Oropharyngeal Cancers from Anatomy to Management

1. OROPHARYNGEAL CANCERS
Dr. Ayush Garg

2.  Anatomy
 Epidemiology
 Risk factors
 Clinical Features
 Staging
 Workup
 Management
 Conclusion
Outline

3. • According to American Joint Committee on Cancer (AJCC)
staging definition:
• The oropharynx is the
portion of the
continuity of the
pharynx extending
from the plane of the
superior surface of
the soft palate to the
superior surface of
the hyoid bone
(or vallecula).

4. Oropharynx
 Base of the tongue,
Vallecula,
 The inferior (anterior)
surface of the soft
palate
 The uvula,
 The anterior and
posterior tonsillar
pillars,
 The glossotonsillar
sulci,
 The pharyngeal tonsils,
and
 The lateral and
posterior pharyngeal
walls.

5. Anatomy
Boundaries
 Superior
 Anterior
 Lateral
 Posterior
 Inferior
(Netter 2003)

6.  Superior
 Anterior
 Lateral
 Posterior
 Inferior
Anatomy
Boundaries
 Soft palate
(Netter 2003)

7.  Superior
 Anterior
 Lateral
 Posterior
 Inferior
Anatomy
Boundaries
 Oropharyngeal isthmus
 Palatoglossal arch
(Netter 2003)

8.  Superior
 Anterior
 Posterior
 Inferior
Anatomy
Boundaries
 Palatopharyngeal arch
 Palatine tonsil
 Lateral
(Netter 2003)

9.  Superior
 Anterior
 Lateral
 Posterior
 Inferior
Anatomy
Boundaries
 Second and third cervical vertebrae
(Netter 2003)

10.  Superior
 Anterior
 Lateral
 Posterior
 Inferior
Anatomy
Boundaries
 Level of hyoid
 Vallecula
(Netter 2003)

11. Lymphatic Drainage
 Levels II, III, and IV most common
 Retropharyngeal
 Posterior pharyngeal wall
 Palatine tonsil
 Bilateral drainage
 Tongue base
 Soft palate
 Posterior pharyngeal wall
 The probability of lymphatic
metastasis is related to the size
and location of the primary tumor
within the oropharynx.

12. DISTRIBUTION OF CLINICAL METASTATIC NECK NODES
FROM HEAD AND NECK SQUAMOUS CELL CARCINOMAS

13. Epidemiology
 Account for approximately 10-12% of head and
neck malignancies worldwide.
 Incidence is high in developing countries 4.8 in
100,000.
 There is increase in HPV associated oropharyngeal
cancers.
 Peak incidence in 6th or 7th decades of life.
 More common in men(4:1).

14. Risk Factors
Patient related-
Age and gender: predisposition in males especially
those who are smokers and older than 50 years.
Lifestyle: cigarette smoking, alcohol, tobacco; tobacco
and alcohol are synergistic risk factors.

15. HPV- associated orpharyngeal cancer
• HPV is a circular double stranded DNA virus
• Found to be associated with cervical cancer in 1983.
• Appr. 150 types of HPV have been identified
• HPV 16 is most common type asso. with more than 90% of all
oropharyngeal cancers.

16. HPV structure
• HPV genome encodes 3
oncoproteins(E5,E6,E7),regula
tory genes(E1,E2),capsid
proteins(L1,L2).
• Oncogenesis is primarily
mediated via the E6 and E7
proteins. HPV E6 complexes
promote ubiquitin-mediated
destruction of p53.
• Loss of cellular p53 function
results in dysregulation of the
G1/S and G2/M checkpoints.
• E7 is believed to be the major
transforming oncogene during
early carcinogenesis, with E6
functioning later.

17. Clinical characteristics-HPV associated
• more likely to occur among men than women (3:1)
• most of whom (80%) will not have a smoking history.
• diagnosed in individuals who are 5 to 10 years younger than HPV-
unassociated oropharyngeal cancers
• p16 IHC testing is an accurate surrogate for HPV infection

18. Response of HPV associated cancers
• Patients with HPV-associated oropharyngeal cancers have
significantly better outcomes compared to HPV-unassociated
oropharyngeal tumors.
• In RTOG 0129, HPV status was independently associated with
improved outcomes. Three-year overall survival was 82% in HPV-
positive patients compared with 54% in HPV-negative patients

19. Pathology
• Squamous cell carcinoma (SCC) accounts for >90% of
oropharyngeal cancer
• Minor salivary gland carcinomas
• Lymphoma
• Plasmacytoma
• Sarcoma
• Melanoma

