Multiple Myeloma Guidelines and Their Recent Updates: Implications for Imaging. / Leitlinien zum multiplen Myelom und ihre aktuellen Anpassungen: Konsequenzen für die Bildgebung.

BACKGROUND: In 2014, the diagnostic criteria for multiple myeloma were updated, leading to revised recommendations for imaging modalities and definition of therapy response. This review provides an overview of the current definitions of monoclonal plasma cell disease, diagnostic options, and changes relevant to radiologists. METHOD: A pubmed search regarding the multiple myeloma guidelines was conducted, and results were filtered considering publications of international associations and expert reviews. Recommendations by the International Myeloma Working Group (IMWG), the National Comprehensive Cancer Network (NCCN, USA), the European Society for Medical Oncology (ESMO), and the European Myeloma Network are acknowledged. RESULTS AND CONCLUSION: Conventional skeletal survey is to be replaced by cross-sectional imaging techniques. For initial diagnostics of bone lesions or bone marrow involvement defining multiple myeloma, whole-body low-dose CT and whole-body MRI are recommended. Two or more focal bone marrow lesions suspicious for myeloma on MRI will now define symptomatic disease even in the case of intact mineralized bone. Follow-up imaging is not clearly specified so far. New guidelines concerning the definitions of minimal residual disease include the assessment of focal lesions before and after treatment using 18F-FDG-PET/CT, with the potential to redefine the role of PET/CT in the diagnostics of multiple myeloma. KEY POINTS: · Whole-body low-dose CT is recommended by international reference organizations for detecting lytic bone lesions.. · Focal myeloma lesions detected on whole-body MRI will indicate symptomatic multiple myeloma requiring therapy, even in the absence of damage to mineralized bone.. · The IMWG recommends using cross-sectional imaging in the initial work-up: whole-body low-dose CT, MRI, or PET/CT, depending on availability and resources.. · The diagnostic potential of 18F-FDG-PET/CT is highlighted by its inclusion in the definition of minimal residual disease after therapy; implementation in Germany is uncertain due to limited access in the daily routine.. CITATION FORMAT: · Mosebach J, Thierjung H, Schlemmer H et al. Multiple Myeloma Guidelines and Their Recent Updates: Implications for Imaging. Fortschr Röntgenstr 2019; 191: 998 - 1009.

A Population-Based Study of Outcomes in Surgically Resected T3N0 Non-Small Cell Lung Cancer in The Netherlands, Defined Using TNM-7 and TNM-8; Justification of Changes and an Argument to Incorporate Histology in the Staging Algorithm.

OBJECTIVE: The objective was to study outcomes in patients in a population registry who were surgically staged as having pT3N0 NSCLC according to the seventh and eighth editions of the TNM staging classification. METHODS: Details of patients who underwent surgery for NSCLC staged as pT3N0M0 from 2010 to 2013 on the basis of the seventh edition of the TNM classification were retrieved from the Netherlands Comprehensive Cancer Organization. These data were next matched with corresponding pathology data from a nationwide registry. Patients were categorized into four major pT3 subgroups as follows: those with a tumor diameter more than 7 cm, those with separate tumor nodules in the same lobe (two or more nodules), those with parietal pleural invasion, and a mixed group (consisting mainly of those with a tumor diameter larger than 7 cm combined with parietal pleural invasion). RESULTS: A total of 683 patients were eligible for analysis. The 3- and 5-year overall survival (OS) rates for the subtype tumor diameter larger than 7 cm were 59.9% and 47.2%, respectively, and were comparable to the rates for the subtype with pleural invasion (50.4% and 45.3%), respectively. The mixed group had worse 3- and 5-year OS rates (37.5% and 28.7%, respectively), which were comparable to the outcomes for TNM eighth edition-staged IIIB and pT4 cases in the International Association for the Study of Lung Cancer database. For the subtype two or more nodules, the 3- and 5-year OS rates were 70.6% and 62.8%, respectively, with patients with adenocarcinoma showing a significantly better OS than did patients with squamous cell carcinoma: a 5-year OS rate of 65.1% versus 47.2%, respectively (p < 0.001), suggesting that the prognosis for the adenocarcinoma subgroup may be comparable to that for the pT2 category, whereas squamous cell carcinoma nodules can remain pT3. CONCLUSION: This population analysis of overall survival rate by pT3N0 subcategory for NSCLC suggests that histologic type is a relevant descriptor in the category two or more nodules. The findings do not support migration of the group with a tumor diameter larger than 7 cm to the category pT4in the eighth edition of the TNM classification, and they suggest that a combination of two pT3 descriptors (the mixed group) merits migration to pT4.

