Is there any survival benefit from post-operative radiation in brain metastases? A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: The benefits of adding upfront post-operative radiation, either whole-brain (WBRT) or cavity, after resection of brain metastases have been debated, particularly due to the long-term sequalae post radiation. We sought to compare the efficacy and safety between post-operative radiation versus resection alone. METHODS: We searched various biomedical databases from 1983 to 2018, for eligible randomized controlled trials (RCT). Outcomes studied were local recurrence (LR), overall survival (OS) and serious (Grade 3 + ) adverse events. We used the random effects model to pool outcomes. Methodological quality of each study was assessed using the Cochrane Risk of Bias tool. We employed the GRADE approach to assess the certainty of evidence. RESULTS: We included 5 RCTs comprising of 673 patients. The pooled odds ratio (OR) for LR is 0.26 (95% confidence interval (CI) 0.19-0.37, P < 0.001, GRADE certainty high), strongly supporting the use of post-operative radiation. Meta-regression analysis done comparing cavity and WBRT, did not show any difference in LR. The pooled hazard ratio (HR) for overall survival (OS) is 1.1 (95% CI 0.90-1.34, P = 0.37, GRADE certainty high). The treatment-related toxicities could not be pooled; the 2 studies which reported this did not find differences between the approaches. The risk of bias across the included studies was low. CONCLUSION: Our analysis confirms that upfront post-operative radiation significantly reduces the risk of LR. However, the lack of improvement in OS suggests that local control alone may not impact survival. Balancing local control, and neuro-cognitive effects of WBRT, cavity radiation seems to be a safe and effective option.

Clinical usefulness and cost effectiveness of fractional flow reserve among Indian patients (FIND study).

OBJECTIVES: To study the clinical usefulness, cost benefit, and medium term outcome of fractional flow reserve (FFR) based management of coronary artery disease of intermediate severity. BACKGROUND: In spite of the advantages of FFR there is paucity of data in Indian population who have frequent diffuse, small and multivessel disease where it would probably be more beneficial in terms of cost and outcome. METHODS: The treating cardiologist's management decision with both FFR and angiographic data was compared with that of a reviewing cardiologist decision based on a retrospective analysis of angiogram alone. RESULTS: Eighty-one vessels with intermediate lesions in 59 patients required 26 stents lesser when FFR data was added to the angiogram. The concordance of management decision was about 58% which means that >40% of intermediate lesions would be misclassified as significant based on angiography alone. There were no major events at a mean follow up of 11 ± 5 months. The net cost benefit in favor of FFR based management was INR 8,57,600 (USD 15,600) in our centre. CONCLUSION: Indians with more severe form of CAD benefit from a FFR based management plan for intermediate lesions, both clinically and economically. © 2014 Wiley Periodicals, Inc.