Treatment of metastatic breast cancer with somatostatin analogues--a meta-analysis.

BACKGROUND: Somatostatin analogues appear to have antiproliferative effects in breast cancer by inhibiting various hormones. Several small phase 1 and 2 clinical trails have evaluated the efficacy of somatostatin analogues, but the results are varied. The purpose of this study was to use the technique of meta-analysis to determine the effect of somatostatin analogues on tumor response, toxicity, and serum hormone levels in women with metastatic breast cancer. METHODS: All published and unpublished trials were reviewed. Meta-analysis was preformed by best linear unbiased estimate regression with observations weighted inversely to their variance. Significance was considered at P < .05. RESULTS: Fourteen studies (N = 210) were included. Positive tumor response was reported in 87 patients (41.4%). Mean duration of response was 3.9 months. Response was best when somatostatin analogues were given as first-line therapy (69.5% versus 28.5%, P < .006) and in patients with < or =2 metastases (45.0% versus 5.6%, P = .3). Mild side effects occurred in 47 of 185 patients (25.4%). Therapy was associated with a decrease in serum insulin-like growth factor (IGF-1) and an increase in growth hormone. CONCLUSIONS: In patients with metastatic breast cancer, treatment with somatostatin analogues was associated with a tumor response of over 40% with few side effects. Best results were achieved when somatostatin analogues were given as first-line therapy.

The role of frozen section, gender, age, and tumor size in the differentiation of follicular adenoma from carcinoma: a meta-analysis.

BACKGROUND: The purpose of this study was to reanalyze modern trials and use meta-analysis to determine how well frozen section gender, age, and tumor size could differentiate follicular adenoma from follicular carcinoma. METHOD: Inclusion criteria were studies where patients had a permanent pathologic diagnosis of follicular adenoma or follicular carcinoma and underwent frozen section or had clinical features recorded. Data were pooled, and the random effects model of meta-analysis was used. A probability value of less than.05 was considered significant. RESULTS: Nineteen studies were included (n = 3486 patients). Frozen section was evaluated in 11 studies (n = 2204 patients). Frozen section had an 87% sensitivity, a 48% specificity, a 92% and 35% positive and negative predictive value, respectively, an 82% accuracy, an odds ratio of 0.181, a 95% confidence interval (CI) of 0.07 to 0.49, and a probability value of.001. Clinical features were evaluated in 10 studies (n = 1954 patients). Of the patients with follicular carcinoma, 27.5% were male compared with patients with follicular adenoma, of whom 17.7% were male (P <.01; odds ratio, 2.17; CI 1.3-3.6; P =.003). Of the patients with follicular carcinoma, 52.2% were older than 50 years (52.2%) compared with patients with follicular adenoma, of whom 28.5% were older than 50 years (P <.001). Of patients with follicular carcinoma, 36.8% had tumors larger than 3 to 5 cm compared with patients with follicular adenoma, of whom 14.7% had tumors larger than 3 to 5 cm (P <.001; odds ratio, 3.99; CI 1.5-10.8; P =.006). CONCLUSIONS: Meta-analysis suggests that frozen section is not a specific test and cannot be used to confidently rule out follicular carcinoma. Male gender and large tumor size are significantly associated with carcinoma.

Cost analysis of breast conservation surgery compared with modified radical mastectomy with and without reconstruction.

BACKGROUND: Breast conservation surgery (BCS), consisting of lumpectomy, axillary lymph node dissection, and radiation therapy, is as effective as modified radical mastectomy (MRM) for the treatment of early stage breast cancer. The costs of these treatment options have not been adequately addressed in the current era of increasing utilization of BCS and breast reconstruction. The purpose of this study is to determine differences in treatment costs among BCS, MRM alone, and MRM with reconstruction. METHODS: Patients with stage I and II breast cancer receiving inpatient treatment at a private university-affiliated hospital between January 1996 and July 1997 were analyzed (n = 230). Charges were determined as follows: inpatient and radiotherapy charges from the hospital billing department, surgeon fees from group practice billing codes, and radiotherapy physician fees from the radiation oncology group practice. Inpatient length of stay was obtained from hospital medical records. RESULTS: Average hospital inpatient charge for BCS was $4,748 (n = 74), $6,280 for MRM alone (P <0.001, n = 132), and $11,946 for MRM with reconstruction (P <0.001, n = 24). Surgeons' fees for BCS were $2,840, $3,500 for MRM alone, and $10,774 for MRM with reconstruction. The average radiotherapy charge was $18,742. Average length of stay was 1.03 days for BCS, 2.44 days for MRM alone (P <0.001), and 3.71 days for MRM with reconstruction (P <0. 001). Average total cost of BCS ($26,330) was significantly greater than the average total cost of either MRM alone ($9,780, P <0.001) or MRM with reconstruction ($22,720, P <0.001). CONCLUSIONS: BCS is more expensive than MRM with or without reconstruction. It is the addition of radiotherapy that results in the higher total cost of CS.

