Long Term Outcomes of Conventional Palliative Radiotherapy in Bone Metastases of Lung Cancer: A Prospective Study

PURPOSE/OBJECTIVE(S)

Bone metastases (BM) are highly prevalent in metastatic lung cancer (LC) leading to consequential morbidity and a decline in quality of life. The identification of oncogenes mutation and introduction of targeted therapy has prolonged the survival and therefore evaluation of long-term pain response rates, durability and re-irradiation (Re-RT) with conventional radiotherapy (RT) is crucial, especially in LMIC where penetration of stereotactic body radiotherapy for BM is poor.

MATERIALS/METHODS

This prospective observational study included consecutive patients with histologically proven LC with radiologically confirmed BM. The primary objective was to evaluate the pain response rates in lung cancer patients with bone metastases treated with palliative RT. Palliative RT to BM was delivered using a conventional/conformal technique. The International Bone Metastases Consensus response criteria using Numeric Pain Rating Scale (NPRS) and Oral Morphine Equivalent Dose (OMED) was used to evaluate the pain response at 12, 24, and 52 weeks. Assuming the worst-case scenario, pain progression-free survival (PPFS) was calculated from the date of baseline assessment to the date of pain progression (PP) or death using Kaplan-Meier survival analysis. Known prognostic factors were evaluated using Cox regression analysis.

RESULTS

From June 2020 to August 2022, 250 patients of NSCLC (94%) were accrued. The majority were male (66%), smokers (35%), lytic lesions (75%) and in the axial skeleton (82%). The oncogenic mutation was seen in 123 (49%) patients. At baseline, the mean OMED was 20mg/day (SD-21), and the mean pain score was 6 (SD-2.3). The majority (66%) received an 8 Gy single fraction with only 3% treated with SBRT. In evaluable patients, the CR and PR rates at 12 (n-161) and 24 weeks (n-121) were 34%, 40%, and 44%, 35% respectively. The indeterminate response rate (IRR) at 3 and 6 months were 18% while the rate of PP was 6%. On multivariate analysis, negative oncogene mutation {HR-0.34 (CI 0.22- 0.50), p<0.0001} and soft tissue mass {HR-0.46 (CI 0.31- 0.68) p<0.0001} were significant prognostic factors for pain progression. Of 71 evaluable patients at 1 year, 56% had a complete response with an ORR of 87%. In patients with oncogene mutation, the CR rates at 12 (n-101), 24 (n-77), and 52 weeks were 40%, 47%, and 60% with an ORR of 86%. PP is observed in less than 4%. Pain response was significantly more durable than mutation negative (8 vs 3 months, p-0.003). Re-RT rate was overall 11% (n = 27) and 8.2% in oncogene mutation patients. Re-RT rate with single-fraction was 8% and 3% with fractionated RT. The median time to Re-RT was 9.7 weeks. The PPFS was 70% and 60% at 12 and 24 weeks, respectively.

CONCLUSION

This prospective study in an LC-specific population demonstrated excellent CR and PR rates with conventional RT. Durable pain relief with modest Re-RT rates with single fraction, particularly in oncogene mutation compels us to evaluate the role of SBRT for BM, especially in LMIC in a randomized setting.

Deep learning based automated epidermal growth factor receptor and anaplastic lymphoma kinase status prediction of brain metastasis in non-small cell lung cancer

Aim

The aim of this study was to investigate the feasibility of developing a deep learning (DL) algorithm for classifying brain metastases from non-small cell lung cancer (NSCLC) into epidermal growth factor receptor (EGFR) mutation and anaplastic lymphoma kinase (ALK) rearrangement groups and to compare the accuracy with classification based on semantic features on imaging.

Methods

Data set of 117 patients was analysed from 2014 to 2018 out of which 33 patients were EGFR positive, 43 patients were ALK positive and 41 patients were negative for either mutation. Convolutional neural network (CNN) architecture efficient net was used to study the accuracy of classification using T1 weighted (T1W) magnetic resonance imaging (MRI) sequence, T2 weighted (T2W) MRI sequence, T1W post contrast (T1post) MRI sequence, fluid attenuated inversion recovery (FLAIR) MRI sequences. The dataset was divided into 80% training and 20% testing. The associations between mutation status and semantic features, specifically sex, smoking history, EGFR mutation and ALK rearrangement status, extracranial metastasis, performance status and imaging variables of brain metastasis were analysed using descriptive analysis [chi-square test (χ2)], univariate and multivariate logistic regression analysis assuming 95% confidence interval (CI).

Results

In this study of 117 patients, the analysis by semantic method showed 79.2% of the patients belonged to ALK positive were non-smokers as compared to double negative groups (P = 0.03). There was a 10-fold increase in ALK positivity as compared to EGFR positivity in ring enhancing lesions patients (P = 0.015) and there was also a 6.4-fold increase in ALK positivity as compared to double negative groups in meningeal involvement patients (P = 0.004). Using CNN Efficient Net DL model, the study achieved 76% accuracy in classifying ALK rearrangement and EGFR mutations without manual segmentation of metastatic lesions. Analysis of the manually segmented dataset resulted in improved accuracy of 89% through this model.

Conclusions

Both semantic features and DL model showed comparable accuracy in classifying EGFR mutation and ALK rearrangement. Both methods can be clinically used to predict mutation status while biopsy or genetic testing is undertaken.

Challenges in the Sustainability of Brachytherapy Service in Contemporary Radiotherapy

Brachytherapy has a long history of delivering a highly conformal radiation dose to the target volume with sparing of adjacent normal tissue and has an irreplaceable role in certain cancers, such as cervical and prostate cancers. There have been futile attempts to replace brachytherapy with other radiation techniques. Despite that there are multifaceted challenges in preserving this dying art, from establishment, to a trained workforce, to maintenance of the equipment and source replacement costs. Here we focus on the challenges to access brachytherapy, the availability and distribution of care across the globe and appropriate training leading to proper implementation of the procedure. Brachytherapy holds a significant place in the treatment armamentarium of most common cancers, such as cervical, prostate, head and neck and skin cancers. However, there is an uneven distribution of brachytherapy facilities, not only across the globe, but also at a national level, with a larger proportion of facilities concentrated in certain regions, more so in low and low-middle income countries. The regions with the highest incidence of cervical cancer have the least access to brachytherapy facilities. Attempts to bridge the gap are essential and should be focused on uniform distribution and access to care, improving training of the workforce through specialised training programmes, reducing the cost of care, planning to reduce the recurring cost, generating evidence and research guidelines, renewing interest in brachytherapy through rebranding, use of social media and building an attainable long-term roadmap.

