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  • 1. Oncology What is UCAN? Management of Primary Lung Cancer The Current Treatment of GIST With Reference to Laparoscopic Resection and Neoadjuvant Treatment Prostate Cancer reviewed: Part 2 - Treatment Options News Volume 3 Issue 2 :August/September 2008 www.oncologynews.biz In this issue ISSN 1751-4975 Subscribe FREEwww.oncologynews.biz
  • 2. Varian Medical Systems International AG, Zug, Switzerland Phone +41 - 41 - 749 88 44 www.varian.com/aria info.europe@varian.com ARIA™. The complete Oncology Information System. Providing quality cancer care to patients requires a team effort by all staff in the cancer center. The ARIA Oncology Information System supports oncology practitioners with the tools needed to effectively manage clinical, financial and administrative data in their departments, eliminating the need for films and paper charts. ARIA streamlines the workflow of advanced techniques such as RapidArc™,IMRT, IGRT, adaptive and concomitant therapies. It features a complete chemotherapy manage- ment system with the most sophisticated clinical trials administration and outcomes assessment tools that help to increase efficiency and reduce clinical risk. ARIA offers powerful and flexible communication tools based on DICOM and HL7, which pass treatment strategy relevant information to the right place in ARIA and connected partner systems. ARIA provides Record & Verify functionality for all Linac brands. Comprehensive workflow and information management. Radiation Oncology SurgicalOncology Medical On cology ARIA_210x297_Zug_ESMO_ESTRO_e:Layout 1 10.07.2008 12:46 Seite 1
  • 3. Volume 3 Issue 2 • August/September 2008 3 Professor Denys Wheatley is Editor of Oncology News, and is Director of BioMedES. He has strong research ties in Albany, Davis, Auckland, Valencia, Detroit, Budapest, St Petersburg, Heidelberg, Zürich and Hong Kong. He is eager to establish strong interaction with cancer and cell biology teams worldwide, and initiate programmes in the areas in which his expertise lies. His work in cancer research, other scientific fields, with IFCB, and in publishing and scientific communication has led to his receiving awards in recent years. Professor Patrick J Bradley is Associate Editor of Oncology News, and, a Head and Neck Oncologic Surgeon at the University Hospital, Nottingham. He is a member of numerous journals’ UK Editorial Boards; Journal of Laryngology and Otology, Oral Oncology, and International Journals: Laryngoscope, Head and Neck, Acta Otolaryngologica Scandinavia, as well as Section Editor of Head and Neck Oncology, and Current Opinions ORL-HNS. Dr Tom Lynch is Assistant Editor – Imaging, and is a Radiologist and Lead Nuclear Medicine Physician in the Northern Ireland Cancer Centre based at the Belfast City Hospital. Tom specialises in PET/CT scanning and nuclear medicine with a special interest in paediatric nuclear medicine. Dr Heidi Sowter is Assistant Editor – Web Review, and is a Lecturer in Forensic Science and Biology, at the Faculty of Education, Health and Science, University of Derby. Heidi continues to pursue her research interests in gynaecological and breast cancer. Ms Kathleen Mais is Assistant Editor – Nursing, and is a Nurse Clinician in Head & Neck Oncology at Christie Hospital, Manchester. Kathleen qualified as a nurse in Newcastle-upon- Tyne. Kathleen is a nurse-prescriber and runs a nurse-led chemotherapy clinic as well as continuing her work in clinical research. Michael Douek is Assistant Editor – Breast, and is a Senior Lecturer and Consultant Surgeon at University College London Hospitals focusing on breast cancer surgery with a particular interest in pre-operative surgical planning using breast MRI. In 2003, he was awarded a prestigious Health Foundation Clinician Scientist grant by the UK Academy of Medical Sciences, fully funding his joint academic and clinical post in breast surgery. Alan Cooper is Assistant Editor – Urology, and is Lead Scientist with the urology research group in Southampton University Hospitals and senior lecturer (albeit with virtually no lecturing burden) in the Department of Biomedical Sciences at Portsmouth University. Marilena Loizidou is Assistant Editor – Colorectal, and is a Non-Clinical Senior Lecturer in the Department of Surgery, UCL. Her research program focuses on aspects of colorectal cancer and liver metastases, from the basic underlying biology to new potential treatments. The current focus of research is the contribution of the peptide endothelin-1 to tumour growth and progression in the bowel. Additional research areas include breast and bladder cancer. Dr S Gokul is Assistant Editor - Journal Reviews, and is a Consultant Medical Oncologist at The James Cook University Hospital, Middlesbrough. His areas of interest are lung and gynaecological cancers. Helen Evans is a Journal Reviewer for Oncology News. Helen recently worked as a Senior Lecturer in Cancer Nursing at the Institute of Nursing and Midwifery, University of Brighton but following the birth of her son has returned to clinical practice as a Clinical Nurse Specialist at St. Wilfrid's Hospice in Chichester. Meet the Editorial Team BioMedES Producing the very best definitive versions of your biomedical reports and papers Never heard of us? Not surprising, since our operations are mostly ‘behind the scenes’. But we may be able to help you with your publication problems, from technical notes to e-books! What does BioMedES do? • BioMedES reworks sound scientific papers, technical reports, and other (biomedical) documents, putting them into the most idiomatic English that passes the most stringent peer review and quality control assessments • It copy edits for a number of big biomedical publishing houses • Four journals in the life sciences are run from, or with the aid of, the company • It helps administer an international organisation for cell biology (www.ifcbiol.org) • It prepares and publishes e-books in biomedicine • It designs logos for biomedical and many other organisations • It collates and prepares abstracts for scientific and other meetings • The company is involved in arranging both national and international conferences. • It also runs courses on scientific and medical writing, and on electronic publishing Why not contact us at: BioMedES, Leggat House, Keithhall, Inverurie, AB51 0LX, UK Tel: +44-1467-670280; Fax: +44-1467-629123 • Email: wheatley@abdn.ac.uk; info@biomedes.co.uk
  • 4. 4 Volume 3 Issue 2 • August/September 2008 T here is little doubt that some of the most serious cases of cancer are those that attack the lungs. If this is truly the main killer amongst the cancers in the UK, is not there a need for a great deal more research into this particular organ and its tumours? The provoking factors have been fairly obvious for years, and in one guise or another are largely attributable to pollution, being self-administered by those of us who continue to smoke tobacco. The lungs have an enormous area that is in immediate contact with the environment, an area which is far greater than that of the skin that covers the body. Lung tissue, in contrast to skin, is moist and extremely thin, with blood vessels intimately associated with the fine walls of the alveoli. How will the situation look in twenty to thirty years from now? If we assume that the effects of smoking will then be affecting only the more aged members of society who had smoked in the past, and far fewer young people will be progressing in the same way, are we going to see it become one of the least common forms of cancer. [With asbestos the same story should unfold as crocidolite is “phased out” and HSE make sure stringent measures are taken to avoid its inhalation by workers in future. We read earlier in ON (Oncology News 2008;4(2):9-11) that mesothelioma will wane in the same way.] The worrying sector at the present time is young women, who continue to smoke and will be at risk of lung cancer for perhaps at least two more generations. Since on average people are living considerably longer these days than 30 or 40 years ago, there is a high probability that sufficient time will elapse for the incidence of lung cancer to rise in this sub-population of women smokers. The problem is that lung cancer can sometime be asymptomatic, or sufferers are too reluctant to seek help that they do not present for so long that patients do not present with tumours until they are considerably advanced. If we screen for bowel and cervical cancer, the question of whether we can do so for lung cancer has already been addressed in the pages of ON. The treatments for lung cancer do not make for good reading - that is, for the sufferer. Life expectancy is low and there seems to be little that can be done to raise the expectation of life by even a short period of time. But in this issue, Espeed Khoshbin and Alan JB Kirk (p10), delve deeply into many of the approaches that can be taken, and emphasise a number of useful points. One is that, given the circumstances, palliative care has to be a priority so that good QOL is achieved in the short respite sufferers may have in their last months. And the delivery of good medicine centres these days on the MultiDisciplinary Team (MDT) that should meet regularly to review all such patients, making for the best possible management. The lung cancer patient needs this more than almost any other cancer patient, especially when bones and brain become affected by metastases. We discussed in a recent editorial the topic of permutations and combinations in the treatment of cancer, and this seems to be particularly pertinent in the case of lung cancer patients. Combinations of treatments that follow one another rather than necessarily being given at about the same time seem to be prevalent because much depends on which type of lung cancer it is, how large it is, whether it is in the local lymph nodes or more widespread, how much co-morbidity is involved, among other mitigating factors. On the last issue, smokers often have a high alcohol consumption, many have a poor diet, and most of them get little exercise - little wonder that their general health is considerably below average. It is also no wonder that patients have to be examined by a whole gamut of different techniques to assess their general state of health prior to surgery, chemotherapy and radiotherapy. Resection of lobes of the lung becomes less advisable when the sufferer has a poor cardiac condition. If done in the more robust patient, the loss of lung tissue puts an immediate stress on the patient, who may thereafter have to use oxygen as a support, or take on a much more sedentary life. The outlook for all lung cancer patients seems bleaker than for most other types of tumour. One would hope that, despite the improvement in the application of established techniques (better delivery of radiation, more specific chemotherapeutic agents, etc.) some new avenues would open in terms of lung cancer treatment. Are there any real grounds for believing that there might be some breakthrough which will provide an effective means of controlling lung cancer? Or do we stick to refining the ways in which the current modalities are administered, to optimise them and combine them using the most carefully devised strategies? If these are the issues before us, then what should be the focus of effort? The latter has to be done whether or not more basic research can find new methods of treatment, such as immunotherapy. Perhaps before basic research could add significantly in this way, it is probable that the tide of lung cancer we have seen through the 20th century and persisting into the first part of the 21st century will have receded, and less pressure will come to bear on getting a better understanding of the fundamental causes and cellular misbehaviour that leads to lung cancer. That leaves screening as the only option needing to be considered, (see John Field K and Duffy SW, Oncology News 2008;3(1):6-8), in which there seems to be little advance even for the most high risk groups. And yet lung cancer remains the most common cause of death amongst cancers in the UK. n Lung Cancer Continues to Occupy the Frame Denys Wheatley, Editor/ Editorial
  • 5. Cytosafe® Tough, polypropylene vial developed to reduce the risk of breakage and leakage New 300mg vial Designed with the typical FOLFIRI regimen* in mind (based on average patient dose)1,2 Indicated for the treatment of patients with advanced colorectal cancer. See prescribing information for full indication. CAMPTO® (irinotecan hydrochloride trihydrate): PRESCRIBING INFORMATION – UK Please refer to the Summary of Product Characteristics (SmPC) before prescribing Campto 20mg/ml. Presentations: Vials of concentrate for infusion containing either 40mg, 100mg or 300mg irinotecan hydrochloride trihydrate. Indications: Treatment of adult patients with advanced colorectal cancer: in combination with 5-fluorouracil, folinic acid in patients without prior chemotherapy and as monotherapy in patients who have failed a 5-fluorouracil, folinic acid based therapy. Campto may be used in combination with cetuximab for the treatment of Epidermal Growth Factor Receptor-expressing metastatic colorectal cancer after failure of Campto-including cytotoxic therapy. Campto may be used in combination with 5-fluorouracil, folinic acid and bevacizumab for the treatment of metastatic carcinoma of the colon and rectum. Dosage & Administration: Campto should be administered as an intravenous infusion over 30 to 90 minutes. In first line: combination therapy of 180mg/m2 every 2 weeks followed by folinic acid and 5-fluorouracil. In second line: monotherapy 350mg/m2 every 3 weeks. In combination with cetuximab: Administer cetuximab first, do not administer Campto earlier than 1 hour after the end of cetuximab infusion. Refer to cetuximab product information for dosage. In combination with bevacizumab, refer to the bevacizumab product information for dosage. Prophylactic antiemetics are recommended. Dosage Adjustments: Subsequent cycles should follow appropriate recovery of all adverse events to grade 0 or 1 NCI-CTC and resolution of diarrhoea. Dose reduction of 15-20% recommended if patients experience significant haematological toxicity, thrombocytopenia and leucopenia (grade 4), and non-haematological toxicity (grade 3-4). Impaired hepatic function: Monitor liver function regularly. In monotherapy blood bilirubin levels (up to 3 times ULN) in patients with performance status ≤2, should determine the starting dose of Campto. No data are available in patients with hepatic impairment treated by Campto in combination. Impaired renal function: Not recommended. Elderly: Care due to the greater frequency of decreased biological functions. Contraindications: Chronic inflammatory bowel disease and/or bowel obstruction; severe hypersensitivity reactions to Campto; pregnancy; breastfeeding; bilirubin >3 ULN; severe bone marrow failure; WHO performance status >2, concomitant use of St John’s Wort. Refer to cetuximab or bevacizumab product information for contraindications. Warnings and Precautions: Use in units specialised in the administration of cytotoxic chemotherapy. Patients should be aware of the risk of delayed diarrhoea (occurring >24 hours after the infusion). Loperamide is the recommended treatment, but should not be given prophylactically. Weekly monitoring of full blood counts recommended. Regular liver function tests should be performed. Prophylactic treatment with antiemetics is recommended. Cases of acute cholinergic syndrome should be treated with atropine. Risk factors for the development of pulmonary infiltrates should be considered. Patients should not drive if dizziness or visual disturbances occur. Women of childbearing age receiving Campto should be advised to avoid becoming pregnant. Interactions: Avoid concomitant use with CYP34A inducers or inhibitors. Care in patients receiving neuromuscular blocking agents. St John’s Wort should not be administered with Campto. SN38 (the active metabolite of Campto) concentrations were increased by 33% when combined with bevacizumab. Patients developing severe diarrhoea, leucopenia or neutropenia in combination with bevacizumab should have Campto dose modification. Adverse Reactions: Delayed diarrhoea (requires immediate treatment with loperamide). Nausea and vomiting, dehydration, neutropenia, fever, acute cholinergic syndrome, dyspnoea, asthenia, reversible alopecia. Infrequently dehydration-related renal insufficiency, hypotension or circulatory failure. Other system disorders include gastrointestinal, blood, infection and infestation, general disorders and infusion site reactions, cardiac, respiratory, skin and subcutaneous tissue, immune system, musculoskeletal, and nervous system. Refer to the relevant product information for details on adverse reactions that may occur when used in combination with cetuximab or bevacizumab. Pharmaceutical Precautions: Solution must be prepared aseptically. Do not mix with other medications. The solution should be used immediately after reconstitution, as it contains no antibacterial preservative. Dilute with infusion solution (0.9% sodium chloride or 5% glucose solution). Protect from light. Comply with prevailing cytotoxic handling guidelines when preparing or handling Campto. Legal category: POM. Basic NHS Price: Vials: Campto 40mg; £53.00; Campto 100mg; £130.00; Campto 300mg; £390.00. Marketing Authorisation Number: 40mg: PL 00057/0626, 100mg & 300mg PL 00057/0627. Marketing Authorisation Holder: Pfizer Limited, Sandwich, Kent, CT13 9NJ, United Kingdom. Date of Revision: February 2008 (REF: CF 5_0). References: 1. Mosteller RD. N Engl J Med 1987;371:1098. 2. Campto® Summary of Product Characteristics, February 2008. 3. Tournigand C et al. J Clin Oncol 2004;22:229-237. *FOLFIRI – irinotecan 180mg/m2 given as a 90-minute infusion and leucovorin 200mg/m2 as a 2-hour infusion, followed by bolus FU 400mg/m2 and a 46-hour infusion FU 2,400mg/m2 for two cycles, increased to 3,000mg/m2 from cycle 3 in case of no toxicity greater than grade 1 during the two first cycles. Repeated every 2 weeks.3 CAM08/019a Further information is available on request from: Medical Information at Pfizer Limited, Walton Oaks, Dorking Road, Tadworth, Surrey, KT20 7NS, UK. Tel: +44 (0) 1304 616161 Adverse events should be reported to Pfizer Medical Information on 01304 616161. Information about adverse event reporting can also be found at www.yellowcard.gov.uk Plan for living Campto® now in CytoSafe® 300mg Vials shown not actual size 100mg40mg PFZ07JO8009_Oncology_News_210x297:PFZ07JO8009_Oncology_News_210x297 2/6/08 12:23 Page 1
  • 6. 6 Volume 3 Issue 2 • August/September 2008 Contents Volume 3 Number 2 August/September 2008 Copyright: All rights reserved; no part of this publica- tion may be reproduced, stored in a retrieval system or transmitted in any form or by any means, elec- tronic, mechanical, photocopying, recording or other- wise without either the prior written permission of the publisher or a license permitting restricted photo- copying issued in the UK by the Copyright Licensing Authority. Disclaimer: The publisher, the authors and editors accept no responsibility for loss incurred by any person acting or refraining from action as a result of material in or omitted from this magazine. Any new methods and techniques described involving drug usage should be followed only in conjunction with drug manufacturers' own published literature. This is an independent publication - none of those con- tributing are in any way supported or remunerated by any of the companies advertising in it, unless other- wise clearly stated. Comments expressed in editorial are those of the author(s) and are not necessarily endorsed by the editor, editorial board or publisher. The editor's decision is final and no correspondence will be entered into. 3 Editorial Board 4 Editorial 8 What is UCAN? Catherine Paterson, Sam McClinton, Aberdeen, UK. 10 Management of Primary Lung Cancer Espeed Khoshbin, Alan JB Kirk, Clydebank, UK. 14 Upper GI Oncology Section - The Current Treatment of GIST With Reference to Laparoscopic Resection and Neoadjuvant Treatment Siobhan Gill, Paras Jethwa, Surrey, UK. 18 Urological Cancer Section – Prostate Cancer Reviewed: Part 2 Treatment Options Simon Mackie and Bhavan Rai, Aberdeen, UK. 20 Book Reviews 21 Conference News Previews and reports from the conference scene. 26 Imaging Section – Introduction to the use of MRI in Staging of Rectal Cancer K Lowry, A Armstrong, T Lynch, E Napier, Belfast, UK. 28 Diary Listing of meetings, courses and conferences, both UK and international. 29 Courses & Conferences 32 Web Review Heidi Sowter, Derby, UK. 33 Society News ECCO-ESMO Collaboration 12 & 34 News Update Details of the latest developments and news from the industry and charities. Oncology News is published by McDonnell Mackie, 84 Camderry Road, Dromore, Co Tyrone, BT78 3AT, N Ireland. Publisher: Patricia McDonnell • Web: www.oncologynews.biz Advertising and Editorial Manager: Patricia McDonnell Tel/Fax: +44 (0)288 289 7023 • Email: Patricia@oncologynews.biz Advertising and Press Releases: Grant Mackie Email: Grant@oncologynews.biz Design & Production Email: design.dept@sky.com Printed by: Warners Midlands PLC Tel: 01778 391000 Copyright: All rights reserved; no part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electron- ic, mechanical, photocopying, recording or otherwise without either the prior writ- ten permission of the publisher or a license permitting restricted photocopying issued in the UK by the Copyright Licensing Authority. Disclaimer: The publisher, the authors and editors accept no responsibility for loss incurred by any person acting or refraining from action as a result of material in or omitted from this mag- azine. Any new methods and techniques described involving drug usage should be followed only in conjunction with drug manufacturers' own published litera- ture. This is an independent publication - none of those contributing are in any way supported or remunerated by any of the companies advertising in it, unless otherwise clearly stated. Comments expressed in editorial are those of the author(s) and are not necessarily endorsed by the editor, editorial board or pub- lisher. The editor's decision is final and no correspondence will be entered into. Oncology What is UCAN? Management of Primary Lung Cancer The Current Treatment of GIST With Reference to Laparoscopic Resection and Neoadjuvant Treatment Prostate Cancer reviewed: Part 2 - Treatment Options News Volume 3 Issue 2 :August/September 2008 www.oncologynews.biz In this issue ISSN 1751-4975 Cover picture: Stockholm Clock Tower by Andrew Conn. 8 Volume 3 Issue 2 • August/September 2008 U CAN is a charitable company set up to improve the quality of life for people and families living with urological cancers in the North of Scotland. Urological cancers, (kidney, prostate, bladder, testicular and penile) are among the most common types of cancers. They account for one in three of all cancers in men and one in five of all cancers in men and women. UCAN was launched in January 2006 by Mr Sam McClinton and Professor James N’Dow, two consultant urological surgeons based at the Aberdeen Royal Infirmary. They created UCAN as a direct result of cancer sufferers, families and health professionals identifying a need to provide additional and improved services which are not, and cannot be, provided under the statutory duties of the NHS. There exists a stigma associated with urological cancers. Quite often patients seek medical advice from their doctor at a point when it is too late to offer curative treatment. Those who have been diagnosed with a urological cancer often suffer long-term social, emotional and psychological problems. Sufferers frequently struggle to come to terms with the trauma of urological cancer and the potentially life-changing effects of treatment, such as urostomy and erectile dysfunction. Long-term psychological problems can affect sufferers’ partners and families as much as the patient themselves, significantly increasing the number of lives blighted by urological cancer. UCAN recognises that a significantly higher level of support is required for those diagnosed with urological cancer than is currently available. What does UCAN plan to achieve? Our plans are split into three main areas: • Improving early diagnosis and knowledge 1) Our awareness campaign has been running for two years. We need to raise the profile of urological cancers to the level of breast and bowel cancer, and educate individuals on the early signs of urological cancers, in a bid to reduce the mortality rates. We also want to take the stigma out of these illnesses which by their nature can cause embarrassment. 