Curr. Oncol., Volume 17, Issue 6 (November 2010) – 17 articles

Aromatase inhibitors have not been adequately assessed in treatment of ovarian cancer. The aromatase inhibitor letrozole (2.5 mg daily) was administered in 2 cases of advanced endometrioid ovarian cancer with positive estrogen receptor. Case 1: A 52-year-old woman with a grade 2–3, stage IIIC endometrioid ovarian cancer was optimally debulked and received 6 cycles of intravenous paclitaxel and intraperitoneal cisplatin–paclitaxel. Post chemotherapy, one of several biopsies showed residual disease during the second-look laparoscopy. This patient was treated with letrozole and remained disease-free during 30 months of follow-up. Case 2: A 47-year-old woman with a grade 3, stage IIIC endometrioid ovarian cancer was optimally debulked and treated with intravenous carboplatin–paclitaxel. After a 15-month remission, her first recurrent disease was treated with carboplatin–docetaxel. The second remission lasted only 11 months, after which the patient was treated with splenectomy and subsequent liposomal doxorubicin. Letrozole was administered after the chemotherapy. The patient had a 30-month remission before the next recurrence of her disease. Conclusions: Endometrioid ovarian carcinoma may benefit from aromatase inhibitors, especially when the tumour burden is low after primary chemotherapy or when the inhibitor is used as maintenance therapy between chemotherapies. Full article

Sister Joseph nodule is a metastatic umbilical lesion secondary to a primary malignancy of any viscera. It can be a presenting symptom (a sign of undiagnosed malignancy) or a symptom or sign of progression or recurrence in a known case. Its incidence is 1–3% of all intra-abdominal or pelvic malignancies. Here, we present 4 such cases, with Sister Joseph nodule as a finding of (1) presentation in a case of gallbladder carcinoma, (2) progression in a case of malignant gastrointestinal stromal tumour, (3) recurrence in a case of ovarian carcinoma, and (4) presentation in a case of rectal carcinoma. The clinicopathologic features of all 4 patients are discussed, and the related literature is briefly reviewed. Full article

Metastasis to the breast is a rare occurrence, constituting fewer than 2% of all breast tumours. Of all metastatic tumours in the breast, most arise from contralateral breast primaries. Other reported primary solid tumour sites include melanoma; lung, gastric, and renal cancers; and approximately 29 cases of carcinoid tumour. Ambiguous presentations and an absence of carcinoid syndrome features make accurate radiographic and histologic assessment of breast carcinoids challenging. Here, we report the case of a 52-year-old woman who presented with a mammographic abnormality in the left breast. Excisional biopsy revealed histopathology consistent with carcinoid. After an exhaustive work-up, carcinoid within the terminal ileum was ultimately identified, and the woman was diagnosed with metastatic breast carcinoid, an exceedingly rare entity. This paper describes the common mammographic, cytologic, and immunohistochemical features typical of metastatic breast carcinoid tumours, together with their common clinical features, prognosis, and treatment options. Full article

Cisplatin-based therapy is curative in testicular cancer. Adverse effects of cisplatin-based chemotherapy include dose-dependent myelosuppression, nephrotoxicity, neurotoxicity, and ototoxicity. By contrast, chemotherapy-associated vascular complications are unpredictable. Few incidents of digital gangrene with cisplatin have been reported. Here, we present a patient who developed arterial occlusion leading to gangrene of the toe after cisplatinbased chemotherapy. Full article

Background: Spontaneous rupture of adrenal pheochromocytoma is an extremely rare condition that can be lethal. Optimal treatment in these cases is still unclear. Methods: We conducted a comprehensive review of MEDLINE articles on ruptured pheochromocytomas to locate all research done on this topic. Based on the literature review and one additional case at European Gaza Hospital, we analyzed clinical presentations, hemorrhage site, tumour side, mortality rate, and treatment options. Results: In addition to our case, we identified 53 cases of ruptured pheochromocytoma. A review of all 53 cases revealed that 17 (32%) of the patients died, and that no mortality occurred among the 12 patients who received an alpha-blocker (to control high blood pressure) and fluid infusion therapy before surgery. Only 3 patients, including our case, underwent elective surgery after transcatheter arterial embolization (TAE). Conclusions: Surgical treatment should be considered for ruptured pheochromocytoma. Surgical approaches involve either emergency or elective surgery. It has been reported that emergency surgery is commonly associated with a high mortality rate; no deaths were reported in patients who underwent elective surgery. We therefore consider that, if a patient has hemodynamic instability, TAE can be an effective and a safe procedure for achieving hemostasis and maintaining the patient in good condition until surgery can be performed. Full article

