J.L. Shah

Lymph Node Count From Neck Dissection Predicts Mortality in Head and Neck Cancer

Purpose Multiple smaller studies have demonstrated an association between overall survival and lymph node (LN) count from neck dissection in patients with head and neck cancer. This is a large cohort study to examine these associations by using a national cancer database. Patients and Methods The National Cancer Database was used to identify patients who underwent upfront nodal dissection for mucosal head and neck squamous cell carcinoma between 2004 and 2013. Patients were stratified by LN count into those with < 18 nodes and those with ≥ 18 nodes on the basis of prior work. A multivariable Cox proportional hazards regression model was constructed to predict hazard of mortality. Stratified models predicted hazard of mortality both for patients who were both node negative and node positive. Results There were 45,113 patients with ≥ 18 LNs and 18,865 patients with < 18 LNs examined. The < 18 LN group, compared with the ≥ 18 LN group, had more favorable tumor characteristics, with a lower proportion of T3 and T4 lesions (27.9% v 39.8%), fewer patients with positive nodes (46.6% v 60.5%), and lower rates of extracapsular extension (9.3% v 15.1%). Risk-adjusted Cox models predicting hazard of mortality by LN count showed an 18% increased hazard of death for patients with < 18 nodes examined (hazard ratio [HR] 1.18; 95% CI, 1.13 to 1.22). When stratified by clinical nodal stage, there was an increased hazard of death in both groups (node negative: HR, 1.24; 95% CI, 1.17 to 1.32; node positive: HR, 1.12; 95% CI, 1.05 to 1.19). Conclusion The results of our study demonstrate a significant overall survival advantage in both patients who are clinically node negative and node positive when ≥ 18 LNs are examined after neck dissection, which suggests that LN count is a potential quality metric for neck dissection.

Stereotactic radiosurgery and hypofractionated radiotherapy for glioblastoma

Glioblastoma is the most common primary brain tumor in adults. Standard therapy depends on patient age and performance status but principally involves surgical resection followed by a 6-wk course of radiation therapy given concurrently with temozolomide chemotherapy. Despite such treatment, prognosis remains poor, with a median survival of 16 mo. Challenges in achieving local control, maintaining quality of life, and limiting toxicity plague treatment strategies for this disease. Radiotherapy dose intensification through hypofractionation and stereotactic radiosurgery is a promising strategy that has been explored to meet these challenges. We review the use of hypofractionated radiotherapy and stereotactic radiosurgery for patients with newly diagnosed and recurrent glioblastoma.

Stereotactic Ablative Radiotherapy for Early-Stage Lung Cancer

The rising incidence of early-stage lung cancer, particularly in medically inoperable patients, is anticipated because of the implementation of early detection strategies and population aging in the United States and worldwide. This mandates the development of noninvasive curative treatment approaches for this disease. Stereotactic ablative radiotherapy (SABR) has recently emerged as a standard of care for early-stage lung cancer in medically inoperable patients who cannot safely tolerate surgical lobectomy, the established standard for operable patients. Further experience has demonstrated key principles with this highly conformal and dose-intensive radiation technique, including the need for sufficiently high biologically effective dose to achieve optimal local control, dose-fractionation modifications needed to treat centrally located tumors safely, and individualization of treatment based on tumor size, location, and other factors. SABR requires particular technical expertise including a nuanced understanding of dose prescription and calculation and appropriate management of tumor and organ motion. Progress continues as increasing experience with and data on SABR in selected cohorts of medically operable patients suggest comparable oncologic outcomes and a more favorable toxicity profile that challenges the historical standard of care for broader patient populations.