Malignant tumors of oropharynx: causes, symptoms, diagnosis, treatment

Of the malignant neoplasms of the oropharynx, cancer is most often observed, sarcoma is less common, lymphoepitheliomas and lymphomas are rare. Malignant tumors develop mainly in people over 40 years of age. This position is true only for malignant neoplasms of epithelial origin. As for connective tissue tumors, they are more often found in young people, and often in children. The initial localization of malignant tumors in 5M% of patients is the palatine tonsils, in 16% - the posterior wall of the pharynx, in 10.5% - the soft palate.

Most malignant neoplasms of the middle pharynx are characterized by rapid infiltrative growth and a tendency to ulceration; apparently, this is why 40% of patients are diagnosed with stages III and IV of the disease and 20% with stages I-II upon admission to the clinic. Malignant tumors of this localization often metastasize. Metastases in regional lymph nodes are detected in 40-45% of patients already upon admission, and in distant organs - in 5%.

Symptoms of malignant tumors of the oropharynx

Malignant tumors of the middle pharynx grow quickly. They may remain unnoticed for some time, usually several weeks, much less often months. The first symptoms of malignant tumors depend on their primary localization. Later, as the tumor grows, the number of symptoms increases rapidly.

One of the early signs of a tumor is a sensation of a foreign body in the throat. Soon it is accompanied by pain in the throat, which, like the sensation of a foreign body, is strictly localized. Epithelial tumors are prone to ulceration and decay, as a result of which the patient develops an unpleasant odor from the mouth and an admixture of blood in saliva and sputum. When the tumor process spreads to the soft palate, its mobility is impaired, a nasal voice develops: liquid food can get into the nose. Since swallowing disorders and food passage disorders occur quite early, patients begin to lose weight early. In addition to local symptoms, general symptoms such as malaise, weakness, and headache develop as a result of intoxication and inflammation associated with the tumor. When the lateral wall of the pharynx is affected, the tumor rather quickly penetrates deep into the tissues towards the vascular-nerve bundle of the neck, which is why there is a risk of profuse bleeding.

Among malignant tumors of the oropharynx, neoplasms of epithelial origin predominate. Epithelial tumors, unlike connective tissue tumors, are prone to ulceration. This to some extent determines the clinical picture of the disease. The appearance of the tumor depends on its histological structure, type, prevalence and, to a lesser extent, on the primary localization. Epithelial exophytic tumors have a wide base, their surface is bumpy, in places with foci of decay: the color is pink with a grayish tint. There is an inflammatory infiltrate around the tumor. The tumor bleeds easily when touched.

Infiltratively growing epithelial tumors tend to ulcerate. Tumor ulcer is quite often localized on the palatine tonsil. The affected tonsil is enlarged compared to the healthy one. Around the deep ulcer with uneven edges, the bottom of which is covered with a dirty gray coating, there is an inflammatory infiltrate.

Diagnosis of malignant tumors of the oropharynx

Laboratory research

It is possible to conduct a cytological examination of smears-prints or reprints. Despite the existence of sufficiently informative research methods, the final diagnosis of the tumor with the determination of its type is established based on the results of studying its histological structure.

It should be emphasized that cytological studies of smears and reprints are uninformative, since they only take into account the result in which signs of malignant growth are detected; in addition, this research method does not provide the opportunity for a detailed study of the histological structure of the neoplasm.

Instrumental research

Biopsy - excision of a piece of tissue for histological examination - is one of the important diagnostic methods in oncology. The result of the histological examination largely depends on how the biopsy is taken. It is well known that a piece of tissue should be taken at the border of the tumor process, but it is not always possible to determine this border, especially in case of tumors of the ENT organs. Neoplasms of the palatine, pharyngeal and lingual tonsils, especially connective tissue, arise in the depth of the tonsil tissue. The tonsil increases. An enlarged tonsil should be a warning sign, as it requires targeted examination, including a biopsy. Most general oncologists do not have the skills of indirect and direct pharyngoscopy and laryngoscopy, they use the services of endoscopists who take biopsies from the upper (nasopharynx), middle (oropharynx), and lower (larynx) parts of the pharynx using a fibroscope. In this way, a biopsy can be taken from the edge of an ulcerated or exophytic growing tumor.

If the neoplasm is located deep in the tonsil, tumor cells and a piece of tissue taken for examination do not get in. Such a biopsy result reassures the doctor and the patient, precious time is lost, over time the biopsy is repeated one or two more times until the tumor approaches the surface of the tonsil. In this case, other signs of the tumor process appear, which progresses quickly. In the case of asymmetry of the palatine tonsils with a suspicion of a tumor process, if there are no contraindications, it is necessary to perform a unilateral tonsillectomy or tonsillotomy as a biopsy. Sometimes such a tonsillectomy can be a radical surgical intervention in relation to the tumor.

