[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: To determine the most accurate noninvasive imaging modality for occult metastasis in clinically node-negative necks in oral squamous cell carcinoma from a granulomatous disease endemic region.
Asia-Pacific Journal of Clinical Oncology 08/2014; · 0.91 Impact Factor
[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: In India, about 60% of tobacco users use smokeless tobacco (ST) alone. Head and neck squamous cell carcinoma is one of the most common cancers in India. International Agency for Research on Cancer (IARC) monograph (Vol 89) found a significant association between ST use and oral cancer. However, only a few articles from India were included in this monograph. To overcome this lacuna, we have reviewed the articles published from India investigating the association between ST use and malignant and premalignant diseases of head and neck region. Data collection has been performed by computer-aided search of the MedLine and PubMed databases using different combinations of the key words. For malignant lesions, only cohort and case control studies were considered for review. For premalignant lesions and dental diseases other than case control studies, some cross-sectional studies have also been reviewed. Studies found a significant association between ST use and cancer of the oral cavity. The association was stronger for the buccal mucosa compared to tongue and for females compared to males. Significant association noted between cancer of the hypopharynx and oropharynx with ST use but no definitive association noted for cancer of the larynx and nasopharynx. Some dental disease and oral premalignant conditions were also associated with ST use. Indian studies suggest ST use is strongly associated with cancer of the oral cavity, oropharynx and hypopharynx.
Indian Journal of Cancer 07/2014; 51(3):200-208. · 1.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background and Aims: To report the incidence of occult papillary carcinoma of thyroid in a tertiary care center in India in post-laryngectomy specimen of carcinoma of hypopharynx. Settings and Design: Retrospective analysis. Materials and Methods: This is a retrospective analysis of incidentally detected papillary carcinoma of thyroid in 358 patients of carcinoma of hypopharynx treated with total/near total laryngectomy at our tertiary care institute from 2005 to 2011. Statistical Analysis Used: Statistical analysis was performed using the software Statistical Package for the Social Sciences 20.0 (IBM, NY, USA). Percentages were calculated. Results: Thyroid cancer was seen in 7/358 patients with incidence of 2%. Five patients had tumor localized to thyroid gland only. One patient had nodal metastasis with thyroid cancer and one had only metastatic cervical node with normal thyroid gland on final histopathology. Three of these patients (3/7) had a recurrence of carcinoma of hypopharynx within 1 year duration. Conclusions: The incidence of occult papillary carcinoma of thyroid varies from 0.25% to 7% in the Indian literature.
Journal of cancer research and therapeutics. 07/2014; 10(3):693-695.
[Show abstract][Hide abstract] ABSTRACT: Background
This study aimed to compare sentinel node biopsy (SNB) and Ultrasonography(US) guided fine needle aspiration cytology (USgFNAC) for preoperative evaluation of the N0 neck in T1-T2 oral cavity squamous cell carcinoma (OCSCC).MethodologyConsecutive 51 patients with T1-T2 N0 OCSCC were included. Pre-operative US was performed in all patients. USgFNAC was performed in patients where US was reported as indeterminate or positive. SNB was done in all patients followed by elective neck dissection (END). Histopathology of END was considered as gold standard for all statistical analysis.ResultsThe incidence of occult metastasis was 26.4%. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 71.4%, 100%, 100% and 90.2% for SNB and 14.3%, 100%, 100% and 76.5% for USgFNAC.ConclusionUSgFNAC lacked sufficient accuracy to detect occult metastases. SNB is a reliable method to detect occult metastasis which has potential to replace END. Head Neck, 2014
[Show abstract][Hide abstract] ABSTRACT: Cancer is one of the major non-communicable diseases posing a threat to world health. Unfortunately, improvements in socioeconomic conditions are usually associated with increased cancer incidence. In this Commission, we focus on China, India, and Russia, which share rapidly rising cancer incidence and have cancer mortality rates that are nearly twice as high as in the UK or the USA, vast geographies, growing economies, ageing populations, increasingly westernised lifestyles, relatively disenfranchised subpopulations, serious contamination of the environment, and uncontrolled cancer-causing communicable infections. We describe the overall state of health and cancer control in each country and additional specifi c issues for consideration: for China, access to care, contamination of the environment, and cancer fatalism and traditional medicine; for India, aff ordability of care, provision of adequate health personnel, and sociocultural barriers to cancer control; and for Russia, monitoring of the burden of cancer, societal attitudes towards cancer prevention, eff ects of inequitable treatment and access to medicine, and a need for improved international engagement.
