Radium Implantation in Certain Growths of the Hypopharynx

Abstract

MALIGNANT growths of the hypopharynx present an unusual number of difficult therapeutic problems. Practically all being surgically inoperable, radiation therapy in some form becomes, of necessity, the only means of treatment. While most growths in this location fall within the general group of epidermoid carcinomas, they nevertheless vary widely in histologic structure, a fact which calls for considerable variation in the method and intensity of irradiation therapy for the individual case. Fortunately, they are as a group rather more radiosensitive than growths of similar histology in the oral cavity. In spite of this, the hypopharynx offers its own peculiar set of complicating factors. Hypopharyngeal growths are at best technically difficult of access. Close observation in some patients is difficult and trying; consequently, there is interference with proper cleansing during treatment procedures. Satisfactory and complete palpation is usually impossible—and palpation is frequently of greater value than direct visualization in determining the actual extent of an infiltrating growth. On account of the location, the processes of swallowing and breathing may be embarrassed; the former is usually hampered to some extent and often seriously. Breathing may be obstructed to the point of tracheotomy, while any ulcerating lesion in the hypopharynx increases the hazard of aspiration infection of the bronchial tree. For these reasons alone it is most important that swelling and local infection be avoided insofar as possible. If the cartilages of the hypopharynx become infected, or if infected material be transferred to depth in and about the tumor-bearing area, the inflammatory phase is not only intensified but prolonged. If the cartilages be unduly damaged by irradiation, this inflammatory phase is still further prolonged and intensified. Even though, under such conditions, primary healing without necrosis is obtained, the danger of secondary necrosis is much greater on account of the low grade infection remaining temporarily quiescent at depth in the tissues which have healed on the surface. In most instances retained infection is the inciting cause of secondary necrosis. The normal favorable reaction of tumor tissue to irradiation in any form is always discounted by infection. In the early days of irradiation therapy, when relative intensities were not as fully appreciated as now and when x-radiation was far less efficient, the hypopharyngeal growths were approached directly with radium in some form. Radium element needles had a limited sphere of application—apart from all other technical considerations it was impossible in the majority of instances to keep them in place for adequate and accurate dosage. Unfiltered radon seeds by direct implantation at that time gave better results. The local reactions, however, were most severe. Due to the beta and soft gamma radiation, necrosis was the rule rather than the exception.