ENT Case

[Reaganite]

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Wondering what you guys would do...

50 year old guy with history of T1N2b Scca of the base of tongue treated with chemo-RT 3 years ago at an outside facility. Had neck disease in right levels 2 and 3. I reviewed radiotherapy plan. CTV50 was basically a 1.5cm margin inferiorly on the gross level 3 node. Patient had no followup imaging for 3 years until a few weeks ago when he had PET/CT which shows a 1.5cm PET avid node (SUV 6) in level4 just below the inferior extent of the original fields. Patient seen first by ENT who calls it benign node and recommends no further workup.

 

[Brim]

Wondering what you guys would do...

50 year old guy with history of T1N2b Scca of the base of tongue treated with chemo-RT 3 years ago at an outside facility. Had neck disease in right levels 2 and 3. I reviewed radiotherapy plan. CTV50 was basically a 1.5cm margin inferiorly on the gross level 3 node. Patient had no followup imaging for 3 years until a few weeks ago when he had PET/CT which shows a 1.5cm PET avid node (SUV 6) in level4 just below the inferior extent of the original fields. Patient seen first by ENT who calls it benign node and recommends no further workup.

Just to be clear, he didn't get comprehensive neck RT for a stage 4 BOT ca?

It sounds very suspicious for nodal recurrence based on PET scan. Next step, FNA of the node. If positive, would recommend neck dissection. Hold off on re-RT if you can , unless there are clear reasons that the benefit of re-RT us greater than the risk.

 

[Gfunk6]

Tough case. Is patient having any clinical symptoms of a URI? That might explain the etiology of the LN.

Otherwise I agree with Brim that this is highly suspicious for the LN. The problem with FNA is false negative rate. You might consider short term follow-up with imaging (CT or MRI of neck with contrast) and, if interval growth, proceed to neck dissection.

 

[Reaganite]

Just to be clear, he didn't get comprehensive neck RT for a stage 4 BOT ca?

It sounds very suspicious for nodal recurrence based on PET scan. Next step, FNA of the node. If positive, would recommend neck dissection. Hold off on re-RT if you can , unless there are clear reasons that the benefit of re-RT us greater than the risk.

 

[Palex80]

SUV 6 is a lot for a single avid node in the neck and sounds very suspicious for recurrence, being just below the original CTV. I'd recommend an excision, followed by RT if it turns out to be positive.
Hopefully the base of tongue primary site has been reviewed by an ENT, don't want to miss a simultaneous recurrence there (despite the negative PET there, as it seems).

 

[seper]

We do US-guided FNA for these; repeat PET in 3 months if FNA is negative.

 

[Reaganite]

I agree with all of you. To me, it certainly seems like a no-brainer to try to get some tissue, but my ENT (basically the ONLY private practice ENT-onc in town) told patient it was a "benign" PET finding since it wasn't palpable. I actually went back and reviewed pre-treatment PET more carefully and the node was there (maybe 0.5cm at that time) but did show increased PET avidity relative to background.

Regarding Brim's question about comprehensive regional RT...nope, didn't get it. I don't think any of the patients I inherited in my practice ever got comprehensive nodal RT, in fact. I've seen so many regional failures in patients treated with IMRT by older docs that I've lost count. I've seen 4 regional recurrences this year in neck levels that were simply omitted from contours (high level 2 or subclav fossa). I've also seen several inguinal failures in patients treated with IMRT for anal Ca (and these were cN0 patients). I'm not gonna act like I'm so much better than my predecessors; rather, I feel lucky to have trained at a time when the guidelines were developed because our predecessors were basically contouring blind.

 

[medgator]

I agree with all of you. To me, it certainly seems like a no-brainer to try to get some tissue, but my ENT (basically the ONLY private practice ENT-onc in town) told patient it was a "benign" PET finding since it wasn't palpable. I actually went back and reviewed pre-treatment PET more carefully and the node was there (maybe 0.5cm at that time) but did show increased PET avidity relative to background.

Regarding Brim's question about comprehensive regional RT...nope, didn't get it. I don't think any of the patients I inherited in my practice ever got comprehensive nodal RT, in fact. I've seen so many regional failures in patients treated with IMRT by older docs that I've lost count. I've seen 4 regional recurrences this year in neck levels that were simply omitted from contours (high level 2 or subclav fossa). I've also seen several inguinal failures in patients treated with IMRT for anal Ca (and these were cN0 patients). I'm not gonna act like I'm so much better than my predecessors; rather, I feel lucky to have trained at a time when the guidelines were developed because our predecessors were basically contouring blind.

