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					IN THIS ISSUE


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                      rpci        roswellness
                                        for doctors

     Case            IN THE
     St u d y        BUSINESS OF
                A3
                     SAVING LIVES…
                     through Research, Prevention and
                     Innovative Treatment
                A4
                     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
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PITUITARY AND OTHER SKULL BASE TUMORS                                                                                                Roswell Park Cancer Institute

Endoscopic skull base surgery:
                                                                                                                                     Case Study
         More complete tumor removal, less risk and discomfort

                                                                                                                                                     r
                                                                                                                                       Pituitary Tumo
                                                                                                                                        The Patient:                             and high blood pr
                                                                                                                                                                                                     essure
                                                                                                                                                            an with diabetes                        shoe size over
                                                                                                                                         • 46-year-old wom                         se in glove and
                                                                                                                                                           fa iling vision, increa
                                                                                                                                         • Presented with                 change in facial
                                                                                                                                                                                            features
                                                                                                                                           two years  and progressive
The resection of pituitary and other skull base tumors
                                                                 METHOD
                                                                                                                                        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,
                                                                                                                                          The Team:
                                                                                                                                                                                                            geon,
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
                                                                                                                                                              rgeon
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
                                                                                                                                           The Treatment:
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
                                                                                                                                                                ith video-assiste
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,”

                                                                                                                                                                                                                Result:
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
                                                                                                                                                            nsterma
                                                                                                                                                   Robert Fe of Neurosurgery,
                                                                                                                                                            nt
                                                                                                                                                   Departme
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
                                                                                                                                                                       titut
                                                                                                                                                                                    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
                                                                                                                                                                                                                              n.
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
                                                                                                                                                   at Robe
                                                                 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
                                                                                                                                                            rmaker &
                                                                 endoscopic skull base procedure and many obtain a gross
                                                                                                                                                  rt Fenste
traditional techniques.                                          total resection,” says Dr. Fenstermaker.
                                                                                                                                             Robe
      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.
                                                                                                                                                                                                                          1-800-ROSWELL
                                                                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
                                                                                                                                                                                                                                   1-800-ROSWELL
                                                                                                                                                                                                                                  www.roswellpark.org

    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.
                                               surprising results!
                                                                                                                                         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


A
        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
                                                                                                                                     weeks post-treatment.
         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




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                                                                                                                                                                                                                                    VISITING SPEAKERS
NEWS you can use




                                                                                                                                                                                         L
                                                                                                                                                                                             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




                                                                                                                                                                                                          L
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
                                                                                                                                                                                                                           now available.
               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:

www.roswellpark.org
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