Tonsil

[deleted4401]

What do you guys use as your primary GTV in tonsil cases where do they do a tonsillectomy that basically takes out the entire mass, but in a non-oncologic procedure? This guy was clinical T1N2aM0

This usually occurs before any imaging, so there is not a good pre-op CT or PET-CT. Just target the tumor bed with a 1-2 cm margin? Do you guys take to full dose, post-op dose, or somewhere in between?

I hate when they do this.
-SimulD

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[Palex80]

Dear SimulD

I guess it's dependent on what the postoperative status is. If this is a small, incidental carcinoma with wide resection margins you have a different situation than if you are dealing with a R1-resection with multiple positive margins.
I would treat a small, incidental carcinoma with wide resection margins as I would treat a postoperative tonsil cancer: 64/2 Gy and the CTV defined as the tonsil region with a 1 cm margin.
I would treat a R1-resected tonsil cancer with uncertain infiltration of the surrounding tissues with a wider GTV->CTV margin of 2 cm and would also order an MRI to rule out deep infiltration of adjacent structures (muscles, etc), although interpreting such an MRI can be quite frustrating in the postoperative setting. R1-resected tonsil cancer with N2a-neck would get radiochemotherapy in my department, I would probably give 70 Gy in most cases. If the MRI looks harmless and the R1-margin was not huge, I may cut back to 66 Gy.

I have also encountered a couple of patients, which were resected upfront with a debulking sling-technique, because the tonsil primaries were so big, that the patients had difficulties breathing & swallowing. Basically R2-resections, so I treated them as I would treat primary tonsil cases: 70 Gy radiochemotherapy (they all had macroscopic neck nodes too).

 

[Reaganite]

What do you guys use as your primary GTV in tonsil cases where do they do a tonsillectomy that basically takes out the entire mass, but in a non-oncologic procedure? This guy was clinical T1N2aM0

This usually occurs before any imaging, so there is not a good pre-op CT or PET-CT. Just target the tumor bed with a 1-2 cm margin? Do you guys take to full dose, post-op dose, or somewhere in between?

I hate when they do this.
-SimulD

Just to throw another wrench in this case...would anyone treat this patient with RT alone?

http://onlinelibrary.wiley.com/doi/...ionid=C9371EC42EBD73419524A0CE022D0405.d03t02

 

[Cancerdancer]

RTOG 00-22 provided good prospective evidence for RT alone in these kind of patients (allowed 'excisional biopsy' of the primary) but included N0-1, or with 'small N2 disease by imaging.' Presuming that meant 2-3 small suspicious LNs. A N2a neck with a >3 cm LN would make me nervous, however, about foregoing the chemo in terms of local control...
If you add the chemo with this rationale (for the LN) I would then feel more comfortable about a postop dose to the primary...

 

[Palex80]

I knew the discussion of whether chemotherapy is a good idea or not would come along...


A R1-resected tonsillary cancer would qualify for RTOG 9501 (PMID: 15128893) and EORTC 22931 (PMID: 15128894). In the Bernier analysis (PMID: 16161069), patients with R1-resected tumors benefited from additional chemotherapy.

Thus, I say:


THIS PATIENT NEEDS

!!!

 

[seper]

In a case like this, target size needs to be generous. I outline tonsillar fossa on CT, add 1 cm PTV margin and then verify that PTV includes potential routes of spread, notably ipislateral BOT.

 

[medgator]

What do you guys use as your primary GTV in tonsil cases where do they do a tonsillectomy that basically takes out the entire mass, but in a non-oncologic procedure? This guy was clinical T1N2aM0

This usually occurs before any imaging, so there is not a good pre-op CT or PET-CT. Just target the tumor bed with a 1-2 cm margin? Do you guys take to full dose, post-op dose, or somewhere in between?

I hate when they do this.
-SimulD

In a case like this, target size needs to be generous. I outline tonsillar fossa on CT, add 1 cm PTV margin and then verify that PTV includes potential routes of spread, notably ipislateral BOT.

I'm generous as well. Essentially the radiation is targeting areas that might have been removed during a radical procedure (including superior along the pillars/fossa, and inferiorly towards the BOT). Since the margins are notoriously difficult to be certain of in those procedures, I'd at least go to 66 Gy/33 Fx, myself.

 

[deleted4401]

Update: was grossly resected, tumor at margin, but nothing seen on PET-CT. MRI pending, but I don't think it will show much. Going to treat both sides, and give weekly cis. I have a feeling it's overtreat, but I just don't feel like I have much room. Going to do UCSF fx - 54.1 to both sides of neck/33 fx (ipsi IB-V, contra IB-IV), 69.96/33 fx to gross dz, no intermediate dose, as dose cloud will take care of adjacent lymphatics. Tumor bed contoured generously + 1.0cm margin, CTV, carving out mandible/vertebra. 0.3 cm margin for PTV. 1.0cm margin on LN for CTV, carving out bone. 0.3cm margin for PTV.

