Reirradiation for recurrent glottic cancer

[Kroll2013]

Dear collegues,
Your opinion is needed plz.

70 yo male, smoker
may 2016: radiochemotherapy for T3N1 supraglottic squamous cell carcinoma
He received 70Gy in 35 fractions to the GTV,60Gy to the intermediate risk regions and 50 Gy to the low risk PTV, 3DRT +IGRT ( could not afford IMRT. In my country VMAT is not covered)
He kept smoking and drinking
Good response to CRT

March 2017: he relapsed with 2cm transglottic lesion and underwent total laryngectomy with bilateral neck dissection
Pathology: invasive moderately differentiated SCC
T 2*1cm , transglottic located at the right side and extends to the anterior commissure and Right aryepiglottic fold and pyriform sinus . No invasion of the cartilage
Negative margins
LVSI + , PNI +
Rt neck: 0/13 LNs , deposit of SCC in dense fibrous tissue with no evidence of residual LN
Lt neck : 0/19

Would you reirradiate and at was dose ?
PS the patient is cachectic!

Tx a lot


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[medgator]

No

 

[w00tz]

I would not. High toxicity and likely little benefit. I would be most worried about cord and esophagus. Older patient, seems like poor PS. Stopping alcohol and smoking would probably benefit him the most!

We have done close follow-up with us or ENT, then if they recur sometimes we offer "aggressive palliative" re-irradiation for local control. Tight margins, SBRT if possible.

 

[Gfunk6]

I had a patient very similar to yours. Locally advanced glottic CA, received definitive CRT. Recurred locally within six months underwent salvage laryngectomy.

Recurred AGAIN six months later locally and regionally and presented with cord compression in lower cervical spine with UE hemiparesis. I was as conservative as possible, treated 30/2 with IMRT to highly local field, did dose summation with old plan to minimize overlap. Pt recovered significant Neuro function.

14 days after XRT, died in hospital of (presumed) carotid rupture. Horrible way to go - nonstop bleeding through nose/mouth. They tried emergent packing with ENT, pressors in ICU and CPR. Pt expired from exsanguination.

Did detailed QA afterwards with department/colleagues and presented in M&M conference. All agreed standard of care was not violated given symptomatic cord compression, pt VERY young age and overall poor prognosis.

Still, didn't help me sleep well at night. I am posting this because sometimes all you see are the "miracle" re-XRT outcomes, weigh the risk/benefit carefully.



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[medgator]

. Pt expired from exsanguination.

Did detailed QA afterwards with department/colleagues and presented in M&M conference. All agreed standard of care was not violated given symptomatic cord compression, pt VERY young age and overall poor prognosis.

Still, didn't help me sleep well at night. I am posting this because sometimes all you see are the "miracle" re-XRT outcomes, weigh the risk/benefit carefully.



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Is it common to see a Carotid blowout that soon after reirradiation?

 

[PruritisAni]

Is it common to see a Carotid blowout that soon after reirradiation?

Not at all. Also lower neck is traditionally thought to be a safer area for the carotid vs say skull base. Without knowing the specifics of this case, I'd suspect he had one (or both) of the major risk factors for reXRT rupture: 360 degree encasement of the vessel and/or overlying skin ulceration/wound.

This is why you do IMRT. Carotid sparing ftw!

 

[Kroll2013]

I had a patient very similar to yours. Locally advanced glottic CA, received definitive CRT. Recurred locally within six months underwent salvage laryngectomy.

Recurred AGAIN six months later locally and regionally and presented with cord compression in lower cervical spine with UE hemiparesis. I was as conservative as possible, treated 30/2 with IMRT to highly local field, did dose summation with old plan to minimize overlap. Pt recovered significant Neuro function.

14 days after XRT, died in hospital of (presumed) carotid rupture. Horrible way to go - nonstop bleeding through nose/mouth. They tried emergent packing with ENT, pressors in ICU and CPR. Pt expired from exsanguination.

Did detailed QA afterwards with department/colleagues and presented in M&M conference. All agreed standard of care was not violated given symptomatic cord compression, pt VERY young age and overall poor prognosis.

