Oral Cavity Cancer

The oral cavity includes the lip, the alveolar ridge (area immediately behind the
top front teeth), the retromolar trigone (small area behind the wisdom teeth), the
floor of the mouth (area under the tongue), the buccal mucosa (lining inside the
lips and cheeks), the tongue, and the hard palate.
Approximately 30,000 new cases of oral cavity cancer occur each year. Studies
show there is a strong link between smoking and alcohol consumption and
disease development. Other factors include genetic susceptibility, diet (vitamin A
deficiency), viruses (herpes simplex virus type 1), chronic irritants (e.g., poor
dental hygiene), and syphilis. Pathologically, the most common tumor type found
in the oral cavity is squamous cell carcinoma.
In the Unites States, cancer of the lip occurs in approximately 4000 people each
year. Most cases occur on the lower lip and as many as 90% of cases occur in
men. Risk factors include smoking (cigarettes and pipes) and sun exposure.
Squamous cell carcinoma of the lip is the most common type, although basal cell
carcinoma also can occur. The typical symptom is an ulcerative lesion or an
exophytic (outward growing) growth on the lower lip.
Cancers of the alveolar ridge (area immediately behind the top front teeth) and
retromolar trigone (small area behind the wisdom teeth) account for
approximately 10% of all oral cancers, or about 4000 cases per year. Four times
as many men are affected than women. Presenting symptoms usually include
pain that is worsened by chewing. Other symptoms include loose teeth and
intermittent bleeding. Nearly all of these cancers are squamous cell carcinomas.
Floor-of-the-mouth cancer usually develops around the age of 60. These cancers
account for 10% to 15% of all oral cavity cancers - about 4000 to 6000 cases per
year. They are approximately 3 times more common in men and typically present
as infiltrating lesions that are very painful.
Cancers of the tongue occur in approximately 6000 individuals per year and
account for about 15% of all oral cavity cancers. The average age at diagnosis is
60, and men are diagnosed three times more often than women. Tongue cancers,
like most other oral cavity cancers, can be infiltrative or exophytic. In most cases,
the primary presenting symptom is pain. Cancers of the tongue have a high risk
of early lymph node involvement and spread to lymph nodes on both sides
(bilateral) in as many as 25% of patients.
Tumors of the hard palate account for 5% of all oral cavity malignancies - about
1500 cases per year. They occur in men 8 times more often than in women.
Squamous cell carcinoma of the hard palate accounts for about 50% of cases and
tumors of the minor salivary glands (e.g., adenoid cystic, adenocarcinoma)
account for the remaining cases.
Cancer of the buccal mucosa (lining inside the lips and cheeks) accounts for
approximately 2500 cases per year. These cancers are often exophytic in nature.
The presenting symptoms are usually pain, followed by bleeding and difficulty

chewing.
Staging
See Staging for general staging rules. Oral cavity tumors are staged as follows:
TX

Primary tumor cannot be assessed

T0

No existence of primary tumor

Tis

Carcinoma in situ

T1

Tumor 2 cm or less in greatest dimension

T2

Tumor more than 2 cm but not more than 4 cm in greatest

dimension.

T3

Tumor more than 4 cm in greatest dimension.

T4 (lip)

Tumor invades adjacent structures (e.g. through cortical bone,

tongue, or skin of neck).

T4
(oral Tumor invades adjacent structures (e.g. through cortical bone, into
cavity)
deep muscle of tongue, maxillary sinus, or skin).
Treatment

Lip
For early disease, either surgery or radiation is the mainstays. The choice
of one over the other depends on the size and location of the disease.
Given the infrequency of spread to the lymph nodes, elective treatment of
the neck is not necessarily required. In advanced disease (Stages 3 and
4), a combination of surgery and postoperative radiation is often required.
Alveolar
Ridge
and
Retromolar
Trigone
In early disease (Stages 1 and 2) surgery or radiation alone with elective
neck treatment (secondary to the tendency for regional nodal spread) is
most often utilized. For advanced stages, multimodality therapy with
surgery and postoperative radiation is often used.
Floor
of
Mouth
Treatment of early disease (Stage 1 and 2) involves surgical resection.
However, either surgery or radiation as single modalities of therapy may
be utilized. In early disease, the treatment of the neck is controversial;
some opt for elective neck treatment in clinically negative necks, while
others take a wait-and-see approach, with treatment reserved for those
who show development of disease. For advanced disease (Stages 3 and 4),
combined modality treatment with surgery and radiation is recommended.
Elective treatment of the neck is required in all cases of advanced disease.
Tongue
Use of either surgery or radiation in early stage disease yields comparable
outcomes. In advanced disease, as in other oral cavity cancers, combined
modality therapy with surgery and radiation is utilized.
Hard
Palate
For both early and advanced disease, surgery is used for primary therapy.
Radiation has a role in advanced disease, depending upon the closeness or
involvement of surgical margins by tumor, evidence of nerve involvement
or the presence of lymph node metastases.
Buccal
Mucosa

