Impact of age on central lymph nodes involvement in papillary thyroid cancer.

BACKGROUND: Total thyroidectomy is the main line of treatment for papillary thyroid cancer. Central lymph node dissection (CLND) is still debatable. In this study, we aimed to correlate the central lymph node status with the age of patients. METHODS: This is a retrospective study including patients with papillary thyroid cancer (PTC) who underwent total thyroidectomy and CLND at a tertiary cancer center during the period from January 2012 to September 2022. Patients were subdivided into 3groups: patients younger than 20 years old, patients between 20 and 40 years old, and patients older than 40 years old. Correlation between central lymph node status, lateral lymph node status, and harvest count with each other and between age groups was done. RESULTS: 315 patients were included. The younger the age group the higher the possibility of harboring positive central nodes, however, the positivity of lateral nodes was similar. Neither central nodal harvest nor positive central node count significantly differed between groups. The lateral nodal harvest was significantly higher in the < 20 years group with no affection to the number of positive nodes retrieved. The younger the age group the longer the disease-free survival (DFS). CONCLUSION: We can conclude that patients younger than twenty years had a higher probability of harboring malignancy in central nodes and higher lateral node harvest on dissection. In contrast, they do have a lower incidence of recurrence.

Screening for the prevalence of rheumatic heart disease among school children in Egypt.

BACKGROUND: In low-income nations, Rheumatic valvular heart disease remains a major cause of morbidity and premature deaths. Accurate prevalence data in Egypt are still lacking yet highly desirable to facilitate health care planning. METHODOLOGY: An cluster sample of school children in eastern Egyptian Governorates was examined clinically and echocardiographically (using abbreviated protocol) for detection of rheumatic valvular heart disease based on 2012 World Heart Federation criteria (the Doppler and the morphological criteria) for diagnosis. According to echocardiography interpretation, participants were categorized as having definite rheumatic heart disease (RHD), borderline RHD or no RHD. RESULTS: A total of 1680 students aged between 6 and 18 years were screened, 119 echocardiographic studies were non-interpretable; so, a total of 1560 studies were evaluated. From the total screened students, 1560 studies were adequate and interpretable according to the criteria specified in the methods section. This revealed a prevalence of 2.3% of the sample with RHD without adding the equivocal cases. The most prevalent lesion as detected by echocardiography was mitral regurgitation (29% of definite RHD cases). CONCLUSION: Rheumatic valvular heart disease remains prevalent in Egypt and the findings of this study should influence early detection, primary and secondary prevention, and adequate future national health plans.

Identification of a circulating microRNAs biomarker panel for non-invasive diagnosis of coronary artery disease: case-control study.

BACKGROUND: Circulating microRNAs (miRNAs) are considered a hot spot of research that can be employed for monitoring and/or diagnostic purposes in coronary artery disease (CAD). Since different disease features might be reflected on altered profiles or plasma miRNAs concentrations, a combination of miRNAs can provide more reliable non-invasive biomarkers for CAD. SUBJECTS AND METHODS: We investigated a panel of 14-miRNAs selected using bioinformatics databases and current literature searching for miRNAs involved in CAD using quantitative real-time PCR technique in 73 CAD patients compared to 73 controls followed by function and pathway enrichment analysis for the 14-miRNAs. RESULTS: Our results revealed three out of the 14 circulating miRNAs understudy; miRNAs miR133a, miR155 and miR208a were downregulated. While 11 miRNAs were up-regulated in a descending order from highest fold change to lowest: miR-182, miR-145, miR-21, miR-126, miR-200b, miR-146A, miR-205, miR-135b, miR-196b, miR-140b and, miR-223. The ROC curve analysis indicated that miR-145, miR-182, miR-133a and, miR-205 were excellent biomarkers with the highest AUCs as biomarkers in CAD. All miRNAs under study except miR-208 revealed a statistically significant relation with dyslipidemia. MiR-126 and miR-155 showed significance with BMI grade, while only miR-133a showed significance with the obese patients in general. MiR-135b and miR-140b showed a significant correlation with the Wall Motion Severity Index. Pathway enrichment analysis for the miRNAS understudy revealed pathways relevant to the fatty acid biosynthesis, ECM-receptor interaction, proteoglycans in cancer, and adherens junction. CONCLUSION: The results of this study identified a differentially expressed circulating miRNAs signature that can discriminate CAD patients from normal subjects. These results provide new insights into the significant role of miRNAs expression associated with CAD pathogenesis.

