Showing papers by "Bryan Burmeister published in 2008"

Clinical practice guidelines for the management of melanoma in Australia and New Zealand

Abstract: In 2002 reporting of melanoma to cancer registries in Australia and New Zealand revealed it to be the fourth most common cancer and ninth most common cancer causing death in Australia and New Zealand. These registries reported melanoma incidence rates in males and females that were substantially above those from all other reporting registries worldwide1 • Increasing mortality from melanoma in Australian and New Zealand men is a disturbing trend • Exposure to ultraviolet (UV) radiation in sunlight is the primary cause of most melanoma • Intermittent pattern of sun exposure is most frequently associated with melanoma • Sun bed and tanning bed exposure is associated with a small increase in melanoma risk and may be more significant when exposure occurs before 35 years of age • Brief periods of sun exposure are needed to maintain vitamin D levels • In the absence of any substantial evidence as to its effectiveness in reducing mortality population-based screening cannot be recommended • It is important for practicing clinicians to be aware of high-risk groups in the population and that those in such groups also be aware of their status and establish a surveillance program • Early detection and diagnosis of melanoma is clearly important in sound management • Doubt in diagnosis or where melanoma is highly suspected, referral to a specialist or biopsy is appropriate. A 2mm margin for the biopsy is adequate. Prophylactic excision of benign naevi is not recommended • Diagnosis may be enhanced by clinicians trained in dermoscopy • It is imperative that all biopsy material be submitted for histopathological examination • Management of involved lymph nodes should be undertaken in specialist centres • Following diagnosis of metastatic melanoma, no further investigations are required unless surgery is planned and the detection of additional sites of distant disease would result in a change in management • Communication skills training should help promote patient-centred care, shared decision-making, empathy and support where desired • Timing of referral for palliative care relates to the needs of the patient and family, not just the stage of the disease • In treating specific populations, it is important to recognise cultural differences, particularly the final disposal of body parts after surgical removal in Maori and Pacific peoples. It is also good practice in physical examination to ensure that skin areas examined include periungual and subungual skin and soles of feet • Patients with high risk primary melanoma, lymph node involvement and melanoma in unusual sites (eg. mucosal and disseminated melanoma) are best managed by multidisciplinary teams in a specialist or melanoma facility • These evidence-based guidelines have been developed by a multidisciplinary volunteer working party. They are aimed at encouraging improved management through evidence-based decision-making • Guidelines are guides not rules and they are not prescriptive in any way. A good approach is to be fully aware of appropriate guidelines before making final management decisions. © Cancer Council Australia/Australian Cancer Network/Ministry of Health, New Zealand (2008).

Refining esophageal cancer staging after neoadjuvant therapy: importance of treatment response

Abstract: Accurate staging is vital for esophageal cancer management. The utility of the American Joint Committee on Cancer (AJCC) staging system 6th edition for esophageal cancer has been questioned for resected patients who receive neoadjuvant chemoradiotherapy (CRT). This study was undertaken to assess the AJCC staging system for patients with esophageal cancer that have received neoadjuvant CRT and to identify clinicopathological variables that predict survival. Review of a prospective esophageal cancer database was undertaken for patients that received neoadjuvant CRT and resection. Primary tumor response was defined as major (≤10% residual tumor cells) or minor (>10% residual tumor cells). Cox regression and concordance analyses were used to determine prognostic factors. Median follow-up was 61 months. Of 131 patients with invasive cancer, there were 40/131 (31%) with squamous cell carcinoma (SCC) and 88/131 (65%) with adenocarcinoma. The procedure-related mortality rate was 3.8%. Median survival was 33 months. A major response was demonstrated by 79/131 (60%) patients. Survival analyses found that the AJCC 6th edition was unable to discriminate between stages 0, I, and IIa or stages IIb and III. Multivariate survival analyses found age, pretreatment tumor length >6 cm, positive lymph nodes, and a major tumor response were independent prognostic factors. These data were used to derive a new staging system that had improved discrimination of stage groups over the current AJCC system. The current AJCC staging system for esophageal cancer is inadequate for patients that receive neoadjuvant CRT. Refinement of the AJCC staging system should include primary tumor response for patients receiving neoadjuvant CRT.

