Quality-of-life (QOL) outcomes in patients with head and neck squamous cell carcinoma (HNSCC) treated with intensity-modulated radiation therapy (IMRT) compared to three-dimensional conformal radiotherapy (3D-CRT): evidence from a prospective randomized study

PURPOSE

To prospectively evaluate and compare health-related quality-of-life (QOL) outcomes in patients with head-neck squamous cell carcinoma randomized to either intensity-modulated radiation therapy (IMRT) or three-dimensional conformal radiotherapy (3D-CRT) and assess serial longitudinal change in QOL over time.

METHODS

QOL outcomes were assessed using the European Organization for Research and Treatment of Cancer (EORTC) QOL questionnaire (QLQ-C30) and Head-Neck module (HN-35) at baseline (pre-treatment) and subsequently periodically on follow-up. Mean scores of individual domains/scales of 3D-CRT and IMRT were compared using 't' test at each time point; while longitudinal change in mean scores of both groups over time was evaluated by repeated measurement analysis of variance.

RESULTS

Fifty eight of the 60 randomized patients who filled the QOL questionnaire at least at one time point were included in the analysis. Several general (emotional functioning, role functioning, social contact) as well as head and neck cancer-specific (dry mouth, opening mouth, sticky saliva, pain, senses) QOL domains were better preserved with IMRT compared to 3D-CRT at different time points. Importantly, none of the QOL domains were worse with IMRT at any time point. There was substantial deterioration in QOL scores immediate post-treatment (3-months) in both arms. However, QOL scores gradually but definitely improved over time for most domains. Global QOL, emotional/role functioning, nausea/vomiting, pain, swallowing, speech, social contact/eating, insomnia showed rapid recovery (<6months) while physical/cognitive functioning, dry mouth, sticky saliva, fatigue, senses showed delayed recovery (>6months). There were no significant differences in loco-regional or survival between the two arms.

CONCLUSIONS

There is substantial deterioration in QOL after curative-intent head-neck irradiation that gradually improves over time. IMRT results in clinically meaningful and statistically better QOL scores for some domains compared to 3D-CRT at several time points with comparable disease outcomes that could support its widespread adoption in routine clinical practice.

A randomized phase II trial of dexamethasone versus prednisolone as secondary hormonal therapy in CRPC

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Background: Dexamethasone and prednisolone are glucocorticosteroids used as second line hormonal treatment for castration refractory prostate cancer (CRPC). The biochemical response rates in cohort studies suggest that dexamethasone may be the more active agent. We conducted an open label, randomised phase II trial of dexamethasone versus prednisolone. Methods: Patients with castration resistant prostate cancer with progressive disease on androgen deprivation therapy were eligible. They were randomized to receive either prednisolone 10mg daily or dexamethasone 0.5mg daily. The main endpoint was confirmed PSA response rate according to the PSA Working Group 2 criteria. Patients with PSA progression on prednisolone crossed over to dexamethasone. Secondary endpoints included time to PSA progression, radiologic response rate using RECIST criteria, and safety. Results: Seventy-five patients were randomized. Confirmed PSA response was achieved in 12/39 patients (31%) on dexamethasone compared to 6/36 (17%) on prednisolone (p = 0.153). Median time to PSA progression was 9.7 months on dexamethasone compared to 5.1 months on prednisolone (HR 1.57, 95% CI 0.90 -2.75). In 43 patients with measurable disease, the response rate by RECIST criteria was 15% and 6% for dexamethasone and prednisolone, respectively (p = 0.606). Clinically significant toxicities were rare. Of 23 patients who crossed over at progression on prednisolone to dexamethasone, 19 patients were evaluable for PSA response. Seven of the 19 patients (37%) had a confirmed PSA response to dexamethasone after progression on prednisolone. Conclusions: The data are consistent with the hypothesis that dexamethasone is more active than prednisolone in the treatment of CRPC. In the absence of definitive, larger trials, dexamethasone should be used in preference to prednisolone in this setting. Clinical trial information: 2005-006018-16.

Hypofractionated radiotherapy for T1N0M0 glottic cancer: retrospective analysis of two different cohorts of dose-fractionation schedules from a single institution

AIMS

To determine the influence of dose and fractionation on tumour characteristics, toxicity, disease control and survival outcomes in T1 glottic carcinoma.

MATERIALS AND METHODS

Between 1975 and 2000, treatment charts of 652 patients with T1 glottic carcinoma who received curative radiation with four hypofractionated schedules (50 Gy/15 fractions [3.3 Gy/fraction] or 55 Gy/16 fractions [3.43 Gy/fraction] or 60 Gy/24 fractions or 62.5 Gy/25 fractions [2.5 Gy/fraction]) were analysed. The patients were divided into two groups based on fraction size <3 Gy and >3 Gy. Local control and overall survival were calculated. Patient- and tumour-related factors affecting local control were analysed using univariate and multivariate analysis. Factors affecting late toxicity were also analysed.

