Panelists weren’t so quick to accept that the mass was a metastasis, though.
Explore This IssueApril 2016
“P16-negative still could be an unknown primary of the head and neck, as opposed to metastatic disease from the esophagus and I think that’s really the critical determinant,” Dr. Smith said. “It’s a totally different treatment paradigm.” He added, “You can’t assume it’s just esophageal metastases. I would feel you have to proceed with an unknown primary workup.”
Dr. Civantos also said he would treat it as a potential second primary tumor. The most likely site for a cryptic primary is still going to be lymph node tissue in the tongue base and the tonsil, he said, so he would do extensive biopsy of the lingual tonsils, or remove them, and biopsy any lymphoid tissue of the nasopharynx and hypopharynx as well.
He said he would perform a modified radical neck dissection and mucosectomy. Additionally, he said, he would try to clarify how much adjuvant therapy could get to the neck, considering the patient’s prior treatment of the neck, because that could affect surgical decisions. “If you presume this patient’s ability to receive standard post-op radiation is somewhat compromised, then I think you could err in the direction of being more radical (with surgery).”
Dr. Kraus said that he did, in fact, consult with the radiologist and was assured that radiation was a viable option. He then asked the panel whether the tonsillectomy, neck dissection, and transoral robotic mucosectomy should all be done at once.
Dr. Johnson said no. “Our experience is that bilateral transoral tonsillectomies, invasive tongue resections with a robot, are associated with unacceptable morbidity,” because scarring contracture can cause dysphagia, he said. “I think it’s a mistake to do it all at once.”
Dr. Kraus said that a bilateral tonsillectomy was done, and they were negative. He also performed an extended radical neck dissection, finding muscle, nerve, and jugular vein involvement. After looking at the original esophageal lesion and the neck lesion, the pathologist again concluded that this was an isolated metastasis from his esophagus, even though he was three years out.
Dr. Johnson doubted the pathologist’s assessment. But he said that if muscle, nerve, and vein were involved, “then this is bad, and I would offer him CRT [conformal radiation therapy].”
Dr. St. John said that “you’re only as good as your team” and that the pathologist’s assessment would “make a difference to me.” She added that the decision on chemoradiation therapy should not be automatic. “If this is a metastatic esophageal [squamous cell carcincoma] with these types of features, then his prognosis is guarded, so one has to really think about side effects” weighed against the survival benefits of the therapy.