Gyn Case

[Reaganite]

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Saw an interesting case the other day...

40 year old female with history of cervical CA initially IIIB. Completed chemo-RT to WP only followed by standard T and O. At the completion of her treatment, she complained of a new left neck mass for which she underwent a neck dissection which revealed a single positive node with ECE. Paraaortics (45Gy) and SCLAV (45 Gy then boost to ECE of 57 Gy) were subsequently treated.

Patient now presents to our clinic approximately 6 months post-treatment with an isolated paraaortic recurrence invading the psoas muscle. She's in excruciating pain, uncontrolled by narcotics. Looking back on her diagnostic and planning CTs, the node was there and did meet size criteria for treatment, however, it was never called by radiology and was not boosted. :i

So...would you offer this patient re-treatment? and if so, to what dose?

 

[Palex80]

Interesting case!

Question: Why did you treat the paraaortics after she demonstrated the neck recurrence? There is a certain logic to it (distant lymph node relapse spread pattern), but I would have probably only treated the neck.
Anyways...

What is the dose the node received during the paraaortic irradiation? Is it a field margin recurrence or did it get the full 45 Gy?
If it already received the full 45 Gy, then it may be quite hard to control this macroscopic disease with a retreatment, since 45 Gy didn't seem to impress it a lot. You will also run into several problems by retreating her, especially in the case of small bower, nerves and possibly kidney (?) too.

I would opt for stereotactic treatment in this case, if possible.
Maybe something like 5x5 Gy to the 60% isodose?

 

[seper]

In-field pelvic relapse is a common situation and prognosis is poor.
I would give palliative re-irradiation to the mass only, and then promptly start chemo.

 

[deleted4401]

Tough case. SRS like below sounds like a reasonable option, I'd agree with 5 Gy x 5, tight margins. Or palliative EBRT, but probably would have to go low and slow, and may not help a whole lot (20 Gy/10 fx, maybe more depending on location - how close to bowel, etc... if situated more laterally, can do a couple of oblique fields and stay off bowel nicely, maybe). Sounds like bad bad news, though.

Not to be a stickler and I'm not going after you, but why the dig on the Dx Rad? I agree it's nice to have them point out every single finding, but I've noted in the community that it's incumbent on the contouring physician to notice findings like all nodes 1cm or greater. I don't know - I don't rely on our community radiologists entirely, and we've had enough radiology experience to see abnormal LNs.

Saw an interesting case the other day...

40 year old female with history of cervical CA initially IIIB. Completed chemo-RT to WP only followed by standard T and O. At the completion of her treatment, she complained of a new left neck mass for which she underwent a neck dissection which revealed a single positive node with ECE. Paraaortics (45Gy) and SCLAV (45 Gy then boost to ECE of 57 Gy) were subsequently treated.

Patient now presents to our clinic approximately 6 months post-treatment with an isolated paraaortic recurrence invading the psoas muscle. She's in excruciating pain, uncontrolled by narcotics. Looking back on her diagnostic and planning CTs, the node was there and did meet size criteria for treatment, however, it was never called by radiology and was not boosted. :i

So...would you offer this patient re-treatment? and if so, to what dose?

 

[seper]

Caution - there is a recent report describing unacceptable toxicity of SBRT for exactly this. PubMed PMID: 20079550. I'd stick to 30 Gy/15 fx or even BID.

 

[Reaganite]

Not to be a stickler and I'm not going after you, but why the dig on the Dx Rad? I agree it's nice to have them point out every single finding, but I've noted in the community that it's incumbent on the contouring physician to notice findings like all nodes 1cm or greater. I don't know - I don't rely on our community radiologists entirely, and we've had enough radiology experience to see abnormal LNs.

Totally agree. Poor choice of words...of course, my colleagues also read this, so don't want to throw anyone I know who may have planned this under the bus. 🙂

 

[Reaganite]

Interesting case!

Question: Why did you treat the paraaortics after she demonstrated the neck recurrence? There is a certain logic to it (distant lymph node relapse spread pattern), but I would have probably only treated the neck.
QUOTE]

I didn't treat the patient, but in retrospect I remember this issue being discussed amongst some fellow residents, and I believe there was some debate in tumor board regarding whether to treat the paraaortics or just SCLAV alone. Ultimately it was decided to cover the paraaortics since they could technically be an in-transit station, although it was certainly acknowledged that isolated SCLAV recurrences are also possible. As it turns out, we apparently were correct in treating the PA chain.

 

[Palex80]

Caution - there is a recent report describing unacceptable toxicity of SBRT for exactly this. PubMed PMID: 20079550. I'd stick to 30 Gy/15 fx or even BID.

I disagree.
What the article describes is giving SBRT boost rather than HDR boost for local recurrent gyn primaries. This is a total different situation, than treating a lymph node somewhere along the M. psoas.

 

[Treestand]

There is a study looking at PET/CT staging of cervical CA ( PMID 20308664 ) in which all patients with (+) SCV had (+) PA nodes.

New to this forum. Very nice.

 

[RadRadRad]

any chance the initial LN was involving the psoas. I recall a case somewhat similar to this from residency. In hindsite looking at the initial planning scan, there was some subtle suggestion of psoas muscle infiltration that was not well covered. Thus when they recurred I felt it was more of a marginal miss.
I think dose and fractionation questions really require more detail regarding size of the tumor and proximity to previously irradiated bowel. Also is this recurrence isolated based on PET? If not I'd get a PET/CT. In an ideal world it would be nice to get in more than 5x5 if this is truly isolated, but may not be possible.