Head and Neck Cancers

Clinical in Oncology Head and Neck Cancers V.1.2009 Continue www.nccn.g

* Arlene A. Fastiere, MD/Chair The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Kie-Kian Ang, MD, PhD The University of Texas M. D. Anderson Cancer Center David Brizel, MD Duke Comprehensive Cancer Center Bruce E. Brockstein, MD Þ Robert H. Lurie Comprehensive Cancer Center of Nthwestern University Barbara A. Burtness, MD Fox Chase Cancer Center Anthony J. Cmelak, MD Vanderbilt-Ingram Cancer Center Alexander D. Colevas, MD Stanfd Comprehensive Cancer Center Frank Dunphy, MD Duke Comprehensive Cancer Center David W. Eisele, MD UCSF Helen Diller Family Comprehensive Cancer Center Matthew Fury, MD Memial Sloan-Kettering Cancer Center Jill Gilbert, MD Vanderbilt-Ingram Cancer Center Helmuth Goepfert, MD The University of Texas M. D. Anderson Cancer Center Guidelines Panel Disclosures Panel Members Wesley L. Hicks, Jr., MD Roswell Park Cancer Institute Merrill S. Kies, MD The University of Texas M. D. Anderson Cancer Center William M. Lydiatt, MD UNMC Eppley Cancer Center at The Nebraska Medical Center Ellie Maghami, MD City of Hope Comprehensive Cancer Center Renato Martins, MD, MPH Fred Hutchinson Cancer Research Center/ Seattle Cancer Care Alliance Thomas McCaffrey, MD, PhD H. Lee Moffitt Cancer Center & Research Institute Bharat B. Mittal, MD Robert H. Lurie Comprehensive Cancer Center of Nthwestern University David G. Pfister, MD Þ Memial Sloan-Kettering Cancer Center Harlan A. Pinto, MD Þ Stanfd Comprehensive Cancer Center Marshall R. Posner, MD Þ Dana-Farber/Brigham and Women s Cancer Center Massachusetts General Hospital Cancer Center John A. Ridge, MD, PhD Fox Chase Cancer Center Continue Sandeep Samant, MD St. Jude Children's Research Hospital/University of Tennessee Cancer Institute Giuseppe Sanguineti, MD The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins David E. Schuller, MD The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute Jatin P. Shah, MD Memial Sloan-Kettering Cancer Center Sharon Spencer, MD University of Alabama at Birmingham Comprehensive Cancer Center * Andy Trotti, III, MD H. Lee Moffitt Cancer Center & Research Institute Randal S. Weber, MD The University of Texas M. D. Anderson Cancer Center Gregy T. Wolf, MD University of Michigan Comprehensive Cancer Center Frank Wden, MD University of Michigan Comprehensive Cancer Center Medical Oncology Surgery/Surgical oncology Radiation oncology/ Radiotherapy Otolaryngology Þ Internal medicine * Writing Committee Member Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of.

Table of Contents Panel Members Summary of Guidelines Updates Multidisciplinary Team Approach (TEAM-1) Suppt Modalities (TEAM-1) Ethmoid Sinus Tums (ETHM-1) Maxillary Sinus Tums (MAXI-1) Salivary Gland Tums (SALI-1) Cancer of the Lip (LIP-1) Cancer of the Oral Cavity (OR-1) Cancer of the Oropharynx (ORPH-1) Cancer of the Hypopharynx (HYPO-1) Occult Primary (OCC-1) Cancer of the Glottic Larynx (GLOT-1) Cancer of the Supraglottic Larynx (N0) (SUPRA-1) Cancer of the Nasopharynx (NASO-1) Unresectable Head and Neck Cancer (ADV-1) Recurrent Head and Neck Cancer (ADV-2) Radiation Techniques (RAD-A) Principles of Systemic Therapy (CHEM-A) F help using these documents, please click here Staging Discussion References Clinical Trials: The believes that the best management f any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. To find clinical trials online at member institutions, click here: nccn.g/clinical_trials/physician.html Categies of Evidence and Consensus: All recommendations are Categy 2A unless otherwise specified. See Categies of Evidence and Consensus Print the Guideline These guidelines are a statement of evidence and consensus of the auths regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply consult these guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient s care treatment. The National Comprehensive Cancer Netwk makes no representations warranties of any kind, regarding their content use application and disclaims any responsibility f their application use in any way. These guidelines are copyrighted by National Comprehensive Cancer Netwk. All rights reserved. These guidelines and the illustrations herein may not be reproduced in any fm without the express written permission of. 2009. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of.

