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The current health-care environment is creating many new challenges for physicians, and addressing these challenges has led to new ideas in office practice management.

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Gallbladder carcinoma and carcinoma of the bile ducts are relativelyrare cancers in the United States. These cancers are often diagnosedin an advanced stage due to their nonspecific symptomatologyand until recently have been associated with a dismal prognosis. Recentadvances in imaging and surgical techniques along with emergingoptions in palliative chemotherapy have improved the outlook inthese cancers. While complete surgical resection remains the only hopeof cure in both these cancers, palliative biliary decompression and chemotherapyresult in substantial improvement in quality of life. Part 1 ofthis review, which appeared in last month’s issue, provided a relevantand comprehensive update of molecular pathology, imaging modalities,and surgical care. In part 2, we examine palliative care and systemictherapy in gallbladder and biliary tract carcinomas, as well asthe use of liver transplantation in the treatment of cholangiocarcinomas.These strategies are of relevance to internists as well as oncologistscaring for these patients.

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Active surveillance is an excellent alternative to surgery or radiation in patients with low-risk cancers. However, the current methods of ascertaining whether a patient harbors a low-risk cancer are flawed.

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Primary systemic therapy (ie, preoperative or neoadjuvant) increasesthe possibility for breast-conserving surgery in patients with primarybreast cancer. Patients with pathologic complete response to primarysystemic therapy have improved survival compared with those with persistenttumors. Several phase II trials have evaluated gemcitabine-containingdoublet or triplet regimens as primary systemic therapy for breastcancer, results of which have shown promising clinical and pathologicresponse rates with manageable toxicity. Results of a phase I/II studyof gemcitabine (Gemzar)/epirubicin (Ellence)/docetaxel (Taxotere), orGEDoc, with prophylactic filgrastim (Neupogen), as primary systemictherapy in 77 evaluable patients with primary breast cancer are reportedherein. Dose-limiting toxicities were grade 3 febrile neutropenia(n = 1) and grade 3 diarrhea (n = 2) at the fourth dose level ofGEDoc tested (gemcitabine at 800 mg/m2 days 1 and 8, epirubicin at90 mg/ m2 day 1, and docetaxel at 75 mg/m2 day 1). As assessed byultrasound, 92% of patients responded overall (22% complete response),and 79% of patients could undergo breast-conserving surgery. Thepathologic complete response rate in resected breast tissue was 26%.

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Early-stage Hodgkin’s disease accounts for approximately 60% of all cases of the illness. Because of its excellent cure rate (80% to 90%) and high salvage rate, it is difficult to demonstrate survival advantages for

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Estrogen is known to play an important role in skeletal health. Femalebreast cancer patients who receive treatments that reduce estrogenlevels, such as aromatase inhibitors, may increase their risk of developingosteoporosis and their risk of fracture. Clinical guidelinesenable the physician to assess the risk of osteoporosis by patient historyand physical examination. For patients identified as being at risk, it isnecessary to test bone mineral density (BMD), using the result to determinewhich patients require treatment. Two groups can be identified asrequiring BMD assessment according to general guidelines: patients< 45 years old who become menopausal due to treatment, and breastcancer patients receiving aromatase inhibitors. Bisphosphonates appearto be the logical treatment of choice for breast cancer patients, asthey do not interact with the estrogen receptor. Although not all womenreceiving aromatase inhibitors will require additional treatment for bonehealth, postmenopausal women with a history of breast cancer at riskof osteoporosis should be identified, monitored, and managed accordingto practice guidelines.

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This video reviews the treatment of mantle cell lymphoma cases that do not fit the typical mold.

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The indolent non-Hodgkin's lymphomas constitute a heterogeneous group of lymphoproliferative disorders usually associated with relatively prolonged survival. They are categorized based on pathologic and cytologic features, and, with few exceptions [1], they are almost exclusively of B-cell origin.

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Although resection currently remains the standard of care for renalcarcinoma, the search for less invasive treatments has led to alternativesurgical approaches. Even less invasive, and appropriate for manygroups of patients, is percutaneous radiofrequency ablation, which inducestumor necrosis via lethal hyperthermia. Multiple series of renaltumors treated with percutaneous ablation in vivo and left in situ havebeen published; these series reveal that for small renal tumors,radiofrequency ablation results in complete necrosis at imaging in 79%to 100% of cases. Because current results come from tumors left in situwith short postablation follow-up, long-term results are necessary tocompare outcomes to surgical standards. Complication rates are lowerthan those following partial nephrectomy. Future reports will shed lighton the long-term outcomes of percutaneous ablation and the relativeadvantages and disadvantages of various technologies for thermal ablation.

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Conservation of blood is apriority during surgery, owingto shortages of donor bloodand risks associated with transfusionof blood products.[9,10] However,blood transfusions have been linkedto a number of negative postoperativesequelae, including poorer prognosisafter cardiac and cancer surgery.[11-21] In this context, recognition thatallogeneic transfusion-associatedimmunomodulation can increasemorbidity in allogeneically transfusedpatients has become a major concernin transfusion medicine.[9,22,23]

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From the results of recent studies, it is likely that multimodality therapy with chemotherapy and radiation treatment may improve the overall outcome of locally advanced upper gastrointestinal (GI) malignancies, including esophageal, gastric, pancreatic, and biliary tract carcinomas. However, more effective, more optimal, and less toxic chemotherapy regimen(s) with concomitant radiotherapy are needed beyond the concurrent continuous-infusion fluorouracil (5-FU) with radiation that is commonly applied in general practice. Epirubicin (Ellence), cisplatin, and irinotecan (Camptosar) are all active cytotoxic chemotherapy agents in upper GI cancers. Two phase I studies were designed to test the tolerability of the combination of radiotherapy with infusional 5-FU, epirubicin, and cisplatin (ECF) or 5-FU, irinotecan, and epirubicin (EIF) in the treatment of locally advanced upper GI malignancies.

