Updated: 12/26/2021

Oropharyngeal Cancer

Review Topic
  • 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
  • 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
  • Prognosis
    • Tumors associated with HPV tend to respond well to treatment
  • Complications
    • Metastasis
    • Airway/esophageal obstruction
    • Death

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Questions (1)

(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?

QID: 106142

Human Herpes Virus-8



Epstein Barr Virus



H. pylori



Clonorchis sinensis



Alcohol Intake



M 6 E

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Evidence (3)
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