JCRT ABSTRACTS

Journal of Cancer Research and Therapeutics - Supplement 1 - 2014 - Volume 10 S17
POSTER PRESENTATIONS
Head and Neck Cancer
Comparison of three dimensional conformal radiotherapy with
cobalt-60 teletherapy in squamous cell carcinoma of the larynx
Akhil Kapoor, Kamlesh Kumar Harsh, Murli P., Rajesh Kumar,
Ramesh Purohit, Harvindra Singh Kumar
Department of Radiation Oncology, Acharya Tulsi Regional Cancer
Treatment and Research Institute, Sardar Patel Medical College and
Hospital, Bikaner, Rajasthan - 334 003, India. E-mail: kapoorakhil1987@
gmail.com
Aim: The aim of the study was to compare the results of radical
radiotherapy performed by three-dimensional conformal radiotherapy
(3D-CRT) and by two dimensional radiotherapy (2DRT) realized with
Cobalt-60 (780-E) teletherapy for squamous cell carcinoma of the
larynx. Materials and Methods: Between January 2008 to December
2010 (3 years) a total of 98 newly diagnosed cases of Stage-I to IV-B
of the carcinoma larynx were consider for study. All cases were staged
according to the TNM-Staging system. Ninety eight patients with
previously untreated were irradiated with curative intent at our institute.
Radical Radiotherapy with the cobalt-60 teletherapy unit was performed
on 56 patients and 42 patients were treated with a Linear Accelerator
using 3D-CRT and were analyzed for overall survival, local recurrence
rate, acute and late radiation reactions, lost to follow up and deaths.
Results: The 2 and 3 years O.S. (Overall Survival) rates for control
group irradiated with the telecobalt therapy were 75.0% and 71.4%
and for the study group treated with 3D-CRT were 76.2% and 73.8%
respectively. The 2 and 3 years Local recurrence rates for control group
irradiated with the telecobalt therapy were 66.0% and 69.6% and for the
study group treated with 3D-CRT were 66.7% and 69.0% respectively.
Conclusion: No Statistically significant difference were observed either
in overall survival or loco regional control between the patients treated
with two different radiotherapy techniques. The grade of acute reactions
of the skin and the larynx differed significantly between the accomplished
radiotherapy techniques. There were statistically significant difference
observed in the grade of late effects in the skin and in the subcutaneous
tissue between the radiotherapy techniques used. According to the
confirmed advantage of 3D-CRT in terms of reduced treatment toxicity
observed in the our study, we consider conformal techniques being a
basis in definitive radiotherapy of squamous cell carcinoma of the larynx
until the new revolutionary techniques will be clinically available.
Is simultaneous integrated boost (sib) imrt superior over
sequential imrt in nasopharyngeal cancer - radiobiologic and
dosimetric analysis
Anbarasi.K, G. Selvaluxmi, Sam Deva Kumar
Cancer Institute, Chennai. E-mail: dranbu_tkmc@rediffmail.com
Aim: Intensity modulated radiotherapy (IMRT) has been accepted
primary treatment in nasopharyngeal carcinoma due to its better
conformity, increased tumor control and lesser dose to critical organs
at risk. The choice between simultaneous integrated boost (SIB) IMRT
and sequential IMRT are always matter of debate. The aim of this study
is to compare SIB IMRT with sequential IMRT radiobiologically and
dosimetrically. Materials and Methods: Twenty patients diagnosed as
nasopharyngeal cancer treated in our institute in 2013 were taken for
study. The planning CT scans reviewed and for all patients PTV1 and
PTV2 contoured. The target dose prescribed to PTV1 and PTV2 were
54Gy and 70Gy respectively. The critical structures contoured were brain
stem, optic nerve, spinal cord, parotid, temporal lobe and mandible. Two
plans IMRT to PTV1 followed by sequential IMRT boost to PTV2 and SIB
IMRT to both PTV1 and PTV2 were planned. Dosimetric comparison
is made by DVH and NTCP and TCP is calculated using MATLAB
software for both plans. Results:Among twenty patients analyzed all of
them having better parotid sparing in SIB IMRT compared to sequential
IMRT. Dose to other critical structures are less in SIB IMRT compared
to sequential IMRT. D95, Dmax, Dmean are comparable in both plans.
Also there is low NTCP in SIB IMRT compared to sequential IMRT.
Conclusions: SIB IMRT is superior in reducing dose to critical organs
at risk. As different dose per fractionation can be delivered to different
target regions simultaneously in SIB IMRT with less toxicity, there is
possibility of reducing overall treatment time with increases dose to tumor.
Can neck irradiation be an alternative to neck dissection in stage 1
carcinoma tongue patients operated for primary alone?
Bansal Anshuma, Ghoshal Sushmita
Department of Radiotherapy, Pgimer Chandigarh,
E-mail: Dranshubansal3@Gmail.com
Introduction: There is limited literature on the efficacy of neck irradiation
in controlling the occult lymph node metastasis from early stage
carcinoma tongue, when neck dissection has not been done. Most of
the data has been extrapolated from the survival benefits achieved by
chemoradiation in patients with carcinoma oropharynx, where neck
irradiation has shown results similar to nodal dissection in controlling the
neck disease. Aims: To study the pattern of failure, locoregional control
rates and disease free survival in different stages in post-operative
patients of carcinoma tongue, and to study the effect of nodal dissection
on nodal failure rates and disease free survival particularly in stage 1
patients. Materials and methods: This retrospective study analyzed
102 post-operative patients of carcinoma tongue treated at our institute
between January 2009 and December 2013.All patients were operated
for the primary disease, but neck dissection was done in 78 (76.5%)
patients only. However, all patients had undergone radiation to both
primary site as well as neck region. Pattern of failure has been studied
in these patients. Stage wise locoregional control rates and disease-free
survival curves were estimated with the Kaplan–Meier method. Survivals
have been compared using log rank test, among stage 1 patients, based
upon nodal dissection. Results: At a median follow up of 12 months,
local failures as well as nodal failures were seen in 10.8% patients each.
2.9% patients failed both at local and nodal site, and 5.9% patients
failed distally. The 1 year disease free survival was 82.4%, 80%, 57.8%
and 20.4 % in stage 1, 2, 3 and 4 respectively. The 1 year disease-free
survival in stage 1 post operative patients of carcinoma tongue, who
underwent nodal dissection (14 patients) was 83.3 % and in those in
whom nodal dissection was not done, but only neck irradiation was
done (15 patients), it was 80.2 %, and the difference was not statistically
significant (p = 0.5). Number of positive lymph nodes post dissection
was identified as a single dominant prognostic factor for disease free
survival in the multivariate analysis. Conclusion: The study indicates
that neck dissection can be replaced by neck radiation alone for stage
1 patients of carcinoma tongue. However a large well randomized study
is needed before inculcating the results into clinical practice.
Clinical outcomes with hdr surface mould brachytherapy in head
and neck malignancies.
Archya Dasgupta,Ashwini Budrukkar, Prakash Pandit, Sarbani Laskar,
Vedang Murthy, Jamema Swamidas, Rituraaj Upereti, Tejpal Gupta,
Jai Prakash Agarwal
Department of Radiation Oncology and Medical Physics, Tata Memorial
Centre, Mumbai, E-mail: archya1010@gmail.com
Background: Surface mould brachytherapy (SMB) is a century
old technique which can be used for various sites such as
skin, nose, ear and hard palate in the head and neck region.
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Abstracts
Journal of Cancer Research and Therapeutics - Supplement 1 - 2014 - Volume 10
S18
There is scarcity of data on high dose rate (HDR) SMB.
Aims and Objectives: To study the outcomes of patients treated with
SMB technique. Methods and Materials: Patients with malignant
localized early T1 or T2, node negative lesions in the head and
neck region treated with SMB during 2008-2013 were considered.
Individualized mould was prepared for all patients. Three dimensional
CT based planning was carried out with the mould in situ using the
Plato planning system (Nucletron). The median number of catheters
was 5 (Range 3-7). Treatment was delivered using HDR 192 Ir source
to a dose ranging from 39 to 52.5 Gy (mean 49 Gy) with 350cGy per
fraction, using bid regimen for radical SMB alone. Median number
of catheters used were 5 (range 3 to 7). For the present analysis
the data was extracted from a prospective brachytherapy database
as well as from patient charts. The data was analysed using SPSS
software (V18). Survival analysis was done using Kaplan Meier
method. Results: Thirty one patients were treated with SMB. The
median age at presentation was 53 years (range 25-82 years).
Most of the patients were males (n=24). The most common site
was hard palate in 14 (45%), followed by nose in 7 (22.5%), soft
palate in 5 (16%), tonsil in 2 (6.5%), skin over face in 2 (6.5%)
and pinna 1 (3.5%). The histology was squamous carcinoma in
27 patients, while the rest were basal cell carcinoma. The median
tumor size was 2 cm. Treatment was given in the primary setting
in 29 and recurrent setting in 2 patients. Twenty three patients
received the SMB as definitive, radical treatment while in 8 it was
used as boost after external beam radiotherapy. Acute skin toxicity
was seen in 17 patients of which 10 were grade II reactions. Acute
mucosal reactions were seen in 19 with grade II in 10 and grade
III in 1. Median follow up was 29 months (range 4 to 78 months).
Eight patients had recurrent disease (4 primary, 3 isolated nodal
recurrences and 1 primary and nodal recurrence). Two patients
had died at 4 months and 14 months. Three year DFS was 70%
and 3 year overall survival was 91%. Grade 1 mucosal atrophy was
seen in 22. Grade 1 xerostomia was seen in 6 and grade II for 1
patient (all of them had received external radiotherapy). On long
term follow up osteo- necrosis was seen for 2 of which 1 recurrence
had at the primary site. Skin hypopigmentation was seen in 3 while
telangiectasia was seen in 9 patients. Conclusion: Surface mould
brachytherapy results in acceptable locoregional control rates and
good overall survival with excellent organ and function preservation.
Clinical profile and treatment outcomes of carcinoma parotid:
A single institution study
Cessal Thomamachan Kainackal, Arun Vasudevan, Rejinish Kumar,
Malu Rafi, Biju Azariah, K. Ramadas
Division of Radiation Oncology, Regional Cancer Centre, Trivandrum,
Kerala, India. E-mail:arunvasudevan61@gmail.com
Introduction: Surgery with or without post operative Radiotherapy is
the standard treatment for carcinoma parotid. The treatment outcome
dependson variousfactorsliketumorstage,histology,gradeofthetumor
and the completeness of surgery. Aim and Objective: To analyze
the clinical profile and treatment outcomes of malignant parotid
tumors treated at Regional cancer centre Trivandrum, during
the time period 2008-2010 and to identify the various factors
influencing the outcome. Materials and Methods: Ninety six patients
treated at Regional cancer centre Trivandrum for malignant
parotid tumor from 2008 to 2010 are included in the study. The
patients were followed up until June 2014.The median follow up
is 52 months. Observation and Results: Among the patients
analysed,the male to female ratio is 1:1.All the patients underwent
primary surgery.Sixty four patients(66%) had mucoepidermoid
carcinoma,fifteen(15%) had adenoid cystic carcinoma,seven (8%)
had acinic cell carcinoma and ten(10.4%) had carcinoma of other
histologies. Seven patients in the analysis had pT1 status, sixty
one patients had pT2 status, twenty seven had pT3 status and one
patient had pT4 status.Post operatively thirteen patients(13.5%) were
found to have positive nodes.Mucoepidermoid carcinoma constituted
the major histology among the patients analysed. Adjuvant
radiotherapy was given to fourty seven patients(48%) at a dose of
55-60Gy. The 3 year disease free survival with respect to Tstage
are100% for pT1,96.3% for pT2,85.7% for pT3 stage.The three year
DFS with respect to histology are 96.7% for mucoepidermoid
carcinoma,100% for acinic cell carcinoma and 89% for adenoid
cystic carcinoma. Conclusion: The most common histology in our
series is mucoepidermoid carcinoma.The most common pathologic T
stage is pT2.The disease free survival for the whole group analysed
at 3 years is 94.5%.The various factors determining the disease
outcome will be discussed.
