Interesting H&N case

[Palex80]

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Here's an interesting case

65 year old patient, heavy smoker.
Had a partial laryngectomy and ipsilateral (right) neck dissection in 2019 for a pT1 pN0 (0/20) G3 SCC in the right supraglottic area. Clear margins, no adjuvant treatment.

A suspicious lymph node was palpated in the left neck (level II) during follow-up, biopsy showed SCC, p16 negative.
PET showed no other uptake, endoscopy showed no recurrence in the larynx or some other primary tumor.
He received a bilateral tonsillectomy and biopsies at the base of tongue area, all negative + a Neck dissection on the left side, which came back as pN1 (1/15), no ECE.

The tumor board (and some of my fellow radiation oncologists) call it a CUP, I think it's a contralateral nodal recurrence of his tumor in the right supraglottis.

What would you do?

a) observe
b) treat bilateral neck
c) treat bilateral neck + larynx
c) treat bilateral neck + pharynx + larynx
d) treat ipsilateral (left) neck + larynx
e) treat ipsilateral (left) neck + pharynx + larynx

 

[Ray D. Ayshun]

Here's an interesting case

65 year old patient, heavy smoker.
Had a partial laryngectomy and ipsilateral (right) neck dissection in 2019 for a pT1 pN0 (0/20) G3 SCC in the right supraglottic area. Clear margins, no adjuvant treatment.

A suspicious lymph node was palpated in the left neck (level II) during follow-up, biopsy showed SCC, p16 negative.
PET showed no other uptake, endoscopy showed no recurrence in the larynx or some other primary tumor.
He received a bilateral tonsillectomy and biopsies at the base of tongue area, all negative + a Neck dissection on the left side, which came back as pN1 (1/15), no ECE.

The tumor board (and some of my fellow radiation oncologists) call it a CUP, I think it's a contralateral nodal recurrence of his tumor in the right supraglottis.

What would you do?

a) observe
b) treat bilateral neck
c) treat bilateral neck + larynx
c) treat bilateral neck + pharynx + larynx
d) treat ipsilateral (left) neck + larynx
e) treat ipsilateral (left) neck + pharynx + larynx

Hard not to agree this is recurrent disease/hard to say this is CUP. In any case, in my mind, for simplicity's sake, he's either T1N0 and TXN1 (in which case obs isn't inappropriate) or T1N2 (in which case obs would be inappropriate). If I choose the latter I'm treating the larynx and both necks. And given that it's recurrent nodal cancer, I'm not sure chemo would be inappropriate.

 

[OTN]

My vote is for recurrent disease as well. I would treat bilateral necks and larynx. His tumor has declared itself to be high risk enough to warrant adjuvant treatment.

 

[communitydoc13]

Bilateral neck and larynx. No chemo. I'm assuming this is a IIA node. IIB involvement would be less common in SG larynx.

 

[Palex80]

Bilateral neck and larynx. No chemo. I'm assuming this is a IIA node. IIB involvement would be less common in SG larynx.

Level IIA, correct

 

[kimplera]

bilateral neck and larynx
and this remains a pT1N0 now recurrent - we don't restage when a patient recurs... 😉

 

[Bequerel]

My vote is for recurrent disease as well. I would treat bilateral necks and larynx. His tumor has declared itself to be high risk enough to warrant adjuvant treatment.

Is it really high risk if it recurred > 2 years later? Easy answer is to just treat bilateral necks and larynx because it’s a recurrence and that’s what I’d probably do if it was my patient. The more I think about it though, I could possibly be persuaded to observe.

 

[ramsesthenice]

Level IIA, correct

My vote is that we keep doing these interesting cases. We are starting the MROSDNGA (Make Rad Onc SND Great Again!) campaign. This is fun.

Also, very hard for me to say this is not a recurrence although rare things do happen. I got burned in the last couple months. Tell me who would have seen this ending the way it did. Guy has had low volume metastatic prostate (bone only) for a while and has done well on ADT with periodic RT for bone mets. In Jan or Feb this year he showed up with a painful lesion in his L spine and a couple small indeterminate nodules in his RUL. What was different from prior recurrences was his PSA did not increase. We figured maybe he was becoming CRPC or undergoing a small cell transformation. His oncologist asked me if we should biopsy the bone and I said what I suspect most of us would have said: "what are the chances this is something else." Well, fast forward to this week and I am treating his whole brain. His next surveillance scan showed more bone mets and a lot of mediastinal adenopathy. Biopsy showed SCLC (definitely lung primary, not consistent with a SC transformation of PC). MRI brain showed diffuse mets. Now I have to ask myself, what are the chances the bone met I treated in Feb was prostate cancer 🙁 . But seriously, without a crystal ball, who in the hell would have said to themselves, yep, I bet its SCLC.