2) One of our key challenges is to get men to take responsibility for their own health to the same degree as women. We are working with employers to help get our messages across in the workplace. Early diagnosis of cancer would not only help the patient but also the employer through reduced time off work. • Building effective support structures 1) There is a desperate need to provide patients and families with new avenues of support to help them adjust to, and live with, the changes a cancer diagnosis might bring to their lives. On occasions, the need will be for human contact; on other occasions the need might be for relative anonymity through online contact. 2) We recognised the need for a central hub close to the clinical services. A new Urological Cancer Care Centre was opened in January 2008, in the department of urology and is already fully operational providing practical support to cancer sufferers. 3) An important element of building effective support structures will be the Plain English Guides which will convert a vast amount of unregulated information into short, easily understood documents, with the facts a cancer patient needs to know. • Acquired knowledge and research 1) By researching the knowledge and experience of urology cancer patients, their families and clinicians worldwide, we will be able to determine what information cancer sufferers need at different stages of treatment. The family unit also needs information as they are affected just as much as the cancer sufferers. This information is vital when deciding which treatment to choose if the cancer sufferer is not to regret that decision at a later date. It is also very important to discover the best ways of managing the often unpleasant effects of treatments. What makes UCAN unique? Our activities are distinctive in the following ways: • Projects are developed in partnership with the beneficiaries; allowing us the best chance of being relevant to urological cancer sufferers and their families. What is UCAN? Catherine Paterson, UCAN Research Nurse, Academic Urology, University of Aberdeen, Health Sciences Building, Aberdeen. Sam McClinton, Consultant Urological Surgeon, Aberdeen Royal Infirmary Correspondence to: Catherine Paterson, UCAN/Total Research Nurse, OTIS Study Co-ordinator, UCAN/Academic Urology, 1st Floor Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK. A Urological CANcer is diagnosed every 10 minutes 10 Volume 3 Issue 2 • August/September 2008 L ung cancer is one of the most common cancers in the Western world, with around 38,000 patients being diagnosed each year in the UK. Rarely diagnosed in the under 40s, lung cancer is a disease of the late middle-aged and elderly. Peak incidence is in the 75-84 age-group, with 85% of patients being over the age of 60 (Figure 1). In the 1950s, the sex ratio was M:F 6:1; with reducing incidence in males and increasing rates in females, wth the current sex ratio being nearly 7:5. Cigarette smoking is linked to lung cancer in well over 90% of cases, although other environmental causes such as asbestos and radon gas exposure have been implicated. Lung cancer is the leading cause of death from cancer in the UK, 22% of all cancer deaths being attributable to lung cancer. The current 5-year survival for lung cancer in the UK is 7% [1]. Types of lung cancer There are two broad groups of lung cancer defined by their histological appearance [2]. These are Small Cell Lung Cancer (SCLC) and Non-Small Cell Lung Cancer (NSCLC). SCLC and NSCLC differ in a number of ways; their cell origin is different, SCLC being neuroendocrine, whereas NSCLC is epithelial. SCLC is very chemosensitive, but NSCLC is less so. SCLC is generally metastatic at presentation, whereas NSCLC may initially be locoregional. SCLC is generally not a surgical disease, while NSCLC may be resectable. Examples of individual types of NSCLC are squamous, adenocarcinoma and large cell carcinoma. The key to current treatment of patients with lung cancer is the multidisciplinary team (MDT) [3]. The workings and membership of the MDT vary from region to region. MDT meetings should ideally be held weekly and attended by all the major players (Table 1). All patients with lung cancer should be reviewed, the object being to deliver the best possible treatment to each patient depending on their tumour stage and state of health. SCLC treatment Patients with SCLC are categorised as either with limited disease (LD), where the disease is confined to the thorax, or extensive disease (ED), where there is evidence of distant metastases [4]. Patients with ED are generally given chemotherapy, designed to produce palliation and shrinkage of the tumour burden. About 50% of patients with SCLC that are in the ED category will have clinical or subclinical cerebral metastases. For this reason, prophylactic cranial irradiation (PCI) is often administered [5]. SCL cases categorised as LD also get chemotherapy. Where there is a complete or good response, mediastinal radiotherapy +/- PCI is considered for survival advantage and improved quality of life [6]. There will be a small group of patients who present with early disease. Under these circumstances, if properly staged, surgery may have a role. NSCLC treatment Key to the management of patients with NSCLC is TNM staging of the tumour, which is based on tumour characteristics (T), nodal involvement (N), and the presence or absence of metastases (M). A summary of lung cancer TNM is given in Table 2. However this classification is being reassessed and updated; the update will be published later in 2008 [7]. Management of Primary Lung Cancer Espeed Khoshbin Registrar in Cardiothoracic Surgery. Alan JB Kirk, Consultant Thoracic & Cardiac Surgeon. Correspondence to: Department of Thoracic Surgery, West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Clydebank, UK. Email: khoshbinuk@ yahoo.co.uk Source: Cancer Research UK Table 1: Key members of the MDT Chest physician Lung Cancer Nurse Specialist Thoracic Surgeon Oncologist (Clinical +/- Medical) Palliative Care Physician and/or nurse Chest radiologist Lung Pathologist Secretarial support and/or MDT coordinator Lung cancer audit staff Primary Care representative 14 Volume 3 Issue 2 • August/September 2008 The Current Treatment of GIST With Reference to Laparoscopic Resection and Neoadjuvant Treatment Miss Siobhan Gill, MRCS, Senior House Officer in Surgery. Mr Paras Jethwa, BSc (Hons), MD, FRCS(Gen), Consultant General & Upper GI Surgeon. Correspondence: P Jethwa, Surrey & Sussex NHS Trust, Dept of Surgery, Canada Avenue, REDHILL, Surrey, RH1 5RH, UK. Upper GI Oncology G astrointestinal stromal tumours (GIST) are the most common mesenchymal tumours of the alimentary tract; they account for <1% of all GI malignancies with approximately 900 new cases per year in UK [1]; primary GISTs tend to arise as solitary lesions most commonly affecting the stomach (60-70%), followed by the small bowel (20- 25%) and less commonly the rectum, oesophagus and colon [2]. Genetic analysis has revised the definition of GIST to be that of “highly cellular mesenchymal tumours of the gastrointestinal tract containing spindle, epitheloid cells or a combination of both and displaying CD117/c- kit positivity”. GISTs have been proposed to originate from the interstitial cells of Cajal, considered to be regulators of gastrointestinal motility but, as they can arise from tissue depleted of Cajal cells, the possibility that they arise from a pluripotent stem cell has been suggested [3]. The management of GISTs has evolved rapidly with our understanding of the molecular pathophysiology of this lesion allowing for the rational development of antitumour agents that target signalling aberrations in these cells. Imatinib mesylate (Gleevac, Glivec), a tyrosine kinase and platelet derived growth factor receptor (PDGR) antagonist, have shown excellent results in patients with unresectable or metastatic GIST, but surgical resection of the primary tumour remains the treatment of choice when cure is sought. There is, however, still debate regarding the most appropriate operative approach and the extent of resection required. While metastatic spread is common at first diagnosis, spread to lymph nodes is rarely seen thus, more extensive resection other than the primary site is questionable and has no bearing on survival or recurrence. Recently the National Comprehensive Cancer Network (NCCN) task force reported that “laparoscopic or laparoscopic-assisted resection may be useful for small (<2cm) GISTs when the risk of intraoperative tumour rupture is low. However, the use of laparoscopic resection is generally discouraged for GIST” [4]; despite this, laparoscopic resection of primary GIST has become the treatment of choice in many centres in the UK and Europe. This article summarises the current role of surgery and targeted chemotherapy in the management of GISTs. Minimally invasive surgery for GIST Laparoscopic surgery for gastrointestinal cancer and, more recently gastric cancer has been widely adopted in Japan, Korea, China, Italy, USA and the UK, but not without some debate. Unlike adenocarcinoma, lymphadenectomy is unnecessary with the aim of GIST surgery being the complete removal (R0) of the tumour with negative resection margins and without capsule rupture or intra-abdominal spillage of 8 10 14
  • 7. Date of Preparation: December 2007 1030/10216 Prescribing Information for Innohep® 20,000 IU/ml and Innohep® Syringe 20,000 IU/ml Presentations: Innohep® 20,000 IU/ml contains tinzaparin sodium 40,000 anti-Factor Xa IU in a 2ml vial with preservative. Innohep® Syringe 20,000 IU/ml contains tinzaparin sodium 20,000 anti- Factor Xa IU/ml without preservative. The syringes contain 10,000 anti-Factor Xa IU in 0.5ml, 14,000 anti-Factor Xa IU in 0.7ml or 18,000 anti-Factor Xa IU in 0.9ml. Indications: Treatment of deep vein thrombosis and of pulmonary embolus. Dosage and Administration: Subcutaneous injection only. Adults: 175 anti-Factor Xa IU/kg bodyweight once daily for at least 6 days and until adequate oral anti-coagulation is established. There is no need to monitor the anticoagulant activity of Innohep® . Use in Children: No experience. Contra-Indications: Known hypersensitivity to constituents. Generalised haemorrhagic tendency, uncontrolled severe hypertension, active peptic ulcer, septic endocarditis. Thrombocytopenia in patients with a positive in vitro aggregation test in the presence of tinzaparin. Locoregional anaesthesia in elective surgical procedures. Precautions: Care in patients with severe liver or kidney insufficiency, a dose reduction should be considered. Do not give by intramuscular injection (risk of haematoma). Caution in patients with a history of asthma (presence of sodium bisulphite). Care in patients who have recently suffered from cerebral haemorrhage, trauma and/or had recent surgery to the central nervous system. Caution in patients with hypersensitivity to heparin or to other low molecular weight heparins. For some patients with pulmonary embolism (e.g. those with severe haemodynamic instability) alternative treatment, such as surgery or thrombolysis may be indicated. Heparin can lead to hyperkalaemia, particularly in patients with diabetes mellitus, chronic renal failure, pre-existing metabolic acidosis, a raised plasma potassium or taking potassium-sparing drugs. The risk appears to increase with duration of therapy but it is usually reversible. Measure plasma potassium in patients at risk before starting therapy and monitor regularly. In patients undergoing spinal/peridural anaesthesia or spinal puncture, the prophylactic use of heparin may be very rarely associated with epidural/spinal haematoma resulting in prolonged or permanent paralysis. Risk is increased by use of peridural/spinal catheter, drugs affecting haemostasis and traumatic/repeated puncture. Extreme vigilance and frequent monitoring are required. Platelet counts should be measured in patients receiving heparin for longer than 5 days (risk of thrombocytopenia). Stop treatment immediately in those who develop thrombocytopenia. Not recommended for use in patients with prosthetic heart valves. Drug Interactions: Any drug which affects platelet function or aggregation or blood coagulation should be used with caution. Pregnancy and Lactation: Do not use in pregnancy unless no safer alternative is available. Not recommended for use in pregnant women with prosthetic heart valves. It is not known whether Innohep® is excreted in breast milk. Stop breast-feeding while receiving Innohep® . Side Effects: Skin rashes and minor bruising at site of injection. Systemic allergic reactions have been reported extremely rarely. Innohep® , like heparin, has been shown to increase the risk of haemorrhage. However, at the recommended dose this risk is low. Thrombocytopenia may occur rarely. As for heparin, a transient rise in aminotransferase levels is frequently seen. Rarely, clinically significant hyperkalaemia may occur with heparin products particularly in patients with chronic renal failure and diabetes mellitus. Very rare cases of epidural/spinal haematoma have been reported in patients undergoing spinal or epidural anaesthesia or spinal puncture while receiving heparin prophylaxis. Skin necrosis has been reported. If this occurs withdraw treatment immediately. Priapism has been reported rarely. Valve thrombosis in patients with prosthetic heart valves have been reported rarely. Legal Category: POM Product Licence Numbers and Holder: Innohep® 20,000 IU/ml – PL 0043/0192, Innohep® Syringe 20,000 IU/ml – PL 0043/0197. LEO Laboratories Limited, Longwick Road, Princes Risborough, Bucks. Basic NHS Price: Innohep® 20,000 IU/ml (40,000 anti- Factor Xa IU vial, 2ml) x 1, £34.20. Innohep® Syringe 20,000 IU/ml, 0.5ml x 2, £17.95. 0.5ml x 6, £53.85. 0.7ml x 2, £25.14. 0.7ml x 6, £75.40. 0.9ml x 2, £32.31. 0.9ml x 6, £96.93. Last revised: January 2006. Further information can be found in the Summary of Product Characteristics or from: LEO Pharma, Longwick Road, Princes Risborough, Buckinghamshire, HP27 9RR. If you wish to report an adverse event, this can be done either by contacting Drug Safety at LEO Pharma (01844 347333) or by logging on to www.yellowcard.gov.uk. ® Registered Trademark e-mail: Innohep.UKenquiries@leo-pharma.com tinzaparin sodium *innohep® - giving more life to patients with pulmonary embolism You’re fighting cancer - Don’t be beaten by a PE 1. Hull RD et al. Am J Med 2006; 119:1062-1072 innohep® - long term efficacy in treatment of PE and DVT in cancer patients1 LEO® ©LEO,LEOPharma,UK,December2007,ALLLEOTRADEMARKSMENTIONEDBELONGTOTHELEOGROUP
  • 8. 8 Volume 3 Issue 2 • August/September 2008 U CAN is a charitable company set up to improve the quality of life for people and families living with urological cancers in the North of Scotland. Urological cancers, (kidney, prostate, bladder, testicular and penile) are among the most common types of cancers. They account for one in three of all cancers in men and one in five of all cancers in men and women. UCAN was launched in January 2006 by Mr Sam McClinton and Professor James N’Dow, two consultant urological surgeons based at the Aberdeen Royal Infirmary. They created UCAN as a direct result of cancer sufferers, families and health professionals identifying a need to provide additional and improved services which are not, and cannot be, provided under the statutory duties of the NHS. There exists a stigma associated with urological cancers. Quite often patients seek medical advice from their doctor at a point when it is too late to offer curative treatment. Those who have been diagnosed with a urological cancer often suffer long-term social, emotional and psychological problems. Sufferers frequently struggle to come to terms with the trauma of urological cancer and the potentially life-changing effects of treatment, such as urostomy and erectile dysfunction. Long-term psychological problems can affect sufferers’ partners and families as much as the patient themselves, significantly increasing the number of lives blighted by urological cancer. UCAN recognises that a significantly higher level of support is required for those diagnosed with urological cancer than is currently available. What does UCAN plan to achieve? Our plans are split into three main areas: • Improving early diagnosis and knowledge 1) Our awareness campaign has been running for two years. We need to raise the profile of urological cancers to the level of breast and bowel cancer, and educate individuals on the early signs of urological cancers, in a bid to reduce the mortality rates. We also want to take the stigma out of these illnesses which by their nature can cause embarrassment. 2) One of our key challenges is to get men to take responsibility for their own health to the same degree as women. We are working with employers to help get our messages across in the workplace. Early diagnosis of cancer would not only help the patient but also the employer through reduced time off work. • Building effective support structures 1) There is a desperate need to provide patients and families with new avenues of support to help them adjust to, and live with, the changes a cancer diagnosis might bring to their lives. On occasions, the need will be for human contact; on other occasions the need might be for relative anonymity through online contact. 2) We recognised the need for a central hub close to the clinical services. A new Urological Cancer Care Centre was opened in January 2008, in the department of urology and is already fully operational providing practical support to cancer sufferers. 3) An important element of building effective support structures will be the Plain English Guides which will convert a vast amount of unregulated information into short, easily understood documents, with the facts a cancer patient needs to know. • Acquired knowledge and research 1) By researching the knowledge and experience of urology cancer patients, their families and clinicians worldwide, we will be able to determine what information cancer sufferers need at different stages of treatment. The family unit also needs information as they are affected just as much as the cancer sufferers. This information is vital when deciding which treatment to choose if the cancer sufferer is not to regret that decision at a later date. It is also very important to discover the best ways of managing the often unpleasant effects of treatments. What makes UCAN unique? Our activities are distinctive in the following ways: • Projects are developed in partnership with the beneficiaries; allowing us the best chance of being relevant to urological cancer sufferers and their families. What is UCAN? Catherine Paterson, UCAN Research Nurse, Academic Urology, University of Aberdeen, Health Sciences Building, Aberdeen. Sam McClinton, Consultant Urological Surgeon, Aberdeen Royal Infirmary Correspondence to: Catherine Paterson, UCAN/Total Research Nurse, OTIS Study Co-ordinator, UCAN/Academic Urology, 1st Floor Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK. A Urological CANcer is diagnosed every 10 minutes
  • 9. Volume 3 Issue 2 • August/September 2008 9 • The development of a comprehensive peer support framework is novel. It entails one-to-one mentoring by other urological sufferers, web based forum support by other sufferers and a world class cancer care centre, supported by skilled personnel, experts in the field of urology. The centre will also be backed by international collaboration, with the experience and expertise necessary for studying the information needs of urological cancer sufferers. • We are proposing not only support for urological cancer sufferers, but the family unit as a whole because we recognise that the impact of a cancer diagnosis and treatment is more far-reaching than just the person with the cancer. The project has the potential to benefit cancer sufferers and their families nationally and internationally. • In addition, specific groups in society will be targeted, such as young men who are traditionally reluctant to address their medical needs. A key emphasis is on prevention and early diagnosis that will limit the effects of these cancers and promote a speedy and full recovery. It is hoped that wider knowledge about these cancers will reduce the social stigma often associated with these illnesses. How our make-up and direction differs from other charities Our work is overseen by an independent UCAN Steering Committee that advises the UCAN Board of Directors. The committee chair, and half of the members, are urological cancer sufferers. Through the UCAN Steering committee, patients will continue to be at the centre of decisions about the activities of the charity. We also have a UCAN Patient Advisory Group (individuals who have had a urological cancer) who independently advises the clinical urology team and the direction of the support services for patients and their families. UCAN in Progress Buddy Network UCAN has recently launched its Buddy Network in partnership with NHS Grampian. The Buddy Network allows cancer patients to seek additional support from other patients as their advisors, who of course have been through a similar treatment experience. This support network allows patients to seek out further emotional support and practical advice from other individuals who have had a similar treatment journey. This is a very distinct support network from the NHS, and unique for patients as it allows an opportunity for newly diagnosed cancer patients to verbalise their concerns and ask questions without the worry about how their loved ones are feeling. We currently have a cohort of patient advisors waiting to be a buddy for a newly diagnosed cancer patient. Progress so far is positive and certainly a valued aspect of patients’ treatment packages. Forum The UCAN online forum was launched in April 2007; this support service is moderated by the patients with an overview from the medical team. Within the forum, we have a general area and cancer restricted areas (individual urological cancers to which only those who have had this cancer can gain access). From our pilot work, we found that this online support service is not only valuable for emotional support, but is an area where practical information, questions and experiences can be shared by patients anonymously. These support services can be accessed in our Urological Care Centre, as shown in the following picture. Health Education TOTAL E&P UK Limited has generously sponsored the UCAN Research Nurse, Catherine Paterson for three years. The North East of Scotland is the oil capital of Europe, with the oil industry being largely a male dominated work force. Consequently, our UCAN nurse has taken the health educational programme to the offshore oil rigs to target mens’ knowledge and attitudes towards the early signs of urological cancers. Since UCAN had endeavoured into this new venture, feedback has proved that this is a success and certainly helps to empower men to take ownership for their health. In line with the health educational programme part our aim to try to combat the stigma attached to these cancers. First Group have helped UCAN to achieve this by a risqué, yet very effective, way of capturing the attention of the general public in the north east of Scotland. n UCAN is working hard to get a handle on urological cancers, for more information please contact; UCAN office, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK. Website: www.ucanhelp.org.uk Email: ucan@abdn.ac.uk Telephone: 01224 559312. UCAN Research Nurse Offshore.
