Advanced Soft Palate Cancer: The Clinical Importance of the Parapharyngeal Space Wade G. Douglas, MD, a Nestor R. Rigual, MD, a William Giese, MD, b Joseph Bauer, PhD, c Sam M. Wiseman, MD, a Thom R. Loree, MD, a James Schwarz, MD, d Sadir Alrawi, MD, a Wesley L. Hicks, Jr, MD a a From the Department of Head and Neck, Plastics and Reconstructive Surgery; b Department of Radiation Oncology; c Department of Cancer Prevention and Population Sciences; and d Department of Medical Oncology, Roswell Park Cancer Institute. OBJECTIVE: To identify the incidence of parapharyngeal space (PPS) recurrences and how they impact survival in advanced-stage soft-palate carcinoma patients. STUDY DESIGN AND SETTING: One hundred thirty-seven patients’ charts were reviewed from 1971 to 1996. Inclusion cri- teria were patients who received a per-oral resection, discontinu- ous neck dissection, and postoperative adjuvant radiation therapy; 15 patients met criteria for inclusion. The incidence of PPS recur- rences, regional failure, and survival were endpoints that were analyzed. RESULTS: There were no local failures in our study. Regional failures excluding the PPS (levels I-V) were 27%, and 40% oc- curred within the PPS. Cervical adenopathy was associated with 83% of the PPS recurrences. Median survival for PPS recurrences was 26 months, compared with 67 months for levels I-V recur- rences (n = ns). CONCLUSIONS: The incidence of PPS recurrences is substan- tial in advanced-stage soft-palate cancer. PPS recurrences nega- tively impact survival; without effective salvage techniques for these recurrences or effective adjuvant therapy, poor patient out- comes can be expected. © 2005 American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. All rights reserved. O ropharyngeal cancer has a worldwide incidence of 8.3 cases per 100,000. 1,2 In the United States, there are 4800 new cases of oropharyngeal squamous cell carcinoma (SCCA) per year. 1 These malignancies are often asymptom- atic and hence can present at an advanced stage. The soft palate, a subsite of the oral-pharynx, represents 5% to 12% of all oropharyngeal carcinomas. 1 Squamous cell cancer is the most common malignancy of the soft palate with the majority of the lesions developing on its oral surface. Epi- demiologically, these tumors are associated with tobacco and alcohol use. The parapharyngeal space (PPS) extends from the skull base to the hyoid bone and is bound medially by the fascia surrounding the pharyngeal constrictors and laterally by the ramus of the mandible, the medial pterygoid muscle, and the deep lobe of the parotid gland. 3 It is filled with loose connec- tive tissue, lymphatic channels, lymph nodes, and the contents of the carotid sheath. The PPS is clinically divided into pre- and poststyloid compartments; the lymphatics of the soft palate travel through the prestyloid portion of the PPS. 3 Resectable advanced-stage (III/IVa) SCCA of the soft palate are composed of primaries larger than 5 cm without nodal disease (T3N0M0) or of small primaries with large (6 cm) multiple or bilateral nodal metastasis (T1N2M0). Survival is impacted by regional failure and distant metas- tasis. 2 Despite combined-modality therapy with surgery and radiation therapy, the survival for stage III and IVa disease at 5 years is 33%-47%. 2,4-7 This study was performed to determine the incidence of Reprint requests: Wesley L. Hicks, Jr, MD, Department of Head and Neck Surgery, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo NY 14263. E-mail address: wesley.hicks@roswellpark.org. Otolaryngology–Head and Neck Surgery (2005) 133, 66-69 0194-5998/$30.00 © 2005 American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. All rights reserved. doi:10.1016/j.otohns.2005.03.007