Does the use of induction chemotherapy in oral cavity cancer compromise subsequent loco‑regional treatment delivery: Results from a matched pair analysis.

BACKGROUND: Neoadjuvant chemotherapy is being increasingly used in patients with unresectable oral cavity cancers to make them resectable. However, its impact on locoregional treatment delivery in such setting remains poorly studied. AIMS: To evaluate the impact of neoadjuvant chemotherapy on delivery of further locoregional treatment. SETTINGS AND DESIGN: Mono institutional retrospective audit of patients with oral cavity squamous cell cancers treated with neoadjuvant triplet chemotherapy in India. MATERIALS AND METHODS: Patients receiving neoadjuvant chemotherapy (n = 14) from May 2012 to April 2014 were matched 1:2 to patients undergoing upfront surgery (n = 28) based on age (>60 or 60 and less), gender (male or female) and subsite site (tongue and floor of mouth or buccoalveolar complex). Data regarding factors related to the delivery of locoregional treatment and toxicities were compiled. STATISTICAL ANALYSIS: Descriptive analysis in the form of median (range) for continuous variables and frequencies for categorical variables. RESULTS: Patients undergoing neoadjuvant chemotherapy required more extensive resections and had greater operative time (460 vs. 415 min, P < 0.001). A greater incidence of locoregional wound complications was seen as a consequence (57.1% vs. 14.3%, P, 0.01). However, toxicities during radiotherapy were not substantially different between the two groups and compliance to radiation was also similar. Total package time of 100 days or less, was maintained in 90% of patients in both groups. CONCLUSIONS: Delivery of neoadjuvant chemotherapy does not impair the ability to deliver locoregional treatment.

Retrospective audit of clinico‑pathologic features and treatment outcomes in a cohort of elderly non‑Hodgkin’s lymphoma patients in a tertiary cancer center.

INTRODUCTION: There is limited data from India regarding elderly non‑Hodgkin’s lymphomas (NHL) patients. Hence, this audit was planned to study the clinic‑pathological features and treatment outcomes in elderly NHL patients. METHODS: Retrospective analysis of all NHL patients above age of 59 years treated at the author’s institute, between December 2010 and December 2013 was done. Case records were reviewed for baseline details, staging details, prognostic factors, treatment delivered, response, toxicity and efficacy. SPSS version 16 (IBM, Newyork) was used for analysis. Descriptive statistics was performed. Kaplan–Meir survival analysis was done for estimation of progression‑free survival (PFS) and overall survival (OS). Univariate analysis was done for identifying factors affecting PFS and OS. RESULTS: Out of 141 NHL patients, 67 patients were identified subjected to the inclusion criteria. The median age was 68 years (60–92). Majority were B‑cell NHL (86.6%). The commonest subtype in B‑cell was diffuse large B‑cell lymphoma (55.2%). Fifty‑four patients took treatment. The treatment intent was curative in 41 patients (61.2%). Among the patients receiving curative treatment, 16 patients couldn’t receive treatment in accordance with NCCN guidelines due to financial issues. Two years PFS was 55%. Two years PFS for B‑cell NHL and T‑cell NHL were 55% and 50% respectively (P = 0.982). Two years PFS for standard Rx and nonstandard Rx were 62% and 50% respectively, but it didn’t reach statistical significance (P = 0.537). Two years OS for the entire cohort was 84%. CONCLUSION: Standard treatment in accordance with guidelines can be delivered in elderly patients irrespective of age. There is a need for creating financial assistance for patients, so that potentially curative treatments are not denied.

Comparative study of neonatal outcome between first and second twin babies delivered by vaginal route.

