How would you best manage a medically inoperable oral cavity squamous cell carcinoma that is locally advanced and node-positive with likely extranodal extension?  

Assuming the patient can receive chemotherapy, the expected DFS from standard concurrent chemo-RT is 50% or less. Options to try and improve the prognosis are 1. Higher RT dose than standard, 2. Altered fractionation alone, 3. Altered fractionation concurrent with chemo, 4. Adding cetuximab to concu...

Chemo RT with altered fractionation. Induction chemo would be ok but probably doesn’t improve cure rate. Brachytherapy would be off the table because of the extent of disease. Simply not reasonably covered with an implant. 

Given that all the above options have a low chance of cure, supportive care with palliative RT or palliative chemo are also good options and should be discussed with the patient.

Aggressive chemoRT which probably won’t work. That said, hats off to Grant Achatz, U. Chicago, and Alinea. Long odds from my perspective. Kudos! My plan probably would not have worked. 74.4 Gy at 1.2 Gy bid with cisplatin 30 mg/M2 per week.

For medically inoperable but surgically resectable patients (T3/T4a), performance status and medical co-morbidities are also an important consideration in my practice while selecting non-surgical treatment. Another important consideration is the sub-site within the oral cavity. In my experience, buc...

It is important to remember that dose/treatment intensification may not be the most optimal/practical approach for patients who are inoperable due to medical co-morbidities. 

Chemo-RT and keep the pd-l1 therapy/keytruda on standby for the inevitable persistent/recurrent disease.