Thyroid Neck Recurrence

[Haybrant]

I got a guy that presented 2 years ago with metastatic thyroid cancer; they did a hemithyroidectomy at presentation to get more definitive diagnosis. Turned out to be hurthle cell ca. They did adjuvant RAI after this although the tumor wasn't hot for iodine uptake. There are 4 mets in the lungs that is it, they are about 1-2 cm and one is 2-3 cm. The primary grew back in the neck and is about 3-4 cm and up against the esophagus and not far from the right Bplexus. They could give systemics, not a good candidate for RAI again apparently, surgeons hesitating to operate fairly sure they wont get clean margins. Systemic Tx was offered but he declined and has never had TKI's.

Felt it would be reasonable to offer palliative RT here esp as his dysphagia is increasing. Pt is old, 73 yo has other comorbidities but ECOG 1. Was going to cover the primary + margin (which is essentially the Level III-IV right neck, wanted to get a sense from you guys what dose you would consider and suggestions on the field. I suspect this guy could live a long time w these thyroid mets? No enlarged nodes seen in bilat necks. Thanks

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[seper]

my gut feeling here is 30 Gy/10 fx.

 

[Brim]

Needs 70ish Gy to gross disease. You'll need to cover much of the central neck for sure (and it sounds like you'll have a pretty big volume of that covered just by treating your GTV) and you could consider giving elective RT to the full neck and upper mediastinum.

 

[seper]

hurthle cell with lungs mets? Prognosis is poor, AFAIK.

 

[Haybrant]

Needs 70ish Gy to gross disease. You'll need to cover much of the central neck for sure (and it sounds like you'll have a pretty big volume of that covered just by treating your GTV) and you could consider giving elective RT to the full neck and upper mediastinum.

brim explain why this in a metastatic patient?

 

[evilbooyaa]

If other specialties aren't willing to be aggressive with him (TKIs, salvage surgery, etc.) then I don't think you have any obligation to be unilaterally aggressive.

If they resected him with positive margins you could offer adjuvant treatment to 60Gy for a good chance at long-term local control. I don't overtly see a role for definitive RT with bulky gross disease. Palliation at whatever dose you want is reasonable.

 

[Haybrant]

If other specialties aren't willing to be aggressive with him (TKIs, salvage surgery, etc.) then I don't think you have any obligation to be unilaterally aggressive.

If they resected him with positive margins you could offer adjuvant treatment to 60Gy for a good chance at long-term local control. I don't overtly see a role for definitive RT with bulky gross disease. Palliation at whatever dose you want is reasonable.

thanks evilB, would tend to agree with this. Would you 300 x 10 or escalate at all beyond that? Thank you,

 

[evilbooyaa]

thanks evilB, would tend to agree with this. Would you 300 x 10 or escalate at all beyond that? Thank you,

Eh, IDK. I don't like 300 x 10 for H&N. I'd lean towards quad shot (3.5Gy BID x 4, can be repeated a few times as necessary, can be done every 4 weeks for total of 3 courses to reach semi-definitive dose)

The 'QUAD SHOT'--a phase II study of palliative radiotherapy for incurable head and neck cancer. - PubMed - NCBI

 

[medgator]

Eh, IDK. I don't like 300 x 10 for H&N. I'd lean towards quad shot (3.5Gy BID x 4, can be repeated a few times as necessary, can be done every 4 weeks for total of 3 courses to reach semi-definitive dose)

The 'QUAD SHOT'--a phase II study of palliative radiotherapy for incurable head and neck cancer. - PubMed - NCBI

I've done 50/20 in a few decent PS patients with some long-term control (for at least several months).

 

[BobbyHeenan]

I've done 50/20 in a few decent PS patients with some long-term control for several months.

I use this too. Princess Margaret regimen. They usually did a 2 week planned break (25 Gy, 2 week break, then 25 Gy). I sometimes just break for 1 week if doing well. Seems to help keep the bad acute mucositis down some.

