Table 1.Hypopharyngeal cancer TNM staging according to the American Joint Committee on Cancer (AJCC).
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\\n\\nIntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
\\n\\nLaunching 2021
\\n\\nArtificial Intelligence, ISSN 2633-1403
\\n\\nVeterinary Medicine and Science, ISSN 2632-0517
\\n\\nBiochemistry, ISSN 2632-0983
\\n\\nBiomedical Engineering, ISSN 2631-5343
\\n\\nInfectious Diseases, ISSN 2631-6188
\\n\\nPhysiology (Coming Soon)
\\n\\nDentistry (Coming Soon)
\\n\\nWe invite you to explore our IntechOpen Book Series, find the right publishing program for you and reach your desired audience in record time.
\\n\\nNote: Edited in October 2021
\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/132"}},components:[{type:"htmlEditorComponent",content:'With the desire to make book publishing more relevant for the digital age and offer innovative Open Access publishing options, we are thrilled to announce the launch of our new publishing format: IntechOpen Book Series.
\n\nDesigned to cover fast-moving research fields in rapidly expanding areas, our Book Series feature a Topic structure allowing us to present the most relevant sub-disciplines. Book Series are headed by Series Editors, and a team of Topic Editors supported by international Editorial Board members. Topics are always open for submissions, with an Annual Volume published each calendar year.
\n\nAfter a robust peer-review process, accepted works are published quickly, thanks to Online First, ensuring research is made available to the scientific community without delay.
\n\nOur innovative Book Series format brings you:
\n\nIntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
\n\nIntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
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\n\nBiomedical Engineering, ISSN 2631-5343
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\n\nDentistry (Coming Soon)
\n\nWe invite you to explore our IntechOpen Book Series, find the right publishing program for you and reach your desired audience in record time.
\n\nNote: Edited in October 2021
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Kasai",coverURL:"https://cdn.intechopen.com/books/images_new/7552.jpg",editedByType:"Edited by",editors:[{id:"29226",title:"Dr.",name:"Minobu",surname:"Kasai",slug:"minobu-kasai",fullName:"Minobu Kasai"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10896",title:"Integrative Advances in Rice Research",subtitle:null,isOpenForSubmission:!1,hash:"47659401ffe512c28313440110c0a903",slug:"integrative-advances-in-rice-research",bookSignature:"Min Huang",coverURL:"https://cdn.intechopen.com/books/images_new/10896.jpg",editedByType:"Edited by",editors:[{id:"189829",title:"Dr.",name:"Min",surname:"Huang",slug:"min-huang",fullName:"Min Huang"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"63055",title:"Red or Blue? Gold Nanoparticles in Colorimetric Sensing",doi:"10.5772/intechopen.80052",slug:"red-or-blue-gold-nanoparticles-in-colorimetric-sensing",body:'\nA molecular sensor (or chemosensor) is a molecule or molecular ensemble designed to indicate the presence of a specific analyte through a detectable change in a macroscopic measurable signal. Molecular sensors are generally composed of two main elements: a recognition unit, which selectively interacts with the molecule or ion to be detected, and a signaling unit that is responsible of generating a macroscopically measurable signal (optical, electrochemical, mechanical…) upon the molecular recognition event. In general, in a chemosensor, the receptor binds the target analyte in a reversible manner. If the recognition event takes place through an irreversible chemical reaction, the chemosensor is better described as “probe.” The transduction mechanism, which is the mechanism by which the chemical interaction between the analyte and the recognition unit is converted into a change in the macroscopic signal of the signaling unit, will depend on the type of signaling unit and the structure of the receptor.
\nThe use of chemosensors or probes for the colorimetric detection of small biologically active molecules offers some advantages over traditional instrumental analytical methods. Chromogenic probes are usually cheap, easy to use, and do not require of expensive instrumentation, and very often, the presence of the analyte can be detected by the naked eye, which allows for rapid
Among the different approaches for colorimetric sensing, the use of gold nanoparticles (AuNPs) as scaffolds and signaling units for the construction of molecular sensors has attracted enormous interest for several reasons: They can be easily synthesized from Au(III) salts in various sizes and shapes. Their surface can be functionalized with a wide range of thiol- or disulfide-terminated organic ligands, by ligand exchange reactions, through the formation of strong Au–S bonds, leading to stable colloidal suspensions in water or organic solvents (depending on the ligand). Finally, gold nanoparticles have remarkable optoelectronic properties. In particular, the localized surface plasmon resonance (SPR) gives rise to a strong absorption band in the visible region. This SPR band is influenced not only by the size and shape of the nanoparticles but also by the dielectric properties of the environment and the proximity of other nanoparticles [1, 2]. This last property is the basis for colorimetric assays using AuNPs. Thus, analyte-triggered aggregation of AuNPs results in an important bathochromic shift of the SPR band (from ca. 520 to ca. 650 nm) and a change in the color of the colloidal solution from red (dispersed) to blue (aggregated) due to interparticle surface plasmon coupling (Figure 1). Moreover, AuNPs have very high molar extinction coefficients (ε) (ca. 108–109 M−1cm−1 for AuNPs with diameters between 10 and 50 nm), which confers this sensing method a great sensitivity. In fact, the color change associated to the aggregation process can be observed by naked eye even at nanomolar concentration [3, 4].
\nAnalyte-induced aggregation of gold nanoparticles with concomitant changes in the color of the colloidal suspensions.
The main challenge in the design of colorimetric sensors with AuNPs is the election of the recognition units to be attached onto the surface of the nanoparticles and the nature of the molecular interaction leading to the aggregation process.
\nA large number of target analytes (metal ions, anions, small organic molecules, or large biomolecules) have been detected using functionalized AuNPs as colorimetric probes. However, in this chapter, the discussion has been limited to the use of functionalized spherical gold nanoparticles for the detection of small molecules with biological activity, such as neurotransmitters, nerve agents, pesticides, and biologically relevant carboxylates.
\nAmong the neurotransmitters, biogenic amines (BA) are of particular interest due to their impact in areas ranging from biomarkers of specific diseases [5, 6, 7] to quality control of foodstuffs [8, 9]. Nitric oxide (NO) is also very important neurotransmitter in the central, peripheral, and enteric nervous systems (ENS) [10, 11].
\nDopamine, the simplest biogenic catecholamine (CA), is an important neurotransmitter of the central and peripheral nervous systems [12]. An approach for the colorimetric detection of dopamine has been developed using 4-amino-3-hydrazino-5-mercapto-1,2,4-triazol functionalized AuNPs (Figure 2). Dopamine induced the aggregation of the AuNPs through hydrogen bonding interactions [13]. Each dopamine molecule has three H-donor groups, which are able to form hydrogen bonds (the amino and both hydroxyl groups). On the other hand, the 4-amino-3-hydrazino-5-mercapto-1,2,4-triazol presents two hydrogen bond acceptors that can interact with the target molecule, inducing aggregation with the concomitant color change. Epinephrine, norepinephrine, and isoprenaline were tested as possible interferants. The three compounds showed lower responses than dopamine.
\nDopamine detection using triazol functionalized AuNPs.
Following the same approach, several functionalized AuNPs have been reported [14, 15, 16] for dopamine detection in biological media. This neurotransmitter has also been detected using unmodified citrate-capped gold nanoparticles [17]. A net of hydrogen bonds among dopamine molecules and dopamine with citrate is responsible for the aggregation of the nanoparticles (Figure 3). Selectivity toward dopamine is achieved by modifying nanoparticle size.
\nMode of interaction and colorimetric response of AuNPs with four different particle sizes against catecholamines (CAs). Experimental conditions: CCAs = 4 μM, CNaCl = 14 mM, pH = 7.0, and incubation time: 10 min. NP1: 13 nm AuNPs; NP2: 23 nm AuNPs; NP3: 32 nm AuNPs; and NP4: 43 nm AuNPs.
Serotonin (5-hydroxytryptamine, 5-HT) is a neurotransmitter that plays a key role in the regulation of various biological functions. 5-HT has been used as a biomarker to detect the presence of carcinoid tumors. A selective and sensitive probe based on AuNPs for detecting serotonin has been reported [18]. In this case, AuNPs were bi-functionalized with dithiobis(succinimidyl propionate) (DSP) and with
Detection of serotonin with DSP and NALC functionalized AuNPs.
Nitric oxide (NO) is one of the gaseous neurotransmitters. NO is generated in the nitric oxide synthase catalyzed oxidation of L-arginine to L-citrulline and is involved in a variety of important biological processes. For example, it stimulates the production of cyclic guanosine monophosphate (cGMP) which acts as a second messenger. In addition, nitric oxide is released by some neurons that innervate the gastrointestinal tract, penis, respiratory passages, and cerebral blood vessels. Nitric oxide is also released as a neurotransmitter in the brain and has been implicated in the processes of learning and memory. Detection of this gas has been carried out using functionalized AuNPs that aggregates through NO-induced “click” reaction [19]. To detect the analyte, both azide- and terminal alkyne-functionalized gold nanoparticles were synthesized.
\nThe sensing mechanism is shown in Figure 5. The initial aqueous solution containing a mixture of azide- and terminal-alkyne functionalized AuNPs remains dispersed in the presence of Cu(II), with its characteristic red-wine color. When NO is added to the solution, Cu(II) is reduced to Cu(I), and then, the “click” reaction between azide and alkyne-terminated nanoparticles takes place, giving rise to the nanoparticles aggregation with the subsequent change in the color of the solution.
\nMechanism for detecting NO with a mixture of azide and alkyne functionalized AuNPs.
The current rise in international concern over the use of chemical warfare (CW) agents in different conflictive sceneries has resulted in an increasing interest in the detection of these lethal chemicals. Among CW species, nerve agents are greatly dangerous and their high toxicity and easy production underscore the need to detect these deadly chemicals via quick and reliable procedures. AuNPs have been used as sensors for some nerve agent simulants with good results. Different sensing mechanisms have been used for detecting these compounds, for example, compensation of charges has been applied for this process [20]. The designed sensing protocol takes advantage of the nucleophilic reactivity of pyridine moieties toward nerve gases [21]. This reactivity generates positive charges on the surface of the gold nanoparticles, diminishing their colloidal stability and inducing aggregation (Figure 6).
\n(a) Nerve agent Tabun and its mimic DCNP (b) Proposed mechanism for the colorimetric detection of DCNP. (c) Pyridine derivative used as recognition unit.
