Volume 3 Issue 2 :August/September 2008

Oncology

What is UCAN?

Management of Primary Lung Cancer

The Current Treatment of GIST With Reference to Laparoscopic Resectionand Neoadjuvant Treatment

Prostate Cancer reviewed: Part 2 - Treatment Options

NewsVolume 3 Issue 2 :August/September 2008 www.oncologynews.biz

In this issue

ISSN 1751-4975

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Volume 3 Issue 2 • August/September 2008 3

Professor Denys Wheatley is Editor of Oncology News, and is Director of BioMedES. Hehas 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 andcell 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 scientificcommunication has led to his receiving awards in recent years.

Professor Patrick J Bradley is Associate Editor of Oncology News, and, a Head andNeck Oncologic Surgeon at the University Hospital, Nottingham. He is a member of numerousjournals’ UK Editorial Boards; Journal of Laryngology and Otology, Oral Oncology, andInternational Journals: Laryngoscope, Head and Neck, Acta Otolaryngologica Scandinavia, aswell 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 NuclearMedicine 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 paediatricnuclear medicine.

Dr Heidi Sowter is Assistant Editor – Web Review, and is a Lecturer in Forensic Scienceand Biology, at the Faculty of Education, Health and Science, University of Derby. Heidicontinues to pursue her research interests in gynaecological and breast cancer.

Ms Kathleen Mais is Assistant Editor – Nursing, and is a Nurse Clinician in Head & NeckOncology 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 ascontinuing her work in clinical research.

Michael Douek is Assistant Editor – Breast, and is a Senior Lecturer and Consultant Surgeonat University College London Hospitals focusing on breast cancer surgery with a particular interestin pre-operative surgical planning using breast MRI. In 2003, he was awarded a prestigiousHealth Foundation Clinician Scientist grant by the UK Academy of Medical Sciences, fully fundinghis joint academic and clinical post in breast surgery.

Alan Cooper is Assistant Editor – Urology, and is Lead Scientist with the urology researchgroup in Southampton University Hospitals and senior lecturer (albeit with virtually no lecturingburden) in the Department of Biomedical Sciences at Portsmouth University.

Marilena Loizidou is Assistant Editor – Colorectal, and is a Non-Clinical Senior Lecturerin the Department of Surgery, UCL. Her research program focuses on aspects of colorectalcancer 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 growthand 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 Oncologistat The James Cook University Hospital, Middlesbrough. His areas of interest are lung andgynaecological cancers.

Helen Evans is a Journal Reviewer for Oncology News. Helen recently worked as a SeniorLecturer in Cancer Nursing at the Institute of Nursing and Midwifery, University of Brighton butfollowing 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

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4 Volume 3 Issue 2 • August/September 2008

There is little doubt that some of themost serious cases of cancer are thosethat attack the lungs. If this is truly the

main killer amongst the cancers in the UK, isnot there a need for a great deal moreresearch into this particular organ and itstumours? The provoking factors have beenfairly obvious for years, and in one guise oranother are largely attributable to pollution,being self-administered by those of us whocontinue to smoke tobacco. The lungs havean enormous area that is in immediate contact withthe environment, an area which is far greater than thatof the skin that covers the body. Lung tissue, incontrast to skin, is moist and extremely thin, withblood vessels intimately associated with the fine wallsof the alveoli.

How will the situation look in twenty to thirty yearsfrom now? If we assume that the effects of smokingwill then be affecting only the more aged members ofsociety who had smoked in the past, and far feweryoung people will be progressing in the same way, arewe going to see it become one of the least commonforms of cancer. [With asbestos the same story shouldunfold as crocidolite is “phased out” and HSE makesure stringent measures are taken to avoid itsinhalation by workers in future. We read earlier in ON(Oncology News 2008;4(2):9-11) that mesotheliomawill wane in the same way.] The worrying sector at thepresent time is young women, who continue to smokeand will be at risk of lung cancer for perhaps at leasttwo more generations. Since on average people areliving considerably longer these days than 30 or 40years ago, there is a high probability that sufficienttime will elapse for the incidence of lung cancer to risein this sub-population of women smokers. Theproblem is that lung cancer can sometime beasymptomatic, or sufferers are too reluctant to seekhelp that they do not present for so long that patientsdo not present with tumours until they areconsiderably advanced. If we screen for bowel andcervical cancer, the question of whether we can do sofor lung cancer has already been addressed in thepages of ON.

The treatments for lung cancer do not make for goodreading - that is, for the sufferer. Life expectancy is lowand there seems to be little that can be done to raisethe 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 thatcan be taken, and emphasise a number of usefulpoints. One is that, given the circumstances, palliativecare has to be a priority so that good QOL is achievedin the short respite sufferers may have in their lastmonths. And the delivery of good medicine centresthese days on the MultiDisciplinary Team (MDT) thatshould meet regularly to review all such patients,making for the best possible management. The lung

cancer patient needs this more than almostany other cancer patient, especially whenbones and brain become affected bymetastases. We discussed in a recenteditorial the topic of permutations andcombinations in the treatment of cancer,and this seems to be particularly pertinentin the case of lung cancer patients.Combinations of treatments that follow oneanother rather than necessarily being givenat about the same time seem to be prevalent

because much depends on which type of lung cancerit is, how large it is, whether it is in the local lymphnodes or more widespread, how much co-morbidity isinvolved, among other mitigating factors. On the lastissue, smokers often have a high alcohol consumption,many have a poor diet, and most of them get littleexercise - little wonder that their general health isconsiderably below average. It is also no wonder thatpatients have to be examined by a whole gamut ofdifferent techniques to assess their general state ofhealth prior to surgery, chemotherapy andradiotherapy. Resection of lobes of the lung becomesless advisable when the sufferer has a poor cardiaccondition. If done in the more robust patient, the lossof 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 seemsbleaker than for most other types of tumour. Onewould hope that, despite the improvement in theapplication of established techniques (better deliveryof radiation, more specific chemotherapeutic agents,etc.) some new avenues would open in terms of lungcancer treatment. Are there any real grounds forbelieving that there might be some breakthroughwhich will provide an effective means of controllinglung cancer? Or do we stick to refining the ways inwhich the current modalities are administered, tooptimise them and combine them using the mostcarefully devised strategies? If these are the issuesbefore us, then what should be the focus of effort?The latter has to be done whether or not more basicresearch can find new methods of treatment, such asimmunotherapy. Perhaps before basic research couldadd significantly in this way, it is probable that thetide of lung cancer we have seen through the 20thcentury and persisting into the first part of the 21stcentury will have receded, and less pressure willcome to bear on getting a better understanding of thefundamental causes and cellular misbehaviour thatleads to lung cancer. That leaves screening as theonly option needing to be considered, (see John FieldK and Duffy SW, Oncology News 2008;3(1):6-8), inwhich there seems to be little advance even for themost high risk groups. And yet lung cancer remainsthe most common cause of death amongst cancers inthe UK. n

Lung Cancer Continues to Occupy the Frame

Denys Wheatley,Editor/

Editorial

Cytosafe®

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New 300mg vialDesigned 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 – UKPlease 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, folinicacid in patients without prior chemotherapy and as monotherapy in patients who have failed a 5-fluorouracil, folinicacid based therapy. Campto may be used in combination with cetuximab for the treatment of Epidermal GrowthFactor Receptor-expressing metastatic colorectal cancer after failure of Campto-including cytotoxic therapy. Camptomay be used in combination with 5-fluorouracil, folinic acid and bevacizumab for the treatment of metastaticcarcinoma of the colon and rectum. Dosage & Administration: Campto should be administered as an intravenousinfusion over 30 to 90 minutes. In first line: combination therapy of 180mg/m2 every 2 weeks followed by folinicacid 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. Referto cetuximab product information for dosage. In combination with bevacizumab, refer to the bevacizumab productinformation for dosage. Prophylactic antiemetics are recommended. Dosage Adjustments: Subsequent cyclesshould follow appropriate recovery of all adverse events to grade 0 or 1 NCI-CTC and resolution of diarrhoea. Dosereduction of 15-20% recommended if patients experience significant haematological toxicity, thrombocytopeniaand leucopenia (grade 4), and non-haematological toxicity (grade 3-4). Impaired hepatic function: Monitor liverfunction 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 impairmenttreated by Campto in combination. Impaired renal function: Not recommended. Elderly: Care due to the greaterfrequency of decreased biological functions. Contraindications: Chronic inflammatory bowel disease and/or bowelobstruction; severe hypersensitivity reactions to Campto; pregnancy; breastfeeding; bilirubin >3 ULN; severe bonemarrow failure; WHO performance status >2, concomitant use of St John’s Wort. Refer to cetuximab orbevacizumab product information for contraindications. Warnings and Precautions: Use in units specialised in theadministration of cytotoxic chemotherapy. Patients should be aware of the risk of delayed diarrhoea (occurring >24hours 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 treatedwith atropine. Risk factors for the development of pulmonary infiltrates should be considered. Patients should notdrive if dizziness or visual disturbances occur. Women of childbearing age receiving Campto should be advised toavoid becoming pregnant. Interactions: Avoid concomitant use with CYP34A inducers or inhibitors. Care in patientsreceiving neuromuscular blocking agents. St John’s Wort should not be administered with Campto. SN38 (theactive metabolite of Campto) concentrations were increased by 33% when combined with bevacizumab. Patientsdeveloping severe diarrhoea, leucopenia or neutropenia in combination with bevacizumab should have Campto dose

modification. Adverse Reactions: Delayed diarrhoea (requires immediate treatment with loperamide). Nausea andvomiting, dehydration, neutropenia, fever, acute cholinergic syndrome, dyspnoea, asthenia, reversible alopecia.Infrequently dehydration-related renal insufficiency, hypotension or circulatory failure. Other system disordersinclude 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 therelevant product information for details on adverse reactions that may occur when used in combination withcetuximab or bevacizumab. Pharmaceutical Precautions: Solution must be prepared aseptically. Do not mix withother medications. The solution should be used immediately after reconstitution, as it contains no antibacterialpreservative. 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. MarketingAuthorisation Number: 40mg: PL 00057/0626, 100mg & 300mg PL 00057/0627. Marketing AuthorisationHolder: 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

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PFZ07JO8009_Oncology_News_210x297:PFZ07JO8009_Oncology_News_210x297 2/6/08 12:23 Page 1


ContentsVolume 3 Number 2 August/September 2008

Copyright: All rights reserved; no part of this publica-tion may be reproduced, stored in a retrieval systemor transmitted in any form or by any means, elec-tronic, mechanical, photocopying, recording or other-wise without either the prior written permission of thepublisher or a license permitting restricted photo-copying issued in the UK by the Copyright LicensingAuthority. Disclaimer: The publisher, the authors andeditors accept no responsibility for loss incurred byany person acting or refraining from action as a resultof material in or omitted from this magazine. Any newmethods and techniques described involving drugusage should be followed only in conjunction withdrug manufacturers' own published literature. This isan independent publication - none of those con-tributing are in any way supported or remunerated byany of the companies advertising in it, unless other-wise clearly stated. Comments expressed in editorialare those of the author(s) and are not necessarilyendorsed by the editor, editorial board or publisher.The editor's decision is final and no correspondencewill 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 LaparoscopicResection and Neoadjuvant Treatment Siobhan Gill, Paras Jethwa, Surrey, UK.

18 Urological Cancer Section –Prostate Cancer Reviewed: Part 2 Treatment OptionsSimon Mackie and Bhavan Rai, Aberdeen, UK.

20 Book Reviews

21 Conference NewsPreviews and reports from the conference scene.

26 Imaging Section –Introduction to the use of MRI in Staging of Rectal CancerK Lowry, A Armstrong, T Lynch, E Napier, Belfast, UK.

28 DiaryListing of meetings, courses and conferences, both UK and international.

29 Courses & Conferences

32 Web ReviewHeidi Sowter, Derby, UK.

33 Society NewsECCO-ESMO Collaboration

12 & 34 News UpdateDetails of the latest developments and news from the industry andcharities.

Oncology News is published by McDonnell Mackie, 84 Camderry Road, Dromore, Co Tyrone, BT78 3AT, N Ireland.

Publisher: Patricia McDonnell • Web: www.oncologynews.bizAdvertising and Editorial Manager: Patricia McDonnellTel/Fax: +44 (0)288 289 7023 • Email: [email protected]

Advertising and Press Releases: Grant MackieEmail: [email protected]

Design & Production Email: [email protected] 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 photocopyingissued in the UK by the Copyright Licensing Authority. Disclaimer: The publisher,the authors and editors accept no responsibility for loss incurred by any personacting 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 shouldbe followed only in conjunction with drug manufacturers' own published litera-ture. This is an independent publication - none of those contributing are in anyway supported or remunerated by any of the companies advertising in it, unlessotherwise clearly stated. Comments expressed in editorial are those of theauthor(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?





In this issue

ISSN 1751-4975

Cover picture:StockholmClock Tower byAndrew Conn.


UCAN is a charitable company set up toimprove the quality of life for peopleand families living with urological

cancers in the North of Scotland. Urological cancers, (kidney, prostate,

bladder, testicular and penile) are among themost common types of cancers. They accountfor one in three of all cancers in men and onein five of all cancers in men and women.

UCAN was launched in January 2006 by MrSam McClinton and Professor James N’Dow,two consultant urological surgeons based atthe Aberdeen Royal Infirmary. They createdUCAN as a direct result of cancer sufferers,families and health professionals identifying aneed to provide additional and improvedservices which are not, and cannot be,provided under the statutory duties of the NHS.

There exists a stigma associated withurological cancers. Quite often patients seekmedical advice from their doctor at a pointwhen it is too late to offer curative treatment.Those who have been diagnosed with aurological cancer often suffer long-termsocial, emotional and psychologicalproblems. Sufferers frequently struggle tocome to terms with the trauma of urologicalcancer and the potentially life-changingeffects of treatment, such as urostomy and

erectile dysfunction. Long-term psychologicalproblems can affect sufferers’ partners andfamilies as much as the patient themselves,significantly increasing the number of livesblighted by urological cancer. UCANrecognises that a significantly higher level ofsupport is required for those diagnosed withurological cancer than is currently available.

What does UCAN plan to achieve?Our plans are split into three main areas:

• Improving early diagnosis and knowledge1) Our awareness campaign has been

running for two years. We need to raise theprofile of urological cancers to the level ofbreast and bowel cancer, and educateindividuals on the early signs of urologicalcancers, in a bid to reduce the mortalityrates. We also want to take the stigma outof these illnesses which by their naturecan cause embarrassment.

2) One of our key challenges is to get men to

take responsibility for their own health tothe same degree as women. We areworking with employers to help get ourmessages across in the workplace. Earlydiagnosis of cancer would not only helpthe patient but also the employer throughreduced time off work.

• Building effective support structures1) There is a desperate need to provide

patients and families with new avenues ofsupport to help them adjust to, and livewith, the changes a cancer diagnosismight bring to their lives. On occasions,the need will be for human contact; onother occasions the need might be forrelative anonymity through online contact.

2) We recognised the need for a central hubclose to the clinical services. A newUrological Cancer Care Centre was openedin January 2008, in the department ofurology and is already fully operationalproviding practical support to cancersufferers.

