Comparison of Solomon technique with selective laser ablation for twin-twin transfusion syndrome: a systematic review

OBJECTIVE

To compare the Solomon and selective techniques for fetoscopic laser ablation (FLA) for the treatment of twin-twin transfusion syndrome (TTTS) in monochorionic-diamniotic twin pregnancies.

METHODS

This was a systematic review conducted in accordance with the PRISMA statement. Electronic searches were performed for relevant citations published from inception to September 2014. Selected studies included pregnancies undergoing FLA for TTTS that reported on recurrence of TTTS, occurrence of twin anemia-polycythemia sequence (TAPS) or survival.

RESULTS

From 270 possible citations, three studies were included, two cohort studies and one randomized controlled trial (RCT), which directly compared the Solomon and selective techniques for FLA. The odds ratios (OR) of recurrent TTTS when using the Solomon vs the selective technique in the two cohort studies (n = 249) were 0.30 (95% CI, 0.00-4.46) and 0.45 (95% CI, 0.07-2.20). The RCT (n = 274) demonstrated a statistically significant reduction in risk of recurrent TTTS with the Solomon technique (OR, 0.21 (95% CI, 0.04-0.98); P = 0.03). The ORs for the development of TAPS following the Solomon and the selective techniques were 0.20 (95% CI, 0.00-2.46) and 0.61 (95% CI, 0.05-5.53) in the cohort studies and 0.16 (95% CI, 0.05-0.49) in the RCT, with statistically significant differences for the RCT only (P < 0.001). Observational evidence suggested overall better survival with the Solomon technique, which was statistically significant for survival of at least one twin. The RCT did not demonstrate a significant difference in survival between the two techniques, most probably owing to the small sample size and lack of power.

CONCLUSION

This systematic review of observational, comparative cohort and RCT data suggests a trend towards a reduction in TAPS and recurrent TTTS and an increase in twin survival, with no increase in the occurrence of complications or adverse events, when using the Solomon compared to the selective technique for the treatment of TTTS. These findings need to be confirmed by an appropriately-powered RCT with long-term neurological follow-up.

The NICE classification for 'Ultra-radical (extensive) surgery for advanced ovarian cancer' guidance does not meaningfully predict postoperative complications: a cohort study

OBJECTIVE

To determine which descriptors of cytoreductive surgical extent in advanced ovarian cancer (AOC) best predict postoperative morbidity.

DESIGN

Retrospective notes review.

SETTING

A gynaecological cancer centre in the UK.

POPULATION

Six hundred and eight women operated on for AOC over a period of 114 months at a tertiary cancer centre, between 16 August 2007 and 16 February 2017.

METHODS

Outcome data were analysed by six approaches to classify the extent of surgery: standard/ultra-radical surgery; standard/radical/supra-radical surgery; presence/absence of gastrointestinal resections; low/intermediate/high surgical complexity score (SCS); presence of bowel anastomoses and/or diaphragmatic surgery; and the presence/absence of multiple bowel resections.

MAIN OUTCOME MEASURES

Major (grades 3-5) postoperative morbidity and mortality.

RESULTS

Forty-three (7.1%) patients experienced major complications. Grade-5 complications occurred in six patients (1.0%). Patients who underwent multiple bowel resections had a relative risk (RR) of 7.73 (95% confidence interval, 95% CI 3.92-15.26), patients with a high SCS had an RR of 6.12 (95% CI 3.25-11.52), patients with diaphragmatic surgery and gastrointestinal anastomosis had an RR of 5.57 (95% CI 2.65-11.72), patients with 'any gastrointestinal resection' had an RR of 4.69 (95% CI 2.66-8.24), patients with ultra-radical surgery had an RR of 4.65 (95% CI 2.26-8.79), and patients with supra-radical surgery had an RR of 4.20 (95% CI 2.35-7.51) of grades 3-5 morbidity, compared with patients undergoing standard surgery as defined by the National Institute for Health and Care Excellence (NICE) in the UK. No significant difference was seen in the rate of major morbidity between standard (6/59, 10.2%) and ultra-radical (9/81, 11.1%) surgery within the cohort who had intermediate complex surgery (P > 0.05).

