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Commentary (Cohen/Glod): Current Management of Childhood EpendymomaEpendymoma is a rare central nervous system (CNS) tumor in children, and our progress in treating this disease has been hampered by its rarity as well as by a nonuniform approach to treatment among practitioners. Dr. Merchant’s comprehensive review provides a framework for plotting a course of further progress in treating children with ependymoma.
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Further Thoughts on a Rare EntityPrimary neuroendocrine neoplasms of the lung represent a clinical spectrum of tumors ranging from the relatively benign and slow-growing typical carcinoid to the highly aggressive small-cell lung carcinoma. The rarity of carcinoids has made the role of radiation therapy in their management controversial. This review considers the results of published studies to generate treatment recommendations and identify areas for future research. Surgery remains the standard of care for medically operable disease. Histology plays the most important role in determining the role of adjuvant radiation. Resected typical carcinoids likely do not require adjuvant therapy irrespective of nodal status. Resected atypical carcinoids and large-cell neuroendocrine carcinomas have a significant risk of local failure, for which adjuvant radiation likely improves local control. Definitive radiation is warranted in unresectable disease. Palliative radiation for symptomatic lesions has demonstrated efficacy for all histologies. Collaborative group trials are warranted.
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Use of Bisphosphonates in the Treatment of Prostate CancerRecently, there has been much controversy over whether patients with prostate cancer should be treated with bisphosphonates not only to decrease pain, but to prevent metastasis.
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Commentary (Wang): Endoscopic Ultrasound Fine-Needle Aspiration in the Staging of Non-Small-Cell Lung CancerPrecise mediastinal staging of non-small-cell lung cancer is extremely important, as mediastinal lymph node metastases generally indicate unresectable disease. Reliance on computed tomography (CT) and positron-emission tomography (PET) alone to stage and determine resectability is limited by false-positive results. Whenever possible, pathologic confirmation of metastases is desirable. Mediastinoscopy and transbronchial fine-needle aspiration are widely established but imperfect modalities. Endoscopic ultrasound fine-needle aspiration (EUS-FNA) has emerged as a diagnostic and staging tool because of its safety, accuracy, and patient convenience. We reviewed 13 prospective studies evaluating the comparative performance of EUS for staging lung cancer. We conclude that EUS is a valuable staging modality. Further studies of the role of EUS compared to other modalities such as integrated PET/CT and endobronchial ultrasound (EBUS) are forthcoming.
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Cisplatin, Fluorouracil, Celecoxib, and RT in Resectable Esophageal Cancer: Preliminary ResultsEsophageal cancer frequently expresses cyclooxygenase-2 (COX-2)enzyme. In preclinical studies, COX-2 inhibition results in decreasedcell proliferation and potentiation of chemotherapy and radiation. Wereport preliminary results of a phase II study conducted by the HoosierOncology Group in patients with potentially resectable esophageal cancer.All patients received cisplatin at 75 mg/m2 given on days 1 and 29and fluorouracil (5-FU) at 1,000 mg/m2 on days 1 to 4 and 29 to 32with radiation (50.4 Gy beginning on day 1). Celecoxib (Celebrex) wasadministered at 200 mg orally twice daily beginning on day 1 untilsurgery and then at 400 mg orally twice daily until disease progressionor unexpected toxicities, or for a maximum of 5 years. Esophagectomywas performed 4 to 6 weeks after completion of chemoradiation. Theprimary study end point was pathologic complete response (pCR). Secondaryend points included response rate, toxicity, overall survival, andcorrelation between COX-2 expression and pCR. Thirty-one patientswere enrolled from March 2001 to July 2002. Respective grade 3/4 toxicitieswere experienced by 58%/19% of patients, and consisted of granulocytopenia(16%), nausea/vomiting (16%), esophagitis (10%), dehydration(10%), stomatitis (6%), and diarrhea (3%). Seven patients (24%)required initiation of enteral feedings. There have been seven deathsso far, resulting from postoperative complications (2), pulmonary embolism(1), pneumonia (1), and progressive disease (3). Of the 22 patients(71%) who underwent surgery, 5 had pCR (22%). We concludethat the addition of celecoxib to chemoradiation is well tolerated. ThepCR rate of 22% in this study is similar to that reported with the use ofpreoperative chemoradiation in other trials. Further follow-up is necessaryto assess the impact of maintenance therapy with celecoxib onoverall survival.
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Whole-Genome Analyses and Circulating Tumor DNA Approaches in CancerIn this interview we discuss advances in whole-genome analyses, as well as novel blood-based assays in development to help diagnose and follow cancer patients through their treatment.
