Sympathetic nerve blocks for persistent pain in adults with inoperable abdominopelvic cancer.

BACKGROUND: Persistent visceral pain is an unpleasant sensation coming from one or more organs within the body. Visceral pain is a common symptom in those with advanced cancer. Interventional procedures, such as neurolytic sympathetic nerve blocks, have been suggested as additional treatments that may play a part in optimising pain management for individuals with this condition. OBJECTIVES: To evaluate the benefits and harms of neurolytic sympathetic nerve blocks for persistent visceral pain in adults with inoperable abdominopelvic cancer compared to standard care or placebo and comparing single blocks to combination blocks. SEARCH METHODS: We searched the following databases without language restrictions on 19 October 2022 and ran a top-up search on 31 October 2023: CENTRAL; MEDLINE via Ovid; Embase via Ovid; LILACS. We searched trial registers without language restrictions on 2 November 2022: ClinicalTrials.gov; WHO International Clinical Trials Registry Platform (ICTRP). We searched grey literature, checked reference lists of reviews and retrieved articles for additional studies, and performed citation searches on key articles. We also contacted experts in the field for unpublished and ongoing trials. Our trial protocol was preregistered in the Cochrane Database of Systematic Reviews on 21 October 2022. SELECTION CRITERIA: We searched for randomised controlled trials (RCTs) comparing any sympathetic nerve block targeting sites commonly used to treat abdominal pelvic pain from inoperable malignancies in adults to standard care or placebo. DATA COLLECTION AND ANALYSIS: We independently selected trials based on predefined inclusion criteria, resolving any differences via adjudication with a third review author. We used a random-effects model as some heterogeneity was expected between the studies due to differences in the interventions being assessed and malignancy types included in the study population. We chose three primary outcomes and four secondary outcomes of interest. We sought consumer input to refine our review outcomes and assessed extracted data using Cochrane's risk of bias 2 tool (RoB 2). We assessed the certainty of evidence using the GRADE system. MAIN RESULTS: We included 17 studies with 1025 participants in this review. Fifteen studies with a total of 951 participants contributed to the quantitative analysis. Single block versus standard care Primary outcomes No included studies reported our primary outcome, 'Proportion of participants reporting no worse than mild pain after treatment at 14 days'. The evidence is very uncertain about the effect of sympathetic nerve blocks on reducing pain to no worse than mild pain at 14 days when compared to standard care due to insufficient data (very low-certainty evidence). Sympathetic nerve blocks may provide small to 'little to no' improvement in quality of life (QOL) scores at 14 days after treatment when compared to standard care, but the evidence is very uncertain (standardised mean difference (SMD) -0.73, 95% confidence interval (CI) -1.70 to 0.25; I² = 87%; 4 studies, 150 participants; very low-certainty evidence). The evidence is very uncertain about the risk of serious adverse events as defined in our review as only one study contributed data to this outcome. Sympathetic nerve blocks may have an 'increased risk' to 'no additional risk' of harm compared with standard care (very low-certainty evidence). Secondary outcomes Sympathetic nerve blocks showed a small to 'little to no' effect on participant-reported pain scores at 14 days using a 0 to 10 visual analogue scale (VAS) for pain compared with standard care, but the evidence is very uncertain (mean difference (MD) -0.44, 95% CI -0.98 to 0.11; I² = 56%; 5 studies, 214 participants; very low-certainty evidence). There may be a 'moderate to large' to 'little to no' reduction in daily consumption of opioids postprocedure at 14 days with sympathetic nerve blocks compared with standard care, but the evidence is very uncertain (change in daily consumption of opioids at 14 days as oral milligrams morphine equivalent (MME): MD -41.63 mg, 95% CI -78.54 mg to -4.72 mg; I² = 90%; 4 studies, 130 participants; very low-certainty evidence). The evidence is very uncertain about the effect of sympathetic nerve blocks on participant satisfaction with procedure at 0 to 7 days and time to need for retreatment or treatment effect failure (or both) due to insufficient data. Combination block versus single block Primary outcomes There is no evidence about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks on the proportion of participants reporting no worse than mild pain after treatment at 14 days because no studies reported this outcome. There may be a small to 'little to no' effect on QOL score at 14 days after treatment, but the evidence is very uncertain (very low-certainty evidence). The evidence is very uncertain about the risk of serious adverse events with combination sympathetic nerve blocks compared with single sympathetic nerve blocks due to limited reporting in the included studies (very low-certainty evidence). Secondary outcomes The evidence is very uncertain about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks on participant-reported pain score and change in daily consumption of opioids postprocedure, at 14 days. There may be a small to 'little to no' effect, but the evidence is very uncertain (very low-certainty evidence). There is no evidence about the effect on participant satisfaction with procedure at 0 to 7 days and time to need for retreatment or treatment effect failure (or both) due to these outcomes not being measured by the studies. Risk of bias The risk of bias was predominately high for most outcomes in most studies due to significant concerns regarding adequate blinding. Very few studies were deemed as low risk across all domains for any outcome. AUTHORS' CONCLUSIONS: There is limited evidence to support or refute the use of sympathetic nerve blocks for persistent abdominopelvic pain due to inoperable malignancy. We are very uncertain about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks. The certainty of the evidence is very low and these findings should be interpreted with caution.

