Pyriform Sinus

[TheWallnerus]

80yo male with history of controlled a-fib presents with BRBPR in Aug 2021 so bad he "almost passed out." H and H 11 and 31. Colonoscopy 9/21 shows 5cm cecal mass. 10/21, hemicolectomy specimen shows pT3 4cm mass, margins all negative, MSI-, 0/24 LNs positive. He is sent to med onc for eval. Med onc orders a pet scan on Oct 27.

He is sent to ENT. ENT scopes him, sees nothing. Takes him to OR for directed biopsies of L pyriform sinus.

Four 0.2 to 0.7cm tissue specimens show

The patient is asymptomatic in the H&N region. And as mentioned clinical exam is negative.

A T1N0 p16+ HNSCC of pyriform is a very rare clinical entity. Especially in an 80yo with recently diagnosed pT3N0 colon Ca.

Wondering about XRT dose de-escalation, chemo, ENI to both necks, etc. My first thoughts are 60 Gy with low dose weekly CDDP to the L pyriform region, 45 Gy as the ENI dose to both necks.

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[temujim]

66 Gy RT alone, 41.4 to 2a/3/4 (6 if apex involved), BID once a week.

 

[TheWallnerus]

66 Gy RT alone, 41.4 to 2a/3/4 (6 if apex involved), BID once a week.

Love the idea. Do you do 6 fractions per week a lot. I honestly never have.

 

[Neuronix]

Without chemo I'd consider it standard

Five compared with six fractions per week of conventional radiotherapy of squamous-cell carcinoma of head and neck: DAHANCA 6 and 7 randomised controlled trial - PubMed

The shortening of overall treatment time by increase of the weekly number of fractions is beneficial in patients with head and neck cancer. The six-fractions-weekly regimen has become the standard treatment in Denmark.

pubmed.ncbi.nlm.nih.gov

 

[temujim]

Love the idea. Do you do 6 fractions per week a lot. I honestly never have.

Yeah. My standard for H&N patients not getting chemo for whatever reason.

That being said, dipped my toe in straight up hyperfractionation -- have to say that I've been impressed with their recovery. Many patients can't tell they've even been treated 3-6 mo plus post RT. Very satisfying. Half or more of patients refuse though because of logistics.

Have done some hypofractionation too for the very elderly... 54 in 18. Gets them through, but recovery is tough... whether it is the regimen or the performance status/age selection bias hard to say.

 

[TheWallnerus]

Without chemo I'd consider it standard

Five compared with six fractions per week of conventional radiotherapy of squamous-cell carcinoma of head and neck: DAHANCA 6 and 7 randomised controlled trial - PubMed

The shortening of overall treatment time by increase of the weekly number of fractions is beneficial in patients with head and neck cancer. The six-fractions-weekly regimen has become the standard treatment in Denmark.

pubmed.ncbi.nlm.nih.gov

I consider it standard too. However it seems Americans' opinion of it have been There is Something Semi Rotten in the State of Denmark. I just don't see much BID once a week in the American wild. Am I sheltered, non-observant, etc.

 

[elementaryschooleconomics]

In my fiefdom we do 6 fractions a week not-infrequently, but this is possible because of the control we have over our environment (we're not a giant insitution beholden to many masters).

It's great. We also switch to that (or BID 5 days a week) for patients who can't get chemo, like @temujim.

 

[mheat3]

Also would consider an MRI of the neck if possible to see if you can get a better sense of submucosal disease. Agree with DAHANCA regimen.

 

[Palex80]

I wouldn't give chemo. Are there any data supporting chemotherapy should be given on top of RT for a cT1 cN0 HNSCC? I am not aware of any.

I am playing with the idea of not covering the contralateral neck...
It's standard of care, I know. But what is the true isolated contralateral nodal recurrence risk in this situation if you do not treat the contralateral neck? Something like 3%?

