This analysis was done with the aim to study the overall impact of docetaxel and cabazitaxel treatment by using quality of life without toxicity or symptoms (QTWiST) analysis in head and neck cancer patients receiving second line treatment
OS (Overall survival) was partitioned in three health states for QTWiST analysis.TOX state was defined as the cumulative number of days spent in grade 3 or above toxicity post randomization and before progression.TWiST state was defined as the cumulative number of days spent post randomization and before progression without grade 3 or above toxicity. REL state was defined as the time spent in days post progression till death. A threshold utility analysis was performed. The difference in mean QTWiST scores with its 95% CI and corresponding p value between the 2 arms was calculated.
The restricted mean TOX state duration in cabazitaxel arm was 2.26 days (95%CI 1.12-3.40) versus 1.543 days (95% CI 0.56-2.53 days) in docetaxel arm. In threshold utility analysis the mean difference in QTWiST was in favour of docetaxel arm and ranged from -7.194 (utility for TOX to -35.96. For any combination of utility score of REL > 0, with any combination of utility score of TOX the difference in mean QTWiST between the 2 arms was greater than 14 days (ie > 10% of OS), in favour of docetaxel arm which is considered clinically meaningful.
Patient randomised to docetaxel arm have higher QTWiST score than patients in cabazitaxel arm and the differences are clinically meaningful in any combination of utility score of TOX with a utility score of REL > 0.
Tata Memorial Hospital
None
All authors have declared no conflicts of interest.
To see long-term oncological outcome of Transoral Robotic Surgery for intensification of treatment in addition to adjuvant Radiotherapy/chemoradiotherapy for Stage IV HPV negative oropharyngeal malignancies.
From March 2013 to September 2015, 86 patients with Stage IV (cT1-3N2) HPV negative oropharyngeal carcinoma underwent TORS & neck dissection using
A total of 86 patients (69 males and 17 females) underwent TORS. All patients were HPV negative. Mean age at presentation was 57.4 years (32-83 years). Escalation of therapy with TORS followed by 60-64Gy ± 5-6 cycles weekly Inj. cisplatin adjuvant RT/CTRT lead to better survival rates as compared to CTRT/RT alone. T1-3N2a: 12 patients: All underwent TORS followed by RT in 7 patients and CTRT in 5 patients. Ten patients are disease free and alive on an average follow-up of 29 months with two patients developed nodal recurrence, but are alive after salvage surgery. T1-3N2b: 56 patients: After TORS, 40 patients received CTRT and 16 patients received only RT. 46 (82.1%) are alive and disease free. Six patients developed loco-regional recurrence of which 4 patients were salvaged and disease free. Four patients expired due to metastasis T1-3N2c: 18 patients: After TORS, 13 received adjuvant CTRT and 5 received RT. 10 (55.6%) were disease free and alive. Seven patients developed locoregional recurrence of which 4 are disease free and alive after salvage surgery. 3 patients expired due to disease. Of 86 patients with Stage IVa Oropharyngeal Carcinoma, escalation of treatment with TORS followed by adjuvant CTRT/RT gave disease free survival of 76.7% and an overall survival of 88.4% on a mean follow-up of 34 months (21-51 months).
Transoral Robotic Surgery is a good option for cure in relatively radio-resistant HPV negative resectable oropharyngeal malignancies. TORS can be used to intensify treatment of Stage IV oropharyngeal carcinoma and avoid early and late toxicities due to higher doses of RT/CRT and achieve better oncological outcome.
FMRI, Gurgaon
None
All authors have declared no conflicts of interest.
Management of neck in clinically node negative, early stage oral cavity squamous cell carcinomas (SCC), especially tongue subsite has been a long-standing controversy. Tumor depth in tongue is shown to predict lymphatic spread but it is difficult to determine pre-operatively and therefore not routinely used in decision-making. We conducted a prospective study to compare the tumor thickness using ultrasonography (USG) and pathological nodal status.
Prospective analysis included 100 patients of early SCC tongue (cT1-T2) with clinically negative neck (cN0), who attended the surgical oncology department at Gujarat Cancer and Research Institute, Ahmedabad, India between September 2013 and September 2015. All the patients underwent USG of tongue pre-operatively to assess the depth of tongue lesion followed by wide local excision of tumor with elective neck dissection (MND). Histopathological findings like pT, pN, differentiation and depth of invasion were compared with pre-op clinical and radiological findings. Relevant statistical tests were used for analysis.
The study had male predominance (62 M: 38 F), with majority in their 5th & 6th decade. Clinically, 44 patients had T1 and 56 had T2 tongue lesion with node negative neck. Pathologically 35 patients were T1 of which 5 had metastatic lymph nodes and 65 were T2 of which 20 had positive nodes. Level II was the most common site for cervical node involvement (48%) followed by level III (28%). Patients were classified according to tumor depth into <2mm, 2-4 mm and >4mm i.e. 22:55:23 sonographically and 20:60:20 histopathologically respectively. Sensitivity of USG for depth< 2mm, 2-4 mm and >4 mm were 100%, 92.3% and 92.3% respectively whereas specificity were 97.6%, 100% and 96.4% respectively. On comparing depth of lesion with node positivity, all the 20 patients with <2 mm depth were node negative, 13 out of 60 with 2-4 mm depth were node positive whereas 12 of 20 with >4 mm depth were node positive. Total 13 patients had recurrence on follow up. Of these, 10 occurred in pN+ patients while 3 in pN0 patients.