Several pyridine derivatives were studied, and their ability to act as probes for DCNP detection was evaluated by UV-vis spectroscopy. After addition of increasing amounts of DCNP, the intensity of the surface plasmon peak of the monodispersed AuNPs at 526 nm decreased and a new peak at c.a. 660 nm appeared as the AuNP clusters were formed. The best results were obtained with compound
Following the same approach, compound
Mechanism of positive charge generation upon reaction of DCNP with AuNPs functionalized with compound 2.
Also, triarylcarbinols have been used as recognition motifs. These compounds can be converted into their corresponding carbocations in the presence of nerve agent simulants through phosphorylation of the OH group followed by SN1 elimination. Consequently, AuNPs functionalized with this type of compounds have been used in detecting simulants of these dangerous compounds (Figure 8, X = F, CN) [22].
\n(Left) AuNPs functionalized with triarylcabinols for detecting nerve agent simulants. (Right) Color change observed on the solution in DMF upon addition of the simulants. UV-vis spectra of the triarylcarbinol functionalized AuNPs on addition of increasing amounts of DCNP expressed mg/m3. Insets: Plots A640/A526 vs. DCNP and DFP concentration, respectively.
An approach based on enzymatic reactions has also been described for detecting nerve agents GB, GD, and VX and the highly toxic pesticide paraoxon (Figure 9). The prepared sensor showed high sensitivity [23].
\nStructures of nerve agents GB, GD, and VX, and pesticide paraoxon.
In this method, thiocholine (TCh), which is generated from S-acetylthiocholine (ATCh) through acetylcholinesterase (AChE) enzymatic hydrolysis, induces aggregation of AuNPs stabilized with lipoic acid. When the analytes are present in the solution, the production of TCh is suppressed, and a disaggregation of the particles is observed with a change of color from blue to red (Figure 10).
\nSensing mechanism based on AChE inhibition.
Neither AChE nor ATCh can induce aggregation of the AuNPs stabilized with lipoic acid, whereas TCh is capable of producing this process. The analytes inactivate AChE via nonreversible phosphorylation even with very low concentrations. In consequence, ATCh cannot be hydrolyzed which inhibits the aggregation. Limits of detection are in the pM range and the system can be used in complex matrices such as in apple juice.
\nOther dangerous pesticides have been detected using AuNP-based colorimetric aptasensors [24]. The sensing mechanism is summarized in Figure 11. Aptamers (organophosphorous pesticide aptamers in this case) are able to be adsorbed on the surface of gold nanoparticles through coordination between Au and N atoms in DNA bases. When salt is added, this adsorption gives rise to stable dispersions of gold nanoparticles with the characteristic red color. However, in the presence of the analytes, the aptamers desorb from the surface of the AuNPs, giving rise to the aggregation process with the concomitant change of color. Because double-stranded DNA is not adsorbed by gold, single-stranded DNA was used in these experiments. Although the sensitivity of these assays is not high enough, this design shows a new approach for preparing sensors based on gold nanoparticles.
\nSensing mechanism using aptamers.
Detection of dicarboxylates is very important, since some of them have critical roles in the most important metabolic cycles of living organisms. Specifically, succinate plays a fundamental role in processes, such as the Krebs cycle and oxidative phosphorylation. It is an inhibitor of mitochondrial lipid peroxidation, preventing or delaying most of the damage caused by the peroxidation on different mitochondrial structures and functions. For all these reasons, it is of interest to detect this compound. Among the different strategies used in designing sensors for these compounds, functionalized gold nanoparticles have shown interesting applications [25].
\nThe sensing protocol, in this case, is related to the well-known interaction between the carboxylate and thioureas groups. For this reason, AuNPs containing thiourea groups were prepared, and their behavior in front of different dicarboxylates was evaluated. Among the different dicarboxylates studied (oxalate (
Detection of succinate.
Following a similar approach, maleate and fumarate were distinguished [26, 27]. Compound
(Left) Ligand used to cap gold nanoparticles for detection of fumarate. (Right) Color changes of an aqueous solution of AuNPs capped with
Pyruvic acid (2-oxopropanoic acid, PA) is the simplest alpha-keto acid. It plays important roles in several biochemical pathways. For example, it supplies energy to cells through the citric acid cycle when oxygen is present and under hypoxic conditions produces lactate. It also appears as an intermediate in several metabolic processes such as the glycolysis of glucose or the synthesis of carbohydrates or fatty acids. Gold nanoparticles have proved to be useful for detecting this acid [28]. The approach, in this case, is also based on the use of unmodified AuNPs and Cytidine-rich oligonucleotides (C-rich DNA). C-rich DNA can fold into one closely packed four-stranded structure called i-motif [29] through protonated cytosine-cytosine (C-C+) base-pair formation under slightly acidic conditions. The principle of the designed PA sensor is similar to that previously indicated in Figure 11. The rigid i-motif structure is unable to stabilize gold nanoparticles, but when a change of pH is induced in the medium from acid to neutral, the C-rich DNA changes its structure and prevents gold nanoparticles aggregation. The change in pH is induced by the addition of PA and pyruvate decarboxylase (PDC). The enzyme transforms PA into acetaldehyde and CO with the corresponding change of pH from acid to neutral. At neutral pH, the C-rich DNA presents its extended single-stranded structure and effectively binds to AuNPs, stabilizing them against NaCl-induced aggregation. Based on this principle, PA can be selectively detected by the color change of the AuNPs (Figure 14).
\n(Left) Mechanism for pyruvic acid detection. (Right) UV-Vis spectra of the AuNP suspensions (3 nM) containing C-rich DNA after incubation with (b) 5.6 mM PA, (c) 16.8 mM PA, (d) 5.6 mM PA + PDC, (e) 16.8 mM PA + PDC, and (f) PDC only; curve (a) is the background signal (reproduced with license number Reprinted with permission from Li et al. [
UV-Vis spectra were recorded to demonstrate the proposed sensing mechanism. Solutions of AuNPs (3 nM) containing C-rich DNA showed a maximum absorption peak centered at 520 nm. After addition of PA, the changes induced in the absorption band depend on the acid concentration. At 5.6 mM, a hypochromic effect was observed, but at 16.8 mM, a bathochromic shift can be observed from 520 to over 600 nm with the corresponding change of color. After addition of PCD, the disaggregation is produced and the solution recovers its red color. Selectivity against lactic acid, ascorbic acid, and glucose was established, and the limit of detection determined was 3.0 mM.
\nAscorbic acid (AA, also known as vitamin C), an antioxidant compound, is present not only in biological fluids but also in foodstuffs and pharmaceuticals. Taking into account the red-ox properties of ascorbic acid, an approach using gold nanoparticles and Cr(VI) has been described for its detection [30]. Gold nanoparticles were stabilized with sodium tripolyphosphate (Na5P3O10), and the sensor was prepared using this AuNPs and Cr (VI) salts. As Cr(VI) exists in the form of HCrO4–, CrO42–, or Cr2O72–, there is an electrical repulsion with tripolyphosphate that precludes the nanoparticles aggregation. By contrast, Cr(III), a hard lewis acid strongly coordinates to the polyphosphate ligand, giving rise to the charges compensation and in consequence the nanoparticles aggregation (Figure 15). Ascorbic acid is able to trigger the process by reducing Cr(VI) to Cr(III). Selectivity studies were carried out with PO43–, Zn2+, Cu2+, SO42−, Ni2+, Li+, Na+, Mg2+, Br–, NO3–, glucose (Glu), citric acid (CA), and oxalic acid (OA) as interferences, and no appreciable changes were observed with any of the studied compounds. The limit of detection determined for this method was 0.15 μM.
\nDetection of ascorbic acid (AA).
Finally, also amino acids have been detected using functionalized gold nanopaticles. Thus, tyrosine (Tyr) was detected using N-acetyl-L-cysteine modified gold nanoparticles [31]. In this case, the chiral ligand N-acetyl-L-cysteine (NALC) was chosen to include chirality in the sensors and study its use in selective recognition and separation of enantiomers.
\nThe chiral selectivity is attributed to a chemical interaction between chiral NALC–Au NPs and L-Tyr at the molecular level as is shown in Figure 16. Tyr interacts with the ligand NALC through hydrogen bonds that involve carboxylic, amino, and hydroxyl groups. The selectivity response may be attributed to the conformation of L-Tyr that seems to be more appropriate for forming the complex with NALC.
\n(Left) Interaction between tyrosine and N-acetyl-L-cystein capped gold nanoparticles. (Right) Chyral selectivity showed by the sensor. Reprinted with permission from Su et al. [
The use of gold nanoparticles for the preparation of colorimetric sensors is a very active field. The changes in the color of colloidal gold nanoparticles in solution because of the change in the surface plasmon absorption band upon aggregation or disaggregation processes can be easily used to transform the molecular recognition event into a macroscopic measurable signal. This change from red to blue can be observed by the nacked eye, allowing in this way cheap and easy detection of the target analytes. In this chapter, different mechanisms for the direct or indirect analyte-triggered aggregation of the AuNPs have been considered, including chemical reactions, supramolecular interactions, or changes in the pH of the medium. The selectivity observed in the sensing response in some cases depends on the conformation or configuration of the analyte, but also it can be achieved by using enzymes that catalyze specific reactions or aptamers able to interact with an analyte. Reactions induced by the analyte have also been explored, for example based on redox transformations. Taking into account the interesting photophysical properties of the gold nanoparticles, their easy functionalization, the use of aqueous solutions, and the detection by naked eye, we can conclude that the red or blue question will continue to be very present in the molecular sensing field.
\nCancer is still a major problem of modern medicine. Research continues trying to understand the tumor biology mechanisms as well as to find new methods of effective treatment [1]. The hypopharynx is a crossroad in the upper part of the digestive and respiratory pathways and malignant appearance at this level leads to the impairment of two vital functions, breathing and feeding. It also affects speech. Therapy of this pathology creates disability for the patient under economic, social, psychological and medical aspects. Therefore, we can advocate that hypopharyngeal cancer is one of the most challenging cancers pathologies regarding location, evolution, prognosis and functional implications. Therapy of hypopharyngeal cancer is a difficult endeavor for both physician and patient and requires a multidisciplinary approach: ENT surgeon, oncologists, radiologists, vocal rehabilitation specialist, psychologist and nutritionist.
