Epilepsy surgery in bifrontal injury from prior craniopharyngioma resections

Epilepsy surgery in frontal lobe epilepsy (FLE) has less favorable seizure-free outcomes than temporal lobe epilepsies. Possible contributing factors include fast propagation patterns and large clinically silent areas which are characteristics of the frontal lobes. Bilateral frontal lobe abnormalities on MRI are another relative contraindication to epilepsy surgery. For example, bilateral encephalomalacia may be a presupposition to bilateral or multifocal epilepsy. The possibility of potential disinhibition with already poor reserves may be another deterrent to consideration for resective epilepsy surgery. As such, conventional surgical approaches to intractable epilepsy with bilateral frontal injury may be limited to palliative procedures like vagus nerve stimulation and corpus callosotomy. We present a case in which the epileptogenic zone was a subset of the acquired, bilateral, cystic encephalomalacia. This iatrogenic injury resulted from two prior craniotomies for excision of craniopharyngioma and its recurrence.

Following the initial bilateral and subsequent unilateral, subdural grid- and depth electrode-based localization and resection, our patient has remained seizure-free 2 years after epilepsy surgery with marked improvement in her quality of life, as corroborated by her neuropsychological test scores. Our patient's clinical course is testament to the potential role for resective strategies in selected cases of intractable epilepsy associated with bifrontal injury. Reversal of behavioral deficits with frontal lobe epilepsy surgery such as in this patient provides a unique opportunity to further our understanding of the complex nature of frontal lobe function.

Phase 2 randomized, flexible crossover, double-blinded, placebo-controlled trial of the farnesyltransferase inhibitor tipifarnib in children and young adults with neurofibromatosis type 1 and progressive plexiform neurofibromas

BACKGROUND

RAS is dysregulated in neurofibromatosis type 1 (NF1) related plexiform neurofibromas (PNs). The activity of tipifarnib, which blocks RAS signaling by inhibiting its farnesylation, was tested in children and young adults with NF1 and progressive PNs.

METHODS

Patients aged 3-25 years with NF1-related PNs and imaging evidence of tumor progression were randomized in a double-blinded fashion to receive tipifarnib (200 mg/m(2) orally every 12 h) or placebo (phase A) and crossed over to the opposite treatment arm at the time of tumor progression (phase B). PN volumes were measured with MRI, and progression was defined as ≥20% volume increase. Time to progression (TTP) in phase A was the primary endpoint, and the trial was powered to detect whether tipifarnib doubled TTP compared with placebo. Toxicity, response, and quality of life were also monitored.

RESULTS

Sixty-two patients were enrolled. Tipifarnib and placebo were well tolerated. On phase A, the median TTP was 10.6 months on the placebo arm and 19.2 months on the tipifarnib arm (P = .12; 1-sided). Quality of life improved significantly compared with baseline on the tipifarnib arm but not on the placebo arm. Volumetric tumor measurement detected tumor progression earlier than conventional 2-dimensional (WHO) and 1-dimensional (RECIST) methods.

CONCLUSIONS

Tipifarnib was well tolerated but did not significantly prolong TTP of PNs compared with placebo. The randomized, flexible crossover design and volumetric PN assessment provided a feasible and efficient means of assessing the efficacy of tipifarnib. The placebo arm serves as an historical control group for phase 2 single-arm trials directed at progressive PNs.

Phase I trial and pharmacokinetic study of sorafenib in children with neurofibromatosis type I and plexiform neurofibromas

BACKGROUND

Sorafenib targets multiple pathways thought to be crucial in growth of plexiform neurofibroma (PN) in children with neurofibromatosis type 1 (NF1). Sorafenib has been tolerated with manageable toxicities in adults and children with refractory cancer. We conducted a separate study in this population. Monitoring long-term toxicities such as effects on growth and obtaining additional pharmacokinetic data were of importance due to the young age and long duration of therapy seen in previous phase I trials in children with NF1.

PROCEDURE

Children ≥3 and ≤18-year-old with NF1 and inoperable PN were eligible. Sorafenib was administered orally twice daily for consecutive 28-day cycles. Maximum tolerated dose (MTD) was determined from toxicities observed during the first three cycles.

RESULTS

Nine children enrolled, median age 8 (6-12) years. At the starting 115 mg/m(2) /dose (n = 5), two experienced dose-limiting grade 3 pain in their PN. At the de-escalated 80 mg/m(2) /dose (n = 4), approximately 40% of the pediatric solid tumor MTD, two had dose-limiting toxicity (grade 3 rash and grade 4 mood alteration), exceeding the MTD. At 80 mg/m(2) /dose, the median AUC(0-12 hours) at steady-state was 39.5 µg hours/ml. Toxicities appeared to correspond with decreases in quality of life (QOL). No tumor shrinkage was observed.

CONCLUSIONS

Children with NF1 and PN did not tolerate sorafenib at doses substantially lower than the MTD in children and adults with malignant solid tumors. Future trials with targeted agents for children with NF1 may require a more conservative starting dose and separate definitions of dose limiting toxicities (DLT) than children with cancer.

