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Controversies in the Management of Intracranial GerminomasPaulino et al provide an excellent summary of the literature on primary germinoma of the central nervous system (CNS). As the authors note, germ-cell tumors of the CNS are rare, comprising about 1% of all brain tumors in patients in the Western
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Hepatic Imaging With Iron Oxide Magnetic Resonance ImagingThe management of hepatic tumors presents a challenging problem. The natural history of primary and metastatic liver lesions portends a poor prognosis. However, surgical resection and newer ablative techniques have had a
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Venetoclax With Rituximab Improves Survival in Relapsed/Refractory CLLIn this interview, we discuss the results of the phase III MURANO trial, which tested the combination of venetoclax with rituximab in relapsed/refractory CLL.
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Prostate Cancer, PSA, and Questions That Can Only Be Answered By Clinical TrialsRising prostate-specific antigen (PSA) in nonmetastatic prostate cancer occurs in two main clinical settings: (1) rising PSA to signal failed initial local therapy and (2) rising PSA in the setting of early hormone-refractory prostate cancer prior to documented clinical metastases. Most urologists and radiation oncologists are very familiar with the initial very common clinical scenario, commonly called "biochemical recurrence." In fact, up to 70,000 men each year will have a PSA-only recurrence after failed definitive therapy. The ideal salvage therapy for these men is not clear and includes salvage local therapies and systemic approaches, of which the mainstay is hormonal therapy. Treatment needs to be individualized based upon the patient's risk of progression and the likelihood of success and the risks involved with the therapy. It is unknown how many men per year progress with rising PSA while on hormonal therapy without documented metastases. This rising PSA disease state is sometimes called, "PSA-only hormone-refractory prostate cancer." As in the setting of initial biochemical recurrence, evidence-based treatment options are limited, and taking a risk-stratified approach is justified. In this article, we will explore these prostate cancer disease states with an emphasis on practical, clinically applicable approaches.
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Controversies in the Management of Stage I SeminomaCurrent controversies in the treatment of stage I seminoma center on the relative roles of surveillance, adjuvant radiotherapy (RT), and adjuvant single-agent chemotherapy. Surveillance has been studied in over 800 patients,
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Book Review:Wintrobe’s Clinical Hematology, 10th EditionThe 10th edition of Wintrobe’s Clinical Hematology is a two volume, multiauthored work that spans the ever-expanding discipline of hematology in over 2,600 pages. The book is appropriately introduced by an excellent short chapter written previously by Dr. Wintrobe on “The Diagnostic and Therapeutic Approach to Hematologic Problems.” There follows a valuable series of six chapters totaling 133 pages devoted to laboratory hematology, including blood and bone marrow examination, immunodiagnosis, clinical flow cytometry, cytogenetics, clusters of differentiation, and molecular genetics. These chapters contain ample illustrations, diagrams, tables, and references.
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Commentary (Baraboutis/Noskin): Management of Health-Care–Associated Infections in the Oncology PatientDrs. Guinan, McGuckin, andNowell have nicely reviewedthe risk factors associatedwith increased susceptibility to hospital-acquired infection in oncologypatients and also discussed preventivesteps to attenuate those risks.We agree that patients with malignanciespresent a challenge to thehealth-care provider, as infection willdevelop at some point in almost allcancer patients[1] and may be associatedwith significant mortality.[2]
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Barrett's Esophagus: Rapidly Evolving Management OptionsBarrett's esophagus represents replacement of normal distal esophageal squamous epithelium with specialized columnar epithelium containing goblet cells. Typically arising in the setting of chronic gastroesophageal reflux disease, the presence of Barrett's esophagus carries a 50- to 100-fold increased risk of developing esophageal cancer. Risk factors include male sex, smoking history, obesity, Caucasian ethnicity, age > 50 and > 5-year history of reflux symptoms. Aggressive medical or surgical antireflux therapy may ameliorate symptoms, but have not yet been proven to affect the risk of developing esophageal adenocarcinoma in randomized trials. Although dysplasia is an imperfect biomarker for the development of subsequent malignancy, random sampling of esophageal tissue for dysplasia remains the clinical standard. There have been no studies to establish that endoscopic screening/surveillance programs decrease the rates of death from cancer. Fit patients with Barrett's esophagus and high-grade dysplasia should undergo esophagectomy to prevent the risk of developing esophageal adenocarcinoma. For non–operative candidates, endoscopic ablative approaches may represent a reasonable therapeutic alternative.