Summary of the Guidelines updates Summary of changes in the 1.2009 version of the Head and Neck Cancer guidelines from the 2.2008 version include: Global Changes In the follow-up section, alcohol counseling was added to smoking cessation counseling. Unresectable was changed to T4b unresectable nodal disease. A page titled Radiation Techniques ( RAD-A) was added to the Guidelines. TEAM-1 Suppt and Services The follow-up providers were expanded to include other healthcare professionals. The following were added: Speech and swallowing therapy, audiology. Ethmoid Sinus Tums ETHM-2 Newly diagnosed, unresectable was changed to Newly diagnosed, T4b. Maxillary Sinus Tums MAXI-2 F T1-2, N0 Adenoid cystic tums, the recommendations f treatment are based on infrastructure suprastructure presentation. Footnote e added to define the terms. MAXI-3 It was clarified that the treatment recommendations on this page are f squamous cell histologies. MAXI-A Altered fractionation schedules added to RT recommendations. Salivary Gland Tums SALI-1 The following clarifications were made: Submaxillary was changed to submandibular. After resection, to primary was added after Adjuvant RT. Not resectable was changed to T4b. Salivary Gland Tums SALI-2 Untreated resectable, clinically benign and < 4 cm, CT/MRI if clinically indicated was added to the wkup section. SALI-4 A categy f metastatic disease was added with the treatment recommendations of chemotherapy, clinical trial, expectant management. Clinical trial was added as a treatment option f locegional disease that is not resectable and expectant management replaced best supptive care. Cancer of the Lip LIP-2 Preferred was added to the recommendation f surgery. LIP-3 Preferred was added to the recommendation f surgery. F extracapsular spread and/ positive margins, the recommendations of re-excision and RT in selected patients were added. Footnote d is new to the page, recommending re-excision f positive margin if technically feasible. A post-treatment evaluation with imaging was added to assist with patient selection f neck dissection. LIP-A The option f brachytherapy alone was removed. The doses of radiation therapy were modified based upon the addition of brachytherapy. The recommended RT dose is 50-60 Gy with brachytherapy and 50-66 Gy without brachytherapy. Continued on next page Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. UPDATES

Summary of the Guidelines updates Summary of changes in the 1.2009 version of the Head and Neck Cancer guidelines from the 2.2008 version include: Cancer of the Oral Cavity OR-2 and OR-3 F extracapsular spread and/ positive margins, the recommendations of re-excision and RT in selected patients were added. Footnote b is new to the page, recommending re-excision f positive margin if technically feasible. OR-A Altered fractionation schedules added to RT recommendations. Cancer of the Oropharynx ORPH-1 In the wkup section, PET-CT and CT with contrast was added to the CT MRI recommendation. ORPH-3 The clinical staging was changed by adding N1 disease. ORPH-4 T3-4a, N+ was removed from the clinical staging. A post-treatment evaluation with imaging was added to assist with patient selection f neck dissection. ORPH-A Accelerated IMRT schedule added to RT recommendations. Cancer of the Hypopharynx HYPO-1 In the wkup section, PET-CT and CT with contrast was added to the CT MRI recommendation. Footnote a is new to the page, stating PET-CT is recommended f stage III-IV disease. HYPO-3 and HYPO-4 A post-treatment evaluation with imaging was added to assist with patient selection f neck dissection. Cancer of the Hypopharynx HYPO-5 The option of RT was added after surgery and comprehensive neck dissection. The option of induction chemotherapy was modified to include sequential therapy recommendations. A post-treatment evaluation with imaging was added to assist with patient selection f neck dissection. HYPO-A Altered fractionation schedules added to RT recommendations. Occult Primary OCC-1 Thyroglobulin staining was added to the wkup of adenocarcinoma and anaplastic undifferentiated tums. Footnote a was clarified: Patient should be prepared f neck dissection at time of open biopsy, if indicated. OCC-2 Adenocarcinoma was clarified as thyroglobulin negative. F Node level IV, lower V, EUA was added. OCC-3 A post-treatment evaluation with imaging was added to assist with patient selection f neck dissection. OCC-4 Patients post neck dissection with level 1 only nodes, observation was added with a categy 3 designation. OCC-6 Footnote f was added, recommending RT f satellitosis, positive nodes, extracapsular spread. OCC-A Footnote 1 is new to the page defining the histologies f the RT recommendations. Altered Fractionation schedules added to RT recommendations. Continued on next page Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. UPDATES

Summary of the Guidelines updates Summary of changes in the 1.2009 version of the Head and Neck Cancer guidelines from the 2.2008 version include: Cancer of the Glottic Larynx GLOT-1 In the wkup section, PET-CT and CT with contrast and thin cuts through larynx was added to the CT MRI recommendation. GLOT-3 This page only addresses N0-1 disease; N2-3 disease was moved to page GLOT-4. RT was added as a treatment option f patients who are not candidates f concurrent chemo/rt. GLOT-4 This is a new page to address N2-3 disease. The treatment option of induction therapy followed by chemadiation was added with the designation of categy 2B; page GLOT-5 now contains the sequential therapy. A post-treatment evaluation with imaging was added to assist with patient selection f neck dissection. GLOT-5 The option of induction chemotherapy was modified to include sequential therapy recommendations. GLOT-6 The treatment option of induction therapy followed by chemadiation was added with the designation of categy 2B; page GLOT-5 now contains the sequential therapy. A post-treatment evaluation with imaging was added to assist with patient selection f neck dissection. Cancer of the Supraglottic Larynx SUPRA-1 In the wkup section, PET-CT and CT with contrast and thin cuts through larynx was added to the CT MRI recommendation. SUPRA-3 RT was added as a treatment option f patients who are not candidates f concurrent chemo/rt. SUPRA-6 The clinical stage was clarified by adding N0-1 to T3-4a. Cancer of the Supraglottic Larynx SUPRA-7 The clinical stage was clarified by changing to T3, N2-3. The categy designation f induction chemotherapy followed by chemadiation was changed from a 3 to a 2B; page SUPRA-8 now contains the sequential therapy. A post-treatment evaluation with imaging was added to assist with patient selection f neck dissection. SUPRA-8 The option of induction chemotherapy was modified to include sequential therapy recommendations. SUPRA-9 The clinical stage was clarified by changing N+ to N2-3. The clinical stage was clarified by adding Massive tongue base invasion. SUPRA-A Altered fractionation schedules added to RT recommendations. Chemadiation schedule added to recommendations. Cancer of the Nasopharynx NASO-1 In the wkup section, PET-CT and CT with contrast was added to the CT MRI recommendation. NASO-2 The cisplatin regimen of 40 mg/m2 every week was added as an option f T1-2a, N1-3; T2b-4, Any N. Advanced Head and Neck Cancer ADV-1 The recommendation f induction chemotherapy f PS 2 patients was deleted. ADV-2 Locegional recurrence with pri RT - the recommendation was removed f reirradiation following surgery f resectable patients. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. UPDATES

