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Year : 2016  |  Volume : 12  |  Issue : 6  |  Page : 44-65

Head and Neck

Date of Web Publication30-Nov-2016

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How to cite this article:
. Head and Neck. J Can Res Ther 2016;12, Suppl S2:44-65

How to cite this URL:
. Head and Neck. J Can Res Ther [serial online] 2016 [cited 2021 Feb 26];12:44-65. Available from: https://www.cancerjournal.net/text.asp?2016/12/6/44/194968

Abstract: 02

Adaptive radiotherapy for quick assessment of target coverage and optimal sparing of critical structures in rapidly regressing PNS tumor

Anu Tiwari , Rajesh K. Agarwal, Aditya Narayan, D. Vasanthamaan, C. Mahendran, T. Brindha

Department of Radiotherapy, Royal Cancer Institute and Research Centre, Kanpur, Uttar Pradesh, India, E-mail: [email protected]

Introduction: VMAT consists of a single plan incorporating differential doses spread over 30 to 35 fractions. Rapid tumor shrinkage during therapy may go unaccounted. Adaptive radiotherapy like "Smart Adapt0" (Varian Medical Systems) allows deformational shrinkage of plan to adapt for better target coverage and further sparing of organs at risk in rapidly shrinking radiosensitive tumors. Materials and Methods: A post chemotherapy patient with paranasal sinus NHL adjacent to critical orbit structures was on involved field radiotherapy, after 15 fractions of radiotherapy a CBCT evaluation showed significant regression and there was need for sparing of critical structures like lens and lacrimal glands. A planning CT was done and using smart adapt deformable registration tools an analysis was carried out for various segmentation, volume and plan parameters. A verified deformational plan was adapted and recalculation of dose was done. Results: Assessment revealed a GTV volume reduction of 7%, PTV volume of 9.2%, left lacrimal gland dose (max) reduction was 21.4%, left lens dose reduction was 3%, right lens dose reduction was 2.7% as compared to initial plan. Conclusions: A new plan was desirable as the tumor was close to critical OAR's and deformational plan analysis showed critical structure dose reduction. Adaptive radiotherapy tools help in quick assessment and define the need of re-planning.

Abstract: 03

Feasibility of implementing volumetric modulated single arc therapy instead of dual arcs in postoperative irradiation of head and neck cancer

Anu Tiwari, Rajesh K. Agarwal, Vishal Khanna, Aditya Narayan , D. Vasanthamaan, Mahendran, T. Brindha

Department of Radiotherapy, Royal Cancer Institute and Research Centre, Kanpur, Uttar Pradesh, India, E-mail: [email protected]

Introduction: Volumetric Modulated Arc Therapy using multiple arcs has the advantage of a shorter treatment time over IMRT and therefore is being used in radiation therapy in head and neck cancer. This study aims to assess the feasibility and applicability of Volumetric Modulated Single Arc instead of typical multi arcs being used currently. Materials and Methods: Four post-operative patients of carcinoma of left buccal mucosa initially treated with standard dual arcs were retrospectively taken for re-planning to the same set of goals and constraints with a single arc modulated volumetric plan using VMAT optimization on Eclipse TPS Version 13.5 (Varian Medical Systems). Results: Comparison of dual arc and single arc plans showed non-inferiority for target coverage as well as equivalent sparing for almost all organs at risk (OAR's) with a single arc. There was uniform reduction in the number of monitor units per session and halving of treatment time with single arc as compared to dual arcs. Conclusions: Single arc therapy in postoperative head and neck irradiation is comparable to dual arcs in terms of PTV coverage and sparing of OAR's. Single arc requires lesser monitor units and time per session thereby increasing treatment precision with lesser intra fraction motion.

Abstract: 05

Radiotherapy in head and neck paraganglioma: An experience at a tertiary care center

Renu Madan 1,2 , Suman Bhasker 1 , Bidhu K. Mohanti 1,3

1 Department of Radiotherapy, AIIMS, New Delhi, 2 Department of Radiotherapy, PGIMER, Chandigarh, 3 Department of Radiotherapy, FMRI, Gurgaon, Haryana, India, E-mail: [email protected]

Introduction: Radiotherapy (RT) is an effective treatment modality for head neck paragangliomas (HNPs). In this article we briefly described our ten years experience of HNPs patients treated with RT. Materials and Methods: The study was conducted at Department of Radiotherapy, AIIMS, New Delhi. Patient records from 2002 to 2012 were collected for analysis and details were entered in a predesigned performa. Results: Fifteen patients of HNPs were treated during this period. Carotid body tumor was the commonest type (10 patients) followed by glomus jugulare (5 patients). Thirteen patients had benign and two patients had malignant disease at presentation. Twelve patients underwent surgery. Radiotherapy was given to all patients either postoperative (n = 7), definitive (n = 3), salvage (n = 3) or palliative (n = 2). Median follow up was 7.2 years (1.9 to 10 years). At the time of last follow up, six patients were alive without disease. Five of these patients were treated with surgery and postoperative RT while one patient received RT alone. Seven patients were found to have persistent residual disease and two patients developed metastasis during follow up. Neurological deficit was seen in one patient after surgery. No patient with RT alone developed neurological deficit. Conclusions: Radiotherapy is equally effective and less morbid as compared to surgery in head neck paraganglioma. However; due to lack of robust data, surgery is still considered as the mainstay of treatment. More clinical trials with large number of patients are required before setting the conclusion that surgery can be replaced by radiotherapy alone in these patients.

Abstract: 10

Advent of new era of radiation techniques with IMRT and VMAT compared to 3DCRT and its role in cranial, head and neck, breast, mediastinal, pelvic and prostate irradiation

Vibhay Pareek , Rajendra Bhalavat, Manish Chandra

Department of Radiotherapy, Jupiter Hospital, Thane, Maharashtra, India, E-mail: [email protected]

Introduction: The irradiation techniques have seen evolution from conventional to conformal techniques. With advent in advancements in IMRT techniques and recent modification in the form of Rapid arc (VMAT), the role needs to be evaluated in the dosimetric advantages as compared to the standard 3D Conformal Radiation Therapy used. This study evaluates the role of different radiation techniques in the dose conformality to PTV and dose assessment to organs at risk in cases of cranial, head and neck, left sided breast, mediastinal, pelvic and prostate irradiation. Materials and Methods: 20 patients were selected each from the medical records of Jupiter Hospital, Thane diagnosed with Cranial, head and neck, left sided breast, mediastinal lymphoma, pelvic and prostate malignancies. Three different plans with 3DCRT, VMAT and IMRT were constructed with specific dose constraints to organs at risk (OARs) at the various concerned sites and compared using Dose volume Histograms, Conformity and Heterogeneity index (C.I; H.I) and Monitoring Units (MU) and statistical analysis with ANOVA and unpaired t test done for the same. Results: The PTV coverage was obtained in all three plans (V95% >95%) and was found to be best in IMRT in head and neck, left sided breast, pelvic and mediastinal irradiation and VMAT showed better results in Cranial and Prostate malignancies. The C.I index was found to be better for both IMRT and VMAT compared to 3DCRT (P < 0.005) in all the malignancies. The normal organs at risk showed volumes receiving higher doses were reduced with IMRT and VMAT compared to 3DCRT however large volumes receiving low doses was high with IMRT and VMAT in respective malignancies. The low doses received showed no significance in the three different techniques. On qualitative comparative scoring in each subset of malignancies, IMRT was found to score better compared to VMAT and 3DCRT. Conclusions: IMRT showed better target coverage and OAR sparing at higher doses with expected large volumes receiving low doses. The normal organs at risk in the respective sites of irradiation were better spared with IMRT and VMAT. On overall scoring IMRT was found to provide better coverage and OAR sparing in head and neck, left sided breast and pelvic and mediastinal irradiation and VMAT was found to better in Prostate and Cranial malignancies as compared to 3DCRT. IMRT and VMAT can be considered to be useful in respective cases where acute toxicities associated with irradiation need to be considered.

Abstract: 100

Hypofractionated palliative radiotherapy for locally advanced or metastatic head and neck cancers: An institutional experience

Sankalp Singh , Arti Sarin, Niharika Bisht, Piyush Dhagat, Neelam

Department of Radiotherapy, Command Hospital (Southern Command), Pune, Maharashtra, India, E-mail: [email protected]

Introduction: A large proportion of patients suffering from head and neck cancers are not fit to tolerate definitive treatment with chemoradiation over 7 to 8 weeks due to advanced age, poor performance status, multiple comorbidities, locally advanced disease or distant metastases. Several short course radiotherapy regimens are utilized by radiation oncologists to palliate local symptoms and provide local control of disease in such cases. We present 3 year data of palliative radiotherapy regime of 30 Gy in 10 fractions at our institute. Materials and Methods: The medical records of all patients of head and neck cancer treated with palliative radiotherapy between January 2013 and December 2015 were analysed retrospectively. All patients who received the two weekly regimen of 30 Gy given over 10 fractions were included in the study. All patients were clinically assessed at four weeks of treatment completion for tumour response, relief from symptoms and improvement in general condition. Patients who showed good response to treatment were treated by a second phase of radiotherapy of 20 Gy in 10 fractions. After completion of treatment all patients were followed up at 3 monthly intervals. Data was collected to assess relief of symptoms, treatment related toxicities and local response. Results: 53 patients were treated with the 30 Gy/10 fractions regimen. The most common symptoms at presentation were pain and dysphagia. 49 (92%) patients completed the treatment but only 45 patients were available for assessment at 4 weeks. Relief from symptoms was seen in 63% to 71% patients while reduction in tumour size was seen in 33 (73%). 19 patients were selected to undergo the second phase of treatment. Amongst patients undergoing second phase of treatment, 11 (58%) had a complete response. 100% patients receiving second phase had reduction in symptoms though 6 (32%) patients had only partial relief from symptoms. Most patients in the study developed grade II skin and mucosal reactions but only 2 patients undergoing second phase of treatment had grade III oral mucositis. Conclusions: Hypofractionated radiotherapy regime of 30 Gy in 10 fractions followed by 20 Gy in 10 fractions is an effective and tolerable treatment option for advanced head and neck cancers patients with poor performance status.

Abstract: 101

Malignancy presenting as proptosis in radiotherapy practice: A series of 5 cases

Sankalp Singh , Arti Sarin, Niharika Bisht

Department of Radiotherapy, Command Hospital (Southern Command), Pune, Maharashtra, India, E-mail: [email protected]

Introduction: Proptosis is defined as a forward protrusion of the eyeball. Though it can be caused by several etiological factors of which malignancy is one of the less likely ones, it's appearance in a patient seen in oncology practice should arise suspicion and all investigations must be carried out to rule out presence of cancer. Materials and Methods: We present a series of 5 cases of proptosis seen during a period of one year from Jan to Dec 2015 at our institute. All patients were seen managed with the multispeciality team including Ophthalmologist and medical oncologist where indicated. First case was a 70 year male who presented with nasal stuffiness and painless proptosis of left eye associated with diplopia. CT scan and biopsy revealed a squamous cell carcinoma of the ethmoid sinus. He was managed with CCRT by IMRT technique and is presently in CR. Second was a 6 year male child who presented with sudden and gross proptosis of left eye of 6 weeks duration with severe pain and loss vision. CT scan revealed a large mass in the left orbit pushing the eyeball. FNAC of the mass was suggestive of a myeloid sarcoma. PBS and BM biopsy confirmed the presence of AML. He was managed with palliative radiotherapy to left eye and the mass lesion regressed almost completely. Third case was a 65 year old male, old case of NHL (MCL) of cervical lymph nodes treated with R-CHOP in 2014, who presented with recent onset proptosis of left eye. MRI revealed an enhancing mass lesion in retro orbital region suggestive of relapse of NHL which was confirmed on PET/CT. Disease progressed despite 2 nd line chemotherapy. He was managed with local radiotherapy with immediate relief of symptoms. Fourth was a 39 year old male with history of painless proptosis of right eye since 01 year. Imaging revealed a homogenous mass lesion superomedial to globe. Biopsy showed a low grade MALT lymphoma. He was treated with radiotherapy alone and is presently in CR. Fifth case was a 72 year old male, known case of multiple myeloma who developed proptosis of left eye while on chemotherapy. CT scan revealed a retro-orbital mass causing significant indentation on the globe. He was treated with palliative radiotherapy and symptoms were rapidly relieved. He continues to be on chemotherapy. Results: As above. Conclusions: Proptosis can be a presentation of several different types of malignancies. Knowledge about the possible causes and role of radiotherapy in management can be extremely helpful.

Abstract: 107

Conventional chemoradiation versus accelerated chemoradiation: A prospective study in oropharngeal cancer

Mangesh Korde , S. N. Prasad, Sharad Singh, Jitendra K. Verma, Pramod K. Singh, R. N. L. Srivastav

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

Introduction: India has the highest incidence rate of oropharyngeal cancer in the world. Surgery having limited role in treatment of oropharyngeal cancers but which can be cured by radiotherapy along with concurrent chemotherapy, the optimum treatment time for locoregional control is unclear. We aimed to find out whether shortening of treatment time by use of six instead of five radiotherapy fractions per week along with concurrent chemotherapy is feasible in terms of loco-regional control, Acute toxicities and treatment breaks in squamous cell carcinomas. Materials and Methods: The study was conducted between August 2014 to April 2016, 86 patients of Histologically proven squamous cell carcinoma of Oropharynx were registered out of which 05 patients defaulted from treatment. Patients with all stages were included. Patients were randomized into two arm, Arm A and Arm B. Arm A (40 patients) received five fractions per week (70 Gy/35#/7 weeks) along with concurrent intravenous cisplatin (100 mg/m 2 ) on day 1, 22 and 43 and Arm B (41 patients) received six fractions per week (70 Gy/35#/6 weeks) along with concurrent intravenous cisplatin (100 mg/m 2 ) on day 1, 22 and 43. Loco-regional control and Acute toxicities were assessed. Results: Median follow-up was 09 months, 22 patients (55%) in Arm A and 27 patients (67.5%) in Arm B had complete response at the end of 4 weeks post treatment. Acute toxicities were higher in six fractions per week arm compared to five fractions per week but were manageable. Grade III and IV reactions were higher in Arm B. Treatment break was given in 15% patients in Arm A and 19.5% patients in Arm B. Conclusion: Use of Accelerated-chemoradiation with cisplatin in Indian patients is beneficial, feasible, well tolerable and with better outcome in patients of oropharyngeal cancer and decreases treatment time.

Abstract: 11

Single institute experience of high dose rate interstitial brachytherapy for head and neck malignancies with curative intent and use of angiocatheters as carriers of iridium-192 implants

Pareek Vibhay , Bhalavat Rajendra, Chandra Manish

Department of Radiotherapy, Jupiter Hospital, Thane, Maharashtra, India, E-mail: [email protected]

Introduction: To evaluate the treatment outcomes with HDR Interstitial Brachytherapy in Head and Neck Cancers at our Institute with use of Angiocatheters as carrier source of Iridium - 192 wire implants. Materials and Methods: 58 Patients with Head and Neck malignancies of varying TNM staging as per AJCC staging criteria were analyzed retrospectively between 2008 and 2015. 42 patients (72.41%) received EBRT with HDR - BRT and 26 patients (27.59%) received BRT alone. 23 patients (39.65%) received concurrent Chemotherapy. The age group ranged from 27 to 81 years (Median age 56 years) with 41 patients (70.69%) males and 17 patients (29.31%) females. HDR - BRT was delivered with Iridium - 192 wire implants using plastic bead techniques with varying dose rates. The Biological equivalent doses (BED) were calculated for both BRT and EBRT keeping α/β = 10 for tumor and α/β = 3 for normal tissue and subsequently median BED doses were calculated and similarly 2 Gy equivalent dose (EQD2) were calculated and loco-regional control and disease free survival was assessed. Results: After completion of HDR - BRT, Patients for followed up one month later and subsequently every 3 months for first 2 years and thereafter every 6 months with median follow up period of 25 months (Range 2-84 months). The DFS probability at year 1 was 82.76% and 68.05% at year 7. The overall survival probability was 91.37% at year 1 and 85.89% at year 5. The local control rate was 67.27% and the control rates according to the stage of disease and T size classification. The rate of local recurrence was 8.62%, Regional Recurrence was 1.72%, Loco-Regional Failure was 3.44% and Distant metastases following local or regional failure was 17.23%. The Median BED for α/β = 10 was 86.775 Gy and DFS was 74.07% in patients receiving more than 86.775 Gy and DFS was 64.82% in patients receiving less than 86.775 Gy and Median BED for α/β = 3 was 128.76 Gy and DFS was 74.07 in patients receiving more than 128.76 Gy as compared to 64.82% in patients receiving less than 128.76 Gy. The median EQD2 for α/β = 10 was 71.6 Gy and for α/β = 3 was 75.85 Gy. The DFS was 75.86% in patients receiving more than median dose of 71.6 Gy compared to 61.53% in those receiving less than the median dose. The DFS was 78.57% in patients receiving median dose of 75.85 Gy as compared to 59.26% in those receiving less than the median dose. Conclusions: The overall outcome in the Patients with oral cavity and oropharyngeal malignancies was good with implementing of HDR - Interstitial Brachytherapy and use of Angiocatheters as carriers of Iridium - 192 wire. The BED10 value of 86.775 Gy and BED3 of 128.76 Gy showed that the dose received more than the median showed better outcomes in the form of DFS. The EQD2 calculated values suggested the dose received more than 71.6 Gy (α/β = 10) and 75.85 Gy (α/β = 3) showed better outcomes. The role of HDR Interstitial Brachytherapy in Head and Neck cancers is a proven, effective and safe treatment method with excellent long term outcome.

