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Yahanda AT, Koueik J, Ackerman LL, Adelson PD, Albert GW, Aldana PR, Alden TD, Anderson RCE, Bauer DF, Bethel-Anderson T, Bierbrauer K, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dlouhy BJ, Durham SR, Ellenbogen RG, Eskandari R, Fuchs HE, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Jallo GI, Johnston JM, Kaufman BA, Keating RF, Khan NR, Krieger MD, Leonard JR, Maher CO, Mangano FT, Martin J, McComb JG, McEvoy SD, Meehan T, Menezes AH, Muhlbauer MS, O'Neill BR, Olavarria G, Ragheb J, Selden NR, Shah MN, Shannon CN, Shimony JS, Smyth MD, Stone SSD, Strahle JM, Tamber MS, Torner JC, Tuite GF, Tyler-Kabara EC, Wait SD, Wellons JC, Whitehead WE, Park TS, Limbrick DD, Ahmed R. The role of occipital condyle and atlas anomalies on occipital cervical fusion outcomes in Chiari malformation type I with syringomyelia: a study from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2024:1-9. [PMID: 38579359 DOI: 10.3171/2024.1.peds23229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 01/30/2024] [Indexed: 04/07/2024]
Abstract
OBJECTIVE Congenital anomalies of the atlanto-occipital articulation may be present in patients with Chiari malformation type I (CM-I). However, it is unclear how these anomalies affect the biomechanical stability of the craniovertebral junction (CVJ) and whether they are associated with an increased incidence of occipitocervical fusion (OCF) following posterior fossa decompression (PFD). The objective of this study was to determine the prevalence of condylar hypoplasia and atlas anomalies in children with CM-I and syringomyelia. The authors also investigated the predictive contribution of these anomalies to the occurrence of OCF following PFD (PFD+OCF). METHODS The authors analyzed the prevalence of condylar hypoplasia and atlas arch anomalies for patients in the Park-Reeves Syringomyelia Research Consortium database who underwent PFD+OCF. Condylar hypoplasia was defined by an atlanto-occipital joint axis angle (AOJAA) ≥ 130°. Atlas assimilation and arch anomalies were identified on presurgical radiographic imaging. This PFD+OCF cohort was compared with a control cohort of patients who underwent PFD alone. The control group was matched to the PFD+OCF cohort according to age, sex, and duration of symptoms at a 2:1 ratio. RESULTS Clinical features and radiographic atlanto-occipital joint parameters were compared between 19 patients in the PFD+OCF cohort and 38 patients in the PFD-only cohort. Demographic data were not significantly different between cohorts (p > 0.05). The mean AOJAA was significantly higher in the PFD+OCF group than in the PFD group (144° ± 12° vs 127° ± 6°, p < 0.0001). In the PFD+OCF group, atlas assimilation and atlas arch anomalies were identified in 10 (53%) and 5 (26%) patients, respectively. These anomalies were absent (n = 0) in the PFD group (p < 0.001). Multivariate regression analysis identified the following 3 CVJ radiographic variables that were predictive of OCF occurrence after PFD: AOJAA ≥ 130° (p = 0.01), clivoaxial angle < 125° (p = 0.02), and occipital condyle-C2 sagittal vertical alignment (C-C2SVA) ≥ 5 mm (p = 0.01). A predictive model based on these 3 factors accurately predicted OCF following PFD (C-statistic 0.95). CONCLUSIONS The authors' results indicate that the occipital condyle-atlas joint complex might affect the biomechanical integrity of the CVJ in children with CM-I and syringomyelia. They describe the role of the AOJAA metric as an independent predictive factor for occurrence of OCF following PFD. Preoperative identification of these skeletal abnormalities may be used to guide surgical planning and treatment of patients with complex CM-I and coexistent osseous pathology.
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Affiliation(s)
| | - Joyce Koueik
- 2Department of Neurological Surgery, University of Wisconsin at Madison, Wisconsin
| | - Laurie L Ackerman
- 3Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - P David Adelson
- 4Department of Neurosurgery, West Virginia University School, Morgantown, West Virginia
| | - Gregory W Albert
- 5Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Philipp R Aldana
- 6Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Tord D Alden
- 7Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois
| | | | - David F Bauer
- 9Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | | | - Karin Bierbrauer
- 10Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Douglas L Brockmeyer
- 11Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Joshua J Chern
- 12Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta University, Atlanta, Georgia
| | - Daniel E Couture
- 13Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - David J Daniels
- 14Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Brian J Dlouhy
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Susan R Durham
- 16Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, USC Keck School of Medicine, Los Angeles, California
| | - Richard G Ellenbogen
- 17Division of Pediatric Neurosurgery, Seattle Children's Hospital, Seattle, Washington
| | - Ramin Eskandari
- 18Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Herbert E Fuchs
- 19Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
| | - Gerald A Grant
- 19Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
| | - Patrick C Graupman
- 20Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, Minnesota
| | - Stephanie Greene
- 21Divsion of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey P Greenfield
- 22Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Naina L Gross
- 23Warren Clinic Pediatric Neurosurgery, Saint Francis Health System, Tulsa, Oklahoma
| | - Daniel J Guillaume
- 24Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Todd C Hankinson
- 25Department of Neurosurgery, Penn State College of Medicine, Hershey, Pennsylvania
| | - Gregory G Heuer
- 26Division of Pediatric Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania
| | - Mark Iantosca
- 27Division of Pediatric Neurosurgery, Penn State Health Children's Hospital, Hershey, Pennsylvania
| | - Bermans J Iskandar
- 2Department of Neurological Surgery, University of Wisconsin at Madison, Wisconsin
| | - Eric M Jackson
- 28Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - George I Jallo
- 29Division of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - James M Johnston
- 30Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Bruce A Kaufman
- 31Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert F Keating
- 32Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Nickalus R Khan
- 33Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mark D Krieger
- 16Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, USC Keck School of Medicine, Los Angeles, California
| | - Jeffrey R Leonard
- 34Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Cormac O Maher
- 35Department of Neurosurgery, Stanford University, Palo Alto, California
| | - Francesco T Mangano
- 10Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Jonathan Martin
- 36Department of Neurosurgery, Connecticut Children's Hospital, Hartford, Connecticut
| | - J Gordon McComb
- 16Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, USC Keck School of Medicine, Los Angeles, California
| | | | | | - Arnold H Menezes
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Michael S Muhlbauer
- 33Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Brent R O'Neill
- 25Department of Neurosurgery, Penn State College of Medicine, Hershey, Pennsylvania
| | - Greg Olavarria
- 37Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, Florida
| | - John Ragheb
- 38Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida
| | - Nathan R Selden
- 39Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Manish N Shah
- 40Division of Pediatric Neurosurgery, McGovern Medical School, Houston, Texas
| | - Chevis N Shannon
- 41American Society for Reproductive Medicine, Birmingham, Alabama
| | - Joshua S Shimony
- 42Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew D Smyth
- 29Division of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Scellig S D Stone
- 43Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
| | | | - Mandeep S Tamber
- 44Division of Neurosurgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - James C Torner
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Gerald F Tuite
- 29Division of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | | | - Scott D Wait
- 46Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - John C Wellons
- 40Division of Pediatric Neurosurgery, McGovern Medical School, Houston, Texas
| | - William E Whitehead
- 9Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | | | | | - Raheel Ahmed
- 2Department of Neurological Surgery, University of Wisconsin at Madison, Wisconsin
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Sribnick EA, Leonard JC, Leonard JR. Limitations to Assessing Withdrawal of Care in Children. JAMA Surg 2024; 159:296. [PMID: 38117511 DOI: 10.1001/jamasurg.2023.6539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Affiliation(s)
- Eric A Sribnick
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
- Department of Surgery, Division of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus
| | - Julie C Leonard
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Jeffrey R Leonard
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
- Department of Surgery, Division of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus
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Almeida JP, Finger G, Weber MD, Damante MA, Wu KC, Walz P, Leonard JR, Carrau RL, Prevedello DM. Intradural Pituitary Hemitransposition: Technical Note and Case Series Illustration. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-01003. [PMID: 38132563 DOI: 10.1227/ons.0000000000001036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/06/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Lesions located in the retrosellar region, interpeduncular cistern, and petroclival region are among the most difficult to access in neurosurgery. Transcranial approaches are useful; however, the large distance between the surgeon and the lesion as well as the presence of major neurovascular structures surrounding the lesion may limit surgical exposure. A midline transsphenoidal route avoids transgression of the neurovascular plane and provides direct access to the interpeduncular cistern. To safely access the interpeduncular fossa, it requires mobilization of the pituitary gland. The pituitary hemitransposition technique permits mobilization of the gland, while preserving its venous drainage and arterial supply to the gland on one of its sides, preserving gland function. The authors aim to describe the intradural pituitary hemitransposition technique and to demonstrate its safe application for resection of skull base tumors in the retrosellar space. METHODS The authors describe the surgical technique and illustrate its application in 5 cases of different types of skull base tumors, including a video demonstrating all the steps to perform this approach. In addition, the authors discuss the advantages and limitations of this technique compared with other approaches to the retrosellar space. RESULTS The intradural pituitary hemitransposition technique was used to safely resect a chondrosarcoma, chordoma, craniopharyngioma, teratoma, and meningioma involving the parasellar and retrosellar spaces, while minimizing endocrine morbidity. We had one patient with mild, albeit permanent hyperprolactinemia and hypothyroidism after surgery. No other patients had permanent dysfunction related to surgery. CONCLUSION The endonasal endoscopic intradural pituitary hemitransposition approach is an effective technique for resection of lesions located within the retrosellar and petroclival regions, allowing adequate exposure while potentially optimizing the preservation of the pituitary function.
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Affiliation(s)
- Joao Paulo Almeida
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Guilherme Finger
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Matthieu D Weber
- The Ohio State University College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Mark A Damante
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kyle C Wu
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Patrick Walz
- Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jeffrey R Leonard
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Gruber MD, Pindrik J, Damante M, Schulz L, Shaikhouni A, Leonard JR. Epileptic versus neuro-oncological focus of management in pediatric patients with concurrent primary brain lesion and seizures: a systematic review. J Neurosurg Pediatr 2023; 32:576-583. [PMID: 37728409 DOI: 10.3171/2023.6.peds22440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/20/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVE Seizures can be a debilitating manifestation of underlying neoplastic intracranial pathology. Existing literature offers a paucity of scientific consensus regarding risk factors, seizure semiology, operative techniques, and tumor characteristics in pediatric patients with a concurrent diagnosis of primary intracranial neoplasm and seizures. To address the limited evidence in current literature, the authors systematically reviewed published literature on current clinical characteristics and management strategies for patients presenting concurrently with seizures and a newly diagnosed brain lesion, while aiming to synthesize a potential management protocol or set of recommendations for these patients. METHODS An initial search revealed 792 papers, of which 196 studies were excluded, leaving 596 studies available for abstract review. After further stratification, 546 studies were eliminated, leaving 50 studies for eligibility assessment. Of the 50 studies, 12 met the criteria for outcome extraction. RESULTS The results indicate that patients with a mean age of 9 years with a newly diagnosed brain tumor and presenting symptoms of seizure are likely to present with daily seizures of the complex partial subtype, with the most likely primary epileptogenic and neoplastic foci occurring in the temporal lobe. The most common tumor subtypes were low-grade gliomas, ganglioglioma, dysembryoplastic neuroepithelial tumor, or astrocytoma. With the aim of gross-total resection, 77.54% of patients are likely to achieve seizure freedom. CONCLUSIONS This study highlights the demographic, clinical, seizure, tumor, and postoperative outcomes for pediatric patients presenting with a primary brain tumor and concurrent seizures. Further prospective multicenter studies are necessary to understand and compare varying treatment approaches and to develop standardized guidelines for these patients, with the goal of optimizing neuro-oncological and seizure-related outcomes.
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Affiliation(s)
- Maxwell D Gruber
- 1Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus; and
| | - Jonathan Pindrik
- 1Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus; and
- 2Department of Neurosurgery, The Ohio State University, Columbus, Ohio
| | - Mark Damante
- 1Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus; and
- 2Department of Neurosurgery, The Ohio State University, Columbus, Ohio
| | - Lauren Schulz
- 1Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus; and
- 2Department of Neurosurgery, The Ohio State University, Columbus, Ohio
| | - Ammar Shaikhouni
- 1Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus; and
- 2Department of Neurosurgery, The Ohio State University, Columbus, Ohio
| | - Jeffrey R Leonard
- 1Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus; and
- 2Department of Neurosurgery, The Ohio State University, Columbus, Ohio
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5
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Bozer JJ, Gruber MD, Letson MM, Crichton KG, Rice CE, Qureshi N, Leonard JR, Sribnick EA. Long-Term Functional Outcome Following Neurosurgical Intervention for Suspected Abusive Head Trauma. Pediatr Neurol 2023; 148:101-107. [PMID: 37699270 DOI: 10.1016/j.pediatrneurol.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 08/04/2023] [Accepted: 08/14/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the long-term functional and neurodevelopmental outcomes in pediatric patients who underwent neurosurgical intervention following suspected abusive head trauma (AHT). METHODS We performed a single-center retrospective review (January 1, 2007, to December 31, 2019) of patients aged less than three years who had intracranial injury suspicious for AHT and received a neurosurgical procedure. Long-term functional outcome was measured using the Pediatric Cerebral Performance Category (PCPC), Pediatric Overall Performance Category (POPC), and the Mullen Scales of Early Learning (MSEL). RESULTS Seventy-seven patients were identified; 53 survived to discharge and had at least one-year follow-up. To examine long-term functional outcome, PCPC at the last available visit was examined and found to be 1 or 2 (normal to mild disability) for 64% of patients and 3 or 4 (moderate to severe disability) for 36%. The last available MSEL composite score for neurodevelopmental assessment also demonstrated that 13% of patients scored in the "average" range, 17% in the "below average" range, and 70% in the "very low" range. There was no statistical difference in the last available PCPC or POPC score or the last available MSEL score for patients who received a craniotomy when compared with those who received an intracranial shunt. CONCLUSIONS For patients with AHT who survived to discharge, functional improvements over time were noted in both patients who received craniotomy or who simply required shunt placement. These results suggest that, for patients who survive to discharge, operative management of AHT can lead to reasonable long-term functional outcomes.
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Affiliation(s)
- Jordan J Bozer
- College of Medicine, The Ohio State University, Columbus, Ohio
| | - Maxwell D Gruber
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Megan M Letson
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Kristin G Crichton
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Courtney E Rice
- Psychiatry and Behavioral Health, Nationwide Children's Hospital, Columbus, Ohio
| | | | - Jeffrey R Leonard
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio; Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Eric A Sribnick
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio; Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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Bollo RJ, Gross PH, Rocque BG, Browd SR, Raskin JS, Leonard JR, Albarqawi L, Bailes AF. A multicenter initiative to reduce intrathecal baclofen pump surgical site infection: a Cerebral Palsy Research Network quality improvement project. J Neurosurg Pediatr 2023; 31:444-452. [PMID: 36840731 DOI: 10.3171/2023.1.peds22368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/17/2023] [Indexed: 02/26/2023]
Abstract
OBJECTIVE Intrathecal baclofen (ITB) therapy is an effective treatment for spasticity and dystonia in children with cerebral palsy (CP). However, ITB pump surgery is associated with one of the highest rates of surgical site infection (SSI) in medicine, leading to significant morbidity and expense. Surgical protocols have reduced the rate of SSI in children with other CNS implants, and single-center protocols have been effective in ITB surgery in pediatrics. The authors describe the first multicenter quality improvement (QI)-driven standardized protocol for ITB pump surgery in children with CP across the Cerebral Palsy Research Network (CPRN), implemented with the aim of reducing ITB-associated SSI. METHODS SSI was defined as a culture-positive infection, ITB pump system removal for suspected infection, or wound dehiscence with exposed hardware. Each center reported historical infection rates for at least 3 years before initiating the SSI protocol (preintervention phase). After initiation of a 13-step surgical protocol, a consecutive series of 130 patients undergoing 149 surgical procedures for ITB at four CPRN tertiary pediatric neurosurgery centers were prospectively enrolled at surgery during a 2-year study period (intervention phase). QI methodology was used, including development of a key driver diagram and tracking performance using run and control charts. The primary process measure goal was documented compliance with 80% of the protocol steps, and the primary outcome measure goal was a 20% reduction in 90-day infection rate. Patient characteristics were collected from the CPRN Research Electronic Data Capture registry, including age at surgery, BMI, Gross Motor Function Classification System level, and pattern of spasticity. RESULTS The aggregated preintervention 90-day ITB SSI rate was 4.9% (223 procedures) between 2014 and 2017. During the intervention phase, 136 of 149 ITB surgeries performed met inclusion criteria for analysis. The mean documented compliance rate with protocol steps was 75%, and the 90-day infection rate was 4.4%, with an average of 42 days from index surgery to infection. CONCLUSIONS This is the first multicenter QI initiative designed to reduce SSI in ITB surgery in children with CP. Ongoing enrollment and expansion of the protocol to other CPRN centers will facilitate identification of patient- and procedure-specific risk factors for SSI, and iterative plan-do-study-act cycles incorporating these data will further decrease the risk of SSI for ITB surgery in children.
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Affiliation(s)
- Robert J Bollo
- 1Department of Neurosurgery, Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Paul H Gross
- 2Cerebral Palsy Research Network, Greensville, South Carolina
| | - Brandon G Rocque
- 3Department of Neurosurgery, Division of Pediatric Neurosurgery, Children's Hospital of Alabama, University of Alabama School of Medicine, Birmingham, Alabama
| | - Samuel R Browd
- 4Department of Neurosurgery, Division of Pediatric Neurosurgery, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Jeffrey S Raskin
- 5Department of Neurosurgery, Division of Pediatric Neurosurgery, Riley Children's Hospital, University of Indiana School of Medicine, Indianapolis, Indiana
| | - Jeffrey R Leonard
- 6Department of Neurosurgery, Division of Pediatric Neurosurgery, Nationwide Children's Hospital, The Ohio State College of Medicine, The Ohio State University, Columbus, Ohio
| | - Lama Albarqawi
- 7Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Amy F Bailes
- 8Division of Occupational Therapy and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
- 9Department of Rehabilitation Exercise and Nutrition Sciences, University of Cincinnati School of Medicine, Cincinnati, Ohio
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7
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CreveCoeur TS, Alexiades NG, Bonfield CM, Brockmeyer DL, Browd SR, Chu J, Figaji AA, Groves ML, Hankinson TC, Harter DH, Hwang SW, Jea A, Kernie SG, Leonard JR, Martin JE, Oetgen ME, Powers AK, Rozzelle CJ, Skaggs DL, Strahle JM, Wellons JC, Vitale MG, Anderson RCE. Building consensus for the medical management of children with moderate and severe acute spinal cord injury: a modified Delphi study. J Neurosurg Spine 2023:1-14. [PMID: 36933257 DOI: 10.3171/2023.1.spine221188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/31/2023] [Indexed: 03/19/2023]
Abstract
OBJECTIVE The focus of this modified Delphi study was to investigate and build consensus regarding the medical management of children with moderate and severe acute spinal cord injury (SCI) during their initial inpatient hospitalization. This impetus for the study was based on the AANS/CNS guidelines for pediatric SCI published in 2013, which indicated that there was no consensus provided in the literature describing the medical management of pediatric patients with SCIs. METHODS An international, multidisciplinary group of 19 physicians, including pediatric neurosurgeons, orthopedic surgeons, and intensivists, were asked to participate. The authors chose to include both complete and incomplete injuries with traumatic as well as iatrogenic etiologies (e.g., spinal deformity surgery, spinal traction, intradural spinal surgery, etc.) due to the overall low incidence of pediatric SCI, potentially similar pathophysiology, and scarce literature exploring whether different etiologies of SCI should be managed differently. An initial survey of current practices was administered, and based on the responses, a follow-up survey of potential consensus statements was distributed. Consensus was defined as ≥ 80% of participants reaching agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). A final meeting was held virtually to generate final consensus statements. RESULTS Following the final Delphi round, 35 statements reached consensus after modification and consolidation of previous statements. Statements were categorized into the following eight sections: inpatient care unit, spinal immobilization, pharmacological management, cardiopulmonary management, venous thromboembolism prophylaxis, genitourinary management, gastrointestinal/nutritional management, and pressure ulcer prophylaxis. All participants stated that they would be willing or somewhat willing to change their practices based on consensus guidelines. CONCLUSIONS General management strategies were similar for both iatrogenic (e.g., spinal deformity, traction, etc.) and traumatic SCIs. Steroids were recommended only for injury after intradural surgery, not after acute traumatic or iatrogenic extradural surgery. Consensus was reached that mean arterial pressure ranges are preferred for blood pressure targets following SCI, with goals between 80 and 90 mm Hg for children at least 6 years of age. Further multicenter study of steroid use following acute neuromonitoring changes was recommended.
