Relapsed/refractory primary mediastinal large B-cell lymphoma: a structured review of epidemiology, treatment guidelines and real-world treatment practices.

Background: Primary mediastinal (thymic) large B-cell lymphoma (PMBCL) is an uncommon subtype of diffuse large B-cell lymphoma. Approximately 10-30% of patients experience refractory or relapsed PMBCL (rrPMBCL) after first-line therapy. Data and treatment guidelines for rrPMBCL are scarce, and management is based on clinical experience.Methods: Two structured literature reviews were undertaken to determine the incidence, prevalence, and mortality rates associated with rrPMBCL, and to identify clinical practice guidelines and real-world patterns of care.Results: Epidemiology studies included reported lymphomas (n = 1), non-Hodgkin lymphoma (n = 1), lymphoid neoplasm (n = 1), PMBCL (n = 6), and rrPMBCL (n = 1). Of 12 published treatment guidelines, only four provided recommendations for rrPMBCL. Sixteen studies provided data on real-world treatment patterns, but most were single-center studies with small patient numbers. Chemotherapy/immunochemotherapy, followed by high-dose treatment (HDT) and stem cell transplantation, was a mainstay of salvage therapy in most studies; real-world care generally followed treatment guidelines.Conclusions: Salvage chemotherapy (often with rituximab and radiotherapy), followed by HDT and stem cell transplantation, appears to be the standard real-world treatment for rrPMBCL. However, large prospective and retrospective studies are warranted to improve our knowledge of real-world treatment patterns.

First-line therapy for treatment-naive patients with advanced/metastatic renal cell carcinoma: a systematic review of published randomized controlled trials.

In the recent years, a number of targeted therapies have been approved for first-line treatment of patients with metastatic renal cell carcinoma. A systematic review was conducted to assess the clinical efficacy, safety and effect of all first-line treatments evaluated to date on health-related quality of life (HRQoL). A systematic search of Embase, Cochrane and MEDLINE databases was performed to identify randomized controlled trials (1980-2015) evaluating any targeted therapy/immunotherapy against placebo or any other targeted intervention/immunotherapy in treatment-naive patients with metastatic renal cell carcinoma. Conference proceedings from major cancer congresses (2007-2015) were handsearched. Sixteen randomized controlled trials were identified, mostly phase III. Overall, targeted therapies were associated with either improved [sunitinib, bevacizumab+interferon α (IFNα) and temsirolimus] or comparable (sorafenib) progression-free survival (PFS) versus IFNα monotherapy. Sunitinib demonstrated comparable PFS and overall survival to pazopanib, comparable PFS to sorafenib and shorter PFS compared with bevacizumab+IFNα (although no conclusions were made with regard to superiority/inferiority). Compared with sorafenib, tivozanib demonstrated a significantly longer PFS, and both tivozanib and axitinib demonstrated higher response rates. Nintedanib demonstrated comparable PFS and overall survival to sunitinib in a phase II trial. Temsirolimus, sunitinib and sorafenib treatment led to better HRQoL versus IFNα; pazopanib was associated with better HRQoL versus sunitinib. No direct meta-analyses or indirect treatment comparison analysis were undertaken because of noncomparability of the trials. In general, targeted therapies demonstrated favourable clinical efficacy and improved HRQoL compared with IFNα monotherapy. The newer therapies, tivozanib and axitinib (but not nintedanib), appeared to exhibit greater clinical benefit (response rate) than older tyrosine kinase inhibitors.

Treatment of chronic symptomatic vertebral compression fractures with percutaneous vertebroplasty.

OBJECTIVE: Most fractures treated with percutaneous vertebroplasty are subacute and less than 1 year old. We report our experience treating chronic vertebral fractures with vertebroplasty. MATERIALS AND METHODS: Our database identified 41 patients with symptomatic fractures more than 1 year old. These patients were categorized into subgroups determined by fracture age: 12 months 1 day-24 months (n = 16) or more than 24 months 1 day (n = 25). Changes in pain and mobility for the study group were compared with those in 49 patients with fractures less than 1 year old. RESULTS: Thirty-three (80%) of the 41 patients in the study group had improvement in pain-seven (17%) had complete and 26 (63%) had partial relief. Forty-five (92%) of the 49 control group patients had improvement in pain-24 (49%) had complete and 21 (43%) had partial relief. The number of patients achieving partial or complete relief of pain was not statistically different between groups (p > 0.05), although complete relief was significantly more frequent in the control group (p = 0.002). Twenty patients (49%) in the study group versus 34 patients (69%) in the control group had improved mobility after vertebroplasty (p = 0.047). Patients with fractures 12 months 1 day-24 months old had improvement in mobility similar to that in patients in the control group (p = 0.962). Fractures more than 24 months 1 day old were associated with significantly less improvement in mobility (p = 0.006). CONCLUSION: Most patients with fractures more than 1 year old will experience clinical benefit from vertebroplasty. Complete relief of pain is more likely when less mature fractures are treated.

Aortoatrial fistula complicating transjugular intrahepatic portosystemic shunt by protrusion of a stent into the right atrium: radiologic/pathologic correlation.

Numerous procedural complications of creation of a transjugular intrahepatic portosystemic shunt (TIPS) have been reported. In this article, a case of an aorto-right-atrial fistula after the revision of a TIPS is reported. The fistula developed from the free edge of a stent that protruded into the right atrium. The patient developed progressive right heart failure and eventually died of complications of right heart failure. Prevention of this potential complication with careful catheter manipulations under fluoroscopic observation around newly placed stents is recommended to prevent dislodgement of the stents. Careful deployment that avoids extension of the stent into the right atrium is essential to avoid the complication of cardiac perforation.