Surgical management of melanoma: an EORTC Melanoma Group survey

Objectives:

The objective of the article is to explore the surgical practices and views in the treatment of melanoma within members and non-members of the EORTC Melanoma Group (MG) during the years 2003–2005.

Methods:

An e-mail questionnaire (see appendix) developed within the EORTC MG was sent to all melanoma units (MUs) of the EORTC (180) and to selected international centres between 2003 and 2005. The questionnaire investigated the different practices regarding surgical management of melanoma patients at all stages.

Results:

A total of 75 questionnaires were returned from centres in Europe (70), Israel (3), Australia (1) and the United States (1). Resection margins on primary melanoma vary according to AJCC 2002 staging. Sixty three of 75 MUs perform Sentinel node biopsy. Modified radical neck dissection is performed in 82% of MUs for macrometastases and in 80% of MUs for micrometastases. Most MUs surveyed perform all three levels of Berg axillary dissection whether for macrometastases (79%) or micrometastases (62%). An ilio inguinal-obturator dissection is proposed with macrometastases (41% of MUs), whereas 33% of MUs perform a pelvic dissection only if the Cloquet node is positive. Twenty five of 75 MUs perform an isolated limb perfusion with a therapeutic indication; three also as an adjuvant. The majority of MUs perform surgery for distant metastases including superficial (53 of 75 [71%]) or solitary visceral metastases (52 of 75[69%]) or for palliation (58 of 75[77%]).

Conclusion:

The adequacy of surgery appears to be the most important milestone in the therapeutic approach of melanoma. Even if surgery is fundamental in the different stages of the disease, there is quite a variability concerning the extension of the surgical treatment related to primary and lymphnodal disease. Phase III randomised trials have shown that wide margins, elective lymph node dissections, and prophylactic isolated limb perfusions have not improved survival and cannot be considered the standard of care in the routine management of primary melanoma. The surgical subgroup of the EORTC Melanoma Group is developing a new version of the surgical survey questionnaire including new treatment modalities like isolated limb infusion and electrochemotherapy, which were not frequently in use some years ago, to obtain new data to be compared to the nearly ten-year-old data.

Teacher efficacy and pupil behaviour: the structure of teachers' individual and collective beliefs and their relationship with numbers of pupils excluded from school

BACKGROUND

Previous work has yielded knowledge of teachers' attributions for children's behaviour. Other studies have helped to develop understanding of teachers' efficacy beliefs. Little work has been undertaken to examine teachers' efficacy beliefs with regard to classroom behaviour.

AIMS

This study aimed to investigate the relationship between teachers' individual and collective beliefs about their efficacy with children's behaviour and whether these beliefs were associated with the use of exclusion as a sanction.

SAMPLE

A total of 197 teachers from 31 primary and nursery schools in the North East of England participated.

METHODS

Participants responded to questionnaires to assess their individual and collective efficacy beliefs. Demographic and school level data were also collected.

RESULTS

Factor analysis indicated that teachers' individual efficacy beliefs were best represented by three factors: 'Classroom Management', 'Children's Engagement', 'Instructional Strategies' that corresponded well to previous findings. Analysis of collective efficacy beliefs showed a similar structure that differed from previous findings. Individual efficacy was not associated with numbers of children excluded. One factor 'Addressing External Influences' in the collective beliefs was negatively correlated with numbers of children excluded and appeared to mitigate the deleterious effects associated with socio-economic deprivation.

CONCLUSIONS

This study adds weight to the importance of understanding and supporting teachers' beliefs in their collective efficacy. In particular, this study underlines the need for strategies that will endorse and develop teachers' beliefs in their ability to manage children's behaviour successfully.

Gastric diverticulum: "a wayside house of ill fame" with a laparoscopic solution

BACKGROUND

Gastric diverticulum (GD) is an extremely rare disorder that can easily be overlooked when investigating the cause of abdominal pain. Its diagnosis is founded on a history of gastrointestinal symptoms and a typically unrevealing physical examination, and diagnosis requires confirmation from UGI contrast studies, EGD, and CT scan. Symptomatic GD should be kept in consideration as a cause of abdominal issues, because not only is it treatable, but also complications of GD can be life threatening. The surgical treatment of GDs has evolved from thoraco-abdominal incisions in the early twentieth century to the laparoscopic approach used today.

CASE REPORT

The patient is a 45-y-old male presenting with a 4-mo case of dysphagia, small amounts of regurgitation, and abdominal pain but no other symptoms.

