Sinus

[deleted4401]

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67 year old man with tobacco hx and sinus drainage. Noticed fullness in right side of face. Imaging showed large, destructive maxillary sinus mass, extending into mouth. MR - 4.7 x 3.3 x 4.7 mass, extended into ethmoid, extending into soft tissues medially, eroded into nasal cavity obliterating R nasal turbinates. Appeared to erode inferior wall of orbit. Multiple enlarged LNs seen bilaterally. Total maxillectomy + B LND, with option of orbital exenteration. Upon visualization, did not need to take out eyeball. Tumor was 3.0 x 2.5 x 1.5cm, grade 3. Positive margin inferiorly, 0.1cm posterioly, 0.3cm medially. 0/52 LNs on ipsi (R), 1/32 on contra (L, level II), was 0.8cm, no ECE. pT3N1M0.

Strange nodal pattern, right? You're not even supposed to treat bilaterally prophylactically.

Recommendation was post-op CRT, consistent with NCCN.

Going to treat B necks to 54 Gy (level I, II, III, IV for both), tumor bed + margin based on pre-op MRI/contra (level I, II, III) neck to 60 Gy, will fuse pre-op MRI and treat inferior aspect of pre-op volume to 66 Gy. Sequential boosts.

Anyone doing dose-paint/SIB for post op? Would anyone include a larger CTV for tumor bed - i.e. adjacent sinuses, nasal cavity, etc.?
S

 

[Palex80]

Is this not actually pN2c and not pN1?

Your treatment plan makes sense, although I'd probably go higher than 60 Gy for the entire primary site. It may be however tough to achieve, given the proximity to critical structures. Sounds like a patients, who may potentially profit from IMPT, if available.

 

[deleted4401]

You're right. That is N2c.

 

[temujim]

Reasonable plan. I personally would not treat the necks, just the primary site. I like the idea of 60 to most of the tumor bed with 66 to the areas of close/positive margins if they can be identified accurately as you suggested.

67 year old man with tobacco hx and sinus drainage. Noticed fullness in right side of face. Imaging showed large, destructive maxillary sinus mass, extending into mouth. MR - 4.7 x 3.3 x 4.7 mass, extended into ethmoid, extending into soft tissues medially, eroded into nasal cavity obliterating R nasal turbinates. Appeared to erode inferior wall of orbit. Multiple enlarged LNs seen bilaterally. Total maxillectomy + B LND, with option of orbital exenteration. Upon visualization, did not need to take out eyeball. Tumor was 3.0 x 2.5 x 1.5cm, grade 3. Positive margin inferiorly, 0.1cm posterioly, 0.3cm medially. 0/52 LNs on ipsi (R), 1/32 on contra (L, level II), was 0.8cm, no ECE. pT3N1M0.

Strange nodal pattern, right? You're not even supposed to treat bilaterally prophylactically.

Recommendation was post-op CRT, consistent with NCCN.

Going to treat B necks to 54 Gy (level I, II, III, IV for both), tumor bed + margin based on pre-op MRI/contra (level I, II, III) neck to 60 Gy, will fuse pre-op MRI and treat inferior aspect of pre-op volume to 66 Gy. Sequential boosts.

Anyone doing dose-paint/SIB for post op? Would anyone include a larger CTV for tumor bed - i.e. adjacent sinuses, nasal cavity, etc.?
S

 

[medgator]

Reasonable plan. I personally would not treat the necks, just the primary site. I like the idea of 60 to most of the tumor bed with 66 to the areas of close/positive margins if they can be identified accurately as you suggested.

With t3/t4 disease, the risk for ln involvement rises significantly. This pt has already declared himself with n2c diseases so my gut feeling would agree with SimulD to treat.