Team Approach MULTIDISCIPLINARY TEAM The management of patients with head and neck cancers is complex. All patients need access to the full range of specialists and suppt services with expertise in the management of patients with head and neck cancer f optimal treatment and follow-up. Head and neck surgery Radiation oncology Medical oncology Plastic and reconstructive surgery Specialized nursing care Dentistry/prosthodontics Physical medicine and rehabilitation Speech and swallowing therapy Clinical Social wk Nutrition suppt Pathology Diagnostic radiology Adjunctive services Neurosurgery Ophthalmology Psychiatry Addiction Services Audiology SUPPORT AND SERVICES Follow-up should be perfmed by a physician and other health care professionals with expertise in the management and prevention of treatment sequelae. It should include a comprehensive head and neck exam. The management of head and neck cancer patients may involve the following: General medical care Pain and symptom management Nutritional suppt Enteral feeding Oral supplements Dental care f RT effects Xerostomia management Smoking and alcohol cessation Speech and swallowing therapy Audiology Tracheotomy care Wound management Depression assessment and management Social wk and Case management Supptive Care (See Palliative Care Guideline) Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. TEAM-1

Ethmoid Sinus Tums WORKUP PATHOLOGY H&P CT and/ MRI Chest imaging Biopsy Squamous cell carcinoma Adenocarcinoma Salivary gland tum Sarcoma (non-rhabdomyosarcoma) Esthesioneuroblastomasa Undifferentiated carcinoma (SNUC, small cell neuroendocrine) a See Primary Treatment and Follow-up (ETHM-2) Lymphoma ( See Non- Hodgkin's Lymphoma Guidelines) Diagnosed with incomplete excision H&P CT and/ MRI Pathology review Chest imaging See Primary Treatment and Follow-up (ETHM-2) a F sinonasal undifferentiated carcinoma (SNUC), esthesioneuroblastoma, and small cell neuroendocrine histologies, systemic therapy should be a part of the overall treatment. Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. ETHM-1

Ethmoid Sinus Tums CLINICAL PRESENTATION PRIMARY TREATMENT ADJUVANT TREATMENT FOLLOW-UP Newly diagnosed; T1, T2 Complete surgical resection (preferred) RT Consider Chemo/RT b (categy 2B) if adverse featuresc Newly diagnosed; T3, T4a resectable Newly diagnosed, T4b Diagnosed after incomplete excision (eg, polypectomy, endoscopic procedure) and gross residual disease Definitive RT Complete surgical resection Chemo/RTb RT Clinical trial (preferred) Surgery (preferred), if feasible RT Chemo/RT b RT Consider Chemo/RT b (categy 2B) if adverse featuresc RT Consider Chemo/RT b (categy 2B) if adverse featuresc Physical exam: Year 1, every 1 3 mo Year 2, every 2 4 mo Years 3 5, every 4 6 mo > 5 years, every 6 12 mo Chest imaging as clinically indicated TSH every 6-12 mo if neck irradiated CT scan/mri- baseline (categy 2B) Diagnosed after incomplete exision (eg, polypectomy, endoscopic procedure) and no disease on physical exam, imaging, and/ endoscopy RT Surgery, if feasible RT Recurrence (see ADV-2) bsee Principles of Systemic Therapy (CHEM-A). cadverse features include positive margins and intracranial extension. Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. ETHM-2

Maxillary Sinus Tums WORKUP PATHOLOGY Lymphoma See Non-Hodgkin s Lymphoma Guidelines H&P Complete head and neck CT with contrast and/ MRI Dental/prosthetic consultation as indicated Chest imaging Biopsy a Squamous cell carcinoma Adenocarcinoma Salivary gland tum Sarcoma (nonrhabdomyosarcoma) Esthesioneuroblastomab Undifferentiated carcinoma (SNUC, small cell neuroendocrine) b T1-2, N0 All histologies T3-4, N0, Any T, N+ All histologies See Primary Treatment (MAXI-2) See Primary Treatment (MAXI-3) a Biopsy: Preferred route is transnasal. Needle biopsy may be acceptable. Avoid canine fossa puncture Caldwell-Luc approach. b F sinonasal undifferentiated carcinoma (SNUC), esthesioneuroblastoma, and small cell neuroendocrine histologies, systemic therapy should be a part of the overall treatment. Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. MAXI-1

