Evaluation and Management of Oropharyngeal Carcinoma

Question 1

What are the two most important risk factors
associated with the development of oropharyngeal
squamous cell carcinoma?

Answer 1

HPV infection and tobacco smoking. Traditional risk factors
for head and neck squamous cell carcinoma are still relevant
(see Oncology section).

Question 2

Which HPV subtypes are associated with an
increased risk of oropharyngeal squamous cell
carcinoma?

Answer 2

HPV 16 (predominant), 18, 31, and 33

Question 3

What is the most common malignancy of the

oropharynx?

Answer 3

Squamous cell carcinoma

Question 4

What rare malignancy arising in the oropharynx
(most commonly in the tonsil and base of tongue)
is a poorly differentiated squamous cell carcinoma
or undifferentiated carcinoma associated with a
reactive lymphoplasmacytic infiltration?

Answer 4

Lymphoepithelial carcinoma

Question 5

What is the most common type of lymphoma

found in the oropharynx?

Answer 5

Non-Hodgkin lymphoma. Diffuse large B-cell lymphomas

are the most common subtype.

Question 6

What percentage of extranodal head and neck

lymphomas are found in the Waldeyer ring?

Answer 6

36%

Question 7

What locally aggressive oral and cutaneous vas-
cular malignancy can be found in the oropharynx
(primarily soft palate) in AIDS patients?

Answer 7

Kaposi sarcoma

Question 8

What are the two most common salivary gland

malignancies that arise in the oropharynx?

Answer 8

They arise from minor salivary glands most commonly in
the soft palate, tonsil, and base of tongue:
● Adenoid cystic carcinoma (cylindromatous or cribriform)
● Mucoepidermoid carcinoma

Question 9

What malignant tumor can rarely arise from

melanocytes in the mucosa of the oropharynx?

Answer 9

Malignant mucosal melanoma

Question 10

What are common initial symptoms of oropharyngeal malignancy?

Answer 10

Odynophagia, referred otalgia, dysphagia, speech distortion, globus, bleeding, painless neck mass

Question 11

Why might patients with oropharyngeal cancer
often be initially diagnosed with stage III or IV
disease?

Answer 11

Vague symptoms that are often experienced in benign

disease processes

Question 12

If a patient with oropharyngeal cancer develops

severe trismus, what might this indicate?

Answer 12

Invasion into the masseteric space with involvement of the

pterygoid musculature

Question 13

A patient has a palpable mass centered in the right
base of the tongue. On tongue protrusion, you note
hemitongue atrophy and fasciculations on the right.
Which nerve is likely involved by the tumor?

Answer 13

Hypoglossal nerve

Question 14

What adjuvant physical examination tool should be used when there is concern for an orophar-
yngeal malignancy?

Answer 14

Flexible endoscopy; evaluate for tumor extension, status of
the larynx, etc. Mirror should be considered if flexible
endoscopy is not available or as an adjunct to flexible
endoscopy.

Question 15

In addition to direct visualization of the anatomy,
what important physical examination maneuver
should be performed in patients with possible
oropharyngeal cancer?

Answer 15

Digital palpation for submucosal disease, friability, and

mobility. Palpation of the neck is also imperative.

Question 16

What structure(s) are potentially involved if a
patient presents with an immobile oropharyngeal
tumor?

Answer 16

● Medial pterygoid muscle
● Mandible
● Maxillary tuberosity
● Hyoid bone
● Parapharyngeal structures

Question 17

Tumors in which oropharyngeal subsite is most commonly diagnosed by visual inspection at ear-
lier stages?

Answer 17

Soft palate. They generally occur on the anterior oropharyngeal surface of soft palate.

Question 18

What patient specific/anatomical factors identified
on physical examination may indicate that a
patient with an oropharyngeal tumor is a poor
candidate for a transoral procedure?

Answer 18

● Severe trismus due to tumor invasion or fibrosis
● Narrow mandibular arch
● Crowded oral cavity, making displacement of the soft
tissues challenging
● Long incisor teeth
● High body mass index
● Retrognathic
● High Mallampati score
● Mandibular tori

Question 19

What tumor specific factors can be identified on

physical examination, which would suggest that a patient is a good candidate for transoral surgery?

Answer 19

● Exophytic
● Mobile
● Proximal oropharynx
● No evidence of involvement of deep structures such as the mandible, pterygoid musculature, maxillary tuber-
osity, hyoid bone, or parapharyngeal structures
● Predicted resection < 50% of the base of tongue or < 75%
of the soft palate

Question 20

Describe the tumor specific contraindications to
transoral tumor resection for an oropharyngeal
tumor.