 

[OTN]

My vote is that we keep doing these interesting cases. We are starting the MROSDNGA (Make Rad Onc SND Great Again!) campaign. This is fun.

Also, very hard for me to say this is not a recurrence although rare things do happen. I got burned in the last couple months. Tell me who would have seen this ending the way it did. Guy has had low volume metastatic prostate (bone only) for a while and has done well on ADT with periodic RT for bone mets. In Jan or Feb this year he showed up with a painful lesion in his L spine and a couple small indeterminate nodules in his RUL. What was different from prior recurrences was his PSA did not increase. We figured maybe he was becoming CRPC or undergoing a small cell transformation. His oncologist asked me if we should biopsy the bone and I said what I suspect most of us would have said: "what are the chances this is something else." Well, fast forward to this week and I am treating his whole brain. His next surveillance scan showed more bone mets and a lot of mediastinal adenopathy. Biopsy showed SCLC (definitely lung primary, not consistent with a SC transformation of PC). MRI brain showed diffuse mets. Now I have to ask myself, what are the chances the bone met I treated in Feb was prostate cancer 🙁 . But seriously, without a crystal ball, who in the hell would have said to themselves, yep, I bet its SCLC.

Interesting case for sure. Hard to blame you for not biopsying- hindsight being 20/20 and all.

 

[Palex80]

It is very interesting to see that most of you are in favor of bilateral neck with larynx and a few would observe.
My colleague discussed treating the ipsilateral neck only with the patient.
Apparenty, the patient voiced concerns about toxicity with more comprehensive treatment. Well it's nice he can still voice them... 😛
My main issue with ipsilateral neck only is that it will burn bridges in case his cancer recurrs in the larynx. The patient may need a laryngectomy then, since full course radiochemotherapy for organ preservation may not be possible any more without a very high risk of complications. That would in fact shift me over to the "observation camp" for now, given the patients concerns and the uncertainty of neck recurrence vs. CUP.
If the patient does not want bilateral neck RT or treatment of the larynx now, maybe it's better to observe at first and keep all options open for later?

 

[ramsesthenice]

It is very interesting to see that most of you are in favor of bilateral neck with larynx and a few would observe.
My colleague discussed treating the ipsilateral neck only with the patient.
Apparenty, the patient voiced concerns about toxicity with more comprehensive treatment. Well it's nice he can still voice them... 😛
My main issue with ipsilateral neck only is that it will burn bridges in case his cancer recurrs in the larynx. The patient may need a laryngectomy then, since full course radiochemotherapy for organ preservation may not be possible any more without a very high risk of complications. That would in fact shift me over to the "observation camp" for now, given the patients concerns and the uncertainty of neck recurrence vs. CUP.
If the patient does not want bilateral neck RT or treatment of the larynx now, maybe it's better to observe at first and keep all options open for later?

100% agree. I think unilateral would be a mistake and tie your hands if things go south. If they are not agreeable to bilateral RT I would observe for all the reasons you said.

 

[seper]

I would treat the left neck only.
Larynx did not recur since 2019 - good

 

[TheWallnerus]

Here's an interesting case

65 year old patient, heavy smoker.
Had a partial laryngectomy and ipsilateral (right) neck dissection in 2019 for a pT1 pN0 (0/20) G3 SCC in the right supraglottic area. Clear margins, no adjuvant treatment.

A suspicious lymph node was palpated in the left neck (level II) during follow-up, biopsy showed SCC, p16 negative.
PET showed no other uptake, endoscopy showed no recurrence in the larynx or some other primary tumor.
He received a bilateral tonsillectomy and biopsies at the base of tongue area, all negative + a Neck dissection on the left side, which came back as pN1 (1/15), no ECE.

The tumor board (and some of my fellow radiation oncologists) call it a CUP, I think it's a contralateral nodal recurrence of his tumor in the right supraglottis.

