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ABSTRACT
Year : 2015  |  Volume : 11  |  Issue : 7  |  Page : 57-87

Head and Neck


Date of Web Publication24-Nov-2015

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How to cite this article:
. Head and Neck. J Can Res Ther 2015;11, Suppl S3:57-87

How to cite this URL:
. Head and Neck. J Can Res Ther [serial online] 2015 [cited 2020 Dec 3];11:57-87. Available from: https://www.cancerjournal.net/text.asp?2015/11/7/57/170047

Abstract: 014

Does the gross tumour volume have an impact on locoregional control and overall survival in locally advanced head and neck cancer treated with concurrent chemoradiation with IGRT?

th
B. Dua , G. Jadhav, A. Thakwani 1 , K. S. Chufal 1

Apollo Hospital, 1 Batra Hospital, New Delhi, India, E-mail: [email protected]

Background: There is increasing evidence to show that the AJCC TNM staging may not be sufficient as a prognostic and predictive tool by itself in head and neck cancer and that tumor volumetry may have a role to play in therapeutic decision making. However inspite of numerous studies done on the subject there is still no consensus on how to best incorporate this into current management paradigms. Ours was a prospective study that attempted to elucidate the role of Gross tumor volume as a prognostic factor in locally advanced oropharyngeal and hypopharyngeal cancer. Aim: To assess the impact of the Gross tumor volume on loco regional control and overall survival in locally advanced cancers of the oropharynx and hypopharynx. Materials and Methods: We enrolled 90 patients of Stage III-IV squamous cell cancer of the hypopharynx, and oropharynx, who subsequently received definitive concurrent chemo radiation with Intensity modulated radiotherapy. The Gross tumor volume (GTV) was delineated on the planning CT scan and its volume was calculated by the volume algorithm in the treatment planning system (Eclipse Version 8). Correlations were sought between this and loco regional relapse free survival (LRFS), as well as overall survival (OS) over a follow up period of 2 years. Results: The 2 year OS and LRFS of our patients was 65 and 55% respectively. The mean Gross tumor volume was 48 cc with a range of 5-167cc. While the GTV was a significant prognostic factor for both locoregional relapse free survival (p = 0.005) and overall survival (p = 0.010) on the univariate analysis, it was not so on the multivariate analysis. Similar results were obtained on the subset analysis of our 60 oropharyngeal patients. Conclusion: Gross tumor volume does not predict loco regional control or overall survival in locally advanced head and neck cancer.

Abstract: 020

A comparative evaluation of concomitant boost with concurrent chemoradiation versus standard fractionation chemoradiation in LAHNC

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P. Gupta , V. Kaushal, A. Dhull, R. Atri, R. Dhankhar, N. Patel,

N. Balasubramanian

Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, E-mail: [email protected]

Aim: To evaluate efficacy, tolerability and toxicity of concomitant boost with concurrent chemoradiation versus standard fractionation chemoradiation in treatment of locally advanced head and neck cancer (LAHNC). Materials and Methods: The study was conducted on 50 treatment naοve patients of LAHNC, who were randomly divided into two groups of 25 each. In arm A, patients received accelerated hyperfractionation with concomitant boost with concurrent chemotherapy; 45 Gy/25 fractions in 5 weeks and 18 Gy/10 fractions concomitant boost in last two weeks of treatment. Total radiation dose of 63 Gy was given. In last 2-weeks concomitant boost radiation was administered after a gap of 6-hours. All 25 patients received injection cisplatin 75 mg/m2 on day 1, 17 and 34 of treatment schedule of 5-weeks. In arm B, all 25 patients received standard fractionation chemoradiation at a dose of 64 Gy/32 fractions/6.2 weeks with injection cisplatin 75 mg/m2 on day 1, 22 and 42 of total 6.2 weeks treatment. Results: The patient parameters were closely matched in two arms. In both arms, the median age at presentation was 58-years (Range: 33-67). The male to female ratio was 9:1. 99% patients had history of tobacco intake and 90% patients were chronic alcoholic. Most common presentation was difficulty in swallowing (95%) and neck mass (40%). 55% patients were of stage III and 45% patients were of stage IV at the time of presentation. Disease response in arms A and B was: CR- 45% vs 40%, PR- 40% vs 42%, NR-15% vs 18%. At completion of treatment 46% & 38% patients had grade II mucositis; 43% & 48% had grade III mucositis in arm A and B respectively. Grade II skin reaction was seen in 81% & 78%; 60% & 58% had grade III skin reaction in arm A and B respectively. Conclusion: The reduction of overall treatment time was possible with concomitant boost with concurrent chemotherapy. This technique as compared to standard chemoradiation had favorable local control with comparable toxicity in both the arms. The present study has shown that concomitant boost with concurrent chemo radiation may be used in LAHNC with comparable local control and acceptable toxicity but significant treatment time reduction.

Abstract: 026

Comparison of toxicity profile of concomitant cisplatin versus carboplatin in locally advanced head and neck cancer

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A. K. Aggarwal

Jindal Hospital, Hissar, Haryana, India

E-mail: [email protected]

Background: To review the recent changes in NCCN guideline of treatment of locally advanced head & Neck carcinoma in Indian population. Aim: To compare the toxicity profile of concomitant chemotherapy with cisplatin (30 mg/m2) versus carboplatin (AUC 1.5) along with radical radiotherapy either with cobalt or linac. Materials and Methods: 100 histopathologically proven squmous cell carcinoma of locally advanced head and neck cancer patient were taken for this retrospective non randomized study, who presented in radiotherapy department from 1/7/2014 to 31/7/2015. Patients who were previously treated or had surgery for head and neck carcinoma were not included in the study. All patients were given neo adjuvant chemotherapy before starting the radical treatment either with six cycle of cisplatin + paclitexol + 5- FU (70%) or with 6-9 cycle of Carboplatin + Paclitexol + 5 FU (20%). Patients are given radiation with linac IMRT (70 Gy/35F/7Wks to GTV) or with tele cobalt (64 Gy/32F/6.2 Wks with reducing spinal sparing fields) along with weekly concomitant chemotherapy either with inj Cisplatin 30 mg/m2 (group I) or Inj carboplatin AUC 1.5 (group II). The toxicity profile of both the regimen during concomitant chemo- radiotherapy were observed in the form of dysphagia, skin reaction, mucositis, nausea or vomiting, loss of weight, and any hematological (measured with Hb, TLC, Platelets) or kidney toxicity (measured with Serum Creatinine values) every week according to RTOG grading system. Results and Conclusion: No major toxicity was observed in initial two weeks of treatment in both the group except 20% patients of group I had grade-1 nausea. Twenty three percent patient in group I required reduction while more than 30% patients required dose reduction of concurrent chemotherapy because of one or the other reasons. Seven percent patients in group I and 12% patients in group II had local or nodal residual diseases. Detailed result and conclusion will be presented in the conference. Patients were followed up for 4 months.

Abstract: 027

Choroidal melanoma of left eye with very early liver metastasis: A case report

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S. Mandal

Saroj Gupta Cancer Centre and Research Institute, Kolkata, West Bengal, India, E-mail: [email protected]


Uveal melanoma is a cancer (melanoma) of the eye involving the iris, ciliary body, or choroid (collectively referred to as the uvea). The liver is a frequent site for metastasis in patients with uveal melanoma. The interval between the diagnosis of the uveal melanoma and the diagnosis of the metastatic lesion can vary. Despite therapy, the median survival of those with liver metastasis is five to seven months. We report here a rare case of choriodal melanoma in a 45 year old male smoker presented with liver metastasis within just eight months after completion of initial treatments consists of enucleation of eye and 3 dimensional-conformal radiation therapy (3D-CRT). The metastasis is an incidental finding on imaging after having some vague symptoms. This type of very early metastasis after completing initial treatment is very rare and proves the aggressiveness of the disease. Conclusion: Metastasis should be zealously sought following treatment of a primary lesion.

Abstract: 035

Prospective study evaluating dosimetric correlation between dysphagia and doses to organs at risk for radiation induced swallowing dysfunction (SWOARS) in head and neck cancer patients receiving intensity modulated radiotherapy

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I. Bashir , S. Jain, K. Bansal, A. Thakwani, A. Bhatnagar, P. Khullar,

I. Ahmad, K. S. Chufal

Batra Hospital, New Delhi, India, E-mail: [email protected]

Background: With the success of IMRT techniques in reducing the severity of xerostomia in head and neck cancer (HNC) patients, efforts should be made to improve swallowing dysfunction, which is potentially more discomforting and incapacitating side effect and adversely affects the quality of life (QOL). Aim: This is a clinical dosimetric study to investigate the correlation between radiation doses delivered to organs at risk for radiation induced swallowing dysfunction (SWOARs) and severity of dysphagia following concurrent chemoradiotherapy to HNC patients and evaluate various factors which assume importance in determining the risk of dysphagia/aspiration. Materials and Methods: 60 Head and Neck cancer patients (Oropharynx 28, Hypopharynx 12 and Larynx 20) were enrolled between May 2013 and June 2014 for this prospective longitudinal study after prior approval from the hospital ethics and review committee. Patients were treated with curative intent by radiotherapy using IMRT and concurrent chemotherapy using cisplatin (40 mg/m2 i.v.) on weekly basis. Delineation of SWOARs was done using RTOG guidelines and following structures were contoured: superior, middle and inferior pharyngeal constrictor, cricopharyngeal muscle, esophageal inlet muscle, cervical esophagus, base of tongue, supraglottic and glottic larynx. Dysphagia endpoints included both patient-reported and observer-rated scores. Correlation between dysphagia and radiation doses to SWOARs was assessed. Results: With an increase in the mean dose to the SWOARs, the grades of dysphagia also increased. Significant correlation was observed between patient reported dysphagia scores and the mean doses to the superior and middle pharyngeal constrictor as well as glottic and supraglottic larynx (p < 0.05). Observer rated dysphagia score correlated significantly with mean superior pharyngeal constrictor dose and not with dose to other SWOARs. Two patients developed stricture which correlated significantly with dose to esophageal inlet muscle and cervical esophagus. Conclusion: Radiotherapy plans in which sparing of SWOARs is done should be generated and implemented to prevent the problem of dysphagia. The structures whose damage may cause dysphagia and aspiration are the pharyngeal constrictors and the glottic and supraglottic larynx. Further studies are required to evaluate dose constrains to these SWOARs to reduce the incidence of radiation induced dysphagia and thus further improve the QOL of HNC patients.

Abstract: 043

Induction chemotherapy in locally advanced squamous cell carcinoma of head and neck

th
V. Kaushal , G. Malik, A. K. Dhull, R. Atri, R. Dhankhar

Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, E-mail: [email protected]

Introduction: Globally head and neck cancer is the 10 th most common malignancy and accounts for 4.8% of all cancers. Head and neck cancers account for 37% of all cancers seen in Department of Radiotherapy, PGIMS, Rohtak, Haryana, India. Materials and Methods: A study for locoregional control and toxicity profiles of two different treatment schedules where induction chemotherapy with TPF (Docetaxel, Carboplatin, 5-Fluorouracil) followed by concomitant chemoradiation with three weekly carboplatin in one group, and same induction chemotherapy followed by conventional radiation therapy alone in other group, in patients of locally advanced head and neck carcinoma (LAHNC). Materials and Methods: A prospective randomized study was conducted on 50 treatment naοve & histopathologically proven patients of squamous cell carcinoma of head & neck, attending the Department of Radiotherapy, PGIMS, Rohtak, Haryana, India. Study group (Group A) comprised of 25 patients, who received induction chemotherapy with 3 weekly TPF for 3 courses; followed by concomitant chemoradiation with 3 courses of three weekly carboplatin were given radiotherapy dose of 64 Gy/32 fractions/6.2 weeks. Control group (Group B) comprised of 25 patients who received induction chemotherapy with 3 weekly TPF for 3 courses, followed by conventional radiation therapy as 64 Gy/32 fractions/6.2 weeks. All patients have a minimum follow up of one year (range 1-3 years). Results: After induction chemotherapy the response rate in Group A vs Group B was as follows: CR 12% vs 12%, PR 88% vs 88% and overall response 100% in both. At last follow-up in Group A, no evidence of disease (NED) was seen in 52%, residual disease in 39%, while recurrence was seen in 9%. Grade III skin reactions at end of radiotherapy were seen in 19% while grade III mucosal reactions were seen in 24% patients. In Group B, NED was seen in 40%, residual disease in 44% and recurrence was seen in 16% patients. Grade III skin and mucosal reactions at end of Radiotherapy were seen in 4% each. Conclusion: Induction chemotherapy followed by concomitant chemoradiation provided better locoregional control compared to induction chemotherapy followed by conventional radiotherapy, with comparable toxicity. Taking into account the improvement in locoregional control and symptom relief in study group with comparable toxicities in both the groups, induction chemotherapy with TPF followed by concomitant chemoradiation is feasible treatment option in patients of LAHNC.

Abstract: 050

Prospective observational study for quantification of volumetric and geometric changes in the target volume and parotid during intensity modulated radiotherapy in locally advanced oropharyngeal cancers

th
S. Gayakwad , J. P. Agarwal, R. Upreti, V. Murthy, U. Upreti,

S. G. Laskar, T. Gupta, A. Budrukkar

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

Background: Intensity modulate radiation therapy (IMRT) has become standard of care for management of locally advanced head and neck cancers (LAHNC) because of parotid sparing ability. But volumetric and geometric changes in target volume and parotids during IMRT need to be quantified as local control and post radiotherapy salivary production are well predicted by dose-volume effects. Aim: To evaluate volumetric and geometric changes in LAHNC. Materials and Methods: 10 Patients receiving radiotherapy using IMRT plus IGRT to a dose of 70 Gy/35 fractions/7weeks for LAHNC were accrued. Radiotherapy planning CT scans were done at pre RT, 20 Gy, 40 Gy and 60 Gy for each patient. Volume changes of target and parotids along with shifts of parotids were assessed with respect to pre RT scan after co registration. In study scans GTVp and GTVn were re contoured as per that particular CT. CTV and PTV were copied from planning CT to study CT. CTV was edited only from anatomical barriers and PTV was edited only from skin in study CT. Parotid volumes were re contoured on each study scan and C2 vertebral body centre of mass was the reference to evaluate its shifts. Results: At 60 Gy we observed significant reduction in GTVp (26% p = 0.042) and GTVn (46% p = 0.004) as compared to baseline. There was statistically significant reduction in CTV and PTV volumes at 60 Gy. There was positive but non-significant correlation between weight loss and regression of PTV volumes during IMRT treatment. There was regression of volume of ipsilateral parotid by 38.5% (p = 0.00) and contralateral parotids by 34.6% (p = 0.008) at 60 Gy. There was a positive but non-significant correlation between dose received by parotid and its regression. Centre of mass of both ipsilateral and contralateral parotids shifted medially by the end of treatment by 3.1 mm in ipsilateral and 2.67 mm in contralateral parotid. This medial shift positively correlated to the weight loss during treatment and dose received by respective parotid. Conclusion: Statistically significant volumetric and geometric changes occurred during IMRT which were most prominent after 40 Gy and were maximum at 60 Gy. It signifies need of nutritional support to maintain weight of patient so that these changes can be minimised. This study can be useful to devise an adaptive radiotherapy strategy in oropharyngeal cases. Medial shift of parotid may result in its movement in the high dose region.

Abstract: 052

Dosimetric analysis of brachial plexus and its relation to tumour and nodal stage in radical radiotherapy of head and neck cancer

th
K. U. Pushpaja , A. Sreekumar, P. S. RenilMon, S. S. Nair, M. Dinesh

Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India, E-mail: [email protected]

Background: Brachial Plexopathy is a potential late toxicity associated with radiotherapy of Head and Neck cancers. Factors contributing to radiation induced brachial plexopathy include treatment technique, total dose, dose per fraction, and volume of brachial plexus. The recommendation by Emami et al. suggested that dose tolerances for 5% risk of developing radiation induced brachial plexopathy at 5 years is 62, 61 and 60 Gy, and for 50% risk at 5 years dose tolerance are 77, 76, and 75 Gy for one-third, two-thirds, and the whole organs. Aim: To evaluate the dosimetry of Brachial Plexus in various head and neck cancers in relation to the tumor, node and staging. Materials and Methods: In this retrospective study, 40 H & N cancer patients who received Radical radiation using either IMRT or 3DCRT at our Centre during the period 2012 - 2015 were selected. The brachial plexus [BP] was delineated as OAR in the planning simulation images. All the patients received 65-70 Gy in 28-35 fractions to the gross tumor and nodal stations. The right and left BP were contoured separately. DVH for the B.P were then recomputed based on the dose distribution of the original treatment plan and minimum, maximum and mean doses as well as V33, V66, V74, and V77 were analyzed. Results: The mean BP volume was 4.83 cc (left: 5.04 cc and right: 4.6 cc) and mean dose to the BP were 6022 cGy (right: 5856.22 cGy and left: 6164.9 cGy) respectively. In this study 30 patients had N2/N3 disease. The mean values for ipsilateral BP minimum, maximum and mean dose for group with N0/N1 disease were 4336.9 cGy, 6792.5 cGy, 5717.9 cGy. And the mean values for ipsilateral BP minimum, maximum and mean dose for N2/N3 disease were 4351.8 cGy, 7205.7 cGy, 6152.6 cGy respectively. Conclusion: BP should be routinely contoured as an OAR with the intention to keep the maximum BP dose <60 Gy to reduce radiation induced brachial plexopathy. In case where the BP overlaps with the PTV prescribed to >60 Gy, priority should be given to the PTV coverage with no hotspots. Monitoring of radiation dose to BP and screening for the symptoms of brachial plexopathy is recommended.

Abstract: 053

A prospective study of skin toxicity with intact thermoplastic immobilization device versus device cut open in the region of radiation field in head and neck cancer treated with concurrent chemoradiation

th
M. Das , R. Jena, A. Adhikary, S. Sarkar

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

Background: Accurate delivery of the prescribed treatment is critical to achieve a successful outcome in radiotherapy. The goal of immobilization & stabilization techniques is to reduce positioning uncertainties from patient motion during each fraction and to also increase the reproducibility of the patient set up for each fraction. Treatment of cancers in the head and neck require a high level of accuracy in the positioning of the patient for daily treatments. Thermoplastic immobilization mask have replaced traditional plaster casting methods in most clinics. The skin sparing effect of mega voltage x-ray beams can be reduced when the patients' skin surface is under the mask material. Aim: To compare acute skin toxicities in patients with intact thermoplastic immobilization device and with thermoplastic immobilization device cut open in the area of radiation portal. Materials and Methods: This is a prospective, comparative, single institutional study from period of January 2014 to April 2015, conducted in Department of Radiotherapy, in a superspeciality tertiary care hospital in Eastern zone of India. 80 cases of histologically confirmed non metastatic advanced squamous cell carcinoma of Head neck are included in the study. In Arm A immobilization done by intact thermoplastic device and in Arm B immobilization done by thermoplastic device cut open in the irradiated field. In both arms patients received 66 Gy at 2 Gy per fraction, 5 fractions a week along with Inj. Cisplatin (40 mg/m2) i.v. weekly during the course of radiotherapy. Acute skin toxicities are analyzed according to RTOG Acute Radiation Morbidity Criteria. Results: In Arm A 42% patients show grade 2 skin toxicity, 55% patients show grade 3 skin toxicity and 2.5% patients show grade 4 skin toxicity whereas in Arm B 50% patients show grade 2 and 47% patients show grade 3 skin toxicity. No patients in Arm B shows grade 4 skin toxicity. Conclusion: This study reveals that thermoplastic immobilization device with window at the radiation portal reduce severity of skin toxicity.

Abstract: 059

Conventional versus hypofractionated chemoradiation in head and neck cancer

th
R. Ghosh , S. Roy, A. G. Dastidar, R. Bhattacharjee

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

Background: Squamous cell carcinoma of the head and neck (HNSCC) is increasingly treated by multimodality approaches combining surgery, radiotherapy and chemotherapy. Randomized controlled trials have demonstrated major improvements in loco-regional tumor control from altered fractionation radiotherapy with or without concurrent chemotherapy as compared with conventional fractionation. Aim: To investigate tumor response and toxicities in HNSCC upon hypofractionated radiotherapy compared with conventional fractionation. Data from patients with squamous cell cancer of oral cavity, oropharynx, hypopharynx and larynx (AJCC, 2010 Stage II to IVB); who received hypofractionated (n = 30) or conventionally fractionated (= 30) radiotherapy, with or without chemotherapy, between January 2013 to June 2014 were retrieved and retrospectively analyzed. Materials and Methods: In conventional arm (Arm A), each patient received 70 Gy at 2 Gy per fraction over 7 weeks, along with concurrent cisplatin (100 mg/m2) on days 1, 22 and 43 for locally advanced stage. In hypofractionated arm (Arm B) each patient received 55 Gy at 2.75 Gy per fraction over 4 weeks, along with concurrent cisplatin (100 mg/m2) on days 1 and 22 for locally advanced stage. The end points were tumor response, acute and late toxicities, overall survival (OS) and diseases free survival (DFS). Results: The tumor response distribution was comparable - 24 (80%) patients in arm A and 23 (76%) in arm B achieved complete response. Significant differences in frequencies of acute grade ≥ 2 skin toxicity, mucositis were found, with higher frequencies in Arm B. Higher frequencies of late grade ≥2 dysphagia, laryngeal edema, xerostomia and confluent mucositis were encountered in Arm B at 6 months from start of chemoradiation. However, OS, DFS and locoregional recurrence rates were comparable between the two arms. Conclusions: Hypofractionated radiotherapy can achieve similar tumor response to conventionally fractionated radiotherapy in HNSCC, although with some increase of toxicity.

Key words: Chemoradiation, conventional fractionation, head neck cancer, hypofractionation

Abstract: 060

Lack of association between XPC polymorphism and the risk of squamous cell carcinoma of head and neck in north Indian population

th
Somali Sanyal

Amity University, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Background: Genetic polymorphisms in DNA repair genes are associated with a number of malignant transformations including squamous cell carcinoma of head and neck (SCCHN). Xeroderma pigmentosum group C (XPC) is involved in DNA repair and was found to be associated with SCCHN by others. However, study on the effect of XPC polymorphisms on SCCHN in Indian population is lacking. Aim: In our study for the first time we have investigated the effect of XPC polymorphism on SCCHN in north Indian population. Materials and Methods: We have genotyped 176 SCCHN cases and 164 healthy controls for the XPC K939Q (A>C) polymorphism by PCR-RFLP method. Results: Frequency distribution for all the three genotypes AA, AC and CC for XPC A>C polymorphism were calculated which showed more or less similar distribution among the SCCHN cases and the controls. Odds ratio and CI for AAvsAC and AAvs CC genotypes were respectively 1.05; 0.665-1.667 and 0.75; 0.39-1.44. We did not find any association of XPC K939Q (A>C) polymorphism on the risk for developing high stage, high grade and invasive disease (RR 1.11, 0.73, and 1.11 respectively). Similarly there were no effect of any genotypes from XPC K939Q (A>C) polymorphism on the histopathological types of SCCHN. Conclusion: In conclusion we did not find any association of XPC (A>C) polymorphism with SCCHN development.

Abstract: 065

Polymorphous low grade adenocarcinoma of base of the tongue: Case report and review of literature

th
A. Khurana , J. Vijaya Kumar, P. Kaur, A. K. Chauhan

Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, E-mail: [email protected]

Background: Polymorphous low grade adenocarcinoma is a tumor of minor salivary glands with indolent course with fewer incidences in oral cavity and oropharynx. It is a malignancy with low grade aggressiveness and less metastatic potential. Aim: A rare case of polymorphous low grade adenocarcinoma of base of tongue is presented. The objective of this study is to assess clinical features, appropriate diagnostic strategies and treatment protocol. Materials and Methods: A seventy six year old male from a rural area presented with complaints of swelling on the left side of neck since two weeks with difficulty in swallowing. Results: On palpation oral cavity was normal whereas there was induration felt over the base of the tongue whose lower extent can't be defined. On indirect laryngoscopy ulceroprolifertive growth was seen involving the base of the tongue with extension into the valleculla and epiglottis. On neck examination there was a level II solitary lymphnode on the right side measuring about 2 cm X 1 cm which was firm in consistency, nontender and mobile in both horizontal and vertical directions. CECT oropharynx and neck demonstrates a moderately enhancing soft tissue density mass lesion with ill defined margins is seen involving right posterior base of the tongue extending to floor of the mouth where it is forming an ill defined enhancing mass lesion. On histopathological examination of incision biopsy from the base of the tongue demonstrated polymorphous low grade adenocarcinoma with origin from the minor salivary gland. There was no any perineural invasion and on immunohistochemical profile epithelial membrane antigen (EMA) was positive (diffusely strong), p63 (irregular positivity) whereas SMA (smooth muscle actin) and S-100 was negative. Based on histopathological and immunohistochemical profile diagnosis of Polymorphous low grade adenocarcinoma of base of the tongue with origin from the minor salivary gland was made. Patient was planned for radical external beam radiation therapy with dose schedule of 66 Gy in 33 fractions with dose rate of 200 cGy per day (Conventional) by bilateral fields to face and neck with spinal cord sparing after 44 Gy to respect the normal tissue tolerance dose of spinal cord (TD 5/5 volume). Conclusion: Polymorphous Low Grade Adenocarcinoma of base of the tongue, which is a tumor with low grade aggressiveness and less incidence of distant metastasis. Main diagnostic method for the diagnosis is biopsy.

Abstract: 067

Radiotherapy for T1-T4 glottic carcinoma: Profile, influence of fraction size, total dose and overall treatment time on local control and toxicity

th
D. Jayachander , B. K. M. Reddy, V. Natarajan, V. Ural, S. Rajan

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

Background: Glottic cancer is one of the most common subsites of head and neck cancer seen in Apollo Hospital, Bengaluru, Karnataka, India. The aim of this study was to evaluate the profile of glottic cancer patients in our hospital over the last seven years. We performed a retrospective analysis of histopathologically proven cases of glottic cancer admitted to our hospital from January 2007 to May 2015. Results: Our study included 92 patients with confirmed diagnosis of glottic cancer. Male to female ratio was 12:1. The common age group being 50-60 years (35%), 11.9% of patients were less than 40 years of age. 75% of the patients were smokers. The most frequent symptom was hoarseness of voice (91.7%) followed by throat pain (81.7%). FOL (83.6%) and CT scan (71.7%) were the most common modalities of evaluation, in addition to clinical examination. All patients had squamous cell carcinoma histology with the most common grade being grade II (61.9%). The majority of patients (57.6%) were diagnosed in the earlier stages of the disease (I-II). The treatment offered consisted of only radiotherapy for 64 patients, chemoradiation for 23 patients, and total laryngectomy with neck dissection followed by RT for 5 patients. 4 patients had to undergo emergency tracheostomy. 94.5% completed RT. Conclusion: We conclude that significant number of glottic cancer patients presented to us with early stage disease. Hoarseness of voice and throat pain were the commonest symptoms. An analysis of dose fractionation, total treatment duration, total dose and its relationship to clinical response and toxicity will be presented.

