training. More intensive experience with relation to symptom control and communication skills would require a longer placement. SpRs’ training in Medicine for the Elderly, e.g., can spend up to 3 months in palliative care.
Training issues clearly need to be appropriate to the seniority of the trainee, and the placement can perhaps be mutually beneficial when the attachment is at a relatively late stage of the Clinical Oncology SpR’s training. This could certainly be the case if the time in palliative care was longer, and could therefore accommodate integration into the team and a more active role within that.
The authors suggest that simply increasing the length of the training period would not necessarily solve the specific problems raised. While this is true, oncology is largely a postgraduate subject and it is therefore difficult to build on undergraduate and general experience which the medical specialties can usefully do. A six year period would allow an option for “time out” in palliative care or others: e.g. high dose chemotherapy which was also mentioned, or diagnostic radiology which could be equally useful.
Much of our workload in clinical oncology is likely to be palliative particularly in certain areas of the site specialisation e.g. lung. It therefore makes sense to prioritise and highlight this particular deficit in training. It is of note than when the author (RMM) was appointed to a substantive clinical oncology consultant post; that further training in palliative care was recommended.
R. M. McMENEMIN Beatson Oncology Centre, K. L. SHERRY Glasgow, UK
REFERENCES
1 Nutting C, Short S. Where now with training in clinical oncology? (Ed). Clin Oncol 2001;13:4-5.
doi:10.1053/clon.2001.0035, available online at http://www. idealibrary.com on IDEAL®
TRAINEE IN CLINICAL ONCOLOGY - HOW MUCH IS ENOUGH PALLIATIVE MEDICINE?
Comment
Sir - Oncology and Palliative Medicine share in the care of patients with progressive and advanced cancer: not surprisingly the two specialties should share some common core skills and knowledge. While the training in palliative medicine requires substantial attach- ment to oncology teams, I suspect that oncologists are less aware of the contributions palliative care can make to their own training. This is reflected in the paucity of experience among oncology trainees.
Confidence in alleviating physical distress needs expertise in a range of options, of which palliative oncological treatment is but a part. Pain and symptom control is not just ‘how to do it’ but requires skilful goal setting, communication with patient and family and liaison with other professionals.
Skilled oncologists can offer support and enable patients to make important decisions at all stages from diagnosis onwards. When doctors make difficult decisions, they should be aware of the ethical dimensions to these, yet the pace of clinical activity rarely permits reflection, let alone discussion, of important issues. Such training is part of the curriculum for palliative medicine.
Awareness of the role of many other professionals who support and care for the patient with cancer - and family - is essential. To achieve this our oncology trainees should see the same patients who attend clinics in other settings, especially at home and in the hospice.
Exposure to palliative care may enrich the knowledge, skills and attitudes of oncology trainees to the benefit of all patients and not just
the terminally ill. Both specialties have much to learn from each other; our oncology trainees deserve more than the attachment of a week which has been suggested. Creative options may include regular sessions with the local palliative care specialist and team, or a block attachment. Less than four weeks is unlikely to achieve the potential benefit to our trainees and their future patients.
DR WENDY MAKIN
Macmillan Consultant in Palliative Care & Oncology, Department of Medical Oncology, Christie Hospital, Wilmslow Road, Manchester M20 4BX, U.K.
doi:10.1053/clon.2001.0027, available online at http://www. idealibrary.com on IDEAL®
ADRENAL CORTICAL CARCINOMA PRESENTING INITIALLY WITH RADIUS METASTASIS
Sir - Adrenal cortical carcinoma is a malignant neoplasm of adrenal cortical cells demonstrating partial or complete histologic and func- tional differentiation. Adrenal cortical carcinomas are rare and com- pose between 0.05% and 0.2% of all cancers.
A 38-year-old woman was admitted to hospital complaining of pain in the right arm. Her physical examination was normal except for mild abdominal tenderness. The pain in the arm had started after trauma and X-ray showed a lytic fracture involving the proximal part of the radius. The MRI of the left arm demonstrated a mass lesion in the proximal part of radius with soft tissue component causing cortical destruction with diameters of 4 × 4.5 x 5 cm. An abdominal ultra- sonography was performed because of her complaint of a vague abdominal pain and a mass lesion around the left kidney was found. Radical nephrectomy was done, the pathology of the specimen was reported as adrenal cortical carcinoma with perirenal implantation. The thoraco-abdominal tomography and radionuclide bone scanning showed multiple metastatic lesions in the liver and lungs and multiple bone metastases in the left scapula, iliac crest, acetabulum and right femur. The tumour was nonfunctional and she received multi-agent chemotherapy consisting of cisplatin and etoposide and palliative radiotherapy was given for her painful bone metastasis located on the proximal part of radius. After two cycles of chemotherapy and a palliative radiotherapy, abdominal ultrasonography revealed recurrent mass in the left surrenal area with intra-abdominal lymphadenopathy. She was inoperable and died due to disease progression 4 months after time of diagnosis.
The adrenal glands have a well-protected position, being located deep within the abdomen retroperitoneally and protected posteriorly and laterally by the rib cage. They are, by this position, inaccessible to physical examination, which in part explains the advanced disease at the time of diagnosis of adrenocortical carcinoma as in our case presenting initially with bone metastases. Symptoms depend on whether the tumour is functional or not. Pain is one of the major forms of presentation, either related to metastasis or a large abdominal mass [1-4].
Most patients are metastatic at the time of diagnosis. Lungs, lymph nodes, liver, bone and contralateral adrenal are the common sites for metastasis. The incidence of bone metastases from adrenal cortical carcinoma is about 10% [5].
MİNE DURUSU Hacettepe University School of Medicine, DUYGU YAZGAN AKSOY Department of Internal Medicine; M. KADRİ ALTUNDAĞ Hacettepe University Institute of Oncology, HÜSEYİN ABALI Department of Medical Oncology
ALEV TÜRKER BEKİR EREN ÇETİN Hacettepe University Institute of Oncology, Department of Radiation Oncology, Ankara, Turkey
REFERENCES
1 Huvos AG, Hajdu SI, Brasfield RD, et al. Adrenal cortical carcinoma-clinicopathologic study of 34 cases. Cancer 1970;25:354- 364.
2 Lewinsky BS, Grigor KM, Symington T, et al. The clinical and pathologic features of non-hormonal adrenocortical tumors. Report of 20 new cases and review of the literature. Cancer 1974;33:778-790.
3 Lipsett MB, Hertz R, Ross GT. Clinical and pathophysiologic aspects of adrenocortical carcinoma. Am J Med 1963;35:374- 383.
4 Hough AJ, Hollifield JW, Page DL, et al. Diagnostic factors in adrenal cortical tumors. Am J Clin Pathol 1979;72:390.
5 Wajchenberg BL, Pereira MAA, Medonca BB, et al. Adrenocortical carcinoma clinical and laboratory observations. Cancer 2000;88: 711-736.