HPV+ OPC Elective Node Irradiation 30 Gy in 15 fx No RCT at MSKCC?

[RadOncMegatron]

Am I reading this right? MSKCC has decided to routinely treat patients with only 30 Gy in15 fractions ENI off trial with limited data? Somebody in the know confirm?

https://www.practicalradonc.org/article/S1879-8500(18)30316-3/abstract

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[Palex80]

"Extrapolated" from anal cancer data (elective inguinal RT up to 30.6-36 Gy)?

"We are going to treat your throat cancer as if it originated from your butt.",

 

[PhotonBomb]

0 Gy elective to certain areas is being looked at in trials, including the next NRG HPV trial.

 

[medgator]

0 Gy elective to certain areas is being looked at in trials, including the next NRG HPV trial.

Is 30 gy elective justified now though?

 

[scarbrtj]

Is 30 gy elective justified now though?

A patient with a neck recurrence at MD Anderson sits prettier than a patient with a controlled neck elsewhere. Perhaps.

 

[SneakyBooger]

I suspect 30+/- Gy of incidental dose is being to delivered to a non targeted contralateral neck and other areas with targeted IMRT to the primary and ipsi neck.

 

[gmsquid]

I suspect 30+/- Gy of incidental dose is being to delivered to a non targeted contralateral neck and other areas with targeted IMRT to the primary and ipsi neck.

If you are dosing 30 Gy to any meaningful amount of the contralateral neck in an ipsilateral neck treatment, you are not pushing your planners hard enough.

 

[SneakyBooger]

If you are dosing 30 Gy to any meaningful amount of the contralateral neck in an ipsilateral neck treatment, you are not pushing your planners hard enough.

Depends on the definition of "meaningful", but it is never "0 Gy" unless the patient doesn't receive any radiotherapy at all.

 

[StIGMA]

Is 30 gy elective justified now though?

My understanding is that these doses have been done in the post-op setting and ENI is either being done to a dissected neck or to a very low risk neck (clinically negative based on good imaging +/- path negative as well). I don't have any inside info regarding these doses in the primary setting like the article discusses.

With regard to these doses in the post-op setting, Mayo looked at 30 Gy in 1.5 Gy BID over 2 weeks with concurrent docetaxel in HPV+ oropharyngeal disease the post op setting with negative margins (and 36 Gy in 1.8 BID over 2 weeks if ENE). 2 year LRC was 96%. "Phase II Evaluation of Aggressive Dose De-Escalation for Adjuvant Chemoradiotherapy in Human Papillomavirus–Associated Oropharynx Squamous Cell Carcinoma" Ma et al, JCO 2019.

MSKCC 30 Gy (with concurrent chemo) is supposed to be a question also done on trial (NCT00606294), and it looks like this is being done in the post-op setting with caveat of dose escalating if nodal disease is found after 30 Gy.

There is data that with lateralized HPV+ oropharyngeal cancer, including lateralized base of tongue, the risk of contralateral nodal disease is < 15%. One series showed ~10% risk of contralateral nodal disease in patients with a clinically negative contralateral neck with lateralized HPV+ OPSCC of the BOT, in 4 of 38 patients (top line in table 4). "Risk and Rate of Occult Contralateral Nodal Disease in Surgically Treated Patients With Human Papillomavirus−Related Squamous Cell Carcinoma of the Base of the Tongue" Last et al Jama Oto Head Neck Surg 2019.

One could argue that radiation to the low-risk neck (contralateral to primary with negative PET +/- additionally negative surgical dissection), elective nodal irradiation would have limited benefit and any dose may more harmful than 0 Gy. One could also argue that with a good neck dissection to the (low nodal burden) pN+ neck, any dose may more harmful than 0 Gy. I would consider that 30 Gy may look good simply because 0 Gy would have done the same thing... and we are not doing a good enough job yet of selecting exactly who needs real ENI.

 

[goodkerma]

Depends on the definition of "meaningful", but it is never "0 Gy" unless the patient doesn't receive any radiotherapy at all.

except when using protons.... zing

 

[goodkerma]

My understanding is MSKCC has some sort of ridiculous imaging grant and gets weekly imaging with MRI and PET on patients.. regardless not sure why that was published in PRO - others should not attempt to generalize to their populations....

