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Oropharyngeal Cancer

Head and Neck Cancer
  1. Squamous cell carcinoma represents more than 90% of all head and neck cancers. Q
  2. Most common site of oral cancer
    - World wide lower lip.
    - In India avelo buccal sulcus. 
  3. Most common site of CA tongue – lateral margin middle 1/3.
  4. The incidence is greater in men than in women
  5. It is predominantly a disease of the elderly
  1. Pathophysiology
    • Squamous cell carcinoma is thought to arise from keratinizing or malpighian epithelial cells
    • The hallmark of squamous cell carcinoma is the presence of keratin or “keratin pearls” on histology.
    • These are well-formed desmosome attachments and intracytoplasmic bundles of keratin tonofilaments.
    • Morphologically, it is variable and may appear as plaques, nodules, or verrucae.
    • These in turn may be scaly or ulcerated, white, red, or brown.
    • Verrucous carcinoma has a more favorable prognosis because of infrequent nodal and distant metastasis.
    1. Relevant Anatomy
      1. The oral cavity is defined as the area extending from the vermilion border of the lips to a plane between the junction of the hard and soft palate superiorly and the circumvallate papillae of the tongue inferiorly.
      2. This region includes the buccal mucosa, upper and lower alveolar ridges, floor of the mouth, retromolar trigone, hard palate, and anterior two thirds of the tongue.
      3.  The lips are the most common site of malignancy in the oral cavity and account for 12% of all head and neck cancers, excluding nonmelanoma skin cancers. Squamous cell carcinoma is the most common histologic type, with 98% involving the lower lip.
      4. This predilection to the lower lip has been attributed to sun exposure. Next most common sites in order of frequency are the tongue, floor of the mouth, mandibular gingiva, buccal mucosa, hard palate, and maxillary gingiva.  
    2. Tumor site and lymphatic drainage
      1. Anterior tongue to subdigastric, submaxillary, or midjugular nodes
      2. Floor of mouth to subdigastric, submaxillary, or midjugular nodes
      3. Gingival to jugulodigastric, submaxillary, or midjugular nodes
      4. Buccal mucosa to submaxillary, preparotid, or jugular nodes
      5. Hard palate to submaxillary or jugulodigastric

Risk factor associated with tobacco and alcohol in head and neck cancer






1.9 fold

3 fold


1.7 fold

1.7 fold

Tobacco and alcohol (Synergistic)

