Management of Early-stage Hodgkin Lymphoma: A Practice Guideline.

In the past, treatment for patients with early-stage Hodgkin lymphoma consisted mainly of radiotherapy. Now, chemotherapy alone and chemoradiotherapy are treatment options. These guidelines aim to provide recommendations on the optimal management of early-stage Hodgkin lymphoma. We conducted a systematic review searching MEDLINE, EMBASE, the Cochrane Library and other literature sources from 2003 to 2015, and applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Two authors independently reviewed and selected studies, and appraised the evidence quality. The document underwent internal and external review by content, methodology experts, a patient representative and clinicians in Ontario. We have issued recommendations for patients with classical Hodgkin lymphoma and with nodular lymphocyte predominant Hodgkin lymphoma; with favourable and unfavourable prognosis; and for the use of positron emission tomography to direct treatment. We have provided our interpretation of the evidence and considerations for implementation. Examples of recommendations are: 'Patients with early-stage classical Hodgkin lymphoma should not be treated with radiotherapy alone'; 'chemotherapy plus radiotherapy or chemotherapy alone are recommended treatment options for patients with early-stage non-bulky Hodgkin lymphoma'; 'The Working Group does not recommend the use of a negative interim positron emission tomography scan alone to identify patients with early-stage Hodgkin lymphoma for whom radiotherapy can be omitted without a reduction in progression-free survival'. Through the use of GRADE, recommendations were geared towards patient important outcomes and their strength reflected the available evidence and its interpretation from the patients' point of view.

Lenalidomide in multiple myeloma-a practice guideline.

BACKGROUND: Promising new drugs such as lenalidomide, an immunomodulatory agent, are available for the treatment of multiple myeloma. We describe the process of creating a provincial guideline for the use of lenalidomide, alone or in combination with other drugs, in relapsed, refractory, or newly diagnosed disease (including smoldering and symptomatic patients, and candidates and non-candidates for transplant) and in maintenance treatment (after transplant or non-transplant therapy); and for strategies to manage lenalidomide-related toxicities. METHODS: Outcomes of interest included overall survival, event-free survival, progression-free survival, time to progression, time to next treatment, response rate, and incidence of serious toxicity. The medline, embase, and Cochrane Library databases, as well as meeting abstracts and the Web sites of relevant organizations, were systematically searched for relevant literature. RESULTS: Recommendations were developed using the evidence from published studies and the clinical expertise of the working group and of the Cancer Care Ontario Hematology Disease Site Group. CONCLUSIONS: Lenalidomide in combination with dexamethasone can be recommended for both previously untreated and treated patients with multiple myeloma. Guidelines for the management of cytopenias, venous thromboembolism, and second primary malignancies are discussed.

Prospective assessment of cardiac function in patients with Kaposi's sarcoma and the acquired immune deficiency syndrome.

Prospective evaluation of cardiac function was undertaken in 21 patients with Kaposi's sarcoma (KS) and the acquired immune deficiency syndrome (AIDS) as part of a phase II clinical trial of 4'epirubicin. All patients were homosexual or bisexual males of median age 34 years (range 23-65). All patients had disseminated cutaneous involvement by KS and seven had systemic organ involvement. No patient had a history of cardiac symptoms, and physical examination of the cardiovascular system was within normal limits for all patients. The baseline ECG was normal in only nine patients (45%). Five had non-specific S-T segment and T-wave changes. Two had poor R-wave progression, and one patient each had incomplete right bundle branch block, left axis deviation, and voltage criteria suggestive of left ventricular hypertrophy. Radionuclide angiography was performed on all patients and compared to 12 age-matched, low-likelihood male controls. The mean ejection fraction (EF) at rest was 61.0 +/- 8.4%, and was not significantly different from the normal control value of 62.4 +/- 7.0%. Similarly the EF during exercise was 66.7 +/- 5.0%, again not significantly different from the control value of 67.8 +/- 5.8%. A drop in EF during exercise was seen in five of 15 KS patients compared to three of 12 controls. Chamber size was normal for both ventricles in only 14 patients (67%) with right ventricular dilatation seen in seven patients (33%). Wall motion abnormalities were also seen in nine patients (42.9%), with the right ventricle affected in eight patients (38.1%), chiefly involving the apex. No chamber size or wall motion abnormalities were seen in the control patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Morbidity and mortality in mitral valve surgery.

To develop strategies for the management of high-risk patients, contemporary risk factors for operative mortality and postoperative ventricular dysfunction were identified in 214 patients undergoing mitral valve surgery in 1982 and 1983. Thirty-eight preoperative and perioperative variables were prospectively collected and analyzed by univariate and multivariate statistics. The overall mortality was 4.6% and the incidence of postoperative low-output syndrome (LOS) was 18.7%. Forty-seven patients with coronary artery disease (CAD) had a higher mortality and incidence of LOS (as evidenced by the need for inotropic drugs or counterpulsation to maintain blood pressure) (those with CAD 15% mortality, 40% LOS; those without CAD 2% mortality, 13% LOS; p less than .05). The presence of unstable angina and ischemic mitral regurgitation further increased the risk. Age was also a predictor of outcome. Patients who died or had LOS were older (those who died, 65 +/- 7 years, those with LOS, 58 +/- 11 years) than patients who survived and did not have postoperative dysfunction (those who survived, 53 +/- 11; those with no LOS, 53 +/- 11; p less than .01). Mitral regurgitation was associated with a higher (p less than .05) mortality and incidence of LOS (mortality 10.5%, LOS 36%; n = 76) than was mitral stenosis (mortality 0%, LOS 4%; n = 74) or mixed lesions (mortality 3%, LOS 15%; n = 64). In patients without CAD, mitral regurgitation remained a significant predictor of mortality and ventricular dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)