Extraosseous Ewing Sarcoma Manifesting as an Acute Abdomen in a Young Adult Male: a Case Report.

Ewing sarcoma is a tumor primarily affecting children and young adults, and usually affects long bones. Extraosseous Ewing sarcoma (EES) is a rare primary tumor of soft tissues. We present a case of abdominal EES with metastasis to thoracic cavity, which presented as abdominal pain and vomiting in a 21-year-old previously healthy gentleman.

Risk factors indicating the need for surgical therapy in patients with pyogenic liver abscesses.

BACKGROUND: Percutaneous drainage (PD) and antibiotics are the therapy of choice (non-surgical therapy [non-ST]) for pyogenic liver abscesses (PLA), reserving surgical therapy (ST) for PD failure. The aim of this retrospective study was to identify risk factors that indicate the need for ST. METHODS: We reviewed the medical charts of all of our institution's adult patients with a diagnosis of PLA between January 2000 and November 2020. A series of 296 patients with PLA was divided into two groups according to the therapy used: ST (n = 41 patients) and non-ST (n = 255). A comparison between groups was performed. RESULTS: The overall median age was 68 years. Demographics, clinical history, underlying pathology, and laboratory variables were similar in both groups, except for the duration of PLA symptoms < 10 days and leukocyte count which were significantly higher in the ST group. The in-hospital mortality rate in the ST group was 12.2% vs. 10.2% in the non-ST group (p = 0.783), with biliary sepsis and tumor-related abscesses as the most frequent causes of death. Hospital stay and PLA recurrence were statistically insignificant between groups. One-year actuarial patient survival was 80.2% in the ST group vs. 84.6% in the non-ST (p = 0.625) group. The presence of underlying biliary disease, intra-abdominal tumor, and duration of symptoms for less than 10 days on presentation comprised the risk factors that indicated the need to perform ST. CONCLUSIONS: There is little evidence regarding the decision to perform ST, but according to this study, the presence of underlying biliary disease or an intra-abdominal tumor and the duration of PLA symptoms < 10 days upon presentation are risk factors that should sway the surgeons to perform ST instead of PD.

[A Case of Intra-Abdominal Testicular Cancer Occurring from an Overlooked Intra-Abdominal Testis in Undescended Testicular Surgery].

Here, we report an adult case of intra-abdominal testicular cancer after surgical treatment of an undescended testis in infancy. A 36-year-old male patient was accidentally diagnosed with a tumor in the pelvic cavity by ultrasonographic examination. He had hematuria and the human chorionic gonadotropin beta subunit level was slightly elevated. T2-weighedmagnetic resonance imaging revealed a well-defined and highly intense mass. Since these findings suggested intra-abdominal testicular cancer, laparoscopic surgery was performed to remove the mass. Laparoscopy revealed an intra-abdominal tumor accompanied by a looping vas deferens entering the left inguinal canal. The distal part of the looping vas had already been removed from the external inguinal ring. The pathological findings revealed a pT1 seminoma. The patient has been recurrence-free for 12 months. The present case implies the importance of careful investigation and treatment for intra-abdominal testicular cancer, since intra-abdominal testis might have been overlooked at the time of surgery for undescended testis.

PRehabIlitatiOn with pReoperatIve exercise and educaTion for patients undergoing major abdominal cancer surgerY: protocol for a multicentre randomised controlled TRIAL (PRIORITY TRIAL).