 

[Krukenberg]

66 Gy RT alone, 41.4 to 2a/3/4 (6 if apex involved), BID once a week.

Is the 41.4 microscopic dose based on data? Haven’t heard of that before in a definitive setting outside of anal

 

[jondunn]

a T1N0 I would treat 66/30 per RTOG 0022

definitely no chemo

and yes treat the necks.

 

[Palex80]

Is the 41.4 microscopic dose based on data? Haven’t heard of that before in a definitive setting outside of anal

There is the Belgian ENI-deescalation trial with 40/2 for cN0 neck.

Recurrence patterns after a decreased dose of 40Gy to the elective treated neck in head and neck cancer - PubMed

The actuarial rate of recurrence in the electively irradiated lymph node regions was 3.9% (95% CI 1.8-6.0) at 2years. This incidence is comparable to recurrence rates after standard dose of 50Gy, suggesting that lower doses to the elective neck do not result in higher regional recurrences.

pubmed.ncbi.nlm.nih.gov

 

[TheWallnerus]

I wouldn't give chemo. Are there any data supporting chemotherapy should be given on top of RT for a cT1 cN0 HNSCC? I am not aware of any.

I am playing with the idea of not covering the contralateral neck...
It's standard of care, I know. But what is the true isolated contralateral nodal recurrence risk in this situation if you do not treat the contralateral neck? Something like 3%?

I don't think I know recurrence risk of t1n0 hypophar in untreated neck but the involvement risk with hypopharynx, even T1, is quite high. (Old data but classic.)

 

[RickyScott]

In terms of treating the necks, I sometimes skimp in older patients with poor performance and would consider treating just level 2 and 3. Judgement call.

 

[communitydoc13]

I say treat level VI. It's right there. Very, very hard to localize HP and chance that micro involvement of lateral pharyngeal wall high, so even RP not unreasonable. Be generous with primary tumor volume.

Agree with hypo and no chemo. (If T2N0, I would do weekly cis and no hypo).

In my mind, this is the absolute best paper for culling through ENI volumes. Maybe there is something better now?

Guidelines for delineation of lymphatic clinical target volumes for high conformal radiotherapy: head and neck region

The success of radiotherapy depends on the accurate delineation of the clinical target volume. The delineation of the lymph node regions has most impact, especially for tumors in the head and neck region. The purpose of this article was the development ...

www.ncbi.nlm.nih.gov

 

[elementaryschooleconomics]

I say treat level VI. It's right there. Very, very hard to localize HP and chance that micro involvement of lateral pharyngeal wall high, so even RP not unreasonable. Be generous with primary tumor volume.

Agree with hypo and no chemo. (If T2N0, I would do weekly cis and no hypo).

In my mind, this is the absolute best paper for culling through ENI volumes. Maybe there is something better now?

Guidelines for delineation of lymphatic clinical target volumes for high conformal radiotherapy: head and neck region

The success of radiotherapy depends on the accurate delineation of the clinical target volume. The delineation of the lymph node regions has most impact, especially for tumors in the head and neck region. The purpose of this article was the development ...

www.ncbi.nlm.nih.gov

That's an amazing paper.

 

[evilbooyaa]

a T1N0 I would treat 66/30 per RTOG 0022

definitely no chemo

and yes treat the necks.

This is also what I would do, but nothing wrong with doing DAHANCA 6fx/week either.

I agree with RT alone, similar to how we treat supraglottic larynx. Cover LNs w/ IMRT.

With RT alone including necks I do 66/30 to gross, 60/30 to intermediate risk, 54/30 to lower risk. For Hypophx would treat RPs, consider V, idk that I would routinely treat VI with focused disease. I don't treat VI for glottic larynx or supraglottic larynx.

What a fortunate spot. Outcomes likely to be excellent.

 

[deleted1111261]

I like Dahanca

I think stage I HP is bad though. Why not radiosensitize if they are good shape?

 

[RickyScott]

I like Dahanca

I think stage I HP is bad though. Why not radiosensitize if they are good shape?

