Non-surgical organ preservation in laryngeal and hypopharyngeal cancers: an audit from the clinic.

BACKGROUND: There is increasing concern regarding efficacy of organ preservation protocol in laryngeal and hypopharyngeal cancers. METHOD: This study retrospectively assessed disease-related and functional outcomes of 191 patients with non-metastatic laryngeal or hypopharyngeal squamous cell carcinoma treated with curative intent (radiotherapy with or without chemotherapy). RESULTS: Seventy-six patients (39.8 per cent) had a primary cancer in the larynx, and 115 patients (60.2 per cent) had a primary cancer in the hypopharynx. The median follow up was 39 months. The 3-year time to progression, overall survival, local control and laryngectomy free survival was 56.2 per cent, 76.3 per cent, 73.2 per cent and 67.2 per cent, respectively. At the time of analysis, 83 patients (43.5 per cent) were alive and disease free at their last follow up and did not require tube feeding or tracheostomy. The laryngo-oesophageal dysfunction-free survival was 61 per cent at 3 years. CONCLUSION: Organ conservation protocols remain the standard of treatment in appropriately selected patients with laryngeal and hypopharyngeal cancers.

Post-cricoid and Upper Oesophagus Cancers Treated with Organ Preservation Using Intensity-modulated Image-guided Radiotherapy: a Phase II Prospective Study of Outcomes, Toxicity and Quality of Life.

AIMS: To prospectively examine the outcomes, toxicity and quality of life (QoL) of patients with post-cricoid and upper oesophagus (PCUE) cancers treated with an organ-preservation approach of (chemo)-radiotherapy using intensity-modulated image-guided radiotherapy (IM-IGRT). MATERIALS AND METHODS: This phase II prospective study was conducted at a tertiary cancer centre from February 2017 to January 2020. Forty patients with squamous cell carcinoma of PCUE of stage T1-3, N0-2, M0 were accrued. Gross exolaryngeal extension/dysfunctional larynx were major exclusion criteria. Patients received 63-66 Gy in once-daily fractions using volumetric modulated arc therapy with daily IGRT. Outcome measures included disease-related outcomes, patterns of failure, Radiation Therapy Oncology Group toxicities, feeding tube dependency and QoL. RESULTS: The median follow-up was 22 months. Twenty-six (87.5%) patients had locoregionally advanced disease and 34 (85%) patients received (chemo)-radiotherapy. A complete response was observed in 26 (65%) patients. The 2-year locoregional control, event-free survival and cause-specific survival were 59.6%, 40.2% and 44.8%, respectively. The volume of primary tumour (GTVPvol) exceeding 28 cm3 had inferior overall survival (P = 0.005) on univariate analysis. Multivariable analysis showed GTVPvol and positron emission tomography-computed tomography maximum standardised uptake value to be independently predictive for event-free and overall survival. A feeding tube requirement at presentation was seen in 11 (27.5%) patients, whereas long-term feeding tube dependency at 6 months was seen in 10 (37%) patients. For QoL, a statistical improvement in pain, appetite loss and swallowing was observed over time. CONCLUSION: Although the outcomes of PCUE cancers remain dismal, the use of state of the art diagnostic modalities, careful case selection and modern radiotherapy techniques improved outcomes as compared with before in this exclusive analysis of PCUE cancers.

Applying the QUARTZ Trial Results in Clinical Practice: Development of a Prognostic Model Predicting Poor Outcomes for Non-small Cell Lung Cancers with Brain Metastases.

