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Archives of Gynecology and Obstetrics Sep 2023Cesarean scar pregnancy (CSP) is a potentially life-threatening disease that has been steadily increasing in prevalence. Pregnancy termination is usually recommended... (Review)
Review
OBJECTIVE
Cesarean scar pregnancy (CSP) is a potentially life-threatening disease that has been steadily increasing in prevalence. Pregnancy termination is usually recommended given the risk of life-threatening complications. In some cases, patients refuse to terminate viable CSPs, even after counseling. Recent studies report that, even with a high burden of possible complications and maternal morbidity, many CSPs progress to live, close to term births. The aim of this study is to further demonstrate the natural history of viable cesarean scar pregnancies.
METHODS
We conducted a systematic review of original studies reporting cases of expectant management of CSPs with positive fetal heartbeats.
RESULTS
After selection, 28 studies were included in the review, with a total of 398 cases of CSP, 136 managed expectantly and 117 with positive fetal heartbeat managed expectantly. This study confirmed that the majority of patients experience live births, as 78% of patients selected for expectant management experienced live births at or close to term, with 79% developing morbidly adherent placenta, 55% requiring hysterectomy, and 40% having severe bleeding.
DISCUSSION
The optimal management protocol for CSP is still to be defined and more studies are needed to further elucidate this rare but rising disease. Our study provides information on the natural history of untreated CSPs and suggests that termination may not be the only option offered to the patient.
Topics: Pregnancy; Female; Humans; Cicatrix; Watchful Waiting; Cesarean Section; Pregnancy, Ectopic; Abortion, Induced
PubMed: 36394667
DOI: 10.1007/s00404-022-06835-3 -
Urologic Oncology Oct 2016Non-muscle-invasive bladder cancer (NMIBC) comprises a wide spectrum of tumors with different behaviors and prognoses. It follows that the surveillance for these tumors... (Review)
Review
OBJECTIVE
Non-muscle-invasive bladder cancer (NMIBC) comprises a wide spectrum of tumors with different behaviors and prognoses. It follows that the surveillance for these tumors should be adapted according to the risks of recurrence and progression and should be dynamic in design.
METHODS AND MATERIALS
Medline search was conducted from 1980 to 2016 using a combination of MeSH and keyword terms. The highest available evidence was reviewed to define different risk groups in NMIBC. The performance of different follow-up tools such as urine cytology, cystoscopy, and upper tract imaging in detecting bladder carcinoma was assessed. Different commercially available urinary markers were investigated to determine whether such markers would contribute to the surveillance of patients with NMIBC. A follow-up scheme based on the early evidence is proposed.
RESULTS
A risk-based approach is paramount. Cystoscopy and cytology are recommended to be done at 3 months following transurethral resection of bladder tumor. For low-risk tumors, annual cystoscopy alone is sufficient; no upper tract evaluations or cytology is needed except at diagnosis. High-risk tumors should be followed up with a more intense schedule: cystoscopy every 3 months for 2 years, 6 months for 2 years, and then annually, with cytology at frequent intervals, and imaging for upper tract evaluation at 1 year and then every 2 years. Intermediate-risk tumors should be subclassified as per the International Bladder Cancer Group recommendations and when associated with 3 or more of the following findings (multiple tumors, size≥3cm, early recurrence<1 year, frequent recurrences>1 per year) then a surveillance strategy similar to that of high risk should be followed. Several urine markers were more sensitive than cytology in the detection of NMIBC; however, these tests are still costly, require specialized laboratories, and do not replace cystoscopy. Until better and cheaper markers are available, their routine use has not been integrated in the follow-up recommendation of current guidelines.
CONCLUSIONS
Surveillance of NMIBC should follow a risk-adapted approach, with a combination of cystoscopy, cytology, and upper tract imaging. The aim of this approach is to minimize the therapeutic burden of a disease with high recurrence rates without missing progressing tumors. When designing a diagnostic pathway, first-line diagnostic imaging tests should have high sensitivity to ensure disease positives are included in the test population for further investigation. Second-line investigations should be highly specific, to ensure false-positives are minimized.
