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Oropharynx extends :
From hard palate superiorly
hyoid bone inferiorly
Surgical Anatomy
Oropharynx includes:
• Tonsillar fossa
• Base of the tongue
• Soft palate
• Pharyngeal wall
Surgical Anatomy
Anterior wall:
• Base of tongue
• Vallecula
• Lingual surface of epiglottis
• Pharyngoepiglottic fold
Surgical Anatomy
Lateral wall:
• Tonsil
• Anterior pillar
• Posterior pillar
Surgical Anatomy
Roof:
• Soft palate containing:
- 2 heads of palatopharyngeus
- levator palati
- tensor palati
- palatoglossus
Surgical Anatomy
Posterior wall:
• Vertebrae of C2&3
• Superior constrictor m.
• Middle constrictor m.
• Buccopharyngeal fascia
Surgical Anatomy
Surgical Anatomy
Saliv 2%
Lymphoma 8%
SCC
Lymphoma
Saliv
SCC 90%
Squamous Cell Carcinoma
soft
palat
e Post wall 5%
10%
lat
TB
TB 25%
soft palate
lat 60% Post wall
Incidence
• Relatively uncommon
• < 1% of all new cancers
• >55-65 years of age
• Male predominance
Aetiological Factors
• Smoking (>10 packs years)
• Heavy alcohol use
• HPV-16 (number of oropharyngeal cancers linked to HPV infection is increasing,
E6,E7 oncoprotein lead to malignamt transformation )
• Other risk factors include:
- diet low in fruits & vegetables.
- drinking yerba maté (stimulant drink common in South America)
- chewing betel quid ( mild stimulant used in Asia)
- exposure to polycyclic aromatic hydrocarbons,
asbestos & welding fumes
Demography
• Younger adults
• Increased incidence among women
• Nonsmokers
• Orogenital sex
• Well-differentiated tumours
– Decrease in incidence
– Five-year survival rates improved by 15%
• Poorly-differentiated tumours
– Increase in incidence
– Five-year survival rates improved by > 50%
HPV
• Predominantly poorly differentiated SCCA
• No increase in lymphovascular or perineural invasion
• Highly predictive of lymph node metastasis
What is new?
• SCC • Management
– Increased – CRT
– Non-smoker – HPV more sensetive
– HPV – Trans-oral
– Younger
Management
ge ry.
sur
ical
80 Rad
.
90 CRT
l.
20 Tran
so ra
?? Immun o
.
Feature HPV -ve HPV +ve
Incidence Decreasing Increasing
Risk factors Tobacco, alc Sexual behavior
Age >60 <60
Field cancer Yes No
Prediliction site None Orophx
T stage Higher Lower
N stage Lower Higher
Prognosis Poor Favorable
Why HPV id
De-escalating
Better Survival Treatment
Regimens
• Contralateral
– Soft>TB>post
– Tonsil 10%
• Cystic (branchial cleft carcinoma)
• Initial presenting sign
Distant Metastasis
• 8% at presentation
• Rich lymphatics
• 15-20% at some stage 80% within 2 years
• > with LN metastasis & recurrence
• Lung,bones, liver
Second Primary
Spread:
• Ant. & upwards retromolar trigone,TB
• Anterolateral angle of mandible
• Posterolateral parapharyngeal space
(carotid art.or superior extension skull base)
• Inferiorly lat pharyngeal wall PF
• Deep pterygoid m.(trismus & pain)
Tongue Base Tumours
Symptoms:
• Often submucosal (detected by palpation)
• Sensation of a mass in the throat
• Mass in the neck
• Referred ear pain or hemoptysis
• Advanced stages appear clinically
Tongue BaseTumours
Spread:
• Cross midline
• Anteriorly oral tongue, floor of mouth
• Inferior & posteriorly vallecula, epiglottis
• Deep genioglossus m.& styloglossus m.
Soft PalateTumours
Symptoms:
• Asymptomatic in the very early stages
• Often found at early stages incidentally
by the patient or the physician
• Ulcerative surface lesions
• Palate mass, bleeding, + foul odour
• Pain in advanced stages
• Velopharyngeal insufficiency
• Altered speech
• Difficult swallowing
• Referred otalgia
• Trismus
• Neck mass (>bilateral)
Soft PalateTumours
Spread:
• Superior pole of tonsils
• Retromolar trigone
• Inferior or superior alveolar process
• Hard palate
• Base of tongue.
