Words from the Editor-in-Chief

In this issue, a new column 'UICC Spirit in China' is created, presenting the announcement ot 2008 UICC world cancer congress.     

Who benefits from hormone therapy?

Not all hormone receptor (HR)-positive tumors respond to hormone therapy, although hormone therapy has brought significant benefits to breast cancer patients. In order to improve the efficacy of hormone therapy, a variety of new approaches are currently being tested in such as extended adjuvant therapy, selection of responders using array-based techniques and combination therapy with signal transduction inhibitors. It is therefore necessary to distinguish between highly hormone responsive tumors and relatively less hormone sensitive tumors. Through reviewing recent outcomes of clinical trials, these issues are summarized and discussed in this review.     

Sarcoma arising from Langerhans cellsĭ

A rare case of tumor arising from Langerhans cells in the tongue and neck area in a 37 year-old man is presented. It was a polymorphocellular sarcoma with bean-like twisted nuclei. Electron microscopy identified granules of Langerhans (Bierbeck), multiple tubulo-vesicular structures, ring-like plates, Golgi apparatus, lysosomes and dendritic processes. Total leukocytic antigen was assayed in tumor cells but no expression of S-100 protein found.     

What do patients want from their radiation oncologist? Initial results from a prospective trial

PURPOSE: To assess patients' initial physician preferences using a newly developed instrument. METHODS AND MATERIALS: A total of 182 patients with a primary diagnosis of prostate, breast, or lung cancer referred for consultation to the University of Pittsburgh Cancer Institute Department of Radiation Oncology enrolled in our institutional review board-approved protocol. All patients completed patient preference instrument surveys before meeting their radiation oncologist. Survey responses to 10 statements were categorized into three groups (agree, neutral, or disagree), and the association of survey responses by cancer site was tested with chi-squared tests. RESULTS: Ninety-nine percent of all patients preferred to be addressed by their first name in encounters with their radiation oncologist. There were significant associations of Item 3 (hand holding) with gender (p = 0.039) and education (p = 0.028). The responses to Item 5, a statement that patients would feel uncomfortable if the radiation oncologist offered to hug them at the end of treatment, was significantly associated with disease site (p < 0.0001). Further analysis was performed for Item 5 and revealed that the male lung cancer patients had a much higher rate of disagreement with Item 5 compared with prostate cancer patients (37% vs. 18%). CONCLUSIONS: Results of this study may afford greater insight and foster better understanding of what patients want from their radiation oncologist. For breast, lung, and prostate cancer patients, initial preferences for their radiation oncologist are generally similar, according to this tool. However, there are important difference among cancer sites (and gender) regarding physical contact at the end of treatment.     

Do children and adults differ in survival from medulloblastoma? A study from the SEER registry

Studies investigating whether adults have diminished survival from medulloblastoma (MB) compared with children have yielded conflicting results. We sought to determine in a population-based registry whether adults and children with MB differ in survival, and to examine whether dissimilar use of chemotherapy might contribute to any disparity. 1,226 MB subjects were identified using the Surveillance Epidemiology and End Results (SEER-9) registry (1973–2002) and survival analysis performed. MB was defined strictly to exclude non-cerebellar primitive neuro-ectodermal tumors. Patients were stratified by age at diagnosis: <3 years (infants), 3–17 years (children) and ≥18 years (adults). Because the SEER-9 registry lacks treatment data, a subset of 142 patients were identified using the San Francisco-Oakland SEER registry (1988–2003) and additional analyses performed. There was no significant difference in survival between children and adults with MB in either the SEER-9 (P = 0.17) or SFO (P = 0.89) cohorts but infants fared worse compared to both children (P < 0.01) and adults (P < 0.01). In the SFO sample, children and adults who received chemotherapy plus radiation therapy (XRT) did not differ in survival. Among patients treated with XRT alone, children showed increased survival (P = 0.04) compared with adults. Children and adults with MB do not differ with respect to overall survival, yet infants fare significantly worse. For children and adults with MB treated with both XRT and chemotherapy, we could not demonstrate a survival difference. Similar outcomes between adult and childhood MB may justify inclusion of adults in pediatric cooperative trials for MB.     

