Head and Neck Adjuvant Case

[Haybrant]

I got a complicated head and neck SCC that had surgery at a (holier than thou) academic center for a T4N3M0 right base of tongue SCC. Primary tumor was extending from BOT to the posterior lateral oral tongue and involving floor of mouth. He had a CT neck and MRI prior to treatment, no PET. Extensive nodal involvement of Right IB,II, and III was noted with ECE and adherent to SCM. He underwent combined TORS and trans cervical resection of the primary as well as right radical neck dissection, inferior right parotidectomy, "submental flap" (looks a lot more submandibular) was also placed with pathology showing close margins, LVI/PNI, and 8/34 lymph nodes positive for metastases w/ extensive ECE. He didn't get referred to me until 6 wks after surgery

I got a PET at the time of his planning. There remains a R1B node, there is uptake in the right base of tongue and GT sulcus and there is a very avid 1.5 cm left IIA node. What are your targets now?

Planning chemo/RT with the gross nodes going to full dose and the area of concern in the post op bed Id like to take to full dose - would you just take the entire post op primary bed to full dose? I wired his scar but superiorly this extends to the postauricular area since they did partial parotidectomy, I was not planning to cover this area as it would obliterate the rest of the parotid on that side. I was planning to cover the entire flap however (it spans the entire length of IB). Attached the PET so you can see the flap and uptake in BOT. Would you cover LIB

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[ramsesthenice]

I got a complicated head and neck SCC that had surgery at a (holier than thou) academic center for a T4N3M0 right base of tongue SCC. Primary tumor was extending from BOT to the posterior lateral oral tongue and involving floor of mouth. He had a CT neck and MRI prior to treatment, no PET. Extensive nodal involvement of Right IB,II, and III was noted with ECE and adherent to SCM. He underwent combined TORS and trans cervical resection of the primary as well as right radical neck dissection, inferior right parotidectomy, "submental flap" (looks a lot more submandibular) was also placed with pathology showing close margins, LVI/PNI, and 8/34 lymph nodes positive for metastases w/ extensive ECE. He didn't get referred to me until 6 wks after surgery

I got a PET at the time of his planning. There remains a R1B node, there is uptake in the right base of tongue and GT sulcus and there is a very avid 1.5 cm left IIA node. What are your targets now?

Planning chemo/RT with the gross nodes going to full dose and the area of concern in the post op bed Id like to take to full dose - would you just take the entire post op primary bed to full dose? I wired his scar but superiorly this extends to the postauricular area since they did partial parotidectomy, I was not planning to cover this area as it would obliterate the rest of the parotid on that side. I was planning to cover the entire flap however (it spans the entire length of IB). Attached the PET so you can see the flap and uptake in BOT. Would you cover LIB

What do you mean when you say full dose? If it were me I would take anything that I truly though was gross disease to 70 Gy but I wouldn't take the whole bed to 70. 66 Gy should suffice for the primary post-op bed and nodal regions with ECE. Deciding what is gross disease vs post-op change is a judgement call but it sounds like you think are concerned he probably does. You could fart around with additional biopsies but the risk of treatment delay may be worse than the added morbidity of just treating them as gross disease IMO. I am bit surprised they did a unilateral neck dissection in someone with an N3 BOT primary.

 

[Haybrant]

What do you mean when you say full dose? If it were me I would take anything that I truly though was gross disease to 70 Gy but I wouldn't take the whole bed to 70. 66 Gy should suffice for the primary post-op bed and nodal regions with ECE. Deciding what is gross disease vs post-op change is a judgement call but it sounds like you think are concerned he probably does. You could fart around with additional biopsies but the risk of treatment delay may be worse than the added morbidity of just treating them as gross disease IMO. I am bit surprised they did a unilateral neck dissection in someone with an N3 BOT primary.