20. Route of spread
Local
Oropharynx cancers may invade
vallecula/larynx,
 parapharyngeal area into the pterygoid muscles/plates,
nasopharynx, and oral cavity (oral tongue and retromolar
trigone)
Perineural invasion especially along branches of CN V and VII

21. Lymph node involvement is seen in 55% of oropharynx
cancers.
• most common location for lymph node metastases from
oropharyngeal cancers is the ipsilateral level II.
• The typical order of metastatic progression is systematic,
from the upper jugular chain nodes superiorly (level I/II; first
echelon), to mid-cervical (level III), and to lower cervical
nodes (level IV), inferiorly. Retropharyngeal nodes represent
a nodal drainage for oropharynx cancers.
• Contralateral nodes are at risk for tumors near midline,
advanced T- and N-stage diseases

22. Distant Metastasis in patients with advanced-stage disease
• The most common site of hematogenous metastasis is Lung.
• Seen in about 20% cases.
• However, a primary lung cancer should always be excluded.

23. Clinical Features
Asymptomatic neck
node/mass.
 Pain
 Dysphagia
 Otalgia
 Foreign body sensation
 Hemoptysis
 Weight loss
 Voice changes

24. Otalgia

25.  T, tumor
 N, node
 M, metastasis
Oropharyngeal Cancer
Staging
 Tx: primary site cannot be evaluated
 T0: no evidence of carcinoma
 Tis: carcinoma in-situ
 T1: tumor < 2cm in greatest dimension
 T2: tumor 2-4cm in greatest dimension
 T3: tumor > 4cm in greatest dimension
 T4
 T4a: invades larynx, deep/extrinsic tongue
muscles, medial pterygoid, hard palate, or
mandible
 T4b: invades lateral pterygoid, pterygoid plates,
lateral nasopharynx, skull base, or carotid

26.  T, tumor
 N, node
 M, metastasis
Invasion of pre-epiglottic fat
(i.e. laryngeal involvement)
Invasion of medial
pterygoid muscle
 T4a: invades larynx, deep/extrinsic tongue muscles, medial
pterygoid, hard palate, or mandible
 T4b: invades lateral pterygoid, pterygoid plates, lateral
nasopharynx, skull base, or carotid

27.  T4
 T4a: invades larynx, deep/extrinsic tongue muscles, medial
pterygoid, hard palate, or mandible
 T4b: invades lateral pterygoid, pterygoid plates, lateral
nasopharynx, skull base, or carotid
Encasement of
carotid artery
Involvement of
foramen ovale

28.  T, tumor
 N, node
 M, metastasis
 Nx: Regional lymph nodes cannot be
assessed
 N0: No regional lymph node metastasis
 N1: single ipsilateral node < 3cm
 N2
 N2a: single ipsilateral node involved, ˃3 but
˂6cm
 N2b: multiple ipsilateral nodes, < 6cm
 N2c: bilateral or contralateral nodal
involvement, none ˃6cm
 N3: nodal involvement > 6cm
Staging

29.  T, tumor
 N, node
 M, metastasis
Staging
 Mx: distant metastasis cannot be evaluated
 M0: no distant metastasis
 M1: distant metastasis present

30. Diagnostic workup
• Complete physical examination-examination of oral cavity,
oropharynx, neck.
• Endoscopic Examination
 Fiberoptic laryngoscopy is done to assess local extent of
dosease.
 Evaluation of the upper aerodigestive tract is crucial to
evaluate the primary site of disease and the presence of
synchronous primaries.

31. Laboratory tests
Includes:
1) Complete blood count
2) Basic blood chemistry
3) Hepatic and metabolic panels
4) Testing for HPV in the biopsy specimen (p16 IHC testing)

32.  Biopsy
 Tissue from either primary tumor or neck lymphadenopathy
is crucial for pathologic diagnosis.
Imaging-
 CECT Face & Neck
 Chest X-ray
 Ultrasound whole abdomen
 CECT Thorax (if indicated)
 FDG-PET/CT scan

33. CT Scan
• Scan slice thickness <5 mm is desirable to optimize the
detection of smaller pathologically involved lymph nodes.
• Pathologically involved lymph nodes are characterized on
CT imaging as those that are enlarged, enhance with
contrast, and have a necrotic centre.
• Primary tumors appear as contrast-enhancing masses,
distorting normal anatomic relationships.
• Whereas ulceration and invasion into surrounding organs
are readily assessed, submucosal spread is often difficult to
characterize with CT.
• Thoracic CT should be performed routinely to assess for
pulmonary spread of oropharyngeal cancer patients with N2
or greater nodal disease, as well as those with advanced
primary tumors due to risk of pulmonary metastases.