Small lesions (T1 or T2) can be handled equally well by either surgery or
radiation. For patients with small lesions and clinically negative necks,
observation can be performed rather than treatment of the neck. For more
advanced lesions, treatment of the neck is advisable. In advanced cancers,
treatment most often consists of surgery followed by postoperative
radiation.

Overview
Head and neck cancer is the term given to a variety of malignant tumors that
develop in the

oral cavity (mouth);

pharynx (throat);
paranasal sinuses (small hollow spaces around the nose lined with cells
that secrete mucus);
nasal cavity (airway just behind the nose);
larynx ("Adam's apple" or voice box); and
salivary glands (parotid, submanidular, sublingual glands that secrete
saliva).

Many authorities also include skin tumors of the face and neck and tumors of the
cervical lymph nodes.
Excluding superficial skin cancers, but including cancer of the larynx and thyroid,
it is conservatively estimated that about 60,000 people are diagnosed with head
and neck cancer annually - about 5% of all cancers diagnosed in the United
States. There are more than half a million survivors of oral, head, and neck
cancer living in the United States today.
Anatomy
of
the
head
and
The head and neck can be divided into several different regions:

neck

nasopharynx:
area behind the
nose
pharynx:
hollow tube at
the upper part
of the throat that
starts
behind
the nose, runs
down to the
neck,
and
becomes part
of
the
esophagus, the
tube that goes to
Click here for image enlargement.
the stomach
oral
cavity:
lips,
floor
of
mouth, tongue,
buccal
mucosa
(lining inside the lips and cheeks), gingiva (gums) and hard palate (bony
top of the mouth), salivary glands (parotid, submandibular and minor
salivary glands)
oropharynx: base of tongue, tonsillar region, soft palate and pharyngeal
walls
hypopharynx: bottom part of the throat
larynx (voice box): supraglottic, glottic (vocal cords), and subglottic
regions

nasal cavity: paranasal sinuses (ethmoid and maxillary)

Risk Factors
Factors known to contribute to the risk of developing head and neck cancers
include smoking (both tobacco and marijuana) or chewing tobacco and alcohol
use. Leukoplakia (white spots or patches in the mouth) also may be considered a
risk factor, as this condition becomes cancerous in approximately one-third of
patients.
Pathology
Most head and neck cancers are squamous cell carcinomas, tumors that develop
in the tissue lining the hollow organs of the body. However, other tumor types
also may be seen and include lymphoepithelioma, spindle cell carcinoma,
verrucous cancer, undifferentiated carcinoma and cancers of the lymph nodes,
called lymphoma (most often diffuse non-Hodgkins lymphoma).
Symptoms
Cancers of the head and neck are some of the few cancers for which a particular
cause can often be identified. When examined, patients who report the symptoms
described below commonly admit to being smokers and/or frequent consumers of
substantial quantities of alcohol. In fact, some doctors candidly admit that it is
quite rare to see patients with head and neck cancer who do not smoke or drink
excessively.
The common symptoms of cancer of the head and neck include

persistent pain in the throat;

pain or difficulty with swallowing;
persistent hoarseness or a change in voice;
pain in the ear; and
bleeding in the mouth or throat.

Because about half of all head and neck cancers originate in the oral cavity, sores
or lesions in the mouth can be warning signs. Two types of lesions that could be
precursors to cancer are leukoplakia (white lesions) and erythroplakia (red
lesions). Although less common than leukoplakia, erythroplakias have a much
greater potential for becoming cancerous. Any white or red lesion that does not
heal or disappear in 2 weeks should be evaluated by a physician and considered
for biopsy.
Other possible signs/symptoms of oral cancer include:

lump or thickening in oral soft tissues;

soreness or feeling that something is stuck in the throat;
difficulty chewing or swallowing;
difficulty moving the jaw or tongue;
numbness of the tongue or other parts of the mouth; and
swelling of the jaw that causes dentures to fit poorly or become
uncomfortable.