  • 10. 10 Volume 3 Issue 2 • August/September 2008 L ung cancer is one of the most common cancers in the Western world, with around 38,000 patients being diagnosed each year in the UK. Rarely diagnosed in the under 40s, lung cancer is a disease of the late middle-aged and elderly. Peak incidence is in the 75-84 age-group, with 85% of patients being over the age of 60 (Figure 1). In the 1950s, the sex ratio was M:F 6:1; with reducing incidence in males and increasing rates in females, wth the current sex ratio being nearly 7:5. Cigarette smoking is linked to lung cancer in well over 90% of cases, although other environmental causes such as asbestos and radon gas exposure have been implicated. Lung cancer is the leading cause of death from cancer in the UK, 22% of all cancer deaths being attributable to lung cancer. The current 5-year survival for lung cancer in the UK is 7% [1]. Types of lung cancer There are two broad groups of lung cancer defined by their histological appearance [2]. These are Small Cell Lung Cancer (SCLC) and Non-Small Cell Lung Cancer (NSCLC). SCLC and NSCLC differ in a number of ways; their cell origin is different, SCLC being neuroendocrine, whereas NSCLC is epithelial. SCLC is very chemosensitive, but NSCLC is less so. SCLC is generally metastatic at presentation, whereas NSCLC may initially be locoregional. SCLC is generally not a surgical disease, while NSCLC may be resectable. Examples of individual types of NSCLC are squamous, adenocarcinoma and large cell carcinoma. The key to current treatment of patients with lung cancer is the multidisciplinary team (MDT) [3]. The workings and membership of the MDT vary from region to region. MDT meetings should ideally be held weekly and attended by all the major players (Table 1). All patients with lung cancer should be reviewed, the object being to deliver the best possible treatment to each patient depending on their tumour stage and state of health. SCLC treatment Patients with SCLC are categorised as either with limited disease (LD), where the disease is confined to the thorax, or extensive disease (ED), where there is evidence of distant metastases [4]. Patients with ED are generally given chemotherapy, designed to produce palliation and shrinkage of the tumour burden. About 50% of patients with SCLC that are in the ED category will have clinical or subclinical cerebral metastases. For this reason, prophylactic cranial irradiation (PCI) is often administered [5]. SCL cases categorised as LD also get chemotherapy. Where there is a complete or good response, mediastinal radiotherapy +/- PCI is considered for survival advantage and improved quality of life [6]. There will be a small group of patients who present with early disease. Under these circumstances, if properly staged, surgery may have a role. NSCLC treatment Key to the management of patients with NSCLC is TNM staging of the tumour, which is based on tumour characteristics (T), nodal involvement (N), and the presence or absence of metastases (M). A summary of lung cancer TNM is given in Table 2. However this classification is being reassessed and updated; the update will be published later in 2008 [7]. Management of Primary Lung Cancer Espeed Khoshbin Registrar in Cardiothoracic Surgery. Alan JB Kirk, Consultant Thoracic & Cardiac Surgeon. Correspondence to: Department of Thoracic Surgery, West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Clydebank, UK. Email: khoshbinuk@ yahoo.co.uk Source: Cancer Research UK Table 1: Key members of the MDT Chest physician Lung Cancer Nurse Specialist Thoracic Surgeon Oncologist (Clinical +/- Medical) Palliative Care Physician and/or nurse Chest radiologist Lung Pathologist Secretarial support and/or MDT coordinator Lung cancer audit staff Primary Care representative
  • 11. Volume 3 Issue 2 • August/September 2008 11 Treatment strategies Management of patients with NSCLC can be considered as either radical (ie with curative intent) or palliative. Radical treatment options These would include surgery, radical radiotherapy and multimodality options. Surgery It is fair to say that surgical resection of primary lung cancer is the mode of therapy most often and consistently associated with cure [8]. The key question at an MDT meeting should be “is this patient suitable for surgery?” If not, the reasons should be documented. Indications for surgery can be subdivided into oncological and medical indications. Oncological considerations: All patients being considered for lung resection have the following investigations performed to stage the disease: chest X-ray, bronchoscopy, CT thorax, and PET/CT scan [9]. In certain circumstances other imaging may be required, eg CT or MR brain scan, isotope bone scan, liver ultrasound. Patients suitable for tumour resection will generally be those in whom the primary tumour is small, where it has not eroded into adjacent structures that would deem it irresectable, and where there is no (or minimal) lymph node spread and distant metastatic spread. Suitable tumour stages would be T1 and T2. Certain T3 tumours may be suitable for resection, such as local overlying rib invasion, where the tumour can be resected by lobectomy and en bloc chest wall resection. T4 tumours (eg where the tumour has infiltrated oesophagus, vertebral column or great vessels) are generally unresectable. Patients who are staged as N0 or N1 are generally suitable for lung resection provided everything else is favourable. If a patient is staged preoperatively as N2 (ipsilateral mediastinal nodes), surgery is not usually the best treatment. Pre- operatively staged N3 nodal disease would generally be a contraindication to surgery, outside a clinical trial. The presence of metastases would also be a contraindication to surgery. For example, a patient with hepatic, bony or adrenal metastases would certainly not be a suitable candidate for surgery. However, a small highly selected group of patients with solitary cerebral metastases and otherwise operable lung cancer might be treated by cerebral metastasectomy and lung resection, with survival benefit [10]. Medical considerations: Bearing in mind that these patients are generally elderly and have probably been cigarette smokers, many of them will have significant co- morbidities. Cardiac disease and COPD are often fellow- travellers, making careful clinical examination essential. Supportive laboratory tests are often required. Cardiac investigations should at a minimum be good clinical history and examination, with ECG. Further tests such as echocardiography, exercise ECG and cardiac catheterisation may be required. Respiratory assessment is clinical, lung function tests being essential. Surgical points If the PET scan shows evidence of FDG uptake in the mediastinum, mediastinoscopy is required for tissue diagnosis. However if the PET scan is negative in the mediastinum, no mediastinoscopy is necessary. Once the decision to operate has been made, the principles of surgery are to resect the tumour widely, leaving as much non-diseased functional lung as possible. In practice, lobectomy is the treatment of choice. This is certainly preferable to wedge resection or segmentectomy. Sometimes, however, lobectomy alone is insufficient to resect the cancer and bi-lobectomy or pneumonectomy is required. Operative mortality is 2-3% for lobectomy and ~7% for pneumonectomy. Long-term survival is dictated by the post- resection histology report. A 1cm T1 lesion with no nodal spread may have a 5-year survival in excess of 80%. A 5cm T2 tumour with resected N2 disease may have a 5 year survival of only 20%. For those patients who undergo a lung resection, their case should be discussed at a MDT meeting. In certain circumstances, adjuvant chemotherapy may be associated with survival advantage. Radical radiotherapy In certain circumstances with small tumours showing no evidence of nodal spread, the patient may not be suitable for surgery. Recent stroke, myocardial infarction or significant COPD may deem surgery inappropriate. In addition, small tumours that are thought to be inoperable may be better treated by radical radiotherapy [11]. With limited disease under these circumstances, radical radiotherapy may be associated with cure or extended survival. High dose radiotherapy (e.g. 60 Gy over four weeks on a daily basis) can be given. An improved form of radiotherapy called CHART Table 2: Lung Cancer TNM (summary) T1 Tumour less than or equal to 3cm in its greatest diameter T2 Tumour >3cm T3 Tumour invading local adjacent structure that can be easily resected eg chest wall diaphragm T4 Tumour invading adjacent structure that cannot be resected eg oesophagus, vertebra, aorta N0 No nodal spread N1 Involvement of local ipsilateral nodes within the envelope of the visceral pleura N2 Involvement of ipsilateral mediastinal nodes N3 Involvement of contralateral mediastinal nodes and/or isilateral/contralateral supraclavicular or scalene nodes M0 No evidence of distant metastases M1 Evidence of distant metastases
  • 12. 12 Volume 3 Issue 2 • August/September 2008 (Continuous Hyperfractionated Accelerated Radiotherapy) is a 3-times daily treatment over about 12 days with no weekend breaks, giving improved survival (12). In certain circumstances chemotherapy can be administered in combination with radiotherapy to attempt to improve the results. Palliative therapy In advanced disease, it is accepted that cure is improbable. The management plan would be to reduce tumour bulk and provide the patient with as good a quality of life as possible. Radiotherapy is an excellent palliative therapy, and can provide relief from bony pain, irritating cough, haemoptysis and cerebral metastases [13]. Chemotherapy can also provide excellent palliation of symptoms and generally promote well- being, improve appetite and slow down weight loss [14]. Surgical procedures can provide palliation, such as pleurodesis of recalcitrant pleural effusions (Figure 2), disobliteration of airways with laser and stenting of oesophageal strictures secondary to mediastinal nodal involvement. These specific interventional measures are undertaken in addition to the general and specialist palliative care input that is provided at all stages of the progression of the disease in the patient, as is appropriate to their needs [15]. n Key points • Lung cancer is a common disease with generally a poor outcome; good results can be achieved in appropriately selected individuals • All patients with lung cancer should be reviewed by the Lung Cancer MDT and optimum treatment established • All patients in whom a radical option is being contemplated should have a CT scan of thorax and abdomen • All patients who might have radical treatment should have a PET scan References 1. Office of National Statistics. Cancer Statistics Registration: Registrations of cancer diagnosed in 2004, England, Series MBI no 33, 2005 2. WHO histological typing of lung cancers. In: International classification of tumours 2nd edition 1981, Geneva 3. Spira A, Ettinger DS. Multidisciplinary management of lung cancer. New England Journal of Medicine 2004;350:379-92. 4. Jackman DM, Johnson BE. Small-cell lung cancer. Lancet 2005;306:1385-96. 5. Prophylactic cranial irradiation in small-cell lung cancer: is it still controversial or is it a no-brainer? The Oncologist 2000;5:299-301. 6. Elias AD, Ayash L, Frei E et al. Intensive combined modality therapy for limited- stage small cell lung cancer. J Natl Cancer Inst 1993;85:559-66. 7. Goldstraw P, Crowley J, Chansky K et al. The IASCLC lung cancer staging project. Journal of Thoracic Oncology 2007;8:706-14. 8. Jablons D. Neoplasms of the lung. In: LW Way, GM Docherty (eds). Current Surgical Diagnosis & Treatment 11th ed: 395-407. 9. Shim SS, Lee KS, Byung-Tae K et al. Non-small cell lung cancer: prospective comparison of integrated FDG PET/CT and CT alone for pre-operative staging. Radiology 2005;236:1011-9. 10. Granone P, Margaritora S, D’Andrilli A, Cesario A, Kawamukai K, Meacci E. Non-small cell lung cancer with single brain metastasis: the role of surgical treatment. Eur J Cardiothorac Surg 2001;20:361-6. 11. Tyldesley S, Boyd C, Schulze K, Walker H, Mackillop WJ. Estimating the need for radiotherapy for lung cancer: an evidence-based, epidemiologic approach. Int J Radiat Oncol Biol Phys 2001;49:973-85. 12. Saunders MI. A randomised multicentre trial of CHART vs conventional radiotherapy in non-small cell lung cancer. Lung Cancer 1997;18:28-9. 13. Lester JF, Macbeth FR, Toy E, Coles B. Palliative radiotherapy regimens for non- small cell lung cancer. The Cochrane Database of Systematic Reviews 2006; issue3: Art no: CD 002143. 14. Tassivari D, Sartori S, Papi M et al. Outcomes of palliative care in stage IV non- small cell lung cancer. Have we found what we are looking for? Lung Cancer 2004;43:373-4. 15. Kvale PA, Selecky PA, Prakash, UBS. Palliative care in lung cancer. CHEST 2007;132:368-403. Figure 2: Malignant pleural effusion secondary to lung cancer. Reel Lives: The Cancer Chronicles Film Festival is the first ever international documentary film competition focused on cancer. It aims to raise awareness of the impact of cancer while also honouring people who have been touched by the disease. Reel Lives is produced by the International Union Against Cancer (UICC) and will be held in Geneva, Switzerland, on 28-30 August. The festival is supported by a grant from GlaxoSmithKline Oncology. In its inaugural year, the festival has already received more than 100 film entries from around the world, and has just added noted oncologist Dr. Larry Norton to its team of expert judges. “We are thrilled with the positive response,” says Isabel Mortara, executive director of UICC, the leading international non-governmental organization dedicated exclusively to the global control of cancer. “We believe the festival will help demystify cancer and deepen awareness of cancer as a pressing global health issue, while also highlighting progress in the fight against the disease.” The festival will take place during the 2008 World Cancer Congress in Geneva. The grand prize winner will receive $10,000. Other monetary prizes will also be awarded. For further information - www.reellives.org Contact: Claudia Durgnat, UICC/Reel Lives Film Festival Switzerland, Tel: +41 79 507 2324. Top Oncologist on Jury Panel
  • 13. A lifeline in relapsed NSCLC Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk. Adverse events should also be reported to Roche Products Limited. Please contact UK Drug Safety Centre on 01707 367554. J340678/JUL08 Prescribing Information Tarceva® (erlotinib) 25, 100 and 150 mg tablets Full prescribing information should be viewed prior to prescription. Indication: Treatment of patients with locally advanced or metastatic non-small cell lung cancer after failure of at least one prior chemotherapy regimen. When prescribing, factors associated with prolonged survival should be taken into account. No survival benefit or other clinically relevant effects of the treatment have been demonstrated in patients with EGFR-negative tumours. Dosage and administration: The daily dose is 150 mg taken orally at least one hour before or two hours after the ingestion of food. When dose adjustment is necessary, reduce in 50 mg steps. Safety and efficacy of Tarceva in children has not been established. Contra-indications: Known hypersensitivity to erlotinib or any of the excipients. Precautions: Smokers should be advised to stop smoking as a clinically significant reduction in plasma concentration is likely. Interstitial lung disease (ILD), including fatalities, has been reported (incidence 0.6%). In patients who develop acute onset of new and/or progressive unexplained pulmonary symptoms such as dyspnoea, cough and fever, interrupt therapy pending diagnostic evaluation. If ILD is diagnosed, discontinue therapy and initiate appropriate treatment. Diarrhoea should be treated with loperamide. Tarceva dose reduction or interruption may be necessary in patients with severe or persistent diarrhoea. It may be necessary to intensively rehydrate the patient intravenously, monitor renal function and serum electrolytes including potassium. In patients with pre-existing liver disease or on concomitant hepatotoxic medications, periodic liver function testing should be considered. Tarceva dosing should be interrupted if changes in liver function are severe. As tablets contain lactose they should not be administered to patients with galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption. Avoid concomitant administration with PPIs (Proton Pump Inhibitors), H2 antagonists and antacids (see Drug Interactions below). Drug Interactions: Plasma concentrations increase when combined with potent CYP3A4 inhibitors e.g. ketoconazole. It may therefore be necessary to reduce the dose of erlotinib. Potent CYP3A4 inducers e.g. rifampicin will decrease erlotinib plasma concentrations. Concomitant treatment should be avoided. If the combination cannot be avoided an increase in Tarceva dose to 300 mg can be considered, provided safety is closely monitored (renal/liver function and serum electrolytes). If well tolerated, after 2 weeks a further increase to 450 mg could be considered with continued monitoring. Caution should be observed in concomitant treatment with other CYP3A4 inducers. Significant interactions with the clearance of CYP3A4 substrates e.g. midazolam, erythromycin and paclitaxel, is unlikely. Potential interactions may occur with active substances which are metabolised by, or are inhibitors or inducers of CYP1A2, CYP1A1 and CYP1B1. Caution should be observed when ciprofloxacin or potent CYP1A2 inhibitors (e.g. fluvoxamine) are combined with erlotinib. Dose reduction may be required if an adverse event occurs. Monitor patients taking warfarin or other coumarin-derivative anticoagulants for changes in prothrombin time or international normalised ratio (INR). Concomitant administration of inhibitors of the P-glycoprotein active substance transporter e.g. cyclosporin and verapamil may lead to altered distribution and/or elimination of erlotinib. Solubility of erlotinib decreases at pH above 5. Drugs that alter the pH of the upper GI tract e.g. omeprazole (PPI) may alter the solubility of erlotinib and hence its bioavailability. Use with antacids and H2 antagonists should be avoided. If use of antacids is necessary take at least 4 hours before or 2 hours after erlotinib. Erlotinib increases platinum concentrations, though this is not considered to be clinically relevant. A study showed that carboplatin and paclitaxel did not affect erlotinib pharmacokinetics. Capecitabine may increase erlotinib concentrations but a clinical study showed there were no significant effects of erlotinib on the pharmacokinetics of capecitabine. Erlotinib and gemcitabine can be combined without significant effects on the pharmacokinetics. The inhibition of glucuronidation may cause interactions with medicinal products which are substrates of UGT1 A1 and exclusively cleared by this pathway. Pregnancy and lactation: There is no adequate experience in human pregnancy and lactation therefore Tarceva should only be used if the potential benefit justifies the potential risks. Women of childbearing potential must be advised to avoid pregnancy while on erlotinib and adequate contraceptive methods should be used during therapy, and for at least 2 weeks after completing therapy. Side effects and adverse reactions: See SmPC for full listing. Serious adverse reactions: Gastrointestinal: Cases of gastrointestinal bleeds have been commonly reported. Hepato-biliary disorders: Rare cases of hepatic failure (including fatalities) have been reported. Respiratory, thoracic and mediastinal disorders: Uncommon reports of serious interstitial lung disease (ILD), including fatalities. Infections and infestations: Severe infections, with or without neutropenia, have included pneumonia, sepsis and cellulitis. Common adverse reactions: Rash (75%), diarrhoea (54%), fatigue (52%) and anorexia (52%) were the most commonly reported adverse events in the BR.21 study. Most were grade 1/2 in severity and manageable without intervention. Diarrhoea can rarely lead to dehydration, hypokalemia and renal failure. Other adverse events reported, which occurred at a frequency ≥3% over placebo included pruritus, dry skin, nausea, vomiting, stomatitis, abdominal pain, dyspnoea, cough, infection, conjunctivitis and keratoconjunctivitis sicca. In the primary safety population the following was observed: Skin and subcutaneous disorders: Alopecia, paronychia, hirsutism, eyelash/eyebrow changes and brittle and loose nails. Hepato-biliary disorders: Liver function test abnormalities have been commonly observed. Most cases were mild or moderate in severity, transient in nature or associated with liver metastases. Eye disorders: Keratitis and corneal ulcerations. Respiratory, thoracic and mediastinal disorders: Epistaxis. Legal category: Presentations, Basic NHS Costs, and Marketing authorisation numbers: Tarceva (erlotinib) tablets 25 mg x 30: pack £378.33. EU/1/05/311/001. Tarceva (erlotinib) tablets 100 mg x 30: pack £1,324.14. EU/1/05/311/002. Tarceva (erlotinib) tablets 150 mg x 30: pack £1,631.53. EU/1/05/311/003. Marketing authorisation holder: Roche Registration Ltd, 6 Falcon Way, Shire Park, Welwyn Garden City, AL7 1TW, United Kingdom. Tarceva is a registered trade mark. Date of preparation: January 2008. POM Journal:OncologyNewsRoche:TarcevaUKAd Size:297x210mmBleed:3mmSupplyashiresPDFJobno:XXXXX Tarceva UK Oncology News Ad 2008_XXXXX 28/7/08 11:13 Page 1
