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World Neurosurgery Oct 2019Bevacizumab plus irinotecan is a new beneficial chemotherapy strategy for patients with malignant glioma. The purpose of this systematic review and meta-analysis was to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Bevacizumab plus irinotecan is a new beneficial chemotherapy strategy for patients with malignant glioma. The purpose of this systematic review and meta-analysis was to comprehensively assess the risk of adverse vascular events in adults with malignant glioma treated with bevacizumab plus irinotecan.
METHODS
The Cochrane Library, Embase and PubMed were searched, and relevant trials were identified up to June 2018. Two investigators screened all titles and abstracts for possible inclusion and extracted data independently. Six studies were included, and 5 of them in the control group using bevacizumab alone or bevacizumab with temozolomide. Three systems were used to assess the quality of evidence and the level of recommendation. The Oxford Centre for Evidence-Based Medicine Levels of Evidence (2009) system was used to classify the evidence into 5 levels (classes I-V). The star system from the Newcastle-Ottawa Scale was used to assess methodological quality. The GRADE profiler was used to evaluate the overall body of evidence.
RESULTS
Our data show that bevacizumab plus irinotecan therapy does not significantly affect the risk of systemic adverse events (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.43-3.18). Patients treated with bevacizumab plus irinotecan had a similar risk of hematotoxicity (OR, 1.06; 95% CI, 0.26-4.38), thrombocytopenia (OR, 1.07; 95% CI, 0.25-4.63), and hypertension (OR, 1.34; 95% CI, 0.28-6.36) compared with the control group (those treated without irinotecan). Thrombosis occurred more frequently in patients treated with bevacizumab plus irinotecan compared with the control group (OR, 3.23; 95% CI, 1.47-7.12).
CONCLUSIONS
The risk of systemic adverse events was not significantly different between patients with malignant glioma treated with bevacizumab plus irinotecan and the control group. The risks of hematotoxicity, thrombocytopenia, and hypertension were similar in the 2 groups. The risk of thrombosis was higher in patients treated with bevacizumab plus irinotecan. Monitoring for thrombosis and administering anticoagulant therapy as necessary merit promotion for patients with malignant glioma receiving treatment with bevacizumab plus irinotecan.
Topics: Antineoplastic Agents, Immunological; Antineoplastic Combined Chemotherapy Protocols; Bevacizumab; Brain Neoplasms; Glioma; Humans; Intracranial Thrombosis; Irinotecan; Risk Factors; Topoisomerase I Inhibitors; Treatment Outcome
PubMed: 31203059
DOI: 10.1016/j.wneu.2019.06.043 -
The Journal of Obstetrics and... Sep 2018Paraganglioma is one of the rarest neoplasms involving the ovary, with only 10 previous reports. We present a case of peritoneal carcinomatosis from primary ovarian...
Paraganglioma is one of the rarest neoplasms involving the ovary, with only 10 previous reports. We present a case of peritoneal carcinomatosis from primary ovarian paraganglioma and a systematic review of the literature. Clinical information was retrieved from medical records, and a systematic review of the literature was performed according to meta-analysis of observational studies in epidemiology guidelines. A 33-year-old woman presented with a 12-month history of hypertension and weight loss. She was diagnosed with ovarian paraganglioma and was treated with extensive debulking surgery to no residual disease after three cycles of neoadjuvant chemotherapy. She recurred after 6 months and was started on somatostatin-analogue. Following further disease progression with bone metastasis (treated with palliative radiotherapy), a trial with Sunitinib was started. The patient died 30 months after initial diagnosis. Of the cases reported to date, only one had peritoneal metastasis at presentation but none of them had such an ominous prognosis. Ovarian paraganglioma is an extremely rare condition. We report the first case of primary malignant ovarian paraganglioma with an exceptionally aggressive behavior. Clinicopathological correlation with immunohistochemistry is essential to avoid misdiagnosis. A standard treatment is not recommended yet but cytoreductive surgery seems to be a favorable approach to prolong survival.