3) An important element of building effectivesupport structures will be the PlainEnglish Guides which will convert a vastamount of unregulated information intoshort, easily understood documents, withthe facts a cancer patient needs to know.

• Acquired knowledge and research1) By researching the knowledge and

experience of urology cancer patients,their families and clinicians worldwide, wewill be able to determine what informationcancer sufferers need at different stages oftreatment. The family unit also needsinformation as they are affected just asmuch as the cancer sufferers. Thisinformation is vital when deciding whichtreatment to choose if the cancer suffereris not to regret that decision at a later date.It is also very important to discover thebest ways of managing the oftenunpleasant effects of treatments.

What makes UCAN unique?Our activities are distinctive in the followingways:• Projects are developed in partnership with

the beneficiaries; allowing us the bestchance of being relevant to urologicalcancer 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 SciencesBuilding,Foresterhill,Aberdeen,AB25 2ZD, UK. A Urological CANcer is diagnosed every 10 minutes


Lung cancer is one of the most commoncancers in the Western world, witharound 38,000 patients being diagnosed

each year in the UK. Rarely diagnosed in theunder 40s, lung cancer is a disease of the latemiddle-aged and elderly. Peak incidence is inthe 75-84 age-group, with 85% of patientsbeing over the age of 60 (Figure 1). In the1950s, the sex ratio was M:F 6:1; withreducing incidence in males and increasingrates in females, wth the current sex ratiobeing nearly 7:5. Cigarette smoking is linkedto lung cancer in well over 90% of cases,although other environmental causes such asasbestos and radon gas exposure have beenimplicated. Lung cancer is the leading causeof death from cancer in the UK, 22% of allcancer deaths being attributable to lungcancer. The current 5-year survival for lungcancer in the UK is 7% [1].

Types of lung cancerThere are two broad groups of lung cancerdefined by their histological appearance [2].These are Small Cell Lung Cancer (SCLC) andNon-Small Cell Lung Cancer (NSCLC). SCLCand NSCLC differ in a number of ways; theircell origin is different, SCLC beingneuroendocrine, whereas NSCLC is epithelial.SCLC is very chemosensitive, but NSCLC isless so. SCLC is generally metastatic atpresentation, whereas NSCLC may initially belocoregional. SCLC is generally not a surgicaldisease, while NSCLC may be resectable.Examples of individual types of NSCLC aresquamous, adenocarcinoma and large cellcarcinoma.

The key to current treatment of patientswith lung cancer is the multidisciplinary

team (MDT) [3]. The workings andmembership of the MDT vary from region toregion. MDT meetings should ideally be heldweekly and attended by all the major players(Table 1). All patients with lung cancershould be reviewed, the object being todeliver the best possible treatment to eachpatient depending on their tumour stage andstate of health.

SCLC treatmentPatients with SCLC are categorised as eitherwith limited disease (LD), where the diseaseis confined to the thorax, or extensive disease(ED), where there is evidence of distantmetastases [4].

Patients with ED are generally givenchemotherapy, designed to produce palliationand shrinkage of the tumour burden. About50% of patients with SCLC that are in the EDcategory will have clinical or subclinicalcerebral metastases. For this reason,prophylactic cranial irradiation (PCI) is oftenadministered [5].

SCL cases categorised as LD also getchemotherapy. Where there is a complete orgood response, mediastinal radiotherapy +/-PCI is considered for survival advantage andimproved quality of life [6].

There will be a small group of patients whopresent with early disease. Under thesecircumstances, if properly staged, surgerymay have a role.

NSCLC treatmentKey to the management of patients withNSCLC is TNM staging of the tumour, whichis based on tumour characteristics (T), nodalinvolvement (N), and the presence orabsence of metastases (M). A summary oflung cancer TNM is given in Table 2.However this classification is beingreassessed and updated; the update will bepublished later in 2008 [7].


Espeed KhoshbinRegistrar in CardiothoracicSurgery.

Alan JB Kirk, Consultant Thoracic & Cardiac Surgeon.

Correspondence to:Department of ThoracicSurgery,West of Scotland RegionalHeart & Lung Centre,Golden Jubilee NationalHospital,Clydebank, UK.Email: [email protected]

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


The Current Treatment of GIST WithReference to Laparoscopic Resection andNeoadjuvant Treatment

Miss Siobhan Gill,MRCS,Senior House Officer inSurgery.

Mr Paras Jethwa, BSc(Hons), MD,FRCS(Gen), Consultant General & UpperGI Surgeon.

Correspondence:P Jethwa,Surrey & Sussex NHS Trust,Dept of Surgery,Canada Avenue,REDHILL,Surrey,RH1 5RH, UK.

Upper GI Oncology

Gastrointestinal stromal tumours (GIST)are the most common mesenchymaltumours of the alimentary tract; they

account for <1% of all GI malignancies withapproximately 900 new cases per year in UK[1]; primary GISTs tend to arise as solitarylesions 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 ofGIST to be that of “highly cellularmesenchymal tumours of the gastrointestinaltract containing spindle, epitheloid cells or acombination of both and displaying CD117/c-kit positivity”. GISTs have been proposed tooriginate from the interstitial cells of Cajal,considered to be regulators of gastrointestinalmotility but, as they can arise from tissuedepleted of Cajal cells, the possibility that theyarise from a pluripotent stem cell has beensuggested [3].

The management of GISTs has evolvedrapidly with our understanding of themolecular pathophysiology of this lesionallowing for the rational development ofantitumour agents that target signallingaberrations in these cells. Imatinib mesylate(Gleevac, Glivec), a tyrosine kinase andplatelet derived growth factor receptor (PDGR)antagonist, have shown excellent results inpatients with unresectable or metastatic GIST,but surgical resection of the primary tumour

remains the treatment of choice when cure issought. There is, however, still debateregarding the most appropriate operativeapproach and the extent of resection required.While metastatic spread is common at firstdiagnosis, spread to lymph nodes is rarely seenthus, more extensive resection other than theprimary site is questionable and has no bearingon survival or recurrence. Recently theNational Comprehensive Cancer Network(NCCN) task force reported that “laparoscopicor laparoscopic-assisted resection may beuseful for small (<2cm) GISTs when the risk ofintraoperative tumour rupture is low. However,the use of laparoscopic resection is generallydiscouraged for GIST” [4]; despite this,laparoscopic resection of primary GIST hasbecome the treatment of choice in manycentres in the UK and Europe. This articlesummarises the current role of surgery andtargeted chemotherapy in the management ofGISTs.

Minimally invasive surgery for GISTLaparoscopic surgery for gastrointestinal cancerand, more recently gastric cancer has beenwidely adopted in Japan, Korea, China, Italy,USA and the UK, but not without some debate.Unlike adenocarcinoma, lymphadenectomy isunnecessary with the aim of GIST surgery beingthe complete removal (R0) of the tumour withnegative resection margins and withoutcapsule rupture or intra-abdominal spillage of

8

10

14

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: [email protected]

tinzaparin sodium

*innohep® - giving more life to patients with pulmonary embolism

You’re fi ghting cancer - Don’t be beaten by a PE

1. Hull RD et al. Am J Med 2006; 119:1062-1072

innohep®- long term effi cacy in treatment of PE and DVT in cancer patients1

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UCAN is a charitable company set up toimprove the quality of life for peopleand families living with urological

cancers in the North of Scotland. Urological cancers, (kidney, prostate,

bladder, testicular and penile) are among themost common types of cancers. They accountfor one in three of all cancers in men and onein five of all cancers in men and women.

UCAN was launched in January 2006 by MrSam McClinton and Professor James N’Dow,two consultant urological surgeons based atthe Aberdeen Royal Infirmary. They createdUCAN as a direct result of cancer sufferers,families and health professionals identifying aneed to provide additional and improvedservices which are not, and cannot be,provided under the statutory duties of the NHS.

There exists a stigma associated withurological cancers. Quite often patients seekmedical advice from their doctor at a pointwhen it is too late to offer curative treatment.Those who have been diagnosed with aurological cancer often suffer long-termsocial, emotional and psychologicalproblems. Sufferers frequently struggle tocome to terms with the trauma of urologicalcancer and the potentially life-changingeffects of treatment, such as urostomy and

erectile dysfunction. Long-term psychologicalproblems can affect sufferers’ partners andfamilies as much as the patient themselves,significantly increasing the number of livesblighted by urological cancer. UCANrecognises that a significantly higher level ofsupport is required for those diagnosed withurological cancer than is currently available.

What does UCAN plan to achieve?Our plans are split into three main areas:

• Improving early diagnosis and knowledge1) Our awareness campaign has been

running for two years. We need to raise theprofile of urological cancers to the level ofbreast and bowel cancer, and educateindividuals on the early signs of urologicalcancers, in a bid to reduce the mortalityrates. We also want to take the stigma outof these illnesses which by their naturecan cause embarrassment.

2) One of our key challenges is to get men to

take responsibility for their own health tothe same degree as women. We areworking with employers to help get ourmessages across in the workplace. Earlydiagnosis of cancer would not only helpthe patient but also the employer throughreduced time off work.

• Building effective support structures1) There is a desperate need to provide

patients and families with new avenues ofsupport to help them adjust to, and livewith, the changes a cancer diagnosismight bring to their lives. On occasions,the need will be for human contact; onother occasions the need might be forrelative anonymity through online contact.

2) We recognised the need for a central hubclose to the clinical services. A newUrological Cancer Care Centre was openedin January 2008, in the department ofurology and is already fully operationalproviding practical support to cancersufferers.

3) An important element of building effectivesupport structures will be the PlainEnglish Guides which will convert a vastamount of unregulated information intoshort, easily understood documents, withthe facts a cancer patient needs to know.

• Acquired knowledge and research1) By researching the knowledge and

experience of urology cancer patients,their families and clinicians worldwide, wewill be able to determine what informationcancer sufferers need at different stages oftreatment. The family unit also needsinformation as they are affected just asmuch as the cancer sufferers. Thisinformation is vital when deciding whichtreatment to choose if the cancer suffereris not to regret that decision at a later date.It is also very important to discover thebest ways of managing the oftenunpleasant effects of treatments.

What makes UCAN unique?Our activities are distinctive in the followingways:• Projects are developed in partnership with

the beneficiaries; allowing us the bestchance of being relevant to urologicalcancer 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 SciencesBuilding,Foresterhill,Aberdeen,AB25 2ZD, UK. A Urological CANcer is diagnosed every 10 minutes


• The development of a comprehensive peer supportframework is novel. It entails one-to-one mentoring byother urological sufferers, web based forum support byother sufferers and a world class cancer care centre,supported by skilled personnel, experts in the field ofurology. The centre will also be backed by internationalcollaboration, with the experience and expertise necessaryfor studying the information needs of urological cancersufferers.

• We are proposing not only support for urological cancersufferers, but the family unit as a whole because werecognise that the impact of a cancer diagnosis andtreatment is more far-reaching than just the person withthe cancer. The project has the potential to benefit cancersufferers and their families nationally and internationally.

• In addition, specific groups in society will be targeted, suchas young men who are traditionally reluctant to addresstheir medical needs. A key emphasis is on prevention andearly diagnosis that will limit the effects of these cancersand promote a speedy and full recovery. It is hoped thatwider knowledge about these cancers will reduce the socialstigma often associated with these illnesses.

How our make-up and direction differs from othercharitiesOur work is overseen by an independent UCAN SteeringCommittee that advises the UCAN Board of Directors. Thecommittee chair, and half of the members, are urologicalcancer sufferers. Through the UCAN Steering committee,patients will continue to be at the centre of decisions aboutthe activities of the charity. We also have a UCAN PatientAdvisory Group (individuals who have had a urologicalcancer) who independently advises the clinical urology teamand the direction of the support services for patients and theirfamilies.

UCAN in Progress

Buddy NetworkUCAN has recently launched its Buddy Network inpartnership with NHS Grampian.

The Buddy Network allows cancer patients to seekadditional support from other patients as their advisors, who ofcourse have been through a similar treatment experience. Thissupport network allows patients to seek out further emotionalsupport and practical advice from other individuals who havehad a similar treatment journey. This is a very distinct supportnetwork from the NHS, and unique for patients as it allows anopportunity for newly diagnosed cancer patients to verbalisetheir concerns and ask questions without the worry about howtheir loved ones are feeling. We currently have a cohort ofpatient advisors waiting to be a buddy for a newly diagnosedcancer patient. Progress so far is positive and certainly a valuedaspect of patients’ treatment packages.

ForumThe UCAN online forum was launched in April 2007; thissupport service is moderated by the patients with anoverview from the medical team. Within the forum, we havea general area and cancer restricted areas (individualurological cancers to which only those who have had thiscancer can gain access). From our pilot work, we found that

this online support service is not only valuable for emotionalsupport, but is an area where practical information, questionsand experiences can be shared by patients anonymously.

These support services can be accessed in our UrologicalCare Centre, as shown in the following picture.

Health EducationTOTAL E&P UK Limited has generously sponsored the UCANResearch Nurse, Catherine Paterson for three years. The NorthEast of Scotland is the oil capital of Europe, with the oilindustry being largely a male dominated work force.Consequently, our UCAN nurse has taken the healtheducational programme to the offshore oil rigs to target mens’knowledge and attitudes towards the early signs of urologicalcancers. Since UCAN had endeavoured into this new venture,feedback has proved that this is a success and certainly helpsto empower men to take ownership for their health.

In line with the health educational programme part our aimto try to combat the stigma attached to these cancers. FirstGroup have helped UCAN to achieve this by a risqué, yet veryeffective, way of capturing the attention of the general publicin the north east of Scotland. n

UCAN is working hard to get a handle on urologicalcancers, for more information please contact;UCAN office, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK.Website: www.ucanhelp.org.ukEmail: [email protected]: 01224 559312.

UCAN Research Nurse Offshore.


Lung cancer is one of the most commoncancers in the Western world, witharound 38,000 patients being diagnosed

each year in the UK. Rarely diagnosed in theunder 40s, lung cancer is a disease of the latemiddle-aged and elderly. Peak incidence is inthe 75-84 age-group, with 85% of patientsbeing over the age of 60 (Figure 1). In the1950s, the sex ratio was M:F 6:1; withreducing incidence in males and increasingrates in females, wth the current sex ratiobeing nearly 7:5. Cigarette smoking is linkedto lung cancer in well over 90% of cases,although other environmental causes such asasbestos and radon gas exposure have beenimplicated. Lung cancer is the leading causeof death from cancer in the UK, 22% of allcancer deaths being attributable to lungcancer. The current 5-year survival for lungcancer in the UK is 7% [1].

Types of lung cancerThere are two broad groups of lung cancerdefined by their histological appearance [2].These are Small Cell Lung Cancer (SCLC) andNon-Small Cell Lung Cancer (NSCLC). SCLCand NSCLC differ in a number of ways; theircell origin is different, SCLC beingneuroendocrine, whereas NSCLC is epithelial.SCLC is very chemosensitive, but NSCLC isless so. SCLC is generally metastatic atpresentation, whereas NSCLC may initially belocoregional. SCLC is generally not a surgicaldisease, while NSCLC may be resectable.Examples of individual types of NSCLC aresquamous, adenocarcinoma and large cellcarcinoma.