Purpose: Our survey aimed to document variability in the practice patterns of Canadian radiation oncologists treating high-grade brain tumours. Materials and Methods: A 20-question survey was developed to address various aspects of treatment: (1) Guidelines used; (2) Types of fusion protocols used; (3) Number of treatment phases; (4) Margins for volume delineation; (5) Dose constraints. The survey was sent to Canadian radiation oncologists currently treating the central nervous system (CNS) as one of their primary sites. Results: We attained a 56% response rate from radiation oncologists across Canada treating CNS sites. In their practice, 14% of respondents reported following guidelines from the European Organisation for Research and Treatment of Cancer; 32%, from the Radiation Therapy Oncology Group; and 56%, centre-specific guidelines. Single-phase treatment was reported by 60% of clinicians, and two-phase or multi-phase treatments, by 37%. For clinicians treating in single phase, margins from the gross treatment volume (GTV) to the planning treatment volume (PTV) included 0.5 cm (6%), 1 cm (6%), 1.5 cm (25%), 2.0 cm (56%), 2.5 cm (25%), and 3 cm (12.5%), with some respondents selecting more than one standard margin. For clinicians treating in multiple phases, margins from gtv to ptv in phase 2 included 1 cm (10%), 2.0 cm (40%), 2.5 cm (30%), and 3.0 cm (20%). Variability was also observed in dose constraints to critical structures. All respondents trimmed their margins to bony structures. Full article

Objectives: The present study investigated factors affecting outcome at relapse after previous surgery and adjuvant chemoradiation (CRT) in high-risk esophageal cancer patients. Patients and Methods: From 1989 to 1999, we followed high-risk resected esophageal cancer patients who had completed postoperative CRT therapy. Patients who relapsed with a disease-free interval of less than 3 months were treated with palliative CRT when appropriate. Patients with a disease-free interval of 3 months or more were treated with best supportive care. Post-recurrence survival was estimated using the Kaplan–Meier technique, and statistical comparisons were made using log-rank chi-square tests and Cox regression. Results: Of the 69 patients treated with adjuvant CRT after esophagectomy, 46 experienced recurrence. Median time to relapse was 28 months (range: 0.1–40 months). Among the 46 relapsed patients, median age was 61 years (range: 37–82 years), and 42 were men. At the initial staging, 44 of 46 were node-positive; 31 of 46 had adenocarcinoma. In 33 of 46, post-esophagectomy resection margins were clear. Median follow-up after recurrence was 30.5 months (range: 1.3–100 months). Median overall survival after recurrence was 5.8 months, and the 12-month, 24-month, and 36-month survival rates were 20%, 10%, and 5% respectively. Of the prognostic factors analyzed, only resection margin status and interval to recurrence were statistically significant for patient outcome in univariate and multivariate analysis. Patients who had positive resection margins and who relapsed 12 or fewer months after surgery and adjuvant CRT had a median post-recurrence overall survival of 0.85 months as compared with 6.0 months in other patients (more than 12 months to relapse, or negative resection margins, or both; log-rank p = 0.003). Conclusions: Resection margin status and interval to disease relapse are significant independent prognostic factors for patient outcome after adjuvant CRT therapy. Full article

