Anaplastic Cancer: Our Experience

Anaplastic thyroid carcinoma (ATC) is a rare thyroid malignancy with a dire prognosis, nearly 100% disease specific mortality and a median overall survival less than 6 months. In view of the limited data from India on anaplastic thyroid cancer, we conducted this audit to analyze the treatment pattern, outcomes and factors influencing it. This is a retrospective analysis of outcomes of patients treated in a single institution between January 2008 and December 2020. Baseline characteristics, treatment received, and outcomes among adult patients with ATC were collected. Progression free survival (PFS) and overall survival (OS) were analyzed. SPSS version 20 and RStudio version 3.1.1 were used for analysis. In this cohort of 134 patients, the median age at diagnosis was 59 years, with 63.4% of them being females. At presentation, 70.9% of them had good performance status (PS 0-1). Only 38.8% received treatment with curative intent (either surgery fb adjuvant or neoadjuvant chemotherapy fb surgery and adjuvant or definitive chemoradiotherapy) while 61.2% patients received palliative treatment (either palliation alone or palliative chemotherapy or palliative surgery or palliative RT). Predominant pattern of progression was local progression (79.8%). Median PFS and OS of the overall cohort were 58 days and 80 days respectively. PFS and OS were significantly better in patients treated with curative intent vs palliative intent (116 and 134 days vs 45 and 50 days; p = 0.00 and 0.00 respectively). Among patients treated with curative intent, OS was significantly better in patients undergoing surgery vs CTRT (155 vs 76 days; p = 0.03). Among patients treated with upfront surgery, both PFS and OS were better with the addition of adjuvant CTRT/RT vs no adjuvant (332 and 540 days vs 55 and 91 days; p = 0.00 and 0.003 respectively). ATC is a rare cancer with dismal prognosis. Local therapy with surgery followed adjuvant seems to be associated with the better outcomes. Systemic therapy seems to be a better option for palliation. Our data reflects the real world data of this rare cancer.

Results of phase 3 randomized trial for use of docetaxel as a radiosensitizer in patients with head and neck cancer unsuitable for cisplatin-based chemoradiation

LBA6003

Background: Systemic therapy options have not been systematically evaluated in cisplatin-ineligible locally advanced head and neck squamous cell carcinoma (LAHNSCC) patients undergoing chemoradiation. This study evaluated docetaxel as a radiosensitizer in this setting. Methods: This was a randomised open-label study. Adults with LAHNSCC planned for radical or adjuvant chemoradiation, with ECOG PS 0-2 and who were cisplatin-ineligible as per the criteria by Ahn et al were enrolled. The patients were randomly assigned 1:1 to receive radiation alone or radiation with concurrent docetaxel 15 mg/m2 weekly for a maximum of 7 cycles. Adverse events were recorded in accordance with CTCAE version 4.03. The FACT-G, and H and N questionnaires (version 4) were self-administered at baseline, 6 months, 12 months and at 24 months. The primary endpoint was disease-free survival (DFS) and key secondary endpoints were overall survival (OS), adverse events and quality of life (Trial outcome index (TOI)). Results: The study recruited 356 patients with 176 in RT and 180 in the docetaxel-RT arm. The 2-year DFS was 30.3% (95%CI 23.6-37.4) versus 42% (95%CI 34.6-49.2) in the RT and docetaxel-RT arms respectively (Hazard ratio- 0.673; 95% CI 0.521-0.868; P-value=0.002). The median overall survival (OS) was 15.3 months (95%CI 13.1-22) in the RT arm and 25.5 months (95% CI 17.6-32.5) in the docetaxel-RT arm. (Log-rank P-value =.0.035). The 2 -year OS was 41.7% (95%CI 34.1-49.1) versus 50.8% (95%CI 43.1-58.1) in the RT and docetaxel-RT arms respectively (Hazard ratio-0.747; 95% CI 0.569-0.98; P-value=0.035). Any grade 3 or above adverse events were seen in 102 patients (58%) in RT and in 146 (81.6%) in docetaxel-RT arms respectively (P-value=0.000). There was a higher incidence of grade 3 and above mucositis (22.2% versus 49.7%; P<0.001), odynophagia (33.5% versus 52.5%; P<0.001) and dysphagia (33% versus 49.7%; P<0.002) with the addition of docetaxel. The addition of docetaxel did not lead to a worsening of TOI scores and FACT-G scores at 6 months. Conclusions: The addition of docetaxel to radiation improved disease-free survival and overall survival in cisplatin-ineligible LAHNSCC and represents a new standard of care. Clinical trial information: CTRI/2017/05/008700.

Phase 3 randomised study evaluating the addition of low-dose nivolumab to palliative chemotherapy in head and neck cancer

LBA6016

Background: The regimens approved for the treatment of advanced head and neck squamous cell carcinoma (HNSCC) are accessible to only 1-3% of patients in low and middle-income countries due to cost. In our previous study, metronomic chemotherapy (MC) improved survival in this setting. Retrospective data suggest that a low dose of nivolumab may be efficacious. Hence, we aimed to assess whether the addition of low dose nivolumab to MC improved the overall survival. Methods: This was a randomised phase 3 superiority open-label study. Adult patients with relapsed -recurrent or newly diagnosed advanced HNSCC being treated with palliative intent with ECOG PS 0-1 were eligible. Patients were randomised 1:1 to MC consisting of methotrexate 15 mg/m2 PO weekly, celecoxib 200 mg PO daily and erlotinib 150 mg PO daily, or MC with intravenous nivolumab 20 mg flat dose once-every-3-weeks. Therapy was continued until disease progression or intolerable adverse events. Response assessment (RECIST version 1.1) was performed every 2 months. The primary endpoint was 1-year overall survival (OS) and this was a pre-specified interim analysis with the nominal p-value for efficacy being 0.006. Results: 151 patients were randomised, 75 in MC and 76 in the MC-I arm respectively. The addition of low dose nivolumab led to an improvement in the 1-year overall survival from 16.3% (95%CI 7.95-27.4) to 43.4% (95% CI 30.8-52.3) [Hazard ratio-0.545; 95%CI 0.362-0.82; P=0.00358]. The median overall survival in MC and MC-I arms was 6.7 months (95%CI 5.83 -8.07) and 10.1 months (95%CI 7.37-12.63) respectively (P=0.0052). The median progression-free survival in MC and MC-I arms was 4.57 months (95%CI 4.2 -5.3) and 6.57 months (95%CI 4.43-8.9) respectively (P=0.0021). Response rate in MC and MC-I arm were 49.3% (95% CI 37.8-60.8) and 65.2% (95%CI 53.4-75.4) respectively (P=0.085). The rate of grade 3 and above adverse events was 50% and 46.1% in MC and MC-I arm respectively (P=0.744). Conclusions: In this first-ever randomised study, the addition of low dose nivolumab led to improved overall survival and is an alternative standard of care for those who cannot access full dose nivolumab. Clinical trial information: CTRI/2020/11/028953.

Geriatric assessment as a predictor of survival among older Indian patients with cancer

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Background: ASCO guidelines recommend that geriatric assessment (GA) should be performed in all older adults with cancer. However, GA is labor- and time-intensive, hence the uptake is poor, especially in crowded resource poor-settings. There are no data correlating GA with overall survival (OS) outcomes from the Indian subcontinent. Methods: A prospective observational study in the geriatric oncology clinic of the Tata Memorial Hospital in Mumbai, India. Patients aged 60 years and above, with cancer who underwent a GA were enrolled. The domains assessed included: function (basic and instrumental activities of daily living, timed-up-and-go), nutrition (body mass index, unintentional weight loss, mini-nutritional assessment), comorbidities, cognition, psychological (depression, anxiety), social support, and medication (polypharmacy and potentially inappropriate medications). Patients with > 2 deranged GA domains were considered frail. Results: Between June 2018 and January 2022, 909 patients were enrolled. The median age was 69 (IQR, 60-88) years. Common malignancies included lung (40%), esophagus (21%) and head and neck (11%); 53% had metastatic disease. 80% had > 2 impaired domains in GA patients had vulnerabilities in a median of 3 (IQR, 0-5) domains. Median OS in fit patients based on the GA was 17.5 (95% CI, 13.9-21.0) months vs 12.1 (95% CI, 10.1-14.0) months in frail patients, (HR 0.66; 95% CI, 0.49-0.88, p = 0.005), which remained significant after adjusting for age, sex, and stage (HR, 0.71; 95% CI: 0.53-0.94, p = 0.021). In the multivariate analysis (Table), the domains that were predictive of survival were nutrition (HR: 0.65, 95% CI: 0.47-0.92, p = 0.014), cognition (HR: 0.65; 95% CI: 0.46-0.91, p = 0.012) and fatigue (HR: 0.74, 95% CI: 0.56-0.98, p = 0.038). Conclusions: In older Indian patients with cancer, GA is a powerful prognosticator of survival. In settings where a complete GA is not possible, nutrition, cognition, and fatigue should be the minimum domains assessed. Clinical trial information: CTRI/2020/04/024675. [Table: see text]

Five years survival outcomes of head and neck cancer patients treated with palliative metronomic chemotherapy

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Background: Palliative metronomic chemotherapy improved overall survival over intravenous chemotherapy in head and neck cancers. However, there is no data available about the 5-year outcomes with this regimen. Methods: This was a single-arm prospective study that enrolled head and neck squamous cell carcinoma patients warranting palliative chemotherapy. The chemotherapy administered was methotrexate 15 mg/m2 per oral weekly and celecoxib 200 mg per oral daily till the development of intolerable side effects or progression. Kaplan Meier method was used for estimation of OS and factors impacting the same were sought. A p-value of 0.05 was considered significant. Results: 200 patients were enrolled with a median age was 49.5 years (Range 22-85 years) and preponderance of male gender (175, 87.5%). The predominant site of malignancy was oral cavity in 144 patients (72.2%). Prior chemotherapy exposure was present in 78 patients (39%). The median FACT trial outcome index score was 43.7 (16.7-80.7). The median OS was 194 days (95%CI 181.7-206.3) . The 1-year, 3-years and 5-years OS were 17 %(Standard error-2.8%), 7.9% (Standard error-2.5%), and 3.9% (Standard error- 2%) respectively. The details of factors impacting OS are given in Table. Conclusions: Oral metronomic chemotherapy leads to a small proportion of patients having long term survival with metronomic chemotherapy. Clinical trial information: CTRI/2015/11/006392. [Table: see text]

Real-world analysis of use of lenvatinib in differentiated thyroid cancers

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Background: Lenvatinib is one of the approved treatments for radioiodine refractory differentiated thyroid cancers. However, there is very limited data from India on real-world efficacy and adverse events of Lenvatinib and hence this analysis was performed. Methods: This was a retrospective analysis in which patients of radioiodine refractory differentiated thyroid cancer as per the select study criteria who received lenvatinib were selected for the study over the last 4 years. The baseline demographic characteristics, adverse events of lenvatinib, the date of progression and the date of overall survival (OS) were extracted from the electronic medical records (EMR) of the Tata Memorial Hospital. SPSS version 20 was used for analysis. Results: Thirty patients were identified. The median age was 54.5 years (25-77). The male: female ratio was1:1. The Eastern Cooperative Oncology Group (ECOG) performance status (PS) was 0-1 in 21(70%), 2 in 4(13.3%) and 3 in 5(16.7%). The thyroid status was hypothyroid in 10 patients (33.3%), euthyroid in 12(40%) and hyperthyroid in 8(26.7%). In 5 patients it had to be stopped because of toxicity, these were proteinuria in 2, a hand-foot syndrome in 2 and diarrhoea in 1. The response rate was 56.7% (n = 17). The median progression-free survival (PFS) on lenvatinib was 366 days(95%CI 170.3-561.67) and the 2 year PFS was 29.3% (standard error 12.1) The median overall survival (OS) on lenvatinib was 411 days (95%CI 95.5-726.6). The 2 year OS was 38.8% (standard error -12.5%) and 5 year OS was 14.6% (standard error 12.1). Conclusions: In the real world lenvatinib provides a 2 year PFS and OS of 29.3% and 38.8% which is lower than that reported in the pivotal SELECT study.

