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Year : 2015  |  Volume : 11  |  Issue : 7  |  Page : 28-35


Date of Web Publication24-Nov-2015

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How to cite this article:
. Gastrointestinal. J Can Res Ther 2015;11, Suppl S3:28-35

How to cite this URL:
. Gastrointestinal. J Can Res Ther [serial online] 2015 [cited 2021 May 17];11:28-35. Available from: https://www.cancerjournal.net/text.asp?2015/11/7/28/169834

Abstract: 016

Role of stereotactic body radiation therapy in liver metastasis: A pilot study

S. Kumar , R. Kapoor, A. Oinam, A. Duseja, N. Kalra

Post Graduate Institute of Medical Education and Research, Chandigarh, India, E-mail: [email protected]

Background: Stereotactic external-beam radiation is an increasingly attractive modality for patients with a limited number of unresectable liver metastases because of their non-invasive nature, excellent tolerability & high rates of local control. This trial studies the feasibility & potential utility of SBRT in these patients. Aims: (1) To assess the local response of the liver lesions post- SBRT in terms of number and size of lesions. (2) To evaluate the toxicity to OARs (Liver, Right kidney, Duodenum, spinal cord). Materials and Methods: 15 patients were planned to be enrolled in this study from November 2014-October 2015. This is an interim analysis of the results of 10 patients who have completed the protocol. The inclusion criteria are patients with 1-3 liver metastasis from any solid tumor except germ cell tumor or lymphoma with adequate liver and kidney function with no evidence of progressive disease outside the liver. A planning 4D-CT scan is taken with patient in immobilization device & the GTV is defined on all respiratory phases 0-90). PTV is generated by giving margin of 5mm. Dose prescribed is 36 Gy/3# on alternate days. Before each fraction, a cone-beam CT is taken with the patient in the treatment position with the help of on-board kVCBCT imaging system. Stereotactic repositioning is done. Patients are followed up to assess toxicity, and response is defined by CECT abdomen done at 6 weeks &3 months post-SBRT as per RECIST guideline (v1.1). Results: The median age of the patients was 64 years (range 36-65 years). The median time since primary tumor diagnosis was 6 months (range 1-13 months). No patient had received prior local therapy for liver metastasis. 3 patients had received prior systemic chemotherapy for metastatic disease. The median aggregate Gross tumor volume was 75 ml (range 0.8 ml-95 ml). The median Maximal tumor diameter was 4.4 cms (range 1 cm-6.5 cms) 5 patients had partial response, 3 patients had stable disease and 2 patients had complete response at site of original lesion but developed new lesion elsewhere i.e., Progressive disease. One patients experienced Grade 2 small bowel toxicity, none of the other patients had Grade 2 or higher Hepatic/Gastric/Renal/Small bowel toxicity. Conclusion: This trial examines the feasibility of SBRT to liver metastasis in the Indian setup. It shows excellent tolerability and is a safe & non-invasive therapeutic option for inoperable patients, showing good local control.

Abstract: 017

Esophageal squamous cell carcinoma with cutaneous metastasis: A case report

N. Bellutagi

Karnataka Cancer Therapy and Research Institute, Hubli, Karnataka, India, E-mail: [email protected]

Introduction: Skin metastasis from internal malignancies are common in breast, lung cancer & melanomas. we are hereby reporting a rare case of skin metastasis in esophageal cancer. Esophageal malignancies most commonly metastasis to lung, liver & bone. In general skin metastasis from internal organs are rarely seen with an incidence of 0.7%-9%. Metastatic spread to the skin occurs through hematogenous or lymphatic pathway & presents in the form of rapidly growing nodules. On histological examination, a cluster of atypical cells infiltrating the dermis without connection to the adjacent epidermis can be seen. Case Presentation: A 58 yrs old man presented with a history of difficulty while swallowing solid food for 20 days. He was evaluated with upper GI scopy which showed ulcero proliferative growth present from 30-35 cm from incisors, bleeds on touch & scope was negotiable beyond the growth. Biopsy from the growth showed moderately differentiated SCC. CT Thorax & abdomen showed circumferential growth involving distal third of esophagus with a maximum thickness of 13 mm, extending for a length of 7.5 cm. Distally the lesion is seen involving the GE junction, contact of angle between the lesion & descending aorta is <90 degrees with enlarged lymph nodes in para esophageal & celiac region, largest of size 12 * 15 mm. Then he was taken up for 3 field esophagectomy with esophago-gastric anastomosis with feeding jejunostomy. Post operative histopathological report showed poorly differentiated SCC with tumour infiltrating the muscularis propria, metastases was seen in 9 lymph nodes with extra nodal extension, surgical excision margins were free of tumour - grade III tumour. Patient came after 6 weeks for adjuvant treatment, he had developed multiple nodular swellings approximately 15 diffuse non tender firm to hard nodules that were 1-2 cm in diameter found on frontal region of scalp on left side, left side of face, left side of neck, 2 nodules on the right anterior aspect of arm, 2 on the left anterior aspect of arm, one each on medial aspect of thigh & 1 on the left gluteal region. Excision biopsy of one nodule showed poorly differentiated SCC Patient then received palliative chemotherapy with inj. cisplatin/5FU over four days. Conclusion: Skin manifestation of esophageal SCC are extremely rare & only a small number of cases with solid metastasis have been reported.

Abstract: 025

Clinicoepidemiological features of colorectal carcinoma: Does change in ageing trend have any role in the management?

P. Kaur , A. Chauhan, J. Vijaya Kumar, A. Khurana, Y. Verma, N. Bansal

Pandit BD Sharma PGIMS, Rohtak, Haryana, India, E-mail: [email protected]

Background: Colorectal carcinoma is more common in the age group of 50 years or older. Its incidence in the younger age group is increasing now a day. Various factors contributing to the poor outcome in the patients of younger age group includes biology of tumor, delay in the diagnosis and also disparities in the care and treatment differences. Colorectal second primary tumors (SPTs) are more common in the younger age group. Incidence of colorectal cancer under the age of 45 is 2 per 100,000 per year. Aim: The aim of the this study was to evaluate clinico-epidemiological profile, treatment pattern and outcome in younger age group patients of colorectal carcinoma. Materials and Methods: A prospective study was conducted from June 2013 to June 2015. Patients were assigned with treatment after diagnostic workup and ruling out the metastasis. All the patients were treated with various treatment modalities such as surgery, radiation therapy, concomitant chemoradiation therapy and chemotherapy. Results: A total of six patients with histopathologically proven colorectal carcinoma were evaluated in department of Radiotherapy -II, Pt B D Sharma PGIMS, Rohtak, Haryana, India. Four patients were male and two female. Age of six patients was 25, 16, 35, 25, 30 and 20, mean age was 25. All the patients in the case series presented with bleeding per rectum. Family history was insignificant in patients. History of smoking was present in one patient whereas there was no history of alcohol consumption in any of the patient. Among 6 patients 5 patients are on follow up with mean duration of follow up of 7 months. All the patients received chemotherapy based on the adult doses; radiation therapy was given on based on the dose schedules indicated in adults. Two patients of colon carcinoma received adjuvant Oxaliplatin based chemotherapy after radical surgery. Remaining four patient of rectum carcinoma received neoadjuvant chemoradiation, and then underwent surgery and adjuvant chemotherapy. Four patients have completed the intended treatment. Two patients are on treatment. Three patients had complete response and are on follow up. Conclusion: Presentation of the tumor in the younger age group did not have variation in response to the particular treatment similar.

