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ABSTRACT
Year : 2018  |  Volume : 14  |  Issue : 11  |  Page : 871-892

Head and Neck Oncology


Date of Web Publication29-Nov-2018

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How to cite this article:
. Head and Neck Oncology. J Can Res Ther 2018;14, Suppl S4:871-92

How to cite this URL:
. Head and Neck Oncology. J Can Res Ther [serial online] 2018 [cited 2019 Sep 15];14:871-92. Available from: http://www.cancerjournal.net/text.asp?2018/14/11/871/246378




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Institutional experience of adaptation from intensity modulated radiation therapy to volumetric modulated arc therapy in postoperative cases of carcinoma tongue

Kushboo Jain, Pooja Nandwani Patel

Aim: Intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT) are being used for treatment of head and neck cancers with discrepancy regarding superiority of one technique over the other. Our aim was to analyse various dosimetric parameters of IMRT and VMAT plans, to compare between the two techniques for treatment of operated cases of Ca. Tongue. Material and method: the study included 50 patients of IMRT and 50 patients of VMAT with patients matched with respect to the pathological stage and volume of PTV to minimise selection bias. Following parameters were assessed for comparison: (1) Target coverage, (2) Dose to Organ at Risk (OAR), conformity index (CI). (3) Homogeneity index (HI), (4) Monitor Unit (MU) delivered, (5) Treatment time. Results: There was no significant difference regarding PTV coverage, HI and CI in both plans (p>0.05). Significantly more MUs were delivered in IMRT with average difference of about 30% more MUs as compared to VMAT (p<0.001). Treatment delivery time was reduced by around 8.5+/-4 minute for VMAT. No significant difference was found in dose to OAR like larynx, Parotid, brain stem and pharyngeal constrictor muscles. Spinal cord maximum dose was about 1+/- 0.4 Gy less in VMAT plans. Conclusion: VMAT is emerging as mainstream treatment option for various sites like pelvis, lung and head and neck. No sufficient data is available for a specific sub site in head and neck cancers. In our study, we found that both VMAT and IMRT plans had comparable coverage of PTV. Sparing of OAR was marginally better with VMAT. But there was marked reduction in treatment delivery time with VMAT. Risk of intrafraction motion was reduced with VMAT with improved patient compliance. VMAT has become an institutional policy for patients of Ca. Tongue receiving adjuvant radiotherapy at our centre. We are exploring role of VMAT in other sub sites too.


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Comparison of outcomes with hypofractionated palliative radiotherapy “christie regimen” versus standard palliative radiation in head and neck squamous cell carcinoma

A. Anand Praveen Kumar, N. V. Kalaiyarasi, R. Giridharan

Aim: To compare the efficacy and toxicity profile of patients with squamous cell carcinoma of the head and neck (HNSCC) treated with Hypofractionated palliative radiotherapy ‘Christie Regimen’ versus Standard Palliative radiation. Materials and Methods: About 60 cases of locally advance Head and Neck cancers were analysed in 2 arms. Patients were treated with 300 cGy /10 # / 30 Gy / 2 weeks in Arm A (Control arm), and 312.5 cGy/16 # /50 Gy /3.1 weeks in Arm B (Study arm). Results: At the end of the study Response, Toxicities and QOL assessed. Locoregional control after the completion of treatment was complete response (CR) (30% and 40%), partial response (PR) (53.33% and 56.66%), and no response (SD) (16.66% and 3.33%) in Arm A and Arm B respectively, but this was not statistically significant (P = 0.209555). Grade II Skin reactions were observed more in both the arms 53.33% and 56.66% in Arm A and Arm B respectively. Grade III radiation skin reactions were 6.66% and 10% in Arm A and Arm B respectively. And also Grade I and II mucosal reactions were observed more in Arm A and Arm B 46.66% vs 40% and 40% vs 46.66%, respectively. Grade III radiation mucosal reactions were equal in both groups (13.33%), statistically not significant. In Oesophagus, Larynx and Salivary glands also Grade III and Grade II reactions are common in both groups. The patients were followed for a minimum period of 6 months. Quality of Life improvement at the end of 6 months was Pain improvement (28% and 59.25%), Performance status improvement (36% and 62.96%), and Weight loss improvement (20% and 33.33%%) in Arm A and Arm B respectively. Conclusion: Hence, it can be concluded that although there was no significant difference in Response rates, QOL improvement was in favour of Christie regimen schedules with manageable toxicities. The total time needed were less in hypofractionated radiotherapy regimen, and this radiobiological superiority is beneficial for centers like ours where the patient load is much higher than the facility available for radiation. Further studies with longer follow-up will be needed for confirmation to establish the long-term effects of this regime.
Table 1

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Metronomic chemotherapy in recurrent and metastatic head and neck carcinoma

Vipul Bansal, Anil Kumar Dhull, Vivek Kaushal, Rajeev Atri

Background: Squamous cell head and neck cancer patients with recurrent or metastatic disease require palliative chemotherapy and because of toxic side effects and poor results of conventional chemotherapy, most of the patients are good candidates of oral metronomic chemotherapy. Materials and Methods: In a single arm, prospective observational study, palliative metronomic chemotherapy with oral methotrexate 15 mg/m2/week and oral celecoxib 200 mg twice daily were given to LAHNC patients with recurrent or metastatic disease, having adequate organ function, till the progression of the disease or till intolerable side effects. Patients underwent toxicity (CTCAE version 4.03) and response (WHO criteria) assessment every 4-weeks. Descriptive statistics and Kaplan–Meier survival analysis have been performed. Results: A total of 90-patients were subjected to receive metronomic chemotherapy. The median age of these patients was 56.5 years (range 38-77). Male to female ratio was 14:1. The Eastern Cooperative Oncology Group performance status was 0–1 in 39 patients (43.3%), and it was 2 in 51 patients (56.7%). Oropharynx was the most common primary ICD site and 48% and 9% patients had recurrence and metastasis respectively. All patients had previously been treated with palliative or curative intent radiotherapy. The reason for discontinuation of metronomic CT was progression of disease in 54% and intolerable toxicity in 8% of patients. There was partial response in 17 % and table disease in 33% patients. The median progression free survival was 169-days and median overall survival was 258-days. Grade 3–4 toxicity was seen in 19-patients (21%). Conclusion: Metronomic chemotherapy is mainly designed for metastasis or recurrent head and neck cancer and has potential role for propitious PFS and OS and should be optimally considered with biological optimized dose. Further, in this trial, lower rates of toxicity were observed probably due to low doses of the chemotherapeutiuc agents. Further, larger studies with metronomic chemotherapy are advocated to establish the palliative study protocol.


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Dosimetrical impact of volume changes in the head-and-neck cases during course of radiotherapy

Sumit Gupta, Virendra Bhandari, O. P. Gurjar, Priyusha Bagdare, Shalu Verma

Aim: To study the dosimetrical impact of volume changes in the Head-and-neck (H&N) cases during course of Radiotherapy. Materials and Methods: Forty five patients with H&N cancer were included in the study who were reported with remarkable weight loss or decrease in the volume of target region. Repeat computed tomography (Re-CT) was done after 15 fractions (#). Gross tumor volume (GTV), clinical target volume (CTV) and planning target volume (PTV) were delineated on Re-CT images. The original plan (created on primary CT images) was imported as it is on the Re-CT images and dose was calculated having same beam arrangements and monitor units. This plan was named as hybrid plan. Another plan was created on Re-CT images and was optimized based on the structural information with Re-CT images. Change in target volumes and the target coverage and doses to OARs in both the plans were noted and compared. Results: The change in GTV, CTV and PTV was found to be 44.13 cubic centimeter (cc), 85.32 cc and 154.54 cc reduction in Re-CT as compared to that in CT. The mean conformity index (CI) and homogeneity index (HI) was found to be 0.67 and 1.05 respectively in actual plan while 0.52 and 1.19 respectively in hybrid plan. The PTV coverage with dose to 95% and 99% volume was found to be 98.72 % (standard deviation, SD: 2.73) and 94.8% (SD: 2.95) respectively in actual plans while 91.9% (SD: 3.76) and 83.7% (SD: 7.60) respectively in hybrid plans. The mean Dmax to spinal cord and brainstem was increased with 1.45 Gray (Gy) and 4.19 Gy respectively. Similarly the mean doses to right and left parotids were increased by 6.13 Gy, 4.21 Gy respectively in hybrid plans as compared to that in actual plans. Conclusion: The statistical significant difference was noted in the target coverage and OAR doses. Target missing and over doses to OARs were reported in the hybrid plans. Therefore it can be concluded that Re-CT should be done after noting the remarkable volume changes in the H&N cases.


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Evaluation of correlation of outcomes with prognostic factors in T1/T2 N0/N1 oral cavity tumors

Nikhil Gopi1, Mihir Mohan2, B. S. Naveen2, K. J. Jabir3, Shawn. T. Joseph2

Departments of1 Radiation Oncology,2 Surgical Oncology, and3 Biostatistics, VPS Lakeshore Hospital Kochi, Kerala, India

Aims and Objectives: Objective of this study was to summarize the treatment outcomes and it relation with observed prognostic factors in treatment of T1/T2 N0/N1 oral cavity tumors treated at our center from July 2014 to July 2018. Materials and Methods: Out of a total of 254 patients treated with radical intent during this period 156 patients were evaluable. A total of 128 patients with T1T2N0 and 28 patients with T1T2N1 Oral Cavity Primary Cancers were retrospectively reviewed and followed up during the period from July 2014 to July 2018. Clinical and demographic features and Histopathological features like Perineural Invasion (PNI), Lymphovascular Invasion (LVI), Depth of Invasion (DOI), Lymphocytic Response, Pattern of Invasion (POI) and Brandwein Gensler Score (BGS) that could influence RFS were collected and analyzed. Statistical analysis was done using the software SPSS version 20.0. To identify factors associated with outcomes, univariate and multivariate analysis were done using the binary logistic regression. Results: Of the 156 patients 83.3% were treated with surgery alone, while 16.7% (12.2% RT and 4.5% CTRT) received adjuvant radiation. Average age of studied patients was 56.4 ± 12.8 years. PNI was seen in 23.7%, DOI was <5 mm, 5-10 mm and >10 mm in 25.0 %, 50.0% and 19.9% of patients respectively, LVI was seen in 7.7%. High BGS score was seen in 44.9%. POI was high (grade 4/5) in 51.9%. At a median follow up period of 19 months, T1T2N0 group had a RFS of 85.9% [average RFI in months 6.89 ± 3.1] and T1T2N1 group a RFS of 71.4% [average RFI in months 8.71 ± 5.22, p=0.068]. As compared to N0, N1 had increased odds of recurrence [OR 2.41 (1.1 - 5.3)] in univariate analysis but not in multivariate analysis. Subgroup analysis showed that T1T2N0 with PNI, High BGS and DOI>10 mm had a RFS of 84%, 83% and 82.6% respectively. When low grade POI (1/2/3) was analyzed against high grade RFS was 94.5% vs 77.8% (p=0.017). Percentage of patients with high grade POI in Relapsed patients and Non-relapsed ones were 85% vs 43%. In the univariate and multivariate analysis none of the adverse prognostic indicators like PNI, LVI, high BGS or DOI>10 mm except high grade POI appeared to influence RFS in otherwise low risk T1T2N0 disease. Conclusion: Adverse prognostic indicators like N1, PNI, LVI, high BGS or DOI>10 mm did not appear to influence RFS significantly. High grade pattern of invasion was significantly more in the relapsed group compared to non relapsed patients. In the non recurrent group, the rates of high grade and low grade pattern of invasion were similar. Molecular studies to accurately identify the predictors of high grade pattern of invasion in the relapsed group of patients may be of help in choosing the group of patients who may have benefit with adjuvant treatment.


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Patient outcomes versus clinician reported outcomes in head and neck radiotherapy

Nikhil Gopi, Nisha Eliza Thomas, Philip George Kuttikkat, Joseph Edison

Department of Radiation Oncology, VPS Lakeshore Hospital and Research Centre, Kochi, Kerala, India

Background: Radiotherapy with or without concurrent chemotherapy has been an essential part of treatment in Head and neck cancers, either in a definitive or adjuvant setting. Such radiotherapy is known for its local adverse reactions. In this prospective observational study we intent to compare Patient reported outcomes (PROs) with clinician reported acute symptoms in head and neck cancer patients receiving radiotherapy. Patients and Methods: 56 patients who were started on radiotherapy at our center, to head and neck site malignancies with definitive of adjuvant radiotherapy with or without concurrent chemotherapy were prospectively observed from January 2017 to March 2018. Clinicians assessed local toxicities weekly using RTOG/EORTC acute toxicity scale and patient reported symptoms were collected weekly on the same day using a Modified EORTC H& N questionnaire. All patients complied with the assessment and all entries with atleast 1 entry from either side on the same day was considered assessable. Cohen's kappa coefficient (κ) was used to evaluate percentage of agreement. Results: Patients reported symptoms suggestive of events like Mucositis, Skin reactions Dysphagia, Xerostomia and hoarseness more often than Clinicians. From Cohen's Kappa (κ) derived on each week for each of these parameters percentage of agreement ranged from 17% to 57.6% which translated into slight to moderate agreement only. Conclusion: Our findings suggest a discrepancy between Clinician and PRO reports. Further prospective studies might bring out potential benefits of collecting PROs in clinical practice.


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Role of diffusion weighted imaging in head and neck cancers

Simon Pavamani, Solly Thomas, Koti Krishna Amulya, Sunithi Mani, I. Aparna

Aims and Objectives: Radiotherapy, with or without concurrent chemotherapy, is the primary modality of treatment in most stages of Head of Neck Cancers. The challenge after radiotherapy is to predict treatment response early enough in order to initiate further treatment. Diffusion Weighted MRI (DW-MRI) is an imaging modality wherein an increase in the Apparent Diffusion Coefficient (ADC) in the tumour indicates an increase in the movement of water molecules. This in turn indicates a decrease in the cellularity & vis-à-vis tumour response. Thus, a rising ADC value during treatment versus pretreatment ADC values may be used to predict treatment response. The aim of this study was to investigate the role of DW-MRI derived parameters like ADC, as an imaging biomarker, to predict response to RT in locally advanced carcinoma of the nasopharynx, larynx and hypopharynx. Materials and Methods: We studied the role of DW-MRI in two cohorts of patients with head & neck cancers. The first cohort consisted of 19 patients with locally advanced laryngeal & hypopharyngeal malignancies, treated with organ preservation intent with concurrent radiotherapy (CRT) with Cisplatin (n=14), radiotherapy with Nimotuzumab (n=2) and radical radiotherapy (n=3). The patients were all male with predominantly T3 stage. They were assessed for treatment response with DW-MRI at baseline, first week, fourth week during RT and at the time of first response assessment at 6 to 8 weeks after RT. The ADC values were compared at different time points and correlated with the treatment response. The second cohort consisted of thirteen patients with non-metastatic carcinoma nasopharynx (NPX) who underwent DWI-MRI before the start of CRT (Pre-RT), one week after start of CRT and at 4-6 weeks follow up. Results: All patients in the first cohort (Ca Larynx/Hypopharynx) showed an increasing trend in the ADC values over the chosen 4 different time points. It was observed that an abrupt rise from the pretreatment ADC to the first week ADC was characteristic of complete response while a gradual rise of ADC over the different points suggested a partial treatment response. The patients who responded to chemoradiation therapy had a higher pretreatment ADC than patients with partial response. At the last follow up, 12 patients were disease free, while 5 patients developed recurrence. Four patients with recurrence had shown a partial response while only one had exhibited a complete response during RT. In the second cohort (Ca NPX), an increase in ADC was observed at each stage of therapy at the primary site and nodes. The difference in ADC values from Pre-RT to follow up was higher in complete responders than partial responders (p=.003). The baseline ADC values were higher in complete responders than partial responders. Conclusions: Serial DW-MRI performed Pre-RT & during RT in the two cohorts of Head & Neck cancer patients demonstrated that a rise in ADC value early during the Radiotherapy can predict treatment response early & can potentially be used to direct further therapy.


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Oral zinc sulphate and prevention of radiation induced mucositis in head and neck cancer patients

M. G. Rahul, N. V. Kalaiyarasi

Aim: This study was conducted to evaluate the potential benefits of zinc sulphate in the prevention of radiation induced mucositis in patients with head and neck cancers. Materials and Methods: Forty patients with proven cancer of head and neck were randomly divided into two groups, viz zinc sulphate group and control group. Patients who received curative radiotherapy with or without weekly cisplatin where instructed to take zinc sulphate tablets 30 mg thrice daily at 8 hours interval orally, beginning at one week before radiation treatment and continuing until two weeks after treatment. Mucositis was evaluated weekly according to WHO Scale. Results: In both groups mucositis was evident during treatment but prevalence was 40% in zinc arm and & 70% in control arm respectively at the end of treatment. The severity of oropharygeal mucositis increased to maximum intensity in 4th week with zinc group showing lesser severity than the control group. Conclusion: The present study shows that Zinc sulphate is effective in reducing the onset and the severity of radiation induced mucositis in head and neck cancer patients.


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Impact of perinodal spread on outcomes in carcinoma tongue postsurgery and adjuvant chemoradiation

Harjot Kaur Bajwa, Rohith Singareddy, Divya Shiva, Krishnam Raju Alluri

Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India

Aim: To evaluate the risk of recurrence in Carcinoma Tongue Patients with Perinodal Spread post definitive surgery and adjuvant chemoradiation. Materials and Methods: Patients diagnosed to have squamous cell carcinoma of the anterior two thirds of the tongue and treated by definitive surgery were included for analysis. Patients that had perinodal spread on post operative histopathology report and treated with adjuvant chemoradiation were analysed for patterns of recurrence. Results: From July 2016 to December 2017, a total of 171 patients of oral tongue squamous cell carcinoma underwent upfront surgery, of which 32 patients had perinodal spread on post operative histopathology. 30 patients were categorized as stage IVA and 2 patients were stage III based on AJCC seventh edition staging system. However, all these patients would be staged as stage IVB according to AJCC eighth edition staging system. All 32 patients underwent adjuvant chemoradiation post surgery. At a median follow up of one year, the overall recurrence rate was 81%. Most of the patients developed locoregional recurrence (66%). The incidence of distant metastasis was 15%. Conclusion: Perinodal spread is an extremely poor prognostic factor causing upstaging of carcinoma tongue patients as per the recent AJCC staging. Even with definitive surgery and adjuvant chemoradiation, the chances of locoregional relapse are high. This warrants further studies to improve outcomes in this subgroup of patients.


