Bds lec

1. Oropharyngeal cancer
Prof. Zahid Mahmood

2. Epidemiology
• In the Western world, oral/oropharyngeal cancer is
uncommon, accounting for only 2–4 per cent of all malignant
tumours
• In the Indian subcontinent, however, oropharyngeal cancer
remains the most common malignant tumour, accounting for
40 per cent of all cancers.

3. Risk Factors
• Tobacco
• Alcohol
• Areca nut/pan masala
• Human papillomavirus
• Epstein–Barr virus
• Plummer–Vinson syndrome
• Poor nutrition

4. INCIDENCE
• The incidence is greater in men than in women and it is pre-
dominantly a disease of the elderly (those over 60 years of
age).
• The incidence in women is increasing, particularly in younger
patients, with oral tongue cancer

5. Common anatomical sites (blue) for oral
squamous cell carcinoma.
• the floor of the mouth
• the lateral border of the anterior
tongue
• the retro molar trigon

6. Conditions associated with malignant
transformation
• High-risk lesions
• Erythroplakia
• Speckled erythroplakia
• Chronic hyperplastic candidiasis
• Medium-risk lesions
• Oral submucous fibrosis
• Syphilitic glossitis
• Sideropenic dysphagia (Paterson–Kelly syndrome)
• Low-risk/equivocal-risk lesions
• Oral lichen planus
• Discoid lupus erythematosus
• Discoid keratosis congenita

7. Leukoplakia
• Leukoplakia is defined as any white patch or plaque that can- not be
characterized clinically or pathologically.
• It is purely a descriptive term with no histological correlation.
• Leukoplakia varies from a small, well-circumscribed, homogenous
white plaque to an extensive lesion involving large surface areas of
the oral mucosa.
• It may be smooth or wrinkled, fissured and vary in color depending
on the thickness of the lesion.

8. Speckled leukoplakia
• This is a variation of leukoplakia
arising on an erythematous base
• It has the highest rate of
malignant trans- formation.

9. Erythroplakia
• Erythroplakia is defined as any lesion of the
oral mucosa that presents as a bright red
plaque which cannot be characterized
clinically or pathologically as any other
recognizable condition.
• The lesions are irregular in outline and
separated from adjacent normal mucosa .
• The surfaces may be nodular. These lesions
occasionally coexist with leukoplakia.

10. Potential for malignant change
• The potential risk for malignant transformation:
• increases with increasing age of the patient
• increases with increasing age of the lesion
• is higher in smokers
increases with alcohol consumption
• depends on the anatomical site of the premalignant lesion
• is particularly high for leukoplakia on the floor of the mouth

11. Chronic hyperplastic candidiasis
• Chronic hyperplastic candidiasis produces dense plaques of
leukoplakia, particularly around the commissures of the
mouth.
• The lesions occasionally extend on to the vermilion and even
the facial skin .
• These lesions have a high incidence of malignant
transformation, thought to be the result of invasion of the
lesion by Candida albicans.
• A small percentage of patients have an associated
immunological defect, which encourages the invasion of C.
albicans, rendering the patient susceptible to malignant
transformation.
• Specific management of chronic hyperplastic candidiasis
includes prolonged (6 weeks) topical antifungal treatment or
systemic antifungal treatment (2 weeks).
• If the lesions persist after medical therapy, surgical excision
or laser vaporization is strongly recommended.

12. Oral submucous fibrosis
• Oral submucous fibrosis is a progressive disease in which
fibrous bands form beneath the oral mucosa.
• Scarring produces contracture, resulting in limited mouth
opening and restricted tongue movement.
• The condition is almost entirely confined to the Asian
population and is characterized pathologically by epithelial
fibrosis with associated atrophy and hyperplasia of the
overlying epithelium
• The epithelium also shows changes of epithelial dysplasia.
• Restricted mouth opening can be treated with either
intralesional steroids or surgical excision and skin grafts.
• Research strongly indicates that oral submucous fibrosis is
significantly associated with the use of pan masala areca nut,
with or without concurrent alcohol use.
• Tobacco smoking alone is not associated with oral
submucous fibrosis.