Abstract: 047

A prospective comparative study between concurrent chemoradiation followed by high dose intraluminal brachytherapy boost versus concurrent chemoradiation alone in locally advanced cancer oesophagus

R. Tudu , D. Barman, B. Dutta, A. Halder, A. R. Deb

Medical College, Kolkata, West Bengal, India, E-mail: [email protected]

Background: Carcinoma oesophagus is a highly malignant disease presenting in very advanced stage. Surgery is considered to be the prime modality of treatment, though radiation therapy is also an important therapeutic modality. Concurrent chemoradiation has been accepted as the standard of care in patients who are deemed unfit for surgery. Intraluminal brachytherapy is effective for palliation of dysphagia and is also used as a boost to external beam radiotherapy in a curative intent. Aim: To compare the treatment outcome in patients of locally advanced oesophageal cancer treated with concurrent chemoradiation followed by brachytherapy boost versus concurrent chemoradiation alone in terms of response and toxicities. Materials and Methods: A study carried out between July 2013 to December 2015 with 42 patients of locally advanced carcinoma oesophagus who were treated with either definitive chemoradiation followed by intraluminal brachytherapy boost or chemoradiation alone. ARM A was treated with external beam irradiation with conventional fractionation to a total dose of 54 Gy. Initially 40-44 Gy was given by AP-PA field, then in phase 2, dose escalation was done through 3 field technique i.e., one anterior field and 2 posterolateral fields. ARM B was treated with external beam irradiation to a total dose of 44 Gy in conventional fractionation using AP-PA field followed by intraluminal brachytherapy with 5 Gy per fraction weekly in a total dose of 15 Gy with dose specified at 1 cm depth from the mid-dwell position. The chemotherapy regimen consisted of injection cisplatin 70 mg/m2 iv D1 with capecitabine 800 mg/m2 b.i.d. D1-4 orally on days 1 and 22 of EBRT. No concurrent chemotherapy was administered during ILRT. The treatment outcome was assessed in terms of response, dysphagia free interval and toxicities. Results: Baseline characteristics were same in both groups. In our study, 36 patients reported no locoregional recurrence at a median follow up period of 10 months. There was non significant statistical significance difference in response rates between the two treatment arms. 1 patient in the brachytherapy arm developed trachea-oesophageal fistula. Other acute toxicities were comparable in both arms. Conclusion: As the treatment was well tolerated, high dose intraluminal therapy can serve as a safe dose escalation tool with the potential to improve treatment outcome in oesophageal cancer with acceptable complications.

Abstract: 150

Anaplastic Large Cell Lymphoma of Oesophagus mimicking as adenocarcinoma

S. Samdariya , P. Bagri, P. Pareek, P. Elhence, S. Bhattacharya

All India Institute of Medical Sciences, Jodhpur, Rajasthan, India, E-mail: [email protected]

Background: Anaplastic large cell Lymphoma (ALCL) is a rare disease accounting for only 2-3% of Non Hodgkins lymphoma (NHL). Usually it affects males with a median age of 54-61 years and a male-to-female ratio of 0.9. They are usually detected in advanced stages with B symptoms, high International Prognostic Index score. They have an aggressive clinical course and overall prognosis is poor with a 5-year Overall Survival of 30-49%. Nearly half of Anaplastic kinase1 (ALK) negative ALCL affects Lymph nodes. Extranodal involvement is seen in only 20% cases which usually affect bone marrow, skin, lungs, soft tissue but gastrointestinal tract especially oesophagus involvement is very rare. Aim: In this paper we present unusual rare case of ALCL of oesophagus affecting a young 26 year old male which mimicked adenocarcinoma in its clinical presentation. Materials and Methods: A 26 year old young farmer from Jaisalmer, Rajasthan presented with complaints of difficulty in swallowing solids, pain in upper abdomen and pain in outer aspect of right upper thigh since 4 months. He didn't have any family h/o-cancer. He didn't have any habits of chewing tobacco, alcohol intake. Examination of upper part of right thigh revealed a diffuse, firm, oval, tender swelling measuring approximately 10 x 7 cm on its lateral aspect. There was an irregular shaped swelling with ill-defined borders measuring 15 x 10 cm palpated in epigastric region which was dull on percussion. There were no palpable Lymphadenopathy in neck, axilla or inguinal region. MRI Right thigh revealed heterogeneously enhancing mass lesion, hypo on T1 and hyperintense on T2 measuring 7.4 x 5.6 x 14.7 cm in right upper thigh muscles with corticle erosion. Computed tomography of Thorax and Abdomen was done which revealed thickening of mucosa of oesophagus, GE junction, lesser curvature stomach measuring 3.9 x 3.4 x 10.4 cm. Enlarged coeliac (25 x 21 mm), retroperitoneal lymph nodes, splenomegaly, mild ascitis and mild right pleural effusion. Upper GI endoscopy revealed circumferential ulcerated friable oozing growth at cardia, its biopsy revealed tumor cells with prominent nucleoli without glandular differentiation or signet ring forms. On immunohistochemistry (IHC) tumor cells were strongly positive.

Abstract: 176

Investigation of optimal strategy of internal target volume generation for liver SBRT

S. Chopra , M. Swain 1 , R. Upreti 1 , R. Engineer 1 , S. K. Srivastava 1

Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, 1 Tata Memorial Hospital, Mumbai, Maharashtra, India, E-mail: [email protected]

Purpose: To investigate if limited number of respiratory phases can be used to accurately generate internal target volume (ITV) for liver stereotactic body radiotherapy (SBRT). Materials and Methods: Free breathing (FB) and four dimensional computerized tomography (4DCT) scans of 10 patients who underwent liver radiation were included. Gross tumour volumes (GTV) were contoured in 10 respiratory phases to generate GTV ITV_4D. Different GTV ITVs were derived from selected phase contouring (GTV ITV2phases (Phase 0 and 50), GTV ITV 3phases (Phase 30, 60 and 90), GTV ITV 5phases (Phase 0, 20, 40, 60 and 80) and their volumes and spatial concordance with GTV ITV_4D was investigated. The position of centre of mass (COM) of individual GTVs were measured and systematic and random errors were calculated. Population internal margin (PM) was generated using van Herk's formula and applied to FB volume to obtain GTV population margin (GTV_PM). Results: GTV ITV 5 phases encompassed 90% (range 82.4-94.8%) of the GTV ITV_4D. The mean volume (in percentage) of GTV ITV2 phases and GTV ITV 3 phases overlapping with GTV ITV_4D was 79.8% (range 69.4-84.4%) and 80.6% (range 71.1-89.1%) respectively. The directional population margins in antero-posterior (AP), medio-lateral (ML) and supero-inferior (SI) directions were 2.46 mm, 1.75 mm, 3.45 mm respectively. GTV ITV_PM encompassed 99.4% GTV ITV_4D, but with highest spatial mismatch. Conclusion: Contouring in alternate respiratory phases may safely be used for generation ITV and is time and labour saving. Adding population based margin to FB volume lead to high spatial mismatch when compared to GTV ITV_4D.