Phase III randomized control study evaluating adjuvant metronomic chemotherapy in locally advanced head and neck cancers post-radical chemoradiation (MACE-CTRT)

6073

Background: Locally advanced head and neck cancer treated with radical chemoradiation have unsatisfactory outcomes. Oral metronomic chemotherapy improves outcomes in comparison to maximum tolerated dose chemotherapy in the palliative setting. There is also limited evidence that it may do so in an adjuvant setting. Hence this randomised study was conducted. Methods: Patients of HN cancer with primary in oropharynx, larynx or hypopharynx, with PS 0-2 post radical chemoradiation with documented complete response were 1:1 randomised to either observation or oral metronomic adjuvant chemotherapy (MAC) for 18 months. MAC consisted of weekly oral methotrexate (15 mg/m2) and celecoxib (200 mg PO BD). The primary endpoint was OS and the overall sample size was 1038. The study had 3 planned interim analyses for efficacy and futility. Results: 137 patients were recruited and an interim analysis was done. The 3 year PFS in the observation arm was 67.1% (95% CI 53.8-77.3) and the same in the MAC arm was 62.5%(95%CI 49.4-73.1). The corresponding hazard ratio was 1.402 (95% CI 0.7393-2.66, P-value = 0.3). The 3 year OS in the observation arm was 77.3% (95% CI 64.4-86) and the same in the MAC arm was 64.1% (95%CI 51-74.5). The corresponding hazard ratio was 1.588 (95% CI 0.8734-2.886, P-value = 0.1). Any grade mucositis was seen in 30 patients (45.5%) in the MAC arm and 20 patients (28.2%) in the observation arm (P-value = 0.05). The rate of grade 3 or above mucositis was 7.6%(n = 5) in the MAC arm and 1.4%(n = 1) in the observation arm (P-value = 0.106). Conclusions: Both arms had similar OS. Hence observation post complete response post radical chemoradiation remains the standard of care. Clinical trial information: CTRI/2016/09/007315.

Long-term outcomes of a randomized controlled clinical trial comparing the efficacy of cabazitaxel versus docetaxel as second-line or above therapy in recurrent head and neck cancer

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Background: Long term outcomes (> 2 years or above) are rarely reported in studies with second line or beyond systemic therapies in head and neck squmouas cell carcinoma (HNSCC). Methods: Recurrent or relapsed adult HNSCC, with ECOG PS 0-2 who have been exposed to at least one line of chemotherapy were 1:1 randomized between Docetaxel (75 mg/m2) and Cabazitaxel (20 mg/m2). The chemotherapy was given till progression or development of intolerable side effects. The outcomes reported are long term overall survival(OS) and progression free survival (PFS) and factors impacting overall survival. Results: On the intention to treat analysis (n = 92), at the time of data censoring, 92 patients had died. The median overall survival was 112 days (95% CI 81 to 178 days) in the cabazitaxel arm versus 192 days (95% CI 153 to 259 days) in the Docetaxel arm (P = 0.048). In cabazitaxel arm, the one year OS was 6.5% (95% CI 1.6-16.06), 2 year OS was 2.17% (95% CI 0.17-9.95) and 3 years was 2.17% (95% CI 0.17-9.95). While the corresponding figures in the docetaxel arm were 21.7% (95% CI 11.23-34.46), 0% and 0%. The median progression-free survival was 21.0 days (95% CI 16.0-42.0 days) in the Cabazitaxel arm versus 57.5 days (95% CI 26.0-85.0 days) in the Docetaxel arm (P = 0.02). Among the tested factors age (p = 0.037) and site of primary(p = 0.023) had an impact on OS. Conclusions: In this phase 2 randomised study, cabazitaxel has inferior PFS and OS than docetaxel. Hence docetaxel remains the option of choice when cytotoxic chemotherapy needs to be used as second line or beyond setting in HNSCC. Clinical trial information: CTRI/2015/06/005848.

Long-term outcomes of phase I/II study of palliative triple metronomic chemotherapy in platinum-refractory/early failure oral cancer

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Background: Triple metronomic chemotherapy is one of the options of treatment in platinum-refractory/early failure oral cancer. However long term outcomes with this regimen are unknown. Methods: Adult patients with platinum-refractory/early failure oral cancer were enrolled in the study. Patients were administered erlotinib 150 mg once daily celecoxib 200 mg twice daily and methotrexate weekly (phase 1 in variable dose 15-6 mg/m2 & 9 mg/m2 in phase 2), all taken orally till progression of disease or development of intolerable adverse events. The primary objective was to estimate the long term overall survival and factors impacting it. Kaplan Meier method was used for time to event analysis. COX proportional hazard model was used to identify factors impacting OS and PFS. The factors included in the model were age, gender, ECOG PS, tobacco exposure, a subsite of primary and circulating endothelial cell levels at baseline. A p-value of 0.05 was considered significant. Results: A total of 91 patients were recruited (15 in phase 1 & 76 in phase 2), the median follow-up was 41 months and 84 events of death had occurred. The median OS was 6.67 months (95%CI 5.43-7.37). The 1-year, 2-years and 3-years OS were 14.07% (95%CI 7.75-22.2), 5.86% (95%CI 2.18-12.2) and 5.86% (95%CI 2.18-12.2) respectively. The only factor favourably impacting OS was the detection of circulating endothelial cells at baseline (HR = 0.459; 95%CI 0.28 -0.753, P = 0.002). The median PFS was 4.3 months (95%CI 4.1-5.1) and the 1-year PFS was 12.97% (95%CI 6.8-21.2). The factors with statistically significant impact on PFS were detection of circulating endothelial cells at baseline (HR = 0.479; 95%CI 0.3 -0.775, P = 0.002) and tobacco exposure at baseline (HR = 0.505; 95%CI 0.272 -0.937, P = 0.03). Conclusions: The long term outcomes with triple oral metronomic chemotherapy with erlotinib, methotrexate and celecoxib are unsatisfactory. Detection of circulating endothelial cells at baseline is a biomarker predicting efficacy of this therapy. Clinical trial information: CTRI/2016/04/006834..

Compliance, adverse events and quality of life of patients in a phase 3 study comparing temozolomide with PCV as adjuvant chemotherapy in grade 2 and 3 glioma

e14010

Background: Both PCV and Temozolomide (TMZ) are options for adjuvant therapy in grade 2 & grade 3 gliomas after maximal safe resection. The RTOG 9802 PCV regimen is not commonly used as it is perceived as a toxic, poorly tolerated regimen. TMZ is often preferred as it is easy to administer and has fewer adverse events. There has been no head-to-head comparison of these regimens, hence we are conducting a study to compare the 2 regimens. Here, we report the adverse event profile, compliance & quality of life (QoL) of patients enrolled in this study. Methods: This is an ongoing phase 3, non-inferiority trial. Adults with grade 2 glioma with high-risk features (age ≥40 years at diagnosis or residual disease ≥1 cm) or grade 3 gliomas, with ECOG PS 0-2 were enrolled. Patients were randomized 2:1 to receive either adjuvant TMZ or PCV after adjuvant focal conformal radiation (RT). In the TMZ arm patients received RT with concurrent TMZ 75 mg/m2/day (max. 49 days) followed by adjuvant TMZ 150 mg/m2/day on days 1-5 of a 28 day cycle for cycle1, & 200 mg/m2/day cycle 2 onwards (max. 12 cycles).In the PCV arm, patients received Procarbazine 60 mg/m2/day on days 8-21, Lomustine (CCNU) 110 mg/m2 on day 1 & Vincristine (VCR) 1.4 mg/m2 on days 8 & 29 of a 56 day cycle (max. 6 cycles). The primary endpoint of the study is progression-free survival. The current analysis focuses on compliance, adverse events (as per CTCAE v4.03) & QoL (EORTC QLQ C-30 & BN-20). Results: This analysis was limited to the first 50 patients who had completed at least 1 year from the start of adjuvant chemotherapy. There were 32 patients in the TMZ arm & 18 patients in the PCV arm. Two patients each in the TMZ & PCV arms did not start adjuvant chemotherapy. Among those who started adjuvant chemotherapy, the completion rates were higher in the TMZ arm (n = 26,86.7%) as compared to the PCV arm (n = 11,68.8%; p = .241). The median number of cycles of TMZ, Procarbazine, CCNU, and VCR were 12, 5.5, 6 and 5.5 respectively. Dose delays were slightly higher in the PCV arm (81.3%) compared to the TMZ arm (73.3%) which was not statistically significant (p = .722). Chemotherapy dose reductions were needed in 11 patients (68.8%) in the PCV arm & only 1 patient (3.3%) in the TMZ arm, this was statistically significant (p = 0.000). Myelosuppression was significantly higher in the PCV arm as compared to the TMZ arm. The incidence of any grade and grade ≥ 3 anemia, neutropenia & thrombocytopenia was significantly higher with PCV. The incidence of grade 3 lymphopenia was significantly higher with PCV (p = .000). Only 2 patients in the PCV arm developed febrile neutropenia. There was no significant difference in the QoL scores between the two arms at various time points. Conclusions: The use of adjuvant PCV is feasible when administered by experienced neuro-medical oncologists with an acceptable compliance and toxicity profile, without adversely impacting the QoL of patients. Clinical trial information: CTRI/2018/07/015056.

Mebendazole in recurrent glioblastoma: Results of a phase 2 randomized study

2029

Background: Recurrent glioblastoma (GBM) has dismal outcomes and limited treatment options. Mebendazole (MBZ) is an anti-helminthic drug with in-vivo and in-vitro activity against glioma cell lines and has been demonstrated to be well tolerated in combination with lomustine (CCNU) and temozolomide (TMZ). In this phase 2 study, we sought to determine whether the addition of MBZ to CCNU or TMZ would improve overall survival (OS) in recurrent GBM. Methods: Adult patients with ECOG PS 0-3, with recurrent glioblastoma who were not eligible for re-radiation, were randomized 1:1 between CCNU-MBZ (n = 44) and TMZ-MBZ (n = 44). The primary endpoint was OS at 9 months, selected to reflect the BELOB trial. A 9-month OS of 55% or more in any arm was hypothesized to warrant further evaluation and a value below 35% was too low to warrant further investigation. Results: At 17.4 months, 68 events for OS analysis had occurred. The 9-month overall survival was 36.6% (95%CI 22.3-51) and 45% (95%CI 29.6-59.2) in the TMZ-MBZ and CCNU-MBZ arms respectively. ECOG PS was the only independent prognostic factor impacting OS (HR-0.478 95%CI 0.268-0.851; P = 0.012). Twenty-three patients (28.6%) enrolled had an ECOG PS 2-3 with inferior outcomes (median OS-5.67, HR-2.092 95%CI 1.175-3.731). Analysis restricted to ECOG PS 0-1 (n = 65) patients revealed a 9-month OS of 39.6% (95% CI 22.4-56.3) and 57.9% (95% CI 38.7-73) in TMZ-MBZ and CCNU-MBZ arms respectively. Grade 3-5 adverse events were seen in 8 (18.6%; n = 43) and 4 (9.5%; n = 42) patients in the TMZ-MBZ and CCNU-MBZ arms respectively. Conclusions: The addition of MBZ to TMZ or CCNU failed to achieve the pre-set benchmark of 55% 9-month OS. This was probably due to 28.6% of patients with poor PS of 2-3. In patients with ECOG PS 0-1, CCNU-MBZ had a 9 month OS of 57.9% and needs to be evaluated further. Clinical trial information: CTRI/2018/01/011542.

