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Current Opinion in Pulmonary Medicine Jul 2018Ground glass nodules (GGNs) represent an indolent subset of lung nodules including preinvasive nonsmall-cell lung cancer associated with a favorable prognosis and low... (Review)
Review
PURPOSE OF REVIEW
Ground glass nodules (GGNs) represent an indolent subset of lung nodules including preinvasive nonsmall-cell lung cancer associated with a favorable prognosis and low risk for progression. Increased performance of screening cat-scan (CT) for high-risk patients has identified an increasing number of GGNs. The management of these nodules is founded mostly on single institution data and currently no universally accepted recommendations help guide clinicians managing these patients.
RECENT FINDINGS
The solid component within a GGN is the key determinant of prognosis and is best defined by evaluating nodule density on mediastinal windows of a chest CT. When a GGN is small (<3 cm), associated with minimal change in size (<25% growth per year), and there is no demonstration of a significant solid component on mediastinal windows (<2 mm in diameter), patients can be safely observed with serially imaging. These imaging features also help distinguish patients that may harbor early-stage lung cancers that benefit from local treatment options.
SUMMARY
The majority of GGNs do not undergo significant progression during surveillance. Evidence of nodule progression on interval imaging may be a trigger for consideration of a local treatment option such as surgical resection. Large prospective studies are needed in the United States to validate the more robust data derived from Asian studies to help formulate formal recommendations for surveillance and treatment. Future improvements in imaging and the molecular characterization of these GGNs may further refine which patients are at risk for progression.
Topics: Diagnosis, Differential; Disease Progression; Humans; Lung Neoplasms; Solitary Pulmonary Nodule; Tomography, X-Ray Computed; Tumor Burden; Watchful Waiting
PubMed: 29634577
DOI: 10.1097/MCP.0000000000000492 -
Journal of Internal Medicine Jul 2020Aortic pathologies such as aneurysm, dissection and trauma are relatively common and potentially fatal diseases. Over the past two decades, we have experienced... (Review)
Review
Aortic pathologies such as aneurysm, dissection and trauma are relatively common and potentially fatal diseases. Over the past two decades, we have experienced unprecedented technical and medical developments in the field. Despite this, there is a great need, and great opportunities, to further explore the area. In this review, we have identified important areas that need to be further studied and selected priority aortic disease trials. There is a pressing need to update the AAA natural history and the role for endovascular AAA repair as well as to define biomarkers and genetic risk factors as well as influence of gender for development and progression of aortic disease. A key limitation of contemporary treatment strategies of AAA is the lack of therapy directed at small AAA, to prevent AAA expansion and need for surgical repair, as well as to reduce the risk for aortic rupture. Currently, the most promising potential drug candidate to slow AAA growth is metformin, and RCTs to verify or reject this hypothesis are warranted. In addition, the role of endovascular treatment for ascending pathologies and for uncomplicated type B aortic dissection needs to be clarified.
Topics: Aortic Dissection; Aorta; Aortic Aneurysm, Abdominal; Balloon Occlusion; Biomarkers; Clinical Trials as Topic; Disease Progression; Endovascular Procedures; Humans; Hypoglycemic Agents; Metformin; Sex Factors; Stents; Vascular Surgical Procedures; Watchful Waiting
PubMed: 32187752
DOI: 10.1111/joim.13042 -
Current Urology Reports Oct 2023Many prostate cancer active surveillance protocols mandate serial monitoring at defined intervals, including but certainly not limited to serum PSA (often every... (Review)
Review
PURPOSE OF REVIEW
Many prostate cancer active surveillance protocols mandate serial monitoring at defined intervals, including but certainly not limited to serum PSA (often every 6 months), clinic visits, prostate multiparametric MRI, and repeat prostate biopsies. The purpose of this article is to evaluate whether current protocols result in excessive testing of patients on active surveillance.
