GASTROINTESTINAL
Abstract: 016
Role of stereotactic body radiation therapy in liver metastasis:
A pilot study
S. Kumar, R. Kapoor, A. Oinam, A. Duseja, N. Kalra
Post Graduate Institute of Medical Education and Research,
Chandigarh, India, E-mail: shikharkumar89@gmail.com
Background: Stereotactic external-beam radiation is an increasingly
attractive modality for patients with a limited number of unresectable
liver metastases because of their non-invasive nature, excellent
tolerability & high rates of local control. This trial studies the feasibility
& potential utility of SBRT in these patients. Aims: (1) To assess the
local response of the liver lesions post- SBRT in terms of number
and size of lesions. (2) To evaluate the toxicity to OARs (Liver,
Right kidney, Duodenum, spinal cord). Materials and Methods: 15
patients were planned to be enrolled in this study from November
2014-October 2015. This is an interim analysis of the results of 10
patients who have completed the protocol. The inclusion criteria are
patients with 1-3 liver metastasis from any solid tumor except germ
cell tumor or lymphoma with adequate liver and kidney function with
no evidence of progressive disease outside the liver. A planning 4D-
CT scan is taken with patient in immobilization device & the GTV is
defined on all respiratory phases 0-90). PTV is generated by giving
margin of 5mm. Dose prescribed is 36 Gy/3# on alternate days.
Before each fraction, a cone-beam CT is taken with the patient in the
treatment position with the help of on-board kVCBCT imaging system.
Stereotactic repositioning is done. Patients are followed up to assess
toxicity, and response is defined by CECT abdomen done at 6 weeks
&3 months post-SBRT as per RECIST guideline (v1.1). Results: The
median age of the patients was 64 years (range 36-65 years). The
median time since primary tumor diagnosis was 6 months (range
1-13 months). No patient had received prior local therapy for liver
metastasis. 3 patients had received prior systemic chemotherapy
for metastatic disease. The median aggregate Gross tumor volume
was 75 ml (range 0.8 ml-95 ml). The median Maximal tumor diameter
was 4.4 cms (range 1 cm-6.5 cms) 5 patients had partial response,
3 patients had stable disease and 2 patients had complete response
at site of original lesion but developed new lesion elsewhere i.e.,
Progressive disease. One patients experienced Grade 2 small bowel
toxicity, none of the other patients had Grade 2 or higher Hepatic/
Gastric/Renal/Small bowel toxicity. Conclusion: This trial examines
the feasibility of SBRT to liver metastasis in the Indian setup. It shows
excellent tolerability and is a safe & non-invasive therapeutic option
for inoperable patients, showing good local control.
Abstract: 017
Esophageal squamous cell carcinoma with cutaneous
metastasis: A case report
N. Bellutagi
Karnataka Cancer Therapy and Research Institute, Hubli, Karnataka,
India, E-mail: naveenbellutagi@gmail.com
Introduction: Skin metastasis from internal malignancies are
common in breast, lung cancer & melanomas. we are hereby
reporting a rare case of skin metastasis in esophageal cancer.
Esophageal malignancies most commonly metastasis to lung, liver
& bone. In general skin metastasis from internal organs are rarely
seen with an incidence of 0.7%-9%. Metastatic spread to the skin
occurs through hematogenous or lymphatic pathway & presents in
the form of rapidly growing nodules. On histological examination,
a cluster of atypical cells infiltrating the dermis without connection
to the adjacent epidermis can be seen. Case Presentation: A 58
S28
yrs old man presented with a history of difficulty while swallowing
solid food for 20 days. He was evaluated with upper GI scopy which
showed ulcero proliferative growth present from 30-35 cm from
incisors, bleeds on touch & scope was negotiable beyond the growth.
Biopsy from the growth showed moderately differentiated SCC. CT
Thorax & abdomen showed circumferential growth involving distal
third of esophagus with a maximum thickness of 13 mm, extending
for a length of 7.5 cm. Distally the lesion is seen involving the GE
junction, contact of angle between the lesion & descending aorta is
<90 degrees with enlarged lymph nodes in para esophageal & celiac
region, largest of size 12 * 15 mm. Then he was taken up for 3 field
esophagectomy with esophago-gastric anastomosis with feeding
jejunostomy. Post operative histopathological report showed poorly
differentiated SCC with tumour infiltrating the muscularis propria,
metastases was seen in 9 lymph nodes with extra nodal extension,
surgical excision margins were free of tumour - grade III tumour.
Patient came after 6 weeks for adjuvant treatment, he had developed
multiple nodular swellings approximately 15 diffuse non tender firm to
hard nodules that were 1-2 cm in diameter found on frontal region of
scalp on left side, left side of face, left side of neck, 2 nodules on the
right anterior aspect of arm, 2 on the left anterior aspect of arm, one
each on medial aspect of thigh & 1 on the left gluteal region. Excision
biopsy of one nodule showed poorly differentiated SCC Patient
then received palliative chemotherapy with inj. cisplatin/5FU over
four days. Conclusion: Skin manifestation of esophageal SCC are
extremely rare & only a small number of cases with solid metastasis
have been reported.
Abstract: 025
Clinicoepidemiological features of colorectal carcinoma: Does
change in ageing trend have any role in the management?
P. Kaur, A. Chauhan, J. Vijaya Kumar, A. Khurana, Y. Verma, N. Bansal
Pandit BD Sharma PGIMS, Rohtak, Haryana, India, E-mail:
drparamjitkaur@rediffmail.com
Background: Colorectal carcinoma is more common in the age group
of 50 years or older. Its incidence in the younger age group is increasing
now a day. Various factors contributing to the poor outcome in the
patients of younger age group includes biology of tumor, delay in the
diagnosis and also disparities in the care and treatment differences.
Colorectal second primary tumors (SPTs) are more common in the
younger age group. Incidence of colorectal cancer under the age of
45 is 2 per 100,000 per year. Aim: The aim of the this study was
to evaluate clinico-epidemiological profile, treatment pattern and
outcome in younger age group patients of colorectal carcinoma.
Materials and Methods: A prospective study was conducted from
June 2013 to June 2015. Patients were assigned with treatment after
diagnostic workup and ruling out the metastasis. All the patients were
treated with various treatment modalities such as surgery, radiation
therapy, concomitant chemoradiation therapy and chemotherapy.
Results: A total of six patients with histopathologically proven
colorectal carcinoma were evaluated in department of Radiotherapy –
II, Pt B D Sharma PGIMS, Rohtak, Haryana, India. Four patients were
male and two female. Age of six patients was 25, 16, 35, 25, 30 and
20, mean age was 25. All the patients in the case series presented
with bleeding per rectum. Family history was insignificant in patients.
History of smoking was present in one patient whereas there was
no history of alcohol consumption in any of the patient. Among 6
patients 5 patients are on follow up with mean duration of follow up of
7 months. All the patients received chemotherapy based on the adult
doses; radiation therapy was given on based on the dose schedules
indicated in adults. Two patients of colon carcinoma received adjuvant
Oxaliplatin based chemotherapy after radical surgery. Remaining four
Journal of Cancer Research and Therapeutics - Supplement 1 - 2015 - Volume 11
 Abstracts
patient of rectum carcinoma received neoadjuvant chemoradiation,
and then underwent surgery and adjuvant chemotherapy. Four
patients have completed the intended treatment. Two patients are on
treatment. Three patients had complete response and are on follow
up. Conclusion: Presentation of the tumor in the younger age group
did not have variation in response to the particular treatment similar.
Abstract: 047
A prospective comparative study between concurrent
chemoradiation followed by high dose intraluminal
brachytherapy boost versus concurrent chemoradiation alone
in locally advanced cancer oesophagus
R. Tudu, D. Barman, B. Dutta, A. Halder, A. R. Deb
Medical College, Kolkata, West Bengal, India, E-mail: rajanitudu@
gmail.com
Background: Carcinoma oesophagus is a highly malignant disease
presenting in very advanced stage. Surgery is considered to be the
prime modality of treatment, though radiation therapy is also an
important therapeutic modality. Concurrent chemoradiation has been
accepted as the standard of care in patients who are deemed unfit
for surgery. Intraluminal brachytherapy is effective for palliation of
dysphagia and is also used as a boost to external beam radiotherapy
in a curative intent. Aim: To compare the treatment outcome in
patients of locally advanced oesophageal cancer treated with
concurrent chemoradiation followed by brachytherapy boost versus
concurrent chemoradiation alone in terms of response and toxicities.
