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» Despite general agreement regarding techniques for extensor mechanism repair, there is very limited guidance in the literature for the management of surgical site infections (SSIs) that may occur after these procedures. » Early or mild superficial SSIs, such as cellulitis, can be managed on an outpatient basis while monitoring for improvement, with escalated intervention if the symptoms do not resolve within 1 week. » Deep SSIs should be managed more aggressively with surgical irrigation and debridement (I&D), including the knee joint, depending on the results of the aspiration, removal of all braided nonabsorbable suture (if necessary) with immediate or delayed exchange with monofilament suture, and the administration of parenteral antibiotics based on culture results and an infectious disease consult. » Arthrocentesis should be performed early to monitor for the spread of infection to the joint space, and diagnosis of a septic knee joint should be immediately followed by arthroscopic or open I&D. » For refractory cases (i.e., wound coverage issues or persistent infections despite multiple attempts at debridement), a consult with a plastic surgeon for consideration of a gastrocnemius flap is recommended, and surgeons should remain suspicious of the possibility of the contiguous spread of osteomyelitis.

Background Metastatic cutaneous squamous cell carcinoma to the axilla is uncommon, with limited data to guide management. We sought to assess the outcomes of patients with this condition after surgery and radiotherapy. Methods A retrospective cohort study of patients treated at two Australian hospitals from 1994 through 2016 was performed. Results A total of 74 patients were identified, including 48 treated curatively with surgery-plus-radiotherapy and 15 with surgery alone. Compared with patients treated with surgery alone, a higher proportion of patients treated with surgery-plus-radiotherapy had lymph nodes larger than 6 cm (53% versus 8%, P = 0.012) and multiple adverse histopathological features (75% versus 47%, P = 0.04). The groups had similar 5-year disease-free survival (45% versus 46%) and overall survival (51% versus 48%). Presence of multiple positive lymph nodes was associated with reduced disease-free survival (hazard ratio 4.57, P = 0.01) and overall survival (hazard ratio 3.53, P = 0.02). Regional recurrence was higher in patients treated with surgery alone (38% versus 22%, P = 0.22) and patients with lymph nodes larger than 6 cm (34% versus 10%, P = 0.03). All recurrences occurred within 2 years following treatment. Conclusion Combined-modality therapy for metastatic cutaneous squamous cell carcinoma to the axilla is recommended for high-risk patients, although outcomes remain modest. The key period for recurrence is within 2 years following treatment.

Myeloid sarcoma (MS) is a rare entity, and FDG PET/CT is a useful tool for staging at diagnosis and response assessment. We present a case of a 72-year-old woman diagnosed with multifocal extramedullary MS, using FDG PET/CT to guide palliative radiotherapy to 13 sites of disease over 2 separate relapses with complete and durable local responses and minimal toxicity. This case represents the largest reported burden of disease in MS successfully treated with FDG PET/CT-guided radiotherapy.

Background and objectives There is limited evidence to guide the management of patients with oligometastatic anal squamous cell carcinoma (SCC). We aimed to address this question by reporting the outcome of SCC patients who were treated with organ-directed therapies at two large cancer centers. Methods Patients with advanced anal SCC who were treated with surgery, stereotactic radiotherapy, or radiofrequency ablation (RFA) with a curative intent from 2008 to 2017 were retrospectively identified from the institutional electronic patient records. Results Eight patients with liver or lung metastases met the study inclusion criteria. Seven were treated with surgery while one received RFA and radiotherapy. Median progression-free survival was 5 months (range, 4-39). Three patients underwent repeat organ-directed treatment upon failure of the initial surgery with no evidence of further recurrent disease at the last follow-up. Median overall survival from the time of the first organ-directed therapy was 31 months (range, 11-96) with two out of eight patients being alive and disease-free at 5 years. Conclusions Our study confirms that consideration should be given to the adoption of a multidisciplinary treatment approach in carefully selected, oligometastatic anal SCC patients as organ-directed therapies may offer the chance of achieving a relatively long disease control.

