Total thyroidectomy alone versus ipsilateral versus bilateral prophylactic central neck dissection in clinically node-negative differentiated thyroid carcinoma. A retrospective multicenter study

Background

Central neck dissection (CND) remains controversial in clinically node-negative differentiated thyroid carcinoma (DTC) patients. The aim of this multicenter retrospective study was to determine the rate of central neck metastases, the morbidity and the rate of recurrence in patients treated with total thyroidectomy (TT) alone or in combination with bilateral or ipsilateral CND.

Enhanced recovery after surgery (ERAS) versus standard recovery for elective gastric cancer surgery: A meta-analysis of randomized controlled trials

Enhanced recovery after surgery (ERAS) protocols have been effective in improving postoperative recovery after major abdominal surgeries including colorectal cancer surgery, however its impact after gastric cancer surgery is unclear. A systematic review and meta-analysis was conducted to evaluate the effect of ERAS after gastric cancer surgery. Medline, EMBASE, CENTRAL, and PubMed was searched from database inception to December 2018. Randomized controlled trials (RCTs) comparing ERAS versus standard care in gastric cancer surgery were included. Outcomes included the postoperative length of stay (LOS), hospital costs, time to first flatus, defecation, oral intake, and ambulation after surgery, and complications. Pooled estimates were calculated using random-effects meta-analysis. The GRADE approach assessed overall quality of evidence. 18 RCTs involving 1782 patients were included. ERAS significantly reduced the LOS (Mean Difference (MD) −1.78 days, 95%CI -2.17 to −1.40, P < 0.0001), reduced hospital costs (MD -650 U S. dollars, 95%CI -840 to −460, P < 0.0001), and reduced time to first flatus, defecation, ambulation, and oral intake. ERAS had significantly lower rates of pulmonary infections (Risk Ratio (RR) 0.48, 95%CI 0.28 to 0.82, P = 0.007), but not surgical site infections, anastomotic leaks, and postoperative complications. However, ERAS significantly increased readmissions (RR 2.43, 95%CI 1.09 to 5.43, P = 0.03). The quality of evidence was low to moderate for all outcomes. Implementation of an ERAS protocol may reduce LOS, costs, and time to return of function after gastric cancer surgery compared to conventional recovery. However, ERAS may increase the number of postoperative readmissions, albeit with no impact on the rate of postoperative complications.     

Radical neck dissection for cancer of the oral cavity

160 radical neck dissections (RND) were performed on 154 patients with cancer of the oral cavity in which cancer of the tongue predominated. The 3-, 5- and 10-year survival rates of these patients were 62.9%, 58.3% and 36.2%, respectively. Those with advanced lesions or positive lymph nodes had poor prognosis. The lymph nodes commonly involved were the submaxillary and the upper deep cervical nodes but "jumping" metastasis to the lower cervical nodes was observed. Elective radical neck dissection is advised for cancer of the tongue. The Survival rate of the patients treated by preoperative irradiation plus RND is higher than that by surgery alone. Proper management of the postoperative complications and regular follow-up of the patients are suggested.     

Laparoscopic versus open colorectal resection for cancer: A meta-analysis of results of randomized controlled trials on recurrence

Aims

Laparoscopic resection for colorectal cancer remains controversial. This is because it is uncertain whether recurrence rates after laparoscopic-assisted surgery is comparable to those reported after open surgery. We performed a meta-analysis of the published literature in an attempt to answer this question.

Methods

Eligible articles were identified by searches of MEDLINE, EMBase and the Cochrane database. Prospective randomized clinical trials were eligible if they included patients with colorectal cancer treated by laparoscopic surgery versus open surgery and followed for recurrence.

Results

Ten trials with information on disease recurrence on 2474 patients were included. In the combined results, no statistically significant difference in the OR for overall recurrence between the laparoscopic surgery and open surgery group was found (OR 0.93, 95% CI 0.71–1.21, P = 0.58). Stratified by recurrence type, the combined results of the individual reports show no statistically significant difference for local recurrence (OR 0.80, 95% CI 0.50–1.29, P = 0.36), distant metastases (OR 0.90, 95% CI 0.62–1.29, P = 0.56) and port or wound-site recurrence (OR 1.04, 95% CI 0.18–6.03, P = 0.97) between the two surgical techniques.

Conclusion

This meta-analysis supports that the recurrence rates for patients with colorectal cancer treated by laparoscopic surgery do not differ from those for open surgery. Longer follow-up studies will further define outcomes, comparing the two techniques in the treatment of colorectal cancer.     

Should an elective contralateral neck dissection be performed in midline-reaching squamous cell carcinomas of the oral cavity and oropharynx?

