Publications by authors named "Ahmad Alzahrani"

13 Publications

  • Page 1 of 1

Does spontaneous renal hemorrhage mandate close surveillance for impending renal cell carcinoma? A case report and literature review.

Int J Surg Case Rep 2020 20;73:44-47. Epub 2020 Jun 20.

Prince Sultan Military Medical City, Riyadh, Saudi Arabia. Electronic address:

Introduction: Renal cell carcinoma (RCC) classically presents as a triad of hematuria, loin pain, and a palpable mass. However, Renal cell carcinomas (RCCs) nowadays are more commonly present as incidental findings rather than symptomatic. Wunderlich syndrome is a rare first presentation of RCC.

Presentation Of Case: We present a clinical case of spontaneous renal hemorrhage with unclear etiology that was treated with therapeutic embolization and was found to have renal mass after long follow up.

Discussion And Conclusion: In regards to treating Wunderlich syndrome, some authors favor angioembolization and follow up. Others proposed radical nephrectomy in conditions with no apparent etiology and normal contralateral kidney because of the high incidence of small renal tumors. Spontaneous perinephric hematoma of unknown etiology should be followed up regularly with a CT image for concerning of impending renal tumor.
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http://dx.doi.org/10.1016/j.ijscr.2020.06.067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7339000PMC
June 2020

An Isolated Hypogonadotropic Hypogonadism due to a L102P Inactivating Mutation of KISS1R/GPR54 in a Large Family.

Case Rep Pediatr 2019 16;2019:3814525. Epub 2019 Oct 16.

Umm Al-Qura University, Medical College, (A.A, L.A), Makkah, Saudi Arabia.

KISS1R (GPR54) mutations have been reported in several patients with congenital normosmic idiopathic hypogonadotropic hypogonadism (nIHH). We aim to describe in detail nIHH patients with KISS1R (GPR54) mutations belonging to one related extended family and to review the literature. A homozygous mutation (T305C) leading to a leucine substitution with proline (L102P) was found in three affected kindred (2 males and 1 female) from a consanguineous Saudi Arabian family. This residue is localized within the first exoloop of the receptor, affects a highly conserved amino acid, perturbs the conformation of the transmembrane segment, and impairs its function. In the affected female, a combined gonadotropin administration restored regular period and ovulation and she conceived with a healthy baby boy after 4 years of marriage. We showed that a loss-of-function mutation (p.Tyr305C) in the KISS1R gene can cause (L102P) KISS1 receptor dysfunction and familial nIHH, revealing the crucial role of this amino acid in KISS1R function. The observed restoration of periods and later on pregnancy by an exogenous gonadotropin administration further support, in humans, that the KISS1R mutation has no other harmful effects on the patients apart from the gonadotropin secretion impairment.
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http://dx.doi.org/10.1155/2019/3814525DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6815991PMC
October 2019

Arabic intensive care delirium screening checklist's validity and reliability: A multicenter study.

J Crit Care 2019 12 26;54:170-174. Epub 2019 Aug 26.

McGill University, Department of Medicine, Regroupement de Soins Critiques Respiratoires, Réseau de Santé Respiratoire FRQS, Montreal, QC, Canada.

Purpose: To develop an Arabic version of Intensive Care Delirium Screening Checklist (ICDSC) and assess its validity and reliability among critically ill patients.

Materials And Methods: Multicentered study of convenience sample of adult ICU patients. Arabic translation was performed with rigorous back-to-back translation methods. Concurrent validity was established by calculating the sensitivity and specificity of two examiner assessments compared to a psychiatric evaluation. Kappa coefficients describe interrater reliability, whereas Cronbach α and composite reliability depict internal consistency.

Results: Three hundred critically ill patients were enrolled. Of these, validity testing was assessed in 180 patients. ICDSC screening was positive for delirium in 11% of enrolled patients. The area under the receiver operator characteristic (ROC) curve is 0.9413, with predicted sensitivity 70% (95% confidence interval [CI]: 60-81%) and specificity 99% (95% CI: 98-100%). The Arabic ICDSC showed acceptable internal consistency (Cronbach α = 0.63 and composite reliability = 0.64). Interrater agreement was excellent (Kappa coefficient [ҡ] = 0.85).

