The role of radiation therapy in the management of primary retroperitoneal sarcoma: A systematic review and clinical practice guidelines from the Australia and New Zealand Sarcoma Association

While surgery is the mainstay of treatment for localised retroperitoneal sarcoma, the use of radiotherapy (RT) remains controversial. This systematic review aimed to evaluate the role of RT for retroperitoneal sarcoma. A systematic review using the population, intervention, comparison, and outcome model from 1990 to 2022 identified 66 studies (a mixture of preoperative and postoperative RT); one randomised controlled trial (RCT) with two publications, 18 registry studies, and 46 retrospective studies. In the RCT of preoperative RT, there was no difference in local/abdominal recurrence. The pooled analysis of this RCT and a retrospective study showed a significant abdominal recurrence free survival benefit with preoperative RT in low grade liposarcoma. The RCT and the majority of retrospective series found RT did not improve recurrence free survival (11 of 16 no difference in combined local and distant RFS, 11 of 13 no difference in distant metastasis free survival), disease specific survival (9 of 12 studies) or overall survival (33 of 49 studies). The majority of studies found no association between RT and perioperative morbidity. In summary, preoperative RT may improve local control for low grade (well-differentiated or grades 1-2 dedifferentiated) liposarcoma, but not other histological subtypes. There is no strong evidence that perioperative RT provides an overall survival benefit. Patients with low grade retroperitoneal liposarcoma can be considered for preoperative RT to improve abdominal recurrence free survival. The rationale and level of evidence in this scenario should be carefully discussed by the multidisciplinary team with patients. RT should not be routinely recommended for other histological subtypes.

Comparison of three analgesic regimens in women undergoing cervical brachytherapy

PURPOSE

Effective periprocedural analgesia is an important aspect of cervical brachytherapy delivery, with implications for patient comfort and attendance for subsequent fractions. We compared the efficacy and safety of three analgesic modalities: intravenous patient-controlled analgesia (IV-PCA), continuous epidural infusion (CEI) and programmed-intermittent epidural bolus with patient-controlled epidural analgesia (PIEB-PCEA).

METHODS AND MATERIALS

Ninety-seven brachytherapy episodes involving 36 patients between July 2016 and June 2019 in a single tertiary center were retrospectively reviewed. Episodes were divided into two key phases: Phase 1 (while applicator remained in situ) and Phase 2 (following applicator removal until discharge or 4 h). For the primary endpoint, pain scores were retrieved and analyzed by analgesic modality with respect to median score and an internally defined "unacceptable" pain experience (>20% of scores being ≥4/10; i.e., moderate or greater). Total nonepidural oral morphine equivalent dose (OMED) and toxicity/complication events were reported as secondary endpoints.

RESULTS

In Phase 1, there was a significantly higher median pain score (p < 0.001) and more episodes with unacceptable pain scores (46%) in the IV-PCA group compared with either epidural modality (6-14%; p < 0.001). In Phase 2, we observed a greater median pain score (p = 0.007) and higher proportion of patient episodes with unacceptable pain scores (38%) in the CEI group compared with both the IV-PCA (13%) and PIEB-PCEA (14%) groups (p = 0.001). There was a significant difference in median OMED used throughout all phases across the PIEB-PCEA (0 mg), IV-PCA (70 mg), and CEI (15 mg) groups (p < 0.001).

CONCLUSIONS

PIEB-PCEA is safe and offers superior analgesia compared to IV-PCA or CEI for pain control after applicator placement in cervical brachytherapy.

Surgery at specialised sarcoma centres improves patient outcomes - A systematic review by the Australia and New Zealand sarcoma association clinical practice guidelines working party

BACKGROUND

Optimal management of sarcoma requires multidisciplinary team input throughout the process of diagnosis, treatment and follow up. This systematic review aimed to evaluate the impact of surgery performed at specialised sarcoma centres on outcomes.

METHODS

A systematic review was conducted using the population, intervention, comparison and outcome (PICO) model. Medline, Embase, Cochrane Central databases were queried for publications that evaluated the local control, limb salvage rate, 30-day and 90-day surgical mortality, and overall survival in patients undergoing surgery in a specialist sarcoma centre compared with non-specialist centre. Each study was screened by two independent reviewers for suitability. A qualitative synthesis of the results was performed.

RESULTS

Sixty-six studies were identified. The majority of studies were Level III-3 as assessed by the NHMRC Evidence Hierarchy, whilst just over half of the studies were of good quality. Definitive surgery performed at specialised sarcoma centres was associated with improved local control as defined by lower rate of local relapse, higher rate of negative surgical margins, improved local recurrence free survival and higher limb conservation rate. Available evidences show a favourable pattern of lower 30-day and 90-day mortality rates, and greater overall survival when surgery was performed in specialist sarcoma centres compared with non-specialised centres.

CONCLUSIONS

Evidences support better oncological outcomes when surgery is performed at specialised sarcoma centre. Patients with suspected sarcoma should be referred early to a specialised sarcoma centre for multidisciplinary management, which includes planned biopsy and definitive surgery.

