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Health Technology Assessment... Aug 2015Initial treatment for early breast cancer is usually either breast-conserving surgery (BCS) or mastectomy. After BCS, whole-breast external beam radiotherapy (WB-EBRT)... (Review)
Review
BACKGROUND
Initial treatment for early breast cancer is usually either breast-conserving surgery (BCS) or mastectomy. After BCS, whole-breast external beam radiotherapy (WB-EBRT) is the standard of care. A potential alternative to post-operative WB-EBRT is intraoperative radiation therapy delivered by the INTRABEAM(®) Photon Radiotherapy System (Carl Zeiss, Oberkochen, Germany) to the tissue adjacent to the resection cavity at the time of surgery.
OBJECTIVE
To assess the clinical effectiveness and cost-effectiveness of INTRABEAM for the adjuvant treatment of early breast cancer during surgical removal of the tumour.
DATA SOURCES
Electronic bibliographic databases, including MEDLINE, EMBASE and The Cochrane Library, were searched from inception to March 2014 for English-language articles. Bibliographies of articles, systematic reviews, clinical guidelines and the manufacturer's submission were also searched. The advisory group was contacted to identify additional evidence.
METHODS
Systematic reviews of clinical effectiveness, health-related quality of life and cost-effectiveness were conducted. Two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to full texts of retrieved papers by one reviewer and checked by a second reviewer. Data extraction and quality assessment were undertaken by one reviewer and checked by a second reviewer, and differences in opinion were resolved through discussion at each stage. Clinical effectiveness studies were included if they were carried out in patients with early operable breast cancer. The intervention was the INTRABEAM system, which was compared with WB-EBRT, and study designs were randomised controlled trials (RCTs). Controlled clinical trials could be considered if data from available RCTs were incomplete (e.g. absence of data on outcomes of interest). A cost-utility decision-analytic model was developed to estimate the costs, benefits and cost-effectiveness of INTRABEAM compared with WB-EBRT for early operable breast cancer.
RESULTS
One non-inferiority RCT, TARGeted Intraoperative radioTherapy Alone (TARGIT-A), met the inclusion criteria for the review. The review found that local recurrence was slightly higher following INTRABEAM than WB-EBRT, but the difference did not exceed the 2.5% non-inferiority margin providing INTRABEAM was given at the same time as BCS. Overall survival was similar with both treatments. Statistically significant differences in complications were found for the occurrence of wound seroma requiring more than three aspirations (more frequent in the INTRABEAM group) and for a Radiation Therapy Oncology Group toxicity score of grade 3 or 4 (less frequent in the INTRABEAM group). Cost-effectiveness base-case analysis indicates that INTRABEAM is less expensive but also less effective than WB-EBRT because it is associated with lower total costs but fewer total quality-adjusted life-years gained. However, sensitivity analyses identified four model parameters that can cause a switch in the treatment option that is considered cost-effective.
LIMITATIONS
The base-case result from the model is subject to uncertainty because the disease progression parameters are largely drawn from the single available RCT. The RCT median follow-up of 2 years 5 months may be inadequate, particularly as the number of participants with local recurrence is low. The model is particularly sensitive to this parameter.
CONCLUSIONS AND IMPLICATIONS
A significant investment in INTRABEAM equipment and staff training (clinical and non-clinical) would be required to make this technology available across the NHS. Longer-term follow-up data from the TARGIT-A trial and analysis of registry data are required as results are currently based on a small number of events and economic modelling results are uncertain.
STUDY REGISTRATION
This study is registered as PROSPERO CRD42013006720.
FUNDING
The National Institute for Health Research Health Technology Assessment programme. Note that the economic model associated with this document is protected by intellectual property rights, which are owned by the University of Southampton. Anyone wishing to modify, adapt, translate, reverse engineer, decompile, dismantle or create derivative work based on the economic model must first seek the agreement of the property owners.
