ONCOLOGY Vol 18 No 1

The use of radiation as adjuvant therapy for patients with cutaneousmalignant melanoma has been hindered by the unsubstantiatedbelief that melanoma cells are radioresistant. An abundance of literaturehas now demonstrated that locoregional relapse of melanoma iscommon after surgery alone when certain clinicopathologic featuresare present. Features associated with a high risk of primary tumor recurrenceinclude desmoplastic subtype, positive microscopic margins,recurrent disease, and thick primary lesions with ulceration or satellitosis.Features associated with a high risk of nodal relapse include extracapsularextension, involvement of four or more lymph nodes, lymphnodes measuring at least 3 cm, cervical lymph node location, and recurrentdisease. Numerous studies support the efficacy of adjuvant irradiationin these clinical situations. Although data in the literatureremain sparse, evidence also indicates that elective irradiation is effectivein eradicating subclinical nodal metastases after removal of theprimary melanoma. Consequently, there may be an opportunity to integrateradiotherapy into the multimodality treatment of patients at highrisk of subclinical nodal disease, particularly those with an involvedsentinel lymph node. Such patients are known to have a low rate ofadditional lymph node involvement, and thus in this group, a shortcourse of radiotherapy may be an adequate substitute for regional lymphnode dissection. This will be the topic of future research.

Dr. Wood has provided a comprehensivebut succinct reviewof the clinical managementoptions available to women withan increased risk of breast cancer. Heclearly defines his approach to riskstratificationamong women likely tosee a breast surgeon with concernsabout their breast cancer risk basedon family history-ie, BRCA1/2 mutationcarriers, those who have not yetbeen tested for BRCA1/2 mutations, and those who have tested negativefor BRCA1/2 mutations but have sufficientfamily and personal history tohave ongoing concern despite the negativetest. In the past, breast surgeonsmight have seen a wider range ofwomen at risk, but many are now toobusy to see anyone who is not contemplatingbilateral mastectomies. It is evenmore important, therefore, that they befamiliar with the basic workings of genetictesting.

Radiation therapy is not part ofthe traditional treatment approachto cutaneous melanoma.Aggressive surgical resection ofboth the primary site and regional nodalmetastases has long been consideredthe only option for achievinglong-term disease-free and overall survival.Many patients who present withmelanoma have thin lesions (< 1 mmBreslow thickness) and are essentiallycured with a wide local excision ofthe primary site. Patients with thickermelanomas and clinically negativeregional nodal basins often undergowide excision and sentinel node biopsyto identify occult nodal metastases.Those who have a sentinel lymphnode positive for metastatic diseaseor clinically positive nodes undergo atherapeutic lymph node dissection toprovide local control and possibly preventdistant metastatic disease. Recentarticles such as the one by Balloand Ang, however, highlight the in-creasedrole of external-beam radiationtherapy in the treatment of malignantmelanoma.

Women with any family history of breast cancer assume a high probabilityof risk. Counseling women involves ascertainment of an accuratefamily history and use of the best predictive models to assess boththe risk of a known mutation and the risk of breast cancer. This riskmust then be considered in the contexts of both the woman’s lifetimeand the next decade, in each instance carefully separating the risk ofdeveloping cancer from the risk of mortality. These two risks are oftenemotionally melded in women who have watched a loved one die ofcancer. The options for a woman at significantly increased risk of breastcancer include optimal surveillance, chemoprevention, and prophylacticsurgery. This entire field is in continuing evolution as better methodsof diagnosis, screening, and chemoprevention continue to enter clinicalpractice.

A review of sentinel node mapping in vulvar and cervical cancer, a technique intended to reduced lymphadenectomy-associated morbidity, and the related controversies.

The rigorous assessment of thebenefits of radiotherapy formelanoma has been confoundedby superstition on one hand, andreligious fervor on the other. In thisissue, Ballo and Ang have reviewedthe use of radiotherapy for melanoma,focusing primarily on the controversialtopic of adjuvant postoperativeradiotherapy to the primary tumor bedand regional lymphatics.

Focusing on the bioinformatics needs of the cancer community,the National Cancer Institute has begun a pilot program aimed atenabling and enhancing collaborative efforts to elucidate thebiology of the disease and create novel interventions for it. Creation ofthe Cancer Biomedical Informatics Grid (caBIG) began last summerwith seminars attended by more than 100 participants from NCIsupportedcancer centers, and visits by five teams of scientists andinformation technology specialists to 49 cancer centers to discusstheir informatics strengths, needs, and potential contributions to thenetwork.

Targeting the relationship between cancer and aging, the NationalCancer Institute and the National Institute on Aging will jointlyfund a new initiative to investigate the correlation between thetwo. The institutes will provide approximately $25 million in grantsover the 5-year program, with $5 million awarded in the initial year toeight institutions.

Iwould like to compliment the authorson an excellent review ofsentinel node evaluation in gynecologiccancer-in particular, vulvarand cervical cancer. The authors havebeen at the forefront of minimally invasivesurgery for gynecologicmalignancies. They have publishedextensively about their experiencewith laparoscopy and radical trachelectomy.Now this group brings forthanother technique that may revolutionizethe way we treat women withvulvar and cervical carcinoma.

Until recently, peritoneal carcinomatosis was a universally fatalmanifestation of gastrointestinal cancer. However, two innovations intreatment have improved outcome for these patients. The new surgicalinterventions are collectively referred to as peritonectomy procedures.During these procedures, all visible cancer is removed in an attempt toleave the patient with only microscopic residual disease. Perioperativeintraperitoneal chemotherapy, the second innovation, is employed toeradicate small-volume residual disease. The intraperitoneal chemotherapyis administered in the operating room with moderate hyperthermiaand is referred to as heated intraoperative intraperitoneal chemotherapy.If tolerated, additional intraperitoneal chemotherapy canbe administered during the first 5 postoperative days. The use of thesecombined treatments, ie, cytoreductive surgery and intraperitoneal chemotherapy,improves survival, optimizes quality of life, and maximallypreserves function. Part 1 of this two-part article describes the naturalhistory of gastrointestinal cancer with carcinomatosis, the patterns ofdissemination within the peritoneal cavity, and the benefits and limitationsof peritoneal chemotherapy. Peritonectomy procedures are also definedand described. Part 2, to be published next month in this journal,discusses the mechanics of delivering perioperative intraperitoneal chemotherapyand the clinical assessments used to select patients who willbenefit from combined treatment. The results of combined treatment asthey vary in mucinous and nonmucinous tumors are also discussed.

Dr. Wood has provided an excellentreview of the issuesfacing women at high risk fordeveloping breast cancer. In additionto emphasizing the significance of accuraterisk assessment, he describessurveillance techniques that enableearly detection of the disease and hasprovided a comprehensive review ofrisk-reduction options for women athigh risk.

By a long-standing strategy,practitioners have sought tolessen the morbidity associatedwith the treatment of pelvic malignancies.With careful understandingof pathologic prognostic factors andthe natural histories of recurrence andmetastatic disease, as well as improvementof imaging studies, there hasbeen a significant reduction in the radicalityof gynecologic surgery.[1-3]

Four newly created Breast Cancer and the Environment ResearchCenters will work together in a $35 million effort to investigatethe prenatal to adult environmental factors that may predisposewoman to developing breast cancer. The centers, jointly financed bythe National Cancer Institute and the National Institute of EnvironmentalHealth Sciences, will receive $5 million annually for 7 years.

In their article on radiotherapy forcutaneous malignant melanoma,Drs. Ballo and Ang discuss fourkey points, which we will addressbelow.