Updated: 6/7/2020

Oropharyngeal Cancer

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Snapshot
  • A 43-year-old man presents to the clinic with complaints of a palpable mass at the neck. He denies any fever, chills, night sweats, or pain at the lesion.  He is otherwise healthy and denies smoking or drug use. The patient reports 5 sexual partners within the last month.
Introduction
  • Overview
    • malignant growth of tissues (most commonly squamous cell) of the oropharynx, which includes base of tongue, tonsils, soft palate, uvula, and posterior/lateral walls of the pharynx 
  • Epidemiology
    • demographics
      • 6th-7th decade (tobacco and alcohol)
      • 4th-5th decade (HPV-associated)
      • male: female ratio of 2.7:1
    • risk factors
      • tobacco (both smoked and smokeless)
      • alcohol
      • human papilloma virus (HPV)
      • betel nut chewing
      • radiation exposure
      • periodontal disease
  • Pathogenesis
    • non-HPV associated
      • continued and repeated exposure to carcinogens leads to malignancy
    • HPV-associated
      • associated with HPV type 16
      • expression of E6 and E7 oncoproteins at the host cell, leading to inactivation of tumor suppressor gene p53 and retinoblastoma proteins
  • Associated conditions
    • HPV infection
  • Prognosis
    • tumors associated with HPV tend to respond well to treatment
Presentation
  • Symptoms
    • dysphagia
    • odynophagia (painful swallowing)
    • otalgia (ear pain)
    • obstructive sleep apnea/snoring
    • bleeding
  • Physical exam
    • neck mass 
      • more common patients with HPV-positive cancer
Imaging
  • All imaging modalities are used in the staging process to assess the degree of local infiltration, lymph node involvement, and presence of distant metastases or second primary tumors 
  • Computed tomography (CT) 
    • indications
      • initial work up for staging
      • allows for greater spatial resolution with faster acquisition time compared to MRI
  • Magnetic resonance imaging (MRI)
    • indications
      • used in conjunction with CT for staing purposes 
      • allows for superior soft tissue definition compare to CT
  • Positron emission tomography (PET)
    • indications
      • used in conjunction with CT/MRI for staging purposes
      • superior for detecting regional nodal and distant metastases.
Studies
  • Labs
    • HPV testing
      • tested on all patients with newly diagnosed oropharyngeal squamous cell carcinoma as HPV status is incorporated into the staging system
      • determined via p16 immunohistochemistry or polymerase chain reaction (PCR)
  • Invasive studies 
    • laryngoscopy 
      • indicated in all patients to evaluate the primary lesion and look for second primary lesions
      • may have exophytic (verrucous or papillipary) and ulcerated appearance
    • biopsy with histology 
      • biopsy often obtained with operative endoscopy
      • 90-95% squamous cell, less common histologies include verrucous carcinoma, adenocarcinoma, adenoid cystic carcinoma, and mucoepidermoid carcinoma
      • histopathologic signs include presence of mitosis, prominent nucleoli, and atypia 
      • cells tend to be moderate to poorly differentiated
Differential 
  • Oral syphilis
    • distinguishing factors
      • patients will have positive VDRL test
      • resolves with antibiotics
  • Oral tuberculosis
    • distinguishing factors
      • granulomatous lesions and acid-fast bacilli on biopsy
Treatment 
  • Nonoperative
    • radiation therapy
      • single modality indicated for early-stage cancers
      • can be used as single modality or combined with surgery or chemotherapy
    • chemotherapy
      • can be used in conjunction with radiation (chemoradiation) 
      • indicated in advanced cancer
  • Operative
    • can be used as single modality treatment for early cancers
    • radical neck dissection
      • indicated if clinically palpable nodal disease
      • radical neck disection removes the sternocleidomastoid muscle, internal jugular vein, submaxillary gland, and spinal accessory nerve, and leaves the carotid artery and its branches
    • transoral laser microsurgery (TLM) and transoral robotic surgery (TORS) becoming more popular
      • less invasive than open surgery
Complications
  • Metastasis
  • Airway/esophageal obstruction
  • Death 
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.ON.16.69) An elderly Chinese male comes into your office for repeated episodes of epistaxis. He also states that he has had trouble hearing in his right ear and feels there is a fullness there. His past medical history is significant for a 40 pack-year history of smoking and he also drinks 6-10 beers on the weekends. On exam, you notice swelling of the nasal mucosa and decide to biopsy the area. Biopsy of this mucosa is shown in Figure A. Which of the following is most associated with this condition? Review Topic | Tested Concept

QID: 106142
FIGURES:
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Human Herpes Virus-8

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Epstein Barr Virus

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H. pylori

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Clonorchis sinensis

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Alcohol Intake

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L 2 E

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