Topics: Breast Neoplasms; Cost-Benefit Analysis; Disease-Free Survival; Female; Humans; Mastectomy; Models, Econometric; Neoplasm Recurrence, Local; Quality of Life; Quality-Adjusted Life Years; Radiotherapy; Radiotherapy, Adjuvant; Randomized Controlled Trials as Topic; State Medicine; Technology Assessment, Biomedical; United Kingdom
PubMed: 26323045
DOI: 10.3310/hta19690 -
Radiotherapy and Oncology : Journal of... Oct 2022Recently, a number of clinical studies have explored links between possible Relative Biological Effectiveness (RBE) elevations and patient toxicities and/or image... (Review)
Review
Recently, a number of clinical studies have explored links between possible Relative Biological Effectiveness (RBE) elevations and patient toxicities and/or image changes following proton therapy. Our objective was to perform a systematic review of such studies. We applied a "Problem [RBE], Intervention [Protons], Population [Patients], Outcome [Side effect]" search strategy to the PubMed database. From our search, we retrieved studies which: (a) performed novel voxel-wise analyses of patient effects versus physical dose and LET (n = 13), and (b) compared image changes between proton and photon cohorts with regard to proton RBE (n = 9). For each retrieved study, we extracted data regarding: primary tumour type; size of patient cohort; type of image change studied; image-registration method (deformable or rigid); LET calculation method, and statistical methodology. We compared and contrasted their methods in order to discuss the weight of clinical evidence for variable proton RBE. We concluded that clinical evidence for variable proton RBE remains statistically weak at present. Our principal recommendation is that proton centres and clinical trial teams collaborate to standardize follow-up protocols and statistical analysis methods, so that larger patient cohorts can ultimately be considered for RBE analyses.
Topics: Humans; Relative Biological Effectiveness; Proton Therapy; Protons; Linear Energy Transfer; Radiotherapy Planning, Computer-Assisted
PubMed: 35988776
DOI: 10.1016/j.radonc.2022.08.014 -
European Journal of Nuclear Medicine... Oct 2023Aim of this study was to define the prognostic value of stress myocardial perfusion imaging by cadmium zinc telluride (CZT) single-photon emission computed tomography... (Meta-Analysis)
Meta-Analysis
Prognostic value of myocardial perfusion imaging by cadmium zinc telluride single-photon emission computed tomography in patients with suspected or known coronary artery disease: a systematic review and meta-analysis.
BACKGROUND
Aim of this study was to define the prognostic value of stress myocardial perfusion imaging by cadmium zinc telluride (CZT) single-photon emission computed tomography (SPECT) for prediction of adverse cardiovascular events in patients with known or suspected coronary artery disease (CAD).
METHODS AND RESULTS
Studies published until November 2022 were identified by database search. We included studies using stress myocardial perfusion imaging by CZT-SPECT to evaluate subjects with known or suspected CAD and providing primary data of adverse cardiovascular events. Total of 12 studies were finally included recruiting 36,415 patients. Pooled hazard ratio (HR) for the occurrence of adverse events was 2.17 (95% confidence interval, CI, 1.78-2.65) and heterogeneity was 66.1% (P = 0.001). Five studies reported data on adjusted HR for the occurrence of adverse events. Pooled HR was 1.69 (95% CI, 1.44-1.98) and heterogeneity was 44.9% (P = 0.123). Seven studies reported data on unadjusted HR for the occurrence of adverse events. Pooled HR was 2.72 (95% CI, 2.00-3.70). Nine studies reported data useful to calculate separately the incidence rate of adverse events in patients with abnormal and normal myocardial perfusion. Pooled incidence rate ratio was 2.38 (95% CI, 1.39-4.06) and heterogeneity was 84.6% (P < 0.001). The funnel plot showed no evidence of asymmetry (P = 0.517). At meta-regression analysis, we found an association between HR for adverse events and presence of angina symptoms and family history of CAD.
CONCLUSIONS
Stress myocardial perfusion imaging by CZT-SPECT is a valuable noninvasive prognostic indicator for adverse cardiovascular events in patients with known or suspected CAD.
Topics: Humans; Coronary Artery Disease; Cadmium; Myocardial Perfusion Imaging; Prognosis; Tomography, Emission-Computed
PubMed: 37480369
DOI: 10.1007/s00259-023-06344-8 -
Biomedical Journal Dec 2015The treatment of amblyopia, particularly anisometropic (difference in refractive correction) and/or strabismic (turn of one eye) amblyopia has long been a challenge for... (Review)
Review
The treatment of amblyopia, particularly anisometropic (difference in refractive correction) and/or strabismic (turn of one eye) amblyopia has long been a challenge for many clinicians. Achieving optimum outcomes, where the amblyopic eye reaches a visual acuity similar to the fellow eye, is often impossible in many patients. Part of this challenge has resulted from a previous lack of scientific evidence for amblyopia treatment that was highlight by a systematic review by Snowdon et al. in 1998. Since this review, a number of publications have revealed new findings in the treatment of amblyopia. This includes the finding that less intensive occlusion treatments can be successful in treating amblyopia. A relationship between adherence to treatment and visual acuity has also been established and has been shown to be influenced by the use of intervention material. In addition, there is growing evidence of that a period of glasses wearing only can significantly improve visual acuity alone without any other modes of treatment. This review article reports findings since the Snowdon's report.
