clinical discussion · • pai p s et al. oral metronomic scheduling of anticancer therapy-based...
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Clinical Discussion
Dr Pankaj ChaturvediProfessor and Surgeon
Tata Memorial Hospital
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• 47/M/smoker
• Hopkins : Trans-glottic lesion
• No cartilage infiltration but sclerosis
• Left vocal cord fixed
• No nodes palpable
Glottic Ca -T3 N0 MO
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Q1 - VOTING Options
1. Surgery -A. Open partial Laryngectomy
B. Laser cordectomy
2. Concurrent Cisplatin + RT
3. Neo adjuvant Chemotherapy
4. Cetuximab + RT
5. Radiotherapy Alone
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Total Laryngectomy TEP PORT
T3 N0 MO Glottic Carcinoma
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Author Year T3
5yr LC
T4
5yr LC
Mendenhall et al 1996 68% 56%
Daugaard et al 1998 38% 29%
Santos et al 1998 12% (OS) 14%(OS)
Sykes et al 2000 67% 73%
Hinerman et al 2002 62% 62%
Radiotherapy for Stage 3 / 4 larynx cancers
Is there a role of RT alone ?YES or NO
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Does NACT still have a role?Yes / No
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Is there a role of Cetuximab +RT
Bonner et al. N Eng J Med 2006;354:567-578
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Surgeon
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• Review of 158,426 cases of larynx cancer between 1985-2001
• Trend toward decreasing survival from the mid-1980s to mid-1990s
• Patterns of initial management across this same period: ↑CTRT and ↓Surgery
• Survival outcome of T3N0M0 laryngeal cancer in 1994-96 period: Poor 5Yr OS with CTRT (59.2%) and RT alone (42.7%) compared to Sx+RT (65.2%) or Sx alone (63.3%)
• The decreased survival recorded for patients with laryngeal cancer in the mid-1990s may be related to changes in patterns of management.
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Despite improvement identified overall for all cancer types, survival among patients with laryngeal cancer has diminished. Data from SEER Cancer Statistics Review, 1975–2000. Bethesda, MD: National Cancer Institute; 2003. Available at: http://seer.cancer.gov/csr/1975_2000 Published by Hoffman et al
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• 47/M/Chronic smoker
• Hoarseness
• Hopkins : Pyriform
• Cartilage not involved
• Left vocal cord fixed
• No nodes palpable
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Q2 - Voting Options
1. Surgery Followed by CT/RT
2. Concurrent Chemo Radiotherapy
3. Neo-adjuvant Chemotherapy
4. Targeted Therapy with RT
5. Radiotherapy alone
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45 yrs young man – Stage 4 a
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Q3 - Voting Options
1. Surgery Followed by CT/RT
2. Concurrent Chemo Radiotherapy
3. Neo-adjuvant Chemotherapy
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Primary Chemotherapy in Resectable OSCC : A Randomized Controlled Trial. J Clin Oncol 2003;21:327-333. L Licitra et al
• Resectable, stage T2-T4(>3 cm), N0-N2 SCC of oral cavity
• PF followed by surgery vs surgery with or without radiotherapy
• No difference in overall survival
Role of Induction chemotherapy in resectableoral cancers?
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Randomized Phase III Trial of ICT with Docetaxel, Cisplatin and FU Followed by Surgery Versus Up-Front Surgery in Locally Advanced Resectable OSCC J ClinOncol. 2012 Nov 5; L Zhong et al
• Resectable stage III or IVA OSCC
• The control and experimental arms did not differ significantly in locoregional recurrence rates.
• Estimated 2-year OS and DFS was same
Role of Induction chemotherapy in resectableoral cancers
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NACT – Does it help?
Patil V M, Noronha V, Muddu V K, Gulia S, Bhosale B, Arya S, Juvekar S, Chatturvedi P, ChaukarD A, Pai P, D'cruz A, Prabhash K. Induction chemotherapy in technically unresectable locally advanced oral cavity cancers: Does it make a difference?. Indian J Cancer 2013;50:1-8
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.
