Head and Neck Cancers
Questions discussed in this category
What would be the optimal choice of chemotherapeutic agents and duration?
Do you approach similar to pleomorphic adenoma since it is still non-invasive? If there are indications for treating the primary, do you also elective...
Do you prefer upfront cisplatin/etoposide for 2 cycles, then 50 Gy with ENI, then resection, or induction chemo followed by definitive chemoradiation?...
Should lymph nodes ever be targeted? If bone invasion or erosion is present, and surgery is not feasible, is radiation appropriate, and to what dose?
What dose would you give for ECE in this setting?
Would a combination of other adverse features such as PNI, GIII, close margin, multiple positive nodes, T4 disease and others make you recommend chemo...
For a non-metastatic head and neck cancer patient in his early 80s with an ECOG PS of 3 who has already lost about 20 pounds, how would you favor appr...
Bentzen et al., IJROBP 2023
Compared with other thyroid carcinomas, Hürthle cell cancer has a lower avidity for 131I; therefore, treatment with radioactive iodide has l...
Biphenotypic sinonasal sarcoma is a recently described malignancy showing dual differentiation with both myogenic and neural elements.
How do the results affect your recommendations for workup and management?
For example, do you favor using different induction chemotherapy (gemcitabine/cisplatin or TPF) for endemic vs non-endemic disease?
Do you favor usin...
Patient has not received radiation therapy in the past. If not, what would you offer for palliation of pain?
Any particular considerations for +PNI, close 1mm margin and 0/29 LN?
Such as those meeting the eligibility criteria for NRG HN002, <10 pack years, HPV+ T1-2N1-2b, T3N0-N2b
In light of the 4/2024 JCO publication by Peng et al., PMID 38215354
Would you recommend neck dissection and adjuvant ipsilateral RT?
As we see more TORS being done, we sometimes run into the above scenario which could have been cured with RT alone.
Do you add concurrent chemotherap...
What techniques and doses would you prescribe to the primary and regional nodes?
This would apply to gynecologic and GI cancers as well. And as long as the patient's partner is within the recommend age of <45 yo
There was a recall on viscous lidocaine and many of our patients cannot find it. What would you recommend as alternatives?
Would you consider it for a patient with good PS but with limited metastatic disease? What dose fractionation would you prefer?
What field design and dosing is most appropriate? Would you use ISRT or a more extended field?
I have an interesting case of gentleman in his 40s, HIV+ but viral count undetectable and CD4 1000+. He had prior diagnosis of Kaposi’s sarcoma ...
Would you still treat the primary site and to what dose?
Would you manage different whether ND was completed or not?
Patient declined additional wider excision due to associated function morbidity as well as neck dissection. What would you estimate is the risk of cli...
Is T4 disease a contraindication?
Are the results superior to alternative treatment methods?
What dose, fractionation, and volume would you choose?
Would you electively cover the vagal nerve(s) and associated recurrent laryngeal nerves?
Does...
Do you have a standard reporting format with specific doses?
Specifically, with respect to sequencing of chemotherapy, dosing and target delineation- would you cover elective areas like standard NPC fields or gr...
What is the preferred dose, fractionation, and role of concurrent chemo?
Does the entire bilateral BOT & ipsilateral tonsil need to be included in the elective CTV?
In an asymptomatic patient, would this be safe?Is there any reason to withhold radiation such as in the case of T1N0 breast cancer advising the patien...
In a patient with a pT1-2 oral tongue cancer resected with negative margins and with a fully negative ipsilateral neck dissection, but with indication...
Would you advise against concurrent ozone during head neck radiotherapy for a locally advanced tumor?
If so, how do you accelerate?
For a patient with pT2N0 oral tongue cancer and no other adverse risk features (no LVI or PNI), would WPOI 4 or 5 be enough to offer adjuvant radiatio...
Do you recomment MRI, CT with contrast or CT angiogram? And at what time intervals post-treatment do you perform surveillance scans?
In an otherwise healthy patient with no contributory PMH, medications and without any evidence of disease.
Does the ENE of 1 mm or less versus >1 mm as in ECOG 3311 affect your decision?
For patients who fall into the E3311 intermediate risk category s/p TORS, do you routinely treat to 50 Gy? Or do you continue to treat to 60 Gy?
Do anticipated fields affect whether extractions are required i.e., limited field glottic larynx could forego?
Do you take it to 66 Gy even in the situation of negative margins/resection of that region of bone? For example, if there is a focal bony invasion tha...
Aside from suctioning, what are other measures could be helpful?
If so, what dose/fractionation?
Pathology: High grade spindle cell sarcoma
I have seen some patients who may undergo large complex closures (sometimes as a separate procedure) for smaller lesions with resulting scars that sig...
What factors influence your decision?
How do you manage these cases differently than HPV positive cases?
Can cisplatin be used again with chemo-radiation?
How do you prioritize treatment? Would you move forward with radiation to the larynx, and if so, any modification to your treatment plan?
If you recommend or use induction chemotherapy, what is your preferred chemotherapy regimen?
Multiple disease sites have studies showing time from surgery to post operation therapy impacts clinical outcomes. Is there any evidence to suggest th...
Severe lymphopenia can develop during treatment and increase the risk of Candida/HSV superinfection, along with potential challenges for any procedure...
When starting HN radiation, which start day do you prefer to add most value to the treatment course?
Would you rather postpone treatment start to the following week if unable to accommodate your preferred start day?
What approach do you take to determine dose constraints for SBRT reirradiation of the head and neck?
Do you have formal constraints and evaluate cumulative doses on the composite plan? Do you use traditional constraints but account for repair?
After initial induction chemo, how do you choose between radiation alone or concurrent CRT?
Would you offer definitive chemoradiation and include the non-regional nodal level in your plan?
Please comment on primary tumor size, extent of nodal involvement, and other adverse features.
Any experience using phenytoin?
How would your neck coverage change (unilateral vs. bilateral, levels etc.)? Are there situations where you would cover bilateral neck for adenosquamo...
What clinical or radiographic factors would lean you in either direction - ie. time since index diagnosis, distribution or appearance of lung and noda...
Is there any role for RAI?
Would you offer RT if persistent disease despite resections?
