Psychological outcomes of siblings of cancer survivors: a report from the Childhood Cancer Survivor Study

OBJECTIVE

To identify risk factors for adverse psychological outcomes among adult siblings of long-term survivors of childhood cancer.

METHODS

Cross-sectional, self-report data from 3083 adult siblings (mean age 29 years, range 18-56 years) of 5 + year survivors of childhood cancer were analyzed to assess psychological outcomes as measured by the Brief Symptom Inventory-18 (BSI-18). Sociodemographic and health data, reported by both the siblings and their matched cancer survivors, were explored as risk factors for adverse sibling psychological outcomes through multivariable logistic regression.

RESULTS

Self-reported symptoms of psychological distress, as measured by the global severity index of the BSI-18, were reported by 3.8% of the sibling sample. Less than 1.5% of siblings reported elevated scores on two or more of the subscales of the BSI-18. Risk factors for sibling depression included having a survivor brother (OR 2.22, 95% CI 1.42-3.55), and having a survivor with impaired general health (OR 2.15, 95% CI 1.18-3.78). Siblings who were younger than the survivor reported increased global psychological distress (OR 1.81, 95% CI 1.05-3.12), as did siblings of survivors reporting global psychological distress (OR 2.32, 95% CI 1.08-4.59). Siblings of sarcoma survivors reported more somatization than did siblings of leukemia survivors (OR 2.07, 95% CI 1.05-3.98).

CONCLUSIONS

These findings suggest that siblings of long-term childhood cancer survivors are psychologically healthy in general. There are, however, small subgroups of siblings at risk for long-term psychological impairment who may benefit from preventive risk-reduction strategies during childhood while their sibling with cancer is undergoing treatment.

Treatment of atypical central neurocytoma in a child with high dose chemotherapy and autologous stem cell rescue

The authors describe a 9 month old female with recurrent atypical central neurocytoma and leptomeningeal spread treated with high dose chemotherapy, autologous stem cell rescue, and adjuvant therapy. She had a complete response to therapy and was disease free at 4 years of age until a recurrence 6 months later. The use of intensive chemotherapy followed by autologous stem cell rescue for atypical neurocytoma may be considered as an adjunct to surgical therapy in young patients with atypical neurocytoma not amenable to radiation therapy.

Psychological status in childhood cancer survivors: a report from the Childhood Cancer Survivor Study

Psychological quality of life (QOL), health-related QOL (HRQOL), and life satisfaction outcomes and their associated risk factors are reviewed for the large cohort of survivors and siblings in the Childhood Cancer Survivor Study (CCSS). This review includes previously published manuscripts that used CCSS data focused on psychological outcome measures, including the Brief Symptom Inventory (BSI-18), the Medical Outcomes Survey Short Form-36 (SF-36), the Cantril Ladder of Life, and other self-report questionnaires. Comparisons and contrasts are made between siblings and survivors, and to normative data when available, in light of demographic/health information and abstracted data from the medical record. These studies demonstrate that a significant proportion of survivors report more symptoms of global distress and poorer physical, but not emotional, domains of HRQOL. Other than brain tumor survivors, most survivors report both good present and expected future life satisfaction. Risk factors for psychological distress and poor HRQOL are female sex, lower educational attainment, unmarried status, annual household income less than $20,000, unemployment, lack of health insurance, presence of a major medical condition, and treatment with cranial radiation and/or surgery. Cranial irradiation impacted neurocognitive outcomes, especially in brain tumor survivors. Psychological distress also predicted poor health behaviors, including smoking, alcohol use, fatigue, and altered sleep. Psychological distress and pain predicted use of complementary and alternative medicine. Overall, most survivors are psychologically healthy and report satisfaction with their lives. However, certain groups of childhood cancer survivors are at high risk for psychological distress, neurocognitive dysfunction, and poor HRQOL, especially in physical domains. These findings suggest targeting interventions for groups at highest risk for adverse outcomes and examining the positive growth that remains despite the trauma of childhood cancer.

