Oropharyngeal and Nasopharyngeal Cancers

oropharyngeal cancers are fast increasing due to rise of _____________

HPV

Most HPV+ occur where in oropharyngeal cancers?

BOT/tonsillar (likes to hide in reticulations)

oropharyngeal cancers are 85-95% ________

squamous cell carcinoma

Oropharyngeal cancer sites:

1. Soft palate

2. Lateral and posterior pharyngeal walls

3. Tonsils (lingual/palatine)

4. Posterior 1/3 of tongue (BOT)

how many levels of of lymph nodes are there?

5 levels

Oropharynx cancer nodal spread

Subdigastric Level 2a

Neck Involvement 

• lateral lesions

• midline lesions

• lateral lesions= unilateral

• midline lesions= bilateral

Single predictive factor for metastatic spread is what?

neck node involvement

Distant metastases of oropharyngeal cancers are associated with:

• Bilateral neck nodes

• Nodes in lower neck

• Large neck nodes

• Extranodal spread

3 most common sites of metastases for oropharyngeal AND nasopharyngeal cancers

1. Lungs

2. Liver

3. Bones

Diagnosis/Staging of Oropharyngeal AND Nasopharyngeal Cancer

1. Clinical exam by ENT

2. Histological evaluation of biopsy

3. TNM stage after physical exam, MRI, CT, and pathology

4. Neck staging

where is biopsy typically performed for oropharyngeal cancer and with what? how is this different that nasopharyngeal cancer?

Typically performed in clinic with local anesthetic due to easy access to oral cavity

nasopharyngeal is not easy access so no local anesthesia, but still done in clinic

TNM stage after what? what are the 2 types?

for both oropharyngeal and nasopharyngeal

physical exam, MRI, CT, and pathology

1. cTNM = clinical stage

2. pTNM = pathologic stage

Neck staging for oropharyngeal cancer

• Palpation of the neck combined with CT or MRI

• Ultrasound and FNA (clinical standard)

What is the most common type of oropharyngeal cancer?

squamous cell carncinoma

Midline lesions are more likely to result in which type of nodal spread?

bilateral

Signs Specific to Oropharynx Cancer

1. Sore throat that does not go away

2. Trouble swallowing

3. Trismus

4. Reduced lingual ROM

5. Unexplained weight loss

6. Ear pain

7. lump in the throat (globus sensation)

8. White patching (leukoplakia)

9. Coughing up blood

Oropharyngeal AND nasopharyngeal cancer Staging

Tumor size: T0-T4 greater size/depth of invasion

Node involvement; N0-N3 ipsilateral/bilateral and size of node

Metastasis: M0/M1 present or absent

Curative Treatment for Oropharyngeal Cancer

easily accessed/small= eligible for surgery or RT

larger the tumor the larger the surgery for resection + CRT

Oropharyngeal RT Side Effects include what 2 types of effects?

1. acute toxicities

2. late toxicities

Acute toxicities of RT effects for the oropharynx

• Mucositis

• Necrosis

• Xerostomia

late toxicities of RT effects of the oropharynx

• Xerostomia

• Dental decay

• Osteoradionecrosis (necrosis of the bone)

Most common approach in oropharyngeal cancers

CRT

radiosensitizer: chemo makes tumor more sensitive to RT

gold standard chemo treatments in oropharyngeal cancer

platinum-based chemo (cisplatinum & carboplatinum)

CRT for Oropharyngeal Cancer per previously discussed protocols (fractionations)

Chemo: 3 infusions every 3 weeks

RT: 7 weeks of 5 days per week RT x 35 fractions

CRT for Oropharyngeal Cancer may be recommended after surgery if:

• + Surgical margins

• + Multiple lymph nodes

• Extranodal spread (through LN and into adjacent tissue)

Neck Dissection is the removal of what?

diseased lymph nodes and those assumed to have disease or in disease area

classification of neck dissection

radical, modified radical, and selective

clearance of all neck levels, SCM, and/or IJV and/or nIX spared

modified radical

clearance of all neck levels, SCM, IJV, and nIX all spared

selective

clearance of all neck levels, SCM, IJV, and nIX sacrificed

radical

What are 2 symptoms of oropharyngeal cancer?

trismus, ear pain

Name 1 surgical treatment option for oropharyngeal cancer.

composite resection- mandible split open, invasive

What is the most common approach to treating oropharyngeal cancers?

