re-radiation in reccurent ca larynx and amifostine

Summary:

Recurrent SCCA (postlaryngectomy) pN0 of Ca Larynx (left anterior vocal cords) Stg cT2N0 verrucous ca (post radical RT) of 5 years DFI in a patient with moderately good GC and comorbidities for adjuvant reradiation vs observation

re-radiation in reccurent ca larynx and amifostine

sandeep jain 27 Apr 2010 06:17

A 73 years male HTN, DM diagnosed as Larynx (left anterior vocal cords) Stg T2N0 verrucous ca received EBRT (Conventional) to neck region using 6MV x-rays to a dose of 66Gy in 33 fractions till June 05. In Phase-I, 20 fractions were given by bilateral portals followed by phase-II two wedged oblique portals in remaining 13 fractions.

Presented after 5 years with persistent progressive hoarseness, MR suggested recurrence, no cartilage invasion, biopsy showed invasive sq. cell ca.

underwent Total laryngectomy, Bilateral SND (II-IV), primary TEP. HPE revealed 1.7 cm longitudinally, poorly differentiated squamous cell carcinoma, involving bilateral vocal cords, extending anteriorly into soft tissue and superiorly upto epiglottis. Ulcer on lingual aspect of epiglottis shows poorly differentiated squamous cell carcinoma. Base of tongue, right & left pharyngeal mucosal margins show extensive lymphovascular emboli in subepithelium. Inferior tracheal margin, superior soft tissue margin, bilateral pyriform sinuses, thyroid and strap muscle appear free. All 7 paratracheal nodes and 31 nodes from right neck dissection and 23 nodes from left neck dissection are free from tumour.

Impression: Recurrent SCCA (postlaryngectomy) pN0 of Ca Larynx (left anterior vocal cords) Stg cT2N0 verrucous ca (post radical RT) of 5 years DFI in a patient with moderately good GC and comorbidities.

Issues:
1. Although the margins are negative lymphatic invasion in subepithelium is presenting suggesting mucosal spread.
Adjuvant reirradiation vs observation?
2. Target volumes, margins and dose fractionation.
3. Role of IG-IMRT and hyperfractionation already evident. Please elaborate on role of amifostine.
4. Possible swallowing outcomes and ways to prevent.

Re: re-radiation in reccurent ca larynx and amifostine

RAJESH R NAIR 27 Apr 2010 07:13

In my opinion it is better to observe with regular imaging. Histo poorly dif,LVI,Soft tissue involved and recurrence it self all point to chance of further recurrence but major factor like positive margin and positive nodes are not there.Although tissue last irradiated may be operated out and 5 year interval may healed most damage now and the volume of radiotherapy may be to tumor bed i feel it is better to observe in 73 year old.

Re: re-radiation in reccurent ca larynx and amifostine

Nikhilesh Patil 27 Apr 2010 19:16

Hi Sandeep, your surgeons did a good job. Looking at your patients it will be tough for a senior man to tolerate some more RT, however if the patient is in excellent general condition with life expectancy of another >5-7 years then one can argue for some more RT. I agree with Rajesh for close observation.
If at all you plan to treat, then obviously any conformal technique will be good with limited volumes. Dose fractionation again is an contentious area. Amifostine is not in vogue and I don't know how safe it is in seniors. It will be interesting to see what our Head Neck guy's say.

Re: re-radiation in reccurent ca larynx and amifostine

Indranil Mallick 27 Apr 2010 19:52

Hi Sandeep
You mention an ulcer on the lingual aspect of epiglottis - is this a separate lesion, or did you mean laryngeal aspect of epiglottis in continuity with the glottic lesion?

Re: re-radiation in reccurent ca larynx and amifostine

Santam Chakraborty 27 Apr 2010 20:22

Hello Sandeep the point raised by Indranil is pertinent here. I am also keen to know about the extent of soft tissue involvement around the vocal cord. Presuming the isocenter of the tumour lies in glottis so the restaging when done will stage this as T3 (invasion of paraglottic space) or T4a (invasion of tissues beyond larynx). In either case the chance of local recurrence will be high and salvage post recurrence more difficult. If the patient was fit enough to tolerate such an extensive surgery he should be fit for PORT with IMRT provided proper nutritional support is maintained. Dose fractionation will depend on the past volume irradiated which I am thinking will be small in view of the T2 lesion.
Chemotherapy probably will do little more than add to the morbidity and reduce the tolerance.
As far as the rest of the questions come that totally depends on the performance status, local wound and condition of tissues .. a few pics including radiology can help in this regard.
Amifostine I am not convinced will do much in reducing salivary toxicity since major parts of the salivary glands can be easily spared with IMRT. It is unlikely to add to mucositis incidence reduction .. if that is what you are looking may I suggest looking into Palifermin.

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Re: re-radiation in reccurent ca larynx and amifostine

Dr Prasad Dandekar 27 Apr 2010 20:13

Hi Sandeep,

This gentleman is 73 with comorbidities, but since he was fit enough for radical surgery, I have a feeling that he may be able to tolerate RT. Considering the poor prognostic factors such as PD ca, soft tissue invasion, extension to epiglottis and LVE, I think leaving him alone at this point will not be the right choice. Any recurrence will be difficult to handle and lets face it most of our patients can not be trusted for rigorous followup. I agree with Nikhilesh that there is not much data for Amifostin in elderly and my experience is that its not very easily tolerated due to hypotension and nausea.

If I was treating him, I would send him to my GI team to get a PEG tube before starting RT or atleast a NG tube and a dietician reference. I would treat him to 60 Gy in 30 # to entire tumour bed and 54 Gy in 30 # to level II, III and IV. I would recommend IGRT in his case with a rigid immobilisation and a tight PTV margin (I use 3 mm). It goes without saying that we need to make sure that the stoma is well covered in the fields.

Prasad

Last edited on 27 Apr 2010 20:14 by Dr Prasad Dandekar Show more

Re: re-radiation in reccurent ca larynx and amifostine

sandeep jain 28 Apr 2010 10:22

Dear All, Thanks for comments. Although the patient is 73 he is well kept and do not have any postop complications. Perhaps the ulcer on the lingual aspect of epiglottis is a separate lesion however with subepithelial LVI of mucosal bridge in between. Past volume irradiated is small 6x6 portals for ca glottis. Often the patients with total layngectomy has subcut edema in submental region. This patient already have it perhaps due to blokage of lymphatics in previous RT field. Are there some physiotherapy exersises for that. Having a PEG is a good idea. However not sure to add nodal targets since BL neck dissection is done with a good yield. In case we do not plan for neck RT should we give constraints to carotids since the patient is a 20 year hypertensive? What's the evidence of cetuximab in such cases and the tolerance in re-radiation setting.

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