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Brandel MG, Lin C, Rennert RC, Plonsker JH, Khan UA, Crawford JR, Nation J, Levy ML. Surgical management of Rathke cleft cysts in pediatric patients: a single institution experience. Childs Nerv Syst 2024; 40:1367-1375. [PMID: 38240786 PMCID: PMC11026193 DOI: 10.1007/s00381-024-06277-z] [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: 09/27/2023] [Accepted: 01/03/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE Rathke cleft cysts (RCCs) are benign, epithelial-lined sellar lesions that arise from remnants of the craniopharyngeal duct. Due to their rarity in the pediatric population, data are limited regarding the natural history and optimal management of growing or symptomatic RCCs. We present our institutional experience with the surgical management of RCCs. METHODS We performed a retrospective study of consecutive RCC patients ≤ 18 years old treated surgically at our institution between 2006 and 2022. RESULTS Overall, 567 patients with a diagnosis of pituitary mass or cyst were identified. Of these, 31 had a histopathological diagnosis of RCC, 58% female and 42% male. The mean age was 13.2 ± 4.2 years. Presenting symptoms included headache (58%), visual changes (32%), and endocrinopathies or growth delay (26%); 13% were identified incidentally and subsequently demonstrated growth on serial imaging. Six percent presented with symptomatic intralesional hemorrhage. Surgical approach was transsphenoidal for 90% of patients and orbitozygomatic for 10%. Preoperative headaches resolved in 61% of patients and preoperative visual deficits improvement in 55% after surgery. New pituitary axis deficits were seen in 9.7% of patients. Only two complications occurred from a first-time surgery: one cerebrospinal fluid leak requiring lumbar drain placement, and one case of epistaxis requiring cauterization. No patients experienced new visual or neurological deficits. Patients were followed postoperatively with serial imaging at a mean follow-up was 62.9 ± 58.4 months. Recurrence requiring reoperation occurred in 32% of patients. Five-year progression-free survival was 47.9%. Except for one patient with multiple neurological deficits from a concurrent tectal glioma, all patients had a modified Rankin Scale score of 0 or 1 (good outcome) at last follow-up. CONCLUSION Due to their secretory epithelium, pediatric RCCs may demonstrate rapid growth and can cause symptoms due to local mass effect. Surgical management of symptomatic or growing pediatric RCCs via cyst fenestration or partial resection of the cyst wall can be performed safely, with good neurologic outcomes. There is a nontrivial risk of endocrinologic injury, and long-term follow up is needed due to high recurrence rates.
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Affiliation(s)
- Michael G Brandel
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
| | - Christine Lin
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
| | - Robert C Rennert
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, 84112, USA
| | - Jillian H Plonsker
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
| | - Usman A Khan
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
| | - John R Crawford
- Division of Child Neurology and Neurosciences Institute, Children's Hospital of Orange County and University of California Irvine, Orange, CA, 92868, USA
- Division of Neurology, Rady Children's Hospital, San Diego, CA, 92123, USA
| | - Javan Nation
- Department of Otolaryngology, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA.
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Brandel MG, Plonsker JH, Rennert RC, Produturi G, Saripella M, Wali AR, McCann C, Ravindra VM, Santiago-Dieppa DR, Pannell JS, Steinberg JA, Khalessi AA, Levy ML. Treatment of pediatric intracranial aneurysms: institutional case series and systematic literature review. Childs Nerv Syst 2024:10.1007/s00381-024-06384-x. [PMID: 38635071 DOI: 10.1007/s00381-024-06384-x] [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: 03/18/2024] [Accepted: 03/27/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Pediatric intracranial aneurysms (IAs) are rare and have distinct clinical profiles compared to adult IAs. They differ in location, size, morphology, presentation, and treatment strategies. We present our experience with pediatric IAs over an 18-year period using surgical and endovascular treatments and review the literature to identify commonalities in epidemiology, treatment, and outcomes. METHODS We identified all patients < 20 years old who underwent treatment for IAs at our institution between 2005 and 2020. Medical records and imaging were examined for demographic, clinical, and operative data. A systematic review was performed to identify studies reporting primary outcomes of surgical and endovascular treatment of pediatric IAs. Demographic information, aneurysm characteristics, treatment strategies, and outcomes were collected. RESULTS Thirty-three patients underwent treatment for 37 aneurysms over 18 years. The mean age was 11.4 years, ranging from one month to 19 years. There were 21 males (63.6%) and 12 females (36.4%), yielding a male: female ratio of 1.75:1. Twenty-six (70.3%) aneurysms arose from the anterior circulation and 11 (29.7%) arose from the posterior circulation. Aneurysmal rupture occurred in 19 (57.5%) patients, of which 8 (24.2%) were categorized as Hunt-Hess grades IV or V. Aneurysm recurrence or rerupture occurred in five (15.2%) patients, and 5 patients (15.2%) died due to sequelae of their aneurysms. Twenty-one patients (63.6%) had a good outcome (modified Rankin Scale score 0-2) on last follow up. The systematic literature review yielded 48 studies which included 1,482 total aneurysms (611 with endovascular treatment; 656 treated surgically; 215 treated conservatively). Mean aneurysm recurrence rates in the literature were 12.7% and 3.9% for endovascular and surgical treatment, respectively. CONCLUSIONS Our study provides data on the natural history and longitudinal outcomes for children treated for IAs at a single institution, in addition to our treatment strategies for various aneurysmal morphologies. Despite the high proportion of patients presenting with rupture, good functional outcomes can be achieved for most patients.
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Affiliation(s)
- Michael G Brandel
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, USA
| | - Jillian H Plonsker
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, USA
| | - Robert C Rennert
- Department of Neurosurgery, University of Utah, 175 North Medical Drive East, Salt Lake City, CA, USA
| | - Gautam Produturi
- School of Medicine, University of California, San Diego, CA, USA
| | - Megana Saripella
- School of Medicine, University of California, San Diego, CA, USA
| | - Arvin R Wali
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, USA
| | - Carson McCann
- School of Medicine, University of California, San Diego, CA, USA
| | - Vijay M Ravindra
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, USA
| | - David R Santiago-Dieppa
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, USA
| | - J Scott Pannell
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, USA
| | - Jeffrey A Steinberg
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, USA
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, USA.
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Valencia-Sanchez BA, Kim JD, Zhou S, Chen S, Levy ML, Roxbury C, Patel VA, Polster SP. Special Considerations in Pediatric Endoscopic Skull Base Surgery. J Clin Med 2024; 13:1924. [PMID: 38610689 PMCID: PMC11013018 DOI: 10.3390/jcm13071924] [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: 02/16/2024] [Revised: 03/20/2024] [Accepted: 03/23/2024] [Indexed: 04/14/2024] Open
Abstract
Originally pioneered in adults, endoscopic endonasal approaches for skull base pathology are being increasingly applied as a minimally invasive alternative for young children. Intrinsic anatomic differences between these patient populations have sparked discussions on the feasibility, safety, and efficacy of these techniques in pediatric patients. This work aims to serve as a primer for clinicians engaged in the rapidly evolving field of pediatric endoscopic skull base surgery. A succinct overview of relevant embryology, sinonasal anatomy, and diagnostic workup is presented to emphasize key differences and unique technical considerations. Additional discussions regarding select skull base lesions, reconstructive paradigms, potential surgical complications, and postoperative care are also highlighted in the setting of multidisciplinary teams.
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Affiliation(s)
| | - Jeeho D. Kim
- Department of Otolaryngology-Head and Neck Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Sheng Zhou
- USC Caruso Department of Otolaryngology-Head and Neck Surgery, Los Angeles, CA 90033, USA
| | - Sonja Chen
- Department of Neurosurgery, University of Chicago, Chicago, IL 60637, USA (S.P.P.)
| | - Michael L. Levy
- Division of Pediatric Neurosurgery, Rady Children’s Hospital, San Diego, CA 92123, USA
- Department of Neurosurgery, University of California San Diego, La Jolla, CA 92093, USA
| | - Christopher Roxbury
- Department of Surgery, Section of Otolaryngology, University of Chicago Medicine, Chicago, IL 60637, USA;
| | - Vijay A. Patel
- Division of Pediatric Otolaryngology, Rady Children’s Hospital, San Diego, CA 92123, USA
- Department of Otolaryngology-Head and Neck Surgery, University of California San Diego, La Jolla, CA 92093, USA
| | - Sean P. Polster
- Department of Neurosurgery, University of Chicago, Chicago, IL 60637, USA (S.P.P.)
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Wiśniewski K, Tyfa Z, Reorowicz P, Brandel MG, Adel T, Obidowski D, Jóźwik K, Levy ML. Numerical flow experiment for assessing predictors for cerebrovascular accidents in patients with PHACES syndrome. Sci Rep 2024; 14:5161. [PMID: 38431727 PMCID: PMC10908848 DOI: 10.1038/s41598-024-55345-6] [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] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 02/22/2024] [Indexed: 03/05/2024] Open
Abstract
There is an increased risk of cerebrovascular accidents (CVA) in individuals with PHACES, yet the precise causes are not well understood. In this analysis, we aimed to examine the role of arteriopathy in PHACES syndrome as a potential contributor to CVA. We analyzed clinical and radiological data from 282 patients with suspected PHACES syndrome. We analyzed clinical features, including the presence of infantile hemangioma and radiological features based on magnetic resonance angiography or computed tomography angiography, in individuals with PHACES syndrome according to the Garzon criteria. To analyze intravascular blood flow, we conducted a simulation based on the Fluid-Structure Interaction (FSI) method, utilizing radiological data. The collected data underwent statistical analysis. Twenty patients with PHACES syndrome were included. CVAs were noted in 6 cases. Hypoplasia (p = 0.03), severe tortuosity (p < 0.01), absence of at least one main cerebral artery (p < 0.01), and presence of persistent arteries (p = 0.01) were associated with CVAs, with severe tortuosity being the strongest predictor. The in-silico analysis showed that the combination of hypoplasia and severe tortuosity resulted in a strongly thrombogenic environment. Severe tortuosity, combined with hypoplasia, is sufficient to create a hemodynamic environment conducive to thrombus formation and should be considered high-risk for cerebrovascular accidents (CVAs) in PHACES patients.
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Affiliation(s)
- Karol Wiśniewski
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA.
- Department of Neurosurgery and Neurooncology, Medical University of Lodz, Barlicki University Hospital, Kopcińskiego 22, 90-153, Lodz, Poland.
- Institute of Turbomachinery, Lodz University of Technology, 219/223 Wolczanska Str., 90-924, Lodz, Poland.
| | - Zbigniew Tyfa
- Institute of Turbomachinery, Lodz University of Technology, 219/223 Wolczanska Str., 90-924, Lodz, Poland
| | - Piotr Reorowicz
- Institute of Turbomachinery, Lodz University of Technology, 219/223 Wolczanska Str., 90-924, Lodz, Poland
| | - Michael G Brandel
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
| | - Thomas Adel
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
- Medical University of Vienna, Spitalgasse 23 Str., 1090, Wien, Austria
| | - Damian Obidowski
- Institute of Turbomachinery, Lodz University of Technology, 219/223 Wolczanska Str., 90-924, Lodz, Poland
| | - Krzysztof Jóźwik
- Institute of Turbomachinery, Lodz University of Technology, 219/223 Wolczanska Str., 90-924, Lodz, Poland
| | - Michael L Levy
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
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Upadhye A, Meza Landeros KE, Ramírez-Suástegui C, Schmiedel BJ, Woo E, Chee SJ, Malicki D, Coufal NG, Gonda D, Levy ML, Greenbaum JA, Seumois G, Crawford J, Roberts WD, Schoenberger SP, Cheroutre H, Ottensmeier CH, Vijayanand P, Ganesan AP. Intra-tumoral T cells in pediatric brain tumors display clonal expansion and effector properties. Nat Cancer 2024:10.1038/s43018-023-00706-9. [PMID: 38228835 DOI: 10.1038/s43018-023-00706-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 12/11/2023] [Indexed: 01/18/2024]
Abstract
Brain tumors in children are a devastating disease in a high proportion of patients. Owing to inconsistent results in clinical trials in unstratified patients, the role of immunotherapy remains unclear. We performed an in-depth survey of the single-cell transcriptomes and clonal relationship of intra-tumoral T cells from children with brain tumors. Our results demonstrate that a large fraction of T cells in the tumor tissue are clonally expanded with the potential to recognize tumor antigens. Such clonally expanded T cells display enrichment of transcripts linked to effector function, tissue residency, immune checkpoints and signatures of neoantigen-specific T cells and immunotherapy response. We identify neoantigens in pediatric brain tumors and show that neoantigen-specific T cell gene signatures are linked to better survival outcomes. Notably, among the patients in our cohort, we observe substantial heterogeneity in the degree of clonal expansion and magnitude of T cell response. Our findings suggest that characterization of intra-tumoral T cell responses may enable selection of patients for immunotherapy, an approach that requires prospective validation in clinical trials.
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Affiliation(s)
- Aditi Upadhye
- La Jolla Institute for Immunology, La Jolla, CA, USA
| | - Kevin E Meza Landeros
- La Jolla Institute for Immunology, La Jolla, CA, USA
- Center for Genomic Sciences, National Autonomous University of Mexico, Cuernavaca, Mexico
| | | | | | - Edwin Woo
- Southampton University Hospitals NHS Trust, Southampton, UK
| | - Serena J Chee
- Department of Respiratory Medicine, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Denise Malicki
- Department of Pathology, University of California San Diego, La Jolla, CA, USA
- Rady Children's Hospital, San Diego, CA, USA
| | - Nicole G Coufal
- Rady Children's Hospital, San Diego, CA, USA
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
| | - David Gonda
- Rady Children's Hospital, San Diego, CA, USA
- Department of Neurological Surgery, University of California San Diego, La Jolla, CA, USA
| | - Michael L Levy
- Rady Children's Hospital, San Diego, CA, USA
- Department of Neurological Surgery, University of California San Diego, La Jolla, CA, USA
| | | | | | - John Crawford
- Rady Children's Hospital, San Diego, CA, USA
- Department of Neurosciences, University of California San Diego, La Jolla, CA, USA
- Department of Pediatrics, University of California Irvine, Irvine, CA, USA
- Children's Hospital Orange County, Irvine, CA, USA
| | - William D Roberts
- Rady Children's Hospital, San Diego, CA, USA
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
| | | | | | - Christian H Ottensmeier
- La Jolla Institute for Immunology, La Jolla, CA, USA
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
- Clatterbridge Cancer Center NHS Foundation Trust, Liverpool, UK
| | - Pandurangan Vijayanand
- La Jolla Institute for Immunology, La Jolla, CA, USA.
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.
- Department of Medicine, University of California San Diego, La Jolla, CA, USA.
| | - Anusha-Preethi Ganesan
- La Jolla Institute for Immunology, La Jolla, CA, USA.
- Rady Children's Hospital, San Diego, CA, USA.
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA.
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Chapman OS, Luebeck J, Sridhar S, Wong ITL, Dixit D, Wang S, Prasad G, Rajkumar U, Pagadala MS, Larson JD, He BJ, Hung KL, Lange JT, Dehkordi SR, Chandran S, Adam M, Morgan L, Wani S, Tiwari A, Guccione C, Lin Y, Dutta A, Lo YY, Juarez E, Robinson JT, Korshunov A, Michaels JEA, Cho YJ, Malicki DM, Coufal NG, Levy ML, Hobbs C, Scheuermann RH, Crawford JR, Pomeroy SL, Rich JN, Zhang X, Chang HY, Dixon JR, Bagchi A, Deshpande AJ, Carter H, Fraenkel E, Mischel PS, Wechsler-Reya RJ, Bafna V, Mesirov JP, Chavez L. Circular extrachromosomal DNA promotes tumor heterogeneity in high-risk medulloblastoma. Nat Genet 2023; 55:2189-2199. [PMID: 37945900 PMCID: PMC10703696 DOI: 10.1038/s41588-023-01551-3] [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] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/22/2023] [Indexed: 11/12/2023]
Abstract
Circular extrachromosomal DNA (ecDNA) in patient tumors is an important driver of oncogenic gene expression, evolution of drug resistance and poor patient outcomes. Applying computational methods for the detection and reconstruction of ecDNA across a retrospective cohort of 481 medulloblastoma tumors from 465 patients, we identify circular ecDNA in 82 patients (18%). Patients with ecDNA-positive medulloblastoma were more than twice as likely to relapse and three times as likely to die within 5 years of diagnosis. A subset of tumors harbored multiple ecDNA lineages, each containing distinct amplified oncogenes. Multimodal sequencing, imaging and CRISPR inhibition experiments in medulloblastoma models reveal intratumoral heterogeneity of ecDNA copy number per cell and frequent putative 'enhancer rewiring' events on ecDNA. This study reveals the frequency and diversity of ecDNA in medulloblastoma, stratified into molecular subgroups, and suggests copy number heterogeneity and enhancer rewiring as oncogenic features of ecDNA.