34. A 2.2-cm enhancing neoplasm of
the tongue base (open arrows)
indicating a T2 primary.
The lesion extends into the
vallecular (dashed white arrow)
but does not invade the adjacent
genioglossus muscle (dashed
black arrow). There are abnormal
heterogeneously enhancing
bilateral level IIa and right level IIb
lymph nodes (black arrows)
consistent with N2c nodal spread.

35. Magnetic Resonance Imaging
• Magnetic resonance imaging (MRI) can be a useful imaging tool for
oropharyngeal tumors.
• Squamous cell carcinoma appears as low signal in T1 MRI and
corresponding high signal in T2 sequences.
• The ability of MRI to differentiate tumor from soft tissues is
particularly useful when determination of the extent of base of
tongue or oral tongue invasion is needed.
• Additionally, MRI is useful in patients with compromised renal
function who are not able to receive iodine-based CT contrast agents.

36. Positron Emission Tomography
• Positron emission tomography (PET) and/or PET/CT
imaging incorporating tumor physiology in conjunction with
anatomic information are now routinely recommended for
the initial staging of oropharyngeal cancer patients.
• PET-based imaging can assess not only the locoregional
burden of disease but also detect and quantify distant
metastases.
• It has high sensitivity approaching 100%, and about 60%
specificity.
• As per NCCN guidelines FDG-PET/CT should generally
considered in Stage III-IV disease.

38. Treatment modalities
• Surgery
• Radiotherapy
• Chemotherapy
• Targeted Therapy

39. • Stage I and stage II tumors are considered as early stage,
whereas stage III and IV (nonmetastatic) are considered
locoregionally advanced disease.
• Early-stage tumors are usually well controlled with a single
local modality, either radiotherapy or surgery.
• For locoregionally advanced disease, two appropriate
treatment strategies are used:
(a) either surgery followed by radiation therapy with or
without chemotherapy based on pathologic risk factors or (b)
radiotherapy usually given with chemotherapy.

40. Surgery
• Base of Tongue
• Surgery plays a limited role in the management of base of
tongue tumors given the inherent morbidity of a near-total or
total glossectomy, which is required for large and/or midline
tumors.
• For select, well-lateralized base of tongue tumors with
minimal cervical lymphadenopathy, a partial glossectomy
can be performed.
• Given the high propensity for occult microscopic nodal
involvement, bilateral cervical lymph node dissection is often
performed.
• Base of tongue tumors in close proximity to the laryngeal
apparatus, such as those arising in the vallecula, often
require a supraglottic or total laryngectomy to achieve
adequate margins of resection.

41. • Traditional surgical approaches for base of tongue tumors
include :
• The midline mandibulotomy (splitting the lip, mandible, and
oral tongue midline),
• The lateral mandibulotomy (dividing the mandible near the
angle and approaching the base of tongue from the side),
• The floor drop procedure (elevating the inner periosteum
from the mandible from angle to angle, which releases the
entire floor of mouth and oral tongue into the neck, exposing
the base of tongue).

42. Tonsil Cancers
• For small (<1 cm) early-stage tonsil cancers confined to the anterior
pillar, a wide local excision can achieve adequate tumor-free margins,
whereas tumors involving the palatine tonsil often require a radical
tonsillectomy.
• For both of these situations, the tonsil is approached transorally, with
primary closure.
• Larger tumors with extension onto the tongue, onto the mandible or
into surrounding tissue often require a composite resection, usually
including resection of the tonsil, tonsillar fossa, pillars, a portion of the
soft palate, tongue, and mandible.
• For tumors not adjacent or adherent to the mandible, a midline
mandibulotomy approach is used.
• For tumors adherent to the mandible, a partial mandibulectomy is
used.
• Defects are often closed with a myocutaneous flap.
• Complications from surgery depend on the extent of resection, with
impairment in swallowing possible by removal of part of the tongue or
soft palate.