Role of simulation in open varicose veins surgery: A systematic review.

OBJECTIVE: To assess the types and effectiveness of simulators present for open varicose vein surgery. METHODS: The systematic review was conducted at The Aga Khan University Hospital Karachi and comprised studies published from 1st January 2000 to 30th June 2020 related to open varicose vein surgical procedures done on simulators. Databases searched were PubMed, Medline, Google Scholar, Cochrane and Scopus using appropriate key words. The primary outcome of the review was to assess the effectiveness of different types of simulators used for varicose vein surgery. RESULTS: Of the 286 articles found, 6(2%) were included. A variety of simulators ranging from animal models, homemade simulators and commercially designed models with high fidelity options had been used. Technical competence was the major domain assessed in most of the studies 5(83.3%), while 1(16.6%) study focussed on self-assessment. Blinding was done in 4(66.6%) studies for assessment purpose, and videorecording of the trainees' performance was done in 5(83.3%) studies. Most studies 4(66.6%) found the use of simulation to be an effective tool in achieving technical competence. CONCLUSION: The use of simulation in the training of surgical residents for open varicose vein surgery was found to be beneficial, but most studies were heterogeneous in terms of design, simulator types and study participants. This makes it difficult to establish the superiority of any one type of simulator over the rest. Further research is needed to develop and validate simulators in open varicose vein surgery procedures.

May-Thurner Syndrome: A Cause of Acute Left Iliac Vein Obstruction in Early Postpartum Period: A Case Report.

May-Thurner syndrome (MTS) is a rare disease common in middle aged females, characterised by left-sided lower limb Deep vein thrombosis (DVT) due to compression of the left iliac vein by the overriding right iliac artery. Pregnanc y and puerperal phases are one of the hypercoagulable states further predisposing towards th rombu s format io n. Treatme nt in c lu de s both conservative and interventional (venous thrombectomy with or without stenting). Here we report a case of a 34- year-old female in her early postpartum period who visited the Agha Khan University Hospital in July 2016, with the onset of acute pain and swelling in the left leg. Her workup revealed left-sided Acute DVT, secondary to MTS. Her case was su cces sfull y mana ged with conservative treatment. This case is an important addition to medical literature in the sense that DVT occurring on the onset of postpartum period should not always be attributed to the hypercoagulability, secondary to pregnancy. With early diagnosis and aggressive management, MT Scan be easily managed .

Template operative note, a better documentation.

Operative notes are a valuable part of patient's medical record, and carry the medico-legal significance. One way of improving it is to introduce the template form operative notes. Only few studies have been done worldwide to compare both the forms of operative notes. This cross-sectional study was conducted in the department of General Surgery, AKUH. This included the patients who underwent Laparoscopic cholecystectomy (Complying with inclusion criteria) from August 2013 till March 2014. Out of 24 patients, 19 were females. The completeness of data in template group was significantly better than traditional group (79.2% vs. 8.3%). There was no significant difference among the residents of different level (writing the notes) and the completeness of data in both the groups. Similarly the timing of day did not affect significantly on the completeness.

Why do patients with limb ischaemia present late to a vascular surgeon? A prospective cohort study from the developing world.