Yup.... not a lot of margin for user error when you have to delineate your target. 3 field h&n plans are probably better in that regard if you trained in a 2D era and don't know what you're doing with imrt. They may get xerostomia but at least they are cured hopefully

 

[Palex80]

. I don't think any of the patients I inherited in my practice ever got comprehensive nodal RT, in fact. I've seen so many regional failures in patients treated with IMRT by older docs that I've lost count. I've seen 4 regional recurrences this year in neck levels that were simply omitted from contours (high level 2 or subclav fossa). I've also seen several inguinal failures in patients treated with IMRT for anal Ca (and these were cN0 patients). I'm not gonna act like I'm so much better than my predecessors; rather, I feel lucky to have trained at a time when the guidelines were developed because our predecessors were basically contouring blind.

I always thought our predecessors contured rather more tissue, than we do nowadays, since they were trying to put the large 2D-fields they had in mind into modern 3D-conturing guidelines.
I have a colleague who love to look at the sagittal and coronar views of his conturing to make sure it looks like it would in the sim portals he has in his head.
To me it sounds more that your predecessors actually tried to spare patients from toxicity and thus spared areas they know generally led to enhanced toxicity (high level 2 = parotis, inguinal nodes = skin).

 

[seper]

regarding inguinal IMRT, one should mention that accepted guidelines for volumes do not yet exist

 

[Gfunk6]

regarding inguinal IMRT, one should mention that accepted guidelines for volumes do not yet exist

Well, there are RTOG anorectal contouring guidelines. http://www.rtog.org/CoreLab/ContouringAtlases/Anorectal.aspx

 

[Palex80]

Well, there are RTOG anorectal contouring guidelines. http://www.rtog.org/CoreLab/ContouringAtlases/Anorectal.aspx

Surely there are guidelines, but noone can truly say if the volumes you should contour for a cT4 cN2 anal cancer are the same as for a cT1 cN0 tumor.
Patters of failure analyses are based on small patient series and of questionable quality. I also supsect a major stage migration, now that anal cancer patients regularly get PET for staging.

 

[seper]

Well, there are RTOG anorectal contouring guidelines. http://www.rtog.org/CoreLab/ContouringAtlases/Anorectal.aspx

If one would take the time to actually read those guidelines, that person would notice that:

a) anatomical borders of inguinal (inguinal-femoral) nodal regions were not defined
b) depth of skin exclusion from planning PTV was not defined
c) not mentioned whether one should exclude more or less skin when using VMAT

 

[Gfunk6]

This may help: http://atc.wustl.edu/protocols/rtog-closed/0529/ANAL_Ca_CTVs_5-21-07_Final.pdf

Anatomical guidelines are fairly clear. Long section on what to do with skin.

 

[medgator]

If one would take the time to actually read those guidelines, that person would notice that:

a) anatomical borders of inguinal (inguinal-femoral) nodal regions were not defined
b) depth of skin exclusion from planning PTV was not defined
c) not mentioned whether one should exclude more or less skin when using VMAT

On top of that, the atlas itself was essentially the product of an algorithm that combined widely varying contours between the contributing authors

 

[Neuronix]

On top of that, the atlas itself was essentially the product of an algorithm that combined widely varying contours between the contributing authors

I've been using this paper based on nodal positivity patterns to help contour groins.

http://www.practicalradonc.org/article/S1879-8500(11)00381-X/abstract

 

[seper]

Neuronix - thanks for the link; was not aware of this paper. I've been contouring inguinal nodes as a compartment disregarding RTOG atlas, and I guess that's the right way.
Gfunk - yes, useful section on how to approach PTV overlapping with the skin.

 

[jb2]

For post-op head and neck cases s/p neck dissection, do you always radiate the neck if nodes are negative? Had a T3 anterior oral tongue case extending slightly across midline, depth of invasion 1.8 cm, with bilateral neck dissection with 48 total negative neck nodes. Would you irradiate the bilateral neck or just primary site?

 

[Palex80]

If you wanna do it by the book, you should irradiate the neck.
However with 48 nodes being negative, I would worry about turning the patient's head into a zeppelin after full cervical nodal irradiation due to lymphedema, so you have 2 choices:
1. Forget about nodal irradiation at all
2. Treat only high-risk areas (levels I-III)

 

[seper]

I see quite a few of these, and usually irradiate B/L neck (54 Gy, appears to me well tolerated).