Post-Op Head and Neck Dosing

[RadOncMegatron]

What dose would you guys do to the dissected neck for T3-4N0 Oral Tongue (no ECE ; negative margins).

UpToDate (UpToDate) had a very interesting regimen for their dissected but not involved nodes:

"Operated but non-tumor-bearing areas typically receive 56 to 57 Gy"

I'd hate to give 60 Gy to the dissected negative neck, but due to the radiobiology of hypoxia want to do more than 54, but is 56 - 57 really that much more?

54 Gy seems reasonable to the undissected neck, esp. if we are thinking 45 Gy can be considered an appropriate microscopic disease dose (I'm trying to tell myself I'm giving an extra 9 Gy for the hypoxia).

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[OTN]

54 Gy in 1.8s for undissected, clinically-negative neck seems reasonable to me.

 

[RadOncMegatron]

54 Gy in 1.8s for undissected, clinically-negative neck seems reasonable to me.

What about dissected negative neck?

 

[Ray D. Ayshun]

What about dissected negative neck?

I just do 50 Gy to elective neck, dissected or not, without chemo. I'd only do 45 Gy, or 44 Gy, if concurrent chemo. Happy to hear if there's a better way as post-op head and neck is the bane of my existence.

 

[OTN]

What about dissected negative neck?

Could drop down to 51 Gy in 1.7s

 

[drewdog1973]

Author must have been from MDACC

 

[seper]

I'd do 54/30 fx to ipsilateral dissected neck and omit contralateral neck if nodal yield was very good

 

[SubserviantToABR]

How about 0 Gy for HPV+ OPX: Surgery alone for transorally resected human papillomavirus–driven head and neck cancer—Can we de‐intensify adjuvant therapy to 0 Gy and 0 mg/m2?

Everyone is coming to omit radiation. No more biryani, only breadlines...

 

[communitydoc13]

I pretty much follow the Uptodate Guidelines in this circumstance. 60/57/54 dose painting with 57 for dissected negative neck. I still treat neck for high risk primary features and never get cute with OC volumes. Outcomes with OC still much worse than OP no matter what you do.

 

[OTN]

How about 0 Gy for HPV+ OPX: Surgery alone for transorally resected human papillomavirus–driven head and neck cancer—Can we de‐intensify adjuvant therapy to 0 Gy and 0 mg/m2?

Everyone is coming to omit radiation. No more biryani, only breadlines...

How about no surgery instead? (ORATOR trial linked below)

Radiotherapy versus transoral robotic surgery and neck dissection for oropharyngeal squamous cell carcinoma (ORATOR): an open-label, phase 2, randomised trial

Patients treated with radiotherapy showed superior swallowing-related QOL scores 1 year after treatment, although the difference did not represent a clinically meaningful change. Toxicity patterns differed between the groups. Patients with OPSCC should be informed about both treatment options.

www.thelancet.com

 

[evilbooyaa]

For oral cavity tumors, I've transitioned to 60 to N+ areas of the neck, 57 to N- dissected neck, and 54 to N- undissected neck.

Maybe it's just bad biology and the extra 3Gy probably doesn't matter in terms of oncologic control but anecdotally saw many nodal failures in 54Gy to N- dissected neck. It's probably treating me mentally more than the patient. Had an attending (not MDACC trained) who did something similar.

This is also supported by a mednet answer from Adam Garden (who is from MDACC) as noted above saying that's what he does.

Could drop down to 51 Gy in 1.7s

Generally dissected N- neck is thought to require more dose due to post-operative hypoxia, not less.

I just do 50 Gy to elective neck, dissected or not, without chemo. I'd only do 45 Gy, or 44 Gy, if concurrent chemo. Happy to hear if there's a better way as post-op head and neck is the bane of my existence.

I would not do < 50Gy at 2Gy/fx, in an oral cavity case especially, with or without chemotherapy.

I'd do 54/30 fx to ipsilateral dissected neck and omit contralateral neck if nodal yield was very good

I consider omission of contralateral neck IF they have a neck dissection on that side per the Contreras Phase II trial. If it is an oral tongue SCC that only had ipsilateral dissection, I still treat bilaterally. There is some retrospective data to suggest treating ipsilateral neck is not unreasonable in oral tongue, but I do not think that is standard as of yet.

 

[evilbooyaa]

How about 0 Gy for HPV+ OPX: Surgery alone for transorally resected human papillomavirus–driven head and neck cancer—Can we de‐intensify adjuvant therapy to 0 Gy and 0 mg/m2?

Everyone is coming to omit radiation. No more biryani, only breadlines...

Yeah no... E3311 (https://ascopubs.org/doi/abs/10.1200/JCO.2020.38.15_suppl.6500) tried that in a well selected patient population and got a 10% rate of patients who were eligible for observation alone. 31% ended up with trimodality therapy instead of just doing chemoRT. So why do surgery at all?

ORATOR-1 showed improvement in swallowing outcomes with RT, not with TORS (but clinically insignificant)

ORATOR-2 closed due to safety concerns in the TORS arm, thread below:

 

[SubserviantToABR]

Yeah no... E3311 (https://ascopubs.org/doi/abs/10.1200/JCO.2020.38.15_suppl.6500) tried that in a well selected patient population and got a 10% rate of patients who were eligible for observation alone. 31% ended up with trimodality therapy instead of just doing chemoRT. So why do surgery at all?

ORATOR-1 showed improvement in swallowing outcomes with RT, not with TORS (but clinically insignificant)

ORATOR-2 closed due to safety concerns in the TORS arm, thread below:

I don't disagree with you at all. H&N is my main practice, and most of my surgeons will offer CRT, except one surgeon who will TORS anything. My quoting of this paper was to reflect that there are people out there advocating no RT in opinion pieces (this guy is a med onc), despite having good prospective studies that you mentioned. An opinion piece is almost as good as an emulated clinical trial . Also, this should be written with a rad onc. I'm surprised that this guy from UNC didn't ask Chera for his input.

 

[evilbooyaa]

In fairness, I had not read the whole article and didn't realize it was a med onc writing (figured was a H&N surgeon). Having now read the whole editorial:

The med onc editorial is asking "can we do it", and there is retrospective data that suggests it's OK. He does mention ORATOR-1 and E3311. He looks to the future awaiting results of multiple trials.

Of course he mentions induction like every med onc who treads H&N seems to be contractually obligated to mention. But yeah, maybe we can revise who needs adjuvant therapy to be broader than it was on E3311. But I think de-escalation should be done based on prospective trial data, not retrospective series.

 

[TheWallnerus]

How about 0 Gy for HPV+ OPX: Surgery alone for transorally resected human papillomavirus–driven head and neck cancer—Can we de‐intensify adjuvant therapy to 0 Gy and 0 mg/m2?

Everyone is coming to omit radiation. No more biryani, only breadlines...

Can I charge a complex treatment plan for 0 Gy?

 

[Ray D. Ayshun]

Does all our hand-waving about post-op hypoxia also apply to nodal basins and not just chunks of meat like brain tissue that have been sliced through?

 

[kimplera]

What about dissected negative neck?

we do 54 in 30 fractions to negative neck

 

[Palex80]

DAHANCA guidelines do allow to go lower than 50/2 for elective neck coverage.

 

[gmsquid]

Post op 57.6 is based on poorer out comes with lower doses in the Peters trial. I never go lower than 57 in dissected tissue.