OBJECTIVE: To look into the factors responsible for delay in presentation of Iimb ischemia patients to a vascular surgeon. Methods: The prospective cohort study was conducted at the Aga Khan University Hospital, Karachi, from October 01, 2016, to August 10, 2018. Patients coming with delayed presentation of both acute and chronic limb ischemia were included. All the patients were assessed by qualified vascular surgeons. SPSS 23 was used for data analysis. Results: Of the 55 patients, 33(60%) had acute and 22(40%) had chronic limb ischaemia. Mean age of acute cases was 44±23.72 years and it was 60±12.49 years for chronic cases. Overall, the commonest reason behind delay was non-referral by primary physician which was the case with 11(33.3%) patients in the acute group, and 13(59%) in the chronic group. The limb loss in the acute group was 20(60%) and 8(36%) in the chronic group.. Conclusion: Delayed presentation of patients with limb ischaemia is mainly due to non-referral. A robust campaign needs to be launched to reduce the rate of limb loss.

Fistulotomy versus fistulectomy for simple fistula in ano: a retrospective cohort study.

OBJECTIVE: To compare fistulotomy with fistulectomy for wound healing, duration of surgery, post-operative pain, incontinence and recurrence in patients with fistula in ano. METHODS: This retrospective cohort study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of adults who had undergone fistulotomy/fistulectomy for simple fistula in ano from January 2007 to August 2012. Data collection was done in August 2013 using questionnaire and telephonic interviews. Outcome variables like duration of wound healing, recurrence, incontinence, duration of surgery and post-operative pain were compared in both the groups. SPSS 19 was used for data analysis. RESULTS: Of the 192 cases, there were 96(50%) in each group. The mean age was 40.51 years (range: 21-72 years) in the fistulotomy group and 41.14 years (range: 21-66 years) in the fistulectomy group (p=0.66). Both groups were comparable for baseline demographic variables. The median duration of wound healing was shorter in the fistulotomy group 15 days (Interquartile range: 7-20 days) compared to the fistulectomy group 30 days (Interquartile range: 15-42 days) (p<0.001). The incidence of recurrence was comparable in fistulotomy vs. fistulectomy (3[3.12%] vs. 4[4.16%]; p=0.70). The incidence of incontinence was higher in fistulotomy compared to fistulectomy (5[5.3%] vs. 12[12.5%]; p=0.07). The severity of incontinence was also compared but the difference was insignificant (p=0.06). The median duration of surgery was significantly shorter in fistulotomy group 17 minutes (Interquartile range: 12-25 minutes) compared to fistulectomy group 25 minutes Interquartile range: 20-35 minutes (p<0.001). The median post-operative pain in the surgical day care unit and at the first follow-up in clinic was zero for both groups. CONCLUSIONS: Fistulotomy yielded better results than fistulectomy since it significantly decreased the duration of wound healing and duration of surgery without increasing the incidence of recurrence, incontinence and post-operative pain.

Hookworm infestation as a cause of melena and severe anaemia in farmer.

Hookworm infections remain a major cause of morbidity in the developing world. Prevalence is highest in agricultural areas, where use of waste water for irrigation and poor hygiene increases infection rates among farmers. Infections present with gastrointestinal symptoms and chronic anaemia, and there are usually no signs of overt blood loss. The following report describes a case of melena in a middle-aged farmer, where the diagnosis of hookworm infestation was delayed due to the unusual presentation. The patient underwent multiple blood transfusions before referral to the Aga Khan University Hospital (AKUH), Karachi and was managed conservatively with mebendazole at our hospital after exclusion of other possible causes of gastrointestinal bleeding. This case highlights the importance of considering hookworm infestations as a cause of melena in the older age group, where other critical differentials such as peptic ulcer disease and occult malignancy may result in delay in initiation of treatment and a significant financial burden on the patient.

Mechanical characteristics of hardened concrete with different mineral admixtures: a review.