Positron emission tomography and pathological evidence of response to neoadjuvant therapy in adenocarcinoma of the esophagus

Abstract: Our aim was to determine if fluorodeoxyglucose positron emission tomography (FDG-PET) could be correlated with a pathological response in patients with esophageal adenocarcinoma receiving neoadjuvant chemotherapy and/or chemoradiation therapy. Patients with resectable, histologically proven adenocarcinoma of the esophagus were entered in the study. Preoperative chemotherapy comprised two cycles of cisplatin and 5-fluorouracil. Radiation therapy commenced with the second cycle on day 22. FDG-PET images were obtained pre-treatment and on completion of intended neo-adjuvant treatment. Quantification was achieved by the calculation of both standardized uptake values (SUV) and tumor/liver ratios (TLR). Evidence of histopathological response was identified according to the Mandard tumor regression scoring system. There were 45 patients, 22 receiving neoadjuvant chemotherapy and 23 chemoradiation therapy. Forty patients underwent surgical resection. Seven patients (16%) had a histopathological response. The mean percentage change in SUV in the histological responders group was -56.8% (SD 29) and in the non-responders -27.8% (SD 32.1) (P = 0.035). The mean percentage change in TLR was -49.1% (SD 44.8) in the responders and in the non-responders -27.3% (SD 31.3) (P = 0.128). There was no difference between the two methods of assessment, however there was less variation with SUV. There was no correlation between the FDG-PET response and the histopathological response. Presently an FDG-PET scan performed 3-6 weeks after neoadjuvant therapy for adenocarcinoma of the esophagus should not be used as a marker of the potential result of the treatment. The optimal timing of a second FDG-PET remains unclear.

Desmoplastic melanoma: the role of radiotherapy in improving local control

Abstract: Background: Desmoplastic melanoma (DM) is a rare subtype of cutaneous malignant melanoma reported to have a high local recurrence rate with surgical excision alone. The incidence of regional and distant metastasis is considered to be lower than traditional cutaneous melanoma, warranting more aggressive treatment of local disease. We conducted a retrospective analysis of patients with DM treated through the Princess Alexandra Hospital Melanoma Clinic to address the role of radiotherapy in the local control of this tumour.

Salvage definitive chemo-radiotherapy for locally recurrent oesophageal carcinoma after primary surgery: Retrospective review

Abstract: To determine the overall survival and gastrointestinal toxicity for patients treated with salvage definitive chemo-radiotherapy after primary surgery for locoregional relapse of oesophageal carcinoma. A retrospective review of 525 patients who had a resection for oesophageal or oesophagogastric carcinoma at Princess Alexandra Hospital identified 14 patients treated with salvage definitive radiotherapy or chemo-radiotherapy, following localized recurrence of their disease. We analysed the patient and treatment characteristics to determine the median overall survival as the primary end point. Gastrointestinal toxicity was examined to determine if increased toxicity occurred when the stomach was irradiated within the intrathoracic radiotherapy field. The median overall survival for patients treated with curative intent using salvage definitive chemo-radiotherapy was 16 months and the 2-year overall survival is 21%. One patient is in clinical remission more than 5 years after therapy. Age <60 years old and nodal recurrence were favourable prognostic factors. Treatment compliance was 93% with only one patient unable to complete the intended schedule. Fourteen per cent of patients experienced grade 3 or 4 gastrointestinal toxicity. Salvage definitive chemo-radiotherapy should be considered for good performance status patients with oesophageal carcinoma who have a locoregional relapse after primary surgery. The schedule is tolerable with low toxicity and an acceptable median survival.

Role of Functional Imaging in Head and Neck Squamous Cell Carcinoma: Fluorodeoxyglucose Positron Emission Tomography and Beyond

Abstract: Positron emission tomography (PET) has emerged as an integral diagnostic tool in the management of head and neck squamous cell carcinoma (HNSCC). This article reviews the usefulness and ongoing dilemmas of fluorine-18 fluorodeoxyglucose (18-F FDG) PET and FDG PET/CT in HNSCC. In addition, it examines the potential role of novel markers and biologic characterization of disease, which in the future may assist in targeted therapeutic strategies.

A comparison of quality of life in patients with T3 rectal cancer receiving short course versus long course preoperative radiation. A Trans-Tasman Radiation Oncology Group Trial (TROG 01.04)

Abstract: 4097 Background: A randomised trial was conducted comparing the efficacy of short course (SC) and long course (LC) radiotherapy, prior to surgery in patients with resectable T3 rectal cancer. The i...

A randomised phase II trial comparing pre-operative chemotherapy with pre-operative chemoradiation therapy for localized carcinoma of the oesophagus

Abstract: Preoperative chemotherapy (CT) and preoperative chemoradiation therapy (CRT) for resectable oesophageal cancer have both been shown to improve overall survival in meta-analyses. However there are no trials comparing these adjuvant therapies with each other. We assessed the outcomes after oesophagectomy following preoperative CT and preoperative CRT in a randomised phase II trial for resectable adenocarcinoma of the oesophagus and gastro-oesophageal junction