Head & neck: Postoperative indications for concurrent chemoRT

Why A is correct

He has features for which the UK guideline advises postoperative radiotherapy (pathological T3 and node-positive disease) but neither feature for which UK and EHNS-ESMO-ESTRO guidance add concurrent chemotherapy: an involved resection margin (≤1 mm) or extranodal extension. Postoperative radiotherapy alone is therefore the appropriate adjuvant treatment. This selection derives from the pooled EORTC 22931/RTOG 9501 analysis (Bernier 2005), in which extracapsular extension and/or microscopically involved margins were the only risk factors with a significant chemoradiotherapy effect in both trials, and patients with two or more involved nodes without extracapsular extension as their only risk factor did not seem to benefit. The authors stated the usual caveats of a retrospective subgroup analysis and reported a trend favouring chemoradiotherapy with other adverse features, so the rule is a guideline selection criterion rather than proof that chemotherapy cannot benefit anyone else.

And why the others are not

• BWrong — UK guidance offers concurrent chemotherapy with postoperative radiotherapy for involved margins (≤1 mm) and/or extranodal extension; he has neither, and two or more nodes without extracapsular extension did not seem to benefit from added cisplatin in the pooled analysis.
• CWrong — concurrent systemic therapy is not indicated without an involved margin or extranodal extension; where it is indicated the postoperative agent is cisplatin, and the UK guideline notes that later studies found cetuximab inferior to cisplatin.
• DWrong — the UK guideline advises considering postoperative radiotherapy for pathologically staged T3/4 tumours and node-positive disease; surveillance would leave him undertreated.
• EWrong — concurrent systemic therapy is not indicated without an involved margin or extranodal extension, and the randomised postoperative evidence (EORTC 22931/RTOG 9501) is for cisplatin, not carboplatin.

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.