Materials and Methods: A study carried out between July 2013
to December 2015 with 42 patients of locally advanced carcinoma
oesophagus who were treated with either definitive chemoradiation
followed by intraluminal brachytherapy boost or chemoradiation alone.
ARM A was treated with external beam irradiation with conventional
fractionation to a total dose of 54 Gy. Initially 40-44 Gy was given by
AP-PA field, then in phase 2, dose escalation was done through 3
field technique i.e., one anterior field and 2 posterolateral fields. ARM
B was treated with external beam irradiation to a total dose of 44 Gy in
conventional fractionation using AP-PA field followed by intraluminal
brachytherapy with 5 Gy per fraction weekly in a total dose of 15
Gy with dose specified at 1 cm depth from the mid-dwell position.
The chemotherapy regimen consisted of injection cisplatin 70 mg/
m2 iv D1 with capecitabine 800 mg/m2 b.i.d. D1-4 orally on days
1 and 22 of EBRT. No concurrent chemotherapy was administered
during ILRT. The treatment outcome was assessed in terms of
response, dysphagia free interval and toxicities. Results: Baseline
characteristics were same in both groups. In our study, 36 patients
reported no locoregional recurrence at a median follow up period of 10
months. There was non significant statistical significance difference
in response rates between the two treatment arms. 1 patient in the
brachytherapy arm developed trachea-oesophageal fistula. Other
acute toxicities were comparable in both arms. Conclusion: As the
treatment was well tolerated, high dose intraluminal therapy can serve
as a safe dose escalation tool with the potential to improve treatment
outcome in oesophageal cancer with acceptable complications.
Abstract: 150
Anaplastic Large Cell Lymphoma of Oesophagus mimicking as
adenocarcinoma
S. Samdariya, P. Bagri, P. Pareek, P. Elhence, S. Bhattacharya
All India Institute of Medical Sciences, Jodhpur, Rajasthan, India,
E-mail: drsaurabh.onco@gmail.com
Background: Anaplastic large cell Lymphoma (ALCL) is a rare disease
accounting for only 2-3% of Non Hodgkins lymphoma (NHL). Usually
it affects males with a median age of 54-61 years and a male-to-
female ratio of 0.9. They are usually detected in advanced stages with
B symptoms, high International Prognostic Index score. They have an
aggressive clinical course and overall prognosis is poor with a 5-year
Overall Survival of 30-49%. Nearly half of Anaplastic kinase1 (ALK)
Journal of Cancer Research and Therapeutics - Supplement 1 - 2015 - Volume 11
negative ALCL affects Lymph nodes. Extranodal involvement is seen in
only 20% cases which usually affect bone marrow, skin, lungs, soft tissue
but gastrointestinal tract especially oesophagus involvement is very rare.
Aim: In this paper we present unusual rare case of ALCL of oesophagus
affecting a young 26 year old male which mimicked adenocarcinoma in
its clinical presentation. Materials and Methods: A 26 year old young
farmer from Jaisalmer, Rajasthan presented with complaints of difficulty
in swallowing solids, pain in upper abdomen and pain in outer aspect of
right upper thigh since 4 months. He didn’t have any family h/o-cancer. He
didn’t have any habits of chewing tobacco, alcohol intake. Examination
of upper part of right thigh revealed a diffuse, firm, oval, tender swelling
measuring approximately 10 x 7 cm on its lateral aspect. There was an
irregular shaped swelling with ill-defined borders measuring 15 x 10 cm
palpated in epigastric region which was dull on percussion. There were
no palpable Lymphadenopathy in neck, axilla or inguinal region. MRI
Right thigh revealed heterogeneously enhancing mass lesion, hypo
on T1 and hyperintense on T2 measuring 7.4 x 5.6 x 14.7 cm in right
upper thigh muscles with corticle erosion. Computed tomography of
Thorax and Abdomen was done which revealed thickening of mucosa
of oesophagus, GE junction, lesser curvature stomach measuring 3.9
x 3.4 x 10.4 cm. Enlarged coeliac (25 x 21 mm), retroperitoneal lymph
nodes, splenomegaly, mild ascitis and mild right pleural effusion. Upper
GI endoscopy revealed circumferential ulcerated friable oozing growth
at cardia, its biopsy revealed tumor cells with prominent nucleoli without
glandular differentiation or signet ring forms. On immunohistochemistry
(IHC) tumor cells were strongly positive.
Abstract: 176
Investigation of optimal strategy of internal target volume
generation for liver SBRT
S. Chopra, M. Swain1, R. Upreti1, R. Engineer1, S. K. Srivastava1
Advanced Centre for Treatment, Research and Education in
Cancer, Tata Memorial Centre, 1Tata Memorial Hospital, Mumbai,
Maharashtra, India, E-mail: supriyasastri@gmail.com
Purpose: To investigate if limited number of respiratory phases can
be used to accurately generate internal target volume (ITV) for liver
stereotactic body radiotherapy (SBRT). Materials and Methods: Free
breathing (FB) and four dimensional computerized tomography (4DCT)
scans of 10 patients who underwent liver radiation were included.
Gross tumour volumes (GTV) were contoured in 10 respiratory
phases to generate GTV ITV_4D. Different GTV ITVs were derived
from selected phase contouring (GTV ITV2phases (Phase 0 and 50),
GTV ITV 3phases (Phase 30, 60 and 90), GTV ITV 5phases (Phase
0, 20, 40, 60 and 80) and their volumes and spatial concordance with
GTV ITV_4D was investigated. The position of centre of mass (COM)
of individual GTVs were measured and systematic and random errors
were calculated. Population internal margin (PM) was generated using
van Herk’s formula and applied to FB volume to obtain GTV population
margin (GTV_PM). Results: GTV ITV 5 phases encompassed
90% (range 82.4-94.8%) of the GTV ITV_4D. The mean volume (in
percentage) of GTV ITV2 phases and GTV ITV 3 phases overlapping
with GTV ITV_4D was 79.8% (range 69.4-84.4%) and 80.6% (range
71.1-89.1%) respectively. The directional population margins in
antero-posterior (AP), medio-lateral (ML) and supero-inferior (SI)
directions were 2.46 mm, 1.75 mm, 3.45 mm respectively. GTV
ITV_PM encompassed 99.4% GTV ITV_4D, but with highest spatial
mismatch. Conclusion: Contouring in alternate respiratory phases
may safely be used for generation ITV and is time and labour saving.
Adding population based margin to FB volume lead to high spatial
mismatch when compared to GTV ITV_4D.
Abstract: 183
Pre operative chemoradiation in carcinoma esophagus – A
single institutional experience
H. Bajwa, R. S. Reddy, A. K. Raju
Basavatarakam Indo American Cancer Hospital and Research Institute,
Hyderabad, Telangana, India, E-mail: harjotbajwa1987@gmail.com
S29
 Abstracts
Background: Esophageal cancer the 4th most common cause of
cancer related deaths in India. In 2012, a phase III study (CROSS trial)
evaluated the benefit of induction therapy with weekly Carboplatin-
Paclitaxel and 41.4 Gy radiation vs surgery alone. Median and
overall survival improved in combined therapy arm. The pCR rates
were 28%. However there is limited data regarding the outcomes of
preoperative chemoradiation in India. Esophageal Cancer in India
has a unique etiology (tobacco, nutritional and dietary factors), is
predominantly squamous and is more advanced at presentation.
This study was conducted to determine the response to preoperative
chemoradiation at a tertiary centre in India. Aim: Primary objective
is to evaluate the rate of Pathological Complete Response (pCR).