RESULTS

The local control and overall survival at 10 years were 84 and 86.1%, respectively, for T1 glottic carcinoma. The response to radiation had a significant effect on local control with univariate analysis (P = 0.001). Other factors, such as beam energy, anterior commissure involvement and fractionation, did not affect local control. Persistent radiation oedema was seen in 123 patients (23.4%) and was significantly worse in patients who received radiation with a larger field size (>36 cm(2)) on a telecobalt machine (P < 0.001).

CONCLUSIONS

Radical radiotherapy schedules incorporating a higher dose per fraction yield acceptable local control rates and late toxicity. Telecobalt therapy for early glottic cancer is a safe alternative to treatment with 6 MV photons on a linear accelerator in terms of local control and late toxicity as long as field sizes smaller than 36 cm(2) are used.

Three-dimensional conformal radiotherapy (3D-CRT) versus intensity modulated radiation therapy (IMRT) in squamous cell carcinoma of the head and neck: a randomized controlled trial

PURPOSE

To compare three-dimensional conformal radiotherapy (3D-CRT) with intensity modulated radiation therapy (IMRT) in curative-intent irradiation of head-neck squamous cell carcinoma (HNSCC).

METHODS

Previously untreated patients with biopsy-proven squamous carcinoma of oropharynx, larynx, or hypopharynx (T1-3, N0-2b) were randomly assigned using computer-generated permuted-block design to either 3D-CRT or IMRT, with incidence of physician-rated Radiation Therapy Oncology Group (RTOG) grade 2 or worse acute salivary gland toxicity as primary end-point.

RESULTS

Between 2005 and 2008, 60 patients randomly allocated to either 3D-CRT (n=28 patients) or IMRT (n=32) were included and analyzed on an intention-to-treat basis. The proportion [95% confidence intervals (CI)] of patients with RTOG grade 2 or worse acute salivary gland toxicity was significantly lesser in the IMRT arm [19 of 32 patients (59%, 95%CI: 42-75%)] as compared to 3D-CRT [25 of 28 patients (89%, 95%CI: 72-97%; p=0.009)]. Late xerostomia and subcutaneous fibrosis were also significantly lesser with IMRT. There was significant recovery of salivary function over time in patients treated with IMRT (p-value for trend=0.0036). At 3-years, there were no significant differences in loco-regional control or survival between the two arms.

CONCLUSION

IMRT significantly reduces the incidence and severity of xerostomia compared to 3D-CRT in curative-intent irradiation of HNSCC.

Toxicity with radiotherapy for oral cancers and its management: a practical approach

Radiotherapy-induced damage in the oral mucosa is the result of the deleterious effects of radiation, not only on the oral mucosa itself but also on the skin, adjacent salivary glands, bone, dentition, and masticatory apparatus. From basic skin care to dental and oral health maintenance, several ointments and lotions, oral and parenteral medications, biological response modifiers, cytoprotective drugs, newer radiation techniques and surgery have been introduced to combat and more importantly to prevent the development of these complications. Radiotherapy-induced oral complications involve complex and dynamic pathobiological processes. This in the immediate- and long-term course lowers the quality of life and predisposes patients to serious clinical disorders. Here, we focus on these oral complications of radiotherapy, highlight preventive and therapeutic developments, and review the current treatment options available for these disorders.

Prospective analysis of reasons for non-enrollment in a phase III randomized controlled trial

AIM

This study aims to provide information on the accrual rate and to identify the reasons for non-enrollment of oral cancer patients into a clinical trial.

SETTING AND DESIGN

Prospective study conducted at the Tertiary Cancer Centre (India).

MATERIALS AND METHODS

Patients eligible and screened for the oral cancer adjuvant therapy (OCAT) were logged prospectively and reasons for non-enrollment were documented which were broadly divided into patient and trial related.

STATISTICAL ANALYSIS USED

Demographic characteristics of the non-enrolees were compared with the enrolled. Factors predicting non-enrollment were analyzed using multivariate logistic regression test.

RESULTS

A total of 1335 patients with locally advanced cancer of the oral cavity were screened of whom 498 (37%) could be enrolled. Among non enrolled 837 patients, 182 (22%) had the trial-related reasons and 655 (78%) had patient-related reasons. Most important patient-related reasons were patients' preference of taking treatment closer to their native place (26.2%), lack of interest (16.8%) in trial participation. Anticipated poor compliance to treatment (5.9%) and follow-up (6.6%), inability to start treatment in time (6.2%) were important trial-related reasons for non-enrollment. Multivariate analysis identified the genders (female), education (illiterate), occupation (laborer) and non availability of support system in the city as significant predictors of non-enrollment.

