Is there a role for complementary therapy in the management of leukemia?

Patients with leukemia often seek additional treatments not prescribed by their oncologist in an effort to improve their cancer treatment outcome or to manage symptoms. Complementary therapies are used in conjunction with traditional cancer treatments to decrease symptoms and side effects associated with cancer or cancer treatment, and to improve patients’ overall quality of life. Complementary therapies are distinct from so-called ‘alternative’ therapies, which are unproven, ineffective and may postpone or interfere with mainstream cancer treatment. Complementary therapies are pleasant, inexpensive, nonpharmacologic and effective. For patients with leukemia, the complementary therapies that are always appropriate include mind–body interventions, such as self-hypnosis, meditation, guided imagery and breath awareness. Massage and reflexology (foot massage) decrease symptoms with effects lasting at least 2 days following treatment. Acupuncture is very beneficial for symptom management without adverse consequences. Physical fitness with regular exercise and healthy dietary habits can significantly decrease side effects of cancer treatments and may prolong survival. Botanical extracts and vitamin supplements may interfere with active cancer treatments, and should be discussed with the oncologist or pharmacist before use.     

Is there a role for radiation therapy in the management of Hürthle cell carcinoma?

PURPOSE: To determine the role that radiation therapy may have in the management of resected, unresectable, and metastatic Hürthle cell carcinoma. METHODS AND MATERIALS: Retrospective review of 18 patients receiving radiation therapy for Hürthle cell carcinoma of the thyroid gland. The diagnosis was established in 10 men and 8 women between November 1943 and January 1995. Median age was 57.9 years. Initially, 5 patients received adjuvant radiation therapy, 7 received salvage radiation therapy for unresectable recurrent disease, and 6 received palliative radiation therapy for distant metastases. Median follow-up was 107.1 months (range 15.7-351 months). The Kaplan-Meier method was used to calculate and estimate overall survival, cause-specific survival, and locoregional tumor control rate. RESULTS: The 5-year overall and cause-specific survival rates were 66.7% (SE 11.1%) and 71.8% (SE 10.7%), respectively. Adjuvant radiation therapy was successful in preventing recurrence in 4 of 5 patients. Salvage radiation therapy was successful in 3 of 5 patients treated with external beam radiation therapy. Palliative radiation therapy provided sustained symptomatic relief at 67% of irradiated sites. CONCLUSIONS: Hürthle cell carcinoma of the thyroid gland is a radiosensitive tumor. Radiation therapy may provide palliative relief from symptomatic metastases, control recurrent tumors, and prevent recurrence of advanced resected tumors.     

Clear cell carcinoma of the ovary: Is there a role of histology-specific treatment?

Several clinical trials to establish standard treatment modality for ovarian cancers included a high abundance of patients with serous histologic tumors, which were quite sensitive to platinum-based chemotherapy. On the other hand, ovarian tumor with rare histologic subtypes such as clear cell or mucinous tumors have been recognized to show chemo-resistant phenotype, leading to poorer prognosis. Especially, clear cell carcinoma of the ovary (CCC) is a distinctive tumor, deriving from endometriosis or clear cell adenofibroma, and response rate to platinum-based therapy is extremely low. It was implied that complete surgical staging enabled us to distinguish a high risk group of recurrence in CCC patients whose disease was confined to the ovary (pT1M0); however, complete surgical staging procedures could not lead to improved survival. Moreover, the status of peritoneal cytology was recognized as an independent prognostic factor in early-staged CCC patients, even after complete surgical staging. In advanced cases with CCC, the patients with no residual tumor had significantly better survival than those with the tumor less than 1 cm or those with tumor diameter more than 1 cm. Therefore, the importance of achieving no macroscopic residual disease at primary surgery is so important compared with other histologic subtypes. On the other hand, many studies have shown that conventional platinum-based chemotherapy regimens yielded a poorer prognosis in patients with CCC than in patients with serous subtypes. The response rate by paclitaxel plus carboplatin (TC) was slightly higher, ranging from 22% to 56%, which was not satisfactory enough. Another regimen for CCC tumors is now being explored: irinotecan plus cisplatin, and molecular targeting agents. In this review article, we discuss the surgical issues for early-staged and advanced CCC including possibility of fertility-sparing surgery, and the chemotherapy for CCC disease.     

Is there a role for radiotherapy in the management of upper gastrointestinal malignancies?

Radiation therapy has several established roles in the management of upper gastrointestinal malignancy. These roles parallel those for which radiation is used in other anatomic regions (e.g., single and multimodality management with curative intent, organ preservation, and palliation). This article provides a brief summary of the use of radiotherapy in the management of upper gastrointestinal malignancies. It includes applications for radiotherapy used with curative and palliative intent.     

