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Intracanalicular tumours efficacy and side-effects of the different modalities (that is those completely within the auditory canal) (including relevant meta-analyses) but acknowledges are often seen to medications varicose veins purchase carbidopa online grow less than those at the 7 these limitations 911 treatment for hair buy generic carbidopa 110mg line. Faster growth rate is 8 given that the patient populations are very different in associated with more rapid hearing loss treatment 2015 purchase discount carbidopa on-line. There are no parameters known that predict which tumours will grow and to symptoms mononucleosis discount carbidopa online mastercard what extent. Further treatment 29–54% of tumours will grow and 16–26% of patients is only required in about 4% of patients during this will require additional treatment, with 54–63% 10,11 extended follow-up. However, the mean over time and it is controversial whether this is faster or follow-up in these studies was short, at just over three slower than in untreated cases. As with other specialist operations, results brainstem compression and hydrocephalus (incidence are often best from high-volume centres. Patients are often in groups have published results using conventionally hospital for at least 1–2 weeks and take a long time to fractionated regimens (45–56 Gy in 1. Radiobiologically, a potential growing quickly or are bulky, and especially those advantage of this approach may be better hearing impinging on the brainstem. More recently, it has preservation or less risk to neighbouring structures become increasingly common to consider partial (especially the brainstem) with larger tumours. Some authors suggest better hearing preservation rates but the quality of studies makes it hard to draw firm conclusions. In the overwhelming majority of the literature relates one study, there was an actuarial rate of 11% for this to gamma knife. Over time, the marginal dose within 19 months of treatment (with larger tumours (usually prescribed to ~50% isodose) has reduced. There is much less evidence for other hypofractionated Currently, the standard is to use ~12 Gray (Gy). Consequently, the risk of a radiation-induced second tumour needs A recent paper attempted to identify methodologically to be considered carefully, particularly when treating robust comparison studies between treatment younger individuals. The risk also needs to be balanced modalities and identified only four useful publications 13 against the significant, often permanent, deficits (none of which were randomised). Factors influencing treatment include: the patient’s symptoms – is hearing preserved? Taking into tumour account the factors listed above, patients can then make choices depending on their Tumour size and rate of growth (if known) – larger individual circumstances, priorities and tumours causing pressure effects will often require preferences (Grade D). It is recognised that this can happen many years recommendations used within this review are after the original treatment. Functional trends in incidence of primary brain tumors in the outcome after gamma knife surgery or United States, 1985–1999. What is the real incidence of Long-term follow-up of acoustic schwannoma vestibular schwannoma? Arch Otolarynglo Head radiosurgery with marginal tumor doses of Neck Surg 2004; 130(2): 216–220. Hasegawa T, Kida Y, Kato T, Iizuka H, Arch Otolarynglo Head Neck Surg 2005; 131(3): Kuramitsu S, Yamamoto T. Management of 1000 patients more than 10 years after treatment vestibular schwannomas (acoustic neuromas): with Gamma Knife surgery. Growth rate characteristics of radiotherapy in the treatment of vestibular acoustic neuromas associated with schwannoma (acoustic neuroma): predicting the neurofibromatosis type 2. Neurosurgical Review 2011; 34(3): Edinburgh: Scottish Intercollegiate Guidelines 265–277; discussion 277–279. The natural history of untreated sporadic vestibular schwannomas: a comprehensive review of hearing outcomes. This is Dupuytren’s disease minimally invasive, but is associated with a of the hand recurrence rate of 65% at three years. Collagenase (Xiapex) is the injection of an enzyme Background that dissolves the collagen in the Dupuytren’s cord, which can then be mechanically broken. Dupuytren’s disease tends to present in the sixth and seventh decade of life, but There are many retrospective studies in the literature can present earlier or later. Additional risk factors include prior hand trauma, epilepsy and diabetes mellitus. The of Dupuytren’s disease is illustrated in Table 13 disease course is variable, but is more severe in males, (overleaf), where stage N is disease with no those with a positive family history, early onset, contracture, stage N/I is disease with up to 5–10 bilateral disease and where there are ectopic lesions degrees of contracture, and subsequent stages (such as Peyronie’s disease). The patients were treated with 120 kilovoltage (kV) photons with a total dose of 30 Gray (Gy) in ten Management fractions, which was split into two phases of 