Head and Neck | Mount Sinai Today

Questions to Ask Your Doctor About HPV-Related Oral Cancer

Updated on Apr 11, 2023 | Cancer, Head and Neck, Sexual Health, Your Health

To make an appointment with Raymond Chai, MD, call 212-844-8775.

Did you know that the human papillomavirus (HPV) can cause cancers of the oropharynx (tongue, tonsils, and back of the throat), similar to how HPV causes cervical cancer?

Most oral HPV infections can clear naturally without treatment. But if the virus persists in the system, it could incite more serious health issues, such as these cancers. Additionally, the incidence is low, with about 12,000 new cases of these HPV-associated cancers diagnosed each year in the United States, but 80 percent affect men.

Raymond Chai, MD, a head and neck surgeon at the Mount Sinai Union Square location of the Head and Neck Institute/Center of Excellence for Head and Neck Cancers, answers some frequently asked questions about oral HPV infections.

What are my options for treatment?

The two main approaches are upfront radiation treatment with chemotherapy versus a primary surgical approach.

Do you offer transoral robotic surgery (TORS)?

This technology has largely replaced traditional surgery, which typically required splitting the lip and cutting the jaw to access the tumor.

Do you have a true multidisciplinary approach to this disease?

Both surgical and non-surgical treatments should be on the table and discussed. In select cases, the use of TORS can either completely eliminate postoperative radiation, lower the dose of postoperative radiation, or eliminate the need for chemotherapy. This may reduce the risk of long-term side effects from high-dose radiation and chemotherapy.

What is your experience level with TORS? How many cases have you performed?

Experience matters with this new technology and as with any new surgery, there is a learning curve. Even seasoned surgeons who are experts with open approaches need to have the appropriate training and experience to become proficient in performing this surgery. Robotic surgery does not have the same tactile feedback that surgeons typically rely on in performing procedures. In addition, in TORS, complex anatomy needs to be re-learned from the inside-out, since the surgeon is now operating from inside the mouth instead of outside from the neck.

What is your rate of complications, particularly bleeding?

TORS has been shown to be very safe in expert hands, with a low rate of postoperative bleeding of 2-4 percent.

What is your average length of stay for TORS patients?

Studies have demonstrated that for high-volume TORS practices, patients on average leave the hospital two days following surgery.

Do you work closely with a swallowing therapist?

Whether the treatment is radiation with chemotherapy or surgery, the best post-treatment swallowing outcomes are seen when patients are followed closely with a seasoned speech-language pathologist.

What are your research efforts with TORS?

Across the country, investigators are actively recruiting patients in clinical trials that are using TORS as a platform for de-intensifying their cancer treatment. Mount Sinai was one of the early adopters of TORS and continues research activities related to the reduction of complications. We are leading efforts in de-intensification with the SIRS 2.0 trial, which relies on a novel blood test evaluating circulating tumor DNA (ctDNA). If HPV ctDNA becomes undetectable after surgery, patients are either observed without additional treatment or receive a highly de-intensified regimen of chemotherapy and radiation.

What is your protocol for follow-up care?

Nearly 100 percent of distant metastases for classic head and neck cancers related to smoking occur within the first two years of treatment. However, for HPV-related throat cancers, recent studies have suggested that distant metastases can occur even five years following treatment. Patients with this disease require long-term close follow-up. Mount Sinai has been a pioneer in the use of ctDNA for follow-up care. This highly accurate test can allow for earlier detection and treatment if the cancer recurs.

Should I get a second opinion?

The answer should always be ‘yes.’ Patients need to be able to fully explore their options and to familiarize themselves with centers that have the most experience with all treatment options for this disease, whether that be TORS or non-surgical therapy.

Learn More about the Head and Neck Institute/Center of Excellence for Head and Neck Cancers

Do I Need a Biopsy or Surgery for My Thyroid Nodule?

Updated on Jun 30, 2022 | Head and Neck, Your Health

Thyroid nodules are very common. These masses within the thyroid gland are composed of tissue and/or fluid and are estimated to be present in more than 50 percent of those aged 50 and older. Nodules can run in families, are more common in women, and increase in frequency with age.

Patients diagnosed with a thyroid nodule often ask if their nodule needs to be biopsied or surgically removed. Sometimes the answer is yes, but often the answer depends on a number of patient and nodule-related factors. Catherine Sinclair, MD, FRACS, head and neck surgeon at Mount Sinai West, explains why your nodule may, or may not, need special attention.

How do you know if you need a biopsy?

More than 95 percent of thyroid nodules are non-cancerous, although a family history of thyroid cancer in a first-degree relative or whole-body/neck/chest radiation exposure may increase the risk. Nodules have a low cancer risk, so whether to biopsy depends on the size and ultrasound appearance of the mass.

