Consensus Recommendations for Radiation Therapy Contouring and Treatment of Vulvar Carcinoma.

PURPOSE: The purpose of this study was to develop a radiation therapy (RT) contouring atlas and recommendations for women with postoperative and locally advanced vulvar carcinoma. METHODS AND MATERIALS: An international committee of 35 expert gynecologic radiation oncologists completed a survey of the treatment of vulvar carcinoma. An initial set of recommendations for contouring was discussed and generated by consensus. Two cases, 1 locally advanced and 1 postoperative, were contoured by 14 physicians. Contours were compared and analyzed using an expectation-maximization algorithm for simultaneous truth and performance level estimation (STAPLE), and a 95% confidence interval contour was developed. The level of agreement among contours was assessed using a kappa statistic. STAPLE contours underwent full committee editing to generate the final atlas consensus contours. RESULTS: Analysis of the 14 contours showed substantial agreement, with kappa statistics of 0.69 and 0.64 for cases 1 and 2, respectively. There was high specificity for both cases (≥99%) and only moderate sensitivity of 71.3% and 64.9% for cases 1 and 2, respectively. Expert review and discussion generated consensus recommendations for contouring target volumes and treatment for postoperative and locally advanced vulvar cancer. CONCLUSIONS: These consensus recommendations for contouring and treatment of vulvar cancer identified areas of complexity and controversy. Given the lack of clinical research evidence in vulvar cancer radiation therapy, the committee advocates a conservative and consistent approach using standardized recommendations.

Variability in clinical target volume delineation for intensity modulated radiation therapy in 3 challenging cervix cancer scenarios.

PURPOSE: The purpose of this study was to assess variability in contouring the gross tumor volume (GTV) and clinical target volume (CTV) of 3 clinical cervix cancer cases by a cohort of international experts in the field in preparation for the development of an online teaching atlas. METHODS AND MATERIALS: Twelve international experts participated. Three clinical scenarios: node positivity (PLN), retroverted uterus (RV), and parametrial invasion (PI) were used. Sagittal and axial magnetic resonance images of the clinical cases were downloaded to participants' treatment planning systems for contouring. The GTV/cervix/uterus/parametria/vagina and nodal CTV were contoured. Contour consensus was assessed for sensitivity/specificity using an expectation maximization algorithm called Simultaneous Truth and Performance Level Estimation and experts' overall agreement was summarized by kappa statistics. RESULTS: Agreement for GTV in the 3 clinical cases was high (Simultaneous Truth and Performance Level Estimation sensitivity, 0.54-0.92; specificity, 0.97-0.98; and kappa measure for PLN, RV, and PI was 0.86, 0.76, and 0.42; P < .0001). Moderate to substantial agreement was seen for nodal CTV (kappa statistics for PLN, RV, and PI was 0.65, 0.58, and 0.62; P < .0001), uterus (kappa for PLN, RV, and PI was 0.45, 0.74, and 0.77; P < .0001), and parametria (kappa for PLN, RV, and PI was 0.49, 0.62, and 0.50; P < .0001). Contouring heterogeneity was greatest for the cervix (kappa measure for PLN, RV, and PI was 0.15, 0.4, and 0.24; P < .0001) and vagina (kappa for PLN, RV, and PI was 0.47, 0.36 and 0.46; P < .0001), reflecting difficulties in determining the interface between GTV and these tissues. CONCLUSION: Kappa statistics of the different CTV components generally demonstrated moderate to substantial agreement among international experts in the field of gynecological radiation therapy. Further planning target volume margins accounting for organ motion and setup errors are a necessary addition to the CTV.

Pathology reporting in head and neck cancer--snapshot of current status.

BACKGROUND: Currently there is no standardized head and neck pathology reporting system in Victoria, Australia. The aim of this study was to document deficiencies in head and neck pathology reports at our institution. METHODS: The pathology reports of all patients with head and neck squamous cell carcinoma (HNSCC) who presented to Peter MacCallum Cancer Centre for postoperative radiotherapy (PORT) between January 1, 2004, and March 31, 2006, were critically assessed for 16 key pathological items. RESULTS: Only 37% reports contained all the 16 items. The most commonly missing items were "diameter of the largest involved lymph node" (38%), "presence/absence of lymphovascular space invasion" (30%), "presence/absence of peri-neural invasion" (28%), "clearance of margins in millimeters" (27%), and "presence/absence of extracapsular extension" (27%). The most variable item was the clearance in millimeters used to determine "clear margins". CONCLUSIONS: Several of the most important pathological factors predicting locoregional relapse in HNSCC are currently the least reliably reported items in head and neck pathology reports.

Food advertising and self-regulation: a view from the trenches.

OBJECTIVE: This study assessed the logic of arguments advanced when the New Zealand advertising self-regulation complaints board adjudicated a complaint about a food product; in addition, it compared these arguments and the complainant's experience of the process to international best practice criteria relating to independence. METHODS: Documents relating to a complaint about chicken nuggets were analysed. Shuy's logical framework was used to analyse the arguments advanced; the case was subsequently compared to the best practice criteria advanced in the Madelin (2006) report. RESULTS: Even a well-informed and expert complainant found the system difficult to use and biased in favour of the advertiser. Analysis of rhetorical strategies used to respond to the complaint reveal use of fallacious reasoning, including ad hominem, to which the complainant was unable to respond. CONCLUSIONS: In the case reviewed, the New Zealand self-regulatory system did not meet the level of openness, independence or transparency that the complainant expected and that are listed as "best practice" criteria in the Madelin Report. A regulatory system run by a government agency could afford greater protection to complainants and consumers and offer a more balanced adjudication process. IMPLICATIONS: As the prevalence of obesity increases, governments are examining how effectively regulation controls marketing activities that encourage consumption of energy dense, nutrient poor foods. This paper raises timely and important questions about the balance and fairness of self-regulation as experienced by a complainant.