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Affiliation(s)
- Owen S Chapman
- Bioinformatics and Systems Biology Graduate Program, University of California San Diego, San Diego, CA, USA
- Department of Medicine, University of California San Diego, San Diego, CA, USA
- Sanford Burnham Prebys Medical Discovery Institute, San Diego, CA, USA
| | - Jens Luebeck
- Bioinformatics and Systems Biology Graduate Program, University of California San Diego, San Diego, CA, USA
- Department of Computer Science and Engineering, University of California San Diego, San Diego, CA, USA
| | - Sunita Sridhar
- Department of Medicine, University of California San Diego, San Diego, CA, USA
- Department of Pediatrics, UC San Diego and Rady Children's Hospital, San Diego, CA, USA
| | - Ivy Tsz-Lo Wong
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
- Sarafan ChEM-H, Stanford University, Stanford, CA, USA
| | - Deobrat Dixit
- Sanford Burnham Prebys Medical Discovery Institute, San Diego, CA, USA
- Department of Neurology and Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Shanqing Wang
- Department of Computer Science and Engineering, University of California San Diego, San Diego, CA, USA
| | - Gino Prasad
- Department of Computer Science and Engineering, University of California San Diego, San Diego, CA, USA
| | - Utkrisht Rajkumar
- Department of Computer Science and Engineering, University of California San Diego, San Diego, CA, USA
| | - Meghana S Pagadala
- Medical Scientist Training Program, University of California San Diego, San Diego, CA, USA
- Biomedical Sciences Graduate Program, University of California San Diego, San Diego, CA, USA
| | - Jon D Larson
- Sanford Burnham Prebys Medical Discovery Institute, San Diego, CA, USA
| | - Britney Jiayu He
- Center for Personal Dynamic Regulomes, Stanford University, Stanford, CA, USA
| | - King L Hung
- Center for Personal Dynamic Regulomes, Stanford University, Stanford, CA, USA
| | - Joshua T Lange
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
- Sarafan ChEM-H, Stanford University, Stanford, CA, USA
| | - Siavash R Dehkordi
- Department of Computer Science and Engineering, University of California San Diego, San Diego, CA, USA
| | | | - Miriam Adam
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Ling Morgan
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Sameena Wani
- Sanford Burnham Prebys Medical Discovery Institute, San Diego, CA, USA
| | - Ashutosh Tiwari
- Sanford Burnham Prebys Medical Discovery Institute, San Diego, CA, USA
| | - Caitlin Guccione
- Bioinformatics and Systems Biology Graduate Program, University of California San Diego, San Diego, CA, USA
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Yingxi Lin
- Department of Computer Science and Engineering, University of California San Diego, San Diego, CA, USA
| | - Aditi Dutta
- Department of Computer Science and Engineering, University of California San Diego, San Diego, CA, USA
| | - Yan Yuen Lo
- Sanford Burnham Prebys Medical Discovery Institute, San Diego, CA, USA
- Rady Children's Institute for Genomic Medicine, Rady Children's Hospital and Healthcare Center, San Diego, CA, USA
| | - Edwin Juarez
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - James T Robinson
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Andrey Korshunov
- Clinical Cooperation Unit Neuropathology (B300), German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), and National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 280, Heidelberg, Germany
| | - John-Edward A Michaels
- Papé Pediatric Research Institute, Department of Pediatrics and Knight Cancer Insitute, Oregon Health and Sciences University, Portland, OR, USA
| | - Yoon-Jae Cho
- Papé Pediatric Research Institute, Department of Pediatrics and Knight Cancer Insitute, Oregon Health and Sciences University, Portland, OR, USA
| | - Denise M Malicki
- Division of Pathology, UC San Diego and Rady Children's Hospital, San Diego, CA, USA
| | - Nicole G Coufal
- Department of Pediatrics, UC San Diego and Rady Children's Hospital, San Diego, CA, USA
| | - Michael L Levy
- Division of Pathology, UC San Diego and Rady Children's Hospital, San Diego, CA, USA
| | - Charlotte Hobbs
- Rady Children's Institute for Genomic Medicine, Rady Children's Hospital and Healthcare Center, San Diego, CA, USA
| | - Richard H Scheuermann
- J. Craig Venter Institute, La Jolla, CA, USA
- Department of Pathology, University of California San Diego, San Diego, CA, USA
| | - John R Crawford
- Department of Pediatrics, University of California Irvine and Children's Hospital Orange County, Irvine, CA, USA
| | - Scott L Pomeroy
- Eli and Edythe Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jeremy N Rich
- UPMC Hillman Cancer Center, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Xinlian Zhang
- Division of Biostatistics and Bioinformatics, Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, USA
| | - Howard Y Chang
- Center for Personal Dynamic Regulomes, Stanford University, Stanford, CA, USA
- Department of Genetics, Stanford University, Stanford, CA, USA
- Howard Hughes Medical Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Jesse R Dixon
- Salk Institute for Biological Studies, La Jolla, CA, USA
| | - Anindya Bagchi
- Sanford Burnham Prebys Medical Discovery Institute, San Diego, CA, USA
| | | | - Hannah Carter
- Department of Medicine, University of California San Diego, San Diego, CA, USA
- Moores Cancer Center, University of California San Diego, San Diego, CA, USA
| | - Ernest Fraenkel
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
- Eli and Edythe Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Paul S Mischel
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
- Sarafan ChEM-H, Stanford University, Stanford, CA, USA
| | - Robert J Wechsler-Reya
- Sanford Burnham Prebys Medical Discovery Institute, San Diego, CA, USA
- Department of Neurology and Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Vineet Bafna
- Department of Computer Science and Engineering, University of California San Diego, San Diego, CA, USA
- Moores Cancer Center, University of California San Diego, San Diego, CA, USA
| | - Jill P Mesirov
- Department of Medicine, University of California San Diego, San Diego, CA, USA
- Moores Cancer Center, University of California San Diego, San Diego, CA, USA
| | - Lukas Chavez
- Department of Medicine, University of California San Diego, San Diego, CA, USA.
- Sanford Burnham Prebys Medical Discovery Institute, San Diego, CA, USA.
- Rady Children's Institute for Genomic Medicine, Rady Children's Hospital and Healthcare Center, San Diego, CA, USA.
- Moores Cancer Center, University of California San Diego, San Diego, CA, USA.
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7
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Narang P, Jandial Z, Aramayo JDB, Crawford J, Levy ML. Artificial cranial deformation in Tiwanaku, Bolivia. Childs Nerv Syst 2023; 39:3051-3055. [PMID: 37594563 PMCID: PMC10643289 DOI: 10.1007/s00381-023-06094-w] [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: 07/13/2023] [Accepted: 07/20/2023] [Indexed: 08/19/2023]
Abstract
PURPOSE Herein lies a brief historical review of the practice of artificial cranial deformation (ACD) in Tiwanaku, Bolivia, a pre-Columbian archeological ruin once regarded as one of the most powerful pre-Inca regions whose influence extended into present-day Peru and Chile from 600 to 1000 AD. We describe the history, purpose, and implications of ACD from both a neuroanatomical and cultural perspective. METHODS A literature review was conducted through PubMed on the history of artificial cranial deformation in South America, concentrating on the Tiwanaku region. The authors searched all available data with no specific time reference, using the mentioned keywords: ACD, neuroanatomical implications of ACD, cultural and social functions of ACD, Tiwanaku society, and Andean civilization. RESULTS Early Andean civilization was hierarchical and stratified. In Tiwanaku, the practice of ACD served to delineate one's social class, caste, lineage, and vocation. This was especially useful for warriors, who distinguished their fellow combatants from insurgents by differences in their cranial structure. ACD was usually conducted within the first few months of an infant's life before morphogenetic features became permanent. Two popular cranial styles-tabular and annular-were achieved by applying various mechanical apparatus and resulted in several cranial shapes (conical, box-like, flattened, etc.). Neuroanatomically, each deformation technique and the duration for which mechanical stress was applied influenced the solidification of cranial bones and shaped the frontal, occipital, parietal, and temporal bones differently. Cognitive deficits and plagiocephalic defects were recorded in limitation and may have been overlooked as the era's occupational demands were more labor-intensive than knowledge-driven. CONCLUSION In Tiwanaku, the custom of ACD was used to demonstrate group identity, with alterations of the cranial shape corresponding to a particular headdress. ACD was used to distinguish an individual's social identity, separating different groups of society into castes, classes, and slaves (Brain, 1979). The custom has also been used to mark territory and emphasize ethnic differences among groups, with potential cognitive implications that were largely unrecorded.
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Affiliation(s)
| | | | | | - John Crawford
- Children's Hospital of Orange County, Orange, CA, USA
| | - Michael L Levy
- Division of Pediatric Neurosurgery, Rady Children's Hospital-San Diego, San Diego, CA, USA
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Sutter PA, Anderson MG, Sahyouni R, Plonsker J, Ravindra VM, Gonda DD, Levy ML, Dziugan K, Votoupal M, DeCuypere M, Leclair NK, Angelo SJ, Halloran PJ, Martin JE, Bookland MJ, Michelow IC, McKay L, Hersh DS. Anticoagulation for the treatment of septic cerebral venous sinus thrombosis in the setting of pediatric sinogenic and otogenic intracranial infections. Neurosurg Focus 2023; 55:E8. [PMID: 37778041 DOI: 10.3171/2023.7.focus23374] [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] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/26/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE Septic cerebral venous sinus thrombosis (CVST) is a recognized complication of pediatric sinogenic and otogenic intracranial infections. The optimal treatment paradigm remains controversial. Proponents of anticoagulation highlight its role in preventing thrombus propagation and promoting recanalization, while others cite the risk of hemorrhagic complications, especially after a neurosurgical procedure for an epidural abscess or subdural empyema. Here, the authors investigated the diagnosis, management, and outcomes of pediatric patients with sinogenic or otogenic intracranial infections and a septic CVST. METHODS All patients 21 years of age or younger, who presented with an intracranial infection in the setting of sinusitis or otitis media and who underwent neurosurgical treatment at Connecticut Children's, Rady Children's Hospital-San Diego, or Ann and Robert H. Lurie Children's Hospital of Chicago from March 2015 to March 2023, were retrospectively reviewed. Demographic, clinical, and radiological data were systematically collated. RESULTS Ninety-six patients were treated for sinusitis-related and/or otitis media-related intracranial infections during the study period, 15 (15.6%) of whom were diagnosed with a CVST. Of the 60 patients who presented prior to the COVID-19 pandemic, 6 (10.0%) were diagnosed with a septic CVST, whereas of the 36 who presented during the COVID-19 pandemic, 9 (25.0%) had a septic CVST (p = 0.050). The superior sagittal sinus was involved in 12 (80.0%) patients and the transverse and/or sigmoid sinuses in 4 (26.7%). Only 1 (6.7%) patient had a fully occlusive thrombus. Of the 15 patients with a septic CVST, 11 (73.3%) were initiated on anticoagulation at a median interval of 4 (IQR 3-5) days from the most recent neurosurgical procedure. Five (45.5%) patients who underwent anticoagulation demonstrated complete recanalization on follow-up imaging, and 4 (36.4%) had partial recanalization. Three (75.0%) patients who did not undergo anticoagulation demonstrated complete recanalization, and 1 (25.0%) had partial recanalization. None of the patients treated with anticoagulation experienced hemorrhagic complications. CONCLUSIONS Septic CVST is frequently identified among pediatric patients undergoing neurosurgical intervention for sinogenic and/or otogenic intracranial infections and may have become more prevalent during the COVID-19 pandemic. Anticoagulation can be used safely in the acute postoperative period if administered cautiously, in a monitored setting, and with interval cross-sectional imaging. However, some patients exhibit excellent outcomes without anticoagulation, and further studies are needed to identify those who may benefit the most from anticoagulation.
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Affiliation(s)
| | | | - Ronald Sahyouni
- 3Department of Neurosurgery, University of California, San Diego, California
| | - Jillian Plonsker
- 3Department of Neurosurgery, University of California, San Diego, California
| | - Vijay M Ravindra
- 3Department of Neurosurgery, University of California, San Diego, California
- 4Division of Pediatric Neurosurgery, Rady Children's Hospital-San Diego, California
| | - David D Gonda
- 3Department of Neurosurgery, University of California, San Diego, California
- 4Division of Pediatric Neurosurgery, Rady Children's Hospital-San Diego, California
| | - Michael L Levy
- 3Department of Neurosurgery, University of California, San Diego, California
- 4Division of Pediatric Neurosurgery, Rady Children's Hospital-San Diego, California
| | - Klaudia Dziugan
- 5Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois
| | - Megan Votoupal
- 5Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois
| | - Michael DeCuypere
- 5Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois
- 6Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; and
| | | | | | | | | | | | - Ian C Michelow
- 9Infectious Diseases and Immunology, and
- 10Pediatrics, UConn School of Medicine, Farmington, Connecticut
| | - Laura McKay
- 11Center for Cancer and Blood Disorders, Connecticut Children's, Hartford, Connecticut
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Han CZ, Li RZ, Hansen E, Trescott S, Fixsen BR, Nguyen CT, Mora CM, Spann NJ, Bennett HR, Poirion O, Buchanan J, Warden AS, Xia B, Schlachetzki JCM, Pasillas MP, Preissl S, Wang A, O'Connor C, Shriram S, Kim R, Schafer D, Ramirez G, Challacombe J, Anavim SA, Johnson A, Gupta M, Glass IA, Levy ML, Haim SB, Gonda DD, Laurent L, Hughes JF, Page DC, Blurton-Jones M, Glass CK, Coufal NG. Human microglia maturation is underpinned by specific gene regulatory networks. Immunity 2023; 56:2152-2171.e13. [PMID: 37582369 PMCID: PMC10529991 DOI: 10.1016/j.immuni.2023.07.016] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 04/11/2023] [Accepted: 07/21/2023] [Indexed: 08/17/2023]
Abstract
Microglia phenotypes are highly regulated by the brain environment, but the transcriptional networks that specify the maturation of human microglia are poorly understood. Here, we characterized stage-specific transcriptomes and epigenetic landscapes of fetal and postnatal human microglia and acquired corresponding data in induced pluripotent stem cell (iPSC)-derived microglia, in cerebral organoids, and following engraftment into humanized mice. Parallel development of computational approaches that considered transcription factor (TF) co-occurrence and enhancer activity allowed prediction of shared and state-specific gene regulatory networks associated with fetal and postnatal microglia. Additionally, many features of the human fetal-to-postnatal transition were recapitulated in a time-dependent manner following the engraftment of iPSC cells into humanized mice. These data and accompanying computational approaches will facilitate further efforts to elucidate mechanisms by which human microglia acquire stage- and disease-specific phenotypes.