Background Patients undergoing surgery for bowel cancer now have a routine screening test to assess their genetic predisposition to this and other cancers (Lynch syndrome). A result indicating a high risk should trigger referral to a genetic clinic for diagnostic testing, information, and management. Appropriate management of Lynch syndrome lowers morbidity and mortality from cancer for patients and their family, but referral rates are low. The aim of this project was to increase referral rates for patients at high risk of Lynch syndrome at two Australian hospitals, using the Theoretical Domains Framework (TDF) Implementation approach. Methods Multidisciplinary teams at each hospital mapped the referral process and discussed barriers to referral. A 12-month retrospective audit measured baseline referral rates. The validated Influences on Patient Safety Behaviours Questionnaire was administered to evaluate barriers using the TDF. Results were discussed in focus groups and interviews, and interventions co-designed, guided by theory. Continuous monitoring audits assessed change in referral rates. Results Teams (n = 8, 11) at each hospital mapped referral processes. Baseline referral rates were 80% (4/5) from 71 screened patients and 8% (1/14) from 113 patients respectively. The questionnaire response rate was 51% (36/71). Most significant barrier domains were: ‘environmental context;’ ‘memory and decision making;’ ‘skills;’ and ‘beliefs about capabilities.’ Focus groups and interviews with 19 healthcare professionals confirmed these domains as significant. Fifteen interventions were proposed considering both emerging and theory-based results. Interventions included: clarification of pathology reports, education, introduction of e-referrals, and inclusion of genetic status in documentation. Audits continued to December 2016 showing a change in pathology processes which increased the accuracy of screening. The referral rate remained low: 46% at Hospital A and 9% Hospital B. Results suggest patients who have their referral deferred for some reason are not referred later. Conclusion Lynch syndrome is typical of low incidence problems likely to overwhelm the system as genomic testing becomes mainstream. It is crucial for health researchers to test methods and define generalizable solutions to address this problem. Whilst our approach did not improve referrals, we have deepened our understanding of barriers to referral and approaches to low frequency conditions. The project team acknowledges funding by a Cancer Challenge of the Year 2015 grant from the NSW Cancer Institute, administered through the Translational Cancer Research Network.

Background Loco-regional failure is the predominant cause of death in anal squamous cell carcinoma. We assessed patterns of loco-regional recurrence to determine the impact of radiotherapy (RT) volumes on patient outcome. Methods Retrospective clinical study, including patients treated curatively with RT or chemo-radiotherapy between 1994 and 2007. RT fields/volumes were reviewed and compared with patterns of failure. Patients were classified as having whole pelvic radiotherapy (WPRT) if RT extended to L5/S1 or lower pelvic radiotherapy (LPRT) if it extended to the lower sacroiliac joints or below. Patients with negative inguinal nodes either underwent prophylactic inguinal radiotherapy (PIRT) or had inguinal observation (IO). Patterns of failure were compared. Results Twenty-seven patients (53%) had WPRT and 24 (47%) had LPRT. Forty-two patients had negative inguinal nodes: 29 (69%) had PIRT and 13 (31%) had IO. Median follow-up was 5.8 years. Twelve regional failures occurred in eight patients: three pelvic, one inguinal and four pelvic and inguinal. All patients with regional failure died of disease. Pelvic nodal failure was 7.7% in N0 and 33% in N1-3 patients (P = 0.012). There was no difference in pelvic regional failure between WPRT and LPRT (11% versus 16%, P = 0.64). There was only one possible regional failure above LPRT in this group (4%). Inguinal failure was 0% in the PIRT group compared with 23% in IO group (P = 0.009). Conclusion There was no difference in pelvic regional failure between WPRT and LPRT. LPRT is likely to be safe in N0 patients. Inguinal nodes should be treated in all patients.

Background To describe the population benefit of radiotherapy in a high-income setting if evidence-based guidelines were routinely followed. Methods Australian decision tree models were utilized. Radiotherapy alone (RT) benefit was defined as the absolute proportional benefit of radiotherapy compared with no treatment for radical indications, and of radiotherapy over surgery alone for adjuvant indications. Chemoradiotherapy (CRT) benefit was the absolute incremental benefit of concurrent chemoradiotherapy over RT. Five-year local control (LC) and overall survival (OS) benefits were measured. Citation databases were systematically queried for benefit data. Meta-analysis and sensitivity analysis were performed. Findings 48% of all cancer patients have indications for radiotherapy, 34% curative and 14% palliative. RT provides 5-year LC benefit in 10.4% of all cancer patients (95% Confidence Interval 9.3, 11.8) and 5-year OS benefit in 2.4% (2.1, 2.7). CRT provides 5-year LC benefit in an additional 0.6% of all cancer patients (0.5, 0.6), and 5-year OS benefit for an additional 0.3% (0.2, 0.4). RT benefit was greatest for head and neck (LC 32%, OS 16%), and cervix (LC 33%, OS 18%). CRT LC benefit was greatest for rectum (6%) and OS for cervix (3%) and brain (3%). Sensitivity analysis confirmed a robust model. Interpretation Radiotherapy provides significant 5-year LC and OS benefits as part of evidence-based cancer care. CRT provides modest additional benefits.

