-
Medicine Aug 2019To verify the accuracy of serum dickkopf-1 protein (DKK-1) in the diagnosis of hepatocellular carcinoma (HCC) by an updated meta-analysis. (Meta-Analysis)
Meta-Analysis
BACKGROUND
To verify the accuracy of serum dickkopf-1 protein (DKK-1) in the diagnosis of hepatocellular carcinoma (HCC) by an updated meta-analysis.
METHODS
We searched potential eligible studies in PubMed and Embase before July 8, 2018. Sensitivity (SN), specificity (SP), positive likelihood ratio (PLR), negative likelihood ratio (NLR), summary receiver operating characteristics curve (sROC), and diagnostic odds ratio (DOR) were pooled with their 95% confidence intervals CIs) using a bivariate random-effects model.
RESULTS
A total of 8 articles contained 10 studies on diagnosis of HCC with DKK-1 alone,7 articles contained 9 studies on diagnosis of HCC with a-fetoprotein (AFP) alone and 5 articles contained 7 studies on diagnosis of HCC with DKK-1 + AFP were identified. The pooled SN, SP, PLR, NLR, and DOR of DKK-1 alone, AFP alone and DKK-1 + AFP were 0.72 (95% CI: 0.70-0.75), 0.62 (95% CI:0.59-0.64) and 0.80 (95% CI:0.78-0.83), 0.86 (95% CI: 0.84-0.87), 0.82 (95% CI:0.80-0.84) and 0.87 (95% CI: 0.85-0.88), 4.91 (95% CI: 2.73-8.83), 3.60 (95% CI:2.01-6.44) and 6.18 (95% CI: 4.68-8.16), 0.32 (95% CI: 0.22-0.47), 0.49 (95% CI:0.40-0.60) and 0.20 (95% CI: 0.15-0.26), and 17.21 (95% CI: 9.10-32.57), 7.45 (95% CI:3.69-15.01) and 31.39 (95% CI: 23.59-43.20), respectively. The area under the sROC was 0.88, 0.70, and 0.92 for the 3 diagnostic methods.
CONCLUSIONS
Serum DKK-1 + AFP showed a high accuracy for diagnosis of HCC, and serum DKK-1 alone had moderate accuracy as compared to a previous meta-analysis, while AFP alone owned an unsatisfied diagnostic behavior for HCC. Due to the limitations of the current analysis, further well-designed studies are needed to confirm the diagnostic value of DKK-1 and DKK-1 + AFP in HCC diagnosis.
Topics: Carcinoma, Hepatocellular; Humans; Intercellular Signaling Peptides and Proteins; Liver Neoplasms; Predictive Value of Tests; alpha-Fetoproteins
PubMed: 31393380
DOI: 10.1097/MD.0000000000016725 -
Medicine Aug 2019Post-treatment alpha-fetoprotein (AFP) response has been reported to be associated with prognosis of hepatocellular carcinoma (HCC) patients, but the results were not... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Post-treatment alpha-fetoprotein (AFP) response has been reported to be associated with prognosis of hepatocellular carcinoma (HCC) patients, but the results were not consistent. This meta-analysis aimed to explore the relationship between AFP response and clinical outcomes of HCC.
METHODS
PubMed, Embase, Medline and Cochrane library were searched for relevant articles published before March 20, 2019. The data were analyzed using RevMan5.3 software.
RESULTS
Twenty-nine articles with 4726 HCC patients were finally included for analysis. The pooled results showed that post-treatment AFP response was significantly associated with overall survival (OS) (hazard ratio (HR) = 0.41, 95% confidence interval (CI): 0.35-0.47, P <.001), progression free survival (PFS) (HR = 0.46, 95% CI: 0.39-0.54, P <.001) and recurrence free survival (RFS) (HR = 0.41, 95% CI: 0.29-0.56, P <.001) of HCC patients.
CONCLUSION
post-treatment AFP response might be a useful prognostic marker for HCC patients.
Topics: Humans; Liver Neoplasms; Prognosis; alpha-Fetoproteins
PubMed: 31374020
DOI: 10.1097/MD.0000000000016557 -
Medicine May 2019Many studies explored the prognostic and clinicopathological significance of pretreatment serum Gamma-Glutamyltransferase (GGT) level in hepatocellular carcinoma (HCC).... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Many studies explored the prognostic and clinicopathological significance of pretreatment serum Gamma-Glutamyltransferase (GGT) level in hepatocellular carcinoma (HCC). However, there are inconsistent results in the prognostic and clinicopathological significance of pretreatment serum GGT level in HCC. Thus, we conducted this meta-analysis to comprehensively assess the prognostic and clinicopathological significance of pretreatment serum GGT level in HCC patients.
METHODS
We systematically searched PubMed, EMBASE and Web of Science for relevant studies (up to June 14, 2018). The estimated hazard ratios (HRs) were used to assess the association between pretreatment serum GGT level and survival in HCC patients. The estimated odds ratios (ORs) were applied to evaluate the correlation between pretreatment serum GGT and clinicopathological features in HCC.
RESULTS
Our results showed that high pretreatment serum GGT level was significantly correlated with poor overall survival (OS) (HR = 1.70, 95% CI: 1.54-1.87; P < .01) and disease-free survival/relapse-free survival (DFS/RFS) (HR = 1.56, 95% CI: 1.42-1.71; P < .01). Additionally, our results also revealed that there was a close correlation between GGT level and several clinicopathological features in HCC patients, including vascular invasion, tumor size, tumor number and Alpha-fetoprotein (AFP) level.
CONCLUSIONS
This meta-analysis shows that high pretreatment serum GGT level is significantly correlated with poor survival and unfavorable clinicopathological features in HCC patients, suggesting that pretreatment serum GGT may be an economical and effective prognostic biomarker for HCC patients. However, more high-quality studies are still warranted to further validate our findings, considering there are several limitations in this meta-analysis.
Topics: Biomarkers, Tumor; Carcinoma, Hepatocellular; Humans; Liver Neoplasms; Prognosis; gamma-Glutamyltransferase
PubMed: 31083251
DOI: 10.1097/MD.0000000000015603 -
The Cochrane Database of Systematic... Feb 2019Hepatocellular carcinoma, also called malignant hepatoma, is a primary malignancy of the liver. Despite regular surveillance conducted in high-risk populations, most... (Meta-Analysis)
Meta-Analysis
Transcatheter arterial chemoembolisation followed by three-dimensional conformal radiotherapy versus transcatheter arterial chemoembolisation alone for primary hepatocellular carcinoma in adults.
BACKGROUND
Hepatocellular carcinoma, also called malignant hepatoma, is a primary malignancy of the liver. Despite regular surveillance conducted in high-risk populations, most people with hepatocellular carcinoma are diagnosed at an advanced stage. Consequently, only a minority of people with the disease are suitable for surgical resection when diagnosed.
OBJECTIVES
To compare the beneficial and harmful effects of transcatheter arterial chemoembolisation (TACE) followed by three-dimensional conformal radiotherapy (3-DCRT) versus TACE alone in adults with primary hepatocellular carcinoma, considered unsuitable for surgical resection.
SEARCH METHODS
We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index - Science up to 31 May 2018. We checked reference lists for all included studies and related reviews for further relevant articles.
SELECTION CRITERIA
We included all randomised clinical trials comparing TACE followed by 3-DCRT versus TACE alone in people with primary hepatocellular carcinoma.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures as suggested by Cochrane. We presented the results of the fixed-effect model in the absence of statistical heterogeneity. Otherwise, we reported the results from the random-effects model meta-analysis. We assessed risk of bias of the included trials using bias risk domains and presented the review results incorporating the methodological quality of the trials using GRADE. Our main conclusions were based on the analysis up to three years' follow-up.
MAIN RESULTS
We identified eight randomised clinical trials (632 participants) that fulfilled our inclusion criteria. All eight trials were at high risk of bias, and we rated the evidence as low to very low certainty. The mean age ranged from 16 years to 78 years. The proportion of men ranged from 60% to 75% and the proportion of people with stage III primary hepatocellular carcinoma ranged from 22% to 85%. The median follow-up duration was 12 months (2 months to 38 months).TACE followed by 3-DCRT compared with TACE alone may have reduced all-cause mortality at three years' follow-up (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.73 to 0.88; 552 participants; 7 trials; low-certainty evidence). TACE followed by 3-DCRT compared with TACE alone may reduce the proportion of participants without tumour response (complete response plus partial response) (RR 0.49, 95% CI 0.39 to 0.61; 632 participants; 8 trials; low-certainty evidence). Data, from one trial on health-related quality of life, favoured the TACE followed by 3-DCRT group, but the provided data were ill-defined (very low-certainty evidence). None of the trials reported serious adverse events. The results on non-serious adverse events were as follows: TACE followed by 3-DCRT compared with TACE alone showed no difference in the results for proportion of participants with leukopenia (RR 1.12, 95% CI 0.92 to 1.34; 438 participants; 5 trials; very low-certainty evidence) and serum transaminases elevation (RR 1.67, 95% CI 0.66 to 4.27; 280 participants; 4 trials; very low-certainty evidence). However, the proportion of participants with total bilirubin elevation was larger in the TACE followed by 3-DCRT group than in the TACE alone group (RR 2.69, 95% CI 1.34 to 5.40; 172 participants; 2 trials; very low-certainty evidence). The rate of participants with serum alpha-fetoprotein (AFP) without decline or normalisation was significantly lower in the TACE followed by 3-DCRT group than in the TACE group, but these data were from one trial only (Chi² = 7.24, P = 0.007; very low-certainty evidence).
AUTHORS' CONCLUSIONS
TACE followed by 3-DCRT may be associated with lower all-cause mortality and increased tumour response, despite the increased toxicity expressed by a higher rise of total bilirubin. Our review findings should be considered with caution because of the methodological weaknesses in the included trials, resulting in low- to very low-certainty evidence. Data on serious adverse events and health-related quality of life are lacking. We are also very much uncertain in the results of the reported non-serious adverse events. High-quality trials are needed to assess further the role of TACE followed by 3-DCRT for unresectable hepatocellular carcinoma.
Topics: Adolescent; Adult; Aged; Carcinoma, Hepatocellular; Cause of Death; Chemoembolization, Therapeutic; Combined Modality Therapy; Female; Humans; Liver Neoplasms; Male; Middle Aged; Radiotherapy, Conformal; Randomized Controlled Trials as Topic; Young Adult
PubMed: 30776082
DOI: 10.1002/14651858.CD012244.pub2 -
International Journal of Surgery... Aug 2018Hepatocellular carcinoma (HCC) is one of most common causes for cancer-related death around the world. Epithelial cell adhesion molecule (EpCAM) is established as a... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Hepatocellular carcinoma (HCC) is one of most common causes for cancer-related death around the world. Epithelial cell adhesion molecule (EpCAM) is established as a vital prognostic factor for the human malignant tumors. However, the potential role of EpCAM in HCC has largely remained elusive. Herein we aimed to gain insight into the clinicopathological and prognostic role of EpCAM in HCC.
METHODS AND MATERIALS
The PubMed, Web of Science, EMBASE and SCOPUS databases were systematically searched from their inception up to 5 December 4, 2017. The hazard ratio (HR) and odds ratio (OR) were respectively used as the effect size to explore the associations between EpCAM expression and the prognosis and clinicopathological features in HCC patients.
RESULTS
Sixteen studies recruiting 2488 HCC patients were included in the meta-analysis, of which the publication year ranging from 2011 to 2017. As a result, the pooled HR of 1.634 indicated that higher EpCAM expression was significantly associated with the shorter overall survival (OS) periods (95%CIs: 1.151-2.320; Z = 2.740, P = 0.006). Next, a meta-analysis of disease-free survival (DFS) was performed for the ten studies. Consequently, for the p-value less than 0.05 for the combined HR, the overexpression of EpCAM was significantly correlated with poorer DFS. Next, the results derived from our study suggest that the overexpression of EpCAM is associated with the clinicopathological features of HCC, including poorer tumor differentiation and high alpha-fetoprotein (AFP) levels.
CONCLUSION
The results derived from our study suggest that the overexpression of EpCAM is associated with the clinicopathological features of HCC, including poorer differentiation and high AFP levels. More importantly, overexpression of EpCAM was confirmed as the unfavorable predictor for the shorter OS and DFS for HCC patients.
Topics: Biomarkers, Tumor; Carcinoma, Hepatocellular; Disease-Free Survival; Epithelial Cell Adhesion Molecule; Female; Humans; Liver Neoplasms; Neoplasm Proteins; Odds Ratio; Prognosis; Proportional Hazards Models
PubMed: 29936198
DOI: 10.1016/j.ijsu.2018.06.025 -
Case Reports in Surgery 2018Primary hepatic lymphomas (PHLs) are rare liver tumors, frequently misdiagnosed preoperatively. As these tumors could be successfully treated with chemotherapy, their...
INTRODUCTION
Primary hepatic lymphomas (PHLs) are rare liver tumors, frequently misdiagnosed preoperatively. As these tumors could be successfully treated with chemotherapy, their early recognition is essential, potentially, to avoid useless surgery. We report on the case of a cirrhotic patient with hemochromatosis who presented a PHL, initially diagnosed as a hepatocellular carcinoma (HCC), and we analyze recent data from the literature on this subject.
CASE PRESENTATION AND REVIEW OF THE LITERATURE
A 45 mm liver tumor was found is a 68-year-old man with alcohol cirrhosis and hemochromatosis. At imaging, the diagnosis of HCC was suspected according to vascular characteristics and the presence of cirrhosis. FDG PET scan showed a solitary hypermetabolic liver tumor. Tumor markers were negative. Surgery consisted in left lateral hepatectomy. At pathology, the diagnosis of the primary hepatic marginal zone B cell lymphoma of mucosa-associated lymphoid tissue (MALT) type was demonstrated. Twenty-two articles reporting 33 cases of true PHL of MALT type were found. Presentation lacked specific symptoms (70% asymptomatic). Half of patients were suspected to have other etiologies of liver mass (HCC, intrahepatic cholangiocarcinoma), and thus diagnosis was established postoperatively. In the patient, diagnosis was made by preoperative biopsy, and chemotherapy was first-line treatment.
DISCUSSION
Preoperative diagnosis of PHL, and particularly of primary hepatic MALT lymphoma, is challenging. This case illustrates that PHL remains to be considered among the differential diagnosis of isolated solid liver tumors. Further, it indicates that biopsy could be still indicated in case of suspected HCC in cirrhotic patients, particularly in the presence of unusual findings such as the combination of a FDG PET scan positive tumor in the absence of elevated alpha-fetoprotein.
PubMed: 29850362
DOI: 10.1155/2018/9183717 -
OncoTargets and Therapy 2018In the recent past, there is increasing evidence demonstrating that HSP27 plays a key role in tumor progression. However, the relationship between HSP27 expression and...
BACKGROUND
In the recent past, there is increasing evidence demonstrating that HSP27 plays a key role in tumor progression. However, the relationship between HSP27 expression and the clinicopathological features of hepatocellular carcinoma (HCC), as well as its prognostic value in HCC patients remain controversial. Accordingly, we conducted a meta-analysis to assess the correlation between HSP27 expression and HCC, and determine the prognostic value of HSP27 in HCC.
METHODS
The data included clinicopathological features and survival information extracted from the published literature in the databases PubMed, EMBASE, Cochrane Library, Web of Science, CNKI, and Wan Fang. The pooled odds ratios and hazard ratios with 95% CIs were calculated using Forest plot analysis.
RESULTS
The meta-analysis results indicated that the positive HSP27 expression was significantly correlated with HCC incidence, tumor differentiation, and α-fetoprotein level in patients with HCC. However, the expression of HSP27 was not associated with metastasis, hepatitis B virus surface antigen, gender, tumor size, TNM stage, and vascular invasion. Additionally, HSP27 expression indicated a poor overall survival rate, but it was not related to disease-free survival rate.
CONCLUSION
This meta-analysis revealed that HSP27 may play a key role in the development of HCC and could be a reliable biomarker for the prognosis of patients with HCC. However, additional high-quality research is needed to support the results.
PubMed: 29563808
DOI: 10.2147/OTT.S154227 -
Gastroenterology May 2018Society guidelines differ in their recommendations for surveillance to detect early-stage hepatocellular carcinoma (HCC) in patients with cirrhosis. We compared the... (Meta-Analysis)
Meta-Analysis
BACKGROUND & AIMS
Society guidelines differ in their recommendations for surveillance to detect early-stage hepatocellular carcinoma (HCC) in patients with cirrhosis. We compared the performance of surveillance imaging, with or without alpha fetoprotein (AFP), for early detection of HCC in patients with cirrhosis.
METHODS
Two reviewers searched MEDLINE and SCOPUS from January 1990 through August 2016 to identify published sensitivity and specificity of surveillance strategies for overall and early detection of HCC. Pooled estimates were calculated and compared using the DerSimonian and Laird method for a random effects model. The study was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis guidelines.
RESULTS
Thirty-two studies (comprising 13,367 patients) characterized sensitivity of imaging with or without AFP measurement for detection of HCC in patients with cirrhosis. Ultrasound detected any stage HCC with 84% sensitivity (95% confidence interval [CI] 76%-92%), but early-stage HCC with only 47% sensitivity (95% CI 33%-61%). In studies comparing ultrasound with vs without AFP measurement, ultrasound detected any stage HCC with a lower level of sensitivity than ultrasound plus AFP measurement (relative risk [RR] 0.88; 95% CI 0.83-0.93) and early-stage HCC with a lower level of sensitivity than ultrasound plus AFP measurement (RR 0.81; 95% CI 0.71-0.93). However, ultrasound alone detected HCC with a higher level of specificity than ultrasound plus AFP measurement (RR 1.08; 95% CI 1.05-1.09). Ultrasound with vs without AFP detected early-stage HCC with 63% sensitivity (95% CI 48%-75%) and 45% sensitivity (95% CI 30%-62%), respectively (P = .002). Only 4 studies evaluated computed tomography or magnetic resonance image-based surveillance, which detected HCC with 84% sensitivity (95% CI 70%-92%).
CONCLUSIONS
We found ultrasound alone has a low sensitivity to detect early stage HCC in patients with cirrhosis. Addition of AFP to ultrasound significantly increases sensitivity of early HCC detection in clinical practice.
Topics: Adult; Aged; Carcinoma, Hepatocellular; Early Detection of Cancer; Female; Humans; Liver Cirrhosis; Liver Neoplasms; Magnetic Resonance Imaging; Male; Middle Aged; Sensitivity and Specificity; Tomography, X-Ray Computed; Ultrasonography; alpha-Fetoproteins
PubMed: 29425931
DOI: 10.1053/j.gastro.2018.01.064 -
Journal of Evidence-based Complementary... Oct 2017Many studies have investigated the efficacy of Endostar combined with transcatheter arterial chemoembolization (TACE) versus TACE alone for hepatocellular carcinoma... (Meta-Analysis)
Meta-Analysis
Many studies have investigated the efficacy of Endostar combined with transcatheter arterial chemoembolization (TACE) versus TACE alone for hepatocellular carcinoma (HCC). A systematic review was conducted to evaluate the efficacy of Endostar. PubMed, Embase, and other databases were searched, and meta-analysis was performed using RevMan 5.3 software. Nine studies, all of which were clinical randomized controlled trials, involving 411 participants were included. The overall response rate, disease control rate and α-fetoprotein negative conversion ratio, and the 6- and 12-month survival rate of HCC patients treated with combined Endostar and TACE were higher than those treated with TACE alone ( P < .01). Furthermore, the incidence of tumor progression was low after Endostar treatment ( P = .005). The incidence of adverse effects (leukocytopenia, liver function damage, and vomiting) was similar in Endostar with TACE and in TACE alone ( P > .05). However, large studies and more randomized trials are necessary to determine the effects of Endostar on HCC.
Topics: Angiogenesis Inhibitors; Carcinoma, Hepatocellular; Chemoembolization, Therapeutic; Combined Modality Therapy; Endostatins; Humans; Liver Neoplasms; Recombinant Proteins
PubMed: 29228810
DOI: 10.1177/2156587217730461 -
The Cochrane Database of Systematic... Mar 2017Down's syndrome occurs when a person has three copies of chromosome 21 (or the specific area of chromosome 21 implicated in causing Down's syndrome) rather than two. It... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Down's syndrome occurs when a person has three copies of chromosome 21 (or the specific area of chromosome 21 implicated in causing Down's syndrome) rather than two. It is the commonest congenital cause of mental disability. Non-invasive screening based on biochemical analysis of maternal serum or urine, or fetal ultrasound measurements, allows estimates of the risk of a pregnancy being affected and provides information to guide decisions about definitive testing. Before agreeing to screening tests, parents need to be fully informed about the risks, benefits and possible consequences of such a test. This includes subsequent choices for further tests they may face, and the implications of both false positive (i.e. invasive diagnostic testing, and the possibility that a miscarried fetus may be chromosomally normal) and false negative screening tests (i.e. a fetus with Down's syndrome will be missed). The decisions that may be faced by expectant parents inevitably engender a high level of anxiety at all stages of the screening process, and the outcomes of screening can be associated with considerable physical and psychological morbidity. No screening test can predict the severity of problems a person with Down's syndrome will have.
