IN THIS ISSUE
Case IN THE
St u d y BUSINESS OF
through Research, Prevention and
A2 Endoscopic skull base surgery
A3 Case Study: Pituitary tumor
A4 ILP, ILI can produce surprising results
for in-transit melanoma and other
regionally advanced cancers
A6 News you can use
A7 Visiting leaders take the stage
PITUITARY AND OTHER SKULL BASE TUMORS Roswell Park Cancer Institute
Endoscopic skull base surgery:
More complete tumor removal, less risk and discomfort
The Patient: and high blood pr
an with diabetes shoe size over
• 46-year-old wom se in glove and
fa iling vision, increa
• Presented with change in facial
two years and progressive
The resection of pituitary and other skull base tumors
The Work-Up: al elevated growth hormone and IGF-I thvebrain
presents unique surgical challenges, sometimes requiring
removal of parts of the skull and facial bones to gain access The surgeon inserts an endoscope (a thin, lighted telescope le ls
ve ies re of e
to the tumor. This can involve considerable invasiveness, with attached camera) through one nostril and visualizes the
• Hormone stud ass at the base
pituitary gland m
along with the risk of injury to nerves, arteries and other skull base anatomy on a TV screen. Through the other nostril,
• M R I sc an shows a 2 cm
critical structures. the surgeon works to develop a channel through the nasal
sinuses to reach and remove the skull base tumor.
The “inside out” approach of endoscopic skull base surgery,
introduced just within the past decade, uses the nose as a “Even other surgeons are astounded by what you can ologist, neurosur
more direct and less-invasive route to the tumor. “It allows reach,” says Dr. Fenstermaker. “Through the nostril, you can her family physician, endocrin
us to remove tumors that we couldn’t previously reach easily reach the upper part of the spine and can remove part of the • Patient seen by
by conventional means,” notes Robert Fenstermaker, MD, bone of the spine, down to the second vertebral body.” head and neck su
FACS, Chair of the Department of Neurosurgery and Director The surgery can be lengthy and requires a team approach
of the Neuro-Oncology Program at Roswell Park Cancer that integrates the skills of the neurosurgeon, working inside surgery
Institute (RPCI). “It also reduces the need for a craniotomy, the skull, with those of the head and neck surgeon, working d endosc opic endonasal
which means that you don’t have to expose or touch the outside the skull base. Surgical planning is therefore done • Tumor removal w
brain as much, or sometimes at all.” jointly. “Neurosurgeons have been doing transsphenoidal
RPCI has offered the treatment option for three years surgery with a surgical microscope for years, but using an
and treats an average of three patients per month with endoscope is in the domain of the head and neck surgeon,”
the procedure. “It’s an evolving and growing area of explains Dr. Fenstermaker. The technique successfully
neurosurgery,” Dr. Fenstermaker says. combines the technologies and skills of both disciplines. ker, MD and
Robert Fe of Neurosurgery,
TUMOR TYPES P O S T O P E R AT I V E E X P E C TAT I O N S igual, MD ck Surge
ry Patient b
Nestor R t of Head and Ne ack to w
n treatmen ork six w
Length of hospitalization is comparable to a craniotomy, but Departme and eeks afte
Endoscopic skull base surgery is used to treat pituitary and
iagnosis t, with n r
other skull base tumors, whether benign or malignant. These patients who undergo transsphenoidal surgery report little pain abo ut the d s at improve o eviden
ce of tum
rmation y tumor d vision
ore info pituitar or;
are most often pituitary tumors and meningiomas. “Those or discomfort – typically just nasal congestion rather than pain.
For m rt ; improv
ain and ct Robe pressure ed blood
nt of br e, conta
are the people we can help the most,” says Dr. and diab
Fenstermaker. The procedure offers significant advantages treatme ncer Ins
54, or v
ia longer o etes cont
A D V A N TA G E S Park Ca -845-31 k.org.
n insuli rol; no
for patients whose only alternative is craniotomy or
Roswell r, MD,
at 716 wellpar
conventional “transsphenoidal” surgery. Using a lighted Because skull base tumors are so difficult to reach with
Fens termake erma ker@ros
endoscope to perform the surgery provides much greater rt.Fenst
conventional surgical methods, some patients come to RPCI
visibility of the tumor and the surrounding normal anatomical after undergoing treatment elsewhere that did not result in email
structures. Consequently, the surgeon’s ability to see and complete tumor removal. “We do the expanded endonasal al
manipulate the anatomy safely is much greater than with Ne stor Rigu
endoscopic skull base procedure and many obtain a gross
traditional techniques. total resection,” says Dr. Fenstermaker.
For more information about endoscopic skull base surgery at Roswell Park Cancer Institute,
For Physician Referrals:
email Dr. Fenstermaker at Robert.Fenstermaker@roswellpark.org or call 1-716-845-3154.