Maxillary Sinus Tums STAGING PRIMARY TREATMENT ADJUVANT TREATMENT FOLLOW-UP Margin negative T1-2, N0 All histologies except adenoid cystic T1-2, N0 Adenoid cystic Complete surgical resection Complete surgical resection Perineural invasion Margin positive Suprastructure e Infrastructure e Consider RTc Consider chemo/rtd (categy 2B) Surgical reresection, if possible RT c RTc per indication Margin negative Margin positive Consider RT c Chemo/RTd (categy 2B) Physical exam: Year 1, every 1 3 mo Year 2, every 2 4 mo Years 3 5, every 4 6 mo > 5 years, every 6 12 mo Chest imaging as clinically indicated TSH every 6-12 mo, if neck irradiated CT/MRI- baseline (categy 2B) csee Principles of Radiation Therapy (MAXI-A). dsee Principles of Systemic Therapy (CHEM-A). e"ohngren's line" runs from the medial canthus of the eye to the angle of the mandible, helping to define a plane passing through the maxillary sinus. Tums "below" "befe" this line involve the maxillary infrastructure. Those "above" "behind" Ohngren's line involve the suprastructure. Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. MAXI-2

Maxillary Sinus Tums STAGING PRIMARY TREATMENT ADJUVANT TREATMENT FOLLOW-UP T3, N0 Operable T4a, squamous cell T4b, N any, squamous cell T any, N+, resectable, squamous cell Complete surgical resection Clinical trial Definitive RTc Chemo/RTd Surgical excision + neck dissection Adverse features f No adverse features f Adverse features f No adverse features f Chemo/RTd to primary and neck (categy 2B) RTc to primary and neck (categy 2B f neck) (f squamous cell carcinoma and undifferentiated tums) Chemo/RTd to primary and neck (categy 2B) RTc to primary + neck Physical exam: Year 1, every 1 3 mo Year 2, every 2 4 mo Years 3 5, every 4 6 mo > 5 years, every 6 12 mo Chest imaging as clinically indicated TSH every 6-12 mo, if neck irradiated CT/MRI-baseline (categy 2B) csee Principles of Radiation Therapy (MAXI-A). dsee Principles of Systemic Therapy (CHEM-A). fadverse features include positive margins extracapsular nodal spread. Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. MAXI-3

Maxillary Sinus Tums PRINCIPLES OF RADIATION THERAPY 1 Definitive RT Primary and gross adenopathy: Conventional: 66 Gy (2.0 Gy/fraction; daily Monday-Friday) Altered fractionation: 6 fractions/week accelerated during weeks 2-6; 70 Gy to gross disease, 50 Gy to subclinical disease. Concomitant boost accelerated RT: 72 Gy/6 weeks (1.8 Gy/fraction, large field; 1.5 Gy boost as second daily fraction during last 12 treatment days) Hyperfractionation: 81.6 Gy/7 weeks (1.2 Gy/fraction, twice daily) Neck Uninvolved nodal stations: 50 Gy (2.0 Gy/day) Postoperative RT Primary: 60 Gy (2.0 Gy/day) Neck Involved nodal stations: 60 Gy (2.0 Gy/day) Uninvolved nodal stations: 50 Gy (2.0 Gy/day) 1 See Radiation Techniques (RAD-A). Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. MAXI-A

Salivary Gland Tums CLINICAL PRESENTATION WORKUP TREATMENT Untreated resectable See Wkup and Primary Treatment (SALI-2) Salivary gland mass Parotid Submandibular Min salivary glanda Previously treated incompletely resected H&P CT/MRI Pathology review Chest imaging Negative physical exam and imaging Gross residual disease on physical exam imaging Surgical resection, if possible No surgical resection possible Adjuvant RT b Adjuvant RT b to primary Definitive RTb Chemo/RT (categy 2B) See Followup (SALI-4) T4b Fine-needle aspiration Open biopsy Definitive RTb Chemo/RT (categy 2B) asite and stage determine therapeutic approaches. bsee Principles of Radiation Therapy (SALI-A). Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. SALI-1

Salivary Gland Tums WORKUP PRIMARY TREATMENT Benign low grade Follow-up Untreated resectable, clinically benign, c < 4 cm (T1, T2) CT/MRI, if clinically indicated Complete surgical excision d Adenoid cystic; Indeterminate high grade Consider RTb (categy 2B f T1) Benign Follow-up Untreated resectable, clinically suspicious f cancer, > 4 cm deep lobe CT/MRI: base of skull to clavicle Consider fine-needle aspiration Lymphoma Surgical resection Cancer Parotid superficial lobe Parotid deep lobe See Treatment (SALI-3) See Treatment (SALI-3) See Non-Hodgkin s Lymphoma Guidelines Other salivary gland sites See Treatment (SALI-3) bsee Principles of Radiation Therapy (SALI-A). ccharacteristics of benign tum include mobile superficial lobe, slow growth, painless, VII intact, and no neck nodes. dsurgical excision of clinically benign tum: no enucleation of lateral lobe, intraoperative communication with pathologist if indicated. Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. SALI-2