Abstract: 113

Aggressive Sino-nasal Malignancies: A descriptive study

Uday Krishna, Md Ismail Sharif , C. Varatharaj 1 , Geetha Patil Okaly 2 , S. D. Madhu 3 , V. Lokesh

Departments of Radiation Oncology, 1 Radiation Physics, 2 Histopathology and 3 Radiodiagnosis, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India, E-mail: [email protected]

Objective: We intend to describe the clinical presentation, radiological features, pathologic characteristics, treatment outcomes and IMRT dosimetric challenges of five aggressive malignancies in Sino-nasal region, treated at our institute. Materials and Methods: Case records, radiology, pathology and IMRT dosimetry of five patients with aggressive sino-nasal malignancies-adenoid cystic carcinoma (p1), malignant solitary fibrous tumour (p2), neuroendocrine carcinoma (p3), terato-carcino-sarcoma (p4) & plasmacytoma (p5). Intracranial extension warranting cranio-facial excision was performed wherever feasible while only biopsy when not. RT planning CT images (3 mm ST) were co-registered with pre/ postoperative MRI. IMRT plans were generated to a dose of 60 Gy/30# (p3, p4), 66 Gy/33# (p1) & 50 Gy/25# (p2, p5). Non coplanar beams were used wherever necessary. Baseline visual Perimetry and endocrine evaluation was done. Patients consented for IMRT on a 6 MV LA. Concurrent Cisplatin chemotherapy was administered when indicated. Results: All patients had endocrine deficits and visual deficits before initiation of IMRT. In p1, 3 & 4 dose constraints to the Optic nerve on the affected side, compromised dose coverage to the target; overall treatment time was affected due to endocrine dysfunctions during the course of RT, complicated in one by seizure. RT/CT related skin, mucosal and marrow toxicity was grade 2. CINV was grade 3. Conclusion: Endocrine dysfunction may be a presenting feature of these malignancies. Tolerance of the optic apparatus and partial brain are major hurdles for delivery of radical radiation doses. Aggressive surgery can cause CSF leaks, affect tissue reconstruction and cosmesis. Neoadjuvant chemotherapy should be used wherever feasible, to maximize control.

Abstract: 118

Retrospective evaluation comparing palliative chemotherapy in management of recurrent head and neck cancer

A. K. Arya, A. Mudgal , I. Yadav, L. Pandey

Department of Radiotherapy, S. N. Medical College, Agra,

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

Background: Patient with recurrence in head and neck Cancer (HNSCC) have poor prognosis and limited treatment options. Aim: Present retrospective analysis was conducted to evaluate the efficacy (progression free survival), toxicity, tumor response and cost effectiveness in four different regimens that is Gefitinib alone, Gefitinib + Methotrexate, Methotrexate alone and Cisplatin + 5 FU. Materials and Methods: This is retrospective analysis. Patients registered before 2016 were analyzed, 46 patients were eligible for analysis. Patients received Gefitinib (250 mg/day), Methotrexate as 50 mg intramuscular weekly, combination of Methotrexate with Gefttinib and Cisplatin with 5-FU. RECIST criteria were used to evaluate the response of therapy. Common Toxicity Criteria version 3.0 was used to assess the toxicity. Results: 39 of 46 patient had clinically meaningful response (CR + PR + STABLE) (84%) and had symptomatic improvement. The mean progression-free survival was significantly superior in responders (those who achieved partial or complete response) (22.7 weeks vs 10.1 weeks). Methotrexate with Gefitinib had maximum progression free survival (18.3 weeks) in comparison to the other treatment regimens. Weekly Methotrexate is relatively cost-effective followed by Gefitinib alone than methotrexate with Gefitinib and the most expensive was cisplatin with 5-FU. Conclusion: In Patients with recurrent head and neck cancer, weekly Methotrexate as single agent or in combination with Gefitinib appears as an attractive alternative regimen. Further trials to evaluate the role of Methotrexate with Gefitinib are warranted.

Abstract: 12

Clinical outcomes of different treatment modalities for mucositis in head and neck cancer undergoing chemo-irradiation

Pareek Vibhay , Bhalavat Rajendra, Chandra Manish

Department of Radiotherapy, Jupiter Hospital, Thane, Maharashtra, India, E-mail: [email protected]

Introduction: Oral Mucositis associated with head and neck chemo-irradiation is a debilitating problem associated with patients undergoing treatment for the same. The role of various modality involved with the treatment of oral Mucositis need to be evaluated. With advent of chlorhexidine, benzydamine and povidone iodine as established modality, the role of each needs to be evaluated for the treatment of the same. The aim of the study is to investigate the role of three modalities of mouth wash to prevent oral mucositis related to chemo-irradiation and its comparative status. Materials and Methods: A Randomized, Prospective, Single Institutional Case Control Study performed comparing the influence of benzydamine, chlorhexidine and povidone iodine (Betadine) on oral mucositis in head and neck cancer patients undergoing chemo-irradiation. 90 Biopsy proven untreated Patients will be allocated in 3 arms and subjected to chlorhexidine, povidone iodine and benzydamine treatment for the duration of treatment were analyzed for the complications related to mucositis. The grading for complications was done as per the RTOG Toxicity grading scale and the patients evaluated at baseline and every week till the completion of treatment and thereafter at 1 and 3 months to assess the acute toxicities. The Quality of Life would be assessed using the EORTC QoL-C30 and H&N-35. Results: The toxities would be graded for the three arms and later compared using ANOVA. The QoL would be analyzed using Wilcoxon Rank test. The duration for upgrading of Mucositis and the duration of presence of mucositis would also be analyzed in all three arms. The assessment of nutrition would also be done through analysis of weight changes during the entire course of treatment. Thus, the three modalities of treatment of mucositis would be compared for chemo-irradiation related toxicities. Conclusions: Benzydamine hydrochloride is safe, well tolerated, helps not just in delaying the progression of mucositis but also reduces the intensity of pain as compared to other treatment modalities.

Abstract: 121

Evaluation of effect of polymorphism in drug metabolising enzyme cytochrome p450 2a6 on treatment response in head and neck squamous cell cancer patients

S. Gupta , M. L. B. Bhatt, D. Parmar, S. Singh, S. Kumar, A. R. Kulshrestha, M. Suhel, P. Katepogu, C. Awasthi, A. Batra

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

Objective: To study the association of polymorphism of cytochrome P4502A6 with treatment response to chemoradiation in patient with cancer of head and neck region. Introduction: Polymorphism in drug metabolising enzyme Cytochrome P450 2A6 affects treatment response in Head And neck Squamous Cell Cancer (HNSCC) Patients. We have done the present study to assess association of polymorphism of cytochrome P4502A6 as a prognostic factor and to study its effect with treatment response to chemoradiation in patient with HNSCC. Materials and Methods: This was a prospective case control study of the hundred patients registered as head and neck cancer patients in the Department of Radiotherapy with equal number of controls at a tertiary care hospital in Northern India for the duration of one year. All patients underwent External beam Radiotherapy (70 Gray/35 fractions) with Concurrent Cisplatin. We assessed treatment response one month after completion of treatment and its association with polymorphism of cytochrome P4502A6. Results: The frequency of wild type polymorphism was 46% in cases as compared to 33% in controls whereas the variant type polymorphism was 54% in cases as compared to 67% in controls. Out of hundred patients, 95 were available for follow up. In patient available for follow up, 48% cases were found as wild type polymorphism while rest 52% were variant type polymorphism. Seventy five percent cases with wild type polymorphism responded to chemoradiation however only 38% cases with variant type polymorphism responded to treatment (P valve < 0.05). Conclusions: Patients with wild type polymorphism of cytochrome P4502A6 respond better to chemoradiation than the variant type in HNSCC. They are not only risk modifying factors but can be used in predictive pharmacogenetics to yield therapies that are more efficient, safer, personalized and cost effective.

Abstract: 124

Recurrent desmoplastic ameloblastoma of maxilla

S. Gupta, Ankur Mudgal , K. N. Pradeep, P. Singh, Durgesh

Department of Radiotherapy, S.N. Medical College, Agra, Uttar Pradesh, India, E-mail: [email protected]

Introduction: Desmoplastic variant account for 4-5% of all ameloblastomas. The present study describes the case of a patient that experienced numerous recurrences in the maxilla and also discusses recommendations for different treatment modalities in this variant. Case Report: A 18 year old female presented to us as a post op (left maxillectomy) case of odontogenic tumor. Her pre op complains was swelling over left cheek since 2 months. Pre op CT PNS showed soft tissue densities in left maxillary sinus with extensive bony destruction and HP report revealed it to be a small cell malignant neoplasm. Patient also had a H/O of surgery 2 years back in which HP report revealed odontogenic squamous tumor. Patient received EBRT to head and neck region 60 GY/30# in 6 weeks. Patient remained asymptomatic till four year and reported with C/O difficulty in swallowing. On examination a huge mass seen on left side of hard palate with extension from soft palate. CECT PNS showed soft tissue mass lesion in post maxillectomy area extending into left nasal cavity, oral cavity and left side of tongue. Biopsy from the lesion revealed mucoepidermoid carcinoma. Patient received 5 cycles of chemotherapy and radiotherapy 20 GY/5# to the same area to debulk the disease after which patient underwent WLE of the tumor and this time HP revealed desmoplastic ameloblastoma. Now patient is asymptomatic and is on follow up. Conclusion: Odontogenic tumor may present with various histopathology variant. Though it is a chemo and radio resistant tumor but these modalities can help in debulking the disease.

Abstract: 134

Retreatment in recurrent head and neck cancer by SBRT

Shashank Shekhar

Department of Radiotherapy, Max Cancer Centre, Saket, Delhi, India, E-mail: [email protected]

Introduction: After completion of radical treatment in head and neck cancer, 50 to 60% will either die from disease progression or have recurrence loco-regionally. Surgery is treatment of choice but feasible in only 50% of cases. These patients are treated with re-irradiation, chemotherapy or best supportive care. In recent years SBRT has emerged as a potential therapy for recurrent head and neck cancer. SBRT provides a potential advantage over shorter treatment course and has fewer systemic side effect. It provides dose escalation to tumor and respecting the normal tissue constraints. That gives the patient better local control and fewer systemic side effects. Materials and Methods: The retrospective study conducted at max cancer center, saket. Total 14 patients were analyzed those undergone SBRT for recurrent head and neck cancer. PET-CT scan was done in every case to establish the recurrence and rule out the distant metastasis. All patients were simulated and planed with PET CT fusion on eclipse planning system. A median dose of 30 Gy was delivered to the GTV. They were evaluated on follow up 3 monthly. Results: In analyzed patients mean age was 58.5 years. 13 were male and 1 female. They presented in stage III and IV (78%). They had performance status of 1 or 2 (80%). Received 60 to 70 Gy by previous irradiation. Mean deases free interval was 2.1 years. Median dose delivered was 35 Gy to GTV. Response was 78%. Median survival was 14.2 months. None had grade III or IV toxicity. Conclusion: SBRT is a potential option for recurrent head neck cancer in terms of local control and side effects. Combination of immunotherapy and adjuvant treatment after SBRT still need exploration.

Abstract: 137

Retrospective study to compare volumetric dose in simultaneuos integrated boost versus sequential boost in head and neck cancers

Heena Kauser , Deleep K. Gudipudi, V. Chandipriya, R. Alluri Krishnam, G. Ashwini

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

Objective: To compare treatment duration, mean dose received by parotids, & volumetric dose in irradiated body for V10, V20, V30, V40, V50 & V60 in Simultaneous Integrated Boost (SIB) vs. Sequential Boost (SeqB) Intensity Modulated Radiotherapy (IMRT) in Head and Neck Cancer. Materials and Methods: Between January 2015 and July 2016, a total of 51 patients (27 controls (SeqB) & 24 cases (SIB) with histologically confirmed squamous cell carcinoma of head and neck cancers treated with external beam radiation therapy either by SeqB-IMRT or SIB-IMRT techniques were analyzed retrospectively. SIB-IMRT technique was planned according to UCSF Protocol at Gross Tumor Volume - Tumor (GTV-T) and Gross Tumor Volume-Node (GTV-N) (69.96 Gy/2.12 Gy), Clinical Target Volume-High Risk (CTV-HR) (59.95 Gy/1.8 Gy), and Clinical Target Volume-Low Risk (CTV-LR) (54.45 Gy/1.65 Gy) in 33 fractions vs. SeqB at GTV-T/GTV-N (66-70 Gy/2 Gy), CTV-High Risk (60 Gy/2 Gy), CTV Low Risk (46-50 Gy/2 Gy) in 33-35 fractions. Results: Both groups were comparable in terms of age (53 yrs vs. 54.2 yrs P = 0.75), Sex (P = 0.94), treatment duration (43.62 vs. 43 days P = 0.62), mean parotid dose (25 Gy vs. 22 Gy P = 0.27). Volumetric dose distribution for V10 (23.83cc vs. 32.31cc P = 0.03), V20 (23.83cc vs. 32.31cc, P = 0.03), V30 (23.83cc vs.32.31cc, P = 0.03), V40 (23.83cc vs. 32.31cc, P = 0.03), V50 (23.83cc vs.32.31cc, P = 0.03), V60 (23.83cc vs. 32.31cc, P - 0.03), for SeqB and SIB IMRT techniques, respectively. Conclusion: SIB-IMRT can be safely practiced with comparable volumetric dose distribution, treatment duration, and higher BED dose to GTVs vs. SeqB-IMRT. Mean Parotid dose was less by 3 Gy in SIB-IMRT, may have clinical significance in prevention of xerostomia.

Abstract: 138

Role of intensity modulated radiotherapy in squamous cell carcinoma of the hypopharynx and larynx: Clinical outcomes and patterns of failure

C. Sham Sundar , Manu Mathew, Rajesh Isiah, Subhashini John

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

Introduction: Limited clinical data exists in India about the use of intensity-modulated radiotherapy (IMRT) for cancers of the hypopharynx (HP) and larynx (LX). We report clinical outcomes and failure patterns for these patients. Materials and Methods: Between February 2013 and March 2016, 60 patients with newly diagnosed SCC of the HP (32) and LX (28) were treated with IMRT with curative intent. Five patients were treated in the postoperative setting and 55 underwent definitive radiotherapy with or without concurrent chemotherapy/biological therapy. Thirty-two patients received concurrent systemic therapy. 26 patients received concurrent cisplatin based chemotherapy, 2 received weekly carboplatin, 3 received weekly nimotuzumab, 1 received weekly Cetuximab and 28 received no systemic therapy. Treatment plans were designed to provide a median dose of 66 Gy at 2 Gy/fraction in the definitive setting and to post-operative cases with positive margins or extranodal extension, and a median dose of 60 Gy at 2 Gy/fraction in the post-operative setting with clear margins. Results: Median follow-up was 12 months (range, 1-40 months). 57 patients had complete clinical response at the end of treatment. Twenty patients developed a loco-regional failure or had persistent disease, with a median time to failure of 14 months. 4 patients had persistent disease at the end of treatment, 9 had local recurrence, 2 had nodal recurrence, 1 had loco-regional recurrence and 4 had distant metastases. Among the 20 patients who failed, 8 had laryngeal primary and 12 had hypopharyngeal primary. Conclusions: This study though retrospective in nature definitively shows a trend towards improved outcomes with the use of IMRT in LX and HP primaries in comparison with historical data published in literature. Pattern of failure analysis showed that majority of loco-regional relapses occurred in the primary site, suggesting that novel strategies to overcome radio-resistance are required. HP tumors faired worse than LX tumors, suggesting that these patients may warrant more aggressive treatment.

Abstract: 14

Role of L-glutamine in reducing severity of oral mucositis induced by chemoradiation in locally advanced head and neck cancer patients

Pareek Vibhay , Bhalavat Rajendra, Chandra Manish

Department of Radiotherapy, Jupiter Hospital, Thane, Maharashtra, India, E-mail: [email protected]

Introduction: The incidence of mucositis in the oral cavity, pharynx and larynx is high among patients with head and neck cancer (HNC) receiving chemo-radiotherapy (CRT), resulting in significant pain and impairment of quality of life. The present study investigated whether L-glutamine (glutamine) decreases the severity of mucositis in the oral cavity, pharynx and larynx induced by CRT. Materials and Methods: Patients were randomized to orally receive either glutamine or placebo at a dose of 10 g 3 times a day throughout the CRT course. Mucositis was assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0. The primary end point was mucositis severity. Seventy biopsy proven patients with head and neck cancer receiving primary or adjuvant radiation therapy were randomized to receive either oral glutamine suspension daily 2 h before radiation in the study arm (10 g in 1000 ml of water) (n = 35) or placebo before radiation; control arm (n = 35). Results: Total 30 patients in the glutamine arm and total 33 patients in placebo developed mucositis. Grade 3 mucositis and grade 4 mucositis in the study arm (who received oral glutamine) were significantly less in the glutamine arm. The mean duration of grade 3 or worse mucositis (grade 3 and grade 4) was significantly less in study arm with P < 0.001. Mean time of onset of mucositis was significantly delayed in patients who took glutamine in comparison to control arm with P < 0.001. Overall, glutamine was associated with a significant reduction of mucositis, WL, and enteral nutrition. Conclusions: Glutamine delays oral mucositis in the head neck cancer patients. Moreover, it reduces the frequency and duration of grade 3 and grade 4 mucositis. More of the patients not receiving glutamine developed severe malnutrition when compared with those receiving this supplement, but there were no differences in other outcomes such as interruption of RT, hospitalization, use of opioid analgesics, or death during RT. Glutamine may have a protective effect during RT, reducing the risk and severity of OM, preventing weight loss, and reducing the need for nutritional support.

Abstract: 140

Prospective randomised study comparing concurrent chemo radiation with weekly and 3 weekly cisplatin in locally advanced orophryngeal carcinoma

N. Suneetha , R. Nanda, K. Aradhana, B. Thejaswini, G. V. Giri, Tanveer Pasha, K. P. Jagannath

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

Objective: To evaluate the efficacy, compliance, acute toxicity and survival of two commonly used schedules of Cisplatin chemoradiation. Materials and Methods: Sixty three patients of locally advanced oropharyngeal cancers of stage III & IV attending the KMIO from December 2010 to July 2013 were included for this prospective randomized study. Of the 59 eligible patients, 28 patients were randomized to 40 mg/m 2 weekly (Arm-I) chemoradiation and the other 31 patients to 3 weekly 100 mg/m 2 (Arm-II) with radical radiotherapy of 70 Gy in 35 fractions. The groups were analyzed for cumulative dose, acute toxicity & treatment outcome. Results: The median number of chemotherapy cycles in arm I was 5 and 2 in arm II, only one patient in arm II received third cycle of chemotherapy. Median total cumulative dose of cisplatin in arm I is 271.8 mg/m 2 ± 53.6 and arm-II is 303.2 mg/m 2 ± 51.9 (P = 0.02). Mean overall treatment time and acute toxicities (RTOG) were similar in both the arms. Two patients of arm II died due to hematological toxicities (grade V) and one in arm I due to aspiration pneumonia. After median follow up of 28 m (range 2.8 to 66.9 m), median overall survival (35.9 m & 32.9 m P = 0.3) and disease free survival (26.4 m & 27.4 m P = 0.9) were same in both the arms. Conclusion: In our study concurrent weekly 40 mg/m 2 cisplatin appears to have similar acute toxicity and efficacy to three weekly 100 mg/m 2 cisplatin despite significant higher total cumulative dose in 3 weekly arm and is an acceptable alternative to three weekly cisplatin in a limited resource setting where large number of patients are treated on outpatient basis.

