Radiation Therapy For Oropharyngeal Squamous Cell Carcinoma

Publication Date: August 1, 2017
Last Updated: March 14, 2022

Recommendations

When is it appropriate to add systemic therapy to definitive RT in the treatment of OPSCC?

In the scenario of stage IVA-B disease?

Concurrent high-dose intermittent cisplatin should be delivered to patients with stage IVA-B OPSCC receiving definitive RT. (Strong, High)
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Concurrent cetuximab or carboplatin-fluorouracil should be delivered to patients with stage IVA-B OPSCC receiving definitive RT who are not medically fit for high-dose cisplatin. (Strong, High)
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Concurrent weekly cisplatin may be delivered to patients with stage IVA-B OPSCC receiving definitive RT who are not medically fit for high-dose cisplatin, after a careful discussion of patient preferences and the limited prospective data supporting this regimen. (Conditional, Low)
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Concurrent cetuximab should not be delivered in combination with chemotherapy to patients with stage IVA-B OPSCC receiving definitive RT. (Strong, High)
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Intra-arterial chemotherapy should not be delivered to patients with stage IVA-B OPSCC receiving definitive RT. (Strong, High)
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In the scenario of stage III disease?

Concurrent systemic therapy should be delivered to patients with T3 N0-1 OPSCC receiving definitive RT. (Strong, Moderate)
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After a careful discussion of patient preferences and the limited evidence supporting its use, concurrent systemic therapy may be delivered to patients with T1-T2 N1 OPSCC receiving definitive RT who are considered at particularly significant risk for locoregional recurrence. (Conditional, Low)
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In the scenario of stage I-II disease?

Concurrent systemic therapy should not be delivered to patients with stage I-II OPSCC receiving definitive RT. (Strong, Low)
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When is it appropriate to deliver postoperative RT with and without systemic therapy following primary surgery of OPSCC?

In the scenario of positive margins and/or extracapsular nodal extension (ECE)?

Concurrent high-dose intermittent cisplatin should be delivered with postoperative RT to patients with positive surgical margins (PSMs) and/or extracapsular nodal extension; this high-risk population includes patients independent of HPV status or the extent of extranodal tumor. (Strong, Moderate)
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Concurrent weekly cisplatin may be delivered 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. (Conditional, Low)
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For the high-risk postoperative patient unable to receive cisplatin-based concurrent chemoradiation therapy, RT alone should be routinely delivered without concurrent systemic therapy; given the limited evidence supporting alternative regimens, treatment with non-cisplatin systemic therapy should be accompanied by a careful discussion of the risks and unknown benefits of the combination. (Strong, Moderate)
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Patients treated with postoperative RT should not receive concurrent weekly carboplatin. (Strong, Moderate)
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Patients treated with postoperative RT should not receive cetuximab, either alone or in combination with chemotherapy, although such regimens are currently under investigation. (Strong, Low)
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Patients treated with postoperative RT should not routinely receive concurrent weekly docetaxel given the limited evidence supporting its use, although such regimens are currently under investigation. (Strong, Low)
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Patients treated with postoperative RT should not receive concurrent mitomycin-C, alone or with bleomycin, given the limited evidence and experience supporting its use. (Strong, Moderate)
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Postoperative chemotherapy should not be delivered alone or sequentially with postoperative RT. (Strong, High)
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In the scenario of intermediate-risk pathologic factors such as lymphovascular invasion (LVI), perineural invasion (PNI), T3-4 disease, or positive lymph nodes?

Patients with intermediate-risk factors should not routinely receive concurrent systemic therapy with PORT. (Strong, Moderate)
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Patients with intermediate-risk factors whose surgical procedure and/or pathologic findings imply a particularly significant risk of locoregional recurrence may receive concurrent cisplatin-based chemotherapy after a careful discussion of patient preferences and the limited evidence supporting its use in this scenario; alternative systemic treatment regimens should only be used in the context of a clinical trial. (Conditional, Low)
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PORT should be delivered to patients with pathologic T3 or T4 disease. (Strong, Low)
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PORT should be delivered to patients with pathologic N2 or N3 disease. (Strong, Low)
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PORT may be delivered to patients with pathologic N1 disease after a careful discussion of patient preferences and the limited evidence of outcomes following surgery alone in this scenario. (Conditional, Low)
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PORT may be delivered to patients with LVI and/or PNI as the only risk factor(s), after a careful discussion of patient preferences and the limited evidence of outcomes following surgery alone in this scenario. (Conditional, Low)
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In the scenario of no pathologic risk factors?