AIM: Superficial soft tissue sarcomas (S-STS) are generally considered low-risk tumors and have an excellent prognosis when treated with appropriate surgery and adjuvant therapy. However, they are often misdiagnosed then mistreated, leading to significant morbidity. This study aims to examine the patterns of care and outcomes of patients with S-STS, comparing those initially managed through sarcoma units versus elsewhere. METHODS: Patients with S-STS from Prince of Wales Hospital in NSW (1995-2013) and Peter MacCallum Cancer Centre in Victoria (2009-2013) were identified from a national sarcoma database. Baseline variables, treatment and disease outcomes were recorded. Statistical tests performed included univariate and multivariate analyses, chi-square tests, as well as the Kaplan-Meier method for 5-year local recurrence and survival rates. RESULTS: Eighty-nine patients were identified, with 35% initially managed at a sarcoma unit and 65% elsewhere. Patients initially managed at sarcoma units had larger tumors (>5 cm 39% vs 17%; P = 0.036) with a trend to higher grade (61% vs 48%; P = 0.39). Patients that were initially managed outside a sarcoma unit more often underwent open surgical biopsies (P

The purpose of this chapter is to review the potential complications of the Latarjet procedure, including preoperative and patient factors, intraoperative technical issues, and postoperative events.

Aims Women treated with pelvic radiation therapy (PRT) for gynaecological or anorectal cancer report a high number of sexual problems and unmet post-treatment psychosexual information needs. Currently, there is suboptimal adherence to recommended rehabilitation aids, such as vaginal dilators, and a paucity of resources to facilitate post-radiation rehabilitation and reduce distress in this population. This randomised controlled trial aimed to evaluate the effectiveness of a study-developed psychosexual rehabilitation booklet in this setting. Materials and methods Eighty-two women scheduled for PRT to treat gynaecological/anorectal cancer were randomised to receive the intervention booklet (n = 44) or standard information materials (n = 38). Self-report questionnaires administered at pre-treatment baseline and at 3, 6 and 12 months post-treatment assessed adherence with rehabilitation aids, booklet knowledge, anxiety, depression and sexual functioning/satisfaction. Results Dilator adherence and booklet knowledge were significantly higher in the intervention group than in the control group (averaged over time points), with scores significantly increasing over time. Younger age and gynaecological cancer were significant predictors of greater dilator adherence. No significant group differences were found on psychological and sexual measures. Conclusions The psychosexual rehabilitation booklet was effective in educating women with gynaecological and anorectal cancers about PRT-related psychosexual side-effects and rehabilitation options, as well as promoting uptake of vaginal dilator use. Future research should elucidate the effectiveness of this booklet in women with greater psychological and sexual functioning needs.

Purpose There are limited data at a population level on adjuvant brachytherapy (BT) practice for uterine corpus malignancies. The aims of the current study were to describe BT practice for this disease in New South Wales (NSW), to assess quality of BT, and to determine if a caseload effect on quality exists.

Introduction To compare outcomes of different salvage treatment modalities in patients with aggressive B-cell non-Hodgkin lymphoma (NHL) who remain FDG-PET positive after R-CHOP chemotherapy. Existing data on these patients with FDG-PET primary refractory disease are limited. Methods Patients with diffuse large B-cell lymphoma or grade 3 follicular lymphoma were retrospectively reviewed from the Prince of Wales Hospital databases. Eligibility criteria were: age≥18 years, treated with R-CHOP, with positive post-chemotherapy FDG-PET. Salvage treatment modalities were: radical radiotherapy (RT, dose≥30 Gy), high dose chemotherapy and autologous stem cell transplant (ASCT), or non-radical management. Survival was calculated from date of post-chemotherapy FDG-PET to last follow-up. Results Twenty-six patients from 2003-2015 met the inclusion criteria. Median age was 60 (range 19-84). Most had adverse baseline features: 21 (81%) stage III-IV, 24 (92%) bulky disease and nine (35%) skeletal involvement. Characteristics of PET-positivity post-chemotherapy were single site in 16 (62%), sites of prior bulk in 24 of 24, skeletal sites in five of nine, and able to be encompassed by RT in 21 (81%). Salvage treatment was: radical RT in 17 (65%), ASCT in four (15%) and non-radical in five (20%). Median follow-up of surviving patients was 31 months. Kaplan-Meier estimates of 3-year PFS and OS were 41% and 52%, respectively. By salvage modality, 3-year PFS was 51% for RT, 25% for ASCT and 20% for non-radical treatment, (P = 0.453); 3-year OS was respectively 65%, 25% and 40% (P = 0.173). Conclusion Patients with FDG-PET positive disease after R-CHOP for aggressive B-cell NHL are salvageable with radiotherapy.

