ACR Appropriateness Criteria® definitive therapy for early-stage cervical cancer.

OBJECTIVES: The definitive treatment of early-stage cervical cancer involves multidisciplinary decision making. This expert panel was convened to reach consensus on the selection of appropriate therapies based on patient and disease characteristics at presentation. METHODS: The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or the treatment. RESULTS: Three clinical variants were developed to represent common scenarios in the treatment of early-stage cervical cancer. Group members reached consensus on the appropriateness of therapeutic options. This process yielded numerical ratings and descriptive commentary. CONCLUSIONS: This manuscript represents the consensus opinion of an expert panel based on a survey of all available medical literature. This manuscript may be used to inform the clinical decision making of physicians involved in the treatment of early-stage cervical cancer.

Comparing central nervous system (CNS) and extra-CNS hemangiopericytomas in the Surveillance, Epidemiology, and End Results program: analysis of 655 patients and review of current literature.

BACKGROUND: Hemangiopericytomas (HPCs) are rare tumors in the central nervous system (CNS) and in extra-CNS sites. The authors of this report used the Surveillance, Epidemiology, and End Results (SEER) Program to study prognostic factors in patients with HPC. METHODS: The SEER database was analyzed for patients who were diagnosed with HPC tumors from 1973 to 2007. Patients were stratified into CNS and extra-CNS groups. Univariate and multivariate analyses were performed for the overall survival (OS) endpoint using major demographic factors (age, race, and sex) and disease factors (tumor site). RESULTS: In total, 655 patients with HPC were stratified into a CNS group (n = 199) and an extra-CNS group (n = 456). The patients with extra-CNS HPC were statistically older (mean age, 53 years vs 49 years; P = .008) and were more likely to have larger tumors (median greatest dimension, 7.0 cm vs 5.2 cm; P < .001). Patients who had CNS tumors had better OS and cause-specific survival (CSS) compared with patients who had extra-CNS tumors (P < .001 for both). Negative predictors of OS on multivariate analysis included extra-CNS tumor site (hazard ratio [HR], 1.6; P = .005) and older age (ages 40-59 years: HR, 2.08; P = .032; ages 60-79 years: HR, 3.9; P < .001; aged ≥80 years: HR, 7.7; P < .001). CONCLUSIONS: The current analysis demonstrated that patients with extra-CNS HPCs had worse OS and CSS than patients with CNS HPCs.

Cancer prevention with natural compounds.

Botanical and nutritional compounds have been used for the treatment of cancer throughout history. These compounds also may be useful in the prevention of cancer. Population studies suggest that a reduced risk of cancer is associated with high consumption of vegetables and fruits. Thus, the cancer chemopreventive potential of naturally occurring phytochemicals is of great interest. There are numerous reports of cancer chemopreventive activity of dietary botanicals, including cruciferous vegetables such as cabbage and broccoli, Allium vegetables such as garlic and onion, green tea, Citrus fruits, soybeans, tomatoes, berries, and ginger, as well as medicinal plants. Several lead compounds, such as genistein (from soybeans), lycopene (from tomatoes), brassinin (from cruciferous vegetables), sulforaphane (from asparagus), indole-3-carbinol (from broccoli), and resveratrol (from grapes and peanuts) are in preclinical or clinical trials for cancer chemoprevention. Phytochemicals have great potential in cancer prevention because of their safety, low cost, and oral bioavailability. In this review, we discuss potential natural cancer preventive compounds and their mechanisms of action.

Update on clinical trials of growth factors and anabolic steroids in cachexia and wasting.

This article and others that focused on the clinical features, mechanisms, and epidemiology of skeletal muscle loss and wasting in chronic diseases, which include chronic kidney disease, cancer, and AIDS, were presented at a symposium entitled "Cachexia and Wasting: Recent Breakthroughs in Understanding and Opportunities for Intervention," held at Experimental Biology 2009. The clinical and anabolic efficacy of specific growth factors and anabolic steroids (eg, growth hormone, testosterone, megestrol acetate) in malnutrition and other catabolic states has been the subject of considerable research during the past several decades. Research on the effects of these agents in cachexia or wasting conditions, characterized by progressive loss of skeletal muscle and adipose tissue, focused on patients with AIDS in the early 1990s, when the devastating effects of the loss of body weight, lean body mass, and adipose tissue were recognized as contributors to these patients' mortality. These same agents have also been studied as methods to attenuate the catabolic responses observed in cancer-induced cachexia and in wasting induced by chronic obstructive pulmonary disease, congestive heart failure, renal failure, and other conditions. This article provides an updated review of recent clinical trials that specifically examined the potential therapeutic roles of growth hormone, testosterone, oxandrolone, and megestrol acetate and emerging data on the orexigenic peptide ghrelin, in human cachexia and wasting.

Cancer-induced cachexia: a guide for the oncologist.

