Cl 104.2 meq/L

Mg 1.60 mg/dl

S.Urea 28 mg/dl

S.Cr 0.87

ALP 89 mu/ml

Local examination of oral cavity

soft palate - stained

oropharynx - WNL

IDL (INDIRECT LARYNGOSCOPY)

PFs - ulcerative growth

pooling of saliva

Unhealthy mucosa

lymph node mobile

Advice :- Biopsy

Biopsy Report (3/12/15)

Proliferative growth involving left Pyriform fossa

extending laterally to lateral pharyngeal wall , partly to

left AE (aryepiglotottic) fold.

False cords - edematous

•Biopsy

squamous cell carcinoma

IMPRESSION

carcinoma of left Pyriform fossa

Carcinoma Of Left Pyriform Fossa

ADVICE

Plan Chemoradiation After Metastatic Evaluation CECT Of Neck USG Abdomen & Pelvis Pre RT Dental Prophylaxsis Chemotherapy :- Curative Treatment Plan:- Concurrent Chemoradiation With Inj. Cisplatin (6 Cycle Of Inj . Cisplatin )

USG Abdomen & pelvis report

Shows: Bilateral Renal Calculi

• R- Multiple calculi , largest measuring 8mm in lower pole

• L- Few calculi in upper & lower pole , largest measuring 6mm in

lower pole.

X Ray : Normal

CECT Neck (Contrast Enhanced Computed Tomography )

Mildly enhancing lesions noted on the region of left pyriform fossa or

sinus with thickening and medical deviations of aryepiglotottic ( AE ) fold .

Superiorly there is invasion in to the false cord with involvement of

paraglotic region. Tiny aspect of calcification noted within the lesion.

Enlargement of level II and III lymph nodes with central hypoderm area, sign

of necrosis . Largest measuring 2* 1.3 cm.

PRESENT MEDICATIONCycle Of Inj . Cisplatin :-1st cycle - 30/12/15 3rd cycle - 12/1/162nd cycle - 6/1/16 4th cycle - 19/1/16

Inj Dexa 8 mg

Inj Rantac 50 mg

Inj granicip 3 mg

Inj KCl+inj MgSO4 in 1000cc NS IV over 24hrs

Inj mannitol 20% 100N IV over 15 mts

Inj Cisplatin 60 mg 500cc NS

RT

IVF 1000 cc NS IV over 4 hr

T . Dexa 4mg BD 1 day

T . Adiza 10 mg OD

T . Perinorm 10 mg TID

T Granicip 10 mg OD

3 days

PRESENT MEDICATIONBrand Name

Generic Name

ROA

dose freq13 14 15 16 17 18 19 20 21 22

Emeset Ondansetron

Po 4g TID

SypMucaineGel

Al(OH)3MgSO4

Po TID

T Dolo Paracetamol

PO 500mg

OD

T Tapentadol

Tapentadol

PO 100mg

OD

T Tim Vitamin c 100mg

BD

T . Perinorm

Metoclopramide

PO 10 mg

TID

Brand Name

Generic Name

ROA dose freq 23 24 25 26 27 28 29

Emeset Ondansetron

Po 4g TID

T Dolo Paracetamol

PO 500mg

OD

T Tapentadol

Tapentadol

PO 100mg

OD

T Tim Vitamin 100mg

BD

Brand Name

Generic Name

ROA

dose freq

12 13 14 15 16 17 18 19 20 21 22

T . Adiza Ilaprazole

PO 10 mg

TID

T. Dexa Dexamethasone

PO 4mg TID

T.Granicip

Granisetron

PO 1mg OD

Ensure Powder

Protein PO 2tsp TID

T Lorel Lorazepam

PO 2mg OD

AloveraCream

Emollient

PO BD

InjEmeset

Ondansetron

IV 4mg OD

Brand Name

Generic Name

ROA dose freq 23 24 25 26 27 28 29

T . Adiza Ilaprazole PO 10 mg TID

T.Granicip

Granisetron PO 1mg OD

Ensure Powder

Protein PO 2tsp TID

T Lorel Lorazepam PO 2mg OD

AloveraCream

Emollient PO BD

T . Perinorm

Metoclopramide

PO 10 mg TID

InjEmeset

Ondansetron

IV 4mg OD

Physiotherapy

Active cycle breathing technique

Segmental expansion exercise

Breathing exercise

ROM for jaws and neck - 10 reps * 3 sets *10days

3 reps * 10 days

S.O.A.P NOTESSUBJECTIVE: pain while swallowing of saliva

OBJECTIVE : physical examinationoral cavity examinationbiopsy and biopsy

Enhancing lesions on PF mucosa

Invasion to false cordCECT calcification within

the lesionEnlarged lymph nodes

ASSESMENT : Carcinoma Of Pyriform FossaPLAN :

Ulcerative and proliferative growth of PF Pooling of saliva Unhealthy mucosa Lymph node mobile

Goals of treatmentPain managementTo control abnormal growth of cellsTo improve the airway clearanceTo decrease secretion To improve the activities of daily lifeTo improve ROM of neck and jawProvide symptomatic relief and reduce anxiety.

Prevent complications and recurrences.

To reduce mortality and improve quality of life.

Treatment Plan:-• Concurrent Chemoradiation With Inj. Cisplatin (6 Cycle Of Inj . Cisplatin ) and

physiotherapy• Pain - Tapentadol, paracetamol,• Gastric disturbances - Ilaprazole, • Nausea and Vomiting - granisetron ,metoclopramide, ondansetron,

ranitidine.• Protein supplement• Anxiety - Lorazepam • Rashes and itching - alovera cream• Vitamins supplements• Inflammations - Dexamethasone• Edema - Mannitol• electrolyte balance - KCL and Mgso4

Cisplatin nephrotoxicity

F-Findings A-Assessment R-Resolution M-Monitoring

Cisplatin Nephrotoxic drug Administer rapidinfusions Mannitol, Mg supplements

Monitor for renal functions

Cisplatin Hyperuricemia Minimize effects with hydration, urinary alkalinization, and allopurinol

Monitor serum uric acid.

FARM Notes

Patient counselling

Drug counselling

Drug counselling

Cisplatin Instruct patient not to take any prescription or OTCmedications or dietary supplements unless advised by thehealth care provider.

Lorazepam Advise patient to avoid sudden position changes to preventorthostatic hypotension.

Anti histaminesand PPI

Take 30 mins prior to food.

Tapentadol Advice the patient not to take Tapentadol more thanprescribed dose.

Dexamethasone Instruct patient to avoid people with infections, particularlyrespiratory.

Disease counselling

Drink lots of water

Avoid alcohol consumption and smoking

Should maintain the body weight as normal.

Advise patient that frequent follow-up visits will be required to

monitor therapy, and to keep appointments.

Eat a diet with enough nutrients.