Oropharynx SCC (p16/HPV+): Definitive Treatment

Oropharynx SCC (p16/HPV+): Definitive Treatment: overview

This algorithm outlines definitive treatment of p16/HPV positive oropharyngeal squamous cell carcinoma, starting from stage. Early disease (T0 to T2, N0 to N1 with a single node of 3 cm or smaller) is treated with resection plus selective neck dissection or with definitive radiotherapy, and enrollment in a clinical trial is also shown. Locally advanced disease (T1 to T2 N2 to N3, or T3 to T4 with any N) is treated with definitive concurrent cisplatin-based chemoradiation, or with transoral robotic surgery (TORS) plus neck dissection with or without adjuvant therapy.

After surgery, adjuvant treatment is chosen by pathologic risk. Patients with no adverse features are observed. Extranodal extension, with or without a positive margin, is treated with cisplatin chemoradiation or radiotherapy, an approach grounded in RTOG 9501, which showed improved locoregional control and disease-free survival with postoperative cisplatin plus radiotherapy in high-risk resected head and neck cancer. A positive margin is managed with re-resection or chemoradiation, and other risk features with radiotherapy or chemoradiation. For selected intermediate-risk patients, the chart shows de-escalation of adjuvant radiotherapy to 50 Gy based on ECOG 3311.

Step by step

• Early disease (T0 to T2, N0 to N1, single node 3 cm or smaller): resection plus selective neck dissection, definitive radiotherapy, or a clinical trial.
• Locally advanced disease (T1 to T2 N2 to N3, or T3 to T4 any N): definitive concurrent chemoradiation with cisplatin, or TORS plus neck dissection with or without adjuvant therapy.
• After surgery with no adverse features: observation.
• Extranodal extension with or without a positive margin: cisplatin chemoradiation or radiotherapy (RTOG 9501).
• Positive margin: re-resection or chemoradiation; other risk features: radiotherapy or chemoradiation.
• Selected intermediate-risk disease: de-escalated adjuvant radiotherapy to 50 Gy (ECOG 3311).

Trials behind this algorithm

• MACH-NC mena-analysis Lacas B et al, J of Radiother Oncol, 2021, PMID: 33515668
• RTOG 9501 Cooper JS et al, N Engl J Med, 2004; PMID: 15128893