Long term outcomes of gastric mucosa-associated lymphoid tissue lymphoma treated with radiotherapy: A multi-center retrospective cohort study

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is a rare disease. Radiotherapy remains an important definitive modality. We assessed the long term outcomes of patients with early stage gastric MALT marginal zone lymphoma (MZL) treated with definitive radiotherapy at three institutions in New South Wales, Australia. A retrospective, multi-center study of patients with gastric MALT MZ lymphoma treated with radiotherapy between 1st of March 1999 and 31st of May 2020 was conducted. Eligible patients were: age ≥18 years, treated with curative-intent radiotherapy, pathological diagnosis of MALT MZ lymphoma. There were 33 eligible patients. Complete response (CR) was reported in 30/31 (96.7%) of endoscopically assessed cases. During median follow up of 66.2 months (IQR 22-119 months), estimated 5 and 10 years local relapse free survival were 92.6% (95% CI: 83-100) and 92.6% (95% CI: 83-100); distant relapse free survival 95.8% (95% CI 88.2-100) and 64.7% (95% CI 43.4-96.4); freedom from treatment failure 92.6% (95% CI; 83.1-100) and 62.5% (95% CI; 41.7-93.7), respectively. There were six documented recurrences; one local, four distant, and both in one patient; two cases were high grade recurrences. 5 and 10 years OS were 92.4% and 73.5% respectively. There were no grade 3-5 late toxicities or treatment related deaths. Patients with gastric MALT MZL treated with definitive radiotherapy have excellent outcomes. In long term follow up a significant proportion developed distant low grade disease. Extended follow up should be considered in these patients. Treatment is well tolerated with minimal toxicity. Radiotherapy remains an important modality in the treatment of gastric MALT MZ lymphoma.

Chemoradiotherapy with concurrent durvalumab for the palliative treatment of oligometastatic oesophageal and gastrooesophageal carcinoma with dysphagia: a single arm phase II clinical trial (PALEO, sponsored by the Australasian Gastro-Intestinal Trials Group)

BACKGROUND

Oesophageal and gastrooesophageal junction (GOJ) carcinoma frequently present with dysphagia and de novo metastatic disease. There is scope to improve treatment paradigms to both address symptoms and improve survival. One method is integrating immune checkpoint inhibition with novel treatment combinations.

METHODS

PALEO is a single arm, phase II clinical trial in patients with previously untreated, oligometastatic or locoregionally advanced oesophageal or GOJ carcinoma and dysphagia. PALEO is sponsored by the Australasian Gastro-Intestinal Trials Group (AGITG). Participants receive 2 weeks of therapy with concurrent hypofractionated radiotherapy of 30Gy in 10 fractions to the primary tumour, weekly carboplatin AUC2, weekly paclitaxel 50 mg/m² and durvalumab 1500 mg q4 weekly, followed by durvalumab monotherapy continuing at 1500 mg q4weekly until disease progression, unacceptable toxicity or 24 months of therapy. A single metastasis is treated with stereotactic radiotherapy of 24Gy in 3 fractions in week 7. The trial primary endpoint is the progression free survival rate at 6 months. Secondary endpoints include duration of dysphagia relief, nutritional status change, quality of life, response rate, toxicity, progression free survival and overall survival. The tertiary endpoint is prediction of outcome based on biomarkers identified from patient serial blood samples collected pre- and post-radiotherapy.

DISCUSSION

This unique investigator-initiated clinical trial is designed to simultaneously address the clinically relevant problems of dysphagia and distant disease control. The overarching aims are to improve patient nutrition, quality of life and survival with low toxicity therapy. AGITG PALEO is a multidisciplinary collaboration and will add to the understanding of the relationship between radiotherapy and the anti-tumour immune response.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry: ACTRN12619001371189 , registered 8 October 2019.

Genome sequencing reveals underdiagnosis of primary ciliary dyskinesia in bronchiectasis

BACKGROUND

Bronchiectasis can result from infectious, genetic, immunological and allergic causes. 60-80% of cases are idiopathic, but a well-recognised genetic cause is the motile ciliopathy, primary ciliary dyskinesia (PCD). Diagnosis of PCD has management implications including addressing comorbidities, implementing genetic and fertility counselling and future access to PCD-specific treatments. Diagnostic testing can be complex; however, PCD genetic testing is moving rapidly from research into clinical diagnostics and would confirm the cause of bronchiectasis.

METHODS

This observational study used genetic data from severe bronchiectasis patients recruited to the UK 100,000 Genomes Project and patients referred for gene panel testing within a tertiary respiratory hospital. Patients referred for genetic testing due to clinical suspicion of PCD were excluded from both analyses. Data were accessed from the British Thoracic Society audit, to investigate whether motile ciliopathies are underdiagnosed in people with bronchiectasis in the UK.

RESULTS

Pathogenic or likely pathogenic variants were identified in motile ciliopathy genes in 17 (12%) out of 142 individuals by whole-genome sequencing. Similarly, in a single centre with access to pathological diagnostic facilities, 5-10% of patients received a PCD diagnosis by gene panel, often linked to normal/inconclusive nasal nitric oxide and cilia functional test results. In 4898 audited patients with bronchiectasis, <2% were tested for PCD and <1% received genetic testing.

CONCLUSIONS

PCD is underdiagnosed as a cause of bronchiectasis. Increased uptake of genetic testing may help to identify bronchiectasis due to motile ciliopathies and ensure appropriate management.

Population-level utilisation of neoadjuvant radiotherapy for the treatment of rectal cancer

PURPOSE

International clinical guidelines recommend long- or short-course neoadjuvant radiotherapy for locally advanced rectal cancer. This study aims to examine variation in the use of neoadjuvant radiotherapy for rectal cancer and identify patient and hospital factors that underpin this variation.

METHODS AND MATERIALS

We conducted a retrospective, consecutive cohort study using statewide hospitalisation and radiotherapy data from New South Wales, Australia, 2013-2018. Included participants had a primary rectal adenocarcinoma and underwent surgical resection. Factors associated with the use or not of any neoadjuvant radiotherapy, and short versus long-course were explored using multilevel logistic regression models.

