Mitali Dandekar

Elective versus Therapeutic Neck Dissection in Node-Negative Oral Cancer

BACKGROUND Whether patients with early-stage oral cancers should be treated with elective neck dissection at the time of the primary surgery or with therapeutic neck dissection after nodal relapse has been a matter of debate. METHODS In this prospective, randomized, controlled trial, we evaluated the effect on survival of elective node dissection (ipsilateral neck dissection at the time of the primary surgery) versus therapeutic node dissection (watchful waiting followed by neck dissection for nodal relapse) in patients with lateralized stage T1 or T2 oral squamous-cell carcinomas. Primary and secondary end points were overall survival and disease-free survival, respectively. RESULTS Between 2004 and 2014, a total of 596 patients were enrolled. As prespecified by the data and safety monitoring committee, this report summarizes results for the first 500 patients (245 in the elective-surgery group and 255 in the therapeutic-surgery group), with a median follow-up of 39 months. There were 81 recurrences and 50 deaths in the elective-surgery group and 146 recurrences and 79 deaths in the therapeutic-surgery group. At 3 years, elective node dissection resulted in an improved rate of overall survival (80.0%; 95% confidence interval [CI], 74.1 to 85.8), as compared with therapeutic dissection (67.5%; 95% CI, 61.0 to 73.9), for a hazard ratio for death of 0.64 in the elective-surgery group (95% CI, 0.45 to 0.92; P=0.01 by the log-rank test). At that time, patients in the elective-surgery group also had a higher rate of disease-free survival than those in the therapeutic-surgery group (69.5% vs. 45.9%, P<0.001). Elective node dissection was superior in most subgroups without significant interactions. Rates of adverse events were 6.6% and 3.6% in the elective-surgery group and the therapeutic-surgery group, respectively. CONCLUSIONS Among patients with early-stage oral squamous-cell cancer, elective neck dissection resulted in higher rates of overall and disease-free survival than did therapeutic neck dissection. (Funded by the Tata Memorial Centre; ClinicalTrials.gov number, NCT00193765.).

Relative value of ultrasound, computed tomography and positron emission tomography imaging in the clinically node‐negative neck in oral cancer

To determine the most accurate noninvasive imaging modality for occult metastasis in clinically node‐negative necks in oral squamous cell carcinoma from a granulomatous disease endemic region.

Defining a rational step-care algorithm for managing thyroid carcinoma patients with elevated thyroglobulin and negative on radioiodine scintigraphy (TENIS): considerations and challenges towards developing an appropriate roadmap

Oneofthemostchallengingclinicalsituationsinpatientswithdifferentiated thyroid cancer (DTC) is an elevated serum thy-roglobulin (Tg) level with negative radioiodine scintigraphy(commonlytermedBTENIS^).Thediagnosticandtherapeuticapproaches adopted by attending physicians in day-to-dayroutine vary quite widely. The main reason for this variationis the rarity of the condition (2 – 13 % from various seriesreported in literature), and its management, especially thera-peuticstrategies, continues tobeimperfect intheabsenceofaclear-cut understanding and lack of evidence of its aetiology,as observed by various authorities [1]. In this editorial, wediscuss the different therapeutic strategies that have beenexplored and the associated pitfalls in interpretation ofclinical findings, and propose a logical step-wise algo-rithmic approach to care to follow in routine clinics inthis particular group of patients. Our views are support-ed by an overview of the evidence in the literature(with respect to both efficacy and adverse effects) andby practical experience. In addition, we critically reviewand analyse the steps needed in the immediate future toenhance and rationalize patient care. We believe thatsuch endeavours toidentifyandprioritizethechallengeswillfurther the roadmap to the development of a systematicand scientific approach to themanagementofpatientswithTENIS.

Organ preservation strategies: Review of literature and their applicability in developing nations

There has been a change in practice in locally advanced laryngopharyngeal cancers toward non-surgical treatment modalities. Although, there have been landmark trials pertinent to organ preservation, their applicability in developing nations is a topic of much debate. The organ preservation concept was based on the findings of pivotal trials by the Veterans Affairs, European Organization for Research and Treatment of Cancer group and Radiation Therapy Oncology Group. Subsequently numerous studies have been designed to evaluate intensification of treatment as well as study toxicity and tolerability. This review critically analyses current evidence for larynx preservation, experience from various centers on organ preservation strategies as well as applicability of these protocols to developing nations.

Elective versus therapeutic neck dissection in the clinically node negative early oral cancer: A randomised control trial (RCT).

LBA3 Background: Management of the neck in early oral cancers has been a matter of debate with clinical equipoise between elective (END) or therapeutic neck dissection (TND). METHODS This is a prospective phase III RCT (NCT00193765) to test the superiority of END at the time of primary surgery over TND (neck dissection at the time of nodal relapse) in patients with lateralized T1 or T2 squamous carcinoma of oral cavity, amenable to peroral excision. Patients were stratified based on size, site, sex and preoperative neck ultrasound. The primary end point was overall survival (OS) and secondary end point was disease-free survival (DFS). The trial was planned to demonstrate a 10% superiority (1-sided α = 0.05 and β = 0.2) in OS for END vs. TND, assuming 60% 5-year OS in TND arm, with a planned sample size of 710. RESULTS This trial was terminated after 596 patients were randomized between January 2004 and June 2014. An interim intent-to-treat analysis of initial 500 patients (255 in TND, 245 END) with a minimum follow-up of 9 months was performed as mandated by Data and Safety Monitoring Committee based on the number of observed deaths in each arm. Both arms were balanced for site and stage. There were 427 tongue, 68 buccal mucosa and 5 floor of mouth tumors; 221 were TI and 279 T2. At a median follow-up of 39 months there were 146 recurrences in TND and 81 in END arms respectively. The 3-year OS was significantly higher in END compared to TND arm (80.0% vs. 67.5%, HR = 0.63, 95%CI 0.44-0.89, p = 0.01) as was 3-year DFS (69.5% vs. 45.9%, HR = 0.44, 95%CI 0.34-0.58, p < 0.001). After adjusting for stratification factors in Cox regression, END continued to be significantly superior to TND for both OS and DFS. CONCLUSIONS There were 8 excess deaths for every 15 excess recurrences in the TND arm. Elective neck dissection in patients with early oral SCC results in 37% reduction in mortality and should be considered the standard of care. CLINICAL TRIAL INFORMATION NCT00193765.

Head and neck cancers in India

Head and neck cancers constitute a third of the cancer burden in India. These cancers have unique patient characteristics, presentation, and etiological differences from those in the West. Socioeconomic constraints, large patient population, scarcity of trained health workers, and inadequate infrastructure are major challenges faced in the management of these cancers. Despite these constraints, patients are treated with evidence based guidelines that are tailored to the local scenario.

Management of thyroid cancers

Thyroid cancers cover a large spectrum of disease with diametrically opposite prognosis. At one end of the spectrum we have the well differentiated cancers which carry an excellent prognosis, while at the other end there is anaplastic cancer with high mortality rates and dismal prognosis. Management of thyroid cancers still has some controversial issues due to lack of randomized controlled trials. Extent of surgery, extent of neck dissection, role of radioiodine treatment and thyroid stimulating hormone suppression are still debatable. In this review, we highlight these controversial issues and give guidelines for the management and follow up of patients with thyroid cancer.