HEAD AND NECK

CANCER
O R O P H A RY N X

Elizabeth Muha

EPIDEMIOLOGY
Head and neck squamous cell carcinomas are the
sixth most common malignancy worldwide
Tonsils are the most common site of malignancy
within the oropharynx
Oropharyngeal cancers associated withHPV tend
to occur in younger, non-smoking individuals
45,000 new cases each year
Male predominance 3-4:1
Most head and neck cancers diagnosed in
patients >40 years of age

ETIOLOGY
Smoking Tobacco
High Alcohol Intake
Poor Oral Hygiene
Epstein-Barr virus (EBV)

Nutritional deficiencies

Betel and Areca nuts

Excessive sunlight for lip CA

(Ultraviolet light)

Inhalation of wood dust for

Nasopharynx CA

Radiation as a child for Thyroid

CA

Human Papilloma Virus

Smokeless tobacco

PRESENTING SIGNS AND

SYMPTOMS
Asymptomatic (abnormality noted by dentist)
Commonly with an ulceration of the submucosa with
raised edges
Hoarseness, mass, hemoptysis, nasal obstruction
Enlarged lymph node, most commonly Jugulodigastric
Dysphagia
Pain on swallowing
Neck mass

DETECTION & DIAGNOSIS

Laryngoscope
MRI
CT
Chest imaging (CXR, CT)
PET/CT for stage III or IV
Biopsy
Lab studies (CBC, Liver & renal function)

ANATOMY AND PHYSIOLOGY

TYPES OF OROPHARYNX CANER AND

DRAINAGE SITES
Base of tongue (post.1/3 of tongue) jugulodigastric, midjugular and
posterior cervical lymph high incidence of lymph node involvement
Tonsillar Fossa - involve the jugulo-digastric, submaxillary, and the
midjugular nodes. Also mets to the junctional and the spinal accessory
nodes.
Soft Palate - involves the jugulo-digastric, sometimes the submaxillary,
junctional, and spinal accessory nodes.
Pharyngeal walls - mets to parapharyngeal and retropharyngeal lymph
nodes.
Vallecula

LYMPH NODE DRAINAGE

INCIDENCE OF LYMPH NODE

INVOLVEMENT AT DIAGNOSIS
Base of Tongue
78%

Tonsil & Tonsillar Fossa

76%

Oropharyngeal Wall
59%

Anterior Pillar
45%

Soft Palate
44%

COMMON SITES OF METASTESIS

Spreads by:
Direct extension
Lymphatics
Hematogenously

MOST COMMON SITE OF LYMPH NODES?

LUNGS
Also commonly spreads to bone and liver

HISTOPATHOLOGY
Squamous cell carcinoma
Most common
Arise from cells lining the oropharynx
Non-keratinized squamous stratified epithilium

Either HPV+ or HPV-

AJCC STAGING
Tumor Staging:

Tx: Primary tumor cannot be assessed

T0: No evidence of primary tumor
Tis: Carcinoma in situ
T1: Tumor 2 cm in greatest dimension
T2: Tumor >2 cm but < 4 cm in greatest dimension
T3: Tumor >4 cm in greatest dimension
T4a: Tumor invades the larynx, deep or extrinsic muscles of the tongue, medial pterygoid muscle, hard palate, or mandible
T4b: Tumor invades the lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, skull base, or encases carotid
artery

Nodal involvement:

Nx: Regional lymph nodes that cannot be assessed

N0: No regional node metastasis
N1: Metastasis in a single ipsilateral lymph node, 3 cm or smaller
N2: Metastasis in a single ipsilateral lymph node, larger than 3 cm but not larger than 6 cm in greatest dimension is found;
multiple ipsilateral lymph nodes, none larger than 6 cm; bilateral or contralateral lymph nodes, none larger than 6 cm
N2a: Metastasis in a single ipsilateral lymph node larger than 3 cm but not larger than 6 cm
N2b: Metastasis in multiple ipsilateral lymph nodes, none larger than 6 cm
N2c: Metastasis in bilateral or contralateral lymph nodes, none larger than 6 cm
N3: Metastasis in a lymph node larger than 6 cm