RESULTS

The patient was diagnosed with a gastric diverticulum, which was subsequently successfully treated with a laparoscopic gastric diverticulectomy.

CONCLUSION

Laparoscopic gastric diverticulectomy is a safe procedure and should be considered as an option to treat symptomatic GD.

ATPase cycle and DNA unwinding kinetics of RecG helicase

The superfamily 2 bacterial helicase, RecG, is a monomeric enzyme with a role in DNA repair by reversing stalled replication forks. The helicase must act specifically and rapidly to prevent replication fork collapse. We have shown that RecG binds tightly and rapidly to four-strand oligonucleotide junctions, which mimic a stalled replication fork. The helicase unwinds such DNA junctions with a step-size of approximately four bases per ATP hydrolyzed. To gain an insight into this mechanism, we used fluorescent stopped-flow and quenched-flow to measure individual steps within the ATPase cycle of RecG, when bound to a DNA junction. The fluorescent ATP analogue, mantATP, was used throughout to determine the rate limiting steps, effects due to DNA and the main states in the cycle. Measurements, when possible, were also performed with unlabeled ATP to confirm the mechanism. The data show that the chemical step of hydrolysis is the rate limiting step in the cycle and that this step is greatly accelerated by bound DNA. The ADP release rate is similar to the cleavage rate, so that bound ATP and ADP would be the main states during the ATP cycle. Evidence is provided that the main structural rearrangements, which bring about DNA unwinding, are linked to these states.

Dental examiners consistency in applying the ICDAS criteria for a caries prevention community trial

AIM

To examine dental examiners' one-year consistency in utilizing the International Caries Detection and Assessment System (ICDAS) criteria after baseline training and calibration.

METHODS

A total of three examiners received baseline training/calibration by a "gold standard" examiner, and one year later re-calibration was conducted. For the baseline training/calibration, subjects aged 8-16 years, and for the re-calibration subjects aged five to six years were recruited for the study. The ICDAS criteria were used to classify visual caries lesion severity (0-6 scale), lesion activity (active/inactive), and presence of filling material (0-9 scale) of all available tooth surfaces of permanent and primary teeth. The examination used a clinical light, mirror and air syringe. Kappa (weighted: Wkappa, unweighted: Kappa) statistics were used to determine inter-and intra-examiner reliability at baseline and re-calibration.

RESULTS

For lesion severity and filling criteria, the baseline calibration on 35 subjects indicated an inter-rater Wkappa ranging from 0.69-0.92 and intra-rater Wkappa ranging from 0.81-0.92. Re-calibration on 22 subjects indicated an inter-rater Wkappa of 0.77-0.98 and intra-rater Wkappa ranged from 0.93-1.00. The Wkappa for filling was consistently in the excellent range, while lesion severity was in the good to excellent range. Activity kappa was in the poor to good range. All examiners improved with time.

CONCLUSIONS

The baseline training/calibration in ICDAS was crucial to maintain the stability of the examiners reliability over a one year period. The ICDAS can be an effective assessment tool for community-based clinical trials.

Transvaginal repair of a large chronic porcine ventral hernia with synthetic mesh using NOTES

Transvaginal placement of synthetic mesh to repair large porcine hernia using NOTES technology appears to be a feasible alternative to traditional techniques.

Background:

Ventral incisional hernias still remain a common surgical problem. We tested the feasibility of transvaginal placement of a large synthetic mesh to repair a porcine hernia.

Methods:

Seven pigs were used in this survival model. Each animal had creation of a 5-cm hernia defect and underwent a transvaginal repair of the defect with synthetic mesh. A single colpotomy was made using a 12-cm trocar for an overtube. The mesh was cut to size and placed through the trocar. A single-channel gastroscope with an endoscopic atraumatic grasper was used for grasping sutures. Further fascial sutures were placed every 5cm.

Results:

Mesh repair was feasible in all 7 animals. Mean operative time was 133 minutes. Technical difficulties were encountered. No gross contamination was seen at the time of necropsy. However, 5 animals had positive mesh cultures; 7 had positive cultures in the rectouterine space in enrichment broth or on direct culture.

Conclusion:

Transvaginal placement of synthetic mesh to repair a large porcine hernia using NOTES is challenging but feasible. Future studies need to be conducted to develop better techniques and determine the significance of mesh contamination.