15 Gy in five fractions over one week, with a six-week gap There is no cure for Dupuytren’s disease, and it is most between the phases. At the most recent follow-up, often treated in the advanced stages, where there is 11% of hands showed stage progression, although 23% significant (for example >30 degrees) contracture, of those with >5 years follow-up were found to have particularly where hand function is impaired. There are three Similarly, a retrospective study with a median follow-up main methods for release of contractures. There fractions) and demonstrated progressive disease in are several variations of this approach. These procedures are Additionally, it was noted that the outcome was associated with a long recovery time and a significantly better if the disease was treated within considerable complication rate. The reported range one year of appearance of symptoms compared of recurrence rates is wide at 18–73%, and depends 3–6 with more than two years since the appearance on follow-up time and definitions of recurrence. Needle aponeurotomy: a needle is used to puncture the fibrous cord in order to weaken it until 86 A prospective trial randomising patients between were increased in the 21 Gy group compared with the two dose levels (with no control group) looked at 30 Gy group. Patients were randomised to two phases of 15 Gy in five fractions each (as above, with an eight-week gap Potential long-term consequences between the phases, total dose 30 Gy), or 21 Gy in of radiotherapy seven fractions, given on alternate days over a period of 15 days. There was no significant energy fractionated X-rays) the risk is estimated to be difference in efficacy or toxicity between the two about 0. Since A long-term follow-up of this study, published as a the excess risk is very small compared to the textbook chapter, looked at the outcomes of patients background risk it is impossible to evaluate this followed up for at least five years (median follow-up of accurately in a clinical study. In particular it is calculated for one 30 Gy, as above, although the gap between the two hand, so the risk doubles if both hands are treated. All had progressive disease in the last remaining hand and body are sufficiently protected 6–12 months. Acute and chronic toxicity rates 25 years the risk is approximately double that of a Outcome of long-term follow-up of Seegenschmiedt study of radiotherapy for Dupuytren’s disease21 Dose Regression or stable Progression Surgery (%) disease (%) (all clinical signs, %) Control (n=122) 38 62 30 21 Gy (n=293) 76 24 12 30 Gy (n=245) 80 19. It should be noted that there are other more the above estimate applies to the risk of a fatal immediate effects that, although less serious than radiation-induced skin cancer. An alternative fractionation is 21 Gy only patients whose disease has progressed in seven fractions on alternate days over two within the last 6–12 months should be treated weeks (Grade B). The types of evidence and the grading of the aim is to treat nodules and cords to the recommendations used within this review are based periostium of the hand bones, for a depth of 5–15 on those proposed by the Scottish Intercollegiate mm. Epidemiological evaluation of Dupuytren’s Dupuytren contracture recurrence following disease incidence and prevalence rates in relation treatment with collagenase clostridium to etiology. Jurisi´c D, Kovi´c I, Luli´c I, Stanec Z, Kapovi´c M, J Dermatol Surg Oncol 1978; 4(8): 620–625. Die Strahlentherapie der Dupuytren contracture following invasive Dupuytrenschen Kontraktur. Increased total mortality and cancer Radiotherapy of early stage Dupuytren disease. Radiotherapy in early-stage carcinogenic risk of radiotherapy of benign Dupuytren’s contracture. Dupuytren’s contracture: First results of a Edinburgh: Scottish Intercollegiate Guidelines randomized clinical study. A prospective non-randomised cohort study looked at Ledderhose disease (plantar fibromatosis) is a rare 158 consecutive patients (with 270 affected feet) benign hyperproliferative fibromatosis of the plantar presenting to a single institution with symptomatic fascia of the foot. It is histologically identical to disease that had progressed over the last 6–12 Dupuytren’s disease of the hand, and the two months. Most were treated with 125–150 kV genetic factors, smoking, alcoholism, diabetes mellitus photons at 40 centimetres (cm) focus to skin distance and anti-epileptic use. Plantar fibromatosis presents as lumps delivered was 15 Gy in five fractions over one week, attached to the central and medial part of the plantar with a further 15 Gy in five fractions repeated after 12 fascia which may cause discomfort and difficulty with weeks for a total dose of 30 Gy in ten fractions. Contractures of the toes mean follow-up of 68 months, 92% of the irradiated occur rarely. Small surgical series (30 or fewer patients in each series) have reported recurrence rates of 30–40%, and a significant chance of postoperative Potential long-term effects complications such as wound healing problems, of radiotherapy chronic pain and poor functional outcome.

