Reccurent Head Neck Cancer

Summary:

75/M had recc sq.ca of right nose treated in Feb 2001 with sx+PORT (face +neck)

Reccurent Head Neck Cancer

Nikhilesh Patil 20 Apr 2010 19:54

75/Male, Former smoker, quit 25 years ago. KPS=90%. On antihypertensives well controlled. Lives alone, no kids.

Feb 2001 - Right nose recurrent Squamous carcinoma Rx= Right lateral rhinotomy, partial maxillectomy and reconstruction followed by adjuvant Radiation (indication close margins) 3DCRT plan to PNS and bilateral neck. Primary dose 66Gy/33#'s @ 5 # per week and bilateral upper neck dose 50Gy/25#.

Feb 2010 has left base tongue lesion going on to left tonsil 3x3 cms exophytic/proliferative growth, minimal extension to left vallecula. Biopsy March 2010 =Poorly differentiated sq.ca.
CT neck: Primary base tongue tumor encroaching on left tonsil minimally, crossing midline and going down to involve left vallecula. No lymph nodes.
CT thorax+ abdomen: No mets.
Stage: T2/3 N0 Mx Left Base tongue Poorly differential sq.ca with prior RT to face & neck 9 yrs ago.
How do you treat this patient?

Last edited on 20 Apr 2010 19:56 by Nikhilesh Patil Show more

Re: Reccurent Head Neck Cancer

Indranil Mallick 20 Apr 2010 20:38

Do you have:
1) Dose to BOT/Tonsil from previous plan?
2) p16 or HPV info (simply for prognostication - sepecially since he quit smoking many years back and has a PDSCC - although he is probably too old to be HPV positive)
FIRST IMPRESSIONS:
This is a second primary I guess and not a recurrence.
I am assuming that he is not a surgical candidate from the site and size of primary and his age. I don't know if he's been seen in a tumor board
My recommendation would be RT +/- cisplatin/cetuximab if he is not a surgical candidate or not keen on Sx. If he is keen on curative treatment -
I would treat primary site only if he is clearly N0. My hunch is that his BOT and Tonsils have received about 30-40Gy. I would go up to 60-66GyGy delivered in 1.1 Gy fractions BID over 5 -6 weeks. I would keep the neck for salvage on failure.
If he is fit for concurrent systemic treatment - I would push for it.

Re: Reccurent Head Neck Cancer

Nikhilesh Patil 20 Apr 2010 20:51

1) Dose received by left BOT was about 42 Gy in 2001.
2) Poorly differentiated keratinizing squamous cell carcinoma - P16 negative, p53 positive on immunostains.
3) Tumor board review= surgery not feasible/ too morbid. Germans do lasers for such patients however we do not have those facilities or experience. Recommendation CT+RT.
Obviously IMRT plan. What will be the CTV margin and then PTV margin ? Role of IMRT + Brachy boost ?

Re: Reccurent Head Neck Cancer

Indranil Mallick 20 Apr 2010 21:28

My impression about brachy in this case is that -
a) it may be difficult to cover the tonsil + BOT unless you are very experienced.
b) it would spare some dose to the neck, but not that much - and really if you target the primary tumor as your target volume with limited margins - the main site of toxicity will be your primary volume itself and brachy will not change that risk.
In terms of margins - I would fuse with MRI and give a 3mm margin. PTV margins will depend on your institutional standards - the BOT is a relatively mobile region, so I'm not in favor of keeping the PTV margins too small here. If you can do daily cone beams and match with soft-tissue consistently then maybe 3mm (with your fingers crossed) - remember there will be some soft-tissue edema as the treatment goes on.

Re: Reccurent Head Neck Cancer

Nikhilesh Patil 21 Apr 2010 01:17

I agree, brachy not an option in this man. Too large volume to implant. Treating him with IMRT GTV+6mm(CTV)+3mm(PTV). Dont know if daily cone beam CT will be done or not but yes daily portal imaging will be done. We will assess the patient at 45-50 Gy and decide total dose. The plan is done for 66 Gy @ 180 cGy daily. We are not geared up for BID treatments.
Thanks

Re: Reccurent Head Neck Cancer

Dr Prasad Dandekar 21 Apr 2010 05:34

Dear Nikhilesh,

I would be reluctant to treat this patient with hyperfractionated RT and rather treat him to 66 Gy in 33 fractions to primary, with a possible boost to primary alone up to 70 GY. The ideal way to boost would be on PET/CT positive volume and it will also give information about the LNs. I would be reluctant to give a CTV margin of only 6mm but prefer to include the entire oropharynx. Considering his age and previous treatments, this seems to be the only chance that he has for curative therapy and thus I would treat bilateral level Ib and II up to 54 Gy.

I don't know your protocol, but this patient will definitely benefit from a PEG tube and we will need to counsel him about the possible late side effects on his swallowing status.

