I've never done this, but was wondering about the logic. In the setting of post-op H&N stuff, where the boost is basically 3-5 days, does anyone start with the boost? I feel like patients are less likely to stop treatment if they make it closer to the end of the course, and in the setting of oral cavity cancer with negative margins, starting with the boost won't prolong elective treatment terribly long, and will get the patients 3-5 fractions closer to the end before the toxicities of treating the bilateral necks start-up. Obviously, treating the tongue is so morbid this may no matter...
What you are essentially asking is that if someone were to quit with only a few fractions left to go at the end, would it be more detrimental to survival to omit the oral cavity only portion after the neck got a full dose or would it be better to omit the oral cavity and neck portion. And hypothesizing that they would be less likely to quit if the oral cavity is boosted first.
Suppose a hypothetical plan where a patient is getting 5600/28 to the bilateral neck (including oral cavity obviously) followed by a 1000/5 boost to the oral cavity.
Scenario 1: Patient receives oral cavity only first week, then cavity/neck the next 5.5 weeks
Scenario 2: Patient receives cavity/neck first 5.5 weeks then oral cavity only last week.
If you quit scenario 1 with a week left, then both the oral cavity and neck do not receive their prescription dose
If you quit scenario 2 with a week left, then neck has received full dose and oral cavity is underdosed.
I don't know the answer to this, and given that radiobiologically we know both scenarios are more likely to fail as the last few fractions are essential for cure.
There are three variables to consider here:
1. The likelihood of a patient quitting at week 5-6 in scenario 1 vs. 2
2. The impact on control rates if a patient quits in scenario 1 vs. 2
3. The risk of progression and distant metastatic spread in/from the neck by delaying neck treatment a week
Personally I would not do this (although personally I treat with SIB). My gut is that the odds of cure are higher if you can adequately dose the neck in a post-op oral cavity patient vs. under-dosing both the primary and the neck. Especially if there is not gross disease in the op bed.
What you are essentially asking is that if someone were to quit with only a few fractions left to go at the end, would it be more detrimental to survival to omit the oral cavity only portion after the neck got a full dose or would it be better to omit the oral cavity and neck portion. And hypothesizing that they would be less likely to quit if the oral cavity is boosted first.
Suppose a hypothetical plan where a patient is getting 5600/28 to the bilateral neck (including oral cavity obviously) followed by a 1000/5 boost to the oral cavity.
Scenario 1: Patient receives oral cavity only first week, then cavity/neck the next 5.5 weeks
Scenario 2: Patient receives cavity/neck first 5.5 weeks then oral cavity only last week.
If you quit scenario 1 with a week left, then both the oral cavity and neck do not receive their prescription dose
If you quit scenario 2 with a week left, then neck has received full dose and oral cavity is underdosed.
I don't know the answer to this, and given that radiobiologically we know both scenarios are more likely to fail as the last few fractions are essential for cure.
There are three variables to consider here:
1. The likelihood of a patient quitting at week 5-6 in scenario 1 vs. 2
2. The impact on control rates if a patient quits in scenario 1 vs. 2
3. The risk of progression and distant metastatic spread in/from the neck by delaying neck treatment a week
Personally I would not do this (although personally I treat with SIB). My gut is that the odds of cure are higher if you can adequately dose the neck in a post-op oral cavity patient vs. under-dosing both the primary and the neck. Especially if there is not gross disease in the op bed.
Thanks for the answer. Glad to have you back. Mostly just mindless pondering about the likelihood of quitting, or even needing a break, if we try to put off the greatest toxicity to the end. I feel like I'd be more likely to push through if I reached my limit with 5 vs 10 fractions left.
Perhaps OP does 50/25 to all (including LN regions in say a pN0 patient) followed by a cone-down boost to 60/30 to primary (old-school 50-60-70 sequential plans rather than 'new school' 56-63-70 all in one plan, or 54-60 for post-op). IDK if that's super common anymore as I think most folks would just do 60/30 with dose painting to 54/30 to node negative LN volumes.