Anyone experiencing such symptoms for more than 2 weeks should see their
physician as soon as possible for a thorough examination and laboratory tests. If
a diagnosis cannot be obtained, your physician will refer you to a specialist.
Diagnosis
Establishing a diagnosis for head and neck cancers typically begins with an
examination and biopsy of any identified suspected cancerous lesions or tumors.
This involves extracting a piece of suspicious tissue and sending it to a laboratory
for examination. In some cases the biopsy can be performed in the physician's
office, although it is more common for the procedure to be done in an operating
room under anesthesia.
Types
There are several different types of head and neck cancer, categorized according
to the specific tissue or organ where the cancer originates ... from cancerous
lesions on the lower lip to paranasal sinus tumors deep within the skull. Click on
one of the links below for detailed information on each type of cancer, including
staging and treatment guidelines.
Tumors
of
the
Nasal
Cavity
and
Paranasal
Sinuses
The nasal cavity is the passageway just behind the nose. When we breathe
through our nose, air passes through the nasal cavity en route to the pharynx and
tracheobronchial tree, which leads into the lungs. The paranasal sinuses are airfilled cavities around the nose.
Nasopharyngeal
Cancer
The nasopharynx is the upper part of the throat behind the nose - the nostrils
lead into it, and openings on the sides of the nasopharynx connect to the ears.
Cancers
of
the
Oral
Cavity
The oral cavity includes all the various parts of the mouth: the lips; the lining
inside the lips and cheeks (the buccal mucosa); the bottom of the mouth; the
front of the tongue; the front part of the top of the mouth (the hard palate); the
gums; and the area behind the wisdom teeth (the retromolar trigone).
Tumors
of
the
Oropharynx
The oropharnyx is the part of the throat at the back of the mouth (the throat is
technically known as the pharynx). It's a 5 inch, hollow tube that extends all the
way from the nose down to the top of the trachea (the windpipe that leads to the
lungs). Parts of the oropharnyx include the back of the tongue, the soft palate
(the back part of the roof of the mouth), the tonsils and the part of the throat
behind the mouth.
Hypopharyngeal
Tumors
The hypopharynx is the bottom part of the pharynx, or throat. The pharynx is a
5-inch hollow tube that extends from the nose, down the neck to the esophagus.
Both air and food pass through the pharynx. The air continues on through the
trachea to the bronchi and lungs. Food continues on to the esophagus and
digestive system.
Laryngeal
Cancer
The larynx is more commonly known as the "voicebox." It's a 2 inch, tube-shaped
organ in the neck. Air passes through the larynx on its way into or out of the

lungs, and when we talk the vocal cords inside of the larynx tighten up and
vibrate, producing sound.
Salivary
Gland
Cancer
Salivary glands are located throughout the oral cavity. They are responsible for
making saliva, a substance that keeps the mouth moist and aids in digestion.
Tumors of the Nasal Cavity and Paranasal Sinuses
The paranasal sinuses include:

frontal sinuses - located above the nose

ethmoid sinuses - located just behind either side of the upper nose
sphenoid sinuses - located behind the ethmoid sinus in the center of the
skull
maxillary sinuses - located under the eyes and in the upper part of either
side of the upper jawbone