Placement of a ventricular drain is Class I: Agree useful in patients with acute Benefit>>>Risk hydrocephalus secondary to useless id symptoms discount carbidopa 125mg with mastercard ischemic Procedure/Treatment stroke (Class I; Level of Evidence C) 20 medications that cause memory loss purchase 300mg carbidopa with amex. This section provides resources treatment 1st degree burns purchase genuine carbidopa on line, strategies and measurement for use in closing the gap between current clinical practice and the recommendations set forth in the guideline symptoms diabetes type 2 order generic carbidopa. Aims and Measures Copyright © 2016 by Institute for Clinical Systems Improvement 48 Diagnosis and Initial Treatment of Ischemic Stroke Eleventh Edition/December 2016 Aims and Measures 1. Increase the percentage of stroke patients age 18 years and over who receive appropriate medical management within the initial 24-48 hours of diagnosis for prevention of complications such as. Percentage of ischemic stroke patients with paralysis or other reason for immobility who receive appropriate prevention for venous thromboembolism (subcutaneous heparin or pneumatic compres sion device). Percentage of ischemic stroke patients who are assessed with a swallow screening test before receiving food, fuids or medications by mouth. Population Defnition Patients age 18 years and older initially presenting with acute symptoms of ischemic stroke with paralysis or other reason for immobility. Denominator: Number of patients presenting with acute symptoms of ischemic stroke and paralysis or other reason for immobility. Notes this is a process measure, and improvement is noted as an increase in the rate. Population Defnition Patients age 18 years and older initially presenting with acute symptoms of ischemic stroke. Data of Interest # of patients who receive an early swallow evaluation # of patients who present with acute ischemic stroke Numerator and Denominator Defnitions Numerator: Number of patients who were screened for dysphagia before taking any food, fuids or medication (including aspirin) by mouth. Denominator: Number of all patients presenting with symptoms of acute ischemic stroke. Relationships between imaging assessments and outcomes in solitaire with the intention for thrombectomy as primary endovascular treatment for acute ischemic stroke. Relevance of prehospital stroke code activation for acute treatment measures in stroke care: a review. Effects of blood pressure and blood pressure-lowering treatment during the frst 24 hours among patients in the third international stroke trial of thrombolytic treatment for acute ischemic stroke. Value of computed tomographic perfusion-based patient selec tion for intra-arterial acute ischemic stroke treatment. Patterns of emergency medical services use and its association with timely stroke treatment: fndings from get with the guidelines-stroke. Visual and region of interest-based inter-rater agreement in the assessment of the diffusion-weighted imaging fuid-attenuated inversion recovery mismatch. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from fve randomised trials. Comparison of computed tomographic and magnetic reso nance perfusion measurements in acute ischemic stroke: back-to-back quantitative analysis. The effect of Cincinnati prehospital stroke scale on telephone triage of stroke patients: evidence-based practice in emergency medical services. Continuous positive airway pressure ventilation for acute ischemic stroke: a randomized feasibility study. Heart disease and stroke statistics – 2015 update: a report from the American heart association. Moving beyond a single perfusion threshold to defne penumbra: a novel probabilistic mismatch defnition. The quality of prehospital ischemic stroke care: compliance with guidelines and impact on in-hospital stroke response. Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis of randomised trials. A systematic review of stroke recognition instruments in hospital and prehospital settings. Endovascular therapy for acute ischemic stroke with occlusion of the middle cerebral artery M2 segment. Validity of acute stroke lesion volume estimation by diffusion weighted imaging-Alberta stroke program early computed tomographic score depends on lesion location in 496 patients with middle cerebral artery stroke. Early decompressive craniectomy for malignant cerebral infarction: meta-analysis and clinical decision algorithm. Impact of collateral status evaluated by dynamic computed tomographic angiography on clinical outcome in patients with ischemic stroke. Blood pressure reduction in the acute phase of an ischemic stroke does not improve short or long-term dependency or mortality: a meta-analysis of current literature. General Supportive Care and Treatment of Acute Complications What cardiac monitoring should be done for ischemic stroke patients? The translation of evidence into practice can be advanced through the use of shared decision-making since shared decision-making results in evidence being incorporated into patient and clinician consultations. Evidence-based guidelines may recommend the use of shared decision-making for