Agree, except for true larynx, I think every hn p16- t1/2 N0 should get chemo assuming pt is fit. It’s not like local control is 95%

 

[communitydoc13]

I like Dahanca

I think stage I HP is bad though. Why not radiosensitize if they are good shape?

It's a good point. I also am not confident that P16+ confers same benefit in non-OP H&N.

 

[temujim]

a T1N0 I would treat 66/30 per RTOG 0022

definitely no chemo

and yes treat the necks.

Really urge people not to do this regimen. 220 a day to 66 to mucosal H&N is associated with higher acute/late effects. If you read between the lines in the MDACC pubs you see this.

 

[temujim]

I like Dahanca

I think stage I HP is bad though. Why not radiosensitize if they are good shape?

no benefit to cis in this situation and only risks. Maybe if you dose reduce to 60 and do week on/week off like the old gortec (or was it gettec?) studies.

 

[TheWallnerus]

I like Dahanca

I think stage I HP is bad though. Why not radiosensitize if they are good shape?

Agree, except for true larynx, I think every hn p16- t1/2 N0 should get chemo assuming pt is fit. It’s not like local control is 95%

I think radiosens is my knee jerk in HNSCC but I don’t know if right knee jerk

I think I might be biased by knowing that certain prominent HN rad oncs at MDACC def give chemo to certain T1N0 HNSCC patients

 

[Lamount]

I think radiosens is my knee jerk in HNSCC but I don’t know if right knee jerk

I think I might be biased by knowing that certain prominent HN rad oncs at MDACC def give chemo to certain T1N0 HNSCC patients

Agree. Hypopharynx is bad news. No reason to chance it, if pt can tolerate.

 

[radoncopotamus]

No data for chemo in T1N0 hypopharynx or any HNSCC site I'm aware of. Esp in an 80 year old. I have seen TORS done in this situation before although also no data for that.

 

[Krukenberg]

Really urge people not to do this regimen. 220 a day to 66 to mucosal H&N is associated with higher acute/late effects. If you read between the lines in the MDACC pubs you see this.

Hypofrac for HN doesn’t make much sense to me from both a late effects and a/b perspective. DAHANCA for me

 

[communitydoc13]

Really urge people not to do this regimen. 220 a day to 66 to mucosal H&N is associated with higher acute/late effects. If you read between the lines in the MDACC pubs you see this.

Will have to look into this more. If you have a reference, please post.

Have routinely used this for pts who are poor candidates for chemo with generally good results. Persistent pain, necrosis seems to be more a function of size and infiltrating quality of the primary than anything else.

Seems a little odd to me with the low hot spots we typically get now vs what was permitted on earlier H&N trials that 110% per day would be that bad.

Hypo is SOC for early stage glottic larynx and here only primary would be getting hypo as electives run at 180.

I do remember hypo + cis/erbitux trial. Agree that was clearly too much.

I agree that purely accelerated schedule biologically better for late effects. Hypo may have some LC benefit.

 

[deleted1111261]

When I went to Houston for some training, they said that they saw toxicity with 2.2, so they didn’t like to use it. They also don’t use for glottis larynx - they do 66/33

 

[jondunn]

Really urge people not to do this regimen. 220 a day to 66 to mucosal H&N is associated with higher acute/late effects. If you read between the lines in the MDACC pubs you see this.

You are silly.

 

[TheWallnerus]

In the very early days of IMRT no one thought you could do less than 1.8 Gy per day as the lowest dose. So some of the first H&N IMRT regimens were 30 fractions: 1.8 Gy/day to ENI and 2.4 Gy/day (72 Gy total dose) to gross disease and nodes. It wasn't long before all the H&N leaders in America using this regimen rapidly abandoned it. People were definitely hurt. I don't think any of the experiences were published but should have been.

 

[medgator]

You are silly.

Guess mdacc is silly too....

 

[RickyScott]

no benefit to cis in this situation and only risks. Maybe if you dose reduce to 60 and do week on/week off like the old gortec (or was it gettec?) studies.

