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The Tonsillar Fossa Battleground
International Journal of
Radiation Oncology biology
physics
www.redjournal.org
Introducing: The Red Journal Gray Zone The ultimate goal of radiation oncology research is to improve clinical care. As a specialty, we tackle diverse research questions, addressing every type of cancer and encompassing cancer biology and radiation physics. But despite our best efforts, evidence-based medicine cannot provide 1 clear answer to every clinical problem. In many patient scenarios, the best management approach remains uncertain, leaving room for differences of opinion and constructive debate. To this end, in this issue we introduce a new feature: The Red Journal Gray Zone. In the Gray Zone, we present difficult or controversial clinical cases. After each case, you will be able to read the management plan favored by a few specialists in that particular field. We aim to provide thought-provoking viewpoints, but also we want to hear from you! After reading the case, share your opinions on Twitter using the hashtag #gyzone. There you can voice your support for one of the experts or provide your own alternative proposal. We want to present a diverse set of clinical problems, so we encourage submission of your own cases through the Red Journal website, to be considered for publication “In the Zone.” We hope that this feature leads to the sharing of opinions and the airing of differences, to better inform and advance management of the difficult cases in our practice. After all e with apologies to the Monkees e often in radiation oncology there is no black and white, only shades of gray. David A. Palma, MD, PhD, Senior Editor Sue S. Yom, MD, PhD, MAS, Deputy Editor Katherine Egan Bennett, Managing Editor June Corry, MD, Associate Editor Anthony L. Zietman, MD, FASTRO, Editor-in-Chief http://dx.doi.org/10.1016/j.ijrobp.2016.11.052
The Tonsillar Fossa Battleground Sue S. Yom MD, PhD, MAS Departments of Radiation Oncology and Otolaryngology-Head and Neck Surgery, University of California, San Francisco A 57-year-old man with a remote 4-pack-year history of cigarette smoking recently experienced globus sensation and intermittent left ear pain, simultaneous with a 10 pound weight loss he had initiated for “personal health reasons.” He had a fine-needle aspiration biopsy of a left level 2 neck mass demonstrating squamous cell carcinoma, which was positive for p16 immunohistochemistry in rare tumor cells and positive for HPV16 on in situ hybridization. He had a diagnostic CT of the neck as well as a PET/CT which showed a 2.6 x 2.2 cm hypermetabolic mass of the L tonsillar fossa (SUV max 13) with an associated 1.6 x 1.9 cm left level 2A lymph node (SUV max 7) and scattered small associated left adenopathy (SUV max 3.6).
See expert opinions on page 3. Int J Radiation Oncol Biol Phys, Vol. 97, No. 1, pp. 1-2, 2017 0360-3016/$ - see front matter Ó 2016 Published by Elsevier Inc.
2
Gray Zone
International Journal of Radiation Oncology Biology Physics
Questions 1. Would you recommend chemotherapy, oncologic resection, chemoradiation, or radiation as the initial treatment and why? 2. If the patient opts for an upfront oncologic resection and has a 1 mm clear margin at the primary site and a level 2-to-4 selective neck dissection finding 2 involved lymph nodes in level 2 with no other negative features, would you recommend postoperative therapy and if so, to which primary and neck regions and why? 3. What if in the previous scenario, the patient was found to have extranodal extension in one node extending 1 mm outside the capsule? 4. If the patient opts for chemoradiation, what type and schedule of chemotherapy and radiation would you recommend? http://dx.doi.org/10.1016/j.ijrobp.2016.11.045
Radiation Oncology biology
physics
www.redjournal.org
Introducing: The Red Journal Gray Zone The ultimate goal of radiation oncology research is to improve clinical care. As a specialty, we tackle diverse research questions, addressing every type of cancer and encompassing cancer biology and radiation physics. But despite our best efforts, evidence-based medicine cannot provide 1 clear answer to every clinical problem. In many patient scenarios, the best management approach remains uncertain, leaving room for differences of opinion and constructive debate. To this end, in this issue we introduce a new feature: The Red Journal Gray Zone. In the Gray Zone, we present difficult or controversial clinical cases. After each case, you will be able to read the management plan favored by a few specialists in that particular field. We aim to provide thought-provoking viewpoints, but also we want to hear from you! After reading the case, share your opinions on Twitter using the hashtag #gyzone. There you can voice your support for one of the experts or provide your own alternative proposal. We want to present a diverse set of clinical problems, so we encourage submission of your own cases through the Red Journal website, to be considered for publication “In the Zone.” We hope that this feature leads to the sharing of opinions and the airing of differences, to better inform and advance management of the difficult cases in our practice. After all e with apologies to the Monkees e often in radiation oncology there is no black and white, only shades of gray. David A. Palma, MD, PhD, Senior Editor Sue S. Yom, MD, PhD, MAS, Deputy Editor Katherine Egan Bennett, Managing Editor June Corry, MD, Associate Editor Anthony L. Zietman, MD, FASTRO, Editor-in-Chief http://dx.doi.org/10.1016/j.ijrobp.2016.11.052
The Tonsillar Fossa Battleground Sue S. Yom MD, PhD, MAS Departments of Radiation Oncology and Otolaryngology-Head and Neck Surgery, University of California, San Francisco A 57-year-old man with a remote 4-pack-year history of cigarette smoking recently experienced globus sensation and intermittent left ear pain, simultaneous with a 10 pound weight loss he had initiated for “personal health reasons.” He had a fine-needle aspiration biopsy of a left level 2 neck mass demonstrating squamous cell carcinoma, which was positive for p16 immunohistochemistry in rare tumor cells and positive for HPV16 on in situ hybridization. He had a diagnostic CT of the neck as well as a PET/CT which showed a 2.6 x 2.2 cm hypermetabolic mass of the L tonsillar fossa (SUV max 13) with an associated 1.6 x 1.9 cm left level 2A lymph node (SUV max 7) and scattered small associated left adenopathy (SUV max 3.6).
See expert opinions on page 3. Int J Radiation Oncol Biol Phys, Vol. 97, No. 1, pp. 1-2, 2017 0360-3016/$ - see front matter Ó 2016 Published by Elsevier Inc.
2
Gray Zone
International Journal of Radiation Oncology Biology Physics
Questions 1. Would you recommend chemotherapy, oncologic resection, chemoradiation, or radiation as the initial treatment and why? 2. If the patient opts for an upfront oncologic resection and has a 1 mm clear margin at the primary site and a level 2-to-4 selective neck dissection finding 2 involved lymph nodes in level 2 with no other negative features, would you recommend postoperative therapy and if so, to which primary and neck regions and why? 3. What if in the previous scenario, the patient was found to have extranodal extension in one node extending 1 mm outside the capsule? 4. If the patient opts for chemoradiation, what type and schedule of chemotherapy and radiation would you recommend? http://dx.doi.org/10.1016/j.ijrobp.2016.11.045