Melanoma sentinel node biopsy and prediction models for relapse and overall survival

BACKGROUND

To optimise predictive models for sentinal node biopsy (SNB) positivity, relapse and survival, using clinico-pathological characteristics and osteopontin gene expression in primary melanomas.

METHODS

A comparison of the clinico-pathological characteristics of SNB positive and negative cases was carried out in 561 melanoma patients. In 199 patients, gene expression in formalin-fixed primary tumours was studied using Illumina's DASL assay. A cross validation approach was used to test prognostic predictive models and receiver operating characteristic curves were produced.

RESULTS

Independent predictors of SNB positivity were Breslow thickness, mitotic count and tumour site. Osteopontin expression best predicted SNB positivity (P=2.4 × 10⁻⁷), remaining significant in multivariable analysis. Osteopontin expression, combined with thickness, mitotic count and site, gave the best area under the curve (AUC) to predict SNB positivity (72.6%). Independent predictors of relapse-free survival were SNB status, thickness, site, ulceration and vessel invasion, whereas only SNB status and thickness predicted overall survival. Using clinico-pathological features (thickness, mitotic count, ulceration, vessel invasion, site, age and sex) gave a better AUC to predict relapse (71.0%) and survival (70.0%) than SNB status alone (57.0, 55.0%). In patients with gene expression data, the SNB status combined with the clinico-pathological features produced the best prediction of relapse (72.7%) and survival (69.0%), which was not increased further with osteopontin expression (72.7, 68.0%).

CONCLUSION

Use of these models should be tested in other data sets in order to improve predictive and prognostic data for patients.

Phase II trial of the oral PARP inhibitor olaparib (AZD2281) in BRCA-deficient advanced ovarian cancer

5500

Background: Olaparib (AZD2281; KU-0059436) is a novel, orally active PARP inhibitor that induces synthetic lethality in homozygous BRCA-deficient cells. A phase I trial identified 400 mg bd as the maximum tolerated dose (MTD) with an initial signal of efficacy in BRCA-deficient cancers (ASCO 2008; abst 5510). The primary aim of this study was to test the efficacy of olaparib in confirmed BRCA1/BRCA2 carriers with advanced chemotherapy-refractory ovarian cancer. The secondary aim was to assess the safety and tolerability profile in ovarian cancer patients with BRCA1/2 deficiency. Methods: In an international, multicenter, proof-of-concept, single-arm, phase II study, two patient (pt) sequential cohorts received continuous oral olaparib in 28-day cycles, initially at the MTD, 400 mg bd (33 pts), and subsequently at 100 mg bd (24 pts), a previously shown clinically active and PARP inhibitory dose. Eligibility criteria included confirmed genetic BRCA1/2 mutation and recurrent, measurable, incurable disease (previous chemotherapy, median 3 lines). The primary efficacy endpoint was best objective response rate (ORR; RECIST) post baseline. Change in CA125 was a secondary efficacy endpoint. All adverse events were reported using CTCAE v3. Results: At this interim analysis dated October 31, 2008, of 57 enrolled pts (39 BRCA1 deficient and 18 BRCA2 deficient), 33 were evaluable at 400 mg bd and 24 at 100 mg bd. The confirmed RECIST ORR was 33% at 400 mg bd and 12.5% at 100 mg bd. Clinical benefit rate (ORR and/or confirmed >50% decline in CA125) was 57.6% at 400 mg bd and 16.7% at 100 mg bd. Toxicity was mainly mild in severity, reflecting grade 1/2 nausea (44%); fatigue (35%); and anemia (14%). Grade 3 toxicity occurred infrequently, and comprised primarily nausea (7%) and leukopenia (5%). Conclusions: Oral olaparib is well tolerated and highly active in advanced, chemotherapy-refractory BRCA-deficient ovarian cancer, with greater activity seen at the higher dose. Toxicity in BRCA1/2 carriers was similar to that seen in non-carriers. This study provides positive proof of the concept of the activity and tolerability of genetically defined targeted therapy with olaparib in BRCA-deficient ovarian cancers.

[Table: see text]

Intra-abdominal pressure measurements in lateral decubitus versus supine position

OBJECTIVE

Intra-abdominal pressure (IAP) has traditionally been measured in the supine position, however, measuring the pressure in lateral semi-recumbent position has not been studied.

DESIGN

A single centre prospective 1-day study.

PATIENTS

10 patients admitted for more then 24 hours who were mechanically ventilated and had an indwelling urinary catheter.