Abstract: 183

Pre operative chemoradiation in carcinoma esophagus - A single institutional experience

H. Bajwa , R. S. Reddy, A. K. Raju

Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India, E-mail: [email protected]

Background: Esophageal cancer the 4 th most common cause of cancer related deaths in India. In 2012, a phase III study (CROSS trial) evaluated the benefit of induction therapy with weekly Carboplatin-Paclitaxel and 41.4 Gy radiation vs surgery alone. Median and overall survival improved in combined therapy arm. The pCR rates were 28%. However there is limited data regarding the outcomes of preoperative chemoradiation in India. Esophageal Cancer in India has a unique etiology (tobacco, nutritional and dietary factors), is predominantly squamous and is more advanced at presentation. This study was conducted to determine the response to preoperative chemoradiation at a tertiary centre in India. Aim: Primary objective is to evaluate the rate of Pathological Complete Response (pCR). Secondary objective is to determine the recurrence rates and recurrence patterns. Materials and Methods: We retrospectively reviewed patients with locally advanced Esophageal Cancer and Gastroesophageal Junction treated at our hospital from Sept2013 to July2015. Patients who recieved preoperative RT 41.4 Gy with chemotherapy (weekly Paclitaxel-Carboplatin or Cisplatin-5 FU or Cisplatin-Capecitabine) were included in this study. The outcomes analysed were pCR, recurrence rates and recurrence patterns. The relationship of various prognostic factors with recurrence was computed using Regression Analysis. Results: 50 patients were included in analysis (median age-50 years). 76% were Squamous cell carcinoma (SCC) and 24% Adenocarcinomas (ACC). All patients received 41.4 Gy pre operative RT. 60% of the patients received weekly Paclitaxel-Carboplatin (CROSS protocol), 32% Cisplatin-5 FU and 8% Cisplatin-Capecitabine. 2 patients progressed on treatment and did not undergo surgery. Median time to surgery was 8 weeks. 38% (19) patients achieved pCR. pCR rates were higher in SCC vs ACC (42% vs 25%) and with Paclitaxel-Carboplatin than Cisplatin-5FU or Cisplatin-Capecitabine (47% vs 25%). On regression analysis, pCR was a significant predictor of local control (p < 0.05). At a median follow up of 9.5 months, 38 patients were alive, 8 patients died and 4 patients were lost to follow up. Overall recurrence rate (ORR) post surgery was 23%. Of the 10 patients that recurred, 1 was local, 1 both local and distant and 8 were distant recurrences. Conclusion : Our study results show favourable pCR rates with preoperative CRT with significant higher rates in SCC and patients treated on CROSS regimen. Majority of the recurrences were distant recurrences.

Abstract: 223

Neoadjuvant short course radiotherapy followed by surgery in locally advanced rectal cancers

M. Vijayakumar

Madras Medical College, Chennai, Tamil Nadu, India

E-mail: [email protected]

Introduction: Before 1900, incidence of colon and rectal cancers were negligible. Since then, following economic development and industrialization the incidence has been rising dramatically. For all rectal cancers, surgery remains as the primary treatment modality. Despite these curative resection, local recurrence remains high. Anatomical confines of the bony pelvis and the necessity of preserving the autonomic nerves makes surgery challenging, which accounts for these high rates of both local and distal relapse. Many European randomized prospective trials have shown that multimodality approach results in significant better outcome. Neoadjuvant treatment has emerged as the standard of care and degree of tumor regression has become an important prognostic factor. A multi modality approach including medical oncology radiation oncology and colorectal surgery is required for optimal treatment plan. Aim: To assess the immediate loco regional response rates of locally advanced rectal cancers treated with short course radiotherapy followed by surgery. And to assess acute toxicity to neoadjuvant short course radiation in locally advanced rectal cancers. Materials and Methods: Single arm prospective study with 30 consecutive patients with locally advanced rectal cancer presented to the department of radiotherapy, Madras Medical College, Chennai. Eligible patients to be treated with short course radiotherapy followed by surgery (TME) - total mesorectal excision, with adjuvant chemotherapy 3-6 cycles of CAPEOX. Radiotherapy: 5 x 5 Gy = 25 Gy in one week. Tumor response to radiotherapy is assessed in the post operative pathological specimen & graded according to tumor regression grade and the CRM-circumferential resection margin status. The toxicity profile of the treatment was assessed with RTOG acute morbidity scoring criteria and CTCAE Version 4. Results: Among 30 patients, majority of them were males. 83% of patients had achieved a good Circumferrential Resection Margin [CRM] of more than 1 cm, and 17% had less than 1 cm CRM. Toxicities observed in the study were diarrhea grade 2 in 6 patients; 4 patients had post operative wound gaping in the perianal region. There was no treatment related deaths. Conclusion: Neoadjuvant short course RT in locally advanced rectal cancers followed by surgery is a feasible treatment regime for an adequate CRM status with manageable toxicities. Short course RT compared to long.

Abstract: 231

An audit of colo-rectal carcinoma at a tertiary cancer centre

H. Mishra , R. Khurana, R. Mishra, M. Rastogi, R. Hadi, S. Sapru,

K. Sahni

Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Background: Incidence of colo-rectal cancer in India is low as compared to the west, being more common in males. It usually affects individuals 50 years of age or more. Aim: To study patient and tumour characteristics, treatment offered and outcomes of all colo-rectal carcinoma patients enrolled in radiotherapy (RT) OPD at a tertiary care centre over last 3 years. Materials and Methods: Files were retrieved and data was collected for all colo-rectal cancer cases registered between July 2012-15. Results: Total 55 patients were registered in RT OPD over 3 years. Age of patients ranged between 20-72 years, 78% (n = 43) were males, 48% (n = 26) patients were referred from inside the institute and 52% (n = 29) from outside. Ninety percent (n = 50) had KPS of 70. 76% (n = 42) had locoregional disease while 24% (n = 13) had metastatis at presentation. Among patients having non-metastatic disease 70% (n = 29) had T3, T4 or N + disease. Per rectal bleeding (63%, n = 35) was the most common presenting symptom. All patients had histology as adenocarcinoma with 18% (n = 10) mucin producing and 7% (n = 4) as signet ring cell variant. Pre- treatment CT scan was done in 70% (n = 39), MRI in 12% (n = 7) and PET-CT in 6% (n = 3) patients. Pre-treatment CEA was done in 36% (n = 20) patients. Surgery was done in 67% (n = 37) patients (LAR -33%, n = 18; APR- 19%, n = 10; palliative -10%, n = 6; local excision- 5%, n = 3; TME- 14%, n = 8). Among the patients who underwent definitive surgery (56%, n = 31), post-operative longitudinal margins were negative in all patients and radial margins were positive in 9% (n = 3), negative in 23% (n = 7) and not known in others. Fifty-eight percent (n = 32) cases received RT, 35% (n = 19) had post- op RT along with concurrent capecitabine, 15% (n = 8) had pre-op RT along with concurrent capecitabine and 8%, n = 5 palliative RT. At last follow- up, 35% (n = 19) had complete response, 38% (n = 21) had partial response, disease progression was seen in 15% (n = 8), 9% (n = 5) were dead and in 3% (n = 2), status was unknown. Conclusion : Most of the patients presented with locally advanced disease but neo-adjuvant chemo-radiotherapy remained underutilized. There is lack of information of pre-operative CEA and radial margins status on post-operative histopathology in a large proportion of patients thus highlighting the need for standard protocols for disease evaluation and multidisciplinary approach for better outcomes.

