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Advances in neuro-oncology II
Letters
67
8. National Institutes of Health. NIH consensus conference: adjuvant therapy for patients with colon and rectal cancer. JAMA 1990;264:1444-50. P. G. CORNES A. G. HERIOT J. P. GLEES D. KUMAR
St George's Hospital London UK
The authors reply as follows: S t R - I am grateful to my colleagues from St George's Hospital for bringing attention to a number of points in my editorial [11. They are perfectly correct in suggesting that the so-called 'American' policy of postoperative radiotherapy requires concurrent chemotherapy to approach the survival advantage demonstrated by so-called 'Swedish' preoperative radiotherapy. However, most American trials also add
adjuvant chemotherapy after the concurrent radio/chemotherapy. The survival advantage for chemotherapy might therefore be a local effect in which local recurrence is reduced, or a distant effect in which the metastases elsewhere are reduced. I fully agree with my colleagues that the toxicity, and indeed the costs, of these two policies are very different. The Swedish technique appears to be much more cost effective. However, the Swedish technique had the disadvantage of irradiating a large number of patients needlessly, and the introduction of more effective pelvic surgery for rectal cancer makes this issue more acute. Furthermore, the Swedish approach is not without problems. Younger patients with a rectal cancer will inevitably lose gonadal function with this type of radiotherapy. The correspondents are perfectly correct in pointing out that postoperative radio-
therapy for rectal cancer has still not been adopted generally in the UK or elsewhere in Europe, even though it is widely used in America. I suspect that the reason for this is not the widespread use of the Swedish preoperative radiotherapy but rather the belief of UK surgeons that their local recurrence rate is low enough not to require radiotherapy in addition. I am delighted that the St George's group is prepared to support this trial and I hope that other clinicians across the country will follow their lead. Reference
1. James RD. Where next in the treatment of rectal cancer? Clin Oncol 1997;9:144-7. R. D. JAMES Christie Hospital NHS Trust Manchester, UK
Book Review Advances in Neuro-Oneology II. Edited by P. L. Kornblith and M. D. Walker. Futura, Armonk, NY, i997. Pages: 565; Price $125.00; Hard cover. ISBN 0-87993-6037. Tumours of the brain present an acknowledged and difficult clinical challenge and, as such, attract few clinicians willing to specialize and push forward the frontiers of therapy. On the other hand, laboratory interest in primary brain tumours, particularly malignant gliomas, has been long-standing, as they represent the classical systems of resistance, de-differentiation and aggressive biological behaviour. This monograph, edited b y two of the leaders in neurooncology, brings a welcome opportunity to update our understanding of recent progress in basic science, diagnosis and therapy. The six basic science chapters describe advances in the development biology of glia, especially the mechanisms of control and molecular biological concepts relevant to progression and the identification of suitable molecular targets for therapy. This leads well into a description of the molecular dynamics of tumour genesis and the role played by the actin cytoskeleton in glial cell transformation. Biochemical regulators such as the fibrinolytic systems and their role in necrosis and peritumoral brain oedema, and the role of fibroblast growth factors as promotors in astrocytomas, are discussed in Chapters 3 and 4. Chapter 5 is devoted to the important and potentially very interesting attempts to inhibit angiogenesis as a potential treatment target, with protein kinase inhibition as a complementary alternative. There are two very useful chapters on critical advances in neuroimaging and molecular neuropathological techniques in diagnosis and pathological classification.
