Authors

Radiofrequency Ablation in Lung Cancer: Promising Results in Safety and Efficacy

Only about 15% of patients diagnosed with lung carcinoma eachyear are surgical candidates, either due to advanced disease orcomorbidities. The past decade has seen the emergence of minimallyinvasive therapies using thermal energy sources: radiofrequency,cryoablation, focused ultrasound, laser, and microwave; radiofrequencyablation (RFA) is the best developed of these. Radiofrequency ablationis safe and technically highly successful in terms of initial ablation.Long-term local control or complete necrosis rates drop considerablywhen tumors are larger than 3 cm, although repeat ablations can beperformed. Patients with lung metastases tend to fare better with RFlung ablation than those with primary lung carcinoma in terms of localcontrol, but it is unclear if this is related to smaller tumor size at time oftreatment, lesion size uniformity, and sphericity with lung metastases,or to differences in patterns of pathologic spread of disease. The effectsof RFA on quality of life, particularly dyspnea and pain, as well aslong-term outcome studies are generally lacking. Even so, the resultsregarding RF lung ablation are comparable to other therapies currentlyavailable, particularly for the conventionally unresectable or high-risklung cancer population. With refinements in technology, patient selection,clinical applications, and methods of follow-up, RFA will continueto flourish as a potentially viable stand-alone or complementarytherapy for both primary and secondary lung malignancies in standardand high-risk populations.

Outlook for 2017: Myeloma, Lymphoma, and MPNs

This look ahead at hematologic malignancies in 2017 focuses on new agents being studied for the treatment of multiple myeloma, Hodgkin lymphoma, non-Hodgkin lymphoma, and myeloproliferative neoplasms.

HIV-Positive Male Presents With Multiple Symptoms and Has a History of Colonic Polyps

The New Generation of Targeted Therapies for Breast Cancer

Syed and Rowinsky present acomprehensive review of newtargeted therapies for breast cancer.This is an important review thatsummarizes new biologic targets andcurrent drugs in development for thetreatment of breast cancer-a rapidlyevolving field. Among the targets addressedin the article are epidermalgrowth factor receptor (EGFR), Ras/Raf/mitogen-activated protein (MAP)kinase, phosphatidylinositol 3-kinase(PI3K)/protein kinase B (AkT)/moleculartarget of rapamycin (mTOR), tumorangiogenesis, apoptosis, andhistone deacetylases. The list shouldalso be expanded to include differentiatingagents and inhibitors of invasionand metastasis. It is critical toemphasize the future of customizedtherapy and the use of biologic agentsalone, together, or in combination withchemotherapy for the treatment ofbreast cancer.

Current Surgical Management of Metastatic Spinal Disease

At the outset of their article, Drs. Gerszten and Welch state that their primary goal is to review factors that affect surgical intervention in patients with metastatic spinal disease. On their way to achieving this goal, the authors touch on some of the

Stereotactic Body Radiation Therapy

Song and colleagues deliver athorough and fair review of theinitial clinical investigations ofa new paradigm in radiotherapy mostrecently called stereotactic body radiationtherapy (SBRT).[1] Oncology observers may take exception withthe use of the designation “new paradigm.”After all, from a tumor controlpoint of view, skeptics might say,“radiotherapy is radiotherapy.” Recentadvances in radiotherapeutictechnology such as three-dimensionsal(3D) conformal therapy and intensity-modulated radiotherapy (IMRT)have made treatments less toxic, butnot particularly more effective in curingcancer.

Brachytherapy in the Treatment of Breast Cancer

Whole-breast external-beam radiation therapy (EBRT) involves a 6-week course of fractionated treatments. In

Defining the Role of Hepatic Arterial Infusion Chemotherapy in Metastatic Colorectal Cancer

In their article, Drs. Whisenant andVenook review data regarding thevalue of hepatic arterial infusion(HAI) chemotherapy for hepatic colorectalmetastases. In fact, their analysisreveals the absence of anymaterial progress in HAI therapy sincethe first reports of continuous infusionof chemotherapy through the hepaticartery.[1] During the sameperiod, there has been dramatic improvementin hepatic imaging, outcomefrom hepatic resection, systemicchemotherapy, and survival followingtreatment of hepatic colorectalmetastases. Failure of HAI therapy toadvance in parallel with other treatmentsfor liver metastases-whetherused prior to or after resection, or asdefinitive treatment for unresectabledisease apparently confined to the liver-suggests a limited role for HAItherapy in this disease. Several pointswarrant discussion.