Topics: Adult; Carcinoma; Fatal Outcome; Female; Humans; Ovarian Neoplasms; Paraganglioma; Peritoneal Neoplasms
PubMed: 29978527
DOI: 10.1111/jog.13713 -
World Neurosurgery Sep 2018Primary solitary intracranial malignant melanoma (PIMM) is extremely rare. In 1992, an extensive review of 81 patients with PIMM was undertaken. Imaging studies,... (Review)
Review
INTRODUCTION
Primary solitary intracranial malignant melanoma (PIMM) is extremely rare. In 1992, an extensive review of 81 patients with PIMM was undertaken. Imaging studies, microsurgery, and adjuvant therapy have developed considerably over the last 25 years, and targeted therapy recently has been proven successful for metastatic melanoma. These factors could influence current and future clinical PIMM results.
METHODS
We undertook a literature search of PIMM patients since 1992.
RESULTS
We reviewed 49 cases of PIMM. The mean age was 45.8 years. No significant sex difference was found. Intracranial hypertension and focal neurologic deficits were commonly observed around 70% and 40%, respectively. There were no significant differences of survival period according to tumor sites. Surgeries were performed in 42 of 49 patients with PIMM reviewed (92%). The mean survival of the gross total removal group was significantly longer than that of surgical results (>22 months vs. 12 months (interquartile range: 5-22 months; P = 0.026). For adjuvant therapy, 9 patients underwent chemotherapy and 18 patients underwent radiotherapy postoperatively There was no significant difference in survival period between with and without adjuvant therapies. Leptomeningeal enhancement diagnosed in the initial MRI, was the worst prognostic factor.
CONCLUSIONS
Gross total removal of the PIMM was the most promising treatment. Currently adjuvant therapy has not been associated with the survival period. To improve clinical outcome, immunotherapy and targeted therapies are likely to become more important.
Topics: Brain Neoplasms; Humans; Melanoma
PubMed: 29959081
DOI: 10.1016/j.wneu.2018.06.138 -
Journal of Minimally Invasive Gynecology 2018In this study, we aimed to estimate the frequency of premalignant and malignant lesions in endometrial polyps, and to evaluate associated clinical and demographic... (Meta-Analysis)
Meta-Analysis
In this study, we aimed to estimate the frequency of premalignant and malignant lesions in endometrial polyps, and to evaluate associated clinical and demographic factors. A literature search was performed in major databases and the gray literature using the terms polyps OR endometrial polyp AND endometrial neoplasms OR endometrial cancer OR endometrial hyperplasia OR malignan*. Studies describing the frequency of premalignant and malignant lesions in endometrial polyps and any clinical or demographic factors associated with malignant lesions extracted using hysteroscopy were considered eligible. Independent investigators selected the studies and extracted the data. A meta-analysis was performed using a random-effects model and meta-regression. We identified 37 studies (comprising 21,057 patients) of endometrial polyps. The prevalence of premalignant and malignant lesions was 3.4% (95% confidence interval [CI], 2.8-4.1; I, 80.5%). Abnormal uterine bleeding (prevalence ratio [PR], 1.47; 95% CI, 1.27-1.69; I, 82.4%), menopausal status (PR, 1.67; 95% CI, 1.48-1.89; I, 78.4%), age >60 years (PR, 2.41; 95% CI, 1.84-3.16; I, 81.5%), diabetes mellitus (PR, 1.76; 95% CI, 1.43-2.16; I, 0.0%), systemic arterial hypertension (PR, 1.50; 95% CI, 1.20-1.88; I, 75.9%), obesity (PR, 1.41; 95% CI:1.13-1.76; I, 41.2%), and tamoxifen use (PR, 1.53; 95% CI, 1.06-2.21; I, 0.0%) were associated with endometrial polyp malignancy. However, breast cancer (PR, 0.83; 95% CI, 0.44-1.57; I, 0.0%), hormonal therapy (PR, 0.93; 95% CI, 0.67-1.30; I, 31.7%), parity (PR, 0.87; 95% CI, 0.39-1.96; I, 78.1%), and endometrial polyp size (PR, 1.05; 95% CI, 0.70-1.57; I, 44.7%) were not associated with malignancy of endometrial polyps. Three of every 100 women with clinically recognized polyps, a condition associated with specific clinical and demographic factors, will harbor premalignant or malignant lesions.
