Causes of Soft Palate Cancer
As with most cancers, doctors can’t tell you with certainty what causes soft palate cancer. It’s a combination of genetic factors and factors in your environment.

By far the most common factor contributing to most head and neck cancers is using tobacco, particularly smoking it. Drinking excessive amounts of alcohol also contributes to the risk of developing head and neck cancer.

 Tobacco: Smoking cigarettes, cigars or pipes and using chewing tobacco greatly increase your chance of getting a throat cancer.
 Alcohol: Drinking excessive amounts of alcohol is also very strongly related to getting a throat cancer. Moreover, if you both smoke and drink heavily, the risk more than doubles.
 Viruses: Exposure to certain strains of human papillomavirus (HPV) is associated with oropharynx cancer. The strains 16 and 18 are the main ones we are concerned about. This virus is quite common, and it is associated with intimate sexual contact. Why some people get cancer from this virus while others don’t is still a mystery.
 Exposure to radiation in the past: Being exposed to radiation as part of a natural disaster, treatment for another disease a long time ago or even through work can increase the chances of some throat cancers.
 Genetic factors: This is important in all cancers, and the details are still being worked out.
 Certain foods: Deficiencies in some vitamins and poor oral hygiene might be associated with oropharynx cancers.

Signs and Symptoms of Soft Palate Cancer
The symptoms of soft palate cancer, like other oropharynx cancers, depend on where the tumour is and how big it is. Most commonly, patients will see or feel a growth in their mouth on the soft palate.

However, it is not uncommon for the first symptom of a cancer in the soft palate to be a lump in the neck. In any case, oropharynx cancer can present with a whole host of different symptoms, including:
 Pain or difficulty with swallowing in the throat: This can occur because a tumour is in the way of swallowing, and so it becomes difficult or painful to swallow. Also, there can be ulceration and bleeding as the tumour grows, causing pain.
 A lump in the neck: This will be a symptom of oropharyngeal cancer if it has spread to lymph nodes in the neck. This can be the first symptom that brings a patient to the doctor. If you have a neck mass, and your doctor is concerned that it represents cancer spread from somewhere else, one of the first places he or she will look is your oropharynx.
 Ear pain (particularly on one side, with no other ear problems): Ear pain, also known as otalgia, happens because the nerves of the throat reach the brain through the same pathway as one of the nerves in the ear. Therefore, your brain might interpret a pain in the throat as coming from the ear. This is called referred pain. Consequently, unexplained ear pain that doesn’t go away should be evaluated by a specialist. It is important to understand that most causes of ear pain are due to simple problems such as middle ear infection or dysfunction of the Eustachian tube. TMJ pain due to a problem in the joint located in front of the ear may also present as otalgia.

Other symptoms might include:
 Difficulty opening your mouth widely (trismus)
 Feeling a lump in the throat
 Bleeding from the mouth
 A change in the way you speak
 Weight loss

But don’t jump to any conclusions. You could have one or more of these symptoms but NOT have oropharyngeal cancer. There are several non-cancerous causes of the same symptoms. That’s why you need to see a specialist.

What to Expect at Your Doctors Visit
Step 1: History
First, your head and neck specialist will take a thorough history of your health and address any specific concerns you may have.
Your doctor might ask questions such as:
 How long has the problem been there?
 Is it getting worse, better or staying the same?
 Does it come and go?
 Have you tried anything to make it better?
 Is it painful?
 Do you have any lumps or bumps in your neck?
 Are you having difficulty with hearing?
 Do you have any lumps or bumps anywhere else in your body?
 Are you losing weight?
 Are there any other problems associated with your main problem?
 Do you have any other medical issues?
 Have you had any surgeries in the past?
 What medications do you take? And do you have any allergies?
 Have you ever been exposed to radiation in the area?
 What do you (or did you) do for a living?
 Do you have a family history of cancer?

Step 2: Physical Exam
Next, your doctor will examine you. Typically, if you’re seeing a specialist in head and neck disorders, you will get a thorough physical examination focused on the area of concern. The oropharynx, including the soft palate, typically requires a specialist to evaluate. It is particularly challenging for a general doctor to see and feel this area without specialised equipment.
Your doctor might do some of the following:
 Look inside and probably even feel inside your mouth
 Feel your neck thoroughly and carefully to check for any lumps or bumps
 Look inside your ears
 Look inside the front of your nose
 Check your cranial nerves by asking you to move your face, stick your tongue out, lift your shoulders, follow his or her fingers around with your eyes, do some simple hearing tests and test your sense of touch all over your face

A few special diagnostic tests might be required as part of your physical exam.

Pharyngoscopy and/or Laryngoscopy (looking at your oropharynx, hypopharynx and larynx): This can be done in a few ways, including with a headlight and mirror placed on the roof of your mouth to look down, or with a flexible camera placed through your nose.

Flexible pharyngo-laryngoscopy: Your doctor may spray your nose with some medications and then slowly and carefully place a flexible tube-like camera through your nose down into your throat. Just sit still, breath slowly and listen to your doctor’s instructions.

Indirect mirror examination: Your doctor will distract you while placing a small mirror into the back of your throat through your mouth. The doctor will ask you to breathe differently and make sounds as he or she observes your oropharynx.

Indirect Transnasal Flexible Endoscopy (Laryngoscopy) Indirect Mirror Examination (Laryngoscopy)

Your doctor may spray your nose with some medications and then slowly and carefully place a flexible tube with a camera through your nose down into your throat. Just sit still, breathe slowly and listen to your doctor’s instructions. Your doctor will distract you while placing a small mirror into the back of your throat through your mouth. The doctor will ask you to breathe through your mouth and make sounds as he or she examines your throat.

Step 3: Reviewing Tests
After getting your history and performing a physical exam, your doctor will review any imaging, laboratory work and pathology results you may have already had. Be sure to bring all of these with you to your appointment. Bring actual discs of any scans you’ve had, as well as any reports of those scans. If you are seeing a head and neck cancer specialist after a lesion was removed by a non-cancer specialist, you need a thorough review of the pathology to discuss whether additional treatment is necessary. Try to obtain the actual glass slides that were prepared by the pathologist with the specimen taken during your biopsy procedure so your doctor can conduct a complete review. You might need more tissue removed or further treatment.

Step 4: Recommendations
Finally, your doctor will make recommendations about your next steps. This will likely include reviewing some of the studies you’ve already had done or ordering more tests. Once your doctor has all the necessary information, you should be given a preliminary stage and discuss treatment plans.
If the tumour is very large and is putting your breathing at risk, your doctor might recommend you undergo a tracheotomy, which is a breathing tube placed into the front part of your neck directly into your windpipe.

Also, if you are just not able to get enough nutrition by mouth because of the tumour, your doctor might recommend that you receive a feeding tube. This will help make sure you are in good shape to undergo the treatment that you will need to beat the cancer. If you have lost weight, your doctor may give you a choice of getting enough nutrition by mouth by increasing the number of calories in your diet or by undergoing placement of a feeding tube. There are a variety of nutritional supplements that you can eat or drink that can help to achieve that goal. You may want to meet with a nutrition expert early during your treatment. Note that for esophageal cancers, your doctor will probably recommend a special type of feeding tube called a J-tube (or jejunal feeding tube). This is different from a G-tube (gastric tube). This is important because if surgical resection is a possible treatment for your cancer, sometimes your stomach is used as a new esophagus, and it is better if the stomach doesn’t have a feeding tube in it. The J-tube is placed in the jejunum, which is the organ further down the GI tract from the stomach.

Diagnosing Soft Palate Cancer
Getting to a diagnosis begins with a history and physical examination. If the symptoms haven’t been present for very long, or if the history and physical examination make the doctor less suspicious that your lesion is cancer, your doctor might try some medications and rehabilitation before jumping to a diagnosis of cancer.
At some point, if your doctor is not certain of a diagnosis, and if symptoms aren’t getting better (and if symptoms are getting worse), your doctor should raise the possibility of starting a cancer work-up.

Like most cancers in the head and neck, this will include some combination of biopsy and imaging tests.

Be sure to bring all reports and images from any prior treatment with you to your appointment with your head and neck cancer specialist.

Imaging
Imaging refers to radiologic studies, or scans, that create pictures of the structures inside your head and neck. In general, for small tumours that are easily evaluated on physical examination, imaging might not be necessary. For larger tumours, or tumours in locations that are difficult to examine, your doctor will probably order some sort of imaging to get more information about the tumour location and possible spread to regional lymph nodes.

