Head and Neck Pathology

, Volume 6, Supplement 1, pp 25–40 | Cite as

Radiographic Imaging of Human Papillomavirus Related Carcinomas of the Oropharynx

Invited Review


Imaging, especially contrast-enhanced computed tomography (CECT) for anatomy and positron emission tomography (PET) with labeled 18F fluorodeoxyglucose for physiologic detail, is critical for staging carcinomas of the oropharynx. As the incidence of human papillomavirus (HPV) infection and related carcinomas of the tonsil and base of tongue (BOT) increases, experience with CECT and PET for staging HPV+ tumors is growing. No imaging modality, however, can determine whether the tumor is HPV+. There are some unique challenges posed by HPV+ oropharyngeal squamous cell carcinoma (SCC). In most locations of the head and neck, a malignancy enhances more than surrounding normal structures, which facilitates tumor mapping. Unfortunately, normal lymphoid tissue of the oropharynx, in the BOT and palatine tonsillar fossa, enhances on CECT and gadolinium enhanced magnetic resonance imaging in a manner similar to SCC. The primary tumor may be small or even occult at presentation, and easily over-looked on CECT. PET coupled with CECT has made a true “unknown primary” very rare, as the metabolically active tumor is almost always detectable on PET. The nodal metastases, so common with HPV+ SCC, can be truly cystic; and as such, can be misdiagnosed as a second branchial cleft cyst, a congenital benign lesion. These pitfalls, coupled with the complex anatomy of the upper aerodigestive tract, make staging these tumors difficult. In this monograph we describe the anatomy of the oropharynx and review the imaging modalities available for staging. Figures highlight the points raised in the text.


Oropharynx Squamous cell carcinoma Human papillomavirus related carcinoma Computed tomography Positron emission computed tomography 


