Oropharyngeal tumorsslideshare

Oropharyngeal
Tumors
Balasubramanian Thiagarajan
drtbalu's otolaryngology online

Introduction
• Oropharynx is at the crossroads between respiratory and digestive tracts
• Malignant lesions in this area alters swallowing, speech and breathing
• Treatment plans should focus on anticipated functional outcome in addition
to disease clearance
• Neoplasm of oropharynx are uncommon. Majority of tumors encountered
in this area are malignant in nature

Anatomy
• Extent:
Superior – Hard Palate
Inferior – Hyoid bone
• For purposes of tumour
classification:
Anterior wall
Posterior wall
Lateral wall
Roof

Anterior wall of oropharynx
• Tongue base posterior to circumvallate
papillae
• Presence of lymphoid aggregates
(Nodular appearance)
• Lymphatics from tongue base course
downwards towards the hyoid bone
• At the level of hyoid bone lymphatics
pierce pharyngeal wall to drain into
upper deep cervical level II nodes
• Midline tumors exhibit bilateral nodal
involvement due to cross over
lymphatic drainage patterns

Lateral wall of oropharynx
Tonsils
Tonsillar fossa
Tonsillar pillars
Lateral pharyngeal wall
Lateral to lateral pharyngeal wall lies
the para pharyngeal space
Lymphatics from upper lateral wall
drain into retropharyngeal nodes

Posterior pharyngeal wall
• Extends from the level of hard palate/Passavant’s ridge
superiorly to the level of hyoid bone inferiorly
• Mucosa is smooth with occasional lymphoid tissue
• First echelon node is retropharyngeal node, then later into
level II and level III nodes

Roof of oropharynx
• Formed by curved arch of the
inferior surface of the soft palate
and uvula in midline
• Tumors of this area drain into
upper JD and retropharyngeal
nodes

Nerve supply of oropharynx
Sensory supply – Glossopharyngeal nerve
Motor supply – Vagus
Base of tongue – Hypoglossal nerve (motor)
Soft palate – Motor and sensory by Trigeminal nerve
Vagus / glossopharyngeal nerves – auricular and tympanic branches causes
referred otalgia in these patients

Blood supply / Lymphatic drainage
• Branches of external carotid artery
• Lymphatic drainage to levels II and III neck nodes
• Central structures – tongue base, soft palate and posterior pharyngeal wall
have bilateral neck node drainage
• Tonsillar region drain into retropharyngeal nodes

Pharyngeal spaces associated with
oropharynx
• Two pharyngeal spaces are associated with oropharynx
• Retropharyngeal space & parapharyngeal spaces

Facial spaces around oropharynx (contd)
Retropharyngeal space
Lies between buccopharyngeal
fascia of pharynx and the alar layer
of prevertebral fascia. Extends from
skull base to the superior
mediastinum. Communicates with
parapharyngeal space laterally.
Parapharyngeal space
Extends from skull base to the hyoid
bone. This space is divided into
prestyloid and post styloid
compartments.
Prestyloid compartment contains fat
and deep lobe of parotid gland and a
small branch of trigeminal nerve to
tensor veli palatini muscle.
Post styloid compartment contains
carotid artery, jugular vein, cranial
nerves 9th to 12th sympathetic chain
and lymph nodes.

Benign tumors
• Common in oral cavity than oropharynx
• Benign tumors include Papilloma, adenoma, fibroma, hemangioma,
leiomyoma, schwannoma, neurofibroma, lingual thyroid.

Benign tumors

Clinical presentation
• Rarely produce symptoms
• Symptoms vague and non specific causing delay in diagnosis
• Usually present very late
• Ear pain
• FB sensation in throat
• Impaired tongue movements and speech due to tongue muscle infiltration
• Fetor / foul breath
• Neck lump

Difference between benign and malignant
tumors

Malignant tumors
• Sq cell carcinoma
• Lymphoepithelioma
• Lymphoma
• Salivary gland tumors
• Metastatic tumors

Squamous cell carcinoma
• Commonest
• Tonsils and faucial pillars – 45%
• Soft palate – 15%
• Posterior tongue – 40%
• Posterior pharyngeal wall – 5%
Sq cell carcinoma
Tonsil Posterior tongue
Soft palate Posterior pharyngeal wall

Etiology of sq cell carcinoma
• Smoking
• Alcohol consumption
• Dietary deficiencies vitamin A
• Chronic irritants
• Papilloma virus
• HIV

Lymphoepithelioma
• Variant of sq cell carcinoma
• Undifferentiated carcinoma
• Common in tonsil and base of tongue
• Associated with nodal metastasis
• Behaviour is similar to NPC

Lymphoma
• Non Hodgkin’s common
• Tonsil / base of tongue
• Commonly High grade B cell type
• Common in Men
• Not associated with fetor

Salivary gland tumors
• Arise from minor salivary glands of soft palate
• Adenocarcinoma / adenocystic carcinoma