Many journals seek to evaluate the quality of reviews performed by their panel of reviewers. The purpose of this study is to determine if members of a journal editorial board can consistently and reliably use a single numeric scoring system to evaluate the quality of peer reviews. A retrospective analysis of 11 randomly selected manuscripts that had undergone external peer review by three reviewers was performed. Six had been rejected and five accepted. Each deputy editor was asked to score each of the reviews. The intraclass correlation was determined for each of the manuscripts to determine the consistency in grading. The intraclass correlation for 10 of the 11 manuscripts was above 0.87. This study demonstrates that an editorial board of deputy editors, without external training, can consistently and reliably grade reviews with excellent agreement.

PURPOSE: We previously conducted modelling and a patterns of care study (POCS) that showed gynaecological brachytherapy (BT) was underutilized in New South Wales (NSW), the USA and Western Europe. The aim of the current study was to assess the quality of cervical BT in NSW, and to determine if caseload affects quality of treatment delivery. MATERIAL AND METHODS: All nine NSW radiation oncology departments that treated patients with cervical BT in 2003 were visited. Patient, tumour and treatment related data were collected. Quality of BT was assessed using published quality benchmarks. Higher and lower caseload departments were compared. RESULTS: The four higher cervical BT caseload departments treated 11-15 NSW residents in 2003, compared to 1-8 patients for the lower caseload departments. Cervix cancer patients treated at the higher caseload departments were more likely to be treated to a point A dose ≥ 80 Gy (58% vs. 14%, p = 0.001), and to have treatment completed within 8 weeks (66% vs. 35%, p = 0.02). Despite higher point A doses, there was no significant difference in proportions achieving lower than recommended rectal or bladder doses, implying better BT insertions in higher caseload departments. CONCLUSIONS: Cervical BT in NSW was dispersed amongst a large number of departments and was frequently of sub-optimal quality. Higher quality BT was achieved in departments treating at least 10 patients per year. It is likely that improved outcomes will be achievable if at least 10 patients are treated per department per year.

Aim Retroperitoneal sarcomas (RPSs) are large, rare tumors. The role of core biopsy for retroperitoneal masses identified by preoperative imaging is unclear and we report the safety and accuracy of core biopsies at a specialized sarcoma unit in Sydney, Australia. Methods A retrospective analysis of a prospectively collected database was performed to identify the safety and accuracy of core biopsies in patients who were confirmed to have RPS. Results Twenty-two patients underwent biopsies with no recorded morbidity or tumor seeding. RPS was correctly identified in 82%. Median follow-up was 19 months. Conclusion We demonstrate that core biopsy is safe and can identify RPSs.