Objectiveto compare the rate of occult contralateral neck metastases (OCNM) in oral and oropharyngeal squamous cell carcinomas (SCC) reaching or crossing the midline and to identify risk factors for OCNM.Materials and methodswe conducted a single-center retrospective study of oral and oropharyngeal SCC with contralateral cN0 neck. The cohort was divided into a midline-reaching (MR; approaching the midline from up to 10 mm) group and a midline-crossing (MC; exceeding the midline by up to 10 mm) group. Clinical N-status was assessed by a radiologist specializing in head and neck imaging. All patients underwent contralateral elective neck dissection (END).ResultsA total of 98 patients were included in this study, 59 in the MR group and 39 in the MC group. OCNM were present in 17.3% of patients, 20.3% in the MR group and 12.8% in the MC group (p = 0.336). In multivariable analysis, MR/MC status as well as distance from the midline (in mm) were not identified as risk factors for OCNM. Conversely, oropharyngeal primary and clinical N-status above N1 were significantly associated with a higher risk of OCNM, with odds ratios (OR) of 3.98 (95% CI = 1.08–14.60; p = 0.037) and 3.41 (95% CI = 1.07–10.85; p = 0.038) respectively.Conclusionin patients with oral and oropharyngeal SCC extending close to or beyond the midline, tumor origin and clinical N-status should carry the most weight when dictating the indications for contralateral END, rather than the midline involvement in itself.     

Stage I-II squamous cell carcinoma of the oral cavity treated by iridium-192: is elective neck dissection indicated?

This is a retrospective analysis of 233 evaluable patients with stage I-II squamous cell carcinoma of the oral cavity treated by definitive branchytherapy. Minimum follow-up is 3 years. Treatment of neck was chosen by a multidisciplinary team, according to age, medical status and availability for regular follow-up. One hundred and ten patients (47%) underwent elective neck dissection (END); 28 (25%) had positive nodes and received neck irradiation post-operatively. One hundred and twenty three patients (53%) were regularly followed up only, with therapeutic neck dissection (TND) reserved for cases of node relapses. In the END group, there were 19 neck relapses (17%): 12/60 (20%) in patients with mobile tongue carcinoma and 7/50 (14%) in patients with floor of the mouth carcinoma. Salvage treatment was successful in 9/19 (47%) cases. In the TND group, there were 21 neck relapses (17%): 16/82 (20%) in patients with mobile tongue carcinoma and 5/41 (10%) in patients with floor of the mouth carcinoma. Salvage treatment was successful in 13/21 (62%) cases. Ten-year survival is 37% for the END group and 31% for the TND group. Tumour stage and infiltration into underlying tissues increased the probability of neck relapse and death. Furthermore, a multivariate analysis showed that patients treated in the TND group had a higher probability of death than patients treated in the END group (p less than 0.04).     

Addressing the contralateral neck for ipsilateral disease recurrence in oral cavity cancers

BackgroundEvidence for performing contralateral neck dissection (CND) of recurrent oral cavity squamous cell cancers (OCSCC) is lacking.Material and methodsThis is a retrospective study of 78 consecutive OCSCC having ipsilateral recurrence recorded over five years. We screened 1658 OCSCC patients and selected those patients who underwent CND as part of treatment for ipsilateral recurrence.ResultsThe median disease-free interval was 32 months. Incidence of contralateral nodal metastasis (CNM) in recurrent OCSCC was 23.1% and of which 14% were occult. The factor significantly influencing CNM was the depth of invasion (DOI) > 10 mm (p < 0.01). In our study, imaging had suboptimal PPV (33%) while it had high NPV (88%) in diagnosing nodal metastasis in recurrent OCSCC.ConclusionDOI is the most important factor predicting CNM in case of ipsilateral primary recurrence. PET-CECT has a high NPV and contralateral neck should be addressed in case of tumours with higher DOI.     

Pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy: A meta-analysis of randomized control trials

Background

Postoperative pancreatic fistula (PF) is the leading morbidity after pancreaticoduodenectomy (PD). The pancreatoenteric anastomosis method after PD is associated with the occurrence of PF. Evidence shows that pancreaticogastrostomy (PG) is possibly superior to pancreaticojejunostomy (PJ) in reducing the incidence of PF after PD; however, this remains to be definitively confirmed.

Methods

Randomized clinical trials (RCTs) comparing the outcomes of PG versus PJ after PD were retrieved for meta-analysis.

Results

After a thorough search of the English literature published until March 23rd, 2014, we identified seven RCTs involving 1095 patients (PG group, 548; PJ group, 547) for final analysis. Meta-analysis revealed that the incidence of PF was significantly lower in the PG group (15.7%) than in the PJ group (23.0%, 126/547; OR = 0.61, 95% CI: 0.45–0.83, P = 0.002). Furthermore, the incidence of intra-abdominal fluid collection was also lower in the PG group than in the PJ group (OR = 0.43, 95% CI: 0.28–0.65, P < 0.0001). No significant differences were found between the PG and PJ groups in terms of delayed gastric emptying, hemorrhage, overall morbidity and mortality.