Abstract: 069

A comparative study of rapid arc (VMAT) versus IMRT for head and neck cancers

th
A. Nachankar , P. Patwe, V. Mhatre, R. Patil, P. Dandekar

Sir H. N. Reliance Foundation Hospital, Mumbai, Maharashtra, India, E-mail: [email protected]

Background: Rapid Arc is a novel technique that has recently been made available for clinical use. Planning study was conducted for volumetric arc modulation with Rapid Arc against conventional IMRT for head and neck cancers. Aim: To evaluate the performance of Rapid Arc (Volumetric Modulated Arc Therapy-VMAT) with conventional IMRT for oral cancers for target coverage and normal tissue sparing. Materials and Methods: Ten patients with advanced carcinoma of oral cavity planned for postoperative irradiation were selected. PTV was delineated for two different dose levels; 60 Gy to high risk volume comprising of tumour bed and involved lymph nodes; and 54 Gy to intermediate risk volume comprising of elective lymph nodes, delivered in 30 fractions over 6 weeks. Normal tissues in head & neck area were delineated including brain, spinal cord, brainstem, parotids, thyroid, DARS (Dysphagia, aspiration related structures). Quantec guidelines were followed for dose volume constraints. Healthy tissue volume was calculated by subtracting PTV from scanned body volume (HT= Body- PTV) to calculate integral dose. Comparative plans were generated for all patients with sliding window IMRT and Rapid Arc (RA) by single or double arcs with 6 MV photons on Eclipse treatment planning system (version 13) using the AAA algorithm for True Beam STX 2.0 Linear Accelerator. Results: RA shows superior dose conformity index (1.01 ΁ 0.33) with (P = 0.09) and homogeneity indices were comparable between two techniques. RA significantly reduced mean dose received by healthy tissue outside of PTV (p = 0.01), V15 Gy (p = 0.02) and V 20 Gy (p = 0.001) integral dose (p = 0.01). Number of MUs per 200 cGy were significantly lower in RA (598.06 ΁ 128.40) compared to IMRT (1225.38 ΁ 447.94) (p = 0.002). Also the treatment time with RA (120.4 sec) was significantly less compared to IMRT (254.1 sec) (P =0.0002). Sparing of spinal cord, brain stem, mandible and DARS was comparable, contralateral parotid doses were within tolerance limits for both techniques however were significantly lower with IMRT (p = 0.003). Conclusion: Rapid Arc offers superior conformity to target, & sparing of healthy tissues for advanced oral cancers compared to IMRT. By virtue of less treatment time rapid arc can reduce patient discomfort & potential intrafraction errors. Also it offers benefit of delivering less MUs & integral dose to healthy tissues.

Abstract: 078

Association of addiction patterns and parameters with clinico-pathological presentation of squamous cell carcinoma of the oral cavity

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R. Jena , A. Bandopadhyay, B. Mandal, M. Das, P. Basu, U. Mukherjee, S. Sarkar

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

Background: Oral cavity cancer is one of the ten most common cancers in the world and is the most common cancer in adult males in India, accounting for 50-70% of all cancers diagnosed. Its incidence is increasing day by day due to the increasing use of tobacco in various forms and alcohol drinking. The addiction patterns and parameters responsible for changes in clinico-pathological presentation including the sites are yet to be studied. Aim: To study addiction to various forms of tobacco and the addiction patterns and other parameters among patients of oral cavity squamous cell cancer, and to find any association of the same to the various clinical and pathological parameters. Materials and Methods: The study consisted of two parts. In one part addiction and clinico-demographic data of 370 patients presenting with Oral cancer during the period of 2011 to 2014 was collected retrospectively. In the other part, about 50 patients were prospectively interviewed regarding their addiction behavior and included in the study. A 17 point questionnaire was used to record the addiction history. An association between the addiction parameters and clinicopathological parameters was sought. Results: 412 patient's data was analysed and included for the study. The median age at presentation was 52 years, of which 75.4% were males. Buccal mucosa was most commonly affected site (42.4%) followed by tongue (32.5%). 78.2% of the cases were well differentiated squamous cell carcinomas, 20.4% were moderately differentiated and rest were poorly differentiated. Smoking tobacco was associated in 29.4%, non-smoke tobacco in the form of khaini/gutkha/paanmasala etc was associated in 38.3% of cases, chewing paan was associated in 13.1%, 9.71% cases had combination of addiction and about 12% had no history of any addiction. While smoke tobacco was mostly associated with tongue primary, chewing paan and non smoke tobacco was mostly associated with buccal mucosa or alveolus/gingival primary. The average interval between the age of initiation of addiction and age of detection of cancer was slightly higher in smoke tobacco (22 yrs) than non smoke tobacco (16 yrs). Conclusion: Among Oral cavity cancers, buccal mucosa is the most involved site followed by tongue. Non-smoke tobacco was the leading cause of Oral cavity cancers followed by smoke tobacco. There is a definite association between the type of addiction and the primary site involved.

Abstract: 080

Comparative evaluation of accelerated radiotherapy versus concomitant chemoradiation in management of locally advanced head and neck cancer

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A. K. Chauhan , T. Takia 1 , P. Kaur, N. Bansal, A. Khurana, Y. Verma

Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, 1 Mahaveer Cancer Hospital, Jaipur, Rajasthan, India, E-mail: [email protected]

Background: The concomitant chemoradiation is the standard of care for locally advanced carcinomas of head and neck region, accompanied with treatment related toxicities. Accelerated radiotherapy schedules have shown better locoregional control than a conventional schedule with acceptable toxicity. Aim: The aim of this study was to compare the efficacy of concurrent chemoradiotherapy versus accelerated radiotherapy as a primary treatment for patients with Stage III-IV squamous cell carcinoma of head and neck in improvement of locoregional disease control and to compare the treatment related toxicities. Materials and Methods: From May 2011 to December 2014, 120 patients with previously untreated squamous cell carcinoma of head and neck region were randomized into two arms of 60 patients each. Arm I was treated with accelerated radiotherapy and received 66 Gy in 33 fractions over 5.3 weeks (6 fractions a week). Arm II was given conventionally fractionated radiotherapy with 66 Gy in 33 fractions over 6.3 weeks (5 fractions a week) with weekly concomitant cisplatin 40 mg/m2. Results and Conclusion: The mean age at presentation in Arm I and Arm II was 53.9 years and 52.2 years respectively. Male: female ratio was 13:1. Site of malignancy was oral cavity, oropharynx, hypopharynx and larynx in 10%, 63.4%, 13.3%, 13.3% and 16.6%, 66.7%, 6.7%, 10% of patients in Arm I and Arm II respectively. Most common histopathological type was moderately differentiated squamous cell carcinoma. During the treatment, no statistical difference was observed in the haematological toxicity between the two groups. Grade III skin reactions were observed in 46.7% and 26.7% of the patients in Arm I and Arm II respectively (p = 0.107). Grade III mucosal reactions were observed in 53.3% and 36.7% of patients in Arm I and Arm II respectively (p = 0.194). Severe (grade III + IV) upper GIT toxicity was observed in two patients in Arm I and eight patients in Arm II (3.3% versus 13.3%, p = 0.161). Complete tumor response to treatment was better in Arm II (70% vs 76.7%, p = 0.559). Complete nodal response for Arm I and Arm II were 63.2% vs 82.4% (p = 0.002). At median follow up of 30 months, locoregional control of disease was seen in 63.3% and 73.4% in Arm I and Arm II respectively (p = 0.405). Conventional radiotherapy regimens with concomitant chemotherapy is slightly better to accelerated fractionation regimens in terms of disease control and toxicity profile.

Abstract: 084

Hypofractionated radical radiation therapy in early glottic cancer

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T. Saxena , V. Goel, J. Jain, A. Verma, P. Agarwal, K. Venkatesan, D. Arora, A. Anand

Max Super Speciality Hospital, Delhi, India, E-mail: [email protected]

Background: The dual objective of treatment - controlling the malignant tumor and preserving functionally useful voice - is best optimized by use of radiotherapy in early glottic cancers. Aim: Retrospective study to assess control rate, toxicity profile & quality of voice of stage T1/T2N0M0 glottic cancer patients treated by hypofractionated radical radiotherapy. Materials and Methods: We conducted a retrospective study of stage T1/2N0M0 glottic cancer patients, diagnosed from 1st June 2009 to 31st December 2014 & treated by hypofractionated radical radiotherapy. All patients were planned by simplified IMRT planning algorithm with three fields & treated in 6 MV LINAC. Bolus on skin was used whenever necessary. The prescription dose was 63-67.5 Gy in 2.25 Gy/fraction & dosimetric analysis was done. All patients were evaluated every three monthly with clinical examination & fibreoptic laryngoscopy. Toxicity was evaluated according to RTOG & CTCAE v4.03 Toxicities Scales. Evaluation of local control rate, larynx preservation rate & quality of voice were studied. Results: Fifteen patients (13 men & 2 women) treated for glottic cancer (squamous cell carcinomas) comprising 13 patients with T1a, 1 patient with T1b and 1 patient with T2 tumour. Median age was 59.6 years (range from 45 to 70 years). Seven patients received 63 Gy & 8 patients received 67.5 Gy @ 2.25Gy/fraction. Median Spinal Cord Dmax was 27.78 Gy (SD ΁5.34 Gy). Average mean dose to left & right carotid was 49.9 Gy (SD ΁5.34) & 49.1 Gy (SD ΁5.43) respectively. Average mean dose to DARS, thyroid & cervical esophagus was 27.74 Gy (SD ΁12.2), 40.9 Gy (SD ΁11.4) & 25.2 Gy (SD ΁11.2) respectively. Mean follow up time is 29.4 months (range from 10 to 60 months). The treatment was well tolerated with median overall treatment time of 42 days (range 36-55 days). Grade 1 & 2 acute laryngeal toxicity was observed, but 5 patients (33.33%) had grade 3 skin reactions. Local control rate was 93.3%. Fourteen patients (93.3%) noted significant improvement in quality of voice. One patient recurred after 6 months & managed by cordectomy. The larynx preservation rate was 100%. Conclusion: Hypofractionated radiotherapy provides a good locoregional control with good quality of voice. As the limitation of present study is small number of patients & lack of long-term follow- up, we hope to update this retrospective study in the future in order to improve the power of the results.

Abstract: 086

Primary extra pulmonary small cell carcinoma of tongue

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A. Soni , S. Aggarwal 1 , R. Verma, V. Kaushal

Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, 1 Tata Memorial Hospital, Mumbai, Maharashtra, India, E-mail: [email protected]

Background: Extrapulmonary small cell carcinoma (EPSCC) is a different entity from small cell carcinoma lung (SCLC). Approx. 2.5-4% of SCLC arises in extra pulmonary sites. Natural history of EPSCC remains undiscovered and hence, optimal therapy is complicated. Oral cavity and oropharynx are the rarest sites for EPSCC. EPSCC is more aggressive than SCLC and being more recurrent, it demonstrates a poorer prognosis. The treatment of EPSCC patients has been very likely to the protocols used for treating SCLC. As it is a systemic disease, multimodality therapy is preferred even at early stage. Aim: To report a case of extra pulmonary small cell carcinoma at a rare site of tongue with excellent prognosis with standard therapy. Materials and Methods: A 65-year-old previously healthy male presented initially with difficulty in swallowing and later, with a solitary neck lump associated with pain, and he was diagnosed as EPSCC of tongue with left sided upper deep cervical lymphadenopathy of neck. The tumor was staged as locally advanced (T4aN2aM0) stage disease. Cisplatin (75 mg/m2) and Etoposide (100 mg/m2) were administered in combination at three weeks interval as neoadjuvant chemotherapy for three cycles, as well as concomitant chemotherapy for three cycles with external beam radiation in a dose of 64 Gy by bilateral parallel opposed field on telecobalt machine. Results: The FNAC of neck node revealed small round cells with scant cytoplasm. The biopsy from base of tongue was consistent with small cell carcinoma. The immunohistochemical staining was positive for CK, synaptophysin and chromogranin A, and was negative for LCA and p63. The patient well tolerated the treatment. PET/CT scan after 6 months showed complete resolution of the disease. Discussion: The chemotherapeutic combinations used are etoposide-cisplatinum or camptothecin- cisplatinum. Cisplatin and etoposide is most commonly used regimen, with 69% response rate. Median overall survival (OS) is 9.6months for limited disease (LD) EPSCC and 9.2months for extensive disease (ED) EPSCC. Cure is possible in LD, and aggressive therapy is recommended. Conclusion: The prognosis of EPSCC is felt to be extremely poor. Contrary to other reports, this case demonstrates that a good response with standard therapy is possible with meticulous treatment planning and multimodality interdisciplinary care.

Abstract: 090

A comparative evaluation of phycocyanin with concomitant chemoradiation versus concomitant chemoradiation alone in locally advanced head and neck cancer

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M. Dubey , R. Dhankhar, A. Soni, A. K. Dhull, R. Atri, V. Kaushal

Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, E-mail: [email protected]

Background: C-phycocyanin (c-PC) is a biliprotein found in edible blue-green algae. Its anti-cancer, anti-proliferative and anti-oxidant activities has been evidenced by many in vitro and in vivo studies. The present prospective, randomized, study was carried out to evaluate the efficacy in terms of local control and toxicity of phycocyanin based anticancer dietary supplement plus chemoradiation with cisplatin versus chemoradiation alone with cisplatin in locally advanced head and neck cancer. Aim: To compare the efficacy, toxicity and tolerability of these schemes of treatments in terms of response to treatment, side effects and completion of treatment. Materials and Methods: This study was conducted on 40 previously untreated, histopathologically proven patients, of locally advanced (satge III/IV) squamous cell carcinoma of head and neck region. Group I (n = 20) i.e., study group was treated with daily twice a day 200 mg oral phycocyanin for six weeks along with concomitant chemoradiation and and group II (n = 20) i.e., control group received only concomitant chemoradiation. Concomitant chemoradiation was delivered with conventional external beam radiotherapy. Results: The patients were followed for a minimum period of 6 months (range 6 to 11 months). Disease status on follow up was noted as follows: Tumor complete response in group I and II are- 60% (12/20) versus 50% (10/20), better in group I. Complete nodal response was 60% (9/15) in group I and 42.1% (8/19) in group II, better in group I. Overall no evidence of disease status was 60% (12/20) in group I and 50% (10/20) group II respectively. There were overall two recurrences (5%) - one (5%) in group I and one (5%) in group II. In group I, one recurrence was at primary site only. In group II, one recurrence was at primary site and one was at nodal site. acute skin toxicity were reported as grade III/IV in group I and group II- 30% versus 60% and acute mucosal toxicity were reporte in group I and group II- 25% versus 60% respectively. Conclusion: This may be concluded from the present study that phycocyanin based dietary supplement plus cisplatin based concomitant chemoradiation is better compared to cisplatin based concomitant chemoradiation alone for better tumor control although statistically not significant, reducing treatment induced toxicities and better tolerability and completion of treatment in the management of locally advanced head and neck cancer patients.

Abstract: 093

Head and neck cancer patients treated with radical radiotherapy: Impact of waiting time on survival

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T. Bhattacharyya , M. Geetha, A. Bhattacharjee

Malabar Cancer Centre, Thalassery, Kerala, India, E-mail: [email protected]

Background: Most of the patients of head and neck cancers are treated with concurrent chemo radiation or radiotherapy alone. Waiting time prior to radiotherapy is a major problem in many radiotherapy centres with reported delays of 70 days or even more especially in developing countries. Aim: This study aims to determine the impact of waiting time for radiotherapy on survival of patients of head and neck cancer. Materials and Methods: Patients of histologically proven squamous cell carcinomas of larynx, oropharynx, hypopharynx and nasopharynx treated with radical radiotherapy between January 2012 to December 2014 are considered in this study. A total of 292 patients' case files were analyzed to explore the effect of delay in starting radiotherapy on overall survival. Data was entered and analyzed using R software (R for Windows, Version 3.1.1). Survival analysis was performed on different patient parameters to point-out the effect of waiting time for treatment intitiation. Results: It has been observed that waiting time for radiotherapy should not cross 45 days to get any survival benefit. However patients will get maximum survival advantage if treatment can be started within 20 days from the date of diagnosis. Waiting time for radiotherapy has significant impact on early stage (stage I &II) disease and especially in laryngeal and hypopharyngeal cancers. In nasopharyngeal cancers and advanced stage disease waiting time does not have significant influence on survival. Conclusion: This study revealed waiting time for radiotherapy has significant impact on survival of head and neck cancer patients. The optimum window period of waiting time for radiotherapy to provide maximal survival benefit to head and neck cancer patients is around 20 to 45 days.

Abstract: 094

A new index to measure intra-observer variation in delineating GTV primary in head and neck cancer

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T. Bhattacharyya , M. Geetha, A. Bhattacharjee

Malabar Cancer Centre, Thalassery, Kerala, India, E-mail: [email protected]

Background: Gross Tumor Volume (GTV) delineation is the most important step in radiotherapy treatment planning in head and neck cancer. The variation in GTV contouring can be of two types viz (I) Inter-observer variation and (II) Intra-observer variation. Aim: The goal of this study is to determine the intra-observer variation in GTV delineations in Head & Neck cancer on CT and MRI images. Materials and Methods: A total of 15 patients with histo-logically confirmed squamous cell carcinoma of oropharynx, larynx and hypo pharynx requiring planning for radical radiotherapy with IMRT were enrolled retrospectively in this study. A database of 311 patients with oropharyngeal, laryngeal and hypopharyngeal and cancer were searched and only 15 patients underwent both CT scan and MRI for treatment planning and were fulfilling the inclusion criteria. One observer contoured GTV primary on four occasions on CT and MRI within a gap of two weeks. The volume of intersections of GTV obtained through contouring on four different occasions in CT and MRI was defined as absolutely correct target volume (ACTV). The uncommon volume in respect to ACTV observed was defined as intra observer variations for respective concessions. A new index is proposed to measure the intra-observer concordance with ACTV and GTVs. Results: The median (IQR) volume of GTVs observed in CT1, CT2, MRI1 and MRI2 were 19.17cc (33.55-12.19), 23.05 cc (28.03-12.4), 18.93 cc (32.05-11.84) and 16.77 cc (32.16-11.07) respectively. The mean (SD) index values for CT1, CT2, MRI1 and MRI2 are 0.51 (0.22), 0.53 (0.23), 0.54 (0.13) and 0.52 (0.12) respectively. It quantifies the measure of concordance of GTVs between different imaging modalities. Conclusion: The index study shows that there is better concordance in delineating GTV primary on two different occasions in MR images as compared to CT images. There is no significant difference in median GTV volumes of CT scan and MRI. However, MRI GTVs were slightly lower than GTVs in CT images.

Abstract: 098

A comparative study to demonstrate effect of age in development of hypothyroidism in head and neck cancer patients receiving external beam radiotherapy in a tertiary cancer care center of India

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S. Sinha , I. Khan, A. Manna

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

Background: Head and neck cancers predominantly of Squamous cell carcinoma is commonly treated with external beam radiotherapy (EBRT). And among the multiple unavoidable side effects, hypothyroidism is one of the commonest side effect of external beam radiation therapy to the head and neck. Various factors like: Age, sex, ethnicity/race, smoking are considered as risk factors for the development of hypothyroidism in these patients. Aim: In this study, we assess the impact of age as a risk factor with regard to development of hypothyroidism in patients receiving external beam radiation therapy to head and neck cancers. Materials and Methods: Since 1 st January 2015 to 30 th March 2015, 60 patients of age group 20-70 years diagnosed with squamous cell carcinoma of the oral cavity and larynx were included in this study. They were divided in two groups, each group having 30 patients. Group A having patients of age group 20-45 years, Group B having patients of age group 46-70 years were enrolled for this study after taking informed consent. Thyroid profile of serum TSH and free T4 was assessed in all patients one week prior to starting of radiotherapy. All the patients received 66 Gy in 33 fractions of EBRT using Cobalt 60 of Theratron 780 C Telecobalt machines of a tertiary cancer care center of eastern India. Serum TSH and free T4 levels were assessed 6 weeks after completion of EBRT. Patients having serum TSH value above 5 mcg/dl were considered having hypothyroidism. Data were tabulated in MS EXCEL and analyzed using the SPSS 16 software and Independent t-test was used to compare between the two groups. Results: It was found that, the occurrence of hypothyroidism was significantly more common in the younger age group (20-45 years) who received external beam radiotherapy for head and neck cancer compared to the older age group (46-70 years). Mean TSH level of 20-45 years age group are significantly more than 46-70 years age group of this study population {t =21.219 (equal variances not assumed), df=40.711, p < 0.001, 95% Confidence Interval (CI) = 2.75-3.32}. Conclusion: The younger population of age group 20-45 years is more vulnerable in developing post radiation hypothyroidism as a consequence of external beam radiation therapy to head and neck cancers.

Abstract: 108

Evaluation of XRCC 1 gene polymorphism as a biomarker in head and neck cancer patients undergoing chemoradiotherapy

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S. S. Nanda , K. Sahni, M. Rastogi, R. Khurana, R. Hadi, S. P. Mishra

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

Background: Traditionally prognostic markers like age, sex, stage and degree of differentiation have been studied in the context of Head and neck cancer (HNC). The advent of newer genetic markers like proto-oncogenes, tumor suppressor genes and Single nucleotide polymorphisms have shed a new light into their role as prognostic and predictive factor in treatment outcome as well as toxicity associated with treatment. Aim: To access clinical response in patients of HNC with or without XRCC 1 codon Arg 194 Trp gene polymorphism receiving a curative dose of chemo radiotherapy (CCRT) and to determine the correlation between XRCC 1 polymorphism and acute toxicity associated with CCRT. Materials and Methods: The study was conducted between 2014-2015. 101 patients with histologically proven squamous cell carcinoma of head and neck region constituted the study sample. Blood samples were collected of these patients which were analyzed for XRCC-1 Arg 194 Trp polymorphism using PCR-RFLP technique. These patients went on to receive cisplatin based CCRT with 66-70 Gy at 2 Gy/# over 6.5-7 weeks using LINAC (ELEKTA) via 6MV Photons. Responses were categorized as complete response (CR), partial response (PR), Stable disease (SD) and progressive disease (PD) based on WHO criteria for response evaluation. Acute toxicity was graded as per RTOG acute toxicity criteria. The polymorphism was correlated with the response and toxicity to draw conclusions. Results: The allelic frequency of XRCC 1 codon Arg 194 Trp gene showed common homozygote (CC) variant in 37.8% and common heterozygote (CT) in 44% patients while polymorphic homozygote variant (TT) was seen in 18% patients. When the WHO response was correlated with the gene polymorphism it was observed that in the patients with polymorphic variant (TT) about 85% had CR and rest 15% PR while no patient had SD or PD and the better outcome observed with polymorphic variant was statistically significant (P-0.0109). The patients with the polymorphic variant the highest grade of mucositis was statistically significantly (p-0.001) higher than the common homozygous and heterozygous variants. Similar results were there for acute skin toxicity, dysphagia and odynophagia where the grade 2 + toxicities were significantly higher in the polymorphic variant then the rest two genotypes. Conclusion: Defect in DNA repair pathway like XRCC-1 polymorphism improve the outcome of CCRT despite enhancing the radiation induced acute toxicities.

Abstract: 113

In post operative radiotherapy for oral cancer, is a uniform PRV margin for the cervical spine appropriate?

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S. Nangia , R. Khosa, A. Aggarwal 1 , P. Balakrishnan, A. SelvaKumar, S. Rout, S. Oomen

Apollo Cancer Institute, New Delhi, 1 Patel Hospital, Jalandhar, Punjab, India, E-mail: [email protected]

Background: In view of the spine being a critical organ at risk in head neck radiotherapy, applying a planning risk volume is essential. This volume is dependent on repositioning accuracy, which may not be uniform along the length of the spine. Aim: To analyse the variability in shifts at C2 and C6 vertebral levels and determine PRV margins for upper & lower cervical spinal levels in patients undergoing post operative radiotherapy for oral cancer. Materials and Methods: Cone beam CT (CBCT) scan data of ten patients who underwent post-operative radiotherapy for oral cancer was analysed offline, for antero-posterior (AP) and medio-lateral (ML) shifts in reference to the planning CT, at C2 and C6 cervical spinal levels, for both acquired and online matched positions, respectively. In view of the primary being in the oral cavity, the C2 level, i.e., the region in close proximity to the high dose volume, was treated as the index site for matching. Results: A total of seventy nine CBCT images were analysed. Mean shifts in AP direction were -1.81 mm and -0.35 mm at C2, and -1.95 mm and -0.5 mm at C6 levels, in acquired and online matched positions, respectively (p value 0.89 and 0.67 respectively, not significant). Mean shifts at C2 and C6 levels in ML direction were 1.51 mm and 1.06 mm in acquired position (p value 0.03, significant); and 0.15 mm and 0.3 mm in online matched position (p value 0.007, significant). Unlike PTV, the recipe for calculation of PRV margins is not well defined and have been postulated as 2.2Σ + 0.5σ for 2 dimensions and 1.3Σ + 0.5σ for one dimension (McKenzie et al.). PRV margins calculated for 2 dimensions, at C2 vertebral levels were 3.94 mm and 1.77 mm for acquired and online matched images and 5.35 mm and 3.67 mm at C6 vertebral levels respectively. Conclusion: Repositioning of the lower cervical spine is sub-optimal in the medio-lateral direction. There is a difference in the PRV margins around spinal cord at C2 and C6 levels, with more generous margins required at lower cervical spine levels to limit doses to spine to prescribed values. The PRV margins at the upper and lower cervical vertebral levels can be reduced by daily image based repositioning.

Abstract: 117

Evaluation of efficacy and toxicity in head and neck cancer patients treated with volumetric intensity modulated arc therapy versus conventional intensity modulated radiation therapy

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I. Jaiswal , R. Khurana, M. Rastogi, K. Sahni, R. Hadi, S. Sapru,

S. P. Mishra

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

Background: Head & neck cancer is a major health problem in India. Worldwide it accounts for 5,99,637 cases (Globocan 2012) of which 1,41,140 cases are from India accounting for 25% of global burden. Radiation therapy is the mainstay of treatment in both early and advanced stages. There have been made significant advances in the delivery of RT in past few decades from 2D conventional to 3D conformal (3D-CRT) to intensity modulated radiotherapy (IMRT). IMRT can be delivered via multiple fixed fields (conventional IMRT) or arc therapy (VMAT) Various planning studies have compared these two techniques in head and neck cancer with comparable results but there have been limited studies on the clinical impact of these 2 technologies. Aim: This paper aims to assess the response to treatment & acute toxicities in H & N cancer patients treated with IMRT & VMAT. Materials and Methods: We analyzed the efficacy & toxicity in patients treated with definitive RT using IMRT & VMAT technique.50 patients with non-metastatic Stage II-IV head and neck squamous cell cancer were treated using IMRT (n = 25) & VMAT (n = 25). RT was delivered as 66 Gy/30# to HR-PTV, 60 Gy/30#to IR-PTV & 54 Gy/30# to LR-PTV. Concurrent chemotherapy was given to patient as per clinical indications & general condition Response & toxicity were assessed as per WHO response assessment & RTOG acute toxicity criteria respectively. Results: 80% of patients in IMRT group & 70% in VMAT group belong to advanced stages (III+IV). 60% of patients in both the treatment group received concurrent chemotherapy. Patients treated with both technique had similar rates of loco-regional control.21/25 patients in IMRT group & 23/25 in VMAT group had complete response & rest had partial response to treatment. Patients treated with VMAT had lower rates of acute toxicity according to Grade ≥3 mucositis (IMRT: 52.0% vs. VMAT: 16% p = 0.006), Grade ≥3 pharynx & esophagus toxicity (IMRT: 44.0% vs. VMAT: 32% p = 0.04). Rest of the toxicities did not differ significantly between two groups. Conclusions: Compared to IMRT, VMAT provided similar outcomes and potentially less toxicity indicating it as better technique for definitive treatment in head and neck cancer.