Dysphagia following total glossectomy and adjuvant chemo-
radiation in a recurrent malignancy of tongue: Cure versus quality
of life?
Chigurupati Namrata, Rahul Ravind, Surya Prakash Vankina,
Chelakkot G. Prameela
Clinical Associate Professor, & Consultant, Department of Radiation
Oncology, Amrita Institute of Medical Sciences, Kochi. Kerala. 682041.
E-mail: nvamsy91@gmail.com
Introduction: Surgery and radiation are factors which can alter
normal functioning of DARS (Dysphagia Aspiration Related
Structures), and can lead to disorders of different grades, post
treatment. Priorities are being placed on better quality of life
with, dysphagia optimized intensity modulated radiation therapy
(doIMRT) as advocated by Eisbruch et al [1]. The Case: A 36
year old lady was diagnosed with primary malignancy of tongue,
T1N0M0 in September 2010, at a local hospital. She underwent
wide local excision of lesion of right lateral border of anterior two
thirds of tongue, with modified neck dissection of ipsilateral level
2 and 3 nodal stations. She was on regular follow up there and
was disease free till January, 2014, following which she had local
recurrence and was referred to our institute for further care. At
presentation she was found to have T3 lesion with suspicious level
IA node. She underwent total glossectomy, with right marginal
mandibulectomy, left selective nodal dissection (Level I to IV),
and right level IIA dissection; and ALT free flap reconstruction
and tracheostomy. Postoperative histo-pathological staging was
recurrent pT3N0M0, Stage III. Surgical margins being positive,
she received concurrent chemoradiotherapy to a dose of 60 Gy
in 30 fractions to tumour bed, and lymph nodal basins bilaterally
and a simultaneous accelerated dose of 66 Gy to positive margin,
using 3DCRT (due to financial constraints), and 3-weekly cisplatin.
Postoperatively she had dysphagia and her nutritional support was
maintained with a PEG tube and continues to be on PEG support.
Swallowing Rehabilitation Procedures: Swallowing assessment
using FEES (Fibre-optic endoscopic evaluation of swallowing) and
video fluoroscopy (VFS) showed poor hyo-laryngeal elevation,
leading to aspiration. Oral and pharyngeal phases of swallowing
were affected, with pooling in oral cavity and poor mobilization of
food bolus to pharyngeal phase. Maneuvers like tilting the head
back while swallowing and jet feeding taught to her, had failed
to improve her swallowing status. Her case was discussed with
experts in swallowing and she is still on swallowing rehabilitation.
Discussion: Total glossectomy is a morbid procedure, which
by itself deranges oral phase of swallowing, and to a certain
extent the pharyngeal phase also. Radical radiation dose could
worsen the pharyngeal phase as well. An earlier analysis from
our centre [2] had shown that dose exceeding 63 Gy to superior
and middle constrictors and 56 Gy to inferior constrictors does
compromise swallowing. Radical intent treatment like this poses
dilemmas to treating oncology team and also drains personal,
social, economical, and emotional resources of patient. Whether
a less morbid organ-preserving oncological surgical procedure,
with supportive optimized adjuvant radiation with or without
brachytherapy could have given the same results, with an improved
quality of life need to be looked into.

Abstracts
Aprospective comparative study of hyperfractionated radiotherapy
alone versus concurrent chemoradiation with conventional
fractionation in locally advanced squamous cell carcinoma of
head and neck
Debottam Barman*, RajanigandhaTudu,Arkoprovo Halder, Kazi S. Manir,
Asit Ranjan Deb, Anjali Majumder
Department of Radiotherapy, Medical College, Kolkata, West Bengal,
India. E-mail:- debottam.barman@gmail.com
Introduction: Loco regional failure represents the major cause of
treatment failure in locally advanced head neck cancer (LAHNCC).
Hyperfractionated radiotherapy (HFRT) increases loco-regional control
(LRC) by increasing total tumor dose. Randomized Control Trials (RCTs)
showed that HFRT schedules improved LRC rates with a modest impact
on survival. Concurrent chemo-radiotherapy (CTRT) improves survival
in LAHNC. Aims and Objectives: This single institutional prospective
comparative study was conducted to compare LRC (primary end point),
Disease Free Survival (DFS) at 1 year and toxicities (secondary end
points) between CTRT with conventional fractionation and HFRT alone
in LAHNC. Material and Methods: Between October 2012 to August
2013, 63 patients with locally advanced squamous cell carcinoma of the
larynx and hypopharynx,American Joint Committee on Cancer (AJCC,7th
Edition) stage III or non-metastatic stage IV, ECOG performance status
0-2 with normal blood parameters were enrolled in this study.The patients
inArmA(ControlArm) received conventional External Beam Radiotherapy
(EBRT) with 2Gy/fraction, 5 days/week for 7 weeks to a total dose of 66-
70Gy along with concurrent inj. Cisplatin 100mg/m2 every three weeks
during radiation and Arm B (Study Arm) received HFRT with 81.6 Gy in
7 weeks, 1.2Gy/fraction twice daily with 6 hours gap between the two
fractions. Patients were followed up for response and toxicities using
Response Evaluation Criteria in Solid Tumors [RECIST version 1.1] and
Common Terminology Criteria for Adverse Events [CTCAE version 4.0]
respectively. Results: 63 eligible patients were enrolled. Two patients of
each arm were excluded from analysis due to protocol deviation. At the
end of the study, 59 patients were eligible for analysis with 33 and 26
patients in Arm A and Arm B respectively. Both groups had comparable
baseline parameters. Median follow up was 14 months for Arm A and 13
months forArm B. Both groups had comparable (p value=0.618) Complete
Response (CR) rates (assessed after 6weeks of completion of treatment),
60.61% (20/33) and 65.38% (17/26) in Arm A and B respectively.
Overall response [= CR +Partial Response (PR)] was better in Arm B
[88.5% (23/26)], thanArmA[81.8% (27/33)], but statistically insignificant
(p value=0.379). DFS rate at 1 yr was comparable (p value=0.553)
[Arm A (63.63%) versus Arm B (69.23%)]. Both the arms did not show
any significant difference in recurrence free survival [ArmA(12.5months)
versusArm B (12.707 months), p=0.782]. Grade 3 and 4 acute mucositis
[Arm A=8/33(24.24%), Arm B=8/26(30.77%), p value= 0.4365] and
acute skin toxicity [Arm A=6/33(18.18%), Arm B=7/26(26.92%),
p value=0.2478] were comparable in both arms. Grade 3 dysphagia
was significantly higher in Arm B [Arm A=5/33(15.15%), Arm B=8/26,
p value=0.0263] but it did not cause treatment interruption. Grade 2 and
3 xerostomia [Arm A=13/33(39.39%), Arm B=9/26(34.62%),p=0.6187]
and subcutaneous tissue fibrosis [Arm A=12/33(36.36%), Arm
B=7/26(26.92%),p=0.3178] showed a non-significant trend towards
lesser incidence in Arm B. Conclusions: HFRT is a well-tolerated
treatment regimen with comparable toxicity events. In this small study
HFRT schedule had better, but statistically insignificant overall response
and DFS rate. Larger multi-institutional studies are required to validate
these results.
Assessment of late thyroid toxicity in head and neck irradiation-
follow up analysis.
C. Priyadarsini, Vishal Manik, S. Shanmugakumar, N. V. Kalaiyarasi,
Baskar, Madhumathi, Sundaresan, Prabhakar
E-mail: pdarsini90@gmail.com
Introduction: Thyroid dysfunction commonly develops after
ionsing radiation therapy at therapeutic doses of neck as a result
of direct radiation effects to thyroid gland.(non-stochaistic effects).
Aim: To analyse the late thyroid toxicity in previously asymptomatic
head and neck cancer cases that were treated with radiation including
the neck portals and to identify the occurrence of clinical and sub clinical
hypothyroidism. Materials And Methods: A total no of 45 head and
neck cancer patients who received radiotherapy in our institute during
2011-12 were analysed. Thyroid function tests were performed 2 years
after patient received radiotherapy and the results are evaluated.
Results: Out of 45 patients, who received radiation to the dose of 60
Gy, 26 patients developed hypothyroidism. 20 are sub clinical and 6
are clinical. All patients are in the age group of 40 to 60 years. Patients
were asked to follow up with endocrinologist for thyroid replacement
therapy. Conclusion: Hypothyroidism causes considerable morbidity
to the patient who undergo external beam radiation therapy. Screening
tests for thyroid dysfunction should be made mandatory as a routine
follow up. Thyroid shielding and designing portals so as to avoid thyroid
gland irradiation should be considered during irradiation.
Expression of p53 and epidermal growth factor receptor (egfr)
is associated with higher possibility of recurrent and residual
disease in squamous cell carcinoma of head and neck region
Archana Jha1
, Arun K. Rathi1
, Mayank Aggarwal2
, Kishore Singh1
,
Savita Arora1
, J. D. Baruah1
1
Department of Radiotherapy, Maulana Azad Medical College and LN
Hospital, 2
Department of Radiation Oncology, BL Kapur Superspeciality
Hospital, New Delhi, India. E-mail: drarchanajha@gmail.com
Introduction: Elevated levels of EGFR mRNA have been detected in
the normal mucosa of head and neck cancer patients. It is implicated
in the pathogenesis of head and neck cancer and has been shown
to be significant predictor of disease free survival in these patients.
p53 mutations are found in over 50% of HNSCC which are commonly
associated with tobacco and alcohol use. Mutated p53 is often incapable
of proper functioning and is unable to induce apoptosis, which result in
uncontrolled progression through cell cycle and tumor development.
Aims and Objectives: The present study was done to study the
expression of p53 and EGFR in recurrent and residual squamous cell
carcinoma of head and neck region and correlate the expression with
the timing of recurrence. Materials and Methods: The pretherapy
biopsy of the 20 selected patients with recurrent or residual disease
were reviewed and the expression of p53 and EGFR was evaluated by
immunohistochemistry. The biopsy of matched control of 20 patients
of HNSCC, who were disease free for 2 or more years after treatment
were evaluated and compared with the study group. The expression
of p53 and EGFR was then correlated with the time of recurrence.
Results: In the study group, the Mean percentage of cells that were
positive for p53 was 45.5 ± 30.40, whereas in control group it was 16.55
± 18.73 (p-value 0.0008). Mean percentage of cells that were positive
for EGFR in study group was 45.8 ± 30.82, whereas in control group
13.15 ± 23.27 (p-value 0.0005). On evaluating the correlation with the
time of recurrence it was seen that in case of p53 vs time of recurrence,
Pearson correlation factor was -0.12 i.e. negative linear relationship
with small correlation, whereas in EGFR vs time of recurrence,
Pearson correlation factor was -0.43 i.e. small negative correlations.
Conclusion: The p53 and EGFR status when correlated with the time
of recurrence showed small negative linear relationship, however the
study shows that expression of EGFR and p53 is associated with higher
possibility of residual/recurrent disease. More specific and aggressive
approach of treatment could be taken with prior knowledge of the
EGFR and p53 status
Re-irradiation in head and neck malignancy- a prospective study
Jyoti Poddar
E-mail: jyopoddar@gmail.com
Introduction: Head and neck carcinoma forms a major part of
all diagnosed cancers in developing countries. Despite of recent
advances in management of locally advanced head and neck cancers,
incidence of recurrences and second primary malignancies is very high.

Abstracts
S20
Treatment of recurrences by re-irradiation is a very challenging situation.