Conclusions

PG seemed to be superior to PJ in reducing the incidence of PF and intra-abdominal fluid collection after PD.     

Prophylactic action of oral fluconazole against fungal infection in neutropenic patients. A meta-analysis of 16 randomized, controlled trials

BACKGROUND: Fluconazole is used widely for fungal prophylaxis. Although studies with bone marrow transplantation (BMT) recipients clearly showed the usefulness of oral fluconazole, results of the studies in neutropenic patients other than BMT recipients have been inconsistent. Therefore, the authors performed a meta-analysis to evaluate the efficacy of fluconazole prophylaxis during chemotherapy-induced neutropenia. METHODS: The authors identified reports that were not restricted to those in English and not restricted to published trials through MEDLINE, CANCERLIT, or the data base of the Pfizer company. The authors included prospective, randomized studies comparing oral fluconazole with placebo, no treatment, or oral polyenes as prophylaxis for fungal infections in neutropenic patients. Two independent authors extracted data from 16 trials with 3734 patients enrolled. The outcome measures were the development of fungal-related death, systemic and superficial fungal infections, the use of empiric intravenous amphotericin-B, and infections or colonization with fluconazole-resistant fungi. The summarized odds ratios (ORs) were calculated using the Mantel-Haenszel method and the DerSimonian-Laird method. RESULTS: Prophylactic fluconazole was not effective in reducing fungal-related death or in reducing proven, systemic fungal infections in non-BMT patients (OR, 0.91; 95% confidence interval [CI], 0.30-2.82 and OR, 0.85; 95% CI, 0.47-1.55, respectively). However, fluconazole was very effective in reducing superficial fungal infections (OR, 0.44; 95% CI, 0.24-0.80), even when it was given in lower doses (50-200 mg per day). There was no increase in proven, systemic infection of fluconazole-resistant fungi, although colonization of those fungi increased. When the results were combined in studies in which the incidence of systemic fungal infections was > 15%, fluconazole was effective in reducing such infections (OR, 0.23; 95% CI, 0.15-0.36). CONCLUSIONS: The current analyses failed to find an effect of fluconazole on both fatal fungal infection and systemic fungal infection in non-BMT patients. Further studies on severely neutropenic patients are warranted because prophylactic fluconazole seemed to be effective when the incidence of systemic fungal infection was expected to be > 15%.     

Cetuximab-based therapy versus non-cetuximab therapy for advanced cancer: a meta-analysis of 17 randomized controlled trials

Purpose

To assess the efficacy and safety of cetuximab-based therapy versus non-cetuximab therapy for advanced cancer.

Methods

A total of 7,954 patients from 17 randomized controlled trials are identified, with 3,965 patients in the cetuximab group and 3,989 patients in the non-cetuximab group. The outcome was progression-free survival (PFS), overall survival (OS), overall response rate (ORR), and grade 3/4 advent events.

Results

There was a significant improvement of PFS (HR 0.83, 95%CI 0.78–0.88), OS (HR 0.89, 0.84–0.95), and ORR in the cetuximab group (OR 1.39, 1.22–1.58). In subgroup analysis, in colorectal cancer, there was a significant improvement of PFS (0.72, 0.66–0.78), OS (0.90, 0.81–1.00), and ORR in the cetuximab group (1.36, 1.15–1.60). In head and neck carcinoma, there was a significant improvement of PFS (0.63, 0.54–0.73), OS (0.78, 0.67–0.91), and ORR in the cetuximab group (1.57, 1.15–2.16). In non-small-cell lung cancer, there was a significant improvement of OS (0.86, 0.76–0.96) in the cetuximab group, and no difference on PFS (0.82, 0.64–1.07) and ORR (1.56, 0.85–2.88). In pancreatic cancer, there was no difference on PFS (1.11, 0.97–1.28), OS (1.07, 0.93–1.25), and ORR (0.94, 0.66–1.33). There were higher incidences of grade 3–4 toxicity (OR 1.84), skin-related toxicity (OR 31.80), acneiform rash (OR 30.14), and hypomagnesemia (OR 6.72) in the cetuximab group.

Conclusions

Cetuximab-based therapy improved PFS and OS, and better ORR versus non-cetuximab therapy. The severe adverse events should be predictable and manageable.     

