Management of N0 neck in head and neck cancer: current controversies.

Squamous cell carcinomas of the upper aerodigestive tract are characterized by a high frequency of lymphogenic metastatic spread. The neck should be included in the treatment concept because almost 25% of all patients develop occult lymph node metastases. The only exception are early carcinomas of the lower lip and the vocal cords. Since currently for high risk patients no prognostic markers or other factors for occult metastatic spread are available, treatment strategies have to include the exact knowledge of direction and extent of regional lymphatic drainage. Based on this prerequisite, concepts for selective cervical lymph node dissection in case of the clinical N0 situation were developed which may also be used for an individually optimized radiotherapy. Intensity modulated radiotherapy (IMRT) bears a high potential for an optimized irradiation in case of potential occult metastatic spread of carcinomas of the upper aerodigestive tract. Without compromising local control rates IMRT allows a considerable reduction of permanent xerostomia by sparing at least one major salivary gland. The significant scientific purpose for the N0 neck, however, will remain the identification of high-risk patients, e.g. by means of tissue and/or serum-related markers, which carry a high risk of local and distant metastases.

The role of radiation therapy in the management of gastric cancer.

Gastric cancer continues to be one of the most important gastrointestinal cancers. Despite improved surgery and resection rates of 30%-60% still most of the patients die of loco-regional recurrence or distant metastasis. The role of adjuvant and palliative treatment of gastric cancer has world-wide been assessed in uncontrolled and prospective studies. Many of those were insufficient with respect to the number of patients and inclusion of prognostic factors as stratification criteria. Furthermore, the radiation oncologist would have preferred if these studies had looked at loco-regional tumor control instead of response rates or overall survival. A comprehensive overview of the currently available data for radiation therapy in adjuvant and palliative treatment schedules of gastric cancer is given and the limits of these studies are critically discussed. Until now, there is no clear evidence of improved overall survival from the addition of radiation therapy. However, the data suggest radiation therapy might be an effective measure to reduce loco-regional recurrence rates and similarly increase the recurrence-free survival. For the next future, optimally designed phase III trials with sufficient numbers of patients should be initiated to assess the definite value of radiation therapy for gastric cancer.