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Year : 2019  |  Volume : 15  |  Issue : 9  |  Page : 233-260

Head and Neck

Date of Web Publication28-Nov-2019

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How to cite this article:
. Head and Neck. J Can Res Ther 2019;15, Suppl S2:233-60

How to cite this URL:
. Head and Neck. J Can Res Ther [serial online] 2019 [cited 2021 Jun 14];15:233-60. Available from: https://www.cancerjournal.net/text.asp?2019/15/9/233/271710

 > Abstract: 115: Clinical and dosimetric outcomes of adaptive radiotherapy in head and neck cancers: A single-centre audit from a hospital in Uttar Pradesh (India) Top

Dulal Kiran Mondal, Anu Tiwari, Rajesh K. Agarwal, T. Vasanthaman

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

Purpose and Objective(s): To evaluate the effects of adaptive radiotherapy on clinical, dosimetric and toxicity outcomes for patients with head and neck cancers treated with radical radiotherapy with or without chemotherapy. Materials and Methods: 29 patients of locally advanced head and neck cancer eligible for radical radiotherapy underwent planning scans and were planned for 36-44 Gy to both high risk and low risk volumes in first phase. All patients underwent rescan at 20-22 fractions. In the second phase, all patients were planned to a total dose of 66-70 Gy. Local control and acute and late toxicities assessed. Extent of GTV reduction and disease free survival calculated. Results: Total 29 patients included in this audit. 26 were male and 3 female. Median age was 57 years. KPS 60-80. Site: Oral cavity 7, Oropharynx 9, Larynx 5, Laryngopharynx 5, Maxilla 2 and Nasopharynx 1. Stage: T2= 4, T3= 8 and T4= 17, N0= 6, N1= 5, N2= 7 and N3= 11. All patients were Stage IVB and non-metastatic. Median change in body contour was 8 mm. Median GTV reduction was 37%. Median reduction in PTV was 32%. With adaptive replanning median reduction of Dmax to spinal cord, brainstem were 4.1Gy and 3.9 Gy respectively and median reduction of Dmean to parotid was 2 Gy.. 10 patients had radiotherapy only whereas 19 patients received chemoradiotherapy. Acute grade 3 mucositis was 34%. 58% of patients needed feeding tube due to grade 3 dysphagia. Grade 3 hematological toxicity was 3% only. Median follow-up was 10 months and median disease free survival was 6 months. Overall response rate was 86% and 48% patients achieved locoregional control. Conclusion: Adaptive replanning with respect to anatomic and tumour volume and shape may lead to better sparing of organs at risk while locoregional control rate remains comparable. Reduction of toxicities may lead to better quality of life.

 > Abstract: 127: A prospective study of posttreatment response assessment in cervical nodal metastasis from head and neck squamous cell carcinoma by using magnetic resonance imaging Top

Suhail Ahmed, Amrut S. Kadam

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

Purpose and Objective(s): To assess the post-treatment response and detect residual malignancy in cervical nodes from Head and Neck squamous cell carcinoma (HNSCC) after CRT(chemoradiation) or RT(radiotherapy) by using MRI. Materials and Methods: 24 patients with histologically proven HNSCC satisfying inclusion and exclusion criteria were enrolled in the study. All the patients were treated with concurrent chemoradiation with 66 -70 Gy/33-35 Fx of RT and 5 cycles of weekly injection cisplatin (40mg/m2) except one patient who was treated with RT alone to 66 Gy due to poor general health and advanced age. All patients underwent pre and post-treatment MRIs and in a sub-set of 10 patients pre and post-treatment CT scan was also done to correlate the findings. A feaseable histological test with FNAC was done in post-treatment palpable lymph nodes. Treatment response was assessed as complete response (CR), partial response (PR) , stable disease (SD) and progressive disease (PD) based on literature from previous studies and RECIST 1.1 criteria for response evaluation in lymph nodes. Results: There was increase in post-treatment ADC values , decrease in post-treatment size and volume of lymph nodes. When the post-treatment parameters mentioned above were correlated with treatment outcome and pre-treatment ADC values, size and volumes, there was significant difference between complete responders and partial responders or non-responders. Conclusion: There was significant difference between post-treatment mean ADC values , size and volume changes between complete responders and partial or non-responders when compared with their pre-treatment mean ADC values, size and volume. Hence this study provides some evidence for using MRIs for assessing treatment response in cervical nodal metastasis from HNSCC.

 > Abstract: 128: The risk of second malignant tumors after definitive treatment of nasopharyngeal carcinoma: Three case reports and literature review Top

Ashwini Lakshmaiah, Pradeep Kumar K. N.

Srinivasam Cancer Centre, Bengaluru, Karnataka, India, E-mail: [email protected]

Introduction: Patients with head and neck squamous cell carcinoma (HNSCC) have an increased incidence of developing second malignant tumors (SMTs). This may possibly be explained by the concept of “field cancerization” or “condemned mucosa syndrome”, implying the importance of other risk factors like smoking, alcohol consumption, genetic factors and viral infections. However, risk factors for SMTs have not been documented well, especially in nasopharyngeal carcinoma (NPC). Objective: Evaluate the presence of risk factors in the development of SMTs after the treatment of NPC at our institution after a 6-year follow up. Methods: In this study, we retrospectively analyzed 63 patients with pathologically confirmed diagnosis of non-metastatic NPC from June 2009 to June 2015 treated with curative intent using EBRT (IMRT/ 3D) with concurrent chemotherapy for the development of SMTs. Apart from our data, literature review on the topic showed an additional 1970 patients who were also analyzed. Results: After a median follow up of 56 months (24–96 months), 2 patients were diagnosed with SMTs of tongue after 5 years and 1 patient developed esthesioneuroblastoma of right nasal cavity 3 years later in the radiation field. Both patients with SMTs in the tongue were diagnosed with Stage 1 SCC of the tongue, in the previously irradiated field and both were treated with HDR Brachytherapy with a dose of 36 Gy in twice daily fractionated schedule for 5–6 days. The third patient diagnosed with esthesioneuroblastoma of right nasal cavity was treated with complete excision of the mass. 60 out of the 1970 patients from the literature reviewed had developed SMTs at various sites. Conclusion: In patients with NPC, radiation therapy is probably a potential risk factor for developing SMTs, apart from other independent risk factors like tobacco and alcohol. SMTs can develop as early as 3 years after the completion of treatment and hence warrant close follow up.

 > Abstract: 132: Treatment outcome of hyperfractionated radiotherapy with concurrent chemotherapy in locally advanced head and neck cancer Top

Namrata Bhagat, Vandana Jain

Pravara Institute of Medical Sciences, Rahata, Maharashtra, India, E-mail: [email protected]

To study the treatment outcome (local control and disease free survival) in head and neck cancer patients undergoing hyperfrationated radiotherapy along with concurrent chemotherapy.


  • To evaluate the tolerability of Hyperfractionated Radiotherapy with concurrent Chemotherapy in locally advanced head and neck cancers
  • To assess local control and disease free survival with hyperfrationated radiotherapy along with concurrent chemotherapy
  • To assess acute and late toxicities using RTOG toxicity criteria.

Materials and Methods: This was an observational study conducted in the Department of Radiotherapy & Oncology, PMT Loni. A total of 30 histopathology proven locally advanced Head and Neack Cancer patients of either gender between 25-65 years on Hyperfractionated Radiotherapy along concurrent chemotherapy were selected for the study. A written informed consent was taken for the participation in the study. Patient's characteristics were assessed by simple statistical techniques techniques using mean,median,standard deviaton for 30patients. who have been given hyperfrationated RT(1.1Gy/# twice a day at 6 hours interval) with weekly Injection Cisplatin (30 mg/m2) for a treatment duration of 6-7weeks. Total dose 66-72Gy.

  • Patients were assessed for toxicity profile every week
  • All patients after completion of treatment were assessed after 6 weeks (first follow up) and three-monthly follow up thereafter
  • On each follow up patient were evaluated by:

    1. Clinical examination
    2. Haematological investigations
    3. Radiological investigations.

Thereafter, the prognostic outcome of each patient were assessed on the following parameters:

  • Acute and late Side effects (grading by RTOG criteria)
  • Disease free survival for minimum of 6 months
  • Loco-regional control for complete or partial response
  • Recurrence.

Results: Out of 30 patients 23(76.66%) were males and 7(23.33%) were females,the average age being 52-55yrs(53.5yrs) The commonest Head and neck malignancy among them was found to be in the Oral cavity 9(30%) followed by Oropharynx 8(26.66%),Hypopharynx 8(26.66%) and lastly Larynx 5(16.66%). These malignancies had a significant addiction history -tobacco forms 15(50%), alcohol consumption 2(6.66%),9(30%) were addicted to both and 4(13.33%) had no addictions. These locally advanced patients of Stage III(46.66%) and Stage IV(53.33%) were assessed for acute and late toxicities, locoregional control, overall survival. The results of which will be presented during the presentation as the last follow up is up till 31st september 2019. Conclusion: The results are awaited and will be updated during presentation.

 > Abstract: 133: Vitamin-D in head and neck radiotherapy: Potential in cancer therapeutics Top

Arya Bhanu, Chaitali Waghmare

Pravara Institute of Medical Science, Rahata, Maharashtra, India, E-mail: [email protected]

Background: Non Nasopharyngeal Head and Neck squamous cell cancer (NNPHNSCC) is a major cause of morbidity and mortality worldwide. Radiation therapy (RT) with/without concurrent chemotherapy (CT) either given as radical /adjuvant treatment remain the classical treatment modality. RT however cause a wide range of adverse effect (acute and late toxicities) which affect quality of life and results in high rate of hospitalization and treatment interruption. Vitamin D is one such effective agent which has shown to have anti-proliferative, anti-invasive, induction of apoptosis in tumor cells as well as precancerous lesion, radiosensitization and chemosensitization effect on tumor cells , thereby decreasing radiation toxicities and overcoming treatment resistance. Hence there is need to evaluate the role of vitamin D level with respect to radiation toxicities and response in NNHNC. Materials and Methods: It was a prospective longitudinal study conducted in Department of radiation oncology from October 2018 till July 2019, after institutional ethics committee approval. Twenty eight patients with NNPHNSCC who had received radical/adjuvant CTRT were assessed for radiation toxicities (Mucositis/skin reactions) and hematological toxicities at regular intervals using CTCAE V5.0 and response was evaluated according to RECIST 1.1 and vitamin D levels were assessed at the time of first follow up. The patients were divided into two groups- Group A: Optimal Vitamin D levels (>/=75 nmol/L) and Group B Suboptimal (<75 nmol/L). The treatment toxicities and response were then co-related with Vitamin D levels. Statistical analysis was done using Graph pad software. Results: The study cohort was of 28 patients, out of which female were 13 (46.42%) and males were 15 (53.57%). The various sites involved were oral cavity 20 (71.42%), oropharynx 2 (7.14%), hypopharynx 2 (7.14%) and larynx 4 (14.28%). Out of total twenty eight patients stage II disease was in 2 (7.14%), stage III in 14 (50%) and stage IV in 12 (42.85%). Radical CTRT was given to 10 (35.71%), adjuvant CTRT in 16 (57.14%) and RT alone in 2 (7.1%). Vitamin D levels were optimal in eight patients (28.57%) and were suboptimal in twenty patients (71.42%). The subgroup analysis of toxicities hemotological-hemoglobin and total blood cell count, skin (dermatitis) and mucositis. We observed relatively lower hemoglobin and total white cell count in the subgroup B(p value not significant). Grade II and Grade III skin toxicities were 65% and 25% in Group B while it was 25% and 25% in Group A respectively showing relatively higher toxicities in subgroup with suboptimal Vitamin D levels. Grade II and Grade III mucosal toxicities were 55% and 45% in Group B while it was 50% and 0% in Group A respectively showing relatively higher toxicities in subgroup with suboptimal Vitamin D levels. Conclusion: The skin and hematological toxicities were relatively(though statistically non significant) more in the subgroup with low Vitamin d levels. Future studies with large number of patients are needed to document the importance of vitamin D in Head and neck radiation therapy.

 > Abstract: 136: Comparison between the clinical outcomes of two hypofractionated palliative radiotherapy schedules in locally advanced inoperable head and neck cancers Top

Subhadra Choubey, Arun Kumar Rathi, Kishore Singh, Savita Arora

Lok Nayak Hospital and MAMC, Delhi, India, E-mail: [email protected]

Purpose and Objective(s): To compare clinical outcomes of two palliative hypofractionated radiotherapy schedules in incurable head and neck cancers. The primary aim of the study was to evaluate the response to treatment objectively (clinically) and in terms of subjective symptom relief. The toxicity of hypofractionated radiotherapy (as per RTOG criteria) was assessed and compared. Quality of life parameters of the patients undergoing treatment were evaluated using EORTC H&N35 Questionnaire. Materials and Methods: The study population consisted of 40 patients, all locally advanced (stage IVA/B) head and neck carcinoma. Twenty patients were randomised in each arm. Patients in arm A received 50 Gy in 16 fractions (Christie regime). Patients in arm B received 14 Gy in 4 fractions twice daily 6 hr apart, for 2 consecutive days repeated three times with 3-4 weeks gap (Quad shot). QoL questionnaires were filled for all patients. Results: Overall, 57.5% patients had improvement and 35% patients had no change in the performance status. However, there was no statistical significant difference between two arms in terms of performance status. The pain relief was reported in 78% of patients with significant decrease in pain score from pre-treatment score (p<0.0001). The median and mean of the pain scores when analysed post radiotherapy in both the arms and it was not statistically significant for the differences (p=0.196). Although, the mean subjective relief was greater in Christie arm (53.75%) as compared to quad shot arm (38%), but again not statistically significant (p=0.092). The median overall survival of our study population was 7 months. Also, there was overall improvement in quality of life (87.5%) in our study population including improvement in pain (78.13%), speech (62.5%) and global health status (87.5%) as reported by majority of patients who filled the QoL questionnaire. There was more (?1 grade) toxicity recorded in Christie arm as compared to Quad shot arm ,[significant in skin (p<0.001), mucositis (p<0.001), salivary gland (p<0.001) and laryngitis (p<0.001) and non-significant for dysphagia (p=0.049) and anaemia (p=0.638)]. While the quality of life plays a major role in deciding efficacy of a palliative regime, there was no statistically significant difference between the two arms in our study. But there was significant improvement in global health status reported post treatment in overall population (p=<0.0001). Conclusion: Both the palliative regimes (Christie and Quad shot) are very effective for palliation in inoperable locally advanced head and neck cancer patients. Though the toxicities were more in Christie regime than Quad shot arm, the overall survival was numerically higher in Christie arm but not significant. There was significant improvement in quality of life of patients in both the arms but, the difference between the two was not statistically significant.

 > Abstract: 150: Lenvatinib: An emerging molecule in carcinoma thyroid Top

Anju Joy, R. Rejnish Kumar, K. Ramdas, Kainickal Cessal Thommachan, Malu Rafi

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

Conclusion: Follicular carcinoma thyroid with brain metastasis carries a poor prognosis carries a poor prognosis with median survival time of 4.7 months. This case study demonstrates a successful treatement option with Lenvatinib which is a multiple kinase inhibitor(VEGF R1-3,FGFR 1-3 etc.). This patient is 65 year old male patient known case of Diabetes Mellitus, diagnosed with Follicular carcinoma thyroid. In August 2016 he underwent total thyroidectomy followed by RaI. After a disease free interval of 1 year 4 months patient developed a large parieto occipital metastatic lesion. Palliative radiotherapy to brain 30Gy/10# was planned but he completed only 5# as patient developed left sided weakness. He was started on Tab Lenvatinib 24mg OD and continued for 18 months. Patient has an excellent response to Lenvatinib with almost near complete response to brain metastasis. This shows efficacy of Lenvatinib and provides strong evidence for new treatment modality in metastatic carcinoma thyroid where options of treatment are limited after surgery and RaI,though recently Sorafenib also has shown limited activity.

 > Abstract: 159: An interim analysis of comparison between hypofractionated radiotherapy with concomitant chemotherapy and conventional chemoradiation in locally advanced head and neck squamous cell carcinomas Top

Uddiptya Goswami

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

Background: Head and neck cancer (HNC) is the 6th most common cancer worldwide. In India, over 200,000 cases of HNCs occur with nearly 60% of this population presents with locally advanced but non metastatic disease. Historically, radiation therapy (RT) alone was the standard non-surgical therapy for locally advanced disease. The state of art radiation dose fractionation has evolved from conventional scheme to altered fractionation schedules. While hyperfractionation spares late responding tissues and allows a higher dose to be delivered, hypofractionation has an advantage of shorter overall treatment time, lesser effect of accelerated repopulation, along with increased patient compliance, but often at the cost of higher normal tissue toxicities. Purpose: To compare tumour response and toxicity profiles in patients receiving hypofractionated radiotherapy with concomitant chemotherapy with that of the patients receiving conventional fractionation with concomitant chemotherapy. Materials and Methods: From November 2018 to March 2019, 42 Patients with locally advanced squamous cell carcinomas of oropharynx, hypopharynx and larynx were allocated into 2 arms. The patients selected in conventional arm(A) received 3DCRT at a dose of 66 Gray (Gy) in 33 fractions (#) to high risk CTV, 60 Gy in 30# to intermediate risk CTV, AND 50 Gy in 25# to low risk CTV, 2Gy per fraction over 6 ½ weeks. The patients in hypofractionated arm (B), received 3DCRT dose of 55 Gray in 20 fractions to high risk CTV, 49.5 Gy in 18# to intermediate risk CTV, and 46.75Gy in 17# to low risk CTV, 2.75 Gy per fraction over 4 weeks. All the patients received injection cisplatin (40 mg/m2) weekly during the treatment with standard anti emetic prophylaxis. On a follow up of 3 months, acute toxicities were assessed using RTOG common toxicity criteria during and after completion of radiotherapy and response assessment was done using RECIST. Results: In terms of age, sex, site and ECOG performance status at presentation, both arms had comparable demographics. Out of 42 patients, 20 and 22 patients were respectively selected in Arm-A and Arm-B respectively. 60% patients (12) in Arm-A had complete response compared to 54.5% in Arm-B (12) (p value=0.496). Partial response was seen in 5 patients of Arm-A and 9 patients of Arm-B. Stable disease was seen in 2 patients of Arm-A and 1 patient of Arm-B. One patient of Arm-A was found to have progressive disease. Toxicity was observed mostly in the form of oral mucositis and radiation dermatitis. Grade 3 mucositis was seen in 35% patients (7) of Arm-A vs 36.3% patients (8) of Arm-B [p value=O.311]. Grade 2 mucositis was present in 50% patients (10) of arm-A & 27.2% patients (6) of Arm-B. Dermatitis grade 3 was seen in 20% (3) patients of Arm-A and 13.63% (4) patients of Arm-B [p value=0.951]. Grade 3 dysphagia was seen in 1 patient of each arm. Conclusion: This hypofractionated regimen has a satisfactory locoregional response with acceptable toxicity profile. This strategy can be applied to utilize our resources optimally and may improve patient compliance. The long term toxicities are yet to be assessed as the study is ongoing.

 > Abstract: 160: Retrospective review of prognostic significance of anemia and neutrophil-to-lymphocyte ratio in head and neck cancer treated with neoadjuvant chemotherapy Top

Abhishek Soni, Anil Khurana, Om Parkash, Yashpal Verma, Ashok Chauhan, Paramjeet Kaur

Pt. B.D.S. PGIMS/Pt B.D.S. UHS, Rohtak, Haryana, India, E-mail: [email protected]

Background: Neoadjuvant chemotherapy (NACT) before definitive (radiation/surgical) treatment can decrease the tumor volume, and can alter systemic inflammatory response and tumor oxygenation. However, there are no validated prognostic markers to predict the response to chemotherapy. The pretreatment anemia is an established poor prognostic marker for head and neck squamous cell carcinoma (HNSCC) treatment as hemoglobin is a marker of the oxygen-binding capacity and is required for cancer oxygenation and for the efficacy of cytotoxic chemotherapy and radiotherapy. Neutrophil-to-lymphocyte ratio (NLR) is the ratio of absolute neutrophil count to the absolute lymphocyte count, and is a marker of systemic inflammation. Its association with survival outcomes is established in literature. But, the association of the anemia and NLR with either response to NACT or treatment outcomes has not been established. Purpose: We retrospectively analyzed the prognostic value of anemia and NLR in HNSCC patients treated with NACT. The endpoints were the response to chemotherapy and survival outcomes. Methodology: Histopathologically proven HNSCC patients treated from 2013 to 2016 were included in the study. The NLR was calculated as described above and anemia was considered according to the reference values of <12 g/dL. NACT was comprised of a combination of platin and fluorouracil (PF), or more recently taxane, platin, and fluorouracil (TPF) administered every 3 weekly for 3-4 cycles. Hematologic parameters were analyzed before and after (3-4 weeks) NACT. Response evaluation was done using RECIST 1.1 and WHO criteria. Correlation analyses were carried out using linear regression and NLR was analyzed as a dichotomous variable. NLR cutoff was chosen as high (>5) or low (≤5) based on previous literature. The statistical analyses were performed using IBM SPSS Statistics version 23. The p values were two sided and p<0.05 was considered significant. Results: Total 139 patients were included in study. The median hemoglobin and NLR level before NACT were 12.5 g/dL (range, 9.2 to 14.7 g/dL) and 3.45 (range, 0.54 to 10.25), and were not dependent on the local extent of the disease. The median hemoglobin and NLR level after NACT were 10.3 g/dL (range, 8.2 to 12.4 g/dL) and 2.42 (range, 0.21 to 15.17), respectively. Seventeen patients were having anemia and NLR > 5 both prior to NACT. The anemia and NLR before NACT were not correlated, and they were also not associated with the response to NACT. Even anemia or NLR >5 before NACT were not associated with poor response to NACT. However, anemia and NLR > 5 before treatment were both associated with shorter overall survival (OS), (p=0.02 and p=0.04 respectively) and disease free survival (DFS), (p=0.02 and p=0.03 respectively). These factors were associated significantly with survival outcomes. Conclusion: In head and neck cancer patients treated with NACT, anemia and high NLR ratio before NACT were associated with shorter overall survival and shorter disease free survival, and were independent of response to chemotherapy.

 > Abstract: 166: Impact of carotid sparing technique using hypofractionated volumetric modulated arc radiotherapy in early glottic cancer patients with high risk features for atherosclerosis: Pilot study Top

Pooja Sethi

JIPMER, Puducherry, India, E-mail: [email protected]

Background: Standard treatment for early stage larynx cancer is Radical RT. Although RT is associated with very high cure rate but nevertheless it is associated with long term side effects of cerebrovascular complications. Purpose: The purpose of this study is to compare the dose distribution parameters between carotid sparing technique using Hypo-fractionated Volumetric Modulated Arc radiotherapy (CS-VMAT) and compare with conventional 2D technique – parallel opposed lateral wedged field technique (2D-PORT), in early glottic cancer patients. Methodology: Twelve histologically proven early (T1aN0), (T1bN0) glottic cancer patients treated with Hypo-fractionated carotid sparing CS-VMAT (63Gy/28#@2.25Gy/#) were included in the study with at least one of the following risk factors for atherosclerosis: Hypertension, Diabetes mellitus, Hyperlipidaemia, Age > 65 years, History of smoking, Previous coronary heart disease, History of stroke. For every patient, the conventional 2D-PORT plan was virtually planned in the treatment planning system for dosimetric comparison. Dual sectoral arc was planned in all cases treated with VMAT. The parameters which were analysed are: CS-VMAT and 2D-PORT plans were compared in terms of planning target volume (PTV) coverage and the doses for carotid arteries, spinal cord and thyroid gland. Daily bolus (5mm) was used in case of anterior commissure involvement. Results: No local Recurrence and cerebrovascular event was observed in any patient during the follow-up period (48 months). V95% for PTV showed no significant difference between CS-VMAT and 2D-PORT plans, while V100% was significantly higher in the CS-VMAT plan (p = 0.005). The median V25Gy (12%), and V50Gy (0.5%) for carotid artery PRV (3 mm) in the CS-VMAT plan were significantly lower than those in the 2D-PORT plan (90.0%, and 74%, respectively) (p = 0.005). Spinal cord PRV Doses were on higher range in CS-VMAT arm but within tolerance limits as per QUANTEC Dose constraints. Thyroid gland (V50 <62%) doses were significantly lower in CS-VMAT arm compared to 2D-PORT. Conclusion: Our study suggests that carotid sparing CS-VMAT can significantly decrease the dose to carotid arteries compared to conventional 2D-PORT, and it should be considered as a better option for early glottic cancer patients especially with high risk of atherosclerosis. However Longer follow-up is required to substantiate clinical outcome in terms of local control.