Myc-Is this the oncogene from Hell?

A new paper implicates the Myc oncoprotein in the direct induction of DNA damage and consequent genome instability in cultured cells. However, it is less clear whether Myc induces the same genetic pandemonium in vivo.     

Intraductal papilloma with bloody discharge from montgomery’s areolar tubercle examined by ductoscopy from the areola

A patient with intraductal papilloma who had abnormal bloody discharge from Montgomery's areolar tubercle underwent mammary ductography, mammary ductoscopy from the tubercle, and microdochectomy.A 43-year-old woman who was being followed-up for left breast cancer noticed bloody discharge from Montgomery's areolar tubercle of the right breast. Because the discharge continued for 2 months, further examinations were conducted. Mammary ductoscopy of Montgomery's areolar tubercle showed a normal internal duct structure. The presence of yellowish superficial lesions suggested intraductal inflammation or superficial hyperplasia of the duct epithelium. Lavage cytology revealed benign papillary lesions. Since the discharge continued and we could not completely exclude malignancy, microdochectomy was performed. Histologically a lactiferous duct was connected to Montgomery's areolar tubercle and an intraductal papilloma was seen in part and considered to have caused the bloody discharge. Bloody discharge from Montgomery's areola tubercles is extremely rare, the present case was our first experience with ductoscopy of Montgomery's areolar tubercle out of 641 cases of mammary ductoscopy performed on patients with bloody nipple discharge from 1998 to 2004. In our case, Montgomery's areolar tubercles were connected to a lactiferous duct. Although there are a few breast carcinomas that cause bloody discharge and eruption of areola, areolar preservation should be performed with the knowledge that disease may also involve the areola through the lactiferous ducts.     

Cutaneous metastases from neuroendocrine carcinoma of the cervix—An unusual metastatic lesion from an uncommon malignancy

Neuroendocrine carcinoma (NEC) is an uncommon and aggressive type of small cell cervical cancer. NECs mostly arise from gastro-entero-pancreatic tract and the lung, but rarely from other organs like cervix. NEC of the cervix is a rare malignancy and constitutes 0.9%-1.5% of cervical tumors. NECs of cervix are common in perimenopausal females and present with abnormal vaginal bleeding and mimic squamous cell cancers, usually with no distinguishing features. On Immunohistochemistry, presence of chromogranin, synaptophysin, and CD-56 is necessary to make a diagnosis of small cell carcinoma. These tumors are notorious for local as well as distant relapses in comparison to their squamous and adenocarcinoma counterpart. NECs are characterized by highly aggressive clinical behavior and carry a poor prognosis. They commonly metastases to lung, liver, brain, and bones even in early stages of the disease. Metastasis to skin is a rare occurrence. We herein report a case of a NEC of the uterine cervix with multiple cutaneous metastases. After the initial diagnosis of NEC of cervix, the patient received concurrent chemoradiation followed by intracavitary brachytherapy. On subsequent follow-up, the patient developed multiple cutaneous metastasis along with liver metastases. This case is reported in view of rarity of the case with skin metastases. To the best of our knowledge, only 3 cases of cutaneous metastases from NEC of the cervix are reported till date. Being a rare malignancy, evidence in the literature is in form of case reports and small case series. Thus, the optimal treatment strategy varies for these patients. Multimodality management with teamwork is necessary to manage individual patients.     

What can oncologists learn from HIV?

Developments in HIV-related medicine have significant implications for the practice of oncology. Although HIV is a relatively new discipline within medicine, the identification and therapeutic targeting of HIV has been rapid. Furthermore, political lobbying has sculpted scientific research and patient care. Rational drug design has reduced morbidity and mortality to such an extent that the development of predictive surrogate endpoints has been necessary to enable randomised assessments of new protocols to continue. These studies now include the routine detection of resistance to tailor specific therapies to the patient. The involvement of affected communities in dynamically modelled studies have shown the efficacy of new, preventive strategies and debates about such approaches have improved the standard of care. In this review, we discuss what oncologists can learn from the HIV epidemic.     