AIMS: The role of whole brain radiotherapy (WBRT) in patients with brain metastases from non-small cell lung cancers (NSCLC) has been questioned. However, no reliable criteria exist to identify patients who do not benefit from WBRT. The objective of the current study was to develop a prognostic model to identify such patients whose survival matches that of the Quality of Life after Treatment for Brain Metastases (QUARTZ) study. MATERIALS AND METHODS: Outcome data of patients with NSCLC with brain metastases undergoing WBRT enrolled in a prospective observational study in a tertiary cancer centre were used to develop a prognostic model. Baseline clinico-radiological factors were used for development of the model. The model was internally validated and calibration accuracy was checked for prediction of 70 day mortality. The generated prognostic model was presented as a nomogram. RESULTS: The median overall survival of 140 patients enrolled in the study was 166 days (95% confidence interval 108-242 days). The prognostic model identified gender, Karnofsky performance status and epidermal growth factor receptor activating mutation status as significant factors influencing overall survival. The model showed a modest discriminative ability with an optimism-corrected C-index of 0.64. However, model calibration error did reveal a moderate degree of calibration error. The high-risk subgroup identified by the model had a median overall survival of 67 days (95% confidence interval 56-101 days), which was similar to that observed in the QUARTZ trial. CONCLUSION: This prognostic model derived from traditional clinico-radiological features had a modest ability to identify patients with poor prognosis who may not benefit from WBRT. However, the high-risk subgroup identified using this prognostic model had a survival similar to that observed for patients in the QUARTZ trial.

A comparative analysis of immunohistochemistry and fluorescent in situ hybridization assay to detect anaplastic lymphoma kinase status in lung adenocarcinoma cases: A search for a testing algorithm.

INTRODUCTION: Testing for echinoderm microtubule-associated protein-like 4 (EML4) anaplastic lymphoma kinase (ALK) translocation by fluorescence in situ hybridization (FISH) is well established whereas the Food and Drug Administration (FDA) ALK immunohistochemical (IHC) test is relatively new. AIMS AND OBJECTIVE: The aim of this study is to compare FDA-approved ALK IHC test (D5F3 clone) with the standard ALK FISH test. MATERIALS AND METHODS: A validation and a test arm with 100 and 200 cases of Formalin-Fixed, Paraffin-embedded blocks of lung adenocarcinoma, respectively, comprised the material. All cases had ALK IHC test on automated Ventana Benchmark XT IHC slide stainer using anti-ALK D5F3 rabbit monoclonal primary antibody; when positive tumor cells (any percentage) showed strong granular cytoplasmic staining. For the FISH test, Vysis ALK Dual Color Break Apart Rearrangement Probe (Abbott Molecular Inc.,) was used to detect ALK gene 2p23 rearrangements; when positive the red and green signals were split two signal diameter apart and/or isolated 3'red signal were detected in more than 15% tumor cells. The ALK FISH results were available in all 100 validation cases and 64-test arm cases which formed the basis of this analysis. RESULTS: The ALK IHC test was positive in 16% cases; four discordant cases were ALK IHC positive but ALK FISH negative, but no case was ALK IHC negative and ALK FISH positive. There was 100% sensitivity, 90.5% specificity, and 93.75% accuracy. CONCLUSION: A negative ALK IHC result obviates the need for a FISH test barring those with a strong clinical profile, and a positive ALK IHC result is sufficient basis for the initiation of treatment.

Palliative thoracic radiotherapy in advanced lung cancer: A single institution experience.

BACKGROUND: Majority of patients of lung cancer present with locally advanced or metastatic disease, where systemic therapy is the treatment of choice. Many of these patients have local symptoms due to thoracic disease, wherein radiotherapy is proven to be an effective modality for alleviation of symptoms. However, the optimal dose of radiotherapy for adequate palliation remains debatable. The purpose of this retrospective study was to assess the efficacy of two different schedules of thoracic radiotherapy (TRT) with respect to symptom palliation. MATERIALS AND METHODS: A total of 100 consecutively treated patients with stages III-IV lung cancer treated with two different fractionation regimens of palliative TRT, either protracted course 20 Gy/5# over 1 week or short course of 17 Gy/2# over 8 days were assessed for symptom relief and survival. Impact of patient, tumor and treatment-related factors on response and overall survival (OS) was done by univariate analysis using log-rank test. RESULTS: Median age of the entire cohort was 60 years, majority being males, smokers with low Eastern Cooperative Oncology Group performance status (performance score ≥2). Predominant symptoms were chest pain (68) followed by cough (21) and dyspnea (15). Palliative TRT was offered as either protracted course 20 Gy/5# over 1 week or short course of 17 Gy/2# over 8 days in 21 and 79 patients respectively. Median duration of symptom relief was 2 months, no differences in OS at 1 year with either regimen. CONCLUSIONS: TRT is an effective means of palliation having similar symptom relief and outcomes with weekly (17 Gy/2# over 8 days) or protracted radiotherapy regimens (20 Gy/5#over 1 week). Short TRT schedules are convenient and economical for patients as well as resource sparing for high volume centers.

