Anatomy
Epidemiology
Risk factors
Clinical Features
Staging
Workup
Management
Conclusion
• According to American Joint Committee on Cancer (AJCC)
staging definition:
Superior
Anterior
Lateral
Posterior
Inferior
(Netter 2003)
Anatomy
Boundaries
Superior Soft palate
Anterior
Lateral
Posterior
Inferior
(Netter 2003)
Anatomy
Boundaries
Superior Oropharyngeal isthmus
Anterior Palatoglossal arch
Lateral
Posterior
Inferior
(Netter 2003)
Anatomy
Boundaries
Palatopharyngeal arch
Superior
Palatine tonsil
Anterior
Lateral
Posterior
Inferior
(Netter 2003)
Anatomy
Boundaries
Superior Second and third cervical vertebrae
Anterior
Lateral
Posterior
Inferior
(Netter 2003)
Anatomy
Boundaries
Superior Level of hyoid
Anterior Vallecula
Lateral
Posterior
Inferior
(Netter 2003)
Lymphatic Drainage
Patient related-
Age and gender: predisposition in males especially
those who are smokers and older than 50 years.
Lifestyle: cigarette smoking, alcohol, tobacco; tobacco
and alcohol are synergistic risk factors.
HPV- associated orpharyngeal cancer
Staging
Tx: primary site cannot be evaluated
T0: no evidence of carcinoma
T, tumor Tis: carcinoma in-situ
N, node T1: tumor < 2cm in greatest dimension
M, metastasis T2: tumor 2-4cm in greatest dimension
T3: tumor > 4cm in greatest dimension
T4
T4a: invades larynx, deep/extrinsic tongue
muscles, medial pterygoid, hard palate, or
mandible
T4b: invades lateral pterygoid, pterygoid plates,
lateral nasopharynx, skull base, or carotid
T, tumor
N, node
M, metastasis
Encasement of Involvement of
carotid artery foramen ovale
T, tumor
Nx: Regional lymph nodes cannot be
N, node assessed
M, metastasis N0: No regional lymph node metastasis
N1: single ipsilateral node < 3cm
N2
N2a: single ipsilateral node involved, ˃3 but
˂6cm
N2b: multiple ipsilateral nodes, < 6cm
N2c: bilateral or contralateral nodal
involvement, none ˃6cm
N3: nodal involvement > 6cm
Staging
T, tumor
N, node
M, metastasis Mx: distant metastasis cannot be evaluated
M0: no distant metastasis
M1: distant metastasis present
Diagnostic workup
• Endoscopic Examination
Fiberoptic laryngoscopy is done to assess local extent of
dosease.
Evaluation of the upper aerodigestive tract is crucial to
evaluate the primary site of disease and the presence of
synchronous primaries.
Laboratory tests
Includes:
1) Complete blood count
2) Basic blood chemistry
3) Hepatic and metabolic panels
4) Testing for HPV in the biopsy specimen (p16 IHC testing)
Biopsy
Tissue from either primary tumor or neck lymphadenopathy
is crucial for pathologic diagnosis.
Imaging-
CECT Face & Neck
Chest X-ray
Ultrasound whole abdomen
CECT Thorax (if indicated)
FDG-PET/CT scan
CT Scan
• Surgery
• Radiotherapy
• Chemotherapy
• Targeted Therapy
• Stage I and stage II tumors are considered as early stage,
whereas stage III and IV (nonmetastatic) are considered
locoregionally advanced disease.
• Early-stage tumors are usually well controlled with a single
local modality, either radiotherapy or surgery.
• For locoregionally advanced disease, two appropriate
treatment strategies are used:
(a) either surgery followed by radiation therapy with or
without chemotherapy based on pathologic risk factors or (b)
radiotherapy usually given with chemotherapy.
Surgery
• Base of Tongue
• Surgery plays a limited role in the management of base of
tongue tumors given the inherent morbidity of a near-total or
total glossectomy, which is required for large and/or midline
tumors.
• For select, well-lateralized base of tongue tumors with
minimal cervical lymphadenopathy, a partial glossectomy
can be performed.
• Given the high propensity for occult microscopic nodal
involvement, bilateral cervical lymph node dissection is often
performed.
• Base of tongue tumors in close proximity to the laryngeal
apparatus, such as those arising in the vallecula, often
require a supraglottic or total laryngectomy to achieve
adequate margins of resection.