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Psychiatric co-morbidities and their pattern in head and neck cancer patients: A prospective study in north Indian tertiary care centre

Dheerendra Kumar Sachan, Manish Kumar, Nupur Bansal, Ruchita Sachan

Introduction: Various psychiatric disorders especially anxiety and depression are big concern among cancer patients. Head and neck cancer constitute a major burden but till date few studies have prospectively evaluated head and neck cancer co-morbidities and mortality risks. Aims and Objectives: Aim of our study is to study the frequency of psychiatric comorbidities in head and neck cancer patients and their correlation with staging of disease. Materials and Methods: This study was conducted in outpatient department of a tertiary care hospital of northern India. 100 Head and neck cancer patients were included in this study and compared with 100 controls. The diagnosis and staging of head and neck cancer were assessed by histopathology and radiological investigation. Staging was done as per American Joint Committee on Cancer 7th edition. Psychiatric co-morbidities were assessed using the Mini International Neuropsychiatric Interview questionnaire. Results: The frequency of psychiatric comorbidities was significantly higher in head and neck cancer patients (49%) as compared to controls (4%). Also frequency was significantly higher in advanced stages. Increasing trend of co-morbidities was noticed in patients with long duration of symptoms. Patients with symptoms more than one year have 68% while only 24% of patients with duration of symptoms less than 1 year. Conclusion: Psychiatric co-morbidities are more in head and neck cancer patients. In majority of cases this part of patient care is overlooked. It would be better if all patients with head and neck cancer are evaluated for psychiatric co-morbidities.


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Reirradiation in head and neck cancers using stereotactic body radiotherapy: A retrospective study

J. Seios, P. Sasikala, Gowshikk Rajkumar, V. Bindya, K. Pradeep, Kumara Swamy, Ramesh S. Bilimagga

Aims: Role of re irradiation is pivotal in patients with unresectable recurrent head and neck cancers. With advent of Stereotactic Body Irradiation Technique (SBRT), acute toxicity is minimal due to short treatment periods and limited radiation fields. The purpose of this study is to assess the efficacy of SBRT with respect to overall survival (OS) and disease free survival (DFS) in patients with recurrent head and neck carcinoma treated with re irradiation using SBRT. Methods: From 2013 to 2016, 20 patients received re irradiation with SBRT for recurrent head and neck cancers. They were previously irradiated with a median dose of 70 Gy with IMRT technique and developed recurrence. The median age was 57 years (range 30-69 years) and included 16 males and 4 females. Primary sites were Nasopharynx (25 %), Hypopharynx (20 %), Oral cavity (20 %), Tongue (15 %), Oropharynx (10 %) and Supraglottic larynx (10 %). Patients were re irradiated with a median dose of 30 Gy (range 25-36 Gy), median of 5 fractions. 2 years and 3 years survival rate (SR), overall survival (OS) and disease free survival (DFS) were analysed. Results: At the end of 2 years, 4/5 patients with Nasopharyngeal cancers were alive and 1 patient died within 6 months due to recurrence. 4 patients with hypo pharyngeal cancers developed recurrence between 20-24 months. All 3 patients with tongue cancers died before 24 months, 2 patients developed recurrence at 18 months. Both the patients with oropharyngeal cancers, died within 12 months of re irradiation. Of 4 patients with oral cavity cancers, 2/4 patients with retro molar trigone lesions were asymptomatic. But 2/4 patients with buccal mucosal lesion died within 24 months. Both the patients with supraglottic larynx lesion developed recurrence within 12 months of treatment and died before 24 months. 10/20 (50%) patients survived of which 4/10 patients developed recurrence. Of the 10 patients who died, 4 patients developed recurrence within 2 years and the remaining 6 patients succumbed to treatment related complications. At the end of 3 years, 5/20(25%) patients were alive of which 3 patients were cases of Nasopharyngeal cancer and 2 patients with Retro molar trigone cancers. But 2/3 of the cases of nasopharyngeal cancers developed recurrence before 36 months and the remaining 3/5 patients were disease free. The median overall survival and disease free survival, post re irradiation with SBRT technique in head and cancers patients were 24 months and 20 months respectively; with a 2 year and 3 year survival rate of 50% and 25% respectively. Conclusion: SBRT is an effective re irradiation technique for patients who develop recurrence in locally advanced head and neck cancers with acceptable toxicity. Patients with nasopharyngeal primary and retro molar trigone have better prognosis when compared with other sites.


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Establishing role of salvage therapy with gefitinib in residual, recurrent and metastatic locally advanced head & neck cancer

Rajeev Atri, Anil Kumar Dhull, Mohd. Faraz Khan, Vivek Kaushal

Aims and Objectives: Head and neck cancer (HNC) is the seventh most common type of cancer in the world and constitute 5% of the entire cancers worldwide. The global burden of HNC accounts for 650,000 new cases and 350,000 deaths worldwide every year and a major proportion of regional malignancies in India. In our institute, in a recent analysis, 92% patients present in locally advanced stage (Stage III & IV). HNCs are responsible for 23% of cancer related mortality. Residual, recurrent and metastatic squamous cell carcinoma carries a poor prognosis. Treatment options in residual cancer include single-agent chemotherapy, combination chemotherapy or targeted therapies, but improvement in overall survival remains a challenge. Gefitinib is an EGFR inhibitor, like erlotinib, which interrupts signaling through the epidermal growth factor receptor (EGFR) in target cells. We have done a chemotherapeutic trial with gefitinib in LAHNC and explored the feasibility and treatment results. Materials and Methods: Study was conducted on 90 histopathologically proven patients of squamous cell carcinoma of head and neck who have received Radiotherapy and have residual, recurrent or metastatic disease. These patients received oral tablet gefitinib 250 mg daily for 18 weeks (3-weekly, 6-cycles). After every 3-weeks patient was assessed clinically and biochemically for feasibility, efficacy and tolerability of the prescribed schedule and also evaluated the PFS and toxicity in these patients. Results: Partial response was noted in 11% and progressive disease was found in 59% of patients. The overall response rate was 12% and median PFS was 4-months. Conclusions: Oral gefitinib, was well tolerated and had fewer systemic effects and have an emerging role in palliation of residual, recurrent or metastatic head and neck cancer. Further larger studies with comparison of other approved schedules are required to establish the treatment protocol in these subset of patients.


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Four different palliative radiotherapy schedules in locally advanced head and neck cancer

Manas Dubey, Anil Kumar Dhull, Tarun Kumar, Rakesh Dhankhar, Rajeev Atri, Vivek Kaushal, Om Parkash

Department of Radiation Oncology, Regional Cancer Centre, Pt. B D Sharma PGIMS, Rohtak, Haryana, India

Aims and Objective: To evaluate and compare efficacy, tolerability and toxicity of four different schedules of palliative Radiotherapy in locally advanced head and neck carcinoma and to evaluate their local control and side effects. Materials and Methods: The study was conducted on 120 previously untreated, histopathologically proven patients of locally advanced head and neck cancer. These patients were randomly divided in four equal groups by draw of lots and treated by different schedules of palliative radiotherapy. Group I - All these patients received total radiation dose of 44.4 Gy delivered by dose of 2 daily fractions of 3.7 Gy for 2 days every 3 weeks for three cycles. All these patients received paclitaxel 60 mg/m2, 1 hour prior to the first day of each radiation cycle. Group II - All these patients received total radiation dose of 44.4 Gy. Radiation therapy delivered in 2 daily fractions of 3.7 Gy for 2 days every 3 weeks for three cycles. Group III - All these patients received total radiation dose of 40 Gy in 10 fractions over 5 weeks with a fraction size of 4 Gy, 2 fractions per week with a gap of at least 2 days between 2 fractions. Group IV - All these patients received total radiation dose of 40 Gy in 10 fractions split into two schedules each of 20 Gy 5 fractions over 5 days in a week, three weeks apart. Results: At the end of treatment, complete tumor response (CR) in Group I, II, III & IV was 40%, 37%, 13% & 3% respectively. Conclusion: Quad Shot schedule with paclitaxel has proved best among all schedules with better local control and acceptable toxicity and larger studies are recommended for Indian settings to establish the protocol.


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Assessment of treatment related mucositis in locally advanced head and neck cancer patients

Praghnya Tejale-Pusate, Vijay K. Mahobia, Ashok K. Diwan

Department of Radiation Oncology, GMC, Nagpur, Maharashtra, India

Aims and Objectives: Radiotherapy and chemotherapy are the mainstay of treatment of locally advanced cancer of head and neck. Oral Mucositis is a common adverse event following radiotherapy and severity increases with addition of chemotherapy. Primary aim of this study was to assess severity of Mucositis in patients undergoing radiotherapy and chemotherapy in locally advanced cancer of head and neck. Secondary aim was to assess weeks required to develop Mucositis. Materials and Methods: 193 consecutive patients of locally advanced cancer of head and neck attending outpatient and inpatient of Radiation and Oncology department of GMC Nagpur were evaluated. Out of 193 patients, 150 complied with the inclusion criteria. 48 of these were submitted to Arm A-Neoadjuvant Chemotherapy followed by Concurrent chemo-radiotherapy, 55 to Arm B-Concurrent Chemo-radiotherapy while 47 to Arm C-Radiotherapy alone. Mucositis was assessed according to Radiation Therapy Oncology Group criteria (RTOG). Results: Out of 150 patients arm A consists of 48, arm B 55 and arm C 47 patients. Grade 1 mucositis developed in 16%, 9% and 10 % patients of arm A, B and C respectively. Grade 2 mucositis developed in 33%, 67% and 63% respectively; grade 3 mucositis developed in 50%, 24% and 25 % respectively. Mucositis mostly developed in 3rd week in arm A (68%) and B (50.9%) while 4th week in arm C (53.1%). Grade 3 mucositis was common in arm A (50%), grade 2 mucositis in arm B (67.2%) and C (63.8%). There was a significant difference in grades of mucositis in the three treatment arms (Chi square 14.08, p < 0.01). Conclusion: In comparision with Radiotherapy, addition of chemotherapy not only increases the severity of mucositis but also causes early development of mucositis.


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Clinical profile and treatment outcomes of squamous cell carcinoma maxilla: A retrospective analysis

Blossom Chacko, C. T. Kainickal, R. Rejnishkumar, Malu Rafi, A. L. Lijeesh, M. P. Aparna, Naveen P. Kumar, K. Ramadas

Department of Radiation Oncology, Regional Cancer Centre, Trivandrum, Kerala, India

Aims and Objectives: To evaluate the clinical profile and treatment outcomes of patients with squamous cell carcinoma Maxilla at Regional Cancer Centre, Trivandrum between January 2012 and December 2014. Materials and Methods: Patients diagnosed with Squamous cell carcinoma Maxilla, who underwent treatment during the period from January 2012 to December 2014 in Regional Cancer Centre, Trivandrum were evaluated retrospectively. Primary end points were locoregional control and three year disease free survival. Secondary end point was overall survival and factors determining treatment outcome. Data was captured using a structured proforma. Disease free survival (DFS) and overall survival (OS) were calculated using Kaplan Meier Method. Results: Thirty nine patients with squamous cell carcinoma Maxilla were treated from January 2011 to December 2014. Out of these, most were males (71.8 %) and the median age at diagnosis was 58 years. None belonged to stage I, One patient (2.6%) belonged to stage II, Nine (23.1%) to stage III, Twenty six (66.7%) to stage IVA and Two (5.1%) to stage IVB. Twenty seven (69.3%) patients were treated with radical intent and 12 (30.7%) patients with palliative intent. Fourteen (35.8%) patients underwent surgical management, of which 5 patients underwent subtotal maxillectomy, 7 patients total maxillectomy, 1 patient medial maxillectomy and 1 patient right extended total maxillectomy. Three patients underwent modified radical neck dissection along with planned procedure. Twelve (85.7%) patients had Primary Surgery, two (14.2%) received Induction chemotherapy prior to Surgery. Eleven (78.5%) patients who had undergone surgery have received postoperative radiation. Twenty one (82%) patients have received radiation treatment, thirteen patients with radical intent and eight patients with palliative intent. Six (28.5%) received Radical chemoradiation, Eight patients (38%) received induction chemotherapy followed by RT and Seven (33.3%) patients received radiation alone. Eight patients received radiation with IMRT/IGRT technique with 66 Gy/30 fractions and Seven patients received conformal radiotherapy with 55 Gy/20 fractions. All patients completed radiotherapy without any interruption. Eight patients attained clinical remission after radiation treatment. Ten (25.6%) patients developed relapse. Out of the 10 relapses, Eight patients (80%) had relapse in the primary site, two (20%) had nodal relapse. None of the patients underwent salvage surgery for the residual disease. One patient underwent salvage surgery for nodal recurrence. One patient developed distant metastasis (liver). One patient developed a second malignancy (lung). After a median follow up of 47 months, three year DFS was 31.7% and 3 year OS was 38%. Stage III has 3 year DFS 33.3% and 3 year overall survival of 62.5% while stage IVA has 3 year DFS 30.8% and 3 year overall survival of 32.7%. Stage IVA disease had a poorer outcome compared with other stages. Conclusion: Most of the patients with Squamous cell carcinoma Maxilla present with an advanced disease. Salvage rates are very poor. Three year DFS was 31.7% and 3 year OS was 38%. Limitations of the study includes the small number of patients and retrospective nature.


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Association of histopathological grading of oral and orophayngeal cancers and its correlation with tobacco abuse both smoked and non-smoked in western part of Uttar Pradesh: A hospital based study

Santanu Chaudhuri, Debashis Panda, Saurabh Goswami, Neeraj Kumar, Navin Kumar, Mamta Sharma, Akash Radia, Sanjeev K. Gupta

Departments of1 Clinical Oncology,2 Biostatistics and3 Outreach, Nayati Healthcare and Research Centre, Mathura, Uttar Pradesh, India

Aims and Objectives: Oral and oropharyngeal cancers are heterogeneous group of diseases that arise in various sub sites of the oral cavity and oropharynx with different risk factors, prevalence and outcomes. It is well proven that tobacco abuse is associated with different kinds of head & neck malignancies. Overall 95% of oral and oropharyngeal cancers are caused by tobacco consumption. Squamous cell carcinoma is the most common histopathology in these sites. Histopathologically these cancers can be well differentiated (grade 1), moderately differentiated (grade 2) and poorly differentiated (grade 3). Here we have tried to correlate the association of these histopathology grades with tobacco chewing habits in western part of Uttar Pradesh. Material and Methods: This study is a retrospective cross-sectional hospital based study, performed in a quaternary care centre in the western part of Uttar Pradesh. Tobacco users with histopathologically proven oral and oropharyngeal malignancies, who were registered in our hospital between Jan 2017 to July 2018, included in our study. Data collected from medical records were analysed using SPSS 21.0 software. Fisher's Exact Test used for categorical variables to see the association between them. The level of statistical significance was set as p<0.05. Results: The data of 40 subjects were analyzed. The most common age group affected by oral and oropharyngeal malignancies is 51-60 (32.5%) followed by 61-70 (25%). Male (87.5%) preponderance was observed. 67.5% cases were of oral cavity cancers and 30% oropharyngeal and 2.5% overlapping oral and oropharyngeal cancers. Subsite analysis suggested buccal mucosa was the commonest subsite involved (32.5%) followed by oral tongue (25%), base of tongue (22.5%), RMT (5%), Soft palate (5%), tonsillar fossa (2.5%), alveolus (2.5%). It was observed that most cases presented to our hospital in stage III and IV which was 82.5%. Grade 2 was more common (65%) followed by grade 1 (25%). There was statistically significant association between grade and gender [p=0.04; i.e. grade 2 &3 is highly associated with males (80.0%)]. No significant association is observed between grade with respect to tobacco habits (p=0.55), grade with smoking (p=0.09), grade with tobacco chewing (p=0.74), grade with both smoking and tobacco chewing (p=0.39). This may be due to smaller sample size. Conclusion: Thus we can conclude that though tobacco acts as a risk factor in oral and oropharyngeal malignancies, still it can't be certainly concluded that tobacco habits could be associated with the grade of the disease, which is a major prognostic factor. We need to do the analysis with bigger sample size to draw any conclusion with certainty in this regards. As in this study male gender is having positive association with grade, so the cancer biology may need to be further explored to see any other associations.


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A prospective randomized controlled comparison of simultaneous integrated boost intensity modulated radiation therapy versus sequential boost intensity modulated radiation therapywith concurrent cisplatin for locally advanced head and neck cancer

Nilesh Mani, Sunil Choudhary, Abhijit Mandal, S. K. Aggarwal

Departments of 1Radiotherapy and Radiation Medicine and 2ENT, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Aim: To compare outcome between two techniques Simultaneously Integrated Boost (SIB) and Sequential boost (SEQ) Intensity Modulated Radiotherapy in terms of disease free survival, overall survival and toxicity. Materials and Methods: This prospective study included 23 patients between February 2017 and December 2017, of which eleven in SIB and twelve in sequential boost arm were allocated randomly. Stage III and IVA cancers of oropharynx, larynx and hypopharynx without prior history of any treatment for the concerned malignancy were included. Both the arms had three PTV (planning target volume), HR (High risk)-PTV, IR (intermediate risk)-PTV and LR (low risk)-PTV. In the SIB arm 70 Gy, 61 Gy and 54 Gy in 35 fractions and in the SEQ arm 70 Gy, 60 Gy and 50 Gy were prescribed to HR-PTV, IR-PTV and LR-PTV respectively. All the patients were treated with 6 MV photons' on Linear Accelerator. Weekly toxicities were recorded during treatment and at 3 monthly follow-up. Loco-regional control, disease free survival, overall survival were estimated via Kaplan-Meier statistical method. Results: The mean OS and DFS for all the entire cohort was 14.6 months and 14.2 months respectively. On sub-set analysis mean OS for SIB and SEQ arms was 14.4 months and 14.8 months respectively (p = 0.807). Mean DFS for SIB and SEQ arms was 14.1 months and 14.2 months respectively (p = 0.888). The median follow up of patients in SIB and SEQ arms who were alive was 10.7 months and 8.5 months respectively. Overall survival at 18 months in SIB arm was 70% while in SEQ arm it was 75% and disease free survival was 68% in SIB and 70% in SEQ arm. The difference in survival was not significant. Acute dermatitis, mucositis, dysphagia and salivary gland toxicities were higher in SIB arm as compared to SEQ arm. Conclusions: The study showed that SIB and SEQ RT schedules were well tolerated. The acute toxicities were higher in SIB arm compared to SEQ arm. OS and DFS were similar in the two groups though the cause specific death was higher in SIB group.


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Assessment of dysphagia in patients with head and neck carcinomas receiving radiotherapy, and its impact of Quality of Life

Krishna Sharan, Priyanka S. Alurkar, Donald Fernandes, Anshul Singh, Anusha Reddy, Prahlad H. Yathiraj, Umesh Velu, Shirley Christabel

Aims: To report the incidence and severity of dysphagia in patients with Head & Neck Squamous Carcinomas (HNSCC) receiving radiotherapy by Volumetric Modulated Arc Radiotherapy technique, and assess its impact on Quality of Life (QoL) using MD Anderson Dysphagia Inventory (MDADI). Materials and Methods: Patients with HNSCC receiving definitive or adjuvant radiotherapy by VMAT between January 2017-March 2018 were considered. The baseline dysphagia was recorded, and dysphagia and MDADI scores were obtained at completion of treatment, 3 months and at 6 months. Independent samples t-test was used to correlate patient and treatment-related variables with MDADI scores. Results: 62 patients were eligible for analysis. Median age was 54 years (range: 25-85 years), and males predominated (91.9%). Oral cavity primary was the commonest subsite (33.9%) and 79% had stages III-IVB at presentation. 30 (48.4%) patients were treated with adjuvant radiotherapy. 37 patients (59.7%) received concurrent chemotherapy. At completion of treatment, 55 (88.7%) experienced dysphagia, of which 17 (27.4%) had grade III dysphagia. The physical component of MDADI was maximally affected, the mean (±SD) emotional, functional, physical and total scores at RT completion being 77.4 (±11.0), 77.7 (±14.5), 59.4 (±13.7) and 67.1 (±13.2), respectively. Concurrent chemotherapy administration, higher mean doses to constrictors (≥50 Gy) and larynx (≥45 Gy) were associated significantly worse scores. Patients receiving definitive RT tended to have worse scores (p= 0.064). By six months, there was significant improvement in QoL, with mean (±SD) emotional, functional, physical and total scores being 94.3 (±7.4), 94.9 (±5.9), 87.7 (±11.7) and 92.1 (±9.3). There was a significant association between mean dose to larynx (≥45 Gy) and physical scores; none of the other parameters correlated with the MDADI scores. Two patients had worsening of QoL, both ascribed to recurrent/metachronus disease. Conclusions: Dysphagia is a frequent acute complication of RT for HNSCC, with all patients experiencing drop in QoL as measured by MDADI, with maximum impact on physical component. By six months however, most patients have improvement in their QoL.


