Gastrointestinal Cancer

Drs. Blackstock, Cox, and Tepper have outlined some salient aspects of the management of pancreatic cancer. I agree with most of their comments, and will address some issues from my own perspective, colored largely by a symposium on cancer of the pancreas held in Newport, Rhode Island, in July 1994. This gathering of a large nucleus of investigators with a major interest in pancreatic cancer provided some additional insights that I will explore in my commentary and that largely complement the points made by Blackstock et al. Among other issues, my remarks will focus on: (1) the use of molecular markers for diagnosis and treatment, (2) preoperative chemoradiation, and (3) some surgical considerations that still generate controversy; ie, the extent of resection.

Blackstock and colleagues present a well-written, comprehensive review of the current state of management of both resectable and unresectable pancreatic carcinoma, as well as ongoing research and future strategies. Unfortunately, in the majority of patients, the disease is locally advanced at diagnosis, with or without regional and distant metastases. Unlike recent advances in screening for both prostate and breast cancer, no reliable and/or cost-effective method for identifying patients at risk for pancreatic cancer is available. Also, there is currently no reliable hematologic marker that can identify patients whose cancers are in the earliest developmental stage. Blackstock et al do emphasize that recent advances in laparoscopic techniques have led to better selection of patients for subsequent exploration and surgical resection. Given the reduction in operative mortality during the last 10 years, survival rates have improved.

Dr. Blackstock and colleagues are to be commended for their concise review broadly outlining current advances in the management of pancreatic cancer and future avenues of development.

In an attempt to improve the grave prognosis associated with the diagnosis of pancreatic cancer, researchers have explored a number of novel therapies. These include hormonal therapy, immunotherapy, radiopharmaceuticals, and novel chemotherapeutic agents.

The hormone somatostatin may be effective in treating some patients with pancreatic cancer, new research suggests. Studies conducted in mice and in laboratory samples found that pancreatic tumors responded to somatostatin only if the tumor cells had receptors for the hormone.

Sulindac sulfone, a nonsteroidal anti-inflammatory drug (NSAID) recently tested in the laboratories of the Arizona Cancer Center, may prove to be an effective colon cancer preventive agent.

NEW YORK--Patients with stage III colon cancer are being sought for a clinical trial newly underway to determine whether the monoclonal antibody (MoAb) 17-1A is an effective adjuvant in combination with 5-fluorouracil (5-FU) plus levamisole, said Richard Pazdur, MD, associate professor of medicine, M.D. Anderson Cancer Center.

CHICAGO--Over the last decade, increasing attention has been paid to the palliative care of patients whose colon cancer has not responded to curative treatment so that they may achieve the best possible quality of life.

NEW YORK--A novel nucleoside analog has demonstrated clinical benefits measured by reduction in pain, weight gain, and an improvement in performance status in patients with advanced pancreatic cancer.

Menko and colleagues review the genetic counseling that occurs after the presymptomatic diagnosis of hereditary nonpolyposis colorectal cancer (HNPCC) is made. The discovery of the mechanism by which tumors develop in this setting and the cloning of the genes responsible for the disease have made possible the DNA-based diagnosis of a disease, which, less than 5 years ago, was a controversial entity. In a remarkably short period, the nature of HNPCC has been greatly elucidated, its relationship to defective DNA mismatch repair has become manifest, and the means to diagnose it in a presymptomatic state has been developed [1].

Recent identification of gene mutations responsible for hereditary nonpolyposis colorectal cancer (HNPCC) has made possible the presymptomatic diagnosis of at-risk family members. If DNA testing shows that a family member is a gene carrier, that individual's lifetime cancer risk is approximately 90%. If the test is negative, the family member's cancer risk drops to that of the general population.

BOSTON--Aspirin appears to reduce the risk of colorectal cancer in women, but only if taken regularly for 10 years or more, report Edward Giovannucci, MD, and his colleagues from Harvard Medical School.