Sinus lift approach for the retrieval of root fragments from the maxillary sinus

A new application of a well-known technique; lateral wall sinus approach, to remove a root fragment from the maxillary sinus with minimal damage to the epithelial lining and anterior face of maxilla is described. The technique presented in this article helps eliminate some of the complications associated with Caldwell Luc procedure while preserving the epithelial lining of the maxillary sinus and bony face of maxilla.

Prosthodontic guidelines for surgical reconstruction of the maxilla: a classification system of defects

Surgical reconstruction of maxillectomy defects has been described as an alternative to prosthetic rehabilitation to close the oral cavity. Advancements in microvascular surgical techniques require comprehensive treatment planning guidelines for functional rehabilitation. This retrospective study evaluated acquired maxillectomy defects after surgical reconstruction and/or prosthodontic rehabilitation in an attempt to establish surgical and prosthodontic guidelines that could be organized into a classification system. Forty-seven consecutive patient treatments of palatomaxillary reconstruction at a single facility, The Mount Sinai Medical Center (New York, N.Y.), were reviewed. All patients were rehabilitated with a tissue-borne obturator, a local advancement flap, a fasciocutaneous free flap, or a vascularized bone-containing free flap. Palatomaxillary defects were divided into 3 major classes and 2 subclasses. The aim of this defect-oriented classification system was to organize and define the complex nature of the restorative decision-making process for the maxillectomy patient.

Iliac crest internal oblique osteomusculocutaneous free flap reconstruction of the postablative palatomaxillary defect

BACKGROUND

Traditionally, restoration of extensive palatomaxillary defects have been achieved by prosthetic restoration, often with suboptimal functional results. More recently, vascularized bone-containing free flaps have been used for this purpose.

OBJECTIVE

To describe 6 patients who underwent palatomaxillary reconstruction using the composite iliac crest-internal oblique osteomusculocutaneous free flap.

METHODS

Six cases of iliac crest osteomusculocutaneous free flap reconstruction of extensive postablative palatomaxillary defects were retrospectively reviewed with clinical follow-up. We reviewed these cases for pathologic findings, defect size, dental restoration, oral rehabilitation, and speech.

RESULTS

Pathologic findings included squamous cell carcinoma (n = 4), osteogenic sarcoma (n = 1), and sinonasal hemangiopericytoma (n = 1). Mean follow-up was 14.5 months (range, 10-25 months). Four patients underwent resection and reconstruction primarily and 2 underwent reconstruction secondarily. Two patients required reconstruction of a cutaneous defect using the iliac skin paddle. The hard palate and lateral nasal wall were reconstructed in all 6 patients, and the orbital rim and zygomatic body were reconstructed in 4. One patient underwent reconstruction with an orbital prosthesis supported by osseointegrated implants. There was 1 donor site complication and 1 recipient site infection, which was treated successfully with oral antibiotics. Four patients were rehabilitated with osseointegrated implants, and all 6 patients maintain an unrestricted oral diet. All 6 patients have normal speech without velopharyngeal or oronasal insufficiency.

CONCLUSION

For extensive palatomaxillary defects, the iliac crest-internal oblique osteomusculocutaneous free flap offers a reliable method of primary reconstruction, allowing for complete orodental rehabilitation without the use of a prosthetic obturator.

Acellular dermis for facial soft tissue augmentation: preliminary report

OBJECTIVE

To evaluate the efficacy of acellular dermis as a viable alternative for soft tissue augmentation in facial reconstruction.

DESIGN

A prospective, nonrandomized observational study consisting of 10 patients who underwent soft tissue augmentation with acellular dermis.

SETTING

A tertiary care university medical center in an urban setting.

PATIENTS

Ten patients who had undergone soft tissue augmentation using acellular dermis participated in this study. Postimplantation follow-up was 17 to 36 months.

INTERVENTION

The amount and location for placement of the acellular dermis was left to the discretion of the surgeon. All implants were placed in the subdermal tissues.