Would you prophylactically treat any lymph nodes due to risk of possible occult invasion...
If so, what is your selection criteria? How long do they remain in place?
Do you have any dose constraints to the nasolacrimal duct?
Please comment on how you view risk factors such as T-stage, tumor grade, P16 positivity, margin status PNI, LVI etc.
What dose/fractionation and vol...
What precautions, if any, should be instituted with the prior cisplatin exposure?
Would you hypofractionate at all? Or use standard H&N doses of 70 Gy/35 fractions?
For example, initial imaging shows numerous bilateral nodal mets extending into the low neck but after induction gem/cis, originally involved nodes ar...
Our patients seem to hate the 20% benzocaine spray (cherry) saying that it burns and causes their eyes to water. Looking for other options.
Tumor factors: Neck mass, 6 cm in length, biopsy proven schwannoma. No extension into base of skull
Patient factors: No dysphagia, no dysphonia i.e. ...
Would you recommend PORT based on LVSI as the sole risk factor (i.e. pT1/T2N0 OP SCCa)?
If using cetuximab, would you recommend accelerated fractionation?
Is there a thickness cutoff you use?
What would you cover?
Is it 54 Gy or do we worry about hypoxia and need to go to 60 Gy? Does it change based on site (i.e., oral cavity versus a T4N0 larynx)?
There appear...
Please specify how your institution is allocating resources now or will be soon.
Do you take this into consideration when recommending treatment?
Margin status? Residual disease? Nodal status/ENE?
If so, what is included in that volume?
If only a few teeth, do you still wait to simulate until after the dental work?
Are you waiting until drug availability or changing to a preferred non-cisplatin radiosensitizer? If you're utilizing an alternative to cisplatin, wha...
Do you leave it in or out during sim and treatment? Any special instructions?
How much time is recommended to wait before? Does the dose or fractionation need to be modified given the flap? Does the scar need to have bolus?
For example, a pT4N0 oral cavity cancer with focally positive margins?
Would you offer full dose adjuvant radiation?
Assume excellent performance status and inability to perform further surgery on margins without causing...
After the randomized Phase IIb showed decreased mucositis, are you incorporating this agent? Please share your regimen and any tips.
No lymph node dissection. cN0
Would you treat a smaller volume than the entire tongue for small, well lateralized tumor with indication for adjuvant radiation based on nodal status...
For example pT4 and PNI, do you target the neck after a negative neck dissection?
What factors influence the decision to treat: - surgical bed alone ...
Medical Oncology did not recommend systemic therapy due to age/comorbidities. Would you consider radiation therapy? If so, what dose/fractionation?
Would you offer adjuvant radiation? Dose/volume in postop setting?
How would you recommend proceeding if there are no other actionable variants on NGS?
What are the factors, if any, that would prompt you to recommend radiation?
Low grade vs High grade?
Dose/volume?
Considering the high retropx drainage to be cranial to C1/hard palate.
If so, what is your dose constraint?
Would you alter the esophagus, trachea, and cord constraint in any way?
Would you add a sequential boost to the node? If so, what dose would you recommend?
If surgery is advised, how you would you time it with chemoradiat...
Does the time from prior RAI affect your decision?
How would you counsel the patient differently about the side effects, if at all?
Does it vary based on tumor site (oral tongue, FOM, gingiva, hard palate, etc.)?
Would you offer definitive radiation, and if so, to what volume and dose/fractionation? Would your recommendation differ depending on if repeat resect...
Is there data on efficacy or toxicity when chemotherapy is added to Proton beam therapy for head and neck cancer like there is data to support adding ...
Would you consider omitting contralateral neck radiation if this was a younger patient (i.e. <50 yo)?
In addition to positive margins, perineural/vascular/lymphatic invasion as listed by NCCN, would features such as close margins or high grade dysplasi...
According to the NCCN guidelines, there is a highly selected group of T4a glottic larynx patients that can undergo observation instead of postoperativ...
Encouraging aggressive PO intake in patients with swallowing dysfunction may place them at risk for aspiration pneumonia, especially risky if undergoi...
The patient previously underwent resection with close margins, adjuvant radiation to 66 Gy/33 fractions.
Serial MRIs demonstrate progression with con...
Are there certain portions of the mandible that you constrain more than others?
What doses do you typically utilize? How does your coverage differ from your recommendation if this was an HPV-negative squamous cell carcinoma of the...
How do you decide if/when to treat the primary disease and when would you treat definitively?
In light of recent trials showing no difference in outcomes with RT+cetuximab vs RT+IO, does this potentially lead us to use immunotherapy in cisplati...
Do you stop treatment? What if an abscess is also present?
Does your approach differ from p16 positive disease?
Assuming a biopsy shows active disease and the metastatic workup is negative, when would you off...
Assouline et al., PMID 24411632 recommend delivering 500cGy x 4 fractions = 2000cGy on days 1, 3, 8, 10. Do you follow this schedule, treat every othe...
There have been reports of pembrolizumab leading to lichen planus (my understanding is lichen planus pathophysiology unclear, but potentially autoimmu...
Does this ever affect your decision for treatment of current disease (eg likely radiation-associated sarcoma vs likely unrelated new oropharynx cancer...
Are there elective neck regions you would choose treat to high risk (ie. 60 Gy) instead of low risk (ie 54Gy) dose?
Are there risk favors that ...
If so, which nodal regions?
SCC measures 5.5 cm, 2.0 cm thickness, closest margin 0.2 cm (deep), high grade, PNI+, LVSI+. Lymphadenectomy was deferre...
Please share your institutional preference.
Do you take this into consideration when recommending treatment?
Is the radiation therapy management equivalent to similarly-staged squamous cell carcinoma? Is there a preferred concurrent chemotherapy regimen? ...
Would you treat it like an “endemic” NPX cancer with induction systemic therapy followed by CRT vs. CRT followed by adjuvant chemo vs CRT ...
Would you offer SBRT (42.5 Gy in 5 fraction regimen off trial with or without Cyberknife)?
How long after grafting do you start radiation?
Is there an optimal/recommended fractionation to preserve the graft?
Contreras et al., Phase II results suggests that elimination of PORT to the pN0 adequately dissected neck may be safe for some head and neck primary s...
