Head & Neck

Throat Cancer

The throat, or pharynx, is a short, hollow tube that starts behind the nose and leads to the esophagus. It has three parts. The upper part of the throat is the nasopharynx (behind the nose). The middle part of the throat is the oropharynx, which includes the soft palate (the back of the mouth), the base of the tongue, and the tonsils. The lower part of the throat is the hypopharynx. Cancers of these regions can be termed as throat cancer or by their specific region, including nasopharyngeal cancer, oropharyngeal cancer or hypopharyngeal cancer (see figure below).

In all three regions of the throat, cancer often starts in the squamous cells that line the mucous membranes of the pharynx. Sometimes more than one cancer can be found in the oropharynx as well as in the hypopharynx.

Diagnosing throat cancer

Cancer that is found in the pharynx is often discovered because of symptoms such as bleeding; a sore throat that doesn’t go away; painful or difficulty swallowing; ill-fitting dentures; difficulty moving the tongue or opening the mouth fully; trouble breathing or speaking; a lump in the back of the mouth, throat or neck; ear pain or decreased hearing; or a change in voice.

If your doctor suspects throat cancer, one or more of the following tests may be ordered: a physical exam, positron emission tomography (PET) and computed tomography (CT).

For nasopharyngeal cancer, the doctor may also order a neurologic exam, an endoscopic biopsy, CT scan, PET scan, magnetic resonance imaging (MRI), blood chemistry studies, a complete blood count, an Epstein–Barr virus (EBV) test and a hearing test.

For oropharyngeal cancer, the doctor may also order a biopsy. If the doctor finds cancer in this area of the throat, CT scan, PET scan and an HPV (human papillomavirus) test may be ordered (see "HPV and Throat Cancer Linked" below).

For hypopharyngeal cancer, the doctor may also order CT scan, PET scan, MRI, barium esophagogram, endoscopy, esophagoscopy, bronchoscopy and/or biopsy.

Staging

After throat cancer is diagnosed, your doctor will determine the extent of the cancer, assign it a stage and develop a personalized treatment plan.

The TNM staging system, developed by the American Joint Committee on Cancer (AJCC), is typically used to stage head and neck cancers. This system classifies the cancer by tumor (T), node (N) and metastasis (M). The T category describes the size and location of the primary tumor. The N category describes lymph node involvement, indicating whether the lymph nodes show evidence of cancer cells. The location of these lymph nodes is important because it shows how far the disease has spread. The pathologic N category (sometimes denoted as pN) describes how many lymph nodes are involved and the amount of tumor cells found in the nodes. The M category describes distant metastasis (spread of cancer to another part of the body), if any. Staging for the M category is mainly clinical; however, a new M subcategory may be given based on the presence of tumor cells that can only be detected using a microscope or molecular testing.

Once the cancer has been classified, an overall stage is assigned. The main stages are Stage 0 (or I) through Stage IV, where Stage 0 (also known as “in situ”) is a precursor of an invasive cancer. Stages I and II are confined to the local area where the cancer is found; Stage III has often spread to the regional lymph nodes or lymphatic channels; and Stage IV has spread to distant sites (such as the lung or bone). Even these basic stages are sometimes further divided into subgroups of tumors that have a similar prognosis (Stage IB, Stage IIIC, etc). This grouping allows doctors to more accurately predict survival outcome according to stage and to adjust the treatment to the stage or substage of the cancer. For certain cancers, the AJCC also recommends tumor genetic testing, which can help determine which treatments are likely to be most effective.

Throat cancer is staged by the region of the throat in which the cancer is found.

Although the original stage at diagnosis does not change, a doctor may reassess an individual’s cancer after treatment or if it has recurred, in a process known as restaging. This is rarely done but will likely involve the same diagnostic tests used for the original diagnosis. If a new stage is assigned, it’s often preceded by an “r” to denote that it’s a restage and different from the original stage given at diagnosis.

TNM classification for nasopharyngeal cancer

Classification Definition
Tumor (T)
Tx Primary tumor cannot be assessed.
T0 No evidence of primary tumor.
Tis Carcinoma in situ.
T1 Tumor confined to the nasopharynx, or tumor extends to the oropharynx and/or nasal cavity but does not extend to area around pharyngeal.
T2 Tumor extends into area around pharyngeal area.
T3 Tumor involves bony structures of skull base and/or paranasal sinuses.
T4 Tumor extends into intracranial area and/or involves cranial nerves, hypopharynx, orbit (eye socket) or extends to the infratemporal fossa/masticator space.
Node (N)
Nx Regional lymph nodes cannot be assessed.
N0 No spread to regional lymph nodes.
N1 Metastasis to cervical lymph node(s) on one side, 6 centimeters (cm) (a little less than 2½ inches) or less in diameter, above the supraclavicular fossa, and/or retropharyngeal lymph nodes on one or both sides, 6 cm or less in diameter.
N2 Metastasis to cervical lymph node(s) on both sides, 6 cm or less in diameter, above the supraclavicular fossa.
N3
  N3a
  N3b
Metastasis to a lymph node(s), more than 6 cm and/or to the supraclavicular fossa.
Metastasis to a lymph node(s), more than 6 cm in diameter.
Metastasis to the supraclavicular fossa.
Metastasis (M)
M0 No distant metastasis, has not spread to distant organs.
M1 Distant metastasis, has spread to distant organs.