RECENT FINDINGS
Multiple studies have been published in the past several years evaluating the utility of multiparametric MRI, serum biomarkers, and serial prostate biopsy for men on active surveillance. While MRI and serum biomarkers have promise with risk stratification, no studies have demonstrated that periodic prostate biopsy can be safely omitted in active surveillance. Active surveillance for prostate cancer is too active for some men with seemingly low-risk cancer. The use of multiple prostate MRIs or additional biomarkers do not always add to the prediction of higher-grade disease on surveillance biopsy.
Topics: Male; Humans; Prostate-Specific Antigen; Watchful Waiting; Prostatic Neoplasms; Biopsy; Prostate; Magnetic Resonance Imaging
PubMed: 37436691
DOI: 10.1007/s11934-023-01177-2 -
Health Technology Assessment... Apr 2017Planned neck dissection (ND) after radical chemoradiotherapy (CRT) for locally advanced nodal metastases in patients with head and neck squamous cell carcinoma (HNSCC)...
PET-NECK: a multicentre randomised Phase III non-inferiority trial comparing a positron emission tomography-computerised tomography-guided watch-and-wait policy with planned neck dissection in the management of locally advanced (N2/N3) nodal metastases in patients with squamous cell head and neck...
BACKGROUND
Planned neck dissection (ND) after radical chemoradiotherapy (CRT) for locally advanced nodal metastases in patients with head and neck squamous cell carcinoma (HNSCC) remains controversial. Thirty per cent of ND specimens show histological evidence of tumour. Consequently, a significant proportion of clinicians still practise planned ND. Fludeoxyglucose positron emission tomography (PET)-computerised tomography (CT) scanning demonstrated high negative predictive values for persistent nodal disease, providing a possible alternative paradigm to ND. Evidence is sparse and drawn mainly from retrospective single-institution studies, illustrating the need for a prospective randomised controlled trial.
OBJECTIVES
To determine the efficacy and cost-effectiveness of PET-CT-guided surveillance, compared with planned ND, in a multicentre, prospective, randomised setting.
DESIGN
A pragmatic randomised non-inferiority trial comparing PET-CT-guided watch-and-wait policy with the current planned ND policy in HNSCC patients with locally advanced nodal metastases and treated with radical CRT. Patients were randomised in a 1 : 1 ratio. Primary outcomes were overall survival (OS) and cost-effectiveness [incremental cost per incremental quality-adjusted life-year (QALY)]. Cost-effectiveness was assessed over the trial period using individual patient data, and over a lifetime horizon using a decision-analytic model. Secondary outcomes were recurrence in the neck, complication rates and quality of life. The recruitment of 560 patients was planned to detect non-inferior OS in the intervention arm with a 90% power and a type I error of 5%, with non-inferiority defined as having a hazard ratio (HR) of no higher than 1.50. An intention-to-treat analysis was performed by Cox's proportional hazards model.
SETTINGS
Thirty-seven head and neck cancer-treating centres (43 NHS hospitals) throughout the UK.
PARTICIPANTS
Patients with locally advanced nodal metastases of oropharynx, hypopharynx, larynx, oral or occult HNSCC receiving CRT and fit for ND were recruited.
INTERVENTION
Patients randomised to planned ND before or after CRT (control), or CRT followed by fludeoxyglucose PET-CT 10-12 weeks post CRT with ND only if PET-CT showed incomplete or equivocal response of nodal disease (intervention). Balanced by centre, planned ND timing, CRT schedule, disease site and the tumour, node, metastasis stage.
RESULTS
In total, 564 patients were recruited (ND arm, = 282; and surveillance arm, = 282; 17% N2a, 61% N2b, 18% N2c and 3% N3). Eighty-four per cent had oropharyngeal cancer. Seventy-five per cent of tested cases were p16 positive. The median time to follow-up was 36 months. The HR for OS was 0.92 [95% confidence interval (CI) 0.65 to 1.32], indicating non-inferiority. The upper limit of the non-inferiority HR margin of 1.50, which was informed by patient advisors to the project, lies at the 99.6 percentile of this estimate ( = 0.004). There were no differences in this result by p16 status. There were 54 NDs performed in the surveillance arm, with 22 surgical complications, and 221 NDs in the ND arm, with 85 complications. Quality-of-life scores were slightly better in the surveillance arm. Compared with planned ND, PET-CT surveillance produced an incremental net health benefit of 0.16 QALYs (95% CI 0.03 to 0.28 QALYs) over the trial period and 0.21 QALYs (95% CI -0.41 to 0.85 QALYs) over the modelled lifetime horizon.
