ONCOLOGY Vol 9 No 10

RTOG 94-13 is a phase III study designed to determine the appropriatetreatment volume and the optimal way to combine radiation and

DNA sequence analysis of the p53 gene may provide information about the response to therapy for breast cancer patients,

In this issue of ONCOLOGY, Waner and Suen review their classification and treatment of congenital vascular lesions of the face and neck region. Certainly, from a therapeutic perspective, this is a nice summary of the state of the art of treatment modalities. The uses of surgery, phototherapy, laser ablation, and other modalities (eg, intralesional injection, steroids, embolization, and interferon) are summarized adequately for the general practitioner. The main focus is on cosmesis, with only little attention paid to the life-threatening conditions of intracranial vascular malformations (Figure 1) and massive head and neck vascular lesions (Figure 2).

Congenital vascular lesions are often misdiagnosed and, for the most part, left untreated. The absence of a uniformly accepted classification of these lesions and confusion over their natural history are partly responsible. A new classification of these lesions recognizes two distinct groups of lesions, hemangiomas and vascular malformations.

Very few people have the level of expertise Dr. Lamm does with the use of bacillus Calmette-Guérin (BCG) for the treatment of superficial bladder cancer. His enthusiasm is based on a large, solid experience with the vaccine. He has pushed the therapeutic effectiveness of BCG to new levels and has reviewed the world literature on the subject frequently and conscientiously. The current review covers most areas of interest in depth. A few key points deserve emphasis, however.

Dr. Lamm's review of bacillus Calmette-Guérin (BCG) in the treatment of carcinoma in situ (CIS) of the bladder reflects one of the largest personal experiences of any investigator worldwide, and he should be congratulated for being one of those most responsible for the improved quality of life of many people due to the widespread use of BCG in bladder cancer. It is clear that BCG therapy allows a majority of patients with CIS to avoid cystectomy, and that it prevents progression to muscle involvement in many high-risk patients with papillary tumors.

Lamm describes a success story in oncology that he helped create, namely, the favorable therapeutic effect of intravesical bacillus Calmette-Guérin (BCG) against carcinoma in situ (CIS) of the bladder. Virtually every study conducted over the past decade reports complete responses in 70% or more patients treated with BCG, which are often durable for years [1]. Such results have been documented empirically in prospective controlled trials without complete understanding of the mechanism of action of BCG or the optimal dose and treatment regimen. More importantly, not only may BCG eradicate CIS but also it may delay or prevent tumor progression and improve patient survival [2]. Conversely, patients failing to respond to an adequate trial of BCG therapy are at increased risk for disease progression and death from bladder cancer. We now realize that the natural history of CIS in the bladder has been significantly altered by intravesical BCG.

Fennelly and Schneider review a controversial area in ovarian cancer management in a comprehensive, objective, and thoughtful manner. This review is particularly timely in light of the ever-increasing number of ovarian cancer patients in whom high-dose chemotherapy, with either bone marrow transplantation or peripheral stem-cell transfusion, is being proposed as a treatment option. The authors support the contention that the majority of such patients are being offered a treatment that has little likelihood of providing a meaningful benefit. The take home message from this review is that outside of an appropriately designed clinical trial, there is no established role for high-dose chemotherapy with hematologic support in any subset of patients with advanced ovarian cancer. At the conclusion of this commentary, I will return to the issue of what constitutes an appropriate clinical trial design to evaluate the efficacy of high-dose chemotherapy in ovarian cancer.

Prior to the advent of BCG immunotherapy, bladder carcinoma in situ often progressed to muscle invasion. Intravesical chemotherapy completely eradicates the disease in 50% of patients, but fewer than 20% remain disease free after 5 years. Complete responses have been reported in 70% or more of BCG treated patients, nearly two-thirds of which are durable.

Kadish and Kochman provide a superb review of the current role of endoscopy in the diagnosis, staging, palliation, and cure of gastrointestinal cancer. There is no doubt that recent technological advances have changed the focus of endoscopy; there is a much greater emphasis now on finding and treating early cancer and precancerous lesions.

Cisplatin (Platinol) has been the most active agent against ovarian cancer. The question of a relationship between platinum dose and response remains unresolved.

We agree with Drs. Fennelly and Schneider that data from prior clinical trials performed in patients with suboptimally debulked ovarian cancer indicate that increasing the dose intensity of cisplatin (Platinol) does not translate into meaningfully higher response rates, longer response durations, or improved survival. The Gynecologic Oncology Group study is most persuasive in showing that doubling the standard dose of cisplatin and cyclophosphamide (Cytoxan, Neosar) while delivering the same total dose does not improve outcome [1].

Drugs similar to chemicals in the body may help prevent a patient from suffering hair loss and other side effects of some cancer

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.

There is a clear need to improve the clinical management of vascular lesions of the head and neck. This paper by Waner and Suen corrects some of the common misconceptions and emphasizes that each vascular lesion must be recognized, understood, and treated on an individual basis.