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[Meta-analysis of laparoscopic versus open surgery for palliative resection of the primary tumor in stage IV colorectal cancer].
Tan, SJ, Jiang, Y, Xi, QL, Meng, QY, Zhuang, QL, Han, YS, Wu, GH
Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery. 2020;(6):589-596
Abstract
Objective: To systematically evaluate the safety and efficacy of laparoscopic versus open surgery for palliative resection of the primary tumor in stage IV colorectal cancer. Methods: The databases of CNKI, Wanfang, VIP, PubMed, EMBASE and Cochrane Library were searched to retrieve randomized controlled trials (RCT) or clinical controlled trials (CCT) comparing laparoscopic surgery with open surgery for palliative resection of the primary tumor in stage IV colorectal cancer published from January 1991 to May 2019. Chinese search terms included "colorectum/colon/rectum" , "cancer/malignant tumor" , "laparoscopy" , "metastasis" , " IV" ; English search terms included "laparoscop*" , "colo*" , "rect*" , "cancer/tumor/carcinoma/neoplasm" , " IV" , "metasta*" . Inclusion criteria: (1) RCT or CCT, with or without allocation concealment or blinding; (2) patients with stage IV colorectal cancer that was diagnosed preoperatively and would receive resection of the primary tumor; (3) the primary tumor that was palliatively resected by laparoscopic or open procedure. Exclusion criteria: (1) no valid data available in the literature; (2) single study sample size ≤20; (3) subjects with colorectal benign disease; (4) metastatic resection or lymph node dissection was performed intraoperatively in an attempt to perform radical surgery; (5) duplicate publication of the literature. Two researchers independently evaluated the quality of the included studies. In case of disagreement, the evaluation was performed by discussion or a third researcher was invited to participate. The data were extracted from the included studies, and the Cochrane Collaboration RevMan 5.1.0 version software was used for this meta-analysis. Results: Four CCTs with a total of 864 patients were included in this study, including 216 patients in the laparoscopic group and 648 patients in the open group. Compared with the open group, except for longer operation time (WMD=37.60, 95% CI: 26.11 to 49.08, P<0.05), laparoscopic group had less intraoperative blood loss (WMD=-74.89, 95% CI: -144.78 to -5.00, P<0.05), earlier first flatus and food intake after surgery (WMD=-1.00, 95% CI: -1.12 to -0.87, P<0.05; WMD=-1.61, 95%CI: -2.16 to -1.06, P<0.05), shorter hospital stay (WMD=-2.01, 95% CI: -2.21 to -1.80, P<0.05) and lower morbidity of postoperative complication (OR=0.52, 95% CI: 0.35 to 0.77, P<0.05). However, no significant differences were found in time to start postoperative chemotherapy, postoperative chemotherapy rate, and mortality (P > all 0.05). Conclusion: Laparoscopic surgery for palliative resection of the primary tumor is safe and feasible to enhance recovery after surgery by promoting postoperative bowel function recovery, shortening hospital stay and reducing postoperative complication in stage IV colorectal cancer.
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Comparative studies on the potential use of 177Lu-based radiopharmaceuticals for the palliative therapy of bone metastases.
