tumors of the pharynx

1. Pharyngeal tumors
Dr samer serhal

4. Neck ln levels

6. Nasopharyngeal cancer
 nasopharyngeal carcinoma (NPC) entails
one of the poorest prognoses because of
the primary tumor’s proximity to the skull
base and multiple vital structures, the
invasive nature that typifies NPC tumor
growth, the subtlety of early symptoms,
and the difficulty of nasopharyngeal
examination that hamper early diagnosis.

9. Nasopharyngeal pathology
 TABLE 113-1. Malignant tumors of nasopharynx from the Mayo Tissue Registry, 1972–1981

 Tumor type No. %
 Squamous SC 120 71
 Lymphoma 31 18
 Miscellaneous 18 11
 Adenocarcinoma 6
 Plasma cell myeloma 3
 Cylindroma 2
 Rhabdomyosarcoma 2
 Melanoma 2
 Fibrosarcoma 1
 Carcinosarcoma 1
 Unclassified, spindling malignant 1
 neoplasm
 Total 169

 aCombined World Health Organization


10. WHO classification of NPC
 WHO type l :SCC , EBV -ve ,25% of
NPC , 5 year survival 10%
 WHO type ll : nonkeratinizing carcinoma
,EBV +ve ,12% of NPC ,5 year
survival 0f 50%
 WHO type lll :undifferentiated
carcinoma,EBV +ve ,63% of NPC , 5
year survival rate of 50%
 Electron microscopy revealed squamous
origine of all the 3 types

11. Risk factors for NPC
 an epidemiologic association has been found
between NPC and the presence of serum
antibodies to components of EBV. Among
both Chinese and North Americans with
nonkeratinizing NPC, 80% to 90% of those
tested have been found to have abnormally
increased antibody titers to EBV viral capsid
antigen (VCA) and early antigen (EA) (Table
113-2)7,8.
 diet
 Genetic predisposition

12. Symptoms and signs of NPC

13. Prognostic factors
Ho’s and Neel’s studies have
identified length and symptomatology
of disease, extension of tumor
outside the nasopharynx, presence of
low neck adenopathy, keratinizing
histologic architecture, cranial nerve
and skull base extension, and the
presence of distant metastasis as
more important adverse prognostic
indicators than implied by standard
AJCC staging procedures.

14. TREATMENT
A-Radiation therapy
External-beam radiation
Primary treatment mode: Field includes primary
tumor, first echelon lymph nodes, and all
clinically involved nodes + prophylactic radiation of
supraclavicular lymph nodes.
B-Surgical treatment
Plays limited role in management
may be preferable to radiation for local
recurrence.
C- Chemotherapy
No proven efficacy regarding survival
May help palliate intractable pain
Vaccines
Future potential development of vaccines for
Epstein-Barr virus–related diseases

15.  In children, in whom NPC is rare, the
differential diagnosis of a destructive
nasopharyngeal mass usually includes
non-Hodgkin’s lymphoma, embryonal
rhabdomyosarcoma, neuroblastoma, and
juvenile nasopharyngeal angiofibroma2.

16. Angioafibroma
 Histologically benign tumor formed from fibrous
tissue with significant vascular tissue that arises
from the posterolateral nasal cavity and the
superolateral nasopharyngeal wall
 Most common benign tumor of the nasopharynx
 Almost exclusively in young adult males
 Commonest syxs are recurrent epistaxis and
nasal obstruction however as they grow they
expand and erode adjacent structures and
produce signs similar to NPC.
 High index of suspicion in order not to bx
 Tx is by surgical excision since they are not
radiosensitive , excision is done after angiography
and embolization of the feeding vessels

18. TABLE 114-3. Diagnosis
Oropharyngeal cancer
History
Alcohol and tobacco abuse
Pain and dysphagia
Physical
Nodal enlargement
Trismus
Cranial nerve deficits
Biopsy of the primary lesion and fine-needle
aspiration of enlarged nodes
Imaging studies
Chest radiograph
CT scan/MRI
Panorex
Laboratory studies
Complete blood count and chemistry
Liver function tests
Electrocardiogram
Examination under anesthesia