Topics: Acupuncture Therapy; Amblyopia; Atropine; Humans; Refractometry; Visual Acuity
PubMed: 27013450
DOI: 10.1016/j.bj.2015.06.001 -
Movement Disorders : Official Journal... Aug 2021Dopamine receptors are abundant along the central nigrostriatal tract and are expressed as 5 subtypes in two receptor families. In PD, compensatory changes in dopamine... (Meta-Analysis)
Meta-Analysis Review
Dopamine receptors are abundant along the central nigrostriatal tract and are expressed as 5 subtypes in two receptor families. In PD, compensatory changes in dopamine receptors emerge as a consequence of the loss of dopamine nerve terminals or dopaminergic pharmacotherapy. We performed a systematic review and meta-analysis of the available PET and single-photon emission computed tomography studies that have investigated dopamine receptors in PD, PSP and MSA. The inclusion criteria were studies including human PET or single-photon emission computed tomography imaging; dopamine receptor tracers (D1-like or D2-like) and idiopathic PD, PSP, or MSA patients compared with healthy controls. The 67 included D2-like studies had 1925 patients. Data were insufficient for an analysis of D1-like studies. PD patients had higher striatal binding early in the disease, but after a disease duration of 4.36 years, PD patients had lower binding values than healthy controls. Striatal D2R binding was highest in unmedicated early PD patients and in the striatum contralateral to the predominant motor symptoms. PSP and MSA-P patients had lower striatal D2R binding than PD patients (14.2% and 21.8%, respectively). There is initial upregulation of striatal D2Rs in PD, which downregulate on average 4 years after motor symptom onset, possibly because of agonist-induced effects. The consistent upregulation of D2Rs in the PD striatum contralateral to the predominant motor symptoms indicates that receptor changes are driven by neurodegeneration and loss of striatal neuropil. Both PSP and MSA patients have clearly lower striatal D2R binding values than PD patients, which offers an opportunity for differential diagnostics. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
Topics: Corpus Striatum; Dopamine; Dopamine Plasma Membrane Transport Proteins; Humans; Parkinson Disease; Receptors, Dopamine D2; Tomography, Emission-Computed, Single-Photon
PubMed: 33955044
DOI: 10.1002/mds.28632 -
Neuro-oncology Practice Sep 2019The availability of image guidance and intensity modulation has led to the increasing use of hypofractionated stereotactic radiotherapy (hSRT) as an alternative to... (Review)
Review
BACKGROUND
The availability of image guidance and intensity modulation has led to the increasing use of hypofractionated stereotactic radiotherapy (hSRT) as an alternative to conventionally fractionated radiotherapy or radiosurgery for intracranial meningiomas (ICMs). As the safety and efficacy of this approach is not well characterized, we conducted a systematic review of the literature to assess the clinical outcomes of hSRT in the setting of ICMs.
METHODS
A systematic review of Medline and EMBASE databases was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included studies were retrospective or prospective series that examined an ICM population of ≥10 patients, delivered >1 fraction of photon hSRT (≥2.5 Gy per fraction), and had a median follow-up of ≥2 years. Descriptive statistics were generated for included studies.
RESULTS
Of 1480 initial studies, 14 met eligibility criteria for inclusion, reporting on 630 patients (age range, 18-90) treated for 638 tumors. Primary radiotherapy was delivered in 37% of patients, 36% had radiation following surgery, and surgical details were unavailable for 27%. In 474 tumors assessed for radiologic response, 78% remained stable, 18% decreased in size, and 4% increased in size. Crude local control was 90%-100% as reported in 10 studies. The median late toxicity rate was 10%. The most common significant late toxicities were decreased visual acuity and new cranial neuropathy.