RESULTS

Of the 2912 people included in the study, 43% received neoadjuvant radiotherapy. There was significant variation in the use of neoadjuvant radiotherapy depending on geographic location. Abdominoperineal excision (odds ratio [OR] = 1.87, 95% confidence interval [CI] = 1.53-2.28) and having surgery in a public hospital (OR = 2.34, 95% CI = 1.92-2.87) were both predictors of use. Among those receiving neoadjuvant radiotherapy, 17% received short-course therapy, with short-course declining over the study period.

CONCLUSIONS

The use of neoadjuvant radiotherapy for rectal cancer is highly variable, with differences only partially explained by assessable patient-or hospital-level factors. Understanding neoadjuvant radiotherapy utilisation patterns may assist in identifying barriers and opportunities to improve adherence to clinical guidelines.

Systemic treatments and outcomes in CIC-rearranged Sarcoma: A national multi-centre clinicopathological series and literature review

CIC‐rearranged sarcoma is a recently established, ultra‐rare, molecularly defined sarcoma subtype. We aimed to further characterise clinical features of CIC‐rearranged sarcomas and explore clinical management including systemic treatments and outcomes.

Outcomes of patients with metastatic cutaneous squamous cell carcinoma to the axilla: a multicentre cohort study

BACKGROUND

Metastatic cutaneous squamous cell carcinoma to the axilla is uncommon, with limited data to guide management. We sought to assess the outcomes of patients with this condition after surgery and radiotherapy.

METHODS

A retrospective cohort study of patients treated at two Australian hospitals from 1994 through 2016 was performed.

RESULTS

A total of 74 patients were identified, including 48 treated curatively with surgery-plus-radiotherapy and 15 with surgery alone. Compared with patients treated with surgery alone, a higher proportion of patients treated with surgery-plus-radiotherapy had lymph nodes larger than 6 cm (53% versus 8%, P = 0.012) and multiple adverse histopathological features (75% versus 47%, P = 0.04). The groups had similar 5-year disease-free survival (45% versus 46%) and overall survival (51% versus 48%). Presence of multiple positive lymph nodes was associated with reduced disease-free survival (hazard ratio 4.57, P = 0.01) and overall survival (hazard ratio 3.53, P = 0.02). Regional recurrence was higher in patients treated with surgery alone (38% versus 22%, P = 0.22) and patients with lymph nodes larger than 6 cm (34% versus 10%, P = 0.03). All recurrences occurred within 2 years following treatment.

CONCLUSION

Combined-modality therapy for metastatic cutaneous squamous cell carcinoma to the axilla is recommended for high-risk patients, although outcomes remain modest. The key period for recurrence is within 2 years following treatment.

Treatment Algorithm for Surgical Site Infections Following Extensor Mechanism Repair

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Despite general agreement regarding techniques for extensor mechanism repair, there is very limited guidance in the literature for the management of surgical site infections (SSIs) that may occur after these procedures.

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Early or mild superficial SSIs, such as cellulitis, can be managed on an outpatient basis while monitoring for improvement, with escalated intervention if the symptoms do not resolve within 1 week.

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Deep SSIs should be managed more aggressively with surgical irrigation and debridement (I&D), including the knee joint, depending on the results of the aspiration, removal of all braided nonabsorbable suture (if necessary) with immediate or delayed exchange with monofilament suture, and the administration of parenteral antibiotics based on culture results and an infectious disease consult.

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Arthrocentesis should be performed early to monitor for the spread of infection to the joint space, and diagnosis of a septic knee joint should be immediately followed by arthroscopic or open I&D.

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For refractory cases (i.e., wound coverage issues or persistent infections despite multiple attempts at debridement), a consult with a plastic surgeon for consideration of a gastrocnemius flap is recommended, and surgeons should remain suspicious of the possibility of the contiguous spread of osteomyelitis.

A Psychosexual Rehabilitation Booklet Increases Vaginal Dilator Adherence and Knowledge in Women Undergoing Pelvic Radiation Therapy for Gynaecological or Anorectal Cancer: A Randomised Controlled Trial

AIMS

Women treated with pelvic radiation therapy (PRT) for gynaecological or anorectal cancer report a high number of sexual problems and unmet post-treatment psychosexual information needs. Currently, there is suboptimal adherence to recommended rehabilitation aids, such as vaginal dilators, and a paucity of resources to facilitate post-radiation rehabilitation and reduce distress in this population. This randomised controlled trial aimed to evaluate the effectiveness of a study-developed psychosexual rehabilitation booklet in this setting.

MATERIALS AND METHODS

Eighty-two women scheduled for PRT to treat gynaecological/anorectal cancer were randomised to receive the intervention booklet (n = 44) or standard information materials (n = 38). Self-report questionnaires administered at pre-treatment baseline and at 3, 6 and 12 months post-treatment assessed adherence with rehabilitation aids, booklet knowledge, anxiety, depression and sexual functioning/satisfaction.

RESULTS

Dilator adherence and booklet knowledge were significantly higher in the intervention group than in the control group (averaged over time points), with scores significantly increasing over time. Younger age and gynaecological cancer were significant predictors of greater dilator adherence. No significant group differences were found on psychological and sexual measures.

CONCLUSIONS

The psychosexual rehabilitation booklet was effective in educating women with gynaecological and anorectal cancers about PRT-related psychosexual side-effects and rehabilitation options, as well as promoting uptake of vaginal dilator use. Future research should elucidate the effectiveness of this booklet in women with greater psychological and sexual functioning needs.

