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Commentary (Taub): Surgical Treatment of Metastatic Pulmonary Soft-Tissue SarcomaIn their literature survey, Drs. Chao and Goldberg reach the conclusion that surgical metastasectomy is the clear treatment of choice and should be the standard of care for patients with pulmonary recurrences of soft-tissue sarcoma. It is assumed that survival without this operation is negligible, even while there are no survival statistics for sarcoma patients who are eligible for metastasectomy and who choose to forgo this option.
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Enhanced Recovery After Surgery for Ovarian Cancer PatientsIn this interview we discuss the idea behind an enhanced recovery program for patients undergoing cytoreductive surgery for ovarian cancer, as well as some of the potential cost savings.
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Patterns of Chemotherapy Administration in Patients With Intermediate-Grade Non-Hodgkin’s LymphomaRecords from 653 patients treated between 1991 and 1998 in the Oncology Practice Patterns Study (OPPS) were analyzed to determine contemporary chemotherapy delivery patterns in patients with intermediate-grade non-
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The Legacy of Intraperitoneal Therapy in Ovarian Cancer: Why Are We Never Satisfied With the AnswerThe evidence suggests that few centers offer IP therapy routinely. Why? The answer may be that oncologists simply don’t know what to do. There have been three completely distinct regimens, none of which has been used in the outpatient setting.
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Commentary (Huben): Management of Asymptomatic Rising PSA After Prostatectomy or Radiation TherapyAs the number of cases of newly diagnosed prostate cancer has risen dramatically in the United States during the past decade, the management of a rising prostate-specific antigen (PSA) level following definitive therapy has become an increasingly common dilemma. Waxman and associates provide a concise, focused review of many of the key issues and controversies surrounding this dilemma. Several of these issues warrant particular attention.
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DNA Ploidy and Cell Cycle Analysis in Cancer Diagnosis and PrognosisThe article by Dr. Ross provides an overview of the current status of the medical literature regarding the role of DNA ploidy and cell cycle analysis in cancer diagnosis and patient prognosis. The scope of the article is quite broad, covering virtually every organ system and, as such, provides only a brief summary of the data in each diagnostic category. From these data, there is general agreement about the value of detection of aneuploidy in tumor specimens but a lack of consensus about the importance of cell proliferation analyses, such as S-phase fraction (SPF) measurements. This conclusion reflects the inherent variability in the two determinations. Detection of aneuploidy by analytic cytometry is reliable; it is accurate and depends upon the specimen (frozen vs formaldehyde- fixed, presence of necrosis, cellularity) as well as the quality of specimen preparation. Thus, DNA ploidy analysis can easily be standardized, minimizing intralaboratory variation. Cell cycle analysis, however, is more complex and as yet is not standardized.
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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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Neoadjuvant Therapy for Hepatocellular Carcinoma: Is There An Optimal Approach?Hepatocellular carcinoma (HCC) is an aggressive tumor that often occurs in the setting of chronic liver disease and cirrhosis. The incidence of hepatocellular carcinoma is increasing in the United States and worldwide. Orthotopic liver transplantation (OLT) is a viable and potentially curative option for selected patients with HCC. Locoregional therapy has been used to control HCC before transplantation because of the limited number of donor organs, to prevent tumor progression, and to decrease the incidence of dropouts from the transplant waiting list. Traditionally, multiple investigational locoregional modalities such as tumor resection, radiofrequency ablation, transarterial chemoembolization, and systemic chemotherapy have been used as "bridging" therapies. While the investigation of novel neoadjuvant treatments is justified in an effort to prevent tumor progression, the absence of randomized controlled trials leaves uncertainty about the utility of these maneuvers in improving outcome. This review summarizes the current data on the different modalities used worldwide in the neoadjuvant treatment of hepatocellular carcinoma, the rationale for these approaches, efficacy, potential complications, and future prospects.
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Rising PSA Level in an Anxious Postprostatectomy PatientA 66-year-old Caucasian man with a history of hypertension, hyperlipidemia, and rheumatoid arthritis was diagnosed with prostate cancer.
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Intravesical Therapy for Superficial Bladder CancerThe intravesical instillation of therapeutic agents for the treatment of localized bladder cancer began in 1903 when Herring[1] summarized his experience with silver nitrate. Since then, intravesical chemotherapy and immunotherapy have emerged as
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Accelerated Partial Breast Irradiation for Breast Cancer: An Innovative Option for Selected Early-Stage CancersTo paraphrase a deep philosophical question: if an important, long-awaited phase III prospective randomized trial from Europe is published and no one pays attention, does it make a sound?
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Clinical Pearls on Recent Advances and the Future of Treatment in RCCMehmet Asim Bilen, MD, summarizes recent advances in metastatic RCC and looks towards the future of the field.
