What is the appropriate management for a patient with Opc (unknown medical condition or treatment)?

Management of Oropharyngeal Squamous Cell Carcinoma (OPC)

All patients with newly diagnosed OPC must be evaluated by a multidisciplinary team that includes a head and neck surgeon, radiation oncologist, medical oncologist, dentist, speech-language pathologist, dietitian, physical therapist, social worker, and pain/palliative care specialists before any treatment decisions are made. 1

Initial Diagnostic Workup

Tissue Diagnosis and Molecular Testing

• Perform tissue biopsy via fine needle aspiration, core-needle biopsy of neck mass, or direct biopsy of the oropharyngeal primary tumor to confirm squamous cell carcinoma 1
• High-risk HPV testing is mandatory on all biopsy specimens from either the primary site or lymph nodes, as HPV status fundamentally determines staging, treatment selection, and prognosis 1

Imaging Requirements

• Obtain high-resolution cross-sectional imaging with contrast-enhanced CT of the neck or MRI to assess tumor extent, relationship to carotid vessels, and parapharyngeal anatomy 1
• Chest evaluation with CT or PET-CT is the next required step to detect distant metastases 1

Functional Assessment

• All patients require pretreatment speech and swallowing evaluation by a speech-language pathologist, including patient-reported outcome measures and objective instrumental assessment with modified barium swallow study, video-fluoroscopic swallowing study, or fiberoptic endoscopic evaluation of swallowing 1, 2
• This functional baseline directly influences treatment selection and predicts post-treatment swallowing outcomes 1, 2

Treatment Selection Algorithm

For T1-T2 HPV-Positive OPC

TORS should be discussed as the primary surgical option when:

• Preoperative assessment indicates high probability of achieving R0 resection (negative margins) 1
• The tumor is lateralized (not midline) 1
• Adequate transoral exposure can be achieved without contraindications such as narrow mandibular arch, trismus, large mandibular tori, or limited neck range of motion 1
• Resection will not require significant soft palate removal that would cause velopharyngeal insufficiency 1

TORS must include appropriate neck dissection as part of comprehensive surgical treatment 1

For T3-T4 OPC

• Consider nonsurgical treatment with definitive chemoradiotherapy as the primary approach 1
• TORS may be considered for select exophytic T3 tumors where resection will not cause significant functional deficit, though this is off-label (FDA approval is only for T1-T2) 1
• T4 tumors are not candidates for transoral surgery alone 1

For Node-Negative Disease

• Assess surgical candidacy and transoral exposure as above 1
• If not a TORS candidate, proceed with nonsurgical treatment 1

Postoperative Adjuvant Therapy Decision-Making

For HPV-Positive OPC After TORS + Neck Dissection

Adjuvant chemoradiotherapy (radiation with concurrent platinum-based chemotherapy) is indicated for:

• Positive tumor margins 1
• Five or more positive lymph nodes 1
• Extranodal extension >1 mm 1

Adjuvant radiation therapy alone is indicated for:

• Two to four positive nodes with or without 1 mm extranodal extension 1
• Close surgical margins 1
• Perineural invasion 1
• Lymphovascular invasion 1

Observation may be considered for:

• One positive node >3 cm with no other adverse features 1
• All other patients not meeting above criteria 1

For HPV-Negative OPC After TORS + Neck Dissection

• Use pathology-directed adjuvant therapy with the same criteria as HPV-positive disease, though outcomes are generally less favorable 1

Critical Timing Considerations

• Complete treatment package within 100 days from surgery to end of radiotherapy, or within 14 weeks total treatment time 1
• Initiate postoperative radiation within 6 weeks of surgery, as this is a key quality metric associated with improved locoregional control and overall survival 1

Salvage/Recurrent Disease

TORS may be offered for salvage of recurrent or residual disease within a previously radiated field as part of curative-intent treatment in select patients who meet surgical candidacy criteria 1

Common Pitfalls to Avoid

• Do not proceed with TORS for midline tumors as lateralized tumors are optimal candidates and midline location is a relative contraindication 1
• Do not perform TORS if adequate transoral exposure cannot be achieved, as this increases risk of positive margins and complications 1
• Do not delay adjuvant radiation beyond 6 weeks post-surgery as this worsens locoregional control 1
• Do not skip pretreatment functional assessment, as baseline swallowing dysfunction affects treatment selection and predicts outcomes 1
• Do not manage OPC patients without multidisciplinary team involvement, as comprehensive care including rehabilitation specialists significantly improves outcomes and quality of life 1