Editor’s Note
	Rounds with the professors

As a senior student at the University of Pennsylvania School of Medicine, medical oncology was the last specialty I ever imagined entering. That notion rapidly changed when I met surgical oncologist Dr Robert Ravdin and medical oncologist Dr Sylvan Eisman. During my elective preceptorship with these caring and knowledgeable physicians, I was able to observe firsthand the art and science of medicine elevated to its highest level.

Making rounds with these doctors was particularly fascinating and taught me more than any textbook ever could. Years later, when I began conducting CME audio interviews, my penchant for case-based learning re-emerged and a favorite question became, “Can you discuss a patient from your practice whose clinical course illustrates your point?” This issue of Colorectal Cancer Update vividly demonstrates how interesting the responses can be.

Richard Goldberg follows up on a patient he first presented in this series two years ago — a young woman with liver-only metastases who responded very well to FOLFOX and then was sent for resection of the residual tumor. At the time of the first interview with Dr Goldberg, this woman was post-op, free of tumor and doing very well.

Unfortunately — as recounted in the current interview — a year after surgery, this woman developed tumor progression. Interestingly, the disease re-responded to the same FOLFOX therapy that Dr Goldberg originally initiated. As I listened to this case, I recalled similar stories in the late 1980s when adjuvant tamoxifen was used for one or two years in breast cancer patients. When some of these women developed tumor recurrence shortly after the discontinuation of their treatment, they experienced significant tumor responses to “tamoxifen rechallenge.”

Dr Goldberg noted that he currently encourages patients to receive systemic therapy after hepatic resection, and both arms of a new NSABP randomized trial include postoperative systemic therapy with a combination of capecitabine and oxaliplatin.

Axel Grothey takes case presentation to yet another level in discussing a 34-year-old woman whose clinical course defies explanation. The patient presented at cesarean section with extensive intra-abdominal carcinomatosis and liver metastases from advanced colon cancer.

The patient also had a massive pulmonary embolus related to tumor compression of the inferior vena cava. Dr Grothey thought that chemotherapy would be futile in this gravely ill patient, but because of her young age, he opted to try an agent that at that time (1996) had just become available to him — oxaliplatin, which was administered with 5-FU/leucovorin.

To the astonishment of the entire treating oncology team, the tumor virtually “melted away.” Following surgical resection of the primary lesion, the patient remains totally well and cancer-free without any further antitumor therapy. Dr Grothey and I mused about how gratifying it would be if scenarios like this one became commonplace in oncology, and one wonders if extraordinary cases like this one might someday be studied for clues about new treatment approaches.

If one wants a glimpse into the future of cancer care, spending 90 minutes with Heinz-Josef Lenz will provide plenty of food for thought. When I asked Dr Lenz to select a patient from his practice who exemplified the future direction of oncology, he described a young woman with unresectable bilobar liver metastases.

This woman’s therapy — FOLFOX and a COX-2 inhibitor — was chosen because of tissue profiling of treatment predictors. The patient had an excellent response and is now being considered for hepatic resection of the remaining tumor. While it is impossible to say how tissue predictive factors actually will play out in clinical practice, it is appealing to consider this type of case scenario for the future.

Clearly, data from randomized clinical trials must continue to shape our treatment guidelines, and the increased emphasis on evidence-based decision making has resulted in improved patient care. However, there will always be an important role for astute observations about individual cases, and nowhere is this more clearly demonstrated than in the clinical courses of the three patients treated by the professors featured in this issue.

—Neil Love, MD