Salvage radiotherapy for postoperative locoregional failure in esophageal cancer: a systematic review and meta-analysis

Locoregional recurrences following surgery for esophageal cancers represent a significant clinical problem with no standard recommendations for management. We conducted this systematic review and meta-analysis with the objective of studying safety and efficacy of salvage radiotherapy in this setting. All prospective and retrospective cohort studies, which studied patients who developed locoregional recurrence following initial radical surgery for esophageal cancer and subsequently received salvage radiation therapy (RT)/chemoradiation with all relevant information regarding survival outcome and toxicity available, were included. The quality of eligible individual studies was assessed using the Newcastle-Ottawa Scale score for risk of bias. R package MetaSurv was used to obtain a summary survival curve from survival probabilities and numbers of at-risk patients collected at various time points and to test the overall heterogeneity using the I2 statistic. Thirty studies (27 retrospective, 3 prospective) published from 1995 to 2020 with 1553 patients were included. The median interval between surgery and disease recurrence was 12.5 months. The median radiation dose used was 60 Gy and 57% received concurrent chemotherapy. The overall incidence of acute grade 3/4 mucositis and dermatitis were 8 and 4%, respectively; grade 3/4 acute pneumonitis was reported in 5%. The overall median follow-up of all studies included was 27 months. The 1-, 2- and 3-year overall survival (OS) probabilities were 67.9, 35.9 and 30.6%, respectively. Factors which predicted better survival on multivariate analysis were good PS, lower group stage, node negativity at index surgery, longer disease-free interval, nodal recurrence (as compared to anastomotic site recurrence), smaller disease volume, single site of recurrence, RT dose >50 Gy, conformal RT, use of concomitant chemotherapy and good radiological response after radiotherapy. Salvage radiotherapy with or without concomitant chemotherapy for locoregional recurrences after surgery for esophageal cancer is safe and effective. Modern radiotherapy techniques may improve outcomes and reduce treatment-related morbidity.

Post-cricoid and Upper Oesophagus Cancers Treated with Organ Preservation Using Intensity-modulated Image-guided Radiotherapy: a Phase II Prospective Study of Outcomes, Toxicity and Quality of Life

AIMS

To prospectively examine the outcomes, toxicity and quality of life (QoL) of patients with post-cricoid and upper oesophagus (PCUE) cancers treated with an organ-preservation approach of (chemo)-radiotherapy using intensity-modulated image-guided radiotherapy (IM-IGRT).

MATERIALS AND METHODS

This phase II prospective study was conducted at a tertiary cancer centre from February 2017 to January 2020. Forty patients with squamous cell carcinoma of PCUE of stage T1-3, N0-2, M0 were accrued. Gross exolaryngeal extension/dysfunctional larynx were major exclusion criteria. Patients received 63-66 Gy in once-daily fractions using volumetric modulated arc therapy with daily IGRT. Outcome measures included disease-related outcomes, patterns of failure, Radiation Therapy Oncology Group toxicities, feeding tube dependency and QoL.

RESULTS

The median follow-up was 22 months. Twenty-six (87.5%) patients had locoregionally advanced disease and 34 (85%) patients received (chemo)-radiotherapy. A complete response was observed in 26 (65%) patients. The 2-year locoregional control, event-free survival and cause-specific survival were 59.6%, 40.2% and 44.8%, respectively. The volume of primary tumour (GTVPvol) exceeding 28 cm³ had inferior overall survival (P = 0.005) on univariate analysis. Multivariable analysis showed GTVPvol and positron emission tomography-computed tomography maximum standardised uptake value to be independently predictive for event-free and overall survival. A feeding tube requirement at presentation was seen in 11 (27.5%) patients, whereas long-term feeding tube dependency at 6 months was seen in 10 (37%) patients. For QoL, a statistical improvement in pain, appetite loss and swallowing was observed over time.

CONCLUSION

Although the outcomes of PCUE cancers remain dismal, the use of state of the art diagnostic modalities, careful case selection and modern radiotherapy techniques improved outcomes as compared with before in this exclusive analysis of PCUE cancers.

South Asian Declaration-Consensus Guidelines for COVID-19 Vaccination in Cancer Patients

We provide the South Asian Declaration, containing the consensus guidelines for coronavirus disease 2019 (COVID-19) vaccination in cancer patients.

Evolving multidisciplinary treatment of squamous cell carcinoma of the head and neck in India✰

In this article, we highlight the evolution of a multimodal approach in the overall management of squamous cell carcinoma of the head and neck (SCCHN) in India; present advances in technology (newer surgical techniques), novel medical and radiotherapy (RT) approaches; review their roles for an integrated approach for treating SCCHN and discuss the current role of immunotherapy in SCCHN. For locally advanced (LA) SCCHN, the multidisciplinary approach includes surgery followed by RT, with or without chemotherapy (CT) or concurrent chemoradiotherapy. Improved surgical techniques of reconstruction and voice-preservation are being implemented. Advanced forms of high-precision conformal techniques like intensity-modulated radiotherapy are used to deliver highly conformal doses to tumors, sparing the surrounding normal tissue. Compared with RT alone, novel CT regimens and targeted therapeutic agents have the potential to improve locoregional control and survival and reduce treatment-induced toxicities. Several clinical trials have demonstrated efficacy, safety, and quality of life benefits of adding cetuximab to RT regimens in LASCCHN. Studies have also suggested a cetuximab-related laryngeal preservation benefit. At progression, platinum-based CT combined with cetuximab (a monoclonal anti-epidermal growth factor receptor antibody) is the only validated option available as the first-line therapy. Thus, an integrated multidisciplinary approach plays a key role in maximizing patient outcomes, reduction in treatment related morbidities that consequently impact quality of life of survivors.

Treatment planning comparison of volumetric modulated arc therapy employing a dual-layer stacked multi-leaf collimator and helical tomotherapy for cervix uteri

Purpose

To ascertain the dosimetric performance of a new delivery system (the Halcyon system, H) equipped with dual-layer stacked multi-leaf collimator (MLC) for risk-adapted targets in cervix uteri cancer patients compared to another ring-based system in clinical operation (Helical Tomotherapy, HT).