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Retrospective analysis of accute toxicity and weight loss pattern in patients undergoing dysphagia and aspiration-related structure and submandibular gland sparing adjuvant volumetric arc therapy for cancer buccal mucosa and alveolus in a rural setup of India

Tapas Dora. Abhishek Chatterjee, Jayashree Deshmukh, Amol Kakade, Avtar Singh, Amit Saini, Shefali Pahwa, Sarbani Ghosh Laskar, J. P. Agarwal

Aims: Intensity Modulated Radiotherapy (IMRT) has been proposed as the standard of care for head & neck cancers. It may be especially relevant when it comes to adjuvant settings like cancer of buccal mucosa & alveolus. We conducted a retrospective audit to study the cut off mean doses for dysphasia aspiration related structures & Esophagus in relation to the patterns of weight loss. Materials and Methods: A prospective database of 41 patients of Carcinoma Buccal Mucosa or Alveolus who had received adjuvant volumetric arc therapy (VMAT) (60-63 Gy/ 30-35#/ 6-7 wks) on Versa-HD (ELEKTA) with IGRT (thrice weekly) and conc. Cisplatin (40 mg/m2) from December 2016 to September 2018 were reviewed. The RTOG grading system for acute toxicity was used to score toxicity of skin, mucous membrane& weight loss. Treatment plans were reviewed for mean doses of uninvolved Oral Cavity (OC), DARS (DR) & Esophagus (EP). Receiver Operating Characteristics was run on SPSS version 21 to get thresholds to categorize the above mean values towards weight loss pattern ≥3 kg or ≥5 kg. Chi-square analysis was performed to find whether the categorized mean values were significant for above weight loss patterns. Results: 21 (51%) patients were of left & 20 (49%) of right side. 17 (41.5%) cases received concurrent chemotherapy. Dose received was 60 Gy in 35 (85%) & 63 Gy in 6 (15%) cases due to close margin. Stage I, II, III, IV distribution was 2%, 22%, 5% & 71%. Grade 0, I, II, III acute skin toxicity was observed in 6%, 34%, 54%, 6%. Grade 0, I, II, III mucosal toxicity was observed in 6%, 20%, 60%, 14%. Mean dose for contralateral Submandibular & Parotid gland achieved was 24.4 Gy (12.8 Gy-56.7 Gy) & 10.8 Gy (4.6 Gy-35.6 Gy). Mean dose for Oral Cavity, DARS & Esophagus achieved was 42 Gy (27.2 Gy - 62.2 Gy), 39 Gy (27.8 Gy - 54.5 Gy) & 33 Gy (20.17 Gy - 49.4 Gy). Total 8 (20%) patients had nasogastric tube feeding. Mean & Median weight loss was 2.7 kg (0 – 9 Kg) & 2 Kg. Weight loss ≥3 Kg & ≥5 Kg was seen in 46% & 20% patients. Mean doses of DARS (<39 Gy) impacted incidence of ≥3 Kg weight loss (25.0% vs. 63.2%, p=0.024) on Chi-square. Mean doses of Esophagus (<30 Gy) impacted incidence of ≥3 Kg weight loss (16.6% vs.60.9%, p=0.013) & ≥5 Kg weight loss (0% vs. 30.4%, p=0.033) on Chi-square. Mean doses of Oral Cavity, Contra lateral Parotid & Submandibular Gland didn't predict for acute ≥ Grade II/ III Mucosal toxicity significantly. Local recurrence, metastasis & both seen in 1, 1 & 2 patient respectively. Conclusions: In patients undergoing VMAT with concurrent chemotherapy restricting mean doses of DARS & Esophagus to less than 39 Gy & 30 Gy significantly reduced the incidence of weight loss to less than 3 kg & 5 kg, respectively.


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Incidence of stage migration as per American Joint Committee on Cancer eighth edition in head and neck carcinomas: Experience from a tertiary cancer center in India

Rohith Singareddy, Harjot Kaur Bajwa, Krishnam Raju Alluri

Aim: To determine the rates of T Stage and N Stage migration in patients with carcinoma oral cavity as per the recent AJCC staging system. Materials and Methods: Patients diagnosed to have squamous cell carcinoma of the oral cavity and treated with definitive surgery were analysed for stage migration. All patients were staged as per the previous AJCC Seventh Edition and the recent AJCC Eighth Edition. Results: Between July 2016 and December 2017, a total of 365 patients were diagnosed to have squamous cell carcinoma of the oral cavity. All patients were staged as per the AJCC Seventh Edition and treated by definitive surgery with or without adjuvant chemoradiation. On staging these patients according to the AJCC Eighth Edition, 149 patients (41%) had a change of overall stage with majority of patients (78) upgrading from stage IVA to IVB due to perinodal spread. 39 patients upgraded from stage II to III due to inclusion of depth of invasion as a factor in stage determination. The incidence of T stage migration was 33.6% with majority of patients getting upgraded from T2 to T3 due to depth of invasion. The incidence of N stage migration was 24% with majority of patients being upgraded from N2b to N3b due to perinodal spread. Conclusion: The new AJCC Staging System has had a significant impact on staging of oral cavity carcinomas. Factors like perinodal spread and depth of invasion lead to upgradation of stage and poor prognosis. Determining the standard of care in such patients warrants studies with long term follow up.


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Postoperative oral tongue cancers: An audit to evaluate the prognostic impact of histo-pathological factors on long term outcome

Sidharth Pant, Punita Lal, Piyush Gupta, Shagun Misra, K. J. Maria Das, Shaleen Kumar

Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Objectives: To critically review the impact of various histo-pathological factors that may determine the outcomes of post-operative oral tongue cancer patients treated at a Tertiary Cancer Care Centre. Material and Methods: Service evaluation of oral tongue cancer patients treated between 2008-2013 was done. Demographic factors, diagnostic workup and stage were documented. Patients who underwent surgery and were referred for adjuvant RT were included. Patients received post op RT (60 Gy/30 fractions/6 weeks) (except very small volume disease); and, patients with features such as positive margins and ECE positivity received concurrent weekly chemotherapy along with post op RT. The impact of histo-pathological features as found in the surgical specimen was studied. Statistical analysis done in September 2018. Results: 267 oral tongue cancer patients were registered at our institute out of which 174 (65%) patients had undergone surgery and were referred for adjuvant treatment. Median age of presentation was 45 years (range 18-85 years); males 84% (223/267) and median KPS was 80. Tobacco habits were present in 197 (74%) cases. Clinical stage IVA was the commonest 80/174 (46%); 46% (80/174) patients were pathologically stage-IV disease and142 (82%) received postoperative RT. The survival end points of Progression free survival (PFS) and overall survival (OS) were studied. In the patient who received post-op RT, median follow up was 57 months. At the time of analysis, 57 patients (33%) were alive, 36 (21%) dead and 81(47%) patients lost to follow up. In the post-op RT group, 5 years PFS and OS were 51% and 53% respectively (Worst case scenario considering all lost to follow up as events-i.e. failed or dead when last seen). Patients with extra-capsular nodal extension (ECE) had significantly inferior PFS (median 44 vs 82 mo, p= 0.02); similar to pathologically positive lymph nodes group of patients (median PFS 44 vs 82 mo, p= 0.06). OS was inferior for patients with age >45 years (p=0.04), pathologically positive LN (p=0.03), presence of ECE (p = 0.06). On multivariate analysis, age >45 years (hazard ratio [HR], 0.47; 95% CI, 0.23 to 0.95) conferred an inferior OS while ECE (HR, 2.8; 95% CI, 1.09 to 7.2) predicted a lower PFS. Conclusions: Radical surgery and post operative radiotherapy (+/- CT) is the standard of care. In our audit we particularly observed that older age worked adversely towards survival possibly because they had difficulty in withstanding radical surgery and RT. ECE was found to be an independent prognostic factor for predicting PFS.


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Importance of multifactorial association of demographic events influencing treatment tolerance in radiation therapy of head and neck cancers: A hospital based retrospective study

Saurabh Goswami, Neeraj Kumar Debashis, Panda Sanjeev, K. Gupta, S. N. Sinha, Navin Kumar, Mamta Sharma, Santanu Chaudhuri

Departments of1 Clinical Oncology,2 Medical Physics and3 Biostatistics, Nayati Healthcare and Research Centre, Mathura, Uttar Pradesh, India

Aims and Objectives: This retrospective trial is helpful in evaluating and studying the impact of different variables of socioeconomic status, nutritional status on radiotherapy treatment in terms of delayed treatment, incomplete treatment and on time finishing treatment in head and neck cancer patients. Materials and Methods: We retrospectively analyzed pooled individual-level data of head and neck cancer patients from December 2017 to July 2018 who underwent radiation therapy. Socioeconomic data analysis done with the help of modified kuppuswamy scale 2018. Anthropometric measurements such as patient's height, weight, and body mass index are considered relevant and objective measures of a cancer patient's nutritional status. Body weight was an essential component of the initial nutritional assessment due to the significant impact of weight loss on morbidity and mortality. Data has been received from the hospital information system and hospital records using a preset proforma entered into excel sheet. Analysis of data will be done using SPSS version 21.0. Collected data was analyzed using chi-square test and p-value for determined to find the statistical significance. P-value was considered significant if its value was <0.05. We also performed logistic regression analysis for variables of socioeconomic status like age, race, marital status, family income, highest level of education achieved. The present review also aimed to define the role of nutritional status by studying the weight loss and change in BMI of head and cancer patients undergoing radiation therapy. Results: In this retrospective study total 57 patients of head and neck cancer, those underwent radiation therapy treatment in our hospital were analyzed. The demographic factors like age, gender, marital status and race shows no significant association with socioeconomic factors. Out of all the patients, 31 (54%) belongs to lower middle class, 24 (42%) upper lower class and only 2 (4%) were from upper middle class according to Kuppuswamy scale. The delayed radiation therapy treatment category of patients shows that 10.5 % belongs to lower middle class, 8.7% patients are from upper lower class and no patients are from upper middle and upper class. Patients who finished treatment on time were 33, of which 2 (6.1%) were from upper middle class, 16 (48.5%) are from lower middle class and 15 (45.5%) are from upper lower class. The average weight loss (Mean±S.D, Kg) of patients during treatment in first week was 0.41±0.22, second week 0.84±1.19, third week 0.76±1.42, fourth week 0.92±1.34, fifth week 1.07±1.05 and sixth week 1.22±1.37. Analysis of pretreatment BMI showed 19 (33.3%) were underweight, 19 (33.3%) were normal weight, and 19 (33.35%) were overweight and on treatment completion 24 (42.1%) were underweight, 20 (35%) were normal weight and 10 (17.5%) are overweight. The average decrease in BMI during treatment (Mean±SD, Kg/m2) from first week to last week was from 21.56±5.57 to 19.86±3.88. Conclusion: Most of the patients of head and cancer belong to lower middle and upper lower socioeconomic class. There is no significant relation found between socioeconomic classes in terms of delay in treatment, which may be due to smaller sample size. There was significant decrease in weekly assessment of weight and BMI from pretreatment to post treatment hence nutritional support play major during treatment of head and neck cancer patients.


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Dosimetric correlation of dysphagia/aspiration at risk structures with late dysphagia: Does standard intensity-modulated radiation therapy have a benefit over conformal radiotherapy

N. H. Hanan, Anup Hegde

Aims and Objectives: Primary objective – (1) Subjective evaluation of late dysphagia in patients who have received IMRT/3D Conformal radiotherapy in radical or adjuvant treatment of their Oral/Oropharyngeal cancers. (2) Evaluation of dosimetric correlation of dose received to DARS with the incidence and grade of late dysphagia. Secondary objectives – (1) Quantification of dosimetric advantage of IMRT over 3DCRT in sparing DARS during Head and Neck Radiotherapy. (2) Volumetric dose correlates of individual DARS with late dysphagia. Materials and Methods: The analysis included 30 patients with Oral and Oropharyngeal malignancies treated from March 2014 to September 2017. A dosimetric and Volumetric evaluation of dose parameters to the dysphagia and Aspiration associated structures were analyzed. The National Cancer Institute Common Toxicity Criteria for Adverse events version 4 was used to grade late Dysphagia. Subjective evaluation was done with University of Washington Head and Neck related Quality of life Questionnaire. As secondary objective, dosimetric comparison between patients receiving IMRT and 3DCRT was done. Results: A greater than Grade II Dysphagia score was observed in 10 Patients (33%). In the 3DCRT cohort Gr III and IV toxicity was higher (50% vs 25%). The mean doses to the Constrictor volume ranged from 16.59 Gy to 71.31 Gy. A threshold mean dose of 63 Gy was identified as a significant parameter above which observed Gr III/IV toxicity was 33%(p=0.028). The volume of inferior constrictor subjected to 60 Gy (V60) was also a significant parameter for anticipated Gr III/IV toxicity. The maximum dose to the Base of Tongue (BOT) and Supraglottic Larynx (SGL) were other parameters which achieved significance (p=0.013). In the 3DCRT cohort 30% (3/10) of patients aspirated while in IMRT group this was 5% (1/20). In all aspiration cases, the Mean dose to SGL and BOT exceeded 60 Gy and in 3 out of 4 patients (80%) the mean dose exceeded 65 Gy. There was no significant dosimetric difference in the comparison of dose delivered to DARS between 3DCRT and IMRT Cohort of patients. However, the patient reported dysphagia scores were higher for pain (0.0014) and may be attributed to higher % of patients exceeding parotid tolerance (70% vs 40%). Gr III/IV toxicity was observed to significantly impair all Quality of life parameters inclusive of late chewing, swallowing and general perception of wellbeing. Conclusion: This study conducted on a small cohort of patients who may practically be eligible for DARS sparing suggest that a threshold dose MD of 63 Gy to the constrictors is statistically correlated to significant Gr III/IV late toxicity. That high doses to the BOT and superior constrictors independently contribute to late toxicity. A mean dose exceeding 60 Gy to the SGL and BOT could be associated with a greater than 80% risk of aspiration. Even with the same dosimetric profile the risk of aspiration was 6 times greater with 3DCRT vs IMRT. IMRT is more efficient in reducing the severe late toxicities compared to 3DCRT and it's also associated with better patient reported Quality of Life parameters and should be the preferred treatment of choice in this selective subset of patients.


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Dose volume correlation of oral mucositis in laryngopharyngeal cancer patients treated with Intensity-modulated radiation therapy technique

M. Lithika Lavanya, Arul Ponni, M. G. Janaki

Background: Laryngopharyngeal (LP) cancers account for 58 % of H& N cancers in South India only. With RT+CT as the standard of care, the use of IMRT techniques have increased in these cancer patients. In conventional era the upper border for most of the LP Cancers was excluding the oral cavity (OC). But now with the extensive use of IMRT & addition of various margins to our GTV, a significant volume of oral cavity comes in the field. In the present study we have analysed the correlation between volume of OC in PTV & the dose with mucositis observed. Objective: Correlate the dose & volume of oral cavity with the mucositis in LP Cancer. Materials and Methods: Forty laryngopharyngeal cancer patients undergoing definitive RT+ CT were accrued. After prior informed consent patients were immobilized with orfit cast & contrast enhanced CT simulation of 3 mm slice thickness was done. Target structures & OAR (Organs At Risk) were contoured as per Gregoire et al & Brouwer et al guidelines respectively. Dose constraints were given to all OAR, including OC (mean dose of 26 Gy) as per QUANTEC. The volume of OC in PTV & the dose received by OC was recorded without compromising the PTV coverage. As per approved plan, patients were started on IMRT to a dose of 60-66 Gy with / without concurrent weekly cisplatin. The oral mucositis grade (as per RTOG Criteria) of the patient was assessed at commencement of RT, weekly intervals & at the end of radiation. Correlation of volume of OC & dose received by the oral cavity and the volume of OC receiving 20 Gy with the 5th week mucositis was done. Using spearman statistical test, the strength of correlation was found between OC dose, 5th week oral mucositis. Results: Total number of patients accrued were 40. Thirty one Male & nine Female. Median age was 56 years (ranging between 33-79 yrs). Five patients belonged to stage I, fifteen to stage II, sixteen to stage III & four to stage IV. Mucositis observed at 5th week are as follows: 2 patients with grade 1, 34 patients with grade 2, 4 patients with grade 3. Mean volume of OC in PTV 7.3 cc (0-37.79 cc), Mean volume of OC receiving 20 Gy was 44 cc & Mean OC dose is 27.7 Gy (9-59 Gy). With the average dose received by 50% volume of OC being 27.7 Gy, the mucositis observed commonly was of grade 2. A significant correlation was observed between dose to OC & volume of OC in PTV with mucositis. Correlation is significant at the 0.01 level & 0.03 respectively. Conclusion: With the advent of IMRT though xerostomia toxicity have reduced, mucositis is still a common toxicity. This oral mucositis observed can add on to the morbidity caused by toxicity of larynx & dysphagia related structure, hence oral hygiene and regular monitoring of oral cavity is also important in LP cancer irradiation.


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Change of Telomerase Activity in Peripheral Blood of Patients with Head and Neck Squamous Cell Carcinoma Pre- and Post-curative Treatment

Gurubasappa, Geeta S. Narayanan

Introduction: Tumors of the head and neck are the most common malignancy in India. Till date there is no clinically applicable tumor marker for head and neck cancer. Telomerase, is detected in approximately 90% of all malignant tumors, it may predict poor or favorable outcome, thus making telomerase both a highly attractive biomarker and target for the development of mechanism-based cancer diagnostics, prognostics, and therapeutics. Aims and Objectives: Primary objective was detection in change of telomerase activity before and after curative treatment in patient with tumors of head and neck. Materials and Methods: Patients with biopsy proven head and neck squamous cell carcinoma, stage I, II, III, IVA and IVB treated with curative intent, performance status 0-2 and malignancy at one primary site were included in the study. The telomerase levels were tested in tissue biopsy levels. The plasma telomerase levels were tested at baseline, 5 days after completion of treatment and at 3rd month follow up using ELISA. Plasma from 20 controls (volunteers) was used for the assay. Results: Data were analyzed using SPSS 16 for windows. The raised plasma telomerase activity was seen in all the patients with cancer at baseline. The mean plasma telomerase level at baseline was 861.4522 ng/ml, at 5 days after completion of curative treatment was 928.92 ng/ml and at 3 months of follow up was 898.87 ng/ml. The mean tissue biopsy telomerase level was 19768.53 ng/mg. There was a significant increase in baseline telomerase levels in cancer patients compared to normal (volunteers) (t=-3.52, p=0.001). There was a significant increase in telomerase levels in tissue samples compared to plasma levels at baseline (z=-8.7, p<0.001) There was a significant increase in plasma levels of telomerase at 3 months compared to baseline values on wilcoxons sign rank test (z= -1.98, p=0.04). The increase in telomerase level did not correlate with the response of the treatment. Use of tobacco, T stage, and N stage did not influence the telomerase levels. Conclusion: Change in telomerase levels in patients diagnosed with head and neck tumors treated with curative intent was found to have no correlation neither with disease status or as prognostic factor.