The key to current treatment of patientswith lung cancer is the multidisciplinary

team (MDT) [3]. The workings andmembership of the MDT vary from region toregion. MDT meetings should ideally be heldweekly and attended by all the major players(Table 1). All patients with lung cancershould be reviewed, the object being todeliver the best possible treatment to eachpatient depending on their tumour stage andstate of health.

SCLC treatmentPatients with SCLC are categorised as eitherwith limited disease (LD), where the diseaseis confined to the thorax, or extensive disease(ED), where there is evidence of distantmetastases [4].

Patients with ED are generally givenchemotherapy, designed to produce palliationand shrinkage of the tumour burden. About50% of patients with SCLC that are in the EDcategory will have clinical or subclinicalcerebral metastases. For this reason,prophylactic cranial irradiation (PCI) is oftenadministered [5].

SCL cases categorised as LD also getchemotherapy. Where there is a complete orgood response, mediastinal radiotherapy +/-PCI is considered for survival advantage andimproved quality of life [6].

There will be a small group of patients whopresent with early disease. Under thesecircumstances, if properly staged, surgerymay have a role.

NSCLC treatmentKey to the management of patients withNSCLC is TNM staging of the tumour, whichis based on tumour characteristics (T), nodalinvolvement (N), and the presence orabsence of metastases (M). A summary oflung cancer TNM is given in Table 2.However this classification is beingreassessed and updated; the update will bepublished later in 2008 [7].


Espeed KhoshbinRegistrar in CardiothoracicSurgery.

Alan JB Kirk, Consultant Thoracic & Cardiac Surgeon.

Correspondence to:Department of ThoracicSurgery,West of Scotland RegionalHeart & Lung Centre,Golden Jubilee NationalHospital,Clydebank, UK.Email: [email protected]

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


Treatment strategiesManagement of patients with NSCLC can be considered aseither radical (ie with curative intent) or palliative.

Radical treatment optionsThese would include surgery, radical radiotherapy andmultimodality options.

SurgeryIt is fair to say that surgical resection of primary lung canceris the mode of therapy most often and consistently associatedwith cure [8]. The key question at an MDT meeting should be“is this patient suitable for surgery?” If not, the reasonsshould be documented. Indications for surgery can besubdivided into oncological and medical indications.

Oncological considerations: All patients being consideredfor lung resection have the following investigationsperformed to stage the disease: chest X-ray, bronchoscopy, CTthorax, and PET/CT scan [9]. In certain circumstances otherimaging may be required, eg CT or MR brain scan, isotopebone scan, liver ultrasound.

Patients suitable for tumour resection will generally be thosein whom the primary tumour is small, where it has not erodedinto adjacent structures that would deem it irresectable, andwhere there is no (or minimal) lymph node spread and distantmetastatic spread. Suitable tumour stages would be T1 andT2. Certain T3 tumours may be suitable for resection, such aslocal overlying rib invasion, where the tumour can be resectedby lobectomy and en bloc chest wall resection. T4 tumours (egwhere the tumour has infiltrated oesophagus, vertebralcolumn or great vessels) are generally unresectable.

Patients who are staged as N0 or N1 are generally suitablefor lung resection provided everything else is favourable. If apatient is staged preoperatively as N2 (ipsilateral mediastinalnodes), surgery is not usually the best treatment. Pre-operatively staged N3 nodal disease would generally be acontraindication to surgery, outside a clinical trial.

The presence of metastases would also be acontraindication to surgery. For example, a patient withhepatic, bony or adrenal metastases would certainly not be asuitable candidate for surgery. However, a small highlyselected group of patients with solitary cerebral metastasesand otherwise operable lung cancer might be treated bycerebral metastasectomy and lung resection, with survivalbenefit [10].

Medical considerations: Bearing in mind that thesepatients are generally elderly and have probably beencigarette 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. Cardiacinvestigations should at a minimum be good clinical historyand examination, with ECG. Further tests such asechocardiography, exercise ECG and cardiac catheterisationmay be required. Respiratory assessment is clinical, lungfunction tests being essential.

Surgical pointsIf the PET scan shows evidence of FDG uptake in themediastinum, mediastinoscopy is required for tissuediagnosis. However if the PET scan is negative in themediastinum, no mediastinoscopy is necessary.

Once the decision to operate has been made, the principlesof surgery are to resect the tumour widely, leaving as muchnon-diseased functional lung as possible. In practice,lobectomy is the treatment of choice. This is certainlypreferable to wedge resection or segmentectomy. Sometimes,however, lobectomy alone is insufficient to resect the cancerand bi-lobectomy or pneumonectomy is required.

Operative mortality is 2-3% for lobectomy and ~7% forpneumonectomy. Long-term survival is dictated by the post-resection histology report. A 1cm T1 lesion with no nodalspread may have a 5-year survival in excess of 80%. A 5cmT2 tumour with resected N2 disease may have a 5 yearsurvival of only 20%. For those patients who undergo a lungresection, their case should be discussed at a MDT meeting.In certain circumstances, adjuvant chemotherapy may beassociated with survival advantage.

Radical radiotherapyIn certain circumstances with small tumours showing noevidence of nodal spread, the patient may not be suitable forsurgery. Recent stroke, myocardial infarction or significantCOPD may deem surgery inappropriate. In addition, smalltumours that are thought to be inoperable may be bettertreated by radical radiotherapy [11]. With limited diseaseunder these circumstances, radical radiotherapy may beassociated with cure or extended survival. High doseradiotherapy (e.g. 60 Gy over four weeks on a daily basis) canbe 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


(Continuous Hyperfractionated Accelerated Radiotherapy) isa 3-times daily treatment over about 12 days with noweekend breaks, giving improved survival (12). In certaincircumstances chemotherapy can be administered incombination with radiotherapy to attempt to improve theresults.

Palliative therapyIn advanced disease, it is accepted that cure is improbable.The management plan would be to reduce tumour bulk andprovide the patient with as good a quality of life as possible.Radiotherapy is an excellent palliative therapy, and canprovide relief from bony pain, irritating cough, haemoptysisand cerebral metastases [13]. Chemotherapy can also provideexcellent palliation of symptoms and generally promote well-being, improve appetite and slow down weight loss [14].

Surgical procedures can provide palliation, such aspleurodesis of recalcitrant pleural effusions (Figure 2),disobliteration of airways with laser and stenting ofoesophageal strictures secondary to mediastinal nodalinvolvement.

These specific interventional measures are undertaken inaddition to the general and specialist palliative care input thatis provided at all stages of the progression of the disease inthe 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 inappropriately selected individuals

• All patients with lung cancer should be reviewedby the Lung Cancer MDT and optimum treatmentestablished

• All patients in whom a radical option is beingcontemplated should have a CT scan of thoraxand abdomen

• All patients who might have radical treatmentshould have a PET scan

References

1. Office of National Statistics. Cancer Statistics Registration: Registrations ofcancer diagnosed in 2004, England, Series MBI no 33, 2005

2. WHO histological typing of lung cancers. In: International classification oftumours 2nd edition 1981, Geneva

3. Spira A, Ettinger DS. Multidisciplinary management of lung cancer. NewEngland 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 controversialor 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 stagingproject. Journal of Thoracic Oncology 2007;8:706-14.

8. Jablons D. Neoplasms of the lung. In: LW Way, GM Docherty (eds). CurrentSurgical Diagnosis & Treatment 11th ed: 395-407.

9. Shim SS, Lee KS, Byung-Tae K et al. Non-small cell lung cancer: prospectivecomparison 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 surgicaltreatment. Eur J Cardiothorac Surg 2001;20:361-6.

11. Tyldesley S, Boyd C, Schulze K, Walker H, Mackillop WJ. Estimating the needfor radiotherapy for lung cancer: an evidence-based, epidemiologic approach. IntJ Radiat Oncol Biol Phys 2001;49:973-85.

12. Saunders MI. A randomised multicentre trial of CHART vs conventionalradiotherapy 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 Cancer2004;43:373-4.

15. Kvale PA, Selecky PA, Prakash, UBS. Palliative care in lung cancer. CHEST2007;132:368-403.

Figure 2: Malignant pleural effusion secondary to lung cancer.

Reel Lives: The Cancer Chronicles Film Festival isthe first ever international documentary filmcompetition focused on cancer. It aims to raiseawareness of the impact of cancer while alsohonouring people who have been touched bythe disease.

Reel Lives is produced by the InternationalUnion Against Cancer (UICC) and will be held inGeneva, Switzerland, on 28-30 August. Thefestival is supported by a grant from GlaxoSmithKline Oncology.

In its inaugural year, the festival has already received more than100 film entries from around the world, and has just added notedoncologist Dr. Larry Norton to its team of expert judges.

“We are thrilled with the positive response,” says Isabel Mortara,

executive director of UICC, the leadinginternational non-governmental organizationdedicated exclusively to the global control ofcancer. “We believe the festival will helpdemystify cancer and deepen awareness ofcancer as a pressing global health issue, whilealso highlighting progress in the fight againstthe disease.”

The festival will take place during the 2008World Cancer Congress in Geneva. The grand prize winner willreceive $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

A lifeline in relapsed NSCLC

Adverse events should be reported. Reportingforms and information can be found at www.yellowcard.gov.uk. Adverse events shouldalso be reported to Roche Products Limited. Pleasecontact UK Drug Safety Centre on 01707 367554.

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Prescribing Information Tarceva® (erlotinib)25, 100 and 150 mg tabletsFull prescribing information should be viewed prior to prescription.Indication: Treatment of patients with locally advanced or metastaticnon-small cell lung cancer after failure of at least one priorchemotherapy regimen. When prescribing, factors associated withprolonged survival should be taken into account. No survival benefit or other clinically relevant effects of the treatment have beendemonstrated in patients with EGFR-negative tumours. Dosage andadministration: 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 stopsmoking as a clinically significant reduction in plasma concentration is likely. Interstitial lung disease (ILD), including fatalities, has beenreported (incidence 0.6%). In patients who develop acute onset of new and/or progressive unexplained pulmonary symptoms such asdyspnoea, cough and fever, interrupt therapy pending diagnosticevaluation. If ILD is diagnosed, discontinue therapy and initiateappropriate treatment. Diarrhoea should be treated with loperamide.Tarceva dose reduction or interruption may be necessary in patientswith severe or persistent diarrhoea. It may be necessary to intensivelyrehydrate the patient intravenously, monitor renal function and serumelectrolytes including potassium. In patients with pre-existing liverdisease or on concomitant hepatotoxic medications, periodic liverfunction testing should be considered. Tarceva dosing should beinterrupted if changes in liver function are severe. As tablets contain lactose they should not be administered to patients withgalactose intolerance, Lapp lactase deficiency or glucose-galactosemalabsorption. Avoid concomitant administration with PPIs (Proton Pump Inhibitors), H2 antagonists and antacids (see DrugInteractions below). Drug Interactions: Plasma concentrationsincrease when combined with potent CYP3A4 inhibitors e.g.ketoconazole. It may therefore be necessary to reduce the dose oferlotinib. Potent CYP3A4 inducers e.g. rifampicin will decreaseerlotinib plasma concentrations. Concomitant treatment should beavoided. 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 observedin concomitant treatment with other CYP3A4 inducers. Significantinteractions with the clearance of CYP3A4 substrates e.g. midazolam,erythromycin and paclitaxel, is unlikely. Potential interactions mayoccur with active substances which are metabolised by, or areinhibitors or inducers of CYP1A2, CYP1A1 and CYP1B1. Caution shouldbe 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 takingwarfarin or other coumarin-derivative anticoagulants for changes inprothrombin time or international normalised ratio (INR). Concomitantadministration of inhibitors of the P-glycoprotein active substancetransporter e.g. cyclosporin and verapamil may lead to altereddistribution and/or elimination of erlotinib. Solubility of erlotinibdecreases at pH above 5. Drugs that alter the pH of the upper GI tract e.g. omeprazole (PPI) may alter the solubility of erlotinib andhence 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 clinicallyrelevant. A study showed that carboplatin and paclitaxel did not affect erlotinib pharmacokinetics. Capecitabine may increase erlotinibconcentrations but a clinical study showed there were no significanteffects of erlotinib on the pharmacokinetics of capecitabine. Erlotiniband gemcitabine can be combined without significant effects on thepharmacokinetics. The inhibition of glucuronidation may causeinteractions with medicinal products which are substrates of UGT1A1 and exclusively cleared by this pathway. Pregnancy andlactation: There is no adequate experience in human pregnancy andlactation therefore Tarceva should only be used if the potential benefitjustifies the potential risks. Women of childbearing potential must beadvised to avoid pregnancy while on erlotinib and adequatecontraceptive methods should be used during therapy, and for at least2 weeks after completing therapy. Side effects and adversereactions: See SmPC for full listing. Serious adverse reactions:Gastrointestinal: Cases of gastrointestinal bleeds have been commonlyreported. Hepato-biliary disorders: Rare cases of hepatic failure(including fatalities) have been reported. Respiratory, thoracic andmediastinal disorders: Uncommon reports of serious interstitial lungdisease (ILD), including fatalities. Infections and infestations: Severeinfections, 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 commonlyreported adverse events in the BR.21 study. Most were grade 1/2 inseverity and manageable without intervention. Diarrhoea can rarelylead to dehydration, hypokalemia and renal failure. Other adverseevents reported, which occurred at a frequency ≥3% over placebo included pruritus, dry skin, nausea, vomiting, stomatitis,abdominal pain, dyspnoea, cough, infection, conjunctivitis andkeratoconjunctivitis sicca. In the primary safety population thefollowing was observed: Skin and subcutaneous disorders: Alopecia,paronychia, hirsutism, eyelash/eyebrow changes and brittle and loose nails. Hepato-biliary disorders: Liver function test abnormalitieshave 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. Legalcategory: Presentations, Basic NHS Costs, and Marketingauthorisation 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 mgx 30: pack £1,631.53. EU/1/05/311/003. Marketing authorisationholder: Roche Registration Ltd, 6 Falcon Way, Shire Park, WelwynGarden City, AL7 1TW, United Kingdom. Tarceva is a registered trade mark. Date of preparation: January 2008.

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Tarceva UK Oncology News Ad 2008_XXXXX 28/7/08 11:13 Page 1


The Current Treatment of GIST WithReference to Laparoscopic Resection andNeoadjuvant Treatment

Miss Siobhan Gill,MRCS,Senior House Officer inSurgery.

Mr Paras Jethwa, BSc(Hons), MD,FRCS(Gen), Consultant General & UpperGI Surgeon.

Correspondence:P Jethwa,Surrey & Sussex NHS Trust,Dept of Surgery,Canada Avenue,REDHILL,Surrey,RH1 5RH, UK.

Upper GI Oncology

Gastrointestinal stromal tumours (GIST)are the most common mesenchymaltumours of the alimentary tract; they

account for <1% of all GI malignancies withapproximately 900 new cases per year in UK[1]; primary GISTs tend to arise as solitarylesions 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 ofGIST to be that of “highly cellularmesenchymal tumours of the gastrointestinaltract containing spindle, epitheloid cells or acombination of both and displaying CD117/c-kit positivity”. GISTs have been proposed tooriginate from the interstitial cells of Cajal,considered to be regulators of gastrointestinalmotility but, as they can arise from tissuedepleted of Cajal cells, the possibility that theyarise from a pluripotent stem cell has beensuggested [3].