Infectious Complications of Pentostatin Therapy

Managing the infectious complications associated with pentostatin (Nipent), used alone or in combination with other agents in patients with low-grade lymphomas, poses a significant problem for clinicians. Since there is limited

Ovarian Cancer in Elderly Women

The incidence of ovarian carcinoma increases with advancing age,peaking during the 7th decade of life and remaining elevated until age80 years. Despite the high prevalence of ovarian cancer in the elderly,the management of these patients is often less aggressive than that oftheir younger counterparts. As a result, many elderly cancer patientsreceive inadequate treatment. However, data do not support the conceptthat age, per se, is a negative prognostic factor. In fact, the majority ofelderly patients are able to tolerate the standard of care for ovariancancer including initial surgical cytoreduction followed by platinumand taxane chemotherapy. Because functional status has not demonstrateda reliable correlation with either tumor stage or comorbidity,each patient’s comorbidities should be assessed independently. Forelderly patients with significant medical comorbidity, the extent ofsurgery and aggressiveness of chemotherapy should be tailored to theextent of disease, symptoms, overall health, and life goals. In addition,enhanced cooperation between geriatricians and oncologists may assistthe pretreatment assessment of elderly patients and improve treatmentguidelines in this population.

Impact of Bone-Targeted Treatments on Skeletal Morbidity and Survival in Breast Cancer

Bone metastases are common in advanced breast cancer, and may be associated with serious morbidity, including fractures, pain, nerve compression, and hypercalcemia. Through optimum multidisciplinary management and the use of bone-targeted treatments, patients with advanced breast cancer have experienced a major reduction in skeletal complications, less bone pain, and an improved quality of life.

An Alternative Algorithm for Dosing Transdermal Fentanyl for Cancer-Related Pain

Many cancer patients are undermedicated and inappropriately managed for pain, leading to a diminished quality of life. Patients with moderate to severe pain often require opioid analgesics. Recently published guidelines

Clinical Trials and NCI Resources for Cancer in HIV-Positive Patients

The association between HIV infection and the development of cancer was noted early in the acquired immunodeficiency syndrome (AIDS) epidemic. The AIDS-defining malignancies are Kaposi’s sarcoma, intermediate- or high-grade B-cell non-Hodgkin’s lymphoma (NHL), and cervical cancer. All of these cancers feature specific infectious agents in their etiology. These agents are human herpesvirus 8/Kaposi’s sarcoma-associated herpesvirus, or HHV-8/KSHV (implicated in Kaposi’s sarcoma), Epstein-Barr virus, or EBV (in primary central nervous system lymphoma and a subset of systemic B-cell NHL) and human papillomavirus, or HPV (in cervical cancer).[1]

Physicians Must Comply With Fraud and Abuse Statutes

The second part of this three-part series discusses the various types of fraud and abuse laws, reviews the laws on false claims, and provides suggestions for limiting a physician's exposure to fraud and abuse claims. Part 1, which appeared in the January, 1995, issue of Oncology News International (page 18), discussed the Stark statute, which prohibits self-referrals for certain services covered by Medicare and Medicaid, while the final article will review the Medicare and Medicaid anti-kickback statute.

Transplantation or Resection for Hepatocellular Carcinoma: Biology Determines Outcome

In their article “Liver Transplantation for the Treatment of Hepatocellular Carcinoma," Drs. Hanish and Knechtle provide a cogent review of many of the issues surrounding the management of hepatocellular carcinoma (HCC) in patients with cirrhosis.