Topics: Biomarkers, Tumor; Cystoscopy; Cytodiagnosis; Disease Progression; Humans; Kidney Neoplasms; Neoplasm Invasiveness; Neoplasm Recurrence, Local; Practice Guidelines as Topic; Risk Factors; Time Factors; Ureteral Neoplasms; Urinary Bladder Neoplasms; Urine; Urography; Watchful Waiting
PubMed: 27368880
DOI: 10.1016/j.urolonc.2016.05.028 -
World Journal of Urology Aug 2021Renal cell carcinoma (RCC) incidence has considerably increased during the last decades without any real impact on age-standardized mortality. It questions the relevance... (Review)
Review
PURPOSE
Renal cell carcinoma (RCC) incidence has considerably increased during the last decades without any real impact on age-standardized mortality. It questions the relevance of aggressive treatments carrying potential side effects. Conservative management should be considered for frail patients. Comorbidity and frailty assessment in RCC patients is paramount before engaging a treatment.
METHODS
Narrative, non-systematic review based on PubMed and EMBASE search with the terms "renal neoplasm", "elderly, frail", "comorbidities", "active surveillance", "metastatic". The selection was restricted to articles written in English.
RESULTS
Comorbidity and frailty assessment go along with the cancer-specific aggressivity and intervention risks assessment. In localized disease, several standardized algorithms offer patient health evaluation to define how suitable the patient would be for curative treatment. The pre-operative American Society of Anesthesiologists and the age-adjusted Charlson's scores are the most widely used. At the metastatic stage, drug combinations based on immunotherapies and targeted therapies improved cancer outcomes at the price of significant toxicities. Frail patients are not always suitable for such strategies. Commonly used scores like the International Metastatic RCC Database Consortium or Memorial Sloan Kettering Cancer Center integrate features to define patients' risk groups, more specifically the Karnofsky Performance Score is an easy way to document the frailty.
CONCLUSIONS
Comorbidity and frailty have to be assessed at any stage of the RCC disease based on a standardized scoring system to define the most suitable treatment strategy ranging from surveillance to aggressive treatment.
Topics: Aged; Carcinoma, Renal Cell; Comorbidity; Frailty; Geriatric Assessment; Humans; Kidney Neoplasms; Patient Selection; Risk Adjustment; Watchful Waiting
PubMed: 33616708
DOI: 10.1007/s00345-021-03632-6 -
JAMA Oncology Apr 2019Across many countries, a rapid escalation of the incidence of thyroid cancer has been observed, a surge that nonetheless underestimates the true extent of the disease.... (Review)
Review
IMPORTANCE
Across many countries, a rapid escalation of the incidence of thyroid cancer has been observed, a surge that nonetheless underestimates the true extent of the disease. Most thyroid cancers now diagnosed comprise small, low-risk cancers that are incidentally found and are unlikely to cause harm. In many ways, prostate cancer similarly harbors a well-behaved subclinical reservoir, a long natural history, and superlative outcomes that have made active surveillance the de facto guideline recommendation for low-risk disease. This review highlights the parallels and differences between prostate cancer and thyroid cancer regarding screening, diagnosis, risk stratification, and considerations for active surveillance.
OBSERVATIONS
Prostate cancer and thyroid cancer have undergone recalibrated, de-escalatory shifts to counter changing epidemiologic landscapes. The US Preventive Services Task Force has issued cautionary recommendations on screening via prostate-specific antigen testing or neck ultrasonography, while the thresholds to performing biopsy have increased. Comparable changes to cancer terminology and staging have also helped alleviate patient anxiety and minimize pressure for overtreatment. Long-term, randomized prospective clinical trials for prostate cancer have established active surveillance as a first-line treatment approach for properly stratified low-risk patients, while observational trials for thyroid cancer have also made strides in defining risk and eligibility for surgery. Caveats requiring deeper investigation include aggressive disease in older patients, underestimation of the extent of the disease, and patient-physician bias in shared decision making. For prostate cancer, survival may not improve and function will likely worsen after intervention; for thyroid cancer, patients are younger, surgery is safer, and the bar for surveillance will likely be higher.
CONCLUSIONS AND RELEVANCE
Despite similarities in biological indolence between low-risk prostate and thyroid malignant neoplasms, key distinctions in life expectancy and treatment sequelae may ultimately confer somewhat disparate management paradigms for the 2 diseases. Nevertheless, the experience forged by prostate cancer trials serves as a model for thyroid cancer management, potentially reshaping the perception of active surveillance into a credible, valuable treatment modality.