 

[Krukenberg]

Phase II trial in Press from Penn. Omitted the primary site for surgical patients with node positive neck but no risk factors at the primary site. Really good local control #s so far but needs more follow up.

https://www.redjournal.org/#/article/S0360-3016(19)34057-X/fulltext

 

[SneakyBooger]

except when using protons.... zing

neutron contamination

 

[RickyScott]

Phase II trial in Press from Penn. Omitted the primary site for surgical patients with node positive neck but no risk factors at the primary site. Really good local control #s so far but needs more follow up.

https://www.redjournal.org/#/article/S0360-3016(19)34057-X/fulltext

None of pts should have had surgery to begin with. I bet the radoncs can’t stand that surgeon.

 

[Haybrant]

A patient with a neck recurrence at MD Anderson sits prettier than a patient with a controlled neck elsewhere. Perhaps.

This one killed me. Thank you scar

 

[evilbooyaa]

I mean MSKCC can do whatever they want but I believe all would agree that this not be adopted nationwide until it's validated in a phase III trial.

This applies to both definitive (as what they are suggesting) and adjuvant (like Mayo study from JCO noted above).

Phase II trial in Press from Penn. Omitted the primary site for surgical patients with node positive neck but no risk factors at the primary site. Really good local control #s so far but needs more follow up.

https://www.redjournal.org/#/article/S0360-3016(19)34057-X/fulltext

Your link is not working for me. Just taking me to the in-press section of IJROBP's website.

Regardless, I really think that this concept of 'doing a neck dissection to avoid elective doses of RT' has really got to stop, or at least needs PRO data before we start adopting it. Surgeons tried in ORATOR and lost. We should be advocating for less neck dissections, not less radiation.

 

[ramsesthenice]

MSKCC pushes the envelop with some regularity in terms of implementing emerging therapies and approaches. I guess you can do that when you are a high-volume, top-tier research center. However, I do grow tired of having to remind people (mostly med oncs) that "they do it at Sloan (or Anderson)" is not level 1 evidence. Had this discussion late last week with one of our med oncs who wants to do induction chemo for all esophageal patients based on the most recent alliance phase 2 switch trial's early pathologic outcomes. When pushed on the fact there is no survival data (yet) and multiple other negative induction trials the fall back was "well they are already doing it at MSKCC and it will be a level 1 recommendation in the upcoming NCCN guidelines."

 

[RadOncMegatron]

MSKCC pushes the envelop with some regularity in terms of implementing emerging therapies and approaches. I guess you can do that when you are a high-volume, top-tier research center. However, I do grow tired of having to remind people (mostly med oncs) that "they do it at Sloan (or Anderson)" is not level 1 evidence. Had this discussion late last week with one of our med oncs who wants to do induction chemo for all esophageal patients based on the most recent alliance phase 2 switch trial's early pathologic outcomes. When pushed on the fact there is no survival data (yet) and multiple other negative induction trials the fall back was "well they are already doing it at MSKCC and it will be a level 1 recommendation in the upcoming NCCN guidelines."

No matter how smart or how awesome a center is, they do not have some magical privileged insight that allows them to bypass RCTs. There is a reason why expert opinion is on the bottom of the EBM pyramid. I think a center of excellence like MSKCC should develop, run, and lead those trials, but one of the main reasons of RCTs exist is to give us all surer footing on these questions. I would not be surprised if someone would adopt this in practice, quote this article, and note "this is what MSKCC does so it's ok." The whole point of running trials and doing things on trials and not off trial is to say "hey, doing XYZ / Protons / 30 Gy ENI/ off trial is not ok and equivalent to experimenting on humans. We need a properly vetted trial, IRB approved, in order to avoid the past mistakes and confounding biases inherent single arm studies."

If MSKCC gets the exemption, hey why not pass the exemption card to us all? Or is that only for certain NCI designated centers?

 

[RickyScott]

In early days of imrt for head and neck mskcc had some complications because some of attending adopted high dose sib-Like 240 fraction to laryngeal primary with concurrent chemo.