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Clinical audit of PTV margins in head and neck cancer patients treated in radiotherapy department of HCG Vadodara

Rahul Misra, Uday, Srikanth, Gaurav

Objective: To evaluate if the PTV margins given as per the population based margins are sufficient enough to cover all setup errors in the head and neck cancer patients treated in our department. Materials and Methods: The setup errors of 50 Patients of head and neck cancer treated at HCG VADODARA by Image Guided Radiotherapy (IGRT) from 24th August 2016 to 14th December 2017 were analyzed retrospectively. The following protocol was followed for IGRT. (1) Immobilisation device of the patient was prepared, (2) CT simulation of region of interest was done, (3) Contouring of normal structures and target volumes was done, (4) Treatment plan was prepared and approved, (5) Patient was taken on the treatment couch and set in treament position, (6) Image of the patient was acquired on the treatment couch and matched with CT simulation image, (7) Required shifts were executed and recorded before every fraction, (8) Treatment was delivered. The daily setup errors of all head and neck cancer patients were recorded after daily imaging on treatment couch before each fraction of radiotherapy. These setup errors were used to derive mean setup error and standard deviation for each patient. These setup errors and standard deviation values were used to calculate the PTV margins using van herk and stroom formulas. These calculations were done using a spreadsheet which autocalculates the PTV margins using the van herk and stroom formulas once the setup errors for all patients were entered. Results: The average setup margins were 0.28 cm in X axis, 0.29 cm in Y axis and 0.29 cm in the Y axis as calculated by the Van Herk formula. The average setup margins were 0.24 cm in X axis, 0.25 cm in Y axis and 0.25 cm in the Y axis as calculated by the Stroom formula. Conclusion: By both the formulas viz. Van Herk and stroom formulas the setup margins in all the three axes (x, y, z) were below the population based margins of 0.5 cm which were used in the department. Thus the current margins applied for setup errors are well within the safety range to offer precise and accurate treatment to the patients.


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An analytical study of organs at risk constraints achieving spinal cord and brainstem tolerance using QUANTAC guidelines in re-irradiation cases of recurrent head and neck cancers

Debashis Panda, Saurabh Goswami, Neeraj Kumar, Sanjeev K. Gupta, Navin Kumar1, Mamta Sharma1, Santanu Chaudhuri

Departments of Clinical Oncology and2 Biostatistics, Nayati Healthcare and Research Centre, Mathura, Uttar Pradesh, India

Aims and Objectives: With development of technology, now a days head and neck cancers are addressed with surgery, radiotherapy, chemotherapy and biological therapy. In spite of achieving a high cure rates, good number of recurrence and second primary cases are detected now a days. Radiotherapy plays an important role in salvage in these recurrence and second primary cases. But the most important is to achieve the constraints for the organs at risk in the re-irradiation cases as per ALARA principle. Here we have studied the dose constraints achieved for spinal cord in the cases of re-irradiation in head and neck cancers. Dose analysis of OAR constraints spinal cord and brainstem for the patients who are undergoing re-irradiation of recurrent head and neck cancers. Material and Methods: This case series is a retrospective pilot institution based study, performed in a quaternary care centre in the western part of Uttar Pradesh. A dose of previous radiation history is collected in details as most of the patient has been treated outside hospital. Dose decay calculated with respect to time gap between both the radiation treatments using the formula;

Dose decay = Previous dose X decay factor

Decay factor = [T/(R+T)]0.11

Where, T=Treated days (Total number of fractions + Gap), R=Rest days (Post RT completion to restart of Re-irradiation), [OAR dose constraint = Normal tolerance dose of the OAR – Residual dose]. All the dose constraint data are collected after calculation and the MEDIAN dose is considered. Plans have been done on Monaco treatment planning system (Version 5.11.02). All the treatments are done using VMAT technique. Results: Total 9 numbers of patients are recruited in this study. Out of 9 patients 55.6% (5 patients) patients are within 51-60 years age group and 44.4% (4 patients) are within 61-70 years age group. The commonest site of recurrence observed in ‘Oral Cavity’ which is 66.67%, followed by ‘Oropharynx’ and ‘Larynx’ in our study. 44.4% of cases have recurred within 2 to 5 years and 33.3% recurred after 5 years of completion of radiotherapy. Mean gap between the first radiation and re-irradiation is 1505.89 days, with a range from 503 to 3615 days, which is statistically significant (p- value = 0.003). Median value of Dmax for ‘Spinal cord’ was 1324.5 cGy and that for ‘Brainstem’ was 1219.9 cGy respectively. Median value of Dmax for ‘Spinal cord PRV’ was 1452.8 cGy and that for ‘Brainstem PRV’ was 1344.4 cGy respectively. The individual values are also below the dose constraints, calculated for every patient. Conclusion: We can conclude from the above study that, re-irradiation is possible with properly achieved OAR constraints as per the ALARA principle, by using ‘high precision radiotherapy’ technique. But we need a larger sample size and long follow up for validating our results.


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A comparative study on safety and efficacy of Turmeric based Mouthwash and sodium bicarbonate based mouthwash in prevention of severe radiation mucositis for patients treated for head and neck cancers

Suparna Kanti Pal, Sumana Maiti, Bidhan Chandra Mondal, Siddhartha Basu

Introduction: Radiation Mucositis is the most common acute adverse event in patients receiving concurrent chemoradiotherapy for head and neck malignancies. Reduction of Oral mucositis results in better tolerability, reduced breaks and consequently better outcome for the patients. Aims and Objectives: To assess if locally prepared Turmeric based mouthwash can be used to reduce the incidence of Grade III and IV oral mucositis in patients undergoing Concurrent chemo-radiotherapy for Head and Neck malignancies. Methodology: Adult patients of locally advanced Carcinoma of head and neck region receiving Concurrent Radical Chemoradiotherapy with at least three portals by conventional Cobalt 60 beam were included in the study after informed consent. They were randomized by Lottery method till sample size in any of the arm was full. Patients on Test arm were asked to use mouthwash prepared with dissolving Turmeric paste resulting in light golden yellow solution for at least 3 times a day. Those in reference arm were asked to do the same with Mouthwash prepared by dissolving Sodium Bi carbonate. Other Oral care was same in both arms. A total of 200 Patients were included in the study with 1:1 randomization from Oct 2017 to July 2018. The sample size was calculated on premise of an incidence of 25% (±5%) Grade III or IV Oral mucositis among patients, and an anticipated reduction of 10-15%, with the intervention. Results: Among the primary 73 patients had primary in Nasopharynx, 52 in Oral cavity, 64 in oropharynx, and 11 were CUP. The Primary areas were nearly evenly distributed in the both arms. There were total of 32 episodes of Severe Mucositis (grade III & Grade IV of CTC v4.4 Criteria). 23 of them were in the Reference arm (19 Grade 3 and 4 Grade4) while there were 9 such events in the test arm (all grade III). Fischer's 2 tailed test was performed which came to be statistically significant (P=0.0113). Both the grade IV reactions were near the lips in patients with carcinoma Tongue. There were a total of seven breaks during the study and barring one all were in the reference arm. The average duration of the breaks were 4 days in the Test arm and 7 days in the reference arm. There were 7 patients (all oropharynx) receiving 6 fractions a week, 2 in the Test arm and 5 in the reference arm. One of those patients in the reference arm had developed Grade III mucositis requiring a break of 4 days. Conclusion: Use of Turmeric based mouthwash can be a cheap and effective way to reduce radiation mucositis in patients undergoing radical Chemoradiotherapy of the Head and Neck region.


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Zinc impacts the therapeutic ratio in head and neck cancers- reality or just a theorized concept

Mohsin Khan, Shahid A. Siddiqui, Mohd. Akram, Mohd. Shadab Alam

Aims and Objectives: To highlight the effects of zinc supplementation on a. adverse events and b. response rates in head and neck cancer patients undergoing definitive concurrent chemo-radiotherapy. Materials and Methods: Case records of patients with oral cavity, oro-pharynx, hypo-pharynx or larynx primaries, who underwent definitive chemo-radiotherapy were analyzed from July 2013 till July 2018. Those who received zinc supplements were categorized as arm A and those who did not received any zinc supplement as arm B. Irrespective of salt/ brand only those patients who received minimum of 40 mg of elemental zinc were studied in arm A. All patients had received a total of 6600 cGray (cGy) – 7000 cGy radiotherapy with 40 mg/m2 weekly intravenous concurrent cis-platinum. Radiation Therapy Oncology Group (RTOG) Radiation Morbidity Scoring System was used to summarize data on adverse events. Computed tomograms (CT) scans available at 2-3 months post completion of treatment were compared for documenting response rates. Results: Data was collected from 95 patients under arm A and 107 patients in arm B. both the arms were well balanced with respect to number of patients, sex, and primary site of disease. However, arm A had slightly more number of combined stage III+ IV patients. 15.8% of patients in arm A and 21.5% in arm B had RT interrupted for more than 1 week. Though the results were not statistically different for >Gr 2 (Grade) toxicities pertaining to skin, mucous membrane and pharyngeal/ esophageal sites, patients in arm A fared slightly better than those in arm B. Interestingly, when the two groups were analysed for salivary gland adverse events, 74 patients in arm B complained of ≥Gr 2 toxicities as compared to 37 of those in arm A, the results being statistically significant (p = 0.000017). Complete response (CR) was noted in 71% of patients in arm A and 75% in arm B. Overall response rates were 88.4% in arm A and 92% in arm B, results being statistically not significant (p= 0.22). Conclusions: Zinc an antioxidant can attenuate the effects of ionizing radiation on cells. Contrary to the theoretical radiobiology concepts, there are studies which have pointed to the differential effects of zinc on normal and tumor cells. Zn down regulates HIF1α (hypoxia inducible factor) in tumor cells and induces apoptosis by up-regulation of p53 and Fas/Fas ligand. Being retrospective, study has its own limitations and biases. Nevertheless, we observed that systemic zinc supplementation lends some of its radio-protective effects in normal tissues with salivary glands deriving the major benefits.


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Demographic profile of Head and neck cancer in a tertiary care hospital for 5 years- A retrospective study

Souvik Ghosh, Partha Das Gupta, Kakali Choudhury, Krishnangsu Bhanja Choudhury, Chandan Das Gupta

Introduction: Head neck and cancer is one of the major cancer in Indian subcontinent. It has an unique demographic profile, personal history, family history and risk factors. Approximately 57% of global head and neck cancer occurs in Asia, 30% in India. Most of the head and neck cancer patient present with advanced stage in Indian subcontinent (60%-80%) compared to the developed country (40%). Aims and Objectives: The main aim of the study was to categorise head and neck cancer on the basis of the age distribution, sex distribution, risk factors, stage and different subsites distribution. Materials and Methods: The study was conducted in the Radiotherapy Department of R. G. Kar. Medical college and Hospital. The study period was from 1st January 2013 to 31 st December 2017. All the diagnosed case of head and cancer was included in the study. After that they are categorised on the basis of the age distribution, sex distribution, risk factors, stage (AJCC 7th edition), different subsites distribution and personal history. Results: It was found that the majority of the patient of Head and neck cancer were in advanced stages at first presentation. Majority of them were middle aged males having a positive history of tobacco use in various forms for at least five years. The majority of the female patients also had a positive history of tobacco use either by chewing or by passive smoking. Conclusions: Head and neck cancer is a major public health problem in India. This study highlights the lack of awareness of the patients about the harmful effect of tobacco on health and early health check up.


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Correlation of pharyngeal constrictor dose with late treatment related dyspahgia postradiotherapy

V. Prathyush, Lithika Lavanya, Nishanth Vidyasagar

Background: Head and neck cancers are treated with a multidisciplinary approach (surgery, radiation, chemotherapy). Due to critical anatomical location and advanced disease status at presentation, radiation in head and neck cancers is a major challenge. Long term sequale after treatment in head and neck cancers are known and it adversely affects QOL of patients. This study aims to correlate pharyngeal constrictor dose with dysphagia. Objective: To correlate the dose received by pharyngeal constrictors with treatment related dysphagia. Materials and Methods: In the present study 39 histologically proven Head and Neck cancer patients treated with radical intent using IMRT technique, from 2016-17, in MS RAMIAH HOSPITAL are taken for the study. Dose received by the pharyngeal constrictors (D50) was noted. Post one year of completion of treatment, the patients were evaluated for dysphagia and graded as per RTOG grading system. Results: In our study 23 patients had Grade 1 dysphagia (76%)), only 3 patient had Grade 2 dysphagia. There is a statistically significant difference between the pharyngeal constrictor dose and dysphagia as seen by ONE WAY ANOVA (F (2,33)=3.560, p=0.040. Conclusion: The incidence of dysphagia was significantly higher than xerostomia. Radiation techniques should focus not only on parotid dose but also on anatomical structures related to dysphagia (DARS).


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Clinicopathological association of p16 and its impact on tumour response in locally advanced head and neck squamous cell carcinoma treated with concurrent chemoradiation using cisplatin

Srigopal Mohanty1, L. Jaichand Singh1, Madhubala Devi2, Y. Sobita Devi1

Departments of1 Radiation Oncology and2 Pathology

Aims and Objectives: To observe the clinicopathological association of p16 and its impact on early tumour response in locally advanced head and neck squamous cell carcinoma (HNSCC) treated with concurrent chemoradiation using cisplatin. Materials and Methods: A prospective cohort study was conducted for a period of two years from August 2016 to July 2018, with approval from Research Ethic Board of the institute. The study population included newly diagnosed and histopathologically or cytologically confirmed cases of locally advanced squamous cell carcinoma of head and neck, who gave consent to participate in the study. All cases were grouped into two different arms, arm-A included all p16 positive cases and arm-B included all p16 negative cases. All patients received external beam radiotherapy using Telecobalt-60 machine to a total dose of 66-70 Gy by conventional fractionation and shrinking field technique with weekly cisplatin 35 mg/m2 during the period of radiation. SPSS version 21 for windows was used for data analysis. All clinicopathological variables and early tumour responses were analyzed by using chi square test and p value <0.05 was considered to be significant. Results: A total of 83 patients were recruited randomly, out of which 34 (40%) cases were p16 positive and 49 (60%) cases were p16 negative. In the present study, we found that p16 positive HNSCC, to be more common in patients with positive history of oro-genital contact (p=0.025), oropharyngeal primary tumours (p=0.05), higher nodal stage (p=0.005), higher histopathological grade of tumours (p=0.04), better early tumour response (p=0.005) as compared to p16 negative patients. After sub site analysis, p16 positive oropharyngeal squamous cell carcinoma (OPSCC) patients were found to have significant higher tumour response as compared to p16 negative OPSCC (p=0.052). Whereas in case of p16 positive non oropharyngeal squamous cell carcinoma (NOPSCC), though the tumour response was found relatively higher as compared to the p16 negative arm, but was not significant (p=0.066). Higher p16 expression score was found to be associated with significantly greater (p=0.016) complete tumour response rate. Advanced tumour stage (T3/T4) was found to have poor tumour response as compared to early tumour (T1/T2) stage (p=0.014), whereas tumour response was found similar with respect to age, sex, smoking, oral tobacco, alcohol, different nodal stages, histological grades, primary tumour locations after matching for p16 status. Conclusions: p16 was found to have an independent positive predictive and prognostic impact in OPSCC. Its impact on tumour response in NOPSCC need further prospective studies with larger sample sizes and longer follow up to reach at a definite conclusion.


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A prospective study to compare patient reported outcome measures and physician reported acute toxicities in patients treated with concurrent chemoradiation for locally advanced head and neck squamous cell carcinoma

Pavitra Vijayaraghavan, Akhter Jawade, Saibal Mukherjee, Jibak Bhattacharya, Asesh Samanta, Riddhijyoti Talukdar, Tanweer Shahid

Aims and Objectives: The purpose of our study was to prospectively assess and compare acute toxicities reported by radiation oncologists and patient reported outcome measures (PROM) during concurrent chemoradiation for locally advanced squamous cell carcinoma of head and neck. The aim was to find discordance between subjective and objective assessments and its characteristics. Materials and Methods: Between January to August 2018, twenty patients diagnosed as locally advanced head and neck squamous cell carcinoma undergoing radical concurrent chemoradiation were included. Non-squamous histology and nasopharyngeal malignancy were excluded. Acute toxicities were assessed at baseline, weekly and at the end of treatment by the radiation oncologists and patients themselves independently. National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE version 5.0) for 12 domains was used by the radiation oncologists while PROM for the same were recorded using PRO-CTCAE. At each point of assessment, the toxicity grades were compared in terms of agreement or disagreement between patients and physicians. The incidence, pattern and degree of disagreement between patients and physicians were analysed statistically. The relation between severity of toxicity, point of assessment and degree of disagreement was studied and plotted. Results: 20 male patients with mean age of 59 years with advanced carcinoma oral cavity, oropharynx, hypopharynx and larynx were assessed. 6 (30%) and 12 (60%) patients presented with T4 disease and Node positive disease respectively. All patients were treated with cisplatin based chemoradiation. 3DCRT or IMRT were used. 30-35% patients developed grade 3 acute toxicity in terms of dysphagia, mucositis or dermatitis as per CTCAE. No grade 4 or above toxicity was noted. Some degree of disagreement existed at baseline for symptoms like pain (10%), dysphagia (20%), anxiety (25%) and depression (20%). The agreement between physician assessments and PROM demonstrated a decreasing trend from 80-100% at baseline to 20-35% at week 6 of treatment for all domains. Maximum disagreement was observed with pain (80%) and Anorexia (20%) at 6th week. The degree of disagreement (by one or two points) was found to be increasing with severity of toxicity grades (mean toxicity grades). The patient reported toxicity grades always remained higher across all domains towards the end of treatment. 3 patients required hospitalisation for toxicity management and treatment was interrupted for 4 patients. Conclusions: The study found that a significant amount of disagreement exists between physician and patients and the gap increases with the severity of toxicity. The result evokes the thought that there is a possibility of under-assessment by the physician or over-assessment of acute toxicities by the patients which may ultimately affect the final clinical outcome. These two scales can be used as complementary tools to assess acute toxicities more accurately so that an early intervention can be done. This is an ongoing prospective study in our department.