The primary purpose of the oncology management of aero-digestive malignant neoplasms is survival. Nevertheless, preserving respiratory, deglutition and speech functions are mandatory if oncology principles are not broken.
The survival rate for hypopharyngeal cancer is low despite advanced surgical techniques, radiotherapy and chemotherapy. Patients go for medical examination in advanced stages of the disease when the tumor already exceeds the mucous layer and causes cervical lymph node metastases, thus being a challenge for the medical oncology team. Hypopharyngeal cancer management requires the presence of experienced surgeons within trained oncology surgery teams due to the radical surgical therapy aimed to locally control this type of cancer. Oncology radicality overcomes the principle of function preservation which is sometimes impossible to achieve.
The pharynx is a muscular-fibrous organ that belongs to the upper aero-digestive tract. It is located anteriorly to the cervical spines and posteriorly to the nasal fossae, oral cavity and larynx with which it communicates at different levels.
From a topographical perspective the pharynx is divided into 3 segments:
superior segment – the rhinopharynx (also known as nasopharynx, epipharynx or cavum) communicates anteriorly with the nasal fossae through the two choanae.
middle segment – the buccopharynx (also known as oropharynx or mesopharynx) communicates anteriorly with the oral cavity.
inferior segment – the hypopharynx (also known as laryngopharynx) communicates with the larynx, extends from the upper junction with the oropharynx at the level of the hyoid bone, and is continued inferiorly with the cervical esophagus. Hypopharyngeal cancer can occur at the site of the lateral walls, piriform sinuses, posterior wall and the retro-cricoid region. The anterior wall consists of the base of the tongue, supraglottic larynx and the posterior blade of the cricoid cartilage. The lateral walls join with the outer limits of the larynx to create two grooves, the piriform sinuses, through which fluids and food pass towards the mouth of the esophagus. The hypopharynx is shaped as a three-walled pyramid (anterior, lateral, medial) with the base located up at the pharyngoepiglottic fold and the free edge of the aryepiglottic fold, and the tip located below the cricoid cartilage. The upper lateral limit of the piriform sinus is considered an oblique line on the pharyngeal lateral wall in opposition to the aryepiglottic fold. The relations of the piriform sinus with the larynx explain why malignant tumors of the hypopharynx invade the larynx early and require surgical resections by partial or total laryngectomies. The posterior wall of the hypopharynx has a close relationship with the retropharyngeal space, the prevertebral fascia, the longitudinal spinal muscles (the long muscle of the head) and has a width of 4 cm–5 cm and a height of 6 cm–7 cm. The distance between the posterior pharyngeal wall and the vertebral bodies is no greater than 1 centimeter, therefore the submucosal protrusions caused by osteophytes or by the anterior edges of the vertebral bodies can be misinterpreted as submucosal tumors. In addition, tumors of the posterior wall of the hypopharynx can invade these prevertebral soft tissues. Between the prevertebral aponeurosis and the posterior pharyngeal and esophagus wall there is a loose cellular tissue that allows surgical and approach and detachment of the two regions. From a surgical perspective, a tumor located in the retro-cricoid region that invades the upper esophageal sphincter raise special problems. Therefore, the anterior wall of the retro-cricoid region is also called “party wall”. The retro-cricoid region extends from the portion immediately below the arytenoids to the upper esophageal sphincter and forms the posterior wall of the larynx in the lower region. The anatomical relations explain the extension of the tumors of the post-cricoid region to the recurrent nerve, the paratracheal lymph nodes, the thyroid gland, the common carotid artery with its terminal branches and to the vagus nerves.
From inside out, in a cross-section, the pharyngeal wall is made out of four layers: the lining mucosa represented by a multi-layered squamous cell epithelium, a fibrous stroma developed from the pharyngeal aponeurosis, the muscular layer formed by the pharynx constrictor muscles arranged circularly and the lifting muscles arranged longitudinally and the buccopharyngeal fascia located on the outside. The constrictor muscles are superior, middle and inferior. The middle and inferior constrictor muscles surround the lateral and posterior walls of the hypopharynx that continue inferiorly with the walls of the cervical esophagus. Anteriorly, the posterior cricoarytenoid muscle represents the muscular layer. Below the hyoid bone, where the middle and lower constrictor do not cross, there is a weak point of the pharyngeal lateral wall represented by the thyrohyoid membrane, which is passed through by the vessels, nerves and lymph vessels of the hypopharynx.
The pharyngo-esophageal junction, also known as “Killian’s mouth of the esophagus”, makes the transition between the hypopharynx and the cervical esophagus. The difficulty of diagnosing pharyngo-esophageal junction cancer is variable depending on the circumstances of appearance and development of the malignant neoplastic lesion at this site.
The branches of the external carotid artery provide the arterial supply. Venous drainage is achieved through the facial vein and pterygoid plexus to the internal jugular vein. Lymphatic circulation drains lymph from the hypopharynx to the jugular lymph nodes. The submucosal layer of the hypopharynx contains a rich lymphatic network that exits superiorly through the thyro-hyoid membrane to reach the superior and middle jugular lymph nodes and the inferior lymphatics drain into the paratracheal and middle jugular lymph nodes.
The hypopharynx is an essential organ in assuring breathing, swallowing and speech. Tumors located at this level can cause swallowing and breathing impairment, both by the mass effect (large tumors) and/or by edema caused by the lymphatic invasion. Tumor invasion of neural structures can cause pharyngeal muscle contraction impairment or intense pain with negative effects on the swallowing process and the quality of life of the patients [2].
Damage to the arytenoid cartilages or recurrent nerves by malignant neoplasia invasion can cause major respiratory impairment with tracheobronchial aspiration phenomena by paresis of the vocal cords. Peritumoral infections can cause impaired swallowing [3, 4].
The epidemiology of the hypopharyngeal and cervical esophageal cancer deals with the spread of the disease in the human population regarding sex, age, profession, time and space, as well as risk factors that contribute to these phenomena [5, 6].
The main factors involved in the occurrence of this type of cancer are chronic smoking and alcoholism. The risk of cancer occurrence is directly proportional to the ingested dose and alcohol concentration. The average age of onset is between 60 and 65 years, more common in men with a sex ratio of 5:1 men to women. The general tendency of the hypopharyngeal and cervical esophageal cancer is that of increased incidence, due to increased tobacco and alcohol consumption. Increased mortality is also associated with late diagnostic of hypopharyngeal and cervical esophageal cancer. 77.3% of patients are diagnosed with stage 3 or 4 upon admittance to the hospital [7, 8].
Usually, due to the anatomic relation between the site of the hypopharyngeal and cervical esophageal cancer, the two are studied together. Tumor lesions invade both regions at the time of diagnosis, which is usually in the late stages. At the beginning of the 21st century, hypopharyngeal and cervical esophageal cancer is still a major concern worldwide [8].
Piriform sinus location accounts for 85% of cases of hypopharyngeal cancer, 15% affect the posterior wall and the retro-cricoid region. The incidence of hypopharyngeal cancers varies from country to country and sometimes from region to region within the same country. The location of the tumor also differs from country to country and is closely related to the etiology factors involved. Hypopharyngeal and esophageal cancers are more common in countries with low social and economic standards and low education levels [3].
The hypopharynx is lined entirely by a malpighian epithelium, so most cancers at this level are differentiated malpighian carcinomas (squamous cell carcinoma). However, hypopharyngeal cancer raises special problems for both pathologists and therapists due to its peculiarities, the way it spreads and the macro-microscopic aspects.
From a macroscopic point of view, the hypopharynx may present two different forms of malignant tumors that are distinguished by their way of extension and prognosis. The ulcero-infiltrative form is most common and is characterized by invasion of the mucosa with more or less deep destruction of adjacent structures. The extension pathways mainly depend on the starting point of the tumor and the greater or lesser resistance of the encountered structures. The diffuse form with extension to the surface has a vegetative aspect being difficult to differentiate from an inflammatory type mucosa. This form develops on the surface without affecting the deep tissues being a carcinoma isolated to the mucosa but with distant spreading, affecting all or only parts of the epithelium of the hypopharynx. It is frequently associated with areas of infiltrative carcinoma and with more or less extensive areas of dysplasia and leucoplakia. There are other forms of cancer at this level with fairly well defined macroscopic and microscopic features: epithelial sarcoma (well-circumscribed tumor, pediculate, with minimal implantation surface, located especially in the membranous part of the piriform sinus and in the retro-cricoid region), wart-like carcinoma or malignant villous keratosis (rare, lymphophilic form, slow evolution, high chemosensitivity), adenoid malpighian carcinoma (muriform appearance, extremely rare, it can be found in the hypopharyngeal adenocarcinomas, non-Hodgkin’s malignant lymphomas, melanomas).
Tumor dissemination is achieved through direct local extension, lymphatic or hematogenous pathways. Finding the primary site and the pathway of dissemination is essential for the management of these tumors. Hypopharyngeal cancer is very rarely detected in the initial stage due to lack of symptoms.
Regarding local dissemination, tumors of the piriform sinus are located in its anterior angle from where the extension is made to the external and internal walls towards: 1. the internal wall of the sinus, from where it extends through the larynx (it is difficult to establish the pharyngeal or laryngeal origin of the tumor); 2. the lateral wall of the hypopharynx, from where it extends anteriorly to the anterior angle of the piriform sinus and the pharyngo-epiglottic fold, then to the thyroid cartilage and soft tissues of the anterior and superior cervical region to the lateral wall of the oropharynx.
The most important dissemination route is lymphatic. Lymph node invasion is present in 75% of patients at the time of diagnosis, detectable by palpation or imaging studies. For 10% of patients, lymph node involvement is bilateral from the time of presentation. Malignant tumors of the piriform sinus, lateral wall and posterior wall of hypopharynx usually spread towards the middle internal jugular lymph nodes. Tumors of the retro-cricoid region spread to the paraoesophageal, paratracheal and supraclavicular fossa [3].
Distant site metastases are common. Patients with advanced cervical lesions and lymph node invasion are prone to develop distant site metastases to the lungs, liver, bones and brain.
According to the American Joint Committee on Cancer (AJCC), the TNM staging of carcinomas originating in the hypopharynx is as follows (Table 1) [9].
