Hypopharynx Tis

[Palex80]

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So, interesting new case...

69 year old patient, who had a pT1 pN0 oropharyngeal cancer a few years ago. He was managed with TORS and neck dissection without adjuvant treatment and remains in remission.

He was now diagnosed with a second primary in the hypopharynx region. It's a rather large lesion but it's spreading superficially.
Biopsy showed only in-situ carcinoma (Tis), no invasive component. The biopsy was quite large/deep and performed at several sites, so I guess it's representative.
PET-CT is clean, not showing any uptake.

Patient was offered surgery, but due to the size of the lesion TORS is not an option, so he would need pharyngotomy. He declined surgery.



RT now?
What dose?
Would you treat nodes (up to a lower dose) too, bearing in mind that it could be (micro)invasive somewhere and might have spread to nodes already?
Would you rather just wait?
Alternatives? I have seen photodynamic therapy been used in in-situ lesions.

 

[medgator]

Intuitively, I'd treat it the way we treat glottic Tis.... Which is to dose it like a T1. PDT might not be an option with a bulky tumor I think.

Basically I'd treat the same dose you'd use for a T1 hypopharynx. I usually do 6996/33. Not clear whether nodal coverage would be needed here

 

[seper]

What does the lesion look like? Is it a mucosal discoloration or an actual defect/raised tumor? I've never seen this situation but it's tempting to treat to 70 Gy presuming invasion.

 

[nkmiami]

What does the lesion look like? Is it a mucosal discoloration or an actual defect/raised tumor? I've never seen this situation but it's tempting to treat to 70 Gy presuming invasion.

I wouldnt assume it is TIS just because of the biopsy. I think you have to assume it is invasive and treat accordingly

 

[evilbooyaa]

Agree with above. If you burn the RT bridge without treating nodes and he recurs in the nodes you're going to look silly. If it's not amenable to lasering or whatever then I'd treat like a T1N0 hypopharynx. Still RT alone, should be well tolerated with IMRT.

 

[Palex80]

What does the lesion look like? Is it a mucosal discoloration or an actual defect/raised tumor? I've never seen this situation but it's tempting to treat to 70 Gy presuming invasion.

It's a mucosal discoloration, not a raised lesion. This is why I thought of PDT. The problem is rather the surface the lesion involves is rather large, making surgery tricky too.

 

[seper]

Well, if it is true CIS caught just in the nick of time, one could consider lower dose. Kind of like treating true vocal cord dysplasia or vaginal VAIN.

 

[xrthopeful]

reason not to treat nodes in a glottic cancer is because there really should be no lymphatic drainage there.

the hypopharynx on the other hand is super rich in lymphatics. A T1N0 is pretty rare, but guess the staging work-up was clean - I agree that if you are going to treat with RT, you got to treat nodes. It's big (sounds like maybe bigger than a T1?), you can't trust that there isn't an invasive component somewhere. I would treat the primary plus small margin to 70 in 35, levels II-IV and RP nodes bilaterally to 56 in 35.

 

[gmsquid]

Sounds ugly. Is the lesion on the posterior pharyngeal wall or involving the pyriform sinus / post cricoid space? Smoker/non smoker? P16 status of initial disease?

 

[Palex80]

Sounds ugly. Is the lesion on the posterior pharyngeal wall or involving the pyriform sinus / post cricoid space? Smoker/non smoker? P16 status of initial disease?

Posterior wall. Smoker. P16 negative.

 

[evilbooyaa]

reason not to treat nodes in a glottic cancer is because there really should be no lymphatic drainage there.

the hypopharynx on the other hand is super rich in lymphatics. A T1N0 is pretty rare, but guess the staging work-up was clean - I agree that if you are going to treat with RT, you got to treat nodes. It's big (sounds like maybe bigger than a T1?), you can't trust that there isn't an invasive component somewhere. I would treat the primary plus small margin to 70 in 35, levels II-IV and RP nodes bilaterally to 56 in 35.

How validated is the concept of < 1.8 Gy/day data in patients not getting chemotherapy? We don't do a ton of RT alone and am not sure if doing sequential boosts after 50/25 wouldn't be a better idea.

 

[xrthopeful]

I guess it depends on your comfort level and how you were trained I suppose. We always do SIB, but you’re right 1.6/fx without chemo hasn’t been necessarily validated, nor will it probably ever be as there aren’t many patients that are getting 35 fix without chemo.

 

[gmsquid]

My preference is 66/30 to gross disease with 54/30 to nodes. I would treat levels 2-5, rps and Likely would include upper mediastinal. I don’t think I’ve ever seen isolated posterior pharyngeal wall involvement without pyriform sinus involvement

 

[thecarbonionangle]

Sounds ugly. If it smells nasty, it probably is...not a true T1, would even consider chemo. Would treat bilateral neck, RP, levels II-V

 

[xrthopeful]

Do you guys regularly treat level V in a node negative neck?

 

[RickyScott]

can make an argument to treat in hypopharynx. It really doesnt get spared much even if you dont contour it. When I plan head and necks, I really push dose away from anterior structures, constrictors, pharyngolarynx, cricopharyngius when appropriate etc, so a lot ends up back there.