Oh, Palex, can't use Bernier and Cooper for justification. Those guys did oncologic resection of primary and bilateral lymph node dissection. No one in my community can do radical tonsillectomy or bilateral LND... I'm in the cut.

-S

 

[medgator]

Oh, Palex, can't use Bernier and Cooper for justification. Those guys did oncologic resection of primary and bilateral lymph node dissection. No one in my community can do radical tonsillectomy or bilateral LND... I'm in the cut.

-S

Wouldn't it make it all the more reason to chemo in this case, since less was taken out, and there is still positive margin?

Also, with N2a disease, I generally give the lymphatics immediately surrounding the positive node 59.4/33 Fx as an "intermediate" risk area.

 

[Reaganite]

Update: was grossly resected, tumor at margin, but nothing seen on PET-CT. MRI pending, but I don't think it will show much. Going to treat both sides, and give weekly cis. I have a feeling it's overtreat, but I just don't feel like I have much room. Going to do UCSF fx - 54.1 to both sides of neck/33 fx (ipsi IB-V, contra IB-IV), 69.96/33 fx to gross dz, no intermediate dose, as dose cloud will take care of adjacent lymphatics. Tumor bed contoured generously + 1.0cm margin, CTV, carving out mandible/vertebra. 0.3 cm margin for PTV. 1.0cm margin on LN for CTV, carving out bone. 0.3cm margin for PTV.

Oh, Palex, can't use Bernier and Cooper for justification. Those guys did oncologic resection of primary and bilateral lymph node dissection. No one in my community can do radical tonsillectomy or bilateral LND... I'm in the cut.

-S

What about RPLNs? Also, do you need to cover contralateral 1B?

I think the chemo question is an interesting one. I once saw a T2N0 supraglottic larynx patient who had a large exophytic component that was causing airway compromise. He ultimately underwent a "debulking" surgery wherein they removed the exophytic component. Obviously, this was not an oncologic resection and residual disease was left behind. So would you say he also had a positive margin and would need chemo-RT? The way I would rationalize this is that a simple tonsillectomy is more akin to a biopsy, and you would not have the same level of devascularization and thus hypoxia as you would get with a true oncologic surgery. So I wouldn't necessarily feel uncomfortable treating the patient with RT alone.

 

[Palex80]

Oh, Palex, can't use Bernier and Cooper for justification. Those guys did oncologic resection of primary and bilateral lymph node dissection. No one in my community can do radical tonsillectomy or bilateral LND... I'm in the cut.

Bilateral LND was not part of the study inclusion criteria for both trials. The EORTC paper says: "The extent of surgical resection of the primary tumor and neck-dissection procedures followed accepted criteria for adequate excision, which depend on the volume and location of the tumor". Whatever that means...

Does the patient have ECE, by the way?
And what about the primary? Is it "just" a purely tonsil cancer or is there involvement of adjacent structures, like uvula, base of tongue, etc?

I like your PTV-definition and dose prescription. I've never done the UCSF fractionation myself, it sounds interesting.

Wouldn't it make it all the more reason to chemo in this case, since less was taken out, and there is still positive margin?

Precisely!

I think the chemo question is an interesting one. I once saw a T2N0 supraglottic larynx patient who had a large exophytic component that was causing airway compromise. He ultimately underwent a "debulking" surgery wherein they removed the exophytic component. Obviously, this was not an oncologic resection and residual disease was left behind. So would you say he also had a positive margin and would need chemo-RT? The way I would rationalize this is that a simple tonsillectomy is more akin to a biopsy, and you would not have the same level of devascularization and thus hypoxia as you would get with a true oncologic surgery. So I wouldn't necessarily feel uncomfortable treating the patient with RT alone.

That's a very interesting theory... but:
T2N0R1 supraglottic larynx formally would be eligible for the RTOG/EORTC trial. However very few patients in those trials had such a constellation, most of them being N+. As an example only 18% of the RTOG-patients had a positive margin and/or a supraglottic tumor site, thus its questionable if any patient at all in the RTOG patient collective was a supraglottic T2N0R1.

 

[deleted4401]

Well formally not required, but in most US patients, indication for treatment was N2b disease (2 or more nodes), so one would assume that was discovered after a neck dissection. I think you're right - if it was small volume and lateralized, would be okay to just have one neck dissected, but as previous poster stated, in this case, the tonsillectomy is barely better than a biopsy, I'd guess.

This was purely tonsillar, not involving BOT or palate.

I didn't see obvious ECE on imaging, but yeah, that would sway me.

I don't routinely include IB in OP, even on ipsi side based on sanguinetti/JHH paper. Even if ipsi level 2 positive, after dissection, level IB rarely involved. Same for level V. But low toxicity treating V. In this case, I treated ipsi IB because positive node was abutting posterior submandibular gland. For oropharynx, I treat RP if it's BOT or pharyngeal primary. I'd treat RP for tonsillar or soft palate if it invaded BOT or pharyngeal wall, but not others. Might as well try to spare constrictors based on Gokhale, et al and others data.

