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Case history

image A 62-year-old woman presented with an 8 week history of worsening sore throat. She had a medical history of migraine and primary sclerosing cholangitis. She was a non-smoker, drank alcohol occasionally and had a performance status of zero.

She was diagnosed with moderately differentiated squamous cell carcinoma of the hypopharynx, T2N0M0. To attempt organ preservation, the proposed management plan was radical chemoradiotherapy (65 Gy in 30 fractions and weekly cisplatin). The multidisciplinary team did not consider localized resection an appropriate option. Before starting treatment the patient underwent dental, nutritional, and speech and language assessments; a gastrostomy tube was also inserted.

During treatment she developed typical side effects of oral mucositis, odynophagia and subsequent dysphagia. Her weight decreased and she became dependent on the gastrostomy tube for all her nutritional and fluid requirements.

Two weeks after completion of treatment she was reviewed by a clinical nurse specialist, dietitian, and speech and language therapist. They advised introducing liquids orally and progressing to a soft diet as soon as possible. The patient struggled with this due to ongoing mucositis and pain. At 6 weeks her symptoms were improving but she still could not swallow. Flexible nasendoscopy showed minimal oedema, but videofluoroscopy demonstrated a stricture and aspiration. An MRI scan 12 weeks after treatment showed a good response and no visible residual tumour.

Improvement over subsequent months was slow, however, and the patient remained completely dysphagic. Several failed attempts were made by ENT and interventional radiology to dilate the cricopharyngeal stricture. An MRI scan 12 months after treatment showed ongoing, significant oedema, and the patient was referred for a second opinion regarding stricture dilation. With successful serial balloon dilations over several months, slow improvements in her swallow were observed. Videofluoroscopy performed by the speech and language therapist 18 months after treatment showed the patient was no longer aspirating and could safely swallow all consistencies. After a further 6 months of intensive support from the dietitian, speech and language therapist, clinical nurse specialist, oncologist and ENT surgeon she was able to have her gastrostomy tube removed, 2 years after completion of treatment. She remained free of disease recurrence and was able to maintain her weight with oral nutrition and continue on routine follow-up.

What was the goal of cancer treatment for this patient?

What is the evidence base for her treatment options?

What interventions help maintain nutritional intake during chemoradiotherapy for head and neck cancer patients?

What head and neck radiotherapy complications can occur and how are they managed?

How did an integrated care team benefit her during and after treatment?

What was the goal of cancer treatment for this patient?

The goals of treatment for a T2N0M0 squamous cell carcinoma of the hypopharynx are cure and organ function preservation, providing the patient is fit enough to undergo concurrent chemoradiotherapy. The side effects expected with radical treatment are substantial and often lead to deterioration or complete loss of swallow ...

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