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Chemotherapy for Soft-Tissue SarcomasIn patients with high-risk localized disease, the use of systemic chemotherapy should be strongly considered to delay recurrence and/or reduce the patient’s risk of developing metastatic disease. In patients with metastatic disease, systemic chemotherapy remains the mainstay of treatment.
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Chronicling Strides in Understanding and Managing Rectal CancerAdvances in the treatment of rectal cancer, such as TME and CMT, have lengthened survival time and enhanced the quality of life. However, radiation therapy may have a negative impact on quality of life, especially in males. Future research needs to focus not only on survival but also on postoperative quality of life.
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Commentary (Mannel): Modern Management of Recurrent Ovarian CarcinomaIn their article, Drs. Michener andBelinson make the case for treatingrecurrent ovarian cancer as achronic disease, with limiting morbidityand providing palliation of symptomstheir major goals. A review ofrecent literature would support their contention and management strategy.The cure rate for patients with recurrentovarian cancer is < 5%, and theaverage patient in the United Statesreceives more than five separate regimensof chemotherapy for recurrentdisease. Previous attempts at aggressivetreatment for recurrent disease haveshown, at best, very modest benefitwith significant expense and morbidity.What we are left with is a strategy oftrying to determine which patients maybenefit from aggressive salvage therapyand which are better managed witha chronic palliative attempt.
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Bone-Modifying Agents as Adjuvant Therapy for Early-Stage Breast CancerIn this review we describe the current evidence for use of bisphosphonates as part of the adjuvant treatment of patients with early-stage breast cancer.
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Pediatric Cancers in the New Millennium: Dramatic Progress, New ChallengesOver the past 50 years, great strides have been made in diagnosis, treatment, and survival of childhood cancer. In the 1960s the probability of survival for a child with cancer was less than 25%, whereas today it may exceed 80%. This dramatic change has occurred through significant and steady progress in our understanding of tumor biology, creation of specialized multidisciplinary care teams, incremental improvements in therapy, establishment of specialized centers with research infrastructure to conduct pivotal clinical studies, and the evolution of a cooperative group mechanism for clinical research. Most children with cancer in the United States, Europe, and Japan receive appropriate diagnosis and treatment, although access is limited in developing countries. The price of success, however, is the growing population of survivors who require medical and psychosocial follow-up and treatment for the late effects of therapy. Here we review the progress made in pediatric oncology over the past 3 decades and consider the new challenges that face us today.
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New Treatments for Multiple MyelomaIn 2004, multiple myeloma was diagnosed in more than 15,000 peoplein the United States and will account for approximately 20% of deathsdue to hematologic malignancies. Although traditional therapies suchas melphalan (Alkeran)/prednisone, combination chemotherapy withVAD (vincristine, doxorubicin [Adriamycin], and dexamethasone), andhigh-dose chemotherapy with stem cell transplantation have shownsome success, median survival remains between 3 to 5 years. Treatmentoptions for patients with multiple myeloma have increased in recentyears, with the promise of improvement in survival. New agents, suchas the proteasome inhibitor bortezomib (Velcade), the antiangiogenicand immunomodulator thalidomide (Thalomid) and its analogs, suchas lenalidomide (Revlimid), together with other small molecules, includingarsenic trioxide (Trisenox), and other targeted therapies, havebeen studied alone and in combination with other antineoplastic therapies,either as induction therapy prior to stem cell transplantation or inpatients with relapsed disease. Bortezomib recently was approved inthe United States for the treatment of multiple myeloma in patientswho have received at least one prior therapy. The use of bortezomibbasedregimens as front-line therapy as well as the use of other agentsin multiple myeloma remain under investigation, and approvals forboth thalidomide and lenalidomide are hoped for soon, with the overallprospect of patient outcome continuing to be increasingly positive.
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Radiofrequency Ablation in Lung Cancer: Promising Results in Safety and EfficacyOnly about 15% of patients diagnosed with lung carcinoma eachyear are surgical candidates, either due to advanced disease orcomorbidities. The past decade has seen the emergence of minimallyinvasive therapies using thermal energy sources: radiofrequency,cryoablation, focused ultrasound, laser, and microwave; radiofrequencyablation (RFA) is the best developed of these. Radiofrequency ablationis safe and technically highly successful in terms of initial ablation.Long-term local control or complete necrosis rates drop considerablywhen tumors are larger than 3 cm, although repeat ablations can beperformed. Patients with lung metastases tend to fare better with RFlung ablation than those with primary lung carcinoma in terms of localcontrol, but it is unclear if this is related to smaller tumor size at time oftreatment, lesion size uniformity, and sphericity with lung metastases,or to differences in patterns of pathologic spread of disease. The effectsof RFA on quality of life, particularly dyspnea and pain, as well aslong-term outcome studies are generally lacking. Even so, the resultsregarding RF lung ablation are comparable to other therapies currentlyavailable, particularly for the conventionally unresectable or high-risklung cancer population. With refinements in technology, patient selection,clinical applications, and methods of follow-up, RFA will continueto flourish as a potentially viable stand-alone or complementarytherapy for both primary and secondary lung malignancies in standardand high-risk populations.