The clinical chapters span from reviews of existing and widely available treatments such as surgical techniques, radiotherapy management and chemotherapy of adult and paediatric brain tumours, which may be useful update material for a general oncologist or set the clinical scene of neuro-oncology for the interested scientist. Chapters on surgical ultrasound, intraoperative neurophysiological monitoring and cortical mapping are useful for non-surgical neuro-oncologists. Balanced and practically minded reviews of stereotactic radiosurgery, both gamma knife and Linacbased, and of the special techniques used in spinal surgery, complete the discussion of current neuro-oncological practice. The last seven chapters summarize developments in most of the novel approaches that have clinical relevance: drug-impregnated biodegradable polymers, interleukin-2 and herpes simplex gene therapy, as well as more general concepts such as immunobiology and targeted toxic therapies. As a neuro-oncologist, I was delighted to read this book and will give it valuable space on my office bookshelf. However, at $125, it will be more suited to the library market. I will recommend certain chapters as valuable update and study material to trainees in neurosurgery and radiation therapy, but, as a whole, its greatest value will be to neuro-oncologists. Its attractive style and enthusiasm for this difficult subject may even persuade some young, eager clinicians with an interest in tumour biology to take on this challenging problem. A. GREGOR
Western General Hospital Edinburgh, UK
67
8. National Institutes of Health. NIH consensus conference: adjuvant therapy for patients with colon and rectal cancer. JAMA 1990;264:1444-50. P. G. CORNES A. G. HERIOT J. P. GLEES D. KUMAR
St George's Hospital London UK
The authors reply as follows: S t R - I am grateful to my colleagues from St George's Hospital for bringing attention to a number of points in my editorial [11. They are perfectly correct in suggesting that the so-called 'American' policy of postoperative radiotherapy requires concurrent chemotherapy to approach the survival advantage demonstrated by so-called 'Swedish' preoperative radiotherapy. However, most American trials also add
adjuvant chemotherapy after the concurrent radio/chemotherapy. The survival advantage for chemotherapy might therefore be a local effect in which local recurrence is reduced, or a distant effect in which the metastases elsewhere are reduced. I fully agree with my colleagues that the toxicity, and indeed the costs, of these two policies are very different. The Swedish technique appears to be much more cost effective. However, the Swedish technique had the disadvantage of irradiating a large number of patients needlessly, and the introduction of more effective pelvic surgery for rectal cancer makes this issue more acute. Furthermore, the Swedish approach is not without problems. Younger patients with a rectal cancer will inevitably lose gonadal function with this type of radiotherapy. The correspondents are perfectly correct in pointing out that postoperative radio-
therapy for rectal cancer has still not been adopted generally in the UK or elsewhere in Europe, even though it is widely used in America. I suspect that the reason for this is not the widespread use of the Swedish preoperative radiotherapy but rather the belief of UK surgeons that their local recurrence rate is low enough not to require radiotherapy in addition. I am delighted that the St George's group is prepared to support this trial and I hope that other clinicians across the country will follow their lead. Reference
1. James RD. Where next in the treatment of rectal cancer? Clin Oncol 1997;9:144-7. R. D. JAMES Christie Hospital NHS Trust Manchester, UK
Book Review Advances in Neuro-Oneology II. Edited by P. L. Kornblith and M. D. Walker. Futura, Armonk, NY, i997. Pages: 565; Price $125.00; Hard cover. ISBN 0-87993-6037. Tumours of the brain present an acknowledged and difficult clinical challenge and, as such, attract few clinicians willing to specialize and push forward the frontiers of therapy. On the other hand, laboratory interest in primary brain tumours, particularly malignant gliomas, has been long-standing, as they represent the classical systems of resistance, de-differentiation and aggressive biological behaviour. This monograph, edited b y two of the leaders in neurooncology, brings a welcome opportunity to update our understanding of recent progress in basic science, diagnosis and therapy. The six basic science chapters describe advances in the development biology of glia, especially the mechanisms of control and molecular biological concepts relevant to progression and the identification of suitable molecular targets for therapy. This leads well into a description of the molecular dynamics of tumour genesis and the role played by the actin cytoskeleton in glial cell transformation. Biochemical regulators such as the fibrinolytic systems and their role in necrosis and peritumoral brain oedema, and the role of fibroblast growth factors as promotors in astrocytomas, are discussed in Chapters 3 and 4. Chapter 5 is devoted to the important and potentially very interesting attempts to inhibit angiogenesis as a potential treatment target, with protein kinase inhibition as a complementary alternative. There are two very useful chapters on critical advances in neuroimaging and molecular neuropathological techniques in diagnosis and pathological classification.
The clinical chapters span from reviews of existing and widely available treatments such as surgical techniques, radiotherapy management and chemotherapy of adult and paediatric brain tumours, which may be useful update material for a general oncologist or set the clinical scene of neuro-oncology for the interested scientist. Chapters on surgical ultrasound, intraoperative neurophysiological monitoring and cortical mapping are useful for non-surgical neuro-oncologists. Balanced and practically minded reviews of stereotactic radiosurgery, both gamma knife and Linacbased, and of the special techniques used in spinal surgery, complete the discussion of current neuro-oncological practice. The last seven chapters summarize developments in most of the novel approaches that have clinical relevance: drug-impregnated biodegradable polymers, interleukin-2 and herpes simplex gene therapy, as well as more general concepts such as immunobiology and targeted toxic therapies. As a neuro-oncologist, I was delighted to read this book and will give it valuable space on my office bookshelf. However, at $125, it will be more suited to the library market. I will recommend certain chapters as valuable update and study material to trainees in neurosurgery and radiation therapy, but, as a whole, its greatest value will be to neuro-oncologists. Its attractive style and enthusiasm for this difficult subject may even persuade some young, eager clinicians with an interest in tumour biology to take on this challenging problem. A. GREGOR
Western General Hospital Edinburgh, UK