Using behaviour change and implementation science to address low referral rates in oncology

Background

Patients undergoing surgery for bowel cancer now have a routine screening test to assess their genetic predisposition to this and other cancers (Lynch syndrome). A result indicating a high risk should trigger referral to a genetic clinic for diagnostic testing, information, and management. Appropriate management of Lynch syndrome lowers morbidity and mortality from cancer for patients and their family, but referral rates are low. The aim of this project was to increase referral rates for patients at high risk of Lynch syndrome at two Australian hospitals, using the Theoretical Domains Framework (TDF) Implementation approach.

Methods

Multidisciplinary teams at each hospital mapped the referral process and discussed barriers to referral. A 12-month retrospective audit measured baseline referral rates. The validated Influences on Patient Safety Behaviours Questionnaire was administered to evaluate barriers using the TDF. Results were discussed in focus groups and interviews, and interventions co-designed, guided by theory. Continuous monitoring audits assessed change in referral rates.

Results

Teams (n = 8, 11) at each hospital mapped referral processes. Baseline referral rates were 80% (4/5) from 71 screened patients and 8% (1/14) from 113 patients respectively. The questionnaire response rate was 51% (36/71). Most significant barrier domains were: ‘environmental context;’ ‘memory and decision making;’ ‘skills;’ and ‘beliefs about capabilities.’ Focus groups and interviews with 19 healthcare professionals confirmed these domains as significant. Fifteen interventions were proposed considering both emerging and theory-based results. Interventions included: clarification of pathology reports, education, introduction of e-referrals, and inclusion of genetic status in documentation.

Audits continued to December 2016 showing a change in pathology processes which increased the accuracy of screening. The referral rate remained low: 46% at Hospital A and 9% Hospital B. Results suggest patients who have their referral deferred for some reason are not referred later.

Conclusion

Lynch syndrome is typical of low incidence problems likely to overwhelm the system as genomic testing becomes mainstream. It is crucial for health researchers to test methods and define generalizable solutions to address this problem. Whilst our approach did not improve referrals, we have deepened our understanding of barriers to referral and approaches to low frequency conditions.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3653-1) contains supplementary material, which is available to authorized users.

Impact of salvage treatment modalities in patients with positive FDG-PET/CT after R-CHOP chemotherapy for aggressive B-cell non-Hodgkin lymphoma

INTRODUCTION

To compare outcomes of different salvage treatment modalities in patients with aggressive B-cell non-Hodgkin lymphoma (NHL) who remain FDG-PET positive after R-CHOP chemotherapy. Existing data on these patients with FDG-PET primary refractory disease are limited.

METHODS

Patients with diffuse large B-cell lymphoma or grade 3 follicular lymphoma were retrospectively reviewed from the Prince of Wales Hospital databases. Eligibility criteria were: age≥18 years, treated with R-CHOP, with positive post-chemotherapy FDG-PET. Salvage treatment modalities were: radical radiotherapy (RT, dose≥30 Gy), high dose chemotherapy and autologous stem cell transplant (ASCT), or non-radical management. Survival was calculated from date of post-chemotherapy FDG-PET to last follow-up.

RESULTS

Twenty-six patients from 2003-2015 met the inclusion criteria. Median age was 60 (range 19-84). Most had adverse baseline features: 21 (81%) stage III-IV, 24 (92%) bulky disease and nine (35%) skeletal involvement. Characteristics of PET-positivity post-chemotherapy were single site in 16 (62%), sites of prior bulk in 24 of 24, skeletal sites in five of nine, and able to be encompassed by RT in 21 (81%). Salvage treatment was: radical RT in 17 (65%), ASCT in four (15%) and non-radical in five (20%). Median follow-up of surviving patients was 31 months. Kaplan-Meier estimates of 3-year PFS and OS were 41% and 52%, respectively. By salvage modality, 3-year PFS was 51% for RT, 25% for ASCT and 20% for non-radical treatment, (P = 0.453); 3-year OS was respectively 65%, 25% and 40% (P = 0.173).

CONCLUSION

Patients with FDG-PET positive disease after R-CHOP for aggressive B-cell NHL are salvageable with radiotherapy.

Radiotherapy for anal squamous cell carcinoma: must the upper pelvic nodes and the inguinal nodes be treated?

BACKGROUND

Loco-regional failure is the predominant cause of death in anal squamous cell carcinoma. We assessed patterns of loco-regional recurrence to determine the impact of radiotherapy (RT) volumes on patient outcome.

METHODS

Retrospective clinical study, including patients treated curatively with RT or chemo-radiotherapy between 1994 and 2007. RT fields/volumes were reviewed and compared with patterns of failure. Patients were classified as having whole pelvic radiotherapy (WPRT) if RT extended to L5/S1 or lower pelvic radiotherapy (LPRT) if it extended to the lower sacroiliac joints or below. Patients with negative inguinal nodes either underwent prophylactic inguinal radiotherapy (PIRT) or had inguinal observation (IO). Patterns of failure were compared.

RESULTS

Twenty-seven patients (53%) had WPRT and 24 (47%) had LPRT. Forty-two patients had negative inguinal nodes: 29 (69%) had PIRT and 13 (31%) had IO. Median follow-up was 5.8 years. Twelve regional failures occurred in eight patients: three pelvic, one inguinal and four pelvic and inguinal. All patients with regional failure died of disease. Pelvic nodal failure was 7.7% in N0 and 33% in N1-3 patients (P = 0.012). There was no difference in pelvic regional failure between WPRT and LPRT (11% versus 16%, P = 0.64). There was only one possible regional failure above LPRT in this group (4%). Inguinal failure was 0% in the PIRT group compared with 23% in IO group (P = 0.009).