Methods

Twenty patients were retrospectively included in a treatment planning study (10 with positive lymph nodes and 10 without). The dose prescription (45Gy to the primary tumour volume and a simultaneously integrated boost up to 55Gy for the positive patients) and the clinical planning objectives were defined consistently as recommended by an ongoing multicentric clinical trial. Halcyon plans were optimised for the volumetric modulated arc therapy. The plan comparison was performed employing the quantitative analysis of the dose-volume histograms.

Results

The coverage of the primary and nodal target volumes was comparable for both techniques and both subsets of patients. The primary planning target volume (PTV) receiving at least 95% of the prescription isodose ranged from 97.2 ± 1.1% (node-negative) to 99.1 ± 1.2% (node-positive) for H and from 96.5 ± 1.9% (node-negative) to 98.3 ± 0.9% (node-positive) for HT. The uncertainty is expressed at one standard deviation from the cohort of patient per each group. For the nodal clinical target volumes, the dose received by 98% of the planning target volume ranged 55.5 ± 0.1 to 56.0 ± 0.8Gy for H and HT, respectively. The only significant and potentially relevant differences were observed for the bowels. In this case, V_40Gy resulted 226.3 ± 35.9 and 186.9 ± 115.9 cm³ for the node-positive and node-negative patients respectively for Halcyon. The corresponding findings for HT were: 258.9 ± 60.5 and 224.9 ± 102.2 cm³. On the contrary, V_15Gy resulted 1279.7 ± 296.5 and 1557.2 ± 359.9 cm³ for HT and H respectively for node-positive and 1010.8 ± 320.9 versus 1203.8 ± 332.8 cm³ for node-negative.

Conclusion

This retrospective treatment planning study, based on the dose constraints derived from the Embrace II study protocol, suggested the essential equivalence between Halcyon based and Helical Tomotherapy based plans for the intensity-modulated rotational treatment of cervix uteri cancer. Different levels of sparing were observed for the bowels with H better protecting in the high-dose region and HT in the mid-low dose regions. The clinical impact of these differences should be further addressed.

Oral Cavity Cancer in the Indian Subcontinent - Challenges and Opportunities

Oral cavity cancer (OCC) poses a global challenge that plagues both the Orient and the Occident, accounting for an estimated 350 000 new cases and 177 000 deaths in 2018. OCC is a major public health problem in the Indian subcontinent, where it ranks among the top three cancer types in both incidence and mortality. Major risk factors are the use of tobacco, betel quid and alcohol consumption. OCC is a heterogeneous group of multiple histologies that affects multiple subsites. The oral cavity includes the lips, buccal mucosa, teeth, gingiva, anterior two-thirds of the tongue, floor of the mouth and hard palate. OCC is defined as cancer of lips, mouth and tongue as defined by the International Classification of Diseases coding scheme. The epidemiology, aetio-pathogenesis and treatment philosophy are similar within this group. Although salivary gland malignancies, sarcomas, mucosal melanomas and lymphomas can also arise within the oral cavity, this review will focus on squamous cell cancer, which is the predominant histology in OCC. We review and contrast data from developing and developed countries. We also highlight the unique regional challenges that countries in the East face; citing India as an example, we elaborate on the opportunities and scope for improvement in the management of OCC.

An Audit for Radiotherapy Planning and Treatment Errors From a Low-Middle-Income Country Centre

AIMS

To report the findings of an audit for radiotherapy errors from a low-middle-income country (LMICs) centre. This would serve as baseline data for radiotherapy error rates, their severity and causes, in such centres where modern error reporting and learning processes still do not exist.

MATERIALS AND METHODS

A planned cross-sectional weekly audit of electronic radiotherapy charts at the radiotherapy planning and delivery step for all patients treated with curative intent was conducted. Detailed analysis was carried out to determine the step of origin of error, time and contributing factors. They were graded as per indigenous institutional (TMC) radiotherapy error grading (TREG) system and the contributing factors identified were prioritised using the product of frequency, severity and ease of detection.

RESULTS

In total, 1005 consecutive radically treated patients' charts were audited, 67 radiotherapy errors affecting 60 patients, including 42 incidents and 25 near-misses were identified. Transcriptional errors (29%) were the most common type. Most errors occurred at the time of treatment planning (59.7%), with "plan information transfer to the radiation oncology information system" being the most frequently affected sub-step of the radiotherapy process (47.8%). More errors were noted at cobalt units (52/67; 77.6%) than at linear accelerators. Trend analysis showed an increased number of radiotherapy incidents on Fridays and near-misses on Mondays. Trend for increased radiotherapy errors noted in the evening over other shifts. On severity grading, most of the errors (54/60; 90%) were clinically insignificant (grade I/II). Inadequacies and non-adherence towards standard operating procedures, poor documentation and lack of continuing education were the three most prominent causes.

CONCLUSION

Preliminary data suggest a vulnerability of LMIC set-up to radiotherapy errors and emphasises the need for the development of longitudinal prospective processes, such as voluntary reporting and a continued education system, to ensure robust and comprehensive safe practises on par with centres in developed countries.

Solitary pulmonary nodule evaluation in regions endemic for infectious diseases: Do regional variations impact the effectiveness of fluorodeoxyglucose positron emission tomography/computed tomography

BACKGROUND

Fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) has become a preferred imaging modality for the evaluation of solitary pulmonary nodule (SPN), particularly in the developed world. Since FDG can concentrate in infective/inflammatory lesions, the diagnostic utility of FDG-PET can be questioned, particularly in regions endemic for infectious decisions.

AIM

To evaluate the accuracy of FDG-PET/CT in evaluation of SPNs in a population endemic for infectious disease and to assess if regional variations have an impact on its effectiveness.

MATERIALS AND METHODS

All patients who underwent an FDG/PET-CT with a clinico-radiological diagnosis of SPN categorized as indeterminate were included. Based on a maximum standardized uptake values (SUVmax) cut-off of 2.5, lesions were classified as benign (<2.5) or malignant (>2.5) and compared with gold standard histopathology. The diagnostic accuracy of PET-CT to detect malignancy was calculated. On the basis of final histopathology, lesions were grouped as (a) malignant nodules (b) infective/granulomatous nodules with a specific diagnosis and (c) nonspecific inflammatory nodules. The SUVmaxbetween these groups was compared using nonparametric statistical tests.

