Palate Cancer

Palate cancer appears in a critical subregion of the oral cavity. The hard palate is formed by the palatine and maxillary bones, while the soft palate covers the lower part of the oropharynx. These two regions have distinct anatomical structures. Among the most common tumors of the hard and soft palate are squamous cell carcinoma (SCC) and mucoepidermoid carcinoma. Additionally, rarer malignancies such as adenoid cystic carcinoma can develop in these areas. These types of cancers typically affect the palate structure, leading to serious health issues.

You can read the content prepared by Prof. Dr. Murat Topdağ, one of the doctors in Istanbul who performs surgery for palate cancer, to learn about the risks, recovery process, and post-operative considerations regarding palate cancer surgery.

Ear, Nose, Throat, Head and Neck Surgery Specialist
Prof. Dr. Murat Topdağ

Born in Malatya in 1978, Murat Topdağ completed his primary and secondary education, then attended high school in Istanbul. He graduated from the English program of Cerrahpaşa Tıp Fakültesi. Performing his surgeries at Acıbadem Altunizade Hospital, Prof. Dr. Murat Topdağ is married and has two children.

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Etiological Factors of Palate Cancer

Tobacco and alcohol use can trigger the formation of malignant lesions in the hard palate. This effect results from tissue damage caused by high temperatures. Additionally, poor oral hygiene and irritating mouthwashes can contribute to lesions in the palate.

Chronic trauma to the oral mucosa and poorly fitting dentures cause constant damage to the mucosa, which can increase the risk of malignancy. Vitamin A deficiency and human papillomavirus (HPV) infection are also among other factors that raise the risk of palate cancer.

List of risk factors:

• Tobacco and alcohol use
• Poor oral hygiene
• Irritating mouthwashes
• Chronic oral mucosal trauma
• Poorly fitting dentures
• Vitamin A deficiency
• Human Papillomavirus (HPV) infection

Minor salivary gland malignancies such as mucoepidermoid carcinoma and adenoid cystic carcinoma have been associated with notable causes like genetic predisposition and hormonal changes. However, the precise causes of these types are not fully understood. Systemic diseases such as Kaposi’s sarcoma and non-Hodgkin lymphoma can be exacerbated by viral infections and immunosuppression. These factors support cancer development in various parts of the body, including the palate.

What is Palate Cancer?

Palate cancer is a disease that develops in a distinct region of the oral cavity and involves specific types of malignant tumors. The hard palate is formed by the palatine and maxillary bones, bounded above by the nasal cavity and below by the oral cavity. Due to the close interaction between the mucosa and the underlying periosteum, this region is rich in minor salivary glands. Such a structure provides a foundation for various types of malignant tumors. In particular, the following types frequently occur in the hard palate:

• Squamous cell carcinoma (SCC) is the most commonly seen type.
• Mucoepidermoid carcinoma and adenoid cystic carcinoma are among other types found.

The soft palate is the transition area to the oropharynx, where various types of tumors may also be present. In the soft palate:

• Polymorphous low-grade adenocarcinoma and low-grade papillary adenocarcinoma can be observed.
• Less common types include acinic cell carcinoma and mucosal melanoma.

Both the hard and soft palate can also host rarer cancer types like Kaposi’s sarcoma and non-Hodgkin lymphoma. This diversity makes diagnosing and treating palate cancer complex. Due to its unique location and histological diversity, palate cancer differs from other oral cancers and requires specific intervention methods.

Palate Cancer Statistics

Malignant lesions of the hard palate account for about 1-5% of oral cavity cancers. Squamous cell carcinoma is the most common cancer type in this region. It also represents about 2% of all head and neck squamous cell carcinomas. It typically occurs in males in their sixties. At the time of initial diagnosis, approximately 23% of patients present with cervical lymph node involvement.

Minor salivary gland tumors (MSGT) are the most common salivary gland neoplasms of the hard palate, with the following malignancy rates:

• Adenoid cystic carcinoma (AdCC): between 41.5% and 51%
• Mucoepidermoid carcinoma (MEC): between 26% and 40%

Adenoid cystic carcinoma occurs more frequently in women and accounts for about 17.5% of all malignant salivary gland tumors. Among MSGT of the hard palate, AdCC and MEC are encountered most often. Additionally, other rare types like polymorphous low-grade adenocarcinoma and low-grade papillary adenocarcinoma also occur in this region.

Other cancer types such as mucosal melanomas and Kaposi’s sarcoma may appear in the palate. Mucosal melanomas tend to occur more frequently in older individuals and in people of Japanese, Indian, or African descent. Kaposi’s sarcoma typically starts in HIV patients and commonly affects the oral mucosa.

