Review article
Carcinoma of the oral pharynx: an analysis of subsite treatment heterogeneity

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Relevant anatomy

The superior and inferior boundaries of the oropharynx are marked by horizontal planes at the levels of the hard palate and vallecula or hyoid bone, respectively. The muscular pharyngeal wall between these two planes defines the posterior limits. The circumvallate papillae and palatoglossal muscle mark the anterior limits. Most of the lateral wall of the oropharynx is primarily composed of the tonsil and the tonsillar fossa. A small contribution comes from the lateral extensions of the

Histopathology

In general, the histopathologic entities seen in the oropharynx represent a derivation of tissue normally present there. Because the oropharynx is lined with stratified squamous epithelium, 85% to 90% of carcinomas seen are squamous cell in origin. The presence of minor salivary glands, neurovascular and fibromuscular structures, and lymphoid aggregates in the Waldeyer's ring opens the possibility to a wide variety of mesemchymally derived sarcomas and carcinomas. A discussion of the management

Assigning tumor to subsite of origin

Determining the subsite of origin in oropharyngeal carcinomas can be a daunting task and frequently comes down to an educated guess based on subjective and objective information. The reason for the great difficulty is twofold. The first factor relates to mucosal continuity between subsites, making it difficult to strictly demarcate one subsite from another. For example, the soft palate, which includes the uvula is continous with the anterior tonsillar pillar. Similarly, the lateral extension of

Posterior pharyngeal wall

Tumors that are isolated to the posterior pharyngeal wall are very uncommon. They tend to be asymptomatic unless they become bulky. They rarely extend laterally to other subsites of the oropharynx but rather infiltrate deeply into the retropharyngeal and prevertebral tissues. They are known for their early metastases to bilateral jugular and retropharyngeal nodes because of their posterior and relatively midline location. The biologic characteristics of these tumors are the same as those of

Soft palate

The soft palate functions to prevent air escape during phonation and nasal regurgitation during deglutition. Of all the subsites of the oropharynx, it may provide the least challenge to routine examination. Thus, despite the relatively asymptomatic presentation of carcinomas in this region, they are usually identified early and referred for definitive management.

SCC of the soft palate is a relatively uncommon malignancy and remains virtually asymptomatic because of its location, until a lesion

Tonsillar complex

Tonsillar carcinoma represents approximately 75% of all carcinomas presenting in the oropharynx. Among carcinomas of the aerodigestive tract, it ranks second only to laryngeal cancer. Unlike the soft palate, the more cryptic locations of the tonsillar complex places this region at high risk for being poorly visualized or overlooked by the casual examiner. This is one reason the source of many unknown primary tumors is ultimately found to originate in the tonsil. Furthermore, its relatively “out

Tongue base

Treatment selection for base of tongue carcinomas is institutionally driven. Some centers primarily use surgery with or without radiotherapy [21], [22], [23], [24], [25], [26], [27], [28]; others use primary radiotherapy and reserve surgery for salvage [29], [30], [31]. The role of brachytherapy remains controversial. Brachytherapy combined with external beam radiotherapy (EBRT) was initially believed to be a superior treatment option to EBRT alone for base of tongue lesions. It has since

Approach to management of the neck

Management of the regional lymphatic spread of disease is virtually the same for all subsites of the oropharynx. The risk of occult cervical metastases ranges from 15% to 30%; therefore, treatment of N0 neck lesions is justified for all T stages of disease. Most early-stage primary lesions are treated with definitive radiotherapy, which is also used to address clinically negative neck lesions. Elective neck dissections also can be used in this setting and produce equal control rates with the

Chemotherapy

In the past, the role of chemotherapy in the treatment of oropharyngeal carcinoma was generally considered experimental and used for palliation. Most patients being treated with chemotherapy were either enrolled in a study or were receiving treatment at a research-based institution.

There are now many promising cytotoxic agents currently under investigation. There exists no way to ascertain from the literature the true independent effects of chemotherapy on oropharyngeal carcinomas, however,

Summary

The data indicate that SCC of the various subsites of the oropharynx can be treated successfully with acceptable locoregional control and survival rates by using either surgery or primary radiotherapy for T1 or T2 primary lesions. Treatment success data for late-stage disease (T3 and T4) are less encouraging, regardless of which modality is used or which treatment center is administering treatment. This finding may suggest an intrinsic property of these lesions or the patient that may be going

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