43. Soft Palate Cancers
• Surgical resection is rarely recommended as initial therapy
for soft palate tumors.
• Resection of the soft palate is often associated with
significant reflux into the nasopharynx during swallowing,
even with the use of custom prostheses.
• Additionally, because of the midline location, primary
disease spreads bilaterally to the neck with frequency high
enough to require elective treatment.
• However, when surgery is performed, the tumors are
approached transorally and a full-thickness wide local
resection is performed for tumors limited to the soft palate.
• A more extensive composite resection is required if disease
extends to surrounding structures.
• Flaps or prostheses are used to preserve velopharyngeal
competence. Nasal speech is also often a consequence.

44. Transoral Laser Surgery
• Small series report favorable outcomes for selected patients
with stage I through stage IV oropharyngeal tumors treated
with transoral laser microsurgery with or without neck
dissection, followed by adjuvant radiotherapy or
chemoradiotherapy.
• Positive margin rates are variable (3% to 24%) and appear
to vary based on primary site, being more common in base
of tongue tumors.
• Complications include postoperative hemorrhage (5% to
10%).
Temporary tracheostomy placement is relatively common
(17% to 30%) and needed for exposure, airway control, or
aspiration following extensive resection.
• High rates of locoregional control following this procedure
have been reported, primarily for stage I/II patients (87% to
100%), although for stage III/IV patients, local recurrence is
more common (20% to 30%).

45. Transoral Robotic Surgery
• The use of a computer-aided interaction between the surgeon and
the patient is commonly referred to as robotic surgery.
• The most common robotic surgical system, the da Vinci Surgical
System, is comprised of three surgical instruments and a binocular
endoscope controlled by robotic arms and inserted under direct or
endoscopic guidance by the surgeon from a patient-side apparatus.
• The surgeon controls the instruments from a console separated from
the patient.
• The operative environment is visualized virtually, in a three-
dimensional (3D) environment created via a computer that links the
environment provided by the binocular endoscope to the position of
the instruments.
• The surgeon’s movements are translated into the micromovements
of the instruments. The advantages of this system include motion
scaling, which can increase precision as well as reduce hand tremor
and fatigue.
• When the system is used for transoral surgeries, an assistant is
often positioned by the patient’s head.

46. • There are no prospective randomized studies supporting the
use of transoral robotic surgery (TORS) for oropharyngeal
tumor resection over conventional surgery.
• Until mature prospective multi-institutional series and
randomized data are available, the true utility of transoral
laser microsurgery and TORS remains unknown.
• Although early results are favorable and associated with
shorter hospital stays, long-term data are needed.
• Additionally, standard oncologic principles limiting the
number of modalities used to minimize treatment related
side effects should be carefully considered prior to
widespread adoption of the surgical techniques.

47. Neck Management
• The type of neck dissection (comprehensive or selective) is
defined according to preoperative clinical staging, is
determined at the discretion of the surgeon, and is based on
the initial preoperative staging as follows:
N0= Selective neck dissection, atleast Levels II-IV
N1-N2a-c= Selective or comprehensive neck dissection
N3= Comprehensive neck dissection

48. Radiotherapy
• Definitive chemoradiotherapy is the treatment of choice.
• For early-stage oropharyngeal cancers, the use of radiation
therapy as a single modality is associated with good
outcomes and functional preservation.
• Patients with locoregionally advanced oropharyngeal cancer,
concurrent chemoradiotherapy is the standard treatment.
Resection is generally not recommended given the
associated surgical morbidity.

49. Chemotherapy
• Used in concurrent setting along with radiotherapy
• Recurrent and metastatic tumors
• As neoadjuvant chemotherapy, but there is no definitive role.

50. Radiotherapy techniques
• Two dimensional planning
• 3D planning
• IMRT

51. Conventional borders

53. Carcinoma Base of tongue lower Neck Field

54. Radiation Fields for Carcinoma Oropharynx
• Conventional RT films for oropharyngeal cancer

55. 3D Planning
• Patients should undergo simulation, preferably CT based, to
allow for optimal radiotherapy planning.
• A peripheral IV should be placed prior to simulation for the
delivery of low osmolar iodinated contrast to optimize the
distinction between vascular structures and lymph nodes.
• Patients are positioned supine, extended head position is
preferable.
• The shoulders should be positioned as caudally as possible
to allow adequate exposure of the neck. This can be
achieved either with shoulder pulls or with commercially
available devices. The head should be immobilized with a
thermoplastic mask.
• Care should be taken to ensure that the mask is tight and
should not allow movement of the nose, chin or, forehead.