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Stage 4B
• 52 year Truck Driver• Lesion involving right Buccal Mcosaand extensive infiltration• No distant metastases
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Q3 - Voting Options
1. Neo adjuvant Chemotherapy
2. Palliative Chemotherapy
3. Palliative Radiotherapy
4. Best Supportive Care
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•56 yrs male, underwent Surgery for Stage 4 Carcinoma Buccal Mucosa with PORT with Chemotherapy
•At first follow up at 4 months diagnosed with recurrence• PET Scan – local recurrence alone
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Q 4 - VOTING Options
1. Symptomatic Treatment
2. Palliative Chemotherapy
3. Targeted Therapy
4. Surgery if Resectable
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• Recurrent/ Metastatic HNSCC
• Cetuximab + Platin + Flurouracil Vs Platin + Flurouracil
• About 20% oral cavity patients
• Better outcome in cetuximab arm
– 2.7 mo median OS improvement ( 10.1 mo Vs 7.4 mo)
– 2.3 mo median PFS improvement (5.6 mo Vs 3.3 mo)
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• Palliative chemotherapy is the standard option for most patients with recurrent or metastatic HNSCC
– First line option should be combination of cetuximab with platin and flurouracil
Cetuximab has a definitive role as a firstl ine therapy along with platin and flurouracil for recurrent and metastatic oral cancer
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• Result
– QALY increased: 0.093
– Cost increased: $36,000 per person
– Incremental cost effectiveness ratio of $386,000 per QALY gained.
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Metronomic Therapy
• Pai P S et al. Oral metronomic scheduling of anticancer therapy-based treatment compared to existing standard of care in locally advanced oral squamous cell cancers: A matched-pair analysis. Indian J Cancer 2013;50:135-41
• Patil V, Noronha V, D'cruz A K, Banavali S D, Prabhash K. Metronomic chemotherapy in advanced oral cancers. J Can Res Ther 2012;8:106-10
Comparison of DFS between the oral metronomic scheduling of anticancer therapy and control groups
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• 3x3cm ulcer Rt. lateral border of tongue
• Not crossing midline / FOM - normal.
• T2N1M0
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Q5 - Voting Options
• Wide Excision alone
• Wide Excision with Neck Dissection
• Neo adjuvant CT
• Radiotherapy alone
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Management issues
• Imaging• Surgery or Radiotherapy• Margins• Neck node management• Sentinel Node Biopsy?• Reconstruction • Should we do HPV testing?
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• 61/M
• Tobacco chewer
• Presented with Right sided neck mass 2.5 months.
• O/E- Right neck, Level II palpable node 5x4 cm.(N2a)
• PET CT – Nodal Mets only
Carcinoma of Unknown Origin
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Q 6 - VOTING Options
1. Surgery followed by CT RT 2. Concurrent CT and RT
Other issues –1. HPV 2. Bilateral Mucosal Radiation3. Tonsillectomy
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• 38/F
• Left Parotid lesion operated 1 month back
• Details of surgery not available.
• Facial nerve intact
• HPR – Mucoepidermoidcarcinoma (intermediate grade) - 3 cm
• Margin status unknown
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MRI
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Question
– Repeat Surgery
–Adjuvant RT
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• 45/F
• Presented with Left Thyroid swelling since 4 years
• FNAC – Bethesda 2
• USG – Benign lesion left lobe. Right lobe normal
• Left Hemi thyroidectomydone
• HPR – Well Diff Pap Ca, 3 cm no ETS, uni-focal
What next?
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Question
• Observation alone
• Observation + Thyroid suppression
• Molecular Markers for decision making
• Completion thyroidectomy alone
• Completion thyroidectomy with bilateral CCND
• Lobar ablation with RAI
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