 > Abstract: 168: A retrospective study of thyroid functional status in patients treated with radiation therapy over head and neck region for squamous cell carcinoma of head and neck Top

Rina Barman, Pradip Kumar Maiti

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

Purpose and Objective(s): Head and neck cancer is the sixth most common carcinoma in the world. Management of head neck cancer is either surgery or radiotherapy (RT) for early stage tumour and surgery combined with radiotherapy, radical radiotherapy or concurrent chemoradiotherapy (CCRT) for advanced stages. One of the most common clinical late effects of thyroid gland irradiation in patients exposed to therapeutic doses to the neck is hypothyroidism. Objectives: To estimate the prevalence of hypothyroidism in post radiation head neck cancer patients where radiation portal included total or most of the thyroid gland and to calculate the Odds ratio for the development of subclinical or clinical hypothyroidism. Materials and Methods: From February 2018 to May 2019, 102 patients with histopathologically proven advanced (stage III, IV) squamous cell carcinoma of head and neck region (excluding patients with thyroid malignancy and prior neck surgery) who were treated with radical external beam radiotherapy (68-70 Gy) delivered by Cobalt 60 Teletherapy machine with conventional fractionation over head and neck region at least 6 months back were studied. Thyroid function tests (T3, T4, TSH, f-T4) were done at 6 months,9 months and 12 months after completion of radiotherapy. Results: Out of the 102 patients with mean age of 50.9 (±9.4) years, 64 (62.7 %) were males and 38 (37.3 %) were females. Most common Primary tumour site was larynx (36.1%). CCRT was given to 65.7 % of patients and 75.5% of patients had stage-III disease. Two patients were lost to follow-up. Overall, 35% developed hypothyroidism of which 18 % were clinical (high TSH, low f-T4) and 17 % were sub-clinical hypothyroidism (high TSH, normal f-T4) at one year of follow-up. No significant associations were found with age, gender, stage and addition of chemotherapy. In comparison with control group (patients attending other OPDs, N=200) odds ratio for the development of hypothyroidism was found to be 3.5 (subclinical-4.9,Clinical- 1.9). Conclusion: Hypothyroidism is an under recognized morbidity of external beam radiation to the neck. Recognizing hypothyroidism early and treating it prevents associated complications. Hence, thyroid function tests should be done during routine follow up.

 > Abstract: 171: A prospective randomized controlled comparison of sequential boost intensity modulated radiotherapy versus simultaneous integrated boost intensity modulated radiotherapy in head and neck cancer Top

Garima Jaiswal, Sushil Agarawal, Sunil Choudhary, Uday Shahi, Nilesh Mani, Rumita Singh, Ritika Ranjan, Rakesh Ranjan, Ishan Kumar

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

Purpose and Objective(s): The advantage of Intensity modulated radiotherapy (IMRT) over conventional and 3D conformal radiotherapy (3DCRT) in head and neck cancer is well established. IMRT can be delivered with the usual Sequential Method (SEQ-IMRT) where shrinking volumes are treated in two or three phases. The other method is Simultaneous Integrated Boost IMRT wherein the different target volumes are treated simultaneously over the same duration. Dosimetric comparison between the two techniques have shown the supremacy of the SIB technique over the other in terms of better dose conformity and sparing of organs at risk (OAR). Since SIB requires a single RT plan, it is less tedious compared to the other. Clinical comparison studies between the two techniques in Head and Neck Cancer is lacking in the literature. The study was done to prove if there was any difference among the two IMRT techniques in terms of acute adverse events and quality of life. Materials and Methods: The study was conducted in SS Hospital, BHU, Varanasi between December, 2017 and August, 2019. Histologically confirmed patients, aged 18 to 75 years with KPS > 60 of squamous cell carcinoma of oropharynx, hypopharynx and larynx with stage II to IVA (AJCC 7th ) were considered for the study. Three planning target volumes (PTV) i.e. PTV HR (high risk), PTV IR (intermediate risk) and PTV LR (low risk) were defined in both the arms. The patients were randomized into two treatment arms:

  1. SEQ IMRT arm: PTV 50 (PTV HR + PTV IR + PTV LR): 50 Gy/25F/5weeks, PTV 60 (PTV HR + PTV IR): 10 Gy/5F/1 week, PTV 70 (PTV HR) 10 Gy/5F/1 week
  2. SIB IMRT arm: PTV HR: 66 Gy/30F/6weeks, PTV IR: 60Gy/30F/6weeks, PTV LR: 54Gy/30F/6weeks.

Stage II patients and those above the age of 65 years in both the groups were treated with RT alone. Stage III and IVA patients and those aged 65 years or below were treated with RT and concurrent Cisplatin given once a week at 35 mg/m2. EORTC-QLQ 30 (version 3) and EORTC QLQ-H&N35 questionnaires were used for QOL assessment. Pure tone (PTA) and Impedence Audiometry (IA) and Quality of Life Assessment (QOL) were done before the start of treatment. Response assessment was done at 3 months of completion of treatment with CECT face and neck using NIRADS (Neck Imaging Reporting and Data System), repeat PTA and IA, and QOL. Results: None of our patients had grade 4 acute toxicity. Grade 3 esophagitis and pharyngitis was seen in two patients in each arm. Rest of the patients had grade 2 or less acute adverse events which was similar in the two groups. Improvement in QOL was seen in both the groups but was better in the SIB arm. Unlike SIB arm, there was significant deterioration in both sensorineural and conductive deafness in SEQ arm. Eustachian tube dysfunction increased after RT in both the arms but its incidence was seen more in patients treated with SIB IMRT. Conclusion: Though the patients in both the arms had no difference in the adverse acute events and effect on the ears, improvement in QOL was significantly better in the SIB arm.

Abstract: 177: Radiation dose to dysphagia aspiration Related structures and its effect on swallowing: Comparison of three Dimensional conformal radiotherapy and intensity modulated radiation therapy plans

Venkata Ravi Teja Matta, K. V. L. Anusha, P. Anandarao

SL Medical College, Rajahmundry, Andhra Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): The aim of this study was to compare radiation dose to dysphagia aspiration related structures (DARS) in intensity modulated radiation therapy (IMRT) and three-dimensional conformal radiotherapy (3DCRT), and assess its relation to post-treatment swallowing status, in patients of head and neck cancers. Materials and Methods: Treatment plans of patients treated with IMRT and 3DCRT, from AUGUST 2018 TO MAY 2019-08-29 were analysed. Swallowing structures were contoured. Dose volume histograms were generated. Constraint doses were considered based on the statistical derivations. Swallowing status was evaluated based on RTOG Toxicity criteria. Results: Definitive statistical and subjective correlations were found to exist between doses of swallowing structures. Probable mean dose constraints derived statistically clinically corroborates with the swallowing status of patients. IMRT had statistically significant advantage over 3DCRT, in terms of V30, V50 ,V60 , and D80 for swallowing structures taken together. Conclusion: Patients of head and neck cancers treated with an advanced state of art technique of IMRT and conventional 3DCRT, has shown that a relationship does exist between the dose received by the swallowing structures and dysphagia, thereby acting as a prime factor deciding the quality of life. Further prospective studies are required to confirm these and to improve the swallowing quality.

 > Abstract: 182: Comparison of triplet (TPF regimen) versus doublet chemotherapy as neo-adjuvant therapy in locally advanced head and neck squamous cell carcinoma Top

R. Srinath Bharadwaj, Harsha Panchal, Itesh Khatwani, Asha Anand, Apurv Patel, Sonia Parekh

B.J. Medical College/The Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]

Introduction: India has the highest incidence of Head and neck cancer in the world. Advanced locoregional disease [stage III or IV(A & B)] is the most frequent presentation. Induction chemotherapy for HNSCC has been evaluated for more than two decades without any consistent proof of benefit except for organ preservation, but widely used in the practice. Common combinations regimens used as neoadjuvant chemotherapy include TPF (taxane,cisplatin and 5-FU), but in India and other developing countries due to poor nutritional and financial status or inability to take chemotherapy for 3 days ,cost effective and relatively less toxic single day regimens are used. Study is necessary to compare the outcome of the 3 drug vs. 2 drug regimens in our institute. Materials and Methods: Observational study of unresectable stage III, IVa or IVb treatment naïve HNSCC patients was conducted from October 2014 to December 2016 at Gujarat Cancer and Research Institute. Results: Out of 100 patients, 30 patients received TPF, while 70 patients received doublet chemotherapy. Median age was 36 years and 55 years respectively. Most common presentation was stage IVA (~74%) in both arms. After induction chemotherapy the ORR was 60% and 58% in TPF and doublet chemotherapy respectively with CR in 10% and 1% respectively (p=0.92 for ORR but p<0.05 for CR). In 57% patients in TPF and 53% in doublet chemotherapy were given curative treatment either surgery or chemoradiation. Most grade 2 to 4 toxicities including neutropenia were more in TPF compared to doublet chemotherapy. Average cost and hospital stay (4vs.1 day) were higher for TPF than doublet chemotherapy. Conclusion: Single day doublet chemotherapy is cost-effective, safer and non-inferior to triplet chemotherapy in locally advanced head and neck squamous cell carcinoma in a resource poor setting and it is an option in those who have logistic issues due to social and financial reasons.

 > Abstract: 185: Tolerance of radical radiotherapy among elderly head and neck cancer patients Top

K. S. Sandeep, A. S. Kirthi Koushik

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

Purpose: Head & Neck cancers usually occur in the elderly age group and about half of the cases Occur at the age >60 years with majority detected in an advanced stage with increased morbidity and decreasing compliance to therapy. Since there are limited data available for adequate Treatment of elderly Head and Neck cancer patients, we proposed a study to analyse tolerance and response based on age, site, modality of treatment received and implication of nutrition vs weight loss during treatment.


  1. Elderly patients will have increased toxicity and decreased tolerance to treatment
  2. Decreased quality of life after radical treatment compared to younger cohort
  3. Influence of other related factors specific to elderly patients like Co-morbidity, nutritional support, treatment duration in the tolerance and response to treatment.

Materials and Methods: 55 eligible patients were evaluated with detailed history and physical examination, biochemical, pathological and radiological investigations. Patients were staged based on TNM staging and treated as per the standard guidelines. Patients were assessed with the weekly routine blood investigation, Weight loss and Toxicity. The response was assessed after 6 weeks and documented as per RECIST criteria. Results: 52/55 (94.5%) patients completed the treatment and 48/55 (92.3%) had a complete response at 6 weeks (p value 0.000) with a mean treatment duration of 46.67days and mean weight loss of 5.44kgs with 55.4% having GR II mucositis, 40% having GRIII mucositis at the time of completion of treatment. 68% having GRII and 38.2% having GR I dermatitis and 80% having moderate pain. Subgroup analysis done for tolerance and response to treatment based on age, site and treatment technique and modality. Patients also assessed for nutrition vs weight loss. Conclusion. We concluded that elderly patients tolerate and response to the treatment is comparable to younger patients with acceptable toxicities, hence age should not be a barrier to decide treatment.

 > Abstract: 187: Role of very low dose chemotherapy under insulin induced hypoglycemia in recurrent and advanced staged head and neck cancer Top

Tauseef Ali, Virendra Bhandari, Aafreen Khan, Shalu Verma, Sahaj Palod, Sumit Gupta

Sri Aurobindo Institute of Medical Sciences and PGI, Indore, Madhya Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): To understand Role of very low dose chemotherapy under insulin induced hypoglycemia in previously treated advanced and recurrent head and neck cancer and evaluate response rate, survival rate and toxicities due to insulin induced hypoglycemia and low dose chemotherapy. Materials and Methods: In this study 8 patients of previously treated recurrent and advanced head and neck cancer were taken. All of these patients received weekly 6 cycles of low dose chemotherapy under insulin induced hypoglycemia with Cisplatin 6mg/m2 and Gemcitabine 200 mg/m2 in Intensive Care Unit under continuous monitoring of neurological and cardiac toxicities. Response rate and survival rate were noted, Overall survival was measured from start of therapy till the last follow up and or death of patient. Toxicities due to low dose chemotherapy and insulin induced hypoglycemia were also noted. Results: The median survival rate was 5.2 months. The overall response was 71.42% there were no neurological or cardiac toxicities due to insulin induced hypoglycemia, there were negligible toxicities of low dose chemotherapy. Conclusion: Low dose chemotherapy under insulin induced hypoglycemia has good response and can be preferred in patients with advanced stage and recurrent head and neck cancer, it has negligible toxicities in comparison to other metronomic chemotherapy.

 > Abstract: 189: Evaluation of clinical outcome of adaptive radiotherapy in head and neck cancer Top

Sumit Gupta, Virendra Bhandari, Shalu Verma, Sahaj Palod, Tauseef Ali, Aafreen Khan

Sri Aurobindo Institute of Medical Science, Indore, Madhya Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): To study the acute and late toxicity in Head-and-neck (H&N) cancer patients treated with adaptive radiotherapy technique. Materials and Methods: twenty-five patients of head and neck cancer undergoing radiation at our institute who had significant weight loss or tumor shrinkage assessed clinically were included in this study. Patients were re planned with adaptive radiotherapy, repeat computed tomography (Re-CT) was done in between 15-20 fractions (#). Patients received External beam radiotherapy with a dose of 66-70 Gray (Gy) in 33-35 #. Acute toxicities were assessed during and after the treatment. Late toxicities were assessed till 1 year of follow up. Results: In this study, the PTV coverage with dose to 95% and 99% volume was found to be 97.72 % (±2.73) and 93.8% (±2.95) respectively in AP while 90.7% (±3.76) and 84.5% (±7.60) respectively in HP. The maximum dose (Dmax) to spinal cord and brainstem was reduced by 1.52 Gray (Gy) and 3.98Gy in AP. Similarly, the mean doses to right and left parotids were also reduced by 5.9 Gy, 3.78 Gy respectively in AP as compared to that in HP. Patients experienced acute mucositis 28% grade (Gr) I, Gr II 39% and Gr III 33%, dermatitis 45% Gr I and 38% Gr II, 17% Gr-III, xerostomia 43% Gr-I, 32% Gr- II, 22% Gr-III, fibrosis 35% Gr-I, 30% Gr- II, 5% Gr-III and ear toxicities 14% Gr- I. None of the patients had grade IV or above toxicity. Conclusion: Thus, patients treated with adaptive radiotherapy in head & neck cancer, there were reduction in the dose of OARs & toxicities were also less. Only grade-I, II and III toxicities were observed. There were with no grade IV toxicity. All the toxicities were managed with minimal medical intervention and none of the patient required hospital admission during or after the treatment amenable to radiation induced toxicities. In terms of toxicities, adaptive radiotherapy is a good technique as there is no treatment interruption during the course of radiation due to grade IV acute toxicities. Late toxicities were also managed with minimal medical intervention.

 > Abstract: 193: Clinico-pathological correlation of p16 expression in oropharyngeal cancer treated with definitive chemoradiotherapy and its impact on response Top

Mashkoor Ahmad, Madhup Rastogi Rastogi, Rahat Hadi

Dr. RMLIMS, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Introduction: Data on p16 expression in Indian Oropharynx squamous cell carcinoma (OPSCC) patient is limited. We aimed to study p16 expression rate in OPSCC patient treated with definitive CTRT and its correlation with response therapy. Materials and Methods: Our study was a prospective observational study in OPSCC patients with stage II to IV A ( AJCC 8th ). p16 analysis was done by Immuno-histochemistry method in biopsy specimen. Definitive radiotherapy (RT) of 70 GRAY in 35 fraction , 5 fraction per week in two phase was given by linear accelerator using 3 dimensional conformal radiotherapy technique with concurrent chemotherapy , cisplatin 35 mg / m2 weekly. Response was evaluated 3 month post RT by contrast enhance computed tomography and direct laryngoscopy. p16 positivity was correlated with WHO response criteria ( CR vs PR) achieved by using chi square test. P value of < 0.05 was considered statistically significant. Results: Total 50 patient were included in the study with median age of 58 years (range 26-75) and male : female ratio of 44:6. Median RT dose and duration were 70 GY (range 66- 70 gray) & 47 days (44-52) with median cisplatin dose 50 mg and median cycle was 6. p16 positivity rate was 16 % (8/50patients ). No definite association between p16 expression and T or N stage was observed in our study. The complete response rate at 3 month of complete of CTRT achieved were higher in p16 +ve patients 87.5% vs 47.6 % for p16 –ve patients (p= 0.05) and partial response in p16 +ve patient was 12.5% vs 45.23% for p16 –ve patients. Conclusion: p16 positivity rate is 16% which is similar to other contemporary Indian studies which report 10-20% of p16 positive rate and better complete response rate in p16 positive patients.

 > Abstract: 194: Controversial issues in management of locally advanced head and neck cancers Top

Anil Kumar Dhull, Vivek Kaushal, Rajeev Atri, Rakesh Dhankhar

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

Purpose and Objective(s): Great strides have been made in managing patients with locally advanced head and neck cancer (LAHNC) over the past 30-years. The co-administration of chemotherapy and chemoradiation both as definitive and adjuvant treatment, has been shown to be more efficacious than radiotherapy alone. The increasing use of longer, more aggressive combined treatments provokes a number of controversies regarding the impact on disease control. Materials and Methods: A comprehensive search and systematic review of electronic databases was carried out to discuss the controversial management of LAHNC. A recent retrospective analysis of 12-years attending RCC Rohtak have shown that most of the HNC patients were presented as LAHNC (i.e. 92.3%). Hence, this is a matter of debate to develop the general consensus for the management of LAHNC with radiotherapy alone, CRT, targeted therapy or only palliation. Novel approaches using chemoradiation (CRT) have improved disease control and quality of life. But controversies remain about how to optimize the use of CRT, including the role for targeted therapies. Studies have shown that most common presenting complaints i.e. dysphagia and cervical nodes are the main areas for palliation. Results: Studies have demonstrated that chemoradiation (CRT) is more effective than radiotherapy alone in the treatment of locally advanced SCCHN. MACHNC showed that addition of chemotherapy to radiotherapy achieves benefits in locoregional control and in overall survival. Results showed that concomitant CRT was more effective than use of adjuvant or neoadjuvant treatment with radiotherapy alone, with a significant gain in survival of 19%. The other side of the coin is toxicity, demonstrating that the use of CRT in the postoperative setting results in a significant increase in acute toxicity compared to radiotherapy alone. Analysis have shown that more than three-quarters of patients treated with CRT had toxicity of grade 3 or more compared to 34% of those who had radiotherapy alone following surgery. Are Targeted Drugs the Answer? EGFR is a member of an important family of transmembrane proteins associated with signalling pathways central to cell growth and differentiation. Among the agents able to inhibit EGFR activation, cetuximab (C225) has been the most explored so far. Studies have shown that addition of C225 to cisplatin leads to complete inhibition of cell growth and further increased median survival from 14.9-months to 24.4-months. The locoregional control rate at three years was 13% higher in favour of the cetuximab arm (47% vs 34%), which was highly significant. The Bonner trial demonstrated that cetuximab plus radiotherapy is more efficacious than radiotherapy alone. Conclusion: The different options are radiotherapy plus targeted therapies , definitive radiotherapy, with altered fractionation and the use of molecular markers as prognostic indicators for treatment outcome. There are lot of controversies in the management of LAHNC using surgical approach, radiation, chemotherapy, targeted therapy or palliative management only and needs tailored approach. Options to reduce the risk of distant metastases include novel multidrug regimens and maintenance treatment with chemotherapy or targeted agents.

 > Abstract: 197: Biodosimetric evaluation of head and neck cancer patients undergoing radiotherapy or concurrent chemoradiotherapy by dicentric chromosomal aberration assay Top

Kumar Prabhat, Arun Kumar Rathi, Kishore Singh, Seema Kapoor, Savita Arora, Sunil Kumar Polipali, Ankur Jindal

Maulana Azad Medical College, Delhi, India, E-mail: [email protected]

Purpose: To evaluate in vivo dose–response relation of dicentric chromosome aberration formation in peripheral blood lymphocyte of head and neck cancer patients undergoing radiotherapy or concurrent chemoradiotherapy. Methodology: A total 40 patients of head and neck cancer (20 patients in each group - CTRT versus RT alone) were enrolled in this study with prior informed consent. Inclusion criteria were

  • Squamous cell carcinoma or adenocarcinoma of head and neck
  • Age group-18 to 60 years
  • ECOG-0-2
  • Complete blood counts, kidney function test, liver function test and 2D-ECHO (within normal limit).

Radiotherapy planning was done as per standard protocol by two parallel opposed fields. Radiotherapy was delivered by TELECOBALT Co-60 (THERATRON 780E). Daily dose of 200 cGy for 5 days a week was given. Total dose varied between 50 Gy to 70 Gy. Patients planned for concurrent chemoradiotherapy were also given weekly chemotherapy with Cisplatin 40 mg/m2 on every week before radiotherapy. After required culture and incubation of heparinized blood samples, the lymphocytes were isolated and stained to identify chromosomal aberrations such as dicentric per one hundred metaphases for each individual. The yield of dicentric chromosome was measured in blood samples taken before starting treatment (day 0), during the course of radiotherapy (6, 11 and 16th fraction), each time one hour after radiotherapy. Results: In our study, comparison of the two groups at individual point of time was done and we found that there was a significant difference in terms of mean dicentric chromosome yield/cm2 at day 6 (p = 0.001), day 11 (p < 0.001), and day 16 of RT (p < 0.001). The mean dicentric chromosome yield/cm2 in the chemoradiotherapy group was greater than that of the radiotherapy alone group by 16.33%, 28.57%, and 18.68 % on day 6, 11, and 16 of RT, respectively. Conclusion: There is a strong effect on the yield of dicentric chromosome/cm2 after adding chemotherapy. The study found that dicentric chromosome yield/cm2 in the CTRT group was greater than that of the RT alone group. The dicentric chromosomal aberration assay is an established biomarker for chromosomal damage used for cytogenetic biodosimetry and the benefit of adding chemotherapy can be radiobiologically proven by dicentric chromosomal analysis.

