Further Treatment Of Patients Research Articles

Bone Metastases: State of the Art in Minimally Invasive Interventional Oncology.

Bone is the third most common site involved by cancer metastases, and skeleton-related events such as intractable pain due to direct osseous tumor involvement, pathologic fracture, and neurologic deficits as a consequence of nerve or spinal cord compression often affect patients' functional independence and quality of life unfavorably. The annual medical-economic burden related to bone metastases is a substantial component of the total direct medical cost estimated by the National Institutes of Health. There have been substantial recent advances in percutaneous image-guided minimally invasive musculoskeletal oncologic interventions for the management of patients with osseous metastatic disease. These advances include thermal ablation, cementation with or without osseous reinforcement with implants, osteosynthesis, thermal and chemical neurolyses, and palliative injections, which are progressively incorporated into the management paradigm for such patients. These interventions are performed in conjunction with or are supplemented by adjuvant radiation therapy, systemic therapy, surgery, or analgesic agents to achieve durable pain palliation, local tumor control, or cure, and they provide a robust armamentarium for interventional radiologists to achieve safe and effective treatment in a multidisciplinary setting. In addition, these procedures are shifting the patient management paradigm in modern-era practice. The authors detail the state of the art in minimally invasive percutaneous image-guided musculoskeletal oncologic interventions and the role of radiologists in managing patients with skeletal metastases. ©RSNA, 2021.

Anlotinib combined with pemetrexed as a further treatment of patients with platinum-resistant ovarian cancer: A single-arm, open-label, phase II study

<h3>Objectives:</h3> Anlotinib is a novel multi-target tyrosine kinase inhibitor for tumor angiogenesis and proliferative signaling. A previous retrospective study achieved the overall response rate (ORR) of 14.3% and the disease control rate (DCR) of 85.7% in platinum-resistant ovarian cancer (PROC) patients (pts) treated with anlotinib monotherapy, and the ORR of 33.3% and the DCR of 100% with anlotinib plus chemotherapy. The current prospective clinical trial (ChiCTR1800018192) aimed to further assess the efficacy and safety of anlotinib combined with pemetrexed and continued as maintenance therapy for PROC. <h3>Methods:</h3> Pts who had received at least two different chemotherapy regimens (including the first line platinum-based regimen), with histologically proven recurrent platinum-refractory or platinum-resistant epithelial ovarian cancer (including fallopian tube carcinoma and primary peritoneal carcinoma), ECOG 0-2, were considered eligible for enrollment to receive six 21-days cycles of anlotinib (12 mg QD from day 1 to 14) orally plus pemetrexed intravenously (0.5 g/m² on day 1). Anlotinib monotherapy was subsequently performed up to 1 year in patients without disease progression or intolerable toxicity. The primary endpoint was ORR, and the secondary endpoints included DCR, progression-free survival (PFS) and safety. <h3>Results:</h3> As of October 2020, 22 pts were enrolled. The median prior lines of chemotherapy was 4 (range, 2-10) and 55% of pts had ever received antiangiogenic therapy. A total of 17 pts had the confirmed best overall response assessments which inferred the ORR of 41.2% (PR in 7 pts; 95% CI, 18.4-67.1) and the DCR of 100% (PR in 7 pts and SD in 10 pts; 95% CI, 80.5-100). The median PFS was 9.3 months (95% CI, 6.0-12.6). Any grades of adverse events (AEs) were observed in 91% (20/22) of pts, containing frequent hand-foot syndrome (36%), hypertension (32%), allergic eruption (27%), fatigue (23%) and oral ulcer (14%). High grade AEs occurred in 3 pts, including 1 with grade III proteinuria, 1 with grade III ascites increase, and 1 with grade IV hemoglobin reduction. <h3>Conclusions:</h3> The treatment of anlotinib plus pemetrexed showed encouraging efficacy and satisfactory safety for platinum-resistant and -refractory, recurrent ovarian cancer pts who were previously treated with chemotherapy.