Distant metastasis:
Mx: Distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis

STAGING
Stage 0 (Carcinoma in Situ) - abnormal cells are found in the lining of the oropharynx.
Stage I - cancer has formed and is 2 centimeters or smaller and is in the oropharynx
only
Stage II - cancer is larger than 2 centimeters but not larger than 4 centimeters and is
found in the oropharynx only.
Stage III - cancer is either:
- 4 centimeters or smaller and spread to one lymph node on the same side of the
neck as the tumor and the lymph node is 3 centimeters or smaller
- larger than 4 centimeters
- spread to the epiglottis
Stage IV - divided into stage IVA, IVB, and IVC:
- stage IVA: cancer spread to the larynx, front part of the roof of the mouth, lower jaw, or
muscles that move the tongue or are used for chewing and/or to more than one lymph node
on the opposite side of the tumor in the neck
- stage IVB: tumor surrounds the carotid artery or has spread to the muscle that opens the
jaw, the bone attached to the muscles that move the jaw, nasopharynx, or base of the skull
or has spread to one or more lymph nodes that are larger than 6 centimeters.
- stage IVC: tumor has spread beyond the oropharynx to other parts of the body

GRADING
tells you how normal or abnormal tumor cells
appear
4 grades of oral and oropharyngeal cancer cells
Grade 1 (low grade) the cancer cells look very much
like normal mouth or oropharyngeal cells
Grade 2 (intermediate grade) the cancer cells look
slightly different to normal mouth or oropharyngeal cells
Grade 3 (high grade) the cancer cells look very
abnormal and not much like normal mouth or
oropharyngeal cells
Grade 4 (high grade) the cancer cells look very
different to normal mouth or oropharyngeal cells

COMMON TREATMENT TYPES

CHEMOTHERAPY
The way the chemotherapy is given depends on the type and stage of
the cancer being treated.

RADIATION THERAPY
IMRT most common
May use 3 Field H & N for late stage disease

IMRT fields may include or match up to a supraclav field

Total dose of 6600 to 7380 cGy with 180 200 cGy/fx primary and gross lymph
nodes

SURGERY
Surgery (removing the cancer in an operation) is a common treatment of
all stages of oropharyngeal cancer.
Usually adjuvant therapy with radiation or chemotherapy

Preventive dental care should occur 10 14 days prior to treatment

SIDE EFFECTS FROM COMMON

TREATMENT
EARLY SIDE EFFECTS
Mucositis
Xerostomia
Erythema, dry & moist
desquamation
Anorexia
Mandibular necrosis
Alopecia
Dysphagia
Candidiasis
Fatigue
Edema

LATE SIDE EFFECTS

Cataracts
Retinopathy, optic atrophy & other
eye injuries
Hypothyroidism
Hypopituitarism
Induction of second malignant
neoplasms
Radiation myelitis
Telangiectasia and atrophy of the
skin
Subcutaneous fibrosis and edema
Xerostomia
Accelerated dental decay
Soft tissue necrosis
Osteonecrosis
Speech & swallowing problems
Truisms

ALTERNATIVE METHOD #1:

TRANSORAL ROBOTIC SURGERY
During transoral robotic surgery, your surgeon sits at a remote control
console a short distance from you and the operating table and precisely
controls the motion of the surgical instruments using two hand-andfinger control devices.
The console displays a magnified, 3-D view of the surgical area that
enables the surgeon to visualize the procedure in much greater detail
than in traditional laparoscopic surgery.
When compared with more-traditional procedures, transoral robotic
surgery for oral cancer tends to result in a quicker recovery and fewer
complications.
Trials are usually done on T1-T2 tumours of the base of the tongue and
larynx with Da Vinci robot
Operating costs are relatively high
Recovery following transoral robotic surgery is significantly shorter
compared to open procedures, with patients experiencing fewer side
effects and returning to normal activities sooner.

TRANSORAL ROBOTIC SURGERY

SIDE EFFECTS
Can leave single scar on neck
The primary side effects of surgery include an
initial period of discomfort much like a
tonsillectomy, and also a small risk of bleeding
after surgery.
Long-term problems with speech and swallowing
after transoral robotic surgery are usually minor.

