T4a Larynx cancer with negative nodal dissection no concerning pathologic features...

[Ray D. Ayshun]

s/p total laryngectomy with negative unilateral neck dissection, some invasion into the contralateral larynx and erosion through thyroid cartilage. ENT not concerned about stomal margins etc. No PNI, no LVSI. Referred him to me because that's what we do, and T4 tumors don't present this way commonly enough to really say much about forgoing adjuvant RT as far as I can tell, though the NCCN seems to allow for observation in a similar setting. Main problem in the present case is no contralateral nodal evaluation, though negative PET and path findings make him lower risk. In any case, wondering if/when people would observe a T4 following total laryngectomy.

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[OTN]

I would treat. T4 laryngeal cancer with cartilage invasion has a high recurrence rate, although other adverse features usually do exist. Without chemo it should be tolerated well in the short- and long-term.

 

[Palex80]

s/p total laryngectomy with negative unilateral neck dissection, some invasion into the contralateral larynx and erosion through thyroid cartilage. ENT not concerned about stomal margins etc. No PNI, no LVSI. Referred him to me because that's what we do, and T4 tumors don't present this way commonly enough to really say much about forgoing adjuvant RT as far as I can tell, though the NCCN seems to allow for observation in a similar setting. Main problem in the present case is no contralateral nodal evaluation, though negative PET and path findings make him lower risk. In any case, wondering if/when people would observe a T4 following total laryngectomy.

I'd definetely treat the primary site. Concerning lymphatics, I'd still treat. I'd be willing to ommit part of the "classic" volumes though, since pN0 unilateraly and PET clear.

 

[Ray D. Ayshun]

So no situation where anyone would observe?

And yeah, part of my predilection to treat always is the relative tolerability compared to oral cavity etc

 

[evilbooyaa]

I would not observe any pT4a Larynx SCC. If it was cT4a and turned out to not be pT4a and was actually say pT3, then could observe in N0 setting.

pT4 primary is an adverse feature per NCCN guidelines, even without PNI/LVSI.

Treat primary and lymphatics (including VI). In Node negative neck, no need to go treat high level II bilaterally which will help with parotid constraints.

 

[thecarbonionangle]

Absolutely not man. Treat primary site and bilateral neck. Believe in radiation! T’is quite good!

 

[Ray D. Ayshun]

I would not observe any pT4a Larynx SCC. If it was cT4a and turned out to not be pT4a and was actually say pT3, then could observe in N0 setting.

pT4 primary is an adverse feature per NCCN guidelines, even without PNI/LVSI.

Treat primary and lymphatics (including VI). In Node negative neck, no need to go treat high level II bilaterally which will help with parotid constraints.

Ah, ok. The NCCN guidelines are a touch confusing wrt to following the pathway, which starts at cT4. Thanks, was wondering about that. In any case, no plans to observe from the outset.

 

[gmsquid]

100% treat. I treat HN. Also not sure why unilateral neck was done to stage the neck in a larynx tumor

 

[Haybrant]

Va larynx is surgery followed by RT vs crt

 

[Radonc90]

Don't listen to the ENT guy if you care about your pt.
I'd Tx the post-op usual volumes, bilat neck + stoma.
Yes, Tx the stoma.

 

[OTN]

Don't listen to the ENT guy if you care about your pt.
I'd Tx the post-op usual volumes, bilat neck + stoma.
Yes, Tx the stoma.

Yep, tumor bed including stoma, bilateral necks and level VI if subglottic extension.

 

[Ray D. Ayshun]

Don't listen to the ENT guy if you love your pt.
I'd Tx the post-op usual volumes, bilat neck + stoma.
Yes, Tx the stoma.

Ent sent to me as per usual. In speaking with him, there were no close or concerning margins. I talked to him to figure out the dose I felt comfortable stopping at. The question originated from the fact that I followed the nccn pathway for ct4 larynx, which allows for observation in certain situations, and was curious about what settings anyone would observe t4 larynx post op. I was reading it as a pt4 larynx pathway, which was incorrect.

 

[FrostyHammer]

100% treat. I treat HN. Also not sure why unilateral neck was done to stage the neck in a larynx tumor

In a cN0 neck, is there a good reason to do a contralateral neck dissection other than cause more morbidity if RT is most likely going to be given adjuvantly?

 

[OTN]

In a cN0 neck, is there a good reason to do a contralateral neck dissection other than cause more morbidity if RT is most likely going to be given adjuvantly?

Good data for dissecting the neck up front for an oral cavity primary, but I haven’t seen any similar data for larynx.

 

[seper]

Definately treat the bed but may omit the necks if high nodal yield is seen on path (helps to prevent head edema).

 

[FrostyHammer]

Good data for dissecting the neck up front for an oral cavity primary, but I haven’t seen any similar data for larynx.

That was ipsi only, not contra.

 

[gmsquid]

In a cN0 neck, is there a good reason to do a contralateral neck dissection other than cause more morbidity if RT is most likely going to be given adjuvantly?

How can you define a lateralized larynx tumor? (Especially a T4) I mean presumably there are bilateral small nodes on preop imaging, how do you know that the side you dissect is the correct side to dissect? If that’s the case, why even do the necks if not for nodal staging at least. You could just do the laryngectomy and omit the nds and treat both sides electively. Also not sure how you don’t contaminate the necks (at least levels 3/4/6) after a largyngectomy with T4 disease. I mean why do these people recur in their stomas if the larynx is removed en bloc and the stoma is made below the tumor?

 

[FrostyHammer]

How can you define a lateralized larynx tumor? (Especially a T4) I mean presumably there are bilateral small nodes on preop imaging, how do you know that the side you dissect is the correct side to dissect? If that’s the case, why even do the necks if not for nodal staging at least. You could just do the laryngectomy and omit the nds and treat both sides electively. Also not sure how you don’t contaminate the necks (at least levels 3/4/6) after a largyngectomy with T4 disease. I mean why do these people recur in their stomas if the larynx is removed en bloc and the stoma is made below the tumor?

Bingo. You just answered your question. Omit the LNDs and treat both sides electively. And FWIW practically speaking, many larynx cases are disproportionately on one side, for instance if they begin from the left FVC or are eroding thru the right sided thyroid cartilage. But all that aside, what you mentioned above is spot on what I would do.

 

[Palex80]

Definately treat the bed but may omit the necks if high nodal yield is seen on path (helps to prevent head edema).

I would still be concerned about the contralateral neck sine it was a mid-line crossing tumor. You can however ommit certain levels.

I'd ommit high level II and level V.

 

[medgator]

Larynx by definition is a midline structure, you treat both sides of the neck afaik

 

[Lamount]

Personally, would treat bed +bilateral necks. Would be reasonable to omit ipsilateral neck given N0 (but I wouldn't). I know some who would favor concurrent chemo per the EORTC 22931 study, which showed a survival benefit to adjuvant CRT independent of the combined analysis with the RTOG 9501 study... but I think that is a judgement call based on biology.