Functional Magnetic Resonance Imaging in Cervical Cancer Diagnosis and Treatment.

Cervical Cancer is the fourth most common cancer in women worldwide. Treatment with chemoradiotherapy followed by brachytherapy achieves high local control, but recurrence with metastatic disease impacts survival. This highlights the need for predictive and prognostic biomarkers identifying populations at risk of poorer treatment response and survival. Magnetic resonance imaging (MRI) is routinely used in cervical cancer and is a potential source for biomarkers. Functional MRI (fMRI) can characterise tumour beyond anatomical MRI, which is limited to the assessment of morphology. This review summarises fMRI techniques used in cervical cancer and examines the role of fMRI parameters as predictive or prognostic biomarkers. Different techniques characterise different tumour factors, which helps to explain the variation in patient outcomes. These can impact simultaneously on outcomes, making biomarker identification challenging. Most studies are small, focussing on single MRI techniques, which raises the need to investigate combined fMRI approaches for a more holistic characterisation of tumour.

Opioids in context: relieving the pain of cancer. The role of comprehensive cancer management.

Optimal pain control requires detailed appraisal of each symptom; in many cases definitive treatment of the underlying cause will be the most effective means of pain control. As an example back pain may be due not only to bone metastases but also enlarging lymph nodes, renal pain or retroperitoneal tumour. Benign causes including degenerative joint disease should also be considered and each cause treated specifically alongside the use of analgesics.

Hypoxic radiosensitizers in radical radiotherapy for patients with bladder carcinoma: hyperbaric oxygen, misonidazole, and accelerated radiotherapy, carbogen, and nicotinamide.

BACKGROUND: In animal models carbogen (normobaric 95% oxygen, 5% carbon dioxide) provides significant enhancement of local tumor control with fractionated radiotherapy. This approach to radiosensitization has been evaluated in the treatment of patients with bladder carcinoma using radical radiotherapy. METHODS: Sixty-one patients with locally advanced bladder carcinoma were treated using a Phase II trial delivering radiotherapy to the bladder (50-55 Grays in 20 daily fractions over 4 weeks) with inhalation of carbogen alone in 30 patients and the addition of oral nicotinamide (80 mg/kg) prior to radiotherapy with carbogen in 31 patients. The results from these 61 patients were compared with those from two earlier attempts at hypoxic sensitization: the second Medical Research Council (MRC) hyperbaric oxygen trial in patients with bladder carcinoma and a Phase III trial of misonidazole with radiotherapy in patients with bladder carcinoma performed at Mount Vernon Hospital. RESULTS: Although there was no difference between the hyperbaric oxygen and misonidazole trials, when compared with the two earlier series there was a large, statistically significant difference in favor of those patients receiving carbogen with or without nicotinamide for local control (P = 0.00001), progression free survival (P = 0.001), and overall survival (P = 0.04). CONCLUSIONS: Although the advantage for the carbogen group may be explained in part by changes in radiotherapy practice over the period of the three studies the improvement in local control is sufficiently great to support the hypothesis that hypoxia is important in modifying the control of bladder carcinoma using radiation therapy. Further evaluation of accelerated radiotherapy, carbogen, and nicotinamide in patients with bladder carcinoma is needed in a Phase III trial.

Carbogen and nicotinamide in the treatment of bladder cancer with radical radiotherapy.

Carbogen and nicotinamide have been evaluated in a phase II study as hypoxia-modifying agents during radical radiotherapy for bladder cancer using a standard daily 20-fraction schedule. Three groups of patients have received (a) nicotinamide alone, given orally in a dose of 80 mg kg(-1) daily with 52.5 Gy in 20 fractions over 4 weeks, (b) carbogen alone, with 50 Gy in 20 fractions over 4 weeks, and (c) carbogen and nicotinamide, with 50-52.5 Gy in 20 fractions over 4 weeks. Ten patients were treated in each group. All patients completed carbogen and radiotherapy as prescribed, but only 45% completed daily nicotinamide over the 4-week treatment period. The end points of this study were acute bowel and bladder morbidity and local control at cystoscopy 6 months after treatment. An expected level of acute bowel and bladder morbidity was seen that reverted to normal in most patients by 12 weeks with no difference between the three treatment groups. Complete response rates at 6 months were seven out of ten (100%) in the nicotinamide alone group, nine out of ten (90%) in the carbogen alone group and seven out of ten (70%) in the carbogen and nicotinamide group. It is concluded that carbogen and nicotinamide may improve the results of daily fractionated radiotherapy in bladder cancer and that further evaluation is required.

Does long-term administration of tamoxifen affect bone mineral density?

A retrospective study was performed to determine whether the long-term (5 years or more) administration of tamoxifen is detrimental to bone mineral density (BMD). 19 patients taking adjuvant tamoxifen for breast cancer were paired with 19 controls comparable in age, time since menopause and performance status. BMD was measured at the femoral neck, lumbar spine and total body by dual energy X-ray absorptiometry (DEXA). There was no detrimental effect on BMD at any site. There was a trend towards an increase in BMD at the femoral neck. There were minor decreases in the serum calcium, phosphate and alkaline phosphatase.

The management of symptoms in advanced cancer: experience in a hospital-based continuing care unit.

The treatment received by 158 patients with advanced cancer admitted over one year to the Continuing Care Unit at the Royal Marsden Hospital has been reviewed. The unit is an integral part of the hospital and this is reflected in the fact that 46 patients (29%) received radiotherapy, hormone therapy, chemotherapy or surgery in addition to symptomatic treatment for palliation of troublesome symptoms. One hundred and thirty-one patients received oral morphine in doses ranging from 2.5 mg 4-hourly to 700 mg 4-hourly. Patients with renal or hepatic impairment required lower doses of morphine and there was a highly significant inverse relationship between morphine dose and age. Eighty-five patients (54%) received parenteral diamorphine at some time due to their inability to take oral morphine. One hundred and twenty-three patients (78%) received a co-analgesic drug and anti-emetics were required by 78 patients (49% overall; 56% of those receiving morphine). Transcutaneous electrical nerve stimulation, acupuncture and relaxation were employed in selected patients, and graduated compression sleeves were used to treat lymphoedema. These data highlight the wide range of therapeutic options available to control the symptoms of advanced cancer and also indicate that tumoricidal treatments used in conjunction with symptomatic treatments may have a significant part to play.