The two main imaging techniques used are computed tomography (CT) scans and magnetic resonance imaging (MRI) scans. Ultrasound is a quick and inexpensive way to get information about disease that is in lymph nodes in the neck. PET scans are studies that look at the function of cells in the body, and they are being used more and more in oncology. PET scans can be combined with other imaging methods such as CT scans to get more detailed information.

CT Scan: This is a quick series of X-rays that can show very good detail of the anatomy. It is helpful in seeing the extent of the main tumour mass and what structures it has invaded. It can also help detect spread into the neck.

 Advantages: A CT scan is a quick test that is readily available and gives a great deal of useful information.
 Disadvantages: A CT scan involves radiation, and the images can be degraded by movement and dental work. It only shows late changes associated with invasion into nerves (such as destruction of the bone where the nerve enters the skull).
 Important points: A CT scan looking for throat tumours should be done with a contrast dye that is injected into your veins, unless there is some reason that you cannot receive contrast. Allergies to iodine and shellfish are common indications that a patient may be allergic to contrast dye.
 What to expect: First, a nurse will insert an intravenous line into a vein to allow for contrast injection. Then you will have to lie flat on a table with your head in a little holster to help keep it totally still. CT scans are typically open, so you shouldn’t feel enclosed. You will then get an injection of contrast, and soon after, the scanner will start moving and taking pictures; this part should only take one or two minutes. Try not to swallow, speak or move during this quick test.

MRI: This test uses magnets to create a picture of the inside of the neck. It is good for showing more subtle details of how extensive the main tumour mass is. It can also help pick up spread of cancer to lymph nodes in the neck.

 Advantages: There is no radiation involved, and the details of the soft tissues are better than that of a CT scan.
 Disadvantages: An MRI takes much longer than a CT scan and is more expensive. Some people feel enclosed inside the MRI machine and may require sedation to get through the study.
 Important points: This test should be done with and without contrast injected into your veins, unless there is some reason you can’t have contrast. Closed MRI machines usually give better pictures than open MRI machines.
 What to expect: First, a nurse will insert an intravenous line into a vein to allow for contrast injection. Then you will have to lie flat on a table with your head in a little holster to help keep it totally still. Due to the strength of the magnets, you will be instructed to remove any metallic objects and to change into a hospital gown before entering the room where the scanner is located. You will then enter the scanner, and the MRI machine will start moving and taking pictures. This can take 30 to 60 minutes, depending on how the scan is done. Try to stay as still as possible throughout the test.

Positron Emission Tomography (PET): Doctors are still studying the most appropriate uses of PET scans for head and neck cancer. The main uses of PET scans at this point are to see if there is spread to sites in the neck or other parts of the body or to help find a primary tumour when the only evidence of cancer is a lymph node that has cancer in it. It is often combined with a CT scan (or in some cases an MRI) to help pinpoint the location of active cells.

Neck ultrasound: An ultrasound is a way to look at vessels, structures and lymph nodes all over the body, particularly in the neck and thyroid gland. You are not exposed to any radiation, and it doesn’t hurt. Basically, a technician or a radiologist will place some cold jelly over the area that is being examined and rub a plastic probe over the area to take pictures. The technician can see enlarged lymph nodes and nodules deep in the neck and describe details about them such as whether they have fluid inside, have a lot of blood vessels around and so on. While the ultrasound is being performed, a doctor can place a needle into a lymph node or nodule and draw off cells (this is an ultrasound-guided biopsy).

Chest X-ray: This is a quick, inexpensive and easy way to look for signs of spread of cancer into the lungs or the possibility of a different cancer in the lungs. Some doctors will recommend a chest X-ray every year as follow-up if you have had a head and neck cancer. This is because patients who have had head and neck cancer are at a higher risk of getting lung cancer as well.

Biopsy
A biopsy is the removal of a small piece of tissue to examine under a microscope to see if it is cancerous. At some point, you will need a biopsy of the suspicious lesion in your throat. The biopsy report is extremely important for determining your diagnosis and treatment plan.

When performing a biopsy on a neck mass, your doctors should test for certain viruses such as human papillomavirus (HPV) and Epstein-Barr Virus (EBV). They can also test for proteins related to these viruses (e.g. P16 as it relates to HPV infection). Cancerous lymph nodes that have the HPV virus (or P16 protein) are very likely to be related to a primary cancer in the oropharynx.

A positive HPV or P16 test should make your doctor spend extra time and effort looking for a small or hidden tumour somewhere in the oropharynx.

Biopsy of soft palate lesions
There are a few different techniques that can be used to biopsy a lesion in the oropharynx.

In-office direct biopsy: Because the soft palate can usually (but not always) be seen by looking into your throat with your mouth wide open, in some cases your doctor might be able to take a biopsy right there in the office with a little numbing medicine (either a spray, or a tiny injection or both).

Just keep your mouth open and stay still. It will only take a few seconds to do the biopsy. Your doctor will probably use a small grasping forceps to remove a piece. After the piece is removed, you will probably have a bit of gauze held in place to apply pressure to stop any tiny amount of bleeding that will result from the biopsy. The bleeding usually stops after a few minutes, or your doctor might dab it with a chemical to stop the bleeding.

Direct laryngoscopy with biopsy: Your doctor might choose this technique if he or she can’t get a good biopsy in the office or wants to get a better look all around your throat in the operating room.
For select oropharynx tumours, your doctor might either take a small piece in the operating room to confirm the diagnosis or remove the entire mass (this is called an excisional biopsy). Also, your surgeon will take the opportunity to thoroughly feel all around your neck, mouth and throat while you are asleep. Finally, he or she will look for any additional suspicious lesions (called second primaries). One of the other advantages of this technique is that frozen section pathology is usually available in the operating room to make certain that enough tissue has been sampled in order to make a definitive diagnosis.

For this to be done, you will go to sleep with anaesthesia in an operating room with a small breathing tube placed through your mouth into your windpipe. Then your surgeon will place an instrument called a laryngoscope through your mouth and look all over your throat. He or she can even use a longer scope, called an esophagoscope, to look at the upper part of your esophagus. The surgeon will then use small forceps to take a piece of tissue from any suspicious looking area. In some cases, the doctor might remove the entire lesion, for which he or she may use a variety of different instruments, including a laser.

If needed, your doctor might talk to you in advance about doing a tracheotomy or a feeding tube during this procedure while you are asleep.

Biopsy of neck masses
If there is also a lump in the neck, your doctor might decide to biopsy that as well. There are a few different ways to do a biopsy of the neck.

Fine needle aspiration biopsy: The most common and easiest way to biopsy is fine needle aspiration biopsy (FNAB), in which a tiny needle is placed into the tumour and some cells are drawn out through a syringe. The pathology doctor, known as a cytologist or cytopathologist, will then immediately look at the cells under the microscope and let your doctor know if there were enough cells to make a diagnosis. Several “passes” might be done to increase the likelihood that there are enough cells to make a diagnosis. The final diagnosis may take a few days to come back, so be patient.

Core biopsy: Core biopsy is an alternative to fine needle aspiration. A core biopsy is done in the same way as an FNA biopsy, but it uses a larger needle and removes a core of tissue from the tumour rather than just a few cells. The likelihood of false positives and false negatives is much lower with a core needle biopsy than with a fine needle biopsy.

Open neck biopsy: An open biopsy involves making an incision over the tumour and removing a piece or all the tumour to make a diagnosis. An open biopsy of a neck mass is performed through an incision over the lump, and either a piece (incisional open neck biopsy) or the entire lump (excisional open neck biopsy) is removed to make a diagnosis. Except in a few special circumstances (such as if the tumour is likely a lymphoma or if other methods of diagnosis have not worked), this method should not be used to find the diagnosis of a neck mass.

Determining the Type of Soft Palate Cancer

Only after a pathologist analyses some cells or actual pieces of tissue from the lesion will your doctor be able to tell you if you have cancer. Your doctor and pathologist should specialise in head and neck cancers because some benign (non-cancerous) lesions can look like cancer on a small biopsy.