Changing indications for pediatric cholecystectomy.

PURPOSE: The purpose of this study was to determine indications for gallbladder surgery and risk factors for urgent surgery. METHODS: We reviewed all patients <19 years old, who underwent cholecystectomy between 1980 and 1996. RESULTS: There were 128 patients (mean age: 10 years). Fifty-two patients had an underlying hematologic disorder, 47 had another medical disorder, and 29 had no preexisting illness or identifiable risk factor for gallstone disease. Twenty-five percent (32/128) of cholecystectomies were performed urgently. Postoperative complications developed in 5 of 32 patients (16%) who underwent emergency surgery and 6 of 96 patients (6%) who underwent elective surgery. There were 3 deaths, all occurring in patients undergoing emergency cholecystectomy (odds ratio: 23). Furthermore, all who died had congenital heart disease (odds ratio: 183), making congenital heart disease an independent risk factor for gallstone-related mortality. CONCLUSIONS: Cholecystectomy is recommended when medically possible for children with underlying medical diseases. Patients with medical disorders that make them a high surgical risk can be followed clinically, realizing that if urgent surgery is necessary, the morbidity is relatively high. Those children with congenital heart disease and gallstones are at a prohibitively high risk for death after urgent cholecystectomy. For these patients, the risk of an elective cholecystectomy may be acceptable when weighed against the high risk of complications from their gallstones.

The efficacy of thyroidectomy for Graves' disease: A meta-analysis.

BACKGROUND: Surgery for Graves' disease was largely replaced in the mid-1900s by radioiodine and antithyroid drugs, due to the belief that they were more safe and effective. Since then, thyroid surgery has improved with preoperative drug therapy and modern operative techniques. Recent clinical studies of thyroidectomy for Graves' disease may not reflect outcomes accurately because of small sample size, especially when estimating ideal thyroid remnant size. The purpose of this study was to combine modern clinical trials and use meta-analysis to determine the overall efficacy of both total (TT) and subtotal thyroidectomy (ST) for Graves' disease, compare thyroid function and complications rates of TT and ST, and determine ideal thyroid remnant size. METHODS: Meta-analysis was performed on published studies in which patients underwent either TT or ST for Graves' disease. Meta-analysis was performed by weighted least-squares linear regression. P < 0.05 was considered significant. RESULTS: There were 35 studies comprising 7241 patients. Mean follow-up was 5.6 years. Overall, persistent or recurrent hyperthyroidism occurred in 7.2% of patients. TT was performed on 538 patients and hypothyroidism occurred in all cases. ST was performed in 6703 patients, 59.7% of whom achieved euthyroidism, 25. 6% became hypothyroid, and 7.9% had either persistent or recurrent hyperthyroidism. Permanent recurrent laryngeal nerve injury occurred in 0.9% of TT patients and 0.7% of ST patients (P = NS). Permanent hypoparathyroidism occurred in 1.6% of TT patients and 1.0% of ST patients (P = NS). There was an 8.9% decrease in hypothyroidism and 6.9% increase in euthyroidism for each gram of thyroid remnant (P < 0.0001 each). CONCLUSIONS: Overall, thyroidectomy successfully treated hyperthyroidism in 92% of patients with Graves' disease. There were no cases of hyperthyroidism following TT. ST achieved a euthyroid state in almost 60% of patients with an 8% rate of persistent or recurrent hyperthyroidism. There was no significant difference in complication rates between TT and ST.

Meta-analysis of sentinel lymph node biopsy in breast cancer.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is a minimally invasive way to diagnose axillary lymph node (ALN) metastases in breast cancer. The most important features are ability to identify the SLN (I.D. rate), how often the SLN and ALN pathology match (concordance), and how often the SLN is negative for cancer when the ALNs are positive (false negative). Technique and patient criteria for SLNB vary among studies. This study performed meta-analysis of published studies to determine the I.D., concordance, and false negative rate (1) overall and for (2) both blue dye and radiocolloid, (3) the injection method, (3) palpable and nonpalpable ALNs, and (4) invasive and in situ disease. METHODS: Inclusion criteria were patients with breast cancer who had SLNB followed by ALN dissection with H&E staining. Meta-analysis was performed using analysis of variance with each observation weighted inversely to its variance. P < 0.05 was considered significant. RESULTS: Eleven studies (n = 912) met the inclusion criteria. Overall, 762 (84%) SLNs were identified, concordance was 747/762 (98%), and 15/296 (5%) were falsely negative. Highest I.D. rates (P < 0.05) were reported with albumin radiocolloid or dye + radiocolloid (97 and 94%, respectively), with injection around an intact tumor (96%), with invasive cancer (95%), and in the clinically negative axilla (96%). Concordance and false negative rates did not vary. CONCLUSIONS: The SLN can be identified in over 97% of patients if certain techniques and inclusion criteria are used. SLNB reflects the status of the axilla in 97% of cases and has a 5% false negative rate.