Commentary (Scully): Extraovarian Primary Peritoneal Carcinoma

The distribution of abdominal serous carcinoma in the female ranges from ovarian carcinoma with no tumor involvement of the peritoneum to peritoneal carcinoma with no evidence of carcinoma in the ovary. For the purposes of investigation and patient care, it has been necessary to formulate criteria to distinguish tumors that are most probably primary ovarian carcinomas from those that are most likely primary peritoneal cancers.

Hematopoietic Management in Oncology Practice

The year 1991 was truly a watershed year in medical oncology,as three events resulted in aparadigm shift in the tolerability,safety, and symptom management ofchemotherapy delivery. The first twoevents moved chemotherapy administrationfrom a user-unfriendly hospitalinpatient environment to whatevolved into a highly efficient, sophisticated,outpatient system led by privatepractitioners of medical oncology.Ondansetron (Zofran), the first of the5HT3-receptor antagonists, providedreliable prophylaxis of immediatechemotherapy-induced nausea andvomiting in highly emetogenic regimens.[1] Recombinant human granulocytecolony-stimulating factor(rhG-CSF, filgrastim [Neupogen]),[2]if dosed appropriately, significantlyreduced the duration of severe neutropeniathrough its role as the primaryregulator of increased production andrelease of granulocytes from the bonemarrow.

Potential Role of Tumor Vaccines in GI Malignancies

The article by Laheru and Jaffee offers an excellent summary of immunotherapies for gastrointestinal malignancies. Thoughtful descriptions of the antibody, cytokine, and cel- lular components of the immune system provide useful background information that facilitates an understanding of specific passive and active cancer immunotherapies. Immunotherapies that have demonstrated efficacy in colon cancer clinical trials, including levamisole (Ergamisol), passive monoclonal antibody vaccines, and bacillus Calmette- Guérin (BCG)–autologous tumor vaccines, are appropriately reviewed. In addition, novel approaches at varying stages of clinical testing are clearly summarized; these include the use of an anti-idiotypic antibody, genetically modified tumor and dendritic cells, recombinant protein, and viral and DNA vaccines. Some additional approaches, studies, and perspectives are also worthy of mention as a supplement to this review.

The Evolution of Medical Journals: Why “Oncology”?

Had Charles Darwin lived in the late 20th century, he might have found amusement in contemplating the evolution of biomedical journals.

Osteoporosis in Breast and Prostate Cancer Survivors

Recent advances in treatment modalities for breast and prostate cancerhave resulted in an increasing number of patients that are cured orthat, despite residual disease, live long enough to start experiencingcomplications from cancer treatment. Osteoporosis is one such problemthat has been increasingly identified in cancer patients. Hypogonadismand glucocorticoid use are the two major causes of bone loss inthese patients. Osteoporosis is characterized by low bone mass and abnormalbone microarchitecture, which results in an increased risk offractures. Vertebral body and hip fractures commonly result in a drasticchange of quality of life as they can result in disabling chronic pain,loss of mobility, and loss of independence in performing routine dailyactivities, as well as in increased mortality. In patients with prostatecarcinoma, androgen-deprivation therapy by either treatment with agonadotropin-releasing hormone (GnRH) or bilateral orchiectomy resultsin increased bone turnover, significant bone loss, and increasedrisk of fractures. Patients with breast cancer are at increased risk forestrogen deficiency due to age-related menopause, ovarian failure fromsystemic chemotherapy, or from the use of drugs such as aromataseinhibitors and GnRH analogs. Several studies have indicated that theprevalence of fractures is higher in breast and prostate cancer patientscompared to the general population. Therefore, patients at risk for boneloss should have an assessment of their bone mineral density so thatprevention or therapeutic interventions are instituted at an early enoughstage to prevent fractures. This article will address the characteristicsof bone loss observed in breast and prostate cancer patients and potentialtreatments.

COUNTERPOINT: Is There Still a Role for Intraperitoneal Platinum Therapy in Ovarian Cancer?

There will be no further randomized phase III trials of cytotoxic IP chemotherapy; IP therapy in ovarian cancer will soon be an historical footnote along with other failed approaches in cancer care.

Comments Regarding Lung Metastasis Surgery for Sarcoma

In this issue of ONCOLOGY, Kon and Martin review the difficult issue of lung metastasis from sarcoma and its management.