Population-based validation of the National Cancer Comprehensive Network recommendations for baseline imaging workup of cutaneous melanoma.

The aim of the current study is to assess the performance of some of the imaging scans recommended in the National Comprehensive Cancer Network Guidelines as part of baseline staging for cutaneous melanoma, regarding the detection of lung, brain, bone, and liver metastases. Surveillance, Epidemiology and End Results database (2010-2015) was used to extract the data, and cases with cutaneous melanoma and complete information about TN stages and sites of distant metastases were explored. Performance parameters assessed in the current study included positive predictive value (PPV), negative predictive value, sensitivity, specificity, number needed to investigate (NNI), and accuracy. A total of 109 971 patients were included in the analysis. If all stage III patients in the study cohort are to be staged through routine imaging, PPV (for the recognition of lung metastases) will be 2.9% and NNI to detect one case of lung metastasis will be 34. Likewise, PPV (for the recognition of bone metastases) will be 1.8% and NNI to detect one case of bone metastasis will be 55. Moreover, PPV (for the recognition of liver metastases) will be 1.8% and NNI to detect one case of liver metastasis will be 55. Excluding stage III patients with clinically node-negative/sentinel node-positive disease would improve PPV and decrease NNI for the three metastatic sites. Adherence to current National Comprehensive Cancer Network guidelines for cutaneous melanoma imaging for baseline staging results in low rates of failure to detect asymptomatic lung, liver, brain, or bone metastases.

Quantifying downstream impact of inappropriate staging imaging in a cohort of veterans with low- and intermediate-risk incident prostate cancer.

INTRODUCTION: According to current National Comprehensive Cancer Network guidelines, routine imagining for staging low-risk prostate cancer is not recommended. However, extensive overuse of guideline-discordant imaging continues to persist. Incidental findings are common on imaging and little is known about the optimal management. Rates of incidental findings vs. false positive diagnosis from inappropriate imaging are poorly understood and have yet to be quantified for low- and intermediate-risk prostate cancer patients. OBJECTIVE: To determine the frequency of positive radiologic findings in patients with low- and intermediate-risk prostate cancer during initial staging at VA New York Harbor Healthcare System. METHODS: We retrospectively reviewed all low- and intermediate-risk prostate cancer patients' medical records from the VA New York Harbor Healthcare System for diagnosis from 2005 to 2015. We reviewed each individual's prebiopsy prostate specific antigen (PSA), Gleason score, and clinical stage. We also determined if imaging obtained yielded a false positive, incidental finding, or if metastatic disease occurred within the 6 months following initial diagnosis. RESULTS: There were 414 men, who were classified as low- to intermediate-risk prostate cancer and underwent inappropriate staging imaging of 4,306 men diagnosed with prostate cancer. Of these 414 men, 178 (43%) had additional follow-up imaging for positive findings. We calculated an incidental finding rate of 10% and a false positive rate of 38% for patients. Five (1%) patients had metastatic disease. CONCLUSION: Despite guideline recommendations, imaging overuse remains an issue for low-intermediate-risk prostate cancer patients. The false positive rate found in this analysis is alarmingly high at 38%. This use of scans is burdensome to the healthcare system and patient. This study highlights the frequency of inappropriate imaging and its negative consequences.

