Oropharyngeal squamous cell carcinoma (SCC) is a common type of head and neck cancer often linked to tobacco, alcohol use, and, in youngers, HPV infection. Standard care for locally advanced SCC involves radiotherapy (RT) and cisplatin, (total doses of 66–70Gy in 30–35fractions). However, some patients with significant comorbidities cannot tolerate chemotherapy, requiring alternative approaches. We present a case of a 66-year-old male with p16-negative oropharyngeal SCC and bulky cervical nodal metastasis, ineligible for chemotherapy.

The patient was treated using adaptive volumetric modulated arc therapy (VMAT) with simultaneous integrated boost (SIB) and central gross tumor volume (GTV) dose escalation. This approach delivered up to 72Gy to the central GTV in 30 fractions; 66 Gy in 30 fractions to the high-risk area; 60Gy in 30 fractions to the intermediate-risk area; 54 Gy in 30 fractions to the low-risk area.

An epithelolysis (grade 3) led to a four-day treatment pause. A mid-treatment CT showed tumor shrinkage, reducing the nodal GTV volume from 107to 33cc, prompting adaptive planning to optimize dose distribution and reduce toxicity. The patient completed RT without further interruptions. At six months post-treatment, no recurrence or severe toxicities were detected and four years post-treatment, the patient remains in complete remission without significant late toxicity.

This case demonstrates the effectiveness of VMAT with SIB in delivering accelerated radiotherapy to a bulky nodal lesion in a patient with p16-negative oropharyngeal SCC unfit for chemotherapy; This allowed for tumor control while minimizing exposure to critical structure.

The Hayes-Martin manoeuvre involves ligation of the posterior facial vein and superior reflection of the investing fascia below the mandible to preserve the marginal mandibular nerve. The peri-facial nodes thus remain undissected. We perform this manoeuvre routinely during modified radical neck dissection for metastatic oropharyngeal squamous cell cancer. Here, we review the oncological safety and marginal mandibular nerve preservation rates of this manoeuvre from 2004 to 2009.

Retrospective review of the head and neck oncology database (2004–2009) at Addenbrooke's Hospital, Cambridge, UK, a tertiary referral centre for head and neck oncology.

Thirty-four patients underwent modified radical neck dissection for metastatic oropharyngeal squamous cell carcinoma. The primary tumour included the tonsil in 19 cases, base of tongue in 10 and posterior pharyngeal wall in 5. The neck nodal status was N1 in 4 cases, N2a in 11, N2b in 10, N2c in 4 and N3 in 5. All patients had adjuvant radiotherapy. Median follow up was four years (range, two to five). No peri-facial nodal region recurrences were seen. Four patients had temporary marginal mandibular nerve weakness; beyond two months, no weakness was seen.

In neck dissections for oropharyngeal squamous cell carcinoma, the marginal mandibular nerve and accompanying facial nodes can be safely preserved without oncological risk using the Hayes-Martin manoeuvre.