Malignant

Malignant

The most important epithelial tumour is squamous cell carci noma, which constitutes approximately 90% of all epithelial tumours in the upper aerodigestive tract ( Figures 52.35 and 52.36 ). In the oropharynx, the proportion is less (70%) because of the higher incidence of lymphoma (25%) and ary gland tumours (5%). Because of the rich lymphatic saliv drainage of the oropharynx, cervical node metastases are common. They may be the only presenting feature with a primary pharyngeal tumour often being unsuspected and missed in the tonsil or tongue base. Aetiology While it has been long established that oropharyngeal squamous cell carcinoma (OPSCC) is strongly associated with cigarette smoking and consumption of alcohol, over recent decades there has been a near epidemic increase in HPV-associated OPSCC (HPV+OPSCC) in the resource-rich world, with prevalences of up to 70% being commonly reported in the USA, UK and northern Europe. That HPV+OPSCC constitutes a separate disease entity is undoubted, as these patients are typically younger with less or - no history of alcohol and tobacco use. The presenting features of HPV+OPSCC include multiple large cystic cervical lymph nodes with a small primary; these are usually associated with better outcomes after treatment. Treatment Treatment varies with facilities around the world, but early- stage tumours may be cured by transoral laser surgery , transoral robotic surgery or radiotherapy . Intermediate- or late-stage disease is usually managed with concurrent chemo - radiotherapy or based on institutional choices, with open surgery and reconstruction using myocutaneous pedicles or free flaps. Recurrent disease following radiotherapy with/ without chemotherapy is a surgical challenge; smaller tumours can be treated by transoral robotic surgery ( Figure 52.37 ), but larger recurrences require open surgery and reconstruction. Neck dissection is required in most cases where surgery is the

(b) Figure 52.37 (a) Recurrent cancer of the soft palate and tonsil set up for transoral robotic resection. (b) Completed resection of the cancer. Note prevertebral fascia that is now continuous with the parapharyn

geal fat.

who have only partially responded following chemoradio therapy . Postoperative dysphagia with aspiration as a result of interference in the complex neuromuscular control of the second phase of swallowing is a particular problem in these patients. The advent of HPV+OPSCC has created a clinical need to define novel de-intensified treatments that maintain current advantageous survival rates while reducing the late morbidity of treatment. Management of such tumours should be multidisciplinary and is best carried out at tertiary centres undertaking this work on a regular basis. Lymphoma of the head and neck Lymphomas of the head and neck may arise in nodal or extranodal sites and both Hodgkin’s disease and non-Hodgkin’s lymphoma commonly present as lymph node enlargement in the neck. Hodgkin’s disease is rare in the oropharynx, but non-Hodgkin’s lymphoma accounts for 15–20% of tumours at this site in some countries. Most are of the B-cell type and have features in common with other MALT tumours. Further evaluation with CT scanning of the thorax and abdomen and bone marrow evaluation are essential. Core biopsy , or, often, excision biopsy to improve tissue yield, is frequently required to establish a firm diagnosis and aid in the classification of lymphomas. Radiotherapy is the treatment of choice for localised non-Hodgkin’s lymphoma; for widespread non-Hodgkin’s lymphoma, systemic treatment is needed. Malignant

The most important epithelial tumour is squamous cell carci noma, which constitutes approximately 90% of all epithelial tumours in the upper aerodigestive tract ( Figures 52.35 and 52.36 ). In the oropharynx, the proportion is less (70%) because of the higher incidence of lymphoma (25%) and ary gland tumours (5%). Because of the rich lymphatic saliv drainage of the oropharynx, cervical node metastases are common. They may be the only presenting feature with a primary pharyngeal tumour often being unsuspected and missed in the tonsil or tongue base. Aetiology While it has been long established that oropharyngeal squamous cell carcinoma (OPSCC) is strongly associated with cigarette smoking and consumption of alcohol, over recent decades there has been a near epidemic increase in HPV-associated OPSCC (HPV+OPSCC) in the resource-rich world, with prevalences of up to 70% being commonly reported in the USA, UK and northern Europe. That HPV+OPSCC constitutes a separate disease entity is undoubted, as these patients are typically younger with less or - no history of alcohol and tobacco use. The presenting features of HPV+OPSCC include multiple large cystic cervical lymph nodes with a small primary; these are usually associated with better outcomes after treatment. Treatment Treatment varies with facilities around the world, but early- stage tumours may be cured by transoral laser surgery , transoral robotic surgery or radiotherapy . Intermediate- or late-stage disease is usually managed with concurrent chemo - radiotherapy or based on institutional choices, with open surgery and reconstruction using myocutaneous pedicles or free flaps. Recurrent disease following radiotherapy with/ without chemotherapy is a surgical challenge; smaller tumours can be treated by transoral robotic surgery ( Figure 52.37 ), but larger recurrences require open surgery and reconstruction. Neck dissection is required in most cases where surgery is the

(b) Figure 52.37 (a) Recurrent cancer of the soft palate and tonsil set up for transoral robotic resection. (b) Completed resection of the cancer. Note prevertebral fascia that is now continuous with the parapharyn

geal fat.

who have only partially responded following chemoradio therapy . Postoperative dysphagia with aspiration as a result of interference in the complex neuromuscular control of the second phase of swallowing is a particular problem in these patients. The advent of HPV+OPSCC has created a clinical need to define novel de-intensified treatments that maintain current advantageous survival rates while reducing the late morbidity of treatment. Management of such tumours should be multidisciplinary and is best carried out at tertiary centres undertaking this work on a regular basis. Lymphoma of the head and neck Lymphomas of the head and neck may arise in nodal or extranodal sites and both Hodgkin’s disease and non-Hodgkin’s lymphoma commonly present as lymph node enlargement in the neck. Hodgkin’s disease is rare in the oropharynx, but non-Hodgkin’s lymphoma accounts for 15–20% of tumours at this site in some countries. Most are of the B-cell type and have features in common with other MALT tumours. Further evaluation with CT scanning of the thorax and abdomen and bone marrow evaluation are essential. Core biopsy , or, often, excision biopsy to improve tissue yield, is frequently required to establish a firm diagnosis and aid in the classification of lymphomas. Radiotherapy is the treatment of choice for localised non-Hodgkin’s lymphoma; for widespread non-Hodgkin’s lymphoma, systemic treatment is needed.