GRADE

Definitie

Hoog

• er is hoge zekerheid dat het ware effect van behandeling dichtbij het geschatte effect van behandeling ligt;
• het is zeer onwaarschijnlijk dat de literatuurconclusie klinisch relevant verandert wanneer er resultaten van nieuw grootschalig onderzoek aan de literatuuranalyse worden toegevoegd.

Redelijk

• er is redelijke zekerheid dat het ware effect van behandeling dichtbij het geschatte effect van behandeling ligt;
• het is mogelijk dat de conclusie klinisch relevant verandert wanneer er resultaten van nieuw grootschalig onderzoek aan de literatuuranalyse worden toegevoegd.

Laag

• er is lage zekerheid dat het ware effect van behandeling dichtbij het geschatte effect van behandeling ligt;
• er is een reële kans dat de conclusie klinisch relevant verandert wanneer er resultaten van nieuw grootschalig onderzoek aan de literatuuranalyse worden toegevoegd.

Zeer laag

• er is zeer lage zekerheid dat het ware effect van behandeling dichtbij het geschatte effect van behandeling ligt;
• de literatuurconclusie is zeer onzeker.

Implicaties van sterke en zwakke aanbevelingen voor verschillende richtlijngebruikers

Sterke aanbeveling

Zwakke (conditionele) aanbeveling

Voor patiënten

De meeste patiënten zouden de aanbevolen interventie of aanpak kiezen en slechts een klein aantal niet.

Een aanzienlijk deel van de patiënten zouden de aanbevolen interventie of aanpak kiezen, maar veel patiënten ook niet. 

Voor behandelaars

De meeste patiënten zouden de aanbevolen interventie of aanpak moeten ontvangen.

Er zijn meerdere geschikte interventies of aanpakken. De patiënt moet worden ondersteund bij de keuze voor de interventie of aanpak die het beste aansluit bij zijn of haar waarden en voorkeuren.

Voor beleidsmakers

De aanbevolen interventie of aanpak kan worden gezien als standaardbeleid.

Beleidsbepaling vereist uitvoerige discussie met betrokkenheid van veel stakeholders. Er is een grotere kans op lokale beleidsverschillen. 

Cluster/richtlijn: Primaire Tumor Onbekend - UV3 Aanvullend beeldvormend onderzoek

Uitgangsvraag/modules: Wat is de plaats van aanvullend beeldvormend onderzoek wanneer er na basisdiagnostiek geen primaire tumor werd aangetoond?

Database(s): Embase.com, Ovid/Medline

Datum: 15 april 2024

Periode: vanaf 2010

Talen: geen restrictie

Literatuurspecialist: Esther van der Bijl

Rayyan review: https://rayyan.ai/reviews/998638

BMI-zoekblokken: voor verschillende opdrachten wordt (deels) gebruik gemaakt van de zoekblokken van BMI-Online https://blocks.bmi-online.nl/ Bij gebruikmaking van een volledig zoekblok zal naar de betreffende link op de website worden verwezen.

Toelichting:

Voor deze vraag is gezocht op de elementen onbekende primaire tumor EN aanvullend beeldvormend onderzoek (mammografie OF MRI OF CT  OF PET-CT  OF echo)

Vanwege de grote opbrengst is in overleg besloten om in eerste instantie alleen de SR’s aan te bieden in Rayyan.

→ Het sleutelartikel wordt gevonden met deze search.

Te gebruiken voor richtlijntekst:

In de databases Embase.com en Ovid/Medline is op 15 april 2024 systematisch gezocht naar systematische reviews over de plaats van aanvullend beeldvormend onderzoek. De literatuurzoekactie leverde 255 unieke treffers op.

EMBASE

OVID/MEDLINE

Ontdubbeld

SR

234

129

255

RCT

505

215

Observationeel

1569

1140

Totaal

2308

1484

255*

No.