MAIN OUTCOME MEASURES

The adequacy of acellular dermis for soft tissue augmentation was assessed by subjective evaluation of implant volume persistence, postoperative complications, and the restoration of normal contour.

RESULTS

Of 10 patients who underwent implantation, 9 had no complications and 1 had a recurrent sterile abscess or mucocele at the implantation site. A 22-month postimplantation tissue sampling of acellular dermis in a patient with recurrent tumor revealed approximately 80% to 85% volume persistence.

CONCLUSION

Preliminary experience with acellular dermis indicates that it shows promise in soft tissue augmentation.

Maxillofacial pathology and management of Pierre Robin sequence

Pierre Robin sequence affects 1:8500 newborns and is characterized by cleft palate, micrognathia, and airway obstruction. Evolution in the understanding of the causes and pathogenesis of this condition is reviewed. Clinical findings and treatment options are also addressed. An overview of syndromes commonly associated with Pierre Robin sequence is provided.

The mandibular symphysis as a donor site in maxillofacial bone grafting: a quantitative anatomic study

PURPOSE

The goal of this study was to quantify the amount of bone graft material present in the mandibular symphysis as well as to determine the maximal size of the corticocancellous bone block that can be harvested while avoiding mental nerve injury, tooth injury, and simultaneously preserving the preoperative facial contour.

MATERIALS AND METHODS

Sixteen fixed dentate cadaver mandibles were studied. Osteotomies were performed in a monocortical fashion, 5 mm anterior to the mental foramen, cephalad to the inferior border of the mandible, caudal to the expected position of the apices of the anterior teeth, and at the midline. The size of the corticocancellous block was then measured. Bone volume, using 2 techniques, was measured by displacement volumetry.

RESULTS

The average volumes obtained were 4.84 mL and 4.71 mL (range, 3.25 to 6.50 mL), respectively, for the 2 techniques of volumetry. The average block size was 20.9 x 9.9 x 6.9 mm; the smallest block was 21.0 x 6.5 x 6.0 mm, and the largest was 25.0 x 13.0 x 9.0 mm.

CONCLUSION

Based on the results of this study, it is apparent that the mandibular symphysis can be reliably selected as the harvest site in a variety of oral and maxillofacial reconstructive procedures.

Reconstruction of the pediatric maxilla and mandible

BACKGROUND

The creation of osseous defects in the upper and lower jaws in children is an uncommon occurrence. It is therefore likely that a head and neck reconstructive surgeon will accumulate only limited experience in restoring such defects. We have reviewed 7 pediatric bone-containing microvascular free flap reconstructions in 6 patients for reconstruction of the upper or lower jaws. Three patients were available for long-term follow-up to evaluate the effect of osseous free flap reconstruction on function and growth and development of the donor site.

DESIGN

Retrospective review.

SETTING

Academic tertiary referral center for otolaryngology.

PATIENTS AND METHODS

Six pediatric patients ranging in age from 8 to 16 years underwent 2 fibular, 4 scapular, and 1 iliac free flap procedure for restoration of 2 maxillary and 5 mandibular defects from 1992 to 1997. Three of the 6 patients were available for long-term follow-up to assess the postoperative donor site function in an effort to determine the effect of this surgery on long-term donor site morbidity and development.

RESULTS

Two patients were lost to follow-up, and 1 died secondary to complications related to distant metastatic disease. Three of 6 patients were observed for 2 years 6 months, 4 years, and 4 years 2 months, respectively. Two of the 3 patients who were observed long term have undergone full dental rehabilitation and currently maintain a regular diet and deny pain with mastication or deglutition. One patient did not require dental rehabilitation. All 3 patients demonstrate gross facial symmetry and normal dental occlusion. Assessment of the fibular donor site demonstrated normal limb length and circumference. The patients denied pain or restriction to recreational activity. Scapular donor sites demonstrated normal range of motion, strength, and shoulder stability.

