Hypofractionated H&N

[Ray D. Ayshun]

Has anyone used 55 Gy in 20 fx, which looks like it may be common in the UK? Looking everywhere for constraints as I'm interested in trying it for something.

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[evilbooyaa]

For definitive or post-op H&N? Outside of cutaneous H&N without ENI, no I have never used that fractionation scheme.

Those UK sons of bitches better not come for standard fx in H&N and stage III NSCLC with their bull**** non-inferiority trials

 

[Ray D. Ayshun]

For definitive or post-op H&N? Outside of cutaneous H&N without ENI, no I have never used that fractionation scheme.

Those UK sons of bitches better not come for standard fx in H&N and stage III NSCLC with their bull**** non-inferiority trials

Neither. Palliative of sorts. Long story, but very locally advanced adenoid cystic of smg eating into the mandible. Has lung mets. Trying to do something that'll give me better long term control than average palliative regimens given biology and patients functional status, which is great excepting the mass and symptoms. Open to other ideas.

 

[dirka]

I have done 50Gy in 20 fractions for these types of scenarios.

 

[FrostyHammer]

For definitive or post-op H&N? Outside of cutaneous H&N without ENI, no I have never used that fractionation scheme.

Those UK sons of bitches better not come for standard fx in H&N and stage III NSCLC with their bull**** non-inferiority trials

I LOLed but actually evidence for shorter courses would be very valuable for rural community centers where there's no guarantee a patient will come for 6-7 weeks and you just want to finish them ASAP because they are at very high risk of not coming back after some weeks.

 

[medgator]

I have done 50Gy in 20 fractions for these types of scenarios.

That's my go to Palliative h&n regimen

 

[Ray D. Ayshun]

I have done 50Gy in 20 fractions for these types of scenarios.

This came to mind as well, but this 55/20 seems to be a well studied scheme. I'm interested in just hearing the constraints as I've googled the **** out of it and found nothing about how it's actually planned.

 

[Ray D. Ayshun]

How do you plan 50/20. Just "minimize" everything?

 

[evilbooyaa]

Neither. Palliative of sorts. Long story, but very locally advanced adenoid cystic of smg eating into the mandible. Has lung mets. Trying to do something that'll give me better long term control than average palliative regimens given biology and patients functional status, which is great excepting the mass and symptoms. Open to other ideas.

Quadshot x 3-4 rounds or 50-55/20. If was not eroding into mandible would consider 35-40/5.

 

[TheWallnerus]

This came to mind as well, but this 55/20 seems to be a well studied scheme. I'm interested in just hearing the constraints as I've googled the **** out of it and found nothing about how it's actually planned.

UK Christie hospital did a lot of definitive larynx at about 51 Gy/16 fx (plain old opposed laterals, but small-ish fields not overdoing it on ENI). Their outcomes were great. That was squamous though. Adenoid cystic is a different, unpredictable beast. Many adenoid cystics of trachea e.g. aren't controlled with 70 Gy. The histology (high grade, low grade) is not that predictive of radio-response either. That said, if you're high dose palliating, why not something like 40-50 Gy in 10 fractions.


SLIGHT NON-SEQUITUR:
Oligomet RT will save us! Not with single fraction RT though.

 

[dirka]

How do you plan 50/20. Just "minimize" everything?

nothing crazy... for OARs parotids 26 mean, spinal cord max 45, esophagus max 45, plexus max 50, lips max 25.. not worried about late effects though. I have only done this conformal IMRT/VMAT so I suppose if your volume is very big then may want closer attention to oral cavity / oropharynx doses.

 

[Radonc90]

Agree with 50 Gy in 20 fx.
FYI, PMH used that regimen for T1 vocal cord ca for yrs...
So 50/20 is also a curative dose for T1 larynx.

Another option is the PMH 0-7-21, the origin of which is from canine melanoma...

 

[Ray D. Ayshun]

UK Christie hospital did a lot of definitive larynx at about 51 Gy/16 fx (plain old opposed laterals, but small-ish fields not overdoing it on ENI). Their outcomes were great. That was squamous though. Adenoid cystic is a different, unpredictable beast. Many adenoid cystics of trachea e.g. aren't controlled with 70 Gy. The histology (high grade, low grade) is not that predictive of radio-response either. That said, if you're high dose palliating, why not something like 40-50 Gy in 10 fractions.


SLIGHT NON-SEQUITUR:
Oligomet RT will save us! Not with single fraction RT though.

Too big to feel comfortable doing 5 x 10. I'm out in the woods. People let things grow big here. I've opted for something weird.

 

[evilbooyaa]

nothing crazy... for OARs parotids 26 mean, spinal cord max 45, esophagus max 45, plexus max 50, lips max 25.. not worried about late effects though. I have only done this conformal IMRT/VMAT so I suppose if your volume is very big then may want closer attention to oral cavity / oropharynx doses.

You'd allow Cord max 45Gy @ 2.25Gy/fx * 20fx but lips max 25Gy in 20fx?

 

[Doctorer]

You'd allow Cord max 45Gy @ 2.25Gy/fx * 20fx but lips max 25Gy in 20fx?

View attachment 338523

Presumably that’s just a planning constraint so his Dosimetrist/optimizer doesn’t just go spraying dose all over the place. If you don’t ask for things like that, you get plans that aren’t that great.

 

[Ray D. Ayshun]

Presumably that’s just a planning constraint so his Dosimetrist/optimizer doesn’t just go spraying dose all over the place. If you don’t ask for things like that, you get plans that aren’t that great.

Yeah, I threw that in there on the constraints sheet. Went a little higher, but was a good reminder to avoid the lips, which I rarely have to think about

 

[RickyScott]

lips can be a disaster if oral cavity/oropharync and carbo/taxol

 

[Ray D. Ayshun]

Here's what I got with contralateral SMG and Parotid with mean of 9 and 5 Gy respectively. Lip max 34 Gy. Treating GTV including primary and mandibular erosion and ipsi level 2 node to 55/20 while treating mandible from entrance to exit of V3 to 48 Gy concurrently (numbness, ear pain, propensity for PNI).

 

[Ray D. Ayshun]

As follow-up to the above patient, he ultimately underwent a resection with a bone graft after slow/incomplete response to rt. again, metastatic adenoid cystic. i talked with the ent, who's great and who i trust, and he talked like resection followed by adjuvant rt is standard. have others approached this disease state in that manner?

 

[evilbooyaa]

Ummm.... I don't think you had ever mentioned the pathology before.

If the case described above was considered resectable and was adenoid cystic histology, then yeah it needed surgery and adjuvant RT (+/- chemo depending on path findings, likely no evidence to actually support chemo though in this histology). Like 100% of the time.

I feel like I must be misunderstanding here, but here's my question: did you definitively radiate an adenoid cystic carcinoma with a hypofx regimen rather than have him to go for surgical resection followed by adjuvant RT?

 

[jondunn]

Well it’s a metastatic patient, only setting in which I think a suboptimal approach can have merit. But generally agree with you

 

[Ray D. Ayshun]

Ummm.... I don't think you had ever mentioned the pathology before.

If the case described above was considered resectable and was adenoid cystic histology, then yeah it needed surgery and adjuvant RT (+/- chemo depending on path findings, likely no evidence to actually support chemo though in this histology). Like 100% of the time.

I feel like I must be misunderstanding here, but here's my question: did you definitively radiate an adenoid cystic carcinoma with a hypofx regimen rather than have him to go for surgical resection followed by adjuvant RT?

Was mentioned above. In any case, metastatic adenoid cystic with about 15 lung mets. Large primary eating through mandible causing pain, numbness and inability to eat solid foods. Sent by local ent given concern about how big the surgery would be given metastatic disease. In turn, given nature of disease I treated for both symptom relief and local control. Symptoms did improve including resolution of numbness and significant reduction in pain. Local med onc got a restaging CT which was concerning for progression, which turned out to be an odontogenic cyst, though cancer was of course still present. Patient then went to academic center where resection and bone grafting were performed. I discussed the case with him and he said a common approach in metastatic disease is to perform even massive surgeries for local control, followed by adjuvant rt. I wasn't aware of this paradigm at the time, and wonder if others are, or disagree. If this is the standard approach in the metastatic setting, not sure how I missed it.

 

[evilbooyaa]

Oh, fair enough, missed that portion of that post. That changes the scenario quite a bit.

With lung mets I see no reason to do upfront surgery. And if surgery IS considered for palliative reasons (I wouldn't do until patient failed RT, personally), then I see no reason to do adjuvant RT when the patient has lung mets chugging along.

 

[salubalu]

Was mentioned above. In any case, metastatic adenoid cystic with about 15 lung mets. Large primary eating through mandible causing pain, numbness and inability to eat solid foods. Sent by local ent given concern about how big the surgery would be given metastatic disease. In turn, given nature of disease I treated for both symptom relief and local control. Symptoms did improve including resolution of numbness and significant reduction in pain. Local med onc got a restaging CT which was concerning for progression, which turned out to be an odontogenic cyst, though cancer was of course still present. Patient then went to academic center where resection and bone grafting were performed. I discussed the case with him and he said a common approach in metastatic disease is to perform even massive surgeries for local control, followed by adjuvant rt. I wasn't aware of this paradigm at the time, and wonder if others are, or disagree. If this is the standard approach in the metastatic setting, not sure how I missed it.

Your telling me you didn’t SBRT the lung Mets?

 

[Palex80]

I discussed the case with him and he said a common approach in metastatic disease is to perform even massive surgeries for local control, followed by adjuvant rt. I wasn't aware of this paradigm at the time, and wonder if others are, or disagree. If this is the standard approach in the metastatic setting, not sure how I missed it.

I think it depends a lot on the dynamic of the metastatic disease. Some patients may benefit, indeed. But you need to carefully select.

 

[Ray D. Ayshun]

Your telling me you didn’t SBRT the lung Mets?

Will wait 90 days between each. In all seriousness, I respect this ents abilities, but he talked like this is just what they do. Maybe just an academic center thing, but wondering if resection of the primary is the common first approach.

 

[gmsquid]

Adenoid cystic carcinoma even with metastatic disease typically has a long natural history. We frequently aggressively treat the primary (surgery and postop rt) in patients with Mets at diagnosis. It’s the norm for people with Mets to go several years without requiring systemic therapy.

 

[Ray D. Ayshun]

Adenoid cystic carcinoma even with metastatic disease typically has a long natural history. We frequently aggressively treat the primary (surgery and postop rt) in patients with Mets at diagnosis. It’s the norm for people with Mets to go several years without requiring systemic therapy.

Is this approach based upon local control outcomes in the nonmetastatic setting? It seems strange to be as aggressive as bimodality therapy in a cancer where lung mets don't appreciably change in size for years sometimes.

 

[jondunn]

Is this approach based upon local control outcomes in the nonmetastatic setting? It seems strange to be as aggressive as bimodality therapy in a cancer where lung mets don't appreciably change in size for years sometimes.

Yeah local control with definitive RT for adenoid cystic primary is terrible, it’s palliative at best

 

[Ray D. Ayshun]

Yeah local control with definitive RT for adenoid cystic primary is terrible, it’s palliative at best

Read an article from Asia with 5 yr lc ~80%

 

[jondunn]

Read an article from Asia with 5 yr lc ~80%

Plenty to say otherwise?

This is like the least controversial thing ever IMO. It’s like a sarcoma or a meso - heal with steel.

 

[Ray D. Ayshun]

Plenty to say otherwise?

This is like the least controversial thing ever IMO. It’s like a sarcoma or a meso - heal with steel.

Well then, it's clear to me that I missed the portion of training where removing part of a patient's mandible in the noncurative setting is not controversial. I must also misunderstand the definition of palliation.

 

[jondunn]

Well then, it's clear to me that I missed the portion of training where removing part of a patient's mandible in the noncurative setting is not controversial. I must also misunderstand the definition of palliation.

I’m not saying anything about it being a slam dunk decision, but yeah it’s true these patients live for years and years and years so doing a good surgery and recon makes more sense than wasting time with definitive RT and causing a lot of misery with no great chance of control - to what end.

But the question I was answering was about whether this is based in data in the non metastatic setting - yes.

 

[Ray D. Ayshun]

I’m not saying anything about it being a slam dunk decision, but yeah it’s true these patients live for years and years and years so doing a good surgery and recon makes more sense than wasting time with definitive RT and causing a lot of misery with no great chance of control - to what end.

But the question I was answering was about whether this is based in data in the non metastatic setting - yes.

Again, still having trouble seeing how it's obvious to apply a curative treatment paradigm in the noncurative setting. It's not even lc that's important, but symptom control. If the primary is as asymptomatic as the innumerable lung mets, who cares? Resection and recon plus adjuvant rt seems like overkill.

 

[jondunn]

‘It's not even lc that's important, but symptom control’

Agreed. So why would you offer definitive radiation and cause misery if something wasn’t bothering them? Give 20/5.

Or do surgery. Agree post op RT is plus/minus.

But also adenoid cystic patients are a different ball game completely. I’m sure you have had a few and are aware of their natural history and how long you will know them, so I’ll spare that part of the discussion

Also - innumerable? That’s different than a few. This this patient have innumerable? How long since diagnosis? Any targeted therapy options?

 

[jondunn]

‘Again, still having trouble seeing how it's obvious to apply a curative treatment paradigm in the noncurative setting’

Also - again - my involvement started by answering your own question about local control in non metastatic patients. That’s the obvious part

 

[medgator]

‘It's not even lc that's important, but symptom control’

Agreed. So why would you offer definitive radiation and cause misery if something wasn’t bothering them? Give 20/5.

Or do surgery. Agree post op RT is plus/minus.

But also adenoid cystic patients are a different ball game completely. I’m sure you have had a few and are aware of their natural history and how long you will know them, so I’ll spare that part of the discussion

Also - innumerable? That’s different than a few. This this patient have innumerable? How long since diagnosis? Any targeted therapy options?

You would treat a h&n Palliative case with 20/5? Cute. Get back to us after board certification and a few years under your belt

 

[jondunn]

You would treat a h&n Palliative case with 20/5?

......you never have? shows you haven't been in lot of tough scenarios.

 

[Ray D. Ayshun]

Rad onc is the flaky brocade ****boi who texts you “u up?” at 3 am

 

[gmsquid]

Again, still having trouble seeing how it's obvious to apply a curative treatment paradigm in the noncurative setting. It's not even lc that's important, but symptom control. If the primary is as asymptomatic as the innumerable lung mets, who cares? Resection and recon plus adjuvant rt seems like overkill.

Local control is symptom control: The primary may be asymptomatic now, but either pnts or mandibular destruction will make it sumpatomatic. In the parotid, facial nerve paralysis. In the submandibular, pnts or bone erosion or direct spread to oral cavity. In the minor salivary glands pain or issues swallowing. A tumor has inches to grow in the lung before it becomes symptomatic. In the hn not much.

 

[gmsquid]

Also the innumerable question is also irrelevant. people live years with slow growing innumerable lung Mets.

 

[Lamount]

Again, still having trouble seeing how it's obvious to apply a curative treatment paradigm in the noncurative setting. It's not even lc that's important, but symptom control. If the primary is as asymptomatic as the innumerable lung mets, who cares? Resection and recon plus adjuvant rt seems like overkill.

I don't know this particular case nor do I fancy myself a H&N expert... but it is conceivable that, depending on the case, it could be similar to an impending asymptomatic pathologic femoral fracture that is treated with prophyalctic fixation and adjuvant RT. Uncontrolled primary H&N disease is awful. ACC is particularly chemo/radio resistant and can have a very long horizon. In my view, there would be a high bar for a surgery like this, but it wouldn't be off the table.

 

[Ray D. Ayshun]

I don't know this particular case nor do I fancy myself a H&N expert... but it is conceivable that, depending on the case, it could be similar to an impending asymptomatic pathologic femoral fracture that is treated with prophyalctic fixation and adjuvant RT. Uncontrolled primary H&N disease is awful. ACC is particularly chemo/radio resistant and can have a very long horizon. In my view, there would be a high bar for a surgery like this, but it wouldn't be off the table.

Thanks, it's not that I disagree with what anyone said. I treated it aggressively for all these reasons. At the same time, I'm genuinely interested in knowing where the line is wrt a surgery being too aggressive as a first step, or if it's (most) ALWAYS the correct first step. FWIW, this guys primary shrank by about 50% at 3 months. I'm happy to admit what I did was suboptimal and learn from it, but I'm also having trouble with the idea that surgery and adjuvant RT is a reasonable first approach. It seems like starting with the single modality that best balances durable symptom relief and toxicity and doing more in the setting of progression is a reasonable approach. There is data out there suggesting that while RT can't necessarily make ACC disappear, it can shrink it some, and slow it's growth, and in a lot of metastatic cases, that may be all that's needed.

 

[evilbooyaa]

What is the evidence for upfront surgery in these cases? If a patient is getting palliative surgery, what in the world is the evidence for ADJUVANT RT afterwards??

I don't think anyone is recommending 70/35 definitive RT in the setting of metastatic adenoid cystic, but I think a high BED SBRT regimen or a quick palliative regimen (higher BED than 20/5 or 30/10, maybe 25-30/5, 40-50/10, etc.) is not at all unreasonable for this diagnosis.