CONCLUSIONS

Both trial design and patient factors were important causes of non enrollment in eligible patients. Patients' need for being closer to home and refusal to participate were the most common reasons for non-enrollment.

Distant metastasis in head and neck cancer: Baseline factors

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Background: Loco-regional relapse is predominant pattern of failure in locally advanced head & neck squamous cell cancer (HNSCC). Distant metastasis (DM) is increasingly detected on follow-up. this study attempts to identify baseline patient, tumor & treatment characteristics which determine poor survival in radically treated HNSCC patients developing DM. Methods: Clinical outcome audit of HNSCC receiving radical treatment from 1990-2010 in a single HNCC radiotherapy (RT) clinic who developed DM, using electronic search of a prospectively maintained database. The Disease free survival (DFS) & overall survival (OS) were calculated using Kaplan Meier method. The Log rank test & Cox regression (p< 0.05 significant) were used for univariate & multivariate analysis respectively. Results: 104 HNC patients developed DM, baseline characteristics are shown in table 1. DM was detected at a median of 7(IQR 3-14) months from treatment completion & median survival after diagnosis of DM was 2.6 (0-6) months. The median DFS & OS were 19(13-26), 21.5(16-29) months respectively. On univariate analysis, factors affecting DFS & OS were advanced tumor and nodal stage, perinodal extension & treatment factors (surgery & RT gap >30 days). On multivariate analysis stage and PNE remained significant for DFS while only stage showed significance for OS. Conclusions: Locally advanced stage of presentation (stage IV, T4, N2+) is the most important baseline factor determining poor outcome in HNC patients developing DM. Trials for aggressive primary systemic treatment (chemotherapy, targeted agents) are needed. [Table: see text]

Treatment of Stage I Seminoma testis with extended field adjuvant radiation

With an aim to analyze and document the outcome of Stage I Seminoma patients we undertook a retrospective analysis of patients treated between January 1990 and December 1998. The treatment charts of patients treated between January 1990 and December 1998 were reviewed. Patient and tumor characteristics, treatment details, relapse rates, late toxicities, or occurrence of second primary was noted. Royal Marsden Staging System was utilized because of its simplicity and wide-use in the above period. Out of 137 patients, 41 (30%) patients did not receive any further treatment, 96 (70%) patients received prophylactic radiotherapy to para-aortic and pelvic nodes. The observation group patients had a median follow-up 20 months, 9 patients had nodal relapse with 7 in retroperitoneal nodes and 2 patients in inguinal nodes. Of these, 7 patients received BEP chemotherapy and 2 patients Chemoradiation. Four patients had complete remission while remaining 5 patients had partial response. The histopathologies of all the 5 patients with partial response were reviewed to reconfirm the diagnosis. Patients of prophylactic radiotherapy group had a follow-up of 33 months, 6 patients relapsed, RP nodal disease in 5 patients and distant metastasis in 1 patient. All these patients received BEP chemotherapy. One had complete response and remaining 5 patients had partial response. The group of patients under observation had a significantly higher relapse rate and lower disease free compared to the adjuvant radiotherapy group (73.5% vs. 91% at five years, p value 0.004). Disease specific survivals for the two groups were however similar (89% vs. 93%) at five years, p value 0.18). We conclude that Stage I Seminoma patients treated with prophylactic radiation to paraaortic and pelvic region had better outcome.

Dose variation during hypofractionated image-guided radiotherapy for prostate cancer: planned versus delivered

AIMS

To determine variation in the actual doses delivered to the organs at risk and the target in patients treated for localized carcinoma of the prostate using image-guided radiotherapy.

MATERIALS AND METHODS

Ten patients treated with helical TomoTherapy underwent daily target localization with megavoltage CT, on which the prostate, rectum and bladder were recontoured. The planned adaptive module was used for dose recalculation. The study endpoints were to analyse the variations in certain dose-volume parameters of the rectum and bladder (BD 2cc , RD 2cc , BV 100% , BV 70% , RV 100% , RV 70% ), the maximum anteroposterior (AP) and lateral rectal diameters, the volume of the CTV receiving 100% of the prescription dose (CTV V 100% ) and the dose to 100% of the CTV (CTV D 100% ).

