anal cancer poor chemo candidate

[BobbyHeenan]

I have an elderly patient with a T3N0 anal squam.

Not a great 5FU/MMC candidate per med onc.

If you were to try to twist the arm of med onc into something radiosensitizing, what would you consider? xeloda or weekly cis?

I see this case series using just 5FU.

Any thoughts are appreciated.

Effective treatment of anal cancer in the elderly with low-dose chemoradiotherapy - British Journal of Cancer

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[Doctorer]

I see this fairly frequently. In the patients who aren't 5fu/mmc candidates, I've typically used single agent capecitabine. For smaller tumors (ie, T1s) you can argue that the older chemoRT studies didn't enroll patients with small/node negative tumors, and treat with radiation alone. There's french retrospective data supporting RT alone in small tumors as well.

 

[mheat3]

Agree. Typically have been using capecitabine and anecdotally have had great results in these cases.

 

[Surf Rx]

I've done concurrent xeloda as well.

I have one patient who had a T3N1a anal cancer who just flat out refused any chemo so I treated with RT alone to 5940 cGy. NED for 5 years now.

 

[RickyScott]

done plenty of anal cancer with low dose xeloda. MitoC only adds around 5- 10% local control

 

[BobbyHeenan]

Thanks all for the input.

I'm going to look into concurrent xeloda.

 

[RickyScott]

Thanks all for the input.

I'm going to look into concurrent xeloda.

Also don’t need elective radiation in poor performance pts. Inguinals are n2. If no n1 disease, I wouldn’t radiate inguinals, external, internal illiac and just worry abt the disease you can see and maybe the n1 nodes (mesorectum)

 

[CaesarRO]

Would he be a candidate for Cis/5FU per ACT II? Technically not superior but curves pretty close.

 

[BobbyHeenan]

Would he be a candidate for Cis/5FU per ACT II? Technically not superior but curves pretty close.

Nope. Already looked into that.

 

[TheWallnerus]

It’s interesting that this is the only squamous cell malignancy (these days) where we believe 5FU (as opposed to say CDDP) is synergistic with RT.

 

[BobbyHeenan]

It’s interesting that this is the only squamous cell malignancy (these days) where we believe 5FU (as opposed to say CDDP) is synergistic with RT.

That's why I was kind of thinking weekly cis may be an option.

I do get the appeal to an oral chemo regimen though. Psychologically to patients that may be easier to , uh, stomach if you will.

 

[evilbooyaa]

Get whatever chemo you can get in. If not 5-FU/MMC then 5-FU/Cis is fine (and I believe the SOC at MDACC). If can't do multiagent then consider Xeloda alone or Cis Alone. If can't do anything then do RT alone.

 

[TheWallnerus]

So here’s the question to anyone who considers themselves an anal cancer guru (I am not): does the clinical and basic science suggest that when there is single agent chemoRT for anal, which carries more radiosensitizing water: cis or 5FU. Are they truly fungible? I know they’re not if we consider squamous cell in general.

 

[medgator]

It’s interesting that this is the only squamous cell malignancy (these days) where we believe 5FU (as opposed to say CDDP) is synergistic with RT.

Goose still gets 5-fu as an option as well iirc

 

[TheWallnerus]

Goose still gets 5-fu as an option as well iirc

Option but not nec THE preferred option and way more emphasis on platinums. I may be hallucinating but I recall some retrospective data favoring platinum regimens in cervical esophageal.

 

[deleted1111261]

Definitely on psilo, bro

 

[A_DeMichele]

Xeloda alone will be hard to justify by data. also doubt if it works, other SCC sites don’t use Xeloda

 

[deleted1111261]

Xeloda alone will be hard to justify by data. also doubt if it works, other SCC sites don’t use Xeloda

Do you think it does nothing ?
Or less than RT alone?

I think it adds more than just toxicity… otherwise why is it in doublet ?

 

[A_DeMichele]

Do you think it does nothing ?
Or less than RT alone?

I think it adds more than just toxicity… otherwise why is it in doublet ?

Doublet data for Xeloda + MMC is also super weak (ph II). So, I would not advocate for Xeloda in anal SCC ever

 

[RickyScott]

Xeloda if anything is more active than 5fu, but basically the same thing.

 

[RadOncDoc21]

I guess we can all speculate why something might not work but I’m in the camp of “something is better then nothing.”

 

[A_DeMichele]

Hit it with what works well: radiation

 

[deleted1111261]

RT alone is pretty darn good

 

[RadOncBeamer]

For those hitting it with just RT alone in these poor performance patients, are you treating just gross disease + margin, or including elective nodes too?

 

[RickyScott]

RT alone is pretty darn good

For T3 anal, back of envelope, rt alone 50-60%. 5fu 10% and mito 10%? Not a lot of toxicity with xeloda and zero reason to think it is worse than 5fu. Almost any GI medonc think it’s slightly more active. Also, you can give less xrt w/xeloda. Rt alone would have to push at least 60 while xeloda/xrt 54 at most. Would only treat gross disease +/- mesorectum.

 

[ramsesthenice]

Doublet data for Xeloda + MMC is also super weak (ph II). So, I would not advocate for Xeloda in anal SCC ever

I treat 10-15 per year. Almost all with Xeloda/MMC. In 7 years I have had 3 local failures that I am aware of (and I follow people close). You are never going to have phase 3 data considering this is a relatively small population and the oral formulation is equivalent in other GI cancers.

