T3 (sort of) glottic cancer in an elderly patient

[Gfunk6]

I am seeing a gentlemen who is > 70 YO (not in the three-digit club) who was diagnosed with cT1bN0 glottis carcinoma. This fellow has multiple co-morbidities and, from what I gather, has a fairly low tolerance to pain. He had a staging CT of his neck with contrast which indicated invasion of the inner cortex of the thyroid cartilage, so technically T3N0.

Surgery is out.

After appropriate discussion of risks and benefits, I am seriously considering treating him like a T2N0 (5 x 5 field using opposed laterals with wedges). I wonder if treating his neck with cause more harm than good.

Thoughts?

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[Pointless]

The accuracy of CT in detecting cartilage involvement is pretty low. I think its perfectly reasonable to treat him as an early glottic, especially given his age and PS.

 

[Cancerdancer]

Agree with your thoughts. Was the disease felt to be bulky on endoscopy? Any other concerning findings like paraglottic extension on imaging? If all point to low volume disease, think the question of some cartilage invasion on CT only isn't likely to appreciably change your risk of subclinical LN involvement...

 

[Palex80]

What dose would you give if treating it as an early stage glottic cancer?

Some people do 70/2, other opts for mild hypofractionation with 2.2-2.5 Gy/fraction, others do hyperfractionated-accelerated treatments...

 

[Gfunk6]

I hypofractionate per the Japanese data.

 

[medgator]

I am seeing a gentlemen who is > 70 YO (not in the three-digit club) who was diagnosed with cT1bN0 glottis carcinoma. This fellow has multiple co-morbidities and, from what I gather, has a fairly low tolerance to pain. He had a staging CT of his neck with contrast which indicated invasion of the inner cortex of the thyroid cartilage, so technically T3N0.

Surgery is out.

After appropriate discussion of risks and benefits, I am seriously considering treating him like a T2N0 (5 x 5 field using opposed laterals with wedges). I wonder if treating his neck with cause more harm than good.

Thoughts?

I figured surgery didn't have to be on the table in the first place if there was just inner cortex invasion?

You'll end up getting some of the next nodes in with the box fields anyways. What I wonder is if there is a need for chemo in this situation with "T3" disease.... assuming he'd tolerate concurrent?

 

[Neuronix]

If he's that frail we'd avoid giving chemo. MACH-NC found no benefit to chemo in the >70yo subset.

 

[medgator]

If he's that frail we'd avoid giving chemo. MACH-NC found no benefit to chemo in the >70yo subset.

Yeah that's true. Do you guys follow that for patients with extensive nodal disease as well?

 

[Neuronix]

Depends on the attendings involved (med onc and rad onc side) and the patient's performance status. 71 year old PS0, would likely give chemo. 85 year old PS2, probably not. Everything in between is a gray area. You have to balance the 6.5% survival benefit from MACH-NC with the real chance of disabling or killing frail patients with the addition of chemo to that already harsh radiotherapy regimen. Since there's no data I'm aware of to help us, it's a judgment call.

 

[Scatter]

CT is not great at identifying TC invasion/penetration. At the ASTRO H&N Cancer Symposium earlier this year (btw, great meeting), Jonathan Beitler from Emory gave a nice talk on this. CT identifies only 59% of the TC invasion/penetration, but if identified on CT, it's confirmed pathologically in <75% patients. (JCO May 2010; vol 28 #14, p. 2318). Dual energy CT scans (100 and 140 kV tube voltage) and/or MRIs (talk to your HN radiologist) or iodine overlay images are better at ID'ing it. (European Journal of Radiology, vol 83, 2014 e23-35). Re: the patient, I agree with postage-stamp fields (anteriorly wedged opposed lats).