|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 3 | Page : 400-401
Response to oral metronomic chemotherapy in carcinoma of the Buccal Mucosa: A case report
A Joshi1, V Agarwala1, V Noronha1, S Dhumal1, S Juvekar2, K Prabhash1
1 Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
2 Department of Radiodiagnosis, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
|Date of Web Publication||10-Dec-2014|
Dr. K Prabhash
Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Joshi A, Agarwala V, Noronha V, Dhumal S, Juvekar S, Prabhash K. Response to oral metronomic chemotherapy in carcinoma of the Buccal Mucosa: A case report. Indian J Cancer 2014;51:400-1
|How to cite this URL:|
Joshi A, Agarwala V, Noronha V, Dhumal S, Juvekar S, Prabhash K. Response to oral metronomic chemotherapy in carcinoma of the Buccal Mucosa: A case report. Indian J Cancer [serial online] 2014 [cited 2020 Feb 24];51:400-1. Available from: http://www.indianjcancer.com/text.asp?2014/51/3/400/146786
Metronomic chemotherapy is the continuous use of fractionated doses, far below the maximum tolerated dose, of chemotherapeutic agents acting on different targets in the tumor micro-environment.  In palliative and resource constraint settings, we have used oral metronomic chemotherapy with methotrexate and celecoxib in metastatic, inoperable recurrent and locally advanced head and neck cancers with promising results. , However, rarely do we get a rapid and complete clinical response. Here, we present such a case.
A 66-year-old male, chronic tobacco chewer and known case of hypertension (HTN), coronary artery disease (CAD) with atrial fibrillation (AF) and history of cerebrovascular accident presented to our hospital in December 2013, with complaints of nonhealing ulcerative lesion over right lower lip extending to buccal mucosa since 8 months. He was symptomatic for pain in the lesion with mild dysphagia and discharge from the wound. Clinically there was a 5 cm × 4 cm ulcero-proliferative growth in right buccal mucosa involving lower lip, angle of mouth, adjoining part of the skin and upper lip. Computed tomography scan showed a plaque-like lesion measuring 20 mm in maximum thickness involving right buccal mucosa-buccinator complex, extending from the maxillary alveolus inferiorly up to the mandibular attachment. The retromolartrigone region and the gingival mucosa were involved with the infiltration of the skin. A right level IB lymph node was seen. Biopsy confirmed a well-differentiated squamous cell carcinoma. Patient was staged as T4a N1 M0 - TNM stage IV (A) in view of skin involvement.
Patient was planned for surgery, but he developed AF during anesthesia induction. In view of persistent AF, HTN, CAD and American Society of Anesthesiology III risk for anesthesia, patient was deemed unfit for surgery. Radiotherapy could not be given in view of skin ulceration and extensive disease. Hence, he was referred for palliative chemotherapy. Patient presented to medical oncology outpatient department in April 2014 with progressive disease. His performance status as per Eastern Cooperative Oncology Group scale was 2. Echocardiography done in January 2014 showed concentric left ventricular hypertrophy, no regional wall motion abnormalities and 60% ejection fraction. Electrocardiogram showed AF with controlled ventricular rate. Patient was on metoprolol, olmesartan, hydrochlorthiazide, rosuvastatin, aspirin and warfarin. In view of multiple comorbidities, old age, reluctance for regular follow-up and risks of intravenous chemotherapy, patient was given oral methotrexate 15 mg/m 2 weekly and 200 mg celecoxib twice a day with palliative intent. The risk of cardiotoxicity with celecoxib was explained. He was called for a reassessment after 1-month.
After 1-month, clinically the lesion over right buccal mucosa involving the angle of mouth and lips had completely resolved [Figure 1] a and b. The earlier symptoms of pain, discharge and dysphagia had completely resolved. Radiologically there was a partial response.
The present case highlights the fact that oral metronomic chemotherapy with methotrexate and celecoxib is an effective alternative to primary systemic chemotherapy with dramatic response in some cases of head and neck cancer. Prospective randomized trials are needed to validate the encouraging response rates and minimal side effects of this schedule. In developing countries like India, this treatment strategy can be effective where most patients cannot afford costly drugs. 
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