AJCC Stage | Stage grouping | Stage description 2 cm = about 4/5 inches; 4 cm = 1.5 inches; 6 cm = about 2.3 inches |
---|---|---|
The tumor is located only in the top layer of cells lining the inside of the hypopharynx and has not grown any deeper (Tis). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0). | ||
The tumor has grown deeper, but it is only in one part of the hypopharynx, and it is no more than 2 centimeters (cm) across (T1). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0). | ||
The tumor has grown into more than one part of the hypopharynx, OR it has grown into a nearby area, OR it is larger than 2 cm but no larger than 4 cm across and has not affected the vocal cords (T2). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0). | ||
The tumor is larger than 4 cm across, OR the tumor is affecting the movement of the vocal cords, OR the tumor has grown into the esophagus (T3). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0). | ||
OR | ||
The tumor can be any size and might or might not have grown into structures outside the hypopharynx, and it might or might not have affected a vocal cord (T1 to T3). The cancer has spread to a single lymph node on the same side of the neck as the tumor, which is no larger than 3 cm across (N1). The cancer has not spread to distant parts of the body (M0). | ||
The tumor has grown into the thyroid or cricoid cartilage, the hyoid bone, the thyroid gland, or nearby areas of muscle or fat. This is also known as a The cancer has not spread to nearby lymph nodes (N0), or it has spread to a single lymph node on the same side of the neck as the tumor, which is no larger than 3 cm across (N1). The cancer has not spread to distant parts of the body (M0). | ||
OR | ||
The tumor can be any size and might or might not have grown into structures outside the hypopharynx (as far as a moderately advanced disease), and it might or might not have affected a vocal cord (T1 to T4a). The cancer is N2: It has spread to a single lymph node on the same side of the neck as the tumor, which is larger than 3 cm but no larger than 6 cm across, OR It has spread to more than one lymph node on the same side of the neck as the tumor, none of which is larger than 6 cm across, OR It has spread to at least one lymph node on the other side of the neck, none of which is larger than 6 cm across. The cancer has not spread to distant parts of the body (M0). | ||
The tumor is growing into the area in front of the spine in the neck, surrounds a carotid artery, or is growing down into the space between the lungs. This is also known as a The cancer might or might not have spread to nearby lymph nodes (any N). It has not spread to distant parts of the body (M0). | ||
OR | ||
The tumor can be any size and might or might not have grown into structures outside the hypopharynx, and it might or might not have affected a vocal cord (any T). The cancer has spread to at least one lymph node that is larger than 6 cm across, OR it has spread to a lymph node and then grown outside of the lymph node (N3). It has not spread to distant parts of the body (M0). | ||
The tumor can be any size and might or might not have grown into structures outside the hypopharynx, and it might or might not have affected a vocal cord (any T). The cancer might or might not have spread to nearby lymph nodes (any N). The cancer has spread to distant parts of the body (M1). |
Table 1.Hypopharyngeal cancer TNM staging according to the American Joint Committee on Cancer (AJCC).
Hypopharyngeal cancer is asymptomatic in the early stages, which is why most patients refer to a doctor in the advanced stages of the disease. The clinical examination corroborated with the paraclinical investigations contribute to positive and differential diagnosis. Histopathological examination is mandatory.
In early-stage tumors, symptoms are non-specific and may mimic laryngopharyngeal reflux or globus sensation. The first manifestation of the disease usually consists of unilateral dysphagia, especially during swallowing saliva. Very often patients go see a specialist due to the appearance of a cervical tumor or due to difficulty in breathing [10]. Dysphagia is progressive, initially for solid food and later for liquids. Severe dysphagia and odynophagia are symptoms that occur in advanced cancers when the entire hypopharynx or cervical esophagus are invaded. Any unilateral dysphagia that persists for more than 2–3 weeks requires an ENT consultation. Weight loss is significant, sometimes leading to cachexia, so the assessment of nutritional status is an important element in establishing therapeutic management. Pharyngeal paresthesia, reflex otalgia, hemoptysis may be present. Dysphonia and dyspnea occur in late stages by the invasion of the pharyngo-laryngeal wall, recurrent paralysis or peritumoral inflammation [7].
Inspection may suggest the condition by the presence of a cachectic patient, with the presence of a latero-cervical tumor or with anterior prominence of the larynx, hypersialorrhea and putrid breath. Performing bucco-pharyngoscopy we can detect synchronous buccopharyngeal cancers or tumor extension to this level.
The most reliable method of diagnosis in hypopharyngeal cancer is a direct examination of the pharynx and larynx so all structures can be assessed. Examination of the mucosa is mandatory and it can be done by using direct pharyngo-laryngocopy or fiber optic examination with or without digital image subtraction filters. Indirect pharyngo-laryngoscopy permits an overview of the tumor, its location and size, as well as the mobility of the vocal cords. Retro-cricoid tumors, as well as those located at the apex of the piriform sinus which is very difficult to highlight. Indirect signs like oedema, mucosal erythema, stagnant secretions or salivary stasis require further investigation. (Figures 1 and 2).
Extensive tumor comprising all walls of the hypopharynx – circular tumor of the hypopharynx.
Infiltrative tumor of the left pyriform sinus with the invasion of the left hemilarynx.
Palpation of the neck leads to the detection of metastatic lymph nodes. Spread towards cervical tissues through the mobility of the laryngeal skeleton can also be appreciated [11].
To establish the correct and complete diagnosis, as well as to achieve the biological balance of the patient, the clinical examination must be completed with a paraclinical evaluation. Pharyngo-esophageal barium examination might reveal the location of the lower limit of the tumor and degree of extension. The main method of pre-therapeutic evaluation is computerized tomography scan (CT) with contrast which, compared to magnetic resonance imaging (MRI), provides us with important data related to cartilage invasion. Positron emission tomography scan and computed tomography (PET-CT) is to be considered mainly for stages III and IV, for the detection of the primary tumor, regional and distant recurrences, as well as for evaluation of oncology therapy response [3]. MRI helps to assess tumor extension to the submucosa, to the hyo-thyro-epiglottic fossa, paraglottic space, subglottic space and invasion of muscle tissue [12]. Rigid endoscopy performed under general anesthesia provides a clear view of the mucosa, determines the lower extension of the tumor and the relationship with the piriform sinus, upper esophageal sphincter and cervical esophagus and allows sampling biopsies in optimal conditions. Breathing and speech cannot be examined.
Since it is a cost-effective, non-invasive method of evaluating lymph nodes ultrasound examination is yet another imaging modality that has been recommended, but not preferred, for assessing the primary tumor site [13]. Chest CT scans or PET-CT are mandatory for the evaluation of distant site metastases. The therapy management plan is established by a multidisciplinary team. In addition, dental and nutritional evaluation should not be forgotten.
The only method that gives a certainty diagnosis is sampling biopsy during the endoscopic examination, followed by the histopathological examination and/or immunohistochemistry. Oncology therapy management, prognosis and follow-up must be determined by the tumor board [14].
The treatment of hypopharyngeal cancer is complex, comprising a series of therapeutic methods consisting of surgery, radiotherapy and chemotherapy. These are applied successively or simultaneously, depending on the stage of the malignant neoplasm, but also on the general biology status of the patient [15]. For stage I and II cancers treatment consist of surgery or radiation therapy. Unfortunately, these patients are difficult to diagnose in stages T1N0 and T2N0 because of their lack of symptoms. Standard regimens of therapy for stages III and IV meaning resectable tumor include radical surgery followed by adjuvant radiotherapy and chemotherapy. Stage IV disease with the unresectable tumor benefits from elective treatment of radiotherapy combined with neoadjuvant chemotherapy [16, 17]. Unresectable tumors benefit from palliative surgical techniques (tracheotomy to maintain respiratory flow, gastrostomy for optimal nutrition). Neoadjuvant chemotherapy is used to reduce the volume of tumors and to convert them into operable or radiation-treatable tumors. It is used to treat patients with advanced local lesions to improve loco-regional control or survival [17, 18]. If the tumor has been converted by chemotherapy to a lower stage surgery will be performed according to the initial T! Psychological counseling of patients with hypopharyngeal cancer is mandatory both in the pre-therapeutic stage, during therapy and post-therapy.
The aim of the surgical treatment is to achieve a complete tumor resection with the preservation of functions as much as possible, minimizing a possible local or systemic recurrence. In some cases, the surgery is not performed either due to the invasion of the common carotid artery, prevertebral fascia or due to the lack of reconstruction possibilities or given by the functional status of the patient.
There are several types of surgery that can be performed:
Suprahyoid pharyngotomy, indicated for tumors limited to the posterior wall of the hypopharynx. The reconstruction is done with a supported skin graft.
Partial pharyngectomy, only for T1-T2 tumors limited to the posterior or lateral wall of the piriform sinus. It is not performed if the tumor is extended to the prevertebral fascia.
Partial laryngo-pharyngectomy or extended supraglottic laryngectomy indicated in T1-T2 lesions of the piriform sinuses. It is not performed in patients over 60 years of age.
Supraglottic hemi-pharyngo-laryngectomy, indicated in T2 cancer, is limited to the upper part of the piriform sinus. Both vocal cords are preserved, half of the ipsilateral wing of the thyroid cartilage is resected. Postoperative swallowing is possible. Removal of the tracheostomy tube is performed a few days after surgery. If chronic pulmonary aspiration occurs, a total laryngectomy will be performed.
Posterior pharyngectomy is indicated in cancers located superiorly on the posterior wall of the pharynx.
Endoscopic resection with CO2 laser does not require tracheotomy and reconstruction. It is performed in the case of T1-T2 tumors, but also the T3-T4 stages, but with a less satisfactory local control because of the narrow line of sight due to the use of a laryngoscope.
Transoral robotic surgery (TORS) can overcome the limitations of CO2 laser surgery. It does not require tracheotomy and it is performed in T1-T2 stages, in some selected cases even T3. A Laryngeal Advanced Retractor System (LARS) to open the patients’ mouths is required for achieving a proper exposure of the surgical site. Intraoperative extemporaneous histopathological examination is required to assess the invasion of the surgical margins [19].
Total laryngectomy with partial pharyngectomy is indicated in T3/T4 tumors. It requires definitive tracheotomy and vocal rehabilitation.
Subtotal laryngectomy, for tumors in stages T2 and T3 that pass through the apex of the piriform sinus and it fixates the ipsilateral hemilarynx. Patient will have permanent tracheostomy.