RESULTS

A total of 191 patients (129 males, 62 females) with a median age of 64 years (range: 36-83) were included. Totally, 144 nodules (75.3%) were malignant and 47 were benign (24.7%). Adenocarcinoma (n = 84) was the most common malignancy. Tuberculosis (n = 16) and nonspecific infections (n = 24) were the two most common benign pathologies. There was a significant overlap in the metabolic uptake of malignant (median SUVmax-11.2, range: 3.3-34.6) and tuberculous nodules (median SUVmax-10.3, range: 2.7-22.5) with no statistically difference between their SUVmaxvalues (P = 0.43). The false-positive rate was 65.2% and the false-negative rate was 5.5%. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of FDG-PET/CT for detecting malignancy were 94.4%, 34.7%, 81.9%, 66.6%, and 79.5%, respectively.

CONCLUSIONS

Though FDG-PET scans show a very high sensitivity for malignant nodules, it has a high false-positive rate and reduced specificity when characterizing SPNs in an infectious endemic region. Physicians must be aware of this limitation in the workup of lung nodules, and regional variations must be considered before further management decisions are taken.

Applying the QUARTZ Trial Results in Clinical Practice: Development of a Prognostic Model Predicting Poor Outcomes for Non-small Cell Lung Cancers with Brain Metastases

AIMS

The role of whole brain radiotherapy (WBRT) in patients with brain metastases from non-small cell lung cancers (NSCLC) has been questioned. However, no reliable criteria exist to identify patients who do not benefit from WBRT. The objective of the current study was to develop a prognostic model to identify such patients whose survival matches that of the Quality of Life after Treatment for Brain Metastases (QUARTZ) study.

MATERIALS AND METHODS

Outcome data of patients with NSCLC with brain metastases undergoing WBRT enrolled in a prospective observational study in a tertiary cancer centre were used to develop a prognostic model. Baseline clinico-radiological factors were used for development of the model. The model was internally validated and calibration accuracy was checked for prediction of 70 day mortality. The generated prognostic model was presented as a nomogram.

RESULTS

The median overall survival of 140 patients enrolled in the study was 166 days (95% confidence interval 108-242 days). The prognostic model identified gender, Karnofsky performance status and epidermal growth factor receptor activating mutation status as significant factors influencing overall survival. The model showed a modest discriminative ability with an optimism-corrected C-index of 0.64. However, model calibration error did reveal a moderate degree of calibration error. The high-risk subgroup identified by the model had a median overall survival of 67 days (95% confidence interval 56-101 days), which was similar to that observed in the QUARTZ trial.

CONCLUSION

This prognostic model derived from traditional clinico-radiological features had a modest ability to identify patients with poor prognosis who may not benefit from WBRT. However, the high-risk subgroup identified using this prognostic model had a survival similar to that observed for patients in the QUARTZ trial.

A comparative analysis of immunohistochemistry and fluorescent in situ hybridization assay to detect anaplastic lymphoma kinase status in lung adenocarcinoma cases: A search for a testing algorithm

INTRODUCTION

Testing for echinoderm microtubule-associated protein-like 4 (EML4) anaplastic lymphoma kinase (ALK) translocation by fluorescence in situ hybridization (FISH) is well established whereas the Food and Drug Administration (FDA) ALK immunohistochemical (IHC) test is relatively new.

AIMS AND OBJECTIVE

The aim of this study is to compare FDA-approved ALK IHC test (D5F3 clone) with the standard ALK FISH test.

MATERIALS AND METHODS

A validation and a test arm with 100 and 200 cases of Formalin-Fixed, Paraffin-embedded blocks of lung adenocarcinoma, respectively, comprised the material. All cases had ALK IHC test on automated Ventana Benchmark XT IHC slide stainer using anti-ALK D5F3 rabbit monoclonal primary antibody; when positive tumor cells (any percentage) showed strong granular cytoplasmic staining. For the FISH test, Vysis ALK Dual Color Break Apart Rearrangement Probe (Abbott Molecular Inc.,) was used to detect ALK gene 2p23 rearrangements; when positive the red and green signals were split two signal diameter apart and/or isolated 3'red signal were detected in more than 15% tumor cells. The ALK FISH results were available in all 100 validation cases and 64-test arm cases which formed the basis of this analysis.

RESULTS

The ALK IHC test was positive in 16% cases; four discordant cases were ALK IHC positive but ALK FISH negative, but no case was ALK IHC negative and ALK FISH positive. There was 100% sensitivity, 90.5% specificity, and 93.75% accuracy.

CONCLUSION

A negative ALK IHC result obviates the need for a FISH test barring those with a strong clinical profile, and a positive ALK IHC result is sufficient basis for the initiation of treatment.

A prospective study of telephonic contact and subsequent physical follow-up of radically treated lung cancer patients

BACKGROUND

We tested the hypothesis that telephonic follow-up (FU) may offer a convenient and equivalent alternative to physical FU of radically treated lung cancer patients.

DESIGN

Prospective study carried out at a tertiary referral cancer care institute, Mumbai.

MATERIALS AND METHODS

Two hundred consecutive lung cancer patients treated with curative intent were followed up regularly with telephonic interviews paired with their routine physical FU visits. Patient satisfaction with the telephonic call and the physical visit, the anxiety level of the patient after meeting the physician and the economic burden of the visit to the patient were noted in a descriptive manner. Kappa statistics was used to assess concurrence between the telephonic and physical impression of disease status.

RESULTS

With a median FU duration of 21.5 months, the median satisfaction scores for telephonic and physical FU were 8 and 9, respectively. The prevalence and bias adjusted kappa (PABAK) score of the entire cohort of patients was 0.64 (95% confidence interval [CI] =0.58-0.70). Data analyzed up to first disease progression/relapse on FU had a PABAK score of 0.71 (95% CI = 0.64-0.77) indicating substantial agreement. Patients with disease controlled at the FU had a significant PABAK score of 0.88 (95% CI = 0.80-0.94) indicating excellent concurrence. On average, each patient spent Rs. 5117.10 on travel and Rs. 3079.06 on lodging per FU visit.

CONCLUSION

Telephonic FU is substantially accurate in assessing disease status until the first relapse. In a resource-constrained country like India, it is worthwhile to further explore the benefits of such an alternative strategy.

Barriers in conducting clinical trials in oncology in the developing world: A cross-sectional survey of oncologists

BACKGROUND

Several obstacles impede oncologists from performing clinical trials in the developing world. This study aimed to identify these barriers in order of importance and suggest possible remedial measures.

