User:Leclairr22/sandbox

Welcome to your sandbox!
Hi Rebecca,

I think the proposed changes look very good. just a few typos and small grammar mistakes " boarder of healthy tissue" vs "border" that type of things.

Mohs micrographic surgery may also be used to insure more precise histological margins - I'm not sure if "more precise histological margins" is the best way to put it. the main advantage of Mohs is conserving healthy tissue for cosmetically sensitive sites, like the eyelids and the nose. In those areas, taking a 1 or 2 cm margin around the lesion is not possible. plastic surgeons will usually do these type of cases with frozen section pathology support, so you find out the margin status at the time of operation. That is essentially the same process as Mohs. So you can just delete this sentence if you want.

Peri-operative RT is recommended for cases with larger primary lesions, with positive margins indicating the possibility of an incomplete excision, and other risk factors for reoccurrence including positive lymph node involvement and immunosuppression. - You were talking about post-operative RT earlier, and this is Peri-operative (which I guess include before and after surgery radiation therapy), just wanted to clarify if this should be post-operative RT as well. Also for a lay person, do you want to explain what post-operative means, like adding post-operative RT (radiation therapy after surgical removal of the tumour) somewhere. or a hyperlink to another Wikipedia page.

"If the patient is to receive RT, the delay between the surgical treatment and RT should be minimized to optimize the clinical outcome" - I think for a lay person, they might want to know what exactly is the a better clinical outcome, is it better wound healing, less recurrence rate, or something else.

This is place to practice clicking the "edit" button and practice adding references (via the citation button). Please see Help:My_sandbox or contact User_talk:JenOttawa with any questions.

Link: Project Homepage and Resources


 * Note: Please use your sandbox to submit assignment # 3 by pasting it below. When uploading your improvements to the article talk page please share your exact proposed edit (not the full assignment 3).


 * Talk Page Template: CARL Medical Editing Initiative/Fall 2019/Talk Page Template

Merkle-Cell Carcinoma
=== Assignment #2 ===

1) How you searched for a source (search strategy – where you went to find it).

Wikipedia won't let me upload the screen shot of my search strategy

2) What potential sources were identified and considered (give examples of 1 or 2).

Bichakjian, Christopher K., et al. “Merkel Cell Carcinoma, Version 1.2018, NCCN Clinical Practice Guidelines in Oncology.” Journal of the National Comprehensive Cancer Network, vol. 16, no. 6, Harborside Press, LLC, June 2018, pp. 742–74, doi:10.6004/jnccn.2018.0055.

3) Why the source was chosen (what made it better than other choices).

This source is a clinical guidelines from the National Comprehensive Cancer Network which consolidates the existing evidence to recommend diagnostic and treatment options. This source was chosen because it is up to date (2018) and likely reflects the clinical treatments patients could reasonably expect to receive at this point in time.

4) List at least three reasons why the source that was selected meets Wikipedia’s reliable medical sources (MEDRS) criteria.

As this source is a clinical guideline it is a secondary course. Guidelines used systematic reviews to give their recommendations and therefore is a higher quality of evidence. The source is recent, from 2018, which means it is up to date and likely reflect current practice. This source also provides explicit biomedical and clinical information. All conflicts of interest and author affiliations are clearly listed in the guideline.

5) How do you plan to use the source for improving the article

This source will be used to improve the section on treatment, specifically the section concerning surgical and radiation treatment. It will be used to help define the use of radiation post-operatively vs. for non resectable tumours

Proposed Changes
Surgery:

The goal of surgical excision is to remove the MCC with negative resection margin, meaning the tumour has been excised completely with a surrounding border of healthy tissue. Complete excision is associated with significantly higher survival rates. Surgical margins should extend 1 to 2 cm beyond the border of the MCC and may include underlaying fascia and muscle if the MCC has invaded deeper than the dermis. Surgical excision should be coordinated with the sentinel lymph node biopsy (SNLB). Reconstruction may also be needed if the surgical treatment requires extensive tissue removal. However, reconstruction should not occur until negative margins and a negative SLNB have been confirmed.

Rationale for proposed change:
The surgical section had many errors, mainly stemming from incomplete information or oversimplifications. It also relies heavily on primary sources. By using the 2018 clinical guideline, I was able to update the information and provide more details of what surgical treatment should include. In particular I fleshed out the general steps of the surgery more, and made the involvement of the SNLB more clear. I also added information about reconstruction since there was previously no mention of reconstruction in the surgical section.

Radiation Therapy:

Evidence on the efficacy of post-operative radiation therapy (RT) for Merkel cell carcinoma is inconclusive as of 2018. Therefore it is unclear which patients should be receiving post-operative RT. However, it has been recommended that observation is sufficient for patients will small primary lesions (<1cm) that have been excised with clear margins and no lymph node involvement, or immunosuppression. Post-operative RT, which is given after surgical treatment, is recommended for cases with larger primary lesions, with positive margins indicating the possibility of an incomplete excision, and other risk factors for reoccurrence including positive lymph node involvement and immunosuppression. If the patient is to receive RT, the delay between the surgical treatment and RT should be minimized to optimize the clinical outcome. Improved clinical outcomes include better wound healing, reduced recurrence rates, and increase overall survival.

Rationale for proposed change:
The original radiation section stated that radiation could be used with or without surgical treatment, and is often used with unresectable tumours. However, current clinical practice is to use radiation therapy along with surgery under certain circumstances. Chemotherapy or immunotherapies are the recommended treatments for unresectable tumours, and will be updated in the chemotherapy section. I also updated the details of when RT should or should not be used based on current recommendations to give patients an idea of what they can reasonably expect.

Critique of Source:
The source selected for revision of the treatment section was the 2018 Merkel Cell Carcinoma clinical guideline created by the National Comprehensive Cancer Network. Clinical guidelines are a set of recommendations based on the current, highest quality evidence available. Most of the evidence is derived from systematic reviews which are considered to be the highest quality of evidence in evidence-based medicine. The 2018 Merkel cell carcinoma guideline does state when the current evidence is not conclusive and if little data is available, however it does not rate the quality and strength of the evidence used to provide the recommendations. For example, the GRADE tool does not appear to be used, as the evidence is not rated from very low too high. It makes it difficult to judge the strength of the recommendations made by the panel. The scope and purpose of the guideline are clearly stated. The objectives and clinical questions were described, and the population to whom the recommendations apply are made clear. The panel is comprised of physicians, and it is unclear if the opinions of patient stakeholders were sought. The potential conflicts of interest fo the panel members were disclosed prior to the discussions and publish with the guideline. Thirteen of the twenty nine panel members disclosed afflictions with industry. Some panellists received clinical research support, were members of scientific or promotional advisory boards of companies such as Bristol-Myers Squibb Company, AstraZeneca Pharmaceuticals, Amgen Inc., and Genetech Inc. While the guideline is not free from bias, it is one of the only clinical guidelines for Merkel Cell Carcinoma and appears to be the most up to date.