BACKGROUND: Radical surgery is the mainstream treatment for patients presenting with advanced primary or recurrent gastrointestinal cancers; however, the rate of postoperative complications is exceptionally high. The current evidence suggests that improving patients' fitness during the preoperative period may enhance postoperative recovery. Thus, the primary aim of this study is to establish the effectiveness of prehabilitation with a progressive, individualised, preoperative exercise and education program compared to usual care alone in reducing the proportion of patients with postoperative in-hospital complications. The secondary aims are to investigate the effectiveness of the preoperative intervention on reducing the length of intensive care unit and hospital stay, improving quality of life and morbidity, and reducing costs. METHODS: This is a multi-centre, assessor-blinded, pragmatic, comparative, randomised controlled trial. A total of 172 patients undergoing pelvic exenteration, cytoreductive surgery, oesophagectomy, hepatectomy, gastrectomy or pancreatectomy will be recruited. Participants will be randomly allocated to prehabilitation with a preoperative exercise and education program (intervention group), delivered over 4 to 8 weeks before surgery by community physiotherapists/exercise physiologists, or usual care alone (control group). The intervention will comprise 12 to 24 individualised, progressive exercise sessions (including aerobic/anaerobic, resistance, and respiratory exercises), recommendations of home exercises (16 to 32 sessions), and daily incidental physical activity advice. Outcome measures will be collected at baseline, the week prior to surgery, during the hospital stay, and on the day of discharge from hospital, and 1 month and 1 months postoperatively. The primary outcome will be the development of in-hospital complications. Secondary outcomes include the length of intensive care unit and hospital stay, quality of life, postoperative morbidity and costs. DISCUSSION: The successful completion of this trial will provide robust and high-quality evidence on the efficacy of a preoperative community- and home-based exercise and education intervention on important postoperative outcomes of patients undergoing major gastrointestinal cancer surgery. TRIAL REGISTRATION: This trial was registered prospectively with the Australian New Zealand Clinical Trials Registry ( ACTRN12621000617864 ) on 24th May 2021.

Pediatric Abdominal Malignancies and Intravascular Extension: Contemporary Single-Center Experience.

INTRODUCTION: Inferior vena cava (IVC) thrombus is an uncommon and challenging complication of abdominal malignancies in the pediatric population, which significantly influences the treatment options and clinical outcomes in this population. METHODS: In this review, we present the presentation, treatments, interventions, and outcomes with this clinically and technically challenging oncological finding from a free-standing children's hospital from 2006 to 2017. RESULTS: Fourteen patients with IVC thrombus were identified as having an associated abdominal malignancy. The abdominal malignancies consisted of eight Wilms tumors (63% stage III and 37% stage IV), and one spindle cell sarcoma, neuroblastoma (stage III), kidney clear cell sarcoma (stage III), sclerosing epithelioid fibrosarcoma, hepatoblastoma-epithelial (stage IV), and hepatic embryonal sarcoma (stage IV). 50% of patients were male, 71% White, 29% Black, 7% Hispanic; mean age at diagnosis was 4.09 (SD 2.43) years. CT imaging identified IVC tumor thrombus for 79% of patients, US abdomen complete recorded 14%, and MRI lumbar 7%. 3Out of 14 patients, 13 patients were taken to the operating room with 12 patients undergoing concurrent tumor resection and IVC thrombectomy. Of the remaining patients, one had IVC thrombectomy via femoral cutdown by interventional radiology, and one was noted to have resolution of IVC thrombus with neoadjuvant chemotherapy. Of patients who underwent resection, one required IVC ligation, and one patient required IVC interposition vein graft reconstruction using a right IJ conduit. 60% of patients undergoing thrombectomy received neoadjuvant chemotherapy. Mean time from the diagnosis of IVC tumor thrombus to surgical thrombectomy was 46 (SD 44) days. No operative mortalities were reported. There were five major complications (hemothorax, pulmonary embolisms, seroma, and sepsis) and two minor complications (pneumonia and UTI). With exclusion of patient who underwent IVC ligation, no patients developed signs of IVC compression or recurrent thrombosis after thrombectomy. CONCLUSIONS: IVC tumor thrombus can significantly alter the clinical treatment, surgical options, and outcomes of malignant abdominal tumors. Treatment of IVC tumor thrombus included adjuvant chemotherapy, segmental IVC resection with or without reconstruction, thrombectomy with intimal stripping, or resection of the thrombus with part of the IVC wall. Evidence for standard treatment practices for IVC tumor thrombus in the setting of abdominal malignancy is lacking due to the rarity of this finding and the varied clinical presentations.

DYNAMICS OF CHANGES IN 2,3 DIPHOSPHOGLYCERATE AND COGNITIVE DYSFUNCTION IN THE POSTOPERATIVE PERIOD IN PATIENTS WITH ABDOMINAL NEOPLASMS.