Ya Im not going to mess w biopsies; if I expand the area I am concerned for gross primary disease that will essentially fill the post op bed. Also not sure why this guy went to surgery tbh. Full dose, ya I meant 70 as opposed to adjuvant dosing

what about covering the entire flap and left IB? Thanks

 

[scarbrtj]

I got a complicated head and neck SCC that had surgery at a (holier than thou) academic center for a T4N3M0 right base of tongue SCC. Primary tumor was extending from BOT to the posterior lateral oral tongue and involving floor of mouth. He had a CT neck and MRI prior to treatment, no PET. Extensive nodal involvement of Right IB,II, and III was noted with ECE and adherent to SCM. He underwent combined TORS and trans cervical resection of the primary as well as right radical neck dissection, inferior right parotidectomy, "submental flap" (looks a lot more submandibular) was also placed with pathology showing close margins, LVI/PNI, and 8/34 lymph nodes positive for metastases w/ extensive ECE. He didn't get referred to me until 6 wks after surgery

I got a PET at the time of his planning. There remains a R1B node, there is uptake in the right base of tongue and GT sulcus and there is a very avid 1.5 cm left IIA node. What are your targets now?

Planning chemo/RT with the gross nodes going to full dose and the area of concern in the post op bed Id like to take to full dose - would you just take the entire post op primary bed to full dose? I wired his scar but superiorly this extends to the postauricular area since they did partial parotidectomy, I was not planning to cover this area as it would obliterate the rest of the parotid on that side. I was planning to cover the entire flap however (it spans the entire length of IB). Attached the PET so you can see the flap and uptake in BOT. Would you cover LIB

What's the HPV status. BTW, I think stage pN3 doesn't exist anymore, regardless the HPV status. He'd be Stage III if HPV+, Stage IV-B if HPV-, clinical stage. You can only be pathologic Stage III now. I'm not too sure what to do with these PET hot spots in technically non-enlarged nodes after surgery, except note them and make sure they're not uncovered. Of course the BOT is going to be PET-hot after surgery. If he's HPV+, I don't think "full dose" is 70 Gy here. I would not contour and prescribe to Level I-B; I'd contour only. I would plan and see what the dosimetry is in the area. If you're getting a subclinical dose there "inadvertently" due to spillover you're OK. If HPV+, my top-end dose here postop is likely to be ~64 Gy. Perhaps in future it will be lower.

 

[Haybrant]

What's the HPV status. BTW, I think stage pN3 doesn't exist anymore, regardless the HPV status. He'd be Stage III if HPV+, Stage IV-B if HPV-, clinical stage. You can only be pathologic Stage III now. I'm not too sure what to do with these PET hot spots in technically non-enlarged nodes after surgery, except note them and make sure they're not uncovered. Of course the BOT is going to be PET-hot after surgery. If he's HPV+, I don't think "full dose" is 70 Gy here. I would not contour and prescribe to Level I-B; I'd contour only. I would plan and see what the dosimetry is in the area. If you're getting a subclinical dose there "inadvertently" due to spillover you're OK. If HPV+, my top-end dose here postop is likely to be ~64 Gy. Perhaps in future it will be lower.

HPV negative, hes a big time smoker. By AJCC 8th ed path N3b includes node >3 cm w ECE which he has. It still includes node > 6 cm as well but that is N3a. The left level II node is definitely involved its SUV is >7and the node size is 1.6cm (the slice I included doesn't show it fully). What about covering the flap? Also, when covering flaps do you need to cover the entire thing or just be sure the interface is covered (meaning where the flap meets the underlying native skin)

 

[scarbrtj]

HPV negative, hes a big time smoker. By AJCC 8th ed path N3b includes node >3 cm w ECE which he has. It still includes node > 6 cm as well but that is N3a. The left level II node is definitely involved its SUV is >7and the node size is 1.6cm (the slice I included doesn't show it fully). What about covering the flap? Also, when covering flaps do you need to cover the entire thing or just be sure the interface is covered (meaning where the flap meets the underlying native skin)

I knew cN3 was in there but didn't think pN3 was. I don't have an 8th edition yet to look . Re: flaps, do what you think is best. His biggest risk of recurrence is in the ECE region and the primary. Scar recurrences, flap recurrences, would be relatively less common. I don't see how you're going to exclude much of the entire flap from getting at least 50Gy regardless what you do. I would not let a postop PET here sway you that he has gross disease. If you do think he has gross dz otherwise (ie calling an area frankly undissected), Rx:70 Gy. Perhaps the rationale for surgery was HPV-; not a horrible rationale.