Prevalence and outcomes of frailty in older patients with cancer: A prospective study from geriatric oncology clinic

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Background: Frail older patients present with increased symptom burden, medical complexity and reduced tolerance to medical and surgical interventions. Data regarding the prevalence of frailty and its association with outcomes, such as overall survival, is limited from India. This study aimed to establish the prevalence of frailty and its association with overall survival (OS) in older patients with cancer. Methods: This was a prospective study conducted in geriatric oncology clinic of Tata memorial hospital (Mumbai India). Patients aged 60 years and above referred to the clinic were included. Frailty was identified using the Rockwoods Clinical frailty scale, and patients with a score of five or more were diagnosed as frail. Demographic details, type of cancer, stage and multi-domains geriatric assessment was done. Cancer and Ageing Research group online toxicity tool was used to assess the chemotherapy toxicity risk. A t-test or two-sample Wilcoxon rank-sum test was used to study the association between frailty status and non-categorical variables and the Pearson chi-squared test was used to measure the association between categorical variables. The Kaplan Meier survival estimation and the Cox proportional hazard model were used to perform the survival analysis. Results: Between June 2018 to January 2022, 909 patients were evaluated and 662 patients with clinical frailty score were included. The median age was 68 (60-86) years and 107 (16%) were above the age of 75 years. The most common malignancies were lung (39%), esophagus (21%) and head and neck (10%); 53% had metastatic disease. 192 (29%) were frail, and it prevalence increased with age. Frailty status was associated with poor OS (unadjusted HR: 2.512; 95% CI: 1.931-3.268). This association was significant even after adjusting for age, gender, BMI and stage of cancer (adjusted HR: 2.104; 95% CI: 1.598-2.770). Frailty was associated with comorbidities such as diabetes (32% vs 23%, p = 0.014), chronic obstructive pulmonary disease (13% vs 7%, p = 0.045) and cardiovascular disease (19% vs 12%, p = 0.017). Among the geriatric domains, frail patients had greater incidence of polypharmacy (52% vs 33%, p < 0.01), slower gait speed (53% vs 12%, p < 0.01), impaired cognition (25% vs 7%, p < 0.01), poor nutritional status (51% vs 17%, p < 0.001), depression (29% vs 8%, p < 0.01) and anxiety (14% vs 5%, p < 0.01). Conclusions: The prevalence of frailty among older cancer patients is high. It is associated with poor physical, cognitive and psychological resilience and is associated with poor overall survival. Our study supports the routine assessment of frailty in older patients with cancer to guide treatment decisions. Clinical trial information: CTRI/2020/04/024675.

Phase III randomized controlled trial comparing chemotherapy to best supportive care in advanced esophageal and gastroesophageal junction cancer

4065

Background: Patients with advanced esophageal/gastroesophageal junction (GEJ) cancer have a dismal outcome. No study has unequivocally proven that systemic chemotherapy prolongs survival. Current NCCN guidelines recommend palliative/best supportive care as a first-line option for patients with unresectable locally advanced, recurrent, or metastatic esophageal/GEJ cancers. Methods: Phase III randomized controlled study conducted in the Department of Medical Oncology at the Tata Memorial Hospital (Mumbai, India) in patients with advanced unresectable or metastatic esophageal or GEJ cancer, planned for palliative intent therapy. Patients aged 18 to 70 years, with a performance status < 2, were stratified based on histopathology, presence of metastatic disease and receipt of prior curative therapy, and randomized 1:1 to best supportive care alone, or best supportive care with chemotherapy consisting of intravenous paclitaxel 80 mg/m2 once-a-week, continued until disease progression or intolerable toxicity. Best supportive care consisted of patient education and counselling, non-chemotherapeutic palliative measures like radiation, or stenting, placement of feeding tube, analgesia, antiemesis and other supportive medications, nutritional support, and referral to a patient support group. Primary endpoint was overall survival (OS); secondary endpoints included progression free survival (PFS), response rate, adverse events, and quality of life. Results: Between May 2016 and Dec 2020, we recruited 281 patients; 143 to chemotherapy and 138 to best supportive care. Histopathology was squamous in 269 (95.7%) patients. In the 143 patients in the chemotherapy arm, median number of paclitaxel cycles was 12 (IQR, 7-23). The response rate was 32%. Grade > 3 toxicities occurred in 82 (57%) patients who received paclitaxel; commonly hyponatremia (18%), anemia (11%), fatigue (10%), peripheral neuropathy (10%), infection (9%), and neutropenia (7%). Median PFS was 2.1 months (95% CI, 1.98-2.23) in the best supportive care arm, and 4.1 months in the chemotherapy arm (95% CI, 3.54-4.74); HR, 0.51 (95% CI, 0.39-0.64); P < 0.001. The 1-year OS was 11.6% in the best supportive care arm, versus 30.8% in the chemotherapy arm. Median OS was 4.2 months (95% CI, 2.93-5.42) in the best supportive care arm, and 8.6 months in the chemotherapy arm (95% CI, 7.56-9.66); HR, 0.52 (95% CI, 0.40-0.66); P < 0.001. Conclusions: Systemic chemotherapy significantly prolongs survival and should be considered the standard of care in patients with advanced esophageal and GEJ squamous cell carcinoma. Metronomic weekly paclitaxel is an attractive option, especially in LMICs with limited access to newer immunotherapy-based combination regimens. Clinical trial information: CTRI/2016/01/006474.

A retrospective analysis of patients administered neoadjuvant chemotherapy (NACT) with paclitaxel plus carboplatin with oral metronomic chemotherapy (OMCT) in locally advanced borderline resectable/technically unresectable head and neck cancers

6030

Background: Neoadjuvant chemotherapy with TPF though the standard is seldom used in India due to its adverse events rate. Two drug regimen of Paclitaxel and Carboplatin (PC) though favoured has inferior outcomes. Hence, we did an analysis to estimate the efficacy and adverse event rate of addition of 3 drug metronomic schedule to PC. Methods: Patients of locally advanced head and neck cancer referred from multidisciplinary board for neoadjuvant chemotherapy and unsuitable for TPF were selected for this analysis. These patients had received 2 drug regimen of intravenous PC with 3 drug regimen of weekly methotrexate 9 mg per m2, Celecoxib 200 mg twice daily, erlotinib 150 mg once daily all administered orally. All patients underwent a response assessment at 5-7 weeks post start of therapy and we're discussed in MDT for further treatment. Adverse events were recorded in accordance with CTCAE version 4.03 and response in accordance with RECIST version 1.1. PFS and OS were estimated with Kaplan Meier method. Results: 72 patients were identified with the median age being 45 (27-80) and M:F ratio (67:5). The indication for NACT were borderline resectability in all patients.. The response rate was 61.1% and grade 3 and above adverse event rate was 33.5%. A total number of 34 among 40 borderline resectable patients underwent surgery. The overall estimated PFS and OS were 18.5 (95%CI = 14.4-22.7) months and 18.05 (95%CI = 14.2-21.8) months respectively. The three most adverse events observed were grade 3 thrombocytopenia in 2 patients (2.8%), grade 3 aspartate aminotransferase (AST) derangement in 4 patients (5.6%) and grade 3 alanine aminotransferase (ALT) in 4 patients (5.6%). Conclusions: The 5 drug combination regimen is safe, tolerable and seems to have similar efficacy as a three drug TPF regimen.

Real world data of neoadjuvant and adjuvant chemotherapy in head neck osteosarcoma: Experience from a tertiary care center in India

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Background: The head and neck (HN) region is a rare sub-site of osteosarcoma(OGS), with less than 10% of all cases of osteosarcoma and < 1% of all the head and neck malignancies . The evidence pertaining to the treatment of OGS of the head & neck region is limited. The role of adjuvant chemotherapy is evolving and research in this field is limited by the rarity of this tumour. However, in multiple small series, adjuvant or neoadjuvant chemotherapy has been found to be beneficial in head and neck OGS. To this end, we have audited our practice of the last 10 years to see the pattern of care, outcomes and advancements in the chemotherapy of HN OGS. Methods: We maintain a record at our outpatient department of patients receiving neoadjuvant and adjuvant chemotherapy. We conducted a database search spanning the data from 2010 to 2020, using the keywords: osteosarcoma, osteogenic sarcoma, OGS and head neck region, maxilla, skull base. Any adult patients who received chemotherapy in the adjuvant or neoadjuvant setting were selected for this study. The baseline demographics, patterns of chemotherapy administration and outcomes were documented. We analysed the data using SPSS descriptive statistical analysis. Survival analysis for progression-free survival and overall survival was done using the Kaplan-Meyer method. Results: 30 patients of HN OGS were treated with neoadjuvant chemotherapy (NACT) or adjuvant chemotherapy (ACT) at our centre from 2010 to 2020. The median age was 25 years, with a male preponderance (n = 21, 70%). The sites of disease were maxilla- 15(50%), mandible- 11 (37%), alveolus- 2 (6.6 %), orbit- 1 (3.3%), masticator space - 1 (3.3%). Out of the study population, 18 patients (60%) received NACT, 17 patients (56%) received ACT, 5(16%) patients received both NACT and ACT. 23 patients (76.6 %) underwent surgical resection, with R0 resection achieved in 17 (56.6%) and R1 in 3 patients(10%). 16 patients (53.3%) received adjuvant radiotherapy. Median progression-free survival was 16.10 months (95% CI: 10.30-21.89). Median overall survival (OS) was 22.56 months (95%CI: 11.16-33.96). 2 years OS was 49.1% (standard error 9.6). Conclusions: The patterns of use of neoadjuatnt and adjuvant chemotherapy in HN OGS are variable. Overall, the outcomes of HN OGS remain unsatisfactory. Further efforts are warranted in this direction to standardise an algorithm for chemotherapy. Further intensification of therapy may be required to improve patient outcomes.

Real world evidence for use of NACT in locally advanced external auditory canal cancer

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Background: The management of very locally advanced external auditory canal cancers (LAEACC) is complicated, has a dismal prognosis and there is limited literature available for guidance. At our institute, we have offered neoadjuvant chemotherapy (NACT) to such patients. The objective of the current analysis was to study the outcomes and adverse events with this approach. Methods: We identified 16 patients with LAEACC over a period of 10 years (2010-2020) from the neoadjuvant chemotherapy (NACT) database of the Head and Neck department at our hospital. All patients were seen in a multidisciplinary clinic before and after NACT. Further local therapy was planned as per the response and ECOG PS of the patient. SPSS version 20 was used for analysis. Descriptive statistics were performed and Kaplan-Meier analysis was done to evaluate overall survival and progression-free survival. Results: Out of 16 patients enrolled in the study, 14 patients eventually received NACT. The median age was 59.5 years (27 - 83), the male to female ratio was 7:1 and the ECOG PS was 0-1 in 14 (87.5%) and PS 2 in rest. The regimen offered was a 2 drug regimen of taxane and platinum in 11 patients and a 3 drug regimen of TPF in (7.14%) patients. The median cycle received was 2. Post NACT 6 (42.85%) patients underwent surgery, 5 (35.71%) received radical CTRT and 3 (21.42%) patients received palliative treatment. The median progression-free survival was 1.67 years [95% CI (0.364 - 6.175)] while the median overall survival was 2.0 years [95% CI (0.455 - 6.175)]. Conclusions: Locally advanced EACC where upfront surgery is not feasible, NACT can be considered an option as patients receiving NACT have a 44.44% response rate and surgical resection rate of 42.8%.

