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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

  • Professor of Medicine
  • Joint Appointment in Radiology and Radiological Science


The training set consists of samples from the scan to discount evista online amex pregnancy zicam be segmented (voxels) that are manually selected and labeled by an operator cheap evista on line breast cancer 05 cm. A probability per class is then assigned to buy cheap evista 60mg menopause forgetfulness each unlabeled voxel based on the classes of its k closest samples, the k parameter being set manually. This relatively simple method requires manual selection of samples on every image to segment and 2. Intro duced in [Boser 1992] for linear binary classification, it has become main stream in machine learn ing and pattern recognition. The optimal hyperplane is chosen so that it maximizes the margin be tween the plane and the closest samples. The Support Vectors are the samples that are the closest to the hyperplane and therefore determine its position. Non linear separation is performed by mapping the data into a higher dimensional feature space x → Φ(x). The optimal hyperplane is then found by minimizing the following objective function: X n 1 2 min kwk + C ξi w,ξ,b 2 (2. This optimization problem is solved using the Lagrangian formulation, where unknown variables αi (lagrange multipliers) are introduced for each constraint. K(xi, xj) = Φ(xi)Φ(xj) that directly computes the dot product of the feature vectors. Using such a formulation, the problem becomes solely dependent on the number of samples, it is therefore pos sible to operate with a feature space of infinite dimension. Eventually, the classification decision of a new sample is recovered as: X h(x) = αiyiK(xi, x) + b (2. Current methods either use a hierarchical approach or a one vs all approach [Duan 2005]. Boosting is a general machine learning method which goal is to improve the accuracy of any learning algorithm. Ad aBoost (short for Adaptive Boosting) is the most popular boosting algorithm and was introduced in [Freund 1997]. It relies on the concept that a classifier with high discriminative performance (strong classifier) can be constructed as a weighted linear combination of weak classifiers. The most commonly used weak classifiers’ structures are decision stumps or tree structured classifiers. The weak prediction rules are learned iteratively by minimizing the classification error with an increased focus on mis classified samples at each new iteration. Several variants of the Adaboost algorithm have been developed, among them the Gentle Adaboost algorithm [Friedman 2000] that will be further de tailed in section 3. The popularity of the algorithm can be explained by its simplicity, flexi bility and speed. An example of AdaBoost being applied for tumor segmentation can be found in [Xuan 2007]. Recent work on Decision Forests (or Randomized Forests) showed strong promises [Zikic 2012, Geremia 2012]. The concept was introduced in [Breiman 2001] and corresponds to a collection of 2. A decision tree consists of a set of binary rules that pro gressively split the data into smaller sets based on their features values. Each leaf node (terminal node of the tree) is associated with a probability that corresponds to the fraction of the data of class c that has been assigned to the node. Several decision trees are learned in a similar fashion and the forest consists of the ensemble of those trees. During testing, the test data is pushed through all the decision trees by applying the different separation rules. Each tree yields a probability per sample and class based on the reached leaf node. The forest probability in then computed as the average probability over all the trees. Decision forests are inherently multi-class classifiers, robust to overfitting and fast, making them an appreciated classification approach. The most straight forward features are intensity based, such as the multi modal intensities, intensity patches around the sample (to incorporate neighborhood information) on which first order statistical moments are often computed (mean, variance or entropy to name a few). Features related to the image texture have also been popular, among them the Haralick features [Haralick 1973], or the Gabor features [Manjunath 1996]. Despite the promises of supervised pattern classification methods, they are constrained by the i. This leads to noisy and irregular segmentations that could be barely compensated by the introduc tion of neighborhood or context aware information in the feature vector or post processing with morphological operators. Those limitations have motivated the use of more elaborated models that take into account the spatial interaction between neighboring pixels. Graph based approaches offer an elegant and flexible way of doing so, modeling the spatial interactions as edges connecting the pixels. Typically, the edges only connect the adjacent nodes (4-neighborhood in 2D, and 6-neighborhood in 3D). In such methods, the edges encode an affinity measure wi,j that represent the similarity between the connected nodes i and j.