Aim and Objectives: Single arm prospective analysis to evaluate the
outcome of re-irradiation, among patients with recurrent and second
primary head and neck carcinoma in previously irradiated area with
respect to acute and late radiation induced morbidity, loco-regional
control and disease free survival. Materials and Methods: Between
August 2012- August 2013, 47 patients of recurrent or second
primary malignancy of head and neck region in previously irradiated
area(>45Gray) were treated with re-radiation either post-operatively
or as definite treatment with or without chemotherapy in our institute.
The median follow-up period was 13 months.
(1) Inclusion criteria
(a)
Biopsy proven recurrence or second primary tumour of head
and neck invicinity of previously irradiated area
(b)
Minimum Interval between initial radiation and re-irradiation
of 18 months
(c)
Previously treated with curative dose radiotherapy with
minimum dose 45Gray
(d) No evidence of distant metastasis
(e) Age between 30 to 80 years
(2)
Exclusion criteria-Patients with severe sequelae of the initial course
of radiotherapy eg. severe subcutaneous fibrosis etc
(3)
Treatment-Out of the 47 patients, 24 were of recurrence and 23
patients had second primary tumour. All patients were delivered
60-66 Gray in 30-33# with daily dose of 2 Gray for 6.5 weeks on
Linear accelerator with 6 MV photons. Initial 50 Gray were delivered
to the primary site and the lymphatic drainage area with adequate
margin. After 50 Gray, patients were re-simulated and spinal cord
was taken out of the field. If there was any persistent node, it was
treated with a separate electron field.
Disease free interval between primary treatment and the recurrence or
second primary tumour was of the range 18-156 months with median
range being 60 months. 79% patients underwent surgery followed by
radiotherapy. 20% received only radiotherapy and only 1% patient
received concurrent CT and RT.
Results: Disease free survival at 6 months, 9 months and 12 months
was 72.3%, 53.1% and 40% respectively.
Regarding Acute Toxicity Mucositis skin Dysphagia
Grade I 02% 39% 11%
Grade II 46% 53% 51%
Grade III 52% 08% 38%
Regarding Late Toxicity: 57% developed grade II, 27% developed grade
I and 14% developed grade III subcutaneous fibrosis. Four patients
developed trismus and one patient developed osteoradionecrosis.
Conclusion: Second course of high dose radiotherapy is feasible
in recurrent and second primary tumours of head and neck in both
operable and inoperable lesions with acceptable toxicity. Severe
treatment related morbidity is the major concern while delivering second
course of radiation. Conformal techniques like IMRT and IGRT can
reduce the dose to the organs at risk with better coverage of the target.
Inverted papilloma of mastoid cavity-a case report
Jyotiman Nath
E-mail: jyotimannath@gmail.com
Introduction: Inverted papilloma originating primarily from the mastoid
cavity is an extremely rare entity. It is a locally aggressive benign
condition with increase risk of recurrence and malignant transformation.
Surgery is the primary treatment for this condition. Radiation therapy
should be considered in patients with incompletely resectable lesions,
multiple recurrent tumors, and tumors associated with malignancy1.
Here we are reporting a case of inverted papilloma of mastoid with
dysplastic changes. Case Report: A 60 year male presented to ENT
OPD ofAssam medical College Dibrugarh in March 2014, with purulent
fowl smelling discharge with severe pain in the right ear associated
with marked hearing loss. There was no history of tinnitus, vertigo,
autophony, hyperacusis or any features of facial nerve palsy. Histories
of two similar episodes were there 40 years back for which surgery
was done but no documentation available. The patient undergone
radical mastoidectomy in May 2014. But after 2 months the patient
again presented with profuse thick purulent discharge from right ear
with sever earache and gaping in the right post auricular wound with
exposed mastoid cavity filled with purulent discharge. The patient
again underwent mastoid exploration on 1st August 2014 with removal
of extensive granulation tissue. Histopathology report came out to
be inverted papilloma with marked dysplastic changes with areas of
microinvasion.Immunohistochemistry was done for ki67 and came
out to be positive. The patient was then referred to the Radiotherapy
department for a course of Radiotherapy. In Radiotherapy department
treatment started with external beam radiation with cobalt 60.Now
the patient is in Radiotherapy inpatient department of Assam medical
College Dibrugarh, Undergoing a course of cobalt teletherapy,
completed 16 fractions at 200cGy per fraction,5 days in a week. At
present the postoperative wound is healthy and the earache has also
subsided.The patient will complete the course of radiotherapy within
few days and he will be followed up in due course of time.
Volumetric changes in gross tumour volume during radiation
therapy in head and neck cancer- need for adaptive radiotherapy
Mohammed Raees, Hhasib Ag, Shridhar
E-mail: drraeestonse@gmail.com
The treatment period over which radiation therapy is administered
extends over several weeks. The anatomical changes of tumor and
parotid should be taken into consideration, since tumor shrinkage
in response to radiation therapy and weight loss due to radiation
induced mucositis may impact on the dose distribution in both target
and organ at risk with patients with head and neck cancer. After the
implementation of the plan, CT scans were repeated after 5# and 20#,
the volumetric changes were noted. We investigated the anatomical
changes that occurred in the tumor during radiation therapy for
head and neck cancer and evaluated the necessity of an adaptive
replanning strategy.
Prospective study of voice outcomes post concurrent
chemoirradiation in non laryngeal head and neck cancer
Nikhila K. R.*, Iqbal Ahmed, Rajesh J, Chendil V, Amruth Kadam
Department of Radiotherapy, Bangalore Medical College; Shivshankar,
Yamini H.K, Department of Speech Pathology and Audiology,
NIMHANS, Bangalore, India. E-mail: nikhilakr@gmail.com
Introduction: Concurrent chemoirradiation (CCRT) is the standard
of care in conservative management of head and neck squamous
cell carcinoma (HNSCC). Radiation induced laryngeal toxicity causes
compromise of voice and speech, thus affecting the patient’s quality of
life (QOL). Objective: To assess the acute changes in the quality of
voice post CCRT in patients with non laryngeal HNSCC and identify its
effect on their QOL. Methodology: 20 patients, diagnosed with HNSCC
were treated with CCRT to a total dose of 66-70 Gy/33-35 fractions
by shrinking field technique at 5 fractions/week with 5 cycles of weekly
cisplatin. Vocal cord was examined by nasopharyngolaryngoscopy
(NPL). Acoustic analysis was performed at the baseline, 6 weeks
and 3 months post RT using the MDVP – CSL (multi dimensional
voice program - computerized speech laboratory) 4500 software.
Sustained phonation of vowels a, i, o and speech sample in the
native language were analysed. The vocal parameters assessed were
fundamental frequency (fo), jitter, shimmer, noise to harmonics ratio
(NHR) and electroglottographic contact quotient (E-CQ). Subjective
assessment of voice was performed at the same intervals using the
30 item VoiSS questionnaire. Statistical correlation was done using
ANNOVA. Results: Of the 20 recruited patients, 14 could be evaluated.
6 weeks post treatment, Grade II laryngeal toxicity was recorded in

Abstracts
5/14 (35.7%); grade III in 9/14 (64.28%) patients by NPL. 3 months
post treatment, only 9/14 were available for analysis. 2/9 (22%) had
improved with residual grade I toxicity only, 5/9 (55%) had grade II
toxicity and 2/9 developed grade IV toxicity.Acoustic analysis revealed
9/14 (64%) patients had a decrease in the Fo from baseline and 5/14
(36%) patients had an increase in Fo. The jitter, shimmer and NHR
values showed a significant increase, indicating the toxicity of CCRT.
The E-CQ showed a variable insignificant change. The VoiSS scores
showed a statistically significant deterioration in the total score 6 weeks
post treatment (p 0.05) following which an improvement in the scores
were recorded over next three months. Conclusions: Acute radiation
toxicity of larynx is a common but understudied impact of CCRT in non
laryngeal HNSCC. Acoustic analysis helps to map and correlate the
vocal toxicity and its impact on QOL.
Synchronous dual primary malignancy of urinary bladder and
hypopharynx in a 62-year-old male patient; An extremely rare
phenomenon
Pranabandhu Das
E-mail:daspranabandhu@gmail.com
Aims and Objectives: The diagnosis of multiple primary malignancy
(MPM) is not very uncommon. Nevertheless synchronous MPM
involving urinary bladder and hypopharynx is an extremely unusual
event.No such cases have been reported so far in English literature as
evidenced by extensive review through MEDLINE in english literature.
We present one such case who was treated with favourable outcome
at our center. Materials and Method: A 62-year-old male who was a
chronic smoker without any significant medical comorbidities presented
with three months history of nocturia and ten days history of hematuria.
Routine hematological investigations were within normal limits. On
routine and microscopic examination of urine revealed plenty of
epithelial and pus cells. Cystoscopic evaluation revealed flat sessile
growth measuring about 6x3x2 cm extending over bladder base
involving left vesicoureteric junction. Transurethral resection of bladder
tumor (TURBT) was done.Histopathology report was suggestive of
poorly differentiated carcinoma of urothelial origin. During this work
up period patient had complaint of dysphagia to solids.Upper gastro
intestinal endoscopy showed proliferative lesion at post cricoid region
of hypopharynx. Biopsy from hypopharynx revealed squamous
epithelium with underlying poorly differentiated malignancy.Whole body
18F-Fluro deoxy glucose Positron emission tomography with computed
tomography (18F-FDG PET/CT) was advised as part of metastatic
work-up which showed intense FDG concentration noted in post
cricoid region of dimension 5x3x1 cm as well as in right para tracheal
and left Level V cervical lymph node. Intense FDG concentration
noted in the bladder wall on postero lateral aspect causing left sided
hydroureteronephrosis.The diagnosis of synchronous dual malignancy
involving urinary bladder (cT2N0M0) and hypopharynx (cT3N2cM0)
was thus conferred. Patient was planned to receive radical radiotherapy
to hypopharynx as the primary concern was progressive dysphagia.
It was to be followed by radical cystectomy.Patient received 59.4
Gy in 33 fractions,1.8 Gy per fraction and five fractions per week
within seven weeks to hypopharynx along with concurrent cisplatin
chemotherapy 40 milligrams per week. Results: Following treatment
he had symptomatic improvement of dysphagia as well as hematuria
which was present prior to the above treatment. Radical cystectomy
was planned to be accomplished four weeks after chemoradiation.
But because of difficulty in intubation for general anesthesia before
surgery the planned radical cystectomy was deferred and then he was
planned for radical radiotherapy treatment to the urinary bladder.Later
with progressive deterioration of his general condition, he expressed his
unwillingness to afford for further treatment that enabled him to be kept
under close observation and best supportive care at home. Currently the
patient is in symptomatic remission six months after completion of the
above treatment. Conclusion: While dealing with a cohort of patients
with known malignancy this is always customary to keep in mind the
possibility of occurrence of a second neoplasm and hence a high index
of suspicion should warrant an aggressive work up for early detection
of malignancy and treatment intervention for an improved outcome.
This case is being reported because of its extremely rare occurrence,
diagnostic as well as therapeutic challenges being encountered during
the management of this rare entity in our clinical practice.
Systematic review and meta-analysis of conventionally
fractionated concurrent chemoradiotherapy versus altered
fractionation radiotherapy alone in the definitive management of
loco-regionally advanced head and neck squamous cell carcinoma
Tejpal Gupta
ACTREC, Tata Memorial Centre, Mumbai,
E-mail:tejpalgupta@rediffmail.com
Background: Treatment intensification either by using concurrent
chemoradiotherapy (CCRT) or altered fractionation radiotherapy
(AFRT) improves outcomes in loco-regionally advanced head and
neck squamous cell carcinoma (HNSCC). However, superiority
of one approach over the other remains to be firmly established.