Mesenteric fat necrosis after recent surgery causing bowel obstruction: a case report and review of the literature

Mesenteric fat necrosis causing bowel obstruction is a rare occurrence with only one case reported in humans. It is due to accidental or surgical trauma to the adipose tissue with extracellular liberation of fat or enzymatic lysis of fat due to the release of lipases resulting in fibrosis. Preoperative imaging may often be misleading and fail to identify fat necrosis as the cause of bowel obstruction. As surgical intervention is the only suitable treatment option in cases of failed conservative treatment, the diagnosis is made postoperatively. There is no published advice on the management of mesenteric fat necrosis. We recommend safe operating techniques to minimize the risk of developing fat necrosis and its potential harmful consequences.

Endoscopic retrograde cholangio-pancreatography practice in district general hospitals in North East England: a Northern Regional Endoscopy Group (NREG) study

AIM

Endoscopic retrograde cholangio-pancreatography (ERCP) is an important tool for the management of pancreato-biliary disease. The aim of this study was to compare the current practice of ERCP in North East England against the key 2004 National Confidential Enquiry Report into Patient Outcome and Death (NCEPOD) recommendations and the standards set by the Joint Advisory Group on Gastrointestinal Endoscopy (JAG).

METHODS

This was a prospective multicentre study involving all hospitals in North East England, coordinated through the Northern Regional Endoscopy Group (NREG).

RESULTS

Fourteen endoscopy units submitted data for 481 ERCPs. Mean dose of midazolam was 3.24 mg (standard deviation 1.35; range 1-8 mg). Coagulation profile results were available on 469 patients (97%). Radiological investigations were documented in 96% of the procedures (463 of 481) prior to ERCP. The most common indication for ERCP was related to choledocholithiasis and its complications.  All procedures were performed with a therapeutic intent. A total of 84% of all patients were either American Society of Anesthesiologists grade I or II. The selective biliary cannulation rate was 87.3%. The total completion rate of all procedures was 80.2% (381 of 475) and completion of therapy was 89.5% (425 of 475). The 30-day mortality rate was 2% (ten patients) and procedure-related complications occurred in 5% of patients. There were no deaths directly as a result of ERCP; all deaths were related to underlying medical conditions.

CONCLUSIONS

The practice of ERCP in North East England adheres to the key recommendations of the NCEPOD and the standards set by JAG. The rates of complications compare favourably with those reported internationally.

GFAP mutations, age at onset, and clinical subtypes in Alexander disease

OBJECTIVE

To characterize Alexander disease (AxD) phenotypes and determine correlations with age at onset (AAO) and genetic mutation. AxD is an astrogliopathy usually characterized on MRI by leukodystrophy and caused by glial fibrillary acidic protein (GFAP) mutations.

METHODS

We present 30 new cases of AxD and reviewed 185 previously reported cases. We conducted Wilcoxon rank sum tests to identify variables scaling with AAO, survival analysis to identify predictors of mortality, and χ(2) tests to assess the effects of common GFAP mutations. Finally, we performed latent class analysis (LCA) to statistically define AxD subtypes.

RESULTS

LCA identified 2 classes of AxD. Type I is characterized by early onset, seizures, macrocephaly, motor delay, encephalopathy, failure to thrive, paroxysmal deterioration, and typical MRI features. Type II is characterized by later onset, autonomic dysfunction, ocular movement abnormalities, bulbar symptoms, and atypical MRI features. Survival analysis predicted a nearly 2-fold increase in mortality among patients with type I AxD relative to those with type II. R79 and R239 GFAP mutations were most common (16.6% and 20.3% of all cases, respectively). These common mutations predicted distinct clinical outcomes, with R239 predicting the most aggressive course.

CONCLUSIONS

AAO and the GFAP mutation site are important clinical predictors in AxD, with clear correlations to defined patterns of phenotypic expression. We propose revised AxD subtypes, type I and type II, based on analysis of statistically defined patient groups.

Safe eye surgery: non-technical aspects

The traditional training of surgeons focused exclusively on developing knowledge, clinical expertise, and technical (surgical) skills. However, analyses of the reasons for adverse events in surgery have revealed that many underlying causes originate from behavioural or non-technical aspects of performance (eg, poor communication among members of the surgical team) rather than from a lack of surgical (ie, technical) skills. Therefore, technical skills appear to be necessary but not sufficient to ensure patient safety. Paying attention to non-technical skills, such as team working, leadership, situation awareness, decision making, and communication, will increase the likelihood of maintaining high levels of error-free performance. Identification and training of non-technical skills has been developed for high-risk careers, such as civil aviation and nuclear power. Only recently, training in non-technical skills has been adopted by the surgical world and anaesthetists. Non-technical skills need to be tailored to the environment where they are used, and eye surgery has some substantial differences compared with other surgical areas, for example, high volume of surgery, use of local anaesthetics, and very sophisticated equipment. This review highlights the need for identification of the non-technical skills relevant to eye surgeons and promotion of their use in the training of eye surgeons.