HNSCC: 40 Gy to the elective neck?

[Palex80]

So, who's doing it already?

Two papers by the same group seem to make the case, that perhaps we should be giving less dose to our patients, when electively treating the neck.

Reduction of the dose of radiotherapy to the elective neck in head and neck squamous cell carcinoma; a randomized clinical trial. Effect on late to... - PubMed - NCBI

Recurrence patterns after a decreased dose of 40Gy to the elective treated neck in head and neck cancer. - PubMed - NCBI

The logical step would probably be to start with those patients getting chemo/certuximab and the ones who are P16-positive.

Any takers?

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[scarbrtj]

I'll likely be a taker. We had hints of this did we not. UF was completely eliminating ENI above the styloid process in N0 necks with success. There was compelling European/UK data re: elimination of >~50% of the ENI fields vs. what we do here in America. We use ipsi-RT for select even N+ tonsillar cancers now--an idea which was complete anathema in Lindberg's day. Not to mention the ever-evolving HPV data you mentioned.

Good article, thanks for sharing. There is nothing surprising about this, overall it should be comforting. Some people will still worry about a "miss," geographic or dosimetric. In the meantime we all worry about the side effects of chemoRT, which are not slight.

 

[nkmiami]

thanks; Most failures are in the gtv. Recent rtog 1016 allows 150 cGy/fraction to low risk neck levels, although i believe it is 6 fractions/week

 

[Phantom1]

Just as important or maybe even more important than dose is making sure you cover the correct LN stations, ie including or not including levels V, RP nodes, levels 1a or 1b. Also re-simming and re-planning due to weight loss. I think slight de-escalation of elective nodal doses may make sense in certain cases but not all. Remember loco-regional recurrence is still a major problem and cause of death currently in head and neck cancer. Also with SIB the elective nodal volume is going in 1.6-1.64cGy per fraction so BED is slightly lower than 54 Gy in standard fractionation anyway..

 

[radia8or]

UChicago has been investigating dose de-escalation to the elective neck for a while now. Their most recent phase II trial completely omitted the elective neck and treated only GTV plus margin (albeit in responders to induction)--was plenary at H&N symposium last year.

 

[OTN]

UChicago has been investigating dose de-escalation to the elective neck for a while now. Their most recent phase II trial completely omitted the elective neck and treated only GTV plus margin (albeit in responders to induction)--was plenary at H&N symposium last year.

That's pretty cool, but I'd never consider doing something that extreme without Phase III data. Hopefully all these de-escalation protocols are moving towards RCT as a goal.

 

[RadOncDoc21]

Anybody doing any kind of de-escalation in the clinic? I treated a 35 yr old, HPV+ oropharynx patient, standard chemoRT, standard fields, it was rough. I think I might consider doing something different next time. He is NED, but is still using a feeding tube 5 months out.

 

[medgator]

Anybody doing any kind of de-escalation in the clinic? I treated a 35 yr old, HPV+ oropharynx patient, standard chemoRT, standard fields, it was rough. I think I might consider doing something different next time. He is NED, but is still using a feeding tube 5 months out.

I'm treating a 33 yo now.

I've actually had a few pts so far in their 30s, and anecdotally, they all seem to have had a tougher time than older folks, esp with pain and swallowing issues

 

[Burt Radnolds]

These people have the rest of their lives to live so I try not to get too cute, such as lowering gross disease dose. I do try to limit volumes as much as possible, such as PET avid disease plus 5mm CTV, then 3mm PTV. I also try to keep my elective neck doses as low as possible, usually 5600 cGy at most, even "high risk" regions. I will push avoidance structures extra hard such as larynx, constrictors, parotids and accept relatively cold elective PTVs near these structures. I will omit high RP nodes and contralateral low neck as well, as much as appropriate. I look forward to when I can deescalate more in good faith.

 

[Phantom1]

Anybody doing any kind of de-escalation in the clinic? I treated a 35 yr old, HPV+ oropharynx patient, standard chemoRT, standard fields, it was rough. I think I might consider doing something different next time. He is NED, but is still using a feeding tube 5 months out.

Doubt this was due to elective neck volumes... more likey due to high dose oropharyngeal volumes..

 

[RadOncDoc21]

Doubt this was due to elective neck volumes... more likey due to high dose oropharyngeal volumes..

I think so also, however more acute on chronic toxicity since he started having symptoms week 1 and never fully recovered. Counts went down also, then intractable nausea, vomiting, 30 lb weight loss, TPN, multiple breaks and hospital admissions. It was a nightmare!

 

[Burt Radnolds]

Doubt this was due to elective neck volumes... more likey due to high dose oropharyngeal volumes..

While that is true, limiting those high dose regions to only what is necessary can really help. Also, elective nodal doses strongly influence your ability to spare uninvolved mucosal surfaces and other OARs, which directly contribute to acute (and late) toxicity.

 

[evilbooyaa]

I think in the oropharynx, for the high-dose region, carving out the CTV out of areas that would not be normal can be useful (instead of a simple 5mm geometric expansion), such as a Tonsil extending into the mandible. One of the folks here is very aggressive with carving out CTV, while another does essentially full geometric expansions. If it's an anterior tonsil tumor, you'll be much more able to minimize constrictor dose if you're carving out as much as possible posteriorly.

I think so also, however more acute on chronic toxicity since he started having symptoms week 1 and never fully recovered. Counts went down also, then intractable nausea, vomiting, 30 lb weight loss, TPN, multiple breaks and hospital admissions. It was a nightmare!

I'm assuming you did a re-plan, especially if they had a bulky tumor, with that amount of weight loss? With IGRT you can really see how much a plan can go from good to bad with even 5-10kg weight loss.

One patient I saw do really poorly in this age group had HIV, any idea if that has been checked on him?

 

[RadOncDoc21]

I think in the oropharynx, for the high-dose region, carving out the CTV out of areas that would not be normal can be useful (instead of a simple 5mm geometric expansion), such as a Tonsil extending into the mandible. One of the folks here is very aggressive with carving out CTV, while another does essentially full geometric expansions. If it's an anterior tonsil tumor, you'll be much more able to minimize constrictor dose if you're carving out as much as possible posteriorly.



I'm assuming you did a re-plan, especially if they had a bulky tumor, with that amount of weight loss? With IGRT you can really see how much a plan can go from good to bad with even 5-10kg weight loss.

One patient I saw do really poorly in this age group had HIV, any idea if that has been checked on him?

Yes, I did everything to keep dose down, IGRT, re-planned, even suggested Cetuximab vs RT alone with DAHANCA fractionation.

Like I said , he got through, but not the way I would have expected. Maybe, there is a lower tolerance with younger age. He was HIV negative.

 

[seper]

Anecdotally, I've noted poor tolerance of 20-30 years olds to head and neck irradiation for lymphoma.

 

[evilbooyaa]

Yes, I did everything to keep dose down, IGRT, re-planned, even suggested Cetuximab vs RT alone with DAHANCA fractionation.

Like I said , he got through, but not the way I would have expected. Maybe, there is a lower tolerance with younger age. He was HIV negative.

Tough case for sure. I had one twenty something with lymphoma who got pretty bad esophagitis.

Maybe inherently high metabolism (as opposed to metabolism slowing down in your 60's) combined with the hypermetabolic response to radiation induces easier weight loss in the younger population. Can't really explain the other side effects, though.

 

[Palex80]

Anecdotally, I've noted poor tolerance of 20-30 years olds to head and neck irradiation for lymphoma.

You raise a very interesting point here. I've also seen this in a number of patients. My boss always makes the argument that many of these patients have received chemotherapy before RT and may already have "damaged" mucosa tissue due to chemotherapy.
I am not fully convinced, since I've seen this in chemo-naive patients too.

I think there may be more to that, perhaps things we do not understand yet. It's perhaps not pure "bad luck" that a patient gets cancer at young age. Perhaps it's more than that, perhaps some genetic subtypes, we are not aware of yet, that make cellsmore prone to mutation (and enhance radiosensitivity too perhaps?).

A good example are seminoma patients who are very prone to nausea, vomiting and fatigue after irradiation of the paraaortal strip +/- ipsilateral pelvic lymphatics in my experience.
They generally seem to develop more of these side effects than other patients with abdominal/pelvic irradiation.

 

[nkmiami]

I just think they mount a stronger inflammatory reaction

 

[Reaganite]

It's so interesting to read these comments here because I just had this long discussion with several of my therapists. Consistently and regardless of site we have noticed our younger patients are having a much tougher time than our older patients. I used to think it was just a "millenial" thing, but I'm seeing objective differences in response (younger patients needing admission for laryngeal edema in head and neck treatments, profound dysuria in younger patients receiving pelvic RT with very dramatic UA findings, etc.), and it's happening so frequently it's hard not to notice. Anyways, I thought it might be exactly what nkmiami said...stronger inflammatory response in younger patients with better immune systems.

 

[Pewl]

It's so interesting to read these comments here because I just had this long discussion with several of my therapists. Consistently and regardless of site we have noticed our younger patients are having a much tougher time than our older patients. I used to think it was just a "millenial" thing, but I'm seeing objective differences in response (younger patients needing admission for laryngeal edema in head and neck treatments, profound dysuria in younger patients receiving pelvic RT with very dramatic UA findings, etc.), and it's happening so frequently it's hard not to notice. Anyways, I thought it might be exactly what nkmiami said...stronger inflammatory response in younger patients with better immune systems.

I've definitely noticed this phenomenon. I've seen a 30 year old female just get wiped out by 30Gy/10fx palliative treatment. I'm talking like grade 2-3 fatigue. It was crazy.

 

[BobbyHeenan]

I see this most often in my cervical cancer patients. I swear my 70 year olds do better than the 40 year olds. The young patients have major pain issues with pelvic pain, bladder irritation, etc, patients unable to under brachytherapy without anesthesia in my younger cohorts versus older.

 

[medgator]

I see this most often in my cervical cancer patients. I swear my 70 year olds do better than the 40 year olds. The young patients have major pain issues with pelvic pain, bladder irritation, etc, patients unable to under brachytherapy without anesthesia in my younger cohorts versus older.

I've got a 71 yo recurrent nsclc pt getting chemoradiation for N2 disease found on imaging all around her esophagus, she's already near 60 with chemo and still doesn't want any magic mouthwash.

Meanwhile,I was writing narcotics week 2 for my 33 y/o p16+ smoker pt with a soft palate scc getting chemo xrt

 

[ramsesthenice]

I don't think there's really any doubt that the dose is coming down for HPV positive oropharyngeal cancers. I've seen some interesting data recently from a couple different groups that suggest novel biomarkers, like circulating HPVDNA, may be able to identify early rapid responders during treatment. Nothing is ready for prime time yet as far as I know, but my personal biases these kinds of tools might really make extreme dose reduction more palatable for the masses.