James C Hebert Cancer of the Pancreas Scope of Problem

Cancer of the pancreas is a highly lethal disease with the worst prognosis among all the common malignancies. Although it accounts for only 2 of new cancer cases per year, it accounts for 5 of all cancer deaths per year and is currently the fourth leading cause of cancer death of both men and women in the United States (Table 11.1). More than 28,000 Americans will be diagnosed in the year 2000 with cancer of the pancreas and an almost equal number will die of this disease. Worldwide, pancreatic...

Table 1111 American Joint Committee on Cancer AJCC staging for gallbladder cancer

TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ T1 Tumor invades lamina propria or muscle layer T1a Tumor invades lamina propria T1b Tumor invades the muscle layer T2 Tumor invades the perimuscular connective tissue no extension beyond the serosa or into the liver T3 Tumor perforates the serosa (visceral peritoneum) or directly invades one adjacent organ, or both (extension 2 cm or less into the liver) T4 Tumor extends more than 2 cm into the liver, and...

Clinical Presentation and Diagnosis

Prior to any discussion on neoplasms of the anal canal, it is essential to define the anal and perianal anatomy. There has been much confusion in the past regarding the anatomy of this region. Based on this, the World Health Organization described standard nomenclature for the anatomy of the anal canal, the anal verge and the anal margin. The anal canal extends from the anorectal ring to the anal verge. This is approximately 2 cm above and 2 cm below the dentate line respectively. The tissue...

Family History

A major breakthrough providing insights into breast cancer risk occurred in 1990 with the identification of the BRCA1 gene. This large gene is located on chromosome 17q. Breast cancer in BRCA1 families is transmitted as a classic Mendelian autosomal dominant trait with high but incomplete penetrance. BRCA1 mutations are associated with an extremely high risk of breast cancer development (50 chance Surgical Oncology, edited by David N. Krag. 2000 Landes Bioscience. dby age 45, and 85 lifetime...

Preoperative Evaluation

Since gastric cancer is for the most part a disease of the elderly, significant medical comorbidities may increase the risk associated with performing a major abdominal operation. The patient's overall medical condition should be optimized before proceeding with surgery. The initial step is a thorough history and physical exam. In order to determine whether the patient can tolerate major abdominal surgery, particular attention should be given to the pulmonary and cardiovascular systems . A...

Immunotherapy

The immune response to melanoma has been extensively studied. With occasional clinical spontaneous regressions, tumor infiltrating lymphocytes capable of destroying melanoma cells, anecdotal responses of patients to immunotherapy, and the ability of cytokines to affect the growth of melanoma without any obvious direct antitumor effects there is promise in therapies that modulate the immune response to cancer. Antibodies specific for melanoma have been well characterized and are used routinely...

Staging

In most programs, the plan for further evaluation is influenced by the local and institutional treatment philosophies and treatment protocols. Esophageal cancer is clearly a disease whose treatment is in transition. In some institutions, the biology of metastasis is interpreted to absolutely prohibit surgery for cervical and midesophageal cancers. In these instances, once the diagnosis of carcinoma is made, further evaluation is designed to stage the patient and discover the risks of planned...

Pregnancy and Melanoma

The role of pregnancy in the clinical course of patients with melanoma has been debated without resolution for years. Melanoma has been reported to enlarge during pregnancy then regress between pregnancies. The possible negative impact of pregnancy on melanoma has left many physicians unsure how to advise their patients who are pregnant or who are thinking of becoming pregnant. Both a decrease in the disease free interval and an increased incidence of nodal metastasis have been reported in...

Invasive Breast Cancer

Infiltrating ductal carcinoma is the most common form of invasive breast cancer and accounts for about 75 of all invasive breast cancers. It arises from ductal cells lining milk ducts. Histologic subtypes which have a more favorable prognosis include tubular, colloid or mucinous, and medullary carcinoma. Infiltrating lobular carcinoma arises from cells of the lobular unit. Lobular carcinoma has a higher frequency of bilaterality. It also tends to be more infiltrative than ductal carcinoma and...

Breast Cancer in the Male Breast

Male breast cancer is unusual, and accounts for about 0.5 of all breast cancer. Risk factors are similar to those for women. The prognosis is similarly related to the stage of presentation. Male breast cancer usually presents as a subcutaneous mass beneath the nipple-areola complex. It usually presents in men between the ages of 60-70 approximately 10 years older than the mean age of presentation of women. The only pathological entity not seen in the male breast is lobular carcinoma in situ,...

Breast Cancer During Pregnancy

Fortunately this occurs in less than 5 of breast cancer patients. It usually presents as a breast mass, and delays in diagnosis are common. This is due to the considerable enlargement of the breast associated with pregnancy precluding effective clinical breast examination. Mammography is generally not utilized during pregnancy because the proliferative changes in the breast result in a white out of the mammogram. Although surgical biopsy or US guided core biopsy are generally well tolerated in...

Adjuvant or Neoadjuvant Chemotherapy for Patients with STS

Single institution and national trials of adjuvant chemotherapy have failed to demonstrate an overall survival benefit for patients treated with adjuvant chemotherapy following resection of STS, although several prospective randomized studies suggest that it may prolong disease free survival. A recent meta-analysis suggests that adjuvant chemotherapy provides a minimal benefit in terms of disease free survival in patients with localized completed resected STS but no improvement in overall...