The available literature identifies that the addition of mineral admixture as partial replacement of cement improves the microstructure of the concrete (i.e., porosity and pore size distribution) as well as increasing the mechanical characteristics such as drying shrinkage and creep, compressive strength, tensile strength, flexural strength, and modulus of elasticity; however, no single document is available in which review and comparison of the influence of the addition of these mineral admixtures on the mechanical characteristics of the hardened pozzolanic concretes are presented. In this paper, based on the reported results in the literature, mechanical characteristics of hardened concrete partially containing mineral admixtures including fly ash (FA), silica fume (SF), ground granulated blast furnace slag (GGBS), metakaolin (MK), and rice husk ash (RHA) are discussed and it is concluded that the content and particle size of mineral admixture are the parameters which significantly influence the mechanical properties of concrete. All mineral admixtures enhance the mechanical properties of concrete except FA and GGBS which do not show a significant effect on the strength of concrete at 28 days; however, gain in strength at later ages is considerable. Moreover, the comparison of the mechanical characteristics of different pozzolanic concretes suggests that RHA and SF are competitive.

Onlay bone graft maintenance using guided bone regeneration, platelet rich plasma, and their combination.

Onlay bone grafts have a bad reputation of resorption with loss of contour and volume. Rigid fixation reduces the incidence of resorption but does not prevent it. Literature shows reduction of resorption by applying guided bone regeneration (GBR) barriers and platelet-rich plasma (PRP). Investigating the effect of combining them together to reduce resorption was the aim of this study. This study included 4 groups: control group, GBR group, PRP group, and GBR + PRP group. Twenty rabbits were used (40 mandibular halves). Onlay bone grafts were fixed by titanium miniscrews in all groups. Computed tomography scans of harvested mandibles after euthanasia allowed calculations of bone graft volume and density. Onlay bone graft volumes in all experimental groups were significantly higher than in the control group. Volume maintenance in the GBR group was significantly higher than in the PRP group. There was no significant difference in the volume of onlay bone grafts between the group of combined GBR + PRP and GBR alone. It was concluded that, to maintain the volume of onlay bone grafts, either GBR or PRP can be added. Combining them did not add any advantage over the GBR alone.

Aetiologies of Leg Pain among Patients Presenting to a Vascular Surgery Clinic.

OBJECTIVE: To determine the frequency and pattern of different aetiologies of leg pain among patients visiting vascular surgery clinics. STUDY DESIGN: Cross-sectional study. Place and Duration of the Study: Vascular Surgery Clinics of the Aga Khan University Hospital, Karachi, Pakistan, between February 2021 and June 2023. METHODOLOGY: This study examined patients presenting with leg pain for the first time at vascular surgery clinics. The socio-demographic and clinical data including the clinical symptoms, physical examination findings, and management of leg pain were noted using a specially designed proforma. RESULTS: In a total of 142 patients (200 limbs), 82 (57.7%) were females and 60 (42.3%) were males, with a mean age of 46.8 ± 15.1 years. The patients' mean body mass index (BMI) was 30.2 ± 7.9 kg/m2. Ninety-one (64.1%) patients had a predominantly standing job compared to 51 (35.9%) patients who had a predominantly sitting job. The most common aetiology of leg pain was chronic venous insufficiency (CVI), diagnosed in 107 (53.5%) patients, followed by neurogenic pain [41 (20.5%)], musculoskeletal pain including knee osteoarthritis [30 (15.0%)], and arterial insufficiency [22 (11.0%)].  Conclusion: CVI followed by neuropathic pain was the leading cause of leg pain in vascular surgery clinics at a tertiary care hospital. KEY WORDS: Chronic venous insufficiency, Arterial insufficiency, Vascular surgery, Leg pain, Musculoskeletal pain, Neuralgia.

Managing Splenic Artery Pseudoaneurysms-An Experience from a Developing Country. A Retrospective Review.

Objectives: Splenic artery pseudoaneurysm is a rare but potentially fatal condition. Early diagnosis and intervention are the key steps in the management of this condition. We have reviewed our institution's 4-year data regarding the presentation and management of this condition. Methods: We conducted a prospective review of the records of 10 patients who presented to our institute from January 2018 to December 2021 with a splenic artery pseudoaneurysm. We found one patient with a true aneurysm, whom we excluded from the study. Results: This study included seven male and two female patients with a mean age of 47.7 years. Six patients presented to the emergency department with bleeding secondary to rupture aneurysm, which is the most common reason for admission. Pancreatitis was found to be the most common cause for splenic artery pseudoaneurysm (five patients). Computed tomography angiogram remained the modality of choice for diagnosing splenic artery pseudoaneurysm. All patients were successfully managed with endovascular intervention. Conclusion: Splenic artery pseudoaneurysm is usually a rare complication of pancreatitis, which is associated with high morbidity and mortality. Timely diagnosis and intervention are the keys to successful management. Endovascular embolization should be the first-line therapy in splenic artery pseudoaneurysm.