Clonal Progression during First Course of Chemotherapy in Acute Myeloid Leukemia Suboptimal Responders Heralds Reinduction Failure and Early Death

INTRODUCTIONOptimal response to induction chemotherapy for acute myeloid leukemia (AML) is achievement of complete remission (CR) and minimal residual disease (MRD) negativity. Suboptimal responses include achievement of CR but MRD positivity (CRMRD+ patients) as well as failure to achieve CR. The prospect is bleak, especially in the latter group, but intensified treatment can cure some of these. Careful deliberation of patient fitness, drug toxicities and level of residual disease is required prior to choice of reinduction therapy. HYPOTHESISWe hypothesized that by studying clonal architecture changes during AML treatment, subclonal development or progression would add another dimension to the chemotherapy response assessment beyond that of merely a quantitative reduction in blasts or a given MRD marker. PATIENTS AND METHODS25 uniformly treated (“3+7” like) AML patients were included, 7 CRMRD+ (flow cytometry-determined MRD levels between 0.02% and 1%), and 18 who did not achieve CR after the first course of chemotherapy, of whom 17 received reinduction chemotherapy. Median time from diagnosis to CR evaluation after first course of chemotherapy: 33 days (range: 20-74 days)For the CRMRD+ patients; MRD cells from bone marrow samples taken after 1st treatment course were isolated using a FACSAria III based on the appropriate leukemia associated phenotype determined at diagnosis.All samples were analyzed using a 26-gene panel (ASXL1, BCOR, CALR, CBL, CSNK1A1, DNMT3A, ETV6, EZH2, FLT3-TKD, GATA2, IDH1, IDH2, JAK2, KIT, KRAS, MPL, NPM1, NRAS, RUNX1, SETBP1, SF3B1, SRSF2, TET2, TP53, U2AF1 and ZRSR2) . Furthermore, CSFR3, GATA1, PTPN11 and WT1 were analyzed in the group who did not achieve CR. The TruSeq Custom Amplicon kit was used for library prep and samples were sequenced using the MiSeq instrument. RESULTSIn the CRMRD+ group clonal architecture in unsorted diagnosis samples were compared to clonal architecture in the FACS products. In 3 informative cases, a development in the clonal architecture was seen. In two cases, a subclone positive for TET2 only persisted even if the fully mutated clones of the patients (one TET2 +/ NRAS +, one TET2 +/ NPM1 +/ IDH2 +) disappeared. Both patients relapsed. In the third patient; a IDH2 + SRSF2 + clone persisted, a IDH2 + SRSF2 + BCOR + clone disappeared. In the remaining 4 patients no mutations were detected in the FACS product.For the group of patients not in CR clonal architecture development between diagnosis and regeneration after first course of chemotherapy could be studied in 16/18 cases. Two cases were negative for all aberrations tested. 9/16 cases were clonally stable, displaying a reduction in mutation load comparable to leukemic burden reduction. In the remaining 7 cases, clonal development was seen: In 4 cases, one or more subclones were selectively eradicated leaving the more resistant clones. NPM1 was the only marker that was eradicated in more than one clone (n=2) and TET2 was the only marker that persisted in more than one clone (n=2). In 3/7 cases subclones emerged during chemotherapy; a WT1 + NRAS + clone in a NRAS + background, a SETBP1 + TET2 + ASXL1 + RUNX1 + clone in an RUNX1 + background and a DNMT3A + NPM1 + clone in a NPM1 + background. The 2-year survival of patients who received further chemotherapy was significantly different in the three groups (Clonally stable (n=9): 0.58, clonal architecture development but no emerging subclones (n=4): 0.25, AMLs with emerging subclones (n=3): 0 (last patient died after 224 days), P = 0.01 (Log-rank test)). CONCLUSIONThis study provides proof of the concept of subclonal architecture changes even in patients with minute amounts of residual leukemia (CRMRD+ group) and we were able to study the subclonal architecture changes in three of these patients.In patients not reaching CR, clonal architecture development was a rather common occurrence (7/16 cases). In three patients we observed that not only did a subclone resist chemotherapy, it grew during treatment. Even in this small study, this finding proved to be a significant marker of ultimate treatment failure.If corroborated in larger studies, we envisage that an approach like the one applied here can assist physicians' decisions in the choice of further treatment in patients experiencing suboptimal response to induction chemotherapy. DisclosuresMeggendorfer:MLL Munich Leukemia Laboratory: Employment. Koch:Munich Leukemia Laboratory: Employment. Fasan:MLL Munich Leukemia Laboratory: Employment. Kern:MLL Munich Leukemia Laboratory: Employment, Equity Ownership.