Regional Chemotherapy for Patients with Extremity STS

Regional chemotherapy is a therapeutic option for patients with advanced STS of the extremity, particularly when amputation is the only alternative. Regional chemotherapy is delivered by surgically isolating the vasculature at the root of the limb and applying a tourniquet proximally. A cardiopulmonary type pump oxygenator is used to maintain circulation and oxygenation of the limb through the cannulated vasculature at the root of the extremity. This procedure is called isolated limb perfusion...

Chemotherapy for Patients with Advanced STS

Currently, a doxorubicin-based regimen should be considered standard therapy for patients with advanced, unresectable STS. Unfortunately, treatment is limited by cardiomyopathy, which occurs in about 10 of patients, and can result in death. Cardiac toxicity can be diminished by giving the drug as a continuous infusion as opposed to a bolus, without comprising therapeutic efficacy. Ifosfamide is the most promising recent addition to the chemotherapeutic armamentarium for patients with stage IV...

Neoadjuvant Chemotherapy

A number of regimens have evolved in an effort to reduce treatment-related morbidity. Most current regimens are variations of combination chemotherapy regimens consisting of cis-platinum, 5-fluorouracil, and other agents used in conjunction with radiation therapy designed to take advantage of the radio-sensitizing properties of cis-DDP and 5-FU. A typical regimen involves 3 cycles of cis-DDP and 5-FU, with radiation therapy timed to begin at the initiation of chemotherapy and continued to a...

Adjuvant Systemic Chemotherapy

Following liver resection or ablation, there is no single agent or combination of agents which have demonstrated a survival benefit in an adjuvant setting. In spite of this, many patients who have not previously received 5-FU chemotherapy will be offered this regimen. Folinic acid (5-FU) is an antimetabolite which works by preventing DNA methylation of tumor cells. Patients who have already received 5-FU may be offered Camptosar (CPT 11) or a continuous infusion of 5-FU. Ideally, these patients...

Regional Chemotherapy

The hepatic artery is the dominant source of blood supply for macroscopic tumor deposits. The liver during the first pass extracts chemotherapeutic drugs that are ideally suited for regional infusion. Floxuridine (5-FUDR) is almost completely extracted (94-99 ) during the first pass through the liver. There are seven randomized trials which showed a significantly higher response rate for intrahepatic infusion (48-62 ) compared to systemic chemotherapy (0-38 ). Two prospective randomized trials...

Chemotherapy

When the issue of chemotherapy is raised with patients, most patients tend to have dramatic images of the expected toxicity. Specifically, nausea, vomiting and hair loss are felt by many to be uniformly associated with all kinds of chemotherapy. As mentioned earlier, traditional adjuvant chemotherapy for colorectal cancer has been 5-FU based. These regimens are usually reasonably well tolerated. The most common adverse effects are diarrhea, stomatitis, neutropenia and leukopenia. However, these...

History and Epidemiology

LC was a curiosity in the nineteenth century. Only 350 cases were reported in the medical literature as late as Adler's review in 1912. There was a sudden increase in incidence in the 1920s. Almost all cases were in men, and a striking association with cigarette smoking was soon noted. Ernst Wynder, a medical student working with Evarts Graham, collected retrospective data documenting a strong correlation of the disease with cigarette smoking. This finding was confirmed in large retrospective...

Chemotherapy and Biologic Agents

Dacarbazine, platinum analogues, nitrosoureas, and tubular toxins have all shown some response, but the response is almost universally short and partial. Patients with skin, subcutaneous, lymph node, and occasionally lung are more likely to have a response. These patients are also the group most likely to benefit from aggressive surgical resections. Some of the agents are now available as outpatient regimens. No combination chemotherapy has been proven more advantageous than to DTIC alone. DTIC...

Mediastinal Tumors

Bruce Jason Leavitt Scope of Problem The mediastinum is an anatomically distinct area of the body located within the center of the chest. The boundaries are the sternum anteriorly and the spine posteriorly. The thoracic inlet is the superior boundary and the diaphragm the inferior one. The lateral pericardium forms the lateral borders. Quite a wide variety of tumors exist in the mediastinum. Approximately two thirds of all mediastinal tumors are benign and the rest are malignant. Mediastinal...

Selected Readings

Greenlee RT, Murray T, Bolden S et al. Cancer Statistics, 2000. CA. A Cancer Journal for Clinicians 2000 50 7-33. Cancer statistics for the year 2000, published by the American Cancer Society. 2. Pollock RE, Karnell LH, Menck HR et al. The National Cancer Data Base report on soft tissue sarcoma. Cancer 1996 78(10) 2247-57. Review of national statistics (USA) for soft tissue sarcoma. 3. Brennan MF. The surgeon as a leader in cancer care lessons learned from the study of soft tissue sarcoma. J Am...

Pagets Disease of the Nipple

This is an uncommon form of breast cancer that is clinically characterized by an eczematoid reaction of the nipple and symptoms of itching, erythema and nipple discharge. In 45 of patients there is an associated underlying breast mass which is an infiltrating ductal carcinoma or ductal carcinoma in situ. It is often treated with mastectomy but may be treated by central breast lumpectomy if the cancer is well localized. Prognosis is similar to infiltrating ductal carcinoma and is determined...