In January 2010, a panel of Canadian oncologists with particular expertise in colorectal cancer (CRC) gathered to develop a consensus guideline on the use of therapies against the epidermal growth factor receptor (EGFR) in the management of metastatic CRC (MCRC). This paper uses a case-based approach to summarize the consensus recommendations developed during that meeting. These are the consensus recommendations: 1. Testing for the KRAS status of the tumour should be performed as soon as an EGFR inhibitor is being considered as an option for treatment. 2. Anti-EGFR therapies are not recommended for the treatment of patients with tumours showing mutated KRAS status. 3. For a patient with wild-type KRAS and an Eastern Cooperative Oncology Group status of 0–2, whose mCRC has previously been treated with a fluoropyrimidine, irinotecan, and oxaliplatin, switching to an EGFR inhibitor is a recommended strategy. 4. Cetuximab, cetuximab plus irinotecan, and panitumumab are all options for third-line therapy in patients with wild-type KRAS, provided that tolerability is acceptable. Full article

Introduction: Hepatitis B virus (HBV) reactivation is a recognized complication of chemotherapy. The U.S. Centers for Disease Control and Prevention recommend that all patients be screened for the HBV surface antigen (HBSAG) before chemotherapy. We sought to determine the frequency of hbsag testing before chemotherapy at our hospital and to increase the frequency of testing to more than 90% of patients starting chemotherapy. Methods: Using a retrospective electronic chart review, we identified the frequency of HBSAG testing for patients initiated on intravenous chemotherapy at out institution between March 2006 and March 2007. The frequency of left ventricular function testing in the subgroup of patients receiving potentially cardiotoxic chemotherapy was identified as a comparator. An educational intervention was developed and delivered to the multidisciplinary oncology team. The frequency of HBSAG testing was determined post intervention. Qualitative interviews were conducted with the members of the oncology team to identify risk perception and barriers to testing. Results: Of 208 patients started on intravenous chemotherapy between March 2006 and March 2007, only 28 (14%) were tested for HBSAG. All 138 patients scheduled for cardiotoxic chemotherapy (100%) underwent left ventricular function testing. In the post-intervention phase, of 74 patients started on intravenous chemotherapy, 24 (31%) underwent HBSAG testing, with 1 patient testing positive. Conclusions: The frequency of testing for HBSAG before chemotherapy was very low at our institution. An educational intervention resulted in only a modest improvement. Potential barriers to routine screening include lack of awareness about existing guidelines, controversy about the evidence that supports HBSAG testing guidelines, and a perception by physicians that HBV reactivation does not occur with solid tumours. Full article

Purpose: To improve outcomes in localized osteosarcoma and to reduce the duration of preoperative chemotherapy, we conducted a phase ii trial assessing the efficacy of an intensive protracted regimen without methotrexate (API-AI regimen) in adolescent and adult patients with newly diagnosed disease. Patients and Methods: Induction chemotherapy consisted of 2 cycles (4 courses) of doxorubicin 60 mg/m² (days 1 and 15), cisplatin 100 mg/m² (day 1), and ifosfamide 5 g/m² (days 2 and 15). The primary endpoint was good histologic response [GHR (≤5% identifiable tumour cells)]. Results: From March 1993 to March 2000, 32 patients [median age: 21 years (range: 15–49 years)] were administered 126 induction courses. The median time between chemotherapy courses was 15 days (range: 12–32 days). All but 3 patients underwent conservative surgery. Toxicity was mainly hematologic, with febrile neutropenia occurring in 35% of patients and grades 3–4 thrombocytopenia in 35%. The GHR rate was 47%. The median follow-up was 64 months (range: 30–115 months). The 5-year event-free and overall survivals were 65% [95% confidence interval (CI): 48–79%] and 69% (95% CI: 50–83%) respectively. Two secondary hematologic malignancies occurred: 1 acute myelocytic leukemia (M5) in a poor responder with concomitant relapse, and 1 myelodysplastic syndrome in a patient achieving GHR. Conclusions: Despite hematologic toxicity, the results observed with the API-AI regimen compare favourably with those observed during previous induction chemotherapy containing methotrexate in adult patients and the pediatric population treated at our institution. These promising results have to be validated by an ongoing national multicentre trial coordinated by the French Sarcoma Group. Full article