I don't think it's worng to start with the boost, but if I had a preference between the patient getting 50Gy to all LNs and 58 to post-op tumor bed and getting 48Gy to all LNs and 58Gy to post-op tumor bed I would favor the former (which would be what happens with omission of a boost treatment).
EDIT - Forgot to hit reply for a while, and the other responses have done a good job summarizing similar issues.
I usually do HDR brachy boost after surgical resection (after checking path with the ENT surgeon).
Then EBRT 45 Gy to oral cavity and upper neck nodes.
We only start with the boost if there are some unclear issues. One thing that I sometimes have seen pop up were patients requiring extended procedures to extract teeth. If the boost was in an area away from the oral cavity, for example in the hypopharynx, and wound healing in the mouth was not good, I'd start with the boost and the proceed to the lymphatics, giving the wounds some more time to heal before they start receicing incidental dose.
Ugh, thats' the worst. I don't plead often with patients but that is definitely one scenario. If they are going to quit I'd almost prefer to have them quit at 20Gy rather than at 40Gy.
I usually do HDR brachy boost after surgical resection (after checking path with the ENT surgeon).
Then EBRT 45 Gy to oral cavity and upper neck nodes.
I thought HDR boost was an old timey technique to boosting gross disease in H&N prior to IMRT. What is the rationale of doing HDR boost to a post-op area? Any data to support this treatment paradigm?
- Not a mold but interstitial catheters. The number of catheters depends on the case.
- HDR replaced LDR in many practices. I have done both LDR and HDR. The HDR approach is better for nursing care (not exposing nursing staff to radiation) and pt. Pt can walk around the floor between fractions, lessening the chance of DVT etc.
- The # fractions can be debated: 3, 4, 5, 6, etc. Usually b.i.d. regimens.
- Brachy (whether LDR, PDR or HDR) in oral cavity, either as definitive or adjuvant, is not an old-timey old-schooled stuff. For those who treat HN, they know that EBRT alone is not as good as Brachy + EBRT. The problem is a "catch 22", many so-called "HN gurus" in the country do not know how to do brachytherapy so they teach residents postop IMRT and these residents think this is the way to do it. However, if you talk to people like Syed, Hu, Peter Levendag or Lou Harrison, then hands down, brachy +EBRT is the way to go. In good hands, the results of brachy + EBRT are superior to EBRT alone.
- Search for adjuvant brachy for oral cavity, no randomized trial but you will see respectable data from Netherlands, MSKCC (search for Hu or Lou data), Gustave Roussy, McGill, Japan, India.
- Trust me, if one of you guys has oral cavity cancer, you want brachy as a component of therapy. Anyway, brachy is a dying art.
I feel bad for the oral cavity pts who are not offered the brachy options.
Radiotherapy plays a critical role in the treatment of oral cavity squamous cell carcinoma as monotherapy in early stage cancer or combined with surgery and/or chemotherapy in advances ones. Recent developments in the imaging of cancer and radiation technology have allowed developing more...
- Not a mold but interstitial catheters. The number of catheters depend on the case.
- HDR replaced LDR in many practices. I have done both LDR and HDR. The HDR approach is better for nursing care (not exposing nursing staff to radiation) and pt. Pt can walk around the floor between fractions, lessening the chance of DVT etc.
- The # fractions can be debated: 3, 4, 5, 6, etc. Usually b.i.d. regimens.
- Brachy (whether LDR, PDR or HDR) in oral cavity, either as definitive or adjuvant, is not an old-timey old-schooled stuff. For those who treat HN, they know that EBRT alone is not as good as Brachy + EBRT. The problem is a "catch 22", many so-called "HN gurus" in the country do not know how to do brachytherapy so they teach residents postop IMRT and these residents think this is the way to do it. However, if you talk to people like Syed, Hu, Peter Levendag or Lou Harrison, then hands down, brachy +EBRT is the way to go. In good hands, the results of brachy + EBRT are superior to EBRT alone.