Is there a role for intraperitoneal chemotherapy in the management of ovarian cancer?

Phase I and II clinical trial data have demonstrated the safety, pharmacokinetic advantage, and potential for enhanced cytotoxicity associated with the intraperitoneal administration of antineoplastic agents in the management of ovarian cancer. In two randomized phase III studies comparing the intraperitoneal and intravenous administration of cisplatin (Platinol) as initial therapy for small-volume residual advanced ovarian cancer, intraperitoneal delivery of the agent produced superior progression-free and overall survival. Reluctance to employ intraperitoneal cisplatin in the standard management of ovarian cancer appears to be related to the added time, effort, and potential morbidity associated with the approach, as well as a general preference for the less toxic, less complicated carboplatin (Paraplatin)-based regimen. However, existing data support the use of this unique method of drug delivery in carefully selected patients outside of the clinical trial setting.     

Is there a role for immunotherapy in malignant pleural mesothelioma?

Malignant pleural mesothelioma (MPM) is a very aggressive malignancy, mainly caused by asbestos exposure. Patients with MPM have a poor prognosis that remained substantially unchanged in the last few years and limited effective therapeutic options with no recognized second or further-line therapy. In this context, also in view of the positive results observed in other tumor types, immunotherapy could play a relevant role. This review focuses on the most promising immunotherapies being investigated in MPM.     

Is there a role for sentinel lymph node biopsy in the management of sarcoma?

Is there a role for sentinel lymph node (SLN) biopsy in the management of sarcoma? Sentinel node biopsy has dramatically changed the management of melanoma and breast cancer, helping surgeons avoid radical lymphadenectomies in node negative patients who would previously have undergone a more morbid operation with little benefit, or remained pathologically unstaged. Many investigators have explored the use of lymphatic mapping for malignancies other than breast cancer or melanoma. Lymphatic mapping and sentinel node biopsy has not been investigated in the management of sarcomas, which is not surprising given that the majority of sarcomas spread by local extension or hematogenously. Regional lymph node metastases are rare; developing in about 3-10% of patients with localized disease. However, among certain subtypes of high-grade sarcomas there is a propensity for regional lymph node metastases. These include rhabdomyosarcoma, epithelioid sarcoma, clear cell sarcoma, synovial sarcoma, and vascular sarcomas. It is in these particular subtypes that there may be a benefit to SLN biopsy.     

Is there a need for autopsies in the management of fungal disease?

The autopsy rates in Germany became low like in other European, American and Asian countries. Main reasons for this development are the lack of acceptance of autopsy in the society as well as in the medical profession, the introduction of a requirement for consent, unclear legal position, the public health system, pressure of costs and a change in the field of activity in pathology with much more diagnostics of surgical and biopsy material. The autopsy is missing with respect to the reliability of causes of death and morbidity statistics and other epidemiological studies. Published data indicate that up to 20–30% of patients who die in hospitals have important diseases/lesions that remain undetected before death but that are found at autopsy. For infectious diseases, the data are similar. Therefore, a higher incidence of invasive fungal infections was found. Some rare fungal disorders are diagnosed by autopsy. Only exact death statistics makes specific health care possible and is cost saving in a public health system in the long term. Autopsy remains an important tool for quality control in medical diagnostic and therapeutic activity. It is also essential for fundamental medical education and further training.     

Is there still a role for stem cell transplantation in multiple myeloma?

High-dose chemotherapy and autologous stem cell transplantation (ASCT) are a standard of care for transplant-eligible patients with newly diagnosed multiple myeloma (MM). The introduction of novel agents, which range from immunomodulatory drugs and proteasome inhibitors to monoclonal antibodies and have now been integrated into both induction and salvage regimens, has dramatically revolutionized the treatment landscape of MM and challenged the role of high-dose chemotherapy and ASCT in treating MM. These advances have led to a number of provocative questions. First, what is the current role of stem cell transplantation (SCT) in comparison with standard-dose therapy incorporating novel agents? Second, should ASCT be performed upfront (“early”) or later (“delayed”) in the course of the disease? Third, should single or double ASCT be performed? Fourth, is allogeneic SCT still an option for patients with MM? This article provides an overview of available data and evidence-based responses regarding the role of SCT in MM.     

Should extragonadal germ cell tumors be included in studies of families with testicular germ cell tumors?