CONCLUSION

There was no difference in pelvic regional failure between WPRT and LPRT. LPRT is likely to be safe in N0 patients. Inguinal nodes should be treated in all patients.

Patterns of care of superficial soft tissue sarcomas: it is not always just a lump

AIM

Superficial soft tissue sarcomas (S-STS) are generally considered low-risk tumors and have an excellent prognosis when treated with appropriate surgery and adjuvant therapy. However, they are often misdiagnosed then mistreated, leading to significant morbidity. This study aims to examine the patterns of care and outcomes of patients with S-STS, comparing those initially managed through sarcoma units versus elsewhere.

METHODS

Patients with S-STS from Prince of Wales Hospital in NSW (1995-2013) and Peter MacCallum Cancer Centre in Victoria (2009-2013) were identified from a national sarcoma database. Baseline variables, treatment and disease outcomes were recorded. Statistical tests performed included univariate and multivariate analyses, chi-square tests, as well as the Kaplan-Meier method for 5-year local recurrence and survival rates.

RESULTS

Eighty-nine patients were identified, with 35% initially managed at a sarcoma unit and 65% elsewhere. Patients initially managed at sarcoma units had larger tumors (>5 cm 39% vs 17%; P  =  0.036) with a trend to higher grade (61% vs 48%; P = 0.39). Patients that were initially managed outside a sarcoma unit more often underwent open surgical biopsies (P < 0.0005), had multiple operations (P < 0.0005) and had higher rates of local recurrences (24% vs 6.5%, P  =  0.038). They also had lower 5-year local recurrence-free survival rates (P = 0.022), but had higher metastasis-free survival (P = 0.014). On multivariate analysis, only larger STS size and male gender predicted for poorer metastasis-free survival (P = 0.042 and 0.018, respectively).

CONCLUSION

Patients with S-STS initially managed outside specialized sarcoma units undergo more operations, with risk of greater morbidity, and have greater risk of local recurrence.

The population benefit of evidence-based radiotherapy: 5-Year local control and overall survival benefits

BACKGROUND

To describe the population benefit of radiotherapy in a high-income setting if evidence-based guidelines were routinely followed.

METHODS

Australian decision tree models were utilized. Radiotherapy alone (RT) benefit was defined as the absolute proportional benefit of radiotherapy compared with no treatment for radical indications, and of radiotherapy over surgery alone for adjuvant indications. Chemoradiotherapy (CRT) benefit was the absolute incremental benefit of concurrent chemoradiotherapy over RT. Five-year local control (LC) and overall survival (OS) benefits were measured. Citation databases were systematically queried for benefit data. Meta-analysis and sensitivity analysis were performed.

FINDINGS

48% of all cancer patients have indications for radiotherapy, 34% curative and 14% palliative. RT provides 5-year LC benefit in 10.4% of all cancer patients (95% Confidence Interval 9.3, 11.8) and 5-year OS benefit in 2.4% (2.1, 2.7). CRT provides 5-year LC benefit in an additional 0.6% of all cancer patients (0.5, 0.6), and 5-year OS benefit for an additional 0.3% (0.2, 0.4). RT benefit was greatest for head and neck (LC 32%, OS 16%), and cervix (LC 33%, OS 18%). CRT LC benefit was greatest for rectum (6%) and OS for cervix (3%) and brain (3%). Sensitivity analysis confirmed a robust model.

INTERPRETATION

Radiotherapy provides significant 5-year LC and OS benefits as part of evidence-based cancer care. CRT provides modest additional benefits.

Diagnostic Knee Arthroscopy and Partial Meniscectomy

Knee arthroscopy is the most commonly performed orthopaedic procedure in the United States. Indications have grown exponentially since the procedure was first popularized by Watanabe and Jackson. Treatment of meniscal tears is the most common reason for knee arthroscopy, with approximately 700,000 arthroscopic partial meniscectomies performed annually. Other indications include assistance for cruciate ligament reconstruction, osteochondral lesions, removal of loose bodies, synovectomy, and septic arthritis. Arthroscopy is accomplished with the use of two small incisions on either side of the patella at the anterior aspect of the knee. An arthroscope is inserted through one incision and used to view the image on a monitor, while the second incision is employed for instrumentation. An examination with the patient under anesthesia should always be performed prior to the initiation of the procedure. The patient is positioned with the knee flexed and a lateral post secured to the side of the bed. Standard anteromedial and anterolateral portals are made, and an arthroscope is introduced through the anterolateral portal. Diagnostic arthroscopy is performed in a systematic fashion. Meniscal tears and other pathology are identified. With use of an arthroscopic probe, the features of the meniscal tear are determined. Arthroscopic punches and shavers are used to debride torn portions back to a stable rim. Knee arthroscopy is a highly effective procedure. Outcomes after partial medial meniscectomy are good to excellent in 80% to 100% of patients. A recent cost-effectiveness analysis demonstrated that knee arthroscopy is more cost-effective than coronary artery bypass surgery or total knee arthroplasty.

Prostate brachytherapy in New South Wales: patterns of care study and impact of caseload on treatment quality

PURPOSE

We performed the first comprehensive, population-based brachytherapy (BT) Patterns of Care Study in the Australian setting. Herein we report on prostate BT and assess the technical quality of BT practice, focusing on whether a caseload effect could be identified in New South Wales (NSW).