Background: Soft-tissue sarcoma spreads predominantly to the lung. The frequency with which positron-emission tomography (PET) detects metastases not already obvious by chest computed tomography (CT) or clinical examination is currently unclear. Methods: We retrospectively identified cases of soft-tissue sarcoma. Ewing sarcoma, rhabdomyosarcoma, and gastrointestinal stromal tumour were excluded, as were cases in which patients underwent imaging for follow-up, response assessment, or recurrence. Patients all had undergone diagnostic chest CT as part of their staging. Directed studies were requested to follow up on abnormal findings in the clinical history or physical examination. All charts and pre-treatment imaging were reviewed retrospectively. Results: From 2004 to 2008, 75 patients met the criteria for the present review. Their median age was 51 years. In 21% of cases, the primary tumour had been removed (by excisional biopsy or unplanned excision) before staging. Of the previously unresected primary tumours, 97% were avid for fluorodeoxyglucose. Of all tumours, 81% were intermediate or high grade (Fédération Nationale des Centres de Lutte Contre le Cancer grades 2–3). The primary tumour was stage T2b in 69% of cases. The most common primary site was a lower extremity (55%). The most common pathologic diagnoses were leiomyosarcoma (21%), liposarcoma (19%), and synovial sarcoma (17%). At the end of staging, 17% of patients were considered to have metastatic disease. Imaging by PET was negative for distant disease in 64 of the 75 cases. In 7 of the 64 cases, metastatic disease was evident on chest CT (negative predictive value: 88%). Imaging by PET was positive in 8 cases, with 5 of those already known to have metastases, 2 having pathologically proven false positives, and 1 being a new finding of a pulmonary metastasis (positive predictive value: 75%). The PET imaging was indeterminate in 3 patients (none of whom subsequently developed metastatic disease). Two incidental benign parotid tumours were found. Overall, only 1 patient was upstaged as a result of PET imaging (1.3%). In addition, PET did not alter the management of patients already know to have M1 disease (no new organ sites identified). Conclusions: Although PET may be helpful in specific circumstances, routine use of fluorodeoxyglucose PET imaging for detection of metastatic disease as part of the initial staging of soft-tissue sarcoma added little to imaging by chest CT and was unlikely to alter management in our series. Full article

The Cancer Nutrition Rehabilitation (CNR) program at the McGill University Health Centre is an interdisciplinary 8-week treatment program offering patients information, education, treatment, and support in areas such as diet, exercise, and rehabilitation, plus resources to address their psychosocial needs. The program social worker helps the patient and the patient’s family to cope with the illness, to problem-solve, and to obtain needed resources. Here, we present a description of these patients—demographics, medical diagnoses, and psychosocial needs as assessed by the Person-in-Environment standardized instrument—derived from the socialwork files of the 75 patients referred to social work in the period February 2007–December 2008. The reason most frequently reported for referral to social work was assistance with psychosocial problems. For 41.3% of the sample, these problems were assessed as high severity, and almost half the patients in the sample (47.8%) were assessed as having inadequate coping ability. Patient age was the most important demographic variable. Although seniors (63–94 years of age) were the least likely to have high-severity psychosocial problems, they were the most likely to have inadequate coping ability. That finding suggests that the CNR social worker, in addition to dealing with the instrumental, practical needs of cancer patients, is in a unique position to respond to their emotional difficulties in coping with their illness, and that health care professionals need to pay particular attention to the coping ability of elderly patients. Full article

Canadian law, and the physician’s code of ethics, requires that informed consent be obtained before any medical act is performed. However, there are no rules about how consent is to be obtained and by whom, and how that consent is to be documented. In April 2008, we asked the heads of all Canadian radiation oncology departments to tell us whether their centre uses a written consent form for external-beam radiotherapy and, if it did, to send us a copy of the form or forms used. Responses were received from 29 of the 38 centres contacted (76%). In 12 centres, all of them in British Columbia or Quebec, no written consent is obtained. Of the 17 centres (59%) that do seek written consent, 9 use a generic hospital or cancer centre form. Only 5 use a form specific to radiotherapy that mentions multiple visits, photographs in the treatment position, use of tattoos, and so on, and only 2 use a form that is specific to the tumour type or site irradiated and that explains the risks associated with treatment. The final centre of the 17 did not provide a form for review. While current practice at the McGill University Health Centre is not out of line with that at other Canadian centres, the results of our survey suggest a need for dialogue on the subject of consent for external-beam radiotherapy. Full article