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A prospective comparative study of quality of life outcomes in patients with head and neck squamous cell carcinoma treated with intensity modulated radiotherapy versus 3-dimensional conformal radiotherapy

Asesh Samanta, Litan Naha Biswas, Jibak Bhattacharya, Mukti Mukherjee, Akhter Jawade, Riddhijyoti Talukdar, Pavitra Vijayaraghavan, Tanweer Shahid, Debottam Barman, Arundhati De, Rejil Rajan, Rishav Raj, Chandrika Saikia

Aims and Objectives: The purpose of the study is to assess and compare the health-related quality of life (HRQOL) of patients with head and neck squamous cell carcinoma (HNSCC) undergoing radical radiotherapy with intensity modulated radiation therapy (IMRT) technique with three-dimensional conformal radiation therapy (3D-CRT) technique. Materials and Methods: From January 2018 to May 2018, 40 patients of biopsy proven squamous cell carcinoma of oropharynx, larynx and hypopharynx (cT1-3 N0-2b M0 except cT1N0 glottic cancer) undergoing radical radiotherapy either alone or with concurrent chemotherapy were included in this study. Patients were treated with radical doses with conventional fractionation using either IMRT or 3DCRT technique. The European Organization for Research and Treatment for Cancer (EORTC) QLQ-C30 and HN35 were used to study the HRQOL and assessed for each patients at baseline i.e. before the commencement of radiation, at 3rd week during radiation, after completion of treatment, at 1 month and at 3 months of follow up Radiation induced acute toxicities were assessed by Radiation Therapy Oncology Group (RTOG) toxicity criteria every week during radiotherapy. For comparison, QOL data collected at different point of time were analyzed using unpaired ‘t’ test. Acute radiation induced toxicities were compared between the two arms using chi-square test. Results: 40 patients were included in the study. The mean age of the sample population was 60 years with predominant male population (90%). Larynx was the commonest site (18 patients, 45%). 13 patients (32.5%) had T3 disease and 10 (25%) patients had node positive disease. 14 (35%) patients received cisplatin based concurrent chemotherapy. The number of patients treated with 3DCRT and IMRT were 19 and 21 respectively. HRQOL scores of various components deteriorated during and after treatment in both the arms. HRQOL scores of fatigue (24 vs 17, p=0.041), appetite loss (73 vs 44, p<0.001) and sense problems (31 vs 15, p<0.001) were significantly worse in IMRT group during and after completion of treatment. However, this difference was not evident at 3 months of follow up. Dryness of mouth and sticky saliva were significantly more in 3D-CRT group (HR-QoL score for dryness of mouth 60 vs 0, p<0.001 and for sticky saliva 9.52 vs 0, p=0.24) during radiation and 3 months after completion of treatment. Insomnia and ill feeling were found to be significantly more in 3DCRT patients. Other parameters of HRQOL, like global health, physical, emotional and social functions, speech and swallowing, nutritional parameters remained comparable in both arms. There was no grade 4 or above acute toxicities. No significant difference was observed in acute toxicities e.g. mucositis, dysphagia, skin toxicities between IMRT and 3DCRT arm during radiotherapy. Conclusions: This prospective observational study shows how technique of radiation (3D-CRT and IMRT) affects QoL in HNSCC patients treated with radical intent. Though there was no difference in terms of acute toxicity in between groups but IMRT group did significantly better considering dryness of mouth and sticky saliva, not only during treatment but 3 months after completion of treatment. This can be explained by the fact that IMRT can spare the major and minor salivary glands quite efficiently compared to 3DCRT. This is an ongoing study in our department.


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Clinical outcomes of robotic fractionated stereotactic radiotherapy in recurrent head and neck cancers: Initial results from a tertiary cancer institute

Shikha Goyal, Tejinder Kataria, Saumya Ranjan Mishra, Deepak Gupta, Shyam Singh Bisht, Susovan Banerjee, Kushal Narang

Aims and Objectives: Nearly 30% of head and neck cancers (HNC) recur following definitive therapy and only 20% of these recurrences are amenable to surgical salvage. Remaining patients were earlier relegated to palliative therapies. Reirradiation with either conventional fractionation (and concurrent chemotherapy) or fractionated stereotactic radiation therapy (FSRT) are both equally effective options for salvage, with differing toxicity spectrums. FSRT also constitutes an attractive option for tumor boost in selected sites. Herein, we report our clinical experience with HNC who received reirradiation with CyberKnife FSRT (CK-FSRT) for recurrent/ second primary disease. Materials and Methods: Patients were referred for FSRT after multidisciplinary tumor board discussion. Only gross disease was treated with FSRT with 2-3 mm PTV margin. Data for HNC patients who were treated with CK-FSRT between 2012 to 2017 were collected prospectively, and included demographics, treatment indication, radiation therapy (RT) details, toxicity profile and outcomes. Results: Forty cases were treated during this period. Of these, 26 patients (19 Males, 7 Females) with median age of 62.5 years received reirradiation for recurrence/ second primary. Median time interval between initial RT and re-RT was 17.8 months (Range: 1—174 months). All except 2 patients (46 Gy and 50.4 Gy) had earlier received a dose of 60-70 Gy to the reirradiated region. Dose schedule was 30 Gy in 5 fractions (Range 10 Gy/ 1 fraction to 49 Gy/7 fractions). Response evaluation at treated site at first follow up imaging showed reduction in 10/26 patients, stable disease in 1/26 patients, progression in 11/26 patients and in 4 patients follow up images were not available. Median follow up post FSRT was 9.8 months (range, 1--61.4 months). On subsequent follow up, 9/26 patients had local disease progression, 2/26 patients had metastatic disease, 2/26 patients died and 1 patient developed second primary in esophagus. One patient developed carotid blow out and was successfully salvaged with angioembolization. One patient was PEG tube dependent till last follow up at 4 months. No other CTCAE grade 3 toxicities were noted. Fourteen patients received definitive radiotherapy with conventional fractionation plus CK-FSRT boost. A dose regimen of 54 Gy in 27 fractions (5 fractions/week) + 15 Gy/3 fractions with FSRT was given. Median follow up period for this group was 24.7 months (range 3.8—53.4 months). At last follow up 11 patients had complete response, 2 had locoregional progression and 1 had distant metastases. Conclusions: FSRT is an attractive and effective option for reirradiation in HNC with encouraging local control and survival outcomes. Toxicities can be limited with judicious patient selection.


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Correlation of high risk planning target volume with grade of mucositis at fifth week of radiation therapy: A prospective institution based study

Nishant Vidyasagar, M. G. Janaki, Arul Ponni, Kirthi Koushik, Ram C. Alva, S. Mohan Kumar

Introduction: Head and neck cancers are one of the most commonly occurring malignancies in India and radiotherapy forms an integral part of its management. Mucositis is the most common side effect of radiation therapy seen in almost 90% of patients with varied severity. Symptoms usually peak during fourth to fifth week of radiotherapy during which patients tend to become malnourished and even forego treatment. The malnutrition prevalence rate due to mucositis is as high as 74.2%. Approximately 20% of the patients succumb as a consequence of malnutrition. In the present era of conformal radiotherapy, the tumour volume receiving the prescribed dose can be quantified easily using the planning CT scan. Although the stage, dose and fractionation remains the same, the tumour volume varies from patient to patient. Our study is an effort towards understanding the relationship between the tumour volume irradiated and the grade of mucositis at fifth week of treatment. Objectives: (1) To record the high risk planning target volume (PTV). (2) To grade the mucositis at fifth week using RTOG acute toxicity grading criteria. (3) To correlate the planning target volume with the grade of mucositis at fifth week. Aims and Objectives: Ours is a prospective study which included 40 head and neck cancer patients from October 2016 to March 2018. Patients receiving a minimum dose of 60 Gy were included in the study. Patients with nasopharyngeal and early glottic tumours, with previous history of irradiation, with second malignancies were excluded from the study. They were treated by external beam radiation therapy to a dose of 60 to 66 Gray in 30-33 fractions using 3DCRT or IMRT technique with or without chemotherapy. The high risk planning tumor volume (PTV) was recorded from planning scan and at the end of 5 weeks, the patient's toxicities were graded using RTOG acute toxicity criteria. Results: The mean age of the patients is 55 years. There are 32 male and 8 female patients in our study. There are 8 patients with stage II, 13 patients with stage III, 18 patients with stage IVA malignancies. There are 11 patients with oral cavity, 9 patients with oropharyngeal, 14 patients with hypopharyngeal, 4 patients with laryngeal, 1 patient with nasal cavity and 1 patient with paranasal sinus malignancies. A Spearman's rank-order correlation was run to determine the relationship between the planning target volume (PTV) and the grade of mucositis at the fifth week. There is a positive correlation between the planning target volume (PTV) and the grade of mucositis at fifth week, which is statistically significant (rs=.489, p<0.01). Conclusion: In the era of computerized tomography based planning, the planning target volume can be used as a look up tool to predict the toxicities at the beginning of the treatment so that individualized prophylactic care and supportive measures can be instituted to improve patient compliance, thereby can contribute to better treatment outcomes.
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A retrospective study of radiotherapy with concurrent cetuximab for locally advanced head neck cancer patients

Nilesh Kucha, Tej Prakash Soni, Pawan Agarwal, Anil K. Gupta, Lalit Mohan Sharma

Aims and Objectives: To assess the compliance, treatment related toxicity and outcomes of radiotherapy with concurrent cetuximab for locally advanced head-neck cancer patients. Materials and Methods: Retrospective analysis of 40 patients of locally advanced carcinoma oropharynx and carcinoma larynx, treated with concurrent weekly cetuximab and radiotherapy (66-70 Gy/33-35 fractions/6-7 week by RapidArc technique) at a Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, from August 2016 to August 2017. Results: Median age of the patients was 61 years. 51% patients had carcinoma oropharynx and remaining 49% patients had carcinoma larynx as primary. 36 patients (90%) were male and 4 patients (10%) were female. Median gap/interruption in radiotherapy treatment was 5 days (range 2 days to 20 days). 18 patients (45%) had gap/interruption of 5 or more days in the radiotherapy treatment. 11 patients (27.5%) developed grade 3 dermatitis skin reaction. 25 patients (62.5%) experienced grade 3 oral mucositis. 25 patients (65%) had significant (more than 3 kg) weight loss after radiotherapy (range 2 kg to 14 kg) completion. Ryle's tube insertion was done for the management of dysphagia in 14 patients (35%). 3 patients (7.5%) developed complications during the treatment (one patient developed Herpes Zoster, 1 patient developed pneumonia and 1 patient developed sepsis). 21 patients (52.5%) patients were required IPD treatment/admission for the supportive/symptomatic care during the treatment. 2 patients (0.5%) could not complete the treatment (1 due to sepsis, 1 patients refused for further treatment). At a median follow-up of 12 months, 17 patients (42.5%) had residual/recurrence (15 patients failed loco-regionally, 2 patients developed distant metastasis). Conclusions: Locally advanced head neck cancer has poor prognosis with higher chances of recurrence and treatment failure. Cetuximab concurrent with radiotherapy has acceptable toxicity profile.


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Does the modification in schedule of concurrent cisplatin (weekly vs. daily) has any effect on compliance and clinical outcomes in cases of locally advanced head and neck cancers

Ayush Garg, Piyush Kumar, Arvind Kumar Chauhan, Pavan Kumar

Aim: Concurrent Cisplatin with radiotherapy improves outcomes in locally advanced squamous cell carcinomas of the head neck. Cisplatin at 35 mg/m2 (weekly) raise compliance, hospitalization and supportive care issues. So far, there are only few reports on efficacy and toxicity of low dose Cisplatin (6 mg/m2). Hence the purpose of this study was to evaluate the compliance and clinical outcomes between weekly and daily low dose cisplatin chemotherapy regimen along with radiation and to see long term effects. Materials and Methods: Total 50 patients were included in the study from November 2015 to March 2017 with 25 in each group. Radiotherapy was given 70 Gy/35# in 7 weeks in both groups and Cisplatin was given at 35 mg/m2 weekly in Group I and 6 mg/m2 daily in Group II. Assessment of toxicity was done by Radiation Therapy Oncology Group scoring criteria. WHO Response criterion was used to assess clinical response. Median follow up was 6 months. Results: Group I (80%) and Group II (84%) patients completed planned Radiotherapy. In Group I 48% patients received less than 6 cycles and Group II 40% received <25 cycles chemotherapy. Median overall treatment time in Group I in was 51 days while in Group II was 52 days. Grade III/IV Neutropenia and Mucositis were statistically insignificant between both groups during treatment. Post treatment Grade I/II Xerostomia seen in 16% patients in Group I (p value-0.03). There was no statistical difference in complete response between the two groups. In Group I 40% patients developed Progressive disease on follow up as compared to 12% in Group II (p value-0.02). After 1.5 years of follow up, Group I vs Group II 4 patients had complete response, 6 had recurrence, 11 vs 4 patients expired (p-0.03), 3 vs 11 patients lost to follow up (p-0.005). At a median follow up of 6 months overall survival in Group I and II was 56% and 44% (p value-0.39). While as median disease free survival in Group I vs Group II was 6.6 vs 11.9 months (p-0.14). Conclusion: Low dose daily Cisplatin offers ease of administration in the outpatient clinic, better tolerability and better quality of life. Group II patients were more compliant in terms of patients receiving chemotherapy or completing radiotherapy. At median follow up of 6 months there was no statistical difference in terms of overall and disease-free survival. The statistical difference was seen in terms of patients expired in Group I (44%) as compared to Group II (16%) but more patients lost to follow up in Group II (44% vs 12%). Therefore, we need a larger number of patients for the use of low dose Cisplatin to be evaluated in future clinical trials.


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The effect of radiotherapy on blood pressure in patients with head and neck cancer

R. Dinesh Kumar, N. V. Kalaiyarasi

Aim: Head and neck cancer is the sixth most common cancer wordwide. Radiotherapy (RT) plays a key role in the management of head and neck cancers (HNC), especially in locally advanced disease. Patients undergoing head and neck RT, especially elderly ones, are suffering from low and labile blood pressure (BP) during the treatment. They complain of weakness and fatigue. The aim of this study was to characterize BP changes during RT period. Patients and Methods: The study included 30 patients (24 males, 6 females), period from july 2017 to july 2018. Patients with HNC, receiving radiation to the neck for a total dose of 45-70 Gy, with ECOG Performance status 1-2 were recruited. The study excludes known orthostatic hypotension, diabetic neuropathy and parkinsons disease patients. Blood pressure measured before starting RT (Baseline) and after 30 days from RT introduction. Results: Office systolic BP diastolic BP decreased significantly after 30 days after RT introduction. Average 24 –Hour BP values decreased after 30 days after RT introduction. A similar trend was observed for day and night BP levels. No orthostatic hypotension was observed during the study period. Conclusion: There is a significant BP reduction noted after 30 days from the introduction of radiotherapy, without orthostatic changes. More studies should be done to evaluate the mechanism of this BP reduction and association with patients complaints. Oncologists should be aware of this phenomenon and consider treatment adaption according.


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Prevalence of psychosocial factors like stress, anxiety and depression among head and neck cancer patients receiving treatment: A cross sectional study

Kawya Karunagaran, N. V. Kalaiyarasi, R. Giridharan, Sundaresan, Sanjal Kumar, Poonkodi, Vijey Karthik, Senthil Kumaran

Department of Radiation Oncology, Madras Medical College, Chennai, Tamil Nadu, India

Background: Some of the studies have shown that cancer patients who have been treated with single modality had lower level of depression, stress and anxiety than multi-modality treated patients. Cancer patients have high risk to develop stress and depression than normal individuals. Objective: To determine the prevalence of stress, anxiety and depression among head & neck cancer patient. Materials and Methods: A Cross-Sectional Institutional based study was conducted among head & neck cancer patients of MMC, Chennai from 1.3.18 to 30.7.18. A purposive sample of 120 cancer patients were selected and taken for the study. Informed consent was obtained from all the participants. A pre-designed, pre-tested interview schedule was used to collect data. DASS 21 was used for measuring stress, anxiety and depression. Data was compiled and analysed. Chi-square test has been applied to test the significance. Results: The prevalence of mild, moderate, severe and extremely severe stress was found to be 20%, 13.3%, 10% and 2.5% respectively. The prevalence of mild, moderate, severe and extremely severe anxiety was found to be 24.2%, 23.3%, 11.7% and 12.5% respectively. The prevalence of mild, moderate, severe and extremely severe anxiety was found to be 20.8%, 27.5%, 6.7% and 6.7% respectively. A statistically significant association has been found between age group, gender, hospital stay, modality of treatment and depression. Conclusion: The cancer patients are found to be having high prevalence of depression which further may affect their quality of life. Future longitudinal research should examine the relationships between psychosocial factors and its variables. Psychosocial intervention involving changes in specific types of social support and changes in mood among cancer patients receiving treatment are required.


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To study the risk factors for hypothyroidism in patients undergoing radiotherapy for head and neck cancer

Bussyaku Shravanthi Reddy, Mahadev Potharaju

Aims and Objectives: Radiation-induced hypothyroidism (RIHT) is a well-known adverselate effect of radiation to the neck, which can develop months to years after radiotherapy. The reported incidence of RIHT varies considerably (17–47.7%). The radiation tolerance level of the thyroid gland and the mechanism of development of post radiotherapy hypothyroidismis poorly defined. Our aim is to study the risk factors for hypothyroidism in patients undergoing radiotherapy for head and neck cancer. Materials and Methods: The study included a cohort of 52 patients with head and neck cancer who were treated with definitive RT to the neck region at Apollo Speciality Hospital, Chennai between January 2013- December 20172017. The thyroid function was evaluated by measuring thyroid-stimulating hormone (TSH) at baseline, 3, 6, 12, 18 and annually thereafter or when there was a clinical suspicion of hypothyroidism. The volume of the thyroid gland and the mean dose to thyroid was calculated from DVH. Results: There were 41 males and 11 females. The median age was 58 (range, 24-79). The median follow-up was 36 months (range, 12-60). 62.5% patients had laryngopharyngeal cancer. Analysis of patient characteristics, precise radiation doses to the thyroid gland and follow-up assessments of thyroid function after radiotherapy gave an estimated five-year incidence of RIHT of 46%. Patients who received a mean thyroid dose <40 Gy had a significantly lower incidence of hypothyroidism. Age, sex and concurrent chemotherapy had no significant effect on the development of hypothyroidism in multivariate cox-regression analysis. Conclusion: Hypothyroidism is a frequent late effect after definitive radiotherapy. As it is linked to increased risk of cardiac disease and mortality, and decreased quality of life, it is important to consider the risk of RIHT when planning radiation treatment. The size of the thyroid gland and the radiation dose to the gland are key factors in the development of RIHT, and both these factors should be considered when determining dose constraints for the thyroid gland. A mean thyroid dose of 40 Gy may be a useful threshold for predicting the development of hypothyroidism after radiation therapy for head and neck cancers. Routine assessment of thyroid gland function should be offered after radiotherapy in the neck area.