decisions in instances where the evidence is equivocal, when patient action or inaction (such as medication adherence or lifestyle changes) can impact the potential outcome, or when the evidence does not indicate a single best recom mendation. It is ideal to involve caregivers and family members in these conversations, as well. Family members and care givers can participate in discussions, ask questions, hear content the patient may miss and provide invalu able support in decision follow-through. Although only patients and clinicians are specifcally mentioned throughout this document for brevity purposes, this does not diminish the importance of caregivers and families in patient-centered care. Both the patient and the clinician bring expertise to the shared decision-making conversation. When conversations discussing options occurs, patients and clinicians are actively engaged while considering the attributes and issues of the available options. This empathic approach results in the clinician and patient co-creating a decision and a plan of care (adapted from Montori, V. Decision aids can be supportive of this conversation when they communicate the best available evidence to inform the patient and clinician discussion. Without a conversation, clinicians may make assumptions about what the patient prefers. Diffculty in initiating a conversation is cited by patients and clinicians as one of the barriers to shared decision-making. Use of Collaborative Conversation™ elements and tools is even more necessary to support patient, care clinician and team relationships when patients and families are dealing with high stakes or highly charged issues. These skills need to be used artfully to address all aspects of the person involved in making a decision: cognitive, affective, social and spiritual. Listening skills Encourage patient to talk by providing prompts to continue such as go on, and then? The clinician should use their own words rather than just parroting what they heard. Refection of feelings usually can be done effectively once trust has been established. The clinician should condense several key comments made by the patient and provide a summary of the situation. This assists the patient in gaining a broader understanding of the situation rather than getting mired down in the details. The most effective times to do this are midway through and at the end of the conversation. An example of this is "You and your family have read the information together, discussed the pros and cons, but are having a hard time making a decision because of the risks. Questioning Skills Open and closed questions are both used, with the emphasis on open questions. Open questions ask for clarifcation or elaboration and cannot have a yes or no answer. Verbal tracking, referring back to a topic the patient mentioned earlier, is an important foundational skill (Ivey & Bradford-Ivey). Information-Giving Skills Providing information and providing feedback are two methods of information giving. Information giving allows a clinician to supplement his or her knowledge and helps to keep the conversation patient centered. More than one of these opportunities may present at a time, and they will occur in no specifc order. Request for support and information: Decisional confict is indicated by, among other things, the patient verbalizing uncertainty or concern about undesired outcomes, expressing concern about choice consistency with personal values, or exhibiting behavior such as wavering, delay, preoc cupation, distress or tension. Support resources may include health care professionals, family, friends, support groups, clergy and social workers. When patient expresses a need for information regarding options and their potential outcomes, the patient should understand the key facts about the options, risks and benefts, and have realistic expectations.

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The pathology report from a subsequent node dissection identifies three cervical nodes medications bipolar purchase discount carbidopa line. Do not double-count when a regional lymph node is aspirated and that node is in the resection field treatment yeast diaper rash cheap carbidopa 125 mg with amex. Code the removal of regional nodes for both primaries when the patient has two primaries with common regional lymph nodes Example: Patient has a cystoprostatectomy and pelvic lymph node dissection for bladder cancer medicine on time order cheapest carbidopa. Pathology identifies prostate cancer as well as the bladder cancer and 4/21 nodes positive for metastatic adenocarcinoma treatment dynamics buy carbidopa 110mg otc. Code Scope of Regional Lymph Node Surgery to 5 (4 or more regional lymph nodes removed) for both primaries. Regional lymph node removal procedure was not performed Note: Excludes all sites and histologies that would be coded 9. The operative report lists a lymph node dissection, but no nodes were found by the pathologist 8. When mapping fails, surgeons usually perform a more extensive dissection of regional lymph nodes. Code these cases as 2 if no further dissection of regional lymph nodes was undertaken, or 6 when regional