Still, didn't help me sleep well at night. I am posting this because sometimes all you see are the "miracle" re-XRT outcomes, weigh the risk/benefit carefully.



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You think it would have been better if you re-irradiated directly afterwards?



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[Gfunk6]

To be clear, we felt that the etiology of carotid rupture was tumor infiltration and not cumulative XRT dose to carotid. Generally expect blowout only if cumulative dose exceeds 90-100. That was clearly not the case here.

Also would NOT have repeated XRT in lieu of salvage surgery in this case. If the tumor shrugged off 2.12 Gy x 33 fx with concurrent high dose CDDP, pretty sure dumping more dose after break will not help.


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[nkmiami]

regarding blowout- around 2/100 pts and those pts had neck dissections in rtog re-irradiation study by langer and Horowitz. I have treated 4 or 5 pts with re-iraddiation 1.2 bid to 60 gy and weekly chemo, one is still alive. Even in the re-irradiation setting, carotid blowout is very rare and I wouldn't try to spare carotids.

 

[medgator]

Also would NOT have repeated XRT in lieu of salvage surgery in this case. If the tumor shrugged off 2.12 Gy x 33 fx with concurrent high dose CDDP, pretty sure dumping more dose after break will not help.

I would, for palliation depending on the circumstances.

 

[evilbooyaa]

I think with negative margins you leave it alone. Could focally treat a positive margin area, or if he had a non-radical surgery.

When he recurs (in the neck hopefully) he gets either a mini salvage surgery and adjuvant SBRT, or SBRT re-tx alone if it's not completely involving the carotid.

 

[cdf95cro]

Dear collegues,
Your opinion is needed plz.

70 yo male, smoker
may 2016: radiochemotherapy for T3N1 supraglottic squamous cell carcinoma
He received 70Gy in 35 fractions to the GTV,60Gy to the intermediate risk regions and 50 Gy to the low risk PTV, 3DRT +IGRT ( could not afford IMRT. In my country VMAT is not covered)
He kept smoking and drinking
Good response to CRT

March 2017: he relapsed with 2cm transglottic lesion and underwent total laryngectomy with bilateral neck dissection
Pathology: invasive moderately differentiated SCC
T 2*1cm , transglottic located at the right side and extends to the anterior commissure and Right aryepiglottic fold and pyriform sinus . No invasion of the cartilage
Negative margins
LVSI + , PNI +
Rt neck: 0/13 LNs , deposit of SCC in dense fibrous tissue with no evidence of residual LN
Lt neck : 0/19

Would you reirradiate and at was dose ?
PS the patient is cachectic!

Tx a lot


Sent from my iPhone using SDN mobile

 

[cdf95cro]

Tough case


Typical internal policy (though of course there are no typical re-irrradiation cases):
-No reirradiation for persistent dx; if no cancer-free interval, palliation only.
-Wouldn't reirradiate if <1yr post XRT; if recurrence is less than 1 year, we do sometimes bridge w induction chemoRT to get them to more than 12 months out (it also serves a selection gradient for explosive dz; if pts dont repond to chemo or occult mets bloom on carbotx, no reirradiation).
-Don't reirradiate larynx without TL (asking for aspiration OTW).
-We see much better results after good surgery or induction response (Reirradiation of Head and Neck Cancers With Intensity Modulated Radiation Therapy: Outcomes and Analyses. - PubMed - NCBI).
-If patient is current smoker, and refuses cessation program, we typically won't reirradiate (just asking for acute-on-chronic complications).
-Don't like to reirradiate carotid unless we also get a tissue flap to cover the artery (prefer big ALT; as noted, blowout is a bad way to die).
-Don't like to reirradiate if there are clear margins/no ECE post-op; we will defer XRT if surgeon OK (multi-D discussion).
-Limited or no elective coverage (just post-op for involved regions at 60Gy w chemo); for unresectable, we typically do 66 Gy to GTV+margin w chemo (again, often after induction).
-PNI is a soft call on recurrence; we don't typically chase small nerve PNI; intermediate is based on consult w path; named nerve like normal (respecting previous RT doses near base of skull)
-KPS has to be good post-surgically
-Start within 6 weeks if you can, and pt should be strong enough for consurrent chemo (doesn't sound like pt is great PS for this).