Lastly, non-Hodgkin lymphoma is another significant malignancy, comprising about 3-5% of oral cavity cases. It is frequently seen in the hard and soft palate, particularly among white males over 75. Diffuse large B-cell lymphoma and mucosa-associated lymphoid tissue (MALT) lymphoma are the most common NHL subtypes seen in the palate.

What Causes Palate Cancer?

Palate cancer includes a range of malignancies that develop based on various risk factors. Tobacco and alcohol, in particular, are classified as carcinogens and play a major role in the development of oral squamous cell carcinoma. Reverse smoking can raise the temperature to about 50 degrees Celsius, posing a cancer risk. Heat itself is considered a potential co-carcinogen. Additionally, poor oral hygiene and chronic oral mucosal trauma are among other factors associated with the formation of malignant lesions in the palate.

Other important risk factors include:

• Ill-fitting dentures
• Human Papillomavirus (HPV) infection
• Irritating mouthwashes
• Vitamin A deficiency

Moreover, the etiology of malignant minor salivary gland tumors such as adenoid cystic carcinoma (AdCC), mucoepidermoid carcinoma (MEC), polymorphous low-grade adenocarcinoma (PLGA), low-grade papillary adenocarcinoma (LGPA), and acinic cell carcinoma (ACC) is not fully known, though it may be related to advanced age and hormonal changes.

Mucosal melanoma is a rare and aggressive malignancy of the palate that originates from melanocytes. Suggested risk factors include:

• Ill-fitting dentures
• Tobacco use
• Pre-existing benign oral melanocytic lesions

Ultraviolet radiation is not considered a risk factor for mucosal melanoma.

Kaposi’s sarcoma (KS) is linked to human herpesvirus 8 (HHV8) and human immunodeficiency virus (HIV). Immunosuppression has a major impact on the development of this cancer type.

For non-Hodgkin lymphoma (NHL), a variety of risk factors exist, including:

• Immunosuppression (HIV, congenital immunodeficiency, organ transplantation, chemotherapy, and radiation)
• Viral infections (EBV, HTLV-1, Herpes, Hepatitis C)
• Bacterial infections (Helicobacter pylori gastritis and Lyme disease)
• Environmental factors (tobacco, animal fats, hair dyes, ultraviolet radiation, pesticides, occupational toxin exposure)

Genetic predisposition for B-cell survival and growth is also significant.

Pathophysiology of Palate Cancer

The pathogenesis of palate cancers results from complex interactions of genetic and epigenetic factors. Different types of palate cancer are associated with disruptions in molecular pathways that allow uncontrolled cell division and dissemination. Palatal squamous cell carcinoma is often linked to genetic mutations associated with smoking, alcohol, and HPV. Specific genetic translocations come to the forefront in types such as adenoid cystic carcinoma and mucoepidermoid carcinoma. These translocations lead to oncogene activation at the cellular level, promoting tumor growth. Environmental factors and immunosuppression can also be influential in the development of palate cancer. Here are some genetic abnormalities associated with these cancer types:

• Squamous cell carcinoma: genetic mutations and epigenetic changes
• Adenoid cystic carcinoma: overexpression of the MYB-NFIB fusion oncogene
• Mucoepidermoid carcinoma: MECT1 and MAML2 gene fusion
• Acinic cell carcinoma: evolution from serous acinar cells or pluripotent intercalated duct cells
• Mucosal melanoma: GNAQ/11 mutations and c-KIT overexpression
• Kaposi’s sarcoma and non-Hodgkin lymphoma: various immunoglobulin chain gene mutations and rearrangements

Palate Cancer: Histopathological Characteristics

The histopathological features of palate cancers span various malignancies, differing by type. Palatal squamous cell carcinoma is characterized by dysplasia in the palatal tissue with cellular differentiation and lymphovascular invasion. This cancer may show aggressive growth, including bone erosion and nerve spread.

Adenoid cystic carcinoma (AdCC) has three main histological subtypes:

• Cribriform: cylindrical pseudocysts and hyaline material
• Tubular: ducts lined by myoepithelial cells
• Solid: epithelial islands with central necrosis areas

Mucoepidermoid carcinoma includes epidermoid and mucus-producing cells, graded histologically:

• Low grade: mostly mucus-filled cystic components
• Intermediate grade: solid nests of epidermoid cells and occasional mitotic figures
• High grade: indistinct borders and marked cellular pleomorphism

Polymorphous low-grade adenocarcinoma is commonly seen in the palate with an infiltrative growth pattern. Low-grade papillary adenocarcinoma is more aggressive, featuring a papillary morphology. Acinic cell carcinoma stands out for its solid and microcystic structures. Mucosal melanoma and Kaposi’s sarcoma manifest respectively with malignant melanocytes and a mix of vascular structures. Non-Hodgkin lymphoma shows diverse lymphoid tissue-related cellular structures and immunophenotypic characteristics.