The management of GISTs has evolvedrapidly with our understanding of themolecular pathophysiology of this lesionallowing for the rational development ofantitumour agents that target signallingaberrations in these cells. Imatinib mesylate(Gleevac, Glivec), a tyrosine kinase andplatelet derived growth factor receptor (PDGR)antagonist, have shown excellent results inpatients with unresectable or metastatic GIST,but surgical resection of the primary tumour

remains the treatment of choice when cure issought. There is, however, still debateregarding the most appropriate operativeapproach and the extent of resection required.While metastatic spread is common at firstdiagnosis, spread to lymph nodes is rarely seenthus, more extensive resection other than theprimary site is questionable and has no bearingon survival or recurrence. Recently theNational Comprehensive Cancer Network(NCCN) task force reported that “laparoscopicor laparoscopic-assisted resection may beuseful for small (<2cm) GISTs when the risk ofintraoperative tumour rupture is low. However,the use of laparoscopic resection is generallydiscouraged for GIST” [4]; despite this,laparoscopic resection of primary GIST hasbecome the treatment of choice in manycentres in the UK and Europe. This articlesummarises the current role of surgery andtargeted chemotherapy in the management ofGISTs.

Minimally invasive surgery for GISTLaparoscopic surgery for gastrointestinal cancerand, more recently gastric cancer has beenwidely adopted in Japan, Korea, China, Italy,USA and the UK, but not without some debate.Unlike adenocarcinoma, lymphadenectomy isunnecessary with the aim of GIST surgery beingthe complete removal (R0) of the tumour withnegative resection margins and withoutcapsule rupture or intra-abdominal spillage of


tumour cells. Evidence has shown that survival is dependanton tumour size (<5cms), mitotic activity (<5/50 mitoses perhigh powered field), angiogenic upregulation and evidence ofmutation rather than the extent of resection [2,5]. ManyGISTs can be treated without major anatomical resection andtherefore are suitable for minimally invasive surgery, withwedge resection of gastric GISTs widely reported to be bothsuccessful and most commonly performed [6]. With thegrowth in laparoscopic surgical experience subtotal and totalgastrectomies are now both practical and suitable for moreproximal lesions however, larger GISTs in difficult anatomicalpositions (oesophagus/oesophagogastric junction/proximalstomach) present a more technically demanding challengeand have a greater propensity for open surgery orintraoperative conversion. The role of laparoscopic surgery inthe resection of small bowel GISTs remains unclear at presentthough laparoscopic excision of large bowel and rectal GISTshave been reported to be technically feasible and havesuccessful outcomes [7,8].

The majority of reported series have supported the role oflaparoscopic treatment of gastric and gastro-oesophagealGISTs, demonstrating it to be associated with lowermorbidity, mortality, length of stay and rates of long termsurvival comparable to, if not better, than that ofconventional surgery [9]. Wherever possible anatomicalfunction should be preserved but this should not be at thecost of an R0 resection with enucleation of the tumour bestavoided. In order to facilitate this a combined endoscopiclaparoscopic local resection of tumours has proven to bebeneficial in patients with upper GI GISTs, known as anendoscopic rendezvous procedure [10]. This techniquefacilitates preservation of anatomical function during theresection by ensuring lumen patency at all time. Despite

initial concerns there have been favourable results reportedfrom the resection of larger GISTs (up to 15cm in size), withno local or peritoneal recurrence after four years [11].

In order to successfully remove GISTs it is imperative togently handle the tumour and, if at all possible, directhandling should be minimised. We have found that once thestomach has been mobilised, normally requiring thedivision of the gastrocolic omentum for tumours on thegreater curve or the gastohepatic ligament for those on thelesser curve, placing stay sutures either side of the tumourmass greatly enhances operative control and reduces therisk of tumour cell spillage. After adequate mobilisationgastric resection is performed by elevating the stomach walland transecting the normal stomach with a linearendoscopic GI anastomosis stapler (Figures 1 & 2, tumourarising from lesser curve). For the resection of larger lesions(>5cm),careful tactile handling and adequate traction ofthe tumour can be more problematic, with the use of handassisted laparoscopic surgery (HALS) advocated by someauthors [12]. While most GISTs are hard, elastic and coatedwith a thin pseudo-capsule some are very fragile and bleed

easily. This latter group requires particular attention toensure no tumour spillage at time of resection. Currentconsensus suggests that if these tumours are encounteredduring laparoscopic surgery, the procedure should beswitched to laparoscopically assisted or conventional opensurgery.

As with the majority of GI neoplasms in western countries,most GIST patients present late, with complaints of vagueabdominal 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 forGISTs however, the introduction of tyrosine kinase inhibitorsas neoadjuvant chemotherapeutic agents has revolutionisedthe approach to these tumours with, previously irresectiblelesions downstaged to the point of curative resection. This isfurther discussed below.

Neoadjuvant treatmentCombined modality strategy has shown significant benefitfrom imatinib mesylate (Gleevac) in downstaging GISTs,thus rendering previously inoperable tumours resectablewith tumour regression of up to 80% of patients. With asmany as 90% of patients developing recurrent diseaseduring their lifetime there has been a considerable rise inour familiarity of the use of imatinib mesylate in the pre-operative setting and, for those patients that developsymptomatic or functional recurrent disease. This has beendemonstrated in a variety of settings with reports ofsuccessful R0 resection in previously advanced tumours ormarginally resectable tumours, including locally advancedlesions of the stomach, metastatic hepatic GISTs and insmall bowel disease [13,14].

Despite an initial response to imatinib secondary or

acquired resistance tends to develop after a median of twoyears with this most commonly due to KIT mutation inclonally expanded cells. Mutational analysis has helped tocharacterise the behaviour of these tumours with proximaldeletions of exon 11 and duplication of exon 9 associated withhigh risk lesions whereas, PDGF α exon 18 mutated GISTshave a lower malignant potential. In light of this drugresistance 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 onephase III trial have reported a significant clinical benefit withan increase in time to tumour progression and death, leadingto suntinib being licensed for all patients in the US withimatinib resistant disease [15]; however tumour shrinkagecompared to placebo was not common and its role as aneoadjuvant downstaging agent needs further clarificationand investigation [16]. In addition, mutational analysis of theprimary tumour may also help to target drug therapy, withexon 9 mutation GISTs especially sensitive to sunitnibtreatment whilst at best having an intermediate response toimatinib. 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


of these agents as neoadjuvant treatments in advanced GISTsis 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 refractoryto therapy proves to be both efficacious and therapeutic. Thisincrease leads, in a sizeable proportion, to a decrease intumour volume and is associated with complete surgicalresection in those with locally advanced primary GISTs [17].Early surgical intervention should be considered for imatinibresponsive disease and in these patients multiplereoperation(s) are associated with prolongation of life.

ConclusionThe current management of GISTs continues to rapidlyprogress with the combination of new surgical techniquesand targeted chemotherapy delivering real benefits in keepingwith their promised potential expectations seen at the cellularlevel. The treatment of GISTs continues to evolve withdramatic reductions seen in mortality and associated surgeryfrom this disease. n

References1. 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, BrennanMF. Two hundred gastrointestinal stromal tumour: recurrence patterns andprognostic factors for survival. Ann Surg 2000 Jan;231:51-8.

3. Connolly EM, Gaffney E, Reynolds JV. Gastrointestinal stromal tumours. Br JSurg 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 ofthe NCCN clinical practice guidelines. J Natl Compr Canc Netw. 2007;Jul;5 Suppl2: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 ingastrointestinal stromal tumors. Mod Pathol 2007:20(5):529-37.

6. Nowain A, Bhakta H, Pais S, Kanel G, Verma S. Gastrointestinal stromaltumours: clinical profile, pathogenesis, treatment strategies and prognosis. JGastroenterol Hepatol. 2005;Jun;20(6):818-24.

7. Nguyen SQ, Divino CM, Wang JL, Dikman SH. Laparoscopic management ofgastrointestinal 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 resectedby 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 oflaparoscopic resection of gastric gastrointestinal stromal tumors. Ann Surg2006;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. 2002Nov;16(11):1561-5.

11. Otani Y, Kitajima M. Laparoscopic surgery for GIST: too soon to decide GastricCancer. 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 fromgastrointestinal 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. Advancedgastrointestinal stromal tumor patients with complete response after treatmentwith imatinib mesylate. World J Gastroenterol. 2006 Apr 7;12(13):2060-4.

15. Hopkins TG, Marples M, Stark D. Sunitinib in the management ofgastrointestinal 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, GeorgeS, Bello CL, Huang X, Baum CM, Casali PG. Efficacy and safety of sunitinib inpatients 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 withimatinib. Ann Surg Oncol. 2007 Jan;14(1):14-24.

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Uftoral Prescribing Information (UK)Presentation: Capsules containing 100 mg tegafur and 224 mg uracil.Therapeutic Indications: First-line chemotherapy treatment of metastaticcolorectal cancer in combination with calcium folinate. Dosage andadministration: The dose of Uftoral is 300 mg/m2/day tegafur and 672mg/m2/day uracil combined with 90 mg/day oral calcium folinate, given inthree divided doses, at least one hour before or after meals. Calciumfolinate should be taken at the same time as Uftoral. The treatment cycleis 35 days. Uftoral/calcium folinate is taken for 28 consecutive daysfollowed by 7 days without Uftoral/calcium folinate. Only suitable foradults. Monitor patients with renal or hepatic impairment carefully.Exercise caution in patients with renal impairment. In the elderly, monitorrenal, hepatic and cardiac function. Contraindications: Hypersensitivityto the constituents or 5-FU; pregnancy or breast feeding; adolescents,children and infants; severe hepatic impairment; deficiency of hepaticCYP2A6; bone marrow suppression from previous radiotherapy orantineoplastic agents; known or suspected dihydropyrimidinedehydrogenase deficiency; current or recent treatment withdihydropyrimidine dehydrogenase inhibitors such as brivudine. SpecialWarnings and Precautions: Patients with: renal or hepatic impairment,signs and symptoms of bowel obstruction, signs and symptoms of liver orrenal disease, diarrhoea, a history of significant cardiac disease and the

elderly. Monitor patients on coumarin anticoagulant treatment (such aswarfarin) and phenytoin treatment. Drug Interactions:Warfarin, phenytoin,substrates or inhibitors of the CYP2A6 enzyme such as coumarin,methoxypsoralen, clotrimazole, ketoconazole, miconazole. Must not beco-administered with inhibitors of dihydropyrimidine dehydrogenase egbrivudine (allow interval of 4 weeks before Uftoral treatment). Pregnancyand Lactation: Should not be administered to patients who are pregnantor attempting to become pregnant or breast feeding. Undesirable Effects:Very common: GI disorders such as diarrhoea, nausea/vomiting, abdominalpain, asthenia, stomatitis and anorexia; blood disorders such asmyelosuppression, anaemia, thrombocytopenia, leucopoenia andneutropenia; increased alkaline phosphatase, ALT, AST and total bilirubin.Common: other GI disorders including intestinal obstruction; fever,headache, malaise, chills, dehydration, cachexia; CNS disorders includingtaste disturbance, dizziness, depression and confusion; eye disorders, cardiacand vascular disorders including DVT; respiratory disorders; skin andmusculoskeletal disorders. Uncommon: Other GI disorders, hepatitis,jaundice, liver failure, chest pain, sepsis, coagulation disorders, febrileneutropenia, arrhythmia, congestive heart failure, myocardial infarction,heart arrest, shock, pulmonary embolism, abnormal kidney function, urinaryretention, 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; packof 120 capsules - £320.40. Marketing Authorisation Holder: MerckPharmaceuticals (A Division of Merck Ltd), Harrier House, High Street, WestDrayton, Middlesex, UB7 7QG, UK. MA Number: PL11648/0065. Date ofPreparation: August 2007. Further information, including a summaryof product characteristics is available from: Merck Serono, BedfontCross, Stanwell Road, Feltham, Middlesex, TW14 8NX, UK Tel: 020 88187373. (Uftoral is a trademark of Taiho Pharmaceutical Co., Ltd, used underlicense 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 theYellow 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 aneffective oral chemotherapy with veryrare incidence of HFS.1

Allow your patients to continue with theeveryday activities that are essential fortheir lifestyle.

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9904 UFT Onc News:Layout 1 20/3/08 09:29 Page 1


Following estimation of pathologicalstaging using the criteria outlined in part1 of this review, there are three

important categories into which tumours areplaced in order to determine the appropriatetreatment options. These include organconfined T1 and T2 lesions, locally advancedT3 and T4 (N0 M0) tumours and metastaticdisease. There are a number of treatmentoptions available for each category andpatients’ care needs to be carefullydetermined taking into account quality of life,competing co-morbidities, life expectancy andpatient preference. The Multi-DisciplinaryTeam (MDT) approach to patient managementis key to this process, involving surgeons,oncologists, radiologists, pathologists andspecialist nursing staff.

Treatment of Organ Confined ProstateCancerOrgan confined disease now represents themajority of tumours at diagnosis and ispotentially curable. However, due to the longnatural history of prostate cancer and theevolution of different interventions it has beendifficult to effectively measure and comparethe outcomes of different treatment strategies.Therefore there is a significant degree ofcontroversy surrounding the optimumtreatment of this category of disease. Again,treatment needs to be carefully planned in theMDT setting taking into account patientpreference, age and co-morbidity. The threemain treatment options include watchfulwaiting or active surveillance, radical surgeryand radical radiotherapy. These options havesimilar long term outcomes but different sideeffects and complications and therefore eachoption should be carefully explained to thepatient who can then make an informeddecision.

Watchful Waiting and Active surveillanceLow risk, low Gleason grade disease carriesonly a 4-7% risk of death at 15 years andGleason 7 disease carries a 42 – 70% risk at 15years [1]. Thus men over the age of 75 yearswith organ confined disease and a lifeexpectancy of less than 10 years are unlikelyto gain benefit from radical treatment. In suchcases it is generally considered appropriate tomonitor disease status, termed watchful

waiting, with regular PSA and DRE, offeringhormone therapy if there is evidence ofsignificant disease progression. A moreproactive form of watchful waiting termedactive surveillance is available for youngermen with low volume, low to moderate gradedisease. With more intensive follow-up usingPSA, DRE and interval repeat TRUS biopsyradical treatment can be deferred until there isevidence of disease progression. Up to 50% ofmen are progression free at 10 years anddeferred radical treatment remains effective[2]. For some men this is a viable alternativeto early radical treatment and its consequentside effects. However, it should be carefullyexplained to patients that there is a risk thatpotentially treatable disease may progressduring the monitoring period with anincreased risk of local progression, metastaticspread and death from prostate cancer [3].

Radical SurgeryRadical surgery is considered the gold standardtreatment for prostate cancer in appropriatelyselected patients. Such patients should have agreater than 10 year life expectancy, with organconfined disease which is biologicallyresectable and they should be fit enough toundergo major surgery. To date there is limiteddata comparing surgery directly with radicalradiotherapy, although surgery is consideredthe optimum treatment option due to thereduced risk of local recurrence. However,there is good evidence that disease progressionand disease specific survival is better withsurgery compared to watchful waiting [3].There are a number of surgical approachesincluding open retropubic, open perineal andlaparoscopic. Acute complications includehaemorrhage, infection, and complicationsrelated to anaesthesia. Significant latecomplications include erectile dysfunction inaround 50% of patients, incontinence in 10%and bladder neck stenosis in 5%. Ten yearprogression free survival is in the region of85% for organ confined disease, but this fallsto 55-65% with evidence of extracapsularextension, 25% with seminal vesical diseaseand 10% if there is nodal disease [4]. Severalseries of laparoscopic and robotic radicalprostatectomy have recently been reported andwhile some reports suggest shorter recoverytime, 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 ofAberdeen, UK.

