10
Systemic Therapy
Figure 2. Diagnosis & Management Algorithm of SCCUP
in the Head and Neck (cont'd)
Patients with multiple
pathologically
involved nodes and/or
pathologic eveidence
of ENE
a
Additional nodal basins should be considered
for dissection depending on the extent of nodal
burden.
b
Specific volumes treated will depend on the
clinicopathologic presentation of the patient aer
complete work-up.
c
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 now risk
of an occult contralateral tonsillar primary.
d
Patients presenting with bilateral (AJCC 8th N2)
adenopathy and CUP require bilateral treatment of
the oropharyngeal mucosa.
e
Nodal volumes in this scenario should be typical for
nasopharygeal management and include bilateral
levels II-V including retropharyngeal nodes.
Unilateral small volume
neck disease
Multidisciplinary discussion
Definitive
surgery
Levels IIA,
III and IV
should be
routinely
dissected
a
Patients with a
single pathologically
positive node
without ENE after
high-quality neck
dissection and no
primary tumor
identified
Adjuvant
radiotherapy ±
chemotherapy
Observation
• Equivalent of 60 Gy to the node levels that
harbored gross resected disease, and 50
Gy to regions beyond this thought to be at
risk of microscopic residual disease.
• Nodal regions from which nodes were
determined to have pathologic ENE
may be considered for higher doses of
adjuvant radiation, the equivalent of 60-
66 Gy. May be considered for adjuvant
concurrent hemotherapy.
Dose
• 70 Gy over 7 weeks to
gross nodal disease
• Approximately 50
Gy in 2 Gy fractions
or slightly higher to
mucosal regions at-risk
of harboring the occult
primary site
• 40-50 Gy in 2 Gy
fractions electively
to clinically and
radiographically
negative nodal regions
at risk for microscopic
spread of tumor
Dose
Radiation of
mucosal sites
should be
avoided in clinical
scenarios highly
suggestive of an
occult cutaneous
primary SCC
Mucosal radiation
treatment may
be limited to the
nasopharynx in
clinicopathologic
presentation
highly suggestive
of an occult
nasopharyngeal
primary
e
Clinical scenarios
Definitive
radiotherapy
