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

Publication Date: February 27, 2019
Last Updated: December 15, 2022

Treatment

Oral Cavity

For patients with oral cavity SCC classified as cT2-cT4, cN0 (i.e. 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. (EB, H, B, S)
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For patients with oral cavity SCC 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. (EB, H, B, M)
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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. (EB, H, B, S)
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In patients with a cN+ contralateral neck, a 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 mouth that is T3/4, or approaches midline. (EB, H, H, M)
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An ipsilateral therapeutic selective neck dissection for a clinically node-positive (cN+) 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 multi-station disease. (EB, H, H, M)
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Adjuvant neck radiotherapy should NOT be administered to patients with pathologically node negative (pN0) or a single pathologically positive node (pN1) without extranodal extension after a 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. (EB, H, H, M)
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Adjuvant neck radiotherapy should be administered to patients with oral cavity cancer and pN1 who did not undergo a high-quality neck dissection (as defined in recommendation 1.2b). (EB, H, H, M)
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Adjuvant neck radiotherapy should be administered to patients with oral cavity cancer and pathologic N2 or N3 disease. (EB, H, B, M)
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Adjuvant chemoradiotherapy using intravenous bolus cisplatin (100mg/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 the extranodal extension and number or size of involved nodes, and no contraindications to high-dose cisplatin. (EB, H, B, S)
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Concurrent weekly cisplatin may be administered with postoperative RT to patients who are considered inappropriate for standard high-dose intermittent cisplatin after a careful discussion of patient preferences and the limited evidence supporting this treatment schedule. (EB, H, H, M)
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Elective neck dissection is the preferred approach for patients with oral cavity cancer who require management of the clinically negative neck as outlined above. Elective radiotherapy to a non-dissected neck (50-56 Gy in 25-30 fractions) may be efficacious and should be administered if surgery is not feasible. (EB, H, H, M)
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For patients who have undergone ipsilateral neck dissection only and are at substantial risk of contralateral nodal involvement (e.g. tumor of the oral tongue and/or floor of mouth that is T3/4 or approaches midline), contralateral neck radiotherapy should be administered to treat potential microscopic disease. (EB, H, H, M)
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Oropharynx

Patients with lateralized oropharyngeal carcinoma who are being treated with upfront curative surgery should undergo an ipsilateral neck dissection of levels II-IV. An adequate dissection should include at least 18 lymph nodes. (EB, H, H, M)
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Patients with lateralized oropharyngeal cancer who have 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 post-operative bleeding. (EB, H, H, W)
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Patients with tumors extending to the midline tongue-base or palate or involving 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 post-operative adjuvant radiation therapy with or without chemotherapy. (EB, H, H, M)
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A non-surgical approach should be offered to patients with cN+ disease who have either unequivocal extranodal extension into surrounding soft tissues or carotid artery or cranial nerve involvement. (EB, H, H, M)
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Patients with biopsy-proven distant metastases should not undergo routine surgical resection of metastatic cervical lymph nodes. (EB, H, B, M)
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If PET/CT scan at ≥12 weeks after completion of radiation/chemoradiation shows intense FDG uptake in any node, the patient should have a neck dissection if feasible. If PET/CT shows no nodal FDG uptake, and the patient has no abnormally enlarged lymph nodes, the patient should not have neck dissection. (EB, H, B, S)
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Patients who complete radiation/chemoradiation and have anatomic cross-sectional imaging (CT or MRI scans) at ≥12 weeks post therapy showing resolution of previously abnormal lymph nodes should not have neck dissection. (EB, H, B, M)
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If PET/CT scan at ≥12 weeks shows mild FDG uptake in a node ≤1 cm or a persistently enlarged node ≥1 cm without either mild or intense FDG uptake, that patient may be followed closely with serial cross-sectional imaging or PET/CT, with neck dissection reserved for clinical or radiographic concern for progressive disease. (EB, H, H, M)
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Recommendation Grading

Overview

Title

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

Authoring Organization

American Society of Clinical Oncology

Publication Month/Year

February 27, 2019

Last Updated Month/Year

November 11, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The aim of the current work is to provide evidence-based recommendations to practicing physicians and others on the management of the neck in patients with squamous cell carcinoma of the oral cavity and oropharynx.

Target Patient Population

Patients with SCCOC or SCCOP with nodal metastases or who are at risk for nodal metastases.

Target Provider Population

Medical oncologists, radiation oncologists, surgeons, nurses, speech pathologists, oncology pharmacists, and patients

PICO Questions

  1. What are the indications for and the hallmarks of a high-quality neck dissection in oral cavity squamous cell carcinoma (SCCOC)?

  2. Under what circumstances should a dissected neck receive adjuvant radiotherapy or chemoradiotherapy in patients with SCCOC?

  3. Is neck radiotherapy to an undissected clinically node-negative (cN0) neck an adequate replacement for high-quality elective neck dissection in SCCOC?

  4. What are the hallmarks of a high-quality neck dissection in oropharynx squamous cell carcinoma (SCCOP)?

  5. For patients with SCCOP, what features of clinical/radiographic nodal involvement would sway management away from surgery in favor of a nonoperative approach?

  6. Under what circumstances should a patient with SCCOP undergo a neck dissection after definitive radiotherapy or chemoradiotherapy?

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient, Radiology services

Intended Users

Nurse, nurse practitioner, health systems pharmacist, physician, physician assistant, radiology technologist, speech language pathologist

Scope

Treatment, Management

Diseases/Conditions (MeSH)

D002294 - Carcinoma, Squamous Cell, D000077195 - Squamous Cell Carcinoma of Head and Neck

Keywords

head and neck squamous cell carcinoma (HNSCC), squamous cell carcinoma, oropharynx, oral cavity, SCCOC, SCCOP, nodal metastases

Source Citation

DOI: 10.1200/JCO.18.01921 Journal of Clinical Oncology 37, no. 20 (July 10, 2019) 1753-1774.

Supplemental Methodology Resources

Data Supplement, Methodology Supplement