Total eso-pharyngo-laryngectomy, indicated for tumors extending to the cervical esophagus. It is a combination of circular pharyngo-laryngectomy and total esophagectomy. Safety resection margins should be at 3 cm from the tumor edges.
Total circular pharyngo-laryngectomy, indicated in cancer of the pharyngo-esophageal junction comprising the retro-cricoid region, the hypopharyngeal posterior wall and the cervical esophagus, T3-T4 stage tumors. Hypopharynx and larynx are completely resected circularly between the plane of the hyoid bone and that of the first tracheal ring, sometimes requiring inferior extension or extension to the thyroid gland [3, 4]. Reconstruction of the remaining defect is the difficult part of this intervention and requires the collaboration of the ENT specialist with the general surgeon and sometimes with the thoracic surgeon if the lower resection limit decreases in the upper mediastinum. Reconstruction is performed with musculo-cutaneous flap from the pectoralis major muscle, delto-pectoral tubular flap, free radial flap or jejunum-free flap, colonic transposition, revascularized fascio-cutaneous flaps, synthetic pharyngeal-esophageal prostheses.
As a first intraoperative stage after total circular pharyngo-laryngectomy a Montgomery tube can be placed between the pharyngostomy and the esophagostomy. In the ENT Clinic of Colțea Clinical Hospital in Bucharest, Romania, Professor Dr. Cristian Radu Popescu restored the pharyngo-esophageal continuity using a Montgomery esophageal prosthesis Figure 3 [20].
Montgomery prosthesis is used for primary reconstruction of the upper digestive tract. The upper funnel-shaped portion of the prosthesis is sutured at the base of the tongue and the lower end is inserted in the esophagus.
This procedure has been used in patients without metastasis to the seventh lymph node station. The insertion of this synthetic prosthesis is done on the inside. The prosthesis is funnel-shaped at the upper pole and after adjusting the trusses of the esophageal and pharyngeal section to fit the ends of the prosthesis it is sutured at the base of the tongue and oro or hypopharynx with non-resorbable threads. The lower end of the prosthesis is inserted into the remaining esophagus over 5 cm. No suture is required at this level. The prelaryngeal muscles are fixed over the prosthesis. Postoperative feeding of the patient is performed by gastrostomy or by the nazo-gastric feeding tube inserted through the prosthesis at the moment of insertion. Because this method shortens and simplifies reconstructive intervention, without the esthetic defect left after flap reconstruction it has tolerance to radiotherapy comparable to other reconstructive methods, the material is biocompatible and allows the resumption of oral nutrition. This method is now used as an alternative to reconstruction with flaps and not as a temporary solution [3].
Reconstruction of the defect can be performed with transposition of the small or large intestine in a mixed surgical team – ENT surgeon – general surgeon – vascular surgeon. This type of reconstruction favors a more natural feeding and deglutition process. However, it has more possible and life-threatening complications than primary reconstruction with Montgomery prosthesis – Figures 4–7.
Dissection and identification of a portion of the small intestine and vessel pedicle which will be resected and transposed to the neck area to reconstruct the upper digestive tract defect.
Small intestine sample prepared for transposition.
Measuring the graft before suturing it in the neck region for reconstruction.
Attaching vascular pedicle to the external carotid artery and internal jugular vein.
Oncological excision of the tumor must be accompanied by lymph node dissection, even if macroscopically metastatic lymph nodes. Micrometastases can occur in fatty tissue after complete resection. Neck dissection is done depending on the degree of lymph node invasion, but regardless of the N staging, station IV must be dissected if the pharyngo-esophageal junction is invaded [4].
There are four major types of neck dissection published by the Academy’s Committee for Head and Neck Surgery and Oncology:
Radical neck dissection – all lymphatic and fatty tissue are removed from the clavicle to the mandible, from the posterior edge of the trapezius muscle to the midline of the neck, spinal nerve, sternocleidomastoid muscle and internal jugular vein.
Modified radical neck dissection – different from the previous one, either the spinal nerve (subtype I), the spinal nerve and internal jugular vein (Subtype II) are preserved, or the spinal nerve, VJI and SCM (subtype III) are preserved.
Selective neck dissection – supraomohyoid, posterolateral, lateral and anterior.
Radical neck dissection – in addition to radical neck dissection, other lymphatic structures are removed.
Radiotherapy as a single therapy is useful in T1 tumors, in rare T2 stage cases, in elderly patients, in patients who refuse surgery or as palliative treatment.
Radiotherapy in combined treatment regimens can be used before and after surgery. In our experience, the best treatment regimen is surgery followed by radiotherapy. Before radiotherapy, the patient needs a dental check-up to treat any conditions in this area, the treatment of comorbidities and the improvement of the general nutrition and biological status.
Chemotherapy is the treatment of hypopharyngeal cancer is used only in association with other methods of oncology therapy, not as a single way of treatment. Cytostatic drugs decrease tumor volume, improve clinical status and can prolong life. Adjuvant chemotherapy is instituted after surgical excision of the tumor and is used after or along with radiotherapy to eradicate a possible residual disease or micrometastases. Neoadjuvant chemotherapy is administered preoperatively to reduce tumor volume and primary tumor vascularization. It plays a role in lowering the chance of intraoperative tumor dissemination.
An important component in the therapeutic management of hypopharyngeal cancer is clinical nutrition. In hypopharyngeal cancer, we find a severe dysphagic syndrome that can lead to altered nutritional status, both by the cachexia-anorexia syndrome specific to the neoplastic disease, and by local causes that lead to weight loss and malnutrition. Tumor resection can cause severe disturbances to the complete cessation of food intake, and radiation therapy alters the taste and affects the surrounding normal tissues, compromising nutritional status.
Clinical nutrition can be achieved by the enteral or parenteral route. Enteral feeding is preferable in the case of a functional gastrointestinal tract and is made through the nasal-intestinal tubes (nasogastric, nasoduodenal or nasojejunal), stents mounted in the upper digestive tract, through the esophagostoma, gastrostoma or jejunostoma. The patient must learn to administer his own enteral nutrition, which can last for several months. If enteral feeding is not possible, the parenteral route of nutritional support is used, so that malnutrition does not compromise the surgery and the patient’s life. Postoperatively, patients have a strict contraindication to oral feeding, and even swallowing saliva can adversely affect the prognosis by the appearance of fistulas. The nutritional intake is ensured on the nasogastric tube, gastrostoma, jejunostoma, nasojejunal tube. The nasogastric tube is kept for at least 10 days, depending on the reconstructive procedure used.
The nutrition of these patients includes a complete plan tailored to the condition of the patients and their nutritional status to reduce morbidity and mortality, being considered a method of adjuvant treatment with chemo- and radiotherapy in patients with hypopharyngeal cancer [3].
Hypopharyngeal cancer is asymptomatic in early-stage and patients go to a physician in advanced disease stages when metastases are already present and the prognosis is reserved. At the presentation, to the physician 50% of patients show cervical lymph node metastases. The survival rate in hypopharyngeal cancer depends on the tumor stage. Patients in T1-T2 stages have a survival rate at five years of approximately 60%. For patients in stages T3-T4 the survival rate decreases to 17–25%. Cancers in stages I and II, located on the posterior wall of the hypopharynx, have a much better prognosis compared to pyriform sinus cancers, even if it is small, but cause early metastases. Cancers of the retro-cricoid region are diagnosed in advanced stages with extended metastases at paratraheal and mediastinal sites with a severe prognosis. Patients with hypopharyngeal cervical esophagus cancer who have suffered reconstructions, have a two-year survival rate between 9 and 39%. The five-year survival rate in hypopharyngeal cancers is the lowest of cancers with other head and neck localizations [3].
Hypopharyngeal cancer mainly affects men around the age of 60. It is mostly located in the pyriform sinus, being a squamous cell carcinoma. Being asymptomatic in the early stages patients at the time of diagnosis are classified in stages III and IV of the disease, presenting cervical lymph node metastases and extensive tumors. Most patients require extensive surgical interventions and only a few can benefit from partial interventions. The type of neck dissection depends on the level of lymph node invasion. More than 50% of patients present local recurrences in the first five years after the surgical intervention, the risk of local recurrences being significantly higher in retro-cricoid and posterior wall tumors than in pyriform sinus tumors. The survival rate of hypopharyngeal cancer patients is influenced by tumor location and tumor stage. Therapy must be individualized, multimodal, with correct evaluation for each case and by involving several specialists like surgeons, radiotherapists, chemotherapists, nutritionists, psychologists. Surgical treatment remains the indication with the best results both as first intent and after radiotherapy failure, although it involves the sacrifice of the larynx. Montgomery pharyngoplasty after circular pharyngo-laryngectomy through the C. R. Popescu technique is a viable reconstructive alternative for oral feeding with small complications, low mortality rates and low hospitalization period. Surgery must be followed by radiotherapy and chemotherapy.
The authors declare no conflict of interest.