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Affiliation(s)
| | - Nikita G Alexiades
- 2Department of Neurological Surgery, University of Arizona-Phoenix, Arizona
| | | | - Douglas L Brockmeyer
- 4Department of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Samuel R Browd
- 5Department of Neurosurgery, University of Washington/Seattle Children's Hospital, Seattle, Washington
| | - Jason Chu
- 6Department of Neurosurgery, Children's Hospital of Los Angeles, California
| | - Anthony A Figaji
- 7Department of Neurosurgery, University of Cape Town, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Mari L Groves
- 8Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd C Hankinson
- 9Department of Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - David H Harter
- 10Department of Neurosurgery, New York University, New York, New York
| | - Steven W Hwang
- 11Shriners Hospital for Children, Philadelphia, Pennsylvania
| | - Andrew Jea
- 12Department of Neurological Surgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - Steven G Kernie
- 13Department of Pediatrics, Columbia University, New York, New York
| | - Jeffrey R Leonard
- 14Department of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Jonathan E Martin
- 15Department of Pediatric Neurosurgery, Connecticut Children's Hospital, Hartford, Connecticut
| | - Matthew E Oetgen
- 16Department of Orthopedic Surgery, Children's National Hospital, Washington, DC
| | - Alexander K Powers
- 17Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina
| | - Curtis J Rozzelle
- 18Department of Pediatric Neurosurgery, University of Alabama, Birmingham, Alabama
| | - David L Skaggs
- 19Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Jennifer M Strahle
- 20Department of Neurosurgery, Washington University in St. Louis, Missouri
| | - John C Wellons
- 3Department of Neurological Surgery, Vanderbilt University, Nashville, Tennessee
| | - Michael G Vitale
- 21Orthopedic Surgery, Columbia University Medical Center, New York, New York
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Behbahani M, Rastatter JC, Eide J, Karras C, Walz P, Suresh K, Leonard JR, Alden TD. Pediatric Endoscopic Endonasal Skull Base Surgery: A Retrospective Review Over 11 Years. World Neurosurg 2023; 170:e70-e78. [PMID: 36273727 DOI: 10.1016/j.wneu.2022.10.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To show the safety and efficacy of the endoscopic endonasal approach (EEA) for skull base surgery in pediatric patients through descriptive analysis of cases over an 11-year period. METHODS The study comprised 94 patients undergoing EEA for skull base surgery, between January 2007 and June 2018, at 2 tertiary pediatric hospitals. Descriptive statistics are presented regarding the presentation, intraoperative details, and complications. RESULTS Over the study period, 130 surgeries were performed in 94 patients: 94 primary surgeries and 36 reoperations. The mean patient age was 13.8 years and 48.9% of patients were female. Presenting signs/symptoms included endocrinopathies (56.4%), vision abnormalities (37.2%), and cranial nerve deficits (20.2%). EEA alone was used in 95.7% of primary surgeries and 91.7% of reoperations. Diseases treated included craniopharyngioma (18.1%), pituitary adenoma (17.0%), Rathke cleft cyst (13.8%), chordoma (9.6%), osteosarcoma (5.3%), juvenile nasopharyngeal angiofibroma (4.3%), skull base fracture (4.3%), and encephalocele (3.2%). A lumbar drain was used in 20.2% of primary surgeries and 25% of reoperations. A nasoseptal flap was used in 36.2% of primary surgeries and 25% of reoperations. Postoperative complications included cerebrospinal fluid leak (12.8%), sinusitis (7.4%), bacterial meningitis (3.2%), and carotid artery injury in 1 reoperation. CONCLUSIONS EEA for anterior cranial base disease is safe and efficacious in pediatric patients and can be used to treat many of the rare and heterogenous diseases that arise in this anatomic location. Management strategies and rates of sinonasal and intracranial complications including cerebrospinal fluid leak rate are similar to those reported in adult cohorts.
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Affiliation(s)
- Mandana Behbahani
- Division of Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA; Division of Pediatrics, Department of Neurosurgery, Montefiore Health System, Bronx, New York, USA; Division of Pediatrics, Department of Neurosurgery, Albert Einstein University, Bronx, New York, USA.
| | - Jeffrey C Rastatter
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA; Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jacob Eide
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA; Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Constantine Karras
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Patrick Walz
- Department of Pediatric Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA; Department of Otolaryngology-Head and Neck Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Krish Suresh
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA; Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jeffrey R Leonard
- Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio, USA; Department of Neurosurgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Tord D Alden
- Division of Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA; Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Dastagirzada YM, Alexiades NG, Kurland DB, Anderson SN, Brockmeyer DL, Bumpass DB, Chatterjee S, Groves ML, Hankinson TC, Harter D, Hedequist D, Jea A, Leonard JR, Martin JE, Oetgen ME, Pahys J, Rozzelle C, Strahle JM, Thompson D, Yaszay B, Anderson RCE. Developing consensus for the management of pediatric cervical spine disorders and stabilization: a modified Delphi study. J Neurosurg Pediatr 2023; 31:32-42. [PMID: 36308472 DOI: 10.3171/2022.9.peds22319] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/14/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cervical spine disorders in children are relatively uncommon; therefore, paradigms for surgical and nonsurgical clinical management are not well established. The purpose of this study was to bring together an international, multidisciplinary group of pediatric cervical spine experts to build consensus via a modified Delphi approach regarding the clinical management of children with cervical spine disorders and those undergoing cervical spine stabilization surgery. METHODS A modified Delphi method was used to identify consensus statements for the management of children with cervical spine disorders requiring stabilization. A survey of current practices, supplemented by a literature review, was electronically distributed to 17 neurosurgeons and orthopedic surgeons experienced with the clinical management of pediatric cervical spine disorders. Subsequently, 52 summary statements were formulated and distributed to the group. Statements that reached near consensus or that were of particular interest were then discussed during an in-person meeting to attain further consensus. Consensus was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). RESULTS Forty-five consensus-driven statements were identified, with all participants willing to incorporate them into their practice. For children with cervical spine disorders and/or stabilization, consensus statements were divided into the following categories: A) preoperative planning (12 statements); B) radiographic thresholds of instability (4); C) intraoperative/perioperative management (15); D) postoperative care (11); and E) nonoperative management (3). Several important statements reaching consensus included the following recommendations: 1) to obtain pre-positioning baseline signals with intraoperative neuromonitoring; 2) to use rigid instrumentation when technically feasible; 3) to provide postoperative external immobilization for 6-12 weeks with a rigid cervical collar rather than halo vest immobilization; and 4) to continue clinical postoperative follow-up at least until anatomical cervical spine maturity was reached. In addition, preoperative radiographic thresholds for instability that reached consensus included the following: 1) translational motion ≥ 5 mm at C1-2 (excluding patients with Down syndrome) or ≥ 4 mm in the subaxial spine; 2) dynamic angulation in the subaxial spine ≥ 10°; and 3) abnormal motion and T2 signal change on MRI seen at the same level. CONCLUSIONS In this study, the authors have demonstrated that a multidisciplinary, international group of pediatric cervical spine experts was able to reach consensus on 45 statements regarding the management of pediatric cervical spine disorders and stabilization. Further study is required to determine if implementation of these practices can lead to reduced complications and improved outcomes for children.
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Affiliation(s)
- Yosef M Dastagirzada
- 1Department of Neurological Surgery, New York University, Hassenfeld Children's Hospital, New York, New York
| | | | - David B Kurland
- 1Department of Neurological Surgery, New York University, Hassenfeld Children's Hospital, New York, New York
| | | | - Douglas L Brockmeyer
- 4Department of Pediatric Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, Utah
| | - David B Bumpass
- 5Department of Orthopedic Surgery, University of Arkansas, Little Rock, Arkansas
| | | | - Mari L Groves
- 7Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd C Hankinson
- 8Department of Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - David Harter
- 1Department of Neurological Surgery, New York University, Hassenfeld Children's Hospital, New York, New York
| | - Daniel Hedequist
- 9Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew Jea
- 10Department of Neurological Surgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - Jeffrey R Leonard
- 11Department of Neurosurgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Jonathan E Martin
- 12Division of Pediatric Neurosurgery, Connecticut Children's, Hartford, Connecticut
| | - Matthew E Oetgen
- 13Division of Orthopedic Surgery and Sports Medicine, Children's National Hospital, Washington, DC
| | - Joshua Pahys
- 14Department of Pediatric Orthopedic Surgery, Shriners Hospital for Children, Philadelphia, Pennsylvania
| | - Curtis Rozzelle
- 15Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Alabama, Birmingham, Alabama
| | - Jennifer M Strahle
- 16Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Dominic Thompson
- 17Department of Neurosurgery, Great Ormond Street Hospital for Children, London, United Kingdom; and
| | - Burt Yaszay
- 18Department of Orthopedics, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Richard C E Anderson
- 1Department of Neurological Surgery, New York University, Hassenfeld Children's Hospital, New York, New York
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10
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Makoshi Z, Leonard JR. Clinical Manifestations of Chiari I Malformation. Neurosurg Clin N Am 2023; 34:25-34. [DOI: 10.1016/j.nec.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Limbrick DD, Leonard JR. Advances in the Field of Chiari I Malformation and Integrating Them into Clinical Practice. Neurosurg Clin N Am 2023; 34:xv. [PMID: 36424070 DOI: 10.1016/j.nec.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- David D Limbrick
- Washington University School of Medicine, St. Louis Children's Hospital.
| | - Jeffrey R Leonard
- Neurosurgery, Nationwide Children's Hospital, Neurological Surgery, The Ohio State University School of Medicine, Columbus, OH 43205, USA.
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12
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Drapeau AI, Onwuka A, Koppera S, Leonard JR. Hospital Case-Volume and Patient Outcomes Following Pediatric Brain Tumor Surgery in the Pediatric Health Information System. Pediatr Neurol 2022; 133:48-54. [PMID: 35759803 DOI: 10.1016/j.pediatrneurol.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 06/03/2022] [Accepted: 06/04/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Markers of quality of care in various surgical specialties have been shown to correlate with hospital volumes. This study investigates the effect of hospital volume and patient-related factors on the outcomes of children undergoing brain tumor resection. METHODS We examined the data within the Pediatric Health Information System (PHIS) for children aged zero to 17 years undergoing brain tumor resection between 2016 and 2020. Length of hospital stay (LOS), costs, and reoperation rates were analyzed for associations with hospital case-volume, patient factors, and other hospital-related factors. RESULTS A total of 2568 patients were included in this PHIS analysis. After adjusting for covariates, care provided by high-case-volume hospitals led to shorter LOS (P = 0.01). The effect of hospital case-volume on median cost was present on univariate analysis (US $63,845 at low-volume hospital versus US $54,909 at high-volume hospital, P = 0.002); this finding was attenuated by LOS. A trend was observed between reoperation rates and hospital case-volume, with lowest quartile volume hospitals having higher odds of reoperation than hospitals with volumes in the highest quartile (P = 0.06). Racial and ethnic minorities, medical comorbidities, and other sociodemographic factors were associated with poorer outcomes following surgery. CONCLUSIONS Centering care around high-case-volume hospitals can potentially lead to shorter hospital stays and decreased costs for children with brain tumors. This PHIS article highlights the association of the studied outcomes with certain sociodemographic factors and illustrates that inequalities in pediatric health care still exist. Further efforts are required to understand and eliminate these potentially harmful differences.
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Affiliation(s)
- Annie I Drapeau
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio; Division of Pediatric Neurological Surgery, Nationwide Children's Hospital, Columbus, Ohio.
| | - Amanda Onwuka
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, Ohio
| | - Swapna Koppera
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, Ohio
| | - Jeffrey R Leonard
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio; Division of Pediatric Neurological Surgery, Nationwide Children's Hospital, Columbus, Ohio
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13
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Miller KE, Wheeler G, LaHaye S, Schieffer KM, Cearlock S, Venkata LPR, Bravo AO, Grischow OE, Kelly BJ, White P, Pierson CR, Boué DR, Koo SC, Klawinski D, Ranalli MA, Shaikhouni A, Salloum R, Shatara M, Leonard JR, Wilson RK, Cottrell CE, Mardis ER, Koboldt DC. Molecular Heterogeneity in Pediatric Malignant Rhabdoid Tumors in Patients With Multi-Organ Involvement. Front Oncol 2022; 12:932337. [PMID: 35912263 PMCID: PMC9326117 DOI: 10.3389/fonc.2022.932337] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/09/2022] [Indexed: 11/13/2022] Open
Abstract
Rhabdoid tumors (RTs) of the brain (atypical teratoid/rhabdoid tumor; AT/RT) and extracranial sites (most often the kidney; RTK) are malignant tumors predominantly occurring in children, frequently those with SMARCB1 germline alterations. Here we present data from seven RTs from three pediatric patients who all had multi-organ involvement. The tumors were analyzed using a multimodal molecular approach, which included exome sequencing of tumor and germline comparator and RNA sequencing and DNA array-based methylation profiling of tumors. SMARCB1 germline alterations were identified in all patients and in all tumors. We observed a second hit in SMARCB1 via chr22 loss of heterozygosity. By methylation profiling, all tumors were classified as rhabdoid tumors with a corresponding subclassification within the MYC, TYR, or SHH AT/RT subgroups. Using RNA-seq gene expression clustering, we recapitulated the classification of known AT/RT subgroups. Synchronous brain and kidney tumors from the same patient showed different patterns of either copy number variants, single-nucleotide variants, and/or genome-wide DNA methylation, suggestive of non-clonal origin. Furthermore, we demonstrated that a lung and abdominal metastasis from two patients shared overlapping molecular features with the patient’s primary kidney tumor, indicating the likely origin of the metastasis. In addition to the SMARCB1 events, we identified other whole-chromosome events and single-nucleotide variants in tumors, but none were found to be prognostic, diagnostic, or offer therapeutic potential for rhabdoid tumors. While our findings are of biological interest, there may also be clinical value in comprehensive molecular profiling in patients with multiple rhabdoid tumors, particularly given the potential prognostic and therapeutic implications for different rhabdoid tumor subgroups demonstrated in recent clinical trials and other large cohort studies.
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Affiliation(s)
- Katherine E. Miller
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
- *Correspondence: Katherine E. Miller, ; Daniel C. Koboldt,
| | - Gregory Wheeler
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States
| | - Stephanie LaHaye
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States
| | - Kathleen M. Schieffer
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
- Department of Pathology, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Sydney Cearlock
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States
| | - Lakshmi Prakruthi Rao Venkata
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States
| | - Alejandro Otero Bravo
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States
| | - Olivia E. Grischow
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States
| | - Benjamin J. Kelly
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States
| | - Peter White
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Christopher R. Pierson
- Department of Pathology, The Ohio State University College of Medicine, Columbus, OH, United States
- Department of Pathology and Laboratory Medicine, Nationwide Children’s Hospital, Columbus, OH, United States
- Department of Biomedical Education and Anatomy, Division of Anatomy, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Daniel R. Boué
- Department of Pathology, The Ohio State University College of Medicine, Columbus, OH, United States
- Department of Pathology and Laboratory Medicine, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Selene C. Koo
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Darren Klawinski
- Division of Hematology, Oncology, and Bone Marrow Transplant, Nationwide Children’s Hospital, Columbus, OH, United States
- Pediatric Neuro-Oncology Program, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Mark A. Ranalli
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
- Division of Hematology, Oncology, and Bone Marrow Transplant, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Ammar Shaikhouni
- Department of Neurosurgery, Nationwide Children’s Hospital, Columbus, OH, United States
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Ralph Salloum
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
- Division of Hematology, Oncology, and Bone Marrow Transplant, Nationwide Children’s Hospital, Columbus, OH, United States
- Pediatric Neuro-Oncology Program, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Margaret Shatara
- The Division of Hematology and Oncology, St. Louis Children’s Hospital, Washington University School of Medicine, St. Louis, MO, United States
| | - Jeffrey R. Leonard
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
- Department of Neurosurgery, Nationwide Children’s Hospital, Columbus, OH, United States
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Richard K. Wilson
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Catherine E. Cottrell
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
- Department of Pathology, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Elaine R. Mardis
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Daniel C. Koboldt
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
- *Correspondence: Katherine E. Miller, ; Daniel C. Koboldt,
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14
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Akbari SHA, Yahanda AT, Ackerman LL, Adelson PD, Ahmed R, Albert GW, Aldana PR, Alden TD, Anderson RCE, Bauer DF, Bethel-Anderson T, Bierbrauer K, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dlouhy BJ, Durham SR, Ellenbogen RG, Eskandari R, Fuchs HE, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Jallo GI, Johnston JM, Kaufman BA, Keating RF, Khan NR, Krieger MD, Leonard JR, Maher CO, Mangano FT, McComb JG, McEvoy SD, Meehan T, Menezes AH, Muhlbauer MS, O'Neill BR, Olavarria G, Ragheb J, Selden NR, Shah MN, Shannon CN, Shimony JS, Smyth MD, Stone SSD, Strahle JM, Tamber MS, Torner JC, Tuite GF, Tyler-Kabara EC, Wait SD, Wellons JC, Whitehead WE, Park TS, Limbrick DD. Complications and outcomes of posterior fossa decompression with duraplasty versus without duraplasty for pediatric patients with Chiari malformation type I and syringomyelia: a study from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2022; 30:1-13. [PMID: 35426814 DOI: 10.3171/2022.2.peds21446] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 02/28/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to determine differences in complications and outcomes between posterior fossa decompression with duraplasty (PFDD) and without duraplasty (PFD) for the treatment of pediatric Chiari malformation type I (CM1) and syringomyelia (SM). METHODS The authors used retrospective and prospective components of the Park-Reeves Syringomyelia Research Consortium database to identify pediatric patients with CM1-SM who received PFD or PFDD and had at least 1 year of follow-up data. Preoperative, treatment, and postoperative characteristics were recorded and compared between groups. RESULTS A total of 692 patients met the inclusion criteria for this database study. PFD was performed in 117 (16.9%) and PFDD in 575 (83.1%) patients. The mean age at surgery was 9.86 years, and the mean follow-up time was 2.73 years. There were no significant differences in presenting signs or symptoms between groups, although the preoperative syrinx size was smaller in the PFD group. The PFD group had a shorter mean operating room time (p < 0.0001), fewer patients with > 50 mL of blood loss (p = 0.04), and shorter hospital stays (p = 0.0001). There were 4 intraoperative complications, all within the PFDD group (0.7%, p > 0.99). Patients undergoing PFDD had a 6-month complication rate of 24.3%, compared with 13.7% in the PFD group (p = 0.01). There were no differences between groups for postoperative complications beyond 6 months (p = 0.33). PFD patients were more likely to require revision surgery (17.9% vs 8.3%, p = 0.002). PFDD was associated with greater improvements in headaches (89.6% vs 80.8%, p = 0.04) and back pain (86.5% vs 59.1%, p = 0.01). There were no differences between groups for improvement in neurological examination findings. PFDD was associated with greater reduction in anteroposterior syrinx size (43.7% vs 26.9%, p = 0.0001) and syrinx length (18.9% vs 5.6%, p = 0.04) compared with PFD. CONCLUSIONS PFD was associated with reduced operative time and blood loss, shorter hospital stays, and fewer postoperative complications within 6 months. However, PFDD was associated with better symptom improvement and reduction in syrinx size and lower rates of revision decompression. The two surgeries have low intraoperative complication rates and comparable complication rates beyond 6 months.
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Affiliation(s)
- S Hassan A Akbari
- 1Division of Pediatric Neurosurgery, Penn State Health Children's Hospital, Hershey, PA
| | - Alexander T Yahanda
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Laurie L Ackerman
- 3Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - P David Adelson
- 4Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Raheel Ahmed
- 5Department of Neurological Surgery, University of Wisconsin at Madison, Madison, WI
| | - Gregory W Albert
- 6Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, AR
| | - Philipp R Aldana
- 7Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, FL
| | - Tord D Alden
- 8Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Richard C E Anderson
- 9Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, NY
| | - David F Bauer
- 10Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX
| | - Tammy Bethel-Anderson
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Karin Bierbrauer
- 36Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | - Douglas L Brockmeyer
- 11Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, UT
| | - Joshua J Chern
- 12Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta University, Atlanta, GA
| | - Daniel E Couture
- 13Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Brian J Dlouhy
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Susan R Durham
- 16Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, Los Angeles, CA
| | | | - Ramin Eskandari
- 18Department of Neurosurgery, Medical University of South Carolina, Charleston, SC
| | - Herbert E Fuchs
- 19Department of Neurosurgery, Duke University School of Medicine, Durham, NC
| | - Gerald A Grant
- 20Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital, Palo Alto, CA
| | - Patrick C Graupman
- 21Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, MN
| | - Stephanie Greene
- 22Division of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jeffrey P Greenfield
- 23Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Naina L Gross
- 24Department of Neurosurgery, University of Oklahoma, Oklahoma City, OK
| | - Daniel J Guillaume
- 25Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN
| | - Todd C Hankinson
- 26Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - Gregory G Heuer
- 27Division of Pediatric Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mark Iantosca
- 1Division of Pediatric Neurosurgery, Penn State Health Children's Hospital, Hershey, PA
| | - Bermans J Iskandar
- 5Department of Neurological Surgery, University of Wisconsin at Madison, Madison, WI
| | - Eric M Jackson
- 28Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - George I Jallo
- 29Division of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - James M Johnston
- 30Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL
| | - Bruce A Kaufman
- 31Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI
| | - Robert F Keating
- 32Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Nicklaus R Khan
- 33Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, TN
| | - Mark D Krieger
- 16Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Jeffrey R Leonard
- 34Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH
| | - Cormac O Maher
- 35Department of Neurosurgery, University of Michigan, Ann Arbor, MI
| | - Francesco T Mangano
- 36Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | - J Gordon McComb
- 16Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Sean D McEvoy
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Thanda Meehan
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Arnold H Menezes
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Michael S Muhlbauer
- 33Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, TN
| | - Brent R O'Neill
- 26Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - Greg Olavarria
- 37Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, FL
| | - John Ragheb
- 38Department of Neurological Surgery, University of Miami School of Medicine, Miami, FL
| | - Nathan R Selden
- 39Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
| | - Manish N Shah
- 40Division of Pediatric Neurosurgery, McGovern Medical School, Houston, TX
| | - Chevis N Shannon
- 41Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital at Vanderbilt University, Nashville, TN
| | - Joshua S Shimony
- 42Department of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Matthew D Smyth
- 29Division of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Scellig S D Stone
- 43Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, MA
| | - Jennifer M Strahle
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Mandeep S Tamber
- 44Division of Neurosurgery, The University of British Columbia, Vancouver, BC, Canada
| | - James C Torner
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Gerald F Tuite
- 29Division of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | | | - Scott D Wait
- 46Carolina Neurosurgery & Spine Associates, Charlotte, NC
| | - John C Wellons
- 41Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital at Vanderbilt University, Nashville, TN
| | - William E Whitehead
- 10Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX
| | - Tae Sung Park
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - David D Limbrick
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
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15
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LaHaye S, Fitch JR, Voytovich KJ, Herman AC, Kelly BJ, Lammi GE, Arbesfeld JA, Wijeratne S, Franklin SJ, Schieffer KM, Bir N, McGrath SD, Miller AR, Wetzel A, Miller KE, Bedrosian TA, Leraas K, Varga EA, Lee K, Gupta A, Setty B, Boué DR, Leonard JR, Finlay JL, Abdelbaki MS, Osorio DS, Koo SC, Koboldt DC, Wagner AH, Eisfeld AK, Mrózek K, Magrini V, Cottrell CE, Mardis ER, Wilson RK, White P. Discovery of clinically relevant fusions in pediatric cancer. BMC Genomics 2021; 22:872. [PMID: 34863095 PMCID: PMC8642973 DOI: 10.1186/s12864-021-08094-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 10/15/2021] [Indexed: 12/13/2022] Open
Abstract
Background Pediatric cancers typically have a distinct genomic landscape when compared to adult cancers and frequently carry somatic gene fusion events that alter gene expression and drive tumorigenesis. Sensitive and specific detection of gene fusions through the analysis of next-generation-based RNA sequencing (RNA-Seq) data is computationally challenging and may be confounded by low tumor cellularity or underlying genomic complexity. Furthermore, numerous computational tools are available to identify fusions from supporting RNA-Seq reads, yet each algorithm demonstrates unique variability in sensitivity and precision, and no clearly superior approach currently exists. To overcome these challenges, we have developed an ensemble fusion calling approach to increase the accuracy of identifying fusions. Results Our Ensemble Fusion (EnFusion) approach utilizes seven fusion calling algorithms: Arriba, CICERO, FusionMap, FusionCatcher, JAFFA, MapSplice, and STAR-Fusion, which are packaged as a fully automated pipeline using Docker and Amazon Web Services (AWS) serverless technology. This method uses paired end RNA-Seq sequence reads as input, and the output from each algorithm is examined to identify fusions detected by a consensus of at least three algorithms. These consensus fusion results are filtered by comparison to an internal database to remove likely artifactual fusions occurring at high frequencies in our internal cohort, while a “known fusion list” prevents failure to report known pathogenic events. We have employed the EnFusion pipeline on RNA-Seq data from 229 patients with pediatric cancer or blood disorders studied under an IRB-approved protocol. The samples consist of 138 central nervous system tumors, 73 solid tumors, and 18 hematologic malignancies or disorders. The combination of an ensemble fusion-calling pipeline and a knowledge-based filtering strategy identified 67 clinically relevant fusions among our cohort (diagnostic yield of 29.3%), including RBPMS-MET, BCAN-NTRK1, and TRIM22-BRAF fusions. Following clinical confirmation and reporting in the patient’s medical record, both known and novel fusions provided medically meaningful information. Conclusions The EnFusion pipeline offers a streamlined approach to discover fusions in cancer, at higher levels of sensitivity and accuracy than single algorithm methods. Furthermore, this method accurately identifies driver fusions in pediatric cancer, providing clinical impact by contributing evidence to diagnosis and, when appropriate, indicating targeted therapies. Supplementary Information The online version contains supplementary material available at 10.1186/s12864-021-08094-z.
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Affiliation(s)
- Stephanie LaHaye
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - James R Fitch
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kyle J Voytovich
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Adam C Herman
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Benjamin J Kelly
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Grant E Lammi
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jeremy A Arbesfeld
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Saranga Wijeratne
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Samuel J Franklin
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kathleen M Schieffer
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Natalie Bir
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Sean D McGrath
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Anthony R Miller
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Amy Wetzel
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Katherine E Miller
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Tracy A Bedrosian
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kristen Leraas
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Elizabeth A Varga
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kristy Lee
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ajay Gupta
- Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, OH, USA
| | - Bhuvana Setty
- Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Daniel R Boué
- Department of Pathology, The Ohio State University, Columbus, OH, USA.,Department of Pathology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jeffrey R Leonard
- Department of Pediatrics, The Ohio State University, Columbus, OH, USA.,Section of Neurosurgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jonathan L Finlay
- Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Mohamed S Abdelbaki
- Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Diana S Osorio
- Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Selene C Koo
- Department of Pathology, The Ohio State University, Columbus, OH, USA.,Department of Pathology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Daniel C Koboldt
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Alex H Wagner
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA.,Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
| | - Ann-Kathrin Eisfeld
- Division of Hematology, The Ohio State University, Columbus, OH, USA.,Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University, Columbus, OH, USA.,The Ohio State Comprehensive Cancer Center, Columbus, OH, USA
| | - Krzysztof Mrózek
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University, Columbus, OH, USA.,The Ohio State Comprehensive Cancer Center, Columbus, OH, USA
| | - Vincent Magrini
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Catherine E Cottrell
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA.,Department of Pathology, The Ohio State University, Columbus, OH, USA
| | - Elaine R Mardis
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Richard K Wilson
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Peter White
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA. .,Department of Pediatrics, The Ohio State University, Columbus, OH, USA.
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16
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Akbari SHA, Rizvi AA, CreveCoeur TS, Han RH, Greenberg JK, Torner J, Brockmeyer DL, Wellons JC, Leonard JR, Mangano FT, Johnston JM, Shah MN, Iskandar BJ, Ahmed R, Tuite GF, Kaufman BA, Daniels DJ, Jackson EM, Grant GA, Powers AK, Couture DE, Adelson PD, Alden TD, Aldana PR, Anderson RCE, Selden NR, Bierbrauer K, Boydston W, Chern JJ, Whitehead WE, Dauser RC, Ellenbogen RG, Ojemann JG, Fuchs HE, Guillaume DJ, Hankinson TC, O'Neill BR, Iantosca M, Oakes WJ, Keating RF, Klimo P, Muhlbauer MS, McComb JG, Menezes AH, Khan NR, Niazi TN, Ragheb J, Shannon CN, Smith JL, Ackerman LL, Jea AH, Maher CO, Narayan P, Albert GW, Stone SSD, Baird LC, Gross NL, Durham SR, Greene S, McKinstry RC, Shimony JS, Strahle JM, Smyth MD, Dacey RG, Park TS, Limbrick DD. Socioeconomic and demographic factors in the diagnosis and treatment of Chiari malformation type I and syringomyelia. J Neurosurg Pediatr 2021:1-10. [PMID: 34861643 DOI: 10.3171/2021.9.peds2185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 09/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to assess the social determinants that influence access and outcomes for pediatric neurosurgical care for patients with Chiari malformation type I (CM-I) and syringomyelia (SM). METHODS The authors used retro- and prospective components of the Park-Reeves Syringomyelia Research Consortium database to identify pediatric patients with CM-I and SM who received surgical treatment and had at least 1 year of follow-up data. Race, ethnicity, and insurance status were used as comparators for preoperative, treatment, and postoperative characteristics and outcomes. RESULTS A total of 637 patients met inclusion criteria, and race or ethnicity data were available for 603 (94.7%) patients. A total of 463 (76.8%) were non-Hispanic White (NHW) and 140 (23.2%) were non-White. The non-White patients were older at diagnosis (p = 0.002) and were more likely to have an individualized education plan (p < 0.01). More non-White than NHW patients presented with cerebellar and cranial nerve deficits (i.e., gait ataxia [p = 0.028], nystagmus [p = 0.002], dysconjugate gaze [p = 0.03], hearing loss [p = 0.003], gait instability [p = 0.003], tremor [p = 0.021], or dysmetria [p < 0.001]). Non-White patients had higher rates of skull malformation (p = 0.004), platybasia (p = 0.002), and basilar invagination (p = 0.036). Non-White patients were more likely to be treated at low-volume centers than at high-volume centers (38.7% vs 15.2%; p < 0.01). Non-White patients were older at the time of surgery (p = 0.001) and had longer operative times (p < 0.001), higher estimated blood loss (p < 0.001), and a longer hospital stay (p = 0.04). There were no major group differences in terms of treatments performed or complications. The majority of subjects used private insurance (440, 71.5%), whereas 175 (28.5%) were using Medicaid or self-pay. Private insurance was used in 42.2% of non-White patients compared to 79.8% of NHW patients (p < 0.01). There were no major differences in presentation, treatment, or outcome between insurance groups. In multivariate modeling, non-White patients were more likely to present at an older age after controlling for sex and insurance status (p < 0.01). Non-White and male patients had a longer duration of symptoms before reaching diagnosis (p = 0.033 and 0.004, respectively). CONCLUSIONS Socioeconomic and demographic factors appear to influence the presentation and management of patients with CM-I and SM. Race is associated with age and timing of diagnosis as well as operating room time, estimated blood loss, and length of hospital stay. This exploration of socioeconomic and demographic barriers to care will be useful in understanding how to improve access to pediatric neurosurgical care for patients with CM-I and SM.
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Affiliation(s)
- Syed Hassan A Akbari
- 1Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | | | | | | | - James Torner
- 4Department of Epidemiology, University of Iowa, Iowa City, Iowa
| | - Douglas L Brockmeyer
- 5Department of Pediatric Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - John C Wellons
- 6Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey R Leonard
- 7Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Francesco T Mangano
- 8Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James M Johnston
- 9Division of Neurosurgery, University of Alabama School of Medicine, Birmingham, Alabama
| | - Manish N Shah
- 10Department of Pediatric Surgery and Neurosurgery, The University of Texas McGovern Medical School, Houston, Texas
| | - Bermans J Iskandar
- 11Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Raheel Ahmed
- 11Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Gerald F Tuite
- 12Department of Neurosurgery, Neuroscience Institute, All Children's Hospital, St. Petersburg, Florida
| | - Bruce A Kaufman
- 13Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David J Daniels
- 14Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Eric M Jackson
- 15Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Gerald A Grant
- 16Department of Neurosurgery, Stanford Child Health Research Institute, Stanford, California
| | - Alexander K Powers
- 17Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Daniel E Couture
- 17Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - P David Adelson
- 18Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Tord D Alden
- 19Department of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Illinois
| | - Philipp R Aldana
- 20Department of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Richard C E Anderson
- 21Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, New York
| | - Nathan R Selden
- 22Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Karin Bierbrauer
- 8Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - William Boydston
- 23Department of Neurosurgery, Children's Healthcare of Atlanta, Georgia
| | - Joshua J Chern
- 23Department of Neurosurgery, Children's Healthcare of Atlanta, Georgia
| | | | - Robert C Dauser
- 24Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Richard G Ellenbogen
- 25Department of Neurosurgery, University of Washington Medicine, Seattle, Washington
| | - Jeffrey G Ojemann
- 25Department of Neurosurgery, University of Washington Medicine, Seattle, Washington
| | - Herbert E Fuchs
- 26Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
| | - Daniel J Guillaume
- 27Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Todd C Hankinson
- 28Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Brent R O'Neill
- 28Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Mark Iantosca
- 1Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - W Jerry Oakes
- 9Division of Neurosurgery, University of Alabama School of Medicine, Birmingham, Alabama
| | - Robert F Keating
- 29Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Paul Klimo
- 30Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Michael S Muhlbauer
- 30Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - J Gordon McComb
- 31Division of Neurosurgery, Children's Hospital Los Angeles, California
| | - Arnold H Menezes
- 32Department of Neurosurgery, University of Iowa Hospitals, Iowa City, Iowa
| | - Nickalus R Khan
- 33Department of Pediatric Neurosurgery, Miami Children's Hospital and University of Miami Miller School of Medicine, Miami, Florida
| | - Toba N Niazi
- 33Department of Pediatric Neurosurgery, Miami Children's Hospital and University of Miami Miller School of Medicine, Miami, Florida
| | - John Ragheb
- 33Department of Pediatric Neurosurgery, Miami Children's Hospital and University of Miami Miller School of Medicine, Miami, Florida
| | - Chevis N Shannon
- 6Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jodi L Smith
- 34Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Laurie L Ackerman
- 34Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Andrew H Jea
- 34Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Cormac O Maher
- 35Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Prithvi Narayan
- 36Department of Neurological Surgery, St. Christopher's Hospital, Philadelphia, Pennsylvania
| | - Gregory W Albert
- 37Department of Neurosurgery, University of Arkansas College of Medicine, Little Rock, Arkansas
| | - Scellig S D Stone
- 38Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
| | - Lissa C Baird
- 38Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
| | - Naina L Gross
- 39Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - Susan R Durham
- 40Division of Neurosurgery, University of Vermont Medical Center, Burlington, Vermont; and
| | - Stephanie Greene
- 41Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert C McKinstry
- 3Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Joshua S Shimony
- 3Radiology, Washington University School of Medicine, St. Louis, Missouri
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17
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CreveCoeur TS, Yahanda AT, Maher CO, Johnson GW, Ackerman LL, Adelson PD, Ahmed R, Albert GW, Aldana PR, Alden TD, Anderson RCE, Baird L, Bauer DF, Bierbrauer KS, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dauser RC, Durham SR, Ellenbogen RG, Eskandari R, Fuchs HE, George TM, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Haller G, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Jea AH, Johnston JM, Keating RF, Kelly MP, Khan N, Krieger MD, Leonard JR, Mangano FT, Mapstone TB, McComb JG, Menezes AH, Muhlbauer M, Oakes WJ, Olavarria G, O’Neill BR, Park TS, Ragheb J, Selden NR, Shah MN, Shannon C, Shimony JS, Smith J, Smyth MD, Stone SSD, Strahle JM, Tamber MS, Torner JC, Tuite GF, Wait SD, Wellons JC, Whitehead WE, Limbrick DD. Occipital-Cervical Fusion and Ventral Decompression in the Surgical Management of Chiari-1 Malformation and Syringomyelia: Analysis of Data From the Park-Reeves Syringomyelia Research Consortium. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa460_s089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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18
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Makoshi ZA, Leonard JR. Editorial. The ongoing dilemma of incidentalomas. J Neurosurg Pediatr 2021:1-2. [PMID: 34715665 DOI: 10.3171/2021.7.peds21318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ziyad A Makoshi
- 1Neurosurgery, Nationwide Children's Hospital and College of Medicine, Columbus, Ohio; and
| | - Jeffrey R Leonard
- 1Neurosurgery, Nationwide Children's Hospital and College of Medicine, Columbus, Ohio; and.,2The Ohio State College of Medicine, The Ohio State University, Columbus, Ohio
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19
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Sadler B, Skidmore A, Gewirtz J, Anderson RCE, Haller G, Ackerman LL, Adelson PD, Ahmed R, Albert GW, Aldana PR, Alden TD, Averill C, Baird LC, Bauer DF, Bethel-Anderson T, Bierbrauer KS, Bonfield CM, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dlouhy BJ, Durham SR, Ellenbogen RG, Eskandari R, Fuchs HE, George TM, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Jea AH, Johnston JM, Keating RF, Khan N, Krieger MD, Leonard JR, Maher CO, Mangano FT, Mapstone TB, McComb JG, McEvoy SD, Meehan T, Menezes AH, Muhlbauer M, Oakes WJ, Olavarria G, O'Neill BR, Ragheb J, Selden NR, Shah MN, Shannon CN, Smith J, Smyth MD, Stone SSD, Tuite GF, Wait SD, Wellons JC, Whitehead WE, Park TS, Limbrick DD, Strahle JM. Extradural decompression versus duraplasty in Chiari malformation type I with syrinx: outcomes on scoliosis from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2021:1-9. [PMID: 34144521 DOI: 10.3171/2020.12.peds20552] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Scoliosis is common in patients with Chiari malformation type I (CM-I)-associated syringomyelia. While it is known that treatment with posterior fossa decompression (PFD) may reduce the progression of scoliosis, it is unknown if decompression with duraplasty is superior to extradural decompression. METHODS A large multicenter retrospective and prospective registry of 1257 pediatric patients with CM-I (tonsils ≥ 5 mm below the foramen magnum) and syrinx (≥ 3 mm in axial width) was reviewed for patients with scoliosis who underwent PFD with or without duraplasty. RESULTS In total, 422 patients who underwent PFD had a clinical diagnosis of scoliosis. Of these patients, 346 underwent duraplasty, 51 received extradural decompression alone, and 25 were excluded because no data were available on the type of PFD. The mean clinical follow-up was 2.6 years. Overall, there was no difference in subsequent occurrence of fusion or proportion of patients with curve progression between those with and those without a duraplasty. However, after controlling for age, sex, preoperative curve magnitude, syrinx length, syrinx width, and holocord syrinx, extradural decompression was associated with curve progression > 10°, but not increased occurrence of fusion. Older age at PFD and larger preoperative curve magnitude were independently associated with subsequent occurrence of fusion. Greater syrinx reduction after PFD of either type was associated with decreased occurrence of fusion. CONCLUSIONS In patients with CM-I, syrinx, and scoliosis undergoing PFD, there was no difference in subsequent occurrence of surgical correction of scoliosis between those receiving a duraplasty and those with an extradural decompression. However, after controlling for preoperative factors including age, syrinx characteristics, and curve magnitude, patients treated with duraplasty were less likely to have curve progression than patients treated with extradural decompression. Further study is needed to evaluate the role of duraplasty in curve stabilization after PFD.