It is very important in oropharynx cancer to know if it is associated with the HPV virus. This can be determined from a biopsy by running some special tests, including looking for DNA of the virus or looking for certain proteins, such as P16, related to the virus. While we do know that patients with HPV-related oropharyngeal cancers have better outcomes, we are not quite at the stage where we can treat them differently.
 Squamous cell carcinoma: These are by far the most common oropharyngeal cancers. They arise from cells lining the oropharynx. They should be divided into two main types depending on some cellular findings (HPV and/or P16 positive versus HPV and/or p16 negative).
o Squamous cell cancers of the oropharynx are typically given a grade by a pathologist after looking at the cells under a microscope. Grade means that the tumour falls on a scale from well differentiated (Grade I) to poorly differentiated (Grade IV). It is generally felt that the prognosis for a more well-differentiated cancer is more favourable.

More rarely, other cancers can be found in the oropharynx as well. Some of them include:
Salivary gland cancers: There are minor salivary glands located under the lining of the throat. Therefore, cancers that we typically see in salivary glands can arise in this region. They include diagnoses such as mucoepidermoid carcinomas, adenocarcinomas and adenoid cystic carcinomas, to name a few. See Salivary Gland Cancer for more information.

Lymphoma: The throat is lined with lymphoid cells. Some major sites of lymphoid tissue include the adenoids in the nasopharynx and palatine tonsils and lingual tonsils in the oropharynx. Therefore, lymphoma might appear as a lump in the throat area.

Mucosal melanoma: These cancers come from skin cells that give skin its colour. In rare cases, melanoma can be found in the lining of the mouth, nose and/or throat.

Other rare cancers include:
 Sarcomas such as chondsarcoma, liposarcoma and synovial sarcoma
 Malignant fibrous histiocytoma
 Peripheral Neuroectodermal Tumour (PNET)
 Cancer spread from another site

Determining the Grade of the Tumour
Pathologists will typically report on the grade of the tumour. This is a qualitative interpretation by the pathologist of how much the cancerous cells resemble normal tissue from that site. There are several different grading systems that might be used. The most common system is as follows:
 GX: Grade cannot be assessed
 G1: Well differentiated
 G2: Moderately differentiated
 G3: Poorly differentiated
 G4: Undifferentiated

Differentiation refers to how closely the cells taken from a tumour or lesion resemble normal cells from the healthy tissue surrounding the tumour. “Well differentiated” means that the cells look like normal cells in that area. “Undifferentiated” means the cells look nothing like normal cells in that area.

While it is important to report the tumour’s grade, few doctors use this information to make decisions regarding treatment or prognosis for this cancer type.

Determining the Stage of the Cancer
The final step before discussing treatment options is a determination of the stage of the cancer. As with all cancers of the head and neck, in Australia it is mandatory for doctors to use the AJCC Cancer Staging Manual (7th Ed) to determine the stage based on three factors.

Factors that go into determining the stage of the cancer
T Characteristics of the main tumour mass
N Status of the lymph nodes in the neck (i.e., evidence of cancer spread)
M Status of cancer spread to parts of the body outside of the head and neck

At first, you will be given a clinical stage based on all of the available information.
Clinical staging (cTNM) is determined from any information your doctor might have about how extensive the cancer is BEFORE starting any treatment. Stage is determined based on your doctor’s physical exam, imaging studies, laboratory work and biopsies. Classification of clinical stage is described using the lowercase prefix c (e.g., cT, cN, cM).

If there is surgical removal of the cancer as part of your treatment, a pathologist will analyze the tumour and any lymph nodes that may have been removed. You will then be assigned a pathologic stage.

Pathologic staging (pTNM) provides more data. Classification of pathology stage is described using the lowercase prefix p (e.g., pT, pN, pM). This may or may not differ from the clinical stage.

There are also a number of other lowercase prefixes that might be used in the staging of your cancer.
 The subscript y (yTNM) is used to assign a cancer stage after some sort of medical, systemic or radiation treatment is given (Posttherapy or Postneoadjuvant Stage). It is typically combined with either a clinical or pathologic stage. For example, ycT2N0M0 indicates that after some sort of non-surgical therapy, the new clinical stage is T2N0M0.
 The subscript r (rTNM) is used when the tumour has recurred after some period in which it was gone. This is called Retreatment Classification Stage. Your doctor will use all the available information to assign you a retreatment stage.

T stage: the main tumour mass
Based on a physical examination and review of any imaging, your doctor should be able to give you a T stage that falls within one of the following categories.

Tx The doctor is unable to assess the primary tumour.
T0 The doctor is unable to find the primary tumour.
Tis Carcinoma in situ (or severe dysplasia); this means there are cancer type cells, but they have not yet invaded deep into tissue. This is more of a pre-cancer lesion.
T1 The tumour is 2 centimetres or less in greatest dimension.
T2 The tumour is more than 2 centimetres but less than or equal to 4 centimetres in greatest dimension.
T3 The tumour is more than 4 centimetres in greatest size or has grown into the tongue side of the epiglottis.
T4a This is moderately advanced local disease. The tumour has grown into the larynx, the outside the tongue muscles, the hard palate, the lower jawbone and/or the medial pterygoid muscles.
T4b This is very advanced local disease. The tumour has invaded into the lateral pterygoid muscle, the pterygoid plates, up to the sides of the nasopharynx, into the skull base or completely around the carotid artery.

N stage: spread of cancer to the lymph nodes in the neck
Next, your doctor will use all the available information and assign you an N stage. This is based on the assessment as to whether the cancer has spread to lymph nodes in the neck.

Nx The neck lymph nodes cannot be assessed.
N0 There is no evidence of any spread to the nodes.
N1 There is a single node, on the same side of the main tumour, that is 3 centimetres or less in greatest size.
N2a Cancer has spread to a single lymph node, on the same side as the main tumour, and it is more than 3 centimetres but less than or equal to 6 centimetres in greatest dimension.
N2b There are multiple lymph nodes that have cancer, on the same side as the main tumour, but none are more than 6 centimetres in size.
N2c There are lymph nodes in the neck on either the opposite side as the main cancer, or on both sides of the neck, but none are more than 6 centimetres.
N3 There is spread to one or more neck lymph nodes, and the size is greater than 6 centimetres.

M stage: spread of cancer outside the head and neck
Finally, based on an assessment on the entire body, you will be assigned an M stage.

M0 No evidence of distant (outside the head and neck) spread.
M1 There is evidence of spread outside of the head and neck (i.e., in the lungs, bone, brain, etc.).

Your cancer stages
After TNM staging, your doctor can assign a cancer stage based on the following chart.

Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
Stage IVA T4a N0 M0
T4a N1 M0
T1 N2 M0
T2 N2 M0
T3 N2 M0
T4a N2 M0
Stage IVB T4b Any N M0
Any T N3 M0
Stage IVC Any T Any N M1

Your clinical stage
Once the diagnostic tests are completed, before deciding what type of treatment you are going to undergo, you should be given a clinical stage that will look like the example below.

CLINICAL STAGE
Example
Site Oropharynx
Subsite Soft Palate
Type Squamous Cell Carcinoma
cT cT3
cN cN1
cM cM0
cStage cIII
* The lowercase subscript c indicates that this is a CLINICAL STAGE, the stage assigned based on all information available to your doctor before starting treatment.

After surgery, you should get a pathologic stage of your tumour. It will look almost like the clinical stage you received before starting treatment, but notice the “p” that indicates the stage group is based on an analysis of the entire tumour, with or without lymph nodes, under a microscope by a pathologist. In many cases, the pathologic stage will be the same as the clinical stage, but sometimes it will change.

After surgery, and after the pathologist has evaluated all the tumour that was removed, you should be given a pathologic stage that looks something like this:

PATHOLOGIC STAGE
Example
Site Oropharynx
Subsite Soft Palate
Type Squamous Cell Carcinoma
pT pT3
pN pN2b
cM cM0
pStage pIVa

* The lowercase subscript p indicates that this is a PATHOLOGIC STAGE, the stage assigned after tumour removal and confirmation of cancer by a pathologist.

* Note also that the M stage is usually clinical, based on all available data without actually analysing any tissue..