35 fold

35 fold

  1. Risk factor associated with cancer of the head and neck.
    1. Tobacco
    2. Alcohol
    3. Areca nut/pan masala
    4. Human papilloma virus 16 & 18
    5. Epstein – Barr virus
    6. Plummer-Vinson syndrome
    7. Poor nutrition
    8. P53 mutation 
  2. Conditions associated with malignant transformation
    1. High-risk lesions
      1. Erythroplakia
      2. Speckled erythroplakia
      3. Chronic hyperplastic candidiasis
    2. Medium – Risk lesions
      1. Oral submucous fibrosis
      2. Syphilitic glossitis
      3. Sideropenic dysphagia (Paterson – Kelly syndrome)
    3. Low – risk / equivocal – risk lesions
      1. Oral lichen planus
      2. Discoid lupus erythematosus
      3. Discoid keratosis congenital
  3. TNM staging for oral cavity carcinoma
    • ​​Primary tumor
      TX : Unable to assess primary tumor
      T0 : No evidence of primary tumor
      Tis : Carcinoma in situ
      T1 : Tumor is <2 cm in greatest dimension
      T2 : Tumor > 2 cm and <4 cm in greatest dimension
      T3 : Tumor >4 cm in greatest dimension
      T4 (lip) : Primary tumor invading cortical bone, inferior alveolar nerve, floor of mouth, or skin of face (e.g nose or chin)
      T4a (Oral) : Tumor invades adjacent structures (e.g cortical bone, into deep tongue musculature, maxillary sinus) or skin of face.
      T4b (oral) : Tumor invades masticator space, pterygoid plates, or skull base and/or encases the internal carotid artery
    • Regional lymphadenopathy
      NX : Unable to assess regional lymph node
      N0 : No evidence of regional metastasis
      N1 : Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
      N2a : Metastasis in single ipsilateral lymph node, >3 cm or <6 cm
      N2b : Metastasis in multiple ipsilateral lymph node, all nodes < 6cm
      N2c : Metastasis in bilateral or contralateral lymph node, all nodes < 6cm
      N3 : Metastasis in a lymph node > 6 cm in greatest dimension 
    • Distant metastases
      MX : Unable to assess for distant metastases
      M0 : No distant metastases
      M1 :  Distant metastases
Tumors found to arise posterior to Ohngren’s line are associated with a worse prognosis than are more anteriorly based lesions (Ohngren’s line – Line joining the medial canthus of eye to angle of the development).Q         
  1. Pattern of lymph node metastasis in head neck cancer.
    Level I –  the submental and submandibular node
    Level Ia  –   The submental nodes; medial to the anterior belly of the digastric muscle bilaterally, symphysis of mandible superiorly, and hyoid inferiorly.
    Level Ib  -  The submandibular nodes and gland; posterior to the anterior belly of digastric, anterior to the posterior belly of digastric and inferior to the body of the mandible.
    Level II  -  Upper jugular chain nodes
    Level IIa -  Jugulodigastric nodes: deep to sternocleidomastoid (SCM) muscle, anterior to the posterior border of the muscle, posterior to the posterior aspect of the posterior belly of digastric, superior to the level of the hyoid, inferior to spinal accessory nerve (CN IX)
    Level IIb  -  Submandibular recess; superior to spinal accessory nerve to the level of the skull base.
    Level III  -  Middle jugular chain nodes; inferior to the hyoid, superior to the level of thehyoid, deep to SCM from posterior border of the muscle to the strap muscles medially.
    Level IV -  Lower jugular chain nodes: inferior to the level of the cricoid, superior to the clavicle, deep to SCM from posterior border of the muscle to the strap muscle medially.
    Level V -  Posterior triangle nodes
    Level Va  - Lateral to the posterior aspect of the SCM, inferior and medial to splenius capitis and trapezius, superior to the spinal accessory nerve,
    Level Vb -  Lateral to the posterior aspect of CSM, medial to trapezius, inferior to the spinal accessory nerve, superior to the clavicle.
    Level VI -  Anterior compartment nodes; inferior to the hyoid, superior to suprasternal notch, medial to the lateral extent of the strap muscle bilaterally.
    Level VII -  Paratracheal nodes; inferior to suprasternal notch in the upper mediastinum.
  1. Investigation: Q 
    1. Orthopantomogram (OPG) – Plain radiography of the jaw is helpful to assess bony invasion particularly from tumors arising on the alveolus and maxillary antrum.
    2. MRI is the investigation of choice for cancer of oral cavity and oropharynx
      CT – It is useful when bony invasion is suspected. Q
    3. Wedge biopsy – is investigation choice for confirmation of lesion.
      Treatment of choice is wide surgical excision of the tumor with neck dissection.
      Radiotherapy used for adjuvent therapy and for palliative therapy.

Type of Neck dissection


Structure which is removed

Radical Neck dissection

Oral cancer with clinically palpable lymph node

Level 1 to 5 lymph node, Sternomastoid muscle, Accessory nerve, IJ vein, Tail of parotid and submendibular gland

Modified neck dissection (Functional neck dissection)

Head neck cancer with clinically impalpable lymph node

Any of the non lymphatic structure is preserved (Sternomastoid muscle, Accessory nerve or IJ vein, or all three are preserved)

Selective neck dissection

1. Lateral neck dissection


2. Posteriolateral neck dissection

3. Supraomohyoid neck dissection

4. Central compartment neck dissection


1. Level I, II & III lymph node removed

2. Level II to V lymph node removed.

3. Level I to III lymph node removed

4. Level VI lymph node removed


1. For Larynxial cancer


2. For Carcinoma thyroid


3. For Oral Cancer


4. For Prophylectic neck dissection in Medullary carcinoma of thyroid.

  1. Radiotherapy
    1. Nearly all patients with advanced disease require adjuvant radiotherapy, preoperatively or postoperatively.
    2. Radiation dosage in excess of 6000 cGy is recommended with a boost to areas of high risk.
    3. Indications for radiotherapy include a bulky tumor with significant risk of recurrence (T3 and T4), histologically positive margins, and perineural or perivascular invasion of tumor.
    4. For the neck, indications for radiotherapy include elective treatment of the N0 neck not treated surgically where risk of micrometastasis is high, gross residual tumor in the neck following neck dissection, multiple positive lymph nodes, and extranodal extension of tumor.  
Bleomycin with or without electroporation has been used. Cisplatin is another chemotherapeutic drug of choice for head and neck cancers.


Splenic lymphoma is? (AIIMS May 09)

A. Small lymphocytic lymphoma
B. Anaplastic lymphoma
C. Hodgkin's lymphoma
D. Burkitt's lymphoma

Ans. 1.
Small lymphocytic lymphoma



A 25 year male presented with pain abdomen, on USG mixed echogenicity was found at left renal hilum and a multifocal necrotic mass is detected. probable diagnosis is? (AIIMS Nov 08)
A. Metastatic germ cell tumour         
B. Transitional cell carcinoma
C. Lymphoma                          
D. Metastatic malignant melanoma


Ans. A.
Metastatic germ cell tumour

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