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Commentary (Crowther/Kelton): Thromboembolic Complications of MalignancyAdvances in cancer treatmentover the past 50 years havecured or prolonged the life expectancyof many patients with cancer.These advances have accelerated overthe past 2 decades. Increasingly, physicianswho manage patients with cancerare turning their attention to the managementof the complications of malignancy,since these complications areoften avoidable, can shorten life spans,and can reduce quality of life.
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Influence of Anticonvulsants on the Metabolism and Elimination of IrinotecanThe hepatic metabolism and biliary secretion of irinotecan (CPT-11, Camptosar) and metabolites is complex and involves cytochrome P450 isoenzymes, carboxylesterases, glucuronosyltransferase, and the ATP-dependent export pumps MRP-2 and MXR. Enzyme-inducing antiepileptic drugs (EIAEDs) such as phenytoin and carbamazepine are known to induce several of the metabolic pathways relevant to ininotecan’s elimination. The North American Brain Tumor Consortium phase I study is designed to determine the maximum tolerated dose and pharmacokinetics of irinotecan given every 3 weeks to patients who are receiving EIAEDs.
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Graft Purging in Autologous Bone Marrow Transplantation: A Promise Not Quite FulfilledThe analysis, “Graft Purging inAutologous Bone MarrowTransplantation: A Promise NotQuite Fulfilled,” by Drs. Joseph Alvarnasand Stephen Forman, is verytimely. The authors’ conclusion is succinctlypresented in their title.
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Optimizing the Dose and Schedule of Darbepoetin Alfa in Patients With Chemotherapy-Induced AnemiaChemotherapy-induced anemia is common in patients who have cancer. Erythropoiesis-stimulating proteins such as epoetin alfa (Procrit) and darbepoetin alfa (Aranesp) have been shown to improve hematologic and clinical outcomes in these patients. Darbepoetin alfa has a longer serum half-life than epoetin alfa, making less frequent administration possible and offering the possibility of synchronizing the administration of erythropoietic therapy and chemotherapy. Several clinical trials have evaluated the utility of darbepoetin alfa given every 3 weeks (q3wk) in patients with chemotherapy-induced anemia. An exploratory study showed that darbepoetin alfa q3wk stabilized hemoglobin levels and reduced transfusion requirements. It was also shown that giving darbepoetin alfa q3wk at the same time as the chemotherapy produced hematopoietic benefits similar to those observed when it is given later in the chemotherapy cycle. The q3wk dosing schedule was effective in patients with mild and moderate anemia, and treatment goals were achieved in most of them. The equivalence of q3wk and qwk darbepoetin alfa has also been established. Synchronous administration of darbepoetin alfa with chemotherapy is a convenient option for patients with chemotherapy-induced anemia, with clinical trials showing it to be an effective treatment strategy.
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Commentary (Cohen/Glod): Current Management of Childhood EpendymomaEpendymoma is a rare central nervous system (CNS) tumor in children, and our progress in treating this disease has been hampered by its rarity as well as by a nonuniform approach to treatment among practitioners. Dr. Merchant’s comprehensive review provides a framework for plotting a course of further progress in treating children with ependymoma.
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The Oregon experiment failedThe Oregon Health Plan was considered by many to be a masterpiece of health care delivery for the poor. It attracted international attention when its plan of explicit rationing of care promised to provide basic health care to virtually every Oregonian living in poverty. Did the plan live up to its promise?
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Allogeneic Transplantation for Chronic Lymphocytic Leukemia in the Age of Novel Treatment StrategiesThe aim of this review is to summarize the current knowledge on HSCT in CLL and to discuss critically its role in the age of novel treatment strategies.
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Tamoxifen's Impact on the Management of Breast Cancer: The Oncologist's PerspectiveBreast cancer treatment has evolved greatly within the last 25 years. Tamoxifen was first introduced for the
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Commentary (Healey): Current Combined Treatment of High-Grade OsteosarcomasThere are few success stories in solid tumor oncology that match osteogenic sarcoma. Drs. Damron and Pritchard have chronicled this story, and present a multidisciplinary overview of the current management of conventional osteogenic sarcoma.
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Evaluating the Role of Serine Protease Inhibition in the Management of Tumor MicrometastasesConservation of blood is apriority during surgery, owingto shortages of donor bloodand risks associated with transfusionof blood products.[9,10] However,blood transfusions have been linkedto a number of negative postoperativesequelae, including poorer prognosisafter cardiac and cancer surgery.[11-21] In this context, recognition thatallogeneic transfusion-associatedimmunomodulation can increasemorbidity in allogeneically transfusedpatients has become a major concernin transfusion medicine.[9,22,23]
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Management of Locally Advanced Prostate CancerThe staging and treatment of prostate cancer are complex, particularly in patients with clinical disease that has advanced locally beyond the confines of the gland. Management choices are made more difficult by a paucity of
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Cryoglobulinemic DiseaseIn spite of the complicated etiologic, clinical, and pathologic scenario of cryoglobulinemia, physicians can play a key role in its successful management by early recognition of the most common clinical presentations.
