patients presenting with suspected nasopharyngeal carcinoma and patients with unknown primary site where nasopharyngeal malignancy is part of the differential diagnosis.
This Patient undergoes panendoscopy and biopsy from tonsil reveals invasive SCC.
IHC test for p16 suggests >70% positive nuclear and cytoplasmic staining (Figure 9.4). On palpation in the OR, the tumor lesion is limited to the tonsil and the base of tongue is soft and without evidence of tumor. A biopsy of the base of tongue adjacent to the tonsil primary is negative for carcinoma.
FIGURE 9.4 Histologic images of a poorly differentiated squamous cell carcinoma with >70% nuclear and cytoplasmic staining for p16.
Question: What is the most appropriate stage assignment?
Answer: cT1N1M0, prognostic stage I. The demographics of patients affected by p16+ OPSCC are distinct from those affected by p16 negative OPSCC. Patients affected by p16+ OPSCC are often younger, have limited or no exposure to tobacco and alcohol, and have fewer comorbidities compared to patients affected by p16 negative disease. These tumors also are significantly more responsive to radiotherapy. As a result, the prognosis of patients with p16+ OPSCC is markedly better. A study by Ang et al. (2010) highlighted that tumor HPV status is a strong, independent prognostic factor for survival in OPSCC (3‐year overall survival for patients with HPV‐positive tumors was 82.4% vs. 57.1% for patients with HPV‐negative tumors, P < 0.001, and HPV‐positive tumors were associated with a 58% reduction in the risk of death [hazard ratio, 0.42; 95% CI, 0.27 to 0.66]). This distinct, favorable prognostic behavior has been recognized in the creation of a separate staging system specific to p16+ OPSCC, which reorganizes the TNM classification and prognostic stage grouping. As a result, a patient with a p16+ T1 or T2 primary neoplasm, and ipsilateral lymph node involvement <6 cm in greatest dimension (irrespective of number of nodes), and no distant metastases, is classified as cT1N1M0, and assigned prognostic stage I.
Question: What is/are the appropriate treatment recommendations for this patient?
Answer: Patients with p16+ OPSCC with small primary neoplasms (T1–2) and single ipsilateral lymph node ≤3 cm, without adverse features on pathology may be treated using single modality treatment (surgery or radiotherapy). It is important to recognize that while there is significant interest in de‐escalation of therapy to minimize treatment‐related morbidity, especially in the context of expected favorable prognosis in patients affected by p16+ OPSCC, any efforts toward de‐escalation should be pursued strictly in the context of clinical trials. The treatment algorithms are best determined by extent and burden of disease, and not on the basis of revised prognostic groups that have been newly assigned to this unique disease.
Key Points
Surgical treatment of oropharyngeal carcinoma is appropriate in patients with transorally accessible early‐stage cancers without pathologically concerning features and no more than one ipsilateral lymph node.
Surgical treatment of oropharyngeal carcinoma can be done through transoral traditional, laser and robotic techniques. Patient factors such as trismus or having a narrow mandible or torus mandibularis may limit exposure. Moreover, a retropharyngeal internal carotid artery is a contraindication for transoral surgery for tumors involving the palatine tonsils.
Patients with obvious indications for postoperative chemoradiation should be given strong consideration for treatment with nonsurgical means to avoid trimodality therapy and reduce treatment burden.
Ipsilateral versus bilateral neck dissection depends on the location of the oropharyngeal tumor. Tumors limited to the palatine tonsil can be managed with ipsilateral dissection, whereas base of tongue cancers or those with significant soft palate extension should be considered for bilateral treatment.
CASE 10
Daniel Sharbel and Kenneth Byrd
History of Present Illness
A 67‐year‐old Caucasian male with a history of cT2N1M0 SCC of the right tongue base treated with chemoradiation 3 years ago presented to his primary care physician complaining of several weeks of severe pain in his right upper neck, right cheek, and ear.
Past Medical History
Coronary artery disease with history of stenting 2 years prior, and peripheral vascular disease.
Nonsmall‐cell lung cancer treated with chemoradiation therapy fifteen years ago.
Past Surgical History
History of prior cervical spine surgery.
Social History
Former smoker with 40 pack‐year history, quit more than 20 years ago. Former drinker, quit more than 20 years ago.
Question: What additional questions would you want to ask?
Any trouble swallowing? Yes.
Any recent infection? Patient Denies.
Any hemoptysis or hematemesis? Patient Denies.
Any difficulty opening and closing the mouth? Patient denies.
Any other masses in the neck that have been noticed? Patient denies.
Any sexually transmitted diseases? None known. The presence of these may increase likelihood of HPV exposure.
History of tracheostomy or gastrostomy? Patient denies. The presence of these may suggest dependence postoperatively.
Performance status? ECOG 1.
Physical Examination
Thin, adult male in mild distress from pain but breathing comfortably.
Skin: no suspicious lesions.
Oral cavity and oropharynx: 3 cm right‐sided nodular tumor arising from the tonsillar bed.
Neck: cervical exam reveals no palpable lymphadenopathy or salivary lesions.
Cranial nerves II–XII intact.
Flexible fiberoptic laryngoscopy: large right tonsillar mass. The epiglottis is displaced inferiorly and posteriorly on exam. The view of the glottis is limited but without any apparent involvement, and the true vocal folds are bilaterally mobile.