  • 14. 14 Volume 3 Issue 2 • August/September 2008 The Current Treatment of GIST With Reference to Laparoscopic Resection and Neoadjuvant Treatment Miss Siobhan Gill, MRCS, Senior House Officer in Surgery. Mr Paras Jethwa, BSc (Hons), MD, FRCS(Gen), Consultant General & Upper GI Surgeon. Correspondence: P Jethwa, Surrey & Sussex NHS Trust, Dept of Surgery, Canada Avenue, REDHILL, Surrey, RH1 5RH, UK. Upper GI Oncology G astrointestinal stromal tumours (GIST) are the most common mesenchymal tumours of the alimentary tract; they account for <1% of all GI malignancies with approximately 900 new cases per year in UK [1]; primary GISTs tend to arise as solitary lesions most commonly affecting the stomach (60-70%), followed by the small bowel (20- 25%) and less commonly the rectum, oesophagus and colon [2]. Genetic analysis has revised the definition of GIST to be that of “highly cellular mesenchymal tumours of the gastrointestinal tract containing spindle, epitheloid cells or a combination of both and displaying CD117/c- kit positivity”. GISTs have been proposed to originate from the interstitial cells of Cajal, considered to be regulators of gastrointestinal motility but, as they can arise from tissue depleted of Cajal cells, the possibility that they arise from a pluripotent stem cell has been suggested [3]. The management of GISTs has evolved rapidly with our understanding of the molecular pathophysiology of this lesion allowing for the rational development of antitumour agents that target signalling aberrations in these cells. Imatinib mesylate (Gleevac, Glivec), a tyrosine kinase and platelet derived growth factor receptor (PDGR) antagonist, have shown excellent results in patients with unresectable or metastatic GIST, but surgical resection of the primary tumour remains the treatment of choice when cure is sought. There is, however, still debate regarding the most appropriate operative approach and the extent of resection required. While metastatic spread is common at first diagnosis, spread to lymph nodes is rarely seen thus, more extensive resection other than the primary site is questionable and has no bearing on survival or recurrence. Recently the National Comprehensive Cancer Network (NCCN) task force reported that “laparoscopic or laparoscopic-assisted resection may be useful for small (<2cm) GISTs when the risk of intraoperative tumour rupture is low. However, the use of laparoscopic resection is generally discouraged for GIST” [4]; despite this, laparoscopic resection of primary GIST has become the treatment of choice in many centres in the UK and Europe. This article summarises the current role of surgery and targeted chemotherapy in the management of GISTs. Minimally invasive surgery for GIST Laparoscopic surgery for gastrointestinal cancer and, more recently gastric cancer has been widely adopted in Japan, Korea, China, Italy, USA and the UK, but not without some debate. Unlike adenocarcinoma, lymphadenectomy is unnecessary with the aim of GIST surgery being the complete removal (R0) of the tumour with negative resection margins and without capsule rupture or intra-abdominal spillage of
  • 15. Volume 3 Issue 2 • August/September 2008 15 tumour cells. Evidence has shown that survival is dependant on tumour size (<5cms), mitotic activity (<5/50 mitoses per high powered field), angiogenic upregulation and evidence of mutation rather than the extent of resection [2,5]. Many GISTs can be treated without major anatomical resection and therefore are suitable for minimally invasive surgery, with wedge resection of gastric GISTs widely reported to be both successful and most commonly performed [6]. With the growth in laparoscopic surgical experience subtotal and total gastrectomies are now both practical and suitable for more proximal lesions however, larger GISTs in difficult anatomical positions (oesophagus/oesophagogastric junction/proximal stomach) present a more technically demanding challenge and have a greater propensity for open surgery or intraoperative conversion. The role of laparoscopic surgery in the resection of small bowel GISTs remains unclear at present though laparoscopic excision of large bowel and rectal GISTs have been reported to be technically feasible and have successful outcomes [7,8]. The majority of reported series have supported the role of laparoscopic treatment of gastric and gastro-oesophageal GISTs, demonstrating it to be associated with lower morbidity, mortality, length of stay and rates of long term survival comparable to, if not better, than that of conventional surgery [9]. Wherever possible anatomical function should be preserved but this should not be at the cost of an R0 resection with enucleation of the tumour best avoided. In order to facilitate this a combined endoscopic laparoscopic local resection of tumours has proven to be beneficial in patients with upper GI GISTs, known as an endoscopic rendezvous procedure [10]. This technique facilitates preservation of anatomical function during the resection by ensuring lumen patency at all time. Despite initial concerns there have been favourable results reported from the resection of larger GISTs (up to 15cm in size), with no local or peritoneal recurrence after four years [11]. In order to successfully remove GISTs it is imperative to gently handle the tumour and, if at all possible, direct handling should be minimised. We have found that once the stomach has been mobilised, normally requiring the division of the gastrocolic omentum for tumours on the greater curve or the gastohepatic ligament for those on the lesser curve, placing stay sutures either side of the tumour mass greatly enhances operative control and reduces the risk of tumour cell spillage. After adequate mobilisation gastric resection is performed by elevating the stomach wall and transecting the normal stomach with a linear endoscopic GI anastomosis stapler (Figures 1 & 2, tumour arising from lesser curve). For the resection of larger lesions (>5cm),careful tactile handling and adequate traction of the tumour can be more problematic, with the use of hand assisted laparoscopic surgery (HALS) advocated by some authors [12]. While most GISTs are hard, elastic and coated with a thin pseudo-capsule some are very fragile and bleed easily. This latter group requires particular attention to ensure no tumour spillage at time of resection. Current consensus suggests that if these tumours are encountered during laparoscopic surgery, the procedure should be switched to laparoscopically assisted or conventional open surgery. As with the majority of GI neoplasms in western countries, most GIST patients present late, with complaints of vague abdominal discomfort or anaemia due to large bulky disease, and are not suitable for primary surgery at first presentation. Before 2001, surgery was the only effective treatment for GISTs however, the introduction of tyrosine kinase inhibitors as neoadjuvant chemotherapeutic agents has revolutionised the approach to these tumours with, previously irresectible lesions downstaged to the point of curative resection. This is further discussed below. Neoadjuvant treatment Combined modality strategy has shown significant benefit from imatinib mesylate (Gleevac) in downstaging GISTs, thus rendering previously inoperable tumours resectable with tumour regression of up to 80% of patients. With as many as 90% of patients developing recurrent disease during their lifetime there has been a considerable rise in our familiarity of the use of imatinib mesylate in the pre- operative setting and, for those patients that develop symptomatic or functional recurrent disease. This has been demonstrated in a variety of settings with reports of successful R0 resection in previously advanced tumours or marginally resectable tumours, including locally advanced lesions of the stomach, metastatic hepatic GISTs and in small bowel disease [13,14]. Despite an initial response to imatinib secondary or acquired resistance tends to develop after a median of two years with this most commonly due to KIT mutation in clonally expanded cells. Mutational analysis has helped to characterise the behaviour of these tumours with proximal deletions of exon 11 and duplication of exon 9 associated with high risk lesions whereas, PDGF α exon 18 mutated GISTs have a lower malignant potential. In light of this drug resistance the use of a newer agent, sunitinib malate (Sutent, SU11248), has been trialed in patients with advanced disease, with GISTs resistance to imatinib. Two phase II trials and one phase III trial have reported a significant clinical benefit with an increase in time to tumour progression and death, leading to suntinib being licensed for all patients in the US with imatinib resistant disease [15]; however tumour shrinkage compared to placebo was not common and its role as a neoadjuvant downstaging agent needs further clarification and investigation [16]. In addition, mutational analysis of the primary tumour may also help to target drug therapy, with exon 9 mutation GISTs especially sensitive to sunitnib treatment whilst at best having an intermediate response to imatinib. It is clear, at present, that a randomised clinical trial Laparoscopic resection of primary GISTs has become the the treatment of choice... with lower morbidity, mortality, length of stay and [improved] rates of longterm survival
  • 16. 16 Volume 3 Issue 2 • August/September 2008 of these agents as neoadjuvant treatments in advanced GISTs is needed to establish any relative superiority. It is our experience that in advanced and recurrent disease, increasing the dose of imatinib mesylate (up to 800mg/day) in patients that initially have a poor response or are refractory to therapy proves to be both efficacious and therapeutic. This increase leads, in a sizeable proportion, to a decrease in tumour volume and is associated with complete surgical resection in those with locally advanced primary GISTs [17]. Early surgical intervention should be considered for imatinib responsive disease and in these patients multiple reoperation(s) are associated with prolongation of life. Conclusion The current management of GISTs continues to rapidly progress with the combination of new surgical techniques and targeted chemotherapy delivering real benefits in keeping with their promised potential expectations seen at the cellular level. The treatment of GISTs continues to evolve with dramatic reductions seen in mortality and associated surgery from this disease. n References 1. Pidhorecky I, Cheney RT, Kraybill WG, Gibbs JF. Gastrointestinal stromal tumors: current diagnosis, biologic behavior, and management. Ann Surg Oncol. 2000;7(9):705-12. 2. DeMatteo RP, Lewis JJ, Leung D, Jeung D, Mudan SS, Woodruff JM, Brennan MF. Two hundred gastrointestinal stromal tumour: recurrence patterns and prognostic factors for survival. Ann Surg 2000 Jan;231:51-8. 3. Connolly EM, Gaffney E, Reynolds JV. Gastrointestinal stromal tumours. Br J Surg 2003;90(10):1178-86. 4. Demetri GD, Benjamin RS, Blanke CD, Blay JY et al. NCCN Task Force report: management of patients with gastrointestinal stromal tumor (GIST) - update of the NCCN clinical practice guidelines. J Natl Compr Canc Netw. 2007;Jul;5 Suppl 2:S1-29. 5. Imamura M, Yamamoto H, Nakamura N, Oda Y, Yao T, Kakeji Y, Baba H, Maehara Y, Tsuneyoshi M. Prognostic significance of angiogenesis in gastrointestinal stromal tumors. Mod Pathol 2007:20(5):529-37. 6. Nowain A, Bhakta H, Pais S, Kanel G, Verma S. Gastrointestinal stromal tumours: clinical profile, pathogenesis, treatment strategies and prognosis. J Gastroenterol Hepatol. 2005;Jun;20(6):818-24. 7. Nguyen SQ, Divino CM, Wang JL, Dikman SH. Laparoscopic management of gastrointestinal stromal tumors. Surg Endosc 2006;20(5):713-6. 8. Nakamura T, Ihara A, Mitomi H, Kokuba Y, Sato T, Ozawa H, Hatade K, Onozato W, Watanabe M. Gastrointestinal stromal tumor of the rectum resected by laparoscopic surgery: report of a case. Surg Today. 2007;37(11):1004-8. 9. Novitsky YW, Kercher KW, Sing RF, Heniford BT. Long-term outcomes of laparoscopic resection of gastric gastrointestinal stromal tumors. Ann Surg 2006;Jun;243(6):738-45; discussion 745-7. 10. Ludwig K, Wilhelm L, Scharlau U, Amtsberg G, Bernhardt J. Laparoscopic- endoscopic rendezvous resection of gastric tumors. Surg Endosc. 2002 Nov;16(11):1561-5. 11. Otani Y, Kitajima M. Laparoscopic surgery for GIST: too soon to decide Gastric Cancer. 2005;8(3):135-6. 12. Yano H, Kimura Y, Iwazawa T, Takemoto H, Imasato M, Monden T, et al. Hand- assisted laparoscopic surgery for a large gastrointestinal tumor of the stomach. Gastric Cancer. 2005;8:186-92. 13. Gomez D, Al-Mukthar A, Menon KV, Toogood GJ, Lodge JP, Prasad KR. Aggressive surgical resection for the management of hepatic metastases from gastrointestinal stromal tumours: a single centre experience. HPB (Oxford). 2007;9(1):64-70. 14. Chiang KC, Chen TW, Yeh CN, Liu FY, Lee HL, Jan YY. Advanced gastrointestinal stromal tumor patients with complete response after treatment with imatinib mesylate. World J Gastroenterol. 2006 Apr 7;12(13):2060-4. 15. Hopkins TG, Marples M, Stark D. Sunitinib in the management of gastrointestinal stromal tumours (GISTs). Eur J Surg Oncol. 2008 Aug;34(8):844- 50. 16. Demetri GD, van Oosterom AT, Garrett CR, Blackstein ME, Shah MH, Verweij J, McArthur G, Judson IR, Heinrich MC, Morgan JA, Desai J, Fletcher CD, George S, Bello CL, Huang X, Baum CM, Casali PG. Efficacy and safety of sunitinib in patients with advanced gastrointestinal stromal tumour after failure of imatinib: a randomised controlled trial. Lancet. 2006 Oct 14;368(9544):1329-38. 17. Andtbacka RH, Ng CS, Scaife CL, Cormier JN, Hunt KK, Pisters PW, Pollock RE, Benjamin RS, Burgess MA, Chen LL, Trent J, Patel SR, Raymond K, Feig BW. Surgical resection of gastrointestinal stromal tumors after treatment with imatinib. Ann Surg Oncol. 2007 Jan;14(1):14-24. Subscription Information International readers can read each issue FREE online at: www.oncologynews.biz Or for a paper copy there is a charge: Europe £30.00 (GBP) Rest of World £50.00 (GBP) Please send a cheque in pounds sterling made payable to: ‘McDonnell Mackie’ and send to: Oncology News 84 Camderry Road, Dromore, Co Tyrone, BT78 3AT, UK Oncology What is UCAN? Management of Primary Lung Cancer The Current Treatment of GIST With Reference to Laparoscopic Resection and Neoadjuvant Treatment Prostate Cancer reviewed: Part 2 - Treatment Options News Volume 3 Issue 2 :August/September 2008 www.oncologynews.biz In this issue ISSN 1751-4975 Oncology Chinese Medicine and Cancer A Potential New Drug that Kills Malignant Cells Without Affecting Healthy Normal Cells The Genetics of Prostate Cancer and the Potential for Targeted Screening: The IMPACT Study News Volume 2 Issue 2 : August/September 2007 www.oncologynews.biz In this issue ISSN 1751-4975 Oncology Sentinel Lymph Node Biopsy: Role in Melanoma Multiple Myeloma Advances in Management of Renal Cell Carcinoma Colorectal Cancer – A Sticky Problem News Volume 2 Issue 3 : October/November 2007 www.oncologynews.biz In this issue ISSN 1751-4975 Oncology Arginine Deprivation Addresses the Achilles Heel of Cancer: Urea Cycle Deficiencies in Melanoma, HCC and other Cancers Future Directions in the Medical Management of Malignant Mesothelioma Role of the Endothelin Axis in Colorectal Cancer CNS/Brain Tumour 2-Week Referral Guidelines: A Review of their Utility in Neurological Practice News Volume 2 Issue 4 : December/January 2008 www.oncologynews.biz In this issue ISSN 1751-4975 Oncology Photodynamic Therapy Role in the Premalignancy / Malignancy of the Head and Neck Nutrition in Upper GI Cancer Urinary Tissue Factor in Bladder Cancer Screening For Colorectal Cancer Diagnosing Lung Cancer on the Chest Radiograph – Pitfalls and Pearls News Volume 2 Issue 5 : February/March 2008 www.oncologynews.biz In this issue ISSN 1751-4975 Oncology Paediatric Oncology: Clinical Practice and Clinical Trials High Impact Trials in Screening and Treatment of Colorectal Cancer Optimising Transurethral Resection for Non-Muscle Invasive Bladder Cancer; A Recurrent Problem An Introduction to MR Imaging of the Spine in Oncology News Volume 2 Issue 6 : April/May 2008 www.oncologynews.biz In this issue ISSN 1751-4975 Oncology Lung Cancer Screening: Stratification of High Risk Populations Stem Cell Therapy for Paediatric Malignant Brain Tumours: The Silver Bullet? 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  • 17. Uftoral Prescribing Information (UK) Presentation: Capsules containing 100 mg tegafur and 224 mg uracil. Therapeutic Indications: First-line chemotherapy treatment of metastatic colorectal cancer in combination with calcium folinate. Dosage and administration: The dose of Uftoral is 300 mg/m2/day tegafur and 672 mg/m2/day uracil combined with 90 mg/day oral calcium folinate, given in three divided doses, at least one hour before or after meals. Calcium folinate should be taken at the same time as Uftoral. The treatment cycle is 35 days. Uftoral/calcium folinate is taken for 28 consecutive days followed by 7 days without Uftoral/calcium folinate. Only suitable for adults. Monitor patients with renal or hepatic impairment carefully. Exercise caution in patients with renal impairment. In the elderly, monitor renal, hepatic and cardiac function. Contraindications: Hypersensitivity to the constituents or 5-FU; pregnancy or breast feeding; adolescents, children and infants; severe hepatic impairment; deficiency of hepatic CYP2A6; bone marrow suppression from previous radiotherapy or antineoplastic agents; known or suspected dihydropyrimidine dehydrogenase deficiency; current or recent treatment with dihydropyrimidine dehydrogenase inhibitors such as brivudine. Special Warnings and Precautions: Patients with: renal or hepatic impairment, signs and symptoms of bowel obstruction, signs and symptoms of liver or renal disease, diarrhoea, a history of significant cardiac disease and the elderly. Monitor patients on coumarin anticoagulant treatment (such as warfarin) and phenytoin treatment. Drug Interactions: Warfarin, phenytoin, substrates or inhibitors of the CYP2A6 enzyme such as coumarin, methoxypsoralen, clotrimazole, ketoconazole, miconazole. Must not be co-administered with inhibitors of dihydropyrimidine dehydrogenase eg brivudine (allow interval of 4 weeks before Uftoral treatment). Pregnancy and Lactation: Should not be administered to patients who are pregnant or attempting to become pregnant or breast feeding. Undesirable Effects: Very common: GI disorders such as diarrhoea, nausea/vomiting, abdominal pain, asthenia, stomatitis and anorexia; blood disorders such as myelosuppression, anaemia, thrombocytopenia, leucopoenia and neutropenia; increased alkaline phosphatase, ALT, AST and total bilirubin. Common: other GI disorders including intestinal obstruction; fever, headache, malaise, chills, dehydration, cachexia; CNS disorders including taste disturbance, dizziness, depression and confusion; eye disorders, cardiac and vascular disorders including DVT; respiratory disorders; skin and musculoskeletal disorders. Uncommon: Other GI disorders, hepatitis, jaundice, liver failure, chest pain, sepsis, coagulation disorders, febrile neutropenia, arrhythmia, congestive heart failure, myocardial infarction, heart arrest, shock, pulmonary embolism, abnormal kidney function, urinary retention, haematuria, impotence. Side effects may require dose modification. Please refer to Uftoral SPC for full details of side effects. Legal Category: POM. Basic NHS cost: pack of 36 capsules - £96.12; pack of 120 capsules - £320.40. Marketing Authorisation Holder: Merck Pharmaceuticals (A Division of Merck Ltd), Harrier House, High Street, West Drayton, Middlesex, UB7 7QG, UK. MA Number: PL11648/0065. Date of Preparation: August 2007. Further information, including a summary of product characteristics is available from: Merck Serono, Bedfont Cross, Stanwell Road, Feltham, Middlesex, TW14 8NX, UK Tel: 020 8818 7373. (Uftoral is a trademark of Taiho Pharmaceutical Co., Ltd, used under license by Merck KGaA, Darmstadt, Germany) References : 1. Uftoral SmPC November 2006 Adverse reactions should be reported to Merck Serono (please see contact details within PI). Alternatively, adverse reactions may be reported using the Yellow Card Scheme (www.yellowcard.gov.uk) Date of preparation: March 2008 UFT08-0007 Uftoral: a lifestyle choice for your patients Uftoral offers people with mCRC an effective oral chemotherapy with very rare incidence of HFS.1 Allow your patients to continue with the everyday activities that are essential for their lifestyle. N ICE recom m ended Merck Serono Oncology 9904 UFT Onc News:Layout 1 20/3/08 09:29 Page 1