Metronomic systemic PCm (paclitaxel, carboplatin + metronomic) neoadjuvant chemotherapy in head and neck cancer

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Background: Neoadjuvant chemotherapy (NACT) in head and neck cancers (HNC) with taxane, platinum, 5-FU (TPF) regimen is both toxic as well as difficult to use in resource-constrained settings. We used a novel combination of weekly chemotherapy and oral metronomic chemotherapy (OMCT) and assessed the efficacy and safety of this combination as NACT in locally advanced HNC patients. Methods: This is a retrospective analysis of prospectively maintained data. 56 patients with technically unresectable HNC received NACT with paclitaxel (80mg/m2) plus carboplatin (AUC2) - weekly schedule and OMCT (methotrexate 9mg/m2 once a week, celecoxib 200mg twice daily, and erlotinib 150mg once daily) - PCm regimen. Patients were assessed clinically and radiologically after a minimum of six cycles for resectability. The radiological response was evaluated as per RECIST 1.1. We report the response rate, resectability, survival, and tolerance of this NACT regimen. Results: The median age of the patients was 41 years. Fifty-two patients (92.9%) were male. Buccal mucosa (60.7%) and oral tongue (17.9%) were the commonest sites of primary seen followed by alveolus (10.7%), the floor of mouth (5.4%), and larynx (5.4%). AJCC 2017 stage IVA and IVB disease were present in 64.3% and 35.7% of patients respectively. Edema up to zygoma (44.6%), high ITF involvement (19.7%), technically unresectable nodal disease (16.1%) and disease reaching up to vallecula (12.5%), or hyoid bone (5.4%), and nodal encasement (180-270 degree) of the internal carotid artery (1.8%) were the reasons for technical unresectability. The median number of NACT administered was six. The tumor showed partial response in 54 (96.4%) patients, 2 (3.6%) patients had stable disease and none of the patients had tumor progression. Surgery was planned in 47 (83.9%) patients after NACT, however due to logistic issues only 35 (62.5%) patients could undergo surgery. Pathological complete response was seen in 27 (48.21%) patients. After a median follow-up of 7.36 months, median PFS was not reached in the whole cohort and surgery group of patients, whereas it was 5.23 (95% CI, 4.08 -6.38) months in the non-surgery group. Median OS was not reached in our cohort. Common grade 3/4 toxicities (CTCAE 5.0) observed were oral mucositis in 6 (10.7%) patients, diarrhea in 4 (7.1%), and febrile neutropenia in 1 (1.7%) patients. Conclusions: Weekly scheduled PCm is an efficacious and well-tolerated regimen and can easily be administered in resource-constrained settings.

Long-term toxicity and tolerance of concurrent docetaxel with radiotherapy in cisplatin ineligible head and neck cancer patients

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Background: Docetaxel can be administered in several situations like low creatinine clearance or pre-existing grade 3-4 ototoxicity, where cisplatin is contraindicated. In this analysis, we present our data on toxicity and tolerance to docetaxel-based chemoradiation in cisplatin-ineligible patients. Methods: Patients who underwent docetaxel-based chemoradiation between January 2015 to December 2017 for locally advanced head and neck cancer, either in the radical or adjuvant setting were selected for this analysis. SPSS version 16 was used for analysis. Results: Nineteen patients were identified and the median age of the cohort was 58 years (range 41-71 years). The most common site of the primary was the oral cavity (n = 9, 47.4%). Sixteen patients (84.2%) had stage IV disease and 3 patients (15.8%) had stage 3 disease. The intent of chemoradiation was radical in 12 (63.9%) patients and adjuvant in 7 (36.1%) patients. Any grade 3 or above adverse events were seen in 12 patients (63.2%). The most common grade 3 or above adverse events observed were mucositis and hyponatremia in 9 patients (47.4%) each. At a median follow up of 5.3 years, the 2-year and 5-year PFS were 26.3% (Standard error-10.1) and 15.8% (Standard error- 8.4) while 2-year and 5-year OS were 36.8% (Standard error-11.1) and 15.8% (Standard error- 8.4). Conclusions: Docetaxel based chemoradiation is a feasible and tolerated option in cisplatin unfit patients and needs further testing in large randomized studies to prove its worth.

Efficacy of Gemcitabine in recurrent meningioma: A phase II study

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Background: Systemic therapy has a limited role in meningiomas. There is in-vivo and in-vitro data that gemcitabine can potentially be useful in meningiomas. We did a phase II study with the primary objective of studying the 6-month progression-free survival (PFS) of gemcitabine in meningiomas. Methods: This was a single-arm prospective phase II study. Adult patients with recurrent meningiomas who were not eligible for local therapies with Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0-1 with normal organ and marrow function were included in this study. Patients who had received any chemotherapy within the last three weeks or on any other investigational agents were excluded. All patients received gemcitabine 1000 mg/m2 administered intravenously over 30 minutes on day 1, day 8 and day 15 every 4 weeks until disease progression or development of intolerable side effects. The response was assessed as per Response Evaluation Criteria in Solid Tumors (RECIST) criteria 1.1. The adverse events were recorded as per the Common Terminology Criteria for Adverse Events (CTCAE) version 4.03. The primary objective of this study was to assess the 6-months progression-free survival (PFS). The 6-months progression-free survival (PFS) of 50% or more was considered sufficient to warrant further studies. Results: Nine patients were recruited in this study. The median age of the patient was 56 years(24-73). The m: f ratio was 2:3. All patients had undergone previous surgeries and 8 patients had undergone previous radiotherapy. The median number of cycles of gemcitabine was 3. Any grade toxicity was observed in all patients. Grade 3 and above adverse events were not observed. The two commonest adverse events noted were anaemia in 7 (77.8%) patients and vomiting in 2 (22.2) patients. The best response was stable disease (SD) in 3 patients (33.4%) and progressive disease (PD) in 6 (66.6%) patients. At a median follow up of 18.8 months, the 6-months progression-free survival (PFS) was 33.3% (95%CI 7.8-62.3). The 1-year overall survival (OS) was 66.7 % (95%CI 28.2-87.8). Conclusions: Gemcitabine failed to meet the prespecified endpoint of 6-month PFS and does not warrant any further investigation in this setting. Clinical trial information: CTRI/2019/02/017499.

Checkpoint inhibitor accessibility in 15,000+ Indian patients

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Background: Access to newer therapies is an issue in low and low middle income countries. Hence we decided to audit our practice in the head and neck and thoracic medical oncology unit from 2015 to 2019 to study the accessibility of checkpoint inhibitors and factors influencing them. Methods: All patients who were registered in the head and neck and thoracic medical oncology unit between 2015-2019 were included in the study. The number of patients who received immunotherapy among them was identified from the prospective database of immunotherapy maintained in the department. We made a list of patients who were eligible for immunotherapy per year and identified how many of them received recommended immunotherapy. The indication for eligibility of immunotherapy was based on published pivotal data and its date of publication of the study online. For nominal and ordinal variable percentage with 95% CI was provided. Factors impacting the accessibility of immunotherapy were identified. Results: A total of 15,674 patients were identified who required immunotherapy; out of them only 444 (2.83%, 95% CI, 2.58-3.1) received it. The distribution of patients eligible as per cancer disease management group and time period is shown in the Table. Among head and neck cancer patients 4.5% (156 out of 3,435) received immunotherapy versus 2.35% (288 out of 12,239) among thoracic cancer patients (p < 0.0001). Among the general category (low socioeconomic), 0.29% (28 out of 9,405) versus 6.6% (416 out of 6,269) among the private category (high socioeconomic) received immunotherapy (p < 0.0001). While 3.7% (361 out of 9,737) among males versus 1.39% (83 out of 5,937) females received immunotherapy (p < 0.0001). There was also a temporal trend seen in the accessibility of immunotherapy (p < 0.0001, Table). Conclusions: The accessibility of immunotherapy is below 3% in India. Patients with head and neck cancers, those with private category and with male gender had higher access to this therapy. There was also a temporal trend observed suggesting increased accessibility over the years. [Table: see text]

Six-year follow-up from the weekly-three-weekly study comparing cisplatin once-a-week to once-every-three-weeks as concurrent chemoradiation for locally advanced head and neck squamous cell carcinoma

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Background: In the weekly-3-weekly (W3W) study, cisplatin at 100 mg/m2 once-every-3-weeks led to superior locoregional control compared to cisplatin 30 mg/m2 once-a-week in combination with radical radiation for locally advanced head and neck squamous cell carcinoma (LAHNSCC). We report the updated analysis of the study. Methods: In this phase III open label non-inferiority study conducted between 2013 and 2017, 300 patients with LAHNSCC were randomly assigned to receive cisplatin 100 mg/m2 once-in-3-weeks or cisplatin 30 mg/m2 once-a-week, concurrently with radiation. The primary endpoint was locoregional control. Secondary outcomes included progression free survival (PFS), overall survival (OS), toxicity, and quality of life. Results: As of February 5, 2022 (median follow-up, 77.3 months), 132 patients (44%) have had an event for locoregional recurrence; 75 (50%) in the once-a-week cisplatin arm and 57 (38%) in the once-every-3-weeks cisplatin arm. The updated estimated cumulative 2-year locoregional control rates were 59.3% and 75.3% in the once-a-week and once-every-3-weeks cisplatin arms, respectively; absolute difference, 16% (95% CI, 7.19 to 24.81). The estimated 5-year locoregional control rates were 48.2% and 55.2% in the once-a-week and once-every-3-weeks cisplatin arms respectively; absolute difference, 7% (95% CI, -2.5 to 16.5). The median time to locoregional failure was 46.1 months (95% CI, 31.63 to 60.56) in the once-a-week cisplatin arm, and 57.9 months (95% CI, 47.1 to 68.6) in the once-every-3-weeks cisplatin arm; HR, 1.43 (95% CI, 1.01 to 2.02); P = 0.042. The estimated median PFS was 17.5 months (95% CI, 0 to 38.31) in the once-a-week cisplatin arm, versus 37.5 months (95% CI, 28.45 to 46.45) in the once-every-3-weeks cisplatin arm; HR, 1.13 (95% CI, 0.85 to 1.5); P = 0.41. Events for OS included 173 (57.7%) deaths; 109 (36.3%) patients are alive, and 18 (6%) are lost to follow-up. The 5-year OS in the once-a-week and once-every-3-weeks cisplatin arms were 43.1% and 48.6%, respectively. Estimated median OS was 38.5 months (95% CI, 16.3 to 60.7) in the once-a-week cisplatin arm, versus 57.3 months (95% CI, 38.6 to 75.9) in the once-every-3-weeks cisplatin arm; HR, 1.19 (95% CI, 0.89 to 1.6); P = 0.238. Details regarding chronic toxicities and second primaries will be presented. Conclusions: Long term follow-up confirms that cisplatin at 100 mg/m2 administered once-every-3-weeks concurrently with radical radiation for LAHNSCC leads to superior locoregional control and should remain the standard of care. The study was not powered to test for a difference in OS; OS was numerically higher in the once-every-3-weeks cisplatin arm, but the difference did not attain statistical significance. Clinical trial information: CTRI/2012/10/ 003062.

An audit of anaplastic carcinoma of thyroid from a single institution

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Background: Anaplastic thyroid carcinoma (ATC) is a rare thyroid malignancy with a dire prognosis, nearly 100% disease specific mortality and a median overall survival of less than 6 months. In view of the limited data from India on anaplastic thyroid cancer we conducted this audit to analyze the treatment pattern, outcomes and factors influencing it. Methods: This is a retrospective analysis of outcomes of patients treated in a single institution between Jan 2008- Dec 2020. Baseline characteristics, treatment received and outcomes among adult patients with ATC were collected. Progression free survival (PFS) and Overall survival (OS) were analyzed. SPSS version 20 and R Studio version 3.1.1 were used for analysis. Results: In this cohort of 134 patients, the median age at diagnosis was 59 years, with 63.4% of them being females. At presentation, 70.9% of them had good performance status (PS 0-1). Only 38.8% received treatment with radical intent (either surgery f.b adjuvant or NACT f.b surgery f.b adjuvant or definitive CTRT) while 61.2% patients received palliative treatment (either palliation alone or palliative chemotherapy or palliative surgery or palliative RT). Predominant pattern of progression was local progression (79.8%). Median PFS and OS of the overall cohort was 58 days and 80 days respectively. PFS and OS was significantly better in patients treated with radical intent vs. palliative intent (116 and 134 days Vs 45 and 50 days; p = 0.00 and 0.00 respectively). Among patients treated with radical intent, OS was significantly better in patients undergoing surgery Vs CTRT (155 Vs 76days; p = 0.03). Among patients treated with upfront surgery, both PFS and OS were better with the addition of adjuvant CTRT/RT Vs no adjuvant (332 and 540 days vs 55 and 91 days; p = 0.00 and 0.003 respectively). Conclusions: ATC is a rare cancer with dismal prognosis. Local therapy with surgery followed adjuvant seems to be associated with the better outcomes. Systemic therapy seems to be a better option for palliation. However the outcomes are far from satisfactory and research is required for development of affordable therapies.