Introducing Circulating Vasculature-Related Transcripts as Biomarkers in Coronary Artery Disease.

BACKGROUND: Atherosclerotic plaque is considered the hallmark of atherosclerotic lesions in coronary atherosclerosis (CAS), the primary pathogenesis in coronary artery disease (CAD), which develops and progresses through a complex interplay between immune cells, vascular cells, and endothelial shear stresses. Early diagnosis of CAS is critical for avoiding plaque rupture and sudden death. Therefore, identifying new CAD biomarkers linked to vessel wall functions, such as RNA molecules with their distinct signature, is a promising development for these patients. With this rationale, the present study investigated the expression level of the vascular-related RNA transcripts (lncRNA ANRIL, miRNA-126-5p, CDK4, CDK6, TGF-ß, E-cadherin, and TNF-α) implicated in the cellular vascular function, proliferation, and inflammatory processes. METHODS: A case-control study design with a total of 180 subjects classified participants into two groups; CAD and control groups. The relative expression levels of the seven transcripts under study-selected using online bioinformatics tools and current literature-were assessed in the plasma of all study participants using RT-qPCR. Their predictive significance testing, scoring of disease prioritization, enrichment analysis, and the miRNA-mRNA regulatory network was investigated. RESULTS: The relative expression levels of all seven of the circulating vascular-related transcripts under study were statistically significant between CAD patients and controls. Receiver operating characteristic (ROC) analysis results indicated the statistical significance of all the transcripts under study with CDK4 showing the highest area under the curve (AUC) equivalent to 0.91, followed by E-cadherin (0.90), miRNA-126-5p (0.83), ANRIL (0.82), TNF-α (0.63), TGF-ß (0.62), and CDK6 (0.59), in descending order. A strong association was detected between most of the transcripts studied in CAD patients with a significant Spearman's correlation coefficient with a two-tailed significance of p < 0.001. Network analysis revealed a strong relationship between the five circulating vasculature transcripts studied and their target miRNAs and miR-126-5p, but not for ANRIL. CONCLUSION: The seven circulating vascular-related RNA transcripts under study could serve as potential CAD biomarkers, reflecting the cellular vascular function, proliferation, and inflammatory processes in CAD patients. Therefore, blood transcriptome analysis opens new frontiers for the non-invasive diagnosis of CAD.

Local Excision Versus Total Mesorectal Excision After Favourable Response to Neoadjuvant Therapy in Low Rectal Cancer: a Multi-centre Experience.

The gold standard surgical management of curable rectal cancer is proctectomy with total mesorectal excision. Adding preoperative radiotherapy improved local control. The promising results of neoadjuvant chemoradiotherapy raised the hopes for conservative, yet oncologically safe management, probably using local excision technique. This study is a prospective comparative phase III study, where 46 rectal cancer patients were recruited from patients attending Oncology Centre of Mansoura University and Queen Alexandra Hospital Portsmouth University Hospital NHS with a median follow-up 36 months. The two recruited groups were as follows: group (A), 18 patients who underwent conventional radical surgery by TME; and group (B), 28 patients who underwent trans-anal endoscopic local excision. Patients of resectable low rectal cancer (below 10 cms from anal verge) with sphincter saving procedures were included: cT1-T3N0. The median operative time for LE was 120 min versus 300 in TME (p < 0.001), and median blood loss was 20 ml versus 100 ml in LE and TME, respectively (p < 0.001). Median hospital stay was 3.5 days versus 6.5 days (p = 0.009). No statistically significant difference in median DFS (64.2 months for LE versus 63.2 months for TME, p = 0.85) and median OS (72.9 months for LE versus 76.3 months for TME, p = 0.43). No statistically significant difference in LARS scores and QoL was observed between LE and TME (p = 0.798, p = 0.799). LE seems a good alternative to radical rectal resection in carefully selected responders to neoadjuvant therapy after thorough pre-operative evaluation, planning and patient counselling.

