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Updated: Dec 26 2021

Oropharyngeal Cancer

  • 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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