Do you cover the entire ipsilateral neck or limit the field to involved nodal level(s), (assuming not chasing nerve for PNI)?
Do you ever cover the c...
Should the dose still be given after completion of RT?
After multiple failed attempts with typical radonc trouble-shooting (ativan, cutting out mask, oxygen, etc)
Would you treat lung and HN at the same time vs sequentially?
E.g. breast or H&N cancers when boosting the supraclav area.
Assuming patient is medically operable, would you always advocate for surgical dissection? If so, how to you approach post op radiation (and chemo).
...
If so, do you use it for all patients or only cisplatin doses >= 70 mg/m2? What dose of mannitol do you use?
Do you have formal constraints and evaluate cumulative doses on the composite plan? Do you use traditional constraints but account for repair?
Assuming additional workup including more extensive biopsy and nodal evaluation shows no evidence of invasive squamous cell carcinoma.
Would this cha...
Have a patient with a multi-year history of a growing substernal goiter. There is mass effect on the trachea, esophagus, and aorta. He is experiencing...
Please share your patient selection criteria and experience.A recent study in H&N patients showed superiority of the StrataXRT gel over standard o...
Hypothetically not an ideal surgical candidate due to weight loss. Both cancers are non-metastatic and resectable if disregarding other cancer and com...
What is your radiotherapy approach? How large is your treatment field, and for the leukoplakia/in situ disease, what is your dose?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice...
Juven protein powder is good for healing and helps with mucositis but has high amounts of antioxidants. Is that of concern while patients are undergoi...
Would you recommend concurrent chemoradiation (organ presrevation) vs. surgery (laryngectomy/pharyngectomy and extensive base of tongue resection) and...
If you do not use prophylaxis, what skin care strategy do you employ?
Sodium alginate, an ingredient found in ice cream, is now being used in Japan to reduce RT-induced esophagitis. Anecdotally, a daily quart of ice crea...
At what disease free interval is the safest to consider this?
Can elective nodal RT be omitted for select patients with T2-4N1 head and neck cancers with multiple commodities and poor KPS with life expectancy <...
Does your recommendation change depending on the disease-free interval?
Stage is cT4N2M0.
Would you avoid radiation/prefer surgical approach? Tighter pharyngeal constraints?
If the only indication were the parotid mets (primary site resected with no high risk features) would you treat the parotid and neck (assuming skin ca...
Is single node >3cm sufficient for you to offer radiation, or do you have a different size cutoff? What other factors (such as those listed in NCCN...
Is it reasonable to dose de-escalate since survival will likely depend on the metastatic lung cancer?
E.g. buccal mucosa, maxillary vestibule tumors
Particularly what do you levels of the contralateral neck do you include?
What factors (T stage...
Do you utilize MRI to aid in planning for oropharyngeal primaries?
Is biopsy necessary to confirm disease?
Would you include the entire parotid in the intermediate risk volume?
If pathology review is done and all imaging scans including CT scan, PET scan and MRI have come back without a primary site, is it reasonable to close...
How does this affect management?
From my review of literature, the rate of contralateral neck failures with ipsilateral radiotherapy for lateralized tonsil T1-2 N2a disease is very lo...
Do you utilize both therapies? Which should come first?
What factors may favor RET inhibition versus observation?
Would the rate of growth, number of nodes involved, size of nodes, ENE etc. affect your decision?
What volume and dose would you recommend?
Based on the results of the phase 2GORTEC study reference; Sun et al., PMID 32758455.
Which sequences/protocols do you find most useful for target delineation (primary? nodes?). Do you use contrast? If you had to choose a few to limit t...
40 yo adult patient with a~6cm mass with concern for skull base bony involvement (group III and stage III, no nodal involvement )
Do you always cover these areas of ipsilateral neck is positive? Does it depend on nodal level involved, primary site (oropharynx vs. larynx/hypophary...
Do you reduce the dose in such cases? Do you treat with six fractions per week similar to RTOG 1016 (w/ or without chemo)?
Would you always radiate? If not, when do you feel comfortable with observation after surgery?
Resected small bilateral tonsil SCC & base of tongue SCC.
The patient received 6 cycles of BEP 30 years ago for testicular cancer, and suffers fr...
Has your practice changed based on the randomized, phase 3 study showing prophylactic gabapentin is not effective?
Please share your thoughts and exp...
Apart from H&N SCC, are there times where adding an extra dose of radiation due to a tx break is appropriate? Is there a decent equatio...
How do HPV-positive patients respond to ICI compared to HPV-negative in your experience?
Would a complete pathologic response impact your dose or decision to treat in absence of studies?
If the glottic cancer is T3 due to thyroid cartilage involvement, can nodal RT be omitted?
Based on the JCO 2020 paper, how are you using this information?
I understand there is no data to change management and most of us will be hesitant t...
The 2019 ASCO guideline suggests contralateral neck radiotherapy for T3-T4 oral tongue and/or floor of mouth primary sites or tumors approaching midli...
What clinical criteria would make you prefer TORS as the initial treatment approach?
Do you offer definitive treatment?
Systemic therapy alone since it's metastatic?
Additionally, what dose constraint(s) do you use to avoid issues with vision?
Patient received full dose concurrent cis + RT previously.
How do you stage? Like nasopharynx or p16+ oropharynx?
Do you treat it like npx ca with chemo xrt + adj chemo or like opx p16+ with definitive chemo ...
Or do you only treat to IA if the primary is in an oral cavity location?
While likely dependent on the case, do you ever view CTV coverage alone as sufficient in certain areas to meet an OAR constraint such as parotids? Thi...
Has anyone tried this approach with success?
Do you treat just gross disease with margin or electively treat levels Ib-V? What if the patient is elderly and there is a pacemaker in level IV...
Is adjuvant RT necessary for a completely resected pT1/2 N0 disease with negative margins?
Aside from symptomatic disease, is there a certain growth cutoff or other criteria that would be a trigger for treatment?
The experience by Hsieh et al. from submandibular gland carcinoma shows an 11% contralateral nodal recurrence.
If you had a parotid gland malignancy ...
For example, much of the data on treatment volumes treating the head and neck with an unknown primary are from the pre-PETCT era. While the posi...