Abstract: 141

A prospective randomized study of locally advanced head and neck cancer comparing concomitant chemoradiotherapy versus pure accelarated radiotherapy

Bodhisatta Roy , Krishnangshu Bhanja Choudhury, Koushik Ghosh, Kakali Choudhhury, Partha Dasgupta

Department of Radiotherapy, R. G. Kar Medical College and Hospital, Kolkata, West Bengal, India, E-mail: [email protected]

Introduction: Although head and neck cancer can be cured by radiotherapy, the optimum treatment time for locoregional control is unclear. The aim of the study is to find out whether shortening of treatment time by use of six instead of five radiotherapy fractions per week improves the tumour response in locally advanced head and neck cancers compared with coventional concomitant chemoradiation. Materials and Methods: A single institutional, prospective, open labeled, interventional parallel randomized controlled study with the accural period of, from January, 2015 to August 2016 with a minimum followup period of 6 months. Total of 57 Patients who did not received any treatment previously and histologically proven squamous cell carcinoma, were treated. In the study group, 27 patients received accelerated radiotherapy with 6 fractions per week with a total dose of 70 Gy, 35#, 5 week 5 days. In the Control group 30 patients received CCRT with 5 fractions per week radiation 70 Gy, 35 #, 7 weeks along with intravenous cisplatin 100 mg/m 2 three weekly. Tumor control, survival, acute and late toxicities were assessed. Results: The median treatment time in the study Arm was 46 days compared with 54 days in the control Arm. There were 27 patients in the study arm against 30 patients in standard control arm who were started on treatment. 2 patients in control arm did not complete the treatment and dropped out of the study due grade 3 mucositis and grade 3 dysphagia. So the Response rates were calculated among 27 patients in study arm against 28 patients in control arm. However adverse events were calculated for all patients with "intention to treat". The local disease control is compareable in both the arms with the P value 0.703 (statistically not significant). Conclusion: Similar local control can be achieved with purely accelerated radiotherapy in locally advanced HNCs, with lower long term toxicities compared to CTRT.

Key words: Accelerated radiotherapy, chemoradiotherapy, head and neck cancer

Abstract: 142

Comparison of dose to CNS structures: 3DCRT versus IMRT in head and neck cancer patients being treated with chemoradiotherapy

C. Daniel Udayan , Jaineet Sachdeva, Navneet Kumar, Rajesh Chander, Pamela Alice Jeyaraj, Preeti Negi, Deepti Phansopkar

Department of Radiotherapy, Christian Medical College, Ludhiana, Punjab, India, E-mail: [email protected]

Introduction: IMRT and 3DCRT are both common head and neck cancer treatment techniques with very different approaches. Although IMRT allows a better dose conformity in PTV, there is much less evidence as to which technique delivers much less dose to OARs especially OARs located outside the PTV which are not considered crucial during planning. Gulliford et al. in their retrospective analysis of phase III parotid sparing radiotherapy trial (PARSPORT) showed statistically significant increase in acute fatigue for those patient treated with IMRT compared to 3DCRT and one possible explanation for this was the dose to CNS structures due to different beam portals. The aim of the present study was to compare the difference in dose distribution to distant OAR (brain stem and cerebellum) for IMRT v/s 3DCRT in series of 30 patients with head and neck cancer receiving radical chemoradiotherapy. Materials and Methods: This was a prospective study of series of 30 cases of head and neck cancer receiving radical chemoradiotherapy by IMRT or 3DCRT with standard fractionation regime, treated in CMC, Ludhiana between Dec 1 st 2014 to Nov 30 th 2015. For each patient plan was made first for 40 Gy/20F and then boost plan made for 20 Gy/10F for both IMRT and 3DCRT. For dosimetric comparison, maximum and minimum dose to OAR (brain stem and cerebellum) was taken. Results: IMRT and 3DCRT delivers almost equal mean dose to brain stem but it was found to deliver significant higher dose to cerebellum in case of IMRT compared to 3DCRT. Conclusions: IMRT delivers higher mean dose to cerebellum compared to 3DCRT. This finding needs further larger studies to confirm dose to distant OARs by both techniques.

Abstract: 149

One year pretreatment quality assurance results of head and neck and pelvic VMAT plans using a PTW-729 ion-chamber array and OCTAVIOUS phantom

Durai Manigandan, Mohan Das, Narendra Bhalla, Abhishek Puri, Midhun Kumar

Department of Radiation Oncology, Fortis Cancer Institute, Fortis Hospital, Mohali, Punjab, India, E-mail: [email protected]

Introduction: The purpose of this study is to report one year pre-treatment plan verification experience of VMAT plans of heads and neck (H&N) and pelvic cancer patients, using PTW-729 ion-chamber array and OCTAVIOUS phantom. Materials and Methods: In this study, 48 VMAT dual arc H&N and 50 pelvic plans were considered with 6MV-Photon beam. For all the patients, treatment plans were created for Elekta Synergy LINAC and 6MV X-rays were used, treatment and verification plans were generated using Monte Carlo Algorithm in Monaco 5.1 Treatment Planning system (TPS). The dose plane measured and calculated plane were compared with 2D Gamma index (<1) analysis method by using various distance-to-agreement (DTA) and percentage dose difference with reference to maximum dose on measured plane. Analysis was done using Verisoft software, pass-rate for different DTA criteria were observed (2 mm/3%, 3 mm/3%, and 4 mm/3%). Results: The average pass rate for H&N plans were 93.78 ± 11% (2 mm/3%), 97.59 ± 5.29% (3 mm/3%) and 98.74 ± 4.54% (5.54). Similarly, for pelvic plans, it was 94.91 ± 5.71, 97.68 ± 4.78 and 98.46 ± 5.062. Comparatively Pelvic passed more than H&N plans. Among the DTA criteria selected 2 mm/3% was the most sensitive with the minimum pass-rate was 82.6% for H&N and 89.2% for pelvic plans. Pass-rates mainly depend on the complexity of the beam modulation and accuracy of the MLC calibration. Whenever there was an unexpected/reduction in the gamma pass-rate with 2 mm/3% DTA, it was a clear indication of deviation in MLC calibration.

The first 48 Plans are head and neck plans and rest 50 are Pelvic Plans. Conclusions: The PTW array is suitable of measuring VMAT plan delivery and 2 mm 3% DTA criteria is an indicator for the plan delivery errors.

Abstract: 152

Extraosseous Ewing's sarcoma of oral cavity: A rare tumor at rare site: A case report

P. R. Aarani Devi , Noble P. Lincoln, Aravindh S. Anand

Department of Radiotherapy and Oncology, Government Medical College, Thiruvananthapuram, Kerala, India, E-mail: [email protected]

Extraosseous Ewings sarcoma belongs to the Ewings sarcoma family of tumors with unique t(11;22)(q24;q12) translocation and expression of EWS-FLI1 protein. Extraosseous Ewings sarcoma of head and neck is extremely rare. The rapid growth, propensity for recurrence and metastasis are dominant features. Case Report: A 15 year old boy presented with painless swelling in the floor of mouth of 1 year duration. Examination revealed 5 × 4 cm nontender firm swelling with ankyloglossia. MRI oral cavity revealed a well defined soft tissue mass lesion, 4.2 × 3.2 × 4.8 cm arising between genioglossus muscles, without mandibular involvement. Biopsy reported malignant round cell neoplasm. Immunohistochemistry showed diffuse strong membrane positivity for CD99 (MIC2) with negative LCA, desmin and synaptophysin consistent with Ewings sarcoma. PET-CT ruled out metastasis. Without mandibular or other bone involvement a final diagnosis of extraosseous Ewings sarcoma was made. Being a primarily inoperable disease, primary systemic chemotherapy was started with VAC alternating with IE three weekly. Reassessment after 12 weeks with PETCT revealed no active disease. Treatment was continued for 40 weeks and re-evaluation MRI and PETCT showed complete response to treatment. Considering the rarity of the disease, patient's growing period and unavailability of standard guidelines, individualized decision of keeping him on follow up and to consider local RT or surgery for relapse was taken. Conclusions: The extreme rarity of tumor and complete clinical and radiological remission with systemic chemotherapy alone make this case unique. It seems necessary to be aware of this rare tumor at this rare site as early diagnosis and treatment can result in best chance of survival.

Abstract: 154

Prognostic significance of gross tumour volume in nasopharyngeal carcinoma treated with chemo radiotherapy

Nivedita Sarkar , S. D. Shamsundar, K. Aradhana, R. Nanda, B. Thejaswini

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

Introduction: Studies reveal that primary tumour volume of nasopharyngeal carcinoma has a significant prognosis in survival. This study is taken up to find such correlation between initial tumour volume to that of survival and recurrence. Materials and Methods: A total of 50 patients treated with concurrent chemo radiation for nasopharyngeal carcinoma between January 2011 and December 2014 were included in the study. All patients were treated via IMRT with dose of 66-70 Gy. Initial tumour volume was measured from CT based contouring and mean dose delivered was calculated. All patients were contacted on telephonic basis and followed up for evaluation of survival, relapse and metastasis. Results: The median follow up for the group was 21 months. The median GTV of primary and retropharyngeal node was 49.7cc. The 3 year DFS and OS was 35% and 41% respectively. The survival and metastasis rate was significantly associated with size of the primary tumour (More results awaited). Conclusions: The patients with NPC in our country present with very bulky disease and this has a significant association with the outcome of patients in terms of survival.

Abstract: 155

Head and neck cancer: Treatment and recovery refreshed by the touch of yoga

Shankar L. Jakhar

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

Objective: Assessment of Yoga in improving quality of life (QOL) and decreasing treatment related mucositis in head and neck cancer (HNC) patients undergoing chemo-radiotherapy (CRT). Methodology: 73 HNC patients were recruited for CRT and randomly assigned yoga group (35 patients) and control group (38 patients). Patients enrolled in yoga group attended 60 minutes guided yoga session, to practice yoga throughout the treatment course while control group received supportive therapy. The FACT-G (version 4) questionnaire was used to assess changes in QOL of patients. Patients were interviewed at the beginning of treatment, at the end of CRT and at 1 month and data were obtained. Weekly assessments of mucosal reactions were performed and grading was done as per WHO criteria. Results: There is significant improvement in the FACT-G total scores of patients enrolled in yoga group as compared to control group (P = 0.02). On assessment of four core subscales of FACT-G, improvement in physical and functional well being (PWB; FWB) was more accentuated in yoga group than control group (P < 0.01). An improvement was seen in yoga group over control group for social and emotional well being also (SWB, EWB; P < 0.04). In yoga group grade II and grade III mucositis (51.42%; 28.57%) were less as compared to non yoga group (60.52%; 34.21%). Conclusions: An improved QOL and decreased severity of treatment related morbidity shall be attained by integrating yoga with CRT and RT protocols. More related studies shall be carried out in favour of patient's benefit.

Abstract: 163

Spectrum of fungal infection in head and neck cancer patients on chemoradiotherapy

Gunjesh Kumar Singh , Jaspreet Kaur, Malini R. Capoor, Deepthi Nair, K. T. Bhowmik

Department of Radiotherapy, Vmmc and Safdarjung Hospital, Delhi, India, E-mail: [email protected]

Background: Radiotherapy for head and neck cancers (HNC) causes alteration of oral mucosal barrier predisposing it to colonization and infection. Such infections often result in pain and burning sensation thus contributing to major morbidity. Objective : (1) To identify the fungi isolated from the patients undergoing radiotherapy for HNC. (2) To determine their antifungal susceptibility and week of colonization. (3) To find out association between oral fungal infection and severity of oral mucositis. Materials and Methods: Study was done on 50 patients of HNC treated with concurrent chemoradiotherapy. Three samples (throat, urine, blood) were collected for fungal culture and sensitivity. These samples were collected before the start of radiotherapy, during radiotherapy (2 nd and 6 th week) and post radiotherapy (10 th week). Results: Only 49 patients were available for analysis as one patient did not complete follow up. Fungal infection was found in 27/49 patients (55.10%) out of which Candida albicans was isolated in 9/49 (18.36%). About 66.66% (18/27) isolates were sensitive to fluconazole (P = 0.271). Maximum isolation of yeast was during 6 th week of radiotherapy. All grade 4 (2/2) and 71.42% (10/14) of grade 3 oral mucositis were found in patients who were positive for fungal infection. Incidentally, complete remission rates were better in patients with throat swab negative for fungal culture (11/15) compared to those who were positive (5/15). Conclusion: Candida albicans was found to be predominant yeast. Higher rate of fungal colonization and infection was found in patients with grade 3/4 oral mucositis. Prophylactic fluconazole in HNC patients on concurrent chemoradiotherapy has the potential to reduce the associated morbidity. However, further studies are needed to confirm this finding.

Abstract: 168

Compliance to chemo-radiotherapy treatment by patients of carcinoma oropharynx and laryngopharynx

Tej Prakash Soni , Abhilasha Siyag, Jaishree Goyal, Naresh Jakhotia, Aaditya Prakash, Anil K. Gupta, Lalit M. Sharma, Tinku Takia

Department of Radiotherapy, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India, E-mail: [email protected]

Objectives: To evaluate the compliance of concuurent chemo-radiotherapy treatment by patients of Carcinoma Oropharynx and Laryngopharynx. Materials and Methods: Patients of Carcinoma Oropharynx and Larynx which were treated by Concuurent chemo-Radiotherapy from August 2014 to February 2016 were included. Retrospective analysis of treatment compliance and potential confounding factors was done. Treatment toxicity grade, missed radiotherapy fractions in days, tumor response after the treatment and other variables were analyzed. Cox regression to investigate potential hazard factors and logistic regression to determine risk factors related to treatment interruptions were used. Results: 319 cases were analyzed. Only 66% patients could complete planned 5 or more cycle of weekly chemotherapy. Only 56% patients completed the radiotherapy in scheduled time period. Median number of missed radiation was 5 days (range 2 days to 14 days). 70% patients in medically insured group completed the treatment without interruptions compared to only 50% patients in uninsured group. 60% patients developed grade 3 acute mucositis. Main cause of poor treatment compliance was treatment toxicities. Linear Accelerator Break-down and Social issues were other reasons. Mean follow up period was 6 months. Locoregional failure rate was 22% vs 35% in the patients who completed the radiotherapy on scheduled time versus who could not. Conclusions: Altered fractionation, treatment on Saturdays and public holidays, weekly/regular review by radiation oncologist during radiotherapy, dietary counseling can be effective methods for uninterrupted radiotherapy treatment. More research and measures are warranted to minimize the treatment toxicities and to increase the compliance.

Abstract: 171

Re-irradiation in head and neck malignancies: Challenges and outcomes

Chelakkot G. Prameela , R. Anoop, K. Sruthi, Rahul Ravind

Department of Radiation Oncology, Amrita School of Medicine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Amrita University, Kochi, Kerala, India, E-mail: [email protected]

Introduction: Head and neck malignancies account for approximately 30% of all malignancies. Almost 30%-50% of these patients present with recurrence, and 20% have second malignancies after primary radiation. Management of recurrence and second primary poses therapeutic challenge. Palliative chemotherapy and targeted agents fail to offer long term local control while salvage surgery is limited to a minority of patients. Re-irradiation, with modern techniques offers a new hope, achieving a better outcome with acceptable toxicities. Aim: Retrospectively analyse, efficacies of re-irradiation pertaining to patterns of care, acute toxicities and prognostic factors affecting the clinical outcome, in recurrent or second primary of the head and neck region. Materials and Methods: Twenty four patients treated with re-irradiation either radically or as an adjuvant were analysed. Factors looked into were site, stage, treatment modality, technique, cumulative dose, interval between treatments, toxicity profile, treatment breaks, and need for hospitalization. Prognostic factors in relation to patient, tumor and treatment factors were analyzed. Anatomical locations and absolute gross tumour volumes were evaluated at recurrence. Results: IMRT was offered for 41.6% patients and 3DCRT for 58.3%. Median cumulative dose in both was 116 Gy. Acute grade III mucositis and candidiasis was observed in 38%. 28.5% had treatment breaks. 16% required hospitalization. No myelotoxicity was recorded. Age and performance status were the significant prognostic factors affecting morbidity and overall survival of the patients. Conclusions: Modern state-of-the-art facilities make re-irradiation a feasible option with favourable outcomes and acceptable toxicities, as proved by the GORTEC trials. Myelotoxicity, a documented serious concern for re-irradiation, was not seen in our patients. Longer follow up of these survivors is essential to better understand the treatment outcomes and late complications.

Abstract: 172

Retrospective comparitive study of different concurrent chemotherapy regimens in head and neck cancer: An institutional experience

Niharika Bisht , Arti Sarin, Sankalp Singh

Department of Radiotherapy, CH(SC), Pune, Maharashtra, India, E-mail: [email protected]

Introduction: The role of concurrent chemoradiotherapy is well established in head and neck cancers. We present a retrospective comparitive study of different chemotherapy regimens followed in our hospital in concurrent with radiation in head and neck cancers. Materials and Methods: Retrospective analysis of the treatment documents of 51 patients of head and neck cancers (subsite-oral cavity, oropharynx, larynx and hypopharynx) treated with concurrent chemoradiotherapy was carried out from Jan 2016 to Dec 2016. The concurrent chemotherapy regimens followed were three weekly cisplatin (Regimen 1), weekly cetuximab (Regimen 2) and weekly cisplatin (Regimen 3). All patients included in the study were compared for overall treatment time and treatment breaks, treatment related toxicities and tumour response at 3 months. Results: 22 patients (43%) received three weekly cisplatin regimen, 16 patients (31%) received weekly cetuximab and 13 patients (26%) were treated with weekly cisplatin. 18 out 22 patients could complete their treatment protocol in Regimen 1, all patients in regimen 2 and 12 out of 13 in Regimen 3 could complete their treatment. Maximum toxicities were seen in Arm 1 with 70% patients having grade II toxicities and one having grade IV toxicitiy. Mediam treatment was shortest in arm 3 which was 51 days in definitive and 45 days in adjuvant setting with minimum treatment breaks. Tumour response was assesed by WHO response criteria. Maximal response was noted in 3 weekly cisplatin arm but was not statistically significant compared to other arms. Conclusions: Three weekly cisplatin regimen though more toxic than the other two regimens, has better response rates in locally advanced head and neck cancers.