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Affiliation(s)
- Claudia Z Han
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Rick Z Li
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Emily Hansen
- Department of Pediatrics, University of California, San Diego, La Jolla, CA 92093, USA; Sanford Consortium for Regenerative Medicine, La Jolla, CA 92037, USA
| | - Samantha Trescott
- Department of Pediatrics, University of California, San Diego, La Jolla, CA 92093, USA; Sanford Consortium for Regenerative Medicine, La Jolla, CA 92037, USA
| | - Bethany R Fixsen
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Celina T Nguyen
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, CA 92093, USA; Department of Pediatrics, University of California, San Diego, La Jolla, CA 92093, USA; Sanford Consortium for Regenerative Medicine, La Jolla, CA 92037, USA
| | - Cristina M Mora
- Department of Pediatrics, University of California, San Diego, La Jolla, CA 92093, USA; Sanford Consortium for Regenerative Medicine, La Jolla, CA 92037, USA
| | - Nathanael J Spann
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Hunter R Bennett
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Olivier Poirion
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, CA 92093, USA; Center for Epigenomics, University of California, San Diego, La Jolla, CA 92093, USA
| | - Justin Buchanan
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, CA 92093, USA; Center for Epigenomics, University of California, San Diego, La Jolla, CA 92093, USA
| | - Anna S Warden
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, CA 92093, USA; Department of Pediatrics, University of California, San Diego, La Jolla, CA 92093, USA; Sanford Consortium for Regenerative Medicine, La Jolla, CA 92037, USA
| | - Bing Xia
- Department of Pediatrics, University of California, San Diego, La Jolla, CA 92093, USA; Sanford Consortium for Regenerative Medicine, La Jolla, CA 92037, USA
| | - Johannes C M Schlachetzki
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Martina P Pasillas
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Sebastian Preissl
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, CA 92093, USA; Center for Epigenomics, University of California, San Diego, La Jolla, CA 92093, USA
| | - Allen Wang
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, CA 92093, USA; Center for Epigenomics, University of California, San Diego, La Jolla, CA 92093, USA
| | | | - Shreya Shriram
- Department of Pediatrics, University of California, San Diego, La Jolla, CA 92093, USA; Sanford Consortium for Regenerative Medicine, La Jolla, CA 92037, USA
| | - Roy Kim
- Department of Pediatrics, University of California, San Diego, La Jolla, CA 92093, USA; Sanford Consortium for Regenerative Medicine, La Jolla, CA 92037, USA
| | - Danielle Schafer
- Department of Pediatrics, University of California, San Diego, La Jolla, CA 92093, USA; Sanford Consortium for Regenerative Medicine, La Jolla, CA 92037, USA
| | - Gabriela Ramirez
- Department of Pediatrics, University of California, San Diego, La Jolla, CA 92093, USA; Sanford Consortium for Regenerative Medicine, La Jolla, CA 92037, USA
| | - Jean Challacombe
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Samuel A Anavim
- Department of Pediatrics, University of California, San Diego, La Jolla, CA 92093, USA; Sanford Consortium for Regenerative Medicine, La Jolla, CA 92037, USA
| | - Avalon Johnson
- Department of Pediatrics, University of California, San Diego, La Jolla, CA 92093, USA; Sanford Consortium for Regenerative Medicine, La Jolla, CA 92037, USA
| | - Mihir Gupta
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA 92037, USA
| | - Ian A Glass
- Department of Pediatrics, University of Washington and Seattle Children's Research Institute, Seattle, WA, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA 92123, USA
| | - Sharona Ben Haim
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA 92037, USA
| | - David D Gonda
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA 92123, USA
| | - Louise Laurent
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego, La Jolla, CA 92093, USA
| | | | - David C Page
- Whitehead Institute, Cambridge, MA 02142, USA; Department of Biology, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Howard Hughes Medical Institute, Whitehead Institute, Cambridge, MA 02142, USA
| | - Mathew Blurton-Jones
- Department of Neurobiology and Behavior, University of California, Irvine, Irvine, CA 92696, USA
| | - Christopher K Glass
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, CA 92093, USA.
| | - Nicole G Coufal
- Department of Pediatrics, University of California, San Diego, La Jolla, CA 92093, USA; Sanford Consortium for Regenerative Medicine, La Jolla, CA 92037, USA; Salk Institute for Biological Studies, La Jolla, CA 92037, USA.
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Brandel MG, Plonsker JH, Rennert R, Khan U, Nation J, Crawford JR, Levy ML. 347 Management of Rathke Cleft Cysts in Children: The Rady Children’s Hospital Approach. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_347] [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: 03/18/2023] Open
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11
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Yakir MJ, Elster JD, Paul MR, Khanna PC, Malicki DM, Levy ML, Crawford JR. Atypical Molecular Features of Pediatric Tectal Glioma: A Single Institutional Series. J Pediatr Hematol Oncol 2023; 45:e410-e414. [PMID: 36730386 DOI: 10.1097/mph.0000000000002596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 10/14/2022] [Indexed: 02/04/2023]
Abstract
We present 4 children (diagnosed between 1 and 8 y, 3 females and 1 male) with molecularly distinct tectal gliomas (2 KRAS mutant, 1 EGFR mutant, 1 SRGAP3-RAF-1 fusion) that contributes to the growing literature of this uncommonly biopsied tumor. The patient with EGFR R222C mutation had a more severe course, earlier diagnosis, subsequent leptomeningeal metastatic disease, required more aggressive therapies, and died 9 years after diagnosis. Patients with KRAS mutations and SRGAP3-RAF-1 fusion had a more indolent course. Our series expands the molecular phenotype of tectal glioma with the potential for leptomeningeal dissemination. Future studies on establishing genotypic/phenotypic correlation from those who undergo biopsy are needed.
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Affiliation(s)
- Maayan Joy Yakir
- Division of Child Neurology, Department of Neurosciences
- Rady Children's Hospital
| | - Jennifer D Elster
- Rady Children's Hospital
- Division of Hematology Oncology, Department of Pediatrics
| | - Megan R Paul
- Rady Children's Hospital
- Division of Hematology Oncology, Department of Pediatrics
| | | | | | - Michael L Levy
- Rady Children's Hospital
- Division of Pediatric Neurosurgery, Department of Neurosurgery
| | - John Ross Crawford
- Division of Child Neurology, Department of Neurosciences
- Rady Children's Hospital
- Division of Hematology Oncology, Department of Pediatrics
- Division of Child Neurology, Neurosciences Institute, Children's Hospital Orange County and UC Irvine
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Levy DM, Kottler JA, Adams JW, Crawford JR, Levy ML. Using a Hybrid Approach to Increase the Impact of Medical Response to Natural Disasters. Disaster Med Public Health Prep 2023; 17:e303. [PMID: 36785529 DOI: 10.1017/dmp.2022.263] [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] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
The United Nations (UN) established an umbrella of organizations to manage distinct clusters of humanitarian aid. The World Health Organization (WHO) oversees the health cluster, giving it responsibility for global, national, and local medical responses to natural disasters. However, this centralized structure insufficiently engages local players, impeding robust local implementation. The Gorkha earthquake struck Nepal on April 25, 2015, becoming Nepal's most severe natural disaster since the 1934 Nepal-Bihar earthquake. In coordinated response, 2 organizations, Empower Nepali Girls and International Neurosurgical Children's Association, used a hybrid approach integrating continuous communication with local recipients. Each organization mobilized its principal resource strengths-material medical supplies or human capital-thereby efficiently deploying resources to maximize the impact of the medical response. In addition to efficient resource use, this approach facilitates dynamic medical responses from highly mobile organizations. Importantly, in addition to future earthquakes in Nepal, this medical response strategy is easily scalable to other natural disaster contexts and other medical relief organizations. Preemptively identifying partner organizations with complementary strengths, continuous engagement with recipient populations, and creating disaster- and region-specific response teams may represent viable variations of the WHO cluster model with greater efficacy in local implementation of treatment in acute disaster scenarios.
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Affiliation(s)
- Danielle M Levy
- Department of Neurosurgery, University of California San Diego, School of Medicine, La Jolla, California, USA
- Empower Nepali Girls, Walnut, California, USA
| | - Jeffrey A Kottler
- Empower Nepali Girls, Walnut, California, USA
- Department of Counseling, California State University, Fullerton, California, USA
| | - Jason W Adams
- Department of Neurosciences, University of California San Diego, School of Medicine, La Jolla, California, USA
| | - John R Crawford
- Department of Neurosciences, University of California San Diego, School of Medicine, La Jolla, California, USA
- Rady Children's Hospital, San Diego, California, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California San Diego, School of Medicine, La Jolla, California, USA
- Rady Children's Hospital, San Diego, California, USA
- International Neurosurgical Children's Association, San Diego, California, USA
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Shahrestani S, Brown NJ, Loya J, Patel NA, Gendreau JL, Himstead AS, Pierzchajlo N, Singh R, Sahyouni R, Diaz-Aguilar LD, Rennert RC, Levy ML. Novel use of nonpenetrating titanium clips for pediatric primary spinal dural closure: A technical note. Clin Neurol Neurosurg 2022; 222:107422. [PMID: 36084429 DOI: 10.1016/j.clineuro.2022.107422] [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: 05/02/2022] [Revised: 08/18/2022] [Accepted: 08/20/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Dural closure is an important part of any pediatric spinal procedure with intradural pathology to prevent post-operative cerebrospinal fluid (CSF) egress and associated complications. Utilization of nonpenetrating titanium clips is one closure option that may have technical advantages such as ease of use and amenability to a narrow surgical corridor. No data exist on the efficacy of these clips for pediatric spinal dural closure. METHODS A single surgeon case series of 152 pediatric patients underwent procedures involving lumbar durotomy with subsequent dural closure using the AnastoClip® nonpenetrating titanium clip closure system. Rates of infection and cerebrospinal fluid leak were measured during the follow-up period. RESULTS A total of 152 pediatric patients (mean age: 6.25 ± 5.85 years, 50.7 % female) underwent intradural surgery with clip closure. The mean follow-up time was 57.0 ± 28.5 months. All patients were initially indicated for procedures involving spinal durotomy, with a majority being isolated tethered cord release (84.2 %). Others required tethered cord release and excision of a lipomyelomeningocele, spinal meningioma or arachnoid cyst (15.8 %). Post operative CSF leak occurred in two (1.32 %) patients at 11 and 18 days. Only one (0.66 %) patient was diagnosed with an infection, which was in a separate patient from those that had CSF leaks. CONCLUSION The remarkably low incidence of post-operative CSF leak and infection with nonpenetrating titanium clips suggests a strong safety and efficacy profile for this form of dural closure in a pediatric cohort. Further research evaluating this technique is required to fully demonstrate its acceptability as a cost-effective alternative to traditional suture-based closure.
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Affiliation(s)
- Shane Shahrestani
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Medical Engineering, California Institute of Technology, Pasadena, CA, USA
| | - Nolan J Brown
- School of Medicine, University of California, Irvine, Orange, CA, USA.
| | - Joshua Loya
- Department of Neurosurgery, University of California, La Jolla, San Diego, CA, USA
| | - Neal A Patel
- School of Medicine, Mercer University, Columbus, GA, USA
| | - Julian L Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, MD, USA
| | | | | | - Rohin Singh
- School of Medicine, University of California, Irvine, Orange, CA, USA
| | - Ronald Sahyouni
- Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, CA, USA
| | - Luis Daniel Diaz-Aguilar
- Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, CA, USA
| | - Robert C Rennert
- Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, CA, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California, La Jolla, San Diego, CA, USA; Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, CA, USA
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Wiśniewski K, Brandel MG, Gonda DD, Crawford JR, Levy ML. Prognostic factors in diffuse leptomeningeal glioneuronal tumor (DLGNT): a systematic review. Childs Nerv Syst 2022; 38:1663-1673. [PMID: 35867118 DOI: 10.1007/s00381-022-05600-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 05/13/2022] [Accepted: 07/02/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Diffuse leptomeningeal glioneuronal tumor (DLGNT) is a rare tumor, first described by the WHO Classification of Central Nervous System Tumors in 2016. The clinical course is variable. Most tumors have low-grade histological findings although some may have more aggressive features. The goal of this systematic review was to identify prognostic factors for poor overall survival (OS). MATERIAL AND METHODS We performed a systematic review using three databases (PubMed, Google Scholar, and Embase) and the following search terms: diffuse leptomeningeal glioneuronal tumor, DLGNT, DLMGNT. Statistical analysis was performed using Statistica 13.3. RESULTS We included 34 reports in our review comprising 63 patients, published from 2016 to 2022. The median OS was 19 months (range: 12-51 months). Using multivariable Cox survival analysis, we showed that Ki-67 ≥ 7%, age > 9 years, symptoms of elevated intracranial pressure (ICP) at admission, and the presence of contrast-enhancing intraparenchymal tumor are associated with poor OS. Receiver operating characteristic (ROC) analysis identified Ki-67 ≥ 7% as a significant predictor of poor OS. CONCLUSIONS Signs or symptoms of increased ICP with imaging findings of diffuse leptomeningeal enhancement should raise suspicion for DLGNT. In our systematic review, Ki-67 ≥ 7% was the most important prognostic factor for OS in DLGNT. The presence of intraparenchymal tumor with contrast enhancement was thought to represent disease progression and, together with patient age, was associated with poor OS.
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Affiliation(s)
- Karol Wiśniewski
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA. .,Department of Neurosurgery and Neurooncology, Medical University of Lodz, Barlicki University Hospital, Kopcińskiego 22, 90-153, Lodz, Poland.
| | - Michael G Brandel
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
| | - David D Gonda
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
| | - John R Crawford
- Neurosciences Institute and Division of Child Neurology, Children's Health of Orange County, Orange, CA, 92868, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
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Kalawi AZ, Malicki DM, Abdullaev Z, Pratt DW, Quezado M, Aldape K, Elster JD, Paul MR, Khanna PC, Levy ML, Crawford JR. The role of methylation profiling in histologically diagnosed neurocytoma: a case series. J Neurooncol 2022; 159:725-733. [PMID: 35994156 PMCID: PMC9477906 DOI: 10.1007/s11060-022-04117-1] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 08/16/2022] [Indexed: 11/28/2022]
Abstract
Purpose To highlight the clinical, neuroradiographic, neuropathologic, and molecular features of histologically identified neurocytoma in a pediatric cohort and highlight the evolving use methylation profiling in providing diagnostic clarity in difficult to diagnosis pediatric brain tumors. Methods Five consecutive children (ages 9–13, 2 girls 3 boys) were histologically diagnosed with neurocytoma at Rady Children’s Hospital San Diego from 2012 to 2018. Clinical and molecular features were analyzed with regards to treatment course and outcome. Results Presenting symptoms included seizures (n = 2), syncope (n = 1), headache (n = 2), visual disturbances (n = 2) and emesis (n = 2). Tumor location included intraventricular (n = 2), intraventricular with parenchymal spread (n = 1), and extraventricular (n = 2). Magnetic resonance imaging demonstrated reduced diffusivity (2/5), signal abnormality on susceptibility-weighted sequences (3/5), and varying degrees of contrast enhancement (4/5). All patients underwent surgical resection alone. Recurrence occurred in four children that were treated with surgery (4/4), adjuvant radiation (2/4), and chemoradiation (1/4). Neuropathologic features included positivity for GFAP (4/5), synaptophysin (4/5), NSE (2/2), NeuN (4/4), and variable Ki-67 (< 1% to 15%). Next generation sequencing (3/5) and microarray (3/5) collectively were abnormal in four of five tumors. Methylation profiling was successfully performed on four of five samples which led to modification of diagnosis in two patients and the others were either unclassifiable or confirmatory with the histologic diagnosis. Mean time to follow up was 77 months (range 44–112 months). Mean progression free survival and overall survival were 24 months (range 6 to 52 months) and 100% respectively. Conclusion Neurocytomas are a rare clinical entity that warrants further investigation into molecular and pathologic prognosticating features. Methylation profiling may aid in differentiation of neurocytoma from other difficult to diagnose tumors who share similar histologic features.
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Affiliation(s)
- Adam Z Kalawi
- Division of Child Neurology, Department of Neurosciences, University of California, San Diego, CA, USA.
