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Oropharyngeal cancer

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Updated 2024 ASTRO guidelines for radiotherapy in HPV-positive oropharyngeal squamous cell carcinoma.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of oropharyngeal cancer are prepared by our editorial team based on guidelines from the American Society for Radiation Oncology (ASTRO 2024), the American Society of Clinical Oncology (ASCO 2023,2019,2018), the European Society for Radiotherapy and Oncology (ESTRO/EHNS/ESMO 2020), the American College of Radiology (ACR 2019), the American Academy of Otolaryngology-Head and ...
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Classification and risk stratification

Staging: as per EHNS/ESMO/ESTRO 2020 guidelines, use the UICC TNM system for staging.
⁄
TNM classification for p16-positive oropharyngeal cancer
Tumor classification
Tx: Primary tumor cannot be assessed
T0: No evidence of primary tumor
T1: Tumor ≤ 2 cm in greatest dimension
T2: Tumor > 2 cm but ≤ 4 cm in greatest dimension
T3: Tumor > 4 cm in greatest dimension or extension to the lingual surface of epiglottis
T4: Tumor invading larynx, extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible or beyond; mucosal extension to the lingual surface of epiglottis from primary tumors of the base of tongue; vallecula does not constitute an invasion of larynx
Lymph node classification
Nx: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Metastasis in ≤ 4 lymph nodes
N2: Metastasis in > 4 lymph nodes
Metastasis classification
M0: No distant metastasis
M1: Distant metastasis present
Stage cannot be fully assessed
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Diagnostic investigations

History and physical examination: as per EHNS/ESMO/ESTRO 2020 guidelines, obtain a clinical assessment in patients with suspected OPC.
B
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  • Diagnostic imaging

Diagnostic procedures

Fine-needle aspiration
As per AAO-HNSF 2017 guidelines:
Perform FNA instead of open biopsy in patients with a neck mass of uncertain diagnosis deemed at increased risk for malignancy.
B
Continue evaluating patients with a cystic neck mass, as determined by FNA or imaging, until a diagnosis is obtained instead of assuming that the mass is benign.
B
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  • Tumor biopsy

  • Immunohistochemistry and mutational testing

  • HPV testing

Medical management

General principles: as per EHNS/ESMO/ESTRO 2020 guidelines, manage patients with OPC at high-volume facilities.
B
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  • Management of locoregional disease (adjuvant chemoradiotherapy)

  • Management of locoregional disease (definitive radiotherapy)

  • Management of advanced/metastatic disease (adjuvant radiotherapy)

  • Management of advanced/metastatic disease (definitive systemic therapy)

  • Management of recurrent disease

Therapeutic procedures

Technical considerations for radiotherapy, modality: as per ASTRO 2024 guidelines, use intensity-modulated radiotherapy over 3D conformal radiation therapy in patients with HPV-positive oropharyngeal SCC receiving definitive or postoperative radiotherapy.
A
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  • Technical considerations for radiotherapy (treatment volumes)

  • Technical considerations for radiotherapy (dosing, adjuvant therapy)

  • Technical considerations for radiotherapy (dosing, definitive therapy)

  • Technical considerations for radiotherapy (dosing, adjustments)

  • Technical considerations for radiotherapy (radiosensitizer)

Surgical interventions

Indications for neck dissection, primary surgery: as per ASCO 2019 guidelines, perform an ipsilateral elective neck dissection in patients with stage cT2-cT4, cN0 oropharyngeal SCC (no clinical or radiographic evidence of metastatic spread to the neck) treated with curative-intent surgery.
A
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  • Indications for neck dissection (post-treatment surgery)

Specific circumstances

Patients with tonsillar cancer
As per ASTRO 2024 guidelines:
Offer unilateral radiotherapy in patients with HPV-positive T1-2 palatine tonsil oropharyngeal SCC confined to the tonsillar fossa and either no positive nodes or a single positive node ≤ 3 cm without extranodal extension treated with definitive or postoperative radiotherapy.
B
Consider offering unilateral radiotherapy for the disease involving minimal soft palate and/or a single positive node > 3 cm but ≤ 6 cm or multiple positive nodes, without evidence of extranodal extension in all nodes in patients with HPV-positive T1-2 palatine tonsil oropharyngeal SCC without base of tongue involvement treated with definitive or postoperative radiotherapy.
C
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Follow-up and surveillance

Clinical follow-up: as per ACS 2016 guidelines, educate and counsel all head and neck cancer survivors about the signs and symptoms of local recurrence.
B
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  • Endoscopic follow-up

  • Imaging follow-up

  • Survivorship and rehabilitation (lifestyle modifications)

  • Survivorship and rehabilitation (neuromuscular complications)

  • Survivorship and rehabilitation (neurosensory complications)

  • Survivorship and rehabilitation (speech disturbance)

  • Survivorship and rehabilitation (oral and dental care)

  • Survivorship and rehabilitation (gastroesophageal complications)

  • Survivorship and rehabilitation (thyroid dysfunction)

  • Survivorship and rehabilitation (lymphedema)

  • Survivorship and rehabilitation (fatigue)

  • Survivorship and rehabilitation (sleep disorders)

  • Survivorship and rehabilitation (psychosocial distress)