When managing nonseminomatous germ cell tumors, contralateral lung abnormalities ≤ 10 mm can be observed if histology of unilateral PM demonstrates complete tumor necrosis. 17. When managing nonseminomatous germ cell tumors, PM is indicated for select patients with limited number of lung abnormalities after first or second-line platin-based chemotherapy suspected of containing viable nonseminomatous cancer and/or malignant transformation of teratoma into non-germ cell cancer. 18. In breast cancer patients, PM can be considered within a MDT construct. Pulmonary metastasectomy literature characteristics Since 1980, greater than 1000 publications addressed pulmonary metastasectomy, without a single randomized controlled trial (RCT). The overwhelming majority is surgical series, usually single institution, and includes single or multiple pathologies. The pool of patients from which metastasectomy patients derive is not reported, allowing no comparative survival analysis. Historical controls are used or metastatic disease survival is assumed to be zero, a contention not supported by the literature. Yet metastasectomy is infrequently performed (1-6.5%) when sizable populations of cancer patients are reported. [1-3] Thus surgical case series manifest inherent selection bias and do not clarify the role of metastasectomy in prolongation of survival or cure. The literature is further hampered by inconsistent or absent description of other local or systemic therapies and variable length of follow up. Finally, the literature fails to distinguish between prognostic (indolent disease which will do well with any or no treatment) or predictive

Introduction RTOG-0937 is a randomized phase-II trial evaluating 1-year OS with PCI or PCI plus consolidative radiation therapy (cRT) to intra-thoracic disease and extracranial metastases for ED-SCLC. Methods Patients with 1–4 extracranial metastases were eligible after CR or PR to chemotherapy. Randomization was to PCI or PCI+cRT to the thorax and metastases. Original stratification included PR vs CR after chemotherapy and 1 vs 2–4 metastases; age < 65 vs ≥ 65 was added after an observed imbalance. PCI was 25GY/10 fractions. cRT was 45GY/15 fractions. To detect an OS improvement from 30% to 45% with a 34% hazard reduction (HR=0·66) under a 0.1 type-1 error (1-sided) and 80% power, 154 patients were required. Results Ninety-seven patients were randomized between March, 2010 and February, 2015. Eleven patients were ineligible (nine PCI, two PCI+cRT), leaving 42 randomized to PCI and 44 to PCI+cRT. At planned interim analysis the study crossed the futility boundary for OS and was closed prior to meeting accrual target. Median follow-up was 9 months. One-year OS was not different between the groups: 60.1% [95% CI: 41.2–74.7%] for PCI and 50.8% [95% CI:34.0–65.3%] for PCI+cRT (p=0.21). Three and 12-month rates of progression were 53.3% and 79.6% for PCI, and 14.5% and 75% for PCI+cRT. Time to progression favored PCI+cRT, HR=0.53 (95% CI: 0.32–0.87, p=0.01). One-patient in each arm had Grade-4 therapy related toxicity and one had Grade-5 therapy related pneumonitis with PCI+cRT. Conclusions OS exceeded predictions for both arms. Consolidative RT delayed progression but did not improve 1-year OS.

Bleeding is a common problem in cancer patients, related to local tumor invasion, tumor angiogenesis, systemic effects of the cancer, or anti-cancer treatments. Existing bleeds can also be exacerbated by medications such as bevacizumab, nonsteroidal anti-inflammatory drugs (NSAIDs), and anticoagulants. Patients may develop acute catastrophic bleeding, episodic major bleeding, or low-volume oozing. Bleeding may present as bruising, petechiae, epistaxis, hemoptysis, hematemesis, hematochezia, melena, hematuria, or vaginal bleeding. Therapeutic intervention for bleeding should start by establishing goals of care, and treatment choice should be guided by life expectancy and quality of life. Careful thought should be given to discontinuation of medications and reversal of anticoagulation. Interventions to stop or slow bleeding may include systemic agents or transfusion of blood products. Noninvasive local treatment options include applied pressure, dressings, packing, and radiation therapy. Invasive local treatments include percutaneous embolization, endoscopic procedures, and surgical treatment.

Background. The management for unplanned excision (UE) of soft tissue sarcomas (STS) has not been established. In this study, we compare outcomes of UE versus planned excision (PE) and determine an optimal treatment for UE in STS. Methods. From 2000 to 2014 a review was performed on all patients treated with localized STS. Clinical outcomes including local recurrence-free survival (LRFS), progression-free survival (PFS), and overall survival (OS) were evaluated using the Kaplan-Meier estimate. Univariate (UVA) and multivariate (MVA) analyses were performed to determine prognostic variables. For MVA, Cox proportional hazards model was used. Results. 245 patients were included in the analysis. 14% underwent UE. Median follow-up was 2.8 years. The LR rate was 8.6%. The LR rate in UE was 35% versus 4.2% in PE patients (p < 0.0001). 2-year PFS in UE versus PE patients was 4.2 years and 9.3 years, respectively (p = 0.08). Preoperative radiation (RT) (p = 0.01) and use of any RT for UE (p = 0.003) led to improved PFS. On MVA, preoperative RT (p = 0.04) and performance status (p = 0.01) led to improved PFS. Conclusions. UEs led to decreased LC and PFS versus PE in patients with STS. The use of preoperative RT followed by reexcision improved LC and PFS in patients who had UE of their STS.