ARTICLES

ONCOINFOSCAN

Dr. R.Sekhar, MS(Cal), FRCS(Glasg), FRCS(Edin)
Surgeon,
Jagjivan Ram Hospital,
Mumbai

BREAST CANCER :

1. According to one study from New York, Monthly breast cancer pain may signal lower breast cancer risk. One suggested reason was that painful breasts may have greater infiltration with immune competent cells or express pain modulation cytokines such as TNF-alpha.
2. Over expression of the antiapoptotic protein BAG-1 seems to have a paradoxical association with improved breast cancer survival. A retrospective analysis of patients with early stage breast cancer showed BAG-1 positive patients to have an 81% 10 yr. Overall survival, compared with 43% for BAG-1 negative patients. Laboratory studies show that BAG-1 over expression in breast cancer cells may inhibit metastasis.
3. In a 15 year study of 520 women less than 40 yrs of age, pregnancy after being diagnosed with breast cancer & successfully treated, did not increase the patients risk for recurrance or death from disease, particularly in women with local disease at diagnosis.
4. According to an interim analysis of the ZIPP (Zoladex in Premenstrual Patients) trial in London, Goserelin- an estrogen suppressor used in premenstrual patients gave a significantly prolonged event free life, especially if young & ER+ve. Though it might not produce better results than adjuvant chemotherapy in younger women, Goseralin is a reversible form of ovarian suppression & does potentially offer a choice for the very young women who wishes to retain her fertility.
5. Brown sea weed & soy may contribute to lower rates of post menopausal breast cancer In Japan. Of particular interest in the study was that women with breast cancer showed lower ratio of 2-Hydroxyestrone to 16- alpha-hydroxyestrone. Sea weed & soy favourably in- creased this ratio.
6. A new biopsy technique, the stereotactic large core approach, in addition to being minimally invasive, retains tissue architecture unlike most FNAC samples, uses computer co-ordinates to localize lesions, takes only one hour and does not require intravenous anaesthesia. It is cheaper than taking a surgical biopsy.

SALIVARY TUMORS :

There is some evidence suggesting that hair dressers are at a higher risk of getting salivary gland cancer than the normal population. One of the incrimninating agents suggested is the sprays & lacquers they use on their customers.

OESOPHAGEAL CANCER :

An Irish study evaluated the results of Chemotherapy plus Radiation followed by resection and compared it to results with surgery alone in adenocarcinomas. Of 113 patients, 58 'were randomly allocated to the first group & received .5FU+ cisplatin+4000cGy from day one. 55 cases were subjected to surgery alone. Patients had to be less than 76 yrs of age, had all the mandatory preoperative evaluation including a physical evaluation for fitness for surgery was given for two cycles along with AT & surgery performed 8 wks after beginning treatment. The median follow-up was 10 months.

Post operative complications were respiratory in 28 cases in the first group & 32 in the- second group. Other minor complications were common in both groups. In 25% of case in the first group, there was a complete response 10 CT + RT, i.e., no evidence of tumor at subsequent surgery. Survival rates at 3 yrs was 37% for the first group & only 7% in the group of surgery only. They suggest that multimodal therapy should be advised to all adenocarcinomas of esophagus where tumor is con- fined to the esophagus & draining Iymphnodes, provided the patient has adequate physiological reserve to withstand the treatment.

BILLIARY & PANCREATIC CANCERS :

Billiary tract drainage, 'with or without placement of an endoprosthesis., is used as a palliation therapy for malignant biliary obstruction. Metallic stents have a long term patency of 6 to 8 months. At present, it appears that unresectable pancreatic cancers should be palliated with endoscopically placed plastic or metallic stents, whereas those with malignant obstructions higher in the biliary tree are probably better managed with transhepatically placed stents. The combination of brachytherapy plus external beam radiation followed by implantation of Gianturco metal stents may be a viable approach. to treating obstruction from cholangiocarcinomas. For noncholangiocarcinomas, particularly when life expectancy exceeds anticipated stent patency duration, the Wallstent may be the device of choice.

COLONIC CANCERS :

1. A phase III trial conducted at Pennsylvania found that the OncoVAX colon cancer vaccine reduced the 5-year recurrance rate of stage II colon cancer patients by 61% & improved cancer-free survival rate by 50%. OncoVAX is an active specific immunotherapeutic that is prepared for each patient using the patient's own surgically removed tumor. The tumor is treated with enzymes to separate the tumor cells. The cells are then frozen for vaccine preparation, & beginning 4 weeks after surgery, the patient receives four injections over a 6-month period. The vaccine has been approved for use in The Netherlands.
2. Newer chemotherapeutic drugs :
   • Raltitrexed- a thymidylate synthetase inhibitor, in combination with SFU or oxaloplatin or IrinIJtecan. Given as a 15 min infusion, repeated every 21 days. Max. tolerated dose was 5.5mg/m2. Being used for advanced colon cancers, Muscositis, diarrhoea can be severe, kidney functions are to be adequate as drug is excreted through kidneys.
   • Gemcitabine- a nucleoside analogue, inhibits deoxycytidine kinase, a key enzyme in the salvage pathway of pyrimidine synthesis. Given along with 5-FU.
   • Trimetrexate- a folate antagonist. 10 times more cytotoxic than methotrexate. Used as a biological modulator of 5-FU in advanced colonic cancers.

   Adjunct drug in F A P-COX-2 inhibitor - CELECOXIB- this cyclooxegenase inhibitor in a dose of 400mg B.D. significantly reduces the number of adenomatous colorectal polyps by an average of 28% -compared to a 5% reduction with placebo.

RENAL CELL CARCINOMAS :

Surgical resection remains the cornerstone of management. No effective post surgical adjuvant has been established in cases with locally advanced disease who have a high chance of recurrance. Interferon alfa & interleukin -2 benefit relatively few. Research is being directed to novel vaccine therapy targeted at both renal epithelium & vascular antigens.

PROSTATE CANCER :

1. A team of researchers led by Patrick Walsh of John Hopkins Hospital have found three factors could be used to reliably predict recurrent disease- the amount of time elapsed after surgery for PSA level to rise above zero, time it took for PSA to double and the patient's Gleason score. The men at greatest risk were those with high Gleason scores, a rise of PSA within 2 years after surgery. and a doubling of PSA in less than 10 months. The findings will reassure patients that a rising PSA is not necessarily a death .sentence & will give surgeons a framework more accuratly base decisions on treatment.
2. A Chicago based study suggests that 3-D CT guided seminal vesicles biopsy by transchiorectal route should be "done for all cases after a positive diagnosis of prostate cancer and prior to implementation of treatment options. It states that' at least 10% of cases were upstaged with this procedure.

TESTICULAR TUMORS :

Both retrospective single institution studies & studies of unselected, consecutive patients have confirmed that vascular invasion, lymphatic invasion, percentage of embryonal carcinoma are predictive of metastasis in patients with low-stage nonseminoma. Low MIB-1 staining, which identifies Ki-67 antigen in conjunction with a low percentage of embryonal carcinoma in the testicular specimen is predictive of low probability of metastasis. CT scan is a useful staging tool. Laparoscopic retroperitoneal lymphadenectomy appears to be a feasible tool with acceptable short term morbidity. Primary chemotherapy is not recommended currently as it has not been proven to be superior in patients with high clinical stage I nonseminomas and can cause significant long term sequelae.

REFERENCES :

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