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The task-focused leadership style is explored under the headings of transactional and autocratic leadership, laissez-faire leadership, and instrumental leadership.",book:{id:"9047",slug:"nursing-new-perspectives",title:"Nursing",fullTitle:"Nursing - New Perspectives"},signatures:"Serpil Çelik Durmuş and Kamile Kırca",authors:null},{id:"58916",title:"Factors Affecting the Attitudes of Women toward Family Planning",slug:"factors-affecting-the-attitudes-of-women-toward-family-planning",totalDownloads:8485,totalCrossrefCites:9,totalDimensionsCites:18,abstract:"Everyone has the right to decide on the number and timing of children without discrimination, violence and oppression, to have the necessary information and facilities for it, to access sexual and reproductive health services at the highest standard. 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",coverUrl:"https://cdn.intechopen.com/series/covers/22.jpg",latestPublicationDate:"June 27th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:1,editor:{id:"356540",title:"Prof.",name:"Taufiq",middleName:null,surname:"Choudhry",slug:"taufiq-choudhry",fullName:"Taufiq Choudhry",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000036X2hvQAC/Profile_Picture_2022-03-14T08:58:03.jpg",biography:"Prof. Choudhry holds a BSc degree in Economics from the University of Iowa, as well as a Masters and Ph.D. in Applied Economics from Clemson University, USA. In January 2006, he became a Professor of Finance at the University of Southampton Business School. He was previously a Professor of Finance at the University of Bradford Management School. He has over 80 articles published in international finance and economics journals. 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Prof. Emeje was a national chairman of academic pharmacists in Nigeria and the 2021 winner of the May & Baker Nigeria Plc–sponsored prize for professional service in research and innovation.",institutionString:"National Institute for Pharmaceutical Research and Development",institution:{name:"National Institute for Pharmaceutical Research and Development",country:{name:"Nigeria"}}},{id:"268659",title:"Ms.",name:"Xianquan",middleName:null,surname:"Zhan",slug:"xianquan-zhan",fullName:"Xianquan Zhan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/268659/images/8143_n.jpg",biography:"Dr. Zhan received his undergraduate and graduate training in the fields of preventive medicine and epidemiology and statistics at the West China University of Medical Sciences in China during 1989 to 1999. He received his post-doctoral training in oncology and cancer proteomics for two years at the Cancer Research Institute of Human Medical University in China. In 2001, he went to the University of Tennessee Health Science Center (UTHSC) in USA, where he was a post-doctoral researcher and focused on mass spectrometry and cancer proteomics. Then, he was appointed as an Assistant Professor of Neurology, UTHSC in 2005. He moved to the Cleveland Clinic in USA as a Project Scientist/Staff in 2006 where he focused on the studies of eye disease proteomics and biomarkers. He returned to UTHSC as an Assistant Professor of Neurology in the end of 2007, engaging in proteomics and biomarker studies of lung diseases and brain tumors, and initiating the studies of predictive, preventive, and personalized medicine (PPPM) in cancer. In 2010, he was promoted to Associate Professor of Neurology, UTHSC. Currently, he is a Professor at Xiangya Hospital of Central South University in China, Fellow of Royal Society of Medicine (FRSM), the European EPMA National Representative in China, Regular Member of American Association for the Advancement of Science (AAAS), European Cooperation of Science and Technology (e-COST) grant evaluator, Associate Editors of BMC Genomics, BMC Medical Genomics, EPMA Journal, and Frontiers in Endocrinology, Executive Editor-in-Chief of Med One. He has\npublished 116 peer-reviewed research articles, 16 book chapters, 2 books, and 2 US patents. His current main research interest focuses on the studies of cancer proteomics and biomarkers, and the use of modern omics techniques and systems biology for PPPM in cancer, and on the development and use of 2DE-LC/MS for the large-scale study of human proteoforms.",institutionString:null,institution:{name:"Xiangya Hospital Central South University",country:{name:"China"}}},{id:"40482",title:null,name:"Rizwan",middleName:null,surname:"Ahmad",slug:"rizwan-ahmad",fullName:"Rizwan Ahmad",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/40482/images/system/40482.jpeg",biography:"Dr. Rizwan Ahmad is a University Professor and Coordinator, Quality and Development, College of Medicine, Imam Abdulrahman bin Faisal University, Saudi Arabia. Previously, he was Associate Professor of Human Function, Oman Medical College, Oman, and SBS University, Dehradun. Dr. Ahmad completed his education at Aligarh Muslim University, Aligarh. He has published several articles in peer-reviewed journals, chapters, and edited books. His area of specialization is free radical biochemistry and autoimmune diseases.",institutionString:"Imam Abdulrahman Bin Faisal University",institution:{name:"Imam Abdulrahman Bin Faisal University",country:{name:"Saudi Arabia"}}},{id:"41865",title:"Prof.",name:"Farid A.",middleName:null,surname:"Badria",slug:"farid-a.-badria",fullName:"Farid A. Badria",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/41865/images/system/41865.jpg",biography:"Farid A. Badria, Ph.D., is the recipient of several awards, including The World Academy of Sciences (TWAS) Prize for Public Understanding of Science; the World Intellectual Property Organization (WIPO) Gold Medal for best invention; Outstanding Arab Scholar, Kuwait; and the Khwarizmi International Award, Iran. He has 250 publications, 12 books, 20 patents, and several marketed pharmaceutical products to his credit. He continues to lead research projects on developing new therapies for liver, skin disorders, and cancer. Dr. Badria was listed among the world’s top 2% of scientists in medicinal and biomolecular chemistry in 2019 and 2020. He is a member of the Arab Development Fund, Kuwait; International Cell Research Organization–United Nations Educational, Scientific and Cultural Organization (ICRO–UNESCO), Chile; and UNESCO Biotechnology France",institutionString:"Mansoura University",institution:{name:"Mansoura University",country:{name:"Egypt"}}},{id:"329385",title:"Dr.",name:"Rajesh K.",middleName:"Kumar",surname:"Singh",slug:"rajesh-k.-singh",fullName:"Rajesh K. Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329385/images/system/329385.png",biography:"Dr. Singh received a BPharm (2003) and MPharm (2005) from Panjab University, Chandigarh, India, and a Ph.D. (2013) from Punjab Technical University (PTU), Jalandhar, India. He has more than sixteen years of teaching experience and has supervised numerous postgraduate and Ph.D. students. He has to his credit more than seventy papers in SCI- and SCOPUS-indexed journals, fifty-five conference proceedings, four books, six Best Paper Awards, and five projects from different government agencies. He is currently an editorial board member of eight international journals and a reviewer for more than fifty scientific journals. He received Top Reviewer and Excellent Peer Reviewer Awards from Publons in 2016 and 2017, respectively. He is also on the panel of The International Reviewer for reviewing research proposals for grants from the Royal Society. He also serves as a Publons Academy mentor and Bentham brand ambassador.",institutionString:"Punjab Technical University",institution:{name:"Punjab Technical University",country:{name:"India"}}},{id:"142388",title:"Dr.",name:"Thiago",middleName:"Gomes",surname:"Gomes Heck",slug:"thiago-gomes-heck",fullName:"Thiago Gomes Heck",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/142388/images/7259_n.jpg",biography:null,institutionString:null,institution:{name:"Universidade Regional do Noroeste do Estado do Rio Grande do Sul",country:{name:"Brazil"}}},{id:"336273",title:"Assistant Prof.",name:"Janja",middleName:null,surname:"Zupan",slug:"janja-zupan",fullName:"Janja Zupan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/336273/images/14853_n.jpeg",biography:"Janja Zupan graduated in 2005 at the Department of Clinical Biochemistry (superviser prof. dr. Janja Marc) in the field of genetics of osteoporosis. Since November 2009 she is working as a Teaching Assistant at the Faculty of Pharmacy, Department of Clinical Biochemistry. In 2011 she completed part of her research and PhD work at Institute of Genetics and Molecular Medicine, University of Edinburgh. She finished her PhD entitled The influence of the proinflammatory cytokines on the RANK/RANKL/OPG in bone tissue of osteoporotic and osteoarthritic patients in 2012. From 2014-2016 she worked at the Institute of Biomedical Sciences, University of Aberdeen as a postdoctoral research fellow on UK Arthritis research project where she gained knowledge in mesenchymal stem cells and regenerative medicine. She returned back to University of Ljubljana, Faculty of Pharmacy in 2016. She is currently leading project entitled Mesenchymal stem cells-the keepers of tissue endogenous regenerative capacity facing up to aging of the musculoskeletal system funded by Slovenian Research Agency.",institutionString:null,institution:{name:"University of Ljubljana",country:{name:"Slovenia"}}},{id:"357453",title:"Dr.",name:"Radheshyam",middleName:null,surname:"Maurya",slug:"radheshyam-maurya",fullName:"Radheshyam Maurya",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/357453/images/16535_n.jpg",biography:null,institutionString:null,institution:{name:"University of Hyderabad",country:{name:"India"}}},{id:"418340",title:"Dr.",name:"Jyotirmoi",middleName:null,surname:"Aich",slug:"jyotirmoi-aich",fullName:"Jyotirmoi Aich",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038Ugi5QAC/Profile_Picture_2022-04-15T07:48:28.png",biography:"Biotechnologist with 15 years of research including 6 years of teaching experience. Demonstrated record of scientific achievements through consistent publication record (H index = 13, with 874 citations) in high impact journals such as Nature Communications, Oncotarget, Annals of Oncology, PNAS, and AJRCCM, etc. Strong research professional with a post-doctorate from ACTREC where I gained experimental oncology experience in clinical settings and a doctorate from IGIB where I gained expertise in asthma pathophysiology. A well-trained biotechnologist with diverse experience on the bench across different research themes ranging from asthma to cancer and other infectious diseases. An individual with a strong commitment and innovative mindset. Have the ability to work on diverse projects such as regenerative and molecular medicine with an overall mindset of improving healthcare.",institutionString:"DY Patil Deemed to Be University",institution:null},{id:"349288",title:"Prof.",name:"Soumya",middleName:null,surname:"Basu",slug:"soumya-basu",fullName:"Soumya Basu",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035QxIDQA0/Profile_Picture_2022-04-15T07:47:01.jpg",biography:"Soumya Basu, Ph.D., is currently working as an Associate Professor at Dr. D. Y. Patil Biotechnology and Bioinformatics Institute, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India. With 16+ years of trans-disciplinary research experience in Drug Design, development, and pre-clinical validation; 20+ research article publications in journals of repute, 9+ years of teaching experience, trained with cross-disciplinary education, Dr. Basu is a life-long learner and always thrives for new challenges.