Zakaly, HMH, Mostafa, MYA, Deryabina, D, Zhukovsky, M
International journal of radiation biology. 2020;(6):779-789
Abstract
Purpose: In recent years, radionuclides like 177Lu have been considered promising material for the creation of therapeutic radiopharmaceuticals. With the therapeutic use of radiopharmaceuticals, the absorbed doses per tumor may exceed 10 Gy. It is extremely important that doses absorbed by healthy organs and tissues do not exceed the threshold for the incidence of deterministic effects.Materials and methods: The potential use of the radionuclide lutetium-177 for the palliative treatment of pain in bone metastases is analyzed. The radionuclide 177Lu is a beta-emitting nuclide with a maximal energy of 0.49 MeV and a half-life of 6.6 days (161 h). Two therapeutic agents were considered: methylene diphosphonate (MDP) and ethylenediamine tetramethylene phosphonic acid (EDTMP). Both drugs contain phosphorus compounds in their composition, which ensures high tropism in bone tissue. For both drugs, biokinetic models of 177Lu's behavior in the human body are created. A number of studies have shown that the radiochemical stability of these drugs is about 99%: these calculations took into account the presence of a free 177Lu radionuclide in each solution. The absorbed doses in organs and tissues when using the radiopharmaceuticals 177Lu-MDP and 177Lu-EDTMP, as well as the currently used drugs 153Sm-EDTMP and 89SrCl2, are compared. In order to assess the risk of the patient's exposure to a radiopharmaceutical, the absorbed doses are calculated for each organ where the radioactive label is mainly deposited: the kidneys, red bone marrow, liver and bone surface.Results: The intensity of dose accumulation when using different drugs on the pathological focus is different. The drug 177Lu-MDP is faster than other drugs when it comes to the full realization of the expected dose; therefore, a therapeutic effect is achieved faster when it is used. The slowest absorbed dose accumulates when strontium chloride is used. To compare the effectiveness of preparations based on the 177Lu radionuclide, an analysis of the radiopharmaceuticals currently used for the palliative therapy of bone metastases (89SrCl2 and 153Sm-EDTMP) was performed. For 89Sr, the most vulnerable organs are the kidneys, red bone marrow and liver, while for 153Sm-EDTMP, red marrow bone is most vulnerable. For radiopharmaceuticals based on the 177Lu radionuclide, the most vulnerable organs are the kidneys, liver and red bone marrow. This proves the effectiveness of the 177Lu-MDP and 177Lu-EDTMP radiopharmaceuticals.Conclusions: According to the results of the calculations, 177Lu-EDTMP and 177Lu-MDP demonstrate the best results for the palliative therapy of bone metastases.
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Comparative study of self-expanding metal stent and intraluminal radioactive stent for inoperable esophageal squamous cell carcinoma.
Tian, D, Wen, H, Fu, M
World journal of surgical oncology. 2016;(1):18
Abstract
BACKGROUND We compared the effectiveness of self-expanding metal stent alone vs. radioactive stent embedded with 125I seeds implantation insertion in patients of inoperable esophageal squamous cell cancer combined with malignant esophageal stenosis. METHODS We studied two groups of patients with stenosis attribute to inoperable esophageal squamous cell carcinoma. Group A had placed self-expanding metal stent alone insertion; group B encountered radioactive stent embedded with 125I seeds. Patients were followed up by monthly home visits or telephone interview. Survival time was analyzed with Kaplan-Meier analysis. Log rank test was used to analyze factors of survival time for all significant differences. RESULTS There was no significant difference between the two groups of all baseline characteristics. There was no statistical difference in complications including massive hematemesis, pain more than 1 month, stent migration, and restenosis. Survival time and causes of death such as tumor metastasis, massive hemorrhage, non-tumor-related factors, and restenosis were comparable between the two groups (P>0.05). The medical costs were significantly less in group A than those in group B (P<0.01). CONCLUSIONS Radioactive stent embedded with (125)I seeds was not significant in improving survival rate, but showed to increase hospitalization costs compared to self-expandable metal stent alone in treating inoperable esophageal squamous cell carcinoma stricture.
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Improving Quality of Life for People with Incurable Large-Bowel Obstruction: Randomized Control Trial of Colonic Stent Insertion.
Young, CJ, De-Loyde, KJ, Young, JM, Solomon, MJ, Chew, EH, Byrne, CM, Salkeld, G, Faragher, IG
Diseases of the colon and rectum. 2015;(9):838-49
Abstract
BACKGROUND Surgery remains the dominant treatment for large-bowel obstruction, with emerging data on self-expanding metallic stents. OBJECTIVE The aim of this study was to assess whether stent insertion improves quality of life and survival in comparison with surgical decompression. DESIGN This study reports on a randomized control trial (registry number ACTRN012606000199516). SETTING This study was conducted at Royal Prince Alfred Hospital, Sydney, and Western Hospital, Melbourne. PATIENTS AND INTERVENTION Patients with malignant incurable large-bowel obstruction were randomly assigned to surgical decompression or stent insertion. MAIN OUTCOME MEASURES The primary end point was differences in EuroQOL EQ-5D quality of life. Secondary end points included overall survival, 30-day mortality, stoma rates, postoperative recovery, complications, and readmissions. RESULTS Fifty-two patients of 58 needed to reach the calculated sample size were evaluated. Stent insertion was successful in 19 of 26 (73%) patients. The remaining 7 patients required a stoma compared with 24 of 26 (92%) surgery group patients (p < 0.001). There were no stent-related perforations or deaths. The surgery group had significantly reduced quality of life compared with the stent group from baseline to 1 and 2 weeks (p = 0.001 and p = 0.012), and from baseline to 12 months (p = 0.01) in favor of the stent group, whereas both reported reduced quality of life. The stent group had an 8% 30-day mortality compared with 15% for the surgery group (p = 0.668). Median survival was 5.2 and 5.5 months for the groups (p = 0.613). The stent group had significantly reduced procedure time (p = 0.014), postprocedure stay (p = 0.027), days nothing by mouth (p = 0.002), and days before free access to solids (p = 0.022). LIMITATIONS This study was limited by the lack of an EQ-5D Australian-based population set. CONCLUSIONS Stent use in patients with incurable large-bowel obstruction has a number of advantages with faster return to diet, decreased stoma rates, reduced postprocedure stay, and some quality-of-life benefits.