Soft PalateTumours
Spread:
• Extension sphenopalatine
foramen may result in palatal
hypostasis
• Extending nasopharynx (middle ear
effusion is common)
• Extend anterosuperiorly pterygo-
palatine & infratemporal fossa
Posterior Wall Tumours
Symptoms:
• Usually late
• Dysphagia
• Sore throat
• Otalgia
Posterior Wall Tumours
Spread:
• Submucosal nasopharyngeal & hypopharyngeal wall
• Prevertebral fascia barrier to spread
Investigations
Laboratory Studies:
• CBC
• Serum alkaline phosphatase
• Liver function test
• HPV testing
• Pulmonary function testing, arterial blood gas
Investigations
HPV testing:
• NCCN (National Comprehensive Cancer Network) guidelines
recommend HPV testing for prognostic factors
• Quantitative reverse transcriptase PCR (QRT-PCR) allows
calculation of relative amounts of mRNA present in the sample
– Able to calculate copy number
– Susceptible to false positives
• Type-specific HPV DNA in situ hybridization
– HPV-16 is most commonly used to examine oropharyngeal carcinomas.
– It is both sensitive and specific.
• P16 can be tested as a biomarker for HPV E7 activity
Investigations
Imaging:
• CT scanning with intravenous contrast (standard imaging technique )
• MRI (offers the advantages of finer tissue detail and multiplanar views)
• PET-CT
• Ba swallow, fluoroscopy
• Chest X-ray, scan (2nd primary, metastasis)
• U/S liver
Biopsy
• Systematic panendoscopy
- definitive histology
- accurate staging
- exclude 2nd primary
- assess surgical resectability
• Incisional [?tonsillectomy]
• Deep biopsy for base of tongue
• FNAC of LN (+/- ultrasound guided)
Staging
N0 N1 N2-3
T1
I
T2 II
T3
III
T4
IV
Staging
N0 N1 N2-3
T1 I
T2 II
T3
III
T4
IV
Staging (Lymphoma)
Management
Multidisciplinary approach:
• H&N surgical team
• Medical oncology
• Radiation oncology
• Dental team
• Nutritionist
• Speech and swallow
• Social work
Management
• Same
• Single modality (RT vs. surgical) • RTH
• Less morbidity
• Surgical treatment • LN
Transmandibular approaches:
• Midline labiomandibular glossotomy:
- rarely used
- incision can be carried hyoid bone
- bleeding & neurological deficits are minimal
- no access to PPS or lateral oropharynx
Advanced stage III and IV
• Mandibular swing approach:
- wide exposure to entire OP & PPS
- en bloc resection of tumour & LN
- mandibulotomy anterior to mental nerve
- soft tissue cut floor of mouth
- destract mandibular segment & tongue
Advanced stage III and IV
• Mandibulectomy:
- oropharyngeal composite resection with mandibulectomy
- used in advanced cancers with bony invasion
- mandibular cut well clear of the tumour
- disadvantage resultant functional & cosmetic deficits
- reconstruction free tissue transfer (osteocutaneous flap)
Advanced stage III and IV
Reconstructive methods:
Provide wound closure, functional stability, and
cosmesis, introduce healthy tissue in a previously
irradiated bed:
• Oral prosthetic
• Healing by secondary intention
( fibrosis ,re-epithelization)
• Primary closure (water tight,no tension)
• Split-thickness skin graft
Advanced stage III and IV
• Mandibular reconstruction
- no bony reconstruction
- free bone graft
- costochondral graft
- serratus muscle/rib myo-osseous flap
- pectoralis major with rib
- fibula flap
- deep circumflex iliac artery flap
- composite radial flap
• Locoregional flaps:
- sternomastoid myofacial flap
- lingual flap
- temporalis flap
- buccal mucosal transposition flap
Advanced stage III and IV
• Chemotherapy :
- Associated with improved overall survival
in advanced OPSCCA
– Given concurrently with RT
– A clinical trial of CT followed by RT
– Primary chemotherapy reserved for palliation
without curative intent
Cetuximab (ERBITUX ®)
• Palliation:
– Metastatic or unresectable disease
– Involve RT, CT, or both
– Tracheostomy, PEG if indicated
– Consider tumour debulking, radio-frequency
ablation for large painful ulcerative lesions
Follow UP
• Close observation
1rst year 1-3 m
2nd year 2-4m
3rd year 3-6 m
4th&5th year 4-6 m
>5 years yearly
• Lifelong follow-up (2nd primary)
• Serial PET/CT evaluation (beginning 8-12 weeks after
completion of therapy)
Prognosis
5-year survival:
• Stage I 67%
• Stage II 46%
• Stage III 31%
• Stage IV 32%
Future and Controversies