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Emotional and Behavioral Responses to Genetic Testing for Susceptibility to CancerAs genetic testing for susceptibility to cancer becomes more widely available, cancer-care providers will become more involved in counseling patients about cancer risks and the meaning of genetic test results. As a result, oncologists and oncology nurses need to be aware of the unique psychological issues and challenges posed by genetic testing for cancer susceptibility. This paper first describes a psychological profile of individuals who are likely to opt for such testing, based on extrapolation from studies of people at high risk of cancer.
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The Radiologic Appearance of Lung CancerThe article by O'Donovan discusses the radiologic appearance of lung cancer, with particular emphasis on the radiographic appearance and work-up of solitary pulmonary nodules (SPNs).
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Clinical Status of Laparoscopic Bowel Surgery for GI MalignancyLaparoscopic surgery for colorectal malignancy is an important topic because of its potential advantages and its oncologic controversies. Drs. Wexner and Hwang have prepared a comprehensive review of the current status of laparoscopic colorectal surgery for malignancy. The relative merits of the new procedure are discussed from a number of perspectives, including the technical aspects of laparoscopic bowel resection, oncologic concerns, and experimental and theoretical effects on tumor growth and host immunity.
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Commentary (Thompson): Update on Radiation Therapy for Endometrial CancerDr. Grigsby does an excellent job of summarizing the accepted, stage-by-stage treatment recommendations as well as the controversies surrounding the treatment of endometrial carcinoma. This review is both important and timely, as we have seen the incidence of endometrial cancer increase over the past few years to the point where it is now the most common gynecologic malignancy.
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BMT for Severe Autoimmune Diseases: An Idea Whose Time Has ComeThe article by Dr. Burt provides an excellent summary of the rationale for using high-dose therapy with autologous or allogeneic bone marrow transplantation (BMT) in patients with severe autoimmune diseases (SADS). The article also describes the approach to BMT adopted by Dr. Burt and colleagues at Northwestern University. Enthusiasm for this form of therapy has been contagious, and numerous US investigators have initiated similar trials, which are outlined in Table 1 of the article.
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Role of Laparoscopy in the Staging of Gastrointestinal CancerAccurate staging plays a primary role in determining the appropriate treatment of gastrointestinal malignancies. Recently, laparoscopy has emerged as a staging modality that is more sensitive and specific in staging most
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mTOR Inhibitors in the Treatment of Breast CancerEfforts to identify clinical biomarkers of response or resistance to mTOR inhibitors are ongoing. This review will summarize results of preclinical and clinical studies as well as ongoing clinical trials with mTOR or dual PI3K/mTOR inhibitors.
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Risk of Endometrial Cancer After Tamoxifen TreatmentA total of 18 studies have been published concerning the possible relationship of tamoxifen to endometrial
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Intravesical Therapy for Superficial Bladder CancerThe intravesical instillation of therapeutic agents for the treatment of localized bladder cancer began in 1903 when Herring[1] summarized his experience with silver nitrate. Since then, intravesical chemotherapy and immunotherapy have emerged as
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Hormone-Refractory Prostate Cancer: Choosing the Appropriate Treatment OptionHormone-refractory prostate cancer (HRCaP) is both heterogeneous and lethal. Multiple treatment options exist, including secondary hormonal manipulations, chemotherapy, experimental options, and best supportive care. Choosing the appropriate therapy for an individual patient depends on several important clinical factors such as the presence or absence of symptomatic metastatic disease, age and comorbidities, and prostate-specific antigen velocity. While only docetaxel (Taxotere)-based chemotherapy has been proven to improve survival in this setting, a wide range of therapies may be effective for any individual. Palliative maneuvers, such as external-beam radiation, bisphosphonate therapy, radiopharmaceuticals, and pain management are critical for appropriate patient management. Several promising novel therapies are in late-stage testing and will hopefully provide more treatment options for these patients.
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Molecular Staging of Prostate Cancer: Dream or Reality?The promise of using reverse transcriptase–polymerase chain reaction (RT-PCR) technology for the detection of circulating prostate cancer cells in peripheral blood, although technically feasible at the molecular level, has proven clinically impractical for routine implementation in patient management. Reverse transcriptase–polymerase chain reaction has been successfully applied to detect and quantify (relatively speaking) genes that are differentially expressed in cells and tissues obtained from patients during various stages of malignant growth. In addition, the method has been applied to the detection of circulating cancer cells in peripheral blood using highly specific primer sets for specific molecular targets. These include epithelial cell cytokeratins for breast cancer, as well as enzymes, such as tyrosinase for melanoma and prostate-specific antigen (PSA) and prostate-specific membrane antigen (PSMA) for prostate cancer, using either nonnested or nested methodologies.