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Affiliation(s)
- Brooke Sadler
- 1Department of Pediatrics, Washington University in St. Louis, MO
| | - Alex Skidmore
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Jordan Gewirtz
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | | | - Gabe Haller
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Laurie L Ackerman
- 4Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - P David Adelson
- 5Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Raheel Ahmed
- 6Department of Neurological Surgery, University of Wisconsin at Madison, WI
| | - Gregory W Albert
- 7Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, AR
| | - Philipp R Aldana
- 8Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, FL
| | - Tord D Alden
- 9Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, IL
| | - Christine Averill
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Lissa C Baird
- 10Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
| | - David F Bauer
- 11Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX
| | - Tammy Bethel-Anderson
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Karin S Bierbrauer
- 12Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | - Christopher M Bonfield
- 43Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
| | - Douglas L Brockmeyer
- 13Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, UT
| | - Joshua J Chern
- 14Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta, GA
| | - Daniel E Couture
- 15Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Brian J Dlouhy
- 39Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Susan R Durham
- 18Department of Neurosurgery, University of Vermont, Burlington, VT
| | | | - Ramin Eskandari
- 20Department of Neurosurgery, Medical University of South Carolina, Charleston, SC
| | | | - Timothy M George
- 22Division of Pediatric Neurosurgery, Dell Children's Medical Center, Austin, TX
| | - Gerald A Grant
- 23Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital and Stanford University School of Medicine, Palo Alto, CA
| | - Patrick C Graupman
- 24Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, MN
| | - Stephanie Greene
- 25Division of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jeffrey P Greenfield
- 26Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Naina L Gross
- 27Department of Neurosurgery, University of Oklahoma, Oklahoma City, OK
| | - Daniel J Guillaume
- 28Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN
| | - Todd C Hankinson
- 29Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - Gregory G Heuer
- 30Division of Pediatric Neurosurgery, Children's Hospital of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mark Iantosca
- 31Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Bermans J Iskandar
- 6Department of Neurological Surgery, University of Wisconsin at Madison, WI
| | - Eric M Jackson
- 32Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew H Jea
- 4Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - James M Johnston
- 33Division of Pediatric Neurosurgery, University of Alabama at Birmingham, AL
| | - Robert F Keating
- 34Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Nickalus Khan
- 36Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, TN
| | - Mark D Krieger
- 37Department of Neurosurgery, Children's Hospital Los Angeles, CA
| | - Jeffrey R Leonard
- 38Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH
| | - Cormac O Maher
- 3Department of Neurosurgery, University of Michigan School of Medicine, Ann Arbor, MI
| | - Francesco T Mangano
- 12Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | | | - J Gordon McComb
- 37Department of Neurosurgery, Children's Hospital Los Angeles, CA
| | - Sean D McEvoy
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Thanda Meehan
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Arnold H Menezes
- 39Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Michael Muhlbauer
- 36Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, TN
| | - W Jerry Oakes
- 33Division of Pediatric Neurosurgery, University of Alabama at Birmingham, AL
| | - Greg Olavarria
- 40Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, FL
| | - Brent R O'Neill
- 29Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - John Ragheb
- 41Department of Neurological Surgery, University of Miami School of Medicine, Miami, FL
| | - Nathan R Selden
- 10Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
| | - Manish N Shah
- 42Division of Pediatric Neurosurgery, McGovern Medical School, Houston, TX
| | - Chevis N Shannon
- 43Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
- 47Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
| | - Jodi Smith
- 4Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Matthew D Smyth
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Scellig S D Stone
- 44Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, MA
| | - Gerald F Tuite
- 45Department of Neurosurgery, Neuroscience Institute, All Children's Hospital, St. Petersburg, FL
| | - Scott D Wait
- 46Carolina Neurosurgery & Spine Associates, Charlotte, NC; and
| | - John C Wellons
- 43Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
- 47Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
| | - William E Whitehead
- 11Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX
| | - Tae Sung Park
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - David D Limbrick
- 1Department of Pediatrics, Washington University in St. Louis, MO
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Jennifer M Strahle
- 1Department of Pediatrics, Washington University in St. Louis, MO
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
- 35Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO
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20
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CreveCoeur TS, Yahanda AT, Maher CO, Johnson GW, Ackerman LL, Adelson PD, Ahmed R, Albert GW, Aldana PR, Alden TD, Anderson RCE, Baird L, Bauer DF, Bierbrauer KS, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dauser RC, Durham SR, Ellenbogen RG, Eskandari R, Fuchs HE, George TM, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Haller G, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Jea AH, Johnston JM, Keating RF, Kelly MP, Khan N, Krieger MD, Leonard JR, Mangano FT, Mapstone TB, McComb JG, Menezes AH, Muhlbauer M, Oakes WJ, Olavarria G, O'Neill BR, Park TS, Ragheb J, Selden NR, Shah MN, Shannon C, Shimony JS, Smith J, Smyth MD, Stone SSD, Strahle JM, Tamber MS, Torner JC, Tuite GF, Wait SD, Wellons JC, Whitehead WE, Limbrick DD. Occipital-Cervical Fusion and Ventral Decompression in the Surgical Management of Chiari-1 Malformation and Syringomyelia: Analysis of Data From the Park-Reeves Syringomyelia Research Consortium. Neurosurgery 2021; 88:332-341. [PMID: 33313928 DOI: 10.1093/neuros/nyaa460] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/12/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Occipital-cervical fusion (OCF) and ventral decompression (VD) may be used in the treatment of pediatric Chiari-1 malformation (CM-1) with syringomyelia (SM) as adjuncts to posterior fossa decompression (PFD) for complex craniovertebral junction pathology. OBJECTIVE To examine factors influencing the use of OCF and OCF/VD in a multicenter cohort of pediatric CM-1 and SM subjects treated with PFD. METHODS The Park-Reeves Syringomyelia Research Consortium registry was used to examine 637 subjects with cerebellar tonsillar ectopia ≥ 5 mm, syrinx diameter ≥ 3 mm, and at least 1 yr of follow-up after their index PFD. Comparisons were made between subjects who received PFD alone and those with PFD + OCF or PFD + OCF/VD. RESULTS All 637 patients underwent PFD, 505 (79.2%) with and 132 (20.8%) without duraplasty. A total of 12 subjects went on to have OCF at some point in their management (PFD + OCF), whereas 4 had OCF and VD (PFD + OCF/VD). Of those with complete data, a history of platybasia (3/10, P = .011), Klippel-Feil (2/10, P = .015), and basilar invagination (3/12, P < .001) were increased within the OCF group, whereas only basilar invagination (1/4, P < .001) was increased in the OCF/VD group. Clivo-axial angle (CXA) was significantly lower for both OCF (128.8 ± 15.3°, P = .008) and OCF/VD (115.0 ± 11.6°, P = .025) groups when compared to PFD-only group (145.3 ± 12.7°). pB-C2 did not differ among groups. CONCLUSION Although PFD alone is adequate for treating the vast majority of CM-1/SM patients, OCF or OCF/VD may be occasionally utilized. Cranial base and spine pathologies and CXA may provide insight into the need for OCF and/or OCF/VD.
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Affiliation(s)
- Travis S CreveCoeur
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Alexander T Yahanda
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Cormac O Maher
- Department of Neurosurgery, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Gabrielle W Johnson
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Laurie L Ackerman
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - P David Adelson
- Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Raheel Ahmed
- Department of Neurological Surgery, University of Wisconsin at Madison, Madison, Wisconsin
| | - Gregory W Albert
- Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Phillipp R Aldana
- Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Tord D Alden
- Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Richard C E Anderson
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, New York
| | - Lissa Baird
- Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - David F Bauer
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Karin S Bierbrauer
- Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Douglas L Brockmeyer
- Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Joshua J Chern
- Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Daniel E Couture
- Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - David J Daniels
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Robert C Dauser
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - Susan R Durham
- Department of Neurosurgery, University of Vermont, Burlington, Vermont
| | - Richard G Ellenbogen
- Division of Pediatric Neurosurgery, Seattle Children's Hospital, Seattle, Washington
| | - Ramin Eskandari
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Herbert E Fuchs
- Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Timothy M George
- Division of Pediatric Neurosurgery, Dell Children's Medical Center, Austin, Texas
| | - Gerald A Grant
- Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital at Stanford, Stanford University School of Medicine, Palo Alto, California
| | - Patrick C Graupman
- Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, Minnesota
| | - Stephanie Greene
- Divsion of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey P Greenfield
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Naina L Gross
- Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - Daniel J Guillaume
- Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Gabe Haller
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Todd C Hankinson
- Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Gregory G Heuer
- Division of Pediatric Neurosurgery, Children's Hospital of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark Iantosca
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Bermans J Iskandar
- Department of Neurological Surgery, University of Wisconsin at Madison, Madison, Wisconsin
| | - Eric M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew H Jea
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - James M Johnston
- Division of Pediatric Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert F Keating
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia
| | - Michael P Kelly
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Nickalus Khan
- Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Mark D Krieger
- Department of Neurosurgery, Children's Hospital of Los Angeles, Los Angeles, California
| | - Jeffrey R Leonard
- Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Francesco T Mangano
- Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Timothy B Mapstone
- Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - J Gordon McComb
- Department of Neurosurgery, Children's Hospital of Los Angeles, Los Angeles, California
| | - Arnold H Menezes
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Michael Muhlbauer
- Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - W Jerry Oakes
- Division of Pediatric Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Greg Olavarria
- Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, Florida
| | - Brent R O'Neill
- Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Tae Sung Park
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - John Ragheb
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida
| | - Nathan R Selden
- Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Manish N Shah
- Division of Pediatric Neurosurgery, McGovern Medical School, Houston, Texas
| | - Chevis Shannon
- Division of Pediatric Neurosurgery, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - Joshua S Shimony
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Jodi Smith
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Matthew D Smyth
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Scellig S D Stone
- Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
| | - Jennifer M Strahle
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Mandeep S Tamber
- Department of Neurosurgery, The University of British Columbia, Vancouver, Canada
| | - James C Torner
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Gerald F Tuite
- Department of Neurosurgery, Neuroscience Institute, All Children's Hospital, St. Petersburg, Florida
| | - Scott D Wait
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - John C Wellons
- Division of Pediatric Neurosurgery, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - William E Whitehead
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - David D Limbrick
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
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21
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Miller KE, Schieffer KM, Grischow O, Rodriguez DP, Cottrell CE, Leonard JR, Finlay JL, Mardis ER. Clinical response to dabrafenib plus trametinib in a pediatric ganglioglioma with BRAF p.T599dup mutation. Cold Spring Harb Mol Case Stud 2021; 7:mcs.a006023. [PMID: 33637608 PMCID: PMC8040738 DOI: 10.1101/mcs.a006023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 02/22/2021] [Indexed: 12/31/2022] Open
Abstract
In this follow-up report, we present updated information regarding a previously reported pediatric patient with a World Health Organization grade I ganglioglioma harboring a BRAF p.T599dup mutation (Cold Spring Harb Mol Case Stud 4: a002618). This patient, based on our initial finding, is receiving combination targeted therapy with a selective BRAF inhibitor (dabrafenib) plus MEK inhibitor (trametinib). The combination therapy was started after the patient experienced progressive tumor growth and worsening neurological symptoms, including visual changes, headaches, and peripheral neuropathy, despite 9 months of treatment with adjuvant chemotherapy (vinblastine). The patient has been receiving dabrafenib plus trametinib for 15 months and continues to have stable disease as well as improved neurological symptoms. Although combinatorial therapy targeting BRAF and MEK using dabrafenib and trametinib, respectively, is indicated for tumors harboring a BRAF p.V600E/K mutation, our report demonstrates efficacy of this combination in a non-V600E BRAF-mutated tumor. The identification of BRAF alterations may assist clinicians in determining alternative targeted treatment strategies, especially considering the paucity of effective treatments for primary brain tumors and the poor prognosis associated with many central nervous system (CNS) diagnoses. Additional case studies or larger cohort reports will continue to clarify the efficacy of BRAF and/or MEK inhibitors in patients whose tumors harbor a BRAF alteration.
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Affiliation(s)
- Katherine E Miller
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio 43215, USA
| | - Kathleen M Schieffer
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio 43215, USA
| | - Olivia Grischow
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio 43215, USA
| | - Diana P Rodriguez
- Department of Radiology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio 43210, USA
| | - Catherine E Cottrell
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio 43215, USA.,Department of Pathology, The Ohio State University College of Medicine, Columbus, Ohio 43210, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio 43210, USA
| | - Jeffrey R Leonard
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio 43210, USA.,Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio 43210, USA.,Department of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio 43205, USA
| | - Jonathan L Finlay
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio 43210, USA.,Division of Hematology/Oncology/Bone Marrow Transplantation, Nationwide Children's Hospital, Columbus, Ohio 43205, USA
| | - Elaine R Mardis
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio 43215, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio 43210, USA.,Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio 43210, USA
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22
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Schieffer KM, Feldman AZ, Kautto EA, McGrath S, Miller AR, Hernandez-Gonzalez ME, LaHaye S, Miller KE, Koboldt DC, Brennan P, Kelly B, Wetzel A, Agarwal V, Shatara M, Conley S, Rodriguez DP, Abu-Arja R, Shaikhkhalil A, Snuderl M, Orr BA, Finlay JL, Osorio DS, Drapeau AI, Leonard JR, Pierson CR, White P, Magrini V, Mardis ER, Wilson RK, Cottrell CE, Boué DR. Molecular classification of a complex structural rearrangement of the RB1 locus in an infant with sporadic, isolated, intracranial, sellar region retinoblastoma. Acta Neuropathol Commun 2021; 9:61. [PMID: 33827698 PMCID: PMC8025529 DOI: 10.1186/s40478-021-01164-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/19/2021] [Indexed: 12/15/2022] Open
Abstract
Retinoblastoma is a childhood cancer of the retina involving germline or somatic alterations of the RB Transcriptional Corepressor 1 gene, RB1. Rare cases of sellar-suprasellar region retinoblastoma without evidence of ocular or pineal tumors have been described. A nine-month-old male presented with a sellar-suprasellar region mass. Histopathology showed an embryonal tumor with focal Flexner-Wintersteiner-like rosettes and loss of retinoblastoma protein (RB1) expression by immunohistochemistry. DNA array-based methylation profiling confidently classified the tumor as pineoblastoma group A/intracranial retinoblastoma. The patient was subsequently enrolled on an institutional translational cancer research protocol and underwent comprehensive molecular profiling, including paired tumor/normal exome and genome sequencing and RNA-sequencing of the tumor. Additionally, Pacific Biosciences (PacBio) Single Molecule Real Time (SMRT) sequencing was performed from comparator normal and disease-involved tissue to resolve complex structural variations. RNA-sequencing revealed multiple fusions clustered within 13q14.1-q21.3, including a novel in-frame fusion of RB1-SIAH3 predicted to prematurely truncate the RB1 protein. SMRT sequencing revealed a complex structural rearrangement spanning 13q14.11-q31.3, including two somatic structural variants within intron 17 of RB1. These events corresponded to the RB1-SIAH3 fusion and a novel RB1 rearrangement expected to correlate with the complete absence of RB1 protein expression. Comprehensive molecular analysis, including DNA array-based methylation profiling and sequencing-based methodologies, were critical for classification and understanding the complex mechanism of RB1 inactivation in this diagnostically challenging tumor.
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23
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Alexiades NG, Shao B, Braga BP, Bonfield CM, Brockmeyer DL, Browd SR, DiLuna M, Groves ML, Hankinson TC, Jea A, Leonard JR, Lew SM, Limbrick DD, Mangano FT, Martin J, Pahys J, Powers A, Proctor MR, Rodriguez L, Rozzelle C, Storm PB, Anderson RCE. Development of best practices in the utilization and implementation of pediatric cervical spine traction: a modified Delphi study. J Neurosurg Pediatr 2021; 27:649-660. [PMID: 33799292 DOI: 10.3171/2020.10.peds20778] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 10/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cervical traction in pediatric patients is an uncommon but invaluable technique in the management of cervical trauma and deformity. Despite its utility, little empirical evidence exists to guide its implementation, with most practitioners employing custom or modified adult protocols. Expert-based best practices may improve the care of children undergoing cervical traction. In this study, the authors aimed to build consensus and establish best practices for the use of pediatric cervical traction in order to enhance its utilization, safety, and efficacy. METHODS A modified Delphi method was employed to try to identify areas of consensus regarding the utilization and implementation of pediatric cervical spine traction. A literature review of pediatric cervical traction was distributed electronically along with a survey of current practices to a group of 20 board-certified pediatric neurosurgeons and orthopedic surgeons with expertise in the pediatric cervical spine. Sixty statements were then formulated and distributed to the group. The results of the second survey were discussed during an in-person meeting leading to further consensus. Consensus was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). RESULTS After the initial round, consensus was achieved with 40 statements regarding the following topics: goals, indications, and contraindications of traction (12), pretraction imaging (6), practical application and initiation of various traction techniques (8), protocols in trauma and deformity patients (8), and management of traction-related complications (6). Following the second round, an additional 9 statements reached consensus related to goals/indications/contraindications of traction (4), related to initiation of traction (4), and related to complication management (1). All participants were willing to incorporate the consensus statements into their practice. CONCLUSIONS In an attempt to improve and standardize the use of cervical traction in pediatric patients, the authors have identified 49 best-practice recommendations, which were generated by reaching consensus among a multidisciplinary group of pediatric spine experts using a modified Delphi technique. Further study is required to determine if implementation of these practices can lead to reduced complications and improved outcomes for children.
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Affiliation(s)
- Nikita G Alexiades
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Belinda Shao
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York.,2Rutgers New Jersey Medical School, Newark, New Jersey
| | - Bruno P Braga
- 3Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christopher M Bonfield
- 4Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Douglas L Brockmeyer
- 5Department of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Samuel R Browd
- 6Department of Neurosurgery, University of Washington/Seattle Children's Hospital, Seattle, Washington
| | - Michael DiLuna
- 7Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Mari L Groves
- 8Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd C Hankinson
- 9Department of Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Andrew Jea
- 10Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeffrey R Leonard
- 11Department of Neurosurgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Sean M Lew
- 12Department of Pediatric Neurosurgery, Children's Wisconsin, Milwaukee, Wisconsin
| | - David D Limbrick
- 13Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Francesco T Mangano
- 14Division of Pediatric Neurosurgery, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Jonathan Martin
- 15Division of Pediatric Neurosurgery, Connecticut Children's Hospital, Hartford, Connecticut
| | - Joshua Pahys
- 16Department of Pediatric Orthopedic Surgery, Shriners Hospital for Children, Philadelphia, Pennsylvania
| | - Alexander Powers
- 17Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Mark R Proctor
- 18Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Luis Rodriguez
- 19Department of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Curtis Rozzelle
- 20Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Alabama, Birmingham; and
| | - Phillip B Storm
- 21Department of Neurosurgery, University of Pennsylvania/Children's Hospital of Philadelphia, Pennsylvania
| | - Richard C E Anderson
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York
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24
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Schieffer KM, Agarwal V, LaHaye S, Miller KE, Koboldt DC, Lichtenberg T, Leraas K, Brennan P, Kelly BJ, Crist E, Rusin J, Finlay JL, Osorio DS, Sribnick EA, Leonard JR, Feldman A, Orr BA, Serrano J, Vasudevaraja V, Snuderl M, White P, Magrini V, Wilson RK, Mardis ER, Boué DR, Cottrell CE. YAP1-FAM118B Fusion Defines a Rare Subset of Childhood and Young Adulthood Meningiomas. Am J Surg Pathol 2021; 45:329-340. [PMID: 33074854 DOI: 10.1097/pas.0000000000001597] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Meningiomas are a central nervous system tumor primarily afflicting adults, with <1% of cases diagnosed during childhood or adolescence. Somatic variation in NF2 may be found in ∼50% of meningiomas, with other genetic drivers (eg, SMO, AKT1, TRAF7) contributing to NF2 wild-type tumors. NF2 is an upstream negative regulator of YAP signaling and loss of the NF2 protein product, Merlin, results in YAP overexpression and target gene transcription. This mechanism of dysregulation is described in NF2-driven meningiomas, but further work is necessary to understand the NF2-independent mechanism of tumorigenesis. Amid our institutional patient-centric comprehensive molecular profiling study, we identified an individual with meningioma harboring a YAP1-FAM118B fusion, previously reported only in supratentorial ependymoma. The tumor histopathology was remarkable, characterized by prominent islands of calcifying fibrous nodules within an overall collagen-rich matrix. To gain insight into this finding, we subsequently evaluated the genetic landscape of 11 additional pediatric and adolescent/young adulthood meningioma patients within the Children's Brain Tumor Tissue Consortium. A second individual harboring a YAP1-FAM118B gene fusion was identified within this database. Transcriptomic profiling suggested that YAP1-fusion meningiomas are biologically distinct from NF2-driven meningiomas. Similar to other meningiomas, however, YAP1-fusion meningiomas demonstrated overexpression of EGFR and MET. DNA methylation profiling further distinguished YAP1-fusion meningiomas from those observed in ependymomas. In summary, we expand the genetic spectrum of somatic alteration associated with NF2 wild-type meningioma to include the YAP1-FAM118B fusion and provide support for aberrant signaling pathways potentially targetable by therapeutic intervention.
