How to Manage a Case of Stage-I Oropharyngeal Cancer with Very Close Cutting End Post-Operatively?

Transcription

1 How to Manage a Case of Stage-I Oropharyngeal Cancer with Very Close Cutting End Post-Operatively? Case Number: RT (M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor Purpose: To present and discuss how to manage a case of stage-i oropharyngeal cancer with very close cutting end post-operatively Scenario: You are radiotherapy (RT) Intent Doctor/Special Nurse/Resident Doctor, and you are assigned to evaluate the following patient before visiting of your RT attending physician. Please review the following description carefully; your RT attending physician will visit this patient later and discuss with you after your review. Case Presentation: This patient, 朱 OO, came to OPD for 'oropharyngeal cancer post op for RT assessment'. S: A case of oropharyngeal cancer s/p op, pt1n0m0, stage I, was referred from ENT section to us for post-op RT evaluation. Review of symptoms: low back pain for months O: ECOG: 1, ambulatory status, speech: OK PE: not seen the Uvula; three blue stitches over the residual soft palate region <1>. Pathology report in 2007/08: 1. OP method: wide excision and bilateral selective neck dissection; 2. tumor size: 1.8*1.2*1.2 cm; 3. tumor type: squamous cell carcinoma; 4. tumor differentiation: moderately; 5. tumor location: oropharynx and uvula; 6. depth of tumor invasion: submucosa; 7. tumor involvement: oropharynx and uvula; 8. bone: not available; 9. margin: free; 10. tumor distal to the nearest resection margin: less than 1 mm; 11. LN: negative ( right level Ib,I,III: 0/13; left level Ib,I,III: 0/16); 12. extracapsular spread of LN: (-); 13. lymphatic permeation: (-). 14. vascular permeation: (-); 15. perineural invasion: (-); 16. submandibular gland: (-); 17. skin: not available; 18. tumor staging: pt1n0mx (AJCC, 2002). <2> CXR in 2007/08: neg <3> Neck CT in 2007/08: pending formal report <4> neck wound: some inherence was found <5> bone scan: not available <6> ABD sono: not available

2 Key Image(s): Fig. 1. CXR Fig. 2. Panel A. Neck CT Fig. 2. Panel B. Neck CT, Uvula level

3 Questions & Discussions: (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? (After your RT attending physician discussed with the radiologist by telephone, the radiologist confirmed preliminarily that no distant metastases were found based on the neck CT films, including visible lungs and ribs & spine, and he said that some mucosa thickness over the oropharynx with multiple small LNs were found. Please further answer the following questions.) Q2: What is your clinical cancer stage, according to the AJCC 2006, for this Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this Q4: What are your Oncology Diagnosis and/or other Assessments for this Q5: What is your Oncology Plan for this Q6: What is your Radiotherapy Plan for this (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) Q7: Why the air-contrast technique was used in this patient in his neck CT examination? Q8: How to manage a case of stage-i oropharyngeal cancer with very close cutting end post-operatively?

4 Questions & Discussions: (with potential answers) (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? A1: As described in the last attached page. (After your RT attending physician discussed with the radiologist by telephone, the radiologist confirmed preliminarily that no distant metastases were found based on the neck CT films, including visible lungs and ribs & spine, and he said that some mucosa thickness over the oropharynx with multiple small LNs were found. Please further answer the following questions.) Q2: What is your clinical cancer stage, according to the AJCC 2006, for this A2: ct1n0m0, stage I (AJCC 2006) Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this A3: pt1(1.8*1.2*1.2cm)n0(0/29)m0, stage I (AJCC 2006, 2007/08) Q4: What are your Oncology Diagnosis and/or other Assessments for this A4: Squamous cell carcinoma, moderately differentiated, of the oropharynx, Uvula and the left soft palate, ct1n0m0, stage I, post wide excision and bilateral upper-neck selective LNs dissection (2007/08), pt1(1.8*1.2*1.2cm)n0(0/29)m0, stage I (AJCC 2006, 2007/08), with very close cutting end (<1mm) Q5: What is your Oncology Plan for this A5: 1. Arrange Bone scan and abdomen sono for further survey. 2. Refer to DEN section for pre-rt evaluation 3. Arrange post-op CCRT for further adjuvant therapy due to high risk for local failure of very close cutting end (< 1mm) Q6: What is your Radiotherapy Plan for this (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) A6: RT Plan may be designed as the following one: (1). Indication: post radical surgery with very close cutting end of less than 1 mm. (2). Goal: potentially curative in post-op CCRT setting. (3). Target & Volume: primary tumor bed and bilateral neck irradiation. (4). Technique: IMRT (5). Dose & Fractionation: cgy in fractions in the highest risk region; 5940 cgy in 33 fractions to the middle risk region; and, the 5040 cgy in 28 fractions to the lowest risk region. Q7: Why the air-contrast technique was used in this patient in his neck CT examination?

5 A7: In the head-and-neck images studies, either CT or MRI, the air-contrast technique was used for intending to well evaluate the lesion on the buccal mucosa. In this case, the aircontrast technique was ordered also under the intention of well survey in the patient s buccal mucosa. This work-up consideration is based on a cancer-field theory in headand-neck cancer patients. The cancer-field theory supposed that the whole upper aerotract mucosal region bears the same risk factors in the same patient, such as cigarette smoking and drinking; therefore, the same cancer induced risk will be found, either in uvula and buccal mucosa in this case. Q8: How to manage a case of stage-i oropharyngeal cancer with very close cutting end post-operatively? A8: A case with free surgical margin (R0 resection) but with very close cutting end in headand-neck cancer disease, including oropharyngeal cancer, needs to be treated aggressively as a potentially positive cutting end (R1 resection). As R1 resection, both re-operation of salvage surgery and post-op concurrent chemoradiotherapy are suggested. Further Readings & References: NCCN 2008 & AJCC 2006 Radiation Oncologist Hon-Yi Lin 2008/09/08

6 Key Image(s): (with marked) Fig. 1. CXR Fig. 1 CXR: unremarkable findings; no noted lung and ribs/bone metastases. Fig. 2. Panel A. Neck CT Fig. 2. Panel A. Sample: 1. The air-contrast technique was done (as the short white arrows). 2. Multiple small LNs over the bilateral level II are not easily differenced from normal vessels in this poor-contrast CT film (as the white arrow heads). Fig. 2. Panel B. Neck CT, Uvula level Fig. 2. Panel B. Neck CT, Uvula level: Moderate soft-tissue predominant of the Uvula, c/w oropharyngeal carcinoma with uvula invasion (as the long white arrow).