Ipsilateral or bilateral neck RT

[Palex80]

45 year old male patient with a righ-side well lateralized tongue SCC pT1 pN0 cM0 G2 R0 resected one year ago. He did not receive adjuvant treatment.
He presented 1 month ago with a growing lateralized lesion in the right neck, Level 2b. Resection revealed a 2,5 cm SCC metastasis, no (residual?) lymph node tissue found, lesion was resected R0. Preoperative PET showed no other lesion.

We want to give 50 Gy for PTV1 and then 14 Gy for PTV2 (LN region).
Would you include the neck levels bilateral or just ipsilateral into PTV1?

---

Members don't see this ad.

 

[deleted4401]

Good question.. I don't know how much data there is to support either option. You can say it came back quick (1 year) and so it's aggressive, so hit it bilaterally, perhaps giving him the best shot for cure or you can say that recurrent head and neck cancer has a terrible prognosis, and there is no use drying out his mouth for the last 12 months of his life.

My non-evidence based opinion would be to treat both sides of the neck, trying to stay low on the contralateral side to spare that parotid as best as possible. Dose seems fine, little higher than I'd go, but Euro is trading higher than the Dollar currently.

-S

 

[Cancerdancer]

Whoops, misread that, retracted to avoid confusing others.

I would still favor ipsilateral though...

 

[deleted4401]

1. it's an oral tongue not tonsil 2. it's recurrent, not primary...

 

[BraggPeak]

I would vote for bilateral for sure

 

[Gfunk6]

I had a case very similar to yours. My patient also had a pT1N0M0 well-lateralized SCC of the oral tongue and underwent and partial glossectomy w/ clear margins. The neck was not addressed.

She ended up failing ~ 1 year later in an ipsilateral Level IA LN. I treated her post-op bed, her ipsi neck and contra neck. Data for this particular clinical scenario is sparse and I think we need to extrapolate a bit from treatment of primary oral tongue cancers.

Nancy Lee gave the Spring Refresher talk last year and she was pretty adamant about treating bilateral neck for oral tongue cancers. She said something along the lines of, "the tongue is not a a bilateral organ! It is a unilateral mid-line structure and therefore both sides of the neck need to be treated." She then gave a couple of anecdotes of patients she treated unilaterally who had a contra failure.

The University of Iowa has published quite a bit on this subject. One of their papers in the Red Journal (2007) looked at patterns of failure after IMRT for primary oral tongue cancers. In their discussion section, they wrote:

Three patients failed in the contralateral lymph nodes; 2 failed in contralateral Level IB, which received 60 Gy, and 1 failed in contralateral Level III, which was not irradiated. Chow et al. (14) reported eight contralateral lymph node recurrences in 72 oral cavity cancer patients after treatment and found that positive ipsilateral lymph nodes was a significant predictive factor. Kurita et al. (15) reported 19 of 129 oral cavity cancer patients had contralateral lymph node metastasis. They found that, whereas T stage, number of involved ipsilateral lymph nodes, and histopathologic grading were independent and significant predictors, contralateral lymph node metastasis never occurred in patients without ipsilateral lymph node metastasis. For oral cavity cancer with ipsilateral lymph node involvement, it is therefore critical to include bilateral neck in the radiation field. For locally advanced oral cavity cancer, particularly those that cross the midline, it is also necessary to include bilateral neck. There is a much higher risk for contralateral regional failure in oral tongue cancer, because oral tongue has multiple and rich lymphatic intercommunications compared with other regions of oral cavity (16). Fakih et al. (17) showed a 40% neck recurrence in the group of patients that underwent hemiglossectomy and radical neck dissection with no adjuvant postoperative radiation. All had recurrence in the contralateral neck. It is possible that elective neck dissection may predispose aberrant migration of in-transit cancer cells to the opposite side of the neck. Therefore, contralateral neck should be included in the radiation field in postoperative IMRT for oral tongue cancer.

 

[Cancerdancer]

Agreed, upfront if you're treating adjuvantly for some reason, you treat bilateral. Good material there Gfunk.

Still, the contralateral neck has stood the test of time. If a tumor cell had split off from the primary a year ago and spread to the contralateral neck, highly unlikely that it would be undetectable at this timepoint.

Furthermore, I disagree that this situation is dire from a prognostic standpoint as we often think of recurrent H&N. I think the likelihood of long-term cancer-specific survival in this patient still approaches that of an upfront T1N0 lateral tongue...without looking at data, just off the cuff, 80-90% at 5 years. So I don't think 'don't treat the contralateral neck to avoid drying his mouth the last 12 months of his life' but more like don't dry his mouth as he's likely to be around another 5-10 years.

 

[Palex80]

Still, the contralateral neck has stood the test of time. If a tumor cell had split off from the primary a year ago and spread to the contralateral neck, highly unlikely that it would be undetectable at this timepoint.

I am not so certain, that is true. A metastatic mass of 2,5 cm without any lymphatic tissue evident may very well find access to lymphatic vessels in the neck and then cross to the other side, aided by the neck dissection one year ago, which has changed the normal pattern of spread now.

Furthermore, I disagree that this situation is dire from a prognostic standpoint as we often think of recurrent H&N. I think the likelihood of long-term cancer-specific survival in this patient still approaches that of an upfront T1N0 lateral tongue...without looking at data, just off the cuff, 80-90% at 5 years. So I don't think 'don't treat the contralateral neck to avoid drying his mouth the last 12 months of his life' but more like don't dry his mouth as he's likely to be around another 5-10 years.

I don't understand your point here. This patient has a stage III recurrent disease right now, he used to have primary stage I disease one year ago. How's his prognosis still the same?

 

[Reaganite]

Agreed, upfront if you're treating adjuvantly for some reason, you treat bilateral. Good material there Gfunk.

Still, the contralateral neck has stood the test of time. If a tumor cell had split off from the primary a year ago and spread to the contralateral neck, highly unlikely that it would be undetectable at this timepoint.

Furthermore, I disagree that this situation is dire from a prognostic standpoint as we often think of recurrent H&N. I think the likelihood of long-term cancer-specific survival in this patient still approaches that of an upfront T1N0 lateral tongue...without looking at data, just off the cuff, 80-90% at 5 years. So I don't think 'don't treat the contralateral neck to avoid drying his mouth the last 12 months of his life' but more like don't dry his mouth as he's likely to be around another 5-10 years.

Hmmm, you think a regionally recurrent head and neck cancer caries the same prognosis as an upfront T1N0? The only scenario that I think would portend well for this patient would be if the neck was not addressed up front. (was it? didn't see mention of a neck dissection). In that case, I guess you could argue that perhaps this patient was T1N+ from the get-go, and now the neck disease is manifesting itself, rather than this being a true regional recurrence after primary treatment of the neck.

In terms of neck treatment, in the face of regionally recurent disease with an oral tongue primary, I'd offer bilateral treatment unless someone could convincingly show me it's not needed. I'd say this is especially true in the era of IMRT since you can spare his contralateral parotid.

 

[medgator]

In terms of neck treatment, in the face of regionally recurent disease with an oral tongue primary, I'd offer bilateral treatment unless someone could convincingly show me it's not needed. I'd say this is especially true in the era of IMRT since you can spare his contralateral parotid.

Thats how I feel. A surgeon OTOH might just do an ipsilateral selective neck

 

[Palex80]

Hmmm, you think a regionally recurrent head and neck cancer caries the same prognosis as an upfront T1N0? The only scenario that I think would portend well for this patient would be if the neck was not addressed up front. (was it? didn't see mention of a neck dissection). In that case, I guess you could argue that perhaps this patient was T1N+ from the get-go, and now the neck disease is manifesting itself, rather than this being a true regional recurrence after primary treatment of the neck.

The neck was adressed during the primary tumor resection, the patient received an ipsilateral neck dissection (pN0), 16 nodes were removed.