Radiotherapy

• Before embarking upon radical radiotherapy, consider smoking cessation support.

• In accordance with national guidelines, all patients with head and neck squamous cell carcinoma (HNSCC) being treated with curative intent are classified as category 1. In making decisions on the management of treatment delays and gaps consider accordingly and in line with Royal College of Radiologists (RCR) guidance. 

• Consider magnetic resonance imaging (MRI) fusion/planning scan where beneficial for tumour/flap and/or organs at risk (OAR) voluming and optimal planning.

• Consider the use of intravenous contrast with computed tomography (CT) and MRI planning scans for all patients with the exception of early-stage larynx cancers and those with contra-indications to contrast. 

• Planning and target volumes should be defined as per national and international guidance, while also considering likely benefit versus morbidity. 

• Radical primary and adjuvant radiation therapy (RT) target volumes should be peer reviewed. Exception can be 55Gy/20# larynx-only volumes. 

• In line with national guidance, consider referral to the UK proton service in selected cases.  

• Offer primary radical RT or chemoradiotherapy as definitive treatment in suitable patients.  

• Consider bulk of disease and likely chance of eradication with radiotherapy as well as likely acute and late morbidity.  

• Consider adjuvant RT for HNSCC commencing within 7 weeks of definitive surgical resection.

• Consider confirming the need for post-operative treatment in the MDT meeting following definitive pathology reporting.  

• Offer RT with concurrent chemotherapy (CRT) in the presence of highest risk features (extra nodal extension and/or positive resection margins) in eligible patients.

• Consider adjuvant RT for other adverse features (close margins, pT3/4, node positive, non-cohesive invasive front, perineural/lymphatic or vascular invasion, poorly differentiated) weighing up benefit versus morbidity.

Primary RT

• Assess existing and likely long-term laryngeal function outcomes with RT - surgery may be preferable if existing/high risk of functional impairment or significant tumour bulk.

Primary RT

• Primary surgery is the recommended definitive treatment for all resectable oral cavity SCC. Consider primary RT only if the patient is not suitable for surgery or has declined this. Counsel patients that primary RT is likely to be less effective with higher morbidity and mortality than surgery.  

Adjuvant RT

• For suitable patients, in the absence of a contralateral neck dissection for negative pathological staging, offer contralateral elective neck radiotherapy if any of the following apply: 
  • T3/4 tumours 
  • Primary ≤10mm from midline 
  • 2 or more involved nodes in ipsilateral neck  
  • ECS in ipsilateral neck 

• Consider adjuvant RT if there is a single node with no ECS involved on ipsilateral side weighing up the benefits and morbidity with the patient. 

Primary RT

• Consider bilateral neck treatment for tumours involving base of tongue, posterior pharyngeal wall or soft palate.

• Offer ipsilateral treatment for lateralised tumours (>10mm from midline and not involving base of tongue, posterior pharyngeal wall and <10mm into soft palate) with ≤1 ipsilateral nodes. Consider in above primaries with >1 ipsilateral node involved.

Adjuvant RT

• For suitable patients, in the absence of a contralateral neck dissection for negative pathological staging, offer contralateral elective neck radiotherapy for tumours involving base of tongue, posterior pharyngeal wall and soft palate. 

Primary RT

• Consider bilateral neck treatment for tumours involving base of tongue, posterior pharyngeal wall or soft palate.

• Offer ipsilateral treatment for lateralised tumours (>10mm from midline and not involving base of tongue, posterior pharyngeal wall and <10mm into soft palate) with ≤1 ipsilateral nodes. Consider in above primaries with >1 ipsilateral node involved.

Adjuvant RT

• For suitable patients, in the absence of a contralateral neck dissection for negative pathological staging, offer contralateral elective neck radiotherapy for tumours involving base of tongue, posterior pharyngeal wall and soft palate. 

Primary RT

• Offer radical radiotherapy or chemoradiotherapy as the recommended definitive treatment for non-metastatic nasopharyngeal carcinoma.

• Aim to start radiotherapy treatment within 21-28 days of last cycle of induction chemotherapy.   

• Consider radical radiotherapy/chemoradiotherapy in patients with low volume metastatic disease following stable/partial response from palliative chemotherapy. 

Primary RT

• Consider radical radiotherapy or chemoradiotherapy as a definitive treatment option for non-resectable, non-metastatic sinonasal carcinoma. 

• For patients with locally advanced SCC and sinonasal undifferentiated carcinoma (SNUC) consider elective neck irradiation including the retropharyngeal nodes and levels I-IV. 

Adjuvant RT

• Consider adjuvant RT in all cases of adenoid cystic or SNUC. 

• Consider in all other cases with exception of early stage with favourable pathology.   

Primary RT

• Consider in patients with unresectable disease or in those who have declined resection. Surgery has better disease control and survival outcomes and is preferred first modality of treatment where possible. 

Adjuvant RT

• Consider adjuvant RT in all high-grade tumours or with high risk features (e.g nodal metastasis, T3/4, involved margins, PNI/LVI). 

• Consider adjuvant RT in all adenoid cystic. 

• Consider adjuvant RT in recurrent or high-risk, low-grade tumours. 

Primary RT

• Make the decision between primary chemo radiotherapy/radiotherapy versus primary surgery by weighing up and taking into consideration age, fitness, bulk of disease, HPV status, benefit and likelihood of disease control and morbidity, particularly when multi-modality treatment is likely.

• Make the decision between involved neck only versus targeted mucosal coverage vs total mucosal irradiation by weighing up the benefit versus acute/late morbidity. Involved neck only radiotherapy is a valid strategy with evidence supporting this approach in patients investigated with modern diagnostic techniques including fluorodeoxyglucose (FDG)-positron emission tomography (PET)-computed tomography (CT) (FDG PET-CT). 

• Consider an EQD2 dose of 50Gy or equivalent if mucosal irradiation is being utilised e.g.
  • 54Gy in 30 fractions
  • 56Gy in 33 fractions 
  • 56-57Gy in 35 fractions   

Adjuvant RT

• Make the decision between involved neck only versus targeted mucosal coverage vs total mucosal irradiation by weighing up the benefit versus acute/late morbidity. Involved neck only radiotherapy is a valid strategy with evidence supporting this approach in patients investigated with modern diagnostic techniques including FDG PET-CT.

• Consider an EQD2 dose of 50Gy or equivalent is recommended if mucosal irradiation is being utilised e.g.
  • 54Gy in 30 fractions
  • 56Gy in 33 fractions 
  • 56-57Gy in 35 fractions   

• Offer essential accurate image guided radiotherapy (IGRT) due to steep dose gradients, proximity of target volumes to organs at risk (OARs) and international adoption of 5+5 voluming technique.

• Offer volumetric imaging verification, which is superior to 2D orthogonal imaging at detecting shifts and rotational errors, in order to detect shifts in target volumes that may not correlate with fixed bony anatomy. 

• Consider managing replans as per category 1 tumour RCR guidance.  

• Consider reirradiation in selected cases, depending on stage, late toxicity, original radiation treatment, time interval from previous RT and likely benefit/morbidity as per RCR guidance.

• Consider palliative RT for symptomatic or local control, evaluating likely benefit vs morbidity.