RESULTS

The difference between the planned and delivered target doses (CTV V100% and CTV D100%) was small and clinically insignificant indicating adequate target coverage during treatment. There was a large variation in the AP and lateral rectal diameters, with no particular trend or correlation to dose parameters being noted during the course of treatment. The mean AP diameter during treatment was significantly less than the planned diameter (P < 0.05). The percentage of fractions where the delivered BV100%, BV70%, RV100%, and RV70% was more than the planned values were 42.8%, 17.1%, 45.4%, and 44.4%, respectively. The delivered BD2cc and RD2cc were similar to their planned values.

CONCLUSIONS

This study demonstrates the usefulness of daily soft tissue image guidance in negating the effects of physiological variation of the rectum and bladder on the dose delivered to the prostate.

Second primary head and neck squamous cell cancers with aggressive behavior in patients with chronic myeloid leukaemia

Patients with chronic myeloid leukaemia (CML) are at considerable risk of developing second primary neoplasms. However, mucosal squamous cell cancers (SCCs) of the head and neck have not been reported. We review the data of 7 patients with mucosal SCC of the head and neck that presented as metachronous second primary tumours in patients with CML. All 7 patients were men (median age 48 years, range 31-67) (site:oral cavity n=6, hypopharynx n=1). The median interval between diagnosis of CML and head neck cancer was 6 years (range 2-15). Treatment was curative in 4 and palliative in 3. At median follow up of 14 months (range 2-44), 3 patients had died of head and neck cancer, 1 of CML, and 3 were alive and free of disease. Mucosal cancers of the head and neck can occur in long-term survivors of CML. They are aggressive and tend to recur.

First-time-in-human study with GSK1018921, a selective GlyT1 inhibitor: relationship between exposure and dizziness

The pharmacokinetics (PK), safety, and tolerability of GSK1018921, a glycine transporter 1 (GlyT-1) inhibitor, were assessed in this first-time-in-human (FTIH) study. Single oral doses ranging from 0.5 to 280 mg and placebo were administered to 25 healthy subjects in a five-period, two-cohort, crossover study. GSK1018921 showed dose-proportional PK with a terminal half-life of ~17 h. The subjects reported dizziness with a dose-dependent frequency of 22-88% at doses of 70-280 mg. The time course of the dizziness paralleled the PK of the drug, with peak response at 2 h after the dose, consistent with time to maximum plasma concentration (T(max)). The dizziness was resolved by 10-12 h in all subjects. A Markov-chain logistic regression model was implemented in NONMEM to determine the probability of developing dizziness as a function of the plasma concentration of the compound. Frequency, onset (<1 h), and offset (4 h) were well described by the model. Exposure resulting in 80% receptor occupancy is predicted to be well tolerated.

Diagnostic performance of post-treatment FDG PET or FDG PET/CT imaging in head and neck cancer: a systematic review and meta-analysis

PURPOSE

Our objective was to conduct a systematic review and meta-analysis of studies assessing the diagnostic performance of (18)F-fluorodeoxyglucose positron emission tomography (FDG PET) with or without computed tomography (CT) in post-treatment response assessment and/or surveillance imaging of head and neck squamous cell carcinoma (HNSCC).

METHODS

A systematic search of the indexed medical literature was done using appropriate keywords to identify relevant studies. Metrics of diagnostic test accuracy, viz. sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were extracted from individual studies and combined using a random effects model to yield weighted mean pooled estimates with 95% confidence intervals (95% CI). The impact of timing of post-treatment scan, study quality and advancements in PET technology was explored through meta-regression.

RESULTS

A total of 51 studies involving 2,335 patients were included in the meta-analysis. The weighted mean (95% CI) pooled sensitivity, specificity, PPV and NPV of post-treatment FDG PET(CT) for the primary site was 79.9% (73.7-85.2%), 87.5% (85.2-89.5%), 58.6% (52.6-64.5%) and 95.1% (93.5-96.5%), respectively. Similar estimates for the neck were 72.7% (66.6-78.2%), 87.6% (85.7-89.3%), 52.1% (46.6-57.6%) and 94.5% (93.1-95.7%), respectively. Scans done ≥ 12 weeks after completion of definitive therapy had moderately higher diagnostic accuracy on meta-regression analysis using time as a covariate.

CONCLUSION

The overall diagnostic performance of post-treatment FDG PET(CT) for response assessment and surveillance imaging of HNSCC is good, but its PPV is somewhat suboptimal. Its NPV remains exceptionally high and a negative post-treatment scan is highly suggestive of absence of viable disease that can guide therapeutic decision-making. Timing of post-treatment imaging has a significant, though moderate impact on diagnostic accuracy.

Mucoepidermoid carcinoma of the parotid gland: factors affecting outcome

BACKGROUND

The purpose of this study was to identify the prognostic factors affecting the outcome in patients with mucoepidermoid carcinoma (MEC) of the parotid gland.

METHODS

A total of 113 patients with MEC who were treated between 1993 and 2002 were analyzed.