Secondary objective is to determine the recurrence rates and
recurrence patterns. Materials and Methods: We retrospectively
reviewed patients with locally advanced Esophageal Cancer and
Gastroesophageal Junction treated at our hospital from Sept2013
to July2015. Patients who recieved preoperative RT 41.4 Gy with
chemotherapy (weekly Paclitaxel-Carboplatin or Cisplatin-5 FU or
Cisplatin-Capecitabine) were included in this study. The outcomes
analysed were pCR, recurrence rates and recurrence patterns.
The relationship of various prognostic factors with recurrence was
computed using Regression Analysis. Results: 50 patients were
included in analysis (median age-50 years). 76% were Squamous
cell carcinoma (SCC) and 24% Adenocarcinomas (ACC). All patients
received 41.4 Gy pre operative RT. 60% of the patients received
weekly Paclitaxel-Carboplatin (CROSS protocol), 32% Cisplatin-5 FU
and 8% Cisplatin-Capecitabine. 2 patients progressed on treatment
and did not undergo surgery. Median time to surgery was 8 weeks.
38% (19) patients achieved pCR. pCR rates were higher in SCC vs
ACC (42% vs 25%) and with Paclitaxel-Carboplatin than Cisplatin-
5FU or Cisplatin-Capecitabine (47% vs 25%). On regression analysis,
pCR was a significant predictor of local control (p < 0.05). At a median
follow up of 9.5 months, 38 patients were alive, 8 patients died and
4 patients were lost to follow up. Overall recurrence rate (ORR) post
surgery was 23%. Of the 10 patients that recurred, 1 was local, 1
both local and distant and 8 were distant recurrences. Conclusion:
Our study results show favourable pCR rates with preoperative CRT
with significant higher rates in SCC and patients treated on CROSS
regimen. Majority of the recurrences were distant recurrences.
Abstract: 223
Neoadjuvant short course radiotherapy followed by surgery in
locally advanced rectal cancers
M. Vijayakumar
Madras Medical College, Chennai, Tamil Nadu, India
E-mail: madhulika.dr@gmail.com
Introduction: Before 1900, incidence of colon and rectal cancers
were negligible. Since then, following economic development and
industrialization the incidence has been rising dramatically. For all
rectal cancers, surgery remains as the primary treatment modality.
Despite these curative resection, local recurrence remains high.
Anatomical confines of the bony pelvis and the necessity of preserving
the autonomic nerves makes surgery challenging, which accounts
for these high rates of both local and distal relapse. Many European
randomized prospective trials have shown that multimodality
approach results in significant better outcome. Neoadjuvant treatment
has emerged as the standard of care and degree of tumor regression
has become an important prognostic factor. A multi modality approach
including medical oncology radiation oncology and colorectal
surgery is required for optimal treatment plan. Aim: To assess the
immediate loco regional response rates of locally advanced rectal
cancers treated with short course radiotherapy followed by surgery.
And to assess acute toxicity to neoadjuvant short course radiation
in locally advanced rectal cancers. Materials and Methods:
Single arm prospective study with 30 consecutive patients with
locally advanced rectal cancer presented to the department of
radiotherapy, Madras Medical College, Chennai. Eligible patients
S30
to be treated with short course radiotherapy followed by surgery
(TME) - total mesorectal excision, with adjuvant chemotherapy 3-6
cycles of CAPEOX. Radiotherapy: 5 x 5 Gy = 25 Gy in one week.
Tumor response to radiotherapy is assessed in the post operative
pathological specimen & graded according to tumor regression grade
and the CRM-circumferential resection margin status. The toxicity
profile of the treatment was assessed with RTOG acute morbidity
scoring criteria and CTCAE Version 4. Results: Among 30 patients,
majority of them were males. 83% of patients had achieved a good
Circumferrential Resection Margin [CRM] of more than 1 cm, and
17% had less than 1 cm CRM. Toxicities observed in the study were
diarrhea grade 2 in 6 patients; 4 patients had post operative wound
gaping in the perianal region. There was no treatment related deaths.
Conclusion: Neoadjuvant short course RT in locally advanced rectal
cancers followed by surgery is a feasible treatment regime for an
adequate CRM status with manageable toxicities. Short course RT
compared to long.
Abstract: 231
An audit of colo-rectal carcinoma at a tertiary cancer centre
H. Mishra, R. Khurana, R. Mishra, M. Rastogi, R. Hadi, S. Sapru,
K. Sahni
Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar
Pradesh, India, E-mail: hmsra1801@gmail.com
Background: Incidence of colo-rectal cancer in India is low as compared
to the west, being more common in males. It usually affects individuals 50
years of age or more. Aim: To study patient and tumour characteristics,
treatment offered and outcomes of all colo-rectal carcinoma patients
enrolled in radiotherapy (RT) OPD at a tertiary care centre over last
3 years. Materials and Methods: Files were retrieved and data was
collected for all colo-rectal cancer cases registered between July 2012-
15. Results: Total 55 patients were registered in RT OPD over 3 years.
Age of patients ranged between 20-72 years, 78% (n = 43) were males,
48% (n = 26) patients were referred from inside the institute and 52%
(n = 29) from outside. Ninety percent (n = 50) had KPS of 70. 76% (n
= 42) had locoregional disease while 24% (n = 13) had metastatis at
presentation. Among patients having non-metastatic disease 70% (n =
29) had T3, T4 or N + disease. Per rectal bleeding (63%, n = 35) was
the most common presenting symptom. All patients had histology as
adenocarcinoma with 18% (n = 10) mucin producing and 7% (n = 4)
as signet ring cell variant. Pre- treatment CT scan was done in 70%
(n = 39), MRI in 12% (n = 7) and PET-CT in 6% (n = 3) patients. Pre-
treatment CEA was done in 36% (n = 20) patients. Surgery was done in
67% (n = 37) patients (LAR -33%, n = 18; APR- 19%, n = 10; palliative
-10%, n = 6; local excision- 5%, n = 3; TME- 14%, n = 8). Among the
patients who underwent definitive surgery (56%, n = 31), post-operative
longitudinal margins were negative in all patients and radial margins
were positive in 9% (n = 3), negative in 23% (n = 7) and not known in
others. Fifty-eight percent (n = 32) cases received RT, 35% (n = 19)
had post- op RT along with concurrent capecitabine, 15% (n = 8) had
pre-op RT along with concurrent capecitabine and 8%, n = 5 palliative
RT. At last follow- up, 35% (n = 19) had complete response, 38% (n
= 21) had partial response, disease progression was seen in 15% (n
= 8), 9% (n = 5) were dead and in 3% (n = 2), status was unknown.
Conclusion: Most of the patients presented with locally advanced
disease but neo-adjuvant chemo-radiotherapy remained underutilized.
There is lack of information of pre-operative CEA and radial margins
status on post-operative histopathology in a large proportion of patients
thus highlighting the need for standard protocols for disease evaluation
and multidisciplinary approach for better outcomes.
Abstract: 243
Robotic radiosurgery in liver tumours: Early experience from an
Indian center
S. Krishnamoorthy
Apollo Hospital, Chennai, Tamil Nadu, India, E-mail: sathusaty86@
gmail.com
Journal of Cancer Research and Therapeutics - Supplement 1 - 2015 - Volume 11
 Abstracts
Purpose: We report initial experience with SBRT in our patients
hepatocellular carcinoma (HCC) and liver metastasis (LM).
Materials and Methods: Fifty liver lesions (n = 50) in thirty-one
consecutive patients (mean age 54.5 years, range 32-81 yrs; 77%
male) treated with fiducial based robotic radiosurgery (CyberKnife®).