Deciding on a Treatment Plan

Before starting treatment, your doctor will make sure that the following steps are completed.
Pre-treatment evaluation
 A full history and physical examination, including a complete head and neck exam (mirror and fibreoptic exam if needed)
 An evaluation by the members of a head and neck cancer team
 A biopsy of primary site or FNA of the neck to confirm a diagnosis of cancer
 Testing for HPV
 Imaging of the lungs to check for spread, if needed
 Imaging of the primary tumour and the neck with CT and/or MRI
 Maybe a PET-CT for advanced cancers
 A dental evaluation with or without jaw x-rays as needed
 Nutrition, speech, and swallowing evaluation and maybe even a hearing evaluation
 Examination under anaesthesia with endoscopy as needed
 Pre-treatment medical clearance and optimisation of medical conditions

Then, your doctor will recommend a course of treatment for you, depending on a number of factors.
As with all cancers in the head and neck, there are three general options to consider:
 Surgical removal (with or without reconstruction)
 Radiation (a few different types)
 Medications (chemotherapy and biologic medications)

For oropharyngeal cancer, there is not one clear treatment method. You should have an extensive discussion with your cancer team to decide upon the best treatment course for you personally.
T1-2, N0-1 For small primary tumours, with at most one lymph node on the same side as the primary tumour (T1-2, N0-1), the options for treatment are as follows:
• Radiation therapy
• Surgery to remove the primary tumour (see Pharyngectomy) with or without removal of lymph nodes from the neck one or both sides of the neck (see Neck Dissection)
• Radiation along with chemotherapy (for T2,N1 only)
• A clinical trial
If treatment without surgery is chosen and there appears to be cancer left after treatment, then surgery should be performed to remove everything (see Pharyngectomy and Neck Dissection).
If the first treatment that you and your doctor decide upon is surgical removal of the cancer, then the cancer must be analysed under the microscope to determine if additional treatment is needed. Your doctors will be on the lookout for any adverse features, which include:
• Spread of cancer outside of a lymph node
• Cancer at the margins of the surgical removal
• A more extensive cancer than anticipated before the operation (pT3 or pT4, or N2 or N3)
• Positive nodes in level IV or V
• Perineural invasion—tumour invasion of surrounding nerves
• Tumour inside veins
For example:
• If there are no adverse features, then no further treatment is needed.
• If there is one positive node without any adverse features, then your doctors might consider radiation therapy for you.
• If there are adverse features, radiation, chemotherapy with radiation, or additional surgery will probably be recommended. Talk to your doctor for details.

T3-4a, N0-1 These are locally advanced cancers, which means that the primary tumour is quite large. In this case, there are a few treatment options that your doctors will consider:
• Chemotherapy along with radiation
• Surgery to remove the main tumour and lymph nodes from the neck, followed by either radiation or chemotherapy with radiation, depending on pathology
• For select patient’s induction chemotherapy, followed by radiation
• For select patient’s induction chemotherapy, followed by more chemotherapy along with radiation
• A clinical trial
Again, if treatment without surgery is chosen and there appears to be cancer left after treatment, then surgery should be performed to remove everything (see Pharyngectomy, and Neck Dissection).
If the first treatment that you and your doctor decide upon is surgical removal of the cancer, then the cancer must be analysed under the microscope to determine if additional treatment is needed. Your doctors will be on the lookout for any adverse features:
• Spread of cancer outside of a lymph node
• Cancer at the margins of the surgical removal
• A more extensive cancer than anticipated before the operation (pT3 or pT4, or N2 or N3)
• Positive nodes in level IV or V
• Perineural invasion
• Tumour inside veins
Then,
• If there are no adverse features (see above), then radiation will be added.
• If the adverse features include spread of cancer outside of the capsule of the lymph node and/or if there is cancer at the margins of the surgical removal, then chemotherapy and radiation will be recommended.
• If the adverse features are any of the others, then either radiation alone or radiation along with chemotherapy will be recommended.
Any T, N2-3 This is a cancer involving either many lymph nodes in the neck, large lymph nodes in the neck, and/or lymph nodes on both sides of the neck and/or lymph nodes on the side of the neck opposite to the main tumour mass. There are a few options for the initial treatment:
• Chemotherapy along with radiation
• Chemotherapy, followed by radiation
• Chemotherapy, followed by more chemotherapy along with radiation
• Surgery to remove the main tumour and lymph nodes from the neck, followed by either radiation or chemotherapy with radiation, depending on pathology
• A clinical trial
If a non-surgical treatment is chosen as the first line, you need to look at whether the cancer is gone:
• If there is any cancer left at the primary site, then your doctor might recommend surgery along with a neck dissection.
• If the cancer is gone from the primary site, then you need to look at the neck. If at any point there is evidence of cancer in the neck, your doctor will likely recommend a neck dissection.
If the first treatment that you and your doctor decide upon is surgical removal of the cancer, then the cancer must be analysed under the microscope to determine if additional treatment is needed. Your doctors will be on the lookout for any adverse features such as:
• Spread of cancer outside of a lymph node
• Cancer at the margins of the surgical removal
• A more extensive cancer than anticipated before the operation (pT3 or pT4, or N2 or N3)
• Positive nodes in level IV or V
• Perineural invasion (invasion of the tumour into surrounding nerves)
• Tumour inside veins
Then,
• If there are no adverse features (see above) after the first-line treatment is completed, then no additional treatment is necessary.
• If the adverse features include spread of cancer outside the capsule of the lymph node, or if there is cancer at the margins of the surgical removal, then chemotherapy and radiation will be recommended.
• If the adverse features are any of the others, then either radiation alone or radiation along with chemotherapy will be recommended.
T4b, any N
Unresectable neck disease
Unfit for surgery In cases that are very advanced, or in patients who are extremely sick, an extensive discussion with your doctors should be undertaken.

Determining Your Prognosis
Your prognosis is a prediction of the outcome of your disease. What is the risk of succumbing to the cancer or the risk of its coming back? These are the big questions on most people’s minds after receiving a diagnosis of throat cancer. Prognosis is based on many factors, and a survival rate is an estimate based on large populations of patients who have been given a similar stage of their throat cancer. There are many specific factors that are unique to each patient that may influence treatment success.

The following aspects of the cancer may affect your prognosis.

Human Papillomavirus (HPV) Status Unlike other head and neck cancers, squamous cell cancers of the oropharynx can be divided into HPV-related and HPV-unrelated cancers. Details are still being worked out, but it is becoming clear that with current treatment methods, patients with HPV-related oropharynx cancer have a better chance at being cured than those with HPV-unrelated oropharynx cancer.
Stage It is very important to know the stage to help determine your chance of cure. However, the staging system at this point does not separate HPV-positive from HPV-negative cancers.
Spread to Lymph Nodes Spread of Cancer Cells Outside Lymph Node Capsule This goes along with stage. However, even without other factors, if there is spread to lymph nodes in the neck, there’s a diminished chance of cure, particularly if there is evidence of spread of cancer outside the lymph node. Still, for HPV-related oropharynx cancer, there is some data indicating that spread outside of lymph nodes is not as bad a sign as HPV-unrelated oropharynx cancer.
Tumour Margins The ability to completely remove the tumour can be a very important factor that will influence the likelihood of being cured.
Spread into Local Structures Spread into large nerves, vessels or lymphatics might make your prognosis worse.

A very interesting study that looked at survival in HPV-related oropharynx cancers versus non-HPV related oropharynx cancers revealed some interesting results. This study found that for Stage III and Stage IV oropharynx cancer, there was a difference in survival after three years based on the HPV status (82 percent in HPV positive cancers versus 57 percent in HPV negative cancers).

What to Expect After Treatment is Completed?
Once you have made it through treatment, you need to have close follow-up with your doctor. This follow-up plan is recommended after being treated for a throat cancer:
 Visit your head and neck specialist on a regular schedule (or earlier if you have any concerning symptoms). This allows your doctor to examine you for any signs that the cancer has come back.
o For the first year, you should go every one to three months.
o For the second year, you should go every two to six months.
o For the third to fifth year, you should go every four to eight months.
o After five years, you can start going every year.
 Your doctor should select a scan to be performed in the first six months after treatment. The first scan serves as a “baseline” study for the purpose of comparing future studies. This will depend on the type, stage, and location of your cancer. Imaging may include CT scans, MRI scans and PET scans. If something suspicious comes up, you might need another biopsy.
 Consider chest imaging to check for any signs of lung cancer if you have an extensive smoking history.
 Check your thyroid function every six to twelve months if you were ever with radiation to the neck area.
 Get help with a therapist as needed for difficulties with speaking, hearing and swallowing.
 See a specialist about appropriate nutrition and diet.
 Alert your doctor if you experience any signs of depression.
 Stop smoking and stop drinking.
 See a dentist.

Causes of Tongue Base Cancer
As with most cancers, doctors can’t tell you with certainty what causes tongue base cancer. It’s a combination of genetic factors and factors in your environment.