Decision-Making in Multidisciplinary Tumor Boards in Breast Cancer Care - An Observational Study.

PurposeHealthcare providers decide on recommendations for further treatment of patients with cancer in multidisciplinary tumor boards (MTBs). As such, communicative processes during MTBs are assumed to influence decision-making and, thereby, treatment planning. The aim of this exploratory study is to gain insights into decision-making during MTBs.MethodsCase discussions from MTBs in breast cancer centers in North Rhine-Westphalia, Germany, were observed and audiotaped. The transcripts of the audio recordings were analyzed by procedures of conversation analysis.ResultsBased on 38 case discussions from 15 MTBs in four breast cancer centers, an action scheme for decision-making in MTBs in breast cancer care was developed. In addition, the conversational practices used by the participants during interactions were analyzed.ConclusionAnalysis indicated that conventions in MTBs were observed during individual phases of decision-making but not for the entire process. Although exchanging multidisciplinary knowledge is an essential aspect of MTBs, this exchange does not always seem to occur in practice. The extent to which recommendations are derived from consensus during MTBs remains unclear. Thus, the study suggests developing standards for communication during MTBs to optimize decision-making and, thus, the quality of recommendation.

Anlotinib plus pemetrexed as a further treatment for patients with platinum-resistant ovarian cancer: A single-arm, open-label, phase II study.

5533 Background: Non-platinum chemotherapy is widely used in platinum-resistant recurrent ovarian cancer treatment but with limited efficacy. Combing chemotherapy with angiogenic inhibitors is a new therapeutic choice. Anlotinib is a novel tyrosine kinase inhibitor targeting multiple receptors involved in tumor proliferation, vasculature, and tumor microenvironment. The study aimed to further assess the efficacy and safety of anlotinib combined with pemetrexed in platinum-resistant ovarian cancer. Methods: Patients who had received at least two different chemotherapy regimens (including the first line platinum-based regimen), with histologically proven recurrent platinum-resistant or platinum-refractory epithelial ovarian cancer (including salpingocarcinoma and peritoneal carcinoma), ECOG 0-2, were considered eligible for enrollment to receive six 21-days cycles of anlotinib (12 mg QD from day 1 to 14; 21 days per cycle) orally plus pemetrexed intravenously (0.5 g/m2 on day 1; 21 days per cycle). Subsequent maintenance treatment was anlotinib monotherapy (12 mg QD from day 1 to 14; 21 days per cycle) till disease progression or intolerant toxicity. The primary endpoint was objective response rate (ORR), and the secondary endpoints included disease control rate (DCR), progression-free survival (PFS) and safety. Results: As of Jan 2021, 27 patients were enrolled. The median number of chemotherapy was 4 (range, 2-10) and 51.9% (14/27) of patients had ever received antiangiogenic therapy. The ORR was 36.4% (partial response (PR) in 8 patients; 95% CI, 17.2-59.3). The DCR was 100.0% (PR in 8 patients and stable disease (SD) in 14 patients; 95% CI, 73.5-100). The median time of the first response was 1.6 months (range, 1.3-4.4). The median PFS was 9.3 months (95% CI, NE-NE). Furthermore, the ORR of patients with and without prior antiangiogenic therapy was 16.7% (95%CI, 2.1-48.4) and 60.0% (95%CI, 26.2-87.8) respectively (P = 0.074). Any grades of adverse events (AEs) were observed in 92.6% (25/27) of patients, containing allergic eruption (33.3%), hand-foot syndrome (29.6%), hypertension (25.9%), and fatigue (25.9%). The grade 3-4 adverse events were only observed in 5 patients, including 1 with grade 3 proteinuria, 1 with grade 3 ascites, 1 with grade 3 fatigue, 1 with grade 3 edema limbs and 1 with grade 4 anemia. Conclusions: The treatment of anlotinib plus pemetrexed showed a promising antitumor activity with tolerable toxicity for patients in platinum-resistant and refractory ovarian cancer. Clinical trial information: ChiCTR2000029654.

