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Prostate Cancer Controversies: PSA Screening; Treatment or Observation for Early DiseaseWe discuss the current controversies in prostate cancer-PSA screening and approaches to initial treatment for men diagnosed with the disease.
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Treatment of Acute Lymphoblastic Leukemia in Adults: Applying Lessons Learned in ChildrenIn this article we discuss the challenges and new advances in adult ALL, as well as our approach to the treatment of these patients.
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Neoadjuvant Chemotherapy for Ovarian CancerPrimary debulking surgery by a gynecologic oncologist remains thestandard of care in advanced ovarian cancer. Optimal debulking surgeryshould be defined as no residual tumor load. In retrospective analyses,neoadjuvant chemotherapy followed by interval debulking surgerydoes not seem to worsen prognosis compared to primary debulking surgeryfollowed by chemotherapy. However, we will have to wait for theresults of future randomized trials to know whether neoadjuvant chemotherapyfollowed by interval debulking surgery is as good as primarydebulking surgery in stage IIIC and IV patients. Interval debulking isdefined as an operation performed after a short course of induction chemotherapy.Based on the randomized European Organization for Researchand Treatment of Cancer–Gynecological Cancer Group (EORTC-GCG)trial, interval debulking by an experienced surgeon improves survival insome patients who did not undergo optimal primary debulking surgery.Based on Gynecologic Oncology Group (GOG) 152 data, intervaldebulking surgery does not seem to be indicated in patients who underwentprimarily a maximal surgical effort by a gynecologic oncologist.Open laparoscopy is probably the most valuable tool for evaluating theoperability primarily or at the time of interval debulking surgery.
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Bronchioloalveolar Carcinoma: a Translational PerspectiveIn this issue of Oncology, Levy and colleagues provide a comprehensive review of bronchioloalveolar carcinoma [BAC], with a focus on the management of this rare disease, which represents 4% of all lung cancers.[1] The definition of BAC was revised by the World Health Organization (WHO) in 2004, with changes made to the diagnostic criteria and classification.[2] BAC was defined as an adenocarcinoma of the lung that grows in a lepidic fashion along the alveolar septa without invasion of stroma, blood vessels, or pleura. BAC has been sub-classified into three types: nonmucinous, mucinous, and mixed.
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New Hutchinson Center Study Helps Lift the Fog on ChemobrainBecause there has been little empirical evidence to back up patients’ stories, chemobrain has been met with skepticism by the medical community and has been a painful puzzle for many patients who couldn’t quite put a name to what they were feeling. This cognitive impairment-characterized by loss of memory and stumbling on words, among other symptoms-has come to be known as “chemobrain” or “chemofog.”
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Biweekly Gemcitabine, Doxorubicin, and Paclitaxel as First-Line Treatment in Metastatic Breast CancerIn a single-center, open, phase II trial, we assessed the toxicity and activity of a triple combination therapy-doxorubicin at 30 mg/m2 (day 1), paclitaxel (Taxol) at 135 mg/m2 (day 2), and gemcitabine (Gemzar) at 2,500 mg/m2
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New Does Not Always Mean Better: Isolated Limb Perfusion Still Has a Role in the Management of In-Transit Melanoma MetastasesIn the recent era of effective systemic therapies for melanoma, the provocative question of whether isolated limb perfusion still plays a role in the treatment of patients with in-transit melanoma metastases is timely and relevant.
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A Urologic Perspective on Management of Localized and Metastatic RCCDrs. Dutcher, Mourad, and Ennis have provided an excellent review of current and potential future treatments of renal cell carcinoma (RCC); we would like to highlight some salient points from a urologic perspective.
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Prostate Cancer Risk Assessment ProgramProstate cancer is the most common form of cancer (except skin cancer) in men. Several factors have been associated with an increased risk for prostate cancer, including age, ethnicity, family history, lifestyle, and
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Solitary Extramedullary Plasmacytoma of the BladderPlasmacytoma is a rare B-lymphocyte neoplastic disorder that usually presents as the generalized disease multiple myeloma. Less than 5% of the cases present as a solitary mass of monoclonal plasma cells in the bone or soft tissue. Although solitary extramedullary plasmacytoma (SEP) may arise in any organ, it rarely involves the urinary bladder. A 67-year-old male without a history of multiple myeloma presented with urinary frequency and nocturia; he was later diagnosed with SEP of the bladder. The patient was initially treated with a course of radiation therapy without symptomatic improvement; therefore a chemotherapy regimen consisting of lenalidomide and dexamethasone was subsequently given for six cycles. SEP usually carries a better prognosis and higher cure rate than solitary plasmacytoma of bone, as SEP is radiation sensitive. The role of adjuvant chemotherapy in the treatment of SEP that is resistant to radiation therapy is not clear, since most of the recommendations have been derived from the experience of head and neck SEP. The literature also lacks recommendations for choice of a chemotherapy regimen and surveillance of isolated bladder plasmacytoma. Here we present the first case of a radiation-resistant solitary plasmacytoma of the bladder that was successfully treated with lenalidomide and dexamethasone with successful clinical remission.