 > Abstract: 198: A prospective study to observe the effects of concurrent chemo radiotherapy on the thyroid gland in head and neck carcinoma Top

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

Sarojini Naidu Medical College, Agra, Uttar Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): Radiotherapy is an integral part of radical management of head and neck malignancies, used either alone or in combination with surgery and/or chemotherapy in advanced stages. Majority of head and neck cancers are loco-regionally advanced at the time of diagnosis. Hence, Radiotherapy portals, apart from including the primary site of the tumor, will invariably cover the whole neck, thereby including the thyroid gland in the radiation field leading to its dysfunction. Objective: To study (i) the acute and late effect of chemo-radiation on thyroid gland (ii) to observe the magnitude of thyroid dysfunction following radiotherapy to the neck (iii) to assess the mean time period for the development of thyroid dysfunction (iv) to give stress upon the necessity of including thyroid function tests as part of follow-up and treating the symptomatic patients. Materials and Methods: This is a prospective study including 65 eligible patients of squamous cell carcinoma of head and neck region, enrolled from Nov 2017 to Nov 2018. All patients received radical radiation dose of 70Gy in 35 fractions at the rate of2Gy per fraction and 5 fractions per week by tele-cobalt-60 machine at SSD with weekly concurrent chemotherapy in the form of inj. cisplatin35mg/m2. Thyroid function tests {thyroid stimulating hormone (TSH), tri-iodothyronine (T3) and thyroxine(T4)} and ultrasonography of neck were performed before commencement of radiotherapy, at mid treatment (after17fractions of radiation), on completion of radiotherapy,3month followup,6month follow and 9month follow up after completion of treatment. Results: Average values of Thyroid Function Test parameters at different time during radiotherapy and follow up period were as follow-Before radiotherapy average T3, T4 and TSH levels were-130.52ng/dl,8.53μg/dl,2.53μIU/ml respectively, on mid radiotherapy average T3, T4 and TSH levels were -148.18ng/dl,10.38μg/dl,1.19μIU/ml and on completion of radiotherapy T3.T4 and TSH values were -168.48ng/dl,12.60μg/dl and0.59μIU/ml respectively. During radiotherapy total 38 out of 65(58.46%) patients showed hyperthyroid state. Follow up T3, T4 and TSH levels at 3 months were- 134.49 ng/dl,8.39μg/dl and 9.90μIU/ml, at 6 month follow up T3,T4 and TSH levels were - 104.5ng/dl,6.9 μg/dl and 17.94μIu/ml and at 9month follow up T3, T4 and TSH values were -94.69 ng/dl, 6.14μg/dl and 40.38μIU/ml respectively. At 9month of follow up 37 out of 65(56.92%) patients showed hypothyroid state. After 9 months of follow up total 9/65(13.8%) patient develops anatomical changes in form of nodular goiter, colloid goiter and simple cyst in thyroid glands. Conclusion: Hypothyroidism (clinical or subclinical) is an under-recognized morbidity of external beam radiation to the neck in case of head and neck malignancies. Recognizing hypothyroidism (clinical or subclinical) early and treating it prevents associated complications which are usually neglected. Hence, thyroid function tests should be made as a routine investigation during follow- up.

 > Abstract: 201: A prospective study of adaptive radiation therapy in head and neck malignancies Top

Saravanan Devarajan, B. Krishnamoorthy Reddy, V. Natarajan, Vasudha Narayanaswamy, Mayur Mayank, P. Subhathra, M. Prasanna Kumar, V. Karthik, M. S. Belliappa, L. Vijay Bhaskar, M. R. Anil Kumar, M. Vinay Ural, Bindu K. Venugopal, Kavitha R, Ravindra G, Chandana S, Srinivasulu Reddy, Shambhavi Sharma, Sadanand Sharosh Gandhi, Prathima Ramachandran

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

Purpose and Objective(s): The purpose of the study is to maximize target coverage and minimize normal tissue toxicity by adaptive radiation therapy in head and neck malignancies. Materials and Methods: 35 Patients diagnosed with head and neck malignances and planned for radiation therapy (Definitive /Adjuvant) were recruited from January 2018 to June 2019. The Primary sites were Oral Cavity (8), Oropharynx (11), Nasopharynx (2), Hypopharynx (9) and larynx (5). All Patients were simulated with Plain and Contrast CT Scan. Target volumes and organs at risk (OAR)were delineated. Base plan was implemented. Repeat CT Scans were done at 16th to 18th Fraction (>36 Gy) and at 25th to 28th Fraction (>50 Gy) (due to changes in tumour volume and/or patient weight-loss) and Target volumes and OAR were re-contoured. Dosimetric evaluation of Target volume coverage and OAR relative to baseline CT was done. Replans were implemented after plan evaluation. All patients were treated with IMRT or VMAT with Image Guidance. Results: Target volume coverage was improved in 29 patients by an average of 1.62 % after the first repeat CT scan and by 3.16 % after the second repeat CT scan. Ipsilateral parotid dose was reduced by 7.76 % and 10.28 %, contralateral parotid dose was reduced by 10.09 % and 12.64 %, spinal cord dose was reduced by 10.58 % and 5.04% and mandible dose was reduced by 0.92% and 1.32 % after the first and the second repeat CT scans respectively. The benefit was maximally seen in the oropharynx. Conclusion: Adaptive radiation therapy with two interval CT Scans for replanning is highly effective in improving target volume coverage and minimizing normal tissue dose in head and neck malignancies. The efficacy of the same needs to be evaluated by long term follow-up of the patients.

 > Abstract: 202: Retrospective analysis of weight loss and accute toxicity pattern in patients undergoing dysphasia aspiration related structures and submandibular gland sparing adjuvant volumetric arc therapy for cancer buccal mucosa and alveolus Top

Tapas Dora, Abhishek Chatterjee, Jayashree Deshmukh, Sarbani Laskar, Amol Kakade

S. C. B Medical College, Cuttack, Odisha, India, E-mail: [email protected]

Purpose and Objective(s): We conducted a retrospective audit to study the cut off mean doses for dysphasia aspiration related structures & contralateral Submandibular gland in relation to the patterns of weight loss & acute mucosal toxicity. Though most of standard guidelines define significant weight loss as 10kg over 3months, here we studied in two categories of >3kg & >5kg because mostly course of adjuvant radiotherapy lasts for 6-7weeks only. Materials and Methods: A retrospective database of 62 patients of Carcinoma Buccal Mucosa or Alveolus who had received adjuvant volumetric arc therapy (VMAT) (60-63Gy/ 30-35#/ 6-7wks) on Versa-HD (ELEKTA) with IGRT (thrice weekly) and conc. Cisplatin (40 mg/m2) from December 2016 to July 2019 were reviewed. The RTOG grading system for acute toxicity was used to score toxicity of skin, mucous membrane& weight loss. Treatment plans were reviewed for mean doses of Oral Cavity (OC), DARS (DR) & Esophagus (EP). Receiver Operating Characteristics was run on SPSS version 21 to get thresholds to categorize the above mean values towards weight loss pattern >3kg or >5kg. Chi-square analysis was performed to find whether the categorized mean values were significant for above weight loss patterns. Results: Mean & Median weight loss was 3.3kg (0-9Kg) & 3Kg for both categories with or without nasogastric tube. Mean dose to DARS & contralateral Submandibular gland was 41Gy (27.8Gy-55.5Gy)& 23.2Gy (9.9Gy-59.8Gy) respectively. Weight loss ≥3Kg & ≥5Kg was seen in 39 (63%) & 18 (29%) patients. In the whole population, weight loss was significantly impacted by mean doses to DARS (<39Gy vs. >39Gy) towards ≥3 Kg (28% vs. 72%, p=0.027) only & not for ≥5 Kg (22% vs. 78%, p=0.088) on Chi-square. But when subcategorized to with (23) or without (39) nasogastric tube, it impacted significantly to the group without nasogastric tube towards weight loss of both ≥3 Kg (27% vs. 73%, p=0.011) & ≥5 Kg (9% vs. 91%, p=0.011) on Chi-square. Whether nasogastric tube was placed prophylactic before (17) the start of radiotherapy or reactive (6) during radiotherapy didn't affect significantly to the pattern of wt loss 3kg (p= 0.560) & 5kg (p=0.226). Grade 0, I, II, III acute skin toxicity was observed in 2%, 50%, 45%, 3%. Grade 0, I, II, III mucosal toxicity was observed in 0%, 32%, 60%, 8%. Mean doses of Contra lateral Submandibular gland (<25Gy vs. >25Gy) favored ≥Gr III acute mucosal toxicity (p=0.068). With a median follow up of 7mo (0-28), 5 patients had loco regional recurrence, 3 had local plus distant metastasis & 2 had distant metastasis alone. None of the recurrences was in the spared submandibular or DARS structures. Median disease free survival was 2mo (0-5). Death is noted in 8 (13%) cases & median overall survival was 6mo (5-12). Conclusion: In patients undergoing adjuvant VMAT with CTRT restricting mean doses of DARS to less than 39Gy, significantly reduced the incidence of weight loss more than 3kg & 5kg in cases without naso-gastric tube & limiting mean dose to contra lateral Submandibular gland to less than 25Gy significantly reduced Gr III acute mucosal toxicity to <8%.

 > Abstract: 206: Mesenchymal chondrosarcoma of infratemporal fossa: A case report Top

S. Devika, K. L. Jayakumar

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

Purpose and Objective(s): Mesenchymal chondrosarcoma is a rare subtype of Chondrosarcoma, arising from embryonic remnants of cartilage or metaplasia of meningial fibroblast. They constitute upto 3-9% of Chondrosarcomas and are highly aggressive tumors usually seen in younger age groups. Mesenchymal chondrosarcoma tends to arise from skeletal and rarely extraskeletal soft tissues, which was first reported in 1964. Wide surgical excision is the primary modality of treatment. Due to high chance of local recurrence and metastatic potential adjuvant therapy is indicated. Post operative Chemotherapy is indicated as these tumors are radioresistant, but preoperative radiotherapy can be used for tumor debulking according to some authorities. Infratemporal fossa is a rare site of occurrence of Mesenchymal chondrosarcoma and only 3 cases has been reported so far in English literature. Materials and Methods: A 38 year old lady, presented with complaints of swelling over the left side of face since 1 year, which was progressively increasing in size and was associated with diminished sensation over the left side of face. Patient had restriction of mouth opening and inability to chew since 6 months. Examination revealed firm tender diffuse swelling over the left side of face with fixity to underlying bone causing facial asymmetry. Skin over the swelling was normal. Intraorally no growth was seen. MRI Brain and Neck done, revealed 6.4 x 6.2 x 6.7 cm heterogeneously enhancing lesion involving deep lobe of parotid and pterygoid muscles. The lesion widens the formaen ovale with extraaxial component in medial temporal region extending to Meckel's cave. Metastatic workup including CECT Chest and Bone scan were negative, so elective maximal debulking of infratemporal fossa tumor was carried out. Gross specimen showed fragments of soft tissue along with bony elements. Microscopy showed small ovoid cells with scanty cytoplasm interspersed among hyaline, fibrous tissue, chondroid matrix, dilated vascular channels as in hemangiopericytoma along with masses of low grade chondrosarcoma, drawing the diagnosis of Mesenchymal chondrosarcoma. This case was discussed in multidisciplinary tumor board and in view of incomplete resection, was planned for adjuvant chemotherapy followed by completion surgery. Conclusion: Being high grade and due to restricted surgical maneuverability in the confined space of skull base, Mesenchymal chondrosarcoma of infratemporal fossa has an increased propensity for local recurrence and systemic metastasis. This case report is to add to the limited literature available about Mesenchymal chondrosarcoma and highlights the need for early detection and institution of aggressive multimodality treatment for good clinical outcome.

 > Abstract: 208: Incidence of nasopharyngeal carcinoma in Nagaland and its association with lifestyle factors: An institution based study Top

Shirley T. Leivon, Sedevi Angami, Khrutzotso Kikhi, Vevosolu Rakhro

Christian Institute of Health Sciences and Research, Dimapur, Nagaland, India, E-mail: [email protected]

Purpose and Objective(s): The incidence of NPC has been found to be common in Southeast Asia, some parts of North Africa and the Arctic. It is common in north-east states of India (especially Nagaland, Manipur, Mizoram) compared to the rest of the country. It has been hypothesized that due to the nature of the migratory population in North-East India, the genetic make-up and lifestyle habits closely bear resemblance to the mongoloids. Also, The age-adjusted rate of NPC in the Kohima district of Nagaland State is 19.4/100 000, which is among the highest recorded rates. Till date, there are limited studies on the etiology, incidence, treatment and survival of patients suffering with nasopharyngeal carcinoma in the north-east region. This study is aimed at providing some data based on a single institution in one year. Materials and Methods: The number of patients seen in the Radiation Oncology department from 1/5/2018 to 1/5/2019 were recorded as per the hospital registry. The association between nasopharyngeal cancer and lifestyle factors like diet (smoked meat and fermented food) and smoking were observed. Results: NPC comprises around 58% of all head and neck cancers in this institution based study. There were a total of 60 patients recorded in one year, out of which 39 were males and 21 were females. The patients under 40 years of age were 19 in number. The most common histology observed was non-keratinizing carcinoma, consisting of 25 patients out of the total number of patients. The association with Epstein Barr Virus infection is strongly suspected. Further immunohistochemistry studies are required to establish this hypothesis in this population. Almost all patients are consumers of smoked meat, salted fish and fermented food. Twenty-six were smokers and males. Most patients presented in stages II and III and the most common presentation was a neck node swelling. Most patients were not aware of the effect of diet and habits on the etiology of cancer at the time of diagnosis. Conclusion: The incidence of NPC in the north-east region of India correlates with the high incidence of this disease in the South-east Asian and South Chinese population. Genetic causes cannot be ruled out, although further genetic studies are required to establish this information. The incidence of EBV infection is also not well studied but its incidence is strongly suspected as most cases present as non-keratinizing carcinoma. More studies are needed in this population to confirm this fact. Diet and habits that causes this disease are observed in this population. More information, IHC-based studies, molecular studies along with patient education and awareness are required to arrive at an optimum prevention and treatment protocol for this specific population.

 > Abstract: 213: Audit of oropharyngeal, laryngeal and hypopharyngeal cancers treated with volumetric arc therapy at Homi Bhabha Cancer Hospital, Sangrur Top

Jayashree Deshmukh, Tapas Kumar Dora, Abhishek Chatterjee, Sarbani Ghosh Laskar, Jai Prakash Agarwal

Homi Bhabha Cancer Hospital, Sangrur, Punjab, India, E-mail: [email protected]

Purpose and Objective(s): External radiation therapy remains a standard modality of treatment of carcinoma of the oropharynx & larynx as either single modality of treatment or in combination with chemotherapy. Intensity modulated radiotherapy is the most common technique of radiotherapy planning in head neck malignancies used now a days due to its effective tumoricidal effect and decreased in dose to normal tissues in vicinity resulting in improved survival and reduced radiation related toxicity and thus improving quality of life. Materials and Methods: The records of 159 patients were evaluated for Pre radiotherapy disease status & Post radiotherapy outcome. There was an overall male preponderance 138 Male (86.9 %) and 21 Female of Squamous Cell Carcinoma of Oropharynx (85), Larynx (36) and Hypopharynx (38) who had received radical volumetric arc therapy (VMAT) (66-70Gy/ 30-35#/ 6-7wks) on Versa-HD (ELEKTA) with IGRT (thrice weekly) and conc Cisplatin (40 mg/m2) from December 2016 to July 2019. Results: Median age at diagnosis was 59 yrs. More than 90 % had advanced Stage Disease (Stage III 28% and Stage IV 63%). Radiotherapy technique used was VMAT in 153 (96%) patients & IMRT in 6 (4%) cases. Out of that 78% received Conc Chemotherapy with radiotherapy. Median RT dose prescribed was 66Gy (66-70Gy). Planned radiotherapy protocol completed in 150 (94%) patients out of which 145 (91%) cases completed treatment without any treatment breaks. Average 6-7 cycles of Concurrent Chemo Cisplatin or Carboplatin was received in 67% & 10% cases respectively. 23% had received radiotherapy alone. Average Weight Loss was 4 kg (0-12 kg). The Most common Grade of acute skin toxicity was Gr I in 59.7 % followed by Gr II in 27.7 %, Gr 0 in 11.3 %, while Gr III toxicity occurred in only 0.6 % of patients. None of the patients experienced Gr IV acute Skin Toxicity. Similar trend of Grading was observed for acute mucositis also (Gr I> Gr II> Gr 0> Gr III > Gr IV) 51.6 %, 35.8 %, 11.3%, 0.6 %, 0 % respectively. With Median follow up of 6 Months (0-34 months), 82 (51.6 %) were alive, 66 (41.5 %) were dead (59 cancer death) and 11 (6.9 %) were lost to follow up. At last follow up 37 (23.3 %) had loco-regional recurrence, out of this 10 had metastatic disease & 6 cases had metastatic failure alone. The most common site of metastasis was Lung (70%). 3 Patients developed Second Primary in Esophagus. 2 Patients had residual disease after completion of planned treatment. Only 6 patients treated with radical intent after recurrence, while remaining patients received Palliative treatment. Median OS was 8mo (6-20) & DFS was 4mo (0-4) and 55.3 % were controlled with no evidence of disease. Conclusion: With image guided radiation technique though the precision of delivering radical dose to gross disease has been achieved but improvement in disease free survival and overall survival is poor in cases of locally advanced disease at presentation due to high incidence of local & distance failure even after treatment completion.

 > Abstract: 214: A comparative study evaluating the role of benzydamine versus povidone iodine gargling in oral mucositis during concomitant chemoradiation in locally advanced head and neck carcinoma Top

Karun Kamboj

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

Purpose and Objective(s): To compare the role of benzydamine versus povidone iodine gargling in oral mucositis during concomitant chemoradiation in locally advanced head and neck carcinoma. Materials and Methods: The study was conducted on 60 previously untreated, histopathologically proven patients of squamous cell carcinoma of head and neck in locally advanced stage, attending the Department of Radiotherapy, PGIMS, Rohtak for concurrent chemoradiotherapy. Conventional radical radiation therapy was given as five fractions per week, total dose 64 Gy/32 fractions/6.2 weeks (i.e. 2 Gy/fraction) with injection Cisplatin 100 mg/m2 repeated every three week for three cycles. Group I patient did gargling with 0.15% benzydamine, four times a day, starting from first day of radiotherapy. Group II patients did gargling with 1% povidone iodine, four times a day starting from first day of radiotherapy. Tumour control was assessed at the completion of treatment. Mucositis was assessed using Radiation Therapy Oncology Group (RTOG) criteria. Results: Most common age group in both the groups is 50-60 years. All the patients were males and all were chronic smokers. In group I - 12 patients were in stage III (60%) and 8 patientsin stage IV-A (40%). In group II, 14 patients were in stage III (70%) and 6 patients in stage IV-A (30%). Complete response after 1 month of completion of treatment was seen in 10 patients in group I (50%) and partial response in 10 patients (50%). In group II complete response is seen in 8 patients (40%) and partial response is seen in 12 patients (60%). In group I mucositis first appear in 3rdweek in 2 patients (10%) and in group II in 10 patients (50%). At the end of treatment in group I, grade II mucositis is seen in 10 patients (50%), grade I in 10 patients (50%). In group II at the end of treatment gradeI mucositis is seen in 2 patients (10%) grade II in 10 patients (50%), grade III in 8 patients (40%). Conclusion: It is seen that in group I patients, mucositis appear late during treatment as compare to group II and grade II and grade III reactions were less in group I patients. The response rate to treatment was almost similar in both the groups. It is concluded that benzydamine gargles is superior in preventing radiation induced mucositis as compared to povidone iodine gargles. Larger study is recommended to confirm the findings.

 > Abstract: 215: Evaluation of interstitial boost by high dose rate brachytherapy in head and neck carcinomas Top

Rumita Singh, Lalit Mohan Aggarwal, U. P. Shahi

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

Purpose and Objective(s): Advanced head and neck cancer required combined modality treatment with surgery and radiotherapy with or without chemotherapy. However surgery in this region is associated with significant functional deficit as well as poor cosmetic outcome. Availability of interstitial brachytherapy has made it possible to avoid surgery and its complication in significant number of patients with Head and neck cancer. Brachytherapy has advantage of giving high dose to the tumor with sparing of normal tissue. Here is our experience to treating selected advanced head and neck cancer with external beam radiotherapy and a boost with HDR brachytherapy. Purpose: Evaluation of interstitial boost by HDR-BT in head and neck cancer. Materials and Methods: From December 2017 to March 2019, 14 patients were considered for the study. Mean age at diagnosis was 52.5years (range 30-70 years). Sex;M:F- 13:1. Site(no of patients)-tongue(11),base of tongue(1), buccal mucosa(2). Stage:T1(n=1),T2(n=10),T4(n=3),N0(n=8),N1(n=6). Brachytherapy as boost was given in two schedules 4.2Gy X 5 fractions, two fractions per day, 6 hours apart (EQD2=30.24Gy) and 4.9 Gy X 4 fractions two fractions per day, 6 hours apart (EQD2=30.96Gy). Through EBRT they received 44-50Gy. Median gap between BT boost and EBRT was three weeks. Patients who had T4 and N+ disease received concurrent Inj cisplatin at 40mg/m2 weekly with EBRT. Patients having T4 disease also received 2 cycles of neoadjuvant chemotherapy. Results: Duration of follow up was (5-18) months. In 4.2 Gy arm,3/7 patients(43%) developed disease ,while in 4.9 Gy arm, 4/7 patients ( 57%) developed disease. Mean disease free survival in 4.2 Gy arm was 9.1 months while in 4.9 Gy arm it was 9months. Median disease free survival for 4.2 Gy arm was 11 months and 8 months for 4.9 Gy arm. Patients who developed disease were send for salvage surgery, Only one patient died because of disease rest were alive without disease. Conclusion: Interstitial high dose rate brachytherapy is an effective method of treatment as boost in head and neck carcinomas. For 4.2 Gy and 4.9 Gy dose per fraction local control and disease free survival is almost similar but toxicities is more for high dose per fraction.

 > Abstract: 219: Auditory dysfunction in head and neck carcinoma patients treated with cisplatin based concurrent chemoradiation Top

Kuntal Ray, Ritam Joarder, Krishnangshu Bhanja Choudhury, Chandan Dasgupta

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

Background: Cisplatin based Concurrent Chemoradiation(CTRT) is the standard treatment modality for locally advanced Head & Neck Squamous cell Carcinoma(LAHNSCC) to achieve better loco-regional control and survival. Inj. Cisplatin is the most commonly used drug either in weekly or 3 weekly interval concomitantly with radiotherapy. Loco-regional radiation causes damage to the cochlea or acoustic nerve leading to Sensorineural hearing loss and Cisplatin being one of the most ototoxic chemotherapeutic drugs, causes high frequency hearing loss when used together. However, though other acute and late toxicities of such therapy have been reported widely, there is very limited data on ototoxicity of cisplatin based CTRT of LAHNSCC particularly in Indian scenario. Purpose and Objective(s): The purpose of this prospective single institutional study is to compare the ototoxicity between the two cohorts of LAHNSCC patients receiving CTRT in two different schedules of chemotherapy (Cisplatin 40mg/m2 weekly versus Cisplatin 100mg/m2 3weekly) by assessing changes in Pure Tone Audiometry (PTA) as well as other normal tissue toxicities (both acute & late), Locoregional control and Progression free survival. Materials and Methods: Total 60 patients of LAHNSCC were randomized 1:1 in two cohorts. Arm A patients received Concurrent Cisplatin (40mg/m2 weekly) & Arm B Concurrent Cisplatin (100mg/m2 3 weekly). All patients were treated with EBRT 66-70Gy in conventional fractionation. PTA was done before starting EBRT and after 2 weeks, 3months and 6 months following EBRT. Responses were assessed by RECIST v1.1 criteria & toxicities were assessed by CTCAE v4.03 criteria. Results: Out of total 60 patients, 26 patients in Arm A and 29 patients in Arm B completed the per protocol treatment. The Mean dose of Inj. Cisplatin received in Arm A was 266 mg (range 144-360 mg) whereas in Arm B 280 mg (range 150-420 mg ). Significantly more no. of patients developed Grade 3 or more hearing loss in Arm B (24.1%) compared to Arm A (3.8%), p value =0.001. Radiation dermatitis, oral mucositis, dysphagia were comparable in both the arms. But, vomiting of all grades was significantly higher in Arm B (100%) compared to arm A (57.5%) (p value = 0.001) & Grade 3 vomiting was also significantly higher in Arm B (34.5%) compared to Arm A (3.8%) (p value=0.005). Post treatment renal function (Creatinine clearance) were compromised in both the arms compared to pre treatment renal function but, more in Arm B (mean decrease 16.71ml/min) compared to Arm A(mean decrease 12.87 ml/min)(p value= 0.219). Overall response rate were higher in Arm B (100%) than Arm A (96.1%) (p value= 0.962). At a median follow up of 11 months PFS was comparable in both the arms. Conclusion: 3weekly cisplatin schedule was found to be more Ototoxic, nephrotoxic and emetogenic compared to weekly cisplatin based schedule when used concomitantly with locoregional RT of LAHNSCC with comparable efficacy in terms of locoregional control and progression free survival.