lymph nodes were dissected during the same operative event. When mapping fails, the surgeon usually performs a more extensive dissection of regional lymph nodes. Code 9: the status of regional lymph node evaluation should be known for surgically treated cases. Review surgically treated cases coded as 9 in Scope of Regional Lymph Node Surgery to confirm the code. The operative report will designate the surgeon’s planned procedure as well as a description of the procedure that was actually performed. Excisional biopsy or aspiration of regional lymph nodes for breast cancer is uncommon. If additional procedures were performed on the lymph nodes, such as axillary lymph node dissection, use the appropriate code 2-7. Review the operative report to confirm that an axillary incision was made and a node exploration was conducted. Do not record the date of lymph node aspiration, fine needle aspiration, fine needle aspiration biopsy, core needle biopsy, or core biopsy. Coding 99999999 to indicate “unknown” is an example of non-date information that was previously transmitted in date fields. This event occurred, but the date is unknown (for example, sentinel lymph node biopsy performed but date is unknown). Code Description 00 No sentinel nodes were examined 01-90 Sentinel nodes were examined (code the exact number of sentinel lymph nodes examined) 95 No sentinel nodes were removed, but aspiration of sentinel node(s) was performed 98 Sentinel lymph nodes were biopsied, but the number is unknown 99 It is unknown whether sentinel nodes were examined; not stated in patient record Coding Instructions 1. Document the total number of nodes sampled during the sentinel node procedure in this data item when both sentinel and non-sentinel nodes are sampled during the sentinel node biopsy procedure; i. A sentinel node biopsy procedure is performed during the same procedure as the regional node dissection 3. The number of sentinel lymph nodes biopsied will typically be found in the pathology report, radiology reports, or documented by the physician. Determination of the exact number of sentinel lymph nodes examined may require assistance from the managing physician for consistent coding. Code Description 00 All sentinel nodes examined are negative 01-90 Sentinel nodes are positive (code exact number of nodes positive) 95 Positive aspiration of sentinel lymph node(s) was performed 97 Positive sentinel nodes are documented, but the number is unspecified. Document the total number of positive nodes identified during the sentinel node procedure in this data item when, during a sentinel node biopsy procedure a few non-sentinel nodes happen to be sampled and are positive; i. The number of sentinel lymph nodes biopsied and found positive will typically be found in the pathology report; radiology reports, or documented by the physician. Determination of the exact number of sentinel lymph nodes positive may require assistance from the managing physician for consistent coding. A sentinel lymph node biopsy is performed in the same procedure as the regional node dissection. Date flag fields were added beginning with diagnoses on or after 01/01/2010 as part of an initiative to standardize date fields. This event occurred, but the date is unknown (for example, regional lymph node dissection was performed but date is unknown). True in situ cases cannot have positive lymph nodes, so the only allowable codes are 00 (negative) or 98 (not examined). Record the total number of regional lymph nodes removed and found to be positive by pathologic examination. The number of regional nodes positive is cumulative from all procedures that remove lymph nodes through the completion of surgeries in the first course of treatment b. Do not count a positive aspiration or core biopsy of a lymph node in the same lymph node chain removed at surgery as an additional node in Regional Nodes Positive when there are positive nodes in the resection. In other words, if there are positive regional lymph nodes in a lymph node dissection, do not count the core needle biopsy or the fine needle aspiration if it is in the same chain. Example 1: Lung cancer patient has a mediastinoscopy and positive core biopsy of a hilar lymph node. Patient then undergoes right upper lobectomy that yields 3 hilar and 2 mediastinal nodes positive out of 11 nodes dissected. Code Regional Nodes Positive as 05 and Regional Nodes Examined as 11 because the core biopsy was of a lymph node in the same chain as the nodes dissected. Example 2: Positive right cervical lymph node aspiration followed by right cervical lymph node dissection showing 1 of 6 nodes positive. Assume the lymph node that is core-biopsied or aspirated is part of the lymph node chain surgically removed and do not include it in the count of Regional Nodes Positive when its location is not known Example: Patient record states that lymph node core biopsy was performed at another facility and 7/14 regional lymph nodes were positive at the time of resection. Use information in the following priority when there is a discrepancy regarding the number of positive lymph nodes a. Determine the histology of the metastases in the nodes and code