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Brain Metastases in Small Cell Lung CancerThe purpose of this paper is to provide an overview of the clinical presentation, diagnosis, and treatment of brain metastases in patients with SCLC, with a focus on current trends and developments in the treatment of this disease.
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Pancreatic,neuroendocrine GI,and adrenal cancersPancreatic cancer is the fifth leading cause of cancer death in the United States.In the year 2005, an estimated 32,180 new cases will be diagnosed, and 31,800deaths will be ascribed to this cancer.
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Hodgkin's in the Elderly: More Questions Than AnswersWith improved prognosis for patients with Hodgkin's lymphoma (HL), interest has increasingly focused on high-risk groups such as elderly patients. Advanced age at presentation is still one of the strongest negative risk factors. Many different factors influence the prognosis in elderly patients. These include biologic differences such as more aggressive histology, different distribution of disease, more frequent diagnosis of advanced stage, and shorter history of disease. In addition, however, aging itself and associated factors such as comorbidity, reduced tolerability of conventional therapy, more severe toxicity and treatment-related deaths, failure to maintain dose intensity, shorter survival after relapse, and death due to other causes contribute to the poorer outcome in elderly patients. Besides the evaluation of specific causes and risk factors, this review highlights recent and ongoing studies for elderly patients with HL as well as international approaches and recommendations for this age group.
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Tumors of the Uterine CorpusCarcinoma of the endometrium is the most common female pelvic malignancy and the fourth most common cancer in females, after breast, bowel, and lung carcinomas. In 1995, an estimated 32,800 new cases of endometrial carcinoma and 5,900 related deaths will occur in the United States [1]. The relatively low mortality for this cancer is probably due to the fact that in 80% of cases, the disease is diagnosed when it is confined to the uterus.
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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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The Pathways of Tomorrow: What Does the Future Hold for the Treatment of Colorectal Cancer?The currently available therapies for colorectal cancer have led to a significant increase in survival, but the majority of patients with advanced disease progress and eventually die of their disease. This is a particularly frustrating scenario when a patient experiences a complete remission, only to recur with refractory disease.
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Catalog of Human Cancer Genes: McKusick’s Mendelian Inheritance in Man for Clinical and Research Oncologists (Onco-MIM)The author of this reference, Dr. John J. Mulvihill, has a long-standing reputation for studying the complexities of human genetic disorders. His experiences, many publications, and collaborations have focused on various topics, including definition of the
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Gene Therapy for Head and Neck CancersDespite advances in surgery, radiotherapy, and chemotherapy, survival of patients with squamous cell carcinoma of the head and neck has not significantly improved over the past 30 years. Locally recurrent or refractory disease is particularly difficult to treat. Repeat surgical resection and/or radiotherapy are often not possible, and long-term results for salvage chemotherapy are poor. Recent advances in gene therapy have been applied to recurrent squamous cell carcinoma of the head and neck. Many of these techniques are now in clinical trials and have shown some efficacy. This article discusses the techniques employed in gene therapy and summarizes the ongoing protocols that are currently being evaluated in clinical trials. [ONCOLOGY 15(3):303-314, 2001]
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Pediatric Anaplastic Large Cell Lymphoma Presenting as Generalized LymphadenopathyHere we present the case of a 3-year-old girl with generalized lymphadenopathy and fever, in whom the cause of the symptoms was initially thought to be infectious. Ultimately, however, anaplastic large cell lymphoma (ALCL) was diagnosed. Using this case as a backdrop, we discuss the wide range of systemic illnesses that the differential diagnosis of generalized lymphadenopathy encompasses.
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Current Clinical Trials of R115777 (Zarnestra)R115777 (Zarnestra) is an orally available methylquinolone derivative from Johnson & Johnson Pharmaceutical Research and Development L.L.C. that is a potent and selective nonpeptidomimetic farnesyltransferase inhibitor (FTI).[1] FTIs represent a new class of agents that were originally developed to inhibit tumors by interfering with posttranslational processing of oncogenic Ras protein. The anticancer activity of FTIs might stem from their ability to effect various proteins other than Ras that can also mediate signal transduction, apoptosis, angiogenesis, and growth.[2]