Abstract: 177

Sinonasal teratocarcinosarcoma: A rare aggressive tumour and a challenge for the clinician

Devika Sunil, Chelakkot G. Prameela , Haridas Mohanachandran Nair,

P. S. Renilmon

Amrita Institute Of Medical Sciences, Kochi, Kerala, India,

E-mail: [email protected]

Background: Heffner and Hyams [1] in 1984 coined the term "Sinonasal teratocarcinosarcoma", an extremely rare, locally aggressive, malignant neoplasm, with mean survival of 1.9 years. [2] Three and five year survival rates are 30% and 20%. No consensus on treatment is available, and proximity of critical structures render treatment challenging. Incidence of local recurrence is 50% after surgery. Only very few case reports are available in literature, [3] and most cases were diagnosed at late stages or after recurrence. Case Report: A 44 year old male presented with head ache and epistaxis of six months duration. Nasal endoscopy showed left nasal polypoidal mass, which was endoscopically excised (3 × 2 × 1 cm), and was reported as "adenocarcinoma low grade, intestinal type". Patient subsequently presented to our tertiary centre, and was evaluated. Nasal endoscopy and CT were negative for any lesion. Slide and block review was reported as "Sinonasal teratocarcinosarcoma". Repeat endoscopic resection for clearance of any residual lesion was done, and he was staged, T1N0M0, stage I. The case was discussed in institutional multi-disciplinary tumour board and adjuvant radiation was suggested, considering the non-oncological surgery and the aggressive tumour biology. Treatment: Radiotherapy planning was challenging as the tumour is relatively radio-resistant and requires higher dose, while adjacent organs need to be spared. After CT simulation, tumour-bed and adjacent organs-at-risk were contoured. CTV included tumour-bed, bilateral ethmoid and sphenoid sinuses and ipsilateral maxillary sinus. High-risk tumour-bed with margin was planned for 6400 cGy; bilateral ethmoids, sphenoids and medial wall of left maxillary sinus 6000 cGy and its lateral wall 5400 cGy in 30 fractions. Literature search failed to show any benefit for elective nodal irradiation. Both VMAT and tomotherapy plans were generated. He was treated using helical tomotherapy with dynamic jaw 2.5 cm, under daily MV CT image guidance, since this offered a better conformality. Dose constraints considered for optic chiasm, bilateral optic nerves, lenses and eyes as per QUANTEC guide-lines, were achieved. Conclusion: Sinonasal teratocarcinosarcoma is a rare morphological diagnosis. Literature search failed to show any stage I tumours and hence there were no definite guidelines for management. With high precision tomotherapy high dose was delivered to tumour bed and high-risk areas, respecting adjacent critical structures. A longer follow up is required for assessing the outcome.


1. Heffner DK, Hyams VJ. Teratocarcinosarcoma (malignant teratoma?) of the nasal cavity and paranasal sinuses: A clinicopathologic study of 20 cases. Cancer 1984;53:2140-54.

2. Rashid T, Baig S, Saeed I, Mahasin Z. Sinonasal teratocarcinosarcoma: Management and literature review. Pak J Med Health Sci 2012;6:7924.

3. Misra P, Husain Q, Svider PF, Sanghvi S, Liu JK, Eloy JA. Management of sinonasal teratocarcinosarcoma: A systematic review. Am J Otolaryngol 2014;35:5-11.

Abstract: 18

Impact of oral palonosetron in improving quality of life as compared to other oral 5HT-3 antagonists in delayed CINV in patients of head and neck, breast and cervical cancer

Abhishek Shrivastava , V. Yogi, O. P. Singh, V. Mandloi

Department of Radioterapy, Gandhi Medical College, Bhopal, Madhya Pradesh, India, E-mail: [email protected]

Introduction: The primary objective was to prevent delayed chemo induced nausea and vomiting (CINV). The primary efficacy end point was complete Response (CR) and improving quality of life (QOL). Materials and Methods: This is a prospective, observational study conducted on 165 previously untreated histopathologically-proven patients of squamous cell carcinoma of Head and Neck (H&N) and Cervix (Cx) and ductal carcinoma of Breast, from January to December 2015. In this study the patients were selected based on our inclusion criteria and each cohort were composed of 55 (25 [H&N], 15 [Cx], 15 [Breast]) patients, each cohort receiving Oral Ondansetron 4 mg TDS (cohort 1); Oral Granisetron 1 mg BD (cohort 2); Oral Palonosetron 0.5 mg OD (cohort 3) and after standard protocol based chemotherapy from day 3 to day 7 (Delayed CINV) and were asked to keep a vomiting diary, interviewed on telephone and on next follow up visit and then results were graded according to the response obtained by each individual. Patients with history of allergy to 5HT-3 antagonists, any associated medical condition causing nausea/vomiting were excluded. Results: A total 165 patients were included in the study, In Palonosetron Cohort 98% patients of H&N have CR and 33% in Cx in Cisplatin based chemotherapy and 64% in Anthracyclin based chemotherapy in Breast Cancer patients. Granisetron Cohort; H& N 53%, Cx 22%. Breast 84%. Ondensetron Cohort; H&N 29%, Cx 13% Breast 57%. Conclusion: This study shows that oral Palonosetron is better than other oral 5HT-3 antagonists to prevent delayed CINV and thereby improving QOL in patients on chemotherapy.

Abstract: 183

Neoadjuvant chemotherapy in head and neck cancer: TMC experience

Sudhir Raj Silwal , M. Arunsingh, I. Mallick, R. K. Shrimali, R. Achari, S. Chatterjee

Department of Radiation Oncology, Tata Medical Centre, Kolkata, West Bengal, India, E-mail: [email protected]

Introduction: A platinum based NACT combination has the potential to downstage disease for radical treatment in locally advanced HNC and possibly improve outcomes. We present the results of an audit of HNC patients who received NACT with platinum, 5FU (PF) and/or docetaxel (TPF). Materials and Methods: HNC patients treated with NACT at TMC between September 2011 and December 2015 were retrieved from electronic medical records and analysed separately for nasopharyngeal cancers (NPC) using PF and other HNC (OHNC) using TPF. One year OS and DFS were estimated using Kaplan-Meier method. Results: Overall 85 patients received NACT, with NPC being 35.3% (n = 30) and OHNC 64.7% (n = 55) [Oropharynx 21.2%, Laryngo-pharynx 30.6%, Oral Cavity 9.4% and others 3.6%]. Median age of NPC and OHNC patients were 45 years and 56 years, respectively. Majority of NPC were stage III (50% n = 15) and stage IV (43.4% n = 13). Amongst OHNC patients 22.4% (n = 19) and 75.2% (n = 64), were stage III and IV respectively. Of the OHNC patients (74.5%, n = 41) received TPF and (20%, n = 11) PF or TP (5.4%, n = 3). A total of 14% and 16% required hospital admission during NACT or during the radical radiation treatment respectively. At a median follow up of 15.3 months and 9.8 months, 1-year OS and DFS for NPC was 89.3%, and 83.2% whilst that for OHNC was and 68.3%, 55.8% respectively. Oral cavity patients fared the worst with 1-year DFS of 25%. Conclusions: Although, NACT facilitates radical treatment in locally advanced cancers, its routine use in sites other than NPC remains controversial, especially of that in oral cavity cancers.

Abstract: 187

Palliative RT in locally very advanced head and neck cancers

If chemoresistance is a harbinger of radioresistance, can it be circumvented by a hybrid fractionation schedule?

Subeera Khan , K. M. Kamble, A. K. Diwan, V. K. Mahobia

Department of Radiation Therapy and Oncology, GMCH, Nagpur, Maharashtra, India, E-mail: [email protected]

Objectives: To compare the outcomes of two palliative fractionation schemes - 'standard' (30 Gy in 10 fractions) versus 'hybrid' (18 Gy in 3 fractions on alternate days during the 1 st week, followed by 10 Gy in 5 daily fractions in the 2 nd week), in patients with locally very advanced head and neck squamous cell cancers who progressed on induction chemotherapy. Cancer which could repair chemotherapy induced damage can repair radiation induced damage as well, given that both chemo and radiation target the tumor DNA, and hence non-response to chemotherapy could indicate subsequent radio resistance. We intend to analyze the outcomes with two different fractionation schemes in this particular subset of patients. Materials and Methods: Prospective randomized controlled two-arm unblinded trial Locally advanced cancers of the oral cavity, oropharynx, larynx, and hypopharynx treated with a minimum of two cycles of TPF or PF based Induction chemotherapy were eligible if the disease progressed on chemotherapy. Kaplan-Meier curves for OS and PFS were compared by the log-rank test. Response rates as per RECIST criteria were compared using chi square test. Toxicities were also compared using chi square test. Results: Total 60 patients enrolled, 30 in each arm, of these 57 could be analyzed (28 from standard arm, and 29 in the hybrid arm. 15 (50%) patients in standard arm Vs 28 (93.3%) patients in hybrid arm achieved a PR (P value = 0.0001, HS). More than 70% regression was seen in 7 (23.3%) in hybrid arm Vs 0 (0%) in standard arm (P value < 0.0001) Median overall survival was 4.5 months in standard and 6 months in hybrid arm. Hybrid arm had significantly better OS as compared to standard. (Log Rank test, P value = 0.0003) HR for death 0.3799 (95% CI 0.1364 TO 0.5002) PFS in hybrid arm was better as compared to standard arm (Log Rank test, P value < 0.0001, HS) HR for progression 0.3799 (95% CI 0.0797 to 0.3102) Acute toxicities were comparable in both arms, there was no incidence of gr 3 dermatitis in both groups, gr 3 mucositis was seen in 1 (3.3%) in standard and in 2 (6.6%) patients in hybrid arm (P value 0.16, NS). Conclusions: In comparison to the routinely used palliative fractionation scheme of 30 Gray (Gy) in 10 fractions (Fr), the use of hybrid fractionation which integrates hypo fractionation in the 1 st week, followed by conventional fractionation in the 2 nd week, could possibly offer better response rates and potential survival benefits among locally very advanced head and neck cancer patients even after they fail to respond to IC.

There is a paucity of radiation therapy facilities. The truth is that very few patients who actually need palliative radiotherapy receive prompt and proper referral to a radiotherapy centre, and even fewer patients are able to actually reach there in the limited time. Despite the fact that concurrent chemo-radiotherapy is the standard of care in locally very advanced inoperable lesions in patients with good PS, the ground reality which cannot be denied is that the situation in our country is far from ideal. Patients with Locally very advanced head and neck squamous cell cancer (T4b, any N, M0) or (unresectable nodal disease) are frequently referred to a radiotherapy institute after having already undergone courses of induction chemotherapy (IC) with an intention to downsize tumor volume prior to further treatment. This study is seeking neither to justify nor refute the existing hot debate on induction chemotherapy, but rather focusing on the grass root ground reality of how to address, those patients with PS ≥2 who were already in locally very advanced stage at presentation yet have progressive disease despite induction chemotherapy.

Abstract: 195

Primary conjunctival melanoma with recurrent metastases: A rare case report

Kaustav Chatterjee , Suparna Kanti Pal, Bidisha Ghosh Naskar

Department of Radiotherapy, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India, E-mail: [email protected]

Conjunctival melanoma is a rare neoplasm of the eye. It constitutes 2% of all ocular malignancy. Most of the ocular melanoma arises from uveal tissue and primary melanoma arising from conjunctiva is rare. Its incidence is 0.2-0.8 per million in the white population. It is identified most frequently in the perilimbal interpalpebral bulbar conjunctiva. It can arise de novo (12%), from an existing nevus (20% to 30%), or, more frequently, from an area of primary acquired melanosis (75%). Here we report a case of conjunctival melanoma in a 27 year old male patient presented with increase in the size of a black spot in conjunctiva of left eye which was excised by cryotherapy. The histology revealed conjunctival melanoma with free margin and the patient was put on follow-up. After a period of twenty-one months, patient developed metastasis to the preauricular lymph node which was histologically confirmed. He was treated with total parotidectomy and supra-omohyoid neck dissection. Again after four months metastasis was found in ipsilateral parotid region which was treated by modified radical neck dissection followed by irradiation. Five months after that the patient presented with metastatic post-auricular lymph-node and malignant pleural effusion. Disease progression occurred despite cisplatin based chemotherapy and ultimately patient succumbed to cerebral metastasis. The overall survival was thirty seven month. This case report suggests that conjunctival melanoma is a highly aggressive malignancy with unsatisfactory amenability to loco-regional and systemic therapy.

Abstract: 199

A prospective Phase II study of purely accelerated 6 fraction per-week radiotherapy in postoperative oral cavity suamous cell carcinomas

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

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

Introduction: Radiotherapy (RT) after adequate surgery is the recommended treatment for post- operative oral cavity squamous cell carcinomas (OCSCC) with high risk features. In margin positive cases and extra-capsular invasion, Chemo-RT (CRT) is the standard of care. Objectives: To assess the feasibility and toxicity of a 6#/week Post-operative RT (PORT) in OCSCC. Materials and Methods: It is a prospective interventional study. All the patients were adequately surgically resected OCSCC who did not fit the indication for definitive CRT. Results: Of the 40 patients, 83% were males. Mean age was 48 years with 63% smokers & 78% tobacco chewers. Buccal mucosa and Tongue were the most common sites. High risk factors for RT were as follows: 38%-pT3 or higher disease, N2a or above 28%, Margins close 23%, LVI positive-20% and PNI positive-25%. The median interval between surgery and RT was 6.6 weeks & for RT completion was 36 days with 98% receiving doses as planned. 83% patients had acute mucositis grade III or higher & grade III dysphagia was observed in 25% patients. Ryle's tube was placed in 48% and IV fluids were given to 58% patients. After 90 days of RT completion, grade III or more mucositis was there in 11%. Median follow up was 9 months. Local failure was seen in 3 patients (2 at primary site & 1 nodal). Conclusions: In view of acceptable acute and late toxicities 6#/week PORT seems feasible. However, a larger study group and a longer follow-up will be needed to validate the data.

Abstract: 210

Radiotherapy planning study comparing volumetric modulated arc therapy with intensity modulated radiation therapy in the treatment of head and neck cancers

Isha Jaiswal , Rohini Khurana, Madhup Rastogi, Rahat Hadi, Kamal Sahni, S. P. Mishra

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

Introduction: Radiation therapy is the mainstay of treatment in head and neck cancer. There have been significant advances in the delivery of RT in past decades from 2D to 3D conformal (3D-CRT) to IMRT & VMAT. The objective of this study was to investigate the differences in treatment plan quality of IMRT and VMAT in H&N cancers. Materials and Methods: Computed tomography scans of 25 patients with non-metastatic Stage III-IV SCC of oropharynx, hypopharynx & larynx were prospectively planned using IMRT (7-9 fields) and VMAT (2-3 arcs). Planning target volumes were delineated for three dose level 66 Gy/30# to (high risk) HR-PTV, 60 Gy/30# to (intermediate risk) IR-PTV & 54 Gy/30# to (low risk) LR-PTV. Spinal cord, brainstem & parotids were delineated as organ at risk (OAR). Planning was done by simultaneous integrated boost technique. Target coverage, dose conformity, homogeneity, monitor units (MU) & treatment time were compared across techniques. Results: HR PTV coverage for 95% of prescribed dose was 99.03% for VMAT & 97.89% for IMRT plans (P = 0.06). IR & LR PTV coverage & sparing of OARs was similar between the two techniques. VMAT plans showed superior dose conformity (1.01 ± 0.25) than IMRT plans (1.19 ± 0.33). The mean MU & delivery time in VMAT were 573 MUs & 120-300 sec & in IMRT were 1124 MUs & 10-12 minutes. Conclusions: VMAT provides superior target coverage and dose conformity than IMRT. Reduced MU and treatment time is beneficial for the patient and also provides opportunity to increase machine output in limited time slots.

Abstract: 222

Impact of repeat CT imaging and single step adaptive replanning of IMRT for head and neck cancer

Sai Kumari , Ramesh S. Bilimagga

Department of Radiotherapy, HCG-NMR Curie Centre of Oncology, Hubli, Karnataka, India, E-mail: [email protected]

Introduction: Standard IMRT plan does not account for uncertainties occurring during weeks of radical radiotherapy. Primary objective of this study was to demonstrate that midway replanning can reduce OAR toxicities and also assure precise dose delivery to PTVs. Materials and Methods: At the end of 20 th fraction of radical IMRT to 25 head and neck cancer patients a repeat CT simulation was performed. Replanning and comparison between the original IMRT plan and the Replan was done. Results: There was 24% and 21% mean reduction in volume of right and left parotids and 23.4%, 17.9% and 7.6% mean volume reduction of GTV, PTV-IR and PTV-LR by the end of 20 th fraction respectively. There was statistically significant increase in actually delivered dose to right and left parotids which was significantly reduced by replanning. Conclusion: Replanning midway through treatment involves time, effort and finance, but also significantly reduce parotid toxicity without changing target coverage significantly.

Abstract: 225

Aspiration pneumonia in irradiated head and neck cancer patients: From a perspective of a developing country

Rishabh Kumar , Divyashree, Vaishnavi Perumareddy, Geeta S. Naryanan, G. Bhanumathy, Bhaskar Vishwanathan

Department of Radiotherapy, Vydehi Institute of Medical Sciences, Bengaluru, Karnataka, India, E-mail: [email protected]

Introduction: Head and Neck cancers are one of the most common cancers in our country. It's often complicated with aspiration pneumonia, especially in irradiated patients. There is paucity of data on risk factors for developing aspiration pneumonia from the developing world. Materials and Methods: In this retrospective study, 233 consecutive patients treated with primary or post-operative RT (radiotherapy) with curative intent for head and neck cancer in a tertiary healthcare centre in South India, from July 2014 to December 2015, were included. Patients were identified from the departmental database and manual extraction of data was done from the case files. Results: Dysphagia (grade III-IV) Mucositis (grade III-IV), presence of feeding tube, Diabetes mellitus, Tuberculosis (TB) and treatment interruptions with grade 3 or more toxicities) were proven statistically significant. On Univariate analysis out of the 6 risk factors only TB, Dysphagia (grade III-IV) and presence feeding tube were proven to be statistically significant and were taken up for multivariate logistic regression. After applying Multivariate Logistic regression, an equation that predicts the development of aspiration pneumonia was created [Table 1]. {Table 1}

Conclusions: The proposed equation for predicting aspiration pneumonia needs to be validated by further prospective studies so that risk stratification can be done. TB, Dysphagia and presence of feeding tube are independent risk factors.

