T2N0 oral tongue

[anotherhopeful]

Curious everyone's thoughts on this case. 45 year old with 1.6cm lateralized oral tongue lesion, 9mm DOI, positive margins initially at a satellite lesion but negative in the end after re-resection, but ultimately with multiple sub-millimeter satellite lesions, negative LVSI, negative PNI, s/p hemiglossectomy and ipsi neck dissection, 0/5 level I, 0/4 level II. ENT is concerned given satellite lesions. Would you guys treat the residual tongue alone? or cover ipsi neck? or cover bilat neck?

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[jondunn]

Deep DOI and a fairly limited dissection, my bias would be to treat the neck. These cases tough

 

[OTN]

I understand his concern, but there's no hard indication for adjuvant RT here. Agree with JD about the adequacy of the dissection. How close were the final SM?

 

[temujim]

Curious everyone's thoughts on this case. 45 year old with 1.6cm lateralized oral tongue lesion, 9mm DOI, positive margins initially at a satellite lesion but negative in the end after re-resection, but ultimately with multiple sub-millimeter satellite lesions, negative LVSI, negative PNI, s/p hemiglossectomy and ipsi neck dissection, 0/5 level I, 0/4 level II. ENT is concerned given satellite lesions. Would you guys treat the residual tongue alone? or cover ipsi neck? or cover bilat neck?

I never really trust re-resections. Cover post-op bed with 1 cm margin, ipsi ND was inadequate, cover 1-4 ipsi and at least 1-2 contra.

56-60 Gy to primary and 45-50 to necks.

 

[anotherhopeful]

unclear what the final margins were based on pathology as there were multiple 'new margins' on the report.

Agree that we're going mostly by gestalt but I have also seen a lot of these T1-2 tumors with satellite lesions recur pretty quickly. I think I'm convinced enough to cover rest of tongue and I-IV ipsi. If I'm covering the contra neck, I'd just cover down to IV as it would be tough to come back and try to salvage if I've only covered a couple of levels. I might just leave the contra neck alone so that it can be more easily salvaged. I do remember this talk by Nancy Lee who said that she sees tons of contra neck recurrences for oral tongue that are disasters and so she covers both necks if she's radiating

 

[OTN]

unclear what the final margins were based on pathology as there were multiple 'new margins' on the report.

Agree that we're going mostly by gestalt but I have also seen a lot of these T1-2 tumors with satellite lesions recur pretty quickly. I think I'm convinced enough to cover rest of tongue and I-IV ipsi. If I'm covering the contra neck, I'd just cover down to IV as it would be tough to come back and try to salvage if I've only covered a couple of levels. I might just leave the contra neck alone so that it can be more easily salvaged. I do remember this talk by Nancy Lee who said that she sees tons of contra neck recurrences for oral tongue that are disasters and so she covers both necks if she's radiating

If they can't tell you margin distance, I would consider that a close margin and good indication for adjuvant RT. Agree with bilateral neck.

 

[RadOncMegatron]

I think we all have heard and witnessed the “don’t mess with oral tongue” mantra. This is a tough case. I’d treat oral cavity and bilateral neck FWIW.

 

[RickyScott]

I think we all have heard and witnessed the “don’t mess with oral tongue” mantra. This is a tough case. I’d treat oral cavity and bilateral neck FWIW.

I have been burned in this situation. For some reason in my experience, tongue cancers in youngish female non smokers are the worst.

 

[evilbooyaa]

Oral tongue = residual oral tongue (can consider tumor bed + 1cm if no satellite lesions) + b/l neck for me if there is indication to RT. There is some early data on 'well-lateralized' oral tongue trying unilateral neck, but it's not at the level of Tonsil data IMO as of yet...

For me if tumor DOI is > 4-5mm I am strongly recommending RT.

 

[evilbooyaa]

I have been burned in this situation. For some reason in my experience, tongue cancers in female non smokers are the worst.

Ditto. N of 3 here that had horrible outcomes. There's something there that I don't think we understand yet.

 

[anotherhopeful]

sounds like consensus is covering rest of tongue and bilat neck, which I am leaning toward as well. count me in as having had a surprisingly aggressive young oral tongue patient

 

[Palex80]

I very well understand the arguments in favor of treating the tongue due to all the satellite lesions, but I am bit puzzled about the neck-discussion.

