A 54-year-old man had a routine checkup and was found to have a right neck mass. He was referred for workup and treatment. Physical examination showed discrete redness and mucosal irregularity in the medial and lateral walls of the right pyriform sinus without changes at the apex. There was a 5-cm firm node, fixed to the sternocleidomastoid muscle, palpated in the right lower jugular area.

A biopsy from the right pyriform sinus showed moderately to well-differentiated squamous cell carcinoma. Stage: T1 N2a M0. The primary tumor, bilateral level II to IV, and retropharyngeal nodes were treated with lateral parallelopposed photon fields (Fig. 10.1). The inferior border was placed just above the shoulders to encompass the involved lower jugular node (wired). Since all disease was located on the right side, the fields were weighted 3:2 in favor of the right side. A total dose of 66.6 Gy was delivered to the isocenter, which resulted in a dose of 68 Gy to the primary and 72 Gy to the involved node in 7 weeks. Off-spinal cord reduction was made at 45 Gy. The posterior cervical nodes were supplemented with electrons to 54 Gy. The supraclavicular nodes were treated with an anterior appositional photon field to 54 Gy. Tissues directly posterior and inferior to the palpable node received additional irradiation to a cumulative dose of 63 Gy. Physical examination 6 weeks after completion of radiotherapy revealed a complete response at the primary site. In the neck, however, a 3-cm residual node was noted. Therefore, patient subsequently underwent a right neck dissection. He was alive and functioning well 2.5 years after therapy.

A 76-year-old man presented with a 10-month history of left-sided sore throat and otalgia. A 1.5-cm tumor was detected on the medial wall of the left pyriform sinus without extension to the apex. The larynx mobility was normal. A 1-cm lymph node was detected in level III in the left neck.

Biopsy of the primary tumor revealed moderately differentiated squamous cell carcinoma. Stage: T1 N1 M0. He was treated with 6 MV photons, with the primary tumor and upper and mid neck lymphatics as well as the retropharyngeal nodes encompassed in parallel-opposed fields (Fig. 10.2A). These portals received 42 Gy. An anterior supraclavicular and low neck field was matched on the skin and treated to 50 Gy. The upper fields were reduced off the spinal cord and continued to 54 Gy. An additional 12 Gy was delivered to coned-down portals to a final dose of 66 Gy. The off-spinal cord and boost fields were treated with parallel right anterior and left posterior oblique fields (Fig. 10.2B) to encompass the gross disease in the photon fields. The boost was preferentially weighted to the left. An isodose distribution through the central axis and primary tumor (T) and gross lymph node (N) is shown in Figure 10.2C. Both posterior cervical strips received 12 Gy supplement in six fractions with 9 MeV electrons, and then the left posterior strip received an additional boost of 12 Gy. The patient is without evidence of disease 2 years later.

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, biopsy of which showed squamous cell carcinoma. There was no clinical evidence of lymphadenopathy. He received concurrent radiation and chemotherapy. While bulky disease was seen filling the right pyriform sinus, the disease had significant superficial spread.

A PET-CT simulation was performed to assist in defining 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 Figure 10.3A. The 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 definition, as this slice was approximately 1 cm below the identified gross target volume.

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 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. The 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 having a T2 N1 M0 and treated with IMRT with three cycles of concurrent high-dose cisplatin.

CTV_HD (70 Gy) encompassed the primary tumor and involved node with margins, CTV_ID (60 Gy) the right posterior neck, and CTV_ED (56 Gy) the left neck (Fig. 10.4D). The ipsilateral hypopharyngeal wall down to the cricoid level was included in CTV_HD, right level III nodal region in CTV_ID, and left level III, and bilateral level IV, nodes in CTV_ED (Fig. 10.4E,F). Figure 10.4G shows the sagittal isodose distribution through the primary tumor. The patient had good function without evidence of disease 3 years after completing treatment.