Topics: Adult; Endometrial Neoplasms; Endometrium; Female; Humans; Hysteroscopy; Polyps; Precancerous Conditions; Pregnancy; Prevalence; Risk Factors; Uterine Neoplasms
PubMed: 29454147
DOI: 10.1016/j.jmig.2018.02.004 -
The Cochrane Database of Systematic... Aug 2017Cystic fibrosis is an autosomal recessive inherited defect in the cystic fibrosis transmembrane conductance regulator (CFTR) gene resulting in abnormal regulation of... (Review)
Review
BACKGROUND
Cystic fibrosis is an autosomal recessive inherited defect in the cystic fibrosis transmembrane conductance regulator (CFTR) gene resulting in abnormal regulation of salt and water movement across the membranes. In the liver this leads to focal biliary fibrosis resulting in progressive portal hypertension and end-stage liver disease in some individuals. This can be asymptomatic, but may lead to splenomegaly and hypersplenism, development of varices and variceal bleeding, and ascites; it has negative impact on overall nutritional status and respiratory function in this population. Prognosis is poor once significant portal hypertension is established. The role and outcome of various interventions for managing advanced liver disease (non-malignant end stage disease) in people with cystic fibrosis is currently unidentified.
OBJECTIVES
To review and assess the efficacy of currently available treatment options for preventing and managing advanced liver disease in children and adults with cystic fibrosis.
SEARCH METHODS
We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books.Date of last search: 06 April 2017.We also searched the reference lists of relevant articles and reviews and online trials registries. Date of last search: 04 January 2017.
SELECTION CRITERIA
Any published and unpublished randomised controlled trials and quasi-randomised controlled trials of advanced liver disease in cystic fibrosis with cirrhosis or liver failure, portal hypertension or variceal bleeding (or both).
DATA COLLECTION AND ANALYSIS
Authors independently examined titles and abstracts to identify potentially relevant trials, but none were eligible for inclusion in this review.
MAIN RESULTS
A comprehensive search of the literature did not identify any published eligible randomised controlled trials.
AUTHORS' CONCLUSIONS
In order to develop the best source of evidence, there is a need to undertake randomised controlled trials of interventions for preventing and managing advanced liver disease in adults and children with cystic fibrosis.
Topics: Cystic Fibrosis; Humans; Liver Diseases
PubMed: 28850173
DOI: 10.1002/14651858.CD012056.pub2 -
World Neurosurgery Dec 2016The most common bone flap storage strategies after decompressive hemicraniectomy for malignant intracranial hypertension include freezer cryopreservation (CP) and... (Review)
Review
INTRODUCTION
The most common bone flap storage strategies after decompressive hemicraniectomy for malignant intracranial hypertension include freezer cryopreservation (CP) and subcutaneous abdominal implantation (AP). Numerous series have reported on patient outcomes after cranioplasty in terms of infection, cosmesis, and resorption. This meta-analysis compares published outcomes of bone flap CP and subcutaneous storage with respect to efficacy and complication risk in patients undergoing cranioplasty after hemicraniectomy.
METHODS
A systematic review was performed using PubMed-searchable studies that included bone flap storage methods and outcome data for cranioplasties performed between 1975 and 2015.
RESULTS
A total of 48 studies including 5346 patients were identified that met the inclusion criteria. Of these patients, 4096 underwent cranioplasty with an autologous flap. Mean bone flap storage times for CP and AP flaps were 69.9 and 69.7 days. Mean follow-up time for CP and AP flaps was 16.9 and 16.5 months. No statistically significant differences were found when comparing CP with subcutaneous storage of bone flaps with respect to percentage of patients developing infection (7.3% vs. 7.1%), percentage of patients needing revision surgery (15.9% vs. 7.6%), and percentage of patients experiencing resorption (9.7% vs. 7.7%).
CONCLUSIONS
This is the largest and most robust review comparing published outcomes of CP and subcutaneous storage of bone flaps in patients who have undergone decompressive hemicraniectomy. This review found no statistically significant differences in clinical outcomes (infection, resorption, reoperation) when comparing storage methods for bone flap preservation. This study suggests that both strategies may be used safely and successfully.