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Dosimeric parameters, acute toxicities and quality of life of patients treated with intensity-modulated radiation therapy, simultaneous integrated boost protocol for nasopharyngeal cancer: A prospective study

Nazneen Ameer, Malu Rafi, R. Rejnish Kumar, Kainickal Cessal Thomas, K. Ramadas

Department of Radiation Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India

Objective: To assess the dosimetry of target volumes and Organ At Risks (OAR), treatment related acute toxicity and quality of life (QOL) of nasopharyngeal carcinoma (NPC) patients treated with concurrent chemo-radiotherapy using volume-modulated arc therapy (VMAT) and simultaneous integrated boost protocol, delivering 66,60 and 54 Gy in 30 fractions to PTV high, standard and low risk respectively. Materials and Methods: Twenty patients of non metastatic stage II –IVA NPC treated using VMAT technique with Simultaneous integrated Boost (SIB) protocol along with concurrent cisplatin 80-100 mg/m2 every 3 weeks were included in the study. Acute toxicities were graded using CTCAE version 4.0. The dosimetric parameters of target volumes including V100 GTV, D100 GTV, V95, Homogienity index (HI) and Conformity Index (CI) of PTV66, PTV60 and PTV 54 respectively, V>110% of PTV 66 and D2cc of PTV66 were obtained. The OARs evaluated include parotid, brainstem, spinal cord, optic nerve and chiasm, cochlea, temporal lobe and constrictors. Quality of Life scores at baseline (before RT), during completion of treatment and further at one, two and three months after RT were assessed using a validated EORTC QOL Questionnaire. Results: Around half of the patients had grade 2 mucositis by 3rd week and grade 3 mucositis by week 6. The skin reaction were mostly grade 2 (70%) by the end of treatment and none of the patients had grade 4 toxicity. Grade 2 weight loss was recorded in 50% of patients by week 6, with no patients having more than 10% weight loss (grade 3) during treatment. No prophylactic nasogastric tube insertion was done and only 55% were nasogastric tube dependent by the end of treatment. Step 3 analgesics were required by 50% patients by week 4 of RT. The optimum target coverage of 98% for V95 of PTV66, PTV60 and PTV54 were achieved respectively. The mean value of D100 GTV was 63.40 Gy. HI of 0.1 for PTV66 and PTV54 and CI of 0.9 for all PTVs were achieved. Dose constraints of all OARs except parotids and constrictors were achieved. The QOL scores of most item scales were the lowest just after treatment completion and steadily improved over three months. Conclusion: Optimum coverage for target volumes and dose constraints of OARs were achieved. All patients completed the treatment with tolerable acute toxicities and reasonable quality of life without any interruption in radiation treatment.


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“New” organ at risk on the block? Comparing dosimetric outcomes and biological correlates, EUD and NTCP, to analyse the benefit of hippocampal sparing in adjuvant radiotherapy for buccoalveolar carcinoma

M. Singh, S. Nangia, R. Khosa, S. K. Rout, S. Oommen

Introduction: Radical radiotherapy plays a pivotal part in the management of HNC and leads to delivery of doses to the brain that are clinically significant for causation of radiation induced brain injury (RIBI) which may manifest as fatigue (acute neurotoxicity) and impaired neurocognitive function (late effect). The latter has been positively correlated with radiation dose to the hippocampusand though several studieshave proved the correlation of hippocampal doses and cognitive impairment in nasopharyngeal carcinoma (NPC), the same has been lacking for non-NPC subsites. We performed a retrospectiveanalysis of dosimetric and biological indices for hippocampal sparing (HS) versus no hippocampal sparing (NHS) RT in two consecutive patient cohorts of buccoalveolar carcinoma. Aims and Objectives: (1) Comparison of bilateral and ipsilateral hippocampal dosimetric indices, and (2) calculation and comparison of EUD and NTCP for impaired NCF, when a separate hippocampus constraint was given prior to plan optimization (HS group) versus no separate hippocampal constraint (NHS group). Materials and Methods: Twenty consecutive patients of bucco-alveolar carcinoma who had received (chemo)-radiotherapy postoperatively using linear accelerator based IMRT/VMAT were included. The study and control groups included 10 patients each with hippocampal dose constraint (HS group) and no hippocampal dose constraint (NHS group), respectively;dosimetric parameters were compared. Treatment plans were also assessed for the PTV using comparative indices, homogeneity index, coverage index and Paddick's conformity index, to ensure similar treatment effect on the PTV regardless of hippocampal sparing. Bilateral and ipsilateral hippocampal EUD and NTCP for NCF impairment were calculated using the equations described by Niemierko et al. Results: Bilateral hippocampal DmaxEQD2, DmeanEQD2 and D40%EQD2 were reduced from mean values of 27 Gy (11.2-50 Gy) to 10.9 Gy (5.63-15 Gy) (p=0.002), 14.3 Gy (5.8-28.7 Gy) to 6.4 Gy (3.78-10.46 Gy) (p=0.002), and 15.5 Gy (7.5 – 33.12 Gy) to 6.6 Gy (4.0-10.7 Gy) (p=0.005)in the NHS and HS groups, respectively. Hippocampal sparing reduced the ipsilateral hippocampal DmaxEQD2, DmeanEQD2 and D40%EQD2 from mean values of 26.5 Gyto 10.9 Gy (p=0.004), 16.8 Gy to 7.2 Gy (p=0.004), and 19.1 Gy to 7.5 Gy (p=0.006), respectively. The hippocampal sparing studies in cranial irradiation provide a starting rationale for hippocampal sparing in HNC RT, reflected by the association of impaired NCF with D40%EQD2 more than 7.3 Gy. The ipsilateral hippocampal EUD and NTCP for NCF impairment, for comparable plan quality indices ensuring treatment isoeffect on PTV, were significantly reduced from 62.1 Gy in NHS group to 22.7 Gy in the HS group (p=0.005) and 0.46 % in the NHS group to 0.00012 % in the HS group (p=0.013), respectively. Conclusion: Significant reduction in hippocampal dosimetric parameters and corroboration with reduced biological indices of hippocampal EUD and NTCP for impaired neurocognition was confirmed in patients of buccoalveolar carcinoma receiving (chemo)-radiotherapy with hippocampal sparing, thus endorsing our hypothesis regarding hippocampus as a new OAR in buccoalveolar carcinoma.


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Efficacy of online cone beam computer tomography-guided intensity-modulated radiotherapy for hypopharyngeal cancers: A prospective single institutional dosimetric study

M. Chaitanya Kumar, Kaustav Talapatra, Rajkumar Chauhan, Pranav Chadha, Vaibhav Mhatre, Vadivel Muthu

Aim and Objectives: Online adaptive correction in image-guided intensity-modulated radiotherapy appears to be a promising approach for precision radiation treatment in head and neck tumors. This study is to evaluate the effect of online cone beam computed tomography (CBCT) guidance in IMRT of Head and Neck Cancers, by taking Hypopharynx as prototype. Materials and Methods: 23 Hypopharyngeal cancer cases treated at our institute were selected for this study from prospectively maintained data (May 2017 to May 2018). The Varian NovalisTx system which integrates an On Board Imager (OBI), was used to deliver radiation treatment. Daily/alternate day CBCT images were acquired and registered to the planning CT for online and offline analysis and to correct the patient setup errors. The setup errors were noted after matching of CBCT with planning CT images. New plans were generated in each patient using the mean lateral, vertical and longitudinal shifts. This DVH was compared to the original planning DVH and doses delivered to the target and various critical structures were evaluated. and the difference in doses received were computed. Statistical analysis was done using paired t-test. Results: The mean setup errors in three directions were: 1.7 mm longitudinal, 1.2 mm vertical and 0.8 mm lateral. Analysis of dosimetric change due to a translational isocenter shift if no correction was applied showed: Mean PTV1 V95% to be dropped to 94.54% from the original of 95.81%, if shifts weren't applied (p=0.019). Similarly PTV2 V95% coverage reduced by -1.37% (96.97% to 95.60%) with p=0.018. There was also considerable dosimetric changes to critical organs as follows : ipsilateral parotid mean doses were increased by 0.84 Gy (40.95 Gy to 41.80 Gy; p=0.09); Contralateral parotid mean doses were increased by 0.94 Gy (26.05 Gy to 26.99 Gy; p=0.18). Dmax to spinal cord was increased by 1.41 Gy (40.05 Gy to 41.46 Gy; p=0.099). Conclusions: Online CBCT correction ensures better coverage of targets (PTV) while reducing doses to normal tissue. There was significant reduction in PTV coverage if translational shifts wouldn't have been applied during the course of radiotherapy. CBCT-based online correction also increased the accuracy of IMRT in Head and neck cancer patients and provides scope to reduce irradiated margins, by decreasing the setup errors.


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Altered fractionated radiotherapy compared with conventional radiotherapy of squamous cell carcinoma of head and neck with concurrent cisplatin

B. Jaba Priya, N. V. Kalaiyarasi, R. Giridharan, Sundereson, Sanjal Kumar, Poonkodi, Vijey Karthick, Senthil Kumaran

Department of Radiation Oncology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India

Introduction: Locally advanced head and neck carcinomas (HNSCC) constitute a substantial proportion of cancer patients in India. This is treated by combined multimodality which includes surgery, radiotherapy, and chemotherapy. Objectives: To compare the tumor response and acute toxicity in Squamous Cell Carcinoma Of Head and Neck using altered fractionation with conventional fractionation with Concurrent Cisplatin. Materials and Methods: In Altered fractionated arm (Arm 1), each patient received 55 Gy/ 2.75 Gy/ 20 fractions/4 weeks. In conventional arm (Arm 2), each patient received 66 Gy/ 2 Gy/ 33 fractions/ 6 weeks 3 days. Both arms received Cisplatin (100 mg/m 2) in divided doses from day 1 of RT for a total of 3 cycles on day 1,22 and 43 every 3 weeks. The end points were tumour response and acute toxicities. Results: In the altered fractionated arm (Arm 1) of 30 patients, 16 (53.3%) achieved Complete Response (CR), 13 (43.3%) achieved Partial Response (PR) and 1 (3.3%) had Stable disease compared to conventional arm (Arm 2) with 17 (56.6%), 12 (40%) and 1 (3.3%) having CR, PR and Stable disease respectively and no patients with disease progression were observed in both arms. The acute skin toxicity (grade≥2) was higher in Arm 1 than in Arm 2 (40% vs 33.3%). Grade ≥ 2 mucositis was also higher in altered fractionated arm (80 %in Arm 1 vs. 73.3% in Arm 2). The patients in both the arms are in follow up to assess the late toxicity and overall survival. Conclusion: The results observed in Altered Fractioned regimen is showing comparable tumour response to conventional fractionation in locally advanced HNSCC with increased but tolerable toxicities. The reduction in number of fractions and treatment time allows for more efficient use of resources which can be helpful to avoid long waiting times in a busy center.


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The Lacrimal Gland as an OAR in Nasopharyngeal and bucco-alveolar cancers: A retrospective review

D. Piyushi, S. Nangia, R. Khosa, M. Singh, B. Goswami, S. Oommen

Department of Radiation Oncology, Indraprastha Apollo Hospital, New Delhi, India

Introduction: The Lacrimal Gland, lying in the supero-lateral extraconal portion of the orbit, is responsible for majority of tear fluid secretion. Radiation-induced damage of Lacrimal Gland can lead to the impairment of tear production with results varying from impaired lubrication of the cornea and the conjunctiva to a dry-eye syndrome. Lacrimal gland is an important organ at risk especially for nasopharyngeal and buccoalveolar cancers. Batth et al. found a correlation between dose to the lacrimal gland and its acute dysfunction, suggesting to maintain V30 less than 50%. Objective: To determine if dose constraint prescribed to the lacrimal gland as organ at risk is achievable during Radiotherapy for patients with Nasopharyngeal and bucco-alveolar cancers. Materials and Methods: Between May 2014 and September 2018, in 23 patients of Ca Oral cavity and 7 patients of Ca Nasopharynx receiving Radiotherapy by IMRT or RA technique, a total of 37 Lacrimal Gland of interest were contoured as organ at risk. The dose to high risk PTV varied from 60 to 70 Gy and the dose to low risk PTV was between 52 to 54 Gy. The mean dose, max dose and dose received by 50% of volume of the lacrimal gland of interest were calculated in the Eclipse treatment planning system. Results: The study population consisted of 14%,30%,16% and 40% respectively of stage groups I, II, III and IV. Majority of the tumors were moderately differentiated (47%). The coverage of High risk PTV by D95 was 98.9 (Range 91.07-99.99). In 28 patients (93%), the dose received by 50 % of the volume of lacrimal gland was <30 Gy. The prescribed dose constraint to the lacrimal gland was met in all but two patients where mean dose was 32 Gy and 38 Gy. None of the patients complained of any dry eye symptom. Conclusions: In our experience, dose to the Lacrimal Gland can be restricted while ensuring adequate dose to the target. Efforts should be made to ensure the same. The next step in our study can be determining Lacrimal Gland function using objective tests such as slit lamp biomicroscopy, Schirmer's test, tear breakup time test etc.


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Clinical profile and treatment outcomes of carcinoma nasopharynx: A single institution study

V. T. Anjaly, Jayaprakash Madhavan, Grace Shirley, T. K. Padmanabhavan, T. V. Sandeep, Swapna Cyriac

KIMS Cancer Center, Thiruvananthapuram, Kerala, India

Aims and Objectives: To analyse the clinical profile and treatment outcomes of carcinoma nasopharynx treated at KIMS Cancer Center, Trivandrum, during the period 2011-2017. Materials and Methods: A retrospective analysis of all carcinoma nasopharynx treated at KIMS Cancer Center, Trivandrum from 2011-2017. Data was retrieved from electronic medical records using a structured proforma. Results: 11 patients with carcinoma nasopharynx were included in the study. The median follow up time was 36 months. The median age at diagnosis was 48 years. Majority of patients were males. In the analysis 2 patients had T1, 4 had T3 and 5 had T4 status. Regarding nodal status 2 had N0, 2 had N1, 5 had N2 and 2 had N3 status. Analysis by composite staging showed 1 with stage I, 4 with stage III, 4 with stage IV A and 2 with stage IV B. All the patients were treated with 6 MV photons using LINAC to a total dose of 66 Gy in 30 #[2.2 Gy per fraction] to high risk CTV, 60 Gy in 30# to intermediate risk CTV, 54 Gy in 30# to low risk CTV[SIB] using either IMRT/VMAT technique. Concurrent chemotherapy used was cisplatin at a dose of 80-100 mg/m2 [3 weekly regime]. Adjuvant chemotherapy was given with 3 cycles of cisplatin and 5-flurouracil. All patients were able to complete the planned treatment protocol without any treatment delays. 1 patient had regional nodal relapse in level V node which was not involved at the time of diagnosis, 1 developed bone metastasis during adjuvant treatment, 1 developed lung metastasis during followup. Locoregional control rate is 90%. The 3 year disease free survival with respect to composite stage are 100% for stage I, 75% [1/4]for stage III, 75%[1/4] for stage IV A, 50% [1/2]for stage IV B. The 3 year disease free survival for the whole group analysed at 3 years is 73%. All patients after treatment had good swallowing capacity. Conclusions: Most of the patients presented with locally advanced disease. With advanced techniques in EBRT it is possible to deliver the entire chemoradiation protocol without any treatment delays due to toxicity. Patients had good locoregional control of the disease. The 3 year disease free survival was 73%.


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Treatment outcome of 8 cases of sinonasal undifferentiated carcinoma treated with definitive chemoradiation: A tertiary cancer care centre experience

Arya Pradhan, Minakshi Mishra, Swaraj Shankar Satpathy, Lincoln Pujari, Lucy Pattanayak, Sanjukta Padhi, Niharika Panda, S. N. Senapati

Aims and Objectives: Tumours of nasal cavity and Paranasal Sinuses are a rare entity. Sinonasal Undifferentiated is an uncommon, highly aggressive, clinicopathologically distinct carcinoma of uncertain histogenesis. Frierson et al identified this tumour type in 1986, fewer than 200 cases have been reported. Thus, the aim of the study is a retrospective analysis of the treatment outcome of 8 cases of Sinonasal Undifferentiated Carcinoma treated with definitive chemoradiation. Materials and Methods: Between October 2015 and October 2017, treatment records of all cases of nasal cavity and Paranasal Sinus Carcinoma who were treated by conformal radiotherapy technique were reviewed. Out of 20 cases, 8 cases were identified as Sinonasal Undifferentiated Carcinoma. The patients were analysed for age, sex, clinical presentation, imaging findings and treatment details. All the patients were given Neoadjuvant Chemotherapy with taxane based chemotherapy (i.e. Docetaxel, Cisplatin, 5-FU) for 3 fractions followed by local radiation therapy by Intensity Modulated Radiation Therapy in 6 MV LINAC in Electa Synergy machine to a dose of 70 Gy to the primary tumour. Elective nodal irradiation was given to a dose of 59.4 Gy to level II and level IB nodes. Results: A total of 8 Sinonasal Undifferentiated Carcinoma patients were analysed out of which 5 were males (62%), 3 females (37%). Median age at diagnosis was 47 years (range 35-60 years). The disease epicentre was nasal cavity for 4 patients and maxilla for 4 patients. Out of 8 patients, 4 were in Kadish staging B and 4 in Kadish staging C. Imaging showed that 2 patients had intracranial extension and 4 hadintraorbital extension. 5 patients had complete response (62%), 3 patients had partial response (37%). The median follow-up time was 10.4 months (range 1-42 months). Conclusions: Sinonasal Undifferentiated Carcinoma generally presents in advanced stage. Locally advanced sinonasal carcinomas with extension of tumour beyond nasal and paranasal sinus may be (1) Resectable, but resection would have been morbid requiring extensive surgery and would have chances of incomplete gross total resection. (2) Unresectable, frank involvement of any vital structure or surgically inaccessible site making upfront surgery not possible. Craniofacial Resection remains the cornerstone of management of sinonasal malignancies, the anatomical proximity to vital structure and its locally aggressive behaviour makes gross total resection difficult. Thus, Neoadjuvant Chemotherapy followed by Concurrent Chemoradiation is a feasible alternative treatment option for locally advanced Sinonasal Undifferentiated Carcinoma. Elective nodal irradiation may be considered to address the high nodal involvement rates to improve surgical rate.