When I went to Houston for some training, they said that they saw toxicity with 2.2, so they didn’t like to use it. They also don’t use for glottis larynx - they do 66/33

I have given it frequently for unilateral tonsil (no Chemo). Never seen toxicity. For glottic larynx, I thought 220/225 was standard? Toxicity occurs when start adding chemo to fraction sizes above 200-212. For true larynx, use imrt and can sometime reduce dose to one of artytenoifs by 5-10% depending on location of tumor

 

[radiation]

I always trust mendenhall papers on these, he actually writes them himself with little fluff

Primary radiotherapy for squamous cell carcinoma of the pyriform sinus - PubMed

The objective of this study is to report the long-term outcomes of primary radiotherapy (RT) for patients with T1-T2 squamous cell carcinomas (SCC) of the pyriform sinus. Between November 1964 and March 2008, 135 patients with T1-T2 pyriform sinus SCC were treated with primary RT at the...

pubmed.ncbi.nlm.nih.gov

"Patients are treated with altered fractionation using either hyperfractionation (7440 cGy in 62 fractions over 31 treatment days) or simultaneous integrated boost (7000 cGy/35 fractions over 30 treatment days). The former is preferred unless logistical considerations dictate otherwise. Patients with positive nodes receive concomitant weekly cisplatin 30 mg/M2. Patients undergo PET-CT scan 3 months following RT and those with residual regional disease undergo a planned neck dissection. Alternatively, the decision to add a neck dissection is based on a contrast-enhanced CT obtained 4 weeks after completion of RT [4, 31]."

 

[Radonc90]

In the very early days of IMRT no one thought you could do less than 1.8 Gy per day as the lowest dose. So some of the first H&N IMRT regimens were 30 fractions: 1.8 Gy/day to ENI and 2.4 Gy/day (72 Gy total dose) to gross disease and nodes. It wasn't long before all the H&N leaders in America using this regimen rapidly abandoned it. People were definitely hurt. I don't think any of the experiences were published but should have been.

IIRC, in the early days of IMRT, it was 2.0 Gy/fx, sometimes 1.8 Gy/fx throughout (primary site and elective neck): this was not the problem.
The problem was when IMRT was modified to S.I.B., primary site getting > 2.0 Gy/fx: the H&N mucosa was already having a hard time with 2.0 Gy/fx, when it is > 2.0 Gy/fx, the mucosa is having a tougher time. For me, 2.4 Gy/fx to mucosa is too much, I may accept 2.1 Gy/fx.

On the issue of elective neck now getting 1.5 Gy/fx (but pushed to 55-56 Gy)...well, it has to do with IMRT billing code.
I can get back to the group later if people want to know the history behind this (True for RTOG 0529 anal canal stuff too).

 

[TheWallnerus]

To add to the story. The fellow is 80 and lives alone. Good P.S. but has zero social or family support. And as mentioned recent history of colon cancer. Taking all this into account and suggestions by Palex and temujim which I kinda liked I am pondering a "DAHANCA cheat" regimen, no chemo.

Plan A: Necks + primary (2 Gy/fx)
Plan B: primary (2 Gy/fx)

Day 1: Plan A
Day 2: Plan A
Day 3: Plan A
Day 4: Plan A
Day 5: AM Plan A/PM Plan B
Day 6: Plan A
Day 7: Plan A
Day 8: Plan A
Day 9: Plan A
Day 10: AM Plan A/PM Plan B
Day 11: Plan A
Day 12: Plan A
Day 13: Plan A
Day 14: Plan A
Day 15: AM Plan A/PM Plan B
Day 16: Plan A
Day 17: Plan A
Day 18: Plan A
Day 19: Plan A
Day 20: AM Plan A/PM Plan B
Day 21: Plan B
Day 22: Plan B
Day 23: Plan B
Day 24: Plan B
Day 25: AM Plan B/PM Plan B
Day 26: Plan B
Day 27: AM Plan B/PM Plan B

40 Gy/20 fx to necks, 66 Gy/33 fx to primary... all over 27 tx days.

Patients are treated with altered fractionation using either hyperfractionation (7440 cGy in 62 fractions over 31 treatment days) or simultaneous integrated boost (7000 cGy/35 fractions over 30 treatment days).