MATERIAL AND METHODS

Site visits were made to all radiation oncology departments in NSW that delivered prostate BT, collecting relevant data on NSW residents treated with prostate BT in 2003. Overall quality of NSW prostate BT treatment was assessed using benchmarks including treatment of appropriate prostate cancer disease risk category, absence of (relative) physical contraindications, optimal planned and treated dosimetry, and pre-/post-implant planning/CT. Quality was compared between higher and lower caseload departments.

RESULTS

One hundred and fifty-seven (67%) patients underwent temporary BT and 79 (33%) permanent seed BT. Prostate BT was concentrated in five departments, with three of four departments with active programmes treating greater than the recommended 25 cases. Rates of concordance with quality benchmarks were high (85-99%) with no consistent caseload effect identified.

CONCLUSIONS

Prostate BT in NSW in 2003 was generally of high quality and a caseload effect on quality could not be identified. This may be because the number of departments was insufficient to determine a caseload effect, or because the prostate BT was largely concentrated in a small number of high caseload departments.

Patterns of care study of brachytherapy in New South Wales: cervical cancer treatment quality depends on caseload

PURPOSE

We previously conducted modelling and a patterns of care study (POCS) that showed gynaecological brachytherapy (BT) was underutilized in New South Wales (NSW), the USA and Western Europe. The aim of the current study was to assess the quality of cervical BT in NSW, and to determine if caseload affects quality of treatment delivery.

MATERIAL AND METHODS

All nine NSW radiation oncology departments that treated patients with cervical BT in 2003 were visited. Patient, tumour and treatment related data were collected. Quality of BT was assessed using published quality benchmarks. Higher and lower caseload departments were compared.

RESULTS

The four higher cervical BT caseload departments treated 11-15 NSW residents in 2003, compared to 1-8 patients for the lower caseload departments. Cervix cancer patients treated at the higher caseload departments were more likely to be treated to a point A dose ≥ 80 Gy (58% vs. 14%, p = 0.001), and to have treatment completed within 8 weeks (66% vs. 35%, p = 0.02). Despite higher point A doses, there was no significant difference in proportions achieving lower than recommended rectal or bladder doses, implying better BT insertions in higher caseload departments.

CONCLUSIONS

Cervical BT in NSW was dispersed amongst a large number of departments and was frequently of sub-optimal quality. Higher quality BT was achieved in departments treating at least 10 patients per year. It is likely that improved outcomes will be achievable if at least 10 patients are treated per department per year.

Biomechanics of complex shoulder instability

Identification and treatment of the osseous lesions associated with complex shoulder instability remains challenging. Further biomechanical testing is required to delineate critical defect values and determine which treatments provide improved glenohumeral joint stability for the various defect sizes, while minimizing the associated complications.

Arthroscopic and computer-assisted high tibial osteotomy using standard total knee arthroplasty navigation software

Opening-wedge high tibial osteotomy is an increasingly performed procedure for treatment of varus gonarthrosis and correction of malalignment during meniscal transplantation or cartilage restoration. Precise preoperative planning and meticulous surgical technique are required to achieve an appropriate mechanical axis correction. We describe our technique of arthroscopic and computer-assisted high tibial osteotomy using commonly available total knee arthroplasty navigation software as an intraoperative goniometer. We believe that our technique, by providing intraoperative real-time guidance of the degree of correction that is accurate and reliable, represents a useful tool for the surgeon who uncommonly performs high tibial osteotomy.

Use of a hip arthroscopy flexible radiofrequency device for capsular release in frozen shoulder

Adhesive capsulitis is a common and challenging condition to treat. Arthroscopic capsular release is usually contemplated when conservative treatment fails or when there is severe and/or chronic loss of range of motion. This procedure can be difficult to perform because of difficult access to the joint, poor visualization, and loss of working space from retraction of the joint capsule. The articular surfaces and the axillary nerve are also at higher risk of injury. Arthroscopic scissors, shavers, and electrocautery are typically used to perform the capsular release. To perform a safer and more precise arthroscopic shoulder capsular release, a creative and innovative use of a flexible hip arthroscopy radiofrequency ablator is described.

Interleukin-18 genetics and inflammatory disease susceptibility

IL18 was mapped to 11q22.2-22.3 in 1998. Owing to interleukin (IL)-18's important and novel role in immunomodulation, the gene itself has been subject to scrutiny, with the aim of discovering variants that may impact on disease susceptibility and/or progression. Despite being sequenced numerous times in different populations, no non-synonymous variants have been found. However, a number of polymorphisms within the proximal promoter have been verified that may interfere with transcription-factor-binding sites. Much of the subsequent association analyses have centred on these variants, but have yielded no consistent results, despite numerous different study populations being genotyped. IL18 has recently been resequenced in its entirety, enabling the tagging-single-nucleotide polymorphism (tSNP) methodology to be adopted. This approach has yielded interesting results, with genetic variation being shown to affect protein levels, and risk. This review aims to compile and reflect on the association data of interest published to date, with a focus on the diseases related to aberrant inflammatory control.