56. Radiotherapy volumes-ICRU 50
• The GTV includes all known primary and cervical lymph
node tumor extension based on clinical, endoscopic, and
imaging findings. Care should be taken to look for fat
stranding, which could be indicative of extranodal extension.
• CTV indicating the margin needed to cover microscopic
extension not visible on clinical and imaging modalities is not
known. Current RTOG guidelines specify an extension of 0.5
to 1 cm from the GTV to form the high-dose CTV.
• CTVs are expanded to account for organ motion and setup
uncertainty ideally based on institution-specific data to form
PTV.

58. (T4aN2bM0). The patient was
treated with concurrent
chemotherapy with the
primary and nodal gross
disease receiving 70 Gy using
IMRT.
Contours:
red colorwash(GTV, 70 Gy),
blue colorwash (CTV1, 60 Gy),
yellow colorwash (CTV2, 56
Gy),
blue (left parotid gland).
Parts A to D are sequential
axial isodose images with the
following isodose lines:
green (70 Gy),
teal (60 Gy),
orange (56 Gy), and
dark green (50 Gy).
E is reconstructed AP
radiographic
study shows the contoured
structures projected

59. Dose & fractionation
Standard is 66-70 Gy delivered @ 1.8-2 Gy/# for 6-7 wks
along with concurrent cisplatin 35mg/m2 weekly.
Hyperfractionation -81.6Gy @ 1.2Gy/# twice daily in 7 weeks,
EORTC 22791,hyperfractionated radiotherapy was associated
with statistically significant improvements in locoregional
control (5-year, 59% vs. 40%).
Additionally, there was a trend toward improved overall
survival (p = 0.08) particularly in stage III patients.

60. Other Fractionation Regime
1. Accelerated regimen of 66 to 70 Gy delivered in 2-Gy
daily fractions 6 days a week
2. Accelerated fractionation with concomitant boost regimen
-72 Gy in 1.8-Gy fractions for 14 fractions followed by a
1.8-Gy morning and a 1.5-Gy afternoon boost to gross
disease
3. Simultaneous integrated boost(SIB)-RTOG completed a
study (00-22) in early-stage (T1-2, N0-2) oropharyngeal
cancer patients treated with bilateral neck radiotherapy,
gross tumor-2.2Gy, intermediate-risk,-2Gy and low-risk-
1.8Gy planning target volume

62. Brachytherapy
Indications
• <= 5 cm lesions in BOT, Soft palate, tonsil or valeculla may be
implanted
• Primary implant in lesions < 1cm or exophytic leisions
• Used in conjunction with EBRT after 40-50 Gy to primary and the
nodes
• Recurrent leisions or new lesions in previously irradiated regions

63. • Brachytherapy, the application of radioactive materials in close
proximity to tumors, was developed in the pre-IMRT, preconcurrent
chemoradiotherapy era as a means to deliver a tumoricidal dose to
gross tumors while minimizing dose to the mandible.
• The advent of improved radiotherapy planning and delivery
techniques, in addition to a recognition that osteoradionecrosis
secondary to brachytherapy is significantly underreported, has
corresponded to a major decrease in the utilization of brachytherapy
for oropharyngeal tumors.

64. • Typically, catheters are implanted under general anesthesia
in the operating room, with two capable physicians present
to handle unexpected events.
• Although low dose rate brachytherapy has previously been
the most common type of brachytherapy used, high dose
rate (HDR) and pulsed dose rate (PDR) techniques are
becoming much more common and sometimes preferred
given the ability to control dwell times and develop more
customized dose distributions.
• High rates of locoregional control have been achieved using
an integrated treatment approach of external-beam
radiotherapy directed at the primary and bilateral neck,
followed by a brachytherapy boost.
• Complications of brachytherapy for base of tongue tumors
include osteoradionecrosis of the mandible. The risk of
complication appears to be related to the technique of
implantation but may approach 30%.
• There is limited information regarding the use of
brachytherapy and chemotherapy concurrently, which should
be avoided.

65. • When brachytherapy is planned following external-beam
radiotherapy, care should be taken to delineate the
pretreatment tumor extent because regression is not always
uniform.
• Tattoos and gold seeds have been used to accomplish this.
• The CTV used is recommended by the European Society for
Radiotherapy and Oncology (ESTRO) to be 5 mm at
minimum and more commonly 1 to 1.5 cm for base of
tongue tumors.
• The PTV is usually equal to the CTV as the implanted
catheters move with the tumor.
• Catheters are typically positioned parallel and equidistant at
1 to 1.5 cm apart.
• The methods of calculating dose are the Paris, Manchester,
or New York systems, computer-derived brachytherapy
plans.

