The oropharynx is the region situated to the rear of the mouth. It includes the tonsil region, the base of the tongue, the posterior wall of the pharyngeal axis, and the soft palate (uvula). 

STAFF

At the IEO oropharynx cancer is treated by a multidisciplinary team consisting of specialists in:

• Otolaryngology - Head and Neck Surgery
• Urogenital and Head and Neck Tumors Medical Treatment
• New Drugs and Early Drug Development for Innovative Therapies
• Department of Pathology and Laboratory Medicine
• Department of Medical Imaging and Radiation Sciences

Heavy smokers and drinkers are subjects at risk of developing these cancers. Another risk factor is represented by infection of human papillomavirus (HPV). Cancers linked to HPV infection are typical of a young population (average age <50 years) and have better prognosis (better response to treatment). 

The most common mouth cancer symptoms are pain on swallowing that does not regress with the use of common symptomatic drugs, a sense of hindrance in swallowing and the presence of an ulcerated and/or bleeding lesion. In some cases, the first mouth cancer symptom may be represented by the appearance of a swollen lymph node in the neck, which is not usually painful and which may occur suddenly and does not regress after systemic therapy (anti-inflammatory and antibiotics).

Good standards for prevention

• Adopting a healthy lifestyle, not smoking and limiting alcohol intake.
• Adopting a few precautions in eating habits: eating fruit, vegetables, and foods rich in carotenoids, such as tomatoes, carrots, sweet and spicy peppers, pumpkins, apricots, herbs (probable evidence).
• Keeping a careful eye on oral hygiene.
• Not underestimating any injury of the mouth although small or painless (nodules, small ulcers, white or red patches, growths).
• After the age of 60 in subjects with risk factors, examination of the oral cavity and pharyngeal-laryngeal district is recommended.
• Undergoing regular visits, if already affected in the past by a carcinoma of the head and neck district.

The most common symptoms and signs are small ulcers of the lip or mouth, a white or red spot in the oral mucosa, frequent epistaxis (nosebleeds), nasal respiratory obstruction, hoarseness, persistent sore throat, feeling of closed ears, pain radiating to the ear, blood in sputum, difficulty chewing, swallowing or breathing, numbness of the tongue, painless and persistent swelling in the neck. The durability of these disorders should be considered as an alarm bell; if they have not resolved spontaneously or with treatment within 3 weeks, a specialist should be consulted.

Diagnosis is easy, given accessibility to the tonsil region in the mouth. Biopsy under local anaesthesia is the most performed procedure. When a tongue cancer lesion occurs in the root of the tongue, difficult to access under local anaesthesia, biopsy is performed under general anaesthesia. The diagnosis of HPV-related cancer is made in conjunction with the histological diagnosis. Ultrasound, magnetic resonance, and PET (or even a total body CT) allow for correct staging the tongue cancer.

The first approach to treatment is essential. Cure is the main goal, and is considered as important as the quality of life and functionality of the treated organs, such as the voice, language, swallowing, taste and breathing. IEO provides patients with a multidisciplinary team dedicated to diagnosis, treatment and rehabilitation

 Innovative and minimally invasive therapies: over the years the Division has developed some original techniques and minimally invasive approaches to improve the oncological and functional results of interventions, so that patients have more therapeutic options with less surgical impact. Some of these therapies are available only here in IEO.

Surgery: our head and neck surgeons perform the highest number of operations for malignant tumours each year than any other center in Italy (AGENAS data). Moreover, for more than 20 years we have been conveying the message of Prof Veronesi, that is, "the minimum effective therapy" also for head and neck lesions. We were the first in Italy to offer conservative thyroid surgery, with over 15 years of experience in hemi-thyroidectomy even for malignant tumours. We were among the first to perform endoscopic conservative surgery of the larynx with over 250 procedures a year, we were pioneers in functional tongue surgery allowing a near normal post-op quality of life. Finally, for over 20 years we have been performing very delicate salivary gland surgery. This is the only recognised head and neck surgery department in Italy.