Abstract: 229

Achieving feasible dose to constrictors in Head and Neck Cancer patients: Possible or not?

Shiv Shankar Mishra

Department of Radiotherapy, Max Super speciality Hospital, Vaishali, India, E-mail: [email protected]

Objective: Assessment of feasibility to limit the dose to constrictor muscles in patients of oropharyngeal and laryngopharyngeal cancer treated with intensity modulated radiotherapy. Materials and Methods: 30 consecutive head and neck cancer patients treated with intensity modulated radiotherapy or image guided intensity modulated radiotherapy between April 2016 to August 2016 were enrolled for the study. Contouring of constrictor muscles according to recent guidelines was done in patients of carcinoma oropharynx and laryngopharynx. These patients also received chemotherapy according to standard guidelines. Both contouring and dose evaluation was done by same oncologist to remove inter-observer bias. Results: 53.3% (16) of carcinoma oropharynx and 46.7% (14) of carcinoma laryngopharynx patients were evaluated in our study. Average mean dose to constrictors were 53.58 Gy and average maximum dose was 73.42 Gy and mean V50 Gy was 61.4% [Table 1]. Conclusion: It is feasible to achieve mean dose and V50 Gy to constrictors according to constraints as mentioned in the literature but achieving maximum dose is a bit challenging. Our future course of action will be to evaluate dose volume relationship with dysphagia to improve patient's quality of life.

Abstract: 237

A study to assess the patterns of care and survival of anaplastic thyroid cancer

V. P. Sanudev Sadanandan , Jyothsna Jayaraj 1 , P. Kiran, N. V. Vinin, M. Geetha

Departments of Radiation Oncology and 1 Medical Oncology, Malabar Cancer Centre, Thalassery, Kerala, India, E-mail: [email protected]

Introduction: Anaplastic carcinoma thyroid (ATC) accounts for 1.7% of all thyroid cancers. Patients have a median survival of 5 months and a 1-year survival rate of 20%. Complete resection is possible in only one-third of patients. Most others are unresectable and treated with palliative radiotherapy (RT)/ palliative chemotherapy and best supportive care. In this study the patterns of care and survival of patients treated at our centre were analyzed. Materials and Methods: Patients treated in our centre from 2010 to 2015, in the age group 18-90 years with histologically or cytologically proven ATC were retrospectively analyzed. The survival curves were analyzed using the Kaplan-Meier method and compared using log-rank test. Results: 22 patients were analyzed, 7 males and 15 females. Mean age was 67 years. Most patients had an ECOG performance status ≥2. 5 patients had distant metastasis at presentation and others were having unresectable local disease. 13 patients underwent palliative radiotherapy and 9 had best supportive care. None received radical surgery or chemotherapy. The median survival was 3 months, 4.7 months in the palliative RT group and 2 months in the BSC only group. Conclusion: This study confirms the advanced age and stage at which ATC presents. A survival benefit has been noted with palliative RT which may be due to the limited number of patients. We suggest multi institutional collaborative studies to understand the biology and survival of ATC in India.

Abstract: 238

Dosimetric profile of dysphagia-aspiration related structures in head and neck cancer patients treated with DARS optimized intensity modulated radiation therapy

Adnan Calcuttawala , Vedang Murthy, Sarbani Ghosh-Laskar, Tejpal Gupta, Suresh Chaudhari 1 , Rituraj Upreti 1 , Jai Prakash Agarwal, Ashwini Budrukkar

Departments of Radiation Oncology and 1 Medical Physics, Tata Memorial Centre, Mumbai, Maharashtra, India, E-mail: [email protected]

Objective: To determine the doses received by the dysphagia-aspiration related structures (DARS) in patients with head and neck cancer treated with definitive DARS optimized intensity modulated radiation therapy (IMRT) and concurrent chemotherapy. Materials and Methods: Standard target volumes and organs at risk were delineated for twenty patients with histologically proven head and neck squamous cell carcionoma. In addition individual DARS were delineated including the superior, middle and inferior pharyngeal constrictor muscles (PCM), supraglottic and glottis larynx, base of tongue (BOT), esophageal inlet muscles and cervical esophagus. Volume based dose constraints were applied to the volume of DARS outside the planning target volume (PTV). IMRT plan was then generated to limit doses to DARS without compromising PTV doses. Dose-volume profiles were recorded and analysed using SPSSv21. Results: Oropharyngeal, hypopharyngeal and laryngeal primaries constituted 40%, 25% and 35% cases respectively. Average high risk PTV volume and D95 was 242cc and 68.4 Gy respectively. Average DARS mean dose was 53.3 Gy. DARS mean dose ≤50 Gy was achievable in 45% cases. It was significantly associated with high risk PTV of ≤150cc (P = 0.007) and laryngeal/hypopharyngeal primary sites (P = 0.017). 58% of DARS volume comprised of BOT and superior PCM hence average DARS mean dose to oropharyngeal primaries was 57.9 Gy. Conclusion: Using the currently available optimization tools, DARS mean dose can be restricted to ≤50 Gy if the high risk PTV volume is ≤150cc. Limiting the mean dose of DARS to ≤50 Gy is more probable for a primary site of larynx or hypopharynx rather than that of oropharynx.

Abstract: 243

Radiotherapy in primary orbital lymphoma: A single institution retrospective analysis

Aswin Kumar, V. R. Anjali , Geetha Narayanan, Jagath Krishnan, Francis V. James

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

Introduction: Orbital lymphoma refers to lymphomas of eye which involve conjunctiva, lacrimal gland, eyelid and retrobulbar region. Primary NHL of orbit constitute 4-8% of ExtraNodalLymphoma. Mainly they are low grade lymphomas, with predominant histology being mucosa associated lymphoid tissue (MALT). Radiotherapy is the treatment of choice for orbital lymphomas. We retrospectively evaluated the treatment outcomes for orbital lymphoma at our institute. Materials and Methods: The clinical data on 40 patients diagnosed with orbital lymphoma between Jan 2009 - Dec 2011 is retrospectively reviewed. Data regarding patient's demographics, tumor related factors such as location and pathology, radiotherapy details, disease status at last follow up are collected. Disease free survival is defined as the absence of any tumor regrowth or progression on imaging was calculated from date of admission. Overall and median survival is calculated from date of admission to last follow up or death from any cause. Results: Mean age of presentation is 50 years. Majority are male patients (M-24, F-16). Most common site is orbit (37 patients) followed by conjunctiva (3 patients). The commonest histology is MALT (29 patients), followed by SLL (7 patients), DLBCL (3 patients), Follicular lymphoma (1 patient). All patients have stage IAE disease. All patients received EBRT.21 patients treated conventionally, 18 patients with 3DCRT and one patient with electron. 30 patient received 30 Gy in 15#, 8 patient received 36 Gy in 18#, 2 patient received 40 Gy in 20#. 22 patients treated with anterior oblique field, 17 patients received anterior oblique and lateral fields, 1 patient with anterior on field. 20 patients treated with Co-60 and the other half with LINAC. 2 patients had B/L disease. After median follow up of 48 months DFS is 97%. Conclusions: Radiotherapy is an effective and at the same time well tolerated treatment for primary orbital lymphomas.

Abstract: 246

Concurrent hypo fractionated radiotherapy with cisplatin and erlotinib in locally advanced head and neck cancer: A feasibility phase ii study of a single institute

R. Manirathanam, Sonia Hage, B. Arun Sharma, Y. Indibor

RCC, Regional Institute of Medical Sciences, Imphal, Manipur, India, E-mail: drindibor @yahoo.com

Introduction: Concurrent chemoradiotherapy (CCRT) is the standard treatment for most locoregionally advanced squamous cell carcinomas of the head and neck. Various approaches has been tried to improve the treatment outcome. EGFR is up regulated in HNSCC and over expressed significantly after RT making the tumour radio resistant. Targeting EGFR with TKI or Mabs along with CCRT is hypothesised to have synergistic effect and are the emerging clinical trials in this direction. Hypofractionation further shortens the overall treatment period and likely to enhance the probability of tumour control. Hence, we embarked on this 3 pronged attack on HNSCC as a feasibility trial. Aims and Objective: To evaluate the efficacy of hypofractionated radiation with concurrent Cisplatin plus Erlotinib (TKI) in locally advanced Head and Neck SCC in terms of response and relapse free survival. Evaluation of acute and late toxicities. Materials and Methods: A non randomised prospective single arm study in patients treated with concurrent biochemoradiotherapy. Histologically confirmed HNSCC stage III, IVA and IVB excluding Nasopharynx with aim to enrol 30 patients having KPS >70%. RT by Theratron Cobalt 780-C at 250cGy/fraction once daily to a maximum of 60 Gy in 24 for equivalent fractions. BED will be calculated for equivalence to conventional fractionation for spine spare and boost, shrinking field technique with appropriate wedge filter and compensators will be used wherever required. Cisplatin will be administered at a dose of 30 mg/m 2 weekly along with erlotinib 100 mg OD from Day 1. Weekly monitoring of haematological and acute toxic effects during RT to be recorded. Late effect will be recorded from 3 months onwards till last date of follow up. Response will be evaluated at the end of treatment and monthly for 3 months using RECIST criteria. Primary end point will be disease response and secondary is relapse free period. Data will be analyzed for treatment response and toxicity profile using SPSS for any statistical significance. Results: Out of 30 patients recruited 26 were evaluable (2 incomplete treatment, one had developed Brain metastasis and out of protocol and one died at the start). Male-19, female-7 and age ranges from 45 to 72 years with median of 58 years. Stage wise III-8, IVA-17, IVB-1. Site wise PFS-7, Larynx-6, oral-7, orophryngeal-6 and histologically grade wise WDSCC-6, Mod. Diff.-12, Poorly diff.-7, undiff.-1. Response rate was CR-12 (46%), PR-12 (46%) and SD 2 (~8%) and overall response rate 92% at 9 months median follow up. Major Acute toxicity at completion of RT was Mucosities gd. III 57%, Gd II 4%, Skin Rkn. Gd. III 34%, Gd IV- 1%, Dysphagia Gd. II-23%, Gd. III-73%. Major late toxicities at median 9 months F. U are Sub cut. Fibrosis Gd. II-31%, persistent Dysphagia Gd. II - 30%, Gd II xerostomia 27%. At 9 months median follow up at the time of reporting only 6 had relapsed at the loco regional sites. Hence Median relapse free period is not yet reached. Of these the 2 non responsive (stable disease) has disease progression. Hence, 18/24 i.e, 75% responsive are relapse free at 9 months median follow up. The results when compared to historical controls of CCRT alone (average 30 to 40% relapse free response at 9 months) shows a marked improvement with acceptable toxicity level. Conclusion: The pilot study shows that the addition of bio molecular targeted therapy to hypofractionated schedule in advanced HNSCC as radiation enhancer is feasible with promising response and acceptable toxicity and merits further trials in large randomised Phase III trial.

Abstract: 248

Head and neck reirradiation: An institutional experience

Arvind Kumar Patidar , Pushpendra H. Hirapara, N. M. Dakshinamurthy, Neha Patel, Sanjay Nandeshwar

Shree D B Tejani Cancer Institute Managed by Lions Cancer Detection Center Trust, Surat, Gujarat, India, E-mail: [email protected]

Objective: To analyze clinical outcome and toxicity profile of reirradiation in Head and neck Squamous cell carcinoma (HNSCC) treated with IMRT. Materials and Methods: We retrospectively analyze 31 patients of loco-regionally recurrent (LRR)/second primary (SP) HNSCC who were reirradiated at our department from May 2014 to Jan 2016. Clinical outcome in term of toxicity profile, disease control and overall survival were analyzed. Results: There were 30 male and one female patient with median age 48 years (35-75). ECOG performance status was 1 and 2 in 15 and 13 patients respectively. Oral cavity was primary site of malignancy in 29/31 patients. LRR and SP tumor occurred in 16 and 15 patient respectively. Oral cavity was most frequent site of disease (27/31) at second time. Disease was diagnosed with early stage in 16/31 and 15/31 in advance stage. Median duration between two course of radiotherapy was 54 months (11-180). Re-irradiation was delivered as adjuvant treatment in 25/31 with IMRT. Median reirradiation dose was 60 Gy (52-70), median reirradiation Dmax to spinal cord was 25 Gy (5-40.4 Gy), brain stem was 26.6 Gy (1.3-49.8 Gy) & mandible 63.5 Gy (49-74.2 Gy). The median cumulative BED of spinal cord was 110.7 Gy (94.8-126.7). Median follow up was 10 months (3-22). One year loco-regional control & overall survival were 60% & 66% respectively. 22/31 had grade III acute skin and mucosal toxicity while majority experienced late subcutaneous (10/28) & mucosal (18/28) toxicities. There was no incidence of radiation myelopathy while one patient developed osteoradionecrosis. Conclusion: Reirradiation is feasible and safe using IMRT technique with acceptable toxicity in LRR/SP HNSCC.

Abstract: 260

Audit of patients of carcinoma head and neck: A university hospital based 2 years retrospective analysis

Satish Kumar Dewangan , Abhijit Mandal, T. B. Singh, Anupam Kumar Asthana

Department of Radiotherapy and Radiation Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India, E-mail: [email protected]

Introduction: A retrospective analysis of Head & Neck Cancer patients attending the radiotherapy outpatient department (OPD) of a single unit during the period of January 2012 till December 2013 was conducted to know the geographical distribution and incidence, their stage of presentation, treatment outcome & compliance. Materials and Methods: A total of 368 head and neck cancer patients registered in the Department of Radiotherapy of our institute during the period of January 2012-December 2013 in an individual unit were included. Data was analyzed using SPSS version 16. Results: Most of the patients hailed from the various districts of UP and Bihar. Males outnumbered females; ratio being 5.13:1. The most common age group was 51-60 years (27.2%) with mean age being 52.9 years. Addiction history was seen in 85% patients. Most frequent site of involvement was oral cavity followed by oropharynx. Stage IV (63.7%) constituted the most common stage at presentation; squamous cell carcinoma was the most common histopathology (91.3%). A significant proportion of patients defaulted after undergoing preliminary investigations (39.9%). Only 221 patients took treatment, out of which 60.6% completed the stage appropriate planned treatment. All the patients were treated on the Telecobalt unit. One year cumulative survival of 134 patients who had completed treatment was 54%. Median follow up period was 11 months. Conclusions: Stage IV was the most common stage at presentation. Lack of complete treatment worsened the outcome further. Proper cancer education programs and accessible treatment facilities in these rural areas are warranted to improve the outcome.

Abstract: 261

Significance of Peri Neural Invasion in locally advanced bucco alveolar complex carcinomas treated

Pankaj Agarwal

Department of Radiotherapy,MAX Hospital, Delhi, India, E-mail: [email protected]

Background: Purpose of this study was to evaluate prognostic factors, loco-regional control and survival in locally advanced bucco-alveolar complex (BAC) cancers. Methods: A retrospective review of 83 consecutive patients treated between Jan' 2009-Dec' 2012 with BAC cancers was conducted. All patients had surgery and adjuvant radiation with IMRT (+/-concurrent chemotherapy). Survival analysis was performed using Kaplan Meier and multivariable cox regression model. Results: On univariate and multivariate analysis, PNI was found to be an independent adverse risk factor. PNI (+) patients had significantly worse 2 and 3 years disease free survival, loco-regional failure free survival and overall survival as compared to PNI (-) patients (P = 0.000, 0.001, 0.000 respectively). Conclusion: Compared to PNI (-) patients, PNI (+) patients had much worse outcome despite aggressive adjuvant treatment. It warrants escalation of therapy and modification in radiation portals to cover neural pathways in PNI (+) patients.

Abstract: 265

A retrospective analysis of set up errors in IMRT of head and neck squamous cell carcinomas and its correlation with PTV margin

R. Ramesh Reddy , Pranabandhu Das, B. V. Subramanian

Department of Radiotherapy, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India, E-mail: [email protected]

Introduction: IMRT for Head and Neck cancers is gaining importance because of its ability to spare normal organs efficiently with preserving the therapeutic outcome. For this a rigid patient set up is needed 3D mask. A PTV margin of 0.5 is usually given around the CTV for compensating movements during interfraction patient position reproducibility. This position is checked regularly with a daily CBCT for first 3 days followed by weekly CBCT. Methods: From June 2015 to August 2016 all the head and neck SCC treated by IMRT are chosen. Weekly CBCT are reviewed for corrections in X, Y, and Z co-ordinates denoting for Horizontal, Longitudinal and Vertical planes is noted. A mean of all the shifts were obtained and analysed. Results: A Total of 75 patients were treated during this period. 664 CBCTs are reviewed. On analysis, mean X, Y, Z of 74 patients (98.66%) were within 0.5 cm. For 61 patients, all the mean errors were within 0.3 cm (81.33%). Conclusion: 0.5 cm PTV margin to CTV was well adequate and with further strict immobilisation, it can further be reduced to 0.3 mm, at least in selected cases.

Abstract: 271

Dosimetric analysis of carcinoma nasopharynx using VMAT: AHRCC experience

Patra Jitendra , Upadhyay Asish, Maharana Prashant, Behera Manoj Pattanayak Lucy, Padhi Sanjukta, Panda Niharika

Department of Radiotherapy, AHRCC, Cuttack, Odisha, India, E-mail: [email protected]

Objective: Advanced radiotherapy techniques like VMAT is being widely used in the treatment of nasopharyngeal cancers, where dose to critical organs is of concern. This preliminary study was undertaken to analyse the dose to the critical organs around the tumor in nasopharynx, treated by VMAT technique. Materials and Methods: 7 patients of carcinoma nasopharynx, treated in AHRCC, Cuttack by VMAT technique in 2016 were analysed. The structures were contoured as per RTOG guidelines and the dose prescription to PTV was such that 95% isodose covered 100% of the PTV. Constraints to the OARs were as per QUANTEC. The plan of four patients were done by single arc and remaining three patients were done by double arc using Monaco treatment planning system. The dose to the critical organs were deduced from the dose volume histogram (DVH) and were analysed. Results: The critical structures that were contoured were temporal lobes, parotids, brainstem and spinal cord. The mean dose to left and right temporal lobes were 24.7 Gy and 26.3 Gy. The mean dose to left and right parotids were 32.7 Gy and 33.6 Gy respectively while, the dose to brain stem and spinal cord were 30.2 Gy and 29.3 Gy. The dose to temporal lobes, brain stem and spinal cord were well below the dose constraints while the dose to parotids were above the dose constraints because five out of seven patients were advanced cases. Conclusion: The doses to temporal lobes, brainstem, spinal cord were less than their dose constraints but the dose to parotids were above the constraint due to advanced disease. VMAT is an attractive and feasible option for the treatment of carcinoma nasopharynx.