Cancerous lesions (sores or tumors) of the maxillary sinuses are twice as

common as those of the nasal cavity. Risk factors associated with the
development of nasal and paranasal sinus tumors include exposure to nickel,
chromium, mustard gas, isopropyl alcohol and radium; thoratrast (a contrast
agent once used in x-ray procedures) and possibly chronic sinusitis also have
been linked with development of paranasal sinus tumors.
The most common type of tumor in these regions is squamous cell carcinoma.
Squamous cells are thin, flat cells resembling fish scales. They are found in the
tissue that forms the surface of the skin, the lining of the hollow organs of the
body, and the passages of the respiratory and digestive tracts. Commonly these
tumors are well defined and slow growing, with a low tendency to spread
(metastasize) either locally, regionally or distantly.
Staging
See Staging for general staging rules. Particular tumor stages for the nasal cavity
and paranasal sinuses are as follows:
TX: Primary tumor cannot be assessed.
T0: No existence of primary tumor.
Tis: Carcinoma in situ (early cancer that has not
spread to neighboring tissues).
T1: Tumor limited to antral mucosa with no erosion
or destruction of bone.
T2: Tumor with erosion of the infrastructure including
the hard palate and/or middle nasal meatus.
T3: Tumor invades any of the following: skin of
cheek, posterior wall of maxillary sinus, floor or
medial wall of orbit, anterior ethmoid sinus.
T4: Tumor invades orbital contents and/or any of the
following: cribriform plate, posterior ethmoid or
sphenoid sinuses, nasopharynx, soft palate,
temporal fossae, pterygomaxillary fossae or base
of skull.
Treatment

Nasal
cavity
Primary therapy is surgical resection (removal) of the tumor, although with
early lesions surgery and radiation treatment yield approximately
equivalent results. Because early stage tumors present a low risk for
spreading to the lymph nodes, elective treatment of the regional lymph
nodes (in the neck) usually is unnecessary. Most advanced tumors (T3 or
T4) are treated with a combination of surgery and postoperative radiation
treatment.
Paranasal
sinuses
Maxillary sinus cancers are treated with surgery and postoperative
radiation. Surgical excision may be impractical if the cancer extends to the
base of the skull, the nasopharynx or the sphenoid sinus. In such cases
radiation alone may be used, although in the long run, its ability to
prevent the cancer from spreading is poor. There is some data to suggest
that combining chemotherapy (either intra-arterial or intravenous) with
radiation may improve local control. The most commonly used
chemotherapy agents are Cisplatin (an anti-cancer drug of the type called
platinum compounds) and/or 5-FU, although newer agents are being
tested.

Nasopharyngeal Cancer
Many factors may influence the development of nasopharyngeal (NP) cancer,
including diet, viruses and genetic susceptibility. In some areas of the world, such
as North Africa and Southern China, the occurrence of nasopharyngeal cancer is
common. It is believed that in these areas diet may play a role in the
development of this disease. Most people in these areas make and consume saltcured meats and fish, and it is thought that cooking these foods releases
nitrosamines into the air which distribute over the mucous membranes of the
nasopharynx (nasopharyngeal mucosa), producing changes which increase the
risk of developing cancer.
Viruses such as Epstein-Barr virus (EBV) may also be a causative agent in the
development of nasopharyngeal cancer. EBV is a common virus that lies dormant
in most people. It has been associated with certain cancers, including Burkitt's
lymphoma, immunoblastic lymphoma, and NP carcinoma. It has been found in
specimens of NP cancer and has been shown to be capable of causing malignant
change in test tube cells.
Lastly, genetic susceptibility may play a role in that individuals with certain HLA
(human lymphocyte antigen) types - specifically H2, BW46 and B17 - have an
increased incidence of developing the disease.
The peak incidence of NP cancer occurs in persons 40 to 50 years of age. Males
outnumber females by approximately 2 to1.
Nasopharyngeal carcinoma is divided pathologically into three types:

Type 1 or keratinizing squamous cell cancer;

Type 2 or nonkeratinizing carcinoma; and
Type 3 or undifferentiated carcinoma.

Undifferentiated cancers are the most common. Any of these cancers can grow,
either by infiltration or by expansion. Most infiltrate into neighboring tissues.
Clinically, Type 1 tumors have a greater risk of uncontrolled local tumor growth

and lower potential for regional or distant spread than Types 2 or 3, which have a
high rate of metastasis to regional lymph nodes.
The most common symptom of NP carcinoma is a mass in the neck. Other
symptoms include alterations in hearing, ringing in the ears (tinnitus), nasal
obstruction and pain.
Staging
See Staging for general staging rules. Nasopharyngeal tumors are staged as
follows:
TX:

Primary tumor cannot be assessed.

T0:

No evidence of primary tumor.

Tis:

Carcinoma in situ.

T1:

Tumor limited to one subsite of nasopharynx.

T2:

Tumor invades more than one subsite of the nasopharynx.

T3:

Tumor invades nasal cavity or oropharynx or both.

T4:

Tumor invades skull, cranial nerves or both.

Treatment
Radiation therapy is the standard treatment for almost all NP cancers. Due to the
high likelihood of lymph node involvement, treatment usually includes radiation
therapy to both sides of the neck. In advanced forms of the disease, radiation
alone is rarely sufficient to control tumor growth. Patients with advanced tumors
typically are treated with a combination of chemotherapy and radiation, followed
by adjuvant chemotherapy - additional drug treatment for patients whose cancers
are thought to have spread outside their original sites.
If the patient's cancer returns at the same site as the original (primary) tumor, or
in another location, after it had disappeared, or if metastasis (spreading) is
present, consideration should be given to a course of chemotherapy using single
agents such as Cisplatin, methotrexate, bleomycin, adriamycin and epirubicin.
Oral Cavity Cancer
The oral cavity includes the lip, the alveolar ridge (area immediately behind the
top front teeth), the retromolar trigone (small area behind the wisdom teeth), the
floor of the mouth (area under the tongue), the buccal mucosa (lining inside the
lips and cheeks), the tongue, and the hard palate.
Approximately 30,000 new cases of oral cavity cancer occur each year. Studies
show there is a strong link between smoking and alcohol consumption and
disease development. Other factors include genetic susceptibility, diet (vitamin A
deficiency), viruses (herpes simplex virus type 1), chronic irritants (e.g., poor
dental hygiene), and syphilis. Pathologically, the most common tumor type found
in the oral cavity is squamous cell carcinoma.
In the Unites States, cancer of the lip occurs in approximately 4000 people each
year. Most cases occur on the lower lip and as many as 90% of cases occur in

men. Risk factors include smoking (cigarettes and pipes) and sun exposure.
Squamous cell carcinoma of the lip is the most common type, although basal cell
carcinoma also can occur. The typical symptom is an ulcerative lesion or an
exophytic (outward growing) growth on the lower lip.
Cancers of the alveolar ridge (area immediately behind the top front teeth) and
retromolar trigone (small area behind the wisdom teeth) account for
approximately 10% of all oral cancers, or about 4000 cases per year. Four times
as many men are affected than women. Presenting symptoms usually include
pain that is worsened by chewing. Other symptoms include loose teeth and
intermittent bleeding. Nearly all of these cancers are squamous cell carcinomas.
Floor-of-the-mouth cancer usually develops around the age of 60. These cancers
account for 10% to 15% of all oral cavity cancers - about 4000 to 6000 cases per
year. They are approximately 3 times more common in men and typically present
as infiltrating lesions that are very painful.
Cancers of the tongue occur in approximately 6000 individuals per year and
account for about 15% of all oral cavity cancers. The average age at diagnosis is
60, and men are diagnosed three times more often than women. Tongue cancers,
like most other oral cavity cancers, can be infiltrative or exophytic. In most cases,
the primary presenting symptom is pain. Cancers of the tongue have a high risk
of early lymph node involvement and spread to lymph nodes on both sides
(bilateral) in as many as 25% of patients.
Tumors of the hard palate account for 5% of all oral cavity malignancies - about
1500 cases per year. They occur in men 8 times more often than in women.
Squamous cell carcinoma of the hard palate accounts for about 50% of cases and
tumors of the minor salivary glands (e.g., adenoid cystic, adenocarcinoma)
account for the remaining cases.
Cancer of the buccal mucosa (lining inside the lips and cheeks) accounts for
approximately 2500 cases per year. These cancers are often exophytic in nature.
The presenting symptoms are usually pain, followed by bleeding and difficulty
chewing.
Staging
See Staging for general staging rules. Oral cavity tumors are staged as follows:
TX

Primary tumor cannot be assessed

T0

No existence of primary tumor

Tis

Carcinoma in situ

T1

Tumor 2 cm or less in greatest dimension

T2

Tumor more than 2 cm but not more than 4 cm in greatest

dimension.

T3

Tumor more than 4 cm in greatest dimension.

T4 (lip)

Tumor invades adjacent structures (e.g. through cortical bone,

tongue, or skin of neck).

T4
(oral Tumor invades adjacent structures (e.g. through cortical bone, into
cavity)
deep muscle of tongue, maxillary sinus, or skin).

