UICC International Union Against Cancer – serie

The suggestion that cancer incidence rates for different parts of the world should be brought together in ~ single volume arose in diSCUssion among mem­ bers of the Geographical Pathology Committee of the International Union Against Cancer during a symposium in Mexico in .1964. That there was a need for such a volume rapidly became apparent when the directors of cancer registries were asked for their opinion. Of those approached, all but one responded enthusias­ tically and immediately agreed to contribute. In the event, data have been col­ lected from 32 cancer registries in 24 countries, and 39 scientists have con­ tributed personally by describing the character of their registry and by collec­ ting and submitting figures in a standard way. The form in whiCh the book appears was suggested by a committee of 15 members, which met at the Ciba Foundation in London in May, 1965, and the editors have been guided in their work by the results of the discussions that took place at that meeting. In a few instances, it has not been possible to follow the Committee's advice, for reasons of finance, and the text which was written by the editors may, in some places, have inadvertently misrepresented the Committee's views. The editors, therefore, take full personal responsibility for all defects in both style and scientific presentation.

The outstanding success of the First Edition and the expansion of our knowledge about cancer over the 5 years since its publication have led to the decision to publish a Second Edition which has been fully revised, rewritten and enlarged by the addition of several sections. The First Edition was translated into Italian, Japanese, Polish, and Serbo-Croat and it is expected that additional translations (French, German, Spanish, Portuguese, etc. ) will make this Second Edition a truly international basic cancer Manual. The Revision Committee is convinced that all students and general physicians should know: (a) the important basic aspects of cancer; (b) some details of the most common cancers; and ( c) a few important points about the less common cancers. An attempt has been made to strengthen Part I, General Aspects, which is considered to be the most important part of the Manual for the world's physicians. However, the most common cancers in one part of the world are not necessarily the same in other parts and it is planned to work with local groups to produce adaptations and translations as seem appropriate. In particular, the UICC is anxious to work with local, national, and international committees to help improve the educational experience of students and general physicians in the geographic areas in question. Regional Conferences held by the UICC in Latin America, Asia and the Middle East have resulted in initial plans to accomplish this aim.

It is a very special honour for me to be able to present this handbook of medical oncology, which under diverse headings and origins covers such a vast spectrum of experience. I be­ lieve the reader will be struck in particular by the impressive volume of information available, especially with regard to childhood tumours, which represent, today, an immense "lab­ oratory of hope". It is in this very field that we oncologists have been able to obtain the most consoling results in recent years. I feel sure that all those who read these chapters will find that their oncological competence is enriched and also in a certain sense that their wish to contribute to progress in can­ cer research and treatment has been renewed. In conclusion, my most heartfelt congratulations go to the authors for the excellent job they have done, as well as my ad­ miration for having been able to concentrate so much pre­ cious and innovative information into so little space. Umberto Veronesi Preface Since 1976, the VICC has been holding chemotherapy courses in all parts of the world, excluding North America and Australia. The Manual of Cancer Chemotherapy, origi­ nally devised as a didactic tool to be used by course partici­ pants, expanded itself in the successive editions to a compre­ hensive, although schematic, textbook of medical oncology.

The History of the TNM System The TNM System for the c1assification of malignant tumours was developed by Pierre Denoix (France) between the years 1943 1 and 1952. In 1950 the UICC appointed a Committee on Thmour Nomen- clature and Statistics and adopted, as a basis for its work on clini- cal stage c1assification, the general definitions of local extension of malignant tumours suggested by the World Health Organiza- tion (WHO) Sub-Committee on The Registration of Cases of 2 Cancer as weIl as their Statistical Presentation. In 1953 the Committee held a joint meeting with the Interna- tional Commission on Stage-Grouping in Cancer and Presenta- tion of the Results of Treatment of Cancer appointed by the International Congress of Radiology. Agreement was reached on a general technique for c1assification by anatomical extent of dis- ease, using the TNM system. In 1954 the Research Comrnission of the UICC set up a spe- cial Committee on Clinical Stage Classification and Applied Statis- ticsto "pursue studies in this field and to extend the general tech- nique of c1assification to cancer at aIl sites".In 1958 the Committee published its first recommendations for the clinical stage classification of cancers of the breast and 1 Denoix, P.F.: BuH. Inst. Nat. Hyg. (Paris) 1: 1-69 (1944) and 5: 52-82 (1944).