13. Sideropenic dysphagia (Plummer–Vincent
and Paterson–Kelly syndromes)
• There is a well-known relationship between Sideropenic (iron
deficiency in the absence of anemia) and the development of oral
cancer.
• Sideropenic is common in Scandinavian women and leads to
epithelial atrophy, which renders the oral mucosa vulnerable to
irritation from topical carcinogens.
• Correction of the Sideropenic with iron supplements reduces the
epithelial atrophy and risk of malignant transformation.

14. CLASSIFICATION AND STAGING
TNM staging
• Primary tumour (T)
• TX Primary tumour cannot be assessed T0 No evidence of primary
tumour
Tis Carcinoma in situ
T1 Tumour <2 cm in greatest dimension T2 Tumour >2 but <4 cm
• T3 Tumour >4 cm but <6 cm
T4 Tumour invades adjacent structures, e.g. mandible, skin

15. • Regional lymph nodes (N)
• NX Regional lymph nodes cannot be assessed
• N0 No regional lymph node metastasis
• N1 Metastasis in a single ipsilateral lymph node <3 cm in
• greatest dimension
• N2a Metastasis in a single ipsilateral lymph node >3 cm but not
• more than 6 cm
• N2b Metastasis in multiple ipsilateral lymph nodes, none >6 cm
• in greatest dimension
• N2c Metastasis in bilateral or contralateral lymph nodes, none
• N3 Metastasis in any lymph node >6

16. Distant Metastasis
• M0
• M1

17. Clinical features of oropharyngeal cancer
• Localized and persistent sore throat
• Difficulty and/or painful swallowing for >4 weeks
• Painless neck lump
• Unilateral tonsillar enlargement or ulceration
• Otalgia

18. Investigations
• Radiography
• Magnetic resonance imaging
• Computed tomography
• Radio nucleotide studies
• Fine-needle aspiration cytology
• Ultrasound
• Biopsy

19. TREATMENT
• General principles
• The two principal treatment modalities of oropharyngeal cancer are
surgery and radiotherapy.
• Small tumours can be managed either by primary radiotherapy or
surgery.
• Large-volume disease, i.e. advanced tumour, usually requires a
combination of surgery and radiotherapy.
• There is an increasing move to manage extensive disease of the
oropharynx with chemoradiotherapy, provided that patients are
medically fit to tolerate the toxicity.

20. Factors that need to be taken into
consideration include…...
• the site of disease
• the stage
• Histology
• concomitant medical disease
• social factors.

21. • The management of head and neck cancer involves a team approach
• Cancer of the oral cavity is frequently managed with primary surgery whereas
cancer of the oropharynx can be treated with either primary radiotherapy or
primary surgery, or a combination
• When the tumour invades bone, e.g. the mandible, primary surgery is deemed
appropriate as radiotherapy is less effective in controlling disease.
• Surgery is also more appropriate for bulky advanced disease, usually followed
by postoperative radiotherapy.
• Tumours of intermediate size, e.g. T2 and T3 tumours, are more problematic
and treatment regimes more controversial, hence the need for planning by a
multidisciplinary team.

22. Cervical node involvement
• When cervical lymph node involvement occurs, treatment should be
geared towards a single modality to deal simultaneously with the
lymph node disease and the primary tumour.

23. • Malignant tumours of the minor salivary glands require primary surgery
whereas lymphoma is managed by radiotherapy, or chemotherapy and
radiotherapy, depending on the stage.
• Postoperative radiotherapy for minor salivary gland tumours is often indicated
to reduce the risk of loco regional recurrence.

24. • Age
• Modern anesthesia and postoperative critical care facilities have allowed major
head and neck surgery to be carried out on patients with significant medical
comorbidity.
• Advancing age is now not considered to be a contraindication to major head
and neck cancer surgery.
• Conversely, young patients should not be denied radiotherapy for fear of
inducing a second malignancy, e.g. sarcoma, in later life.
• Previous radiotherapy
• A second course of radiotherapy to a previously irradiated site is
contraindicated as the tumour is likely to be radio resistant and reirradiation will
invariably result in extensive tissue necrosis.