Topics: Decompressive Craniectomy; Humans; Postoperative Complications; Risk Factors; Skull; Surgical Flaps
PubMed: 27647038
DOI: 10.1016/j.wneu.2016.09.025 -
Journal of Endovascular Therapy : An... Jun 2015To review the literature on pararenal endovascular aneurysm repair (EVAR) to determine the frequency and clinical relevance of chimney graft occlusions. (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To review the literature on pararenal endovascular aneurysm repair (EVAR) to determine the frequency and clinical relevance of chimney graft occlusions.
METHODS
A comprehensive search of the English-language literature abstracted in the Medline and the Cochrane Library databases was performed to identify case series involving pararenal aortic pathologies (degenerative aneurysms, penetrating atherosclerotic ulcers, type Ia endoleaks, and para-anastomotic aneurysms) treated with EVAR and chimney grafts; thoracoabdominal, iliac, or aortic arch chimney graft placements were excluded, as were case reports in which the total number of chimney grafts implanted at the reporting center could not be determined. The literature search identified 83 studies regarding chimneys/snorkels for pararenal pathologies published between January 2007 and March 2014. Of these, 7 studies met the inclusion criteria and were included in the analysis.
RESULTS
There were 15 (4.5%) occlusions in the overall 334 renovisceral vessels in which chimney grafts were deployed. The mean time to chimney graft occlusion was 3.5 months (range 1-270 days) over a mean follow-up of 1.4 months (range 9-24). The target arteries were the renal artery (n=12) and the superior mesenteric artery (SMA; n=3). Seven patients were asymptomatic, and no description was given in 5 cases. In the other 3 patients, the symptoms were acute renal failure, intestinal ischemia, and malignant hypertension. The treatment strategy included open conversion and iliorenal bypass (n=1), exploratory laparotomy to revascularize the SMA (n=1), hemodialysis (n=1), placement of bare metal stents (n=4), conservative treatment (n=2), and unknown (n=6). One (6.7%) patient died (an occluded SMA). Two patients with renal chimney occlusion suffered from temporary renal function deterioration.
CONCLUSION
The present analysis identified a low rate of chimney graft occlusions, which appear to occur generally a few months after placement. Involvement of the renal artery had no severe clinical consequences, while occlusion of the SMA can be associated with life-threatening complications. More detailed information regarding occluded chimney grafts will be needed in future publications to help identify the causes.
Topics: Aortic Diseases; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Graft Occlusion, Vascular; Humans; Mesenteric Artery, Superior; Mesenteric Vascular Occlusion; Prosthesis Design; Renal Artery Obstruction; Risk Assessment; Risk Factors; Stents; Time Factors; Treatment Outcome; Vascular Patency
PubMed: 25878021
DOI: 10.1177/1526602815581161 -
The Surgeon : Journal of the Royal... Aug 2015Malignant middle cerebral artery infarctions (mMCAI) are one of the most devastating ischemic strokes, with up to 80% mortality in non-surgically treated patients. With... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND & PURPOSE
Malignant middle cerebral artery infarctions (mMCAI) are one of the most devastating ischemic strokes, with up to 80% mortality in non-surgically treated patients. With the publication of three European randomized controlled trials (RCTs), decompressive hemicraniectomy (DHC) was recommended in patients with mMCAI who are aged ≤ 60 years. Recently, three other RCTs enrolling patients aged > 60 years were published; thus, it is necessary to update the previous meta-analysis to re-evaluate the effects of DHC in mMCAI.
METHODS
A systematic literature search of PubMed, EMBASE, and the Cochrane Library was conducted for published RCTs investigating the effects of DHC in mMCAI. Primary outcomes were mortality and major disability (modified Rankin Scale score: 4-5) among survivors. Secondary outcomes were death or major disability (mRS score > 3), and death or severe disability (mRS score > 4). Effect sizes were expressed in Peto odds ratio (Peto OR) with 95% confidence intervals.