Interestingly with time correction...

74.4*(1+1.2/10)-(43/2) = 62 BED Gy-10
66*(1+2/10)-(37/2) = 61 BED Gy-10

(43 elapsed days for 74.4/62, 37 elapsed days for 66/33)

 

[TheWallnerus]

IIRC, in the early days of IMRT, it was 2.0 Gy/fx, sometimes 1.8 Gy/fx throughout (primary site and elective neck): this was not the problem.

It was a "mathematical problem" only. One IMRT plan and one plan only was all that was possible or conceivable. The basic numerators (dose, to either elective or primary), denominators (fractions, same for elective and primary), constrained the bounds of reasonableness. Definitely saw many HN patients first-hand treated to 72 Gy/30 fx.

 

[Radonc90]

Well,

IMRT billing code allows only one charge for CPT 77301 per course of Tx, thus one IMRT plan for the whole Tx.
So, it was somewhat more economic (you can only bill one 77301 per course of Tx) than science (what is the appropriate dose/fx to the elective neck?).
There is more to it than "mathematical problem"...

 

[TheWallnerus]

Well,

IMRT billing code allows only one charge for CPT 77301 per course of Tx, thus one IMRT plan for the whole Tx.
So, it was somewhat more economic (you can only bill one 77301 per course of Tx) than science (what is the appropriate dose/fx to the elective neck?).
There is more to it than "mathematical problem"...

I am not certain whether people were thinking "billing constraint" re: one IMRT plan. Now we routinely do more than one IMRT plan per course of treatment so billing constraints went away? There was no software 20y ago to sum two disparate computed axial tomography IMRT plans. You could have obtained new scans and did new plans halfway through treatment 20 years ago, but no software was available to sum the two plans and create composite doses. The SIB/one IMRT plan concept emerged out of (lack of technology) technological necessity... not scientific necessity. It certainly appeared on the scene with ZERO randomized or retrospective evidence.

 

[Ray D. Ayshun]

40/20 to the necks? Where is this from?

 

[SubserviantToABR]

40/20 to the necks? Where is this from?

Recurrence patterns after a decreased dose of 40Gy to the elective treated neck in head and neck cancer - PubMed

The actuarial rate of recurrence in the electively irradiated lymph node regions was 3.9% (95% CI 1.8-6.0) at 2years. This incidence is comparable to recurrence rates after standard dose of 50Gy, suggesting that lower doses to the elective neck do not result in higher regional recurrences.

pubmed.ncbi.nlm.nih.gov

Reduction of the dose of radiotherapy to the elective neck in head and neck squamous cell carcinoma; a randomized clinical trial. Effect on late toxicity and tumor control - PubMed

In our study population there was no statistically significant difference regarding survival and estimated recurrence rates between both arms of this study. We found a trend toward less dysphagia at 6months (however not significant after longitudinal analysis) and found a significant reduction...

pubmed.ncbi.nlm.nih.gov

Prospective Phase 2 Study of Radiation Therapy Dose and Volume De-escalation for Elective Neck Treatment of Oropharyngeal and Laryngeal Cancer - PubMed

The results of this trial suggest that elective dose and volume reduction is oncologically sound for oropharyngeal and laryngeal cancer treated with intensity modulated radiation therapy, with promising quality-of-life outcomes.

pubmed.ncbi.nlm.nih.gov

 

[temujim]

To add to the story. The fellow is 80 and lives alone. Good P.S. but has zero social or family support. And as mentioned recent history of colon cancer. Taking all this into account and suggestions by Palex and temujim which I kinda liked I am pondering a "DAHANCA cheat" regimen, no chemo.

