Attempt at least 60 Gy range with chemo and BID 1.2 Gy fractions and a cord max of about 20 Gy if possible. Very involved fieldish I would think (ie avoid sclav ENI, no need).
p16 positive. Thanks. I haven't seen his prior plan yet so I'll have to check dose constraints. I assume he received 70 Gy though.
Agree, assume max doses. You kind of have to not get too worried about dose constraints (at the end of day, you’re trying to achieve at least a summed in field dose of 120 Gy or more, lifetime) except the cord. I give it a 50% discount off its previous dose and always assume it got a max of 50 Gy in the prior plan regardless (unless I know for sure it got more which obv has been known to happen, sometimes).
Not whole neck. I would stay in the general LN station region. Would talk to ENT, ideally in presence of patient, to get sense of extent(s) of disease and the areas they’re concerned about if any.
I totally missed that update from OP. I would absolutely treat that postop to 66 Gy. No elective neck.
Rtog protocol for reirradiation similar to this and I have had some success. Minimal if any elective xrt. I am more liberal with the cord. I think rtog allowed a bit more. If cord revived 45 gy originally at 1-4-1.5 fraction and allow for recovery, do have some room.
20 Gy max is aspirational
oof. 60 in 30 fx with cisplatin. Target only areas of prior gross disease.
My own feeling is that DVH factors are not the primary predictor but malignancy/carotid propinquity
Hx Neck surgery is the main predictor of a blowout. In re xrt rtog series almost all blowouts are in pts with hx neck dissection,
Thank you.
that said I have had 2 blowouts (~1 per 10y) and both were definitive chemoRT with LNs socked in/around carotid
I am sure if disease invades the carotid wall, either the treatment or the disease could result in a blowout.
Reading that this was p16+ and is a OPhx primary -
Explain what I need to be looking at/for here lol (I mean I see the T7 tongue tumor)
Mostly just showing the primary to illustrate the degree of invasion at presentation. The more interesting pic is the CT 2.5 months after RT. In case it's not obvious, and wasn't to me, you shouldn't see the vasculature on a non-con CT (those aren't gyri).
So what do they think happened. He just had a stroke? Any cancer can make you hypercoaguable I suppose?
I'm not sure I've gotten a straight answer on that as he was helicoptered out and thats the last image I saw. The presumption was some type of connection between a blood vessel and an airway. He didn't bleed out, so presumptively a vein. Going back in time, at pres, the venous trunk that receives blood from the mouth and face goes straight into the tumor, though no clear involvement of the IJV. Presumably there were pulmonary infarcts as well, and could've had a PFO. Basically the entirety of the cerebral circulation and right carotid below the lower extent of the CT head were filled with air.
I agree. None of the explanations I've gotten have made sense. What I do know is that his entire tongue was a cancer, and killing it had to do something to the structural integrity of the involved normal anatomy. I'm not up on all the causes of an aeroembolus affecting the entirety of the cerebral circulation.