Real-world analysis of BRAF inhibitors with patients positive for BRAF V600E mutations diagnosed with rare tumors

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Background: BRAF mutation is seen in multiple cancers and BRAF inhibitors have a tumor agnostic nature. However there is very limited real world data for BRAF inhibitors and hence we have performed this analysis. Methods: In Tata Memorial Hospital, the medical oncology solid unit 2 maintains a prospective database of all patients who undergo molecular testing. A query was raised from this database and 17 patients were identified who were BRAF mutant positive. The demographic details of these patients, the previous treatment details, the therapy received by these patients, the response to the therapy, the date of progression and the date of death was recorded. Descriptive statistics were performed and Kaplan-Meier analysis was used to estimate the progression-free survival (PFS) and overall survival (OS). Results: In all the 17 patients the mutation was BRAF V600E.The median age of the patients was 58 years (16-77). The m:f ratio was 13:4. The Eastern Cooperative Oncology Group (ECOG) performance status (PS) was 0-1 in 9 patients (52.9%) and 2-3 in 8 patients (47.1%). The primary sites included in the analysis were lung cancer in 8 (47.1), glioma in 3 (17.7), thyroid in 2 (11.8%) and one each of parotid, melanoma, esophagus, thymoma. BRAF inhibitors could be provided in 9 patients (52.9%) and its was dabrafenib-trametinib in 8 patients and vemurafenib then dabrafenib-trametinib in 1 patient. The median progression free survival was 203 days (95% CI 25.1-380.9) and overall survival was 220 days (95% CI 49.8-408.2) . Conclusions: The real world data suggests that the efficacy of BRAF inhibitors seems to be lower than that seen in pivotal studies. The reasons for which is unknown.

Neoadjuvent chemotherapy in rare sinonasal teratocarcinosarcoma: Long-term result from tertiary center

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Background: Sinonasal teratocarcinosarcoma (SNTCS) is a rare and highly aggressive disease entity having poor outcomes with available treatment modalities. Surgery followed by radiation or radical chemoradiation are considered standard therapy. However, in very locally advanced diseases surgery or radiation is not feasible and such patients are subjected to palliative therapy and have dismal outcomes. Methods: We identified 21 patients with very locally advanced SNTCS in our prospectively maintained head and neck cancer database over the last 8 years. All patients were seen in a multidisciplinary clinic prior to the start of therapy and were deemed unfit for local therapy. They were planned for 2 – 3 cycles of Neoadjuvant chemotherapy (NACT). They were then assessed in the multidisciplinary clinic for local therapy. Depending upon the response and performance status further therapy was planned. SPSS version 20 was used for the analysis. Descriptive statistics were performed and the Kaplan Meier method was used to evaluate overall survival(OS) and progression-free survival(PFS). Results: Median age was 50 years (range 27-80 Years) with male to female ratio being 6:1. ECOG PS was 0 in 3(14%), PS 1 in 14(67%) and PS 2 in 2 (9%) patients. 14 (67%) patients had Kadish C and the rest (33%) had Kadish D stage at presentation. Cisplatin & Etoposide was the chemotherapy of choice for the majority of patients (14/21 patients, 67%) with Docetaxel – Cisplatin (5/21 patients,19%), and Ifosfamide – Adriamycin (2/21 patients, 9%) being the other regimens. After NACT 14/21(66%) patients underwent surgery,1/21(4%) underwent radical Chemoradiation,1/21(4%) for palliative radiation therapy and rest for best supportive care. R0 resection was achieved in 11 out of 14 (78.6%) patients. The median PFS of the study was 17.5 months (95% CI 8.2 – 26.7) and the median OS was 19 months (95% CI = 0 -47). Those who underwent surgery after NACT have achieved a median OS of 37.3 months(95% CI 0-77.7) in comparison to 6.3 months (95% CI 0.3 -12.2) for those without surgery (p value 0.02). Conclusions: NACT in very locally advanced SNTCS achieves resectability in ⅔ patients who were unresectable upfront and would have received palliative therapy. This is important as patients who undergo surgery have prolonged overall survival.

Demographics, Pattern of Care, and Outcome Analysis of Malignant Melanomas - Experience From a Tertiary Cancer Centre in India

Background

Treatment of malignant melanoma has undergone a paradigm shift with the advent of immune checkpoint inhibitors (ICI) and targeted therapies. However, access to ICI is limited in low-middle income countries (LMICs).

Patients and Methods

Histologically confirmed malignant melanoma cases registered from 2013 to 2019 were analysed for pattern of care, safety, and efficacy of systemic therapies (ST).

Results

There were 659 patients with a median age of 53 (range 44–63) years; 58.9% were males; 55.2% were mucosal melanomas. Most common primary sites were extremities (36.6%) and anorectum (31.4%). Nearly 10.8% of the metastatic cohort were BRAF mutated. Among 368 non-metastatic patients (172 prior treated, 185 de novo, and 11 unresectable), with a median follow-up of 26 months (0–83 months), median EFS and OS were 29.5 (95% CI: 22–40) and 33.3 (95% CI: 29.5–41.2) months, respectively. In the metastatic cohort, with a median follow up of 24 (0–85) months, the median EFS for BSC was 3.1 (95% CI 1.9–4.8) months versus 3.98 (95% CI 3.2–4.7) months with any ST (HR: 0.69, 95% CI: 0.52–0.92; P = 0.011). The median OS was 3.9 (95% CI 3.3–6.4) months for BSC alone versus 12.0 (95% CI 10.5–15.1) months in any ST (HR: 0.38, 95% CI: 0.28–0.50; P < 0.001). The disease control rate was 51.55%. Commonest grade 3–4 toxicity was anemia with chemotherapy (9.5%) and ICI (8.8%). In multivariate analysis, any ST received had a better prognostic impact in the metastatic cohort.

Conclusions

Large real-world data reflects the treatment patterns adopted in LMIC for melanomas and poor access to expensive, standard of care therapies. Other systemic therapies provide meaningful clinical benefit and are worth exploring especially when the standard therapies are challenging to administer.

Effect of Early Palliative Care on Quality of Life of Advanced Head and Neck Cancer Patients: A Phase III Trial

BACKGROUND

Early palliative care (EPC) is an important aspect of cancer management but, to our knowledge, has never been evaluated in patients with head and neck cancer. Hence, we performed this study to determine whether the addition of EPC to standard therapy leads to an improvement in the quality of life (QOL), decrease in symptom burden, and improvement in overall survival.

METHODS

Adult patients with squamous cell carcinoma of the head and neck region planned for palliative systemic therapy were allocated 1:1 to either standard systemic therapy without or with comprehensive EPC service referral. Patients were administered the revised Edmonton Symptom Assessment Scale and the Functional Assessment of Cancer Therapy for head and neck cancer (FACT-H&N) questionnaire at baseline and every 1 month thereafter for 3 months. The primary endpoint was a change in the QOL measured at 3 months after random assignment. All statistical tests were 2-sided.

RESULTS

Ninety patients were randomly assigned to each arm. There was no statistical difference in the change in the FACT-H&N total score (P = .94), FACT-H&N Trial Outcome Index (P = .95), FACT-general total (P = .84), and Edmonton Symptom Assessment Scale scores at 3 months between the 2 arms. The median overall survival was similar between the 2 arms (hazard ratio for death = 1.01, 95% confidence interval = 0.74 to 1.35). There were 5 in-hospital deaths in both arms (5.6% for both, P = .99).

CONCLUSIONS

In this phase III study, the integration of EPC in head and neck cancer patients did not lead to an improvement in the QOL or survival.

A retrospective study of primitive neuroectodermal tumor (PNET) of the kidney in a tertiary cancer center in India

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Background: Primitive neuroectodermal tumours (PNET) of the kidney are rare tumours with aggressive behaviour. This study was conducted to review the diagnosis and management of patients with renal PNET at our centre. Methods: This was a retrospective study conducted at a tertiary cancer care centre in Mumbai, India. The demographic and clinical data of 17 patients treated by the uro-oncology services were retrieved from electronic medical records. Descriptive analysis was performed for baseline characteristics.Overall & progression-free survival was determined using the Kaplan Meier method. Cox regression was used for multivariate analysis. Results: There were 12 male and 5 female patients in this cohort with a median age of 27 years. At diagnosis 2 patients had metastatic disease and 15 patients had non-metastatic disease. Median follow up in this cohort was 22 months (range 2-30 months). Presenting complaints were hematuria, abdominal pain, flank pain, fever, bone pain, and incidentally detected renal mass. All patients were Mic -2 positive and 13 were FLI-1 positive on immunohistochemistry. Fourteen patients underwent radical nephrectomy. One (5.9%) patient received both neoadjuvant and adjuvant chemotherapy, 8 (47.1%) received adjuvant and 2 (11.8%) received palliative chemotherapy upfront. Eight patients received adjuvant radiation to the renal bed.There was disease progression in12 patients,10 of 15 patients with non metastatic disease at diagnosis eventually developed metastasis.The median progression free survival (PFS) was 10.55 months.The pathological feature that was associated with a shorter PFS was tumor size ⩾10 cm(p = 0.044).The median overall survival was 20.04 months (95% CI 9.49 -not reached). The presence of metastasis and treatment received significantly impacted overall survival (OS). Median OS in patients with non-metastatic disease was not reached versus 14.1 months in those with metastatic disease (p = .019).The median OS in patients treated with multimodality approach was 20.11 months. Patients did not undergo surgery had a median OS of 5.45 months (p < .001) and those who did not receive any chemotherapy had a median OS of 4.57 months (p = .024).Thus, patients who received multimodality treatment had better outcomes. Conclusions: PNET kidney is an aggressive tumor which should be treated with a multimodality approach. Tumor size ⩾10 cm was an adverse prognostic factor.

A randomized clinical trial evaluating the efficacy and safety of the addition of oral metronomic chemotherapy after completion of standard chemoradiation versus observation in patients with locally advanced esophageal and gastroesophageal junction squamous cell carcinoma

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Background: In RTOG 85-01, patients with locally advanced esophageal and gastroesophageal junction (GEJ) cancer treated with concurrent chemoradiotherapy (CRT) had a median overall survival (OS) of 14 months and 5-year OS of 27%. Improving outcomes in these patients is an unmet need. We investigated the addition of oral metronomic chemotherapy (OMC) following definitive CRT. Methods: A randomized integrated phase II/III clinical trial (CTRI/2015/09/006204) in patients with squamous cell carcinoma of the esophagus or the GEJ who had completed definitive radical CRT within the past 12 weeks, had an ECOG PS 0-2 and no clinical or radiologic evidence of progressive disease. Patients were stratified based on whether or not they had received induction chemotherapy followed by CRT, and then randomized 1:1 to receive OMC (celecoxib 200 mg twice daily and methotrexate 15 mg/m2 weekly) for 12 months or observation. The primary efficacy endpoint for the phase II portion was progression free survival (PFS). The secondary endpoints were OS and toxicity. With a power of 70% and an alpha of 10%, we hypothesized a hazard ratio of 1.5, with a median follow-up of 6 months. The planned sample size for the phase II portion was 151 patients. The p-value for stopping the trial after the phase II part of the study was set at 0.2 for the PFS. Results: Between Jan 2016 and Dec 2019, we enrolled 151 patients, 75 to the OMC arm and 76 to observation. The median age was 57 years, 59% were male. The tumor originated in the upper thoracic esophagus in 79% patients, with median tumor length 6 cm. Induction chemotherapy was received by 14% of the patients. Concurrent CRT consisted of median 63 Gy in median 35 fractions; 91% patients received concurrent weekly paclitaxel and carboplatin with radiation. OMC was started at a median of 11 weeks (IQR, 9 to 12) from the start of CRT. Grade 3 or higher toxicities (regardless of relatedness to study intervention) were noted in 27 patients (17.9%), 18 in the OMC arm and 9 in the observation arm; P=0.071. The median time to disease progression or death was 23 months (95% CI, 7.9-38.1) in the OMC arm and not reached in the observation arm; HR, 1.33, 95% CI, 0.83-2.14; P=0.23. The 1-year PFS was 67% in both the arms; the 2-year PFS were 48% and 61% in the OMC and observation arms respectively. The median OS was 36 months (95% CI, 17.9-54) in the OMC arm and not reached in the observation arm; HR, 1.75; 95% CI, 1.02-2.99; P, 0.037. The 1-year OS was 74.7% in the OMC arm and 88% in the observation arm; the 2-year OS was 53.9% in the OMC arm and 75% in the observation arm. Conclusion: Adjuvant oral metronomic chemotherapy after radical CRT does not improve outcomes in patients with locally advanced esophageal or GEJ squamous cell carcinoma. Clinical trial information: CTRI/2015/09/006204.