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Affiliation(s)
| | - Vibhuti Agarwal
- Division of Hematology, Oncology, and Bone Marrow Transplant
| | | | | | - Daniel C Koboldt
- The Steve and Cindy Rasmussen Institute for Genomic Medicine.,Departments of Pediatrics
| | | | - Kristen Leraas
- The Steve and Cindy Rasmussen Institute for Genomic Medicine
| | - Patrick Brennan
- The Steve and Cindy Rasmussen Institute for Genomic Medicine
| | | | - Erin Crist
- The Steve and Cindy Rasmussen Institute for Genomic Medicine
| | | | - Jonathan L Finlay
- Division of Hematology, Oncology, and Bone Marrow Transplant.,Departments of Pediatrics.,Division of Hematology and Oncology, The Ohio State University College of Medicine, Columbus, OH
| | - Diana S Osorio
- Division of Hematology, Oncology, and Bone Marrow Transplant.,Departments of Pediatrics.,Division of Hematology and Oncology, The Ohio State University College of Medicine, Columbus, OH
| | | | | | | | - Brent A Orr
- St. Jude Children's Research Hospital, Memphis, TN
| | - Jonathan Serrano
- Department of Pathology, New York University Langone Health, New York City, NY
| | | | - Matija Snuderl
- Department of Pathology, New York University Langone Health, New York City, NY
| | - Peter White
- The Steve and Cindy Rasmussen Institute for Genomic Medicine.,Departments of Pediatrics
| | - Vincent Magrini
- The Steve and Cindy Rasmussen Institute for Genomic Medicine.,Departments of Pediatrics
| | - Richard K Wilson
- The Steve and Cindy Rasmussen Institute for Genomic Medicine.,Departments of Pediatrics
| | - Elaine R Mardis
- The Steve and Cindy Rasmussen Institute for Genomic Medicine.,Departments of Pediatrics
| | - Daniel R Boué
- Pathology and Laboratory Medicine, Nationwide Children's Hospital.,Pathology
| | - Catherine E Cottrell
- The Steve and Cindy Rasmussen Institute for Genomic Medicine.,Departments of Pediatrics.,Pathology
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25
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Yahanda AT, Adelson PD, Akbari SHA, Albert GW, Aldana PR, Alden TD, Anderson RCE, Bauer DF, Bethel-Anderson T, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dlouhy BJ, Durham SR, Ellenbogen RG, Eskandari R, George TM, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Johnston JM, Keating RF, Krieger MD, Leonard JR, Maher CO, Mangano FT, McComb JG, McEvoy SD, Meehan T, Menezes AH, O'Neill BR, Olavarria G, Ragheb J, Selden NR, Shah MN, Shannon CN, Shimony JS, Smyth MD, Stone SSD, Strahle JM, Torner JC, Tuite GF, Wait SD, Wellons JC, Whitehead WE, Park TS, Limbrick DD. Dural augmentation approaches and complication rates after posterior fossa decompression for Chiari I malformation and syringomyelia: a Park-Reeves Syringomyelia Research Consortium study. J Neurosurg Pediatr 2021; 27:459-468. [PMID: 33578390 DOI: 10.3171/2020.8.peds2087] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/24/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Posterior fossa decompression with duraplasty (PFDD) is commonly performed for Chiari I malformation (CM-I) with syringomyelia (SM). However, complication rates associated with various dural graft types are not well established. The objective of this study was to elucidate complication rates within 6 months of surgery among autograft and commonly used nonautologous grafts for pediatric patients who underwent PFDD for CM-I/SM. METHODS The Park-Reeves Syringomyelia Research Consortium database was queried for pediatric patients who had undergone PFDD for CM-I with SM. All patients had tonsillar ectopia ≥ 5 mm, syrinx diameter ≥ 3 mm, and ≥ 6 months of postoperative follow-up after PFDD. Complications (e.g., pseudomeningocele, CSF leak, meningitis, and hydrocephalus) and postoperative changes in syrinx size, headaches, and neck pain were compared for autograft versus nonautologous graft. RESULTS A total of 781 PFDD cases were analyzed (359 autograft, 422 nonautologous graft). Nonautologous grafts included bovine pericardium (n = 63), bovine collagen (n = 225), synthetic (n = 99), and human cadaveric allograft (n = 35). Autograft (103/359, 28.7%) had a similar overall complication rate compared to nonautologous graft (143/422, 33.9%) (p = 0.12). However, nonautologous graft was associated with significantly higher rates of pseudomeningocele (p = 0.04) and meningitis (p < 0.001). The higher rate of meningitis was influenced particularly by the higher rate of chemical meningitis (p = 0.002) versus infectious meningitis (p = 0.132). Among 4 types of nonautologous grafts, there were differences in complication rates (p = 0.02), including chemical meningitis (p = 0.01) and postoperative nausea/vomiting (p = 0.03). Allograft demonstrated the lowest complication rates overall (14.3%) and yielded significantly fewer complications compared to bovine collagen (p = 0.02) and synthetic (p = 0.003) grafts. Synthetic graft yielded higher complication rates than autograft (p = 0.01). Autograft and nonautologous graft resulted in equal improvements in syrinx size (p < 0.0001). No differences were found for postoperative changes in headaches or neck pain. CONCLUSIONS In the largest multicenter cohort to date, complication rates for dural autograft and nonautologous graft are similar after PFDD for CM-I/SM, although nonautologous graft results in higher rates of pseudomeningocele and meningitis. Rates of meningitis differ among nonautologous graft types. Autograft and nonautologous graft are equivalent for reducing syrinx size, headaches, and neck pain.
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Affiliation(s)
- Alexander T Yahanda
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - P David Adelson
- 2Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - S Hassan A Akbari
- 3Division of Pediatric Neurosurgery, University of Alabama at Birmingham, AL
| | - Gregory W Albert
- 4Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, AR
| | - Philipp R Aldana
- 5Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, FL
| | - Tord D Alden
- 6Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, IL
| | - Richard C E Anderson
- 7Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, NY
| | - David F Bauer
- 8Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Tammy Bethel-Anderson
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Douglas L Brockmeyer
- 9Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, UT
| | - Joshua J Chern
- 10Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta, GA
| | - Daniel E Couture
- 11Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Brian J Dlouhy
- 13Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Susan R Durham
- 14Department of Neurosurgery, University of Vermont, Burlington, VT
| | | | - Ramin Eskandari
- 16Department of Neurosurgery, Medical University of South Carolina, Charleston, SC
| | - Timothy M George
- 17Division of Pediatric Neurosurgery, Dell Children's Medical Center, Austin, TX
| | - Gerald A Grant
- 18Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital, Palo Alto, CA
| | - Patrick C Graupman
- 19Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, MN
| | - Stephanie Greene
- 20Division of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jeffrey P Greenfield
- 21Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Naina L Gross
- 22Department of Neurosurgery, University of Oklahoma, Oklahoma City, OK
| | - Daniel J Guillaume
- 23Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN
| | - Todd C Hankinson
- 24Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - Gregory G Heuer
- 25Division of Pediatric Neurosurgery, Children's Hospital of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mark Iantosca
- 26Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Bermans J Iskandar
- 27Department of Neurological Surgery, University of Wisconsin at Madison, WI
| | - Eric M Jackson
- 28Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - James M Johnston
- 3Division of Pediatric Neurosurgery, University of Alabama at Birmingham, AL
| | - Robert F Keating
- 29Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Mark D Krieger
- 30Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, CA
| | - Jeffrey R Leonard
- 31Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH
| | - Cormac O Maher
- 32Department of Neurosurgery, University of Michigan, Ann Arbor, MI
| | - Francesco T Mangano
- 33Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | - J Gordon McComb
- 30Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, CA
| | - Sean D McEvoy
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Thanda Meehan
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Arnold H Menezes
- 13Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Brent R O'Neill
- 24Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - Greg Olavarria
- 34Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, FL
| | - John Ragheb
- 35Department of Neurological Surgery, University of Miami School of Medicine, Miami, FL
| | - Nathan R Selden
- 36Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
| | - Manish N Shah
- 37Division of Pediatric Neurosurgery, McGovern Medical School, Houston, TX
| | - Chevis N Shannon
- 38Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
| | - Joshua S Shimony
- 39Department of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Matthew D Smyth
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Scellig S D Stone
- 40Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, MA
| | - Jennifer M Strahle
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - James C Torner
- 13Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Gerald F Tuite
- 41Department of Neurosurgery, Neuroscience Institute, All Children's Hospital, St. Petersburg, FL
| | - Scott D Wait
- 42Carolina Neurosurgery & Spine Associates, Charlotte, NC; and
| | - John C Wellons
- 38Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
| | - William E Whitehead
- 43Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX
| | - Tae Sung Park
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - David D Limbrick
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
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26
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Cam M, Charan M, Welker AM, Dravid P, Studebaker AW, Leonard JR, Pierson CR, Nakano I, Beattie CE, Hwang EI, Kambhampati M, Nazarian J, Finlay JL, Cam H. ΔNp73/ETS2 complex drives glioblastoma pathogenesis- targeting downstream mediators by rebastinib prolongs survival in preclinical models of glioblastoma. Neuro Oncol 2021; 22:345-356. [PMID: 31763674 DOI: 10.1093/neuonc/noz190] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Glioblastoma (GBM) remains one of the least successfully treated cancers. It is essential to understand the basic biology of this lethal disease and investigate novel pharmacological targets to treat GBM. The aims of this study were to determine the biological consequences of elevated expression of ΔNp73, an N-terminal truncated isoform of TP73, and to evaluate targeting of its downstream mediators, the angiopoietin 1 (ANGPT1)/tunica interna endothelial cell kinase 2 (Tie2) axis, by using a highly potent, orally available small-molecule inhibitor (rebastinib) in GBM. METHODS ΔNp73 expression was assessed in glioma sphere cultures, xenograft glioblastoma tumors, and glioblastoma patients by western blot, quantitative reverse transcription PCR, and immunohistochemistry. Immunoprecipitation, chromatin immunoprecipitation (ChiP) and sequential ChIP were performed to determine the interaction between ΔNp73 and E26 transformation-specific (ETS) proto-oncogene 2 (ETS2) proteins. The oncogenic consequences of ΔNp73 expression in glioblastomas were examined by in vitro and in vivo experiments, including orthotopic zebrafish and mouse intracranial-injection models. Effects of rebastinib on growth of established tumors and survival were examined in an intracranial-injection mouse model. RESULTS ΔNp73 upregulates both ANGPT1 and Tie2 transcriptionally through ETS conserved binding sites on the promoters by interacting with ETS2. Elevated expression of ΔNp73 promotes tumor progression by mediating angiogenesis and survival. Therapeutic targeting of downstream ΔNp73 signaling pathways by rebastinib inhibits growth of established tumors and extends survival in preclinical models of glioblastoma. CONCLUSION Aberrant expression of ΔNp73 in GBM promotes tumor progression through autocrine and paracrine signaling dependent on Tie2 activation by ANGPT1. Disruption of this signaling by rebastinib improves tumor response to treatment in glioblastoma.
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Affiliation(s)
- Maren Cam
- Center for Childhood Cancer and Blood Diseases, Nationwide Children's Hospital, Columbus, Ohio
| | - Manish Charan
- Center for Childhood Cancer and Blood Diseases, Nationwide Children's Hospital, Columbus, Ohio
| | - Alessandra M Welker
- Cancer Center and Regenerative Medicine, Massachusetts General Hospital, Boston
| | - Piyush Dravid
- Center for Childhood Cancer and Blood Diseases, Nationwide Children's Hospital, Columbus, Ohio
| | - Adam W Studebaker
- Center for Childhood Cancer and Blood Diseases, Nationwide Children's Hospital, Columbus, Ohio
| | - Jeffrey R Leonard
- Center for Childhood Cancer and Blood Diseases, Nationwide Children's Hospital, Columbus, Ohio
| | - Christopher R Pierson
- Department of Pathology & Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Ichiro Nakano
- Comprehensive Cancer Center, University of Alabama, Birmingham, Alabama
| | - Christine E Beattie
- Department of Neuroscience, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Eugene I Hwang
- Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, DC
| | - Madhuri Kambhampati
- Center for Genetic Medicine Research, Children's National Medical Center, Washington, DC
| | - Javad Nazarian
- Center for Genetic Medicine Research, Children's National Medical Center, Washington, DC
| | - Jonathan L Finlay
- Neuro-oncology Program, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Hakan Cam
- Center for Childhood Cancer and Blood Diseases, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University, Columbus, Ohio
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27
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Finlay JL, Abu-Arja MH, Abu-Arja R, Auletta J, AbdelBaki MS, Osorio DS, Conley S, Shatara M, Boué DR, Pierson CR, Rusin J, Martin L, Jones J, Palmer JD, Vatner R, Drapeau A, Sribnick E, Leonard JR. GCT-25. INNOVATIVE, INTENSIVE IRRADIATION-AVOIDING/MINIMIZING CHEMOTHERAPY FOR HIGH-RISK PRIMARY CENTRAL NERVOUS SYSTEM (CNS) MIXED MALIGNANT GERM CELL TUMORS (HR-MMGCT): A PILOT STUDY AND PROPOSED MULTI-NATIONAL PROSPECTIVE TRIAL. Neuro Oncol 2020. [PMCID: PMC7715075 DOI: 10.1093/neuonc/noaa222.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND About one-third of children with primary CNS MMGCT experience incomplete responses to initial induction chemotherapy prior to irradiation, many of whom will subsequently relapse. Such high-risk patients are variably defined as having initial alpha-fetoprotein (AFP) elevations exceeding 1,000ng/mL, predominant histopathologies of malignant non-germinomatous GCT and incomplete responses to induction chemotherapy. Drugs targeting GCT-specific molecular markers have been identified for non-germinomatous GCT elements but have yet to be incorporated into prospective clinical trials. Four children with clearly identified HR-MMGCT characteristics have been treated on an innovative pilot regimen incorporating intensified chemotherapy and molecularly targeted agents, with avoidance or minimization of irradiation. METHODS Four children (two with pure suprasellar embryonal carcinoma (EC) - one with Down syndrome and the other with pre-diagnosis cognitive dysfunction; one with initial serum AFP exceeding 7,000ng/mL and yolk sac tumor (YST)+EC+Teratoma pathology; one with initial serum AFP exceeding 1,000ng/mL) were treated with 3 cycles of “standard” induction chemotherapy (ACNS1123), followed by 1–3 transplant cycles (thiotepa/carboplatin) each with complete radiographic and tumor marker responses. Two children with pure EC subsequently received six cycles of brentuximab-vedotin without irradiation and remain disease-free off therapy for 2–4 years. One child with YST+EC+Teratoma has subsequently received reduced dose craniospinal irradiation and pineal region boost, and will receive oral everolimus, erlotinib, palbocyclib and intravenous brentuximab-vedotin. The fourth child with YST+MT will commence everolimus, erlotinib and palbocyclib without irradiation. CONCLUSION This treatment strategy for HR-MMGCT patients provides preliminary tolerance and response data justifying extension to a multi-center trial.
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Affiliation(s)
- Jonathan L Finlay
- Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University, Columbus, OH, USA
| | - Mohammad H Abu-Arja
- New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
- Weill-Cornell College of Medicine, New York, NY, USA
| | - Rolla Abu-Arja
- Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University, Columbus, OH, USA
| | - Jeffery Auletta
- Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University, Columbus, OH, USA
| | - Mohamed S AbdelBaki
- Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University, Columbus, OH, USA
| | - Diana S Osorio
- Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University, Columbus, OH, USA
| | | | | | - Daniel R Boué
- Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University, Columbus, OH, USA
| | - Christopher R Pierson
- Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University, Columbus, OH, USA
| | - Jerome Rusin
- Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University, Columbus, OH, USA
| | - Lisa Martin
- Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University, Columbus, OH, USA
| | - Jeremy Jones
- Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University, Columbus, OH, USA
| | - Joshua D Palmer
- Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University, Columbus, OH, USA
| | - Ralph Vatner
- Cincinnati Children’s Hospital, Cincinnati, OH, USA
- University of Cincinnati, Cincinnati, OH, USA
| | - Annie Drapeau
- Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University, Columbus, OH, USA
| | - Eric Sribnick
- Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University, Columbus, OH, USA
| | - Jeffrey R Leonard
- Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University, Columbus, OH, USA
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28
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Osorio DS, Abu-Arja R, Abdel-Baki MS, Leonard JR, Sribnick EA, Finlay JL, Ellison DW, Picarsic J, Kahwash S, Boue’ DR. RARE-40. CASE REPORT: LONG-TERM SURVIVOR OF A RARE, PEDIATRIC PRIMARY HISTIOCYTIC SARCOMA (HS) OF THE CENTRAL NERVOUS SYSTEM (CNS) FOLLOWING COMPLETE RESECTION, CHEMOTHERAPY AND ALLOGENEIC HEMATOPOIETIC CELL TRANSPLANTATION (ALLO-HCT). Neuro Oncol 2020. [PMCID: PMC7715933 DOI: 10.1093/neuonc/noaa222.750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
We report an unusual case of a patient with primary CNS-HS a very rare neoplasm of histiocytic lineage with usually poor prognosis. An 8 year old boy presented with a one month history of headaches, nausea and vomiting. Physical examination revealed nystagmus and dysmetria. Brain MRI revealed a localized 2.4 cm posterior fossa (cerebellar) mass with restricted diffusion. The patient underwent a gross total resection of the mass. Initial post-operative lumbar puncture was positive for rare malignant cells. Pathology showed a focally necrotic neoplasm, composed of nests and cords of large relatively uniform cells with abundant eosinophilic cytoplasm, moderately pleomorphic nuclei and numerous mitotic figures, consistent with CNS-HS with juvenile xanthogranuloma phenotype, as supported by positive IHC expression of CD163, CD68, CD14, fascin, and Factor XIIIa, while negative for CD1a, Lymphoid and Myeloid markers, and BRAFv600e mutation. He was treated with two cycles of clofarabine and cytarabine and triple intrathecal (IT) chemotherapy. He developed generalized seizures and MRI showed demyelination consistent with IT methotrexate toxicity; MTX was then discontinued. He was then given two additional cycles of cladribine and weekly intrathecal therapy prior to consolidation with an Allo-HCT using a 10/10 HLA allelic-matched unrelated donor. His conditioning regimen included total body irradiation and cyclophosphamide. He did well post-transplant with peripheral blood chimerism at 1 year showing > 95% donor cells. He remains disease-free with an excellent quality of life since August 2016. We report one of the few known survivors of this unusual and highly malignant entity.
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Affiliation(s)
- Diana S Osorio
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Rolla Abu-Arja
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Mohamed S Abdel-Baki
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Jeffrey R Leonard
- Department of Pediatric Neurosurgery, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Eric A Sribnick
- Department of Pediatric Neurosurgery, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Jonathan L Finlay
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - David W Ellison
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Jennifer Picarsic
- Department of Pathology, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Samir Kahwash
- Department of Pathology and Laboratory Medicine, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Daniel R Boue’
- Department of Pathology and Laboratory Medicine, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
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29
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Shatara M, Varga EA, Boué DR, Martin L, Rusin JA, Rodriguez DP, Jones J, McAllister A, Leonard JR, Pindrik J, Schieffer KM, Leraas KM, Lichtenberg TM, Mardis ER, Cottrell CE, Osorio DS, AbdelBaki MS, Finlay JL. RARE-37. NOONAN SYNDROME AND GLIONEURONAL TUMORS: A CENTRAL NERVOUS SYSTEM CANCER PREDISPOSITION ASSOCIATION? Neuro Oncol 2020. [PMCID: PMC7715866 DOI: 10.1093/neuonc/noaa222.747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Noonan syndrome (NS) is associated with germline Ras signaling pathway mutations, RAS overactivation and increased tumorigenesis risk. Rosette-forming glioneuronal tumors (RFGT) are rare indolent tumors. We report the molecular profiling of two patients with NS and RFGT. PATIENT 1: A 22-year-old male with NS was diagnosed with RFGT after partial tumor resection followed by focal irradiation. He was enrolled on a comprehensive genomic profiling study involving paired tumor-normal whole exome sequencing and RNA sequencing of the disease-involved tissue, revealing a germline PTPN11 alteration (p.Gly60Ala) consistent with NS, and a somatic deletion (p.Ile442_Thr454del) in PIK3R1 and a somatic variant (p.Lys656Glu) in FGFR1 with concomitant increased expression of PIK3R1 and FGFR1 by RNA-sequencing. The patient remains without tumor progression now nine months since irradiation. PATIENT 2: A 19-year-old male with persistent headaches, underwent a brain MRI demonstrated multiple abnormal signals in the pineal region and midbrain. He had a stereotactic biopsy revealing RFGT. He was enrolled on the genomic study revealing a germline PTPN11 alteration (p.Asn308Asp) resulting in a new diagnosis of NS. Several family members were subsequently identified with clinical features of NS, including his mother and two siblings, enabling appropriate counseling. Two somatic variants were found in trans in PIK3R1 (p.Thr454_Phe456del and p.Glu451_Asn453delinsAsp), and a somatic variant (p.Val695Met) in FGFR1, with resultant overexpression of PIK3R1. The patient is monitored with surveillance imaging. CONCLUSION We report the molecular profiling of two patients with NS and RFGT; strongly suggesting their connection to RASopathies through the overactivation of the MAPK and PI3K/AKT/mTOR signaling pathways.