Abstract: 120

Standardization of tumour volume delineation by FDGPET and CT in patients with head and neck cancer

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B. K. Yadav , S. Ghoshal, D. Bhattacharya, B. Rai, R. Sharma

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

Background: 18F-FDG-PET-CT is increasingly being used to guide radiotherapy target volume delineation in head and neck cancers and standard uptake values (SUV) act as a tool to assess the uptake by the tumor, but there is no consensus till date, as to the best threshold method to use for delineation. Aim: To compare the difference in the target volumes delineated by CT scan and 18F-FDG PET using different SUV in terms of gross tumour volume and to determine the most appropriate threshold level for delineating tumors in FDG-PET. Materials and Methods: 15 patients of head and neck cancers planned for concurrent chemoradiotherapy underwent planning CT scan and FDG-PET scan of head and neck region. The target volumes were contoured on both separately. The gross volumes CT-GTVp (primary), CT-GTVn (nodal) and CT-GTVt (total) were contoured according to RTOG guidelines on CT. The tumor volumes were delineated on FDG-PET using auto contouring method taking three different threshold levels-2.5 SUV, 30% of maximum SUV and 50% of maximum SUV and were labelled as PET-GTVp2.5, PET-GTVp30 and PET-GTVp50 respectively, for nodal volumes as PET-GTVn2.5, PET-GTVn30 and PET-GTVn50, and for total volumes as PET-GTVt2.5, PET-GTVt30 and PET-GTVt50. The mean of the target volumes obtained by CT and FDG PET was then calculated and compared. Results: CT- GTVp (45.94 cc) was not significantly different from the PET-GTVp 2.5 (44 cc), with p = 0.49. CT-GTVn (12.28 cc) was significantly different from PET-GTVn2.5 (8.45 cc) with p value of 0.005. However, the mean total GTV obtained by CT (CT-GTVt =58.27 cc) was also not significantly different from the PET volume (PET-GTVt 2.5 = 52.49 cc) with p value of 0.30. PET-GTVp30 (26.27 cc) and PET-GTVp50 (12.11 cc) was significantly lesser than CT-GTVp (45.94 cc) (p = 0.01 and 0.001). PET-GTVn30 (3.9 cc) and PET-GTVn50 (2.0 cc) was significantly lesser than CT-GTVn, p values of 0.002 for both. The mean volume of GTV total using PET with SUV30 (PET-GTVt30 = 30.17cc) and PET with SUV50 (PET-GTVt50 = 14.19 cc) was also significantly lesser than GTV total delineated on CT (CT-GTVt = 58.27 cc), with p values of 0.009 and 0.001 respectively. PET-GTVt2.5 was positively correlated with CT-GTVt (Pearson correlation = 0.49; p < 0.06). Conclusion: FDG PET based tumor and nodal volumes are strongly affected by the choice of threshold level. In our study, SUV 2.5 on FDG PET based delineation correlated well with CT based delineation, SUV 30% and SUV 50% can result in gross miss in the target volume.

Abstract: 123

Study of toxicity assessment of intensity modulated radiation therapy with simultaneously integrated boost in head and neck squamous cell carcinoma

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P. Gupta , M. Rastogi, K. Sahni, R. Khurana R. Hadi, S. P. Mishra, S. Sapru, A. Srivastava

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

Background: Radiotherapy (RT) plays a major role in management of Head and neck cancer patients. In early-stage disease, radical RT alone can cure around 90% of cancers in some tumor sub sites (i.e., oropharynx, hypopharynx, and larynx). In more advanced-stage disease, RT is usually used in combination with chemotherapy. With the advent of the linear accelerator, the radiation technique has shifted to Intensity Modulated radiation therapy (IMRT) which is an advanced approach with variable intensities across multiple radiation beamlets and the ability to conform the target volume as well as better sparing of critical structures. In addition, IMRT has the ability to selectively increase the dose per fraction to selected sub-volumes of the target where more radio-resistant clones are anticipated to be present - an approach known as simultaneous integrated boost IMRT (SIB-IMRT). This IMRT technique offers a possibility of planned dose inhomogeneity in the planning target volume (PTV) in order to achieve enhanced cure. Aim: Acute toxicity assessment using RTOG acute Radiation Morbidity scoring criteria in patient treated with IMRT-SIB technique. Materials and Methods: Thirty Patients with histologically proven squamous cell carcinoma of the oropharynx, hypopharynx and larynx with TNM stage T1-3 N0-3 M0 who were not candidates for concurrent chemotherapy, treated with IMRT using SIB technique with radical intent from November 2014 to July 2015. Results: The median age was 55 year male to female ratio was 9:1. Primary site was oropharynx (53.33%) followed by larynx (23.33%) and hypopharynx (20%). Forty percent of patients were of stage II, 40% stage III and 20% of stage IV. Eighty percent patients were treated with 6600 cGy to PTV-HR, 6000 cGy to PTV-IR, 5400 cGy to PTV-LR; 10% of patients with 6600 cGy to PTV-HR, 5400 cGy to PTV-LR; 3.33% of patients with 6600 cGy to PTV-HR, 5400 cGy to PTV-IR, 4400 cGy to PTV-LR in 30 fractions; 3.33% of patients with 7000 cGy to PTV-HR, 5940 cGy to PTV-IR, 5600 cGy to PTV-LR and 3.33% of patients with 7000 cGy to PTV-HR, 5940 cGy to PTV-IR in 33 fractions. The median overall treatment time was 45 days. Maximum Grade III toxicity as mucositis, skin, pharynx & oesophageal and laryngeal were 56.66%, 23.33%, 26.67%, and 6.67% respectively. Grade II toxicity as mucositis, skin, pharynx & oesophageal, xerostomia and laryngeal were 43.33%, 50%, 63.33%, 80% and 63.33% respectively. Conclusion: IMRT-SIB is feasible in terms of acute toxicity.

Abstract: 130

Brachytherapy in head and neck cancer - in the era of intensity modulated radiotherapy: Our experience

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B. Sweta , A. S. KirthiKoushik, R. C. Alva, Yuvarajan, M. G. Janaki,

T. R. ArulPonni, M. Kumar

M.S. Ramaiah Medical College, Bengaluru, Karnataka, India, E-mail: [email protected]

Background: Head and neck cancer treatment includes a multidisciplinary approach involving all specialties. Surgery and radiotherapy are equally effective in controlling small oral tongue cancers. Intensity-modulated radiotherapy (IMRT) technique in external beam radiotherapy and interstitial brachytherapy (ISBT) plays an important role in the treatment of head and neck cancers. Both are proved to be highly conformal techniques of radiotherapy. Aim: To compare the dosimetric results of brachytherapy with IMRT in early stage node negative oral cavity cancer. Materials and Methods: 10 cases of histopathologically proven oral cavity cancer were treated either with external beam therapy followed by interstitial brachytherapy boost or ISBT alone. All patients are doing well with a median follow up of 10 months. For all these patients, replanning and evaluation with the IMRT planning system was done. Dosimetric comparision between IMRT and ISBT with dose to critical organ, irradiated volumes and conformity index were calculated. Planning time and cost was also looked at. Results: The median dose to critical organs with IMRT were: brainstem 12 Gy, spinal cord 20 Gy, IPSI parotid 47 Gy, C/L parotid 25 Gy and mandible 62 Gy where as in ISBT brainstem 0.3 Gy, spinal cord 0.25 Gy, IPSI parotid 0.3 Gy, C/L parotid 0.2 Gy and mandible 3.2 Gy. ISBT fared better in terms of reducing the dose to critical organs which was statistically significant (P value < 0.05). As far as coverage goes both the techniques faired similar. As expected the cost of treatment and planning time were significantly lesser in ISBT. Conclusion : Brachytherapy is the most conformal technique available and can be employed in selective cases of head and neck cancer. It gives excellent results both in terms of toxicities and cosmesis.

Abstract: 131

Adjuvant radiotherapy in carcinoma buccal mucosa; more conformal the best: Is it so?

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J. Sebastian , M. G. Janki, A. S. Kirthi Koushik, K. Sathish

M.S. Ramaiah Medical College, Bengaluru, Karnataka, India, E-mail: [email protected]

Background: Over the past two decades, radiation delivery has evolved from conventional to 3D conformal and further to intensity modulated radiotherapy (IMRT) allowing better target coverage and minimal dose to organs at risk (OAR). But IMRT has its own disadvantages resulting from complex planning and delivery processes. It is not the magic wand that solves all the problems. Here is an attempt to evaluate dosimetrically the target coverage and dose received by normal tissues by different radiotherapy delivery techniques. Aim: To compare target dose distribution and dose to OARs using conventional, 3DCRT and IMRT technique in early stage carcinoma buccal mucosa where only post op bed irradiation is indicated. Materials and Methods: Ten post op cases of early stage carcinoma buccal mucosa patients in whom only post op bed irradiation was indicated was enrolled and was planned with conventional, 3DCRT and IMRT techniques. 95% PTV coverage and dose received by organs at risk were recorded and evaluated. Results: Mean and standard deviation values for PTV 95% for IMRT, 3DCRT and conventional plans were (96.4+/-1.8), (95.1+/-1.9) and (91+/-2.7) respectively. Dose received by OARs were high in conventional technique when compared with other two. Maximum dose received by 1cc of brain (46.2+/-7.9) & (60.8+/-3.8) (priority was given for PTV coverage) and mean dose received by same eye (13.6+/-1.4) & (22+/-2.4) was less in IMRT when compared with 3DCRT. But, maximum dose received by 1cc of brainstem (29.7+/-7.6) & (14.1+/-9.5) and same side optic nerve (22+/-6.9) & (11.7+/-9.4) and mean dose received by opposite side parotid (8.7+/-1.1) & (1.7+/-0.4) and submandibular gland (18.6+/-1.7) & (3.2+/-0.9) were more with IMRT when compared with 3DCRT. Conclusion: In post op cases of early stage carcinoma buccal mucosa it is good enough to treat with 3DCRT technique. Here the target area will be well lateralised and 3DCRT technique can give good target coverage and less dose to OARs, especially the only remaining major salivary glands.

Abstract: 136

Comparative evaluation of concurrent chemoradiation with or without induction chemotherapy in locally advanced inoperable squamous cell carcinoma of the head and neck

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S. Zaheer , S. A. Siddiqui, M. Akram, S. A. Hasan, M. N. Alam

J N Medical College, Aligarh, Uttar Pradesh, India, E-mail: [email protected]

Background: Most clinical trials show the superiority of combined radiotherapy (RT) & chemotherapy to RT alone for locally advanced squamous cell carcinomas of head and neck (SCCHN). Induction chemotherapy (ICT) helps in organ preservation & may prevent distant failure. There is still controversy regarding its real impact. Combination chemotherapy of Taxanes cisplatin & 5FU is current standard regimen for ICT. We used Cisplatin & Ifosfamide for ICT assuming it to be effective, less toxic & more economic alternative of taxol based combination. Aim: To compare ICT followed by concurrent chemoradiotherapy (CRT) versus CRT alone in locally advanced unresectable SCCHN in terms of (1) Acute toxicities. (2) Late Toxicities. (3) Response to therapy. Materials and Methods: Prospective randomised study on 85 patients with locoregionally advanced unresectable SCCHN with no distant metastasis. Patients were assigned into study group; 43 patients & control group; 42 patients. Study Group received 2cycles of ICT- Cisplatin 100 mg/m2 on day1 and Ifosfamide 1500 mg/m2 on day1-3 every 21days for 2cycles followed by Concurrent CRT. Control Group were given only Concurrent CRT. EBRT was delivered as 70 Gy/35 fractions/2 Gy Daily/5 fractions weekly by Co60machine with concurrent cisplatin weekly. RECIST criteria used for response evaluation. Data analyzed by Fisher's exact & Chi-square test. Results: Both the groups were balanced for age, sex, addiction, site & stage. In study group, after ICT, overall response rate (ORR) was 75% at primary, 70% at nodal, 67.5%for combined primary & nodal disease. Complete response (CR) & partial response (PR) for combined primary & nodal site were 10.0% &57.5% whereas 10%patient had stable disease (SD) & 22.5% had progressive disease (PD). On concurrent CRT, acute toxicities of skin reactions, mucositis, laryngeal, pharyngeal, salivary gland & neutropenia were seen. Grade3 & 4 skin toxicity were statistically significant (p = 0.04). Mucosal, laryngeal, pharyngeal toxicities & neutropenia were comparable. Of 32 patients in study group who received CRT after ICT, CR was 53.1%, PR 31.3% compared to 68.3% & 17.1% in control group. 9.4% patients in study group had PD & 6.3% had SD. In control group, 9.8% had PD & 4.9% SD. The ORR was 84.4% in the study and 85.4% in the control group. Late toxicities were comparable. Conclusion: Response rate after ICT (Cisplatin & Ifosfamide) comparable to trials using PF/TPF. This combination is economical & well tolerated.

Abstract: 138

Comparison of skin reactions and mucositis in concurrent chemoradiation with or without induction chemotherapy in squamous cell carcinoma of the head and neck

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S. Zaheer , S. A. Siddiqui, M. Akram, M. Khan, S. Alam

J N Medical College, Aligarh, Uttar Pradesh, India, E-mail: [email protected]

Background: Induction chemotherapy is the most important change in the management of patients with locally advanced squamous cell carcinomas of the head and neck over the last 30 years. This therapeutic modality helps in organ preservation as well as is useful for the treatment of patients with unresectable disease and may prevent distant failure. In this study we used Cisplatin and Ifosfamide combination for induction chemotherapy. Aim: To compare acute skin reactions and mucositis in the induction chemotherapy (Cisplatin and ifosfamide regimen) followed by concurrent chemoradiotherapy versus concurrent chemoradiotherapy alone in locally advanced unresectable Head and Neck Squamous Cell Carcinoma. Materials and Methods: Prospective randomised study. The selection criteria was advanced locoregional, unresectable disease with no distant metastasis. Patients were randomly assigned into study group & control group. Study Group patients received 2 cycles of Induction Chemotherapy in the form of Cisplatin 100 mg/m2 on day 1 and Ifosfamide 1500 mg/m2 on day1-3 every 21 days for two cycles followed by Concurrent Chemoradiation. Patients in Control Group were given only Concurrent Chemoradiation. Both arms were compared for skin reactions and mucositis using RTOG grading. The data was analyzed and p-values were calculated. Results: During concurrent chemoradiation, most of the patients developed G2 skin reactions. In the study group 10 (31.3%) patients and in the control group 4 (9.8%) patients developed grade 3 skin reactions. Grade 4 skin toxicity was seen in 3 (9.4%) patients in study group and only 1 (2.4%) patient in the control group. There difference were statistically significant (p = 0.04). There was no statistically significant difference between the two arms on comparing combined grade 3 and 4 mucositis (56.2% in study group vs. 48.8% in control group) and combined grade 1 and 2 mucositis (43.8% in both the arms). Conclusion: Skin toxicity was more in induction chemotherapy followed by concurrent chemoradiation group whereas mucosal reactions were comparable. These toxicities were conservatively manageable.

Abstract: 142

Study of palliative radiotherapy along with nimorazole as hypoxic radiosensitizer in locally advanced head and neck squamous cell carcinoma

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R. A. Kumar , S. Kumar

Madras Medical College, Chennai, Tamil Nadu, India, E-mail: [email protected]

Background: Solid tumors may contain oxygen-deficient hypoxic areas and cells in such areas may cause tumors to become radioresistant. Modification of tumor hypoxia significantly improved the loco-regional tumor control. Aim: To assess the immediate loco regional response rates of locally advanced head and neck squamous cell carcinoma with the treatment protocol of hypofractionated RT with nimorazole. To assess acute toxicity to the treatment. To assess the degree of symptom relief. Materials and Methods: 30 patients presenting to our department with biopsy proven head and neck squamous cell carcinoma (stage IV A and IV B) from sites such as oropharynx, hypopharynx and larynx, with poor performance status (ECOG 2 or 3) and non metastatic disease in the age group of 18-70, who are treatment naive and willing to participate in the study are included. Patients are treated with hypofractionated radiotherapy 48 Gy/300 cGy#/3.2 weeks and Tab. Nimorazole 1500 mg (1.2 gm/m΂) daily 90 minutes before RT. The response to treatment was assessed after 6 weeks clinically and radiologically using RECIST criteria. The symptoms experienced by the patients at the baseline and after treatment were recorded using symptom assessment scale. The common side effects of treatment and acute radiation induced toxicities were recorded during and after treatment. Results: All the patients were males; 21 were in stage IV B and 9 in stage IV A. Primary site is oropharynx in 15 patients, hypopharynx in 9 and larynx in 6; 24 had moderately, 4 had poorly and 2 had well differentiated tumors. 14 among 21 showed partial response and others had static response in stage IV B. Among the stage IV A 6 had complete response and 3 had partial. None of the patients developed toxicities specific to nimorazole such as nausea, vomiting and rashes. None of the patients developed grade 4 mucositis or haematological toxicity. 21 patients showed improvement in symptoms. Conclusion: Hypofractionated Radiotherapy with nimorazole demonstrated a significant benefit in the palliative treatment of locally advanced head and neck malignancies in patients with poor performance status without added toxicities.

Abstract: 144

Analysis of 5 years survival in head and neck cancer patients

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R. Narmadha , S. Shanmugakumar, N. V. Kalaiyarasi, Baskaran, Madhumathi, Sundaresan, S. Kumar, V. Kumar

Madras Medical College, Chennai, Tamil Nadu, India, E-mail: [email protected]

Background: Head and neck cancer constitutes the major proportion of all malignancies. 65% of patients present with locally advanced disease. Aim: Main objective is to analysis the overall survival in head and neck patients treated at our institute. Materials and Methods: Retrospective analysis of head and neck cancer patients treated during 2009-2010. Survival was assessed according to the primary subsite and the stage of the disease at the time of starting chemoradiation with/without surgery. Results: Around 800 patients presented with head and neck malignancies. Based on the observation it was found that oral cavity constitutes the majority of patients. Recurrence was common during the first two years of postchemoradiation. Carcinoma of hypoharynx presenting as locally advanced disease had short overall survival. Conclusion: Delay in diagnosis of head and neck cancers leading to advanced nature of disease lead to more residual or recurrent disease following definite therapy or palliative therapy. Addictive habits in the form of tobacco products and alcohol must be prevented thereby reducing the cancer incidence. Early diagnosis of malignancy must be done to provide better outcome following treatment by curative therapies. There is better outcome currently with newer methods of treatment options available.

Abstract: 146

Analysis of locally advanced cases of head and neck carcinoma treated with induction chemotherapy followed by concurrent chemoradiation and interpretation of their results, BIRO MMC experience

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C. S. Shalini , S. Shanmugakumar, N. V. Kalaiyarasi, Baskar, Sundaresan, Prabagaran, Madhumathi

Madras Medical College, Chennai, Tamil Nadu, India, E-mail: [email protected]

Aim: To retrospectively analyse the locally advanced cases of head and neck cancers treated with induction chemotherapy followed by concurrent chemoradiation and interpretation of their results in terms of tumour response rate, pattern of failure, toxicity and survival. Materials and Methods: The data was analysed from case records of 50 patients with locally advanced head and neck cancers treated between the year June 2011 to July 2012. The subsites were nasopharynx = 22 (44%), oropharynx = 18 (36%), hypopharynx = 10 (20%) who were N2 or N3. The diagnosis was confirmed by histopathological examination in all patients. Most common histology was poorly differentiated followed by moderately differentiated carcinoma. The patients were treated with 3 cycles of induction chemotherapy that consisted of Inj. Paclitaxel (175 mg/m2), Inj. Cisplatin (100 mg/m2) and Inj.5-Flourouracil (750 mg/m2) in divided doses for 3 doses on day 1, 22 and 43 followed 3 weeks later by external beam radiation 66 Gy in conventional fractionation along with weekly cisplatin 40 mg/m2. Results: Among the 50 patients analysed 31 patients (62%) achieved immediate locoregional complete response following induction chemotherapy and 19 patients (38%) achieved partial response who achieved complete response following chemoradiation. With a median follow up of 36 months 12 patients developed failure out of which 7 had locoregional, 3 had distant and 2 had both. At 3 years progression free survival is 68%and overall survival is 62%. Toxicities observed in the study were mucositis grade 3 in 15 patients, skin reactions grade 2 in 2 patients leucopenia grade 2 in 2 patients. Conclusion: PFT is a highly active regimen that induced complete response in two third of patients. When followed by concurrent chemoradiation resultant locoregional and distant metastasis control, organ preservation and overall 3 year survival are very promising with manageable toxicities in locally advanced cases of head and neck cancers.

Abstract: 147

Venous thromboembolism in head and neck cancer patients retrospective analysis of incidence and risk factors and outcome

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P. Chinnaraju , S. Shanmugakumar, N. V. Kalaiyarasi, Baskar, Prabhakar, Madhumathi, Sundaresan, S. Kumar, V. Karthik

Madras Medical College, Chennai, Tamil Nadu, India, E-mail: [email protected]

Background: Venous thromboembolism (VTE) is a life threatening and significant complication in cancer patients. Morbidity associated with VTE is substantial with reduced outcome after treatment and considerable mortality. Aim: To retrospectively analyse the incidence and risk factors of venous thromboembolism in head and neck cancer patients and its outcome. Materials and Methods: Head and neck cancer patients diagnosed and treated in our institution during the period of 2007-2014 were analysed. Treated patients with residual, recurrent disease under treatment, treated patients with no active disease at present on active follow up, treated patients expired during the treatment/post treatment are all included in our study. Results: Out of all patients analysed, 18 patients are diagnosed with confirmed VTE by Doppler and CT/MRI imaging out of which 10 of them had IJV thrombosis. Most common risk factor observed was in advanced stage, post operative group. Conclusion : Cancer patients with VTE have reduced life expectancy. It is anticipated that a better understanding of the interactions between tumor related risk factors and the treatment related risk factors will help to improve the prophylactic and treatment strategies for VTE in these complex patients.

Abstract: 153

Concomitant boost irradiation with weekly low dose chemotherapy in locally advanced squamous cell carcinoma of head and neck

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S. Selvalakshmi , S. Shanmugakumar, N. V. Kalaiyarasi, Baskar, Madhumathi, Sundaresan, Prabakaran Sanjal, Karthick

Madras Medical College, Chennai, Tamil Nadu, India, E-mail: [email protected]

Introduction: 65% patients with head and neck tumors present with locally advanced disease. Concurrent chemoradiotherapy is a treatment program for locoregionally advanced squamous cell carcinomas of the head and neck (SCCHN), with established benefits in both organ preservation and survival. Aim: To assess the immediate locoregional response rates of locally advanced squamous cell carcinomas of the head and neck treated with concomitant boost radiotherapy and chemotherapy using low dose weekly cisplatin and paclitaxel. To assess acute toxicity to the treatment. Materials and Methods: Single arm prospective study with 30 consecutive patients with locally advanced head and neck cancer presented to the department of radiotherapy, Madras Medical College, Chennai. All patients were treated with Radiotherapy using concomitant boost 45 Gy/25#/1.8 Gy/5 weeks, 22.5 Gy/15#/1.5 Gy given as a boost only to small field including primary and involved node at an interval of 6 hrs during last 3 weeks of treatment along with weekly CDDP and low dose paclitaxel. The immediate loco regional response rates were assessed clinically and radiologically 6 weeks after concurrent chemo radiotherapy. The toxicity profile of the treatment was assessed with RTOG acute morbidity scoring criteria and CTCAE Version 4. Results: Among 30 patients, Ca Oropharynx was 9 patients, followed by Ca Hypopharynx 8 patients, Ca Oral cavity with 5 patients and Ca Supraglottis 8 patients. 83% of patients had complete response and 17% had partial response. Toxicities observed in the study were Mucositis grade 3 in 5 patients and grade 4 in 2 patients; Skin reactions grade 2 in 3patients. Leucopenia grade 2 in 7patients grade 3 in 5 patients. There was no renal toxicity in this study. There was no treatment related deaths in this study. Conclusion : Concomitant Boost Irradiation with weekly low dose chemotherapy in locally advanced squamous cell carcinoma of head and neck cancer is better regimen with manageable toxicity with higher complete response rate.

Abstract: 160

A prospective study to assess loco-regional control, acute and late toxicity, average treatment time and monitor unit delivery in head and neck squamous cell carcinoma by using rapid arc technique

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V. K. Kontham

Apollo Gleneagles Hospitals, Kolkata, West Bengal, India, E-mail: [email protected]

Background: Head and neck squamous cell carcinoma displays a clear radiation dose-response relationship. Radiotherapy is the main non-surgical modality of treatment for squamous-cell carcinoma of the head and neck. However, treatment planning for head and neck cancers is challenging because of the complex anatomy, with soft tissues and air cavities. Rapid arc enables IMRT-like dose distributions to be delivered using a single rotation or multiple rotations of the gantry. Rapid arc improve Organs at Risk and healthy tissue sparing compared to other IMRT solutions and maintain or improve the same degree of target coverage. Aim: To evaluate the acute and late toxicity profiles of patients according to RTOG toxicity criteria. -To assess the average treatment time per fraction of radiation. -To assess average monitor unit (MU) delivery. Materials and Methods: This is a single arm prospective, single institutional study, conducted between January 2014 to July 2015 at Apollo Gleneagles Hospital, Kolkata, West Bengal, India. Study population were Patients who are ≤ 75years of age, PS ECOG grade 0-2, Biopsy proven squamous cell carcinoma of the larynx, oropharynx, oral cavity (except buccal mucosa), hypopharynx and larynx who are TNM stage II-IV who are receiving radical or adjuvant radiation with or without concurrent chemotherapy. Results: 51 patients were registered in the study, which includes 44 male and 7 female patients. Median age of the study group was 52 (min-36; max-74). All patients were PS 1, 32 patients have both smoking and alcohol addictions. 21 patients were stage II, 12 patients stage III and 18 patients stage IVA. 27 patients received radical radiotherapy and 24 patients received post-operative radiotherapy. 26 patients were treated with concurrent chemo-radiation. 27 patients were eligible for response assessment out of which 19 CR and 8 PR. Average treatment time per fraction was 193.6 sec. Average MU delivery per fraction was 478.7. Max acute toxicity for skin was grade 2 in 17 (33%) patients, grade 3 for mucositis in 13 (25%) patients, grade 3 for dysphagia and xerostomia in 8 (15%) patients each. Late toxicity results showed no grade 3 toxicity at 12months and only 20 (39%) patients had grade 2 salivary gland toxicity. Conclusion: Rapid arc technique in head and neck cancers has got less toxicity profiles compared to other techniques and average treatment time and MU per fraction were much less.

