[Show abstract][Hide abstract] ABSTRACT: Context: Various studies have shown the important risk factors for distant metastasis in head and neck cancer (HNC) which are present in most of the patients in developing countries. Identification of factors on the basis of time to distant metastasis (TDM) can help in future trials targeting smaller subgroups. Aims and Objectives: To identify the factors that predict TDM in radically treated HNC patients. Settings and Design: Retrospective audit. Materials and Methods: Retrospective audit of the prospectively maintained electronic database of a single HNC radiotherapy clinic from 1990 to 2010 was done to identify radically treated patients of HNC who developed distant metastasis. Univariate and multivariate analysis were done to identify baseline (demographic, clinical, pathological, and treatment) factors which could predict TDM, early time to metastasis (ETM; <12 months), intermediate time to metastasis (ITM; 12-24 months), and late time to metastasis (LTM; >2 years) using Kaplan Meier and Cox regression analysis, respectively. Results: One hundred patients with distant metastasis were identified with a median TDM of 7.4 months; 66 had ETM, 17 had ITM, and 17 had LTM. On multivariate analysis, the nodal stage 2-3 (N2/3) was the only baseline factor independently predicting TDM, ETM, and ITM, whereas none of the baseline factors predicted LTM. Conclusions: Higher nodal burden (N2/3) is associated with both ETM and ITM, and calls for aggressive screening, systemic therapy options, and surveillance. It is difficult to predict patients who are at a risk of developing LTM with baseline factors alone and evaluation of biological data is needed.
Indian Journal of Cancer 12/2014; 51(3):231-235. · 1.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
The median survival of technically unresectable oral-cavity cancers (T4a and T4b) with non surgical therapy is 2–12 months. We hypothesized that neoadjuvant chemotherapy (NACT) could reduce the tumour size and result in successful resection and ultimately improved outcomes. We present a retrospective analysis of consecutive patients who received NACT at our centre between January 2008 and August 2012.
Patients and methods
All patients with technically unresectable oral cancers were assessed in a multidisciplinary clinic and received 2 cycles of NACT. After 2 cycles, patients were reassessed and planned for either surgery with subsequent CTRT or nonsurgical therapy including CT-RT, RT or palliation. SPSS version 16 was used for analysis of locoregional control and overall survival (OS). Univariate and multivariate analysis was done for factors affecting the OS.
721 patients with stage IV oral-cavity cancer received NACT. 310 patients (43%) had sufficient reduction in tumour size and underwent surgical resection. Of the remaining patients, 167 received chemoradiation, 3 radical radiation and 241 palliative treatment alone The locoregional control rate at 24 months was 20.6% for the overall cohort, 32% in patients undergoing surgery and 15% in patients undergoing non surgical treatment (p = 0.0001). The median estimated OS in patients undergoing surgery was 19.6 months (95% CI, 9.59–25.21 months) and 8.16 months (95%, CI 7.57–8.76) in patients treated with non surgical treatment (p = 0.0001).
In our analysis, NACT led to successful resection and improved overall survival in a significant proportion of technically unresectable oral-cancer patients.
[Show abstract][Hide abstract] ABSTRACT: Background:To report the results of a phase III, three arm, randomised trial comparing conventional radiotherapy (RT) to concurrent chemo-radiotherapy (CTRT) and accelerated radiotherapy (ART), in advanced head and neck Squamous Cell Carcinoma.Methods:One hundred and eighty six of planned 750 patients who were randomised to receive 1. RT (66-70Gy / 2 Gy fraction / 5 fractions weekly, 2. CTRT- weekly Cisplatin (30 mg/m2) with same RT dose, 3. ART alone- 66-70 Gy / 2 Gy fraction / 6 fractions weekly were available for analysis. The primary end point was loco-regional control (LRC) at 5 years.Results:The mean follow up was 54 months. Among the three arms, CTRT showed superior LRC (49%, p=0.049). RT had lower grade ≥ 3 mucositis and late toxicity.Conclusion:CTRT is associated with significantly better LRC as compared to RT and ART with higher but acceptable acute and late toxicities. Head Neck, 2014
[Show abstract][Hide abstract] ABSTRACT: Background: We hypothesized that pathological N1 (pN1) and N2a (pN2a) nodal disease portend a similar prognosis in patients with oral cancer.Methods: An international multicenter study of 739 patients with oral cancer and pN1 or pN2a stage disease. Multivariable analyses were performed using Cox proportional hazard models to compare locoregional failure (LRF), disease-specific (DSS) and overall survival (OS). Institutional heterogeneity was assessed using two-stage random effects meta-analysis techniques.Results: Univariate analysis revealed no difference in LRF (p=0.184), DSS (p=0.761) or OS (p=0.475). Similar results were obtained in adjusted multivariable models and no evidence of institutional heterogeneity was demonstrated.Conclusion: The prognosis of pN2a and pN1 disease are similar in oral SCC suggesting these categories could be combined in future revisions of the nodal staging system to enhance prognostic accuracy. However, these results may reflect more aggressive treatment of N2a disease hence we caution against using this data to de-intensify treatment. Head Neck, 2014
[Show abstract][Hide abstract] ABSTRACT: Malignant melanomas involving the mucosa are rare and aggressive lesions. Their rarity has made the formulation of staging and treatment protocols very difficult, as most of the available information comes from case reports and small case series. We conducted a retrospective study to analyze the behavior of melanomas of the oral mucosa in patients who were treated at Tata Memorial Hospital in Mumbai, a tertiary care referral center for malignancies and one of the largest cancer centers on the Indian subcontinent. During the 22-year period from January 1986 through December 2007, we found only 13 such cases, which had occurred in 8 men and 5 women, aged 26 to 70 years (mean: 37.5). All patients had been offered surgery with curative intent. Mucosal melanomas have exhibited a greater tendency for distant recurrence than for local treatment failure, which is why adjuvant radiation therapy has not been shown to confer any consistent benefit. In our study, only 3 of the 13 patients (23.1%) remained alive 2 years after diagnosis, despite aggressive treatment. Tumor staging, optimal treatment, and prognostic factors for oral mucosal melanoma are far from clear, and further research is needed. Despite the small number of patients in this study, it still represents one of the largest series of oral mucosal melanoma patients in India.