Quality of life in patients with locally advanced head and neck cancer undergoing chemoradiation with once-a-week versus once-every-three-weeks cisplatin

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Background: This trial was conducted to compare the efficacy of low dose once-a-week cisplatin with once-every-3-weeks cisplatin with radiation in locally advanced head and neck squamous cell carcinoma (LAHNSCC). The current analysis focuses on the quality of life (QoL) of patients in this trial. Methods: In this phase III randomized trial, patients with stage III or IV non-metastatic LAHNSCC were randomized to receive cisplatin 30 mg/m2 once a week or cisplatin 100 mg/m2 once every 3 weeks concurrently with curative intent radiotherapy. The primary endpoint was locoregional control. QoL was a key secondary endpoint. QoL was assessed using the EORTC QLQ-C30 (v.3) and EORTC QLQ-H&N35 (v.1). QoL data were assessed at baseline and days 22 and 43 during treatment; at the end of chemoradiation and at each follow-up. The linear mixed effects model was used for longitudinal analysis of QoL domains to determine the impact of treatment (arm) and time on QoL scores. Results: Three hundred patients were enrolled, 150 in each arm. QoL data from 283 patients with at least one assessable questionnaire were analyzed. The pretreatment QoL scores were similar in both the arms in all domains. There was no significant difference in the global health status/QoL with respect to the treatment arm ( P =0.608) or time ( P=0.0544 ). There was no significant difference in the longitudinal QoL scores between the two treatment arms in all domains except the physical function ( P= .0074), constipation ( P= .0326), trouble with social contact ( P= .0321) and sexuality ( P= .0004). There was a decline in the QoL scores in all domains in both arms during treatment. After completion of treatment, the QoL scores started improving steadily up to 1 year and plateaued thereafter in both arms. Conclusions: The use of once-every-three weeks cisplatin significantly improved the locoregional control without adversely impacting the quality of life as compared to once-a-week cisplatin in combination with radical radiotherapy in locally advanced HNSCC. Clinical trial information: CTRI/2012/10/ 003062. .

Second malignancy post-chemoradiation in head and neck cancer patients

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Background: There is limited data available in the literature regarding incidence and treatment of second malignancy post-chemo-radiation (CTRT) in head and neck cancer patients. Hence we planned this analysis to address this lacuna in the current literature. Methods: We have already published a randomized study of 536 head and neck cancer patients, comparing radical CTRT with weekly cisplatin with or without nimotuzumab. The database of this study was used for the current analysis. Data regarding occurrence, site, stage, treatment details and outcomes were extracted from the database. Continuous variables were expressed in terms of the median with range, while non-continuous variables were reported in percentage. Kaplan Meier method was used for estimating the overall survival (OS). Results: Out of 536 patients, 18 (3.35%) patients developed second malignancy. The most common site was head and neck (44.44%) followed by lung (27.77%), prostate, ovary, breast, gallbladder and thyroid. 16/18 (88.88%) patients developed metachronous, while 2/18 (11.11%) had synchronous second malignancy. Most of the patients (55.55%) presented with locally advanced and metastatic disease, while 44.44% of patients had early-stage disease. 8/18 (44.44%) patients received palliative treatment. Of these, 6/18 (33.33%) patients received best supportive care and 2/18 (11.11%) patients were given palliative chemotherapy and palliative radiotherapy. 10/18 (55.55%) patients received radical treatment in the form of radical surgery (22.22%), CTRT (11.11%) and radical radiotherapy (5.55%), while 16.66% patients were kept under observation only. The median OS after the diagnosis of second malignancy was 451 days (95% CI, 301.45-600.59). It was seen that median OS the diagnosis of second malignancy in the aerodigestive and non-aerodigestive system was 446 days (95% CI, 39.10 - 852.89) and 840 days (95% CI, 278.46 - 1401.53), log-rank test P-value = 0.24. Conclusions: Second malignancy is not an uncommon phenomenon in head and neck cancer patients after CTRT and if properly taken care of, the improved outcome can be expected.

Association of immune-related adverse effects and survival in responders treated with immune checkpoint inhibitors

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Background: The development of immune-related adverse effects (irAEs) can corroborate with the response to immune checkpoint inhibitors (ICIs). However, there is very limited data on the association of irAEs with survival in patients who have shown response to ICIs. Methods: This study is a retrospective audit of prospectively collected database of patients who received ICIs for advanced solid tumors. Responders were defined as patients who attained best response of either complete response (CR) or partial response (PR). Time-to-event analysis was done using Kaplan-Meier estimator and hazard ratio was calculated by using Cox proportional model. Results: A total of 155 patients who received ICI during the specified period were evaluated for this study. The response rate was 19.4%. One year OS for responders was 75.6% (SD 8.8) versus 26.1% (SD 5.1). The median OS for patients who developed irAE was 12.3 months (95% CI: 8.9-15.6) while it was not reached for patients without irAE (HR 10.5, 95% CI 1.2-NR, p=0.007). One-year OS for the corresponding group of patients was 53.6% (SD 15.6) versus 92.9% (SD 6.9), respectively. Conclusions: This study reports negative association of immune-related adverse effects and survival in responding patients of solid tumors treated with immune checkpoint inhibitors. [Table: see text]

Indication of adjuvant chemoradiation post neoadjuvant chemotherapy in very locally advanced borderline resectable head and neck cancer

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Background: Adjuvant chemoradiation (ACRT) is indicated in the presence of margin positivity or extranodal extension. However, indications of ACRT post neoadjuvant chemotherapy (NACT) is not well defined. At our centre, ACRT is administered in the majority of patients who undergo NACT. This analysis was performed to identify indications for the avoidance of ACRT post NACT. Methods: 160 very locally advanced borderline resectable HNSCC who underwent surgery after NACT were selected. The adjuvant treatment administered was either radiation or chemoradiation at the discretion of the joint clinic. The post-surgical tumour and nodal specimen were graded in accordance with modified tumour regression grade (MTRG). Where grade 1 indicated a complete pathological response. The primary endpoint was disease-free survival (DFS). The patients were divided into 3 biological distinct classes. Group-1 had a pathological complete response (CR) in both tumour and nodes, Group-2 had pathological CR in either tumour or nodes and Group 3 had no pathological CR. Kaplan Meier method was used for the estimation of DFS. The stratified (for groups) log-rank test was used for evaluating the impact of adjuvant radiation. Stratified Cox regression analysis was used for the calculation of hazard ratio. A p-value of 0.05 was considered significant. Results: There were 56 patients (35%) in group 3, 75 (46.9%) in group 2 and 29 (18.1%) in group 1. The overall median DFS was 89.067 months (95%CI 15.345-162.788). The 5-year DFS was 22.1% in group 3, 75.4% in group 2 and 92.3% in group 1 ( P-value < 0.0001). Adjuvant radiation was received by all patients and concurrent chemotherapy was received by 134 (83.8%) patients. Use of concurrent chemotherapy decreased the hazard of disease recurrence (HR-0.297 95%CI 0.135-0.656, P-value = 0.003). The stratified log-rank test p-value was 0.002. Conclusions: Adjuvant chemoradiation is needed after neoadjuvant chemotherapy in very locally advanced borderline resectable head and neck cancer

Low-cost oral metronomic versus intravenous chemotherapy in recurrent, inoperable and metastatic head and neck cancer: Phase III Metro-CIS study

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Background: The NCCN preferred regimens for palliation in head and neck cancer, either EXTREME or KEYNOTE-048 are the only two regimens which have improved outcomes over chemotherapy, but they have limited applicability (1-3%) in low and middle-income countries due to the cost. Oral metronomic chemotherapy (OMC) has shown better outcomes than intravenous cisplatin; these results were obtained with a low incidence of adverse events and the cost of 1/100th of NCCN-preferred regimens in a Phase II study. Methods: This was a randomized Phase III non-inferiority open-label study. Adult patients with relapsed-recurrent or metastatic upfront palliatively treated squamous cell carcinoma of head and neck and ECOG PS 0-1 were eligible. Patients were randomized 1:1 between OMC (oral methotrexate 15 mg/m2 weekly with celecoxib 200 mg once daily or intravenous cisplatin (IVC) 75 mg/m2, 3-weekly for 6 cycles. CTCAE version 4.0 was used for adverse event recording. Response assessment (RECIST version 1.1) was performed every 2 months. EORTC QLQ-C 30 and EORTC QLQ -H&N 35 questionnaires were self-administered at baseline and 2-monthly thereafter. The primary endpoint was overall survival (OS) and was measured from the date of randomization to death. Assuming a 6-month OS in IVC arm of 40%, the non-inferiority margin of 13%, type 1 error of 5% (2-sided), type 2 error of 20% and lost-to-follow up rate of 20%, a total sample size of 422 subjects was required. Kaplan Meier method was used for the estimation of OS and progression-free survival (PFS). To determine non-inferiority the upper limit of 95% CI of difference between 6 months OS of the 2 arms had to be below 13%. Results: In the intention to treat analysis, the 6-months OS was 50.89% (95% CI, 43.3-57.97) and 62.26% (95% CI, 54.72-68.9) in the IVC and OMC arm respectively. The difference in 6-months OS between the 2 arms was - 11.37% (95% CI, -20.77 to -0.97). The median OS was 6.1 (95% CI, 5.33-6.93) versus 7.5 (95% CI, 6.5-8.8) months in IVC arm and OMC arm respectively ( P= .026). The unadjusted hazard ratio for death was 0.773 (95% CI, 0.615-0.97, P= .026). The median PFS was 1.67 (95% CI, 1.47-2.03) versus 3.23 (95% CI, 2.57-4.13) months in IVC and OMC arms respectively ( P< 0.001). Any grade 3 or above adverse events were seen in 61 (30.2%) versus 37 (18.9%) patients in IVC and OMC arm respectively ( P= .01). Conclusions: OMC improves outcomes in palliatively treated head and neck cancer and is a new standard of care in this setting, in addition to the EXTREME and KEYNOTE-048 regimen. Clinical trial information: CTRI/2015/11/006388 .

