Exploring the role of “Glycerine plus Honey” in delaying chemoradiation induced oral mucositis in head and neck cancers

Purpose: The purpose of this study was to assess the efficacy of adding “Glycerine plus Honey” to standard management protocol, in terms of time to delay in oral mucositis ≥ grade 2.Methods: Hundred patients of oral cavity and oropharangeal cancers, planned for concurrent chemoradiation (Dose: 60–66 Gy/30-33 fractions) were randomized 1:1 to receive either home-made remedy made of “Glycerine plus Honey” added to the standard management protocol to prevent mucositis versus standard treatment alone. CTCAE v 4 (Common toxicity criteria for adverse events) was used for assessing oral mucositis scores weekly. Chi square test was used to compare mucositis scores, weight loss, opioid use, ryles tube feeding, and unplanned treatment breaks in each cohort. Independent T-test was used to compare means to assess the effect of treatment in delaying mucositis ≥ grade 2.Results: Significantly higher number of patients developed grade ≥ 2 mucositis in control arm [n = 43 (86%)] compared to study arm [n = 30 (60%)] (p = 0.003). CTCAE scores favored Glycerine plus honey at week 4, and on last day of radiotherapy. Whereas, time to first occurrence of oral mucositis grade ≥ 2 was 23.17 (± 1.01) days for study arm [radiation dose 31.67 Gy (± 1.44)], it was 20.65 (± 0.8) days for control arm [radiation dose 28.14 Gy (± 1.16)] (p = 0.05). Study patients had lesser weight loss (2.76 kg) than control subjects (3.9 kg) with p = 0.008. There were significantly higher number of patients in control arm who required opioid analgesia, ryles tube insertion and had unplanned treatment breaks, compared to study arm.Conclusion: Glycerine plus honey demonstrated superiority in delaying oral mucositis, and the combination is safe and well tolerable.

Can neck irradiation be an alternative to neck dissection in early stage carcinoma oral tongue operated for primary alone? Experience from a single institute

Purpose: To study pattern of failure, locoregional control rates (LCR) and disease free survival (DFS) in post-operative patients of carcinoma oral tongue, and to study the impact of nodal dissection on DFS in stage I and II patients.Methods: 102 patients of carcinoma oral tongue treated between January 2009 and December 2013 were analyzed. All patients were operated for primary disease, but neck dissection was done in 78 (76.5%) patients only. However, radiation to primary site along with neck region was received by all patients. Pattern of failure, LCR and DFS were estimated.Results: At median follow up of 12 months, 10.8% patients failed locally, 10.8% in nodal region, 2.9% both at local and nodal site, and 5.9% patients failed distally. 2 year LCR and DFS was 71.2%, 90.9%, 79.5%, 0% and 55.2%, 64.4%, 57.8%, 0% in stage I, II, III, IV respectively. 2 year DFS in stage I patients, who underwent nodal dissection and post-operative radiation (14 patients) was 64.3% and in whom only neck irradiation was done (15 patients), it was 45.8%, however difference was not significant (p = 0.5). But in stage II patients, 33 patients who underwent nodal dissection and post-operative radiation, 2 year DFS was 85.4% and it was 21.4% in 7 patients who underwent neck radiation only, and difference showed trend towards significance (p = 0.05). 2 or more positive lymph nodes post dissection was the only poor prognostic factor that correlated with DFS (p = 0.02)Conclusion: While in stage I, neck irradiation alone can be a possible alternative to neck dissection and post-operative radiation; for stage II, neck dissection is mandatory

Comparison of concomitant boost radiotherapy against concurrent chemoradiation in locally advanced oropharyngeal cancers: A phase III randomised trial

AbstractPurposeTo test the toxicity and efficacy of concomitant boost radiotherapy alone against concurrent chemoradiation (conventional fractionation) in locally advanced oropharyngeal cancer in our patient population.Methods and materialsIn this open-label, randomised trial, 216 patients with histologically proven Stage III–IVA oropharyngeal cancer were randomly assigned between June 2006 and December 2010 to receive either chemoradiation (CRT) to a dose of 66Gy in 33 fractions over 6.5weeks with concurrent cisplatin (100mg/m2 on days 1, 22 and 43) or accelerated radiotherapy with concomitant boost (CBRT) to a dose of 67.5Gy in 40 fractions over 5weeks. The compliance, toxicity and quality of life were investigated. Disease-free survival (DFS) and overall survival (OS) curves were estimated with the Kaplan–Meier method and compared using log rank test.ResultsThe compliance to radiotherapy was superior in concomitant boost with lesser treatment interruptions (p=0.004). Expected acute toxicities were significantly higher in CRT, except for grade 3/4 mucositis which was seen more in CBRT arm (39% and 55% in CRT and CBRT, respectively; p=0.02). Late toxicities like Grade 3 xerostomia were significantly high in CRT arm than CBRT arm (33% versus 18%; p<0.0001). The quality of life was significantly poor in CRT arm at all follow up visits (p<0.0001). The rates of 2year disease-free survival were similar with 56% in the chemoradiotherapy group and 61% in CBRT group (p=0.2; HR-0.81, 95%CI-0.53–1.2). Subgroup analysis revealed that patients with nodal size >2cm had significantly better DFS with CRT (p=0.05; HR-1.59, 95%CI-0.93–2.7).ConclusionIn selected patients of locally advanced oropharyngeal cancer, concomitant boost offers a better compliance, toxicity profile and quality of life with similar disease control, than chemoradiation

Shielding in whole brain irradiation in the multileaf collimator era: Dosimetric evaluation of coverage using SFOP guidelines against in-house guidelines