A prospective study of telephonic contact and subsequent physical follow-up of radically treated lung cancer patients.

BACKGROUND: We tested the hypothesis that telephonic follow-up (FU) may offer a convenient and equivalent alternative to physical FU of radically treated lung cancer patients. DESIGN: Prospective study carried out at a tertiary referral cancer care institute, Mumbai. MATERIALS AND METHODS: Two hundred consecutive lung cancer patients treated with curative intent were followed up regularly with telephonic interviews paired with their routine physical FU visits. Patient satisfaction with the telephonic call and the physical visit, the anxiety level of the patient after meeting the physician and the economic burden of the visit to the patient were noted in a descriptive manner. Kappa statistics was used to assess concurrence between the telephonic and physical impression of disease status. RESULTS: With a median FU duration of 21.5 months, the median satisfaction scores for telephonic and physical FU were 8 and 9, respectively. The prevalence and bias adjusted kappa (PABAK) score of the entire cohort of patients was 0.64 (95% confidence interval [CI] =0.58-0.70). Data analyzed up to first disease progression/relapse on FU had a PABAK score of 0.71 (95% CI = 0.64-0.77) indicating substantial agreement. Patients with disease controlled at the FU had a significant PABAK score of 0.88 (95% CI = 0.80-0.94) indicating excellent concurrence. On average, each patient spent Rs. 5117.10 on travel and Rs. 3079.06 on lodging per FU visit. CONCLUSION: Telephonic FU is substantially accurate in assessing disease status until the first relapse. In a resource-constrained country like India, it is worthwhile to further explore the benefits of such an alternative strategy.

Carboplatin-based concurrent chemoradiation therapy in locally advanced head and neck cancer patients who are unfit for cisplatin therapy.

BACKGROUND: Cisplatin-based chemoradiation (CTRT) is the standard of care in locally advanced head and neck cancers. Limited treatment options are available in patients unfit for cisplatin. AIMS: This audit was carried out to study the toxicities, tolerance, and outcomes of carboplatin-based CTRT in patients who are not eligible for cisplatin. MATERIALS AND METHODS: A total of 63 locally advanced head and neck cancer patients treated between January 2011 and October 2015 were administered carboplatin-based CTRT. The dose of carboplatin was equivalent to area under the curve equivalent to 2 administered once a week for a maximum of 7 cycles. Toxicity was coded as per the CTCAE version 4.03. SPSS software version 16 was used for statistical analysis. STATISTICAL ANALYSIS: Descriptive statistics was performed. Progression-free survival (PFS) and overall survival (OS) were estimated by Kaplan-Meier survival analysis. Cox proportional hazard model was used for identifying factors affecting PFS and OS. RESULTS: The reasons for patients being unfit for cisplatin were low serum creatinine clearance in 41 (65.07%), sensorineural hearing loss in 18 (28.57%), uncontrolled medical comorbidities in 3 (4.76%), and old age in 1 patient (1.6%). 53 patients (84.1%) completed planned radiotherapy. The median number of chemotherapy cycles administered was 6. Grade 3-4 toxicities were seen in 32 patients (50.8%). The median OS and PFS were 28 months (95% confidence interval [CI]: 20.9-34.6 months) and 17 months (95% CI: 08.2-25.7 months), respectively. Age was the only factor significantly affecting OS and PFS. CONCLUSION: Carboplatin-based CTRT is well tolerated in patients unfit for cisplatin and seems to have superior outcomes than those reported in radical radiotherapy studies.