Key words: Critical structures, nasopharynx, VMAT

Abstract: 272

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

A. Upadhyay , A. Das, D. R. Samanta, B. Routray, M. Swain, M. K. Behera, L. Pattanayak, S. Padhi, N. Panda, S. N. Senapati

Department of Radiotherapy, AHRCC, Cuttack, Odisha, India,

E-mail: [email protected]

Objective: Many histopathologic parameters in head and neck squamous cell carcinoma have been identified as predictive factors for lymph node metastasis. Many studies have compared the depth of invasion with pathological lymph node metastasis. No definite treatment protocol has been defined with respect to depth of invasion. 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. Materials and Methods: Retrospectively the histopathology report of cases of operated carcinoma buccal mucosa and tongue respectively from January 2014 to February 2016 were reviewed. Total 250 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 250 patients, there were 186 cases of Carcinoma Buccal Mucosa and 64 cases of Carcinoma Tongue. The overall cervical metastatic rate was 47.3% (n = 88/186) in Carcinoma Buccal Mucosa and 54.7% (n = 35/64) in Carcinoma Tongue. Upto 10 mm depth of invasion in case of Carcinoma Buccal Mucosa there is 34.02% (n = 33/97) involvement of cervical lymph nodes, whereas from depth of invasion more than 10 mm nodal metastasis is 62.9% (n = 56/89) of cases. While in Carcinoma Tongue upto 6 mm depth of invasion lymph node metastasis is seen in 34.5% (n = 5/13) cases and above 6 mm depth of invasion it is seen in 58.8% (n = 30/51) cases. 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 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.

Key words: Carcinoma buccal mucosa, carcinoma tongue, depth of invasion

Abstract: 273

Dosimetric analysis of VMAT for carcinoma larynx and carcinoma hypopharynx: An AHRCC experience

S. S. Mohapatra , A. Upadhyay, I. Priyadarshini, M. K. Behera,

L. Pattanayak, S. Padhi, N. Panda

Department of Radiotherapy, AHRCC, Cuttack, Odisha, India, E-mail: [email protected]

Objective: Head and neck cancer is the most common cancer in males in India and radiation is an important modality for treatment in these cancers. Dose to Parotid and Spinal cord has been a matter of concern and VMAT is a good option to provide adequate coverage of tumour with sparing of critical organs. We present a preliminary data of 10 patients of carcinoma larynx and hypophartnx treated with VMAT. Materials and Methods: 4 cases of carcinoma larynx and 6 cases of carcinoma hypopharynx were treated by VMAT in AHRCC, Cuttack in 2016 were analysed. Target volumes ad critical structures were delineated on 3 mm slice planning CT according RTOG atlas. 70 Gy in 33# was prescribed to PTV1 (high risk). The parotid glands and spinal cord were delineated as critical organs and dose constraints were as per QUANTEC. All the treatment were Planned with VMAT technique using Monaco TPS, dose was calculated from the DVH and analysed. Results: The minimum, maximum and mean doses to left parotid were 6.0 Gy, 61.4 Gy and 31.9 Gy respectively. Minimum, maximum and mean doses to right parotid were 4.6 Gy, 56 Gy, 30.3 Gy respectively. Minimum, maximum and mean doses to spinal cord were 15.7 Gy, 36.6 Gy and 27.8 Gy respectively. 60% (6/10) of patients had advanced disease received dose to parotid above the dose constraint. 40% (4/10) of patient with localised disease receivied less dose to parotid than the constraint. Conclusion: VMAT provides optimum coverage of target volumes while sparing critical structures for majority of patients of carcinoma larynx and hypopharynx.

Key words: Critical structures, hypopharynx, larynx, VMAT

Abstract: 279

Adaptive radiotherapy for head and neck cancers

S. Manikumar , A. G. Hasib, V. G. Almeida, M. S. Athiyamaan, R. B. Sandesh, S. Sharaschandra

Department of Radiotherapy, Father Muller Medical College, Mangalore, Karnataka, India, E-mail: [email protected]

Introduction: Adaptive radiotherapy is conceptually an attractive approach to compensate for tumor and normal tissue variations during treatment but limited work exists currently to guide its clinical application in day to day practice. Little practical evidence exists regarding issues like the timing of rescan, the dose at which adaptive planning to be executed, the basis of patient selection for adaptive planning and the volumes and margins to be considered. Objectives: To assess whether Adaptive radiotherapy using re - scans after 5 and 20 fractions results in any significant volumetric changes in target volumes and OAR. Materials and Methods : This study was carried out on patients coming to the department of Radiation Oncology in Father Muller Medical College Hospital. 30 patients with head and neck cancer treated with Intensity modulated radiotherapy were enrolled in this study. A repeat CT scan was acquired for each patient after the 5 th fraction and after 20 th fraction. A new mould was made for immobilization before getting a repeat CT scan in patients for whom the initial mould could not be fit properly as a result of weight loss and tumour shrinkage. The repeat scan was done limited to the tumour volume considering the dose constraints of the patient and was fused automatically to the initial scan in coronal, axial and sagittal views. The initial and re-scan plans after 5 th fraction and after 20 th fraction were analyzed for volumetric changes (decrease or increase in volume). The change in volume of the target structures were calculated in the form of Volume Reduction Rate (VRR) and Daily Volume Reduction Rate (DVRR). They were calculated for each volume like GTVP, GTVN, GTVT (GTVP+GTVN) using some formulae. Results: The mean volume of primary GTV on initial scan was 55.82 cc (SD = 58). After 5# of RT the mean volume of primary GTV was 46.04cc (SD = 50.3) and after 20# the mean volume of primary GTV was 32.78 cc (42.98). The mean reduction of volume after 5# was 9.78cc constituted 17.5% drop, and mean reduction of volume after 20# was 23cc constituted 41.2% drop which was statistically significant. GTV NODE: The mean volume of nodal GTV on initial scan was 46.66cc (SD=58.84). After 5# of RT the mean volume of nodal GTV was 38.71 (SD = 54.57) and after 20# the mean volume of nodal GTV was 25.42cc (SD = 46.07). The mean reduction of volume after 5# was 7.95cc constituted 17.0% drop. The mean reduction of volume after 20# was 21.24cc constituted 45.5% drop which was statistically significant. Conclusion: This study showed that adaptive radiotherapy with a single scan after one week of treatment and a mid treatment re-scan seems to be a feasible approach in the treatment of head and neck cancers where it results in significant reduction in the target volumes. Since this strategy involves two re-scans only, it seems to be cost effective also. This novel approach carries a potential to increase the efficacy of IMRT by increasing the conformity of the treatments according to changes in anatomy which in turn can be used as a basis for increasing the dose of RT or chemotherapy and better clinical outcomes.

Abstract: 32

Dosimetric comparison of volumetric modulated arc therapy with or without flattening filter for head and neck cancer

Suresh Chaudhari , Mithun Sajeev, R. Vysakh, Rajesh A. Kinhikar, Sarbani Ghosh Laskar 1 , Deepak D. Deshpande, Shyam Kishor Shrivastava 1

Departments of Medical Physics and 1 Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India, E-mail: [email protected]

Objective: To compare Ca Nasopharynx treatment plans with FF and FFF beam using VMAT technique. Materials and Methods: A cohort of 5 head and neck (H&N) cases, were included in the study. Target volumes and organs at risk (OAR) were contoured as per ICRU62. The plans were generated with 6MV FF-VMAT and FFF-VMAT keeping all the parameters constant. Plans were optimized for at least 95% prescribed dose covering 95% of PTV volume (V95%) and OAR tolerance doses were adopted from RTOG225 guidelines. The plans were compared for plan quality, monitor units, integral dose, Conformity index (CI) and Homogeneity index (HI). Peripheral doses upto 40 cm from field edge were measured with TLD. Mean of all the evaluated parameters is reported. The statistical significance was calculated with student's t test. Results: V95% for FF-VMAT was better than FFF-VMAT by 0.16%. CI and HI for FF-VMAT was better than FFF-VMAT by 0.84% and 0.74%. No significant difference was found for OAR. Average integral dose for FFF-VMAT was less by 1.02%. FFF-VMAT required 30% more MU compared to FF-VMAT, however treatment time was not increased due to higher dose rate in FFF-VMAT. Peripheral dose for FFF-VMAT was 60% less than FF-VMAT plans which was found statistically significant with p value 0.00004. Conclusion: It was possible to generate FFF-VMAT plans with the similar target dose coverage and doses to organs at risk as FF-VMAT plans. The FFF beam significantly reduces peripheral dose which may reduce the secondary cancer risk.

Abstract: 33

Role of DNA repair gene polymorphisms in radiotoxicity prediction in oropharyngeal cancers

Ankita Gupta , Don Mathew, Sushmita Ghoshal, Arnab Pal, Amit Bahl, Jaimanti Bakshi

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

Background: Acute radiation toxicities are the major causes of morbidity associated with radiotherapy in patients of head and neck cancers, resulting in unplanned treatment breaks and/or modifications. Patients undergoing radiotherapy demonstrate variable normal tissue reactions despite uniform treatment protocol. It is hypothesized that genetic variants like single nucleotide polymorphisms (SNPs) of DNA repair genes affect normal tissue reactions during/after radiotherapy. Identification of these SNPs before commencement of the treatment can predict toxicities and subsequently help in formulating personalized treatment protocols. Aim: Evaluation of acute radiotixicities and their association with DNA repair gene polymorphisms in patients of squamous cell carcinoma of oropharynx. Materials and Methods: 80 cases of biopsy proven cases of squamous cell carcinoma of oropharynx treated with conventional radical radiotherapy were evaluated for acute radiation reactions, namely, mucositis, dermatitis and dysphagia, requirement of Ryle's tube placement, and weight loss incurred during treatment. 5 SNPs in DNA repair genes were correlated with the ocurrence, severity and duration of these reactions using appropriate statistical tests. Results: The presence of T allele of XRCC4-1394T>G is found to be associated with grade III dermatitis (P = 0.05) and prolonged (>6 weeks) duration of mucositis (P = 0.088). G allele of XRCC11196G>A results in grade III dysphagia (P = 0.046) and its prolonged duration (P= 0.017). Homozygous GG genotype of ERCC4Ex81244G>A is associated with requirement of Ryle's tube insertion (P = 0.039) while ERCC4Ex112505T>C is associated with a weight loss of >5% (P = 0.046). Conclusion: SNPs of DNA repair genes can be used as tools for radiotoxicity prediction.

Abstract: 40

Setup uncertainties and PTV margins at different anatomical levels in intensity modulated radiotherapy for nasopharyngeal cancer

A. Milan , Malu Rafi, Saju Bhasi 1 , R. Rejnish Kumar, C. T. Kainickal, Tapesh Bhattacharya, K. Ramadas

Departments of Radiation Oncology and 1 Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala, India, E-mail: [email protected]

Aim: To determine the systematic error (∑), random error (σ) and derive PTV margin at different levels of the target volumes in Nasopharyngeal Cancer. Materials and Methods: A retrospective offline review was done for patients who have undergone IMRT for nasopharyngeal cancer from June 2015 to May 2016 at our institution. Alternate day kV images were matched with digitally reconstructed radiograph to know the setup errors. All radiographs were matched at three levels-the clivus, third cervical (C3) and sixth cervical (C6) vertebra. The shifts in positions along the vertical, longitudinal and lateral axes were noted and the ∑ and σ at three levels were calculated. PTV margins were derived using van Herk's formula. Results: Twenty patients and 300 pairs of orthogonal portal films were reviewed. The ∑ for vertical, longitudinal and lateral directions for clivus, C3 and C6 match were 0.16 vs. 0.18 vs. 0.2, 0.12 vs. 0.14 vs. 0.14 and 0.09 vs. 0.16 and 0.23 respectively. Similarly, the random errors were 0.11 vs. 0.14 vs. 0.18, 0.11 vs. 0.12 vs. 0.12 and 0.12 vs. 0.13 vs. 0.16. The PTV margin at clivus was 0.4 cm along vertical and longitudinal direction and 0.3 cm in lateral direction. At the C3 level, it was 0.5 cm in vertical and lateral direction and 0.4 cm in longitudinal direction. At the C6 level, it was 0.6 cm in vertical and lateral direction and 0.5 cm in longitudinal direction. Conclusion: A differential margin along different levels of target may be necessary to adequately cover the target.

Abstract: 41

Volumetric modulated arc therapy vs conventional: IMRT in head and neck cancers: A comparative planning and dosimetric study

M. Spoorthi Shelometh , P. P. Mohanty, Ramalingam, Ashok, Kathekeyan, Jagdeesh

Department of Radiotherapy, Yashoda Cancer Institute, Hyderabad, Telangana, India, E-mail: [email protected]

Double Arc Volumetric Modulated Arc Therapy (DA VMAT) allows for rapid delivery of highly conformal dose distributions. In this study, planning and dosimetry of DA VMAT plans were compared with seven field (7F) - IMRT plans of head and neck cancer patients. Materials and Methods: CT datasets of 25 patients of locally Advanced Head Neck Cancers were included. Plans for 7F-IMRT, DA-IMRT were optimized. Planning Target Volumes are prescribed to doses of 70 Gy, 60 Gy and 50 Gy (2 Gy equivalent doses) by using simultaneous integrated Boost (SIB) technique. The planning objective for PTV were minimum dose >95% and maximum dose <107%. Maximum dose to spinal cord and Brainstem was limited to 45 Gy and 54 Gy respectively. For parotids, mean dose <26 Gy was assumed as the objective. The MUs and delivery times were scored to measure expected treatment efficiency. Results: DA VMAT plans allowed for a mean reduction in number of monitor units (MUs) by nearly 60% and reduction in treatment time by 60%, relative to 7F IMRT plans. DA VMAT plans achieved similar dose homogeneity to PTV as compared to 7F IMRT. DA VMAT plans achieved better sparing of OAR, especially spinal cord and parotid glands. Conclusions: DA VMAT is a fast, safe and accurate technique that uses lower MUs than 7F IMRT. DA plans provided similar dose homogeneity and better sparing of spinal cord and parotid glands.

Abstract: 47

Assessment of xerostomia in patients receiving radiotherapy to head and neck region: AHRCC experience

Mishra Tanushree , Padhi Sanjukta, Routray Biswaranjan,

Panda Niharika, S. N. Senapati

Department of Radiation Oncology, AHRCC, Cuttack, Odisha, India, E-mail: [email protected]

Introduction: Head & neck carcinoma is the most common cancers among Indian population. Radiotherapy is one of the treatment modality in head & neck cancers. Patients receiving radiotherapy to head & neck regions experience xerostomia as an adverse effect of radiation. As the salivary flow rate decreases, quality of life in terms of speech, eating habit, pain parameters, physical and psychosocial aspect also affected adversely. Aim: Aim of this study was to assess xerostomia quantitatively and quality of life along with eating habit, in patients receiving radiotherapy for different head and neck malignancies. Methodology: After fulfilling the eligibility criteria, patients planned for radiotherapy at AHRCC, during the period of March 2014 to December 2015 were enrolled in the study. Patients were asked to spit into a glass funnel connected to a graduated test tube relaxly for 5 minutes. 3 ml of water was added to it and unstimulated rate of flow of saliva was calculated as ml/min. This process was repeated three times, i.e. once at the start of treatment, again at the start of 3 rd week and lastly once at the end of treatment. For subjective assessment, XeQoL questionnaire and EAT 10 questionnaire was distributed to patients for their response at the start of treatment, again at 3 rd week and lastly at the end of treatment. All data were analysed using paired t test in SPSS 21 version. Observation and Results: Out of 41 patients, 29 patients were suffering from carcinoma oral cavity region, 10 patients were from carcinoma oropharynx and 2 patients from carcinoma hypopharynx region. 29 patients out of 41 were treated with bilateral face and neck portals and 12 patients were treated with ipsilateral radiation portal. 17 patients received radiation in radical intent and 12 in adjuvant intent. 7 patients received radiotherapy to left face and neck (1 radical and 6 adjuvant). 5 patients received radiotherapy to right face and neck (3 radical and 2 adjuvant). The mean rate of salivary flow was 0.95 ml/min at the start of treatment, 0.52 ml/min at 3 rd week and 0.29 ml/min at the end of the treatment. The XeQoL score was 11.1 at baseline; 47.75 at third week and 55.52 at the end of treatment. EAT10 score was 6.65 at baseline; 32.87 at third week and 35.92 at the end of treatment. Conclusion: In the present study, the salivary flow rate started decreasing from the start of the 3 rd week of treatment, which further deteriorated with increasing dose of radiation. As the salivary flow decreased the quality of life with respect to social, psychological, psychosocial and personal also deteriorated. Simultaneously the eating habit with respect to quality, quantity also deteriorated.

Abstract: 52

A prospective randomized comparative double arm study to evaluate the responses and toxicities with conventional external beam radiotherapy versus intensity modulated radiotherapy, after neoadjuvant chemotherapy in locally advanced oropharyngeal cancers

Ravi Kiran Pothamsetty , Paul Thaliath, Radha Rani Ghosh

Department of Radiation Oncology, KNMH, RCC, Allahabad, Uttar Pradesh, India, E-mail: [email protected]

Background: Oropharyngeal cancer is primarily a disease of elderly but its trends in recent years has been increasing among younsters due to tobacco abuse. Objectives: To evaluate loco-regional failures, overall survival and disease free survival in Arm A and Arm B. Materials and Methods: Biopsy proved squamous cell carcinoma of oropharynx (stage: T3-T4a N0-N2 M0) were enrolled and had subjected to 3 courses of NACT. Complete and partial responders were randomized by computer into 2 arms: Arm A (Conventional EBRT) and Arm B (IMRT). Both the arms received 70 Gy/35 fractions/7 weeks as per institutional protocol. Results: At 6 th month follow up local control, disease free survival, overall survival, found in arm A vs arm B was 45% vs 50%, 25% vs 35%, 85% vs 95% respectively. Progressive disease and lost to follow up was 15% vs 10%, 10% vs 5% respectively. Patients died in arm A vs arm B was 5% vs 0% respectively. Late radiation toxicities at 6 months had found not statistically significant. Conclusion: As observed in our study, 40 patients out of 54 had been downstaged. With debulking the disease subsequent to neoadjuvant chemotherapy, patient improved symptomatically and delivering radiation becomes easier with less radiation related complications. However, this study definitely showed downstaging and better treatment tolerance towards IMRT arm in locally advanced oropharyngeal carcinoma. A long term study for longer follow up required for any statistical significance. Better response can be expected in early stage disease.