Correspondence to: Dept Urology, Aberdeen Royal Infirmary,Foresterhill, Aberdeen,AB252ZN, UK.

Urological Cancer

Factors IndirectlyAffectingTreatmentQuality of LifeCo-morbidityLife expectancyPatient preference

Results PendingDefinitive data onoptimum treatmentstrategy for organconfined disease issome way off.

The results of a numberof studies investigatingthe role of cancerscreening are awaited


incontinence and impotence rates [5] other reports show moremixed results [6] However, oncological outcomes betweenopen and minimally invasive techniques are similar andtherefore with continued advances in technology minimallyinvasive surgery for prostate cancer is likely to become thestandard in the future.

RadiotherapyExternal beam radiotherapy (EBR) has seen significantadvances in technology in recent years with the developmentof 3-dimensional conformal radiotherapy (3D-CRT). Thistargets the radiation more accurately to the shape of theprostate gland avoiding damage to adjacent tissues andallowing higher doses of 70–80 Gy to be administered.Further improvements in accuracy have been made withintensity modulated radiotherapy (IMRT) which utilisescomputer technology to allow precise targeting.Brachytherapy is the implantation of radioactive seeds intothe prostate. Computer models are used to guide preciseplacement of the seeds allowing high radiation doses of up to145 Gy to be given. Adjuvant hormone therapy isrecommended for 2-3 years in high risk disease and sixmonths in low and intermediate risk disease due to improvedlocal control and survival [7,8]. Cancer specific outcomes areequivalent to surgery but there are problems making directcomparisons as many of the end points used in the study ofthe different treatment modalities have not been comparable[9]. The five year progression free survival rates forradiotherapy are in the range 70-85% [10]. However, localrecurrence has been noted in up to two thirds of patients onlong term follow up [11]. Long term complications includechronic cystitis and proctitis and erectile dysfunction inaround 50% of patients at one year.

A number of other treatment options are currentlyundergoing evaluation including cryotherapy, radio-frequencyablation and high intensity focussed ultrasound (HIFU).Comparison of radical treatment options have shown broadlysimilar outcomes but different end points have been used andthere are no randomised controlled studies available [12].However, an ongoing multi-centre research project in the UKcomparing radical surgery, radiotherapy and activesurveillance is underway. The Prostate testing for cancer andTreatment (ProecT) trial was started in 2001, has beenrandomising patients to the different treatment groups andaims to report in 2015. Therefore, definitive data on theoptimum treatment strategy for organ confined disease is stillsome way off and the management of prostate cancer willcontinue to centre around a careful and thorough discussionof all the available options with the patient.

Treatment of Locally Advanced and Metastatic ProstateCancerIn the UK locally advanced disease is most frequentlymanaged with radiotherapy combined with adjuvanthormonal therapy. This approach has been shown to offerimproved disease free and overall survival compared toradiotherapy alone with five year survival rates in the regionof 80% [10]. For elderly patients with limited life expectancyor those patients wishing to avoid the complications andimpact on quality of life of radiotherapy, hormone therapyalone or watchful waiting may be appropriate alternatives.

Hormone therapy in the form of androgen deprivationforms the mainstay of management for metastatic disease. It

was noted over 60 years ago that prostate cancer respondedto surgical castration or oestrogen therapy that reducedcirculating testosterone levels by negative feedback on thehypothalamic-pituitary axis [13]. Since then a number ofalternative agents have been produced including leutenisinghormone releasing hormone (LHRH) analogues which reducetestosterone production by negative feedback and steroidaland non-steroidal anti-androgens which block testosteroneaction in the prostate. Both normal prostatic epithelial cellsand cancer cells are dependent on androgens for normalgrowth and around 70% of tumours will respond to androgendeprivation. However, tumours rapidly develop androgenindependence with a mean time to progression of 14 months.When disease progresses, changing the type of androgendeprivation therapy or combining treatments, which istermed 2nd or 3rd line hormonal therapy, offers someimprovement but response times are limited and treatmentshould be aimed at palliation of the symptoms of metastaticcomplications. In selected patients with androgenindependent disease chemotherapy with docetaxol may beindicated with response rates of 20 – 40%, but again mediansurvival rates are low at 24 – 44 weeks [14].

Thus prostate cancer is a serious disease with significantmorbidity and mortality and although there are effectiveinterventions available for organ confined disease treatmentoptions for more advanced disease are limited. However, workcontinues in an attempt to define the molecular genetics andnatural history of the disease as well as to optimise both radicaland palliative treatment. Moreover, the results of a number ofstudies investigating the role of cancer screening are awaited,the outcomes of which will have a significant impact on men’shealth in the primary and secondary care setting. n

References1. Albertsen PC, Hanley JA, Gleason DF, Barry MJ. Competing risk analysis of men

aged 55 to 74 years at diagnosis managed conservatively for clinically localizedprostate cancer. JAMA 1998:280:975-80.

2. Patel MI, DeConcini DT, Lopez-Corona E, Ohori M, Wheeler T, Scardino PT. Ananalysis of men with clinically localized prostate cancer who deferred definitivetherapy. J Urol 2004:171:1520-4.

3. Bill-Axelson A, Holmberg L, Ruutu M, Haggman M, Andersson SO, Bratell S etal. Radical prostatectomy versus watchful waiting in early prostate cancer. NEngl J Med 2005:352:1977-84.

4. Catalona WJ, Ramos CG, Carvalhal GF. Contemporary results of anatomicradical 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 Leipzigexperience 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 andlaparoscopic radical prostatectomy conducted in 2003 to 2005. J Urol2008:179:1811-7.

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 inpatients with locally advanced prostate cancer (an EORTC study): a phase IIIrandomised 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 alonefor patients with clinically localized prostate cancer: a randomized controlledtrial. JAMA 2004:292:821-7.

9. Gretzer MB, Trock BJ, Han M, Walsh PC. A critical analysis of the interpretationof biochemical failure in surgically treated patients using the American Societyfor 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 withradiotherapy and goserelin. N Engl J Med 1997:337:295-300.

11. Swanson GP, Riggs MW, Earle JD. Long-term follow-up of radiotherapy forprostate cancer. Int J Radiat Oncol Biol Phys 2004: 59:406-11.

12. Nilsson S, Norlen BJ, Widmark A. A systematic overview of radiation therapyeffects in prostate cancer. Acta Oncol 2004:43:316-81.

13. Huggins C, Hodges CV. Studies on prostatic cancer: I. The effect of castration, ofestrogen and of androgen injection on serum phosphatases in metastaticcarcinoma 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. Docetaxelplus prednisone or mitoxantrone plus prednisone for advanced prostate cancer.N Engl J Med 2004:351:1502-12.


Book Reviews

Neuro-oncology is a broad discipline encompassing thework of oncologists, radiotherapists, neurosurgeons,and even an occasional neurologist (although I am only

aware of two such dedicated neurologists in the UK), in bothadult and paediatric practice, not to mention basic scientists. Toproduce a text which pleases all in this diverse constituency isdifficult, but in my view the current text, with a largely NorthAmerican authorship based around centres of excellence in SanFrancisco and Toronto, has largely succeeded.

The book is divided into eight sections: Biology, Evaluation,Surgery, Radiation, Chemotherapy, Biological Therapy, SpecificTumours, and Related Issues. Biology addresses epidemiologyand the basic sciences of tumour molecular pathology andtumorigenesis, including the possible role of cancer stem cells.This section might profitably be read in conjunction with that onBiological Therapy, which reviews innovative treatments stem-ming from increasing understanding of tumour biology such astumour 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 modalitiesnow available (anatomic, metabolic, physiological and function-al), although there was no mention of longitudinal volumetric MRimaging for assessing change in tumour size. The core of thebook, around 40% of the text, is devoted to Specific Tumours,addressing clinical presentation, investigation and diagnosis, andtreatment of individual tumour types. Generally these chaptersare excellent summaries, although one or two have a tendency toread 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 drugsand anticoagulation; quality of life, with a particular focus onneuropsychological consequences of brain tumours and theirtreatment; 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, retainedfrom the first edition of 2000, is the supplementation of the textwith special boxed features (“Pearls”, “Controversies”, “SpecialConsiderations”, and “Pitfalls”). There is some repetition ofmaterial between chapters, perhaps inevitable in a multi-authorwork, but this is not intrusive. Typographical errors and editori-al oversights are few: the two references to chromosomalabnormalities 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 itshigher side-effect profile and lower efficacy” (337). These areminor quibbles, though.

“Everything you need to know about neuro-oncology” claimsthe blurb, and although this may be overstatement it is difficultto think of any serious omissions. Something on the WHO clas-sification of tumours would have been appropriate, as maysome commentary on the use of “guidelines” for tumour iden-tification such as those inspired (imposed?) by the UKDepartment of Health. As a neurologist, I would have liked achapter on paraneoplastic syndromes. Nevertheless, one has nohesitation 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.

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Conference NewsAre you organising an annual meeting or conference which you would like to tell our readers about? Or would you like towrite 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: [email protected]

1st Wales Cancer Conference Venue: Cardiff, Wales. Date: 30 April-1 May, 2008.

Jointly organised by the Wales CancerInstitute and the Wales Cancer Alliance

we welcomed 300 delegates includingpatients, research nurses, laboratoryresearchers, policy makers, clinicians andWelsh Assembly Members to the variedtwo day programme.

Upcoming researchers were given theopportunity to showcase their work onthe second day in a Young Investigatorssession where the prize winning talk on“Using an in-vitro MTOR kinase assay tofurther characterise the MTOR pathway”by Elaine Dunlop give the name set thehigh standard of the science in Wales.This described a way to understand a keypathway that is often affected in thecancer cell, making the cancer morelikely to respond to one treatment ratherthan another.

The conference began with a talk fromProf Paul Workman of the Institute ofCancer Research, Sutton, on “Druggingthe cancer genome: Developments innovel therapies” which highlighted twoother new approaches to cancertreatment which have been developed inhis laboratory and are now in earlyclinical studies (that is inhibition of theactivity of PI3 kinase, a key signallingpathway, and HSP-90, a nuclearchaperone molecule). This linked with DrAndy Futreal who is one of the leaders inthe Human Genome Project from theWellcome Trust Sanger Institute inCambridge. He showed the way in whichthe new technology is able to identify

major changes (translaocations andrearrangements) in the genetic code ofcancer which will help to identify newways to target treatment. DennisSlamon, the discoverer of Herceptin fromUCLA in California, gave an excellent talkabout the discovery of herceptin and theunderlying abnormalities in breastcancer that makes it work so effectivelyin the 20-25% of women whose breastcancer is driven by an amplification ofthat gene, and how this could furtheraffect decisions about treatment. Thesetalks all pointed out the fundamentalimportance of genetic changes in thecancer cell and that these are a key basisfor identifying new targets for therapyand in turn begin to influence how

therapies can be chosen to fit thepatient’s needs in the clinic..

Away from the science CancerResearch UK organised a very livelyquestion and answer session with crossparty representation of Welsh Assemblymembers chaired by the BBC’s HealthCorrespondent Hywel Griffiths. Thissession covered a range of topics fromthe need for a cancer plan in Wales andthe roll out of the bowel screeningprogramme to views on co-payments forcancer treatment.

An Oxford Union style debate on “Alleffective treatment should be free” sawthe case for being argued for the motionby Prof Richard Sullivan of the LondonSchool of Economics and Political Scienceand Prof Gordan McVie, Managing Editorof ecancermedicalscience, CancerIntelligence, Bristol. The case against wasargued by Dr Fergus McBeth, Director ofthe National Collaborating Centre forCancer and Sir Michael Rawlins,Chairman of the National Institute forHealth and Clinical Excellence. The votefrom the chamber was for the motionbut Sir Rawlins went on to give a plenarylecture on “NICE and its role in cancercare” highlighting to the audience thatproviding the correct individualisedtreatment for patients is what would alsobe the most cost-effective and thisshould be the drive of research.

Professor Lesley Fallowfield from theSussex Psychosocial Oncology Group atUniversity of Sussex spoke on

Dennis Slamon


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 worldmedical oncology calendar, once again featured numerous

advances in several cancers with many arising from Europeanresearch. The Medical Research Council’s testicular cancer trialis a prime example. Latest findings of the trial, TE19/EORTC30982, which began in 1996, confirmed a single dose ofcarboplatin following orchiectomy is as effective as adjuvantradiotherapy in preventing disease recurrence among men withstage 1 seminoma. Tim Oliver, MD, Emeritus Professor ofMedical Oncology at St. Bartholomew's Hospital, London,presented results of the trial which randomised 573 patients tocarboplatin, administered over one hour, and 904 patients todaily radiotherapy for 2-3 weeks. After five years, cancerrecurrence rates for the two study arms were comparable (5 percent for carboplatin vs 4 per cent for radiotherapy). Patientswho received the full dose of carboplatin had a relapse-free rateof 96.1 per cent, which was identical to that of radiotherapy.Within five years, carboplatin-treated patients were also 82 percent less likely to develop a cancer in the contralateral testicle.“The rate was better than tamoxifen achieves in breast cancerand opens up the possibility of testis conservation for thesepatients,” he commented. Future studies will investigatelumpectomy and single-dose carboplatin as an option for menwith small tumours presenting early enough who wish to avoidlosing the diseased testicle. But 20 years of follow-up areneeded to examine death rates from non-germ cell cancer andheart disease and to establish the final incidence ofcontralateral tumours, he stressed.

In metastatic renal cell cancer (mRCC), there was good newson survival. Overall survival (OS) data from a randomised phaseIII study comparing first-line sunitinib (Sutent) with standardinterferon (IFN) alpha therapy in 750 previously untreatedpatients with mRCC show sunitinib extends median survival tomore than two years. Around 80 per cent had metastases attwo or more sites. This finding breaks new ground and morethan doubles survival time typically observed with IFN alphatreatment, say oncologists. Sunitininb is a multi-targetingtyrosine kinase inhibitor whose targets include vascular

endothelial growth factor and platelet derived growth factorreceptors - both implicated in tumour progression. Dr RobertFiglin of City of Hope Hospital, Duarte, California said medianOS for patients remaining on allotted therapies fromrandomisation and receiving no post-study treatment were 28months for sunitinib and 14 months for IFN alpha (p=0.0033).However, patients failing IFN alpha at pre-specified interimanalyses were crossed over to sunitinib. Overall, patientsrandomised to sunitinib had a median survival of 26.4 monthscompared to 21.8 months for those randomised to IFN alphagiving a hazard ratio of 0.82 (p<0.05). Updated efficacy datashow the median progression free survival (PFS) was 11 monthsfor sunitinib and 5 months for IFN alpha and objective responserates, according to investigators were 47 and 12 per centrespectively (p<0.000001). The data confirm sunitinib as thereference standard for first-line therapy for advanced renalcancer, 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 Lungcancer with ErbituX) trial showed a significant overall survivalbenefit for non-small cell lung cancer (NSCLC) patients whenthe epidermal growth factor receptor (EGFR) inhibitorcetuximab (Erbitux) was added to platinum-basedchemotherapy. Benefit was seen across all histologicalsubtypes, and irrespective of age, gender, smoking status andtumour size. The trial included 1125 previously-untreatedpatients with advanced (stage IIIB/IV) NSCLC and EGFR-positivetumours. All NSCLC histological types were included;adenocarcinomas represented 47 per cent and squamous cellcarcinomas 34 per cent. Almost all patients (94 per cent) hadstage IV metastatic disease and 17 per cent had an ECOGperformance status (PS) of 2. Overall, patients randomised to acetuximab / cisplatin / vinorelbine regimen survived 1.2 monthslonger than patients randomised to chemotherapy alone (11.3vs 10.1 months HR 0.87, p=0.04). One-year survival rateswere 47 and 42 per cent respectively. Lead investigatorProfessor 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 beworking with the Wales Cancer Trials Network across Wales tohelp integrate the “teams talking trials” programme intomultidisciplinary teams.