Thirteen patients had HCC and eighteen had LM. 20/31 patient (65%)
were with Child Pugh A/B, 8/13 with HCC had infective hepatitis
(4 each with hepatitis B & C), 5/31 (16%) had diffuse cirrhosis,
70% (12/17) had single lesion in liver and target volume <1cc in 5
patient (16%), 11-90cc in 18 (58%) and >90 cc in 8 (35%) patients
respectively. 25/31 (80%) patients had prior treatment [chemotherapy
18/31 (58%), TACE 7/31 (22%)] and these patiens were treated with
SBRT on progression. Only 6/31 (19%) were treated primarily with
SBRT without any prior treatment. All patients were treated with 3
fractions (21-45 Gy/3#; mean dose 33 Gy, prescription isodose 84%,
target coverage 94%); fiducial tracking based CyberKnife. Mean CI,
nCI, HI was 1.19, 1.31 and 1.18 respectively. Mean liver dose was 5.4
Gy, 800 cc liver dose 11.1 Gy; 2% small intestine dose 12.5 Gy. Mean
nodes, beamlets, monitor units and treatment time 79, 183, 44498
and 59.1 min respectively. Results: At mean follow up of 12.5 months
(range 1.9-44.6 months), 19/31 (61%) patients expired and 12/31
(39%) alive (9 patient with stable disease, two local progression and
one with metastasis). Median overall survival (OS) of all patients are 9
months (1.9-44.6 months), in HCC patients was 10.5 months (2.1-44.6
months) and MT 6.5 months (1.9-24.6 months) respectively. 11/31
(35%) patients had grade I-II GI toxicities, no grade III-IV toxicities
were observed and only one patient (7%) had anicteric ascites with
high serum alkaline phosphatase two months after CK and recovered
with supportive care. Median OS (month) were significantly influenced
by factors such as performance status (KPS 70-80 vs 90-100: 9.9 vs
16.4; p = 0.024), Child Pugh (CP A/B vs C: 23.6 vs 6.5; p = 0.069),
cirrhosis (only fatty liver vs diffuse cirrhosis: 17.8 vs 10.6; p = 0.003),
prior treatment (no Rx vs prior Rx: 30.1 vs 8.2; p = 0.08), number of
lesions (single vs multiple: 16.4 vs 6.9; p = 0.001) and target volume
(<10 cc vs >90 cc: 24.6 vs 11.2; p = 0.03) respectively. There was
no fiducial related toxicity or migration. Conclusion: SBRT is safe
and effective local treatment modality in selected patients with liver
malignancies with minimal adverse events.
Abstract: 259
Correlation between pathologic complete response to
neoadjuvant therapy and recurrence in patients with esophageal
cancer
R. Pandey, K. P. Haresh, S. Gupta, D. N. Sharma, P. K. Julka, G. K.
Rath, D. Pandey
All India Institute of Medical Sciences, New Delhi, India, E-mail:
rambha151@gmail.com
Background: Multimodal treatment options in carcinoma esophagus
include neoadjuvant chemoradiotherapy or chemotherapy followed by
surgery. The degree of pathologic response to different neoadjuvant
options and its impact on the oncologic outcome is a matter of debate.
Aim: To analyze the rate of pathologic complete response (pCR)
and its effect on recurrence in patients with carcinoma esophagus
treated with various combinations of neoadjuvant chemotherapy/
radiotherapy and surgery. Materials and Methods: The records of
all patients with carcinoma esophagus registered in our unit between
June 2012 and December 2014 were retrieved from a prospectively
maintained database and were analyzed. Results: Seventy patients
with histologically proven esophageal cancer were treated with curative
intent between June 2012 and December 2014. Forty patients had
squamous cell carcinoma, 28 had adenocarcinoma, 1 had plasmablastic
lymphoma and 1 had metastatic carcinoma from previously treated
breast cancer. Forty eight (48) patients received neoadjuvant
chemotherapy (NACT), 16 were treated with short course radiotherapy
(SRT), and 3 patients received neoadjuvant chemoradiation (CRT).
Grade III to IV neutropenia was seen in 6% of patients requiring dose
modification in NACT group. Four patients developed metastatic
disease on neoadjuvant therapy and were offered best supportive
Journal of Cancer Research and Therapeutics - Supplement 1 - 2015 - Volume 11
care. Three patients underwent upfront surgery. A total of 66 patients
(63 after neoadjuvant therapy and 3 upfront) underwent surgery.
Transthoracic esophagectomy with extended lymphadenectomy
was performed in 63 patients; 3 patients had unresectable disease
on exploration. Three patients had postoperative mortality related to
pulmonary complications. Morbidities included anastomotic leak in 3,
necrosis of gastric conduit in 1, and abdominal dehiscence in 1 patient.
Pathological CR was seen 12 patients (25%) in NACT-surgery arm,
2 (12%) in SRT-surgery and 1 (33%) in CRT-surgery groups. With a
median follow-up of 16 months (range 4-32 months), 28 patients (58%)
in NACT-surgery group, 7 (44%) in SRT-surgery group, and 2 (66%)
in CRT-surgery group were free of disease. All the 15 patients who
had pathologic CR are presently alive without recurrence. Conclusion:
Neoadjuvant therapy followed by radical surgery is a safe and effective
treatment option for the management of carcinoma esophagus.
Pathologic CR strongly correlates with recurrence-free survival.
Abstract: 262
Adenocarcinoma of rectum with multiple scalp nodules: A rare
case report
P. Meher, L. Pujari, B. Routroy, S. Padhi, S. Senapati
Acharya Harihar Regional Cancer Centre, Cuttack, Odisha, India,
E-mail: papuji.meher@gmail.com
Background: Colorectal cancers account for 10% of all incident cancers.
Colorectal adenocarcinoma most frequently metastasizes to the liver,
the peritoneum, the pelvis, the lung and bone. Patient initially presenting
with scalp nodule is very unusual. Aim: To present a case of carcinoma
rectum presenting with scalp nodules. Case: A 55 yr old female
presented with scalp nodules and bleeding per rectum for 2 months.
Clinically there were multiple scalp nodules over scalp of various sizes
0.5 cm to 1 cm, hard, nontender, free from underlying bone. Per-rectally a
mass was palpable around 8 cm from anal verge encircling anterior and
right lateral wall which bleeds on touch. Colonoscopy showed a large
semi-circumferential growth 10 cm from anal verge. Rectal biopsy came
invasive adenocarcinoma. CECT abdomen and pelvis demonstrated
irregular thickening of anterior, right lateral and posterior wall of rectum
extending upto rectosigmoid junction with involvement of mesorectum
and pararectal node. Plain MRI head revealed small hypointense lesions
(sagittal T1 image) seen in scalp over posterior parietal region involving
skin and subcutaneous tissue- likely metastasis, no evidence of bony
erosion seen. FNAC of scalp nodule showed poorly differentiated
carcinoma which was later confirmed by biopsy. On evaluation patient
has no any other site of visceral metastases clinically or radiologically.
Patient is posted for chemotherapy with diagnosis of stage IV rectal
cancer. Discussion: Skin secondaries from internal malignancies are
uncommon and occur in 0.6%–10.4% of all patients with cancer. Skin
involvement is seen most commonly in carcinoma breast in women,
and in carcinoma lungs in men. Cutaneous metastases in case of
carcinoma rectum is very rare and it occurs in <5% of cases. Usually
presents as skin nodules and also can be an initial presentation. Skin
metastasis of rectal cancer is usually detected around surgical scars
or on the abdominal wall, especially in the periumbilical region, it rarely
presents at other sites. Scalp is one of the uncommon sites and has
been reported in small case series and reports. When presents with
such metastases it indicates advanced disease and carries poor
prognosis. Conclusion: Though cutaneous and soft tissue metastases
in carcinoma rectum are extremely uncommon, it can affect the staging
and prognosis adversely. Therefore thorough examination and stringent
follow up is mandatory.
Abstract: 267
Single institutional audit of pancreatic cancers treated using
CyberKnife radiosurgery
R. Ravind, P. S. Sridhar, S. Bhattacharjee, M. S. Belliappa,
Kumaraswamy, B. S. Ramesh, G. Kilara
HCG Hospital, Bengaluru, Karnataka, India, E-mail: rahulravind@
gmail.com
S31
 Abstracts
Introduction: Pancreatic cancer is one of the common digestive
system cancers and it mostly presents as an advanced disease at
diagnosis. Surgery is the only modality that offers a chance of cure.