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Feeding dysfunction in children with single ventricle following staged palliation.
Hill, GD, Silverman, AH, Noel, RJ, Simpson, PM, Slicker, J, Scott, AE, Bartz, PJ
The Journal of pediatrics. 2014;(2):243-6.e1
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Abstract
OBJECTIVE To determine the prevalence of feeding dysfunction in children with single ventricle defects and identify associated risk factors. STUDY DESIGN Patients aged 2-6 years with single ventricle physiology presenting for routine cardiology follow-up at the Children's Hospital of Wisconsin were prospectively identified. Parents of the patients completed 2 validated instruments for assessment of feeding dysfunction. Chart review was performed to retrospectively obtain demographic and diagnostic data. RESULTS Instruments were completed for 56 patients; median age was 39 months. Overall, 28 (50%) patients had some form of feeding dysfunction. Compared with a normal reference population, patients with single ventricle had statistically significant differences in dysfunctional food manipulation (P < .001), mealtime aggression (P = .002), choking/gagging/vomiting (P < .001), resistance to eating (P < .001), and parental aversion to mealtime (P < .001). Weight and height for age z-scores were significantly lower in subjects with feeding dysfunction (-0.84 vs -0.33; P < .05 and -1.46 vs -0.56; P = .001, respectively). Multivariable analysis identified current gastrostomy tube use (P = .02) and a single parent household (P = .01) as risk factors for feeding dysfunction. CONCLUSION Feeding dysfunction is common in children with single ventricle defects, occurring in 50% of our cohort. Feeding dysfunction is associated with worse growth measures. Current gastrostomy tube use and a single parent household were identified as independent risk factors for feeding dysfunction.
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[Is the pharmacological treatment of constipation in palliative care evidence based? : a systematic literature review].
Bader, S, Weber, M, Becker, G
Schmerz (Berlin, Germany). 2012;(5):568-86
Abstract
MATERIALS AND METHODS To evaluate the evidence for clinically established pharmacological therapies for constipation in palliative care, a systematic literature review was performed in different databases (Cochrane Library, Embase, PubMed, Ovid MEDLINE, CINAHL), textbooks, and publications. RESULTS Whereas 130 randomized controlled trials were found with patients outside of palliative care settings, only 10 controlled studies with patients in end-of-life situations were identified: three RCTs with methylnaltrexone and one with the combination of oxycodone and naloxone showed the effect and safety of opiate antagonists for patients who are not at risk of gastrointestinal perforation. There have been no studies which test methylnaltrexone against the optimization of therapy with conventional laxatives. Six other controlled studies of limited quality in design and execution and with only few participants tested naloxone, senna, lactulose, Co-danthramer, an Ayurvedic preparation (Misrakasneham), magnesium hydroxide, fluid paraffin, sodium picosulfate and docusate without finding statistically significant differences in efficacy or side effects. Most patients in these studies had cancer. Only case studies with few patients in palliative care were found for meglumine, neostigmine, and other substances mentioned above. CONCLUSION Evidence on medical treatment of constipation in palliative care is sparse and guidelines have to refer to evidence from outside the palliative care setting and to expert opinions. Results from studies with other patient groups can only be transferred with limitations to very ill patients at the end of life who might have a higher risk for potential side effects such as gastrointestinal perforation in case of abdominal tumor manifestation. Therefore further studies are required to evaluate the medical treatment of multiple reasons for constipation in these patients. These studies should focus on feasibility, clinical relevance and quality of life. The English full text version of this article will be available in SpringerLink as of November 2012 (under "Supplemental").