Introduction: The incidence of twinning has been increasing due to availability and increased use of ovulation inducing drugs and assisted reproductive technology. Despite substantial concerns over the well-being of the second twin with regard to intra partum events, outcome studies on this issue are conflicting. Some have reported no increase in perinatal complications, while others showed significant associations between labor and delivery of the second twin and increased perinatal morbidity and mortality. Material and methods: 106 cases of twin pregnancy fulfilling of age 18 - 35 years, at more than 32 weeks gestation, first twin with cephalic presentation and selected for vaginal delivery were included in the study. Intrauterine death of either one of the twins before the onset of labour, pregnancies complicated or fetal malformations and those with contraindication to vaginal birth were excluded. After thorough screening of included cases delivery was performed according to fixed protocol. After delivery, mode of delivery, cry, APGAR score, birth weight, complications, birth injury, time interval between deliveries, NICU admission and condition on discharge of each baby was noted. Results: 106 twins were included as delivered vaginally, including 3 patients who were delivered by vaginal delivery for 1st twin followed by caesarean delivery for 2nd twin. Stillbirth and early neonatal deaths resulted in 24 deaths. There is no significant difference between mortality of 1st and 2nd born twins. The neonatal mortality was equal in first and second twin. Neonatal morbidity was more in 2nd twin than 1st twin (27.65% v/s 15.95%). There were 41 NICU admissions (19.34%), out of those 36.6% were for first twin (n=15) and 63.4% for second twin (n=26), (p value 0.056). Incidence of RDS, invasive ventilator support, NICU Stay >7 days is significantly higher in second twin as compared to first twin. Breech presentations were associated with 10% neonatal mortality for second twin compared to none for first twin. Most common group for neonatal mortality and morbidity was birth weight 1000-1499 gm. Neonatal morbidity was 100% for discordancy 30 to 40% group while 85.71% for discordancy 20 to 30% group. These results are significant when compared for heavier twin v/s lighter twin (p value 0.001).Neonatal mortality and morbidity between first and second twin is statistically significant when compared according to Apgar score (p value 0.037). Incidences of stillbirth + early neonatal death for 2nd twin less in early preterm group but increased in in late preterm group. Neonatal outcome of 2nd twin was better in dichorionic pregnancies 11% v/s 16.67% in monochorionic pregnancies (p>0.05). Conclusion: Twin vaginal delivery is safe in first cephalic presentation in twin pregnancy. Caution should taken while delivering babies < 1500 gm, birth discordancy > 20% , gestational age < 34 weeks, as vaginal delivery in these conditions is associated with increased early neonatal morbidity and neonatal mortality.

Predictivity of human papillomavirus positivity in advanced oral cancer.

BACKGROUND AND OBJECTIVE: Human papillomavirus (HPV) is a known prognostic factor world over in patients of carcinoma oropharynx. The role of HPV in oral cancers has not been investigated adequately. We tried to identify standard clinicopathological features in oral cancer, which would predict HPV‑positivity. METHODS: This was a retrospective analysis of 124 cases of T4 oral cancer patients at our center. HPV‑positive was defined in accordance with positive p16 immunohistochemistry done on pretreatment local tumor site biopsy. Age, sex, habits (smoking history and oral tobacco), Eastern Cooperative Oncology Group performance status (ECOG PS), T stage, N stage, grade, and site were selected, for testing of prediction for HPV‑positivity. The analysis was performed by R studio version 3.1.1. Two‑sample test for equality of proportions with continuity correction was used to identify factors predicting for HPV‑positivity. P = 0.05 was considered as significant. RESULTS: Of 124 patients, 16 patients (12.9%) were HPV‑positive. The median age of the whole cohort was 43 years (interquartile range 37–52 years) with 15 females (12.1%). All had squamous cell carcinoma (100%). The grade of the tumor was well differentiated in 9 patients (7.2%), moderately differentiated in 98 patients (79.1%), and poorly differentiated in 17 patients (13.7%). The ECOG PS 0 in 19 patients (15.3%), 1 in 104 patients (83.9%), and 2 in 1 patient (0.8%). The subsite of the tumor was buccal mucosa in 74 patients (59.7%), anterior two‑third of tongue in 33 patients (26.6%), and others in 17 patients (13.7%). None of the tested factors except the use of oral tobacco were statistically significantly associated with HPV‑positivity. History of tobacco usage had a statistical trend toward ability to predict HPV‑positivity. The proportion of patients with HPV‑positive oral cancer in patients without history usage of oral tobacco was 31.3% while it was 10.2% in patients with previous history of tobacco use (P = 0.03). CONCLUSION: Standard clinicopathological variables could not predict for HPV‑positivity. Negative history of tobacco (smokeless) usage showed statistical trends toward ability to predict HPV‑positivity in oral cancer patients.

