Head & neck: Postoperative indications for concurrent chemoRT — high-risk features

Why D is correct

She has both features for which postoperative concurrent chemoradiotherapy is indicated: a positive surgical margin and extracapsular (extranodal) extension. In the pooled EORTC 22931/RTOG 9501 analysis these were the risk factors for which the effect of chemoradiotherapy was significant in both trials, and the EHNS-ESMO-ESTRO guideline indicates postoperative concurrent chemoradiotherapy for them. She is fit, with good renal function, so the appropriate treatment is postoperative radiotherapy with concurrent high-dose cisplatin (100 mg/m2 on days 1, 22 and 43).

And why the others are not

• AWrong — the randomised evidence and guideline indication for adding concurrent systemic therapy to postoperative radiotherapy for these features is cisplatin (100 mg/m2 on days 1, 22 and 43), and she is fit for it.
• BWrong — a positive margin and extracapsular extension are indications for postoperative concurrent chemoradiotherapy; surveillance leaves them untreated.
• CWrong — with a positive margin and extracapsular extension, adding concurrent cisplatin to postoperative radiotherapy improves outcome in patients fit for chemotherapy, as she is.
• EWrong — extracapsular extension is itself an indication for concurrent cisplatin (positive margins and/or extracapsular extension), so clearing the margin would not make radiotherapy alone adequate.

Source RTOG 9501 long-term follow-up and EORTC 22931/RTOG 9501 pooled analysis — postoperative chemoradiotherapy in high-risk head and neck cancer — Cooper JS, Zhang Q, Pajak TF, et al. Int J Radiat Oncol Biol Phys 2012 (RTOG 9501 long-term); Bernier J, Cooper JS, Pajak TF, et al. Head Neck 2005;27(10):843-850, PMID 16161069.