Aim : Compare the planning target volume (PTV) coverage in three different shielding techniques in cranial irradiation. Settings and Design : Tertiary care center, prospective study. Materials and Methods : The whole brain and meninges were contoured in ten planning CT scans, and expanded by 5 mm for the PTV. Shielding was designed using the French Society of Pediatric Oncology (SFOP) guidelines (SFOP plan), in-house recommendation (with 1 cm margin from the orbital roof and sphenoid wing) on a igitally Reconstructed Radiograph (DRR) and a third plan was generated using a 3D conformal radiation technique (3DCRT). The coverage of the PTV was noted using the isodose covering 95% of the PTV(D95), minimum dose within the PTV(D min ), and maximum dose within the PTV(D max ). The location of PTV not covered by the 95% isodose curve was noted. The median dose and maximum dose (D max ) to both eyes and maximum dose D max for the lens were noted. Statistical Analysis : General linear model method repeated the measure of analysis of variance test (ANOVA). Results : PTV coverage was significantly poorer in the SFOP and in-house plans as compared to 3DCRT plan (P=0.04). Median volume of PTV not covered by 95% isodose curve was 4.18 cc, 1.01 cc, and 0 cc in SFOP, in-house, and 3DCRT plan, respectively. Conclusions : In the absence of volumetric planning techniques, SFOP guidelines lead to inadequate coverage and the in-house method is recommended

Evaluation of Reirradiation in Locally Advanced Head and Neck Cancers: Toxicity and Early Clinical Outcomes

Objectives. Locoregional recurrence is the predominant pattern of treatment failure in advanced head and neck cancers. Reirradiation is a useful modality to treat inoperable head and neck cancer patients with recurrent disease. The aim of the present study was to analyze the treatment toxicity and early clinical outcomes in patients undergoing reirradiation. Methods. Twenty patients of head and neck cancers with recurrences or second cancers were evaluated. Reirradiation was done using simultaneous integrated boost volumetric modulated arc therapy (SIB VMAT), intensity modulated radiotherapy (IMRT), or conventional radiotherapy using 6MV photons. Dose prescription ranged from 30 to 60 Gy in conventional fractionation. Results. Seventeen males and three females were evaluated in this analysis. The median age of patients under study was 56.5 years. At time of analysis 8 patients (40%) had a complete response, 7 patients (35%) had progressive disease, and 25% had partial response or stable disease. Grade III-IV mucositis, dermatitis, xerostomia, dysphagia, and trismus were seen in 20%, 20%, 50%, 35%, and 45% patients, respectively, during retreatment. Patients receiving a radiotherapy dose less than 45 Gy showed a higher incidence of progressive disease (p=0.01). The median disease-free survival for patients receiving reirradiation dose of ≥46 Gy was 19±3.3 months (median ± S Error) compared to 8±2.61 months for those with a dose prescription less than 45 Gy (p=0.03). At 18-month follow-up 26% of patients undergoing reirradiation were disease-free. Conclusions. Our results show improved tumor control using a prescription of doses ≥46 Gy in retreatment setting

Breast cancer in males: A PGIMER experience

Aim: Male breast cancer is a rare disease representing 1% of all breast cancers and less than 1% of all cancers in men. Because of its rarity, carcinoma breast has not been studied extensively and this prompted us to carry out this retrospective study. The aim of the study was to observe the clinical and pathological features, evaluate the prognostic factors and to co-relate the outcome in patients of male breast cancer. Materials and Methods : Thirty patients of male breast cancer treated in the department of radiotherapy from year 1996-2000 were retrospectively analyzed. Results: The actuarial five- year disease free survival was 40%. Three out of 30 i.e. 10% patients had loco-regional recurrence and all of them had locally advanced disease at presentation. Distant metastasis occurred in 9 patients of whom 6 patients had T3-T4 tumor and 1 patient had T1-T2 tumor. Conclusion: Modified radical mastectomy followed by external radiation therapy is the standard treatment for male breast cancer. Hormone therapy, as an adjuvant treatment, is the first line approach in a majority of patients and chemotherapy is reserved for patients with poor prognostic factors

Split-Course radiotherapy: A nonideal treatment in a nonideal patient

Background: Radical chemoradiation is the standard of care for locally advanced head-and-neck cancer. However, patients with pretreatment poor risk features exhibit a poor tolerance to these rigorous regimens and are then usually prescribed short-course palliative radiotherapy which provides symptomatic relief; however, survival outcomes are poor. However, a proportion of these patients may tolerate higher dose of radiation with planned treatment break which in turn may translate into improved locoregional control. Materials and Methods: Patients with histologically confirmed nonmetastatic locally advanced squamous cell carcinoma of oropharynx with poor risk features, treated with split-course radiotherapy were included in this retrospective study. A dose of 35 Gy in 15# 3 weeks was initially prescribed. After planned treatment break of 2 weeks, an additional dose of 25 Gy in 10# 2 weeks was delivered. A weekly assessment of radiation reactions was performed during the treatment course, and response to the treatment was assessed clinically at 8 weeks after treatment completion and on subsequent follow-up. Survival analysis was done at median follow-up. Results: Of the 117 eligible patients, 14 (11.9%) had Stage III (with poor Karnofsky Performance Score) and 103 (88.1%) had Stage IV disease. Toxicity was observed as Grade I 80/117 (68.4%), Grade II 20/117 (17.1%), and Grade III as 17/117 (14.5%). A complete clinical response was observed in 45.3% patients at first follow-up. Patients had a median follow-up of 20 months (range 0–62 months). Median progression-free survival and overall survival were 12 and 16 months, respectively. Conclusions: This regimen can be delivered effectively and has an acceptable toxicity profile. It can be used as a treatment option in patients with poor risk pretreatment features