Conclusions: Arabic ICDSC is a valid and reliable delirium-screening tool among Arabic-speaking ICU population. Future studies could address whether these findings are generalizable to a higher proportion of mechanically ventilated patients, and address acceptability and reliability in other Arabic language critical care settings.
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http://dx.doi.org/10.1016/j.jcrc.2019.08.025DOI Listing
December 2019

Attitudes of cancer patients and their families toward disclosure of cancer diagnosis in Saudi Arabia: a Middle Eastern population example.

Patient Prefer Adherence 2018 3;12:1659-1666. Epub 2018 Sep 3.

College of Medicine, Umm Al-Qura University, Mecca, Saudi Arabia.

Objectives: Particularly in the Middle East, few studies have explored the attitude of cancer patients and their families toward cancer diagnosis disclosure (CDD). This study was conducted to investigate the preference and attitude of a sample of cancer patients and their families in Saudi Arabia toward CDD.

Methods: We constructed a questionnaire based on previous studies. The questionnaire assessed preference and attitude toward CDD. Participants were recruited from the King Abdullah Medical City, which has one of the largest cancer centers in Saudi Arabia.

Results: Three hundred and four cancer patients and 277 of their family members participated in the study. The patient group preferred CDD more than the family group (82.6% vs 75.3%, <0.05). This preference is especially more evident toward disclosure of detailed cancer information (status, prognosis, and treatment) (83.6% vs 59.9%, <0.001). In a binary logistic regression, factors associated with preference toward CDD included having information about cancer (odds ratio [OR] 1.8; 95% confidence interval [CI], 1.15-2.84) and being employed (OR, 1.77; 95% CI, 1-2.82) while being from the patient group was the only factor associated with preference toward detailed cancer information (OR, 3.25; 95% CI, 2.11-5.05). In terms of patient reaction after CDD, "fear" was the attitude expected by the family group more than the patient group (56.3% vs 70.4%, <0.001) while "acceptance" was the attitude anticipated by the patient group more than the family group (38% vs 15.2%, <0.001).

Conclusion: Patients preferred CDD and disclosure of related information, while their families were more inclined toward scarce disclosure. Family members seem to experience negative attitudes more than the patients themselves.
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http://dx.doi.org/10.2147/PPA.S176651DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6126501PMC
September 2018

Improving referral to psychological support unit at Saudi Red Crescent Authority in Riyadh Region.

BMJ Open Qual 2017 21;6(2):e000089. Epub 2017 Oct 21.

Department of Health System and Quality Management, King Saud bin Abdulaziz University for Health Sciences, College of Public Health and Health Informatics, Riyadh, Saudi Arabia.

The Psychological Support Unit (PSU) performance in Saudi Red Crescent Authority (SRCA) showed that only a small number of case referred seeking psychological advice and management from PSU among all SRCA employees. However, research shows that between 28% and 52% of emergency medical services (EMS) providers usually seek psychological help in various EMS cultures, where 86% of them usually suffer from critical stress. Thus, we decided to design a quality improvement project that aims to improve the referral process by increasing cases referred to the PSU at SRCA in Riyadh Region by 75% in 2 months. A multidisciplinary team has been formed to analyse the problem using quality tools including, brainstorming, fishbone diagram and flow chart of the PSU processes. Several possible reasons have been identified, such as lack of awareness among the SRCA's employees about PSU and its services, and the concern about privacy and confidentiality during psychological consultations in the PSU, in addition to the long referring process to PSU. The team decided to test the following change ideas: increasing the awareness of employees about the PSU services, improving the privacy and confidentiality during the consultation using electronic channels, and finally re-engineering the referral process to make it lean and remove all the unnecessary steps. Several improvement interventions have been tested sequentially in three consecutive Plan-Do-Study-Act cycles on a weekly basis. The project findings demonstrated that the first change idea was successful but not reaching the target while the second change had led to huge impact exceeding our target but with short effect. On the other hand, although the third change idea of re-engineering the PSU referral process had led to negative result initially, over the following weeks of measurement the results turned to be positive and meeting our expectations. We concluded that re-engineering referral process is most effective improvement intervention among other change ideas in term of magnitude and sustainability of the effect on increasing the number of referral cases to the PSU. We recommend conducting further testing and measuring of these change ideas in other PSU across the SRCA to understand the diffident context in other regions of SRCA.
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http://dx.doi.org/10.1136/bmjoq-2017-000089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5699156PMC
October 2017

