Pharyngeal SCC

• 70% neck mass
• 50% unilateral serous otitis media

• T1: confined to the nasopharynx, or tumor extends to oropharynx and/or nasal cavity without parapharyngeal extension (eg, without posterolateral infiltration of tumor)
• T2: parapharyngeal extension (posterolateral infiltration of tumor)
• T3: involves bony structures of skull base and/or paranasal sinuses
• T4: with intracranial extension and/or involvement of cranial nerves, hypopharynx, or orbit, or with extension to the infratemporal fossa/masticator space

• N1 Unilateral metastasis in cervical lymph nodes ≤6cm in greatest dimension, above the supraclavicular fossa, and/or unilateral or bilateral retropharyngeal lymph nodes ≤6 cm in greatest dimension (midline nodes are considered ipsilateral nodes)
• N2Bilateral metastasis in cervical lymph nodes ≤6cm in greatest dimension, above the supraclavicular fossa
• N3Metastasis in a lymph node >6cm and/or to the supraclavicular fossa
• N3a>6cm in dimension
• N3bExtension to the supraclavicular fossa

• WHO criteria
• Type 1 Differentiated (keratinizing) squamous cell carcinoma (worse prognosis, poorly radiosensitive)
• Type 2 Nonkeratinizing carcinoma (assoc with EBV, better prognosis, radiosensitive)
• Type 3 Undifferentiated carcinoma (assoc with EBV, better prognosis, radiosensitivite)

Radiotherapy to primary site and bilateral necks

Based on Intergroup study 0099, concurrent chemoRT (cisplatin 5-fu) followed by adjuvant chemo

• Alcohol
• Tobacco
• Plummer Vinson syndrome
• Reflux/Barretts Esophagus

• Piriform sinus: most common subsite, 75%. 75% regional mets.
• Posterior pharyngeal wall, 25%. 60% regional mets.
• post cricoid, <5%. 40% regional mets. Assoc with Plummer-Vinson

• T1: The tumor is limited to one subsite of the hypopharynx and is 2 cm or less at its greatest dimension.
• T2: The tumor involves more than one subsite of the hypopharynx or an adjacent site or is larger than 2 cm but not larger than 4 cm at its greatest diameter without fixation of the hemilarynx.
• T3: The tumor is larger than 4 cm at its greatest dimension or involves fixation of the hemilarynx.
• T4a – The tumor invades the thyroid/cricoid cartilage, hyoid bone, thyroid gland, esophagus, or central compartment soft tissues, including prelaryngeal strap muscles and subcutaneous fat.
• T4b - The tumor invades the prevertebral fascia, encases the carotid artery, or involves mediastinal structures.

• N1: Metastasis is found in a single ipsilateral node (≤ 3 cm at its greatest dimension).
• N2: Metastasis is found in a single ipsilateral lymph node (>3 cm but < 6 cm in greatest dimension) or in multiple ipsilateral lymph nodes (none >6 cm at greatest dimension).
• N2a - Metastasis in a single ipsilateral lymph node (>3 cm but < 6 cm at its greatest dimension)
• N2b - Metastasis in multiple ipsilateral lymph nodes (none >6 cm at greatest dimension)
• N2c - Metastasis in bilateral or contralateral lymph nodes (none >6 cm at greatest dimension)
• N3: Metastasis is found in a lymph node larger than 6 cm at its greatest dimension.

• Radiotherapy alone (commonly 66-70 Gy) including bilateral necks
• surgery including ipsilateral neck dissection unless primary disease crosses midline, then B/L necks. Possibly with postoperative irradiation, depending on the pathology findings.
• Larynx preservation therapy is typically possible and is strongly favored.

• concurrent chemoRT with surgical salvage for poor responders (first choice)
• Partial or total laryngopharyngectomy, neck dissection, postoperative radiotherapy
• Address bilateral necks

Advanced disease, 40-70% have nodal disease.

10-37%.

Secondary to poor absorption from decreased gastric acidity, decreased transit time due to truncal vagotomy, and disruption of vascular supply to parathyroids.

• Early antigen (EA)
• Viral capsule antigen (VCA): late antigen, most specific for NPC
• Low titers of IgA EA and IgA VCA predict poorer prognosis.  High titers predict better prognosis.

• Fossa of Rosenmuller: slitlike region medial to the medial crura of the eustachian tube orifice
• 

circumvallate papillae, junction of hard and soft palate

• Tonsil/lateral pharyngeal wall
• 65-75% with neck disease at presentation
• lymphoma and lymphoepitheloma is more common here than elsewhere in OP

• more aggressive than oral tongue
• >60% rate of cervical mets
• 20% B/L cervical mets
• 65% five year survival for all stages

• T1 <2cm
• T2 2-4cm
• T3 >4cm
• T4a invades larynx, extrinsic muscles of tongue, medial pterygoid, hard palate, or mandible
• T4b invades lateral pterygoid, pterygoid plates, lateral nasopharynx, skull base, or encases carotid

• subgroup of poorly diffferentiated carcinoma
• may present in the tonsil
• exophytic
• radiosensitive

• N0: elective B/L ND vs RT
• N1-3: MRND

• aggressive disease (eg tongue base ca)
• close or positive margins
• multiple positive nodes
• extracapsular ext
• perineural or intravascular spread
• invasion of bone, cartilage, soft tissue

• Anteriorly at hard palate/soft palate junction and circumvillate papillae
• superiorly at hard palate
• inferiorly at superior surface of hyoid

tonsil/lateral pharyngeal wall.  Usually p/w neck disease (65-75%).  Higher incidence of lymphoma and lymphoepithelioma at this site.

• 20% B/L neck disease
• 65% 5-year survival