4
Surgical Considerations
➤ 3.1: For unilateral, small-volume neck disease, either definitive
surgery or radiation therapy may be offered after multidisciplinary
discussion. (Moderate recommendation; EB-B-I)
➤ 3.2: For small-volume bilateral neck disease with no clinical evidence
of extranodal extension, either definitive surgery (with or without
adjuvant therapy) or radiation therapy (with or without concurrent
chemotherapy) may be offered after multidisciplinary discussion.
(Moderate recommendation; EB-B-I)
➤ 3.3: Large-volume bilateral neck disease, and/or gross (macroscopic)
extranodal extension (ENE) favor definitive chemoradiation therapy
given the possible increased morbidity of extensive bilateral neck
dissection and increased likelihood of trimodality therapy in such
cases. (Moderate recommendation; EB-B-I)
➤ 3.4: When primary surgery is planned, Levels IIA, III and IV should
be routinely dissected in cases where an oropharyngeal primary is
suspected or confirmed for SCCUP. Additional nodal basins should be
considered for dissection depending on the extent of nodal burden.
(Strong recommendation; EB-B-I)
Radiotherapy
➤ 4.1: Patients receiving radiotherapy or concurrent chemoradiotherapy
as primary management of CUP should receive treatment to gross
nodal disease, neck regions at-risk of containing microscopic
disease and the anatomic mucosal regions at-risk of harboring
the occult primary. Specific volumes treated will depend on the
clinicopathologic presentation of the patient after complete work-up
as outlined in recommendations 1 and 2. (Strong recommendation;
EB-B-I)
➤ 4.2: Patients treated with primary radiotherapy for unilateral (American
Joint Committee on Cancer [AJCC] 8th N1) HPV-related adenopathy
and CUP should receive treatment 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
(see Recommendation 2.2) at the discretion of the radiation oncologist.
(Moderate recommendation; EB-B-I)
Note: Consideration may be given to including additional areas in the oropharynx in
patients for whom a PET scan was not available or who did not undergo a contralateral
tonsillectomy because of the low risk of an occult contralateral tonsillar primary. Patients
presenting with bilateral (AJCC 8th N2) adenopathy and CUP require bilateral
treatment of the oropharyngeal mucosa.
