Role of Selective Neck Dissection in Clinically Single Node Positive Disease in Oral Cavity Cancers.

Management of the neck in oral cavity squamous carcinoma is debatable. There is controversy regarding role of SND in single node positive neck in oral SCC. The aim of this study was to determine the efficacy of selective neck dissection (SND) for cN1 neck in patients with oral cancer. A retrospective chart review of 266 oral cancer patients who were clinically single node positive from August 2013 to December 2019 was done. Patients having clinical or radiological cN1 disease undergoing SND were included. Two hundred sixty-six patients were analysed with 86% male predominance. Median age was 48 years. The commonest primary site was Bucco-alveolar complex (64%). Total of 319 SNDs were done in 266 patients. At median follow-up of 29 months, 29 patients (9%) had neck recurrence among which 4 patients had recurrence at level V, along with recurrence at other nodal levels. Three-year regional control was 86%, while DFS and OS were 66% and 68% respectively. For oral cancer with single clinically node positive neck (cN1), SND is an effective and oncological safe treatment. Outcomes are similar with modified neck dissection reported in the literature.

Reirradiation with advanced brachytherapy techniques in recurrent GYN cancers.

PURPOSE: To evaluate clinical outcomes of recurrent gynaecological cancers treated with reirradiation (reRT) using advanced brachytherapy (BT) technique. METHODS AND MATERIALS: Seventy-six women who underwent reRT with BT for gynaecological cancers at our institute between January 2000 and December 2019 were analysed to determine patient, disease and treatment characteristics and clinical outcomes. Descriptive analysis was used for demographics, and the Kaplan Meir method was used for survival analysis. RESULTS: Median age at recurrence was 55 years (Range: 35-73). Forty-three patients had recurrent cervical cancer with intact uterus, and 33 had recurrent vault/vaginal cancers post adjuvant RT. Eight patients received EBRT prior to BT (Range: 30-50Gy). Twenty-two patients (28.9%) received salvage chemotherapy before consideration of brachytherapy. Brachytherapy application was done using MUPIT in 38, Vienna applicator in 20, Syed Neblett in 8, central vaginal cylinder in 3, multicatheter intravaginal applicator in 2, tandem-ovoids in 4 and Houdek applicator in 1 patient. Median cumulative EQD2 for all courses of radiation was 108 Gy (IQR 92-123 Gy). At median follow up of 39 months, local control (LC), progression-free survival (PFS) and Overall survival (OS) at 2-years was 60%, 56.3%, and 72.9 respectively. Patients who had recurrences beyond 2 years had significantly better OS compared to early recurrences. Patients who received BT doses >40 Gy had a higher LC and PFS. Grade 3 to 4 late rectal toxicity was seen in 10 (13%), bladder toxicity in 6 (8%) and vaginal fibrosis in 24 (31%) patients. CONCLUSION: The use of advanced BT approach in reirradiation setting is a feasible and safe option in treatment of post-treatment recurrent cervical, endometrial, and vaginal cancers.

Pedicled Flap vs. Free Flap Reconstruction in Head and Neck Cancers: Clinical Outcome Analysis from a Single Surgical Team.

Head and neck cancers are one of the leading causes of morbidity and mortality in Indian population. Reconstruction and restoration of function are also of paramount importance in these patients. The aim of this study was to report outcomes for free flaps and pedicle flaps in patients with oral cavity cancers. A retrospective analysis of 628 patients with oral cavity cancers who underwent reconstruction with either free flaps or pedicle flaps during 2014-2020 was done. The median age of the cohort was 49 years. The free flap reconstruction was performed in 481 (76%) and pedicle flap in 147 (24%) patients. Among free and pedicle flaps, 27 (5.6%) and 3 (2.1%) respectively had major flap complications and 25 (5.1%) and 14 (9.9%) respectively had minor complications. CCI score > 4 was associated with higher events (p = 0.02) in free flap group. The outcomes of free flaps are similar in comparison to pedicle flaps in patients with oral cavity cancers. The higher CCI score is significantly associated with increased flap-related complications for the free flap group.