The positioning of cytoplasmic protein clusters in bacteria

Cell division is a carefully orchestrated procedure. Bacterial cells have intricate mechanisms to ensure that genetic material is copied, proofread, and accurately partitioned into daughter cells. Partitioning now appears to also occur for some cytoplasmic proteins. Previously, using chromosomal fluorescent protein fusions, we demonstrated that a subset of Rhodobacter sphaeroides chemotaxis proteins colocalize to a discrete region within the bacterial cytoplasm. Using TlpT-yellow fluorescent protein as a marker for the position of the cytoplasmic protein clusters, we show most cells contain either one cluster localized at mid-cell or two clusters at the one-fourth and three-fourths positions of cell length. The number and positioning of these protein clusters depend on a previously unrecognized bacterial protein positioning factor, PpfA, which has homology to bacterial type I DNA partitioning factors. These data suggest that there is a mechanism involved in partitioning some cytoplasmic proteins upon cell division that is analogous to a mechanism seen for plasmid and chromosomal DNA.

Evolution of non-operative management for blunt splenic trauma in children

Until the late 1960s, splenectomy was routinely performed in children who had sustained blunt splenic injury. There was based on the ability to perform splenectomy without obvious consequence; the cited 90-100% mortality for splenic trauma and the possibility of delayed rupture of the spleen. In contrast, contemporary findings in immunology and surgery demonstrated that non-operative management was not only feasible but desirable in view of the potential for overwhelming post-plenectomy infection. The history of universal splenectomy following blunt splenic trauma has been reviewed and we outline the findings that have resulted in the current standard of non-operative management following blunt splenic trauma.

CURRENT MANAGEMENT OF BLUNT SPLENIC TRAUMA IN CHILDREN

BACKGROUND

Non-operative management of the great majority of blunt splenic injuries in children has become routine. Debate continues on the need for intensive care unit (ICU) admission, follow-up imaging and the duration of physical activity restrictions following injury. The purpose of this study was to review the recent experience of an Australian Paediatric Trauma Centre with splenic trauma to define current practice.

METHODS

A retrospective chart review of patients with splenic trauma admitted to the Children's Hospital at Westmead between November 1995 and December 2003.

RESULTS

A total of 39 patients with blunt splenic trauma were identified: 20 (51%) were multiply injured. Thirty-three (85%) children were managed non-operatively. The most common initial imaging method was computed tomography (n = 28, 72%). Fourteen patients (36%) were admitted to the ICU with a mean length of stay (LOS) of 4.1 days (range 1-13 days). The overall mean LOS was 10.8 days (range 1-43 days). Nineteen patients (50%) had imaging studies performed after diagnosis but before discharge. Further post-discharge imaging was carried out in 21 cases (54%). There were no deaths, but 10 patients developed complications. The mean documented activity restriction was 7.4 weeks (range 1-16 weeks).

CONCLUSION

The majority of children who had suffered blunt splenic trauma were safely managed non-operatively outside an ICU. In stable patients, there appeared to be no benefits associated with repeated imaging following the diagnosis of splenic trauma. Physical activity restriction in excess of 3-4 weeks did not appear to be warranted.

Perforating small bowel injuries in children: influence of time to operation on outcome

The purpose of this study was to determine whether delay in the diagnosis of small bowel injury (SBI) affected the outcome of paediatric patients who required surgical interventions in the treatment of small bowel injuries. A retrospective chart review was performed on children with traumatic SBI requiring surgical management between January 2000 and December 2002. Diagnostic interval was defined as the time from presentation to operative treatment and delay was an interval of greater than 8 h. Thirteen patients were admitted for operative treatment of SBI. Nine cases were the result of motor vehicle trauma. The mean diagnostic interval for all patients was 9.1 h+/-7.4 h (range 0.6 h-22.5 h). Six patients had a diagnostic delay with a mean diagnostic interval of 15.5 h+/-5.5 h. There was no statistically significant difference found between the prompt and delayed diagnosis groups in terms of complications or length of hospital stay. Our finding of no difference between the prompt and delayed diagnosis groups and a diagnostic delay no longer than 22.5 h may suggest that our local methods of diagnosis and treatment assist in the prevention of unnecessary complications and death.

Leptomeningeal carcinomatosis from squamous cell carcinoma of the supraglottic larynx

Leptomeningeal carcinomatosis is an uncommon but devastating form of metastatic spread. To our knowledge, only 16 cases originating from a head and neck cancer have been reported. We describe the first case of a patient with leptomeningeal carcinomatosis arising from a laryngeal squamous cell carcinoma. Shortly after completing treatment for an advanced supraglottic laryngeal cancer, this 63-year-old man presented with lower limb neurological symptoms and signs. Radiological and cytological evidence of leptomeningeal carcinomatosis of the distal spinal canal was identified. He was treated with intrathecal methotrexate and palliative radiotherapy. Although his pain improved, his lower limb weakness worsened. He died 3 weeks after completing radiotherapy. Presumed mode of spread was via the haematogenous route. The natural history and management of leptomeningeal carcinomatosis are discussed. Clinicians should be aware of the uncommon possibility of leptomeningeal carcinomatosis in a patient presenting with an appropriate constellation of symptoms and signs, and a past history of cancer.

Sleep as a teaching tool for integrating respiratory physiology and motor control

Sleep exerts major effects on most fundamental homeostatic mechanisms. Current data suggest, however, that students of physiology and medicine typically receive little or no formal teaching in sleep. Because sleep takes up a significant component of our life span, it is proposed that current teaching in systems and integrative physiology is not representative if it is confined to functions describing wakefulness only. We propose that sleep can be readily integrated into various components of physiology and medical curricula simply by emphasizing how commonly taught physiological processes are importantly affected by sleep mechanisms. In our experience, this approach can be used to reinforce basic physiological principles while simultaneously introducing sleep physiology into the students' training. We find that students have a general and inherent interest in sleep and related clinical disorders, and this proves useful as an effective means to teach the material. In this paper, examples of how sleep influences motor control and the respiratory system will illustrate these points. These considerations also highlight some important gaps in traditional teaching of respiratory physiology.