- Rady Children's Hospital, San Diego, CA, USA.
| | - Denise M Malicki
- Rady Children's Hospital, San Diego, CA, USA
- Department of Pathology, University of California, San Diego, CA, USA
| | - Zied Abdullaev
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD, USA
| | - Drew W Pratt
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Martha Quezado
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD, USA
| | - Kenneth Aldape
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD, USA
| | - Jennifer D Elster
- Rady Children's Hospital, San Diego, CA, USA
- Division of Hematology Oncology, Department of Pediatrics, University of California, San Diego, CA, USA
| | - Megan R Paul
- Rady Children's Hospital, San Diego, CA, USA
- Division of Hematology Oncology, Department of Pediatrics, University of California, San Diego, CA, USA
| | - Paritosh C Khanna
- Rady Children's Hospital, San Diego, CA, USA
- Department of Radiology, University of California, San Diego, CA, USA
| | - Michael L Levy
- Rady Children's Hospital, San Diego, CA, USA
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California, San Diego, CA, USA
| | - John R Crawford
- Division of Child Neurology, Department of Neurosciences, University of California, San Diego, CA, USA
- Rady Children's Hospital, San Diego, CA, USA
- Division of Hematology Oncology, Department of Pediatrics, University of California, San Diego, CA, USA
- Division of Child Neurology, Children's Hospital of Orange County, Orange, CA, USA
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16
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Rennert RC, Brandel MG, Steinberg JA, Nation J, Couldwell WT, Fukushima T, Day JD, Khalessi AA, Levy ML. Maturation of the sella turcica and parasellar region: Surgical relevance for anterior skull base approaches in pediatric patients. Clin Neurol Neurosurg 2022; 215:107168. [PMID: 35247690 DOI: 10.1016/j.clineuro.2022.107168] [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: 12/09/2021] [Revised: 01/13/2022] [Accepted: 02/02/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Traditional and extended transnasal transsphenoidal approaches provide direct access to a variety of anterior skull base pathologies. Despite increased utilization of transnasal approaches in children, anatomic studies on pediatric skull base maturation are limited. We herein perform a surgically relevant morphometric analysis of the sella and parasellar regions during pediatric maturation. METHODS Measurements of sellar length (SL), sellar depth (SDp), sellar diameter (SDm), interclinoid distance (ID), intercavernous distance (ICD), and the presence of sphenoid sinus pneumatization (SSP), and sphenoid sinus type (SST) were made on thin-cut CT scans from 60 patients (evenly grouped by ages 0-3, 4-7, 8-11 12-15, 16-18, and >18 years) for analysis. Data were analyzed by sex and age groups using t-tests and linear regression. RESULTS Sella and parasellar parameters did not differ by sex. SL steadily increased from 8.5 ± 1.2 mm to 11.5 ± 1.6 mm throughout development. SDp and SDm increased from 6.0 ± 0.9 mm to 9.3 ± 1.4 mm and 9.0 ± 1.6 mm to 14.4 ± 1.8 mm during maturation, with significant interval growth from ages 16-18 to adult (p < 0.01). ID displayed significant growth from ages 0-3 to 4-7 (18.0 ± 2.4 mm to 20.7 ± 1.9 mm; p = 0.002) and ICD from ages 0-3 to 8-11 (12.0 ± 1.8 mm to 13.5 ± 2.1 mm; p < 0.001), without further significant interval growth. SSP was not seen in patients < 3, but was 100% by ages 8-11. SSTs progressed from conchal/presellar (60% at ages 4-7) to sellar/postsellar (80% at adulthood). CONCLUSION The sella and parasellar regions have varied growth patterns with development. Knowledge of the expected maturation of key anterior skull base structures may augment surgical planning in younger patients.
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Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, University of California, San Diego, La Jolla, CA, United States
| | - Michael G Brandel
- Department of Neurological Surgery, University of California, San Diego, La Jolla, CA, United States
| | - Jeffrey A Steinberg
- Department of Neurological Surgery, University of California, San Diego, La Jolla, CA, United States
| | - Javan Nation
- Department of Head and Neck Surgery, University California San Diego, San Diego, CA, United States
| | - William T Couldwell
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, United States
| | | | - John D Day
- Department of Neurosurgery, University of Arkansas, Little Rock, AR, United States
| | - Alexander A Khalessi
- Department of Neurological Surgery, University of California, San Diego, La Jolla, CA, United States
| | - Michael L Levy
- Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, CA, United States.
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17
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Brandel MG, Rennert R, Steinberg J, Gonda DD, Levy ML. 375 Volume-Outcome Relationships in Pediatric Neurosurgery: An Analysis of the Kids’ Inpatient Database. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_375] [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: 11/19/2022] Open
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18
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Garancher A, Suzuki H, Haricharan S, Chau LQ, Masihi MB, Rusert JM, Norris PS, Carrette F, Romero MM, Morrissy SA, Skowron P, Cavalli FMG, Farooq H, Ramaswamy V, Jones SJM, Moore RA, Mungall AJ, Ma Y, Thiessen N, Li Y, Morcavallo A, Qi L, Kogiso M, Du Y, Baxter P, Henderson JJ, Crawford JR, Levy ML, Olson JM, Cho YJ, Deshpande AJ, Li XN, Chesler L, Marra MA, Wajant H, Becher OJ, Bradley LM, Ware CF, Taylor MD, Wechsler-Reya RJ. Retraction Note: Tumor necrosis factor overcomes immune evasion in p53-mutant medulloblastoma. Nat Neurosci 2021; 25:127. [PMID: 34907396 DOI: 10.1038/s41593-021-00994-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Alexandra Garancher
- Tumor Initiation & Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Hiromichi Suzuki
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Svasti Haricharan
- Tumor Microenvironment and Cancer Immunology Program, NCI-Designated Cancer Center and the Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Lianne Q Chau
- Tumor Initiation & Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Meher Beigi Masihi
- Tumor Initiation & Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Jessica M Rusert
- Tumor Initiation & Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Paula S Norris
- Tumor Microenvironment and Cancer Immunology Program, NCI-Designated Cancer Center and the Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Florent Carrette
- Tumor Microenvironment and Cancer Immunology Program, NCI-Designated Cancer Center and the Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Megan M Romero
- Department of Pediatrics, Northwestern University, Chicago, IL, USA
| | - Sorana A Morrissy
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada.,Dept. of Biochemistry and Molecular Biology, Charbonneau Cancer Institute, University of Calgary, Calgary, Alberta, Canada
| | - Patryk Skowron
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Florence M G Cavalli
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Hamza Farooq
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology and Department of Paediatrics, Hospital for Sick Children, Toronto, Canada
| | - Steven J M Jones
- Canada's Michael Smith Genome Sciences Centre, BC Cancer, Vancouver, Canada
| | - Richard A Moore
- Canada's Michael Smith Genome Sciences Centre, BC Cancer, Vancouver, Canada
| | - Andrew J Mungall
- Canada's Michael Smith Genome Sciences Centre, BC Cancer, Vancouver, Canada
| | - Yussanne Ma
- Canada's Michael Smith Genome Sciences Centre, BC Cancer, Vancouver, Canada
| | - Nina Thiessen
- Canada's Michael Smith Genome Sciences Centre, BC Cancer, Vancouver, Canada
| | - Yisu Li
- Canada's Michael Smith Genome Sciences Centre, BC Cancer, Vancouver, Canada
| | - Alaide Morcavallo
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Lin Qi
- Brain Tumor Program, Texas Children's Cancer Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Program of Precision Medicine PDOX Modeling of Pediatric Tumors, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University, Chicago, IL, USA
| | - Mari Kogiso
- Brain Tumor Program, Texas Children's Cancer Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Yuchen Du
- Brain Tumor Program, Texas Children's Cancer Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Program of Precision Medicine PDOX Modeling of Pediatric Tumors, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University, Chicago, IL, USA
| | - Patricia Baxter
- Brain Tumor Program, Texas Children's Cancer Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Jacob J Henderson
- Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
| | - John R Crawford
- Departments of Pediatrics and Neurosciences, University of California, San Diego - Rady Children's Hospital, San Diego, CA, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California San Diego - Rady Children's Hospital, San Diego, CA, USA
| | - James M Olson
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Yoon-Jae Cho
- Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
| | - Aniruddha J Deshpande
- Tumor Initiation & Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Xiao-Nan Li
- Brain Tumor Program, Texas Children's Cancer Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Program of Precision Medicine PDOX Modeling of Pediatric Tumors, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University, Chicago, IL, USA
| | - Louis Chesler
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Marco A Marra
- Canada's Michael Smith Genome Sciences Centre, BC Cancer, Vancouver, Canada
| | - Harald Wajant
- Division of Molecular Internal Medicine, Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Oren J Becher
- Department of Pediatrics, Northwestern University, Chicago, IL, USA
| | - Linda M Bradley
- Tumor Microenvironment and Cancer Immunology Program, NCI-Designated Cancer Center and the Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Carl F Ware
- Tumor Microenvironment and Cancer Immunology Program, NCI-Designated Cancer Center and the Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Michael D Taylor
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Robert J Wechsler-Reya
- Tumor Initiation & Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA.
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19
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Rennert RC, Kang KM, Santiago-Dieppa DR, Steinberg JA, Pannell JS, Olson SE, Levy ML. Microsurgical Resection of a Giant Posterior Fossa Aneurysmal Malformation in a 21-Month-Old. World Neurosurg 2021; 158:165. [PMID: 34844006 DOI: 10.1016/j.wneu.2021.11.088] [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: 08/25/2021] [Revised: 11/19/2021] [Accepted: 11/20/2021] [Indexed: 10/19/2022]
Abstract
Pediatric aneurysms commonly occur in the vertebrobasilar circulation with complex morphologies.1 "Aneurysmal malformations," or fistulous vessel dilations without a nidus, have also been described.2 Vessel friability and sensitivity to blood loss can complicate surgery. A 21-month-old male with motor and speech delay was found to have a giant posterior fossa aneurysmal malformation. He was lethargic, with minimal speech, and moved all extremities with mild hypotonia. Imaging demonstrated a 6.9 × 5.1 × 4.6 cm aneurysm arising from a fenestrated right V4 segment. This communicated via a single connection with the deep venous system, draining through the superior vermian cistern veins, posterior mesencephalic vein, basal vein of Galen, and inferior sagittal sinus, consistent with an arteriovenous fistula with secondary aneurysmal dilatation. Endovascular sacrifice was not feasible, in addition to concern for swelling after embolization. Three-dimensional modeling confirmed close proximity of the single inflow and outflow tracts. A suboccipital and left far lateral craniotomy for clip trapping and excision of the aneurysmal arteriovenous malformation was performed in a lateral position to completely decompress the brainstem (Video 1). Angiography before closure and postoperative vascular imaging demonstrated complete aneurysmal resection and fistula disconnection, with patency of normal vasculature. The postoperative course was notable for transient swallowing difficulties likely from lower cranial nerve irritation and refractory hydrocephalus requiring a shunt. The patient was meeting all developmental milestones at 2-year follow-up. This case highlights the complex vascular pathology often seen in pediatric patients, as well as the importance of presurgical planning and careful microsurgical technique in achieving a successful outcome.
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Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California, USA
| | - Keiko M Kang
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California, USA
| | - David R Santiago-Dieppa
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California, USA
| | - Jeffrey A Steinberg
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California, USA
| | - J Scott Pannell
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California, USA
| | - Scott E Olson
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California, USA
| | - Michael L Levy
- Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, California, USA.
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20
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Liu MA, Gendreau JL, Loya JJ, Brown NJ, Keith A, Sahyouni R, Abraham ME, Gonda D, Levy ML. Management of pediatric clival chordoma with extension to the craniocervical junction and occipito-cervical fusion: illustrative case. Journal of Neurosurgery: Case Lessons 2021; 2:CASE21434. [PMID: 36060426 PMCID: PMC9435547 DOI: 10.3171/case21434] [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] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/19/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Chordomas are rare malignant neoplasms that develop from the primitive notochord with < 5% of the tumors occurring in pediatric patients younger than the age of 20. Of these pediatric chordomas, those affecting the craniocervical junction (C1–C2) are even more rare; therefore, parameters for surgical management of these pediatric tumors are not well characterized. OBSERVATIONS In this case, a 3-year-old male was found to have a clival chordoma on imaging with extension to the craniocervical junction resulting in spinal cord compression. Endoscopic-assisted transoral transclival approach for clival tumor resection was performed first. As a second stage, the patient underwent a left-sided far lateral craniotomy and cervical laminectomy for resection of the skull base chordoma and instrumented fusion of the occiput to C3. He made excellent improvements in strength and dexterity during rehab and was discharged after 3 weeks. LESSONS In pediatric patients with chordoma with extension to the craniocervical junction and spinal cord compression, decompression with additional occipito-cervical fusion appears to offer a good clinical outcome. Fusion performed as a separate surgery before or at the same time as the initial tumor resection surgery may lead to better outcomes.
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Affiliation(s)
- Matthew A. Liu
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Julian L. Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland
| | - Joshua J. Loya
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Nolan J. Brown
- Department of Neurosurgery, University of California Irvine, Orange, California; and
| | - Amber Keith
- Department of Neurosurgery, University of California Irvine, Orange, California; and
| | - Ronald Sahyouni
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Mickey E. Abraham
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - David Gonda
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
- Rady Children’s Hospital San Diego, California
| | - Michael L. Levy
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
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21
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Sun S, Mo JQ, Levy ML, Crawford J. Atypical Giant Suprasellar Prolactinoma Presenting With Visual Field Changes in the Absence of Symptoms of Hyperprolactinemia. Cureus 2021; 13:e19632. [PMID: 34926083 PMCID: PMC8673687 DOI: 10.7759/cureus.19632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 11/25/2022] Open
Abstract
Prolactinomas are benign tumors that make up the majority of all pituitary adenoma cases and present most commonly in women. Prolactinomas presenting in adolescents and children, however, are extremely rare. We report a case of a 17-year-old male who presented with a six-month history of headaches and a previously unrecognized visual field deficit on examination. Neuroimaging revealed a large suprasellar tumor with imaging, more characteristic of a craniopharyngioma or suprasellar low-grade glioma impinging, on the left intracranial optic nerve causing right-sided hemianopsia. Due to the extensive mass effect and bitemporal hemianopsia on examination, the decision to proceed with initial surgical debulking was made following informed consent. A subtotal resection was performed where the pathology was consistent with a prolactinoma that correlated with markedly elevated prolactin (PRL) levels obtained pre and post-operatively that have not resulted until five days post procedure. The patient was subsequently treated with dopamine agonist (DA) cabergoline therapy and is now five-years disease-free with normal neurological examination and no residual tumor on neuroimaging. DA therapy has shown high clinical efficacy and should be considered prior to any surgical intervention; however, extensive mass effect may appropriate surgical debulking to increase therapy efficacy. Our case highlights an atypical appearance of a giant prolactinoma that may mimic other more common suprasellar tumors, a presentation associated with unrecognized visual field deficits, and the importance of rapid turnaround testing for serum PRL that may aid in the upfront diagnosis and management of prolactinomas.
