Generally less than 20% of patients with metastatic solid tumor malignancies show significant tumor regression using chemotherapy, which, like surgery and radiation, fails to address the immunosuppressive nature of the disease. In addition, myelosuppressive chemotherapy and radiation therapy can impair the patientís immune response and further weaken his or her resistance to cancer. Clearly a more effective class of systemic therapies is needed.
Long-term questions naturally exist and should be addressed even as the therapy is refined and made more widely available. What is the precise efficacy of OncoPherese in each major cancer type? What drives recurrence and why does it sometimes not occur? For those patients in whom OncoPherese is ineffective, could adjunctive therapies improve outcomes? We are currently planning new, highly focused clinical trials to answer these and other questions.
Tumors in anatomic sites intolerant of tumor swelling require special attention, e.g. the CNS, where edema and hemorrhage are particular concerns. Vascular tumors that die too fast can hemorrhage. Transmural tumors in hollow viscera that necrose too fast can lead to perforation. In summary, great care and medical planning must be exercised, and complications anticipated, before effective immunologic treatments are applied. Sometimes surgical intervention or tumor de-bulking is necessary to maximize safety and optimize clinical outcomes.
Nutrition plays a vital role in this regard as well. Most people who live above 30 degrees north latitude become vitamin D deficient after October and begin to raise their levels as late as April. Vitamin D is essential for obtaining and maintaining a good immune response against cancers, viruses and fungi. Zinc is also an important co-factor in immune reactions, as are vitamin C, vitamin A and other micronutrients. Proper protein intake is also vital. Daily exercise, relaxation and proper sleep patterns are essential, too. The patient should be in proper endocrine balance. Thyroid function, adrenal cortical function and reproductive endocrinology must be managed effectively. Co-existing medical conditions must be addressed and corrected as much as possible to optimize immune strength.
In most cases consulting radiologists have simply never seen such reactions and may be uncertain how to interpret what they are observing. The expected response to any effective pro-inflammatory tumor therapy is: short-term tumor inflammation and swelling followed by necrosis, loss of blood supply, tumor shrinkage, and fibrosis. Radiographically, this first produces increased tumor size – which can be misread as cancer progression – attended by decreasing density on non-contrasted CAT scan and increased SUV on PET. Later, one observes decreased density in Hounsfield Units and decreased contrast enhancement on CAT with decreased SUV on PET.
At the height of tumor inflammation the PET is positive not from tumor metabolism but rather from increased metabolism of inflammatory and other stromal cells, a sign of healing. This is followed by tumor shrinkage with failure of the mass to contrast enhance on contrasted CAT scan, but the lesion remains PET positive until healing is complete and the mass either resolves or becomes scar tissue.
Finally, the lesion assumes the density of scar tissue, reveals no contrast enhancement and becomes PET negative. In bone, lytic lesions will progress to sclerosis by CAT scan and plain X-ray. Such lesions will reveal PET scans that remain positive for many months possibly relating to increased metabolism of healing tissue and bone remodeling. Close coordination and ongoing discussion with the entire health care team is essential.
This procedure is the most remarkable therapy I have ever seen. JAMES FRACKELTON, M.D.
In my medical opinion this treatment is a great advance in cancer therapeutics and should be made available on a wide basis and covered by insurance as soon as possible. ROBERT S. WATERS, M.D.
Each and every sarcoma patient deserves to have the same life-saving and limb preserving treatment that has been available to me. AM, PH.D.
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