When should one cover lymphatics and when not, when one only has an indication for RT based on the primary tumor is a good question.
Indeed, not a lot of nodes were resected, but bilateral neck irradiation given the primary site, means bye, bye submandibular glands and the parotid doses will also be significant.

If this was a larger primary or LVSI was present, I would be more in favor of covering the neck, but do we have a good estimate on what the risk of isolated nodal recurrence in a small primary tumor (the invasion depth is indeed problematic, I agree) with a limited, yet negative neck dissection is?

I'd discuss with the patient. I'd treat the residual tongue, but most I would additionalyadvise would be ipsilateral neck.

Tough case!

 

[deleted1111261]

I think all the old data treated neck + primary site for post op (mostly oral cavity). Like, if you look at the RTOG and EORTC RT vs CRT trials.

So, it is taking time for people to shift to primary only. Is there data for treating primary only? I think I saw an institutional series in the last few years, but it’s still new-ish to do that.

 

[gmsquid]

100% treat and cover bilateral neck.

 

[thecarbonionangle]

I would not f$$$ with a tongue, especially one where margin is questionable (is this even negative, reeks of piecemeal butcher job), deep DOI, questionable extent of dissection. If this was a healthy patient i might even advocate for chemo given very questionable margin. Treat the primary and bilateral neck. Data shows that it is tough to salvage these patients who fail in neck. I would treat bilateral 1-4.

Anybody who has tried to salvage these patients and seen their miserable death knows what im saying.

 

[TheWallnerus]

I would treat both necks but in a pN0 situation I would do very generous contra-parotid sparing UF-style. I make custom mouth inserts that provide space between roof of mouth and tongue (built into the mask) so that there's not more oral cavity toxicity (on the roof of mouth and upper gingiva etc) than needs be. We cut the middle finger of a latex glove and stretch that over the insert/depressor each day so that it stays clean and non-stanky for the patient.

 

[evilbooyaa]

I very well understand the arguments in favor of treating the tongue due to all the satellite lesions, but I am bit puzzled about the neck-discussion.

When should one cover lymphatics and when not, when one only has an indication for RT based on the primary tumor is a good question.
Indeed, not a lot of nodes were resected, but bilateral neck irradiation given the primary site, means bye, bye submandibular glands and the parotid doses will also be significant.

If this was a larger primary or LVSI was present, I would be more in favor of covering the neck, but do we have a good estimate on what the risk of isolated nodal recurrence in a small primary tumor (the invasion depth is indeed problematic, I agree) with a limited, yet negative neck dissection is?

I'd discuss with the patient. I'd treat the residual tongue, but most I would additionalyadvise would be ipsilateral neck.

Tough case!

Long-term regional control and survival in patients with "low-risk," early stage oral tongue cancer managed by partial glossectomy and neck dissection without postoperative radiation: the importance of tumor thickness - PubMed

Patients with low-risk, pathologic T1-T2N0 OTSCC had a greater than expected rate of neck failure, with contralateral recurrence accounting for close to 40% of recurrences. Failure occurred predominantly in patients who had primary tumors that were ≥ 4 mm thick.

pubmed.ncbi.nlm.nih.gov

They use tumor thickness instead of DOI (which is slightly different, but overall relatively similar based on previous studies looking at correlation between TT and DOI) but use a cut-off of > 4mm to separate out risk of neck recurrence from ~5% to ~25%

40% of all nodal relapses were contralateral, so in that 25% risk, 10% of that is for contralateral nodal recurrence. Too high for something that would be problematic to salvage.

SMGs will be toast for an oral cavity tumor, yes. If you're treating remainder of tongue SMG will be (not toast but) negatively effected as well.

Parotid doses should be very reasonable if you don't cover high level II as an extrapolation of N- oropharynx data.

 

[Palex80]

Long-term regional control and survival in patients with "low-risk," early stage oral tongue cancer managed by partial glossectomy and neck dissection without postoperative radiation: the importance of tumor thickness - PubMed

Patients with low-risk, pathologic T1-T2N0 OTSCC had a greater than expected rate of neck failure, with contralateral recurrence accounting for close to 40% of recurrences. Failure occurred predominantly in patients who had primary tumors that were ≥ 4 mm thick.

pubmed.ncbi.nlm.nih.gov

Thank you! I learned something new today!