What would you do?

a) observe
b) treat bilateral neck
c) treat bilateral neck + larynx
c) treat bilateral neck + pharynx + larynx
d) treat ipsilateral (left) neck + larynx
e) treat ipsilateral (left) neck + pharynx + larynx

Calling this CUP is wrong. (Just think, it wouldn't even be allowed had he been entered on a study.) He presented with a head and neck cancer, not a head and right neck cancer. In retrospect the sole right neck dissection was a little bit of an iffy call (it's the larynx; lymphatics cross over, and tumors sure as heck do). We are taught that any neck dissection "messes up" logical lymph drainage in the future so a contralateral neck recurrence is not surprising. If the recurrence had happened 3 or more years after the primary, a CUP maybe. But again, not a CUP. You have to treat the primary site and likely nodal basins, which in this case are both sides of the neck; 50 Gy to primary and R/L neck, 10 Gy boost encompassing to the recurrent L neck LN station. I wouldn't irradiate above the tip of the styloid process on either side and do very good parotid sparing.


a) observe >50% chance of a relapse now
b) treat bilateral neck tough to do in reality and get total larynx sparing
c) treat bilateral neck + larynx yes
c) treat bilateral neck + pharynx + larynx ??
d) treat ipsilateral (left) neck + larynx ?
e) treat ipsilateral (left) neck + pharynx + larynx ????

 

[gmsquid]

Single node under 3 cm. No ece? Two years after? I would observe. You could reasonably observe a T1N1 upfront. Could easily salvage another nodal recurrence. If it’s truly a larynx, we treat those with chemo rt all the time without surgery.

If I were to treat, would not treat primary site and would likely treat unilaterally. Unnecessary morbidity for a primary that has yet to recur. I don’t treat primary site in oral cavity with delayed nodal recurrences (>1 year). has not thus far recurred in primary site, so likely low risk for recurrence. Should be able to spare larynx

 

[FrostyHammer]

I would very closely (q 3 months scope & CT/MRI) observe. Here's my logic.

I agree that this is not a CUP but a recurrence - if this was a primary cancer then larynx and bilateral neck would be the treatment of choice.

If he recurs locoregionally, it could be @ the larynx, ipsi neck, or contra neck. Risk is highest for ipsi neck, then larynx/contra neck both around the same. Using that thought, if you are going to treat now, then treat all 3 areas because if I were to eyeball it, the recurrence rate in the ipsi neck would be about the same (or slightly higher) as recurrence in the contra neck plus larynx put together. So treating ipsi neck only is literally half-assing it.

Having established that you treat all or none, I would personally just closely observe because there's no good data to do comprehensive salvage RT for a small isolated recurrence. In this case, the recurrence was salvaged by a neck dissection. If he recurs again, which is far from a certainty, your magic bullet for comprehensive RT is at the ready.

 

[Ray D. Ayshun]

I would very closely (q 3 months scope & CT/MRI) observe. Here's my logic.

I agree that this is not a CUP but a recurrence - if this was a primary cancer then larynx and bilateral neck would be the treatment of choice.

If he recurs locoregionally, it could be @ the larynx, ipsi neck, or contra neck. Risk is highest for ipsi neck, then larynx/contra neck both around the same. Using that thought, if you are going to treat now, then treat all 3 areas because if I were to eyeball it, the recurrence rate in the ipsi neck would be about the same (or slightly higher) as recurrence in the contra neck plus larynx put together. So treating ipsi neck only is literally half-assing it.

Having established that you treat all or none, I would personally just closely observe because there's no good data to do comprehensive salvage RT for a small isolated recurrence. In this case, the recurrence was salvaged by a neck dissection. If he recurs again, which is far from a certainty, your magic bullet for comprehensive RT is at the ready.

If he's lucky enough to only recur locally, magic bullet is comprehensive RT or CRT?

 

[FrostyHammer]

If he's lucky enough to only recur locally, magic bullet is comprehensive RT or CRT?

Good question. I don't have a definitive answer, but I'd see how extensive the recurrence is. Higher volumes would make me lean towards chemo more. But it's a judgment call, definitely a good spin-off situation with discussing.

 

[TheWallnerus]

Here's an interesting case

65 year old patient, heavy smoker.
Had a partial laryngectomy and ipsilateral (right) neck dissection in 2019 for a pT1 pN0 (0/20) G3 SCC in the right supraglottic area. Clear margins, no adjuvant treatment.