Pre-operative chemoradiotherapy using capecitabine and cetuximab followed by definitive surgery in patients with operable rectal cancer.

Hematol Oncol Stem Cell Ther 2016 Dec 2;9(4):147-153. Epub 2016 Sep 2.

Section of Anatomic Pathology, Department of pathology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.

Background: Achieving a high rate of complete pathological response with pre-operative chemoradiotherapy in rectal cancer is an unmet need. We evaluated the efficacy and toxicity of the combination of cetuximab, capecitabine and radiation therapy in the pre-operative setting of localized rectal cancer.

Patients And Methods: Patients with clinically staged T3, T4 or nodepositive rectal cancer were treated with concurrent capecitabine and radiotherapy with weekly cetuximab starting one week before the start of radiation. This was followed by total mesorectal excision within 6-8 weeks. All patients achieving R0 resection received adjuvant capecitabine for 6 cycles.

Results: Fifteen patients were treated and all underwent surgery. Sphincter preservation was achieved in 11 patients (73.3%) and pathological complete response in two. With a median follow up of 48 months (range 8.4-57.5), 12 patients were relapse-free and 14 were alive with 4-year relapse free survival of 80%. Overall survival was 93%. Significant grade 3 and 4 toxicity was mainly cetuximab-induced skin reactions (33%), radiation-induced skin toxicity (13%) and diarrhea (20%).

Conclusions: Adding cetuximab to pre-operative concurrent capecitabine and radiotherapy provides modest efficacy with manageable toxicity.
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http://dx.doi.org/10.1016/j.hemonc.2016.08.004DOI Listing
December 2016

Loss-of-Function Mutations in ELMO2 Cause Intraosseous Vascular Malformation by Impeding RAC1 Signaling.

Am J Hum Genet 2016 08 28;99(2):299-317. Epub 2016 Jul 28.

Department of Medical Genetics, Gene Mapping Laboratory, Faculty of Medicine, Hacettepe University, Ankara 06100, Turkey; Center for Biobanking and Genomics, Hacettepe University, Ankara 06100, Turkey. Electronic address:

Vascular malformations are non-neoplastic expansions of blood vessels that arise due to errors during angiogenesis. They are a heterogeneous group of sporadic or inherited vascular disorders characterized by localized lesions of arteriovenous, capillary, or lymphatic origin. Vascular malformations that occur inside bone tissue are rare. Herein, we report loss-of-function mutations in ELMO2 (which translates extracellular signals into cellular movements) that are causative for autosomal-recessive intraosseous vascular malformation (VMOS) in five different families. Individuals with VMOS suffer from life-threatening progressive expansion of the jaw, craniofacial, and other intramembranous bones caused by malformed blood vessels that lack a mature vascular smooth muscle layer. Analysis of primary fibroblasts from an affected individual showed that absence of ELMO2 correlated with a significant downregulation of binding partner DOCK1, resulting in deficient RAC1-dependent cell migration. Unexpectedly, elmo2-knockout zebrafish appeared phenotypically normal, suggesting that there might be human-specific ELMO2 requirements in bone vasculature homeostasis or genetic compensation by related genes. Comparative phylogenetic analysis indicated that elmo2 originated upon the appearance of intramembranous bones and the jaw in ancestral vertebrates, implying that elmo2 might have been involved in the evolution of these novel traits. The present findings highlight the necessity of ELMO2 for maintaining vascular integrity, specifically in intramembranous bones.
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http://dx.doi.org/10.1016/j.ajhg.2016.06.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4974086PMC
August 2016

Recurrence and progression in nonmuscle invasive transitional cell carcinoma of urinary bladder treated with intravesical Bacillus Calmette-Guerin: A single center experience and analysis of prognostic factors.