Plan A: Necks + primary (2 Gy/fx)
Plan B: primary (2 Gy/fx)

Day 1: Plan A
Day 2: Plan A
Day 3: Plan A
Day 4: Plan A
Day 5: AM Plan A/PM Plan B
Day 6: Plan A
Day 7: Plan A
Day 8: Plan A
Day 9: Plan A
Day 10: AM Plan A/PM Plan B
Day 11: Plan A
Day 12: Plan A
Day 13: Plan A
Day 14: Plan A
Day 15: AM Plan A/PM Plan B
Day 16: Plan A
Day 17: Plan A
Day 18: Plan A
Day 19: Plan A
Day 20: AM Plan A/PM Plan B
Day 21: Plan B
Day 22: Plan B
Day 23: Plan B
Day 24: Plan B
Day 25: AM Plan B/PM Plan B
Day 26: Plan B
Day 27: AM Plan B/PM Plan B

40 Gy/20 fx to necks, 66 Gy/33 fx to primary... all over 27 tx days.


Interestingly with time correction...

74.4*(1+1.2/10)-(43/2) = 62 BED Gy-10
66*(1+2/10)-(37/2) = 61 BED Gy-10

(43 elapsed days for 74.4/62, 37 elapsed days for 66/33)

Only caveat is I find much better control of the dose wash with 2 Gy to primary and 1.8 to the necks rather than 2 Gy to both primary/neck-- so will usually do 46 Gy/41.4 Gy in 23 fractions with a 20 Gy/10 fx boost.

 

[Ray D. Ayshun]

Recurrence patterns after a decreased dose of 40Gy to the elective treated neck in head and neck cancer - PubMed

The actuarial rate of recurrence in the electively irradiated lymph node regions was 3.9% (95% CI 1.8-6.0) at 2years. This incidence is comparable to recurrence rates after standard dose of 50Gy, suggesting that lower doses to the elective neck do not result in higher regional recurrences.

pubmed.ncbi.nlm.nih.gov

Reduction of the dose of radiotherapy to the elective neck in head and neck squamous cell carcinoma; a randomized clinical trial. Effect on late toxicity and tumor control - PubMed

In our study population there was no statistically significant difference regarding survival and estimated recurrence rates between both arms of this study. We found a trend toward less dysphagia at 6months (however not significant after longitudinal analysis) and found a significant reduction...

pubmed.ncbi.nlm.nih.gov

Prospective Phase 2 Study of Radiation Therapy Dose and Volume De-escalation for Elective Neck Treatment of Oropharyngeal and Laryngeal Cancer - PubMed

The results of this trial suggest that elective dose and volume reduction is oncologically sound for oropharyngeal and laryngeal cancer treated with intensity modulated radiation therapy, with promising quality-of-life outcomes.

pubmed.ncbi.nlm.nih.gov

Unable to open papers, but one study appeared to give chemo to all, and I commonly give 44 with chemo, which is also on nccn. The other paper looked to have all of 17 patients who got no chemo with 40 gy. This doesn't seem like a well studied approach. I don't do less than 50 for elective without chemo, and even less comfortable in p16-.

 

[communitydoc13]

When I went to Houston for some training, they said that they saw toxicity with 2.2, so they didn’t like to use it. They also don’t use for glottis larynx - they do 66/33

They weren’t including proton head and neck tx in this experience were they? Because as discussed in other thread uncertainty of those plans in terms of RBE likely very big.

Case is tough because it’s HP, which is bad. Salvage is laryngopharyngectomy and failure after salvage significant.

I never trained with Mendenhall so not an acolyte but guy does things differently than everybody else.

Regional failure was more in those neck De-escalation trials without chemo. I think 50 equivalent to neck without chemo well tolerated across the board with judicious volumes. Mucosal toxicity is what makes people quit.

Not pushing chemo here but benefit is two fold. Improved control and you are not hosed if you have to take a significant break. Durable control decreases rapidly with breaks with RT alone.

