BEPERKEN VAN DE BESTRALING TOT EENZIJDIGE HALS MIDDELS SPECT-CT ONCOLOGIE IN PERSPECTIEF: (OVER)LEVEN AL-MAMGANI, MD, PHD RADIOTHERAPEUT-ONCOLOOG

WAAROM BILATERAAL

WAAROM BILATERAAL

BACKGROUND BILATERALE BESTRALING VAN DE HALS IN HOOFDHALSTUMROEN

• Rich lymphatic supply, also contralateral drainage. • Occult nodal metastasis? also Contralateral? • 80-85 of all HNSCC will be treated bilaterally. Only small tumors of the tonsil and the

larynx are treaed unilaterally. In the NKI/AVL, only 6% are treated to one side of the neck.

ELECTIVE LEVELS IN HNSCC

Subsite N0 N= Oral cavity I-III I-V Oropharynx I-IV I-V and RP Hypopharynx II-IV I-V and VI Larynx II-IV I-V and VI

BACKGROUND BILATERALE BESTRALING VAN DE HALS IN HOOFDHALSTUMROEN

• Rich lymphatic supply, also contralateral drainage. • Occult nodal metastasis? also Contralateral? • 80-85 of all HNSCC will be treated bilaterally. Only small tumors of the tonsil and the

larynx are treaed unilaterally. In the NKI/AVL, only 6% are treated to one side of the neck.

Is this really necessary?

Current

REDUCING TREATED VOLUMES

Current Future

WHY FROM BILATERAL TO UNILATERAL RT

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Sparen van omringende organen: • Speekselklieren • Slikspieren • Kauwspieren • Kaak • Larynx • Schildklier

T1N1 HPC (46 GY BOTH SIDES OF THE NECK AND BOOST 70 GY TO THE PT AND INVOLVED NODE)

T1N1 HPC (46 GY BOTH SIDES OF THE NECK AND BOOST 70 GY TO THE PT AND INVOLVED NODE)

OAR Dose Spinal cord 49.4 Gy Parotid gland, R (mean) 29.5 Gy Parotid gland, L (mean) 15.3 Gy SMG, R (mean) 71.1 Gy SMG, L (mean) 40.0 Gy Constrictor M (mean) 57.7 Gy Thyroid gland (mean) 48.0 Gy

T2N1 LC (46 GY BOTH SIDES OF THE NECK AND BOOST 70 GY TO THE PT AND INVOLVED NODE)

T2N1 LC (46 GY BOTH SIDES OF THE NECK AND BOOST 70 GY TO THE PT AND INVOLVED NODE)

OAR Dose Spinal cord 47.1 Gy Parotid gland, R (mean) 46.8 Gy Parotid gland, L (mean) 17.9 Gy SMG, R (mean) 71.1 Gy SMG, L (mean) 40.0 Gy Constrictor M (mean) 58.9 Gy Thyroid gland (mean) 46.6 Gy

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Current

18

Current Future

HOW TO ADDRESS?

• Review of literature

• Tools to identify lymphatic drainage

• SUSPECT study

Non-invasive

accurate

INCIDENCE OF CONTRALATERAL RF (CRF) IN LATERALIZED OPC

PREDICTIVE FACTORS FOR CRF

p-value

T-stage P=0.345

N-stage P=0.092

No nodes (1 vs. more) P=0.106

SP involvement P=0.178

Midline involvement P=0.002

INCIDENCE OF CONTRALATERAL RF (CRF) IN LATERALIZED OPC (O 'SULLIVAN)

6%

20%

16%

INCIDENCE OF CONTRALATERAL RF (CRF) IN LATERALIZED OPC (O 'SULLIVAN) Toronto

O’Sullivan

No patients 228

FU time 7 Y

T-stage All

N-stage All

T subsite All

RT technique 2D/3D

LC 77%

RC 81%

Contralateral RF 3.5%

3/37 (8%)

4/46 (9%)

cRF

0%

• 90 patients with T1-3N0 included • SN was detected in all patients. • 22% of the whole group showed occult metastasis in the removed SN 2/3 of all

positive SNL were located at level II.

1 NUMBER OF PATIENTS (90)

SN number No SN founded

micromets macromets Total SN+

SN1 90 (100%) 3 11 14 (15%) SN2 50 (55%) 4 1 5 (10%) SN3 19 (21%) 0 1 1 (5.2%) CL SN* 16 (17%) 1 0 1 (6%, 1%

whole group)

1 NUMBER OF PATIENTS (90)

SN number No SN founded

micromets macromets Total SN+

SN1 90 (100%) 3 11 14 (15%) SN2 50 (55%) 4 1 5 (10%) SN3 19 (21%) 0 1 1 (5.2%) CL SN 16 (17%) 1 0 1 (6%, 1%

whole group)

• Number of harvested SN decreased by distance from primary tumor location and intensity node

• Number of positive SN decrease also by distance from the primary tumor location and intensity node

SN MAPPING USING SPECT (SUSPECT) AIM OF THE STUDY

To exclude the contralateral neck (totally or partially) from the irradiated fields, when justified.

ELIGIBLE PATIENTS

Eligible patients (40 patients): • Early-stage HNC (T1-3N0-2b SCC oral cavity,

oropharynx, hypopharynx, and larynx) • Will be treated by primary RT, with or without CT • Clinically and radiologically node-negative neck, at

least on one side (N0-1) • Not crossing the midline

END POINTS

• Feasibility and safety • Regional control at 1 year • Acute and late toxicity • QoL

STUDY PROCEDURE

• Intensive work up for highly accurate nodal staging: 1.US-FNA, done by dedicated HN radiologist 2.CT or MRI 3.When indicated: FDG-PET, in 5-points

thermoplastic mask according to standard RT protocol

Work up according to the IGL

Lateralized T not crossing midline

Yes No

Not eligible Eligible

EUA and intra-tumoral injection of 99mTc followed by SPECT

Contralateral tracer accumulation?

Yes No

STUDY PROCEDURE

Elective RT only to the IL neck Elective RT to the IL neck and the level CL with +SN

BNI

PET, when indicated

MRI/CT

US-FNA

Included N=41

Level VI 3%

CURRENT STATUS SUSPECT (IPSILATERAL DRAINAGE SPECT)

Treated accordingly N=31

Excluded N=7

No CL SN N=2 laser

Level V 12%

RP 3%

Level I 6%

Level II 70%

Level III 60%

Level IV 45%

Included N=41

OPC N=21

LC N=5

CURRENT STATUS SUSPECT (CONTRALATERAL DRAINAGE SPECT)

OCC N=2

HPC N=3

Treated accordingly N=31

Excluded N=7

CL SN N=4 (L II, III)

CL SN N=1 (L II)

CL SN N=1 (L III)

CL SN N=2 (L IV)

CL SN Total=8/33 (24.2%)

No CL SN N=2 laser

VERY PRELIMINARY RESULTS (MATCH-PAIRED ANALYSIS 25 UNI X 25 BNI)

0

5

10

15

20

25

UNIBNI

Tumor site

T-stage

N-stage

HPV-status

Chemo

VERY PRELIMINARY RESULTS (MATCH-PAIRED ANALYSIS 25 UNI X 25 BNI)

0

5

10

15

20

25

UNIBNI

Chi square p=0.004

Chi square p=0.02

Chi square p=0.05

DANK VOOR UW AANDACHT