Head & Neck

Throat Cancer

The pharynx, or throat, is a short, hollow tube that starts behind the nose and leads to the esophagus. It has three parts. The upper part is the nasopharynx (behind the nose). The middle part is the oropharynx, which includes the soft palate (the back of the roof of the mouth), the base of the tongue, and the tonsils. The lower part is the hypopharynx. Cancers of these regions are referred to as pharyngeal, or throat, cancers or in more specific terms according to their region: 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 throat. Occasionally, more than one cancer can be found in the throat.

Diagnosing Throat Cancer

Cancer that is found in the throat is often discovered because of symptoms such as bleeding; a sore throat that doesn’t go away; pain or difficulty with swallowing; 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, diagnostic tests will be done.

Staging

After throat cancer is diagnosed, your doctor will use the TNM (tumor, node, metastasis) system to determine the extent of the cancer, assign it a stage and develop a personalized treatment plan.

Throat cancer is staged by the region of the throat in which the cancer is found. To stage oropharyngeal cancer, doctors also consider the presence of certain human papillomavirus (HPV) related biomarkers. When referring to the staging tables in this section, look carefully at the table headlines to ensure you view the information that applies to your diagnosis.

Treatment Options

Your doctor will consider many factors when exploring treatment options, including the stage of disease, the location and size of the tumor, and your overall health status. Your doctor will also focus on preserving as much normal function as possible. Treatment options also depend on whether the throat cancer is primary or recurrent. Standard treatment options for throat cancer include surgery, radiation therapy and chemotherapy. Advances in cancer research have led to more recent options, such as immunotherapy and targeted therapy. You should talk to your health care team about the goal of treatment — whether the goal is to cure the cancer or to keep the cancer under control and relieve symptoms. Understanding the goal, as well as the benefits and risks of each option, will help you become better informed for making shared treatment decisions with your doctor.

Surgery

Surgery may be recommended for early to locally advanced stages of throat cancer. Surgical options include laser surgery (for early-stage tumors) or surgical removal of the tumor and some surrounding tissue. A new option is transoral robotic surgery (TORS), in which the surgeon uses robot-like instruments to remove a tumor from the throat. For tumors that may have spread to the lymph nodes in the neck, surgery will include removal of the lymph nodes, also called lymph node dissection or neck dissection. After surgery, reconstructive surgery may be recommended for patients with large or recurrent tumors to replace missing tissue, skin or jawbone to restore a person’s appearance and function (see Reconstructive Surgery).

Radiation Therapy

Radiation therapy is the use of high-energy particles, such as X-rays, to kill cancer cells. It can be used after surgery to destroy any cancer cells that may remain (also called adjuvant radiation therapy). Radiation therapy may also be given alone or with chemotherapy as a first-line treatment for some throat cancers in which surgery would cause great difficulty swallowing. In these cases, surgery is reserved as a treatment option to be used if the cancer comes back.

Chemotherapy

Chemotherapy drugs kill cells that divide quickly, such as cancer cells. Chemotherapy is considered a systemic treatment because the 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. Chemotherapy may be used with radiation therapy after surgery to remove larger throat cancers if the risk for recurrence is high. This is known as chemoradiation therapy. Chemoradiation may also be an option for first-line treatment. Chemotherapy given alone is not curative for throat cancers, but may be used in patients with recurrent cancer (cancer that has come back) or in patients where the goal of treatment is not cure but to prevent growth or spread of their cancer.

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. Immunotherapy for head and neck cancers involves the use of drugs known as immune checkpoint inhibitors. These inhibitors may be given with or without chemotherapy. Immunotherapy may be an option for recurrent or metastatic throat cancer and may be an option for throat cancer that has stopped responding to chemotherapy.

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. Targeted therapy drugs are usually given in combination with chemotherapy and are used for throat cancer that has spread or has recurred (returned).

 

HPV and Throat Cancer Linked

Human papillomavirus (HPV) is a virus and is the most common sexually transmitted infection in the United States. HPV is easily spread through sexual contact from the skin and mucous membranes (lining of the mouth, throat or genital tract) of infected people to the skin and mucous membranes of their partners.

HPV is linked to up to 70 percent of oropharyngeal cancers, which affect the middle part of the throat, including the base of the tongue and tonsils. HPV-related throat cancers are on the rise among men in the United States.