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22
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Rennert RC, Brandel MG, Steinberg JA, Gonda DD, Friedman RA, Fukushima T, Day JD, Khalessi AA, Levy ML. Maturation of the anterior petrous apex: surgical relevance for performance of the middle fossa transpetrosal approach in pediatric patients. J Neurosurg 2021:1-7. [PMID: 34534955 DOI: 10.3171/2021.3.jns202648] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 03/24/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The middle fossa transpetrosal approach to the petroclival and posterior cavernous sinus regions includes removal of the anterior petrous apex (APA), an area well studied in adults but not in children. To this end, the authors performed a morphometric analysis of the APA region during pediatric maturation. METHODS Measurements of the distance from the clivus to the internal auditory canal (IAC; C-IAC), the distance of the petrous segment of the internal carotid artery (petrous carotid; PC) to the mesial petrous bone (MPB; PC-MPB), the distance of the PC to the mesial petrous apex (MPA; PC-MPA), and the IAC depth from the middle fossa floor (IAC-D) were made on thin-cut CT scans from 60 patients (distributed across ages 0-3, 4-7, 8-11, 12-15, 16-18, and > 18 years). The APA volume was calculated as a cylinder using C-IAC (length) and PC-MPB (diameter). APA pneumatization was noted. Data were analyzed by laterality, sex, and age. RESULTS APA parameters did not differ by laterality or sex. APA pneumatization was seen on 20 of 60 scans (33.3%) in patients ≥ 4 years. The majority of the APA region growth occurred by ages 8-11 years, with PC-MPA and PC-MPB increasing 15.9% (from 9.4 to 10.9 mm, p = 0.08) and 23.5% (from 8.9 to 11.0 mm, p < 0.01) between ages 0-3 and 8-11 years, and C-IAC increasing 20.7% (from 13.0 to 15.7 mm, p < 0.01) between ages 0-3 and 4-7 years. APA volume increased 79.6% from ages 0-3 to 8-11 years (from 834.3 to 1499.2 mm3, p < 0.01). None of these parameters displayed further significant growth. Finally, IAC-D increased 51.1% (from 4.3 to 6.5 mm, p < 0.01) between ages 0-3 and adult, without significant differences between successive age groups. CONCLUSIONS APA development is largely complete by the ages of 8-11 years. Knowledge of APA growth patterns may aid approach selection and APA removal in pediatric patients.
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Affiliation(s)
- Robert C Rennert
- 1Department of Neurological Surgery, University of California, San Diego, La Jolla
| | - Michael G Brandel
- 1Department of Neurological Surgery, University of California, San Diego, La Jolla
| | - Jeffrey A Steinberg
- 1Department of Neurological Surgery, University of California, San Diego, La Jolla
| | - David D Gonda
- 2Department of Neurosciences and Pediatrics, University of California, San Diego, San Diego
| | - Rick A Friedman
- 3Department of Surgery, Division of Otolaryngology, Head and Neck Surgery, University of California, San Diego, La Jolla, California
| | | | - John D Day
- 5Department of Neurosurgery, University of Arkansas, Little Rock, Arkansas
| | - Alexander A Khalessi
- 1Department of Neurological Surgery, University of California, San Diego, La Jolla
| | - Michael L Levy
- 2Department of Neurosciences and Pediatrics, University of California, San Diego, San Diego
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23
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Jandial R, Narang P, Brun JD, Levy ML. Optimizing international neurosurgical outreach missions: 15-year appraisal of operative skill transfer in Lima, Peru. Surg Neurol Int 2021; 12:425. [PMID: 34513188 PMCID: PMC8422466 DOI: 10.25259/sni_241_2021] [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: 03/09/2021] [Accepted: 05/12/2021] [Indexed: 11/24/2022] Open
Abstract
Background: While several medical outreach models have been designed and executed to alleviate the unmet need for international neurosurgical care, disparate strategies have evolved. There is a need to determine the optimal pediatric neurosurgical outreach model through which resources are efficiently utilized while imparting the largest possible impact on global health. This study evaluates the efficacy of an international pediatric neurosurgery outreach model at transferring operative skill in a sustainable and scalable manner in Lima, Peru over a 15-year duration. Methods: Three 1-week neurosurgical missions were carried out (2004–2006) in Lima, Peru to teach neuroendoscopic techniques and to provide equipment to host neurosurgeons, equipping the hosts to provide care to indigent citizens beyond the duration of the missions. Follow-up data were obtained over a 15 year span, with collaboration maintained over email, two in-person visits, and video-conferencing services. Results: Since the outreach missions in 2004–2006, the host neurosurgeons demonstrated sustainability of the neuroendoscopic instruction by independently performing neuroendoscopic operations on a growing caseload: at baseline, 0 cases were performed in 2003, but since 2012 and onwards, 40–45 cases have been performed annually. Scalability is illustrated by the fact that the institution established a rigorous neuroendoscopy training program to independently pass on the techniques to resident physicians. Conclusion: The described international pediatric neurosurgical outreach model, centered around teaching operative technique as opposed to solely providing care to citizens, allowed operative skill to be sustainably transferred to surgeons in Lima, Peru. Having served the neuroendoscopic needs of hundreds of citizens, the strategic design is replicable and should be mirrored by future medical endeavors seeking to substantially impact the deficit in global surgical care.
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Affiliation(s)
- Rahul Jandial
- Division of Neurosurgery, City of Hope National Medical Center, Los Angeles, California, United States
| | - Pranay Narang
- Halmos College of Natural Sciences and Oceanography, Nova Southeastern University, Fort Lauderdale, Florida, United States
| | - Jorge Daniel Brun
- Department of Neurological Surgery, Hospital Del Nino, Murillo, Bolivia
| | - Michael L Levy
- Department of Pediatric Neurosurgery, University of California San Diego, San Diego, California, United States
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24
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Rennert RC, Brandel MG, Srinivas S, Prajapati D, Al Jammal OM, Brown NJ, Diaz-Aguilar LD, Elster J, Gonda DD, Crawford JR, Levy ML. Palliative endoscopic third ventriculostomy for pediatric primary brain tumors: a single-institution case series. J Neurosurg Pediatr 2021; 28:387-394. [PMID: 34359046 DOI: 10.3171/2021.3.peds20952] [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: 12/06/2020] [Accepted: 03/29/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Children with nonoperative brain tumors, such as diffuse intrinsic pontine gliomas (DIPGs), often have life-threatening hydrocephalus. Palliative shunting is common in such cases but can be complicated by hardware infection and mechanical failure. Endoscopic third ventriculostomy (ETV) is a minimally invasive alternative to treat hydrocephalus without implanted hardware. Herein, the authors report their institutional experience with palliative ETV for primary pediatric brain tumors. METHODS The authors conducted a retrospective review of consecutive patients who had undergone palliative ETV for hydrocephalus secondary to nonresectable primary brain tumors over a 10-year period at Rady Children's Hospital. Collected variables included age, sex, tumor type, tumor location, presence of leptomeningeal spread, use of a robot for ETV, complications, ETV Success Score (ETVSS), functional status, length of survival, and follow-up time. A successful outcome was defined as an ETV performed without clinically significant perioperative complications or secondary requirement for a new shunt. RESULTS Fifteen patients met the study inclusion criteria (11 males, 4 females; average age 7.9 years, range 0.8-21 years). Thirteen patients underwent manual ETV, and 2 patients underwent robotic ETV. Preoperative symptoms included gaze palsy, nausea/vomiting, headache, lethargy, hemiparesis, and seizures. Tumor types included DIPG (3), intraventricular/thalamic glioblastoma (2), and leptomeningeal spread of medulloblastoma (2), anaplastic oligo-/astrocytoma (2), rhabdoid tumor (2), primitive neuroectodermal tumor (1), ganglioglioma (1), pineoblastoma (1), and embryonal carcinoma (1). The mean preoperative ETVSS was 79 ± 8.8. There was 1 perioperative complication, a wound breakdown consistent with refractory hydrocephalus. The mean follow-up was 4.9 ± 5.5 months overall, and mean survival for the patients who died was 3.2 ± 3.6 months. Two patients remained alive at a mean follow-up of 15.7 months. Palliative ETV was successful in 7 patients (47%) and unsuccessful in 8 (53%). While patients with successful ETV were significantly older (11.9 ± 5.6 vs 4.4 ± 4.1 years, p = 0.010), there were no significant differences in preoperative ETVSS (p = 0.796) or postoperative survival (p = 0.476) between the successful and unsuccessful groups. Overall, functional outcomes were similar between the two groups; there was no significant difference in posttreatment Karnofsky Performance Status scores (68.6 ± 19.5 vs 61.3 ± 16.3, p = 0.454), suggesting that including ETV in the treatment algorithm did not worsen outcomes. CONCLUSIONS Palliative ETV is a safe and potentially efficacious treatment option in selected pediatric patients with hydrocephalus from nonoperative brain tumors. Close follow-up, especially in younger children, is required to ensure that patients with refractory symptoms receive appropriate secondary CSF diversion.
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Affiliation(s)
| | | | | | | | | | | | | | - Jennifer Elster
- 3Pediatrics, University of California San Diego, La Jolla; and.,4Rady Children's Hospital, San Diego, California
| | - David D Gonda
- Departments of1Neurological Surgery and.,2Neurosciences, and
| | - John R Crawford
- 2Neurosciences, and.,3Pediatrics, University of California San Diego, La Jolla; and
| | - Michael L Levy
- Departments of1Neurological Surgery and.,2Neurosciences, and
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Aristizabal P, Burns LP, Kumar NV, Perdomo BP, Rivera-Gomez R, Ornelas MA, Gonda D, Malicki D, Thornburg CD, Roberts W, Levy ML, Crawford JR. Improving Pediatric Neuro-Oncology Survival Disparities in the United States-Mexico Border Region: A Cross-Border Initiative Between San Diego, California, and Tijuana, Mexico. JCO Glob Oncol 2021; 6:1791-1802. [PMID: 33216645 PMCID: PMC7713516 DOI: 10.1200/go.20.00377] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Treatment of children with CNS tumors (CNSTs) demands a complex, interdisciplinary approach that is rarely available in low- and middle-income countries. We established the Cross-Border Neuro-Oncology Program (CBNP) between Rady Children's Hospital, San Diego (RCHSD), and Hospital General, Tijuana (HGT), Mexico, to provide access to neuro-oncology care, including neurosurgic services, for children with CNSTs diagnosed at HGT. Our purpose was to assess the feasibility of the CBNP across the United States-Mexico border and improve survival for children with CNSTs at HGT by implementing the CBNP. PATIENTS AND METHODS We prospectively assessed clinicopathologic profiles, the extent of resection, progression-free survival, and overall survival (OS) in children with CNSTs at HGT from 2010 to 2017. RESULTS Sixty patients with CNSTs participated in the CBNP during the study period. The most common diagnoses were low-grade glioma (24.5%) and medulloblastoma (22.4%). Of patients who were eligible for surgery, 49 underwent resection at RCHSD and returned to HGT for collaborative management. Gross total resection was achieved in 78% of cases at RCHSD compared with 0% at HGT (P < .001) and was a predictor of 5-year OS (hazard ratio, 0.250; 95% CI, 0.067 to 0.934; P = .024). Five-year OS improved from 0% before 2010 to 52% in 2017. CONCLUSION The CBNP facilitated access to complex neuro-oncology care for underserved children in Mexico through binational exchanges of resources and expertise. Survival for patients in the CBNP dramatically improved. Gross total resection at RCHSD was associated with higher OS, highlighting the critical role of experienced neurosurgeons in the treatment of CNSTs. The CBNP model offers an attractive alternative for children with CNSTs in low- and middle-income countries who require complex neuro-oncology care, particularly those in close proximity to institutions in high-income countries with extensive neuro-oncology expertise.
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Affiliation(s)
- Paula Aristizabal
- Peckham Center for Cancer and Blood Disorders, Rady Children's Hospital San Diego, San Diego, CA.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of California, San Diego, La Jolla, CA.,Population Sciences, Disparities and Community Engagement, Moores Cancer Center, University of California, San Diego, La Jolla, CA
| | - Luke P Burns
- School of Medicine, University of California, San Diego, La Jolla, CA
| | - Nikhil V Kumar
- School of Medicine, University of California, San Diego, La Jolla, CA
| | - Bianca P Perdomo
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of California, San Diego, La Jolla, CA
| | - Rebeca Rivera-Gomez
- Hospital General de Tijuana/Universidad Autónoma de Baja California Tijuana, Baja California, Mexico
| | - Mario A Ornelas
- Hospital General de Tijuana/Universidad Autónoma de Baja California Tijuana, Baja California, Mexico
| | - David Gonda
- Department of Neurosciences, University of California, San Diego, La Jolla, CA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California, San Diego, La Jolla, CA
| | - Denise Malicki
- Department of Pathology, University of California, San Diego, La Jolla, CA
| | - Courtney D Thornburg
- Peckham Center for Cancer and Blood Disorders, Rady Children's Hospital San Diego, San Diego, CA.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of California, San Diego, La Jolla, CA
| | - William Roberts
- Peckham Center for Cancer and Blood Disorders, Rady Children's Hospital San Diego, San Diego, CA.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of California, San Diego, La Jolla, CA
| | - Michael L Levy
- Department of Neurosciences, University of California, San Diego, La Jolla, CA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California, San Diego, La Jolla, CA
| | - John R Crawford
- Peckham Center for Cancer and Blood Disorders, Rady Children's Hospital San Diego, San Diego, CA.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of California, San Diego, La Jolla, CA.,Department of Neurosciences, University of California, San Diego, La Jolla, CA.,Division of Pediatric Neurology, Department of Pediatrics, University of California San Diego, La Jolla, CA
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26
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Rennert RC, Brandel MG, Steinberg JA, Martin JR, Gonda DD, Fukushima T, Day JD, Khalessi AA, Levy ML. Surgical Relevance of Pediatric Anterior Clinoid Process Maturation for Anterior Skull Base Approaches. Oper Neurosurg (Hagerstown) 2021; 20:E200-E207. [PMID: 33372959 DOI: 10.1093/ons/opaa374] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 09/06/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Removal of the anterior clinoid process (ACP) can expand anterior skull base surgical corridors. ACP development and anatomical variations are poorly defined in children. OBJECTIVE To perform a morphometric analysis of the ACP during pediatric maturation. METHODS Measurements of ACP base thickness (ACP-BT), midpoint thickness (ACP-MT), length (ACP-L), length from optic strut to ACP tip (ACP-OS), pneumatization (ACP-pneumo), and the presence of an ossified carotico-clinoid ligament (OCCL) or interclinoid ligament (OIL) were made from high-resolution computed-tomography scans from 60 patients (ages 0-3, 4-7, 8-11 12-15, 16-18, and >18 yr). Data were analyzed by laterality, sex, and age groups using t-tests and linear regression. RESULTS There were no significant differences in ACP parameters by laterality or sex, and no significant growth in ACP-BT or ACP-MT during development. From ages 0-3 yr to adult, mean ACP-L increased 49%, from 7.7 to 11.5 mm. The majority of ACP-L growth occurred in 2 phases between ages 0-3 to 8-11 and ages 16-18 to adult. Conversely, ACP-OS was stable from ages 0-3 to 8-11 but increased by 63% between ages 8-11 to adult. Variations in ACP morphology (OCCL/OIL/ACP-pneumo) were found in 15% (9/60) of scans. OCCL and OIL occurred in patients as young as 3 yrs, whereas ACP-pneumo was not seen in patients younger than 11 yrs. CONCLUSION The ACP demonstrates stable thickness and a complex triphasic elongation and remodeling pattern with development, the understanding of which may facilitate removal in patients <12. Clinically relevant ACP anatomic variations can occur at any age.