Incidence of 5-fluorouracil related in cardiotoxicity in patients with head and neck cancer

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Background: Combination chemotherapy with cisplatin-fluoropyrimidine backbone is the standard of care for locally advanced head and neck cancer in the neoadjuvant setting. 5-Fluorouracil (5FU) is administered as a continuous intravenous infusion over 5 days. However, 5-FU may induce acute cardiotoxicity preventing its subsequent use. Incidence of 5-FU-induced cardiotoxicity ranges from 0.99 to 19.9% in published studies, which have been assessed predominantly in gastrointestinal malignancies. In the pivotal TAX323 and TAX324 trials, utilizing 5FU (750 mg/m2 continuous infusion for 5 days), docetaxel and cisplatin (TPF) as neoadjuvant chemotherapy, no cardiotoxicity was reported. We evaluated the development of cardiotoxicity from the use of the TPF regime in our patients with locally advanced head and neck cancer. Methods: Post-hoc analysis of patients treated on the TPF arm of a randomized controlled trial in our institution for locally advanced head and neck cancer in the neoadjuvant setting from 2016 to 2019. Results: 246 patients received TPF neoadjuvant chemotherapy for locally advanced head and neck cancer. Cardiotoxicity occurred in 16 patients; thus, the incidence was 6.5% (95% CI, 3-10%). Two-thirds of the cardiac events occurred in the 1st cycle. Mean time to onset of symptoms was 109.5 hours (4th day of the infusion). The most common events were chest pain (9 patients [56%]), asymptomatic bradycardia (5 patients [31%]) and syncope (2 patients [12%]). Dynamic ECG changes were seen in 5 patients with ST-segment elevation myocardial infarction occurring in one patient. Most common rhythm abnormality identified was bradycardia (7 patients) and in most cases, patients were asymptomatic (5 patients) for the same. Only 2 patients had LV dysfunction detected on echocardiography after the event. Cardiotoxicity resolved in 12 patients (75%). Conclusions: 6.5% of patients treated with 5-FU developed cardiotoxicity with most patients developing symptoms by day 4 of the 1st cycle; chest pain was the most common symptom.

Hypothyroidism and its impact on outcomes in head and neck cancer

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Background: Hypothyroidism is a known late side effect of chemo-radiation in head and neck cancer. Hypothyroidism has been known to be associated with improved outcomes in renal cell carcinoma. Whether such a phenomenon exists in head and neck cancer is unknown. Methods: We performed a phase 3 study evaluating the role of Nimotuzumab in head and neck squamous cell cancers (HNSCC). In this study adult HNSCC patients treated with Cisplatin and radiation were randomly assigned to receive Nimotuzumab or not. The data of this study has been utilized for this analysis. Hypothyroidism was defined as TSH level more than 4.95 U/L. The cumulative incidence of hypothyroidism and its impact on PFS (progression free survival), OS (overall survival) and loco-regional control (LRC) was evaluated using binary regression analysis. To study the impact of hypothyroidism in outcomes a landmark analysis was performed. Results: 176/536 patients analyzed developed hypothyroidism with a cumulative incidence of 33%. Hypothyroidism showed a favorable impact on PFS, OS and LRC. Median PFS was 19.5 months while median OS was 22.2 months in the euthyroid subgroup vs not reached (NR) for both in the hypothyroid subgroup. The respective hazard rates (HR) for PFS and OS was 0.37 (95% CI: 0.27 - 0.52) and 0.15 (95% CI: 0.11 - 0.23). The LRC was also better with its median duration being 39.2 months vs NR in the euthyroid and hypothyroid subgroups respectively; HR for LRC being 0.40 (95% CI: 0.28 - 0.58). Conclusions: Thus development of hypothyroidism is associated with improved outcomes in HNSCC in terms of LRC and survival.

Prognostic value of radiological extranodal extension detected by computed tomography for predicting outcomes in head and neck squamous cell cancer patients treated with radical chemoradiotherapy

6560

Background: As per the AJCC 8th edition ENE/ECS is the most important predictor for N staging of HNSCC and is one of the key predictor of outcomes. Because ENE/ECS is based on pathological findings after surgery and it is difficult to predict outcomes for locally advanced squamous head and neck cancer (LASHNC) treated radically with CCRT. We hypothesized that ENE assessed by CT imaging (rENE) may directly correlate with outcomes in LASHNC treated radically with CCRT. Methods: This open-label, investigator-initiated, phase 3, randomized trial was conducted from 2012 to 2018. Adult patients with LASHNC who were fit for radical chemoradiation were randomized 1:1 to receive either radical radiotherapy (66-70 grays) with concurrent weekly cisplatin (30 mg/m2) (CRT) or the same schedule of CRT with weekly nimotuzumab (200 mg) (NCRT). 536 patients were accrued,182 were excluded due to non-availability DICOM CT scan, 354 patients were analysed for rENE (based on 6 criterion for metastasis and 3 for rENE). Near equal distribution of patients was achieved in CRT arm (170 patients) and NCRT arm (184 patients). There were 181 (51.1%) oropharynx and 173(48.9%) larynx and hypopharynx patients. We evaluated association of radiological ENE and clinical outcomes.The endpoints were disease-free survival (DFS), duration of locoregional control (LRC), and overall survival (OS). Results: There were 244(68.9%) patients with radiologically metastatic nodes, out of which 140(57.3%) had rENE. There was no significant association between rENE and CRT (p value 0.3) or NCRT (p value 0.412). The median follow-up was 33.0 months (95%CI 30.7-35.2 months). Complete response was achieved in 204 (57.6%) cases, PR/SD in 126(35.6%) cases and PD in 24(6.8%) cases. rENE positive patients had poor overall 3-year survival (46.7%), poor DFS (48.8%) and LRC (39.9%) than rENE negative cases (63.6%, 87%, 60.4%). rENE positive cases had 1.71 times increase chances of incomplete response than rENE negative cases. Overall stage, clinical positive node, response, rENE and site were the only significant factors for predicting OS, DFS and LRC. Conclusions: In conclusion, pre-treatment rENE can be regarded as an independent prognostic factor for survival (OS, DFS, LRC) in patients with LASHNC treated radically with CCRT. Pre-treatment rENE is not only associated with CCRT response but is also associated with poor prognosis and hence rENE, as an imaging biomarker, can stratify responder’s vs non-responders. Clinical trial information: CTRI/2014/09/004980 .

Leptomeningeal metastasis from non-small cell lung cancer- outcomes from a tertiary care center

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Background: Leptomeningeal metastasis from Non-Small Cell Lung Cancer is often an underdiagnosed entity. Despite advances in treatment, the outcomes of Leptomeningeal Metastasis continues to be dismal. The data on outcomes of leptomeningeal metastasis from a tertiary care centre is limited. Methods: Data collected from the 4 prospective randomised controlled trials conducted on Non Small cell Lung cancer patients at our centre in the last decade was used in the analysis. These included 1. Patients who had EGFR sensitizing mutations enrolled in the Pemetrexed versus Gefitinib maintenance trial and Gefitinib versus Gefitinib plus chemotherapy trial. 2. Patients who were diagnosed as Squamous Cell Carcinoma of lung enrolled in the Low Dose Gemcitabine versus Standard-Dose Gemcitabine trial. 3. Patients with adenocarcinoma who were enrolled in the Pemetrexed versus Erlotinib maintenance trial. We separated the patients who developed Leptomeningeal Metastasis from these trials and studied its incidence, presenting features and outcomes. Statistical analysis was done using cox regression analysis and kaplan meier plots. Results: Out of 1148 patients, 36 patients (0.031%; 95%CI 0.022-0.043) developed leptomeningeal metastasis. In these patients, the median time to development of LM was 14.92 months (IQR 7.7-21.84). The median overall survival after development of LM was 61 days (95%CI 38.95-83.05). None of the tested factors- Age (Hazard ratio-0.886; 95% CI 0.424-1.851, P-value = 0.747), ECOG PS (Hazard ratio-0.719; 95%CI 0.299-1.729) or driver mutation status ( Hazard ratio-2.080, 95%CI 0.739-5.855) had an impact on OS. The median OS in driver mutated patients was 66 days (95% CI 14.74-117.26) versus 51 days (95% CI 14.5-87.5) (P-value = 0.201). Conclusions: In our study, there was no single factor which impacted survival in patients who developed Leptomeningeal Metastasis. The median survival was in the range of 2 months. This reiterates the overall poor prognosis of development of Leptomeningeal Metastasis in Non small Cell Lung Cancer even with the development of newer therapeutic modalities. Keywords- Leptomeningeal metastasis, Non small cell lung cancer, Incidence, Survival.

Aprepitant in weekly cisplatin with radiation in head and neck cancer: Is it required?

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Background: Weekly cisplatin below 50 mg/m2 has lower emetogenic potential than 100 mg/m2 3weekly regimen. There is limited data on the utility of Aprepitant with weekly cisplatin used in radiation in head and neck squamous cell cancer (HNSCC). Methods: We conducted a phase 3 randomized trial in locally advanced HNSCC patients who were treated with definitive chemoradiation either with cisplatin or cisplatin-nimotuzumab. 5HT3 inhibitor and steroids +/- aprepitant were used as antiemetic prophylaxis as per physician discretion. The current analysis is focussed on studying the impact of aprepitant on nausea and vomiting. Fischer’s exact test was used to compare the chemotherapy induced nausea vomiting (CINV) rates between aprepitant and non-aprepitant groups. Binary logistic regression analysis was used to calculate the odds of CINV with the use of aprepitant. Results: Data on CINV is available for 524/536 patients. Nausea was present in 251 (47.9%) patients while vomiting was seen in 155 (29.6%) patients. Aprepitant, 5HT3 antagonist and dexamethasone were administered to 265 (50.86%), while 256 received 5HT3 antagonist and dexamethasone. Among patients receiving aprepitant, nausea was present in 112 (42.3%), while there was no nausea in 153 (57.7%) patients (p = 0.011). Vomiting with aprepitant was seen in 71 (26.8%) patients while 194 (73.2%) had no vomiting (p = 0.151). Adjusted odds ratio for use of aprepitant containing antiemetic prophylaxis in prevention of CINV were 1.585 (1.116-2.249;p = 0.010) and 1.328 (0.904-1.951;p = 0.149) as depicted in the table. Conclusions: Use of aprepitant significantly decreases nausea and is needed for weekly cisplatin regimens used in radiation in head and neck cancers. [Table: see text]

Effect of early integration of specialized palliative care into standard oncologic treatment on the quality of life of patients with advanced head and neck cancers: A phase III randomized controlled trial

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Background: Early palliative care is an important aspect of palliative treatment but has never been evaluated in head and neck cancer. Hence we performed this study. Methods: This was an open-label phase 3 randomised study which enrolled adult patients with squamous cell carcinoma of the head and neck region which warranted palliative systemic therapy. They were 1:1 allocated to either systemic therapy with (EPC arm) or without the addition of early palliative care service (STD arm). Patients were administered the Edmonton Symptom Assessment Scale (ESAS-r) and FACIT HN questionnaire at baseline and 4 weekly thereafter for 12 weeks. The primary endpoint was change in the quality of life (QOL) measured using FACIT HN 12 weeks after randomization. The secondary endpoints were changed in symptom burden at 12 weeks in ESAS-r and overall survival. A repeated-measures analysis of covariance (ANCOVA) was performed to examine the effects of arm and stratum on change in QOL (or symptom score), after controlling for baseline score. Results: Ninety patients were randomised in each arm between 1st June 2016 to 14th August 2017. The compliance with the questionnaires was 100% at baseline. In EPC arm the 70 patients were alive at 3 months and 67 (95.7%) completed the FACIT HN and 64 (91.4%) completed ESAS-r questionnaires. While in the STD arm out of 69 alive the corresponding figures were 61(88.4%) and 59 (85.5%) respectively. There was no statistical difference in change in QOL scores and ΔESAS-r at 12 weeks between the 2 arms (Table). The median overall survival was similar between the 2 arms. (Hazard ratio for death-1.006 (95%CI 0.7347-1.346)). Conclusion: In this phase 3 study, integration of early palliative care in head and neck cancer patients did not result in improvement in the quality of life scores, symptom scores or overall survival. Clinical trial information: CTRI/2016/03/006693 . [Table: see text]

A phase III randomized clinical trial of diclofenac versus tramadol for mucositis-related pain in head and neck cancer patients undergoing concurrent chemoradiation

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Background: Oral mucositis related pain during CTRT in head and neck cancers is a common problem. Unfortunately, in spite of it being common, there is limited evidence for selection of systemic analgesic in this situation. Hence, this study was designed to compare the analgesic effect of an NSAID (diclofenac) versus a weak opioid (tramadol). Methods: This was an open-label, parallel design, superiority randomized controlled study. In this study head and neck cancer patients undergoing radical or adjuvant chemoradiation, who had grade 1 or above mucositis (in accordance with CTCAE version 4.03) and had pain related to it were randomly assigned to either diclofenac or tramadol for mucositis related pain control. The primary endpoint was analgesia after the 1st dose. The secondary endpoints were the rate of change in analgesic within 1 week, adverse events, and quality of life. Results: 128 patients were randomized, 66 in diclofenac and 62 in tramadol arm. The median AUC for the diclofenac arm and the tramadol arm were 348.936 units (Range 113.64-1969.23) & 420.87 (101.97-1465.96) respectively (p = 0.05619). Five patients (8.1%) in the tramadol arm and 11 patients (16.7%) in the diclofenac arm required a change in analgesic within 1 week of starting the analgesic (p = 0.184). There was no statistically significant difference in any adverse events between the 2 arms. However, the rate of any grade of renal dysfunction was numerically higher in diclofenac arm (10.6% versus 4.8%, p = 0.326). Conclusions: In this phase 3 study, evaluating diclofenac and tramadol for Chemoradiation induced mucositis pain, the analgesic efficacy of both analgesics was found to be similar but diclofenac was associated with a higher rate of renal dysfunction. Clinical trial information: CTRI/2016/09/007302 .