Prof Jane Maher the National Clinical Lead NHS Improvementand Chief Medical Officer from MacMillan Cancer Supporttalked about “Life after cancer treatment: a spectrum of chronicsurvivorship conditions” on issues of survivorship and livingwith cancer. This picked up from Prof Jessica Corner’s talkhighlighting the problems of long terms toxicities of cancertherapy.

In addition to the plenary lectures, sessions were held onmany research aspects including basic science, from bench tobedside, on new therapies for cancer and their evaluation inclinical trials, a translational science focus, a clinical trialssymposium, cancer immunology, palliative care and also cancerand the primary care setting.

The conference attracted a huge breadth of topics in cancer

from people’s perception of cancer to targeting cancertumours; from stem cells to evaluating the HPV vaccine todiscussions on do we need a cancer plan for Wales? Thebreadth of delegates gave a real sense of everyone pullingtogether.

The conference highlighted the issues of payment for cancertreatment, the need for an updated cancer policy in Wales andthat research should be driven by the focus on predictivegenetic markers and trial programmes incorporating molecularselection and individualisation of therapy.

The Wales Cancer Alliance and the Wales Cancer Institutewould like to thank all speakers, chairs, poster judges anddelegates and we look forward to welcoming you to the nextconference in 2010. n

More information available at:www.walescancerinstitute.co.uk


The British Association of Cancer Research(BACR), Royal Society of Medicine (RSM)

Oncology section and the Academy ofPharmaceutical Sciences of Great Britain (APSGB)are holding the second in a series of inter-disciplinary meetings on Thursday 27thNovember 2008. This one-day meeting will beheld in the Royal Society of Medicine.

The aim of these meetings is to provide anopportunity to discuss issues relating totranslational preclinical research and thechallenges for transfer of agents into the clinic.

This meeting is to be on the role of modelsystems in informing the clinical and pre-clinicaldevelopment of cancer drugs and drug/genedelivery systems, working through the challengesin taking targeted therapies forward to the clinic.Specifically we want to address the requirementfor robust biomarkers in the development oftargeted therapies and explore how informativecurrent preclinical models are in taking theseforward to the clinical setting. The day will beginwith three introductory lectures exploring theseissues from a clinical, academic and industrialperspective, followed by a panel discussion

session. Following lunch there will be a postersession in which selected posters will be chosen fordiscussion. In the afternoon there will bepresentations discussing more specific examples ofthe development of preclinical models to validatethe use of biomarkers.

Confirmed speakers: Johann de Bono (RoyalMarsden Hospital, UK), Sally Burtles (CancerResearch UK), Steve Wedge (AstraZeneca, UK),Chand Khanna (National Cancer Institute, US), BobBrown (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 MolecularMedicine) will lead panel and poster discussionsessions. We hope you will agree this is animportant area and will support this excitinginitiative by putting the date in your diary andcoming along to the meeting. n

For further information contact:Barbara Cavilla, BACR, c/o The Institute of

Cancer Research, Email: [email protected]

BACR/RSM Oncology Section/Academy of PharmaceuticalSciences 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 trialof a front-line targeted therapy to include patients withsquamous cell carcinomas, and patients who have aparticularly poor prognosis,” he pointed out.

In metastatic colorectal cancer (mCRC) there was news thatpatients whose tumours express KRAS normal or wild-typegenes have a significantly greater chance of responding to first-line targeted EGFR-inhibitor treatment as has beendemonstrated previously for second/third line therapy. Onaverage, the ratio of wild-type to mutant KRAS in mCRCtumours is 2:1. Tumours with mutant KRAS derive no benefitfrom EGFR inhibition, said researchers. Data from the 1198-patient CRYSTAL trial on 540 archived tumour tissue samplesevaluable for KRAS, found response rates for first-linecetuximab and FOLFIRI were much higher in the presence ofwild-type KRAS (59 per cent vs 43 per cent for FOLFIRI alone)and PFS was increased by 32 per cent in the cetuximab/FOLFIRIarm (HR 0.68 p=0.017). KRAS mutant tumours showed noenhanced response from adding cetuximab to FOLFIRI;response rates were 36 per cent for cetuximab/FOLFIRI and 40per cent for FOLFIRI alone and PFS was actually shorter HR1.07p=0.75. Professor Eric Van Cutsem of University HospitalGasthuisberg, Leuven, Belgium, who presented the data hailedthe findings as “a real advance”. It showed patients with wild-type KRAS had twice the chance of surviving one year withouttumour growth if they received EGFR-targeted therapyalongside irinotecan-containing therapy, he said. KRAS status oftumours 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) significantlyreduced risk of recurrence when added to hormone therapywith tamoxifen or anastrazole. After median follow-up of 60months it was found adding zoledronic acid reduced risk ofrelapse by 35 per cent. Lead investigator Michael Gnant,Professor of Surgery at Vienna University said future researchwould now focus on optimising the dosing schedule andidentifying patients who benefit most.

A British-led international trial in locally advanced ormetastatic breast cancer showed adding the anti-angiogenictherapy bevacizumab (Avastin) to taxane chemotherapy withdocetaxel (Taxotere) slows disease progression in patients withno prior chemotherapy exposure. In the AVADO trial 736patients receiving docetaxel were randomised to either placeboor one of two doses of bevacizumab (7.5 or 15mg/kg). Leadinvestigator David Miles, Professor of Medical Oncology atMount Vernon Cancer Centre, London, said after medianfollow-up of 11 months patients in the lower dosebevacizumab group were 21 per cent, and those in the higherdose group were 28 per cent, less likely to have their diseaseprogress compared to those receiving docetaxel only. Responserates were 55.2, 63.1 and 44.4 per cent respectively.Bevacizumab added limited incremental toxicity, mostlytreatable hypertension, commented Professor Miles. n

Olwen Glynn Owen, Medical Journalist.


ORBS 2008 - The first Scientific Meeting in Oncoplastic andReconstructive Breast SurgeryVenue: Nottingham, UK. Date: 22-24 September, 2008.

The ORBS meetings are aimed to give both a scientific andteaching platform for this rapidly expanding specialty. As

the surgical approaches to breast cancer surgery expand therequirements for knowledge of these new techniques expand asdoes the need for evidence based practice. The meetings willplan to span the breadth of modern oncoplastic breast cancersurgical management and is aimed at all members of themedical and nursing breast cancer surgical teams from bothbreast and plastic surgery. Teaching and presentations will be inthe full spectrum of techniques from the role of adjuvanttherapy, improved breast conservation techniques through tomicrosurgical reconstruction. This spectrum emphasises theexpanding options available and the need for broaderunderstanding and integration of teams delivering surgicalbreast cancer care.

Broaden your horizons in breast cancer surgery at ORBS2008: • IMPORTANT TOPICS & TECHNICAL DEMONSTRATIONS

FROM WORLD EXPERTS - Breast reshaping, Implant, LD andDIEP reconstruction

• HOT TOPICS - Fat Injection techniques, Advanced techniquesin breast conservation, New Implants

• DIFFICULT TOPICS - Radiotherapy strategies, Assessingoutcomes, 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 TherapeuticRadiology and Oncology Annual Congress

More than 4,500 cancer specialists from all over the world willattend a challenging, state-of-the-art programme in Göteborg thisSeptember. Over 500 presentations will highlight advances inradiotherapy and multidisciplinary approaches to the treatment of cancer.

Advances in all aspects of theuse and delivery of radiotherapyhave improved cancer care formillions of people acrossEurope, and ESTRO 27 providesthe opportunity for specialiststo publish their results anddebate critically how best toimprove care still furtherthrough:

• Teaching sessions in clinicalradiotherapy, brachytherapy,radiobiology, physics,

• Joint sessions to maximisethe use of multi-disciplinarycancer management,

• Presentation of researchresults and major break-throughs,

• Proffered papers, poster presentations and discus-sions,

• 10.000 m2 exhibition of brandnew materials, which makesESTRO 27 the largestEuropean industrial exhibi-tion in Radiotherapy.

Late registration deadlineis 22 August 2008.Details about the congressincluding programme, reg-istrations, exhibition andhotel accommodation willbe available on the websitewww.estro27.org.

For more information:ESTRO – +32 2 775 93 40 –[email protected]

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Imaging 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 imagedwith MRI. In patients with rectal cancer prior to theintroduction of MRI surgeons relied upon rectal examinationin deciding whether tumours where fixed or tethered withinthe pelvis. MRI has been shown to be accurate in both stagingof rectal tumours and in defining there relationship to themesorectal fascia. It has been shown to be an accurate tool indeciding pre-operative management and in predictingoutcome. MRI is often the first investigation orderedfollowing histological confirmation of the tumour andpatients normally have their MRI prior to being discussed inthe multidisciplinary meeting to decide upon treatment.

In this article we discuss the use of body coil MRI in imagingrectal cancer, as this is the most commonly used technique.After discussing the important anatomical landmarks within thepelvis we will look at the MRI techniques involved in acquiringthe correct sequences in the appropriate planes. We will thenfocus on the role of MRI in determining the stages of rectalcancer and look at treatment options.

The most significant advance in the management of rectalcancer has come with the development of total mesorectalexcision surgery, in which the rectum is removed along with itssurrounding mesorectum and the nodes within it. Thecircumferential margin in this procedure is the mesorectalfascia. This technique has been shown to lower the rates oflocal recurrence and improve long term survival. It is widelyaccepted as best practice. MRI has been shown to complementTME well, providing important anatomical and tumourmorphological information prior to surgery.

AnatomyThe rectum is classically divided into upper, middle and lowerthirds, each section being on average 5cm long, with the borderof the lowest section being the anal verge. The peritonealreflection extends posteriorly from the bladder to meet theanterior border of the rectum. In males this occurs between thelower and middle two thirds of the rectum but can be lower infemales. It is important to identify this structure as invasion willchange 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 tothe level of the anorectal junction. Denonvilliers fascia is afibrous band that separates the rectum from the prostate glandand seminal vesicles; it is fused with the anterior aspect of themesorectal fascia. Denonvilliers fascia is removed during totalmesorectal excision. The inferior hypogastric nerves areimportant for genitourinary function and care must be takenwhen dissecting Denonvilliers fascia as the nerves lie very closeto the mesorectum at this level. Posteriorly the mesorectal fasciameets the presacral fascia.

Ideally MRI for rectal cancer should be undertaken byexperienced radiographers with knowledge of the pelvicanatomy and correct imaging planes so that the sequencesobtained allow accurate staging. Intravenous buscopan can begiven to decrease artefact from peristalsing adjacent bowel. Inour centre the sequences listed in Table 1 are undertaken. Theimages are normally checked by the supervising consultantradiologist and further sequences can be done as necessary.Initial wide field of view sagittal imaging delineates the lengthof the tumour and allows planning of the small field of viewimages. The axial small field of view images are performedperpendicular to the long axis of the rectum. These images arethe most useful when looking at the relationship of the tumourto the mesorectal fascia. Coronal imaging is frequently used inlooking at low rectal tumours and in determining theirrelationship with the anus. The axial T1 images of the wholepelvis are helpful in identifying involved lymph nodes andmetastatic bone involvement.

Body coil MRI has been shown to be accurate in T staging ofrectal cancers. It is difficult to usefully delineate early T1 and T2stage tumours but it is an accurate technique for assessment ofthe more advanced tumours in the T3 and T4 categories ofdisease. CT is routinely used to look for more distantmetastases within the chest or abdomen (typically liver).

T1 tumours are limited to the sub-mucosa and account forapproximately 10% of all rectal cancers. Body coil imaging asdescribed here is not the optimal imaging to discern T1 from T2disease, if local excision rather than TME is being considered.In this case endoluminal imaging either with ultrasound orendoanal coil MRI is more appropriate. Until relatively recentlyit was felt that curative treatment of low risk, that is withoutevidence of neurovascular invasion or poorly differentiatedtumours, could be achieved with local excision but more recentpapers have shown that there remains a significant risk of localrecurrence and that perhaps more radical surgery should beundertake 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 IrelandCancer Centre, Belfast Trust.

Dr T

om L

ynch

Introduction to the use of MRI in Staging of RectalCancer

MRI TechniqueWFOV 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


T2 tumours extend to the muscularispropria, but not beyond it. T3 tumours cango as far as the mesorectal fascia, but donot invade other organs or the pelvicsidewall. T2/T3 tumours are the mostcommon and it is in these patients thatradical surgery, based on total mesorectalexcision is undertaken. Involvement of thecircumferential resection margin, or tumourwithin 1mm of it. has a high predictivevalue for local recurrence and long termsurvival. The mesorectal fascia forms thecircumferential margin in total mesorectalexcision and as this can be clearly seen onMRI, this technique is ideal in pre-operatively staging these patients. Somestudies now advocate the use of pre-operative radiotherapy or chemotherapy inpatients with known involvement of themesorectal fascia prior to surgery, withfindings showing that this can both down-stage the tumour and reduce the incidenceof local recurrence. MRI can be used torestage tumours following treatment withchemo/radiotherapy, but this is not asaccurate as staging without treatment. MRIoverestimates the stage in these patients,having difficulty differentiating betweentumour and changes related to tumourtreatment.

T4 tumours invade adjacent organs or thepelvic sidewall. More radical multivisceralresection may be considered for thesepatients, although again pre-operativetreatments with radio/chemotherapyshould be given.

Lymph nodes down to approximately3mm can be detected using body-coil MRI.Nodes smaller than this, although not seenon MRI, are virtually never infiltrated withtumour. Lymph node staging using MRI hastraditionally used size as the main factor indetermining nodal involvement, howeverdifferent centres use between 5 and 10mmas there cut-off point for normal. Theevidence suggests that most lymph nodes over 8mm are likelyto be involved. It is important to consider that enlarged nodesthat border close to the mesorectal fascia likely threaten theCRM. The absence of detectable lymphadenopathy on MRI hasa strong predictive value that no positive nodes will be seen inthe histological specimen. This has led other authors to look atother features of the lymph nodes. The presence of an irregularborder and/or signal heterogeneity increases the probabilitythat the node is involved. MRI scanning following injection ofiron oxide particles has been shown to increase the detection ofinvolved lymph nodes, although this is not as yet used inroutine practice.

