"postop bed"

[Reaganite]

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It seems like it's radonc dogma to cover the entire post-op bed in head and neck cases. Wondering how you all feel about this? Our local ENT-onc's neck dissection scars almost always extend over almost the entire length of the parotid. Have a young patient now (<40) with a well-lateralized T4N0 mandible CA s/p composite resection and bilateral neck dissection. 40 something nodes negative, no LVSI, but close margins at the primary. If I cover the entire post-op bed and scar, I'm knocking out both parotids. Was a contralateral neck dissection even necessary and do I really have to go back and chase the node negative neck because of possible contamination?!

 

[medgator]

I believe the N0 data for imrt in the undissected neck allows you to "cheat" and only cover up to c2 contralaterally. That's where I would skimp to spare parotid

 

[Palex80]

We do not cover the scar. Are there any data out there saying you need to cover the scar?
The target volume is not the skin and unless you are confronted with a case where affected nodes were really close / fixed to the skin, I do not see a reason you have to cover the scar.
I'd stick to treating nodal volumes per guideline.

On the other hand being a pN0 case with 40 nodes dissected, one can argue about which levels you need to cover in the first place... We had this discussion a while back and divergent opinions exist. It's also a question of why this was a T4. Was it a small tumor with small bone involvement or was it a a big primary with diffuse infiltration in adjacent structures?

 

[scarbrtj]

Our local ENT-onc's neck dissection scars almost always extend over almost the entire length of the parotid

Have you ever asked "Why?" Surely he's not doing parotidectomies!

close margins at the primary

Not a negative risk factor AFAIK.

well-lateralized T4N0 mandible CA

Like... oral cavity, generally? That in and of itself is a negative risk factor, one could say. As is of course the T4ness. If oral cavity, I would not allow well-lateralized to equal ipsi neck RT only.

Have a young patient now (<40)

p16 status?

Are there any data out there saying you need to cover the scar?

I don't think so, in that scar=skin, and I have literally never seen a skin recurrence of SCC whose primary was the aerodigestive tract. However, you may be thinking "Do I need to cover the tissue UNDER the scar?" I don't think that's nec. true either, because:

I believe the N0 data for imrt in the undissected neck allows you to "cheat"

UMich and UF data: generally OK to spare parotids in N0 necks (and I would also say spare high RP region too). I have been doing for years, knock on wood. My upper CTV ENI contour stops at the styloid process.

Now. Is this 40yo someone we would want to give chemoRT to...

 

[evilbooyaa]

No need to cover the entire scar to prescription dose if it's not relevant to the post-operative bed, in this scenario.

I believe the covering the scar bit to be a bigger issue for post-parotidectomy (be it primary adeno or metastatic squamous), or with positive nodes with ECE or direct invasion to the skin.

If well-dissected N0 neck and OC primary, could make strong argument to not treat high level II on both ipsilateral and contralateral neck, which will help parotid sparing immensely.

If it was an oral cavity that involved the oral tongue or any other bilateral drainage organ (FOM, BoT, etc.) then I'd treat contralateral neck. If it was a buccal mucosa tumor that invaded a little bit of mandible without busting through it and into those more midline structures, then you can get away, IMO, with unilateral neck.

So, depends on what the primary was invading into. Hopefully patient isn't getting chemo.

 

[seper]

Scars and post-op H&N is a tricky issue. Squamous cell recurs in scars. Some experienced people go after scars very aggressively, with bolus and TLD's. I do agree with not chasing parotid scar is the case outlined above.

 

[nkmiami]

I would guess this is likely alveolar ridge /possible lateral FOM if it needed a composite resection, and would not treat the contralateral neck, especially if it is pathologically negative. (if it is buccal mucosa- these do really badly in my experience)
To play devil's advocate, why should the ipsilateral neck be treated if node negative with extensive dissection and no LVI?

 

[evilbooyaa]

I would guess this is likely alveolar ridge /possible lateral FOM if it needed a composite resection, and would not treat the contralateral neck, especially if it is pathologically negative. (if it is buccal mucosa- these do really badly in my experience)
To play devil's advocate, why should the ipsilateral neck be treated if node negative with extensive dissection?

Because we know that in earlier stage, T2N0 oral tongue SCC, even in a well dissected neck, patients with tumor invasion >4mm have a 25% chance of recurring, with 60% of those being in the ipsi neck (so 15% chance of recurrence in ipsi neck, Long-term regional control and survival in patients with "low-risk," early stage oral tongue cancer managed by partial glossectomy and neck dissect... - PubMed - NCBI). Given that T4 is significantly likely to have more than 4mm of invasion, I'd radiate.

I don't trust FOM invasion to be 'lateral', personally.

 

[nkmiami]

Because we know that in earlier stage, T2N0 oral tongue SCC, even in a well dissected neck, patients with tumor invasion >4mm have a 25% chance of recurring, with 60% of those being in the ipsi neck (so 15% chance of recurrence in ipsi neck, Long-term regional control and survival in patients with "low-risk," early stage oral tongue cancer managed by partial glossectomy and neck dissect... - PubMed - NCBI). Given that T4 is significantly likely to have more than 4mm of invasion, I'd radiate.

I don't trust FOM invasion to be 'lateral', personally.

I agree with you about the oral tongue which can have complex drainage, but not the alveolar ridge.