However, only 5% to 15% of pancreatic cancers has the opportunity
of radical resection. Over all survival rate at 5 years is 10-20%. As
majority of the cases are inoperable (locally advanced), the role of
alternative treatment modality that could offer local control needs to be
explored and SBRT (stereotactic body radiation therapy) is one such
option for these advanced tumors. Materials and Methods: This is
a single institution retrospective audit of all cases of locally advanced
inoperable cancers of pancreas that were histopathologically proven
and treated using Cyberknife (robotic sterotactic radiosurgery). The
time period for this study is from January 2009 to June 2015 and
had a total of 36 evaluable patients. The patient data was retrieved
from EMR (Electronic medical records), radiotherapy planning charts
and radiotherapy planning CT scans. Results: Out of the total 36
patients, 9 were lost to follow and the rest 27 were taken for analysis.
Majority of the patients were male (Male:Female – 17:10). Average
age at diagnosis is (mean) 57.9 years. Tumors arising from the head
and neck were 19, body alone were 7 and involving body and tail
was one. Dose Schedules used for Cyberknife were ranging from 24
Gy to 40 Gy (in 3-5 fractions). Average stomach dose was (mean)
– 664.21 cGy and average duodenal dose was (mean) – 1248.49
cGy. The mean disease free survival is 6.4 months. Eight patients had
symptomatic pain relief after treatment. One patient had treatment
related complication (duodenitis). At the time of follow up 26 patients
had expired due to progressive disease and one patient was alive.
Conclusion: Robotic sterotactic radiosurgery using Cyberknife offers
an alternative treatment to surgery in patients of locally advanced
(inoperable) and metastatic cancers of pancreas. This novel
technology aids to deliver a high dose to the tumor and decrease
dose to the nearby organs at risk thereby helping to improve local
control and to aid in symptom relief.
Abstract: 277
Primary malignant melanoma of the esophagus
S. Mohandas, S. Roshni, V. Arun, T. R. Preethi, A. Peter, A. L. Lijeesh,
M. H. Geethi, P. G. Jayaprakash
Regional Cancer Centre, Trivandrum, Kerala, India, E-mail:
seethamohandas7@gmail.com
Primary malignant melanoma of the esophagus (PMME) comprises
0.1–0.2% of all malignant esophageal tumors. It has extremely
poor prognosis and is seen predominantly in older men. The major
symptoms are dysphagia, retrosternal pain and weight loss. The
characteristic endoscopic finding of PMME is a large polypoidal
tumor, rarely accompanied by ulcers. PMME is considered as the
primary tumor if it includes the typical histologic pattern of melanoma
containing melanin, if the adjacent epithelium contains melanocytes
and if it arises from an area of junctional changes in the squamous
epithelium. S100 protein, HMB45 and neuron-specific enolase
positivity also aid in the diagnosis. At diagnosis, approximately 50% of
patients present with metastases. Surgical resection is the standard,
and only treatment option that influences survival. The 5-year survival
rate is 4.5%. Other options for non-surgical or adjuvant treatment
includes chemotherapy, chemoradiotherapy, endocrine therapy,
and immunotherapy. Here, we present 2 cases of PMME, first case
is of a 75 year old lady with progressive dysphagia to solids for
the past 6 months. Imaging showed eccentric wall thickening with
luminal narrowing at distal thoracic esophagus extending through
the OG junction to the proximal part of lesser curvature of stomach
with peri-gastric lymphadenopathy. Endoscopy showed an ulcero-
proliferative lesion with luminal narrowing from 28 cm. Histopathology
report showed malignant melanoma with positive HMB-45, Vimentin
and S-100. Considering her age and poor performance status
she was advised palliative treatment in the form of supportive and
symptomatic care. Second case is of a 55 year old gentle man
who presented with dysphagia to solids, abdominal discomfort and
constipation for the past 4 months with recent onset abdominal
S32
distention. Endoscopic evaluation showed melanosis in the upper
esophagus and proliferative lesion starting from 27 cm. His imaging
showed large exophytic enhancing lesion involving mid and distal
esophagus extending upto GE junction with obstruction of the lumen
and a large epigastric nodal mass, retroperitoneal lymphadenopathy
and peritoneal deposits. Histopathology report showed malignant
melanoma with cells positive for S-100 and HMB-45 and omental
deposit showed metastasis. Considering his advanced stage of the
disease and poor performance status he was advised endoscopic
Ryle’s tube insertion and palliative chemotherapy.
Abstract: 293
Patterns of failure in cases of carcinoma of esophagus treated
with concurrent chemo irradiation by radical intent
S. Goyal, L. Kashyap, H. B. Govardhan
Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India,
E-mail: surekhagoyal16@gmail.com
Background: Radical chemoradiation has been the main stay of
treatment in inoperable cases of carcinoma of thoracic esophagus.
The purpose of the study is to determine the pattern of recurrence
after radical concurrent chemoradiation. Materials and Methods: Fifty
patients with carcinoma esophagus treated with chemoradiation in
the Department of radiation oncology from 2011 to 2014 were taken
retrospectively for this study. All the patients were treated with external
beam radiation therapy (3DCRT/IMRT) of 54 to 59.4 Gy with 3 weekly
cisplatin 80 mg/m2 and capecitabine 1250 mg/m2. All patients were
followed with upper GI endoscopy at 3-4 monthly for first 3 years,
CECT thorax and abdomen 3 monthly for 1 year then 6 monthly upto 3
year thereafter yearly follow up. Appropriate statistics were used for the
analysis. All the patient information was taken out from the case files
and by telephonic interview. Results: Median age of the patients was
54 years and 26 (52%) were males and 24 (48%) were females. Most
common tumour histology being squamous cell carcinoma and most
common site being the middle 1/3 of esophagus 30/50 (60%). 47/50
(94%) patients received concurrent chemoradiation with cisplatin
with capecitabine and 3/50 (6%) received induction chemotherapy
with cisplatin and 5-FU. Patterns of failure: Patients were followed up
for a period of 8 months to 34 months (median: 21 months). At the
time of last follow up in September 2015, 23/50 (46%) patients had
local recurrence, 14 (28%) patients had distant failure and 13 (26%)
patients had no evidence of disease at the time of last follow up. Overall
survival: With a median follow up of 21 months, mean overall survival
for all the patients was 17.5 months. Overall survival at 1 year was
28/41 (68%), at 2 years was 13/33 (36%), at 3 years was 1/23 (4.3%).
Conclusion: This study concludes that there is a higher incidence
of failure and recurrences occuring most commonly locally (within
the previously irradiated field) even after definitive radical treatment
with concurrent chemoradiation, as the local recurrence is more than
distant failure we should aim at consolidating the local therapy by dose
escalation or alternative radiation therapy.
Abstract: 307
A prospective study comparing a combination of oxaliplatin
and 5-FU versus gemcitabine and cisplatin in advanced stage
carcinoma gall bladder
R. Chaudhari, S. Gupta, M. L. B. Bhatt, S. Singh, S. Mishra, S. Kumar,
K. Srivastava
King George’s Medical University, Lucknow, Uttar Pradesh, India,
E-mail: 17dec87roopali@gmail.com
Background: Gall Bladder carcinoma is often diagnosed at advanced
stage, with median survival approximately 6 months. Till date there is no
established standard of care palliative chemotherapy. There are some
trials which showed benefits of Gemcitabine and Cisplatin while others
showed benefits of Oxaliplatin and 5-FU in terms of overall survival
and progression free survival in advanced carcinoma Gall Bladder.
Aim: To compare the combination of Gemcitabine and Cisplatin Vs
Journal of Cancer Research and Therapeutics - Supplement 1 - 2015 - Volume 11
 Abstracts
Oxaliplatin and 5FU in advance stage carcinoma Gall Bladder in terms
of efficacy and toxicity. Materials and Methods: This prospective study
included 50 cytopathologically and histopathologically proven advance
stage Carcinoma Gall Bladder patients registered in Tertiary Centre of
Northern India, between September 2014 and May 2015. All Patients
were randomized into two groups ARM A (Gemcitabine and Cisplatin)
and ARM B (Oxaliplatin and 5-FU). Results: Results for ARM –A (n
= 25) were Partial Response (PR) 10 (40%), Stable Disease (SD) 8
(42%) and Progressive Disease (PD) 7 (28%), Overall Survival (OS)
5.99±0.39 [95%CI 5.21-6.77] months, Median Progression Free
Survival (PFS) 5.76±0.46 (95% CI 4.86-6.67) months, while Results for
ARM- B (n = 25) were Partial Response (PR) 15 (60%), Stable Disease
(SD) 6 (24%) and Progressive Disease (PD) 4 (16%), Overall Survival
(OS) 11.43±0.72 [95%CI 10.02-12.84] months, Median Progression
Free Survival 11.33±0.76 (95%CI 9.83-12.84) months. Toxicity was
manageable in both arms with no patients having grade 3 and 4 toxicity
in both arms. There is no therapy related death. Conclusion: Oxaliplatin
and 5-FU is slightly superior than Gemcitabine and Cisplatin in terms
of overall response, overall survival and progression free survival in
advanced Carcinoma Gall Bladder. But, to confirm these results study
on a larger pt population needs to be undertaken with randomization.
