oropharynx cancer Flashcards
subsides of the ooropharynx
tonsil
BOT
Soft palate
posterior pharyngeal wall
most common subsite of ooropharyx cancer
tonsil
M:F oropharynx cancer
4:1 M:F
age for oropharynx cancer
55-65 but younger when associated with HPV
causes of oropharynx cancer
smoking
drinking
HPV (becoming more common)
Patients with previous oropharynx have highest incidence of second primary tumours of the upper aerodigestive tract
Oropharynx is ____to oral cavity _____to level of soft palate and _____to upper margin of the epiglottis and is situated between the axis and ___.
posterior, inferior, superior between axis and C3
the _____ are on the lateral was of the ooropharynx
palatine tonsils
the pharynx links what?
the oral and nasal cavities in the Head to the larynx and esophagus in the neck
what LN are most commonly involved in oropharynx cancer
cervical LN
lymphatic drainage of the tonsil
jugulodigastric and maxillary LN
lymphatic drainage of the soft palate
jugulodigastric, retropharyngeal,submaxillary and spinal accessory LN
lymphatic drainage of base of tounge
jugulodigastric
retropharyngeal
lower cervical
most common pathology of oropharynx cancer
SCC
TNM staging of oropharynx cancer
T1 <2CM
T2 2-4CM
T3 >4cm or extension to linuginal surface of the epiglottis
T4a tumur invades larynx, muscle of the lounge, medial pterygoid, hard palate or mandible
T4b-tumpur invades peterygoid muscle, pterygoid spaces , lateral nasopharynx, skull base or encases carotid artery
N1 - 1 ipsilateral LN <3cm
N2-mets in ipsilateral LN 3-6cm
N3-mets >6cm
grades of oropharynx cancer
grade is same for all H&N cancer except nasopharynx stage 1 T1 N0 M0 Stage 2 T2 N0 M0 stage 3 T3 N0 M0 T(1-3), N1 M0 Stage 4 T4 any N M0 any T N2,N3 M0 any T any N M1
oropharynx cancers usually present _____.
late
route of spread of the tonsils
Palatine-lingual tonsil Tonsillar pillars Soft palate Base of tongue Pharyngeal wall
route of spread of the soft palate
Tonsillar pillars
Pharyngeal walls
Hard palate
Nasopharynx
route of spread of the tounge
Ant ⅔ of tongue
Lateral borders
Base and underside of tongue
Floor of mouth
most common site of distant mets
lung most common distant site
also: bone brain and cervical LN
most common presentation
persistent sore throat and pain during swallowing
presentation of oropharynx not including advanced disease
Persistent sore throat and pain during swallowing **most common
Otalgia
Enlargement of cervical nodes
advanced disease presentation for oropharynx cancer
Fetor oris (unpleasant smell) Dyspnea Dysphagia Hoarseness Dysarthria (difficult or unclear articulation of speech that is otherwise linguistically normal) Hypersalivation
which sub site of oropharynx cancer has the worst prognosis and why?
BOT has worst prognosis because of greater size at diagnosis, more frequent spread to adjacent structures, and higher rate of lymphatic spread
which sub site of oropharynx has the best prognosis?
tonsils and soft palate are better
diagnostic methods used for oropharynx cancer
biopsy (FNA)
Inspection and palpation
flexible nasopharyngoscopy ( a thin tubs is put up the nose and down the larynx to view any abnormalities)
prognostic indicatos for oropharynx cancer
performance status, stage, location of the primary, LN mets, distant mets, HPV (good)
indications for chemo in ooropharynx
used concurrently with XRT
used for stage 3 and 4
chemo agents used for oropharynx cancer
cisplatinum and 5FU
What vertebral body is known as the atlas? A. C1 B.C2 C.C7 D.T3
A
What vertebral body is known as the axis? A.C1 B.C2 C.C7 D.T3
B
surgery for T1 and T2 oropharynx cancer
mandibulectomy and neck dissection
surgeries for: Tumours of the lower BOT that involved the valleculae and extend inferiorly to the supraglottic larynx and pyriform sinus
partial glossectomy and subtotal supraglottic laryngectomy, or partial laryngopharyngectomy with preservation of voice
requirements for a subtotal supraglottic larygectomy
no gross involvement of pharyngoepiglottic fold, preservation of one lingual artery, resection of <80% of the BOT, pulmonary function suitable for supraglottic laryngectomy and medical condition suitable for a major operation
primary treatment for oropharynx cancer
XRT
BOT is bounded ant by ______. lat by _______. and _______and inferiorly by _______and ________.
anteriorly by circumvallate papillae, laterally by glossopharyngeal sulk and oropharyngeal walls and inferiorly by glossoepiglottic fossaor valecula and the pharyngoepiglottic fold
what % BOT patients have mets at presentation?
