small cell cancer of the supraglottic larynx

[radoncle]

Hi! I have an interesting case of a woman presenting with a supraglottic laryngeal mass measuring 3.1 cm and enlarged R cervical nodes. Biopsy of the primary and the neck nodes both returned c/w small cell cancer. Would you treat elective nodes given the site of primary or just gross disease? Plan from med onc is concurrent cis/etoposide.

Thanks!

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[Ray D. Ayshun]

Hi! I have an interesting case of a woman presenting with a supraglottic laryngeal mass measuring 3.1 cm and enlarged R cervical nodes. Biopsy of the primary and the neck nodes both returned c/w small cell cancer. Would you treat elective nodes given the site of primary or just gross disease? Plan from med onc is concurrent cis/etoposide.

Thanks!

Doing 60-66 gy? I suppose I'd treat the nodes as it probably won't add much toxicity. Perhaps just unilaterally. Or even uninvolved to 44 gy or something. Mix genres. My other question would be about whether to hold etoposide during rt. Any increased risk for mucositis that could cause a break?

 

[radoncle]

Doing 60-66 gy? I suppose I'd treat the nodes as it probably won't add much toxicity. Perhaps just unilaterally. Or even uninvolved to 44 gy or something. Mix genres. My other question would be about whether to hold etoposide during rt. Any increased risk for mucositis that could cause a break?

Thanks. Yes, was planning 66 Gy.

 

[NotMattSpraker]

Hi! I have an interesting case of a woman presenting with a supraglottic laryngeal mass measuring 3.1 cm and enlarged R cervical nodes. Biopsy of the primary and the neck nodes both returned c/w small cell cancer. Would you treat elective nodes given the site of primary or just gross disease? Plan from med onc is concurrent cis/etoposide.

Thanks!

Supraglottis is very vascular, I'd cover elective nodes in the neck to microscopic dose.

 

[BobbyHeenan]

I had an almost exact same case as this in an otherwise healthy young male.

Did concurrent cis/etop. Covered elective nodes.

Just MASSIVE mucositis at treatment site. Was more toxic than weekly cis easily. He initially declined feeding tube going into it (I knew it would be ugly but he wouldn't consent to one at first). Needed a semi-urgent tube when the mucositis hit.

Long term he did recover ability to swallow but needed feeding tube in spite of swallowing well at presentation.

Unfortunately had distant mets with liver mets and brain mets arond 9 months after treatment. Part of me wished we woudl have considered/done sequential treatment here. Cis/etop concurrent to head and neck was really really tough.

I would advise prophylactic tube in your patients case if doing cis/etop.

 

[Mandelin Rain]

Has anyone ever had an extrapulmonary small cell turn out well?

I think I'd do cis/etoposide x 4 and see if mets declare. If not, then weekly cis with RT. Re-scan brain before starting.

This is really an opportunity to offer an incredibly toxic/morbid local therapy for what is systemic disease in nearly everyone.

 

[TheWallnerus]

Would do ENI and tumor to 45 and boost supraglottic larynx with… 7 days of 1.5 bid for a total of 66 Gy. A total of 45 of ENI won’t set the woods on fire for mucositis even with cis etop. And 7 days of a pretty small volume twice a day won’t either. EDIT: would prob do feeding tube tho 😉

 

[temujim]

Hi! I have an interesting case of a woman presenting with a supraglottic laryngeal mass measuring 3.1 cm and enlarged R cervical nodes. Biopsy of the primary and the neck nodes both returned c/w small cell cancer. Would you treat elective nodes given the site of primary or just gross disease? Plan from med onc is concurrent cis/etoposide.

Thanks!

60 Gy to gross dz. ~40 to elective neck.

 

[Palex80]

Would do ENI and tumor to 45 and boost supraglottic larynx with… 7 days of 1.5 bid for a total of 66 Gy. A total of 45 of ENI won’t set the woods on fire for mucositis even with cis etop. And 7 days of a pretty small volume twice a day won’t either. EDIT: would prob do feeding tube tho 😉

 

[radoncle]

I had an almost exact same case as this in an otherwise healthy young male.