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Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - Michael G Brandel
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - Jeffrey A Steinberg
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - Joel R Martin
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - David D Gonda
- Department of Neurosciences and Pediatrics, University of California, San Diego, San Diego, California
| | | | - John D Day
- Department of Neurosurgery, University of Arkansas, Little Rock, Arkansas
| | - Alexander A Khalessi
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - Michael L Levy
- Department of Neurosciences and Pediatrics, University of California, San Diego, San Diego, California
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Ramien ML, Bahubeshi A, Lara-Corrales I, Pope E, Levy ML, Nopper AJ, Shear NH, Eichenfield L. Blistering severe cutaneous adverse reactions in children: proposal for paediatric-focused clinical criteria. Br J Dermatol 2021; 185:447-449. [PMID: 33730370 DOI: 10.1111/bjd.20063] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 02/23/2021] [Accepted: 03/14/2021] [Indexed: 11/29/2022]
Affiliation(s)
- M L Ramien
- Division of Community Pediatrics, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada.,Division of Dermatology, Department of Medicine, University of Calgary, Calgary, AB, Canada.,University of Ottawa, Ottawa, ON, Canada
| | | | - I Lara-Corrales
- Section of Paediatric Dermatology, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - E Pope
- Section of Paediatric Dermatology, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - M L Levy
- Department of Pediatrics and Medicine (Dermatology), Dell Medical School, University of Texas, Austin, TX, USA.,Pediatric/Adolescent Dermatology, Dell Children's Medical Center, Austin, TX, USA
| | - A J Nopper
- Division of Dermatology, Children's Mercy-Kansas City, Kansas City, MO, USA
| | - N H Shear
- Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - L Eichenfield
- Division of Pediatric and Adolescent Dermatology, Rady Children's Hospital, San Diego, CA, USA.,Departments of Dermatology and Pediatrics, University of California, San Diego School of Medicine, University of California, San Diego, CA, USA
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28
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Steinberg JA, Brandel MG, Kang KM, Rennert RC, Pannell JS, Olson SE, Gonda DD, Khalessi AA, Levy ML. Arteriovenous malformation surgery in children: the Rady Children's Hospital experience (2002-2019). Childs Nerv Syst 2021; 37:1267-1277. [PMID: 33404725 DOI: 10.1007/s00381-020-04994-9] [Citation(s) in RCA: 3] [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: 08/19/2020] [Accepted: 11/30/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Compared to adult AVMs, there is a paucity of data on the microsurgical treatment of pediatric AVMs. We report our institutional experience with pediatric AVMs treated by microsurgical resection with or without endovascular embolization and radiation therapy. METHODS We retrospectively reviewed all patients ≤ 18 years of age with cerebral AVMs that underwent microsurgical resection at Rady Children's Hospital 2002-2019. RESULTS Eighty-nine patients met inclusion criteria. The mean age was 10.3 ± 5.0 years, and 56% of patients were male. In total, 72 (81%) patients presented with rupture. Patients with unruptured AVMs presented with headache (n = 5, 29.4%), seizure (n = 9, 52.9%), or incidental finding (n = 3, 17.7%). The mean presenting mRS was 2.8 ± 1.8. AVM location was lobar in 78%, cerebellar/brainstem in 15%, and deep supratentorial in 8%. Spetzler-Martin grade was I in 28%, II in 45%, III in 20%, IV in 6%, and V in 1%. Preoperative embolization was utilized in 38% of patients and more frequently in unruptured than ruptured AVMs (62% vs. 32%, p = 0.022). Radiographic obliteration was achieved in 76/89 (85.4%) patients. Complications occurred in 7 (8%) patients. Annualized rates of delayed rebleeding and recurrence were 1.2% and 0.9%, respectively. The mean follow-up was 2.8 ± 3.1 years. A good neurological outcome (mRS score ≤ 2) was obtained in 80.9% of patients at last follow-up and was improved relative to presentation for 75% of patients. CONCLUSIONS Our case series demonstrates high rates of radiographic obliteration and relatively low incidence of neurologic complications of treatment or AVM recurrence.
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Affiliation(s)
- Jeffrey A Steinberg
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Michael G Brandel
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Keiko M Kang
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Robert C Rennert
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - J Scott Pannell
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Scott E Olson
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - David D Gonda
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA.,Division of Pediatric Neurosurgery, Rady Children's Hospital, San Diego, CA, USA
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA. .,Division of Pediatric Neurosurgery, Rady Children's Hospital, San Diego, CA, USA.
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29
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Wong A, Wali AR, Ryba B, Gupta M, Levy ML, Gosman AA. Rotation flap distraction osteogenesis for unicoronal synostosis. Neurosurgical Focus: Video 2021; 4:V16. [PMID: 36284847 PMCID: PMC9542226 DOI: 10.3171/2021.1.focvid20124] [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] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/20/2021] [Indexed: 11/06/2022]
Abstract
Unicoronal craniosynostosis is notoriously difficult to treat, with long-term studies demonstrating high rates of relapse and the need for reoperation using open fronto-orbital advancement. Applying the principles of distraction osteogenesis to cranial vault remodeling has demonstrated promising short-term results that compare favorably with traditional methods, with simultaneous correction of both frontofacial and endocranial morphology, along with significant increases in intracranial volume. Here, the authors demonstrate their technique for rotation flap distraction osteogenesis in the treatment of unicoronal synostosis and provide case examples.
The video can be found here: https://vimeo.com/519505008.
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Affiliation(s)
- Alvin Wong
- Divisions of Plastic Surgery and
- Rady Children's Hospital, San Diego; and
| | - Arvin R. Wali
- Neurosurgery, Department of Surgery, University of California, San Diego
| | - Bryan Ryba
- University of San Diego School of Medicine, San Diego, California
| | - Mihir Gupta
- Neurosurgery, Department of Surgery, University of California, San Diego
| | - Michael L. Levy
- Rady Children's Hospital, San Diego; and
- Neurosurgery, Department of Surgery, University of California, San Diego
| | - Amanda A. Gosman
- Divisions of Plastic Surgery and
- Rady Children's Hospital, San Diego; and
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30
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Pehlivan KC, Khanna PC, Elster JD, Paul MR, Levy ML, Crawford JR, Gonda DD. Clinical and Neuroimaging Features of Magnetic Resonance-Guided Stereotactic Laser Ablation for Newly Diagnosed and Recurrent Pediatric Brain Tumors: A Single Institutional Series. World Neurosurg 2021; 150:e378-e387. [PMID: 33722713 DOI: 10.1016/j.wneu.2021.03.027] [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: 11/11/2020] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We describe our single-institutional experience with magnetic resonance-guided stereotactic laser ablation (SLA) for the treatment of newly diagnosed and recurrent pediatric brain tumors. METHODS Eighteen consecutive ablation procedures were performed in 17 patients from March 2016-April 2020. Patient demographics, indications, procedures, neuroimaging features, and outcomes were reviewed retrospectively. RESULTS Seventeen patients (mean age of 11.4 years, 11 boys, 6 girls) underwent SLA with a mean follow-up of 24 months (range: 3-45 months). Tumor histologies included pilocytic astrocytoma (n = 5), ganglioglioma (n = 3), low-grade glioma not otherwise specified (n = 4), glioblastoma (n = 2), meningioma (n = 1), medulloblastoma (n = 1), and metastatic malignant peripheral nerve sheath tumor (n = 1). SLA was first-line therapy in 10 patients. Mean procedure duration including anesthesia time was 328 minutes (range: 244-529 minutes), and mean postoperative length of stay was 1.5 days (range 1-5 days). The complication rate was 29%, which included 3 patients who experienced postoperative motor changes, which resolved within several weeks of surgery, 1 patient with self-limited intraoperative bradycardia and hypotension, and 1 patient who died postoperatively due to intracranial hemorrhage from a distant lesion. Twelve of 17 patients had a neuroimaging response after SLA (4 complete responses, 8 partial responses, 1 stable disease). Percentage of tumor shrinkage from baseline ranged from 33%-100% (mean 75%). Patients with low-grade glioma exhibited the best responses to SLA (range 3%-100% decrease; mean 90%; 36% complete response rate). CONCLUSIONS SLA is a minimally invasive modality for the treatment of newly diagnosed and recurrent low-grade pediatric brain tumors. Low-grade glioma exhibited the best responses. Identification of ideal candidates for SLA, mitigation of perioperative complications, and demonstration of long-term outcomes need to be better defined in a clinical trial setting.
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Affiliation(s)
- Katherine C Pehlivan
- Department of Neurosciences, University of California San Diego, La Jolla, California, USA; Rady Children's Hospital, San Diego, California, USA
| | - Paritosh C Khanna
- Department of Radiology, University of California San Diego, La Jolla, California, USA; Rady Children's Hospital, San Diego, California, USA
| | - Jennifer D Elster
- Department of Pediatrics, University of California San Diego, La Jolla, California, USA; Rady Children's Hospital, San Diego, California, USA
| | - Megan Rose Paul
- Department of Neurosciences, University of California San Diego, La Jolla, California, USA; Rady Children's Hospital, San Diego, California, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California San Diego, La Jolla, California, USA; Rady Children's Hospital, San Diego, California, USA
| | - John R Crawford
- Department of Neurosciences, University of California San Diego, La Jolla, California, USA; Department of Pediatrics, University of California San Diego, La Jolla, California, USA; Rady Children's Hospital, San Diego, California, USA.
| | - David D Gonda
- Department of Neurosurgery, University of California San Diego, La Jolla, California, USA; Rady Children's Hospital, San Diego, California, USA
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Yang JH, Tucker SM, Levy ML, Crawford JR. Rare case of BRAF V600E mutant anaplastic pleomorphic xanthroastrocytoma in a 5-year survivor of acute lymphoblastic leukaemia. BMJ Case Rep 2021; 14:14/2/e241815. [PMID: 33637515 PMCID: PMC7919580 DOI: 10.1136/bcr-2021-241815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Jennifer H Yang
- Department of Neuroscienes, University of California San Diego, La Jolla, California, USA
| | - Suzanne M Tucker
- Department of Pathology, Rady Children's Hospital, San Diego, California, USA
| | - Michael L Levy
- Neurosurgery, University of California San Diego, San Diego, California, USA
| | - John Ross Crawford
- Neurosciences and Pediatrics, University of California San Diego, La Jolla, California, USA
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Yang JH, Malicki DM, Levy ML, Crawford JR. Unusual case of occipital lobe dysembryoplastic neuroepithelial tumour with GNAi1-BRAF fusion. BMJ Case Rep 2021; 14:14/1/e241440. [PMID: 33504544 PMCID: PMC7843307 DOI: 10.1136/bcr-2020-241440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- Jennifer H Yang
- Department of Neurosciences, University of California San Diego, La Jolla, California, USA
| | - Denise M Malicki
- Pathology, Rady Children's Hospital University of California San Diego, San Diego, California, USA
| | - Michael L Levy
- Neurosurgery, University of California San Diego, San Diego, California, USA
| | - John Ross Crawford
- Neurosciences and Pediatrics, University of California San Diego, La Jolla, California, USA
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Schaerer D, Nation J, Rennert RC, DeConde A, Levy ML. Pediatric Nasal Chondromesenchymal Tumors: Case Report and Review of the Literature. Pediatr Neurosurg 2021; 56:61-66. [PMID: 33571989 PMCID: PMC7969402 DOI: 10.1159/000512717] [Citation(s) in RCA: 3] [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: 10/01/2019] [Accepted: 10/16/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Nasal chondromesenchymal tumors (NCMT) are rare benign neoplasms that usually present in children <1 year of age. They can display rapid growth and significant local bony remodeling that can mimic a malignant process. Of the ∼50 published cases to date, few have documented the need for neurosurgical intervention. We herein report a NCMT in an infant treated with a staged cranial and transnasal approach, as well as summarize the available literature on this pathology. CASE REPORT A newborn male with a compromised airway was noted to have a large sinonasal lesion. After stabilization, MRI demonstrated a 4-cm enhancing mass with diffuse sinus involvement and significant extension into the anterior cranial fossa, with displacement of the optic apparatus and hypothalamic pituitary axis. After an initial biopsy, the patient underwent a bifrontal craniofacial approach at 2 months of age, followed by a second-stage transnasal endoscopic approach at 15 months which resulted in a complete resection. There were no neurosurgical complications. Pathology was consistent with a NCMT. DISCUSSION Although rare, neurosurgical involvement is critical for the treatment of NCMTs with intracranial extension. Staged cranial and endonasal endoscopic approaches may be needed for complete resection of such lesions.
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Affiliation(s)
- Daniel Schaerer
- Department of Head and Neck Surgery, University California San Diego, San Diego, California, USA
| | - Javan Nation
- Department of Head and Neck Surgery, University California San Diego, San Diego, California, USA
| | - Robert C Rennert
- Department of Neurosurgery, University California San Diego, San Diego, California, USA
| | - Adam DeConde
- Department of Head and Neck Surgery, University California San Diego, San Diego, California, USA
| | - Michael L Levy
- Department of Neurosurgery, University California San Diego, San Diego, California, USA, .,Rady Children's Hospital of San Diego, San Diego, California, USA,
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Oviedo P, Zamora S, Vinocur D, Levy ML, Nation J. Influence of Pediatric Endoscopic Endonasal Skull Base Resections on Midface and Skull Base Development. Pediatr Neurosurg 2021; 56:345-356. [PMID: 34010830 DOI: 10.1159/000516236] [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: 06/02/2020] [Accepted: 03/27/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of this study is to use imaging data to determine if endoscopic endonasal surgery (EES) for skull base tumor resection interrupts skull base growth and development, resulting in an atrophic midface skeletal structure, compared to matched normal controls. METHODS Data were collected by a retrospective chart review done on children aged 16 years and below who underwent endoscopic tumor resection and had pre- and postoperative magnetic resonance imaging with relevant midface anatomy. 121 normal controls were matched to 20 EES patients by age and gender. Three measurements related to midface anatomy were taken from 1 sagittal T1 slice and 1 axial T2 slice of each scan. Statistical analysis was used to compare growth measures between cases and controls. RESULTS Twenty patients who underwent EES between November 2015 and April 2018 met our inclusion criteria. The mean age of the patients, 11 males and 9 females, was 10 years, and 8 patients (38%) were aged 7 years or younger. Six patients who had a high-flow CSF leak obtained a nasoseptal flap. A student T test and multivariate regression analysis found that EES did not affect midface and skull base growth. Among the variables assessed, age appears to be the only driver of growth. CONCLUSION There were no identified differences in craniofacial growth in pediatric patients undergoing EES for skull base tumor resection as compared to the control group. EES does not appear to significantly interfere with midface/skull base development and is a good surgical option for pediatric patients.
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Affiliation(s)
- Parisa Oviedo
- University of California San Diego School of Medicine, La Jolla, California, USA
| | - Steven Zamora
- Division of Pediatric Otolaryngology, Rady Children's Hospital San Diego, San Diego, California, USA
| | - Daniel Vinocur
- University of California San Diego School of Medicine, La Jolla, California, USA.,Division of Pediatric Radiology, Rady Children's Hospital San Diego, San Diego, California, USA
| | - Michael L Levy
- University of California San Diego School of Medicine, La Jolla, California, USA.,Division of Pediatric Neurosurgery, Rady Children's Hospital San Diego, San Diego, California, USA
| | - Javan Nation
- University of California San Diego School of Medicine, La Jolla, California, USA.,Division of Pediatric Otolaryngology, Rady Children's Hospital San Diego, San Diego, California, USA.,Division of Otolarngology/Head and Neck Surgery, University of California San Diego, San Diego, California, USA
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35
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Gupta M, Chan TM, Santiago-Dieppa DR, Yekula A, Sanchez CE, Elster JD, Crawford JR, Levy ML, Gonda DD. Robot-assisted stereotactic biopsy of pediatric brainstem and thalamic lesions. J Neurosurg Pediatr 2020; 27:317-324. [PMID: 33361479 DOI: 10.3171/2020.7.peds20373] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 05/19/2020] [Accepted: 07/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Biopsies of tumors located in deep midline structures require highly accurate stereotaxy to safely obtain lesional tissue suitable for molecular and histological analysis. Versatile platforms are needed to meet a broad range of technical requirements and surgeon preferences. The authors present their institutional experience with the robotic stereotactic assistance (ROSA) system in a series of robot-assisted biopsies of pediatric brainstem and thalamic tumors. METHODS A retrospective analysis was performed of 22 consecutive patients who underwent 23 stereotactic biopsies of brainstem or thalamic lesions using the ROSA platform at Rady Children's Hospital in San Diego between December 2015 and January 2020. RESULTS The ROSA platform enabled rapid acquisition of lesional tissue across various combinations of approaches, registration techniques, and positioning. No permanent deficits, major adverse outcomes, or deaths were encountered. One patient experienced temporary cranial neuropathy, and 3 developed small asymptomatic hematomas. The diagnostic success rate of the ROSA system was 91.3%. CONCLUSIONS Robot-assisted stereotactic biopsy of these lesions may be safely performed using the ROSA platform. This experience comprises the largest clinical series to date dedicated to robot-assisted biopsies of brainstem and diencephalic tumors.