Effect of used engine oil on the mechanical properties and embodied carbon of concrete blended with wheat straw ash as cementitious material.

Every day, more and more binding materials are being used in the construction industry all over the world. However, Portland cement (PC) is used as a binding material, and its production discharges a high amount of undesirable greenhouse gases into the environment. This research work is done to reduce the amount of greenhouse gases discharged during PC manufacturing and to reduce the cost and energy incurred in the cement manufacturing process by making effective consumption of industrial/agricultural wastes in the construction sector. Therefore, wheat straw ash (WSA) as an agricultural waste is utilized as cement replacement material, while used engine oil as an industrial waste is utilized as an air-entraining admixture in concrete. This study's main goal was to examine the cumulative impact of both waste materials on fresh (slump test) and hardened concrete (compressive strength, split tensile strength, water absorption, and dry density). The cement was replaced by up to 15% and used engine oil incorporated up to 0.75% by weight of cement. Moreover, the cubical samples were cast for determining the compressive strength, dry density, and water absorption, while the cylindrical specimen was cast for evaluating the splitting tensile strength of concrete. The results confirmed that compressive and tensile strengths augmented by 19.40% and 16.67%, at 10% cement replacement by wheat straw ash at 90 days, respectively. Besides, the workability, water absorption, dry density, and embodied carbon were decreased as the quantity of WSA increased with the mass of PC, and all of these properties are increased with the incorporation of used engine oil in concrete after 28 days, respectively.

Autologous vein graft repair of mycotic innominate artery aneurysm: A case report.

INTRODUCTION: Innominate artery aneurysm (IAA) is an extremely rare fatal condition with an overall prevalence of less than 3 % of all supra-aortic artery aneurysms. These infrequent lesions usually present as an emergency and require challenging surgical procedures. CASE PRESENTATION: We report an interesting case of mycotic IAA in a 25 years old male patient. He was a known intravenous drug abuser having mycotic aneurysm arising from brachiocephalic artery with eccentric thrombus causing adjacent mass effect over the trachea. He underwent successful emergent surgical management of aneurysm with autologous vein graft using superficial femoral vein. Unfortunately, he died due to massive upper gastrointestinal bleeding leading to multi-organ failure after a prolonged post-operative course. CLINICAL DISCUSSION: Mycotic aneurysms of the IA are extremely rare with an overall incidence of 1-2.7 % cases of all IAA. Presentation of the IAA can be quite variable from asymptomatic to symptoms exhibiting mass effect over surrounding structures. Rupture of IAA can be fatal and can occur if not treated promptly. There are no current recommendations or guidelines for treatment and interventions in IAA. Surgical management involves complete excision of the aneurysm and then revascularization. CONCLUSION: Infected Innominate artery aneurysm is a rare surgical entity requiring early diagnosis, detailed investigation and prompt surgical management involving multidisciplinary team approach. Our case describes a relatively innovative approach to this scarce condition.

Correlation between mitral valve area and left atrial function in rheumatic mitral valve stenosis patients.

BACKGROUND: Rheumatic heart disease (RHD) continues to be one of the leading causes of cardiovascular morbidity and mortality. The mitral valve frequently develops mitral stenosis (MS), and it is the most prevalent valve lesion in patients with chronic RHD. Left atrial (LA) functional impairment is associated with rheumatic MS. AIM: The aim of this study was to evaluate the association between LA function and mitral valve area (MVA) in rheumatic MS patients, and to assess the echocardiographic parameters in sinus rhythm and atrial fibrillation (AF) patients. METHODS: This was a cross-sectional, descriptive study that involved patients with rheumatic MS. Patients underwent a standard 12-lead electrocardiogram and echocardiographic examination. MVA was assessed and correlated with LA function. Comparison was made between sinus rhythm and AF patients. RESULTS: Eighty-one patients with rheumatic MS were included in this study, with 71.6% of them having associated MR. MVA showed a statistically highly significant positive correlation with LA and right ventricular (RV) function, and a statistically significant/highly significant negative correlation with their dimensions. A higher percentage of patients with severe MS was in AF (58.1%). CONCLUSIONS: There was a positive correlation between LA function and MVA in rheumatic MS patients. AF was related to the severity of MS.