Single agent Xeloda I have not tried for this particular disease. Typically opt for weekly cis if doing anything single agent (though many elderly can’t do cis).

Someone mentioned ACTII and that warms my heart. Cis gets a bad rap from that stupid induction trial but as a sensitizer it actually does really well. Read the discussion of that paper for Can interesting exercise. They straight up say Cis/FU worked as well with less severe hematologic toxicity but since it requires more infusions (or something like that), MMC should remain SOC. It’s an interesting conclusion. My most common doublet is MMC/FU but those cases where you are not really sure if it’s a true skin cancer or anal cancer, I typically opt for Cis.

 

[Palex80]

If you can give low-dose Cisplatin, go ahead.
Carboplatin likely works too, but no data (I‘ve given carboplatin in Cis-ineligible cervix).

I would treat elective nodes, including inguinals.

 

[Palex80]

Someone mentioned ACTII and that warms my heart.

I accidentally read "and that warms my butt" for a moment there...

 

[madchemist89]

Butt is very warm after a few weeks of anal RT.

 

[sirspamalot]

You haven't lived until you do anal with an HIV patient.

Wait that's not sounding good..

 

[madchemist89]

Did it plenty of times in residency. Hello break for neutropenia.

 

[A_DeMichele]

what is original doctor is asking, can I do some light chemo and get away with 50GY? No, this is the case that you need to go > 60 Gy and not mess with dancing around the chemo issue.

 

[Palex80]

what is original doctor is asking, can I do some light chemo and get away with 50GY? No, this is the case that you need to go > 60 Gy and not mess with dancing around the chemo issue.

Im not sure if the data for >60 Gy are good. Pushing the dose high to maximize local control may jeopardize sphincter function.
In the end, colostomy-free survival may be the same.

 

[ramsesthenice]

Im not sure if the data for >60 Gy are good. Pushing the dose high to maximize local control may jeopardize sphincter function.
In the end, colostomy-free survival may be the same.

I strongly agree. You are asking for trouble. With chemo, I don't go higher than 54, even for the big ones unless (and control is still excellent). If you want to go to 59.4 sans chemo, thats probably cool but do try hard not to let it get too hot over the complex.

 

[deleted1111261]

I strongly agree. You are asking for trouble. With chemo, I don't go higher than 54, even for the big ones unless (and control is still excellent). If you want to go to 59.4 sans chemo, thats probably cool but do try hard not to let it get too hot over the complex.

59.4 was the highest dose on RTOG 3D studies - to isocenter

54 to PTV with 7% hotspot is 58 or so

I know, I know - I show my age - but people forgot this

 

[ramsesthenice]

59.4 was the highest dose on RTOG 3D studies - to isocenter

54 to PTV with 7% hotspot is 58 or so

I know, I know - I show my age - but people forgot this

What you are showing is your experience

Comes up a lot when discussing dose limits with residents. Don't love to push it, but we know we can get away with a good bit more than our traditional metrics would lead us to believe and I have to think improved heterogeneity is a big part of it. Whether or not always striving for heterogeneity is a good thing or not is a very different discussion.

 

[RadOncDoc21]

What you are showing is your experience

Comes up a lot when discussing dose limits with residents. Don't love to push it, but we know we can get away with a good bit more than our traditional metrics would lead us to believe and I have to think improved heterogeneity is a big part of it. Whether or not always striving for heterogeneity is a good thing or not is a very different discussion.

I love how we make constraints almost impossible to meet. I miss the old quantec dose limitations. That was back in the day when dose tolerance actually mattered… If you didn’t meet dose constraints, events were going to happen. Now a days, we’re contouring individual chest hairs!

 

[deleted1111261]

I reviewed a case for a 0.5cm basal cell on ala of nose requesting IMRT to protect parotids, brain and … wait for it… eyebrows

 

[ramsesthenice]

I love how we make constraints almost impossible to meet. I miss the old quantec dose limitations. That was back in the day when dose tolerance actually mattered… If you didn’t meet dose constraints, events were going to happen. Now a days, we’re contouring individual chest hairs!

One of our younger attendings routinely asks 3-4 volumetric constraints for each OAR RTOG style. It’s umm, something.

 

[A_DeMichele]

60 Gy without chemo is fine. I would go higher based on personal experience with these pts

 

[evilbooyaa]

For those hitting it with just RT alone in these poor performance patients, are you treating just gross disease + margin, or including elective nodes too?

RT alone is definitive treatment. I would still treat the elective nodal basins.

Xeloda alone will be hard to justify by data. also doubt if it works, other SCC sites don’t use Xeloda

Where did Xeloda hurt you? Xeloda = 5-FU across disease sites IMO. Infusional 5-FU is super annoying as hell for patients.

Agree with considering escalating to max of 59.4, and not going over 60.

For T3 anal, back of envelope, rt alone 50-60%. 5fu 10% and mito 10%? Not a lot of toxicity with xeloda and zero reason to think it is worse than 5fu. Almost any GI medonc think it’s slightly more active. Also, you can give less xrt w/xeloda. Rt alone would have to push at least 60 while xeloda/xrt 54 at most. Would only treat gross disease +/- mesorectum.

If you're treating just gross disease + mesorectum then why not just do a palliative reigmen since you're not doing curative intent therapy? I would 100% cover inguinals/pelvic nodes unless you thought the patient had such poor PS that they wouldn't be able to tolerate pelvic nodal coverage to somewhere in the range of 36-45Gy conventionally fractionated....