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Papillary thyroid cancer is the most common neoplasm of the thyroid gland. Surgical resection is the cornerstone of therapy. There is controversy regarding the extent of resection, ranging from thyroid lobectomy plus isthmusectomy to total thyroidectomy, but in experienced hands total thyroidectomy has many significant advantages over a lesser operation. Nonoperative therapy has no role as primary therapy for papillary thyroid cancer, but can be used in conjunction with surgery to improve outcome. Radioiodine in patients who have received total thyroidectomy can be used to identify residual occult tumor, recurrence, and metastasis, and can also be used to ablate the neoplasm, resulting in a substantial cure rate. Thyroid hormone is needed as replacement after total thyroidectomy, but can also be given as thyroid-stimulating hormone suppression, which may have an adjunctive benefit after resection.

Small Cell Lung Cancer (SCLC) is highly sensitive to chemotherapy and radiotherapy. However, despite initial responses, relapses are common and most patients eventually succumb to this disease. Patients with limited-disease SCLC represent approximately 30% of all patients with SCLC, and are potentially curable when treated with combined chemotherapy and thoracic radiotherapy (TRT). Chemotherapy consists of four cycles of the combination of cisplatin and etoposide (PE). Thoracic radiotherapy should be started with the first or second cycle of chemotherapy, and preferably administered twice daily for 3 weeks. Prophylactic cranial irradiation (PCI) is recommended for patients who achieve a complete response. Surgery is of limited value in SCLC, except in patients who present with a solitary pulmonary nodule. Approximately 20% to 25% of patients with limited disease (LD)-SCLC can be cured with this aggressive approach. Newer treatment modalities are currently under investigation.

Sentinel lymph node biopsy (SLNB) is a standard staging procedure for many patients with clinically node negative, invasive melanoma, providing excellent prognostic information in appropriately selected patients. The broad acceptance of SLNB into clinical practice has resulted in substantial numbers of patients found to have microscopic nodal metastases. For patients with a positive sentinel node, a completion lymph node dissection (CLND) is the current standard of care. The majority of patients who undergo CLND are found to have histologically negative non-sentinel nodes, and yet are exposed to the potential morbidity of CLND, including infection, wound complications, and lymphedema. We do not yet know if there is a survival benefit from CLND that justifies its morbidity and we are currently unable to identify clinical and pathologic factors that may be associated with the likelihood of benefit from CLND. Controversy regarding the management of melanoma patients with a positive sentinel node highlights the need for continued investigation in melanoma biology, treatment, and outcomes. Patients with minimal tumor burden in their regional nodes would especially benefit from a better understanding of the appropriate management strategies. Ongoing clinical trials are aimed at determining whether CLND is superior to nodal observation and surveillance in patients with positive sentinel nodes, and at determining the outcome of patients with minimal disease in their sentinel node who forego CLND. These studies may help to resolve the uncertainties of the management in these patients. Until we have further information, CLND for melanoma patients with positive sentinel nodes remains the preferred, standard management strategy.

A minority (less than 2%) of all lymphoproliferative disorders are derived from small T cells. These include T-cell prolymphocytic leukemia, T-cell granular lymphocytic leukemia, and mycosis fungoides/Sézary syndrome. With the possible exception of early-stage, skin-localized mycosis fungoides, all are considered incurable, although palliation can be achieved with radiation therapy, chemotherapy, biologic therapy, and combinations of these modalities. Of these disorders, mycosis fungoides is the most common; it follows an indolent, though gradually progressive, course that spans years. The T-cell prolymphocytic leukemias, in contrast, are generally refractory to treatment, with a median survival of typically less than 1 year. Although effective therapy remains elusive in most cases, the development of nucleosides as a class of chemotherapeutic agents and biologics, including interferon, monoclonal antibodies, and vitamin A derivatives, offers new hope for at least more effective palliation of these progressive lymphoproliferative disorders. However, rapid improvement in the treatment of these disorders remains hampered by the rarity of these individual entities. More rapid progress in treatment depends on national and international cooperation to accrue patients for definitive trials of sufficient size to evaluate new treatment options quickly.

