Elective LN levels to cover

[Mandelin Rain]

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Squamous cell of the skin of right temple s/p excision. A year later, recurrent to large (N3) ipsilateral parotid LN with extensive extranodal spread including to around mandible and into infratemporal fossa. Additionally involvement of CN VII. s/p parotidectomy and extensive ipsilateral LN dissection. No other nodes involved. But high risk features as above and questionable margin status.

What elective levels (if any) are you covering? What about primary site? No evidence of recurrence there.

 

[OTN]

I would treat the ipsilateral neck. If the primary had PNI or close SMs I would treat, which it sounds like it does. There's decent data which suggests that intraparotid LN mets suggest an increased risk of occult nodal disease in the neck. This isn't the study I was thinking of, but it's similar:

Relevance of Intraparotid Metastases in Head and Neck Skin Squamous Cell Carcinoma - PubMed

4 Laryngoscope, 131:788-793, 2021.

pubmed.ncbi.nlm.nih.gov

 

[scarbrtj]

We can quibble on LN levels (I don’t think you need to cover level 1, just 2-4 ipsi), but it sounds as if you should make sure to cover the stylomastoid foramen level.

 

[Mandelin Rain]

We can quibble on LN levels (I don’t think you need to cover level 1, just 2-4 ipsi), but it sounds as if you should make sure to cover the stylomastoid foramen level.

LOL. Definitely planning on that. I was thinking 2-4 as well.

FWIW, patient is 80+ yo with multiple comorbidities.

Had 35 nodes taken out levels 1-5 in neck dissection. All negative. Not sure if that changes anyone's calculus.

I was hoping to spare extensive nodal XRT. Ipsilateral only is typically tolerated okay, but still looking to decrease toxicity as much as possible to get him through treatment.

 

[BobbyHeenan]

Squamous cell of the skin of right temple s/p excision. A year later, recurrent to large (N3) ipsilateral parotid LN with extensive extranodal spread including to around mandible and into infratemporal fossa. Additionally involvement of CN VII. s/p parotidectomy and extensive ipsilateral LN dissection. No other nodes involved. But high risk features as above and questionable margin status.

What elective levels (if any) are you covering? What about primary site? No evidence of recurrence there.

Would cover at minimum II-IV. I'd probably cover Ib too. Take the nerve root to skull base up to 50-54 Gy. Get MRI to see if nerve enhancement tracking back to skull base. If thick, enhancing nerve would think about going even higher than 60 Gy to that.

Would not treat contralateral neck.

Would not cover primary site if no evidence of relapse there after a year. I think treatment is fine on it, I just personally wouldn't do it.

It sounds like a huge tumor, so by the time you treat the operative bed you'll already have treated a TON of that neck I'd imagine.

Would aggressively spare pharynx/uppper esophagus/larynx to point of under dosing if necessary though.

 

[drewdog1973]

Agree with our wrestling buddy, except I'd add the tumor bed.

 

[Ray D. Ayshun]

I'm doing a somewhat similar patient now, though with hypoglossal nerve involvement, which changes the location I'm going to in the skull base. In any case, I'm doing just 2 & 3 given similar dissection findings. I'm also going into posterior auricular basin, which was where his primary was located, though maybe at risk in your patient too

 

[communitydoc13]

I'd cover entire ipsilateral side, including level 1. Infratemporal squamous cell is very bad. Very nice contouring guidelines from COSTAR trial out of UK for parotid tumors is applicable here. Parotid surgical bed pretty much spills into ipsilateral levels I and II. I think added toxicity of lower neck is minimal and would do with high risk features even in a negative neck. Agree if PNI you can trace back to base of skull (can make sure you get ipsi pterygopalatine fossa).

I have personally seen level IB failures from intraparotid squamous.

 

[evilbooyaa]

Ipsilateral IB - IV. I would also include pre and post-auriculars.

 

[w00tz]

I would do Pre and post-auriculars, IB-IV, CN VII. My arbitrary cut off for tumor bed is 6 months, so would skip if it's been a year.

 

[Ray D. Ayshun]

What to treat is easy. What not to treat a little less so. I feel like the number of negative nodes in the bucket justifies being more conservative wrt nodal coverage, while pni justifies more aggression up top, and perhaps more srs'y immobilization.

 

[Mandelin Rain]

Thanks all for your feedback. The hive brain of this board is fantastic.

 

[Palex80]

Thanks all for your feedback. The hive brain of this board is fantastic.

The future of radiation oncology...

 

[metview]

Ipsilateral only. No primary.
Ib-III/IV
Pre auricular
Cover CNVII back to BOS

 

[RollTideRadOnc]

Also must cover course of ATN given it goes "around mandible" (though this area would likely be encompassed in your post-op volumes anyhow). Would look at pre-op imaging to see it exact proximity to Ib and spare if possible, but treat if node was inferior/anterior. Would also treat all areas of dissected neck. Would not treat contralateral neck. If any clinical nerve deficits prior to surgery, I always get a cranial nerve protocol MRI even though it is post-op, just to check for any "skip" lesions (though low likelihood).

 

[Mandelin Rain]

Ipsilateral only. No primary.
Ib-III/IV
Pre auricular
Cover CNVII back to BOS

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