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Concomitant chemoradiation is the treatment of choice for most of head and neck cancer patients in developing countries since these patients present in locally advanced stage. They account for 4% of all cancers. Despite treatment, loco-regional failure is seen in 51-59% patients. There is often a deferral in start of radiation therapy due to large number of cases and lesser number of existing radiation set ups. Hence, several oncologists use neo-adjuvant systemic therapy prior to external beam radiotherapy. Some oncologists prefer hypofractionated radiation therapy over conventional fractionation. Yet there is no data available comparing neoadjuvant chemotherapy followed by hypofractionation with usual concurrent chemoradiation.METHODSBiopsy proved squamous cell carcinoma of larynx and pharynx of stage III & IV excluding IVC were incorporated in this study. Patients attending Bankura Sammilani Medical College Hospital in West Bengal, were randomized to get either concurrent chemoradiation with concomitant weekly injection of cisplatin 40 mg/m2 along with an external beam radiotherapy (EBRT) dose of 70 Gy. in conventional dose fractionation; or neoadjuvant chemotherapy for three cycles with carboplatin AUC 6, injection paclitaxel 175 mg/m2 and injection 5-fluorouracil 1000 mg/m2 day 1-4 followed by hypo-fractionated EBRT (40 Gy. in 16 fractions for 3.5 weeks followed by boost dose of 20 Gy. over 8 fractions in 1.5 weeks) commenced within 3 weeks after completion of chemotherapy. Disease-free survival (DFS) at three years and complications of treatment (using version 5.0 Common-Terminology-Criteria for Adverse-Events) were compared statistically using one-way ANOVA by means of version 20 IBM SPSS Statistics® software.RESULTSCharacteristics of patients were comparable in the two arms. Acute toxicities were less after neoadjuvant chemotherapy followed by hypo fractionated radiotherapy arm. DFS and tumor control were same. Lesser treatment days made this arm more convenient to patients. This is also financially helpful in Bankura where poor patients have to stay near hospital in some rented room or they have to come regularly from long distance by hired vehicle or ambulance. Tumor control and survival advantage was same in both modalities of treatment. Thus hypo fractionated radiotherapy arm was non-inferior statistically when compared to concomitant arm in terms of tumor control and survival.CONCLUSIONSManagement by neo-adjuvant chemotherapy followed by hypo-fractionated radiation is a non-inferior apposite substitute to the usual concurrent chemo-radiation in cancer treatment centers overburdened with patients.
RESUMO
Introduction: Loco-regional radiotherapy to supraclavicularand Axillary region has been the standard of care for treatmentof locally advanced carcinoma breast without or doubtfulaxillary clearance. We did a clinical audit of the patient careprovided and the outcome of the same relating to loco-regionalradiotherapy for such patients at a district medical college inIndia.Material and methods: All patients with locally advancedcarcinoma breast between 2007 and 2013 who had treatmentin the Department of Radiotherapy were audited. The patientswere stratified as per surgery they had and pathologicalinformation that was available in their post op HPE reportalong with type of radiotherapy they received. The analysiswas done with IBM SPSS V23.Results: over the period of 6 years there were 874 patientsof carcinoma breast registered in the Department. Out ofthem 246 were metastatic. 12 were early breast carcinomas,rest 616 were LABC who had indications of Supraclavicularand Axillary RT due to any reason. Out of these 616 patientsthe indication in 592 patients was lack of pathologicalinformation in terms of number of nodes dissected beinglesser than 10. 138 of them were referred from other centerswhere Radiotherapy was not available and therefore theyfollowed up at other centers. 77 patients never completed theirtreatment (radiotherapy or chemotherapy). Additionally 42patients never came for any follow up after their treatmentcompletion. A total of 359 analyzable patient records werefound who had at least one follow up.Conclusion: In our audit due to limited resources nearly 63%of the patients received RT only chest wall and supraclavicularregion RT. However it did not change the loco-regionalfailure rate at 5.3 years. A longer follow up data of 10 yearsis necessary to see whether this trend is continued to OS.However the present retrospective data provides a startingpoint for prospective clinical trials to look if certain groupof patients may benefit from omitting Axillary Radiotherapyeven when the dissection had yielded lesser than 10 nodes