How is it Diagnosed?

Palate cancer is associated with symptoms related to palatal masses. Patients often present with bad breath, mismatched prostheses, and swallowing difficulties. Loosening of the teeth and speech changes are among other symptoms. Pain and the timeline of the palatal mass onset and growth rate should be carefully evaluated. In addition, the patient’s past medical and surgical history, any prior malignancies, and social risk factors are investigated:

• Smoking and alcohol use
• Drug use
• Occupational risks

During the physical examination, doctors meticulously assess the oral cavity and surrounding structures. Bilateral palpation of cervical lymph nodes is essential to detect potential metastasis. The exam typically confirms the presence of a palatal mass, which may or may not be accompanied by oral bleeding or pain. During this examination, the specific features of the following malignancies are taken into account:

• Cervical lymph node metastasis of squamous cell carcinoma
• Painful growth in adenoid cystic carcinoma
• Fluctuating nature of mucoepidermoid carcinoma
• Non-ulcerated appearance of polymorphous low-grade adenocarcinoma
• Lobulated structure of low-grade papillary adenocarcinoma
• Slow-growing mass of acinic cell carcinoma
• Pigmented lesions of mucosal melanomas
• Violaceous-brown lesions of Kaposi’s sarcoma
• Submucosal mass of non-Hodgkin lymphoma

This examination and assessment process play a critical role in diagnosis and treatment.

Diagnostic Methods for Palate Cancer

Various methods are used in conjunction to diagnose palate cancer. The patient’s history and physical examination are the first steps. The history provides an account of the patient’s symptoms and medical background; the physical exam reveals clinical findings indicative of the disease. Moreover, imaging techniques and biopsy methods are critical.

Imaging Techniques:

• Computed Tomography (CT) is particularly used to detect bone erosion and lymphadenopathy.
• Magnetic Resonance Imaging (MRI) enables a detailed examination of soft tissue and shows important findings like perineural spread.
• Panoramic X-ray (Panorex) is used particularly for identifying bone involvement.
• Positron Emission Tomography (PET) is highly effective in detecting metastases and monitoring treatment.

Types of Biopsy:

• Fine Needle Aspiration Biopsy (FNA) allows detailed cellular examination.
• Incisional Biopsy yields larger tissue samples, improving diagnostic accuracy.

Data obtained through these methods are crucial for accurately identifying palate cancer and forming an effective treatment plan.

Palate Cancer Treatment Approaches

The treatment of palate cancer varies according to the patient’s condition and the characteristics of the cancer. The main treatment methods are surgery, radiotherapy, and chemotherapy. The first choice is usually surgery, which is determined by the type of cancer and the extent of its spread.

Wide local excision is used in the initial treatment of palate cancer.

Cervical metastases or high-grade tumors require additional treatment:

• Neck dissection
• Adjuvant chemotherapy
• Radiotherapy

Radiotherapy combined with chemotherapy becomes important, especially in cases of recurrent disease or perineural invasion. In malignant salivary gland tumors, when radiotherapy is ineffective, chemotherapy takes priority. For Kaposi’s sarcoma, antiretroviral therapy is adjusted according to the patient’s immune status. In non-Hodgkin lymphoma, chemoradiation therapy is preferred.

Surgical Treatment Approaches

Surgery plays a major role in treating palate cancer. Small, superficial tumors are generally treated via a transoral approach, while larger malignancies may require various external approaches. For extensive tumors, techniques such as the Upper Buccal flap or Lateral rhinotomy may be utilized. The Weber-Ferguson approach provides wide oncologic clearance. During these procedures, tumor removal and verification of margins are critical for improving patient survival. If the tumor involves nerves, the effects on those nerves must be carefully examined.

Defects following maxillectomy and palatectomy:

• Temporary obturator prostheses
• Rotation flaps, e.g., buccal myomucosal flaps
• Free tissue transfer flaps, such as fibula or iliac crest

Postoperative reconstruction aims to improve speech and swallowing functions. Especially for large defects, free tissue transfer is preferred. These approaches can significantly enhance the patient’s quality of life. Oncologic follow-up of the treated area is essential to evaluate the success of the therapy. Surgical interventions remain an effective treatment choice for palatal malignancies.

