Shashikant Juvekar

CT-guided percutaneous core needle biopsy in deep seated musculoskeletal lesions : a prospective study of 128 cases

ObjectivesAlthough large lesions of the limbs can easily be biopsied without image guidance, lesions in the spine, paraspinal area and pelvis are difficult to target, and benefit from CT guidance to improve the accuracy of targeting the lesion for biopsy purposes. A prospective study of CT-guided core needle biopsies for deep-seated musculoskeletal lesions was conducted at a referral cancer institute over a 4-year period with the aim of assessing the safety and efficacy of the procedure.Patients & methodsFrom January 2000 to December 2003, 136 consecutive CT-guided biopsy sessions were undertaken for musculoskeletal lesions in 128 patients comprising 73 males and 55 females. The following data was recorded in all patients: demographic data, suspected clinicoradiological diagnosis, data related to core biopsy session (date, site, approach, total time required in minutes, number of cores, surgeon satisfaction with adequacy of cores), patient discomfort, complications, histopathology report and number of further sessions if material obtained during the first biopsy session was not confirmatory. The sample obtained during the biopsy session was considered inconclusive if, in the opinion of the pathologist, inadequate or non-representative tissue had been obtained. The diagnosis was considered inaccurate if the final histopathological diagnosis did not match with the biopsy diagnosis, or if subsequent clinicoradiological evaluation at follow up did not correlate with the biopsy diagnosis in those patients who were treated with modalities other than surgery.ResultsIn 121 patients, a single session was sufficient to obtain representative material, whilst for six patients two sessions, and for one patient three sessions were necessary. The time taken for biopsy, including the pre-biopsy CT examination time, varied from 15 min to 60 min (median 30 min). For 110 bony lesions 116 sessions were required, and for 18 soft-tissue lesions 20 sessions were required. 108 biopsy sessions yielded a diagnosis, whilst 28 were inconclusive (diagnostic yield of 79.41%). Of 108 diagnostic biopsies, five were considered inaccurate (accuracy rate of 95.37%). The overall diagnostic yield and accuracy rate for bony lesions were 81.03% and 95.74%; and those for soft-tissue lesions were 70% and 92.85%. There were two complications with no permanent sequelae.ConclusionCT-guided core needle biopsy is a safe, easy, and effective technique for the evaluation of deep-seated musculoskeletal lesions, with a high rate of diagnostic yield and accuracy. It facilitates definitive therapy without the patient having to undergo a major surgical procedure for diagnosis.

A prospective randomized phase II study comparing metronomic chemotherapy with chemotherapy (single agent cisplatin), in patients with metastatic, relapsed or inoperable squamous cell carcinoma of head and neck.

BACKGROUND Cetuximab based treatment is the recommended chemotherapy for head and neck squamous cell cancers in the palliative setting. However, due to financial constraints, intravenous (IV) chemotherapy without cetuximab is commonly used in lesser developed countries. We believe that oral metronomic chemotherapy may be safer and more effective in this setting. METHODS We conducted an open label, superiority, parallel design, randomized phase II trial comparing oral MCT [daily celecoxib (200mg twice daily) and weekly methotrexate (15mg/m(2))] to intravenous single agent cisplatin (IP) (75mg/m(2)) given 3 weekly. Eligible patients had head and neck cancers requiring palliative chemotherapy with ECOG PS 0-2 and adequate organ functions who could not afford cetuximab. The primary end point was progression-free survival. RESULTS 110 Patients were recruited between July 2011 to May 2013, 57 randomized to the MCT arm and 53 to the IP arm. Patients in the MCT arm had significantly longer PFS (median 101 days, 95% CI: 58.2-143.7 days) compared to the IP arm (median 66 days, 95% CI; 55.8-76.1 days) (p=0.014). The overall survival (OS) was also increased significantly in the MCT arm (median 249 days, 95% CI: 222.5-275.5 days) compared to the IP arm (median 152 days, 95% CI: 104.2-199.8 days) (p=0.02). There were fewer grade 3/4 adverse effects with MCT, which was not significant. (18.9% vs. 31.4%, P=0.14). CONCLUSION Oral metronomic chemotherapy has significantly better PFS and OS than single agent platinum in the palliative setting.