Prognostic Value of National Comprehensive Cancer Network Lung Cancer Resection Quality Criteria.

BACKGROUND: The National Comprehensive Cancer Network (NCCN) surgical resection guidelines for non-small cell lung cancer recommend anatomic resection, negative margins, examination of hilar/intrapulmonary lymph nodes, and examination of three or more mediastinal nodal stations. We examined the survival impact of these criteria. METHODS: A population-based observational study was done using patient-level data from all curative-intent, non-small cell lung cancer resections from 2004 to 2013 at 11 institutions in four contiguous Dartmouth Hospital referral regions in three US states. We used an adjusted Cox proportional hazards model to assess the overall survival impact of attaining NCCN guidelines. RESULTS: Of 2,429 eligible resections, 91% were anatomic, 94% had negative margins, 51% sampled hilar nodes, and 26% examined three or more mediastinal nodal stations. Only 17% of resections met all four criteria; however, there was a significant increasing trend from 2% in 2004 to 39% in 2013 (p < 0.001). Compared with patients whose surgery missed one or more criteria, the hazard ratio for patients whose surgery met all four criteria was 0.71 (95% confidence interval: 0.59 to 0.86, p < 0.001). Margin status and the nodal staging criteria were most strongly linked with survival. CONCLUSIONS: Attainment of NCCN surgical quality guidelines was low, but improving, over the past decade in this cohort from a high lung cancer mortality region of the United States. The NCCN quality criteria, especially the nodal examination criteria, were strongly associated with survival. The quality of nodal examination should be a focus of quality improvement in non-small cell lung cancer care.

SEOM Clinical Guideline for the treatment of pancreatic cancer (2016)

Pancreatic cancer remains an aggressive disease with a 5 year survival rate of 5%. Only 15% of patients with pancreatic cancer are eligible for radical surgery. Evidence suggests a benefit on survival with adjuvant chemotherapy (gemcitabine o fluourouracil) after R1/R0 resection. Adjuvant chemoradiotherapy is also a valid option in patients with positive margins. Borderline resectable pancreatic cancer is defined as the involvement of the mesenteric vasculature with a limited extension. These tumors are technically resectable, but with a high risk of positive margins. Neoadjuvant treatment represents the best option for achieving an R0 resection. In advanced disease, two new chemotherapy treatment schemes (Folfirinox or Gemcitabine plus nab-paclitaxel) have showed improvements in overall survival compared with gemcitabine alone. Progress in pancreatic cancer treatment will require a better knowledge of the molecular biology of this disease, focusing on personalized cancer therapies in the near future (AU)

