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What is your general approach on H&N adjuvant reirradiation?
There are a lot of retrospective series out there covering the field of reirradiation in H&N cancer, but I feel most publications / guidelines throw everything in a single bucket.
- From true reirradiation (recurrent tumor completely in the CTV of the first treatment), to marginal misses, to recurrences outside the initial CTV (e.g. contralateral neck recurrences).
- From retreatment with the goal of durable control, to palliation.
- From retreatment as definitive treatment, to discussing the value of adjuvant treatment after resection of a recurrence.
I am mostly interested in the last topic, based on a current case.
Elderly patient with an oral cavity cancer, treated with resection and adjuvant RT to 60 Gy about 3 years ago.
Initially it was a pT3 pN0 primary.
She now presented, 2 years following treatment of the initial tumor, with a large tumor of the hard palate, with involvement of the maxilla. It's difficult to tell, if it's a second primary or a recurrence (perhaps through perineural involvement?). No nodes. Most of the recurrent tumor was within the inital CTV, some parts of it (esp. in the maxillary sinus) grew outside the initially treated volumes.
An extensive resection with reconstruction was carried out. The margins came out clear >5mm, there was no perineural involvement, it was pT4 due to bone/muscle involvement.
The question popped up now, if one should retreat with RT in an adjuvant fashion.
On paper, there are enough risk factors present (i..e. pT4) and a local re-recurence will not be salvageable. On the other hand, it would be a retreatment with >120 Gy at parts of the upper jaw and non resected maxilla, after a rather short time interval and potentially jeopardizing the reconstruction / functional outcome (which isn't great right now, anyhow).
I am reluctant to retreat.
Thoughts?
There are a lot of retrospective series out there covering the field of reirradiation in H&N cancer, but I feel most publications / guidelines throw everything in a single bucket.
- From true reirradiation (recurrent tumor completely in the CTV of the first treatment), to marginal misses, to recurrences outside the initial CTV (e.g. contralateral neck recurrences).
- From retreatment with the goal of durable control, to palliation.
- From retreatment as definitive treatment, to discussing the value of adjuvant treatment after resection of a recurrence.
I am mostly interested in the last topic, based on a current case.
Elderly patient with an oral cavity cancer, treated with resection and adjuvant RT to 60 Gy about 3 years ago.
Initially it was a pT3 pN0 primary.
She now presented, 2 years following treatment of the initial tumor, with a large tumor of the hard palate, with involvement of the maxilla. It's difficult to tell, if it's a second primary or a recurrence (perhaps through perineural involvement?). No nodes. Most of the recurrent tumor was within the inital CTV, some parts of it (esp. in the maxillary sinus) grew outside the initially treated volumes.
An extensive resection with reconstruction was carried out. The margins came out clear >5mm, there was no perineural involvement, it was pT4 due to bone/muscle involvement.
The question popped up now, if one should retreat with RT in an adjuvant fashion.
On paper, there are enough risk factors present (i..e. pT4) and a local re-recurence will not be salvageable. On the other hand, it would be a retreatment with >120 Gy at parts of the upper jaw and non resected maxilla, after a rather short time interval and potentially jeopardizing the reconstruction / functional outcome (which isn't great right now, anyhow).
I am reluctant to retreat.
Thoughts?
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