Purpose We aimed to estimate the optimal proportion of all gynecological cancers that should be treated with brachytherapy (BT)—the optimal brachytherapy utilization rate (BTU)—to compare this with actual gynecological BTU and to assess the effects of nonmedical factors on access to BT. Methods and Materials The previously constructed inter/multinational guideline-based peer-reviewed models of optimal BTU for cancers of the uterine cervix, uterine corpus, and vagina were combined to estimate optimal BTU for all gynecological cancers. The robustness of the model was tested by univariate and multivariate sensitivity analyses. The resulting model was applied to New South Wales (NSW), the United States, and Western Europe. Actual BTU was determined for NSW by a retrospective patterns-of-care study of BT; for Western Europe from published reports; and for the United States from Surveillance, Epidemiology, and End Results data. Differences between optimal and actual BTU were assessed. The effect of nonmedical factors on access to BT in NSW were analyzed. Results Gynecological BTU was as follows: NSW 28% optimal (95% confidence interval [CI] 26%-33%) compared with 14% actual; United States 30% optimal (95% CI 26%-34%) and 10% actual; and Western Europe 27% optimal (95% CI 25%-32%) and 16% actual. On multivariate analysis, NSW patients were more likely to undergo gynecological BT if residing in Area Health Service equipped with BT (odds ratio 1.76, P=.008) and if residing in socioeconomically disadvantaged postcodes (odds ratio 1.12, P=.05), but remoteness of residence was not significant. Conclusions Gynecological BT is underutilized in NSW, Western Europe, and the United States given evidence-based guidelines. Access to BT equipment in NSW was significantly associated with higher utilization rates. Causes of underutilization elsewhere were undetermined. Our model of optimal BTU can be used as a quality assurance tool, providing an evidence-based benchmark against which actual patterns of practice can be measured. It can also be used to assist in determining the adequacy of BT resource allocation.

Introduction: Having previously modelled the optimal proportion of uterine cervix and corpus cancers that should be treated with brachytherapy (BT), we aimed to complete the assessment of the role of BT for gynaecological cancers by estimating the optimal proportion of vaginal cancer cases that should be treated with BT, the optimal BT utilisation (BTU) rate for vaginal cancer. We compared this with actual vaginal BTU and assessed quality of BT for vaginal cancer by a Patterns-of-Care Study (POCS). Methods: Evidence-based guidelines were used to construct an optimal BTU decision tree for vaginal cancer. Searches of the epidemiological literature to ascertain the proportion of patients who fulfilled the criteria for BT were conducted. The robustness of the model was tested by sensitivity analyses and by peer review. A retrospective POCS of BT in New South Wales (NSW) for 2003 was conducted, and actual BTU for vaginal cancer was determined. Differences between optimal and actual BTU were assessed. Quality of BT for vaginal cancer was compared with published benchmarks. Results: The optimal vaginal cancer BTU rate was estimated to be 85% (range 81–87%). In NSW in 2003, actual vaginal cancer BTU was only 42% (95% confidence interval 22–62%). In NSW, only nine patients were treated, all with intra-vaginal cylinders, and two of four to lower than recommended doses. Conclusions: BT for vaginal cancers is underutilised in NSW compared with the proposed optimal models of care. BT quality may have been suboptimal and this may relate to the rarity of this disease.

Purpose Brachytherapy (BT) is an important treatment technique for uterine corpus malignancies. We modeled the optimal proportion of these cases that should be treated with BT—the optimal rate of brachytherapy utilization (BTU). We compared this optimal BTU rate with the actual BTU rate. Methods and Materials Evidence-based guidelines and the primary evidence were used to construct a decision tree for BTU for malignancies of the uterine corpus. Searches of the literature to ascertain the proportion of patients who fulfilled the criteria for BT were conducted. The robustness of the model was tested by sensitivity analyses and peer review. A retrospective Patterns of Care Study of BT in New South Wales for 2003 was conducted, and the actual BTU for uterine corpus malignancies was determined. The actual BTU in other geographic areas was calculated from published reports. The differences between the optimal and actual rates of BTU were assessed. Results The optimal uterine corpus BTU rate was estimated to be 40% (range, 36–49%). In New South Wales in 2003, the actual BTU rate was only 14% of the 545 patients with uterine corpus cancer. The actual BTU rate in 2001 was 11% in the Surveillance, Epidemiology, and End Results areas and 30% in Sweden. Conclusion The results of this study have shown that BT for uterine corpus malignancies is underused in New South Wales and in the Surveillance, Epidemiology, and End Results areas. Our model of optimal BTU can be used as a quality assurance tool, providing an evidence-based benchmark against which can be measured actual patterns of practice. It can also be used to assist in determining the adequacy of BT resource allocation.

Metastatic basal cell carcinoma is exceedingly uncommon, with a poorly defined natural history, and its incidence, risk factors, patterns of spread, prognosis and potential treatment options are not well understood. This retrospective single institution case series aims to shed light on these issues. Aggressive local management in patients with locoregional disease may result in long-term survivors.