METHODS

Inclusion criteria included were age > 18 years, sedated to a RASS score of -5 and mechanically ventilated. The pressures were measured via the bladder with the mid-axillary line as zero reference point. When patients were nursed in lateral decubitus, pressures were measured and compared immediately to the supine position.

RESULTS

10 patients were included with a total of 60 measurements.The male/female ratio was 9:1 with a mean APACHE Pi score of 11.5 [95% CI 4.8-22.4], SAPS 2 of 31.5 [95% CI 8.9-35.8] and SOFA score of 4.0 [95% CI 1.8-7.2]. Four patients were medical and 6 were surgical. The mean IAP at different time intervals (morning, afternoon and evening) in lateral and supine position were 10.9 +/- 2.0 (in mmHg) vs 6.6 +/- 3.2 (SD with p < 0.001); 11.0 +/- 4.0 vs 5.4 +/- 2.2 (p < 0.0005) and 11.6 +/- 3.8 vs 7.8 +/- 3.0 (p< 0.001). Overall, the LSP did not change significantly (p= 0.76), but the SP did (p=0.006) with the afternoon reading being significantly lower than the evening measurement. However, the trend in the difference (LSP minus SP) was not significant (p=0.43).

CONCLUSION

There was a significant statistical difference in the pressures measured in LSP versus SP.The LSP position should not be used to measure IAP.

Auto-SCT for AML in second remission: CALGB study 9620

We studied the feasibility and efficacy of a two-step approach to Auto-SCT for patients with AML in second remission. Step 1 consisted of consolidation chemotherapy using cytarabine 2000 mg/m(2) i.v. every 12 h for 4 days plus etoposide 40 mg/kg total dose by continuous i.v. infusion over the same 4 days. PBSC were collected after G-CSF stimulation during recovery from this chemotherapy. Step 2, auto-SCT, used a preparative regimen of oral BU 16 mg/kg over 4 days followed by etoposide 60 mg/kg i.v. Of the 50 patients entered on Step 1, two died from treatment complications, and seven failed to proceed to transplantation. A median CD34+ cell dose of 5.9 x 10(6)/kg was collected in a median of three collections. With a median follow-up of 8.2 years, 5-year disease-free survival (DFS) is 28%. The most important prognostic factor was cytogenetics, with acute promyelocytic leukemia (APL) patients having a 5-year DFS of 67% compared with 16% for others. We conclude that this two-step approach to autologous transplantation produces good CD34+ mobilization and that this approach has cured some patients. Results in patients with APL are especially promising.

What is normal intra-abdominal pressure and how is it affected by positioning, body mass and positive end-expiratory pressure?

PURPOSE

To describe what is defined as normal intra-abdominal pressure (IAP) and how body positioning, body mass index (BMI) and positive end-expiratory pressure (PEEP) affect IAP monitoring.

METHODS

A review of different databases was made (Pubmed, MEDLINE (January 1966-June 2007) and EMBASE.com (January 1966-June 2007)) using the search terms of "IAP", "intra-abdominal hypertension" (IAH), "abdominal compartment syndrome" (ACS), "body positioning", "prone positioning", "PEEP" and "acute respiratory distress syndrome" (ARDS). Prior to 1966, we selected older articles by looking at the reference lists displayed in the more recent papers.

RESULTS

This review focuses on the concept that the abdomen truly behaves as a hydraulic system. The definitions of a normal IAP in the general patient population and morbidly obese patients are reviewed. Subsequently, factors that affect the accuracy of IAP monitoring, i.e., body position (head of bed elevation, lateral decubitus and prone position) and PEEP, are explored.

CONCLUSION

The abdomen behaves as a hydraulic system with a normal IAP of about 5-7 mmHg, and with higher baseline levels in morbidly obese patients of about 9-14 mmHg. Measuring IAP via the bladder in the supine position is still the accepted standard method, but in patients in the semi-recumbent position (head of the bed elevated to 30 degrees and 45 degrees ), the IAP on average is 4 and 9 mmHg, respectively, higher. Future research should be focused on developing and validating predictive equations to correct for supine IAP towards the semi-recumbent position. Small increases in IAP in stable patients without IAH, turned prone, have no detrimental effects. The role of prone positioning in the unstable patient with or without IAH still needs to be established.