A Multi-View SVM Approach for Seizure Detection from Single Channel EEG Signals

Seizures are the part of the epilepsy that occurs in central nervous system which leads to abnormal brain activity. Electroencephalogram (EEG) signal recordings are mostly used in epileptic seizure detection process. Detection of seizures is a crucial part for further treatment of patients. This paper proposes a multi-view SVM model for seizure detection using the single channel EEG signals. In this experiment, two views of the EEG data have been extracted, (1) the time domain features using Independent Component Analysis (ICA) and (2) power spectral densities are obtained in the frequency domain. Extracted features have been fed to multi-view SVM classification model. In this study, a single channel EEG dataset is used for seizure detection. Performance estimation parameters namely Accuracy, Sensitivity, Specificity, F1-score, and AUC value have been estimated for evaluating the proposed model. The model classified seizure and non-seizure over the sets A vs E and B vs E with an accuracy greater than 99% using k-fold cross validation. The classification accuracy obtained by multi-view SVM is better by 1–4% than single view SVM using the same features. Furthermore, the proposed model is also compared with existing single view SVM models. It is observed that the multi view SVM model performed significantly better, compare to a single view SVM model over the same features.

The 2016 Edition of the WHO Classification of Primary Brain Tumors: Applicable to Assess Individual Risk of Recurrence in Atypical Meningioma? A Single-Center Experience

Despite the relevance of molecular criteria for brain tumor diagnosis and prognosis, meningioma grading is still solely based on histologic features. Atypical meningiomas (AMs; WHO grade II) display a great histologic heterogeneity and individual courses of disease can differ significantly. This study aimed to identify clinically aggressive AMs that are prone to early recurrence after gross total resection (GTR) by assessing a specific histologic score. A retrospective analysis of 28 consecutive patients (17 females and 11 males; mean age of 62 years [range: 35-88 years]) treated in our institution between January 2006 and December 2015 was performed. Basic demographic and clinical characteristics were assessed. A scoring scale was designed to address the histologic diversity by summing up the individual histologic features in every tumor sample. According to that, points were awarded as follows: major AM defining criterion (3 points) and minor criterion (1 point). The subclassification based on our specific histologic score revealed no significant difference in frequency of one (46.4%) or two (42.9%) AM defining features; three criteria were less frequently seen (10.7%). Mean follow-up was 61.89 ± 9.03 months. Local recurrence occurred in 35.7% after a mean time of 37.4 ± 22.6 months after primary surgery. Age > 60 years was significantly associated with a shorter progression-free survival (PFS). There was a trend toward shorter PFS with increasing scores, tantamount with the presence of several AM defining histologic criteria in one sample. No tumor relapse was seen when diagnosis was based only on minor criteria. AMs display a histologic diversity. There is a trend toward shorter PFS with increasing numbers of AM defining histologic features. The inclusion of this score in the decision algorithm regarding further treatment for patients >60 years after GTR might be helpful and should be evaluated in further studies.

Rehabilitation of the alveolar bone after tooth extraction. Analysis of methods

Resorption of the alveolar bone after tooth extraction is an irreversible process due to biological bone remodeling. It will greatly complicate the further treatment of patients for dental implantation, since for the latter a prerequisite is a sufficient volume of bone tissue. It leads to a protracted treatment process: the volume and timing of interventions increases. The literature review has shown possible methods of preservation of the alveolar ridge after tooth extraction and the results of their application.

Diagnosis of Alzheimer's Disease Based on Deeply-Fused Nets.