 

[jondunn]

I like that paper too - only caveat being that some of those contra recurrences may have been new primaries I thought?

 

[RadOncDoc21]

Great and timely discussion, I have a pT3N0 I’m dreadfully planning now.

 

[deleted1111261]

I like that paper too - only caveat being that some of those contra recurrences may have been new primaries I thought?

I thought in HNC that is a timing issue - if within 5 years, recurrence, if after, new primary? Or something like that

 

[temujim]

I thought in HNC that is a timing issue - if within 5 years, recurrence, if after, new primary? Or something like that

Genetic studies really suggest it is ~2 years. Mostly immaterial from a treatment perspective, but definite prognostic impact.

 

[jondunn]

 

[Palex80]

"We need more RCTs of our target volumes. "

Can anyone name me ONE randomized clinical trial in H&N cancer on treatment volumes? Just one, please.

 

[jondunn]

"We need more RCTs of our target volumes. "

Can anyone name me ONE randomized clinical trial in H&N cancer on treatment volumes? Just one, please.

ongoing trial

Preservation of swallowing in resected oral cavity squamous cell carcinoma: examining radiation volume effects (PRESERVE): study protocol for a randomized phase II trial - Radiation Oncology

Background Patients with resected oral cavity squamous cell carcinoma (OCSCC) are often treated with adjuvant radiation (RT) ± concomitant chemotherapy based on pathological findings. Standard RT volumes include all surgically dissected areas, including the tumour bed and dissected neck. RT has...

ro-journal.biomedcentral.com

but I'm pretty sure you agree with palma - we need more in HN. every other disease site has multiple.

 

[temujim]

"We need more RCTs of our target volumes. "

Can anyone name me ONE randomized clinical trial in H&N cancer on treatment volumes? Just one, please.

An old one but here you go: PMID: 8040015

 

[jondunn]

two other randomized trials, both from Nutting. not specifically target volumes in this case, but OAR sparing trials

Parotid-sparing intensity modulated versus conventional radiotherapy in head and neck cancer (PARSPORT): a phase 3 multicentre randomised controlled trial

Sparing the parotid glands with IMRT significantly reduces the incidence of xerostomia and leads to recovery of saliva secretion and improvements in associated quality of life, and thus strongly supports a role for IMRT in squamous-cell carcinoma of the head and neck.

www.thelancet.com

https://ascopubs.org/doi/abs/10.1200/JCO.2020.38.15_suppl.6508

 

[Palex80]

ongoing trial

Preservation of swallowing in resected oral cavity squamous cell carcinoma: examining radiation volume effects (PRESERVE): study protocol for a randomized phase II trial - Radiation Oncology

Background Patients with resected oral cavity squamous cell carcinoma (OCSCC) are often treated with adjuvant radiation (RT) ± concomitant chemotherapy based on pathological findings. Standard RT volumes include all surgically dissected areas, including the tumour bed and dissected neck. RT has...

ro-journal.biomedcentral.com

but I'm pretty sure you agree with palma - we need more in HN. every other disease site has multiple.

Of course I do, that was the bloody point! I was being ironic, because „more“ sounded like if we had done ANY AT ALL…

„Every other site has multiple“ is rather exaggerated.
Look at the prostate-lymphatics-mess: One French trial (flawed), one RTOG 9413 (total mess due to 2x2 design), one POP-RT (rather small and somehow too good to be true). And it took us… 30 years to run those trials. In prostate cancer. To us prostate cancer is what hips protheses are to ortho.

But what randomized trials did we do in H&N cancer?
Dozens of trials on chemotherapy - most of them useful, indeed
Dozens of trials on radioprotectors, radiosensetizers (not chemo) - most of them useless
Dozens of trials of fractionation - now, that‘s a tricky one, many useless however.

In this thread, 3 trials were raised on „volumes“.
One was an ancient one showing us how to shield the hypothalamus in nasopharyngeal carcinoma RT - not quite a volumes trial
The other two was on how to spare the swallowing tract and the parotids- also not volumes trials.
These are rather „techniques“ trials.