 

[medgator]

67 year old man with tobacco hx and sinus drainage. Noticed fullness in right side of face. Imaging showed large, destructive maxillary sinus mass, extending into mouth. MR - 4.7 x 3.3 x 4.7 mass, extended into ethmoid, extending into soft tissues medially, eroded into nasal cavity obliterating R nasal turbinates. Appeared to erode inferior wall of orbit. Multiple enlarged LNs seen bilaterally. Total maxillectomy + B LND, with option of orbital exenteration. Upon visualization, did not need to take out eyeball. Tumor was 3.0 x 2.5 x 1.5cm, grade 3. Positive margin inferiorly, 0.1cm posterioly, 0.3cm medially. 0/52 LNs on ipsi (R), 1/32 on contra (L, level II), was 0.8cm, no ECE. pT3N1M0.

Strange nodal pattern, right? You're not even supposed to treat bilaterally prophylactically.

sounds like the patient had locally destructive crossing midline in the mouth which contributed to that ln spread

 

[Gfunk6]

Reasonable plan. I personally would not treat the necks, just the primary site. I like the idea of 60 to most of the tumor bed with 66 to the areas of close/positive margins if they can be identified accurately as you suggested.

I'm inclined to agree with temujim. Since he had an excellent bilateral lymph node dissection with very minimal nodal burden, I would avoid treating his neck.

 

[Reaganite]

With t3/t4 disease, the risk for ln involvement rises significantly. This pt has already declared himself with n2c diseases so my gut feeling would agree with SimulD to treat.

This issue comes up a lot in our case conferences. That is, what do you do when a patient has a really extensive lymph node dissection (>80 in this case?!), and has 0 or only 1 small node positive (which would not be an indication for postop RT), but has indications for irradiation at the primary site (T3-4, close/positive margins, etc)? Do you even need to cover the neck at all? I can tell you that opinions are quite varied. I guess I'd pose the question of: if you wanted to strike a balance between overtreating vs. undertreating, can you just treat the involved contralateral neck to 60 and leave out the ipsilateral neck entirely since it was negative?

 

[deleted4401]

That's a very good point - should we dismiss the fact that neck dissections are therapeutic?
I don't know. I know the post op data for head and neck cancers - the EORTC and RTOG chemoRT v RT trials, and older post-op trials treated the dissected necks. Partly because of dogma from Fletcher's day and partly because older techniques made it difficult to omit one side of the neck or to selectively omit certain levels while treating a large tumor bed.

Does anyone have data in which patients with indications for post op treatment have had omission of treatment of the dissected pN0/N1 neck?

Would save a lot of toxicity...
S

 

[Gfunk6]

PMID 18648835

Retrospective. Do not recommend post op RT in pN1 neck without ECE.

 

[Palex80]

One problem is what one defines as "neck".

The risk of nodal failure in the cervical lymph node levels, which have been operated on and found not to harbor disease may be low, but what happens with all the other lymph nodes that cannot be operated on?
Would you not treat the retropharyngeal/prevertebral nodes for example?

The next problem is that we tend to pool the data on risk of nodal failure in HNSCC from different site, which IMHO is not a good approach. The nodal spread pattern of a T2N1 tonsillar carcinoma is totally different than that of a T2N1 hypopharynx carcinoma.
Or let me put you in a different dillema:

Patient is presented with a left-side cT2 hypopharynx carcinoma and one enlarged left cervical node. Ipsilateral neck dissection is performed, 19 nodes removed, all tumor free, the enlarged lymph node shows merely inflammation. The primary tumor is not resected. The patient is referred for radiation therapy.
Would you:
a) Treat only the primary (Argument: It's cN0 contralateral and pN0 ipsilateral, let's spare him the toxicity)
b) Treat the primary and the ipsilateral neck (Argument: The ipsilateral neck is the site with the highest risk for microscopic disease, despite being pN0)
c) Treat the primary and both neck sides (Argument: It's a hypopharynx carcinoma, silly)
d) Treat the primary and the contralateral neck (Argument: The ipsilateral side was pN0, so we can ommit radiation there, but the contralateral side is at risk of microscopic disease.)

So?

