Richa Vaish

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.).

Molecular markers in well-differentiated thyroid cancer

PurposeThyroid nodules are of common occurrence in the general population. About a fourth of these nodules are indeterminate on aspiration cytology placing many a patient at risk of unwanted surgery. The purpose of this review is to discuss various molecular markers described to date and place their role in proper perspective. This review covers the fundamental role of the signaling pathways and genetic changes involved in thyroid carcinogenesis. The current literature on the prognostic significance of these markers is also described.MethodsPubMed was used to search relevant articles. The key terms “thyroid nodules”, “thyroid cancer papillary”, “carcinoma papillary follicular”, “carcinoma papillary”, “adenocarcinoma follicular” were searched in MeSH, and “molecular markers”, “molecular testing”, mutation, BRAF, RAS, RET/PTC, PAX 8, miRNA, NIFTP in title and abstract fields. Multiple combinations were done and a group of experts in the subject from the International Head and Neck Scientific Group extracted the relevant articles and formulated the review.ResultsThere has been considerable progress in the understanding of thyroid carcinogenesis and the emergence of numerous molecular markers in the recent years with potential to be used in the diagnostic algorithm of these nodules. However, their precise role in routine clinical practice continues to be a contentious issue. Majority of the studies in this context are retrospective and impact of these mutations is not independent of other prognostic factors making the interpretation difficult.ConclusionThe prevalence of these mutations in thyroid nodule is high and it is a continuously evolving field. Clinicians should stay informed as recommendation on the use of these markers is expected to evolve.

Gnathic Osteosarcoma: Clinical, Radiologic, and Pathologic Review of Bone Beard Tumor

Gnathic (mandibular) osteosarcomas (OSs) account for approximately 6.5% of all OS, and most of them are secondary in nature, occurring in patients with Paget disease or fibrous dysplasia or as a late sequela to craniofacial radiotherapy. Primary OS of the jaw is rare and presents approximately two decades later than its appendicular counterpart; metastasis is uncommon with primary OS, and it has a better prognosis than appendicular OS. Radiologic depiction of a sunburst pattern of new bone formation is characteristic. Early diagnosis and complete tumor resection are mandatory to improve the prognosis of jaw OS.

Positron emission tomography thyroid incidentaloma: Is it different in Indian subcontinent?

BACKGROUND Positron emission tomography (PET) forms an integral part in work-up and follow-up of various malignancies. With the increased use of PET in oncology, finding of an incidental focal thyroid uptake (incidentaloma) is not unusual and presents a diagnostic challenge. AIM The aim of the following study is to evaluate the frequency and radio-pathologic correlation of focal 18-fluoro deoxyglucose uptake (FDG) on PET within the thyroid from a large series. MATERIALS AND METHODS Retrospective review of 37,000 consecutive patients who underwent FDG-PET at tertiary cancer center in India. Radiological, pathological, PET scan and follow-up details were evaluated. Statistical analyzes were carried out using Mann Whitney test and Pearson correlation. RESULTS Abnormal thyroid uptake was seen in 78 (0.2%) patients. Nearly 61 (0.16%) scans had focal and 17 (0.04%) had diffuse FDG uptake. A total of 57 patients with focal uptake were available for further evaluation. No further evaluation was done in 24 (42.1%) patients who had advanced index malignancy. Of the remaining 33 patients 26 were benign and seven were a cause for concern (four primary thyroid cancers, one follicular neoplasm with hurthle cell change and two metastatic cancers). There was no significant correlation in Standardized uptake value (SUV) max of benign and malignant lesion (P = 0.5 on Mann Whitney) or size (r = 0.087 Pearson correlation co-efficient P= 0.667). CONCLUSION Incidence of PET incidentaloma is low in this large cohort of Indian patients. Nearly 27% of focal incidentaloma were malignant. There was no correlation between the SUVmax, size and malignancy.

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.

Oral cancers: Current status

Oral cancer is a global disease. Despite a well elucidated tumour progression model, these cancers present late. Attempts at early detection by way of adjunctive diagnostic technologies and screening have not lived up to expectations in spite initial promise. Surgery is the mainstay of treatment. Treatment intensification by way of adjuvant radiation/chemo radiation is warranted for those with high risk features. Recent studies have explored intensification in those with intermediate risk factors in an attempt to improve outcomes. There has been generation of recent robust evidence that has influenced the need and extent of neck dissection. Neoadjuvant chemotherapy (NACT) may have a potential role in organ preservation and borderline resectable oral cancers. Recurrent tumours should be offered surgery whenever feasible while the addition of biological agents to chemotherapy gives best results in the palliative settings.

Case of victims of modern imaging technology: Increased information noise concealing the diagnosis

We present a case of tubercular arthritis who underwent numerous unnecessary investigations what is known as “victims of modern imaging technology” or VOMIT. Today there is an exponential rise in the volume of the medical imaging, part of which is contributed by unnecessary and unjustified indications. We discuss about the untoward effects of the uninhibited and careless use of modern imaging modalities and possible ways to avoid. Skeletal manifestation of the tuberculosis is still common in the endemic countries like India. Although the final diagnosis of the skeletal tuberculosis like tubercular arthritis is made by bacteriological and histological studies, few demographic, clinical and radiological features might help making early diagnosis.

Beyond Me, Too

TO THE EDITOR: The article by Gyawali highlights the important issue of rising costs associated with the cancer treatment that is important to our part of the world. The article rightly enumerates challenges facedby the health care system in lowand low-middle– income countries (LLMICs). Increasing financial burden associatedwith cancer treatment is a cause of concern not only in developing countries, but in the developed world as well. The author has highlighted the current paradox that plagues the medical fraternity. On one hand, we discuss breakthrough research at premier scientific meetings (eg, those of the American Society of Clinical Oncology), while on the other, the majority of the world is unable to provide basic cancer care for patients.

Multicompartmental Trigeminal Schwannomas: Dumbbell Tumors Revisited

Multicompartmental trigeminal schwannomas (MTSs) are a rare and complex but treatable group of tumors. Herein, we describe the clinicoradiologic presentation of two patients with MTS. The two illustrated distinct case reports highlight the role of imaging and the outcome of two different types of MTS. The Discussion summarizes the literature to date, which will help the reader diagnose these tumors in a timely manner and manage them appropriately.

Current scenario and efforts to propound equal and affordable global cancer surgery

With over 70 major cancer centers presently involved in this initiative, NCG is paralleling uniform high standards of cancer care and overall cancer outcomes across India.[4] The results of recently published prospective randomized controlled trial by D’Cruz et al.[5] addressing a long-standing issue on management of early stage oral squamous cell cancer is another encouraging example, emphasizing one of the important solutions suggested in the Sullivan et al. review.[1]