BR-001 allows treatment of oligometastatic disease in cervical lymph nodes but provides few dose constraints for SBRT in the head and neck. (Most of t...
Do you routinely include elective nodes in your radiation volume?
How, if at all, does your approach to NUT differ between various sinonasal carcinom...
Do you always radiate the elective neck in addition to the primary site?
If they had one-sided neck dissection and radiation for their prior cancer, ...
Lymph node is 4.5cm with no reported ECE. Does the size of the LN or presence or absence of ECE affect your decision?
What are the data for loco-regional and distant recurrence rates with and without local therapy? What is the OS advantage?
Would you prioritize the head and neck cancer or treat the lung cancer first with SBRT to take care of it first? How about if there is mediastinal inv...
How do you adequately balance treating a gross retropharngeal lymph node and limiting dose to the carotid? What would you quote the risk of carotid bl...
Would you elect for concurrent chemoRT or RT alone?
What dose and fractionation would you use, and would it differ from other types of H&N cancers?
Would you consider Quadshot scheme?
What are the advantages and disadvantages or using films vs. CBCT? What are you looking for in each case?
How often should you CBCT, and what are the...
Patient previously had adjuvant radiation to the tumor bed only.
What is your radiation volume and dose?
Any elective nodal levels (ipsilateral vs. ...
Or would you recommend upfront resection as long as borderline resectable?
In what situations would you advocate for orbital exenteration vs orbit sparing surgery with adjuvant radiation (particle therapy)?
What doses and constraints do you use?
What dose/fractionation would you utilize?
Is there any role of radiation therapy for these patient for symptomatic relief?
Is this necessary given that they are benign lesions?
What factors would make you consider tracing the facial nerve?
(1) How inferior would you take your level VI lymph nodes?
(2) Would you cover the TE fistula/esophagus area?
When do you start fluoride treatment?
Do you recommend definitive chemoradiation?
What is your treatment volume, dose, fractionation?
What margin would you consider to be necessary to omit radiation?
What can be done to promote wound healing?
How far down would you delay radiation?
Would you start at 6 weeks anyway if certain high risk features a...
Would you consider induction: TPF vs cis/gem or would you proceed with chemoradiation with cis/RT and consider adjuvant cis/5FU?
If so, how do you sequence it? Would you consider before adjuvant radiation vs concurrent with adjuvant (chemo)radiation vs after adjuvant radiation? ...
Addition of Cetuximab with re-irradiation SBRT in H&N Ca was mentioned previously:
https://www.themednet.org/question/1936
https://www.themednet...
What target volume (node with margin only or include other areas) do you treat and to what dose? What if patient had previous radiation?
Any concurre...
Histology 1st described 2010, and acknowledged by WHO 2017. Probably previously usually diagnosed as Acinic Cell Carcinoma. In one source (Chiosea SI ...
How would you manage a clinically suspicious (CT/PET) but undissected (ie., level V or paratracheal) lymph node in the setting of post-op RT for an or...
I am curious if anyone has tried to split the arcs in a way that minimizes dose being pumped from the outside edge of the shoulder to reach low cervic...
Would you add radiation, if so any concurrent systemic therapy?
Would you consider hypofractionation, if so, what dose/fx and reference for constrain...
Can the ASCO guidelines for oral cavity be applied to other head/neck subsites?
NCCN, ASTRO, and ASCO guidelines vary widely and depends on the prima...
Would you always/never include the initial tumor bed?
Is there a time interval or any other factors that would affect your management?
Would you add concurrent systemic therapy with radiation due to concern for field cancerization?
If no, would your recommendation change if there is obvious extranodal extension with invasion of adjacent muscle? Does p16 status affect your d...
Only when esophagus or thyroid involved? Or also when subglottis and hypopharynx involved?
How do you define the CTV border? Some commonly stated bou...
Is it essential to wait one week after loading dose of erbitux to start RT for head and neck cancer?
In the post-op setting, would you delay 1 week even if it took them out of the 6 weeks post-op window? Meaning the loading dose of erbitux was given d...
Would you have reservations in treating patients with breast, GI, or pelvic malignancies with radiation alone or concurrent chemoradiation?
For example, for a cN0 oral tongue cancer with I-III dissected with involved LN, pN1, would you use 54 Gy or 60 Gy for level IV? Or do you always take...
In primary surgical resection, ENE on surgical path would be indication to add adjuvant chemoradiation. After progression through definitive chemoradi...
What dose level do you take it to if it is a buccal mucosa/retromolar trigone?
Any additional factors that would change your decision?
Would you consider PCI?
If advanced stage do you follow same guidelines as Scc? Do you use same Cth regimen? Role of total laryngectomy ?
NCCN guidelines lists adverse features as positive margin, but does not appears to include close margin. If felt to be an indication similiar to a pos...
This has a big impact on treatment volume delineation if one schema classifies a lesion as T2 and the other leads to classifcation as a T4.
In the T4...
Leukoplakia is present throughout but no exophytic masses seen.
Is radiation an option (dose/fractionation)? Surgery? PDT?
What is your preferred concomitant chemotherapy FOLFOX? Carbo-Taxol?
Which dose would you give? SIB?
Have you found any of the more common medical treatments (chlorpromazine, baclofen) to be most effective in the setting of throacic radiation or head ...
Any experiences using 50/20 with a break, or 30/5 in the adjuvant setting?
At what point do you hold surgery and switch to definitive chemoradiation?
What is your treatment volume?
If additional surgery is preferred, do you...
Consider 6 fractions weekly chemoRT? Add cetuximab to chemoRT? Proton boost? Induction chemo prior to chemoRT? Interstitial H&N brachytherapy boos...
What constraints do you use if using IMRT/VMAT?
What constraint to the repaired carotid artery and bovine pericardial tissue used to patch the defect? How long should we wait from surgery to start o...
Does your recommendation change if the patient is elderly?
Dose/fractionation/volume?
Systemic therapy?
Are there factors that would make you worry about occult separate primary?
For example, in a small, well-lateralized tonsilar cancer presenting with ...
What dose limits do you use and in which situations will you exceed them? How do you counsel your patients on risk of severe trismus and how do you ma...
Do you limit the delineation to the initial tumor bed, or do you delineate the whole body of the flap (eventually sparing the pedicle of the flap)?