Topics: Disease Progression; Early Detection of Cancer; Humans; Male; Prostatic Neoplasms; Risk; Thyroid Neoplasms; Watchful Waiting
PubMed: 30543358
DOI: 10.1001/jamaoncol.2018.5321 -
Annals of Plastic Surgery Nov 2017Squamosal craniosynostosis is seldom reported in the craniofacial literature. Given that this is an uncommon diagnosis, phenotype and management remain unclear. The... (Comparative Study)
Comparative Study Review
BACKGROUND
Squamosal craniosynostosis is seldom reported in the craniofacial literature. Given that this is an uncommon diagnosis, phenotype and management remain unclear. The authors present a case series and review the literature to define the phenotype and management of these patients.
METHODS
We retrospectively reviewed 7 patients from our institution and systematically reviewed all published cases of squamosal craniosynostosis. Demographics, medical history, imaging, clinical presentation, subsequent workup, and treatment were examined and analyzed.
RESULTS
A comprehensive review of the literature yielded a total of 31 cases (including our new series) of squamosal craniosynostosis. Average age of presentation was 25.3 months, 52% of female patients, 74% of cases with bilateral squamosal involvement, 44% syndromic, 39% isolated squamosal (vs 61% multisutural). Overall, 56% of cases were handled surgically, whereas 44% were managed conservatively. Thirty-three percent of surgical cases required multiple operations. One patient with isolated bilateral squamosal craniosynostosis developed elevated intracranial pressure, requiring cranial vault remodeling.
CONCLUSIONS
Squamosal craniosynostosis frequently presents in a delayed fashion with nonsyndromic, bilateral involvement. In isolated bilateral squamosal cases, the associated phenotype is frontal prominence, occipital flattening, scaphocephalic tendency (low-end normocephalic cranial index), and superior parietal cornering. Evaluation of clinical signs and computed tomography imaging guides management, as evidence of increased intracranial pressure may indicate need for cranial vault expansion. Although previous literature suggests that nonsyndromic cases are nonsurgical, the majority of cases reviewed required surgical intervention, including our case of isolated bilateral squamosal craniosynostosis. We recommend vigilant management in patients with squamosal craniosynostosis, even those with isolated squamosal involvement.
Topics: Craniosynostoses; Craniotomy; Epithelial Cells; Female; Humans; Imaging, Three-Dimensional; Infant; Male; Observation; Patient Selection; Phenotype; Prognosis; Rare Diseases; Retrospective Studies; Risk Assessment; Sampling Studies; Severity of Illness Index; Treatment Outcome
PubMed: 28953518
DOI: 10.1097/SAP.0000000000001170 -
Ideggyogyaszati Szemle Jul 2015Although still a controversial management option, radio-surgery of intracranial cavernomas has become increasingly popular world-wide during the last decade.... (Review)
Review
Although still a controversial management option, radio-surgery of intracranial cavernomas has become increasingly popular world-wide during the last decade. Microsurgery is a safe and effective treatment for symptomatic hemispheric cavernomas. However, the indication for microsurgical resection of deep eloquent cavernomas is relatively limited even in experienced hands. The importance of radiosurgery has recently been appreciated in parallel with increasing positive experiences both in terms of effectiveness and safety, especially for cases high risk for surgical resection, in the brainstem, thalamus and basal ganglia. While radiosurgery was earlier indicated mainly for surgically inaccessible lesions that had bled multiple times, a more proactive policy has recently become more accepted. In our opinion preventive treatment with the low morbidity radiosurgery serves the patients' interest especially for deep eloquent lesions that had bled not more than once, due to the cumulative morbidity of repeated hemorrhages. Despite our increasing knowledge on natural history, there is currently no available treatment algorithm for cavernomas. Arguments for all three treatment modalities (observation, microsurgery and radiosurgery) are established, but their indication criteria are yet to be defined. It is time to organize a prospective population based data collection in Hungary, which appears to be the most realistic way to clarify indication criteria.
Topics: Basal Ganglia; Blood Loss, Surgical; Brain Neoplasms; Brain Stem; Broca Area; Epilepsy; Hemangioma, Cavernous, Central Nervous System; Humans; Internationality; Microsurgery; Neurosurgical Procedures; Patient Selection; Radiosurgery; Thalamus; Treatment Outcome; Watchful Waiting
PubMed: 26380417
DOI: 10.18071/isz.68.0229 -
Philosophical Transactions. Series A,... Jul 2022One of the challenges of defining emergence is that one observer's prior knowledge may cause a phenomenon to present itself as emergent that to another observer appears...