So, broadly, I agree, not a case I'd feel enthusiastic about retreating; however each case is unique and you can discuss w patient. These are very risky scenarios; agree you have to let pt know they may die and die horribly. However, around a third of *super-selected* cases can live 5-years, which is not bad for what is otherwise a terminal diagnosis.

Super snobby biased tertiary med center personal opinion:
I know this will call down the wrath of every SDNer who believes that they can do anything as well as the MDACCs/MSKCCs/UCSFs/WUSTLs/etcs. on their hometown Clinacs in between golf and single iso breast cases (which, I'll be honest, I couldn't treat since I haven't done anything below the clavicles in 7 years), but if you don't do a lot of head and neck reirradiation as a group, and patient can travel, send to a place that does do a lot of these. Head and neck reirradiation is not a thing you want to be doing once or twice a year, and if you're asking online for recs, I'd send to a place that sees these with some frequency...but if patient has no ability to travel, then you gotta ask whether this is within your personal scope, or whether you need to tap out. Get contours/case reviewed by another rad onc (ideally w joint exam in-house, remotely if not) no matter what; you need a second (or third or fourth) set of eyes on these cases.

For context, in training I lost 2 patients over 4 years to carotid blowout. I had a pt exsanguinate in front of their spouse/children/grandkids, and it was one of the more traumatic experiences hearing them recollect the events of their catastrophic death (similar to GFunk's case); though we do a lot of these, you never take these lightly.

 

[medgator]

on their hometown Clinacs in between golf and single iso breast cases

Made me lol. It's ridiculous how many retreat cases I've seen in pp lately (not h&n, a couple of breasts and a sacral lymphoma currently)

 

[Reaganite]

Tough case

Super snobby biased tertiary med center personal opinion:
I know this will call down the wrath of every SDNer who believes that they can do anything as well as the MDACCs/MSKCCs/UCSFs/WUSTLs/etcs. on their hometown Clinacs in between golf and single iso breast cases (which, I'll be honest, I couldn't treat since I haven't done anything below the clavicles in 7 years), but if you don't do a lot of head and neck reirradiation as a group, and patient can travel, send to a place that does do a lot of these. .

No problem! You guys in academics can send us all your single iso breasts and prostates since we have way more experience with those things (I even check my films from the golf course), and we'll send you all our complicated re-treats.

 

[medgator]

yo, that's cool. just make sure you're at least in the country when you're checking those films though.....Radiation Bills Raise Question of Supervision at Florida Clinic

gosh, hard to believe that happened in florida!!!!

Oh they nail plenty of people who don't leave the state either

These guys were trying to cover 3 centers with 2 docs

Fla. radiation oncologists pay $3.5M settlement

 

[OTN]

"I know this will call down the wrath of every SDNer who believes that they can do anything as well as the MDACCs/MSKCCs/UCSFs/WUSTLs/etcs. on their hometown Clinacs in between golf and single iso breast cases (which, I'll be honest, I couldn't treat since I haven't done anything below the clavicles in 7 years)"

/rant on

The problem I have is when my patients see you guys down at your super snobby academic center, my team/equipment/experience/knowledge base is thrown right under the bus. Then, you back up the bus and drive forward and back a bit just to make sure the patients are extra sure you've destroyed any bit of my reputation that's left. While I know you were joking, I'm completely serious when I say radiation oncologists at MDACC - and I can name them by name- have told my patients I "won't be able to avoid the heart in my treatment plan" (I did) and don't know how to properly provide sarcoma XRT because I'm not a "sarcoma radiation oncologist" (I do). I had a patient who was told she "had to come down to MDACC to get proton XRT" for her thymoma, but then she was treated with IMRT and IGRT when she got to Houston...and this 32-year-old mother of 3 was very, very unhappy she had to leave her family for that length of time. I could go on and on.

I know recent leadership did a great job destroying the center from a financial standpoint, but it's just a shame they've decided the best way to recoup that $$ is to attempt to destroy the reputations of the rest of us who practice in Texas.

/rant off