Abstract: 243

Robotic radiosurgery in liver tumours: Early experience from an Indian center

S. Krishnamoorthy

Apollo Hospital, Chennai, Tamil Nadu, India, E-mail: [email protected]

Purpose: We report initial experience with SBRT in our patients hepatocellular carcinoma (HCC) and liver metastasis (LM). Materials and Methods: Fifty liver lesions (n = 50) in thirty-one consecutive patients (mean age 54.5 years, range 32-81 yrs; 77% male) treated with fiducial based robotic radiosurgery (CyberKnife; ). Thirteen patients had HCC and eighteen had LM. 20/31 patient (65%) were with Child Pugh A/B, 8/13 with HCC had infective hepatitis (4 each with hepatitis B & C), 5/31 (16%) had diffuse cirrhosis, 70% (12/17) had single lesion in liver and target volume <1cc in 5 patient (16%), 11-90cc in 18 (58%) and >90 cc in 8 (35%) patients respectively. 25/31 (80%) patients had prior treatment [chemotherapy 18/31 (58%), TACE 7/31 (22%)] and these patiens were treated with SBRT on progression. Only 6/31 (19%) were treated primarily with SBRT without any prior treatment. All patients were treated with 3 fractions (21-45 Gy/3#; mean dose 33 Gy, prescription isodose 84%, target coverage 94%); fiducial tracking based CyberKnife. Mean CI, nCI, HI was 1.19, 1.31 and 1.18 respectively. Mean liver dose was 5.4 Gy, 800 cc liver dose 11.1 Gy; 2% small intestine dose 12.5 Gy. Mean nodes, beamlets, monitor units and treatment time 79, 183, 44498 and 59.1 min respectively. Results: At mean follow up of 12.5 months (range 1.9-44.6 months), 19/31 (61%) patients expired and 12/31 (39%) alive (9 patient with stable disease, two local progression and one with metastasis). Median overall survival (OS) of all patients are 9 months (1.9-44.6 months), in HCC patients was 10.5 months (2.1-44.6 months) and MT 6.5 months (1.9-24.6 months) respectively. 11/31 (35%) patients had grade I-II GI toxicities, no grade III-IV toxicities were observed and only one patient (7%) had anicteric ascites with high serum alkaline phosphatase two months after CK and recovered with supportive care. Median OS (month) were significantly influenced by factors such as performance status (KPS 70-80 vs 90-100: 9.9 vs 16.4; p = 0.024), Child Pugh (CP A/B vs C: 23.6 vs 6.5; p = 0.069), cirrhosis (only fatty liver vs diffuse cirrhosis: 17.8 vs 10.6; p = 0.003), prior treatment (no Rx vs prior Rx: 30.1 vs 8.2; p = 0.08), number of lesions (single vs multiple: 16.4 vs 6.9; p = 0.001) and target volume (<10 cc vs >90 cc: 24.6 vs 11.2; p = 0.03) respectively. There was no fiducial related toxicity or migration. Conclusion: SBRT is safe and effective local treatment modality in selected patients with liver malignancies with minimal adverse events.

Abstract: 259

Correlation between pathologic complete response to neoadjuvant therapy and recurrence in patients with esophageal cancer

R. Pandey , K. P. Haresh, S. Gupta, D. N. Sharma, P. K. Julka, G. K. Rath, D. Pandey

All India Institute of Medical Sciences, New Delhi, India, E-mail: [email protected]

Background: Multimodal treatment options in carcinoma esophagus include neoadjuvant chemoradiotherapy or chemotherapy followed by surgery. The degree of pathologic response to different neoadjuvant options and its impact on the oncologic outcome is a matter of debate. Aim: To analyze the rate of pathologic complete response (pCR) and its effect on recurrence in patients with carcinoma esophagus treated with various combinations of neoadjuvant chemotherapy/radiotherapy and surgery. Materials and Methods: The records of all patients with carcinoma esophagus registered in our unit between June 2012 and December 2014 were retrieved from a prospectively maintained database and were analyzed. Results: Seventy patients with histologically proven esophageal cancer were treated with curative intent between June 2012 and December 2014. Forty patients had squamous cell carcinoma, 28 had adenocarcinoma, 1 had plasmablastic lymphoma and 1 had metastatic carcinoma from previously treated breast cancer. Forty eight (48) patients received neoadjuvant chemotherapy (NACT), 16 were treated with short course radiotherapy (SRT), and 3 patients received neoadjuvant chemoradiation (CRT). Grade III to IV neutropenia was seen in 6% of patients requiring dose modification in NACT group. Four patients developed metastatic disease on neoadjuvant therapy and were offered best supportive care. Three patients underwent upfront surgery. A total of 66 patients (63 after neoadjuvant therapy and 3 upfront) underwent surgery. Transthoracic esophagectomy with extended lymphadenectomy was performed in 63 patients; 3 patients had unresectable disease on exploration. Three patients had postoperative mortality related to pulmonary complications. Morbidities included anastomotic leak in 3, necrosis of gastric conduit in 1, and abdominal dehiscence in 1 patient. Pathological CR was seen 12 patients (25%) in NACT-surgery arm, 2 (12%) in SRT-surgery and 1 (33%) in CRT-surgery groups. With a median follow-up of 16 months (range 4-32 months), 28 patients (58%) in NACT-surgery group, 7 (44%) in SRT-surgery group, and 2 (66%) in CRT-surgery group were free of disease. All the 15 patients who had pathologic CR are presently alive without recurrence. Conclusion: Neoadjuvant therapy followed by radical surgery is a safe and effective treatment option for the management of carcinoma esophagus. Pathologic CR strongly correlates with recurrence-free survival.

Abstract: 262

Adenocarcinoma of rectum with multiple scalp nodules: A rare case report

P. Meher , L. Pujari, B. Routroy, S. Padhi, S. Senapati

Acharya Harihar Regional Cancer Centre, Cuttack, Odisha, India, E-mail: [email protected]

Background: Colorectal cancers account for 10% of all incident cancers. Colorectal adenocarcinoma most frequently metastasizes to the liver, the peritoneum, the pelvis, the lung and bone. Patient initially presenting with scalp nodule is very unusual. Aim: To present a case of carcinoma rectum presenting with scalp nodules. Case: A 55 yr old female presented with scalp nodules and bleeding per rectum for 2 months. Clinically there were multiple scalp nodules over scalp of various sizes 0.5 cm to 1 cm, hard, nontender, free from underlying bone. Per-rectally a mass was palpable around 8 cm from anal verge encircling anterior and right lateral wall which bleeds on touch. Colonoscopy showed a large semi-circumferential growth 10 cm from anal verge. Rectal biopsy came invasive adenocarcinoma. CECT abdomen and pelvis demonstrated irregular thickening of anterior, right lateral and posterior wall of rectum extending upto rectosigmoid junction with involvement of mesorectum and pararectal node. Plain MRI head revealed small hypointense lesions (sagittal T1 image) seen in scalp over posterior parietal region involving skin and subcutaneous tissue- likely metastasis, no evidence of bony erosion seen. FNAC of scalp nodule showed poorly differentiated carcinoma which was later confirmed by biopsy. On evaluation patient has no any other site of visceral metastases clinically or radiologically. Patient is posted for chemotherapy with diagnosis of stage IV rectal cancer. Discussion: Skin secondaries from internal malignancies are uncommon and occur in 0.6%-10.4% of all patients with cancer. Skin involvement is seen most commonly in carcinoma breast in women, and in carcinoma lungs in men. Cutaneous metastases in case of carcinoma rectum is very rare and it occurs in <5% of cases. Usually presents as skin nodules and also can be an initial presentation. Skin metastasis of rectal cancer is usually detected around surgical scars or on the abdominal wall, especially in the periumbilical region, it rarely presents at other sites. Scalp is one of the uncommon sites and has been reported in small case series and reports. When presents with such metastases it indicates advanced disease and carries poor prognosis. Conclusion: Though cutaneous and soft tissue metastases in carcinoma rectum are extremely uncommon, it can affect the staging and prognosis adversely. Therefore thorough examination and stringent follow up is mandatory.