The problem of analysis of clinical - diagnostic and biochemical criteria of postoperative cognitive dysfunction in abdominal oncosurgery, depending on the degree and structure of disorders, remains unresolved, which determines its relevance. The role of 2, 3-diphosphoglycerate is essential, because its increase in the concentration of red blood cells in hypoxic conditions is one of the adaptive mechanisms that improve oxygen transport to tissues. Purpose. The influence of the dynamics of 2,3 diphosphoglycerate content, as the main indicator of hypoxia, on the occurrence of cognitive dysfunction in the postoperative period in patients with neoplasms of the abdominal cavity. The study was conducted on the basis of departments for patients of the surgical profile of the municipal institution "Kharkiv City Clinical Hospital of Ambulance and Emergency Care named after Professor OI Meshchaninov ". To achieve this goal, we examined 80 patients with abdominal neoplasms who underwent surgery under general anesthesia using propofol and fentanyl. All patients were divided into 2 groups depending on the age of patients on the WHO scale, who underwent surgery using general anesthesia: Group 1 (n = 39) - middle-aged patients (50-59 years); Group 2 (n = 41) - elderly and senile patients (60-80 years). The control points of the examination were the day before the operation and the 1st, 7th, 30th day from the moment of the operation. The state of cognitive function in these patients was determined by conducting neuropsychological tests. To assess the state of cognitive function of patients, neuropsychological tests were used: MMSE scale (Mini-Mental State Examination, MMSE), the method of memorizing 10 words AR Luria, frontal dysfunction battery (FAB), Schulte technique. To assess the state of energy metabolism in patients, the level of erythrocytes and hemoglobin in the blood analysis was determined by well-known methods, the level of 2,3 diphosphoglycerate in erythrocytes and its ratio to hemoglobin. Anemia in the first week after surgery in patients of group 1 contributes to the development of a hypoxic state, in erythrocytes there is an increase in the content of 2,3 41 diphosphoglycerate, which promotes the transport of oxygen to tissues. During the week there is an increase in the intensity of the formation of 2,3 diphosphoglycerate, as evidenced by the ratio of 2,3 diphosphoglycerate to hemoglobin. In patients of group 2, the changes are more pronounced: anemia with a significant decrease in erythrocytes and hemoglobin in the blood, a decrease in 2.3 diphosphoglycerate in erythrocytes, reflects changes in erythrocyte metabolism, namely a decrease in biosynthesis of important organophosphorus compounds, in particular 2,3 diphosphogly by reducing the basic enzymes of glycolysis. Decreased energy metabolism in the elderly contributes to impaired cell function. With age, the content of adenosine triphosphate, 2,3 diphosphoglycerate decreases, thus increasing the affinity of hemoglobin for oxygen, impaired transport of oxygen to tissues, which leads to the development of hypoxia. According to the results of neuropsychological tests, we found postoperative cognitive dysfunction in patients with neoplasms of the abdominal cavity. Disruption of energy metabolism and changes in the activity of glycolysis enzymes in erythrocytes contributes to a decrease in the concentration of 2, 3 diphosphoglycerate, increase the affinity of hemoglobin for oxygen and the development of tissue hypoxia. The obtained results indicate the interdependence of these processes and allow continuing research in this direction with the development of appropriate clinical and diagnostic measures and areas of intensive care to improve the condition of patients with abdominal tumors and their quality of life after surgery.

Imaging for Staging of Pediatric Abdominal Tumors: An Update, From the AJR Special Series on Cancer Staging.

The three most common pediatric solid tumors of the abdomen are neuroblastoma, Wilms tumor, and hepatoblastoma. These embryonal tumors most commonly present in the first decade of life. Each tumor has unique imaging findings, including locoregional presentation and patterns of distant spread. Neuroblastoma, Wilms tumor, and hepatoblastoma have unique staging systems that rely heavily on imaging and influence surgical and oncologic management. The staging systems include image-defined risk factors for neuroblastoma, the Children's Oncology Group staging system for Wilms tumor, and the pretreatment extent of tumor system (PRETEXT) for hepatoblastoma. It is important for radiologists to be aware of these staging systems to optimize image acquisition and interpretation. This article provides a practical and clinically oriented approach to the role of imaging in the staging of these common embryonal tumors of childhood. The selection among imaging modalities, key findings for determining tumor stage, and the role of imaging in posttreatment response evaluation and surveillance are discussed. Recent updates to the relevant staging systems are highlighted with attention to imaging findings of particular prognostic importance. The information presented will help radiologists tailor the imaging approach to the individual patient and guide optimal oncologic management.

Cardiopulmonary Exercise Testing Versus Frailty, Measured by the Clinical Frailty Score, in Predicting Morbidity in Patients Undergoing Major Abdominal Cancer Surgery.

