T2n3a buccal mucosa

[RickyScott]

70 year old pt s/p resection and modified radical neck for r 1.8 cm buccal mucosal carcinoma. Negative margins. 4/4 level 1 nodes (each abt 1 cm) involved w/ENE. Remaining ipsilateral levels negative. What contralateral levels would you include and would you exclude the ispilateral reteopharyngeal nodes? Preop
Pet showed only primary and r level 1 activity/nodes.

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[Palex80]

 

[elementaryschooleconomics]

View attachment 351445

Yeah...

1A, 1B, or not specified?

 

[RickyScott]

Yeah...

1A, 1B, or not specified?

1b

 

[elementaryschooleconomics]

No one's jumping on this eh? SDN is slow these days.

I vote contralateral I/II/III.

I don't feel strongly about it, but I would probably cover the lateral ispi RP nodes, mostly because I assume the dose cloud will incidentally treat them anyway, might as well make it official. I would ask Dosi to prioritize constrictors outside the CTV over RP node coverage, though.

Alright, everyone can take my head now.

 

[deleted1111261]

No RP nodes

Contra 1A/B,II, III, IV

High level 2 or start at C1-C2 interspace ? I’d probably start at interspace.

 

[TheWallnerus]

I bet in the era of lifestyle changes and unknown viral factors and improved staging technology, elective nodal RT in many sites will need to be questioned in the future.

Elective upper-neck versus whole-neck irradiation of the uninvolved neck in patients with nasopharyngeal carcinoma: an open-label, non-inferiority, multicentre, randomised phase 3 trial

Elective UNI of the uninvolved neck provides similar regional control and results in less radiation toxicity compared with standard WNI in patients with N0–N1 nasopharyngeal carcinoma.

www.thelancet.com

The ENE in ipsi level 1 means you at least cover that contra station too. And while you’re there just get II and III like ESE said?

 

[RickyScott]

I bet in the era of lifestyle changes and unknown viral factors and improved staging technology, elective nodal RT in many sites will need to be questioned in the future.

Elective upper-neck versus whole-neck irradiation of the uninvolved neck in patients with nasopharyngeal carcinoma: an open-label, non-inferiority, multicentre, randomised phase 3 trial

Elective UNI of the uninvolved neck provides similar regional control and results in less radiation toxicity compared with standard WNI in patients with N0–N1 nasopharyngeal carcinoma.

www.thelancet.com

The ENE in ipsi level 1 means you at least cover that contra station too. And while you’re there just get II and III like ESE said?

that was my inclination as well. Would probably hold off on rp nodes.

 

[temujim]

70 year old pt s/p resection and modified radical neck for r 1.8 cm buccal mucosal carcinoma. Negative margins. 4/4 level 1 nodes (each abt 1 cm) involved w/ENE. Remaining ipsilateral levels negative. What contralateral levels would you include and would you exclude the ispilateral reteopharyngeal nodes? Preop
Pet showed only primary and r level 1 activity/nodes.

No RP nodes. Contralateral nodes depend on location of primary and size/extent/location of nodes in IB.

 

[jondunn]

No RP.

Without seeing imaging hard to know for sure but for a 1.8 cm tumor that was confined and didn’t invade the floor of mouth or something I wouldn’t trewt contralateral.

Assuming the patient is getting chemo

 

[RickyScott]

No RP.

Without seeing imaging hard to know for sure but for a 1.8 cm tumor that was confined and didn’t invade the floor of mouth or something I wouldn’t trewt contralateral.

Assuming the patient is getting chemo

1.8 posterior tumor near retromolar tigone confined to buccal mucosa but t2 because of depth of invasion. 4 level 1b nodes with ene (they were each abt 1cm in size) My inclination was also to omit contralateral nodes, but tumor board was quite adamant about including them and I don’t want to risk liability.

 

[metallica81788]

1.8 posterior tumor near retromolar tigone confined to buccal mucosa but t2 because of depth of invasion. 4 level 1b nodes with ene (they were each abt 1cm in size) My inclination was also to omit contralateral nodes, but tumor board was quite adamant about including them and I don’t want to risk liability.

You're in a tough spot re contralaterals here esp with tumor board notes saying treat (my first thought upon reading was to omit contra but...)

Wish our academicians would do useful treatment volume based studies on H&N cases like this re nodal volumes which could be useful to everyone instead of useless fluff. I think we all would like to treat less elective nodes but most err on side of caution.