\r\nHer research area is the design and synthesis of small molecule partial agonists of PPAR-γ in lung cancer. She is also using artificial intelligence and deep learning methods to understand the exosomal miRNA’s role in cancer metastasis. Dr. Basu is the recipient of many awards including the Early Career Research Award from the Department of Science and Technology, Govt. of India. She is a reviewer of many journals like Molecular Biology Reports, Frontiers in Oncology, RSC Advances, PLOS ONE, Journal of Biomolecular Structure & Dynamics, Journal of Molecular Graphics and Modelling, etc. She has edited and authored/co-authored 21 journal papers, 3 book chapters, and 15 abstracts. She is a Board of Studies member at her university. She is a life member of 'The Cytometry Society”-in India and 'All India Cell Biology Society”- in India.",institutionString:"Dr. D.Y. Patil Vidyapeeth, Pune",institution:{name:"Dr. D.Y. Patil Vidyapeeth, Pune",country:{name:"India"}}},{id:"354817",title:"Dr.",name:"Anubhab",middleName:null,surname:"Mukherjee",slug:"anubhab-mukherjee",fullName:"Anubhab Mukherjee",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y0000365PbRQAU/ProfilePicture%202022-04-15%2005%3A11%3A18.480",biography:"A former member of Laboratory of Nanomedicine, Brigham and Women’s Hospital, Harvard University, Boston, USA, Dr. Anubhab Mukherjee is an ardent votary of science who strives to make an impact in the lives of those afflicted with cancer and other chronic/acute ailments. He completed his Ph.D. from CSIR-Indian Institute of Chemical Technology, Hyderabad, India, having been skilled with RNAi, liposomal drug delivery, preclinical cell and animal studies. He pursued post-doctoral research at College of Pharmacy, Health Science Center, Texas A & M University and was involved in another postdoctoral research at Department of Translational Neurosciences and Neurotherapeutics, John Wayne Cancer Institute, Santa Monica, California. In 2015, he worked in Harvard-MIT Health Sciences & Technology as a visiting scientist. He has substantial experience in nanotechnology-based formulation development and successfully served various Indian organizations to develop pharmaceuticals and nutraceutical products. He is an inventor in many US patents and an author in many peer-reviewed articles, book chapters and books published in various media of international repute. Dr. Mukherjee is currently serving as Principal Scientist, R&D at Esperer Onco Nutrition (EON) Pvt. Ltd. and heads the Hyderabad R&D center of the organization.",institutionString:"Esperer Onco Nutrition Pvt Ltd.",institution:null},{id:"319365",title:"Assistant Prof.",name:"Manash K.",middleName:null,surname:"Paul",slug:"manash-k.-paul",fullName:"Manash K. Paul",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/319365/images/system/319365.png",biography:"Manash K. Paul is a Principal Investigator and Scientist at the University of California Los Angeles. He has contributed significantly to the fields of stem cell biology, regenerative medicine, and lung cancer. His research focuses on various signaling processes involved in maintaining stem cell homeostasis during the injury-repair process, deciphering lung stem cell niche, pulmonary disease modeling, immuno-oncology, and drug discovery. He is currently investigating the role of extracellular vesicles in premalignant lung cell migration and detecting the metastatic phenotype of lung cancer via machine-learning-based analyses of exosomal signatures. Dr. Paul has published in more than fifty peer-reviewed international journals and is highly cited. He is the recipient of many awards, including the UCLA Vice Chancellor’s award, a senior member of the Institute of Electrical and Electronics Engineers (IEEE), and an editorial board member for several international journals.",institutionString:"University of California Los Angeles",institution:{name:"University of California Los Angeles",country:{name:"United States of America"}}},{id:"311457",title:"Dr.",name:"Júlia",middleName:null,surname:"Scherer Santos",slug:"julia-scherer-santos",fullName:"Júlia Scherer Santos",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/311457/images/system/311457.jpg",biography:"Dr. Júlia Scherer Santos works in the areas of cosmetology, nanotechnology, pharmaceutical technology, beauty, and aesthetics. Dr. Santos also has experience as a professor of graduate courses. Graduated in Pharmacy, specialization in Cosmetology and Cosmeceuticals applied to aesthetics, specialization in Aesthetic and Cosmetic Health, and a doctorate in Pharmaceutical Nanotechnology. Teaching experience in Pharmacy and Aesthetics and Cosmetics courses. She works mainly on the following subjects: nanotechnology, cosmetology, pharmaceutical technology, aesthetics.",institutionString:"Universidade Federal de Juiz de Fora",institution:{name:"Universidade Federal de Juiz de Fora",country:{name:"Brazil"}}},{id:"219081",title:"Dr.",name:"Abdulsamed",middleName:null,surname:"Kükürt",slug:"abdulsamed-kukurt",fullName:"Abdulsamed Kükürt",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/219081/images/system/219081.png",biography:"Dr. Kükürt graduated from Uludağ University in Turkey. He started his academic career as a Research Assistant in the Department of Biochemistry at Kafkas University. In 2019, he completed his Ph.D. program in the Department of Biochemistry at the Institute of Health Sciences. He is currently working at the Department of Biochemistry, Kafkas University. He has 27 published research articles in academic journals, 11 book chapters, and 37 papers. He took part in 10 academic projects. He served as a reviewer for many articles. He still serves as a member of the review board in many academic journals. He is currently working on the protective activity of phenolic compounds in disorders associated with oxidative stress and inflammation.",institutionString:null,institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"178366",title:"Dr.",name:"Volkan",middleName:null,surname:"Gelen",slug:"volkan-gelen",fullName:"Volkan Gelen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178366/images/system/178366.jpg",biography:"Volkan Gelen is a Physiology specialist who received his veterinary degree from Kafkas University in 2011. Between 2011-2015, he worked as an assistant at Atatürk University, Faculty of Veterinary Medicine, Department of Physiology. In 2016, he joined Kafkas University, Faculty of Veterinary Medicine, Department of Physiology as an assistant professor. Dr. Gelen has been engaged in various academic activities at Kafkas University since 2016. There he completed 5 projects and has 3 ongoing projects. He has 60 articles published in scientific journals and 20 poster presentations in scientific congresses. His research interests include physiology, endocrine system, cancer, diabetes, cardiovascular system diseases, and isolated organ bath system studies.",institutionString:"Kafkas University",institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"418963",title:"Dr.",name:"Augustine Ododo",middleName:"Augustine",surname:"Osagie",slug:"augustine-ododo-osagie",fullName:"Augustine Ododo Osagie",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/418963/images/16900_n.jpg",biography:"Born into the family of Osagie, a prince of the Benin Kingdom. I am currently an academic in the Department of Medical Biochemistry, University of Benin. Part of the duties are to teach undergraduate students and conduct academic research.",institutionString:null,institution:{name:"University of Benin",country:{name:"Nigeria"}}},{id:"192992",title:"Prof.",name:"Shagufta",middleName:null,surname:"Perveen",slug:"shagufta-perveen",fullName:"Shagufta Perveen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192992/images/system/192992.png",biography:"Prof. Shagufta Perveen is a Distinguish Professor in the Department of Pharmacognosy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia. Dr. Perveen has acted as the principal investigator of major research projects funded by the research unit of King Saud University. She has more than ninety original research papers in peer-reviewed journals of international repute to her credit. She is a fellow member of the Royal Society of Chemistry UK and the American Chemical Society of the United States.",institutionString:"King Saud University",institution:{name:"King Saud University",country:{name:"Saudi Arabia"}}},{id:"49848",title:"Dr.",name:"Wen-Long",middleName:null,surname:"Hu",slug:"wen-long-hu",fullName:"Wen-Long Hu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49848/images/system/49848.jpg",biography:"Wen-Long Hu is Chief of the Division of Acupuncture, Department of Chinese Medicine at Kaohsiung Chang Gung Memorial Hospital, as well as an adjunct associate professor at Fooyin University and Kaohsiung Medical University. Wen-Long is President of Taiwan Traditional Chinese Medicine Medical Association. He has 28 years of experience in clinical practice in laser acupuncture therapy and 34 years in acupuncture. He is an invited speaker for lectures and workshops in laser acupuncture at many symposiums held by medical associations. He owns the patent for herbal preparation and producing, and for the supercritical fluid-treated needle. Dr. Hu has published three books, 12 book chapters, and more than 30 papers in reputed journals, besides serving as an editorial board member of repute.",institutionString:"Kaohsiung Chang Gung Memorial Hospital",institution:{name:"Kaohsiung Chang Gung Memorial Hospital",country:{name:"Taiwan"}}},{id:"298472",title:"Prof.",name:"Andrey V.",middleName:null,surname:"Grechko",slug:"andrey-v.-grechko",fullName:"Andrey V. Grechko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/298472/images/system/298472.png",biography:"Andrey Vyacheslavovich Grechko, Ph.D., Professor, is a Corresponding Member of the Russian Academy of Sciences. He graduated from the Semashko Moscow Medical Institute (Semashko National Research Institute of Public Health) with a degree in Medicine (1998), the Clinical Department of Dermatovenerology (2000), and received a second higher education in Psychology (2009). Professor A.V. Grechko held the position of Сhief Physician of the Central Clinical Hospital in Moscow. He worked as a professor at the faculty and was engaged in scientific research at the Medical University. Starting in 2013, he has been the initiator of the creation of the Federal Scientific and Clinical Center for Intensive Care and Rehabilitology, Moscow, Russian Federation, where he also serves as Director since 2015. He has many years of experience in research and teaching in various fields of medicine, is an author/co-author of more than 200 scientific publications, 13 patents, 15 medical books/chapters, including Chapter in Book «Metabolomics», IntechOpen, 2020 «Metabolomic Discovery of Microbiota Dysfunction as the Cause of Pathology».",institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"199461",title:"Prof.",name:"Natalia V.",middleName:null,surname:"Beloborodova",slug:"natalia-v.-beloborodova",fullName:"Natalia V. Beloborodova",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/199461/images/system/199461.jpg",biography:'Natalia Vladimirovna Beloborodova was educated at the Pirogov Russian National Research Medical University, with a degree in pediatrics in 1980, a Ph.D. in 1987, and a specialization in Clinical Microbiology from First Moscow State Medical University in 2004. She has been a Professor since 1996. Currently, she is the Head of the Laboratory of Metabolism, a division of the Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russian Federation. N.V. Beloborodova has many years of clinical experience in the field of intensive care and surgery. She studies infectious complications and sepsis. She initiated a series of interdisciplinary clinical and experimental studies based on the concept of integrating human metabolism and its microbiota. Her scientific achievements are widely known: she is the recipient of the Marie E. Coates Award \\"Best lecturer-scientist\\" Gustafsson Fund, Karolinska Institutes, Stockholm, Sweden, and the International Sepsis Forum Award, Pasteur Institute, Paris, France (2014), etc. Professor N.V. Beloborodova wrote 210 papers, five books, 10 chapters and has edited four books.',institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"354260",title:"Ph.D.",name:"Tércio Elyan",middleName:"Azevedo",surname:"Azevedo Martins",slug:"tercio-elyan-azevedo-martins",fullName:"Tércio Elyan Azevedo Martins",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/354260/images/16241_n.jpg",biography:"Graduated in Pharmacy from the Federal University of Ceará with the modality in Industrial Pharmacy, Specialist in Production and Control of Medicines from the University of São Paulo (USP), Master in Pharmaceuticals and Medicines from the University of São Paulo (USP) and Doctor of Science in the program of Pharmaceuticals and Medicines by the University of São Paulo. Professor at Universidade Paulista (UNIP) in the areas of chemistry, cosmetology and trichology. Assistant Coordinator of the Higher Course in Aesthetic and Cosmetic Technology at Universidade Paulista Campus Chácara Santo Antônio. Experience in the Pharmacy area, with emphasis on Pharmacotechnics, Pharmaceutical Technology, Research and Development of Cosmetics, acting mainly on topics such as cosmetology, antioxidant activity, aesthetics, photoprotection, cyclodextrin and thermal analysis.",institutionString:null,institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"334285",title:"Ph.D. Student",name:"Sameer",middleName:"Kumar",surname:"Jagirdar",slug:"sameer-jagirdar",fullName:"Sameer Jagirdar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334285/images/14691_n.jpg",biography:"I\\'m a graduate student at the center for biosystems science and engineering at the Indian Institute of Science, Bangalore, India. I am interested in studying host-pathogen interactions at the biomaterial interface.",institutionString:null,institution:{name:"Indian Institute of Science Bangalore",country:{name:"India"}}},{id:"329248",title:"Dr.",name:"Md. Faheem",middleName:null,surname:"Haider",slug:"md.