Abstract: 174

Tonsillar malignancy: A histopathological dilemma

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A. K. Dhull , V. Bansal, A. Soni, R. Atri, R. Dhankhar, V. Kaushal,

S. Malik, S. Singh

Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, E-mail: [email protected]

Background: Tonsillar malignancy is the second most common malignancy of the head and neck and squamous cell carcinoma (SCC) is the commonest histopathological subtype constituting 90% of the tumors in this region. Non-Hodgkin's lymphomas account for 8% and minor salivary gland tumors for 2%. The incidence in men is 2−5 times greater than the incidence observed in women. The lack of symptoms is responsible for 67−77% patients presenting with locally advanced disease. Case Discussion : A 53-years old male patient presented with chief complaints of cervical swelling along with difficulty in swallowing for the past two months. The swelling was insidious in onset and progressive in size. The patient was a chronic alcoholic and smoker. On palpation, multiple mobile, non-tender, bilateral cervical lymph nodes were present. On examination, an ulcero-proliferative lesion was seen over right tonsil which was locally advanced. CT scan revealed heterogenous enhancing soft tissue lesion on the right side of oropharynx. Craniocaudally, the lesion extended from base of tongue up to epiglottis obliterating the preglottic space. Multiple bilateral cervical lymph nodes were enlarged. Biopsy from the lesion revealed to be a small round cell tumor with poor differentiation with possibility of primary or metastatic carcinoma. For confirmation, a repeat biopsy was done. On histopathological examination, there was a hypercellular proliferation of monomorphic medium sized round blue cells replacing normal parenchyma. The neoplastic cells illustrated wide spread positivity for CD3 and CD5 immunocytochemical stain. A possibility of haematolymphoid malignancy; non-Hodgkin's lymphoma - Peripheral T cell type was suggested. Hence, based on the clinical findings, radiological examination and immunohistochemical typing of the tumor, clinical diagnosis of lymphomatous lesion was rendered and treatment was started for Non-Hodgkins lymphoma. 6−cycles of CHOP regimen with cyclophosphamide, doxorubicin, vincristine and prednisolone were given. The patient responded well and there was significant clinical regression of the disease. Conclusion : Early identification of tonsillar growth as malignancy followed by proper histological typing of the tumor provides improved results. In case of histomorphologically undifferentiated malignancies like small round cell tumors, the IHC markers can lead to more accurate diagnostic approach.

Abstract: 178

A treatment planning study comparing volumetric intensity-modulated arc therapy (Rapidarc) and fixed field IMRT for early oropharyngeal cancers

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M. Gupta , A. Budrukkar, R. Kinhikar, V. Murthy

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

Aim: To evaluate the performance of volumetric intensity modulated arc therapy (RapidArc) against conventional IMRT for early head neck cancers Background: RA allows for rapid delivery of highly conformal dose distributions. In this study, planning and dosimetry of RA was compared with conventional IMRT for early head neck cancer Materials and Methods: Ten patients with early, node negative tumors of oropharynx, were selected for planning comparison study. PTV was delineated for two different dose levels and planning was done by simultaneously integrated boost technique. A total dose of 70 Gy was delivered to primary tumor and 50 Gy to elective nodal regions (bilateral cervical nodes II-IV) in 35 fractions. Planning was done for IMRT using 9 equally spaced fields and for RapidArc with double arcs consisting of 2 co-planar arcs of 360◦ in clockwise and counter clockwise direction. All plans were generated with 6MV X-rays for LA. Calculations were done in the Eclipse using the AAA algorithm. The plans were normalized to 100% (70 Gy) dose which covered the PTV. For OAR, maximum doses to spinal cord, mandible, larynx and brainstem were tried to limit within 50 Gy, 70 Gy, 66 Gy, and 54 Gy respectively. Mean dose for both parotids was aimed to restrict below 26 Gy. The dose-volume parameters for PTV, parotids, spinal cord, larynx, thyroid, mandible and brain stem were calculated and used to estimate plans. Low dose volumes (V5, V10 and V50%) were calculated. For healthy tissue Integral dose and External index were scored. The paired, two-tailed Student's t-test was used to evaluate difference between the techniques. Results: These are the results of first 5 patient. Target coverage was almost similar in both the techniques. PTV coverage by 95% of the prescribed dose was 99.34% in RA and 98% in IMRT. The Homogeneity Index improved by 29% in RA plans (p = 0.09). The conformity index was similarin both (CI95%= 1.19 ΁ 0.8 for RA and 1.19 ΁ 0.1 for IMRT). The brainstem and spine objectives were met by both techniques. No difference was observed between the plans in terms of integral dose. V5 and V10 were significantly higher in Rapid Arc plans compared to IMRT (p = 0.004 and p = 0.022, respectively). Conclusion : RA demonstrated a similar target coverage and dose sparing to OARs. RA showed a much better dose homogeneity in both high risk and low risk target coverage. It required lesser number of MU/Gy and resulted in greater irradiation to healthy tissue at low doses.

Abstract: 180

Three dimension (3D-3D) matching for image guided setup of head and neck cancer patient comparison of two dimension - two dimension (2D-2D) versus three dimension-and its implication for set-up margin

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S. Goyal , S. Dhal, R. Pasricha 1

Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, 1 American Cancer Hospital, Udaipur, India, E-mail: [email protected]

Background: By imaging and measuring the error of specific patient group regularly with the devices like KV portal and computed tomography (CT) scan (in IGRT) the typical size of the systemic and the random positioning deviations for a setup can be determined, which may be the base for establishing the specific correction protocol in order to improve specific setup techniques and reduce the errors to minimum level. Aim: Compare the 2D-2D matching with 3D-3D matching and its effect on PTV margins and locoregional failures at the field edge. Materials and Methods: It is an observational and prospective randomized study in which 36 consecutive patients with squamous cell carcinoma of oropharynx, staged III-IVa were treated with radical intent with concurrent chemoradiation using Image Guided Radiotherapy (IGRT)/Volumetric modulated arc therapy (VMAT) technique. Patients with age > 65 year, Kornofsky Performance Score (KPS) < 70, metastatic disease, and second primary tumor of head and neck region, previously irradiated patients in head and neck were not included in the study. Both KV images and Cone Beam Computed Tomography (CBCT) were done for all patients before treatment delivery. The Digitally Reconstructed Radiograph (DRR) served as reference image, which was matched manually with orthogonal KV images taken on the machine just before delivery of radiation for a 2D match. Thereafter each patient also underwent KV CBCT. The corresponding set of shifts was obtained for 3D matching for the same patient. Results: A total of 1080 individual CBCT and 1080 individual KV portal image were analyzed. When the errors obtained through the shifts of 2D-2D match were compared with that of 3D-3D match for all 36 patients, systematic errors for individual patient was significantly higher in 3D-3D group as compared to 2D-2D group along X axis (p: 0.049); systematic errors for individual patient was significantly higher in 2D-2D group as compared to 3D-3D group along Y axis (p: 0.025) and systematic error along Z axis and random errors along X, Y and Z axes were insignificant in both the groups. PTV margins were (3.2, 3.2, 3.2) and (3.3, 3.9, 3.8) using 2D-2D and 3D-3D matching along X, Y and Z axes.4/36 patients had marginal failure; 2 each in both groups. Conclusion: IGRT using pretreatment imaging is useful in decreasing the PTV margins. CBCT is more effective than 2D KV image in detecting the systematic errors.

Abstract: 181

Assessment of three-dimensional set-up errors in conformal head and neck radiotherapy using electronic portal imaging device

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S. Dhal , S. Goyal, R. Pasricha 1

Gujarat Cancer and Research Institute, Ahmadabad, Gujarat, 1 American Cancer Hospital, Udaipur, Rajasthan, India, E-mail: [email protected]

Background: By imaging and measuring the error in a specific patient group regularly with the devices like EPID (Electronic Portal Imaging Device) and Cone Beam Computed Tomograph the typical size of the systemic and the random positioning deviations for a setup can be determined, which provide the base for establishing the specific correction protocol in order to improve specific setup and subsequent treatment delivery. EPID or portal images are taken for individual patients and can be compared with a reference image (simulator image or a Digitally Reconstructed Radiograph). Aim: To assess and quantify three dimensional set up errors in conformal head and neck radiotherapy and calculate the optimal Clinical Target Volume (CTV) to Planning Target Volume (PTV) margin for the high-precision conformal techniques. Materials and Methods: In this prospective observational study, 30 consecutive patients with histologically proven squamous cell carcinoma of oropharynx, larynx and hypopharynx, staged IIb-IVa, treated with radical intent for concurrent chemoradiation with IMRT technique were accrued. Anterior and lateral portal images were acquired using EPID on the day of starting treatment and once a week thereafter during the course of radiotherapy. For each patient 12 portal images were acquired. All the images were automatically overlaid and fused by the Varian system using Rigid Registration Algorithm. The bony landmarks, cervical vertebra (C2, C4) and occiput were then matched manually online. Results: Translational displacements were measured in 360 portal images and assessed over 1080-point positions in antero-posterior (AP), medio-lateral (ML) and supero-inferior (SI) direction. The mean displacement in AP; ML; and SI direction was 0.91 mm (Range -3 to +6mm); 0.02 mm (range -4 to +4 mm); and +0.48 mm (range -4 to +4 mm) respectively. The population systematic error (∑ pop) in AP; ML; and SI direction was 1.01, 1.33 and 0.72 mm respectively. The population random error (σ pop ) in the corresponding directions was 1.48, 1.44 and 1.33 mm respectively. Using the ICRU recommendation, the CTV-PTV margin in the AP; ML; and SI direction was 1.79, 1.96, and 1.51 mm respectively; 3.056, 3.67 and 2.37 mm with Stroom's formula and 3.56, 4.33 and 2.73 mm with Van Herk's formula. Conclusion : The set-up PTV margins were < 5 mm in all the three directions.

Abstract: 182

Rapid arc radiation therapy: Early experience in head and neck cancer treatment at SCHRI

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B. Satapathy , V. Pathak, R. Bishnoi, R. Sheoran, U. Kalra

Sarvodaya Cancer Hospital and Research Institute, Hisar, Haryana, India, E-mail: [email protected]

Background: Rapid Arc is volumetric modulated arc radiotherapy technique (VMAT) in which rotational beams with continuous modulation of variable gantry speed, dose rate and multileaf collimator speed, are used to optimize fluence using progressive resolution optimizer with multiresolution dose calculation and Anisotropic Analytical algorithms. Aim: The aim of the study is to evaluate the efficacy of dose delivery, quality of treatment plan and sparing of organ at risk using the technique. Materials and Methods: A study of comprising 55 patients of head and neck cancer which includes Oropharynx (35), Larynx (16), Hypopharynx (1) and Buccal Mucosa (3) treated during last six months was conducted in the department of radiation oncology. Target volumes and organs at Risk (OARs) of the patients were delineated on contrast enhanced CT scans as per the guidelines of ICRU83. GTV, CTV and OARs were delineated in the Eclipse planning system version (11.0). PTV was defined as CTV plus 3 mm margin with exclusion of the skin. Total dose were delivered to GTV (66-70 Gy), CTV (60-66 Gy), PTV (56 Gy), PTV-N (54 Gy) in 30 -33 fractions, using SIB technique. The plans were optimized using the PRO with AAA. For dosimetric comparison and evaluation - homogeneity, conformity indices were calculated for Rapid Arc and IMRT plans. In Rapid Arc plans we used 2 co-planner arcs - one clockwise and another anticlockwise and in IMRT plans we used 7- 9 fields. Gamma analysis of patient specific QA for VMAT (RapidArc*) plans and IMRT plans had shown good results (between 95% and 100% of passed points) with the criteria of 3% dose difference, 3 mm distance to agreement and Gamma area <1. For all patients, cumulative dose volume histograms and dosimetric parameters were calculated and compared for PTV and OARs. Results: RapidArc* showed superior dose homogeneity in PTV coverage compared to IMRT (7-9 field) technique. The sparing of OARs, in terms of the maximum dose was better in double arc technique against IMRT (7-9 fields). The average monitoring units (MUs) and delivery time required in RapidArc are 400-500 MUs and 80-150 secs. In IMRT (7-9 field) they were 700 -800 MUs and 15-20 minutes. Conclusion: In our experience, RapidArc plans and subsequent delivery is a practical proposition for a busy clinic.

Abstract: 184

Preservation of quality of life in patients with squamous cell carcinomas of head and neck cancers treated with simultaneous integrated boost radiotherapy by volumetric modulated arc therapy

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E. Thiraviyam , A. Mukherji, S. Vivekanandham, N. Vijayaprabhu,

S. Saxena

Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India, E-mail: [email protected]

Background: In modern radiotherapy, dose escalation and quality of life (QOL) are important treatment endpoints. The simultaneous integrated boost (SIB) technique offers advantages of decreasing treatment time while increasing the biologically equivalent dose to the tumour however at the cost of increased acute reactions in conventional radiotherapy. Volumetric modulated arc therapy (VMAT) with SIB helps improve both plan quality and delivery efficiency. Aim: In this study, we assessed the change in quality of life and clinical outcomes in head and neck cancer patients treated with SIB by VMAT and analysed plan parameter in VMAT for head and neck cancer patients using SIB approach. Materials and Methods: Thirty patients with stage II - IVA head and neck cancers were treated with VMAT and SIB technique. Doses prescribed were 68.2 Gy at 2.2 Gy/fraction to gross tumour volume, 62 Gy at 2 Gy/fraction to intermediate risk volume and 55.8 Gy at 1.8 Gy/fraction to low risk volume. Concurrent chemotherapy with cisplatin 100 mg/m2 3 weekly was administered where indicated during week 1 and week 4 of radiation therapy. Acute toxicities were evaluated and scored according to the RTOG grading system. Clinical outcomes were assessed with WHO system. Quality of life (QOL) was assessed using European Organization of Research and Treatment of Cancer (EORTC) QLQC30 and HN35 questionnaires before treatment, at the end of treatment, 1 month and 3 months post treatment. Results: Acute grade 3 skin and grade 3 mucosal toxicities were seen in 3 (10%) and 10 (33.33%) patients respectively. Acute grade 3 dysphagia and laryngeal toxicity appeared in 11 (36%) and 10 (33.33%) patients respectively. No grade 4 skin and mucosal toxicities were observed. 17 patients had complete response (CR) at median follow up of 6 months while 3 patients died and 7 had stable disease. All planning objectives were achieved for organs at risk and PTV. There was significant reduction in quality of life scores at the end of treatment when compared to baseline scores but by 3 months, there was return of QOL scores in most scales to baseline value. Conclusion: VMAT based Simultaneous boost radiotherapy is feasible in terms of better toxicity profile with acceptable transient change in quality of life and allows faster return to baseline quality of life compared to historical controls.

Abstract: 185

Effect on cochlear function sparing in head and neck cancer patients treated by simultaneous integrated boost and volumetric modulated arc therapy

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E. Thiraviyam , A. Mukherji, S. Vivekanandham, N. Vijayaprabhu,

S. Saxena

Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India, E-mail: [email protected]

Background: Chemo-radiation to the inner ear may lead to sensorineural hearing loss (SNHL). However the relative contribution to SNHL from RT alone, chemo radiation, and the dose-effect relationship for radiation with or without cisplatin-based chemotherapy remain undefined in the literature, but the severity of damage increases with dose. Aim: Study was done to quantify the severity of SNHL produced after irradiation in patients of head and neck cancer and assess the effect of dose reduction to cochlea with VMAT and SIB. Materials and Methods: Pre-treatment and post-treatment audiograms for 31 patients who received combined modality therapy for head and neck cancers were analysed. Doses prescribed were 68.2 Gy at 2.2 Gy/fraction to gross tumour volume, 62 Gy at 2 Gy/fraction to intermediate risk volume and 55.8 Gy at 1.8 Gy/fraction to low risk volume. Locally advanced disease patients received 2 cycles of three weekly cisplatin regimen. Radiation was delivered by VMAT technique with SIB. Hearing changes were assessed by comparing the mean threshold values of the baseline audiogram to the corresponding values of the most recent follow-up audiogram. Significant sensorineural hearing loss was defined as ≥20 dB increase in bone conduction threshold at one frequency or ≥10 dB increase at two consecutive frequencies. Results: The mean audiogram follow-up time was 8 months (range 2-14 months). 2 patients required dose reduction due to altered renal parameters. The mean radiation dose to the cochlea was 1070 cGy (range 290-3947 cGy). Nine of 31 patients (30%) developed significant sensorineural hearing loss at 8000 Hz with a mean threshold increase of 22.6 dB (CI 10.6 - 37.6 dB) at months follow. The mean cochlea dose for these patients was 27 Gy (range 15 Gy - 34 Gy). For patients only receiving RT, no significant hearing loss was found even at 40 Gy. About half (46%) of the patients who received cisplatin with mean cochlea dose of <8 Gy had no documented audiogram abnormalities. Conclusion: High frequency SNHL was observed in one third of patients who received both concomitant cisplatin and radiotherapy even at expected tolerable doses (mean cochlea dose was 27 Gy). Hence optimization of radiation doses using VMAT could spare the inner ear from cumulative toxicities of chemotherapy and reducing dose to 1.8 Gy/fraction to cochlea using SIB, late effects can be reduced.

Abstract: 186

F-18 FDG PET-CT based IMRT treatment planning for head and neck cancer: Impact on staging and target volume

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T. P. Soni , N. Burela, J. K. Bhagat, L. M. Sharma, A. Gupta, S. Sharma 1 , R. Gothwal 1 , J. S. Goyal

Bhagwan Mahaveer Cancer Hospital and Research Centre, 1 Sawai Man Singh Medical College, Jaipur, Rajasthan, India, E-mail: drtejp[email protected]

Background: To compare quantitatively Gross Tumor Volume (GTV) (primary and nodal) of locally advanced head and neck cancers, delineated on 18F-FDG-PET-CT scan to those delineated on CECT scan and its impact on staging, treated by Intensity Modulated Radiotherapy. Materials and Methods: A total of 30 consecutive patients with locally advanced squamous cell carcinoma of head and neck were included in this study. All patients underwent routine staging work up. FDG-PET and CECT scans were performed with dedicated PET-CT scanner in single session as a part of the radiotherapy treatment planning for IMRT (Intensity Modulated Radiotherapy). While contouring on CECT scans, PET images were completely blinded. GTV PET was delineated by visual interpretation method adjusting the window level of the PET images. Volumetric comparison of GTV-PET versus GTV-CT was performed. After treatment with concurrent chemo-radiotherapy all patients were followed for 1 year. Results: Three out of 30 patients were excluded from the final analysis, as there was complete remission in PET-CT after neoadjuvant chemotherapy. For the reaming 27 cases, the primary sites were oropharynx (n = 17), hypopharynx (n = 2), larynx (n = 7) and one with unknown primary and secondary neck node. PET-CT resulted in changes of CT-based staging in 7 of 27 (25%) patients (up-staged in 3 and down-staged in 4). No significant difference was observed between Gross tumor volumes delineated on PTV-CT vs CT scan alone (GTV-PET (primary): 20.15cc vs GTV-CT (primary) 18.75cc, p = 0.803; GTV-PET (nodes): 28.45 cc vs GTV-CT (nodes) 21.56 cc, p = 0.589). The mismatch between two target volumes was statistically insignificant (p = 0.635 for GTV primary, p = 0.187 for node). The mean GTV-PET outside CT for primary was 5.83 cc, for node 8.47 cc. Median follow up was 12 months. One year loco-regional control was 77.78%. One year event free survival rate was 75.4%. Conclusion: PET-CT scan is strongly advised for staging in advanced Head and Neck cancer. Accuracy of delineation of GTV can be improved along with functional imaging using [18F]-FDG. These metabolically active volumes could be missed during conventional CT-based target delineation of GTVs. We need a study with large number of patients to ascertain whether PET-CT based radiotherapy planning and target delineation by visual interpretation method, should be a standard for advanced Head Neck Cancer patients.

Abstract: 187

An analysis of treatment results and impact of pathological factors affecting locoregional control and survival in buccal mucosa, alveolus and retromolar trigone cancers

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P. Agarwal , A. Gulia, V. Goel, J. Jain, A. Verma, G. Kumar, A. K. Anand

Max Hospital, New Delhi, India, E-mail: [email protected]

Background: we analyzed the outcome of buccal mucosa, alveolus and retromolar trigone (RMT) cancers treated with surgery followed by post operative radiation therapy and tried to determine the influence of various prognostic factors on loco-regional control and survival. Materials and Methods: We retrospectively reviewed the records of 88 patients treated between 2009 and 2012, at our institution. 5 patients were excluded from final analysis. 70 (84%) patients were males & 13 (16%) females. Mean age was 54 years (range 27 to 76 years). Out of 83 evaluated patients, 66 patients were with primary disease at buccal mucosa, 10 patients had alveolar carcinoma and 7 patients had lesion at RMT. 62 (74%) patients had stage III-IV disease. 7 patients received neo adjuvant chemotherapy. All patients underwent wide local excision and ipsilateral nodal dissection followed by adjuvant radiation therapy. Concurrent chemotherapy was given for patients with high risk features. Results: The median follow up of the study was 31.3 months (range 3-70 months). The loco-regional control rate was 71%. The overall rate of local recurrence was 27% (2 nodal, 17 local, 2 both local with nodal disease and 2 patient failed both locally with distant metastasis). Median time to relapse is 18.9 months. The actuarial disease free survival at 1 year and 2 years was 92% and 83% respectively. The actuarial overall survival at 1 year and 2 year was 97% and 92% respectively. Pathological factors analysed were perineural invasion, lymphovascular invasion, close margins (defined as margins <= 0.3cm) and extracapsular extension. Univariate and multivariate analysis has been done and its impact on overall and disease free survival will be presented. Conclusion: Management of locally advanced oral cancers need multimodality approach. It has yielded impressive locoregional control and survival in Indian population. There is a need to further analyze prognostic factors to optimize the management of these cancers.

Abstract: 199

Association of polymorphisms in glutathione s transferase with laryngeal cancer and treatment response to chemoradiotherapy

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R. Mishra , N. Jamal, S. Singh, D. Parmar 1 , R. Kumar

King George's Medical University, 1 Indian Institute of Toxicology and Research, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Background: Tobacco and alcohol consumption are recognized as the major causes of laryngeal cancer, but only a small number of smokers actually develop cancer suggesting a gene-environmental interaction where host components, likely genetics, have an influential role in the susceptibility to cancer. The role of the glutathione S-transferases (GSTs) enzymes in detoxification mechanisms of the carcinogenic compounds has led to the hypothesis that if the individual's genotype at GST locus encodes a deficient GST enzyme it may result in increased risk of cancer. Aim: To study the association of genetic polymorphisms of glutathione S-transferases in patients with laryngeal cancer and treatment response to chemoradiation. Materials and Methods: A case control study was conducted at King George's Medical University, Lucknow, Uttar Pradesh, India in cases suffering from laryngeal cancer and visiting the OPD facility of Radiotherapy Department of KGMU from august 2013 to august 2014. The study group comprised 150 cases with laryngeal cancer and equal number of healthy controls. Results: The prevalence of the null genotypes of both GSTM1 and GSTT1 was higher in cases when compared with the controls which resulted in a statistically significant increase in laryngeal cancer risk associated with null genotype of GSTM1 (O.R. 3.71; 95% C.I: 2.29-6.008) and GSTT1 (O.R. 1.13; 95% C.I: 0.69-1.83). The Hetero phenotype of GSTP1 also shows similar association with cases (O.R.1.54, 95% C.I: 0.96-2.48). In Post treatment analysis GSTM1 wild genotype frequencies were compared amongst responders and non-responders and it was observed that the number of responders was more as compared to GSTM1 null genotype and it was significant. GSTT1 wild type also showed similar trend with responders more than in GSTT1 null genotype but it was not significant. In contrast wild-type GSTP1 was associated with more non responders as compared to GSTP1 hetero and mutant and it showed a trend towards good response with mutant and hetero genotypes but was not significant. Conclusion: our data suggests that null genotypes of GSTM1, GSTT1 and GSTP1 hetero are strong association factors for laryngeal cancer. Further, poor treatment response of chemoradiotherapy in cases with wild-type genotype of GSTP1 and null type GSTM1and null type GSTT1 has demonstrated an association in predicting an individual's response to chemoradiotherapy.

Abstract: 200

An unusual rare presentation of primary upper alveolar carcinoma metastasising to right lacrimal sac

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P. Shruthi , V. Chendil, V. Ganesh

Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India, E-mail: [email protected]

Background: The most common site of metastasis in head and neck cancer is in lung, liver and bone. Aim: Here we are reporting a case of 65 year old male diagnosed with primary site of carcinoma in upper alveolus treated with concurrent chemoradiotherapy. After 6 months of treatment completion he presented with growth in the right medial canthus of eye. FNAC of the lesion showed metastatic deposits. Conclusion: An unusual case of metastasis to right lacrimal sac from the primary alveolar carcinoma.

Abstract: 201

Field cancerization in head and neck cancers is a known fact but still under diagnosed

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V. Ganesh , S. Parashivaiah, C. Vishwanathan

Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India, E-mail: [email protected]

Background: Field cancerization in Head & Neck cancers is a known fact but still under diagnosed. Aims: (1) To evaluate field cancerization in Head & Neck cancers. (2) Ideal investigations- Imaging-CT/MRI -Oesophageogastroduodenoscopy. Materials and Methods: A 55 year elderly man presented with Carcinoma Left Tonsil, who was previously evaluated for the same, was started on Concurrent CT-RT. About 2 weeks later he developed difficulty in swallowing liquids which was severe for which endoscopy was done which showed a lesion in the upper oesophagus, biopsy from the lesion revealed Carcinoma Oesophagus. Conclusion: Field cancerization in Head & Neck cancers is a known fact but still under diagnosed and necessary investigations should be done, not to miss the second primary.