BACKGROUND: The primary outcome of this study is to investigate the association between the cardiopulmonary exercise testing (CPET) variables: anaerobic threshold (AT), peak oxygen uptake (VO2 peak), peak work rate (WR), ventilatory equivalence of CO2 (VE/VCO2) at the anaerobic threshold (AT) with frailty, measured by the clinical frailty scale (CFS) in patients planned to undergo major abdominal cancer surgery. The secondary outcome is to compare the CPET variables (VO2 peak, peak WR, VE/VCO2 at AT) with frailty measured by the CFS in predicting postoperative surgical morbidity in patients following major abdominal cancer surgery. METHODS: This study was a single-centre prospective cohort analysis of consecutive adult patients undergoing CPET and CFS scoring as part of their pre-operative work-up for major abdominal cancer surgery. RESULTS: A total of n = 317 patients underwent CPET and CFS assessment ahead of planned abdominal oncological surgery. Negative correlations were observed between the CPET variables: AT - 0.42 p < 0.01; VO2 peak - 0.53 p < 0.01; peak WR - 0.54 p < 0.01 with CFS scores and a positive correlation between CFS scores and VE/VCO2 0.29 p < 0.01. Only CFS remained statistically significant in a multivariate model OR 2.11 (1.42-3.15) 95% CI associated with Clavien-Dindo (CD) ≥ 1 defined morbidity including the significant univariate variables (VO2 peak, peak WR and CFS scores). No variables were associated with CD ≥ 3 morbidity. CONCLUSIONS: In patients scheduled to have major abdominal cancer surgery there was a weak association between poor performance on CPET and increasing frailty measured by the CFS. The CFS score unlike CPET was associated with all post-operative morbidity, but not major complications alone, in these patients. This suggests that CFS may be used as a less expensive alternative to CPET for predicting any postoperative morbidity in major abdominal cancer surgery.

Treatment of infantile fibrosarcoma associated to an abdominal aortic aneurysm with larotrectinib: a case report.

Infantile fibrosarcoma (IFS) is a rare pediatric tumor which often presents the ETV6-NTRK3 gene fusion. NTRK3 encodes the neurotrophin-3 growth factor receptor tyrosine kinase, a druggable therapeutic target. Selective tropomyosin receptor kinase (TRK) inhibitors, such as larotrectinib, have shown efficacy and safety in the treatment of IFS. We report a case of an abdominal IFS diagnosed in a newborn associated with an aortic aneurysm that was successfully treated with larotrectinib without relevant adverse effects.

[Treatment of Concomitant Intra-abdominal Malignancy and Abdominal Aortic Aneurysm].

Objective To explore the outcomes in patients who receive the endovascular abdominal aortic aneurysm repair(EVAR)and have concomitant intra-abdominal malignancy.Methods Between January 2014 and December 2019,all the patients who underwent surgery for malignancy and/or EVAR were retrospectively reviewed.Results Twenty-eight abdominal aortic aneurysm(AAA)patients with concomitant intra-abdominal malignancy were included.The patients were treated by two-stage operation and the priority was given for EVAR in 21 patients.There was no perioperative death or major complications.In the follow-up,one patient developed graft thrombosis and one had type Ⅱ endoleak.There was no AAA-associated death.Conclusions It is preferred that EVAR should come first followed by operation for malignancy.Details of treatment strategy still need further investigation.

Contrast-enhanced ultrasound-guided celiac plexus neurolysis in patients with upper abdominal cancer pain: initial experience.

OBJECTIVES: The purpose of this study was to determine the efficacy and safety of contrast-enhanced ultrasound (CEUS)-guided celiac plexus neurolysis (CPN) in patients with upper abdominal cancer pain. METHODS: Thirty-five patients with upper abdominal cancers tortured by intractable upper abdominal pain underwent CEUS-guided CPN with ethanol. The pain alleviation and opioid intake were observed and evaluated during a 3-month follow-up after CPN. The dispersion of alcohol around the aorta was evaluated on 3D-CEUS. Complications were assessed during CPN and at follow-up. RESULTS: All of the 35 patients' CPN was successfully achieved. Pain relief was observed in 28 (80%), 20 (57.1%), 27 (77.1%), 20 (57.1%), and 10 (29.4%) patients immediately, 1 day, 1 month, 2 months, and 3 months after CPN, respectively. The agent dispersion around the aorta on CEUS images of 28 patients who showed pain relief was at least 90° of the circumference around the aorta. The median duration of pain alleviation was 2.7 months (95% confidence interval [CI], 2.5-2.9). Less than half of the patients had minor complications including irritant pain at the puncture site (8 of 35; 22.9%), diarrhea (4 of 35; 11.4%), nausea and vomiting (3 of 35; 8.6%), and post-procedural hypotension (1 of 35; 2.9%). CONCLUSIONS: CEUS-guided CPN is a safe and effective method to alleviate refractory upper abdominal pain in patients with upper abdominal cancers. CEUS image allows the visualization of puncture path and observation of drug dispersion. The pain relief is relevant to the dispersion of neurolytic agent around the aorta. KEY POINTS: • CEUS-guided celiac plexus neurolysis (CPN) is feasible and easy. • It allows direct visualization of the diffusion of the neurolytic agent in the retroperitoneal anatomic space. • CEUS-guided CPN improves safety of CPN by clearly delineating the needle path.