25. • Field change
• Surgery is preferred when multiple tumours are present or there is extensive
premalignant change of the oropharyngeal mucosa. Radiotherapy is
unsatisfactory as the entire oral cavity requires treatment, causing severe
morbidity.
• In addition, subsequent post radiotherapy changes make the diagnosis of
future premalignancy and malignancy more difficult.
• Management of premalignant conditions
• Elimination of associated etiological factors is the basis of the management of
premalignant oral mucosal lesions. Cessation of smoking, elimination of the
areca nut/pan habit.

26. • reduction in alcohol consumption should be encouraged in all patients with
premalignant lesions.
• A photographic record of the lesion is useful, particularly for long-term follow
up.
• All erythroplakia and speckled leukoplakia should undergo urgent incisional
biopsy.
• Biopsy from more than one site provides a better representation of histological
changes within a lesion.
• Severe epithelial dysplasia and carcinoma in situ should be ablated by surgical
excision or laser vaporization.

27. • Small lesions, particularly on the lateral border of the tongue or buccal
mucosa, may be managed with surgical excision and primary closure by
undermining the adjacent mucosa.
• Larger defects can be managed with laser vaporization and allowed to
epithelialize spontaneously
• With mild-to-moderate epithelial dysplasia, treatment is facilitated by
elimination of causative agents.
• Patients who continue to smoke should be managed as for severe dysplasia
and carcinoma in situ.
• Patients who cease smoking and areca nut/pan habits may be followed up
closely at three-monthly intervals.

28. LIP CANCER
• Surgery and external beam radiotherapy are highly effective methods
of treatment for lip cancer. The cure rate approaches 90 per cent for
either modality.
• Premalignant changes on the lower lip mucosa are frequently
extensive and are best managed by a lower lip shave, in which the
vermilion defect is closed by advancement of the lower labial mucosa.

29. • Small tumours
• Small tumours (<2 cm) of the lip can be managed with either a V-
or W-shaped excision under local or general anesthesia.
• The defect, which should be no larger than one-third of the total
lip size, is closed in three layers – mucosa, muscle and skin – with
particular attention paid to the correct alignment of the vermilion
border

31. • Intermediate tumours
• Larger tumours, which produce defects of between one-third and
two-thirds the size of the lower lip, require local flaps for
reconstruction.
• V or W excision will result in microstomia.
• Large central defects are best managed using the Johansen step
technique. This allows closure of the defect by symmetrical
advancement of soft-tissue flaps, utilizing the excess skin in the
labiomental grooves.
• Alternative techniques include the Bernard rotational flap.

33. • Total lip reconstruction
• Extensive tumours of the lower lip, which invade adjacent tissues
(T4), have a high incidence of neck node metastasis.
• Patients with such advanced disease require surgery that may
include unilateral or bilateral selective neck dissection and total
excision of the lower lip and chin.
• The lower lip defect is best reconstructed with a forearm flap
suspended with palmaris longus tendon

35. TONGUE CANCER
• Up to 30 per cent of patients with a T1 (<2 cm diameter)
tumour have occult metastasis at presentation and should
undergo simultaneous treatment of the neck by either
selective neck dissection or radiotherapy.
• When performing surgical excision of the primary tumour, a
2-cm margin in all planes should be achieved to ensure a
wide, complete excision.

36. • Resection resulting in partial or hemiglossectomy can be
performed with either a cutting diathermy or laser if
available.
• Advanced tumours (T3 and T4) often encroach upon the
floor of the mouth and, occasionally, the mandible. In
these circumstances, a major resection of the tongue and
floor of the mouth and mandible is required. T4 tumours
of the oral tongue often cross the midline, for which total
glossectomy is the only option to achieve adequate
tumour clearance.

37. • When a patient undergoes simultaneous neck dissection, the
resection of the primary tumour should preferably be in
continuity with the neck node specimen.
• This eliminates ‘lingual’ lymph nodes (lying between the primary
tumour and submandibular (level I) nodes); these nodes may
contain micro-deposits of tumour, which may lead to local
recurrence.