RESULTS

At median follow-up of 49 months (range, 1-143 months), disease-free survival (DFS) at 5 and 10 years was 84.6 and 84.6%, 80.7% and 67.3%, and 52.5% and 35.0% for low-grade, intermediate-grade, and high-grade tumors, respectively. Five-year and 10-year overall survival was 96.8% for low-grade tumors; 94.1% and 82.4%, respectively, for intermediate-grade tumors; and 73.3% for high-grade tumors. High-grade tumors and lymph node cancer-positive neck tumors strongly predicted poor locoregional control and DFS, while close or positive cut margins showed a trend toward poorer outcomes.

CONCLUSION

Histologic grade is the most important factor affecting outcome in parotid MEC. Adjuvant radiotherapy is recommended for high-grade tumors and should be tailored according to the expected risk of recurrence for low-grade and intermediate-grade tumors.

'Non-criteria' aPL tests: report of a task force and preconference workshop at the 13th International Congress on Antiphospholipid Antibodies, Galveston, TX, USA, April 2010

Abstract: Current classification criteria for definite APS recommend the use of one or more of three positive standardized laboratory assays, including anticardiolipin antibodies (aCL), lupus anticoagulant (LA), and antibodies directed to β(2)glycoprotein I (anti-β(2)GPI) to detect antiphospholipid antibodies (aPL) in the presence of at least one of the two major clinical manifestations (i.e., thrombosis or pregnancy morbidity) of the syndrome. Several other autoantibodies shown to be directed to phospholipids and/or their complexes with phospholipids and/or to proteins of the coagulation cascade, as well as a mechanistic test for resistance to annexin A5 anticoagulant activity, have been proposed to be relevant to APS. A task force of worldwide scientists in the field discussed and analyzed critical questions related to 'non-criteria' aPL tests in an evidence-based manner during the 13th International Congress on Antiphospholipid Antibodies (APLA 2010, 13-16 April 2010, Galveston, Texas, USA). This report summarizes the findings, conclusions, and recommendations of this task force.

Severe orthostatic hypotension in a diabetic patient may not be due to diabetic autonomic neuropathy

This lesson describes an unusual case of a man who was recently diagnosed with type 1 diabetes and who presented with severe orthostatic hypotension. As his diabetes was recent in onset, well controlled, and he had no other signs of microvascular disease, other causes of orthostatic hypotension were sought. His serum and cerebrospinal fluid were strongly positive for Borrelia burgdorferi IgG, suggesting a diagnosis of Lyme neuroborreliosis. Autonomic instability in Lyme, while rare, has been previously reported.

A 12-year-old boy presenting with unilateral proximal interphalangeal joint swelling

Pachydermodactyly is a rare and benign superficial dermal fibromatosis, characterised by asymptomatic soft tissue hypertrophy of the lateral and dorsal aspects of the proximal interphalangeal joints. The majority affected are males, with only a few reported female cases, and usually begins to develop around the age of puberty. Pachydermodactyly affects the second, middle and ring fingers of the hand symmetrically and bilaterally. The majority of reported cases demonstrate bilateral involvement of joints, only a small proportion report unilateral involvement. In this case report the authors review literature and discuss a case of pachydermodactyly presenting a unilateral swelling of the proximal interphalangeal joints of only the left hand in a right-handed young male.

Does Helical Tomotherapy Improve Dose Conformity and Normal Tissue Sparing Compared to Conventional IMRT? A Dosimetric Comparison in High Risk Prostate Cancer

The study was designed to compare Helical Tomotherapy (HT) based IMRT and conventional sliding window (SW IMRT) in patients with high risk prostate cancer. Complementary plans with HT and SWIMRT were compared using DVH parameters. The PTV Prostate was prescribed 74 Gy in 37 fractions and the nodal PTV received 55 Gy in 37 fractions by simultaneous integrated boost. Conformity Index, Homogeneity Index and dose-volume parameters were compared. The conformity index (CI) of HT (0.77, SD = 0.54) plans tended to be better (p = 0.069) compared to SWIMRT (0.70, SD = 0.01) for prostate PTV. CI for nodal PTV was similar. Helical tomotherapy plans were more homogeneous, with homogeneity index (HI) of 0.04 compared to 0.06 in SWIMRT (p = 0.018) for PTV prostate and HI of 0.06 and 0.15 (p = 0.025) for PTV nodes respectively. Median dose to bladder (p = 0.025) and rectum (p = 0.012) were less with HT. However, HT delivered a higher D10Gy and D1Gy to rectum and bladder overlap volumes as a consequence of achieving better homogeneity. Femoral heads were better spared with HT plans (p = 0.012). HT improves dose homogeneity, target coverage and conformity as compared to SWIMRT, with overall improvement in critical organ sparing.