Abstract: 203

Comparative study between concomitant boost radiotherapy and concurrent chemoradiation in locally advanced head and neck squamous cell cancers

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S. Maitra , A. Roy 1 , A. Bera

Nil Ratan Sircar Medical College, 1 Bankura Sammilani Medical College, Kolkata, West Bengal, India, E-mail: [email protected]

Background: Concurrent chemoradiation (CRT) is now the standard organ preserving approach for locally advanced head-neck squamous cell cancers (HNSCC). But for 7 weeks treatment accelerated tumour cell repopulation is encountered and thus some of the radiation dose is lost. Compliance and toxicity associated with CRT is frequently unsatisfactory and is more in frail, poorly nourished patients in developing countries. So, a pragmatic approach is to explore options reducing toxicity, rising compliance but not compromising disease control. Accelerated fractionation with concomitant boost (CBRT) can counter accelerated repopulation along with avoidance of chemotherapy. Hence it might be worthy to compare disease control, toxicity, compliance in between CRT and CBRT. Aim: To compare the toxicity and efficacy of CBRT against CRT in locally advanced Head-Neck cancer in our patient population. Materials and Methods: In this randomised trial, 65 patients with histologically proven HNSCC stage III-IVA were randomly assigned from January 2014 to February 2015 to receive either CRT to a dose of 66 Gy/33#/6.5 weeks with concurrent cisplatin (40 mg/m2/week x 6 cycles) or CBRT to a dose of 67.5 Gy/40#/5 weeks. The compliance, toxicity and quality of life (QoL) were investigated. Patients were monitored for hemogram, liver and renal function, mucosal and skin reactions at least weekly during radiotherapy. Patients' weight was also recorded weekly to monitor nutritional status. Assessment of QoL was done at start, 3rd week and at completion of treatment, 6 weeks and 3 months of follow up. CT of head and neck region done at 3 monthly interval and locoregional control was assessed. Results: The compliance to radiotherapy was superior in CBRT with lesser treatment interruptions (p = 0.005). Acute toxicities were significantly higher in CRT, except for grade 3/4 mucositis which was seen more in CBRT arm (39% and 55% in CRT and CBRT, respectively; p = 0.02). The quality of life was significantly poor in CRT arm at all follow up visits (p < 0.001). The response to treatment was assessed at 6 weeks and at 3 months after therapy according to RECIST criteria for assessing response in solid tumours. Overall, the complete remission rate for locoregional disease was comparable (p = 0.3) between the treatment groups. Conclusion : In selected cases of locally advanced HNSCC, CBRT can offer a better compliance, toxicity profile and QoL with similar locoregional disease control, than CRT.

Abstract: 209

A prospective phase III study comparing primary tumor regression by clinical versus linear quadratic model parameters in oropharyngeal carcinoma treated by conventional and hyper fractionated radiotherapy

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A. Kapoor , H. S. Kumar, N. Kumar 1 , S. Narayan, R. K. Nirban,

S. Maharia, A. Kalwar 2 , N. Sharma

Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College, Bikaner, 2 Dr. SN Medical College, Jodhpur, Rajasthan, 1 Delhi State Cancer Research Institute, New Delhi, India, E-mail: [email protected]

Background: Estimation of linear quadratic model parameters requires subjecting the patients to at least two different fractionation schedules, which is not always practically feasible. Aim: This study was undertaken to estimate the primary tumor regression parameters (virtual α/β) and linear quadratic model parameter (true α/β) in patients of oropharyngeal carcinoma undergoing conventional and hyper fractionated external beam radiotherapy using calculated values of BED for acute normal tissue reactions. Materials and Methods: Sixty patients of locally advanced, unresectable oropharyngeal carcinoma were randomized to receive concurrent chemoradiotherapy by either conventional fractionation (66 Gy, 2 Gy per fraction, 1 fraction per day, 5 fractions per week, in 6-7 weeks) or hyperfractionated radiotherapy (72 Gy, 1.2 Gy per fraction, 2 fractions per day separated by a gap of 6 hrs, 10 fractions per week, in 6-7 weeks). The patients of both the arms received concurrent weekly cisplatin (40 mg/m2, ceiling dose 50 mg). Isoeffect doses for the development of RTOG grade specific end point acute skin and mucosal reactions were estimated by regular clinical assessment of the patients during the radiotherapy. To estimate the α/β; Fe plot, Boer's and Tucker's methods were used. Linear regression method was used to derive the estimates of various coefficients using the model, RF = constant + a1 (D) + a2 (D2), where RF represents response fraction and D represents total EBRT dose for various cumulative dose intervals. Results: The mean α/β for acute skin and mucosal reactions by Fe plot method were 10.005 Gy and 11.086 Gy, respectively. By Boer's method, these values were 10.014 Gy and 11.168 Gy, respectively while by Tucker's method, mean α/β for acute reactions was 10.228 Gy. Thus, the mean α/β (true α/β) for acute reactions by all three methods used was 10.454 Gy. On the basis of Linear Regression Model, the equation y = 1.280 - 0.0243x + 0.001x2 was derived. The coefficients a1 and a2 were not the actual estimates of α and β, but the ratio a1/a2 could be considered to represent α/β. This ratio (virtual α/β) was calculated to be 3.078 Gy in present study. Conclusions: Any mathematical model used to represent complex biological phenomena should be based on careful clinical observations to guide treatment. Further studies involving larger number of patients are warranted to address this topic and to validate the results of present study.

Abstract: 217

Prospective study to compare conventional chemoradiotherapy with hypofractionated chemoradiotherapy in carcinoma larynx

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M. Himthani , S. N. Prasad, S. Singh

J.K. Cancer Institute, Kanpur, Uttar Pradesh, India, E-mail: [email protected]

Background: Carcinoma larynx represents about 2% of total cancer cases. The incidence of laryngeal squamous cell carcinoma has been gradually increasing. Organ preservation is an important concern in laryngeal cancers in view of speech & swallowing functions and radiation plays an important role in its preservation. Treatment modification with hyperfractionation or concurrent chemotherapy tends to be standard for advanced laryngeal but those modalities have the burden of greater treatment cost and time. In our institute, we focused on hypofractionated radiotherapy, which is a modality without additional burden to the patients. We conducted a clinical study to evaluate the effect of fraction size of 3 Gy on local control in advanced stage laryngeal cancer. Aim: To evaluate the efficacy in terms of loco-regional response & toxicity of a hypo-fractionated chemoradiation regimen of Carcinoma Larynx vs. Conventional fractionated chemoradiation. Materials and Methods: 50 eligible patients with Stage 3 and Stage 4 non metastatic squamous cell carcinoma Larynx were randomly divided into two groups of 25 patients each: GROUP I EBRT/60 Co/70 Gy/35 #/7 weeks/2F to Face and neck with shrinking field technique With concurrent cisplatin 100 mg/m2 x 3 weekly GROUP II EBRT/60 Co/60 Gy/20 #/4 week/2F to Face and neck with shrinking field technique With concurrent cisplatin 100 mg/m2 x3 weekly. Results: Between January 2014 to July 2015 a total of 50 patients were enrolled, 25 in each group. Total treatment time in group I was avg.7.5 weeks and 4.5 weeks in group II. Response rate was comparable between two groups, with complete response in group I and group II 56% vs. 48% respectively. On comparing the incidence of dysphagia (grade III) was 20% in group I vs. 24% in group II. Skin (grade II/III) were 80% in the former group vs. 88% in the latter whereas haematological toxicity 12% vs. 16% in group I and group II respectively. Intervention in the form of Ryle's tube intubation or Tracheostomy was required in 56% vs. 64% in group I and II respectively. Conclusion: In locally advanced carcinoma larynx hypofractionated radiotherapy with concurrent cisplatin x 3 weekly is a reasonable alternative to the standard fractionated regimen with concurrent cisplatin offers advantages of decreased overall treatment time, better compliance, decreased hospital stay with comparable response rate and toxicity profile. Decreased treatment time seems an upper edge in view of work load.

Abstract: 220

Neoadjuvant electrochemotherapy in advanced lip and buccal mucosa cancers - BIRO, single institution experience

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M. Vijayakumar

Madras Medical College, Chennai, Tamil Nadu, India, E-mail:[email protected]

Background: Lip and Buccal mucosa cancers are the most common malignancies in our practice. Locally advanced cases are difficult to operate upfront and are usually taken up for pre-operative chemoradiotherapy. Tumouricidal doses of chemotherapy has its own systemic toxic effects. Electro-chemotherapy is a local treatment. Electrical impulses delivered to the tumour, open up the cell membrane channels temporarily resulting in increased drug concentration and improved cell kill, leading to adequate downsizing. Added to this, radiotherapy results in good cytoreduction which in-turn improves the likelihood of negative margins and improved loco-regional control. Aim: To assess the feasibility of treating locally advanced lip and buccal mucosa cancer with electro-chemotherapy using bleomycin followed by pre-operative radiotherapy. Materials and Methods: Around 65 cases of squamous cell carcinoma of oral cavity, stage IV, surgically inoperable were treated with electro-chemotherapy using intravenous bleomycin at a dose of 15 U/m2. Patients were assessed for toxicities and clinical response to electrochemotherapy two weeks after the procedure. In selected patients 2 to 3 sitting were given. Then proceeded with chemoradiation 50 Gy (2 Gy/#). Toxicities were re-assessed weekly during radiotherapy and at the end. Results: Out of 65 pts, 60% were males and 40% were females. Age group was 35 to 65 years. Stage IV A was 92.8% of cases. 28 pts had adequate downsizing after Ect and preop ccrt, and they underwent curative surgery. Rest of the pts not amenable for surgery had radical RT 66 Gy with chemotherapy. No patient developed systemic toxicity to bleomycin. Two weeks post procedure, electrode site skin scarring was observed in 76.9% cases, which reduced by end of radiotherapy to 19.2% cases. Toxicities like radiation mucositis-grade III (23%), post-RT hyperpigmentation (26.9%) and ulceration over treated site (15%) were observed. Partial response noted in all cases 2 weeks post electro-chemotherapy. Discussion: Electrochemotherapy combines administration of non or poorly permeant chemotherapeutic drugs with application of electric impluses to tumors, to facilitate the drug delivery into cells. Enhanced drug delivery can potentiate the effectiveness, locally at the site of cell electropermeabilization by electric pulses without affecting the tissues unexposed to electric impulse.

Abstract: 221

Oral cavity carcinogenesis - does your gender make a difference?

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M. Himthani , S. N. Prasad, S. Singh

J.K. Cancer Institute, Kanpur, Uttar Pradesh, India, E-mail: [email protected]

Background: Although oral cancer has multifaceted etiology, tobacco use and smoking are widely considered to be its major risk factors. Although other lifestyle and environment factors also have been identified as risk factors for oral cancer, tobacco use remains the single most important and preventable cause of this disease. Materials and Methods: 2087 carcinoma oral cavity patients registered in J K Cancer Institute, Kanpur between January 2013 to July 2014 were retrospectively studied and various factors affecting the disease were analysed. Results: We found in our study (a) Oral Cavity carcinoma mainly affects middle age population (40 to 60 years) of about 64% (b) 94% patients were addicted to tobacco. 87% addiction males vs 44% in females. (c) Majority patients registered presented at stage IV (46%) followed by stage III (22%). (d) Female gender was afflicted much less as compared to males 14% vs 86%. (e) Cause to Disease time was much less in females as compared to males 2-3 years versus 5-7 yrs in the latter group. (f) Addiction duration was substantially less in females for the same stage of presentation versus males. (g) Females presented predominantly with early stage cancer (Stage I/II) (57%) as compared to Males who reported mainly during Late stages (Stage III/IV) (82%). Conclusion: This study throws light on the disparity between Carcinoma oral cavity in males and female gender in terms of incidence, addiction habit, duration of addiction, stage of presentation and progression time to disease after etiological agent (tobacco) exposure. We can conclude from this study that in the females despite there being lesser incidence of addiction to tobacco and other products for lesser duration in comparison to their male counterparts, the development of carcinoma oral cavity was earlier and presentation was at an early stage. This may warrant a larger sample size study to evaluate the same and additional contributing factors which might add on to the difference.

Abstract: 230

Comparative study of the effects and results of unplanned interruptions after standard corrections versus uninterrupted treatment by conventional radiotherapy in locally advanced head and neck cancer

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S. Narayan , N. Sharma, R. Sharma 1 , A. Kapoor, H. Kumar, S. Jakhar, S. Maharia

Acharya Tulsi Regional Cancer Treatment and Research Institute Hospital, 1 SP Medical College, Bikaner, Rajasthan, India, E-mail: [email protected]

Background: To achieve a full cure of patients with cancer, radiotherapy must eradicate every tumor stem cell. The longer a course of treatment, the more stem cells can repopulate, increasing the number of stem cells that have to be obliterated. As overall treatment time increases, the probability of local cure by radiotherapy decreases. Aim: Good clinical practice dictates that radical course of radiotherapy (RT) treatment should not be interrupted. Materials and Methods: The study consists of 105 patients of head and neck cancer (Oropharynx) with ECOG performance score ≤ 2, have squamous cell carcinoma histo-pathology and presented with stage III and IVa were enrolled and 91 patients have completed treatment accordingly to plan. Patients were planned for Concurrent chemo-radiotherapy with Cisplatin 40 mg/m2 with EBRT (66 Gy/33#/2 Gy/#) treatment completed in 6.5 weeks. During the treatment the patients were grouped into uninterrupted arm (48) and interrupted arm with standard correction (47). Results: In our study the clinical response results were assessed according to WHO criteria while the toxicity assessment was done as per RTOG criteria. The complete response (CR) in uninterrupted arm was 64.5% and CR in interrupted arm with standard correction was 61.7% at 6 months (p value=). The acute toxicity skin, mucositis was more in interrupted arm, but was fully manageable. The Xerostomia incidence was (48.9% vs 55.3%) and dysphasia and aspiration was in (25.5% vs 31.9%) in the uninterrupted versus interrupted arm. The quality of life was slightly poor, but was statistically insignificant in interrupted arm. Conclusion: Study concluded that treatment with CCRT for locally advanced head and neck cancer if once interrupted, should requires gap correction to overcome increased risk of local failure due to treatment time prolongation with increased incidence of acute and late toxicities.

Abstract: 232

Comparison with conventional radiotherapy with weekly cisplatin with concomitant boost radiotherapy in locally advanced oropharyngeal cancers: A randomized trial from North West India

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M. Singhal , A. Kapoor, S. Maharia, K. Harsh, S. Kumari, S. Narayan, P. Kumari, H. Kumar

Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College, Bikaner, Rajasthan, India, E-mail: [email protected]

Background: Concurrent Chemoradiation (CCRT) is the current standard of care in the treatment of locally advanced oropharyngeal carcinoma. However, local control is still far from satisfactory with significant toxicity. Aim: We designed a randomized controlled trial to compare the efficacy and toxicity of accelerated concomitant boost radiotherapy (CBRT) against CCRT (conventional fractionation with weekly cisplatin) in locally advanced oropharyngeal carcinoma patients. Materials and Methods: In this single institutional study, 60 cases of locally advanced oropharyngeal carcinoma were registered to be treated either by CCRT to a total dose of 66 Gy/33 fractions/6.5 weeks along with weekly cisplatin (40 mg/m2) or by CBRT to a dose of 67.5 Gy/40 fractions/5 weeks. The primary endpoint of the study was to assess the local control by the two schedules. Simultaneously, compliance and toxicity were also observed. Kaplan Meier method was used to estimate three years disease free survival (DFS) and overall survival (OS) and compared using the log rank test, breslow and tarone-ware test. All statistical calculations were performed using SPSS for windows, version 20.0 (Armonk, New York, IBM Corp). Results: Grade 3/4 mucositis was seen more in the CBRT arm (35.5% and 55.8% in CCRT and CBRT, respectively; p = 0.02). However, other acute toxicities were significantly higher in CCRT arm. Also, the late toxicities like Grade 3 xerostomia were significantly higher in the CCRT than CBRT arm (35.5% versus 13.2%; p < 0.001). Three years DFS was 55.5% in the CCRT group and 64.3% in CBRT group (log rank test, p = 0.015; breslow test, p = 0.003; tarone ware test, p = 0.007). Conclusion: Concomitant boost radiotherapy is an alternative to chemoradiation in patients of locally advanced oropharyngeal carcinoma with similar tumor control and better toxicity profile and compliance; it may be especially suitable for patients who are medically unfit to receive concurrent chemotherapy.

Abstract: 233

A prospective study of functional swallowing consequences in correlation with dosimetry by constrictor sparing IMRT in post operative oral cavity cancers

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S. Prabha , Y. S. Leela, P. K. Pidatala, N. Madhavi, J. Nandigam,

B. Perumal, S. Jagadeesan, S. Ibrahim

Omega Hospitals, Hyderabad, Telangana, India, E-mail: [email protected]

Background: Dysphagia is a major problem during and after Radiotherapy in post operative oral cavity cancers. This may be a result of various factors related to the patient, planning and other treatment parameters. Aim: To study the dosimetric correlation of dysphagia outcomes with constrictor sparing IMRT. Materials and Methods: 26 patients from September 2014 to August 2015 with eligibility criteria from ages 27 to 60years with Zubrod performance status 0-1, postoperative stages I, II, III, IVA squamous cell carcinoma of oral cavity were taken in the study to assess the dysphagia and its outcomes during and after follow up of 2weeks, 1month and 3months of RT. The pharyngeal constrictors were contoured along with other OAR's according to RTOG contouring guidelines. The total dose to the PTV of 60 Gy in 30fractions with 2 Gy per fraction for 6weeks was prescribed. Dose constraints to normal tissues are achieved. Dose to the constrictors was limited with mean dose of <45 Gy.17 out of 26 patients received mean dose <45 Gy. 5 out of 26 patients who had nodal status N2b and N2c received a mean constrictor dose of > 45 Gy with no more than 33% of the OARpharynx exceeding 50 Gy and no more than 15% of the OAR pharynx exceeding 60 Gy. In 3 patients pharyngeal constrictors were not contoured and spared. Results: All the patients tolerated the treatment well without any interruption. 65.3% patients where constrictors were spared had CTCAEv4.03 grade 2 and grade 3 toxicities of dysphagia starting from 3 rd week and 4 th , 5 th and 6 th weeks of treatment respectively and mean weight loss of 6% starting from 3 rd week. 34.6 patients where constraints were not achieved had grade 2 toxicities from 2 nd week, grade 3 in 3 rd week and grade 4 in 4 th , 5 th and 6 th weeks and mean weight loss of 15% from 2nd week onwards. Ryle's tube placement in all the patients was encouraged during and after completion of 1st week of treatment. In comparison with the patients where constrictors are not spared, the patients with constrictor sparing had gained normal swallowing function soon, increased food intake thereby increasing the quality of life. Conclusion: There is significant decrease in dysphagia due to constrictor sparing. There is decreased weight loss, better tolerance and faster recovery during and after treatment resulting in improved quality of life.

Abstract: 234

Comparative study of conventional versus concomitant boost radiotherapy schedules in locally advanced oropharanygeal carcinoma

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M. Paramanandhan , S. Jakhar, A. Sharma, R. Kumar, R. Purohit

Acharya Tulsi Regional Cancer Treatment and Research Institute, Bikaner, Rajasthan, India, E-mail: [email protected]

Background: Head and neck carcinoma is the most common cancer in India with more than 70% of the cases presenting in advanced stages. The disease remains confined to the loco-regional site of origin in a significant proportion of patients and the most important cause of death is locoregional recurrence. Various studies have shown concurrent chemoradiation schedules to have better locoregional control (LRC) and improved the overall survival. Accelerated fractionation schedules have been studied effectively in head and neck cancers. It is one method which tends to concentrate on shortening the overall treatment time and thus hampering tumor cell proliferation. Concomitant boost is one of the ways of acceleration wherein a second daily fraction is introduced during any phase of treatment, thus completing the treatment in 5-6 weeks.

Aim: To compare the LRC, acute and late toxicities in locally advanced (stage III/IV) oropharyngeal carcinoma in two different radiotherapy schedules mentioned below. Materials and Methods: 50 untreated, biopsy proven patients of oropharyngeal cancer (stage III, IV) with ECOG status 0-1, age <70 years were included from April 2014 and March 2015. All the patients were treated in supine position after proper immobilization by thermoplastic cast. ARM A: 66 Gy/33# over a period of 6 ΍ weeks, 1#/day, 5 days a week with weekly concurrent Cisplatin (40 mg/m΂). ARM B: 45 Gy/25#/5weeks, 1.8 Gy/#/day, 5days/week delivered to the larger field comprising the primary disease with extension and the neck nodes. Simultaneously a boost of 22.5 Gy/15#, 1.5 Gy/# on alternate day from the 1st day of the treatment for 5weeks to the primary+ nodal area. The fractions were delivered 6 hours apart. The patients in both arms were assessed after every 5 fraction for treatment related acute toxicity. Follow up was done on the completion of treatment, 1st follow up at 6 weeks, and then 2 monthly for 6 months. Results: CR was seen in 68% vs 72%, PR was seen in 24% vs 28%, Grade II skin reactions were 16% vs 76%, and Grade III mucositis was 20% vs 68% in conventional arm and in boost arm respectively. Conclusion : The concomitant boost schedule provides a slightly better tumour control and patient compliance with a relatively good quality of life at the cost of increase in confluent mucositis.

Abstract: 236

Mucoepidermoid carcinoma of parotid in children: A rare case report

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D. Borade , M. Chandra, R. Bhalavat, K. George, K. Kalariya,

V. Pareek

Jupiter Hospital, Mumbai, Maharashtra, India, E-mail: [email protected]

Background: Mucoepidermoid carcinoma of the parotid arises from the pleuripotent cells of the gland. It accounts for 5% of all salivary gland tumors. About 45% of mucoepidermoid carcinomas occur in the parotid gland. They usually appear in 5th decade of life but it is very rarely found in pediatric age group. Usually such tumors are low grade and present without nodal metastasis, so surgery is the treatment of choice. Here we report a case of mucoepidermoid carcinoma in a young patient. Case Report: Seven year old girl presented with painless swelling over right cheek and right upper neck since 7 months. MRI Parotid and Neck showed a focal lesion involving superficial and deep lobe of right parotid along with multiple bilateral submandibular (Ib & IIa) and posterior cervical (V) lymph nodes, FNAC was s/o pleomorphic adenoma. She was treated with right total parotidectomy (Nerve Sparing Surgery) & right selective neck dissection. Histopathology revealed low grade mucoepidermoid carcinoma with one positive node. Post operative radiation therapy was given to the tumor bed and ipsilateral neck nodes. At her last follow up, she has completed 6 months and she is asymptomatic without any evidence of recurrence. Conclusion: Mucoepidermoid carcinoma of parotid is very rare in children. Clinical stage and histological grade are the main prognostic factors. Complete excision with preservation of facial nerve is the treatment of choice. Neck dissection is considered when there is clinical evidence of regional metastasis, high TNM stage, high histological grade and involvement of regional nodes. Because of the possibility of long term adverse effects in pediatric patients, radiotherapy should be used only in selected cases. Long term follow up is essential to rule out late recurrence and to see the side effects of therapy. Although rare, it should be suspected in pediatric patients with asymptomatic parotid mass.

Abstract: 245

Average haemoglobin during treatment as a prognostic factor in locally advanced head and neck cancer patients treated with concurrent chemoradiation and IGRT

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B. Dua , K. S. Chufal 1 , G. Jadhav

Apollo Hospital, 1 Batra Hospital, Delhi, India, E-mail: [email protected]

Background: Anaemia is a well documented adverse prognostic factor in head and neck cancer. There is a plethora of data available but the data on patients treated with definitive chemoradiation with IGRT is sparse, more so in the Indian subcontinent. There are certain questions that still remain, such as is it the pretreatment hemoglobin level, the value during treatment or the degree of fall during treatment that is the most significant. We have attempted to elucidate the role of hemoglobin as a prognostic factor in locally advanced head and neck cancer. Aim: To assess the impact of pretreatment hemoglobin (PreHb), the average haemoglobin during treatment (AHDT) and the difference between them (Hbdiff) on overall survival (OS), loco regional relapse free survival (LRFS), Response, local control (LC) as well as regional control (RC) in locally advanced cancers of the oropharynx and hypopharynx. Materials and Methods: We analysed 87 patients of Stage III-IV squamous cell cancer of the hypo pharynx, and oropharynx, who subsequently received definitive chemo radiation with IGRT. During the treatment, weekly complete blood counts were done. The pretreatment Hemoglobin was the level measured before treatment whereas the AHDT was the mean of all measured values during treatment and the Hbdiff was the difference between the two. Correlations were sought between these and OS, LRFS, Response, LC and RC over a follow up period of 2 years. Results: The 2 year OS, LRFS, LC and RC, was 65%, 55%, 63% and 83% respectively. Complete responders to chemoradiation were 53 leading to a response rate of 61%. The mean PreHb was 12.45 gm/dl (range 10.0-16.90) with a SD of 1.43 & mean AHDT was 11.73 gm/dl (range 9.4-15.2) with a SD of 1.25. The mean Hbdiff was 0.712 (range -2.00 to + 3.30) with a SD of 0.86. On the univariate analysis, all three were significant prognostic factors whereas on the multivariate analysis only the AHDT was significant for overall survival and the response. By dividing the AHDT values into 0.5 gm/dl increments and using a sequential Kaplan Meir analysis technique and ROC curve analysis we also found an optimal cut off point of 10.9 gm/dl. We also did a subgroup analysis on our 57 oropharyngeal patients and achieved similar results. Conclusion: AHDT predicts overall survival and response to chemoradiation in locally advanced head and neck cancer patients and a level above 10.9 gm/dl should be maintained during treatment to optimize outcomes.

Abstract: 246

A comparative study to evaluate the response and toxicities in locally advanced head and neck cancer patients treated with pcf versus dcf as neoadjuvant chemotherapy followed by concurrent chemoradiation

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C. Bose , D. Samanta, S. Senapati

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

Background: To evaluate the response and toxicity of docetaxel, cisplatinum, 5-FU (DCF) vs paclitaxel, cisplatinum, 5-FU (PCF) as neoadjuvant chemotherapy (NACT) followed by concurrent chemoradiation (CTRT) with weekly cisplatinum in locally advanced head and neck cancer. Materials and Methods: 62 locally advanced head and neck cancer patients who satisfied the eligibility criteria were randomized 35 patients received three cycles of NACT i.e., paclitaxel (175 mg/m2) on d1, cisplatinum (30 mg/m2) and 5-FU (600 mg/m2) d2-d4 (PCF) and 27 patients received three cycles of NACT docetaxel (75 mg/m2) on d1, cisplatinum (30 mg/m2) and 5-FU (600 mg/m2) d2-d4 (DCF) at three week intervals, followed by concurrent weekly cisplatinum 30 mg/m2 along with conventional external beam radiation of total tumor dose 66 Gy. Response was assessed after NACT and again after six weeks, three months interval for 2 yrs. Toxicities were assessed after each cycles of NACT and also weekly during CTRT. Results: Two weeks after completion of NACT complete response (CR) in PCF was 14.28%, partial response (PR) 82.85% and no response 2.85%. However in DCF, CR was 25.92% PR was 62.96%.11.11% patient died due to toxicity. With a median follow up of twenty months, in PCF CR was 57.14%, PR 34.28% and no response was 8.57%, whereas in DCF CR was 77.77%, PR 11.11% and death11.11%. On evaluation of toxicities during NACT, patients in DCF had more significant neutropenia and in PCF more incidence of neuropathy. During CTRT, in PCF grade II and III mucositis was 57.14%, grade II neutropenia 14.28%, and grade II anemia 25.71%. In DCF mucositis grade II and III was 66.66%, neutropenia grade II 25.92% and anemia grade II was 18.51%. Late toxicities included were comparable in both arms. Conclusion: With a median follow up of twenty months, the CR in DCF was 77.77%, superior to PCF i.e., 57.14%. Neutropenia was significant in DCF and neuropathy was high in PCF. In CTRT mucositis was the commonest toxicity observed in both PCF and DCF which was not statistically significant.