Salivary Gland Tums Untreated resectable, clinically suspicious f cancer, > 4 cm deep lobe TREATMENT Parotid superficial lobe Clinical N0 Clinical N+ Parotidectomy Parotidectomy + comprehensive neck dissection Completely excised No adverse characteristics Adenoid cystic See Followup (SALI-4) RT b (categy 2B) Parotid deep lobe Clinical N0 Clinical N+ Total parotidectomy Total parotidectomy + comprehensive neck dissection Intermediate high grade Close positive margins Neural/perineural invasion Lymph node metastases Lymphatic/vascular invasion Adjuvant RT b Consider chemo/rt (categy 2B) Other salivary gland sites Clinical N0 Clinical N+ Complete gland excision Complete gland excision and lymph node dissection Incompletely excised gross residual disease No further surgical resection possible Definitive RTb Chemo/RT (categy 2B) b See Principles of Radiation Therapy (SALI-A). Follow-up and Recurrence (see SALI-4) Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. SALI-3

Salivary Gland Tums FOLLOW-UP RECURRENCE Locegional distant disease; Resectable Surgery selected metastasectomy (categy 3) RT b Physical exam: Year 1, every 1 3 mo Year 2, every 2 4 mo Years 3 5, every 4 6 mo > 5 yr, every 6 12 mo Chest imaging as clinically indicated TSH every 6-12 mo, if neck irradiated Locegional disease; Not resectable RTb Chemo/RT (categy 2B) Clinical trial Chemotherapy Expectant management Metastatic; Not resectable Chemotherapy Clinical trial Expectant management b See Principles of Radiation Therapy (SALI-A). Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. SALI-4

Salivary Gland Tums PRINCIPLES OF RADIATION THERAPY 1 Definitive RT Unresectable disease gross residual disease Photon/electron therapy neutron therapy Dose Primary and gross adenopathy: 70 Gy (1.8-2.0 Gy/day) 2 19.2 ngy (1.2 ngy/day) Uninvolved nodal stations: 45-54 Gy (1.8-2.0 Gy/day) 2 13.2 ngy (1.2 ngy/day) Postoperative RT Photon/electron therapy neutron therapy Dose Primary: 60 Gy (1.8-2.0 Gy/day) 2 18 ngy (1.2 ngy/day) Neck: 45-54 Gy (1.8-2.0 Gy/day) 2 13.2 ngy (1.2 ngy/day) 1 See Radiation Techniques (RAD-A). 2 Range based on grade/natural histy of disease (eg, 1.8 Gy fraction may be used f slower growing tums). Back to Wkup and Primary Treatment (SALI-1) Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. SALI-A

Cancer of the Lip WORKUP CLINICAL STAGING T1-2, N0 See Treatment of Primary and Neck (LIP-2) H&P Biopsy Chest imaging As indicated f primary evaluation Panex CT/MRI Preanesthesia studies Dental evaluation Multidisciplinary consultation as indicated Resectable T3, T4a, N0 Any T, N1-3 Surgical candidate Po surgical risk See Treatment of Primary and Neck (LIP-3) Definitive RTa to primary and nodes Follow-up Chemo/RTb T4b unresectable nodal disease See Treatment of Head and Neck Cancer (ADV-1) asee Principles of Radiation Therapy (LIP-A). bsee Principles of Systemic Therapy (CHEM-A). Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. LIP-1

Cancer of the Lip CLINICAL STAGING TREATMENT OF PRIMARY AND NECK ADJUVANT TREATMENT FOLLOW-UP T1-2, N0 Surgical excision (preferred) External-beam RT 50 Gy + brachytherapy external-beam RT 66 Gy Positive margins, perineural/vascular/ lymphatic invasion No adverse pathologic findings Residual recurrent tum post-rt Re-excision RT a Surgery/ reconstruction Physical exam: Year 1, every 1-3 mo Year 2, every 2-4 mo Years 3-5, every 4-6 mo > 5 yr, every 6-12 mo a See Principles of Radiation Therapy (LIP-A). Recurrence (see ADV-2) Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. LIP-2

Cancer of the Lip CLINICAL STAGING: TREATMENT OF PRIMARY AND NECK RESECTABLE T3, T4a, N0; Any T, N1-3 Excision of primary ± unilateral N0 bilateral selective neck dissection (reconstruction as indicated) Surgery (preferred) N1 External RT a ± brachytherapy Chemo/RT b N2a-b, N3 N2c (bilateral) Excision of primary, ipsilateral selective comprehensive neck dissection ± contralateral selective neck dissection (reconstruction as indicated) Excision of primary, ipsilateral comprehensive neck dissection ± contralateral selective neck dissection (reconstruction as indicated) Excision of primary and bilateral comprehensive neck dissection (reconstruction as indicated) Primary site: Complete response (N0 at initial staging) Primary site: Complete response (N+ at initial staging) Primary site: < complete response Residual tum in neck Complete response of neck Salvage surgery + neck dissection as indicated One positive node without adverse features c Adverse features c Other risk features Neck dissection asee Principles of Radiation Therapy (LIP-A). bsee Principles of Systemic Therapy (CHEM-A). crisk features: extracapsular nodal spread, positive margins, multiple positive nodes perineural/lymphatic/vascular invasion. df positive margin only, re-excise if technically feasible. eif a PET-CT is perfmed and negative f suspicion of persistent cancer, further cross-sectional imaging is optional. ADJUVANT TREATMENT RTa optional RT a Consider chemo/rt b Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. N0 Post-treatment evaluation (minimum 12 wks) PETe Contrast-enhanced CT MRI Physical exam Extracapsular spread and/ positive margin d Negative Positive Re-excision (categy 1) Chemo/RT b (categy 1) RT a (selected patients) Observe Neck dissection FOLLOW-UP Physical exam: Year 1, every 1-3 mo Year 2, every 2-4 mo Years 3-5, every 4-6 mo > 5 yr, every 6-12 mo Recurrence (see ADV-2) Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. LIP-3

