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The workup and management of squamous cell anal carcinoma, which represents the most common histologic form of the disease, are addressed in the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Anal Carcinoma. These NCCN Guidelines Insights provide a summary of major discussion points of the 2012 NCCN Anal Carcinoma Panel meeting. In summary, the panel made 4 significant changes to the 2012 NCCN Guidelines for Anal Carcinoma: 1) local radiation therapy was added as an option for the treatment of patients with metastatic disease; 2) multifield technique is now preferred over anteroposterior-posteroanterior (AP-PA) technique for radiation delivery and the AP-PA technique is no longer recommended as the standard of care; 3) PET/CT should now be considered for radiation therapy planning; and 4) a section on risk reduction was added to the discussion section. In addition, the panel discussed the use of PET/CT for the workup of anal canal cancer and decided to maintain the recommendation that it can be considered in this setting. They also discussed the use of PET/CT for the workup of anal margin cancer and for the assessment of treatment response. They reaffirmed their recommendation that PET/CT is not appropriate in these settings.

Complications after pancreatic resection remain prevalent. Procedure-related morbidity has previously focused on prevention of pancreatic and biliary fistulas (PFs and BFs) with other complications receiving less attention. We examined morbidity and its impact on reoperation, length of stay (LOS), and mortality following pancreatic resection. We retrospectively reviewed patients having elective pancreatectomy at the University of Tennessee affiliated hospitals during a recent 5-year time period. Factors examined included morbidity, mortality, and the need for reoperation. Patient deaths were analyzed with a focus on antecedent complications. Comparisons were made using Student's t test and χ2 analysis where appropriated. From 1997 to 2003, 125 patients had pancreatic resections: 93 Whipple procedures, 27 distal, and 5 total pancreatectomies. Twenty-nine patients (23%) did not have intraperitoneal drainage (IPD). Resections were performed for cancer in 75 per cent. Seventy complications occurred in 55 patients (44%). Morbidity related to an intra-abdominal process resulted in 16 reoperations and 4/6 deaths in this series (overall mortality, 4.8%). There were no BFs. Of 10 patients with PFs (8%), none required reoperation, and there was no PF-related mortality. No patient without IPD developed a PF. The presence of a PF significantly increased LOS when compared to those without (30.9 ± 13.1 vs 17.4 ± 12.2 days, P < 0.01). Forty-four per cent of all complications were related to either intra-abdominal abscess (IAA), hemorrhage, or feeding tube placement (18, 8, and 5, respectively). Management of IAA included percutaneous drainage in 16 and reoperation in 2 with 1 associated death. Hemorrhage necessitated reoperation in 6, resulted in 1 patient death, and was followed by IAA in 2. Of 5 jejunostomy tube complications, 4 required reoperation and 2 patients died. LOS was significantly greater in these 28 patients when compared to all others (28.1 ± 16.9 vs 15.8 ± 9.9 days, P < 0.001). Following pancreatectomy, 1) BFs should be a rare event; 2) PFs remain important but are most often managed nonoperatively with few sequelae; 3) in this series, IAA and hemorrhage were more common than PF, frequently mandated reoperation, prolonged hospitalization, and were associated with procedure related mortality; 4) feeding tube complications, though rare, are often catastrophic; 5) future efforts should focus on factors that could reduce abscess formation and a reduction in overall complications—many of which are potentially preventable.

The NCCN Rectal Cancer Guidelines panel believes that a multidisciplinary approach is necessary for treating patients with colorectal cancer. Patients with T1 or T2 lesions that are node negative by endorectal ultrasound and who meet carefully defined criteria can be managed with a transanal excision. Abdominal peritoneal resection or low anterior resection with total mesorectal excision is appropriate for all other rectal lesions. Either preoperative chemoradiation or postoperative chemoradiotherapy is standard for patients with suspected or proven serosal invasion (pT3) or regional node involvement. Patients with recurrent localized disease should be considered for resection with or without radiotherapy. Chemotherapy regimens using irinotecan or oxaliplatin should be considered for patients with distant metastasis. The panel endorses the concept that treating patients in a clinical trial has priority over standard or accepted therapy.