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Management of thyroid cancer: United Kingdom National Multidisciplinary Guidelines.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. This paper provides recommendations on the management of thyroid cancer in adults and is based on the 2014 British Thyroid Association guidelines. Recommendations • Ultrasound scanning (USS) of the nodule or goitre is a crucial investigation in guiding the need for fine needle aspiration cytology (FNAC). (R) • FNAC should be considered for all nodules with suspicious ultrasound features (U3-U5). If a nodule is smaller than 10 mm in diameter, USS guided FNAC is not recommended unless clinically suspicious lymph nodes on USS are also present. (R) • Cytological analysis and categorisation should be reported according to the current British Thyroid Association Guidance. (R) • Ultrasound scanning assessment of cervical nodes should be done in FNAC-proven cancer. (R) • Magnetic resonance imaging (MRI) or computed tomography (CT) should be done in suspected cases of retrosternal extension, fixed tumours (local invasion with or without vocal cord paralysis) or when haemoptysis is reported. When CT with contrast is used pre-operatively, there should be a two-month delay between the use of iodinated contrast media and subsequent radioactive iodine (I131) therapy. (R) • Fluoro-deoxy-glucose positron emission tomography imaging is not recommended for routine evaluation. (G) • In patients with thyroid cancer, assessment of extrathyroidal extension and lymph node disease in the central and lateral neck compartments should be undertaken pre-operatively by USS and cross-sectional imaging (CT or MRI) if indicated. (R) • For patients with Thy 3f or Thy 4 FNAC a diagnostic hemithyroidectomy is recommended. (R) • Total thyroidectomy is recommended for patients with tumours greater than 4 cm in diameter or tumours of any size in association with any of the following characteristics: multifocal disease, bilateral disease, extrathyroidal spread (pT3 and pT4a), familial disease and those with clinically or radiologically involved nodes and/or distant metastases. (R) • Subtotal thyroidectomy should not be used in the management of thyroid cancer. (G) • Central compartment neck dissection is not routinely recommended for patients with papillary thyroid cancer without clinical or radiological evidence of lymph node involvement, provided they meet all of the following criteria: classical type papillary thyroid cancer, patient less than 45 years old, unifocal tumour, less than 4 cm, no extrathyroidal extension on ultrasound. (R) • Patients with metastases in the lateral compartment should undergo therapeutic lateral and central compartment neck dissection. (R) • Patients with follicular cancer with greater than 4 cm tumours should be treated with total thyroidectomy. (R) • I131 ablation should be carried out only in centres with appropriate facilities. (R) • Serum thyroglobulin (Tg) should be checked in all post-operative patients with differentiated thyroid cancer (DTC), but not sooner than six weeks after surgery. (R) • Patients who have undergone total or near total thyroidectomy should be started on levothyroxine 2 µg per kg or liothyronine 20 mcg tds after surgery. (R) • The majority of patients with a tumour more than 1 cm in diameter, who have undergone total or near-total thyroidectomy, should have I131 ablation. (R) • A post-ablation scan should be performed 3-10 days after I131 ablation. (R) • Post-therapy dynamic risk stratification at 9-12 months is used to guide further management. (G) • Potentially resectable recurrent or persistent disease should be managed with surgery whenever possible. (R) • Distant metastases and sites not amenable to surgery which are iodine avid should be treated with I131 therapy. (R) • Long-term follow-up for patients with differentiated thyroid cancer (DTC) is recommended. (G) • Follow-up should be based on clinical examination, serum Tg and thyroid-stimulating hormone assessments. (R) • Patients with suspected medullary thyroid cancer (MTC) should be investigated with calcitonin and carcino-embryonic antigen levels (CEA), 24 hour catecholamine and nor metanephrine urine estimation (or plasma free nor metanephrine estimation), serum calcium and parathyroid hormone. (R) • Relevant imaging studies are advisable to guide the extent of surgery. (R) • RET (Proto-oncogene tyrosine-protein kinase receptor) proto-oncogene analysis should be performed after surgery. (R) • All patients with known or suspected MTC should have serum calcitonin and biochemical screening for phaeochromocytoma pre-operatively. (R) • All patients with proven MTC greater than 5 mm should undergo total thyroidectomy and central compartment neck dissection. (R) • Patients with MTC with lateral nodal involvement should undergo selective neck dissection (IIa-Vb). (R) • Patients with MTC with central node metastases should undergo ipsilateral prophylactic lateral node dissection. (R) • Prophylactic thyroidectomy should be offered to RET-positive family members. (R) • All patients with proven MTC should have genetic screening. (R) • Radiotherapy may be useful in controlling local symptoms in patients with inoperable disease. (R) • Chemotherapy with tyrosine kinase inhibitors may help in controlling local symptoms. (R) • For individuals with anaplastic thyroid carcinoma, initial assessment should focus on identifying the small proportion of patients with localised disease and good performance status, which may benefit from surgical resection and other adjuvant therapies. (G) • The surgical intent should be gross tumour resection and not merely an attempt at debulking. (G).

Variation in Definitive Therapy for Localized Non-Small Cell Lung Cancer Among National Comprehensive Cancer Network Institutions.