CONCLUSIONS

Free flap reconstruction of the pediatric maxilla and mandible requires harvesting bone from actively growing donor sites. We have found no evidence of functional deficit after bone harvest from the fibular or scapular donor sites. Patients demonstrate normal growth at the donor sites, and symmetry of the mandible and maxilla is preserved.

Complications of microvascular head and neck surgery in the elderly

OBJECTIVES

To evaluate the complications of head and neck reconstruction using microvascular free tissue transfers (MFTTs) performed in an elderly population and to determine whether these complications are more common than in a younger population.

SETTING

Tertiary referral center.

PATIENTS AND DESIGN

Retrospective, consecutive chart review of patients older than 70 years who underwent MFTT in the past 5 years (group 1). The complications in this population were compared with those in a second group (group 2) of consecutive patients younger than 70 years who were matched according to the site of the primary tumor.

MAIN OUTCOME MEASURES

Surgical and medical complications.

RESULTS

The median age for group 1 was 74 years and for group 2, 55 years. The overall complication rate for group 1 was 48%, compared with 57% for group 2. In group 1, surgical morbidity was less common and medical morbidity was more common than in group 2. Mortality rate was 6% for group 1 and 0% for group 2. The types of complications were similar for both groups. There was no difference in complication rates when complications were classified by site of the defect, patient status determined by American Society of Anesthesiologists classification, or use of preoperative radiation. The overall success rate of MFTT was 100% for group 1 and 94% for group 2.

CONCLUSIONS

Microvascular free tissue transfers for head and neck reconstruction can be safely performed in the elderly. An age older than 70 years does not increase the rate of surgical complications following head and neck reconstruction with MFTT. Medical complications, however, are more common and are equally divided between bronchopulmonary and cardiovascular effects.

Oromandibular reconstruction using microvascular composite flaps: report of 210 cases

OBJECTIVE

To review the experience of 1 microvascular surgeon during an 11-year period in performing 210 vascularized bone-containing free flaps for oromandibular reconstruction.

DESIGN

Retrospective medical records review of patients who underwent primary and secondary oromandibular reconstruction with the use of vascularized bone free flaps.

SETTING

Academic medical center.

PATIENTS

A total of 201 patients underwent 210 composite free-flap reconstructions of the mandible for various disorders and with a range of bony and soft tissue defects.

INTERVENTION

All patients underwent the microvascular transfer of vascularized bone flaps from the ilium, fibula, or scapula. In selected cases, 2 simultaneous free flaps were transferred to achieve an optimal bone and soft tissue reconstruction. Endosteal dental implants were used in 81 patients, with a total of 360 fixtures placed during these 11 years.

MAIN OUTCOME MEASURES

The success of microvascular free tissue transfer, dental implant extrusion, and short- and long-term complications at the recipient and donor sites.

RESULTS

Of the 210 mandibular reconstructions that were performed, 202 were successful in reestablishing mandibular continuity. Reexploration for vascular-related complications was done in 16 patients, 8 of whom were successfully treated, yielding an overall success rate of 96%. The overall success rate for endosteal dental implants was 92%. The implant success rate was 86% when the bone in which the fixtures were placed was irradiated postoperatively. The success rate was 64% in the 14 fixtures that were placed into previously irradiated bone.

CONCLUSIONS

The success of the use of vascularized bone free flaps in restoring continuity to the mandible is clearly demonstrated in this series. There was an acceptable incidence of donor- and recipient-site complications that resulted in minimal long-term morbidity. The careful selection of a donor site(s) for oromandibular reconstruction allows for an optimal restoration of bony and soft tissue defects. Dental implants can be safely used in oromandibular reconstruction with a high level of success. Placing these implants during the initial surgery shortens the duration for achieving dental rehabilitation and enhances the success of the implants when postoperative radiotherapy is administered.

Reconstruction of massive defects in the head and neck: the role of simultaneous distant and regional flaps

BACKGROUND

Massive defects resulting from excision of advanced head and neck tumors may not be amenable to reconstruction using a single technique of tissue transfer. Sixteen patients undergoing reconstruction using simultaneous free flaps and pedicled regional flaps are presented.