A...
PMH O'Sullivan et al used 50Gy/20fx or 60Gy/25fx
https://pubmed.ncbi.nlm.nih.gov/18707828/
Or extrapolate from SCC larynx using 2.25Gy/fx to 63-65.2...
Would gross ENE or R1 resection trigger you to consider adding chemo? If so, do you use weekly cisplatin or cisplatin/etoposide?
Are there situations where you skip radiation despite risk factor(s) commonly listed or do you always give adjuvant radiation?
For example, for FOM p...
Would you do IMRT or 20MeV/6MV electron/photon mix (traditional moustache field)?
When do you treat LNs? T3/T4?
What LN levels would you include? le...
In addition to TSH suppression, would you opt for RAI, targeted treatment based off NGS, or lenvatinib?
Can you comment on fractionation schedules with and without chemotherapy or immunotherapy.
NCCN list T3 as an indication for PORT for all head/neck subsites including supraglottic larynx with the sole exception of glottic larynx. (Some other...
Have you seen worse toxicities in these patients?
Degree of subglottic extension is often difficult to determine from office scope examinations and ENTs do not always include this. Do you have any tip...
Are you employing more or less primary chemoRT v. surgery for some cancers? Are you dose de-escalating? What are issues radiation oncologists should b...
Older data suggests that local control with RT alone for supraglottic tumors >6cc is fairly low.
Would you employ altered fractionation (what dose...
What levels would you cover and to what dose?
If so, do you have a threshold for number of involved sites i.e. X lesions in Y organs, etc.
What is your general approach to this rare histology?
If proton therapy is not available would you consider radiosurgery?
How would your management differ if residual disease is present?
How does your setup differ from oral cavity cases?
Definitive RT only?
Concurrent chemo-RT?
Technique, dose (for radiation and chemo, if any), fractionation?
Would you observe or radiate?What volume, dose, fractionation would you use?
Systemic therapy?
A HA-WBRT patient developed brisk mucositis on the soft palate at fraction 8/10
How do you decide on other chemo regimen? (Dosing, frequency, carboplatin based, non-platinum based etc.)
Would you use Cetuximab?
Altered fractiona...
In the case of a nodal mass of several nodes matted together due to ENE but without apparent ENE at the surface, does your management change?
Is ENE ...
In a case with negative margins, T1-2 primary, no ECE, no perineural invasion, etc, is adjuvant radiotherapy indicated based on N2a stage?
Is the approach similar to squamous cell carcinoma?
How can this be done logistically to coordinate the proton boost off site? Should everything be done up front? How are the logistics regarding plannin...
Would you spare contralateral neck?
Does your recommendation change depending on p16 status?
Do you alter treatment and/or fractionation?
Are there increased concerns of infection or fistula formation with such nodes?
Would there be any indication for postoperative RT if cervical lymph nodes are negative?
Would you use general sarcoma expansions or would smaller expansions like the ones in head and neck would be reasonable?
Is surgery still indicated? If no surgery is pursued, (how) would you deliver consolidative radiation therapy?
Is there data to show efficacy of radiation in this situation? What dose/fractionation/volume?
Any dental extraction of the mandible could lead to healing problems and thus delaying reirradiation.
Is there data to support every 3 week dosage v. weekly?
https://ascopost.com/news/march-2022/postoperative-weekly-vs-every-3-week-cisplatin-i...
What would be your radiation dose and target volumes? Concurrent chemo? Would you offer neck node radiation if no neck dissection was done?
Do you encourage patients to take a break from/stop taking Fosamax or similar medications for their osteopenia or osteoporosis in order to prevent dev...
What if this recurrence is not resectable?
Does the availability of first line checkpoint inhibitor therapy affect your treatment decision?
Do different modalities of imaging (PET vs MRI vs CT) help you to distinguish one etiology versus the others? What about other clinical characteristic...
The traditional 2-field parallel opposed field technique irradiates the whole larynx to the same dose and includes unaffected structures.
This ...
i.e. T4 sinus tumor with advanced orbital invasion? Would your opinion and approach change in the event the patient responds favorably to neoadjuvant ...
Please see this article for referrence https://www.sciencedirect.com/science/article/pii/S0167814020301638
Aside from smoking cessation, what interventions have you found useful to manage patients with chronic symptomatic laryngeal edema? Steroids seem to b...
Didn’t 0129 establish no difference between conventional vs Accelerated RT with the same Cisplatin regimen? Are there still thoughts of benefit ...
Such as in patients who are elderly or have borderline performance status
How would you approach a patient who is receiving chemoRT but has confirmed COVID-19 with minor symptoms, as breaking treatment for 2 weeks quarantine...
For example, a patient with SCC of the H&N and has a lung mass that is SCC, would these be two separate primaries or metastasis? What is the best ...
For instance, VMAT planning can sometimes deliver very low doses to the contralateral base of tongue. Do you worry about this? What is your approach?
If so, what dose fractionation and field is recommended?
Is there data for weekly versus every 3 week cisplatin in this setting?
Would you offer adjuvant TKI to patients with locally recurrent multifocal adenoid cystic carcinoma?
For example, for a patient that has been through multiple disfiguring surgeries and radiation and wants to delay time to next resection.
Please comment specifically on fillings, crowns, and implants.
How do you advise your patients on toxicity?
Do you start with TKIs or platinums?
Sometimes wound healing can delay adjuvant radiotherapy by several months. For aggressive histology, such as high grade sarcomas or skin cancers with&...
Specifically with reference to rural settings where the logistics of early in the week delivery may be more challenging.
Patient had superficial parotidectomy, with negative margins. No nodes on imaging. Specifically, treat parotid bed alone? Add nodes if N0 on scanning?...
How long do you allow for response before deeming it suspicious for residual disease?
What work up (imaging, biopsy) do you recommend?
How do you sa...
If so, how do you address the Joint Commission's cleaning requirements? The Joint Commission recently inspected our hospital including the radiation o...
Benzodiazepines are not ideal in this population. Are there superior alternatives, perhaps antipsychotics, that are effective and superior?
If re-resection would yield negative margins, is observation appropriate? Does the presence of focal PNI push you toward adjuvant RT (without re-resec...