MATERIALS AND METHODS

Design - cross-sectional survey. Two part questionnaire capturing experience of oncologists in practice and conducting trials (Part 1) and perceived barriers pertaining to investigator (training, time), patient (strict follow-up protocol), infrastructure (funds) and professional environment (encouragement from seniors) (Part 2) were administered to oncologists in two different settings: (1) Online portal (Survey Monkey) (2) In person during a national conference (Best of American Society of Clinical Oncology). Responses were captured on a Likert scale (1-5).

RESULTS

(436/3021) 14.04% responded. A total of 313 (71.8%) had experience in conducting trials, but these were mainly industry-sponsored or small nonpractice changing studies. Lack of patient follow-up was the most significant barrier (inter quartile range [IQR] 4-5) followed by inadequate training, time and funds (IQR 2-5) and lack of encouragement (IQR 2-4) in decreasing order of frequency. Lack of adequate training was a barrier across all specialties (113 [71.97%] radiation oncologists, 71 [60.68%] medical oncologists and 73 [71.56%] surgical oncologists). More than half of the respondents without experience in clinical trials worked in academic institutions (50.48%). They perceived time constraint as a barrier more than their counterparts into private practice (175/242 [72.31%] vs. 119/177 [66.47%] respectively).

CONCLUSION

Inability to maintain patient follow-up, lack of protected time and funds, inadequate training were the most significant barriers. Most of these can be addressed.

Optimizing treatment and analysis of prognostic factors for locally advanced nonsmall cell lung cancer in resource-limited population

BACKGROUND

Lung cancer most commonly presents in advanced stages in developing countries, where combined modality treatment using chemo-radiotherapy (CTRT) is the standard of care.

MATERIALS AND METHODS

A retrospective audit of patients of nonsmall cell lung cancer (NSCLC) treated at a single Institute from January 2008 to December 2012 was conducted. Various prognostic factors affecting disease-free survival (DFS) and overall survival (OS) were studied by univariate and multivariate analysis. All patients were meticulously followed-up clinically and telephonic contacts.

RESULTS

Overall 171 patients of NSCLC were treated with definitive CTRT using concurrent chemotherapy in 66% patients and sequential therapy in 28% patients. The actuarial 2 years DFS was 17.5% and 2 years OS was 61.5%. Complete response to treatment resulted in significantly better DFS and OS. Definitive CTRT was very well-tolerated in these patients with good compliance.

CONCLUSION

Definitive CTRT, sequence being individualized depending on performance status and disease stage at presentation, is a feasible and effective treatment modality for locally advanced NSCLC patients in the developing world. Response to treatment is an important prognostic factor for treatment outcomes.

Thymic epithelial tumors: Can fluorodeoxyglucose positron emission tomography help in predicting histologic type and stage?

OBJECTIVES

To study the utility of fluorodeoxyglucose (FDG) positron emission tomography (PET) in predicting (1) the World Health Organization (WHO) histologic type and differentiating low-risk from high-risk types. (2) Tumor stage and differentiate early from advanced stage disease.

MATERIALS AND METHODS

Patients with thymic epithelial neoplasia who underwent a pretreatment FDG-PET study were included. Tumor maximum standardized uptake value (SUVmax) was correlated with the WHO histologic type and also with the Masaoka-Koga (MK) staging system. Patients with WHO Type A, AB, and B1 were classified as low risk and those with B2 and B3 as high risk. Thymic carcinomas belonged to Type C. Patients with MK Stage I and II disease were grouped as early stage and those with Stage III and IV as an advanced stage. Differences in SUVmax between the various groups were calculated.

RESULTS

The SUVmax of thymic carcinomas was significantly higher as compared to low-risk (P = 0.001) and high-risk groups (P = 0.007). The SUVmax of high-risk group was also significantly higher than the low-risk group (P = 0.002). SUVmax cutoff of 6.5 was able to differentiate thymic carcinomas from thymomas with 100% sensitivity and 87.2% specificity. The SUVmax in patients with advanced stage disease showed a higher trend compared to those with early stage, but the difference was not significant (P = 0.167).

CONCLUSION

PET can differentiate thymic carcinomas from rest of the thymoma subtypes by the virtue of their higher FDG uptake. It can also provide valuable information in differentiating high-risk from low-risk thymomas and in predicting disease stage.

Practice of stereotactic body radiotherapy in a developing country: Perception, aspiration, and limitation - A survey

BACKGROUND

Stereotactic body radiotherapy (SBRT) is an effective and established modern technology now used more commonly. Radiation oncology personnel's (ROP) opinion toward SBRT in the developing countries like India is unknown.

SUBJECTS AND METHODS

A 30 question survey evaluating ROP's profile, technological details, and SBRT's perceptive were seeked. Tata Memorial Center - ROP's email database was used.

RESULTS

Survey questionnaire was emailed to 500 ROP's and 224 ROP's were contactable. Majority of the responders were from corporate hospitals and half of responders had experience of 5 or more years of experience in radiation oncology. SBRT was practiced by 70% of responders and the majority had adopted SBRT in 2010 or later. Quick turn around time, high dose delivery and competitive market forces were major factors to adopt SBRT. Lung was the most common site practiced followed by prostate, spine, and liver. All SBRT users were keen to increase SBRT in practice and the majority of non-responders were planning to adapt SBRT in the recent future. Almost half of SBRT users were willing to share data and expertise for training others. Lack of infrastructure was the prime reason for not practicing SBRT. ROP's perceived physics, radiobiology as the biggest challenge in SBRT. International collaboration may be helpful.

CONCLUSION

Use of SBRT is expected to increase in India. Limited experience with lack of infrastructure in public funded centers is a major limitation. Unmet need of infrastructure, training and guidelines is enormous and formulation of Indian SBRT consortium will help reforming at all levels.

Fluorodeoxyglucose-positron emission tomography in carcinoma nasopharynx: Can we predict outcomes and tailor therapy based on postradiotherapy fluorodeoxyglucose-positron emission tomography?

BACKGROUND

Positron emission tomography-computed tomography (PET-CT) is an emerging modality for staging and response evaluation in carcinoma nasopharynx. This study was conducted to evaluate the impact of PET-CT in assessing response and outcomes in carcinoma nasopharynx.

MATERIALS AND METHODS

Forty-five patients of nonmetastatic carcinoma nasopharynx who underwent PET-CT for response evaluation at 10-12 weeks posttherapy between 2004 and 2009 were evaluated. Patients were classified as responders (Group A) if there was a complete response on PET-CT or as nonresponders (Group B) if there was any uptake above the background activity. Data regarding demographics, treatment, and outcomes were collected from their records and compared across the Groups A and B.