Commentary (Downey/Ginsberg): Surgical Treatment of Metastatic Pulmonary Soft-Tissue Sarcoma

In their article, Chao and Goldberg provide a concise overview of the literature on pulmonary metastasectomy for sarcoma, including a brief history of the procedure, guidelines for preoperative evaluation, conduct of the operation, and probable outcomes achieved. Several points that they review deserve further discussion.

Pelvic MRI for Guiding Treatment Decisions in Rectal Cancer

This article discusses features that predict local recurrence and distant metastasis in rectal cancer, and how to use MRI to guide treatment decisions.

Economic Savings and Costs of Periodic Mammographic Screening in the Workplace

his article discusses the costs and benefits of mammographic screening in the workplace. The cost of mammography itself and of diagnostic work-up are two of the largest costs involved.

Proton beam RT not exempt from evidence-based medicine

In May 2008, ONI reviewed an article by Herman Suit, MD, and colleagues in which they argued that randomized trials of proton beam therapy vs standard radiotherapy are not needed prior to a wider use of proton beam therapy. In an ONI reader poll, 81% disagreed with Dr. Suit, as does Dr. Robert Parker, of SUNY Stony Brook, in his letter below.

Modulation of Dose Intensity in Aerodigestive Tract Cancers: Strategies to Reduce Toxicity

Dr. Rich and colleagues present a compelling argument for the manipulation of temporal and spatial treatment parameters in chemoradiation programs. In essence, the authors address the shielding of normal tissues from the effects of cytotoxic agents. With respect to radiotherapy, this can be achieved via physical shielding by computer-generated dose algorithms using elaborate new planning technology (eg, intensity-modulated radiation therapy [IMRT]), chemical shielding with radioprotectants (eg, amifostine [Ethyol]), or temporal shielding by altered-fractionation schemes that exploit the differential alpha/beta ratios between tumor and normal tissue (eg, hyperfractionation).

Curing Pediatric Cancers: A Success Story Reconsidered

Over the past 50 years, great strides have been made in diagnosis, treatment, and survival of childhood cancer. In the 1960s the probability of survival for a child with cancer was less than 25%, whereas today it may exceed 80%. This dramatic change has occurred through significant and steady progress in our understanding of tumor biology, creation of specialized multidisciplinary care teams, incremental improvements in therapy, establishment of specialized centers with research infrastructure to conduct pivotal clinical studies, and the evolution of a cooperative group mechanism for clinical research. Most children with cancer in the United States, Europe, and Japan receive appropriate diagnosis and treatment, although access is limited in developing countries. The price of success, however, is the growing population of survivors who require medical and psychosocial follow-up and treatment for the late effects of therapy. Here we review the progress made in pediatric oncology over the past 3 decades and consider the new challenges that face us today.

AIDS-Related Cancers in the Era of Highly Active Antiretroviral Therapy

Highly active antiretroviral therapy (HAART) has shown great efficacy in reducing human immunodeficiency virus levels, increasing immunity, and prolonging the survival of persons with acquired immunodeficiency

Commentary (Cerfolio): Endoscopic Ultrasound Fine-Needle Aspiration in the Staging of Non-Small-Cell Lung Cancer

Precise mediastinal staging of non-small-cell lung cancer is extremely important, as mediastinal lymph node metastases generally indicate unresectable disease. Reliance on computed tomography (CT) and positron-emission tomography (PET) alone to stage and determine resectability is limited by false-positive results. Whenever possible, pathologic confirmation of metastases is desirable. Mediastinoscopy and transbronchial fine-needle aspiration are widely established but imperfect modalities. Endoscopic ultrasound fine-needle aspiration (EUS-FNA) has emerged as a diagnostic and staging tool because of its safety, accuracy, and patient convenience. We reviewed 13 prospective studies evaluating the comparative performance of EUS for staging lung cancer. We conclude that EUS is a valuable staging modality. Further studies of the role of EUS compared to other modalities such as integrated PET/CT and endobronchial ultrasound (EBUS) are forthcoming.