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Thyroid : Official Journal of the... Nov 2022Active surveillance (AS) is an alternative to thyroidectomy for the management of low-risk papillary thyroid microcarcinoma (PTMC). However, prospective AS data...
Progression of Low-Risk Papillary Thyroid Microcarcinoma During Active Surveillance: Interim Analysis of a Multicenter Prospective Cohort Study of Active Surveillance on Papillary Thyroid Microcarcinoma in Korea.
Active surveillance (AS) is an alternative to thyroidectomy for the management of low-risk papillary thyroid microcarcinoma (PTMC). However, prospective AS data collected from diverse populations are needed. This multicenter prospective cohort study enrolled patients from three referral hospitals in Korea. The participants were self-assigned into two groups, AS or immediate surgery. All patients underwent neck ultrasound every 6-12 months to monitor for disease progression. Progression under AS was evaluated by a criterion of tumor size increment by 3 mm in one dimension (3 mm), 2 mm in two dimensions (2 × 2 mm), new extrathyroidal extension (ETE), or new lymph node metastasis (LNM), and a composite outcome was defined using all four criteria. A total of 1177 eligible patients with PTMC (919 female, 78.1%) with a median age of 48 years (range 19-87) were enrolled; 755 (64.1%) patients chose AS and 422 (35.9%) underwent surgery. Among 755 patients under AS, 706 (female 537, 76.1%) underwent at least two ultrasound examinations and were analyzed. Over a follow-up period of 41.4 months (standard deviation, 16.0), 163 AS patients (23.1%) underwent surgery. Progression defined by the composite outcome was observed in 9.6% (68/706) of patients, and the 2- and 5-year progression estimates were 5.3% and 14.2%, respectively. The observed progression rates were 5.8% (41/706) and 5.4% (38/706) as defined by tumor size enlargement by 3 mm and 2 × 2 mm, respectively, and 1.3% (9/706) and 0.4% (3/706) for new LNM and ETE, respectively. No distant metastases developed during AS. In multivariate logistic regression analysis examining variables associated with progression under AS, age at diagnosis <30 years (odds ratio [OR], 2.86; 95% confidence interval [CI], 1.10 - 7.45), male sex (OR, 2.48; 95% CI, 1.47 - 4.20), and tumor size ≥6 mm (OR, 1.89; 95% CI, 1.09 - 3.27) were independently significant. The progression of low-risk PTMC during AS in the Korean population was low, but slightly higher than previously reported in other populations. Risk factors for disease progression under AS include younger age, male sex, and larger tumor size. Clinicaltrials.gov NCT02938702.
Topics: Humans; Male; Female; Young Adult; Adult; Middle Aged; Aged; Aged, 80 and over; Prospective Studies; Watchful Waiting; Carcinoma, Papillary; Thyroid Neoplasms; Thyroidectomy; Lymphatic Metastasis; Risk Factors; Disease Progression; Retrospective Studies
PubMed: 36205563
DOI: 10.1089/thy.2021.0614 -
Expert Review of Hematology Feb 2017Chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) are considered indolent lymphocytic malignancies, more often requiring active surveillance rather... (Review)
Review
Chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) are considered indolent lymphocytic malignancies, more often requiring active surveillance rather than intervention. Despite the indolent nature of CLL/SLL, treatment is likely indicated in a patients' lifetime. Recent changes in the therapeutic landscape have created more options to the clinician. Areas covered: The authors provide a broad assessment of the current state of disease, including the work-up, prognostic features, and mutational aspects of the disease that should be acknowledged when developing a rational treatment plan. Key studies, guideline recommendations, and expert analysis are used to create this update on CLL/SLL. Expert commentary: The recent pace of treatment additions in CLL/SLL is a welcome addition. Moving forward, it is anticipated that treatment modalities will continue to evolve, leading to additional management options that truly would define CLL/SLL as a chronic disease.
Topics: B-Lymphocytes; Biomarkers; Combined Modality Therapy; Humans; Immunophenotyping; Leukemia, Lymphocytic, Chronic, B-Cell; Neoplasm Staging; Phenotype; Prognosis; Risk Factors; Treatment Outcome; Watchful Waiting
PubMed: 27936980
DOI: 10.1080/17474086.2017.1270203 -
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 -
Asian Journal of Andrology 2015There are no agreed upon guidelines for placing patients on active surveillance (AS). Therefore, there are no absolute criteria for taking patients off AS and when to... (Review)
Review
There are no agreed upon guidelines for placing patients on active surveillance (AS). Therefore, there are no absolute criteria for taking patients off AS and when to recommend treatment. The criteria used to define progression are currently based on prostate specific antigen (PSA) kinetics, biopsy reclassification, and change in clinical stage. Multiple studies have evaluated predictors of progression such as PSA, PSA density (PSAD), prostate volume, core positivity, and visible lesion on multiparametric magnetic resonance imaging (mpMRI). Furthermore, published nomograms designed to predict indolent prostate cancer do not perform well when used to predict progression. Newer biomarkers have also not performed well to predict progression. These findings highlight that clinical and pathologic variables are not enough to identify patients that will progress while on AS. In the future, with the use of imaging, biomarkers, and gene expression assays, we should be better equipped to diagnose/stage prostate cancer and to distinguish between insignificant and significant disease.