Do you routinely employ dental wax? Does it depend on the material (titanum vs. other)? Do you take the extra time to replace metal with porcelain whe...
For example, HPV+ SCC in a single level II node
How do you account for the change in tumor volume? Do you use pre or post-chemo volume?
Do you alter dose based on response?
-The data on induction for adult H&N ca has been mixed (excluded NPX) but recent data suggest a benefit for adult NPX.
-Given that this is standa...
For what is clearly a oropharyngeal primary, with clear extension up the soft palate and into the nasopharyngeal lateral wall, should the intermediate...
p16 positive vs negative?
Patient initially was started on cetuximab due to renal insufficiency of unclear chronicity (uncontrolled hypertension) that significantly improved du...
Do you recommend for EUA/biopsies/tonsillectomies to look for primary as well as neck dissection (at the same time to save a trip to the OR), or attem...
Although platinum/5-FU was used in KEYNOTE-048, can an alternative like carbo/paclitaxel be given since it may be better tolerated?
Given not surgical candidate and within 1 year of chemoRT (recurrence within RT field), would you repeat chemoRT, RT alone, or systemic therapy alone?...
Assuming the answer is quite low, the next question is why?
Is there any literature on the safety of giving radiation to patients with scleroderma in H&N setting?
Do you favor tongue depressor instead? Does this change based on what primary you're targeting (i.e. base of tongue)?
NCCN suggests either concurrent chemoRT or induction chemotherapy in these patients.
Does your approach differ by EBV status?
Provided that staging PET/CT showed no residual disease or neck involvement, would you recommend completion surgery and neck dissection? Or do you vie...
If so, which levels? Bilateral? What about parotids or submandibular gland?
Custom devices with dentistry can be cost-prohibitive.
Would you recommend surgery, definitive chemoRT, or chemotherapy alone?
Should this be part of the follow up?
Aggressive histology with tall cell variant papillary thyroid carcinoma that's progressed 2 months after RAI and while on TSH suppression, without tra...
Let's re-open the debate!
This is an uncommon clinical scenario where textbooks suggest to cover the primary tumor and elective coverage of levels II-IV
Do you cover any addit...
In a patient with indication for adjuvant radiation (ie. positive margins) after surgery without recurrence, when would you opt for observation only, ...
What factors do you consider in offering adjuvant radiation to the primary and/or elective nodes in nasal SCC?
What volumes would you cover?
Some ENTs advocate for a neck dissection as a way to avoid chemotherapy if there is a high chance there is no ECE. This is without removing the primar...
Would you proceed with induction chemotherapy (eg TPF or cis/gem) to downstage or neoadjuvant chemoRT? Would your approach be different if there is or...
Have you seen RAI or lenvatinib be efficacious for locally advanced disease — allowing for better surgical outcomes? Do you utilize EBRT?
Is there a time cutoff where there is no longer a benefit to adjuvant radiation and you recommend reserving radiation only in case of recurrence?
Sim...
Do you use same contour guidelines of nasopharyngeal cancer?
What levels would you cover on the involved neck side? When would you electively cover t...
For example, when a patient has received 60-70 Gy with concurrent chemotherapy, do you consider dmax, BED, and interval between repeat courses of trea...
Does the full dissection with no LN mets allow sparing PORT to the contralateral side?
If neck dissection was done, do you offer adjuvant chemo and/or XRT?
If not, how long would you wait between chemotherapy cycles to give treatment?
What field size and dose/fractionation would you use?
Would you treat lymph nodes?
Most of the literature experiences seem to focus only in the recurrent settings.
If clinically node negative, would you add elective nodal radiation?Does it depend on location (upper vs. lower trachea)?
Is there a role for an altered fractionation regimen as an organ-preservation approach?
This pathological variant is uncommon and the older literatur...
Do you routinely adjust margins to account for internal target motion?
NCCN Guidelines do not address this rare form of H&N cancer.
What dose/fractionation would you use for definitive radiation? Is elective nodal co...
Is there an age in which you would not offer definitive treatment?
How do systemic therapy options, dose, and field sizes change with age of the pati...
Per NCCN, treatment options include endoscopic resection (preferred) or definitive RT. The recommended dose is 60.75 Gy in 27 fractions for in-situ vs...
Do you have a time threshold for re-challenge with platinum? Of note, Checkmate 141 defined platinum refractory as relapse within 6 months of pl...
What dose and fractionation would you use. What is your target volume?
For the first treatment day (during combined chemo/XRT courses), is it ok to give XRT first then send the patient for chemo or should the chemo be giv...
If so, what high risk features would influence your decision? Would + margins, PNI, LVSI etc be reason to treat LN? If you would treat lymph nod...
Acknowledging the mixed data, would you feel comfortable that radiation could compensate for the R1 margin? Would you push the surgeons to re-resect?
Please share your tips on dealing with short and long term xerostomia.
How do you balance the goal of effective definitive treatment while minimizing the risk of injury to critical structures?
Do you modify your dose based on p16 or extent of ECE (e.g. microscopic vs macroscopic)?
Do you prefer covering bilateral neck in all cases or do you make exceptions?
There appears to be conflicting opinions in the literature:
https://ww...
What about in the metastatic and non-metastatic setting, specifically? Any additional treatment (dose/fractionation) or toxicity considerations for th...
Surgical salvage is indicated but not possible in all cases due to comorbidities or patient preference.
Would you re-irradiate and how?
Would you co...
Do you ever start radiation +/- 24-48 hrs from C1D1 for chemotherapy due to logistical barriers?
Do you prefer chemotherapy to start at beginning of ...
Is concurrent chemotherapy necessary for these patients?
The surgical bed created by reconstruction is often quite larger than the surgical bed from tumor resection and neck dissection.
Does the histology (primary salivary gland vs metastatic squamous from a skin primary) affect your decision making?
Any other factors that influence ...
Are there any general principles you apply for how far to track along a given nerve in either direction?
If you would re-irradiate, what dose/fractionation would you use? What systemic therapy would you use concurrent with treatment, if any?
If so, what dose constraints do you use?
Does papillary histology influence your decisions regarding surgery, chemo, radiation dose or nodal coverage?
Routinely? Only with oropharyngeal cancer etc.? Given that low expression of EGFR subset did better, do you believe there is a true benefit in cetuxim...