The Role of Radiation Oncology in Treating Palate Cancer

Radiation therapy plays a key role in various situations when dealing with palate cancers. Adjuvant radiotherapy is commonly used after surgery in high-grade squamous cell carcinoma to reduce the risk of recurrence and improve local control.

• In adenoid cystic carcinoma, adjuvant chemoradiation is recommended, considering tumor proximity to the skull base and cervical metastasis.
• In mucoepidermoid carcinoma, radiotherapy is suggested to manage postoperative complications.
• For polymorphous low-grade adenocarcinoma and cases with lymph node metastasis, radiotherapy may also be applied. However, conflicting data exist regarding its effectiveness.
• In non-resectable low-grade papillary adenocarcinoma lesions, radiotherapy at certain dose levels can successfully achieve tumor shrinkage.
• The effect of radiation in acinic cell carcinoma is limited.
• In more aggressive tumor types such as mucosal melanoma and non-Hodgkin lymphoma, different dose and fractionation regimens are used. Radiotherapy reduces local recurrence but does not necessarily show a pronounced effect on overall survival.

Medical Oncology

In hard palate SCC cases, adding cisplatin-based chemotherapy when positive margins or extracapsular nodal spread is detected improves regional control and overall survival rates. This is more effective than adjuvant radiation alone. In metastatic or recurrent salivary gland tumors, chemotherapy is used mainly as a palliative treatment.

In mucosal melanoma cases, therapy consists of chemotherapy, targeted therapies, and immunotherapy.

In Kaposi’s sarcoma, chemotherapy is necessary, especially if there is extensive involvement of the skin and intraoral regions.

For NHL patients, chemotherapy in addition to radiotherapy is considered standard treatment. These approaches play an important role in the treatment of palate cancer.

Palate Cancer Staging System

Staging of palate cancer is critical to determine the extent of disease and guide treatment planning. This staging is based on tumor size, regional lymph node status, and the presence of distant metastases.

T Category: Tumor Size and Extension

• Tx: Primary tumor cannot be assessed.
• Tis: Carcinoma in situ.
• T0: No evidence of primary tumor.
• T1: Tumor ≤ 2 cm, invasion depth < 5 mm.
• T2: Tumor ≤ 2 cm with 5-10 mm invasion depth, or tumor > 2 cm but < 4 cm and invasion depth < 10 mm.
• T3: Tumor > 4 cm, or invasion depth 10-20 mm.
• T4a: Tumor invades the mandibular or maxillary cortical bone, maxillary sinus, facial skin, bilateral tongue, or invasion depth > 20 mm.
• T4b: Tumor invades the masticator space, pterygoid plates, skull base, or encases the internal carotid artery.

Node Category: Regional Lymph Node Status

• cNx: Regional lymph nodes cannot be assessed.
• cN0: No regional lymph node metastasis.
• cN1: Single ipsilateral lymph node ≤ 3 cm, no extranodal extension.
• cN2a: Single ipsilateral node > 3 cm but < 6 cm, no extranodal extension.
• cN2b: Multiple ipsilateral nodes < 6 cm, no extranodal extension.
• cN2c: Bilateral or contralateral nodes < 6 cm, no extranodal extension.
• cN3a: Metastatic lymph node > 6 cm, no extranodal extension.
• cN3b: Metastatic lymph node with extranodal extension.

Metastasis Category: Distant Spread

• Mx: Metastasis cannot be assessed.
• M0: No distant metastasis.
• M1: Distant metastasis present.

This staging system is crucial for determining treatment approaches and predicting the prognosis of the disease.

Estimated Outcomes of Palate Cancer

Various factors, including histology type, tumor stage, and disease spread, play significant roles in the outcome. Each type of palate cancer has different expectations:

Squamous Cell Carcinoma (SCC):

• Poor outcomes in advanced stages.
• High tumor grade, positive surgical margins, cervical metastases, and recurrences indicate a worse prognosis.
• HPV-positive cases have better survival.

Adenoid Cystic Carcinoma (AdCC):

• Overall five-year survival rate ranges from 60% to 90%.
• Ten-year survival rates drop to 40-50%.
• The solid variant is associated with poorer outcomes.

Mucoepidermoid Carcinoma (MEC):

• For low-grade MEC, five-year survival rates exceed 90%.
• High-grade variants carry a risk of recurrence and metastasis.

Polymorphous Low-Grade Adenocarcinoma (PLGA):

• Local recurrence rates range from 9% to 33%.
• Cervical lymph node metastasis varies between 6% and 35%.
• Distant metastasis is rare.

Low-Grade Papillary Adenocarcinoma (LGPA):

• High local recurrence rates.
• About 40% cervical node metastasis.