Short-duration versus 1-year adjuvant trastuzumab in early HER2 positive breast cancer: A meta-analysis of randomized controlled trials

BackgroundOne year of adjuvant trastuzumab treatment is the standard of care for early stage human epidermal growth factor receptor 2 (HER2)-positive breast cancer patients; however, controversy remains regarding the optimal schedule of trastuzumab because the selection of the 1-year schedule was arbitrary. After the remarkable results of the PERSEPHONE trial as well as the updated final results of the PHARE trial, we performed an updated meta-analysis to reassess the efficacy and safety of shorter durations of trastuzumab.MethodsA literature search of databases was conducted to identify randomized controlled trials reporting the efficacy and cardiotoxicity of shorter-duration and standard 1-year trastuzumab treatment. The hazard ratios (HRs) of disease-free survival (DFS) and overall survival (OS), and the odds ratios (ORs) of cardiac events were also estimated and pooled.ResultsSix studies were eligible, including a total of 11,496 patients. Both DFS (HR = 1.13; 95% confidence interval [CI] = 1.03–1.25; p = 0.01) and OS (HR = 1.16; 95% CI = 1.01–1.32; p = 0.03) were significantly improved with conventional 1-year trastuzumab treatment compared with shorter treatments. The more pronounced survival benefits observed in patients with negative estrogen receptor (ER) tumor and nodal involvement should be interpreted cautiously because of the lack of interaction between the survival benefit and ER, as well as the nodal status (interaction test, ER status: p = 0.26; nodal status: p = 0.60). One year of trastuzumab treatment resulted in a substantial DFS benefit compared with shorter schedules when administered concurrently with chemotherapy (HR = 1.22; 95% CI = 1.09–1.38; p = 0.0008; p = 0.02 for the interaction test). Patients in the shorter duration group experienced significantly fewer cardiac events (OR = 0.52; 95% CI = 0.43–0.62; p < 0.00001).ConclusionsThough correlated with an increasing risk of cardiotoxicity, 1 year of adjuvant trastuzumab treatment conferred substantial survival benefits and should remain as the preferred treatment for early stage HER2-positive breast cancer. Shorter durations of trastuzumab may serve as an alternative choice for patients with cardiac disease and those at lower risk of recurrence.     

The role of elective pelvic radiotherapy in clinically node-negative prostate cancer: A systematic review

The role of elective radiotherapy of the pelvic nodal regions in clinically node-negative prostate cancer patients remains highly controversial. This review will address the difficulty of non-invasive nodal staging, even with more advanced imaging techniques, and will show that surgical staging still finds a relatively high percentage of patients with intermediate- or high-risk prostate cancer that have microscopic tumor invasion in the pelvic nodes. Finally, an overview of the current literature on elective pelvic irradiation will be provided.     

Treatment of community-acquired pneumonia with moxifloxacin: a meta-analysis of randomized controlled trials

Abstract

Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality throughout the world. To investigate whether moxifloxacin monotherapy is associated with better clinical outcomes than other antibiotics recommended for CAP among adults with mild-to-moderate or severe CAP, we performed a meta-analysis. MEDLINE, EMBASE, Web of Science, and the Cochrane Library were searched for randomized control trials (RCTs). The efficacy and safety of moxifloxacin were compared with other antimicrobial agents used to treat CAP. Fourteen RCTs, consisting of 6923 total patients, were included in the meta-analysis. No difference was found regarding the incidence of adverse events and mortality between moxifloxacin and the compared regimens. We found that moxifloxacin is as effective and well-tolerated as other recommended antibiotics for the treatment of CAP and possesses a better pathogen eradication rate than beta-lactam-based therapy.     

Chemotherapy alone versus chemotherapy followed by consolidative radiotherapy for limited-stage aggressive non-Hodgkin's lymphoma: A meta-analysis of randomized controlled trials

ObjectiveTo systematically investigate chemotherapy versus chemotherapy followed by involved field radiotherapy for limited-stage aggressive non-Hodgkin's lymphoma.MethodA systematic literature search of Pubmed, EMBASE, and the Cochrane central register of controlled trials was performed. Data from all randomized controlled trials comparing chemotherapy alone with chemotherapy followed by involved field radiotherapy in patients with limited-stage aggressive non-Hodgkin's lymphoma was collaborate. The primary outcome was overall survival; secondary outcomes were event-free survival and cumulative incidences of toxicity.ResultsThree randomized controlled trials, with 1263 participants in total, were analyzed. Median follow-up was 11 years. Patients receiving chemotherapy followed by involved field radiotherapy had a significant benefit on event-free survival (hazards ratio [HR] = 1.47, 95% confidence interval [CI]: 1.14 to 1.90; P = 0.003), but not improved overall survival (HR = 1.00, 95% CI: 0.80 to 1.25; P = 0.978) at 8 years, in relation to those in the chemotherapy alone arm. There were great differences in the reporting of cumulative incidences of toxicity.ConclusionChemotherapy followed by involved field radiotherapy, as compared with chemotherapy alone, is associated with better event-free survival, but no survival benefit is observed for patients for limited-stage aggressive non-Hodgkin's lymphoma. These results needed to be confirmed by high quality trials and further studies in the East.