Australian & New Zealand Faculty of Radiation Oncology Genito-Urinary Group: 2011 consensus guidelines for curative radiotherapy for urothelial carcinoma of the bladder.

Curative radiotherapy, with or without concurrent chemotherapy, is recognized as a standard treatment option for muscle-invasive bladder cancer. It is commonly used for two distinct groups of patients: either for those medically unfit for surgery, or as part of a 'bladder preserving' management plan incorporating the possibility of salvage cystectomy. However, in both situations, the approach to radiotherapy varies widely around the world. The Australian and New Zealand Faculty of Radiation Oncology Genito-Urinary Group recognised a need to develop consistent, evidence-based guidelines for patient selection and radiotherapy technique in the delivery of curative radiotherapy. Following a workshop convened in May 2009, a working party collated opinions and conducted a wide literature appraisal linking each recommendation with the best available evidence. This process was subject to ongoing re-presentation to the Faculty of Radiation Oncology Genito-Urinary Group members prior to final endorsement. These Guidelines include patient selection, radiation target delineation, dose and fractionation schedules, normal tissue constraints and investigational techniques. Particular emphasis is given to the rationale for the target volumes described. These Guidelines provide a consensus-based framework for the delivery of curative radiotherapy for muscle-invasive bladder cancer. Widespread input from radiation oncologists treating bladder cancer ensures that these techniques are feasible in practice. We recommend these Guidelines be adopted widely in order to encourage a uniformly high standard of radiotherapy in this setting, and to allow for better comparison of outcomes.

'GAP' in radiotherapy services in Australia and New Zealand in 2009.

AIM: In this study we estimated (a) the number of linear accelerators required in Australia and New Zealand to achieve a 52.3% treatment rate; (b) the 'GAP' between the actual and required number of linear accelerators; c) the number of persons not treated (PNT), premature deaths (PD) and years of life lost (YLL) as a result of the 'GAP'; and (d) to review the actions being taken by health jurisdictions in Australia and in New Zealand to address the 'GAP' and reach the 52.3% treatment rate. MATERIAL AND METHODS: The actual number of fully staffed and operating linear accelerators (A) in Australian and New Zealand was obtained from a survey of radiotherapy facilities in December 2009. The required number of linear accelerators (R) was calculated from the projected cancer incidence figures for 2009 and was based on 1.6 linear accelerators being required per 1000 new cancer patients. The 'GAP' in Radiotherapy services (G) was R minus A. The maximum treatment capacity (MTC) was the ratio of A over R multiplied by 52.3%, assuming that all linear accelerators were operating at 100% capacity. As each linear accelerator can treat 331 new patients each year, the number of new cancer PNT is G x 331. The estimated 5-year survival benefit from radiotherapy is 16%, and the average survival for all patients receiving radiotherapy (radical and palliative) is 0.76 year. Hence, the number of PD attributed to the 'GAP' is PNT x 16%, and the YLL to cancer is PNT x 0.76. A literature search and local knowledge of health department Radiotherapy Plans in all jurisdictions were used to determine the action being taken to achieve a 52.3% treatment rate. RESULTS: In 2009, the 'GAP' was 50 linear accelerators in Australia and the MTC was 38%, the same as it was in 1999, but there has been an increase in PNT each year from 7419 in 1999 to 16,550 in 2009, and PD each year increased from 1187 in 1999 to 2649 in 2009, and YLL each year increased from 5638 in 1999 to 12,585 in 2009. In New Zealand in 2009, the 'GAP' was nine linear accelerators and the MTC was 38%. An estimated 3310 persons did not receive radiotherapy in 2009 in New Zealand, and as a result, there were 523 PD and 2266 YLL. The review showed that new and replacement machines were being installed in all jurisdictions in Australia and in New Zealand. Only Victoria and Queensland have a Radiotherapy Plan beyond 2010, but both have underestimated the projected cancer incidence. CONCLUSION: Urgent action is needed by health departments and governments on both sides of the Tasman to improve access and equity to this essential cancer treatment. There is merit in the Baume Report recommendation of establishing a national body to oversee radiotherapy services in all jurisdictions in Australia. A similar central body should also be considered for New Zealand.

