Pharyngeal tumors

What is the pharynx

 What is the function of the pharynx?

The function of the pharynx is to support

breathing and swallowing, and to
effectively and safely separate the two
What is the pharynx?
 So, what is pharyngeal cancer?
A fancy word for throat cancer
Throat cancer is divided into laryngeal and
pharyngeal cancer
Pharyngeal tumours are further subdivided
into nasopharyngeal, oropharyngeal and
laryngopharyngeal
 Pharyngeal tumours present at a mean age of
65, general risk factors include smoking,
alcohol and infection with HPV virus
 Nasopharyngeal tumours: epidemiology
rare in the Western world
Higher incidence in Southeast China, Tunisia,
Sudan and parts of Kenya and Uganda
three times more common in men than in
women.
 Nasopharyngeal tumours: aetiology
three main etiological factors that predispose
to the development of NPC:
1. VIRAL
2. GENETIC
3. ENVIRONMENTAL
 Nasopharyngeal tumours: VIRAL
The link between infection with the Epstein
Barr virus (EBV) and histological types II and III
of NPC is now well established
Only a small subgroup of infected people
develop NPC
the virus impairs tumour suppression by the
host defences
Epstein Barr viral titres can be used to monitor
disease status.
 Nasopharyngeal tumours: GENETIC
The incidence of NPC in Chinese people
remained high even after emigration to North
America and western Europe

Nasopharyngeal tumours:
ENVIRONMENTAL
NPC development is associated with a high
dietary intake of salted fish. The content of
carcinogenic nitrosamines in the fish appears to
be the crucial factor
 Nasopharyngeal tumours:
Histopathology
The great majority of malignancies originate
from the squamous mucosa of the
nasopharynx

Other histological types include

adenocarcinomas, carcinomas of salivary
gland origin, sarcomas, melanomas and solid
haematological malignancies
 Nasopharyngeal tumours:
Histopathology
The WHO describes three histological types of
carcinoma of squamous mucosal origin:
Type 1 squamous cell carcinoma
Type 2 keratinizing undifferentiated
carcinoma
Type 3 non-keratinizing undifferentiated
carcinoma
 Nasopharyngeal tumours: staging
Important because it determines the treatment
protocol to be used
T1 tumour involves the nasopharynx alone or
the nasopharynx and oropharynx.
T2 tumour extends into parapharyngeal tissues
but does not involve bone.
T3 tumour spreads to involve bone or
paranasal sinuses.
T4 tumour involves the skull base/orbit/
hypopharynx/pterygopalatine fossa.
 Nasopharyngeal tumours: clinical
presentation
nasal obstruction, nasal speech, epistaxis and
nasal regurgitation of food.
proptosis and diplopia
chronic headache and secondary sphenoiditis
Obstruction of the ipsilateral eustachian tube
leading to conductive hearing loss
swelling of the cheek or dental symptoms
 Nasopharyngeal tumours: clinical
presentation
palsy of one or more of any of the cranial
nerves, Diplopia or jugular foramen syndrome