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Affiliation(s)
- Margaret Shatara
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Elizabeth A Varga
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Daniel R Boué
- Department of Pathology and Laboratory Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Lisa Martin
- The Department of Radiology, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Jerome A Rusin
- The Department of Radiology, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Diana P Rodriguez
- The Department of Radiology, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Jeremy Jones
- The Department of Radiology, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Aaron McAllister
- The Department of Radiology, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Jeffrey R Leonard
- The Division of Pediatric Neurosurgery, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Jonathan Pindrik
- The Division of Pediatric Neurosurgery, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Kathleen M Schieffer
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Kristen M Leraas
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Tara M Lichtenberg
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Elaine R Mardis
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Catherine E Cottrell
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Diana S Osorio
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Mohamed S AbdelBaki
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Jonathan L Finlay
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
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Shatara M, Gupta A, Arja MHA, Conley SE, Patel P, Boué DR, Pierson CR, Thomas DL, Meyer EK, Shah SH, Jones J, Martin L, McAllister A, Schieffer KM, Varga EA, Leraas K, Lichtenberg T, LaHaye S, Miller KE, Magrini V, Wilson RK, Cottrell CE, Mardis ER, Aldrink JH, Auletta JJ, Pindrik J, Leonard JR, Osorio DS, Finlay JL, Ranalli M, AbdelBaki MS. ATRT-21. RHABDOID PREDISPOSITION SYNDROME: REPORT OF MOLECULAR PROFILES AND TREATMENT APPROACH IN THREE CHILDREN WITH SYNCHRONOUS ATYPICAL TERATOID/RHABDOID TUMOR AND MALIGNANT RHABDOID TUMOR. Neuro Oncol 2020. [PMCID: PMC7715330 DOI: 10.1093/neuonc/noaa222.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Rhabdoid predisposition syndrome is characterized by germline alterations in SMARCB1 or SMARCA4, leading to synchronous or metachronous central nervous system (CNS) and extra-CNS rhabdoid tumors. Rare survivors have been reported to date. METHODS We describe the molecular profiling and treatment regimen of three patients with synchronous atypical teratoid/rhabdoid tumor (ATRT) and malignant rhabdoid tumor of the kidney (MRT-K). All patients underwent radical nephrectomy of the kidney, and gross total resection of the primary CNS tumor was achieved for two patients. An intensive chemotherapy regimen was administered; an induction phase based on the modified Third Intergroup Rhabdomyosarcoma Study (IRS-III) for ATRT followed by a consolidation phase with three cycles of high-dose chemotherapy and autologous hematopoietic progenitor cell rescue, without irradiation. All three patients were enrolled on an institutional comprehensive genomic profiling protocol. RESULTS A germline focal 22q deletion, including SMARCB1, was detected in two patients, while the third patient had a maternally-inherited heterozygous frameshift variant in SMARCB1. Somatic loss of heterozygosity of 22q was identified in all patients, resulting in biallelic inactivation of SMARCB1. Divergent tumor subgroups were described using DNA methylation. The three MRT-K samples were classified as MYC subtype. One ATRT was classified as SHH while the other as TYR. One patient is currently three years off-therapy without evidence of disease, while the other two patients have completed the consolidation phase without recurrent disease. CONCLUSION Molecular profiling of CNS and extra-CNS rhabdoid tumors revealed different epigenetic subgroups. An intensive multimodal therapeutic approach without irradiation may achieve prolonged survival.
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Affiliation(s)
- Margaret Shatara
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Ajay Gupta
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Mohamed H Abu Arja
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Suzanne E Conley
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Priyal Patel
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Daniel R Boué
- Department of Pathology and Laboratory Medicine, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Christopher R Pierson
- Department of Pathology and Laboratory Medicine, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Diana L Thomas
- Department of Pathology and Laboratory Medicine, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Erin K Meyer
- Department of Pathology and Laboratory Medicine, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Summit H Shah
- The Department of Radiology, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Jeremy Jones
- The Department of Radiology, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Lisa Martin
- The Department of Radiology, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Aaron McAllister
- The Department of Radiology, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Kathleen M Schieffer
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Elizabeth A Varga
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Kristen Leraas
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Tara Lichtenberg
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Stephanie LaHaye
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Katherine E Miller
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Vincent Magrini
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Richard K Wilson
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Catherine E Cottrell
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Elaine R Mardis
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Jennifer H Aldrink
- Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Jeffery J Auletta
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Jonathan Pindrik
- The Division of Pediatric Neurosurgery, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Jeffrey R Leonard
- The Division of Pediatric Neurosurgery, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Diana S Osorio
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Jonathan L Finlay
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Mark Ranalli
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Mohamed S AbdelBaki
- The Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
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Yahanda AT, Shah AS, Sylvester P, Evans J, Dunn GP, Jensen RL, Honeycutt JH, Cahill DP, Sutherland GR, Oswood MC, Shah MV, Abram SR, Rich KM, Dowling JL, Leuthardt EC, Dacey RG, Kim AH, Zipfel GJ, Limbrick DD, Smyth MD, Leonard JR, Chicoine MR. Using Histopathology to Assess the Reliability With Which Intraoperative MRI Identifies Residual Brain Tumor. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
OBJECTIVE CSF shunt placement is the primary therapy for hydrocephalus; however, shunt malfunctions remain common and lead to neurological deficits if missed. There is a lack of literature characterizing the epidemiology of children with possible shunt malfunctions presenting to United States emergency departments (EDs). METHODS A retrospective study was conducted of the 2006-2017 National Emergency Department Sample. The data were queried using an exhaustive list of Current Procedural Terminology and International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes representing children with hydrocephalus diagnoses, diagnostic imaging for shunt malfunctions, and shunt-related surgical revision procedures. RESULTS In 2017, there were an estimated 16,376 ED visits for suspected shunt malfunction. Children were more commonly male (57.9%), ages 0-4 years (42.2%), and publicly insured (55.8%). Many did not undergo diagnostic imaging (37.2%), and of those who did, most underwent head CT scans (43.7%). Between 2006 and 2017, pediatric ED visits for suspected shunt malfunction increased 18% (95% CI 12.1-23.8). The use of MRI increased substantially (178.0%, 95% CI 176.9-179.2). Visits resulting in discharge home from the ED increased by 76.3% (95% CI 73.1-79.4), and those involving no surgical intervention increased by 32.9% (95% CI 29.2-36.6). CONCLUSIONS Between 2006 and 2017, ED visits for children to rule out shunt malfunction increased, yet there was a decline in surgical intervention and an increase in discharges home from the ED. Possible contributing factors include improved clinical criteria for shunt evaluation, alternative CSF diversion techniques, changing indications for shunt placement, and increased use of advanced imaging in the ED. ABBREVIATIONS CPT = Current Procedural Terminology; ED = emergency department; ETV = endoscopic third ventriculostomy; ICD-9 = International Classification of Diseases, Ninth Revision; ICD-10 = International Classification of Diseases, Tenth Revision; NEDS = National Emergency Department Sample.
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Affiliation(s)
| | - Lauren Q Malthaner
- 2The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus
| | - Junxin Shi
- 2The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus
| | - Jeffrey R Leonard
- 1The Ohio State University College of Medicine, Columbus.,3Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus; and
| | - Julie C Leonard
- 1The Ohio State University College of Medicine, Columbus.,2The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus.,4Division of Pediatric Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
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Leonard JR, Pindrik J. Commentary: Evaluating the Effects of Cerebrospinal Fluid Protein Content on the Performance of Differential Pressure Valves and Antisiphon Devices Using a Novel Benchtop Shunting Model. Neurosurgery 2020; 87:E565. [PMID: 32615598 DOI: 10.1093/neuros/nyaa235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jeffrey R Leonard
- Department of Neurosurgery, Ohio State University Wexner Medical Center, Columbus, Ohio.,Department of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Jonathan Pindrik
- Department of Neurosurgery, Ohio State University Wexner Medical Center, Columbus, Ohio.,Department of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
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Yahanda AT, Patel B, Shah AS, Cahill DP, Sutherland G, Honeycutt J, Jensen RL, Rich KM, Dowling JL, Limbrick DD, Dacey RG, Kim AH, Leuthardt EC, Dunn GP, Zipfel GJ, Leonard JR, Smyth MD, Shah MV, Abram SR, Evans J, Chicoine MR. Impact of Intraoperative Magnetic Resonance Imaging and Other Factors on Surgical Outcomes for Newly Diagnosed Grade II Astrocytomas and Oligodendrogliomas: A Multicenter Study. Neurosurgery 2020; 88:63-73. [DOI: 10.1093/neuros/nyaa320] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/24/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Few studies use large, multi-institutional patient cohorts to examine the role of intraoperative magnetic resonance imaging (iMRI) in the resection of grade II gliomas.
OBJECTIVE
To assess the impact of iMRI and other factors on overall survival (OS) and progression-free survival (PFS) for newly diagnosed grade II astrocytomas and oligodendrogliomas.
METHODS
Retrospective analyses of a multicenter database assessed the impact of patient-, treatment-, and tumor-related factors on OS and PFS.
RESULTS
A total of 232 resections (112 astrocytomas and 120 oligodendrogliomas) were analyzed. Oligodendrogliomas had longer OS (P < .001) and PFS (P = .01) than astrocytomas. Multivariate analyses demonstrated improved OS for gross total resection (GTR) vs subtotal resection (STR; P = .006, hazard ratio [HR]: .23) and near total resection (NTR; P = .02, HR: .64). GTR vs STR (P = .02, HR: .54), GTR vs NTR (P = .04, HR: .49), and iMRI use (P = .02, HR: .54) were associated with longer PFS. Frontal (P = .048, HR: 2.11) and occipital/parietal (P = .003, HR: 3.59) locations were associated with shorter PFS (vs temporal). Kaplan-Meier analyses showed longer OS with increasing extent of surgical resection (EOR) (P = .03) and 1p/19q gene deletions (P = .02). PFS improved with increasing EOR (P = .01), GTR vs NTR (P = .02), and resections above STR (P = .04). Factors influencing adjuvant treatment (35.3% of patients) included age (P = .002, odds ratio [OR]: 1.04) and EOR (P = .003, OR: .39) but not glioma subtype or location. Additional tumor resection after iMRI was performed in 105/159 (66%) iMRI cases, yielding GTR in 54.5% of these instances.
CONCLUSION
EOR is a major determinant of OS and PFS for patients with grade II astrocytomas and oligodendrogliomas. Intraoperative MRI may improve EOR and was associated with increased PFS.
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Affiliation(s)
- Alexander T Yahanda
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Bhuvic Patel
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Amar S Shah
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Daniel P Cahill
- Department of Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Garnette Sutherland
- Department of Neurological Surgery, University of Calgary School of Medicine, Calgary, Canada
| | - John Honeycutt
- Department of Neurological Surgery, Cook Children's Medical Center, Fort Worth, Texas
| | - Randy L Jensen
- Department of Neurological Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Keith M Rich
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Joshua L Dowling
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - David D Limbrick
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Ralph G Dacey
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Albert H Kim
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Eric C Leuthardt
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Gavin P Dunn
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Gregory J Zipfel
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Jeffrey R Leonard
- Department of Neurological Surgery, Ohio State University College of Medicine, Columbus, Ohio
| | - Matthew D Smyth
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Mitesh V Shah
- Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Steven R Abram
- Department of Neurological Surgery, St. Thomas Hospital, Nashville, Tennessee
| | - John Evans
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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Miles DK, Ponisio MR, Colvin R, Limbrick D, Greenberg JK, Brancato C, Leonard JR, Pineda JA. Predictors of intracranial hypertension in children undergoing ICP monitoring after severe traumatic brain injury. Childs Nerv Syst 2020; 36:1453-1460. [PMID: 31970473 DOI: 10.1007/s00381-020-04516-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/18/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Intracranial hypertension (ICH) is a common and treatable complication after severe traumatic brain injury (sTBI) in children. Describing the incidence and risk factors for developing ICH after sTBI could impact clinical practice. METHODS Retrospective cohort study from 2006 to 2015 at two university-affiliated level I pediatric trauma centers of children admitted with accidental or abusive TBI, a post-resuscitation Glasgow Coma Score (GCS) of 8 or less, and an invasive intracranial pressure (ICP) monitor. Bivariate and multivariable logistic regression analysis were performed to identify demographic, injury, and imaging characteristics in patients who received ICP directed therapies for ICH (ICP > 20 mmHg). RESULTS Eight to 5% (271/321) of monitored patients received ICP directed therapy for ICH during their PICU stay. Ninety-seven percent of patients had an abnormality on CT scan by either the Marshall or the Rotterdam score. Of the analyzed clinical and radiologic variables, only presence of hypoxia prior to PICU arrival, female sex, and a higher Injury Severity Score (ISS) were associated with increased risk of ICH (p < 0.05). CONCLUSIONS In this retrospective study of clinical practice of ICP monitoring in children after sTBI, the vast majority of children had an abnormal CT scan and experienced ICH requiring clinical intervention. Commonly measured clinical variables and radiologic classification scores did not significantly add to the prediction for developing of ICH and further efforts are needed to define low-risk populations that would not develop ICH.
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Affiliation(s)
- Darryl K Miles
- Department of Pediatrics, Division of Critical Care, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9063, USA.
| | - Maria R Ponisio
- Department of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ryan Colvin
- Department of Pediatrics, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - David Limbrick
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jacob K Greenberg
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Celeste Brancato
- Department of Pediatrics, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Jeffrey R Leonard
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jose A Pineda
- Department of Pediatrics, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Richardson TE, Tang K, Vasudevaraja V, Serrano J, William CM, Mirchia K, Pierson CR, Leonard JR, AbdelBaki MS, Schieffer KM, Cottrell CE, Tovar-Spinoza Z, Comito MA, Boué DR, Jour G, Snuderl M. GOPC-ROS1 Fusion Due to Microdeletion at 6q22 Is an Oncogenic Driver in a Subset of Pediatric Gliomas and Glioneuronal Tumors. J Neuropathol Exp Neurol 2020; 78:1089-1099. [PMID: 31626289 DOI: 10.1093/jnen/nlz093] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
ROS1 is a transmembrane receptor tyrosine kinase proto-oncogene that has been shown to have rearrangements with several genes in glioblastoma and other neoplasms, including intrachromosomal fusion with GOPC due to microdeletions at 6q22.1. ROS1 fusion events are important findings in these tumors, as they are potentially targetable alterations with newer tyrosine kinase inhibitors; however, whether these tumors represent a distinct entity remains unknown. In this report, we identify 3 cases of unusual pediatric glioma with GOPC-ROS1 fusion. We reviewed the clinical history, radiologic and histologic features, performed methylation analysis, whole genome copy number profiling, and next generation sequencing analysis for the detection of oncogenic mutation and fusion events to fully characterize the genetic and epigenetic alterations present in these tumors. Two of 3 tumors showed pilocytic features with focal expression of synaptophysin staining and variable high-grade histologic features; the third tumor aligned best with glioblastoma and showed no evidence of neuronal differentiation. Copy number profiling revealed chromosome 6q22 microdeletions corresponding to the GOPC-ROS1 fusion in all 3 cases and methylation profiling showed that the tumors did not cluster together as a single entity or within known methylation classes by t-Distributed Stochastic Neighbor Embedding.
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Affiliation(s)
- Timothy E Richardson
- Department of Pathology, State University of New York, Upstate Medical University, Syracuse, New York
| | | | | | - Jonathan Serrano
- Department of Pathology & Laboratory Medicine, Nationwide Children's Hospital and The Ohio State University
| | | | - Kanish Mirchia
- Department of Hematology, Oncology, and Bone Marrow Transplant, Nationwide Children's Hospital and The Ohio State University
| | | | | | - Mohamed S AbdelBaki
- Department of Pediatrics (MAC), State University of New York, Upstate Medical University, Syracuse, New York
| | - Kathleen M Schieffer
- Waters Center for Children's Cancer and Blood Disorders, State University of New York, Upstate Cancer Center, Syracuse, New York
| | - Catherine E Cottrell
- Department of Pathology, State University of New York, Upstate Medical University, Syracuse, New York
| | | | - Melanie A Comito
- Department of Pathology, New York University Langone Health, New York, New York
| | - Daniel R Boué
- Department of Pathology & Laboratory Medicine, Nationwide Children's Hospital and The Ohio State University
| | - George Jour
- Department of Neurological Surgery, Nationwide Children's Hospital
| | - Matija Snuderl
- Department of Hematology, Oncology, and Bone Marrow Transplant, Nationwide Children's Hospital and The Ohio State University
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Madsen JR, Boyle TP, Neuman MI, Park EH, Tamber MS, Hickey RW, Heuer GG, Zorc JJ, Leonard JR, Leonard JC, Keating R, Chamberlain JM, Frim DM, Zakrzewski P, Klinge P, Merck LH, Piatt J, Bennett JE, Sandberg DI, Boop FA, Hameed MQ. Diagnostic Accuracy of Non-Invasive Thermal Evaluation of Ventriculoperitoneal Shunt Flow in Shunt Malfunction: A Prospective, Multi-Site, Operator-Blinded Study. Neurosurgery 2020; 87:939-948. [PMID: 32459841 PMCID: PMC7566379 DOI: 10.1093/neuros/nyaa128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/27/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Thermal flow evaluation (TFE) is a non-invasive method to assess ventriculoperitoneal shunt function. Flow detected by TFE is a negative predictor of the need for revision surgery. Further optimization of testing protocols, evaluation in multiple centers, and integration with clinical and imaging impressions prompted the current study. OBJECTIVE To compare the diagnostic accuracy of 2 TFE protocols, with micropumper (TFE+MP) or without (TFE-only), to neuro-imaging in patients emergently presenting with symptoms concerning for shunt malfunction. METHODS We performed a prospective multicenter operator-blinded trial of a consecutive series of patients who underwent evaluation for shunt malfunction. TFE was performed, and preimaging clinician impressions and imaging results were recorded. The primary outcome was shunt obstruction requiring neurosurgical revision within 7 d. Non-inferiority of the sensitivity of TFE vs neuro-imaging for detecting shunt obstruction was tested using a prospectively determined a priori margin of −2.5%. RESULTS We enrolled 406 patients at 10 centers. Of these, 68/348 (20%) evaluated with TFE+MP and 30/215 (14%) with TFE-only had shunt obstruction. The sensitivity for detecting obstruction was 100% (95% CI: 88%-100%) for TFE-only, 90% (95% CI: 80%-96%) for TFE+MP, 76% (95% CI: 65%-86%) for imaging in TFE+MP cohort, and 77% (95% CI: 58%-90%) for imaging in the TFE-only cohort. Difference in sensitivities between TFE methods and imaging did not exceed the non-inferiority margin. CONCLUSION TFE is non-inferior to imaging in ruling out shunt malfunction and may help avoid imaging and other steps. For this purpose, TFE only is favored over TFE+MP.