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A prospective evaluation of volumetric changes in tumor and nodal volume in locally advanced head and neck squamous cell carcinoma treated with definitive concurrent chemo-radiotherapy

Niraj Agarwal, Madhup Rastogi, Kamal Sahni, Rohini Khurana, Rahat Hadi, S. P. Mishra, Shantanu Sapru, Anoop Kr. Srivastava, Ajeet Kr. Gandhi, Avinav Bharati, Sambit S. Nanda, Satyajeet Rath, Harikesh B. Singh, Prabha Verma, Abhay P. Singh

Aims and Objectives: The definitive treatment of locally advanced head and neck squamous cell carcinoma (LA-HNSCC) by concurrent chemoradiotherapy (CCRT) includes radiotherapy (RT) in 2/3 phases. Volumetric changes of tumors and organs at risk (OARs) during treatment are well-known and it may lead to geographical misses due to change in spatial positioning of tumor or overdosing of OARs contributing to increased toxicity. To ensure proper coverage of planning target volume (PTV) and least possible irradiation of OARs in LA-HNSCC, adaptive radiotherapy (ART) can be used. We evaluated the volumetric changes of tumor and nodes in LA-HNSCC treated with definitive CCRT. Further an attempt was made to ascertain the ideal timing of repeat scan for ART. Materials and Methods: A total of 35 patients were enrolled in our study with a median age 51 years (range 26-70 years) of which 91.4% were male. Patients with histopathologically proven squamous cell carcinoma of pharynx and larynx of AJCC 7th stage III-IVB; treated with definitive CCRT were included in the study. Patient characteristics are given in the [Table 1]. The patients were treated on the plans drawn on pretreatment CT (CT1). Further, the patients were subjected to repeat CT at 2 weeks of treatment (CT2) and at the time of cord off (CT3). The contrast enhanced volume of the primary site and radiologically evident node were delineated as primary gross tumor volume (pGTV) and nodal gross tumor volume (nGTV), respectively. In case of multiple nodes, sum of the different volumes were considered as nGTV. The changes in pGTV and nGTV were evaluated by comparing CT1, CT2 & CT3. Paired student's t-test was used to analyse the volumetric changes. All the patients were treated using 3D-CRT technique with a median dose of 70 Gray/ 35 fractions. All the patients received CCRT with Cisplatin 40 mg/m2. Results: The mean pGTV at CT1 was 30.25±16.56 cc, at CT2 was 17.0±9.02 cc and at CT3 was 10.97±5.84 cc. The mean of percentage difference for pGTV between CT1-CT2 was 41.35±11.64, between CT1-CT3 was 60.46±12.83 and between CT2-CT3 was 33.35±13.26. All the differences were statistically significant (p ≤ 0.001). The mean nGTV at CT1 was 25.66±32.64 cc, at CT2 was 18.08±23.38 cc and at CT3 was 8.07±15.42 cc. The mean of percentage difference between CT1-CT2 was 33.99±12.46, between CT1-CT3 mean was 79.57±12.7 and between CT2-CT3 mean was 69.78±16.79 and the differences were statistically significant (p ≤ 0.001). Conclusion: The reduction in volume of primary tumor occurred predominantly during first two weeks of treatment as compared to next 2 weeks. The reduction in volume of nodal tumor occurred predominantly between 2nd and 4th weeks of treatment as compared to initial 2 weeks of treatment and this may assist us in planning ART.
Table 1

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Effect of HPV-associated P16INK4A expression on response to chemoradiotherapy in oropharyngeal cancer

Jatin Kumar Soren, L. Pujhari, L. Pattanayak, S. Padhi, S. N. Senapati, Niharika Panda, A. H. R. C. C. Cuttack

Aims and Objective: The aims and objectives of the present study is to determine the effect of HPV-associated P16INK4A expression on response to chemoradiotherapy in oropharyngeal cancer patients. The primary end point is to evaluate the influence of HPVP16INK4A status on locoregional tumor control after chemoradiotherapy in a group of oropharyngeal cancer patients. Materials and Methods: This study was conducted at PG Department of Radiotherapy Acharya Harihara Regional Cancer Centre, cuttack. Odisha. withen a study period from November 2016 to November 2017.30 elegible patients of carcinoma oropharynx presented to A.H.R.C.C Cuttack and satisfied elegible criteria are included in this study. Inclusion criteria - Age 30-70 years, histologically confermed primary squamous cell carcinoma of oropharynx, paraffin block and HP slide should available for P16INK4A study, ECOG performance status 0-1, stage II- stage IV A disease. All patients has given EBRT 70 Gy in 35# + weekly CDDP 40 mg/m2. Assessment of response and locoregional control was done in all patients (HPV +VE or HPV –VE) on completion of EBRT, at 6 weeks and at 3 monthes. Statistical analysis was done by SPSS 24.0. Results: Out of 30 patients 5 patients have found HPVP16INK4A positive. 60% of HPV +VE patients have N3 disease. In this study, 4 (80)% of patients having HPVP16INK4A positive had attended complete response and 1 (20)% patient had partial response. P value 0.047 (significant).8 (32)% patients having HPVP16INK4A negative status had attended complet response where as 17 (68)% attended partial response at 6 weeks and 3 months. Conclusion: The present study on effect of HPV-associated P16INK4A expression on response to chemoradiotherapy in oropharynx cancer revels that HPV associated oropharyngeal cancer treated with a standard regimen of concurrent cisplatin and radiation has a superior outcome compare with HPV negative oropharyngeal cancer. Interpretation of past trials in oropharyngeal cancer may be confounded by the absence of information about HPV status; at the very least, HPV status must be included as a stratification factor in future trials. The focus in HPV-positive oropharyngeal cancer will be on determining whether the intensity of treatment and the consequential toxicity can be decreased without compromising the excellent outcomes currently achieved with chemoradiotherapy. Thus patients with p16INK4A-positive tumors are candidates for organ preservative therapeutic procedures, and the approach to elective neck dissection after radiotherapy in these patients should be rather cautious to minimize long-term morbidity of therapy. That p16INK4A expression status should be a major determinant of future therapeutic strategies in patients with HNSCC. As the number of patients accrued in the study are less and duration of follow up is also short, it is very premature to derive any definitive conclusion from this study. This study needs more number of patients accrual and long duration of follow up to derive any definitive conclusion.


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Outcomes of chemoradiation for nasopharyngeal cancer: A single institution experience

Vinay Babu, V. Kannan, V. Anand, R. Bajpai, A. Kolse, S. Deshpande, S. Naidu, S. Almel, M. Shaikh, S. Pradhan, M. Lala, A. Kapadia

P.D. Hinduja Hospital, Mumbai, Maharashtra, India

Aim: The aim is to report long-term results of combined modality management using radiotherapy and chemotherapy in patients with non-metastatic nasopharyngeal carcinoma (NPC) treated at the P D Hinduja Hospital, Mumbai. Materials and Methods: Between January 1999 and December 2017, a total of 56 biopsy proven NPC patients who received combined modality management using radiotherapy and chemotherapy at our institution were analyzed retrospectively. Rates of local control, distant control, disease-free survival and overall survival were calculated from the date of biopsy using Kaplan-Meier method. Results: Median follow-up was 56 months (range, 3-211 months). The median age was 40 years (range, 10-77 years) and the male to female ratio was 4:1. Most of the tumor histopathology was undifferentiated nonkeratinizing carcinoma (76.8%). The number of patients staged with I, II, III and IV were 1 (1.8%), 10 (17.9%), 26 (46.4%) and 19 (33.9%), respectively. Platinum based chemotherapy was administered to 96.5%, including 57% who received concurrent and adjuvant chemotherapy. 6.5% received concurrent chemotherapy alone, and 32% received induction chemotherapy with or without concurrent chemotherapy. Seventy-nine percent received intensity modulated radiotherapy. Median RT dose was 70Gy. For all patients, the 5-year local control, distant control, overall survival and disease-free survival were 77.9%, 72.7%, 71.1% and 68.6%, respectively. Conclusion: Combined modality management using radiotherapy and chemotherapy resulted in satisfactory locoregional control and overall survival in patients with non-metastatic nasopharyngeal carcinoma.


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Time to diagnosis, time to treatment, age, smoking status, and comorbidity index as independent predictors in laryngeal cancer assessment: A preliminary analysis to predict survival outcome

Karan Sood, Kislay Dimri, Bivek Saroya, A. K. Pandey

Government Medical College and Hospital, Chandigarh, India

Introduction: Cancer of the larynx represents about 2% of total cancer burden and accounts for.3% of all cancer deaths. It is the second most common head and neck mucosal cancer. The prognosis of laryngeal cancer depends on the stage at presentation and the site of involvement. Five-year overall survival in patients with stage I or stage II disease is typically 70 to 90 percent. The prognosis for patients who present with more advanced (stage III or IV) disease is poorer. Now with new AJCC guidelines focussing on a system that should address and respond to new information that influences patient outcome. The TNM system has strongly predicted prognosis over the years and is adopted worldwide. Befitting the above, we want to highlight the role of important clinical indicators that could give us an insight into projected survival. Aims and Objectives: To analyze supplementary data in terms of TTD, TTT, age, smoking history, and CI as a prognostic indicator in patients with laryngeal cancer. Materials and Methods: A retrospective cohort study using data of 238 cancer patients in Chandigarh we determined median TTD and median TTT in patients with biopsy-proven squamous cell laryngeal cancer. Two sets of patients were analyzed who underwent surgery and those underwent laryngeal preservation. Patients were stratified either with comorbidities or without comorbidities and Charlson comorbidity index was calculated to get estimated survival rates. Statistical tests were done using the latest spss. Results: Out of 238 patients, 37 were female and 201 were males. Maximum patients were in the age group of 40 to 70 years. Maximum patients 125 received concomitant CT with RT followed by RT alone in 59 patients. Laryngeal preservation was done in 225 patients that accounted for 94.5% of all cases. 6.3% patients presented with stage 1, 18.1% with stage 2, 36.6% with stage 3 and 39.1% with stage 4. Out of the total sample, 51.3% were smokers. 57.6 % patients had a high Charlson comorbidity score (>= 4). The median TTD was 13 days and the median TTT was 25.50 days. Conclusion: There was a linear correlation between the TTD and TTT but no significant relation could be made with CI and estimated survival. This leads us to believe that the significance of TTT could be proved with actual survival analysis and comparing its projection to the estimated survival calculated by CCI to use it as a supplement for prognostication. We also strive towards a prospective study for developing an objective score which could be used at the time of diagnosis that presents patients with options as to much delay in treatment can he afford before his chances of survival dimish.


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Assessment of setup errors by portal imaging device in head and neck cancer patients to define planning target volume margin: An institutional study

Jyoti Bisht, Ravi Kant, Rishabh Dobhal, Meenu Gupta, Vipul Nautiyal, Saurabh Bansal, Mushtaq Ahmad, Sunil Saini

Objective: Objective of this study is to find out PTV margin via assessment of setup errors in head and neck cancer patient undergoing radiotherapy. Electronic Portal imaging Device (EPID) is used to assess the setup errors in treatment position on Linear Accelerator. Materials and Methods: In this study total 15 patients were taken for the procedure. Patients were immobilized with orfit cast. Portal images were acquired in anterioposterior and lateral fields for each patient by electronic portal imaging device (EPID) in 6MV Primus HI Linear Accelerator. The Digitally Reconstructed Radiographs (DRR) images of the treatment fields were used as references. The DRR images were imported from the Treatment Planning System to therapist system at treatment machine console and compared with the acquired portal images by Portal Imaging (PI) tool in therapist system. DRR images were compared to the PI and the differences between the PI and the DRR were measured in cranio-caudal (CC), anterior-posterior (AP) and medio-lateral (ML) directions using bony landmarks. Reference bony landmarks for the Lateral (L) image: base of the skull and visible bony structures and for anterio-posterior (AP) image: nasal septum, maxillary sinus, base of posterior skull. Standard deviations were calculated using an easy excel programme. For each individual patient, the random displacement for a particular direction was assessed by the subtraction of the systematic displacement from the present day displacement. For all patients, the distribution of random displacement was expressed by the standard deviation (SD) from all individual random values. Total standard deviation's square is the sum of square of random and systematic error. Anterior to posterior, craniocaudally and medial lateral displacement had been observed. The random (σ) and the systematic (Σ) components of the errors were calculated using margin formula (2.5 x Σ + 0.7 x σ) proposed by Van Herk to find out the planning target volume (PTV) margin. Results: Standard deviation is found by standard mathematical formula using the excel program. Random error (σ) is calculated by taking mean of all standard deviation is 5.7 mm. Systematic error (Σ) is calculated by taking mean of average of all shifts and was found 3.4 mm. Planning target volume (PTV) margin was found 12.4 mm applying the Van Herk formulae. Conclusion: Setup errors can be minimised with better immobilization systems including the shoulders and specific protocols in case of head and neck cases. Image Guided Radiotherapy is a better tool to reduce the setup error while treatment. Although for final PTV margin the patient number should ample and portal images should be taken throughout the treatment according the institutional protocol.


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Radiobiological Modeling of Clinical Data of Radiation Induced Acute Toxicity (Mucositis): An Institutional Data

Balbir Singh, Gaganpreet Singh, Arun S. Oinam, Vivek Kumar, Christy Alekchander, Rajesh Vashistha, Manjinder Singh

Aims and Objective: The aim of this study is to calculate the NTCP by determining the radiobiological parameters n, m, TD50, from the fitted dose response curve. The radiobiological model is used for best fit of the observed mucositis toxicity data of the clinical outcomes of the patients which gives dose response sigmoidal shape curve of parameters, where n is the dose-volume relationship parameter, m is a measure of the slope of the sigmoid curve represented by the integral of the normal distribution, TD50 is the uniform dose given to the entire OAR which results in a 50% risk of complication and is the slope of dose response. Materials and Methods: This is a single institutional prospective study of 43 patients of head and neck cancer which were available for mucositis toxicity analysis. There were 31 males and 12 females with median age of 59 years (range 35-77 years). Wipro GE CT machine was used for patient CT planning. Focal Sim Monaco (version 5.11) was used for contouring OARs and normal structures using RTOG guidelines of H&N cancer. XiO TPS (version 5.0) with superposition algorithm was used to create patient IMRT plan with mean coverage of PTV by 95% of the prescribed dose. Patient were evaluated weekly for acute radiation mucositis toxicity and scoring (Grading) as per CTCAE (v4.03) protocol. Mean and standard deviation of doses for different grades (toxicities levels) were calculated and fitted to the normal (Gaussian) distribution. Further, sigmoidal dose response curve was generated for normal tissues with the help of Gaussian function. Radiobiological parameters i.e. n, m, TD50 and were calculated from the sigmoidal dose response curve obtained from the clinical data of H&N cancer patients. Indigenous MATLAB® program (version 2011b of Mathworks Inc.) was written to calculate the NTCP using LKB model utilizing radiobiological parameters. Results: Acute radiation toxicity for oral mucosa in Carcinoma of H&N patients was calculated for the end point mucositis. The n, m and TD50, parameters for Grade 1 and Grade 2 mucositis from the fitted sigmoidal dose response curve are found to be 0.35,0.33, 23.40 (μ) ±1.17 (CI. 95%),1.17 and 0.35, 0.22, 43.05 (μ) ± 2.15 (CI. 95%), 1.72 respectively and average NTCP for Grade 1 and Grade 2 are found to be 95.94% ± 5.04 and 40.18% ± 20.78 respectively. Conclusion: This study presents the fitting parameters for NTCP calculation of Grade-I and Grade-II toxicities of mucositis in the H&N patients. Results showed the importance of radiobiological models based on the institutional data for the prediction of normal tissue toxicities which incorporates the socio-economic (health, environment and economic) conditions of the local patient. This study can be further extended for the large number of patients and for different sites.


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Assessment and results of early active nutritional interventions during radiotherapy with or without chemotherapy of head and neck cancer

Harikesh Bahadur Singh, Rohini Khurana, Madhup Rastogi, Kamal Sahni, Ajeet Kumar Gandhi, Sambit Swaroop Nanda, Satyjeet Rath, Praffulla Chandra Rai

Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

E-mail:harikeshsingh2005@gmail.com

Background: Patients with head and neck cancer (HNC) undergoing chemo-radiotherapy are at high risk of malnutrition, which is related to complication rate. Most patient facing toxicity related to radiotherapy with or without chemotherapy during course of treatment. Purpose of this study to determine the effect of active dietary counseling and or increase oral supplements on outcome for patients with cancer, specifically, nutritional outcome including assessment of physical parameter and reduced to its minimal amount to improve the tolerance of treatment and further intention to completion the treatment. Aims and Objective: Primary end point is to assess loss of weight and body mass index during radiotherapy with or without chemotherapy depending upon current standard care of management. Secondary end point is intention to complete the treatment, assess no. of patients requiring ryle's tube feeding, intravenous support, frequency and no of day stay in hospital during course of treatment and toxicity including both acute and late toxicity as per RTOG guideline. Materials and Methods: A prospective observational study was performed. Active nutritional counselling with proper diet chart provided in our radiation oncology department prior to start of radiotherapy and further weekly assessment of body weight, body mass index and toxicity assessment were done. Results: Median follow up 1 year. Total no of patient recruited in this study is 128 (Oral cavity, oropharynx, hypopharynx and larynx are 69, 33, 9 and 17). Mean body weight loss on weekly assessment (Week 1, week 2 week 3, week 4, week 5, week 6 end of radiotherapy are 0.81%, 3.16%, 4.01%, 4.67%, 5.28%, 6.65% and 7.71% respectively). Weekly mean body mass index are 21.37 (95% CI 0.35-0.61, p=NS),20.88 (95% CI 0.54-0.81, p=NS), 20.55 (95% CI 0.68-0.95, p=NS), 20.41 (95% CI 0.80-1.1 p<0.001), and 19.87 (95% CI 1.29-170 p<0.001). During treatment total 21 patient were assessed for ryle's tube feeding,7 patient denied for ryle's tube feeding and 23 patient admitted to provide intra venous fluid supplement, median hospital stay is 3 day (range,1-5 day, including the patient denied for ryle's tube feeding) to complete the course of treatment. Conclusions: Early nutrition intervention in patients with head and neck cancer receiving radiotherapy with or without concurrent chemotherapy resulted in an improved treatment tolerance with proper diet counselling and active nutritional intervention and fewer admissions to hospital.


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Correlation of parotid dose with late treatment related xerostomia post radiotherapy

V. Prathyush, Lithika Lavanya, Nishanth Vidyasagar

Background: Head and neck cancers are treated with a multidisciplinary approach (surgery, radiation, chemotherapy). Due to critical anatomical location and advanced disease status at presentation, radiation in head and neck cancers is a major challenge. Long term sequale after treatment in head and neck cancers are known and it adversely affects QOL of patients. This study aims to correlate parotid dose with xerostomia. Objective: To correlate the dose received by parotid with xerostomia. Materials and Methods: In the present study 39 histologically proven Head and Neck cancer patients treated with radical intent using IMRT technique, from 2016-17, in MS RAMIAH HOSPITAL are taken for the study. Dose received by the parotid was noted. Post one year of completion of treatment, the patients were evaluated for xerostomia and graded as per RTOG grading system. Results: In our study 10 patients had Grade 1 xerostomia (27%), only 1 patient had Grade 2 xerostomia. There is no statistically significant difference between the parotid dose and xerostomia as seen by ONE WAY ANOVA (F (2,33)=2.655, p=0.085. Conclusion: IMRT helps in reducing the incidence of xerostomia. The other probable reason might be due to recovery of salivary flow as time progresses.


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A prospective study to assess the effect of external beam radiotherapy on thyroid gland in head and neck cancer patients

Shashi Bhushan Upadhyay, Surabhi Gupta, Sarvesh Yadav, Juhi Singhal, Hari Singh, Ritu Gupta

Aims and Objectives: To assess acute reactions of thyroid gland, functional as well as structural changes due to external beam irradiation of neck during the treatment of head and neck carcinoma patients. Materials and Methods: This is a prospective study including 30 eligible patients of head and neck carcinoma, enrolled from November 2017 to August 2018. All patients received radical radiation dose of 66-70 Gy/33-35 fractions @2 Gy/fraction by telecobalt machine at SSD. Thyroid function tests {thyroid stimulating hormone (TSH), triiodothyronine (T3) and thyroxine (T4)} and ultrasonography of neck were performed before radiotherapy, mid treatment (after17 fractions of irradiation) and on completion of radiotherapy. Results: Before radiotherapy, mid treatment and at completion of irradiation, mean serum levels of T3 was 1.97 nmole/L, 1.87 nmole/L, 1.94 nmole/L, T4 level were 7.88 μg/dl, 9.15 μg/dl, 9.63 μg/dl and TSH level were 1.99 μIU/ml, 0.76 μIU/ml, 0.52 μIU/ml respectively. Thus levels of T3 exhibit continuous static level during whole treatment while serum T4 level show gradual increase level associated with increase of radiation dose, while serum TSH level progressively decreased. Increases of thyroid hormones were subtle during radiotherapy. Ultrasonography neck does not show significant changes in thyroid architecture during the irradiation. Conclusions: In this study we find that radiation causes release of excessive amounts of thyroid hormone, during radiotherapy of head and neck cancer patients as thyroid gland also receives external radiation leading to increase release of thyroxin hormone (T4). Increase level of thyroid hormone causes negative feedback effect leading to suppression of TSH secretion. Due to increase level of thyroid hormone patient show weight loss, palpitation and fine hand tremor. In these patients close monitoring and regular thyroid function test is advisable and symptomatic treatment should be given. However long term follow up is required to assess the late functional and anatomical change.


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Pattern of failure and prognostic in patients in H and N cancer: A study from regional cancer centre, an A.H.R.C.C. experience

Puspamanjari Nayak, S. N. Senapati

Objectives: To review the pattern of failurein treated patient of H & N cancer, at A.H.R.C.C. Materials and Methods: Cases of 77 patients with histo-pathologically proved squamous cell carcinoma with local or loco-regional and distant failure after treatment by radically or adjuvantly with radiation from 2016-2017 retrospectively were analysed from hospital and radiation treatment records. Results: Here is on analysis of 77 patients of H & N cancer who had failed at local or regional or distant site. Majority of patients were in 5th to 6th decade with age group between 41-50 (31.2%). On analysis of sex, most of the patients were male constitute 83.1% and female constitute 16.9%. On site wise analysis, patient having carcinoma of oral tongue had maximum failure constitute 48.1% followed by buccal mucosa 33.8%, lower alveolus 3.9%, retro-molar trigone 2.6%, hard palate 2.6%, hypopharynx 2.6%, oropharynx 2.6%. Majority of patients were in stage III (54.5%), stage II (40.3%) at initial presentation. Out of 77 patients, local failure was 68.8%, nodal failure was 26.0% and distant failure was 7.8%. 74% of patient had failure observed within 12 months of completion of treatment, 11.7% within 24 months, 7.8% within 3 years and 10.4% observed beyond 4 years. All patients were treated with either adjuvant or radical intent. Out of 77 patients of failure 2.6% had not completed the intended dose prescribed. Conclusion: Patient of H & N cancer, specifically those presented with carcinoma tongue and were in advanced stage of disease should be kept on close observation for atleast two years to detect the local or regional failure early, so that further salvage can be thought for that patient.


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Can we predict the subset of head and neck cancer patients

B. R. Kiran Kumar, Vijetha Jayakumar, Richa Tiwari, Geeta S. Narayanan

Introduction: Head and neck cancers are among the 10 most common cancers globallyand are the most common cancers in developing countries, especially in Southeast Asia. In India, it accounts for one fourth of male cancers and one tenth of female cancers. Airway obstruction is one of the major morbidities caused by these tumours. Prompt relief of the obstruction would not just save lives but also makes delivery of definitive treatment more effective. The severity of symptoms depends upon the site of obstruction, degree of obstruction and also other physiological factors. Here, we attempted to analyse the correlation between the degree of obstruction at the level of larynx with outcome of the patients in terms of tracheostomy rates and completion of definitive treatment without tracheostomy. Materials and Methods: All patients diagnosed to have primary cancers of head and neck (includes oropharynx, hypopharynx and larynx) who were treated with radiotherapy between the year January 2009– June2017 were included in the study. Area of the narrowest airway was measured on simulation CT. All the patients who had radiologically significant airway narrowing were analysed in terms of tracheostomy rates. Results: Out of 377 head and neck cancer patients which were treated, radiologically significant narrowing of laryngeal airway was observed in 179 patients. 53 patients of them required tracheostomy. Laryngeal airway narrowing could be classified into low, intermediate, high and highest risk for tracheostomy with corresponding tracheostomy rates of 5.8%, 23.5%, 41.6% and 80% respectively. Conclusions: All highest risk patients will require prophylactic tracheostomy where as high risk patients may benefit from tracheostomy. Intermediate risk patients can be considered depending upon other factors like age and co-morbidities.


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Percutaneous gastrostomy site metastasis from head and neck tumors: A single institution case series

Jeevi Mona Priyadharshni, A. K. Anand, Ritesh Sharma, Rajender Kumar, Bharat Dua, Jaspriya Bal1

Departments of Radiation Oncology and1 Nuclear Medicine, Max Super Speciality Hospital, New Delhi, India

Objectives: Head and neck cancer (HNC) patients often require percutaneous gastrostomy (PEG) tube placement due to dysphagia, in an effort to maintain adequate caloric balance. While beneficial, PEG tube placement by the “pull” method has been most associated with cases of metastasis to the PEG exit site in the literature. Our aim was to present data on HNC patients treated at our institution who developed PEG site metastasis. Materials and Methods: We herein present a case series of 4 HNC patients who underwent PEG tube placement and developed PEG site metastasis. All 4 patients had their PEG tubes placed by the “pull” method. We also report on symptoms, time to development of PEG site recurrence and outcome. Literature review of various databases viz. PUBMed, Medline was done. Results: Of the 4 patients, 3 had carcinoma oral cavity and 1 recurrent carcinoma nasopharynx. Time to development of PEG site metastasis were 2, 3, 7, 16 months from completion of treatment. All 4 patients were diagnosed with PEG site metastasis on PET CT. One patient was FNAC proven from PEG site. The shortest and longest time interval between completion of treatment and metastasis were 2 and 16 months. Conclusion: The metastatic spread of HNC to the percutaneous endoscopic gastrostomy site is a very rare occurrence. Direct implantation of tumor is the most likely explanation for metastasis; however, hematogenous seeding is also a possibility. To prevent this complication, other techniques of tube insertion need to be considered which avoid contact with the primary tumor.


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Evaluation of hearing loss in locally advanced oropharyngeal cancer patients treated with radical chemoradiotherapy

A. Lokeswari, Amitbahl, S. Ghoshal, M. Bhanumathy

Introduction: Oropharyngeal cancers are the most common head and neck subtype of cancer seen in our country. About 70% of patients present with clinically advanced disease, either at the primary site or in the cervical lymph nodes. Multimodality approach (Chemoradiation and surgery) is treatment of choice in locally advanced head and neck cancers. Radiation damage to auditory pathway can occur from the pharyngotympanic tube to the brain stem and therefore may cause hearing loss. But the radiotherapy techniques have not been evolved to protect the inner ear till date. Aim and Objectives: We did this study to compare the incidence and magnitude of sensorineural hearing loss (SNHL) in locally advanced oropharyngeal cancers treated by 3-dimentional conformal radiotherapy (3DCRT) and Rapid Arc techniques along with concurrent cisplatin chemotherapy. Materials and Methods: A total of 30 patients with previously untreated locally advanced oropharyngeal carcinoma were enrolled and randomized into two groups. Patients in arm 1 received external beam radiotherapy (EBRT) dose of 66 GY/30#/6 weeks with rapid arc technique under image guidance (IGRT), patients in arm 2 received EBRT dose of 70 GY/35#/7 weeks with 3DCRT, and both arms received two cycles of three-weekly concurrent cisplatin 100 mg/m2 on D1, 2, 22, 23. SNHL was assessed by pure tone audiometry & impedance audiometry at baseline, 6-weeks, 3-months and 6-months after completion of treatment and compared between two arms. Results: Sensorineural hearing loss was seen in higher frequencies in entire cohort. A paired sample t-test was conducted to compare the hearing loss. Arm 2 patients had significantly higher grade 3 and grade 4 ototoxicity as compared to arm 1 (grade3-60%, grade 4-10% vs grade 3 -10%) (p<0.05). Conclusion: Patients who received radiation with 3DCRT had experienced greater sensorineural hearing loss compared with patients treated with IGRT. Concern for the quality of life of patients undergoing cancer treatment is necessarily growing, and prevention of hearing loss should be a part of treatment approach to improve the quality of life.


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Distress screening in head and neck cancer patients undergoing active cancer directed treatment and impact of referral to psycho-oncology and palliative care

Shirley Lewis Salins, Saket Pandey1, Naveen Salins2, Jayita Deodhar3, Vijay Patil4, Tejpal Gupta1, Sarbani Ghosh Laskar1, Ashwini Budrukkar1, Vedang Murthy1, Amit Joshi4, Kumar Prabhash4, Sudhir Nair5, Pankaj Chaturvedi5, Vanita Noronha4, J. P. Agarwal1

Departments of Radiotherapy and Oncology,2 Palliative Medicine, Kasturba Medical College, Manipal, Karnataka, Departments of1 Radiation Oncology,3 Palliative Medicine,4 Medical Oncology,5 Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India

Aims: To estimate the prevalence of clinically significant distress (Distress score > or equal to 4) in Head and Neck cancer patients treated with a radical intent using the NCCN Distress thermometer (DT) and to evaluate the impact of referral to psycho-oncology and palliative care. Methods: This is a prospective study evaluating distress in head and neck cancer patients and patients were accrued from February 2016 to May 2017 (CTRI No. : CTRI/2016/01/006549). The study was conducted in two parts (Parts A and B). Part A: Total of consecutive 600 head and neck cancer patients undergoing curative radiation therapy (definitive and adjuvant), aged more than 18 years, aware of their diagnosis and treatment plan ECOG 2 or less and signed inform consent were considered for accrual. Patients were screened for distress using DT. Part B: This is a prospective randomized controlled trial and 212 patients receiving curative treatment either definitive or adjuvant were randomly assigned to the control (care as usual by the treating physician) or intervention group (referral to psycho-oncology and palliative care) from February 2016 to May 2017. Patients who scored 4 or above on DT in Part A of the study, reliable for follow up and signed the inform consent form were eligible for the study. Randomization was done centrally by electronic block randomization stratified for treatment, age and site. All patients were administered the DT with NCCN problem check list, Edmonton symptom assessment system (ESAS) and EORTC QLQ-C-30 and HN35 questionnaires at baseline and 6 month post treatment. Intention to treat analysis was done for Part B. Results: Part A: Six hundred and twenty one patients were screened for the study and 600 patients were accrued in the study. The median distress score of entire cohort was 4 (IQR: 3-5) and clinically significant distress (score ≥ 4) was seen in 340 patients (56.7%). At a median follow up of 15 months, 1 year and 2 year overall survival (OS) and disease free survival (DFS) rates were 95%, 93% and 71%, 59% respectively. Patients with clinically significant distress had inferior survival (2 year: 91% v/s 96%; p=0.04). Part B: Three hundred and forty patients with a distress score of 4 or more were screened for the Part B study and 212 patients were accrued in the study. The median distress score at baseline in both groups was 6 (IQR: 5-8). At 6 month follow up, the median distress score in both groups was 2 (IQR: 2-3). At 6 month follow up, there was no difference in clinically significant distress (4 or more) between the two groups (16% v/s 9.3%; p= 0.19). There was no difference in the distress checklist domains (physical, practical, family, spiritual and emotional) between the 2 groups. At 6 months follow up, there was reduction in all symptoms as measured by ESAS and improvement in quality of life (QOL) both groups however not statistically significant. Conclusion: Clinically significant distress was seen in 56% of all head and neck cancer patients treated with a curative intent and the survival is significantly poor. Although there was improvement in the distress scores, symptom scores and QOL domains with psycho-oncology and palliative care referral, in comparison to the primary treating physician care, there was no statistically significant difference.


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A prospective comparative study of quality of life outcomes in patients with head and neck squamous cell carcinoma treated with intensity modulated radiotherapy versus 3-dimensional conformal radiotherapy

Asesh Samanta, Litan Naha Biswas, Jibak Bhattacharya, Mukti Mukherjee, Akhter Jawade, Tanweer Shahid, Debottam Barman, Arundhati De, Riddhijyoti Talukdar, Pavitra Vijayaraghavan, Rejil Rajan, Rishav Raj, Chandrika Saikia

Aims and Objectives: The purpose of the study is to assess and compare the health-related quality of life (HRQOL) of patients with head and neck squamous cell carcinoma (HNSCC) undergoing radical radiotherapy with intensity modulated radiation therapy (IMRT) technique with three-dimensional conformal radiation therapy (3D-CRT) technique. Materials and Methods: From January 2018 to May 2018, 40 patients of biopsy proven squamous cell carcinoma of oropharynx, larynx and hypopharynx (cT1-3 N0-2b M0 except cT1N0 glottic cancer) undergoing radical radiotherapy either alone or with concurrent chemotherapy were included in this study. Patients were treated with radical doses with conventional fractionation using either IMRT or 3DCRT technique. The European Organization for Research and Treatment for Cancer (EORTC) QLQ-C30 and HN35 were used to study the HRQOL and assessed for each patients at baseline i.e. before the commencement of radiation, at 3rd week during radiation, after completion of treatment, at 1 month and at 3 months of follow up Radiation induced acute toxicities were assessed by Radiation Therapy Oncology Group (RTOG) toxicity criteria every week during radiotherapy. For comparison, QOL data collected at different point of time were analyzed using unpaired ‘t’ test. Acute radiation induced toxicities were compared between the two arms using chi-square test. Results: 40 patients were included in the study. The mean age of the sample population was 60 years with predominant male population (90%). Larynx was the commonest site (18 patients, 45%). 13 patients (32.5%) had T3 disease and 10 (25%) patients had node positive disease. 14 (35%) patients received cisplatin based concurrent chemotherapy. The number of patients treated with 3DCRT and IMRT were 19 and 21 respectively. HRQOL scores of various components deteriorated during and after treatment in both the arms. HRQOL scores of fatigue (24 vs 17, p=0.041), appetite loss (73 vs 44, p<0.001) and sense problems (31 vs 15, p<0.001) were significantly worse in IMRT group during and after completion of treatment. However, this difference was not evident at 3 months of follow up. Dryness of mouth and sticky saliva were significantly more in 3D-CRT group (HR-QoL score for dryness of mouth 60 vs 0, p<0.001 and for sticky saliva 9.52 vs 0, p=0.24) during radiation and 3 months after completion of treatment. Insomnia and ill feeling were found to be significantly more in 3DCRT patients. Other parameters of HRQOL, like global health, physical, emotional and social functions, speech and swallowing, nutritional parameters remained comparable in both arms. There was no grade 4 or above acute toxicities. No significant difference was observed in acute toxicities e.g. mucositis, dysphagia, skin toxicities between IMRT and 3DCRT arm during radiotherapy. Conclusions: This prospective observational study shows how technique of radiation (3D-CRT and IMRT) affects QoL in HNSCC patients treated with radical intent. Though there was no difference in terms of acute toxicity in between groups but IMRT group did significantly better considering dryness of mouth and sticky saliva, not only during treatment but 3 months after completion of treatment. This can be explained by the fact that IMRT can spare the major and minor salivary glands quite efficiently compared to 3DCRT. More number of patients and long term follow up is required to validate theses findings.


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High dose rate interstitial brachytherapy in recurrent head and neck cancer: An effective salvage option

Vibhay Pareek, Rajendra Bhalavat, Manish Chandra

Department of Radiation Oncology, Jupiter Hospital, Thane, Maharashtra, India

Objective: High Dose Rate Interstitial Brachytherapy (HDRBT) has an established role in head and neck malignancies and offers good survival rates, however, there is scant data on improved local control (LC) and treatment-related complications in recurrent cases. We present our results in patients with recurrent H&N cancers treated with interstitial HDRBT. Materials and Methods: Twenty-Five patients with recurrent H&N cancers were treated with HDR interstitial brachytherapy using Iridium 192 as the source between 2009 and 2016. Of these, 75% received radical brachytherapy and 25% received external beam radiation therapy (EBRT) followed by brachytherapy boost. Treatment sites included oral cavity (15/25) and oropharynx (10/25). Median dose was 4.5 Gy twice per day with median total dose with brachytherapy of 40.5 Gy in radical and 27 Gy for EBRT cases. Results: With median follow-up of 25 months, 4 local recurrences were observed within first year of follow up. 2-year local control and overall survival outcomes for the entire group were 75% and 68%, respectively. The local control rate with radical BRT vs BRT as boost following EBRT was found to be significant. (2 year LCR 62% vs 85%; p<0.02). Dosimetric assessment revealed D90 – 4.08 Gy, V100 – 94.1%, V150 – 24.7% and V200 – 10.1%. Xerostomia, altered taste and dysphagia was seen as major complications commonly grade I and II. Grade III toxicity was only 2%. Pre-treatment volume >85 cc had a negative impact on overall survival (26 months vs 12 month; p = 0.02) and time interval between primary and recurrence more than 15 months had an impact on the local control rate (p < 0.01). Conclusion: Results of HDR Interstitial brachytherapy have shown acceptable local control and overall survival rates along with tolerable toxicities and morbidity in recurrent H&N cancers.


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Qualitative and quantitative analysis of xerostomia in patients of head and neck cancers treated with concurrent chemoradiation by 3DCRT and IMRT techniques

A. Srinivas, P. Kumar, A. K. Chauhan

Department of Radiation Oncology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India

Aims and Objectives: Concurrent chemo-radiotherapy (CCRT) has emerged as an accepted standard of care for locally advanced head and neck squamous cell cancer. Xerostomia is a known late side effect which disturbs the quality of life. The present study was done to compare radiation induced xerostomia in patients of head and neck cancers treated with three dimensional conformal radiotherapy and intensity modulated radiotherapy. Materials and Methods: Fifty patients were included in the study from November 2016 to December 2017. All patients were planned with Radiotherapy dose of 70 Gy in 35 fractions over 7 weeks with concurrent Cisplatin 35mg/m2 weekly. The patients were divided into two groups of 25 each (Group I- 3DCRT and Group II- IMRT). For assessment of Xerostomia, Objective grading was done using RTOG toxicity scale, qualitative assessment was done using EORTC H&N 35 Questionnaire and quantitative assessment was done by Saxons test. Three assessments were done for each patient- Prior to radiotherapy, on completion of radiotherapy and at 6 months post radiotherapy. Results: After completion of radiotherapy, objective grading (RTOG) grade 2 or worse xerostomia was present in 21 patients of Group I (84%) and 20 patients of Group II (80%), there was no significant difference. Quantitative Saxon test showed no significant difference in both the groups (p value 0.459) with 20 patients of Group I (83.3%), 18 patients of Group II (75%) had Grade II or worse xerostomia. At 6 months, objective grading (RTOG) grade 2 or worse xerostomia was present in 12 patients of Group I(48%) and 9 patients of Group II (36 %), p value was significant (p value 0.014). Quantitative Saxon test showed significant difference in both the groups (p value 0.001) with 16 patients of Group I (64%), 4 patients of Group II (8%) had Grade II or worse xerostomia. Subjective assessment with EORTC QOL questionnaire showed scores of no significant difference from baseline at the completion of radiotherapy but significant difference was seen at 6 months with patients in Group II having better scores compared to Group I. Conclusion: The present study reveals IMRT significantly reduces the incidence and severity of xerostomia compared to 3D-CRT in patients of locally advanced head and neck cancers treated with chemoradiation. Long term follow up needs to validate the result.




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