OBJECTIVES
To estimate and compare the accuracy of first and second trimester serum markers with and without first trimester ultrasound markers for the detection of Down's syndrome in the antenatal period, as combinations of markers.
SEARCH METHODS
We conducted a sensitive and comprehensive literature search of MEDLINE (1980 to 25 August 2011), Embase (1980 to 25 August 2011), BIOSIS via EDINA (1985 to 25 August 2011), CINAHL via OVID (1982 to 25 August 2011), the Database of Abstracts of Reviews of Effectiveness (the Cochrane Library 25 August 2011), MEDION (25 August 2011), the Database of Systematic Reviews and Meta-Analyses in Laboratory Medicine (25 August 2011), the National Research Register (Archived 2007), and Health Services Research Projects in Progress database (25 August 2011). We did not apply a diagnostic test search filter. We did forward citation searching in ISI citation indices, Google Scholar and PubMed 'related articles'. We also searched reference lists of retrieved articles SELECTION CRITERIA: Studies evaluating tests of combining first and second trimester maternal serum markers in women up to 24 weeks of gestation for Down's syndrome, with or without first trimester ultrasound markers, compared with a reference standard, either chromosomal verification or macroscopic postnatal inspection.
DATA COLLECTION AND ANALYSIS
Data were extracted as test positive/test negative results for Down's and non-Down's pregnancies allowing estimation of detection rates (sensitivity) and false positive rates (1-specificity). We performed quality assessment according to QUADAS criteria. We used hierarchical summary ROC meta-analytical methods to analyse test performance and compare test accuracy. Analysis of studies allowing direct comparison between tests was undertaken. We investigated the impact of maternal age on test performance in subgroup analyses.
MAIN RESULTS
Twenty-two studies (reported in 25 publications) involving 228,615 pregnancies (including 1067 with Down's syndrome) were included. Studies were generally high quality, although differential verification was common with invasive testing of only high risk pregnancies. Ten studies made direct comparisons between tests. Thirty-two different test combinations were evaluated formed from combinations of eight different tests and maternal age; first trimester nuchal translucency (NT) and the serum markers AFP, uE3, total hCG, free βhCG, Inhibin A, PAPP-A and ADAM 12. We looked at tests combining first and second trimester markers with or without ultrasound as complete tests, and we also examined stepwise and contingent strategies.Meta-analysis of the six most frequently evaluated test combinations showed that a test strategy involving maternal age and a combination of first trimester NT and PAPP-A, and second trimester total hCG, uE3, AFP and Inhibin A significantly outperformed other test combinations that involved only one serum marker or NT in the first trimester, detecting about nine out of every 10 Down's syndrome pregnancies at a 5% false positive rate. However, the evidence was limited in terms of the number of studies evaluating this strategy, and we therefore cannot recommend one single screening strategy.
AUTHORS' CONCLUSIONS
Tests involving first trimester ultrasound with first and second trimester serum markers in combination with maternal age are significantly better than those without ultrasound, or those evaluating first trimester ultrasound in combination with second trimester serum markers, without first trimester serum markers. We cannot make recommendations about a specific strategy on the basis of the small number of studies available.
Topics: Biomarkers; Chorionic Gonadotropin; Down Syndrome; Estriol; False Positive Reactions; Female; Humans; Inhibins; Maternal Age; Nuchal Translucency Measurement; Pregnancy; Pregnancy Trimester, First; Pregnancy Trimester, Second; Pregnancy-Associated Plasma Protein-A; Sensitivity and Specificity; alpha-Fetoproteins
PubMed: 28295159
DOI: 10.1002/14651858.CD012599