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Bladder Cancer and Current Evidence for TreatmentOccult distant micrometastasis at the time of radical cystectomy leads predominantly to distant failures in patients with locally advanced muscle-invasive transitional cell carcinoma of the bladder. Cisplatin-based combination chemotherapy enhances survival in patients with metastatic urothelial cancer. Studies evaluating adjuvant chemotherapy have been limited by inadequate statistical power. However, randomized clinical trials have demonstrated a survival benefit for neoadjvuant cisplatin-based combination chemotherapy, which should be considered a standard of care. In addition, neoadjuvant therapy may assist in the rapid development of novel systemic therapy regimens, since pathologic complete remission appears to be a powerful prognostic factor for long-term outcomes. Patients who are either unfit for or refuse radical cystectomy may benefit from neoadjuvant chemotherapy with or without radiation to enable bladder preservation.
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Supraclavicular Extraskeletal Myxoid Chondrosarcoma Presenting With a Sensorimotor Polyneuropathy Associated With Anti-Hu AntibodiesThis case shows the importance of searching for antineural antibodies in oncologic patients with new neurologic deficits, and of having a judicious workup for occult malignancies in patients with known antineural antibodies.
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Cancer Management Chapter 36: Depression, anxiety, and deliriumAlthough many cancer patients cope well with their disease, psychiatric disorders occur in almost 50% of patients in the setting of malignancy. Untreated psychological and neuropsychiatric disorders can compromise quality of life as well as treatment compliance. Three behavioral syndromes that are often encountered in clinical practice will be discussed here: depression, anxiety, and delirium.
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Paclitaxel Plus Epirubicin in Advanced Breast CancerThis phase I-II study aimed to determine the maximum tolerated dose (MTD) of paclitaxel (Taxol), infused over 3 hours, when combined with a fixed dose (90 mg/m²) of epirubicin. Other aims were to investigate the combination’s
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Hormone Replacement Therapy: Making Informed DecisionsThe controversies regarding the association between hormonal replacement therapy (HRT) and cancers, the questions about HRT use in women with a high risk of breast cancer, and the increasing number of women with breast cancer and menopausal symptoms make HRT a significant cancer issue.
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Can Patient Reporting Affect Radiation Pneumonitis?Radiation therapy (RT) is an important treatment modality for multiple thoracic malignancies. Incidental irradiation of the lungs, which are particularly susceptible to injury, is unavoidable and often dose-limiting. The most radiosensitive subunit of the lung is the alveolar/capillary complex, and RT-induced lung injury is often described as diffuse alveolar damage. Reactive oxygen species generated by RT are directly toxic to parenchymal cells and initiate a cascade of molecular events that alter the cytokine milieu of the microenvironment, creating a self-sustaining cycle of inflammation and chronic oxidative stress. Replacement of normal lung parenchyma by fibrosis is the culminating event. Depending on the dose and volume of lung irradiated, acute radiation pneumonitis may develop, characterized by dry cough and dyspnea. Fibrosis of the lung, which can also cause dyspnea, is the late complication. Imaging studies and pulmonary function tests can be used to quantify the extent of lung injury. While strict dose-volume constraints to minimize the risk of injury are difficult to impose, substantial data support some general guidelines. New modalities such as intensity-modulated radiation therapy and stereotactic body radiation therapy provide new treatment options but also pose new challenges in safely delivering thoracic RT.
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ACR Appropriateness Criteria® Nonsurgical Treatment for Locally Advanced Non–Small-Cell Lung Cancer: Good Performance Status/Definitive IntentThe treatment of inoperable stage III non–small-cell lung cancer (NSCLC) remains a challenge due to high rates of distant metastasis, local recurrence, and toxicity associated with definitive therapy.
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Tackling Endocrine Resistance in Breast CancerThis video reviews the mechanisms of acquired and upfront endocrine resistance in estrogen receptor–positive breast cancer as well as research into strategies for overcoming this resistance.
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Do Families Understand "Do Not Resuscitate" Orders?Do not resuscitate (DNR) orders have become an integral part of the care of the terminally ill patient. Often, the decision whether or not to resuscitate a patient in the event of cardiopulmonary arrest must be made by the patient's family members. This is a difficult decision that is made at an emotionally trying time. Our study investigated the satisfaction, understanding, and feelings of families who sign DNR orders for their relatives. We are not aware of any other studies that have evaluated this aspect of the DNR order.
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Predicting Disease Progression in CLL Patients on IbrutinibIn this interview we discuss prognostic models that may be able to predict disease progression in patients with chronic lymphocytic leukemia treated with the targeted agent ibrutinib.
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Cancer Care and Accountable Care Organizations: The Unknown Patient Experience LandscapeACOs can provide the structure, but it’s up to the stakeholders to establish mutually agreeable goals for this new care delivery model. Achieving these goals will require a different set of dialogues and conversations among stakeholders, and patients and their advocates must have seats at the table.