 

Stages of nasopharyngeal cancer

Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T1
T2
T2
N1
N0
N1
M0
M0
M0
III T1
T2
T3
T3
T3
N2
N2
N0
N1
N2
M0
M0
M0
M0
M0
IVA T4
T4
T4
N0
N1
N2
M0
M0
M0
IVB Any T N3 M0
IVC Any T Any N M1

TNM classification for oropharyngeal and hypopharyngeal cancers

Classification Definition
Tumor (T)
Tx Primary tumor cannot be assessed.
T0 No evidence of primary tumor.
Tis Carcinoma in situ.
Oropharyngeal
T1 Tumor is 2 centimeters (cm) (about ¾ inch) or less in diameter.
T2 Tumor is more than 2 cm but not more than 4 cm in diameter.
T3 Tumor is more than 4 cm in diameteror extends to lingual surface of the epiglottis.
T4a Moderately advanced local disease. Tumor invades the larynx, extrinsic muscle of tongue, medial pterygoid, hard palate or mandible.
T4b Very advanced local disease. Tumor invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx or skull base, or encases carotid artery.
Hypopharyngeal
T1 Tumor is limited to 1 subsite of the hypopharynx and/or is 2 centimeters (cm) (about ¾ inch) or less in diameter.
T2 Tumor invades more than 1 subsite of the hypopharynx or an adjacent site, or it is more than 2 cm but not more than 4 cm in diameter without fixation of the hemilarynx.
T3 Tumor is more than 4 cm in greatest dimension or is fixed to the hemilarynx or extends to the esophagus.
T4a Moderately advanced local disease. Tumor invades the thyroid/cricoid cartilage, hyoid bone, thyroid gland or central compartment soft tissue.
T4b Very advanced local disease. Tumor invades the prevertebral fascia, encases the carotid artery, or involves mediastinal structures.
Node (N)
Nx Regional lymph nodes cannot be assessed.
N0 No metastasis to regional lymph nodes.
N1 Metastasis to a single lymph node on same side as tumor, 3 cm or smaller in diameter.
N2


  N2a

  N2b
  N2c
Metastasis to a single lymph node on same side as tumor, more than 3 cm but smaller than 6 cm in diameter, or in multiple lymph nodes on same side as tumor, none larger than 6 cm in diameter, or in lymph nodes on opposite side or both sides, none more than 6 cm in diameter.
Metastasis to a single lymph node on same side as tumor, more than 3 cm but less than 6 cm in diameter.
Metastasis to multiple lymph nodes on same side as tumor, none more than 6 cm in diameter.
Metastasis to lymph nodes on opposite side of tumor or both sides, none more than 6 cm in diameter.
N3 Metastasis to a lymph node, more than 6 cm in diameter.
Metastasis (M)
M0 No distant metastasis.
M1 Distant metastasis.

 

Stages of oropharyngeal and hypopharyngeal cancers

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

Treatment options

Treatment for pharyngeal cancer may include surgery, radiation therapy, chemotherapy, immunotherapy and targeted therapy.

Surgery

Surgery may be recommended for early to locally advanced stages of pharyngeal cancer. Types of surgeries that may be performed include laser surgery (for early-stage tumors), excision to remove the tumor and some surrounding tissue, lymph node dissection or neck dissection to remove lymph nodes, and reconstructive (plastic) surgery to replace missing tissue, skin or jaw bone to restore a person’s appearance and function. A new option is transoral robotic surgery (TORS), in which the surgeon uses robot-like instruments to remove a tumor from the mouth or throat.

Radiation therapy

Radiation therapy is the use of high-energy particles such as X-rays to kill cancer cells. It can be used as the main treatment, after surgery to destroy any cancer cells that may remain or for pharyngeal cancers that cannot be removed surgically.

Chemotherapy

Chemotherapy drugs, also called cytotoxic drugs, kill cells that divide quickly, such as cancer cells. Chemotherapy is considered a systemic treatment because the chemotherapy drugs travel throughout the body in the bloodstream. Chemotherapy drugs are given in cycles and may involve the use of a single drug or multiple drugs in combination.

Immunotherapy

Immunotherapy uses the body’s own immune system to slow and kill cancer cells. With this treatment approach, substances—made either by the body or in a laboratory—are used to identify cancer cells as a threat and target them for destruction.

Targeted therapy

Targeted therapy drugs work by targeting specific proteins and genes that help cancer cells grow. Some of these drugs target the epidermal growth factor receptor (EGFR), a protein on the surface of cancer cells that helps them grow and divide. The drugs block EGFR and stop it from working, which can help slow or stop cancer growth.

 

HPV and Throat Cancer Linked

Human papillomavirus (HPV) is linked as the cause of up to 70 percent of oropharyngeal cancers (including the middle part of the throat, which includes the soft palate, base of the tongue and tonsils). And HPV-caused throat cancers are on the rise among men in the United States.

HPV infections are the most common sexually transmitted infections in the United States. HPV is easily spread through sexual contact from the skin and mucous membranes of infected people to the skin and mucous membranes of their partners.

HPV is categorized into two types of sexually transmitted viruses: low-risk and high-risk. Low-risk HPVs do not cause cancer, but they can cause skin warts on or near the genitals, anus, mouth or throat. High-risk HPVs cause cancer. Approximately a dozen of these types have been identified to date. HPV types 16 and 18 are responsible for most HPV-caused cancers.

Three vaccines are approved by the U.S. Food and Drug Administration (FDA) for both male and female children and young adults, 9 to 26 years old, to provide protection against new HPV infections. These vaccines are Gardasil (Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) Vaccine, Recombinant), Gardasil 9 (Human Papillomavirus 9-valent Vaccine, Recombinant) and Cervarix (Human Papillomavirus Bivalent (Types 16 and 18) Vaccine, Recombinant). These vaccines do not treat already existing HPV infections.

 

Additional Resources

 

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