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Genetic Testing in Gastrointestinal Cancers: A Case-Based ApproachIn this article, we use a case-based approach to focus on the hereditary aspects of the most common GI cancers, including pancreatic, gastric, and colon cancer.
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Gemcitabine, Paclitaxel, and Trastuzumab in Metastatic Breast CancerA phase II trial evaluated the effectiveness and toxicity of combination paclitaxel (Taxol), gemcitabine (Gemzar), and trastuzumab (Herceptin) as first-line therapy for patients with newly diagnosed HER2-overexpressing
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ASCO: Pros/Cons of Follow-Up Imaging in LymphomaAs part of our coverage of the 2014 American Society of Clinical Oncology (ASCO) Annual Meeting, we discuss the pros and cons of follow-up imaging in lymphoma.
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Weekly Irinotecan and Concurrent Radiation Therapy for Stage III Unresectable NSCLCIn preclinical studies, the topoisomerase I inhibitor irinotecan (Camptosar, CPT-11) has demonstrated activity as a radiosensitizer, probably due to its ability to inhibit potentially lethal radiation damage repair. We conducted a
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Intravenous Itraconazole in the Management of Fungal Infections in Bone Marrow TransplantationThe frequency of major fungal infections continues to increase, whether in association with increasing numbers of patients at risk due to under lying disease or its treatment, selection pressures related to increased use of broad-spectrum antimicrobials
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Stereotactic Body Radiation Therapy as an Alternative to Surgery in Early-Stage Non–Small-Cell Lung CancerThree randomized trials of SBRT vs surgical resection closed due to poor accrual, but an analysis of patients treated in these trials suggested that SBRT might even be superior to surgery. New trials are underway to further assess the question of whether SBRT can be the definitive treatment for early-stage NSCLC instead of surgery.
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Bone marrow procedures move into the 21st centuryMore than 700,000 biopsies are performed in the U.S. every year, but the technology has not always kept pace with cancer diagnosis and therapy. A new technique allows rapid and easy access to the marrow space.
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Current Treatment of Infection in the Neutropenic PatientNeutropenia was recognized almost 3 decades ago as a major predisposing factor for the development of infection in patients with cancer [1]. The risk begins to increase when the neutrophil count drops below 1,000/mm³ and is greatest at counts of 100/mm³ or lower. At this level, approximately 20% of febrile episodes are caused by a bacteremic process [2].
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Handbook of Gynecologic OncologyHandbook of Gynecologic Oncology, edited by Drs. Barakat, Bevers, Gershenson, and Hoskins, is a first-edition clinical handbook formulated primarily for fellows in gynecologic oncology as well as for interested fellows in medical oncology and radiation oncology. The textbook presents concise summaries of the critical issues in the care of gynecologic cancer patients and would also be of interest to residents preparing for their gynecologic oncology rotations, obstetrician/gynecologists, other physicians who care for gynecologic cancer patients, and practicing gynecologic oncologists.
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Current Management of Adult T-Cell Leukemia/LymphomaAdult T-cell leukemia/lymphoma (ATL) is defined as a histologically or cytologically proven peripheral T-cell malignancy associated with a retrovirus, human T-cell lymphotropic virus type I (HTLV-1).[1] Southwestern Japan is the district with the highest prevalence of HTLV-1 infection and the highest incidence of ATL in the world. A high prevalence of HTLV-1 infection is also found in the Caribbean islands, tropical Africa, South America, and northern Oceania.
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Current Issues in the Treatment of Resistant Bloodstream InfectionsBloodstream infections cause significant morbidity and mortality for patients with hematologic malignancy. Antimicrobial drugs are the most reliable currently available treatment for infection, but several issues must be
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Androgen Deprivation Therapy: A Survival Benefit or Detriment in Men With High-Risk Prostate Cancer?Androgen deprivation therapy (ADT) has been used in the management of prostate cancer for more than four decades. Initially, hormone therapy was given largely for palliation of symptomatic metastases. Following several randomized trials of patients with intermediate- to high-risk prostate cancer that demonstrated improvements in biochemical control and survival with the addition of ADT to external beam radiotherapy, there was a dramatic increase in the use of hormone therapy in the definitive setting. More recently, the safety of ADT has been questioned, as some studies have suggested an association of hormone therapy with increased cardiovascular morbidity and mortality. This is particularly worrisome in light of practice patterns that show ADT use extrapolated to situations for which there has been no proven benefit. In the setting of dose escalation with modern radiotherapy, in conjunction with the latest concerns about cardiovascular morbidity with ADT, the magnitude of expected benefit along with potential risks of ADT use must be carefully considered for each patient.