Topics: Biomarkers, Tumor; Biopsy; Diffusion Magnetic Resonance Imaging; Disease Management; Disease Progression; Humans; Kallikreins; Magnetic Resonance Imaging; Male; Neoplasm Grading; Nomograms; Organ Size; Prostate-Specific Antigen; Prostatic Neoplasms; Watchful Waiting
PubMed: 26178391
DOI: 10.4103/1008-682X.151396 -
Thoracic Surgery Clinics Nov 2019Giant paraesophageal hernias can present as an asymptomatic incidentally detected paraesophageal hernia to an emergent gastric volvulus with concern for ischemia. In the... (Review)
Review
Giant paraesophageal hernias can present as an asymptomatic incidentally detected paraesophageal hernia to an emergent gastric volvulus with concern for ischemia. In the acute setting, the preoperative evaluation aims to determine the extent of complications from gastric volvulus. In the elective setting, preoperative testing defines the gastroesophageal anatomy and function to select the optimal operation. Through thoughtful preoperative evaluation, the best operative approach can be tailored to each patient.
Topics: Algorithms; Asymptomatic Diseases; Clinical Decision-Making; Endoscopy, Digestive System; Gastric Emptying; Hernia, Hiatal; Herniorrhaphy; Humans; Laparoscopy; Patient Selection; Preoperative Care; Risk Assessment; Stomach Volvulus; Watchful Waiting
PubMed: 31564398
DOI: 10.1016/j.thorsurg.2019.07.006 -
Actas Urologicas Espanolas 2013The current management of localized prostate cancer is a therapeutic challenge with different options including active radicals or active follow-up. The aim of this... (Review)
Review
CONTEXT
The current management of localized prostate cancer is a therapeutic challenge with different options including active radicals or active follow-up. The aim of this paper is to analyze the feasibility and validity of the «Focal» active treatment versus the concept of active follow-up or Radical Treatment.
EVIDENCE ACQUISITION
We reviewed the literature on the various diagnostic methods, advantages, and difficulties of active follow-up and Radical Treatment, versus focal therapy with the possibilities of defining characteristics of aggressiveness and patient selection.
EVIDENCE SYNTHESIS
The mesh biopsy techniques along with multiparametric magnetic resonance imaging and association of factors such as tumor size, length of affected cylinder and Gleason are parameters that allow us to define location and definition of clinically significant tumors and subsidiary of focal therapies.
CONCLUSIONS
The definition, location and aggressiveness of prostate cancer in low-intermediate risk tumors can be defined avoiding radical therapies with their side effects or the risks of underestimating tumors as in active follow-up without the minimum side effects.
Topics: Humans; Male; Prostatic Neoplasms; Watchful Waiting
PubMed: 23870479
DOI: 10.1016/j.acuro.2013.02.008 -
Journal of Vascular Surgery Feb 2012Controversy persists as to whether all calf vein thrombi should be treated with anticoagulation or observed with duplex surveillance. We performed a systematic review of... (Review)
Review
BACKGROUND
Controversy persists as to whether all calf vein thrombi should be treated with anticoagulation or observed with duplex surveillance. We performed a systematic review of the literature to assess whether data could support either approach, followed by examination of its natural history by stratifying results according to early clot propagation, pulmonary emboli (PE), recurrence, and postthrombotic syndrome (PTS).
METHODS
A total of 1513 articles were reviewed that were published from January 1975 to August 2010 using computerized database searches of PubMed, Cochrane Controlled Trials Register, and extensive cross-references. English-language studies specifically examining calf deep vein thrombosis (C-DVT) defined as axial and/or muscular veins of the calf, not involving the popliteal vein, were included. Papers were independently reviewed by two investigators (E.M., F.L.) and quality graded based on nine methodologic standards reporting on four outcome parameters.
RESULTS
Of the 1513 citations reviewed, 31 relevant papers meeting predefined criteria were found: six randomized controlled trials (RCT) and 25 observational cohort studies or case series. There was a single RCT directly comparing anticoagulation with no anticoagulation with compression and duplex surveillance, and they found no difference in propagation, PE, or bleeding in a low-risk population. Based on two studies of moderately strong methodology, C-DVT propagation was reduced with anticoagulation. When treatment was unassigned, moderately strong evidence suggested that about 15% propagate to the popliteal vein or higher. However, based on nonrandomized data but with moderate to high quality (level A and B studies), propagation to popliteal or higher was 8% in those with no anticoagulation treated with surveillance only. Propagation involving adjacent calf veins but remaining in the calf occured in up to one-half of all those who propagate. Major bleeding was an intended endpoint in three RCTs and was reported as 0% to 6%, with a trend toward lower bleeding risk in more recent studies. PE during surveillance in studies with unassigned treatment was strikingly lower than the historical reports of PE recorded at presentation, emphasizing the distinction that must be made between the two entities. Recurrence in C-DVT is lower than thigh DVT, and data suggest that in low-risk groups with transient risk factors, 6 weeks of anticoagulation may be sufficient, as opposed to 12 weeks. Studies of PTS reported that patients with C-DVT had fewer symptoms than their thigh DVT counterparts. Approximately one out of 10 showed symptoms of CEAP Class 4 to 6; however, C5 or C6 with healed or active ulceration were not commonly encountered.
CONCLUSIONS
No study of strong methodology could be found to resolve the controversy of optimal treatment of C-DVT. Given the risks of propagation, PE, and recurrence, the option of doing nothing should be considered unacceptable. In the absence of strong evidence to support anticoagulation over imaging surveillance with selective anticoagulation, either method of managing calf DVT must remain as current acceptable standards.
Topics: Anticoagulants; Evidence-Based Medicine; Humans; Leg; Patient Selection; Predictive Value of Tests; Pulmonary Embolism; Recurrence; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Duplex; Venous Thrombosis; Watchful Waiting
PubMed: 22032881
DOI: 10.1016/j.jvs.2011.05.092 -
Journal of Neuro-oncology Feb 2022Low-grade glioma (LGG) exhibits longer median survival than high-grade brain tumors, and thus impact of our therapies on patient quality of life remains a crucial...
PURPOSE
Low-grade glioma (LGG) exhibits longer median survival than high-grade brain tumors, and thus impact of our therapies on patient quality of life remains a crucial consideration. This study evaluated the effects of concurrent temozolomide-based chemoradiation (RT + TMZ) or observation on quality of life (QOL) in patients with low-grade glioma.
METHODS
We completed a retrospective cross-sectional study of adults with LGG who underwent surgery with known molecular classification from 1980 to 2018. Postoperatively, patients were either observed or received adjuvant concurrent temozolomide-based chemoradiation. EQ-5D and PHQ-9 depression screen were completed before outpatient visits every 2-3 months. Baseline score was defined as ± 30 days within initial operation.
RESULTS
Of the 63 patients (mean age 44 ± 17 years, 51% female) with baseline EQ-5D or PHQ-9 depression screen data and at least one follow-up measure, 30 (48%) were observed and 33 (52%) received RT + TMZ. No significant decline was seen in EQ-5D or PHQ-9 scores at 3, 6, 9, 12, and 24 months compared to baseline scores for all patients. At each time point, there was no significant difference between those who were observed or received adjuvant therapy. The linear mixed model estimating PHQ-9 value or EQ-5D index demonstrated that there was no significant difference in PHQ-9 or EQ-5D index between treatment groups (p = 0.42 and p = 0.54, respectively) or time points (p = 0.24 and p = 0.99, respectively).
CONCLUSION
Our study found no significant decline in patient QOL or depression scores as assessed by patient- reported outcome measures for patients with low-grade glioma up to 2 years following surgery. We found no difference between RT + TMZ compared to observation during this time frame. Additional follow-up can help identify the longer-term impact of treatment strategy on patient experience.
Topics: Adult; Brain Neoplasms; Chemoradiotherapy; Cross-Sectional Studies; Female; Glioma; Humans; Male; Middle Aged; Neoplasm Grading; Quality of Life; Retrospective Studies; Temozolomide; Treatment Outcome; Watchful Waiting
PubMed: 35064450
DOI: 10.1007/s11060-021-03920-6 -
BMJ Case Reports Dec 2018Clinical evaluation of an early-onset left esotropia in an adolescent revealed a large macular lesion with extensive posterior pole retinochoroidal atrophy from superior...
Clinical evaluation of an early-onset left esotropia in an adolescent revealed a large macular lesion with extensive posterior pole retinochoroidal atrophy from superior arcade to inferior arcade. The lesion also showed pigmentary changes over the base, edges and beyond, along with a popcorn-like calcification just above the inferior arcade. Swept-source optical CT (SS-OCT) confirmed extensive chorioretinal thinning with hyper-reflective foci corresponding to the calcification, and optical CT angiography revealed a disorganised superficial retinal plexus. Likewise, fundus screening of the other eye showed a well-defined fleshy mass lesion along the temporal retina in absence of any calcification. SS-OCT of the left eye lesion showed intraretinal mass with poorly defined retinal layers.
Topics: Adolescent; Disease Progression; Esotropia; Fluorescein Angiography; Fundus Oculi; Humans; Male; Multimodal Imaging; Retina; Retinal Neoplasms; Tomography, Optical Coherence; Visual Acuity; Watchful Waiting
PubMed: 30567213
DOI: 10.1136/bcr-2018-225908 -
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