  • 18. 18 Volume 3 Issue 2 • August/September 2008 F ollowing estimation of pathological staging using the criteria outlined in part 1 of this review, there are three important categories into which tumours are placed in order to determine the appropriate treatment options. These include organ confined T1 and T2 lesions, locally advanced T3 and T4 (N0 M0) tumours and metastatic disease. There are a number of treatment options available for each category and patients’ care needs to be carefully determined taking into account quality of life, competing co-morbidities, life expectancy and patient preference. The Multi-Disciplinary Team (MDT) approach to patient management is key to this process, involving surgeons, oncologists, radiologists, pathologists and specialist nursing staff. Treatment of Organ Confined Prostate Cancer Organ confined disease now represents the majority of tumours at diagnosis and is potentially curable. However, due to the long natural history of prostate cancer and the evolution of different interventions it has been difficult to effectively measure and compare the outcomes of different treatment strategies. Therefore there is a significant degree of controversy surrounding the optimum treatment of this category of disease. Again, treatment needs to be carefully planned in the MDT setting taking into account patient preference, age and co-morbidity. The three main treatment options include watchful waiting or active surveillance, radical surgery and radical radiotherapy. These options have similar long term outcomes but different side effects and complications and therefore each option should be carefully explained to the patient who can then make an informed decision. Watchful Waiting and Active surveillance Low risk, low Gleason grade disease carries only a 4-7% risk of death at 15 years and Gleason 7 disease carries a 42 – 70% risk at 15 years [1]. Thus men over the age of 75 years with organ confined disease and a life expectancy of less than 10 years are unlikely to gain benefit from radical treatment. In such cases it is generally considered appropriate to monitor disease status, termed watchful waiting, with regular PSA and DRE, offering hormone therapy if there is evidence of significant disease progression. A more proactive form of watchful waiting termed active surveillance is available for younger men with low volume, low to moderate grade disease. With more intensive follow-up using PSA, DRE and interval repeat TRUS biopsy radical treatment can be deferred until there is evidence of disease progression. Up to 50% of men are progression free at 10 years and deferred radical treatment remains effective [2]. For some men this is a viable alternative to early radical treatment and its consequent side effects. However, it should be carefully explained to patients that there is a risk that potentially treatable disease may progress during the monitoring period with an increased risk of local progression, metastatic spread and death from prostate cancer [3]. Radical Surgery Radical surgery is considered the gold standard treatment for prostate cancer in appropriately selected patients. Such patients should have a greater than 10 year life expectancy, with organ confined disease which is biologically resectable and they should be fit enough to undergo major surgery. To date there is limited data comparing surgery directly with radical radiotherapy, although surgery is considered the optimum treatment option due to the reduced risk of local recurrence. However, there is good evidence that disease progression and disease specific survival is better with surgery compared to watchful waiting [3]. There are a number of surgical approaches including open retropubic, open perineal and laparoscopic. Acute complications include haemorrhage, infection, and complications related to anaesthesia. Significant late complications include erectile dysfunction in around 50% of patients, incontinence in 10% and bladder neck stenosis in 5%. Ten year progression free survival is in the region of 85% for organ confined disease, but this falls to 55-65% with evidence of extracapsular extension, 25% with seminal vesical disease and 10% if there is nodal disease [4]. Several series of laparoscopic and robotic radical prostatectomy have recently been reported and while some reports suggest shorter recovery time, less blood loss and improved Prostate Cancer reviewed: Part 2 - Treatment Options Simon Mackie, SpR in Urology, Aberdeen Royal Infirmary, UK. Bhavan Rai, Urology Research Fellow, University of Aberdeen, UK. Correspondence to: Dept Urology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, AB252ZN, UK. Urological Cancer Factors Indirectly Affecting Treatment Quality of Life Co-morbidity Life expectancy Patient preference Results Pending Definitive data on optimum treatment strategy for organ confined disease is some way off. The results of a number of studies investigating the role of cancer screening are awaited
  • 19. Volume 3 Issue 2 • August/September 2008 19 incontinence and impotence rates [5] other reports show more mixed results [6] However, oncological outcomes between open and minimally invasive techniques are similar and therefore with continued advances in technology minimally invasive surgery for prostate cancer is likely to become the standard in the future. Radiotherapy External beam radiotherapy (EBR) has seen significant advances in technology in recent years with the development of 3-dimensional conformal radiotherapy (3D-CRT). This targets the radiation more accurately to the shape of the prostate gland avoiding damage to adjacent tissues and allowing higher doses of 70–80 Gy to be administered. Further improvements in accuracy have been made with intensity modulated radiotherapy (IMRT) which utilises computer technology to allow precise targeting. Brachytherapy is the implantation of radioactive seeds into the prostate. Computer models are used to guide precise placement of the seeds allowing high radiation doses of up to 145 Gy to be given. Adjuvant hormone therapy is recommended for 2-3 years in high risk disease and six months in low and intermediate risk disease due to improved local control and survival [7,8]. Cancer specific outcomes are equivalent to surgery but there are problems making direct comparisons as many of the end points used in the study of the different treatment modalities have not been comparable [9]. The five year progression free survival rates for radiotherapy are in the range 70-85% [10]. However, local recurrence has been noted in up to two thirds of patients on long term follow up [11]. Long term complications include chronic cystitis and proctitis and erectile dysfunction in around 50% of patients at one year. A number of other treatment options are currently undergoing evaluation including cryotherapy, radio-frequency ablation and high intensity focussed ultrasound (HIFU). Comparison of radical treatment options have shown broadly similar outcomes but different end points have been used and there are no randomised controlled studies available [12]. However, an ongoing multi-centre research project in the UK comparing radical surgery, radiotherapy and active surveillance is underway. The Prostate testing for cancer and Treatment (ProecT) trial was started in 2001, has been randomising patients to the different treatment groups and aims to report in 2015. Therefore, definitive data on the optimum treatment strategy for organ confined disease is still some way off and the management of prostate cancer will continue to centre around a careful and thorough discussion of all the available options with the patient. Treatment of Locally Advanced and Metastatic Prostate Cancer In the UK locally advanced disease is most frequently managed with radiotherapy combined with adjuvant hormonal therapy. This approach has been shown to offer improved disease free and overall survival compared to radiotherapy alone with five year survival rates in the region of 80% [10]. For elderly patients with limited life expectancy or those patients wishing to avoid the complications and impact on quality of life of radiotherapy, hormone therapy alone or watchful waiting may be appropriate alternatives. Hormone therapy in the form of androgen deprivation forms the mainstay of management for metastatic disease. It was noted over 60 years ago that prostate cancer responded to surgical castration or oestrogen therapy that reduced circulating testosterone levels by negative feedback on the hypothalamic-pituitary axis [13]. Since then a number of alternative agents have been produced including leutenising hormone releasing hormone (LHRH) analogues which reduce testosterone production by negative feedback and steroidal and non-steroidal anti-androgens which block testosterone action in the prostate. Both normal prostatic epithelial cells and cancer cells are dependent on androgens for normal growth and around 70% of tumours will respond to androgen deprivation. However, tumours rapidly develop androgen independence with a mean time to progression of 14 months. When disease progresses, changing the type of androgen deprivation therapy or combining treatments, which is termed 2nd or 3rd line hormonal therapy, offers some improvement but response times are limited and treatment should be aimed at palliation of the symptoms of metastatic complications. In selected patients with androgen independent disease chemotherapy with docetaxol may be indicated with response rates of 20 – 40%, but again median survival rates are low at 24 – 44 weeks [14]. Thus prostate cancer is a serious disease with significant morbidity and mortality and although there are effective interventions available for organ confined disease treatment options for more advanced disease are limited. However, work continues in an attempt to define the molecular genetics and natural history of the disease as well as to optimise both radical and palliative treatment. Moreover, the results of a number of studies investigating the role of cancer screening are awaited, the outcomes of which will have a significant impact on men’s health in the primary and secondary care setting. n References 1. Albertsen PC, Hanley JA, Gleason DF, Barry MJ. Competing risk analysis of men aged 55 to 74 years at diagnosis managed conservatively for clinically localized prostate cancer. JAMA 1998:280:975-80. 2. Patel MI, DeConcini DT, Lopez-Corona E, Ohori M, Wheeler T, Scardino PT. An analysis of men with clinically localized prostate cancer who deferred definitive therapy. J Urol 2004:171:1520-4. 3. Bill-Axelson A, Holmberg L, Ruutu M, Haggman M, Andersson SO, Bratell S et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 2005:352:1977-84. 4. Catalona WJ, Ramos CG, Carvalhal GF. Contemporary results of anatomic radical prostatectomy. CA Cancer J Clin 1999:49:282-96. 5. Stolzenburg JU, Rabenalt R, Do M, Truss MC, Burchardt M, Herrmann TR et al. Endoscopic extraperitoneal radical prostatectomy: the University of Leipzig experience of 1,300 cases. World J Urol 2007:25:45-51. 6. Touijer K, Eastham JA, Secin FP, Romero OJ, Serio A, Stasi J et al. Comprehensive prospective comparative analysis of outcomes between open and laparoscopic radical prostatectomy conducted in 2003 to 2005. J Urol 2008:179:1811-7. 7. Bolla M, Collette L, Blank L, Warde P, Dubois JB, Mirimanoff RO et al. Long- term results with immediate androgen suppression and external irradiation in patients with locally advanced prostate cancer (an EORTC study): a phase III randomised trial. Lancet 2002: 360:103-6. 8. D'Amico AV, Manola J, Loffredo M, Renshaw AA, DellaCroce A, Kantoff PW. 6- month androgen suppression plus radiation therapy vs radiation therapy alone for patients with clinically localized prostate cancer: a randomized controlled trial. JAMA 2004:292:821-7. 9. Gretzer MB, Trock BJ, Han M, Walsh PC. A critical analysis of the interpretation of biochemical failure in surgically treated patients using the American Society for Therapeutic Radiation and Oncology criteria. J Urol 2002:168:1419-22. 10. Bolla M, Gonzalez D, Warde P, Dubois JB, Mirimanoff RO, Storme G et al. Improved survival in patients with locally advanced prostate cancer treated with radiotherapy and goserelin. N Engl J Med 1997:337:295-300. 11. Swanson GP, Riggs MW, Earle JD. Long-term follow-up of radiotherapy for prostate cancer. Int J Radiat Oncol Biol Phys 2004: 59:406-11. 12. Nilsson S, Norlen BJ, Widmark A. A systematic overview of radiation therapy effects in prostate cancer. Acta Oncol 2004:43:316-81. 13. Huggins C, Hodges CV. Studies on prostatic cancer: I. The effect of castration, of estrogen and of androgen injection on serum phosphatases in metastatic carcinoma of the prostate. 1941. J Urol 2002: 168:9-12. 14 Tannock IF, de Wit R, Berry WR, Horti J, Pluzanska A, Chi KN et al. Docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer. N Engl J Med 2004:351:1502-12.
  • 20. 20 Volume 3 Issue 2 • August/September 2008 Book Reviews N euro-oncology is a broad discipline encompassing the work of oncologists, radiotherapists, neurosurgeons, and even an occasional neurologist (although I am only aware of two such dedicated neurologists in the UK), in both adult and paediatric practice, not to mention basic scientists. To produce a text which pleases all in this diverse constituency is difficult, but in my view the current text, with a largely North American authorship based around centres of excellence in San Francisco and Toronto, has largely succeeded. The book is divided into eight sections: Biology, Evaluation, Surgery, Radiation, Chemotherapy, Biological Therapy, Specific Tumours, and Related Issues. Biology addresses epidemiology and the basic sciences of tumour molecular pathology and tumorigenesis, including the possible role of cancer stem cells. This section might profitably be read in conjunction with that on Biological Therapy, which reviews innovative treatments stem- ming from increasing understanding of tumour biology such as tumour vaccines, gene therapy, and small-molecule-based thera- pies, including use of convection-enhanced delivery mechanisms. The latter also crops up in the section on Chemotherapy, a pro- pos intratumoral chemotherapy; this section also covers photody- namic therapy as well as more conventional systemic chemother- apy. Evaluation revolves around the diverse imaging modalities now available (anatomic, metabolic, physiological and function- al), although there was no mention of longitudinal volumetric MR imaging for assessing change in tumour size. The core of the book, around 40% of the text, is devoted to Specific Tumours, addressing clinical presentation, investigation and diagnosis, and treatment of individual tumour types. Generally these chapters are excellent summaries, although one or two have a tendency to read like manuals of surgical procedure. The book’s final section, Related Issues, addresses complications of medical therapy, not only chemotherapy and radiotherapy but also antiepileptic drugs and anticoagulation; quality of life, with a particular focus on neuropsychological consequences of brain tumours and their treatment; and ethics, especially with respect to clinical trials. Production qualities are high, with excellent illustrations, although a few figure legends are incongruous (e.g. 5.12A, 37.1). A key point according to the editors’ preface, retained from the first edition of 2000, is the supplementation of the text with special boxed features (“Pearls”, “Controversies”, “Special Considerations”, and “Pitfalls”). There is some repetition of material between chapters, perhaps inevitable in a multi-author work, but this is not intrusive. Typographical errors and editori- al oversights are few: the two references to chromosomal abnormalities in meningiomas do not exactly correspond (308, 321-2; loss of 18p or 18q?) and it seems unlikely that cabergo- line has become first-line therapy for prolactinoma “due to its higher side-effect profile and lower efficacy” (337). These are minor quibbles, though. “Everything you need to know about neuro-oncology” claims the blurb, and although this may be overstatement it is difficult to think of any serious omissions. Something on the WHO clas- sification of tumours would have been appropriate, as may some commentary on the use of “guidelines” for tumour iden- tification such as those inspired (imposed?) by the UK Department of Health. As a neurologist, I would have liked a chapter on paraneoplastic syndromes. Nevertheless, one has no hesitation in recommending this book, perhaps for the person- al library and definitely for the departmental library. n Andrew J Larner, Walton Centre for Neurology and Neurosurgery, Liverpool, UK. Neuro-oncology. The essentials (2nd edition) Bernstein M, Berger MS (eds.). Publisher: Thieme, 2008. ISBN: 9781588904973 / 9783131163325. Price €149.95. CLINICAL PUBLISHING www.clinicalpublishing.co.uk Special Reader Offer! Problem Solving in Oncology D O’Donnell, M Leahy, M Marples, A Protheroe, P Selby • Comprehensive range of 54 case studies • Practical approach including pictorial overviews • Valuable training and CPD resource Detailed studies covering: breast, ovarian, urological, gastrointestinal, lung, melanoma and more uncommon cancers ( e.g. endocrine/neuro-endocrine tumours, GISTs, chorionic malignancy and head/neck tumours). General aspects of oncology therapy are also covered including work ups, assessment of chemotherapy response, toxicity and psychological aspects of management. Each case begins with practical questions followed by the clinical presentation and a logical work-up to reach a diagnosis. An algorithm accompanies most cases to provide a rapid pictorial overview of the clinical steps. Essential references are provided throughout. 256pp 240 x 170 mm Paperback Illustrations: Tables, algorithms & diagrams. RRP £35-00 978 1 904392 84 2 To order at the special offer price of £30 (incl’ p&p)* Please call 01235 465500 (quoting ref ONC 1) * UK & Eire only
  • 21. Volume 3 Issue 2 • August/September 2008 21 Conference News Are you organising an annual meeting or conference which you would like to tell our readers about? Or would you like to write a report on a meeting or conference of particular interest? If so, contact Patricia McDonnell at Oncology News on Tel/Fax: +44 (0)288 289 7023, Email: patricia@oncologynews.biz 1st Wales Cancer Conference Venue: Cardiff, Wales. Date: 30 April-1 May, 2008. Jointly organised by the Wales Cancer Institute and the Wales Cancer Alliance we welcomed 300 delegates including patients, research nurses, laboratory researchers, policy makers, clinicians and Welsh Assembly Members to the varied two day programme. Upcoming researchers were given the opportunity to showcase their work on the second day in a Young Investigators session where the prize winning talk on “Using an in-vitro MTOR kinase assay to further characterise the MTOR pathway” by Elaine Dunlop give the name set the high standard of the science in Wales. This described a way to understand a key pathway that is often affected in the cancer cell, making the cancer more likely to respond to one treatment rather than another. The conference began with a talk from Prof Paul Workman of the Institute of Cancer Research, Sutton, on “Drugging the cancer genome: Developments in novel therapies” which highlighted two other new approaches to cancer treatment which have been developed in his laboratory and are now in early clinical studies (that is inhibition of the activity of PI3 kinase, a key signalling pathway, and HSP-90, a nuclear chaperone molecule). This linked with Dr Andy Futreal who is one of the leaders in the Human Genome Project from the Wellcome Trust Sanger Institute in Cambridge. He showed the way in which the new technology is able to identify major changes (translaocations and rearrangements) in the genetic code of cancer which will help to identify new ways to target treatment. Dennis Slamon, the discoverer of Herceptin from UCLA in California, gave an excellent talk about the discovery of herceptin and the underlying abnormalities in breast cancer that makes it work so effectively in the 20-25% of women whose breast cancer is driven by an amplification of that gene, and how this could further affect decisions about treatment. These talks all pointed out the fundamental importance of genetic changes in the cancer cell and that these are a key basis for identifying new targets for therapy and in turn begin to influence how therapies can be chosen to fit the patient’s needs in the clinic.. Away from the science Cancer Research UK organised a very lively question and answer session with cross party representation of Welsh Assembly members chaired by the BBC’s Health Correspondent Hywel Griffiths. This session covered a range of topics from the need for a cancer plan in Wales and the roll out of the bowel screening programme to views on co-payments for cancer treatment. An Oxford Union style debate on “All effective treatment should be free” saw the case for being argued for the motion by Prof Richard Sullivan of the London School of Economics and Political Science and Prof Gordan McVie, Managing Editor of ecancermedicalscience, Cancer Intelligence, Bristol. The case against was argued by Dr Fergus McBeth, Director of the National Collaborating Centre for Cancer and Sir Michael Rawlins, Chairman of the National Institute for Health and Clinical Excellence. The vote from the chamber was for the motion but Sir Rawlins went on to give a plenary lecture on “NICE and its role in cancer care” highlighting to the audience that providing the correct individualised treatment for patients is what would also be the most cost-effective and this should be the drive of research. Professor Lesley Fallowfield from the Sussex Psychosocial Oncology Group at University of Sussex spoke on Dennis Slamon