• Traditional surgical approaches for base of tongue tumors
include :
• The midline mandibulotomy (splitting the lip, mandible, and
oral tongue midline),
• The lateral mandibulotomy (dividing the mandible near the
angle and approaching the base of tongue from the side),
• The floor drop procedure (elevating the inner periosteum
from the mandible from angle to angle, which releases the
entire floor of mouth and oral tongue into the neck, exposing
the base of tongue).
Tonsil Cancers
• For small (<1 cm) early-stage tonsil cancers confined to the anterior
pillar, a wide local excision can achieve adequate tumor-free margins,
whereas tumors involving the palatine tonsil often require a radical
tonsillectomy.
• For both of these situations, the tonsil is approached transorally, with
primary closure.
• Larger tumors with extension onto the tongue, onto the mandible or
into surrounding tissue often require a composite resection, usually
including resection of the tonsil, tonsillar fossa, pillars, a portion of the
soft palate, tongue, and mandible.
• For tumors not adjacent or adherent to the mandible, a midline
mandibulotomy approach is used.
• For tumors adherent to the mandible, a partial mandibulectomy is
used.
• Defects are often closed with a myocutaneous flap.
• Complications from surgery depend on the extent of resection, with
impairment in swallowing possible by removal of part of the tongue or
soft palate.
Soft Palate Cancers
• Surgical resection is rarely recommended as initial therapy
for soft palate tumors.
• Resection of the soft palate is often associated with
significant reflux into the nasopharynx during swallowing,
even with the use of custom prostheses.
• Additionally, because of the midline location, primary
disease spreads bilaterally to the neck with frequency high
enough to require elective treatment.
• However, when surgery is performed, the tumors are
approached transorally and a full-thickness wide local
resection is performed for tumors limited to the soft palate.
• A more extensive composite resection is required if disease
extends to surrounding structures.
• Flaps or prostheses are used to preserve velopharyngeal
competence. Nasal speech is also often a consequence.
Transoral Laser Surgery
• Small series report favorable outcomes for selected patients
with stage I through stage IV oropharyngeal tumors treated
with transoral laser microsurgery with or without neck
dissection, followed by adjuvant radiotherapy or
chemoradiotherapy.
• Positive margin rates are variable (3% to 24%) and appear
to vary based on primary site, being more common in base
of tongue tumors.
• Complications include postoperative hemorrhage (5% to
10%).
Temporary tracheostomy placement is relatively common
(17% to 30%) and needed for exposure, airway control, or
aspiration following extensive resection.
• High rates of locoregional control following this procedure
have been reported, primarily for stage I/II patients (87% to
100%), although for stage III/IV patients, local recurrence is
more common (20% to 30%).
Transoral Robotic Surgery
• The use of a computer-aided interaction between the surgeon and
the patient is commonly referred to as robotic surgery.
• The most common robotic surgical system, the da Vinci Surgical
System, is comprised of three surgical instruments and a binocular
endoscope controlled by robotic arms and inserted under direct or
endoscopic guidance by the surgeon from a patient-side apparatus.
• The surgeon controls the instruments from a console separated from
the patient.
• The operative environment is visualized virtually, in a three-
dimensional (3D) environment created via a computer that links the
environment provided by the binocular endoscope to the position of
the instruments.
• The surgeon’s movements are translated into the micromovements
of the instruments. The advantages of this system include motion
scaling, which can increase precision as well as reduce hand tremor
and fatigue.
• When the system is used for transoral surgeries, an assistant is
often positioned by the patient’s head.
• There are no prospective randomized studies supporting the
use of transoral robotic surgery (TORS) for oropharyngeal
tumor resection over conventional surgery.
• Until mature prospective multi-institutional series and
randomized data are available, the true utility of transoral
laser microsurgery and TORS remains unknown.
• Although early results are favorable and associated with
shorter hospital stays, long-term data are needed.
• Additionally, standard oncologic principles limiting the
number of modalities used to minimize treatment related
side effects should be carefully considered prior to
widespread adoption of the surgical techniques.
Neck Management
• Fibrosis,
• Osteoradionecrosis,
• Trismus,
• Xerostomia,
• Dental caries,
• Feeding tube dependence, and neuritis.
Chemotherapy
Role of Targeted therapy