Which approach is better in eliciting health state utilities from breast cancer patients? Evidence from mainland China

Accurately measuring health state utilities is crucial for health economic evaluation. This study empirically investigated both indirect approaches (including using the latest version of five‐level EQ‐5D questionnaire, EQ‐5D‐5L and the popular SF‐6D), as well as a direct approach (the time trade‐off, TTO) for eliciting utilities in breast cancer patients. A valid sample of 608 breast cancer patients (48% TNM Stages III/IV) in mainland China was analysed. Mean utilities elicited from the TTO, EQ‐5D‐5L and SF‐6D were 0.80, 0.83 and 0.65 respectively. There is poor to fair agreement between direct and indirect approaches on measuring health state utilities with breast cancer patients. The absolute agreement was higher between EQ‐5D‐5L and SF‐6D utilities (intraclass correlation coefficient, ICC = 0.55) than between TTO and EQ‐5D‐5L/SF‐6D utilities (ICCs < 0.3). Regression analyses found that both EQ‐5D‐5L and SF‐6D utilities were responsive to five out of eight breast cancer‐specific symptom and functional scales. In sum, criterion and known‐group validities of three health state utility measures which were investigated in this research suggest that, the EQ‐5D‐5L is currently the optimal approach (followed by the SF‐6D) to elicit health state utilities from breast cancer patients in mainland China.     

Peritoneal carcinomatosis from colorectal cancer: HIPEC?

Peritoneal carcinomatosis (PC) is a frequent terminal evolution from colorectal cancer. At the time of diagnosis of colon malignancies, PC affects approximately 10% of the patients [1]. Medical oncologists and gastrointestinal surgeons had considered it to be an untreatable condition for its unfavorable prognosis with a median survival of 6-9 months [1], suitable only for palliative treatment. Recurrence with carcinomatosis occurs in 25% of patients [2] and seems to be the only site of disease in 25-35% of these [3]. In a recent review of the literature on 12 trials, the incidence of peritoneal seeding during potentially curative surgery for PC from colorectal cancer varied from 3% to 28% [4]. Sugarbaker has suggested that peritoneal carcinomatosis is a locoregional cancer spread as a result of a molecular crosstalk between cancer cells and host elements [9]. Based on this concept and after Spratt first performed a debulking surgery (CR) followed by an intraperitoneal hyperthermic chemotherapy (HIPEC) in 1980 [5] and [6], numerous trials and investigations have been conducted on this technique [4]. Phase II studies on patients with PC of colorectal origin treated with CR plus HEPIC reported 5-year survival rates from 20% to 30% [7], while in a randomized controlled single-institution phase III trial this technique improved survival of patients affected by peritoneal carcinomatosis from colorectal malignancies (22.3 months versus 12.6 months) [8]. In all the series, an optimal cytoreduction is the most important prognostic factor for these patients [4]. The aim of this study is to demonstrate that peritoneum, as first line defense from carcinomatosis, is like an organ and so, the treatment of PC in selected patients should be a locoregional therapy with HIPEC in addition to CR [9].     

Presentation of Axillary Metastases from Occult Breast Carcinoma

Axillary presentation from occult breast cancer is uncommon and continues to be a diagnostic and therapeutic challenge to physicians. Once the diagnosis of adenocarcinoma metastatic to an axillary lymph node has been confi rmed, a preoperative workup should be done. The current experience is based on several relatively small retrospective reviews and case reports. It is diffi cult to determine the best management of occult breast cancer. However, treatment of axillary lymph node dissection is recommended for local control and complete staging information. Treatment of breast should be a choice between breast conservation with whole-breast radiotherapy and mastectomy. Adjuvant systemic treatment should be offered.