LIMITATIONS
Pragmatic randomised controlled trial with a 36-month median follow-up.
CONCLUSIONS
PET-CT-guided active surveillance showed similar survival outcomes to ND but resulted in considerably fewer NDs, fewer complications and lower costs, supporting its use in routine practice.
FUTURE WORK
PET-CT surveillance is cost-effective in the short term, and long-term cost-effectiveness could be addressed in future work.
TRIAL REGISTRATION
Current Controlled Trials ISRCTN13735240.
FUNDING
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in ; Vol. 21, No. 17. See the NIHR Journals Library website for further project information.
Topics: Carcinoma, Squamous Cell; Chemoradiotherapy; Cost-Benefit Analysis; Female; Head and Neck Neoplasms; Humans; Male; Middle Aged; Neck Dissection; Positron Emission Tomography Computed Tomography; Quality-Adjusted Life Years; Squamous Cell Carcinoma of Head and Neck; Survival Rate; Technology Assessment, Biomedical; United Kingdom; Watchful Waiting
PubMed: 28409743
DOI: 10.3310/hta21170 -
Current Opinion in Pediatrics Jun 2015To reflect the recent advances in the field of pediatric sleep medicine. The pediatrician will be able to define which children to refer for a sleep study and what to... (Review)
Review
PURPOSE OF REVIEW
To reflect the recent advances in the field of pediatric sleep medicine. The pediatrician will be able to define which children to refer for a sleep study and what to expect from the sleep specialist in 2015.
RECENT FINDINGS
In the first study that compared adeno tonsillectomy (TA) to watchful waiting, TA reduced symptoms and improved children's behavior, quality of life, and polysomnographic results. Anti-inflammatory therapy for mild obstructive sleep apnea was effective and well tolerated according to a double-blind study. A retrospective study showed that it is beneficial for 80% of the patients. TA is associated with a decrease in asthma symptoms and medication utilization.
SUMMARY
Pediatricians need to be aware of the clear benefits of tonsillectomy (including better asthma control), although anti-inflammatory therapy may improve symptoms and polysomnographic findings in children with nonsevere obstructive sleep apnea.
Topics: Adenoidectomy; Child; Child Behavior; Child, Preschool; Double-Blind Method; Humans; Polysomnography; Quality of Life; Retrospective Studies; Sleep Apnea, Obstructive; Tonsillectomy; Treatment Outcome; Watchful Waiting
PubMed: 25944313
DOI: 10.1097/MOP.0000000000000218 -
Current Treatment Options in Oncology Apr 2020Despite its rarity, hairy cell leukemia (HCL) remains a fascinating disease and the physiopathology is becoming more and more understood. The accurate diagnosis of HCL... (Review)
Review
Despite its rarity, hairy cell leukemia (HCL) remains a fascinating disease and the physiopathology is becoming more and more understood. The accurate diagnosis of HCL relies on the recognition of hairy cells by morphology and flow cytometry (FCM) in the blood and/or bone marrow (BM). The BRAF V600E mutation, an HCL-defining mutation, represents a novel diagnostic parameter and a potential therapeutic target. The precise cellular origin of HCL is a late-activated postgerminal center memory B cell. BRAF mutations were detected in hematopoietic stem cells (HSCs) of patients with HCL, suggesting that this is an early HCL-defining event. Watch-and-wait strategy is necessary in approximately 10% of asymptomatic HCL patients, sometimes for several years. Purine analogs (PNAs) are the established first-line options for symptomatic HCL patients. In second-line treatment, chemoimmunotherapy combining PNA plus rituximab should be considered in high-risk HCL patients. The three options for relapsed/refractory HCL patients include recombinant immunoconjugates targeting CD22, BRAF inhibitors, and BCR inhibitors. The clinical interest to investigate blood minimal residual disease (MRD) was recently demonstrated, with a high risk of relapse in patients with positive testing for MRD and a low risk in patients with negative testing. However, efforts must be made to standardize MRD analyses in the near future. Patients with HCL are at risk of second malignancies. The increased risk could be related to the disease and/or the treatment, and the respective role of PNAs in the development of secondary malignancies remains a topic of debate.