  1. 1.
    Osborne RG, Brown JJ. Carcinoma of the oral pharynx: an analysis of subsite treatment heterogeneity. Surg Oncol Clin N Am. 2004;13:71–80.PubMedCrossRefGoogle Scholar
  2. 2.
    Filion E, Le Q-T. Oropharynx: epidemiology and treatment outcome. In: Harari PM, Connor NP, Grau C, editors. Functional preservation and quality of life in head and neck radiotherapy. Berlin: Springer; 2009.Google Scholar
  3. 3.
    Simard EP, Ward EM, Siegel R, Jemal A. Cancers with increasing incidence trends in the United States: 1999–2008. CA Cancer J Clin. 2012 (epub ahead of print). doi:10.3322/caac.20141.
  4. 4.
    Saba NF, Goodman M, Ward K, et al. Gender and ethnic disparities in incidence and survival of squamous cell carcinoma of the oral tongue, base of tongue and tonsils: a surveillance, epidemiology and end results program-based analysis. Oncology. 2011;81:12–20.PubMedCrossRefGoogle Scholar
  5. 5.
    D’Souza F, Kreimer AR, Viscidi R, et al. Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med. 2007;356:1944–56.PubMedCrossRefGoogle Scholar
  6. 6.
    Chaturverdi AK, Engels EA, Pfeiffer RM, et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol. 2011;29:4294–301.CrossRefGoogle Scholar
  7. 7.
    Lin DT, Cohen SM, Coppit GL, et al. Squamous cell carcinoma of the oropharynx and hypopharynx. Otolaryngol Clinc N Am. 2005;38:59–74.CrossRefGoogle Scholar
  8. 8.
    Trotta BM, Pease CS, Rasamny JJ, et al. Oral cavity and oropharyngeal squamous cell cancer: key imaging findings for staging and treatment planning. Radiographics. 2011;31:339–54.PubMedCrossRefGoogle Scholar
  9. 9.
    Cohan DM, Popat S, Kaplan SE, et al. Oropharyngeal cancer: current understanding and management. Curr Opin Otolaryngol Head Neck Surg. 2009;17:88–94.PubMedCrossRefGoogle Scholar
  10. 10.
    Stambuk HE, Karimi S, Lee N, et al. Oral cavity and oropharynx tumors. Radiol Clin N Am. 2007;45:1–20.PubMedCrossRefGoogle Scholar
  11. 11.
    Wesolowski JR, Mukherji S. Pathology of the pharynx. In: Som PM, Curtin HD, editors. Head and neck imaging. 5th ed. Amsterdam: Elsevier; 2011.Google Scholar
  12. 12.
    Edge S, Byrd D, Compton C, et al. AJCC7 cancer staging manual. New York: Springer; 2010.Google Scholar
  13. 13.
    Syms MJ, Birkmire-Peters DP, Holtel MR. Incidence of carcinoma in incidental tonsil asymmetry. Laryngoscope. 2000;11:1807–10.CrossRefGoogle Scholar
  14. 14.
    Yoon DY, Hwang HS, Chang SK, et al. CT, MR, US, 18F-FDG PET/CT, and their combined use for the assessment of cervical lymph node metastases in squamous cell carcinoma of the head and neck. Eur Radiol. 2009;19:634–43.PubMedCrossRefGoogle Scholar
  15. 15.
    Xu G-Z, Zhu X-D, Li M-Y. Accuracy of whole-body PET and PET-CT in initial M staging of head and neck cancer: a meta-analysis. Head Neck. 2011;33:87–94.PubMedCrossRefGoogle Scholar
  16. 16.
    Bannas P, Habermann CR, Jung C, et al. Diagnostic accuracy of state-of-the-art MDCT scanners without gantry tilt in patient with oral and oropharyngeal cancer. Eur J Radiol. 2011;. doi:10.1016/j.ejrad.2011.07.009.Google Scholar
  17. 17.
    Bhargava P, Rahman S, Wendt J. Atlas of confounding factors in head and neck PET/CT imaging. Clin Nucl Med. 2011;36:e20–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Blodgett TM, Fukui MB, Snyderman CH, et al. Combined PET-CT in the head and neck. Part 1. Physiologic, altered physiologic and artifactual FDG uptake. Radiographics. 2005;25:897–912.PubMedCrossRefGoogle Scholar
  19. 19.
    Schmalbach CE, Miller FR. Occult primary head and neck cancer. Curr Oncol Rep. 2007;9:139–46.PubMedCrossRefGoogle Scholar
  20. 20.
    Wong WL, Sonoda LI, Gharpurhy, et al. 18F-fluorodeoxyglucose positron emission tomography/computed tomography in the assessment of occult primary head and neck cancers—an audit and review of published studies. Clin Oncol. Available on-line 17 Dec 2011.Google Scholar
  21. 21.
    Fakhry C, Westra WH, Li S, et al. Improved survival of patients with human papillomavirus-positive head and neck squamous cell carcinoma in a prospective clinical trial. J Natl Cancer Inst. 2008;100:261–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Westra WH. The changing face of head and neck cancer in the 21st century: the impact of HPV on the epidemiology and pathology of oral cancer. Head Neck Pathol. 2009;3:78–81.PubMedCrossRefGoogle Scholar
  23. 23.
    Goldenberg D, Begu S, Westra WH, et al. Cystic lymph node metastatsis in patients with head and neck cancer: an HPV-associated phenomenon. Head Neck. 2008;30(7):898–903.PubMedCrossRefGoogle Scholar
  24. 24.
    Morani A, Shah G, Eisbruch A, et al. Intranodal cystic changes: a potential radiological signature/biomarker to assess the human papilloma virus status of patients with oropharyngeal carcinoma. AJR 2011;196:A47. Abstract presented in scientific session 14—neuroradiology: head and neck on 4 May 2011 at the ARRS meeting.Google Scholar
  25. 25.
    Hudgins PA, Gillison M. Editorial: second branchial cleft cyst: NOT!! AJNR. 2009;30:1628–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Ahuga AT, Ying M. Sonographic evaluation of cervical lymph nodes. AJR. 2005;184:1691–9.Google Scholar
  27. 27.
    King KG, Kositwattanarerk A, Genden E, et al. Cancers of the oral cavity and oropharynx: FDG-PET with contrast enhanced CT in the posttreatment setting. Radiographics. 2011;31:355–73.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Department of Radiology and Imaging Sciences, Head and Neck Radiology SectionEmory University School of MedicineAtlantaUSA

Personalised recommendations