Urol Ann 2016 Jul-Sep;8(3):333-7

Department of Urology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.

Background: Intravesical Bacillus Calmette-Guerin (BCG) has been the standard of care for the prevention of nonmuscle invasive bladder cancer (NMIBC) recurrence following resection. Attempts to improve on the result by combining it with other agents have largely failed. This study addresses the result of BCG therapy in our patient population and compares the result with our combination BCG and interferon therapy published earlier.

Materials And Methods: The medical records of patients diagnosed with NMIBC and treated with transurethral resection and intravesical BCG were reviewed. Univariate analysis was performed on most known prognostic factors. Results were compared to published data on the use of BCG and interferon from the same institution.

Results: Thirty-one patients were identified. Median age was 66 (range 33-109), 80.6% were males. Fourteen patients (45%) had ≤ 3 tumors and 18 (58.1%) had T1 lesions. Four patients (12.9%) had Grade 3 tumors and 25 (80.6%) had Grade 2 tumors. One patient (3.2) had concurrent carcinoma in situ and 11 (35.5%) were treated upon initial diagnosis. At 5 years, the relapse-free survival was 61.3% (95% confidence interval (CI) 44.2-78.4%), progression-free survival was 85.6% (95% CI 73.3-97.9%), and overall survival was 93% (95% CI 84.1-100%). Comparison with the BCG and interferon data showed no significant difference.

Conclusion: The result of BCG therapy in our patient population is similar to western reported data. Efficacy of BCG alone is equal to BCG and interferon within our institution.
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http://dx.doi.org/10.4103/0974-7796.184891DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4944627PMC
July 2016

Time to Consultation-Liaison Psychiatry Service Referral as a Predictor of Length of Stay.

Psychosomatics 2016 May-Jun;57(3):264-72. Epub 2016 Jan 29.

Centre for Mental Health, University Health Network, Ontario, Canada; Department of Psychiatry, University of Toronto, Ontario, Canada.

Objectives: The aim of this study was to determine the relationship between the time to referral (TTR) to psychiatric consultation and the length of stay (LOS) after adjusting for medical comorbity.

Methods: Using a naturalistic study design, we collected and analyzed inpatient consultation-liaison psychiatry service data over a 12-month period from 2 Canadian hospital sites. Data collected included demographic characteristics, referral characteristics, Charlson Comorbidity Index to measure medical comorbidity severity, psychiatric diagnoses, type of psychiatric intervention, and time variables, namely TTR and LOS. We modeled the relationship LOS and TTR after adjusting for Charlson Index using a 3-component finite mixture of exponential regression models.

Results: A total of 814 patients were included. The median LOS was 12 days (interquartile range : 4-28 days). Median TTR was 3 days (interquartile range: 1,9), and median Charlson Index was 5 (interquartile range 3,6). Bivariate analysis indicated a strong positive correlation among LOS and TTR (Spearman correlation: 0.77, p < 0.0001) and Charlson Index(Spearman correlation: 0.34, p < 0.0001), respectively. After controlling for Charlson Index, we observe that TTR was significantly associated with LOS in each of the 3 components of the mixture of exponential regression models. Persons with longer TTR have longer expected LOS. Graphical summaries suggest that the mixture of exponential regression model provides a good fit to these LOS response data.

Conclusions: Patients with longer TTR had significantly longer LOS. The association between TTR and LOS holds after controlling for severity of medical comorbidity. Our results support the role of integrated and proactive consultation-liaison psychiatry programs aimed at reducing TTR to improve LOS outcomes.
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http://dx.doi.org/10.1016/j.psym.2016.01.005DOI Listing
August 2017

Adjuvant chemotherapy for rectal cancer: time to change the guidelines.