Abstract: 247

Conventional radiotherapy versus hypofractionated in early glottic cancer: A comparative study

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T. Syiem , N. Sharma, A. Sharma

Acharya Tulsi Regional Cancer Treatment and Research Institute, Bikaner, Rajasthan, India, E-mail: [email protected]

Background: Cancer of the larynx represents about 2% of the total cancers. Glottis accounts for 60-65% of all laryngeal carcinoma. Most laryngeal malignancies are squamous cell carcinoma with various grades of differentiation. Glottic cancer has a high rate of cure and regardless of the modality used, T1 and T2 carcinomas have an excellent prognosis. The aims of treatment for early glottic cancer are cure, laryngeal voice preservation, optimal voice quality with minimal morbidity, expense and inconvenience. Radiotherapy is generally the favored treatment despite comparable cure rates for selected T1 and T2 glottis tumors with laser excision, cordectomy and hemilaryngectomy. The preference of radiotherapy over surgery stems from a less restrictive selection criteria, better quality of voice with comparable local control and survival rates. Aim: To assess local control rates and radiation induced toxicities in above mentioned groups. Materials and Methods: 30 histologically proven T1/2NO cases who were ≤70 years with ECOG performance status (0-1-2), no prior malignancy oriented treatment, adequate base line organ functions were enrolled. Patients with distant metastases or other malignancies, pregnant/lactating women were excluded. Arm A: Received 55 Gy in 20#, each dose of 2.75 Gy, 5 days a week for 4weeks. Arm B: Received 66 Gy in 33# 2 Gy each, 5 days a week for 6.5 weeks. Field size taken: 5 Χ 5 cm. Treatment field size was not reduced or increased at any time during the treatment period. Patients were followed up on a weekly basis during the course of treatment. Radiation reactions and response to radiation were assessed at 1month, 3months and 6months after end of treatment according to criteria. Results: After 6months follow up, CR of 100% was seen in both arms. Skin reaction was 3/15, 7/15, 5/15 in grade I, II, III respectively in study arm and in control arm, 4/15, 6/15, 5/15 in grade I, II, III respectively. Mucositis was 5/15, 6/15, 4/15 in gradeI, II, III in study arm and 5/15, 7/15, 3/15 in gradeI, II, III in control arm. Dysphagia was 9/15, 6/15 in grade I, II in study arm and 8/15, 7/15 in grade I, II in control arm respectively. Conclusion : The shorter treatment duration, similar treatment related toxicities and outcome seen in the study arm favors use of hypofractionated method in a busy setup.

Abstract: 250

A retrospective analysis of treatment of nasopharyngeal carcinoma

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N. Dharra , S. Hukku, S. Halder, R. Srivastava, P. Kumar, E. H. Annex

B. L. Kapur Super Speciality Hospital, New Delhi, India, E-mail: [email protected]

Background: Nasopharyngeal carcinoma (NPC) is uncommon in Indian sub-continent except for NE region of the country. NPC is quite high in Nagaland (about 4.3/lakh/year). For advanced NPC (stage II-IV), standard-care is concurrent chemo radiation therapy with high-dose radiation combined with Cisplatin-based regimens followed by adjuvant chemotherapy. Aim: A retrospective analysis of patients with stage I- IV nasopharyngeal carcinoma treated in our department from April 2009- April 2015. Materials and Methods: 41 patients with nasopharyngeal carcinoma were biopsy proven and the metastatic work-up was done with PET CT in 22 patients while in others USG whole abdomen, chest X-ray PA view, bone scan were used. Radiotherapy was given at 70 Gy/35 fractions with concurrent chemotherapy (followed by adjuvant chemotherapy in some patients). For stage I disease Radiotherapy alone was given. Statistical analysis was done using SPSS software version- 17, toxicity was assessed using CTCAE- V4.03 and RTOG radiation morbidity scale. Results: Of the 41 patients reviewed (female= 13, male= 28) stage wise distribution was as follows: stage I- 3 patients (7.3%), stage II- 6patients (14.6%), stage III-maximum number of patients (19 patients, 46.3%), stage IV- 13 patients (31.7%). Median age was 50. The median progression-free survival (PFS) time was 15 months (4-36 months). The overall survival (OS) was 87.7% (median OS time - 40 months). Incidence and severity of mucositis was as follows: grade II- 24 patients (56.1%), grade III-17 patients (41.5%) and did not cause treatment breaks. Xerostomia (grade I) was reported in 10 patients (24.4%) while 31 patients (75.6%) did not experience this late effect (based on validated Xerostomia questionnaire). Conclusion: Treatment results with chemo-radiotherapy in our department for nasopharyngeal carcinoma showed good progression free survival (PFS) and overall survival (OS) with well preservation of salivary function using Intensity modulated radiotherapy (IMRT).

Abstract: 256

A phase III randomized study of weekly versus daily schedule of hypofractionated palliative radiotherapy with concurrent chemotherapy in the treatment of locally advanced head and neck cancer

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R. K. Nirban , A. Kapoor, S. Narayan, S. Maharia, M. K. Singhal,

H. S. Kumar, A. Sharma

Sardar Patel Medical College, Bikaner, Rajasthan, India, E-mail: [email protected]

Background: Palliative radiotherapy for locally advanced head and neck cancer (LA-HNC) patients usually comprises of 30 Gy/2 weeks/10 fractions. However, recent phase II trials have suggested alternative hypofractionated schedules for palliation where the overall treatment duration is further reduced. Aim: This study was undertaken to evaluate and compare the local tumor control (both primary & nodal site) in weekly versus daily hypofractionated radiotherapy schedules with concurrent chemotherapy in LA-HNC along with evaluation of acute local and systemic toxicity in the two arms. Materials and Methods: Fifty patients of LA-HNC requiring palliation were randomized to receive concurrent chemo radiotherapy by the following two hypofractionated schedules: Arm A: 36 Gy/6 fractions, 6 Gy/fraction, 1fraction/week, in 6weeks (BED-54.4 Gy) Arm B: 42 Gy/14 fractions, 3 Gy/fraction, 5 fractions/week, in 3 weeks (BED-54.6 Gy) The patients of both the arms received concurrent weekly inj. cisplatin (40 mg/m2, ceiling dose 50 mg). The primary and nodal response of treatment in both the groups was assessed by RECIST criteria. Results: At the completion of study (1st month follow up visit), 20% patients of arm-A (36 Gy/6F) and 36% of arm-B (42 Gy/14F) patients had complete response, the response in arm-B was slightly better than arm-A, which was statistically significant (p = 0.032). 52% of patients in arm-A and 44% in arm-B had partial response (p = 0.414). 28% of patients in arm-A and 20% in arm-B had stable and progressive disease which was not statistically significant (p = 0.414). The incidence of acute mucositis as well as skin reactions were more in the arm-B as compared to arm-A (p = 0.001). Systemic toxicities were similar in both the arms. Both treatment schedules were well tolerated by the patients. The 300 cGy daily arm patients completed treatment in 3 weeks as against 6 weeks for 600 cGy weekly arm. Conclusion: Hypofractionated radiotherapy with either 600 cGy per fraction given weekly or 300 cGy per fraction given daily along with concurrent chemotherapy are feasible options for palliation in advanced head and neck cancers. 600 cGy weekly radiotherapy given on Saturday is a feasible alternative to daily 300 cGy schedule with lesser burden to the busy radiotherapy department. This has an advantage that the radiotherapy machine can be used for curative radiation treatment during weekdays.

Abstract: 258

Brain metastases from a buccal mucosal primary: A rare case report

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M. Aarthi , S. Shanmugakumar, N. V. Kalaiyarasi, P. Balasubramaniam, V. Karthick, S. Kumar

Madras Medical College, Chennai, Tamil Nadu, India, E-mail: [email protected]

Background: Buccal mucosal squamous cell carcinoma (BMSCC) is an aggressive form of oral cavity cancer, associated with a high rate of locoregional recurrence and poor survival. Most frequent sites of distant metastasis from cancer of the oral cavity include lung, bone and liver. Distant metastases are uncommon in buccal carcinoma. Case Presentation: 45 years old male patient with no known comorbidity was treated with concurrent chemoradiotherapy for carcinoma of right buccal mucosa of stage T3N2cM0 in 2013. After one year of regular follow-up, patient reported with sudden right lower limb weakness and multiple episodes of seizures. MRI Brain revealed a space occupying lesion in left parietal region. Stereotactic biopsy from the lesion revealed metastatic squamous cell deposits. Further metastatic work-up with CT chest revealed a cavitory lesion in the upper lobe of left lung and biopsy from the same revealed inflammatory cells with no evidence of malignancy. IHC study of brain lesion revealed positivity for EMA & P63. Negative TTF1 & CK7 ruled out a lung primary and favoured the diagnosis of metastatic squamous deposits of buccal mucosal origin. Patient was then given Whole Brain RT and was followed up with palliative chemotherapy. Conclusion: Brain metastases though rare from an oral cavity cancer should be considered as a possibility and this case is being presented for its rarity.

Abstract: 265

An audit and analysis of different causes of defaults in head and neck irradiation patients and a tertiary regional cancer center experience

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L. Pujari , S. Padhi, B. Routray, C. Bose, L. Pattanayak, N. Panda,

S. Senapati

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

Background: Strict adherence to the EBRT schedule is one of the most important prognostic factors in survival of head and neck cancer patients. However many patients do not complete the radiation treatment due to various reasons resulting in a poor outcome. Aim: To study the pattern of defaults and it to identify various possible causes for possible intervention. Materials and Methods: We did a retrospective epidemiological analysis of the patient data from the treatment record of the patients in dept. of radiotherapy, AHRCC, Cuttack. Patients who had started taking EBRT for head and neck cancers with curative intent from January 2014 to December 2014 and did not receive the prescribed dose were included. Unplanned treatment breaks in the treatment was not considered. Data were analysed by SPSS V.21. Results: 92 out of 458 (20.08%) patients didn't complete the EBRT. 63 out of 347 (18.15%) male and 29 out of 111 (26.1%) (p = 0.06) female patients defaulted. 56 out of total 92 patients (60.9%) stopped taking treatment within 15#s i.e., halfway in the treatment.12 out of total 92 patients (13%) stopped taking treatment just at the 22 nd /23 rd #. Defaulter rates in patients from nearby districts and distant places are in the range of 12.8-33.0% (p = 0.224). There was no particular age (p = 0.966), disease site (p = 0.354) preponderance among defaulters. There was no difference among various treatment modalities prior to radiotherapy (p = 0.597) or intent of treatment even with use of concurrent chemo-radiation in radical or adjuvant settings (p = 0.406). Conclusion: Radiation induced acute toxicity may be one cause of patients defaulting. Distance of home from the radiotherapy center may be factor. Though the difference is not statistically significant (p = 0.224) there is a general tendency that patients from distant places tend to default more. Female patients are more likely to default as compared to their male counterparts. There no relation between age, disease site and defaults in patients. Use of concurrent chemo-radiotherapy doesn't make any significant difference in defaults. There may be some causes unique to that particular RT center which needs to be explored and addressed. Proper counselling of the patients and timely management of any radiation toxicity can immensely improve the compliance and so as treatment outcome. There is also great need to expand RT treatment facilities to far flung areas by which patients can get treatment at their nearby places.

Abstract: 266

Does adjuvant radiation therapy improve outcomes in pT1-2N0 oral tongue squamous cell carcinoma patients with isolated perineural invasion?

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R. Singareddy , H. Kaur, K. Alluri, C. Rao

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

Background: Perineural invasion (PNI) has been classified as an intermediate risk factor for recurrence and decreased survival. Treatment decision on adjuvant radiotherapy becomes difficult in pathologically negative neck with clear evidence of PNI when high risk factors such as extracapsular spread and nodal metastasis and intermediate risk factors like close margins, lymphovascular invasion and node positivity are absent. Adjuvant therapies are not without risks and selecting the appropriate treatment regimen based on risk assessment, while maintaining optimal survival outcomes is vital to the overall management of patients with oral tongue squamous cell carcinoma (OTSCC). Aim: To assess the role of adjuvant radiation in pT1-2N0 OTSCC patients with isolated Perineural invasion for Locoregional control (LRC), Disease Free Survival (DFS) and Overall Survival (OS) Materials and Methods: We retrospectively reviewed our hospital records from January 2012-September 2014 for pT1-2N0 OTSCC patients with isolated PNI.40 patients were found among which 27 (67.5%) patients received adjuvant radiation and the remaining 13 (32.5%) did not, Statistical analysis for locoregional control was done by two tailed Fischers exact test. DFS and OS were compared using Kaplan Meir method. Results: Median followup was 25 months. LRC for patients who received adjuvant radiation and who did not receive adjuvant radiation was 88.88% (2 local & 1 regional recurrence) and 76.92% (1 local & 2 regional recurrence) respectively. There was no statistically significant difference in LRC (p = 0.36) and in DFS and OS (p = 0.41) Conclusions: Our results are against the practice of giving adjuvant radiation in isolated PNI cases of pT1-2N0 OTSCC. Our study showed no difference in locoregional control or survival. Giving adjuvant radiation in such cases would only compromise the Quality of Life. There is a need of a well designed randomised controlled trial to establish solid evidence.

Abstract: 274

Response assessment of hypofractionated radiotherapy in locally advanced head and neck cancers

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V. U. Salini , S. Shanmugakumar, N. V. Kalaiyarasi, Baskar, Madhumathi, Sundaresan, Prabakaran, S. Kumar, V. Karthik

Madras, Medical College, Chennai, Tamil Nadu, India, E-mail: [email protected]

Background: Head and neck cancer is one of the highly prevalent cancers in developing countries. Most patients present with extensive locoregional involvement, poor general condition and associated comorbid conditions. Hypofractionated radiotherapy is helpful in such patients in whom aggressive treatment is not possible. Aim: To retrospectively analyse the cases of locally advanced head and neck cancers treated with hypofractionated regimen along with radiosensitising chemotherapy during the year 2012-2014. Materials and Methods: Records of 150 patients who presented with stage III and stage IV H&N cancers were analysed. All patients had received 48 Gy in 16 fractions with 5 fractions per week along with radiosensitising chemotherapy (inj. cisplatin-40 mg). The parameters analysed were primary tumour and nodal response, improvement in symptoms and toxicity. Results: Of the 150 patients studied, 57% had stage IV A, 23% had stage IV B and 20% had stage III disease. Oral cavity cancers (48%) were the commonest followed by larynx (31%), hypopharynx (15%) and orpharynx (48%). Histologically 52% was moderately differentiated, 15% well differentiated and 12% poorly differentiated. Pain at primary site, dysphagia, neck swelling, hoarseness were common presenting symptoms. 22% had associated comorbidites. Most patients had ECOG status II. All patients received atleast one cycle of chemotherapy with 48% completing three cycles. 74% had partial response, 18%complete response and 8% had static response at primary and nodal site. More than 92% had symptom improvement. Incidence of grade II mucositis-54%, grade III mucositis-34%, grade I mocositis-12%. Treatment breaks were <2%. Conclusion: Hypofractionated radiotherapy with sensitising chemotherapy produces good response rates with sustained symptoms relief and has limited toxicity.

Abstract: 281

Histopathological correlation of depth of invasion and cervical lymph node metastasis in post operative cases of carcinoma buccal mucosa and carcinoma tongue

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A. Upadhyay , D. Samanta, S. Padhi, N. Panda, S. Senapati

Shrirama Chandra Bhanj Medical College, Cuttack, Odisha, India, E-mail: [email protected]

Background: Many histopathologic parameters in head and neck squamous cell carcinoma have been identified as predictive factors for lymph node metastasis. Studies has compared the depth of invasion with pathological lymph node metastasis. No definite treatment protocol has been defined with respect to depth of invasion. Aim: This study is taken up to correlate between depth of invasion and lymph node metastasis in post operative cases of carcinoma buccal mucosa and tongue respectively. Materials and Methods: Retrospectively the histopathology report of cases of operated carcinoma buccal mucosa and carcinoma tongue respectively from august 2014 to august 2015 were reviewed. Total 56 cases were retrieved. All the patients had adequate neck dissection. The depth of invasion and lymph node involvement were analysed using SPSS v. 21. Results: Among 56 patients there were 37 cases of carcinoma buccal mucosa and 19 cases of carcinoma tongue. The overall cervical metastatic rate was64.86% (n = 24/37) in carcinoma buccal mucosa and 68.42% (n = 13/19) in carcinoma tongue. In case of carcinoma buccal mucosa upto 10 mm depth of invasion there is 35.29% (n = 6/17) involvement of cervical lymph nodes, whereas for depth of invasion more than 10 mm nodal metastasis is 90% (n = 18/20). Similarly in carcinoma tongue upto 6 mm depth of invasion lymph node metastasis is 33.33%, (n = 1/3) and above 6 mm depth of invasion nodal metastasis is 68.75% (n = 11/16). Conclusion: With increasing depth of invasion, the frequency and number of lymph node involvement increases in both carcinoma buccal mucosa and carcinoma tongue. At 10 mm and 6 mm depth of invasion lymph node involvement increases significantly in carcinoma buccal mucosa and carcinoma tongue respectively. Elective neck therapy should be considered at 10 mm and 6 mm of depth of invasion in carcinoma buccal mucosa and carcinoma tongue.

Abstract: 284

Outcome and toxicity after induction chemotherapy and risk-based definitive therapy for locally advanced squamous cell carcinoma of head and neck

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V. Nautiyal , M. Gupta, R. Kant, S. Bansal, J. Bisth, D. S. Pruthi,

M. Ahmad, S. Saini

Cancer Research Institute, SRHU, Dehradun, Uttarakhand, India, E-mail: [email protected]

Background: To evaluate outcome and toxicities after induction chemotherapy (IC) followed by "risk based" radical treatment for locally advanced head & neck squamous cell cancer (LAHNSCC). Materials and Methods: 24 patients (stage IVA and IVB, T4, N3) LAHNSCC were treated with induction IC from April 2013 to July 2015. ECOG Performance status was ≤ 2 and they underwent 2 cycles of 3 weekly IC (Taxane and Cisplatin). Patient who responded (CR + PR), underwent Radical treatment (CTRT or Sx → CTRT) and non responders were treated with palliative treatment. The response rates, toxicity (accordance with RTOG), completion rate of radical treatment post NACT and overall survival are reported. Results: Median follow up and age of patients was 9 months (2-28 months) and 54 (30-74) years respectively. Ratio of M:F was 22:2. Out of a total of 24 patients, site wise distribution was as follows: Oral cavity-9 (37.5%), oropharyngeal-5 (20.8%), laryngopharynx-7 (29.16%) and unknown primary with neck secondary UNP-3 (12.5%) respectively. After 2 cycles of IC, 16 patients (66.66%) responded, following which they underwent radical treatment and remaining 8 (33.33%) were treated with palliative treatment. On site wise subgroup analysis of radically treated patients (>50% response), 4 patients were of oral cavity, 5 patients of oropharyngeal, 5 of laryngopharynx and 2 patients of UNP, of which only 2 patients of Oral Cavity underwent surgery followed by CTRT and remaining patients were treated with CTRT. At the end of treatment maximum 12 patients had grade 2 mucositis, 4 patients had grade 3 mucositis and 2 patients developed grade 2 hematological toxicities in radical treatment group. No toxicity related mortality was seen. The completion rate of radical treatment post IC was 93.5%. The median OS was 15.36 month (95% CI 1.6-26.34). Total 6 patients died and 4 patients were lost to follow up. Conclusion: Use of IC is safe & effective in selected cohort of patients with LAHNSCC, who are not feasible for upfront radical treatment.

Abstract: 287

Analysis of outcomes of adjuvant ebrt in pt1/2 n0 anterior two-third tongue carcinoma patients

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K. Patel , S. Gupta, J. Bhattacharya, P. Agarwal, M. Anand,

U. Suryanarayana, R. K. Vyas

Gujrat Cancer Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]

Background: Current guidelines do not define the role of adjuvant RT in pT1/2N0 anterior 2/3 tongue carcinoma patients except for margin +ve cases. At our institute we prefer adjuvant EBRT for such patients depending upon the depth of invasion, margin status, LVI/PNI status and number of lymph nodes dissected. Aim: The primary aim of this study is to analyse the outcomes of adjuvant EBRT in pT1/2N0 oral tongue carcinoma patients in the form of DFS and 5-yr survival. Secondary aim of the study is to analyse the outcome of such patients who were not given EBRT. Materials and Methods: A set of 100 patients of T1/2 N0 anterior two-third tongue carcinoma patients were chosen retrospectively who were treated in Radiotherapy department of GCRI, Ahmedabad in the period of 2009 to 2010. Surgery was done in all patients in the form of hemiglossectomy with Lymph node dissection (MND/SOHND/RND). All patients with pathological stage T1/2N0 and any of the adverse features like depth of invasion ≥4mm, margins<5mm or number of lymph nodes dissected <25 or LVI/PNI +ve were considered for adjuvant radiotherapy. EBRT dose 60 Gy/30 fr @ 2 Gy/fr was given to all the patients in a period over 6 wks. The DFS, 5-yr survival and toxicity were analysed in all the patients. Results: Results of the study are being compiled and will be presented in the conference.

Abstract: 294

Case report of two cases of primary oral malignant melanoma

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

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

Background: Malignant melanomas of oral cavity are rare and aggressive tumors accounting for 0.5% to 1% of all melanomas. Because of delay in diagnosis and early invasion, oral cavity melanoma has poor prognosis and the 5 yr OS is approximately 0-15%. Aim: There are very few cases of primary oral malignant melanoma reported till date. Management protocols of these cases were widely variable. Due to rarity of this malignancy, no randomized trials have been conducted till today to compare the various treatment modalities. Because of this, establishment of any standard of care for malignant melanoma is still a controversy. Thus we are presenting 2 cases of oral malignant melanoma treated in our institution for its rarity and variable management protocol. Case 1: A 24 year old male reported with an ulcero-proliferative growth involving the right gingivobuccal sulcus extending from molars to retromolar trigone with erosion of wall of maxillary sinus and multiple right neck nodes. Biopsy of the lymph node showed metastatic melanoma. Patient underwent right partial maxillectomy and radical lymphnode dissection in our institute. On the basis of post-op HPE, final diagnosis was malignant melanoma right upper alveolus pT4aN2bM0 with mucosal margin and bony infiltration. Patient was planned on radiotherapy of 40 Gy/15fr and is still on treatment. He is tolerating RT well. Case 2: A 50yr old male reported with an exophytic growth present in the upper gingiva extending into the hard palate with mobile, non-tender and hard level Ib lymph node on left side of neck. FNAC of the lymph node revealed metastatic melanoma. After the entire workup the final diagnosis was Malignant Melanoma upper alveolus T4aN2aM0. Patient received EBRT of 30 Gy/10fr to face and neck on telecobalt in February 2011 followed by Cap. Temozolamide and Inj. Interferon- alpha. With this therapy, patient was stable for a year post which he recurred and was given supportive treatment. Conclusion: Treatment of oral malignant melanoma is still controversial. Though primary modality is considered to be surgical excision with neck node dissection, there seems to be a high risk of local recurrence. The role of adjuvant therapy and treatment in case of unresectable disease is still a topic of debate. The advent of radiotherapy and increasing understanding of tumor immunology has introduced many options for treatment. Further multicenter studies are needed to derive the best treatment protocol.

Abstract: 295

Evaluation of concurrent capecitabine versus concurrent cisplatin in locally advanced head and neck squamous cell carcinoma undergoing radiotherapy

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J. Gaur , M. L. B. Bhatt, S. Singh, D. Kishan, V. Raturi, M. Saha

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

Background: Concurrent cisplatin is a standard of care in most of the loco-regionally advanced head and neck squamous cell carcinoma (HNSCC) patients. As this treatment leads to more toxicity, molecule with less toxicity and equal efficacy can be a better substitute. Oral fluoropyrimidine (capecitabine) preferentially generate 5-FU in tumor tissue and mimic continuous-infusion 5-FU. The impact of radiation-induced toxicity on quality of life and treatment compliance justifies the use of capecitabine in concurrent chemoradiotherapy. Aim: The aim of study was to assess the efficacy and safety of concurrent capecitabine over concurrent cisplatin in locally advanced squamous cell carcinoma of the head and neck. Materials and Methods: A randomised control study was conducted to evaluate the response of concurrent capecitabine to concurrent cisplatin in HNSCC in Uttar Pradesh, Lucknow. 42 HNSCC patients with loco-regionally advanced stage (Unresectable stage III or IV disease without distant metastases) registered between July 2014 to July 2015 were enrolled in the study. All patients received three cycles of paclitaxel and cisplatin based neoadjuvant chemotherapy in both arms. Patients were randomly assigned to receive either concurrent cisplatin (35 mg/m΂ weekly) from the first day of radiotherapy to a total of 7 cycles (Arm I-23 patients) or capecitabine (750 mg/m΂ in two divided doses) from day 1 till completion of radiation on treatment days only (Arm II-19 patients). Results: Clinical response was similar in both the arms of study. Variables indicating the quality of life of the two groups were compared. Patients in Arm II had significantly higher quality of life & less treatment-related acute toxicity as compared to those in Arm I. Conclusion: These results have thoroughly substantiated the contention that concurrent chemoradiation with capecitabine may be regarded as an effective and well-tolerated regimen in the treatment of the patients with locally advanced head and neck cancer with similar response rate and reduced toxicity as compared to synchronous cisplatin chemotherapy. Long term outcome on disease control and survival needs to be evaluated and a study on larger patient population needs to be done to confirm the above.

Abstract: 296

Radiation associated patterns of dysphagia in head and neck cancer: Is it tumor site specific?

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R. K. Grover , P. Jeyaraj, P. Negi, U. B. George, J. Sachdeva

Christian Medical College and Hospital, Ludhiana, Punjab, India, E-mail: [email protected]

Background: Carcinoma Head and neck represents one of the commonest tumor worldwide especially in Asia where most patients present in locally advanced stage. Among various treatment modalities available, organ-preservation protocols using radiation or concurrent chemoradiation (CRT) has become the standard of care for locally advanced stage. However, radiation therapy has been associated with early and late tissue toxicities with dysphagia being the most common quality of life issue and has been observed to affect upto 50%-64% of patients after chemoradiotherapy. Among various instrumental methods, Modified barium swallow study (MBSS) is most commonly used for swallowing dysfunction. Hence, this study was done to find out the association of dysphagia with the primary tumour site following treatment with radiation therapy alone or concurrent chemoradiation using MBSS. Aim: To explore the relationship between radiation associated patterns of dysphagia and primary tumor site using MBSS. Materials and Methods: Head and neck cancer patients who were treated with radiation or CRT and fulfilled the Inclusion - Exclusion criteria, were taken for MBSS test after taking informed consent. MBSS was done to assess swallowing dysfunction at baseline before starting treatment followed by repeat MBSS at 3 months and 6 months after completion of treatment. Results: A substantial increase in number of patients with dysphagia at 3 months following treatment was observed on MBSS as compared to baseline. However, there was decrease in number of patients with dysphagia at 6 months follow up. It was also seen that all patients with primary in oral cavity and hypopharynx had dysphagia at 3 months as compared to presence of dysphagia in approximately 3/4th and 1/2 of patients with primary in oropharynx and larynx respectively (p = 0.04). Conclusion: Tumor related factors i.e., location of the primary tumour significantly affects swallowing function following treatment. Following RT or CRT, there is significant increase in swallowing dysfunctions specially increased risk of silent aspiration which can be life threatening. Hence, we conclude that understanding the trajectory of post - CRT dysphagia is of utmost importance in order to tailor patients expectations and to identify and treat patients who are at risk of protracted swallowing difficulties.