80%
treatment for exophytic and surface tumours vs for ulcerative and endophytic tumours
XRT alone for exophytic and surface tumours, surgery for ulcerative and endophytic tumours
in general what is the best treatment for oropharynx tumours
best prognosis when treated with XRT+SX intermediate results for surgery alone and worst results for XRT alone
indications for XRT alone BOT
small T1and T2 lesions without significant infiltration on surface or exophytic T2-T3 lesions of the glossopharyngeal are controlled with high dose XRT
Large unresectable BOT that cross the midline are given palliative XRT
Dose for EBRT for BOT
60Gy
indications for SX+XRT for BOT
best suited for patients with larger tumours that extend beyond the BOT or infiltrate and partially fix the tongue
XRT should be given adjuvantly for T3and T4 tumours of the BOT
Borders BOT XRT
superior: base of skull and floor of sphenoid sinus to include retropharyngeal LN
anteriorly to include faucial arch and part of the oral tongue
inferiorly include supraglottic larynx
post include posterior cervical triangle
spinal cord is shielded to ____Gy in BOT EBRT
40-45Gy
CTVs for BOT tumours
CTV1 i the high risk volume
CTV2 is intermediate risk volume
CTV3 is the low risk volume
CTV1 for T1/T2
for T3/T4 BOT cancer
in general includes all primary and nodal gross volume (GTV) within 10mm margin
T1/T2 truncate CTV inside hyoid bone
T3/T4 truncate CTV just outside hyoid bone
exclude sift palate if its not involved
CTV 2 for BOT cancer
(mid risk volume) includes 5mm margin on CTV 1 anteral nodal levels IB, II and V
extends superiorly to the base of the skull
extends inferiorly to the sternoclavicular joint when the neck is treated with IMRT
CTV 3 For BOT cancer
low risk volume includes contralateral uninvolved nodal disease
excludes contralateral nodal levels V and IB if primary tumour is confined ipsilaterally inf margin extends to 2 cm above sternoclavicular joint superior margin extends to transverse process of C1
side effects of XRT in BOT cancer
xerostomia occurs in 75% of cases, IMRT reduces this risk a lot 4% per Gy of parotid mean dose
how is the palatine arch formed
an area between the oral cavity and laryngopharynx is formed by the soft palate and the uvula above and anterior tonsillar pillar and glassopalaitine sulcus laterally and the glossopharyngeal sulcus and the BOT inferiorly
the tonsillar fossa and faucial arch lymphatic networjs
laterally grouped into 4-6 lymphatic ducts -subdigastric upper cerviclal parapharyngeal submaxillary
tonsillar foss tumours usually involve:
are infiltrative and involve the adjacent retromolar trigone =, soft palate, bot
tumours of the faucial arch spreading types
superficial spreading , exophytic, ulcerative infiltrative and ulcerative and infiltrative are often combined they become extensive involving the adjacent hard palate or buccal mucosa in 20% of patientd
how often does LN involvement occur in tonsillar fossa tumours
60-70% of cases
ln invoelde in tonsillar fossa tumours
subdigastric most commonly and also the mid jugular chain and submaxillary LN
which oropharynx tumour usually has involved contralateral LN when the ipsilateral LN are +
occurs in 10-15% of tonsillar tumours especially when the tumour invades mid line
LN progression in oropharynx tumours is usually _____. goes from the _____LN to the _____L;n.
is usually systematic,
goes from the upper jugular to the lower cervical Ln
most common S&S for tonsillar fossa and faucial arch
Sire throat is the most common symtom
difficulty swallowing or pain in the ear is symbolic of the involvement of what structur
anastomotic -tympanic nerve of Jacobson
trismus is symbolic of the involvement of what structure ? is this an early or late symptom
it is a late presentation of involvement of master or pterygoid muscle
which tumour tends to be more keratinizing and more differentiated : faucial arch or tonsillar fossa?