Background

Family history is among the few established risk factors for testicular germ cell tumor (TGCT). Approximately 1.4% of newly diagnosed TGCT patients report a positive family history of TGCT. Sons and siblings of TGCT patients have four- to six fold and eight- to tenfold increase in TGCT risk, respectively. In twins of men with TGCT the relative risk of testicular cancer is 37.5 (12.3-115.6). Nevertheless, information about the occurrence of TGCT in relatives of patients with extragonadal germ cell tumor is limited.

Case report

A 24 year-old male patient was diagnosed with a mediastinum tumor and was submitted to image-guided biopsy, which revealed a seminoma. Two months later, his non-identical asymptomatic twin brother was submitted to an elective ultrasound of the testes, which showed a left testicular mass of 4.2 cm. This patient underwent orchiectomy revealing a seminoma of the left testis. There are no other cases of seminoma or other types of cancers reported in first-degree relatives in this family.

Conclusions

Although familial aggregations of TGCT have been well described, to the best of our knowledge, no data concerning the association of gonadal and extragonadal germ cell tumor in relatives has been previously reported. Further investigation on this association is warranted and may help in improving our knowledge of familial pattern inheritance.     

Is there a role for fractionated radiotherapy in the treatment of arteriovenous malformations?

Single fraction radiotherapy for the treatment of arteriovenous malformations (AVMs) is appropriate when brain tolerance is not a limiting factor, but when tolerance is a concern, there is a potential for therapeutic gain with fractionated treatment. alpha/beta values for AVM obliteration have been derived and found to be higher than previously assumed and are likely to be approximately 10.0 Gy or more compared with approximately 1.5 Gy for the tolerance of small volumes of brain. Models are derived to describe, qualitatively, the potential gain that can be achieved with fractionation. Past experience has identified an important volume effect that has limited the use of stereotactic treatments to small volumes. Volume-dependent, dose-volume relationships are described, including a tissue-specific volume exponent (phi) which was found to apply across a relatively wide range of target volumes, thereby permitting the derivation of tolerance guidelines to volumes larger than previously available. More data to define parameter values more precisely are desirable.     

Is there a role for chemotherapy in prostate cancer?

There is evidence from randomised-controlled trials that patients with symptomatic hormone-refractory prostate cancer may experience palliative benefit from chemotherapy with mitoxantrone and prednisone. This treatment is well tolerated, even by elderly patients, although the cumulative dose of mitoxantrone is limited by cardiotoxicity. Treatment with docetaxel or paclitaxel, with or without estramustine, appears to convey higher rates of prostate-specific antigen response in phase II trials, but is more toxic. Large phase III trials comparing docetaxel with mitoxantrone have completed accrual. There is no role for chemotherapy in earlier stages of disease except in the context of a well-designed clinical trial.     

Is there a role for a brachytherapy vaginal cuff boost in the adjuvant management of patients with uterine-confined endometrial cancer?

Purpose/Objective: Many patients who have uterine-confined endometrial cancer with prognostic factors predictive of recurrence are treated with adjuvant pelvic radiation. The addition of a brachytherapy vaginal cuff boost is controversial.Materials and Methods: Between 1983 and 1993, 270 patients received adjuvant postoperative pelvic irradiation following hysterectomy for Stage I or II endometrial cancer. Group A includes 173 patients who received external beam irradiation alone (EBRT), while group B includes 97 patients who received EBRT with a vaginal brachytherapy application. The median dose of EBRT was 45 Gy. Vaginal brachytherapy consisted of a low dose rate ovoid or cylinder in 41 patients, a high dose rate cylinder in 54 patients, and a radioactive gold seed implant in two patients. The median follow-up time was 64 months. The two groups were compared in terms of age, histologic grade, favorable versus unfavorable histology, capillary space invasion, depth of myometrial invasion, and pathologic stage.Results: Chi-square analysis revealed that the only difference between the two groups was the presence of more Stage II patients in group B (38% versus 14%). No difference was detected for 5 year pelvic control and disease-free survival rates between groups A and B.Conclusion: There is no suggestion that the addition of a vaginal cuff brachytherapy boost to pelvic radiation is beneficial for pelvic control or disease-free survival for patients with Stage I or II endometrial cancer. Prospective randomized trials designed to study external irradiation alone versus external beam treatment plus vaginal brachytherapy are unlikely to show a positive result. Because EBRT provides excellent pelvic control, protocol development for uterine-confined corpus cancer should focus on identifying patients at risk for recurrence as well as other means of augmenting EBRT (e.g. addition of chemotherapy) in order to improve disease free survival in those subgroups.     