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Affiliation(s)
- Mihir Gupta
- 1Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Tiffany M Chan
- 2Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | | - Anudeep Yekula
- 3Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Carlos E Sanchez
- 4Department of Neurosurgery, Children's National Health System, Washington, DC; and
| | | | | | - Michael L Levy
- 1Department of Neurosurgery, University of California, San Diego, La Jolla, California.,6Division of Neurosurgery, Rady Children's Hospital, San Diego, California
| | - David D Gonda
- 1Department of Neurosurgery, University of California, San Diego, La Jolla, California.,6Division of Neurosurgery, Rady Children's Hospital, San Diego, California
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36
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Rusert JM, Juarez EF, Brabetz S, Jensen J, Garancher A, Chau LQ, Tacheva-Grigorova SK, Wahab S, Udaka YT, Finlay D, Seker-Cin H, Reardon B, Gröbner S, Serrano J, Ecker J, Qi L, Kogiso M, Du Y, Baxter PA, Henderson JJ, Berens ME, Vuori K, Milde T, Cho YJ, Li XN, Olson JM, Reyes I, Snuderl M, Wong TC, Dimmock DP, Nahas SA, Malicki D, Crawford JR, Levy ML, Van Allen EM, Pfister SM, Tamayo P, Kool M, Mesirov JP, Wechsler-Reya RJ. Functional Precision Medicine Identifies New Therapeutic Candidates for Medulloblastoma. Cancer Res 2020; 80:5393-5407. [PMID: 33046443 DOI: 10.1158/0008-5472.can-20-1655] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 09/04/2020] [Accepted: 10/07/2020] [Indexed: 12/14/2022]
Abstract
Medulloblastoma is among the most common malignant brain tumors in children. Recent studies have identified at least four subgroups of the disease that differ in terms of molecular characteristics and patient outcomes. Despite this heterogeneity, most patients with medulloblastoma receive similar therapies, including surgery, radiation, and intensive chemotherapy. Although these treatments prolong survival, many patients still die from the disease and survivors suffer severe long-term side effects from therapy. We hypothesize that each patient with medulloblastoma is sensitive to different therapies and that tailoring therapy based on the molecular and cellular characteristics of patients' tumors will improve outcomes. To test this, we assembled a panel of orthotopic patient-derived xenografts (PDX) and subjected them to DNA sequencing, gene expression profiling, and high-throughput drug screening. Analysis of DNA sequencing revealed that most medulloblastomas do not have actionable mutations that point to effective therapies. In contrast, gene expression and drug response data provided valuable information about potential therapies for every tumor. For example, drug screening demonstrated that actinomycin D, which is used for treatment of sarcoma but rarely for medulloblastoma, was active against PDXs representing Group 3 medulloblastoma, the most aggressive form of the disease. Functional analysis of tumor cells was successfully used in a clinical setting to identify more treatment options than sequencing alone. These studies suggest that it should be possible to move away from a one-size-fits-all approach and begin to treat each patient with therapies that are effective against their specific tumor. SIGNIFICANCE: These findings show that high-throughput drug screening identifies therapies for medulloblastoma that cannot be predicted by genomic or transcriptomic analysis.
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Affiliation(s)
- Jessica M Rusert
- Tumor Initiation and Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California
| | - Edwin F Juarez
- Department of Medicine, University of California San Diego, La Jolla, California
- Moores Cancer Center, University of California San Diego, La Jolla, California
| | - Sebastian Brabetz
- Hopp Children's Cancer Center (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ) and German Cancer Consortium (DKTK), Heidelberg, Germany
| | - James Jensen
- Department of Medicine, University of California San Diego, La Jolla, California
- Moores Cancer Center, University of California San Diego, La Jolla, California
| | - Alexandra Garancher
- Tumor Initiation and Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California
| | - Lianne Q Chau
- Tumor Initiation and Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California
| | - Silvia K Tacheva-Grigorova
- Tumor Initiation and Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California
| | - Sameerah Wahab
- Tumor Initiation and Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California
| | - Yoko T Udaka
- Rady Children's Hospital San Diego, San Diego, California
| | - Darren Finlay
- Tumor Microenvironment and Cancer Immunology Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California
| | - Huriye Seker-Cin
- Hopp Children's Cancer Center (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ) and German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Brendan Reardon
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Susanne Gröbner
- Hopp Children's Cancer Center (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ) and German Cancer Consortium (DKTK), Heidelberg, Germany
| | | | - Jonas Ecker
- Hopp Children's Cancer Center (KiTZ), Heidelberg, Germany
- CCU Pediatric Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Pediatric Oncology and Hematology, University Hospital Heidelberg, Heidelberg, Germany
| | - Lin Qi
- Brain Tumor Program, Texas Children's Cancer Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Mari Kogiso
- Brain Tumor Program, Texas Children's Cancer Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Yuchen Du
- Brain Tumor Program, Texas Children's Cancer Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Program of Precision Medicine PDOX Modeling of Pediatric Tumors, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University, Chicago, Illinois
| | - Patricia A Baxter
- Brain Tumor Program, Texas Children's Cancer Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Program of Precision Medicine PDOX Modeling of Pediatric Tumors, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University, Chicago, Illinois
| | - Jacob J Henderson
- Papé Family Pediatric Research Institute, Department of Pediatrics, and Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
| | - Michael E Berens
- Cancer and Cell Biology Division, The Translational Genomics Research Institute, Phoenix, Arizona
| | - Kristiina Vuori
- Tumor Microenvironment and Cancer Immunology Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California
| | - Till Milde
- Hopp Children's Cancer Center (KiTZ), Heidelberg, Germany
- CCU Pediatric Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Pediatric Oncology and Hematology, University Hospital Heidelberg, Heidelberg, Germany
| | - Yoon-Jae Cho
- Papé Family Pediatric Research Institute, Department of Pediatrics, and Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
| | - Xiao-Nan Li
- Brain Tumor Program, Texas Children's Cancer Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Program of Precision Medicine PDOX Modeling of Pediatric Tumors, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University, Chicago, Illinois
| | - James M Olson
- Fred Hutchinson Cancer Research Center and Seattle Children's Hospital, Seattle, Washington
| | - Iris Reyes
- Rady Children's Institute for Genomic Medicine, San Diego, California
| | - Matija Snuderl
- Department of Pathology, NYU Langone Health, New York, New York
| | - Terence C Wong
- Rady Children's Institute for Genomic Medicine, San Diego, California
| | - David P Dimmock
- Rady Children's Institute for Genomic Medicine, San Diego, California
| | - Shareef A Nahas
- Rady Children's Institute for Genomic Medicine, San Diego, California
| | - Denise Malicki
- Rady Children's Hospital, San Diego, California
- Department of Pathology, University of California San Diego, La Jolla, California
- Department of Pediatrics, University of California San Diego, La Jolla, California
| | - John R Crawford
- Rady Children's Hospital, San Diego, California
- Department of Pediatrics, University of California San Diego, La Jolla, California
- Department of Neurosciences, University of California San Diego, La Jolla, California
| | - Michael L Levy
- Rady Children's Hospital, San Diego, California
- Department of Surgery, University of California San Diego, La Jolla, California
| | - Eliezer M Van Allen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Stefan M Pfister
- Hopp Children's Cancer Center (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ) and German Cancer Consortium (DKTK), Heidelberg, Germany
- Department of Pediatric Oncology and Hematology, University Hospital Heidelberg, Heidelberg, Germany
| | - Pablo Tamayo
- Department of Medicine, University of California San Diego, La Jolla, California
- Moores Cancer Center, University of California San Diego, La Jolla, California
| | - Marcel Kool
- Hopp Children's Cancer Center (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ) and German Cancer Consortium (DKTK), Heidelberg, Germany
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Jill P Mesirov
- Department of Medicine, University of California San Diego, La Jolla, California
- Moores Cancer Center, University of California San Diego, La Jolla, California
| | - Robert J Wechsler-Reya
- Tumor Initiation and Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California.
- Rady Children's Institute for Genomic Medicine, San Diego, California
- Department of Pediatrics, University of California San Diego, La Jolla, California
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Rennert RC, Levy ML. Commentary: What Variables Correlate With Different Clinical Outcomes of Abusive Head Injury? Neurosurgery 2020; 87:E497. [PMID: 32374846 DOI: 10.1093/neuros/nyaa153] [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: 03/15/2020] [Accepted: 03/16/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - Michael L Levy
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California.,Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, California
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38
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Lo YY, Malicki DM, Levy ML, Crawford JR. Low-grade glioneuronal tumour with novel molecular features associated with unusual partial epilepsy in a child. BMJ Case Rep 2020; 13:13/9/e237373. [PMID: 32900747 DOI: 10.1136/bcr-2020-237373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Yan Yuen Lo
- Neurosciences, University of California San Diego, La Jolla, California, USA
| | - Denise M Malicki
- Pathology, Rady Children's Hospital University of California San Diego, San Diego, California, USA
| | - Michael L Levy
- Neurosurgery, University of California San Diego, San Diego, California, USA
| | - John Ross Crawford
- Neurosciences and Pediatrics, University of California San Diego, San Diego, California, USA
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39
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Rennert RC, Levy DM, Plonsker J, Steinberg JA, Friedman RA, Crawford JR, Levy ML. Middle fossa approach for a pediatric facial nerve meningioma. J Neurosurg Pediatr 2020; 26:578-582. [PMID: 32858509 DOI: 10.3171/2020.5.peds2034] [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: 01/11/2020] [Accepted: 05/19/2020] [Indexed: 11/06/2022]
Abstract
Pediatric cerebellopontine angle (CPA) meningiomas are extremely rare and are usually treated with a retrosigmoid surgical approach or radiation. The authors present the use of a middle fossa approach for the treatment of a symptomatic CPA meningioma in a 22-month-old female. The patient initially presented at 17 months with isolated progressive, long-standing right-sided facial weakness. MRI demonstrated a 5.0 × 5.0-mm right CPA lesion just superior to the cisternal segment of cranial nerve (CN) VII, which demonstrated growth on interval imaging. At 22 months of age she underwent a successful middle fossa craniotomy, including wide exposure of the porus acusticus, allowing for a gross-total resection with preservation of CNs VII and VIII. Pathological analysis revealed a WHO grade I meningioma. The patient remained neurologically stable on follow-up. The middle fossa approach can be used to safely access the CPA in properly selected pediatric patients.
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Affiliation(s)
| | | | | | | | - Rick A Friedman
- 2Surgery, Division of Otolaryngology, Head and Neck Surgery, and
| | - John R Crawford
- 3Neurosciences and Pediatrics, University of California, San Diego, California
| | - Michael L Levy
- 3Neurosciences and Pediatrics, University of California, San Diego, California
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40
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Steinberg JA, Rennert RC, Brandel MG, Levy ML. A Paramedian Supracerebellar, Infratentorial Approach for Resection of Midbrain Tumor. World Neurosurg 2020; 143:83. [PMID: 32652277 DOI: 10.1016/j.wneu.2020.06.243] [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: 03/21/2020] [Revised: 06/28/2020] [Accepted: 06/30/2020] [Indexed: 11/30/2022]
Abstract
Brainstem tumors represent formidable lesions for neurosurgical intervention. They should be approached with a thorough understanding of the anatomy and clear sense of surgical goals. A 14-year-old previously healthy girl presented with 2 weeks of nausea, headaches, diplopia, and gait instability. Workup revealed a 3.5 x 2.5 x 2.5 cm contrast-enhancing mass within the right midbrain. The patient consented to the surgical procedure. Preoperative imaging demonstrated superior displacement of the deep venous system because of the tumor, as well as inferior displacement of the fourth cranial nerve exit zone and posterior bowing of the entire tectal region. This allowed a safe corridor from a supracerebellar infratentorial approach. The three quarters lateral position was chosen to optimize surgeon ergonomics and allow for gravity to drain blood from the operative field. Near total resection was obtained without any new neurologic deficit. Final pathology was consistent with pilocytic astrocytoma, World Health Organization grade I. The video demonstrates the surgical approach in addition to techniques for brainstem tumor resection (Video 1).
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Affiliation(s)
- Jeffrey A Steinberg
- Pediatric Division of Neurosurgery, University of California at San Diego, San Diego, California, USA
| | - Robert C Rennert
- Pediatric Division of Neurosurgery, University of California at San Diego, San Diego, California, USA
| | - Michael G Brandel
- Pediatric Division of Neurosurgery, University of California at San Diego, San Diego, California, USA
| | - Michael L Levy
- Pediatric Division of Neurosurgery, University of California at San Diego, San Diego, California, USA.
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41
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Garancher A, Suzuki H, Haricharan S, Chau LQ, Masihi MB, Rusert JM, Norris PS, Carrette F, Romero MM, Morrissy SA, Skowron P, Cavalli FMG, Farooq H, Ramaswamy V, Jones SJM, Moore RA, Mungall AJ, Ma Y, Thiessen N, Li Y, Morcavallo A, Qi L, Kogiso M, Du Y, Baxter P, Henderson JJ, Crawford JR, Levy ML, Olson JM, Cho YJ, Deshpande AJ, Li XN, Chesler L, Marra MA, Wajant H, Becher OJ, Bradley LM, Ware CF, Taylor MD, Wechsler-Reya RJ. Tumor necrosis factor overcomes immune evasion in p53-mutant medulloblastoma. Nat Neurosci 2020; 23:842-853. [PMID: 32424282 PMCID: PMC7456619 DOI: 10.1038/s41593-020-0628-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 03/20/2020] [Indexed: 12/18/2022]
Abstract
Many immunotherapies act by enhancing the ability of cytotoxic T cells to kill tumor cells. Killing depends on T cell recognition of antigens presented by class I major histocompatibility complex (MHC-I) proteins on tumor cells. In this study, we showed that medulloblastomas lacking the p53 tumor suppressor do not express surface MHC-I and are therefore resistant to immune rejection. Mechanistically, this is because p53 regulates expression of the peptide transporter Tap1 and the aminopeptidase Erap1, which are required for MHC-I trafficking to the cell surface. In vitro, tumor necrosis factor (TNF) or lymphotoxin-β receptor agonist can rescue expression of Erap1, Tap1 and MHC-I on p53-mutant tumor cells. In vivo, low doses of TNF prolong survival and synergize with immune checkpoint inhibitors to promote tumor rejection. These studies identified p53 as a key regulator of immune evasion and suggest that TNF could be used to enhance sensitivity of tumors to immunotherapy.