Is it preferable to do HPV RNA FISH testing or p16 immunostain testing to determine HPV status? Is one test more accurate than the other? &...
Do you routinely offer definitive head and neck chemoradiation and aggressive local therapies to the oligometastatic sites?
Patient's with Fanconi's anemia can have severe/fatal toxicity with chemotherapy and radiation but unfortunately can also present with aggressive head...
Because patients with locally advanced H&N cancers are at increased risk for aspiration, and radiation may increase that risk, some clinicians rem...
Would you offer locoregional control alone, locoregional with adjuvant therapy, or active surveillance?
At what point would you consider the treatment break to be too long for curative treatment?
If so, what dose would you use?
Do you have concern for aberrant lymphatic drainage?
Do you cover more generously (ie. add IB/V on the contralateral cN0 neck etc.)?
What are your criteria for inclusion of the retropharyngeal LN in node negative H&N cancer patients?
Aside from Other nasopharyngeal ca patients and those with cancers of the posterior pharyngeal wall, how do you contend with risks of dysphagia w...
Would you treat all cases or only select risk factors (T4, N+/ECE, margin+, LVI etc.)? What would you treat? Would a negative neck diseect...
Which of the systemic options would you give concurrently with radiation therapy in the adjuvant setting? According to NCCN guidelines, high dose...
The new AJCC staging factors in HPV status and can drastically alter a patients overall stage group, hence dramatically change definitive treatment re...
The NCCN guidelines give the option of "consider systemic tx/RT" for "other factors," what do you consider as other factors? For example: close margin...
If the oropharyngeal cancer is operable (ex T1N1), would would your preference be upfront surgery?
Would you use chemoradiation therapy to bo...
In the context of the new staging systems and possible differences of HPV mediated vs smoking mediated oropharynx SCC, would you ever not recommend co...
If treating the H&N first, would you anticipate some effect of chemo on the rectal cancer? Would you include 5FU in the H&N chemo for be...
Is conventional fractionation acceptable, or would you use altered fractionation (DAHANCA, SIB, BID etc.)?
The reports I've read indicate a fairly high rate of local recurrence and wanted to see if any can give guidance on this fairly rare tumor.
Should any additional anatomical areas be intentionally included in CTV-P2 if it goes beyond the "5+5" expansion? The text (found here:https://www.ncb...
Is close margins <=1mm alone enough to warrant adjuvant radiation?
What about other factors such as p-Staging, PNI, LVI etc.?
Do you routinely screen for pituitary dysfunction after radiation therapy for nasopharyngeal cancer?
Studies have shown increased rate of endocrine dysfunction in these patients:
https://www.ncbi.nlm.nih.gov/pubmed/26011172
https://www.ncbi.nlm.nih....
Do you still treat with definitive radiation and counsel about the risk of osteoradionecrosis? Or consider a palliative approach?
In the case where patient history and pathology markers are uninformative to distinguish oral cavity vs oropharynx, do you tend to favor up front surg...
Would you recommend chemo alone first? Would you treat with definite chemo-RT to the lung then the head/neck or vice versa?
How would this chan...
How would you use the information regarding extent of ECE? What if the patient was HPV negative? What is the impact of systemic therapy on...
For example, do you ever offer adjuvant RT for pT2N1 SCC of BOT without any of the above adverse features?
There have been some retrospective studies in the literature describing recurrences in the the site of a temporary trachoestomy for head and neck mali...
Would you treat a T2N0 high grade neuroendocrine carcinoma of the nasal cavity after a R1 resection?
Would you prophylactically treat LNs as well?
Is so, what lymph node regions would you treat if it arose from the sphenoethmoidal recess?
When would you use EBRT? What dose should be used and what extent of nodal treatment should be included? Is there a tracheal dose constraint?
Is any further imaging warranted or is clinical surveillance sufficient? Do you recommend a repeat PET at a year (PMID: 28854069) or beyond...
Is there any evidence that this improves outcomes over a more simple and cost effective follow up of careful physical examination and checking a perio...
Is there strong evidence to guide this decision?
Any role for endotracheal brachytherapy? If so, how long after laser treatment would it be safe to use endotracheal brachytherapy and at what dose?
In the new AJCC 8th edition, p16+ downstages many patients from what used to be stage IV. Should the adjuvant therapy for these patients be de-escalat...
Do you always take scar to full dose or do you use specific criteria (e.g. ECE or LVI) to determine dosing and coverage? Do you routinely bolus with I...
How does it vary based on disease site, lymphatics involvement, emergent vs. non-emergent trach etc.?
Is there any experience with radiation therapy?
How does your dose/fractionation vary for patients with and without prior radiation?
How do you decide on the treatment volume? In particular, how do...
A retrospective review of the use of adjuvant radiation in the recurrent setting for pleomorphic adenoma of the parotid gland reported a 20 year actua...
If you leave it in, do you still use bolus?
Would the risk of secondary malignancy affect the decision?
What dose-fractionation schedule and treatment volumes would you utilize for adjuvant radiation therapy status-post total parotidectomy with negative ...
For pN2b disease after bilateral neck dissection, is PORT to the negative side of the neck indicated?
Do you have a KPS or other cutoffs that would deter you from using accelerated fractionation due to concern for toxicity?
What factors would push you to consider using IMRT vs opposed lateral fields for a T2N0 glottic SCC?
Would having supraglottic extension lead you to use IMRT?
Would you insist that they shave or cut the beard? Is there a way to make the simulation reproducible without removing the beard?
Would you consider altered fractionation in a postop patient who has ECE or positive margins but is refusing chemotherapy?
Do you have a max dose constraint for PTV? Volume receiving dose higher than prescription? There seems to be variation among RTOG protocols from max d...
Do you consider this a positive margin? Would you boost this area to a higher dose? Would you recommend concurrent chemotherapy in the abs...
If not, what is your thyroid hormone withdrawal protocol? If so, would you still treat a patient with possibly metastatic disease?
The Phase II Austrialian study mentioned here only specified a spinal cord constraint of 28Gy in 8 fractions. Should other normal tissue constrai...
Specifically, the cheek? If so, which nodes should be treated and to what dose?
