Case report

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Introduction
Case Report
•Histopathological Examination showed Keratin pearls with pleomorphic squamous cells
show well inferring well differentiated Squamous cell carcinoma.(figure)
•USG neck showed Hypo echoic mass lesion of 5cm length involving the pharyngo-
esophageal junction.
•CT scan of Head , Neck and Chest showed circumferential irregular thickening with
heterogenous enhancement noted in the hypo-pharyngeal –oesophageal junction and enlarged
bilateral level 2 lymph nodes
Figure 5:CT scan showing heterogenous lesion in the posterior pharyngeal wall
•Well differentiated squamous cell carcinoma of hypopharynx ,T3 N 2c M0 with a group
staging IV A .
•She was planned to be treated with concurrent radio-chemotherapy with 70Gy/35# with
weekly cisplatin
DISCUSSION
• Proposed etio-pathogenic mechanisms for plummer vinsion syndrome include iron and
nutritional deficiencies, genetic predisposition, and autoimmunity.
• Iron defeciency anemia is the primary cause of dysphagia and not esophageal webs.
• The depletion of iron-dependent oxidative enzymes may produce myasthenic changes in
muscles involved in the swallowing mechanism, atrophy of the esophageal mucosa, and
formation of webs as epithelial complications
• Hence a complete panel of IDA which include S.iron ,S. Ferritin , TIBC , Reticulocyte
count . A test for Helicobacter pylori should be included .
• Celiac disease is commonly seen associated with the syndrome, hence investigations
should include anti-endomysial IgA and anti-tTG .
• PVS has also been viewed as an autoimmune phenomenon
• Treatment with iron supplementation usually produces complete resolution of the
dysphagia. Refractory cases require endoscopic esophageal dilation.
• In of diagnosed cases of Ca hypopharynx radiochemotherapy and surgery is the
treatment of choice.
• Multiple studies report that a low hemoglobin before or during radiation therapy is an
important risk factor for poor locoregional disease control and survival In diagnosed cases
of hypopharyngeal cancer , it is of importance to diagnose the cause of anemia
• Firstly red blood cell transfusion is considered . Transfusion goal is to maintain Hb 8-
10g/dl as needed for prevention of synptoms .
• Iron sucrose injection can be used to decrease the requirement of blood transfusions
• Post treatment use of oral iron supplements in absence of malabsorption is recommended
• Around 10%-20% of them develop second primary overt ime . It may be due to “field
cancerization “ like effect caused by iron defeciency anemia
CONCLUSION
•Pre treatment , treatment and post treatment hemoglobin values were found to be an
independent prognostic factor for loco-regional tumour control in head and neck cancers
•A radiation oncologist plays an important role in the diagnosis and treatment of the anemia
associated with plummer vinson syndrome and cancers associated with it.
Figure 3: Peripheral smear with microcytic hypochromic anemia
• No evidence of hepato-spleenomegaly on palpation
• Her initial evaluation with indirect laryngoscopy revealed ulcero-proliferative growth in
the posterior pharyngeal wall Biopsy from the ulcero-proliferative lesion in the posterior
pharyngeal wall was taken.
• Laboratory evaluation yielded anemia, with a hemoglobin level of 6.8gm/dl, hematocrit
of 29.1%, mean corpuscular volume of 62.7fl, mean corpuscular haemoglobin 14.7pg
and mean corpuscular haemoglobin concentration 23.4g/dl . TSH was within normal
limits
• Peripheral smear showed Microcytic hypochromic anemia with
anisopoikilocytosis(Figure 3)
Video Laryngoscopy (Figure 4)
HCG Hospitals, Bangalore
Sanjee.C1,Bhaskar.V1 ,Gurnani.R2, Yashaswini.S 1,Chundru.S 1.
1. Department of Radiation oncology ,2.Department of Pathology
Dysphagia in a middle aged woman .Was it a Plummer Vinson syndrome
with squamous cell carcinoma of hypopharynx ?- A case report
References:
1. NCCN Clinical Practice guidelines in Oncology – Cancer induced anaemia -2016
2. Perez and Brady’s , Principles and Practice of Radiation Oncology
• In India the incidence of hypo-pharyngeal cancers in women is 1:100,000 ..
• Plummer-Vinson syndrome is a rare disease defined by the classic triad of dysphagia,
iron-deficiency anemia and esophageal webs.
• It is considered relevant due increased risk of about 3%-15 %f squamous cell carcinoma
of hypopharynx and oesophagus .
• The exact incidence of Plummer Vinson syndrome is unknown.
• It was first described by Patterson and Kelly in 1919.
• A 35-year-old lady presented to the outpatient clinic with difficulty in swallowing solid
food which was gradually progressive, to reach the present stage, where she was
dependent on liquids since 1 year and easy fatigability since 6 months No medical or
surgical co-morbidities. Her menstrual and obstetric history is uneventful. No habit of
tobacco consumption
• Patient physically looked emaciated, severely dehydrated, pale and lethargic . She
weighed 45kg with a height of 155cm (BMI-18.73)
• Physical examination revealed Pallor, atrophic glossitis(fig no.1) angular stomatitis(fig
no.2) koilonychia ,dry skin, large volume pulse and tachycardia.
• Thyroid was normal.
Figure1: Angular stomatitis Figure 2 Angular stomatitis