Over the past decade, many nodules smaller than one centimeter have been incidentally detected on imaging (CT, MRI) that was ordered for another reason. Often these nodules were inappropriately biopsied, and, if the biopsy was positive for thyroid cancer, overly extensive total thyroid surgery was performed. Recent data from Japan and the United States suggests that appropriately selected thyroid cancers can remain stable over time. Termed “microcarcinomas,” these cancers are less than one centimeter in size and may be adequately managed without surgery or with limited thyroid surgery.

How is risk measured?

In an effort to reduce “incidentally diagnosed” microcarcinomas, the American Thyroid Association (ATA) Guidelines for Thyroid Nodules and Differentiated Thyroid Cancer classifies nodules into risk categories for biopsy based on thyroid nodule size and ultrasound appearance. Those classified as high-risk nodules should be biopsied when more than one centimeter in size, whereas low-risk nodules—depending on their appearance on ultrasound—should not be biopsied until they are one and a half to two centimeters in size. Many thyroid surgeons perform their own ultrasounds and use the ATA risk classification system (along with any biopsy results) to determine who should have a biopsy, which nodules should be operated on, and which nodules can be safely observed.

What are the symptoms and treatment for thyroid nodules?

In addition to posing a cancer risk, nodules may also need to be removed if they grow very large (greater than four centimeters) and cause symptoms like difficulty swallowing, neck discomfort, hoarseness of the voice, and airway compression with shortness of breath. Frequently, a thyroid lobectomy—the removal of a portion of the thyroid gland—may be adequate treatment for a non-cancerous thyroid nodule as well as for small cancerous nodules that are less than four centimeters. However, patients should speak with their surgeon in detail beforehand about the many additional factors affecting surgery, such as the status of the other thyroid lobe, your age, and your personal preferences.

In summary, a thyroid nodule may require an operation if there is a high risk of the nodule being cancerous or if the non-cancerous nodule is large and causing symptoms.

Non-cancerous nodules that are asymptomatic should be observed with intermittent ultrasound follow-up when appropriate. If surgery is necessary, the least aggressive option that will effectively treat the nodule should be chosen.

Thyroid Cancer Pathology Reports

Sep 23, 2016 | Head and Neck, Health Tips, Your Health

Guest post by Mark Urken, MD, Chief of Mount Sinai Beth Israel’s Division of Head and Neck Oncology. To make an appointment with Dr. Urken, call 212-844-8775.

Thyroid cancer is the most common endocrine cancer and it is one of the few cancers that has increased in incidence over recent years. Thyroid cancer occurs across all age groups, but is more common among people ages 20 to 55 and occurs more frequently in women. Before treatment begins, it is important to make sure your disease has been diagnosed accurately to ensure that the treatment options offered are right for the specific disease. (more…)

Thyroid Cancer: It’s Not Simply a Pain in the Neck

Sep 20, 2016 | Cancer, Head and Neck, Health Tips, Your Health

Guest blog written by Deena Adimoolam, MD, Assistant Professor, Department of Medicine, Division of Endocrinology, Diabetes and Bone Disease

The thyroid is a butterfly-shaped gland with two sides that sits in front of your windpipe and when it is functioning normally you don’t even know it exists. The main hormone it secretes is thyroxine, which helps to regulate metabolism, growth and development, as well as body temperature. The thyroid gland should not be mistaken for the parathyroid glands, which are completely different entities with separate functions. (more…)

Low-Risk Thyroid Cancer: Surveillance or Surgery?

Nov 18, 2015 | Cancer, Head and Neck

Guest post by Ilya Likhterov, MD, Assistant Professor of Otolaryngology – Head and Neck Surgery and member of the Division of Head and Neck Oncology at Mount Sinai Beth Israel. To make an appointment with Dr. Likhterov, call 212-844-8775.

Thyroid cancer diagnosis is becoming more and more common among patients of all ages, but in the vast majority of cases, thyroid cancer is slow growing and rarely causes symptoms while it is small. Although there is potential for thyroid cancer to spread to the lymph nodes in the neck, overall prognosis is excellent even in the high risk, advanced stages of disease. (more…)

Thyroid Nodules and Genetic Testing

Updated on Jun 30, 2022 | Cancer, Head and Neck, Women's Health

Guest post by Marita Teng, MD, Associate Professor, Otolaryngology-Head and Neck Surgery and member of the Head and Neck Institute and Center for Thyroid and Parathyroid Diseases at The Mount Sinai Hospital.

Thyroid nodules are exceedingly common, especially in women. By age 50, up to 70 percent of women have one or more thyroid nodules, but the vast majority of these are noncancerous. In fact, of all thyroid nodules, up to 95 percent are ultimately characterized as benign.

However, largely because of the increased use of radiologic imaging, the incidence of thyroid nodules – and the incidence of thyroid cancer – is increasing. Though this statistic may seem alarming, thyroid cancer is by far one of the most curable cancers. (more…)