By far the most common factor contributing to most head and neck cancers is using tobacco, particularly smoking it. Drinking excessive amounts of alcohol also contributes to the risk of developing head and neck cancer.
 Tobacco: Smoking cigarettes, cigars or pipes and using chewing tobacco greatly increase your chance of getting a throat cancer.
 Alcohol: Drinking excessive amounts of alcohol is also very strongly related to getting a throat cancer. Moreover, if you both smoke and drink heavily, the risk more than doubles.
 Viruses: Exposure to certain strains of human papillomavirus (HPV) is associated with oropharynx cancer. The strains 16 and 18 are the main ones we are concerned about. This virus is quite common, and it is associated with intimate sexual contact. Why some people get cancer from this virus while others don’t is still a mystery.
 Exposure to radiation in the past: Being exposed to radiation as part of a natural disaster, treatment for another disease a long time ago or even through work can increase the chances of some throat cancers.
 Genetic factors: This is important in all cancers, and the details are still being worked out.
 Certain foods: Deficiencies in some vitamins and poor oral hygiene might be associated with oropharynx cancers.

Signs and Symptoms of Tongue Base Cancer
The symptoms of soft palate cancer, like other oropharynx cancers, depend on where the tumour is and how big it is. In many cases, patients will have some difficulty with swallowing or feel something way back in their tongue but not be able to see anything. However, it is not uncommon for the first symptom of a cancer in the base of tongue to be a lump in the neck. In any case, tongue base cancer can present with a whole host of different symptoms, including:
 Pain or difficulty with swallowing in the throat: This can occur because a tumour is in the way of swallowing, and so it becomes difficult or painful to swallow. Also, there can be ulceration and bleeding as the tumour grows, causing pain.
 A lump in the neck: This will be a symptom of oropharyngeal cancer if it has spread to lymph nodes in the neck. This can be the first symptom that brings a patient to the doctor. If you have a neck mass, and your doctor is concerned that it represents cancer spread from somewhere else, one of the first places he or she will look is your oropharynx.
 Ear pain (particularly on one side, with no other ear problems): Ear pain, also known as otalgia, happens because the nerves of the throat reach the brain through the same pathway as one of the nerves in the ear. Therefore, your brain might interpret a pain in the throat as coming from the ear. This is called referred pain. Consequently, unexplained ear pain that doesn’t go away should be evaluated by a specialist. It is important to understand that most causes of ear pain are due to simple problems such as middle ear infection or dysfunction of the Eustachian tube. TMJ pain due to a problem in the joint located in front of the ear may also present as otalgia.

Other symptoms might include:
 Difficulty opening your mouth widely (trismus)
 Feeling a lump in the throat
 Bleeding from the mouth
 A change in the way you speak
 Weight loss

But don’t jump to any conclusions. You could have one or more of these symptoms but NOT have oropharyngeal cancer. There are several non-cancerous causes of the same symptoms. That’s why you need to see a specialist.

What to Expect at Your Doctor’s Visit?
Step 1: History
First, your head and neck specialist will take a thorough history of your health and address any specific concerns you may have.
Your doctor might ask questions such as:
 How long has the problem been there?
 Is it getting worse, better or staying the same?
 Does it come and go?
 Have you tried anything to make it better?
 Is it painful?
 Do you have any lumps or bumps in your neck?
 Are you having difficulty with hearing?
 Do you have any lumps or bumps anywhere else in your body?
 Are you losing weight?
 Are there any other problems associated with your main problem?
 Do you have any other medical issues?
 Have you had any surgeries in the past?
 What medications do you take? And do you have any allergies?
 Have you ever been exposed to radiation in the area?
 What do you (or did you) do for a living?
 Do you have a family history of cancer?

Step 2: Physical Exam
Next, your doctor will examine you. Typically, if you’re seeing a specialist in head and neck disorders, you will get a thorough physical examination focused on the area of concern. The oropharynx, including the tongue base, typically requires a specialist to evaluate. It is particularly challenging for a general doctor to see and feel this area without specialised equipment.
Your doctor might do some of the following:
 Look inside and probably even feel inside your mouth
 Feel your neck to carefully check for any lumps or bumps
 Look inside your ears
 Look inside the front of your nose
 Check your cranial nerves by asking you to move your face, stick your tongue out, lift your shoulders, follow his or her fingers around with your eyes, do some simple hearing tests and test your sense of touch all over your face

A few special diagnostic tests might be required as part of your physical exam.
 Pharyngoscopy and/or Laryngoscopy (looking at your oropharynx, hypopharynx and larynx): This can be done in a few ways, including with a headlight and mirror placed on the roof of your mouth to look down or with a flexible camera placed through your nose.
 Flexible pharyngo-laryngoscopy: Your doctor may spray your nose with some medications and then slowly and carefully place a flexible tube with a camera through your nose down into your throat. Just sit still, breathe slowly and listen to your doctor’s instructions.
 Indirect mirror examination: Your doctor will distract you while placing a small mirror into the back of your throat through your mouth. The doctor will ask you to breathe through your mouth and make sounds as he or she examines your throat.

Your doctor may spray your nose with some medications and then slowly and carefully place a flexible tube with a camera through your nose down into your throat. Just sit still, breathe slowly and listen to your doctor’s instructions. Your doctor will distract you while placing a small mirror into the back of your throat through your mouth. The doctor will ask you to breathe through your mouth and make sounds as he or she examines your throat.

Step 3: Reviewing Tests
After getting your history and performing a physical exam, your doctor will review any imaging, laboratory work and pathology results you may have already had. Be sure to bring all of these with you to your appointment. Bring actual discs of any scans you’ve had, as well as any reports of those scans. If you are seeing a head and neck cancer specialist after a lesion was removed by a non-cancer specialist, you need a thorough review of the pathology to discuss whether additional treatment is necessary. Try to obtain the actual glass slides that were prepared by the pathologist with the specimen taken during your biopsy procedure so your doctor can conduct a complete review. You might need more tissue removed or further treatment.

Step 4: Recommendations
Finally, your doctor will make recommendations about your next steps. This will likely include reviewing some of the studies you’ve already had done or ordering more tests. Once your doctor has all the necessary information, you should be given a preliminary stage and discuss treatment plans.

If the tumour is very large and is putting your breathing at risk, your doctor might recommend you undergo a tracheotomy, which is a breathing tube placed into the front part of your neck directly into your windpipe.

Also, if you are just not able to get enough nutrition by mouth because of the tumour, your doctor might recommend that you receive a feeding tube. This will help make sure you are in good shape to undergo the treatment that you will need to beat the cancer. If you have lost weight, your doctor may give you a choice of getting enough nutrition by mouth by increasing the number of calories in your diet or by undergoing placement of a feeding tube. There are a variety of nutritional supplements that you can eat or drink that can help to achieve that goal. You may want to meet with a nutrition expert early during your treatment. Note that for esophageal cancers, your doctor will probably recommend a special type of feeding tube called a J-tube (or jejunal feeding tube). This is different from a G-tube (gastric tube). This is important because if surgical resection is a possible treatment for your cancer, sometimes your stomach is used as a new esophagus, and it is better if the stomach doesn’t have a feeding tube in it. The J-tube is placed in the jejunum, which is the organ further down the GI tract from the stomach.

Diagnosing Tongue Base Cancer
Getting to a diagnosis begins with a history and physical examination. If the symptoms haven’t been present for very long, or if the history and physical examination make the doctor less suspicious that your lesion is cancer, your doctor might try some medications and rehabilitation before jumping to a diagnosis of cancer.

At some point, if your doctor is not certain of a diagnosis, and if symptoms aren’t getting better (and if symptoms are getting worse), your doctor should raise the possibility of starting a cancer work-up. Like most cancers in the head and neck, this will include some combination of biopsy and imaging tests.

Be sure to bring all reports and images from any prior treatment with you to your appointment with your head and neck cancer specialist.

Imaging
Imaging refers to radiologic studies, or scans, that create pictures of the structures inside your head and neck. In general, for small tumours that are easily evaluated on physical examination, imaging might not be necessary. For larger tumours, or tumours in locations that are difficult to examine, your doctor will probably order some sort of imaging to get more information about the tumour location and possible spread to regional lymph nodes.