Head and neck cancer in geriatric patients: Analysis of the pattern of care given at a tertiary cancer care center.

BACKGROUND AND AIM: The percentage of elderly people with head and neck cancers (HNC) is on the rise. This makes HNC in this group of patients an important issue for healthcare providers. The present study was planned to analyze the patterns of care given to the geriatric patients and to identify the factors influencing the decision making process. MATERIALS AND METHODS: Data of all the elderly patients (≥65 years) registered in the year 2012, with histologically proven HNC (all sites, stages, histopathological types, except lymphoma, sarcoma and cervical metastasis of unknown origin) receiving treatment (definitive/palliative) were collected. RESULTS: A total of 270 patients were included in this study. The median age was 72 years (range: 65–101), with predominant male population (70%, n = 190). Oral cavity squamous cell carcinoma (SCC) was the most common cancer (57%, n = 154). Eastern Co‑Operative Oncology Group performance status (PS) of 0–2 was seen in 91% of the patients. Co‑morbidities were present in 139 (51.5%) patients. 50% (n = 134) of the patients received palliative intent treatment, 45% (n = 123) definitive treatment, whereas in 5% (n = 13) the intent was not mentioned. Age, a clinical stage and PS significantly influenced the decision making on the intent of treatment. 208 (77%) patients completed their treatment irrespective of the intent. Age was the only factor influencing treatment completion irrespective of the intent. CONCLUSION: Geriatric HNC patients frequently present with advanced disease, having multiple co‑morbidities. Hence, a multidisciplinary team management of these patients is essential, also taking into account of the social and financial support available to these patients.

Patterns of care in geriatric cancer patients – An audit from a rural based hospital cancer registry in Kerala.

BACKGROUND: There is deficit of data from India on elderly patients with cancer. Comprehensive geriatric assessment may lead to a better decision making capacity in this population. However, routine implementation of such assessment is resource consuming. AIM: The aim of this study was to determine the patterns of care in elderly patients treated at a tertiary rural cancer center in India. MATERIALS AND METHODS: All patients with age 70 or above with solid tumors without any definitive treatment prior to the registration at our center and registered between 01/01/2010 and 31/12/2011 were selected for this study. The baseline demographic pattern and the pattern of care of treatment were analyzed. SPSS version 16 (IBM Inc, Armonk, New York, U.S.) was used for analysis. Descriptive data are provided. RESULTS: A total of 761 patients were evaluable subject to the aforementioned inclusion criteria. The median age of this cohort was 75 years (70‑95 years). The most frequent primary sites of malignancies in 451 males were head neck (32.4%), lung (23.3%) and gastrointestinal (23.3%). In 310 females, the most common sites were head neck (31.6%), gynecological (18.4%) and gastrointestinal (24.5%). 228 (30%) of the patients had localized disease, 376 (49.4%) had loco‑regionally advanced disease and 145 (19.1%) had distant metastases at presentation. 334 (46.32%) of patients were treated with curative intent. On logistic regression analysis the factors that predicted use of curative intent treatment were age <75 years, performance status 0‑1, primary site and clinical extent of disease. CONCLUSION: Routine comprehensive geriatric assessment needs to be implemented in our setting as almost 50% of our geriatric patients undergo curative intent treatment.

An audit of febrile neutropenia cases from a rural cancer center in India.