CONCLUSIONS
With limited follow-up, the available literature suggests hSRT for ICMs has local control and toxicity profiles comparable to other radiotherapy approaches. Confirmation in larger patient cohorts with a longer duration of follow-up is required.
PubMed: 31555449
DOI: 10.1093/nop/npy053 -
Schizophrenia (Heidelberg, Germany) Sep 2023This systematic review aimed to review neuroimaging studies comparing clozapine-resistant schizophrenia patients with clozapine-responding patients, and with first-line... (Review)
Review
This systematic review aimed to review neuroimaging studies comparing clozapine-resistant schizophrenia patients with clozapine-responding patients, and with first-line antipsychotic responding (FLR) patients. A total of 19 studies including 6 longitudinal studies were identified. Imaging techniques comprised computerized tomography (CT, n = 3), structural magnetic resonance imaging (MRI, n = 7), magnetic resonance spectroscopy (MRS, n = 5), functional MRI (n = 1), single-photon emission computerized tomography (SPECT, n = 3) and diffusion tensor imaging (DTI, n = 1). The most consistent finding was hypo-frontality in the clozapine-resistant group compared with the clozapine-responding group with possible differences in frontal-striatal-basal ganglia circuitry as well as the GABA level between the two treatment-resistant groups. Additional statistically significant findings were reported when comparing clozapine-resistant patients with the FLR group, including lower cortical thickness and brain volume of multiple brain regions as well as lower Glx/Cr level in the dorsolateral prefrontal cortex. Both treatment-resistant groups were found to have extensive differences in neurobiological features in comparison with the FLR group. Overall results suggested treatment-resistant schizophrenia is likely to be a neurobiological distinct type of the illness. Clozapine-resistant and clozapine-responding schizophrenia are likely to have both shared and distinct neurobiological features. However, conclusions from existing studies are limited, and future multi-center collaborative studies are required with a consensus clinical definition of patient samples, multimodal imaging tools, and longitudinal study designs.
PubMed: 37752161
DOI: 10.1038/s41537-023-00392-7 -
Advances in Nutrition (Bethesda, Md.) Aug 2022Body composition parameters are not captured by measures of body mass, which may explain inconsistent associations between body weight and prostate cancer (PC) risk. The...
Body composition parameters are not captured by measures of body mass, which may explain inconsistent associations between body weight and prostate cancer (PC) risk. The objective of this systematic review was to characterize the association between fat mass (FM) and fat-free mass (FFM) parameters and PC risk. A search of PubMed, Embase, and Web of Science identified case-control and cohort studies that measured body composition in relation to PC risk. Methodological quality was assessed using the Newcastle-Ottawa Scale (NOS). Thirteen observational studies were included, of which 8 were case-control studies (n = 1572 cases, n = 1937 controls) and 5 were prospective cohort studies (n = 7854 incident cases with PC). The NOS score was 5.9 ± 1.1 for case-control studies and 8.4 ± 1.3 for cohort studies. The most common body composition technique was bioelectrical impedance analysis (n = 9 studies), followed by DXA (n = 2), computed tomography (n = 2), air displacement plethysmography (n = 1), and MRI (n = 1). No case-control studies reported differences in %FM between PC cases and controls and no consistent differences in FM or FFM (in kilograms) were observed. Two out of 5 cohort studies reported that higher %FM was associated with lower PC risk. Conversely, 3 cohort studies reported a greater risk of being diagnosed with advanced/aggressive PC with higher FM (expressed in kilograms, %FM, or fat distribution). Two out of 4 studies (both case-control and cohort) found that higher abdominal adipose tissue was associated with increased PC risk. In conclusion, although results were inconsistent, there is some evidence that FM may be negatively associated with total PC risk but positively associated with the risk of advanced/aggressive PC; modest evidence suggests that abdominal adipose tissue may increase the risk of PC. Future work should elucidate unique patterns of FM distribution and PC risk to triage men at risk for developing PC. This study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database as CRD42019133388.
