Throat cancer may refer to multiple different types of cancer. Cancers of the throat may refer to nasopharynx (area behind the nose, pharynx cancer (beginning of the swallowing portion of the throat), larynx cancer (voice box), hypopharyngeal cancer (area right before the esophagus), or supraglottic cancer (area above the voice box).
What Is Throat Cancer?
Throat cancer refers to cancer of any of the structures of the upper throat and airway. This includes laryngeal cancer (cancer of the voice box), nasopharynx (area behind the nose), pharyngeal cancer (area behind the tongue), hypopharyngeal cancer (area right before the esophagus), or supraglottic cancer (area above the voice box).
What Are The Causes Of Throat Cancer?
Like all other head and neck cancers, chronic exposure to irritants such as alcohol and tobacco pose a significant risk to the development of throat cancer. Plummer-Vinson syndrome, characterized by iron deficiency anemia as well as swallowing problems, is also a risk factor for the development of throat cancer. Other risk factors include asbestos exposure, radiation exposure, marijuana use, genetic or familial predisposition to cancer, or history of HPV papillomatous infections in childhood.
What Are The Signs And Symptoms Of Throat Cancer?
Lump in the Neck. Throat cancers may present as enlarged neck masses. These typically are present for a prolonged period of time (weeks to months), often are increasing in size, and may be painful or uncomfortable.
Pain. Frequently patients may present with throat soreness, that is non-specific in quality and nature. Conversely, patients may present with increasing pain with swallowing.
Bleeding. Bleeding from a site within the throat may be a presenting sign. Any bleeding without full visualization or characterization of the involved site, warrants further workup.
Hoarseness. Frequently, patients will present with hoarse voice, or changes in voice quality. Any voice changes that do not resolve after three months of conservative management should be evaluated by a specialist.
Breathing Difficulties. Patient’s may report breathing difficulties or noisy breathing, particularly when lesions increase in size and encroach on the airway.
Swallowing Difficulties. Masses near or around the esophagus or vocal cords may cause intolerance to solid food that may progress to intolerance to liquid. Patients may also have a sensation of food being stuck in their throat that does not resolve with throat clearing (globus).
What Are The Risk Factors Of Throat Cancer?
RIsk factors to throat cancer are chronic alcohol abuse, smoking, environmental exposure to irritants (such as nickle, arsenic, chromium), radiation exposure, family history of cancer, or personal history of other cancers.
How Is Throat Cancer Diagnosed?
In addition to routine history and physical examination, the physician may perform ancillary tests and procedures in order to confirm the presence and type of throat cancer, as well as to determine the presence of second primary cancers (SPC) or the spread of malignant disease elsewhere.
Biopsy. Often times the first step in the diagnosis of throat cancer is to perform a biopsy. Taking a biopsy will confirm the presence of abnormal cells under microscopic view, and is imperative in making the diagnosis of laryngeal cancer.
- Operative Biopsy. Throat biopsies are performed in the operating room under general anesthesia. This allows for more complete visualization and mapping of the tumor and tissue sampling, and is known as “direct laryngoscopy with biopsy”.
- Lymph Node Biopsy. If a patient presents with a neck mass, particularly in the setting of no identifiable lesion, the physician may sample tissue from lymph node. There are several types of lymph node biopsy.
- Fine Needle Biopsy (FNB). If the mass can be felt by the clinician, then a small needle can be introduced with an attempt at extracting cells for microscopic assessment. The appearance of abnormal cells will help support the diagnosis of cancer. Sometimes, not enough cells are extracted, and repeat biopsies may need to be performed. This may also be performed with the help of ultrasound or computed tomography (CT) guidance
- Core Biopsy (CB). Similar to the Fine Needle Biopsy, a core biopsy is performed by introducing a larger caliber needle, with extraction of tissue as opposed to cells. This core biopsy allows for extraction of more tissue and can be more useful, but often times not necessary, as an FNB is sufficient. This can also be done with or without ultrasound or CT-guided assistance
- Operative Biopsy. If the location of the node is too deep, or not readily felt by a clinician, the surgeon may elect to perform biopsy under general anesthesia in an operating room.