Regarding non-standard regimens? If quasi palliative always fine, but when possible bad biology I steer clear. 2 Early stage HP in elderly pts in past couple years.

T1N2c (tiny-subclinical nodes) and failed locally 1 year out. Glad I gave standard concurrent. Now salvaged and will see.

T2N0. Gave concurrent to 70 with 40 q week cis. NED 18 mos out and glad I gave std.

 

[deleted1111261]

Photons
70/35
66/33
Never more than 2 per fx
At least as of year ago

 

[TheWallnerus]

Only caveat is I find much better control of the dose wash with 2 Gy to primary and 1.8 to the necks rather than 2 Gy to both primary/neck-- so will usually do 46 Gy/41.4 Gy in 23 fractions with a 20 Gy/10 fx boost.

I am trying to avoid giving big field "Plan A" twice on same day on the BID days; thus the need/desire to run two plans simultaneously (vs SIB) for the first 4 weeks (and 24 fx) of tx. I don't see a reason to accelerate the fractionation in the elective region for this guy.

Unable to open papers, but one study appeared to give chemo to all, and I commonly give 44 with chemo, which is also on nccn. The other paper looked to have all of 17 patients who got no chemo with 40 gy. This doesn't seem like a well studied approach. I don't do less than 50 for elective without chemo, and even less comfortable in p16-.

He is p16+ and in fact a never-smoker. I admit I am trending toward lowest possible reasonable dosing here (although I think the primary dose turns out being reasonably brisk, but it will be a much smaller volume in a T1 hypophar obv). I just think with chemo, and/or excessive mucosal toxicity, we risk a tx break and/or he will not feel like driving himself in for treatment. He has to be his own 80yo caretaker himself throughout tx.

 

[Ray D. Ayshun]

I am trying to avoid giving big field "Plan A" twice on same day on the BID days; thus the need/desire to run two plans simultaneously (vs SIB) for the first 4 weeks (and 24 fx) of tx. I don't see a reason to accelerate the fractionation in the elective region for this guy.

He is p16+. I admit I am trending toward lowest possible reasonable dosing here (although I think the primary dose turns out being reasonably brisk, but it will be a much smaller volume in a T1 hypophar obv). I just think with chemo, and/or excessive mucosal toxicity, we risk a tx break and/or he will not feel like driving himself in for treatment. He has to be his own 80yo caretaker himself throughout tx.

Oh, neglected that. Just took it as a given that it's not related to HPV. If giving chemo fair enough. It's not the 80 yos I generally have probs with, it's the 50 yos

 

[TheWallnerus]

Oh, neglected that. Just took it as a given that it's not related to HPV

To me this was a very important part of the puzzle. On top of this also being essentially an "incidentaloma." It's all very peculiar, but favorably peculiar.

 

[Reaganite]

I often flip the order of treatment in these cases and start with GTV only to 20-24 (giving me the option of 46-50 to neck later), and let treatment tolerance dictate what I do later. If patient doing great, I proceed to whole neck or at least highest risk neck levels based on the frequency of involved nodal stations you posted earlier. I feel like this approach gives me the best chance at getting in the highest uninterrupted GTV dose on a patient who may not tolerate true definitive treatment.

 

[medgator]

Well,

IMRT billing code allows only one charge for CPT 77301 per course of Tx, thus one IMRT plan for the whole Tx.
So, it was somewhat more economic (you can only bill one 77301 per course of Tx) than science (what is the appropriate dose/fx to the elective neck?).
There is more to it than "mathematical problem"...

Dose painting is easier to plan than doing sequential boosts, esp for things like nasopharynx

 

[SneakyBooger]

200 X 23 = 4600 to neck and primary.
200 x 10 = 2000 for the boost.
Total to GTV = 6600.

From DAHANCA trial referenced above:
"Acute morbidity was significantly more frequent with six than with five fractions..."

For those who treat using the DAHANCA data, are you doing this also:
"All patients, except those with glottic cancers, also received the hypoxic radiosensitiser nimorazole."