Cancer-induced cachexia (CIC) is a paraneoplastic syndrome that may account for up to 20% of deaths in cancer patients. Cachexia includes distinct metabolic changes that are the result of an acute-phase response (APR) mounted by the host as a reaction to tumor cells. These changes include increased muscle proteolysis, increased fat lipolysis, and increased hepatic production of acute-phase proteins such as C-reactive protein and fibrinogen. This APR pathogenesis is an important consideration in trying to treat cachectic patients as most therapies do not target the APR and its subsequent metabolic effects. Although there is currently no cure for CIC, the oncologist frequently encounters cachectic patients in practice, and evidence-based management is needed. We review the current data for assessment of starvation and cachexia, providing guidelines for management that include serum markers and functional assessment. In addition, a review of current therapies is provided, including hypercaloric feeding and nutritional intervention to address starvation, as well as data on appetite stimulants such as corticosteroids and megestrol acetate. Experimental therapies are also discussed, including nonsteroidal antiinflammatory drugs, tumor necrosis factor alpha antagonists, tetrahydrocannabinol, growth hormone, ghrelin, oxandrolone, and omega-3 fatty acids.

National surgical patterns of care for primary surgery and axillary staging of phyllodes tumors.

Phyllodes tumors (PT) are rare and unique in their suspected stromal and epithelial origin, and their propensity to recur despite surgical resection. Current surgical treatment of PT does not include sampling of regional lymph nodes (LNs) as malignant PT infrequently spread to LNs. We hypothesize that, because of substantial experience with common epithelial lesions of the breast, surgeons are more prone to sample LNs in PT patients. We reviewed national surgical patterns of care of axillary LN sampling for PT using the Surveillance Epidemiology & End Results (SEER) registry. SEER data for LN evaluation are available from 1988. The public-access SEER data-base was queried for patients presenting over all 17 registries between 1988 and 2003 with PT of the breast. Data were collated by type of surgery and number of LNs examined, and further analyzed by tumor size of the primary lesion where available; 1,035 cases of PT were identified for the 16-year period. Patients had a median age of 50 (range 12-96). Of the specimens with SEER grade listed, 117 were well-differentiated, 186 moderately differentiated, 79 poorly differentiated, and 132 undifferentiated; 612 (59.1%) cases had specific surgical procedures reported: 191 partial, 251 simple, 5 subcutaneous, 154 modified radical, and 6 radical mastectomies, with 5 mastectomies (NOS) documented. The remainder of cases had surgery that was coded as "undocumented" or unknown. When surveyed by LNs examined, 25.5% of patients (n=264) underwent some degree of regional lymphadenectomy; the median number of LNs examined in these patients was 7 (range 1-37). Of all PT patients, 9.0% of patients underwent axillary sampling of 10 LN or more. Only nine patients (3.4%) had positive LNs. When assessing axillary sampling rate by tumor size, smaller lesions were less likely to undergo sampling than larger lesions (19.3% for lesions <2 cm, 20.5% for lesions 2-4.9 cm, 27.9% for 5-9.9 cm); although this was nonsignificant. In spite of the lack of supporting data for LN examination axillary staging continues to be performed for many cases of PT.

National surgical patterns of care: regional lymphadenectomy of breast sarcomas.

PURPOSE: Soft tissue sarcomas (STS) of the breast are rare tumors with few large experiences available regarding their optimal management. Although assessment of the draining lymphatics is not a component of standard surgical treatment of soft tissue sarcomas, we hypothesized that the management of breast STS may present a unique situation: given their experience with the more common epithelial lesions of the breast, surgeons may be more prone to sample lymph nodes (LNs) in these patients than would otherwise be indicated based on histologic subtype. We reviewed national surgical patterns of care for regional lymphadenectomy for breast STS using the Surveillance Epidemiology & End Results (SEER) registry. MATERIALS/METHODS: SEER data for LN evaluation are available from 1988. The public-access SEER registry was queried for patients presenting between 1988 and 2002 with breast STS. Data were collated by number of LNs examined and further analyzed by histology, grade, and size of the primary lesion where available. For 5-year relative survival calculations, 210 patients with STS from 1988 to 1998 were analyzed. Relative survival in SEER is defined as the observed survival of a cohort divided by the observed survival of an age-, race-, and gender-matched cohort without disease; it thus serves as a surrogate for disease-free survival. RESULTS: A total of 333 cases of STS were identified for the 15-year period; 39% of patients underwent some degree of regional lymphadenectomy, and the median number of LNs examined in these patients was 10 (range, 1-34). Of all patients, 17.4% underwent lymphadenectomy of 10 LNs or more. More axillary procedures were performed as grade increased (30.8% grade I/II, 53.8% grade III/IV ([chi]2 = 10.8; P < 0.001). The percentage of patients undergoing radical or modified radical mastectomy did not change significantly over the 15-year period (chi2 = 1.25; P < 1.0), although procedures sampling the axilla were significantly more frequent when lesions were larger than 5 cm (chi2 = 4.14; P < 0.05). None of 6 patients with positive LNs survived 5 years. Examination of nodes did not impact survival: 117 patients without LNs sampled had 5-year related survival of 68.7% (SE = 5.5%); 89 patients with LN sampling had 64.3% 5-year related survival (SE = 5.8%). CONCLUSION: Lymphadenectomy is frequently performed despite nodal metastasis being an infrequent occurrence in breast STS. LN metastases were rarely identified and lymphadenectomy did not confer a survival benefit.