Patients with clinically evident medullary thyroid cancer should have a total extracapsular thyroidectomy with bilateral central neck dissection and an ipsilateral prophylactic or therapeutic modified (functional) radical neck dissection when the primary tumor is greater than 1 cm and when the central neck nodes are positive. A prophylactic contralateral neck dissection should be done when the primary tumor is bilateral and when there is extensive lymphadenopathy on the side of the primary tumor. Patients who have gross, unresectable residual medullary thyroid cancer should receive postoperative external radiotherapy. Patients who are carriers of germ-line RET proto-oncogene point mutations or have an elevated (basal or stimulated) calcitonin levels on screening should have a prophylactic total thyroidectomy before age 6 years. In patients with an elevated basal or stimulated plasma calcitonin level and an intrathyroidal nodule on ultrasound, a total thyroidectomy and central neck lymph node dissection should be done. Patients with persistent or recurrent medullary thyroid cancer should have a complete thyroidectomy (if not done initially) and bilateral central and modified radical neck dissection, including upper mediastinal lymphadenectomy. Patients who are symptomatic from distant medullary thyroid cancer metastases (diarrhea, flushing, weight loss, or bone pain) should be treated with somatostatin analogs. Bone metastases should be resected if possible, and symptomatic lesions that are unresectable should be treated with external radiotherapy. Cytoreductive procedures such as radiofrequency ablation or cryoablation for liver metastases should be considered in symptomatic patients to reduce tumor burden. Localized pulmonary metastases should be resected. Chemotherapy or radioactive immunotherapy (iodine 131 labeled carcinoembryonic antigen monoclonal antibody) protocols should be considered in patients with nonoperative widely metastatic progressing medullary thyroid cancer.

Epigenetic mutations are frequent and pathogenic in select subtypes of lymphoma, and agents modulating DNA and histone methylation—such as inhibitors of DNMT and EZH2, respectively—have demonstrated promise in treating these diseases. In particular, lymphomas derived from the germinal center—GC-DLBCL, FL, and AITL—are all characterized by epigenetic derangements. In an effort to target these derangements, DNMT inhibitors have been investigated as a means of improving responsiveness to chemotherapy in DLBCL patients, or as monotherapy or in combination with other epigenetic agents in the treatment of TCL. Histone methyltransferase inhibitors have demonstrated effectiveness in R/R FL patients with EZH2-activating mutations. New treatment options that target the pathogenesis of disease are needed. HDAC inhibitors have been in the clinic for over a decade for the treatment of lymphoma, and now methyltransferase inhibitors are finding their niche for this disease.

Care delivery innovation is necessary to address the growing complexity of cancer care across specialties and integrate new diagnostics, treatments, and services into care delivery. Informed by Cancer Care Delivery Research (CCDR), multilevel intervention research, and other disciplines, this article describes the 4-step cancer care delivery innovation cycle. The cycle guides collaborative efforts of cancer clinicians, researchers, patients, and other stakeholders to systematically define care delivery problems and formulate, test, and implement care innovations to effectively address problems. We illustrate the 4 steps of the innovation cycle with the example of developing the 4R Oncology Model for colorectal cancer (4R is Right Information and Right Care for the Right Patient at the Right Time). The 4R is a multilevel intervention informed by CCDR, the team science, and lessons learned from other models, such as survivorship care planning. We offer additional considerations for balancing the need to innovate with concerns about constrained resources and overextended workforce. We suggest to focus on care delivery models which are synergistic with other efforts and do not require extensive information systems support in earlier cycles of development.

State-of-the-art treatment for advanced ovarian cancer requires a multimodality approach. Aggressive surgical debulking with the goal of optimal cytoreduction is the initial step. After primary cytoreductive surgery, standard treatment for patients with stage III and IV disease is systemic combination chemotherapy consisting of six cycles of paclitaxel and carboplatin. Approximately 70% of patients enter a clinical remission with this approach, yet less than 30% remain disease free. Options following primary therapy include observation or second surgical assessment if no clinical evidence of disease is present. Novel strategies for consolidation are needed. Second-look surgery can be performed safely and effectively laparoscopically, and this is the most accurate means of identifying patients who appear to be clinically free of disease but actually harbor persistent cancer. Although this procedure is an extremely accurate means of identifying these patients, women who have pathologically negative second-look surgery are still at risk for relapse. Patients can receive additional treatment following second-look surgical assessment via the intraperitoneal route if they are pathologically negative or if they have microscopic or small volume disease. Alternatively, additional systemic chemotherapy can be given with non-cross-resistant systemic agents, but no current standard approach for consolidation therapy exists for patients following the completion of primary treatment. Unfortunately, most patients relapse. Multiple agents with similar activity in phase II trials are available to treat patients with advanced recurrent disease. Combination therapy in this setting has not been shown to have significantly superior progressionfree or overall survival compared with single agents. The selection of treatment for patients with recurrent disease is currently based on a determination of the treatmentfree interval since last treatment, as well as the route, schedule, and expected side effects of the agent.