Abstract: 309
Dosimetric analysis of lumbosacral plexus in patients of rectal
cancer treated with intensity modulated radiotherapy
P. Chaudhary, S. Gupta, S. Chaturvedi, R. Agarwal, R. Chandra,
R. Shankar, S. Agarwal, S. De
Galaxy Cancer Institute, Pushpanjali Crosslay Hospital, Ghaziabad,
Uttar Pradesh, India, E-mail: prekshi29@gmail.com
Background: IMRT allows limitation of radiation dose to nearby
normal organs at risk, while allowing delivery of high doses to the
target. Although, the incidence of side effects have been minimized
but they still do exist. One of the rare late sequelae of pelvic
irradiation is lumbosacral plexopathy. Patients present with lower
limb weakness, numbness and paresthesia. Presentation is from 3
months to years after completion of radiation. Neurologic deficit is
irreversible and no effective therapy other than supportive care has
been found. Lumbosacral plexus (LSP) is not routinely delineated
or given dose constraints during IMRT and it may lead to excessive
dose dumping in this structure. A retrospective evaluation of the dose
distribution in LSP in patients of rectal carcinoma treated with IMRT
was done in this study. Aim: Delineation of LSP and evaluation of
dose distribution of this organ at risk in rectal cancer patients treated
with IMRT. Materials and Methods: 15 patients of rectal cancer,
who were treated with IMRT technique, were included in the present
study. LSP was delineated in every patient from L4-L5 interspace to
the level of sciatic nerve on planning CT scan of 2 mm thickness by
Radiation Oncologist with assistance of Radiologist using anatomic
atlas and Yi et al. protocol. No dose limitation was placed for this
organ during planning. After delineation, based on each patient’s
DVH, total LSP volume, mean dose, maximum dose and volume
percentages of LSP receiving 30, 40, 50, 55 Gy were calculated.
Results: PTV dose to the target region was 50.4 Gy. Mean LSP
volume was 59.84 cc (range, 33-77.7), mean dose and maximum
dose to LSP were 45.5 Gy (range 39.7-55.5) and 55.67 Gy (range
36.6-63.8) respectively. Mean volume percentages of the LSP 30
Gy, 40 Gy, 50 Gy, 55 Gy were 84.6%, 78.16%, 55.04% and 0%
respectively. Conclusion: Radiation induced lumbosacral plexopathy
(RILSP) is a rare but known complication of pelvic irradiation for lower
GI or gynecological malignancies. Commonly, cases receiving EBRT
and brachytherapy for cervical cancer, who receive the doses of 70-
80 Gy have been reported to develop RILSP. However, rectal and
anal cancer patients treated with concurrent CTRT to doses of 50-
70 Gy have also been described to develop this complication. LSP
delineationis not performed routinely in IMRT for pelvic malignancies
and dose dumping may lead to increased rates of toxicity if this
structure remains undelineated. Mean dose lower than 45 Gy can
reduce the risk of RILSP.
Journal of Cancer Research and Therapeutics - Supplement 1 - 2015 - Volume 11
Abstract: 317
Pleomorphic Rhabdomyosarcoma of pancreas
R. S. Rajendra, A. Goel, S. Gupta, M. Nandy, S. De, R. Parmar1,
V. Zamre
Pushpanjali Crosslay Hospital, Vaishali, Ghaziabad, Uttar Pradesh,
1
Oncquest Laboratory, Safdarjung, Delhi, India, E-mail: rsravibjmc@
gmail.com
Introduction: Rhabdomyosarcoma (RMS) is a highly malignant
soft tissue sarcoma that arises from unsegmented, undifferentiated
mesoderm or myotome derived skeletal muscle. Most common
sites are head & neck, genitourinary, extremities, orbit, trunk, and
retroperitoneum. Pleomorphic RMS (P-RMS) in the biliary tree is
extremely rare (0.5%). To the best of our knowledge, in adults, only 2
cases of P-RMS have been reported in liver, and 1 in pancreas. We
report a case of pleomorphic RMS involving pancreas. Presentation of
Case: A 42 year old woman with history of diabetes, hypertension
and hypothyroidism, presented with episodes of generalized pain
abdomen, decreased appetite for 1 month, palpable abdominal
mass and contrast-enhanced computed tomographic (CECT) finding
of a mass in tail of pancreas. CT guided trucut biopsy from tail of
pancreas showed poorly differentiated malignant tumor. Positron
emission tomography with 2-deoxy-2-[fluorine-18]fluoro- D-glucose
with computed tomography showed diffuse enlargement and avidity of
distal body and tail of pancreas with hypodense areas in tail region and
lymph node of size 2.8 x 1.9 cm was seen in peri-pancreatic region.
Patient underwent distal pancreatectomy and splenectomy. Post
operative histopathology reported undifferentiated carcinoma 8 x 5 x 5
cm size lesion in body and tail of pancreas microscopically extending to
peripancreatic soft tissue and also upto splenic hilum. Lymphovascular
extension and perineural invasion were present. 1/12 nodes positive.
Immunohistochemistry reported was positive for desmin and myogenin
consistent with pleomorphic rhabdomyosarcoma of pancreas. Patient
received 3 cycles adjuvant chemotherapy (MAID: Ifosfamide, Mesna,
Doxorubicin, and Dacarbazine) followed by adjuvant radiotherapy
(PTV 50.4 Gy/28 fractions). She is asymptomatic till date.
Discussion: Pleomorphic RMS in pancreas is extremely rare. Muscle
specific markers like myogenin, desmin, SMA and vimentin are helpful
in making diagnosis. Surgical resection followed by chemotherapy
and radiotherapy are the standard of treatment. Long term prognosis
of pleomorphic RMS, predominantly reported for limbs, is poor. Only
one pancreatic pleomorphic RMS has been reported in literature till
date. Conclusion: P-RMS is an extremely rare tumor in adult and
may present in uncommon sites like pancreas. It should be included in
differential diagnosis of abdominal lump.
Abstract: 343
Achieving further response in poor responders to neoadjuvant
chemoradiation by chemotherapy: A Prospective study
P. Gupta, R. Engineer, V. Ostwal, S. Chopra, P. Patil, A. Saklani,
S. Arya, S. K. Shrivastava
Tata Memorial Centre, Mumbai, Maharashtra, India, E-mail:
priya_1grd@yahoo.co.in
Background and Aim: Among patients with locally advanced
carcinoma rectum, 25-30% remain surgically unresectable after
neoadjuvant chemoradiation (NACRT). These patients showing
predicted/threatened CRM positivity on post NACRT MRI are offered
palliative chemotherapy. Many oncologists wait up to 12 weeks post
NACRT to assess response MRI before declaring unresectability,
citing possibility of delayed tumour response to NACRT. We treated
these patients with further 4 cycles of chemotherapy and reassessed
them for operability. Materials and Methods: Patients with locally
advanced carcinoma rectum having unresectable disease on MRI at
presentation received NACRT 50 Gy at 1.8-2 Gy/day with concurrent
capecitabine 825 mg/m2 daily. Follow up MRI done at 6 weeks post
NACRT was assessed in a joint multidisciplinary meeting. Patients
with persisting unresectable local disease were planned for 4 cycles of
S33
 Abstracts
chemotherapy followed by reassessment for resectability. We present
the results of the patients with poor response to NACTRT having
further treated with chemotherapy. Results: From January 2013 to
December 2014, 50 patients with locally advanced unresectable rectal
cancer receiving NACRT had persistent unresectable disease on MRI.