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We encourage you to purchase evista 60mg overnight delivery women's health clinic on wright street discuss with your physician any questions and concerns that you may have purchase 60 mg evista visa breast cancer latest studies. Three Day Menu Plan: 3 Meals + Snack this menu is based on 1600 calories purchase genuine evista line breast cancer zumba pants, calories can be adjusted by altering portion sizes. The menu has been designed to merely serve as a guide in making healthy food choices. Day 1 Day 2 Day 3 Oatmeal, cooked (1cup) Green Smoothie Egg scramble Non-dairy milk (1 cup) Greens (3 cups) Eggs (2 lg) Flaxseed, ground (1 tbsp) Berries, frozen (1/2 cup) Onions (1/4 cup) Chia seeds (1 tbsp) Protein powder (1 svg) Spinach (1 cup) Blueberries (1/2 cup) Ground flax (1-2 tbsp) Mushrooms (1/2 cup) Chia seed (1 tbsp) Egg, hard boiled (1 lg) Apple (1 med) Almond milk, unsweetened Almond butter (1 tbsp) Green tea (2 cups) (3/4 cup) Green tea (2 cups) Salad Vegetable Bean Soup (2 cups) Black bean corn salad (2 cups) Spinach (3 cups) over steamed kale (1 cup) Corn tortilla (1 med) Broccoli (1/2 cup) Carrots (1/2 cup) Green salad (2 cups) Tomato (1/2 cup) Oil/vinegar dressing (1 tbsp) Chicken breast (4 oz) Barley, cooked (1/2 cup) Avocado (4 slices) Olive oil (1/2 tbsp) Vinegar, balsamic (1 1/2 tbsp) Orange (1 med) Vegetable juice (12 oz) Fruit salad (1 cup) Fruit smoothie Banana (1/2 med) Popcorn, air-popped (2 cups) Almonds (1/4 cup) Berries (1/2 cup) Flaxseed, ground (2 tbsp) Chia seeds (1 tbsp) Yogurt, Greek plain (1/2 cup) Non-dairy milk (1 cup) Tempeh fajitas (4 oz) Chicken & vegetable stir-fry Salmon (4 oz) Onions & peppers (1. Nutrition Information (per 16 oz): Calories: 363 Dietary fiber: 15gm Protein: 30 gm Sodium: 300 mg Fat: 14. Nutrition Information (per 4 oz serving): Calories:120 Dietaryfiber: <1gm Protein:8 gm Sodium:575 mg Fat:5 gm Calcium: 155mg Saturated fat:<1 gm Iron:1. Nutrition Information (per serving): Calories: 215 Protein: 10 gm Fat: 4 gm Dietary fiber: 9 gm Recipe developed by Sous Chef Chris at the Occidental Grill, Washington D. Nutrition information (per serving): Calories: 39 Sodium: 82 mg Fat: 1 gm Calcium: 51 mg Saturated fat: 0 gm Carbohydrate: 5 gm Protein: 4 gm Dietary Fiber: 2 gm Recipe from the U. Combine the chickpeas, water, lemon juice, tahini, olive oil, curry powder, ginger, and salt in a food processor and process until smooth. Nutrition Information (per serving): Calories: 180 Carbohydrate: 27 gm Protein: 7 gm Dietary fiber: 7 gm Fat: 5. Lemon wedges Mix together mustard, olive oil, and honey in a small bowl; set aside. Bake at 450 F for 10 minutes per inch of thickness or until salmon just flakes when tested with a fork. Make oat flour: Place oatmeal into blender or food processor and blend for 1-2 minutes until oatmeal resembles flour. You may need to stop blender and stir oats a couple of times to ensure that all oats have been blended. In a separate large bowl, whisk together pumpkin, brown sugar, vanilla extract, oil, and applesauce for 1-2 minutes until the consistency is smooth and creamy. Bake for 15-25 minutes or until knife inserted into center comes out clean or with just a few crumbs attached. Timing will depend on what size pan you use, but definitely check around 15 minutes. Nutrition Information (per serving): Calories: 107 Carbohydrate: 20 gm Protein: 3 gm Dietary fiber: 2. With clean hands, massage the salt into the leaves until the kale begins to feel moist and darken a bit, about 2 or 3 minutes. You