Did concurrent cis/etop. Covered elective nodes.

Just MASSIVE mucositis at treatment site. Was more toxic than weekly cis easily. He initially declined feeding tube going into it (I knew it would be ugly but he wouldn't consent to one at first). Needed a semi-urgent tube when the mucositis hit.

Long term he did recover ability to swallow but needed feeding tube in spite of swallowing well at presentation.

Unfortunately had distant mets with liver mets and brain mets arond 9 months after treatment. Part of me wished we woudl have considered/done sequential treatment here. Cis/etop concurrent to head and neck was really really tough.

I would advise prophylactic tube in your patients case if doing cis/etop.

Thanks, very helpful

 

[Barcelona PSG]

Would consider starting with Cis+Etoposide for 2 cycles and then radiation to primary and bilateral neck with Cisplatin alone.

 

[medgator]

Has anyone ever had an extrathoracic small cell turn out well?

I think I'd do cis/etoposide x 4 and see if mets declare. If not, then weekly cis with RT. Re-scan brain before starting.

Yeah had a localized bladder with regional n+ disease metted out and dead within a year after crt

 

[Mandelin Rain]

metted out and dead within a year after crt

Unfortunately, this has been my experience with every extrapulmonary I've ever treated.

 

[gvsudew]

I had an almost exact same case as this in an otherwise healthy young male.

Did concurrent cis/etop. Covered elective nodes.

Just MASSIVE mucositis at treatment site. Was more toxic than weekly cis easily. He initially declined feeding tube going into it (I knew it would be ugly but he wouldn't consent to one at first). Needed a semi-urgent tube when the mucositis hit.

Long term he did recover ability to swallow but needed feeding tube in spite of swallowing well at presentation.

Unfortunately had distant mets with liver mets and brain mets arond 9 months after treatment. Part of me wished we woudl have considered/done sequential treatment here. Cis/etop concurrent to head and neck was really really tough.

I would advise prophylactic tube in your patients case if doing cis/etop.

I'll add my 2 cents with another anecdote. I had a 60ish year old woman with synchronous stage 2 squamous cell carcinoma of the superglottic larynx and early stage (AJCC T1 N0) small cell of the lung. After multidisciplinary discussion we elected to treat with SBRT to the primary lung tumor and then proceed with full dose chemotherapy for small cell. She achieved a complete response in the larynx site but we still consolidated with radiation alone (so I guess sequential) using the RTOG 30 fraction regimen. She had perhaps the worst toxicity I've seen (significant acute and subacute mucositis and laryngeal edema). No evidence of disease or infection (did treat for the latter just in case). I have to think the chemo sensitivity was a major reason for that...

 

[evilbooyaa]

Has anyone ever had an extrapulmonary small cell turn out well?

I think I'd do cis/etoposide x 4 and see if mets declare. If not, then weekly cis with RT. Re-scan brain before starting.

This is really an opportunity to offer an incredibly toxic/morbid local therapy for what is systemic disease in nearly everyone.

Had a small cell of the cervix I treated as a first rotation PGY-2 who I believe was still cNED when I was a second half of year PGY-5. Not 'cure' but pretty good.

To OP - I'd do CarboEtoposide rather than CisEtop in a H&N small cell patient. Yes I would treat elective neck. Most of the toxicity is going to be from the primary which will need it. I would make an attempt at definitive management with appropriate counseling. I extrapolate Turrisi regimen to extrapulmonary pure small cells - most recently a small cell of the prostate. 45/30 BID. Just checked his chart - at ~6 months he has distant mets only. Consider doing this in your scenario to reduce acute toxicity compared to 60/30

Whether covering ENI in this rare cell type in a larynx primary will not be known. It may not but I wouldn't really advocate for getting that cute. If pure small cell though, I'd be comfortable with 45/30 BID.