 > Abstract: 225: A prospective randomised comparative study of two palliative radiotherapy regimens in advanced squamous cell carcinoma of head and neck region Top

Dhananjay Mondal, Biswamit Bhattacharya, Rajat Bandyopadhyay

Burdwan Medical College and Hospital, Burdwan, West Bengal, India, E-mail: [email protected]

Purpose and Objective(s): Squamous cell carcinoma of head and neck constitutes about 30-40% of all cancer burden in this country. Unfortunately, majority presents with advanced stage or recurrence after initial definitive therapy. Earlier, the initial treatment of patients with locally advanced stage III or IV (M0) was mainly surgery and/or radiation therapy. Radiotherapy alone has been the “traditional” single treatment for patients with unresectable and/or inoperable locally advanced head and neck cancers, and still relevant despite advent of better chemotherapeutic drugs and monoclonal antibodies. The study aimed to compare which of commonly used palliative schedules i,e 30 Gy in 10 fractions in 2 week or 20 Gy in 5 fractions in 1 week in terms of treatment outcome and toxicities encountered. Materials and Methods: From February 2018 to May 2019, 61 patients with histopathologically proven advanced (stage III, IV) squamous cell carcinoma of head and neck region were recruited. They were divided into a ARM A [who received External Beam Radiotherapy with 3Gy /fraction, five days a week for 2 weeks upto total dose of 30 Gy and ARM B who received radiotherapy with 4Gy/fraction, five days a week for 1week upto total dose of 20 Gy, the two groups were comparable in terms of age distribution, sex distribution, ECOG performance status, stage, primary site and histological grade. Results: Overall response (CR+PR) was achieved in 61.28% patients in the ARM A which was comparable with other studies. The ARM B, although a lesser proportion of patients achieved overall response (56.66%), could not yield a statistically significant inferior outcome in terms of the same parameter. 3.22% patients achieved Complete Response (CR) in the ARM Awhile 3.33% patients achieved Complete Response(CR) in the ARM B (CR). However, this result could not be validated with a statistical significance. The lack of statistical significance may probably be a reflection of the relatively small sample size of the present study. Palliation of symptoms like PAIN CONTROL was studied in both arms according to visual analogue scale. It was found to be comparable in both arms. In ARM A moderate to significant pain control was 90.31% whereas in ARM B was 93.33% tough slightly higher in ARM B that is statistically insignificant. Other symptom control was also comparable. Average duration of pain relief in ARM A is 7.34 months vs 7.96 months in ARM B, the slight difference is not statistically significant. The acute and late toxicities like mucositis and xerostomia were comparable. Conclusion: Hypofractionated RT regimen with both schedule of 30Gy in 10fractions in 2 weeks and 20Gy in 5 fractions in 1 week are effective palliative tools for controlling symptoms and disease in patients with advanced head and neck cancers where curative treatment options is unsuitable. Even in patients with moderate-to-poor performance status, there were significant symptom control and tumour responses in most patients similar to other published series. Thus, hypo-fractionated palliative RT is a good option for disease control, palliation of symptoms with manageable toxicities.

Abstract: 227: Radiation dose to dysphagia-aspiration related structure and it's effect on dysphagia in patients of carcinoma oropharynx: Comparison between three-dimensional conformal radiotherapy and intensity-modulated radiotherapy – A randomised prospective hospital based study

Moumita Paul, Mouchumee Bhattacharyya, Apurba Kumar Kalita, Partha Pratim Medhi, Shashi Bhushan Sharma, Moirangthem Nara Singh

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

Aims and Objectives: Dosimetric comparison of DARS in IMRT and 3DCRT and subjective evaluation of dysphagia in both the arms. Materials and Methods: This is a hospital based prospective randomised study conducted in the period from June 2018 to May 2019. Histologically proven Oropharyngeal Carcinoma patients with Stage I to IV A were selected for the study. A total of 30 patients were randomly allocated to one of the two treatment arms: A) IMRT; B)3DCRT. EBRT was delivered to a dose of 70 Gy/35#. The target volumes and the DARS (Superior pharyngeal constrictor, Middle pharyngeal constrictor, Inferior pharyngeal constrictor, Larynx and Esophagus) were delineated as per contouring guidelines. The supragloottis and glottis together formed the Larynx and the Cricopharyngeus, Esophageal inlet muscle and the cervical esophagus together constituted the Esophagus. The dose-volume parameters were taken out for the DARS combined together and the mean doses to each of these structures were found out to compare between the two arms. The CT regimen used was Cisplatin at a dose of 40mg/m2 weekly. Results: IMRT was found to be superior to 3DCRT in reducing the dose to the DARS. On comparison of IMRT with 3DCRT, it is seen that the p value is significant ( IMRT vs 3DCRT) for the mean of the mean dose to the pharyngeal constrictor muscles(superior, middle and inferior taken individually) and larynx(p value <0.05) but it is not significant for the esophagus. On comparison of the DARS DVH, it is seen that the p value is significant (IMRT vs 3DCRT) in the higher dose range (65 and 70 Gy) and also for 30 Gy. But the lower dose irradiation (50Gy and 60Gy) although reduced, the difference is not statistically significant. Dysphagia was found to be of higher grades for more number of patients in the 3DCRT arm than in the IMRT arm during radiation, at the end of radiation therapy and at 6 weeks and 3 months after completion of Radiotherapy. Conclusion: Thus IMRT results in significant reduction of dose to the dysphagia-aspiration related structures(DARS) which can further help in reducing dysphagia associated with head and neck radiation therapy. The main limitation is less patient data and need of clinical follow up. More prospective data to further validate the subject is essential.

 > Abstract: 236: Myths, facts and scope of spinal cord tolerance dose revision in intensity modulated simultaneous integrated boost treatment of locally advanced head and neck cancer: A dosimetrical and radiobiological demonstration Top

Abhijit Mandal, Ganeshkumar Patel, Sunil Chaudhary, Ritusha Mishra, Himanshu Mishra

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

Purpose and Objective(s): To explore the possibility of revising the spinal cord tolerance dose in intensity modulation radiation SIB treatment of locally advanced head and neck cancer and assessment of achieved planning gain due to the revision. Background: Myths: Radiation therapy professionals are always tried to limits the maximum dose to spinal cord less than 45 Gy. Sometimes, we compromise the target coverage with adequate radiation dose or sacrifice the other OARs in the cost spinal cord spairing. Facts: A number of publications and dose constraint recommendation suggest that spinal cord can tolerate higher maximum dose than our myth allows. We always over guarded the spinal cord from radiation and compromised other treatment benefits. Scope of Revision: In SIB regimen the OARs tolerance dose is equally distributed throughout the treatment. In SIB fractionation regimen with intensity modulation treatment, the spinal cord may receive physical dose of 45 Gy , with much lesser dose per fraction than 2 Gy per fraction. So when the dose of spinal cord is distributed throughout the treatment, the tolerance dose limit of physical dose can be considered higher than the usual conventional limits. Materials and Methods: A total of 12 patients CT data set along with approved structure set of head and neck cancer in ECLIPSE treatment planning system were considered for this study. Three intensity modulated arc Simultaneous Integrated boost (SIB) plan were generated for all the patients. First plan was generated considering spinal cord tissue constraint of maximum dose 45 Gy and PRV spinal cord maximum dose 50 Gy and second plan was generated considering spinal cord tissue constraint of maximum dose 52.50Gy (EQD2 = 50 Gy). and PRV spinal cord maximum dose 56.35Gy (EQD2 = 50 Gy) during volumetric arc intensity modulation optimization. The rest of the tissue objectives were kept same in both the plan during optimization. The third plan was generated increasing the dose per fraction for target volumes, reaching up to spinal cord tissue constraint of maximum dose 52.50Gy and PRV spinal cord maximum dose 56.35Gy. Results: Using the “window of opportunity” of spinal cord tolerance dose, an average dose escalation of 18.2 %, 18.3%, 18.3% and 18.4% for LR PTV, IR PTV, HR PTV and GTV target volumes respectively is possible. An average BED10 values escalation of 21.0 %, 21.4%, 21.7% and 21.9 % were observed for LR PTV, IR PTV, HR PTV and GTV target volumes respectively. With the same dose- fractionation prescription, the revision of spinal cord tolerance dose one may achieve other planning benefits. Average dose reduction of 16.9%, 15.1 % and 23.1% were observed for Right, Left parotids and Lip respectively. As an additional benefit 6.9% MU reduction is also observed. Negligible variations in target volume coverage were observed. Conclusion: A sufficient dose escalation for target volumes or effective planning benefits can be can be achieved by revising the spinal cord tolerance dose in intensity modulated SIB treatment of locally advanced head and neck cancers. Randomised prospective clinical trials are needed to establish the conclusions of this study.

 > Abstract: 238: Effect of adaptive radiation therapy in head and neck cancer patients treated with helical tomotherapy: An initial clinical experience Top

R. A. Sunil, Somorat Bhattacharjee, M. Muttuselvi, Shilpa Mohan, Sourab Bhattachrjee, V. Pichandi

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

Purpose and Objective(s): Adaptive radiotherapy is a technique that is in development with limited published data in our setting. Establishing its usefulness might further help reduce treatment related morbidity by ensuring better conformity and precision. Hence the current study was conducted to elicit the benefit of two step adaptive radiotherapy with helical tomotherapy by analysing the geometric and dosimetric changes. Materials and Methods: This is a prospective study design conducted among 25 head and neck cancer patients treated with two phase radiotherapy with helical Tomotherapy combined with concurrent chemotherapy. Before starting of PHASE-I radiation therapy [CT-1], treatment planning PET CT/ CT scans were done and were repeated at the 4th to 5th week of the radiation therapy for remaining fractions [CT-2] adhering to the standard recommendations. Planning for full intended dose (66Gy- 70Gy) was done on both the scans and clinical target volumes and dose delivery to OARs were compared. Wilcoxon signed-rank test was used to compare the means of the outcomes among the scans. A P-value of <0.05 was considered statistically significant. Results: A significant reduction in the volumes of CTV-P [CT-1 v/s CT-2: 166.82 cc v/s 150.63 cc], CTV-N [CT-1 v/s CT-2: 260.29 cc v/s 228.00 cc], contralateral Parotid gland [CT-1 v/s CT-2: 33.00 cc v/s 18.72 cc ] were observed (P<0.05). The distance between the skin to contralateral parotid gland was also noted to be significantly reduced [CT-1 v/s CT-2: 53.36 mm v/s 38.92 mm] (P<0.05). The mean doses received by the mandible [CT-1 v/s CT-2: 53.71 Gy v/s 52.22 Gy] and contralateral parotid gland [CT-1 v/s CT-2: 23.14 Gy v/s 21.26 Gy] were significantly lesser in the CT-2 scans (P<0.05). Even the mean maximum doses were also recorded to be significantly lesser to the OARs mandible [CT-1 v/s CT-2: 68.528 Gy v/s 67.39 Gy], contralateral parotid gland [CT-1 v/s CT-2: 23.14 Gy v/s 21.26Gy] and spinal cord [CT-1 v/s CT-2: 39.45 Gy v/s 37.33 Gy] (P<0.05). Conclusion: Hence with this pilot study we conclude that in the 4th to 5th week of radiation therapy, a significant reduction in the clinical target volumes were observed and dose delivery to the OARs were also significantly reduced. Thus we recommend repeated simulation scans during radiation therapy and adaptive radiotherapy for head and neck cancer patients.

 > Abstract: 239: Evaluation of dysphagia and its impact on quality of life in patients with head and neck cancers treated with volumetric modulated arc therapy Top

Priyanka Alurkar, Krishna Sharan

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

Aim: To assess the frequency and severity of dysphagia among patients with head and neck squamous cell carcinoma (HNSCC), who are treated with either definitive or adjuvant radiotherapy by volumetric modulated arc therapy (VMAT), and its impact on the quality of life evaluated on the basis of a subjective dysphagia-specific questionnaire. Materials and Methods: Patients who were treated between January 2017 and March 2018 were recruited for this prospective observational study. The grade of dysphagia was recorded before treatment and at completion, 3 months and 6 months. Quality of life (QoL) was measured using the M.D. Anderson dysphagia inventory (MDADI), which is a dysphagia-specific quality-of-Life Questionnaire. Chi-square test and Independent samples t-test were applied to find the association of the patient and treatment-related variables with MDADI scores. Results: 62 patients were eligible for analysis. Median age was 54 years (range:25-85 years), and males predominated (91.9%). Oral cavity primary was the commonest subsite (33.9%) and 79% had stages III-IVB at presentation. 30 (48.4%) patients were treated with adjuvant radiotherapy. 37 patients (59.7%) received concurrent chemotherapy. At completion of treatment, 55 (88.7%) experienced dysphagia, of which 17 (27.4%) had grade III dysphagia. The physical component of MDADI was maximally affected, the mean (±SD) emotional, functional, physical and total scores at RT completion being 77.4(±11.0), 77.7(±14.5), 59.4(±13.7) and 67.1(±13.2), respectively. Concurrent chemotherapy administration, higher mean doses to constrictors (?50Gy) and larynx (?45Gy) were associated significantly worse scores. Patients receiving definitive RT tended to have worse scores (p= 0.064). By six months, there was significant improvement in QoL, with mean (±SD) emotional, functional, physical and total scores being 94.3(±7.4), 94.9(±5.9), 87.7(±11.7) and 92.1(±9.3). There was a significant association between mean dose to larynx (?45Gy) and physical scores; none of the other parameters correlated with the MDADI scores. Two patients had worsening of QoL, both owing to recurrent/metachronous disease. Conclusion: Dysphagia is a frequent acute complication of head and neck radiotherapy, with all patients experiencing a drop in QoL as measured by MDADI scores. But due to modern RT techniques like VMAT most patients have an improvement in their QoL by six months.

 > Abstract: 249: Clinical comparison of mucositis, skin reaction and xerostomia in oral cavity cancer treated with three dimensional conformal radiotherapy and intensity modulated radiotherapy Top

Mahendra Dhakar, H. U. Ghori Ghori, O. P. Singh, Veenita Yogi, Vivek Tiwari, Rakesh Mahawar

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

Background: The treatment for head and neck cancer has evolved from conventional two-dimensional radiotherapy (RT) to three-dimensional conformal RT (3D-CRT) and recently to intensity modulated RT (IMRT). Purpose: The aim of this study was to demonstrate difference of toxicity profile [mucositis, skin reaction and xerostomia] between 3D-CRT and IMRT in patients of oral cavity cancer. Materials and Methods: 60 patients of pathologically proven oral cavity cancers were randomly selected and divided into two groups of 30 patients each. Group A received 3DCRT and group B received IMRT. Patients of both arms received concurrent chemo-radiation, Patient were assessed weekly for toxicities (acute skin or mucosal reactions and xerostomia). Toxicity was further assessed at the end of treatment and every 2month up to 1 year. Xerostomia, skin reaction and mucositis were assessed and graded as per the Radiation Therapy Oncology Group and European Organization for the research and treatment of cancer. Results: The mean age of patients in group A was 46.60±11.58 years while in group B was 48.0±11.38 years. Males constituted 76.7% in (group A) and 80% (group B) of the study population. Mucositis was observed in both the groups till 4 month following RT but the difference observed was not statistically significant (p>0.05). Among group A, 40%,46.7% and 6.7% patients reported with grade I, II and III skin reaction while grade I and II skin reactions were noticed in53.3% and 33% patients in group B. Test of significance observed statistically significant difference in occurrence of skin reaction between the two groups at 4 month follow up (p<0.05); whereas no statistical difference was observed during, and till 4 months of RT (p>0.05). The occurrence post RT skin reactions were observed till 4 months in group A and till 8 months in group B. No significant difference in occurrence of xerostomia was observed between the groups during RT and at 2 and 4 month follow up (p>0.05) but a statistically significant difference in occurrence of xerostomia was observed between the two groups from 6 to 10 months following RT (p<0.05). The occurrence of grade II xerostomia was equal in both the groups but the occurrence of grade III xerostomia was observed to be more in Group A (10 patients (33%) while only in 02 patients (6.7%) in group B. Conclusion: Major outcomes of this study are, result of both arms IMRT arm and 3DCRT arm were comparable in terms of tumour control. Upon assessment of toxicities, statistically significant difference (p value<0.05) in incidence of xerostomia was seen, more in 3DCRT arm. No difference in incidence of acute skin reaction and mucositis was observed. We would conclude by saying that our study encourages use of IMRT in the treatment of oral cavity cancer to provide better quality of life to patient by reducing xerostomia incidence. However studies with larger sample size and longer follow up preferably in trial setting are required to establish IMRT as standard of care in treatment oral cavity cancer patient.

 > Abstract: 250: A dosimetric analysis of dysphagia aspiration related structures sparing using volumetric modulated arc therapy in cancers of head and neck Top

Hegde Adarsh Gajanan, Shyama Prem, S. Mourougan, Shiva Siripuram

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

Purpose and Objective(s): Persistent dysphagia post chemoradiation in head and neck cancers is a common side effect and can have a devastating impact on the patients quality of life. The structures related to swallowing dysfunction are the pharyngeal constrictor muscles (PCM), glottis and supra-glottic larynx (SGL). Since these structures are adjacent to the tumor, sparing them is challenging without compromising on the tumor dose. Single-arm studies have shown that dosimetric sparing of these critical swallowing structures can produce better outcomes functionally. This prospective study is a feasibility study and dosimetric analysis of sparing the pharyngeal constrictor muscles in the treatment of head and neck cancers using VMAT. By sparing DARS using Volumetric Modulated Arc Technique [VMAT] in carcinoma of the oral cavity, oropharynx, larynx and hypopharynx the late complications of treatment can be reduced thereby improving the swallowing function. This will positively impact the quality of life and also reduce aspiration and dysphagia. At present DARS is not spared routinely. However the results of the study can be used to develop a new protocol which can be incorporated into routine practice. Materials and Methods: The study included 23 patients of squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, and larynx. The superior, middle, and inferior constrictors were contoured separately. All the patients were planned using simultaneous integrated boost using VMAT. The volume of the constrictors lying outside the PTV was given the following constraints: Superior and middle constrictors: Dmean < 50 Gy, and Inferior constrictor : Dmean <20 Gy. The initial dosimetric data on the target volume, DARS, larynx, spinal cord, parotid gland, and cochlea is presented below. Results: Out of the 23 cases {SIte wise: Oral cavity (7), Oropharynx (10), supraglottis (5), Glottis (1) }, 18 cases had pharyngeal constrictors involved in the gross tumour volume. Constraints were given to the volumes of pharyngeal constrictors lying outside the PTV without compromising the dose to the PTV. The dosimetric data is as follows: Mean doses received by PTV-HR and PTV-IR were 67.79Gy(SD=1.60Gy), 65.43Gy (SD=2.60Gy) respectively; six patients had a low risk volume receiving a mean dose of 65.14Gy(SD=2.40Gy). The means of Dmax of spinal cord, right cochlea, and left cochlea were 44.93Gy(SD=1.9 0Gy), 9.34Gy(SD=7.30Gy), and 11.97Gy(SD=11.35Gy) respectively. The mean of the mean doses (Dmean) received by constrictors outside the PTV, were SC-out 43.17Gy, MC-out 48.08Gy, IC-out 25Gy. Larynx 50.4.Gy. Conclusion: It is feasible to spare the constrictors, as seen by the dosimetric analysis in the cancers of oral cavity, oropharynx, hypopharynx, and larynx thereby leading to an improvement in the swallowing function. The patients are on follow up and will be assessed for dysphagia and aspiration related toxicities.

 > Abstract: 255: A study to compare the thyroid toxicity in 3-dimensional conformal radiotherapy and intensity modulated radiotherapy in head and neck cancer patients Top

Megha Choudhary, Veenita Yogi, O. P. Singh

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

Purpose and Objective(s): To assess the dosimetric evaluation of Thyroid in 3D-Conformal Radiation Therapy (3D-CRT) versus Intensity Modulated Radiation Therapy (IMRT) in Head and neck squamous cell carcinoma (HNSCC). To assess Thyroid toxicity profile with pre & post-radiation therapy evaluation of T3, T4, TSH. Materials and Methods: Thirty patients treated with 3-dimensional conformal radiation therapy (3D-CRT: 70Gy/35#) and thirty patients treated with intensity-modulated radiation therapy (IMRT: 70Gy/35#) in the prospective observational study. In those patients, thyroid was not contoured during treatment planning. Thyroid function was assessed before starting radiotherapy and after completion of therapy at 3month, 6 month and 12 months. A diagnosis of hypothyroidism was based on thyroid stimulating hormone (TSH) more than the institutional value (normal TSH - 0.4-5.5 μIU/ml), and T4 below than institutional value (Normal T4 - 5-13 μgm/dl), regardless of symptoms. In all patients, the dosimetric parameter was analyzed by contouring thyroid gland after treatment. Results: At a 12 month follow up, 43.3% of patients developed hypothyroidism in IMRT arm and 23.3% of patients in the 3D-CRT arm. Hypothyroidism was a peak around 1 year after radiotherapy in both arms. On dosimetric analysis, >V40 (p<0.05) and mean dose results were significantly associated with hypothyroidism. Conclusion: Hypothyroidism peaks at one year after radiation therapy when the thyroid was not contoured and avoided. >V40 may predict the risk of developing hypothyroidism after radiotherapy for head and neck cancer. Thyroid glands should be considered as an organ at risk for radiation in head and neck region.

 > Abstract: 256: Organs at risk constraints for spinal cord and brain stem using QUANTEC guidelines in the cases of re-irradiation of recurrent head and neck cancers: An observational study Top

Debashis Panda, Sanjeev K. Gupta, Neeraj Kumar, Saumen Basu, Ajendra Pratap Sharma, Santanu Chaudhuri

Nayati Multi Super Specialty Hospital, Mathura, Uttar Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): In spite of multi-modality approach in treating Head & Neck cancers and achieving a high cure rates, good number of recurrence and second primary cases are detected. Radiotherapy plays an important role for salvage in these recurrences and second primary cases. But it is very important is to achieve the constraints for the organs at risk in the re-irradiation cases as per ALARA principle. Here we have studied the dose constraints achieved for spinal cord and brain stem for the patients who underwent re-irradiation for recurrent head and neck cancers in our institute. Materials and Methods: This case series is a retrospective pilot institution-based study of 20 patients, performed in a Quaternary care centre in the western part of Uttar Pradesh, India from December 2017 to August 2019. A dose of previous radiation history is collected in details as most of the patient has been treated outside hospital. Dose decay calculated with respect to time gap between both the radiation treatments using the formula;

Dose Decay = Previous dose X decay factor

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


T=Treated days (Total number of fractions + Gap)

R=Rest days (Post RT completion to restart of Re-irradiation)

[OAR dose constraint = Normal tolerance dose of the OAR – Residual dose]

All the dose constraint data are collected after calculation and the Mean ± SD is considered. Plans have been done on Monaco treatment planning system (Version 5.11.02). All the treatments are done using VMAT technique. Results: Out of total 20 patients, 60% patients are in 51-60 years age group and 40% are in 61-70 years age group. Male preponderance is observed (90%). The commonest site of recurrence observed in Oral Cavity (50%), followed by Larynx (15%) and Nodal recurrence (15%) in our study. Recurrence observed in 25% cases within 2 years, 35% within 2-5 years and 40% after 5 years of completion of radiotherapy. Median gap between the first radiation and re-irradiation is 1055 days, with a range from 384 to 7110 days. Mean ± SD of Dmax for 'Spinal cord' was 1719.8 ± 785.24 cGy and that for 'Brain stem' was 1455.1 ± 914.85 cGy respectively. Mean + SD of Dmax for 'Spinal cord PRV' was 1915.6 ± 845.36 cGy and that for 'Brain stem PRV' was 11770.9 ± 1074.2 cGy respectively. The individual values are also below the dose constraints, calculated for every patient. Conclusion: We can conclude from the above study that, re-irradiation is possible with properly achieved OAR constraints as per the ALARA principle, by using 'high precision radiotherapy' technique especially VMAT.

