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Current Management of Unusual Genitourinary Cancers: Part IIOften overshadowed by more common genitourinary cancers, such as prostate, testicular, and kidney cancers, penile and urethral cancers nonetheless represent difficult treatment challenges for the clinician. The management of these cancers is slowly evolving. In the past, surgery, often extensive, was the treatment of choice. Recently, however, radiation and chemotherapy have begun to play larger roles as initial therapies, with surgery being reserved for salvage. With these modalities in their treatment armamentarium, oncologists may now be able to spare patients some of the physical and psychological sequelae that often follow surgical intervention without compromising local control and survival. Part 1 of this two-part article, published in last month’s issue, dealt with cancer of the penis. This second part focuses on cancer of the urethra in both females and males. [ONCOLOGY 13(11):1511-1520, 1999]
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Imagery and Hypnosis in the Treatment of Cancer PatientsMany patients with cancer often seek some means of connecting their mental activity with the unwelcome events occurring in their bodies, via techniques such as imagery and hypnosis. Hypnosis has been shown to be an
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Contemporary Management of Locally Invasive Bladder CancerMuscle-invasive bladder cancer is an aggressive and potentially lethal disease. Integration of multimodal therapies, improved surgical techniques, and utilization of targeted agents has tremendously improved outcomes.
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Man With Locally Advanced, High-Risk Prostate Cancer Asks About Adding Chemotherapy to His TreatmentA 55-year-old Hispanic male presents with a family history of gastric cancer in one sibling and prostate cancer in an older brother. CT performed in March 2015 for IMT surveillance showed a heterogeneous prostate with local invasion involving the bladder, seminal vesicles, and perirectal fat.
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Is Personalized Medicine Here?This review describes the achievements in therapeutic and molecular diagnostics, details evolving molecular platforms, and highlights the challenges for the translation of these developments to daily clinical practice.
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Commentary (Cruciani/Portenoy)-Opioid Rotation in Cancer Patients: Pros and ConsOpioid rotation is now consideredstandard practice in themanagement of cancer pain.The rationale for the approach hasbeen well summarized by Estfan andcolleagues. Rotation should be viewedas one strategy among many to dealwith patients who demonstrate relativelypoor responsiveness to an opioid.[1] Application of well acceptedclinical guidelines for opioid administration,beginning with those originallypromulgated by the WorldHealth Organization,[1] emphasizethe need to individualize the opioiddose through a process of gradualdose titration, irrespective of the specificdrug. Most cancer patients attainan adequate balance betweenanalgesia and side effects, at leastinitially. Some, however, experiencetreatment-limiting toxicity, the sinequa non of “poor responsiveness.”This response reflects an outcome thatis related to a specific drug, route ofadministration, set of patient-relatedvariables, and time.
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Management of Fungal and Viral Infections in Cancer PatientsWith the advent of modern therapeutic and prophylactic regimens, bacterial infections have become more effectively controlled, while fungal and viral infections have emerged as more prominent complications in the management of immunocompromised patients.
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A Case of Merkel Cell CarcinomaThe University of Colorado Health Sciences Center holds weekly second opinion conferences focusing on cancer cases that represent most major cancer sites. Patients seen for second opinions are evaluated by an oncologist. Their history, pathology, and radiographs are reviewed during the multidisciplinary conference, and then specific recommendations are made. These cases are usually challenging, and these conferences provide an outstanding educational opportunity for staff, fellows, and residents in training.
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Management of Tumors of the Parapharyngeal SpaceBenign and malignant tumors can arise from any of the structures contained within the parapharyngeal space. Such tumors are very rare, however. Also, malignant tumors from adjacent areas (eg, the pharynx) can extend into the parapharyngeal space by direct growth, or distant tumors may metastasize to the lymphatics within the space. Although the history and physical examination can provide clues to the site of origin and nature of a parapharyngeal space tumor, imaging studies are more useful for defining the site of origin and extent of the mass, as well as its vascularity and relationship to the great vessels of the neck and other neurovascular structures. Surgery is the mainstay of treatment. The surgical approach chosen should facilitate complete tumor extirpation with minimal morbidity. Irradiation is administered as primary therapy in patients with unresectable tumors, poor surgical candidates, and selected other patients. Radiation therapy is also used after surgery for high-grade malignancies or when wide surgical margins cannot be achieved. [ONCOLOGY 11(5):633-640, 1997]
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Commentary (Munarriz): Sexual Health Issues in Men With CancerWhile the cancer patient may be affected by sexual dysfunction throughout the entire course of the disease, sexual health is largely underevaluated and undertreated. Sexual problems should be anticipated and patients should be actively screened as they are unlikely to initiate discussion on sexual issues.