Compartmental Clearance of Infratemporal Fossa for T4b Carcinoma of Buccal Mucosa/Alveolus: Clinical Outcomes.

T4 b carcinoma of oral cavity has poor outcomes. The aim for analysis is to evaluate the clinical outcomes with infratemporal fossa clearance for stage T4b carcinoma of oral cavity. Fifty four patients out of maintained data of 528 patients of oral cavity carcinoma were evaluated for current retrospective analysis. All had T4b disease on imaging and underwent bite composite resection with ITF clearance. The median age of the cohort was 52 years. At last follow-up, 28 patients were alive. Twenty two patients had loco-regional recurrence (ITF recurrence 7), and 16 patients had distant metastasis. At median follow-up of 29 months, 2-year loco-regional control, DFS and OS were 52%, 54% and 54%, respectively. Perineural invasion, pathological tumour stage, node positive and ITF tissue involvement were associated with poor oncological outcomes. ITF clearance is feasible in clinical practice and provides curative option for this group.

Free thyroid transfer to anterolateral thigh for prevention of radiation induced hypothyroidism: An initial experience.

AIM: Radiation induced hypothyroidism (RIHT) is one of the commonest late side effects of radiation therapy and is seen in more than half of patients and affects quality of life significantly. We report our initial experience on feasibility of free microvascular transfer of thyroid gland out of radiation field to prevent development of RIHT. MATERIAL AND METHODS: A prospective pilot study was undertaken during August 2017 to May 2018. Six Patients with stage III/IV patients of oral cavity cancers who required wide excision/composite resections with microvascular free flap (ALT) reconstruction and adjuvant radiation therapy were enrolled. A written informed consent was obtained from all patients prior to the procedure. RESULTS: The mean age of cohort was 51 years with tongue most common site of primary cancer. The free transfer of thyroid gland to anterolateral thigh was done using microvascular technique. The mean additional time for procedure was 51 min. All patients had successful transfer with no associated immediate complications. Patients were followed up with Tc99 scan, USG Doppler and biochemical assay at routine intervals in peri and postoperative period to assess the anatomical and physiological function of the transferred gland. At median follow up of 8 months, 5 patients were euthyroid and remaining one had biochemical hypothyroidism. All patients had functional thyroid gland in anetrolateral thigh. Five patient were alive, one patient died due to disease. CONCLUSION: This is a small and early feasibility study for free thyroid gland transfer and validates the previously published data. The selected group of patients who have high chances of developing RIHT may benefit from this strategy. Further validation of the technique may be explored in a larger cohort.

High dose chemoradiation for unresectable hilar cholangiocarcinomas using intensity modulated external beam radiotherapy: a single tertiary care centre experience.

BACKGROUND: We present results of patients diagnosed with unresectable hilar cholangiocarcinomas treated with high dose radiotherapy and concurrent chemotherapy. METHODS: From Aug 2005 to Dec 2012, 68 consecutive patients were treated. Fifty patients (group 1) presenting to us with obstructive jaundice were planned for endobiliary brachytherapy (EBBT 14 Gy) followed external beam radiotherapy (EBRT 45 Gy). Twenty-two patients (group 2) who had previously undergone biliary drainage underwent EBRT (57 Gy). All patients received injection Gemcitabine 300 mg/m2/weekly along with EBRT. RESULTS: Twenty-nine patients in group 1 and 22 patients in group 2 completed the treatment. Twenty-six (55%) patients achieved complete radiological response, 16 (64%) belonging to group 1 and 8 (44%) of group 2 (P=0.05). The median overall survival (MOS) was 17.5 and 16 months for group 1 and 2 respectively (P=0.07). The 1- and 2-year survival was 63%, and 18% for group I and 61% and 22% for group II respectively. The MOS was 5 months and 1 year survival was 14% for patients receiving EBBT only. MOS was significantly better after complete response (P=0.001). CONCLUSIONS: Intensity modulated radiotherapy (IMRT) modulated high dose radiotherapy used either alone or with brachytherapy demonstrates potential to prolonged overall survival in unresectable hilar cholangiocarcinomas.