38. Access
• Access for oropharyngeal cancer is important to allow
accurate assessment and clear visualization to enable
tumour clearance to be achieved. Access techniques include:
• trans oral – small anterior oral tumours only;
lip-split technique and paramedian or median
mandibulotomy
visor incision

42. Reconstruction
• Small defects of the lateral tongue can be managed by primary closure or
allowed to heal by secondary intention.
• Larger defects, e.g. T2, T3 and T4 resections, require formal reconstruction
to encourage good speech and swallowing.
• A radial forearm flap either with skin and/or fascia, utilizing microvascular
anastomosis, gives a good functional result.
• Large-volume defects, including total glossectomy, require more bulky
flaps such as the rectus abdominus free flap.
• If feasible, the preservation of one or both hypoglossal nerves is useful to
encourage floor of mouth function to help relearn swallowing.

43. FLOOR OF MOUTH
• Carcinoma of the floor of the mouth can spread to the ventral surface
of the anterior tongue or encroach upon the lower anterior alveolus
• Surgical excision may include a partial anterior glossectomy and
anterior mandibular resection.
• Only very small tumours of the floor of mouth can be managed by
simple excision.
• The visor procedure provides excellent access

45. Reconstruction
• Small tumours of the floor of the mouth frequently require
formal reconstruction.
• It is unacceptable to advance the cut surface of the ventral
tongue to the labial mucosa as severe difficulties with
speech, swallowing and mastication ensue.
• Simple soft-tissue defects of the anterior floor of mouth are
best reconstructed with a radial artery forearm flap.

46. • If a patient is unfit for microvascular free flap surgery or the
facilities are limited, bilateral nasolabial flaps tunnelled into the
mouth and interdigitated provide an acceptable alternative .
• Three weeks later their pedicles are divided and inset into the
lateral floor of mouth defects.
• Large defects that involve rim resection of the anterior mandible
may also be managed with soft tissue reconstruction only.

47. • Full-thickness resection of the anterior mandible,
however, requires immediate reconstruction to prevent
severe functional defects or a cosmetic deformity.
• Vascularized bone with a soft-tissue component
provides the most up-to-date method of reconstruction.
• A fibula flap or a vascularized iliac crest graft (deep
circumflex iliac artery (DCIA)) are two options in the
management of anterior mandible defects with
simultaneous floor of mouth defects.

49. BUCCAL MUCOSA
• Squamous cell carcinoma of the buccal mucosa should be excised
widely, including the underlying buccinators muscle.
• Larger tumours occasionally extend onto the maxillary tuberosity,
tonsillar fossa or mandibular alveolus.
• Facial skin involvement is rare but carries a poor prognosis.
• Although cervical node metastasis from buccal mucosa usually occurs
less readily than in tongue and floor of mouth cancer, a simultaneous
ipsilateral selective supraomohyoid neck dissection (levels I, II, III) is
considered good practice.

50. • Access for buccal carcinoma can be achieved either trans- orally for
smaller lesions (T1, T2) or using the lip-splitting technique for larger
lesions (T3, T4).
• Reconstruction of the buccal mucosa prevents scarring and trismus.
• Options include the radial artery forearm flap or a temporalis muscle
flap.
• Raw temporalis muscle inset into the buccal mucosal defect will
epithelialise spontaneously over several weeks.

52. LOWER ALVEOLUS
• Surgery is the treatment of choice for tumours that involve the
mandibular alveolus
• Ipsilateral selective neck dissections should be performed for lateral
tumours although the incidence of occult neck node metastasis is low.
• Bilateral selective neck dissection should be considered for anterior
tumours.
• Bone invasion demands segmental resection of the mandible in
continuity with neck dissection. Primary or immediate reconstruction
is preferred as the functional and cosmetic outcomes are usually
superior to those of delayed reconstruction.