Prasad

Re: Reccurent Head Neck Cancer

Ashwini Budrukkar 21 Apr 2010 06:47

I think the best option for this patient is RT+ CT/Cetuximab
RT: External RT+ Brachytherapy boost
External RT: IMRT: Target volume primary+ bil level II/III nodes
Dose: 50Gy in 25 fractions over 5 weeks
Brachytherapy: Interstitial: 24-28Gy LDR equivalent after reactions have resolved

Re: Reccurent Head Neck Cancer

Indranil Mallick 21 Apr 2010 17:53

Prasad
I agree with your approach on giving him a high dose - but I am not sure why you are against hyperfractionation. I think hyperfractionation is one way of delivering a higher dose to the tumor without increasing late toxicity. It is almost a standard way of re-irradiation in several centers.

Re: Reccurent Head Neck Cancer

Nikhilesh Patil 21 Apr 2010 19:40

We ruled out brachy since his neck is treated in the past that increases the risk of soft tissue necrosis and bleeding. Implanting BOT+tonsil will be technically challenging for many RO's, I know we can do it and have done it in India often. Here the system is not geared up for Head Neck brachy. Doing IMRT is much simpler.
Re: Chemo, our medonco team is looking into Cetuximab, its only approved in Alberta for patients >75 yrs.
Radiobiologically I also feel it makes sense to do hyperfractionation but our team does not agree doing that.
I think you are all correct in terms of your treatment advice. Many thanks.

Re: Reccurent Head Neck Cancer

Pranshu Mohindra 23 Apr 2010 18:35

Hi all,
Just wanted opinion on the brachy issue here. If it was feasible, would HDR brachy be acceptable in re-irradiation? I was just thinking more from radiobiology point of view. I know most centres now don't do LDR, which I think should be preferred in re-irradiations. Do we have any data on role of HDR brachy in re-irradiation scenarios and it's impact on late toxicity with specific reference to Head-neck cancers?

About neck nodal volumes, He was treated only to upper neck previously. So now, if we want to treat nodal volumes, we should treat full neck and not partial neck. Especially because previous radiations to upper neck may have altered his lymphatic pathways and may actually predispose him more to lower neck failures [just a thought.. i don't think there is any evidence for this].

Having said that, in a 75 Yr old, with hypertension, we also need to think about carotid stenosis; already existent and also what would be caused by added neck radiation. I think I would agree with Indranil, if imaging is not showing any suspicious LN then we may choose the option of keeping neck on surveillance and surgically salvaging it if it does recurr there. The most likely site of failure in his case is going to be primary especially because of dose compromise.

Neck re-irradiation will also add to his swallowing related acute and long term problems.

PET would really be helpful here.

Cetuximab is offered to patients above 70 Yrs in Ontario… see if patient is willing to come down here.

Re: Reccurent Head Neck Cancer

Pranshu Mohindra 23 Apr 2010 18:37

Also Prasad, I too am keen to know why you felt you would be reluctant for hyperfractionation.. it surely is better radiobiologically.

Re: Reccurent Head Neck Cancer

Pranshu Mohindra 23 Apr 2010 18:42

sorry.. just some lingering thoughts..
normally we try and avoid put a mouth bite in base tongue, since it pushes tongue behind etc etc. In this case, it might have some role in atleast placing a cork between his incisors to possibly help limit dose to nose and hard palate.

Re: Reccurent Head Neck Cancer

Nikhilesh Patil 23 Apr 2010 20:15

I have not seen bite-block or anything like that being used here, don't know if you use it at PMH ?
re: brachy , you have already mentioned the reasons why we opted out, What if he bleeds when you are trying to implant tonsil ?
Recent Brachy series: http://www.ncbi.nlm.nih.gov/pubmed/19405086
http://www.ncbi.nlm.nih.gov/pubmed/17434110
http://www.ncbi.nlm.nih.gov/pubmed/19733128
http://www.ncbi.nlm.nih.gov/pubmed/18076842
http://www.ncbi.nlm.nih.gov/pubmed/19563709
http://www.ncbi.nlm.nih.gov/pubmed/19446500
and two interesting articles from our very own country
http://www.ncbi.nlm.nih.gov/pubmed/19230791
http://www.ncbi.nlm.nih.gov/pubmed/20226741

No great data on late toxicities in re-irradiation setting.

Last edited on 23 Apr 2010 20:56 by Nikhilesh Patil Show more

Re: Reccurent Head Neck Cancer

Ashwini Budrukkar 24 Apr 2010 04:49

Pranshu

There is no large trial/ series evaluating role of reirradiation with HDR brachytherapy.

We have reasonably large experience of HDR brachy especially for reirradiation. The complication rates appear to be similar to reirradiation with ext RT. However formal comparisons are still pending.

PET is definately useful modaility in this case.

In reirradiation we try to restrict volumes as much as possible. So i am not infavour of radiating full neck. I may agree with you on observation of neck if PET is negtive.