What I am asking are trials like…

“Do we need bilateral irradiation in N0 supralaryngeal cancer & non-tonsil oropharyngeal cancer?“

 

[temujim]

Of course I do, that was the bloody point! I was being ironic, because „more“ sounded like if we had done ANY AT ALL…

„Every other site has multiple“ is rather exaggerated.
Look at the prostate-lymphatics-mess: One French trial (flawed), one RTOG 9413 (total mess due to 2x2 design), one POP-RT (rather small and somehow too good to be true). And it took us… 30 years to run those trials. In prostate cancer. To us prostate cancer is what hips protheses are to ortho.

But what randomized trials did we do in H&N cancer?
Dozens of trials on chemotherapy - most of them useful, indeed
Dozens of trials on radioprotectors, radiosensetizers (not chemo) - most of them useless
Dozens of trials of fractionation - now, that‘s a tricky one, many useless however.

In this thread, 3 trials were raised on „volumes“.
One was an ancient one showing us how to shield the hypothalamus in nasopharyngeal carcinoma RT - not quite a volumes trial
The other two was on how to spare the swallowing tract and the parotids- also not volumes trials.
These are rather „techniques“ trials.

What I am asking are trials like…

“Do we need bilateral irradiation in N0 supralaryngeal cancer & non-tonsil oropharyngeal cancer?“

2D era shielding = volumes

Have to be super careful with neck volumes -- given the indian randomized trial of END vs observation trial resulted in an OS benefit for elective neck dissection. The idea that we can salvage neck recurrences is dicey.

There are SPECT directed randomized ENI trials coming for H&N, but 5+ years away from read out.

 

[sueyom]

so within NRG HN we are trying to develop trials of RT volumes but it's actually really hard because 1) Americans both patients and doctors don't easily commit to randomize, or they will only commit under very specific conditions which are challenging to standardize 2) the statistics needed to show differences, if you are doing it rigorously with intention to go to phase III, are large scale

 

[TheWallnerus]

What I am asking are trials like…

“Do we need bilateral irradiation in N0 supralaryngeal cancer & non-tonsil oropharyngeal cancer?“

Tx volumes are a great unexplored "continent" in H&N radiation oncology (of the many unexplored continents in our field). I certainly suspect we irradiate far more normal tissue than necessary in many cases. E.g., at the Christie using fields (roughly POP lat 6x6 to 7x7 cm in size and ~50 Gy/17fx) like this for cT1-4N0 supraglottic:

they saw reasonable rates of locoregional control (70-90% at 10y) and estimated about an NNT of 10 for whole neck (vs ~level 3 only) RT to control out-of-field LNs (and almost 0% tx interruption rates). Things like this would make for very good studies!

 

[sueyom]

!! are you proposing a trial of 3D opposed laterals !! LOL - just kidding
actually at UCSF we treat ipsi oropharynx type fields which is pretty similar to what you're showing there
in this case in terms of national trial possibilities the issue is the low(ering) numbers and the increasingly interventional surgical approaches for this situation which introduce a lot of heterogeneity

 

[Palex80]

2D era shielding = volumes

I agree, but look at what the trial was trying to prove. It was not about lymphatics, it was merely about shielding the hypothalamus / hypophysis in patients with no signs of scull base invasion. I mean, yes, you can argue if it's volume or technique, but stil...

 

[OTN]

Tx volumes are a great unexplored "continent" in H&N radiation oncology (of the many unexplored continents in our field). I certainly suspect we irradiate far more normal tissue than necessary in many cases. E.g., at the Christie using fields (roughly POP lat 6x6 to 7x7 cm in size and ~50 Gy/17fx) like this for cT1-4N0 supraglottic:

they saw reasonable rates of locoregional control (70-90% at 10y) and estimated about an NNT of 10 for whole neck (vs ~level 3 only) RT to control out-of-field LNs (and almost 0% tx interruption rates). Things like this would make for very good studies!

Wouldn't it be great if academic radoncs produced data which was clinically useful and helped either improve survival or toxicity? Nah, nevermind let's just do another non-inferiority study.

 

[Radonc90]

Does anyone here offer adjuvant brachy (interstitial, of course) + in combination with IMRT?
Some of the best data come from institutions that do brachy for this.