Intracranial germ cell tumors: a multi-institutional experience from three tertiary care centers in India.

OBJECTIVE: Central nervous system germ cell tumors (CNS GCTs) are relatively rare neoplasms. Incidence of CNS GCTs in Western literature is low (0.3-0.6 %) as compared to East Asia (3-4 %). No large study is available on CNS GCTs from India. METHODS: Intracranial GCT cases were retrieved from databases of three tertiary care institutes in India; clinicopathological data was reviewed. RESULTS: Ninety-five intracranial GCT cases were identified, accounting for 0.43 % of CNS tumors. Median age was 12 years (range, birth to 48 years); male preponderance was noted (66 %). Most patients (86.3 %) were aged <18 years. Pineal location was most common (45 %) and was associated with male gender and age >14 years. Germinoma was the commonest histopathological type (63.2 %), followed by teratoma (20 %). Suprasellar location was associated with germinoma histology. Follow-up was available for 71 patients (median, 15 months). Of these, 48 received adjuvant chemotherapy and/or radiotherapy. At the last follow-up, 44 patients showed no evidence of disease. Age >10 years, male gender, pineal location, and germinoma histology were associated with favorable outcome. CONCLUSION: This is the first multicentric study from India establishing that incidence of CNS GCT in India is similar to that in the West and differs from that in East Asian countries. However, similar to both, germinoma is the commonest histological type, and pineal location is most frequent. Studies on molecular alterations based on ethnicity and geographical location are necessary to provide clarity on differences in incidence. Attention needs to be focused on decreasing treatment heterogeneity and minimizing treatment-related morbidity and mortality, improving the cure rate of these highly treatable tumors.

Clinical Outcomes With Dose-Escalated Adaptive Radiation Therapy for Urinary Bladder Cancer: A Prospective Study.

PURPOSE: The purpose of this study was to assess feasibility, clinical outcomes, and toxicity in patients with bladder cancer treated with adaptive, image guided radiation therapy (IGRT) for bladder preservation as a part of trimodality treatment. The role of dose escalation was also studied. METHODS AND MATERIALS: Forty-four patients with localized bladder cancer were enrolled in a prospective study. They underwent maximal safe resection of bladder tumor and concurrent platinum-based chemotherapy. Patients with large tumors were offered induction chemotherapy. Radiation therapy planning was done using either 3 (n=34) or 6 (n=10) concentrically grown planning target volumes (PTV). Patients received 64 Gy in 32 fractions to the whole bladder and 55 Gy to the pelvic nodes and, if appropriate, a simultaneous integrated boost to the tumor bed to 68 Gy (equivalent dose for 2-Gy fractions assuming α/ß of 10 [EQD2]10 = 68.7 Gy). Daily megavoltage (MV) imaging helped to choose the most appropriate PTV encompassing bladder for the particular day (using plan-of-the-day approach). RESULTS: Most patients (88%) had T2 disease. Sixteen patients (36%) received neoadjuvant chemotherapy. A majority of the patients (73%) received prophylactic nodal irradiation, whereas 55% of the patients received escalated dose to the tumor bed. With a median follow-up of 30 months, the 3-year locoregional control (LRC), disease-free survival, and overall survival (OS) were 78%, 66%, and 67%, respectively. The bladder preservation rate was 83%. LRC (87% vs 68%, respectively, P=.748) and OS (74% vs 60%, respectively, P=.36) rates were better in patients receiving dose escalation. Instances of acute and late Radiation Therapy Oncology Group (RTOG) grade 3 genitourinary toxicity was seen in 5 (11%) and 2 (4%) patients, respectively. There was no acute or late RTOG grade 3 or higher gastrointestinal toxicity. CONCLUSIONS: Adaptive IGRT using plan-of-the-day approach for bladder preservation is clinically feasible, with good oncological outcomes and low rates of acute and late toxicities. Dose escalation is safe and possibly improves outcomes in bladder preservation.

Conventional radiotherapy versus concurrent chemoradiotherapy versus accelerated radiotherapy in locoregionally advanced carcinoma of head and neck: Results of a prospective randomized trial.