RESULTS
Six studies with 314 patients were subjected to meta-analysis. Data showed that DHC, significantly decreased mortality risk, death or major disability (mRS score > 3), and death or severe disability (mRS score > 4); but was associated with a slightly higher proportion of major disability (mRS score: 4-5) among survivors. There were no statistically significant age differences.
CONCLUSIONS
Compared to conservative treatment, DHC significantly decreased mortality and improved functional outcome, with a non-significant increase in the proportion of survivors with major disability. Further studies are required for multidimensional evaluation of DHC for mMCAI.
Topics: Brain Edema; Craniotomy; Decompression, Surgical; Humans; Infarction, Middle Cerebral Artery; Intracranial Hypertension; Stroke; Treatment Outcome
PubMed: 25661677
DOI: 10.1016/j.surge.2014.12.002 -
Ochsner Journal 2014Few clinical practice guidelines provide management recommendations for acute hypertensive episodes except in the context of specific conditions such as pregnancy and... (Review)
Review
BACKGROUND
Few clinical practice guidelines provide management recommendations for acute hypertensive episodes except in the context of specific conditions such as pregnancy and stroke.
METHODS
We performed a systematic search to identify guidelines addressing acute hypertension and appraised the guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) validated quality assessment tool. Two reviewers independently appraised and one extracted key recommendations. Literature on secondary hypertension, hypertension in pregnancy, preeclampsia/eclampsia, stroke, aortic dissection, and pheochromocytoma was excluded.
RESULTS
Three guidelines were identified, sponsored by the American College of Emergency Physicians (ACEP), the National Heart, Lung, and Blood Institute (NHLBI), and the European Society of Hypertension (ESH) in conjunction with the European Society of Cardiology (ESC). AGREE II yielded mean domain (%) and overall assessment scores (1-7) as follows: NHLBI: 73%, 5.5; ACEP: 67%, 5.5; and ESH/ESC: 56%, 4.5. In hypertensive emergencies, the NHLBI guideline recommends reducing mean arterial pressure by ≤25% for the first hour, and then to 160/100-110 mmHg by 2-6 hours with subsequent gradual normalization in 24-48 hours. The ESH/ESC has similar recommendations. The ACEP does not address guidelines for hypertensive emergency but focuses on whether screening for target organ damage or medical intervention in patients with asymptomatic elevated blood pressure in emergency departments reduces the rate of adverse outcomes, concluding that routine screening does not reduce adverse outcomes, but patients with poor follow-up may benefit from routine screening.
CONCLUSION
NHLBI and ESH/ESC guidelines are high quality and provide similar recommendations for management of asymptomatic acute hypertensive episodes and hypertensive emergencies. Additional research is needed to inform clinical practice guidelines for this common condition.
PubMed: 25598731
DOI: No ID Found -
The Cochrane Database of Systematic... Oct 2013Great improvements in diagnostics and treatment for malignant disease in childhood have led to a major increase in survival. However, childhood cancer survivors (CCS)... (Review)
Review
BACKGROUND
Great improvements in diagnostics and treatment for malignant disease in childhood have led to a major increase in survival. However, childhood cancer survivors (CCS) are at great risk for developing adverse effects caused by multimodal treatment for their malignancy. Nephrotoxicity is one of these known (acute) side effects of several treatments, including cisplatin, carboplatin, ifosfamide, radiotherapy and nephrectomy, and can cause glomerular filtration rate impairment, proteinuria, tubulopathy and hypertension. However, evidence about the long-term effects of these treatments on renal function remains inconclusive. To reduce the number of (long-term) nephrotoxic events in CCS, it is important to know the risk of, and risk factors for, early and late renal adverse effects, so that ultimately treatment and screening protocols can be adjusted.
OBJECTIVES
To evaluate existing evidence on the effects of potentially nephrotoxic treatment modalities on the prevalence of and associated risk factors for renal dysfunction in survivors treated for childhood cancer with a median or mean survival of at least one year after cessation of treatment, where possible in comparison with healthy controls or CCS treated without potentially nephrotoxic treatment.
SEARCH METHODS
We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 4, 2011), MEDLINE/PubMed (from 1945 to December 2011) and EMBASE/Ovid (from 1980 to December 2011).