RESULTS

The median age was 41 years. 42 out of 45 (93.3%) patients had WHO Grade 2B disease (undifferentiated squamous carcinoma). 24.4%, 31.1%, 15.6, and 28.8% patients were in American Joint Committee on Cancer Stage IIb, III, Iva, and IVb. All patients were treated with neoadjuvant chemotherapy followed by concomitant chemoradiotherapy. Forty-five patients, 28 (62.2%) were classified as responders, whereas 17 (37.8%) were classified as nonresponders. There was no significant difference in the age, sex, WHO grade, and stage distribution between the groups. Compliance to treatment was comparable across both groups. The median follow-up was 25.3 months (759 days). The disease-free survival (DFS) of the group was 57.3% at 3 years. The DFS at 3 years was 87.3% and 19.7% for Group A and B, respectively (log-rank test, P < 0.001). Univariate and multivariate analysis revealed Groups to be the only significant factor predicting DFS (P value 0.002 and < 0.001, respectively). In Group B, the most common site of disease failure was distant (9, 53%).

CONCLUSION

PET-CT can be used to evaluate response and as a tool to identify patients at higher risk of distant failure. Further, this could be exploited to identify patients who may need treatment intensification. This needs to be validated prospectively.

Prognostic Performance of Current Stage III Oral Cancer Patients After Curative Intent Resection: Evidence to Support a Revision of the American Joint Committee on Cancer Staging System

BACKGROUND

The American Joint Committee on Cancer (AJCC) stage III classification of oral cavity squamous cell carcinoma (OCSCC) represents a heterogeneous group of patients with early local disease with regional metastases (T1N1 and T2N1) and advanced local disease with or without regional metastasis (T3N0 and T3N1).

OBJECTIVE

The aim of this study was to evaluate prognostic heterogeneity in the stage III category.

METHODS AND PATIENTS

An international retrospective multicenter study of 1815 patients who were treated for OCSCC from 2003 to 2011.

RESULTS

Kaplan-Meier survival analysis and multivariate models of stage III patients revealed better overall survival (OS; HR 2.12, 95 % CI 1.03-4.15; p = 0.01) and disease-specific survival (DSS; HR 1.7, 95 % CI 1.16-4.12; p = 0.04) rates for patients with T1-2N1/T3N0 disease than for patients with T3N1 disease. The outcomes of patients with T3N1 and stage IVa disease were similar (p = 0.89 and p = 0.78 for OS and DSS, respectively). Modifying stage classification by transferring the T3N1 category to the stage VIa group resulted in a better prognostic performance [Harrell's concordance index, C index 0.76; Akaike's Information Criterion (AIC) 4131.6] compared with the AJCC 7th edition staging system (C index 0.65; AIC 4144.9) for OS. When DSS was assessed, the suggested staging system remained the best performing model (C index 0.71; AIC 1061.3) compared with the current AJCC 7th edition staging (C index 0.64; AIC 1066.2).

CONCLUSIONS

The prognosis of T3N1 and stage IVa disease are similar in OCSCC, suggesting that these categories could be combined in future revisions of the nodal staging system to enhance prognostic accuracy.

Neoadjuvant chemotherapy followed by surgery in very locally advanced technically unresectable oral cavity cancers

BACKGROUND

The median survival of technically unresectable oral-cavity cancers (T4a and T4b) with non surgical therapy is 2-12 months. We hypothesized that neoadjuvant chemotherapy (NACT) could reduce the tumour size and result in successful resection and ultimately improved outcomes. We present a retrospective analysis of consecutive patients who received NACT at our centre between January 2008 and August 2012.

PATIENTS AND METHODS

All patients with technically unresectable oral cancers were assessed in a multidisciplinary clinic and received 2 cycles of NACT. After 2 cycles, patients were reassessed and planned for either surgery with subsequent CTRT or nonsurgical therapy including CT-RT, RT or palliation. SPSS version 16 was used for analysis of locoregional control and overall survival (OS). Univariate and multivariate analysis was done for factors affecting the OS.

RESULTS

721 patients with stage IV oral-cavity cancer received NACT. 310 patients (43%) had sufficient reduction in tumour size and underwent surgical resection. Of the remaining patients, 167 received chemoradiation, 3 radical radiation and 241 palliative treatment alone The locoregional control rate at 24 months was 20.6% for the overall cohort, 32% in patients undergoing surgery and 15% in patients undergoing non surgical treatment (p=0.0001). The median estimated OS in patients undergoing surgery was 19.6 months (95% CI, 9.59-25.21 months) and 8.16 months (95%, CI 7.57-8.76) in patients treated with non surgical treatment (p=0.0001).

CONCLUSION

In our analysis, NACT led to successful resection and improved overall survival in a significant proportion of technically unresectable oral-cancer patients.

Stereotactic body radiotherapy in early stage non-small cell lung cancer: first experience from an Indian Centre

BACKGROUND

Surgery is the standard of care for early stage (T1-2, N0, M0) non-small cell lung cancer. A considerable number of these patients are ineligible for surgery due to age and comorbidities. Hypo fractionated high-dose stereotactic body radiotherapy (SBRT) is being performed for these group of patients. There is paucity of literature regarding this novel technique from the Indian subcontinent.

AIMS AND OBJECTIVES

We hereby report the dosimetry, response and outcome of our small cohort of early stage non-small cell lung cancer patients treated with SBRT.

MATERIALS AND METHODS

Between December 2007 and December 2010, 8 patients of early stage (T1-2N0M0) underwent SBRT at our centre. All the patients had undergone whole body PET-CT scan, MRI brain and pulmonary function test (PFT with DLCO). The SBRT schedules included 48 Gy in 6 fractions for peripherally located and 48 Gy in 8 fractions for centrally located tumors. Response and toxicity were assessed in 3 monthly follow up visits.

RESULTS

The median duration of follow up was 18 months (range 8-44 months). The median age of the patients was 70 years (range 63-82 years) and the median tumor diameter was 4 cm (range 2.8-5.0 cm). The mean PTV volume was 165 cc(range 127.3- 193.9 cc). The mean dose to the PTV was 99.5% (range 97.7- 102.1%). After 3 months, 7 patients had complete metabolic response and 1 patient had partial metabolic response. Overall survival at 1.5 years was 87.5%. One patient had grade 2 pneumonitis. No toxicities of grade 3 or higher were identified.

CONCLUSION

SBRT for early stage NSCLC resulted in excellent local control with minimal toxicity and can be considered as a treatment option in properly selected patients.