Future Oncol 2016 10;12(8):1009-13. Epub 2016 Feb 10.

Section of Medical Oncology, Oncology Center, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia.

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http://dx.doi.org/10.2217/fon-2015-0042DOI Listing
December 2016

Comprehensive analysis of the clinical and urodynamic outcomes of secondary tethered spinal cord before and after spinal cord untethering.

J Pediatr Urol 2016 Apr 26;12(2):101.e1-6. Epub 2015 Sep 26.

Department of Pediatric Surgery, Division of Pediatric Urology and Neurosurgery, The Montreal Children's Hospital and McGill University Health Center, Shriners Hospital of Montréal, QC, Canada.

Objective: Secondary tethering of the spinal cord (TSC) occurs in 3-30% of patients with history of spinal cord dysraphism repair. As many patients with spinal cord dysraphism already have symptoms, it might be difficult to diagnose secondary TSC. Regular clinical/urodynamic (UDS) evaluation is therefore advised to pick-up changes early before they progress. This study aimed at presenting clinical/UDS outcomes for patients with secondary TSC who underwent spinal cord untethering (SCU).

Study Design: Charts of patients with secondary TSC between 1998 and 2010 were reviewed retrospectively. Patients who underwent pre/post SCU clinical/UDS evaluation were included. All patients were followed-up for a minimum of 5 years for proper clinical outcomes assessment. Urologic, neuro-orthopedic, and UDS outcomes were collected and studied. Continence status was assessed in children aged ≥5 years. Patients were considered continent if they were dry for ≥4 h or socially continent if they stayed dry most of the day using maximum 1-2 pads/day. Categorical data were compared using the Fisher-Exact test and continuous variables were compared using the Wilcoxon Signed Rank test. A p-value < 0.05 was considered significant.

Results: Twenty-three patients met our inclusion criteria. The median age at time of SCU was 8.8 (range 2.3-16.2) years. The median age at time of UDS follow-up after SCU was 8.8 (range 2.9-17) years. The median follow-up time was 5 (range 5-13.4) years. Urological symptoms were reported in 56.5% of patients before SCU and improved in 61.5% post SCU. Neuro-orthopedic symptoms were reported in 87% of patients before SCU and improved in 65% post SCU. Continence was achieved in 73.9% of the entire cohort on long-term follow-up, while 26.1% had socially acceptable continence. UDS outcomes are summarized in the Table.

Conclusions: Patients with secondary TSC are expected to have progression of their symptoms over time if not untethered. From here comes the importance of closely performing clinical/UDS evaluation to pick-up changes early before they progress. Surprisingly, clinical outcomes after SCU with detailed description of the auxiliary management are sparse in the literature. Most studies focus on UDS outcomes. We provided in the current study a detailed discussion of the clinical outcomes, auxiliary-managements used to achieve continence, and the UDS outcomes. Careful periodic clinical/UDS evaluation is recommended for early pick-up of changes suggestive of TSC. SCU could improve existing symptoms, and prevent worsening or development of new symptoms. UDS parameters that showed most improvement were intravesical pressure at TCBC and bladder compliance.
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http://dx.doi.org/10.1016/j.jpurol.2015.08.011DOI Listing
April 2016

National Guidelines for Colorectal Cancer Screening in Saudi Arabia with strength of recommendations and quality of evidence.

Ann Saudi Med 2015 May-Jun;35(3):189-95

Nasser Alsanea, MBBCh, President, Saudi Society of Colon & Rectal Surgery,, Head Section, Colon & Rectal Surgery,, King Faisal Specialist Hospital & Research Centre-Riyadh, (MBC-40), PO Box 3354, Riyadh 11211,, Saudi Arabia, T: 966-1-442 7754, F: 966-1-442.7772,

Background: Colorectal cancer is the most common cancer among Saudi men and the third commonest among Saudi women. Given the predominance of colorectal cancer compared with other cancers in Saudi Arabia, context-specific guidelines are needed for screening.