Blood Work. The physician may elect to perform routine blood analysis to assist in determining the presence of oropharyngeal cancer or other present diseases. Blood work may not be necessary, and the decision to obtain blood work is individualized to every patient.
- Liver Function Tests (LFTs): Can be utilized to determine the presence of concurrent liver disease that may be associated with risk factors for the development of oropharyngeal cancer (alcohol consumption, hepatitis). Furthermore, abnormal values may indicate the presence of metastatic liver disease.
- Complete Blood Count (CBC): This will identify the presence of any anemia that can sometimes be associated with poor nutrition, or chronic illness.
- Nutritional Blood Work: If a patient seems nutritionally depleted, particularly in advanced cases, the clinician may elect to obtain laboratory work up to measure nutrition markers in the blood work. This may assist in determining if a patient requires supplemental nutrition.
Imaging. Oftentimes a physician may elect to obtain imaging that will help in better understanding the presence of cancer and any other underlying issues. Imaging may be performed of the primary site, or of the general region to better define disease extent. The physician may elect to obtain further imaging in situations in which they are concerned for local invasion (e.g. into bone, muscle, adjacent sites), or regional invasion (to the neck).
- Chest X-rays: Chest radiography may be obtained in order to define the presence of disease in the lungs. Often times patients with larygneal cancer, have a longstanding history of smoking may have associated lesions in their lungs that should be identified.
- Computed Tomography (CT): CT-Scans usually provide a more detailed image of the head and neck region, identifying parts of the tumor that is not readily seen on exam, as well as the presence of regional disease not readily detected (e.g. in the neck). CT-Scans can be obtained with or without contrast. Given the complexity of the region, usually CT scans are obtained with scans, to help in identify the vascular architecture within the neck. However, this is not always necessary, and CT scans may be obtained without contrast in circumstances that preclude patient receiving contrast (iodine allergies, kidney disease).
- Magnetic Resonanice Imaging (MRI): MRI can also be utilized with or without contrast in order to provide superior visualization of soft tissue as well as the brain. Often times an MRI may be needed if there is indeterminate findings on other imaging modalities, with a need for more accurate mapping.
- 18-Fluorodeoxyglucose Positron Emission Tomography (18-FDG PET): FDG-PET scans may be performed with CT or MRI imaging modalities and are utilized for the identification of regional or distant metastases.
- Ultrasound (US): Ultrasound may be utilized to better characterize neck masses, or used in conjunction with biopsy techniques. US can indicate suspicious characters of lesions that would direct a physician to more aggressive workup (biopsy, excision).
- Barium Swallow: Swallow studies may be performed in order to determine the degree of obstruction, and presence of any other lesions within the esophagus.
What Are The Possible Treatments For Throat Cancer?
Depending on the site of disease, the clinical staging, and patient factors (co-morbid health conditions, patient preferences) a patient specific treatment plan should be outlined. Broadly speaking there are 3 types of treatment that can be used in combination or separately depending on the type and stage of cancer. The decision to embark on a particular treatment plan should be made involving a multidisciplinary team of physicians (surgeons, radiation oncologists, and medical oncologists) and the patient. Patient specific goals and outcomes should be defined, with a thorough discussion of the risks, benefits, and alternatives of all the separate treatment types. Broadly state, nasopharyngeal cancer is usually treated with Radiation with or without chemotherapy.
Surgery. Surgery is commonly performed in the treatment of throat cancer. The extent and type of surgery is heavily influenced on the site of lesion, as well as patient’s general health status.
- Transoral/Conservative Surgery: Transoral surgery for throat cancer can be performed with endoscopes, robots, and lasers. These minimally invasive procedures are used in specific circumstances whereby the tumor is confined, and can be fully visualized with a transoral approach.
- Radical Surgery: In advanced lesions with extensive spread to critical structures, surgery may involve removal of part or entire voice box and throat in order to fully remove all present disease.
Radiation. Radiation is another option for treatment of throat cancer.
- Definitive Radiation (with or without chemotherapy). This type of radiation treatment involves using radiation as the primary mode to treat the tumor. The goals of definitive radiation therapy is complete removal of all tumor with external sources of radiation.