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Percutaneous palliation of pancreatic head cancer: randomized comparison of ePTFE/FEP-covered versus uncovered nitinol biliary stents.
Krokidis, M, Fanelli, F, Orgera, G, Tsetis, D, Mouzas, I, Bezzi, M, Kouroumalis, E, Pasariello, R, Hatzidakis, A
Cardiovascular and interventional radiology. 2011;(2):352-61
Abstract
The purpose of this study was to compare the clinical effectiveness of expanded polytetrafluoroethylene/fluorinated-ethylene-propylene (ePTFE/FEP)-covered stents with that of uncovered nitinol stents for the palliation of malignant jaundice caused by inoperable pancreatic head cancer. Eighty patients were enrolled in a prospective randomized study. Bare nitinol stents were used in half of the patients, and ePTFE/FEP-covered stents were used in the remaining patients. Patency, survival, complications, and mean cost were calculated in both groups. Mean patency was 166.0 ± 13.11 days for the bare-stent group and 234.0 ± 20.87 days for the covered-stent group (p = 0.007). Primary patency rates at 3, 6, and 12 months were 77.5, 69.8, and 69.8% for the bare-stent group and 97.5, 92.2, and 87.6% for the covered-stent group, respectively. Mean secondary patency was 123.7 ± 22.5 days for the bare-stent group and 130.3 ± 21.4 days for the covered-stent group. Tumour ingrowth occurred exclusively in the bare-stent group in 27.5% of cases (p = 0.002). Median survival was 203.2 ± 11.8 days for the bare-stent group and 247.0 ± 20 days for the covered-stent group (p = 0.06). Complications and mean cost were similar in both groups. Regarding primary patency and ingrowth rate, ePTFE/FEP-covered stents have shown to be significantly superior to bare nitinol stents for the palliation of malignant jaundice caused by inoperable pancreatic head cancer and pose comparable cost and complications. Use of a covered stent does not significantly influence overall survival rate; nevertheless, the covered endoprosthesis seems to offer result in fewer reinterventions and better quality of patient life.
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Palliative nutritional intervention in addition to cyclooxygenase and erythropoietin treatment for patients with malignant disease: Effects on survival, metabolism, and function.
Lundholm, K, Daneryd, P, Bosaeus, I, Körner, U, Lindholm, E
Cancer. 2004;(9):1967-77
Abstract
BACKGROUND The role of nutrition in the palliative treatment of patients with malignancy-related cachexia is unclear. The goal of the current study was to determine whether specialized, nutrition-focused patient care could improve integrated whole-body metabolism and functional outcome in unselected weight-losing patients with malignant disease who were receiving systemic antiinflammatory (cyclooxygenase [COX]-inhibitory) treatment along with erythropoietin (EPO) support. METHODS Three hundred nine patients with malignant disease who experienced progressive cachexia due to solid tumors (primarily gastrointestinal lesions) were randomized to receive a COX inhibitor (indomethacin, 50 mg twice daily) and EPO (15-40,000 units per week) along with specialized, nutrition-focused patient care (oral nutritional support and home total parenteral nutrition [TPN]) provided on a patient-by-patient basis to attenuate inflammation, prevent anemia, and improve nutritional status. Control patients received the same indomethacin and EPO doses that study patients received without the added nutritional support. All patients were treated and followed until death. Biochemical assays (blood, liver, kidney, and thyroid), nutritional state assessment (food intake and body composition), and exercise testing with simultaneous measurement of whole-body respiratory gas exchange before and during exercise were performed before the start of treatment and then at regular intervals during the treatment period (every 2-30 months after treatment initiation). Statistical analyses were performed on 'intention-to-treat' and 'as-treated' bases. RESULTS Home TPN was provided to approximately 50% of the study patients without severe complications. Over the entire observation period, rhEPO prevented the development of anemia in both study patients and control patients. Intention-to-treat analysis revealed an improvement in energy balance for nutritionally supported patients (P < 0.03); no other significant differences in outcome between study patients and control patients were observed. As-treated analysis demonstrated that patients receiving nutrition experienced prolonged survival (P < 0.01), which was accompanied by improved energy balance (P < 0.001), increasing body fat (P < 0.05), and a greater maximum exercise capacity (P < 0.04). A trend toward increased metabolic efficiency at maximum exercise (P < 0.06) for study patients relative to control patients also was observed. CONCLUSIONS The results of the current study strongly support that nutrition is a limiting factor influencing survival and that nutritional support protects integrated metabolism and metabolic function in patients with progressive cachexia secondary to malignant disease.