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

Classifying Oropharyngeal (HPV-) And Hypopharyngeal Cancers

Classification Definition
Tumor (T)
TX Primary tumor cannot be assessed.
Tis Carcinoma in situ.
Oropharyngeal (HPV-)
T1 Tumor 2 cm or smaller in greatest dimension.
T2 Tumor larger than 2 cm but not larger than 4 cm in greatest dimension.
T3 Tumor larger than 4 cm in greatest dimension or extension to lingual surface of epiglottis.
T4 Moderately advanced or very advanced local disease.
  T4a Moderately advanced local disease. Tumor invades the larynx, extrinsic muscle of tongue, medial pterygoid, hard palate or mandible (jawbone).
  T4b Very advanced local disease. Tumor invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, or skull base or encases carotid artery.
Hypopharyngeal
T1 Tumor limited to one subsite of hypopharynx and/or 2 cm or smaller in greatest dimension.
T2 Tumor invades more than one subsite of hypopharynx or an adjacent site, or measures larger than 2 cm but not larger than 4 cm in greatest dimension without fixation of hemilarynx.
T3 Tumor larger than 4 cm in greatest dimension or with fixation of hemilarynx or extension to esophageal mucosa.
T4 Moderately advanced and very advanced local disease.
  T4a Moderately advanced local disease. Tumor invades thyroid/cricoid cartilage, hyoid bone, thyroid gland, esophageal muscle or central compartment soft tissue.
  T4b Very advanced local disease. Tumor invades prevertebral fascia, encases carotid artery or involves mediastinal structures.
Node (N)
NX Regional lymph nodes cannot be assessed.
N0 No regional lymph node metastasis.
N1 Metastasis in a single ipsilateral (on the same side) lymph node 3 cm or smaller in greatest dimension and ENE*(-).
N2 Metastasis in a single ipsilateral (on the same side) lymph node 3 cm or smaller in greatest dimension and ENE*(+);
or larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-);
or metastases in multiple ipsilateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(-);
or in bilateral (on both sides) or contralateral (on the opposite side) lymph node(s), none larger than 6 cm in greatest dimension and ENE(-).
  N2a Metastasis in single ipsilateral (on the same side) node 3 cm or smaller in greatest dimension and ENE*(+);
or a single ipsilateral node larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-).
  N2b Metastasis in multiple ipsilateral (on the same side) nodes none larger than 6 cm in greatest dimension and ENE*(-).
  N2c Metastasis in bilateral (on both sides) or contralateral (on the opposite side) lymph node(s), none larger than 6 cm in greatest dimension and ENE*(-).
N3 Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE*(-);
or metastasis in a single ipsilateral (on the same side) node larger than 3 cm in greatest dimension and ENE*(+);
or multiple ipsilateral, contralateral (on the opposite side) or bilateral (on both sides) nodes, any with ENE(+);
or a single contralateral node of any size and ENE(+).
  N3a Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE*(-).
  N3b Metastasis in a single ipsilateral (on the same side) node larger than 3 cm in greatest dimension and ENE*(+);
or multiple ipsilateral, contralateral (on the opposite side) or bilateral (on both sides) nodes, any with ENE(+);
or a single contralateral node of any size and ENE(+).
Metastasis (M)
M0 No distant metastasis.
M1 Distant metastasis.
*Extranodal extension (ENE) refers to cancer cells that have spread beyond the lymph node into surrounding tissues.

Staging Oropharyngeal (HPV-) 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
M0
M0
IVA T4a
T1, T2, T3, T4a
N0, N1
N2
M0
M0
IVB Any T
T4b
N3
Any N
M0
M0
IVC Any T Any N M1

Classifying Oropharyngeal (HPV+) Cancer

Classification Definition
Tumor (T)
T0 No primary identified.
T1 Tumor 2 cm or smaller in greatest dimension.
T2 Tumor larger than 2 cm but not larger than 4 cm in greatest dimension.
T3 Tumor larger than 4 cm in greatest dimension or extension to lingual surface of epiglottis.
T4 Moderately advanced local disease. Tumor invades the larynx, extrinsic muscle of tongue, medial pterygoid, hard palate or mandible (jawbone) or beyond.
Node (N)
NX Regional lymph nodes cannot be assessed.
N0 No regional lymph node metastasis.
N1 Metastasis in four or fewer lymph nodes.
N2 Metastasis in more than four lymph nodes.
Metastasis (M)
M0 No distant metastasis.
M1 Distant metastasis.

Staging Oropharyngeal (HPV+) Cancer

Stage T N M
I T0, T1, T2 N0, N1 M0
II T0, T1, T2
T3, T4
N2
N0, N1
M0
M0
III T3, T4 N2 M0
IV Any T Any N M1

Classifying Nasopharyngeal Cancer

Classification Definition
Tumor (T)
TX Primary tumor cannot be assessed.
T0 No tumor identified, but EBV-positive cervical node(s) involvement.
Tis Carcinoma in situ.
T1 Tumor confined to nasopharynx (behind nasal cavity/upper part of throat), or extension to oropharynx and/or nasal cavity without parapharyngeal involvement.
T2 Tumor with extension to parapharyngeal space, and/or adjacent soft tissue involvement (medial pterygoid, lateral pterygoid, prevertebral muscles).
T3 Tumor with infiltration of bony structures at skull base, cervical vertebra, pterygoid structures, and/or paranasal sinuses.
T4 Tumor with intracranial extension, involvement of cranial nerves, hypopharynx, orbit, parotid gland, and/or extensive soft tissue infiltration beyond the lateral surface of the lateral pterygoid muscle.
Node (N)
NX Regional lymph nodes cannot be assessed.
N0 No regional lymph node metastasis.
N1 Unilateral (on one side) metastasis in cervical lymph node(s) and/or unilateral or bilateral metastasis (on both sides) in retropharyngeal lymph node(s), 6 cm or smaller in greatest dimension, above the caudal border of cricoid cartilage.
N2 Bilateral metastasis in cervical lymph node(s), 6 cm or smaller in greatest dimension, above the caudal border of cricoid cartilage.
N3 Unilateral (on one side) or bilateral (on both sides) metastasis in cervical lymph node(s), larger than 6 cm in greatest dimension, and/or extension below the caudal border of cricoid cartilage.
Metastasis (M)
M0 No distant metastasis.
M1 Distant metastasis.

Staging Nasopharyngeal Cancer

Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T0, T1, T2
T2
N1
N0
M0
M0
III T0, T1, T2, T3
T3
T3
N2
N0
N1
M0
M0
M0
IVA T4
T4
T4
Any T
N0
N1
N2
N3
M0
M0
M0
M0
IVB Any T Any N M1

Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original and primary source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017) published by Springer Science+Business Media.

Additional Resources

 

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