Query

Results

#1

(((unknown OR undetermined OR unidentified OR undefined OR undifferentiat* OR uncertain OR 'no detectable') NEAR/6 (primar* OR origin*)):ti,ab,kw) AND ('cancer'/exp OR cancer*:ti,ab,kw OR neoplasm*:ti,ab,kw OR tumo*:ti,ab,kw OR carcinoma*:ti,ab,kw OR adeno*:ti,ab,kw OR metasta*:ti,ab,kw OR micrometasta*:ti,ab,kw OR malignan*:ti,ab,kw OR lymphoma*:ti,ab,kw OR sarcoma*:ti,ab,kw OR melanoma*:ti,ab,kw) OR 'cancer of unknown primary site'/exp OR ((occult NEAR/3 (cancer* OR neoplasm* OR tumo* OR carcinoma* OR adeno* OR metasta* OR micrometasta* OR malignan* OR lymphoma* OR sarcoma* OR melanoma*)):ti,ab,kw)

35558

#2

'mammography'/exp OR 'breast imaging'/exp OR ((breast* NEAR/3 (imag* OR screen* OR 'x ray*' OR scan* OR mri OR tomosynthes*)):ti,ab,kw) OR 'mamilloscop*':ti,ab,kw OR 'mammo graph*':ti,ab,kw OR 'mammogram*':ti,ab,kw OR 'mammograph*':ti,ab,kw OR 'mastograph*':ti,ab,kw

97560

#3

'nuclear magnetic resonance imaging'/exp OR 'mri scanner'/exp OR ('magnetic resonance':ab,ti AND (image:ab,ti OR images:ab,ti OR imaging:ab,ti)) OR mri:ab,ti OR mris:ab,ti OR nmr:ab,ti OR mra:ab,ti OR mras:ab,ti OR zeugmatograph*:ab,ti OR 'mr tomography':ab,ti OR 'mr tomographies':ab,ti OR 'mr tomographic':ab,ti OR 'mr imag*':ti,ab,kw OR 'proton spin':ab,ti OR ((magneti*:ab,ti OR 'chemical shift':ab,ti) AND imaging:ab,ti) OR fmri:ab,ti OR fmris:ab,ti OR rsfmri:ti,ab,kw

1625056

#4

'computer assisted tomography'/exp OR 'cat scan':ti,ab,kw OR ((compute* NEAR/3 tomograph*):ti,ab,kw) OR ct:ti,ab,kw

1789854

#5

'computer assisted emission tomography'/exp OR 'gated single photon emission computed tomography'/exp OR 'single photon emission computer tomography'/exp OR (((emission* OR positron*) NEAR/3 tomograph*):ti,ab,kw) OR radionuclid*:ti,ab,kw OR petscan*:ti,ab,kw OR pet:ti,ab,kw

467441

#6

'ultrasound'/exp OR 'ultrasound scanner'/exp OR 'echography'/exp OR 'endoscopic ultrasonography'/exp OR ultraso*:ti,ab,kw OR sonograph*:ti,ab,kw OR echograph*:ti,ab,kw OR sonogram*:ti,ab,kw

1487447

#7

#2 OR #3 OR #4 OR #5 OR #6

4187841

#8

#1 AND #7

13211

#9

#8 AND [2010-2024]/py NOT ('conference abstract'/it OR 'editorial'/it OR 'letter'/it OR 'note'/it) NOT (('animal'/exp OR 'animal experiment'/exp OR 'animal model'/exp OR 'nonhuman'/exp) NOT 'human'/exp)

5524

#10

'meta analysis'/exp OR 'meta analysis (topic)'/exp OR metaanaly*:ti,ab OR 'meta analy*':ti,ab OR metanaly*:ti,ab OR 'systematic review'/de OR 'cochrane database of systematic reviews'/jt OR prisma:ti,ab OR prospero:ti,ab OR (((systemati* OR scoping OR umbrella OR 'structured literature') NEAR/3 (review* OR overview*)):ti,ab) OR ((systemic* NEAR/1 review*):ti,ab) OR (((systemati* OR literature OR database* OR 'data base*') NEAR/10 search*):ti,ab) OR (((structured OR comprehensive* OR systemic*) NEAR/3 search*):ti,ab) OR (((literature NEAR/3 review*):ti,ab) AND (search*:ti,ab OR database*:ti,ab OR 'data base*':ti,ab)) OR (('data extraction':ti,ab OR 'data source*':ti,ab) AND 'study selection':ti,ab) OR ('search strategy':ti,ab AND 'selection criteria':ti,ab) OR ('data source*':ti,ab AND 'data synthesis':ti,ab) OR medline:ab OR pubmed:ab OR embase:ab OR cochrane:ab OR (((critical OR rapid) NEAR/2 (review* OR overview* OR synthes*)):ti) OR ((((critical* OR rapid*) NEAR/3 (review* OR overview* OR synthes*)):ab) AND (search*:ab OR database*:ab OR 'data base*':ab)) OR metasynthes*:ti,ab OR 'meta synthes*':ti,ab