Head and neck is fun to banter about and study. Pure hell treating it. Sucks for the patient and spend hours thinking about and planning. Level 5, son!

S

 

[Reaganite]

Just wanted to provide an update to this case...I presented this case to Dr. David Brizel at Duke, and he made the following points:

1. He would treat a simple tonsillectomy as an excisional biopsy. He does not think the patient has a true positive margin. He would only consider it a positive margin if patient had undergone a radical tonsillectomy.

2. He would ask the surgeon about the extent of the primary (i.e. did it invade soft palate/BOT) and consider omitting the contralateral neck.

3. He would not offer chemo, but would treat RTOG 0022 style. He felt that most early t-stage opx cancers do not benefit from chemo-RT vs. altered fractionation and provided some data which I'll try to post in a follow up once I can track down some of the papers.

 

[deleted4401]

Thanks for doing that.

 

[medgator]

3. He would not offer chemo, but would treat RTOG 0022 style.

I could see that for maybe N1 disease, but I don't think it's a slam dunk decision for an N2a patient. In fact, with N2a disease, this patient would not even be eligible for that protocol.

From 0022:

"Stage T1-T2, N0-N1, M0; both sides of the neck are judged to be at risk of metastatic disease
- Surgery of the primary tumor or lymph nodes is limited to incisional or excisional biopsies"

 

[Reaganite]

I could see that for maybe N1 disease, but I don't think it's a slam dunk decision for an N2a patient. In fact, with N2a disease, this patient would not even be eligible for that protocol.

From 0022:

"Stage T1-T2, N0-N1, M0; both sides of the neck are judged to be at risk of metastatic disease
- Surgery of the primary tumor or lymph nodes is limited to incisional or excisional biopsies"

I should rephrase my statement to 'he would use altered fx of some sort of which 0022 is an example.' That being said, there is an interesting line in the protocol: "Biopsy-proven stage I-III (T1-T2, N0-N1) squamous cell carcinoma of the oropharynx (tonsil, base of tongue, or palate) with primary RT as the treatment plan. The neck staging is based on palpation. Patients who are "upstaged" by imaging to N2 are still eligible."

This being said, he told me he did not consider N2a an absolute indication for chemo-RT either (for early t-stage OPX cancers). He seemed to favor chemo mainly when patients have a big, fixed node (big meaning bordering on N3).

He also brought up the interesting point that he thinks SIB is overkill in the context of chemotherapy and that there is no evidence to support it...that all trials that have compared chemo-RT with standard fx vs. alt fx have showed no additional benefit to alt fx.

For those interested, you can discuss your cases with experts like Dr. Brizel and others at chartrounds.com.

 

[medgator]

He also brought up the interesting point that he thinks SIB is overkill in the context of chemotherapy and that there is no evidence to support it...that all trials that have compared chemo-RT with standard fx vs. alt fx have showed no additional benefit to alt fx.

Yeah. I know many of us dose-paint in H&N in Stage III/IV with chemo using single-institution data from places like UCSF and MSKCC, but you're right in that it's not clear about how to integrate SIB and chemotherapy into overall treatment scheme (although the majority of those patients in those were stage III/IV and were getting chemo).

This being said, he told me he did not consider N2a an absolute indication for chemo-RT either (for early t-stage OPX cancers). He seemed to favor chemo mainly when patients have a big, fixed node (big meaning bordering on N3).

It's hard to ignore the data from individual trials and the MACH meta-analysis regarding the benefits of chemotherapy in these patients (N2 disease makes a patient Stage IVA, and that in my book = chemotherapy in most situations).

http://www.asco.org/ascov2/Meetings/Abstracts?&vmview=abst_detail_view&confID=26&abstractID=3198

http://jco.ascopubs.org/content/21/1/92.full

 

[Palex80]

He also brought up the interesting point that he thinks SIB is overkill in the context of chemotherapy and that there is no evidence to support it...that all trials that have compared chemo-RT with standard fx vs. alt fx have showed no additional benefit to alt fx.

This argument sounds like we have TONS of trials comparing standard to alternate fractionation in the context of radiochemotherapy, which is an overstatement. We merely have 2 trials: RTOG 0129 and GORTEC 99-02.

PMID: 22261362 for the GORTEC paper, the RTOG 0129 results have been only released as an abstract as far as I know...

 

[deleted4401]

The single institution data for SIB/chemo from UCSF and that Portland group are impressive, but agreed, no solid data.

I think the spectrum of opinions - from treating ipsi lateral with RT alone to treating bilateral with chemo to 70 Gy goes to show you that a lot of head and neck is just rampant speculation.

S

 

[Palex80]

I think the spectrum of opinions - from treating ipsi lateral with RT alone to treating bilateral with chemo to 70 Gy goes to show you that a lot of head and neck is just rampant speculation.

I'd go beyond that. I think it may also be a sign of overconfidence in modern techniques sometimes (like SIB), which have not been tested in randomized settings.
Sometimes such overconfidence is good and may spare the patients from additional toxicity, on the other hand it may also mean risking recurrencies, which are hard to treat.