 > Abstract: 257: Scenario of head and neck cancer in females – A retrospective analysis of 12-year Top

Anil Kumar Dhull, Rajeev Atri, Rakesh Dhankhar, Ashok K. Chauhan, Vivek Kaushal

Department of Radiation Oncology, Regional Cancer Centre, Pt. B. D. Sharma Post Graduate Institute of Medical Science, Rohtak, Haryana, India, E-mail: [email protected]

Background: Head and neck cancer (HNC) is the seventh most common type of cancer in the world and constitute 5% of the entire cancers worldwide. The global burden of HNC accounts for 6,50,000 new cases and 3,50,000 deaths worldwide every year and a major proportion of regional malignancies in India. Methodology: A retrospective analysis of 12-years from year 2001-2012, of head and neck cancer patients attending Regional Cancer Centre, PGIMS Rohtak was done. Total numbers of cancer patients seen were 26,295 which were retrospectively analyzed for demo-graphical presentation of female HNC patients. Results: Total 26,295 cancer patients were analyzed, out of which, 9,950 (37.8%) patients were of head & neck cancer (HNC), with a predominance of male population as 8,686 (87%); and females were 1,264 (13%). It has been observed that among all the patients of HNCs, men were predominant with male to female ratio of 7:1 and most common presenting complaints were cervical swelling (62%), dysphagia (37%) and odynophagia (19%). It was also observed that most common age of presentation was 5th & 6th decade of life (330 patients; 26% each) and median age of presentation was 53-years. Out of the total female patients, 86% presented as locally advanced head and neck cancer (LAHNC Stage III & IV). Further analysis have shown that in this defined population of 1,264 female HNC patients, 609-patients (48%) were smokers, 94 (7%) were alcoholics and 54-patients (4%) presented with distant metastasis. Oropharynx (39%) was the most common ICD site in FHNCs. Out of the total female HNC patients, 625-patients received radical treatment and 437-patients received palliative treatment, while 148-patients didn't receive any type of oncology treatment and lost to follow-up in subsequent visits. Total 517-patients (41%) received some type of chemotherapy during their course of treatment and 796-patients (75%; n=1,062), out of total 1062 treated patients, completed the intended treatment. Total 502-patients (40%; n=1,264) received different schedules of radical radiotherapy while 463-patients (37%) received palliative radiotherapy. At last follow-up, CR was seen in 245-patients, PR in 458- and PD in 189-patients. Conclusion: The present study has highlighted the demo-graphical presentation of the HNC patients as well as their associations with HNC-subtypes, and different risk factors.

 > Abstract: 258: Association and importance of socioeconomic, demographic factors on treatment tolerance in radiation therapy of head and neck cancers Top

Neeraj Kumar, Debashis Panda, Sanjeev K. Gupta, Saumen Basu, Ajendra Pratap Sharma, Santanu Chaudhuri

Nayati Multi Super Specialty Hospital, Mathura, Uttar Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): To study the impact of different variables like socioeconomic status, nutritional status on radiation treatment in terms of treatment delay, incomplete treatment and treatment completion on time in head and neck cancer patients. Materials and Methods: We retrospectively analyzed pooled individual-level data of head and neck cancer patients from December 2018 to July 2019 who underwent radiation treatment. Socioeconomic data analysis done with the help of modified kuppuswamy scale 2018. Anthropometric measurements such as patient's height, weight, and body mass index(BMI) are considered relevant and objective measures of a cancer patient's nutritional status. Body weight was an essential component of the initial nutritional assessment due to the significant impact of weight loss on morbidity and mortality. Collected data was analyzed using chi-square test and P-value <0.05 considered significant. We also performed logistic regression analysis for variables of socioeconomic status like age, race, marital status, family income, highest level of education achieved. The present review also aimed to define the role of nutritional status by studying the weight loss and change in BMI of head and cancer patients undergoing radiotherapy. Results: In this retrospective study total 51 patients of head and neck cancer, those underwent Radiation therapy treatment in our hospital were analyzed. The demographic factors like age, gender, marital status and race showed no significant association with socioeconomic factors. Out of all the patients, 32 (62.74%) belongs to lower middle class, 8 (15.68%) upper lower class, 9 (17.64%) were from upper middle class and only 2 (3.92%) were from upper class according to modified Kuppuswamy scale 2018. The delayed radiation therapy treatment category of patients shows that 9.5 % belongs to lower middle class, 7.7% patients are from upper lower class and no patients are from upper middle and upper class. Patients who finished treatment on time were 32, of which 4(12.5%) were from upper middle class, 21(65.62%) are from lower middle class and 7(21.87%) are from upper lower class. The median weight loss in first week was 0.00Kg (P = 0.014), second week 0.80 Kg (P=0.004), third week 1.50Kg (P <0.0001), fourth week 2.90Kg (P <0.0001), fifth week 4.00Kg (P <0.0001) and sixth week 4.70Kg (P <0.0001) while compared to pre-treatment weight. Analysis of pre-treatment BMI showed 14 (15.68%) were underweight, 17(33.33%) were normal weight, 17(33.33%) were overweight and 3 (5.88%) obese. The average decrease in BMI during treatment (Mean±SD, Kg/m2) from first week to last week was from 22.64±4.81 to 20.65±4.41. Conclusion: Majority of head and neck cancer patients belong to lower middle and upper lower socioeconomic class. There is no significant relation found between socioeconomic classes in terms of delay in treatment, which may be due to smaller sample size. There was significant decrease in weight and BMI on weekly assessment from pretreatment to post treatment; hence nutritional support plays a major role during head and neck cancer treatment.

 > Abstract: 259: Analysis of clinical assessment of dysphagia and its correlation with weight loss during head and neck cancer radiation therapy Top

Neeraj Kumar, Santanu Chaudhuri, Debashis Panda, Saumen Basu, Ajendra Pratap Sharma, Sanjeev K. Gupta

Nayati Multi Super Specialty Hospital, Mathura, Uttar Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): Radiotherapy plays major role in treatment of head and neck cancer in radical as well as in adjuvant settings. During the course of treatment oral and oropharyngeal mucositis are more common, which leads to dysphagia and weight loss, which may cause treatment interruption that may affect the treatment outcome. This study focuses on assessment of dysphagia and its association with loss of weight in head & neck cancer radiotherapy. Materials and Methods: We retrospectively analyzed data of 51 head and neck cancer patients from December 2018 to July 2019 who underwent radiotherapy in a Quaternary care centre in western part of Uttar Pradesh, India. Patients were reviewed weekly during the course of Radiotherapy to document the grades of Dysphagia and weight loss. Collected data was analyzed using chi-square test and Pearson's correlation. Results: In the study total 51 patients of head and neck cancer, those underwent Radiation therapy treatment in our hospital were analyzed. At the completion of Radiotherapy, the incidence of dysphagia with grade 1, grade 2, grade 3, and grade 4 were 0%, 54.90%, 45.10% and 0.0% respectively. On correlation with weight loss we found that patients with grade 2 dysphagia had an average weight loss of 4.66 Kg (7.36%) and patients with grade 3 dysphagia had average weight loss of 6.80 Kg (11.11%). Grades of Dysphagia were compared with initial weight groups which depicted that patients having weight group above the median weight had lower grades of dysphagia as compared to patients with lower weight group and correlation between initial weight and weight loss was negatively correlated. Conclusion: In this study, weight loss is directly proportional to the grade of dysphagia in head & neck cancer patients during radiotherapy. The 'initial weight' and 'weight loss' were negatively correlated. Thus it is suggested that more focused dietary counselling and timely intervention like nasogastric tube placement would be beneficial to the patients, who have lower initial weight (body mass index).

 > Abstract: 261: Machine learning of baseline computed tomography radiomics to predict local failure after radiotherapy in locally advanced head and neck lung cancer patients: A feasibility study Top

Goutham Sunny, Hannah Thomas, Balu Krishna, Manu Mathew, Simon Pavamani, Subhashini John, Rajesh Isiah, Devakumar Devadhas, Stephen Bowen

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

Purpose: Head and neck cancers are challenging to diagnose and treat due to the heterogeneity of cancer etiology and the complex anatomy leading to narrow therapeutic window. Radiomics, the high throughput extraction of quantitative data from medical images, has shown potential in improving models for predicting patient outcomes. In this study, we test the feasibility of developing a prediction model using machine learning of radiomic features derived from baseline planning CT imaging data to predict local disease-failure following radiation treatment. Methods: Twenty patients with advanced head and neck cancer who were part of an observational imaging study in Christian Medical College, Vellore were included. All patients received conformal chemo-radiation. The gross tumour volumes (GTV) were delineated on baseline CT using a semi-automatic Gradient based segmentation algorithm in 3D Slicer. Within the GTV PyRadiomics features (110 shape/intensity/texture) were extracted using fixed Bin Count (128) discretization and isotropic resampling (1 mm). Radiomic feature selection included: (i) inter-patient variance inflation, (ii) co-linearity reduction and (iii) information-gain ratio. Treatment failure prediction model of pre-treatment CT radiomic features consisted of the Naïve-Bayes classifier algorithm. The model was trained and internally validated with a random sampling strategy: 90% of the data was randomly allocated for training with the remaining 10 % reserved for testing. This process was repeated 100 times to guard the model against over-fitting. The performance was quantified by area-under-ROC-curve (AUC) for predicting incidence of local disease-failure. Results: Only the highest ranked 10 features were used for the radiomics model for predicting local disease failure (6/20 patients). The model achieved a cross-validated classification performance of AUC=0.803. The best CT based predictors were MinorAxisLength (Shape), InterquartileRange (Intensity), Flatness (Shape) and GrayLevelVariance (GLDM texture feature). The study only provides a preliminary model requiring external validation on a larger independent dataset. Limitations included small sample size and heterogeneity in image acquisition parameters, part of which was harmonized by resampling the data to a common voxel grid. Conclusion: Machine learning of pre-treatment radiomics may improve local disease-failure risk stratification in patients with locally advanced HNC, and could eventually lead to the personalization of treatment. Although we have demonstrated the feasibility of the prediction model, additional independent validation data is crucial for the implementation of radiomic models for clinical risk stratification. The findings of this study will be validated in a future prospective radiomics trial to develop clinical decision support tools. The study also draws attention to challenges in the application of imaging data science when investigating specific oncologic outcomes, including standardization and harmonization of radiomics pipelines.

 > Abstract: 262: Esthesioneuroblastoma – A rarest malignant neuroectodermal nasal tumor Top

Anil Kumar Dhull, Himanshi Joon, Ashok Chauhan, Vivek Kaushal

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

Background: Esthesioneuroblastoma also known as olfactory neuroblastoma (ONB) is an uncommon malignant neuroectodermal nasal tumor with distinctive clinical, histopathological, radiological and molecular features. They comprises about 2% of all sinonasal tract tumors with an incidence of approximately 0.4 per million population. ONB are thought to arise from the specialized sensory neuroepithelial olfactory cells present in Jacobson's vomero-nasal organ, mervous terminals, sphenopalatine ganglion, ectodermal olfactory placode, autonomic ganglia of the nasal mucosa and the olfactory neuroepithelium. A bimodal age distribution in the 2nd and 6th decades of life are most common without a gender predilection. Olfactory neuroblastomas are generally slow growing, but faster growing tumors may lead to widespread metastasis, frequently in lungs and bones. Methodology and Results: A 29-year young adult presented with a one month history of swelling involving the left side of face, protrusion of the left eyeball and left sided nasal obstruction. An MRI revealed a large soft tissue mass with epicenter in the left nasal cavity and showing moderate heterogenous enhancement with areas of cystic degeneration, extending superiorly through the cribriform plate, laterally into the left orbit and into the maxillary sinus with invasion of the alveolar process of maxilla. Histopathological examination of the nasal mass revealed olfactory neuroblastoma. Surgical resection of the tumor could not be possible due to its locally advanced stage, so planned with palliative chemotherapy. Conclusion: The treatment of choice remains surgical resection of the tumor which frequently requires a bicranial-facial approach (trephination) and is usually followed by a course of radiotherapy to achieve better long term outcome. Palliative chemotherapy is utilized as an approach for advanced unresectable tumors with disseminated disease. The intent of the treatment should be tailored approach based on the prognostic features like high grade, distant metastasis, age of presentation, tumor recurrence, high proliferation index and polyploidy/aneuploidy.

 > Abstract: 263: Pattern of failure in head and neck squamous cell cancer treated with intensity modulated radiotherapy – Initial experience from AIIMS, Rishikesh Top

Debanjan Sikdar, Ajay S. Krishnan, Nidhi Sharma, Sagar Raut, T. S. Athira, Rohit Mahajan, Sweety Gupta, Deepa M. Joseph, Rajesh Pasricha, Manoj Gupta

AIIMS, Rishikesh, Uttarakhand, India, E-mail: [email protected]

Purpose and Objective(s): Radiotherapy plays an integral part in the radical treatment of non-metastatic Head and Neck cancer (HNC) treatment. For early stage head & neck cancers, it is used as single modality. Concurrent Chemo-Radiation is the treatment of choice for inoperable locally advance HNC. Modern radiotherapy is delivered using highly advance techniques like IMRT & VMAT. Although we can spare lot of normal tissues and decrease morbidity using these techniques, they are highly sensitive to intra & inter fraction errors leading to geographical miss and ultimately treatment failure. Analysis of patterns of failure provides an opportunity to improve our treatment techniques and minimise failures. We here present our data regarding patterns of failure of HNC treated by IMRT &VMAT and exploration of possible reasons for treatment failures. Materials and Methods: This is a retrospective evaluation of of patients of non-metastatic Head and Neck carcinoma treated with radiotherapy or concurrent chemo-radiotherapy using IMRT & VMAT techniques at department of Radiation oncology, AIIMS Rishikesh between 1st June 2018 and 31st Dec 2018. Case files were checked to record disease status at last follow up visit. Associated factors also evaluated for recurrence. Results: Files of 62 patients meeting the requirements were secured from the records section. Mean age of patients was 57.4 yrs. Most common hostopathology among inoperable HNC was Squamous Cell Carcinoma of the Oropharynx (51%). 17 (24.1%) of the evaluated patients have residual or recurrent disease present after a median follow up of 7 months, 14 (22%) patients have loco-regional residual or recurrent disease among them 15 patients are locally advanced head and neck cancer 1 patient is post op and 2 patients have distant mets (all in lungs). 3 patients had a disease free period before recurrence was diagnosed. Conclusion: Recurrence after radical treatment of Head and Neck Squamous cell carcinoma is not infrequent. Globally, failure rate post radical treatment of Head and Neck cancer is between 18-26% after a median follow up of 3 to 5 years. In our study total failure rate is 20.7% post median follow up of 7 months. Two thirds of these patients never had complete response to treatment suggesting resistance to the treatment offered. Longer follow up is needed for more meaningful data about local control, pattern of failure of radiotherapy in both radical and adjuvant setting.

 > Abstract: 270: Analysis of treatment outcome in early stage oral tongue squamous cell carcinoma: A retrospective study Top

Priya Sinha, Ramesh S. Bilimagga, Sasikala Prabharan, Durai Murukan Gunasekaran, Ancy Mathew, Akhila K. Bharathan

Health Care Global Hospital, Bengaluru, Karnataka, India, E-mail: [email protected]

Background: Carcinoma tongue contributes to a quarter of all head and neck cancers. Oral tongue cancers are a distinct clinical entity and must be differentiated from the cancers of the base of tongue. Most common site of involvement is lateral border of tongue accounting for 85% of oral tongue carcinoma cases. In the patients with early stage disease (T1/T2 N0) outcomes generally are good and the reported 5 year overall survival rate range between 75-80%. Median age at diagnosis is 63 years. Purpose and Objective(s): The purpose of this study is to analyse the treatment outcomes of early stage oral tongue squamous cell carcinoma (pT1/T2 N0) in terms of disease free survival and determine the predictive factors for recurrence. Materials and Methods: Between 2013 to 2018; the records of 150 patients of squamous cell carcinoma of tongue were reviewed and 30 patients among them were taken for retrospective study. All 30 patients underwent surgery either in the form of hemiglossectomy, partial glossectomy or wide local excision with either supraomohyoid or modified radical neck dissection followed by with or without adjuvant treatment in the form of radiation therapy or concurrent chemoradiation. Patient, tumour and treatment characteristics were recorded and disease free survival were calculated using the Kaplan-Meier method and predictors of outcome were identified using bivariate analysis. Results: With a median follow up of 36 months (range, 10-67 months), the 3-year disease free survival rate was 86.6%. Median age of the patients in this study was 47 years. Out of 30 patients, local and neck recurrences occurred in 4 patients (13%) and 1 patient (3%) respectively. None of the patient had distant metastasis. Death occurred in two out of the 5 recurred patients. Bivariate analysis identified that none of the patient , tumour or treatment characteristics were statistically significant to predict the outcome in early stage oral tongue squamous cell carcinoma. Only patient's age showed near to significance (p value=0.059) i.e younger patients (<50 years) had better outcome in terms of disease free survival as compared to older patients. All the patients with locoregional tumour recurrence had pathological depth of invasion >4mm but was not statistically significant (p=0.2) to affect the outcome. Other characteristics as gender of the patient,tobacco or alcohol intake, clinical or pathological tumour staging, pathological grading of tumour and adjuvant treatment did not show any statistical significance with respect to predicting outcomes in these patients. Conclusion: The patients with early stage oral tongue squamous cell carcinoma have excellent outcomes. In the current study 3 year disease free survival rate was 86.6%, yet a longer follow up period and more number of patients are required to analyse the outcome and determine various factors predicting the outcome.

 > Abstract: 293: A prospective study to determine the impact of tumor volume on locoregional control and toxicity in oropharynx, nasopharynx and hypopharyngeal cancers treated with radical chemoradiation Top

Karishma Sewaramani, Tejinder Kataria, Deepak Gupta

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

A prospective study to determine the impact of tumor volume on locoregional control and toxicity in oropharynx, nasopharynx and hypopharyngeal cancers treated with radical chemoradiation. Introduction: Head and neck squamous cell cancers (HNSCC), constitutes a group of heterogeneous tumors, evident by their diverse behavior and natural history. TNM staging is widely used in head and neck cancers. Furthermore, TNM staging is crucial for assessing prognostic outlook and implicates line of management. While, TNM staging has served as an important tool in the treatment of head and neck cancers, it however comes with substantial pitfalls. Most notably, TNM staging fails to define three-dimensional tumor volume. As a result, a superficial tumor with good prognosis will be staged under the same category as a deep tumor with poor prognosis. Moreover, improvements in imaging techniques over time have now enabled precise digital calculation of the volume of primary tumor. Methodology: 50 patients within age range of 18-70 years with histologically confirmed case of squamous cell carcinoma of the oropharynx, nasopharynx and hypopharyngeal, stage I-IV, with no distant metastasis were included in the study. Approved target volumes, more specifically, Gross Tumor Volume-Primary (GTV-P) and Gross Tumor Volume-Nodal (GTV-N) were recorded at baseline for all patients enrolled in this study. The recorded tumor volumes (GTV-P and GTV-N) were correlated with disease outcome and clinical response in terms of local and locoregional control. Results: Our study findings demonstrate that primary tumor volume and nodal volume are a powerful predictive factor capable of predicting local control in small group of patients with locally advanced head neck cancers treated with radical chemoradiation. GTV-P, GTV-N, and GTV-Total were found to have statistically significant association with local control. We also classified patients in various stages such as stage II, III, IV taking into consideration varying tumor volumes within each stage. Overall, a statistically significant increase in partial response or disease progression was observed with increase in gross tumor volume. Conclusion: This prospective study in HNSCC identifies gross tumor volume as an important prognostic factor. We observe a significant association of clinical response with primary, nodal and total tumor volumes. The results of this work are widely applicable and pose significant merit for patient selection when deciding concurrent radiochemotherapy without the added risks of overdosage led toxicity events.

 > Abstract: 294: Dosimetric analysis and comparison of radiation induced treatment toxicities in intensity modulated radiation therapy and 3 dimensional conformal radiotherapy among head and neck cancer patients Top

Sachet Saxena, O. P. Singh, Pushpraj Pathak, H. U. Ghori, Veenita Yogi, Vivek Tiwari, Suresh Yadav

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

Background: Radiotherapy (RT), since its inception has played a significant role in management of HNC. With the introduction of novel radiation delivery machines, it is possible to deliver a higher dose to the cancer tissues without damaging the nearby critical structures. This has led to the increased use of IMRT over 3D-CRT in HNC. Purpose: The present study aims at comparing the toxicity profile in terms of xerostomia, oral mucositis and skin reactions in patients treated with IMRT to those treated with 3D-CRT. Methodology: Sixty newly registered histopathologically proven squamous cell HNC passing predefined inclusion and exclusion criteria were taken for the study. Patients were randomized into both 3D-CRT (group A) & IMRT (group B) arms using a computer generated software. Pre operative patients received 70 Gray (Gy) in 35 fractions and post operative patients received 60-66 Gy in 30-33 fractions. All patients received concurrent cisplatin 40 mg/m2 weekly during RT. Patients were then analysed prospectively for a period of one year for both acute and late toxicities. Common Terminology Criteria for Adverse Events (CTCAE) Grading was used to assess the toxicities. Statistical analysis was done using SSPS software version 20 and a value of p< 0.05 was considered significant. Results: The mean age of patients of group A was 47.97±12.44 and that of group B was 47.98±10.94 years, with males occupying a higher percentage of patients in both arms (83.3% & 76.7%). Acute mucositis and skin reactions ( grade 2 and above) were observed in both the groups (24 in group A vs 23 in group B for mucositis and 21 in group A vs 25 in group B for skin reactions) during RT but the difference between the groups were not statistically significant (P = 0.35 & 0.49). Mean dose to Parotid was 46.11±9.08 Gy for group A and 24.10 ± 4.48 Gy for group B. This difference was found to be highly significant (p=0.001). V30 was also higher for group A (41.36±11.06 ) as compared to group B (33.23±9.77) and this difference was found to be statistically significant (p=0.004). Both acute and late Xerostomia (grade 2 and above) was significantly higher in group A during RT (P=0.04) & at 6 (p=0.03), 8 (p=0.04), 10 (p=0.003) & 12 months (p=0.003) follow up. Conclusion: The study showed superiority of IMRT over 3D-CRT in terms of dose distribution to the organ at risk. There was no ststistically significant difference in the incidence of acute mucositis and skin reactions between the groups. There was decreased occurrence of both acute and late salivary gland toxicities in patients treated by IMRT. However generalised application of IMRT in HNC is still questionable as its better side effect profile must be matched with the local control of the disease which was beyond the scope of the study and still remains an active area of research and discussion.

 > Abstract: 296: Evaluation of outcome and quality of life using European Organisation for the Research and Treatment of Cancer questionnaire in oropharyngeal cancer patients treated with chemo-radiation Top

G. V. Ajay, Ashalatha Devalla, Sanjog Pal, Manas Dubey, Lincoln Pujari, Resham Srivastava, Dandapani Epili, Priyanka Agarwal, Satyajit Pradhan, Vinita Kumari

Homi Bhabha Cancer Hospital (TMH) Varanasi, Uttar Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): With advances in modern radiation therapy (RT) techniques, many patients with Oropharyngeal Cancer Patients are effectively cured. In these patients, health related quality of life (HR-QoL) has become an important issue. The present study evaluates QoL using EORTC QLQ-C30/QLQ-H&N35 questionnaires used at time of diagnosis, immediately after and 4 months after treatment completion. Materials and Methods: A total of 33 histo-pathologically proven patients of oropharyngeal cancers were treated with concurrent chemoradiotherapy (CCRT) to a total dose of 70Gy/35# during the period June 2018- May 2019. Informed consent was taken from each patient and the EORTC QLQ-C30 questionnaire and QLQ-H&N35 module were used for assessing the QOL. Eight patients were treated using 2D technique and 25 patients using 3DCRT and Rapid Arc techniques. Global health status(GHS), Functional scale (FS) and Symptom scale (SS) values were assessed for various parameters. A general linear model multivariate analysis of variance was used to analyse the prognosticators of HR-QoL. Results: The mean age at the time of diagnosis was 50±9yrs and male to female ratio was 2:1 in the study population. The study population had a mean global health status (GHS) for overall QOL of 55.5 ± 13.4. Twenty-eight of the 33 patients had Stage III and IVA disease. All 33 patients completed the treatment and 1 death after treatment due to aspiration, was noted. The GHS, FS and SS score at the start of treatment was 54.2±12.1, 86.0±6.2, 10.0±8.01, at the end of treatment was 50.8±9.6, 82.0±5.5, 12.4±6.6 and 4 months after treatment was 58.4±4.6, 88.9±4.8, 8.3±3.6 respectively. Gender and age did not contribute significantly but stage of the disease was the significant factor for group comparisons of QOL parameters. The QOL studies also showed that the symptoms gradually improved after treatment. Conclusion: Technological advancement of RT substantially improves head-and-neck related symptoms and broad aspects of HR-QoL for HNC survivors from 2D to conformal technique. Compromised HRQOL and functional deficits among patients with advanced oropharyngeal cancer before the start of treatment, was observed in this study. The adoption of a QOL assessment as a standard procedure in hospital settings can contribute to anticipating interventions aimed at reducing impact of therapeutic applications and improve subsequent patient management.