1018893

#11

'clinical trial'/exp OR 'randomization'/exp OR 'single blind procedure'/exp OR 'double blind procedure'/exp OR 'crossover procedure'/exp OR 'placebo'/exp OR 'prospective study'/exp OR rct:ab,ti OR random*:ab,ti OR 'single blind':ab,ti OR 'randomised controlled trial':ab,ti OR 'randomized controlled trial'/exp OR placebo*:ab,ti

4010868

#12

'major clinical study'/de OR 'clinical study'/de OR 'case control study'/de OR 'family study'/de OR 'longitudinal study'/de OR 'retrospective study'/de OR 'prospective study'/de OR 'comparative study'/de OR 'cohort analysis'/de OR ((cohort NEAR/1 (study OR studies)):ab,ti) OR (('case control' NEAR/1 (study OR studies)):ab,ti) OR (('follow up' NEAR/1 (study OR studies)):ab,ti) OR (observational NEAR/1 (study OR studies)) OR ((epidemiologic NEAR/1 (study OR studies)):ab,ti) OR (('cross sectional' NEAR/1 (study OR studies)):ab,ti)

8172045

#13

'case control study'/de OR 'comparative study'/exp OR 'control group'/de OR 'controlled study'/de OR 'controlled clinical trial'/de OR 'crossover procedure'/de OR 'double blind procedure'/de OR 'phase 2 clinical trial'/de OR 'phase 3 clinical trial'/de OR 'phase 4 clinical trial'/de OR 'pretest posttest design'/de OR 'pretest posttest control group design'/de OR 'quasi experimental study'/de OR 'single blind procedure'/de OR 'triple blind procedure'/de OR (((control OR controlled) NEAR/6 trial):ti,ab,kw) OR (((control OR controlled) NEAR/6 (study OR studies)):ti,ab,kw) OR (((control OR controlled) NEAR/1 active):ti,ab,kw) OR 'open label*':ti,ab,kw OR (((double OR two OR three OR multi OR trial) NEAR/1 (arm OR arms)):ti,ab,kw) OR ((allocat* NEAR/10 (arm OR arms)):ti,ab,kw) OR placebo*:ti,ab,kw OR 'sham-control*':ti,ab,kw OR (((single OR double OR triple OR assessor) NEAR/1 (blind* OR masked)):ti,ab,kw) OR nonrandom*:ti,ab,kw OR 'non-random*':ti,ab,kw OR 'quasi-experiment*':ti,ab,kw OR crossover:ti,ab,kw OR 'cross over':ti,ab,kw OR 'parallel group*':ti,ab,kw OR 'factorial trial':ti,ab,kw OR ((phase NEAR/5 (study OR trial)):ti,ab,kw) OR ((case* NEAR/6 (matched OR control*)):ti,ab,kw) OR ((match* NEAR/6 (pair OR pairs OR cohort* OR control* OR group* OR healthy OR age OR sex OR gender OR patient* OR subject* OR participant*)):ti,ab,kw) OR ((propensity NEAR/6 (scor* OR match*)):ti,ab,kw) OR versus:ti OR vs:ti OR compar*:ti OR ((compar* NEAR/1 study):ti,ab,kw) OR (('major clinical study'/de OR 'clinical study'/de OR 'cohort analysis'/de OR 'observational study'/de OR 'cross-sectional study'/de OR 'multicenter study'/de OR 'correlational study'/de OR 'follow up'/de OR cohort*:ti,ab,kw OR 'follow up':ti,ab,kw OR followup:ti,ab,kw OR longitudinal*:ti,ab,kw OR prospective*:ti,ab,kw OR retrospective*:ti,ab,kw OR observational*:ti,ab,kw OR 'cross sectional*':ti,ab,kw OR cross?ectional*:ti,ab,kw OR multicent*:ti,ab,kw OR 'multi-cent*':ti,ab,kw OR consecutive*:ti,ab,kw) AND (group:ti,ab,kw OR groups:ti,ab,kw OR subgroup*:ti,ab,kw OR versus:ti,ab,kw OR vs:ti,ab,kw OR compar*:ti,ab,kw OR 'odds ratio*':ab OR 'relative odds':ab OR 'risk ratio*':ab OR 'relative risk*':ab OR 'rate ratio':ab OR aor:ab OR arr:ab OR rrr:ab OR ((('or' OR 'rr') NEAR/6 ci):ab)))