 

[deleted4401]

That report is not about those that had indications for post-op RT to tumor bed after resection and neck dissection (T3-T4, close margin, PNI, LVSI, etc.) and were only treated with RT to primary site. It's about whether or not neck dissections are therapeutic in patients with N1 disease that don't have any other indications for RT. I.e. what I'm wondering is - do these factors also predict for neck recurrence after a dissection or do they strictly predict for a local recurrence at the tumor bed? If it's the latter, is there a data set that can make me feel comfortable?

I'm wondering if there is evidence that the paradigm has changed, and there is evidence to go away from the dogma that if you are going to radiate, you basically have to treat all surgically disturbed areas. The post op trials all included bilateral neck (RTOG 9501, EORTC 22931)

In the States, unless you are dealing with some real goofballs, people treat the primary with the same modality that they treat the neck - i.e. if you radiate the primary, then you radiate the neck, and save surgery for later. If you operate on the primary, you operate on the neck, and use pathology to figure out adjuvant treatment. Very seldom would someone operate on the neck and then send for radiation to the primary - am I wrong, Donny? But, for fun's sake, I would continue to say "c" because again - I don't know what the right answer is and I'd rather just pretend the dissection never happened. Then, I would ask the surgeon to not to do that again.

-S

 

[Gfunk6]

Simul,

Upon further reflection I think I fully support what you recommended initially. Although it makes sense logically to not treat a dissected neck with XRT, this approach is not supported well by evidence. Looking at the Ang/Garden H&N Bible they too recommend treatment of the dissected neck.

 

[Reaganite]

Simul,

Upon further reflection I think I fully support what you recommended initially. Although it makes sense logically to not treat a dissected neck with XRT, this approach is not supported well by evidence. Looking at the Ang/Garden H&N Bible they too recommend treatment of the dissected neck.

I agree with this, and that's how our H&N attending would treat, although there are some attendings who do question the approach. ACR actually addresses this issue in their H&N postop recs:

http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonRadiationOncologyHeadNeckWorkGroup/Adjuvant-Therapy-for-Resected-Squamous-Cell-Carcinoma-of-the-Head-and-Neck.aspx

Variant 2 T4N1 s/p bilateral neck dissection. There's also a comment in the text that reads: "The typical treatment volume used in PORT for head and neck cancer includes the bilateral neck as well as the surgically dissected primary tumor site. However, it is
unclear whether both the neck and primary always need to be within the PORT volume. For patients with completely resected primary tumors whose sole indication for PORT
is pathologic cervical adenopathy, some would direct therapy only to the neck. Additionally for patients with a positive margin as the sole indication for treatment in the
setting of a comprehensive neck surgery, some would direct treatment to the primary resection bed only."

 

[ShirleyT]

Yes, I agree that I would treat both sides of the neck though i can see why you would be tempted to not treat since toxicity would definitely be decreased. The surgeon's knife was there, so there is a risk of surgical spread and if you are treating the primary anyway.I would also include the RP nodes for max sinus cases. and since the contra neck was positive, i would take contra level II to 60 rather than a lower dose, although this may be debatable since volume was so small. where i trained, any part of the neck that was positive, we treated that area postop to 60 Gy.

Normally, I treat my postop head neck cases with IMRT with one plan 60 Gy in 30 fx to high risk (presurg tumor with generous volume). 57 to surgical bed and 54 Gy to undissected areas all in 30 fx. If there is a positive margin or especially gross residual, i will sometimes integrate the boost and go up to 66 gy in 30 at 2.2 per fraction to a small volume which is biologically higher than 66, but this is highly depending on location. In your case, i agree with sequential plans, because i would not want to go higher than 2 gy per fraction by the eye. These cases are always nightmares to plan, and it is often easier for me if the surgeon goes ahead and takes the eye up front. Otherwise, I have to be the one to tell the patient, well the surgeon was able to spare your eye, but your eye may be rendered nonfunctional or painful dry eye from the xrt............... it is hard to keep cornea, optic nerve and lacrimal gland within tolerance on these cases so i do a detailed informed consent.