A2 A3 www.roswellpark.org
For Physician Referrals:
EXTREMITY IN-TRANSIT MELANOMA AND OTHER R E G I O N A L LY A D V A N C E D C A N C E R S
Despite the visual appearance of advanced
While the response rate to ILI is not as high as for ILP, ILI
disease, ILP and ILI can produce is better tolerated by patients because it is less invasive.
being treated. Because the catheters are long and thin, may also turn a complicated problem into a simple problem:
it is not possible to deliver the chemotherapy under high if you have 80 lesions in the leg and they go away, but three
METHOD pressure, as with ILP, so a syringe is used to circulate the come back, you might be able to resect the three, while you
Both ILP and ILI are regional therapies that deliver very high drug. Unlike ILP, ILI does not employ an oxygenator. As couldn’t have resected the 80.”
doses of chemotherapy to the tumor site while preventing the affected limb is ischemic during the infusion,
the drugs from circulating elsewhere in the body, thus treatment time is shorter. For ILI, “there is a complete response rate of about 40%,
reducing toxicity. half of which are durable, but because it doesn’t involve
While the response rate to ILI is not as high as for ILP, ILI is invasive surgery, it’s easy to repeat the treatment if someone
• ILP uses the same general approach employed in better tolerated by patients because it is less invasive. Data gets a good response and the disease comes back, or if
cardiac bypass surgery. Catheters are surgically inserted suggest that the limb ischemia that occurs during ILI may there’s a mixed response.”
into the artery and vein supplying the affected limb. A also actually help kill the tumor by depriving it of oxygen.
tourniquet is placed above the limb to restrict blood Before the development of ILP, amputation was the standard
flow to the region, and the limb is connected to a of care for the treatment of advanced extremity in-transit
heart/lung bypass machine for oxygenation. Once the
P O S T- T R E AT M E N T melanoma with a five-year survival between 25-35%. With
limb is functionally isolated from the rest of the body, a E X P E C TAT I O N S ILP or ILI, he says, these treatments provide “a way to
chemotherapy drug—usually melphalan—is introduced After ILP or ILI, the affected limb takes on the appearance potentially control the tumor, preserve the extremity, and,
at very high doses. At the same time, the limb is heated of a severe sunburn, with swelling, redness, and tenderness. therefore, dramatically improve quality of life.”
ILI in progress These effects tend to peak at two weeks, followed by
to the equivalent of low- to moderate-range fever.
When the perfusion is complete, the chemotherapy browning of the skin, sometimes with flaking. The tumor
ppearances can be deceiving when it comes to patients
drug is rinsed out of the limb, the tourniquet is response to ILP or ILI is usually not seen until around eight
with in-transit melanoma. “It looks so bad that people
often think that there’s nothing you can do,” says John
M. Kane III, MD, a surgical oncologist at Roswell Park Cancer Before the development
Institute (RPCI). “And unfortunately, it almost never responds to
conventional melanoma treatments such as chemotherapy, of ILP, amputation was the ELIGIBILITY John M. Kane III, MD,
Both ILP and ILI are used for the treatment of advanced Surgical Oncologist at
interleukin-2, or other immune therapies. So people think,
That’s so much disease, the patient is going to die.
standard of care for the extremity in-transit melanoma, Merkel cell carcinoma, Roswell Park Cancer Institute,
treatment of advanced and certain unresectable sarcomas. For many patients,
amputation is often the only other treatment option with
has been recognized by
“But if patients have in-transit melanoma, with or without
lymph node involvement, they’re actually stage IIIB or IIIC, extremity in-transit a reasonable chance for cure. Dr. Kane cautions that cure is
other physicians in his field
as among the Best Doctors®
a goal only if the disease is isolated to the limb. However,
not stage IV—therefore, it’s still potentially curable.” melanoma with a five-year “we would occasionally do it in the setting of very limited in America for 2007-08.
In patients with tumor confined to the arm or leg, isolated survival between 25-35%. distant disease as a palliative approach to controlling pain
or bleeding, in essence to try to improve quality of life, if
limb perfusion (ILP) or isolated limb infusion (ILI) can
removed, and the blood vessels are closed. the patient had a reasonable life expectancy.”
produce extraordinary results. “The five-year survival is
• As a newer and less-invasive procedure, ILI does not For further information about
somewhere between 25-35%; many of them will never
require surgically entering the vessels. Rather, small ILP and ILI at Roswell Park Cancer
develop distant spread,” notes Dr. Kane. “I have patients
who are years out from their regional therapy who have not arterial and venous catheters are inserted percutaneously B E N E F I T S A N D A D VA N TA G E S Institute, or to arrange a preliminary
under x-ray guidance for correct placement; this requires What about outcomes? “Data are strongest for ILP for review of patient eligibility,
recurred and are cured. Just because it looks bad doesn’t
only two small punctures in the leg away from the limb melanoma,” says Dr. Kane. “Initial complete response rates contact Dr. Kane at 716-845-3516.
mean there isn’t a potential solution to the problem.”
are 50-70%; durable complete response is about 25-35%. It
NEWS you can use
Working together to improve the survival of lung cancer patients, leaders
from government, the pharmaceutical industry, and the academic, medical
and scientific communities shared ideas and strategies at Lung Cancer
Symposium 2008. Sponsored by Roswell Park Cancer Institute in Buffalo,
New test at RPCI PSA screening after 75 – NY, the symposium was held Sept. 5-7 at Niagara-on-the-Lake, Ontario.