The continuing success of the VICC's Manual of Clinical Oncology and the continuing refinement of our educational objectives in cancer designed for graduating medical students and young practitioners, cou­ pled with significant additional knowledge in the cancer field have allIed to the decision to publish a Fourth Edition. The collaboration of the World Health Organization (WHO) and the Pan-American Health Orga­ nization (PAHO) in our international and regional conferences in cancer education and the development of courses using the Manual as a basic resource have aided further definition of the VICC's role in cancer educa­ tion throughout the world. Our Revision Committee believes that we have incorporated in this small volume most of the knowledge about cancer which is essential for all students and practioners to know and that we have done so in a clear and concise manner. A large proportion of the material presented herein is devoted to basic aspects, yet presented so that the clinical implications are clear. Although we do not feel that general physicians need to know minor details about all cancers, we feel it is particularly important to be somewhat thorough in our discussions of the more common cancers. We have omitted discussion of the rare cancers, and limited ourselves to the major concepts and princi­ ples of the less common cancers.

During the last few decades, there has been a tremendous improvement in the treatment of cancer. There is evidence that this trend is continuing, based on the achievements re­ sulting from the combined efforts of clinicians and basic re­ search workers. This book is an example of such interaction and collaboration. It was prepared by authors representing both areas of work. Most of the work reported in this book is not merely theoretical, but has been experimentally successfully tested and sometimes applied clinically. This work has, however, not yet been generalized and practiced on a wide scale. Some of the results reported here relate to new aspects and open new horizons for future progress. This book will be of great value for both clinicians and basic research workers. VICC Treatment and Rehabilitation Programme ISMAIL ELSEBAI Chairman Preface The three main approaches to the treatment of cancer are surgery, radiotherapy, and chemotherapy. Today, all malignant neoplasms are managed by one or more of these modalities, with varying success rates depending on the type of tumor, its degree of spread, and the knowl­ edge and skill with which the treatment plan has been designed and executed. In the United States of America and in Europe, approximate­ ly half of all cancer is presently curable, but this has been the case for approximately 20 years.

Die TNM-Klassifikation ist das international anerkannte und verwendete System zur Bestimmung der klinisch und histopathologisch anatomischen Ausbreitung einer Tumorerkrankung. Dieses System ist aus der engen Zusammenarbeit aller nationalen und internationalen Komitees entstanden und bildet die Grundvoraussetzung einer sinnvollen Befundbeschreibung und somit die Basis einer Therapieform und ihrer Prognose. Nur so ist eine einheitliche Sprache aller Onkologen beim Vergleich ihrer klinischen Befunde und bei der Bewertung ihrer Behandlungsresultate zu erreichen. Die 6. Auflage enthält die ab 2003 gültigen, für einige Tumoren überarbeiteten, neuen Richtlinien der Tumorklassifikation.

The fourth edition of the TNM Classification was published in 1987,1 and a revision in 1992.2 It was the result of efforts by all national TNM Committees towards a worldwide uniform classification. The classifica­ tion criteria are identical with the fourth edition of the Manual for 3 Staging of Cancer of the American Joint Committee on Cancer (AJCC). Although the classification has found wide acceptance, some workers have pointed out that individual definitions and rules for staging are not sufficiently detailed. This can lead to inconsistent application of the clas­ sification. the antithesis of standardization. This source of differences in interpretation applies not only to the classification of individual organs but also to the general rules of the system, especially to the definitions of the requirements for the pathological classification (pT, pN). These are specified only for carcinoma of the breast; for other sites, reference must be made back to the general rules. which can lead to variable interpreta­ tions. The TNM Project Committee of the UICC has addressed this prob­ lem and collected and considered the criticisms and suggestions from the national TNM Committees as well as from cancer registries, oncolo­ gical associations and individual users. The result was the decision to complement the 4th edition of the TN M Classification 1.2. 3 with the publi­ cation of a TNM Supplement containing recommendations for the uni­ form use of TNM.