Neoadjuvant chemotherapy followed by surgery in very locally advanced technically unresectable oral cavity cancers

BACKGROUND The median survival of technically unresectable oral-cavity cancers (T4a and T4b) with non surgical therapy is 2-12 months. We hypothesized that neoadjuvant chemotherapy (NACT) could reduce the tumour size and result in successful resection and ultimately improved outcomes. We present a retrospective analysis of consecutive patients who received NACT at our centre between January 2008 and August 2012. PATIENTS AND METHODS All patients with technically unresectable oral cancers were assessed in a multidisciplinary clinic and received 2 cycles of NACT. After 2 cycles, patients were reassessed and planned for either surgery with subsequent CTRT or nonsurgical therapy including CT-RT, RT or palliation. SPSS version 16 was used for analysis of locoregional control and overall survival (OS). Univariate and multivariate analysis was done for factors affecting the OS. RESULTS 721 patients with stage IV oral-cavity cancer received NACT. 310 patients (43%) had sufficient reduction in tumour size and underwent surgical resection. Of the remaining patients, 167 received chemoradiation, 3 radical radiation and 241 palliative treatment alone The locoregional control rate at 24 months was 20.6% for the overall cohort, 32% in patients undergoing surgery and 15% in patients undergoing non surgical treatment (p=0.0001). The median estimated OS in patients undergoing surgery was 19.6 months (95% CI, 9.59-25.21 months) and 8.16 months (95%, CI 7.57-8.76) in patients treated with non surgical treatment (p=0.0001). CONCLUSION In our analysis, NACT led to successful resection and improved overall survival in a significant proportion of technically unresectable oral-cancer patients.

Role of 3T multiparametric-MRI with BOLD hypoxia imaging for diagnosis and post therapy response evaluation of postoperative recurrent cervical cancers

Highlights • In operated cervix cancer, the accuracy of diagnosing vaginal vault/local recurrent lesions was higher at combined multiparametric MR imaging and conventional MR imaging (100%) than at conventional MR imaging (70%) or multiparametric MR imaging (96.7%) alone.• We found a significant correlation between percentage tumor regression and pre-treatment parameters: NEI (p = 0.02), the maximum slope (p = 0.04), mADC value (p = 0.001) and amount of hypoxic fraction present in the pretherapy MRI (p = 0.01).• Multiparametric and BOLD hypoxia MR Imaging are feasible and reliable in diagnosing post-operative recurrence in cervical cancer and should be applied when there is clinical suspicion of post-operative recurrence.• Quantitative image features obtained at multiparametric-MRI with BOLD hypoxia imaging has potential to be an appropriate and reliable biologic target for radiation dose painting to optimize therapy in future.

Osteoradionecrosis of the mandible: through a radiologist's eyes.

Head and neck malignancies constitute a major cause of morbidity and mortality all over the world. Radiotherapy plays a pivotal role in the management of these tumours; however, it has associated complications, with mandibular osteoradionecrosis (ORN) being one of the gravest orofacial complications. Early diagnosis, extent evaluation, and detection of complications of ORN are imperative for instituting an appropriate management protocol. ORN can closely mimic tumour recurrence, the differentiation of which has obvious clinical implications. The purpose of the present review is to acquaint the radiologist with the imaging features of mandibular ORN and the ways to differentiate ORN from tumour recurrence.

Induction chemotherapy in technically unresectable locally advanced oral cavity cancers: Does it make a difference?