Metastatic disease : some patients have

cervical lymphadenopathy at the time of
presentation.
Nasopharyngeal tumours: assessment
fibre-optic examination of the nasopharynx +
biopsy
Imaging of the head and neck:
CT useful for demonstrating bone involvement or
destruction
MRI for demonstrating the soft tissue extent of the
disease and involvement of adjacent muscles and
neurovascular structures
PET for excluding infraclavicular metastases.
 Tumours of the oropharynx:
epidemeology and risk factors
Risk factors include smoking, alcohol and HPV
virus infection
HPV-driven tumours arise in younger patients
and have an overall better prognosis than
alcohol or tobacco driven tumours
 Oropharyngeal tumours:
histopathology
the most common malignant tumour of the
oropharynx is oropharyngeal squamous cell
carcinoma (OPSCC)
lymphomas and salivary gland cancers also
arise due to the presence of lymphoid tissue
and minor salivary glands
SCC of the tonsil involving the soft
SCC of the soft palate involving the
palate and anterior faucial pillar
hard palate
 Oropharyngeal tumours: clinical
presentation
The oropharynx is of a crucial importance in
both swallowing and speech.
dysphagia
odynophagia
otalgia
sore throat or tongue
change of voice
palpable lymph node
 Tonsil tumours may present as unilateral
tonsillar enlargement or as an ulcer.
 Oropharyngeal tumours: assessment
and staging
fibre-optic laryngopharyngoscopy
MRI is the best modality to assess the primary
site and cervical nodes
CT may be required for the evaluation of any
bony involvement and assessment of the
chest and upper abdomen
Staging is mostly dependent on the size of the
tumour
 TX Primary tumour cannot be assessed
T0 No evidence of primary tumour
Tis Carcinoma in situ
T1 Tumour up to 2 cm in greatest dimension
T2 Tumour larger than 2 cm but 4 cm or less in
greatest dimension
T3 Tumour larger than 4 cm in greatest dimension
T4a Tumour invades larynx, deep/extrinsic tongue
muscles, medial pterygoid muscle, hard palate or
mandible
T4b Tumour invades lateral pterygoid muscle,
pterygoid plates, lateral nasopharynx or skull base
or encases the carotid artery
 Tumours of the hypopharynx:
epidemeology
it is one of the rarest of head and neck
cancers.
is also associated with poor socio-economic
status
it is more commonly seen in Eastern Europe
than in Western Europe and has the highest
incidence in Southeast Asia and South
America
 Tumours of the hypopharynx: risk
factors
Smoking is the most important factor,
followed by heavy alcohol consumption. The
combined effect of these two factors greatly
increases the risk of cancer at this site
HPV plays less of a role at this site than at the
oropharynx.
 Tumours of the hypopharynx: signs
and symptoms
Dysphagia
Dysphonia
Unilateral otalgia
Lymphadenopathy
Sore throat for more than 2 weeks
Odynophagia
Stridor
Cough
 Tumours of the hypopharynx: signs
and symptoms
Lymphadenopathy
Patient with upper cervical
lymphadenopathy due to metastatic
involvement of lymph nodes from a
hypopharyngeal cancer
 Tumours of the hypopharynx: signs
and symptoms
a fibre-optic laryngoscopic examination can
show the tumour as an ulcerative or
polypoidal mass in the hypopharynx
Pooling of blood or saliva in the piriform fossa
may indicate a tumour hidden in the
hypopharynx.
the tumour mass can impair movement of the
vocal cord or invade the recurrent laryngeal
nerve which results in a fixed vocal cord
Endoscopic appearance of a hypopharyngeal
cancer. Note the ulcerating tumour
on the left aryepiglottic fold.
Tumours of the hypopharynx: staging
 Tumours of the hypopharynx:
investigations and imaging
Panendoscopy and incisional biopsy
CT scan is necessary to stage hypopharyngeal
cancer. It allows assessment of the size of the
tumour, its upper and lower extent, Invasion
of local structures, spread to lymph nodes and
presence of distant metastasis
 Treatment of pharyngeal tumours
Three modalities
Chemotherapy
Radiotherapy
Surgery

In general, treatment with surgery has better

survival rates, but traditional surgery techniques
are less preferable because they are debilitating
Treatment of pharyngeal tumours
Transoral robotic surgery
 Treatment of pharyngeal tumours:
Nasopharyngeal tumours
Radiotherapy: has many side effects,
including: xerostomia, sensorineural hearing
loss, trismus, exacerbation of dental caries
Chemotherapy: used in combination with
radiotherapy, it has better survival rates than
radiotherapy alone, but increased morbidity
and mortality. Used for advanced stages
Surgery: used only for type 1 NPC and for neck
dissection
 Treatment of pharyngeal tumours:
oropharyngeal tumours
Early-stage tumours (T12 N0) can be treated
by primary surgery or radiotherapy. Cure rates
of 8090 per cent can be expected with either
modality. Surgery can be carried out using
open techniques or by transoral resection.
The management of T3/T4 N+ OPSCC is most
commonly by the use of chemo-radiation.
Surgery results in a significant loss of tissue
and therefore deterioration in function.
 Treatment of pharyngeal tumours:
hypopharyngeal tumours
In general, early-stage tumours receive single
modality treatment, whilst advanced require
combined modality treatment
External beam radiotherapy treatment (EBRT) is
used as curative treatment for early-stages,
however it can cause: erythema mimicking a
burn, Mucositis which can affect speech and
swallowing, fibrosis and scarring of the pharynx
and larynx which can result in dysphagia.
 Treatment of pharyngeal tumours:
hypopharyngeal tumours
For advanced-stage hypopharyngeal cancer, the
treatment would be chemo-radiation
Chemotherapy can cause neutropenia,
ototoxicity, renal damage, nausea, vomiting and
alopecia.
Surgery tends to be reserved for the most
advanced types of hypopharyngeal cancer (stage
T4) or for recurrent disease. The operation
required is total laryngo-pharyngectomy.
complications include pharyno-cutaneous fistula
and hypocalcaemia.
 Survival and prognosis
nasopharyngeal: Overall 5-year survival
figures range from 3757% and are generally
better for the type II and type III
oropharyngeal: the relative 5-year survival
rate is 66%
Hypopharyngeal: has the worst overall survival
rate, it ranges between 30 and 50% according
to the stage
 In summary
Pharyngeal tumours are divided according to site
General risk factors: smoking, alcohol, HPV
Staging according to size and extent of tumour
Investigated with fiber optic laryngoscopy, MRI,
CT. PET scans
Treated with surgery, radiotherapy,
chemotherapy
New robotic surgical techniques are arising