BACKGROUND: Data of febrile neutropenia (FN) from rural cancer centers is sparse. We did a audit of outcome of patients with FN in the period of March 2013‑August 2013. The aim was to help us to develop rational antibiotic usage policies. MATERIALS AND METHODS: Retrospective analysis of all consecutive patients presenting with FN. Data regarding demographic profile, tumor type, intent of treatment, chemotherapy regimen, blood culture susceptibility details, use of antibiotics, response to antibiotics and complications of FN were noted. SPSS (Statistical Product and Service Solutions) 16 was used for analysis. RESULTS: 67 patients had FN and there were 91 episodes. The median day of presentation with FN after start of chemotherapy was 10 days. The nadir absolute neutrophil count was 161.5 and nadir platelet count 1,00,000. The median multinational association for supportive care in cancer (MASCC) Score was 24. In accordance with MASCC there were 27 high risk FN and 64 low risk FN episodes. On multivariate analysis using logistic regression MASCC score strata was the only significant variable that predicted failure to 1st line antibiotics (P = 0.03) and mortality (P = 0.01). Nine patients (9.9%) had positive isolates on blood cultures. The blood culture isolates were predominantly Gram negative (66.7%). CONCLUSION: The importance of developing local guidelines for rational antibiotic usage is highlighted.

Pattern of infection, therapy, outcome and risk stratification of patients with febrile neutropenia in a tertiary care oncology hospital in India.

CONTEXT: Indian febrile neutropenia (FN) data are limited, especially in adult solid tumor patients. AIMS: The aim was to study patterns of presentation, source of infection, management and outcome and to evaluate the factors which may correlate with outcome. MATERIALS AND METHODS: A retrospective analysis of prospective data of FN patients at a tertiary care oncology teaching hospital in India between 2007 and 2012. A standardized form was filled for each patient. Patient management was at the discretion of the treating physician. Multinational Association for Supportive Care in Cancer (MASCC) score was retrospectively calculated. Failure of therapy was defined as death, organ failure, shifting from outpatient to inpatient or requirement of intensive care support. SPSS version 16 was used for analysis. RESULTS: A total of 388 FN episodes were included: 256 in hematolymphoid and 132 in solid tumor patients. 156 episodes were high‑risk by MASCC score. Focus of infection was clinical in 45% and radiologic in 16%. Blood cultures were positive in 18% cases, most commonly Gram‑negative organisms (72%). 93% patients were treated with an antibiotic combination of third‑generation cephalosporin/beta‑lactamase inhibitor, with aminoglycoside or fluoroquinolone. Antibiotic sensitivity to ceftriaxone was low at 38% while sensitivity to cefoperazone/sulbactam and piperacillin/tazobactam ranged between 50% and 55% and for carbapenems 75%. Failure of therapy occurred in 156 episodes, most commonly due to the need for second line antibiotics. Mortality was 5.5%. On univariate analysis, MASCC score, age, type of malignancy, prophylactic growth factors, presence of focus of infection, hemoglobin and nadir platelet count correlated with FN complications. CONCLUSION: Gram‑negative bacteremia continues to be the predominant cause of FN in our setup.

Referral pattern for neoadjuvant chemotherapy in the head and neck cancers in a tertiary care center.