67. Brachytherapy Guidelines
• The American Brachytherapy Society (ABS) has published
guidelines for the use of HDR brachytherapy for head and neck
tumors and oropharyngeal tumors in particular.
• Prophylactic tracheostomy is recommended because posterior and
large tumors are at risk to cause airway obstruction.
• External-beam radiotherapy doses of 45 to 60 Gy followed by an
HDR brachytherapy boost of 3 to 4 Gy per fraction for 6 to 10
doses with locoregional control of implanted tumors reaching 82%
to 94%.
• The European Brachytherapy Group (GEC) and ESTRO have also
published joint guidelines for the use of brachytherapy for head
and neck malignancies.
• For oropharyngeal tumors, these guidelines recommend 45 to 50
Gy external-beam radiotherapy followed by 25 to 30 Gy boost for
tonsillar tumors, and 30 to 35 Gy boost to base of tongue tumors.
The total brachytherapy boost dose is fraction-size dependent: 21
to 30 Gy in 3-Gy fractions and 16 to 24 Gy in 4-Gy fractions.
• Quality of life analyses comparing a combined regimen of
brachytherapy and external-beam radiotherapy to surgery and
PORT favored a primary radiotherapy-only approach.

68. • Interstitial brachytherapy
• Mass General Hospital, 2005 → 40 cases. Primary or recurrent
base of tongue. 54% T3/T4 tumor.
• Median implant dose 17.4 and 61 Gy external RT (equivalent
total dose 80 Gy).
• Five-year OS: 62%. Local control: 78%. Ten-year local control:
70%.
• Organ preservation rate: 78%. Grade III osteoradionecrosis in
two patients (2%).
• Foote RL et al (1990) Is interstitial implantation essential for
successful radiotherapeutic treatment of base of tongue
carcinoma? Int J Radiat Oncol Biol Phys. 18(6): 1293–8

70. Toxicity-chemoradiotherapy
Acute
• Fatigue,
• Nausea, emesis,
• Thickened secretions,
• Xerostomia,
• Mucositis,
• Dysphagia, odynophagia,
• Alopecia, dermatitis,
• Anemia, neutropenia,
• Hoarseness,
• Dysphagia is perhaps the most difficult acute complication of
chemoradiotherapy for oropharyngeal cancer.
• Patients should be instructed to swallow as large a volume as
possible during and after treatment and to perform exercises
shown to improve swallowing ability.

71. Late toxicity
• Fibrosis,
• Osteoradionecrosis,
• Trismus,
• Xerostomia,
• Dental caries,
• Feeding tube dependence, and neuritis.

72. Chemotherapy

74. Role of Targeted therapy
• Weekly Cetuximab loading dose of 400 mg/m2 followed by 250
mg/m2 for locoregionally advanced head and neck cancer patients.
The combination therapy was found to improve locoregional control,
disease-free survival, and overall survival.
• Consideration should be given to the use of altered radiation
fractionation with cetuximab because improved overall survival was
seen in patients who were treated with accelerated concomitant
boost and hyperfractionated radiotherapy.

75. Follow up
• Every 1 to 3 months for the first year post RT
• Every 2 to 4 months in the second year post RT, and every 4
to 6 months in the next 3 to 5 years.
• The intensity of the examinations within the first 2 years
coincides with the likelihood of recurrence in the interval.
Given that radiation to the neck commonly causes
hypothyroidism, thyroid-stimulating hormone levels should
be evaluated every 6 months.
• Follow-up imaging should be performed within the first 3
months of treatment

76. Reirradiation for Locoregionally Confined Recurrent or Second
Primary Disease
• Surgical resection is recommended, although this is possible
only in a small proportion of patients.
• Following surgery in those with high-risk pathologic features
or in those who are not surgical candidates,a second course
of full-dose radiotherapy with chemotherapy has been
shown to result in long-term survival in approximately 20% of
patients.

77. Conclusion
• Oropharyngeal cancers include 10-12% of head & neck
cancers
• Squamous cell carcinoma is most common histopathology
• HPV is most common risk factor associated
• Concurrent chemoradiotherapy is mainstay of treatment.

78. T H A N K Y O U

79. • LN Incidence and Percentage
• Role of Imaging
Diagnostic Role
CT Indications
MRI Indications
PET Indications
• Role of HPV in Oropharynx
• Radical Surgery role in Oropharynx- Stage, Site and Name of Surgery
• Brachy in Oropharynx