Bladder preservation with helical tomotherapy-based, image-guided radiotherapy: A clinical study using “plan of the day” adaptive radiotherapy

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Background: This clinical study assessed the potential of helical tomotherapy-based, image-guided radiotherapy (IGRT) to increase the accuracy of bladder irradiation using a plan of the day adaptive radiotherapy (ART) technique.

Methods: Ten patients with stage T2b-T4- N0 M0, histologically proven bladder transitional cell carcinoma, who underwent bladder preservation with trimodality therapy in an ongoing trial, are reported. All patients received a dose of 64Gy/32# to the whole bladder. Seven of these also received a simultaneous integrated boost of 68Gy/32 fractions to tumor bed. The ART technique entailed the generation of six planning PTVs and thus six separate IMRT plans for each patient. All patients underwent daily pre and post treatment MVCT imaging to correct for positioning errors, choose the plan of the day, depending on deformation of the bladder, and verify intrafraction filling at the end of treatment. Margins needed to encompass the bladder wall in each direction during radiotherapy was determined in the following three scenarios: (a) centers with availability of daily IGRT and performing ART, (b) centers with IGRT not doing ART, and (c) centers without IGRT using electronic portal imaging for setup.

Results: At a median follow-up of 12.2 months, all patients had a complete response in the bladder and one patient had a pelvic nodal recurrence. No patient developed treatment related grade 3 toxicity. Post treatment MVCT scans (n=315) were used to generate margins for centers with varying resources. Overall, the margin needed to encompass the anterior and superior walls 85 to 95% of the time was more than the other walls (Table, margins for six walls in cm). Maximum geographical miss in spite of IGRT was noted for the superior (13.8%) and anterior walls (10.3%).

Conclusions: Plan of the day ART is a feasible and promising technique for optimal treatment and dose escalation in bladder cancer.

[Table: see text]

No significant financial relationships to disclose.

Objective assessment of swallowing function after definitive concurrent (chemo)radiotherapy in patients with head and neck cancer

The aim of this study was to objectively assess swallowing function and factors impacting it after curative intent definitive (chemo)radiotherapy (CRT) for head and neck squamous cell carcinoma (HNSCC). Swallowing function was studied in a cohort of 47 patients with locoregionally advanced (T1-4, N0-3) HNSCC treated with definitive CRT. Objective assessment of swallowing function was done using modified barium swallow (MBS) at baseline (pre-CRT) and subsequent follow-ups. Scoring of MBS was done using penetration-aspiration scale (PAS). Abnormal swallowing was defined in terms of incidence and severity of penetration-aspiration, pharyngeal residue, postural change, and regurgitation. Aspiration, residual, postural change, and regurgitation were present on baseline pre-CRT assessment in 9 (19%), 11 (23%), 10 (21%), and 5 (10%) patients that increased to 11 (29%), 11 (29%), 12 (32%), and 10 (26%) patients, respectively, at 6-month post-CRT evaluation. The proportion of patients with high PAS scores (3-7) increased from 27% at baseline to 37% at 6-month post-CRT evaluation. Among patients (n = 34) with low PAS scores (≤2) at baseline, additional impairment of swallowing function was seen in 53 and 46% at 2- and 6-month assessment, respectively. Residue (44%) and aspiration (18%) domains were impaired in a higher proportion of patients after CRT. Thin and thick barium had higher aspiration and residue function impairment, respectively. Patients with pre-CRT poor subjective swallowing function (P = 0.004), hypopharyngeal primary (P = 0.05), and large tumor volume (P = 0.05) had significantly worse objective swallowing function at baseline as demonstrated by pretreatment PAS scores. This study provides useful information regarding patterns of objective swallowing dysfunction in patients treated with definitive (chemo)radiotherapy. There is significant impairment of objective swallowing function in all domains following CRT, with residue and aspiration domains being affected most significantly.

Objective assessment of swallowing function after definitive concurrent (chemo)radiotherapy in patients with head and neck cancer