Differential diagnostics

Ulcerated tonsil tumor must be differentiated from Simonon-Venan ulcerative-membranous angina, syphilis, and Wegener's disease. For this purpose, smears taken from the edges of the ulcer must be examined and the Wasserman reaction must be performed.

Treatment of patients with neoplasms of the oropharynx

The main method of treating patients with benign tumors of the middle pharynx is surgery. The extent of surgical intervention depends on the prevalence, histological structure and localization of the tumor. Limited neoplasms, such as papilloma of the palatine arches, can be removed in the clinic using a loop, scissors or forceps.

The original site of the tumor after its removal is treated with a galvanocautery or a laser beam. A small, superficially located tonsil or palatine arch cyst, a fibroma on a stalk, can be removed in a similar manner.

A small mixed tumor of the soft palate can be removed through the mouth under local anesthesia. Most often, when removing tumors of the oropharynx, anesthesia is used, using a sublingual pharyngotomy as an access, which is often supplemented by a lateral one. A wide external access will allow for complete removal of the tumor and ensure good hemostasis.

External access is also required for removal of vascular tumors of the pharynx. Before removing hemangiomas, the external carotid artery is preliminarily ligated or embolization of the afferent vessels is performed. Intervention regarding these tumors is always associated with the risk of severe intraoperative bleeding, which may require ligation of not only the external, but also the internal or common carotid artery. Given the possibility of intraoperative bleeding and the severity of the consequences of ligation of the internal or common carotid artery, in patients with parapharyngeal chemodectomas and hemangiomas, we perform "training" of intracerebral anastomoses for 2-3 weeks before surgery. It consists of pinching the common carotid artery on the side of the tumor with a finger 2-3 times a day for 1-2 minutes. Gradually, the duration of the procedure is increased to 25-30 minutes. At the beginning of the "training" and subsequently with an increase in the duration of the common carotid artery clamping, the patient experiences a feeling of dizziness. This sensation serves as a criterion for determining the duration of the artery clamping, as well as the duration of the "training" course. If clamping the artery for 30 minutes does not cause a feeling of dizziness, then after repeating the clamping for another 3-4 days, the operation can begin.

Cryotherapy as an independent method of treating patients with benign tumors is indicated mainly for superficial (located under the mucous membrane) diffuse hemangiomas. It can be used in the treatment of deep hemangiomas in combination with surgical interventions.

The main methods of treatment for malignant tumors of the oropharynx, as well as for neoplasms of other localizations, are surgical and radiation. The effectiveness of surgical treatment is higher than that of radiation and combined treatment, at the first stage of which radiation is carried out.

Only limited neoplasms that do not extend beyond one of the fragments of a given area (soft palate, palatoglossal arch, palatine tonsil) can be removed through the mouth. In all other cases, external approaches are indicated - transhyoid or subhyoid pharyngotomy in combination with lateral; sometimes, in order to obtain wider access to the root of the tongue, in addition to pharyngotomy, a resection of the lower jaw is performed.

Operations for malignant tumors are performed under general anesthesia with preliminary ligation of the external carotid artery and tracheotomy. Tracheotomy is performed under local anesthesia, and subsequent stages of the intervention are performed under intratracheal anesthesia (intubation through a tracheostomy).

When the palatine tonsil is affected by a tumor that does not extend beyond its limits, the removal of the tonsil, palatine arches, laratonsillar tissue, and part of the root of the tongue adjacent to the lower pole of the tonsil is limited. The reserve of unaffected tissue around the tumor focus should not be less than 1 cm. This rule is also followed when removing widespread tumors using external access.

Radiation therapy of patients with pharyngeal neoplasms should be performed according to strict indications. This therapeutic effect can be used only for malignant tumors. As an independent method of treatment, irradiation can be recommended only in cases where surgical intervention is contraindicated or the patient refuses surgery. We recommend combined treatment, the first stage of which is surgery, for patients with stage III tumors. In other cases, surgery alone can be enough.

In case of tumors occupying the middle and lower parts of the pharynx, spreading to the larynx, a circular resection of the pharynx with removal of the larynx is performed. After such an extensive intervention, an orostoma, tracheostomy and esophagostomy are formed. After 2-3 months, plastic surgery of the lateral and anterior walls of the pharynx is performed, thereby restoring the food passage.

Comparing the results of treatment using different methods, we were convinced of the high efficiency of the surgical method; the five-year survival rate of patients after surgical treatment was 65±10.9%, after combined treatment (surgery + radiation) - 64.7+11.9%, after radiation therapy - 23±4.2% (Nasyrov V.A., 1982).

[ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ]