How do you treat a patient with locazlied disease breaking through the skin with necrotic lymph node

[RadOnc2013]

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At my center we have a patient with isolated small cell carcinoma of the right axillary lymph nodes. She is in severe pain from this. On exam, there are fixed, matted nodes in the right axilla that are necrotic and protruding through the skin. How would you treat this patient? Palliative RT alone (30 Gy)? Definitive dose of RT (60 Gy)? Concurrent chemoradiation as is done for small cell of the lung? Most specifically, I am concerned about the wound from the protruding disease not healing after a definitive or even palliative dose of RT.

 

[Neuronix]

Consider secondary pathology review. Could it be Merkel cell for example? Is it some other small round blue cell tumor that's being confused with "small cell" ?

If it really is a small cell carcinoma localized to the axilla, do a PET/CT and brain MRI. If no evidence of additional disease, I'd treat definitively with chemoRT if eligible (good PS, etc) 45 Gy in 1.5 Gy BID vs 60 Gy in 2 Gy daily.

Sure it's going to be rough on the skin, but deal with it supportively. If it doesn't heal, I'd deal with that later. Consent for chronic wound care, plastic surgery repair, etc. That's better than having cancer.

 

[Radiator20]

fixed, matted nodes in the right axilla that are necrotic and protruding through the skin

Sounds potentially unresectable. True? But if it were resectable, and only site of disease, I wonder if anyone would consider ALND, probably f/b adjuvant RT/CRT? Certainly not the answer from the lung paradigm, but I wonder if there's any reason to consider a situation like this differently. Also, would give more tissue for diagnosis, if there is any uncertainty based on biopsy.

I am concerned about the wound from the protruding disease not healing after a definitive or even palliative dose of RT.

Well, unless you get local control, the tumor itself is going to prevent the wound from ever healing. That's the biggest threat to wound healing at the moment. So I think your only choice is to treat so as to maximize your chance of local control, and deal with any tx-related consequences down the road.

Palliative RT alone (30 Gy)?

Certainly would not treat palliatively if isolated disease. Even if there were a limited burden of metastatic disease, I wonder if one should go a bit higher than 30 Gy--there is a high risk of local failure at 30 Gy based on historical lung SCLC data, which would be morbid in this case, whereas going a bit higher (even if not to a definitive dose) shouldn't give prohibitive toxicity in this circumstance.


Other than that, agree with everything Neuronix said: path review (critical first step!), systemic staging, consider definitive CRT.

 

[OTN]

Assuming path review confirms the dx and metastatic workup is negative, I'd go with concurrent chemoRT with curative intent- 60 Gy in 20 Gy fx.

BID obviously also ok, but every patient I've ever offered BID to here refuses to drive in twice a day, so we usually end up going with daily to 60 Gy. Traffic can suck in their defense.

I'd just go ahead and treat and deal with wound care after tx. I agree with Radiator20 that resection at this point has a high chance of leading to a non-healing wound.

 

[evilbooyaa]

Assuming path review confirms the dx and metastatic workup is negative, I'd go with concurrent chemoRT with curative intent- 60 Gy in 20 Gy fx.

BID obviously also ok, but every patient I've ever offered BID to here refuses to drive in twice a day, so we usually end up going with daily to 60 Gy. Traffic can suck in their defense.

I'd just go ahead and treat and deal with wound care after tx. I agree with Radiator20 that resection at this point has a high chance of leading to a non-healing wound.

Assuming you meant 60 in 30? I'd follow CONVERT and go 66/33 with concurrent chemoif treating definitively. If it's really a small cell carcinoma (and not something like Merkel which is a very important consideration) and only site of disease, no role for surgery IMO.

 

[Radiator20]

If this were confirmed to be a localized small cell of the axilla--would anyone do PCI?

Also, would anyone consider going higher than 60 Gy qd based on 0538?

 

[evilbooyaa]

I'm biased against PCI personally and would rather monitor closely and because of the extremely strange presentation and potential for other neuroendocrine diagnoses that aren't frank small cell, I wouldn't be enthusiastic in this patient. Not unreasonable, though.

 

[Neuronix]

I don't do PCI anymore at all based on Japanese trial. Prophylactic cranial irradiation versus observation in patients with extensive-disease small-cell lung cancer: a multicentre, randomised, open-labe... - PubMed - NCBI

I know that's for extensive stage, and I know that's an unpopular opinion. Flame me. I think the logic extends just fine to limited stage. I guess we need another study to prove it.

Reasonable to go higher than 60 Gy. If anything SCLC is more sensitive than NSCLC so I doubt dose escalation will get you anything. In this particular case good luck getting the patient to tolerate all that skin to the high dose with chemo.

 

[medgator]

Wouldn't do pci, probably should do a baseline and periodic MRI brain though.

agree with chemo rt, 60-63, keeping brachial plexus under 66 (some might feel ok taking it to 66, keeping plexus point dose under 70).

Wound will never heal until cancer is gone. Surgery will only make it worse by introducing an iatrogenic wound, pt will still need rt after

 

[OTN]

Assuming you meant 60 in 30? I'd follow CONVERT and go 66/33 with concurrent chemoif treating definitively. If it's really a small cell carcinoma (and not something like Merkel which is a very important consideration) and only site of disease, no role for surgery IMO.

Ha yep, good catch. 60 Gy in 30 fractions. No PCI.

 

[evilbooyaa]

I don't do PCI anymore at all based on Japanese trial. Prophylactic cranial irradiation versus observation in patients with extensive-disease small-cell lung cancer: a multicentre, randomised, open-labe... - PubMed - NCBI

I know that's for extensive stage, and I know that's an unpopular opinion. Flame me. I think the logic extends just fine to limited stage. I guess we need another study to prove it.

Reasonable to go higher than 60 Gy. If anything SCLC is more sensitive than NSCLC so I doubt dose escalation will get you anything. In this particular case good luck getting the patient to tolerate all that skin to the high dose with chemo.

Agree with you on the bolded. I think in PP though without guidelines and trials supporting it, most ROs probably toe the NCCN line.

 

[Reaganite]

At my center we have a patient with isolated small cell carcinoma of the right axillary lymph nodes. She is in severe pain from this. On exam, there are fixed, matted nodes in the right axilla that are necrotic and protruding through the skin. How would you treat this patient? Palliative RT alone (30 Gy)? Definitive dose of RT (60 Gy)? Concurrent chemoradiation as is done for small cell of the lung? Most specifically, I am concerned about the wound from the protruding disease not healing after a definitive or even palliative dose of RT.

If you don't treat the tumor, the wound will never heal. I've treated many "open" wounds from tumor invading through the skin, and most all healed as tumor regressed. You have to do it. Would treat with chemoXRT to definitive dose.

 

[medgator]

If you don't treat the tumor, the wound will never heal. I've treated many "open" wounds from tumor invading through the skin, and most all healed as tumor regressed. You have to do it. Would treat with chemoXRT to definitive dose.

It's the same thing when I see patients with large ulcerated skin cancers. Finally heals up during/after xrt

 

[PhotonBomb]

for those not giving PCI to limited patients - are you getting 3 month MRI scans like on trial?

 

[Neuronix]

Absolutely. IMO routine MRI surveillance is a requirement for omitting PCI in small cell disease.

As a foot note, I also get routine brain MRIs even after whole brain or PCI. The recurrence rates after whole brain or PCI at one year are not trivial. Patients can benefit from SRS boost, SRS for isolated future mets, or from repeat whole brain before things get out of control and patient ends up on hospice.

 

[Palex80]

Absolutely. IMO routine MRI surveillance is a requirement for omitting PCI in small cell disease.

As a foot note, I also get routine brain MRIs even after whole brain or PCI. The recurrence rates after whole brain or PCI at one year are not trivial. Patients can benefit from SRS boost, SRS for isolated future mets, or from repeat whole brain before things get out of control and patient ends up on hospice.

I‘ve said it before and i will say it again... 3 month intervall MRI are done, because they were done in thr trial as well.

– Is treatment of extensive disease SCLC palliative?
Yes

– Is the evidence on the value of PCI for ED–SCLC limited?
Yes. The EORTC probably included alot of patients with asymptomatic brain mets at baseline and its OS benefit was measurable in weeks.

– Does any other disease exist where we do 3 month intervall MRIs to pick up early brain mets (I am not talking about patients who had brain mets already and we do MRI to check treatment results, i.e. after SRS)?
No. Although their inciden e is quite high for example in metastatic tripple negative or Her2neu–positive breast cancer

– Do we have proven survival benefit of treating asymptomatic vs. symptomatic brain mets in SCLC?
No. I mean „visible“ mets, not invisible ones like in PCI.

– Do we have some data pointing out that treating mets in patients with advanced lung cancer may not even make lots of difference?
Yes, Quartz–trial. Although that‘s NSCLC.


In summary, 3–monthly MRIs are ok if you are not doing PCI, but the evidence for it is limited.