Methods: Experts from the Saudi Society of Colon and Rectal Surgery, Saudi Gastroenterology Association, Saudi Oncology Society, Saudi Chapter of Enterostomal Therapy, Family Medicine and Department of Public Health at the Saudi Arabian Ministry of Health and a patient advocate was assembled by the Saudi Centre for Evidence-Based Healthcare, a subsidiary of the Saudi Arabian Ministry of Health. The panel collaborated with a methodological team from McMaster University, Canada to develop national guidelines for colorectal cancer screening. After identifying key questions, the panel conducted a systematic review of all reports on the utility of screening, the cost of screening for colorectal cancer in Saudi Arabia and on the values and preferences of Saudi patients. Meta- analyses, when appropriate, were performed to generate pooled estimates of effect. Using the GRADE approach, the panel used the evidence-to-decision (EtD) framework to assess all domains important in determining the strength and direction of the recommendations (benefits and harms, values and preferences, resource implications, equity, acceptability, and feasibility). Judgments related to the EtD domains were resolved through consensus or voting, if consensus was not reached. The final recommendations were developed during a two-day meeting held in Riyadh, Saudi Arabia in March 2015. Conflicts of interests among the panel members were handled according to the World Health Organization rules.

Limitations: There is lack of national data on the incidence of adenomatous polyps or the age groups in which the incidence surges. There were no national clinical trials assessing the effectiveness of the different modalities of screening for colorectal cancer and their impact on mortality.

Conclusion: The panel recommends screening for colorectal cancer in Saudi Arabia in asymptomatic Saudi patients at average risk of colorectal cancer. An infrastructure should be built to achieve that goal.
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http://dx.doi.org/10.5144/0256-4947.2015.189DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6074460PMC
June 2016

Phase I/II trial of capecitabine, oxaliplatin, and irinotecan in combination with bevacizumab in first line treatment of metastatic colorectal cancer.

Cancer Med 2015 Oct 24;4(10):1505-13. Epub 2015 Jul 24.

Department of Biostatistics, Epidemiology and Scientific Computing, Research Center, King Faisal Specialist Hospital and Research Center, PO Box 3354, Riyadh, 11211, Saudi Arabia.

Phase III studies have demonstrated the efficacy of FOLFOXIRI regimens (5-fluorouracil/leucovorin, oxaliplatin, irinotecan) with/without bevacizumab in metastatic colorectal cancer (mCRC). Capecitabine is an orally administered fluoropyrimidine that may be used instead of 5-fluorouracil/leucovorin. We evaluated a triple-chemotherapy regimen of capecitabine, oxaliplatin, and irinotecan, plus bevacizumab in 53 patients with mCRC. A Phase I study identified the maximum tolerated dose of irinotecan as 150 mg/m². Median follow-up in a subsequent Phase II study using this dose was 28 months (74% progressed). For all patients, a complete response was achieved in 4% and a partial response in 60%; median progression-free survival (PFS) was 16 months and median overall survival (OS) was 28 months. Median PFS was longer for patients with an early treatment response (28 vs. 9 months for others; P = 0.024), or early tumor shrinkage (25 vs. 9 months for others; P = 0.006), or for patients suitable for surgical removal of metastases with curative intent (median not reached vs. 9 months for others; P = 0.001). Median OS was longer for patients with early tumor shrinkage (median not reached vs. 22 months for others; P = 0.006) or surgery (median not reached vs. 22 months for others, P = 0.002). K-ras mutations status did not influence PFS (P = 0.88) or OS (P = 0.82). Considerable Grade 3/4 toxicity was encountered (36% for diarrhea, 21% for vomiting and 17% for fatigue). In conclusion, the 3-weekly triple-chemotherapy regimen of capecitabine, oxaliplatin, and irinotecan, plus bevacizumab, was active in the first-line treatment of mCRC, although at the expense of a high level of toxicity.
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http://dx.doi.org/10.1002/cam4.497DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4618621PMC
October 2015