Aims: To compare outcomes of CCRT with AFRT in the definitive
management of loco-regionally advanced HNSCC for evidence-
based decision-making regarding the best form of treatment
intensification. Methods:Randomized controlled trials directly
comparing conventionally fractionated CCRT with AFRT alone were
identified through a systematic literature search. Only appropriate arms
were included in the comparison from multi-arm trials. Overall survival
was the primary outcome of interest whereas disease-free survival,
loco-regional control, and toxicity were secondary endpoints. Outcome
data was extracted independently by two reviewers and pooled using
the Cochrane methodology for meta-analysis and expressed as hazard
ratio (HR) or odds ratio (OR) as appropriate with 95% confidence
intervals (CIs). Results: Five randomized controlled trials (involving
1117 patients and 627 deaths) directly comparing conventionally
fractionated CCRT with AFRT alone were included. The risk of bias in
included studies was low for efficacy outcomes, but high for toxicity
outcomes. The overall pooled HR of death was 0.73 (95%CI=0.62-
0.86) that significantly favored conventionally fractionated CCRT over
AFRT alone (p0.0001). Similarly, disease-free survival (HR=0.79,
95%CI=0.68-0.92; p=0.002) and loco-regional control (HR=0.71,
95%CI=0.59-0.84; p0.0001) were significantly improved with CCRT.
There was no significant difference in severe acute dermatitis between
both approaches of treatment intensification; severe acute mucositis
though was borderline increased with AFRT. Late xerostomia was
significantly increased with CCRT. Significant hematologic toxicity
and nephrotoxicity was seen exclusively with chemotherapy.
Conclusion: Conventionally fractionated CCRT improves disease
outcomes compared to AFRT alone in the definitive management of
loco-regionally advanced HNSCC, although at increased risk of toxicity.
No form of acceleration can compensate fully for lack of concurrent
chemotherapy.
Treatment of carcinoma of external auditory canal and middle ear:
a tertiary cancer centre experience of 50 patients
Ajeet Kumar Gandhi
MD, DNB, Senior Resident, Department of Radiation Oncology,
All India Institute of Medical Sciences, New Delhi, India-110029,
E-mail: ajeetgandhi23@gmail.com
Introduction: Carcinoma of EAC (external auditory canal) and ME
(middle ear) is an extremely rare disease entity accounting as a
cause of 1 in 5,000 to 15, 000 ear complaints [1]. Due to rarity, the
available literature does not provide a complete understanding of
this disease entity. There is also conflicting and limited information
available on clinical staging of this malignancy leading to discrepancy
in staging and management of this tumour in different series [1, 2]
Aims and Objectives: We aimed to analyze treatment modalities.
and outcomes in patients of carcinoma of EAC and ME treated at our
institution. Materials and Methods: Fifty patients of carcinoma of EAC
and ME (2000-2012) were analyzed for clinical presentation, lymph node

Abstracts
S22
involvement, stage, histopathology, surgical procedures and radiation
modalities employed. Stell and McCormick’s staging system was used.
The primary end point of the study was assessment of Progression free
survival (PFS). Results: Median age at presentation was noted to be
50 years (range: 12-84 years). Male to female ratio was 17:8. Forty five
patients had carcinoma of EAC. Stage was T1, T2 and T3 in 21, 21 and
2 patients respectively. Twenty two patients underwent surgery and 16
of them received post-operative radiotherapy (PORT). Fifteen patients
underwent definitive radiotherapy (RT) and 13 received RT with palliative
intent. After a median follow-up of 16 months (range: 5-251.4 months),
median PFS for the entire cohort was 14 months. At 2 years, PFS rate
was 90% for patients treated with surgery and PORT, 52% for definitive
RT and 0% for patients treated with palliative RT (p=0.0001). Stratified
according to Stell`s staging system, median PFS for patients with T1/
T2 tumours was 17.6 months (2 year actuarial PFS rate-48%) versus
7.5 months for those with T3 tumours (2 year actuarial PFS rate-22%)
(p=0.03). Median PFS of patients with facial nerve palsy was 7.54 months
versus 17.6 months for those without facial nerve palsy. Two year PFS
rates were 90%, 52% and 0% for patients treated with surgery and PORT,
definitive RT and palliative RT respectively. On univariate analysis, Stell
and McCormick tumour stage (HR: 2.67; 95% C.I: 1.06-6.71; p=0.03),
lymph node involvement (HR: 2.63; 95% C.I: 1.04-7.40; p=0.03), facial
nerve palsy at presentation (HR: 3.04; 95% C.I: 1.5-9.5; p=0.01) were
found to have significant impact on PFS. Conclusion: Patients with
carcinoma of EAC and ME present mostly in advanced stage at our
centre. Higher stage (T3), lymph node involvement and facial nerve
palsy at presentation portend poorer outcome.
Bleomycin based chemotherapy as an addition to cisplatin in
concurrent chemo radiation of oral cavity cancer- cancer institute
experience
Anbarasi Kumaresan
E-mail: dranbu_tkmc@rediffmail.com
Background: Oral cavity cancer constitutes two thirds of locally
advanced head and neck cancer in India and majority presents in
advanced stage. Despite aggressive treatment disease outcome is poor.
The aim of this study is to compare concurrent chemo radiation with
cisplatin and bleomycin versus concurrent chemo radiation with cisplatin
alone. Patients and Methods: Patients with locally advanced squamous
cell carcinoma of oral cavity cancers registered at cancer institute from
2009 – 2011 were included in the study. Patients who were either taken
up for initial surgery or treated with radiation therapy alone were excluded
from study. Of 515 patients treated with concurrent chemo radiation,
112 patients were treated with three weekly cisplatin along with biweekly
bleomycin and 104 patients were treated with 3 weekly cisplatin alone
concurrent with radiation therapy. Results: Among the patient treated
with three weekly cisplatin and biweekly bleomycin there is increased
two year disease free survival (45.5% versus 35.6%) and two year overall
survival(60% versus 45.2%)on comparison with patients treated with three
weekly cisplatin alone.(P0.05).Among the patients with treatment breaks
there is increased two year disease free survival (52% versus 11.1%) and
overall survival(60% versus 11.1%) in patients treated with cisplatin and
bleomycin.(P0.02). Three weekly cisplatin alone has lesser incidence
of grade III mucositis, treatment breaks but comparable haematological
toxicity, vomiting, treatment response when compared to three weekly
cisplatin along with biweekly bleomycin. Conclusion: The addition
bleomycintocisplatinconcurrentlywithradiationtherapyincreasesdisease
free survival and overall survival, with acceptable toxicity.
Impact of molecular profiling on the response rates in head and
neck cancer patients: An observational study.
Arvind S, Kirthi Koushik A.S, Mangala Gowri*, Janaki M. G,
Arul Ponni T. R, Ram Charith Alva
Department of Radiation Oncology, *Department of Pathology,
M.S.Ramaiah Medical College, Bangalore, India.
E-mail: dr.arvind.s.murthy@gmail.com
Introduction: Squamous cell carcinoma of head and neck region
account for more than 25% of male and more than 10% of female
cancers in India(1). Head and neck cancer treatment includes a
multidisciplinary approach involving all specialties. Concurrent chemo-
radiation is the standard of care in most of the subsites(2). Inspite of
the multi-disciplinary approach, a plateau has been reached in terms
of results with 5 year survival of locally advanced disease of around
30%(3). In order to improve outcomes, there has been considerable
interest in molecular profiling of head and neck cancers(4-10). However
there is still significant paucity in terms of Indian data, hence the need for
the study. Objectives: •To Assess the HPV-p16,EGFR and p53 status
•
To Correlate HPV-p16,EGFR and p53 status with the response
rates
•
To Correlate HPV-p16,EGFR and p53 status with other factors like
age,sex,tobacco use.
Methods and Materials: 25 consecutive cases of histopathologically
proven head and neck cancers were accrued. All patients were treated
with external radiation to a dose of 66Gy in 33 fractions along with
concurrent weekly cisplatin chemotherapy at a dose of 40mg/sqm.
HPV-p16,EGFR and p53 mutation analysis was done on paraffin
embedded histopathological blocks.PCR technique used for HPV-
p16,EGFR and p53 status detection. Response assessment was done
based on RECIST Criteria. Correlation of HPV,EGFR and p53 status
on Response was done. Results: •Mean Age of the study population:
59 years
• Sex: 76% Male and 24% Female
• Stage: I-8%,II-4%,III-36%,IV-52%
•
Tobacco Use: 92% were tobacco consumers either in the smoke
or smokeless form and 8% were non-tobacco users
• The EGFR positivity rate was 84%
• The p53 positivity rate was 76%
• The HPV p-16 positivity rate was 28%
•
Out of 25 patients, 13(52%) had Complete Response, 7(28%)
had Partial Response, 3(12%) had Stable Disease and 2(8%) had
Progressive Disease.
•
On correlation of molecular profile with response, there was no
statistical significance between EGFR status and response(p
0.5) or HPV-p16 and response(p 0.8).However,p53 positivity was
significantly associated with good response (p 0.03)
•
Among other factors there was significant correlation between
smoking and HPV status (p 0.01). However there was no significant
correlation between other factors like age, sex and socio-economic
status. Conclusion: The HPV, EGFR and p53 positivity rates were
in concordance with hitherto published literature. The HPV and
EGFR did not have significant impact on response rate however
p53 positivity was associated with higher percentage of complete
response rate which was statistically significant.
Patterns of failure after intensity modulated radiotherapy for
nasopharyngeal cancer.
Avinash Pilar, Sarbani Ghosh Laskar, JaiPrakash Agarwal,
Ashwini Budrukkar, Tejpal Gupta, Vedang Murthy
E-mail: avinashpilar@gmail.com
Purpose: To evaluate the patterns of failure, clinical outcomes and
factors affecting these outcomes in patients of nasopharyngeal cancer
(NPC) treated with intensity-modulated radiation therapy (IMRT).
Methods and Materials: One hundred and thirteen patients of
non- metastatic NPC treated radically with IMRT between 2008 -2013
were included in the study. All patients had been treated with 7-9 field
LA-based IMRT/tomotherapy. Prescribed dose was 66Gy/30# to high
risk PTV (primary and involved lymph node regions with margins) and
54Gy/30# was delivered to the uninvolved neck. One hundred and
four patients (92%) completed the planned radiotherapy. One hundred
and eleven patients (98%) received concurrent chemoradiotherapy.
Hundred patients (88%) also received Neoadjuvant chemotherapy prior
to chemoradiation. Results: The median age was 46years (range:
18-85yrs). Undifferentiated Carcinoma was the most common histology

Abstracts
(95%). Seventy nine percent patients were in stage III/IV. At a median
follow-up (FU) of 27 months (range: 6-78months), 86 patients were
alive at last FU. The 3 year local (LC) and regional control (RC) rates
were 86% and 85%, respectively. Freedom from distant metastases
(DMFS), progression-free survival (PFS), and overall survival (OS)
at 3 years were 81%, 65%, and 87%, respectively. The LC for Stage
I/II disease was 91%, compared to 84% for III/IV disease (p=0.23).
RC for stage II disease was 100% while for stage III/IV it was 81%
(p=0.035). Estimated 3 year OS for stage I/II was 96% and stage III/
IV was 87% (p=0.31). Nodal stage had a significant impact on DMFS,
early nodal stage (N0-N2) had 3 year DMFS of 84% as compared to
N3 which had 3year DMFS of 69%. (p = 0.04). Nodal stage also had
a significant impact on RC with early stage (N0-N1) having a 3 year
RC of 97.6% v/s 77% for N2-N3. (p=0.009). Nodal stage influenced
PFS with 3 year estimate being 75% for N0-N1 and 57% for N2-N3
disease. (p=0.03). T stage influenced only the DMFS with T1-T3
showing a 86% 3 year DMFS while T4 had a 63%, 3 year DMFS.