Glenwood Goss, MD, BCh, FCP, FRCPC, (left) head of Medical Oncology
identifies patients YES OR NO? at Ottawa Regional Cancer Centre, and Ravi Salia, MD, PhD, Director of the
most likely to The U.S. Preventive Services Task
Thoracic Oncology Research Program at the University of Chicago Medical
Center, co-chaired a session on “Locally Advanced Disease.” Dr. Goss also
benefit from Erbitux® Force (Department of Health &
Human Services) announced recently
addressed RPCI faculty recently at Grand Rounds.
The drug Erbitux® (cetuximab) has that it does not recommend prostate
been FDA-approved since 2004 for cancer screening for men 75 and
the treatment of advanced colorectal older, concluding that screening
cancer that has spread to other parts does not confer significant health benefits and may lead
of the body. When combined with to physical problems and emotional distress in that
the chemotherapy drug irinotecan, population. But James Mohler, MD, Chair of Urologic
it produces major tumor shrinkage in Oncology and Leader of the Prostate Program at Roswell
about 20% of patients. But several studies presented at Park Cancer Institute, cautions that a man’s projected life
Takeshi Sano, MD, (right) discussed “Japanese vs. Western
the 2008 meeting of the American Society for Clinical expectancy—not his chronological age—should be the
main factor in deciding whether he should get a PSA test. Approaches to Gastric Cancer: Why So Different?” for an
Oncology (ASCO) demonstrate that it’s not likely to work
American Joint Committee on Cancer (AJCC)/Union Internationale
in tumors that have a mutation in the K-RAS gene—a group
“The American Urological Association and National Contre le Cancer (UICC) meeting on gastric cancer, held Aug.
that includes about 40% of all colon cancer tumors. On the
Comprehensive Cancer Network (NCCN) have said for 19 at Roswell Park Cancer Institute. Dr. Sano comes from the
other hand, patients with the “wild type” K-RAS gene
years that PSA should not be used for prostate cancer Gastric Surgery Division, National Cancer Center Hospital,
respond better, and their disease progresses more slowly.
screening for men with life expectancies of less than 10 Tokyo, Japan.
Roswell Park Cancer Institute now offers testing for the years,” explains Mohler. “But many 75-year-old men are
K-RAS gene mutation for patients who may be considering going to live more than 10 years, and many 60-year-olds
Erbitux treatment. The test means the drug can be targeted do not have a 10-year life expectancy. The best course of
toward patients who could benefit, while sparing others action is always based on a fully informed decision made
the cost and potential side effects of a therapy that is
unlikely to help them. For more information about the
between the patient and physician.”
This holiday season, give
K-RAS lab test, call 1-877-ASK-RPCI (1-877-275-7724). Mohler chairs the NCCN Prostate Cancer Guidelines
Committee, which publishes the most widely used
guidelines for cancer treatment. The NCCN is an alliance
the gift of a masterpiece!
INTRODUCING... Celebrate the beautiful artwork and inspiring strength of
of 21 of the nation’s top cancer centers.
roswellness The Radio Show
For more information visit Roswell Park’s new prostate
cancer microsite at www.ProstatePros.com.
pediatric cancer patients through this exclusive collection.
• Holiday and all-occasion cards, teddy bears, candles,
ornaments, Choco-Logo chocolates and other gifts
a half-hour show featuring
• Easy online card customization for home or business.
RPCI cancer experts, every Sunday,
SAVE 10% ON SELECT CORPORATE
6:30 am, WBEN radio AND THE WINNER IS… ORDERS PLACED BEFORE NOVEMBER 1!
(930 on the AM dial) Family practice physician Dr. Deborah Freda
• Shop online today, call 1-800-959-5931 to speak with
Miller of Kenmore, New York shown at left at a dedicated volunteer, or visit retail sites including
Hear shows online at Roswellness.org or download
the Chollipo Arboretum in Chungchong Tops and Wegmans starting October 1, 2008.
to MP3 players from iTunes or the WBEN website.
Namdo, South Korea), heard Celine Dion in
Celebrate the artwork
concert September 3 at HSBC Arena, courtesy of Roswell Park Cancer
Institute. Dr. Miller won two concert tickets by participating in Roswell
of patient-artists like
Rachel by purchasing www.PaintBoxProject.com
holiday cards and gifts All proceeds support the most promising cancer research and
Park’s annual Physicians Practice readership survey. Look for a new from The Paint Box Project.
For Physician Referrals: compassionate patient care programs at Roswell Park Cancer Institute.
prize and another chance to win in the May 2009 issue.
1-800-ROSWELL Presented by: