Anaplastic thyroid cancer and primary thyroid lymphoma: a review of these rare thyroid malignancies.

BACKGROUND: To review the current literature on the treatment of anaplastic thyroid cancer (ATC) and thyroid lymphoma (TL). RESULTS: Both anaplastic carcinoma (ATC) and TL represent rare forms of thyroid cancer. ATC behaves in a highly aggressive manner, resulting in significant morbidity and mortality. Multimodality therapy consisting of both radiotherapy (RT) and chemotherapy is essential in obtaining local/regional control. Although ATC has been relatively chemo resistant, newer agents such like taxotere show promise. The role of surgery in the treatment of ATC continues to evolve, presently it should be reserved for patients who have shown an initial response to multimodality therapy and in patients in whom a complete macroscopic resection can be achieved with minimal morbidity. The successful treatment of TL currently lies in accurately diagnosing the histological subtype. Both large B-cell and mixed lymphomas are best treated with multimodality therapy consisting of CHOP combined with hyper-fractioned RT. MALT lymphomas with there more indolent course may be amenable to single modality RT or total thyroidectomy if diagnosed at an early stage IE. DISCUSSION: Although both ATC and TL are rare, it is important for surgeons to be aware of the need for multimodality therapy when treating these patients and to understand the limited role surgery plays in diagnosis and treatment.

Effectiveness of implantable defibrillators for preventing arrhythmic events and death: a meta-analysis.

OBJECTIVES: The aim of this study was to compare the effectiveness of the implantable cardioverter defibrillator (ICD) and medical strategies for prevention of arrhythmic events and death. BACKGROUND: The ICD is a potential strategy to reduce mortality in patients at risk of sudden death. METHODS: The MEDLINE, EMBASE, and Cochrane Library electronic databases were searched from January 1966 to April 2002. All published randomized controlled trials comparing ICD implantation with medical therapy were reviewed. Four independent reviewers extracted data on all-cause mortality, nonarrhythmic death, and arrhythmic death using a standardized protocol. RESULTS: Nine studies including over 5,000 patients were synthesized using both fixed-effects and random-effects models. The primary and secondary prevention trials showed a significant benefit of the ICD with respect to arrhythmic death, with relative risks (RR) of 0.34 and 0.50, respectively (both p < 0.001). The mortality benefit of the ICD was entirely attributable to a reduction in arrhythmic death (all trials: p < 0.00001). Whereas the secondary prevention trials exhibited a robust decrease in all-cause ICD mortality (RR 0.75; p < 0.001), the pooled primary prevention trials demonstrated decreased all-cause ICD mortality (RR 0.66; p < 0.05) which was dependent on selected individual trials. The disparity in ICD-related mortality reductions in the primary prevention trials was related to variability in the incidence of arrhythmic death between individual studies. CONCLUSIONS: Although the ICD decreases the risk of arrhythmic death, its impact on all-cause mortality is related to the underlying risk of arrhythmia-related death relative to competing causes. Given the cost of the device strategy, policies of targeted intervention based on the future risk of arrhythmia are warranted.

A metaanalysis comparing surgical thrombectomy, mechanical thrombectomy, and pharmacomechanical thrombolysis for thrombosed dialysis grafts.

BACKGROUND: The achievement and maintenance of access sites for hemodialysis is a persistent challenge for both the vascular surgeon and the clinical nephrologist. The advent of improved interventional, endovascular, and pharmacomechanical techniques for the treatment of thrombosis has raised questions as to whether surgical thrombectomy is the most effective treatment. OBJECTIVE: The purpose of this study was to determine the role of surgical thrombectomy as the standard of care for the patient with end-stage renal disease and a thrombosed/stenosed arteriovenous graft (AVG). DESIGN AND METHODS: The study was designed as a metaanalysis. All publications that directly or indirectly described randomized controlled trials for the treatment of thrombosed dialysis grafts in patients with end-stage renal disease and AVG were searched. Relative risk (RR) and risk difference were used as the measure of effect for each dichotomous outcome. All of the studies that met the inclusion criteria were limited to prosthetic AVGs. RESULTS: The overall results suggested a clear superiority of surgery over endovascular procedures at 30 days, 60 days, 90 days, and 1 year. The RRs (95% CI) at these time points were 1.32 (1.07, 1.60), 1.34 (1.13, 1.58), 1.22 (1.05, 1.40), and 1.22 (1.07, 140), respectively, and favored surgery in all cases (30 days, P =.010; 60 days, P =.0007; 90 days, P =.007; and 1 year P =.003). The number needed to treat to prevent one endovascular occlusion after thrombectomy was 8 at 30 days, 6 at 60 days, 8 at 90 days, and 7 at 1 year. The rates of technical failure were significantly greater in the endovascular group compared with the surgical group (RR, 1.90; 95% CI, 1.32, 2.73; P =.0005), which generated an absolute risk reduction of 16% (P =.0002). No significant difference was seen in the complication rates between the two groups. CONCLUSION: The analysis of all currently available randomized controlled trials clearly supports the use of surgical thrombectomy for the treatment of thrombosed prosthetic vascular access grafts. The use of endovascular techniques has been found to be inferior to surgery in terms of both primary patency and technical failure rates.