SELECTION CRITERIA
With the exception of case reports, case series and studies including fewer than 20 participants, we included studies with all study designs that reported on renal function (one year or longer after cessation of treatment) in children and adults who were treated for a paediatric malignancy (aged 18 years or younger at diagnosis) with cisplatin, carboplatin, ifosfamide, radiation including the kidney region and/or a nephrectomy.
DATA COLLECTION AND ANALYSIS
Two review authors independently performed study selection, risk of bias assessment and data extraction using standardised data collection forms. Analyses were performed according to the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions.
MAIN RESULTS
The search strategy identified 5504 studies, of which 5138 were excluded on the basis of title and/or abstract. The full-text screening of the remaining 366 articles resulted in the inclusion of 57 studies investigating the prevalence of and sometimes also risk factors for early and late renal adverse effects of treatment for childhood cancer. The 57 studies included at least 13,338 participants of interest for this study, of whom at least 6516 underwent renal function testing. The prevalence of renal adverse effects ranged from 0% to 84%. This variation may be due to diversity in included malignancies, prescribed treatments, reported outcome measurements and the methodological quality of available evidence.Chronic kidney disease/renal insufficiency (as defined by the authors of the original studies) was reported in 10 of 57 studies. The prevalence of chronic kidney disease ranged between 0.5% and 70.4% in the 10 studies and between 0.5% and 18.8% in the six studies that specifically investigated Wilms' tumour survivors treated with a unilateral nephrectomy.A decreased (estimated) glomerular filtration rate was present in 0% to 50% of all assessed survivors (32/57 studies). Total body irradiation; concomitant treatment with aminoglycosides, vancomycin, amphotericin B or cyclosporin A; older age at treatment and longer interval from therapy to follow-up were significant risk factors reported in multivariate analyses. Proteinuria was present in 0% to 84% of all survivors (17/57 studies). No study performed multivariate analysis to assess risk factors for proteinuria.Hypophosphataemia was assessed in seven studies. Reported prevalences ranged between 0% and 47.6%, but four of seven studies found a prevalence of 0%. No studies assessed risk factors for hypophosphataemia using multivariate analysis. The prevalence of impairment of tubular phosphate reabsorption was mostly higher (range 0% to 62.5%; 11/57 studies). Higher cumulative ifosfamide dose, concomitant cisplatin treatment, nephrectomy and longer follow-up duration were significant risk factors for impaired tubular phosphate reabsorption in multivariate analyses.Treatment with cisplatin and carboplatin was associated with a significantly lower serum magnesium level in multivariate analysis, and the prevalence of hypomagnesaemia ranged between 0% and 37.5% in the eight studies investigating serum magnesium.Hypertension was investigated in 24 of the 57 studies. Reported prevalences ranged from 0% to 18.2%. A higher body mass index was the only significant risk factor noted in more than one multivariate analysis. Other reported factors that significantly increased the risk of hypertension were use of total body irradiation, abdominal irradiation, acute kidney injury, unrelated or autologous stem cell donor type, growth hormone therapy and older age at screening. Previous infection with hepatitis C significantly decreased the risk of hypertension.Because of the profound heterogeneity of the studies, it was not possible to perform any meta-analysis.
AUTHORS' CONCLUSIONS
The prevalence of renal adverse events after treatment with cisplatin, carboplatin, ifosfamide, radiation therapy involving the kidney region and/or nephrectomy ranged from 0% to 84%. With currently available evidence, it was not possible to draw any conclusions with regard to prevalence of and risk factors for renal adverse effects. Future studies should focus on adequate study design and reporting and should deploy multivariate risk factor analysis to correct for possible confounding. Until more evidence becomes available, CCS should be enrolled into long-term follow-up programmes to monitor their renal function and blood pressure.
Topics: Adult; Antineoplastic Agents; Carboplatin; Child; Cisplatin; Glomerular Filtration Rate; Humans; Hypertension; Hypophosphatemia; Ifosfamide; Magnesium Deficiency; Nephrectomy; Proteinuria; Radiotherapy; Renal Insufficiency, Chronic; Risk Factors; Survivors
PubMed: 24101439
DOI: 10.1002/14651858.CD008944.pub2