Fast and accurate diagnosis of Alzheimer's disease is very important for the care and further treatment of patients. Along with the development of deep learning, impressive progress has also been made in the automatic diagnosis of AD. Most existing studies on automatic diagnosis are concerned with a single base network, whose accuracy for disease diagnosis still needs to be improved. This study was undertaken to propose a method to improve the accuracy of the automatic diagnosis of AD. MRI image data from the Alzheimer's Disease Neuroimaging Initiative were used to train a deep learning model to achieve a computer-aided diagnosis of Alzheimer's disease. The data consisted of 138 with AD, 280 with mild cognitive impairment, and 138 normal controls. Here, a new deeply-fused net is proposed, which combines several deep convolutional neural networks, thereby avoiding the error of a single base network and increasing the classification accuracy and generalization capacity. Experiments show that when differentiating between patients with AD, mild cognitive impairment, and normal controls on a subset of the ADNI database without data leakage, the new architecture improves the accuracy by about 4 percentage points as compared to a single standard based network. This new approach exhibits better performance, but there is still much to be done before its clinical application. In the future, greater research effort will be devoted to improving the performance of the deeply-fused net.

The Importance of High Quality Discharge Letters: An Empirical Investigation

The discharge letter is part of the discharge management. This study empirically examines the quality of discharge letters after a stay in a psychiatric/psychosomatic clinic using a self-developed code list. Suggestions are made for the creation and structuring of high-quality discharge letters that provide information to practitioners and institutions that should help in the seamless further treatment of patients. Different aspects of the social-psychiatric and social-medical assessments in 50 discharge letters were evaluated by 2 raters each; in case of disagreements in evaluation, a consensus was reached. The average time between discharge from hospital and completion of the discharge letter was 22.4 days (median: 15.0 days). In 18% of cases, the letter of discharge was available at the time of discharge and in 14% within one week. In 24% of cases, the letter of discharge was only available after 27 days or longer. In 97.5% of the cases, the medication was completely listed, but in 52% of the cases, there was no information on further medical treatment by the specialist. When further treatment was recommended (n=10, e. g. day clinic or PIA), it was initiated in only three cases. At the time of admission, 28 patients had a job. Information on the employment status of 11 patients was missing. Information on the ability to work at the time of admission was complete in 44% and incomplete in 20%. At the time of discharge, seven patients were able to work, 19 were incapacitated and information on work ability was missing in the discharge report of 24 patients. A high quality discharge letter contains clear formulations, is structured, contains only relevant information and a separate chapter "Therapy recommendations/recommendations for further action". Electronic discharge letters with automated inclusion of examination findings/assessments save time and money during preparation and reading.

671 SENTINEL LYMPH NODE SAMPLING AND EMPIRIC CHEMORADIATION AS AN ORGAN SPARING APPROACH AFTER ENDOSCOPIC RESECTION OF INTERMEDIATE RISK EARLY FOREGUT CANCERS: A US PILOT STUDY