Treatment

Lip
For early disease, either surgery or radiation is the mainstays. The choice
of one over the other depends on the size and location of the disease.
Given the infrequency of spread to the lymph nodes, elective treatment of
the neck is not necessarily required. In advanced disease (Stages 3 and
4), a combination of surgery and postoperative radiation is often required.
Alveolar
Ridge
and
Retromolar
Trigone
In early disease (Stages 1 and 2) surgery or radiation alone with elective
neck treatment (secondary to the tendency for regional nodal spread) is
most often utilized. For advanced stages, multimodality therapy with
surgery and postoperative radiation is often used.
Floor
of
Mouth
Treatment of early disease (Stage 1 and 2) involves surgical resection.
However, either surgery or radiation as single modalities of therapy may
be utilized. In early disease, the treatment of the neck is controversial;
some opt for elective neck treatment in clinically negative necks, while
others take a wait-and-see approach, with treatment reserved for those
who show development of disease. For advanced disease (Stages 3 and 4),
combined modality treatment with surgery and radiation is recommended.
Elective treatment of the neck is required in all cases of advanced disease.
Tongue
Use of either surgery or radiation in early stage disease yields comparable
outcomes. In advanced disease, as in other oral cavity cancers, combined
modality therapy with surgery and radiation is utilized.
Hard
Palate
For both early and advanced disease, surgery is used for primary therapy.
Radiation has a role in advanced disease, depending upon the closeness or
involvement of surgical margins by tumor, evidence of nerve involvement
or the presence of lymph node metastases.
Buccal
Mucosa
Small lesions (T1 or T2) can be handled equally well by either surgery or
radiation. For patients with small lesions and clinically negative necks,
observation can be performed rather than treatment of the neck. For more
advanced lesions, treatment of the neck is advisable. In advanced cancers,
treatment most often consists of surgery followed by postoperative
radiation.

Tumors of the Oropharynx

Cancer of the oropharynx is expected to occur in approximately 4,000 individuals
per year. It is seen in men five to eight times more often than in women, and
typically develops during the 50th to 70th year. Risk factors for the development
of the disease include smoking and alcohol use.
Base of tongue tumors are less frequent than other cancers of the tongue, and
pathologically are made up predominantly of squamous cell cancers. These
cancers have a high propensity to spread to lymph nodes and can grow in either
an exophytic or infiltrating pattern. Presenting symptoms often include pain and
difficulty swallowing.
Tumors of the tonsil, tonsillar pillar and soft palate, although anatomically located
close to one another, behave quite differently from each other. Tumors of the
tonsillar pillar tend to be more superficial and tend to spread over a broad region.
By comparison, tonsillar fossa cancers often present with advanced, bulky

tumors. Tumors of the soft palate often are less aggressive. Soft palate tumors
linger in early stages and remain superficial for longer periods.
Tumors of the pharyngeal walls often are found at advanced stages. Presenting
symptoms often include pain, bleeding, weight loss and occasionally a mass in the
neck. These tumors have a propensity to spread to lymph nodes of the neck.
Bilateral (both sides) involvement is often seen. Pathologically, the majority of
these cancers are squamous cell carcinomas.
Staging
See Staging for general staging rules. Specific tumor stages for the oropharynx
region are as follows:
TX

Primary tumor cannot be assessed

T0

No existence of primary tumor

Tis Carcinoma in situ

T1

Tumor 2 cm or less in greatest dimension

T2

Tumor more than 2 cm but not more than 4 cm in greatest dimension.

T3

Tumor more than 4 cm in greatest dimension.

T4

Tumor invades adjacent structures (e.g. through cortical bone, soft tissues of
the neck, and deep muscles of the tongue).

Treatment

Base
of
Tongue
For early stage tumors of the base of tongue, either surgery or radiation
may be used as primary therapy with equally good results. Treatment of
the neck should be performed in patients with clinically positive necks
regardless of the size of the primary tumor. For more advanced (T3)
disease, radiation therapy may be considered. With T4 lesions, surgical
therapy is probably more advantageous.
Tonsil,
Tonsillar
Pillar
and
Soft
Palate
Like most other areas already discussed, treatment of this area for early
stage disease can be adequately performed using either surgery or
radiation. Due to the high risk of the disease spreading to nearby lymph
nodes, treatment of the neck should be considered in all such patients.
Advanced disease usually requires surgical intervention followed by
postoperative radiation therapy. However, treatment primarily with
radiation followed by surgical treatment of the neck also may be an option.
Therapy should be tailored to the exact tumor (T) and node (N) stage of
the patient.
Pharyngeal
Wall
For early stage disease, either radiation or surgery may be contemplated.
However, even early stage disease typically calls for bilateral (both sides)
neck dissections. In advanced disease multimodality therapy should be
considered.