Abstract: 267

Single institutional audit of pancreatic cancers treated using CyberKnife radiosurgery

R. Ravind , P. S. Sridhar, S. Bhattacharjee, M. S. Belliappa, Kumaraswamy, B. S. Ramesh, G. Kilara

HCG Hospital, Bengaluru, Karnataka, India, E-mail: [email protected]

Introduction: Pancreatic cancer is one of the common digestive system cancers and it mostly presents as an advanced disease at diagnosis. Surgery is the only modality that offers a chance of cure. However, only 5% to 15% of pancreatic cancers has the opportunity of radical resection. Over all survival rate at 5 years is 10-20%. As majority of the cases are inoperable (locally advanced), the role of alternative treatment modality that could offer local control needs to be explored and SBRT (stereotactic body radiation therapy) is one such option for these advanced tumors. Materials and Methods: This is a single institution retrospective audit of all cases of locally advanced inoperable cancers of pancreas that were histopathologically proven and treated using Cyberknife (robotic sterotactic radiosurgery). The time period for this study is from January 2009 to June 2015 and had a total of 36 evaluable patients. The patient data was retrieved from EMR (Electronic medical records), radiotherapy planning charts and radiotherapy planning CT scans. Results: Out of the total 36 patients, 9 were lost to follow and the rest 27 were taken for analysis. Majority of the patients were male (Male:Female - 17:10). Average age at diagnosis is (mean) 57.9 years. Tumors arising from the head and neck were 19, body alone were 7 and involving body and tail was one. Dose Schedules used for Cyberknife were ranging from 24 Gy to 40 Gy (in 3-5 fractions). Average stomach dose was (mean) - 664.21 cGy and average duodenal dose was (mean) - 1248.49 cGy. The mean disease free survival is 6.4 months. Eight patients had symptomatic pain relief after treatment. One patient had treatment related complication (duodenitis). At the time of follow up 26 patients had expired due to progressive disease and one patient was alive. Conclusion: Robotic sterotactic radiosurgery using Cyberknife offers an alternative treatment to surgery in patients of locally advanced (inoperable) and metastatic cancers of pancreas. This novel technology aids to deliver a high dose to the tumor and decrease dose to the nearby organs at risk thereby helping to improve local control and to aid in symptom relief.

Abstract: 277

Primary malignant melanoma of the esophagus

S. Mohandas , S. Roshni, V. Arun, T. R. Preethi, A. Peter, A. L. Lijeesh, M. H. Geethi, P. G. Jayaprakash

Regional Cancer Centre, Trivandrum, Kerala, India, E-mail: [email protected]

Primary malignant melanoma of the esophagus (PMME) comprises 0.1-0.2% of all malignant esophageal tumors. It has extremely poor prognosis and is seen predominantly in older men. The major symptoms are dysphagia, retrosternal pain and weight loss. The characteristic endoscopic finding of PMME is a large polypoidal tumor, rarely accompanied by ulcers. PMME is considered as the primary tumor if it includes the typical histologic pattern of melanoma containing melanin, if the adjacent epithelium contains melanocytes and if it arises from an area of junctional changes in the squamous epithelium. S100 protein, HMB45 and neuron-specific enolase positivity also aid in the diagnosis. At diagnosis, approximately 50% of patients present with metastases. Surgical resection is the standard, and only treatment option that influences survival. The 5-year survival rate is 4.5%. Other options for non-surgical or adjuvant treatment includes chemotherapy, chemoradiotherapy, endocrine therapy, and immunotherapy. Here, we present 2 cases of PMME, first case is of a 75 year old lady with progressive dysphagia to solids for the past 6 months. Imaging showed eccentric wall thickening with luminal narrowing at distal thoracic esophagus extending through the OG junction to the proximal part of lesser curvature of stomach with peri-gastric lymphadenopathy. Endoscopy showed an ulcero-proliferative lesion with luminal narrowing from 28 cm. Histopathology report showed malignant melanoma with positive HMB-45, Vimentin and S-100. Considering her age and poor performance status she was advised palliative treatment in the form of supportive and symptomatic care. Second case is of a 55 year old gentle man who presented with dysphagia to solids, abdominal discomfort and constipation for the past 4 months with recent onset abdominal distention. Endoscopic evaluation showed melanosis in the upper esophagus and proliferative lesion starting from 27 cm. His imaging showed large exophytic enhancing lesion involving mid and distal esophagus extending upto GE junction with obstruction of the lumen and a large epigastric nodal mass, retroperitoneal lymphadenopathy and peritoneal deposits. Histopathology report showed malignant melanoma with cells positive for S-100 and HMB-45 and omental deposit showed metastasis. Considering his advanced stage of the disease and poor performance status he was advised endoscopic Ryle's tube insertion and palliative chemotherapy.

Abstract: 293

Patterns of failure in cases of carcinoma of esophagus treated with concurrent chemo irradiation by radical intent

S. Goyal , L. Kashyap, H. B. Govardhan

Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India, E-mail: [email protected]

Background: Radical chemoradiation has been the main stay of treatment in inoperable cases of carcinoma of thoracic esophagus. The purpose of the study is to determine the pattern of recurrence after radical concurrent chemoradiation. Materials and Methods: Fifty patients with carcinoma esophagus treated with chemoradiation in the Department of radiation oncology from 2011 to 2014 were taken retrospectively for this study. All the patients were treated with external beam radiation therapy (3DCRT/IMRT) of 54 to 59.4 Gy with 3 weekly cisplatin 80 mg/m2 and capecitabine 1250 mg/m2. All patients were followed with upper GI endoscopy at 3-4 monthly for first 3 years, CECT thorax and abdomen 3 monthly for 1 year then 6 monthly upto 3 year thereafter yearly follow up. Appropriate statistics were used for the analysis. All the patient information was taken out from the case files and by telephonic interview. Results: Median age of the patients was 54 years and 26 (52%) were males and 24 (48%) were females. Most common tumour histology being squamous cell carcinoma and most common site being the middle 1/3 of esophagus 30/50 (60%). 47/50 (94%) patients received concurrent chemoradiation with cisplatin with capecitabine and 3/50 (6%) received induction chemotherapy with cisplatin and 5-FU. Patterns of failure: Patients were followed up for a period of 8 months to 34 months (median: 21 months). At the time of last follow up in September 2015, 23/50 (46%) patients had local recurrence, 14 (28%) patients had distant failure and 13 (26%) patients had no evidence of disease at the time of last follow up. Overall survival: With a median follow up of 21 months, mean overall survival for all the patients was 17.5 months. Overall survival at 1 year was 28/41 (68%), at 2 years was 13/33 (36%), at 3 years was 1/23 (4.3%). Conclusion: This study concludes that there is a higher incidence of failure and recurrences occuring most commonly locally (within the previously irradiated field) even after definitive radical treatment with concurrent chemoradiation, as the local recurrence is more than distant failure we should aim at consolidating the local therapy by dose escalation or alternative radiation therapy.

Abstract: 307

A prospective study comparing a combination of oxaliplatin and 5-FU versus gemcitabine and cisplatin in advanced stage carcinoma gall bladder

R. Chaudhari , S. Gupta, M. L. B. Bhatt, S. Singh, S. Mishra, S. Kumar, K. Srivastava

King George's Medical University, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Background: Gall Bladder carcinoma is often diagnosed at advanced stage, with median survival approximately 6 months. Till date there is no established standard of care palliative chemotherapy. There are some trials which showed benefits of Gemcitabine and Cisplatin while others showed benefits of Oxaliplatin and 5-FU in terms of overall survival and progression free survival in advanced carcinoma Gall Bladder. Aim: To compare the combination of Gemcitabine and Cisplatin Vs Oxaliplatin and 5FU in advance stage carcinoma Gall Bladder in terms of efficacy and toxicity. Materials and Methods: This prospective study included 50 cytopathologically and histopathologically proven advance stage Carcinoma Gall Bladder patients registered in Tertiary Centre of Northern India, between September 2014 and May 2015. All Patients were randomized into two groups ARM A (Gemcitabine and Cisplatin) and ARM B (Oxaliplatin and 5-FU). Results: Results for ARM -A (n = 25) were Partial Response (PR) 10 (40%), Stable Disease (SD) 8 (42%) and Progressive Disease (PD) 7 (28%), Overall Survival (OS) 5.99΁0.39 [95%CI 5.21-6.77] months, Median Progression Free Survival (PFS) 5.76΁0.46 (95% CI 4.86-6.67) months, while Results for ARM- B (n = 25) were Partial Response (PR) 15 (60%), Stable Disease (SD) 6 (24%) and Progressive Disease (PD) 4 (16%), Overall Survival (OS) 11.43΁0.72 [95%CI 10.02-12.84] months, Median Progression Free Survival 11.33΁0.76 (95%CI 9.83-12.84) months. Toxicity was manageable in both arms with no patients having grade 3 and 4 toxicity in both arms. There is no therapy related death. Conclusion: Oxaliplatin and 5-FU is slightly superior than Gemcitabine and Cisplatin in terms of overall response, overall survival and progression free survival in advanced Carcinoma Gall Bladder. But, to confirm these results study on a larger pt population needs to be undertaken with randomization.