For low risk early foregut cancers, endoscopic submucosal dissection (ESD) is curative. For high-risk cancers, esophagectomy/gastrectomy is required for definitive staging and treatment. For ‘intermediate risk’ patients at ∼5-20% risk of lymph node (LN) metastasis, however, local resection in conjunction with systemic therapy could rival radical surgery. In this context, after local resection, Sentinel LN sampling (SLNS) may offer added value compared to a ‘wait and watch’ or ‘empiric chemotherapy’ approach. SLNS has not been used in clinical practice after ESD of T1 Barrett’s cancers. For gastric cancers it represents an emerging technique limited to Asia. We report the 1st US pilot study on SLNS after ESD for these foregut cancers. Patients who had ESD for T1 Barrett’s or gastric carcinomas and met both criteria below were offered SLNS: 1) ESD pathology with high-risk T1 cancer (deep invasion; lymhovascular invasion, G3,4 grade). 2) Patient with high surgical risk or refusing surgery. Indocyanine green (ICG) was injected endoscopically in the submucosa around the ESD site intra-operatively and fluorescent LNs were harvested including paraesophageal/EGJ stations in Barrett’s patients. Pts with positive SLNs and high-risk patients with negative SLNs were offered adjuvant therapy. 10 pts received ESD with SLNS. Mean age 70 (50-79). 9 males. The ASA class was 3 in 8 and 2 in 2 patients. There were 7 EGJ Barrett’s cancers (5 with T1a m3 invasion as the only risk factor) and 3 gastric cancers. We consider Barrett’s T1a m3 carcinomas as high-risk based on reports of LN involvement in up to 5%. Our finding of a positive SLN in 1/5 of these patients supports this. Median cancer size 1.3 cm (0.5-3.5). Grade: G1 in 4 patients, G2 in 5 and G4 in 1. T stage was T1a m3 in 5 and T1b in 5. R0 ESD achieved in 8 patients. SLNS was successful in all patients and returned a median of 9 LNs (4-20). 9 pts discharged on the same day and 1 on the next day. No significant adverse events. 4 patients had positive SLNs (1 N1, 2 N2, and 1 N3) and received adjuvant chemotherapy +/- radiation. Of the 6 N0 patients 1 received a 2nd ESD for indeterminate lateral margin and one with SM2 Barrett’s cancer and only 4 SLNs sampled was offered chemotherapy. After a median follow-up of 30 months (range 15-64), 8 patients including all 6 with negative SLNs were in remission. 2/4 patients with positive SLNs died, one from disseminated cancer, and one while in remission, from unrelated cause. This pilot study in patients with ESD of T1 Barrett’s and gastric cancers with high risk histologic features suggests potential feasibility of SLNS to risk-stratify and direct further treatment in patients in whom the standard of care of organ resection and lymphadenectomy is not possible due to high surgical risk or patient preference.

Safety and accuracy of frameless electromagnetic-navigated (AXIEMTM)-guided brain lesion biopsies: a large single-unit study.

Brain biopsies are required to establish a definitive histological diagnosis for brain lesions that have been identified on imaging in order to guide further treatment for patients. Various navigation systems are in use but little up to date evidence is available regarding the safety and accuracy of a frameless, electromagnetic technique to target brain lesions. Data was collected retrospectively on all patients that had brain biopsies at our institution from 01/01/2010 to 31/12/2017. Operation notes, neuropathology reports, and clinical notes on electronic patient record were used to determine whether biopsy of adequate identifiable abnormal tissue was achieved, whether a definitive diagnosis was established, any adverse events occurred, and if a repeat biopsy was carried out. Three hundred seventy-one AxiEM (Medtronic, Minneapolis, USA)-guided brain tumor biopsies were performed in this 8-year period. Three hundred forty-nine (94.07%) procedures provided definitive tissue diagnosis, 22 (5.93%) were non diagnostic; in 6 cases (1.62%), repeat biopsy was performed and adverse events which caused clinical compromise were observed in 4 patients (1.08%). The AxiEM is a fast, effective, and safe frameless and pinless neuronavigational system. It offers a high degree of accuracy required for the establishment of a definitive diagnosis, permitting optimal further treatment, and thus improving patient outcomes.

Decision-making in temporal lobe epilepsy surgery based on invasive stereo-electroencephalography (sEEG).

In medical refractory temporal lobe epilepsy (TLE), the epileptogenic zone can be difficult to identify and therefore difficult to treat, especially in the absence of clear MRI pathologies and specific results from presurgical evaluation. Invasive monitoring with stereo-electroencephalography (sEEG) is a tool for a better determination of the epileptogenic zone. Here, we investigate the impact of sEEG on decision-making in temporal lobe epilepsy surgery. We reviewed patients with TLE who underwent further investigation with sEEG in our epilepsy unit. We examined specifically how sEEG findings influenced our decision regarding indication for a surgical procedure and resection volume. From 2013 to 2017, we performed 152 temporal resections in epilepsy patients. Twenty-one of these patients were designated for further preoperative investigation with sEEG due to incongruent findings in presurgical evaluation. Six patients were implanted bitemporally. In five cases, the hypothesis for the epileptogenic zone and localization had to be changed due to sEEG findings and resulted in a different tailored resection than intended. In three cases, sEEG findings led to the cancelation of the originally intended temporal resection as the epileptogenic zone was not definable or bilateral. In another three cases, the prognosis for reduction of seizures postoperatively had to be reduced due to the sEEG findings. However, the resection was performed after interdisciplinary discussion and informed consent of the patient. The examination by sEEG led to a change of plan for further treatment in 13 patients (61.9%) suffering TLE in total. Invasive monitoring with sEEG electrodes had a strong impact on decision-making for further treatment in patients suffering from temporal lobe epilepsy with incongruent findings in presurgical examination designated for epilepsy surgery. This applies to resection volumes as well as to prediction of seizure outcome.