Ectopic ACTH Syndrome in a Child With Abdominal Ewing Sarcoma: A Rare Paraneoplastic Phenomenon.

Ectopic adrenocorticotropic hormone syndrome is a paraneoplastic phenomenon rarely seen in pediatrics and rarely described in Ewing sarcoma. We report a 15-year-old boy with abdominal Ewing sarcoma and clinical and laboratory findings of ectopic adrenocorticotropic hormone syndrome that promptly resolved with treatment of the tumor.

Repeated subcutaneous esketamine administration for depressive symptoms and pain relief in a terminally ill cancer patient: A case report.

BACKGROUND: Depressive disorders are common among cancer patients. Ketamine can quickly relieve depression, and its subcutaneous administration appears to be as effective as and probably safer than its standard intravenous administration. Herein, we report a case verifying the antidepressant effect of a subcutaneous esketamine formulation. CASE PRESENTATION: A 65-year-old male with metastatic abdominal tumor reported sadness, weight loss, fatigue, hopelessness, insomnia, inattention, and reduced motivation. His scores on the visual analogical scale for pain and Montgomery-Asberg depression rating scale were 8/10 and 30/60, respectively. POSSIBLE COURSES OF ACTION: Monoaminergic antidepressants are effective, but their response is slow for end-of-life care. FORMULATION OF A PLAN: Esketamine was preferred because it possibly contributes to pain relief. It can repeatedly be infused intravenously, but was subcutaneously administered twice a week for safety reasons. OUTCOME: The patient showed continuous mood improvement, achieving depression remission on day 7. Pain relief was observed but without stability. His vital signs remained stable, and he remained calm, without major complaints. LESSONS FROM THE CASE: Repeated subcutaneous esketamine injections are possibly safe and effective in pain and depression relief in palliative care cancer patients. VIEW ON RESEARCH PROBLEMS, OBJECTIVES, OR QUESTIONS GENERATED BY THE CASE: Placebo-controlled studies with similar cases are needed to establish efficacy and safety.

Alopecia neoplastica as a sign of visceral malignancies: a systematic review.

Alopecia neoplastica (AN) from visceral tumours is a rare form of cutaneous metastasis in which internal malignancies spread to the scalp. The diagnosis of AN may be very challenging, especially when its onset precedes the diagnosis of the primary tumour. We aimed to improve the knowledge on AN, highlighting that in case of scarring localized alopecia, a differential diagnosis with metastasis should always be considered. We performed a systematic review to describe the main demographic and clinical features associated with AN from visceral malignancies; a survival analysis was also performed. In 118 reports, accounting for 123 patients, we found that women were more affected by AN than men (53.7% vs. 46.3%). The most frequent site of the primary tumour was the gastrointestinal tract (24.4%), followed by breast (17.9%), kidney (8.1%), lung (7.3%), thyroid (7.3%), uterus (6.5%), central nervous system (6.5%), liver (3.3%) and other anatomic areas for 18.7% of cases. Furthermore, in more than half of the cases (66.1%), AN lesions were single and were mainly diagnosed after the primary visceral tumour (71.5%). Finally, survival analysis highlighted a lower progression-free survival in men; while, no significant differences in overall survival were reported among genders. In conclusion, metastatic skin disease should always be taken into consideration when dealing with patients with localized scarring alopecia.

Endovascular Denervation: A New Approach for Cancer Pain Relief?

