Chemotherapy Only For High-risk Features

Abstract

A 50-year-old never smoker presented with p16+ squamous cell carcinoma, confined to the tonsil with 2 avid lymph nodes in the ipsilateral neck, both less than 3 cm. With these pretreatment findings, an initial approach with surgery was almost assured of requiring adjuvant radiation therapy. Two recently published phase 2 randomized trials of surgery or radiation therapy1Nichols AC Theurer J Prisman E et al.Radiotherapy versus transoral robotic surgery and neck dissection for oropharyngeal squamous cell carcinoma (ORATOR): An open-label, phase 2, randomised trial.Lancet Oncol. 2019; 20: 1349-1359Abstract Full Text Full Text PDF PubMed Scopus (204) Google Scholar,2Palma DA Prisman E Berthelet E et al.Assessment of toxic effects and survival in treatment deescalation with radiotherapy vs transoral surgery for HPV-associated oropharyngeal squamous cell carcinoma: The ORATOR2 phase 2 randomized clinical trial.JAMA Oncol. 2022; 8: 1-7Crossref Scopus (13) Google Scholar in such patients suggest definitive radiation therapy and concurrent systemic therapy may have lower overall morbidity, and this would have been our recommended initial approach. Although on Eastern Cooperative Oncology Group (ECOG) 3311 the patient would have been assigned to the adjuvant radiation therapy and concurrent cisplatin arm postoperatively,3Ferris RL Flamand Y Weinstein GS et al.Phase II randomized trial of transoral surgery and low-dose intensity modulated radiation therapy in resectable p16+ locally advanced oropharynx cancer: An ECOG-ACRIN Cancer Research Group trial (E3311).J Clin Oncol. 2022; 40: 138-149Crossref PubMed Scopus (43) Google Scholar a recent secondary analysis of NRG/Radiation Therapy Oncology Group (RTOG) 9501/0234 and European Organization for Research and Treatment of Cancer (EORTC) 22391 did not find a cutoff on positive lymph nodes where concurrent systemic therapy demonstrated a significantly improved outcome.4Lu DJ Luu M Gay C et al.Nodal metastasis count and oncologic outcomes in head and neck cancer: A secondary analysis of NRG/RTOG 9501, NRG/RTOG 0234, and EORTC 22931.Int J Radiat Oncol Biol Phys. 2022; 113: 787-795Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Therefore, we would recommend adjuvant radiation therapy without concurrent chemotherapy given the lack of high-risk features of extranodal extension or a positive margin. With a small T1 tonsillar primary tumor that did not involve the tongue base or soft palate, it may be reasonable to avoid contralateral neck radiation. However, for patients not evaluated by a radiation oncologist pretreatment, caution should be exercised with this approach. Although it may be reasonable to spare the postoperative tonsillar bed in the absence of intermediate-risk features, only low-level evidence supports this approach. We would prescribe 60 Gy at 2 Gy per fraction to the tonsillar bed and involved ipsilateral lymph node levels II and III and 54 Gy at 1.8 Gy per fraction to the elective neck levels IV, V, and VIIb using a simultaneous integrated boost technique. Low Risk, High Risk: Adjuvant Therapy in Resected p16+ Oropharyngeal Cancer with ≥5 Positive Ipsilateral Lymph NodesInternational Journal of Radiation Oncology, Biology, PhysicsVol. 114Issue 1PreviewA 50-year-old, previously healthy man presented with a 2-month history of an enlarging left neck mass and odynophagia. He is a never smoker. Physical examination revealed a mobile 2.5 cm left level 2 cervical lymph node. Fine needle aspiration of the node was positive for p16+ squamous cell carcinoma. Positron emission tomographic computed tomography demonstrated at least 2 avid left level 2 cervical lymph nodes with no obvious primary lesion and no distant metastatic disease (Fig 1). Quadroscopy revealed an abnormal lesion in the left palatine tonsil and biopsy was positive for p16+ squamous cell carcinoma. Full-Text PDF