Abstract: 298

Adult rhabdomyosarcoma: A rare head and neck malignancy

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N. Kathiresan , K. N. L. Jayakumar

Government Medical College, Trivandrum, Kerala, India, E-mail: [email protected]

Background: Adult rhabdomyosarcoma is a rare and highly malignant neoplasm. Head-and-neck and extremities are the common sites. There are significant incidences of metastases also. In spite of its aggressive nature and poor prognosis, multimodality treatment including surgery, chemotherapy and radiotherapy has markedly increased the survival in diagnosed cases. Case Report: We report a case of a 29-year-old male who presented with a seven month history of nasal discharge, right-eye swelling, and nasal obstruction. On examination, he had right-eye proptosis and periorbital oedema. Magnetic Resonance Image (MRI) study of the head revealed a mass in the sinonasal complex right orbit extending to the base of the skull. The patient underwent rhinotomy orbitotomy and maxillectomy for maximum debulking after biopsy of the lesion. Histopathologically it was reported as malignant small round cell neoplasm. A diagnosis of rhabdomyosarcoma was confirmed by positive staining for myogenin, desmin and synaptophysin. He received a combination chemotherapy with VAC (vincristine, adriamycin and cyclophosphamide) alternating with IE (ifosfamide and etoposide) regimen after metastatic workup. Radiation treatment with 50.4 Gy in 28 fraction was given after completion of 3 cycles of VAC and 3 cycles of IE. Follow up MRI of the head and neck, three months after the start of chemotherapy showed complete disappearance of tumour mass. The patient is planned for completion chemotherapy with three more cycles of VAC and IE. Conclusion: Adult rhabdomyosarcoma is a rare diagnosis with very less number of cases reported all over the world. Despite its poor outcome and severe complications, adequate local control may be attainable with multidisciplinary treatment and proper supportive care. There is high chance of systemic metastases and patients should be kept under followup.

Abstract: 302

Association of polymorphism in X-ray repair cross completmenting-1 gene in laryngeal carcinoma and its association with treatment response

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V. Raturi , J. Gaur, D. Kishan, R. Singh, M. Saha, M. Suhel,

P. Katepogu, M. L. B. Bhatt

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

Background: The protein encoded by XRCC-1 gene is involved in the efficient repair of DNA single-strand breaks formed by exposure to ionizing radiation and alkylating agents. A SNP (Single Nucleotide Polymorphism) is a specific type of allele caused by a small genetic change, or variation that occurred generations ago within a DNA sequence. They are highly abundant, stable and distributed throughout the genome. In this study we have focused on polymorphisms of XRCC1 with greater allele frequencies: a G - A substitution at position 28152 of the XRCC1 gene (codon 399, exon 10). Aim: To study the association of genetic polymorphisms of X-ray Repair Cross Complementing -1 Gene inlaryngeal cancer & it's association with treatment response to chemoradiotherapy. Materials and Methods: Ethanol was obtained from Bengal Chemicals, India, Dimethyl sulfoxide (DMSO), Agrose powder, boric acid crystal and tris buffer were obtained from SISCO Rsearch Laboratories Pvt. Ltd (SRL), Mumbai, Maharashtra, India.10X buffer, MgCl 2 , dntps, Forward Primer, Reverse Primer, Taq Polymerase for PCR amplifications were obtained from MBI Fermentas, Germany. EDTA (Ethylene Diamine Tetra Acetic Acid) were obtain from Ranbaxy, New Delhi. Genomic DNA isolation kit was obtained from QIAGEN, Genetix Najafgarh Road, New Delhi. Restriction Enzyme and its buffer obtained from MBI Fermentas, Germany. Results: The prevalence of hetero & mutant phenotypes was higher in cases when compared with the controls which resulted in a statistically significant increase in laryngeal cancer risk associated with hetero phenotype of XRCC-1 (O.R. 1.67; 95% C.I: 0.98-2.82) & mutant phenotype (O.R. 0.51; 95% C.I: 0.11-2.43). This increase in risk associated with genotypes of XRCC-1 hetero & mutant phenotype persisted even when the data were adjusted for age, smoking, daily consumption of alcohol, and tobacco chewing in multivariate logistic regression and was statistically significant. Our results showed that XRCC1 G/G enhanced cancer chemo-radio sensitivity to cisplatin based chemo-radiotherapy and prolonged TTP in advanced laryngeal cancer patients. Conclusion: Genotypes of XRCC-1 hetero & mutant are strong pre-disposing factors for Laryngeal cancer. An increase in risk in cases with genotypes of XRCC-1 hetero and with a history of tobacco use or alcohol consumption, clearly.

Abstract: 305
"SMART boost" technique to treat locally advanced squamous cell carcinoma of head and neck how smart is it? A feasibility study

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S. Tandon , S. Rawat, P. Ahlawat, D. Chauhan, M. Pal, R. Khurana, M. Mayank, S. Tiwari

Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India, E-mail: [email protected]

Background: The treatment for head and neck cancer (HNC) has considerably changed from previous conventional fractionation to SIB (Simultaneous integrated boost) IMRT. But despite sincere efforts, these approaches have been associated with comorbidities & locoregional disease recurrence. It has always been necessary to find new and novel ways of treating HNC to gain maximum locoregional control & decrease morbid side-effects both in terms of cost & adverse reactions (acute & long term). SMART (simultaneous modulated accelerated radiotherapy) is one such new accelerated fractionation schedule requiring attention. Aim: To compare early tumour response (3 months post chemoradiation) & acute toxicities between IMRT using conventional fractionation & IMRT using SMART boost radiotherapy in locally advanced HNC. Materials and Methods: Forty patients were recruited in the study, divided equally in two arms - standard control arm & study arm. In the conventional fractionation IMRT arm (Arm A), patients received doses 70 Gy/35 #, 63 Gy/35# and 54 Gy/35# to PTV 1, PTV2 and PTV3 respectively. In the SMART boost IMRT arm (Arm B), patients received 60 Gy/25# and 50 Gy/25# to PTV1 and PTV2 respectively. Weekly Cisplatin 40 mg/m2 was given concurrently in both arms. The endpoints were early tumor response & acute toxicities. Results: Heterogeneity analysis showed that both the arms were comparable in their patient and disease characteristics. The Analysis performed with the data available from 40 patients showed that the complete response rate in ARM B was superior to ARM A (88.2% (ARM B) Vs 52.6% (ARM A); p = 0.024). It was also seen that patient being treated under ARM A had higher statistically significant break in radiation in comparison to ARM B (Mean: 2.45 days (ARM A) Vs 0.35 days (ARM B); p = 0.029). There was no statistically significant difference seen in mucositis, dermatitis, dysphagia, weight loss, assisted feeding, fatigue, xerostomia, dysguesia, hoarseness, vomiting, anemia, neutropenia and thrombocytopenia between both arms. Conclusion: Compared to IMRT using conventional fractionation schedule, IMRT using SMART boost technique provides superior early tumour response without increasing acute toxicities. The added potential advantage with this schedule is overcoming tumour repopulation by early completion of RT & lesser breaks in treatment required. Hence, we conclude SMART boost technique may increase the early tumour control rate in shorter duration.

Abstract: 306

Incorporation of tumour volume data in predicting early outcome in locally advanced head and neck cancer treated with definitive chemoradiation

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P. Ahlawat , S. Rawat, A. Kakria, M. Pal, G. Gupta, D. Chauhan, R. Khurana

Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India, E-mail: [email protected]

Background: T classification in TNM staging system depends mainly on the measurement of maximum single dimension of the primary tumour. Head and neck tumours are 3-dimentional structures not only spreading into different planes and directions but also with unequal rate of spread/invasion/infiltration into the tissues. Hence the largest diameter of tumour measured for T classification may not necessarily reflect the true tumour dimensions. Thus, there is a need to take into account certain other features of these tumours other than the maximum single dimension which can reflect the total tumour burden more accurately. Aim: To analyze the impact of primary tumour volume (PTV), total nodal volume (TNV) and total tumour volume (TTV) on early treatment outcome (at 3 months post definitive chemo-radiation) in patients with locally advanced head and neck squamous cell carcinoma. Materials and Methods: It is a single institutional prospective correlational study including 60 patients with locally advanced squamous cell carcinoma treated with definitive CCRT. Response evaluation was done at 3 months after completion of definitive CCRT and based on response were categorized either complete response or residual disease. Results: Of 54 patients analyzed, 27 (50%) were found to have complete response and remaining 27 (50%) were found to have residual disease. Patients who did not have complete remission at 3 months evaluation were found to have larger tumour volume compared with those patients who achieved CR. There is significant inverse correlation between PTV and response at 3 months (p = 0.001). Similarly, there is significant inverse correlation between TTV and response at 3 months (p < 0.001). ROC curve analysis done showed PTV of <41cc and TTV of <42cc predicted CR. Conclusion: Tumour volume, particularly PTV and TTV are powerful predictors for 3 months post chemo-radiation response evaluation. Hence, PTV and TTV should also be taken into account in prognostification.

Abstract: 316

Hypothyroidism post external beam radiation in head and neck cancer with a cobalt-60: An institutional experience

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V. R. Kota , R. K. Singh, S. Devi, G. K. Sinha, M. Geeta

Indira Gandhi Institute of Medical Sciences, Regional Cancer Center, Patna, Bihar, India, E-mail: [email protected]

Background: In developing countries like India patients are treated with cobalt-60, being head and neck cancer one of the most common cancers treated with radiation; hypothyroidism seems to be the long term complication. Aim: We evaluated the incidence of hypothyroidism in patient treated with radiation to head and neck cancer which includes thyroid gland in radiation portal. Materials and Methods: This is a single center non randomized prospective study of 126 patients of head and neck cancer stage III and IV, receiving radiotherapy. Thyroid function tests were measured at baseline and at 4 months and 9 months following radiotherapy. Results: Of the 126 patients, 101 (80.1%) were males and twenty five (19.9%) were females. All patients received radiation to neck by EBRT. 38.2% received concurrent chemotherapy. Six patients had undergone previous neck dissection. Forty-one (32.7) patients were found to have clinical hypothyroidism. Nine (7.1%) patients were found to have subclinical hypothyroidism with a total 50 0f 126 (39.8%) patients developing radiation induced hypothyroidism. Twenty six of 41 patients with clinical hypothyroidism were in age group of 51-60 years. Eleven of 46 patients who received chemo radiation and thirty of 80 who received RT alone developed clinical hypothyroidism. All patients received more than 44 Gy with portals including whole of thyroid. Conclusion: Hypothyroidism is an under recognized in external beam radiation to neck. Early follow up is needed for preventing and managing complications. The timing of regular follow up and how long should be validated in further larger studies.

Abstract: 320

Management of head and neck cancer in geriatric patients: A retrospective analysis

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Meka Geeta , V. R. Kota, R. K. Singh, S. Devi, D. K. Sinha, R. Madhawi

Sri Aurobindo Medical College and Post Graduate Institute, E-mail: [email protected]

Background: In India geriatric cancer population is on increasing trend since the past few years. Aggressive treatment is not always considerable due to ageing process and physiological alterations along with other co-morbidities like cardiovascular disease, endocrine disorders, pulmonary disorders and cerebrovascular disorders. Aim: This is a retrospective analysis of tolerance and toxicity of radiation treatment with or without concurrent chemotherapy in elderly head and neck cancer patients. Materials and Methods: This study has been done from records of cancer patients who attended radiotherapy outdoor during January 2009 to December 2013 with total of 183 patients aged ≥60 years. Results: Median age group of elderly were 65 years (60-88). 77% (141/183) were Males with 22.9% (42/183) females. There were no major differences in the aspects of histology, staging. Performance status were as follows ECOG 0-13.6%, 1-22.4%, 2-35.5%, 3-28.4%. Smokers males-57.9% (106/183) and females-13% (24/183). Stage 1-10.3% (19/183), 2-28.9% (53/183), 3-39.3% (72/183), 4-21.3% (39/183). Out of 150/183 radical treatment 62% were EBRT (radiation) only vs 38%concurrent chemoradiation (cisplatin 30 mg/m2 or carboplatin 100 mg/m2) in elderly patients. 18% (33/183) received palliative radiation for symptomatic relief and 18% were defaulters of treatment. Major defaulters were due to higher toxicities with concurrent chemo. 21% (12/57) had grade 3 toxicities with concurrent chemotherapy vs 14% (21/150) in only radiation modality. Majority tolerated treatment well. Conclusion: Elderly patients tolerated well with radiation therapy. However concurrent chemoradiation had increased toxicity which were manageable. Multi-institutional trial addressing this population be needed to assess outcomes of the treatment.

Abstract: 321

Treatment outcome of intensity modulated radiotherapy in head and neck cancers

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P. Archana , M. Nagarajan, A. Rajkumar, R. Mohanraj, V. Nagarajan, T. Sundaram, T. P. Chellapandiyan, T Balaji

GKNM Hospital, Coimbatore, Tamil Nadu, India, E-mail: [email protected]

Background: The aim of this study is to retrospectively analyse the results of IMRT in a series of 100 Head and Neck cancer patients treated between January to December 2011 in our cancer center. Materials and Methods: 100 patients of Head and Neck cancer treated with radical intent by inverse planning IMRT were included in this study. The prescribed dose was 66 Gy for Radical RT, 60 Gy for Adjuvant RT and 50 Gy for re-irradiation. IMRT was given either alone, with concurrent chemotherapy, adjuvant chemotherapy or Neo-adjuvant chemotherapy. Clinico-radiological response at 2 months post RT, median follow up, time to local recurrence and distant mets were analysed. Results: 83% of patients were males. Median age was 60 years. Majority of tumours were of oral cavity (34%). Other sites included Oropharynx (20%), hypopharynx (22%), larynx (15%), salivary glands and others (9%). 72% of patients were tobacco users and 56% were alcohol users. Most of the tumours were T2 (44%), N1 (40%). RT was given as Radical RT to a dose of 66 Gy in 79% of the patients and Post OP RT to a dose of 60 Gy in 21% of the patients. 91% of the patients had chemotherapy. Average duration of RT was 47days for radical RT and 45days for Adjuvant RT. Clinico-radiological response at 2months post radiation showed a Tumour response of CR-81%, PR-14%, SD-5%; Nodal response of CR-75%, PR-19%, SD-6%; Overall response of CR-80%, PR-15%, SD-5%. Median followup duration was 16.5 months (2-46 mnths). 11% of patients developed recurrence (7% within 2 years and 4% after 2 years of followup). 9% of the patients had mets (6% within 2 years and 3% after 2 years of followup). Conclusion: IMRT is standard of care for the treatment of head and neck cancers either as Radical or post op treatment with or without chemotherapy. Our results are comparable with that of published literature.

Abstract: 322

Evaluation of cytochrome p450 1a1 as a biomarker of head and neck cancer patient and it's correlation with response to chemoradiation

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M. Saha , M. L. B. Bhatt, D. Parmar 1 , R. Gupta, K. Srivastava, S. Gupta, S. Singh, R. Kumar

King George's Medical University, 1 Indian Institute of Toxicology and Research, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Background: Head and neck Squamous cell carcinoma (HNSCC) are the most common cancers in developing countries, especially in Southeast Asia. Tobacco use and alcohol consumption are the most important causes in development of HNSCC. Tobacco users are exposed daily to a large variety of carcinogenic compounds present in tobacco that are detoxified by various xenobiotic enzymes. Cytochrome P450 1A1 (CYP1A1) is one of the most important phase 1 enzyme of detoxification. This enzyme is expressed by both normal as well as tumour tissue. So high activity of CYP1A1 enzyme is detected by high expression of mRNA in blood lymphocytes in HNSCC patients. Aim: To study the expression of Cytochrome P450 1A1 (CYP1A1) mRNA and the effect of treatment response with alterations of mRNA expression in circulating Cytochrome P450 1A1 (CYP1A1) in peripheral blood lymphocytes of HNSCC patients. Materials and Methods: Prospective study was conducted on 30 patients of HNSCC registered in our institute from July 2014 to July 2015. We analysed expression of CYP1A1 mRNA of patients before treatment and just after completion of treatment. All patients were treated with chemoradiotherapy comprising of 70 Gy radiation in 7 weeks by shrinking field technique with concurrent cisplatin (35 mg/m2 weekly). Results: All 30 patients of HNSCC (tobacco users) showed at least 2 to 5 times higher level of CYP1A1 mRNA expression before treatment as compared to control (p < 0.05). Sharp fall in mRNA expression (p < 0.05) in blood was seen in patients who has shown good response to CRT and this fall was significantly higher as compared to patients having less response to CRT (p < 0.05). Conclusion: All Patients had shown very high level of CYP1A1 mRNA expression as compared to control. This was significantly decreased in patients who showed good response to CRT as compared to partial response to CRT. So it can be used as a prognostic marker, though further studies are required to validate this findings on a larger patient population.

Abstract: 331

Prophylactic nodal doses in head and neck cancers treated with IMRT: Results of matched pair analysis

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G. Lavanya , V. Murthy 1 , S. Kannan 1 , T. Gupta 1 , S. G. Laskar,

A. Budrukkar, J. P. Agarwal

Tata Memorial Hospital, 1 ACTREC, Tata Memorial Centre, Mumbai, Maharashtra, India, E-mail: [email protected]

Background: With the use of IMRT in head & neck cancer, it has been observed that there is a wide variation in the definition of prophylactic nodal target volumes & dose prescriptions. It is important to evaluate the appropriate doses to these regions to improve the therapeutic ratio by reducing doses to organs at risk (OARS) such as parotids & thyroid gland to improve quality of life. Aim: To evaluate & compare the isolated regional recurrences (IRR) & dose reduction to the parotid & thyroid glands depending on the dose received by the elective nodal regions (60 Gy vs 50 Gy) in patients treated with IMRT. Materials and Methods: We conducted a matched pair analysis of two groups of non nasopharyngeal head & neck squamous cell carcinoma (HNSCC) patients treated with IMRT prospectively in which one group received 60 Gy to the elective nodal regions where as another group received 50 Gy (ENI60 & ENI50 groups respectively). Matching was done in a 1:1 ratio with baseline characteristics. Ninety seven patients were eligible for the study. We evaluated & compared the rates of IRR in both the groups & dose reduction to the OARS. Results: The 3 year locoregional control was 76.8% & 70% in ENI60 & ENI50 respectively (p-0.78). There were no IRR in the ENI regions in either of the groups. The mean ipsilateral parotid doses in ENI60 was significantly higher compared to ENI50 (42 vs 35.7 Gy, p-0.03) whereas there was no significant difference in the mean contralateral parotid doses (32.5 vs 31.7 Gy, p-0.6). Similarly, the mean thyroid doses were high in ENI60 as compared to ENI50 (54.7 vs 43.3 Gy, p value < 0.001) There was a significant difference in the ipsilateral parotid SEF ratios at 1 year (p-0.03), the SEFs were poorer in ENI60 group patients with higher mean parotid doses (p-0.009). There was no difference in the mean SEF ratios of the contralateral parotid gland. The time taken for improvement in the SEFs was significantly shorter in ENI50 group as compared to ENI60 group although the values equalized at 2 years. At 2 years, 26 patients (54%) in ENI60 group & 13 patients (26.5%) in ENI50 group developed biochemical hypothyroidism (p-0.007). Conclusion: Doses of 50 Gy equivalent are sufficient to sterilize the uninvolved nodal regions as the rates of IRR are extremely low. There is a significant dose reduction to the ipsilateral parotid gland & the thyroid which in turn improves the salivary function & thyroid functions respectively.

Abstract: 336

Neoadjuvant chemotherapy followed by concurrent chemoradiation versus concurrent chemoradiation in locally advanced head and neck cancer: A prospective study to assess the toxicity pattern and effect on quality of life

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S. Kapoor , M. L. B. Bhatt, S. Kumar, S. Gupta, S. Singh, K. Srivastava, R. Mishra 1 , R. Kumar

King George's Medical University, 1 Sanjay Gandhi Post Graduate Institute, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Background: Head and neck cancer (HNC) refers to a group of biologically similar cancers originating at different sites in the upper aero digestive tract. Head and neck consist of oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx Risk factors of head and neck includes tobacco use, frequent and heavy consumption of alcohol, prolonged sun exposure, Human papillomavirus (HPV), Epstein-Barr virus (EBV), Poor oral/dental hygiene, Environmental/occupational inhalants, Poor nutrition, premalignant lesion like leukoplakiaMost important prognostic factors are T and N status. Probability of Cervical lymph node involvement depends upon the site of the lesion and T status. Aim: To compare sitewise toxicity pattern and effect on quality of life in unresectable squamous cell Head and Neck Cancer undergoing neoadjuvant chemotherapy followed by chemoradiation versus chemoradiation alone. Materials and Methods: Between June 2013 to June 2014, total 133 patient of locally advanced head and neck cancer undergoing neoadjuvant chemotherapy followed by chemoradiotherapy (groupI) or chemoradiotherapy (groupII) alone were included in this study. Toxicity was graded according to RTOG criteria. Quality of life in both the group assessed by using a questionaire as a tool according to Functional Assessment of Cancer Therapy- Head and Neck Version 4 (FACT version 4 H & N). Results: Patient of locally advanced HNC treated with CRT has 58% grade III mucositis V/s 66% in another group treated with NACT followed by CRT. Group I patients has 15% grade III and IV skin reaction while group II has 10%. Quality of life and was better in Concurrent Chemoradiation arm in compared to another arm. Conclusion: Concurrent chemoradiation is main modelity of treatment in locally advanced HNC in term of better quality of life and less toxicity.

Abstract: 337

Prospective randomized study of concomitant chemoradiation in locally advanced head and neck carcinoma comparing conventional fractionation versus hyperfractionated accelerated irradiation

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S. Ghosh , K. Bhanja Chowdhury, A. Basu, K. Ghosh, K. Sazzad Manir, C. Dasgupta, S. Gangopadhyay

R. G. Kar Medical College, Kolkata, West Bengal, India, E-mail: [email protected]

Background: Locally advanced squamous cell carcinoma of head and neck (LAHNSCC) constitutes a considerable burden of disease worldwide. Concomitant platinum based chemoradiotherapy remains the standard of care as a radical treatment modality for LAHNSCC. Despite this, locoregional failure remains a major cause of death. Altered fractionation with or without chemotherapy is another viable option in these patients. Hence we studied hyperfractionated accelerated radiotherapy with concurrent cisplatin in comparison to conventional chemoradiation in LAHNSCC. Aim: To compare the locoregional response, toxicities and progression free survival (PFS) between concurrent chemoradiation using hyperfractionated accelerated radiotherapy versus conventionally fractionated radiotherapy. Materials and Methods: Between February 2014 to July 2015, a total of 80 patients of locally advanced inoperable head and neck squamous cell carcinoma (stage III & IVA) were accrued for this study and randomized into two groups: Arm A receiving external beam radiotherapy 72 Gy in 60 fractions over 6 weeks (1.2 Gy per fraction b.i.d.) and Arm B receiving 70 Gy in 35 fractions over 7 weeks. In both arms patients received concurrent cisplatin 30 mg/m2 weekly. Radiotherapy in both arms was delivered by Theratron 780 E cobalt-60 machine. Results: 32 patients in Arm A and 31 patients in Arm B completed treatment and were available for response assessment by using RECIST v1.1. Toxicities were analyzed using CTCAE v4.0 and RTOG late radiation morbidity criteria. Median follow up period was 6 months (range 1 to 16 months). Median treatment duration in arm A was 51 days (42 to 74 days) and Arm B was 54 days (51 to 69 days). Complete response rate at the end of study was better in Arm A (n = 17) in respect to Arm B (n = 14), p value 0.87. Acute oral mucositis was higher in Arm A than in arm B, p value 0.027. Higher grades of xerostomia, dysphagia and cutaneous toxicities were in arm A but were not statistically significant. There was no significant difference in late radiation toxicity between the two arms. Mean PFS was comparable in both arms (p value 0.89, log rank test). Conclusion: Hyperfractionated accelerated radiation schedule with weekly concurrent cisplatin is comparable to conventional chemoradiation with weekly cisplatin in terms of locoregional control with more acute toxicity within acceptable limit. However, large prospective study with long follow up needed to validate this issue.

Abstract: 350

Metabolic tumor volume as a predictor for survival among recurrent head and neck cancer patients undergoing cyberknife stereotactic re-irradiation

th
T. Basu , T. Kataria, S. Goyal, D. Gupta, A. Abhishek, S. Bisht, K. Narang

Radiation Oncology, Medanta - The Medicity, Gurgaon, Haryana, India, E-mail: [email protected]

Background: There are established guidelines for baseline diagnosis and post treatment surveillance with PETCT parameters like standardized uptake value (SUV), metabolic tumor volume (MTV) and Total lesion glycolysis (TLG) among primary head and neck cancer (HNC) patients. The same remains controversial and experimental among post irradiation recurrent HNC. Aim: To analyze PETCT parameters correlating response and survival among post RT recurrent HNC (rHNC) undergoing Cyberknife stereotactic irradiation. Materials and Methods: Thirteen (13) patients with post RT recurrence undergoing Cyberknife stereotactic radiotherapy were analyzed. There were 10 male and 3 female patients with median age 59 years (range: 31-83 yrs). Six patients had loco-regional recurrences, five had nodal while one each had distant nodal and 2 nd primary HNC. All patients received Cyberknife fractionated radiotherapy alone with median dose per fraction 6 Gy (5-12 Gy) in 5 fractions (3-7 fractions). Pre Cyberknife and post treatment at 10-12 weeks PETCT parameters were calculated and median values of PET parameters were used as cutoff for assessing their prognostic potential through Chi sqaure test, Cox regression analyses and Pearson's correlation respectively. Results: Among the 13 rHNC patients the median values of PETCT SUVmax, MTV and TLG pre and post therapy were 14.5/6.19, 25.5/1.43 and 155.03/7.42 respectively. The median reduction in SUV, MTV and TLG pre and post Cyberknife were 21.1, 69.2 and 72.8% respectively. With a median gap of 18 months (3-77 months) between 1st and 2nd RT, the median recurrent gross tumor volume (GTV) was 32.6 cc (9.2-243 cc). At median follow up of 9 months post Cyberknife, 6/13 patients had loco-regionally stable disease. Chi square test and likelihood ratios between median pre therapy and post Cyberknife showed median pre therapy MTV to be statistically significant (p = 0.04). The likelihood ratios for median reduction in SUVmax, MTV and TLG and post CK response also revealed MTV and TLG to be closer to statistical significance (p = 0.06). The Pearson's correlation between median PETCT parameters and median GTV volumes were positively correlated though statistically non-significant. Conclusion: PETCT parameters like MTV and TLG has definite role among patients for rHNC and can predict response to re-radiation and overall survival. Future prospective studies needed with larger population and serial measurement.