TNM classification
• T0 – No evidence of primary tumor
• Tis – Carcinoma in situ
• T1 – Tumor 2 cm or less in greatest dimension
• T2 – Tumor more than 2 cm but not more than 4 cm in greatest dimension
• T3 – tumor more than 4 cm in greatest dimension
• T4a – Tumor invades larynx, deep/extrinsic muscle of tongue, medial
pterygoid, hard palate or mandible
• T4b – Tumor invades lateral pterygoid, pterygoid plates, lateral
nasopharynx, skull base, carotids

Nodal status
• Nx – regional nodes cannot be assessed
• N0 – No regional node metastasis
• N1UL – Metastasis in a single ipsilateral node 3 cm or less in greatest dimension
• N2UL – Metastasis of single ipsilateral node more than 3 cms but not more than 6 cms in
greatest dimension. If multiple none of the nodes should be more than 6 cms
• N2a – Metastasis of single ipsilateral node more than 3 cms but less than 6 cms
• N2b – Multiple ipsilateral nodes none more than 6 cms
• N2c – Metastasis in bilateral / contralateral nodes none more than 6 cms
• N3UL – Metastasis in a node more than 6 cms

Histological classification
• Gx – Grade cannot be assessed
• G1 – Well differentiated
• G2 – Moderately differentiated
• G3 – Poorly differentiated

UICC / AJCC Staging
N0 N1 N2 N3
I
II
III
IV
T1
T2
T3
T4

Evaluation
• Symptoms vague
• Present at advanced stage (stage III / IV)
• Complete examination of upper aerodigestive tract
• Tongue lesions should be palpated
• Examination under GA is preferred if trismus is present
• Lymphomas / adenocarcinoma present as smooth non ulcerative lesions
• Examination of neck nodes
• CT / MRI imaging

Biopsy
• All patients with oropharyngeal tumor should be examined under GA
• If smooth swelling is seen in tonsil – tonsillectomy is preferred
• Tru-cut needle biopsy of posterior third of tongue should be performed
under GA
• Possibility of debulking the tumor should be explored

Factors affecting choice of treatment
Tumor factors:
Small accessible tumors – excision
Advanced tongue base tumors – Total glossectomy with total laryngectomy to
prevent aspiration. Irradiation is of use in these patients.
Margins of oropharyngeal tumors are not discrete, hence wider resection is
preferred.
Exophytic tumors fare well with radiotherapy.
Deep ulcerative tumors are better managed by surgical excision followed by
RT

Patient factors affecting treatment
modality
• Comorbid conditions
• Patient’s preference
• Presence of advanced dental disease may delay irradiation

Radiotherapy
• Bilateral radiation fields are used to treat whole oropharynx including
prophylactic nodal irradiation. Small tonsillar tumors are an exception.
• Concomitant Chemotherapy has improved survival rates
• T1 and T2 tumors respond better to irradiation
• Patients who smoke during irradiation have lower response rates
• Total dose as well as overall treatment duration is important for favourable
treatment outcome

Surgery
• Transoral approach
• Transoral/transcervical combined approach
• Transpharyngeal approach
• Transmandibular approach

Transoral approach

Transoral / Transcervical combined
approach
• Useful for tongue base lesions
• Tongue and floor of mouth are released, in order to pull these structures
below the mandible into the neck
• Mandible split can be resorted to. This helps in improving access.
• Lingual arteries and hypoglossal nerves are at risk during this procedure

Trans pharyngeal approaches
Suprahyoid pharyngotomy – used for small tumors of the tongue base and
pharyngeal wall. Entrance into pharynx is usually through the vallecula. This
approach allows for preservation of lingual arteries and hypoglossal nerves.
Extension of pharyngotomy incision laterally and inferiorly along thyroid ala
allows for wider exposure. Superior margins of large tumors cannot be
visualized completely. Major advantage of this approach is better functional
and cosmetic result.
Lateral pharyngotomy – useful for small tumors of tongue base, tonsil and
lateral pharyngeal wall. Pharynx is entered posterior to thyroid ala on the
diseased side. Hypoglossal and superior laryngeal nerves should be guarded.
After entering the pharynx, larynx is retracted to opposite side before
commencement of surgery.

Transmandibular approach
• Includes mandibulotomy and
mandibulectomy
• Mandibular split is used if patient
has full complement of teeth
• Mandibulotomy should be avoided
if periosteum of mandible is
involved by the tumor
• Mandibulotomy is made anterior
to mental foramen through a tooth
socket

Neck management
• Should be considered in all cases of sq cell carcinoma
• Surgery / irradiation can be used
• No neck – Levels I, IIa, IIb, III and upper Va should be performed
• N+ neck – modified / radical neck dissection

Irradiation
• External beam irradiation is preferred
• Stages II / III lesions irradiation followed by neck dissection provides better
survival rates.
• Stages III / IV lesions – surgical resection followed by irradiation

RADPLAT
• Targeted chemo radiation protocol
• Cisplatin is infused directly into tumor bed
• Targeted dose of cisplatin is nearly 5 times than that of systemic
administration
• Complete regression of tumor occurs in primary site nearly 80% of the time
• Radiotherapy follows chemo
• Very useful in managing advanced oropharyngeal malignancies

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