  • 22. 22 Volume 3 Issue 2 • August/September 2008 44th American Society of Clinical Oncology (ASCO) meeting Venue: Chicago, USA. Date: 31 May - 3 June, 2008. ASCO’s main meeting, the premier event in the world medical oncology calendar, once again featured numerous advances in several cancers with many arising from European research. The Medical Research Council’s testicular cancer trial is a prime example. Latest findings of the trial, TE19/EORTC 30982, which began in 1996, confirmed a single dose of carboplatin following orchiectomy is as effective as adjuvant radiotherapy in preventing disease recurrence among men with stage 1 seminoma. Tim Oliver, MD, Emeritus Professor of Medical Oncology at St. Bartholomew's Hospital, London, presented results of the trial which randomised 573 patients to carboplatin, administered over one hour, and 904 patients to daily radiotherapy for 2-3 weeks. After five years, cancer recurrence rates for the two study arms were comparable (5 per cent for carboplatin vs 4 per cent for radiotherapy). Patients who received the full dose of carboplatin had a relapse-free rate of 96.1 per cent, which was identical to that of radiotherapy. Within five years, carboplatin-treated patients were also 82 per cent less likely to develop a cancer in the contralateral testicle. “The rate was better than tamoxifen achieves in breast cancer and opens up the possibility of testis conservation for these patients,” he commented. Future studies will investigate lumpectomy and single-dose carboplatin as an option for men with small tumours presenting early enough who wish to avoid losing the diseased testicle. But 20 years of follow-up are needed to examine death rates from non-germ cell cancer and heart disease and to establish the final incidence of contralateral tumours, he stressed. In metastatic renal cell cancer (mRCC), there was good news on survival. Overall survival (OS) data from a randomised phase III study comparing first-line sunitinib (Sutent) with standard interferon (IFN) alpha therapy in 750 previously untreated patients with mRCC show sunitinib extends median survival to more than two years. Around 80 per cent had metastases at two or more sites. This finding breaks new ground and more than doubles survival time typically observed with IFN alpha treatment, say oncologists. Sunitininb is a multi-targeting tyrosine kinase inhibitor whose targets include vascular endothelial growth factor and platelet derived growth factor receptors - both implicated in tumour progression. Dr Robert Figlin of City of Hope Hospital, Duarte, California said median OS for patients remaining on allotted therapies from randomisation and receiving no post-study treatment were 28 months for sunitinib and 14 months for IFN alpha (p=0.0033). However, patients failing IFN alpha at pre-specified interim analyses were crossed over to sunitinib. Overall, patients randomised to sunitinib had a median survival of 26.4 months compared to 21.8 months for those randomised to IFN alpha giving a hazard ratio of 0.82 (p<0.05). Updated efficacy data show the median progression free survival (PFS) was 11 months for sunitinib and 5 months for IFN alpha and objective response rates, according to investigators were 47 and 12 per cent respectively (p<0.000001). The data confirm sunitinib as the reference standard for first-line therapy for advanced renal cancer, Dr Figlin concluded. In lung cancer the big news was the FLEX study. Late- breaking data reported for the phase III FLEX (First-line in Lung cancer with ErbituX) trial showed a significant overall survival benefit for non-small cell lung cancer (NSCLC) patients when the epidermal growth factor receptor (EGFR) inhibitor cetuximab (Erbitux) was added to platinum-based chemotherapy. Benefit was seen across all histological subtypes, and irrespective of age, gender, smoking status and tumour size. The trial included 1125 previously-untreated patients with advanced (stage IIIB/IV) NSCLC and EGFR-positive tumours. All NSCLC histological types were included; adenocarcinomas represented 47 per cent and squamous cell carcinomas 34 per cent. Almost all patients (94 per cent) had stage IV metastatic disease and 17 per cent had an ECOG performance status (PS) of 2. Overall, patients randomised to a cetuximab / cisplatin / vinorelbine regimen survived 1.2 months longer than patients randomised to chemotherapy alone (11.3 vs 10.1 months HR 0.87, p=0.04). One-year survival rates were 47 and 42 per cent respectively. Lead investigator Professor Robert Pirker of Medical University of Vienna, Austria, said: “The data set a new standard for treating newly- “Communicating effectively with patients” and she will be working with the Wales Cancer Trials Network across Wales to help integrate the “teams talking trials” programme into multidisciplinary teams. Prof Jane Maher the National Clinical Lead NHS Improvement and Chief Medical Officer from MacMillan Cancer Support talked about “Life after cancer treatment: a spectrum of chronic survivorship conditions” on issues of survivorship and living with cancer. This picked up from Prof Jessica Corner’s talk highlighting the problems of long terms toxicities of cancer therapy. In addition to the plenary lectures, sessions were held on many research aspects including basic science, from bench to bedside, on new therapies for cancer and their evaluation in clinical trials, a translational science focus, a clinical trials symposium, cancer immunology, palliative care and also cancer and the primary care setting. The conference attracted a huge breadth of topics in cancer from people’s perception of cancer to targeting cancer tumours; from stem cells to evaluating the HPV vaccine to discussions on do we need a cancer plan for Wales? The breadth of delegates gave a real sense of everyone pulling together. The conference highlighted the issues of payment for cancer treatment, the need for an updated cancer policy in Wales and that research should be driven by the focus on predictive genetic markers and trial programmes incorporating molecular selection and individualisation of therapy. The Wales Cancer Alliance and the Wales Cancer Institute would like to thank all speakers, chairs, poster judges and delegates and we look forward to welcoming you to the next conference in 2010. n More information available at: www.walescancerinstitute.co.uk
  • 23. Volume 3 Issue 2 • August/September 2008 23 The British Association of Cancer Research (BACR), Royal Society of Medicine (RSM) Oncology section and the Academy of Pharmaceutical Sciences of Great Britain (APSGB) are holding the second in a series of inter- disciplinary meetings on Thursday 27th November 2008. This one-day meeting will be held in the Royal Society of Medicine. The aim of these meetings is to provide an opportunity to discuss issues relating to translational preclinical research and the challenges for transfer of agents into the clinic. This meeting is to be on the role of model systems in informing the clinical and pre-clinical development of cancer drugs and drug/gene delivery systems, working through the challenges in taking targeted therapies forward to the clinic. Specifically we want to address the requirement for robust biomarkers in the development of targeted therapies and explore how informative current preclinical models are in taking these forward to the clinical setting. The day will begin with three introductory lectures exploring these issues from a clinical, academic and industrial perspective, followed by a panel discussion session. Following lunch there will be a poster session in which selected posters will be chosen for discussion. In the afternoon there will be presentations discussing more specific examples of the development of preclinical models to validate the use of biomarkers. Confirmed speakers: Johann de Bono (Royal Marsden Hospital, UK), Sally Burtles (Cancer Research UK), Steve Wedge (AstraZeneca, UK), Chand Khanna (National Cancer Institute, US), Bob Brown (Imperial College London, UK), Val Brunton (University of Edinburgh, UK) and Gill Tozer (University of Sheffield, UK). Paul Workman (The Institute of Cancer Research, UK) and Sue Burchill (Leeds Institute of Molecular Medicine) will lead panel and poster discussion sessions. We hope you will agree this is an important area and will support this exciting initiative by putting the date in your diary and coming along to the meeting. n For further information contact: Barbara Cavilla, BACR, c/o The Institute of Cancer Research, Email: bacr@icr.ac.uk BACR/RSM Oncology Section/Academy of Pharmaceutical Sciences Joint Meeting “Preclinical models; biomarkers and targeted therapy” Venue: London, UK. Date: 27 November, 2008. PREVIEW diagnosed patients with advanced NSCLC. This is the first trial of a front-line targeted therapy to include patients with squamous cell carcinomas, and patients who have a particularly poor prognosis,” he pointed out. In metastatic colorectal cancer (mCRC) there was news that patients whose tumours express KRAS normal or wild-type genes have a significantly greater chance of responding to first- line targeted EGFR-inhibitor treatment as has been demonstrated previously for second/third line therapy. On average, the ratio of wild-type to mutant KRAS in mCRC tumours is 2:1. Tumours with mutant KRAS derive no benefit from EGFR inhibition, said researchers. Data from the 1198- patient CRYSTAL trial on 540 archived tumour tissue samples evaluable for KRAS, found response rates for first-line cetuximab and FOLFIRI were much higher in the presence of wild-type KRAS (59 per cent vs 43 per cent for FOLFIRI alone) and PFS was increased by 32 per cent in the cetuximab/FOLFIRI arm (HR 0.68 p=0.017). KRAS mutant tumours showed no enhanced response from adding cetuximab to FOLFIRI; response rates were 36 per cent for cetuximab/FOLFIRI and 40 per cent for FOLFIRI alone and PFS was actually shorter HR1.07 p=0.75. Professor Eric Van Cutsem of University Hospital Gasthuisberg, Leuven, Belgium, who presented the data hailed the findings as “a real advance”. It showed patients with wild- type KRAS had twice the chance of surviving one year without tumour growth if they received EGFR-targeted therapy alongside irinotecan-containing therapy, he said. KRAS status of tumours is now likely to be determined ahead of patients being randomised in further clinical trials of EGFR inhibitors in mCRC. In early-stage breast cancer, a 1803-patient study showed the bisphosponate zoledronic acid (Zometa) significantly reduced risk of recurrence when added to hormone therapy with tamoxifen or anastrazole. After median follow-up of 60 months it was found adding zoledronic acid reduced risk of relapse by 35 per cent. Lead investigator Michael Gnant, Professor of Surgery at Vienna University said future research would now focus on optimising the dosing schedule and identifying patients who benefit most. A British-led international trial in locally advanced or metastatic breast cancer showed adding the anti-angiogenic therapy bevacizumab (Avastin) to taxane chemotherapy with docetaxel (Taxotere) slows disease progression in patients with no prior chemotherapy exposure. In the AVADO trial 736 patients receiving docetaxel were randomised to either placebo or one of two doses of bevacizumab (7.5 or 15mg/kg). Lead investigator David Miles, Professor of Medical Oncology at Mount Vernon Cancer Centre, London, said after median follow-up of 11 months patients in the lower dose bevacizumab group were 21 per cent, and those in the higher dose group were 28 per cent, less likely to have their disease progress compared to those receiving docetaxel only. Response rates were 55.2, 63.1 and 44.4 per cent respectively. Bevacizumab added limited incremental toxicity, mostly treatable hypertension, commented Professor Miles. n Olwen Glynn Owen, Medical Journalist.
  • 24. 24 Volume 3 Issue 2 • August/September 2008 ORBS 2008 - The first Scientific Meeting in Oncoplastic and Reconstructive Breast Surgery Venue: Nottingham, UK. Date: 22-24 September, 2008. The ORBS meetings are aimed to give both a scientific and teaching platform for this rapidly expanding specialty. As the surgical approaches to breast cancer surgery expand the requirements for knowledge of these new techniques expand as does the need for evidence based practice. The meetings will plan to span the breadth of modern oncoplastic breast cancer surgical management and is aimed at all members of the medical and nursing breast cancer surgical teams from both breast and plastic surgery. Teaching and presentations will be in the full spectrum of techniques from the role of adjuvant therapy, improved breast conservation techniques through to microsurgical reconstruction. This spectrum emphasises the expanding options available and the need for broader understanding and integration of teams delivering surgical breast cancer care. Broaden your horizons in breast cancer surgery at ORBS 2008: • IMPORTANT TOPICS & TECHNICAL DEMONSTRATIONS FROM WORLD EXPERTS - Breast reshaping, Implant, LD and DIEP reconstruction • HOT TOPICS - Fat Injection techniques, Advanced techniques in breast conservation, New Implants • DIFFICULT TOPICS - Radiotherapy strategies, Assessing outcomes, Neoadjuvant therapy • NEW DATA - Hear and discuss the latest studies • FUN TOPICS - Wine tasting at social evening!! n For further information contact: Stephen McCulley and Douglas Macmillan (Course Convenors), www.orbs2008.com PREVIEW European Society for Therapeutic Radiology and Oncology Annual Congress More than 4,500 cancer specialists from all over the world will attend a challenging, state-of-the-art programme in Göteborg this September. Over 500 presentations will highlight advances in radiotherapy and multidisciplinary approaches to the treatment of cancer. Advances in all aspects of the use and delivery of radiotherapy have improved cancer care for millions of people across Europe, and ESTRO 27 provides the opportunity for specialists to publish their results and debate critically how best to improve care still further through: • Teaching sessions in clinical radiotherapy, brachytherapy, radiobiology, physics, • Joint sessions to maximise the use of multi-disciplinary cancer management, • Presentation of research results and major break- throughs, • Proffered papers, poster presentations and discus- sions, • 10.000 m2 exhibition of brand new materials, which makes ESTRO 27 the largest European industrial exhibi- tion in Radiotherapy. Late registration deadline is 22 August 2008. Details about the congress including programme, reg- istrations, exhibition and hotel accommodation will be available on the website www.estro27.org. For more information: ESTRO – +32 2 775 93 40 – muriel.hallet@estro.be
  • 25. MOSAIQ TM management information system managing the spectrum of cancer care MOSAIQ combines a complete image enabled oncology medical chart, capable of streamlining advanced therapies regardless of equipment, with fundamental patient administration, workflow management and flexible reporting features. The result is a system that actually increases staff productivity yet still promotes quality patient care. Patients no longer have to wait, why should you? what are you waiting for? VISIT ESMO B O O T H 16 www.elekta.com IMPAC ESMO 2008.indd 1 24/7/08 12:30:41
  • 26. 26 Volume 3 Issue 2 • August/September 2008 I maging of the rectum with magnetic resonance imaging (MRI) is frequently used for both malignant and non- malignant conditions, such as fistulae and abscesses. It remains the only part of the bowel that is regularly imaged with MRI. In patients with rectal cancer prior to the introduction of MRI surgeons relied upon rectal examination in deciding whether tumours where fixed or tethered within the pelvis. MRI has been shown to be accurate in both staging of rectal tumours and in defining there relationship to the mesorectal fascia. It has been shown to be an accurate tool in deciding pre-operative management and in predicting outcome. MRI is often the first investigation ordered following histological confirmation of the tumour and patients normally have their MRI prior to being discussed in the multidisciplinary meeting to decide upon treatment. In this article we discuss the use of body coil MRI in imaging rectal cancer, as this is the most commonly used technique. After discussing the important anatomical landmarks within the pelvis we will look at the MRI techniques involved in acquiring the correct sequences in the appropriate planes. We will then focus on the role of MRI in determining the stages of rectal cancer and look at treatment options. The most significant advance in the management of rectal cancer has come with the development of total mesorectal excision surgery, in which the rectum is removed along with its surrounding mesorectum and the nodes within it. The circumferential margin in this procedure is the mesorectal fascia. This technique has been shown to lower the rates of local recurrence and improve long term survival. It is widely accepted as best practice. MRI has been shown to complement TME well, providing important anatomical and tumour morphological information prior to surgery. Anatomy The rectum is classically divided into upper, middle and lower thirds, each section being on average 5cm long, with the border of the lowest section being the anal verge. The peritoneal reflection extends posteriorly from the bladder to meet the anterior border of the rectum. In males this occurs between the lower and middle two thirds of the rectum but can be lower in females. It is important to identify this structure as invasion will change both staging and the type of operation required. The mesorectal fascia completely surrounds the mesorectum, which contains fatty tissue, lymphatics and lymph nodes. The mesorectal fascia extends down from the peritoneal reflection to the level of the anorectal junction. Denonvilliers fascia is a fibrous band that separates the rectum from the prostate gland and seminal vesicles; it is fused with the anterior aspect of the mesorectal fascia. Denonvilliers fascia is removed during total mesorectal excision. The inferior hypogastric nerves are important for genitourinary function and care must be taken when dissecting Denonvilliers fascia as the nerves lie very close to the mesorectum at this level. Posteriorly the mesorectal fascia meets the presacral fascia. Ideally MRI for rectal cancer should be undertaken by experienced radiographers with knowledge of the pelvic anatomy and correct imaging planes so that the sequences obtained allow accurate staging. Intravenous buscopan can be given to decrease artefact from peristalsing adjacent bowel. In our centre the sequences listed in Table 1 are undertaken. The images are normally checked by the supervising consultant radiologist and further sequences can be done as necessary. Initial wide field of view sagittal imaging delineates the length of the tumour and allows planning of the small field of view images. The axial small field of view images are performed perpendicular to the long axis of the rectum. These images are the most useful when looking at the relationship of the tumour to the mesorectal fascia. Coronal imaging is frequently used in looking at low rectal tumours and in determining their relationship with the anus. The axial T1 images of the whole pelvis are helpful in identifying involved lymph nodes and metastatic bone involvement. Body coil MRI has been shown to be accurate in T staging of rectal cancers. It is difficult to usefully delineate early T1 and T2 stage tumours but it is an accurate technique for assessment of the more advanced tumours in the T3 and T4 categories of disease. CT is routinely used to look for more distant metastases within the chest or abdomen (typically liver). T1 tumours are limited to the sub-mucosa and account for approximately 10% of all rectal cancers. Body coil imaging as described here is not the optimal imaging to discern T1 from T2 disease, if local excision rather than TME is being considered. In this case endoluminal imaging either with ultrasound or endoanal coil MRI is more appropriate. Until relatively recently it was felt that curative treatment of low risk, that is without evidence of neurovascular invasion or poorly differentiated tumours, could be achieved with local excision but more recent papers have shown that there remains a significant risk of local recurrence and that perhaps more radical surgery should be undertake despite the apparent low stage of the tumour. Imaging Lowry K1 , Armstrong A2 , Lynch T1 , Napier E1 . 1. Department of Radiology and Nuclear Medicine, Northern Ireland Cancer Centre, Belfast Trust. 2. Department of Surgery, Northern Ireland Cancer Centre, Belfast Trust. DrTomLynch Introduction to the use of MRI in Staging of Rectal Cancer MRI Technique WFOV T2 5mm sag WFOV T1 5mm axial SFOV T2 3mm sagittal, coronal and axial (WFOV; Wide Field of View. SFOV; Small field of View) Table 1
