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REVIEW ARTICLE
Year : 2020  |  Volume : 57  |  Issue : 5  |  Page : 12-15
 

Indian clinical practice consensus guidelines for the management of oropharyngeal cancer


1 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India
3 Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
4 Department of Surgical Oncology, Cochin Cancer Research Centre, Cochin, Kerala, India
5 Department of Oral Medicine and Radiology, KLE Society's Institute of Dental Sciences (KLESIDS), Bangalore, Karnataka, India
6 Department of Radiation Oncology, Max Super Speciality Hospital, Saket, New Delhi, India
7 Department of Medical Oncology, HCG Cancer Centre, Ahmedabad, Gujarat, India
8 Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
9 Department of Radiation Oncology, Civil Hospital, Shillong, Meghalaya, India
10 Department of Medical Oncology, Indraprastha Apollo Hospital, New Delhi, India
11 Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, India
12 Department of Radiation Oncology, Sri Shankara Cancer Hospital and Research Centre, Bangalore, Karnataka, India
13 Department of Medical Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, India
14 Department of Radiotherapy, Christian Medical College, Vellore, Tamil Nadu, India
15 Department of Surgical Oncology, Max Super Speciality Hospital, Saket, New Delhi, India
16 Department of Surgical Oncology, HCG Cancer Centre, Bangalore, Karnataka, India
17 Department of Radiation Oncology, Shri Mata Vaishno Devi Narayana Superspeciality Hospital, Jammu, Jammu and Kashmir, India
18 Department of Radiation Oncology, National Cancer Institute, All India Institute of Medical Sciences, Delhi, India

Date of Submission25-Jul-2019
Date of Decision13-Nov-2019
Date of Acceptance29-Dec-2019
Date of Web Publication25-Feb-2020

Correspondence Address:
Kumar Prabhash
Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.278976

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How to cite this article:
Prabhash K, Babu G, Chaturvedi P, Kuriakose M, Birur P, Anand AK, Kaushal A, Mahajan A, Syiemlieh J, Singhal M, Gairola M, Ramachandra P, Goyal S, John S, Nayyar R, Patil VM, Rao V, Roshan V, Rath G K. Indian clinical practice consensus guidelines for the management of oropharyngeal cancer. Indian J Cancer 2020;57, Suppl S1:12-5

How to cite this URL:
Prabhash K, Babu G, Chaturvedi P, Kuriakose M, Birur P, Anand AK, Kaushal A, Mahajan A, Syiemlieh J, Singhal M, Gairola M, Ramachandra P, Goyal S, John S, Nayyar R, Patil VM, Rao V, Roshan V, Rath G K. Indian clinical practice consensus guidelines for the management of oropharyngeal cancer. Indian J Cancer [serial online] 2020 [cited 2022 Dec 5];57, Suppl S1:12-5. Available from: https://www.indianjcancer.com/text.asp?2020/57/5/12/278976