[Show abstract][Hide abstract] ABSTRACT: Cancer is one of the major non-communicable diseases posing a threat to world health. Unfortunately, improvements in socioeconomic conditions are usually associated with increased cancer incidence. In this Commission, we focus on China, India, and Russia, which share rapidly rising cancer incidence and have cancer mortality rates that are nearly twice as high as in the UK or the USA, vast geographies, growing economies, ageing populations, increasingly westernised lifestyles, relatively disenfranchised subpopulations, serious contamination of the environment, and uncontrolled cancer-causing communicable infections. We describe the overall state of health and cancer control in each country and additional specific issues for consideration: for China, access to care, contamination of the environment, and cancer fatalism and traditional medicine; for India, affordability of care, provision of adequate health personnel, and sociocultural barriers to cancer control; and for Russia, monitoring of the burden of cancer, societal attitudes towards cancer prevention, effects of inequitable treatment and access to medicine, and a need for improved international engagement.
The Lancet Oncology 04/2014; 15(5):489-538. · 25.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction: Tracheoesophageal speech using the voice prosthesis is considered to be the "gold standard" with success rates as high as 90%. Despite significant developments, majority eventually develop dysfunction due to microbial deterioration. We did a pilot study of 58 laryngectomy patients who developed prosthesis dysfunction. Materials and Methods: A total of 58 laryngectomy patients who had their dysfunctional prosthesis removed were included in this study. Dysfunctional prostheses were removed and examined. Esophageal and tracheal flanges were examined separately. After obtaining pure fungal and bacterial cultures, the yeast strains were identified. Bacteria were identified with the light microscope and gram staining. We analyzed prosthesis lifespan and probable factors affecting it. Results: Central leak was found in 43% cases while in 57% peri-prosthetic leakage was the most common reason for prosthesis replacement. Microbial analysis revealed a combination of yeast and bacteria in approximately 55% culture samples. Out of these, almost 90% had the presence of single yeast species with bacteria. Pure fungal culture was identified in rest of the 45% cultures while none detected pure bacterial forms. Candida tropicalis was the solitary yeast in 81% while Candida albicans was seen in 10% as the solitary yeast. Bacterial isolates revealed Klebsiella pneumonia in 19%, Escherichia coli in 8% while Staphylococcus aureus was grown in 1% cultures. The consumption of curd (P = 0.036, 95% confidence intervals [CI]: 2.292-64.285) to have a significant correlation of the mean prosthesis lifespan. Consumption of curd (P = 0.001, 95% CI: 0.564-2.008) and history of prior radiotherapy (P = 0.015, 95% CI: 0.104-0.909) had a significant bearing on the Provox prosthesis lifespan. Conclusions: Candida is the most common organism grown on voice prosthesis in Indian scenario. Consumption of curd and history of prior radiotherapy significantly affect Provox prosthesis lifespan.
Indian Journal of Cancer 04/2014; 51(2):184-188. · 1.13 Impact Factor
[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: Head and neck cancers are the most common cancers in developing countries, especially in Southeast Asia. Head and neck cancers are more common in males compared to females. This is mainly attributed to tobacco, areca nut, alcohol, etc. Oral cancers are most common amongst all head and neck squamous cell cancers (HNSCC). HNSCC in the developing world differ from those in the Western world in terms of age, site of disease, etiology, and molecular biology. Poverty, illiteracy, advanced stage at presentation, lack of access to health care, and poor treatment infrastructure pose a major challenge in management of these cancers. The annual GDP (gross domestic product) spent on health care is very low in developing countries compared to the developed countries. Cancer treatment leads to a significant financial burden on the cancer patients and their families. Several health programs have been implemented to curb this rising burden of disease. The main aims of these health programs are to increase awareness among people regarding tobacco and to improve access to health care facilities, early diagnosis, treatment, and palliative care.
Rambam Maimonides medical journal. 04/2014; 5(2):e0009.
[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.