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Affiliation(s)
- Joseph R Madsen
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tehnaz P Boyle
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
- Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Mark I Neuman
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eun-Hyoung Park
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mandeep S Tamber
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Robert W Hickey
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gregory G Heuer
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph J Zorc
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey R Leonard
- Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, Ohio
| | - Julie C Leonard
- Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, Ohio
| | - Robert Keating
- Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - James M Chamberlain
- Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - David M Frim
- The University of Chicago Comer Children's Hospital, Chicago, Illinois
| | - Paula Zakrzewski
- The University of Chicago Comer Children's Hospital, Chicago, Illinois
| | - Petra Klinge
- Rhode Island Hospital, Brown University, Providence, Rhode Island
| | - Lisa H Merck
- Rhode Island Hospital, Brown University, Providence, Rhode Island
- University of Florida College of Medicine, Gainesville, Florida
| | - Joseph Piatt
- Alfred I. DuPont Hospital for Children, Nemours Children's Health System, Wilmington, Delaware
| | - Jonathan E Bennett
- Alfred I. DuPont Hospital for Children, Nemours Children's Health System, Wilmington, Delaware
| | - David I Sandberg
- University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas
| | - Frederick A Boop
- University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mustafa Q Hameed
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Weiner HL, Adelson PD, Brockmeyer DL, Maher CO, Gupta N, Smyth MD, Jea A, Blount JP, Riva-Cambrin J, Lam SK, Ahn ES, Albert GW, Leonard JR. Editorial. Pediatric neurosurgery along with Children's Hospitals' innovations are rapid and uniform in response to the COVID-19 pandemic. J Neurosurg Pediatr 2020; 26:3-5. [PMID: 32302988 PMCID: PMC7164397 DOI: 10.3171/2020.4.peds20240] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Howard L. Weiner
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - P. David Adelson
- Department of Neurosurgery, Barrow Neurological Institute at Phoenix Children’s Hospital, University of Arizona College of Medicine, Phoenix, Arizona
| | - Douglas L. Brockmeyer
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah
| | - Cormac O. Maher
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan
| | - Nalin Gupta
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, UCSF Benioff Children’s Hospital, University of California, San Francisco, California
| | - Matthew D. Smyth
- Department of Neurological Surgery, Division of Pediatric Neurological Surgery, St. Louis Children’s Hospital, Washington University School of Medicine in St. Louis, Missouri
| | - Andrew Jea
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeffrey P. Blount
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Children’s of Alabama, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Alberta, Canada
| | - Sandi K. Lam
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Edward S. Ahn
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Children’s Center, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Gregory W. Albert
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Arkansas Children’s Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
| | - Jeffrey R. Leonard
- Department of Neurological Surgery, Section of Neurosurgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio
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Dornbos D, Monson C, Look A, Huntoon K, Smith LGF, Leonard JR, Dhall SS, Sribnick EA. Validation of the Surgical Intervention for Traumatic Injury scale in the pediatric population. J Neurosurg Pediatr 2020; 26:92-97. [PMID: 32276255 DOI: 10.3171/2020.2.peds19474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 02/05/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While the Glasgow Coma Scale (GCS) has been effective in describing severity in traumatic brain injury (TBI), there is no current method for communicating the possible need for surgical intervention. This study utilizes a recently developed scoring system, the Surgical Intervention for Traumatic Injury (SITI) scale, which was developed to efficiently communicate the potential need for surgical decompression in adult patients with TBI. The objective of this study was to apply the SITI scale to a pediatric population to provide a tool to increase communication of possible surgical urgency. METHODS The SITI scale uses both radiographic and clinical findings, including the GCS score on presentation, pupillary examination, and CT findings. To examine the scale in pediatric TBI, a neurotrauma database at a level 1 pediatric trauma center was retrospectively evaluated, and the SITI score for all patients with an admission diagnosis of TBI between 2010 and 2015 was calculated. The primary endpoint was operative intervention, defined as a craniotomy or craniectomy for decompression, performed within the first 24 hours of admission. RESULTS A total of 1524 patients met inclusion criteria for the study during the 5-year span: 1469 (96.4%) were managed nonoperatively and 55 (3.6%) patients underwent emergent operative intervention. The mean SITI score was 4.98 ± 0.31 for patients undergoing surgical intervention and 0.41 ± 0.02 for patients treated nonoperatively (p < 0.0001). The area under the receiver operating characteristic (AUROC) curve was used to examine the diagnostic accuracy of the SITI scale in this pediatric population and was found to be 0.98. Further evaluation of patients presenting with moderate to severe TBI revealed a mean SITI score of 5.51 ± 0.31 in 40 (15.3%) operative patients and 1.55 ± 0.02 in 221 (84.7%) nonoperative patients, with an AUROC curve of 0.95. CONCLUSIONS The SITI scale was designed to be a simple, objective communication tool regarding the potential need for surgical decompression after TBI. Application of this scale to a pediatric population reveals that the score correlated with the perceived need for emergent surgical intervention, further suggesting its potential utility in clinical practice.
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Affiliation(s)
- David Dornbos
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.,2Department of Neurological Surgery, University of Tennessee Health Science Center and Semmes Murphey Clinic, Memphis, Tennessee
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- 3Division of Pediatric Neurological Surgery, Nationwide Children's Hospital, Columbus, Ohio; and
| | - Andrew Look
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kristin Huntoon
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Luke G F Smith
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jeffrey R Leonard
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.,3Division of Pediatric Neurological Surgery, Nationwide Children's Hospital, Columbus, Ohio; and
| | - Sanjay S Dhall
- 4Department of Neurological Surgery, University of California, San Francisco, California
| | - Eric A Sribnick
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.,3Division of Pediatric Neurological Surgery, Nationwide Children's Hospital, Columbus, Ohio; and
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Hale AT, Adelson PD, Albert GW, Aldana PR, Alden TD, Anderson RCE, Bauer DF, Bonfield CM, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Durham SR, Ellenbogen RG, Eskandari R, George TM, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Johnston JM, Keating RF, Leonard JR, Maher CO, Mangano FT, McComb JG, Meehan T, Menezes AH, O'Neill B, Olavarria G, Park TS, Ragheb J, Selden NR, Shah MN, Smyth MD, Stone SSD, Strahle JM, Wait SD, Wellons JC, Whitehead WE, Shannon CN, Limbrick DD. Factors associated with syrinx size in pediatric patients treated for Chiari malformation type I and syringomyelia: a study from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2020; 25:1-11. [PMID: 32114543 DOI: 10.3171/2020.1.peds19493] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 01/07/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Factors associated with syrinx size in pediatric patients undergoing posterior fossa decompression (PFD) or PFD with duraplasty (PFDD) for Chiari malformation type I (CM-I) with syringomyelia (SM; CM-I+SM) are not well established. METHODS Using the Park-Reeves Syringomyelia Research Consortium registry, the authors analyzed variables associated with syrinx radiological outcomes in patients (< 20 years old at the time of surgery) with CM-I+SM undergoing PFD or PFDD. Syrinx resolution was defined as an anteroposterior (AP) diameter of ≤ 2 mm or ≤ 3 mm or a reduction in AP diameter of ≥ 50%. Syrinx regression or progression was defined using 1) change in syrinx AP diameter (≥ 1 mm), or 2) change in syrinx length (craniocaudal, ≥ 1 vertebral level). Syrinx stability was defined as a < 1-mm change in syrinx AP diameter and no change in syrinx length. RESULTS The authors identified 380 patients with CM-I+SM who underwent PFD or PFDD. Cox proportional hazards modeling revealed younger age at surgery and PFDD as being independently associated with syrinx resolution, defined as a ≤ 2-mm or ≤ 3-mm AP diameter or ≥ 50% reduction in AP diameter. Radiological syrinx resolution was associated with improvement in headache (p < 0.005) and neck pain (p < 0.011) after PFD or PFDD. Next, PFDD (p = 0.005), scoliosis (p = 0.007), and syrinx location across multiple spinal segments (p = 0.001) were associated with syrinx diameter regression, whereas increased preoperative frontal-occipital horn ratio (FOHR; p = 0.007) and syrinx location spanning multiple spinal segments (p = 0.04) were associated with syrinx length regression. Scoliosis (HR 0.38 [95% CI 0.16-0.91], p = 0.03) and smaller syrinx diameter (5.82 ± 3.38 vs 7.86 ± 3.05 mm; HR 0.60 [95% CI 0.34-1.03], p = 0.002) were associated with syrinx diameter stability, whereas shorter preoperative syrinx length (5.75 ± 4.01 vs 9.65 ± 4.31 levels; HR 0.21 [95% CI 0.12-0.38], p = 0.0001) and smaller pB-C2 distance (6.86 ± 1.27 vs 7.18 ± 1.38 mm; HR 1.44 [95% CI 1.02-2.05], p = 0.04) were associated with syrinx length stability. Finally, younger age at surgery (8.19 ± 5.02 vs 10.29 ± 4.25 years; HR 1.89 [95% CI 1.31-3.04], p = 0.01) was associated with syrinx diameter progression, whereas increased postoperative syrinx diameter (6.73 ± 3.64 vs 3.97 ± 3.07 mm; HR 3.10 [95% CI 1.67-5.76], p = 0.003), was associated with syrinx length progression. PFD versus PFDD was not associated with syrinx progression or reoperation rate. CONCLUSIONS These data suggest that PFDD and age are independently associated with radiological syrinx improvement, although forthcoming results from the PFDD versus PFD randomized controlled trial (NCT02669836, clinicaltrials.gov) will best answer this question.
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Affiliation(s)
- Andrew T Hale
- 1Vanderbilt University School of Medicine, Medical Scientist Training Program, Nashville, Tennessee
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - P David Adelson
- 3Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Gregory W Albert
- 4Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Philipp R Aldana
- 5Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Tord D Alden
- 6Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois
| | - Richard C E Anderson
- 7Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, New York
| | - David F Bauer
- 8Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Christopher M Bonfield
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
- 9Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - Douglas L Brockmeyer
- 10Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Joshua J Chern
- 11Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta University, Atlanta, Georgia
| | - Daniel E Couture
- 12Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - David J Daniels
- 13Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Susan R Durham
- 14Department of Neurosurgery, University of Vermont, Burlington, Vermont
| | - Richard G Ellenbogen
- 15Division of Pediatric Neurosurgery, Seattle Children's Hospital, Seattle, Washington
| | - Ramin Eskandari
- 16Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Timothy M George
- 17Division of Pediatric Neurosurgery, Dell Children's Medical Center, Austin, Texas
| | - Gerald A Grant
- 18Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital, Palo Alto, California
| | - Patrick C Graupman
- 19Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, Minnesota
| | - Stephanie Greene
- 20Division of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey P Greenfield
- 21Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Naina L Gross
- 22Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Daniel J Guillaume
- 23Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Gregory G Heuer
- 24Division of Pediatric Neurosurgery, Children's Hospital of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark Iantosca
- 25Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Bermans J Iskandar
- 26Department of Neurological Surgery, University of Wisconsin at Madison, Wisconsin
| | - Eric M Jackson
- 27Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James M Johnston
- 28Division of Pediatric Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Robert F Keating
- 29Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Jeffrey R Leonard
- 30Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Cormac O Maher
- 31Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Francesco T Mangano
- 32Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - J Gordon McComb
- 33Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, California
| | - Thanda Meehan
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Arnold H Menezes
- 35Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Brent O'Neill
- 36Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Greg Olavarria
- 37Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, Florida
| | - Tae Sung Park
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - John Ragheb
- 38Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Nathan R Selden
- 39Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Manish N Shah
- 40Division of Pediatric Neurosurgery, McGovern Medical School, Houston, Texas
| | - Matthew D Smyth
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Scellig S D Stone
- 41Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
| | - Jennifer M Strahle
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Scott D Wait
- 42Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina; and
| | - John C Wellons
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
- 9Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - William E Whitehead
- 43Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - Chevis N Shannon
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
- 9Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - David D Limbrick
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
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41
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Weiner HL, Adelson PD, Brockmeyer DL, Maher CO, Gupta N, Smyth MD, Jea A, Blount JP, Riva-Cambrin J, Lam SK, Ahn ES, Albert GW, Leonard JR. Prenatal counseling for myelomeningocele in the era of fetal surgery: a shared decision-making approach. J Neurosurg Pediatr 2020; 25:1-8. [PMID: 32109872 PMCID: PMC7164397 DOI: 10.3171/2019.12.peds19449] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 12/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Management of Myelomeningocele Study demonstrated that fetal surgery, as compared to postnatal repair, decreases the rate of hydrocephalus and improves expected motor function. However, fetal surgery is associated with significant maternal and neonatal risks including uterine wall dehiscence, prematurity, and fetal or neonatal death. The goal of this study was to provide information about counseling expectant mothers regarding myelomeningocele in the era of fetal surgery. METHODS The authors conducted an extensive review of topics pertinent to counseling in the setting of myelomeningocele and introduce a new model for shared decision-making to aid practitioners during counseling. RESULTS Expectant mothers must decide in a timely manner among several potential options, namely termination of pregnancy, postnatal surgery, or fetal surgery. Multiple factors influence the decision, including maternal health, fetal heath, financial resources, social support, risk aversion, access to care, family planning, and values. In many cases, it is a difficult decision that benefits from the guidance of a pediatric neurosurgeon. CONCLUSIONS The authors review critical issues of prenatal counseling for myelomeningocele and discuss the process of shared decision-making as a framework to aid expectant mothers in choosing the treatment option best for them.
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Affiliation(s)
- Howard L. Weiner
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - P. David Adelson
- Department of Neurosurgery, Barrow Neurological Institute at Phoenix Children’s Hospital, University of Arizona College of Medicine, Phoenix, Arizona
| | - Douglas L. Brockmeyer
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah
| | - Cormac O. Maher
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan
| | - Nalin Gupta
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, UCSF Benioff Children’s Hospital, University of California, San Francisco, California
| | - Matthew D. Smyth
- Department of Neurological Surgery, Division of Pediatric Neurological Surgery, St. Louis Children’s Hospital, Washington University School of Medicine in St. Louis, Missouri
| | - Andrew Jea
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeffrey P. Blount
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Children’s of Alabama, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Alberta, Canada
| | - Sandi K. Lam
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Edward S. Ahn
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Children’s Center, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Gregory W. Albert
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Arkansas Children’s Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
| | - Jeffrey R. Leonard
- Department of Neurological Surgery, Section of Neurosurgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio
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42
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Liu H, Guinipero TL, Schieffer KM, Carter C, Colace S, Leonard JR, Orr BA, Kahwash SB, Brennan PJ, Fitch JR, Kelly B, Magrini VJ, White P, Wilson RK, Mardis ER, Cottrell CE, Boué DR. De novo primary central nervous system pure erythroid leukemia/sarcoma with t(1;16)(p31;q24) NFIA/CBFA2T3 translocation. Haematologica 2020; 105:e194-e197. [PMID: 31949013 DOI: 10.3324/haematol.2019.231928] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Huifei Liu
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Terri L Guinipero
- Department of Hematology/Oncology/BMT, Division of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Kathleen M Schieffer
- The Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Chris Carter
- Indiana University Health Bloomington Hospital, Bloomington, IN
| | - Susan Colace
- Department of Hematology/Oncology/BMT, Division of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Jeffrey R Leonard
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH
| | - Brent A Orr
- Pathology Department, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Samir B Kahwash
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Patrick J Brennan
- The Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH
| | - James R Fitch
- The Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Benjamin Kelly
- The Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Vincent J Magrini
- The Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Peter White
- The Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Richard K Wilson
- The Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Elaine R Mardis
- The Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Catherine E Cottrell
- The Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Daniel R Boué
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
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Hatef J, Smith LGF, Veneziano GC, Martin DP, Bhalla T, Leonard JR. Postoperative Pain Protocol in Children after Selective Dorsal Rhizotomy. Pediatr Neurosurg 2020; 55:181-187. [PMID: 32894856 DOI: 10.1159/000509333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 06/09/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Selective dorsal rhizotomy (SDR) provides lasting relief of spasticity for children suffering from cerebral palsy, although controlling postoperative pain is challenging. Postoperatively, escalation of therapies to include a patient-controlled analgesia (PCA) pump and intensive care unit (ICU) admission is common. OBJECTIVES We developed a multimodal pain management protocol that included intraoperative placement of an epidural catheter with continuous opioid administration. We present the 3-year results of protocol implementation. METHODS With institutional review board approval, all patients who were subjected to SDR at our institution were identified for review. Hourly pain scores were recorded. Adverse effects of medication, including desaturation, nausea/vomiting, and pruritus, were also noted. Comparisons were made between patients treated with PCA and those treated with multimodal pain control using t and χ2 tests as appropriate. RESULTS Thirty-nine patients undergoing the procedure with protocolized pain control (average age 6.8 years, 57% male) were compared to 7 PCA-treated controls (average age 6.6 years, 54% male). Pain control was satisfactory in both groups, with average pain scores of 1.5 in both groups on postoperative day 0, decreasing by postoperative day 3 to 1.1 in the PCA group and 0.5 in the protocol group. No patients under the protocol required ICU admission; all patients with PCA spent at least 1 day in the ICU. Desaturations were seen in 16 patients in the protocol group (41%), but none required ICU transfer. Treatment for pruritis was given to 57% of PCA patients and 15% of protocol patients. Treatment for nausea and vomiting was given to 100% of PCA patients and 51% of protocol patients. Medication requirements for the hospitalization were decreased from 1.1 to 0.28 doses per patient for pruritis, and from 3 to 1.1 doses per patient for nausea. CONCLUSIONS Multimodal analgesia is an excellent alternative to PCA for postoperative pain after SDR. Actual analgesia is comparative to that of controls without the need for intensive care monitoring. Side effects of high-dose opiates were less frequent and required less medication. With the protocol, patients were safely treated outside the ICU.
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Affiliation(s)
- Jeffrey Hatef
- Department of Neurological Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Luke G F Smith
- Department of Neurological Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Giorgio C Veneziano
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - David P Martin
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Tarun Bhalla
- Department of Anesthesiology and Pain Medicine, Akron Children's Hospital, Akron, Ohio, USA
| | - Jeffrey R Leonard
- Department of Neurological Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA, .,Department of Neurological Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA,
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44
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Strahle JM, Taiwo R, Averill C, Torner J, Shannon CN, Bonfield CM, Tuite GF, Bethel-Anderson T, Rutlin J, Brockmeyer DL, Wellons JC, Leonard JR, Mangano FT, Johnston JM, Shah MN, Iskandar BJ, Tyler-Kabara EC, Daniels DJ, Jackson EM, Grant GA, Couture DE, Adelson PD, Alden TD, Aldana PR, Anderson RCE, Selden NR, Baird LC, Bierbrauer K, Chern JJ, Whitehead WE, Ellenbogen RG, Fuchs HE, Guillaume DJ, Hankinson TC, Iantosca MR, Oakes WJ, Keating RF, Khan NR, Muhlbauer MS, McComb JG, Menezes AH, Ragheb J, Smith JL, Maher CO, Greene S, Kelly M, O'Neill BR, Krieger MD, Tamber M, Durham SR, Olavarria G, Stone SSD, Kaufman BA, Heuer GG, Bauer DF, Albert G, Greenfield JP, Wait SD, Van Poppel MD, Eskandari R, Mapstone T, Shimony JS, Dacey RG, Smyth MD, Park TS, Limbrick DD. Radiological and clinical predictors of scoliosis in patients with Chiari malformation type I and spinal cord syrinx from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2019; 24:1-8. [PMID: 31419800 DOI: 10.3171/2019.5.peds18527] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 05/09/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Scoliosis is frequently a presenting sign of Chiari malformation type I (CM-I) with syrinx. The authors' goal was to define scoliosis in this population and describe how radiological characteristics of CM-I and syrinx relate to the presence and severity of scoliosis. METHODS A large multicenter retrospective and prospective registry of pediatric patients with CM-I (tonsils ≥ 5 mm below the foramen magnum) and syrinx (≥ 3 mm in axial width) was reviewed for clinical and radiological characteristics of CM-I, syrinx, and scoliosis (coronal curve ≥ 10°). RESULTS Based on available imaging of patients with CM-I and syrinx, 260 of 825 patients (31%) had a clear diagnosis of scoliosis based on radiographs or coronal MRI. Forty-nine patients (5.9%) did not have scoliosis, and in 516 (63%) patients, a clear determination of the presence or absence of scoliosis could not be made. Comparison of patients with and those without a definite scoliosis diagnosis indicated that scoliosis was associated with wider syrinxes (8.7 vs 6.3 mm, OR 1.25, p < 0.001), longer syrinxes (10.3 vs 6.2 levels, OR 1.18, p < 0.001), syrinxes with their rostral extent located in the cervical spine (94% vs 80%, OR 3.91, p = 0.001), and holocord syrinxes (50% vs 16%, OR 5.61, p < 0.001). Multivariable regression analysis revealed syrinx length and the presence of holocord syrinx to be independent predictors of scoliosis in this patient cohort. Scoliosis was not associated with sex, age at CM-I diagnosis, tonsil position, pB-C2 distance (measured perpendicular distance from the ventral dura to a line drawn from the basion to the posterior-inferior aspect of C2), clivoaxial angle, or frontal-occipital horn ratio. Average curve magnitude was 29.9°, and 37.7% of patients had a left thoracic curve. Older age at CM-I or syrinx diagnosis (p < 0.0001) was associated with greater curve magnitude whereas there was no association between syrinx dimensions and curve magnitude. CONCLUSIONS Syrinx characteristics, but not tonsil position, were related to the presence of scoliosis in patients with CM-I, and there was an independent association of syrinx length and holocord syrinx with scoliosis. Further study is needed to evaluate the nature of the relationship between syrinx and scoliosis in patients with CM-I.