 

[scarbrtj]

I didn't notice you said FOM involved, which is uncommon obv, but that would be rationale to cover Level 1

 

[medgator]

Perhaps the rationale for surgery was HPV-; not a horrible rationale.

For a T4 BOT?

 

[seper]

I know surgery here was contrary to the Radiation Oncology dogma, but in reality chance for non-operative cure would have been 20-25%, my guess. Now there is something to fight for. Luckily, his mandible did not need to be cut.

 

[evilbooyaa]

Academic centers love doing surgery. Of course he's probably a smoker with 11 pack years and/or p16 negative and therefore surgery is "indicated". (started writing this out before we could see p16 status)

Very surprised he didn't get a PET/CT, of course he likely didn't meet the radiation oncologist who would've ordered a pre-op PET/CT prior to surgery.

Regardless - on to your question:

Gross disease gets 70Gy. Did they say which nodes had ECE? Probably not. Area most concerning for ECE (all of it if necessary) gets 66. If I'm treating L level II node to 70, I'm taking L IB to at least 54/56, if not 60/63. If there's FOM extension reasonable to take it to 60/63. Depends on if you do 54/60 + 10Gy boost for your Ophx or 70/63/56 all in one plan.

Close margins to me means a small area of the post-op bed gets 66 (if you can identify the area most at risk), rest of it gets 60. You have to cover the flap if it's in the tumor bed.

 

[ramsesthenice]

what about covering the entire flap and left IB? Thanks

I think you are probably being too generous with what you are considering gross disease. Most, if not all, of the PET uptake in the surgical bed is probably post-surgical. Unless you have a CT correlate to go along with the uptake I wouldn't be inclined to assume he has gross disease in the operative bed at this point. The left node you could make a better argument for though it could be reactive as well. Its going to be a judgement call but either way I think the 70 Gy volume (if you elect to use one) should be a good bit smaller than the post-op bed. This was a huge tumor.

They did surgery because recent data suggests better disease control and cancer specific outcomes for surgery with PORT than definitive CRT. Not saying right or wrong or commenting on quality of that data. But surgeons have always felt surgery has to be better and they have data to say they might be right. You know they are going to use it.

As for de-escalation I would be very careful doing it off trial at this point. Even if this guy were HPV positive, his tumor is not behaving like the run of the mill HPV tumor. Most of the de-esclation trials did not include T4 or N3 patients so Im not sure I would take him to anything less than 66 no matter what his HPV status was. Just my opinion.

 

[evilbooyaa]

I know surgery here was contrary to the Radiation Oncology dogma, but in reality chance for non-operative cure would have been 20-25%, my guess. Now there is something to fight for. Luckily, his mandible did not need to be cut.

Fully agree. P16- with this advanced stage is not a good outcome with chemoRT alone.

What's the HPV status. BTW, I think stage pN3 doesn't exist anymore, regardless the HPV status. He'd be Stage III if HPV+, Stage IV-B if HPV-, clinical stage. You can only be pathologic Stage III now. I'm not too sure what to do with these PET hot spots in technically non-enlarged nodes after surgery, except note them and make sure they're not uncovered. Of course the BOT is going to be PET-hot after surgery. If he's HPV+, I don't think "full dose" is 70 Gy here. I would not contour and prescribe to Level I-B; I'd contour only. I would plan and see what the dosimetry is in the area. If you're getting a subclinical dose there "inadvertently" due to spillover you're OK. If HPV+, my top-end dose here postop is likely to be ~64 Gy. Perhaps in future it will be lower.

Disagree. 66 for areas of ECE. 70 Gy to the gross disease. I'm not doing < 70Gy to gross disease off protocol (even if it's p16+) until those studies are published saying that it's safe.

Also, I don't understand the rationale of a unilateral neck dissection in a BASE OF TONGUE cancer. It has bilateral drainage. Especially when it's T4 and N3.