 

[Haybrant]

I use this too. Princess Margaret regimen. They usually did a 2 week planned break (25 Gy, 2 week break, then 25 Gy). I sometimes just break for 1 week if doing well. Seems to help keep the bad acute mucositis down some.

50 in 25 w a 2 week break looks like a good dose/frac actually, hadnt used it before. I wonder though just 300 x 10 now and if needed again in the future you still have an option to 250 x 10 at a later time as well.

 

[mavrik13]

Agree with being locally aggressive, but not definitive. I've always found thyroid weird and difficult to prognosticate - I don't think anyone would fault you for 30/10 vs 40/15 vs 50/20

 

[Reaganite]

Agree with 50 in 20 as several others have suggested. Has led to durable palliation/control in several cases of mine where patients had predominantly locoregional disease and limited mets. Ill even contour in "throat" as an avoidance structure. Ive been surprised about how long some of these patients live and was glad i was a little morr aggressive.

 

[scarbrtj]

I'm not afraid to be publicly pilloried. Apply a high dose to the neck disease and all 4 lung mets. 70/35 to the tumor in the neck only (neck CTV of about 30 cc's) with IG-IMRT would not be that morbid. Do SBRT to the lung lesions. I would treat only the gross disease. Elective neck nodal coverage is a moot point. It would be a *really* moot point if you treat the primary (and treat occult microscopic locoreg. mets in the neck) but don't treat gross mets in the lung. What I'm hypothesizing is that you could render him temporarily cNED with XRT (possible) and that patients with metastatic disease tend to live longer if they can achieve a cNED interval (likely). Nothing ventured, nothing gained. Right to try! (I get, somewhat, the call for quad-shotting him or 30/10. But this is indolent ~2 year duration, thyroid, non-squamous H&N cancer in a high PS patient for whom other systemic options are off the table.)

 

[evilbooyaa]

We all like to be aggressive, and people always remember the patient who survived 2 years after aggressive treatment, but how many of those we treat aggressively who die within 3-6 months do we usually remember?

Again, if patient and other specialties were on board with being aggressive (btwhe hasn't been on ANY systemic therapy to date including TKIs, per patient preference) then what's the purpose of all this? He needs systemic treatment to maximize his long-term chances.

This should be a discussion with the patient regarding his options, including any of the major 3-4 discussed above. I forgot about 50/20, certainly a reasonable option as well in this scenario. At this point the goal is primarily to do no harm. Relieve his dysphagia without making him G-tube dependent (in either the short or long-term), without putting him at risk for brachial plexopathy, without other toxicities from high dose radiation to the bilateral neck (depends on how close tumor extends near skin as well).

Just my 2 cents. I don't think it's unreasonable to treat aggressively, but if the patient and his other physicians are being hands off (and he's not even getting systemic treatment) I don't see what we're trying to do here.

 

[scarbrtj]

We use words like "aggressive" a lot... in rad onc, aggressiveness is directly proportional to dose I reckon. I have seen plenty of people get bad side effects from 30/10 to a large pelvic field whilst others have zero side effects from 85 gray in one fraction to the trigeminal nerve (I never hear the latter called aggressive, and it's maybe the most aggressive thing we do). (The old surgeons used to say stuff to the med oncs like, "Why did you poison this patient?"... and I would think "No one ever asks, 'Why did you maul that guy's abdomen?'") SBRT is not aggressive. It's essentially zero morbidity and low-effort-output by the patient. 70/35 to a 3cm sphere in the low neck will give him some esophagitis/pharyngitis, probably, but it will be manageable and very unlikely to make him PEG dependent. You could fractionate it differently, but for a host of reasons it's what I'd choose. Brachial plexopathy risk, given very conformal therapy, is not even entering my major calculation process. His ENT and med oncs are being "hands off" based on their own particular assessments plus the patient's wishes; lots of different ways to skin this cat were he at a different institution. We would've never gotten lung SBRT were it not for surgeons wanting to be hands-off; I can remember some people discussing SBRT approaches and dose for lung cancer in the 90's and some "non-aggressive" rad oncs thought they were crazy. The OP started off with saying there was at least a countenancing of further neck surgery and the ENT's "fear" was not morbidity per se but positive margin futility. Well heck... even if they resected the whole of the neck disease and did the world's best surgery they'd have positive margins in the four spots in his lung.