Figure 1 is an axial T2 image demonstrating a T2 tumour.Tumour material is contained within the muscularis propriawhich is appreciated as a smooth darker line surrounding therectum (asterisk). The mesorectal fat surrounding the rectum isnormal and contains a few tiny nodes. The mesorectal fascialline is shown as a thin dark line surrounding the fat

(arrowheads). Seminal vesicles are seenanteriorly (arrow).

Figure 2 is an axial T2 image showing a T3tumour with disruption of the muscularispropria indicating extension into mesorectalfat as indicated by loss of dark line (arrow).There is an enlarged lymph node in themesorectal fat (arrowhead). Neither thetumour material or node is close to themesorectal fascial line and hence anticipatedcircumferential resection margins are clear.

Figure 3 is an axial T2 image showing a T3tumour with a tongue of tumour extending outthrough mesorectal fat to contact themesorectal fascial line and hence threaten thecircumferential resection margin (arrow).

Figure 4 is a sagittal T2 imagedemonstrating a tumour of the upper third ofthe rectum which extends out of themesorectum to involve peritoneal reflectionand hence represent T4 disease (arrows).Enlarged nodes are also seen (arrowheads).Multiplanar examinations allow betterappreciation of anatomical extent of localdisease.

ConclusionAll patients with rectal cancer in whomsurgery is being considered should have anMRI unless contraindicated, i.e. permanentpacemaker in situ. Body-coil imaging can bedone well in different centres if standardsequences and planes are used. It has beenshown to be well tolerated by patients andaccurate in assessment of relevant T and Nstaging and of tumour proximity to routinecircumferential resection margins. Once theseare established the multidisciplinary teamcan decide whether to undertake pre-operative treatment and then proceed tosurgery if appropriate. The MRI will allow theoperating surgeon to plan the approach to thetumour and alert them to where the tumourmay come close to their resection margin. n

Suggested readingMERCURY Study Group. Diagnostic accuracy of magnetic resonance imaging inpredicting surgical resection margin status: prospective observational study. BMJ2006;333: doi:10.1136/bmj.38937.646400.55Madbouly KM, Remzi FH, Erkek BA, Senagore AJ, Baeslach CM, Khandwala F, FazioVW, Lavery IC. Recurrence after transanal excision of T1 rectal cancer: should we beconcerned? 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-spatialresolution 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 fornodal staging in rectal cancer: are there any criteria in addition to the size? Eur J Radiol2004;52:78–83.Hermanek P, Heald RJ. (2004) Pre-operative radiotherapy for rectal carcinoma? Has thecase really been made for short course pre-operative radiotherapy if surgical standardsfor rectal carcinoma are optimal? Colorectal Disease 2004;6(1):10–4. doi:10.1111/j.1463-1318.2004.00569.xSebag-Montefiore D, Steele R, Quirke P, et al. Routine short course pre-op radiotherapyor selective post-op chemoradiotherapy for resectable rectal cancer? Preliminary results ofthe MRC CR07 randomized trial. Proc Am Soc Clin Oncol. J Clin Oncol2005;24(Suppl):148s abstract 3511.Lahaye MJ, et al. USPIO-enhanced MR imaging for nodal staging in patients withprimary rectal cancer: predictive criteria. Radiology. 2008 Mar;246(3):804-11. Epub2008 Jan 14.Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery: the clue topelvic recurrence? Br J Surg. 1982;69:613-6.

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Diary of Events2008

AugustInternational Conference on Headand Neck Cancer9-13 August, 2008; San Francisco, USAAmerican Head & Neck Society Tel: +1 (310) 437-0559 Web: www.headandneckcancer.org

International Union Against CancerWorld Cancer Congress27-31 August, 2008; Geneva,SwitzerlandWorld Cancer Congress 2008 Tel: +41 22 809 1811 Fax: +41 22 809 1810 Web: www.uicccongress08.org

Breast Cancer Current Therapeutics28 August, 2008; London, UKWeb: www.mahealthcareevents.co.uk

SeptemberFoundations in Cancer OncologyModule (Level 2 or 3)1 September, 2008; Clatterbridge, UKEmail: [email protected]

Influences on Cancer CareOncology Module (Level 2 or 3)1 September, 2008; Clatterbridge, UKEmail: [email protected]

Care of the Patient RequiringChemotherapy (Leve1 2 or 3)1 September, 2008; Clatterbridge, UKEmail: [email protected]

Oncology Course for Allied HealthProfessionalsModule 1: An Introduction toOncology for AHPs RADT 5001 September, 2008; Clatterbridge, UKEmail: [email protected]

NEWSymptom Management in PalliativeCare for Healthcare Professionals5 September, 2008; Tamworth, UKBarbara Hirons Tel: 01883 832664Email:[email protected]

11th European Worksop onCytogenetics and MolecularGenetics of Solid Tumours6-9 September, 2008; Bilbao, SpainWeb: www.cicbiogune.es/congreso/congreso1_CMGST/index.php

14th European Society of SurgicalOncologists10-13 September, 2008; The Hague,the NetherlandsESSO 2008 Conference secretariat,Federation of European CancerSocieties Tel: +32 (0)2 775 02 05Fax: +32 (0)2 775 02 00Email: [email protected]

Improve Your CommunicationsSkills11-12 September, 2008; Glasgow, UKEmail: [email protected]

33rd ESMO Congress12-16 September, 2008; Stockholm,SwedenEuropean Society for MedicalOncology Tel: + 41 (0) 91 973 19 19 Email: [email protected] Web: www.esmo.org

NEWPalliative Care for Non-MalignantConditions for HealthcareProfessionals16 September, 2008; Stevenage, UKBarbara Hirons Tel: 01883 832664Email:[email protected]

Gynaecological Cancer Study Day17 September, 2008; London, UKTel: 020 7808 2921 Email: [email protected]: www.royalmarsden.nhs.uk

NEWEssentials in Palliative Care forHealthcare Professionals17-18 September, 2008;Southampton, UKBarbara Hirons Tel: 01883 832664Email:[email protected]

NEWPalliative Care in Action forHealthcare Professionals23 September, 2008; Tiverton, UKBarbara Hirons Tel: 01883 832664Email:[email protected]

Oncoplastic & ReconstructiveBreast Surgery Meeting23-24 September, 2008; Nottingham,UKEmail: [email protected]: www.orbs2008.com

Living with cancer study day24 September, 2008; Middlesex, UKAnni Hall Tel: 01923 844177 Fax: 01923 844172Email: [email protected]

BTOG Small Cell Lung Cancer(SCLC) Study Day 200825 September, 2008; Manchester, UKWeb: www.btog.org

OctoberBreast Cancer Awareness Month1-31 October, 2008.www.breakthrough.org.uk

MAGIC for Nurses Education Day3 October, 2008; London, UKTel: 0131 557 3332 Web: www.myeloma.org.uk

British Lymphology Society AnnualConference – Lymphoedema:Alternative Pathways5-7 October, 2008; Belfast, UKWeb: www.thebls.com

NCRI Cancer Conference 20085-8 October, 2008; Birmingham, UKSharon Vanloo Tel : +44 (0)20 7269 3420 Email: [email protected]

American Society for TherapeuticRadiology and Oncology, AnnualMeeting5-9 October, 2008; Baltimore, USAASTRO Tel: +1 (800) 962-7876, (703) 502-1550 Web: www.astro.org

End of Life Issues in Cancer CareStudy Day9 October, 2008; Clatterbridge, UKEmail: [email protected]

Royal Marsden Palliative CareUpdate Day10 October, 2008; London, UKTel: 020 7808 2921 Email: [email protected]: www.royalmarsden.nhs.uk

Annual Meeting of the AmericanCollege of Surgeons12-17 October, 2008; San Francisco,USAConvention and Meeting Division,American College of Surgeons Tel: +1 (312) 202-5244 Web: www.facs.org

Advanced Chemotherapy Study Day15 October, 2008; London, UKTel: 020 7808 2921 Email: [email protected]: www.royalmarsden.nhs.uk

NEWLocal Training Seminar - Rare sce-narios within breast cancer16 October, 2008; Southampton, UKKylie Vilcins Tel: 0845 092 0802

11th Annual BOPA Symposium17-19 October, 2008; Liverpool, UKWeb: succinctcomms.com

8th International Conference ofAnticancer Research17-22 October 2008; Kos, Greecewww.iiar-anticancer.org/

Lymphoedema: Diagnosis,Assessment & Prevention ofComplications21-24 October, 2008; Glasgow, UKKaren Hegyi or Margaret Sneddon,Tel: 0141 330 2072/2071Email: [email protected]: www.gla.ac.uk/schools/nursing/lymphoedema

20th EORTC-NCI-AACRSymposium on “Molecular Targetsand Cancer Therapeutics”21-24 October, 2008; Geneva,Switzerland20th EORTC – NCI- AACRSymposium Secretariat, Federation ofEuropean Cancer Societies, Tel: +32 (0)2 775 02 01, Fax: +32 (0)2 775 02 00, Email: [email protected]

Female Cancers study day22 October, 2008; Middlesex, UKAnni Hall Tel: 01923 844177 Fax: 01923 844172 Email: [email protected]

NEWDrug Therapy in Palliative Care forHealthcare Professionals23 October, 2008; Caterham, UKBarbara Hirons Tel: 01883 832664Email:[email protected]

Frenchay Breast Ultrasound Coursefor Surgeons30-31 October, 2008, Bristol, UKTel: 0117 9753753 Email: [email protected]

Managing Oedema due to AdvancedDisease30-31 October, 2008; Glasgow, UKKaren Hegyi or Margaret Sneddon,Tel: 0141 330 2072/2071 Email: [email protected]: www.gla.ac.uk/schools/nursing/lymphoedema

NovemberLung Cancer Awareness Month1-30 November, 2008.Web: www.lungcanceralliance.org

Joint ABS at BASO & BASO ~ ACSScientific Conference3-4 November, 2008; London, UKEmail: [email protected]: 020 7405 5612 Web: www.baso.org.uk

Influencing policy, changing prac-tice: Improving the care of peoplewith metastatic breast cancer4 November, 2008; London, UKJan Hannell Tel: 0845 092 0802 Email: [email protected] Web: www.breastcancercare.org.uk/stfc

Chemotherapy FoundationSymposium5-8 November, 2008; New York City,USAThe Mount Sinai Medical Center Tel: +1 (212) 241-6772 Web: www.mssm.edu/tcf

Staff Nurse Study Day7 November, 2008; London, UKTel: 020 7808 2921 Email: [email protected]: www.royalmarsden.nhs.uk

NEWPalliative Care in Action forHealthcare Professionals10 November, 2008; Worcester, UKBarbara Hirons Tel: 01883 832664Email:[email protected]

If you would like an event listed in the Oncology News diary please send the relevant information to email [email protected] by September 5th, 2008.


29-30 September 2008International Federation of Head and Neck OncologicSociety (IFHNOS) World Tour: London Conference 2008£300 (participants) • £250 ( Trainees)The Royal Society of Medicine, 1 Wimpole Street, London W1G 0AE

03 October 2008The 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 2008Update on Aspects of Diagnosis and Management in Malignant Haematology£75The Royal Marsden Education and Conference Centre, Fulham Road,London SW3 6JJ

29 January 2009A 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/studydaysor contact The Royal Marsden Education and Conference Centre: Tel: 020 7808 2921 Fax: 020 7808 2334Email: [email protected]

The Royal Marsden NHS Foundation Trust

Organised by

Institute of Physics, London, W1Thursday 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 websitewww.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 Cancer

A 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 Physiotherapists10 November, 2008; London, UKTel: 020 7808 2921 Email: [email protected]: www.royalmarsden.nhs.uk

Nature of Cancer Course10-17 November, 2008;Clatterbridge, UKEmail: [email protected]

Management & Use ofPICC/Hickman & Port Lines11 November, 2008; Middlesex, UKAnni Hall Tel: 01923 844177 Fax: 01923 844172 Email: [email protected]

British Gynaecological CancerSociety Scientific Meeting 200812-14 November, 2008; Liverpool,UKEmail: [email protected]

NEWPain Management in Palliative Carefor Healthcare Professionals13 November, 2008; London, UKBarbara Hirons Tel: 01883 832664Email:[email protected]

14th Annual CTOS Meeting13-15 November, 2008; London, UKwww.ctos.org/

Haemato-Oncology Study Day14 November, 2008; London, UKTel: 020 7808 2921 Email: [email protected]: www.royalmarsden.nhs.uk

NEWBreast Cancer Study Day18 November, 2008; Newmarket, UKBev Johnson Tel: 01223 596627 Email: [email protected]

NEWCancer: Nature; Treatment andImpact for All21 November, 2008; Stevenage, UKBarbara Hirons Tel: 01883 832664Email:[email protected]

International Conference LearningFrom The Past, Influencing TheFuture24-25 November, 2008; Liverpool,UKEmail: [email protected]

Lymphoedema In Breast CancerPatients27 November, 2008; London, UKTel: 020 7830 2323 Fax: 020 7830 2324 Email: [email protected]

RCN Breast Cancer Care NursingSociety Conference and Exhibition,One size doesn’t fit all28 November, 2008; London, UKEmail: [email protected]: www.rcn.org.uk/events

December50th ASH Annual Meeting andExposition6-9 December, 2008; San Francisco,USAAmerican Society of Hematology Tel: +1 (202) 776-0544 Email: [email protected] Web: www.hematology.org

Bowel Cancer Study Day10 December, 2008; Clatterbridge,UKEmail: [email protected]

Lymphoedema: Assessment andManagement10-12 December, 2008; Glasgow, UKKaren Hegyi or Margaret Sneddon,Tel: 0141 330 2072/2071 Email: [email protected]: www.gla.ac.uk/schools/nursing/lymphoedema

San Antonio Breast CancerSymposium11-14 December, 2008; - SanAntonio, TXRich Markow, Symposia Director,CTRC/Breast Cancer Symposium Tel: +1 (210) 616-5912 Web: www.sabcs.org

NEWCancer: Nature; Treatment andImpact for All18 December, 2008; Stevenage, UKBarbara Hirons Tel: 01883 832664Email:[email protected]

2009

JanuaryPREVENT (Prediction,Recognition, Evaluation andEradication of Normal Tissueeffects of radiotherapy)11-12 January, 2009; Brussels,BelgiumWeb: www.estro.be/estro/index.cfm

Clatterbridge Centre for OncologyNHS Foundation Trust and theRoyal College of Nursing AnnualNational Conference23-24 January, 2009; Chester, UKContact [email protected]: www.rcn.org.uk/events

NEWLymphoedema: Diagnosis,Assessment & Prevention ofComplications27-30 January, 2009; Newcastle, UKKaren Hegyi or Margaret Sneddon,Tel: 0141 330 2072/2071 Email: [email protected]: www.gla.ac.uk/schools/nursing/lymphoedema

NEWPalliative Care for Non-MalignantConditions for HealthcareProfessionals28 January, 2009; Caterham, UKBarbara Hirons Tel: 01883 832664Email:[email protected]


Dates to rememberMonday 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 leadingexperts from all cancer research disciplines.

