ASCO Clinical Practice Guideline for Management of the Neck in SCC of the Oral Cavity and Orophyarynx

by Amy E. Hamaker •

Comment: This recent clinical practice guideline from ASCO provides recommendations and their supporting evidence for many of the important questions relating to management of the neck in oral and oropharyngeal squamous cell carcinomas. Most notably, with growing evidence that elective neck dissection improves disease-free and overall survival in patients with clinically node-negative oral cancers, the expert panel recommends neck dissection for all patients with clinically node-negative oral squamous cell carcinoma, with the option of close observation in conjunction with neck ultrasound only for “selected highly reliable patients with cT1” tumors. —Andres Bur, MD

What are evidence-based recommendations for the management of the neck in patients with squamous cell carcinoma (SCC) of the oral cavity and oropharynx?

Bottom Line: For oral cavity cancers, clinical scenarios focused on the indications for and the hallmarks of a high-quality neck dissection, indications for postoperative radiotherapy or chemoradiotherapy, and the question of whether radiotherapy alone is sufficient elective treatment of an undissected neck compared with high-quality neck dissection. For oropharynx cancers, clinical scenarios focused on hallmarks of a high-quality neck dissection, factors that would favor operative versus nonoperative primary management, and clarifying criteria for an incomplete response to definitive chemoradiation for which salvage neck dissection would be recommended (see Table 1, below).

Background: Head and neck cancer (HNC) remains a significant global public health problem, with more than 450,000 new diagnoses worldwide each year. For patients with HNC, the presence of cervical lymph node metastases is associated with diminished overall survival. As squamous cell carcinoma of oral cavity (SCCOC) and oropharynx (SCCOP) comprise the majority of these cancers, and effective management of neck disease improves disease-specific and overall survival, these clinical practice guidelines were developed to clarify the guiding principles of managing the neck for these patients

Methods: The American Society of Clinical Oncology convened an expert panel of medical oncology, surgery, radiation oncology, and advocacy experts to conduct a literature search, which included literature published from 1990 to 2018.

Summary: The literature search identified 124 relevant studies to inform the evidence base for this guideline. Six clinical
scenarios were devised—three for oral cavity cancer and three for oropharynx cancer—and recommendations were generated for each one.

Citation: Koyfman 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 (published online ahead of print February 27, 2019). J Clin Oncol. doi: 10.1200/JCO.18.01921.

Table 1

Oral Cavity

Recommendation 1.1a. For patients with SCCOC classified as cT2 to cT4, cN0 and treated with curative-intent surgery, an ipsilateral elective neck dissection should be performed.