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The War on WasteReal healthcare reform would address these socioeconomic realities. Instead, the US is waging a regulatory “war” on exaggerated measures of waste, one that shows little promise of reducing costs or increasing quality but will assuredly crush “needed innovation by practicing physicians, who best understand the delivery of care.”
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Role of Interferon-Alfa in NHL: Still Controversial?The malignant lymphomas are among the most responsive of neoplastic disorders. Objective tumor shrinkage has been seen after therapy with virtually all classes of chemotherapeutic agents, including alkylating agents, antimetabolites, vinca alkaloids,
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Acute Myeloid Leukemia: The Challenge of Unfavorable CytogeneticsPrognostic factors in acute myeloid leukemia (AML) may be subdivided into those related to patient characteristics and general health condition, and those related to characteristics of the tumor.
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BMT for Severe Autoimmune Diseases: An Idea Whose Time Has ComeStudies of hematopoietic stem-cell transplantation as a treatment for severe autoimmune diseases (SADS) are currently in progress. Dr. Burt thoroughly reviews the rationale for these studies. It includes: (1) preclinical studies showing that marrow transplantation is an effective therapy in animal models of autoimmune disease; (2) observations of the effect of stem-cell grafts on SADS in patients transplanted for other indications; and (3) improvements in the safety of the transplant procedure.
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Management of Asymptomatic Rising PSA After Prostatectomy or Radiation TherapyControversy exists over the optimal management of patients with an asymptomatic rising prostate-specific antigen (PSA) following definitive therapy for clinically localized prostate adenocarcinoma.
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Pregnancy After Breast Cancer: From Psychosocial Issues Through ConceptionWomen face numerous issues if they either contemplate childbearing or become pregnant after the diagnosis of breast cancer. Based on a search of the English medical literature from 1966 to 1997, we make the following
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Breakthrough Pain in Cancer Patients: Characteristics, Prevalence, and Treatment"Breakthrough pain" is a common clinical term that has not been conclusively defined or described. Breakthrough pain is a transitory flare of pain experienced when baseline pain has been reduced to a mild or moderate level.
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A Young Woman With Distant Recurrent Metastatic Primary Vaginal Carcinoma Salvaged With Radical RadiotherapyPrimary carcinoma of the vagina accounts for 1% to 3% of all gynecologic malignancies, with 70% of cases occurring in women over age 60.[1] Hematogenous dissemination is rare at diagnosis but is more common in patients with advanced, neglected lesions.
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Can HNPCC Be Diagnosed in Presymptomatic Patients?This special series on cancer and genetics is compiled and edited by Henry T. Lynch, MD, director of the Hereditary Cancer Institute and professor of medicine and chairman of the Department of Preventive Medicine and Public
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Commentary (Frazee)-Stereotactic Breast Biopsy: Indications and ResultsMethods for detecting breast cancer are evolving as new technology provides a wider range of options for screening and definitive diagnosis. In addition to mammography and physical examination, screening techniques now include ultrasonography, technetium-99m sestamibi nuclear scanning, and magnetic resonance imaging.
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Deemphasize Dogma: Consider the Local Control–Overall Survival LinkAuthors Winkfield and Harris kindly submit to the reader an article that reemphasizes the link between local control (LC) and overall survival (OS).
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SBRT Effective in Lung Cancer Patients 80 and OlderThis video examines the safety and efficacy of definitive stereotactic body radiation therapy in patients 80 and older with inoperable, early-stage lung cancer.