PURPOSE: This study determined practice patterns in the staging and treatment of patients with stage I non-small cell lung cancer (NSCLC) among National Comprehensive Cancer Network (NCCN) member institutions. Secondary aims were to determine trends in the use of definitive therapy, predictors of treatment type, and acute adverse events associated with primary modalities of treatment. METHODS AND MATERIALS: Data from the National Comprehensive Cancer Network Oncology Outcomes Database from 2007 to 2011 for US patients with stage I NSCLC were used. Main outcome measures included patterns of care, predictors of treatment, acute morbidity, and acute mortality. RESULTS: Seventy-nine percent of patients received surgery, 16% received definitive radiation therapy (RT), and 3% were not treated. Seventy-four percent of the RT patients received stereotactic body RT (SBRT), and the remainder received nonstereotactic RT (NSRT). Among participating NCCN member institutions, the number of surgeries-to-RT course ratios varied between 1.6 and 34.7 (P<.01), and the SBRT-to-NSRT ratio varied between 0 and 13 (P=.01). Significant variations were also observed in staging practices, with brain imaging 0.33 (0.25-0.43) times as likely and mediastinoscopy 31.26 (21.84-44.76) times more likely for surgical patients than for RT patients. Toxicity rates for surgical and for SBRT patients were similar, although the rates were double for NSRT patients. CONCLUSIONS: The variations in treatment observed among NCCN institutions reflects the lack of level I evidence directing the use of surgery or SBRT for stage I NSCLC. In this setting, research of patient and physician preferences may help to guide future decision making.

Current strategy for staging and treatment: the BCLC update and future prospects.

Staging and treatment indication are relevant topics in the management of patients with hepatocellular carcinoma (HCC) and for optimal results, they have to take into account liver function, tumor stage, and physical status. For any staging system to be meaningful it has to link staging with treatment indication; this should be based on robust scientific data. Currently, the sole proposal that serves both aims is the Barcelona Clinic Liver Cancer (BCLC) approach. It takes into account the relevant parameters of all important dimensions and divides patients into very early/early, intermediate, advanced, and end-stage. Early-stage HCC patients should be considered for potentially curative options such as resection, ablation, and transplantation. Patients at intermediate stage benefit from chemoembolization, whereas patients at an advanced stage, or who cannot benefit from options of higher priority, have sorafenib as the standard treatment. Finally, patients at end-stage should merely receive palliative care.

Up-regulated proteins in the fluid bathing the tumour cell microenvironment as potential serological markers for early detection of cancer of the breast.

Breast cancer is by far the most common diagnosed form of cancer and the leading cause of cancer death in women today. Clinically useful biomarkers for early detection of breast cancer could lead to a significant reduction in mortality. Here we describe a detailed analysis using gel-based proteomics in combination with mass spectrometry and immunohistochemistry (IHC) of the tumour interstitial fluids (TIF) and normal interstitial fluids (NIF) collected from 69 prospective breast cancer patients. The goal of this study was to identify abundant cancer up-regulated proteins that are externalised by cells in the tumour microenvironment of most if not all these lesions. To this end, we applied a phased biomarker discovery research strategy to the analysis of these samples rather than comparing all samples among each other, with inherent inter and intra-sample variability problems. To this end, we chose to use samples derived from a single tumour/benign tissue pair (patient 46, triple negative tumour), for which we had well-matched samples in terms of epithelial cell numbers, to generate the initial dataset. In this first phase we found 110 proteins that were up-regulated by a factor of 2 or more in the TIF, some of which were confirmed by IHC. In the second phase, we carried out a systematic computer assisted analysis of the 2D gels of the remaining 68 TIF samples in order to identify TIF 46 up-regulated proteins that were deregulated in 90% or more of all the available TIFs, thus representing common breast cancer markers. This second phase singled out a set of 26 breast cancer markers, most of which were also identified by a complementary analysis using LC-MS/MS. The expression of calreticulin, cellular retinoic acid-binding protein II, chloride intracellular channel protein 1, EF-1-beta, galectin 1, peroxiredoxin-2, platelet-derived endothelial cell growth factor, protein disulfide isomerase and ubiquitin carboxyl-terminal hydrolase 5 were further validated using a tissue microarray containing 70 malignant breast carcinomas of various grades of atypia. A significant number of these proteins have already been detected in the blood/plasma/secretome by others. The next steps, which include biomarker prioritization based on the hierarchal evaluation of these markers, antibody and antigen development, assay development, analytical validation, and preliminary testing in the blood of healthy and breast cancer patients, are discussed.

