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ORIGINAL ARTICLE
Year : 2017  |  Volume : 13  |  Issue : 6  |  Page : 943-946

Accelerated hypofractionation (OCTA SHOT): Palliative radiation schedule in advanced head and neck carcinoma


Department of Radiation Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College and Associate Group of Hospitals, Bikaner, Rajasthan, India

Date of Web Publication13-Dec-2017

Correspondence Address:
Dr. Shankar Lal Jakhar
Department of Radiation Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College and Associate Group of Hospitals, Bikaner, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_767_16

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 > Abstract 

Background: Head and neck cancers are attributed to be the most common type of malignancy in the developing countries with most cases presenting in advanced stage. This pilot study was performed to evaluate the effect of an accelerated hypofractionated 4 days schedule (octa shot) in providing palliation to such advanced cases of head and neck cancer.
Materials and Methods: Twenty-two patients with advanced (Stage VIB-IVB) squamous cell carcinoma of head and neck region were enrolled in the study. All these patients were planned for radiotherapy at Cobalt Unit with a fractionation schedule of 3.5 Gy/fraction, 2 fractions/day with 6 h interval between two fractions, for four days (28 Gy/8Fr/4 days). Patients were reviewed at 2 and 4 weeks to assess change in tumor size, any symptomatic relief, or toxicity. The tumor response, dermal, and mucosal toxicities were assessed using WHO criteria.
Results: Median age of these 22 patients (17M male + 5F female) in the study was 59.8 years. After completion of radiotherapy, first response evaluation done at 15th day showed ≥50% objective response in 14 patients. At 1 month, this response increased to ≥75% in 16 patients and 50%–75% in three patients. None of the patients had disease progression. Improvement in symptoms was reported with respect to pain and dysphagia by patients subjectively. Only two patients reported Grade III mucositis; remaining patients had mucositis and dermatitis up to Grade II.
Conclusion: The study concludes that this “octa shot” is an effective palliative radiotherapy schedule. With a decreased duration of hospital stay, it is also favorable for outpatients.

Keywords: Accelerated hypofractionation, advanced stage, head and neck cancer, octa shot, palliative


How to cite this article:
Jakhar SL, Purohit R, Solanki A, Murali P, Kothari T, Sharma N, Kumar HS. Accelerated hypofractionation (OCTA SHOT): Palliative radiation schedule in advanced head and neck carcinoma. J Can Res Ther 2017;13:943-6

How to cite this URL:
Jakhar SL, Purohit R, Solanki A, Murali P, Kothari T, Sharma N, Kumar HS. Accelerated hypofractionation (OCTA SHOT): Palliative radiation schedule in advanced head and neck carcinoma. J Can Res Ther [serial online] 2017 [cited 2019 Nov 14];13:943-6. Available from: http://www.cancerjournal.net/text.asp?2017/13/6/943/214519


 > Introduction Top


Head and neck cancers are attributed to be the most common type of malignancy in the developing countries with most cases presenting in advanced stage.[1] At our regional cancer center, 25% patients are registered with squamous cell cancer of head and neck region. Of these, 35% patients are inoperable and advanced stage, treated with palliative intent. Usually, these patients are treated with a schedule of 30Gy/10fractions/2weeks at our center.[2],[3] There are several studies available regarding evaluation of tumor response and symptomatic relief in patients with different palliative radiotherapy schedules.[4],[5],[6],[7],[8] Along with response, these studies have also made efforts to decrease total duration of treatment and hospital stay of palliative patients. In the present study, an effort has been made to evaluate one such hypofractionated schedule which is also accelerated to give two fractions per day with an overall duration of 4 days of radiation treatment. In total, 8 fractions are given over a duration of four days.


 > Materials and Methods Top


A total of 22 histologically proven cases of squamous cell carcinoma of head and neck region were enrolled in the study from August to October 2015, after proper informed consent. Patients' inclusion criteria were histologically squamous cell carcinoma of oral cavity, pharynx and larynx, tumor-node-metastasis Stage IVB, T4b and/or N3 (American Joint Committee on Cancer Seventh Edition Staging System), inoperable disease, or unfit for surgery. Patients who received previous irradiation and were non-compliant for follow-up were excluded from the study. Seventeen male and five female patients with median age of 59.8 years were included in the study.

All these patients were planned for an “Octa Shot” schedule, 28 Gy/8 fractions/4 days, in which, 3.5 Gy were delivered per fraction, two such fractions were delivered in a day, 6 h apart. The radiotherapy was planned for Cobalt-60 teletherapy unit, and marking of patients was done around gross tumor volume (primary tumor and involved nodes) with an additional margin of 2 cm all around. The biologically equivalent dose (BED) for this Octa Shot regimen for tumor and late reacting tissue is 37.8 Gy10 and 60.48 Gy3, respectively. The equivalent dose to 2 Gy/fraction schedule is 31.5 Gy10 for tumor and 36.43 Gy3 for late reacting tissue. No previous study used the exact same regimen. Ghoshal et al. in their study have given two successive “quad shots”, and the BED of two quad shots is equal to one OCTA shot. After completion of treatment, patients were called for review at 15 days and 1 month.