PORT may be delivered to patients without conventional adverse pathologic risk factors only if the clinical and surgical findings imply a particularly significant risk of locoregional recurrence, after a careful discussion of patient preferences and the potential harms and benefits of RT. (Conditional, Low)
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When is it appropriate to use induction chemotherapy (IC) in the treatment of OPSCC?

IC should not be routinely delivered to patients with OPSCC. (Strong, High)
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What are the appropriate dose, fractionation, and volume regimens with and without systemic therapy in the treatment of OPSCC?

In the scenario of definitive nonsurgical therapy?

A dose of 70 Gy over 7 weeks should be delivered to gross primary and nodal disease in patients with stage III-IV OPSCC selected to receive standard, once-daily definitive RT. (Strong, Moderate)
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The biologically equivalent dose of approximately 50 Gy in 2-Gy fractions or slightly higher should be delivered electively to clinically and radiographically negative regions at-risk for microscopic spread of tumor. (Strong, Low)
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Altered fractionation should be used in patients with stage IVA-B OPSCC treated with definitive RT who are not receiving concurrent systemic therapy. (Strong, High)
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Either accelerated RT or hyperfractionated RT may be used in patients with OPSCC treated with altered fractionation definitive RT after a careful discussion of patient preferences and the limited evidence supporting 1 regimen over the other. (Conditional, High)
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Either standard, once-daily RT or accelerated fractionation may be used when treating OPSCC with concurrent systemic therapy, after a careful discussion of patient preferences and the risks and benefits of both approaches. (Conditional, High)
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Altered fractionation should be used in patients with T3 N0-1 OPSCC treated with definitive RT who do not receive concurrent systemic therapy. (Strong, Moderate)
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Altered fractionation may be used in patients with T1-2 N1 or T2 N0 OPSCC treated with definitive RT alone who are considered at particularly significant risk of locoregional recurrence, after a careful discussion of patient preferences and the limited evidence supporting its use in this scenario. (Conditional, Low)
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In the scenario of adjuvant PORT?

Adjuvant PORT should be delivered to regions of microscopically positive primary site surgical margins and extracapsular nodal extension at 2 Gy/fraction once daily to a total dose between 60 and 66 Gy. (Strong, Moderate)
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Adjuvant PORT delivered without concurrent systemic therapy should treat regions of microscopically positive primary site surgical margins and extracapsular nodal extension at 2 Gy/fraction once daily to a total dose of 66 Gy, although there are limited data guiding this recommendation. (Conditional, Low)
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Adjuvant PORT should be delivered to the tumor bed, and involved, dissected lymph node regions at 2 Gy/fraction once daily to a total dose of at least 60 Gy in the absence of primary site positive margins and extracapsular nodal extension. (Strong, Moderate)
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In the scenario of early T-stage tonsillar carcinoma?

Unilateral RT should be delivered to patients with well-lateralized (confined to tonsillar fossa) T1-T2 tonsillar cancer and N0-N1 nodal category. (Strong, Moderate)
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Unilateral RT may be delivered to patients with lateralized (<1 cm of soft palate extension but without base of tongue involvement) T1-T2 N0-N2a tonsillar cancer without clinical or radiographic evidence of extracapsular extension, after careful discussion of patient preferences and the relative benefits of unilateral treatment versus the potential for contralateral nodal recurrence and subsequent salvage treatment. (Conditional, Low)
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Recommendation Grading

Overview

Title

Radiation Therapy For Oropharyngeal Squamous Cell Carcinoma

Authoring Organization

Publication Month/Year

August 1, 2017

Last Updated Month/Year

December 5, 2022

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

To present evidence-based guidelines for the treatment of oropharyngeal squamous cell carcinoma (OPSCC) with definitive or adjuvant radiation therapy (RT).

Target Patient Population

Patients with oropharyngeal squamous cell carcinoma

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient, Radiology services

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management, Treatment

Diseases/Conditions (MeSH)

D018787 - Radiation Oncology, D011827 - Radiation, D009959 - Oropharyngeal Neoplasms

Keywords

radiation therapy, Oropharyngeal Cancer, Adjuvant Radiation Therapy