can do this well ahead of time, cover the salad with plastic wrap, and leave at room temperature or refrigerate for several hours. Taste for balance and add as much lemon juice, salt, and pepper as needed to create a vibrant, fresh, sweet/tart balance. When ready to serve, toss the greens with the dressing, shallots, apple or dried fruit, and nuts. Add the toasted quinoa to the boiling water and cook, with lid off, for ~15 minutes. Nutrition Information (per serving): Calories: 125 Sodium: 165 mg Protein: 4 gm Cholesterol: 0 mg Fat: 2 gm Carbohydrate: 22 gm Recipe adapted from the Vegetarian Resource Group. In a small bowl, melt coconut oil in a microwave and add maple syrup and vanilla extract. Nutrition Resources Books Anticancer: A New Way of Life written by David Servan-Schreiber (2008) Five to Thrive written by Lise Alschuler & Karolyn Gazolla (2011) How to Prevent & Treat Cancer with Natural Medicine – written by Michael Murray (2002) Life Over Cancer written by Keith Block (2009) the Color Code – written by James Joseph, Daniel Nadeau, & Anne Underwood (2002) the UltraMind Solution written by Mark Hyman (2009) Ultra Metabolism – written by Mark Hyman (2006) Cookbooks One Bite at a Time – written by Rebecca Katz, Marsha Tomassi, & Mat Edelson (2004) the Cancer-Fighting Kitchen written by Rebecca Katz with Mat Edelson (2009) the Cancer Wellness Cookbook written by Kimberly Mathai (2014) the Healthy Mind Cookbook written by Rebecca Katz with Mat Edelson (2015) the UltraMetabolism Cookbook written by Mark Hyman (2007) Newsletters/Magazines Cooking Light. Antioxidant – A substance that inhibits oxidation or inhibits reactions promoted by oxygen or peroxides. Case-Control Studies – An epidemiological study in which a group of, say, cancer patients (cases) is compared to a similar but cancer-free population (controls) to help establish whether the past or recent history of a specific exposure such as smoking, alcohol consumption and dietary intake, etc. Catechin – One of the tannic acids; phytonutrient, specifically, one of the flavonoids found in green tea. Creatine – An amino acid that is formed in the muscle tissue of vertebrates; supplies energy for muscle contraction. Differences in disease incidence within the cohort are calculated in relation to different levels of exposure to specific factors, such as smoking, alcohol consumption, diet and exercise, that were measured at the start of the study and, sometimes, at later times during the study. Eicosanoids – Biologically active compounds that regulate blood pressure, blood clotting, and other body functions. Estradiol – A naturally occurring powerful estrogen secreted by the mammalian ovary. Glycemic Index A numerical value given to a carbohydrate-rich food that is based on the average increase in blood glucose levels occurring after the food is eaten. Glycemic Load An index indicating the amount of carbohydrate contained in a specified serving of a particular food. Insulin Insulin is a hormone produced by the pancreas in the body that regulates the metabolism of carbohydrates and fats, especially the conversion of glucose to glycogen, which lowers the body’s blood sugar level. Lignans Phytoestrogens that have a similar chemical structure to estradiol and tamoxifen; appear to offer protection against breast cancer. Meta-analysis – the process of using statistical methods to combine the results of different studies. Nitrosamines – Derivatives of nitrites that may be formed in the stomach when nitrites combine with amines; carcinogenic in animals.