- Search for adjuvant brachy for oral cavity, no randomized trial but you will see respectable data from Netherlands, MSKCC (search for Hu or Lou data), Gustave Roussy, McGill, Japan, India.
- Trust me, if one of you guys has oral cavity cancer, you want brachy as a component of therapy. Anyway, brachy is a dying art.
I feel bad for the oral cavity pts who are not offered the brachy options.
Radiotherapy plays a critical role in the treatment of oral cavity squamous cell carcinoma as monotherapy in early stage cancer or combined with surgery and/or chemotherapy in advances ones. Recent developments in the imaging of cancer and radiation technology have allowed developing more...
Trained at a smaller program with a pretty decent brachy program, including h&n and sarcoma. Did planned BOT boosts as well as oral cavity recurrences with HDR after the ENT placed a protective trach. Definitely needs the right setup/team to do it
I have always loved the idea of the approach. I do a lot of brachy and this is one thing I have never personally seen or tried. Could our team figure it out? Maybe, but I think this would solidly fall in the brachy done poorly can be more dangerous than cancer camp. Glad to hear people are still doing it with some regularity.
Oral cavity cancer is a deadly disease, even for T1N0.
Of all HN cancers (larynx, oropharynx etc. etc.), I have the most respect for oral tongue cancer.
That particular HN subsite is nasty, nasty, and nasty.
The biology of oral tongue cancer is so aggressive...
Oral cavity cancer is a deadly disease, even for T1N0.
Of all HN cancers (larynx, oropharynx etc. etc.), I have the most respect for oral tongue cancer.
That particular HN subsite is nasty, nasty, and nasty.
The biology of oral tongue cancer is so aggressive...
Fair enough - let me re-phrase: If you wanted to push for brachy as a component of definitive oral cavity treatment instead of an IMRT boost I can see the rationale as a practice option. Brachytherapy in definitive management of oral cavity is present, even on the most recent NCCN guidelines (yours are from Jan 2018), so reasonable. Definitive management of oral cavity cancers is quite rare, and only in those who aren't good surgical candidates.
What's the value of brachytherapy in the post-operative setting?
NCCN does not recommend it in the post-operative setting.
Yes, for unresectable disease the role is clear, though few offer it.
However, I agree with the issue raised above: where is the evidence base for postoperative interstitial?
"NCCN does not recommend it in the post-operative setting."
Actually NCCN does not mention it, it does not mean it cannot be used.
Look up who is on the panel, these HN experts are from NCCN designated centers, and virtually all of them are not brachytherapists.
They don't feel comfortable doing brachy, so they don't "mention" it, does not mean the "don't recommend it".
Conceptually this is similar to vaginal cuff boost (philosophically speaking). Or interstitial implant for breast post lumpectomy.
This stuff (brachy) works.
If you talk to Chadha, Hu, Lou Harrison, Syed, Don Goffinet, they will recommend brachy in the adjuvant setting.
Do a google search using key words "Adjuvant brachytherapy oral tongue" and see what you get. Once you do adjuvant brachy and see how good it is, you don't go back to ext beam alone, which is way inferior.
The problem in the US: I can count on my fingers who can do this brachy stuff properly. It is what it is.
Examples...
1. Table #3 in the link I posted above.
2. This set of data comes from MSKCC and Mt Sinai (after Lou moved to Mt Sinai, before Florida):
To determine the feasibility of combined perioperative high-dose-rate brachytherapy (PHDRB) and intermediate-dose external beam radiation therapy (EBR…
www.sciencedirect.com
4. ASTRO 2006. This study showed actuarial control rate of 95%.
I mean.... if NCCN doesn't even mention it, it's not recommended. That's generally how NCCN guidelines work. They mention brachy for definitive management of oral tongue or lip cancers. There isn't some 'hidden' treatment modality that they just failed to mention.
Similar example outside of RT - Cryotherapy isn't listed as an option for localized prostate cancer - therefore it's not recommended. They do mention it as an option in patients who developed recurrence after RT, so it's not like they don't know it exists.