- Adjuvant Radiation (with or without chemotherapy). This refers to the use of radiation in combination with surgery. The goal of adjuvant radiation is to treat any remaining disease after surgical removal (e.g in circumstances with positive margins).
- Neoadjuvant Radiation (with or without chemotherapy). Radiation given prior to surgery is referred to as neoadjuvant radiation. This is not routinely performed in the treatment of hypopharyngeal cancers and is used in academic centers as part of larger studies.
Chemotherapy. The use of systemic medications is used adjunctively with either surgery or radiation, and is used to target disease distant from the local site. It is not used as a primary treatment modality as it does not facilitate eradication at the primary site. Chemotherapy is often used in circumstances of advanced disease (Stage III or IV), or when certain risk factors for distant disease are present. Such risk factors include lymph nodes with disease that have extended out of their capsule (not contained), positive surgical margins, or involvement of nerves and blood vessels.
- Induction Chemotherapy. This refers to chemotherapy performed prior to surgery or radiation. This may be used to determine the biological response of the tumor to chemotherapy, as well as “shrink” tumors to a manageable size that can be better removed with surgery or radiation.
- Adjuvant Chemotherapy. This refers to chemotherapy given after definitive treatment with another modality was performed (either surgery or radiation).
- Concurrent Chemotherapy. This refers to the decision to administer chemotherapy and radiation concurrently after surgery. This may be the case in situations of predictors of aggressive disease on pathology.
Other Considerations. Specific attention should be given to the presence or absence of neck disease in the patient.
- Therapeutic Neck Interventions. If there is any presence of disease within the neck it should be addressed with some type of therapeutic intervention. Positive neck disease is usually treated through surgical resection or radiation of the actual positive nodes, and all intervening nodes in the neck. This is to ensure accurate pathological characterization of the nodes in the neck, and prevent recurrence in the neck (from missed disease).
- Elective Neck Interventions. In the absence of any clinical evidence of disease, an elective neck intervention may be performed. This means to treat the neck (with radiation or surgery) due to the potential for “occult” or hidden disease that is not clinically apparent.
Are There Preventative Steps Or Measures To Avoid Throat Cancer?
The best steps to prevent throat cancer is to avoid offending agents, specifically alcohol and tobacco.
What Are The Risks If Throat Cancer Is Left Untreated?
Throat cancer that is not treated will continue to progress and cause significant detriment to a patient’s health. As the tumor grows patients will experience progressive worsening of their ability to swallow, speak, and breathe. Ultimately this can cause severe nutritional problems, and ultimately result in the untimely death of a patient.
Key Takeaways About Throat Cancer
- Symptoms related to swallowing, speaking, or breathing that do not resolve or progress over the course of weeks to months should be evaluated by a specialist.
- Smoking cessation is an important part in the prevention and treatment of throat cancer.
- Multiple options exist in the treatment of throat cancer. It is important to speak with a specialist that can discuss all surgical and non-surgical options available.
What Makes Dr. Mourad The Right Doctor For Throat Cancer?
Dr. Mourad is a Head and Neck Surgeon with advanced training in reconstructive surgery. He performs all aspects of head and neck cancer surgery including minimally invasive and reconstructive procedures. He is also a leader in his field with two published books, numerous book chapters, and more than 40 peer reviewed publications in the scientific literature. He frequently speaks at national and international conferences to help in advancing this field. Most importantly, Dr. Mourad is empathetic to the needs of his patients. He views the ability to treat his patients to be nothing short of an honor and a privilege.
Select Relevant Publications
Mofiyinfolu Sokoya, Arash Bahrami, Jason Cohn, Sameep Kadakia, Moustafa Mourad, Yadranko Ducic. Orbital Skull Base Reconstruction with Temporalis Muscle: The Sphenoid Keyhole Technique. CMTR Open. 2018; 02(01): e27-e30. Link to Article.
Moustafa W Mourad, M. Z. Mat Saman, Yadranko Ducic. Internal to External Jugular Vein Bypass Allowing for Simultaneous Bilateral Radical Neck Dissection. Laryngoscope. 2015 Nov;125(11):2480-4. Link to Article.