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Focal therapy is an appealing addition to our current AS strategies. As a “lesser evil,” focal therapy is showing promise as a therapy that can provide cancer control, while also avoiding many of the radical treatment–associated morbidities.

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Breast cancer is second only to lung cancer as a leading cause of cancer mortality in women. In women with metastatic, hence, essentially incurable disease, we strive to find effective chemotherapeutic regimens that offer a

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The relatively recent introduction of a new class of chemotherapeutic agents--the taxoids--has raised hope of improved survival for patients with advanced or metastatic cancer. Following encouraging preclinical results of taxoid combinations, this phase I, nonrandomized trial was designed to evaluate a 1-hour intravenous infusion of docetaxel (Taxotere) on day 1 combined with fluorouracil (5-FU) as a daily intravenous bolus for 5 consecutive days.

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A number of randomized clinical trials and meta-analyses now support the conclusion that combined modality regimens that include cisplatin (Platinol)-based chemotherapy improve survival in stage III non–small-cell lung

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Vascular endothelial growth factor (VEGF) plays a crucial role inthe growth and metastatic spread of cancer. Bevacizumab (Avastin) isthe first commercially available VEGF inhibitor, earning US Food andDrug Administration (FDA) approval in February 2004. In combinationwith fluorouracil (5-FU)-based chemotherapy, this agent significantlyprolongs overall and progression-free survival of patients withmetastatic colorectal cancer. This review details the emerging role ofthe drug, its unique side effects, and other practical considerations relatedto bevacizumab therapy. Ongoing trials attempting to define additionalindications for bevacizumab as well as the development ofother promising angiogenesis inhibitors are also reviewed.

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Michael H. Levy, MD: This 38-year-old white male first came to his physician in January of 1993 complaining of epigastric and low back pain. In March of 1993, he was diagnosed with pancreatic cancer that was metastatic to his

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The past 30 years have seen tremendous advances in the treatment of pediatric leukemia. What was once an invariably fatal diagnosis is now quite curable in close to 80% of cases. Unfortunately for children with acute myelogenous leukemia (AML), most of these developments have been in the treatment of acute lymphoblastic leukemia (ALL); even today, nearly half of all children diagnosed with AML will die of the disease.

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This is an expertly written summary of the experience with cryotherapy as primary treatment of prostate cancer and the rationale for proceeding toward more limited, organ-sparing approaches with this procedure as focal treatment for low-risk cancers. Growing evidence of overdetection and overtreatment in many men with low-risk tumors has resulted in the recognition that alternatives to conventional treatment strategies are needed. Observation, a laudable and appropriate approach, appeals to relatively few patients.

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Genome-wide association studies (GWAS) have emerged as a new approach for investigating the genetic basis of complex diseases. In oncology, genome-wide studies of nearly all common malignancies have been performed and more than 100 genetic variants associated with increased risks have been identified. GWAS approaches are powerful research tools that are revealing novel pathways important in carcinogenesis and promise to further enhance our understanding of the basis of inherited cancer susceptibility. However, “personal genomic tests” based on cancer GWAS results that are currently being offered by for-profit commercial companies for cancer risk prediction have unproven clinical utility and may risk false conveyance of reassurance or alarm.

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This review focuses on the underlying rationale for the use of cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CS + HIPEC) in the treatment of patients with primary gastrointestinal tumors with metastatic peritoneal disease.

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The soft-tissue sarcomas are a group of rare but anatomically and histologically diverse neoplasms. This is due to the ubiquitous location of the soft tissues and the nearly three dozen recognized histologic subtypes of soft-tissue sarcomas.

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We investigated the incidence of micrometastases from squamous cell carcinomas of the head and neck in neck dissection specimens originally staged as pN0. A total of 76 dissection specimens from 60 patients were

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Closing out their panel on advanced bladder cancer management, key opinion leaders share their excitement for future evolutions within the treatment landscape.

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This video covers the latest research in pancreatic cancer, including the possible role of PARP inhibitors, immunotherapy, and the novel drug PEGPH20.

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Treatment of fever and neutropenia in cancer patients has been recognized for 30 years as a medical emergency, requiring prompt in-hospital evaluation and institution of broad-spectrum intravenous (IV) antibiotics. This action

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Dr Castellanos et al have provided a very comprehensive review of the multimodality therapy of localized pancreatic cancer, with an emphasis on adjuvant and neoadjuvant therapies.

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Over the past 2 decades, our understanding of the pathobiological events underlying chronic myelogenous leukemia (CML) has grown. At the same time, effective transplant and nontransplant treatment approaches to

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Chemotherapy has been shown to prolong survival in patients with stage IV non-small-cell lung cancer (NSCLC). However, traditional cisplatin (Platinol)-containing regimens are associated with significant toxicity.