 > Abstract: 307: Complete response to radical concomitant radiation therapy in metastatic pyriform fossa cancer: A case report Top

Pournima Kale, Ashok Singh, Virendra Vyas, Deepika Malik, Manoj Birajdar, Pallavi Kalbande

Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India, E-mail: [email protected]

Purpose and Objective(s): Recommended treatment of Carcinoma Pyriform fossa with metastatic presentation is by palliative chemo-radiotherapy. Here we report a case of histologically proven Carcinoma Pyriform fossa with mediastinal lymphadenopathy in a male patient treated by radical intent and achieving complete response. Materials and Methods: A 2 x 1.2 cms lesion in right pyriform fossa extending upto cricopharynx on imaging studies as well as Upper GIscopy in a 67 year old male who came with a 2 month history of difficulty in swallowing. Biopsy suggestive of squamous cell carcinoma. PET CT scan revealed - the primary with mediastinal lymphadenopathy. Results: Based on histological examination and imaging studies, the patient was treated by Radical Concomitant Chemoradiation with a total dose of (70Gy in 35 fractions) by 2D Technique to the primary with weekly cisplatin (40 mg/m2 ) and total dose of (60 Gy in 30 fractions) by electron therapy to the mediastinal lymphadenopathy. The patient exhibited complete response to the treatment modality and post treatment PET CT scan showed no residual disease. On follow up 2 year post treatment PET CT scan was negative. A disease free survival of 2.5 years is achieved till date. Conclusion: This is an interesting case showing complete response to radical treatment in a presentation that is considered to be palliative as per recommended treatment protocols. Therefore radical concomitant radiation therapy should be considered as an effective modality of treatment even in patients with metastatic presentation in a case of Carcinoma Pyriform fossa.

 > Abstract: 310: Treatment pattern and outcomes in verrucous carcinoma of oral cavity: A single institutional retrospective analysis from a tertiary cancer center Top

Ayushi Patni, Satyajeet Rath, Ajeet K. Gandhi, Akash Agarwal, Vikas Sharma, Rohini Khurana, Rahat Hadi, Shantanu Sparu, Nuzhat Husain, Ashish Singhal, Madhup Rastogi

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

Purpose and Objective(s): We intend to report the outcomes of verrucous carcinoma of oral cavity treated at our institute in terms of administered treatment and control rates. Materials and Methods: Twenty-eight patients of oral cavity verrucous carcinomas treated at our institute from March 2014 to December 2018 were reviewed retrospectively. Pre-operative and post-operative histopathology of all the patients were analysed at our central pathology review. Demographic profile, addiction patterns, histopathological features and clinical outcomes were analyzed. Statistical analysis was performed with SPSS for Mac (version 23.0). Survival analysis was done by Kaplan Meier method and all events were calculated from the date of registration. Results: Median age was 54 years (range 31-75) with M: F ratio of 25:3. Median duration of symptoms after which the patient presented to out-patient was 8 months (range 3-72). Buccal mucosa was the most common site (23/28), followed by lip (3/28), tongue (1/28) and hard palate (1/28). All the patients underwent surgical resection except one. Of these twenty-four had neck dissection; 12 had supra-omohyoid neck dissection, eleven had modified neck dissection and one patient underwent radical neck dissection. Three of the patients had their histology upgraded to squamous cell carcinomas in the post-operative histopathology. The post-operative staging was as follows: pTis-11/28, pT1-6/28 and pT2-11/28. The median pathological tumour size was 3 cm (range 1-6). Only one patient had a positive node. 21% were stage I and 35% had stage II disease. Two patients received neo-adjuvant chemotherapy. One patient received adjuvant radiotherapy. One patient opted for non-surgical approach and received radical concurrent chemoradiotherapy. Median follow up was 12 months (range 6-36). Two patients had local failures and one had a regional failure. No distant metastasis was found. There was one death. The 14 months overall survival rate was 92%. The 12-month local and regional control rates were 100%. The estimated 18 months loco-regional control rate was 92%. Conclusion: Management of verrucous carcinoma needs to be tailored as per the stage and histopathology. Any change of histopathology post-operatively to squamous cell carcinoma is a poor prognostic sign and appropriate adjuvant treatment modality needs to adopted in such a scenario.

 > Abstract: 318: Use of nasolabial flap in oral cancer surgery: Our experience in 100 patients Top

Akansha Bajpai, Rajen Tankshali

GCRI, Ahmedabad, Gujarat, India, E-mail: [email protected]

Purpose and Objective(s): Reconstruction of defects following oral cancer surgery can be done with several methods. The flaps can be pedicled or free flaps. PMMC being the most versatile flap is relatively bulky and free flaps require a lot of expertise. Nasolabial flap is a relatively simple flap and can be used with great advantage for reconstruction of small defects. This article reviews our experience of nasolabial flaps for reconstruction of intraoral defects. So the purpose of this study is to assess the feasibility & usefulness of nasolabial flaps for intraoral defects. Materials and Methods: We conducted a retrospective study in 100 patients undergoing surgery for oral cavity cancers in whom reconstruction was done using nasolabial flap. This study was conducted in the period between 2016-2018 in GCRI, Ahmedabad a leading cancer centre in India. Patient demographic, site of lesion, size of lesion and postoperative course was recorded. Results: The flap had good cosmetic and functional outcome in almost all patients. Almost all patients were able to complete their adjuvant treatment without any iatrogenic delay. 10 patients developed wound dehiscence. Out of 10, 9 we're successfully managed conservatively and 1 had complete flap loss. Conclusion: For reconstruction of small defects following oral cancer surgery nasolabial flaps can be used with good results and less morbidity as compared to PMMC flaps.

 > Abstract: 320: Comparison of hypo-fractionated palliative radiotherapy regimens in locally advanced head and neck cancer: Our institutional experience Top

Kushboo Jain, Pooja Nandwani Patel, U. Suryanarayana, Parag Roy, Shreena Patidar

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

Purpose and Objective(s): To compare the efficacy of weekly palliative radiation regimen used in our institute, 36 Gy delivered in 6 fractions once weekly over 6 weeks to single fraction of 8Gy. Materials and Methods: 64 Patients with stage IVB HNC, with PS ? 2, symptomatic for the disease, and those who are radiotherapy naive, were included. 32 patients received 36 Gy/6#, once weekly fraction over 6 weeks (group 1) and another 32 patients received 8Gy in single fraction (group 2). Symptoms assessed mainly included pain, dysphagia, swelling and bleeding. Treatment related toxicity was assessed using Radiation Therapy Oncology Group (RTOG) criteria with weekly assessment of symptomatic improvement, mucositis, dermatitis and any other related toxicities. Results: 64 patients (male: 47, female: 17; age: 48±11 years) during the period of march 2019-july 2019 were randomised to each arm. Beginning of Symptomatic improvement in group 1: 3 patients did not experience any relief

Other toxicities included dysguesia, nausea, fatigue and treatment related dysphagia more in group 1. Conclusion: This study indicates that weekly palliative schedule is a clinically viable option for locally advanced head and neck cancer to achieve palliation with good patient compliance and acceptable toxicity and it is better in terms of symptomatic improvement and disease regression when compared to 8Gy/single fraction schedule. However, for extremely frail patients with large fungating lesions, 8Gy/1 # appears to be better in terms of logistics and cost effectiveness and also, when patient is not compliant for visiting once every 6 weeks.

 > Abstract: 326: Impact of pathological extranodal extension on prognosis in oral cavity squamous cell carcinoma – A tertiary cancer centre experience Top

Rohith Singareddy, Krishnam Raju Alluri, Harjot Kaur Bajwa

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

Purpose and Objective(s): To evaluate the risk of recurrence in Carcinoma Oral Cavity Patients with Extranodal Spread post definitive surgery with neck dissection and adjuvant chemoradiation. Materials and Methods: Patients diagnosed to have squamous cell carcinoma of the oral cavity and treated by definitive surgery between July 2016 – November 2017 were included for analysis. Patients that had extranodal extension on post operative histopathology report and treated with adjuvant chemoradiation were analysed for patterns of recurrence. All patients received adjuvant radiotherapy 60-66Gy along with weekly chemotherapy Inj Cisplatin 40mg/m2. Results: A total of 360 patients were diagnosed to have squamous cell carcinoma of the oral cavity between July 2016 – November 2017. The most common site of oral cavity carcinomas was anterior two thirds of tongue (47%). Median lymph nodes dissected were 31. 70 (19.4%) patients had extranodal extension on postop histopathology report and were included in final analysis. 55(78.5%) patients had recurrence of which 47.2% had neck recurrence followed by distant metastasis 42%. Presence of extranodal extension in more than 50% of the total positive nodes had higher incidence of distant metastasis. Most common site of distant metastasis was lung. Median disease free interval in patients who had recurrence was 4 months. Median disease free survival was 9 months. Conclusion: Pathological extranodal extension was a poor prognostic factor in patients with oral cavity squamous cell carcinoma. Future studies should focus on treatment intensification in this subgroup of patients to improve outcomes.

 > Abstract: 327: Dosimetric comparison in spinal cord for post cricoid region malignancies with three-dimensional conformal radiotherapy versus intensity modulated radiation therapy Top

Kartick Rastogi, Poonam Goyal

Smt. Lilaben Chimanlal Parikh Cancer Center, Navsari, Gujarat, India, E-mail: [email protected]

Purpose and Objective(s): The present study aims to compare the dosimetric parameters of spinal cord and planning difficulties encountered during Post cricoid (PC) region malignancies treatment by 3DCRT versus IMRT. Materials and Methods: The present retrospective study was carried out at the Linear Accelerator Centre, SMS Medical College, Jaipur; from January 2017 to July 2018 over 20 PC region patients. Both plans (3DCRT and IMRT) were generated on the same patients. The dosimetric parameters in terms of Dmax to spinal cord, volume of spinal cord receiving >45 Gy, junctional point dose, conformity index (CI) and homogeneity index (HI) were calculated and compared. Results: 3DCRT in comparison to IMRT was associated with significantly higher Dmax to the spinal cord (62.26 vs 44.25 Gy, P<0.001) with significant volume of spinal cord receiving > 45 Gy & junctional point hotspot, whereas IMRT plans had better CI (1.019 vs 0.851, P<0.001) and HI (0.082 vs 0.293, P<0.001) compared to 3DCRT. Conclusion: In PC region malignancies, 3DCRT provides a higher total dose to the spinal cord and target volume with junctional point hot spot & significant volume of spinal cord receiving more than 45 Gy compared to IMRT plans. IMRT setting gives a better dose conformity and homogeneity to the target volume with better sparing of spinal cord, so IMRT should be the preferred treatment modality in PC region malignancies.

 > Abstract: 328: Christie regimen in advanced head and neck cancer: Boon or bane? Top

Deepak Raj Sonkar, Narayan Adhikari, Anurita Srivastava, Kishore Singh

Maulana Azad Medical College, New Delhi, India, E-mail: [email protected]

Background: Relevance of aggressive treatment in locally advanced head neck squamous cell cancers (HNSCC) is debatable in view of expected poor outcome. Long treatment duration only adds up to the cost of treatment without any improvements in outcomes. Keeping in mind these factors and the long waiting times in our resource constrained hospital, we treated these patients with the 'Christie Regimen'. Purpose and Objective(s): The purpose of the following study is to evaluate the efficacy of the Christie Regimen in locally advanced HNSCC. Materials and Methods: We retrospectively evaluated the case records of HNSCC treated with Christie regimen from June 2015 to June 2019. Patients of advanced HNSCC not amenable for radical treatment were treated by parallel pair field technique on Cobalt60 machine (Theatron 780E) to total dose of 50 Gray/16 fractions over 3.2 weeks with cord sparing after phase I (37.5Gray in 12 fractions). Toxicity was scored using Radiation Therapy Oncology Group (RTOG) criteria and response was evaluated as per WHO criteria. Analysis was done with SPSS version 25.1. Results: Records of 81 patients of HNSCC with median age 60 years (range 22-85) and male: female ratio 8:1 were analysed. Half the patients treated belonged to Delhi (50%), followed by UP (32%) and remaining 18% were from Bihar, Jharkhand, Uttrakhand, Rajasthan, Haryana and Punjab. Oropharynx was the predominant site with 44% (N=36) cases, followed by oral cavity 26%(N=21), larynx 25%(N=20) and hypopharynx 5%(N=4). Stage at presentation was IVA 73%(N=59), followed by IVB 16%(N=13), III with poor GC 6%(N=5) and IVC 5%(N=4). Eastern Cooperative Oncology Group Performance Status was 1 in 89%(N=72), 2 in 7%(N=6) and 3 in 1%(N=1) at time of radiotherapy. 53%(N=43) patients had received neoadjuvant chemotherapy prior to radiotherapy. Of the 81 patients, 68% (N=55) completed the prescribed radiotherapy whereas 85%(N=69) completed phase I alone. 65% patients completed the entire treatment without interruption, while 72% patients had no interruption during phase I. Grade III-IV dermatitis and mucositis were seen in 6% and 22% cases respectively. 16% (n=13) patients were lost to follow up. Of the evaluable 68 patients who were assessed at 1 month post treatment, 42% had disease regression, 23.5% had stable disease and 19% had disease progression. Median follow up post treatment was 2.5 months (range=20.1months). Conclusion: Christie regimen for locally advanced HNSCC is a clinically viable option with acceptable outcomes in a resource constrained setting. Feasibility of adopting this in routine practice needs to be tested in randomised trial.

 > Abstract: 329: Assessment of toxicity during intensity modulated radiation therapy with simultaneous integrated boost in postoperative oral cavity carcinoma Top

Udal Yadav, Rohini Khurana, Madhup Rastogi, Rahat Hadi, Shantanu Sapru, Ajeet kumar Gandhi, S. P. Mishra, Anoop Kumar Srivastava, Sambit Swarup Nanda

Dr. RMLIMS, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): Surgery followed by post-operative radiotherapy (PORT) with or without chemotherapy depending upon post-operative histopathology is the standard treatment for oral cavity squamous cell cancers (OSCC). We intend to evaluate the clinical outcome and toxicity of moderate dose acceleration using Intensity Modulated Radiotherapy with Simultaneous Integrated Boost (IMRT-SIB) in post-operative OCC. Materials and Methods: This study was a prospective, observational study conducted in a tertiary care center between November 2017 and August 2019. The indication for PORT were included T3/T4 stage, node positive without extra capsular extension, lympho vascular invasion (LVI), perineural invasion (PNI) and close margin (1-5mm), depth of invasion ≥3 mm for tongue and ≥7mm for buccal mucosa. PORT was delivered with IMRT-SIB technique with LINAC (ELEKTA infinity). A dose of 63.6 Gy in 30 fractions was delivered to high risk clinical target volume (CTV), 54 Gray in 30 fractions to intermediate risk CTV and 51 Gray in 30 fractions to low risk CTV. Dose constraint was spinal cord, Dmax≤42Gy, PRV cord Dmax≤48Gy, Brainstem-Dmax≤50.4 Gy, Each parotid Dmean≤26 Gy. Acute and late toxicity was graded as per RTOG radiation morbidity criteria. Progression free survival rates (PFSR) was calculated from date of surgery to progression/last follow up using Kaplan Maier survival analysis. Results: 30 patients were included in the study with a median age of presentation of 48.5 years (range 33-75 year). 12/30 patients received ipsilateral RT. The median duration of RT was 42 days [mean days 42.3±0.93]. Overall, maximum acute grade ≤2 vs >2 toxicity in terms of oral mucositis were 46.67% vs 53.33%, radiation dermatitis 100% vs 0 %, Dysphagia were 66.67% vs 33.33% respectively. No patients had grade 4 or 5 acute toxicity. 10 patients received intra-venous fluid support among which 60% also required ryle's tube support during RT, all of which were taken off within 2 weeks of RT completion. The acute RT toxicities tend to peak mostly on last week, however in 40% patients it tend to peak 1 week post RT completion. Overall, grade1 late toxicities were 53.33% (subcutaneous toxicity) and 33.33% (xerostomia). Loco regional control rate at a median follow up of 11 months [range 6-18 month] was 96.67%.1/30 patient developed contralateral nodal recurrence. Primary site of this patient was left lateral border of tongue [Table 1]. Conclusion: IMRT-SIB is a safe and acceptable treatment option with minimal acute toxicity for patients of intermediate risk postoperative OSCC.
Table 1: Patients characteristics

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 > Abstract: 331: Clinical outcomes of adjuvant radiotherapy in early stage head and neck cancer Top

Sandip Kumar Barik, Sulagna Mohanty, Niharika Panda, C. Priyadarsini, N. Gajendran, Kamal Sahni, Prashant Kumar Maharana, Itishree Priyadarshini

Regency Cancer Center, Kanpur, Uttar Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): The Role of Adjuvant Radiotherapy in post operative Early Stage Head and Neck Cancer (ESHNC) is yet to be elucidated. The Objective of the study was to study the Clinical Outcome of Adjuvant Radiotherapy in post op pT1,T2,N0 ESHNC with Depth of Invasion(DOI) 0.5mm or more and/Or PNI positive tumours. The Clinical Outcomes was studied in form of Loco Regional Control as Primary Objective and Disease Free Survival,Overall Survival,Acute and Late Toxicity as Secondary Objectives. Materials and Methods: Between Jan 2016 and Oct 2019, 46 patients of ESHNC who had undergone Post operative Adjuvant Radiotherapy(PORT)with pathological pT1,T2,N0 with DOI 5 mm or more and /or PNI Positive tumours were retrospective analysed. Only Squamous cell histology was taken for the study. Pathologically Close or Positive margins,Incomplete Surgery were excluded from the study. The Clinical Outcomes and statistics was done using SPSS v 20. Results: 46 patients of ESHNC were selected for the study.38 patients were pT2 and 8 pts were pT1. 20 pts were of Ca Tongue and 26 were of Carcinoma Buccal Mucosa.12 patients were only PNI positive,24 pts were DOI Positive and 10 included both the factors. The median follow up was 18 months. Tumor thickness >5 mm, PNI was associated with a poor disease-free survival (DFS; p .003). The overall survival (OS) and disease-free survival (DFS) rates were 83.8% and 84.2%, respectively. There were 2 intracranial failure cases in PNI positive Tongue and Buccal Mucosa. 2 Cases of distance metastases wewe noted in Ca Tongue cases. Rest of the patients did not have any local recurrences. The Acute Radiation Toxicity was maximum Grade III Toxicity 65%. Skin toxicity was Grade II 76%,Dysphagia was Grade III 23%. Conclusion: Addition of Adjuvant Radiation to Post operative cases of ESHNC with DOI equals to more than 0.5 and in cases with PNI Positive is beneficial in terms of Improved Local Control. In younger patients age < 40 there were more distance metastases and more of local failure. A Retrospective trial should adress this issue in coming years.

 > Abstract: 333: Prospective evaluation of cfDNA as a potential biomarker for response assessment in locally advanced head and neck squamous cell carcinoma treated with chemoradiotherapy Top

Sourajit Parida, Madhup Rastogi, Rohini Khurana, Shantanu Sapru, Ajeet Gandhi, Rahat Hadi, Nuzhat Husain, Surendra Mishra, Anoop Srivastava, Avinav Bharati, Sambit Nanda, Satyajeet Rath, Harikesh Singh, Siddharth Kumar, Narayan Singh, Smriti Srivastava, Udal Yadav, Mashkoor Ahmad, Ayushi Patni, P Avinash

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

Purpose and Objective(s): Treatment response assessment in locally advanced head and neck squamous cell carcinomas (HNSCC) treated with chemoradiotherapy is being done with conventional imaging and clinical examination. Changes in levels of cfDNA after treatment have been correlated with treatment response in lung, ovarian and colorectal cancers. We aimed to correlate cfDNA levels with treatment response in HNSCC. Materials and Methods: This was a prospective observational cohort study carried out on HNSCC patients (stage III-IVA, AJCC 8th) in our institution between May 2018 to April 2019. All patients received 2 cycles of taxane based induction chemotherapy (TPF) followed by definitive chemoradiotherapy (66-70Gy in 33-35 fractions) with concurrent cisplatin (at 40mg/m2). Serum cfDNA levels were quantified by qPCR in blood samples collected prior to treatment (S1) and 3 months post treatment completion (S2). Response assessment was done 3 months post treatment completion based on WHO response criteria. Correlation between S2-S1 and response was evaluated by Spearman's rank order correlation. P value of < 0.05 was considered statistically significant. Results: Of 34 patients, the median age at presentation was 55 years (range 32-67) with M: F = 31:3. Oropharynx (55.9%) was the most common site followed by larynx (29.4%) and hypopharynx (14.7%). 74% patients were of stage IVA. The median RT dose was 70Gy. The crude complete response rate, partial response rate and progression rates were 82.35%, 14.7% and 2.94% respectively at 3 months post completion of radiotherapy. CR rate was 100%, 84.2% and 40% for patients of larynx, oropharynx and hypopharynx respectively. The median S1 and S2 cfDNA levels were 212.4 ng/ml (range 31.4 – 660.8) and 100.3 ng/ml (range 19.6 – 1043.8) respectively. The median difference between two serum cfDNA levels was -113.1 ng/ml (range -557.5 – 599.1). Significant change of cfDNA was found between S2 and S1 (p < 0.001). In all complete responders' group, the median cfDNA level showed a declining trend from S1 to S2. Spearman correlation coefficient between S2-S1 and response (CR vs non-CR) was 0.370 (p = 0.031). Conclusion: As compared to baseline, statistically significant decrease in level of cfDNA was seen 3 months post treatment completion. Moderate positive correlation was found between tumor response and difference in cfDNA levels. Based on our results, change in cfDNA level may be used as a surrogate marker of tumor response. Larger prospective studies can be done to confirm cfDNA as biomarker in HNSCC.

 > Abstract: 341: Verification of setup errors in planning external beam radiation therapy on linear accelerator in head and neck cancers Top

Aarathi Ardha

MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana, India, E-mail: [email protected]

Background: Monitoring setup errors for better tumour targeting is essential. Many studies have shown that Tumour Control Probability (TCP) is congruous with accurate beam placement and execution of treatment. Deriving a PTV margin to account for most of the setup inaccuracies has to be institutionalized and is done using various formulae. These formulae incorporate the observed systemic and random errors recorded to give a PTV margin. The formula by van Herk (2.5∑ + 0.7σ) is the most pertinent as it ensures that 90% of patients receive cumulative CTV dose of at least 95% of the prescribed dose. Introspection into the cause for the documented errors and measures for rectification completes the Quality Assurance for setup accuracy. Purpose/Objective(s):Primary objective was to document setup errors in treatment fields' position for deriving our institutional PTV margin. Materials and Methods: We have studied the systematic and random errors in head and neck cancer patients at our institution using EPID (Electronic portal imaging systems). Imaging was done weekly and compared to the initial DRR image to note the error in vertical, longitudinal and horizontal directions. Results: The calculated errors in vertical, lateral and longitudinal directions using ICRU 62 formula are 1.92, 2.26 and 3.2 respectively. Using Stroom's formula errors in vertical, lateral and longitudinal directions are 3.30, 3.89 and 5.69 respectively. Van Herk formula based error calculations have given the results as 3.85mm in vertical direction, 4.55 mm in lateral direction and 6.67mm in longitudinal direction. The maximum error occurred in superior-inferior direction. Conclusion: Systematic and random errors that occur during radiation delivery on Linear accelerator in head and neck cancer patients were observed. The observed errors were used to derive an average PTV margin to be given according to our institutional setup using the Van Herk's formula. It was noticed that the maximum error occurred in superior-inferior direction. The possible explanation for the occurrence of this error is the loss of subcutaneous fat in head and neck region, especially the submandibular region leading to improper neck fixation as treatment progresses. This may lead to a loose fitting ray cast resulting in maximum movement in the superior-inferior direction. As systematic error is the major component, it's correction has to be given the highest importance among all the error correction strategies. This study accentuates the necessity for an observation of setup errors in every institution and framing a PTV margin according to the setup variability.