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Intravenous Itraconazole in the Management of Fungal Infections in Bone Marrow TransplantationThe frequency of major fungal infections continues to increase, whether in association with increasing numbers of patients at risk due to under lying disease or its treatment, selection pressures related to increased use of broad-spectrum antimicrobials
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Plastic Surgery: A Component in the Comprehensive Care of Cancer PatientsPlastic surgery represents a small but critical component of the comprehensive care of cancer patients. Its primary role in the treatment of cancer patients is to extend the ability of other surgeons and specialists to more
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Irradiation in Early-Stage Breast Cancer: Conventional Whole-Breast, Accelerated Partial-Breast, and Accelerated Whole-Breast Strategies ComparedGiven their greater convenience and, in most cases, decreased costs, APBI and AWBI are becoming increasingly popular alternatives to conventional WBI for early-stage breast cancer patients who desire BCT. However, given the protracted time to local recurrence and complications following BCT, definitive results from randomized clinical trials comparing conventional WBI vs AWBI or APBI are limited.
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Translation Requires Evidence: Does Cancer-Specific CGA Lead to Better Care and Outcomes?he field of geriatric assessment is crowded by a variety of assessment domains, a plethora of assessment tools, and research spanning diverse care settings. In their article published in this issue of the journal ONCOLOGY, Schubert, Gross, and Hurria have synthesized the evidence and propose a subset of commonly used functional assessment tools for assessing older adults with cancer.[1]
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The Last-Dose-of-Chemo BluesSome patients go through the end of treatment without a hint of emotional distress. But for many others, ending acute treatment becomes an emotional “pothole” on the cancer journey.
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Psychological Complications of Prostate CancerPirl and Mello carefully review the current state of knowledge about the psychological complications of prostate cancer. Their discussion is worth reading, particularly by those who treat patients with the disease. To put this knowledge in context for the general reader, we should give some thought to what this review illustrates about all patients with a serious life-threatening illness.
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Quality-Adjusted Life-Years, Comparative Effectiveness in Cancer CareRecently, the American Recovery and Reinvestment Act (ARRA) set aside $1.1 billion for comparative effectiveness research (CER) to investigate what healthcare strategies and interventions offer the greatest benefits to individual patients and the population as a whole. The Institute of Medicine has identified CER in cancer care as a high priority research focus for ARRA funding. The ability to measure quality of life will be central to CER in oncology because survival and disease-free survival do not adequately capture outcomes important to policy makers, physicians, and patients. There are two ways to measure quality of life: descriptive health status and patient preference weights (utilities). However, only patient preference weights can be incorporated into the economic analysis of medical resources and be used in the calculation of quality-adjusted life-years (QALYs). Some of the advantages and limitations inherent in measuring quality of life with descriptive health status and patient preference weights are discussed. Both types of measurements face health literacy barriers to their application in underserved populations, an important concern for CER in all medical fields.
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Commentary (Stenson): Indications for Selective Neck Dissection: When, How, and WhySelective neck dissection is a procedure that is primarily indicated in patients with clinically negative nodal disease in which there is a high risk of occult metastases. Others have advocated its use for patients with
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Continuous Low-Dose GM-CSF as Salvage Therapy in Refractory Recurrent Breast or Female Genital Tract CarcinomaGranulocyte-macrophage colony-stimulating factor (GM-CSF,sargramostim [Leukine]) is a powerful cytokine that is able to stimulatethe generation of dendritic cells. Adjuvant treatment with continuous lowdoseGM-CSF has been shown to prolong survival of stage III/IV melanomapatients. Data on continuous low-dose GM-CSF therapy in tumorsother than prostate cancer are still lacking.
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Optimizing the Benefit of CNS Radiation Therapy in the Pediatric Population-PART 1: Understanding and Managing Acute and Late ToxicitiesMinimizing late treatment toxicities in these patients remains an important priority due to both the young age of the patients and the high cure rate that can be achieved.
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Performing Economic Evaluations Alongside of Cancer Clinical TrialsHealth care providers and financing organizations have become more aware of the resource constraints on the provision of medical services, thus increasing the importance of economic evaluations within the health care industry.[1,2] This has carried over to the evaluation of new, therapeutic strategies for cancer, which have traditionally been evaluated exclusively for safety and clinical efficacy.
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The Past, Present, and Future of Melanoma TherapyWe will absolutely need to continue our endeavors to evaluate reliable predictive biomarkers for both targeted drugs and immunotherapeutic agents to achieve a truly personalized melanoma therapy with the maximal clinical benefit.