BACKGROUND Locally advanced and unresectable oral cavity cancers have a poor prognosis. Induction might be beneficial in this setting by reducing tumor bulk and allowing definitive surgery. AIM To analyze the impact of induction chemotherapy on locally advanced, technically unresectable oral cavity cancers. MATERIALS AND METHODS Retrospective analysis of patients with locally advanced oral cavity cancers, who were treated with neoadjuvant chemotherapy (NACT) during the period between June 2009 and December 2010. Data from a prospectively filled database were analyzed for information on patient characteristics, chemotherapy received, toxicity, response rates, local treatment offered, patterns of failure, and overall survival. The statistical analysis was performed with SPSS version 16. RESULTS 123 patients, with a median age of 42 years were analyzed. Buccal mucosa was the most common subsite (68.30%). Three drug regimen was utilized in 26 patients (21.10%) and the rest received two drug regimen. Resectability was achieved in 17 patients treated with 3 drug regimen (68.00%) and 36 patients receiving 2 drug regimen. Febrile neutropenia was seen in 3 patients (3.09%) receiving 2 drug regimen and in 9 patients (34.62%) receiving 3 drug regimen. The estimated median OS was not reached in patients who had clinical response and underwent surgery as opposed to 8 months in patients treated with non-surgical modality post NACT (P = 0.0001). CONCLUSION 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.

Is there a role of induction chemotherapy followed by resection in T4b oral cavity cancers

OBJECTIVE The objective of the following study is to investigate the efficacy and impact of induction chemotherapy in T4b oral cavity cancers. MATERIALS AND METHODS Its a retrospective analysis of prospectively collected data of T4b oral cavity cancer patients who were offered induction chemotherapy and then assessed for resectability at the end of 2 cycles of chemotherapy. Post-induction these patients either underwent surgical or non-surgical local intervention depending upon their response. These patients were then followed-up until either recurrence progression or death whichever was later. Statistical analysis was performed by SPSS version 16. Descriptive analysis was performed. Factors affecting achievement of resectability were sought by univariate and multivariate analysis. The impact of surgery on overall survival (OS) was studied using Kaplan Meier survival analysis with the use of log rank test. RESULTS A total of 110 patients received chemotherapy. Median age been 41.5 years (range 25-66 years). 21 (20%) of our patient received 3 drug regimen while the rest of our patients received 2 drug regimen. Partial response was achieved in 28 patients, stable disease in 49 patients and progression was noted in 23 patients. Resectability was achieved in 34 (30.9%) of 110 patients. The estimated median OS in patients who underwent surgery was 18.0 months (95% confidence interval [CI]: 13.6-22.46 months) and for those treated with non-surgical treatment was 6.5 months (95% CI: 5.6-7.4 months) (P = 0.0001). CONCLUSION Use of induction chemotherapy is safe and can achieve resectability in 30.9% of our T4b patients. In those patients undergoing resection have much better OS then those who underwent non-surgical local treatment.

Retromolar trigone squamous cell cancers: A reappraisal of 16 section MDCT for assessing mandibular invasion

AIM To reinvestigate the accuracy of 16 section multidetector computed tomography (MDCT) in assessing mandibular invasion in retromolar trigone (RMT) squamous cell cancers (SCC). MATERIALS AND METHODS A search for diagnosed cases of early RMT SCC that were both imaged and treated at Tata Memorial Centre, Mumbai, India, between 2007 and 2010, was undertaken and yielded 37 patients. The average tumour size was 2.6 cm. All patients had undergone segmental, marginal, or hemimandibulectomy within 2 weeks of imaging. Imaging records archived on the picture archiving and communication system (PACS) were analysed. Contrast-enhanced CT had been performed using a 16 section MDCT system using the puffed-cheek technique. Image acquisition was at 2.5 mm section thickness, but axial images and isotropic coronal and sagittal multiplanar reformations were generated ad hoc from 0.625 mm retro-reconstructed images. Optimal oblique reformations were generated at will by the radiologist to depict the RMT in its entirety. The soft-tissue algorithm and bone window or bone algorithm reformations and axial images were analysed on a volume viewer integrated within the PACS using triangulation. Two investigators independently studied the images and these were compared with the findings at histopathology. RESULTS The sensitivity, specificity, and accuracy of 16 section MDCT for mandibular cortical and marrow invasion was 94, 90, and 91.8% and 83, 92, and 89%, respectively. Use of ad hoc generated oblique reformation contributed to the enhanced sensitivity and specificity. The accuracy for inferior alveolar canal invasion was 100%. There was excellent agreement between the two observers. CONCLUSION Sixteen-section MDCT used to its full potential has high accuracy for the detection of mandibular invasion in RMT SCC.

