What is the management plan for post-operative cancer of the alveolus with lymphovascular invasion (LVI) present?

Management of Post-Operative Cancer of the Alveolus with Lymphovascular Invasion (LVI)

Postoperative radiotherapy should be delivered to patients with lymphovascular invasion (LVI) as this represents an intermediate-risk pathologic factor that significantly increases the risk of locoregional recurrence and distant metastasis. 1

Risk Stratification Based on LVI

LVI is a significant adverse prognostic factor that affects treatment decisions:

• LVI is classified as an intermediate-risk pathologic factor along with perineural invasion (PNI), T3-T4 disease, or positive lymph nodes 1
• The presence of LVI significantly increases the risk of nodal recurrence and distant metastasis, even in early-stage cancers 2, 3
• LVI has been shown to be an independent negative prognostic factor for disease-free survival and overall survival 4, 5

Recommended Management Algorithm

1. Postoperative Radiotherapy

• Postoperative radiotherapy is recommended for patients with LVI as the only risk factor after careful discussion of patient preferences and the evidence of outcomes 1
• The biologically equivalent dose of approximately 50 Gy in 2-Gy fractions or slightly higher should be delivered to regions at risk for microscopic spread 1
• For oropharyngeal cancers, risk-adapted approaches have shown that reduced-dose PORT (50 Gy) may be appropriate for intermediate-risk factors including LVI 1

2. Consideration of Concurrent Systemic Therapy

• Patients with intermediate-risk factors (including LVI) should not routinely receive concurrent systemic therapy with postoperative radiotherapy 1
• However, if the surgical procedure and/or pathologic findings suggest a particularly significant risk of locoregional recurrence, concurrent cisplatin-based chemotherapy may be considered after careful discussion of patient preferences 1
• Alternative systemic treatment regimens should only be used in the context of a clinical trial 1

3. Follow-up Recommendations

• Regular follow-up examinations should be scheduled to monitor for local recurrence and distant metastases 1
• Given the increased risk of distant metastases associated with LVI, appropriate surveillance imaging should be considered 4, 2

Special Considerations

• The presence of multiple risk factors (LVI plus other adverse features) may warrant more aggressive treatment approaches 1
• In HPV-positive oropharyngeal cancers, emerging evidence suggests potential for treatment de-escalation even with intermediate risk factors, but this should be approached cautiously when LVI is present 1
• For patients with alveolar cancers specifically, treatment decisions should consider the anatomical location and proximity to critical structures 1

Common Pitfalls to Avoid

• Underestimating the significance of LVI as a single risk factor - studies show it independently increases recurrence risk and decreases survival 2, 6
• Overtreatment with concurrent chemoradiation when LVI is the only risk factor - guidelines recommend radiotherapy alone in most cases 1
• Failing to consider patient-specific factors such as age, comorbidities, and functional status when determining treatment intensity 1
• Not discussing the potential benefits and risks of adjuvant therapy with patients, as this is essential for shared decision-making 1