While our knowledge about cancer is proliferating rapidly, our principles of cancer medicine for individual patients and for populations are evolving only gradually. Our fundamental understanding of cancer causes and deve­ lopment is incomplete, and our treatments are nonspecific and less often curative than we would like. Nevertheless, worldwide, our major challenge remains to apply to our populations all that we know about cancer. To meet this challenge, doctors everywhere need a broad view and under­ standing of cancer causes and control. This book is intended for doctors-in-training and clinical medical practi­ tioners; it provides principles across the breadth of cancer medicine. The editors and authors believe that it is possible to reduce the exposition of current knowledge to the compact 40 chapters and 600 pages presented here without losing the comprehensiveness, richness, and pragmatic detail that doctors need. This compilation presumes knowledge of the basic sciences, particularly genetics, pathology, anatomy, and physiology. We have tried to balance scientific exposition with practical material in preven­ tion, early detection, and palliative care, which are the major areas of pub­ lic health medicine where greater attention is needed worldwide. While this book is based, in part, on material prepared for previous edi­ tions, each chapter has been newly written and edited by the authors and editorial staff for this edition.

This monograph is the result of an effort by the International Union Against Cancer (UICC) to study prognostic factors related to cancer. It is an extension of the long-term work on the TNM classification and the strongest prognostic tool for most cancers. The monograph aims to compile information on prognostic factors for most tumour sites and selected tumour types. Each site- or tumour-specific chapter provides a general overview of the relevant literature on prognostic factors. Where possible, the authors have attempted to assess these factors in terms of their clinical relevance and of their strength and independence in influencing prognosis.

th At the 6 International Cancer Congress held meantime the new committee has endeavored at Sao Paulo a list of tumors, intended to produce a simple, generally acceptable primarily for the purpose of statistical codi- tumor nomenclature founded on logical prin- fication, was presented and accepted with ciples of pathology. A first draft without pictures was published in slight alterations only. This list had been prepared by the Committee on Tumor Nomen- "ACTA" Vol. XIV No. 3-1958, which is now clature and Statistics, of the International followed by an illustrated edition. We are Union against Cancer, under the chairman- greatly indebted to all the authors and publish- ship of Dr. PERRY. It had also served as ers for permission to use their illustrations and a basis for the somewhat simplified code for providing us with the original prints. submitted to WHO, which circulated it Unfortunately it was not possible to obtain as document WHOjHSjCANCj24.1.An al- the original prints for the figures from the Atlas of Tumor Pathology; we therefore had phabetical index to the code, mostly ba- sed on terms in use in the United States, to use the printed illustrations for repro- constitutes part 2 of this document (WHOj duction and are grateful to the Armed Forces Institute of Pathology for permission HSjCAN/C24.2). The preparation of a list of descriptive terms to use them.

In 1966, following the Ninth International Cancer Congress in Tokyo, the Commission on Epidemiology and Prevention of the International Union against Cancer formed a new Committee on Cancer Incidence. This Committee met in Lausanne in May 1968 and decided that the monograph on Cancer Incidence in Five Continents, which had been published by the UICC tw~ years previously, had been so useful that a second volume should be published as soon as a suf­ ficient amount of new material could be collected. The Committee delegated the responsibility for the production of this volume to the Editors of the original monograph and to the Honorary Secretary of the Committee, Dr C. S. Muir. Mr P. Payne, however, was unable to continue in this capacity because of the pressure of other commitments. The Editors have 1eant heavily on the skills and knowledge of Dr A. J. Tuyns and Dr H. Tu1inius, who have been responsible for the preparation of Chapters II and IV respectively and for the collection of a large part of the material presented in them. They are also greatly indebted to Miss J~ Powell of the Birmingham Cancer Registry, who wrote the computer programme for calcu­ lating the age-specific and standardized incidence rates, in conjunction with Dr J. A. H. Waterhouse, and supervised the operation of the computer, as well as to Mme J.