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Tumor Categorization Figure 1: Location of histological categories of malignant glioneuronal tumors buy evista paypal breast cancer zumbathon. The gray circles denote category generic evista 60mg free shipping womens health 60 years, white The tumors were categorized into three morphologically circles denote category 2 order evista 60 mg line the women's health big book of exercises free download, and patterned circles denote category distinct categories based on the malignant component: 3 tumors. The malignant glial one case, small cell clusters with better diferentiated small components were positive for glial fbrillary acidic protein neuronal populations resembling mature small neurons in all cases where the staining was performed (Figure 2D). Focal PnEt-like areas were seen in one case in immunohistochemical staining for proliferation marker this group. Tree of the cases had microscopically distinct Ki-67 (Mib) in six tumors demonstrated approximately regions that fulflled the diagnostic criteria for grade i 0% labeling index in the malignant glial component. Glioneuronal tumors with malignant neuronal in patient # 6, a tumor had been removed from the components (4 tumors) cerebellum approximately 46 years ago. Even though the Tere were three females 5, 59, and 69 years of age and clinical diagnosis was pilocytic astrocytoma, no pathology one male at the age of 43 in this category. This patient developed a well defned showed a malignant neuronal component that resembled tumor in the same region, and the radiological impression neuroblastoma. The neuroblastic component ofen formed was that of an extra-axial tumor (Figure 3A). Tere were ofen nests of cells including developed a recurrent tumor in the same region (Figure larger cells suggesting ganglion cell diferentiation. B: Malignant glial component showing prominent vascular proliferation (H&E, x200). C: The malignant glial component showing necrosis, consistent with glioblastoma (H&E, x200). Patient # 7 developed a malignant neoplasm in the cervical spinal cord resembling a neuroblastoma six months afer a grade i ganglioglioma was resected from the same region. Case # 8 had a biphasic tumor with a neuroblastic component and better diferentiated areas with papillary structures resembling the so-called papillary glioneuronal tumor (Figure 4A). The cells in the papillary component were positive for neuronal markers (Figure 4b). The glial component in this tumor was more typical of the glial component in gangliogliomas with pilocytic astrocytoma like areas. Patient # 9 had an unusual malignant neuronal tumor with focal pseudopapillary architecture (Figure 4C,D). The pseudopapillary pattern exhibited pleomorphic cells in vague clusters and nests in a discohesive alveolar pattern, and was strongly positive for synaptophysin, anti A B C D Figure 3: radiological and histological features of tumors in Category 2: A: Patient# 6: Contrast-enhanced axial t -weighted (tr/ tE=600/ 5) Mr image at presentation shows a heterogeneously enhancing right cerebellar mass (arrow). B: Histological features of the well-diferentiated glioneuronal component in Category 2 tumors (Patient # 6; H&E, x400). Contrast-enhanced coronal t -weighted (tr/tE=600/ 5) Mr image shows an enhancing infratentorial mass attached to the dura mater (arrow). D: The malignant neuronal component of the recurrent neoplasm showing neuronal diferentiation (Patient # 6; H&E, x 00). Occasional tumors showed binucleated neoplastic neuronal components (17 tumors) ganglion cells singly or in clusters. The majority of tumors involved ganglion cells, resembling a ganglioneuroblastoma (Figure the frontal lobe (Figure). The glial component in chromogranin positivity, highlighting the biphasic nature the remaining two tumors was anaplastic astrocytoma of the neoplasms. A B C D Figure 4: tumors with unusual neuronal components in Category 2: A: Patient # 8 with a biphasic tumor including a neuronal component with papillary architecture resembling the so-called papillary glioneuronal tumor (H&E, x200). B: The cells in the papillary component were strongly positive for synaptophysin (x 00). C: Patient # 9 who had an unusual pseudopapillary architecture within the malignant neuronal component (H&E, x200). D: Higher magnifcation of the pseudo papillary pattern in Patient # 9 (H&E, x600). B: immunohistochemical staining for synaptophysin identifes the neuronal component (x 00). C: Occasionally, the neuronal component harbored neuroblastic cells intimately associated with atypical ganglion cells, resembling a ganglioneuroblastoma (H&E, x400). D: undiferentiated small blue cells resembling a PnEt as the neuronal component in Category 2 (H&E, x40). Copies of radiological studies or pre-operative imaging The radiological studies were available in three of the reports were available for review in 7 cases. The radiological The cerebellar tumor in case # 6 was radiologically well impression was that of a well-circumscribed mass and circumscribed and partially cystic. The postoperative scans reported radiological evidence of calcifcations was noted within the no residual enhancing lesion. Eight of the 7 cases in category 3 included radiological radiological fndings as reports or copies of flms were information. Postoperatively, 28 patients received radiotherapy and chemotherapy, two received radiotherapy only, and three received chemotherapy only. Tere was no extracranial metastasis, and cerebrospinal dissemination was found in one patient 2 months afer partial excision and radiotherapy. A twelve patients in category received radiotherapy followed by chemotherapy, one patient received radiotherapy only. At the end of the follow up period, six patients were dead of disease and six were alive with disease. Tirteen patients A: Contrast-enhanced coronal t -weighted (tr/tE=600/ 5) received both radiotherapy and chemotherapy, three Mr image depicts a predominantly peripheral enhancement and a centrally necrotic mass (large arrow) that partially expands the received chemotherapy only. At the end of the follow-up period, fve image shows a heterogeneously enhancing mass predominantly patients were dead of disease, were alive with residual in the posterior right temporal lobe (large arrow).