TRANSORAL ROBOTIC SURGERY

ALTERNATIVE TREATMENT #2:

TARGETED (BIOLOGICAL) THERAPY
Targeted therapy is a type of treatment that uses drugs or other substances to
attack specific cancer cells.
Targeted therapies usually cause less harm to normal cells than chemotherapy
or radiation therapy do.
many targeted drugs go after the cancer cells inner workingsthe
programming that sets them apart from normal, healthy cells. These drugs tend
to have different (and often less severe) side effects than standard chemo
drugs.
Monoclonal antibodies are a type of targeted therapy being used in the
treatment of oropharyngeal cancer.
Monoclonal antibody therapy is a cancer treatment that uses antibodies made in the
laboratory from a single type of immune system cell. These antibodies can identify
substances on cancer cells or normal substances in the blood or tissues that may help cancer
cells grow. The antibodies attach to the substances and kill the cancer cells, block their
growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may
be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells.
Cetuximab is a type of monoclonal antibody that works by binding to a protein on the surface
of the cancer cells and stops the cells from growing and dividing.

TARGETED THERAPY SIDE EFFECTS

When drugs attack more than one target, side
effects are more likely.
Not every person gets every side effect, and
some people get few, if any.

Skin reactions
High blood pressure
Problems with blood clotting

Problems with wound healing

Heart damage
Auto-immune reactions

Nausea and vomiting

Diarrhea or constipation
Mouth sores
Shortness of breath
Cough
Fatigue
Headache
Swelling in the hands and
feet
Damage to organs such
as the thyroid gland, liver,
or kidneys

PROGNOSIS/ SURVIVAL RATES FOR

DIFFERENT TREATMENT OPTIONS

STANDARD CARE METHODS

Better prognosis for HPV+ tumors
Prognosis depends on HPV status, Mets status, stage, lymph
node involvement, and tumor margins.

TRANSORAL ROBOTIC SURGURY

Disease specific survival ranged from 95.1 to 98% at 1 year
and from 90 to 93% at 2 years

TARGETED THERAPY
Mostly still in clinical trials so not much information on
prognosis and survival

PROFESSIONAL OPINION?
Head and Neck Cancer does not have a very good
prognosis/survival rate
I THINK ITS GOOD TO TAKE A CHANCE!
Both alternative options may have adjuvant therapy
**IF POSSIBLE I WOULD CHOOSE TRANSORAL SURGERY
WITH ADJUCANT RADIATION/CHEMO**

REFERENCES
1. Chaturvedi P. Targeted Molecular Therapy in Head and Neck Squamous Cell Carcinoma:
Overview of Targeted Molecular Therapy in HNSCC, Techniques for Targeted Molecular
Therapy, Intervention With Targeted Molecular Therapy. Emedicinemedscapecom. 2015.
Available at: http://emedicine.medscape.com/article/854971-overview#a1. Accessed
November 13, 2015.
2. Gurberg J and Prisman E. Transoral Robotic Surgery for Oropharyngeal Carcinoma:
Update. Austin J Otolaryngol. 2014;1(2): 6.
3. American Cancer Society. Cancer Facts & Figures 2015. Atlanta, Ga: American Cancer
Society; 2015.
4. Cancer.org. Whats new in oral cavity and oropharyngeal cancer research and
treatment?. 2015. Available at:
http://www.cancer.org/cancer/oralcavityandoropharyngealcancer/detailedguide/oral-cavityand-oropharyngeal-cancer-new-research. Accessed November 13, 2015.
5. National Cancer Institute. Oropharyngeal Cancer Treatment. 2015. Available at:
http://www.cancer.gov/types/head-and-neck/patient/oropharyngeal-treatmentpdq#section/_48. Accessed November 13, 2015.
6. Cancer.Net. Oral and Oropharyngeal Cancer - Treatment Options. 2012. Available at:
http://www.cancer.net/cancer-types/oral-and-oropharyngeal-cancer/treatment-options.
Accessed November 13, 2015.