  • 27. Volume 3 Issue 2 • August/September 2008 27 T2 tumours extend to the muscularis propria, but not beyond it. T3 tumours can go as far as the mesorectal fascia, but do not invade other organs or the pelvic sidewall. T2/T3 tumours are the most common and it is in these patients that radical surgery, based on total mesorectal excision is undertaken. Involvement of the circumferential resection margin, or tumour within 1mm of it. has a high predictive value for local recurrence and long term survival. The mesorectal fascia forms the circumferential margin in total mesorectal excision and as this can be clearly seen on MRI, this technique is ideal in pre- operatively staging these patients. Some studies now advocate the use of pre- operative radiotherapy or chemotherapy in patients with known involvement of the mesorectal fascia prior to surgery, with findings showing that this can both down- stage the tumour and reduce the incidence of local recurrence. MRI can be used to restage tumours following treatment with chemo/radiotherapy, but this is not as accurate as staging without treatment. MRI overestimates the stage in these patients, having difficulty differentiating between tumour and changes related to tumour treatment. T4 tumours invade adjacent organs or the pelvic sidewall. More radical multivisceral resection may be considered for these patients, although again pre-operative treatments with radio/chemotherapy should be given. Lymph nodes down to approximately 3mm can be detected using body-coil MRI. Nodes smaller than this, although not seen on MRI, are virtually never infiltrated with tumour. Lymph node staging using MRI has traditionally used size as the main factor in determining nodal involvement, however different centres use between 5 and 10mm as there cut-off point for normal. The evidence suggests that most lymph nodes over 8mm are likely to be involved. It is important to consider that enlarged nodes that border close to the mesorectal fascia likely threaten the CRM. The absence of detectable lymphadenopathy on MRI has a strong predictive value that no positive nodes will be seen in the histological specimen. This has led other authors to look at other features of the lymph nodes. The presence of an irregular border and/or signal heterogeneity increases the probability that the node is involved. MRI scanning following injection of iron oxide particles has been shown to increase the detection of involved lymph nodes, although this is not as yet used in routine practice. Figure 1 is an axial T2 image demonstrating a T2 tumour. Tumour material is contained within the muscularis propria which is appreciated as a smooth darker line surrounding the rectum (asterisk). The mesorectal fat surrounding the rectum is normal and contains a few tiny nodes. The mesorectal fascial line is shown as a thin dark line surrounding the fat (arrowheads). Seminal vesicles are seen anteriorly (arrow). Figure 2 is an axial T2 image showing a T3 tumour with disruption of the muscularis propria indicating extension into mesorectal fat as indicated by loss of dark line (arrow). There is an enlarged lymph node in the mesorectal fat (arrowhead). Neither the tumour material or node is close to the mesorectal fascial line and hence anticipated circumferential resection margins are clear. Figure 3 is an axial T2 image showing a T3 tumour with a tongue of tumour extending out through mesorectal fat to contact the mesorectal fascial line and hence threaten the circumferential resection margin (arrow). Figure 4 is a sagittal T2 image demonstrating a tumour of the upper third of the rectum which extends out of the mesorectum to involve peritoneal reflection and hence represent T4 disease (arrows). Enlarged nodes are also seen (arrowheads). Multiplanar examinations allow better appreciation of anatomical extent of local disease. Conclusion All patients with rectal cancer in whom surgery is being considered should have an MRI unless contraindicated, i.e. permanent pacemaker in situ. Body-coil imaging can be done well in different centres if standard sequences and planes are used. It has been shown to be well tolerated by patients and accurate in assessment of relevant T and N staging and of tumour proximity to routine circumferential resection margins. Once these are established the multidisciplinary team can decide whether to undertake pre- operative treatment and then proceed to surgery if appropriate. The MRI will allow the operating surgeon to plan the approach to the tumour and alert them to where the tumour may come close to their resection margin. n Suggested reading MERCURY Study Group. Diagnostic accuracy of magnetic resonance imaging in predicting surgical resection margin status: prospective observational study. BMJ 2006;333: doi:10.1136/bmj.38937.646400.55 Madbouly KM, Remzi FH, Erkek BA, Senagore AJ, Baeslach CM, Khandwala F, Fazio VW, Lavery IC. Recurrence after transanal excision of T1 rectal cancer: should we be concerned? Dis Colon Rectum 2005; 48: 711-9. Brown G, Richards CJ, Bourne MW, Newcombe RG, Radcliffe AG, Dallimore NS, et al. Morphologic predictors of lymph node status in rectal cancer with use of high-spatial resolution MR imaging with histopathologic comparison. Radiology 2003;227:371–7. Kim JH, Beets GL, Kim MJ, Kessels AG, Beets-Tan RG. High resolution MR imaging for nodal staging in rectal cancer: are there any criteria in addition to the size? Eur J Radiol 2004;52:78–83. Hermanek P, Heald RJ. (2004) Pre-operative radiotherapy for rectal carcinoma? Has the case really been made for short course pre-operative radiotherapy if surgical standards for rectal carcinoma are optimal? Colorectal Disease 2004;6(1):10–4. doi:10.1111/j.1463-1318.2004.00569.x Sebag-Montefiore D, Steele R, Quirke P, et al. Routine short course pre-op radiotherapy or selective post-op chemoradiotherapy for resectable rectal cancer? Preliminary results of the MRC CR07 randomized trial. Proc Am Soc Clin Oncol. J Clin Oncol 2005;24(Suppl):148s abstract 3511. Lahaye MJ, et al. USPIO-enhanced MR imaging for nodal staging in patients with primary rectal cancer: predictive criteria. Radiology. 2008 Mar;246(3):804-11. Epub 2008 Jan 14. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery: the clue to pelvic recurrence? Br J Surg. 1982;69:613-6. Figure 1 Figure 2 Figure 3 Figure 4
  • 28. 28 Volume 3 Issue 2 • August/September 2008 Diary of Events 2008 August International Conference on Head and Neck Cancer 9-13 August, 2008; San Francisco, USA American Head & Neck Society Tel: +1 (310) 437-0559 Web: www.headandneckcancer.org International Union Against Cancer World Cancer Congress 27-31 August, 2008; Geneva, Switzerland World Cancer Congress 2008 Tel: +41 22 809 1811 Fax: +41 22 809 1810 Web: www.uicccongress08.org Breast Cancer Current Therapeutics 28 August, 2008; London, UK Web: www.mahealthcareevents.co.uk September Foundations in Cancer Oncology Module (Level 2 or 3) 1 September, 2008; Clatterbridge, UK Email: teresa.mealor@ccotrust.nhs.uk Influences on Cancer Care Oncology Module (Level 2 or 3) 1 September, 2008; Clatterbridge, UK Email: teresa.mealor@ccotrust.nhs.uk Care of the Patient Requiring Chemotherapy (Leve1 2 or 3) 1 September, 2008; Clatterbridge, UK Email: teresa.mealor@ccotrust.nhs.uk Oncology Course for Allied Health Professionals Module 1: An Introduction to Oncology for AHPs RADT 500 1 September, 2008; Clatterbridge, UK Email: teresa.mealor@ccotrust.nhs.uk NEW Symptom Management in Palliative Care for Healthcare Professionals 5 September, 2008; Tamworth, UK Barbara Hirons Tel: 01883 832664 Email:barbara.hirons@ mariecurie.org.uk 11th European Worksop on Cytogenetics and Molecular Genetics of Solid Tumours 6-9 September, 2008; Bilbao, Spain Web: www.cicbiogune.es/congreso/ congreso1_CMGST/index.php 14th European Society of Surgical Oncologists 10-13 September, 2008; The Hague, the Netherlands ESSO 2008 Conference secretariat, Federation of European Cancer Societies Tel: +32 (0)2 775 02 05 Fax: +32 (0)2 775 02 00 Email: ESSO2008@fecs.be Improve Your Communications Skills 11-12 September, 2008; Glasgow, UK Email: K.Hegyi@clinmed.gla.ac.uk 33rd ESMO Congress 12-16 September, 2008; Stockholm, Sweden European Society for Medical Oncology Tel: + 41 (0) 91 973 19 19 Email: congress@esmo.org Web: www.esmo.org NEW Palliative Care for Non-Malignant Conditions for Healthcare Professionals 16 September, 2008; Stevenage, UK Barbara Hirons Tel: 01883 832664 Email:barbara.hirons@ mariecurie.org.uk Gynaecological Cancer Study Day 17 September, 2008; London, UK Tel: 020 7808 2921 Email: conferencecentre@rmh.nhs.uk Web: www.royalmarsden.nhs.uk NEW Essentials in Palliative Care for Healthcare Professionals 17-18 September, 2008; Southampton, UK Barbara Hirons Tel: 01883 832664 Email:barbara.hirons@ mariecurie.org.uk NEW Palliative Care in Action for Healthcare Professionals 23 September, 2008; Tiverton, UK Barbara Hirons Tel: 01883 832664 Email:barbara.hirons@ mariecurie.org.uk Oncoplastic & Reconstructive Breast Surgery Meeting 23-24 September, 2008; Nottingham, UK Email: joanna.cooper@nuh.nhs.uk Web: www.orbs2008.com Living with cancer study day 24 September, 2008; Middlesex, UK Anni Hall Tel: 01923 844177 Fax: 01923 844172 Email: anni.hall@mvh-ljmc.org BTOG Small Cell Lung Cancer (SCLC) Study Day 2008 25 September, 2008; Manchester, UK Web: www.btog.org October Breast Cancer Awareness Month 1-31 October, 2008. www.breakthrough.org.uk MAGIC for Nurses Education Day 3 October, 2008; London, UK Tel: 0131 557 3332 Web: www.myeloma.org.uk British Lymphology Society Annual Conference – Lymphoedema: Alternative Pathways 5-7 October, 2008; Belfast, UK Web: www.thebls.com NCRI Cancer Conference 2008 5-8 October, 2008; Birmingham, UK Sharon Vanloo Tel : +44 (0)20 7269 3420 Email: ncriconference@ncri.org.uk American Society for Therapeutic Radiology and Oncology, Annual Meeting 5-9 October, 2008; Baltimore, USA ASTRO Tel: +1 (800) 962-7876, (703) 502-1550 Web: www.astro.org End of Life Issues in Cancer Care Study Day 9 October, 2008; Clatterbridge, UK Email: teresa.mealor@ccotrust.nhs.uk Royal Marsden Palliative Care Update Day 10 October, 2008; London, UK Tel: 020 7808 2921 Email: conferencecentre@rmh.nhs.uk Web: www.royalmarsden.nhs.uk Annual Meeting of the American College of Surgeons 12-17 October, 2008; San Francisco, USA Convention and Meeting Division, American College of Surgeons Tel: +1 (312) 202-5244 Web: www.facs.org Advanced Chemotherapy Study Day 15 October, 2008; London, UK Tel: 020 7808 2921 Email: conferencecentre@rmh.nhs.uk Web: www.royalmarsden.nhs.uk NEW Local Training Seminar - Rare sce- narios within breast cancer 16 October, 2008; Southampton, UK Kylie Vilcins Tel: 0845 092 0802 11th Annual BOPA Symposium 17-19 October, 2008; Liverpool, UK Web: succinctcomms.com 8th International Conference of Anticancer Research 17-22 October 2008; Kos, Greece www.iiar-anticancer.org/ Lymphoedema: Diagnosis, Assessment & Prevention of Complications 21-24 October, 2008; Glasgow, UK Karen Hegyi or Margaret Sneddon, Tel: 0141 330 2072/2071 Email: k.hegyi@clinmed.gla.ac.uk Web: www.gla.ac.uk/schools/nursing/ lymphoedema 20th EORTC-NCI-AACR Symposium on “Molecular Targets and Cancer Therapeutics” 21-24 October, 2008; Geneva, Switzerland 20th EORTC – NCI- AACR Symposium Secretariat, Federation of European Cancer Societies, Tel: +32 (0)2 775 02 01, Fax: +32 (0)2 775 02 00, Email: ENA2008@fecs.be Female Cancers study day 22 October, 2008; Middlesex, UK Anni Hall Tel: 01923 844177 Fax: 01923 844172 Email: anni.hall@mvh-ljmc.org NEW Drug Therapy in Palliative Care for Healthcare Professionals 23 October, 2008; Caterham, UK Barbara Hirons Tel: 01883 832664 Email:barbara.hirons@ mariecurie.org.uk Frenchay Breast Ultrasound Course for Surgeons 30-31 October, 2008, Bristol, UK Tel: 0117 9753753 Email: mike.shere@nbt.nhs.uk Managing Oedema due to Advanced Disease 30-31 October, 2008; Glasgow, UK Karen Hegyi or Margaret Sneddon, Tel: 0141 330 2072/2071 Email: k.hegyi@clinmed.gla.ac.uk Web: www.gla.ac.uk/schools/nursing/ lymphoedema November Lung Cancer Awareness Month 1-30 November, 2008. Web: www.lungcanceralliance.org Joint ABS at BASO & BASO ~ ACS Scientific Conference 3-4 November, 2008; London, UK Email: jackiespencer@baso.org.uk Tel: 020 7405 5612 Web: www.baso.org.uk Influencing policy, changing prac- tice: Improving the care of people with metastatic breast cancer 4 November, 2008; London, UK Jan Hannell Tel: 0845 092 0802 Email: nursetraining@ breastcancercare.org.uk Web: www.breastcancercare.org.uk/stfc Chemotherapy Foundation Symposium 5-8 November, 2008; New York City, USA The Mount Sinai Medical Center Tel: +1 (212) 241-6772 Web: www.mssm.edu/tcf Staff Nurse Study Day 7 November, 2008; London, UK Tel: 020 7808 2921 Email: conferencecentre@rmh.nhs.uk Web: www.royalmarsden.nhs.uk NEW Palliative Care in Action for Healthcare Professionals 10 November, 2008; Worcester, UK Barbara Hirons Tel: 01883 832664 Email:barbara.hirons@ mariecurie.org.uk If you would like an event listed in the Oncology News diary please send the relevant information to email Patricia@oncologynews.biz by September 5th, 2008.
  • 29. Volume 3 Issue 2 • August/September 2008 29 29-30 September 2008 International Federation of Head and Neck Oncologic Society (IFHNOS) World Tour: London Conference 2008 £300 (participants) • £250 ( Trainees) The Royal Society of Medicine, 1 Wimpole Street, London W1G 0AE 03 October 2008 The 1st Annual Royal Marsden Breast Cancer Meeting: Neoadjuvant Therapy £100 (Full delegates) • £75 (CNSs/Trainees) The Royal College of Physicians, 11 St. Andrew's Place, Regent's Park, London NW1 14 November 2008 Update on Aspects of Diagnosis and Management in Malignant Haematology £75 The Royal Marsden Education and Conference Centre, Fulham Road, London SW3 6JJ 29 January 2009 A state of the art Multidisciplinary Approach to: Cholangiocarcinoma £100 (Full delegates) • £75 (CNSs/Trainees) The Royal Society of Medicine, 1 Wimpole Street, London W1G 0AE For further information on the Royal Marsden conference events, please visit http://www.royalmarsden.nhs.uk/studydays or contact The Royal Marsden Education and Conference Centre: Tel: 020 7808 2921 Fax: 020 7808 2334 Email: conferencecentre@rmh.nhs.uk The Royal Marsden NHS Foundation Trust Organised by Institute of Physics, London, W1 Thursday 28th August 2008 40 YEARS OF MEDICAL EDUCATION CPD APPROVED For full programme details and to book your place at this event please visit our website www.mahealthcareevents.co.uk Alternatively call our booking hotline on 020 7501 6762 MA Healthcare Ltd, St. Jude’s Church, Dulwich Road, London SE24 0PB CONFERENCE FEE INCLUDES ENTRANCE TO THE CONFERENCE, LUNCH AND REFRESHMENTS, FULL CONFERENCE DOCUMENTATION AND CERTIFICATE OF ACCREDITATION 2. Breast CancerA series of one day meetings aimed at general medical practitioners and postgraduate medical trainees Current Therapeutics Series Management of the Cancer Patient: An Overview for Physiotherapists 10 November, 2008; London, UK Tel: 020 7808 2921 Email: conferencecentre@rmh.nhs.uk Web: www.royalmarsden.nhs.uk Nature of Cancer Course 10-17 November, 2008; Clatterbridge, UK Email: teresa.mealor@ccotrust.nhs.uk Management & Use of PICC/Hickman & Port Lines 11 November, 2008; Middlesex, UK Anni Hall Tel: 01923 844177 Fax: 01923 844172 Email: anni.hall@mvh-ljmc.org British Gynaecological Cancer Society Scientific Meeting 2008 12-14 November, 2008; Liverpool, UK Email: j.a.green@liv.ac.uk NEW Pain Management in Palliative Care for Healthcare Professionals 13 November, 2008; London, UK Barbara Hirons Tel: 01883 832664 Email:barbara.hirons@ mariecurie.org.uk 14th Annual CTOS Meeting 13-15 November, 2008; London, UK www.ctos.org/ Haemato-Oncology Study Day 14 November, 2008; London, UK Tel: 020 7808 2921 Email: conferencecentre@rmh.nhs.uk Web: www.royalmarsden.nhs.uk NEW Breast Cancer Study Day 18 November, 2008; Newmarket, UK Bev Johnson Tel: 01223 596627 Email: beverley.johnson@ addenbrookes.nhs.uk NEW Cancer: Nature; Treatment and Impact for All 21 November, 2008; Stevenage, UK Barbara Hirons Tel: 01883 832664 Email:barbara.hirons@ mariecurie.org.uk International Conference Learning From The Past, Influencing The Future 24-25 November, 2008; Liverpool, UK Email: teresa.mealor@ccotrust.nhs.uk Lymphoedema In Breast Cancer Patients 27 November, 2008; London, UK Tel: 020 7830 2323 Fax: 020 7830 2324 Email: j.hafezi@medsch.ucl.ac.uk RCN Breast Cancer Care Nursing Society Conference and Exhibition, One size doesn’t fit all 28 November, 2008; London, UK Email: laura.benfield@rcn.org.uk Web: www.rcn.org.uk/events December 50th ASH Annual Meeting and Exposition 6-9 December, 2008; San Francisco, USA American Society of Hematology Tel: +1 (202) 776-0544 Email: ash@hematology.org Web: www.hematology.org Bowel Cancer Study Day 10 December, 2008; Clatterbridge, UK Email: teresa.mealor@ccotrust.nhs.uk Lymphoedema: Assessment and Management 10-12 December, 2008; Glasgow, UK Karen Hegyi or Margaret Sneddon, Tel: 0141 330 2072/2071 Email: k.hegyi@clinmed.gla.ac.uk Web: www.gla.ac.uk/schools/nursing/ lymphoedema San Antonio Breast Cancer Symposium 11-14 December, 2008; - San Antonio, TX Rich Markow, Symposia Director, CTRC/Breast Cancer Symposium Tel: +1 (210) 616-5912 Web: www.sabcs.org NEW Cancer: Nature; Treatment and Impact for All 18 December, 2008; Stevenage, UK Barbara Hirons Tel: 01883 832664 Email:barbara.hirons@ mariecurie.org.uk 2009 January PREVENT (Prediction, Recognition, Evaluation and Eradication of Normal Tissue effects of radiotherapy) 11-12 January, 2009; Brussels, Belgium Web: www.estro.be/estro/index.cfm Clatterbridge Centre for Oncology NHS Foundation Trust and the Royal College of Nursing Annual National Conference 23-24 January, 2009; Chester, UK Contact mirka.ferdosian@rcn.org.uk Web: www.rcn.org.uk/events NEW Lymphoedema: Diagnosis, Assessment & Prevention of Complications 27-30 January, 2009; Newcastle, UK Karen Hegyi or Margaret Sneddon, Tel: 0141 330 2072/2071 Email: k.hegyi@clinmed.gla.ac.uk Web: www.gla.ac.uk/schools/nursing/ lymphoedema NEW Palliative Care for Non-Malignant Conditions for Healthcare Professionals 28 January, 2009; Caterham, UK Barbara Hirons Tel: 01883 832664 Email:barbara.hirons@ mariecurie.org.uk
  • 30. 30 Volume 3 Issue 2 • August/September 2008 Dates to remember Monday 2 June: Registration opens Monday 7 July: Late-breaking abstract submission opens Thursday 31 July: Earlybird registration deadline Monday 4 August: Late-breaking abstract submission deadline Monday 1 September: Online registration deadline Sunday 5 October: NCRI Cancer Conference commences Registration open please register online at www.ncri.org.uk/ncriconference The NCRI Cancer Conference is the major forum in the UK for showcasing the best British and international cancer research. It offers unique opportunities for networking and sharing knowledge by bringing together the leading experts from all cancer research disciplines. Confirmed speakers include: Mariano Barbacid (Spain) Valerie Beral (UK) Harvey Chochinov (Canada) Lisa Coussens (USA) Rebecca Fitzgerald (UK) Joe Gray (USA) Rakesh Jain (USA) Tony Kouzarides (UK) Paul Nurse (USA) Martine Piccart (Belgium) Howard Scher (USA) Sunday 5 October – Wednesday 8 October 2008 The International Convention Centre, Birmingham, UK www.ncri.org.uk/ncriconference NCRI Cancer Conference Secretariat | t: +44 (0)20 7438 5453 | e: ncriconference@ncri.org.uk SECOND WORLD CONGRESS OF THE INTERNATIONAL ACADEMY OF ORAL ONCOLOGY (IAOO) Toronto, Canada July 8–11, 2009 ORAL ONCOLOGY IMAGINE THE FUTURE For further information and to submit abstracts visit www.iaoo2009.com KEYNOTE PRESENTERS James S. Brown, UK Maura Gillison, USA David Jaffray, Canada Merrill Kies, USA Jens Overgaard, Denmark Poul Erik Petersen, Switzerland Richard Reznick, Canada Following the success of its inaugural congress the International Academy of Oral Oncology is pleased to announce a Second World Congress. The program will include keynote addresses, panel discussions, debates, instructional courses, oral papers and posters supported by a commercial exhibition, delegate receptions and a gala dinner. A half day workshop ‘Supportive Care: Prevention and Management of Complications of Cancer Therapy’ will follow the congress. CALL FOR PAPERS Contributions are invited by December 1, 2008 on the following topics for oral and poster presentation at the Congress. Epidemiology and Health Economics Molecular Biology and Genetics Diagnosis, Staging and Prognosis Pathology Surgery Radiotherapy and Combined Treatments Chemotherapy, Immunotherapy, Alternative and Future Treatments Reconstruction Dental Rehabilitation and Quality of Life Recurrences, Metastasis, Nursing and Terminal Care. Enquiries: Janet Seabrook. Tel: +44 1865 843691 Email jm.seabrook@elsevier.com Courses & Conferences