The two main imaging techniques used are computed tomography (CT) scans and magnetic resonance imaging (MRI) scans. Ultrasound is a quick and inexpensive way to get information about disease that is in lymph nodes in the neck. PET scans are studies that look at the function of cells in the body, and they are being used more and more in oncology. PET scans can be combined with other imaging methods such as CT scans to get more detailed information.

CT Scan: This is a quick series of X-rays that can show very good detail of the anatomy. It is helpful in seeing the extent of the main tumour mass and what structures it has invaded. It can also help detect spread into the neck.
 Advantages: A CT scan is a quick test that is readily available and gives a great deal of useful information.
 Disadvantages: A CT scan involves radiation, and the images can be degraded by movement and dental work. It only shows late changes associated with invasion into nerves (such as destruction of the bone where the nerve enters the skull).
 Important points: A CT scan looking for throat tumours should be done with a contrast dye that is injected into your veins, unless there is some reason that you cannot receive contrast. Allergies to iodine and shellfish are common indications that a patient may be allergic to contrast dye.
 What to expect: First, a nurse will insert an intravenous line into a vein to allow for contrast injection. Then you will have to lie flat on a table with your head in a little holster to help keep it totally still. CT scans are typically open, so you shouldn’t feel enclosed. You will then get an injection of contrast, and soon after, the scanner will start moving and taking pictures; this part should only take one or two minutes. Try not to swallow, speak or move during this quick test.

MRI: This test uses magnets to create a picture of the inside of the neck. It is good for showing more subtle details of how extensive the main tumour mass is. It can also help pick up spread of cancer to lymph nodes in the neck.
 Advantages: There is no radiation involved, and the details of the soft tissues are better than that of a CT scan.
 Disadvantages: An MRI takes much longer than a CT scan and is more expensive. Some people feel enclosed inside the MRI machine and may require sedation to get through the study.
 Important points: This test should be done with and without contrast injected into your veins, unless there is some reason you can’t have contrast. Closed MRI machines usually give better pictures than open MRI machines.
 What to expect: First, a nurse will insert an intravenous line into a vein to allow for contrast injection. Then you will have to lie flat on a table with your head in a little holster to help keep it totally still. Due to the strength of the magnets, you will be instructed to remove any metallic objects and to change into a hospital gown before entering the room where the scanner is located. You will then enter the scanner, and the MRI machine will start moving and taking pictures. This can take 30 to 60 minutes, depending on how the scan is done. Try to stay as still as possible throughout the test.

Positron Emission Tomography (PET): Doctors are still studying the most appropriate uses of PET scans for head and neck cancer. The main uses of PET scans at this point are to see if there is spread to sites in the neck or other parts of the body or to help find a primary tumour when the only evidence of cancer is a lymph node that has cancer in it. It is often combined with a CT scan (or in some cases an MRI) to help pinpoint the location of active cells.

Neck ultrasound: An ultrasound is a way to look at vessels, structures and lymph nodes all over the body, particularly in the neck and thyroid gland. You are not exposed to any radiation, and it doesn’t hurt. Basically, a technician or a radiologist will place some cold jelly over the area that is being examined and rub a plastic probe over the area to take pictures. The technician can see enlarged lymph nodes and nodules deep in the neck and describe details about them such as whether they have fluid inside, have a lot of blood vessels around and so on. While the ultrasound is being performed, a doctor can place a needle into a lymph node or nodule and draw off cells (this is an ultrasound-guided biopsy).

Chest X-ray: This is a quick, inexpensive and easy way to look for signs of spread of cancer into the lungs or the possibility of a different cancer in the lungs. Some doctors will recommend a chest X-ray every year as follow-up if you have had a head and neck cancer. This is because patients who have had head and neck cancer are at a higher risk of getting lung cancer as well.

Biopsy
A biopsy is the removal of a small piece of tissue to examine under a microscope to see if it is cancerous. At some point, you will need a biopsy of the suspicious lesion in your throat. The biopsy report is extremely important for determining your diagnosis and treatment plan.
When performing a biopsy on a neck mass, your doctors should test for certain viruses such as human papillomavirus (HPV) and Epstein-Barr Virus (EBV). They can also test for proteins related to these viruses (e.g. P16 as it relates to HPV infection). Cancerous lymph nodes that have the HPV virus (or P16 protein) are very likely to be related to a primary cancer in the oropharynx. A positive HPV or P16 test should make your doctor spend extra time and effort looking for a small or hidden tumour somewhere in the oropharynx.
Biopsy of base of tongue lesions
Typically, you will undergo endoscopy with biopsy. Exactly how the endoscopy is done will be up to your physician. The three general ways to biopsy a suspicious area in the oropharynx are:

Transnasal flexible endoscopy with biopsy: If your doctor sees a suspicious lesion that he or she might be able to biopsy in the office, this method is a possibility. This is just like having a transnasal flexible laryngoscopy, except the camera used in this case has a special attachment through which your doctor can spray medicine directly onto the area of interest to numb it. Through that same attachment, your doctor can pass a thin biopsy forceps and clip off a tiny piece of the suspicious growth.

The main advantage of transnasal flexible endoscopy with biopsy is that it is usually quick and easy, and you don’t need to go to an operating room or go under general anaesthesia. However, your doctor can only get a tiny piece of tissue this way, and it might not lead to the correct diagnosis. Also, it’s not as good a view as a direct examination in the operating room. Finally, your doctor can’t feel around or get as good a look as with a direct laryngoscopy.

Direct laryngoscopy with biopsy: Your doctor might choose this technique if he or she can’t get a good biopsy in the office or wants to get a better look all around your throat in the operating room.
For the base of tongue, your doctor might either take a small piece in the operating room to confirm the diagnosis, or he or she might remove a large piece of the base of tongue (sometimes using tools like lasers and robots to help) to try to remove the entire tumour. Also, your surgeon will take the opportunity to thoroughly feel all around your neck, mouth and throat while you are asleep. Finally, he or she will look for any additional suspicious lesions (called second primaries). One of the other advantages of this technique is that frozen section pathology is usually available in the operating room to make certain that enough tissue has been sampled in order to make a definitive diagnosis.
For this to be done, you will go to sleep with anaesthesia in an operating room with a small breathing tube placed through your mouth into your windpipe. Then your surgeon will place an instrument called a laryngoscope through your mouth and look all over your throat. He or she can even use a longer scope, called an esophagoscope, to look at the upper part of your esophagus. The surgeon will then use small forceps to take a piece of tissue from any suspicious looking area. In some cases, the doctor might remove the entire lesion, for which he or she may use a variety of different instruments, including a laser.

If needed, your doctor might talk to you in advance about doing a tracheotomy or a feeding tube during this procedure while you are asleep.

Biopsy of neck masses
If there is also a lump in the neck, your doctor might decide to biopsy that as well. There are a few different ways to do a biopsy of the neck.

Fine needle aspiration biopsy: The most common and easiest way to biopsy is fine needle aspiration biopsy (FNAB), in which a tiny needle is placed into the tumour and some cells are drawn out through a syringe. The pathology doctor, known as a cytologist or cytopathologist, will then immediately look at the cells under the microscope and let your doctor know if there were enough cells to make a diagnosis. Several “passes” might be done to increase the likelihood that there are enough cells to make a diagnosis. The final diagnosis may take a few days to come back, so be patient.

Core biopsy: Core biopsy is an alternative to fine needle aspiration. A core biopsy is done in the same way as an FNA biopsy, but it uses a larger needle and removes a core of tissue from the tumour rather than just a few cells. The likelihood of false positives and false negatives is much lower with a core needle biopsy than with a fine needle biopsy.

Open neck biopsy: An open biopsy involves making an incision over the tumour and removing a piece or all of the tumour to make a diagnosis. An open biopsy of a neck mass is performed through an incision over the lump, and either a piece (incisional open neck biopsy) or the entire lump (excisional open neck biopsy) is removed to make a diagnosis. Except in a few special circumstances (such as if the tumour is likely a lymphoma or if other methods of diagnosis have not worked), this method should not be used to find the diagnosis of a neck mass.

Determining the Type of Tongue Base Cancer
Only after a pathologist analyses some cells or actual pieces of tissue from the lesion will your doctor be able to tell you if you have cancer. Your doctor and pathologist should specialise in head and neck cancers because some benign (non-cancerous) lesions can look like cancer on a small biopsy.