53. • Options include the fibula flap for the edentulous mandible
and the iliac crest (DCIA) for patients with a dentate mandible .
• The vascularized iliac crest can be wrapped with internal
oblique abdominal wall muscle, which epithelializes
spontaneously.
• This intraoral epithelialization provides an excellent surface for
prosthetic replacement.
• Although non-vascularised bone grafts have a place in
mandibular reconstruction, the long-term success is frequently
low as many patients receive postoperative radiotherapy,
which results in the loss of the bone and dehiscence of the
titanium tray or reconstruction plate.

55. RETROMOLAR PAD
• Tumours at this site frequently, but not always, invade the ascending
ramus of the mandible.
• They also spread medially into the soft palate or even the tonsillar
fossa.
• Access for excision is carried out via a lip split and mandibulotomy
• Small defects are managed either with a temporalis muscle flap or a
radial artery forearm flap.
• Segmental mandibular resections require vascularised bone to
achieve adequate reconstruction.

56. HARD PALATE AND MAXILLARY ALVEOLUS
• The maxillary alveolus and hard palate are relatively uncommon sites
for SCC.
• A tumour arising in these areas may arise either from the oral mucosa
per se or from the maxillary antrum penetrating the oral cavity.
• In the Indian subcontinent, carcinoma of the hard palate is common
and particularly associated with reverse smoking.
• Occasionally, malignant tumours of minor salivary glands present as
swellings of the hard palate.
• Small tumours of the maxillary alveolus can be managed by transoral
partial maxillectomy.

57. • More extensive tumours involving the floor of the maxillary
sinus require wider access by a Weber– Ferguson incision .
• If the preoperative investigations demonstrate extension of
the disease into the pterygoid space or the infratemporal
fossa, the prognosis is poor as surgical clearance is difficult if
not impossible.
• Tumour extending into the orbit requires simultaneous
orbital exenteration or even a combined neurosurgical
resection.
• The vascularised iliac crest graft is the method of choice for
immediate maxillary reconstruction although the fibula
provides adequate bony replacement to maintain facial
contour.

58. • Microvascular free tissue transfer remains the method of choice for
the management of defects in the oropharynx . Free flaps are
superior reconstructive options to pedicled or local flaps, which may
be used for salvage procedures or recurrent disease.
• Each ‘free’ flap has a principal blood supply and a concomitant
venous drainage. The flaps can be tailored to the defect to include
skin, fascia, bone and muscle.
• The techniques of free tissue transfer demand specialist training and
a micro- scope to connect blood vessels in the neck after neck
dissection, e.g. facial artery to the prepared artery attached to the
flap.

60. OROPHARYNX
• Tumours of the oropharynx are frequently not amenable to
surgery because of the morbid nature of the resection –
small and intermediate (T1, T2) tongue base tumours may
necessitate total glossectomy to achieve adequate clearance
at the root of the tongue.
• Tumours of the soft palate and tonsil, however, can be
managed with either primary surgery in continuity with neck
dissection or primary radiotherapy. Subsequent defects of
the tonsillar area can be managed with a forearm flap.

61. • Defects of the soft palate, including total soft palate
reconstruction, are best managed with a combined
reconstruction consisting of a superiorly based pharyngeal flap
to line the nasal surface and a forearm flap for the oral surface
of the new soft palate.
• Chemoradiotherapy is now increasingly used to manage
tumors of the oropharynx in which organ preservation, but not
necessarily function, is the goal.
• In patients with large-volume neck disease, e.g. N2 and N3, a
combined modality of neck dissection followed by
chemoradiotherapy to manage the tumor at the primary site
and residual neck disease is gaining popularity.

62. Chemotherapy
• The role of chemotherapy has evolved over the last 20–30 years. It was
initially reserved for treatment of recurrent and incurable disease, often
using single-agent therapy.
• Combination chemo- therapy, particularly platinum agents and 5-
fluorouracil, is now more effective in controlling recurrent and incurable
disease.
• combination chemotherapy is associated with more severe side effects
and a balance needs to be reached between efficacy, palliation and quality
of life.
• Chemotherapy also now has an important role in the treatment of locally
advanced and previously untreated oropharyngeal carcinoma.