faucial arch
prognostic indicators in faucial arch and tonsillar fossa cancers
- stage
- extenson into the BOT = worse survival
surgery for T1/T2 vs T3/T4 tonsil tumours
T1/T2- tonsillectomy
T3/T4- partial removal of the mandible and ipsilateral neck dissection
treatment for T1/T2 tonsil cancer
T1/T2 tonsil tumours can be treated with XRT or surgery alone
Xrt alone for tonsil cancer
T1,T2,T3 tumours can be treated with XRT alone 60-75Gy in 6-8 weeks LN are treated to 50-75Gy and interstitial bratty is used to deliver additional dose of 25-30Gy to the tumour in some cases
treatment for T3 and T4 tumours tonsil
combo of xrt and Sx
Pre op XRT of 30-50Gy-3/5.5 weeks to the tumour and neck
then radical tonsillectomy and radical neck direction
then 50-60XRT depending on margins and cervical LN involvement
advanced tumours tend to get concurrent t XRT and chemo with cetuximab
treatment for T1 tumours of the faucial arch
<1cm in diameter is treated with wide surgical resection or XRT alone 60-65Gy
T2 tumours of the faucial arch treatment
require more extensive procedures including partial mandible resection if there’d bone involvement neck dissection should be done in patients with palpable cervical Ln
T2 cn also be given XRT alone (65-70Gy) or EBRT (50GY) +intrstitial brachy (20-30Gy)
T3/T4 tumours of the faudicial arch treatment
same as for tonsil
combo of xrt and Sx
Pre op XRT of 30-50Gy-3/5.5 weeks to the tumour and neck
then radical tonsillectomy and radical neck direction
then 50-60XRT depending on margins and cervical LN involvement
advanced tumours tend to get concurrent XRT and chemo with cetuximab
dose for XRT alone for T1, T2, T3-T4 cancers of the tonsil and faucial arch
T1-65
T2-70
T3-T4-70-75
Doses to cervical LN For tonsillar fossa and faucial arch N0 N1 N2a,b N3`
N0 50
N1 66 (reduce fields after 50 Gy)
N2a,b 70 (reduce fields after 50)
N3 70-75 (reduce fields AFTER 50-60)
PREOP XRT dose for tonsillar fossa and faucial arch
40-45Gy to primary tumour and ipsila1teral or both necks
post op XRT for:
negative margins
t3-T4 or N2b, N3 or positive margins
50 for negative margins or 50 for T2N0 tumours post op with - margins
50 to primary site and both necks plus boost to selected volume to total dose of 60-66Gy
boost can be an extra 5-10Gywith reduced portals using 12-16Mev electrons or interstitial brachy
CTV’s for the tonsil
CTV 1 (high risk) includes primary and nodes (GTV) +10mm margins ant ma2rgin 5mm into the uninvolved m area CTV2(mid risk) includes 5margin on CTV1 and nodal levels 1B, 2 and 5
subsides of the hypopharynx
piriform sinus, posterior cricoid, posterolateral pharynx
which is the most common subset of the hypopharynx
piriform sinus
most common age of hypopharnx cancer
50-60
most common gender hypopharynx
m;f 2;1
what are the parts of the ooropharynx
BOT, tonsils, soft palate and post pharyngeal wall
what is most common risk for ooropharynx in older pts vs younger pts
smoking and drinking in older pts
HPV in younger pts
CTV expansion tonsil vs BOT vs Soft palate
GTV +1-1.5cm for tonsil
GTV +2cm for BOT
GTV +1-1.5cm for Soft palate
what subsite has lowest incidence of + LN at dx?
the soft palate
what can increase a patients risk of secondary H&N cancer
drinking +14 alcoholic drinks/ week after the end of tx
what subsited has the highsest risk of LN + at dx
Base of tongue
what is first symptom, sign ?
symptom: pain radiating to the ear
Sign: neck mass
what subsite is diagnosed at the latest stage? why?
BOT
because other subsites a neck mass can be seen evidently on examination, BOT can notg be visualized directly
which oropharynx subsite has good and poor prognosis?
BOT= worse, these tumours are largr and diagnosed later and soft palate and tonsil have better prognosis
prognosis in younger or older pts = better?
younger- associated with HPV is better
what LN are most commonly in the TX field?
RP