Abstract: 54

Adjuvant strontium 90 β-irradiation in conjunctival carcinoma: A comparison of efficacy and toxicity with topical chemotherapy

Bodhisattwa Dutta , R. Tudu, N. Biswas, A. Halder, R. Roy, A. R. Deb

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

Objectives: We have compared efficacies and toxicities of two principal adjuvant modalities for conjunctival squamous cell carcinoma, a rare malignancy with a high rate of local recurrence after simple excision. Materials and Methods: From April 2006 to August 2016, 37 patients (corresponding to 38 eyes) were registered after excision of conjunctival growths and histological diagnosis of invasive or in-situ squamous carcinoma. Beta irradiation was given to 29 of those eyes using a Strontium90 β-ray Applicator to a dose of 80 Gy in 8-10 fractions, 3 fractions a week. The Applicator is a Strontium source mounted on a handle, with an intervening Perspex disc for shielding the radiotherapist. Strontium90 and its decay product, Yttrium90 are pure β-emitters of low penetration, ideal for treatment of surface lesions, including conjunctival carcinoma. The patients were followed up at our OPD for recording response, recurrence and toxicities. Efficacy and toxicity data of topical chemotherapy, a competing adjuvant modality, were reviewed from the published literature. Results: After a median follow up of 9 months only 1 patient had a preauricular nodal failure. Three reported with cataracts, of which only 1 could be definitely labelled radiation induced. All patients reported mild eye irritation during treatment, which was well controlled with steroid-antibiotic and lubricant eye drops. No other adverse events were seen. Our results tally with previous reports regarding response and adverse effects. Conclusion: Adjuvant Srontium90 β-irradiation is one of the first choices for conjunctival intraepithelial or invasive carcinoma in view of its simplicity, efficacy and minimal morbidity.

Abstract: 56

Accelerated radiotherapy with weekly cisplatin and nimorazole in locally advanced head and neck squamous cell carcinoma

Christal Suji , N. V. Kalaiyarasi, R. Giridharan, P. K. Baskar,

S. Madhumathi, K. Sanjal, Vijay karthick

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

Aims and Objectives: To assess the immediate locoregional response rates and to assess the toxicity profile of accelerated radiation with weekly cisplatin and tablet nimorazole in locally advanced head and neck cancers. Materials and Methods: 30 Consecutive patients with locally advanced head and neck cancers attending the OPD at our institute were included in the study. All patients were treated with accelerated radiation 6#/week (2 Gy * 33# = 66 Gy) along with 5-6 cycles of weekly Inj. cisplatin 40 mg/m 2 and tablet nimorazole 1200 mg/m 2 . Results: Among the 30 patients recruited 6 were laryngeal carcinoma patients and hypopharynx, oropharynx and oral cavity patients were 8, 9, 7 respectively. In this study, 73% of patients had complete response and 27% had partial response. There was no static response or progression in this study. The subsites of hypopharynx and oropharynx had the best outcomes for this management protocol. Analysis showed that outcome was significantly related to the T classification, neck nodes, histology and sex. Conclusion: Accelerated radiation with cisplatin and tablet nimorazole is a feasible alternative for locally advanced head and neck squaamous cell carcinoma patients. The compliance to radiotherapy was good and 100% of the patients received the planned radiotherapy dose. Drug related side effects were minir and tolerable with transient nausea and vomiting being the most frequent complications.

Abstract: 57

Carcinoma nasopharynx: Analysis of dosimetric parameters in 3DCRT, IMRT and rapid Arc treatment plans

Koustav Mazumder , A. Bahl, S. Kaur, F. Thasneem, S. A. Oinam, R. Verma 1 , S. Mahindra 1 , S. Bahadur 2 , N. K. Panda 1 , S. Ghoshal

Departments of Radiotherapy and Oncology, 1 Otolaryngology and 2 Oral Health Sciences, Post Graduate Institute of Medical Education and Research, Chandigarh, India, E-mail: [email protected]

Introduction: To analyze dosimetric data in target volumes and organ at risk in 3-Dimensinal conformal Radiotherapy (3D-CRT), Intensity modulated Radiotherapy (IMRT) & Rapid Arc (RA) in Nasopharyngeal Cancer (NPC). Materials and Methods: CT scan data of 9 patients of NPC who were originally treated with RA were selected. For each patient 3DCRT and IMRT plan were made. The RA and IMRT were planned for PTV70 Gy and PTV59.4 Gy in 33 fractions using SIB technique. 3DCRT planned with shrinking field technique to dose of 70 Gy in conventional fractionation. Plan was compared in terms of target volume coverage, sparing organ at risk, conformity Index (CI), Homogeneity index (HI), required Monitor Units (MU) to deliver the treatment. Repeated measure ANOVA was used for statistical comparison. Results: The mean doses of PTV for 3DCRT, IMRT, RA were 68.07 ± 2.7 Gy (mean ± SD), 69.9 ± 0.18 Gy, 69.64 ± 0.31 Gy respectively. Mean MU required to deliver IMRT were 2244 ± 229 which was significantly more than 3D CRT (835.67 ± 136) (P < 0.05), and RA (682.5 ± 142.3) (P < 0.05). In 3DCRT mean dose to B/L parotids (63.9 ± 6 Gy) was significantly more than IMRT (27.8 ± 3 Gy) (P < 0.05) and RA (25 ± 3.4 Gy) (P < 0.05). Dmax to Brain stem in RA (51.2 ± 2.4 Gy) was significantly lower (P = 0.04) than IMRT (54.3 ± 2.6 Gy). Dmax to spinal cord was lower in RA (43.8 ± 1.4 Gy) compared to 3DCRT (46.5 ± 1.3 Gy) (P < 0.05) and IMRT (45.2 ± 1.4 Gy) (P = 0.21). Doses to temporal lobes were significantly lower in RA compared to IMRT and 3DCRT. Mean CI and HI were 3.3 ± 0.6 & 0.15 ± 0.05 for 3DCRT, 1.3 ± 0.22 & 0.052 ± 0.02 for IMRT, 1.09 ± 0.04 & 0.05 ± 0.01 for RA. Mean Integral dose for 3DCRT, IMRT & RA were 170.08, 182.8, 175.8 Litre-Gray respectively. Conclusions: RA has dosimetric advantages over 3DCRT and IMRT in terms of tumor coverage, sparing organ at risk, integral dose and MU required to deliver the plan.

Abstract: 61

Feasibility study of concurrent chemo-radiotherapy with six fractions a week radiotherapy in locally advanced head and neck cancer

Neeraj Dhingra, Kundan S. Chufal, Anil Thakwani, Irfan Bashir,

Pooja Khullar, Sunny Jain, Irfan Ahmad

Department of Radiotherapy, Batra Hospital And Medical Research Centre, Delhi, India, E-mail: [email protected]

Objectives: This prospective study is an attempt to assess the feasibility of combining Accelerated radiotherapy in the form of 6 fractions per week with concurrent platinum based chemotherapy. We have assessed the acute side effects and the response rates in the treatment cohort. Methods: We enrolled patients with newly diagnosed locally advanced carcinomas of oropharynx, hypopharynx and larynx. Since December 2015 we have completed treatment of 21 patients out of which response assessment has been done in 16. Concurrent chemoradiotherapy (CTRT) was given in the form of 6 fractions a week IMRT with simultaneous integrated boost (planned dose: 70 Gy/35 fractions) and platinum based chemotherapy (Cisplatin or Carboplatin). Results: The median age was 52 years with oropharynx forming bulk of patients (76%). Stage wise distribution was 42% & 58% for stage III & IV respectively. Median treatment completion time was 43 days with 58% patients able to complete treatment within the range. 15 patients could complete 5-6 chemotherapy cycles. Grade 3 hematological toxicities were most important cause of treatment interruption. Complete response at first follow up was seen in 87% patients. Conclusion: The accelerated fractionation in the form of 6 fractions a week with concurrent chemotherapy is feasible with manageable toxicities and very good response rates.

Abstract: 64

Role of re-computed tomography scan and re-planning for radiotherapy of head and neck cancer cases

R. Y. Saadvik

Department of Radiotherapy, Sri Aurobindo Medical College and Pgi, Indore, Madhya Pradesh, India, E-mail: [email protected]

Objectives: To study the impact of repeat (re)-CT and re-planning on target volume and dosimetric parameters. Materials and Methods: In 25 patients with primary H&N cancer, a re-CT during 4 th week when clinically indicated was done and then two plans were generated on re-CT, actual plan (AP) planned on re-CT scan, and hybrid plan (HP), HP was generated by applying the first intensity-modulated radiation therapy (IMRT) plan (including monitoring units) to the images of re-CT. Both plans (AP and HP) on re-CT were compared for volumetric and dosimetric parameters. Results: The mean variation in volumes between CT and re-CT were 43.47cc, 79.2cc, and 152.02cc for GTV, CTV and PTV, respectively. Mean conformity index and homogeneity index was 0.71 and 1.08, respectively for AP and 0.49 and 1.18, respectively for HP. Mean D95 and D99 of PTV was 96.82% (standard deviation, SD 2.02) and 94.3% (SD 2.75), respectively for AP and 91.9% (SD 3.92) and 84.7% (SD: 7.79), respectively for HP. Increase in mean doses to right parotid, left parotid, spine, and brainstem were 4.97 Gy (Dmean), 3.23 Gy (Dmean), 1.43 Gy (D max) and 3.74 Gy (Dmax), respectively in HP compared to AP. Conclusion: Dose disparities due to volume changes are reduced and coverage to target volume is improved and further dose reduction to organ at risk can be achieved by re-CT and re-planning.

Abstract: 65

Primary Ewing's sarcoma of the nasal cavity a rare entity: Report and review of literature

Subhalakshmi Saikia , Vikas Jagtap, Rubu Sunku, A. K. Kalita, M. Bhattacharyya, J. D. Sharma, Munlima Hazarika

Department of Radiotherapy, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India, E-mail: [email protected]

Objective: Evaluation and review of literature in primary Nasal cavity Ewing's tumor at our institute. Materials and Methods: 8 year old girl presented with symptoms of nasal obstruction, proptosis and occasional nasal bleeding of one month history. CT scan showed a tumor arising from nasal cavity with extension into paranasal sinuses and orbital areas with bony destruction. Biopsy and immunohistochemical evaluation was done to confirm Ewing's sarcoma. Results: Histopathogical examination showed a small round cell tumor. On Immunohistochemistry the tumor cells were positive for CD99 and FLI-1 confirming Ewing's sarcoma. Patient received induction chemotherapy with Vincristine, Doxorubicin, Cyclophosphamide. Due to unresectability she was treated with radiotherapy to a dose of 54 Gy/30# (its close to optic chiasma) with IMRT-IGRT technique was given as a local treatment. Patient responded very well and now she is on maintenance chemotherapy. Review of Literature: Primary Ewing's sarcoma of the head and neck is very rare (only 2-3%) and even rarer in the nasal cavity and/or paranasal sinuses. Ewing's tumor appears to be less aggressive in this location than their more typical extremity bone and soft tissue counterparts. Limited follow-up in literature precludes a definitive statement on behavior of EFT in these sites. Chemo-radiation has improved survival rates in this site to more than 50%. Conclusion: The possibility of round cell tumors should be kept in mind in the pediatric age group presenting with nasal mass and obstruction. Proper clinical, radiological and immunohistochemical tests are essential. Induction chemotherapy followed by radiotherapy leads to favorable outcome in unresectable cases.

Abstract: 66

Role of FDG PET - CT scan in treatment of recurrent head and neck cancers: Our experience at Jindal Institute of Medical Sciences

Arun K. Aggarwal , Deepak Kumar, Deepak Shukla, Lovnish Goyal 1 , Aftab, Gleetus Thimothy, Shaili, Anuradha Rani 1

Department of Radiotherapy, Jindal Institute of Medical Sciences, 1 Hisar, Aadhar Hospital, Hissar, Haryana, India, E-mail: [email protected]

Aim: (1) To confirm the staging and distant metastasis. (2) To define the GTV and CTV. Background: Many patients of head and neck cancers develop recurrences within two years of radical treatment. To give re irradiation to primary in these patients with minimum morbidity is very challenging. Materials and Methods: Ten patients presented to radiation department from 1 st January 2016 to 31 st July 2016 previously treated with radical treatment without surgery, biopsy proven of recurrent head and neck squamous cell carcinoma who can afford PET CT were enrolled for the prospective study. Various volumes (GTV, CTV etc) were contoured by two independent radiation oncologists on these patients one on CT SCAN and other on PET - CT SCAN fusion images and difference between the various volumes were noted. Treatment were given according to PET based planning volumes. All radical treatment included concurrent chemo- radiation 70 Gy/35 F/7 Wks to PET CT countered GTV by LINAC and weekly chemotherapy by inj. Cisplatin 30 mg/m 2 with all the supportive care. Results and Conclusion: PET-CT is particularly useful for staging and radiotherapy planning as well as for assessment of treatment response in HNSCC due to its superior accuracy over clinical examination and conventional anatomic staging. The main limitations especially in the post treatment setting are the false positive results due to inflammation and the inability to detect microscopic disease. It was found that there is statistically significant difference in the planning volumes (GTV, CTVs) in both the independent doctors' contouring in all the patients (lesser being in PET based contouring). The details will be submitted.

Abstract: 69

A prospective study evaluating tumour volumes as a predictor of clinical outcome in locally advanced head and neck carcinoma following chemoradiotherapy with weekly cisplatin 40 mg/m 2 along with conventional radiotherapy

Avik Maji , Pratyusha Mukherjee, Abhishek Basu, Bidyut Mondal, Anish Bandyopadhyaya, Swapan Sikdar

Department of Radiotherapy, Medical College and Hospital, Kolkata, West Bengal, India, E-mail: [email protected]

Objective: To study the role of tumour volume (primary & nodal) as predictive marker for response to curative chemoradiation & also to assess the effect of tumour volume on acute toxicity pattern & 1 year DFS. Materials and Methods: This is a prospective study of patients with LAHNSCC in Medical College, Kolkata between 1 st January 2014 & 31 st August 2015. Pre-treatment CT scan of base of skull to thoracic inlet done for primary tumour volume. All patients are treated with chemoradiation (Conventional RT 66 Gy & Weekly Cisplatin 40 mg/m 2 ). Tumour volume is assessed by CT scan at 1 month & 3 months after treatment completion. CR, PR of disease is assessed as per RECIST criteria (version 1.1), Acute toxicity pattern & 1 year DFS are also assessed. Statistical analysis of data is done by Bivariate analysis, one way ANNOVA test & Chi-square test. Results: 58 eligible patients. Median primary tumour volume is 28.25cc. CR is more in patients with tumour volume ≤28.25cc in Bivariate analysis (P = 0.000) & in One way ANNOVA test (P = 0.003). Recurrence within 12 month is significant with stage (P = 0.000) & histologic grade (P = 0.000). 1 year DFS is poor & Grade III skin toxicity, mucositis, dysphagia, xerostomia are more with primary tumour volume ≥28.25cc. Conclusions: Primary tumour volume is an important predictor of clinical outcome & acute toxicity profile in LAHNSCC. Study with larger sample size is warranted.

Abstract: 71

Case report on frontal sinus malignancy

R. Narmadha , N. V. Kalaiyarasi, Giridharan

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

Introduction: Malignancy of paranasal sinus is rare with incidence of less than 1 per 1,00,000 population with frontal sinus tumours accounting for 0.3%. Malignancy of frontal sinus is 43-60% squamous cell carcinoma with high male predominance and common in older age. Due to nonspecific symptoms mimicking inflammatory pathology or misdiagnosed as mucocele, usually diagnosed at advanced stage. Management is often difficult due to complex anatomy and prognosis is generally poor inspite of the treatment modalities used. Case Report: We present a 45 year old male farmer by occupation with complaints of ride sided headache for 6 months duration and a swelling of 4 × 5 cm in the right side of forehead. Patient was initially evaluated in ENT and CT scan and MRI PNS was suggestive of mucocele with lesion in right frontal sinus extending into left and bilateral ethmoids with erosion of roof of right orbit. Patient underwent FESS twice with removal of frontal sinus lesion and post-operative HPE showed dysplasia. Patient was referred with progession of symptoms including diplopia, proptosis. CT brain showed intracranial extension of lesion into right frontal lobe. As patient refused repeat surgery, patient was given concurrent chemo radiotherapy with cisplatin and 5-fluorouarcil and RT dose of 66 Gy using 3D-CRT. Conclusions: This case is presented due to the rarity of its presentation and the need to double check suspicious lesions arising in the frontal sinus to diagnose rare tumours at earlier stage and for a better management with surgical excision and/or chemoradiation.

Abstract: 73

Neoadjuvant chemotherapy in carcinoma nasopharynx: Analysis of treatment outcomes and pattern of failure

M. P. Arun Krishnan , Subhashini John, I. Rajesh, Manu Mathew

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

Background: Number of studies have postulated role of Neoadjuvant chemotherapy (NACT) in downstaging and reducing the incidence of distant metastases in selected group of patients with locally advanced nasopharyngeal cancer. This retrospective study looked at the response rate, toxicity profile, and outcome of this group of patients in our institute. Methods: Between 2011 and 2016, Among the 52 patients who underwent treatment for locally advanced carcinoma nasopharynx; we studied 19 patients who received neoadjuvant chemotherapy followed by concurrent chemoradiotherapy. Results : Majority of the patients were men (63%) with a median age of 30 years. About 47% of patients had skull base involvement, 36% had intracranial involvement and 26% presented with cranial nerve palsies. Bulky nodal disease (31.6%) was the most common indication for NACT. Docetaxel+Cisplatin+5-Flurouracil (68.4%) and carboplatin-5-Flurouracil (15.8%) were the commonly used regimens. Seventy four percent of patients received minimum three cycles of Neoadjuvant chemotherapy. Siginificant Toxicity profile noted includes Febrile neutropenia (5%) and 5-Flurouracil induced bradycardia & vasospasm (21%). Post neoadjuvant chemotherapy clinicoradiological response evaluation showed 84% had partial response, 11% had stable disease and 5% had disease progression. 95% of patients completed radiotherapy all of them had complete reponse on first followup. At a median follow up of 15 months, 75% of patients remained disease free, 5% patient had local recurrence and 15% of patients developed distant metastases. Conclusions : Results of our study shows that neoadjuvant chemotherapy provides a reasonable treatment option, with an acceptable rate of complication and good clinical results in selected group of patients without affecting local control.