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Affiliation(s)
- Jennifer M Strahle
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Rukayat Taiwo
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Christine Averill
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - James Torner
- 2Department of Epidemiology, University of Iowa, Iowa City, Iowa
| | - Chevis N Shannon
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher M Bonfield
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gerald F Tuite
- 4Department of Neurosurgery, Neuroscience Institute, All Children's Hospital, St. Petersburg, Florida
| | - Tammy Bethel-Anderson
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jerrel Rutlin
- 5Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Douglas L Brockmeyer
- 6Department of Pediatric Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - John C Wellons
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey R Leonard
- 7Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Francesco T Mangano
- 8Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James M Johnston
- 9Division of Neurosurgery, University of Alabama School of Medicine, Birmingham, Alabama
| | - Manish N Shah
- 10Department of Pediatric Surgery and Neurosurgery, The University of Texas McGovern Medical School, Houston, Texas
| | - Bermans J Iskandar
- 11Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Elizabeth C Tyler-Kabara
- 12Department of Neurosurgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - David J Daniels
- 13Department of Neurosurgery, The Mayo Clinic, Rochester, Minnesota
| | - Eric M Jackson
- 14Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Gerald A Grant
- 15Department of Neurosurgery, Stanford Child Health Research Institute, Stanford, California
| | - Daniel E Couture
- 16Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - P David Adelson
- 17Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Tord D Alden
- 18Department of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Philipp R Aldana
- 19Department of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Richard C E Anderson
- 20Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, New York
| | - Nathan R Selden
- 21Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Lissa C Baird
- 21Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Karin Bierbrauer
- 8Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joshua J Chern
- 22Department of Neurosurgery, Children's Healthcare of Atlanta, Georgia
| | | | - Richard G Ellenbogen
- 24Department of Neurosurgery, University of Washington Medicine, Seattle, Washington
| | - Herbert E Fuchs
- 25Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
| | - Daniel J Guillaume
- 26Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Todd C Hankinson
- 27Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Mark R Iantosca
- 28Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - W Jerry Oakes
- 9Division of Neurosurgery, University of Alabama School of Medicine, Birmingham, Alabama
| | - Robert F Keating
- 29Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Nickalus R Khan
- 30Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Michael S Muhlbauer
- 30Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - J Gordon McComb
- 31Division of Neurosurgery, Children's Hospital Los Angeles, California
| | - Arnold H Menezes
- 32Department of Neurosurgery, University of Iowa Hospitals, Iowa City, Iowa
| | - John Ragheb
- 33Department of Pediatric Neurosurgery, Miami Children's Hospital and University of Miami Miller School of Medicine, Miami, Florida
| | - Jodi L Smith
- 34Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Cormac O Maher
- 35Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Stephanie Greene
- 12Department of Neurosurgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Michael Kelly
- 36Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Brent R O'Neill
- 27Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Mark D Krieger
- 31Division of Neurosurgery, Children's Hospital Los Angeles, California
| | - Mandeep Tamber
- 37Department of Neurosurgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Susan R Durham
- 38Department of Neurosurgery, University of Vermont College of Medicine, Burlington, Vermont
| | | | - Scellig S D Stone
- 40Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
| | - Bruce A Kaufman
- 41Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Gregory G Heuer
- 42Division of Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania
| | - David F Bauer
- 43Department of Neurosurgery, Dartmouth Geisel School of Medicine, Hanover, New Hampshire
| | - Gregory Albert
- 44Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jeffrey P Greenfield
- 45Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Scott D Wait
- 46Department of Neurological Surgery, Levine Children's Hospital, Charlotte, North Carolina
| | - Mark D Van Poppel
- 46Department of Neurological Surgery, Levine Children's Hospital, Charlotte, North Carolina
| | - Ramin Eskandari
- 47Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina; and
| | - Timothy Mapstone
- 48Department of Neurosurgery, Oklahoma University Medical Center, Oklahoma City, Oklahoma
| | - Joshua S Shimony
- 5Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Ralph G Dacey
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew D Smyth
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Tae Sung Park
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - David D Limbrick
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
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45
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Schieffer KM, Miller KE, Boue DR, Koboldt DC, Brennan P, Kelly BJ, Wheeler G, Magrini V, Wetzel A, Varga E, Dishman D, Leraas K, Agarwal V, AbdelBaki MS, Finlay JL, Leonard JR, White P, Gastier-Foster JM, Cottrell CE, Mardis ER, Wilson RK. Abstract 484: Molecular profiling identifies a second malignancy in a patient with medulloblastoma. Cancer Res 2019. [DOI: 10.1158/1538-7445.am2019-484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Medulloblastoma is a pediatric embryonal tumor that can be classified into four molecular subgroups, each derived from a different progenitor cell. It is estimated that about 30-40% of patients will relapse, typically with recurrence at the primary site and of the same molecular subgroup. We present paired tumor/normal genomic analysis of an 18 year-old male who presented with non-Wnt/non-SHH medulloblastoma at age 12 and relapsed with metastatic disease of the falx cerebri 3 years later. Combination surgery, chemotherapy, and radiation were used in treatment of the primary and recurrent tumor. At a timepoint 6 years from original diagnosis, the patient presented with a cerebellar tumor histologically described as “consistent with recurrent medulloblastoma” with comment recommending genomics to confirm. The diagnosis was made based on near identifical morphology and retention of Neu-N and Synaptophysin in the tumor (confirmed by subsequent genetic analysis). The primary tumor and the tumor occurring 6 years after the primary diagnosis were analyzed by whole exome sequencing (blood and tumor tissues) to assess for germline variants, somatic mutation, and copy number variation. We observed no pathogenic germline variants in cancer predisposition genes. The tumor mutational profiles were distinct, with only 6 (1.8%) shared somatic variants between tumors. Specimen provenance was verified by germline variation and SRY coverage. Two targetable mutations within the RAS-MAPK pathway (PTPN11 p.Glu76Lys and PIK3CA p.Gly1007Arg) were present only in the new CNS tumor. Although the primary tumor harbored isochromosome 17q and a gain of chromosome 4, these somatic chromosomal aberrations were not detected in the new CNS tumor. RNA-seq was performed on both tumors and compared to pediatric CNS tumors from the University of California Santa Cruz Treehouse Initiative (n=434). The primary tumor clustered with the medulloblastoma patients by principal component analysis while the new CNS tumor clustered with a group of gliomas and non-medulloblastoma embryonal tumors. The primary tumor displayed evidence of overexpression of Group 4 medulloblastoma genes (e.g. EOMES, RBM24, SNCAIP, and UNC5D). These genes were not overexpressed in the new CNS tumor. Enrichment of genes commonly found in gliomas (e.g. BCAN, CHI3L2, PDGFRA, and SOX2) were noted in the new CNS tumor only. In summary, tumor genomic profiling of a primary medulloblastoma and the new CNS tumor arising 6 years later revealed two distinct sets of somatic mutations suggestive of second malignancy rather than recurrence in this patient. While second malignancy in the setting of medulloblastoma is a rare event, it has been documented, both in a time period consistent with that described in our patient and in the form of glioma. Thus, tumor profiling refined diagnosis in this patient allowing for a more accurate assessment of treatment and management options.
Citation Format: Kathleen M. Schieffer, Katherine E. Miller, Daniel R. Boue, Daniel C. Koboldt, Patrick Brennan, Benjamin J. Kelly, Gregory Wheeler, Vincent Magrini, Amy Wetzel, Elizabeth Varga, Devon Dishman, Kristen Leraas, Vibhuti Agarwal, Mohamed S. AbdelBaki, Jonathan L. Finlay, Jeffrey R. Leonard, Peter White, Julie M. Gastier-Foster, Catherine E. Cottrell, Elaine R. Mardis, Richard K. Wilson. Molecular profiling identifies a second malignancy in a patient with medulloblastoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 484.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Amy Wetzel
- Nationwide Children's Hospital, Columbus, OH
| | | | | | | | | | | | | | | | - Peter White
- Nationwide Children's Hospital, Columbus, OH
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46
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Leonard JC, Browne LR, Ahmad FA, Schwartz H, Wallendorf M, Leonard JR, Lerner EB, Kuppermann N. Cervical Spine Injury Risk Factors in Children With Blunt Trauma. Pediatrics 2019; 144:peds.2018-3221. [PMID: 31221898 PMCID: PMC6615532 DOI: 10.1542/peds.2018-3221] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Adult prediction rules for cervical spine injury (CSI) exist; however, pediatric rules do not. Our objectives were to determine test accuracies of retrospectively identified CSI risk factors in a prospective pediatric cohort and compare them to a de novo risk model. METHODS We conducted a 4-center, prospective observational study of children 0 to 17 years old who experienced blunt trauma and underwent emergency medical services scene response, trauma evaluation, and/or cervical imaging. Emergency department providers recorded CSI risk factors. CSIs were classified by reviewing imaging, consultations, and/or telephone follow-up. We calculated bivariable relative risks, multivariable odds ratios, and test characteristics for the retrospective risk model and a de novo model. RESULTS Of 4091 enrolled children, 74 (1.8%) had CSIs. Fourteen factors had bivariable associations with CSIs: diving, axial load, clotheslining, loss of consciousness, neck pain, inability to move neck, altered mental status, signs of basilar skull fracture, torso injury, thoracic injury, intubation, respiratory distress, decreased oxygen saturation, and neurologic deficits. The retrospective model (high-risk motor vehicle crash, diving, predisposing condition, neck pain, decreased neck mobility (report or exam), altered mental status, neurologic deficits, or torso injury) was 90.5% (95% confidence interval: 83.9%-97.2%) sensitive and 45.6% (44.0%-47.1%) specific for CSIs. The de novo model (diving, axial load, neck pain, inability to move neck, altered mental status, intubation, or respiratory distress) was 92.0% (85.7%-98.1%) sensitive and 50.3% (48.7%-51.8%) specific. CONCLUSIONS Our findings support previously identified pediatric CSI risk factors and prospective pediatric CSI prediction rule development.
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Affiliation(s)
| | - Lorin R. Browne
- Department of Pediatrics and Emergency Medicine,
Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Hamilton Schwartz
- Department of Pediatrics, Cincinnati
Children’s Hospital Medical Center and College of Medicine, University of
Cincinnati, Cincinnati, Ohio; and
| | - Michael Wallendorf
- Biostatistics, School of Medicine, Washington
University, St Louis, Missouri
| | - Jeffrey R. Leonard
- Neurosurgery, Nationwide Children’s Hospital
and College of Medicine, The Ohio State University, Columbus, Ohio
| | - E. Brooke Lerner
- Department of Pediatrics and Emergency Medicine,
Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics,
School of Medicine, University of California, Davis, Sacramento,
California
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47
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Sribnick EA, Lunney M, Wright DW, Allen JW, Hudgins PA, Shi J, Wheeler K, Leonard JR, Dhall SS, Xiangh H. The Surgical Intervention for Traumatic Injury Scale: A Clinical Tool for Traumatic Brain Injury. West J Emerg Med 2019; 20:578-584. [PMID: 31316696 PMCID: PMC6625684 DOI: 10.5811/westjem.2019.4.41802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/25/2019] [Accepted: 04/05/2019] [Indexed: 11/25/2022] Open
Abstract
Introduction There is no widely used method for communicating the possible need for surgical intervention in patients with traumatic brain injury (TBI). This study describes a scoring system designed to communicate the potential need for surgical decompression in TBI patients. The scoring system, named the Surgical Intervention for Traumatic Injury (SITI), was designed to be objective and easy to use. Methods The SITI scale uses radiographic and clinical findings, including the Glasgow Coma Scale Score, pupil examination, and findings noted on computed tomography. To examine the scale, we used the patient database for the Progesterone for the Treatment of Traumatic Brain Injury III (ProTECT III) trial, and retrospectively applied the SITI scale to these patients. Results Of the 871 patients reviewed, 164 (18.8%) underwent craniotomy or craniectomy, and 707 (81.2%) were treated nonoperatively. The mean SITI score was 5.1 for patients who underwent surgery and 2.5 for patients treated nonoperatively (P<0.001). The area under the receiver operating characteristic curve was 0.887. Conclusion The SITI scale was designed to be a simple, objective, clinical decision tool regarding the potential need for surgical decompression after TBI. Application of the SITI scale to the ProTECT III database demonstrated that a score of 3 or more was well associated with a perceived need for surgical decompression. These results further demonstrate the potential utility of the SITI scale in clinical practice.
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Affiliation(s)
- Eric A Sribnick
- Nationwide Children's Hospital, Division of Neurosurgery, Columbus, Ohio.,The Ohio State University, Department of Neurosurgery, Columbus, Ohio
| | - Michael Lunney
- Emory University, Department of Emergency Medicine, Atlanta, Georgia
| | - David W Wright
- Emory University, Department of Emergency Medicine, Atlanta, Georgia
| | - Jason W Allen
- Emory University, Department of Radiology and Imaging Sciences, Atlanta, Georgia
| | - Patricia A Hudgins
- Emory University, Department of Radiology and Imaging Sciences, Atlanta, Georgia
| | - Junxin Shi
- Nationwide Children's Hospital, Center for Pediatric Trauma Research, Columbus, Ohio
| | - Krista Wheeler
- Nationwide Children's Hospital, Center for Pediatric Trauma Research, Columbus, Ohio
| | - Jeffrey R Leonard
- Nationwide Children's Hospital, Division of Neurosurgery, Columbus, Ohio.,The Ohio State University, Department of Neurosurgery, Columbus, Ohio
| | - Sanjay S Dhall
- University of California, San Francisco, Department of Neurosurgery, San Francisco, California
| | - Henry Xiangh
- Nationwide Children's Hospital, Center for Pediatric Trauma Research, Columbus, Ohio
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48
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Lovett ME, O'Brien NF, Leonard JR. Children With Severe Traumatic Brain Injury, Intracranial Pressure, Cerebral Perfusion Pressure, What Does it Mean? A Review of the Literature. Pediatr Neurol 2019; 94:3-20. [PMID: 30765136 DOI: 10.1016/j.pediatrneurol.2018.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 11/28/2018] [Accepted: 12/06/2018] [Indexed: 11/18/2022]
Abstract
Severe traumatic brain injury is a leading cause of morbidity and mortality in children. In 2003 the Brain Trauma Foundation released guidelines that have since been updated (2010) and have helped standardize and improve care. One area of care that remains controversial is whether the placement of an intracranial pressure monitor is advantageous in the management of traumatic brain injury. Another aspect of care that is widely debated is whether management after traumatic brain injury should be based on intracranial pressure-directed therapy, cerebral perfusion pressure-directed therapy, or a combination of the two. The aim of this article was to provide an overview and review the current evidence regarding these questions.
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Affiliation(s)
- Marlina E Lovett
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio.
| | - Nicole F O'Brien
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Jeffrey R Leonard
- Division of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
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49
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Alexiades NG, Ahn ES, Blount JP, Brockmeyer DL, Browd SR, Grant GA, Heuer GG, Hankinson TC, Iskandar BJ, Jea A, Krieger MD, Leonard JR, Limbrick DD, Maher CO, Proctor MR, Sandberg DI, Wellons JC, Shao B, Feldstein NA, Anderson RCE. Development of best practices to minimize wound complications after complex tethered spinal cord surgery: a modified Delphi study. J Neurosurg Pediatr 2018; 22:701-709. [PMID: 30215584 DOI: 10.3171/2018.6.peds18243] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 06/13/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEComplications after complex tethered spinal cord (cTSC) surgery include infections and cerebrospinal fluid (CSF) leaks. With little empirical evidence to guide management, there is variability in the interventions undertaken to limit complications. Expert-based best practices may improve the care of patients undergoing cTSC surgery. Here, authors conducted a study to identify consensus-driven best practices.METHODSThe Delphi method was employed to identify consensual best practices. A literature review regarding cTSC surgery together with a survey of current practices was distributed to 17 board-certified pediatric neurosurgeons. Thirty statements were then formulated and distributed to the group. Results of the second survey were discussed during an in-person meeting leading to further consensus, which was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree).RESULTSSeventeen consensus-driven best practices were identified, with all participants willing to incorporate them into their practice. There were four preoperative interventions: (1, 2) asymptomatic AND symptomatic patients should be referred to urology preoperatively, (3, 4) routine preoperative urine cultures are not necessary for asymptomatic AND symptomatic patients. There were nine intraoperative interventions: (5) patients should receive perioperative cefazolin or an equivalent alternative in the event of allergy, (6) chlorhexidine-based skin preparation is the preferred regimen, (7) saline irrigation should be used intermittently throughout the case, (8) antibiotic-containing irrigation should be used following dural closure, (9) a nonlocking running suture technique should be used for dural closure, (10) dural graft overlay should be used when unable to obtain primary dural closure, (11) an expansile dural graft should be incorporated in cases of lipomyelomeningocele in which primary dural closure does not permit free flow of CSF, (12) paraxial muscles should be closed as a layer separate from the fascia, (13) routine placement of postoperative drains is not necessary. There were three postoperative interventions: (14) postoperative antibiotics are an option and, if given, should be discontinued within 24 hours; (15) patients should remain flat for at least 24 hours postoperatively; (16) routine use of abdominal binders or other compressive devices postoperatively is not necessary. One intervention was prioritized for additional study: (17) further study of additional gram-negative perioperative coverage is needed.CONCLUSIONSA modified Delphi technique was used to develop consensus-driven best practices for decreasing wound complications after cTSC surgery. Further study is required to determine if implementation of these practices will lead to reduced complications. Discussion through the course of this study resulted in the initiation of a multicenter study of gram-negative surgical site infections in cTSC surgery.
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Affiliation(s)
- Nikita G Alexiades
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Edward S Ahn
- 2Department of Neurological Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeffrey P Blount
- 3Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Alabama, Birmingham, Alabama
| | - Douglas L Brockmeyer
- 4Department of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Samuel R Browd
- 5Department of Neurosurgery, University of Washington Seattle Children's Hospital, Seattle, Washington
| | - Gerald A Grant
- 6Department of Neurosurgery, Stanford University, Stanford, California
| | - Gregory G Heuer
- 7Department of Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania
| | - Todd C Hankinson
- 8Department of Pediatric Neurosurgery, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Bermans J Iskandar
- 9Department of Neurosurgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Andrew Jea
- 10Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mark D Krieger
- 11Department of Neurological Surgery, USC Keck School of Medicine/Children's Hospital of Los Angeles, California
| | - Jeffrey R Leonard
- 12Department of Neurosurgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - David D Limbrick
- 13Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Cormac O Maher
- 14Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Mark R Proctor
- 15Department of Neurosurgery, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts
| | - David I Sandberg
- 16Department of Neurosurgery, McGovern Medical School/University of Texas Health Science Center, Houston, Texas
| | - John C Wellons
- 17Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Belinda Shao
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York.,18Rutgers New Jersey Medical School, Newark, New Jersey
| | - Neil A Feldstein
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Richard C E Anderson
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York
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50
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Karsy M, Akbari SH, Limbrick DD, Leuthardt EC, Evans J, Smyth MD, Strahle J, Leonard JR, Brockmeyer DL, Bollo RJ, Kestle JR, Honeycutt JH, Donahue DJ, Roberts RA, Hansen D, Sutherland GR, Gallagher C, Hader W, Starreveld YP, Hamilton MG, Duhaime AC, Jensen RL, Chicoine MR. 356 Evaluation of Pediatric Glioma Outcomes Using Intraoperative MRI. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy303.356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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