Age, gender and endemicity had no influence on the LC, RC, DMFS
or OS. There were 35 failures of which 3 (8.5%) were at primary site
alone, 6 (17%) were nodal failures, 8 (23%) failed both at primary and
nodal sites and 18 patients (51.5%) had distant metastases. Median
time to failure was 4 months (Range 0-38months). All the primary
and nodal failures were inside the high dose region (66Gy/30#) with
exception of 1 patient (failed at edge of high dose volume). 9 of the
35 patients who failed were effectively salvaged (n=4 solitary distant
metastases, n=5 nodal recurrences) and remain controlled at last FU.
Conclusions: IMRT results in high locoregional control in NPC. The
predominant site of locoregional failure is within the high dose region.
Despite a good locoregional control, distant failure remains a common
problem and is influenced by nodal stage.
Radiation treatment in cemento ossifying fibroma of paranasal
sinus first of its kind in human bieng
Kanhu Charan Patro*, Parthasaradhi Bhattacharaya*, Chittaranjan
Kundu*, E. B. Rajmohon**, A. C. Prabhu**, Subhra Das**
*Radiation Oncologist, **Medical Physicyst, Mahatma Gandhi
Cancer Hospital and Research Institute, Visakhapatnam, A.P.,
E-mail: drkcpatro@gmail.com
Case Detail: A 45yaer old female, p/w-nasal obstruction, Facial
swelling, Proptosis of left eye, duration of more than one year and
later stage she presnted with pain due to expansion of tumor.Patient
presented to surgical oncologist with this feature. On imaging CT
scan reavled mass in left maxillary sinus involving and destructing
the sphenoidal, zygomatic bone, nasal cavity, nasopharynx and
extension to subcutaneous tissue and total tumor volume was 250
cc approx. Biopsy of the tumor came out to be a cemento ossyfying
fibroma. Because of inoperability patient was sent for opinion
about radiaton therapy. The case evaluated by radiaton oncologist
and planned for radical radiotherapy after tumor board decission.
Material and Method: Radiation plannng was done by IMRT techinque
with an aim of sparing the opposite optical apparatus. Plan evaluated
with accaptable constraint specification planned for 50Gy in 25
fractions. Patient copmpleted radiation therapy over 5 weeks and with
dry desquamation of skin [RTOG grade II]. Results: At the end of the
treatment the response evaluated morphologically and which is an
insignificant response, then patient was kept under follow up. After 3
months the proptosis decreased, pain was minimal and patient was
better than before. CT scan volume revealed around 170 cc comparing
pre radiation volume of 250cc. Review of Literature: Cemento
ossyfying fibroma a bony origin of benign cause, sugery is the
most desirable option, frequently from mabndible and facial bones.
Pathologically it mostly comprises of fibrous, ossificaton with cement
formation. If not removed completely recurrance is common. Radiation
therapy is reserved for recurrent and incompleted removal cases.
Radiation therapy offered in most of the cases which are reported in
literature was on animal studies and not a single case reported in human
studies. Discussion: This is the first case in literature where we treated
with radiation as extreme indication in a human bieng. Benign conditions
can be taken care when there is no option. The response should not
be expected as for malignant condition. Radiation usually takes care
of rapidly proliferating tissue. As benign it is a slow growing tumour,
response evaluation as not like others-it will take time to decrease the
volume. Hypofractonation schedule may be tried. Needs more cases to
reach the conclusion about dose farctionation schedule, response etc.
Re-irradiation in head and neck cancer: Outcomes with conformal
techniques from a single institution
Lavanya G, Sarbani Ghosh Laskar, Ashwini Budrukkar, Tejpal Gupta,
Vedang Murthy, Jai Prakash Agarwal
Department of Radiation Oncology, Tata Memorial Hospital, Mumbai,
India. E-mail: naidu.lavanya@gmail.com
Introduction: Despite improvement in disease related outcomes
of Head and Neck Cancer (HNC) with the use of aggressive
multi-modality treatments, locoregional recurrences and second
primary neoplasms (SPM) remain a common problem. Treatment
of these patients is a challenge for the oncologist. Re-irradiation
(reRT) is one of the options in the management of these patients.
Aims and Objectives: To evaluate the outcomes and toxicities of
HNC patients undergoing reRT with curative intent radiotherapy, using
conformal techniques. Materials and Methods: Records of 63 patients
with HNC who had been treated with curative intent, conformal reRT
between January 2007 to May 2014 were analysed. Target volumes
included the grossly involved regions with an adequate margin. Elective
nodal irradiation was not carried out. Disease free survival (DFS),
overall survival (OS) and toxicities were analysed. Results: Median age
at the time of reRT was 55 years (range: 17-63 years). Majority (86%) of
the patients were males. Median time to the development of recurrence
was 48 months (range: 5-239 months). Most common site of primary
for reRT was the nasopharynx (29%) followed by oral cavity (22%)
and oropharynx (22%). Twenty-four (38%) patients received adjuvant
reRT. Chemotherapy was used in 19 patients (30%) in neo-adjuvant/
concurrent setting. Median dose of reRT was 60 Gy (range: 38-66 Gy).
Total cumulative dose to the target was 124 Gy (range: 110-136 Gy).
Median mean doses to the spinal cord and brainstem were 8.72 Gy
(range: 0.41-25.4 Gy) and 12 Gy (range: 1.64-38.24 Gy). Median mean
cumulative doses to the spinal cord and brainstem were 53 Gy (range:
37.89-71.4 Gy) and 57 Gy (31.8-84 Gy), respectively. At median follow
up of 10 months (range: 1-113 months), median DFS and OS were 8.5
and 10 months, respectively. Thirty-one patients were alive and disease
free at last follow up. Locoregional control rates at 1 and 2 years were
58.9% and 47.7% respectively. The 1 and 2 year actuarial DFS and OS
were 54.8%, 44.3% and 72.3%, 63.9%, respectively. The 2 year distant
metastases free survival was 70.8%. On univariate analysis patients
who received adjuvant reRT after salvage surgery had a significantly
better 2 year OS compared to RT/CTRT alone (85.6% vs 50.8%,
p-0.04). Age at the time of reRT, time to reRT, site of recurrence, stage,
dose of reRT and addition of chemotherapy did not influence DFS or
OS significantly. Patients with treatment time 45 days had worse
OS as compared to patients with a treatment time 45 days (2 yr OS:
36.6% vs 76.7%, p-0.06). This was because most of the patients 45
days treatment time did not complete the planned radiotherapy due to
various reasons. Two patients died on treatment. Seventeen patients
(26.9%) developed grade III/IV late sequelae requiring intervention.
Conclusion: reRT with conformal techniques to a dose of 60 Gy with
conventional fractionation is an effective option in the treatment of
recurrent HNC with acceptable toxicity. Further follow up is needed to
assess long term outcomes.
A comparative study of hypofractionated versus conventional
radiotherapy in terms of toxicities and treatment outcome in early
stage glottic cancer
Monidipa Mondal, Arnab Adhikary, Shyamal Kumar Sarkar
Department of Radiotherapy, Medical College, Kolkata, India.
E-mail:monidipamondal1@gmail.com

Abstracts
S24
Introduction: Radiotherapy is the treatment of choice in early stage
glottis cancer because it provides excellent local control rate along
with a good preservation of the voice. A range of radiation fractionation
schedules exists for the treatment of early glottic cancer. Several
studies have shown that hypofractionated radiotherapy with short
overall treatment time provides better local control and survival than
conventional radiotherapy. In our institution, both of the radiation
fractionation schedules are practised. We therefore conducted a
comparative retrospective analysis of the two fractionation schedules.
Aims and Objectives: The aim of the study was to compare the two
radiation fractionation schedules – hypofractionation and conventional
fractionation in terms of treatment outcome and treatment related
toxicities in patient of early glottis carcinomas. Primary objectives
were (1) to compare the response rates after radiation in two treatment
groups, (2) to compare acute and late radiation toxicities in between
the two groups and (3) to compare 3-year local control rates and
loco-regional recurrence free survival in between the two groups.
Materials and Method: Between January 2009 and December 2012,
78 patients of newly diagnosed, biopsy proven, early stage (stage I
and II) squamous cell carcinoma of glottis treated in Radiotherapy
Department of our Institution were retrospectively analyzed. Two
fractionation groups were identified with respect to daily fraction size
and overall treatment time.ArmAconsisted of 38 patients who received
radiation dose of 60 GY at 2.5Gy per fraction, 5 days a week for a total
of 24 fractions over 32 days (5 weeks). Arm B consisted of 40 patients
who received radiation dose of 66 GY at 2 Gy per fraction, 5 days a
week for a total of 33 fractions over 46 days (7 weeks). All patients
were treated with EBRT using conventional planning in cobalt-60
teletherapy machine. Response to radiation was assessed at 6 weeks
after completion of therapy by RECIST Criteria version 1.1. Acute and
Late toxicities of Radiation were recorded according to RTOGAcute and
Late Radiation Morbidity Scoring Criteria. 3-year local control and loco-
regional recurrence free survival were analyzed using the Kaplan-Meier
method. Results: Median follow-up was 37 months.After completion of
radiotherapy, patients treated in Arm A had a complete response rate
of 91.8% vs 87.5% in Arm B (P=0.71), partial response rate of 8.2%
vs 12.5%, respectively. There was no treatment interruption due to
toxicity. No statistically significant difference in acute and late toxicity
rates were found in the two treatment group. The 3-year Loco-regional
Control rates (LRC) were 86% for the entire study population, 91.4% in
Arm A and 81.1% Arm B. No significant differences in the 3-year LRC
rates were detected between treatment groups. (p= 0.20, log rank test).
Conclusions: Hypofractionated radiotherapy has the same response
rate and local control rate as that of conventional radiotherapy without
significance increase in toxicity in early stage glottic cancer.
Prospective study of palliative chemotherapy in recurrent locally
advanced head and neck squamous cell carcinoma
Ramya A
E-mail: drramya2005@gmail.com
Background: Patients with recurrent head and neck cancer after
concurrent chemoradiotherapy have poor prognosis thus need to be
treated with palliative chemotherapy. Aim: To assess different palliative
chemotherapy regimens based on outcome and quality of life. Materials
and Methods: 100 patients with recurrent head and neck cancer after
completion of chemo-radiation at the Dept. of Radiotherapy during
the period of one year were given palliative treatment under three
arms having 36, 38, 26 patients respectively– Arm A:Inj.Methotrexate
100mg q15days and Tab.Geftinib 250mg od for 30days till progression;
Arm B:Inj.Cisplatin75mg/m2 in divided doses and Inj.5-Fluorouracil
750mg D1-D3 q21days for six cycles. Arm C:Inj.Cisplatin 75mg/m2in
divided doses D1-D3 and Inj.Paclitaxel 175mg/m2 D1q21 days for
six cycles. Symptom relief and toxicity was assessed also quality
of life analysedusing EORTC QOL questionnaire. Results: Of the
100 patients, toxicity assessment as per CTCAE version 4- Anaemia
Gr II 16% in Arm A; 20-22% in Arm B and C. Neutropenia Gr III
30% in Arm C.Acute kidney injury Gr II 25-30% in both Arm B
and C.MucositisGr II and III 15- 30% in Arm B and C.Symptomatic
relief,regression of residual disease and quality of life were better in
Arm A. Conclusion:Based on these results Inj.Methotrexate with Tab.
Geftinib as palliative chemotherapy in recurrent head and neck cancer
patients has improved the quality of life; reduction in symptoms and is
less toxic as compared to other chemotherapy regimens.
Simultaneous integrated boost (SIB)-intensity modulated
radiotherapy in nasopharyngeal carcinoma(NPC) - a single center
experience from Nepal
Subhas Pandit
B.P. Koirala Memorial Cancer Hospital, Chitwan, Nepal.
