Malignant Tumors of the Palate Workup

Updated: Jun 09, 2017
  • Author: Nader Sadeghi, MD, FRCSC; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Workup

Imaging Studies

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  • Radiologic evaluation helps to increase the accuracy of staging. Computed tomography (CT) scanning and magnetic resonance imaging (MRI) are the imaging modalities of choice.
  • Perform CT scanning in axial and coronal planes. Coronal images, as seen in the image below, are best for assessing bony invasion of the palate and extension into the nasal fossa or maxillary sinus.
    Coronal CT scan revealing intranasal extension of Coronal CT scan revealing intranasal extension of the tumor.
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    • CT scanning aids in assessing skull-base extension. Enlargement of skull-base foramina is indicative of tumor invasion. Axial images aid in assessing extension in the horizontal plane along the soft palate, pterygoid plates and muscles, infratemporal fossa, and masticator space.
    • CT scanning with intravenous contrast infusion should include the neck to assess for cervical node involvement. This is especially important for SCC and high-grade mucoepidermoid carcinoma.
    • MRI, as seen in the images below, is more accurate for assessing perineural extension along the foramina. This is especially important in adenoid cystic carcinoma with the propensity for perineural invasion.
      Sagittal MRI revealing a mass confined to the pala Sagittal MRI revealing a mass confined to the palate, without sinonasal extension.
      Coronal MRI. Coronal MRI.
    • In advanced tumors with paranasal sinus involvement, MRI is superior to CT scanning in distinguishing inflammatory disease from a neoplasm.
    • For extensive lesions with intracranial involvement, MRI aids in assessing dural invasion.
  • Perform chest radiography to assess for pulmonary metastasis, a second primary site, or both.
  • A liver function test is adequate to assess for liver metastasis. Consider CT scanning of the abdomen and chest if distant metastasis is highly probable.
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Diagnostic Procedures

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  • Biopsy of an ulcerative lesion may be easily obtained in the office transorally using biopsy forceps with the patient under local anesthesia. Alternatively, fine-needle aspiration cytology studies may be performed if an experienced cytopathologist is available.
    • For ulcerative lesions, obtaining a biopsy specimen from closer to the edge of the tumor is important to avoid the necrotic central component.
    • In large, nonulcerated palatal lumps, an incision through the intact mucosa may be required prior to biopsy. Place the biopsy incision in a manner that allows for subsequent removal of the biopsy scar in continuity with the tumor.
    • Smaller submucosal lesions may be managed with excisional biopsy. If the pathology results indicate malignancy, further treatment is initiated.
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Staging

Perform staging of the tumor according to the American Joint Committee on Cancer staging protocol because this is of critical importance to the patient's prognosis. Tumor and nodal status for oral cavity and oropharynx tumors are used for staging. Staging for cancer of the oropharynx and oral cavity, adapted from the 2002 American Joint Committee on Cancer, is as follows:

  • Staging of primary tumor (T)
    • TX - Primary tumor not assessable
    • T0 - No evidence of primary tumor (T is carcinoma in situ.)
    • 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
    • T4 - Tumor invades adjacent structures (eg, through cortical bone, soft tissues of neck, deep [extrinsic] muscle of tongue)
  • Staging of regional lymph nodes (N)
    • NX - Regional lymph nodes not assessable
    • N0 - No regional lymph node metastasis
    • N1 - Metastasis in a single ipsilateral lymph node, 3 cm or smaller in greatest dimension
    • N2 - Metastasis in a single ipsilateral lymph node, larger than 3 cm but not larger than 6 cm in greatest dimension; in multiple ipsilateral lymph nodes, none larger than 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none larger than 6 cm in greatest dimension
    • N2a - Metastasis in a single ipsilateral lymph node larger than 3 cm but not larger than 6 cm in greatest dimension
    • N2b - Metastasis in multiple ipsilateral lymph nodes, none larger than 6 cm in greatest dimension
    • N2c - Metastasis in bilateral or contralateral lymph nodes, none larger than 6 cm in greatest dimension
    • N3 - Metastasis in a lymph node larger than 6 cm in greatest dimension
  • Staging of distant metastasis (M)
    • MX - Presence of distant metastasis cannot be assessed
    • M0 - No distant metastasis
    • M1 - Distant metastasis
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