Topics: Animals; Biomarkers, Tumor; Biopsy; Bone Marrow; Clinical Decision-Making; Combined Modality Therapy; Disease Management; Disease Progression; Disease Susceptibility; Genetic Predisposition to Disease; Histocytochemistry; Humans; Immunophenotyping; Leukemia, Hairy Cell; Mutation; Retreatment; Signal Transduction; Treatment Outcome; Watchful Waiting
PubMed: 32350628
DOI: 10.1007/s11864-020-00732-0 -
Chinese Clinical Oncology Mar 2015Follicular lymphoma (FL) is the most common indolent non-hodgkin lymphoma. Most patients with FL are diagnosed with advanced disease and are considered incurable. The... (Review)
Review
Follicular lymphoma (FL) is the most common indolent non-hodgkin lymphoma. Most patients with FL are diagnosed with advanced disease and are considered incurable. The classical prognostic index in FL is the FL international prognostic index (FLIPI). The management of FL is mainly determined by histologic grading, clinical stage, and tumor burden. For patients with stage I and II disease, an involved-site radiation therapy (ISRT) is recommended and may be potentially curative approach with 60% to 80% of 10-year overall survival (OS) rates, while patients with stage III and IV should be treated with systemic therapy. The watchful waiting is still an option for patients without symptoms or/and low tumor burden. Induction of immuno-chemotherapy combined with consolidation of rituximab maintenance (MR) is standard care for patients with symptomatic disease or with high tumor burden when treatment indicated. The major indication for systemic therapy is including candidate for clinical trials, threatened end organ function, cytopenia secondary to lymphoma bulky disease and steady progress etc. at present time. Routine baseline and regular hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (HBcAb) testing is strongly recommended for all patients before the initiation of immuno-chemotherapy in order to minimize the risk of hepatitis B virus (HBV) reactivation which has been observed approximately 20% to 50% of patients with positive HBsAg and 3% to 45% of patients with positive HBcAb. Prophylactic antiviral treatment in patients who are HBsAg-positive or HBcAb-positive is indicated before immuno-chemotherapy. The management for elderly patients should be carefully selected to avoid overtreatment and severe toxicities. Individualized dose adjustment for chemotherapy and an adequate supportive treatment are essential for this special population. Novel agents such as lenalidomide, ibrutinib and idelalisib are promising. In conclusion, individualized management of FL remains challenging and role of new targeted agents need to be defined.
Topics: Age Factors; Antineoplastic Agents; Antiviral Agents; Hepatitis B; Hepatitis B virus; Humans; Lymphoma, Follicular; Molecular Targeted Therapy; Neoplasm Grading; Neoplasm Staging; Patient Selection; Predictive Value of Tests; Radiotherapy; Risk Factors; Stem Cell Transplantation; Treatment Outcome; Virus Activation; Watchful Waiting
PubMed: 25841714
DOI: 10.3978/j.issn.2304-3865.2015.01.01 -
Hamostaseologie Jan 2017Evidence-based medicine is growing in immune thrombocytopenia (ITP), but solid clinical data are still lacking in many areas. A majority of children has self-limited... (Review)
Review
Evidence-based medicine is growing in immune thrombocytopenia (ITP), but solid clinical data are still lacking in many areas. A majority of children has self-limited ITP, but chronic symptomatic ITP exists also in pediatrics. Management includes a watch-and-wait strategy for children with newly diagnosed ITP and no or mild bleeding, and immunoglobulins and corticosteroids, if more bleeding and mucous membrane involvement is present. Treatment endpoints differ in clinical research and in clinical practice. The requirement of platelet enhancing drugs needs to be better defined in guidelines. Second-line therapies for children are rarely required and include thrombopoietin-receptor agonists, rituximab, dexamethasone and immunosuppressants. Thrombopoietin-receptor agonists are successful in adult but also in pediatric ITP. The strategical position of splenectomy differs from that in adults. Although effective in children it is less frequently used because of its life-long cumulative risk of infectious diseases and a higher potential of spontaneous remission in ITP, providing a strong argument to defer splenectomy. The rarity of ITP makes clinical research expensive.