Abstract: 309

Dosimetric analysis of lumbosacral plexus in patients of rectal cancer treated with intensity modulated radiotherapy

P. Chaudhary , S. Gupta, S. Chaturvedi, R. Agarwal, R. Chandra,

R. Shankar, S. Agarwal, S. De

Galaxy Cancer Institute, Pushpanjali Crosslay Hospital, Ghaziabad, Uttar Pradesh, India, E-mail: [email protected]

Background: IMRT allows limitation of radiation dose to nearby normal organs at risk, while allowing delivery of high doses to the target. Although, the incidence of side effects have been minimized but they still do exist. One of the rare late sequelae of pelvic irradiation is lumbosacral plexopathy. Patients present with lower limb weakness, numbness and paresthesia. Presentation is from 3 months to years after completion of radiation. Neurologic deficit is irreversible and no effective therapy other than supportive care has been found. Lumbosacral plexus (LSP) is not routinely delineated or given dose constraints during IMRT and it may lead to excessive dose dumping in this structure. A retrospective evaluation of the dose distribution in LSP in patients of rectal carcinoma treated with IMRT was done in this study. Aim: Delineation of LSP and evaluation of dose distribution of this organ at risk in rectal cancer patients treated with IMRT. Materials and Methods: 15 patients of rectal cancer, who were treated with IMRT technique, were included in the present study. LSP was delineated in every patient from L4-L5 interspace to the level of sciatic nerve on planning CT scan of 2 mm thickness by Radiation Oncologist with assistance of Radiologist using anatomic atlas and Yi et al. protocol. No dose limitation was placed for this organ during planning. After delineation, based on each patient's DVH, total LSP volume, mean dose, maximum dose and volume percentages of LSP receiving 30, 40, 50, 55 Gy were calculated. Results: PTV dose to the target region was 50.4 Gy. Mean LSP volume was 59.84 cc (range, 33-77.7), mean dose and maximum dose to LSP were 45.5 Gy (range 39.7-55.5) and 55.67 Gy (range 36.6-63.8) respectively. Mean volume percentages of the LSP 30 Gy, 40 Gy, 50 Gy, 55 Gy were 84.6%, 78.16%, 55.04% and 0% respectively. Conclusion: Radiation induced lumbosacral plexopathy (RILSP) is a rare but known complication of pelvic irradiation for lower GI or gynecological malignancies. Commonly, cases receiving EBRT and brachytherapy for cervical cancer, who receive the doses of 70-80 Gy have been reported to develop RILSP. However, rectal and anal cancer patients treated with concurrent CTRT to doses of 50-70 Gy have also been described to develop this complication. LSP delineationis not performed routinely in IMRT for pelvic malignancies and dose dumping may lead to increased rates of toxicity if this structure remains undelineated. Mean dose lower than 45 Gy can reduce the risk of RILSP.

Abstract: 317

Pleomorphic Rhabdomyosarcoma of pancreas

R. S. Rajendra , A. Goel, S. Gupta, M. Nandy, S. De, R. Parmar 1 ,

V. Zamre

Pushpanjali Crosslay Hospital, Vaishali, Ghaziabad, Uttar Pradesh, 1 Oncquest Laboratory, Safdarjung, Delhi, India, E-mail: [email protected]

Introduction: Rhabdomyosarcoma (RMS) is a highly malignant soft tissue sarcoma that arises from unsegmented, undifferentiated mesoderm or myotome derived skeletal muscle. Most common sites are head & neck, genitourinary, extremities, orbit, trunk, and retroperitoneum. Pleomorphic RMS (P-RMS) in the biliary tree is extremely rare (0.5%). To the best of our knowledge, in adults, only 2 cases of P-RMS have been reported in liver, and 1 in pancreas. We report a case of pleomorphic RMS involving pancreas. Presentation of Case: A 42 year old woman with history of diabetes, hypertension and hypothyroidism, presented with episodes of generalized pain abdomen, decreased appetite for 1 month, palpable abdominal mass and contrast-enhanced computed tomographic (CECT) finding of a mass in tail of pancreas. CT guided trucut biopsy from tail of pancreas showed poorly differentiated malignant tumor. Positron emission tomography with 2-deoxy-2-{fluorine-18}fluoro- D-glucose with computed tomography showed diffuse enlargement and avidity of distal body and tail of pancreas with hypodense areas in tail region and lymph node of size 2.8 x 1.9 cm was seen in peri-pancreatic region. Patient underwent distal pancreatectomy and splenectomy. Post operative histopathology reported undifferentiated carcinoma 8 x 5 x 5 cm size lesion in body and tail of pancreas microscopically extending to peripancreatic soft tissue and also upto splenic hilum. Lymphovascular extension and perineural invasion were present. 1/12 nodes positive. Immunohistochemistry reported was positive for desmin and myogenin consistent with pleomorphic rhabdomyosarcoma of pancreas. Patient received 3 cycles adjuvant chemotherapy (MAID: Ifosfamide, Mesna, Doxorubicin, and Dacarbazine) followed by adjuvant radiotherapy (PTV 50.4 Gy/28 fractions). She is asymptomatic till date. Discussion: Pleomorphic RMS in pancreas is extremely rare. Muscle specific markers like myogenin, desmin, SMA and vimentin are helpful in making diagnosis. Surgical resection followed by chemotherapy and radiotherapy are the standard of treatment. Long term prognosis of pleomorphic RMS, predominantly reported for limbs, is poor. Only one pancreatic pleomorphic RMS has been reported in literature till date. Conclusion: P-RMS is an extremely rare tumor in adult and may present in uncommon sites like pancreas. It should be included in differential diagnosis of abdominal lump.