It is very important in oropharynx cancer to know if it is associated with HPV. This can be determined from a biopsy by running some special tests, including looking for DNA of the virus or looking for certain proteins, such as P16, related to the virus. While we do know that patients with HPV-related oropharyngeal cancers have a better prognosis, we are not quite at the stage where we can treat them differently.

Squamous cell carcinoma: These are by far the most common oropharyngeal cancers. They arise from cells lining the oropharynx. They should be divided into two main types, depending on some cellular findings relating the cancer to the human papillomavirus (HPV positive versus HPV negative).
Squamous cell cancers of the oropharynx are typically given a grade by a pathologist after looking at the cells under a microscope. Grade means that the tumour falls on a scale from well differentiated (Grade I) to poorly differentiated (Grade IV). It is generally felt that the prognosis for a more well-differentiated cancer is more favourable.

More rarely, other cancers can be found in the oropharynx as well. Some of them include:
Salivary gland cancers: There are minor salivary glands located under the lining of the throat. Therefore, cancers that we typically see in salivary glands can arise in this region and they include diagnoses such as mucoepidermoid carcinomas, adenocarcinomas and adenoid cystic carcinomas, to name a few. See Salivary Gland Cancer for more information.

Lymphoma: The throat is lined with lymphoid cells. Some major sites of lymphoid tissue include the adenoids in the nasopharynx and palatine tonsils and lingual tonsils in the oropharynx. This is why lymphoma might appear as a lump in the throat area.

Mucosal melanoma: These cancers come from skin cells that give skin its color. In rare cases, melanoma can be found in the lining of the mouth, nose and/or throat.

Other rare cancers include:
 Sarcomas such as chondsarcoma, liposarcoma and synovial sarcoma
 Malignant fibrous histiocytoma
 Peripheral Neuroectodermal Tumour (PNET)
 Cancer spread from another site

Determining the Grade of the Tumour
Pathologists will typically report on the grade of the tumour. This is a qualitative interpretation by the pathologist of how much the cancerous cells resemble normal tissue from that site. There are several different grading systems that might be used.

The most common system is as follows:
 GX: Grade cannot be assessed
 G1: Well differentiated
 G2: Moderately differentiated
 G3: Poorly differentiated
 G4: Undifferentiated

Differentiation refers to how closely the cells taken from a tumour or lesion resemble normal cells from the healthy tissue surrounding the tumour. “Well differentiated” means that the cells look like normal cells in that area. “Undifferentiated” means the cells look nothing like normal cells in that area.

While it is important to report the tumour’s grade, few doctors use this information to make decisions regarding treatment or prognosis for this cancer type.

Determining the Stage of the Cancer
The final step before discussing treatment options is a determination of the stage of the cancer. As with all cancers of the head and neck, in Australia it is mandatory for doctors to use the AJCC Cancer Staging Manual (7th Ed) to determine the stage based on three factors.

Factors that go into determining the stage of the cancer
T Characteristics of the main tumour mass
N Status of the lymph nodes in the neck (i.e., evidence of cancer spread)
M Status of cancer spread to parts of the body outside of the head and neck

At first, you will be given a clinical stage based on all the available information.

Clinical staging (cTNM) is determined from any information your doctor might have about how extensive the cancer is BEFORE starting any treatment. Stage is determined based on your doctor’s physical exam, imaging studies, laboratory work and biopsies. Classification of clinical stage is described using the lowercase prefix c (e.g., cT, cN, cM).

If there is surgical removal of the cancer as part of your treatment, a pathologist will analyze the tumour and any lymph nodes that may have been removed. You will then be assigned a pathologic stage.

Pathologic staging (pTNM) provides more data. Classification of pathology stage is described using the lowercase prefix p (e.g., pT, pN, pM). This may or may not differ from the clinical stage.

There are also several other lowercase prefixes that might be used in the staging of your cancer.
 The subscript y (yTNM) is used to assign a cancer stage after some sort of medical, systemic or radiation treatment is given (Posttherapy or Postneoadjuvant Stage). It is typically combined with either a clinical or pathologic stage. For example, ycT2N0M0 indicates that after some sort of non-surgical therapy, the new clinical stage is T2N0M0.
 The subscript r (rTNM) is used when the tumour has recurred after some period of time in which it was gone. This is called Retreatment Classification Stage. Your doctor will use all the available information to assign you a retreatment stage.

T stage: the main tumour mass
Based on a physical examination and review of any imaging, your doctor should be able to give you a T stage that falls within one of the following categories.

Tx The doctor is unable to assess the primary tumour.
T0 The doctor is unable to find the primary tumour.
Tis Carcinoma in situ (or severe dysplasia); this means there are cancer type cells, but they have not yet invaded deep into tissue. This is more of a pre-cancer lesion.
T1 The tumour is 2 centimetres or less in greatest dimension.
T2 The tumour is more than 2 centimetres but less than or equal to 4 centimetres in greatest dimension.
T3 The tumour is more than 4 centimetres in greatest size or has grown into the tongue side of the epiglottis.
T4a This is moderately advanced local disease. The tumour has grown into the larynx, the outside the tongue muscles, the hard palate, the lower jawbone and/or the medial pterygoid muscles.
T4b This is very advanced local disease. The tumour has invaded into the lateral pterygoid muscle, the pterygoid plates, up to the sides of the nasopharynx, into the skull base or completely around the carotid artery.

* Note that a little extension to the lingual surface of the epiglottis from a base of tongue tumour does not constitute spread into the larynx.

N stage: spread of cancer to the lymph nodes in the neck
Next, your doctor will use all the available information and assign you an N stage. This is based on the assessment as to whether the cancer has spread to lymph nodes in the neck.

Nx The neck lymph nodes cannot be assessed.
N0 There is no evidence of any spread to the nodes.
N1 There is a single node, on the same side of the main tumour, that is 3 centimetres or less in greatest size.
N2a Cancer has spread to a single lymph node, on the same side as the main tumour, and it is more than 3 centimetres but less than or equal to 6 centimetres in greatest dimension.
N2b There are multiple lymph nodes that have cancer, on the same side as the main tumour, but none are more than 6 centimetres in size.
N2c There are lymph nodes in the neck on either the opposite side as the main cancer, or on both sides of the neck, but none are more than 6 centimetres.
N3 There is spread to one or more neck lymph nodes, and the size is greater than 6 centimetres.

M stage: spread of cancer outside the head and neck
Finally, based on an assessment on the entire body, you will be assigned an M stage.

M0 No evidence of distant (outside the head and neck) spread.
M1 There is evidence of spread outside of the head and neck (i.e., in the lungs, bone, brain, etc.).

Your cancer stages
After TNM staging, your doctor can assign a cancer stage based on the following chart.

Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
Stage IVA T4a N0 M0
T4a N1 M0
T1 N2 M0
T2 N2 M0
T3 N2 M0
T4a N2 M0
Stage IVB T4b Any N M0
Any T N3 M0
Stage IVC Any T Any N M1

Your clinical stage
Once the diagnostic tests are completed, before deciding what type of treatment you are going to undergo, you should be given a clinical stage that will look like the example below.

CLINICAL STAGE
Example
Site Oropharynx
Subsite Base of Tongue
Type Squamous Cell Carcinoma
cT cT3
cN cN1
cM cM0
cStage cIII

* The lowercase subscript c indicates that this is a CLINICAL STAGE, the stage assigned based on all information available to your doctor before starting treatment.

After surgery, you should get a pathologic stage of your tumour. It will look almost like the clinical stage you received before starting treatment, but notice the “p” that indicates the stage group is based on an analysis of the entire tumour, with or without lymph nodes, under a microscope by a pathologist. In many cases, the pathologic stage will be the same as the clinical stage, but sometimes it will change.

After surgery, and after the pathologist has evaluated all the tumour that was removed, you should be given a pathologic stage that looks something like this:

PATHOLOGIC STAGE
Example
Site Oropharynx
Subsite Base of Tongue
Type Squamous Cell Carcinoma
pT pT3
pN pN2b
cM cM0
pStage pIVa

*The lowercase subscript p indicates that this is a PATHOLOGIC STAGE, the stage assigned after tumour removal and confirmation of cancer by a pathologist.

*Note also that the M stage is usually clinical, based on all available data without analysing any tissue.

Deciding on a Treatment Plan

Before starting treatment, your doctor will make sure that the following steps are completed.

