How would you approach a patient with synchronous HPV-mediated bilateral tonsil primary with ipsilateral lymph nodes who cannot receive chemotherapy?

We address this type of scenario in the guideline published last year in PRO Margalit et al., PMID 39078350. I hope the explanations there are useful, but to summarize, in the MARCH meta-analyses, most altered fractionation types improve locoregional control, but only hyperfractionation (often 1.2 G...

Other than the 2 primaries instead of one, the approach shouldn't be different.

With regard to radiation, without details of the staging, it is hard to make a specific recommendation. Usually, though, bilateral tonsil disease has at least one side with T1 and is often an incidental surgical or radio...

DAHANCA style - 6 Fx per week, one day a week BID. This study was for glottic larynx, but can extrapolate. Also, the Danes studied a complete BID approach for unresectable head and neck cancer that had great results, delivering 76 Gy in 56 Fx.

Dahanca accelerated RT, 6# per week, is very effective at mitigating omission of chemotherapy for T1-2N1 HPV-related OPC (Barcelona et al., PMID 40262333).

The stage of primary disease and resectability isn’t given, but an alternative approach to explore in this patient would be upfront surgery with ...

Depends on age, performance status, logistics, and disease burden/symptoms. If able to do hyperfractionation (6960-8160 in 120 BID, depending on disease burden), would prefer. If not, consider a hypofractionated course of 5,400 in 18 fractions. As noted in other answers, DAHANCA with 6 fractions a w...