TORS (Transoral Robotic Surgery): we were the first in Italy and among the first in the world to use robotic surgery for oropharyngeal and parapharyngeal lesions, managing to treat many patients with conservative surgery with minimally invasive access for parapharyngeal masses and neoplasms of the tonsillar region, ensuring a lower impact of this surgery.[1]

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TLM (Transoral Laser Microsurgery) the Division has extensive experience in laser microsurgery of early laryngeal neoplasms, avoiding radiotherapy, which can eventually be proposed at later date if necessary[2]

THE VALUE OF A MULTIDISCIPLINARY TEAM

Our multidisciplinary team is dedicated to the diagnosis, treatment and rehabilitation of patients with tumors of the head and neck, and to the study of these diseases. Our team includes over thirty oncology professionals with expertise in various specialties, such as ENT, maxillofacial surgery, emergency surgery, plastic-reconstructive surgery, radiotherapy, medical oncology, radiology, pathology, nuclear medicine, nutrition, physiotherapy, endocrinology, dentistry, voice therapy, speech therapy, psychology, and biology.

The integration of various skills can address complex clinical problems, from diagnosis and treatment planning, to the functional recovery (speech, breathing, swallowing) in order to achieve the best results with cancer and adequate quality of life.The cervicofacial surgery program consists of the medical-surgical team, Radiotherapy and Medical Oncology specialists, dedicated radiologists, endocrinologists, nuclear physicians and pathologists. The team works in harmony and meets on a weekly basis to discuss cases of patients who trust in our structure. They develop comprehensive personalized care plans considering all aspects of treatment and rehabilitation, considering the different treatment options, taking into account the needs of individual patients in accordance with internal, national and international guidelines.

The team, in close collaboration with the Scientific and Health Management Board, monitors the results of treatment and the quality of the performances in real time in order to point out critical issues and identify areas for improvement and development. The multidisciplinary meetings are an opportunity for professional development based on the exchanges in the group, the evidence in the literature, and the critical review and update of guidelines as well as diagnostic and therapeutic approaches. The information obtained from the critical review of the clinical activities, from technological innovations, from the study of the evolution of the cancers treated, and from continuous updating are used to identify open issues and propose research activities. Thanks to this approach, clinical research activities and institutional research projects in collaboration with national and international institutions have been put in place.

Cancers of the oropharynx

The treatment of oropharyngeal cancers depends on a few factors such as the disease stage, site of occurrence and risk factors. In principle, in the initial stage, treatment is single mode (radiotherapy alone or minimally invasive surgery), while in locally-advanced stages it is multimodal (chemo-radiotherapy, or surgery followed by radiotherapy or chemo-radiotherapy).

Squamous cell carcinomas of the oropharynx, particularly if linked to HPV infection in non-smoking patients, have a good chance of cure with radio-chemotherapy treatment alone. The main side-effects of radio-chemotherapy treatments in the past were linked to the late effects of radiotherapy (dry mouth resulting in dental problems, difficulty in swallowing, jaw problems, hardening of the neck tissues). Modern techniques of radiotherapy (IMRT Intensity Modulated Radiotherapy) have allowed a better conformation of the dose to the target volume, with greater savings of the surrounding healthy tissues. This technological evolution has resulted in a reduction of late side-effects, in particular the incidence and severity of dry mouth.

A feasible alternative to radiotherapy in selected patients who have small localised tumours in particular in the region of the tonsil or base of the tongue, is mini-invasive endoscopic robotic surgery (robot-assisted surgery). The main advantage is a low incidence of side-effects and the ability to perform the treatment with a hospitalisation lasting a few days. In selected young patients having small localised tumours of the oropharynx in the tonsil region or at the base of the tongue, an alternative to radiotherapy is robotic surgery (robot-assisted minimally invasive surgery). The main advantage is a low incidence of side-effects due to a targeted and high precision intervention.