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Ninety-seven patients reported using metformin before their diagnosis cheap evista 60 mg with visa women's health clinic redding ca, and 97 reported use of the drug after diagnosis evista 60mg amex womens health apta. Results of the study showed that the patients who used metformin before being diagnosed with breast cancer were more than twice as likely to cheap evista master card pregnancy 8 months die as patients who never used the drug, while patients who began using metformin after their cancer diagnosis were almost 50% more likely to survive than non-users. The theory behind Metronomic Chemotherapy is that it promotes the continual death of endothelial cells that are attempting to form new blood vessels (blood vessels are required for tumors to survive). It seems very unlikely that a single metronomic regimen will have universal efficacy and the optimal combination regimens of metronomic chemotherapy remain to be determined for any given tumor type. Future preclinical and clinical studies will need to define the best agents to use according to tumor type, the number of agents to be incorporated, the doses of each agent to be used alone or in combination, and the timing of drug administration. The results suggested that metronomic chemotherapy is useful for palliative care and also improved clinical outcomes as a regimen for which long-term administration may be expected. The median survival © Copyright 2019 Anne Loeser Updated April 2019 Page 123 rate of the breast cancer patients was 17. Fast Track is a process designed to facilitate the development and review of drugs to treat serious conditions and fill an unmet medical need. Researchers found that only a few T-Cells get to the tumor while many more are stuck at or double back to the vaccination site. Switching to a saline-based adjuvant in a melanoma vaccine reversed the T cell effect in mice. A combination of three stimulatory molecules (Covax) was added to the saline/peptide vaccine, which produced a strong T cell response. It is unlikely that most of these tumors experienced an antiangiogenic environment long enough to evaluate clinical response to this type of therapy. The study included a total of 4,443 patients with breast cancer, all of whom were followed for an average of 9 years. Patients were divided into groups dependent on the levels of 25-hydroxyvitamin D in their blood. Women in the "high" group had an average of 30 nanograms per milliliter (ng/ml) of 25-hydroxyvitamin D in their blood, while women in the "low" group had an average of 17 ng/ml in their blood. The team found that women who had high levels of 25-hydroxyvitamin D in their blood had a 50% lower fatality rate, compared with women who had low levels of 25-hydroxyvitamin D in their blood. The theory behind Vitamin D’s success against breast cancer is that Vitamin D metabolites increase communication between cells by activating a protein that halts aggressive cell division. As long as vitamin D receptors are present, tumor growth is prevented and kept from expanding its blood supply. And the good news is that Vitamin D receptors are not lost until a tumor is very advanced. They revealed that treatment of breast cancer cells with hormones that © Copyright 2019 Anne Loeser Updated April 2019 Page 124 activate vitamin D and testosterone receptors reduced the growth of cancer cells. Zytiga works by interrupting the androgen-making process at three sources: the testes (in men), the adrenal glands, and the tumor itself. Of these patients, there was one response to Zytiga with an Overall Survival of 14 months. This is an important result and shows that Zytiga can continue to work when other therapies such as chemotherapy have failed. In a study of 45 response-evaluable patients, 6 (13%) had a Partial Response and 26 (58%) had stable disease. Median duration of stable disease was 68 days, of which 2 patients (4%) had stable disease longer than 6 months. Patients in this trial had received 1 or more lines of prior hormonal therapy but no chemotherapy. The results, assessed after a median follow-up of 20 months, translated into a 35% reduction in the risk of progression or death in favor of Faslodex/Alpelisib arm. The Faslodex dosage used in the study was 250 mg per month after