Paul Sugarbaker and his colleagues have persevered in the study and treat ment of peritoneal carcinomatosis. The peritoneal cavity has many unique and incompletely appreciated properties. These properties, coupled with the biologic behavior of many cancers, results in the seeding and growth of these cancers on the peritoneum. Many of these cancers remain localized to the peritoneum only, never metastasizing to other sites. One possible reason for this may be the obstruction of the afferent lymphatics on the undersurface of the diaphragm. The mucopolysaccharides produced by many of these neoplasma are probably viscous enough to obstruct these lymphatics, leading to the syndrome of pseudomyxoma peritonei. Many of the neoplasms taking residence on the peritoneum have extremely long cell-cycle times and are resistant to radiotherapy and many chemotherapeutic agents. How ever, much can be done for these patients - resection of primary cancers, omentectomies to reduce ascites formation, management of recurrent ascites, management of intestinal obstruction, nutritional care, and, hopefully, intraperitoneal chemotherapy. We have reviewed many of these problems in the past [1-7]. Dr. Sugarbaker and his colleagues have organized the current state of knowledge and technology for continuing use. The book provides a basis for thoughtful, prospective research planning. John S. Spratt, M. D. , F. A. C. S. Professor of Surgery The James Graham Brown Cancer Center University of Louisville Louisville, Kentucky References 1. Long RTL, Spratt JS, Dowling E.

Peritoneal carcinomatosis dominates the clinical picture of many patients with gastrointestinal, gynecological and urological cancers. For many of them its dev astating effects contribute directly to their death. Most clinicians consider peritoneal carcinomatosis an incurable metastatic disease and give palliative treatment, re stricted to limited surgery and systemic chemotherapy. Contrary to this view, Paul Sugarbaker and his collegues base their approach on the concept that peritoneal carcinomatosis represents regional tumor spread, similar in its impact on treatment and prognosis to that of lymph node metastases in other malignancies. This concept emphasises the value of regional tumor control, as a potentially curative measure. In this book the combination of aggressive cytoreduction and intraperitoneal chemotherapy to control peritoneal carcinomatosis is extensively explored. Basic to this approach is the observation that most cancer cells show only relative resistence against commonly available drugs, which can be overcome by a sufficient increase of drug concentrations in tumor tissue. After intraperitoneal delivery, drugs will reach high tissue concentrations in the superficial few cell layers, while plasma concentrations will remain below toxic levels. Patients with only limited residual tumor at the peritoneal surface after cytoreduction may therefore benefit from intraperitoneal chemotherapy.

Gastric cancer has been one of the great malignant scourges affecting man kind for as long as medical records have been kept. Until operative resection pioneered by Bilroth and others became available, no effective treatment was feasible and death from cancer was virtually inevitable. Even with resection by total gastrectomy, the chances of tumor eradication remained small. Over recent years, however, the situation has been changing. Some changes have resulted from better understanding of the disease, early detec tion, and better management techniques with applied clinical research, but the reasons for other changes are poorly understood. For example, the incidence of gastric cancer is decreasing, especially in westernized societies, where it has fallen from one of the most common cancers to no longer being in the top five causes of cancer death. Still it remains the number one killer of adult males in Japan and Korea. Whether the reduced incidence in western societies is a result of dietary changes or methods of food preservation, or some other reason, is as yet uncertain. Improvements in outcome have been reported from mass screening and early detection; more refined techniques of establishing early diagnosis, tumor type, and tumor extent; more radical surgical resection; and resection at earlier stages of disease."

When one deals with cancer, the hepatobiliary malignancies present a challenge to the oncologist that can be best characterized as a series of unsolved clinical and biological dilemmas. Liver metastases from colorectal and other gastrointestinal malignancies, hepatocellular carcinoma, cholangiocarcinoma and gall bladder cancer present an array of problems but have two features in common; these are high morbidity and mortality with an overall poor result from treatment. Even though there are many reasons to be discouraged in the treatment of hepatobiliary cancer, there are some unique features that the liver presents which allow innovative treatment options. First, the liver is one of the few organs in the body that will regenerate over time. Patients who can be made disease free will usually return to a fully functional state despite the ablation of up to 80% of this organ. Secondly, the liver has an isolated vasculature. Intraarterial infusion, portal venous infusion, and even isolated perfusion are not only possible but have been accomplished and been used in clinical trials. Third, this organ is extremely well characterized radiologically and the progress of treatments can be monitored with great accuracy. Tumor markers assist in this follow-up. Finally, this is an organ that can be transplanted with great success when there is benign disease. If one could control small volume systemic malignancy outside of the liver, transplantation would offer a curative approach in a large majority of patients. The book presents both the credits and debits that one must encounter in dealing with hepatobiliary cancer. The traditional discouragement is blended with opportunity so that the oncologistfinds himself wishing to know more and in knowing more to do more in the treatment of hepatobiliary cancer.

Steven A. Rosenberg, MD In the past two decades significant progress has quality of life. The use of local radiation therapy has occurred, in the management of patients with mus- had a profound impact on the ability to achieve local loskeletal cancers, that has improved both the survival control. Cooperation between surgeons and radiation and the quality of life of afflicted patients. Changes in therapists often results in the tailoring of surgical p- the management of these patients have mirrored cedures to maximize the combined application of these trends in the entire field of oncology. two effective treatment modalities. Although impact on The most significant change has been improvement overall survival has not been demonstrated due to the in the surgical techniques for the resection of musculo- addition of radiation therapy, important advances in skeletal cancers based on a detailed understanding of improving the quality of life of patients receiving this the anatomic features of each particular tumor site, as combined-modality treatment have been evident. well as an appreciation of the natural biology that affects A third change impacting on the survival of patients the local spread of these tumors. The current volume of with musculoskeletal cancers has been the aggressive Musculoskeletal Cancer Surgery: Treatment of Sarcomas and resection of metastatic deposits.

When one deals with cancer, the hepatobiliary malignancies present a chal lenge to the oncologists that can be characterized as a series of unsolved clinical and biological dilemmas. Liver metastases from colorectal and other gastrointestinal malignancies, hepatocellular carcinoma, cholangiocar cinoma, and gall bladder cancer present an array of problems but have two features in common. These are high morbidity and mortality with an overall poor result from treatment. Why is it that hepatobiliary cancer carries with it such a dismal prognosis? First of all, these diseases present, for the most part, in an advanced state. To this point in time the oncologist has had no help from early diagnosis or screening. Only the occasional patient followed by ultrasound or a tumor marker has the disease diagnosed in an asymptomatic state. By the time these diseases become symptomatic, curative treatment options have usually disappeared. Evolution has placed the liver in a protected position in order to avoid injury to the soft parenchyma. As with many other internal organs, the nerve supply is extremely limited. These two anatomic features result in a great lack of early warning signs of cancer.

Gastric cancer has been one of the great malignant scourges affecting man kind for as long as medical records have been kept. Until operative resection pioneered by Bilroth and others became available, no effective treatment was feasible and death from cancer was virtually inevitable. Even with resection by total gastrectomy, the chances of tumor eradication remained small. Over recent years, however, the situation has been changing. Some changes have resulted from better understanding of the disease, early detec tion, and better management techniques with applied clinical research, but the reasons for other changes are poorly understood. For example, the incidence of gastric cancer is decreasing, especially in westernized societies, where it has fallen from one of the most common cancers to no longer being in the top five causes of cancer death. Still it remains the number one killer of adult males in Japan and Korea. Whether the reduced incidence in western societies is a result of dietary changes or methods of food preservation, or some other reason, is as yet uncertain. Improvements in outcome have been reported from mass screening and early detection; more refined techniques of establishing early diagnosis, tumor type, and tumor extent; more radical surgical resection; and resection at earlier stages of disease."

B. CADY Hepatic met, ' tasl S present one of the major therapeutic challenges of cancer patien: management, for it is the destruction of vital organ function that makes cancer fatal, not local tumor growth. The process of tumor cell dislodgement from the primary cancer, their spread through the lymphatic and hematogenous channels, their lodgement in distant sites, and their subsequent progressive growth tax our comprehension a'ld i. -ustrate our therapies. The proceedings of this International Con, t ss on Hepatic Metastasis address these aspects of metastases to t: '. >2 _ . ver, and predominatly focus on metastatic colon cancer because of t . s frequency, its prominent hepatic only pattern of spread, and enticing preliminary data about prevention and control of small sub . '(ts of the afflicted population. Predictably, the "false technologies" of Dr. Lewis Thomas that involve surgical, radiotherapeutic and chemo therapeutic attack on these metastases after elaborate diagnostic studies take precedence because of the clinical imperatives of sick patients. This is displayed in the preponderance of papers and in terest in various diagnostic scanning techniques by means of radio isotopes, radiographically useful dyes, biochemical markers, interest in developing accurate staging systems to categorize patients for therapeutic comparisons, and interest in elaborate, and expensive, technology to increase the effectiveness of chemotherap utic agents that are of limited benefit with simple intravenous administration. Behind this clinical enthusiasm, however, lies the research to develop the "true technology," in Thomas' words, that will prevent such clinical catastrophies as hepatic metastases."