[Show abstract][Hide abstract] ABSTRACT: The current American Joint Committee on Cancer (AJCC) staging system for oral cancer demonstrates wide prognostic variability within each primary tumor stage and provides suboptimal staging and prognostic information for some patients.
JAMA otolaryngology-- head & neck surgery. 07/2014;
[Show abstract][Hide abstract] ABSTRACT: Objective: Advanced oral cancers are a challenge for treatment, as they require complex procedures for excision and reconstruction. Despite being occurring at a visible site and can be detected easily, many patients present in advanced stages with large tumors. Timely intervention is important in improving survival and quality of life in these patients. The aim of the present study was to find out the causes of delay in seeking specialist care in advanced oral cancer patients. Materials and Methods: A prospective questionnaire based study was done on 201 consecutive advanced oral squamous cancer patients who underwent surgery at our hospital. All patients had either cancer of gingivobuccal complex (GBC) or tongue and had tumors of size more than 4 cm (T3/T4) and were treatment naοve at presentation.
Indian Journal of Cancer 04/2014; 51(2):95-97. · 1.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The judiciousness of the use of clozapine in patients with schizophrenia in clinical practice is brought to an even sharper focus when it has to be used in combination with other agents that cause myelosuppression, for example, chemotherapy and radiation treatment. There are a few references till date illustrating the combination of clozapine and chemotherapy and/or radiation therapy. To the best of our knowledge, such a case has not been reported from India. We report the case of a 39-year-old gentleman with a diagnosis of schizophrenia, remaining psychiatrically stable on clozapine, who underwent combination treatment of chemotherapy and radiotherapy for the treatment of cancer of the tongue in a tertiary care oncology centre in India.
Indian Journal of Psychiatry 04/2014; 56(2):191-3.
[Show abstract][Hide abstract] ABSTRACT: Background: Thymoma is the most common tumor of the anterior mediastinum. Surgery is mainstay of treatment, with adjuvant radiation recommended for invasive thymoma. Because of rarity, prospective randomized trials may not be feasible even in multicentric settings hence the best possible evidence can be large series. Till date Thymoma has not been studied in Indian settings. Materials and methods: All patients presenting to Thoracic disease management group at our Centre during 2006-2011 were screened. Sixty two patients' with histo-pathological confirmation of thymoma medical records could be retrieved and are presented in this study. Mosaoka staging and WHO classification was used. The clinical, therapeutic factors and follow up parameters were recorded and survival was calculated. Effects of prognostic factors were compared. Results: Sixty two patients were identified (36M, 26F; age 22-84, median 51.5 years) and majorities (57%) of thymoma were stage I-II. WHO pathological subtype B was most common 30 (49%). Mean tumor size was smaller in patients with myasthenia (5.3cm) than the entire group (7.6cm). Neoadjuvant therapy was offered to five unresectable stages III or IV a patient's with 40% resectability rates. Median overall survival was 60 months (Inter quartile-range 3-44 months) with overall survival rate (OS) at three year being 90%. Resectable tumors had better outcomes (94%) than non resectable (81%) at three years. Mosaoka Stage was the only significant (P = 0.03) prognostic factor on multivariate analysis. Conclusion: This is first thymoma series from India with large number of patients where staging is an important prognostic factor and surgery is the mainstay of therapy. In Indian context aggressive multimodality treatment should be offered to advanced stage patients and which yields good survival rates and comparable.