METHODS

Regional flaps included the pectoralis major, deltopectoral, cervical visor, paramedian forehead, cervicofacial, and nape of neck flaps. Microvascular tissue transfers included the radial forearm, iliac crest, parascapular/latissimus dorsi, rectus abdominis, fibula, and lateral thigh free flaps.

RESULTS

Most defects involved both aerodigestive mucosa and external cutaneous skin. Mucosal reconstruction was carried out using the soft-tissue component of the free flaps, whereas vascularized bone was used for mandibular reconstruction. Regional flaps were used to reconstruct skin of the face and neck.

CONCLUSIONS

When planned and applied in a stepwise fashion, simultaneous free flaps and regional flaps are complimentary for the reconstruction of complex wounds in the head and neck.

Regional/local anesthesia: a safe and reasonable choice for patients undergoing carotid endarterectomy

PURPOSE

The study compares the outcome of carotid endarterectomy in the community hospital setting using regional versus general anesthesia.

METHODS

Two hundred thirty-six consecutive operations performed on 200 patients (99 operations using superficial and deep cervical block with local supplementation, and 137 procedures using general anesthesia) during a three-year period were analyzed retrospectively. Noncontinuous data were analyzed using Pearson chi-square, continuous data using Student's t-test.

RESULTS

Demographic data and risk factors were similar for both groups. However, patients in the regional anesthesia group had a higher incidence of contralateral stroke and a lower incidence of peripheral vascular disease than patients in the general anesthesia group. Shunts were used less frequently for the regional anesthesia group. The neurologic complication rate was 2.2% for the general anesthesia group and 2.0% for the regional anesthesia group. The single death (fatal stroke) occurred in the general anesthesia group. Four of five major cardiopulmonary complications occurred in the general anesthesia group.

CONCLUSIONS

Carotid endarterectomy can be performed with an acceptable neurologic complication rate under either type of anesthesia. Use of regional anesthesia decreases intraoperative shunting and may decrease the rate of cardiopulmonary complications.

Guided tissue regeneration in dentistry

Guided tissue regeneration (GTR) is a technique currently used in dentistry for periodontal surgery, oral surgery, implant dentistry and reconstruction of maxillomandibular defects. The basic premise for this technique is to allow for osseous regeneration prior to soft tissue migration into the area of interest. This is accomplished with the use of membranes that prevent the migration of the soft tissue element into the bony defect. This paper discusses current uses for GTR techniques and reviews some of the materials now available for this purpose.

Periadventitial delivery of heparin in the prevention of microvenous thrombosis

PURPOSE

In spite of advances in technique and instrumentation, microvascular free tissue transfer remains associated with a persistent risk of flap failure. The use of systemic anticoagulants to overcome the formation of vasoocclusive thrombi at reactive anastomotic sites is associated with a high rate of flap hematoma and is ill advised in the operative setting. The purpose of this study was to investigate the use of a biodegradable, nontoxic polymer gel (polyvinyl alcohol, PVA) to effect a sustained localized release of perivascular heparin around thrombogenic venous anastomoses.

MATERIALS AND METHODS

A modified adventitial inclusion model was created in the femoral vein of 64 adult female Sprague-Dawley rats. Animals were divided into four experimental groups: 1) no treatment (controls), 2) periadventitial PVA gel contained in a vicryl chamber, 3) periadventitial PVA gel mixed with heparin, and 4) systemic heparin (intravenous pump). Patency rates in the femoral vein were checked at 10 minutes, 1 hour, 1 day, and 4 days after surgery. Systemic coagulation parameters and histology (scanning electron microscopy, SEM) were assessed in representative animals from all groups.

RESULTS

Patency rates for experimental groups showed a significant improvement in animals treated with PVA/heparin and systemic heparin over controls. Wound hematomas occurred in 7 of 16 animals in group 3, and in 4 of 16 animals in group 4. Activated partial thromboplastin times were elevated in group 4 only (> 150 seconds).