Is there a role for molecular prognostic factors in the clinical management of ductal carcinoma in situ (DCIS) of the breast?

INTRODUCTION: The incidence of ductal carcinoma of the breast (DCIS) increased in Europe and the US up to 10-fold over the last 20 years ?8. This could be linked to more vigorous screening mammography, as well as changes of histopathologic and diagnostic criteria for breast lesions during the last decades ?31,26. Optimal screening for DCIS, the diagnostic procedures and best treatment is still controversial. For many DCIS patients lumpectomy and adjuvant radiotherapy are a valid treatment option. There is need for better prognostic factors in DCIS, which indicate the need for therapy and tailor the intensity of treatment. Recently prognostic factors based on clinical and pathological findings for DCIS were established and are currently validated. Molecular mechanisms involved in DCIS formation, DCIS progression to invasive breast cancer, and predicting DCIS treatment response are rapidly emerging ?46. RESULTS AND CONCLUSION: Here we discuss some of the known molecular mechanisms of DCIS and how they could be further exploited as prognostic factors for screening and tailoring DCIS therapy. This review will summarize relevant molecular mechanism of DCIS carcinogenesis including dysregulation of the cell cycle clock and changes of the apoptotic threshold. In particular, recently published molecular and cellular abnormalities in DCIS, potentially relevant for treatment decision, will be discussed.     

Is there still a role for the uniscale assessment of quality of life?

AIMS AND BACKGROUND: To obtain proof of external validity of the visual analogue scale and re-evaluate the use of this instrument in assessing cancer patients' quality of life. METHODS: Consecutive patients attending 79 Italian medical oncology and radiotherapy centers over a period of 1 week were asked to fill out both a questionnaire concerning the presence of 19 problems and a 100-mm linear visual analogue scale evaluating their quality of life. Quality of life was rated as "good" and "bad" when given a score of 70-100 and 0-30, respectively. Multifactorial logistic models were used where good and bad quality of life were correlated with explanatory variables including patient and disease characteristics and the presence or absence of the 19 problems. RESULTS: Gender, level of education, treatment setting, Karnofsky performance status, disease extent, and the presence of 12 out of 19 problems were found to be correlated with good quality of life. A similar pattern of correlations was found with bad quality of life. CONCLUSIONS: Due to the difficulties in attaining reliable assessment of quality of life using psychometric questionnaires, the further proof of validity obtained in this study allows us to propose the re-evaluation of the role of the uniscale in measuring the quality of life of cancer patients.     

Is there a role for dose-intensive chemotherapy with stem cell rescue in breast cancer?

Over the past decade, high-dose chemotherapy with autologous bone marrow and/or peripheral blood rescue has been increasingly used to treat women with breast cancer. Laboratory and clinical studies have shown that dose intensity may be important in treating selected patients with breast cancer. Initial phase I studies showed good response rates of short durations. Further trials in metastatic disease with high-dose chemotherapy and stem cell rescue earlier in the treatment course had been encouraging. However, the optimal timing of high-dose chemotherapy remains a question. In addition, randomized trials in high-risk early-stage breast cancer have completed accrual. Technologic improvements in stem cell procurement and hematopoietic growth factors have contributed to decreased morbidity and mortality. This review will discuss the role of such therapy in the treatment of women with breast cancer.     

Acute left-sided malignant colonic obstruction: Is there a role for endoscopic stenting?

The therapy of left-sided malignant colonic obstruction continues to be one of the largest problems in clinical practice. Numerous studies on colonic stenting for neoplastic colonic obstruction have been reported in the last decades. Thereby the role of self-expandable metal stents (SEMS) in the treatment of malignant colonic obstruction has become better defined. However, numerous prospective and retrospective investigations have highlighted serious concerns about a possible worse outcome after endoscopic colorectal stenting as a bridge to surgery, particularly in case of perforation. This review analyzes the most recent evidence in order to highlight pros and cons of SEMS placement in left-sided malignant colonic obstruction.     

Is there a role for advanced radiation therapy technologies in the treatment of pancreatic adenocarcinoma?

Pancreatic cancer remains a highly challenging problem in oncology. Oncologists continue to search for therapies that are more effective than those currently available to improve on the existing poor treatment results. Persistence of both systemic and local disease causes high rates of morbidity and mortality for patients. Radiation continues to play a role in the treatment of pancreatic cancer, in both the adjuvant and locally advanced settings. Efforts to improve on the results of radiotherapy have led to the use of new and improved technologies. This review discusses a variety of these technological improvements and their current and potential future roles in the clinic.