Hypopharynx Tumors
The hypopharynx is located behind and below the oropharynx. It is not visible by
routine office examination. The area consists of three subsites: the pyriform
sinuses; the posterior pharyngeal wall, and the postcricoid area.
About 70% of all hypopharyngeal lesions are found in the pyriform sinuses,
followed by the posterior pharyngeal wall (about 25%) and the postcricoid area
(about 5%). Overall, approximately 3,000 new cases are diagnosed each year,
with the majority occurring in men.
Pathologically, the majority of these cancers are squamous cell carcinomas. They
generally behave in an aggressive fashion, with diffuse local spread, early
metastasis to lymph nodes and a relatively high rate of distant spread
(metastasis).
Staging
Unfortunately, the staging system for the hypopharyngeal cancers is not adequate
and has several limitations in its use. Therefore, unlike most other cancers
discussed in this site, no tumor, node, metastasis (TNM) staging system will be
presented here. It is advisable for anyone confronting hypopharyngeal cancer to
discuss his or her condition thoroughly and carefully with a physician regarding
stage and prognosis.
Treatment
The appropriate therapy for tumors of the hypopharynx depends upon several
factors:

the
the
the
the

patient's health (performance status);

extent of disease,
presence of absence of laryngeal involvement; and
presence or absence of either local (lymph node) or distant metastasis.

In general, for early stage disease (T1 or T2 lesions) surgery or radiation may be
considered equally. More advanced disease typically calls for combined therapy
with surgery and radiation. In recent years, surgeons have tried to utilize
chemotherapy prior to a definitive surgical procedure, in order to achieve organ
preservation.
Salivary Gland Cancer
Salivary gland cancers account for approximately 5% of all head and neck
malignancies. The major salivary glands consist of the parotids, located just in
front of the ears, the submandibulars, located just under the jawline, and the
sublingual glands, which are located in the floor of the mouth. The minor salivary
glands are located throughout the upper aerodigestive tract, mostly in the oral
and nasal cavities and throughout the paranasal sinuses.
Most salivary glands tumors occur in the parotid glands.
Several risk factors are associated with the development of salivary gland
cancers, but more research must be done before it can be said conclusively that
they are proven causes. These factors include ionizing radiation, wood dust
inhalation and genetic or familial predisposition to the disease. Pathologically,

tumors arising in the salivary glands may be either benign or malignant

neoplasms.
Benign tumors include benign mixed tumors, Warthin's tumor (benign papillary
cystadenoma), monomorphic adenoma and benign lymphoepithelial lesions.
Malignant tumors include mucoepidermoid carcinoma, adenoid cystic carcinoma,
adenocarcinoma, malignant mixed tumor, acinic cell carcinoma and epidermoid
carcinoma:

Warthin's tumor is a slow-growing, cystic tumor that almost always occurs

in older men.
Monomorphic adenomas are a group of benign lesions with a variety of
growth patterns. These lesions usually are found in the parotid glands.
Benign lymphoepithelial lesions include a wide range of cystic changes that
share the common denominator in atypical lymphoid hyperplasia.
Hyperplasia refers to a proliferation of cells that is non-neoplastic. These
changes are found often in HIV-infected persons.
Benign mixed tumor is the most common tumor of the major salivary
glands. Pathologically, it is characterized by slow growth and few
symptoms.
Acinic cell cancers are rare, accounting for less than 10% of all salivary
gland tumors. They tend to arise in the parotid and submandibular glands,
and are considered low-grade malignancies.
Mucoepidermoid cancer is unique in that the tumors it produces can vary
in aggressiveness from low-grade and slow growing to high-grade and
rapidly growing. It occurs more frequently than any other malignancy of
the major salivary glands.
Adenocarcinomas are most frequently found in the minor salivary glands of
the nose and paranasal sinuses. They do, however, account for 15% of
malignancies of the parotid and 10% of malignancies of the submandibular
glands. Squamous cell cancers are uncommon in salivary gland tissue. In
many cases they originate not in the parotid itself, but stem from
metastases originating elsewhere in the head and neck.
Malignant mixed tumors make up approximately 15% and 12% of parotid
and submandibular neoplasms respectively. The disease typically is
characterized by slow, protracted growth.
Adenoid cystic carcinomas account for 25% of malignant salivary gland
tumors and 15% of all parotid gland tumors. However, they seem to occur
most often in the minor, rather than major, salivary glands. The disease is
unique in that its tumors grow slowly, but metastasize readily.