CONCLUSIONS

Continuous release of periadventitial heparin using a polymeric delivery system may represent an efficient means of attenuating the reactivity of microvenous anastomoses without affecting systemic coagulation parameters. In this model, however, its use was associated with a high rate of local wound hematoma.

Lateral mandibular reconstruction using soft-tissue free flaps and plates

OBJECTIVE

To assess the outcome of patients who are undergoing reconstruction of segmental lateral mandibular defects by using soft-tissue free flaps combined with mandibular reconstruction plates.

DESIGN

Retrospective case series of 15 patients who were undergoing primary reconstruction of mandibular segments posterior to the mental foramen, resulting from treatment of head and neck cancer. All patients received either preoperative or postoperative radiation therapy.

SETTING

Academic tertiary care referral center.

INTERVENTIONS

Fourteen patients had mandibular continuity restored by using the titanium hollow screw reconstruction plate system, and 1 patient received a stainless steel mandibular reconstruction plate. Associated soft-tissue defects were repaired by using radial forearm (n = 11), rectus abdominis (n = 2), scapular and parascapular (n = 1), or lateral arm (n = 1) free flaps.

MAIN OUTCOME MEASURES

Early and delayed complications.

RESULTS

All 15 microvascular free tissue transfers were successful. Early complications were minor and occurred in 5 (33%) of 15 patients. One patient in whom the titanium hollow screw reconstruction plate system had been used experienced a fracture at 15 months after reconstruction. Three patients experienced delayed external plate exposure between 7 and 15 months after primary oromandibular reconstruction. Patients who experienced delayed external plate exposure required secondary reconstruction with a vascularized bone-containing free flap. The overall rate of delayed reconstructive failure was 40% in patients who were followed up for a minimum of 1 year.

CONCLUSIONS

For patients who are undergoing free flap reconstruction of lateral mandibulectomy defects, the technique that used soft-tissue free flaps combined with mandibular reconstruction plates has been abandoned in favor of using vascularized bone-containing free flaps or a combination of free flaps to achieve optimal long-term results.

Rigid fixation of vascularized bone grafts in mandibular reconstruction

OBJECTIVE

To evaluate the nature of complications and complication rates with the use of three different reconstruction plates for the rigid fixation of vascularized bone grafts in oromandibular reconstruction.

DESIGN

We conducted a case series of 95 patients over a 6-year period, with a minimum follow-up of 6 months and a maximum follow-up of 66 months.

SETTING

Academic tertiary referral medical center.

PATIENTS

Forty-eight patients had vascularized bone grafts fixated to native mandible with AO stainless steel reconstruction plates; 25 patients, with AO titanium plates; and 22 patients, with titanium hollow screw reconstruction plates (THORPs). Types of vascularized flaps, mandibular defects to be reconstructed, and use of radiation therapy were similar among the three groups.

INTERVENTION

The surgical approach involved oromandibular reconstruction with a vascularized bone graft rigidly fixated with a reconstruction plate.

OUTCOME MEASURES

Clinically and radiographically noted complications and resultant treatment.

RESULTS

In the grafts fixated with AO stainless steel reconstruction plates, three plate fractures, seven instances of loose screws, eight plate exposures, and two cases of nonunion occurred. No cases of plate fracture or nonunion occurred in the titanium or THORP groups. One titanium plate and two THORPs were exposed during the study period. One instance of loose screws occurred in the titanium group; none in the THORP group. Seventy-four percent of those complications occurred within 12.4 months (the mean follow-up time of the THORP group). The incidence of complications in the stainless steel group was significantly greater than that in the titanium or THORP groups. No statistically significant increase in the rate of complications was noted when radiation therapy was used as a component of treatment.

CONCLUSIONS

To our knowledge, this is the first study to compare three different reconstruction plates for fixation in vascularized bone reconstruction of the mandible. AO THORPs are now used almost exclusively to rigidly fixate vascularized bone grafts because of their advanced design and their potential for osseointegration and because fewer screws are necessary to attain adequate fixation than with conventional AO reconstruction plates.