Efficacy and safety of neoadjuvant chemotherapy (NACT) with paclitaxel plus carboplatin and oral metronomic chemotherapy (OMCT) in patients with technically unresectable oral cavity squamous cell carcinoma (SCC)

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Background: NACT regimen for patients with oral cavity scc is based on maximum tolerated doses (MTD). Combination of MTD and metronomic chemotherapy schedule will lead to initial debulking of tumor and subsequent inhibition of angiogenesis, this may produce synergistic effect and overcome the drug resistance of MTD schedule. We assessed the efficacy and safety of this combination as NACT in patients with technically unresectable oral cavity SCC. Methods: This is retrospective analysis of prospectively maintained data. Fourteen patients having technically unresectable oral cavity SCC received NACT with paclitaxel (175mg/m2) plus carboplatin (AUC5) 3 weekly (MTD schedule) and OMCT (methotrexate 9mg/m2 once a week, celecoxib 200mg twice daily and erlotinib 150mg once daily). Patient were assessed clinically and radiologically after minimum of two cycles for resectability. Radiological response was evaluated as per RECIST 1.1. We report response rate, resectability and tolerance of this NACT regimen. Results: Median age of the patients was 38 years. Twelve patients (85%) were male. Twelve (85%) and two (15%) patients had buccal mucosa and oral tongue primary respectively. AJCC 2017 stage IVA and IVB disease was present in 85% and 15% patients respectively. Reason for technical unresectabilty was skin edema above zygoma in five (36%), high infratemporal fossa involvement in five (36%), nodal encasement of major vessels in two (14%) and posterior extent of oral tongue tumor into oropharynx in two (14%) patients. Median number of NACT administered were three. The tumor of nine (64%) patients showed partial response and none of the patients had tumor progression. Tumor of nine patients (64%) were deemed resectable after NACT. Common grade 3/4 toxicities (CTCAE 5.0) were neutropenia in eight (57%), thrombocytopenia in three (21%), febrile neutropenia, hypokalemia and diarrhoea in two patients (14%) each. Conclusions: Paclitaxel and carboplatin along with OMCT is well tolerated and easily administered NACT regimen with high response rate and resectabilty in patients with technically unresectable oral cavity SCC.

Optimal cumulative cisplatin dose for radio-sensitization in locally advanced head and neck cancer

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Background: Evidence to choose the optimum chemotherapy between weekly and 3 weekly cisplatin for prolonging the duration of progression free survival in head and neck squamous cell carcinoma (HNSCC) is equivocal. This urged us to look into the cumulative dose of chemotherapy rather than the frequency of administration i.e. weekly or 3 weekly. The aim of this study was to determine the optimal cumulative dose of cisplatin to improve the progression-free survival (PFS). Methods: Between January 2011 and January 2018, a total of 836 consecutive patients with histologically proven primary squamous cell carcinoma of the oral cavity, larynx, hypopharynx, and oropharynx were included. The effect of the cumulative dose on progression-free survival was studied to obtain the optimal cumulative dose of cisplatin. Results: A total of 11 cohorts were generated to represent the cumulative doses. The cumulative doses were measured at 30, 60, 90,120,150,180,200,210,240 and 300 mg/m2 respectively. The maximum duration of progression-free survival (PFS) was considered to define the best effective cumulative dose. Conclusions: This study confirms that a cumulative cisplatin dose of ~ 210 mg/m2 is optimum for increasing PFS in patients with head and neck cancer. Therefore, doses with weekly 30 mg/m2 for seven cycles or 3-weekly 70 mg/m2 for 3 cycles could be equally effective to prolong the PFS. Clinical trial information: CTRI/2012/10/003062, CTRI/2014/09/004980.

Deep learning-based predictive imaging biomarker model for EGFR mutation status in non-small cell lung cancer from CT imaging

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Background: Deep learning based radiogenomic (DLR) models present a promising performance in assisting lung cancer care. The purpose of this study was 1) To develop and validate DLR signatures to predict the EGFR mutation, 2) To assess the incremental value of these DLR signatures in comparison to the traditional clinical and semantic features. Methods: 223 patients were selected from two phase III randomized trials in patients with advanced non-squamous NSCLC with EGFR-sensitizing mutation and EGFR wild type who were planned to receive palliative therapy (trial 1: gefitinib or gefitinib plus pemetrexed and carboplatin and trial 2: pemetrexed maintenance and erlotinib maintenance). Our method is an end-to-end pipeline that requires only the manually selected tumour region in a CT image without precise tumour boundary segmentation or human-defined features. Two deep convolutional neural networks with 3D U-Net architectures are trained to segment lung masses and nodules from 3D regions of the CT image. The primary end point was EGFR prediction using Radiomics and DLR pipeline. We also compared the performance of combination of models in predicting the mutational status. Results: A total of 223 patients (mean age, 54.18 years; age range, 28–80 years) were included in this study. There were 121 (54.3%) patients with EGFR mutation and 102 (45.7%) patients who were EGFR wild type. On multivariate logistic regression analysis, Clinical variable and CT semantic features that were found to be significantly associated EGFR mutation were tumor stage, smoking status, pure solid texture, presence of non-tumor lobe nodule, and average enhancement. For predicting EGFR mutation, ROC curve plotted with clinical variables model, CT semantic variables model, Radiomics model, DLR model showed an AUC value of 0.70, 0.73, 0.94, 0.72 respectively. Clinical variables and semantic features were added to the radiomics predictive model and deep learning predictive model independently, showed further improvement in the accuracy for either model from AUC 0.94+/-0.02 to 0.96+/-0.02 and from AUC 0.72+/-0.02 to 0.82+/-0.04 respectively. Conclusions: The radiomics and DLR model by machine-learned information, extracted from CT images without precise manual segmentation, could predict EGFR mutation with very high accuracy. This AI based model can be used as non-invasive and easy-to-use surrogate imaging biomarker for EGFR mutation status prediction. Clinical trial information: CTRI/2018/10/022102 .

Long-term outcomes of locally advanced and borderline resectable esthesioneuroblastoma and sinonasal tumor with neuroendocrine differentiation treated with neoadjuvant chemotherapy

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Background: Sinonasal tumors are a rare subgroup of head and neck cancers. Locally advanced esthesioneuroblastoma and sinonasal neuroendocrine tumors (SNEC) are treated with a multidisciplinary approach with combination of surgery followed by adjuvant radiation or chemo radiation; but have unsatisfactory outcomes. Hence we devised the approach of administering neoadjuvant chemotherapy (platinum and etoposide) followed by surgery and adjuvant chemoradiation. This approach had the advantage of improved response rates, orbital preservation and improvement in short term outcomes. The present analysis was done to estimate the 5 year outcomes and late adverse events of locally advanced sinonasal tumors treated with induction chemotherapy followed by local therapy. Methods: Twenty five patients with locally advanced esthesioneuroblastoma or SNEC treated between August 2010 to August 2014 with induction chemotherapy followed by local therapy were selected. The 5 year outcomes and late adverse events (CTCAE version 4.02) were noted. Progression free survival (PFS) and overall survival (OS) were estimated using the Kaplan Meier method. COX regression analysis was used to identify factors impacting PFS and OS. Results: The median follow up was 5.15 years. The 5 year PFS in esthesioneuroblastoma cohort and in SNEC cohort was 63.5% (95%CI 28.9-84.7) and 34.6% (95%CI 10.1-61.1) respectively (p = 0.1). The only factor impacting PFS on multivariate analysis was response to neoadjuvant chemotherapy (p = 0.033). The 5 year OS in esthesioneuroblastoma cohort and in SNEC cohort were 91.7% (95%CI 53.9-98.9) and 46.2% (95%CI 19.2-69.6) respectively (p = 0.024). Any grade late adverse event was seen in 20 patients (80%). Metabolic late adverse events were seen in 19 patients (76%). Conclusions: Neoadjuvant chemotherapy in advanced sinonasal cancers is associated with improvement in 5 year outcomes. However late side effects especially metabolic are seen in these patients and should be evaluated during follow up. Keywords: Sinonasal; Adverse event; Esthesioneuroblastoma; SNEC; Induction; Neoadjuvant [Table: see text]

Acute lead encephalopathy in early infancy--clinical presentation and outcome

We studied 19 infants with a mean age of 3.8 months who presented with features consistent with acute lead encephalopathy following the use of traditional medicines. All presented with convulsions; CT scans of the brain on admission showed brain oedema in four, atrophy in four and normal findings in 11. Cerebrospinal fluid analysis in nine patients showed pleocytosis in six and a high protein content in eight. The median lead level in these 19 infants which encephalopathy was 3.6 mumol/l (74.5 micrograms/dl). Seven had a mean lead level of only 2.7 mumol/l (56.9 micrograms/dl) which is much below 70 micrograms/dl, the level usually proposed as the threshold for encephalopathy. Thirteen infants developed brain damage during follow-up; statistical analysis correlated the lead level at 2 months post chelation with an abnormal neurological outcome. Our findings indicate that in very young infants acute lead encephalopathy may occur at lead level lower than previously reported.

del(18p) syndrome with complex tetralogy of Fallot in an infant with 45,X,t(Y;18)(q12;q11.2)

We report on an infant with multiple congenital anomalies, tetralogy of Fallot, and Karyotype 45,X,t(Y;18)(q12;11.2). The infant's anomalies are consistent with a del(18p) syndrome, except for the exceptional severity of the heart defect.

Neonatal congenital Factor X deficiency

Four neonates with congenital Factor X deficiency presented soon after birth with bleeding episodes. Two of the newborns had intracranial hemorrhages; one of them also had antenatal ventricular dilatation and postnatal hydrocephalus and died of massive intracerebral hemorrhage at four months. One patient was lost for follow up. The two surviving infants were followed up for four years and two years respectively, while on replacement therapy with three injections of 40 units/kg prothrombin complex a month. In spite of markedly elevated prothrombin time and partial thromboplastin time, these two infants remain free of major bleeding manifestations except for troublesome petechiae and ecchymoses. A schedule for substitution therapy with Factor X is proposed for infants and children to prevent bleeding in severe Factor X deficiency.

Mebendazole poisoning in infancy

Accidental mebendazole poisoning in an 8-week-old infant and respiratory arrest with tachyarrhythmia associated with continuous seizures is reported. Exchange transfusion was undertaken as a life-saving measure. Mebendazole, like piperazine citrate, has considerable neurotoxicity, especially in infancy, and we propose the use of exchange transfusion as a means of mebendazole elimination in infants.