Clinical evaluation of a potential salivary gland mass typically includes a physical

examination, a CT scan and/or an MRI, followed by surgical excision of the
abnormality.
Staging
See Staging for general staging rules. Salivary gland tumors are staged as
follows:
TX Primary tumor cannot be assessed
T0

No existence of primary tumor

Tis Carcinoma in situ

T1

Tumor 2 cm or less in greatest dimension without extraparenchymal

extension.

T2

Tumor more than 2 cm but not more than 4 cm in greatest dimension without
extraparenchymal extension.

T3

Tumor having extraparenchymal extension without seventh nerve involvement

and/or more than 4 cm but not more than 6 cm in greatest dimension.

T4

Tumor invades base of skull, seventh nerve, and/or exceeds 6 cm in greatest

dimension.

Treatment
Major
Salivary
Glands
The primary treatment of major salivary gland tumors is surgical excision.
Postoperative radiation may be featured in treating some parotid gland tumors, as
well as tumors with positive margins, advanced stage tumors, tumor spillage,
high-grade histology or positive neck nodes. Additionally, all adenoid cystic
carcinomas should receive post-operative radiation.
Patients with metastatic disease or those with locally advanced and unresectable
disease, usually receive chemotherapy. The chemotherapeutic agents most often
employed are combinations of Cytoxan, Cisplatin and Adriamycin. However, newer
drugs such as Taxol, Taxotere and Gemzar now are being used in combination
with the older chemotherapeutic agents.
Minor
Salivary
Glands
Surgery is the procedure of choice for minor salivary gland tumors. It is unclear,
currently, which patients benefit most from postoperative radiation therapy.

Classification of cancer determines appropriate treatment and helps determine the

prognosis. Cancer develops progressively from an alteration in a cells genetic structure
due to mutations, to cells with uncontrolled growth patterns.
Classification is made according to the site of origin, histology (or cell analysis; called
grading),
and the extent of the disease (called staging).
Site of Origin
This classification describes the type of tissue in which the cancer cells begin to develop.
Here are some common examples of site of origin classification:

Adenocarcinoma originates in glandular tissue

Blastoma originates in embryonic tissue of organs
Carcinoma originates in epithelial tissue (i.e., tissue that lines organs and tubes)

Leukemia originates in tissues that form blood cells

Lymphoma originates in lymphatic tissue
Myeloma originates in bone marrow
Sarcoma originates in connective or supportive tissue (e.g., bone, cartilage,
muscle)

Grading
Grading involves examining tumor cells that have been obtained through biopsy under a
microscope.
The abnormality of the cells determines the grade of the cancer. Increasing abnormality
increases the grade, from 1 4.
Cells that are well differentiated closely resemble mature, specialized cells. Cells that are
undifferentiated are highly abnormal,
that is, immature and primitive.
Grade 1
Grade 2
Grade 3
Grade 4

Cells
slightly
abnormal
and
well
differentiated
Cells more abnormal and moderately
differentiated
Cells
very
abnormal
and
poorly
differentiated
Cells immature and undifferentiated

Staging
Staging is the classification of the extent of the disease. There are several types of staging
methods.
The tumor, node, metastases (TNM) system classifies cancer by tumor size (T), the
degree of regional spread or node
involvement (N), and distant metastasis (M).

Tumor (T)
T0

No evidence of tumor

Tis

Carcinoma in situ (limited to surface cells)

T14 Increasing tumor size and involvement

Node (N)
N0

No lymph node involvement

N14 Increasing degrees of lymph node involvement

Nx

Lymph node involvement cannot be assessed

Metastases (M)
M0 No evidence of distant metastases
M1 Evidence of distant metastases
A numerical system also is used to classify the extent of disease.
Stage 0

Cancer in situ (limited to surface cells)

Stage I

Cancer limited to the tissue

evidence of tumor growth

of

Stage II Limited local spread of cancerous cells

Stage
III

Extensive local and regional spread

Stage IV Distant metastasis

origin,