  • 31. The BTOG Small Cell Lung Cancer (SCLC) Study Day 2008 Date Thursday 25th September 2008 Venue Education Centre, Christie Hospital, Manchester • Multi-disciplinary • State of the art management of SCLC, SCLC clinical practice and research • Travel bursaries will be available • CPD credits from the Royal College of Physicians, London will be applied for • Sponsored by GSK Oncology • Further details and how to register are available on www.BTOG.org or from the secretariat 7th Annual BTOG Meeting 2009 Dates Wednesday 28th January 2009 to Friday 30th January 2009 Venue Clontarf Castle Hotel, Clontarf, Dublin 3 • Wednesday BTOG Symposium • Sponsored Satellite Meetings Wednesday • Sponsored Thursday & Friday Breakfast Meetings • Thursday & Friday Annual Meeting • Please visit the website, www.BTOG.org for details British Thoracic Oncology Group (BTOG) is a lung cancer and mesothelioma research group. The principal aim of BTOG is to encourage the development of clinical and scientific research in all areas of Thoracic Oncology and the provision of a multi-disciplinary educational forum. All individuals involved in any aspect of lung cancer or mesothelioma research, treatment or care are eligible to become members of the Group. BTOG Secretariat Dawn Mckinley, Operational Manager, British Thoracic Oncology Group (BTOG) Hospital Management Offices, Glenfield Hospital, Leicester LE3 9QP England Tel: 00 44 116 2502811 • Fax: 00 44 116 2502810 Email: dawn.mckinley@uhl-tr.nhs.uk • www.BTOG.org ANNOUNCEMENT
  • 32. 32 Volume 3 Issue 2 • August/September 2008 Web Review Web Review is compiled by Heidi Sowter, who is a lecturer in Forensic and Biological Science at Derby University, where she continues to pursue her research interests in gynaecological and breast cancer. Heidi aims to analyse, inform and encourage enhanced online activity and creativity within the oncology profession. Submit your comments, suggestions or website details for review by email to: H.Sowter@oncologynews.biz Dr Heidi Sowter Lecturer in Forensic Science and Biology Faculty of Education, Health and Science University of Derby. Today’s featured website is ecancermedicalscience, founded by the European Institute of Oncology in Milan, the home of an independent online journal that (refreshingly) features open access cancer journals. Scientists are able to submit articles online which are then fully peer-reviewed before being published immediately on acceptance. With Open Access publishing a reality and an urgent need for improved cancer communications, ecancermedicalscience fits the 21st century bill for a cancer journal. Their vision is to create a free future; free to publish, free to read and free to comment. The articles section is easy to navigate, and papers are listed in various ways (for example, research, conference reports, most viewed) to ease searching. Another way in which this website stands out is by providing an ecancer.tv service, through which you can watch, amongst other things, live surgery, new imaging techniques and interviews from their editorial board. An educational programme is also offered via a collaboration with the UK Key Advances in Clinical Practice Series. This is a series of symposia and masterclasses run in association with King's College London, and links to several speakers who discuss the currently available scientific evidence and expert clinical opinion for the prevention, investigation and management of different cancers. The Key Advances educational programmes are webcast on ecancermedicalscience and are available to watch, free of charge, at any time. Current topics listed are Key Advances in the Effective Management of Thyroid and Head and Neck Cancer, and other educational initiatives will be forthcoming. You need to register to access these services, although (being a member myself), I can recommend the news email that keeps you up-to-date with latest developments. Thanks to online, multimedia technology and a community poised to podcast and blog, ecancermedicalscience offers a multimedia and multidisciplinary approach to cancer. ■ http://www.ecancermedicalscience.com You can read every issue free of charge by downloading from our website: www.oncologynews.biz Simply register by sending an email to Register@oncologynews.biz or by visiting the website. We’ll notify you each time a new issue is uploaded to the website. Do you have an idea for an article? Are you organising an event, can we help with publicity? Would you like to review a book, perhaps you’re writing one? Contact: Patricia McDonnell, Publisher Patricia@oncologynews.biz Read Oncology News free on-line If you are planning to attend any of these meetings, please stop by and: • Meet the team • Start your free subscription • Give us feedback, comments and suggestions to improve the magazine • Discuss a potential article or report • Learn how to advertise • Learn how to become a journal or book reviewer We look forward to seeing you there! For further information contact Patricia on 0288 289 7023 or Patricia@oncologynews.biz Come and see us... 2008 ESMO September, Stockholm ESTRO September, Gothenburg NCRI October, Birmingham 2009 IAOO July, Toronto NCRI October, Birmingham
  • 33. Volume 3 Issue 2 • August/September 2008 33 Society News The ECCO-ESMO Collaboration: A Powerful Force in Combating Cancer B ridging the bench to bedside gap and the widely accepted approach of mulitdisciplinarity are pivotal in advancing research and improving patient treatment and care. The actual reality in the implementation and measurable outcomes of both ideals generally translates into palpable debate between professional specialties and communities. In the relentless battle to eliminate cancer much more can - and will - be done. The recently announced collaboration between ECCO – the European CanCer Organisation, and ESMO, the European Society for Medical Oncology, was happily received by the oncology community as a turning point in uniting forces, efforts and professionals across Europe. The win/win spin ECCO exists to both uphold the right of all European cancer patients to the best possible treatment and care and promote interaction between all organisations involved in cancer research, education, treatment and care. ESMO represents one of the most implicated specialties in such interaction since medical oncology demands a scientific and academic base, a vision toward developing and evaluating novel treatment methodologies, and an involvement in total cancer care. To deliver on multidisciplinarity and provide equal access to quality care, neither ECCO nor ESMO can stand alone - a reality that has connected the two in unison. ESMO’s membership in ECCO represents a further step forward in shaping a united front – the convergence of specialty organisations that share the same determination to uphold a coherent, concise and harmonised approach to tackling the second leading cause of death in Europe. A mass gathering of cancer science, treatment and technology One critical outcome of the ECCO-ESMO collaboration has been the paring of the two leading educational opportunities in European oncology: ECCO and ESMO Congresses. By fusing excellence and expertise, the joint ECCO and ESMO Multidisciplinary Congresses are set to draw record attendance through all-encompassing comprehensive programmes of the highest calibre. Setting the standard for congresses to come, the first ECCO- ESMO Congress will take place in Berlin, Germany, 20-24 September 2009. An organised approach to oncopolicy Efforts aimed at strengthening oncopolicy will only succeed by standing united. Heterogeneity will fail. Cancer naturally poses a challenge in this respect since, unlike many other fields, it incorporates a multiplicity of interrelated disciplines. The time to get organised is now. ESMO’s membership in ECCO will be crucial in road mapping the collective campaign to create awareness of patients’ needs and encourage progressive thinking in cancer policy, training and education at the EU level. Never before has the oncology community been better situated to improve care and research interactivity across Europe. Alexander MM Eggermont and José Baselga. We would like to publish information on other societies and associations in future issues of Oncology News. If you’d like your association considered for this feature please send details to Patricia@oncologynews.biz Alexander MM Eggermont and José Baselga.
  • 34. 34 Volume 3 Issue 2 • August/September 2008 News update Latest developments on products and services from the industry. To have your news included contact Grant Mackie on Grant@oncologynews.biz or Tel/Fax: +44 (0)288 289 7023. Cancer patients in eastern France now have access to advanced image-guided radiotherapy treatments with the arrival of the first Trilogy® linear accelerator in the country. The treatment machine has been unveiled by French health minister Roselyne Bachelot in a special inauguration ceremony. Professor Philippe Maingon, head of radiation oncology at the Georges-François Leclerc Cancer Center in Dijon, said, “We were honoured that the health minister was able to attend our unveiling ceremony and acknowledge the vital role of radiotherapy in treating cancer patients.” Carrying out the opening ceremony, Madame Bachelot praised the work of the Georges-François Leclerc Cancer Center and reiterated radiotherapy's status as a key weapon in the battle against cancer in France. The Trilogy device is the hospital’s third Varian linear accelerator. “The Trilogy enables us to carry out very precise image-guided stereotactic treatments in addition to our established program of intensity-modulated radiotherapy (IMRT) treatments,” said Professor Maingon. For further information contact: Neil Madle, Varian Medical Systems, Tel: +44 7786 526068, Email: neil.madle@varian.com BMI, The London Independent Hospital, has installed the UK’s first SOMATOM Definition AS+ CT scanner from Siemens. The system is one of the world’s first adaptive scanners that not only provides exceptional image quality but is suited to any patient, from paediatric to bariatric, or any clinical need. Without exclusions, the AS+ makes complex examinations routine. The SOMATOM Definition AS+ is an expert in cardiac imaging obtaining extremely fast coverage with 128 slices per rotation. With a temporal resolution of 150ms, images are free from movement artefacts and show the finest anatomical details. “Currently 64-slice CT scanners are the gold standard, so a 128-slice adaptive scanner could be considered platinum,” said Dr Charles Blakeney, Consultant Radiologist at BMI London Independent Hospital. “With the SOMATOM Definition AS+ CT, we are able to offer the people of East London access to one of the most advanced CT scanners in the country. Patients can be assured that we are employing some of the latest, fastest and safest CT technology to quickly determine their best course of personalised treatment and care.” For more information contact: Siemens, Tel: +44 (0)1276 696000, Email: medmarketing.med.gb@siemens.com Web: http://www.siemens.co.uk/medical BMI installs the UK’s First 128-slice adaptive CT scanner First Varian Trilogy in France unveiled by Health Minister The Elekta Virtual Clinic was initially designed as an Elekta internal training aid, however, Elekta are now making this exciting platform available for general view. The clinic, available via http://www.elekta.com/evc allows the user to follow the course of treatment for a patient undergoing lung treatment, from initial consultation, treatment planning, radiation treatment all the way through to completion in the MOSAIQ® patient management system. Alternatively, it is possible to ‘fly over’ and zoom in to find out more about specific treatment tools, such as Elekta Synergy® . Also available is an auditorium to view movies and a library which contains case-studies and treatment protocol papers. Voice over commentary guides users through various parts of the clinic and further functionality and content, including a focus on Elekta VMAT* are planned in the future. Elekta are inviting all interested parties to visit www.elekta.com where they can view or download the entire clinic and leave feedback via 'Send a Comment'. For further information please contact Email: inquiries@elekta.com One of Denmark’s leading cancer centers has placed an order for three new treatment machines and nine advanced RapidArc™ volumetric arc therapy systems from Varian Medical Systems, the world leader in radiotherapy. Aarhus University Hospital plans to have RapidArc installed on all nine of its Clinac® linear accelerators. The order is the latest wave of a multi-year investment program by Aarhus University Hospital to consolidate all radiotherapy hardware and software in an integrated system. Two of the additional treatment machines will be installed at a new radiotherapy center being constructed alongside the general hospital in the town of Herning, which is sixty miles from Aarhus but will effectively be a part of the Aarhus campus. Cai Grau, research professor at Aarhus University Hospital, says, “We are very much looking forward to the efficiency gains that RapidArc will bring, which will mean we can treat more people with advanced techniques in less time. We have a roadmap for replacing all our older machines and introducing image-guided radiotherapy throughout the department, and this order means we are on course to achieve this goal.” For further information contact: Neil Madle, Varian Medical Systems, Tel: +44 7786 526068, Email: neil.madle@varian.com The health minister being given an overview of the Trilogy by Professor Maingon. Siemens’ SOMATOM Definition AS+ CT adapts to each patient to provide fast image acquisition, 4D high quality scans and low radiation exposure. Varian products ordered by leading Danish cancer center Elekta announce global launch of Virtual Clinic
  • 35. Volume 3 Issue 2 • August/September 2008 35 The University of Bradford’s Chancellor, Imran Khan, recently opened its new Institute of Cancer Therapeutics (Thursday 17 July 2008). To mark the event, Imran also announced a new three-year student scholarship that will see a researcher from his own Shaukat Khanum Memorial Hospital come to Bradford to do a PhD. Imran said: “This scholarship is vitally important. Pakistan has almost twice as many people than here yet only one specialist cancer hospital and research centre which is why such a partnership will be a great help to us.” Director of the Institute of Cancer Therapeutics, Professor Laurence Patterson, said: “This official opening will let people know we’re in the business of anti-cancer drug discovery and we’re open for business.” Research themes at the Institute include the development of new molecules and describe three broad stages of medicine development: discovery, pre-clinical evaluation and clinical application. It costs over £3 million a year to fund the work of the Institute, supported mainly by Yorkshire Cancer Research as well as grants from research councils, Government and industry. For more information about the Institute of Cancer Therapeutics, visit: Web: www.cancer.brad.ac.uk Imran Khan opens Bradford’s new cancer research centre Three Novalis Tx radiosurgery platforms ordered by top Danish cancer hospital Varian Medical Systems (NYSE: VAR) and BrainLAB AG are announcing that one of Scandinavia’s leading cancer centres has ordered three Novalis Tx™ radiosurgery platforms which combine the most advanced technologies from both companies to offer superior non-invasive radiosurgery for patients. Rigshospitalet in Copenhagen has ordered two new Novalis Tx radiosurgery platforms and the associated suite of accessories and will upgrade an existing BrainLAB Novalis device to the more advanced new generation Novalis Tx. All three machines will be equipped with Varian’s RapidArc™ radiotherapy technology for image- guided, intensity-modulated radiotherapy (IMRT) treatments, meaning seven treatment machines at the hospital will have this new capability. They will also include the BrainLAB ExacTrac® X-Ray 6D imaging system and the Varian On-Board Imager® for precise patient positioning. Dr Svend Aage Engelholm, chief radiation oncologist of the Department of Radiation Oncology at Copenhagen University Hospital (Rigshospitalet), stated that Rigshospitalet has a long tradition of carrying out high- precision radiotherapy treatments and is one of the two leading hospitals in Denmark for stereotactic radiosurgery. The hospital was the first in Scandinavia to introduce IMRT treatments and was also the region’s first hospital to offer image-guided radiotherapy (IGRT) as a routine preferred treatment for a number of cancer indications. For further information contact: Neil Madle, Varian Medical Systems, Tel: +44 7786 526068, Email: neil.madle@varian.com Oncology Imaging Systems Ltd. is introducing a new superficial radiotherapy system for the treatment of skin cancer this year, manufactured by TOPEX Inc. The TOPEX SRT 100™ System has been specifically designed to meet the increasing number of skin cancer cases diagnosed each year, offering a superior non-surgical treatment. The TOPEX SRT 100™ System is a compact, mobile, productive and cost effective solution for the non-surgical treatment of skin cancer. Created in consultation with the medical community, this system has a footprint of just 30” x 30” and a broad range of motion (both horizontal and vertical) to allow the patient to be treated either sitting or lying down. The reduction of set-up procedures, ease of use and reduced installation and operational costs, provides maximum system up-time and greatly improves a clinic’s productivity and scheduling, whilst providing all patients with a considerably better, broader and more efficient treatment method. For more information on the TOPEX SRT 100™ System and all other patient positioning and immobilisation devices, please contact Oncology Imaging Systems Ltd, Tel: 01825 744 063, Fax: 01825 749 557, Email: sales@oncologyimaging.com Web: www.oncologyimaging.com OIS adds skin cancer treatment system to portfolio Chancellor, Imran Khan and Director of the Institute of Cancer Therapeutics, Professor Laurence Patterson. The Japanese Ministry for Health, Labour and Welfare, MHLW, has given approval for Leksell Gamma KnifeR PerfexionT, which Elelkta claim is the world-leading clinical solution for non- invasive radiosurgical treatments of tumors, vascular malformations and other brain disorders. Elekta, the international medical technology group and developer of Gamma KnifeR surgery, will now be able to deliver and install this advanced technology at new and existing customer sites in Japan. Gamma Knife surgery has become the world's most widely used radiosurgery treatment due to its extraordinary accuracy, reduction of excess radiation dose to the body, extensive history and clinical documentation. Unlike other systems, invoking compromises in order to be able to treat the whole body, Leksell Gamma Knife is specifically designed to optimize treatment to the head and neck area - a fact appreciated by neurosurgeons and patients alike. Launched by Elektain 2006 and now in clinical use in over 30 locations around the world, Elekta claim the Leksell Gamma Knife Perfexion combines the proven precision of the revolutionary Leksell Gamma Knife, with a dramatic increase in clinical reach to treat a wider range of targets faster and more efficiently than ever before. For further information please contact Email: inquiries@elekta.com Leksell Gamma Knife® Perfexion™ receives regulatory approval In Japan
  • 36. Roche has been a world leader in Oncology for over 40 years, discovering, researching and developing innovative treatments for cancer. Now world number 1 in oncology, the Roche oncology portfolio includes innovative targeted treatments for breast, colorectal, lung and haematological cancers, along with supportive care treatments for patients undergoing chemotherapy. Roche was the first company to introduce monoclonal antibodies in the treatment of cancer – novel drugs which, unlike chemotherapy target the cancer cells directly. Current products within the Roche Oncology portfolio include: MabThera® (rituximab), Xeloda® (capecitabine), Herceptin® (trastuzumab), Bondronat® (ibandronic acid), NeoRecormon® (epoetin beta), Avastin® (bevacizumab), Tarceva® (erlotinib). MabThera® , Xeloda® , Herceptin® , Bondronat® , NeoRecormon® , Avastin® , Tarceva® are registered trade marks. Legal Category: POM ROCHE IN ONCOLOGY Full prescribing information available on request. Roche Products Ltd, Hexagon Place, 6 Falcon Way, Shire Park, Welwyn Garden City, Herts Al7 1TW Information about adverse event reporting can be found at yellowcard.gov.uk. Adverse events shoud also be reported to Roche Products Limited. Please contact UK Drug Safety Centre on: 01707 367554 ® trastuzumab p p p p p J999119A, August 07