ONCOLOGY Vol 19 No 9

In this installment of Second Opinion, we are presenting two cases of tumors of the female genital tract, specifically, the ovary and uterus, which contain both epithelial and mesenchymal components and therefore have unique diagnostic and therapeutic implications. The first has an unusually poor prognosis and the second is notoriously difficult to diagnose.

Drs. Chadha, Kuvshinoff, andJavle have provided a wellwrittenreview of the rationaleand literature supporting neoadjuvanttherapy and gastric cancer.Although the incidence of gastric canceris declining in the United States,approximately 1 million new caseswill be diagnosed worldwide this yearwith over 700,000 deaths, resulting ina disease-related mortality of nearly75%.[1] These figures emphasize theneed for new and improved treatmentstrategies in this disease. In contrastto other gastrointestinal malignancies,there has been little systematic evaluationof neoadjuvant multimodalityapproaches for patients with gastriccancer. Given its natural history andbiology, this approach is logical andmay yield therapeutic benefit.

The increasing number of patientson chronic renal replacementtherapy translates to additionalpatients living long enoughto develop a malignancy. For the mostpart this population will also be elderly,adding the nuances associated withpracticing oncology in a geriatric population.As discussed by Eneman andPhillips, the use of chemotherapeuticagents in patients with end-stage renaldisease (ESRD) is complicated byboth practical and ethical issues.

Mohs surgery has been well-established as the gold standard for the treatment of BCCs and SCCs. And, as described in this article, preliminary reports suggest that it may play an equally important role in the management of several other cutaneous malignancies.

Despite enormous advances in the treatment of colorectal cancer,there is no single standard treatment approach for all patients. However,there are general principles of management that can be used toguide therapy. The clinician who fails to individualize therapy forcolorectal cancer is likely not taking full advantage of all therapeuticoptions available. Reviewing key clinical evidence that can help informdecision-making, this article addresses important questions in colorectalcancer management, including: Should bevacizumab (Avastin) be acomponent of most patients’ first-line treatment? Is there a role forcontinuing bevacizumab in subsequent regimens? Is there a role forcetuximab (Erbitux) in standard first-line chemotherapy? Are therepractices in colorectal cancer that have become widely accepted withoutdirect supportive data?

Significant improvements in the management of patients with endstagerenal disease (ESRD) who are on chronic renal replacementtherapy (CRRT), has led to an increased prevalence of this populationamong older Americans. Since cancer is also common in the elderly,oncologists are likely to be faced with patients who suffer from bothcancer and ESRD. There is a paucity of information regarding issuessurrounding the optimal management of such patients, especially thoseneeding chemotherapy. This review surveys the relevant problemsoncologists may encounter in such patients and summarizes the availableliterature on chemotherapeutic management of common cancers.The reader is strongly urged to consult the original references for detailsof chemotherapy administration prior to use in an individualpatient.

Eneman and Philips' review,"Cancer Management in PatientsWith End-Stage RenalDisease," comes at a time when thisissue is of critical importance to oncologists.As the authors indicate, theconfluence of two factors-chronicrenal replacement therapy (CRRT)lengthening lives and an aging populationin general-have made thestudy of organ dysfunction a pressingissue.[1] The authors provide comprehensivestatistics on CRRT. Agestatistics also support the necessityfor further study of this special population.For all types of cancer, themedian age at diagnosis is 68 years,and 70% of all cancer deaths occur inpeople aged 65 years or older. By2050, experts expect that more than40% of cases will occur in this agegroup.[2,3] Many of these people willhave end-stage organ dysfunction andlimited access to care because of theircomorbidities.

Because of recent advances ineach discipline we commonlyrecommend and deliver threemodalities-chemotherapy, radiation,and surgery-in the management oflocalized gastrointestinal cancers inpatients who are judged to be suitablecandidates for aggressive therapy.After years of experimentation andsome therapeutic misadventures, combinationchemotherapy can now bedelivered with greater safety and effectiveness.This is based in part onbetter antiemetics, better supportivetherapies such as judicious use of granulocytecolony-stimulating factors,and more accurate models for adjustingdosages based on pharmacokineticand pharmacodynamic profiling.

In this issue, Dr. Saltz articulateshis opinion on a variety of questionsconcerning therapy for patientswith metastatic colorectal cancer.My commentary will reflect myopinions concerning these questions.

Drs. Pennington and Leffellhave provided an excellentoverview of the current uses ofMohs micrographic surgery. The procedurehas certainly come a long waysince the days of Frederic Mohs andthe application of zinc chloride paste(chemosurgery). Despite the fact that ithas indeed become the “gold standard”for the removal of basal cell carcinoma(BCC) and squamous cell carcinoma(SCC), there remain areas of controversyfor its use in melanoma and otherless common cutaneous neoplasms. Asmore dermatologists (and even a fewnondermatologists) have becometrained and gain experience in this specializedprocedure, and as more communitiesand university teaching centershave established growing Mohs practices,the procedure has become recognizedand embraced by health-careprofessionals and patients alike.

Pennington and Leffell have reviewedthe literature with regardto the relative efficacy ofthe Mohs technique vs conventionalsurgery in the treatment of commonand uncommon cutaneous neoplasms.The reason for the success of Mohssurgery can be summarized simply: TheMohs surgeon examines the entire microscopicsurgical margin for tumor,whereas the pathologist working with aconventional surgeon does not.

Gastric cancer is a global health issue. Most cases are diagnosed atan advanced stage with poor prognosis. Current therapies have a modestimpact on survival. Surgery remains the only potentially curativetreatment, but is associated with a high rate of locoregional recurrenceand distant metastases. Total gastrectomy for proximal cancers is complicatedby postoperative morbidity and quality-of-life impairment.Combined-modality therapy may improve outcomes in this disease.Adjuvant therapy for gastric cancer has now become the standard inthe Western world. However, adjuvant therapy improves survival by onlya few months and is associated with high morbidity. Neoadjuvant therapyis commonly used for esophageal and gastroesophageal junction cancers,but is still regarded as investigational in gastric cancer. Severalsmall phase II studies indicate the feasibility of neoadjuvant strategies.The incorporation of novel, targeted agents into neoadjuvant programsand an assessment of biologic changes within the tumor may refinetherapy. This article provides a concise review of the literature onneoadjuvant therapy for gastric cancer and suggests avenues for furtherinvestigation.

Advances in the treatment ofmetastatic colorectal cancer inthe past several years havebeen expeditious and exciting-evenchaotic-but with the median survivaldoubled since the use of single-agentfluoropyrimidines alone. However, newquestions continue to arise, directly affectingour daily practice in the care ofpatients with colorectal cancer. One ofthese issues, the optimal therapy formetastatic colorectal cancer, is wonderfullyexplored by Dr. Saltz in thisissue of ONCOLOGY. To understandthis issue better, we may have to approachthe question a little differently:That is, is it possible to standardizetreatment options for metastatic colorectalcancer?