American Society of Clinical Oncology/National Comprehensive Cancer Network Quality Measures.

PURPOSE: The National Cancer Policy Board recommended the creation of quality measures and a national reporting system in 1999. Representatives from the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) collaborated to create metrics suitable for national performance measurement. METHODS: Content and methodology experts nominated by ASCO and NCCN met to select and refine metrics for breast, colon, and rectal cancer based on National Initiative for Cancer Care Quality and NCCN measures and NCCN and ASCO guidelines. Measures were selected based on their impact on disease free and overall survival, the degree to which opportunities for improvement exist, and the feasibility of data collection. RESULTS: Three breast cancer measures and four colorectal cancer measures were chosen. Measures for breast cancer included adjuvant hormone therapy for hormone receptor-positive tumors, chemotherapy for hormone receptor-negative cancer, and radiation after lumpectomy. Colorectal measures included adjuvant radiation and chemotherapy for rectal cancer, and adjuvant chemotherapy for colon cancer. All but one were recommended as accountability measures and one for quality improvement (removal and examination of 12 or more lymph nodes in colon cancer). Specifications were developed for each measure using tumor registries as the data source. CONCLUSION: ASCO/NCCN measures can be implemented by health systems, provider groups or payors for improvement or accountability using local tumor registries to furnish data on staging and treatment.

Splenic marginal zone lymphoma proposals for a revision of diagnostic, staging and therapeutic criteria.

Since the initial description of splenic marginal zone lymphoma (SMZL) in 1992, an increasing number of publications have dealt with multiple aspects of SMZL diagnosis, molecular pathogenesis and treatment. This process has identified multiple inconsistencies in the diagnostic criteria and lack of clear guidelines for the staging and treatment. The authors of this review have held several meetings and exchanged series of cases with the objective of agreeing on the main diagnostic, staging and therapeutic guidelines for patients with this condition. Specific working groups were created for diagnostic criteria, immunophenotype, staging and treatment. As results of this work, guidelines are proposed for diagnosis, differential diagnosis, staging, prognostic factors, treatment and response criteria. The guidelines proposed here are intended to contribute to the standardization of the diagnosis and treatment of these patients, and should facilitate the future development of clinical trials that could define more precisely predictive markers for histological progression or lack of response, and evaluate new drugs or treatments.

[Clinical practice guideline: 2005 update of recommendations for the management of patients with cutaneous melanoma without distant metastases (summary report)]. / Recommandations pour la pratique clinique: mise à jour 2005 des recommandations pour la prise en charge des patients adultes atteints d'un mélanome cutané sans métastase à distance (rapport abrégé).

CONTEXT: The National French federation of comprehensive cancer centres (FNCLCC) and the French society of dermatology (SFD) initiated together the update of clinical practice guideline for the management of patients with cutaneous melanoma in collaboration with the French national cancer institute and with specialists from French public universities, general hospitals and private clinics. This work is based on the methodology developed in the "Standards, Options and Recommendations" (SOR) project. OBJECTIVES: To update SOR guidelines for the management of patients with cutaneous melanoma previously validated in 1998 and French melanoma consensus conference published by SFD and ANAES in 1995. METHODS: The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts who define the CPGs according to the definitions of the Standards, Options and Recommendations project. Once the guidelines have been developed, they are reviewed by independent reviewers. RESULTS: This article is a summary version of the updated clinical practice guidelines with algorithms. The main questions addressed by the expert group in this update concerned (1) The new AJCC-UICC classification (2) Excision margins (3) Sentinel node biopsy (4) Adjuvant treatments (5) Initial staging and follow up of operated patients.

