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    Management of the Neck in Squamous Cell Carcinoma of the Oral Cavity and Oropharynx (beta)

    Based on guidelines from the American Society of Clinical Oncology.

    Strength
    Strong recommendation
    Moderate recommendation
    Weak recommendation
    Evidence
    High quality evidence
    Intermediate quality evidence
    Low quality evidence
    Insufficient evidence

    SCC of Oral Cavity (SCCOC)

    Neck Dissection
    1. For patients with SCCOC classified as cT2 to cT4, cN0—that is, no clinical nor radiographic evidence of metastatic spread to the neck—and treated with curative-intent surgery, an ipsilateral elective neck dissection should be performed.
    2. For patients with SCCOC classified as cT1, cN0, an ipsilateral elective neck dissection should be performed. Alternatively, for selected highly reliable patients with cT1, cN0, close surveillance may be offered by a surgeon in conjunction with specialized neck ultrasound surveillance techniques.
    3. For patients with a cN0 neck, an ipsilateral elective neck dissection should include nodal levels, Ia, Ib, II, and III. An adequate dissection should include at least 18 lymph nodes.
    4. An ipsilateral therapeutic selective neck dissection for a clinically node-positive neck should include nodal levels Ia, Ib, IIa, IIb, III, and IV. An adequate dissection should include at least 18 lymph nodes. Dissection of level V may be offered in patients with multistation disease.
    5. In patients with a clinically node-positive contralateral neck, contralateral neck dissection should be performed. In patients with a cN0 contralateral neck, an elective contralateral neck dissection may be offered in patients with a tumor of the oral tongue and/or floor of the mouth that is T3/4 or approaches midline.
    Adjuvant Neck Radiotherapy
    1. Adjuvant neck radiotherapy should not be administered to patients with pathologically node-negative or a single pathologically positive node without extranodal extension after high-quality neck dissection, unless there are indications from the primary tumor characteristics, such as perineural invasion, lymphovascular space invasion, or a T3/4 primary.
    2. Adjuvant neck radiotherapy should be administered to patients with oral cavity cancer and a single pathologically positive node who did not undergo high-quality neck dissection.
    3. Adjuvant neck radiotherapy should be administered to patients with oral cavity cancer and pathologic N2 or N3 disease.
    Adjuvant Chemoradiotherapy
    1. Adjuvant chemoradiotherapy using intravenous bolus cisplatin 100 mg/m2 every 3 weeks should be offered to patients with oral cavity cancer and extranodal extension in any positive node, regardless of the extent of extranodal extension and the number or size of involved nodes, and no contraindications to high-dose cisplatin.
    2. Concurrent weekly cisplatin may be administered with postoperative radiotherapy to patients who are considered inappropriate for standard high-dose intermittent cisplatin after a careful discussion of patient preferences and the limited evidence that supports this treatment schedule.
    Neck Dissection vs Radiotherapy
    1. Elective neck dissection is the preferred approach for patients with oral cavity cancer who require management of the clinically negative neck. Elective radiotherapy to a nondissected neck—50 to 56 Gy in 25 to 30 fractions—may be efficacious and should be administered if surgery is not feasible.
    2. For patients who have undergone ipsilateral neck dissection only and are at substantial risk of contralateral nodal involvement—for example, tumor of the oral tongue and/or floor of the mouth that is T3/4 or approaches midline—contralateral neck radiotherapy should be administered to treat potential microscopic disease.

    SCC of Oropharynx (SCCOP)

    Neck Dissection
    1. Patients with lateralized oropharyngeal carcinoma who are being treated with upfront curative surgery should undergo an ipsilateral neck dissection of levels II to IV. An adequate dissection should include at least 18 lymph nodes.
    2. Patients with lateralized oropharyngeal cancer who undergo neck dissection concurrently or before transoral endoscopic head and neck surgery should have ligation of at-risk feeding blood vessels to reduce the severity and incidence of postoperative bleeding.
    3. Patients with tumors that extend to the midline tongue base or palate or that involve the posterior oropharyngeal wall should have bilateral neck dissections performed unless bilateral adjuvant radiotherapy is planned. The multidisciplinary team should discuss with patients the potential functional impact of bilateral neck dissection and postoperative adjuvant radiation therapy with or without chemotherapy.
    Surgical vs Nonsurgical Approach
    1. A nonsurgical approach should be offered to patients with clinically node-positive disease who have either unequivocal extranodal extension into surrounding soft tissues or carotid artery or cranial nerve involvement.
    2. Patients with biopsy-proven distant metastases should not undergo routine surgical resection of metastatic cervical lymph nodes.
    Neck Dissection Post-radiotherapy/chemoradiotherapy
    1. If PET/CT scan at 12 or more weeks after completion of radiation/chemoradiation shows intense fluorodeoxyglucose uptake in any node, the patient should undergo neck dissection if feasible. If PET/CT shows no nodal fluorodeoxyglucose uptake and the patient has no abnormally enlarged lymph nodes, the patient should not have neck dissection.
    2. Patients who complete radiation/chemoradiation and receive anatomic cross-sectional imaging—CT or magnetic resonance imaging scans—at 12 or more weeks post-therapy that shows resolution of previously abnormal lymph nodes should not undergo neck dissection.
    3. If PET/CT scan at 12 or more weeks shows mild fluorodexoyglucose uptake in a node of 1 cm or less or a persistently enlarged node of 1 cm or more without either mild or intense fluorodexoyglucose uptake, that patient may be observed closely with serial cross-sectional imaging or PET/CT, with neck dissection reserved for clinical or radiographic concern for progressive disease.
    What do the icons mean?  
    Research PaperKoyfman SA, Ismaila N, Crook D, et al. Management of the Neck in Squamous Cell Carcinoma of the Oral Cavity and Oropharynx: ASCO Clinical Practice Guideline. J Clin Oncol. 2019;15(5):273-278.