WOULD YOU TREAT THE IPSILATERAL NODAL STATIONS?

Summary:

parameningeal embryonal RMS with huge residual

WOULD YOU TREAT THE IPSILATERAL NODAL STATIONS?

Ayan Basu 19 Feb 2011 08:00

14 year old girl with a parameningeal embryonal rhabdomyosarcoma

post-op —>4 cycles of adjuvant chemotherapy (VAC/VAI)

plan to start radiotherapy at the earliest omitting AMD and Etoposide from her chemotherapy in consultation with the medical oncologist since she has a) large residual tumor b) orbital extension c) limited intracranial extension in ipsilateral temporal lobe —she is IRSG post-surgical Group 3 .

Planning CT scan showed the residual tumor with extension as mentioned above ( image attached)and we are trying to protect as much of the visual pathway and brain as achievable.

Pre-op CT/MRI showed no evidence of lymph node involvement -not sampled surgically.

WOULD YOU INCLUDE IPSILATERAL NODAL STATIONS IN THE CTV —IF SO , WHAT LEVELS? I could not find literature supporting prophylactic nodal irradiation in this scenario .

I am planning to deliver 50.4 Gy @ 1.8 in 28 # .

Last edited on 19 Feb 2011 14:37 by Ayan Basu Show more

Re: WOULD YOU TREAT THE IPSILATERAL NODAL STATIONS?

Indranil Mallick 19 Feb 2011 15:44

In this case I would treat the neck in theory, but from what I can see in the photograph her tumor size is huge. Size is perhaps the most important prognostic factor in RMS. Is this post chemo x 3? I won't be very positive about her prognosis. She's probably going to met out very soon - bones/visceral.

Last edited on 19 Feb 2011 15:49 by Indranil Mallick Show more

Re: WOULD YOU TREAT THE IPSILATERAL NODAL STATIONS?

Nikhilesh Patil 19 Feb 2011 18:24

I agree with Indranil. Thanks for the pics.

Re: WOULD YOU TREAT THE IPSILATERAL NODAL STATIONS?

Ayan Basu 20 Feb 2011 05:51

I agree , tumor size is huge—and this is , post op( though the extent of surgery was unsatisfactory according to me , even considering the fact that surgeon was handicapped by the orbital and intracranial extensions) and post chemotherapy —i myself am not very optimistic about the outcome —though since ERMS tends to respond significantly to RT , giving it a try along with chemo as per protocol.

Last edited on 20 Feb 2011 08:44 by Ayan Basu Show more

Re: WOULD YOU TREAT THE IPSILATERAL NODAL STATIONS?

Pranshu Mohindra 25 Feb 2011 15:39

Hi,

Typically head-neck RMS do not have as high a incidence of lymph nodal involvement as against a Bladder/ Prostate/ Paratesticular RMS. I think, if the CT is not concerning and if PET has been done and is negative, it probably is reasonable to just treat the primary (that too with conservative margins) in a 14 year old girl (or for that matter any age). From my understanding, this is what most ongoing protocols specify. This is probably related to the extreme toxicity of the treatment when combined with concurrent RMS type chemotherapy as against a standard head-neck with cisplatin based therapy. Also, there is a higher chance of distant relapse followed by persistent/ progressive/ recurrent disease at primary site rather than nodal relapse alone.

The AMORE protocol for advanced non-orbital RMS infact just uses brachytherapy after a massive surgical resection and reconstruction.
[http://www.ncbi.nlm.nih.gov/pubmed/19250759]

Int J Radiat Oncol Biol Phys. 2009 Aug 1;74(5):1555-62. Epub 2009 Feb 26.
The AMORE protocol for advanced-stage and recurrent nonorbital rhabdomyosarcoma in the head-and-neck region of children: a radiation oncology view. Blank LE, et al. Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.

Just a quick point, I am sure your pathologists are great, but a RMS not responding at all to four cycles of chemo is not very common. You may consider getting a pathological review if feasible.

Will be interested to know what others feel.

Re: WOULD YOU TREAT THE IPSILATERAL NODAL STATIONS?

VIMOJ J NAIR 26 Feb 2011 03:36

I agree with Pranshu.

Treating the primary only, after ruling out lymphnode mets. - considering the very low incidence of lymph node mets in this subsite.

http://onlinelibrary.wiley.com/doi/10.1002/1097-0142%2819870815%2960:4%3C910::AID-CNCR2820600433%3E3.0.CO;2-8/abstract

some literature on this site.

http://www.ncbi.nlm.nih.gov/pubmed/15817347?dopt=Abstract

http://www.ncbi.nlm.nih.gov/pubmed/17854490?dopt=Abstract

http://www.ncbi.nlm.nih.gov/pubmed/18455321?dopt=Abstract

http://www.ncbi.nlm.nih.gov/pubmed/18501529?dopt=Abstract

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