An international multicenter study evaluating the impact of an alternative biochemical failure definition on the judgment of prostate cancer risk.

PURPOSE: To evaluate the impact of an alternative biochemical failure (bF) definition on the performance of existing plus de novo prognostic models. METHODS AND MATERIALS: The outcomes data of 1,458 Australian and 703 Canadian men treated with external-beam radiation monotherapy between 1993 and 1997 were analyzed using a lowest prostate-specific antigen (PSA) level to date plus 2 ng/mL (L + 2) bF definition. Two existing prognostic models were scrutinized using discrimination (Somers Dxy [SDxy]) and calibration indices. Alternative prognostic models were also created using recursive partitioning analysis (RPA) and multivariate nomogram methods for comparison. RESULTS: Discrimination of bF was improved using the L + 2 definition compared with the American Society for Therapeutic Radiology and Oncology (ASTRO) definition using both the three-level risk model (SDxy 0.30 and 0.22, respectively) or the nomogram (SDxy 0.35 and 0.27, respectively). Both existing prognostic models showed only modest calibration accuracy. Using RPA, five distinct risk groups were identified based primarily on Gleason score (GS) and all subsequent divisions based on PSA. All GS 7-10 tumors were intermediate or high risk. This model and the developed nomogram showed improved discrimination over the existing models as well as accurate calibration against the Canadian data, apart from the 30-50% failure region. CONCLUSIONS: The L + 2 definition of bF provides improved capacity for discrimination of failure risk. New prognostic models based on this endpoint have overall statistical performance superior to those based on the ASTRO consensus definition but continue to have unreliable discrimination in the intermediate-risk region.

Outcome, morbidity, and prognostic factors in post-prostatectomy radiotherapy: an Australian multicenter study.

OBJECTIVES: To report the outcome and morbidity data for patients treated with post-prostatectomy radiotherapy (PPRT) in a multicenter collaboration. METHODS: The case records of all patients treated with PPRT from 1996 to 1998 were reviewed. Survival was calculated using Kaplan-Meier methods. Potential prognostic factors were evaluated using the Cox proportional hazards regression model. Prostate-specific antigen (PSA) remission was defined as a PSA level of 0.2 ng/mL or less. Acute and late morbidities were documented. RESULTS: We reviewed the data of 115 patients, with a median follow-up from the start of PPRT of 28.7 months. Patients were treated with adjuvant intent (n = 23), for local recurrence (n = 27), or for a detectable PSA level (n = 65). The overall and cause-specific survival rate at 5 years was 73.7% and 81.4%, respectively. The biochemical disease-free survival rate was 69.6% at 2 years and 50% at 5 years. Factors predicting for subsequent relapse on multivariate analysis were pre-PPRT PSA (P = 0.013) and post-PPRT nadir (P <0.0001). Patients with a PSA greater than 1 ng/mL fared significantly worse than those with lower levels (P <0.0001). For patients with a pretreatment PSA of less than 1 ng/mL and an operative Gleason score of 7 or less, the 5-year projected biochemical disease-free survival rate was 71%. One case of grade 3 late proctitis was recorded, and 4 patients had continued grade 3 late urinary incontinence. CONCLUSIONS: Early use of PPRT is effective and well tolerated in patients at risk of, or with proven, local recurrence.

Chemoradiation for inoperable non small cell lung cancer: a phase II study using a regimen with acceptable toxicity.

Over the past few years there have been numerous schedules of combined modality therapy proposed as being useful in the management of inoperable non-small cell lung cancer (NSCLC). These have generally involved the use of high dose radiation therapy to doses of the order of 60 Gy combined with chemotherapy given prior to or concurrently with the radiation. Concurrent chemotherapy has been given with the intention of being both active in NSCLC and with the role of being a possible radiosensitiser. The most commonly employed drugs have been cisplatin, etoposide, 5-fluorouracil, vindesine and mitomycin. Although response rates of the primary tumour to the combined therapy have been optimistic, there has not been a great survival benefit with the median survival in most series remaining at just over 12 months. In this study we have prospectively treated a group of patients with non-metastatic inoperable NSCLC with a regimen of known acceptable toxicity. These patients were inoperable because they were unfit for surgery or had locally advanced disease. The local radiological response rate was 86% and the median survival for the whole group was 13 months. Adenocarcinomas appeared to do significantly worse than squamous cell carcinomas. Toxicity was acceptable and lower than reported in other similar series. There was one treatment related death. We feel that this combination of radiation therapy and chemotherapy is a reasonable compromise for a disease which still has a very poor outlook.