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Preliminary experience in radionuclide therapy of hepatocellular carcinoma using hepatic intra-arterial radio-conjugates.
Keng, GH, Sundram, FX, Yu, SW, Somanesan, S, Premaraj, J, Oon, CJ, Kwok, R, Htoo, MM
Annals of the Academy of Medicine, Singapore. 2002;(3):382-6
Abstract
INTRODUCTION In a minority of the cases, resection of hepatocellular carcinoma (HCC) is potentially curative but local recurrence is common. Adjuvant intra-arterial radio-conjugate therapy could potentially reduce the rate of local recurrence and increase disease-free and overall survival. However, in the majority of cases, treatment of HCC is largely palliative. A wide range of palliative treatment options are available and these include external radiation, hepatic intra-arterial chemo-embolisation, systemic chemotherapy and percutaneous ethanol injection. The long-term survival rate is poor. Hepatic intra-arterial radio-conjugate therapy provides a new and promising means of palliation. MATERIALS AND METHODS We share our initial experience in the treatment of patients with HCC. A total of 32 patients were recruited between October 1999 and June 2001. Group 1 comprised 15 patients who had potentially curative resection of HCC who were treated with Iodine-131 (I131) lipiodol as a form of adjuvant therapy. Group 2 comprised 17 patients with unresectable HCC, 12 of whom were treated with Yttrium-90 (Y90) microspheres and 5 with Rhenium-188 (Re188) lipiodol. The radio-conjugates were administered via the intra-arterial route. RESULTS Thirteen of the 15 patients in group 1 who were treated with I131 lipiodol following curative resection of HCC were free of disease, 1 patient died and 1 patient who developed recurrence was retreated with Re188 lipiodol and was subsequently free of disease. The 6-month disease-free survival rate was 100% and the 12-month disease-free and overall survival rates were 72% and 85%, respectively. Of the 12 patients in group 2 who were treated with Y90 microspheres for unresectable HCC, 6 had stable disease, 2 showed tumour regression and 4 died. The 6-month and 12-month survival rates were 75% and 66%, respectively. Of the 5 patients in group 2 who were treated with Re188 lipiodol for unresectable HCC, 4 had stable disease and 1 had regression of the right lobe tumour but progression of the left lobe tumour. CONCLUSION Our results in the adjuvant treatment of patients with I131 lipiodol following curative resection of early HCC and in the palliative treatment of unresectable HCC using Y90 microspheres and Re188 lipiodol are preliminary and not fully conclusive. These preliminary results have to be confirmed in larger groups of patients and by prospective, randomised, controlled trials. This study highlights the preliminary experience in radionuclide therapy of HCC using hepatic intra-arterial radio-conjugates in a local context.
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Quality of life assessment in radionuclide therapy: a feasibility study of the EORTC QLQ-C30 questionnaire in palliative (131)I-lipiodol therapy.
Brans, B, Lambert, B, De Beule, E, De Winter, F, Van Belle, S, Van Vlierberghe, H, de Hemptinne, B, Dierckx, RA
European journal of nuclear medicine and molecular imaging. 2002;(10):1374-9
Abstract
The good tolerance of radionuclide therapy has frequently been proposed as a major advantage. This study explored the feasibility of using the EORTC QLQ-C30 questionnaire in palliative iodine-131 lipiodol therapy for hepatocellular carcinoma. Questionnaires were completed during interviews in which all symptoms, co-morbidity and medication were assessed at baseline within 1 week before (131)I-lipiodol therapy, and subsequently after 1 and 3 months, in 20 patients treated with locoregional, intra-arterial (131)I-lipiodol therapy with or without cisplatin. Principal observations were that (1) a number of important scales, i.e. overall quality of life, physical functioning and pain, worsened between 0 and 3 months after (131)I-lipiodol therapy, irrespective of tumour response, and (2) the occurrence of clinical side-effects was associated with a negative impact on quality of life and physical functioning 1 and 3 months after (131)I-lipiodol. The QLQ-C30 can be regarded as a feasible method for quality of life assessment in (131)I-lipiodol therapy for hepatocellular carcinoma and possibly in other radionuclide therapies. These observations should be related to the impact of other treatment modalities on quality of life.