BACKGROUND: Use of any treatment modality in cancer depends not only on the effectiveness of the modality, but also on other factors such as local expertise, tolerance of the modality, cost and prevalence of the disease. Oropharyngeal and laryngeal cancer are the major subsites in which majority of neoadjuvant chemotherapy (NACT) literature in the head and neck cancers is available. However, oral cancers form a major subsite in India. MATERIALS AND METHODS: This is an analysis of a prospectively maintained data on NACT in the head and neck cancers from 2008 to 2012. All these patients were referred for NACT for various indications from a multidisciplinary clinic. Descriptive analysis of indications for NACT in this data base is presented. RESULTS: A total of 862 patients received NACT within the stipulated time period. The sites where oral cavity 721 patients (83.6%), maxilla 41 patients (4.8%), larynx 33 patients (3.8%), laryngopharynx 8 patients (0.9%) and hypopharynx 59 patients (8.2%). Out of oral cancers, the major indication for NACT was to make the cancer resectable in all (100%) patients. The indication in carcinoma of maxilla was to make the disease resectable in 29 patients (70.7% of maxillary cancers) and in 12 patients (29.3% of maxillary cancers) it was given as an attempt to preserve the eyeball. The indication for NACT in laryngeal cancers was organ preservation in 14 patients (42.4% of larnyngeal cancer) and to achieve resectability in 19 patients (57.6% of larnyngeal cancer). The group with laryngopharynx is a cohort of eight patients in whom NACT was given to prevent tracheostomy, these patients had presented with early stridor (common terminology criteria for adverse events Version 4.02). The reason for NACT in hypopharyngeal cancers was for organ preservation in 24 patients (40.7% of hypopharyngeal cancer) and for achievement of resectability in 35 patients (59.3% of hypopharyngeal cancer). CONCLUSION: The major indication for NACT is to make disease resectable at our center while cases for organ preservation are few.

Tolerance and toxicity of neoadjuvant docetaxel, cisplatin and 5 fluorouracil regimen in technically unresectable oral cancer in resource limited rural based tertiary cancer center.

BACKGROUND: Recent studies indicate neoadjuvant chemotherapy (NACT) can result in R0 resection in a substantial proportion of patients with technically unresectable oral cavity cancers. However, data regarding the efficacy and safety of docetaxel, cisplatin and 5 fluorouracil (TPF) NACT in our setting is lacking. The present audit was proposed to evaluate the toxicities encountered during administration of this regimen. It was hypothesized that TPF NACT would be considered feasible for routine administration if an average relative dose intensity (ARDI) of ≥0.90 or more in at least 70% of the patients. MATERIALS AND METHODS: Technically unresectable oral cancers with Eastern Cooperative Oncology Group PS 0-2, with biopsy proven squamous cell carcinoma underwent two cycles of NACT with TPF regimen. Toxicity and response rates were noted following the CTCAE 4.03 and RECIST criteria. Descriptive analysis of completion rates (completing 2 cycles of planned chemotherapy with ARDI of 0.85 or more), reason for delay, toxicity, and response are presented. RESULTS: The NACT was completed by all patients. The number of subjects who completed all planned cycles of chemotherapy are with the ARDI of the delivered chemotherapy been equal to or >0.85 was 11 (91.67%). All toxicity inclusive Grade 3-5 toxicity was seen in 11 patients (91.67%). The response rate of chemotherapy was 83.33%. There were three complete response, seven partial response, and two stable disease seen post NACT in this study. CONCLUSION: Docetaxel, cisplatin and 5 fluorouracil regimen can be routinely administered at our center with the supportive care methods and precautionary methods used in our study.

Efficacy and safety of metronomic administration of paclitaxel for advanced recurrent non-small-cell lung cancer.