If a patient has undergone wide local excision with residual disease, but negative margins, is it safe to observe? If adjuvant treatment is indicated,...
Aside from relocating the generators, does anyone have any experience or knowledge about tolerance of the devices?
Are there dose-response studies establishing 70Gy is the optimal dose for gross tumor control, or is it simply thought to be the maximally tolerated d...
Is there data to support that surgery works better than chemo-RT in p16 negative patients?
For example, a larynx primary with direct extension to medial pyriform sinus?
Would you recommend a mastectomy for her breast cancer in attempts to avoid RT? If the patient undergoes a lumpectomy or needs PMRT, would you a...
Especially in patients who are not candidates for chemotherapy, what dose and fractionation should be applied given the fact that hyperfractionation w...
For an N0 patient with locally advanced (T4a) SNUC of the ethmoid sinus, would you include elective cervical lymph node irradiation? If so, what...
If a holiday falls during the week do you treat all patients, a select subset of patients (i.e. cervix, head and neck) or give everyone the ...
Do you ever hold treatment? Would you consider any of the following: decongestants, anti-inflammatories (e.g. steroid burst), antibiotics, or myringot...
Do you typically use 5-FU/cisplatin/cetuximab, or do you prefer other options?
Would you include the surgical scar? If so, what margin around the scar would suffice?
We have seen a lot of patients referred to oral surgeons who insist all their teeth are in poor shape, leaving these patients edentulous.
What do you...
Any up to date interventions? Which expectorants have been effective?
Do you have any rules of thumb regarding amount of weight loss, a percentage change in the size of the primary/node, or the fit of the mask?
Following Mohs surgery and in the absence of other high risk features, do you offer RT for any PNI? A single nerve < 0.1 mm? A single ne...
If so, is the time different based on intermediate (T4, N+, LVI etc.) vs high (ECE, +Margin etc.) risk indications for adjuvant RT?"
If so, when? Although anemia is associated with worse local control in HN cancer, I don't know of any data that shows that blood transfusions can help...
What about Lv V and VI?
Do you treat patients who are clinically hypothyroid but biochemically euthyroid?
Do HPV and/or PD-L1 status influence your decision making?
Does it make a difference if you place the bolus above or below the mask?
Specifically, what arguments can be made for or against upfront neck dissection in patients who present with necrotic neck nodes? How would the ...
Does the better prognosis associated with p16+ H&N cancers relate only to patients who are treated with RT +/- chemo? Or do they do better in...
If a patient had a recurrence that was pathologically proven despite negative idodine scans, what imaging scans would you follow up with for surveilla...
Should post-op RT be offered to patients after a recurrence in the cervical lymph nodes after a neck dissection?
In the case of a partial resection with focal perineural invasion, but no lymphadenectomy due to severe fibrosis from prior radio-ablation for hyperth...
Does your postop dose change or use of chemo change if you have close margins?
What dose would you boost to in each situation?
Is RAI sufficient in cases of +margin but negative post-op iodine scan? In cases where there was no pre-op radioactive iodine scan to ensure iodi...
What are the contraints you look for?
In this circumstance is their any evidence that indicates a locoregional control benefit to PORT?
Is there a hypofractionated dose regimen that would be suitable for palliation prior to the patient going to hospice?
If so, what is your treatment volume?
For example: Initial primary of early stage completely resected oral cavity or oral tongue cancer with no adverse features and therefore did not get r...
Is modern surgical/reconstruction treatment superior to radiation therapy?
If contact brachytherapy or superficial (orthovoltage) therapy isnt possib...
For elective target volumes it makes sense in most cases to pull in the PTV 3-5mm from the skin for planning, but for gross disease close to the skin ...
After a wide excision for a <3mm lesion, flap reconstruction and selective neck dissection and no initial PNI, residual tumor, or positive ymph nod...
Since the Bonner trial only found a benefit to the combination of cetuximab with the concomitant boost arm, do you routinely recommend this fractionat...
If so, when is the right time to obtain this? Are there situations when you recommend postop MRI ( for example, for patients with a large reconstructi...
Conversely, should OARs be kept within contraints if it requires dose compromise on these high risk CTV structures?
Even if there is a gap, it is dosimetrically hard to spare that little strip.
Particularly the old T2b with sluggish cords and rather diffuse involvement? The data is mixed with regard to hyper- fractionation, vs. hypo-frac...
What dose and volume would you use?
Do you treat the enlarged PET negative nodes to the high risk dose as well?
In a patient with recurrent SCC in the neck s/p ***remote*** partial glossectomy (R0, 6 months ago), who is now s/p neck dissection for gross disease ...
After a nerve sparing parotidectomy, would you offer postoperative radiotherapy? If so, what volume and dose? Would it change your management if the p...
Do you prophylactically treat the entire parotid gland as well?
It seems that postoperative RT is indicated to help improve local control (based on small series from MD Anderson and Mayo Clinic). What areas s...
Do you pre-medicate with steroids?
For a T3N0 SCC of the larynx with PET/CT showing negative cervical nodes, but with CT neck showing a 1.5cm level II cervical node, to what dose to you...
Our ENT surgeons often tell patients with evidence of matted nodes on imaging that their swallowing function will be much worse after 70Gy as compared...
Do the level II lymph nodes need to be covered for T2 SCC of the retormolar trigone if it is completely resected but has close margins?
Definitive chemoradiation vs. surgery followed by adjuvant radiation/chemoradiation?
In contouring base of tongue, tonsil, larynx and other H+N tumors, the CTV and PTV will frequently encroach on the posterior pharyngeal wall. I'd appr...
Is there a benefit to IMRT when we treat to relatively low doses (as compared to squamous cell cancers of the head and neck)?
Additionally, what lymph node levels do you typically treat?
What dose and fractionation is appropriate for medullary thyroid carcinoma with extrathyroid extension, bilateral cervical lymph node levels 2-5 with ...
For example, for a tumor arising from the true cord and extending superiorly to false cord and inferiorly to subglottis with mobile vocal cords?
For example, if there is extensive ipsilateral lymph node involvement and extracapsular extension for a submandibular gland tumor?
Even though we do not have the best data on the use of induction chemotherapy, what are current practices?
Is your practice different between HPV+ an...
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