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Nonmyeloablative Preparative Regimens for Allogeneic Hematopoietic TransplantationHigh-dose myeloablative therapy with allogeneic hematopoietictransplantation is an effective treatment for hematologic malignancies,but this approach is associated with a high risk of complications.The use of relatively nontoxic, nonmyeloablative, or reduced-intensitypreparative regimens still allows engraftment and the generation ofgraft-vs-malignancy effects, is potentially curative for susceptiblemalignancies, and reduces the risk of treatment-related morbidity.Two general strategies along these lines have emerged, based on theuse of (1) immunosuppressive chemotherapeutic drugs, usually apurine analog in combination with an alkylating agent, and (2) lowdosetotal body irradiation, alone or in combination with fludarabine(Fludara).
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Epidermal Growth Factor Receptor Inhibitors for the Treatment of Epithelial Ovarian CancerThe majority of patients with ovarian cancer, especially those whopresent with stages IIIC and IV, will relapse soon after completion ofplatinum-based induction treatment. It is imperative to find ways to improveand/or enhance the efficacy of induction and to prolong the durationof the first remission. The epidermal growth factor receptor (EGFR)family has been exploited, and currently, three agents that directly targetthis group of receptors are in use in the treatment of colorectal,non–small-cell lung and breast cancers. EGFR and HER2/neu areoverexpressed in a significant percentage of epithelial ovarian cancers.Thus, it would be reasonable to explore directly targeted therapyin ovarian cancer. Numerous investigational trials involving a varietyof EGFR inhibitors in ovarian cancer are ongoing. Our institution hasan active phase II clinical study that seeks to define the role of erlotinib(Tarceva) in potentiating first-line chemotherapy, and to determinewhether the drug offers a significant contribution as maintenancetherapy. It is hoped that data from these and other studies will helpinvestigators to understand more clearly the biology of ovarian cancerand to delineate the role of EGFR inhibitors in the management ofovarian cancer.
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Commentary (Cumberlin): An Overview of Radiotherapy Trials for the Treatment of Brain MetastasesThe author gives a comprehensive review of the literature on the treatment of brain metastasis by radiation therapy. His emphasis is on randomized trials, the most extensive and comprehensive of which are those conducted by the Radiation Therapy Oncology Group (RTOG). This commentary will provide some amplification of the data presented in the review.
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Prognostic Value of Low Tumor Burden in Patients With MelanomaIn this article, we review the role of baseline tumor size in response and survival on traditional and contemporary therapies for the treatment of locoregional and distant melanoma recurrences.
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Current Clinical Trials of FenretinideFenretinide (N-4-hydroxyphenyl-retinamide, or 4-HPR) is a semisynthetic retinoid that was initially developed as a low-dose chemopreventative agent.[1-3] Unlike other naturally occurring retinoids such as all-trans, 13-cis, and 9-cis retinoic acids, fenretinide does not induce systemic catabolism that interferes with the maintenance of effective plasma levels during long-term use. This characteristic, combined with the agent’s low toxicity and its ability to block aspects of carcinogenesis, provided the rationale for the development of fenretinide in lower doses as a chemoprevention agent for breast, prostate, and bladder cancer.
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Autologous Transplantation: Basic Concepts and ControversiesHigh-dose chemotherapy (HDCT) with autologous stem-cell is effective against a wide range of malignant diseases. This approach is increasingly used for treating hematologic malignancies and selected solid tumors. Since 1990, the number of autologous transplantations has exceeded the number of allogeneic transplantations.
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Maintenance Therapy for Superficial Bladder CancerTransurethral resection remains the standard for first-line treatment of transitional cell carcinoma of the bladder. This technique clearly defines the pathologic grade and is essential in determining the clinical stage of
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Hereditary Cancer Litigation: A Status ReportDr. Severin's article is a valuable asset for the practitioner--legal or medical--or academician concerned with the burgeoning of civil lawsuits over failure to comply with new approaches to the management and control of cancer. The article identifies two types of such suits and explores the history of medical malpractice litigation relating to cancer care. The focus is the physician who either misses or fails to make a timely diagnosis of hereditable cancer.