E-mail: subhaspandit@gmail.com
Objective: NPC is relatively common cancer in our center with around
50 cases per year.The purpose of this study was to retrospectively
analyze the Simultaneous Integrated Boost - Intensity-modulated
radiotherapy (IMRT) results in patients with nasopharyngeal
cancer (NPC) treated in a single center under a single protocol.
Methods: Patients with early and loco-regionally advanced NPC were
treated with inverse-planned dynamic IMRT. Contouring, planning and
plan evaluation was done as per RTOG 0615 protocol. The prescribed
dose was 70Gy, 59.4 Gy and 54 Gy in high-risk, intermediate-risk and
low-risk PTV in 33 fractions by SIB technique. IMRT was given alone or
with chemotherapy in induction, concurrent or adjuvant setting. Cisplatin
was used in concurrent setting while Cisplatin/5-Fu or Taxane/Platinum
doublet was used in indiction/adjuvant setting. Loco- regional control
(LRC) and overall survival (OS) were calculated from the start of
radiation. Results: SIB-IMRT was used in 12 patients, of whom 11 also
received chemotherapy (Concurrent only in 5;Concurrent/adjuvant in
4 and Induction/concurrent in 2). All patients completed their planned
course of treatment with median duration of radiation of 61 days
(range 49-71days). Acute toxicity scoring revealed 3 cases (25%) of
grade 3 skin toxicity and 4 cases (33%) of grade 3 mucosal toxicity.After
a median follow-up of 13.1 months, 2 patients had tumor recurrence and
one died. The LRC, LRRFS and OS at 1 years are 83.3% and 91.6%.
Regarding late toxicity,1 patient experienced grade 2 xerostomia and
no patient have neck fibrosis. Conclusion: We consider SIB-IMRT for
NPC is feasible in our setup and results are comparable to published
series when a standardized protocol is strictly followed.
Analysis of carcinoma hypopharynx treated in a tertiary cancer
center
Valiyaveettil Deepthi
E-mail: deepthinair13@gmail.com
Introduction: Hypopharyngeal cancer is usually diagnosed at a locally
advanced stage. Prognosis for patients with hypopharyngeal cancer
is poor compared to the other head and neck cancers. Multimodality
treatment with concomitant chemoradiotherapy is the standard
of care. Aims and objectives: Retrospective survival analysis of
Carcinoma Hypopharynx. Compare the stricture formation based on
dose of radiotherapy. Materials and Methods: A total of 67 patients
with the pathological diagnosis of carcinoma hypopharynx admitted
for radiotherapy at NIMS, Hyderabad from January 2011 to March
2014 were analyzed. Statistical analysis was done by Kaplan Meier
Method using SPSS 22 software. Results: The median age was 50.5
years with M: F ratio of 1.9:1. History of tobacco use was seen in 20
patients. 14% patients presented in early stage and the rest were in
advanced stage. Out of 67, 30 patients had Post Cricoid, 30 patients
had Pyriform Sinus, and two patients had Posterior Pharyngeal Wall
as the primary site of involvement. In 5 patients the primary site was
not specified. Out of 67 patients, 2 patients presented with metastasis
and received palliative radiotherapy while 65 patients received Radical
radiotherapy. Most of them received concurrent chemotherapy with
Cisplatin. 33 patients received 70 Gy and 34 received ≤ 66 Gy. The
median overall survival was 11 months. Median survival in males was
10 months and in females was 11 months (log rank p=0.77). Median
Survival in Carcinoma Post Cricoid was 13 months; in Carcinoma

Abstracts
Pyriform Sinus was 9 months and in Carcinoma Pyriform Sinus with
post cricoid involvement was 4 months. 19 patients (29%) developed
stricture on follow up. Among them 10 received 70 Gy and 9 patients
received ≤66 Gy. i.e 30% patients who received 70 Gy, 26% patients
who received ≤66 Gy developed strictures on follow up.6 patients had
local recurrence and two patients had distant metastasis on follow-
up. Conclusions: Median overall survival was 11 months as most
patients in the study had advanced disease at presentation. There
was no significant difference in the stricture formation based on the
dose of radiotherapy.
Split-course hypofractionated radiotherapy for palliation of
advanced head and neck squamous cell carcinoma.
Vishal D Manik
Madras Medical college, Chennai, E-mail: vishalnick@gmail.com
Introduction: A significant proportion of patients with head and
neck squamous cell carcinoma (HNSCC) are unsuitable for radical
treatment due to factors including tumour stage, performance status
(PS) and co-morbidity. Palliative radiotherapy has a useful role in
the control of local symptoms. Aim: To assess the local symptom
control of advanced HNSCC treated with split course hypofractionated
radiotherapy.Additionally, to assess the Quality of Life (QoL); the acute
toxicity to the treatment and the immediate loco-regional response.
Materials and Methods: Thirty patients of very advanced HNSCC
with PS of 2-4 were selected. All the patients after basic work up, were
planned to receive initial course of 20Gy radiation (4Gy/5 fractions)
followed by a two week gap and then re-assessment. All patients with
absent or manageable toxicity were further treated with one more
course of 20 Gy radiation. Symptom relief was assessed before and
after each course of radiation. QoL was assessed using the EORTC
QoL questionnaire, before and after radiotherapy. Results: Out of the
study population, 70% were males, 50% belonged to age group
61-70years and all had a PS ≥3. Oropharynx (33.3%) was the
commonest site with base of tongue (20%), the commonest subsite.
Stage grouping was IVB in 56.67% with 46.67% having a N3 node and
dysphagia (43.3%) at presentation. Only 3 patients could not complete
the planned courses of RT. Good symptom relief was observed in
83.3%. Improvement in symptom scales was seen, however, functional
and global health scores remained low. None had more than Grade
1-2 toxicity from first course. Grade 2 toxicity was seen in majority
of patients after second course. Partial response to treatment was
observed in all cases. Median progression free survival was 2 months
post-treatment. Conclusion: Split course hypofractionated palliative
RT is feasible in advanced HNSCC and allows for shorter treatment
time with acceptable symptom relief.
Sandwich mould brachytherapy for cancer lip-a non invasive
approach
Kanhu Charan Patro, E. B. Rajmohon
E-mail: drkcpatro@gmail.com
Carcinoma lip one of the common malignancies among gutkha chewers.
Surgery is the mainstay of treatment. Radiotherapy is another option
for cosmetic region. External beam radiotherapy can be considered for
where surgery is not feasible, medical co morbidity, and when surgery
is not acceptable for cosmetic disfigurement. Brachytherapy can be
considered for node negative diseases, interstitial brachytherapy is a
established procedure. Here we are describing another brachytherapy
procedure called sandwich mould as a curative option for node negative
disease. A 67 year old male presented with 2 skip lesions on lower lip,
one is measuring 3cm x 3cm and another is at right angle of mouth 3cm
x2cm without any neck node. Patient was not interested for surgery
because of cosmetic issues. Options are discussed with patient and
patient was agreed for sandwich mould brachytherapy. A mould was
made on a orfit frame.around 22 needles are planned in two plane. A
CT based plan was done. Patient received @3.5Gy twice dally fraction
for 15 fractions BED 2Gy equivalent calculated and discharged with
grade 3 RTOG skin and mucosal toxicity. The toxicity increase till
3 weeks of radiation.now there is complete response of tumor. We
concluded that sandwich mould brachytherapy is a good option and
can be accepted as good option comparing to other options and more
suitable for patients having medical co-morbidity and patients are not
accepting the cosmetic defects. It is also a good option comparing to
interstitial as non invasive.
Impact of human papillomavirus infection on treatment response
and outcome in oral cavity and oropharyngeal cancer: An Indian
perspective
Monidipa Mondal
Radiotherapy Dept, Medical College, Kolkata.
E-mail: monidipamondal1@gmail.com
Introduction: India has the highest prevalence of oral cancers globally
and its incidence is rising. Several studies suggest that HPV infection
is an independent risk factor for development of oropharyngeal
and oral cavity cancers and it is associated with better prognosis.
[1] But most of the studies are based on Western population and
not much data is available regarding prognostic significance of
HPV infection in Indian scenario. Aims and Objectives: Aim of the
study was to assess impact of HPV status on response to therapy
and survival in oral cavity and oropharyngeal carcinoma patients
attending Radiotherapy and ENT OPD of a tertiary care centre of
Eastern India. Primary Objectives were (1) to compare response
rates in HPV positive and negative patients receiving induction
chemotherapy followed by concurrent chemoradiation and (2) to
compare progression free survival and overall survival in HPV positive
and negative patients. Material and Method: 42 patients of newly
diagnosed, stage III, IVA and IVB squamous cell carcinoma of oral
cavity and oropharynx were prospectively evaluated. Biopsy specimens
were collected from the patients before receiving any treatment, and
stored in - 80°C. Resectable cases of oral cavity cancer underwent
surgery including modified lymph node dissection followed by adjuvant
radiation or chemoradiation. All cases of oropharyngeal cancers and
unresectable cases of oral cavity cancers received 2 cycles of induction
chemotherapy with Inj Paclitaxel, Inj Cisplatin, and Inj 5-Fluorouracil
(TPF) followed by concurrent chemoradiation with weekly Cisplatin.
Dose of radiation used were 60-66Gy in postoperative setting and
66Gy in definitive setting using conventional fractionation. Presence
or absence of HPV DNA was determined by real time PCR in fresh
frozen biopsy samples. Tumor DNAs were also tested for HPV16
and HPV18 by use of type-specific primers. Two-year overall and
progression-free survival for HPV-positive and HPV-negative patients
was estimated by Kaplan– Meier analysis. Results: Genomic DNA
of high risk HPV was detected in 38% of tumor specimens. HPV16
was detected in 16% and 65% of tumor specimens from oral cavity
and oropharynx respectively. 12 out of 16 HPV positive tumors (75%)
were found in the oropharynx (p0.001). 30 patients received induction
chemotherapy followed by concurrent chemoradiation. There was no
difference in the response rates seen after induction chemotherapy
(p=0.28) and after chemoradiation (p=0.67) for HPV-positive and
negative tumors. After a median follow-up of 25 months, patients with
HPV-positive tumor had better 2-year progression-free survival (85%
vs 65%, p=0.17) and 2-year overall survival (93% vs 69%, p=0.19) but
these were not statistically significant. Conclusions: HPV positive oral
cavity and oropharyngeal cancers patients have a trend towards better
progression-free survival and overall survival although not statistically
significant due to the small patient number. HPV positivity did not confer
any significant difference in response to therapy.
Objective assessment of swallowing dysfunction and aspiration
after chemoradiation for head and neck cancer with its impact
on quality of life
Nithin Bhaskar. V, Iqbal Ahmed, Rajesh. J, Chendil V, Amruth Kadam
Bangalore Medical College and research institute. Email: charu.nithin@
gmail.com

Abstracts
S26
Background/Objective: To assess the prevalence, severity and
morbidity of dysphagia following concurrent chemo-radiation for
head and neck cancer. Materials/Methods: Between November
2012 and October 2014, 20 patients with squamous cell carcinoma
of the oral cavity, oropharynx, larynx, or hypopharynx were studied.
All patients received conventional EBRT on Telecobalt to a total dose
of 66-70 Gy (by shrinking field technique) with concurrent weekly
cisplatin 40 mg/m2. All patients were given symptomatic care in the
form of analgesics, antiemetic. Patients were evaluated before and
after RT to assess the swallowing dysfunction by nasopharengeal
larygoscopy. Results: Flexible endoscopy was performed pre-therapy
in 22 patients, early post treatment in 17 patients and late post-therapy
in 12. Post therapy dysfunction was characterized by pooling of food
in and around pyriform sinus. Defective swallowing characterized by
pooling of liquids/solids was noticed in 15 patients (68%) in the early
post-therapy period and nine patients (41%). Aspiration noted in the
post therapy period was mostly silent aspiration eliciting no cough
reflex. Post-therapy aspiration was noticed in 11 patients (50%) out
of which 10 patients (45%) had silent aspiration. 8 patients were
diagnosed of pneumonia and required admission and i.v antibiotics.
