11
Treatment must
be to gross nodal
disease, neck regions
at-risk of containing
microscopic disease
and the anatomic
mucosal regions at-risk
of harboring the occult
primary
b
Definitive
chemoradiotherapy
Bilateral adenopathy
Large volume neck disease
Gross (macroscopic) ENE
Multidisciplinary discussion
Concurrent cisplatin should
be offered to patients
without contraindications to
cisplatin chemotherapy
• Suspected mucosal primary
HPV/p16-negative squamous
cell carcinoma in the
presence of unresected AJCC
8th N2-N3 nodal disease
• Suspected mucosal primary
HPV/p16-negative squamous
cell carcinoma in the
presence of unresected
multiple ipsilateral or bilateral
lymph node involvement or
lymph nodes >3cm in size
• Suspected mucosal primary
squamous cell carcinoma and
pathologic evidence of ENE
• EBER-positive Stage II-IVA
(AJCC 8th) carcinoma of
unknown primary
Patients treated with
primary radiotherapy
for unilateral
involvement of
multiple nodes
and no clinical and
radiologic evidence of
ENE should routinely
receive bilateral
treatment
Patients treated with
primary radiotherapy for
unilateral involvement of a
single node and no clinical
and radiologic evidence of
EN may consider treatment
only to the unilateral
involved neck (with the
exception of those at risk of
a nasopharyngeal primary)
Patients treated with
primary radiotherapy
for N3 and/or bilateral
nodal involvement
and/or clinical and/or
radiologic evidence of
ENE require bilateral
neck treatment
Radiotherapy must be to
the gross node(s) and with
consideration of coverage
of putative primary sites in
the ipsilateral tonsillar bed,
ipsilateral soft palate, and
the mucosa of the entire
base of tongue, which
may be modified based on
prior surgical diagnostics
at the discretion of the
radiation oncologist.
c,d
Bilateral
treatment
of the
oropharyngeal
mucosa
Unilateral
(AJCC 8th N1)
HPV-related
adenopathy
Unilateral (AJCC
8th N1-N2b)
HPV-negative
nodal disease
Bilateral
(AJCC 8th
N1-N2c)
adenopathy