Radiotherapeutic management of locally advanced head and neck cancer

Head and neck cancer management has undergone several paradigm shifts for several relevant reasons. From the dismal experience with the use of radiotherapy as the sole modality in the treatment of this group of patients with advanced disease, radiotherapy has been evaluated as an adjuvant for the same group of patients who had undergone successful surgery. Although there is no level 1 evidence to support postoperative adjuvant radiation, several studies have demonstrated that adjuvant radiotherapy reduces the local failures and, thereby, improves survival. Predictors of recurrence after surgical resection are: positive margins of resection; extranodal spread in involved nodes; perineural invasion; and presence of two or more involved regional lymph nodes. Realization of the advantages of a combination of chemotherapy with radiotherapy has had a major impact on the management of these cancers. There is emerging evidence for the use of adjuvant concurrent chemoradiotherapy in the group with high-risk features. Multiple organ conservation strategies in the management of locally advanced head and neck cancers have evolved over the years. However, the meta-analyses of impact of chemotherapy in various settings reveal that concomitant chemoradiotherapy is superior to any of the other regimens. Increasing use of computed tomography, magnetic resonance imaging and positron emission tomography scan images has resulted in better visualization of target volumes and critical structures. Delineation of these structures is of paramount importance and has resulted in a profound change in conformal treatment planning. Better understanding of the physical aspects of delivery of radiotherapy and the advent of modern treatment planning systems have led to the development of conformal techniques. Although the benefit of these techniques on survival have yet to be demonstrated, there is evidence to suggest that they reduce treatment-related toxicities significantly and facilitate dose escalation. Increased knowledge of radiobiology has led to the development of various altered fractionation regimens in the management of locally advanced head and neck cancers. Discovery of cell-cycle kinetics and signal transduction pathways has led to the unearthing of several potential targets for targeted therapy. The epidermal growth factor receptor gene has emerged as the most promising target. The role of biological radiation response modifiers is evolving. All of these approaches to improve the therapeutic gain would be incomplete without evaluating their effect on the quality of life of these patients.

Factors predicting 'time to distant metastasis' in radically treated head and neck cancer

Context: Various studies have shown the important risk factors for distant metastasis in head and neck cancer (HNC) which are present in most of the patients in developing countries. Identification of factors on the basis of time to distant metastasis (TDM) can help in future trials targeting smaller subgroups. Aims and Objectives: To identify the factors that predict TDM in radically treated HNC patients. Settings and Design: Retrospective audit. Materials and Methods: Retrospective audit of the prospectively maintained electronic database of a single HNC radiotherapy clinic from 1990 to 2010 was done to identify radically treated patients of HNC who developed distant metastasis. Univariate and multivariate analysis were done to identify baseline (demographic, clinical, pathological, and treatment) factors which could predict TDM, early time to metastasis (ETM; <12 months), intermediate time to metastasis (ITM; 12-24 months), and late time to metastasis (LTM; >2 years) using Kaplan Meier and Cox regression analysis, respectively. Results: One hundred patients with distant metastasis were identified with a median TDM of 7.4 months; 66 had ETM, 17 had ITM, and 17 had LTM. On multivariate analysis, the nodal stage 2-3 (N2/3) was the only baseline factor independently predicting TDM, ETM, and ITM, whereas none of the baseline factors predicted LTM. Conclusions: Higher nodal burden (N2/3) is associated with both ETM and ITM, and calls for aggressive screening, systemic therapy options, and surveillance. It is difficult to predict patients who are at a risk of developing LTM with baseline factors alone and evaluation of biological data is needed.

Toward an evidence-based proposal for the best minimal immunohistochemical panel to infer lung carcinoma in metastatic supraclavicular lymph node

Carcinomas from either pulmonary or extrapulmonary sites can metastatise to supraclavicular lymph nodes. Immunohistochemistry (IHC) is invaluable to comment on the possible primary site. However, the optimal number of antibodies to be tested is debatable. Seven antibodies were tested on 135 metastatic supraclavicular lymph node biopsies to propose a "best minimal" IHC panel to infer lung carcinoma, incorporating the principles of "evidence-based medicine." The 135 cases were divided into the following: category I (110 cases), wherein the primary was in the lung based on histologic analysis (Ia, n = 14 [12.7%]), cytologic analysis (Ib, n = 43 [39.1%]), or strong clinicoradiologic evidence (Ic, n = 53 [48.2%]), and category II (25 cases) with a histologically proven extrapulmonary primary site. Categories Ia and Ib were together designated as the "control group," and category Ic was designated as the "test group." The antibodies tested were cytokeratin (CK 7, CK20), epithelial membrane antigen, carcinoembryonic antigen, thyroid transcription factor-1 (TTF-1), surfactant protein B (SPB), and vimentin. Results of both individual and panels of antibodies were statistically evaluated. The sensitivity and specificity of single antibodies for inferring a lung primary was as follows: CK7 (90%/56%), CK20 (98%/40%), epithelial membrane antigen (90.9%/4%), carcinoembryonic antigen (80.9%/36%), TTF-1 (62.7%/100%), SPB (65.6%/100%), and vimentin (60.9%/60%). The highest sensitivity (85%) and specificity (100%) were seen with a 4-antibody panel: CK7, CK20, TTF-1, and SPB. This panel revealed the highest binomial probability (.8), for diagnosing lung cancer. The results were validated using a "split sample method," and a high concordance was noted between the control and test groups. To conclude, such evidence-based validated studies analyzing IHC results would be invaluable to guide the practice of surgical pathology in the future.

Epidemiology of lung cancer in India: focus on the differences between non-smokers and smokers: a single-centre experience

CONTEXT

Lung cancer has varied epidemiology depending on the geographic region. Globally, there have been important changes in incidence trends amongst men and women, histology, and incidence in non-smokers. Indian epidemiological data on lung cancer is scarce.

AIMS

We set out to study the epidemiological patterns and clinical profile of lung cancer in India.

MATERIALS AND METHODS

We interviewed patients discussed in the thoracic oncology multidisciplinary meetings between 2008 and 2009. Demographic data, smoking history, place of residence, histology, stage at presentation, and treatment details were collected. Data was entered and analyzed in SPSS.