Research on intelligent assistant diagnosis method of CT image for lung nodule based on mobile computing

Mobile computing techniques have facilitated our life greatly, but it is rarely used in medical computing. The automatic diagnosis of benign and malignant pulmonary nodules is of great significance for the further treatment of patients. Therefore, taking the three-dimensional nature of clinical pulmonary nodules into account, in a mobile computing environment, an algorithm that combines three-dimensional deep and visual features (CTDDV) is proposed to achieve the classification of benign and malignant pulmonary nodules. In the new framework, deep features, visual features as well as shape descriptors were extracted using different three-dimensional algorithms. Then, Multiple Kernel Adaboost (MKAdaboost) classifiers were trained for each type of feature, and the results of the three classifiers were combined to distinguish lung nodules. We compared the four most advanced nodule classification methods on the LIDC-IDRI dataset. The results showed that our proposed CTDDV algorithm has achieved higher classification performance.

Case Report of a 12-Year-Old Girl with Imperforate Hymen—Review of the Literature on Incision Techniques and Further Treatment of Patients

Background: Imperforate hymen (IH) is formed if no canal is created between the vaginal plate and the urogenital sinus. Treatment of IH is surgical. Different types of incisions and postoperative treatment are proposed. Case: A 12-year-old girl presented with a 3-day history of pain in the lower abdomen. Examination of the external genitalia disclosed a bulging hymen. Ultrasound examination of her lower abdomen revealed hematocolpos. A diagnosis of hematocolpos caused by IH was established and surgical treatment was decided. Conclusion: Treatment of choice for IH is undeniably surgical. Although different types of procedures have been proposed, the surgeon should choose the one that best suits the patient’s needs without harming anatomical structures closely related to the hymen.

Guidelines for the diagnosis and management of primary central nervous system diffuse large B-cell lymphoma.

Guidelines for the diagnosis and management of primary central nervous system diffuse large B-cell lymphoma.

Immune check point inhibitors for metastatic urothelial carcinoma: current evidence-based approach for urology daily practice.

Treatment strategy for inoperable and metastatic urothelial carcinoma (mUC) has been revolutionized by the introduction of programmed cell death protein 1 (PD-1) and programmed cell death protein ligand (PD-L1) antibodies. During the last 3 decades treatment options were limited to chemotherapy, making further treatment of patients whose disease progressed under ongoing therapy or who were ineligible to receive cytotoxic therapy in the first place, nearly impossible. Five antibodies including pembrolizumab (PD-L1 antibody), atezolizumab (PD-1 antibody), nivolumab (PD-1 antibody), avelumab and durvalumab (PD-L1 antibodies) have been approved in the treatment of advanced urothelial carcinoma in first- and second-line treatment setting. The objective of this review was to examine and compare the different cohorts and to discuss the quality of the respective studies in order to set up selection criteria for clinical decision making. So far pembrolizumab and atezolizumab have demonstrated overall survival (OS) benefit in phase II studies and have shown superiority over standard chemotherapy in phase III studies which has granted them approval in first and second-line treatment setting. Improved OS and durable responses were also seen in phase Ib/II non-randomized, single-arm trials conducted with nivolumab, avelumab and durvalumab and granting accelerated approval for second-line treatment. The huge advantage of immunotherapy and one of the reasons for its overall recognition is its good tolerability profile especially in comparison to chemotherapy. Pembrolizumab has to be recommended in second-line therapy due to reporting in a phase III trial and OS survival benefit compared to chemotherapy control group. In cisplatin-eligible and treatment-naïve patients with visceral or liver metastases data also slightly favors pembrolizumab rather than atezolizumab.