The assessment of tumor response and toxicity namely mucositis and dermatitis was done according to WHO criteria.[9] The tumor was measured bidimensionally, and surface area approximation method was used. In this method, the product of longest diameter and greatest perpendicular diameter was taken. These measurements were taken at the beginning of treatment, 15th day, and 1 month. The readings after treatment were compared with those before treatment. Patient's symptom relief assessment was done by using 0-10 numeric rating scale. Mucosal and dermal toxicities were categorized into four grades as per WHO criteria.


 > Results Top


After completion of the “octa shot,” the patients were called for 1st review at 15th day. Out of 22 patients, 14 patients (64%) showed ≥50% response [Figure 1]. While at the end of 1 month, 16 patients (73%) had response ≥75% and three patients (13.5%) came within the range of 51%–75% response. Therefore, a total of 19 patients accounted to have partial response (50%). At 1 month, three patients (13.5%) had stable disease. No patient was observed to have progressive disease. All the patients were alive at 1-month follow-up. The above data have been shown in the form of table [Table 1] and pie chart [Figure 1] and [Figure 2].
Figure 1: Tumor response evaluation at 15th day

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Table 1: Tumor response evaluation at 15 days and 1 month

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Figure 2: Tumor response at 1 month

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In terms of toxicities, at 15th day, six patients reported Grade I mucositis, 14 patients (64%) presented with Grade II mucositis, and only two patients had Grade III mucositis. Patients also presented with dermatitis, with four patients showing Grade I dermatitis and remaining 18 patients showing Grade II dermatitis. All these patients were managed symptomatically. On the next follow-up at 1 month, all these mucosal and skin reactions had subsided effectively. Mucosal [Table 2] and dermal [Table 3] reaction data for patients are shown in tables.
Table 2: Mucositis evaluation

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Table 3: Dermatitis evaluation

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In addition to the above tumor response and toxicities, symptomatic relief mainly with respective to pain and dysphagia was also observed and subjectively reported by patients. For a better analysis, these data need to be practically collected and evaluated.


 > Discussion Top


In a developing country like India, head and neck cancers are the most common type of malignancy with most patients presenting in advanced stage. Even at their first presentations, many patients are having metastatic and inoperable disease. The main intent for the management of these patients is palliative to provide symptomatic relief and improved quality of rest of their life. All of the palliative regimens are planned with the above objectives, and they also look forward to have such a course to decrease stay of patients, making it more convenient for outstation patients and their caregivers.

Several studies regarding different palliative courses [Table 4] have been conducted by different authors. A comparative data have been obtained from such studies for tumor response, toxicities, and symptomatic response. Corry et al.[8] and Ghoshal et al.[10] have performed studies describing “Quad Shot” in which a short course of palliative radiation 3.5 Gy/fraction is given in 4 fractions in 2 days. Such two days regime has shown objective response, i.e., complete and partial response in 53% patients at the end of 6 weeks. Ghoshal et al. in their study have given two successive “quad shots” to responding patients and have reported partial response in 66.67% patients. In our study, we have delivered a four-day “octa shot” regimen with similar dose per fraction, two fractions each day. We have achieved an objective response (partial response) in 73% patients at the end of 1 month.
Table 4: Comparison of different hypofractionation schedules in head and neck cancers

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For evaluation of symptomatic parameters, proper scaling needs to be added in the study. A longer follow-up is desired to study for disease progression and patients' survival data. In addition, it is a single-armed study, which demands for studies comparing it with conventional schedules of radiation. In the case of effectiveness of this schedule being comparable with that of conventional schedule, this “octa shot” may prove to be a good option for palliative and outpatients. This will decrease the hospital stay of patients and also hospital workload significantly.

Acknowledgment

We would like to thank Dr. M. R. Bardia, Director Acharya Tulsi Regional Cancer Treatment and Research Institute, Bikaner.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.[16]

 
 > References Top

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Joshi P, Dutta S, Chaturvedi P, Nair S. Head and neck cancers in developing countries. Rambam Maimonides Med J 2014;5:e0009.  Back to cited text no. 1
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Lusinchi A, Bourhis J, Wibault P, Le Ridant AM, Eschwege F. Radiation therapy for head and neck cancers in the elderly. Int J Radiat Oncol Biol Phys 1990;18:819-23.  Back to cited text no. 5
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World Health Organisation. WHO Handbook for Reporting Results of Cancer Treatment (WHO Offset Publ. No. 4). Geneva: World Health Organisation; 1979.  Back to cited text no. 9
    
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Ghoshal S, Chakraborty S, Moudgil N, Kaur M, Patel FD. Quad shot: A short but effective schedule for palliative radiation for head and neck carcinoma. Indian J Palliat Care 2009;15:137-40.  Back to cited text no. 10
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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