Regardless, a quote from the link you posted a few posts above (I did read through table 3 that showed not great outcomes in a comparatively low-risk cohort compared to those who would get EBRT):
" While in early-stage OCSCC treated with radical RT adding BT plays a critical role in cure and local control, it is not the case of adjuvant setting (early nor advanced stage OCSCC) as either LRC and OS are equivalent between PORT-EBRT or PORT-BT. "
I don't think I'm going to convince you as you seem to rely mostly on dogma and not data in your support for this.
I really do enjoy brachy, and I get the interest in it before the advent of IMRT in the post-operative setting, but I'm challenging whether that's truly necessary in the current era. If you are routinely doing BT for your oral cavity cases, I encourage you to publish your results compared to some other institutions similarly defined patient population to determine if there's actually a benefit of doing brachy.
Have guy refusing surgery (seen by both ENT and a cancer oral surgeon) for a T3N0 floor of mouth squamous cell carcinoma. 3cm, crawling up to ventral tongue.
This.Is.Going.To.Suck. for all involved parties treating this to 70 Gy. I'm doing the oral stent thing to push the tongue down/hard palate up...but no way to avoid mandible getting 70 Gy here to a big area.
Planning 70 Gy to tumor, 56 Gy to bilateral necks with weekly cis.
Have guy refusing surgery (seen by both ENT and a cancer oral surgeon) for a T3N0 floor of mouth squamous cell carcinoma. 3cm, crawling up to ventral tongue.
This.Is.Going.To.Suck. for all involved parties treating this to 70 Gy. I'm doing the oral stent thing to push the tongue down/hard palate up...but no way to avoid mandible getting 70 Gy here to a big area.
Planning 70 Gy to tumor, 56 Gy to bilateral necks with weekly cis.
Have guy refusing surgery (seen by both ENT and a cancer oral surgeon) for a T3N0 floor of mouth squamous cell carcinoma. 3cm, crawling up to ventral tongue.
This.Is.Going.To.Suck. for all involved parties treating this to 70 Gy. I'm doing the oral stent thing to push the tongue down/hard palate up...but no way to avoid mandible getting 70 Gy here to a big area.
Planning 70 Gy to tumor, 56 Gy to bilateral necks with weekly cis.
Have similar, but not same. cT1.5N0, lingual frenulum, would be super easy to resect, maybe not even need to address neck. Healthy guy, refused surgery multiple times. Refused evaluation by local brachytherapist. So, 70/35, hoping for the best.
Had a patient more like yours in the past, but was very old, though fairly healthy, early 90s. Did 55/20 with lateral fields, didn't treat neck and NED 3 years out.
I know it is oncologic first principles to avoid definitive RT, but with VMAT, I wonder if the difference between surgery and RT is as much as it was in the past.
EDIT: just saw above paper. 20% ORN is high, but can't open paper. What grade? Clinically significant? Says it didn't seem to relate to technique (IMRT or not).
BTW, speaking of pain control, anybody tried the high dose prophylactic gabapentin yet? Some interesting data presented at ASTRO by Gopal Bajaj (JJ Mandia et al). They did up to 1200mg TID with excellent results.
Have similar, but not same. cT1.5N0, lingual frenulum, would be super easy to resect, maybe not even need to address neck. Healthy guy, refused surgery multiple times. Refused evaluation by local brachytherapist. So, 70/35, hoping for the best.
Had a patient more like yours in the past, but was very old, though fairly healthy, early 90s. Did 55/20 with lateral fields, didn't treat neck and NED 3 years out.
I know it is oncologic first principles to avoid definitive RT, but with VMAT, I wonder if the difference between surgery and RT is as much as it was in the past.
EDIT: just saw above paper. 20% ORN is high, but can't open paper. What grade? Clinically significant? Says it didn't seem to relate to technique (IMRT or not).