 

[medgator]

Fully agree. P16- with this advanced stage is not a good outcome with chemoRT alone.

this is where a trach and BOT boost implant might have a role.... something I actually did in residency but never do now

The issue I have with trimodality is the toxicity without solid data to back it up

 

[nkmiami]

would agree with covering contralateral 1b. would also base my final doses on hpv status. Make sure at least 2 doses of 100 cis. make a lot of effort to spare the larynx-this guy will have a lot of toxicity. May want to do sequential imrt plans. Take everything to 50 Gy. and then boost areas of concern. I am not sure what to make of postop pets.

 

[Haybrant]

thanks all good input. I think youre right im overplaying the remaining BOT GT sulcus uptake. Will prob go to 66 to extensive ECE and that djacent area of the GT sulcus and and 60 BOT and 70 to the L node -not sure why everyone thinks the left node may be reactive - the thing is super hot and its 1.5-1.6 cm, im as certain as can be that its tumor

i dont dose de-escalate right now, and didnt the results of that ecog 1308 study show pretty poor local control at 2 years 80% at 2 years in a pretty favorable group of h&n patients <10 pack year smokers (http://ascopubs.org/doi/abs/10.1200/jco.2016.68.3300). I think there is a separate thread dedicated to it

 

[scarbrtj]

For a T4 BOT?

I'm assuming it was not a cT4 and instead was a pT4

 

[scarbrtj]

70 Gy to the gross disease.

But no one has firmly convinced me this guy has gross residual disease, unless I've missed something. I haven't seen pre- vs post-op CTs, we have a 1.5 or 1.6cm LII contra node that is PET SUV 7 postop. Meh. What if the BOT is SUV7? What if you never got a PET? (I would have, too, but I still maintain PET "positivity" skepticism in the postop setting; if he had a preop PET, of course you wouldn't get a PET 6 weeks postop ever.) So go to 70 Gy, fine. 66 Gy, fine. But if it were HPV+, I still would feel comfortable with 64 Gy postop dose sans gross dz (and we're quibbling over 2 Gy... I'm willing to dose de-escalate by 2 Gy, given the HPV dose de-escalation data).

 

[scarbrtj]

the thing is super hot and its 1.5-1.6 cm, im as certain as can be that its tumor

"Certain as can be" = 100% pretest (biopsy) probability, implying the specificity of PET+ SUV 7 with a 1.5cm lymph node (not technically pathologically enlarged) in the *postop* setting is 100%

I can be "certain as can be" the specificity of PET is not 100% in this scenario. You may be right, and you're welcome to treat on that basis with no clinical downside probably.

 

[evilbooyaa]

But no one has firmly convinced me this guy has gross residual disease, unless I've missed something. I haven't seen pre- vs post-op CTs, we have a 1.5 or 1.6cm LII contra node that is PET SUV 7 postop. Meh. What if the BOT is SUV7? What if you never got a PET? (I would have, too, but I still maintain PET "positivity" skepticism in the postop setting; if he had a preop PET, of course you wouldn't get a PET 6 weeks postop ever.) So go to 70 Gy, fine. 66 Gy, fine. But if it were HPV+, I still would feel comfortable with 64 Gy postop dose sans gross dz (and we're quibbling over 2 Gy... I'm willing to dose de-escalate by 2 Gy, given the HPV dose de-escalation data).

If he had a left neck dissection, I might be inclined to agree with you. Not having undergone a neck dissection, I'm not sold on it not being disease. Sure, take a close look and see if it was there on pre-op MRI, OP.

We're quibbling over 70Gy vs 64Gy for gross disease.

 

[Palex80]

I would do FNA of the left level IIA node to be certain it's involved. Extending the boost volume to the contralateral side of the neck is going to ruin any chance of sparing his contralateral parotid. There is quite a difference if you are going to give 50-54 Gy or 66-70 Gy on the contralateral side of the neck.
Our H&N love doing FNAs and sometimes some of the PET-finding during planning are artificial, for example if the patient had extensive dental procedures carried out prior to planning. A big flap can also lead to inflammation if it becomes infected or the wound doesn't heal well.

