Previous. Case presentation.
In many hospital settings, chemo-radiation is often the preferred treatment choice for cases like this. The tumour is classified as T3 (large size, locally advanced). There is a massive lymph node with presumably extra-nodal extension (ENE), possibly requiring a radical neck dissection if surgery is offered. Any case, chemo-radiation is likely to be necessary. Given this circumstances most would opt for up-front chemo-radiation.
Let us now discuss the limitations associated with this line of thinking.
While the tumour is classified as T3 based on its size, it is confined to the tonsillar fossa. Therefore, regardless of whether it is categorized as T1, T2, or T3, the surgical technique remains basically the same. The tumour growth is actually towards the pharyngeal lumen. In the surgeon´s view, size is not critical if it does not exceed the limits of the tonsillar fossa.
The lymph node is another aspect of concern. Predicting ENE remains a challenge, particularly in the case of HPV+ oropharyngeal tumours, which typically exhibit rapidly growing voluminous nodes. Surgeons often find that even large nodes tend not to be infiltrative. Nevertheless, in this case, this HPV+ tumour is still classified as N1.
So the main issue is that according to the 8th edition of the TNM staging system, this is considered a stage II tumour (T3N1 HPV+), that is, an early stage. Conceptually we should be able to use a single modality treatment. Would anyone consider offering radiation therapy alone for this case? As our understanding continues to evolve guidelines are not properly updated with our vision. It is possible that ENE dos not have the same implications in VPH+ tumours as in HPV- tumours (most of us think so). It is also the author´s view that traditional systemic therapy should have a limited or no role in HPV+ oropharyngeal tumours.
It is important to remember that there is no pathologic N3 for VPH+ tumours (maximum pN is pN2, and it is dependent solely in the number of affected nodes). Also that true nodal stage can only be determined through surgical intervention. And it is really difficult to became an advanced pathologic stage for a VPH+ tumour (pT3 or pT4 AND pN2 to be stage III; M+ to be stage IV).
Considering this factors, would you contemplate another treatment option?
Next, let´s move on to discussing conventional surgery.