Extramammary Paget disease: review of patients seen in a non-melanoma skin cancer clinic.

Extramammary Paget disease (EMPD) is a rare skin disease commonly found in the anogenital region. In this study, we aimed to identify EMPD patients seen in the non-melanoma skin cancer clinic at Odette Cancer Centre and to describe the treatments delivered and outcomes achieved. From 2000 to 2009, 14 patients were seen. Initial treatment recommendations included imiquimod and surgical excision, although half the patients required more than one treatment modality, highlighting the difficulty of achieving complete eradication of this disease.

Palliative radiotherapy for non-melanoma skin cancer.

AIMS: The primary objective of this study was to assess the rate of tumour response to the palliative radiotherapy regimen used at our centre (8 Gy/fraction on days 0, 7, 21) for non-melanoma skin cancer. The secondary objective was to evaluate symptom palliation. MATERIALS AND METHODS: A retrospective chart review identified patients treated with this palliative radiotherapy regimen from August 2003 to December 2008. Patient age, gender, tumour histology, location, size, presenting symptoms and radiation treatment factors were recorded at baseline. The tumour size and tumour-related symptoms were recorded at each fraction and follow-up visit. The results were analysed on an intent to treat basis. RESULTS: Twenty-eight patients received 31 courses of palliative radiation for basal cell (five) or squamous cell (26) carcinoma of the skin. Twenty-one patients with 23 tumours attended at least one follow-up visit, and seven patients had incomplete follow-up data. At the time of last follow-up (median 17 weeks), the response rate was 58.1% (complete response 15/31; partial response 3/31). A complete response to treatment was correlated with a smaller tumour size at day 21 (P=0.0143). Presenting symptoms were alleviated in 61.3% (19/31) of symptomatic sites. No severe late toxicities were seen. CONCLUSIONS: This palliative regimen offers impressive response rates and effective symptom palliation for patients with non-melanoma skin cancer.

Treating recurrent cases of squamous cell carcinoma with radiotherapy.

Patients with chronic lymphocytic leukemia (CLL) are at a significantly increased risk of developing cutaneous squamous cell carcinoma (SCC), in part because of their impaired immunosurveillance. Here, we report the cases of 4 patients with CLL who had locally aggressive cutaneous scc managed with radiotherapy for local recurrence following surgical excision. All tumours were located in the head-and-neck region. All patients initially achieved complete regression of disease; however, 2 had local recurrence a mean of 8 months after treatment completion. One patient died from progressive SCC. Our findings agree with the high rates reported in literature of multiple tumours, local recurrence, metastases, and mortality from scc in patients with cll. Radiotherapy plays an important role in patient management, and it is the recommended treatment modality when complete surgical excision of disease would result in anatomic and functional defects. Radiotherapy is often used in the case of local recurrence after one or more attempts at surgical excision. Dose escalation through intensity-modulated radiotherapy, hyperfractionation, or novel treatment techniques such as high-intensity focused ultrasound may be explored to improve local control of scc lesions. To optimize patient outcomes, cutaneous SCC arising in patients with a history of cll should be managed and followed in a multidisciplinary clinic, with regular skin surveillance and prompt treatment.

Improving observer variability in target delineation for gastro-oesophageal cancer--the role of (18F)fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography.

AIM: To evaluate the effect of the addition of fused positron emission tomography-computed tomography (PET-CT) imaging vs computed tomography alone in the identification of the gross tumour volume (GTV) in patients with gastro-oesophageal carcinoma. MATERIALS AND METHODS: Ten patients with gastro-oesophageal cancer referred for radiation therapy underwent both (18F)fluoro-2-deoxy-d-glucose-PET (FDG-PET) and computed tomography in the treatment position. Image sets were anonymised and co-registered. Six radiation oncologists independently defined the GTV, first using the computed tomography data alone supplemented by standardised clinical and diagnostic imaging information, and second, using co-registered computed tomography and FDG-PET data (PET-CT). The standard deviation for both GTV length and volume (excluding involved lymph nodes) was taken as a measurement of inter-observer and intra-observer variability. Computer software that calculates volume overlap between contours was also used to generate an observer agreement index to compare intra- and inter-observer variability. RESULTS: The addition of FDG-PET imaging decreased the median standard deviation for tumour length from 10 mm (range 8.1-33.3, mean 12.4 mm) for computed tomography alone to 8mm (range 4.4-18.1, mean 8.1 mm) for PET-CT (P = 0.02). Eight of the 10 patients showed an increase in volume of overlap between observers with the addition of FDG-PET imaging to the contouring process (P = 0.05). The average observer agreement index in PET-CT was 72.7% compared with 69.1% when using computed tomography alone. There was significantly less intra-observer variability in all measures when PET-CT was used. The median standard deviation in length improved from 5.3 to 1.8 mm, the median standard deviation in volume improved from 4.5 to 3 cm3 and the median observer agreement index improved from 76.2 to 78.7% when computed tomography alone was compared with PET-CT. The corresponding P values were 0.001, 0.033 and 0.022, respectively. CONCLUSIONS: The addition of FDG-PET to computed tomography-based planning for the identification of primary tumour GTV in patients with gastro-oesophageal carcinoma decreases both inter-observer and intra-observer variability.

A phase I/II study to evaluate the toxicity and efficacy of accelerated fractionation radiotherapy for the palliation of dysphagia from carcinoma of the oesophagus.

AIMS: We hypothesised that accelerated fractionated radiotherapy may provide a good palliative approach for dysphagia relief in patients with incurable oesophageal cancer, significantly reducing the overall duration of treatment, while providing symptom response with an acceptable toxicity profile. A phase I/II accelerated fractionation study was conducted to evaluate the efficacy and toxicity of this approach. MATERIALS AND METHODS: Patients with incurable oesophageal cancer, symptomatic with dysphagia, Eastern Cooperative Oncology Group performance statusor=6 h apart), 5 days a week, over 2 weeks. RESULTS: Of the 39 evaluable patients, the dysphagia response rate was 69% (27/39) with a median response duration of 5.5 months. The median time to response was 4 weeks. Twenty-eight per cent (11/39) of patients had transient worsening in their dysphagia scores. Acute toxicity (weeks 1-8) occurred in 41% (16/39) of patients. An improvement in global quality of life by week 8 was seen in 42% of patients. There were no late neurological sequelae. The median overall survival was 8 (range 1.7-58+) months. CONCLUSION: The ideal palliative regimen should be relatively short, with minimal toxicity, while offering a favourable response profile. Accelerated fractionation fulfils these criteria and is a suitable treatment alternative for the palliation of dysphagia, especially if the goal is to deliver a higher total biological dose within a shorter (2 week) period of time.