CRT

SLP Role in Oropharyngeal Cancer

• Early evaluation, education, counseling

• Swallow intervention pre-HNC tx if baseline dysphagia

• Swallow intervention post-op or during C/RT

• Post-tx swallow therapy

swallow intervention deals more with what swallow components in oropharyngeal cancer?

pharyngeal clearance & reduced efficiency

can still affect oral prep/transit

Post-tx swallow therapy in Oropharyngeal Cancer

1. Exercise based therapy

2. Manual therapy

3. Diet advancement

Manual therapy in Oropharyngeal Cancer

• Scar management

• Manual manipulation and lymphatic drainage

• Myofascial release of neck/jaw/face

oropharyngeal etiology

HPV, Alcohol and tobacco

oropharyngeal AND nasophayrngeal lymph nodes

Level 2A

oropharyngeal AND nasophayrngeal risk of metastasis (node involvement)

Bilateral neck nodes, Nodes in lower neck, Large neck nodes, Extranodal spread

oropharyngeal AND nasophayrngeal metastasis areas

Lungs, liver, bone

oropharyngeal AND nasopharyngeal evaluation

Exam by ENT, biopsy, MRI/CT, PET-CT

oropharyngeal treatment

• CRT

• Small (<2cm) easily accessible tumors may be removed surgically (less common)

• Neck dissection

Large surgeries require reconstruction with flap from where?

from arm or leg

FLAPS DON’T FUNCTION

oropharyngeal additional rehab

May need dentures post-CRT if many extractions

NPC often associated (75%) with _________

Epstein-Barr virus (mono)

Types of NPC

1. Keratinizing ScCa

2. Nonkeratinizing ScCa (EBV related)

3. Undifferentiated nonkeratinizing ScCa (EBV related)

NPC population tends to be:

younger; higher likelihood in men

NPC has a higher incidence where?

China, Indonesia

Incidence = 5-6 per 100,000 people

what type of incidence of NPS in US?

Sporadic cases in the US 

Incidence = .5 per 100,00 people (lower)

Signs Specific to Nasopharyngeal Cancer

1. Neck swelling

2. Neck mass (75% @ dx)

3. Nasal blockage in advanced cases

4. Bleeding from nose or throat

5. Eustachian tube dysfunction causing aural symptoms

6. Headache

7. Cranial nerve palsy

What is the most common virus associated with nasopharyngeal carcinoma?

Epstein-Barr virus

Who is at higher risk for NPC?

males and younger people

What are two signs/symptoms specific to pts with NPC?

headaches, hearing loss

sites of nasopharyngeal cancers

1. Fossa of Rosenmuller

2. Lateral/Posterior pharyngeal walls

NPC may extend to what structures?

• Skull base

• Parapharyngeal space

is lymph node involvement common in nasopharyrngeal cancer?

yes, very common

Bulky, bilateral nodal involvement

biopsy of Nasopharyngeal Cancer is typically performed where?

in clinic

neck staging of nasopharyngeal cancer

• Palpation of the neck combined with CT or MRI

• Ultrasound and FNA (clinical standard)

• 60-70% present at stage 3 or 4

  • PET to evaluate for distant spread

Treatment for Nasopharyngeal Cancer

• C/RT is primary modality

• Surgery in selected cases

• OMFS collaboration often necessary for functionality given limitations of surgical reconstruction

what is the field of C/RT like for nasopharyngeal cancer?

Radiation field very large; primary site + bilateral neck

What percentage of NPC pts present at stage 3 or 4?

60-70%

What is the primary treatment modality for NPC?

C/RT

nasopharyngeal structures

Mucosa of roof of nasopharynx, Fossa of Rosenmuller, Skill base, Parapharyngeal space

nasopharyngeal etiology

EBV, Alcohol and tobacco

nasopharyngeal additional rehab

Work with OMFS for creation of obturators, dentures, lifts, etc.