the nodes as positive for the primary with that histology when there are multiple primary cancers with different histologic types in the same organ and the pathology report just states the number of nodes positive b. The pathology report states "3 of 11 lymph nodes positive for metastasis" with no further information available. Code Regional Nodes Positive as 03 and Regional Nodes Examined as 11 for both primaries. For all primary sites except cutaneous melanoma and Merkel cell carcinoma of skin i. Count only lymph nodes that contain micrometastases or larger (metastases greater than 0. The only procedure for regional lymph nodes is a needle aspiration (cytology) or core biopsy (tissue) b. A positive lymph node is aspirated and there are no surgically resected lymph nodes Example: Patient with esophageal cancer. A positive lymph node is aspirated and surgically resected lymph nodes are negative Example: Lung cancer patient has aspiration of suspicious hilar mass that shows metastatic squamous carcinoma in lymph node tissue. Patient undergoes neoadjuvant (preoperative) radiation therapy followed by lobectomy showing 6 negative hilar lymph nodes. Code Regional Nodes Positive as 95 and Regional Nodes Examined as the 06 nodes surgically resected. Use code 97 for any combination of positive aspirated, biopsied, sampled, or dissected lymph nodes when the number of involved nodes cannot be determined on the basis of cytology or histology. The patient has neoadjuvant (preoperative) chemotherapy, then resection of the primary tumor and a radical neck dissection. In the radical neck dissection, “several” of 10 nodes are positive; the remainder of the nodes show chemotherapy effect. Code Regional Nodes Positive as 97 because the total number of positive nodes biopsied and removed is unknown, and code Regional Nodes Examined as 10. Note: If the aspirated node is the only one that is microscopically positive, use code 95. A “dissection” of a lymph node drainage area is found to contain no lymph nodes at the time of pathologic examination d. Regional Nodes Positive is coded 98, Regional Nodes Examined is usually coded 00 11. This field is to be recorded regardless of whether the patient received neoadjuvant (preoperative) treatment. A “dissection” of a lymph node drainage area is found to contain no lymph nodes at the time of pathologic examination Note: When Regional Nodes Examined is coded 00, Regional Nodes Positive is coded 98.

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The Deeks funnel plot demonstrated be obtained29-40; 2) seven studies not in the field of interest41-47; that no publication bias was present (P medicine queen mary purchase carbidopa 125mg on-line. In the subgroup anal hancing area were selected in 12 studies3 symptoms youre pregnant buy cheap carbidopa 125 mg on-line,5-11 treatment zone guiseley purchase carbidopa online pills,13-16; enhancing ysis according to symptoms nervous breakdown purchase line carbidopa study population, the studies including glio tumor only, in 1 study4; and perienhancing area only, in 1 blastoma showed only a pooled sensitivity of 82. Multiple subgroup analyses also demonstrated and anaplastic astrocytoma showed a pooled sensitivity of similar diagnostic performances (sensitivities of 76. Analysis of fractional anisotropy Glioma cells tend to produce large amounts of extracellular 19,20 facilitatesdifferentiationofglioblastomaandbrainmetastasesina matrix components. Eur J Radiol 2016;85:2182–87 CrossRef Medline strate for adhesion and subsequent migration of the tumor cells 5. Acta Radiol 2017;59:599–605 CrossRef enhancing tumor than brain metastases; in 2 of these studies, the Medline difference was statistically significant,4,15 though the difference 7. A Bayesian diagnostic system to 3 differentiate glioblastomas from solitary brain metastases. However, 2 radiol J 2013;26:175–83 CrossRef Medline further studies did not show any meaningful differences between 8. J Magn Reson Imaging 2015; 60 42:80–86 CrossRef Medline grade glioma and brain metastasis. High-grade gliomas exhibit for this discrepancy is not fully understood, and further studies higher peritumoral fractional anisotropy and lower mean diffusiv are required. Acta Radiol 2009;50:682–89 CrossRef Medline cluded studies are the only currently available ones. Third, the included studies used vari 84:2618–24 CrossRef Medline ous parameters. In addition, we also tensor imaging in differentiating glioblastomas from brain metas performed multiple subgroup analyses. Neuroradiology 1992;34:463–69 laboration, and the Agency for Healthcare Research and 63 CrossRef Medline Quality). Cancer Imaging 2012;12:423–36 CrossRef Medline Ann Intern Med 2009;151:W65–94 Medline 40. Successful publication of systematic review and and diffusivity of the pyramidal tract and motor cortex within and meta-analysisofstudiesevaluatingdiagnostictestaccuracy. Korean adjacent to brain tumour in patients with or without neurological J Radiol 2016;17:5–6 CrossRef Medline deficits. The added value of the ofstudiesevaluatingdiagnostictestaccuracy:apracticalreviewfor apparent diffusion coefficient calculation to magnetic resonance