Role of the pectoralis major myofascial flap in preventing pharyngocutaneous fistula following salvage laryngectomy.

OBJECTIVE: This study aimed to assess the utility of onlay pectoralis major myofascial flap in preventing pharyngocutaneous fistula following salvage total laryngectomy. METHODS: A retrospective analysis was performed of 172 patients who underwent salvage laryngectomy for recurrent carcinoma of the larynx or hypopharynx between 1999 and 2014. One hundred and ten patients underwent primary closure and 62 patients had pectoralis major myofascial flap onlay. RESULTS: The overall pharyngocutaneous fistula rate was 43 per cent, and was similar in both groups (primary closure group, 43.6 per cent; onlay flap group, 41.9 per cent; p = 0.8). Fistulae in the onlay flap group healed faster: the median and mean fistula duration were 37 and 55 days, respectively, in the primary closure group and 20 and 25 days, respectively, in the onlay flap group (p = 0.008). CONCLUSION: Use of an onlay pectoralis major myofascial flap did not decrease the pharyngocutaneous fistula rate, although fistula duration was shortened. A well-designed randomised-controlled trial is needed to establish parameters for its routine use in clinical practice.

Optimizing treatment and analysis of prognostic factors for locally advanced nonsmall cell lung cancer in resource-limited population.

BACKGROUND: Lung cancer most commonly presents in advanced stages in developing countries, where combined modality treatment using chemo-radiotherapy (CTRT) is the standard of care. MATERIALS AND METHODS: A retrospective audit of patients of nonsmall cell lung cancer (NSCLC) treated at a single Institute from January 2008 to December 2012 was conducted. Various prognostic factors affecting disease-free survival (DFS) and overall survival (OS) were studied by univariate and multivariate analysis. All patients were meticulously followed-up clinically and telephonic contacts. RESULTS: Overall 171 patients of NSCLC were treated with definitive CTRT using concurrent chemotherapy in 66% patients and sequential therapy in 28% patients. The actuarial 2 years DFS was 17.5% and 2 years OS was 61.5%. Complete response to treatment resulted in significantly better DFS and OS. Definitive CTRT was very well-tolerated in these patients with good compliance. CONCLUSION: Definitive CTRT, sequence being individualized depending on performance status and disease stage at presentation, is a feasible and effective treatment modality for locally advanced NSCLC patients in the developing world. Response to treatment is an important prognostic factor for treatment outcomes.

Outcomes in nasopharyngeal carcinoma: Results from a nonendemic cohort.

INTRODUCTION: The treatment of nasopharyngeal carcinoma (NPC) has come a long way from treatment with conventional radiotherapy (RT) alone for the use of concurrent chemoradiotherapy (CCRT) and sequential chemotherapy (CT). We report the outcomes of patients treated with combined modality at a tertiary cancer center in India over a period of 10 years. MATERIALS AND METHODS: A total of 206 patients with NPC between 1994 and 2004, who completed planned treatment, were retrospectively analyzed. Demographic features, disease, and treatment-related factors were analyzed for their impact on loco-regional control (LRC), disease-free survival (DFS), and overall survival (OS). RESULTS: Most patients had Stage III or IV (70.8%) disease. Twenty-six percent received RT alone, 37% received neoadjuvant chemotherapy (NACT) followed by RT alone, 29% received NACT + CCRT, and 8% received CCRT alone. Median RT dose was 64 Gy with 84% receiving RT doses of ≥60 Gy. At a median follow-up of 29 months, 112 (54.4%) patients were alive and disease free. Three-year DFS and OS were 64% and 82.3%, respectively. LRC at 3 years was 71.1%. Independent factors for significantly better LRC and DFS were younger age at presentation, RT dose of more than 64 Gy, and immediate response to RT. The use of CCRT in advanced nodal stages (N2-N3) resulted in significantly better LRC and DFS on multivariate analysis. CONCLUSIONS: Combined modality treatment in advanced stage NPC results in favorable outcomes. RT doses of more than 64 Gy should be considered in all patients, respecting normal tissue tolerances. The role of NACT remains debatable.