Acinic Cell Carcinoma (ACC):

• Overall five-year survival rate is approximately 88.6%.

Mucosal Melanoma (MM):

• Poor prognosis.
• Five-year survival rate is between 15% and 45%.

Kaposi’s Sarcoma (KS):

• Antiretroviral therapy improves survival rates.

Non-Hodgkin Lymphoma (NHL):

• After radiotherapy, five-year progression-free survival rate is 88%.
• Local control rates are generally high.

All types of palate cancer require careful treatment and follow-up. Early detection and timely intervention can improve treatment outcomes.

Complications of Palate Cancer Treatment

Surgical interventions may adversely affect speech and swallowing functions, often necessitating enteral feeding and causing communication problems. Postoperative patients may experience pain and sensory loss. Flap reconstructions can particularly hamper food manipulation during chewing. Patients undergoing neck dissection face increased risk of neurological injury. Nerves that can be affected include:

• Spinal accessory nerve
• Phrenic nerve
• Hypoglossal nerve
• Lingual nerve
• Vagus nerve
• Sympathetic trunk
• Marginal mandibular branch of the facial nerve

Acute toxicities from adjuvant radiation therapy are generally not life-threatening. New radiation techniques have reduced damage to the salivary glands. However, patients may experience:

• Mucositis
• Pharyngitis
• Esophagitis
• Dysphagia
• Odynophagia
• Trismus
• Xerostomia (dry mouth)
• Dermatitis

Mandibular osteoradionecrosis is a severe form of late radiation toxicity. Chemotherapy is linked to various side effects:

• Mucositis
• Fungal and viral infections
• Xerostomia
• Dysgeusia (taste alteration)
• Malnutrition
• Pain

Postoperative Recovery and Support Processes

During the post-treatment period, restoring oral functions is crucial. Swallowing and speech abilities are frequently impaired by the combined effects of radiation therapy and chemotherapy. Speech and swallowing therapists are needed early in the recovery to address these problems. Specialists focus on rehabilitating swallowing function and speech as fully as possible.

• First year after treatment: check-ups every 1 to 3 months
• Second year: check-ups every 2 to 6 months
• Third to fifth years: check-ups every 4 to 8 months
• After the fifth year: yearly check-ups

The risk of recurrence and the need for long-term health monitoring are especially high at this stage. The National Comprehensive Cancer Network (NCCN) guidelines recommend follow-up for more than 10 years. Such regular follow-ups are essential for early detection of recurrences and improving the patient’s quality of life.

Dietary and Lifestyle Changes after Surgery

After palate cancer surgery, the following dietary and lifestyle changes are recommended:

• Consume soft, moist foods. Soups, smoothies, and yogurt are suggested because they are easier to swallow.
• Maintain a protein-rich and high-calorie diet. Foods like fish, chicken, and dairy products support recovery.
• Eat small, frequent meals to ensure adequate nutrient intake and minimize discomfort.
• Drink plenty of water and unsweetened beverages. Avoid alcoholic and caffeinated drinks as they can dehydrate the body.
• Stay away from irritating foods. Spicy and acidic foods can irritate the surgical site.

Additionally, lifestyle changes are crucial:

• Pay attention to oral hygiene. Gargling with saline solution can reduce infection risk.
• Quit smoking. Smoking impairs blood circulation and slows the healing process.
• Limit alcohol intake. Alcohol can interact with medications and negatively affect recovery.
• Do light exercise. This improves circulation and reduces stress.
• Attend regular follow-up appointments with your healthcare team. These appointments ensure proper management of the recovery process.

Frequently Asked Questions

Is there a chance of survival in Stage 4 palate cancer?

At Stage 4 of palatal cancer, five-year overall survival rates range from about 21% to 37.2%. Thus, there is a limited but real possibility of survival.

Looking at images or photos of people with palate cancer to self-diagnose can be misleading, so consult your physician if you have any doubts.

Could a lump-like swelling in the palate be a sign of cancer?

A lump-like swelling in the palate may indeed indicate palate cancer. The early signs of palate cancer are not always very obvious; however, swelling, irritation, and small bumps in the palate may appear. Difficulty swallowing and pain in the mouth are also common. Other symptoms include bleeding, a mass that the tongue can feel, and sore throat. In addition, bad breath, loose teeth, white or red patches, and ear pain may occur. Taste disturbances are also possible, though rare.

References:

https://my.clevelandclinic.org/health/diseases/24789-hard-palate-cancer

https://www.mayoclinic.org/diseases-conditions/soft-palate-cancer/symptoms-causes/syc-20354183