clinical researchers, Part I: general guidance and tips. Korean J Ra imaging in the differentiation and grading of malignant brain tu diol 2015;16:1175–87 CrossRef Medline mors. Diffusion tensor imaging tion bias and other sample size effects in systematic reviews of di shows corpus callosum differences between high-grade gliomas agnostictestaccuracywasassessed. Nonenhancing Accessed October 2, 2017 peritumoral hyperintense lesion on diffusion-weighted imaging in 28. Conducting systematic glioblastoma: a novel diagnostic and specific prognostic indicator. Differentiation between glioblas radiology 2004;46:619–27 Medline tomas,solitarybrainmetastases,andprimarycerebrallymphomas 31. Egyptian Journal of Radiology CrossRef Medline and Nuclear Medicine 2016;47:1037–42 CrossRef 50. Contribution of the ap tomas and solitary brain metastases using diffusion tensor imag parent diffusion coefficient in perilesional edema for the assess ing. Discrimination between glio Medline blastoma multiforme and solitary metastasis using morphological 33. Minimum apparent diffusion coeffi features derived from the p:q tensor decomposition of diffusion cients in the evaluation of brain tumors. Diffusion edema and tumor-infiltrated edema in patients with peritumoral tensorimaginginbraintumors:astudyongliomasandmetastases. The differences of water diffu Medline sion between brain tissue infiltrated by tumor and peritumoral va 54. Clin Imaging 2009;33:96–101 CrossRef Medline ficients and T2 relaxation times in characterizing contrast enhanc 37. J Magn Reson sion coefficient and intravoxel incoherent motion for differentiat Imaging 2005;21:701–08 CrossRef Medline ing among glioblastoma, metastasis, and lymphoma focusing on 55. Statistical analysis of in differentiating high-grade gliomas from brain metastases: a multi-b factor diffusion weighted images can help distinguish be systematic review and meta-analysis. The Co diffusion and perfusion magnetic resonance imaging in assessing chrane Collaboration, 2013. Differential gene expression in ysis of test performance when there is a “gold standard. Tumors that result from these cells entering the bones are called bone metastases. When cancer spreads from the part of the body where it started (its primarysite) to other parts of the body it’s called metastasis. Metastasis can happen when cells break away from a cancer tumor and travel through the bloodstream or through lymph vessels to other parts of the body. Many of the cancer cells that break off from the original tumor die without causing any problems. Sometimes metastatic tumors are found on tests done when the primary cancer is first diagnosed. In other cases, the metastasis is found first, causing the doctor to look for the place that the cancer started. Different cancers tend to spread to different sites, but some of the most common sites of metastasis are the bones, liver, brain, and lungs. A bone metastasis is an area of bone that contains cancer that spread there from somewhere else. Cancer can spread to any bone in the body, but metastases are most often found in bones near the center of the body. Other common sites are the hip bone (pelvis), upper leg bone (femur), upper arm bone (humerus), ribs, and the skull. Once cancer has spread to the bones or to other parts of the body it’s rarely able to be cured. Even if a cure is no longer possible, treating the cancer may be able to help you live longer and feel better. Bones are made of a network of fibrous tissue called matrix, minerals such as calcium that attach to the matrix and give the bone its strength and hardness, and 2 main kinds of bone cells are osteoblasts and osteoclasts. Knowing a little about these 2 kinds of cells can help you understand how bone metastases grow, and how some medicines work to treat bone metastases. The osteoblast is the cell that forms new bone, and the osteoclast is the cell that dissolves old bone. When these cells are both working right, new bone is always forming while old bone is dissolving. Cancer cells can affect the bones by interfering with osteoblasts and osteoclasts: q Often, the cancer cells make substances that turn on the osteoclasts. This leads to new bone being made without breaking down the old bone broken down first. Although these blastic areas are harder, the structure of the bone is not normal and these areas actually break more easily than normal bone. Bone metastasis can cause other problems as well: q When cancer spreads to the bones of the spine, it can press on the spinal cord. For cancer cells to spread to other parts of the body, they have to go through many changes: q They have to be able to break away from the original (primary) tumor and get into the bloodstream or lymph system, which can carry them to another part of the body. All the while, the cancer cells need to be able to avoid attacks from the body’s immune system. Going through all these steps means the cells that start new tumors may no longer be exactly the same as the ones in the tumor where they started, But they will still be called the same name. For instance, breast cancer that spreads to the bone is called metastatic breast cancer, not bone cancer.