Abstract: 343

Achieving further response in poor responders to neoadjuvant chemoradiation by chemotherapy: A Prospective study

P. Gupta , R. Engineer, V. Ostwal, S. Chopra, P. Patil, A. Saklani,

S. Arya, S. K. Shrivastava

Tata Memorial Centre, Mumbai, Maharashtra, India, E-mail: [email protected]

Background and Aim: Among patients with locally advanced carcinoma rectum, 25-30% remain surgically unresectable after neoadjuvant chemoradiation (NACRT). These patients showing predicted/threatened CRM positivity on post NACRT MRI are offered palliative chemotherapy. Many oncologists wait up to 12 weeks post NACRT to assess response MRI before declaring unresectability, citing possibility of delayed tumour response to NACRT. We treated these patients with further 4 cycles of chemotherapy and reassessed them for operability. Materials and Methods: Patients with locally advanced carcinoma rectum having unresectable disease on MRI at presentation received NACRT 50 Gy at 1.8-2 Gy/day with concurrent capecitabine 825 mg/m2 daily. Follow up MRI done at 6 weeks post NACRT was assessed in a joint multidisciplinary meeting. Patients with persisting unresectable local disease were planned for 4 cycles of chemotherapy followed by reassessment for resectability. We present the results of the patients with poor response to NACTRT having further treated with chemotherapy. Results: From January 2013 to December 2014, 50 patients with locally advanced unresectable rectal cancer receiving NACRT had persistent unresectable disease on MRI. 31 patients received further FOLFIRINOX and 19 patients received FOLFOX/CAPOX chemotherapy. CRM was involved in 45 patients and threatened in 5 patients. 16 patients had signet ring cell histology. Nodal stage was N0 in 2, N1 in 33 and N2 in 13 patients. R0 resection was achieved in 32/50 (64%) patients. 68% in FOLFIRINOX group and 58% in FOLFOX/CAPOX group achieved R0 resection. 11 patients underwent pelvic exenteration. 12% patients were still inoperable after extended chemotherapy, metastatic disease was found in 10%, and 12% patients refused surgery. Tumour regression grade in histopathology was 1/5 in 22%, 2/5 in 37%, 3/5 in 16%, 4/5 in 16% and 5/5 (complete response) in 6%. Conclusion: Achieving R0 resection in this subset has been heartening. Whether this continued decrease in primary tumour volume can be attributed to delayed response to radiotherapy or addition of further chemotherapy, or both, is yet to be ascertained. Hence for patients with advanced local disease not yet in palliative stage, further intensive chemotherapy with clinicoradiological follow-up should be done to facilitate successful surgical resection.

Abstract: 372

Safety and efficacy of epirubicin (E) or doxorubicin (A), cisplatin (C) and 5 fluorouracil (F) or capecitabine (X) in unresectable or metastatic (M+) stomach cancer

R. Sachan , R. K. Singh, R. Harshvardhan, S. Agrawal, S. Kumar

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Background and Aim: A triplet combination of an anthracycline (A or E), a platin (C) and a fluoropyrimidine (F or X) is the current standard of care of palliative unresectable or M+ stomach cancer. A service evaluation on safety and efficacy is reported. Materials and Methods: Between 2008 to 2014, 181 gastric cancer were treated, of which 60 unresectable or M+ patients had received either ECX or ACF/ECF. Planned doses of A - 40 mg/m 2 D1, E - 50 mg/m 2 D1, C - 60 mg/m 2 D1, F - 300-500 mg/m 2 D1-5 or X - 1000-1250 mg/m 2 D1-21 were offered every 3 weekly for a maximum of 6-8 cycles. Response was assessed clinically (appetite, weight and melena) or objectively (decrease in refilling of ascites or size of measurable disease on ultrasonographic assessment) and data reported as summary measures with statistical significance determined by the Chi-square test or log rank test as appropriate. Results: Of the 60 patients, 75% were males; mean age 51.7 years (SD 12.1); 92% were M+, 80% had KPS of 80 or more; 57% had documented significant weight loss. Twenty seven received ACF/ECF (Gp-1) and 33 received ECX (Gp-2). Six cycles or more were completed in 22% vs. 36% (p = 0.1); clinical/radiological improvement was seen in 48% vs. 70% (p = 0.1); grade 3 hematological toxicity 7% vs. 12% (p = 0.4); grade 3-4 diarrhea 15% vs. 3% (p = 0.8) in Gp-1 vs. Gp-2 respectively. At a median follow up of 8.5 months of all alive patients, 44% vs. 27% were dead, 56% vs. 52% were lost to follow up with active disease and 0% vs. 21% were alive. Median overall survival was 5 months vs. 6 months (p = 0.5) and 10 months vs. 11 months (p = 0.1) assuming the worst case scenario and best case scenario respectively, for patients lost to follow up. Conclusion: ACF/ECF and ECX, appear similar in efficacy but ECX appears to be more tolerable with lesser GI toxicity. The large number of patients lost to follow up represent the main challenge to reliably ascertain safety and efficacy of interventions.

Abstract: 373

Service evaluation of neoadjuvant chemoradiotherapy followed by surgery in patients of rectal cancer treated at a tertiary care center between 2008 and 2014

L. Mohan , A. Kumar, R. K. Singh, N. Rastogi, R. Harsvardhan, S. Kumar

Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Background: Surgery with CTRT in a neoadjuvant or adjuvant role is the recommended treatment for locally advanced rectal cancers. A service evaluation of rectal cancers referred for neoadjuvant CTRT is reported . Materials and Methods: Patients for upfront CTRT were planned with radiotherapy (RT) 45 Gy/25 fr/5 weeks or 50.4 Gy/28 fr/5΍ weeks with concurrent 5FU 325 mg/m 2 D1-3 and D29-31 or Tab Capacitabine 1650 mg/m 2 in two divided doses for duration of RT including weekends. Demography, acute toxicity and complication are reported in summary measures; survival was calculated using the Kaplan Meier method. Results: Of the 267 patients, 54% (144/267) were planned for upfront CTRT; 66% (95/144) were males; mean age 41 years (SD: 15.5); stage II were 21% (30/144), stage III-73% (106/144), stage IV-3% (4/144) and stage not documented in 3% (4/144) cases. Seventeen patients did not take any treatment. Of the remaining 127 patients, 86% (109/127) could complete the CTRT and 40% (51/127) could undergo radical surgery (LAR -25 & APR- 26). Ten patients progressed during treatment and remained inoperable while 75% (38/51) patients received post surgery adjuvant CT and only 45% (23/51) could complete the planned treatment. 34% (43/127) patient had diarrhea (89% - grade I, 9% - grade-II, 1%- grade III and 1% grade IV). At a median follow up of all alive was 26 months, 17% (22/127) patients were alive and well, 9% (11/127) were lost to follow up without disease, 54% (68/127) patients were lost to follow up with disease, 5% (7/127) patients were on follow up with disease and 15% (19/127) were dead. Median overall survival was 35 months (95% CI 22-52) and not reached in worst case and best case scenario respectively. Conclusion: The compliance to upfront CTRT is fairly good as 86% (109/127) patients completed CTRT, but only 38% (51/127) are known to have undergone radical surgery. The percentage of patient completing planned treatment is as low as 18% (23/127) and lost to follow up is of the order of 63%, which is the main challenge in determining the efficacy of the strategy. The low percentage of patients undergoing surgery following CTRT is reflection of patient selection, inadequate finances to undergo surgery or inappropriate counseling of patients.

Abstract: 402

A study to assess the survival in cancer esophagus

N. Patange , V. Mahobia, N. Patange, D. Arora

Government Medical College and Hospital, Nagpur, India, E-mail: [email protected]

Background: Cancer Esophagus is associated with poor overall survival. It is one of the second and fifth leading cause of mortality in males and females respectively according to 2005-09 data. Its dismal prognosis can be attributed to various factors like poor compliance of patients to available treatment modalities. Aim: To assess the survival in Cancer Esophagus of patients treated with Combined modality and Radiotherapy alone in our region. Materials and Methods: A retrospective analysis of 150 patients enrolled in our Department of Radiation Therapy and Oncology during 2010-2011 was conducted. Compliance to treatment was assessed in terms of swallowing capacity and survival rate. The data pertaining to survival was collected through the file records and by telephonically contacting the relatives. Only 70 contacts could be reached. Results: The survival of the patients was analyzed according to the site of involvement, gender, mean age, distance from our center and treatment modality received - Surgery, Radiotherapy and Chemotherapy. 60% patients had a survival of <6 months and of these 61% had middle third carcinoma. Concurrent Radiotherapy was received by 55% patients and <2% of patients had 5 year survival. Patients who received both chemotherapy and radiotherapy had 5% 2-4 year survival with 65% being able to swallow liquid. Affording and educated patients who received ILRT with EBRT had only 7% 2-4 year survival with 4% patients being able to swallow semisolids. Conclusion: Cancer Esophagus is an aggressive disease. Combined modality treatment with Chemotherapy and Radiotherapy (EBRT and ILRT) shows a significant improvement in survival and quality of life of patients. Thus it should be the preferred mode of treatment in advanvced stages of the disease.