2 patients expired in the early post treatment time due to pneumonia.
One patient was lost to follow-up in the early post treatment period and
four in the late post treatment periods. Conclusions: After concurrent
chemo-radiotherapy, significant objective swallowing dysfunction is
prevalent. It promotes aspiration, which may not elicit a cough reflex
and can contribute to pneumonia.
Three weekly versus weekly concomitant chemoradiation
with cisplatin in locally advanced head and neck cancer- a
prospective, randomised study
Parna Basu*, Krishnangshu B. Chowdhury*, Abhishek Basu*,
Kazi S. Manir*, Partha Dasgupta*, Subir Gangopadhayay*
*Department of Radiotherapy, R.G.Kar Medical College and Hospital,
Kolkata, India. E-mail: doc.parna08@gmail.com
Background: Concurrent Cisplatin based chemoradiotherapy (CTRT)
is now the standard of care for locally advanced head neck cancer
patients (LAHNC). The most common chemotherapy regimen is high
dose (100mg/m2) three weekly Cisplatin with CTRT. This protocol
is associated with significant acute and late toxicities which resuls in
either early treatment termination or decrease in treatment compliance.
Therefore splitting full dose three weekly Cisplatin as weekly Cisplatin
schedule (30 mg/m2) maintaining the dose intensity might decrease
toxicity and increase compliance. Objectives: This prospective study
compares the differences in response rate, acute toxicity and PFS
outcomes between weekly Cisplatin and 3-weekly Cisplatin based
concurrent chemotherapy (CTRT) regimens given to patients of
Stage III/IV head and neck cancer. (T3-4b, N1-3) Methods: The study
was designed as single institutional, open label, parallel 2 arm
phase 3 randomized controlled clinical trial. LAHNC (squamous
cell histology) patients with Eastern Co-operative Oncology Group
(ECOG) performance status 0-2, normal hematological parameters,
creatinine clearance 50 ml/min, with no significant co-morbid
conditions were randomized into 2 arms:ArmAwas treated with weekly
Cisplatin (30 mg/m2) concomitantly with conventional RT and Arm B
received 3 weekly Cisplatin(100 mg/m2) for 3 intended cycles along
with similar RT schedule, i.e.,66-70 Gy in conventional fractionation.
The groups were compared for response rate (RECIST V1.1), acute
toxicity (CTCAEv4) and progression free survival (PFS, Kaplan Meier
Survival). The statistical analysis was done using two tailed tests with
alpha 0.05 statistical significant, SPSS v16, Chicago. Results: Initially
80 patients were recruited in study with 60 patients elgible for analysis
for PFS (intention to treat). At median follow up period of 12 months
(range 5- 19 months)the baseline parameters of demographic profiles
and tumour characteristics were comparable in both arms. Majority of
patients were in stage III, 20 (66.7 %) and 14 (48.3%) for Arm A and B.
Response rates at the end of 2 months post treatment were comparable
in both arms Arm A (N=27) patients and Arm B (N=30) patients, with
Complete Response inArmA17(65.4%) vs 19 (63.3%) inArm B, Partial
Response 8 (30.8%) in Arm A vs 6 (20%) in Arm B and Progressive
Disease 1(3.8%) in Arm A vs 5(16.7%) in Arm B, p value 0.248.
Response at last follow up CR 15 (57.7%) in Arm A vs 17 (56.7%) in
Arm B, and PD 10 (38.5%) inArmAvs 9 (30%) inArm B, p value 0.427.
Majority of patients with oropharngeal subsite had local recurrence or
progressive disease. Median PFS was 16 months (mean ± SE: 10.36 ±
1.25 months; 95% CI 7.903, 12.81) inArmAvs 14 months (mean ± SE:
12.15± 0.74 months; 95% CI 10.70,13.60) inArm B, log rank test 0.062.
Weekly cisplatin arm was showing statistically significant toxicities in
the form of dysphagia (Grade3- 36.7%); mucositis (Grade3 - 30%) and
dermatitis (Grade 3- 13.3%). Among hematotoxicies,neutropenia was
numerically more in Arm A and anemia and thrombocytopenia more
in Arm B. Conclusion: In this study, Three weekly high dose Cisplatin
treatment showed better locoregional response and lower acute toxicity
compared to weekly low dose Cisplatin treatment.
Study of role of HPV in oesophageal carcinomas
P. U. Prakash Saxena
Kasturba Medical College, Mangalore (Manipal University).
E-mail: pu_saxena83@yahoo.co.in
Background: The role of HPV as one of the causative agents in
oropharyngeal malignancies has been established. Evidence suggest
that such cases may fare better than conventional head and neck
malignancies and for such subtypes dose de-escalation studies are
already being conducted. The method of transmission is yet to be
defined, most of the studies implicate oral sex (from mouth to-genital
or mouth-to-anus contact).As oesophagus is anatomically a continuous
structure with the upper aero-digestive tract, we hypothesized that
HPV may be associated with some oesophageal cancers as well.
Methods: 21 cases of squamous cell carcinomas oesophagus treated
with radical chemo-radiotherapy were included. Post treatment these
patients were followed up every month for dysphagia assessment.The
tissue biopsy sample preserved in wax block were sent for analysis.
HYBRID DNACAPTURE technique was used for identifying HPV DNA
in the sample. The HPV types included in the test were: 16, 18, 31,
33, 35, 39, 45, 51, 52, 56, 58, 59 and 68.A cut-Off Ratio of 0 to 0.99 is
NEGATIVE for HR HPV; Cut-Off Ratio 1.0 or above is POSITIVE for
HR HPV based upon the semi -quantitative viral load, represented as a
numeric positive cut-off value. The Cut -Off Ratio at 1.0 correspond to
viral DNA load of ~5,000 copies/assay or 1 picogram/ml at a threshold
of finding a clinical disease. Results: There were 10 male (47.61 %)
and 11 female patients (52.38%) with median age being 60 yrs. Out of
21 samples analysed 9 were positive for high risk HPV DNA (42.8 %),
one was classified as borderline negative (4.76%). Out of positive
samples 3 were males (33%) and 6 were females (66%). 77.77 % of
the HPV positive group were non-smokers. 55 % of the HPV positive
tumours (5/9) were located in the lower third of oesophagus. 77.7%
of HPV positive tumour patients had no evidence of dysphagia after 1
month of finishing treatment as compared to 66.6 % of HPV negative
tumours. Conclusions: This study shows that there may be a possible
association between HPV viruses and oesophageal cancers despite
having small numbers. A possible association also may exist between
non-smokers and HPV. In future we plan to conduct studies where in
addition to other predictive markers available for response assessment
to chemo-radiation, HPV will also be tested.
Delay in primary cancer treatment of head and neck
R. Narmadha, S. Shanmugakumar, N. V. Kalaiyarasi, Baskar,
Madhumathi, Sundaresan, Prabhakaran, Vishal Malik
Dept. of Radiotherapy, Madras medical college, chennai
E-mail: narmipriya@gmail.com
Introduction: In India, Head and neck cancers accounts for about 30% of
all cancers.60% to 80% of patients present with advanced disease. Head
and neck cancer can cause varying degrees of structural deformities and
functional handicaps thereby compromising the self-esteem and quality
of life. Objectives: Our aim was to identify the cause for delay in primary

Abstracts
treatment of the head and neck cancer patients under two categories as
`patient delay` that is, interval between onset of symptoms to diagnosis
and `Professional delay` that is interval between diagnosis and initiation
of treatment. Method and Materials: Study included 140 primary head
and neck cancer patients diagnosed and treated in our dept, Barnard
Institute Of Radiation Oncology, MMC Chennai. Result: Among 140
patients, there was a delay of 2 months of symptom duration in 34%.
There was a hospital related delay in 20% patients of which there was
a mean delay of 7 days for the investigations (Imaging) and time taken
for dental prophylaxis was 20 days. Conclusion: There s a significant
overall delay of 2.5 months due to all reasons in initiation of treatment
which is found to exceed the tumour doubling time of head and neck
cancer. This might be a significant contributing factor causing the patient
to present in advanced stage. Delay can be avoided by educating the
people to seek health care soon after the onset of symptoms. Hospital
delay can be reduced by shortening the time taken for investigations.
Patterns of care and treatment outcomes of squamous cell
carcinoma(scc) Hypopharynx: a single institution experience
Rejinish Kumar K, R.Resmi, Cessal Thomamachan Kainackal,
Malu Rafi, Preethi Sara George, K. Ramadas
Division of Radiation Oncology, Regional Cancer Centre, Trivandrum,
Kerala, India. E-mail: resmi277@gmail.com
Introduction: Hypopharyngeal cancers constitute about 7% of all
head and neck malignancies. Early stage disease is treated either by
radiotherapy or surgery. Advanced stage (stage III and IVA) disease
is managed by combined modality treatment. Most patients present
late, are nutritionally compromised and due to poor general condition a
substantial number will undergo palliative treatment unlike in other head
and neck cancers. Aims and Objectives: To analyze the clinical profile
and treatment outcomes of hypopharyngeal squamous cell carcinoma
treated at Regional Cancer Centre, Trivandrum, during the time period
2010-2011 and to identify the various factors influencing the outcome.
Materials and Methods: This is a retrospective analysis of all squamous
cell carcinoma(SCC)of hypopharynx treated at Regional Cancer
Centre(RCC) from 2010 to 2011.Data was retrieved from case sheets
using a structured proforma. Observation and Results: One hundred
and sixty four patients with SCC hypopharynx were included in the
study. Median follow up time was 16.9 months.Majority of patients were
males(137 -83.5%). Most common subsite was pyriform sinus 114 (70 %),
followed by postcricoid 42(25.6%) and posterior pharyngeal wall 5(3%).
Eleven patients(6.7%) had stage II disease, thirty one patients(18.9%)
had stage III, sixty three patients (38.4 %) had stage IVA, fifty four
patients(32.9%) had IVB disease and two patients(1.2%) presented
with stage IVC disease. One hundred twenty eight(78%)patients were
treated with radical intent and thirty six(22%) with palliative intent.Among
patients who underwent radical treatment,fourty five patients (27.4 %)
were treated with concurrent chemo radiation, thirty four patients(20.7%)
underwent RT alone and twenty one patients(13%) underwent induction
chemo followed by chemoradiation. Four patients(6.25%) underwent
primary surgery, of which three received adjuvant RT. All patients were
treated either with 6 MV photon or in cobalt 60 to a total dose of 60-
66 Gy. Concurrent chemotherapy used was cisplatin at a dose of 80
mg/m2 given 3 weekly. Six patients had treatment interruptions.Thirty
four patients(20.7%)developed recurrence with the most common site
being the primary site. Median time to recurrence is 11.63 months. Six
patients(3.65%) developed 2nd malignancies. At 3 yrs, disease free
survival was 69.5% and overall survival was 43.7%. Conclusion: In
our series, most common subsite at presentation was pyriform sinus.
Most patients presented with advanced stage-T4a disease. Twenty
two percentage of patients received palliative treatment. Disease free
survival at 3 yrs was 69.5%.
Role of sialography in head and neck cancer
Rahul misra, R. K. Vyas, Rahul, Maitrik Mehta, J. P. Neema,
Om Prakash
GCRI, Ahmedabad. E-mail: rahul.medico04@gmail.com
Introduction: Xerostomia is a common complication of head and neck
irradiation depending upon the cumulative dose and volume of parotids
involved. But there are almost no objective tests to compare patients
treated by different modalities of radiotherapy. Hence, we decided to
use sialography to compare patients treated by different modalities.