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Controversies in the Management of Advanced Ovarian CancerWhether advanced ovarian cancer should be treated with neoadjuvant chemotherapy or primary debulking surgery is one of the most debated topics in gynecologic oncology.
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Role of Radiation Therapy in Retroperitoneal SarcomasSoft-tissue sarcomas arising in the retroperitoneum represent an uncommon diagnosis, with approximately 600 new cases per year in the United States. Due to this small database, an assessment of the relative merits of different treatment strategies is not available. It is known is that patients with retroperitoneal sarcomas fare worse in terms of local control and disease-free survival than do patients with soft-tissue sarcoma of an extremity. The reasons for this are unclear but may be due, in part, to the large size of these tumors at diagnosis and the difficulty in obtaining adequate surgical margins.
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Early Engagement in Physical Activity and Exercise Is Key in Managing Cancer CachexiaDespite consensus on the diagnosis and staging of cancer anorexia/cachexia syndrome, there is currently no accepted standard of care, and affected patients remain widely undertreated.
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MGUS and Smoldering Myeloma: the Most Prevalent of Plasma Cell DyscrasiasMonoclonal gammopathy of undetermined significance (MGUS) is the most prevalent of the plasma cell dyscrasias and is characterized by a low level of production of serum monoclonal (M) protein (classically less than 3 g/dL).
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Supraclavicular Extraskeletal Myxoid Chondrosarcoma Presenting With a Sensorimotor Polyneuropathy Associated With Anti-Hu AntibodiesThis case shows the importance of searching for antineural antibodies in oncologic patients with new neurologic deficits, and of having a judicious workup for occult malignancies in patients with known antineural antibodies.
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Chemotherapy for Brain TumorsTraditionally, cytotoxic drugs have played a limited role in the treatment of brain tumors, but important advances in chemotherapy have occurred during the past decade. Certain central nervous system (CNS) malignancies are
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Commentary (Sachelarie et al): Optimizing Adjuvant Chemotherapy in Early-Stage Breast CancerDrs. Perez and Muss provide acomprehensive review of therole of adjuvant chemotherapyin the management of breast cancerpatients. The benefits of anthracyclinevs nonanthracycline regimens are discussed,the taxanes are reviewed indetail, and data regarding dose intensity,dose density, and optimal numberof chemotherapy cycles areexplored. Data on newer agents andbiologic agents also are presented.Debate continues regarding the subsetsof patients who will derive thegreatest benefit from chemotherapyand which regimen is most appropriate.While the review indicates theefficacy of several regimens as definedby randomized clinical trials, itdoes not emphasize patient-specificfactors in determining the optimaltherapy for a given patient.
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Primary Cutaneous and Systemic Anaplastic Large Cell LymphomaAnaplastic large cell lymphoma (ALCL) is a biologic and clinically heterogenous subtype of T-cell lymphoma. Clinically, ALCL may present as localized (primary) cutaneous disease or widespread systemic disease. These two forms of ALCL are distinct entities with different clinical and biologic features. Both types share similar histology, however, with cohesive sheets of large lymphoid cells expressing the Ki-1 (CD30) molecule. Primary cutaneous ALCL (C-ALCL) is part of the spectrum of CD30+ lymphoproliferative diseases of the skin including lymphomatoid papulosis. Using conservative measures, 5-year disease-free survival rates are>90%. The systemic ALCL type is an aggressive lymphoma that may secondarily involve the skin, in addition to other extranodal sites. Further, systemic ALCL may be divided based on the expression of anaplastic lymphoma kinase (ALK) protein, which is activated most frequently through the nonrandom t(2;5) chromosome translocation, causing the fusion of the nucleophosmin (NPM) gene located at 5q35 to 2p23 encoding the receptor tyrosine kinase ALK. Systemic ALK+ ALCLs have improved prognosis compared with ALK-negative ALCL, although both subtypes warrant treatment with polychemotherapy. Allogeneic and, to a lesser extent, autologous stem cell transplantation play a role in relapsed disease, while the benefit of upfront transplant is not clearly defined. Treatment options for relapsed patients include agents such as pralatrexate (Folotyn) and vinblastine. In addition, a multitude of novel therapeutics are being studied, including anti-CD30 antibodies, histone deacetylase inhibitors, immunomodulatory drugs, proteasome inhibitors, and inhibitors of ALK and its downstream signaling pathways. Continued clinical trial involvement by oncologists and patients is imperative to improve the outcomes for this malignancy.
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Current Status of Gastroenteropancreatic Tumor ManagementGastroenteropancreatic tumors, although relatively rare, present management problems that may last many years, in comparison with the usually more aggressive adenocarcinomas whose management may encompass a far briefer span of time. In general, 50% of such tumors are insulinomas, while gastrinomas comprise 25%, and nonfunctional tumors 20% VIPomas and glucagonomas are the predominant lesions of the remaining 5%. Clinical diagnosis is usually made on the presence of the classical symptom complex. In uncertain circumstances or covert presentations, the critical diagnostic biochemical test is plasma chromogranin A as well as measurement of the specific peptide.