Laparoscopic evaluation of the pediatric inguinal hernia--a meta-analysis.

BACKGROUND/PURPOSE: For over 50 years there has been debate over how to manage the contralateral groin in children who present with a unilateral inguinal hernia. Many preoperative and intraoperative tools to diagnose a contralateral patent processus vaginalis or true inguinal hernia have been described. In 1992 laparoscopy was introduced as a new diagnostic test. Although multiple series have assessed this new tool, none of them have been able to statistically show that laparoscopy is effective in assessing the contralateral groin. By combining all published studies and using the technique of meta-analysis, intraoperative laparoscopy can be shown to be effective in diagnosing a contralateral patent processus vaginalis in children undergoing unilateral inguinal herniorrhaphy. METHODS: All available studies of children with a unilateral hernia who had exploration of the contralateral groin by laparoscopy were reanalyzed. Sensitivity and specificity of laparoscopy was determined using open exploration or development of a metachronous hernia as the gold standard. RESULTS: Nine hundred sixty-four patients were suitable for analysis. A contralateral hernia was seen on laparoscopy in 376 patients. All of these patients underwent open contralateral exploration. A patent processus vaginalis or true hernia sac was found in 373. The sensitivity of laparoscopy was 99.4% (95% confidence interval 97.87 to 99.91). Five hundred eighty-eight patients had a laparoscopy with negative results. Sixty-two of these patients then had open contralateral exploration. In one case, a patent processus vaginalis was found; the other 61 patients underwent exploration with negative results. In the remaining 526 laparoscopy-negative patients, follow-up (1 month to 3 years) was used to see if a contralateral hernia developed. A metachronous hernia developed in one of the 526 patients. The specificity of laparoscopy was 99.5% (95% confidence interval 98.39 to 99.87). Laparoscopy added an average of 6 minutes to the surgical time and was accurate regardless of the technique. There were two minor complications related to laparoscopy and no deaths. CONCLUSIONS: Laparoscopy may be the ideal tool to diagnose a contralateral patent processus vaginalis intraoperatively. It is sensitive, specific, fast, and safe. Although the presence of a patent processus does not imply that the patient will go on to develop a metachronous hernia, identifying and ligating a patent processus should certainly prevent the development of an indirect inguinal hernia.

Meta-analysis of the risk of metachronous hernia in infants and children.

BACKGROUND: Inguinal herniorrhaphy is the most common general surgical procedure performed in children. The presence of a contralateral patent processus vaginalis forms the basis of the recommendation for contralateral exploration in patients undergoing unilateral herniorrhaphy. However, a patent processus vaginalis does not necessarily go on to become a clinically apparent inguinal hernia. METHODS: All published pediatric series, in which patients underwent unilateral inguinal hernia repair and were evaluated for the development of a metachronous hernia, were included. The incidence of and risk factors associated with development a metachronous hernia were evaluated with meta-analysis. RESULTS: There were 15,310 patients ranging in age from birth to 16 years, including premature infants. Of these, 1,062 patients (7%) developed a metachronous hernia. Gender and age were not risk factors. There was an 11% risk of metachronous hernia if the original hernia was on the left side, a risk that was 50% greater than if the original hernia was on the right. Of patients who developed a metachronous hernia, 90% did so within 5 years. The complication rate of metachronous hernia was 0.5%. CONCLUSION: There is no role for routine contralateral groin exploration. High-risk infants and children, especially those who undergo left inguinal herniorrhaphy, may benefit from contralateral groin exploration. If a patent processus vaginalis is found, it should be ligated. Patients who do not undergo contralateral groin exploration should be followed up for 5 years.

The validity of tuning fork tests in diagnosing hearing loss.

Tuning fork tests are subjective and response bias must be accounted for when determining their validity as diagnostic tools. A significant proportion of patients who present for otologic evaluation have mixed hearing loss and it is important to know how this group responds to tuning fork testing. The need for masking in audiometry is indisputable but its role in tuning fork testing has never been established. The purpose of this study was to determine the sensitivity of tuning fork tests. The Weber, unmasked and masked Rinne, and Bing tests were administered in a prospective, random, and blind manner to 68 patients referred for audiologic assessment. Patients found to have normal hearing served as the control group. Signal Detection Theory was used to compare the results to pure-tone air- and bone-conduction audiometry. Overall the Rinne is an unbiased test with a sensitivity of 0.84 regardless of the type, severity, or frequency of hearing loss. This is not improved by masking. There is no role for either the Weber or Bing as independent tests. Mixed hearing loss behaves as conductive hearing loss. The Rinne without masking should be administered to patients suspected of having a hearing loss.