The Impact of Narrow and Infiltrated Distal Margin After Proctectomy for Rectal Cancer on Patients' Outcomes: a Systematic Review and Meta-analysis.

Rectal cancer is a common tumor within a difficult anatomic constraint. Total mesorectal excision with longitudinal and circumferential free margins is considered imperative for good prognosis. In this article, the authors systematically reviewed all published literature with specific Mesh terms until the end of year 2019. Thereafter, retrieved articles were assessed using the Newcastle-Ottawa Scale and meta-analysis was conducted comparing local recurrence among 1-cm, 5-mm, and narrow (< 1-mm)/infiltrated margins. Thirty-nine articles were included in the study. Macroscopic distal margin < 1 cm carried a higher incidence of recurrence for those who did not receive neoadjuvant radiation, without affecting neither estimated overall nor disease-free survival. Less than 5-mm margin after radiation therapy is accepted oncologically. Infiltrated margins and narrow margins (< 1 mm) microscopically are associated with higher incidence of local recurrence and shorter overall and disease-free survival. Surgeons should aim at 1-cm safety margin in radiotherapy-naïve patients and microscopic free margin > 1 mm for those who received neoadjuvant therapy. The cost/benefit of reoperation for patients with infiltrated margins is still inadequately studied.

Chemotherapy alone versus chemotherapy plus radiotherapy for early stage Hodgkin lymphoma.

BACKGROUND: Combined modality treatment (CMT) consisting of chemotherapy followed by localised radiotherapy is standard treatment for patients with early stage Hodgkin lymphoma (HL). However, due to long term adverse effects such as secondary malignancies, the role of radiotherapy has been questioned recently and some clinical study groups advocate chemotherapy only for this indication. OBJECTIVES: We performed a systematic review with meta-analysis of randomised controlled trials (RCTs) comparing chemotherapy alone with CMT in patients with early stage Hodgkin lymphoma with respect to response rate, progression-free survival (alternatively tumour control) and overall survival (OS). SEARCH STRATEGY: We searched MEDLINE, EMBASE and CENTRAL as well as conference proceedings from January 1980 to November 2010 for randomised controlled trials comparing chemotherapy alone to the same chemotherapy regimen plus radiotherapy.  SELECTION CRITERIA: Randomised controlled trials comparing chemotherapy alone with CMT in patients with early stage HL. Trials in which the chemotherapy differed between treatment arms were excluded. Trials with more than 20% of patients in advanced stage were also excluded. DATA COLLECTION AND ANALYSIS: Effect measures used were hazard ratios (HR) for tumour control and OS as well as relative risks for response rates. Two review authors independently extracted data and assessed quality of trials. We contacted study authors to obtain missing information. Since none of the trials reported progression-free survival according to our definitions, all similar outcomes were evaluated as tumour control. MAIN RESULTS: Five RCTs involving 1245 patients were included. The HR was 0.41 (95% confidence interval (CI) 0.25 to 0.66) for tumour control and 0.40 (95% CI 0.27 to 0.61) for OS for patients receiving CMT compared to chemotherapy alone. Complete response rates were similar between treatment groups. In sensitivity analyses another six trials were included that did not fulfil the inclusion criteria of our protocol but were considered relevant to the topic. These trials underlined the results of the main analysis. AUTHORS' CONCLUSIONS: Adding radiotherapy to chemotherapy improves tumour control and overall survival in patients with early stage Hodgkin lymphoma.