Human papillomavirus/p16 positive head and neck cancer in India: Prevalence, clinical impact, and influence of tobacco use.

BACKGROUND: Limited data are available on the prevalence and prognostic significance of human papillomavirus (HPV) in squamous cell carcinoma of head and neck (SCCHN) in the Indian population. AIM: The present study aimed to determine the prevalence of HPV and p16 in an Indian cohort of SCCHN and assess their correlation and influence of tobacco use on patient outcomes. MATERIALS AND METHODS: The p16 and HPV status of 170 patients of SCCHN treated with curative chemoradiotherapy was determined using immunohistochemistry and polymerase chain reaction, respectively, and further correlated with their demographic characteristics. In addition, genotyping of HPV-positive samples was performed. Survival outcomes were analyzed and compared for both p16 positive (p16 +ve) and p16 negative (p16 -ve) population. The influence of tobacco use on outcomes was assessed. RESULTS: p16 expression was observed in 20% (34/170) cases whereas HPV positivity was detected in 39.4% (67/170) of SCCHN patients with HPV16 being the most common (91%) subtype. About 73.5% patients were p16 +ve among the tobacco users in this cohort (83.5%). Interestingly, p16 positivity was significantly associated with nonusers of tobacco (P = 0.02) and younger females (P = 0.06). The p16 +ve and p16 -ve groups did not exhibit a significant difference in the 5-year cause-specific survival (CSS) (79% vs. 72.2%), disease-free survival (DFS) (78.3% vs. 68.3%, P = 0.5), and locoregional control (LRC) (82.2% vs. 71.5%, P = 0.4). However, the outcome analyses in tobacco nonusers revealed a definite large improvement in CSS (P = 0.08) and a trend toward improvement in DFS (P = 0.15) and LRC (P = 0.11) in the p16 +ve versus the p16 -ve groups. CONCLUSION: The low prevalence of p16 positivity (20%) and dual HPV and p16 positivity (38.8%) in the studied Indian cohort indicates the low utility of p16 as a surrogate for HPV in the background of high tobacco burden. The outcomes are largely improved in a small subset of SCCHN cases comprising p16 +ve tobacco nonusers.

Hypofractionated radiotherapy for T1N0M0 glottic cancer: retrospective analysis of two different cohorts of dose-fractionation schedules from a single institution.

AIMS: To determine the influence of dose and fractionation on tumour characteristics, toxicity, disease control and survival outcomes in T1 glottic carcinoma. MATERIALS AND METHODS: Between 1975 and 2000, treatment charts of 652 patients with T1 glottic carcinoma who received curative radiation with four hypofractionated schedules (50 Gy/15 fractions [3.3 Gy/fraction] or 55 Gy/16 fractions [3.43 Gy/fraction] or 60 Gy/24 fractions or 62.5 Gy/25 fractions [2.5 Gy/fraction]) were analysed. The patients were divided into two groups based on fraction size <3 Gy and >3 Gy. Local control and overall survival were calculated. Patient- and tumour-related factors affecting local control were analysed using univariate and multivariate analysis. Factors affecting late toxicity were also analysed. RESULTS: The local control and overall survival at 10 years were 84 and 86.1%, respectively, for T1 glottic carcinoma. The response to radiation had a significant effect on local control with univariate analysis (P = 0.001). Other factors, such as beam energy, anterior commissure involvement and fractionation, did not affect local control. Persistent radiation oedema was seen in 123 patients (23.4%) and was significantly worse in patients who received radiation with a larger field size (>36 cm(2)) on a telecobalt machine (P < 0.001). CONCLUSIONS: Radical radiotherapy schedules incorporating a higher dose per fraction yield acceptable local control rates and late toxicity. Telecobalt therapy for early glottic cancer is a safe alternative to treatment with 6 MV photons on a linear accelerator in terms of local control and late toxicity as long as field sizes smaller than 36 cm(2) are used.