RESULTS

There were 489 patients, with a median age of 56 years, of which 255 (52%) were non-smokers and 234 (48%) were smokers. One hundred and thirty-three patients had consumed smokeless tobacco. The male-to-female ratio was 3.5:1. Sixty-nine patients (14.1%) were incorrectly diagnosed and treated with anti-tuberculosis treatment, which delayed the diagnosis of lung cancer by four months. Eight percent of patients had small-cell carcinoma; of the 92% patients with non-small-cell carcinoma (NSCLC), the most common histology was adenocarcinoma (43.8%), followed by squamous cell (26.2%), large cell (2.1%) and other (8.3%). Eighteen percent of patients were diagnosed by cytology, therefore were diagnosed as NSCLC, without further histologic subtyping. Most patients (43%) were in Stage III at presentation. Lung followed by bone were the common sites of metastases. The majority of the patients (49%) received palliative chemotherapy. Among definitive therapy, concurrent chemo-radiation (13%) was offered more frequently than surgery (6%).

CONCLUSION

Considerably higher numbers of Indian patients with lung cancer are non-smokers, compared to the West. The global trend of rise in adenocarcinoma is paralleled in India. Non-tobacco-related risk factors need further investigation.

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.

Cetuximab and cancers of the head and neck: tapping the circadian rhythm

Proteins in tissue obtained from human skin and oral mucosa have shown a significant circadian rhythm, with the peak expression of p27 at 6:00 AM (early G1-phase marker), p53 at 10:50 AM (late G1-phase marker) and cyclin-E at 2:50 PM (S-phase marker). Patients irradiated in late afternoon/evening have shown a higher grade of mucositis and dermatitis. Studies evaluating the effect of EGFR blockade on cell cycle progression in several human cell types, including A431 squamous epithelial carcinoma cells, suggest that cetuximab leads to cell cycle arrest in G1 phase. On concurrent administration with radiation, mucositis and dermatitis are its main side-effects. So we can hypothesize that cetuximab administration after 11:00 AM would decrease these toxicities. In addition, its administration prior to late afternoon/evening (3:00 PM) can further reduce the radiation associated mucositis and dermatitis due to the occurrence of S-phase during this time and thus increase the therapeutic benefit.

Radiation therapy with implanted cardiac pacemaker devices: a clinical and dosimetric analysis of patients and proposed precautions

AIMS

To report the radiation planning dosimetric aspects and clinical outcomes of patients with implanted cardiac pacemakers.

MATERIALS AND METHODS

Between 2005 and 2009, eight patients with in situ cardiac pacemakers of varied primary site were treated at our hospital. All patients underwent computed tomography-based treatment planning. The target volumes, organs at risk and pacemaker device were all contoured. A treatment plan optimally covering the target area and maximally sparing the pacemaker was generated. All patients were evaluated at baseline, during radiotherapy and after radiotherapy conclusion by a cardiologist as well as pacemaker company personnel.

RESULTS

The median age at presentation was 67 (range 53-77) years. There were three men with head and neck primaries, two men with lung primaries and three women with breast primaries. The prescribed dose ranged from 45 to 70 Gy in 25-35 fractions with a daily dose of 1.8-2.0 Gy. Four patients had the pacemaker implanted on the same side as the radiotherapy target. The dose ranges for the minimum, mean and maximum doses to the pacemaker were 0.06-2.0, 0.07-20.6 and 0.14-60.0 Gy, respectively. Radiation therapy was safely delivered in all patients without any untoward effects. At 5 months of median follow-up, all patients were well with no malfunction of the pacemaker.

CONCLUSION

A series of eight patients with in situ pacemakers treated with radiotherapy is reported. Radiotherapy can be safely delivered in patients with implanted cardiac pacemakers. However, it mandates a cautious approach in planning and treatment delivery to ensure the least possible dose to the pacemaker. Close liaison with the cardiologist and a pacemaker clinic before, during and after the course of treatment is essential to ensure patient safety.

Validation of recursive partitioning analysis classification in patients with brain metastases from non-small cell lung cancer treated with short-course accelerated radiotherapy

AIMS

To study various prognostic factors affecting outcome and to validate Radiation Therapy Oncology Group recursive partitioning analysis (RPA) class in non-small cell lung cancer (NSCLC) with brain metastases treated with short-course accelerated radiotherapy (SCAR).

MATERIALS AND METHODS

The case records of 100 patients with NSCLC consecutively treated at Tata Memorial Hospital from August 2006 to August 2009 were studied for various patient, tumour and treatment-related prognostic factors. Patients received whole-brain radiotherapy to a dose of 20 Gy/five fractions over 1 week (n=90) or 30 Gy/10 fractions over 2 weeks (n=10). The Kaplan-Meier estimate was used for survival analysis in SPSS v15.

RESULTS

The median overall survival was 4.0 months (range 0.5-30.0 months). The 6-, 12-, 18- and 24-month survival rates were 35.8, 18.0, 9.3 and 6.2%, respectively. Of the various prognostic factors, RPA class (II versus III, P value=0.023), Karnofsky performance score (<70 versus ≥70, P value=0.039) and the use of systemic therapy (yes versus no, P value=0.00) emerged as significant on univariate analysis. RPA classification effectively separated the patient population into prognostically distinct subgroups. The median overall survival for RPA class II and RPA class III was 6 and 4 months, respectively. The use of systemic therapy prolonged overall survival by 6 months (3 months versus 9 months).

CONCLUSION

The SCAR regimen is an effective and resource-sparing palliative strategy for brain metastases in NSCLC. The results validate the usefulness of RPA classification in this specific subset of patients treated with SCAR.

PET-CT in recurrent head neck cancers: a study to evaluate impact on patient management

BACKGROUND AND OBJECTIVES

PET-CT has shown promise in the management of head neck cancers. However, there have been only few studies evaluating its impact on management of patients with recurrent cancers in the presence of available clinicoradiologic methods of assessment. We conducted this study to assess the same in patients with suspected recurrent head and neck cancer.

METHODS

Case histories were presented to two oncologists, who were blinded to PET-CT reports. Treatment plans were made by these oncologists based on clinical findings and other conventional imaging. These plans were then compared to the actual treatment received by patients after PET-CT. Any change was recorded as "change in management."

RESULTS

Forty-nine patients with suspected recurrent head and neck cancer were evaluated in the study. Overall, there was a 38.7% change in management because of the addition of PET-CT to conventional methods of assessment. Eight patients (16.3%) had a major change in therapy while in 11 patients (22.4%), diagnostic procedures like endoscopies, biopsies and examination under anesthesia were avoided.

CONCLUSION

In our study, PET-CT had a significant impact on the management of patients with suspected recurrent head neck cancer.