the first loading dose (as compared to the usual 500 mg per month dosage). A Duke Cancer Institute study indicates that Bazedoxifene packs a powerful tow-way punch that not only prevents estrogen from fueling breast cancer cell growth, but also flags the estrogen receptor for destruction. Researchers found that Bazedoxifene binds to the estrogen receptor and interferes with its activity, but the surprising thing was that it also “degrades” the estrogen receptor (gets rid of it). In animal and cell culture studies, the drug inhibited growth both in estrogen-dependent breast cancer cells and in cells that had developed resistance to Tamoxifen and/or to Aromatase Inhibitors. The study enrolled 118 post-menopausal women with metastatic hormone-receptor-positive breast cancer whose cancer continued to progress after being treated with an Aromatase Inhibitor. The result was that the combination of the drugs Bortezomib and Faslodex — versus Faslodex alone — doubled the rate of survival at 12 months and doubled the number of patients whose cancer had not progressed after one year from 14% to 28%. Bortezomib is a “proteasome inhibitor” that prevents cancer cells from clearing toxic material. When Bortezomib blocks the ability of the cell to clear these protein clumps, they grow larger and become toxic to the cancer cells. The study results also suggest that the drug combination can delay or overcome resistance to Faslodex. It should be noted that Buparlisib may cause substantial side effects such as elevated liver enzymes, nausea, diarrhea, and depression. These proteins interact with other proteins to instruct a cell when to grow and when not to grow. Common adverse events among patients taking Ibrance +letrozole were neutropenia – (low levels of neutrophils which are a type of white blood cell) (79. The patients were randomized to treatment and control arms at a 2:1 ratio (with 345 treated and 172 receiving placebo). The treatment arm received Ibrance together with Faslodex, and the placebo arm received Faslodex plus placebo. The study was stopped after only 10 months because it met the primary endpoint of improving Progression Free Survival (time to cancer relapse).

Australian Cancer Network Diagnosis and Management of Lymphoma Guidelines Working Party purchase generic evista from india pregnancy bloody show. Available from cancer gov/cancertopics/pdq/treatment/adulthodgkins/HealthProfessional 2011 [cited 2012 Feb 15]; 4 buy evista 60mg with visa womens health 4th edition by youngkin. Available from: cancer gov/cancertopics/pdq/treatment/adult-non-hodgkins/HealthProfessional 2012 10 buy generic evista 60 mg line women's health big book of exercises app. Clinical practice guidelines for first-line/after relapse treatment of patients with follicular lymphoma. Eradication of Helicobacter pylori and stability of emissions in low-grade gastric B-cell lymphomas of the mucosa-associated lymphoid tissue: results of an ongoing multicenter trial. Long-term effect of a watch and wait policy versus immediate systemic treatment for asymptomatic advanced-stage non-Hodgkin lymphoma: a randomised controlled trial. Prognosis of follicular lymphoma: a predictive model based on a retrospective analysis of 987 cases. Prolonged single agent versus combination chemotherapy in indolent follicular lymphomas: a study of the cancer and leukaemia group B. Patterns of survival in patients with recurrent follicular lymphoma: a 20-year study from a single centre. Survival after progression in patients with follicular lymphoma: analysis of prognostic factors. Brief chemotherapy and involved-region irradiation for limited-stage diffuse large-cell lymphoma: An 18-Year experience from the British Columbia Cancer Agency. Favorable outcome of primary mediastinal large B-cell lymphoma in a single institution: the British Columbia experience. Ultimate results of radiation therapy for T1-T2 mycosis fungoides (including reirradiation). Level of evidence According to the methods applied for the previous radiotherapy utilisation model, the indications of radiotherapy for melanoma have been derived from evidence-based treatment guidelines issued by major national and international organisations. The guidelines reviewed are those published after the Page | 243 previous radiotherapy utilisation study was