Paul Sugarbaker and his colleagues have persevered in the study and treat ment of peritoneal carcinomatosis. The peritoneal cavity has many unique and incompletely appreciated properties. These properties, coupled with the biologic behavior of many cancers, results in the seeding and growth of these cancers on the peritoneum. Many of these cancers remain localized to the peritoneum only, never metastasizing to other sites. One possible reason for this may be the obstruction of the afferent lymphatics on the undersurface of the diaphragm. The mucopolysaccharides produced by many of these neoplasma are probably viscous enough to obstruct these lymphatics, leading to the syndrome of pseudomyxoma peritonei. Many of the neoplasms taking residence on the peritoneum have extremely long cell-cycle times and are resistant to radiotherapy and many chemotherapeutic agents. How ever, much can be done for these patients - resection of primary cancers, omentectomies to reduce ascites formation, management of recurrent ascites, management of intestinal obstruction, nutritional care, and, hopefully, intraperitoneal chemotherapy. We have reviewed many of these problems in the past [1-7]. Dr. Sugarbaker and his colleagues have organized the current state of knowledge and technology for continuing use. The book provides a basis for thoughtful, prospective research planning. John S. Spratt, M. D. , F. A. C. S. Professor of Surgery The James Graham Brown Cancer Center University of Louisville Louisville, Kentucky References 1. Long RTL, Spratt JS, Dowling E.

Peritoneal carcinomatosis dominates the clinical picture of many patients with gastrointestinal, gynecological and urological cancers. For many of them its dev astating effects contribute directly to their death. Most clinicians consider peritoneal carcinomatosis an incurable metastatic disease and give palliative treatment, re stricted to limited surgery and systemic chemotherapy. Contrary to this view, Paul Sugarbaker and his collegues base their approach on the concept that peritoneal carcinomatosis represents regional tumor spread, similar in its impact on treatment and prognosis to that of lymph node metastases in other malignancies. This concept emphasises the value of regional tumor control, as a potentially curative measure. In this book the combination of aggressive cytoreduction and intraperitoneal chemotherapy to control peritoneal carcinomatosis is extensively explored. Basic to this approach is the observation that most cancer cells show only relative resistence against commonly available drugs, which can be overcome by a sufficient increase of drug concentrations in tumor tissue. After intraperitoneal delivery, drugs will reach high tissue concentrations in the superficial few cell layers, while plasma concentrations will remain below toxic levels. Patients with only limited residual tumor at the peritoneal surface after cytoreduction may therefore benefit from intraperitoneal chemotherapy.

Peritoneal metastases continue to be a potentially lethal manifestation of gastrointestinal and gynecologic malignancy. In the past little if any treatments except systemic chemotherapy were available. Outcomes of treatment were poor and were routinely regarded as palliative. This dismal outlook has gradually changed as a result of two technical innovations: 1) Cytoreductive surgery with peritonectomy procedures and visceral resections and 2) Perioperative intraperitoneal and systemic chemotherapy. At this time approximately 2000 peritoneal oncology centers are active around the globe. With prevention and treatment of peritoneal metastases a reality the traditional role of the radiologist to characterize the malignancy is mandatory for knowledgeable management. We have discovered that the radiologic description of peritoneal metastases is challenging, to say the least. Progress has occurred. In our Pictorial Essays on Peritoneal Metastases Imaging: CT, MRI and PET-CT our radiologists have gathered together an abundance of information. Our book has established a role of the radiologist as an essential part of multidisciplinary management of a common and complex clinical problem. No longer is the radiologist's role only to determine if peritoneal metastases are absent versus present. The best technology or combinations of technology as CT, MRI or PET-CT must be selected. Not only a diagnosis of peritoneal metastases but extent and distribution of disease is required. The oncologist and surgeon need to know the likelihood of success with treatment. For primary cancer identification of patients at high risk for local-regional recurrence allows special treatments to be utilized before treatment failure occurs. If recurrent disease is suspect, the radiologist may interpret its causation and describe the interventions required to treat or suggest only palliation. The associated features of peritoneal metastases such as ascites or lymphadenopathy must be interpreted. The report must be complete with all information required by the clinician. Finally, the knowledgeable quantitation of concerning radiologic features can have profound prognostic implications. There is a large amount of information in this book that is not available anywhere else. Our book fills a large GAP in the management of gastrointestinal and gynecologic cancer. Our book not only verbally describes the images of peritoneal metastases, it shows them in carefully selected radiographs. The figures, figure legends and text allow the findings to be interpreted so they are clinically relevant. The images become a visible guide to construct a management plan. The radiologist's accurate description of peritoneal metastases is difficult at best, sometimes impossible, but comprehensively presented in this book. If one is interested in peritoneal metastases, the Pictorial Essays on Peritoneal Metastases Imaging: CT, MRI and PET-CT is a required addition to the personal library.