 > Abstract: 342: Experience and outcomes in olfactory neuroblastoma over a decade at tertiary cancer center Top

Himabindu Nenavath, Sowjanya Kondru

MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana, India, E-mail: [email protected]

Background: Olfactory neuroblastoma is a rare epithelial malignancy arising from the odorant receptors in nasal mucosa or along the cribriform plate of ethmoid bone. Intracranial extension is commonly seen due to the close continuity of olfactory nerves with sub arachnoid space associated with considerable mortality and morbidity. Clinical presentation includes nasal stuffiness, local pain, epistaxis, anosmia, visual impairment, proptosis, headache and seizures. Radiologic imaging with CT or MRI, an ophthalmic evaluation and Histopathologic confirmation with Immunohistochemistry are a part of the initial diagnostic workup. Although surgery, chemotherapy and radiation have equally important role in the management, earlier stages may preferably be treated with surgery or radiotherapy and the later stages with multimodality approach. Purpose and Objective(s): Olfactory neuroblastoma being a rare pathology, not much evidence exists to create standard management protocols. There is always a need for strengthening the data available in order to provide the most appropriate treatment modality for achieving better outcomes. We wish to put forth our institutional experience in managing this rare entity after our multidisciplinary tumour board discussions. Materials and Methods: We conducted a retrospective review in a total of 13 patients diagnosed with olfactory neuroblastoma and registered at MNJ Cancer Hospital over a decade (2010-2019). We analyzed the age and sex distribution, performance status at presentation, clinical symptomatology and the Kadish stage. Therapeutic aspects of the patients were studied. Results: In our study we noticed a near bimodal age distribution with the youngest at 14 years and the eldest at 65 years. There was a female preponderance with male to female ratio of 5:8. Most common presentation noted was nasal stuffiness followed by epistaxis and proptosis. Majority patients had good performance status at presentation. 10 patients presented with a Kadish stage C while remaining patients presented with Kadish stage B. Cervical nodal metastasis was seen in 3 patients. Chromogranin, synaptophysin and CD 56 positivity was found in most of the patients. 2 patients received multimodality treatment with surgery followed by concurrent chemo radiation, 8 patients received neo-adjuvant chemotherapy and 6 patients had radiation as a part of their treatment. Conformal radiation techniques were used to deliver doses as high as 66 Gy in 2 Gy per fraction. 2 patients presented with distant metastasis during follow up, one with bone metastasis and the other with retroperitoneal nodal metastasis. Conclusion: Olfactory neuroblastoma being a rare malignancy, treatment protocols need to be constructed after reviewing many institutional experiences. Our study concludes that neoadjuvant chemotherapy followed by radiation gives the best outcomes. Doses of 66 Gy can be delivered using conformal radiation techniques while respecting the doses to organs at risk, especially the eye, optic nerve, optic chiasm, brain and the pituitary gland. Multidisciplinary discussions provide a better into the sequencing of management.

 > Abstract: 348: Outcome analysis of 122 consecutive head and neck cancer patients treated with helical arc therapy (tomotherapy): Institutional audit report Top

R. Anoop, K. U. Pushpaja, Ajinkya Gupte, Deepak Balasubramanian, Krishnakumar Thankappan, Debnarayan Dutta, Subramania Iyer

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

Aim: To report a single institutional experience with the use of Intensity modulated radiotherapy (IMRT) with helical tomotherapy (HT) for head and neck cancer. Methods: 122 consecutive patients were treated with HT for squamous cell carcinoma of the head and neck (HNSCC) with radical and adjuvant RTafter appropriate imaging, contouring, planning and treatment delivery as per institutional protocol. GTV is considered as gross disease, CTV margin of 0.5 cm and PTV of 3-5mm. OARS contoured and constraint given as per protocol. Dose for radical intent RT was 66-70Gy in 30-33 fractions. Adjuvant RT dosage schedule was 60 to 66Gy in 30 fractions. Concurrent CT received by71/122 (58%)patients. Results: Among 122 pts [male 101 (83%), Stage I-II: 14, III: 22, IVA: 50, IVB: 27, IVC: 1, mean age 58 yrs]; oral cavity, oropharynx, larynx, hypopharynx, nasopharynx patients were 61 (50%), 12 (10%), 13 (11%), 12 (10%) & 7 (6%) respectively. Radical intent RT was in 47 (38%), adjuvant RT in 61 (50%) and RT for recurrent disease in 14 (11%) patients. RT schedule was 66Gy/30fr, 70Gy/33fr, 60Gy/30fr in 46 (38%), 40 (33%), 33 (27%) respectively. At mean follow up of --- months, 81 (66%) patients were alive and 37 (30%) expired due to disease progression. 47 (38%) patients had controlled disease, 43 (35%) had progression. Actuarial mean OS in oral cavity patients (n=61) were 25.1 months (SE 1.4, 95%CI 22.3-27.9). Actuarial mean OS in adjuvant RT (n=47) and radical RT (n=61) patients were 23.5 months (SE 1.5; 95%CI 20.4-26.4) and 25.7 months (SE 1.4; 95%CI 22.8-28.5). Bony invasion present in 14 (11%), extra-nodal extension in 30 (24.6%), LVI in 5 (4%), PNI in 22 (18%) and margin positive in 7 (6%) patients. Bony invasion (invasion Vs no invasion: 15 Vs 26.1 months, p-0.043) and margin status (margin free Vs positive: 25.1 Vs 12 months; p-0.026) had influence in outcome. RT dose in radical intent (70Gy/33fr Vs 66Gy/30fr: p-value 0.416); extra-nodal extension (present vs absent 20.5 Vs 26.1: p-0.451); Perineural invasion (positive Vs negative: 23.1 Vs 25.1; p- 0.325) and LVI (present Vs absent; p-value 0.368) did not have impact on survival function. Conclusion: HT achieves clinical outcomes comparable to contemporary series reporting on IMRT for head and neck cancer. Prognostic factors such as margin status & bony invasion influence survival. Radical RT dose, LVI, PNI & ENE did not influence survival function.

 > Abstract: 349: Prognostic nutritional index: A predictive tool of treatment tolerance in head and neck radiotherapy? Top

Anu George

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

Purpose and Objective(s): Poor nutritional status is common in head and neck cancer patients which influences treatment compliance, quality of life ,and survival. Thus, a major treatment challenge for physicians. Aim of our study was to assess role of pre-treatment biomarkers like Neutrophil lymphocyte ratio(NLR), Platelet lymphocyte ratio(PLR) and Prognostic nutritional index(PNI) in predicting treatment tolerance. Materials and Methods: A prospective observational study on 50 patients who received definitive head and neck radiotherapy from October 2018 to July 2019 in Ramiah hospital,bangalore. Patient , tumour and treatment characteristics were documented in a structured format. All routine blood tests were done prior to start of treatment. NLR( neutrophil to lymphocyte ratio), PLR(platelet to lymphocyte ratio) and PNI (10x S.Albumin + 0.005x Lymphocyte count) was calculated. Cut off values for NLR,PLR,PNI derived based on median values were 3, 152 and 48 respectively Treatment tolerance in terms of not completing planned treatment, need for parenteral nutrition, unplanned hospitalizations were assessed. Results: The median age in our study group was 59 year with Male : female ratio being 2.2:1. The median Hb, TLC ,NLR,PLR,PNI were 12,4943, 3,162,47 Respectively.25 (51%)patients received radical chemoradiation and out of 24 post op cases, 16(32.7%) received adjuvant RT alone and 8 cases(16.3%) received adjuvant chemoradiation. 6 patients did not complete planned radiation fractions, 10 patients had treatment breaks with mean of 4 days gap. 10 patients required parenteral nutrition during the course of treatment.2 patients had recurrence and 6 patients died during a median follow up of 6 months. Out of patients who did complete planned radiotherapy, 60 % had a NLR >3, 80% had PLR>152 and 83% had a PNI < 47 (p value 0.058). 70% of patients requiring parenteral nutrition during course of treatment had a PNI of < 47(p value 0.08). Among patients who died 100 % had a PNI<47, and 83% had a PLR>152(statistically significant). Both patients who had recurrence had a PNI < 47 and PLR>152 which was statistically significant(p value 0.003 and 0.03 respectively). Conclusion: Low PNI was a predictive factor of treatment tolerance and outcome. PNI could be considered as a surrogate marker both of nutritional status and systemic inflammation and hence is an easy screening tool to select patients in whom early nutritional and treatment interventions are required. Role of PNI in long term survival outcomes is to be explored, and will be future line of research.

 > Abstract: 360: Prospective randomized study comparing sequential intensity-modulated radiation therapy boost versus simultaneous integrated boost intensity-modulated radiation therapy with concurrent chemotherapy in locally advanced head and neck cancer Top

Debanjan Sikdar, Nidhi Sharma, Ajay S. Krishnan, Sagar Raut, T. S. Athira, Rachit Ahuja, Rohit Mahajan, Sweety Gupta, Deepa M. Joseph, Rajesh Pasricha, Manoj Gupta

AIIMS, Rishikesh, Uttarakhand, India, E-mail: [email protected]

Purpose and Objective(s): Concurrent chemo-radiation is the treatment of choice in most locally advanced Head and Neck cancer. Modern radiotherapy techniques like IMRT and VMAT for LAHNC can be performed using sequential boost (SEQ-IMRT) or simultaneous integrated boost (IMRT-SIB) techniques. Differences in the treatment related outcomes of both these techniques like disease control & toxicities remain largely unexplored except some retrospective comparisions. Hence we planned to compare local control & primarily acute toxicity between SEQ-IMRT and IMRT-SIB with concurrent chemotherapy in locally advanced head and neck cancer patients (excluding nasopharyngeal cancers). Materials and Methods: We performed a single institutional prospective randomized study on patients with locally advanced head and neck cancer (Stage III and Stage IVA, AJCC 8th edition, with squamous cell histology, Oropharynx, Hypopharynx and Larynx as major sites). Patients were randomized in to 2 arms (A & B) using computerized method. Patients in Group A were treated using SEQ – IMRT (50Gy in 25# to whole PTV followed by 20Gy in 10# Boost to PTV high risk) technique while Group B patients received treatment with IMRT-SIB technique(66Gy in 30# to PTV high risk and 54Gy in 30# to PTV low risk simultaneously). Both arms received concurrent chemotherapy (weekly Injection Cisplatin 40 mg/m2, 5-6 cycles). Acute toxicities were recorded weekly and at first follow up 15 day, followed by 3 monthly assessment according to the NCI-CTCAE version 4.0. First analysis of immediate outcomes including local control & toxicities was done at 90 day follow up according to Recist criteria version 1.0 and the results are presented here. Results: 64 patients were randomized in two arms with 32 patients are in arm A & B each. Among them 22(10 in A + 12 in B) patients were stage III and 42(22 in A + 20 in B) patients were Stage IVA. There were no significant difference in PTV coverage (Mean - V95 in IS 97.43% in A vs 97.40% in B), mean Homogeneity (0.062 in A vs 0.065 in B) and mean Conformity Index (0.66 in A vs 0.69 in B) in both arms. IMRT SIB was associated with slightly higher toxicities in the form of more grade 3 and more dermatitis (12.9% in A vs 23.3% in B, p - 0.512), mucositis (19.4% in A vs 30% in B, p – 0.563), dysphagia (12.5% in A vs 23.3% in B, p – 0.512) with higher rate of RT tube dependency (12.9% in A vs 27.3% in B, p - 0.217). At 90 day follow up there was no significant difference in immediate out come in view of Local control (72.7% in A vs 61.3% in B, p – 0.202). Conclusion: This prospective randomized data showed similar tumor out come in both the arm with trend of higher toxicities in arm B leads to more nasogastric tube dependency, more treatment breaks and increased number of hospitalization but it was not statistically significant. Larger sample size and longer follow up is needed for long term outcome in the form of local control and survival of the patients.

 > Abstract: 365: Estimation of prognostic impact of plasma fibrinogen in patients with locally advanced squamous cell carcinoma of head and neck Top

Shashank Joshi, Paramjeet Kaur, Ashok Chauhan, Abhishek Soni, Shailley Arora Sehgal

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

Introduction: Head and neck cancers being the sixth most leading cancer and a major cause of morbidity and mortality contributing 4.87% of all new cancer cases and 4.83% of cancer related deaths worldwide. In India, it constituted 17% of all cancers and accounted for 15% of all cancer deaths. In recent years, cancer research has been concentrated on the characterization of novel markers, which ideally should have the potential to select patients who will benefit from specific treatment and identify those at high risk for disease recurrence and death. Many prognostic factors that have been studied and pretreatment plasma fibrinogen has emerged as an independent predictor of poor prognosis. The results of numerous clinical studies have shown that elevated pretreatment plasma fibrinogen levels are associated with worse survival in a diversity of malignancies, including lung, gastroesophageal, colorectal, ovarian, pancreatic, and hepatobiliary cancer. Evidence for the use of plasma fibrinogen as predictor of clinical outcome in patients with head and neck cancer is limited. Materials and Methods: This prospective study was conducted in Department of Radiation Oncology, PGIMS, Rohtak in hundred patients with locally advanced head and neck cancer (stage III and IV) fulfilling the inclusion criteria who were recruited and evaluated for plasma fibrinogen, one week prior to the commencement of the treatment. The cut off value (355 mg/ dL) was used for randomization of the patients into two groups having fifty patients in each. The patients recruited in Group I had values > 355 mg/ dL while those who were recruited in Group II had values < / = 355 mg/ dL. Patients in both the groups were treated with Radical EBRT 66 Gy/ 33 fractions/ 6.3 weeks (5 fractions per week) to face and neck delivered using telecobalt-60 teletherapy machine along with concomitant inj. Cisplatin 100 mg/ m2 intravenous on day 1, 22 and 43. Patients were assessed for treatment related toxicities during and after treatment. Response was assessed after completion of treatment and patients were followed till a period of one year. Results: At the end of treatment, complete response seen in group II patients (70%) when compared to group I patients (66.67%), was slightly better but statistically insignificant. Partial response was seen in 30% and 33.33% patients of group II and I respectively at the end of treatment. Disease free survival at 1 year was higher and statistically significant in group II patients (83.33%), when compared to patients in group I (66.67%). Residual disease was present in 13.33% and 23.33% patients in group II and group I respectively. Recurrence was observed in 3.33% patients in group II when compared to 10% patients in group I, but was not statistically significant. Pretreatment plasma fibrinogen values were found to have statistically significant association with higher nodal status i.e. N2 disease, higher AJCC stage i.e. stage IV and poor disease free survival. Conclusion: The present study showed the role of pretreatment plasma fibrinogen as a prognostic indicator in patients with head and neck squamous cell carcinoma. To further establish the role of pretreatment plasma fibrinogen as a negative prognostic factor in patients with head and neck squamous cell carcinoma, a larger study with more number of patients and longer follow up is needed.

 > Abstract: 375: A prospective study on correlation between oral mucositis and timing of radiation for head and neck cancer patients Top

M. Lithika Lavanya, T. Arul Ponni

Mysore Medical College, Mysore, Karnataka, India, E-mail: [email protected]

Purpose: Head and Neck (H&N) cancers are one of the most common malignancies, constituting nearly 30% of all cancers in males & 16% of all cancers in females as per ICMR( Indian Council of Medical Research) data. Though more & more patients present at early stage & show improved overall survival, the quality of life is low due to treatment related toxicities. Grade 3 & 4 mucositis is seen approximately in 25% of the patients. Oral mucositis indirectly leads to decreased quality of life and inferior results & recurrences. Any measure to prevent mucositis should be taken up, hence the need for this study. This study is designed to correlate and analysis the effect of timing of radiotherapy (RT) on development of oral mucositis.


  1. To assess oral mucositis in head and neck cancer patients being irradiated in morning versus evening
  2. To compare mucositis between the two groups
  3. To record & compare the weight changes between the two groups.

Materials and Methods: Sixty four head and neck cancer patients who fit the inclusion criteria were enrolled in the study from October 2016 to March 2018. They were divided into morning (8am-11am) or evening (5pm-8pm) group. Patient's weight & grade of mucositis were recorded at the commencement of EBRT (External Beam Radiotherapy), weekly during the period of radiotherapy and during the 2nd and 6th week post treatment. Observed mucositis were graded based on Radiation Therapy Oncology Group (RTOG) Acute Radiation Morbidity Scoring Criteria. Results: Mean age was 58 & 54 years in morning & evening respectively. Male patients & Smokers dominated in number in both the groups. All other variables were equally distributed among both groups with none showing any significant difference. In group A 21.9% developed grade 3 mucositis versus 25% in group B at the end of treatment, but it did not translate into statistical significance ( p =0.7). This decrease in grade 3 mucositis also led to decreased wt loss in morning group (mean weight loss= 3.91 kgs) as compared to evening group (mean weight loss= 4.25 kgs) but the p value was 0.3. Conclusion: Irradiation in the morning shows a better toxicity profile. There is need for further chronoradiotherapy studies with larger study size & longer follow up to know its effect on long term tumour outcome & late toxicities.

 > Abstract: 379: Sino-nasal palatal mucosal melanoma - A case report Top

Motepalli Pandu Ranga Kumari, Ghanta Sateesh Kumar, Karra Pradeep, Srinivas

Government Hospital, Kakinada, Andhra Pradesh, India, E-mail: [email protected]

Background: Mucosal melanoma of the oral cavity is extremely rare tumour consisting approximately 0.2 - 8.0% of all melanoma cases and 0.5% of all oral malignancies with aggressive behaviour, early metastatic spread and poor prognosis. Most common sites (70-80%) are nasal cavity and para nasal sinus, reminder in oral cavity and with male prepondence. Tobacco, alcohol, chronic irritation, and formaldehyde exposure are possible risk factors. Surgery is the treatment of choice for AJCC stage III,IVA with lymphnodal dissection followed by adjuvant radiotherapy. Radical or palliative radiotherapy for stage IVB,IVC. Systemic therapy (interleukin-2,interferon,imatinib)for metastatic and unresectable disease. Here we are presenting a rare presentation of sinonasal-palatal mucosal melanoma. Case Report: A 75 yrs. old male with ECOG 2 presented with cheif complaints of nasal obstruction, bleeding, painless pigmented growth over palate and facial asymmetry especially on the right side for past two months with neck swelling.

  • It started as small growth which gradually increased in size, with associated difficulty in breathing and swallowing and change of voice, with no other significant complaints
  • He is chronic smoker for past 30yr with 50 cigerrettes per day, occasional alcoholic and hypertensive on regular treatment with no other significant co morbidities and family or past personal history of skin lesions.

On examination his vitals are stable and general systemic examination normal. Local examination showed right facial asymmetry and right level 2 and posterior cervical lymphadenopathy of size 2*2cm, firm in consistency and with restricted mobility. Oral cavity examination showed pigmented lesion involving entire palatal surface with nodular surface and irregular borders. Growth extension is seen into the nasal cavity on right side (Figure 1). With this history and examination a provisional diagnosis of mucosal melanoma was made and patient was investigated further. Complete hemogram and biochemicals are within normal limits. chest X-ray and ultrasound abdomen and pelvis were normal. Histopathology suggestive of malignant melanoma (Figures 2 and 3). CT scan showed soft tissue density in right maxillary sinus obliterating right osteomeatal unit with erosion of anterior and posterior lateral walls and involving alveolar margin, molar apices, hard palate, right medial pterygoid plates (Figures 4-6). Surgical opinion was taken and it was inoperable. Radiotherapy was given 66Gy in 33 fraction and patients didn't turn up for chemotherapy. Conclusion: OMMs are rare, but aggressive tumors with very low survival rates which can metastasize rapidly. owing to its rarity, all pigmented lesions in the oral cavity should be examined with suspicion. The purpose of this manuscript is to emphasize on early diagnosis and to maintain high index of suspicion for those pigmented lesions occurring in the high risk sites such as sinonasal and palatal region.

 > Abstract: 380: Compliance to head and neck radiotherapy in beneficiaries of cashless scheme a rural tertiary cancer care center experience Top

Pallavi Kalbande

MGIMS, Wardha, Maharashtra, India, E-mail: [email protected]

Background: Head and neck cancers are the most common cancer among males in India. Early diagnosis and complete treatment including radiotherapy form cornerstone in cure of head and neck cancers. Most commonly prescribed radiotherapy is 1.8-2 Gy per fraction for 5 days/wk over 6-7 weeks. Treatment of head and neck cancer is toxic,costly and challenging in underserved population of country. Adherence to treatment is the key predictor of outcome. Treatment interruptions are known to reduce local control and overall survival. High cost of treatment keeps large number of patient untreated. Considering this government of India has provided complete treatment free of cost including travel expenses. Objective: Our study estimates the compliance to radiotherapy in insured patients of head and neck cancer and identify factors associated. Methodology: A retrospective study head and neck cancer patients registered to rural tertiary cancer care center, Sevagram. Clinical and demographic details were fetched from hospital records. All patients were treated on linac with 2D technique. Prescribed dose was 60 to 70Gy. Patients who defaulted to initiate and complete treatment were contacted over phone and reasons for each default were noted down. They were also persuaded to complete the treatment course. Results: Total 228 patients were included in the study 78.6% were males and 21.3%were females. Median age was 50 yrs(26-80yrs). Carcinoma of the oral cavity was commonest.20.73% patients presented in early stage whereas 78% presented in locally advanced stage. IVA was commonest stage of presentation. 56.14%(128)patient defaulted to start radiotherapy after approval of package. Early stage at presentation is associated with 3.31 (1.79-6.4) higher odds and operated patients have 3.8 (2.2-6.7) higher odds of initiating treatment. Age,Sex,employment status,distance to travel,BSA,education are not significantly associated. 71/128 (55.4%) defaulted due to fear of radiation toxicities, 30/128 (23.4%)due to poor family support, 20/128 (15.6%)due to financial crisis and 7 patients defaulted without any reason. 100 patients were started on radiotherapy out of them 55% patients have successfully completed treatment with gaps less than five days. 45% didn't complete the prescribed treatment. Education above 10th standard is associated with 4.78 (1.27-17.8) higher odds of completing prescribed treatment. Other factors like age,sex,stage,neoadjuvant or concurrent chemotherapy,BSA,surgery are not significantly associated with completion of treatment. 25/45 (55.5%) defaulted due to unbearable treatment related toxicities, 12/45 (26%)due to poor family support and 8/45 (17%) due to financial crisis. Conclusion: Large number of patients are defaulting to initiate radiotherapy due to fear of toxicity. Community based approaches needs to be strengthened in rural under served population of India Efficiency of cashless schemes are limited due to lack of awareness,education,late presentation and social stigma.