Answer 20

● Invasion of the skull base
● Invasion or encasement of the great vessels
● Invasion of the mandible
● Confluent primary tumor and neck metastasis
● Tumor extension potentially necessitating an R1 or R2
resection.

Question 21

How is T4a oropharyngeal cancer defined?

Answer 21

Moderately advanced local disease: Tumor invades larynx,
extrinsic tongue musculature (genioglossus, hyoglossus,
styloglossus, palatoglossus), medial pterygoid muscle, hard
palate, or mandible

Question 22

How is T4b oropharyngeal cancer defined?

Answer 22

Very advanced local disease: Tumor invades lateral pter-
ygoid muscle, pterygoid plates, lateral nasopharynx, skull
base, or encases the carotid.

Question 23

With regard to tongue-base tumors, does mucosal
extension of a tumor to the lingual surface of the
epiglottis constitute invasion of the larynx and T4a
status?

Answer 23

No

Question 24

True or False. Nodal metastases to level VII
(superior mediastinal lymph nodes: between the
common carotid arteries laterally, superior border
of manubrium, and innominate artery) are not
considered distant metastases.

Answer 24

True

Question 25

Currently, there is no widely accepted staging
system that takes into account HPV status of an
oropharyngeal tumor. However, the NCCN (2013)
does recommend HPV testing to better define
prognosis. What test is currently recommended?

Answer 25

Immunohistochemical staining for p16

Note: The best test to diagnose HPV status is controversial.

Question 26

What prognostic role does HPV positivity play in

oropharyngeal squamous cell carcinoma?

Answer 26

Improved disease-free survival and overall survival when
compared with HPV-negative oropharyngeal squamous cell
carcinoma

Question 27

What are the adverse features identified by the

NCCN (2013) for oropharyngeal cancer?

Answer 27

● Extracapsular nodal spread
● Positive margins
● pT3 or pT4 primary
● N2 or N3 nodal disease
● Nodal disease in levels IV or V
● Perineural invasion
● Vascular embolism

Question 28

What treatment modalities does the NCCN (2013)
recommend for patients with T1–2, N0–1 oro-
pharyngeal cancer?

Answer 28

● Definitive radiation therapy
● Surgical resection of the primary ± ipsilateral or bilateral
neck dissection as indicated; additional intervention
based on adverse features:
○ None → no additional intervention
○ One positive node, no adverse features consider
radiation therapy
○ Positive margin → Reexcision or radiation therapy (CRT
for T2)
○ Extracapsular spread→CRT
○ Other risk feature → radiation therapy ± concomitant
chemotherapy
○ T2N1: Consider primary chemoradiation therapy

Question 29

What treatment modalities does the NCNN (2013)
recommend for patients with T3–4a, N0–1 or-
opharyngeal cancer?

Answer 29

● Concurrent chemoradiation therapy with cisplatin (cat-
egory 1, preferred)
● Surgical resection of the primary ± ipsilateral or bilateral
neck dissection as indicated; additional intervention
based on adverse features:
○ None → Radiation therapy
○ Extracapsular spread and or positive margin → Che-
moradiation therapy
○ Other risk feature → radiation therapy ± concomitant
chemotherapy
○ Induction chemotherapy + radiation therapy ± con-
comitant chemotherapy
○ Multimodality clinical trials

Question 30

What treatment modalities does the NCCN (2013)
recommend for patients with any T, N2–3
oropharyngeal cancer?

Answer 30

● Concurrent chemoradiation therapy with cisplatin ± neck
dissection for residual nodal disease
● Induction chemotherapy + radiation therapy ± chemo-
therapy
● Surgical resection of the primary ± ipsilateral or bilateral
neck dissection as indicated; additional intervention
based on adverse features:
○ None → no additional intervention (N1 only)
○ Extracapsular spread and/or positive margin → che-
moradiation therapy
○ Other risk feature → radiation therapy ± concomitant
chemotherapy
○ Multimodality clinical trials

Question 31

For all stages of oropharyngeal cancer, if there is
residual disease with radiation therapy ± concom-
itant chemotherapy, what intervention is recom-
mended?

Answer 31

Salvage surgery

Question 32

What radiation technique or modality is recommended for management of oropharyngeal tumors?

Answer 32

Intensity modulated radiation therapy (IMRT)

Question 33

What does the NCCN (2013) recommend for
definitive radiation therapy for oropharyngeal
cancer?