19. Premalignant lesions
 Leukoplakia (white lesion):carcinoma in
situ (2%) , invasive SCC (8%), epithelial
hyperplasia ,epithelial dysplasia
 Erythroplakia ( red plaques): 90% of
these lesion excebited sever dysplasia ,
CIS or invasive SCC

21. Squamous papilloma
 Not locally invasive unlike the nasal
and laryngeal pappilomas
 PCR shows 60% correlation with HPV
types 6 and 11

22.  Squamous cell carcinoma (SCC) and its
variants account for more than 90% of
malignant oropharyngeal lesions. The spindle
cell variant is clinically and biologically similar
to SCC, whereas others behave differently
and deserve further discussion.
Verrucous carcinoma is a fungating, slow
growing tumor with well-differentiated
keratinizing epithelium and rare cellular
atypia or mitosis on histology. These lesions
erode into deep structures and rarely
metastasize. Treatment is through a wide
local excision.
Lymphoepithelioma grows rapidly and readily
metastasizes. These lesions usually occur in
the tonsillar region of young adults that do
not have the typical risk factors.

23. Lymphomas from Waldeyer’s ring (usually the non-Hodgkin’s type),
minor salivary gland tumors, mucosal melanomas, and sarcomas are
other malignant lesions found in the oropharynx. Lymphomas are
treated by chemotherapy and radiation, with surgery playing a role
only in diagnosis. Malignant minor salivary gland tumors are found in
the soft palate and tongue base and usually behave as their
counterparts in the major salivary glands. They are treated with wide
local excisions with or without postoperative radiation.

27. TABLE 114-4. Treatment
Oropharyngeal cancer
Team approach
Primary tumor treatment
T1 and T2: surgery or radiation
T3 and T4: combined modality
Neck treatment
N0 and N1: surgery or radiation
N2 and N3: combined modality
Both necks are treated with central
lesions
Retropharyngeal nodes are treated in
advanced
lesions

31. Hypopharynx
 Extends from the level of the hyoid
bone down to the lower level of the
cricoid cartilage at the opening of the
esophagus
 Three anatomical sites :pyriform fossa
,postcricoid and posterior pharyngeal
wall

32. Hypopharyngeal tumors
 90% SCC
 Uncommon disease
 Disease of the elderly , affects males more
then females except in the postcricoid site
 Tobacco , alcohol
 site of origin :Pyriform fossa (60%),postcricoid
(30%) ,posterior pharyngeal wall (10%)
 More then 10% has a second tumor in the
esophagus
 More than 2/3 will have neck ln metastasis at
presentation and half of these bilateral because
the pyriform fossa has the richest lymphatic
drainage

33. men are about eight times more susceptible than women to
cancers of the hypopharynx, one group of female patients
requires special mention2.
A high incidence of cancer of the postcricoid region is found
in women of Irish and Scandinavian descent who have
Plummer-Vinson syndrome3. This syndrome is characterized
by glossitis, splenomegaly, esophageal stenosis, achlorhydria,
and iron deficiency anemia. It is usually accompanied by
severe gastroesophageal reflux.

34. Hypopharyngeal carcinoma
 Early syxs : sensation of lump or
discomfort in the throat, latter the pt
will have dysphagia at first to solids
and latter to liquids ,hoarseness may
occur as a result of invasion of the
larynx or VCs paralysis .
 Generally has a poor prognosis even
with extensive surgery and 60% of
patients are dead within the 1st year

36. The choice of treatment for hypopharyngeal cancer has been
limited to radiation therapy, surgery, or a combination of the two.
In general, most patients with advanced lesions (stage III or IV)
require combination therapy. Chemotherapy is mentioned as an
adjuvant to surgery or radiation therapy when these cancers
present in an advanced stage.
Radiation therapy alone may be used for curative treatment of
small lesions, T1 and some T2, with surgery reserved for salvage
therapy.
The high incidence of lymph node metastases from
hypopharyngeal cancer requires that treatment of the lymph
nodes be considered even in patients with no palpable disease.