Topics: Humans; Male; Absorptiometry, Photon; Adipose Tissue; Body Composition; Body Mass Index; Electric Impedance; Prospective Studies; Prostatic Neoplasms; Observational Studies as Topic
PubMed: 34918023
DOI: 10.1093/advances/nmab153 -
EJNMMI Physics May 2023While diagnostic reference levels (DRLs) are well-established for the radiopharmaceutical part, published DRLs for the CT component of positron emission... (Review)
Review
BACKGROUND
While diagnostic reference levels (DRLs) are well-established for the radiopharmaceutical part, published DRLs for the CT component of positron emission tomography/computed tomography (PET/CT) and single photon emission computed tomography/computed tomography (SPECT/CT) are limited. This systematic review and meta-analysis provides an overview of the different objectives of CT in hybrid imaging and summarizes reported CT dose values for the most common PET/CT and SPECT/CT examinations. Also, an overview of already proposed national DRLs is given.
METHODS
A systematic literature search was performed to identify original articles reporting CT dose index volume (CTDI), dose-length product (DLP) and/or national DRLs for the most frequently performed PET/CT and/or SPECT/CT examinations. Data were grouped according to the clinical objective: diagnostic (D-CT), anatomical localisation (AL-CT) or attenuation correction (AC-CT) CT. Random-effects meta-analyses were conducted.
RESULTS
Twenty-seven articles were identified of which twelve reported national DRLs. For brain and tumour PET/CT imaging, CTDI and DLP values were higher for a D-CT (brain: 26.7 mGy, 483 mGy cm; tumour: 8.8 mGy, 697 mGy cm) than for an AC/AL-CT (brain: 11.3 mGy, 216 mGy cm; tumour: 4.3 mGy, 419 mGy cm). Similar conclusions were found for bone and parathyroid SPECT/CT studies: D-CT (bone: 6.5 mGy, 339 mGy cm; parathyroid: 15.1 mGy, 347 mGy cm) results in higher doses than AL-CT (bone: 3.8 mGy, 156 mGy cm; parathyroid: 4.9 mGy, 166 mGy cm). For cardiac (AC-CT), mIBG/octreotide, thyroid and post-thyroid ablation (AC/AL-CT) SPECT/CT pooled mean CTDI (DLP) values were 1.8 mGy (33 mGy cm), 4.6 mGy (208 mGy cm), 3.1 mGy (105 mGy cm) and 4.6 mGy (145 mGy cm), respectively. For all examinations, high variability in nuclear medicine practice was observed.
CONCLUSION
The large variation in CT dose values and national DRLs highlights the need for optimisation in hybrid imaging and justifies the clinical implementation for nuclear medicine specific DRLs.
PubMed: 37227561
DOI: 10.1186/s40658-023-00553-8 -
Asia Oceania Journal of Nuclear... 2018Systemic lupus erythematosus (SLE) is an autoimmune disease with a wide range of clinical manifestations. Cognitive dysfunction is one of the manifestations that could... (Review)
Review
OBJECTIVES
Systemic lupus erythematosus (SLE) is an autoimmune disease with a wide range of clinical manifestations. Cognitive dysfunction is one of the manifestations that could present prior to the emergence of any other neuropsychiatric involvements in SLE. Cognitive dysfunction is a subtle condition occurring with a high frequency. However, there is no data on the correlation of cognitive dysfunction with central nervous system (CNS) imaging findings, in particular single-photon emission computed tomography scan (SPECT) and functional MRI. We decided to perform a systematic review of brain SPECT and fMRI in SLE patients with cognitive dysfunction.
METHODS
PubMed, Scopus, and Google Scholar databases were searched until April 2017 with the following keywords: "SLE OR systemic lupus erythematous OR lupus" AND "functional MRI OR functional magnetic resonance imaging OR fMRI OR SPECT or SCAN". A total of 1,767articles were found. Two rheumatologists reviewed the articles and finally 14 articles were selected for the final systematic review.
RESULTS
The fMRI and SPECT imaging techniques could provide valuable information regarding the SLE patients with cognitive dysfunction at the early stages of the disease.
CONCLUSION
Brain SPECT scan and fMRI are used as functional imaging tools in SLE. Both of these diagnostic modalities are sensitive in reflecting the subtle brain damages in SLE patients with cognitive dysfunction. Brain fMRI and SPECT scan could be significantly beneficial in the diagnosis and initial management of cognitive dysfunction in SLE. Nevertheless, prospective studies could be useful in confirming the application of these diagnostic modalities in the clinical setting.
PubMed: 29998142
DOI: 10.22038/aojnmb.2018.26381.1184