Answer 33

● Conventional fractionation: 66 to 74 Gy, daily Monday
through Friday for 7 weeks
● Altered fractionation:
○ Accelerated: 66 to 74 Gy to gross disease, 44 to 64 Gy
to occult disease; six fractions/week
○ Concurrent boost accelerated: 72 Gy, daily + twice daily
for last 12 treatments, for 6 weeks
○ Hyperfractionation: 81.6 Gy, twice daily, Monday
through Friday, for 7 weeks

Question 34

When considering concurrent chemoradiation
therapy, what amount of energy does the NCCN
(2013) recommend for (1) primary disease, (2)
gross adenopathy, and (3) occult adenopathy?

Answer 34

Conventional fractionation
● ≥ 70 Gy
● ≥ 70 Gy
● 44–64 Gy

Question 35

What does the NCCN (2013) recommend for
adjuvant radiation therapy after primary surgical
intervention for oropharyngeal cancer?

Answer 35

Conventional fractionation
● 60 to 66 Gy to the primary and gross nodal disease
● 44 to 64 Gy to occult nodal disease for 6 weeks

Question 36

What is the recommended radiation target vol-
ume of the neck in patients with oropharyngeal
squamous cell carcinoma and ipsilateral N2a or
N2b disease?

Answer 36

Levels IB-V and retropharyngeal lymph nodes

Question 37

What chemotherapy regimen is recommended for
concurrent chemoradiation therapy in orophar-
yngeal squamous cell carcinoma?

Answer 37

Cisplatin: 100 mg/m2 every 3 weeks x three doses

Question 38

What surgical approach can be used for most early

and some advanced oropharyngeal malignancies?

Answer 38

Transoral approach, including laser microsurgery or robotic

surgery

Question 39

What surgical approach can be used for more
extensive inferiorly located oropharyngeal tumors
not amendable to transoral approaches and does
not require mandibulotomy?

Answer 39

● Lateral pharyngotomy
● Transhyoid pharyngotomy
● Lingual release and pull-through technique

Question 40

What surgical approach can be used for the most
advanced oropharyngeal lesions often requiring
reconstruction?

Answer 40

Mandibulotomy with mandibular swing

Question 41

Similar to the management recommendations for
oral cavity cancers, what options are available for
surgical management of oropharyngeal tumors
that invade the mandible?

Answer 41

● Periosteal or superficial cortical invasion only: Rim
mandibulectomy
● Medullary invasion: Segmental mandibulectomy
See oral cavity malignancy for additional discussion of
mandibulectomy indications.

Question 42

How should retropharyngeal lymph nodes be addressed in patients with advanced oropharyngeal squamous cell carcinoma?

Answer 42

Retropharyngeal lymph node dissection and/or radiation

therapy

Question 43

When performing transoral lateral oropharyngectomy or base-of-tongue resection, in addition to clipping named vessels in the operative field with
two or three clips and meticulous hemostasis,
what additional procedures should be considered
to decrease the risk of postoperative hemorrhage?

Answer 43

Ligation of vessels at risk for bleeding into the oropharynx
(lingual, facial, and superior laryngeal arteries; some
authorities consider tying off the external carotid system).
This can be done during concomitant neck dissection or as
a separate procedure.

Question 44

What is the most common method used for
reconstruction of oropharyngeal defects after
transoral procedures?

Answer 44

None: The wound is allowed to heal by secondary intention.

Question 45

If a patient undergoes transoral tumor extirpation
for a primary base-of-tongue or tonsil tumor at the
same time as a neck dissection, and the decision is
made to allow the wound to heal by second
intention, what should be carefully ruled out
before closure of the neck?

Answer 45

Orocervical fistula

Question 46

What is the best reconstructive option for large
oropharyngeal defects involving the tonsillar fossa,
pharyngeal wall, and tongue base?

Answer 46

Fasciocutaneous free flap (radial forearm free flap is used

most commonly)

Question 47

What are the most important goals of tongue base

reconstruction?

Answer 47

● Maintenance of the airway with prevention of aspiration
● Preservation of swallowing
● Preservation of speech

Question 48

When considering a pectoralis major myocuta-
neous flap or a fasciocutaneous free flap for reconstruction of the oropharynx, which recon-
structive option provides the best functional out-
come with respect to swallowing?

Answer 48

Free flap reconstruction (decreased percutaneous endo-

scopic gastrostomy tube dependence)

Question 49

Although multiple reconstructive options are
available for soft palate reconstruction, including
primary closure, local mucosal flaps, and free
tissue transfer, what additional option should be
considered for smaller defects, and what healing

process may contribute to decreased velopharyngeal insufficiency over time?

Answer 49

● Healing by second intention

● Cicatricial scarring

Question 50

What might result if a large portion of the soft
palate is resected and not reconstructed after
surgery for oropharyngeal tumors?

Answer 50

Velopharyngeal insufficiency with nasopharyngeal reflux

and hypernasal speech