 

[elementaryschooleconomics]

Does anyone here offer adjuvant brachy (interstitial, of course) + in combination with IMRT?
Some of the best data come from institutions that do brachy for this.

 

[TheWallnerus]

Does anyone here offer adjuvant brachy (interstitial, of course) + in combination with IMRT?
Some of the best data come from institutions that do brachy for this.

some of the highest rates of salvation amongst all the Christian faiths are reported by the Catholic Church

 

[evilbooyaa]

Does anyone here offer adjuvant brachy (interstitial, of course) + in combination with IMRT?
Some of the best data come from institutions that do brachy for this.

I believe you've mentioned before that you do this. It's kinda weird to like self-promote like this in an anonymous forum. Get a twitter handle and start espousing the gospel of adjuvant IMRT + brachy for oral tongue cancer

As an aside, we were discussing a resected oral tongue case, are you brachying that? I figured the brachy was only in definitive oral tongue, base of tongue, etc.?

 

[Radonc90]

My post above has nothing to do with the 1990s (although they did more HN brachy in 1990s, too few resdients now trained in HN brachy anyway)...or the Christian faiths/Catholic Church...

As an aside, when dealing with endometrial ca, we do EBRT + vagina cuff brachy frequently.
The problem with HN brachy is that fewer residents trained in HN brachy, also the procedure itself, being interstitial in nature, is certainly more invasive than vagina cuff HDR boost. It is a difficult procedure for pt to endure, this part I understand why the reluctance to do it, both from the MD and pt's standpoint...

This is GEC-ESTRO ACROP recommendations for head & neck brachytherapy in squamous cell carcinomas FYI...

DEFINE_ME

 

[evilbooyaa]

My post above has nothing to do with the 1990s (although they did more HN brachy in 1990s, too few resdients now trained in HN brachy anyway)...or the Christian faiths/Catholic Church...

As an aside, when dealing with endometrial ca, we do EBRT + vagina cuff brachy frequently.
The problem with HN brachy is that fewer residents trained in HN brachy, also the procedure itself, being interstitial in nature, is certainly more invasive than vagina cuff HDR boost. It is a difficult procedure for pt to endure, this part I understand why the reluctance to do it, both from the MD and pt's standpoint...

This is GEC-ESTRO ACROP recommendations for head & neck brachytherapy in squamous cell carcinomas FYI...

DEFINE_ME

Right. You're recommending the functional equivalent of doing a Syed implant for boost of potential microscopic disease. You see why people aren't doing that.

Lots of questions about need for vaginal cuff brachytherapy in all endometrial cancer patients receiving EBRT and how to best select, and that's just for a itty bitty cylinder. If you're going to advocate for interstitialing someone, should have some robust improvements in local control at least, right?

 

[RickyScott]

I did one tongue implant in training and it was quite the production and included a prophylactic trach

 

[medgator]

I did one tongue implant in training and it was quite the production and included a prophylactic trach

Yep, did a few in training. Always a prophy trach, admitted to ENT service. Untenable in most practice settings

 

[joeshmo27]

"We need more RCTs of our target volumes. "

Can anyone name me ONE randomized clinical trial in H&N cancer on treatment volumes? Just one, please.

Omitting low neck in NPC.

DEFINE_ME

 

[RSAOaky]

Curious everyone's thoughts on this case. 45 year old with 1.6cm lateralized oral tongue lesion, 9mm DOI, positive margins initially at a satellite lesion but negative in the end after re-resection, but ultimately with multiple sub-millimeter satellite lesions, negative LVSI, negative PNI, s/p hemiglossectomy and ipsi neck dissection, 0/5 level I, 0/4 level II. ENT is concerned given satellite lesions. Would you guys treat the residual tongue alone? or cover ipsi neck? or cover bilat neck?

Just had an extremely similar case. 1cm well lateralized tongue, 8mm DOI. Biopsy showed PNI, final path did not, -LVSI, negative ipsilateral neck dissection. ENT felt contralateral neck was low risk but I was treating the whole tongue anyways and when you add a margin to the tongue you’re basically treating the contralateral SMG. I’m treating whole tongue and bilateral neck. Ipsi to 60, contra to 54, IB-IV. If you’re treating there’s no good way to get around toxicity because the majority is from treating the OC. Recurrences are morbid at best and fatal at worst.