Background Local control for extremity soft tissue sarcomas (STS) requires surgery combined with radiotherapy, usually given pre-operatively or post-operatively. The modified Eilber protocol, a neoadjuvant chemoradiation regimen, has been reported with excellent local control rates. This retrospective single-centre study compared outcomes for patients treated with the modified Eilber protocol with those treated with standard adjuvant radiotherapy. Methods Patients with a diagnosis of extremity STS were retrospectively reviewed from the Prince of Wales Hospital Sarcoma Database from 1995 to 2012. Sixty-three patients underwent curative surgery with either neoadjuvant Eilber chemoradiotherapy (Eilber) or adjuvant radiotherapy (Adjuvant). Results Twenty-nine patients were treated with modified Eilber protocol. Thirty-four patients received adjuvant radiotherapy. Three patients (10%) in the Eilber group and five patients (15%) in the Adjuvant group developed local recurrence (P = 0.87). Major acute wound complications were noted in four patients in each group (P = 0.55). One patient (3.4%) in the Eilber group developed Grade 3 or 4 late toxicities after 1 year compared with nine patients (27%) in the Adjuvant group (P = 0.02). Conclusion Neoadjuvant chemoradiation (Eilber protocol) provided similar rates of local control when compared with adjuvant radiotherapy. Acute wound complication rates were similar but there was less severe late toxicity in the Eilber group.

Background and purpose We aimed to construct an evidence-based model of optimal treatment utilisation for prostate cancer, incorporating all local treatment modalities: radical prostatectomy (RP), external beam radiotherapy (EBRT), and brachytherapy (BT); and then to compare this optimal model with actual practice. Materials and methods Evidence-based guidelines were used to construct a prostate cancer treatment decision-tree. The proportion of patients who fulfilled treatment criteria was drawn from the epidemiological literature. These data were combined to calculate the overall proportion of patients that should optimally have RP, EBRT and/or BT at least once during the course of their disease. The model was peer reviewed and tested by sensitivity analyses and compared with actual practice. Results Optimal utilisation rates, at some point during the disease course, were: RP, 24% (range 15–30%); EBRT, 58% (range 54–64%); BT, 9.6% (range 6.0–17.9%); and any RT, 60% (range 56–66%). Many patients had indications for more than one of these treatments, and at least one of these treatments was indicated in 76% of patients. The model was sensitive to patient preference estimates. Optimal rates were achievable in some health care jurisdictions. Conclusions Modelling optimal utilisation of all local treatment options for a particular cancer is possible. These optimal prostate cancer treatment rates can be used as a planning and quality assurance tool, providing an evidence-based benchmark against which can be measured patterns of practice.

Summary The purpose of this study was to determine whether delay in the diagnosis of small bowel injury (SBI) affected the outcome of paediatric patients who required surgical interventions in the treatment of small bowel injuries. A retrospective chart review was performed on children with traumatic SBI requiring surgical management between January 2000 and December 2002. Diagnostic interval was defined as the time from presentation to operative treatment and delay was an interval of greater than 8 h. Thirteen patients were admitted for operative treatment of SBI. Nine cases were the result of motor vehicle trauma. The mean diagnostic interval for all patients was 9.1 h ± 7.4 h (range 0.6 h–22.5 h). Six patients had a diagnostic delay with a mean diagnostic interval of 15.5 h ± 5.5 h. There was no statistically significant difference found between the prompt and delayed diagnosis groups in terms of complications or length of hospital stay. Our finding of no difference between the prompt and delayed diagnosis groups and a diagnostic delay no longer than 22.5 h may suggest that our local methods of diagnosis and treatment assist in the prevention of unnecessary complications and death.

Leptomeningeal carcinomatosis is an uncommon but devastating form of metastatic spread. To our knowledge, only 16 cases originating from a head and neck cancer have been reported. We describe the first case of a patient with leptomeningeal carcinomatosis arising from a laryngeal squamous cell carcinoma. Shortly after completing treatment for an advanced supraglottic laryngeal cancer, this 63-year-old man presented with lower limb neurological symptoms and signs. Radiological and cytological evidence of leptomeningeal carcinomatosis of the distal spinal canal was identified. He was treated with intrathecal methotrexate and palliative radiotherapy. Although his pain improved, his lower limb weakness worsened. He died 3 weeks after completing radiotherapy. Presumed mode of spread was via the haematogenous route. The natural history and management of leptomeningeal carcinomatosis are discussed. Clinicians should be aware of the uncommon possibility of leptomeningeal carcinomatosis in a patient presenting with an appropriate constellation of symptoms and signs, and a past history of cancer.

