Interesting discussion in tumor board

[Gfunk6]

We had a case of a women in her 60s w/ supraglottic larynx SCC cT2-3N0. She presented with a nearly compromised airway and required trach/PEG. CT Chest showed suspicious LNs in mediastinum (AP Window, paratracheal), PET is pending. Her biopsy showed HPV negativity (plus she has an extensive h/o smoking/drinking).

If her mediastinum is metastatic, there was a divergence of opinions in tumor board:

1. My take - if she is M1, it is game over. 3 year OS for pt's with metastatic SCC of H&N (HPV negative) is probably < 5%. I would endorse 'aggressive palliation' to palliate local symptoms (perhaps quad shot) followed by chemo.

2. Med Onc take - would still do 'definitive' chemoXRT to H&N because a local recurrence is a horrible way to die (as opposed to 'mediastinal death').

My response was that it would be, in my mind, malpractice to take someone with known metastatic SCC fo 70 Gy given the substantial acute and subacute morbidity.

Curious to see what others would recommend in a metastatic scenario . . .

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[medgator]

Had a pt with a basaloid type scc of the bot with a similar presentation, with the difference being that he was asymptomatic from his primary, and it was found for another reason. Actually referred him to a pulmonary doc myself who was capable of doing ebus to document metastatic mediastinal nodes. I would recommend that in your case even with the pet being hypermetabolic in the area especially if there are no other mets.

I agree with your recommendation. The pt actually wanted no chemo of any kind, and decided to go on a long cruise instead. I recently treated his L spine for cauda equinae syndrome when he metted out further six months after his initial consult with me. I never treated his primary and he has never been symptomatic from it. I figured I would keep rt in reserve for when he develops symptoms.

I would have ideally recommended upfront chemo and rt afterwards if distant disease responded and/or he became symptomatic

 

[Palex80]

Gfunk, I agree with you recommendation.

However, it's also possibe, that she has a second primary in the lung or esophagus, so I would push for panendoscopy. A cT2 larynx-ca with a cN0-neck rarely presents with metastatic nodes in the mediastinum. PET should help you, but I would still push for panendoscopy.

 

[temujim]

We had a case of a women in her 60s w/ supraglottic larynx SCC cT2-3N0. She presented with a nearly compromised airway and required trach/PEG. CT Chest showed suspicious LNs in mediastinum (AP Window, paratracheal), PET is pending. Her biopsy showed HPV negativity (plus she has an extensive h/o smoking/drinking).

If her mediastinum is metastatic, there was a divergence of opinions in tumor board:

1. My take - if she is M1, it is game over. 3 year OS for pt's with metastatic SCC of H&N (HPV negative) is probably < 5%. I would endorse 'aggressive palliation' to palliate local symptoms (perhaps quad shot) followed by chemo.

2. Med Onc take - would still do 'definitive' chemoXRT to H&N because a local recurrence is a horrible way to die (as opposed to 'mediastinal death').

My response was that it would be, in my mind, malpractice to take someone with known metastatic SCC fo 70 Gy given the substantial acute and subacute morbidity.

Curious to see what others would recommend in a metastatic scenario . . .

If LNs in question are in the upper mediastinum (Level 7 for H&N), those are considered regional LNs by AJCC and not metastatic.

If not, depending on performance status etc, it may be reasonable to take the primary to 66-70 Gy. I wouldn't go so far as to say "malpractice". See eg PMID: 18798313.

 

[TarHeelRadOnc]

If LNs in question are in the upper mediastinum (Level 7 for H&N), those are considered regional LNs by AJCC and not metastatic.

If not, depending on performance status etc, it may be reasonable to take the primary to 66-70 Gy. I wouldn't go so far as to say "malpractice". See eg PMID: 18798313.

I agree with you that full dose, conventionally fx chemoRT is non-standard for M1 disease, but do not think that it is malpractice. We did that for select, good PS pts where I trained, and it is my impression that this is common at other institutions as well. I typically treat to 50-55Gy in 2.5Gy/fx w/o concurrent chemo in this setting. This is supported by data from PMH (Red J a few years back). Agree with med onc that death from uncontrolled local disease is a terrible way to die, but would not want to reflexively subject metastatic patients to the late effects of 70Gy + chemo.

 

[IndyXRT]

I've seen some patients die from uncontrolled H&N primaries (we do all of the RT for the county hospital, so we see lots of advanced cases). It's very unpleasant. I would want to do something more than a quad shot if the patient had minimal metastatic disease and decent PS (50 Gy in 20 fractions as suggested by TarHeelRadOnc might be something I would choose). However, if pt's PS is poor, then quad shot may be your best bet. This is one of those situations where it's difficult to choose the right path without laying eyes on the patient.

 

[Palex80]

How about starting palliative chemo and irradiating according to response or symptoms in the future?
We know, that over 80% of patients with larynxca will respond to chemo well (data coming from the neoadjuvant chemo trials). What is there to lose by switching sequence of treatment.
Concurrent radiochemo should not be used for palliation in my opinion, when single modality treatment is also effective.

 

[seper]

I treat most metastatic H&N to the primary site first, to provide durable local control.

 

[Leforte]

Agreed that a T2-3N0 Supraglottic SCCa would rarely have metastatic LN to the mediastinum.

If the patient had a trach - I would have done the panendoscopy at the same time (which I assume was done since you know the HPV status.

If the mediastinal LN are determining treatment, get CTS to do a mediastinoscopy with biopsy if you cant get a needle into for an FNA.

The superior mediastinal LAD may be trach related (infectious) - especially if it is a new trach or poorly taken care of.

This is coming from an ENTs perspective.

 

[seper]

Agreed that a T2-3N0 Supraglottic SCCa would rarely have metastatic LN to the mediastinum.
.

I don't believe you are an ENT.

 

[Leforte]

I don't believe you are an ENT.

Seriously? How many times have you seen an initial presentation T2-3N0 supraglotitic scca with mediastinal mets in the absence of level 2-6 neck disease?

 

[seper]

twice in 2 years of being an attending

 

[Leforte]

Interesting pathology then - 5 years out for me and haven't seen it yet.

 

[user_name]

Bill Brasky has seen it 8 times today already.

Too obscure?