14991452

#14

#9 AND #10 – SR’s

234

#15

#9 AND #11 NOT #14 – RCT’s

505

#16

#9 AND (#12 OR #13) NOT (#14 OR #15) – observationele studies

1569

#17

#14 OR #15 OR #16

2308

#

Searches

Results

1

(((unknown or undetermined or unidentified or undefined or undifferentiat* or uncertain or 'no detectable') adj6 (primar* or origin*)).ti,ab,kf. and (exp Neoplasms/ or cancer*.ti,ab,kf. or neoplasm*.ti,ab,kf. or tumo*.ti,ab,kf. or carcinoma*.ti,ab,kf. or adeno*.ti,ab,kf. or metasta*.ti,ab,kf. or micrometasta*.ti,ab,kf. or malignan*.ti,ab,kf. or lymphoma*.ti,ab,kf. or sarcoma*.ti,ab,kf. or melanoma*.ti,ab,kf.)) or exp Neoplasms, Unknown Primary/ or (occult adj3 (cancer* or neoplasm* or tumo* or carcinoma* or adeno* or metasta* or micrometasta* or malignan* or lymphoma* or sarcoma* or melanoma*)).ti,ab,kf.

23627

2

exp Mammography/ or (breast* adj3 (imag* or screen* or X-ray* or scan* or MRI or tomosynthes*)).ti,ab,kf. or 'mamilloscop*'.ti,ab,kf. or 'mammo graph*'.ti,ab,kf. or 'mammogram*'.ti,ab,kf. or 'mammograph*'.ti,ab,kf. or 'mastograph*'.ti,ab,kf.

62577

3

exp magnetic resonance imaging/ or ("magnetic resonance" and (image or images or imaging)).ti,ab,kf. or mri.ti,ab,kf. or mris.ti,ab,kf. or nmr.ti,ab,kf. or mra.ti,ab,kf. or mras.ti,ab,kf. or zeugmatograph*.ti,ab,kf. or "mr tomography".ti,ab,kf. or "mr tomographies".ti,ab,kf. or "mr tomographic".ti,ab,kf. or 'mr imag*'.ti,ab,kf. or "proton spin".ti,ab,kf. or ((magneti* or "chemical shift") and imaging).ti,ab,kf. or fmri.ti,ab,kf. or fmris.ti,ab,kf. or rsfmri.ti,ab,kf.

991052

4

exp Tomography, X-Ray Computed/ or computed tomograph*.ti,ab,kf. or ct.ti,ab,kf. or cts.ti,ab,kf. or cat scan*.ti,ab,kf. or computer assisted tomograph*.ti,ab,kf. or computerized tomograph*.ti,ab,kf. or computerised tomograph*.ti,ab,kf. or computed x ray tomograph*.ti,ab,kf. or computed xray tomograph*.ti,ab,kf.

879633

5

exp Tomography, Emission-Computed/ or ((emission* or positron*) adj3 tomograph*).ti,ab,kf. or radionuclid*.ti,ab,kf. or petscan*.ti,ab,kf. or pet.ti,ab,kf.

248159

6

exp Ultrasonography/ or exp Ultrasonics/ or exp Endosonography/ or ultraso*.ti,ab,kf. or sonograph*.ti,ab,kf. or echograph*.ti,ab,kf. or sonogram*.ti,ab,kf.

