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Case history

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Image not available. A 60-year-old man presented with a sensation of a lump on the left side of the throat and ipsilateral otalgia. He was otherwise fit and well, a non-smoker and teetotaller, with an Eastern Cooperative Oncology Group performance status of 0. Clinical examination revealed a mass based within the left tonsil and palpable lymph nodes on the left side of the neck. Staging imaging confirmed asymmetric left tonsillar enlargement, with two pathologically enlarged nodes at levels II and III (Figure 15.1), but with no evidence of distant metastatic disease.

On the basis of clinical and radiological features, the patient was staged as having a T2N2bM0 left tonsil tumour. He underwent pan-endoscopy and biopsy under general anaesthetic, which confirmed non-keratinizing, moderately differentiated squamous cell carcinoma. There was intense p16 immunoreactivity on immunohistochemistry; in situ hybridization (ISH) for high-risk human papillomavirus (HPV) DNA was positive. On the basis of combined p16/ISH analysis, the tumour was defined as HPV-positive.

The case was discussed in the head and neck multidisciplinary team setting. The patient was eligible for, and consented to, enrolment in the Postoperative Adjuvant Treatment for HPV-Positive Tumours (PATHOS) trial, prior to undergoing transoral laser resection of the left-sided tonsillar tumour and concurrent left-sided selective (levels I-IV) neck dissection. Pathological staging was pT2N2b. The tumour was macroscopically completely excised, albeit with microscopically involved margins (<1 mm; negative marginal biopsies). Two metastatic nodes were identified, both in level IIa, with no evidence of extracapsular spread.

The patient was stratified to the high-risk group and randomized to receive adjuvant chemoradiotherapy (60 Gy in 30 fractions with cisplatin 100 mg/m2 on days 1 and 22). He completed treatment as per protocol; however, the chemoradiation induced severe (grade 3) mucositis, causing decreased oral intake, weight loss and severe pain requiring admission to the hospital for over a week for symptom control.

What other treatment options would have been available for this patient, and what is the evidence guiding choice of treatment?

What are the potential long-term toxicities of his treatment?

How does HPV affect prognosis?

How does HPV status influence choice of therapy?

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Figure 15.1

Representative T2 axial MRI images showing (A) left tonsillar asymmetry and (B) level II lymph node with evidence of cystic degeneration.

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What other treatment options would have been available for this patient, and what is the evidence guiding choice of treatment?

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The management of locally advanced oropharyngeal squamous cell carcinoma (OPSCC) typically involves multimodality therapy. Two principal approaches can be applied: either primary surgery followed by radiotherapy/chemoradiotherapy, depending on postoperative pathology, or primary chemoradiation with salvage surgery if required. In addition, radiotherapy may be combined with cetuximab instead of chemotherapy as primary treatment. Whilst the patient in this example was treated using surgery as part of the PATHOS trial protocol, primary chemoradiation would have been a feasible (and commonly employed) alternative. There is, to date, no randomized evidence proving the superiority of one strategy over the other, and ...

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