 » Diagnosis Workflow for Evaluation of Clinical Stages Top


Human papillomavirus (HPV) is associated with oropharyngeal squamous cell carcinoma (SCC) and p16 staining is used to predict the HPV status and prognosis. It has been demonstrated that patients with p16 expression have a better outcome and longer disease-specific survival than p16-negative patients.[1],[2],[3] However, with few exceptions, management of HPV-positive and HPV-negative oropharyngeal cancer remains similar. HPV testing by p16 immunohistochemistry (IHC) is mostly preferred; however, polymerase chain reaction-based assays or in-situ hybridization can also be used for diagnosis of p16 expression. HPV testing is recommended for testing (1) newly diagnosed oropharyngeal SCC, nontobacco users (males/females), patients with high-risk sexual behavior, early T-stage with advanced N-stage, cystic nodal metastasis on radiological imaging, nonkeratinizing or basaloid SCC, and carcinoma unknown primary with neck nodes. HPV testing is done either from the primary tumor or from cervical nodal metastases, using p16 IHC with a 70% nuclear and cytoplasmic staining cutoff, and (2) not to be routinely tested for nonsquamous oropharyngeal carcinomas or nonoropharyngeal carcinomas (evidence level [EL] 4; Grade A).[3],[4] Routine examination includes history and physical examination (with complete head and neck exam, mirror and fiberoptic examination), biopsy of primary site or fine-needle aspiration of the neck, pre-anesthesia studies, and examination under anesthesia with endoscopy, if indicated. Computed tomography and/or magnetic resonance imaging (with contrast) of primary and neck, chest CT (with or without contrast) or fluorodeoxyglucose -positron emission tomography/computed tomography (FDG-PET/CT) for stage III–IV disease, if indicated, should be performed.[5] Dental evaluation, including panorex and nutrition, speech and swallowing evaluation/therapy only for selected at-risk patients (if indicated) should be performed. Pure tone audiometry may be performed prior to administering cisplatin (EL 2 and EL 4; Grade A).[6]


 » Treatment of Oropharyngeal Cancer Top


The aim of the treatment of oropharyngeal cancer should be to treat the disease and also to preserve speech and swallowing functions. The choice of treatment should be decided by the multidisciplinary team.

Early stage oropharyngeal cancer (T1–2, N0–1)

Surgery

Early stage disease is generally treated using single modality. The patients with p16-negative (T1–2, N0)/positive (T1–2, N0–1) HPV status should be treated with transoral or open resection of the primary—with or without ipsilateral/bilateral neck dissection. Postsurgery in the case of adverse features, adjuvant chemotherapy and radiotherapy (CT/RT) or radiotherapy (RT) is recommended. Particularly, in cases with positive margins, re-resection is the preferred choice; however, alternative options are CT/RT or RT.[6],[7],[8]

Definitive RT

Selected patients, who are medically inoperable or refuse surgery, should be given a definitive RT, an alternative option for surgery. High-risk patients (EL 1; Grade A) may be treated with three alternative options: (i) conventional fractionation (66 Gy [2.2 Gy/fraction] to 70 Gy [2.0 Gy/fraction]; daily, Monday–Friday in 6–7 weeks), (ii) concomitant boost accelerated RT (72 Gy/6 weeks [1.8 Gy/fraction, large field; 1.5 Gy boost as second daily fraction during last 12 treatment days] or 66–70 Gy [2.0 Gy/fraction]; 6 fractions/week accelerated), or (iii) hyperfractionation (81.6 Gy/7 weeks [1.2 Gy/fraction, twice daily]), while low-to-intermediate risk (IIB) patients can be given 44–50 Gy (2.0 Gy/fraction) to 54–63 Gy (1.6–1.8 Gy/fraction) of radiation.[9]

Concurrent CT/RT

Patients with p16-negative (T1–2, N1 only)/positive (T2 only) HPV status should be treated with concurrent CT/RT (EL 1; Grade A).[10]

Locally advanced oropharyngeal cancer (T3–4a, N0–1; any T, N2–3)

Concurrent CT/RT

For patients with locally advanced disease, chemoradiation should be considered instead of radiation alone.[11],[12] Several studies with different schedules of cisplatin have confirmed that the concurrent chemoradiation is superior to radiation alone.[13],[14] A recent study in locally advanced head and neck carcinomas showed that concurrent chemoradiotherapy (CTRT) was significantly better in locoregional control than RT and accelerated RT.[15]

The concurrent CTRT regimens for patients with p16-negative/positive disease (T3–4a, N0–1; any T, N2–3) include three-weekly cisplatin (100 mg/m2), nimotuzumab + weekly cisplatin (30 or 40 mg/m2)[16],[17],[18],[19],[20] (EL 1; Grade A), HPV-negative oropharyngeal tumors nimouzumab + weekly cisplatin (30 mg/m2)[16],[21] (EL 1; Grade A), weekly cisplatin (30 or 40 mg/m2), cisplatin + paclitaxel, carboplatin + infusional 5-FU, or weekly cisplatin (30 or 40 mg/m2).[15],[16] However, patients unsuitable for cisplatin should be treated with weekly cetuximab, weekly nimotuzumab, carboplatin + infusional 5-FU, 5-FU + hydroxyurea, or carboplatin + paclitaxel.