Purpose: We performed the first comprehensive, population-based brachytherapy (BT) Patterns of Care Study in the Australian setting. Herein we report on prostate BT and assess the technical quality of BT practice, focusing on whether a caseload effect could be identified in New South Wales (NSW). Material and methods: Site visits were made to all radiation oncology departments in NSW that delivered prostate BT, collecting relevant data on NSW residents treated with prostate BT in 2003. Overall quality of NSW prostate BT treatment was assessed using benchmarks including treatment of appropriate prostate cancer disease risk category, absence of (relative) physical contraindications, optimal planned and treated dosimetry, and pre-/post-implant planning/CT. Quality was compared between higher and lower caseload departments. Results: One hundred and fifty-seven (67%) patients underwent temporary BT and 79 (33%) permanent seed BT. Prostate BT was concentrated in five departments, with three of four departments with active programmes treating greater than the recommended 25 cases. Rates of concordance with quality benchmarks were high (85-99%) with no consistent caseload effect identified. Conclusions: Prostate BT in NSW in 2003 was generally of high quality and a caseload effect on quality could not be identified. This may be because the number of departments was insufficient to determine a caseload effect, or because the prostate BT was largely concentrated in a small number of high caseload departments. J Contemp Brachytherapy 2014; 6, 4: 344–349 DOI: 10.5114/jcb.2014.46610

Background and Purpose In 2003 we estimated that 52.3% of new cases of cancer in Australia had an indication for external beam radiotherapy at least once at some time during the course of their illness. This update reviews the contemporary evidence to define the optimal proportion of new cancers that would benefit from radiotherapy as part of their treatment and estimates the changes to the optimal radiotherapy utilisation rate from 2003 to 2012. Materials and Methods National and international guidelines were reviewed for external beam radiotherapy indications in the management of cancers. Epidemiological data on the proportion of new cases of cancer with each indication for radiotherapy were identified. Indications and epidemiological data were merged to develop an optimal radiotherapy utilisation tree. Univariate and Monte Carlo simulations were used in sensitivity analysis. Results The overall optimal radiotherapy utilisation rate (external beam radiotherapy) for all registered cancers in Australia changed from 52.3% in 2003 to 48.3% in 2012. Overall 8.9% of all cancer patients in Australia have at least one indication for concurrent chemo-radiotherapy during the course of their illness. Conclusions The reduction in the radiotherapy utilisation rate was due to changes in epidemiological data, changes to radiotherapy indications and refinements of the model structure.

Opening-wedge high tibial osteotomy is an increasingly performed procedure for treatment of varus gonarthrosis and correction of malalignment during meniscal transplantation or cartilage restoration. Precise preoperative planning and meticulous surgical technique are required to achieve an appropriate mechanical axis correction. We describe our technique of arthroscopic and computer-assisted high tibial osteotomy using commonly available total knee arthroplasty navigation software as an intraoperative goniometer. We believe that our technique, by providing intraoperative real-time guidance of the degree of correction that is accurate and reliable, represents a useful tool for the surgeon who uncommonly performs high tibial osteotomy.

Knee arthroscopy is the most commonly performed orthopaedic procedure in the United States. Indications have grown exponentially since the procedure was first popularized by Watanabe and Jackson. Treatment of meniscal tears is the most common reason for knee arthroscopy, with approximately 700,000 arthroscopic partial meniscectomies performed annually. Other indications include assistance for cruciate ligament reconstruction, osteochondral lesions, removal of loose bodies, synovectomy, and septic arthritis. Arthroscopy is accomplished with the use of two small incisions on either side of the patella at the anterior aspect of the knee. An arthroscope is inserted through one incision and used to view the image on a monitor, while the second incision is employed for instrumentation. An examination with the patient under anesthesia should always be performed prior to the initiation of the procedure. The patient is positioned with the knee flexed and a lateral post secured to the side of the bed. Standard anteromedial and anterolateral portals are made, and an arthroscope is introduced through the anterolateral portal. Diagnostic arthroscopy is performed in a systematic fashion. Meniscal tears and other pathology are identified. With use of an arthroscopic probe, the features of the meniscal tear are determined. Arthroscopic punches and shavers are used to debride torn portions back to a stable rim. Knee arthroscopy is a highly effective procedure. Outcomes after partial medial meniscectomy are good to excellent in 80% to 100% of patients. A recent cost-effectiveness analysis demonstrated that knee arthroscopy is more cost-effective than coronary artery bypass surgery or total knee arthroplasty.