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Affiliation(s)
- Alexandra Garancher
- Tumor Initiation & Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Hiromichi Suzuki
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Svasti Haricharan
- Tumor Microenvironment and Cancer Immunology Program, NCI-Designated Cancer Center and the Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Lianne Q Chau
- Tumor Initiation & Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Meher Beigi Masihi
- Tumor Initiation & Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Jessica M Rusert
- Tumor Initiation & Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Paula S Norris
- Tumor Microenvironment and Cancer Immunology Program, NCI-Designated Cancer Center and the Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Florent Carrette
- Tumor Microenvironment and Cancer Immunology Program, NCI-Designated Cancer Center and the Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Megan M Romero
- Department of Pediatrics, Northwestern University, Chicago, IL, USA
| | - Sorana A Morrissy
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
- Dept. of Biochemistry and Molecular Biology, Charbonneau Cancer Institute, University of Calgary, Calgary, Alberta, Canada
| | - Patryk Skowron
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Florence M G Cavalli
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Hamza Farooq
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology and Department of Paediatrics, Hospital for Sick Children, Toronto, Canada
| | - Steven J M Jones
- Canada's Michael Smith Genome Sciences Centre, BC Cancer, Vancouver, Canada
| | - Richard A Moore
- Canada's Michael Smith Genome Sciences Centre, BC Cancer, Vancouver, Canada
| | - Andrew J Mungall
- Canada's Michael Smith Genome Sciences Centre, BC Cancer, Vancouver, Canada
| | - Yussanne Ma
- Canada's Michael Smith Genome Sciences Centre, BC Cancer, Vancouver, Canada
| | - Nina Thiessen
- Canada's Michael Smith Genome Sciences Centre, BC Cancer, Vancouver, Canada
| | - Yisu Li
- Canada's Michael Smith Genome Sciences Centre, BC Cancer, Vancouver, Canada
| | - Alaide Morcavallo
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Lin Qi
- Brain Tumor Program, Texas Children's Cancer Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Program of Precision Medicine PDOX Modeling of Pediatric Tumors, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University, Chicago, IL, USA
| | - Mari Kogiso
- Brain Tumor Program, Texas Children's Cancer Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Yuchen Du
- Brain Tumor Program, Texas Children's Cancer Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Program of Precision Medicine PDOX Modeling of Pediatric Tumors, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University, Chicago, IL, USA
| | - Patricia Baxter
- Brain Tumor Program, Texas Children's Cancer Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Jacob J Henderson
- Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
| | - John R Crawford
- Departments of Pediatrics and Neurosciences, University of California, San Diego - Rady Children's Hospital, San Diego, CA, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California San Diego - Rady Children's Hospital, San Diego, CA, USA
| | - James M Olson
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Yoon-Jae Cho
- Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
| | - Aniruddha J Deshpande
- Tumor Initiation & Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Xiao-Nan Li
- Brain Tumor Program, Texas Children's Cancer Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Program of Precision Medicine PDOX Modeling of Pediatric Tumors, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University, Chicago, IL, USA
| | - Louis Chesler
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Marco A Marra
- Canada's Michael Smith Genome Sciences Centre, BC Cancer, Vancouver, Canada
| | - Harald Wajant
- Division of Molecular Internal Medicine, Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Oren J Becher
- Department of Pediatrics, Northwestern University, Chicago, IL, USA
| | - Linda M Bradley
- Tumor Microenvironment and Cancer Immunology Program, NCI-Designated Cancer Center and the Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Carl F Ware
- Tumor Microenvironment and Cancer Immunology Program, NCI-Designated Cancer Center and the Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Michael D Taylor
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Robert J Wechsler-Reya
- Tumor Initiation & Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA.
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42
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Affiliation(s)
- Scott Sun
- Dearptment of Neurosciences, University of California San Diego, San Diego, California, USA
| | - Denise M Malicki
- Pathology, Rady Children's Hospital University of California San Diego, San Diego, California, USA
| | - Michael L Levy
- Neurosurgery, University of California San Diego, San Diego, California, USA
| | - John Ross Crawford
- Neurosciences and Pediatrics, University of California San Diego, San Diego, California, USA
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43
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Rennert RC, Levy ML. Commentary: Microsurgical Resection of Brain Stem Ependymoma: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2020; 18:E242. [PMID: 31690933 DOI: 10.1093/ons/opz323] [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: 08/13/2019] [Accepted: 09/02/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, University of California San Diego, La Jolla, California
| | - Michael L Levy
- Department of Neurological Surgery, University of California San Diego, La Jolla, California.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Diego, San Diego, California
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44
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Affiliation(s)
- Lianne Chau
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California, USA
| | - Denise M Malicki
- Pathology, Rady Children's Hospital University of California San Diego, San Diego, California, USA
| | - Michael L Levy
- Neurosurgery, University of California San Diego, San Diego, California, USA
| | - John Ross Crawford
- Neurosciences and Pediatrics, University of California San Diego, San Diego, California, USA
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45
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Arocho-Quinones EV, Lew SM, Handler MH, Tovar-Spinoza Z, Smyth M, Bollo R, Donahue D, Perry MS, Levy ML, Gonda D, Mangano FT, Storm PB, Price AV, Couture DE, Oluigbo C, Duhaime AC, Barnett GH, Muh CR, Sather MD, Fallah A, Wang AC, Bhatia S, Patel K, Tarima S, Graber S, Huckins S, Hafez DM, Rumalla K, Bailey L, Shandley S, Roach A, Alexander E, Jenkins W, Tsering D, Price G, Meola A, Evanoff W, Thompson EM, Brandmeir N. Magnetic resonance-guided stereotactic laser ablation therapy for the treatment of pediatric brain tumors: a multiinstitutional retrospective study. J Neurosurg Pediatr 2020; 26:13-21. [PMID: 32217793 PMCID: PMC7885863 DOI: 10.3171/2020.1.peds19496] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 08/24/2019] [Accepted: 01/22/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study aimed to assess the safety and efficacy of MR-guided stereotactic laser ablation (SLA) therapy in the treatment of pediatric brain tumors. METHODS Data from 17 North American centers were retrospectively reviewed. Clinical, technical, and radiographic data for pediatric patients treated with SLA for a diagnosis of brain tumor from 2008 to 2016 were collected and analyzed. RESULTS A total of 86 patients (mean age 12.2 ± 4.5 years) with 76 low-grade (I or II) and 10 high-grade (III or IV) tumors were included. Tumor location included lobar (38.4%), deep (45.3%), and cerebellar (16.3%) compartments. The mean follow-up time was 24 months (median 18 months, range 3-72 months). At the last follow-up, the volume of SLA-treated tumors had decreased in 80.6% of patients with follow-up data. Patients with high-grade tumors were more likely to have an unchanged or larger tumor size after SLA treatment than those with low-grade tumors (OR 7.49, p = 0.0364). Subsequent surgery and adjuvant treatment were not required after SLA treatment in 90.4% and 86.7% of patients, respectively. Patients with high-grade tumors were more likely to receive subsequent surgery (OR 2.25, p = 0.4957) and adjuvant treatment (OR 3.77, p = 0.1711) after SLA therapy, without reaching significance. A total of 29 acute complications in 23 patients were reported and included malpositioned catheters (n = 3), intracranial hemorrhages (n = 2), transient neurological deficits (n = 11), permanent neurological deficits (n = 5), symptomatic perilesional edema (n = 2), hydrocephalus (n = 4), and death (n = 2). On long-term follow-up, 3 patients were reported to have worsened neuropsychological test results. Pre-SLA tumor volume, tumor location, number of laser trajectories, and number of lesions created did not result in a significantly increased risk of complications; however, the odds of complications increased by 14% (OR 1.14, p = 0.0159) with every 1-cm3 increase in the volume of the lesion created. CONCLUSIONS SLA is an effective, minimally invasive treatment option for pediatric brain tumors, although it is not without risks. Limiting the volume of the generated thermal lesion may help decrease the incidence of complications.
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Affiliation(s)
| | - Sean M. Lew
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin,Department of Neurosurgery, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Michael H. Handler
- Department of Neurosurgery, Children’s Hospital Colorado, Aurora, Colorado
| | - Zulma Tovar-Spinoza
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, New York
| | - Matthew Smyth
- Department of Neurosurgery, St. Louis Children’s Hospital, St. Louis, Missouri
| | - Robert Bollo
- Department of Neurosurgery, Primary Children’s Hospital, Salt Lake City, Utah
| | - David Donahue
- Department of Neurosurgery, Cook Children’s Hospital, Fort Worth, Texas
| | - M. Scott Perry
- Department of Neurology, Cook Children’s Hospital, Fort Worth, Texas
| | - Michael L. Levy
- Department of Neurosurgery, Rady Children’s Hospital-San Diego, California
| | - David Gonda
- Department of Neurosurgery, Rady Children’s Hospital-San Diego, California
| | | | - Phillip B. Storm
- Department of Neurosurgery, Children’s Hospital of Philadelphia, Pennsylvania
| | - Angela V. Price
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Daniel E. Couture
- Department of Neurosurgery, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Chima Oluigbo
- Department of Neurosurgery, Children’s National Health System, Washington, DC
| | - Ann-Christine Duhaime
- Department of Neurosurgery, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Gene H. Barnett
- Department of Neurosurgery, Cleveland Clinic Children’s, Cleveland, Ohio
| | - Carrie R. Muh
- Department of Neurosurgery, Duke Children’s Hospital, Durham, North Carolina
| | - Michael D. Sather
- Department of Neurosurgery, Penn State Health, Hershey, Pennsylvania
| | - Aria Fallah
- Department of Neurosurgery, UCLA Mattel Children’s Hospital, Los Angeles, California
| | - Anthony C. Wang
- Department of Neurosurgery, UCLA Mattel Children’s Hospital, Los Angeles, California
| | - Sanjiv Bhatia
- Department of Neurosurgery, Nicklaus Children’s Hospital, Miami, Florida
| | - Kadam Patel
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sergey Tarima
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sarah Graber
- Department of Neurosurgery, Children’s Hospital Colorado, Aurora, Colorado
| | - Sean Huckins
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, New York
| | - Daniel M. Hafez
- Department of Neurosurgery, St. Louis Children’s Hospital, St. Louis, Missouri
| | - Kavelin Rumalla
- Department of Neurosurgery, St. Louis Children’s Hospital, St. Louis, Missouri
| | - Laurie Bailey
- Department of Neurosurgery, Cook Children’s Hospital, Fort Worth, Texas
| | - Sabrina Shandley
- Department of Neurosurgery, Cook Children’s Hospital, Fort Worth, Texas
| | - Ashton Roach
- Department of Neurosurgery, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Erin Alexander
- Department of Neurosurgery, Children’s Hospital of Philadelphia, Pennsylvania
| | - Wendy Jenkins
- Department of Neurosurgery, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Deki Tsering
- Department of Neurosurgery, Children’s National Health System, Washington, DC
| | - George Price
- Department of Neurosurgery, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Antonio Meola
- Department of Neurosurgery, Cleveland Clinic Children’s, Cleveland, Ohio
| | - Wendi Evanoff
- Department of Neurosurgery, Cleveland Clinic Children’s, Cleveland, Ohio
| | - Eric M. Thompson
- Department of Neurosurgery, Duke Children’s Hospital, Durham, North Carolina
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Sun S, Shayan K, Levy ML, Crawford JR. Novel cavernous sinus TSC2/JAK3 mutant hemangioendothelioma in a teenager. BMJ Case Rep 2020; 13:13/3/e234677. [PMID: 32193183 DOI: 10.1136/bcr-2020-234677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Scott Sun
- Department of Neurosciences, University of California San Diego, La Jolla, California, USA
| | - Katayoon Shayan
- Pathology, Rady Children's Hospital, San Diego, California, USA
| | - Michael L Levy
- Neurosurgery, University of California San Diego, San Diego, California, USA
| | - John Ross Crawford
- Neurosciences and Pediatrics, University of California San Diego, San Diego, California, USA
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Pehlivan KC, Malicki DM, Levy ML, Crawford JR. Rare gain of chromosome 5 in a supratentorial hemispheric paediatric pilomyxoid astrocytoma. BMJ Case Rep 2020; 13:13/3/e234878. [PMID: 32188622 DOI: 10.1136/bcr-2020-234878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - Denise M Malicki
- Department of Pathology, Rady Children's Hospital University of California San Diego, San Diego, California, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California San Diego, San Diego, California, USA
| | - John Ross Crawford
- Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, California, USA
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Pehlivan KC, Malicki DM, Levy ML, Crawford JR. TPM3-NTRK1 fusion in a pleomorphic xanthoastrocytoma presenting with haemorrhage in a child. BMJ Case Rep 2020; 13:13/3/e234347. [PMID: 32169993 DOI: 10.1136/bcr-2020-234347] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
| | - Denise M Malicki
- Pathology, Rady Children's Hospital University of California San Diego, San Diego, California, USA
| | - Michael L Levy
- Neurosurgery, University of California San Diego, San Diego, California, USA
| | - John Ross Crawford
- Neurosciences and Pediatrics, University of California San Diego, San Diego, California, USA
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49
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Rennert RC, Levy DM, Steinberg JA, Levy ML. Keyhole Microsurgical Middle Fossa Arachnoid Cyst Fenestration: 2-Dimensional Operative Video. World Neurosurg 2020; 137:93. [PMID: 32035207 DOI: 10.1016/j.wneu.2020.01.222] [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] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 10/25/2022]
Abstract
Surgical options for symptomatic intracranial arachnoid cysts include cyst shunting and microscopic or endoscopic fenestration.1 We advocate a microsurgical keyhole approach for the durable fenestration of middle fossa arachnoid cysts, taking advantage of the superior magnification, depth perception, and illumination of the operating microscope, as well as the ability to use bimanual surgical technique and variable suction to ensure safe manipulation of arachnoid membranes and fenestration of these lesions into the deep cisterns.2 Key technical aspects of this approach demonstrated in this video (Video 1) include performance of a dime-sized temporal craniotomy; strict microsurgical technique with sharp dissection via a No. 11 blade, sharp microdissectors, and microscissors; disruption of the arachnoid membranes overlying cranial nerves II/III, the internal carotid artery, and the posterior communicating artery; and fenestration of the membrane of Lilliquist through the opticocarotid, oculomotor, and/or supratrochlear triangles. The utility of this approach is illustrated by the case of a 5-year-old male with a history of headaches and interval progression of a left temporal grade 2 arachnoid cyst, who experienced symptom resolution and cyst shrinkage after keyhole microsurgical fenestration.
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Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California, USA
| | - Danielle M Levy
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California, USA
| | - Jeffrey A Steinberg
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California, USA
| | - Michael L Levy
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California, USA.
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Hoshide R, Rennert RC, Sanchez CE, Martin JR, Cheung VJ, Gyles G, Levy ML. Rate-controlled intraventricular endoscopic irrigation via bipolar foot pedal activation: technical note. J Neurosurg Pediatr 2019; 25:1-5. [PMID: 31881535 DOI: 10.3171/2019.11.peds19471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 08/08/2019] [Accepted: 11/01/2019] [Indexed: 11/06/2022]
Abstract
Irrigation during intraventricular endoscopic surgery is critical for visualization, with normal intracranial pressure maintained by balancing fluid ingress and egress. Although irrigation is typically achieved through manual manipulation of inexact stopcocks, the authors have developed a rate-controlled, foot pedal-activated system for precise intraventricular irrigation by using a standard irrigating bipolar electrocautery machine.This study is a retrospective review of patients who underwent endoscopic intraventricular surgery between January 1, 2018, and September 25, 2019, in which this irrigation system was used. Important components of this system include a bipolar module irrigation regulator that is set to a desired rate, a secure connection of the bipolar irrigation tubing to the endoscope, and one or more open egress ports on the endoscope for passive fluid drainage. Nineteen consecutive patients were identified on review (average age ± SD, 4.3 ± 4.1 years). Procedures performed included third ventriculostomies (n = 10); arachnoid/choroid cyst fenestrations/resections (n = 3); biopsy/tumor resection (n = 1); and combined procedures (n = 5). Foot pedal-controlled irrigation provided visualization of all intraventricular structures. A single operator was able to control the endoscope, endoscopic instruments, and irrigation, with assistance as indicated for more complex maneuvers. There were no perioperative complications. Because this setup is easily constructed from a standard irrigating bipolar machine, delivers precise irrigation flow rates, and facilitates a single-surgeon bimanual technique, these data support the utility of foot-controlled irrigation for endoscopic intraventricular surgery.
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Affiliation(s)
- Reid Hoshide
- 1Rady Children's Hospital of San Diego; and
- 2Department of Neurosurgery, University of California, San Diego, California
| | - Robert C Rennert
- 1Rady Children's Hospital of San Diego; and
- 2Department of Neurosurgery, University of California, San Diego, California
| | - Carlos E Sanchez
- 1Rady Children's Hospital of San Diego; and
- 2Department of Neurosurgery, University of California, San Diego, California
| | - Joel R Martin
- 1Rady Children's Hospital of San Diego; and
- 2Department of Neurosurgery, University of California, San Diego, California
| | - Vincent J Cheung
- 1Rady Children's Hospital of San Diego; and
- 2Department of Neurosurgery, University of California, San Diego, California
| | | | - Michael L Levy
- 1Rady Children's Hospital of San Diego; and
- 2Department of Neurosurgery, University of California, San Diego, California
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