Cancer of the Lip PRINCIPLES OF RADIATION THERAPY 1 Definitive RT Primary and gross adenopathy: 66 Gy (2.0 Gy/day) External-beam RT ± brachytherapy 50-60 Gy with brachytherapy 50-66 Gy without brachytherapy Neck Uninvolved nodal stations: 50 Gy (2.0 Gy/day) Postoperative RT Primary: 60 Gy (2.0 Gy/day) Neck Involved nodal stations: 60 Gy (2.0 Gy/day) Uninvolved nodal stations: 50 Gy (2.0 Gy/day) 1 See Radiation Techniques (RAD-A). Back to Clinical Staging (LIP-1) Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. LIP-A

Cancer of the Oral Cavity Buccal mucosa, flo of mouth, anteri tongue, alveolar ridge, retromolar trigone, hard palate WORKUP CLINICAL STAGING T1 2, N0 See Treatment of Primary and Neck (OR-2) H&P Biopsy Chest imaging CT/MRI as indicated Examination under anesthesia, if indicated Preanesthesia studies Dental evaluation, including panex as indicated Multidisciplinary consultation as indicated T3, N0 T1 3, N1 3 T4a, any N See Treatment of Primary and Neck (OR-2) See Treatment of Primary and Neck (OR-3) See Treatment of Primary and Neck (OR-3) T4b unresectable nodal disease See Treatment of Head and Neck Cancer (ADV-1) Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. OR-1

CLINICAL STAGING T1 2, N0 T3, N0 Buccal mucosa, flo of mouth, anteri tongue, alveolar ridge, retromolar trigone, hard palate TREATMENT OF PRIMARY AND NECK Excision of primary (preferred) ± unilateral bilateral selective neck dissection External-beam RT ± brachytherapy 70 Gy to primary 50 Gy to neck at risk Excision of primary and reconstruction as indicated and unilateral bilateral selective neck dissection No adverse features a One positive node without adverse features a RTc optional (categy 2B) Adverse features a No residual disease Residual disease No adverse features a Adverse features a Cancer of the Oral Cavity Extracapsular spread and/ positive margin b Other risk features Extracapsular spread and/ positive margin b Other risk features ADJUVANT TREATMENT Re-excision (categy 1) Chemo/RT c,d (categy 1) RT c (selected patients) RT c Consider chemo/rt c,d Salvage surgery RT c (optional) Re-excision (categy 1) Chemo/RT c,d (categy 1) RT c (selected patients) RT c Consider chemo/rt c,d Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. FOLLOW-UP Physical exam: Year 1, every 1-3 mo Year 2, every 2-4 mo Years 3-5, every 4-6 mo > 5 yr, every 6-12 mo Chest imaging as clinically indicated TSH every 6-12 mo, if neck irradiated Speech/hearing and swallowing evaluation and rehabilitation as indicated Smoking cessation and alcohol counseling Dental follow-up recommended arisk features: extracapsular nodal spread, positive margins, pt3 pt4 primary, N2 N3 nodal disease, nodal disease in levels IV V, perineural invasion, vascular embolism. b F positive margin only, re-excise if technically feasible. csee Principles of Radiation Therapy (OR-A). dsee Principles of Systemic Therapy (CHEM-A). Recurrence (see ADV-2) Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. OR-2

CLINICAL STAGING Buccal mucosa, flo of mouth, anteri tongue, alveolar ridge, retromolar trigone, hard palate TREATMENT OF PRIMARY AND NECK Cancer of the Oral Cavity ADJUVANT TREATMENT FOLLOW-UP T4a, Any N; T1-3, N1-3 Surgery N0, N1, N2a-b, N3 N2c (bilateral) Excision of primary, ipsilateral comprehensive neck dissection ± contralateral selective neck dissection (reconstruction as indicated) Excision of primary and bilateral comprehensive neck dissection (reconstruction as indicated) No adverse features a Adverse features a Extracapsular spread and/ positive margin b Other risk features RT c (optional) Re-excision (categy 1) Chemo/RT c,d (categy 1) RT c (selected patients) RT c Consider chemo/rt c,d Physical exam: Year 1, every 1-3 mo Year 2, every 2-4 mo Years 3-5, every 4-6 mo > 5 yr, every 6-12 mo Chest imaging as clinically indicated TSH every 6-12 mo, if neck irradiated Speech/hearing and swallowing evaluation and rehabilitation as indicated Smoking cessation and alcohol counseling Dental follow-up recommended arisk features: extracapsular nodal spread, positive margins, pt3 pt4 primary, N2 N3 nodal disease, nodal disease in levels IV V, perineural invasion, vascular embolism. b F positive margin only, re-excise if technically feasible. csee Principles of Radiation Therapy (OR-A). dsee Principles of Systemic Therapy (CHEM-A). Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Recurrence (see ADV-2) Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. OR-3

