5
➤ 4.3: Patients treated with primary radiotherapy for unilateral (AJCC
8th N1-N2b) HPV-negative nodal disease and SCCUP should receive
treatment as to the above (Recommendation 4.2). Patients presenting
with bilateral (AJCC 8th N2c) adenopathy and SCCUP should
receive bilateral treatment of the oropharyngeal mucosa. (Moderate
recommendation; EB-B-I)
➤ 4.4: In patients presenting with clinical scenarios highly suggestive of
an occult cutaneous primary SCC, radiation of mucosal sites should
be avoided. (Moderate recommendation; EB-B-I)
➤ 4.5: In patients with a clinicopathologic presentation highly
suggestive of an occult nasopharyngeal primary, the mucosal
radiation treatment may be limited to the nasopharynx. Nodal
volumes in this scenario should be typical for nasopharyngeal
management and include bilateral levels II-V including
retropharyngeal nodes. (Moderate recommendation; EB-B-I)
➤ 4.6: Patients treated with primary radiotherapy for unilateral
involvement of multiple nodes and no clinical and radiologic
evidence of ENE should routinely receive bilateral treatment. (Strong
recommendation; EB-B-I)
➤ 4.7: In addition to anatomic mucosal regions at risk, patients treated
with primary radiotherapy for unilateral involvement of a single
node and no clinical and radiologic evidence of ENE may consider
treatment only to the unilateral involved neck (with the exception of
those at risk of a nasopharyngeal primary [Recommendation 4.5]).
(Moderate recommendation; EB-B-I)
➤ 4.8: 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. (Strong recommendation; EB-B-I)
➤ 4.9: For patients treated with primary radiotherapy, a biologically
equivalent dose of 70 Gy over 7 weeks should be delivered to gross
nodal disease. The biologically equivalent dose of approximately 50
Gy in 2 Gy fractions or slightly higher should be delivered to mucosal
regions at risk of harboring the occult primary site, and a biologically
equivalent dose of 40-50 Gy in 2 Gy fractions electively to clinically
and radiographically negative nodal regions at risk for microscopic
spread of tumor. (Moderate recommendation; EB-B-I)
➤ 4.10: Patients receiving radiotherapy or concurrent
chemoradiotherapy adjuvant to surgical management of carcinoma
of unknown primary (CUP) should receive treatment to regions of
the neck and mucosa at-risk of containing microscopic disease.
The need for treatment should be determined by the extent of the
surgery performed and pathologic results of the surgery. (Strong
recommendation; EB-B-I)
Radiotherapy