Non-government organisation engagement in the sanitation sector: opportunities to maximise benefits

Non-government organisations (NGOs) have long played a role in delivering sanitation services to communities in Southeast Asia and Pacific countries, particularly in rural areas. In contrast with large scale infrastructure focused initiatives, NGO programs commonly focus on building linkages between technical and social realms. Drawing on the breadth and depth of NGO experiences, there are opportunities for NGOs to play a greater role in the sanitation sector and to work in partnership with other actors including utilities and government agencies to ensure both 'hardware' and 'software' components of sanitation are built in to project design and delivery to maximise community benefits and ensure longer term system sustainability. This paper discusses these issues and considers how the contribution of NGOs to the sanitation sector in developing countries might be enhanced. The paper is based on recent research for the Australian Agency for International Development (AusAID) intended to guide investment in the water and sanitation sectors of Asia and Pacific partner countries, exploring the potential for increased NGO engagement. The paper presents findings of the research concerning NGO roles and approaches, discusses existing NGO activities in the sanitation sector in Vietnam and Timor Leste and identifies strategies for NGOs and for other sector actors including utilities and government agencies to maximise the benefits of NGO engagement in the sanitation sector.

Malignant melanoma following scalp irradiation for tinea capitis

X-Rays were discovered by Roentgen in 1895 and were subsequently used in the treatment of many ailments. Numerous benign skin conditions including eczema and psoriasis have historically been treated with X-rays. During the 1930s and 1940s radiotherapy was introduced as an effective treatment for scalp ringworm (tinea capitis). Over the past few years radio-induced malignancies have been reported, with basal cell carcinoma predominating. We report a very rare case of a 64-year-old male with a 9.5mm Breslow thickness melanoma occurring over 50 years following irradiation. This case highlights the presence of another risk factor in the development of melanoma. With the increasing age of this irradiated population we may continue to see further evidence of the link between melanoma and skin irradiation.

A review of the surgical treatment of vulval lymphangioma and lymphangiectasia: four case reviews

OBJECTIVE

To evaluate whether surgical management of vulval lymphoedema and/or lymphangiectasia conveys any longstanding patient benefit.

PATIENT AND METHODS

A qualitative analysis of signs and symptoms that occurred before and after surgical treatment for vulval lymphoedema and/or lymphangiectasia was performed. This was done by analysis of patient notes and telephone conducted interview.

RESULTS

From a hospital database search, four patients were found to have had surgical treatment--three for lymphangioma and one for lymphangiectasia. Overall there was a clear improvement in the signs and symptoms associated with these conditions. In particular, all patients reported an improvement (i.e. a reduction or elimination) in the amount of oedema following surgery.

CONCLUSION

Carbon dioxide laser therapy and superficial radiotherapy have been previously described for the management of vulval lymphangioma and lymphangiectasia with limited success, whereas our data suggests surgery offers a more permanent solution. In particular, labial reduction seems to be more successful than methods such as lymphovenous anastomoses and lymphangioplasties. A single operation may provide benefit for up to ten years. This approach has the potential to allow patients to be rehabilitated to normal life and activity.

Structural characterization of autoinhibited c-Met kinase produced by coexpression in bacteria with phosphatase

Protein kinases are a large family of cell signaling mediators undergoing intensive research to identify inhibitors or modulators useful for medicine. As one strategy, small-molecule compounds that bind the active site with high affinity can be used to inhibit the enzyme activity. X-ray crystallography is a powerful method to reveal the structures of the kinase active sites, and thus aid in the design of high-affinity, selective inhibitors. However, a limitation still exists in the ability to produce purified kinases in amounts sufficient for crystallography. Furthermore, kinases exist in different conformation states as part of their normal regulation, and the ability to prepare crystals of kinases in these various states also remains a limitation. In this study, the c-Abl, c-Src, and c-Met kinases are produced in high yields in Escherichia coli by using a bicistronic vector encoding the PTP1B tyrosine phosphatase. A 100-fold lower dose of the inhibitor, Imatinib, was observed to inhibit the unphosphorylated form of c-Abl kinase prepared by using this vector, compared to the phosphorylated form produced without PTP1B, consistent with the known selectivity of this inhibitor for the unactivated conformation of the enzyme. Unphosphorylated c-Met kinase produced with this vector was used to obtain the crystal structure, at 2.15-A resolution, of the autoinhibited form of the kinase domain, revealing an intricate network of interactions involving c-Met residues documented previously to cause dysregulation when mutated in several cancers.