completed (July 2003) up to December 2010. Highest priority has been given to Australian evidence-based clinical-practice guidelines (eg. Epidemiology of cancer stages the epidemiological data in the melanoma utilisation tree have been reviewed to see if more recent data are available through extensive electronic search using the key words ‘Australia’, ‘epidemiology melanoma’, ‘incidence’, ‘melanoma stage‘, ‘radiotherapy treatment’, ‘recurrence’, ‘survival’ ‘treatment outcome’ in various combinations. This has been applied particularly to the early branches in the tree for which national or State level data on cancer incidence rates and stages are available. If there is a change in the hierarchical quality of the epidemiological data, this has also been noted (Table 2). The epidemiological evidence for several indications in the current model has been upgraded accordingly to be more representative of the Australian population. Page | 244 Estimation of the optimal radiotherapy utilisation From the evidence on the efficacy of radiotherapy and the most recent epidemiological data on the occurrence of indications for radiotherapy, the proportion of melanoma patients in whom radiotherapy would be recommended is 21% (Table 1 and Figure 1) compared with the original estimate of 23%. The change in overall utilisation rate is due to changes in the epidemiological data for the model. Although new indications of radiotherapy have been added to the model there are substantial changes in the clinical scenarios with updated epidemiological data added to the model. Estimation of the optimal brachytherapy utilisation for ocular melanoma According to the most updated treatment guidelines (1-2) plaque brachytherapy is preferred over surgery in treatment of ocular melanoma (melanoma of choroid, conjunctiva) because of better tumour control and lower ocular morbidity. Hence, a brachytherapy utilisation model for melanoma has been developed and the optimal utilization rate estimate is 2%. Estimation of the optimal combined radiotherapy and chemotherapy utilisation the indications of radiotherapy for melanoma were reviewed to identify those indications where radiotherapy is recommended in conjunction with concurrent chemotherapy as the first treatment. According to the best available practice evidence there are no indications identified for which concurrent chemoradiation is beneficial over radiotherapy alone as the first indicated treatment. The variability in the estimate of optimal radiotherapy utilisation due to these uncertainties was 3% and the expected value ranged from 18% to 21% as shown in the Tornado diagram (Figure 2). Indications for brachytherapy Levels and sources of evidence Outcome Clinical Scenario Level of References Proportion of all lung cancer No. Clinical Practice Guidelines for the Management of Melanoma in Australia and New Zealand. Cancer Council Australia and Australian Cancer Network, Sydney and New Zealand Guidelines Group, Wellington; 2008. Evidence and interdisciplinary consensus-based German guidelines: surgical treatment and radiotherapy of melanoma. Radiation therapy as primary and adjuvant treatment for local and regional melanoma. Prognostic factors analysis of 17,600 melanoma patients: validation of the American Joint Committee on Cancer melanoma staging system. Sydney Health Projects Group, School of Public Health, University of Sydney; 2005. Factors predicting recurrence and survival in sentinel lymph node-positive melanoma patients. A retrospective study of 150 patients with lentigo maligna and lentigo maligna melanoma and the efficacy of radiotherapy using Grenz or soft X rays. Histopathologic excision margin affects local recurrence rate: analysis of 2681 patients with melanomas < or =2 mm thick. Long term results of a randomized study by the Swedish Melanoma Study Group on 2-cm versus 5-cm resection margins for patients with cutaneous melanoma with a tumor thickness of 0. All of the radiotherapy indications in the model are for palliative intent; a new indication of solitary plasmacytoma has been added where radiotherapy is recommended as the primary treatment. Based on radiotherapy recommendation for solitary plasmacytoma, a new clinical outcome has been added to the model 16.


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