Colorectal cancer is the third most frequently diagnosed cancer in men and women in the United States, and in 2005, an estimated 104,950 new cases of colon cancer will occur. Despite these statistics, mortality from colon cancer has decreased over the past 30 years, possibly because of earlier diagnosis through screening and better treatment modalities. The NCCN guidelines summarize the management of colon cancer, from disease presentation through management of recurrent disease and patient surveillance. For the most recent version of the guidelines, please visit NCCN.org

Complications after pancreatic resection remain prevalent. Procedure-related morbidity has previously focused on prevention of pancreatic and biliary fistulas (PFs and BFs) with other complications receiving less attention. We examined morbidity and its impact on reoperation, length of stay (LOS), and mortality following pancreatic resection. We retrospectively reviewed patients having elective pancreatectomy at the University of Tennessee affiliated hospitals during a recent 5-year time period. Factors examined included morbidity, mortality, and the need for reoperation. Patient deaths were analyzed with a focus on antecedent complications. Comparisons were made using Student's t test and chi2 analysis where appropriated. From 1997 to 2003, 125 patients had pancreatic resections: 93 Whipple procedures, 27 distal, and 5 total pancreatectomies. Twenty-nine patients (23%) did not have intraperitoneal drainage (IPD). Resections were performed for cancer in 75 per cent. Seventy complications occurred in 55 patients (44%). Morbidity related to an intra-abdominal process resulted in 16 reoperations and 4/6 deaths in this series (overall mortality, 4.8%). There were no BFs. Of 10 patients with PFs (8%), none required reoperation, and there was no PF-related mortality. No patient without IPD developed a PF. The presence of a PF significantly increased LOS when compared to those without (30.9 +/- 13.1 vs 17.4 +/- 12.2 days, P0.01). Forty-four per cent of all complications were related to either intra-abdominal abscess (IAA), hemorrhage, or feeding tube placement (18, 8, and 5, respectively). Management of IAA included percutaneous drainage in 16 and reoperation in 2 with 1 associated death. Hemorrhage necessitated reoperation in 6, resulted in 1 patient death, and was followed by IAA in 2. Of 5 jejunostomy tube complications, 4 required reoperation and 2 patients died. LOS was significantly greater in these 28 patients when compared to all others (28.1 +/- 16.9 vs 15.8 +/- 9.9 days, P0.001). Following pancreatectomy, 1) BFs should be a rare event; 2) PFs remain important but are most often managed nonoperatively with few sequelae; 3) in this series, IAA and hemorrhage were more common than PF, frequently mandated reoperation, prolonged hospitalization, and were associated with procedure related mortality; 4) feeding tube complications, though rare, are often catastrophic; 5) future efforts should focus on factors that could reduce abscess formation and a reduction in overall complications--many of which are potentially preventable.

In 2006, an estimated 62,190 new cases of melanoma will be diagnosed, and approximately 7910 patients will die of the disease in the United States. The incidence of melanoma continues to increase dramatically. Risk factors for melanoma include family history, dysplastic nevi, and fair skin that sunburns easily; however, melanoma can occur in any ethnic group and in people who have not had substantial sun exposure. The NCCN Melanoma guidelines attempt to distill and simplify an enormous body of knowledge and experience into fairly simple management algorithms. For the most recent version of the guidelines, please visit NCCN.org

An estimated 3,990 new cases of anal cancer will occur in 2005, accounting for approximately 1.6% of digestive system cancers in the United States. Prognosis directly depends on the size of the primary tumor and the likelihood of lymphatic spread, with tumors 2 cm or smaller cured in 80% of cases. The NCCN guidelines recommend a thorough evaluation for any patient with a suspicious lesion in the anal canal and include additional recommendations for diagnosis, treatment, and follow up for anal canal cancer. For the most recent version of the guidelines, please visit NCCN.org

In 2005, approximately 1,490 cancer deaths will occur among persons living with thyroid carcinoma in the United States. Interestingly, although thyroid carcinoma occurs more often in women, mortality rates are higher for men, probably because men are usually older at the time of diagnosis. The incidence of thyroid carcinoma increased almost 240% between 1950 and 2000, but mortality rates decreased more than 44%. Although the causes of these statistically significant changes are uncertain, the increasing incidence may be caused by the increase in radiation-induced thyroid carcinoma. Conversely, the decrease in mortality may be related to earlier diagnosis, when the disease is presumably more amenable to intervention. However, this conclusion is confounded by a possible lead time bias. For the most recent version of the guidelines, please visit NCCN.org