Poly(A) polymerase and the regulation of cytoplasmic polyadenylation

Translational activation in oocytes and embryos is often regulated via increases in poly(A) length. Cleavage and polyadenylation specificity factor (CPSF), cytoplasmic polyadenylation element binding protein (CPEB), and poly(A) polymerase (PAP) have each been implicated in cytoplasmic polyadenylation in Xenopus laevis oocytes. Cytoplasmic polyadenylation activity first appears in vertebrate oocytes during meiotic maturation. Data presented here shows that complexes containing both CPSF and CPEB are present in extracts of X. laevis oocytes prepared before or after meiotic maturation. Assessment of a variety of RNA sequences as polyadenylation substrates indicates that the sequence specificity of polyadenylation in egg extracts is comparable to that observed with highly purified mammalian CPSF and recombinant PAP. The two in vitro systems exhibit a sequence specificity that is similar, but not identical, to that observed in vivo, as assessed by injection of the same RNAs into the oocyte. These findings imply that CPSFs intrinsic RNA sequence preferences are sufficient to account for the specificity of cytoplasmic polyadenylation of some mRNAs. We discuss the hypothesis that CPSF is required for all polyadenylation reactions, but that the polyadenylation of some mRNAs may require additional factors such as CPEB. To test the consequences of PAP binding to mRNAs in vivo, PAP was tethered to a reporter mRNA in resting oocytes using MS2 coat protein. Tethered PAP catalyzed polyadenylation and stimulated translation approximately 40-fold; stimulation was exclusively cis-acting, but was independent of a CPE and AAUAAA. Both polyadenylation and translational stimulation required PAPs catalytic core, but did not require the putative CPSF interaction domain of PAP. These results demonstrate that premature recruitment of PAP can cause precocious polyadenylation and translational stimulation in the resting oocyte, and can be interpreted to suggest that the role of other factors is to deliver PAP to the mRNA.

Internal initiation in Saccharomyces cerevisiae mediated by an initiator tRNA/eIF2-independent internal ribosome entry site element

Internal initiation of translation can be mediated by specific internal ribosome entry site (IRES) elements that are located in certain mammalian and viral mRNA molecules. Thus far, these mammalian cellular and viral IRES elements have not been shown to function in the yeast Saccharomyces cerevisiae. We report here that a recently discovered IRES located in the genome of cricket paralysis virus can direct the efficient translation of a second URA3 cistron in dicistronic mRNAs in S. cerevisiae, thereby conferring uracil-independent growth. Curiously, the IRES functions poorly in wild-type yeast but functions efficiently either in the presence of constitutive expression of the eIF2 kinase GCN2 or in cells that have two initiator tRNA(met) genes disrupted. Both of these conditions have been shown to lower the amounts of ternary eIF2-GTP/initiator tRNA(met) complexes. Furthermore, tRNA(met)-independent initiation was also observed in translation-competent extracts prepared from S. cerevisiae in the presence of edeine, a compound that has been shown to interfere with start codon recognition by ribosomal subunits carrying ternary complexes. Therefore, the cricket paralysis virus IRES is likely to recruit ribosomes by internal initiation in S. cerevisiae in the absence of eIF2 and initiator tRNA(met), by the same mechanism of factor-independent ribosome recruitment used in mammalian cells. These findings will allow the use of yeast genetics to determine the mechanism of internal ribosome entry.

Regulation of host cell translation by viruses and effects on cell function

Viruses have evolved a remarkable variety of strategies to modulate the host cell translation apparatus with the aim of optimizing viral mRNA translation and replication. Recent studies have revealed that modulation of both host and viral mRNA translation can be accomplished by selective alteration of translation factors in virus-infected cells. These findings provide new insights into the functioning of the translational apparatus in both uninfected and infected cells.

Rapid deadenylation and Poly(A)-dependent translational repression mediated by the Caenorhabditis elegans tra-2 3' untranslated region in Xenopus embryos

The 3' untranslated region (3'UTR) of many eukaryotic mRNAs is essential for their control during early development. Negative translational control elements in 3'UTRs regulate pattern formation, cell fate, and sex determination in a variety of organisms. tra-2 mRNA in Caenorhabditis elegans is required for female development but must be repressed to permit spermatogenesis in hermaphrodites. Translational repression of tra-2 mRNA in C. elegans is mediated by tandemly repeated elements in its 3'UTR; these elements are called TGEs (for tra-2 and GLI element). To examine the mechanism of TGE-mediated repression, we first demonstrate that TGE-mediated translational repression occurs in Xenopus embryos and that Xenopus egg extracts contain a TGE-specific binding factor. Translational repression by the TGEs requires that the mRNA possess a poly(A) tail. We show that in C. elegans, the poly(A) tail of wild-type tra-2 mRNA is shorter than that of a mutant mRNA lacking the TGEs. To determine whether TGEs regulate poly(A) length directly, synthetic tra-2 3'UTRs with and without the TGEs were injected into Xenopus embryos. We find that TGEs accelerate the rate of deadenylation and permit the last 15 adenosines to be removed from the RNA, resulting in the accumulation of fully deadenylated molecules. We conclude that TGE-mediated translational repression involves either interference with poly(A)'s function in translation and/or regulated deadenylation.