Efficacy and safety assessment of apatinib in patients with advanced gastric cancer: a meta-analysis.

AimThis meta-analysis was performed to evaluate the efficacy and safety of apatinib in patients with advanced gastric cancer (AGC).MethodsAfter evaluating the inclusion and exclusion criteria, the data of eligible randomized clinical trials (RCTs) were extracted. Outcomes including objective response rate (ORR), disease control rate (DCR), and adverse events (AEs) were analyzed in the meta-analysis.ResultsData of 1,069 patients from 13 RCTs were statistically analyzed. Pooled odds ratio (OR) for ORR and DCR was found to be 0.46 (95% confidence interval [CI]: 0.33, 0.64; P<0.00001) and 0.23 (95% CI: 0.15, 0.36; P<0.00001), respectively. Compared with placebo, apatinib showed statistical significance in AEs at any grade, including leucopenia, neutropenia, thrombocytopenia, diarrhea, hypertension, proteinuria, hand-foot syndrome, and fatigue (all P<0.05).ConclusionThe results of our meta-analysis revealed that apatinib shows short-term efficacy over no-apatinib regimens or placebo regardless of its use as first- or second-line chemotherapy or for further treatment in patients with AGC accompanied with apparent AEs of any grade.

The cost-effectiveness of immediate treatment or watch and wait with deferred chemotherapy for advanced asymptomatic follicular lymphoma.

Recent evidence has shown that immediate treatment with rituximab induction, with and without maintenance, substantially reduces the need for further treatment in patients with advanced asymptomatic follicular lymphoma. This analysis estimates the cost-effectiveness of immediate treatment approaches in comparison to a watch and wait approach from the perspective of the UK National Health Service. A Markov decision model was developed to estimate the cost-effectiveness of treatment strategies in patients with asymptomatic follicular lymphoma. The model was populated using effectiveness data from a systematic literature review with the key clinical data sourced from a randomised trial, in which the treatment strategies were compared. Costs were estimated using UK national sources. In comparison to watchful waiting, both rituximab strategies were found to be more effective and cost saving. In comparison to rituximab induction, the addition of rituximab maintenance marginally increased effectiveness but substantially increased costs, resulting in an incremental cost-effectiveness ratio (ICER) of £69406 per quality-adjusted life year (QALY). In probabilistic sensitivity analysis, rituximab induction was found to have a 68% probability of being cost-effective at a threshold of £20000 per QALY. In conclusion, active treatment with rituximab induction is a cost-effective strategy to adopt in patients with asymptomatic follicular lymphoma.

An update on cladribine for relapsing-remitting multiple sclerosis

ABSTRACTIntroduction: Despite recent progress, currently available therapies for relapsing remitting multiple sclerosis (MS) are only partly effective, and their use is limited by tolerability and safety issues, as well as high cost. Cladribine was originally rejected by the regulatory authorities in both the European Union and USA in 2011, but in June 2017 the European Medical Agency recommended marketing authorization for treatment of aggressive relapsing MS.Areas covered: We provide an update on chemistry, mechanism of action, efficacy and safety of cladribine for the treatment of MS.Expert opinion: Cladribine is well tolerated, it is dosed orally in cycles of one year, the need for regular blood testing during treatment is likely limited, and the two-year efficacy data for treatment of relapsing MS are at least in the same range as the most efficient licensed treatments. The increased risk of malignancies reported in the pivotal trial seems to be caused by unexpectedly low numbers of malignancies in the placebo group. Cladribine could therefore be an alternative for many patients with relapsing remitting MS. The main caveat is the lack of long term efficacy and safety data. Currently there are insufficient data to guide further treatment of patients who have completed two treatment cycles of cladribine.