Cetuximab with radiotherapy in patients with loco-regionally advanced squamous cell carcinoma of head and neck unsuitable or ineligible for concurrent platinum-based chemo-radiotherapy: Ready for routine clinical practice?

PURPOSE: To report outcomes of cetuximab concurrent with radiotherapy in advanced head-neck cancer unsuitable for platinum-based chemo-radiotherapy. MATERIALS AND METHODS: Retrospective chart review of 37 patients treated with cetuximab and radiotherapy at a comprehensive cancer centre. RESULTS: Median age of study cohort was 59 years. Thirty four (92%) patients had advanced stage disease (stage III-IV). Reasons for ineligibility for platinum included impaired creatinine-clearance, old age, and/or co-morbidities. Thirty-two (86%) patients completed planned radiotherapy without interruption; 29 (80%) patients received ≥6 cycles of cetuximab. Fifteen patients (40.5%) developed ≥grade 3 dermatitis; 9 patients (25%) experienced ≥grade 3 mucositis. At a median follow-up of 16 months, the 2-year loco-regional control, disease-free survival, and overall survival was 35.5%, 29.5%, and 44.4% respectively. Stage grouping and severe dermatitis were significant predictors of outcome. CONCLUSIONS: Cetuximab concurrent with radiotherapy is a reasonable alternative in advanced head-neck cancer patients with acceptable compliance and outcomes, but higher skin toxicity.

Radiation therapy with implanted cardiac pacemaker devices: a clinical and dosimetric analysis of patients and proposed precautions.

AIMS: To report the radiation planning dosimetric aspects and clinical outcomes of patients with implanted cardiac pacemakers. MATERIALS AND METHODS: Between 2005 and 2009, eight patients with in situ cardiac pacemakers of varied primary site were treated at our hospital. All patients underwent computed tomography-based treatment planning. The target volumes, organs at risk and pacemaker device were all contoured. A treatment plan optimally covering the target area and maximally sparing the pacemaker was generated. All patients were evaluated at baseline, during radiotherapy and after radiotherapy conclusion by a cardiologist as well as pacemaker company personnel. RESULTS: The median age at presentation was 67 (range 53-77) years. There were three men with head and neck primaries, two men with lung primaries and three women with breast primaries. The prescribed dose ranged from 45 to 70 Gy in 25-35 fractions with a daily dose of 1.8-2.0 Gy. Four patients had the pacemaker implanted on the same side as the radiotherapy target. The dose ranges for the minimum, mean and maximum doses to the pacemaker were 0.06-2.0, 0.07-20.6 and 0.14-60.0 Gy, respectively. Radiation therapy was safely delivered in all patients without any untoward effects. At 5 months of median follow-up, all patients were well with no malfunction of the pacemaker. CONCLUSION: A series of eight patients with in situ pacemakers treated with radiotherapy is reported. Radiotherapy can be safely delivered in patients with implanted cardiac pacemakers. However, it mandates a cautious approach in planning and treatment delivery to ensure the least possible dose to the pacemaker. Close liaison with the cardiologist and a pacemaker clinic before, during and after the course of treatment is essential to ensure patient safety.

Validation of recursive partitioning analysis classification in patients with brain metastases from non-small cell lung cancer treated with short-course accelerated radiotherapy.