Abstract: 407

Does PET-CT influence response assessment in patients of advanced gallbladder cancer on chemotherapy?

S. Agrawal , M. Ravina, S. Gambhir

Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Aim: Gall bladder carcinoma (GBC) is the most common cancer of the biliary tract in North India. 90% of these patients are detected in advanced stages and merit chemotherapy. CT scan is the standard modality for assessment of response (by RECIST criteria). Since PET-CT gives information on metabolic response, our aim was to evaluate the utility of PET-CT in addition to CT scan (by PERCIST criteria). Materials and Methods: P atients with locally advanced and/or metastatic GBC were treated with a combination of cisplatin 25 mg/m2 and gemcitabine 1gm/m2 day 1 and 8 repeated 3 weekly for a total of 3 cycles. Response assessment was done with CECT as well as PET. Responders were continued on further 3-5 cycles of the same regime while non-responders were treated with a second line regime. Response assessment was done with RECIST as well as PERCIST. The response was categorised in four categories according to RECIST [Complete response (CR), Partial response (PR), Stable disease (SD) and progressive disease (PD)] and PERCIST criteria [Complete metabolic response (CMR), Partial metabolic response (PMR), Stable disease (SD), progressive metabolic disease (PMD)]. Upstaging or downstaging of RECIST response was computed for each category. Results: 31 patients (24 females and 7 males) had a median age of 50 years. According to RECIST criteria, partial response (PR) rate was 16% (n = 5), stable disease (SD) 68% (n = 21) and progressive disease (PD) 16% (n = 5). Complete metabolic response (CMR) was noted in 16%, partial metabolic response (PMR) 32%, progressive metabolic disease (PMD) in 52%. Agreement was poor with Cohen kappa coefficient of 0.2. PET upstaged response in 51% and downstaged in 16% patients. Amongst partial responders (n = 5), there was downstaging in one (CMR), and upstaging in 2 patients (PMD). Among patients with stable disease (n = 16) there was downstaging in 3 (CMR) and upstaging in 10 patients (PMD). Among patients with progressive disease (n = 5) there was downstaging in one (CMR) and upstaging in 4 patients (PMD). Conclusions: PET upstaged response in 51% and downstaged in 16% patients. The study elaborates that the metabolic response criteria (PERCIST) might be considered more suitable for evaluation of therapeutic response assessment for patients on chemotherapy in GBC in comparison to anatomical response criteria (RECIST). Further, use of 18F FDG PET-CT for monitoring therapy response offers improved patient care by individualising treatment and avoiding ineffective therapy.

Abstract: 408

Radiological downstaging with neoadjuvant therapy in unresectable gall bladder cancers

S. Agrawal , L. Mohan, Z. Neyaz, R. Saxena

Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Introduction: Gallbladder cancer is endemic in the Indogangetic belt and often present as unresecatble or metastatic disease. We conducted a prospective feasibility study to evaluate the effect of neoadjuvant therapy on radiologic downstaging and resectability. We report our prelimnary results on radiologic downstaging in a cohort of patients. Materials and Methods: The inclusion criteria for patients was involvement of Right branch of hepatic artery or portal vein or common bile duct, common hepatic duct and primary biliary confluence or liver, duodenum and colon involvement and lymphadenopathy in hepato-duodenal, peri-pancreatic, common hepatic artery region. These patients were offered chemoradiotherapy [CTRT] (external radiotherapy (45 Gy) along with weekly concurrent cisplatin 35 mg/m2 and 5-FU 500 mg). Since patient recruitment was not as per our expectations and many of them presented with paraaortic lymphnodes, we relaxed our inclusion criteria to include these patients and offered them neoadjuvant chemotherapy [CT] (cisplatin 25 mg/m2 and gemcitabine 1 gm/m2 day 1 and 8, 3 weekly for 3 cycles). Radiological downstaging was evaluated by downstaging of liver involvement and lymphadenopathy according to RECIST criteria. Results: 40 patients have been inducted into this study from January 2012 to December 2014 but some patients (n = 9) deteriorated on treatment and hence 2 sets of CT scans for response assessment was available for 31 patients. The pretreatment CT scans revealed involvement of porta hepatis (19), liver infiltration (38), duodenum involvement (n = 22), colon involvement (n = 11), N1 involvement (n = 11), N2 disease (n = 8), paraaortic LN (n = 15), no LN (n = 6). After neoadjuvant therapy (CTRT = 19, CT = 21), liver involvement completely disappeared in 12 (30%), partially in 17 (42.5%), was static in 9 (5%) and lymphnode involvement completely disappeared in 20 (50%), partially in 7 (17.5%), was static in 4 (10%). 6 patients could undergo extended cholecystectomy who had 50% and 66% downstaging of liver and lymphnodes which translated into 74% and 84% histopathological downstaging of liver and lymphnodes. All resctions were R0. Conclusions: Neoadjuvant therapy in unresectable gall bladder cancer results in 15% resectability rate and radiologic downstaging of liver involvement by 72.5% and lymphadenopathy by 67.5%. Our prelimnary results reveal strong potential of this approach in achieving R0 and node negative disease and hence improvement of survival.

Abstract: 409

Does CA 19.9 have prognostic relevance in carcinoma gallbladder?

S. Agrawal , A. Lawrence, R. Saxena

Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Background: CA 19.9 has 80% specificity for diagnosis of GBC. There is scarce data on its prognostic relevance. This retrospective study was undertaken to evaluate the prognostic relevance of CA 19.9 in different prognostic subsets of GBC. Materials and Methods: 142 patients of GBC treated between January 2012 to December 2014 were the subjects of this retrospective analysis. Baseline Ca 19.9 levels of four cohorts of patients: Extended cholecystectomy [EC], simple cholecystectomy [SC] with residual or recurrent disease, locally advanced disease (LA-GBC), and metastatic disease were ascertained. The difference in the median baseline values of CA 19.9 among different prognostic group was ascertained by independent sample t test. The effect of log transformed value of CA 19.9 on overall survival (OS) was also analysed to evaluate its role as a predictive marker. Results: Patients of EC (n = 24) had a baseline median levels of 10 units/ml (range 2-20 units/ml) and a median OS of 24 months (range 12.5-30 mo). Patients of SC (n = 26) had a median Ca 19.9 level of 12 units/ml (range 4.5 to 35 units/ml) and a median OS of 15 months (range 11.7-25 mo). Patients with LA-GBC (n = 39) had a baseline median levels of 35 units/ml (range 8- 130 units/ml) and a median OS of 7 months (range 4-12 mo). Patients with metastatic disease (n = 53) had baseline median Ca 19.9 level of 75 units/ml (range 8 to 970 units/ml) and a median OS of 6 months (range 3-11 mo). The difference in the median baseline value of CA 19.9 and OS among the 4 subgroups was 0.000 and 0.000 (p value). Cox regression analysis revealed a significant influence of log transformed value of CA 19.9 on OS (HR 1.1, 95% Confidence interval 1.026-1.19, p = 0.009) without stratification for prognostic subgroups. Conclusions: Ca 19.9 has prognostic relevance in different subsets of GBC and its role as a predictive marker needs to be further explored.


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