PURPOSE: To evaluate the effects of endovascular denervation (EDN) on abdominal cancer pain relief. MATERIALS AND METHODS: From April 2017 to February 2018, 7 cancer patients (2 males and 5 females) were enrolled in this study. The diagnoses of the patients included 3 pancreatic cancer, 2 cervical carcinoma, 1 cholangiocarcinoma, and 1 esophageal cancer with retroperitoneum lymph nodes invasion. Denervation was carried out at the abdominal aorta close to the origin of celiac artery and superior mesenteric artery with the use of a multielectrode radiofrequency ablation catheter with settings of time 120 seconds and temperature 60°C. The primary end point was improvement in pain scores. The secondary end points included change in quality of life, intake of narcotics, and the safety of EDN. RESULTS: All of the patients experienced pain relief. The pain scores as measured by means of visual analog scores at 1, 2, 4, 8, and 12 weeks after the procedure were significantly lower than before the operation (P < .001). A > 4 score reduction was observed in all cases. A significant reduction in narcotics use within 3 months after the operation was also seen. The quality of life scores of the patients improved significantly (P < .005) with better sleep. No severe treatment-related adverse events or major complications were observed. CONCLUSIONS: EDN is a safe and effective means to alleviate pain caused by cancer and may serve as a new approach for cancer pain relief and palliative care.

Home parenteral nutrition for people with inoperable malignant bowel obstruction.

BACKGROUND: People with advanced ovarian or gastrointestinal cancer may develop malignant bowel obstruction (MBO). They are able to tolerate limited, if any, oral or enteral (via a tube directly into the gut) nutrition. Parenteral nutrition (PN) is the provision of macronutrients, micronutrients, electrolytes and fluid infused as an intravenous solution and provides a method for these people to receive nutrients. There are clinical and ethical arguments for and against the administration of PN to people receiving palliative care. OBJECTIVES: To assess the effectiveness of home parenteral nutrition (HPN) in improving survival and quality of life in people with inoperable MBO. SEARCH METHODS: We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1), MEDLINE (Ovid), Embase (Ovid), BNI, CINAHL, Web of Science and NHS Economic Evaluation and Health Technology Assessment up to January 2018, ClinicalTrials.gov (http://clinicaltrials.gov/) and in the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal (http://apps.who.int/trialsearch/). In addition, we handsearched included studies and used the 'Similar articles' feature on PubMed for included articles. SELECTION CRITERIA: We included any studies with more than five participants investigating HPN in people over 16 years of age with inoperable MBO. DATA COLLECTION AND ANALYSIS: We extracted the data and assessed risk of bias for each study. We entered data into Review Manager 5 and used GRADEpro to assess the quality of the evidence. MAIN RESULTS: We included 13 studies with a total of 721 participants in the review. The studies were observational, 12 studies had only one relevant treatment arm and no control and for the one study with a control arm, very few details were given. The risk of bias was high and the certainty of evidence was graded as very low for all outcomes. Due to heterogeneity of data, meta-analysis was not performed and therefore the data were synthesised via a narrative summary.The evidence for benefit derived from PN was very low for survival and quality of life. All the studies measured overall survival and 636 (88%) of participants were deceased at the end of the study. However there were varying definitions of overall survival that yielded median survival intervals between 15 to 155 days (range three to 1278 days). Three studies used validated measures of quality of life. The results from assessment of quality of life were equivocal; one study reported improvements up until three months and two studies reported approximately similar numbers of participants with improvements and deterioration. Different quality of life scales were used in each of the studies and quality of life was measured at different time points. Due to the very low certainty of the evidence, we are very uncertain about the adverse events related to PN use. Adverse events were measured by nine studies and data for individual participants could be extracted from eight studies. This revealed that 32 of 260 (12%) patients developed a central venous catheter infection or were hospitalised because of complications related to PN. AUTHORS' CONCLUSIONS: We are very uncertain whether HPN improves survival or quality of life in people with MBO as the certainty of evidence was very low for both outcomes. As the evidence base is limited and at high risk of bias, further higher-quality prospective studies are required.

Oral water soluble contrast for malignant bowel obstruction.