Lung dose rate and interstitial pneumonitis in total body irradiation for bone marrow transplantation.

The effect of dose rate to the lungs and development of interstitial pneumonitis (IP) was evaluated in 114 bone marrow transplant patients receiving fractionated total body irradiation (TBI) (1200 rads TD in 6 fractions twice daily over 3 days) as part of their pre-conditioning regimen. The tumour dose (TD) was calculated as the mean lung dose as previously described (1). A 6MV linear accelerator at a mid-line dose rate of 7.5 rads/minute was used between March 1981 and June 1985 and a Co-60 source at 5 rads/minute thereafter. This resulted in a range of dose rates to the lung of between 6.9 and 8.9 rads/minute and 2.9 and 6.5 rads/minute respectively. In the majority of patients the aetiology of IP was investigated by lung biopsy with histology and culture. There was no statistically significant difference in the incidence of IP over the two sets of dose rates. Our study suggest that the incidence of IP using fractionated TBI is not influenced by dose rates below 8.9 rads per minute.

Low birthweight and mortality in Australian Aboriginal babies at the Royal Darwin Hospital: a 15 year study.

A retrospective analysis was made of all births at the Royal Darwin Hospital from 1 January 1969 to 31 December 1983. The births were divided into weight categories and racial groups (Aboriginal and non-Aboriginal). The study showed that there was a 23.2% incidence of low birthweight (LBW) babies (less than 2500 g) in Aboriginals compared with an incidence of 6.4% in non-Aboriginals. It was found that Aboriginals had a better chance of surviving the neonatal periods than non-Aboriginals of the same birthweight for all birthweights up to 2500 g. It is suggested that this occurred because most LBW Aboriginals were more mature than their birthweight would have suggested. The perinatal and neonatal mortality, however, remains high in the Aboriginal babies and this can also be attributed to the high incidence of LBW babies in this group, and perhaps to the limited use of antenatal care by the Aboriginal mothers.

Norwegian scabies in Australian Aborigines.

Norwegian scabies is a rare, but distinctive, variant of scabies. The infestation by the parasite is massive, and the lesions consist of hyperkeratotic plaques affecting the skin of the whole body. Predisposition to this form of scabies occurs in association with a variety of conditions. Three cases of Norwegian scabies, which occurred in full-blood Australian Aborigines, and were managed in the Royal Darwin Hospital, are reported.

Epidemic of acute poststreptococcal glomerulonephritis in aboriginal communities.

During 1980, an epidemic of acute glomerulonephritis occurred in a number of Aboriginal communities in the Northern Territory, affecting several hundred people. Clinical and laboratory studies of children admitted to the paediatric wards of Darwin Hospital, and of a larger number of individuals in the communities, have established that the nephritis was preceded by a streptococcal infection, and a recognised nephritogenic streptococcal strain was isolated from a number of children. The clinical course of the disease was mild in the majority of those affected and none had had serious complications. Serological results indicate the importance of measuring antideoxyribonuclease B levels as well as antistreptolysin O titres when seeking evidence of antecedent streptococcal infection.

Wound botulism.

It is well recognized that food contamination can result in botulism either from ingestion of performed toxin, in classical botulism, or through absorption of toxin from bacteria within the gut, in infant botulism. Botulism due to contamination of wounds with Clostridium botulinum is not commonly recognized. We report a case of wound botulism occurring in an eight-year-old boy, characterized by early ptosis, dysphagia and dysarthria and then followed by progressive generalized paralysis and fixed dilated pupils, but with intact sensorium. Management consisted of early wound debridement and prolonged intensive respiratory and nutritional support. Recovery was complete.