Pulmonary staging in colorectal cancer--is computerised tomography the answer?

INTRODUCTION: Pulmonary staging in colorectal cancer (CRC) has traditionally been carried out by means of plain chest radiograph (CXR), although computerised tomography (CT) imaging of the chest is increasingly being performed for this purpose. The aim of this study was to assess the value of pre-operative thoracic CT for pulmonary staging in CRC. PATIENTS AND METHODS: Data were collected prospectively on all patients referred into hospital over a 20-month study period for double contrast barium enema evaluation of symptoms suggestive of an underlying CRC. Patients with a CRC went on to have a staging intravenous, contrast-enhanced CT of the chest, abdomen and pelvis prior to an out-patient appointment with a colorectal surgeon. The CXRs of those patients in whom a radiological abnormality was seen on thoracic CT were reviewed blindly by an independent consultant radiologist. RESULTS: A total of 403 barium enemas were performed, of which 38 demonstrated a CRC (9%). In those patients diagnosed with CRC, nine (24%) had an abnormality on thoracic CT. Four patients with positive thoracic CTs had chemotherapy and or radiotherapy with no surgery. One patient underwent colectomy, and 2 patients who had primary lung tumours as opposed to metastases also underwent colectomies. One patient received palliative care only. In addition, one of the patients underwent multiple, non-diagnostic thoracic investigations prior to a diagnosis of sarcoidosis being made and then proceeding to surgery. An independent consultant radiologist reviewed seven out of the nine CXRs of patients with an abnormality on thoracic CT without knowledge of the clinical diagnosis, and reported three of the CXRs to be normal. CONCLUSIONS: Thoracic CT appears to improve the accuracy of pulmonary staging in CRC allowing a more appropriate level of intervention. However, CT is likely to identify more benign radiological abnormalities than CXR alone, and investigations should not occur to the detriment of treating the primary tumour.

Melanoma: treatment guidelines for patients (part 2).

The mutual goal of the National Comprehensive Cancer Network (NCCN) and the American Cancer Society partnership is to provide patients and the generalpublic with state of the art cancer treatment information in understandable language. This treatment information is based on the professional guidelines developed by the NCCN. It is intended to assist patients in a discussion with their doctor about the treatment that is best for their specific situation. Part I of these guidelines addressed melanoma risk factors, prevention, diagnosis, stages, prevention, and clinical trials (Vol. 17, No 2, pp. 119-131). Part II describes decision trees for evaluation and treatment.

Controversies and consensus in the diagnosis, work-up and treatment of gastric lymphoma: an international survey.

BACKGROUND: Variations in diagnostic criteria and staging procedures in cancer patients have important consequences for patient selection and often preclude meaningful comparison of published series. In gastric lymphoma, these effects will play a role, since diagnostic criteria are controversial. Moreover, staging procedures and therapeutic choices are influenced by insights from different clinical specialisms. METHODS: To review the management of gastric lymphoma, formatted questionnaires were mailed to leading institutes with a special interest in this field in Europe, the United States and Japan. RESULTS: Nineteen centers agreed to contribute. Minimum histological criteria varied among pathologists with a notable influence of the classification system used in the different countries. Detailed evaluation of the lymphoma distribution in the gastric wall and routine staging of the GI-tract differed between groups leaded by medical oncologists and gastroenterologists. This results in basically different patient selections and bias in treatment outcome. Similar effects were recorded for the role of gastric resection and radiotherapy. CONCLUSIONS: This study gives insight in the basis of the decisions that result in different approaches in the management of gastric MALT-NHL and in the effects for patient selection and treatment results and may help in the design of future clinical trials.