 

[seper]

70Gy/35 to a neck mass can hit a 73 yo man pretty hard. 5-10 % risk of >= G3 toxicity I'd guess. 4 cm mass is at least a 5 cm in diameter "sphere" in-field, right up against mucosa...

 

[scarbrtj]

70Gy/35 to a neck mass can hit a 73 yo man pretty hard. 5-10 % risk of >= G3 toxicity I'd guess. 4 cm mass is at least a 5 cm in diameter "sphere" in-field, right up against mucosa...

We aren't saying different things. While it can "hit a 73 yo man pretty hard" it also has a ~90%-95% chance of hitting him pretty mildly. I said a Gr 3 toxicity like a PEG would be "very unlikely." In RTOG 9512 they treated a relatively small low-ish neck field to 70/35 and saw a <5% PEG rate, ~5-10% overall acute Gr 3 toxicity with no Gr 4. Very low rates of late Gr 3. Treating a 3-4cm mass with a conformal IMRT technique would treat much less volume to higher dose than the fields in 9512 though (see below) and toxicity ∝ volume. Anecdotally, I have never had a Gr 3 toxicity from treating a glottic field, whether 63 or 66 or 70 Gy.

 

[nkmiami]

would probably do 50/20 without a break. i agree that there is a low chance of significant mucositits. Would treat gross disease and 5 mm margin and use daily cbct/imrt.
historically, plenty of lungs treated 50/20 in the NHS with concurrent chemo that involved much longer segments of esophagus.

 

[seper]

OK points on side effects taken. But why do aggressive course? He has no chance of cure. His metastatic cancer is demonstrating an aggressive behavior. Local therapy only does not prolong survival. If patient is dissatisfied with results achieved with 30/10, you can re-treat.

 

[scarbrtj]

But why do aggressive course?

What is aggressive? Is that defined? Getting your kidney cut out if you have metastatic renal cell sounds aggressive, but I'd do it to improve my chances if I had it. Is 70 Gy vs 50 Gy aggressive? Is 3 Gy/day more aggressive than 2 Gy/day? Different regimens will have different BED Gy3 or Gy10; determining aggressiveness is very subjective. Is 50 Gy more aggressive than 30 Gy? Is the goal to be as low-dose/non-aggressive as possible? 70 Gy has better chance of local control; of course a million gray has even better chances than that. Depending on the "game" and the rules, I often choose better chances vs worse. Sometimes the game is futile, true; occasionally though it only appears futile. Needless to say, we have an orgy of data at present that "agressive" (whatever that means!) approaches in metastatic settings in many disease sites improve survival.

He has no chance of cure

I never said he did. But like James Bond said, "Never say never"... and if you can get 10 year cNED survival in a metastatic thyroid setting, maybe even more so.

His metastatic cancer is demonstrating an aggressive behavior.

This whole aggressiveness thing is an idée fixe aorund here. His metastatic disease was diagnosed two years ago and he has had no intervening treatments since then. And his local disease morbidity is grade 1 at present. His disease matches indolence vs aggressiveness, but again I guess these appellations are subjective.

Local therapy only does not prolong survival.

Local therapy extends survival in many metastatic situations (I mentioned kidney) where we wouldn't even expect it to, so I disagree with that too.

If patient is dissatisfied with results achieved with 30/10, you can re-treat.

At the end of the day, I can't hit you with any great sockdolager radiotherapy data for metastatic Hürthle cell. I'm of course trying (unsuccessfully) to make the case that 30/10 to only the neck disease leaves much of the bulk (his lung nodules) of his disease untreated, and the local disease relatively undertreated, and we have numerous situations/sites/studies now where this seemingly "orthodox" approach compared to unorthodox (ie more "aggressive") approaches has led to inferior survivals. Dead men tell no tales, nor do they fill out patient satisfaction surveys.