31 patients received further FOLFIRINOX and 19 patients received
FOLFOX/CAPOX chemotherapy. CRM was involved in 45 patients
and threatened in 5 patients. 16 patients had signet ring cell histology.
Nodal stage was N0 in 2, N1 in 33 and N2 in 13 patients. R0 resection
was achieved in 32/50 (64%) patients. 68% in FOLFIRINOX group and
58% in FOLFOX/CAPOX group achieved R0 resection. 11 patients
underwent pelvic exenteration. 12% patients were still inoperable
after extended chemotherapy, metastatic disease was found in
10%, and 12% patients refused surgery. Tumour regression grade in
histopathology was 1/5 in 22%, 2/5 in 37%, 3/5 in 16%, 4/5 in 16% and
5/5 (complete response) in 6%. Conclusion: Achieving R0 resection
in this subset has been heartening. Whether this continued decrease
in primary tumour volume can be attributed to delayed response to
radiotherapy or addition of further chemotherapy, or both, is yet to be
ascertained. Hence for patients with advanced local disease not yet in
palliative stage, further intensive chemotherapy with clinicoradiological
follow-up should be done to facilitate successful surgical resection.
Abstract: 372
Safety and efficacy of epirubicin (E) or doxorubicin (A), cisplatin
(C) and 5 fluorouracil (F) or capecitabine (X) in unresectable or
metastatic (M+) stomach cancer
R. Sachan, R. K. Singh, R. Harshvardhan, S. Agrawal, S. Kumar
Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow,
Uttar Pradesh, India, E-mail: sachanrashika@gmail.com
Background and Aim: A triplet combination of an anthracycline
(A or E), a platin (C) and a fluoropyrimidine (F or X) is the current
standard of care of palliative unresectable or M+ stomach
cancer. A service evaluation on safety and efficacy is reported.
Materials and Methods: Between 2008 to 2014, 181 gastric cancer
were treated, of which 60 unresectable or M+ patients had received
either ECX or ACF/ECF. Planned doses of A - 40 mg/m2 D1, E - 50 mg/
m2 D1, C - 60 mg/m2 D1, F - 300-500 mg/m2 D1-5 or X - 1000-1250 mg/
m2 D1-21 were offered every 3 weekly for a maximum of 6-8 cycles.
Response was assessed clinically (appetite, weight and melena)
or objectively (decrease in refilling of ascites or size of measurable
disease on ultrasonographic assessment) and data reported as
summary measures with statistical significance determined by the
Chi-square test or log rank test as appropriate. Results: Of the 60
patients, 75% were males; mean age 51.7 years (SD 12.1); 92% were
M+, 80% had KPS of 80 or more; 57% had documented significant
weight loss. Twenty seven received ACF/ECF (Gp-1) and 33 received
ECX (Gp-2). Six cycles or more were completed in 22% vs. 36% (p
= 0.1); clinical/radiological improvement was seen in 48% vs. 70% (p
= 0.1); grade 3 hematological toxicity 7% vs. 12% (p = 0.4); grade
3-4 diarrhea 15% vs. 3% (p = 0.8) in Gp-1 vs. Gp-2 respectively. At a
median follow up of 8.5 months of all alive patients, 44% vs. 27% were
dead, 56% vs. 52% were lost to follow up with active disease and 0%
vs. 21% were alive. Median overall survival was 5 months vs. 6 months
(p = 0.5) and 10 months vs. 11 months (p = 0.1) assuming the worst
case scenario and best case scenario respectively, for patients lost to
follow up. Conclusion: ACF/ECF and ECX, appear similar in efficacy
but ECX appears to be more tolerable with lesser GI toxicity. The large
number of patients lost to follow up represent the main challenge to
reliably ascertain safety and efficacy of interventions.
Abstract: 373
Service evaluation of neoadjuvant chemoradiotherapy followed
by surgery in patients of rectal cancer treated at a tertiary care
center between 2008 and 2014
L. Mohan, A. Kumar, R. K. Singh, N. Rastogi, R. Harsvardhan, S.
Kumar
S34
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow,
Uttar Pradesh, India, E-mail: contactdrlalit@gmail.com
Background: Surgery with CTRT in a neoadjuvant or adjuvant role is the
recommended treatment for locally advanced rectal cancers. A service
evaluation of rectal cancers referred for neoadjuvant CTRT is reported.
Materials and Methods: Patients for upfront CTRT were planned with
radiotherapy (RT) 45 Gy/25 fr/5 weeks or 50.4 Gy/28 fr/5½ weeks with
concurrent 5FU 325 mg/m2 D1-3 and D29-31 or Tab Capacitabine 1650
mg/m2 in two divided doses for duration of RT including weekends.
Demography, acute toxicity and complication are reported in summary
measures; survival was calculated using the Kaplan Meier method.
Results: Of the 267 patients, 54% (144/267) were planned for upfront
CTRT; 66% (95/144) were males; mean age 41 years (SD: 15.5);
stage II were 21% (30/144), stage III-73% (106/144), stage IV-3%
(4/144) and stage not documented in 3% (4/144) cases. Seventeen
patients did not take any treatment. Of the remaining 127 patients, 86%
(109/127) could complete the CTRT and 40% (51/127) could undergo
radical surgery (LAR -25 & APR- 26). Ten patients progressed during
treatment and remained inoperable while 75% (38/51) patients received
post surgery adjuvant CT and only 45% (23/51) could complete the
planned treatment. 34% (43/127) patient had diarrhea (89% - grade
I, 9% - grade-II, 1%- grade III and 1% grade IV). At a median follow
up of all alive was 26 months, 17% (22/127) patients were alive and
well, 9% (11/127) were lost to follow up without disease, 54% (68/127)
patients were lost to follow up with disease, 5% (7/127) patients were
on follow up with disease and 15% (19/127) were dead. Median overall
survival was 35 months (95% CI 22-52) and not reached in worst case
and best case scenario respectively. Conclusion: The compliance
to upfront CTRT is fairly good as 86% (109/127) patients completed
CTRT, but only 38% (51/127) are known to have undergone radical
surgery. The percentage of patient completing planned treatment is
as low as 18% (23/127) and lost to follow up is of the order of 63%,
which is the main challenge in determining the efficacy of the strategy.
The low percentage of patients undergoing surgery following CTRT is
reflection of patient selection, inadequate finances to undergo surgery
or inappropriate counseling of patients.
Abstract: 402
A study to assess the survival in cancer esophagus
N. Patange, V. Mahobia, N. Patange, D. Arora
Government Medical College and Hospital, Nagpur, India, E-mail:
namita.nangia@gmail.com
Background: Cancer Esophagus is associated with poor overall
survival. It is one of the second and fifth leading cause of mortality in
males and females respectively according to 2005-09 data. Its dismal
prognosis can be attributed to various factors like poor compliance of
patients to available treatment modalities. Aim: To assess the survival
in Cancer Esophagus of patients treated with Combined modality
and Radiotherapy alone in our region. Materials and Methods: A
retrospective analysis of 150 patients enrolled in our Department of
Radiation Therapy and Oncology during 2010-2011 was conducted.
Compliance to treatment was assessed in terms of swallowing capacity
and survival rate. The data pertaining to survival was collected through
the file records and by telephonically contacting the relatives. Only
70 contacts could be reached. Results: The survival of the patients
was analyzed according to the site of involvement, gender, mean age,
distance from our center and treatment modality received – Surgery,
Radiotherapy and Chemotherapy. 60% patients had a survival of <6
months and of these 61% had middle third carcinoma. Concurrent
Radiotherapy was received by 55% patients and <2% of patients
had 5 year survival. Patients who received both chemotherapy and
radiotherapy had 5% 2-4 year survival with 65% being able to swallow
liquid. Affording and educated patients who received ILRT with EBRT
had only 7% 2-4 year survival with 4% patients being able to swallow
semisolids. Conclusion: Cancer Esophagus is an aggressive disease.