MIAMI BEACH--Patients treated for Hodgkin's disease are at moderately increased risk of developing secondary gastrointestinal (GI) cancer, Sandra H. Birdwell, MD, said at the American Society for Therapeutic Radiology and Oncol-ogy (ASTRO) meeting.

The endoscopic diagnosis, staging, and therapy of gastrointestinal (GI) malignancies has advanced rapidly and dramatically over the past 15 years. Video-endoscopy has generally replaced fiberoptic endoscopy, and the digitally based fidelity, sharper resolution, and improved magnification of the video-endoscopic image offers a potentially better approach for the evaluation of mucosal abnormalities.

ROCKVILLE, Md--Because advanced pancreatic cancer is a devastating disease with no effective treatment, members of the FDA Oncologic Drugs Advisory Committee (ODAC) voted to recommend approval of the nucleoside analog Gemzar (gemcitabine hydrochloride, Eli Lilly) as a first-line treatment for patients with nonresectable stage II, stage III, or metastatic (stage IV) adenocarcinoma of the pancreas.

MONTREAL, Canada--Tomudex (ZD1694), a new direct and specific thymidylate synthase (TS) inhibitor, has been shown to be especially promising for the treatment of patients with advanced colorectal cancer, David Cunningham, MD, said at the 19th International Congress of Chemotherapy.

PARIS, France--Biochemical modulators have brightened the prospects for patients with advanced gastrointestinal cancer, Scott Wadler, MD, reported at the American Radium Society annual meeting.

BOSTON--A radiolabeled monoclonal antibody (MoAb) currently under investigation may improve detection of recurrent colorectal cancer, said Dr. Frederick Moffat, associate professor of surgery, University of Miami Medical School.

Intraoperative radiation therapy (IORT) has the obvious advantage of maximally irradiating the tumor bed while eliminating surrounding normal organs from the field of radiation. This approach has been especially useful when the required radiation dose exceeds the tolerance dose of the surrounding normal tissues. However, the application of IORT has been significantly limited by cost, logistic issues, and technical problems related to delivering treatment to difficult anatomic areas. We have developed a new approach to IORT that obviates the need for patient transport: In a dedicated, shielded operating room, the surgery is performed and IORT is delivered via HDR remote afterloading. We have found this approach to be cost effective, logistically sound, and suitable for a wide range of anatomic sites. The technical aspects of the procedure, as well our preliminary results in colorectal cancer, will be presented. Lastly, the authors present the technical aspects of delivering HDR intraoperative brachytherapy, their dosimetry atlas, and their results using HDR-IORT in the treatment of patients with colorectal cancer[ONCOLOGY 9(7):679-683, 1995]

FORT LAUDERDALE, Fla--Because colon cancer develops in a stepwise progression that occurs over 10 to 15 years, physicians have a "tremendous window of opportunity for prevention," Sidney Winawer, MD, of Memorial Sloan-Kettering Cancer Center, said in a presentation at the second annual Industries' Coalition Against Cancer (ICAC) conference. He believes that colorectal cancer screening is "no longer controversial," based on available data.

The authors have nicely reviewed many of the issues surrounding laparoscopic colon cancer surgery. However, we would like to offer a slightly different perspective on several points which they make.

INDIANAPOLIS--Eli Lilly and Company has received FDA approval to provide gemcitabine (Gemzar) to advanced pancreatic cancer patients through a Treatment Investigational New Drug program.

LISBON, Portugal--Although folinic acid and interferon have been shown to heighten the efficacy of 5-fluorouracil (5-FU) in colorectal cancer, the ability of these biochemical modulators to prolong survival is less certain. Now a prospective randomized trial conducted in Germany has revealed that patients with advanced, symptomatic colorectal cancer who are treated with 5-FU and folinic acid live longer and have a better quality of life than do those who receive 5-FU and interferon.

Carcinoma of the gallbladder is a rare malignancy, with an incidence rate in the United States of 2.2 to 4.4 per 100,000 persons. Its clinical presentation is nonspecific, and the majority of patients have advanced disease at