773205

7

2 or 3 or 4 or 5 or 6

2498148

8

1 and 7

6810

9

limit 8 to yr="2010 -Current"

3681

10

9 not (comment/ or editorial/ or letter/) not ((exp animals/ or exp models, animal/) not humans/)

3577

11

meta-analysis/ or meta-analysis as topic/ or (metaanaly* or meta-analy* or metanaly*).ti,ab,kf. or systematic review/ or cochrane.jw. or (prisma or prospero).ti,ab,kf. or ((systemati* or scoping or umbrella or "structured literature") adj3 (review* or overview*)).ti,ab,kf. or (systemic* adj1 review*).ti,ab,kf. or ((systemati* or literature or database* or data-base*) adj10 search*).ti,ab,kf. or ((structured or comprehensive* or systemic*) adj3 search*).ti,ab,kf. or ((literature adj3 review*) and (search* or database* or data-base*)).ti,ab,kf. or (("data extraction" or "data source*") and "study selection").ti,ab,kf. or ("search strategy" and "selection criteria").ti,ab,kf. or ("data source*" and "data synthesis").ti,ab,kf. or (medline or pubmed or embase or cochrane).ab. or ((critical or rapid) adj2 (review* or overview* or synthes*)).ti. or (((critical* or rapid*) adj3 (review* or overview* or synthes*)) and (search* or database* or data-base*)).ab. or (metasynthes* or meta-synthes*).ti,ab,kf.

739031

12

exp clinical trial/ or randomized controlled trial/ or exp clinical trials as topic/ or randomized controlled trials as topic/ or Random Allocation/ or Double-Blind Method/ or Single-Blind Method/ or (clinical trial, phase i or clinical trial, phase ii or clinical trial, phase iii or clinical trial, phase iv or controlled clinical trial or randomized controlled trial or multicenter study or clinical trial).pt. or random*.ti,ab. or (clinic* adj trial*).tw. or ((singl* or doubl* or treb* or tripl*) adj (blind$3 or mask$3)).tw. or Placebos/ or placebo*.tw.

2712861

13

Epidemiologic studies/ or case control studies/ or exp cohort studies/ or Controlled Before-After Studies/ or Case control.tw. or cohort.tw. or Cohort analy$.tw. or (Follow up adj (study or studies)).tw. or (observational adj (study or studies)).tw. or Longitudinal.tw. or Retrospective*.tw. or prospective*.tw. or consecutive*.tw. or Cross sectional.tw. or Cross-sectional studies/ or historically controlled study/ or interrupted time series analysis/ [Onder exp cohort studies vallen ook longitudinale, prospectieve en retrospectieve studies]

4699953

14

Case-control Studies/ or clinical trial, phase ii/ or clinical trial, phase iii/ or clinical trial, phase iv/ or comparative study/ or control groups/ or controlled before-after studies/ or controlled clinical trial/ or double-blind method/ or historically controlled study/ or matched-pair analysis/ or single-blind method/ or (((control or controlled) adj6 (study or studies or trial)) or (compar* adj (study or studies)) or ((control or controlled) adj1 active) or "open label*" or ((double or two or three or multi or trial) adj (arm or arms)) or (allocat* adj10 (arm or arms)) or placebo* or "sham-control*" or ((single or double or triple or assessor) adj1 (blind* or masked)) or nonrandom* or "non-random*" or "quasi-experiment*" or "parallel group*" or "factorial trial" or "pretest posttest" or (phase adj5 (study or trial)) or (case* adj6 (matched or control*)) or (match* adj6 (pair or pairs or cohort* or control* or group* or healthy or age or sex or gender or patient* or subject* or participant*)) or (propensity adj6 (scor* or match*))).ti,ab,kf. or (confounding adj6 adjust*).ti,ab. or (versus or vs or compar*).ti. or ((exp cohort studies/ or epidemiologic studies/ or multicenter study/ or observational study/ or seroepidemiologic studies/ or (cohort* or 'follow up' or followup or longitudinal* or prospective* or retrospective* or observational* or multicent* or 'multi-cent*' or consecutive*).ti,ab,kf.) and ((group or groups or subgroup* or versus or vs or compar*).ti,ab,kf. or ('odds ratio*' or 'relative odds' or 'risk ratio*' or 'relative risk*' or aor or arr or rrr).ab. or (("OR" or "RR") adj6 CI).ab.))

5665970

15

10 and 11 – SR’s

129

16

(10 and 12) not 15 – RCT’s

215

17

(10 and (13 or 14)) not (15 or 16) – Observationele studies

1140

18

15 or 16 or 17

1484