Management of the Neck in Squamous Cell Carcinoma of the Oral Cavity and Oropharynx

For patients with oral cavity SCC classified as cT2-cT4, cN0 (i.e. no clinical nor radiographic evidence of metastatic spread to the neck) and treated with curative-intent surgery, an ipsilateral elective neck dissection should be performed. ( EB , H , B , S )

For patients with oral cavity SCC classified as cT1, cN0, an ipsilateral elective neck dissection should be performed. Alternatively, for selected highly reliable patients with cT1, cN0, close surveillance may be offered by a surgeon in conjunction with specialized neck ultrasound surveillance techniques. ( EB , H , B , M )

For patients with a cN0 neck, an ipsilateral elective neck dissection should include nodal levels, Ia, Ib, II, and III. An adequate dissection should include at least 18 lymph nodes. ( EB , H , B , S )

In patients with a cN+ contralateral neck, a contralateral neck dissection should be performed. In patients with a cN0 contralateral neck, an elective contralateral neck dissection may be offered in patients with a tumor of the oral tongue and/or floor of mouth that is T3/4, or approaches midline. ( EB , H , H , M )

An ipsilateral therapeutic selective neck dissection for a clinically node-positive (cN+) neck should include nodal levels Ia, Ib, IIa, IIb, III and IV. An adequate dissection should include at least 18 lymph nodes. Dissection of level V may be offered in patients with multi-station disease. ( EB , H , H , M )

Adjuvant neck radiotherapy should NOT be administered to patients with pathologically node negative (pN0) or a single pathologically positive node (pN1) without extranodal extension after a high-quality neck dissection, unless there are indications from the primary tumor characteristics, such as perineural invasion, lymphovascular space invasion, or a T3/4 primary. ( EB , H , H , M )

Adjuvant neck radiotherapy should be administered to patients with oral cavity cancer and pN1 who did not undergo a high-quality neck dissection (as defined in recommendation 1.2b). ( EB , H , H , M )

Adjuvant neck radiotherapy should be administered to patients with oral cavity cancer and pathologic N2 or N3 disease. ( EB , H , B , M )

Adjuvant chemoradiotherapy using intravenous bolus cisplatin (100mg/m² every 3 weeks) should be offered to patients with oral cavity cancer and extranodal extension in any positive node, regardless of the extent of the extranodal extension and number or size of involved nodes, and no contraindications to high-dose cisplatin. ( EB , H , B , S )

Concurrent weekly cisplatin may be administered with postoperative RT to patients who are considered inappropriate for standard high-dose intermittent cisplatin after a careful discussion of patient preferences and the limited evidence supporting this treatment schedule. ( EB , H , H , M )

Elective neck dissection is the preferred approach for patients with oral cavity cancer who require management of the clinically negative neck as outlined above. Elective radiotherapy to a non-dissected neck (50-56 Gy in 25-30 fractions) may be efficacious and should be administered if surgery is not feasible. ( EB , H , H , M )

For patients who have undergone ipsilateral neck dissection only and are at substantial risk of contralateral nodal involvement (e.g. tumor of the oral tongue and/or floor of mouth that is T3/4 or approaches midline), contralateral neck radiotherapy should be administered to treat potential microscopic disease. ( EB , H , H , M )