The aim of this study was to objectively assess swallowing function and factors impacting it after curative intent definitive (chemo)radiotherapy (CRT) for head and neck squamous cell carcinoma (HNSCC). Swallowing function was studied in a cohort of 47 patients with locoregionally advanced (T1-4, N0-3) HNSCC treated with definitive CRT. Objective assessment of swallowing function was done using modified barium swallow (MBS) at baseline (pre-CRT) and subsequent follow-ups. Scoring of MBS was done using penetration-aspiration scale (PAS). Abnormal swallowing was defined in terms of incidence and severity of penetration-aspiration, pharyngeal residue, postural change, and regurgitation. Aspiration, residual, postural change, and regurgitation were present on baseline pre-CRT assessment in 9 (19%), 11 (23%), 10 (21%), and 5 (10%) patients that increased to 11 (29%), 11 (29%), 12 (32%), and 10 (26%) patients, respectively, at 6-month post-CRT evaluation. The proportion of patients with high PAS scores (3-7) increased from 27% at baseline to 37% at 6-month post-CRT evaluation. Among patients (n = 34) with low PAS scores (≤2) at baseline, additional impairment of swallowing function was seen in 53 and 46% at 2- and 6-month assessment, respectively. Residue (44%) and aspiration (18%) domains were impaired in a higher proportion of patients after CRT. Thin and thick barium had higher aspiration and residue function impairment, respectively. Patients with pre-CRT poor subjective swallowing function (P = 0.004), hypopharyngeal primary (P = 0.05), and large tumor volume (P = 0.05) had significantly worse objective swallowing function at baseline as demonstrated by pretreatment PAS scores. This study provides useful information regarding patterns of objective swallowing dysfunction in patients treated with definitive (chemo)radiotherapy. There is significant impairment of objective swallowing function in all domains following CRT, with residue and aspiration domains being affected most significantly.

Squamous cell carcinoma of base of tongue in a patient with Fanconi's anemia treated with radiation therapy: case report and review of literature

BACKGROUND

Fanconi's anemia (FA) is a rare autosomal recessive genetic disorder characterized by congenital anomalies, progressive aplastic anemia, and a predisposition for malignancies. Solid tumors in the head and neck region, especially in the tongue, are rarely observed. Management of these patients is a challenge because of hematological complications and increased toxicities.

METHODS

We report a case of Fanconi's anemia in a 27-year-old man with carcinoma of the base of tongue (T2N0M0) who was treated with radical radiation therapy to a dose of 70 Gy/35 fractions/51 days. We have also done in vitro radiosensitivity tests.

RESULTS

The patient tolerated the radiation treatment well and completed it without any interruptions. In vitro studies did not show any increased radiosensitivity in this patient.

CONCLUSION

Head and neck cancer in a patient with FA requires individualized treatment. The decision about opting for different modalities should be based on a balanced approach with respect to locoregional control and toxicities of the treatment.

From two-dimensional to three-dimensional conformal radiotherapy in prostate cancer: an Indian experience

BACKGROUND

Sparse data from India are available regarding the outcome of prostate cancer treatment. We report our experience in treating prostate cancer with radiotherapy (RT).

MATERIALS AND METHODS

This study included 159 men with locally advanced cancer treated with RT with or without hormone therapy between 1984 and 2004. The median RT dose was 70 Gy over 35 fractions. Eighty-five patients received whole pelvic RT and prostate boost, and 74 patients were treated with 3-dimensional conformal radiotherapy (3DCRT) to prostate and seminal vesicles alone.

RESULTS

The median follow-up was 25 months and the freedom from biochemical failure for all the patients at 5 years was 76%, disease-free survival (DFS) 59.1%, and overall survival (OAS) was 70.1%. The risk stratification (91% vs 52%, P < 0.03) and RT dose (72.8% for dose > 66 Gy vs 43.5% for dose < 66 Gy; P = 0.01) affected the DFS. DFS at 5 years was better in the group receiving 3DCRT to prostate and seminal vesicles (78% vs 51.5%; P = 0.001) and was reflected in OAS as well (P = 0.01).

CONCLUSION

CRT technique with dose escalation results in significant benefit in DFS and OAS in locally advanced prostate cancer.

IMRT and IGRT in head and neck cancer: Have we delivered what we promised?

Intensity-modulated radiation therapy (IMRT) is a revolutionary new paradigm that aims at improving the therapeutic ratio by increasing the dosegradient between target tissues and surrounding normal structures thereby offering probability of better loco-regional control with decreased risk of complications. IMRT is relatively intolerant to set-up uncertainties, warranting periodic image-guidance, making Image-Guided Radiation Therapy (IGRT) a natural corollary to IMRT. There are several challenges associated with the planning, delivery, and quality assurance of the IMRT and IGRT processes that must be addressed to realize the full potential of such exciting and promising technology. Given the complexities involved, it is quite intuitive to understand that IMRT and IGRT are resource-intensive, demanding increased labor, rigour, and expenses too. Other disadvantages associated with high-precision techniques include potentially increased risk of marginal failures, decreased dose homogeneity, and an increase in total body dose with increased risk of secondary carcinogenesis. The aim of this review is to define the role of IMRT and IGRT in contemporary head and neck oncologic practice through a critical appraisal of pertinent literature. Despite relatively short follow-up and limited clinical outcomes data, the weight of evidence suggests that loco-regional control is not inferior (either comparable or even better) and toxicity lesser with IMRT resulting in potentially improved quality-of-life, prompting the widespread adoption of such technology in community practice. Ongoing clinical trials in head and neck IMRT are currently addressing issues to optimize the IMRT process, adopting functional imaging for dose-painting, and incorporating adaptive re-planning strategies to further improve outcomes.

