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Head and neck squamous cell carcinoma
Early head and neck cancer is treated with a single modality — surgery or radiation — and locally advanced cancer with a combination: surgery with adjuvant radiation, or chemoradiation with cisplatin; HPV in the oropharynx improves prognosis and changes the stage.
Why it matters in the exam
Head and neck questions appear in the radiation part of the exam every year. They ask about the treatment of an early glottic tumour in a hoarse smoker, when to add cisplatin to radiation after surgery, the benefit of hyperfractionation, and the meaning of HPV as a predictive and prognostic marker in oropharyngeal tumours.
Common distractors are replacing cisplatin with cetuximab in a cisplatin-fit patient, forgetting dental care before radiation, or choosing larynx preservation in a T4a tumour that has destroyed cartilage. Late radiation effects are also asked — dry mouth, osteoradionecrosis of the jaw, hypothyroidism and carotid stenosis.
Key points
- An early tumour is treated with a single modality — surgery or radiation — with high cure rates, especially in the glottis.
- A locally advanced tumour is treated with surgery and adjuvant radiation, or with cisplatin chemoradiation for organ preservation.
- Positive margins or extranodal extension require adding cisplatin to adjuvant radiation after surgery.
- HPV in the oropharynx marks a better prognosis and a better response, and has a separate staging system.
- Late radiation effects: dry mouth, jaw osteoradionecrosis, hypothyroidism, swallowing difficulty and carotid stenosis.
Summary table
| Situation | Treatment | Exam detail |
|---|---|---|
| Early glottic tumour (T1–T2 N0) | Radiation alone or transoral laser resection | High cure rates; the glottis has little lymphatic drainage so nodes are not irradiated |
| Resectable locally advanced | Surgery with adjuvant radiation | Positive margins or extranodal extension — adjuvant chemoradiation with cisplatin |
| Unresectable locally advanced or for organ preservation | Chemoradiation 70 Gy in 35 fractions with cisplatin | Cisplatin 100 mg/m² every 3 weeks or a weekly dose; larynx preservation — concurrent chemoradiation is best |
| T4a laryngeal tumour with cartilage destruction | Total laryngectomy followed by radiation | Larynx preservation is not suitable |
| Unfit for cisplatin | Radiation alone, or radiation with cetuximab | In HPV-positive oropharyngeal tumours cetuximab is inferior to cisplatin |
| Recurrence or metastases | Pembrolizumab alone or with platinum and 5-FU, by CPS | CPS of 1 or more — pembrolizumab alone is possible |
| Hyperfractionation | More, smaller fractions per day | Better regional control and survival than conventional fractionation |
A free exam question
חולה בת 45 ,עם מלנומה של הקרקפת .ללא גרורות עברה כריתה מקומית ודיסקציה צווארית, בה נראו שתי בלוטות מעורבות בפרוטיד האם יש מקום ל המליץ ?על קרינה משלימה ומדוע. (the question as examined, in Hebrew)
- א. לא , .בהעדר מעורבות שוליים אין אינדיקציה לטיפול קרינתי
- ב. לא היתרון לקרינה משלימה נראה במעורבות של 3 .בלוטות ויותר
- ג. כן, יש יתרון לקרינה משלימה ב מלנומה ממקור ראש- .צוואר
- ד. כן, יש יתרון לקרינ ה משלימה בהישרדות בקבוצת הגיל מתחת ל- 50
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Oncology, ENT and head and neck surgery, Medical licensing exam (IMLE).
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Sources
- NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancers, 2026 — Principles of radiation therapy and systemic therapy
- ESMO-EURACAN Clinical Practice Guideline: Squamous cell carcinoma of the head and neck, 2020 — Diagnosis, treatment and follow-up
- Gunderson and Tepper's Clinical Radiation Oncology, 5th ed. (2021) — Larynx and hypopharynx; oropharynx
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.