46 year old male with left parotid salivary gland tumor s/p left total parotidectomy and radical neck dissection.
Final path: high grade MEC with mets to 5/9 LN, +margins, pathological staging is pT4a pN3b, no distant mets on PET.
Patient is being referred for consideration of adjuvant chemoRT. While there is clear data supporting adjuvant RT, i am less clear on the benefit of adding chemo and NCCN lists this as category 2B.
What are your thoughts?
Although young and fit patient with many high risk features, there is limited data if any outlining benefit of adding platinum chemo hence Im looking for some guidance.
There have been metanalyses showing lack of benefit of adding chemo. Recently completed RTOG trial is not reported as yet, but the role of chemo is really questionable. I have extensive discussion with pt and offer it as an option with unclear benefit. Your patient is young and like you mention, high risk, I would favor chemo for someone like this as a radiosensitizer.
Great, thanks. I agree, I think the many high risk features makes our ENT and rad onc a bit nervous, but I cant make a strong recommendation for it. Are you aware of any detrimental effect of chemo with RT in this population? I believe the data reported in this paper (JAMA Otolaryngol Head Neck Surg. 2016 Nov;142(11):1100-1110) suggested inferior outcome with chemoRT vs RT alone. Thoughts on that?
yes, that is correct, but it should be noted that high risk definition varies based on studies. I would have this discussion with the patient, but also highlight the gray area in terms of specific guidelines. The problem is that the risk is high no matter what you offer and the reason for chemo would be purely as a radiosensitizer after discussing pros and cons.
Only RT or RT+chemo both reasonable per NCCN