Prognostic factors in oropharyngeal cancer--analysis of 627 cases receiving definitive radiotherapy

INTRODUCTION

The aim of this retrospective analysis was to analyze the results of conventional radical radiotherapy in the treatment of oropharyngeal cancer and to identify pre-treatment and treatment-related prognostic factors for outcome.

MATERIAL AND METHODS

The records of 627 patients with oropharyngeal cancer treated with radical radiotherapy with conventional techniques were analyzed.

RESULTS

The median age was 56 years. History of tobacco abuse was present in 80.5%. Eighty six percent had stage III or IV disease. Radical radiotherapy alone was the treatment modality for 71.2% and concomitant or neoadjuvant chemotherapy was used in 28.8%. The 3-year local control (LC), loco-regional control (LRC), disease-free survival (DFS) and overall survival (OS) was 49%, 40.6%, 38.9% and 36.1% respectively. The 3-year DFS rates were 80.3% for stage I, 65.8% for stage II, 46.1% for stage III and 25.2% for stage IV disease. Multivariate analysis was performed for prognostic factors. Prior history of tobacco abuse was an independent prognostic factor for both DFS and LRC. Karnofsky Performance Score (KPS) < 80, higher nodal stage, lower total radiotherapy dose (<66 Gy) in those receiving > 60 Gy, and overall treatment time > 50 days were other independent prognostic factors for inferior DFS and LRC. KPS < 80, higher T stage, higher nodal stage, RT dose < 66 Gy and longer overall treatment time (>50 days) were independent prognostic factors for poorer local control.

CONCLUSIONS

Several patient-, disease- and treatment-related variables independently affect survival outcomes after radical radiotherapy for oropharyngeal cancer. Oropharyngeal cancers in those without a history of tobacco abuse may be biologically different and more amenable to cure with radiotherapy.

Postoperative Radiotherapy in Head and Neck Cancer

Though early stage head and neck cancers can be cured either by surgery or radiation, patients with locally advanced disease continues to pose a therapeutic challenge. Locoregional failure is the major cause of death in head and neck cancers. As the outcome of locally advanced head and neck cancer is less than promising, a combined modality approach is generally undertaken in this group of patients. The combination of surgery, radiation and more recently, chemotherapy and targeted therapy can improve outcomes in locally advanced head and neck cancer patients. This overview discusses the rationale and role of postoperative radiotherapy (PORT) in advanced head and neck cancers, the radiotherapy technique in brief and methods of enhancing the efficacy of postoperative RT by altering the fractionation schedules and adding chemotherapy and targeted therapy.

Time trial: a prospective comparative study of the time-resource burden for three-dimensional conformal radiotherapy and intensity-modulated radiotherapy in head and neck cancers

INTRODUCTION

An ongoing institutional randomized clinical trial comparing three-dimensional conformal radiotherapy (3D CRT) and intensity-modulated radiotherapy (IMRT) provided us an opportunity to document and compare the time-manpower burden with these high-precision techniques in head and neck cancers.

MATERIALS AND METHODS

A cohort of 20 consecutive patients in the ongoing trial was studied. The radiotherapy planning and delivery process was divided into well-defined steps and allocated human resource based on prevalent departmental practice. Person-hours for each step were calculated.

RESULTS

Twelve patients underwent IMRT and eight patients had 3D CRT. The prerandomization steps (upto and including approval of contours) were common between the two arms, and expectedly, the time taken to complete each step was similar. The planning step was carried out postrandomization and the median times were similar for 3D CRT (312 min, 5.2 person-hours) and IMRT (325.6 min, 5.4 person-hours). The median treatment delivery time taken per fraction varied between the two arms, with 3D CRT taking 15.2 min (0.6 person-hours), while IMRT taking 27.8 min (0.9 person-hours) (P< 0.001). The total treatment time was also significantly longer in the IMRT arm (median 27.7 versus 17.8 person-hours, P< 0.001). The entire process of IMRT took 48.5 person-hours while 3D CRT took a median of 37.3 person-hours. The monitor units delivered per fraction and the actual "beam-on" time was also statistically longer with IMRT.

CONCLUSIONS

IMRT required more person-hours than 3D CRT, the main difference being in the time taken to deliver the step-and-shoot IMRT and the patient-specific quality assurance associated with IMRT.