Abstract: 351

Image guided intensity modulated radiotherapy in recurrent and second primary head and neck cancers: Our institutional experience

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S. Srinivasan , S. Gupta

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

Background: Primary treatment for advanced stage head and neck cancer is generally a combined modality approach that includes surgery, radiation therapy, and chemotherapy. Despite combined modality treatment local persistent or recurrent disease is the primary cause of treatment failure in 30%-50% of patients with advanced head and neck cancer. Also there is a risk of 25% at 5 years to develop a second primary head and neck cancer. Management after recurrence includes salvage surgery. Role of reirradiation is feared because of increased risk of acute toxicity due to previously irradiated target volume. In our present study we evaluated reirradiation by IG-IMRT in recurrent and second primary head and neck cancers and its clinical outcome. Materials and Methods: 24 patients between January 2009-August 2014 with recurrence or second primary in head and neck cancer were treated by IG-IMRT technique.13/24 patients had second primary and 11/24 had recurrence. All 13 patients had metachronous second primary. Most common site of recurrence/second primary was oral tongue (5/24), followed by oropharynx (4/24) and 2 patients had nodal recurrence. Time interval between initial radiotherapy and reirradiation ranged from 8 months to 17 years. Salvage surgery preceeded radiotherapy in 10 patients. 9/24 patients received concurrent chemotherapy. PTV included Clinical Target volume with a margin. No prophylactic nodal irradiation was done. Results: PTV volume of reirradiation ranged from 26.72cc to 469.32 cc (median 118.71 cc). PTV dose ranged from 45-70.3 Gy with median dose 60 Gy. The most common acute side-effect was mucositis. Toxicity was more in patients receiving concurrent chemoradiation and in patients with less interval time between reirradiation. Out of 24 patients 9 are NED, 8 patients expired (5 disease progression, 2 comorbidities and 1 due to hematemesis after development of third primary), 2 recurred, 1 developed distant metastases and 4 lost to follow up. Conclusion: Locoregional recurrences after radiotherapy in head and neck cancer represent a challenging clinical problem. Surgical resection, with or without re-irradiaton provides the highest likelihood for successful salvage. Toxicity during irradiation is an important issue. Patients re-irradiated after a long time from initial irradiation have better tolerance compared to patients irradiated after shorter intervals.

Abstract: 352

An audit of adjuvant radiotherapy in post-operative squamous cell carcinoma of oral cavity: A single institutional experience

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S. Rath , R. Khurana, S. Sapru, R. Hadi, M. Rastogi, K. Sahni

Dr. Ram Manohar Lohia Institute of Medical Institute, Lucknow,

Uttar Pradesh, India, E-mail: [email protected]

Background: Radiotherapy (RT) after surgery is the recommended treatment for oral cavity squamous cell carcinomas (OCSCC) with high risk features such as T3/T4, N2a or above nodal stage, close resection margins, Lympho-vascular invasion (LVI) and perineural invasion (PNI). In margin positive cases and extra-capsular extension (ECE), there is evidence in literature for Chemo-RT (CRT). Aim: The purpose was to analyze the RT practices and outcomes at a tertiary cancer center. This audit covered the surgical procedures, Surgery-RT interval, RT dose, compliance and toxicity observed in these patients. Materials and Methods: Data of seventy-two patients who received RT at our centre for post-operative OCSCC over 2.5 years period of February 2013 and August 2015 were retrieved. Site wise distribution, tobacco usage, median time to RT, median RT dose, reasons for RT/CRT, RT compliance, median follow up and local and distant failure rates were looked into. Results: Of the 72 patients, 92% (66/72) were males, with median age of 45 years. 56% (40/72) patients were smokers & 63% (45/72) were tobacco chewers. Buccal mucosa, tongue and alveolus were involved in 39% (28/72), 36% (26/72) and 25% (18/72) patients, respectively. 38% (27/72) received neo-adjuvant chemotherapy before surgery. Presence of high risk factors for RT were as follows: 42% had pT3/T4 disease, N2a or above 14%, margins close in 16%, LVI positive in 13% and PNI positive in 34%. ECE was found in 28% cases. The median interval between surgery and RT was 7.3 weeks with 95% receiving RT doses as planned. RT was delayed more than 8 weeks in 27% and more than 6 weeks in 65% cases. 58% patients received CRT. The median time for RT completion was 43 days with treatment breaks in 18% cases.34% patients had mucositis grade III or higher, 20% had grade III or above skin reaction and grade II dysphagia was observed in 21% of patients. Ryle's tube was placed in 23% and parenteral nutritionwas given to 26% patients. Median follow up was 10 months. Local and distant failure was seen in 13.3% and 9.6% respectively. Conclusion: Post-operative RT for OCSCC is well tolerated with acceptable morbidity. However, in a large number of patients interval between surgery and RT was more than 6 weeks.

Abstract: 354

Impact of radiotherapy dose fractionation on laryngectomy and tracheostomy free survival in locally advanced carcinoma larynx: A retrospective analysis

th
G. Muttath , T. Bhattacharyya, J. Jones, K. Ratheesan

Malabar Cancer Centre, Thalassery, Kerala, India, E-mail: [email protected]

Background: Concurrent Chemo radiation is currently the standard of care in carcinoma larynx. RTOG 9111 trial has already shown that CT-RT is better than induction chemotherapy followed by radiation and radiotherapy alone in terms of laryngeal preservation. Various SIB schedules have been tried in locally advanced laryngeal cancer. However head to head comparison between different SIB schedules are sparse. Aim: This study aims to show the impact of different SIB schedules on laryngectomy and tracheotomy survival and to assess the laryngeal and pharyngeal toxicities. Materials and Methods: The retrospective audit data was carried out at Malabar Cancer Centre during Januray-2012 to March-2015. A total of 40 patients of locally advanced histologically proven Squamous cell carcinoma of larynx were included in this study. These patients were treated with either concurrent chemo radiation or radiotherapy alone. The different dose fractionations used were 69.3 Gy in 33 fractions& 70 Gy in 35 fractions. The laryngectomy and tracheostomy free survival and the laryngeal and pharyngeal toxicities were analyzed from case records. The descriptive data analysis was performed to explore the laryngeal and pharyngeal toxicity level. The Cox-PH model was adopted to perform the survival analysis. All the statistical analysis has been performed on software SPSS version 16. Results: The median age group of the patients was 61 years. Most of the patients belong to T3 stage (75%) and N2 (42.5%) stage respectively. A majority of the patients were treated with 69.3 Gy in 33 fractions. Most of patients (54.3%) suffered from Grade 3 pharyngeal toxicities and grade 3 laryngeal oedema was seen in 28% patients. In 69.3 Gy/33# group 18.5% and 11% patients underwent tracheostomy and laryngectomy respectively. In 70 Gy/35 # group tracheostomy was done in only 11% cases. Laryngectomy was not required for anyone in 70 Gy group. Laryngeal oedema was higher in the 69.3 Gy arm (27%) as compared to 70 Gy arm (17.6%). Grade III skin toxicities were significantly higher in the conventional fractionation arm as compared to the hypofractionation one. All other acute toxicities were comparable in both the arms. Conclusion: Laryngeal toxicities and laryngectomy rates were higher in the hypofractionation arm. We should be judicious in using this kind of schedule keeping in mind the location of hot spots and its volume.

Abstract: 360

Intensity-modulated radiotherapy in nasopharyngeal carcinoma: An institutional audit

th
N. Mummudi , B. Sasidharan, S. Pavamani

Christian Medical College, Vellore, Tamil Nadu, India, E-mail: [email protected]

Background : Nasopharyngeal carcinoma (NPC) is common amongst adolescent and young adults. More than 70% of patients with NPC present with stage III or IV disease. Radiation therapy with or without chemotherapy remains the definitive treatment. Reported 5 year overall survival (OS) in patients with locally advanced NPC ranges from 65 to 90%. Aim: We studied the treatment, outcome and patterns of care in NPC patients treated with IMRT at our center, over the last four years. Materials and Methods: Forty consecutive patients treated between 2011 and 2015 with IMRT were suitable for analysis. All patients were treated with curative intent and had undergone standard clinical and radiological staging workup. Patient and treatment characteristics were extracted; outcomes and pattern of failure were analyzed using data collected from the electronic medical record and RT chart. Data analysis was done using SPSS software. Institutional ethical review board clearance was obtained. Results: Median age of the cohort was 40 years (range - 9 to 65 years). More than 3/4th were males (77.5%). Non keratinizing undifferentiated carcinoma was the commonest histology (60%). At presentation, 34 patients (85%) had locally advanced (stage III or IV) disease. Ten patients received neoadjuvant chemotherapy. Using SIB-IMRT, 70 Gy/35 fractions (14 patients), 70 Gy/33 fractions (20 patients) or 66 Gy/33 fractions was delivered to the high risk PTV. Concurrent chemotherapy (weekly or 3 weekly Cisplatin) was administered in 35 patients (87.5%). Treatment break of 1 week or more was seen in 20%. Acute skin toxicity was grade 1/2 except for in 1 patient (Grade 3 - 2.5%). Grade 3/4 mucositis was observed in 2.5%/0% of patients respectively. 74% of patients planned for adjuvant chemotherapy completed their schedule. At first follow up post treatment, 34 patients were available for evaluation; 30 (88%) were disease free, 2 had persistent primary, 2 had distant metastases. At a median follow up of 15 months, four more patients developed distant metastases; disease free survival (DFS) was 74%. Conclusion: Our study shows that, good local control can be achieved even in locally advanced NPC. Toxicity profile was not different amongst the different fractionation schedules. The addition of concurrent chemotherapy does not seem to increase the acute toxicity, even when Simultaneous Integrated Boost (SIB) is used. Also, a high percentage of patients completed their scheduled adjuvant chemotherapy.

Abstract: 361

Synchronous dual primary malignancy of urinary bladder and hypopharynx in a 62-year-old male patient; an extremely rare phenomenon

th
R. Reddy , P. Das, B. Subramanian

Sri Venkateswara Institute of Medical Sciences Hospital Cancer Center, Tirupati, Andra Pradesh, India, E-mail: [email protected]

Background: The diagnosis of multiple primary malignancy (MPM) is not very uncommon. Nevertheless synchronous MPM involving urinary bladder and hypopharynx is an extremely unusual event. No such cases have been reported so far in English literature to our review. We report a case of 62-year-old male patient with synchronous dual primary malignancy was treated with a better outcome. Materials and Methods: A 62 year-old-male patient presented with hematuria and later dysphagia to solids. Whole body 18F-Fluro deoxy glucose Positron emission tomography combined with computed tomography (18F-FDG PET/CT) revealed two distinct lesions one in hypopharynx and another in urinary bladder. Biopsy from the urinary bladder mass and the hypopharyngeal lesion suggestive of urothelial carcinoma and poorly differentiated squamous cell carcinoma respectively. Patient was treated with concurrent chemo-radiotherapy to hypopharynx. Results: Following treatment he had improvement of dysphagia. Hematuria which was present before the onset of the treatment was also reduced. Because of severe comorbidities the planned radical cystectomy or radiotherapy were deferred. Currently the patient is in symptomatic remission eight months following treatment. Conclusion : While dealing with a cohort of patients with knownmalignancythis is always customary to keep in mind the possibility of occurrence of a second neoplasm in view of any additional signs or symptoms. Hence a high index of suspicion of second malignancy shouldwarrant an aggressive work up for early detection of malignancy and treatment intervention for an improved outcome. This case is being reported because of its extremely rare occurrence, diagnostic as well as therapeutic challenges being encountered during the management of this rare entity in our clinical practice.

Abstract: 364

Prevalence of high risk human papilloma virus in oral squamous cell carcinoma: A study in Indian population

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N. Akhtar , S. Misra 1 , V. Kumar, N. Hussain 2 , V. Singh 2

King George's Medical University, 2 Dr. Ram Manohar Lohia Institute of Medical Science, Lucknow, Uttar Pradesh, 1 All Insititute of Medical Sciences, Jodhpur, Rajasthan, India, E-mail: [email protected]

Background: Oral squamous cell carcinoma (OSCC) is one of the most prevalent malignancy in India. It ranks number one in terms of incidence among men and third among women. An increased involvement of Human papilloma virus (HPV) in the HNSCC has been reported in past 10 years but its presence is not as consistent in it as in cervical cancers and therefore its actual prevalence is still vague in HNSCC. Aim: Present study aims to explore the prevalence of HPV association in OSCC and its correlation with other risk factors in North Indian population. Materials and Methods: Study Population: A total of 250 clinically and histological proven cases of OSCC were included prospectively in the study between Oct 2013 to Jan 2015. Tissue biopsies were collected in 10% buffered formalin and in 1X phosphate buffer saline (PBS, pH 7.4) and stored at -80΀C for molecular analysis. The demographic and clinical details of the patients were recorded on the standard questionnaire. HPV detection was performed by using Real Time PCR. The Chi-square test was used to compare the dichotomous/categorical variables and unpaired t-test was used to compare the continuous variables. The p-value < 0.05 was considered significant. All the analysis was carried out by using SPSS 16.0 version (Chicago, Inc., USA). Results: The study encompasses 250 cases of OSCC. Out of these HPV presence was confirmed in 23 (9.2%) cases. The mean age of HPV positive patients was 47.17 while HPV negative cases had mean age 47.69, but this difference was statistically insignificant. HPV presence associated significantly with male gender [p = 0.02*, OR (95%CI) =0.34 (0.13-0.83)]. Buccal Mucosa was the most frequent site (52.2%) in patients. Most of HPV positive cases were well differentiated SCC (60.9%), eight cases were moderately differentiated or keratinized while only 4.3% cases showed a basaloid morphology. According to Log rank test median survival of HPV positive patients was better (16.5) compared to HPV negative patients (12.9) but the difference was not significant (p = 0.62). Conclusion: Our findings illustrate that 9.2% OSCC cases harbor HPV in North Indian population which is slightly lower than that observed in previous studies and we report tobacco as a major risk factor in both HPV negative as well as positive cases. Therefore the independent role of HPV in the causation of oral cancer is difficult to evaluate in our case series due to the strong confounding influence of tobacco.

Abstract: 367

Gene environment interactions determining difference in genetic susceptibility to cancer in subsites of head and neck cancer

th
A. Singh , S. S. Maurya, T. Katiyar, A. Dhawan, S. Singh, S. K. Jain, M. C. Pant D. Parmar

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

Background: Head and neck squamous cell carcinoma [HNSCC] is the 6th most common cancer in the world. Tobacco [either in form of chewing or smoking] and alcohol use separately or in combination are the major risk factor for the cancer of head and neck. Combined effects of tobacco and alcohol drinking appear to be more than multiplicative for cancer of oral cavity and pharynx and larynx. Genetics risk factors and more importantly, their interaction with environmental risk factors, may play a critical role in determining susceptibility to malignancies in subsides of head and neck. Aim: To identify the Gene Environment Interactions in determining differences in genetic susceptibility to cancer in subsites of head and neck cancer. Materials and Methods: This case control study included 750 male cases of head and neck squamous cell cancer registered at tertiary medical care centre with equal number of healthy controls from the same ethnic group of north India. Detailed questionniare eliciting past and present history was filled and blood samples were taken from the patients. Genomic DNA was isolated from whole blood using QIAGEN kit PCR- RFLP based methodology were used to detect polymorphism CYP1A1, CYP1B1, CYP2E1 and GIST1 gene. Results: The frequency of smokers was higher in cases compared to those who chewed tobacco or consumed alcohol. Increased frequency of CYP1A12A in cases was associated with a statistically significant increase in the risk of oral cavity, pharynx and larynx cancer. Tobacco smoking significantly increased risk of laryngeal cancer (13 fold), oral cavity cancer (8 fold) in cases with mutant genotype of CYP1A1*2A. Tobacco smokers among cases with the null GTSM1 genotytpe also had an increased risk of laryngeal (11 fold), oral cavity (9 fold) or pharyngeal (8 fold) cancers. Smaller increase in risk (2 to 4 fold) of oral cavity, pharynx and larynx cancers were observed among tobacco chewers. Conclusion : Polymorphism in DMEs not only modify the HNSCC risk, but also influence susceptibility to malignancies of the oral cavity, larynx and pharynx. Variant genotypes of CYPs or the null genotype of GSTM1 was higher in cases of larynx, pharynx or oral cavity cancer compared to the controls. Mutant genotypes of Rsal polymorphism of CYP2E1 was associated with increased risk for oral cavity and pharyngeal cancer.

Abstract: 401

Clinical outcome of patients with carcinoma of the oral tongue treated with a curative intent combined modality treatment: A retrospective analysis

th
A. Menon , K. Beena, R. Anoop, M. Dinesh

Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India, E-mail: [email protected]

Background: The aim of this study was to report the survival, morbidity and the clinico-pathological predictive factors for carcinoma of the oral tongue treated with a curative intent combined modality treatment. Materials and Methods: We retrospectively reviewed the medical records of 72 oral tongue cancer patients treated from January 2004 to December 2010, with curative intent surgery followed by post operative conformal radiotherapy with or without concurrent chemotherapy. Adjuvant treatment was offered to all pT3, T4 and pN+ cases. A few early stage patients (n = 11) were also offered adjuvant treatment in view of adverse risk factors like lympho-vascular emboli (LVE), Peri-neural invasion (PNI) and depth of invasion >8mm. Concurrent chemotherapy was administered if peri-nodal spread and/or positive margins were present. Patient, tumor and treatment related characteristics were recorded. Survival analysis was done using Kaplan-Meier method and the predictors of outcome were identified using uni-variate/multi-variate analysis. Results: The median survival was 104 months with a median follow up of 41 months (1-106 months). The 5 year overall survival (OS) and disease free survival (DFS) were 62.4% and 51.4% respectively. Eighteen patients (25%) developed recurrence of which 9 (12.5%) were loco-regional and 9 (12.5%) were systemic. Uni-variate analysis showed statistically significant reduction in the OS with age <55 years, presence of LVE, node positivity, advanced stage and disease recurrence. However, on multi-variate analysis, only age and disease recurrence were found to be significant. DFS was reduced by presence of LVE, tumor thickness >10 mm and multiple nodes (uni-variate analysis). The late toxicity was less in the IMRT compared to the 3DCRT group. Conclusion: Median survival and loco-regional control was better in our group when compared to other reported data. Younger age and disease recurrence were found to be predictive of poor overall survival. IMRT was significantly better than 3DCRT in reducing the late toxicity, with no difference in local control or survival.

Abstract: 403

A randomised study to compare concomitant boost radiotherapy with concurrent chemotherapy versus concomitant boost radiotherapy alone in management of locally advanced head and neck cancer

th
A. Srivastava , A. K. Arya, P. Kumar 1

Sarojini Naidu Medical College, Agra, 1 Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India, E-mail: [email protected]

Background: Worldwide approximately 600,000 patients are afflicted with head and neck carcinoma. Nearly 60% of this population presents with locally advanced but non- metastatic disease. Radiotherapy alone was long standard non- surgical treatment for locally advanced disease. Radiation dose fractionation has evolved from once daily treatment to hyperfractionation and accelerated hyperfractionation. Aim: To investigate the feasibility of combining concomitant boost radiation regimen with chemotherapy and to assess its toxicity versus concomitant boost alone in locally advanced carcinoma of head and neck. Materials and Methods: Between January 2013 to October 2014, 32 patients with locally advanced head and neck squamous cell carcinoma, who met the eligibility criteria were enrolled. Radiation in both the arms consisted of 72 Gy in 42 fractions over 6 weeks (daily for 3.5 weeks then twice a day after 2.5 weeks). The Boost was given concomitantly during the large field treatment as a second daily (1.5 Gy) fraction, with an interfraction interval of 4-6 hours. Cisplatin 50 mg was given weekly in the study arm with pre-medication and adequate hydration. Tumour and loco-regional status were assessed, and acute late toxicities were graded. Results: 76.7% patients received RT and 76.5% patients received chemoradiotherapy as per protocol or with minor variations. Overall survival after 6 months of median follow up being better in the study arm; 76.4% and 60% in the concomitant boost with chemotherapy versus concomitant boost only (p = 0.95). Disease free survival after 6 months of median follow up in the RT versus CRT arm being 40% and 52.9% (p = 0.95). Acute grade 3 toxicity was seen in 40% patients in the RT arm and in 41.1% patients in the CRT arm. Acute grade 4 toxicity being higher in the CRT arm (17.64%) compared to RT arm (6.67%). Conclusion: This study on Indian head and neck squamous cell carcinoma patients confirms that the use of weekly cisplatin is safe and chemotherapy with Concomitant RT is superior to RT alone resulting in higher locoregional control. Longer duration of study is required to comment on statistical significance.

Abstract: 406

Prognostic factors in early glottic carcinoma and its implication for treatment

th
S. Agarwal , R. Gupta, P. Kumar, A. K. Chauhan, D. P. Singh

Shri Ram Murti Smarak Institute of Medical Science, Bareilly, Uttar Pradesh, India, E-mail: [email protected]

Background: Early glottic laryngeal cancer is a highly curable disease showing excellent localcontrol (LC) rates with either definitive radiotherapy or surgery. However, compared to surgery, radiotherapy has the advantage of organ preservation and consequently better voice quality. For this reason it is regarded as the treatment of choice in early glottis lesions. Aim: The purpose of this study is to retrieve the data of patients of vocal cord carcinoma presenting in our department treated with radiotherapy and study the clinical parameters and their outcomes. Materials and Methods: Retrospective data was retrieved from the patients of vocal cord carcinoma presenting in our department in last four years (from 2011 to 2015). The prognostic parameters analyzed for LC, disease free survival (DFS) & overall survival (OS) were T classification, anterior commissure involvement, posterior third involvement, vocal cord mobility, tumor grade, field size, total RT dose, overall treatment time, and post RT persistent laryngeal edema. Results: Between 2011 and 2015, 14 patients with early squamous cell carcinoma of the glottis were treated with definitive RT at our institution. Only two (14.2%) patients were women. The median age was 52.5 (35-69) years. 71.4%, of the patients had T1a and 14.3% each had T1b and T2 tumors. Six (42.9%) patients each had anterior commissure invasion & posterior third involvement. Vocal cord mobility was present in 8 patients & absent or restricted in 3, while it was not specified in 3. 42.9% each had grade 1 & 2 tumors while 14.3% patients had grade 3 tumors. Prior to RT 1 patient had undergone vocal cord stripping and 1 cordectomy. A mean dose of 70.14 Gy (70-72) Gy was given over a mean period of 51.14 days (46-63). 2 (14.2%) patients had persistent laryngeal edema post RT. 2 patients showed recurrence over a mean period of 11.7 months. 85.7% patients had disease free survival with a mean follow up of 19.35 months. Conclusion: In patients with early glottic carcinoma, T classification proved to be the only independent prognostic factor affecting LC after primary radiotherapy according to the results of this study.

Abstract: 429

Prospective clinico-dosimetric evaluation of fatigue among head and neck cancer patients treated by IMRT

th
T. Basu , T. Kataria, S. Goyal, D. Gupta, A. Abhishek, S. S. Bisht,

K. P. Karrthick

Medanta - The Medicity, Gurgaon, Haryana, India, E-mail: [email protected]

Introduction: Fatigue has always been a distressing symptom for patients of head and neck cancer (HNC) on radiotherapy. Improved radiation delivery through IMRT has been instrumental in reducing many of the acute and late side effects. The recent observation of increased fatigue with IMRT has been a concern. Few recent publications hinted at possible correlation with dosage to CNS structures. We have previously published our data on dose received to CNS structures while on IMRT. The current prospective study aims at correlating CNS structures dose with IMRT and Brief fatigue inventory (BFI) scale scores to arrive at an objective criteria to reduce fatigue. Materials and Methods: This prospective analysis comprising of twenty (28) HNC patients receiving either postoperative or radical radiotherapy by IMRT. Patients were administered BFI scale before and after completion of IMRT. The score is a simple Likert type with 0 being no fatigue and 10 being worst fatigue. There were sub-divisions again on a scale of 0-10 on mood, activity and enjoyment of life. CNS structures were additionally contoured besides standard contouring guideline. The main organs contoured in planning CT scan were brainstem and posterior fossa excluding brainstem. The dose received to these organs was recorded. All the data were analyzed using SPSS version 18.0 and Spearman correlation was used to correlate between CNS structures dosage and their relation to fatigue scale score. Results: Among the 28 (male: 20, Female: 8) non nasopharyngeal HNC, 21 received radical radiotherapy and 7 had postoperative radiotherapy. Most of them were locally advanced (25) with median age of 57 years. Most of them had concurrent chemotherapy with Cisplatin being the commonest drug. BFI was available pre and post IMRT for all the patients. 20/28 patients had preexisting fatigue and on a scale of 10, majority reported score 3. Almost all the patients reported post IMRT fatigue with median score of 6. The main affected domain being mood and social life. The dosimetric correlation suggested that Dmax of brainstem and post IMRT fatigue score and worst fatigue score (Spearman correlation: 0.028 and 0.008) and Dmax of post fossa with post IMRT fatigue and worst fatigue score (Spearman correlation: 0.051and 0.033) respectively. It was also noted that higher the dosage to these structures (typically more than 40 Gy) higher the fatigue score. No definite dose cut off and BFI score change could be established. Conclusion: This prospective study shows a possible correlation between CNS structures dose and post IMRT increased fatigue. The future inclusion of dose constrained IMRT for CNS structures would help to establish definite dose point cut off for reducing fatigue. The possible confounding factors like chemotherapy, comorbidities and associated general condition of the patient also needs to be accounted while evaluating fatigue.

Abstract: 436

Efficacy of submandibular gland sparing in reducing xerostomia in locally advanced head and neck cancers

th
P. A. Shah , N. Ashwin, A. Kumar

Cancer Institute (WIA), Chennai, Tamil Nadu, India, E-mail: [email protected]

Background: Xerostomia is one of the most prominent complications in patients with Head and Neck cancers who receive radiation, as it usually involves delivering a high dose to the salivary glands bilaterally. Xerostomia significantly reduces quality of life (QoL) and only parotid gland sparing has shown inconsistent results in improving xerostomia. Materials and Methods: This was a prospective study in which locally advanced (stage III/IV) oropharynx, hypopharynx and supraglottic larynx cases that were treated from January 2015 to April 2015 were included. Out of the 37 patients, 17 were included in the study arm (contralateral SMG spared). Parotid gland sparing was done in both the groups. The mean doses of the contralateral parotid and submandibular glands were kept under 26 Gy and 39 Gy respectively. Xerostomia outcomes were assessed based on RTOG grading and patient rated xerostomia specific QoL questionnaire. Results: The grading for xerostomia (of 2 or higher) at the end of treatment, at 3 and 6 months from commencement of treatment were 76%, 47% and 29% respectively in the study group and 80%, 55% and 45% in the control group. The difference at 6 months was statistically significant (p <0.004) The xerostomia questionnaire scored by the patients at the end of 6 months showed a mean score of 13 in the study arm against a score of 24 in the control arm. Conclusion: Sparing of the contralateral SMG in a selected group of patients of locally advanced head and neck cancers using IMRT is feasible and results in improvement of overall xerostomia outcomes which ultimately can lead to better QoL.






 

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