John P. Hoffman, MD

The article by Drs. Wagman and Minsky is an excellent overview of the history, indications, treatment considerations, and comparative results of local excision alone and local excision plus chemoradiotherapy for selected distal rectal cancers. Although the literature and experience with local excision have increased, use of the technique has probably diminished over the past decade, primarily due to the groundswell of publications that lionize total mesorectal excision with low colorectal or coloanal anastomosis for most rectal cancers, as well as our inability to stage and predict nodal involvement, even in T1 cancers.

Drs. Weber and Petrelli review much of the literature regarding patient outcomes after local excision alone, as well as local excision plus chemoradiotherapy, in patients with various stages of low rectal adenocarcinoma. The authors apparently were unaware that the Radiation Therapy Oncology Group (RTOG) experience with local excision plus chemoradiation, which antedated the Cancer and Leukemia Group B (CALGB) study, will soon be in print to provide further multi-institutional support for these methods along with much greater follow-up. They also omitted our long-term data (median follow-up of survivors is 67 months) showing the very low locoregional recurrence rates in patients with T2 cancers treated by local excision and chemoradiotherapy.[1]

Over the past 7 years, 58 saline-filled tissues expanders (TEs) have been temporarily placed in 57 patients. The

The authors provide a comprehensive overview of the role of axillary lymphadenectomy in the treatment of early-stage breast cancer. They do not argue against lymphadenectomy for patients with clinical T2 and 3 tumors and clinical N1 and 2 nodes. However, for clinical N0 cancers and for postmenopausal patients with hormone-receptor-positive tumors, the authors propose radiotherapy to the axilla as a modality less expensive than surgery and with fewer complications. They suggest observation only for lesions associated with a less than 10% to 15% chance of axillary metastasis (T1a cancers, tubular carcinomas, ductal carcinoma in situ [DCIS] with microinvasion). However, for patients with lesionsless than 1 cm with “high-risk features (presence of tumor emboli in vessels, poor nuclear grade, etc),” axillary lymphadenectomy “should continue to serve as a refined prognostic indicator for selection of patients for adjuvant therapy.”

The treatment of patients with pancreatic cancer requires the expertise of medical oncologists, radiation oncologists, radiologists, and surgical oncologists. The surgeon's role