Combined modality treatment with Chemotherapy and Radiotherapy
Journal of Cancer Research and Therapeutics - Supplement 1 - 2015 - Volume 11
 Abstracts
(EBRT and ILRT) shows a significant improvement in survival and
quality of life of patients. Thus it should be the preferred mode of
treatment in advanvced stages of the disease.
Abstract: 407
Does PET-CT influence response assessment in patients of
advanced gallbladder cancer on chemotherapy?
S. Agrawal, M. Ravina, S. Gambhir
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow,
Uttar Pradesh, India, E-mail: sushmaagrawal@yahoo.co.uk
Aim: Gall bladder carcinoma (GBC) is the most common cancer of
the biliary tract in North India. 90% of these patients are detected in
advanced stages and merit chemotherapy. CT scan is the standard
modality for assessment of response (by RECIST criteria). Since
PET-CT gives information on metabolic response, our aim was to
evaluate the utility of PET-CT in addition to CT scan (by PERCIST
criteria). Materials and Methods: Patients with locally advanced
and/or metastatic GBC were treated with a combination of cisplatin
25 mg/m2 and gemcitabine 1gm/m2 day 1 and 8 repeated 3 weekly
for a total of 3 cycles. Response assessment was done with CECT
as well as PET. Responders were continued on further 3-5 cycles of
the same regime while non-responders were treated with a second
line regime. Response assessment was done with RECIST as well as
PERCIST. The response was categorised in four categories according
to RECIST [Complete response (CR), Partial response (PR), Stable
disease (SD) and progressive disease (PD)] and PERCIST criteria
[Complete metabolic response (CMR), Partial metabolic response
(PMR), Stable disease (SD), progressive metabolic disease (PMD)].
Upstaging or downstaging of RECIST response was computed for
each category. Results: 31 patients (24 females and 7 males) had
a median age of 50 years. According to RECIST criteria, partial
response (PR) rate was 16% (n = 5), stable disease (SD) 68% (n =
21) and progressive disease (PD) 16% (n = 5). Complete metabolic
response (CMR) was noted in 16%, partial metabolic response (PMR)
32%, progressive metabolic disease (PMD) in 52%. Agreement was
poor with Cohen kappa coefficient of 0.2. PET upstaged response in
51% and downstaged in 16% patients. Amongst partial responders
(n = 5), there was downstaging in one (CMR), and upstaging in 2
patients (PMD). Among patients with stable disease (n = 16) there was
downstaging in 3 (CMR) and upstaging in 10 patients (PMD). Among
patients with progressive disease (n = 5) there was downstaging in
one (CMR) and upstaging in 4 patients (PMD). Conclusions: PET
upstaged response in 51% and downstaged in 16% patients. The
study elaborates that the metabolic response criteria (PERCIST) might
be considered more suitable for evaluation of therapeutic response
assessment for patients on chemotherapy in GBC in comparison
to anatomical response criteria (RECIST). Further, use of 18F FDG
PET-CT for monitoring therapy response offers improved patient care
by individualising treatment and avoiding ineffective therapy.
Abstract: 408
Radiological downstaging with neoadjuvant therapy in
unresectable gall bladder cancers
S. Agrawal, L. Mohan, Z. Neyaz, R. Saxena
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow,
Uttar Pradesh, India, E-mail: sushmaagrawal@yahoo.co.uk
Introduction: Gallbladder cancer is endemic in the Indogangetic
belt and often present as unresecatble or metastatic disease. We
conducted a prospective feasibility study to evaluate the effect of
neoadjuvant therapy on radiologic downstaging and resectability. We
report our prelimnary results on radiologic downstaging in a cohort of
patients. Materials and Methods: The inclusion criteria for patients
was involvement of Right branch of hepatic artery or portal vein or
common bile duct, common hepatic duct and primary biliary confluence
or liver, duodenum and colon involvement and lymphadenopathy in
Journal of Cancer Research and Therapeutics - Supplement 1 - 2015 - Volume 11
hepato-duodenal, peri-pancreatic, common hepatic artery region.
These patients were offered chemoradiotherapy [CTRT] (external
radiotherapy (45 Gy) along with weekly concurrent cisplatin 35
mg/m2 and 5-FU 500 mg). Since patient recruitment was not as
per our expectations and many of them presented with paraaortic
lymphnodes, we relaxed our inclusion criteria to include these
patients and offered them neoadjuvant chemotherapy [CT] (cisplatin
25 mg/m2 and gemcitabine 1 gm/m2 day 1 and 8, 3 weekly for 3
cycles). Radiological downstaging was evaluated by downstaging of
liver involvement and lymphadenopathy according to RECIST criteria.
Results: 40 patients have been inducted into this study from January
2012 to December 2014 but some patients (n = 9) deteriorated on
treatment and hence 2 sets of CT scans for response assessment
was available for 31 patients. The pretreatment CT scans revealed
involvement of porta hepatis (19), liver infiltration (38), duodenum
involvement (n = 22), colon involvement (n = 11), N1 involvement
(n = 11), N2 disease (n = 8), paraaortic LN (n = 15), no LN (n = 6).
After neoadjuvant therapy (CTRT = 19, CT = 21), liver involvement
completely disappeared in 12 (30%), partially in 17 (42.5%), was
static in 9 (5%) and lymphnode involvement completely disappeared
in 20 (50%), partially in 7 (17.5%), was static in 4 (10%). 6 patients
could undergo extended cholecystectomy who had 50% and 66%
downstaging of liver and lymphnodes which translated into 74%
and 84% histopathological downstaging of liver and lymphnodes.
All resctions were R0. Conclusions: Neoadjuvant therapy in
unresectable gall bladder cancer results in 15% resectability rate
and radiologic downstaging of liver involvement by 72.5% and
lymphadenopathy by 67.5%. Our prelimnary results reveal strong
potential of this approach in achieving R0 and node negative disease
and hence improvement of survival.
Abstract: 409
Does CA 19.9 have prognostic relevance in carcinoma
gallbladder?
S. Agrawal, A. Lawrence, R. Saxena
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow,
Uttar Pradesh, India, E-mail: sushmaagrawal@yahoo.co.uk
Background: CA 19.9 has 80% specificity for diagnosis of GBC.
There is scarce data on its prognostic relevance. This retrospective
study was undertaken to evaluate the prognostic relevance of CA 19.9
in different prognostic subsets of GBC. Materials and Methods: 142
patients of GBC treated between January 2012 to December 2014
were the subjects of this retrospective analysis. Baseline Ca 19.9
levels of four cohorts of patients: Extended cholecystectomy [EC],
simple cholecystectomy [SC] with residual or recurrent disease,
locally advanced disease (LA-GBC), and metastatic disease were
ascertained. The difference in the median baseline values of CA 19.9
among different prognostic group was ascertained by independent
sample t test. The effect of log transformed value of CA 19.9 on overall
survival (OS) was also analysed to evaluate its role as a predictive
marker. Results: Patients of EC (n = 24) had a baseline median
levels of 10 units/ml (range 2-20 units/ml) and a median OS of 24
months (range 12.5-30 mo). Patients of SC (n = 26) had a median Ca
19.9 level of 12 units/ml (range 4.5 to 35 units/ml) and a median OS
of 15 months (range 11.7-25 mo). Patients with LA-GBC (n = 39) had
a baseline median levels of 35 units/ml (range 8- 130 units/ml) and
a median OS of 7 months (range 4-12 mo). Patients with metastatic
disease (n = 53) had baseline median Ca 19.9 level of 75 units/ml
(range 8 to 970 units/ml) and a median OS of 6 months (range 3-11
mo). The difference in the median baseline value of CA 19.9 and OS
among the 4 subgroups was 0.000 and 0.000 (p value). Cox regression
analysis revealed a significant influence of log transformed value of
CA 19.9 on OS (HR 1.1, 95% Confidence interval 1.026-1.19, p =
0.009) without stratification for prognostic subgroups. Conclusions:
Ca 19.9 has prognostic relevance in different subsets of GBC and its
role as a predictive marker needs to be further explored.
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