Cancer of the Oral Cavity PRINCIPLES OF RADIATION THERAPY 1 Definitive RT Primary and gross adenopathy: Conventional: 66 Gy (2.0 Gy/fraction; daily Monday-Friday) Altered fractionation: 6 fractions/week accelerated during weeks 2-6; 70 Gy to gross disease, 50 Gy to subclinical disease. Concomitant boost accelerated RT: 72 Gy/6 weeks (1.8 Gy/fraction, large field; 1.5 Gy boost as second daily fraction during last 12 treatment days) Hyperfractionation: 81.6 Gy/7 weeks (1.2 Gy/fraction, twice daily) Neck Uninvolved nodal stations: 50 Gy (2.0 Gy/day) Postoperative RT Indicated f pt3 pt4 primary; N2 N3 nodal disease, nodal disease in levels IV V, perineural invasion, vascular embolism. Preferred interval between resection and postoperative RT is 6 weeks. Primary: 60 Gy (2.0 Gy/day) Neck Involved nodal stations: 60 Gy (2.0 Gy/day) Uninvolved nodal stations: 50 Gy (2.0 Gy/day) Postoperative chemadiation Indicated f extracapsular nodal spread and/ positive margins2-4 Consider f other risk features: pt3 pt4 primary; N2 N3 nodal disease, nodal disease in levels IV V, perineural invasion, vascular embolism. Concurrent single agent cisplatin at 100 mg/m2 every 3 wks is recommended. 1 See Radiation Techniques (RAD-A). 2Bernier J, Domenge C, Ozsahin M et al. Postoperative irradiation with without concomitant chemotherapy f locally advanced head and neck cancer. N Engl J Med 2004;350:1945-1952. 3Cooper JS, Pajak TF, Fastiere AA et al. Postoperative concurrent radiotherapy and chemotherapy f high-risk squamous-cell carcinoma of the head and neck. N Engl J Med 2004;350(19):1937-1944. 4Bernier J, Cooper JS, Pajuk TF, et al. Defining risk levels in locally advanced head and neck cancers: A comparative analysis of concurrent postoperative radiation plus chemotherapy trials of the EORTC (#22931) and RTOG (#9501). Head Neck 2005;27:843-850. Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. OR-A

Base of tongue/tonsil/posteri pharyngeal wall/soft palate WORKUP Cancer of the Oropharynx CLINICAL STAGING H&P Biopsy HPV testing suggested Chest imaging CT with contrast MRI PET- CT and CT with contrast of primary and neck Dental evaluation, including panex as indicated Speech & swallowing evaluation as indicated Examination under anesthesia with endoscopy Preanesthesia studies Multidisciplinary consultation as indicated T1-2, N0-1 T3-4a, N0-1 Any T, N2-3 T4b unresectable nodal disease See Treatment of Primary and Neck (ORPH-2) See Treatment of Primary and Neck (ORPH-3) See Treatment of Primary and Neck (ORPH-4) See Treatment of Head and Neck Cancer (ADV-1) Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. ORPH-1

CLINICAL STAGING Base of tongue/tonsil/posteri pharyngeal wall/soft palate TREATMENT OF PRIMARY AND NECK Cancer of the Oropharynx Complete response ADJUVANT TREATMENT Definitive RT a Residual disease Salvage surgery No adverse features b T1-2, N0-1 Excision of primary ± unilateral bilateral neck dissection One positive node without adverse features b Adverse features b Extracapsular spread and/ positive margin Other risk features Consider RT a Chemo/RT a,c (categy 1) RT a Consider chemo/rt a,c See Follow-up (ORPH-5) F T1-T2, N1 only, RT a + systemic therapy c (categy 3) Complete response Residual disease Salvage surgery asee Principles of Radiation Therapy (ORPH-A). brisk features: extracapsular nodal spread, positive margins, pt3 pt4 primary, N2 N3 nodal disease, nodal disease in levels IV V, perineural invasion, vascular embolism. csee Principles of Systemic Therapy (CHEM-A). Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. ORPH-2

CLINICAL STAGING Base of tongue/tonsil/posteri pharyngeal wall/soft palate TREATMENT OF PRIMARY AND NECK Cancer of the Oropharynx ADJUVANT TREATMENT Concurrent systemic therapy/rta,c cisplatin (categy 1) preferred Complete response Residual disease No adverse features b Salvage surgery RT a T3-4a, N0-1 Surgery Adverse features b Extracapsular spread and/ positive margin Other risk features Chemo/RT a,c (categy 1) RT a Consider chemo/rt a,c See Follow-up (ORPH-5) Induction chemotherapyc followed by chemo/rt (categy 3) Complete response Residual disease Salvage surgery Multimodality clinical trials that include function evaluation asee Principles of Radiation Therapy (ORPH-A). brisk features: extracapsular nodal spread, positive margins, pt3 pt4 primary, N2 N3 nodal disease, nodal disease in levels IV V, perineural invasion, vascular embolism. csee Principles of Systemic Therapy (CHEM-A). Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. ORPH-3