From paper:
"ORN was defined as symptomatic exposure of bone requiring surgery. "
Results:
" The rate of ORN requiring surgery was 20.7% for 82 patients with known post-CRT ORN status. The highest rates of ORN were observed for primary tumors in the floor of mouth (47.1%, n = 8/17) and buccal mucosa (50.0%, n = 2/4). Lower rates were seen for patients with primary disease involving the oral tongue (12.8%, n = 6/47), retromolar trigone (10.0%, n = 1/10), and gingiva (0.0%, n = 0/4). The results of logistic regression analysis for the development of ORN are shown in Table 4. Only primary subsite (floor of mouth vs. other) was significantly associated with the development of ORN (OR 5.53, 95% CI 1.69–18.1, P < 0.01). Treatment during 2004–2014 with exclusive use of IMRT was not significantly associated with a reduced rate of ORN (OR 0.61, 95% CI 0.37–3.86, P = 0.76)."
Nothing else mattered. I don't see any evaluation of elective dental procedures after RT, however.
Have guy refusing surgery (seen by both ENT and a cancer oral surgeon) for a T3N0 floor of mouth squamous cell carcinoma. 3cm, crawling up to ventral tongue.
This.Is.Going.To.Suck. for all involved parties treating this to 70 Gy. I'm doing the oral stent thing to push the tongue down/hard palate up...but no way to avoid mandible getting 70 Gy here to a big area.
Planning 70 Gy to tumor, 56 Gy to bilateral necks with weekly cis.
Hope all his teeth are already out. Counsel on risks and blast away. Good luck. Challenged an attending during my last year of residenncy who said ability to control was 'maybe 20%' with definitive chemoRT, showed them some (other) results suggesting 50% PFS similar to the above linked paper.
Only caveat I'll make to your plan is I generally consider an intermediate risk volume (like a PTV63) to 'highest' risk areas (maybe level I, II) in HPV-negative cancers getting definitive chemoRT. Certainly not mandatory, but just a consideration
We've been doing prophylactic Gabapentin for most. Seems like it doesn't do a whole lot compared to those who don't get it, but who knows. My N is not as high as that paper, so happy to trust the data. No real downsides of it for (most) patients.
I would do gtv + 3 mm to ptv to 70 (no Ctv margin) and all elective to 54-56 including whole floor of mouth and tongue. Could also do 2.2 to 66 to GTV plus ptv margin and 54 elective. Watch heat (keep max under 70) and this way you reduce total fx though likely increase severity of mucosiris with concurrent chemo. Also max dose matters but volume of mandible probably matters more. So keeping high dose volume smaller helps
I think plan on OC is fine and I’ve had long term NED pts with definitive chemorads. No way Local control as low as 20%.
I would not get cute with PTV. I’ve found OC cancers to be infiltrating and I have had marginal failures. I would do 1 cm CTV expansion and then PTV on top of that. Agree that much better when all teeth gone. I’ve also had regional failures with infiltration along vascular sheath in neck, so my CTV for involved neck nodes higher for OC than for your p16 OP pts.
Ive done prophylactic Gabapentin with mixed results. It makes many pts (seems to me particularly older ones) very sleepy at the doses that are considered good prophylaxis (~900 tid on up). I’ve had pts where it seems to work.
I think plan on OC is fine and I’ve had long term NED pts with definitive chemorads. No way Local control as low as 20%.
I would not get cute with PTV. I’ve found OC cancers to be infiltrating and I have had marginal failures. I would do 1 cm CTV expansion and then PTV on top of that. Agree that much better when all teeth gone. I’ve also had regional failures with infiltration along vascular sheath in neck, so my CTV for involved neck nodes higher for OC than for your p16 OP pts.
Ive done prophylactic Gabapentin with mixed results. It makes many pts (seems to me particularly older ones) very sleepy at the doses that are considered good prophylaxis (~900 tid on up). I’ve had pts where it seems to work.
In my experience local control is only half the battle, outside of nasopharynx I've never seen a head and neck site met out (typically to lungs first) with such ferocity