Tumor thickness/depth is a significant predictor of nodal metastasis and elective neck dissection should be considered when this depth is 3mm or more. In the present study, ultrasonography was validated as a reliable diagnostic tool in assessing the depth of tumor pre-operatively, with sensitivity and specificity more than 90%.
Tapan Singh Chauhan
None
All authors have declared no conflicts of interest.
Second primary tumor (SPT) is a serious complication after definitive radiotherapy for nasopharyngeal carcinoma (NPC). This current study aimed to evaluate the incidence of SPT and the excess cancer risks in NPC patients treated with intensity-modulated radiotherapy (IMRT).
Case records of 759 non-metastatic NPC patients who underwent definitive IMRT between February 2003 and September 2011 were reviewed. Cumulative SPT incidence and overall survival after SPT diagnosis were estimated. Associations between clinical characteristics and SPT risk were analyzed using the Cox proportional hazard model. Standardized incidence ratios (SIR) were calculated using age, gender and calendar year specific incidence rates from the Hong Kong Cancer Registry to quantify excess cancer risks compared with the general population.
The median follow-up was 7.5 years. Fifty-one SPTs (6.7%) were identified, 22 (43.1%) of which occurred within previous radiotherapy fields. The 3-year, 5-year and 8-year cumulative SPT incidences were 1.0%, 3.7% and 7.7% respectively. Most common in-field SPTs were tongue cancers (31.8%) and sarcomas (31.8%). Median overall survival after diagnosis of SPT was 2.9 years. Age was the only independent factor associated with SPT development [Hazard ratio, 1.061; 95% confidence interval (CI), 1.029 – 1.094; p < 0.001]. There was an 84% increase in cancer risk (SIR, 1.84; 95% CI, 1.37 – 2.42). Significant excess risks were observed for sarcoma (SIR, 38.10; 95% CI, 16.41 – 75.06), tongue (SIR, 33.33; 95% CI, 13.36 – 68.67), oropharyngeal (SIR, 25.00; 95% CI, 2.81 – 90.25), prostate (SIR, 3.19; 95% CI, 1.17 – 6.95) and liver cancer (SIR, 2.80; 95% CI, 1.02 – 6.10). The excess risks were higher beyond 5 years of follow-up.
High SPT incidence and excess cancer risks were observed after definitive IMRT for NPC, in particular for tumors arising within radiotherapy fields. SPT severely negates longevity of NPC survivors. High awareness is warranted for this lethal late complication in clinical follow-up.
Department of Clinical Oncology, Queen Elizabeth Hospital, Hong Kong
None
All authors have declared no conflicts of interest.
T4 disease is divided as T4a (moderately advanced) and T4b (very advanced) for oral cavity cancers as per American Joint Committee on cancer (AJCC) 7th edition. Liao et al showed no statistical difference in the 5-year survival rates between the T4a and T4b groups. But it was a retrospective study with a small sample size. Thus, there was a need of a prospective study comparing the survival outcomes between T4a and T4b lesions.
This is a prospective study of 210 treatment naïve biopsy proven T4 buccal mucosa cancer patients operated between January 2010 to December 2013.Surgery was the primary modality of treatment followed by adjuvant therapy. Patients with Extracapsular spread(ECS) and margin positivity received chemoradiation and remaining patients received radiation alone. Follow up was done every 3 months. In the case of clinical suspicion of recurrence, confirmation was done using biopsy and or imaging.
The mean age was 49 years (26-73 years) with a male to female ratio of 4.6:1. T4a disease was seen in 135(64.3%) patients and T4b in 75(35.7%) patients. The mean disease-free survival(DFS) in T4a and T4b group was 41 months and 30 months respectively(p-0.001).The mean overall survival was 46 months for T4a lesion and 30 months for T4b lesion(p-0.0012). Differences in the DFS of the patients who received chemoradiation and those who received only radiation is given in the Table below. As expected, it is seen that patients with Extracapsular spread(ECS) and margin positivity have poor survival. But it is difficult to explain why patients with T4b disease without ECS or positive margins also have poor survival. Intensification of treatment in these select group of patients is important which might improve outcomes. Also, the rate of distant metastasis in patients with T4b disease was 19% and among those with T4a disease was 11%.3 –year DFS T4a T4b Chemo-radiation(with ECS & margin positivity) 41.6% 33.6% Radiation alone 72.2% 42.1% p-value 0.000 0.074
T4b is more aggressive disease than T4a.Treatment intensification with the addition of chemotherapy to radiation may benefit select patients with T4b buccal mucosa cancers and might help in reducing the rate of distant metastasis.
Manish Mair
None
All authors have declared no conflicts of interest.