 

[Haybrant]

I would do FNA of the left level IIA node to be certain it's involved. Extending the boost volume to the contralateral side of the neck is going to ruin any chance of sparing his contralateral parotid. There is quite a difference if you are going to give 50-54 Gy or 66-70 Gy on the contralateral side of the neck.
Our H&N love doing FNAs and sometimes some of the PET-finding during planning are artificial, for example if the patient had extensive dental procedures carried out prior to planning. A big flap can also lead to inflammation if it becomes infected or the wound doesn't heal well.

its for sure involved, went back to presurgery CT and the node wasn't there, now its 1.6 cm necrotic and SUV is 9. Fortuantely its below the parotid will see how good we do with the parotid on planning

 

[scarbrtj]

there is a very avid 1.5 cm left IIA node

its SUV is >7and the node size is 1.6cm

its 1.6 cm necrotic and SUV is 9

Dang, you've convinced me it must be involved 'cause it's growing worse with every post

 

[Haybrant]

Dang, you've convinced me it must be involved 'cause it's growing worse with every post

ha! wasnt sitting in front of the scan when written, its definitely tumor.

 

[Haybrant]

I want to get some dosing clarification from you guys. I essentially have 3 dose levels and 4 volumes. What is the best way to do this? Does postop bed need to go in 200's? Should I just go 2.12 to the gross node so its all done in 33?

5940 to prophylactic region and post op bed <-- 1.8 x 33
6600 to region of ECE <--2 x 33
then boost:
7000 to gross positive node <---2 x 35

Thanks

 

[Palex80]

I want to get some dosing clarification from you guys. I essentially have 3 dose levels and 4 volumes. What is the best way to do this? Does postop bed need to go in 200's? Should I just go 2.12 to the gross node so its all done in 33?

5940 to prophylactic region and post op bed <-- 1.8 x 33
6600 to region of ECE <--2 x 33
then boost:
7000 to gross positive node <---2 x 35

Thanks

I'm not sure I would be comfortable with "only" 59.4 / 1.8 to the post op bed. It's more than 6 weeks since surgery and it was a big tumor. I'd probably ive 66 / 2 to that area too, but that's just me...

 

[ramsesthenice]

I want to get some dosing clarification from you guys. I essentially have 3 dose levels and 4 volumes. What is the best way to do this? Does postop bed need to go in 200's? Should I just go 2.12 to the gross node so its all done in 33?

5940 to prophylactic region and post op bed <-- 1.8 x 33
6600 to region of ECE <--2 x 33
then boost:
7000 to gross positive node <---2 x 35

Thanks

5940 is a bit high for the prophylactic regions. I also don't tend to go over 2 Gy per day. I do these with two plans as follows.

Plan 1: 33 fractions
56.1 to uninvolved prophylactic regions
59.4 to involved/dissected regions
66 to region of ECE

Plan 2
2 fraction boost to involved node

 

[scarbrtj]

50/25 to all regions (ENI, N+, 1°, and the hot node)
(Replan and rescan around 40-45 Gy)
SIB: 16/8 to N+ and 1°, 20/8 to the hot node (it's a very small area, it will be fine at 2.5 a day)
(Or... do a third plan, sans rescan, for 4/2 to the hot node, if you're loathe to go 20/8.)

 

[Haybrant]

I'm not sure I would be comfortable with "only" 59.4 / 1.8 to the post op bed. It's more than 6 weeks since surgery and it was a big tumor. I'd probably ive 66 / 2 to that area too, but that's just me...

thanks all. Yes I initially planned this taking the region of ECE and the post op bed to 6600. honestly the size was massive thanks to the nodal conglomerate that was 6-7 cm itself and the resection bed was massive too so i settled on 66 to ece and 5940 to the bed w chemo. The margins of the surgery were negative, I feel that should buy the guy something. I guess if he was going to be definitive CRT the 7000 would have been huge and those guys get through it. You cant see the right neck lower (scm removed) but they f'ed this guy up pretty good

 

[evilbooyaa]

In terms of how I would dose this:

60/30 to post-op primary bed and high-risk lymph node areas. 54/30 to low-risk lymph node areas.

Sequential 6Gy boost to ECE area and Gross tumor in 3 fractions.

Sequential 4Gy boost to gross tumor.