The RT schedule for high-risk patients includes treatment with 70 Gy (2.0 Gy/fraction) and for low-to-intermediate risk patients, 44–50 Gy (2.0 Gy/fraction) to 54–63 Gy (1.6–1.8 Gy/fraction) (EL 1; Grade A) of radiation doses.

Surgery

Patients with locally advanced disease can be treated with the transoral or open resection of primary + ipsilateral/bilateral neck dissection ± adjuvant CTRT/adjuvant RT.

Adjuvant treatment: Choice of adjuvant treatment should be based on the presence of adverse features postsurgery/neck dissection.[15] Among patients with extranodal extension and/or positive margin, CTRT is recommended, and in patients with other risk factors, RT or CTRT is recommended. Postoperative RT is recommended only for p16-negative T3–4a, N0–1 patients who do not have adverse features.

Induction CT

In unresectable locally advanced disease, use of sequential induction chemotherapy (TPF [docetaxel, cisplatin, fluorouracil]) followed by locoregional treatment with RT or CT/RT can be considered.[22],[23],[24],[25]

Cisplatin-based induction CT regimen is as follows:

  • Docetaxel 75 mg/m2 on day 1 + cisplatin 75 mg/m2 on day 1 + 5-FU 750 mg/m2/day for 5 days every 3 weeks for three cycles
  • Paclitaxel 175 mg/m2 on day 1 + cisplatin 100 mg/m2 on day 2 + 5-FU 500–750 mg/m2/day from day 2 to day 6 every 3 weeks for three cycles
  • Cisplatin 100 mg/m2 on day 1 + 5-FU 1000 mg/m2/day for 4 days every 3 weeks for three cycles.


Algorithm for management of oropharyngeal cancer is given in [Figure 1]. Appendix 1 gives the summary of clinical evidences in oropharyngeal cancer.
Figure 1: Algorithm for management of oropharyngeal cancer

Click here to view


Acknowledgement

We acknowledge the significant contribution of J Balawardana, C Vithanage, S Resnayaka from Sri Lanka during the meeting and S Ghosh Laskar, S Ranjan, P Chavan, R Halkud and C Ramachandra for their involvement and insights. We also acknowledge the medical writing support provided by an independent medical writing agency, IQVIA. We are fully responsible for the content of this manuscript and the recommendations described in the review reflect the views and opinions of the authors only.

Financial Support and Sponsorship

Oral Cancer Task Force (OCTF) with a multidisciplinary expert panel, has a long standing commitment to work for early detection and management of oral cancer in underserved populations. The task force members have taken this educational initiative of developing India specific consensus guidelines for management of head and neck cancer under its ambit. The meeting and supplement were supported by an unrestricted grant by Biocon Foundation.

Conflicts of interest

Oral Cancer Task Force (OCTF) members and authors do not have any conflicts of interest.

 
 » References Top

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Sedghizadeh PP, Billington WD, Paxton D, Ebeed R, Mahabady S, Clark GT, et al. Is p16-positive oropharyngeal squamous cell carcinoma associated with favorable prognosis? A systematic review and meta-analysis. Oral Oncol 2016;54:15-27.  Back to cited text no. 1
    
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Barasch S, Mohindra P, Hennrick K, Hartig GK, Harari PM, Yang DT. Assessing p16 status of oropharyngeal squamous cell carcinoma by combined assessment of the number of cells stained and the confluence of p16 staining: A validation by clinical outcomes. Am J Surg Pathol 2016;40:1261-9.  Back to cited text no. 2
    
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    Figures

  [Figure 1]

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