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.)
A2:
cT1N0M0, stage I (AJCC 2006)
A3:
pT1(1.8*1.2*1.2cm)N0(0/29)M0, stage I (AJCC 2006, 2007/08)
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)
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)
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: 6300-6660 cGy in 35-37 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. ????
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 air-contrast 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 head-and-neck cancer patients. The cancer-field theory supposed that the whole upper aero-tract 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.?
A8:
A case with free surgical margin (R0 resection) but with very close cutting end in head-and-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
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Radiation Oncologist
Hon-Yi Lin 2008/09/08 |
