Oropharyngeal Cancer – Flashcards
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risk factors for oropharyngeal cancer
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smoking alcohol tobacco abuse EBV HPV
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oropharynx anatomy
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anterior boundary at junction of hard and soft palate and circumvallate papillae superior boundary at level of hard palate inferior boundary at the superior surface of the hyoid
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oropharynx subsites
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tonsil/lateral pharyngeal wall posterior pharyngeal wall soft palate base of tongue vallecula
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tonsil/lateral pharyngeal wall cancer
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exophytic mass or ulcerative lesion aggressive usually with regional neck disease (65-75%) higher instance of lymphom and lymphoepithelioma
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posterior pharyngeal wall cancer
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less common aggressive less metastatic potential than base of tongue
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soft palate cancer
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rare found in early stages 20-45% regional mets 70% 5-year survival
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base of tongue cancer
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more aggressive tumor than oral tongue high rate of cervical metastasis (>60%, 20% bilateral mets) poorer prognosis (65% 5-year survival for all stages)
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most common sites of HPV-associated oropharyngeal SCC
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base of tongue tonsils
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demographic of HPV positive SCC patients
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younger by 10 years associated with multiple sex partners
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most common HPV subtype seen in carcinoma
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type 16
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etiology of HPV
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double-stranded DNA virus that infects stratified squamous epithelial cells oncogenes E6 and E7 are responsible for malignancies in both the anogenital and head and neck areas E6 binds and inactivates the p53 tumor suppressor gene E7 binds and inactivates the Rb protein leading to release of E2F transcription factor causing cell cycle progression
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dx of HPV
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DNA in situ hybridization PCR immunostaining for p16 (can be positive in 10-20% of oropharyngeal SCC in absence of HPV
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oropharynx T1
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primary </= 2 cm
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oropharynx T2
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>2 and </= 4 cm
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oropharynx T3
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primary > 4 cm or extension to lingual surface of epiglottis
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oropharynx T4a
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moderately advanced local disease invasion through larynx, extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible mucosal extension to lingual surface of epiglottis from primary tumors of the base of tongue and vallecula does not constitute invasion of larynx
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oropharynx T4b
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very advanced local disease invasion through lateral pterygoid, pterygoid plates, lateral nasopharynx, skull base, or encases carotid
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SCC is what percent of oropharyngeal cancer
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>95%
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SCC lymph node mets path
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cystic
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lymphoepithelioma
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subgroup of poorly differentiated carcinoma may present in tonsil, exophytic, radiosensitive
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lymphoma of oropharynx
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10-15% of base of tongue and tonsillar cancers
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mgmt of T1-T2 oropharynx cancer
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1. excision of primary tumor with primary recon 2. primary radiation 3. chemoradiation for select T2N1 patients
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T1-2 oropharynx cancer and N0 neck
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1. elective ipsilateral or bilateral SND (II-IV) 2. radiation
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T1-2 oropharynx cancer and N1 neck
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1. SND (II-IV) or mRND for clinical nodes 2. radiation
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T1-2 oropharynx cancer and N2-3 neck
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1. concurrent chemorads (preferred) 2. induction chemo followed by radiation or chemorads 3. surgery for primary and neck 3. multimodality trials
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T1-T2 oropharynx cancer aduvant therapy
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no adverse features - none 1 pos node without adverse features - radiation optional adverse features - cheomrads (preferred), re-resection, or radiation other risk features - adjuvant radiation or chemoradiation residual tumor postradiation - salvage surgery
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T3-T4a oropharynx cancer mgmt
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1. concurrent chemorads (preferred) 2. excision of primary tumor with primary reconstruction 3. induction chemotherapy followed by radiation or chemorads 4. multimodality clinical trials
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adjuvant therapy for T3-T4a oropharynx cancer
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no adverse features - radiation adverse features - chemorads other risk features - managed by adjuvant radiation or chemorads residual tumor postrads - salvage surgery
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transoral laser microsurgery
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ideal treatment for early to intermediate glottic and supraglottic lesions as well as certain oropharyngeal and hypopharyngeal tumor
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advantages of transoral laser microsurgery
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similar to TORS faster OR time reduced cost presence of tactile (haptic) feedback
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disadvantages of transoral laser microsugery
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line of sight long instrumentation with limited degrees of motion presence of tremor exaggerated movements
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transcervical/visor flap
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considered for large tumors of the base of tongue or tonsil access oropharynx from a transoral incision of the floor of mouth preserves mandibular integrity poor exposure chin numbness
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mandibulectomy
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indicated for larger lesions, mandibular extension, or multiple sites (composite resection) may be approached laterally orm edially with a lip-splitting incision (mandibular swing) excellent exposure easier soft tissue closure risk of malocclusion and plate extrusion
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mandibulotomy
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spares mandible may be approached laterally or midline with a lip-splitting incision osteotomy is performed in a stepwise fashion to create a favorable repair followed by rigid fixation excellent occlusion less risk of malocclusion
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lateral pharyngotomy
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consider for small base of tongue or posterior pharyngeal wall tumors enter pharynx between hypoglossal and superior laryngeal nerves limited exposure spares mandible avoids lip-splitting incision
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transhyoid pharyngotomy
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consider for small base of tongue or posterior pharyngeal wall tumors without significant superior or tonsillar extension enters pharynx above or through hyoid bone spares mandible avoids lip-splitting incision vallecula must be free of tumor poor exposure superiorly
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healing by secondary intention
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useful in small partial glossectomies simplest and best functional outcome (speech, swallowing) associated with slightly increased pain often after TORS
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primary closure
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good functional outcome (speech and swallow) ideal method of reconstruction if a tension-free closure can be obtained without resulting in significant stenosis
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split thickness skin graft recon oropharynx
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allows resurfacing with good functional outcomes does not provide tissue bulk
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pedicled regional flap for oropharynx recon
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soft tissue bulk with compromise of speech and swallowing function
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free tissue transfer for oropharynx recon
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soft tissue bulk with compromise of speech and swallowing function radial forearm for large partial glossectomy as well as pharyngeal wall defects and anterolateral thigh or rectus flap for total glossecotmies fibular or iliac crest for mandibular recon of > 5 cm of bone loss other options are osteocutaneous radial forearm and scapular flaps for small mandibular defects