Adhesive capsulitis is a common and challenging condition to treat. Arthroscopic capsular release is usually contemplated when conservative treatment fails or when there is severe and/or chronic loss of range of motion. This procedure can be difficult to perform because of difficult access to the joint, poor visualization, and loss of working space from retraction of the joint capsule. The articular surfaces and the axillary nerve are also at higher risk of injury. Arthroscopic scissors, shavers, and electrocautery are typically used to perform the capsular release. To perform a safer and more precise arthroscopic shoulder capsular release, a creative and innovative use of a flexible hip arthroscopy radiofrequency ablator is described.

BACKGROUND. Brachytherapy (BT) is an integral part of cervical carcinoma treatment. There have been no attempts to estimate the optimal proportion of new cervical carcinoma cases that should be treated with BT, that is, the optimal rate of brachytherapy utilization (BTU). METHODS. Evidence-based guidelines and primary evidence were used to construct a BTU tree for carcinoma of the uterine cervix. Searches were performed of the epidemiological literature to ascertain the proportion of patients who fulfilled criteria for BT. The robustness of the model was tested by sensitivity analyses and by peer review. A patterns of care study of BT in New South Wales for 2003 was conducted, and actual BTU for cervical carcinoma determined. The differences between optimal and actual rates of BTU were assessed. RESULTS. The optimal cervical carcinoma BTU was 49% (range, 42% to 50%). In New South Wales in 2003, actual BTU was only 30% of 256 cervical carcinoma patients. The major discrepancy was for FIGO stage IB-IIA disease, where there was an underutilization of BT, estimated to be 15% actual use compared with 47% optimal use. In Surveillence, Epidemiology, and End Results (SEER) areas, there was underutilization for stage IB-IIA (22% actual BTU versus 47% optimal BTU) and for stage IIB-IVA (54% actual BTU versus 100% optimal BTU). CONCLUSIONS. BT for cervical carcinoma is underutilized in New South Wales and in SEER areas. The authors' model of optimal BTU can be used as a quality assurance tool to provide an evidence-based benchmark against which actual patterns of practice can be measured. The model can also be used to help determine adequacy of BT resource allocation. Cancer 2006. © 2006 American Cancer Society.

Until the late 1960s, splenectomy was routinely performed in children who had sustained blunt splenic injury. There was based on the ability to perform splenectomy without obvious consequence; the cited 90-100% mortality for splenic trauma and the possibility of delayed rupture of the spleen. In contrast, contemporary findings in immunology and surgery demonstrated that non-operative management was not only feasible but desirable in view of the potential for overwhelming post-plenectomy infection. The history of universal splenectomy following blunt splenic trauma has been reviewed and we outline the findings that have resulted in the current standard of non-operative management following blunt splenic trauma.

Background: Non-operative management of the great majority of blunt splenic injuries in children has become routine. Debate continues on the need for intensive care unit (ICU) admission, follow-up imaging and the duration of physical activity restrictions following injury. The purpose of this study was to review the recent experience of an Australian Paediatric Trauma Centre with splenic trauma to define current practice. Methods: A retrospective chart review of patients with splenic trauma admitted to the Children's Hospital at Westmead between November 1995 and December 2003. Results: A total of 39 patients with blunt splenic trauma were identified: 20 (51%) were multiply injured. Thirty-three (85%) children were managed non-operatively. The most common initial imaging method was computed tomography (n = 28, 72%). Fourteen patients (36%) were admitted to the ICU with a mean length of stay (LOS) of 4.1 days (range 1–13 days). The overall mean LOS was 10.8 days (range 1–43 days). Nineteen patients (50%) had imaging studies performed after diagnosis but before discharge. Further post-discharge imaging was carried out in 21 cases (54%). There were no deaths, but 10 patients developed complications. The mean documented activity restriction was 7.4 weeks (range 1–16 weeks). Conclusion: The majority of children who had suffered blunt splenic trauma were safely managed non-operatively outside an ICU. In stable patients, there appeared to be no benefits associated with repeated imaging following the diagnosis of splenic trauma. Physical activity restriction in excess of 3–4 weeks did not appear to be warranted.