AIMS: To study various prognostic factors affecting outcome and to validate Radiation Therapy Oncology Group recursive partitioning analysis (RPA) class in non-small cell lung cancer (NSCLC) with brain metastases treated with short-course accelerated radiotherapy (SCAR). MATERIALS AND METHODS: The case records of 100 patients with NSCLC consecutively treated at Tata Memorial Hospital from August 2006 to August 2009 were studied for various patient, tumour and treatment-related prognostic factors. Patients received whole-brain radiotherapy to a dose of 20 Gy/five fractions over 1 week (n=90) or 30 Gy/10 fractions over 2 weeks (n=10). The Kaplan-Meier estimate was used for survival analysis in SPSS v15. RESULTS: The median overall survival was 4.0 months (range 0.5-30.0 months). The 6-, 12-, 18- and 24-month survival rates were 35.8, 18.0, 9.3 and 6.2%, respectively. Of the various prognostic factors, RPA class (II versus III, P value=0.023), Karnofsky performance score (<70 versus ≥70, P value=0.039) and the use of systemic therapy (yes versus no, P value=0.00) emerged as significant on univariate analysis. RPA classification effectively separated the patient population into prognostically distinct subgroups. The median overall survival for RPA class II and RPA class III was 6 and 4 months, respectively. The use of systemic therapy prolonged overall survival by 6 months (3 months versus 9 months). CONCLUSION: The SCAR regimen is an effective and resource-sparing palliative strategy for brain metastases in NSCLC. The results validate the usefulness of RPA classification in this specific subset of patients treated with SCAR.

Intraoral adenoid cystic carcinoma: prognostic factors and outcome.

Intraoral (oral cavity and oropharynx) adenoid cystic carcinomas are uncommon cancers characterized by slow evolution, protracted clinical course, multiple and/or delayed recurrences, and late distant metastases. The molecular biology behind this enigmatic disease remains poorly characterized. To analyze and correlate prognostic factors with outcome in intraoral adenoid cystic carcinoma. Medical records of 76 patients with intraoral adenoid cystic carcinoma treated with definitive loco-regional therapy at the institute between 1992 and 2004 were retrospectively reviewed and analyzed.Majority (85.5%) of the patients had advanced stage disease. Seventy-four patients underwent surgery, of which 51 (68.9%) received adjuvant radiotherapy. The median dose of radiation was 56 Gy (range 44-66 Gy). Two patients with medical co-morbidities received radical radiotherapy. Perineural invasion, margin positivity and nodal positivity were present in 24 (32.4%); 27 (36.4%); and 15 (19.7%) patients, respectively. Ten (13.1%) patients developed local recurrence and 6 (7.8%) distant metastases. With a median follow-up of 20 months (range 1-137 months), the 5-year Kaplan-Meier estimates of local control and disease-free survival were 57.9% and 47.1%, respectively. On uni-variate analysis, perineural invasion (p=0.003), oropharyngeal primary (p=0.033), and advanced T-stage (p=0.047) were associated with increased local recurrences. Perineural invasion (p=0.05) and primary site (p=0.042) also predicted disease-free survival. On multivariate analysis, both perineural invasion and primary site retained significance for local control (p=0.007, p=0.011) and disease-free survival (p=0.018, p=0.014), respectively. Intraoral adenoid cystic carcinoma is an uncommon disease with an enigmatic clinical course. Perineural invasion, site of primary, and T-stage significantly impact upon local control and disease-free survival. The role of adjuvant radiotherapy remains controversial. Larger prospective studies with mature follow-up are needed to define the optimal treatment of intraoral adenoid cystic carcinoma.

Ultrasonographic changes in malignant neck nodes during radiotherapy in head and neck squamous carcinoma.

Limited information is available about the sonomorphological changes in metastatic neck nodes during radiotherapy. The aim of this study was to evaluate the pattern of sonomorphological changes in metastatic neck nodes with radiotherapy. The study population consisted of 16 consecutive patients planned for radical radiotherapy to the head and neck. All patients were subjected to four ultrasound examinations: before therapy, at 46 Gy, at the conclusion of radiation and at first follow up. A total of 59 ultrasound examinations were performed on 16 patients. The difference between the mean number of nodes detected per patient before (10.6) and after (7.8) radiation was significant (P = 0.05). Sixteen nodes were categorized as malignant at first sonography, half of which reverted back to normal by the end of radiation. Changes in the sonomorphology of malignant cervical lymph nodes occur with radiotherapy with more that half demonstrating reversion to normal pattern. Future studies correlating this with histopathology should be considered.