How would you manage a small to medium sized but unresectable nodal recurrence within the original treatment volume for a head and neck squamous cell carcinoma?

There are a lot of points to consider before you can make this decision:

1. what is the time interval from prior RT?
2. what dose was received to this node from prior RT?
3. what are the critical organs at risk if you were to treat this node?
4. why is this node considered unresectable?
5. how large is the nodal recurrence? what level?

If the RT was in the prior year and dose was 70Gy, I don't see the value to more RT. I think you need surgery, or in an extreme scenario, could consider SBRT +- Immunotherapy if there are no better options. This is high morbidity.

If the RT was >18 mos, not 70Gy, and critical organs are limited in the field (eg mandible, plexus), I would consider SBRT. Data for SBRT and chemo together are limited, but you may want to co...

There are 3 papers published in 2018 addressing some of these questions. A prognostic index, a comparison of conventional (IMRT) re-irradiation and SBRT, and an assessment of dose, fractionation, and volumes if performing conventional IMRT re-irradiation (Mar 2018, IJROBP).

If electing SBRT, doses in excess of 35 Gy in 5 fractions qod are probably advisable. If electing conventional IMRT, then doses of 66 - 70 Gy conventionally fractionated to the gross disease plus margin are probably advisable. Hyperfractionation and elective nodal radiation did not appear to be helpful.