CONTEXT: There are limited effective therapeutic options in the relapsed setting for non-small cell lung cancer (NSCLC) or in the first line for platinum‑ineligible patients. AIM: To evaluate the safety and efficacy of a metronomic schedule of paclitaxel administered weekly in relapsed refractory NSCLC or upfront in patients not eligible for platinum‑based chemotherapy. SETTINGS AND DESIGN: Retrospective analysis of a prospectively collected database from the medical oncology department at Tata Memorial Hospital in Mumbai, India. MATERIALS AND METHODS: Patients with recurrent and treatment-naïve platinum-ineligible advanced NSCLC were treated with weekly paclitaxel at 80 mg/m2 with palliative intent. Restaging scans were obtained every two months. Chemotherapy was continued until progressive disease, intolerable side effects, or decision of the patient. STATISTICAL ANALYSIS USED: SPSS version 16 was used for analysis. Simple percentages were used for descriptive statistics. Progression‑free survival (PFS) was calculated from date of start of paclitaxel till the date of progression, change of therapy due to any reason, or death due to any cause. Overall survival (OS) was calculated from date of start of paclitaxel to death. The Kaplan Meier method was used for estimation of survival. RESULTS: There were 37 patients over eight months. The median age was 59 years, with a male‑to‑female ratio of 5:1. Two patients received paclitaxel in the first line, 18 patients in second line, nine in third line, five in fourth line, and three were in fifth line. 73% patients had received prior platinum and 48.6% patients had Eastern Cooperative Oncology Group performance status (ECOG PS) >2. The median number of weekly cycles delivered was 14. The response rate was 35% [complete remission (CR): 2.7%, partial remission (PR): 32.4%, stable disease (SD): 32.4%, progressive disease (PD): 27%], the median PFS was four months, and the estimated median OS was seven months. Chemotherapy was well tolerated. The most frequent grade 3 toxicities included anemia: 8%, neutropenia: 5.4%, and sensory neuropathy: 8%. There were no grade 4 toxicities and no episodes of febrile neutropenia. CONCLUSIONS: Weekly low‑dose continuous metronomic‑type scheduling of paclitaxel is safe and effective for relapsed refractory NSCLC and in the first line in platinum-ineligible patients.

Induction chemotherapy in technically unresectable locally advanced oral cavity cancers: Does it make a difference.

Impact Factor for 2013 is 1.131 Click here to download free Android Application for this and other journals Click here to view optimized website for mobile devices Journal is indexed with MEDLINE/Index Medicus and Science Citation Index ExpandedShare on facebookShare on twitterShare on citeulikeShare on connoteaShare on googleShare on linkedinMore Sharing Services MINI SYMPOSIUM: HEAD NECK CANCER Year : 2013 | Volume : 50 | Issue : 1 | Page : 1-8 Induction chemotherapy in technically unresectable locally advanced oral cavity cancers: Does it make a difference? VM Patil1, V Noronha1, VK Muddu1, S Gulia1, B Bhosale1, S Arya2, S Juvekar2, P Chatturvedi3, DA Chaukar3, P Pai3, A D'cruz3, K Prabhash1 1 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India 2 Department of Radio-Diagnosis, Tata Memorial Hospital, Mumbai, Maharashtra, India 3 Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India Date of Web Publication 20-May-2013 Correspondence Address: K Prabhash Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra India DOI: 10.4103/0019-509X.112263 PMID: 23713035 » Abstract Background: Locally advanced and unresectable oral cavity cancers have a poor prognosis. Induction might be beneficial in this setting by reducing tumor bulk and allowing definitive surgery. Aim: To analyze the impact of induction chemotherapy on locally advanced, technically unresectable oral cavity cancers. Materials and Methods: Retrospective analysis of patients with locally advanced oral cavity cancers, who were treated with neoadjuvant chemotherapy (NACT) during the period between June 2009 and December 2010. Data from a prospectively filled database were analyzed for information on patient characteristics, chemotherapy received, toxicity, response rates, local treatment offered, patterns of failure, and overall survival. The statistical analysis was performed with SPSS version 16. Results: 123 patients, with a median age of 42 years were analyzed. Buccal mucosa was the most common subsite (68.30%). Three drug regimen was utilized in 26 patients (21.10%) and the rest received two drug regimen. Resectability was achieved in 17 patients treated with 3 drug regimen (68.00%) and 36 patients receiving 2 drug regimen. Febrile neutropenia was seen in 3 patients (3.09%) receiving 2 drug regimen and in 9 patients (34.62%) receiving 3 drug regimen. The estimated median OS was not reached in patients who had clinical response and underwent surgery as opposed to 8 months in patients treated with non-surgical modality post NACT (P = 0.0001). Conclusion: Induction chemotherapy was effective in converting technically unresectable oral cavity cancers to operable disease in approximately 40% of patients and was associated with significantly improved overall survival in comparison to nonsurgical treatment.