CLINICAL STAGING Any T, N2-3 Base of tongue/tonsil/posteri pharyngeal wall/soft palate TREATMENT OF PRIMARY AND NECK Concurrent systemic therapy/rta,c cisplatin (categy 1) preferred Induction chemotherapyc followed by chemo/rt (categy 2B) Surgery: primary and neck N1 N2a-b N3 N2c Multimodality clinical trials that include function evaluation preferred See Principles of Radiation Therapy (ORPH-A). Primary site: Complete response Primary site: residual tum Cancer of the Oropharynx Residual tum in neck Complete response of neck Excision of primary, ipsilateral comprehensive neck dissection (reconstruction as indicated) Excision of primary and bilateral comprehensive neck dissection (bilateral is categy 3 if neck nodes contralateral only) (reconstruction as indicated) Post-treatment evaluation (minimum 12 wks) PETd Contrast-enhanced CT MRI Physical exam Salvage surgery + neck dissection as indicated No adverse features b Adverse features b Negative Positive Extracapsular spread and/ positive margin Other risk features ADJUVANT TREATMENT Neck dissection Observe Neck dissection Chemo/RT a,c (categy 1) RT a Consider chemo/rta,c a brisk features: extracapsular nodal spread, positive margins, pt3 pt4 primary, N2 N3 nodal disease, nodal disease in levels IV V, perineural invasion, vascular embolism. csee Principles of Systemic Therapy (CHEM-A). d If a PET-CT is perfmed and negative f suspicion of persistent cancer, further cross-sectional imaging is optional. See Follow-up (ORPH-5) Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. ORPH-4

Cancer of the Oropharynx FOLLOW-UP Physical exam: Year 1, every 1-3 mo Year 2, every 2-4 mo Years 3-5, every 4-6 mo > 5 yr, every 6-12 mo Post-treatment baseline imaging of primary and neck recommended within 6 mo of treatment1 Reimaging as indicated only by signs/symptoms on physical examination Chest imaging as clinically indicated TSH every 6-12 mo, if neck irradiated Speech, hearing and swallowing evaluation and rehabilitation as indicated Smoking cessation and alcohol counseling Dental evaluation as indicated Recurrence (see ADV-2) 1 Recommended f T3-4 and N2-3 disease only. Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. ORPH-5

Cancer of the Oropharynx PRINCIPLES OF RADIATION THERAPY 1 Selected T1-2, N0 Conventional fractionation: 70 Gy (2.0 Gy/day) Selected T1, N1; T2, N0-1 Definitive RT Altered fractionation: 6 fractions/week accelerated during weeks 2-6; 70 Gy to gross disease, 50 Gy to subclinical disease. Concomitant boost accelerated RT: 72 Gy/6 weeks (1.8 Gy/fraction, large field; 1.5 Gy boost as second daily fraction during last 12 treatment days) Hyperfractionation: 81.6 Gy/7 weeks (1.2 Gy/fraction, twice daily) Postoperative RT Indicated f pt3 pt4 primary; N2 N3 nodal disease, nodal disease in levels IV V, perineural invasion, vascular embolism. Preferred interval between resection and postoperative RT is 6 weeks. Primary: 60 Gy (2.0 Gy/day) Neck Involved nodal stations: 60 Gy (2.0 Gy/day) Uninvolved nodal stations: 50 Gy (2.0 Gy/day) T2-4a, N0-3 Concurrent chemadiation Conventional fractionation: 2 Primary and gross adenopathy: 70 Gy (2.0 Gy/day) Neck Uninvolved nodal stations: 44-50 Gy (2.0 Gy/day) Postoperative chemadiation Indicated f extracapsular nodal spread and/ positive margins3-5 Concurrent single agent cisplatin at 100 mg/m2 every 3 wks x 3 doses is recommended. Consider f other risk features: pt3 pt4 primary; N2 N3 nodal disease, nodal disease in levels IV V, perineural invasion, vascular embolism. 1 See Radiation Techniques (RAD-A). 2 Based on published data, concurrent chemadiation typically uses conventional fractionation at 2.0 g per fraction to 70 Gy in 7 wks with single agent cisplatin given every 3 wks at 100 mg/m2 x 3 doses. Use of other fraction sizes (eg, 1.8 Gy, conventional), multiagent chemotherapy, altered fractionation with chemotherapy has been evaluated with no consensus on the optimal approach. In general, the use of concurrent chemadiation carries a high toxicity burden--altered fractionation multiagent chemotherapy will likely further increase toxicity burden. F any chemadiation approach, close attention should be paid to published repts f the specific chemotherapy agent, dose, and schedule of administration. Chemadiation should be perfmed by an experienced team and should include substantial supptive care. 3Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with without concomitant chemotherapy f locally advanced head and neck cancer. N Engl J Med 2004;350:1945-1952. 4 5 Cooper JS, Pajak TF, Fastiere AA, et al. Postoperative concurrent radiotherapy and chemotherapy f high-risk squamous-cell carcinoma of the head and neck. N Engl J Med 2004;350:1937-1944. Bernier J, Cooper JS, Pajuk TF, et al. Defining risk levels in locally advanced head and neck cancers: A comparative analysis of concurrent postoperative radiation plus chemotherapy trials of the EORTC (#22931) and RTOG (#9501). Head Neck 2005;27:843-850. Note: All recommendations are categy 2A unless otherwise indicated. Clinical Trials: believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2009, 05/27/09 2009 National Comprehensive Cancer Netwk, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any fm without the express written permission of. ORPH-A