Pre-treatment Evaluation
 A full history and physical examination, including a complete head and neck exam (mirror and fibreoptic exam, if needed)
 An evaluation by the members of a head and neck cancer team
 A biopsy of the primary site or FNA of the neck to confirm a diagnosis of cancer
 Imaging of the lungs to check for spread, if needed
 Imaging of the primary tumour and the neck with CT and/or MRI
 Maybe a PET-CT for advanced cancers
 Testing for HPV
 EUA with endoscopy as needed
 A dental evaluation with or without jaw x-rays
 Nutrition, speech and swallowing evaluation and maybe even a hearing evaluation
 Pre-treatment medical clearance and evaluation of medical conditions

Then your doctor will recommend a course of treatment for you, depending on several factors. As with all cancers in the head and neck, there are three general options to consider:
 Surgical removal (with or without reconstruction)
 Radiation (a few different types)
 Medications (chemotherapy and biologic medications)

For oropharyngeal cancer, there is not one clear treatment method. You should have an extensive discussion with your cancer team to decide upon the best treatment course for you personally.

T1-2, N0-1 For small primary tumours, with at most one lymph node on the same side as the primary tumour (T1-2, N0-1), the options for treatment are as follows:
• Radiation therapy
• Surgery to remove the primary tumour (see Pharyngectomy) with or without removal of lymph nodes from the neck one or both sides of the neck (see Neck Dissection)
• Radiation along with chemotherapy (for T2, N1 only)
• A clinical trial
If treatment without surgery is chosen and there appears to be cancer left after treatment, then surgery should be performed to remove everything (see Pharyngectomy and Neck Dissection).
If the first treatment that you and your doctor decide upon is surgical removal of the cancer, then the cancer must be analysed under the microscope to determine if additional treatment is needed. Your doctors will be on the lookout for any adverse features, which include:
• Spread of cancer outside of a lymph node
• Cancer at the margins of the surgical removal
• A more extensive cancer than anticipated before the operation (pT3 or pT4, or N2 or N3)
• Positive nodes in level IV or V
• Perineural invasion
• Tumour inside veins
For example:
• If there are no adverse features, then no further treatment is needed
• If there is one positive node without any adverse features, then your doctors might consider radiation therapy for you
• If there are adverse features, radiation, chemotherapy with radiation, or additional surgery will probably be recommended. Talk to your doctor for details
T3-4a, N0-1 These are locally advanced cancers, which means that the primary tumour is quite large. In this case, there are a few treatment options that your doctors will consider:
• Chemotherapy along with radiation
• Surgery to remove the main tumour and lymph nodes from the neck, followed by either radiation or chemotherapy with radiation, depending on pathology
• For select patients, induction chemotherapy, followed by radiation
• For select patients, induction chemotherapy, followed by more chemotherapy along with radiation
• A clinical trial
Again, if treatment without surgery is chosen and there appears to be cancer left after treatment, then surgery should be performed to remove everything (see Pharyngectomy and Neck Dissection).
If the first treatment that you and your doctor decide upon is surgical removal of the cancer, then the cancer must be analysed under the microscope to determine if additional treatment is needed. Your doctors will be on the lookout for any adverse features:
• Spread of cancer outside of a lymph node
• Cancer at the margins of the surgical removal
• A more extensive cancer than anticipated before the operation (pT3 or pT4, or N2 or N3)
• Positive nodes in level IV or V
• Perineural invasion
• Tumour inside veins
Then,
• If there are no adverse features (see above), then radiation will be added
• If the adverse features include spread of cancer outside of the capsule of the lymph node and/or if there is cancer at the margins of the surgical removal, then chemotherapy and radiation will be recommended
• If the adverse features are any of the others, then either radiation alone or radiation along with chemotherapy will be recommended
Any T, N2-3 This is a cancer involving either many lymph nodes in the neck, large lymph nodes in the neck, and/or lymph nodes on both sides of the neck and/or lymph nodes on the side of the neck opposite to the main tumour mass. There are a few options for the initial treatment:
• Chemotherapy along with radiation
• For select patients, induction chemotherapy, followed by radiation
• For select patients, induction chemotherapy, followed by more chemotherapy along with radiation
• Surgery to remove the main tumour and lymph nodes from the neck, followed by either radiation or chemotherapy with radiation, depending on pathology
• A clinical trial
If a non-surgical treatment is chosen as the first line, your doctor will determine whether the cancer is gone:
• If there is any cancer left at the primary site, then your doctor might recommend surgery along with a neck dissection
• If the cancer is gone from the primary site, then the lymph nodes in the neck will have to be evaluated. If at any point there is evidence of cancer in the neck, your doctor will likely recommend a neck dissection
If the first treatment that you and your doctor decide upon is surgical removal of the cancer, then the cancer must be analysed under the microscope to determine if additional treatment is needed. Your doctors will be on the lookout for any adverse features such as:
• Spread of cancer outside of a lymph node
• Cancer at the margins of the surgical removal
• A more extensive cancer than anticipated before the operation (pT3 or pT4, or N2 or N3)
• Positive nodes in level IV or V
• Perineural invasion
• Tumour inside veins
Then, If there are no adverse features (see above), then no additional treatment is necessary
• If the adverse features include spread of cancer outside the capsule of the lymph node, or if there is cancer at the margins of the surgical removal, then chemotherapy and radiation will be recommended
• If the adverse features are any of the others, then either radiation alone or radiation along with chemotherapy will be recommended
T4b, any N
Unresectable neck disease
Unfit for surgery In cases that are very advanced, or in patients who are extremely sick, an extensive discussion with your doctors should be undertaken.

Determining Your Prognosis

Your prognosis is a prediction of the outcome of your disease. What is the risk of succumbing to the cancer or the risk of its coming back? These are the big questions on most people’s minds after receiving a diagnosis of throat cancer. Prognosis is based on many factors, and a survival rate is an estimate based on large populations of patients who have been given a similar stage of their throat cancer. There are many specific factors that are unique to each patient that may influence treatment success.

The following aspects of the cancer may affect your prognosis.

Human Papillomavirus (HPV) Status Unlike other head and neck cancers, squamous cell cancers of the oropharynx can be divided into HPV-related and HPV-unrelated cancers. Details are still being worked out, but it is becoming clear that with current treatment methods, patients with HPV-related oropharynx cancer have a better chance at being cured than those with HPV-unrelated oropharynx cancer.
Stage It is very important to know the stage to help determine your chance of cure. However, the staging system at this point does not separate HPV-positive from HPV-negative cancers.
Spread to Lymph Nodes Spread of Cancer Cells Outside Lymph Node Capsule This goes along with stage. However, even without other factors, if there is spread to lymph nodes in the neck, there’s a diminished chance of cure. This is particularly true if there is evidence of spread of cancer outside the lymph node. Still, for HPV-related oropharynx cancer, there is some data indicating that spread outside of lymph nodes is not as bad a sign as HPV-unrelated oropharynx cancer.
Tumour Margins The ability to completely remove the tumour can be a very important factor that will influence the likelihood of being cured.
Spread into Local Structures Spread into large nerves, vessels or lymphatics might make your prognosis worse.

A very interesting study that looked at survival in HPV-related oropharynx cancers versus non-HPV related oropharynx cancers revealed some interesting results. This study found that for Stage III and Stage IV oropharynx cancer, there was a difference in survival after three years based on the HPV status (82 percent in HPV positive cancers versus 57 percent in HPV negative cancers).

What to Expect After Treatment is Completed?

Once you have made it through treatment, you need to have close follow-up with your doctor. This follow-up plan is recommended after being treated for a throat cancer:
 Visit your head and neck specialist on a regular schedule (or earlier if you have any concerning symptoms). This allows your doctor to examine you for any signs that the cancer has come back.
o For the first year, you should go every one to three months.
o For the second year, you should go every two to six months.
o For the third to fifth year, you should go every four to eight months.
o After five years, you can start going every year.
 Your doctor should select a scan to be performed in the first six months after treatment. The first scan serves as a “baseline” study for the purpose of comparing future studies. This will depend on the type, stage, and location of your cancer. Imaging may include CT scans, MRI scans and PET scans. If something suspicious comes up, you might need another biopsy.
 Consider chest imaging to check for any signs of lung cancer if you have an extensive smoking history.
 Check your thyroid function every six to twelve months if you have had radiation to the neck area.
 Get help with a therapist as needed for difficulties with speaking, hearing and swallowing.
 See a specialist about appropriate nutrition and diet.
 Alert your doctor if you experience any signs of depression.
 Stop smoking and drinking.
 See a dentist.