Once-a-Week Versus Once-Every-3-Weeks Cisplatin Chemoradiation for Locally Advanced Head and Neck Cancer: A Phase III Randomized Noninferiority Trial

Purpose Chemoradiation with cisplatin 100 mg/m2 given once every 3 weeks is the standard of care in locally advanced head and neck squamous cell cancer (LAHNSCC). Increasingly, low-dose once-a-week cisplatin is substituted because of perceived lower toxicity and convenience. However, there is no level 1 evidence of comparable efficacy to cisplatin once every 3 weeks. Patients and Methods In this phase III randomized trial, we assessed the noninferiority of cisplatin 30 mg/m2 given once a week compared with cisplatin 100 mg/m2 given once every 3 weeks, both administered concurrently with curative intent radiotherapy in patients with LAHNSCC. The primary end point was locoregional control (LRC); secondary end points included toxicity, compliance, response, progression-free survival, and overall survival. Results Between 2013 and 2017, we randomly assigned 300 patients, 150 to each arm. Two hundred seventy-nine patients (93%) received chemoradiotherapy in the adjuvant setting. At a median follow-up of 22 months, the estimated cumulative 2-year LRC rate was 58.5% in the once-a-week arm and 73.1% in the once-every-3-weeks arm, leading to an absolute difference of 14.6% (95% CI, 5.7% to 23.5%); P = .014; hazard ratio (HR), 1.76 (95% CI, 1.11 to 2.79). Acute toxicities of grade 3 or higher occurred in 71.6% of patients in the once-a-week arm and in 84.6% of patients in the once-every-3-weeks arm ( P = .006). Estimated median progression-free survival in the once-a-week arm was 17.7 months (95% CI, 0.42 to 35.05 months) and in the once-every-3-weeks arm, 28.6 months (95% CI, 15.90 to 41.30 months); HR, 1.24 (95% CI, 0.89 to 1.73); P = .21. Estimated median overall survival in the once-a-week arm was 39.5 months and was not reached in the once-every-3-weeks arm (HR, 1.14 [95% CI, 0.79 to 1.65]; P = .48). Conclusion Once-every-3-weeks cisplatin at 100 mg/m2 resulted in superior LRC, albeit with more toxicity, than did once-a-week cisplatin at 30 mg/m2, and should remain the preferred chemoradiotherapy regimen for LAHNSCC in the adjuvant setting.

Induction Chemotherapy in Technically Unresectable Locally Advanced Carcinoma of Maxillary Sinus

Background. Locally advanced carcinoma of maxillary sinus has been historically reported to have poor prognosis. We evaluated the role of NACT in improving the outcome in these patients. Methods. 41 patients with locally advanced technically unresectable (stage IVa) or unresectable maxillary carcinoma (stage IVb) were treated with induction chemotherapy between 2008 and 2011. The demographic profile, response and toxicity of chemotherapy, definitive treatment received, progression free survival (PFS), and overall survival (OS) were analyzed. Univariate and multivariate analysis were performed to determine factors associated with PFS and OS. Results. The chemotherapy included two drugs (platinum and taxane) in 34 patients (82.9%) and three drugs (platinum, taxane, and 5 FU) in 7 (17.1%). There was no complete response seen in any of the patients, stable disease in 18 (43.9%), partial response in 16 (39%), and progression in 7 (17.1%) patients. After induction, the treatment planned included surgery in 12 (29.3%), CT-RT in 24 (58.5%), radical RT in 1 (2.4%), palliative RT in 1 (2.4%), and palliative chemotherapy in 3 (7.3%) patients. Overall, the median PFS was 10.0 months. The OS at 24 months and 36 months was 41% and 35%, respectively. Conclusion. In unresectable maxillary carcinoma, induction chemotherapy has clinically significant benefit with acceptable toxicity.