 > Abstract: 397: Intensifying radiation treatment in advanced/poor prognosis laryngeal, hypopharyngeal and oropharyngeal cancers using positron emission tomography-computed tomography based dose escalation strategies (intelhope) interim update Top

Shaurav Maulik, B. Arun, sanjoy Chatterjee, Indranil Mallick, Rimpa Achari, Moses Arunsingh, Santam Chakraborty, Sriram Prasath

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

Purpose and Objective(s): Intensifying radiation treatment in advanced/ poor prognosis Laryngeal, Hypopharyngeal (LH) and Oropharyngeal cancers (OPC) using PET –CT based dose escalation strategies. Interim Update. Materials and Methods: Non-metastatic locoregionally advanced histologically confirmed squamous cell cancers of Larynx/Hypopharynx (T3-4, any N, or T1-3, N2-3) or Oropharynx (HPV negative with T2-T4, N1-3, and HPV positive with more than 10 pack year smoking history and N2b disease, M0) are eligible. RT planning PET-CECT is done for all patients. Randomisation is done after finalization of gross tumour volumes, to either standard arm (66Gy in 30 fractions) or escalated arm (73.5Gy in 30 fractions) of radiotherapy along with concurrent weekly cisplatin @ 40 mg/m2. Results: We have previously demonstrated the feasibility of planning in our report of dosimetric parameters of the first thirty treated patients. Till date, 66 of the planned 100 patients have been accrued and treated. To demonstrate the nature of disease being treated in this study, we report on the sum of GTV Primary and nodal volume in a patient (GTVTot) as a measure of tumour burden (and planning challenge) -and summarize distribution by site and arm:

Oropharynx Standard (18) vs escalated (20) Median GTV Total (cc) 51.9 vs 54.6

Larynx Standard (5) vs escalated (9) Median GTV Total (cc) 9.1 vs 21.8

Hypopharynx Standard (9) vs escalated (5) Median GTV Total (cc) 45.1 vs 24.

Conclusion: Modest dose escalation to gross tumour volume is feasible using contemporary planning techniques. Interim reviews of toxicity supports comparable safety of the standard and escalated arms. Mature reporting of outcomes will be possible after the study completes planned accrual of 100 patients.

 > Abstract: 408: Clinical outcomes and toxicity profile with intensity modulated radiation therapy or brachytherapy boost in oropharyngeal malignancies: A randomized, open label study Top

Vibhay Pareek, Rajendra Bhalavat, Manish Chandra

NCI, AIIMS, New Delhi, India, E-mail: [email protected]

Purpose and Objective(s): Radical radiation therapy in oropharyngeal malignancies have a significant toxicity especially in relation to dose to dysphagia aspiration related structures (DARS), mucositis and aspiration which leads to prolonged overall treatment times, thereby, having an impact on survival outcomes. Interstitial Brachytherapy (ISBT) has significant role in reducing these toxicities, however, literature comparing Intensity modulated radiation therapy (IMRT) with Brachytherapy boost is lacking. Our study looks in to the clinical outcomes and toxicity profile while comparing the two treatment modalities. Materials and Methods: A total of 70 patients diagnosed histopathologically as squamous carcinoma of oropharynx were randomized to receive radical radiation therapy with IMRT (n=35) or IMRT with ISBT boost (n=35). The total dose with IMRT was 70Gy and in ISBT, initial dose was 50Gy with IMRT followed by 24.5Gy dose (3.5Gy in 12 fractions). Patients were followed up as per institute protocol and assessed for a median follow-up of 36 months. Assessment of survival outcomes in terms of progression free survival (PFS) and overall survival (OS) were assessed. Toxicity profile was assessed as per CTCAE 4.0 criteria and quality of life was assessed as per EORTC-C30 and HN35 questionnaires. Dosimetric parameters for the target volumes were compared along with assessment of various important organs at risk (OAR). Results: After a median follow up of 36 months, PFS was 86% vs 81% favoring ISBT arm (p=0.032), however, there was no difference in overall survival. On assessment of toxicities, dysphagia and xerostomia were significantly reduced with ISBT boost with Grade II and III toxicities 12% and 18% vs 18% and 24% respectively. On QoL assessment, physical (p<0.001) and social functioning (p=0.012) favored ISBT boost. On symptom assessment, fatigue, dyspnea, appetite loss, speech problems, swallowing and pain was significantly reduced with ISBT boost. Dosimetric parameters showed significant dose reduction to DARS (p<0.001) and parotid glands (p<0.001) with ISBT boost. Conclusion: ISBT boost has shown to be effective in improving PFS, toxicity profile and quality of life outcomes in oropharyngeal malignancies in spite of technological advancements in form of IMRT. ISBT should be employed in treatment armamentarium to dose escalate and thereby improve survival especially in oropharyngeal malignancies.

 > Abstract: 412: Squamous cell carcinoma of larynx with cutaneous metastasis: A rare presentation Top

Vinodh Kumar Selvaraj, Deleep Kumar Gudipudi

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

Purpose and Objective(s): Distant metastases from laryngeal carcinoma are frequently seen in the lung, bone and liver, while cutaneous metastasis is a rare occurrence. Metastatic skin lesions from a primary squamous cell carcinoma of the head and neck have only been reported in 1%-2% of these patients. Especially cutaneous nodules in irradiated site is a rare phenomena. Here, we report a case series of two cases of squamous cell carcinoma of larynx developing skin metastasis within the radiation field. Materials and Methods: 65 year and 59 year old males, known cases of squamous cell carcinoma of vocal cord/larynx who received definitive chemo radiation to head and neck region using conventional technique to a total dose of 70Gy in 35 fractions along with weekly Cisplatin 40mg/m2. On follow up, both the patients developed skin nodules in the neck, in areas covered by radiation field. Initially they were thought to be infective in nature but FNAC showed metastatic malignant cells. Hence, both the patients were referred for palliative chemotherapy. Results: In review of literature, cutaneous metastasis from squamous cell carcinoma of larynx is very rarely reported. Among the reported cases, the sites of metastasis were face, thigh, knee and heel. These are the first reported cases in the field of radiation in neck. Conclusion: Fine needle aspiration cytology/biospy should be done in cutaneous nodules associated with laryngeal cancers to rule out malignancy, even if it clinically appears to be benign/infectious in nature.

Abstract: 427: Subjective, objective and quantitative evaluation of xerostomia with parotid gland dosimetric correlation in patients of head and neck cancers treated with three-dimensional conformal radiotherapyand intensity modulated radiotherapytechniques

Adadi Srinivasa Naidu, Piyush Kumar

Sri Ram Murti Smarak Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Background: Concurrent chemo-radiotherapy has emerged as an accepted standard of care for locally advanced head and neck squamous cell cancer. Radiation induced Xerostomia is a known late side effect which disturbs the quality of life. 3DCRT& IMRT are commonly used conformal techniques. Purpose: The present study was done to compare radiation induced xerostomia in patients of head and neck cancers treated with 3DCRT & IMRT and correlate with doses received by parotid glands in both techniques. Methodology: Fifty patients were included in the study from November 2016 to December 2017. All patients were planned with Radiotherapy dose of 70 Gy in 35 fractions over 7 weeks with concurrent Cisplatin weekly. The patients were divided into two groups of 25 each (Group I- 3DCRT & Group II- IMRT). For assessment of Xerostomia, Objective grading was done using RTOG toxicity scale, Qualitative assessment was done using EORTC H&N 35 Questionnaire and Quantitative assessment was done by Saxons test. Assessments were done for each patient- Prior to radiotherapy, on completion of radiotherapy, at 6 months and at 18 months post radiotherapy. Results: After completion of radiotherapy, objective grading (RTOG) grade 2 or worse xerostomia was present in 21 patients of Group I (84%) and 20 patients of Group II (80%), there was no significant difference (p value 0. 52). Quantitative Saxon test showed no significant difference in both the groups (p value 0.45) with 20 patients of Group I (83.3%), 18 patients of Group II (75%) had Grade II or worse xerostomia. At 6 months, Objective grading (RTOG) grade 2 or worse xerostomia was present in 12 patients of Group I(48%) and 9 patients of Group II (36 %), p value was significant (p value 0.014). Subjective assessment with questionnaire showed significantly better scores for Group II (p value 0.02). Quantitative Saxon test showed significant difference in both the groups (p value 0.001) with 16 patients of Group I(64%), 4 patients of Group II (8%) had Grade II or worse xerostomia. At 18 months, Objective grading (RTOG) grade 2 or worse xerostomia was present in 8 patients of Group I (32%) and 6 patients of Group II (24 %), with no statistical significance (p value 0.34). Subjective assessment questionnaire showed significantly better scores for Group II(p-0.01). Quantitative analysis showed showed no significant difference in both the groups (p value 0.32) with 7 patients of Group I (28%), 6 patients of Group II (24%) had Grade II or worse xerostomia. This study is having mean parotid doses of 52 Gy in whole parotid of 3DCRT and 31 Gy in IMRT group. The incidence, severity and recovery of Xerostomia correlated significantly with Parotid gland doses (p-0.04). Conclusion: Present study concludes that:

  • IMRT significantly reduces the incidence and severity of xerostomia compared to 3D-CRT
  • Long-term follow up of 18 months has validated that 3DCRT patients have also recovered
  • Subjective reporting of QoL with better scores in IMRT patients even at 18 month follow up.

A dose dependent gradient is seen between parotid doses and salivary function.

 > Abstract: 430: Outcomes and toxicities in patients with advanced laryngeal and hypopharyngeal cancers treated with definitive chemoradiotherapy Top

Fathima Almas

Kasturba Medical College, Manipal, Karnataka, India, E-mail: [email protected]

Purpose and Objective(s): This study aims to add to the body of knowledge pertaining to the treatment of advanced laryngeal and hypopharyngeal cancer using definitive chemoradiation by the VMAT technique and assess its effectiveness and challenges. To report the median disease-free survival, median overall survival and toxicities on follow-up. Materials and Methods: This is a prospective, observational, single institutional study over a period of two years from September 2017 to September 2019. SPSS software version 22 was used to analyze the data. Results: 28 patients who met the inclusion criteria were included out of which 12 had carcinoma larynx and 16 had carcinoma hypopharynx. The median age was 59 years. Median treatment time was 48 days. Mean dose to parotid, superior and mid constrictors was 32Gy, 45Gy and 64GY. 19% patients developed leucopenia that was grade 3 or higher. At completion 7% patients had grade 3 or more dermatitis, 4% had grade 3 or higher mucositis and no patient had grade 3 or higher xerostomia. 20% patients developed stricture on follow up and all these patients had a hypopharyngeal primary. At a median follow up of 6.5 months, DFS is 75% and OS is 78.6%. Conclusion: Our results are comparable with that of similar studies and show that concurrent chemoradiotherapy is a promising method of treatment for advanced laryngeal and hypopharyngeal squamous cell cancer with favourable outcomes and an acceptable toxicity profile.

Abstract: 431: Subjective evaluation of change in swallowing function and dietary pattern using performance status scale head and neck for patients of head and neck cancer undergoing curative intent intensity-modulated radiation therapy with or without chemotherapy

Prattusha Mukherjee, Nikhil Kalyani, Suhrut Kommineni, Ajay Doshi, Sharmila Agarwal

Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India, E-mail: [email protected]

Introduction: Head neck radiotherapy is associated with significant swallowing and speech dysfunction. Intensity modulated radiotherapy may reduce the doses to swallowing structures and decrease associated morbidity. Aim of the Study: Primary: To prospectively and subjectively assess change in swallowing function using PSSHN questionnaire.


  1. To assess the magnitude of post-treatment dysphagia, weight loss, change in dietary pattern and speech in this study population
  2. To identify the patient and the tumor related factors which are influencing the PSS-HN scores.
  3. To assess the impact of Concurrent Chemotherapy on post-treatment dysphagia.

Materials and Methods: Ethics approval was obtained for the project. Only histologically proven HNSCC treated with curative intent IMRT patients, having a PS 0-1 were included in the study. DARS were contoured and the doses observed. They were asked to fill up PSSHN questionnaire at baseline, at conclusion of radiation and at 3 months and one at 6 months post treatment completion. Change in PSSHN scores were evaluated for all patients. CTRI Registration No is CTRI/2017/11/010378. Results: Between August 2017 to April 2018, 62 patients were enrolled in the study and written informed consent was obtained. Considering 1 dropout, 1 disease progression and 1 on -treatment death, 59 patients were analysed. There were 47 males and 12 females with a median age of 58 years and a mean KPS of 80. 36 of them were addicted to tobacco and or alcohol. Locally advanced oral cavity cancers were the commonest subsite being buccal mucosa and majority patients were Stage IV-A. The median RT dose was 60 Gy. 31 patients received adjuvant and 28 received definitve radiotherapy. 37 patients received concurrent chemotherapy. 48 patients underwent bilateral neck irradiation. The mean weight loss was 5 kgs (range: 3-12 kgs). Eighteen patients needed nasogastric tube / PEG tube during radiation. Majority of the patients 35 were eating solids and 3 patients were dependant on Ryle's tube at the beginning of the treatment. However, 20.3 % patients resumed back to eating solids by the end of 1st follow up and 59.3 % patients were on solid diet again by the end of 2nd follow-up. 1 patient continued to be on Ryle's tube support at the end of 6 months. At 3 months follow up, 1 patient had persistent nasogastric tube. Mean PSSHN score at baseline was 228. The mean score at completion of RT was 142, mean decline in score was 86. The mean score at 3 months post RT was 225 and improved to 264 at then end of 6months. Normalcy of diet was worst affected domain in PSSHN. Conclusion: There is a significant decline in the PSSHN scores at completion of radiation with normalcy of diet being worst affected domain. However, there was almost recovery of the PSSHN scores after 3 months and improved further at 6 months post completion of radiation.

 > Abstract: 432: Reirradiation for recurrent head and neck squamous cell cracinoma: Clinical outcomes Top

Ajay Doshi

Jaslok Hospital and Research Center, Mumbai, Maharashtra, India, E-mail: [email protected]

Purpose and Objective(s): Locally advanced head &neck cancers are the commonest cancers in India. Loco-regional recurrence is a predominant pattern of failure occurring in about 40% of the patients. Few of these patients may be offered curative intent reirrdiation (Definitive / Adjuvant). With an aim to analyze the clinical outcomes with reirradiation for recurrent head and neck cancer, present retrospective analysis was done. Materials and Methods: Between January 2007 to May 2019, 71 patients were treated with curative intent reirradiation to face and neck at our institute. All the enrolled patients had biopsy proven evidence of recurrent and/or new primary carcinoma of the head and neck. Patients were treated with either definitive or post-operative adjuvant irradiation. Target volume included gross disease with margin / tumour bed with involved nodal region. No prophylactic irradiation was done. Patients were treated with IMRT / 3DCRT for reirradiation. Patients were followed up every 3 monthly after completion of treatment for tumour control and toxicity evaluation. Results: We included 71 patients in the analysis. There were 57 males. The median duration between two courses of radiation was 38 months (range: 6-180 months). Thirty two patients had definitive RT while remaining 39 patients had adjuvant treatment after surgery. The median dose for reirradiation was 60 Gy (Range 50-66 Gy). Sixty seven patients completed planned treatment. Six patients developed grade III mucositis. One patient was dependent on Ryles tube feeding post radiation. One patient developed grade III dermatitis for which treatment stopped at 40 Gy. At median follow up of 13 months, 56 patients were alive (45 disease free). Twenty five patients had recurrent / residual loco-regional disease. One patient had second primary disease. One and Two year OS post reirradiation were 70% and 51% respectively. Conclusion: Curative intent reirradiation is a feasible treatment option with acceptable toxicities. A reasonable DFS and OS can be offered for selected group of patients. Reirradiation may be considered as a viable option for management of recurrent head and neck cancers.

 > Abstract: 435: A study on sensorineural hearing loss in patients of carcinoma of head and neck treated with radiation versus cisplatin based chemoradiation Top

Ajitesh Avinash, Surendranath Senapati

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

Purpose and Objective(s): To evaluate the incidence of sensorineural hearing loss (SNHL) in patients of carcinoma of head and neck treated with radiation vs cisplatin based chemoradiation. To correlate the relationship between SNHL and radiation dose to the cochlea in patients of carcinoma of head and neck treated with radiation vs cisplatin based chemoradiation. Materials and Methods: 38 patients of histopathology proved squamous cell carcinoma of head and neck who satisfied the eligibility criteria were taken for the study. Out of 38 patients, 18 patients were treated with radiation alone (dose 60gy to 70 gy) and 20 patients with concurrent chemoradiation with cisplatin at a dose of 40 mg/m2. After simulation, cochlea contouring was done as organ at risk. Pure tone audiometry evaluation were performed before the start of treatment as baseline, at middle of radiation (after 30 gy – 35 gy) , immediately after radiation and at 3 months and 6 months after the completion of radiation. SNHL was evaluated as per ctcae version 5.0 Results: the study included the prospective randomised analyses of 38 eligible head and neck cancer patients. out of 38 patients, 29 were male and 9 were females. the mean age of presentation was 42.6 years (ranging from - 18 to 60 years). on analysis of site of primary, carcinoma nasopharynx was 8, carcinoma oro-pharynx 10, carcinoma oral cavity 18 and carcinoma nasal cavity and para- nasal sinus 1 case each. according to ctcae version 5.0, 20 patients (52.6%) out of 38 developed sensori-neural hearing loss (SNHL). out of 20 patients who developed SNHL, 7 patients (38.8 %) were treated with radiation alone and 13 patients (65 %) were treated with cisplatin based chemoradiation. all the patients on concurrent chemoradiation received at least five cycles of cisplatin. in the radiation only arm, SNHL was observed for the ears that received a mean dose of 5000 cgy to cochlea. but in chemo-radiation arm, SNHL was seen in those ears that received 3000 cgy or higher dose to cochlea. majority of patients (100%) experienced SNHL at 3 months of the completion of treatment. but at 6 months of treatment the SNHL was reduced to 65%. 13 patients who developed SNHL at middle of treatment were on concurrent chemoradiation, while 7 patients on radiation alone experienced SNHL at the 3 months of completion of treatment. at 3 months of completion of treatment, grade 1 SNHL was 30%, grade 2 5% and grade 3 80%. at 6 months of completion of treatment grade 1 was 15%, grade 2 15% and grade 3 60%. Conclusion: The incidence of SNHL was more on cisplatin based chemoradiation as compared to radiation alone. SNHL was observed at a radiation dose of atleast 50gy while it is seen with atleast 30gy when treated with cisplatin based chemoradiation. it is seen that there is a latency period between the start of radiation and onset of SNHL which occurs early in chemoradiation than radiation alone. as this study includes only small number of patients, further evaluation necessary.

 > Abstract: 436: An analysis of radiation dose to the brainstem associated with the incidence of acute fatigue in patients of head and neck carcinoma treated with radiation Top

Arya Pradhan, Manoj Kumar Behera, Bijayalaxmi Sahoo, Sulagna Mohanty, Sandip Barik, Lucy Pattanayak, Abinash Patra, Sanjukta Padhi, Niharika Panda, Surendranath Senapati

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

Purpose and Objective(s): Radiotherapy is a vital component of treatment required by almost 75 percent of all Head and Neck cancer patients with either curative or palliative intent. Fatigue is one of the most common quality of life effects experienced during RT for Head and Neck Cancer, virtually all patients. As physician assessments are considered suboptimal for assessing Quality Of Life in cancer therapy, patient reported outcomes {PRO} are recognised to be superior means of evaluating treatment- related toxicities compared to physician assessments. Thus, this study evaluates the association of radiation dose to brainstem with patient reported fatigue {PRO} scores in a population of head and neck cancer patients undergoing radiation therapy. Materials and Methods: This prospective study was conducted from July 2018 to June 2019 at P.G. Department Of Radiotherapy , A.H.R.C.C, Cuttack. All eligible patients undergoing both radical and adjuvant radiation to Head and Neck Cancer enrolled in the study were treated in the Linear Accelerator by conformal radiotherapy technique. Multidimensional Fatigue Inventory{MFI-20} scores were prospectively obtained from the patients at pre-radiation{baseline}, 6th week of RT and 1 month post RT time points. The whole brainstem besides the OARs including the pituitary and medulla oblongata were separately contoured and dosimetry was evaluated. The MFI-20 scores obtained were correlated with the dosimetry and using statistics the associations with MFI-20 scores were analyzed. The MFI-20 is a 20 item self report questionnaire consisting of five dimensions: general fatigue, physical fatigue, mental fatigue, reduced motivation and reduced activity. Results: A total of 60 patients enrolled in the stiudy out of which twelve patients received post operative RT. Six of the post -operative patients underwent concurrent chemotherapy. The remaining 48 patients received definitive radiotherapy to intact disease, all but four of these concurrent with chemotherapy. Maximum dose{Dmax} to the brainstem was significantly associated with MFI-20 scores at 6th week of RT and 1 month post RT time points, after controlling for baseline scores{p<0.05}. Brainstem D2 was significantly associated with higher fatigue at only the combined time point. Each 1 Gy increase in medulla Dmax resulted in an increase in total MFI-20 score over baseline of 0.30{ p=0.024} and 0.26{ p=0.038} and each 1Gy increase in brainstem Dmax was associated with an increase of total MFI-20 score over baseline of 0.30{p=0.022} and 0.25{p=0.037} at 6th week of RT, 1month post RT respectively. Statistically significant associations were not found between dosimetry for other CNS structures and MFI scores. Conclusion: In this analysis of PRO fatigue scores from a population of patients undergoing radiation for Head And Neck Cancer, maximum dose to the brainstem and medulla oblongata were associated with a significantly increased risk of acute patient fatigue. This study found a link between one of the most important Quality Of Life concerns in Head And Neck Cancer. Chemotherapy in the study did not seem to contribute to treatment related fatigue in the multivariate analysis which seems to suggest that RT plays the prominent role as a contributor to fatigue during Head And Neck Cancer treatment.

 > Abstract: 452: Chondroid syringoma of a upper eye-lid tumor: Unusual case report Top

Chinmaykumar Prajapati, Maitrik Mehta

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

Objective: Chondroid syringoma is a rare mixed tumour of the skin as it contains epithelial and mesenchymal stromal components which are present in myxoid and chondroid matrix. It was first described by Hirsch and Helwig. Although chondroid syringoma was predominantly benign, sweat-gland tumor, the usual presentation is of an asymptomatic, slowly growing mass, typically located on the head and neck region. The present case was located in upper eye lid and rare. Methodology: A 58-year-old male reported at our institute with complain of right upper eyelid with slow growing painful mass since the last 3 months. The lesion was present for duration of 3 years. On Orbital Computed Tomography scan, 49×29 mm Soft tissue lesion was noted in right orbit which involve superior rectus and superior oblique muscle with right upper eyelid. Because of patient developed gradually increasing orbital pain & restricted movement of adduction and upward with partial visual field defect, he underwent right eye complete exenteration. Clinical diagnosis of chondroid syringoma was confirmed by histopathological examination in which tissue was well-encapsulated and consisted of two-layered epithelium lined glandular structures with varying cystic dilation. These glands were suggestive of chondroid syringoma, surrounded by abundant basophilic chondroid like stroma. For further investigation, cells positive for EMA & CEA were noted. He was then referred for post-operative radiation treatment to our department. We have planned post-operative radiotherapy with dose of 50 Gy in 25 fractions. Results: After completion of radiotherapy, the patient was called for monthly follow-up where excellent symptomatic relief and no side effects were observed. Patient is now called for 3rd month follow up for complete clinical and radiological assessment. We plan to do clinical examination and MRI of upper eye lid to see the response of treatment. Conclusion: We presented this case because chondroid syringoma of upper eye-lid is a rare tumor. Complete surgical resection and post operative radiotherapy are essential in the management of these cases. The role of radiotherapy can be enhanced and can be tried prior radiotherapy to tumor bed to avoid metastasis before or after surgical excision. Our patient responded very well with radiotherapy after complete surgical exenteration.

 > Abstract: 474: Radial forearm flap for tongue reconstruction Top

Dhaval Kamleshbhai Patel

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

Objective: A case of tongue reconstruction using Radial forearm free flap.


  1. Design: Case report
  2. Study setting: Tertiary care hospital
  3. Sample: One

Results: A 54 years old male patient with T2N1M0 stage II right tongue carcinoma underwent right hemiglossectomy with modified radical neck dissection with Radial Forearm Free Flap reconstruction had acceptable appearance and good tongue mobility with good speech. Conclusion: The Radial Forearm Free Flap is a viable reconstructive option for tongue defects because it is thin, pliable and sensate flap with minimal donor site morbidity.

 > References Top

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