Confi rmed 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: [email protected]

SECOND WORLD CONGRESS OF THE INTERNATIONAL ACADEMY OF ORAL ONCOLOGY (IAOO)

Toronto, Canada July 8–11, 2009

ORAL ONCOLOGYIMAGINE 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 EconomicsMolecular Biology and GeneticsDiagnosis, Staging and PrognosisPathologySurgeryRadiotherapy and Combined TreatmentsChemotherapy, Immunotherapy, Alternative and Future TreatmentsReconstructionDental Rehabilitation and Quality of LifeRecurrences, Metastasis, Nursing and Terminal Care.

Enquiries: Janet Seabrook. Tel: +44 1865 843691 Email [email protected]

Courses & Conferences

The BTOG Small CellLung Cancer (SCLC)

Study Day 2008

DateThursday 25th September

2008Venue

Education Centre, ChristieHospital, 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 thesecretariat

7th Annual BTOGMeeting 2009

DatesWednesday 28th January

2009 toFriday 30th January 2009

VenueClontarf 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 allareas 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 SecretariatDawn 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 2502810Email: [email protected] • www.BTOG.org

ANNOUNCEMENT


Web ReviewWeb Review is compiled by Heidi Sowter, who is a lecturer in Forensic andBiological Science at Derby University, where she continues to pursue herresearch interests in gynaecological and breast cancer. Heidi aims to analyse, inform and encourage enhanced online activity and creativitywithin the oncology profession. Submit your comments, suggestions orwebsite details for review by email to: [email protected]

Dr Heidi SowterLecturer in Forensic Science and BiologyFaculty of Education, Health and ScienceUniversity of Derby.

Today’s featured website isecancermedicalscience, founded by

the European Institute of Oncology inMilan, the home of an independentonline journal that (refreshingly) featuresopen access cancer journals. Scientistsare able to submit articles online whichare then fully peer-reviewed beforebeing published immediately onacceptance. With Open Accesspublishing a reality and an urgent needfor improved cancer communications,ecancermedicalscience fits the 21stcentury bill for a cancer journal. Theirvision is to create a free future; free topublish, free to read and free tocomment. The articles section is easy tonavigate, and papers are listed in variousways (for example, research, conferencereports, most viewed) to ease searching.Another way in which this websitestands out is by providing an ecancer.tv service, through whichyou can watch, amongst other things, live surgery, new imagingtechniques and interviews from their editorial board. Aneducational programme is also offered via a collaboration withthe UK Key Advances in Clinical Practice Series. This is a series of

symposia and masterclasses runin association with King's CollegeLondon, and links to severalspeakers who discuss thecurrently available scientificevidence and expert clinicalopinion for the prevention,investigation and managementof different cancers.

The Key Advances educationalprogrammes are webcast onecancermedicalscience and areavailable to watch, free ofcharge, at any time. Currenttopics listed are Key Advances inthe Effective Management ofThyroid and Head and NeckCancer, and other educationalinitiatives will be forthcoming.You need to register to accessthese services, although (being a

member myself), I can recommend the news email that keepsyou up-to-date with latest developments. Thanks to online,multimedia technology and a community poised to podcast andblog, ecancermedicalscience offers a multimedia andmultidisciplinary 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 [email protected] 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, [email protected]

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 reviewerWe look forward to seeing you there!For further information contact Patricia on 0288 289 7023or [email protected]

Come and see us...2008ESMO September, StockholmESTRO September, GothenburgNCRI October, Birmingham

2009IAOO July, TorontoNCRI October, Birmingham


Society News

The ECCO-ESMO Collaboration: A Powerful Force in CombatingCancer

Bridging the bench to bedside gap and the widelyaccepted approach of mulitdisciplinarity are pivotal inadvancing research and improving patient treatment

and care. The actual reality in the implementation and measurable

outcomes of both ideals generally translates into palpabledebate between professional specialties and communities. Inthe relentless battle to eliminate cancer much more can - andwill - be done.

The recently announced collaboration between ECCO – theEuropean CanCer Organisation, and ESMO, the EuropeanSociety for Medical Oncology, was happily received by theoncology community as a turning point in uniting forces,efforts and professionals across Europe.

The win/win spinECCO exists to both uphold the right of all European cancerpatients to the best possible treatment and care and promoteinteraction between all organisations involved in cancerresearch, education, treatment and care. ESMO represents oneof the most implicated specialties in such interaction sincemedical oncology demands a scientific and academic base, avision toward developing and evaluating novel treatmentmethodologies, and an involvement in total cancer care.

To deliver on multidisciplinarity and provide equal access toquality care, neither ECCO nor ESMO can stand alone - a realitythat has connected the two in unison. ESMO’s membership inECCO represents a further step forward in shaping a unitedfront – the convergence of specialty organisations that sharethe same determination to uphold a coherent, concise andharmonised approach to tackling the second leading cause ofdeath in Europe.

A mass gathering of cancer science, treatment andtechnologyOne critical outcome of the ECCO-ESMO collaboration has beenthe paring of the two leading educational opportunities inEuropean oncology: ECCO and ESMO Congresses. By fusingexcellence and expertise, the joint ECCO and ESMOMultidisciplinary Congresses are set to draw record attendance

through all-encompassing comprehensive programmes of thehighest calibre.

Setting the standard for congresses to come, the first ECCO-ESMO Congress will take place in Berlin, Germany, 20-24September 2009.

An organised approach to oncopolicyEfforts aimed at strengthening oncopolicy will only succeed bystanding united. Heterogeneity will fail. Cancer naturally posesa challenge in this respect since, unlike many other fields, itincorporates a multiplicity of interrelated disciplines. The timeto get organised is now.

ESMO’s membership in ECCO will be crucial in road mappingthe collective campaign to create awareness of patients’ needsand encourage progressive thinking in cancer policy, trainingand education at the EU level. Never before has the oncologycommunity been better situated to improve care and researchinteractivity across Europe.

Alexander MM Eggermont and José Baselga.

We would like to publish information on other societies and associations infuture issues of Oncology News. If you’d like your association consideredfor this feature please send details to [email protected]

Alexander MM Eggermont and José Baselga.


News updateLatest developments on products and services from the industry. To have your news included contact Grant Mackie [email protected] or Tel/Fax: +44 (0)288 289 7023.

Cancer patients in eastern France now haveaccess to advanced image-guided radiotherapytreatments with the arrival of the first Trilogy®

linear accelerator in the country. The treatmentmachine has been unveiled by French healthminister Roselyne Bachelot in a specialinauguration ceremony.

Professor Philippe Maingon, head of radiationoncology at the Georges-François Leclerc CancerCenter in Dijon, said, “We were honoured thatthe health minister was able to attend ourunveiling ceremony and acknowledge the vitalrole of radiotherapy in treating cancer patients.”Carrying out the opening ceremony, Madame

Bachelot praised the work of the Georges-FrançoisLeclerc Cancer Center and reiterated radiotherapy'sstatus as a key weapon in the battle against cancerin France.

The Trilogy device is the hospital’s third Varianlinear accelerator. “The Trilogy enables us to carryout very precise image-guided stereotactictreatments in addition to our established programof intensity-modulated radiotherapy (IMRT)treatments,” said Professor Maingon.

For further information contact: Neil Madle, Varian Medical Systems, Tel: +44 7786 526068, Email: [email protected]

BMI, The London Independent Hospital, hasinstalled the UK’s first SOMATOM Definition AS+CT scanner from Siemens. The system is one of theworld’s first adaptive scanners that not onlyprovides exceptional image quality but is suited toany patient, from paediatric to bariatric, or anyclinical need. Without exclusions, the AS+ makescomplex examinations routine.

The SOMATOM Definition AS+ is an expert incardiac imaging obtaining extremely fast coveragewith 128 slices per rotation. With a temporalresolution of 150ms, images are free frommovement artefacts and show the finestanatomical details.

“Currently 64-slice CT scanners are the gold

standard, so a 128-slice adaptive scanner couldbe considered platinum,” said Dr CharlesBlakeney, Consultant Radiologist at BMI LondonIndependent Hospital. “With the SOMATOMDefinition AS+ CT, we are able to offer the peopleof East London access to one of the mostadvanced CT scanners in the country. Patients canbe assured that we are employing some of thelatest, fastest and safest CT technology to quicklydetermine their best course of personalisedtreatment and care.”

For more information contact: Siemens, Tel: +44 (0)1276 696000, Email: [email protected] 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 designedas an Elekta internal training aid, however,Elekta are now making this exciting platformavailable for general view. The clinic, availablevia http://www.elekta.com/evc allows the userto follow the course of treatment for a patientundergoing lung treatment, from initialconsultation, treatment planning, radiationtreatment all the way through to completion inthe MOSAIQ® patient management system.

Alternatively, it is possible to ‘fly over’ andzoom in to find out more about specific

treatment tools, such as Elekta Synergy®. Alsoavailable is an auditorium to view movies and a

library which contains case-studies andtreatment protocol papers.

Voice over commentary guides usersthrough various parts of the clinic and furtherfunctionality and content, including a focus onElekta VMAT* are planned in the future. Elektaare inviting all interested parties to visitwww.elekta.com where they can view ordownload the entire clinic and leave feedbackvia 'Send a Comment'.

For further information please contactEmail: [email protected]

One of Denmark’s leading cancer centers has placed anorder for three new treatment machines and nineadvanced RapidArc™ volumetric arc therapy systems fromVarian Medical Systems, the world leader in radiotherapy.Aarhus University Hospital plans to have RapidArc installedon all nine of its Clinac® linear accelerators.

The order is the latest wave of a multi-year investmentprogram by Aarhus University Hospital to consolidate allradiotherapy hardware and software in an integratedsystem. Two of the additional treatment machines will beinstalled at a new radiotherapy center being constructedalongside 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 theefficiency gains that RapidArc will bring, which will meanwe can treat more people with advanced techniques in lesstime. We have a roadmap for replacing all our oldermachines and introducing image-guided radiotherapythroughout the department, and this order means we areon course to achieve this goal.”

For further information contact:Neil Madle, Varian Medical Systems, Tel: +44 7786 526068, Email: [email protected]

The health minister being given an overview of theTrilogy by Professor Maingon.

Siemens’ SOMATOM Definition AS+ CT adapts toeach patient to provide fast image acquisition, 4Dhigh quality scans and low radiation exposure.

Varian products ordered by leading Danish cancer center

Elekta announce global launch of Virtual Clinic


The University of Bradford’s Chancellor, ImranKhan, recently opened its new Institute ofCancer Therapeutics (Thursday 17 July 2008).

To mark the event, Imran also announced anew three-year student scholarship that will see aresearcher from his own Shaukat KhanumMemorial Hospital come to Bradford to do a PhD.

Imran said: “This scholarship is vitallyimportant. Pakistan has almost twice as manypeople than here yet only one specialist cancerhospital and research centre which is why sucha partnership will be a great help to us.”

Director of the Institute of CancerTherapeutics, Professor Laurence Patterson,said: “This official opening will let people know

we’re in the business of anti-cancer drugdiscovery and we’re open for business.”

Research themes at the Institute include thedevelopment of new molecules and describethree broad stages of medicine development:discovery, pre-clinical evaluation and clinicalapplication.

It costs over £3 million a year to fund thework of the Institute, supported mainly byYorkshire Cancer Research as well as grantsfrom research councils, Government andindustry.

For more information about the Institute ofCancer Therapeutics, visit: Web: www.cancer.brad.ac.uk

Imran Khan opens Bradford’s new cancer research centre

Three Novalis Tx radiosurgery platforms orderedby top Danish cancer hospitalVarian Medical Systems(NYSE: VAR) and BrainLABAG are announcing that oneof Scandinavia’s leadingcancer centres has orderedthree Novalis Tx™radiosurgery platforms whichcombine the most advancedtechnologies from bothcompanies to offer superiornon-invasive radiosurgery forpatients.

Rigshospitalet in Copenhagen has orderedtwo new Novalis Tx radiosurgery platforms andthe associated suite of accessories and willupgrade an existing BrainLAB Novalis device tothe more advanced new generation Novalis Tx.All three machines will be equipped with Varian’sRapidArc™ radiotherapy technology for image-guided, intensity-modulated radiotherapy (IMRT)treatments, meaning seven treatment machinesat the hospital will have this new capability. Theywill also include the BrainLAB ExacTrac® X-Ray 6D

imaging system and theVarian On-Board Imager® forprecise patient positioning.

Dr Svend Aage Engelholm,chief radiation oncologist ofthe Department of RadiationOncology at CopenhagenUniversity Hospital(Rigshospitalet), stated thatRigshospitalet has a longtradition of carrying out high-precision radiotherapy

treatments and is one of the two leadinghospitals in Denmark for stereotacticradiosurgery. The hospital was the first inScandinavia to introduce IMRT treatments andwas also the region’s first hospital to offerimage-guided radiotherapy (IGRT) as a routinepreferred treatment for a number of cancerindications.

For further information contact: Neil Madle,Varian Medical Systems, Tel: +44 7786 526068,Email: [email protected]

Oncology Imaging Systems Ltd. is introducing anew superficial radiotherapy system for thetreatment of skin cancer this year,manufactured by TOPEX Inc. The TOPEX SRT100™ System has been specifically designed tomeet the increasing number of skin cancercases diagnosed each year, offering a superiornon-surgical treatment.

The TOPEX SRT 100™ System is a compact,mobile, productive and cost effective solutionfor the non-surgical treatment of skin cancer.Created in consultation with the medicalcommunity, this system has a footprint of just30” x 30” and a broad range of motion (bothhorizontal and vertical) to allow the patient tobe treated either sitting or lying down. Thereduction of set-up procedures, ease of use andreduced installation and operational costs,provides maximum system up-time and greatlyimproves a clinic’s productivity and scheduling,whilst providing all patients with a considerablybetter, broader and more efficient treatmentmethod.

For more information on the TOPEX SRT100™ System and all other patientpositioning and immobilisation devices, pleasecontact Oncology Imaging Systems Ltd, Tel: 01825 744 063, Fax: 01825 749 557,Email: [email protected] Web: www.oncologyimaging.com

OIS adds skin cancertreatment system toportfolio

Chancellor, Imran Khan and Director of the Instituteof Cancer Therapeutics, Professor Laurence Patterson.

The Japanese Ministryfor Health, Labour andWelfare, MHLW, hasgiven approval forLeksell Gamma KnifeRPerfexionT, whichElelkta claim is theworld-leading clinicalsolution for non-invasive radiosurgicaltreatments of tumors,vascular malformationsand other brain disorders. Elekta, theinternational medical technology group anddeveloper of Gamma KnifeR surgery, will nowbe able to deliver and install this advancedtechnology at new and existing customer sites inJapan.

Gamma Knife surgery has become the world'smost widely used radiosurgery treatment due toits extraordinary accuracy, reduction of excessradiation dose to the body, extensive history and

clinical documentation.Unlike other systems,invoking compromisesin order to be able totreat the whole body,Leksell Gamma Knife isspecifically designed tooptimize treatment tothe head and neck area -a fact appreciated byneurosurgeons andpatients alike.

Launched by Elektain 2006 and now in clinicaluse in over 30 locations around the world, Elektaclaim the Leksell Gamma Knife Perfexioncombines the proven precision of therevolutionary Leksell Gamma Knife, with adramatic increase in clinical reach to treat awider range of targets faster and more efficientlythan ever before.

For further information please contactEmail: [email protected]

Leksell Gamma Knife® Perfexion™ receives regulatory approval In Japan

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

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Volume 3 Issue 2 :August/September 2008

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