Indian Journal of Cancer 04/2014; 51(2):109-112. · 1.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Treatment intensification by using chemo-radiotherapy (CT-RT) or altered fractionation radiotherapy (AF-RT) improves outcomes in loco-regionally advanced head and neck squamous cell carcinoma (HNSCC). Methods: Two comprehensive meta-analyses with similar control arms (conventionally fractionated radiotherapy) were compared indirectly. Results: The hazard ratio (HR) of death with 95% confidence interval (CI) for the overall comparison of AF-RT with concomitant CT-RT was 1.13 (95%CI: 0.97-1.29, p=0.07) suggesting no significant difference between both approaches. Compared to concomitant CT-RT, the HR for death was 1.01 (95%CI: 0.89-1.15, p=0.82); 1.22 (95%CI: 0.94-1.59, p=0.13); and 1.22 (95%CI: 1.07-1.39, p=0.002) for hyperfractionated radiotherapy (HF-RT); accelerated radiotherapy (AX-RT) without total dose reduction; and AX-RT with total dose reduction respectively. Conclusion: Concomitant CT-RT and HF-RT are comparable to one another on indirect comparison in the radiotherapeutic management of loco-regionally advanced HNSCC. Any form of acceleration (with or without total dose reduction) may not compensate fully for lack of chemotherapy. Head Neck, 2014
[Show abstract][Hide abstract] ABSTRACT: Background: Various mouthwashes are used by specialists to reduce the side effects of anticancer therapies. At present, there is no
gold standard available for the prevention and treatment of oral effects. In clinical practice, diversity exists in different treatment
strategies used and their way of use.
Aim: To get an understanding of various prescriptions given by various specialists treating cancer patients in Tertiary cancer hospital
Materials and Methods: A questionnaire was formulated by two experts on the prescription and method of use of mouthwashes.
Ethical committee approval was obtained. Survey questionnaire included : type of mouthwash prescribed, objective for use : primary
objective behind its prescription, method of use, efficacy, adverse effects, awareness of evidence base. Data obtained was statistically
analysed and results were obtained.
Statistical Analysis: Data obtained was statistically analysed using SPSS software version 16.0
Results: Lot of variations exist in the type of mouthwashes prescribed, there way of use, duration and efficacy perceived by various
Conclusion: There is an urgent need of extensive research for the standardization of mouthwash prescriptions and clinical trials for
the rationale of use of various mouthwashes. Evidence basis must be provided to the specialists for the better palliative care of the
patients with oral mucositis. Also collaboration with a multidisciplinary team should be included in all phases of treatment for the
better management of all the symptoms.
Keywords: Oral Mucositis, Mouthwash, Mucositis Treatment, Mucositis Awareness.
Unique Journal of Medical and Dental Sciences. 01/2014; 02(01):15-21.
[Show abstract][Hide abstract] ABSTRACT: Background. Locally advanced carcinoma of maxillary sinus has been historically reported to have poor prognosis. We evaluated the role of NACT in improving the outcome in these patients. Methods. 41 patients with locally advanced technically unresectable (stage IVa) or unresectable maxillary carcinoma (stage IVb) were treated with induction chemotherapy between 2008 and 2011. The demographic profile, response and toxicity of chemotherapy, definitive treatment received, progression free survival (PFS), and overall survival (OS) were analyzed. Univariate and multivariate analysis were performed to determine factors associated with PFS and OS. Results. The chemotherapy included two drugs (platinum and taxane) in 34 patients (82.9%) and three drugs (platinum, taxane, and 5 FU) in 7 (17.1%). There was no complete response seen in any of the patients, stable disease in 18 (43.9%), partial response in 16 (39%), and progression in 7 (17.1%) patients. After induction, the treatment planned included surgery in 12 (29.3%), CT-RT in 24 (58.5%), radical RT in 1 (2.4%), palliative RT in 1 (2.4%), and palliative chemotherapy in 3 (7.3%) patients. Overall, the median PFS was 10.0 months. The OS at 24 months and 36 months was 41% and 35%, respectively. Conclusion. In unresectable maxillary carcinoma, induction chemotherapy has clinically significant benefit with acceptable toxicity.
Chemotherapy research and practice. 01/2014; 2014:487872.
[Show abstract][Hide abstract] ABSTRACT: Alopecia due to radiation has remained a widely accepted aspect of radiotherapy. We present an unexpected clinical scenario, where a patient with left lung stage IIIB nonsmall cell adenocarcinoma, treated with radiochemotherapy achieved a complete response and developed an obscure late effect in terms of paradoxical hypertrichosis in the radiation portals. The paper presents plausible hypothesis for this unusual phenomenon.
Journal of cancer research and therapeutics 01/2014; 10(1):203-6. · 0.95 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Seminoma is one of the most radio and chemo sensitive tumors. Aggressive variant of primary mediastinal seminoma (PMS) are rarely described in the literature. We here discuss an interesting case of young male (22 years) presenting with superior vena cava syndrome due to PMS that showed poor response to conventional platinum based chemotherapy and radiotherapy. Furthermore, with a short disease free interval (one year) relapsed at unusual sites of bone and soft-tissue deposits in check. This emphasizes the importance of identifying methods to pre-screen such aggressive variants for more effective treatment options.
Indian journal of medical and paediatric oncology 10/2013; 34(4):309-12.