One of the challenges of defining emergence is that one observer's prior knowledge may cause a phenomenon to present itself as emergent that to another observer appears reducible. By formalizing the act of observing as mutual perturbations between dynamical systems, we demonstrate that the emergence of algorithmic information does depend on the observer's formal knowledge, while being robust vis-a-vis other subjective factors, particularly: the choice of programming language and method of measurement; errors or distortions during the observation; and the informational cost of processing. This is called observer-dependent emergence (ODE). In addition, we demonstrate that the unbounded and rapid increase of emergent algorithmic information implies asymptotically observer-independent emergence (AOIE). Unlike ODE, AOIE is a type of emergence for which emergent phenomena will be considered emergent no matter what formal theory an observer might bring to bear. We demonstrate the existence of an evolutionary model that displays the diachronic variant of AOIE and a network model that displays the holistic variant of AOIE. Our results show that, restricted to the context of finite discrete deterministic dynamical systems, computable systems and irreducible information content measures, AOIE is the strongest form of emergence that formal theories can attain. This article is part of the theme issue 'Emergent phenomena in complex physical and socio-technical systems: from cells to societies'.
Topics: Biological Evolution; Knowledge
PubMed: 35599568
DOI: 10.1098/rsta.2020.0429 -
Progres En Urologie : Journal de... Jan 2015The widespread use of prostate cancer screening has led to a stage migration resulting in an increase in the diagnosis of low-risk disease, which currently accounts for... (Review)
Review
INTRODUCTION
The widespread use of prostate cancer screening has led to a stage migration resulting in an increase in the diagnosis of low-risk disease, which currently accounts for 40-50% of diagnosed forms. New therapeutic strategies have been developed in order to minimize the risk of overtreatment.
METHODS
A systematic review of the literature over the past 20 years was performed using the Medline database. The literature selection was based on evidence and practical considerations.
RESULTS
Low-risk tumors are conventionally defined by the d'Amico classification. The use of multiparametric MRI helps to better characterize these tumors. The contribution of molecular biology remains to be determined in clinical practice. Novel therapeutic options for low-risk disease are currently being evaluated.
CONCLUSION
The new therapeutic strategies are evolving. They seek to reduce overtreatment without compromising oncological success.
Topics: Disease Progression; Humans; Magnetic Resonance Imaging; Male; Patient Selection; Prostate-Specific Antigen; Prostatectomy; Prostatic Neoplasms; Secondary Prevention; Watchful Waiting
PubMed: 25454776
DOI: 10.1016/j.purol.2014.10.007 -
European Urology Focus Sep 2019The indeterminate multiparametric prostate magnetic resonance image (mpMRI) lesion is one which cannot be classified as "positive" or "negative" for suspected cancer.... (Comparative Study)
Comparative Study Review
CONTEXT
The indeterminate multiparametric prostate magnetic resonance image (mpMRI) lesion is one which cannot be classified as "positive" or "negative" for suspected cancer. Currently, there is no consensus on how to manage patients with indeterminate mpMRIs where areas cannot be classified as positives or negatives (Prostate Imaging Reporting and Data System [PI-RADS] 3 or Likert 3).
OBJECTIVE
To define the concept of indeterminate lesion and describe the management strategies that may be adopted for these patients.
EVIDENCE ACQUISITION
A literature search of the PubMed database was performed including the search terms "prostate indeterminate lesions", "PI-RADS 3", "Likert 3", "magnetic resonance imaging", and "prostate cancer".
EVIDENCE SYNTHESIS
There is no universally accepted definition of what constitutes an indeterminate lesion on mpMRI. This is partly due to the experience of the reporting radiologist and their willingness to call a lesion indeterminate, knowing that this may have consequences for biopsy decisions. This is also partly due to the significant variation in mpMRI acquisition parameters used between different sites. Strategies for managing the indeterminate lesion include: (1) biopsy, where there is a highly variable prevalence of prostate cancer (PCa), reflecting the differences in clinically significant PCa definitions, mpMRI protocols and interobserver variability in characterization of indeterminate lesions and (2) surveillance, where early results suggest that this strategy may be of value for some selected patients with prostate-specific antigen (PSA) monitoring and/or interval mpMRI. The use of prebiopsy MRI, in conjunction with traditional clinical parameters and secondary biomarkers-nomograms, may allow a more accurate selection of patients who can avoid biopsy.