Aims and Objectives: To assess role of sialography in head and
neck cancer. Material and Methods: 32 newly diagnosed stage T1-
3oropharynx or oral cavity cancer patients were chosen. They were
treated with conventional radiation with amifostine. (500mg of amifostine
diluted in 3mL.of normal saline subcutaneously in the shoulder region
20 to 30 minutes before the radiotherapy fraction every day).All patients
had a ECOG performance status above 2 and were treated upto doses
of 66gy/33#. 99mTcpertecnetate scintigraphy scan (sialography) was
performed as a baseline scan, after 1 month,6 months and 1 year post
treatment. Sialography is of value in determining changing, preserved
or lost salivary gland function during radiation. Sodium pertechnetate
(Na-99mTcO4) is injected followed by oral administration of oral
sialagouge (lemon juice). Dynamic image acquisition is started 1minute
after administration of technicium to determine its uptake. Later with
good accrual these values were also compared with sialography of
patients undergoing imrt. Result: The values of sialography correlated
well with the subjective improvement of symptoms of the patients. They
also varied among the different arms showing that each intervention
has its own importance. significant improvement was noted 6 months
post treatment in those with preserved salivary function. Conclusion:
The salivary scintigraphy tests support the finding of improvement in
excretory parameters (SEF and SEF ratio) salivary gland function of
the patient cohort undergoing radioprotective interventions.
Concurrent chemoradiotherapy in locally advanced squamous
cell carcinoma of head and neck with capecitabine and weekly
cisplatin
Ramya.A*, S. Shanmugakumar, N. V. Kalaiyarasi, Bhaskar,
Madhumathi, Sundaresan, Prabakaran, Arun ramanan
Department of Radiotherapy, Madras Medical College, Chennai.
E-mail: drramya2005@gmail.com
Aims and Objectives:To assess the immediate loco regional response
rates and acute toxicity in patients of locally advanced squamous cell
carcinomas of the head and neck with conventional radiotherapy with
weekly cisplatin and capecitabine. Materials and Methodology: Single
arm prospective study with 30 consecutive patients with locally
advanced head and neck cancer presented to the department of
radiotherapy, Madras medical college, Chennai. All patients were
treated with conventional radiotherapy 66Gy along with weekly Inj.
Cisplatin 40mg/m2 and T.capecitabine 500mg/m2 daily along with
radiation. The immediate loco regional response rates were assessed
clinically and radiologically 4-6 weeks after concurrent chemo
radiotherapy. The toxicity profile of the treatment was assessed
with RTOG acute morbidity scoring criteria and CTCAE Version 4.
Results: Among 30 patients, Ca Oropharynx were 9 patients, followed
by Ca Hypopharynx 8 patients, Ca Oral cavity with 7 patients and
Ca Supraglottis 6 patients. 73% of patients had complete response.
Toxicities observed in the study were Mucositis grade 3 in 15
patients;Skin reactions grade 2 in 2 patients. Leucopenia grade 2 in 2
patients. Conclusion: Concurrent chemoradiotherapy with Inj.Cisplatin
and T.Capecitabine in locally advanced squamous cell carcinoma of
head and neck cancer is preferred regimen with manageable toxicity.
Undifferentiated nasopharyngeal carcinoma with bilateral inguinal
lymphnode recurrence: A case report and literature review
Ravindra Nandhana
E-mail: ravindra.nandhana@gmail.com
Nasopharyngeal carcinoma (NPC) is a rare malignancy arising from
the epithelium of nasopharynx. Unlike other malignant head and neck
cancers NPC has highest propensity to develop distant metastasis.
Despite of definitive treatment there is a high rate of recurrence most

Abstracts
S28
commonly in bone, lung, liver, distant lymph nodes in decreasing
order of frequency in the literature. We present here a case of
recurrent nasopharyngeal carcinoma with bilateral inguinal lymph
node metastasis seven months after primary treatment. Involvement
of bilateral inguinal lymph nodes is extremely rare. Management of
metastatic disease is usually palliative platinum based chemotherapy.
Reirradiation for head and neck cancers with cyberknife-based
stereotactic radiosurgery: Evaluation of carotid artery doses
Shikha Goyal
Division of Radiation Oncology, Medanta - The Medicity, Gurgaon,
Haryana-122001. E-mail: drshikhagoyal@gmail.com
Background: Carotid blowout is an uncommon but serious complication
of salvage reirradiation for H and N cancer. We evaluated the doses
to carotid arteries in the high dose regions during CyberKnife-
based fractionated stereotactic reirradiation (CK-FSRT) of head
and neck cancers (HNC), and correlated them to complication
risk. Materials and Methods: Patients who received CK-FRRT at our
department in the period October 2012 to July 2014 were included. Entire
course of internal or common carotid arteries ipsilateral to the high dose
region either within or adjacent to the target volume was contoured, and
doses to these vessels evaluated (Dmax, Dmean, D0.2 cc, D0.5cc, D1cc,
V25, V30). The clinical course including responses and complications
were prospectively recorded. Results: Twenty-two patients received
CK-FSRT during this period; of these, 13 (11 males, 2 females) with
median age 56 years (range 31-83 years) received reirradiation, either
for second primary (2) or recurrence (11). Of these, one received a
combination of IMRT with CK-FSRT boost while 12 received CK-FSRT
alone, dose delivered being 20-37.5 Gy in 3-7 fractions (commonest
schedule, 30 Gy in 5 fractions). The median interval between the two
RT courses was 13 months (range 3.8-47.7 months). All patients had
earlier received a dose of 64-70 Gy to the reirradiated region. Median
follow up post CK-FSRT was 6.5 months (range 2-17 months). During
this period, only one patient developed carotid bleed 7 months post-
reirradiation that was salvageable with angioembolization. There were
no treatment-related deaths. Dose-volumes were noted for 16 vessels
in 12 patients where Dmax exceeded 24 Gy for the reirradiation course.
Median integral dose (volume in ml X dose in Gy) to the vessels was
41.8 ml-Gy (range 22.4-71.6). Median Dmax(range), D0.2cc(range) and
D1cc(range) were 33.5 Gy (24.1-44.1), 30.6 Gy (22.0-37.6), and 20.37
Gy (7.6-37.6), respectively. Median V25 and V30 were 1.08 cc(39.7%)
and 0.7 cc(29.7%), respectively. Six patients (7 vessels) had at least
50% volume within PTV, but only 3 of these were constrained to receive
doses equal to or less than PTV dose during the initial plan. The patient
who developed bleeding was a 73-year lady who had earlier undergone
surgeries for 2 primaries. The first and repeat irradiation interval was 47.7
months and the respective dose-volume parameters for reirradiation
(30 Gy in 5 fractions) were: Dmax 39.9 Gy, Dmean 36.2 Gy, and V30
18.9cc (100%).Conclusions: Attention to carotid doses during repeat
irradiation courses and subsequent constraints to the vessels in high
dose regions courses may help prevent or reduce the risk of carotid
rupture or bleed. Evaluation of a larger number of patients with longer
follow up and more events would help estimate the relationship between
carotid vessel doses and observed toxicity, which would serve as a
useful reference to define respective dose constraints for reirradiation.
Hypofractionated IMRT for early glottis cancers leads to higher
local failure
S. M. Arunsingh, R. Karmacharya, P. Arun, R. K. Shrimali, R. Achari,
I. Mallick, S. Chatterjee
Department of Radiation Oncology, Tata Medical Centre, Kolkata.
E-mail: 85moses@gmail.com
Aim: Radical radiotherapy is often a preferred treatment approach for
early glottic cancers. Busy centres often use treatment hypofractionated
treatment schedules. Conformal forward planned delivery is used as
routine but advanced inversed planned techniques are sometimes
used. Methods: 59 unselected patients of histologically confirmed
glottis squamous cell cancer patients treated during September 2011
to July 2014, were analysed. Only patients with stage T1/T2 N0 as per
the 7th edition ofAJCC and who were treated using a hypofractionated
radical radiotherapy regimen of 5500cGy delivered in 20 fractions of
275cGy each over a period of 4 weeks were included.Also, patients with
a minimum follow up of six months from treatment completion, n=56,
were included in the present analysis. The outcomes and treatment as
well as tumour related factors associated were systematically analysed
and correlated to outcome. Results: 89.3% of the patients were T1 and
10.7% were T2. 57.1% patients were treated using IMRT (93.8 % VMAT
and 6.2% helical tomotherapy), the remaining were treated using
3DCRT. 18 patients in the IMRT group had undergone carotid sparing
as part of a prospective study. A bolus was required for dose build
up in the anterior commissure region in 72.7% patients with a risk of
involvement to that area. All patients tolerated the treatment well with
7 patients (12.5%) having radiation dermatitis of grade 2 or above. 15
patients (26.8%) developed grade 2 or more dysphagia during or after
the third week of the radiation therapy.All patients achieved a complete
response at the first post radiation visit 4-6 weeks post therapy. 98.2%
patients completed treatment within 28 days (median-26 days, range 22
to 26). Overall 10.7% patients had failure of treatment with 5 patients
having a local recurrence and 1 patient failing regionally in the nodal
region. One patient died due to unrelated medical condition. Clinical
stage did not have any significant bearing on the control rates (T1a
vs T1b vs T2 8.6% vs 13.3% vs 16.7%; p0.05). All failures occurred
in the IMRT group with 10.7% failures overall and 18.8% within the
group. All failures occurred in the Helical Tomotherapy IMRT arm.
Other treatment related factors like the use of bolus, carotid sparing
techniques, prolongation of the duration of radiation course did not
have significant relation with the outcomes. Similarly dosimetric indices
like D99, D50, Mean dose (MD) and homogeneity index (HI) were also
analysed. None of the CTV indices were significantly related to the
outcomes. The PTV indices D99 (p=0.01), D50 (p=0.001), MD (p=0.00)
and HI (p=0.00) were significantly better in those who failed. This was
so because all these indices were significantly better in the IMRT group
compared to the 3DCRT patients and all the failures had occurred in
the IMRT group. Conclusions: Hypofractionated radiotherapy is safe
with acceptable toxicities. However the early results presented above
show that helical tomotherapy in early glottic cancers may lead to extra
failure rates. This could be because of higher anterior dose gradient in
the HT arm resulting from smaller penumbra/field width.
Clinical profile and treatment outcomes of squamous cell
carcinoma (SCC) Oropharynx: A single institution study
Cessal Thommachan Kainickal1
, Sorun A Shishak1
, Rejinish Kumar1
,
Malu Rafi1
, Preethi Sara George2
, K. Ramdas1
1
Division of Radiation Oncology, 2
Division of Epidemiology and
Biostatistics, Regional Cancer Centre, Trivandrum, Kerala, India.
E-mail: sorunshishak@yahoo.co.in
Introduction: Oropharyngeal carcinomas constitute about 7% of
all head and neck cancers. Radical Radiotherapy is the standard
treatment for early stage disease. Locally advanced disease (Stage
III and IVA) is treated by combined chemo radiation. The role of
surgery is very limited and is mostly done as a salvage measure.
Aims and Objectives: To analyse the clinical profile and treatment
outcomes of SCC oropharynx treated at Regional Cancer Centre
(RCC), Trivandrum, during the time period from 2007 to 2008.
Materials and Methods: A retrospective analysis of all Squamous Cell
Carcinoma (SCC)of oropharynx treated at RCC Trivandrum from 2007
to 2008 are included in the study. The patients were followed up until
September 2014. Observation and Results: One hundred and ninety
five patients were analysed, of which majority were males(95.4%).
The median follow up was 23.9 months. The median age was 61.1
years. The sites involved were tonsil (47.2%),base of tongue(21%),soft
palate(17.9%), uvula(7.7.%),vallecula(3.1%) and pharyngeal wall(3.1%).
One patient (0.5%) presented in stage I disease, eighteen patients(9.2%)
in stage II, fifty patients (25.6%) in stage III, ninety five patients (48.7%) in

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