Adjuvant therapy for lower-risk patients: Concurrent chemoradiation should not be routinely used in intermediate-risk disease. Adjuvant RT is strongly recommended for post-operative OPSCC patients at significant risk of locoregional recurrence but only conditionally recommended in scenarios (e.g. pathologic N1 disease, perineural invasion, lymphovascular invasion) with a more uncertain risk of locoregional failure. Adjuvant radiotherapy may be delivered to patients without conventional adverse pathologic risk factors only if the clinical and surgical findings imply a particularly significant risk of locoregional recurrence.
The guideline also outlines optimal dosing and fractionation schedules based on treatment approach, disease profile and risk of recurrence. Recommendations by treatment setting are as follows:
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Definitive RT: Patients with stage III-IV OPSCC should receive a cumulative dose of 70 Gray (Gy) delivered to the primary tumor site and positive nodes in 2-Gy daily fractions over seven weeks, as well as an equivalent dose of 50 Gy delivered in 2-Gy daily fractions to the surrounding region at risk for tumor spread. For stage IV A-B patients not receiving concurrent systemic therapy, altered fractionation schedules (either accelerated or hyperfractionated) are recommended. For Stage IV A-B patients undergoing concurrent CRT, either standard or accelerated fractionation may be implemented. Altered fractionation also should be used for patients with T3 N0-1 disease not receiving concurrent chemoradiation, and it may be used for patients with T1-2 N1 or T2 N0 disease at high risk for recurrence.
Post-surgical/Adjuvant RT: Post-operative OPSCC patients at high risk for recurrence (e.g., those with positive surgical margins) should receive a total dose of 60 to 66 Gy delivered to the positive margins and region of extranodal extension in 2-Gy daily fractions. High-risk patients not undergoing concurrent systemic therapy should receive the upper limit of this range, while the 60-Gy total dose is recommended for patients with negative margins following surgery.
Early T-stage tonsillar carcinoma: Ipsilateral RT, which involves treating only one side of the oropharyngeal area, is strongly recommended for the subset of OPSCC patients with early-stage tonsillar cancer, specifically well-lateralized T1-2 N0-1 tumors. It is conditionally recommended for patients with lateralized T1-2 N0-2a disease without evidence of extra-capsular extension.