BACKGROUND: Malignant bowel obstruction (MBO) is a common problem in patients with intra-abdominal cancer. Oral water soluble contrast (OWSC) has been shown to be useful in the management of adhesive small bowel obstruction in identifying patients who will recover with conservative management alone and also in reducing the length of hospital stay. It is not clear whether the benefits of OWSC in adhesive small bowel obstruction are also seen in patients with MBO. OBJECTIVES: To determine the reliability of OWSC media and follow-up abdominal radiographs in predicting the success of conservative treatment in resolving inoperable MBO with conservative management.To determine the efficacy and safety of OWSC media in reducing the duration of obstruction and reducing hospital stay in people with MBO. SEARCH METHODS: We identified studies from searching Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in Process, Embase, CINAHL, Science Citation Index (Web of Science) and Conference Proceedings Citation Index - Science (Web of Science). We also searched registries of clinical trials and the CareSearch Grey Literature database. The date of the search was the 6 June 2017. SELECTION CRITERIA: Randomised controlled trials (RCTs), or prospective controlled studies, that evaluated the diagnostic potential of OWSC in predicting which malignant bowel obstructions will resolve with conservative treatment.RCTs, or prospective controlled studies, that assessed the therapeutic potential of OWSC in managing MBO at any level compared with placebo, no intervention or usual treatment or supportive care. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We assessed risk of bias and assessed the evidence using GRADE and created a 'Summary of findings' table. MAIN RESULTS: We found only one RCT meeting the selection criteria for the second objective (therapeutic potential) of this review. This study recruited nine participants. It compared the use of gastrografin versus placebo in adult patients with MBO with no indication for further intervention (surgery, endoscopy) apart from standardised conservative management.The overall risk of bias for the study was high due to issues with low numbers of participants, selective reporting of outcomes and a high attrition rate for the intervention arm.Primary outcomesThe included trial was a pilot study whose primary outcome was to test the feasibility for a large study. The authors reported specifically on the number of patients screened, the number recruited and reasons for exclusion; this was not the focus of our review.Due to the low number of participants, the authors of the study decided not to report on our primary outcome of assessing the ability of OWSC to predict the likelihood of malignant small bowel obstruction resolving with conservative treatment alone (diagnostic effect). It also did not report on our primary outcome of rate of resolution of MBO in patients receiving OWSC compared with those not receiving it (therapeutic effect).The study reported that no issues regarding safety or tolerability of either gastrografin or placebo were identified. The overall quality of the evidence for the incidence of adverse events with OWSC was very low, downgraded twice for serious limitations to study quality (high risk of selective reporting and attrition bias) and downgraded once for imprecision (sparse data).Secondary outcomesThe study planned to report on this review's secondary outcome measures of length of hospital stay and time from administration of OWSC to resolution of MBO. However the authors of the study decided not to do so due to the low numbers of patients recruited. The study did not report on our secondary outcome measure of survival times from onset of inoperable MBO until death. AUTHORS' CONCLUSIONS: There is insufficient evidence from RCTs to determine the place of OWSC in predicting which patients with inoperable MBO will respond with conservative treatment alone. There is also insufficient evidence from RCTs to determine the therapeutic effects and safety of OWSC in patients with malignant small bowel obstruction.

Paraneoplastic pemphigus without antibodies to desmoglein 1 and 3.

Paraneoplastic pemphigus is a severe autoimmune blistering disease presenting in the setting of underlying malignancy. Paraneoplastic pemphigus is associated with diffuse painful stomatitis throughout the oral cavity with extension to the lips. The cutaneous findings are varied and have been described as lichenoid, pemphigoid, and targetoid lesions. Herein, we report a patient with paraneoplastic pemphigus whose routine testing led to a diagnosis of pemphigus vulgaris. However, further testing was pursued revealing an antibody profile consistent with paraneoplastic pemphigus. Subsequent neoplastic workup revealed an intra-abdominal mass. Our case represents a subtle, non-classic presentation of paraneoplastic pemphigus and suggests the importance of a comprehensive investigative work-up in atypical cases of pemphigus.

Epidemiological Data on the Nutritional Status of Cancer Patients Receiving Treatment with Concomitant Chemoradiotherapy, Radiotherapy or Sequential Chemoradiotherapy to the Abdominopelvic Area.

Cancer patients are particularly susceptible to undernourishment so associated weight loss is frequent. Approximately 15% of patients lose >10% of their usual body weight, 40-80% become undernourished, and about 20% die as a result. Well-nourished patients have a higher survival rate when compared with patients at risk of undernourishment (19.9 vs. 3.7 months); hence, nutritional intervention is pivotal. Undernourishment negatively influences the patient's prognosis, and its prevalence depends on the tumor type and location, disease stage, treatment, and the applied nutritional evaluation tool. During abdominopelvic radiotherapy, up to 90% of patients experience symptoms of varying severity; weight loss during radiotherapy is an early indicator of nutritional deterioration, and he the use of radiation is associated with a higher likelihood of undernourishment. In patients with gynecological malignancies, 12.5-54% are malnourished before receiving oncological treatment, worsening after treatment in 35.8-82% of cases. There is also deterioration of the nutritional status in patients with colorectal cancer once pelvic radiotherapy is initiated, whereby 50% of cases are malnourished at the beginning of treatment, and 66.7% are so when it ends. Although there are notable differences in the impact of radiotherapy on weight according to the radiated region, 88% patients receiving abdominal radiotherapy were found to lose weight compared to 38% of patients whose treatment was limited to the pelvis.