BACKGROUND: The purpose of this study was to report the results of a phase III, 3-arm, randomized trial comparing conventional radiotherapy (RT) to concurrent chemoradiotherapy (CRT) and accelerated RT in advanced head and neck squamous cell carcinoma (HNSCC). METHODS: One hundred eighty-six of 750 planned patients were randomized to receive one of the following treatment plans: RT (66-70 Gy/2 Gy fraction/5 fractions weekly; CRT of weekly cisplatin (30 mg/m(2) ) with the same RT dose; or accelerated RT alone of 66 to 70 Gy/2 Gy fraction/6 fractions weekly were available for analysis. The primary endpoint was locoregional control at 5 years. RESULTS: The mean follow-up was 54 months. Among the 3 arms, CRT showed superior locoregional control (49%; p = .049). RT had lower grade ≥3 mucositis and late toxicity. CONCLUSION: CRT is associated with significantly better locoregional control as compared to RT and accelerated RT with higher but acceptable acute and late toxicities.

Reirradiation using high-dose-rate brachytherapy in recurrent carcinoma of uterine cervix.

PURPOSE: To assess the feasibility of reirradiation with image-based high-dose-rate brachytherapy in previously irradiated patients with recurrent carcinoma of uterine cervix. METHODS AND MATERIALS: Thirty previously irradiated patients diagnosed with central recurrence were treated with reirradiation. Martinez Universal Perineal Implant Template was used in 24 patients and Vienna applicator in 6 patients. Median interval between two radiation schedules was 25 months. Median delivered dose was 42 Gy equivalent dose at 2 Gy (EQD2; interquartile range, 37-46 Gy EQD2). RESULTS: All 30 patients tolerated reirradiation well. Complete response was seen in 23 (76%) patients. With a median followup of 25 months, 2-year local control, disease-free survival, and overall survival were 44%, 42%, and 52%, respectively. Fifteen patients developed local recurrences; Local control rate was significantly higher with doses >40 Gy EQD2 (52% vs. 34%; p = 0.05). Disease-free survival was better for patients with longer interval (>25 months) between two radiotherapy schedules. Grade III radiation proctitis and cystitis was seen in 3 patients each, and Grade II small bowel toxicity was seen in 3 patients. CONCLUSIONS: Reirradiation using high-dose-rate brachytherapy is feasible with acceptable outcomes in isolated local recurrence deemed unsuitable for surgery. The outcome is better with higher doses.

Template-based high-dose-rate interstitial brachytherapy in gynecologic cancers: a single institutional experience.

PURPOSE: To report the outcome and toxicities of radical external beam radiotherapy (EBRT) and template-based high-dose-rate interstitial brachytherapy (ISBT) in patients diagnosed with cervical cancer undergoing inadvertent surgery, vault cancers, and vaginal cancers at our institution. METHODS AND MATERIALS: Between January 2000 and December 2008, 113 patients (37 patients of cervical cancer post-inadvertent surgery, 57 patients with vault cancers, and 19 patients with primary vaginal cancers) were treated with Martinez Universal Perineal Interstitial Template brachytherapy boost after EBRT. The median EBRT dose was 50 Gy, median ISBT dose was 20 Gy, whereas median total dose was 73 Gy equivalent dose at 2 Gy per fraction in all three groups. RESULTS: Median followup of surviving patients for the whole group was 43 months (interquartile range, 19-67 months). The 3-year actuarial disease-free survival and overall survival for three groups was 61%, 61%, 59% and 64%, 64%, and 56%, respectively. Grade III/IV rectal toxicity was seen in 11 (10%) patients, bladder toxicity in 5 (4.5%) patients, whereas 7 (6%) patients developed Grade III small bowel toxicity. Residual disease at brachytherapy had significant impact on DFS and OS. Other factors such as age, disease volume, parametrial extension, and vaginal extension did not impact the survivals. CONCLUSIONS: Martinez Universal Perineal Interstitial Template-based high-dose-rate ISBT boost in gynecologic cancer results in a reasonable outcome in terms of survivals with acceptable late toxicities. The use of template-based ISBT is associated with a definite learning curve.