 

[TheWallnerus]

You're in a tough spot re contralaterals here esp with tumor board notes saying treat (my first thought upon reading was to omit contra but...)

Wish our academicians would do useful treatment volume based studies on H&N cases like this re nodal volumes which could be useful to everyone instead of useless fluff. I think we all would like to treat less elective nodes but most err on side of caution.

In the year 2122 the last HNSCC patient to be treated at the last functioning linear accelerator in the US will get irradiated. And he will get ENI to the uninvolved contralateral neck. Because the rad onc will say "We don't really have any data for omitting ENI in the contralateral neck."

 

[jondunn]

1.8 posterior tumor near retromolar tigone confined to buccal mucosa but t2 because of depth of invasion. 4 level 1b nodes with ene (they were each abt 1cm in size) My inclination was also to omit contralateral nodes, but tumor board was quite adamant about including them and I don’t want to risk liability.

Okay in that case to appease all I would include contra IB and some of II

But its as lateralized as it gets. An RMT, buccal mucosa, parotid - in these cases the question isn’t ‘what’s the data to not trewt contralaterally’ because the standard is unilateral

I’m not talking about getting cute on an oral tongue here. It’s a buccal tumor.

 

[temujim]

1.8 posterior tumor near retromolar tigone confined to buccal mucosa but t2 because of depth of invasion. 4 level 1b nodes with ene (they were each abt 1cm in size) My inclination was also to omit contralateral nodes, but tumor board was quite adamant about including them and I don’t want to risk liability.

Meh -- cover IA completely and maybe a bite of IB contralateral, but not enough where you can't spare the contralateral submandibular.

 

[cdf95cro]

2 cents, YMMV, etc, but FWIW, for buccal mucosa/RMT, in the absence of floor of mouth, soft-palate or tonsil involvement, we almost always treat post-op unilaterally, even for pts w T3-4 disease, as long as no evidence of contra-nodes pre-op.

Ipsi RP nodes get covered incidentally as part of your masticator space coverage, but we don't really push high RP coverage anymore (we did until about 5 years ago). If nodes were big in level 2, that can drive RP coverage as a function of parapharyngeal space, but broadly would cover lower ispi RPs, ispi 1B-4, with level 5 almost always incidentally as function of the dissected neck low-intermediate dose. IA coverage depends how close to the lateral commissure primary was; if it was > 2cm, we often omit or cover w elective if undirected. If dissected it gets intermediate/elective dose.

Attached are indicative anonymous screen caps from a pT2N1M0 buccal mucosa case w a single node+ in level 1b...hopefully useful.

 

[deleted1111261]

2 cents, YMMV, etc, but FWIW, for buccal mucosa/RMT, in the absence of floor of mouth, soft-palate or tonsil involvement, we almost always treat post-op unilaterally, even for pts w T3-4 disease, as long as no evidence of contra-nodes pre-op.

Ipsi RP nodes get covered incidentally as part of your masticator space coverage, but we don't really push high RP coverage anymore (we did until about 5 years ago). If nodes were big in level 2, that can drive RP coverage as a function of parapharyngeal space, but broadly would cover lower ispi RPs, ispi 1B-4, with level 5 almost always incidentally as function of the dissected neck low-intermediate dose. IA coverage depends how close to the lateral commissure primary was; if it was > 2cm, we often omit or cover w elective if undirected. If dissected it gets intermediate/elective dose.

Attached are indicative anonymous screen caps from a pT2N1M0 buccal mucosa case w a single node+ in level 1b...hopefully useful.

Houston?

 

[RickyScott]

looked this up on mednet- consensus seems to be omitting contralateral neck.

 

[jondunn]

Houston?

Lol same thought

 

[gmsquid]

Agree with omitting contra neck if lateralized.

 

[evilbooyaa]

Don't see a need for contralateral ENI either. IA-IV, wouldn't cover high level IIs for isolated IB nodal disease. If level II LNs were + then I'd cover to base of skull on ipsi side.

If TB forces your hand then IB-III (or IV if you really want to) contralateral should be plenty, again not covering high level IIs. Just unfortunate to toast contralateral SMG without great indication. Would see if you can discuss with somebody at the TB. If you were present and still the 'consensus' was treat contralateral, then OK. But, if you spare high level IIs, should be able to keep individual parotids mean < 26 (or push dosi for lower if you're feeling frisky) and leave patient with G1-2 long-term xerostomia.

Don't see a need to cover ipsi RPs in this case...