CONCLUSIONS
A strategy of close surveillance based on PSA monitoring and interval mpMRI is a feasible management option for motivated patients with indeterminate mpMRI. This surveillance strategy could result in fewer men needing to undergo biopsy, and although early results are promising, long-term results for such a strategy are awaited.
PATIENT SUMMARY
In some patients who have an MRI scan of their prostate, the scan may identify an area which may or may not contain cancer. This area is typically called the "indeterminate" lesion. In this report, we attempted to define the concept of indeterminate lesion on multiparametric magnetic resonance (mpMRI) and described the strategies that may be performed for these patients. The use of mpMRI in conjunction with traditional clinical parameters may allow more accurate risk stratification and assessment of the need for prostate biopsy.
Topics: Humans; Image-Guided Biopsy; Magnetic Resonance Imaging; Male; Multiparametric Magnetic Resonance Imaging; Prostatic Neoplasms; Watchful Waiting
PubMed: 29525382
DOI: 10.1016/j.euf.2018.02.012 -
JAMA Oncology Jan 2024In March 2023, the National Comprehensive Cancer Network endorsed watch and wait for those with complete clinical response to total neoadjuvant therapy. Neoadjuvant... (Observational Study)
Observational Study
IMPORTANCE
In March 2023, the National Comprehensive Cancer Network endorsed watch and wait for those with complete clinical response to total neoadjuvant therapy. Neoadjuvant therapy is highly efficacious, so this recommendation may have broad implications, but the current trends in organ preservation in the US are unknown.
OBJECTIVE
To describe organ preservation trends among patients with rectal cancer in the US from 2006 to 2020.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective, observational case series included adults (aged ≥18 years) with rectal adenocarcinoma managed with curative intent from 2006 to 2020 in the National Cancer Database.
EXPOSURE
The year of treatment was the primary exposure. The type of therapy was chemotherapy, radiation, or surgery (proctectomy, transanal local excision, no tumor resection). The timing of therapy was classified as neoadjuvant or adjuvant.
MAIN OUTCOMES AND MEASURES
The primary outcome was the absolute annual proportion of organ preservation after radical treatment, defined as chemotherapy and/or radiation without tumor resection, proctectomy, or transanal local excision. A secondary analysis examined complete pathologic responses among eligible patients.
RESULTS
Of the 175 545 patients included, the mean (SD) age was 63 (13) years, 39.7% were female, 17.4% had clinical stage I disease, 24.7% had stage IIA to IIC disease, 32.1% had stage IIIA to IIIC disease, and 25.7% had unknown stage. The absolute annual proportion of organ preservation increased by 9.8 percentage points (from 18.4% in 2006 to 28.2% in 2020; P < .001). From 2006 to 2020, the absolute rate of organ preservation increased by 13.0 percentage points for patients with stage IIA to IIC disease (19.5% to 32.5%), 12.9 percentage points for patients with stage IIIA to IIC disease (16.2% to 29.1%), and 10.1 percentage points for unknown stages (16.5% to 26.6%; all P < .001). Conversely, patients with stage I disease experienced a 6.1-percentage point absolute decline in organ preservation (from 26.4% in 2006 to 20.3% in 2020; P < .001). The annual rate of transanal local excisions decreased for all stages. In the subgroup of 80 607 eligible patients, the proportion of complete pathologic responses increased from 6.5% in 2006 to 18.8% in 2020 (P < .001).
CONCLUSIONS AND RELEVANCE
This case series shows that rectal cancer is increasingly being managed medically, especially among patients whose treatment historically relied on proctectomy. Given the National Comprehensive Cancer Network endorsement of watch and wait, the increasing trends in organ preservation, and the nearly 3-fold increase in complete pathologic responses, international professional societies should urgently develop multidisciplinary core outcome sets and care quality indicators to ensure high-quality rectal cancer research and care delivery accounting for organ preservation.
Topics: Adolescent; Adult; Female; Humans; Male; Middle Aged; Chemoradiotherapy; Neoadjuvant Therapy; Neoplasm Recurrence, Local; Neoplasm Staging; Organ Preservation; Pathologic Complete Response; Rectal Neoplasms; Retrospective Studies; Treatment Outcome; Watchful Waiting
PubMed: 37943566
DOI: 10.1001/jamaoncol.2023.4845