63. • There is compelling evidence that tumors of the tongue base may
best be managed with primary chemoradiotherapy rather than
radical surgery.
• The addition of chemotherapy with radiotherapy does, however,
increase the morbidity and mortality rates. Patients who are frail or
who have significant medical comorbidity may not tolerate the
regime.
• Chemoradiotherapy has been shown to improve survival in patients
whose tumors are deemed unresectable, although organ
preservation, i.e. swallowing and speech, is not always sustained.
• There is good evidence for the superiority of chemoradiotherapy over
radiotherapy alone; however, chemoradiotherapy is rarely effective in
large-volume disease.

64. Management of the neck
• The management of the cervical lymph nodes is highly
dependent on the planned treatment of the primary tumour.
When surgery is deemed appropriate for the primary tumour,
simultaneous neck dissection should be considered. If
radiotherapy is preferred, treatment to the neck should be
contemplated, particularly when there is a high risk of occult
metastases, e.g. tongue.

65. The clinically node-negative neck
• The cervical lymph nodes contain occult metastases in up to 30 per cent of
patients. This is particularly significant with patients presenting with primary
carcinomas of the tongue and, to a lesser extent, floor of mouth.
• Tumours arising in the buccal mucosa and mandibular alveolus are less likely to
have occult metastasis.
• Nevertheless, increasing evidence exists that active treatment of cervical lymph
nodes in the absence of obvious disease is considered good practice.
• Patients with carcinoma of the lateral tongue, floor of mouth and mandibular
alveolus are best managed by supraomohyoid neck dissection (surgical removal
of lymph node levels I, II and III in continuity with the primary tumour)

67. COMPLICATIONS
• Speech deficiencies, especially with resection of the anterior floor of
the mouth and tongue
• Swallowing dysfunction and aspiration, especially after
oropharyngeal resection
• Neurological injury, e.g. lingual nerve, hypoglossal nerve palsy
• Wound breakdown and cervical fistula formation
• Failure of internal fixation/reconstruction plates
• Failure of microvascular anastomosis
• Flap failure.

68. • Patients undergoing treatment for oropharyngeal cancer
frequently develop severe functional problems.
• The size and location of the tumor will dictate the extent of
resection and the sacrifice of important structures.
• Loss of tongue and floor of mouth musculature and the
removal of bone and associated muscle attachments together

69. • with the sacrifice of sensory and motor cranial nerves all greatly affect
not only appearance but also speech, swallowing and nutritional
status. Psychological disturbance is universal in patients undergoing
major head and neck cancer surgery and radiotherapy.
• The techniques of immediate reconstruction, particularly with
microvascular flaps, minimize the complications and side effects but
many patients are, nevertheless, radically changed for the remainder
of their lives. Patients undergoing ‘salvage’ surgery following primary
radiotherapy frequently undergo delayed wound healing, cervical
fistula formation and, occasionally, carotid artery blowout/rupture.
Skin anesthesia associated with scar contracture creates additional
problems, particularly with neck mobility and trismus.

70. POST-TREATMENT MANAGEMENT
• Patients with oropharyngeal cancer need to be followed up regu-
larly, not only to detect possible recurrence but also to manage the
morbidity associated with treatment.
• In total, 70 per cent of recurrences occur in the first 12 months
following treatment and 90 per cent in the first two years.
• Patients who survive for five years are cured and discharged.
• Recurrence after extensive surgery and radiotherapy is frequently
beyond any further treatment and palliative care is a logical pathway.

71. OUTCOME AND PROGNOSIS
• Survival after oropharyngeal cancer is directly related to:
• the size of the primary tumour (T stage)
• the evidence of neck node metastasis (N stage)
concomitant medical problems, e.g. cardiorespiratory disease.

72. • Patients with large primary tumours are more likely to develop
cervical node metastasis. Cervical node metastasis, particularly
with extracapsular spread, is the most significant factor in
determining prognosis for oropharyngeal cancer.
• Supportive treatment is important for patients with oropharyngeal
cancer, particularly in the form of speech and language support
and dietetic and psychological input.
• Smoking cessation and a drastic reduction in alcohol intake
reduces the risk of developing further metachronous carcinomas in
the aerodigestive tract.