Abstract: 75

Dosimetric impact of adaptive radiotherapy in the treatment of locoregionally advanced head and neck cancers

K. Mohammad Naumaan, Srinivas Chilukuri

Department of Radiotherapy, Yashoda Cancer Institute, Hyderabad, Telangana, India, E-mail: [email protected]

Objectives: Anatomic modifications during typical 6-7 week radiotherapy schedules used for treatment of H&N cancers may compromise therapeutic index of IMRT. This study evaluates the impact of Adaptive Radiotherapy (ART) by repeat imaging and repeat planning in such cases and also explores the potential of Deformable Image Registration (DIR). Materials and Methods: 22 patients diagnosed with primary LAHNC eligible for ART fulfilling pre-defined criteria were selected. Re-CT and re-planning was done in each case after a significant anatomical change is observed (Median = 20 th fraction). DIR sequences are generated by modified DEMONS algorithm. Volumes and dosimetry of OARs and targets were compared on repeat CTs as well as DIR CTs. Results: On repeat CTs, the parotid and the target volumes have decreased (all P-values <0.01). DIR CTs under-estimated and over-estimated the volumes of parotids and target volumes respectively. Mean doses of ipsilateral and contralateral parotids would have increased by 3.7 Gy (P = 0.0001) and 2.1 Gy (P = 0.001) respectively in scenario of no re-planning. For PTV HR , D 99 decreased by 7.3% (P = < 0.0001), D 95 decreased by 4.1% (P < 0.0001) if not re-planned. None of the dosimetric comparisons between re-plans done on repeat CTs and DIR CTs yielded a statistically significant result. Conclusion: ART in selected patients (significant tumor shrinkage, weight loss of >10% of baseline weight, and/or loose-fitting mask that causes difficulty with accurate repositioning) of LAHNC decreased doses to both parotids and improved dose coverage to target volumes. DIR is very useful tool for ART but with certain limitations and should be used with caution.

Abstract: 76

Objective: To determine the factors predictive of improved survival among patients with locally advanced laryngeal cancer

Deep Shankar Pruthi

Department of Radiotherapy, Cancer Research Institute, Swami Rama Himalayan University, Dehradun, Uttarakhand, India, E-mail: [email protected]

Objective: To determine the factors predictive of improved survival among patients with locally advanced laryngeal cancer. Materials and Methods: A total number of 60 patients, treated with Total Laryngectomy (TL) or Radical chemo-radiotherapy (CRT) were analysed in this retrospective study conducted in the Department of Radiotherapy, Cancer Research Institute, Swami Rama Himalayan University, Dehradun. 30 patients were in SX-CRT group and 30 patients in CRT group. In multi-modality (Sx-CTRT) arm, 28 patients were stage IV and remaining 2 were stage III. But in CRT Arm 50-50% patients were stage III and stage IV. Our study end point was to determine the factors predictive of improved survival. Results: The median follow up of study was 19 months and there was no difference in survival at 2 year in both treatment groups. But at four years survival rates were 53.1%, and 30% respectively. Overall, Sx-Chemo-RT was significantly associated with increased likelihood of survival compared with chemo-RT. Predictive factors for decreased overall survival included T4 stage (P value 0.545), node positivity (P value 0.568), LVSI (P value 0.352) and PNI (P value 0.309). Predictive factors for CRT group included poorly differentiated on histology (P value 0.421) and addition of concurrent chemotherapy. The technique of Radiotherapy was not a factor in survival although there was difference in Grades of Mucositis when 2D and 3DCRT techniques were compared. Conclusion: In our study Survival was improved in the Surgery followed by Chemo-radiotherapy group. Predictive factors included node positivity, LVSI, PNI and addition of chemotherapy.

Abstract: 82

Comparision of conventional fractionation (5#/week) and accelerated fractionation (6#/week) in squamous cell carcinoma of oropharynx: A prospective study

Jyoti Poddar , J. P. Neema, U. Suryanarayana, R. K. Vyas

Department of Radiotherapy, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]

Aim: To compare the response of Accelerated Fractionation ( 6# per week) Vs Conventional Fractionation (5#/week) in Squamous Cell Carcinoma of Oro-pharynx (T1-3N0 M0). Objective: To assess Disease-free survival and acute and late radiation toxicity. Materials and Methods: 50 patients of SCC of Oropharynx (T1-3N0 M0) from August 2012 - August 2013 were recruited and followed up till October 2014. Type of study: Analytical, prospective two arm 10 study with 25 patients in each arm with a study duration of 2 years. ARM I: Conventional fractionationated RT with 66 Gy/33 # with 5 fractions per week. ARM II: Altered fractionated RT 66 Gy/33# with 6 fractions per week. Assesment of: (1) Response to the treatment i.e. complete, partial or stable disease. (2) Acute reactions i.e. mucositis, skin reactions and dysphagia. (3) Late reactions i.e. Xerostomia, subcutaneous fibrosis.


Conclusions: Complete response and loco-regional tumour control rate was higher in the accelerated arm. Acute reactions were comparable in both arms though the onset was earlier in the accelerated arm. Late reactions were comparable in both the arms. The results were in accordance to the major trials i.e. DAHANCA 6 & 7. Acclerated fractionation has radiobiological advantage of combating accelerated repopulation in oropharngeal cancers.

Abstract: 87

Adaptive radiotherapy in locally advanced head and neck cancer: A dosimetric and volumetric study

Nagarjuna Burela , T. Natrajan, Tej Prakash Soni, T. Senthil Kumar

Department of Radiotherapy, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India, E-mail: [email protected]

Introduction: To evaluate the volumetric and dosimetric alterations occurring during radiotherapy in locally advanced head and neck cancers (LAHNC). Materials and Methods: Ten patients of LAHNC, 6 oropharynx, 3 larynx and 1 hypopharynx were enrolled in prospective study. CT scans were acquired before treatment and 4 weeks after during radiotherapy treatment. Plan (OPLAN) was generated based on initial CT scan for entire course of treatment. Beam configuration of OPLAN was applied to anatomy of mid treatment scan and hybrid plan (HPLAN30) was generated. Adaptive replanning (RPLAN30) for remaining fractions was done. Dose distribution with and without replanning compared for remaining fractions. Results: The shrinkage of planning target volume (PTV), ipsilateral and contralateral parotid after 4 weeks of radiotherapy was statistically significant (P < 0.05). D2% and V>107% of PTV were higher in HPLAN than RPLAN (P < 0.05). Hybrid plans showed increase in delivered dose to spinal cord for remaining fractions. Mid treatment replanning reduced doses to spinal cord (Dmax and D1%) which is statistically significant (P < 0.05). Mean doses to ipsilateral and contralateral parotid of RPLAN (21.4 Gy & 16.74 Gy) were reduced when compared to HPLAN (22.99 Gy & 22 Gy). Conclusions: Interim CT scanning and replanning (adaptive) improves target volume coverage and normal tissue sparing.

Abstract: 91

Comparison of oral cavity and oropharynx lesion presentation at regional cancer center in rural population: An observational study

S. L. Jakhar, Neeti Sharma, H. S. Kumar, Simrandeep Singh

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

Introduction: Head and neck squamous cell carcinoma (HNSCC) is the sixth commonest cancer in the world. In India alone, 2.5 lakhs new patients are diagnosed each year. Among the HNSCCs, carcinoma of oral cavity and oropharynx predominates in Indian population. The present study is aimed to identifying the stage of presentation according to site (i.e. oral cavity and oropharynx) and presenting symptoms. Materials and Methods: A total of 120 randomly selected patients proved histo-pathologically oral cavity and or oro-pharynx squamous cell cancer were enrolled in the study. We check the stage at time of presentation in relation to presenting complains. Results: Among 120 patients of oral cavity and oro-pharynx were 52:68 (43.3% and 56.7%) patients respectively. Most common presenting complaint of oral cavity cancer is visible non healing ulcer and oropharynx cancer is dysphagia. The oral cavity patients presents with stage I are 13 (25%), stage II are 19 (36.6%), stage III are 12 (23.5%) and stage IV are 8 (14.9%) disease. The oropharynx patients presents with stage I are 4 (5.9%), stage II are 13 (19.1%), stage III are 28 (41.2%) and stage IV are 23 (33.8%) disease respectively. The oral cavity and oropharynx patients present in early stage (I and II) were 62%: 25% (P < 0.01) and in late stage (III and IV) were 38%: 75% (P < 0.01) respectively. Conclusions: Oral cavity cancers presented at early stage than oropharynx cancer because oral cavity lesions are visible and oropharynx lesions are symptoms based.

Abstract: 94

Survival and patterns of failure in oral cancers: Single institution retrospective study

Abdul Wahab Abdullah , G. Ashwini, B. Sukrutha, V. Chandipriya, Heena Kauser, L. Tasneem, Swarna Kumari, S. Rohith, K. Harjot, A. Krishnam Raju, B. Nagarjun Reddy, Sudhakar Kumar, E. Vasundhara, M. Suneetha, Deleep Kumar Gudipudi

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

Objectives: To determine patterns of failure and survival after postoperative radiotherapy in oral cancers. Materials and Methods: 100 patients with oral cancers who underwent surgery followed by postoperative radiotherapy with or without concurrent chemotherapy at our institution from June 2011 to December 2013 were retrospectively analysed. Patients were contacted over phone. Pathological status, treatment given and details of documented failures were obtained from hospital records and considered for analysis. Primary end point was median survival and patterns of failure. Kaplan Meier survival analysis and Student t test for factors predicting survival were done. Results: 23 patients could not be contacted and were excluded from analysis. 40 patients had died and 37 were alive at time of analysis. Median survival was 32 months. 26 documented failures with 7 local, 9 regional, 7 distant recurrences (4 in lung and 3 in bones) were observed. 1 patient had developed both regional and distant metastasis. 3 patients had developed local, regional and distant recurrences. Pathological status such as tumour grade (P = 0.022), number of metastatic lymph nodes (P = 0.024), stage (P = 0.001), involved margin (P = 0.026), and ECE (P = 0.007) were predictors of survival. Tumour size (P = 0.088), PNI (P = 0.0722), LVSI (P = 0.11), depth of infiltration (P = 0.24) were not associated with increased survival. Conclusions: Oral cancer patients who underwent surgery followed by postoperative radiotherapy had median survival of 32 months. Most common failure observed was regional followed by distant metastasis. Factors predicting survival were tumour grade, stage, margin status, number of metastatic lymph nodes and extracapsular extension.

Abstract: 97

An analysis of outcome of 608 head and neck cancer patients from an well-equipped radiatin oncology facility

Tejinder Kataria, Susovan Banerjee , Trinanjan Basu, Deepak Gupta, Shikha Goyal, Shyam Bisht, Ashu Abhishek, Kushal Narang, Manoj Tayal

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

Introduction: The present study evaluated the survival outcome of radiotherapy (RT) (radical and post-operative) among patients with head and neck cancer (HNC) treated at our Institute. Materials and Methods: A total of 608 HNC patients eligible for radical or post-operative RT between March 2010 to Dec 2014 were analysed. More than 90% patients received modulated radiotherapy with concurrent chemotherapy as per indications. Demographic parameters and disease related factors were analysed. Disease free survival (DFS) was calculated from end date of radiotherapy till last follow up or last date of disease control. Overall survival (OS) was calculated from date of registration to last follow up date if alive. The primary end point was survival. The statistical analysis were performed using SPSS version 20.0 and Kaplan Meir method was used for calculation survival. Results: The median age was 60 years with male preponderance (Male 513/608). Majority was squamous cell carcinoma (568/608). The subsites treated were Oral cavity (217). oropharynx (154), larynx (136), hypopharynx (61) and nasopharynx (40). RT intent was radical (386) and post-operative (222) with 60% receiving concurrent chemotherapy. There were 77% patients with advanced stage disease. The median follow up period is of 2.5 years. Among the evaluable patients, 110 patients developed disease recurrence with 70% being loco-regional. They received surgical salvage, chemoradiation or hypofractionated RT depending upon multidisciplinary tumour board decision. Conclusions: The single centre large cohort of HNC patient's data was analysed to re-validate need and benefit of RT both in post- operative and radical setting. Final results of the study are yet to be derived.

Abstract: 280

A quantitative comparison of gross tumor volumes delineated on 18F-FDG PET-CT scan and contrast enhanced computed tomography scan in locally advanced head and neck carcinoma treated with intensity modulated radiotherapy

Nagarjuna Burela

Department of Radiotherapy, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India, E-mail: [email protected]

Background: Accurate tumor diagnosis is important in highly conformal techniques like Intensity Modulated Radiotherapy (IMRT), which aims high therapeutic ratio. We compared Gross Tumor Volume (GTV) (primary and nodal) delineated on 18F-FDG-PET-CT scan to those delineated on CECT scan and its impact on staging, treated by IMRT. Materials and Methods: A total of 30 consecutive patients with locally advanced squamous cell carcinoma of head and neck were included in this study. FDG-PET and CECT scans were performed with dedicated PET-CT scanner in single session as part of radiotherapy treatment planning for IMRT. 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 remaining 27 cases, the primary sites were 17 oropharynx, 2 hypopharynx, 7 larynx and one unknown primary with secondary neck node. PET-CT resulted in changes of CT-based staging in 25% patients (up-staged in 3 and down-staged in 4). No significant difference between GTV delineated on PET vs CT scan (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 and event free survival was 76% & 76%, respectively. Conclusion: The target delineation of GTV can be improved with functional imaging 18F-FDG PET-CT.

Key words: Gross tumor volume, head and neck cancer, IMRT, PET/CT, target delineation

Abstract: 281

Re-irradiation in head and neck cancers: A single institutional experience

R. K. Spartacus , Rohitashwa Dana, Aseem Rai Bhatnagar 1 , Kartick Rastogi, Kampra Gupta, Ajay Singh Chaudhary, Neeraj Sharma, Sandeep Bhaskar, Nikesh Agarwal, Sushil Kumar Saini

Department of Radiotherapy, SMS Medical College and Attached Group of Hospitals, 1 Linear Accelerator Centre, SMS Hospital, Jaipur, Rajasthan, India, E-mail: [email protected]

Introduction: In head and neck cancers, the incidence of recurrence after radiation therapy or second primary tumors is 30%-50% and 20% respectively. Because loco-regional tumor progression is the predominant cause of death in patients with head and neck cancer, achieving local control in patients with recurrent disease becomes important. For patients with operable recurrence, surgical resection is considered the standard of care. Postoperative re-irradiation with chemotherapy improves local control and disease-free survival. For patients presenting with unresectable recurrence or medically unfit for surgery or refusing surgery, definitive re-irradiation with chemotherapy is the only potentially curative treatment. Aims and Objectives: The aim of this study was to evaluate loco-regional control, overall survival and toxicity in patients receiving re-irradiation for recurrent head and neck cancers. Materials and Methods: Records of 35 patients re-irradiated with 3DCRT and IMRT for head and neck cancer between January 2013 and June 2015 were reviewed and analyzed. Patients were followed on a quarterly basis for 2 years. The Radiation Therapy Oncology Group (RTOG) morbidity criteria were employed to assess acute and late toxicity. Loco-regional control (LRC) and overall survival (OS) were calculated from the final day of radiation treatment using the Kaplan-Meier method. Results: The median follow-up was 14 months. Median time interval between initial radiation and re-irradiation was 51 months (range 12-240 months). The median re-irradiation dose was 60 Gy (range 24-70 Gy). Eight (23%) patients underwent prior salvage surgical resection. Most of the patients received concurrent chemotherapy. The 1-year overall survival and loco-regional control rates were 48% and 60%, respectively. Severe grade 3-4 re-irradiation related toxicity occurred in 12 patients (34.28%); one death was observed during treatment. Conclusions: The present study achieved local control and overall survival comparable to those with available literature. The treatment related morbidity was higher due to the high cumulative doses received and the fact that all patients did not receive IMRT in re-irradiation setting.

Abstract: 282

Neo adjuvant chemo-radiation therapy in T4 resectable oral cavity cancers: A prospective single institute clinical trial

Shreeya Pabi , Cheemala Sushmitha, S. N. Geeta, M. S. Ganesh, G. Bhanumathy, Namratha

Departments of Radiotherapy and Surgical Oncology, Vydehi Institute of Medical Sciences and Research Center, Bengaluru, Karnataka, India, E-mail: [email protected]

Background: Locally advanced operable oral squamous cell carcinoma (OSCC) continues to be a major therapeutic challenge despite the implementation of novel multi-modal treatment approaches. To improve local-regional control and to allow better functional and cosmetic results after surgery, neoadjuvant protocols have been developed during the last decade implementing radiochemotherapy prior to selective surgery. The theoretical advantages of preoperative chemoradiotherapy are downstaging of the primary tumor, an increased resectability rate, and the elimination of micrometastases. Currently there is no well defined protocol for neoadjuvant chemoradiotherapy for resectable oral cavity cancers. Hence this study is undertaken. Aims and Objectives: Primary objective is to evaluate clinical and pathological response at both primary and neck and margin status in T4 resectable oral cavity cancer patients treated with neo adjuvant chemo-radiotherapy. Secondary objective is to evaluate postoperative morbidity. Materials and Methods: 33 patients, presenting with stage IV oral cavity cancers were treated with neoadjuvant chemo radiation. Radiotherapy was delivered to a dose of 4600cGy in 23 fractions, 200cGy per fraction, 5 fractions per week to primary and neck, using 3 dimensional conformal radiation therapy (3DCRT) with 6 MV photons. Chemotherapy drug was Inj. Cisplatin (70 mg/m 2 ) which was delivered concurrently with radiation therapy on day 1 and day 21. Surgery was performed after 2 to 6 weeks. Results: In our study, out of 33 patients receiving NACT-RT, 23 (69.7%) patients underwent surgery in which 12 (36.7%) had pathological complete response with no residual disease, 23 (63.6%) had partial response with negative margins and negative nodes. 2 (6%) of patients had positive margins. Postoperative morbidity, 2 patients had developed fistula which was managed conservatively. Neoadjuvant chemo radiotherapy did not increase post op morbidity. Conclusion: Our study concludes that neo adjuvant chemo-radiotherapy followed by surgery is feasible with good pathological complete responses. Since response to chemo radiotherapy is an important prognostic factor, results may translate in better disease free survival in the future.

Key words: Neo adjuvant chemo-radiotherapy, resectable oral cavity cancer


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