Topics: Adrenal Cortex Hormones; Child; Child, Preschool; Combined Modality Therapy; Diagnosis, Differential; Evidence-Based Medicine; Female; Humans; Immunoglobulins; Immunosuppressive Agents; Infant; Infant, Newborn; Male; Purpura, Thrombocytopenic, Idiopathic; Splenectomy; Treatment Outcome; Watchful Waiting
PubMed: 27699328
DOI: 10.5482/HAMO-16-06-0017 -
Clinical Obstetrics and Gynecology Mar 2015With the advent of routine obstetrical ultrasound, the diagnosis of an adnexal mass in pregnancy has become increasingly common. Although the reported incidence and... (Review)
Review
With the advent of routine obstetrical ultrasound, the diagnosis of an adnexal mass in pregnancy has become increasingly common. Although the reported incidence and expected clinical course varies based on the gestational age at the time of diagnosis and the criteria used to define an adnexal mass, the majority of adnexal masses diagnosed in pregnancy are benign and are likely to resolve without complication or intervention. This review will discuss the epidemiology of adnexal masses in pregnancy, diagnostic tools, potential complications, and management options during pregnancy.
Topics: Adnexal Diseases; Biomarkers, Tumor; Female; Humans; Laparoscopy; Magnetic Resonance Imaging; Ovarian Cysts; Pregnancy; Pregnancy Complications; Pregnancy Complications, Neoplastic; Torsion Abnormality; Ultrasonography; Watchful Waiting
PubMed: 25551696
DOI: 10.1097/GRF.0000000000000088 -
AJR. American Journal of Roentgenology Mar 2017Current clinical guidelines are consistent in supporting annual mammography for women after treatment of primary breast cancer. Surveillance imaging beyond standard... (Review)
Review
OBJECTIVE
Current clinical guidelines are consistent in supporting annual mammography for women after treatment of primary breast cancer. Surveillance imaging beyond standard digital mammography, including digital breast tomosynthesis (DBT), breast ultrasound, and MRI, may improve outcomes. This article reviews the evidence on the performance and effectiveness of breast imaging modalities available for surveillance after treatment of sporadic unilateral primary breast cancer and identifies additional factors to be considered when selecting an imaging surveillance regimen.
CONCLUSION
Evidence review supports the use of mammography for surveillance after primary breast cancer treatment. Variability exists in guideline recommendations for surveillance initiation, interval, and cessation. DBT offers the most promise as a potential modality to replace standard digital mammography as a front-line surveillance test; a single published study to date has shown a significant decrease in recall rates compared with standard digital mammography alone. Most guidelines do not support the use of whole-breast ultrasound in breast cancer surveillance, and further studies are needed to define the characteristics of women who may benefit from MRI surveillance. The emerging evidence about surveillance imaging outcomes suggests that additional factors, including patient and imaging characteristics, tumor biology and gene expression profile, and choice of treatment, warrant consideration in selecting personalized posttreatment imaging surveillance regimens.
Topics: Breast Neoplasms; Evidence-Based Medicine; Female; Humans; Magnetic Resonance Imaging; Mammography; Prognosis; Reproducibility of Results; Sensitivity and Specificity; Treatment Outcome; Watchful Waiting
PubMed: 28075622
DOI: 10.2214/AJR.16.16300