In selected cases, robotic surgery is applied to relapsed oropharyngeal cancers previously treated with radiotherapy or chemo-radiotherapy. When applicable, this surgery brings functional advantages over traditional surgery.

Distant metastases of head and neck carcinoma

Distant metastases are defined as tumor spread to other organs. Lung, liver, and bone are the most common sites for hematogenous metastases of head and neck squamous cell carcinoma. The incidence of distant metastasis in head and neck squamous cell carcinoma is low for the general head and neck squamous cell carcinoma population: generally below 5% at presentation. Head and neck squamous cell carcinoma patients with distant metastases are generally candidates for palliative treatment scenarios only, because currently no systemic therapy has curative potential in head and neck squamous cell carcinoma patients with distant disease. Consequently, extensive locoregional treatment is usually considered futile in these patients. Particular attention is paid to our collaboration with CNAO, National Centre of Oncology Hadrontherapy) for Phase II, the clinical trial on radiotherapy boost, using protons (hadron therapy) for locally advanced tumours of the cervical-cephalic region.

Attention to the patient and his quality of life: since 2003, the department has been equipped with a speech therapy service, one of the best in Italy, which deals with the rehabilitation of swallowing, phonation and the articulation of the word. The division also has a dentistry service that deals with the preparation for surgery and postoperative dental rehabilitation. The IEO also has a physiotherapy service for motor and respiratory rehabilitation and a dietician for the management of nutritional aspects.  Pain management and Psychological support services are also offered. A holistic approach which takes care of all the needs of the patient, allowing a more rapid return to normal life.

Translational research on HPV and genetic tests: a Molecular Biologist who directs studies in the field of HPV oropharyngeal pathology is part of the team. In fact, our division has set up a Comprehensive Oropharyngeal Cancer Center, in collaboration with the divisions of Gynecology, Urology and General Surgery, which carries out active studies on minimally invasive surgical and radiotherapeutic therapies, on the prognosis and on the personal and family prevention of the infection. We also collect histological material on which we perform genetic tests to better personalize care in the future.

Clinical nutrition

Stage and location of the disease, anatomical changes resulting from any surgical procedure, and the acute and late toxicity of chemo-radiotherapy are all factors that may contribute to the impairment of swallowing and create deficiency in the oral protein-calorie intake.
Artificial Nutrition (AN) is indicated in cases of cancers that cause a stenosis (narrowing), severe dysphagia (difficulty in eating that contraindicates oral feeding), or in the case of evident malnutrition or in the patient who, although feeding through the mouth, takes on a calorie-protein amount <50% of nutritional needs. AN must also be started when you expect a period of severe dysphagia longer than 7 days or inadequate intake (<60% of the nutritional requirements) for at least 10 days.

In patients with cancer of the cervical-facial district, Enteral Nutrition (EN) represents the primary route of choice when the gastrointestinal tract is accessible and functioning. It can be performed via nasogastric tube or via Percutaneous Endoscopic Gastrostomy (PEG) or Jejunostomy Nutrition, in case of expected duration of nutritional support greater than 3-4 weeks. EN is effective in containing the decline in body weight, preventing dehydration and interruptions of the radio-chemotherapy treatment, reducing the frequency and duration of hospitalisations, and improving the quality of life.
Adequate nutritional support during radiotherapy treatment can reduce the impact and degree of morbidity (mucositis, odynophagia, dysphagia, xerostomia, dysgeusia, nausea, vomiting, and anorexia), minimise weight loss, preserve the nutritional status, improve the quality of life and optimise by speeding it up the recovery of the patient at the end of treatment.

The use of early and intensive nutritional counseling and oral caloric supplementation have been shown to increase the protein-calorie oral intake, reduce the extent of body weight loss, and reduce the interruptions of the cancer treatment.
In the presence of a sufficiently safe swallowing, oral feeding (using a diet modified in consistency) is the first choice.