Radiation Oncology

Head and Neck Cancers   

Questions discussed in this category



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?

Would you have reservations in treating patients with breast, GI, or pelvic malignancies with radiation alone or concurrent chemoradiation?

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. 

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...

Consider 6 fractions weekly chemoRT? Add cetuximab to chemoRT? Proton boost? Induction chemo prior to chemoRT? Interstitial H&N brachytherapy boos...

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 ...

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...

From my review of literature, the rate of contralateral neck failures with ipsilateral radiotherapy for lateralized tonsil T1-2 N2a disease is very lo...

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 ...

Does your recommendation change depending on the disease-free interval?

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 ...

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...

Would a combination of other adverse features such as PNI, GIII, close margin, multiple positive nodes, T4 disease and others make you recommend chemo...

Sometimes wound healing can delay adjuvant radiotherapy by several months. For aggressive histology, such as high grade sarcoma or skin cancers, is th...

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...

I have a patient with metastatic NSCLC and a concurrent head and neck primary.

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...

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...

 Assuming the answer is quite low, the next question is why?

Do you favor tongue depressor instead? Does this change based on what primary you're targeting (i.e. base of tongue)?

MD Anderson 5 year data was published earlier this year. would also like to know how those who are using IMRT approach planning and constraints.

Provided that staging PET/CT showed no residual disease or neck involvement, would you recommend completion surgery and neck dissection? Or do you vie...

Our patients seem to hate the 20% benzocaine spray (cherry) saying that it burns and causes their eyes to water. Looking for other options. 

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...

What clinical criteria would make you prefer TORS as the initial treatment approach?  

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...

Degree of subglottic extension is often difficult to determine from office scope examinations and ENTs do not always include this. Do you have any rul...

Have you seen RAI or lenvatinib be efficacious for locally advanced disease — allowing for better surgical outcomes?  Do you utilize EBRT?

How do you decide?  Do the results of recently published phase III data in the Lancet Oncology (Sun et al, Sept 2016) influence your decisio...

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...

What field size and dose/fractionation would you use? Would you treat lymph nodes? 

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...

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...

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...

Do you have formal constraints and evaluate cumulative doses on the composite plan? Do you use traditional constraints but account for repair? 

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...

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...

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 ...

If you would re-irradiate, what dose/fractionation would you use? What systemic therapy would you use concurrent with treatment, if any?

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...

At what point would you consider the treatment break to be too long for curative treatment?

Do you have concern for aberrant lymphatic drainage? Do you cover more generously (ie. add IB/V on the contralateral cN0 neck etc.)?

In an asymptomatic patient, would this be safe? Is there any reason to withhold radiation such as in case of T1N0 breast cancer advising patient to n...

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...

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...

Do you always cover these areas of ipsilateral neck is positive? Does it depend on nodal level involved, primary site (oropharynx vs. larynx/hypophary...

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...

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...

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.?

Studies have shown increased rate of endocrine dysfunction in these patients: https://www.ncbi.nlm.nih.gov/pubmed/26011172 https://www.ncbi.nlm.nih....

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...

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 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...

Such as those meeting the eligibility criteria for NRG HN002, <10 pack years, HPV+ T1-2N1-2b, T3N0-N2b

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...

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.?

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...

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?  

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?

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...

Have you found any of the more common medical treatments (chlorpromazine, baclofen) to be most effective in the setting of throacic radiation or head ...

For an N0 patient with locally advanced (T4a) SNUC of the ethmoid sinus, would you include elective cervical lymph node irradiation?  If so, what...

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...

Do you reduce the dose in such cases? Do you treat with six fractions per week similar to RTOG 1016 (w/ or without chemo)?

Do you ever hold treatment? Would you consider any of the following: decongestants, anti-inflammatories (e.g. steroid burst), antibiotics, or myringot...

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...

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...

Do you treat patients who are clinically hypothyroid but biochemically euthyroid?

Specifically, what arguments can be made for or against upfront neck dissection in patients who present with necrotic neck nodes?  How would the ...

Should lymph nodes ever be targeted?  If bone invasion or erosion is present, and surgery is not feasible, is radiation appropriate and to what d...

I have seen some patients who may undergo large complex closures (sometimes as a separate procedure) for smaller lesions with resulting scars that sig...

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?

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...

Is there a hypofractionated dose regimen that would be suitable for palliation prior to the patient going to hospice?

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...

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...

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...

In a case with negative margins, T1-2 primary, no ECE, no perineural invasion, etc, is adjuvant radiotherapy indicated based on N2a stage?

Conversely, should OARs be kept within contraints if it requires dose compromise on these high risk CTV structures?

Particularly the old T2b with sluggish cords and rather diffuse involvement? The data is mixed with regard to hyper- fractionation, vs. hypo-frac...

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 ...

What is the preferred dose, fractionation, and role of concurrent chemo? 

After a nerve sparing parotidectomy, would you offer postoperative radiotherapy? If so, what volume and dose? Would it change your management if the p...

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...

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...

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? 

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)?

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?


Papers discussed in this category


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Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2014-09-20

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