-faheem-haider",fullName:"Md. Faheem Haider",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329248/images/system/329248.jpg",biography:"Dr. Md. Faheem Haider completed his BPharm in 2012 at Integral University, Lucknow, India. In 2014, he completed his MPharm with specialization in Pharmaceutics at Babasaheb Bhimrao Ambedkar University, Lucknow, India. He received his Ph.D. degree from Jamia Hamdard University, New Delhi, India, in 2018. He was selected for the GPAT six times and his best All India Rank was 34. Currently, he is an assistant professor at Integral University. Previously he was an assistant professor at IIMT University, Meerut, India. He has experience teaching DPharm, Pharm.D, BPharm, and MPharm students. He has more than five publications in reputed journals to his credit. Dr. Faheem’s research area is the development and characterization of nanoformulation for the delivery of drugs to various organs.",institutionString:"Integral University",institution:{name:"Integral University",country:{name:"India"}}},{id:"329795",title:"Dr.",name:"Mohd Aftab",middleName:"Aftab",surname:"Siddiqui",slug:"mohd-aftab-siddiqui",fullName:"Mohd Aftab Siddiqui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329795/images/system/329795.png",biography:"Dr. Mohd Aftab Siddiqui is an assistant professor in the Faculty of Pharmacy, Integral University, Lucknow, India, where he obtained a Ph.D. in Pharmacology in 2020. He also obtained a BPharm and MPharm from the same university in 2013 and 2015, respectively. His area of research is the pharmacological screening of herbal drugs/natural products in liver cancer and cardiac diseases. He is a member of many professional bodies and has guided many MPharm and PharmD research projects. Dr. Siddiqui has many national and international publications and one German patent to his credit.",institutionString:"Integral University",institution:null},{id:"255360",title:"Dr.",name:"Usama",middleName:null,surname:"Ahmad",slug:"usama-ahmad",fullName:"Usama Ahmad",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255360/images/system/255360.png",biography:"Dr. Usama Ahmad holds a specialization in Pharmaceutics from Amity University, Lucknow, India. He received his Ph.D. from Integral University, Lucknow, India, with his work titled ‘Development and evaluation of silymarin nanoformulation for hepatic carcinoma’. Currently, he is an Assistant Professor of Pharmaceutics, at the Faculty of Pharmacy, Integral University. He has been teaching PharmD, BPharm, and MPharm students and conducting research in the novel drug delivery domain. From 2013 to 2014 he worked on a research project funded by SERB-DST, Government of India. He has a rich publication record with more than twenty-four original journal articles, two edited books, four book chapters, and several scientific articles to his credit. He is a member of the American Association for Cancer Research, the International Association for the Study of Lung Cancer, and the British Society for Nanomedicine. Dr. Ahmad’s research focus is on the development of nanoformulations to facilitate the delivery of drugs.",institutionString:"Integral University",institution:{name:"Integral University",country:{name:"India"}}},{id:"333824",title:"Dr.",name:"Ahmad Farouk",middleName:null,surname:"Musa",slug:"ahmad-farouk-musa",fullName:"Ahmad Farouk Musa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333824/images/22684_n.jpg",biography:"Dato’ Dr Ahmad Farouk Musa\nMD, MMED (Surgery) (Mal), Fellowship in Cardiothoracic Surgery (Monash Health, Aust), Graduate Certificate in Higher Education (Aust), Academy of Medicine (Mal)\n\n\n\nDato’ Dr Ahmad Farouk Musa obtained his Doctor of Medicine from USM in 1992. He then obtained his Master of Medicine in Surgery from the same university in the year 2000 before subspecialising in Cardiothoracic Surgery at Institut Jantung Negara (IJN), Kuala Lumpur from 2002 until 2005. He then completed his Fellowship in Cardiothoracic Surgery at Monash Health, Melbourne, Australia in 2008. He has served in the Malaysian army as a Medical Officer with the rank of Captain upon completing his Internship before joining USM as a trainee lecturer. He is now serving as an academic and researcher at Monash University Malaysia. He is a life-member of the Malaysian Association of Thoracic & Cardiovascular Surgery (MATCVS) and a committee member of the MATCVS Database. He is also a life-member of the College of Surgeons, Academy of Medicine of Malaysia; a life-member of Malaysian Medical Association (MMA), and a life-member of Islamic Medical Association of Malaysia (IMAM). Recently he was appointed as an Interim Chairperson of Examination & Assessment Subcommittee of the UiTM-IJN Cardiothoracic Surgery Postgraduate Program. As an academic, he has published numerous research papers and book chapters. He has also been appointed to review many scientific manuscripts by established journals such as the British Medical Journal (BMJ). He has presented his research works at numerous local and international conferences such as the European Association for Cardiothoracic Surgery (EACTS) and the European Society of Cardiovascular Surgery (ESCVS), to name a few. He has also won many awards for his research presentations at meetings and conferences like the prestigious International Invention, Innovation & Technology Exhibition (ITEX); Design, Research and Innovation Exhibition, the National Conference on Medical Sciences and the Annual Scientific Meetings of the Malaysian Association for Thoracic and Cardiovascular Surgery. He was awarded the Darjah Setia Pangkuan Negeri (DSPN) by the Governor of Penang in July, 2015.",institutionString:null,institution:{name:"Monash University Malaysia",country:{name:"Malaysia"}}},{id:"30568",title:"Prof.",name:"Madhu",middleName:null,surname:"Khullar",slug:"madhu-khullar",fullName:"Madhu Khullar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/30568/images/system/30568.jpg",biography:"Dr. Madhu Khullar is a Professor of Experimental Medicine and Biotechnology at the Post Graduate Institute of Medical Education and Research, Chandigarh, India. She completed her Post Doctorate in hypertension research at the Henry Ford Hospital, Detroit, USA in 1985. She is an editor and reviewer of several international journals, and a fellow and member of several cardiovascular research societies. 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Since 1995, he has been working on: i) the determination in biological fluids (serum, urine, bronchoalveolar lavage, sputum) of proteolytic activities involved in the degradation processes of connective tissue matrix, and ii) on the identification of biological markers of lung diseases. In this context, he has developed and validated new methodologies (e.g., Capillary Electrophoresis coupled to Laser-Induced Fluorescence, CE-LIF) whose application enabled him to determine both the amounts of biochemical markers (Desmosines) in urine/serum of patients affected by Chronic Obstructive Pulmonary Disease (COPD) and the activity of proteolytic enzymes (Human Neutrophil Elastase, Cathepsin G, Pseudomonas aeruginosa elastase) in sputa of these patients. 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She gained considerable experience in developing and validating new methodologies whose applications allowed her to determine both the amount of biomarkers (Desmosine and Isodesmosine) in the urine of patients affected by COPD, and the activity of proteolytic enzymes (HNE, Cathepsin G, Pseudomonas aeruginosa elastase) in the sputa of these patients. Simona Viglio was also involved in research dealing with the supplementation of amino acids in patients with brain injury and chronic heart failure. She is presently engaged in the development of 2-DE and LC-MS techniques for the study of proteomics in biological fluids. The aim of this research is the identification of potential biomarkers of lung diseases. 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Biochemistry examines macromolecules - proteins, nucleic acids, carbohydrates, and lipids – and their building blocks, structures, functions, and interactions. Much of biochemistry is devoted to enzymes, proteins that catalyze chemical reactions, enzyme structures, mechanisms of action and their roles within cells. Biochemistry also studies small signaling molecules, coenzymes, inhibitors, vitamins, and hormones, which play roles in life processes. Biochemical experimentation, besides coopting classical chemistry methods, e.g., chromatography, adopted new techniques, e.g., X-ray diffraction, electron microscopy, NMR, radioisotopes, and developed sophisticated microbial genetic tools, e.g., auxotroph mutants and their revertants, fermentation, etc. More recently, biochemistry embraced the ‘big data’ omics systems. Initial biochemical studies have been exclusively analytic: dissecting, purifying, and examining individual components of a biological system; in the apt words of Efraim Racker (1913 –1991), “Don’t waste clean thinking on dirty enzymes.” Today, however, biochemistry is becoming more agglomerative and comprehensive, setting out to integrate and describe entirely particular biological systems. The ‘big data’ metabolomics can define the complement of small molecules, e.g., in a soil or biofilm sample; proteomics can distinguish all the comprising proteins, e.g., serum; metagenomics can identify all the genes in a complex environment, e.g., the bovine rumen. 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Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. 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Behind these definitions are hidden all the aspects of normal and pathological functioning of all processes that the topic ‘Metabolism’ will cover within the Biochemistry Series. 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Thus proteomics, an area of research that detects all protein forms expressed in an organism, including splice isoforms and post-translational modifications, is more suitable than genomics for a comprehensive understanding of the biochemical processes that govern life. The most common proteomics applications are currently in the clinical field for the identification, in a variety of biological matrices, of biomarkers for diagnosis and therapeutic intervention of disorders. From the comparison of proteomic profiles of control and disease or different physiological states, which may emerge, changes in protein expression can provide new insights into the roles played by some proteins in human pathologies. Understanding how proteins function and interact with each other is another goal of proteomics that makes this approach even more intriguing. Specialized technology and expertise are required to assess the proteome of any biological sample. 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