Stage III/IV hpv+ oropharynx rt alone

[Ray D. Ayshun]

Have a patient with the above (old stage IV) who can't do chemo and is a transportation nightmare. Wondering what the shortest course is you can get away with. Adapting 0022, 66/30?

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[RadOncMegatron]

Have a patient with the above (old stage IV) who can't do chemo and is a transportation nightmare. Wondering what the shortest course is you can get away with. Adapting 0022, 66/30?

Can’t think of much else. I hesitate to be too creative on these folks.

 

[RADONC4285]

I would consider adding cetuximab if possible. It's inferior to chemo but likely better than nothing per Bonner's trial.

 

[evilbooyaa]

Yeah unfortunately not a ton of wiggle room in definitive H&N. 66/30 reasonable option, could consider doing it with Cetux concurrently if primary wasn't too mucosal and large given Bonner allowed some acceleration.

 

[gmsquid]

Can consider 55/20 though the experience is largely with cis or carbo: Feasibility of concomitant cisplatin with hypofractionated radiotherapy for locally advanced head and neck squamous cell carcinoma

I typically do 0022 for these patients though

 

[Palex80]

I presume you will be treating this patient on an outpatient basis. If keeping the patient in the hospital is an option, you could attempt a sort of acceleration with 1.5-1.8 Gy BID.

 

[Ray D. Ayshun]

Can consider 55/20 though the experience is largely with cis or carbo: Feasibility of concomitant cisplatin with hypofractionated radiotherapy for locally advanced head and neck squamous cell carcinoma

I typically do 0022 for these patients though

Yeah, just did this to a degree in a met adenoid cystic with great performance status for a smaller field. Wasn't sure if this had caught on much with a lot of gross disease in the neck. Yes, treating as an outpatient.

 

[metallica81788]

I like 66/30 or 55/20 in these folks. It's still a rough treatment as these folks toe a thin line before decompensating.

 

[TheWallnerus]

As someone who’s done a lot of Erbitux, it wasn’t all it was cracked up to be, not sure it was better than nothing, and wasn’t as sparing-from-chemo-toxicity as touted either. If Jim Bonner was my server at Applebee’s, I’d ask to speak to his manager.

 

[medgator]

As someone who’s done a lot of Erbitux, it wasn’t all it was cracked up to be, not sure it was better than nothing, and wasn’t as sparing-from-chemo-toxicity as touted either. If Jim Bonner was my server at Applebee’s, I’d ask to speak to his manager.

Erbi-tox

 

[ramsesthenice]

As someone who’s done a lot of Erbitux, it wasn’t all it was cracked up to be, not sure it was better than nothing, and wasn’t as sparing-from-chemo-toxicity as touted either. If Jim Bonner was my server at Applebee’s, I’d ask to speak to his manager.

At both my current institution and where I trained concurrent EGFR inhibitors were not used because of toxicity. This was mutually agreed by the med oncs and rad oncs. I've known people at other institutions who swear the toxicity is fine but I know when I was a resident we saw a couple grade 5s and that was that. What is the function of EGF in normal mucosal epithelium? Just endothelial cell turnover. Nothing too important in the setting of radiation.

 

[Ray D. Ayshun]

At both my current institution and where I trained concurrent EGFR inhibitors were not used because of toxicity. This was mutually agreed by the med oncs and rad oncs. I've known people at other institutions who swear the toxicity is fine but I know when I was a resident we saw a couple grade 5s and that was that. What is the function of EGF in normal mucosal epithelium? Just endothelial cell turnover. Nothing too important in the setting of radiation.

I live in the southeastern tick belt, so generally try to avoid. Would expect dahanca regimen is just as good as cetuximab if that ever crosses my mind.

 

[TheWallnerus]

At both my current institution and where I trained concurrent EGFR inhibitors were not used because of toxicity. This was mutually agreed by the med oncs and rad oncs. I've known people at other institutions who swear the toxicity is fine but I know when I was a resident we saw a couple grade 5s and that was that.

For real. Ironically saw the infamous renal scorcher that CDDP can be get outshone by ctxmb a few times. Sometimes the skin stuff would be treatment-break inducing (and the mucosa would be fine). It doesn't increase common toxicities (maybe), just uncommon ones!

 

[temujim]

Have a patient with the above (old stage IV) who can't do chemo and is a transportation nightmare. Wondering what the shortest course is you can get away with. Adapting 0022, 66/30?

54/18

 

[evilbooyaa]

Can consider 55/20 though the experience is largely with cis or carbo: Feasibility of concomitant cisplatin with hypofractionated radiotherapy for locally advanced head and neck squamous cell carcinoma

I typically do 0022 for these patients though

75% rate of feeding tube (NGT??) placement would make me quite wary of adopting this regimen.

 

[deleted1111261]

75% rate of feeding tube (NGT??) placement would make me quite wary of adopting this regimen.

I think NGT is different than true feeding tube? It’s listed as separate items. And the wording says “offered”. Did they accept this offer? But yah… seems like could be a little rough.

 

[evilbooyaa]

I think NGT is different than true feeding tube? It’s listed as separate items. And the wording says “offered”. Did they accept this offer? But yah… seems like could be a little rough.

Yeah but seems relatively standard indications for feeding tube as per their methods: "Patients with weight loss higher than 5–10% of the initial body weight (defined as the weight measured before treatment) and patients with grade 3 dysphagia were offered nasogastric tubes (NGTs)."

From results: "Most patients (95%) lost weight during treatment, and the median percentage of weight loss during treatment was 7.8%. All patients received nutritional supplementation during treatment, and 15 patients (75%) required NGT; most patients required NGTs due to weight loss > 5% and grade 3 dysphagia or odynophagia. At the last follow-up visit, only one patient was still using the NGT."

Maybe 5% weight loss is a touch too low to jump to a feeding tube and I generally start offering at 10% weight loss, but additionally, 40% had G3 mucositis and 30% had G3 dermatitis. Just higher than I see even with 70/35 with Cis, and definitely higher than 66/30 without chemo.

 

[gmsquid]

Most patients had T3-T4 primary disease so may be more expected. Hard to know who they were treating.

 

[seper]

Never treated that way myself, but I like the new UK prescription: 64 Gy/25fx

 

[metview]

Maybe do 6 fractions/week, BID one day of the week to 66-70 Gy per DAHANCA?

 

[Ray D. Ayshun]

Maybe do 6 fractions/week, BID one day of the week to 66-70 Gy per DAHANCA?

I love dahanca, but it was a matter of fewest total number of treatments.