CONCLUSIONS

The numbers of procedures performed significantly correlate with major morbidity. The number of procedures performed better predicted major postoperative morbidity than the performance of certain 'high risk' procedures. We recommend using SCS to define a higher risk operation. NICE should re-evaluate the use of the term 'ultra-radical' surgery.

TWEETABLE ABSTRACT

Multiple bowel resection is the best predictor of morbidity and is more predictive than 'ultra-radical surgery'.

Histopathological correlation of splenic disease with radiological and surgical findings: should we incorporate splenectomy into standard procedures for disseminated Millerian adenocarcinoma?

PURPOSE OF INVESTIGATION

To determine the positive predictive value (PPV) of both preoperative radiological and intraoperative identification of splenic disease in cases of advanced and recurrent gynaecological malignancy.

MATERIALS AND METHODS

A retrospective study of all splenectomies performed during surgeries for disseminated gynaecological malignancy at the Pan Birmingham Gynaecological Cancer Centre between May 21st, 2008 and January 31st, 2015.

RESULTS

Forty-one women were identified, most of whom had Stage 3C, high grade, serous Milllerian adenocarcinomas. Thirty-seven (90.2%) spleens were removed because of intraoperative suspicion of disease and the remaining four (9.8%) were removed following inadvertent injury. No spleens were detected radiologically that did not have obvious macroscopic disease. The PPV for the preoperative and intraoperative detection of splenic disease were 88.9% and 91.9%, respectively. Half of the spleens removed following inadvertent injury had disease identified following histopathological examination.

CONCLUSION

Intraoperative identification of splenic disease correlates well with histopathological examination. However, in 50% of splenectomies performed following inadvertent trauma and where disease was not suspected, metastases were identified.

The chromatin landscape of high-grade serous ovarian cancer metastasis identifies regulatory drivers in post-chemotherapy residual tumour cells

Disease recurrence following chemotherapy is a major clinical challenge in ovarian cancer (OC), but little is known regarding how the tumour epigenome regulates transcriptional programs underpinning chemoresistance. We determine the single cell chromatin accessibility landscape of omental OC metastasis from treatment-naïve and neoadjuvant chemotherapy-treated patients and define the chromatin accessibility profiles of epithelial, fibroblast, myeloid and lymphoid cells. Epithelial tumour cells display open chromatin regions enriched with motifs for the oncogenic transcription factors MEIS and PBX. Post chemotherapy microenvironments show profound tumour heterogeneity and selection for cells with accessible chromatin enriched for TP53, TP63, TWIST1 and resistance-pathway-activating transcription factor binding motifs. An OC chemoresistant tumour subpopulation known to be present prior to treatment, and characterised by stress-associated gene expression, is enriched post chemotherapy. Nuclear receptors RORa, NR2F6 and HNF4G are uncovered as candidate transcriptional drivers of these cells whilst closure of binding sites for E2F2 and E2F4 indicate post-treated tumour having low proliferative capacity. Delineation of the gene regulatory landscape of ovarian cancer cells surviving chemotherapy treatment therefore reveals potential core transcriptional regulators of chemoresistance, suggesting novel therapeutic targets for improving clinical outcome.

A review of the medical and social consequences of generalized anxiety disorder and panic disorder

Over the past two decades, anxiety disorders have become the focus of much research after years of relative obscurity. The accumulating data has suggested that anxiety disorders may have many consequences including decreased quality of life, economic dependence, multiple somatic complaints, maladaptive personality traits, and increased mortality due to suicide, cardiovascular, and cerebrovascular causes. Aggressive management of these disorders may greatly lessen the impact.