Carcinoma of the large bowel is rare in persons under the age of 30, and generally presents with advanced stages of disease. From 1964 to 1984, 30 patients presented with nonfamilial large bowel malignancies. Seventeen patients were male, and 13 female (age range, 8-25 years). In 15 patients the primary was in the right transverse colon. In 26 patients the lesion was above the peritoneal reflection. Classification by Dukes' staging demonstrated Stage B in 3 patients, Stage C in 7 patients, and Stage D in 20 patients. Twenty-five patients had a mucinous variety of adenocarcinoma. Surgery at initial laparotomy consisted of biopsy (10 patients), palliative segmental resection (7 patients) and complete resection (13 patients; survival in each of these groups ranged from 1 to 15 months (median, 6 months), 6 to 36 months (median, 8 months) and 7 months to 14 years (median, 6 months), respectively. The only long-term survivors are three patients who had complete resection, two of whom are surviving free of disease after 5 and 15 years, respectively. Common sites of abdominal recurrence were the omentum (6 patients) and ovaries (7 patients). All patients received chemotherapy. In 16 of 24 evaluable patients, responses lasting 3 to 18 months were observed. Five patients also received radiation therapy. Follow-up of these patients included computed tomographic scans, ultrasound, and determination of carcinoembryonic antigen (CEA) levels. The CEA level in 9 of 23 patients did not correspond with the presence of either residual disease or progression of disease. Chemotherapy combined with a second-look surgical procedure in selected cases may improve the proportion of patients surviving and the duration of survival.

With the development of more effective combination chemotherapy and radiation, the role of surgical resection in the management of gastric lymphoma is reappraised. A retrospective review of 32 patients with gastric lymphoma, diagnosed and treated during the period between 1966-1979, is presented in an attempt to evaluate the relative effectiveness of the various modalities of diagnosis and treatment. Preoperative gastric barium x-ray studies were abnormal in 28 patients but were infrequently diagnostic of lymphoma. Endoscopy was employed in 15 patients with washings and biopsy. The biopsies were reported: four nondiagnostic; three suspicious of tumor; three carcinomas; and in only five patients was a clear diagnosis of lymphoma established. Fifteen patients were treated on the basis of biopsy via gastroscopy, or were explored and not resected and were treated with chemotherapy and/or radiation therapy. Fourteen of the nonresected patients have died with disease; one patient is surviving with disease at 20 months. Surgical resection was accomplished in 17 of the 32 cases, with seven patients (41%) surviving from 2-12 years. Aggressive primary chemotherapy with four-drug combination (CAOP) without surgical resection has resulted in massive upper gastrointestinal hemorrhage in four of five patients thus treated. This required emergency surgery for patients with depressed leukocyte and platelet counts. No perforation of the stomach was seen with primary chemotherapy as reported by other authors. In this series surgical exploration was necessary to establish a definite histologic diagnosis in 27 of the 32 patients. Exploration was an essential step in establishing the extent of disease to plan therapy. The only long-term survivors free of tumor were those which had been surgically resected. Resection of the gastric lymphoma prevented the complication of hemorrhage and perforation associated with chemotherapy and radiation therapy.

Of 49 patients with midgut and hindgut carcinoids, second primary distinct carcinomas occurred in 12. The most aggressive carcinoids were the 24 that arose in the distal small bowel and cecum. Of the patients affected, 15 had lymph node metastases and eight had liver metastases at the time of diagnosis. That only five patients were completely relieved of symptoms following resection was partially explained by autopsy findings in 15 patients, six of whom had metastatic extra-abdominal carcinoid without liver metastases (most commonly, bone metastases).

Metastatic basal-cell carcinoma is a rare entity, and for that reason a patient with local and distant metastases from a basal-cell carcinoma is reported. The literature is reviewed and problems of surgical management are discussed.

We have evaluated the usefulness of the tumor colony assay in predicting chemotherapeutic drug response in our cancer patient population. We found that a wide variety of human tumors will produce clonal growth in this in vitro assay. Low growth rates in many of the common human tumors, however, severely restrict the utility of this assay in a large number of cancer patients. A retrospective analysis using the assay to predict anticancer drug response revealed a true-positive predictive rate of 63% and a true-negative predictive rate of 96%. We conclude that if growth stimulants can be developed to enhance clonal growth without altering the predictability of the assay, the tumor colony assay could prove to be extremely useful in selecting appropriate chemotherapy for individual cancer patients.