A suspicious lymph node was palpated in the left neck (level II) during follow-up, biopsy showed SCC, p16 negative.
PET showed no other uptake, endoscopy showed no recurrence in the larynx or some other primary tumor.
He received a bilateral tonsillectomy and biopsies at the base of tongue area, all negative + a Neck dissection on the left side, which came back as pN1 (1/15), no ECE.

The tumor board (and some of my fellow radiation oncologists) call it a CUP, I think it's a contralateral nodal recurrence of his tumor in the right supraglottis.

What would you do?

a) observe
b) treat bilateral neck
c) treat bilateral neck + larynx
c) treat bilateral neck + pharynx + larynx
d) treat ipsilateral (left) neck + larynx
e) treat ipsilateral (left) neck + pharynx + larynx

Btw, when exactly (month-day) was the surgery in 2019, and the palpated LN in 2021. And do you think there were any followup timing irregularities due to COVID.

And what have you decided to do 🙂

 

[Palex80]

Btw, when exactly (month-day) was the surgery in 2019, and the palpated LN in 2021. And do you think there were any followup timing irregularities due to COVID.

And what have you decided to do 🙂

It was pretty much 2 years apart (early 2019 & early 2021), follow-up was regular, no appointments missed.

 

[BobbyHeenan]

It was pretty much 2 years apart (early 2019 & early 2021), follow-up was regular, no appointments missed.

If patient compliant with follow up I think I’d slightly lean toward close observation here. Stop smoking (if they do that).

I don’t have string objection with treating now though. If patient uncomfortable with observing I’d be easily convinced to treat.

Kind of a wimpy stance, but there’s a reason it’s a tough case.

 

[DebtRising]

My interpretation is that he has microscopic residual disease left at the primary site which seeded the contra lateral neck because ipsilateral drainage was changed after the initial surgery and it is reasonable to treat both necks and the larynx.

observation is a reasonable second line choice as well with close ent surveillance and I agree a high risk of recurrence.

Find it hard to classify nodal scc within 2 years of first presentation as a second primary cup and so ipsilteral neck rt makes little sense to me, but does if that clinical scenario is believed.

May have missed but has the primary resection from 2019 been hpv/p16 stained?

 

[TheWallnerus]

This is like a good oral boards gotcha...

Me: I would like to treat both necks and the larynx.
Examiner: But the recurrence is 2 years after the surgery. And the surgery was on the opposite neck only.
Me: But it’s still a locoregional recurrence.
Examiner: But it’s not that big.
Me: I don’t have great data on how small locoregional recurrences do versus larger ones.
Examiner: But the patient doesn’t want radiation.
Me: I still have to recommend it here.
Examiner: The patient begs you not to treat and swears he will come in for regular follow up.
Me: Well ok. I guess we can observe.
Examiner: Ok. You observe. He comes back to see you a year later with left neck adenopathy. You decide to treat. On CT sim you see some nodules in the upper lung fields...

 

[ramsesthenice]

This is like a good oral boards gotcha...

Me: I would like to treat both necks and the larynx.
Examiner: But the recurrence is 2 years after the surgery. And the surgery was on the opposite neck only.
Me: But it’s still a locoregional recurrence.
Examiner: But it’s not that big.
Me: I don’t have great data on how small locoregional recurrences do versus larger ones.
Examiner: But the patient doesn’t want radiation.
Me: I still have to recommend it here.
Examiner: The patient begs you not to treat and swears he will come in for regular follow up.
Me: Well ok. I guess we can observe.
Examiner: Ok. You observe. He comes back to see you a year later with left neck adenopathy. You decide to treat. On CT sim you see some nodules in the upper lung fields...

To be clear (for those who have not taken them), you would have aced that case because you still explicitly stated you still would have recommended treatment which by ending it this way was obviously the opinion of the examiner. Patient declined and you can’t make them do anything, even on the oral boards 🙂. In that particular vignette they confirmed that your instinct was probably right. In situations that you could argue either way (meaning there is not great data for observation) I would always err on the side of caution and treat on your oral boards. In real life, poll your friends and critically assess the situation. I have no problem telling patients this is complicated and I am not entirely sure what to do here. Our patients are not on an OR table, we have time to think and get back to them.

 

[Palex80]

May have missed but has the primary resection from 2019 been hpv/p16 stained?

It was not stained and the procedure performed in another institution. If it was positive and we know that node is negative now, it would back the hypothesis of two indepenend tumors. On the other hand, if it comes back negative, it doesn't prove anything. 🙂

 

[RSAOaky]

My interpretation is that he has microscopic residual disease left at the primary site which seeded the contra lateral neck because ipsilateral drainage was changed after the initial surgery and it is reasonable to treat both necks and the larynx.

observation is a reasonable second line choice as well with close ent surveillance and I agree a high risk of recurrence.

Find it hard to classify nodal scc within 2 years of first presentation as a second primary cup and so ipsilteral neck rt makes little sense to me, but does if that clinical scenario is believed.

May have missed but has the primary resection from 2019 been hpv/p16 stained?

You think he has microscopic residual left at the primary site that hasn't grown/declared itself in 2 years but has metastasized to a lymph node and started growing there. I think that he had microscopic disease in the contralateral neck at presentation that was never treated and has taken 2 years to declare itself. Either option is certainly possible and there is no way to know for sure which is what makes a treatment decision tough.

I really don't know the answer and I suspect there would be many different opinions. I think you can make a case for anything from observation to comprehensive treatment, so it may be helpful to see what the patient wants.

In the boards world I would treat comprehensively, but in the real world I would consider observation unless my colleagues or the patient felt very strong about treating. If you observe you may never have to treat him which is the biggest win for him. If the patient fails, you have curative salvage options though they may have slightly more morbidity than treatment now. Even if he fails 2 years from now, that's 2 years that you've spared him the toxicity of treatment which I think we sometimes understate the significance of.

Head and neck sucks.

 

[temujim]

Observation seems reasonable. Right neck and larynx have proven themselves. Left neck now with 1 node, < 3 cm, no ENE. Low risk I think.

 

[BobbyHeenan]

This is like a good oral boards gotcha...

Me: I would like to treat both necks and the larynx.
Examiner: But the recurrence is 2 years after the surgery. And the surgery was on the opposite neck only.
Me: But it’s still a locoregional recurrence.
Examiner: But it’s not that big.
Me: I don’t have great data on how small locoregional recurrences do versus larger ones.
Examiner: But the patient doesn’t want radiation.
Me: I still have to recommend it here.
Examiner: The patient begs you not to treat and swears he will come in for regular follow up.
Me: Well ok. I guess we can observe.
Examiner: Ok. You observe. He comes back to see you a year later with left neck adenopathy. You decide to treat. On CT sim you see some nodules in the upper lung fields...

Me (if I had stones like Simul): oh, are we doing that timeline? Or should we do the one where he has life altering side effects from his chemo xrt and has lung nodules on his 6 month follow up anyway?

 

[DebtRising]

It was not stained and the procedure performed in another institution. If it was positive and we know that node is negative now, it would back the hypothesis of two indepenend tumors. On the other hand, if it comes back negative, it doesn't prove anything. 🙂

Yep but it’s an easy test to ask for which may help make the clinical decision easier without any harm to the pt.

And yes, I think it is equally plausible that there is microscopic disease left at the primary / larynx the same as microscopic disease in a contra lateral neck that took 2 years to blossom. Not all local recurrences occur within 18 months.

 

[evilbooyaa]

This patient has undergone a lot of unnecessary yet incomplete surgery and has been quite poorly served by it. I would be quite disappointed in this management if I was an observer of this case at tumor board.

Heavy smoker.

Supraglottic larynx cancer that got surgery instead of definitive RT to primary + b/l necks off the bat? And on top of that, they only did an ipsilateral neck dissection??

OK, then he recurs with biopsy proven p16 negative disease, and they decide to take his tonsils and base of tongue out? Why?? HEAVY SMOKER. HISTORY OF LARYNX CANCER. At 2 years post previous head and neck diagnosis that was incompletely treated they're thinking CUP?? Like a P16+ CUP?? Then they do a contralateral neck dissection? So now the patient has had everything he might've initially needed but in a completely jacked up time line.

I would do either full post-op (larynx + b/l necks) or observe. Yes 2 years can be considered A milestone for H&N, and I get the folks who are saying just do ipsi neck +/- larynx. But again, it's a half ass treatment. Either go whole ass or no ass at all, IMO. You might get lucky, but if he recurs contralaterally (R neck) and already got larynx + ipsi neck, life will be painful and difficult.

 

[Ray D. Ayshun]

This patient has undergone a lot of unnecessary yet incomplete surgery and has been quite poorly served by it. I would be quite disappointed in this management if I was an observer of this case at tumor board.

Heavy smoker.

Supraglottic larynx cancer that got surgery instead of definitive RT to primary + b/l necks off the bat? And on top of that, they only did an ipsilateral neck dissection??

OK, then he recurs with biopsy proven p16 negative disease, and they decide to take his tonsils and base of tongue out? Why?? HEAVY SMOKER. HISTORY OF LARYNX CANCER. At 2 years post previous head and neck diagnosis that was incompletely treated they're thinking CUP?? Like a P16+ CUP?? Then they do a contralateral neck dissection? So now the patient has had everything he might've initially needed but in a completely jacked up time line.

I would do either full post-op (larynx + b/l necks) or observe. Yes 2 years can be considered A milestone for H&N, and I get the folks who are saying just do ipsi neck +/- larynx. But again, it's a half ass treatment. Either go whole ass or no ass at all, IMO. You might get lucky, but if he recurs contralaterally (R neck) and already got larynx + ipsi neck, life will be painful and difficult.

Yes, it's like an attempted cover-up with this cup talk. I asked myself what would be the least likely to wake me up in the middle of the night, and larynx plus bilateral necks wins. Op knows his ents better than we, but if there's the least bit of mistrust, it's time to clean this up.

 

[Radonc90]

My 2 cents...

- 2019: a partial was not wrong surgery, but the better option at that time was limited RT (primary + some upper neck stuff).

- The problem is when he recurred and they called it CUP! If they stained the neck LN for P16, and the LN was neg for HPV P16,
then it is from the supraglottic larynx.

- If multiple co-morbid conditions: I guess you can closely observe the pt every 2-3 months with physical exam and CT etc., and treat if and when he recurs again.

- If the pt can handle Tx, then RT +/- concurrent chemo. The data for concurrent chemo in only 1 LN is a bit tricky (EORTC vs RTOG classic studies).

- @evilbooyaa, the reason for bilat tonsillectomies and random biopsies of the BOT is that: they called it CUP and *some* (OK *some*) people recommend bilat tonsillectomies and random biopsies of the BOT for CUP, which I am not 100% convinced is the way to search for primary (if truly a CUP in a fresh brand-new pt) bc for me it does not change the management: I treat potential primary sites anyway, but this is a different animal (CUP).

 

[evilbooyaa]

- @evilbooyaa, the reason for bilat tonsillectomies and random biopsies of the BOT is that: they called it CUP and *some* (OK *some*) people recommend bilat tonsillectomies and random biopsies of the BOT for CUP, which I am not 100% convinced is the way to search for primary (if truly a CUP in a fresh brand-new pt) bc for me it does not change the management: I treat potential primary sites anyway, but this is a different animal (CUP).

I mean, yeah I get why they did it as part of the work-up for PET-negative CUP.

But it's still the wrong answer and IMO would be a very strange boards answer. And focusing on just Oropharynx when you know the node is P16 negative is doubly head scratching.

 

[Phantom1]

I would observe. Single node resected without ECE and extensive search for any local recurrence or new primary was negative. Thus most likely that single node represents microscopic disease from original laryngeal primary. Also treating his entire remaining partial larynx with RT electively could lead to significant dysfunction or aspiration.

If he recurs then you could treat comprehensively with chemoRT or he could get TL and post-op RT if laryngeal function is already compromised.

 

[Haybrant]

Yes, it's like an attempted cover-up with this cup talk. I asked myself what would be the least likely to wake me up in the middle of the night, and larynx plus bilateral necks wins. Op knows his ents better than we, but if there's the least bit of mistrust, it's time to clean this up.

You see this quite often from derm and occasionally from ENT but less from ENT because they generally do understand cancer well- this mental attempt to cover up substandard decision making up front. Not saying anything substandard in this situation but yes, when we start to treat less (lower dose, no adjuvant RT, smaller surgeries, micrographic surgeries!) more recurrences happen. You've been given a second chance and it's time to not mess it up like we did the first time. It was wild when I realized that, after maybe 6 months as an attending, that often you are the parent in oncologic cases and have to break the bad news to the kids that their fun and games of MOH's surgery or super partial impartial laryngectomies is up, its time to move to modalities that work against cancer.

Of course the above balances with gosh, what would I do if it were a family member. And TBH I want to avoid the side effects for that family member so I would tell them lets observe but to observe closely, not q4-6 months like derm does. The consultation is your chance to get the patient to understand the difficulties of making decisions in these spaces we dont have great answers too