Mosaic BRAF Fusions Are a Recurrent Cause of Congenital Melanocytic Nevi Targetable by MAPK Pathway Inhibition

Among children with multiple congenital melanocytic nevi, 25% have no established genetic cause, of whom many develop a hyperproliferative and severely pruritic phenotype resistant to treatment. Gene fusions have been reported in individual cases of congenital melanocytic nevi. We studied 169 patients with congenital melanocytic nevi in this study, 38 of whom were double wild type for pathogenic NRAS/BRAF variants. Nineteen of these 38 patients had sufficient tissue to undergo RNA sequencing, which revealed mosaic BRAF fusions in 11 of 19 patients and mosaic RAF1 fusions in 1 of 19. Recurrently, fusions involved the loss of the 5´ regulatory domain of BRAF or RAF1 but preserved the kinase domain. We validated all cases and detected the fusions in two separate nevi in 5 of 12 patients, confirming clonality. The absence of the fusion in blood in 8 of 12 patients indicated mosaicism. Primary culture of BRAF-fusion nevus cells from 3 of 12 patients demonstrated highly increased MAPK activation, despite only mildly increased BRAF expression, suggesting additional mechanisms of kinase activation. Trametinib quenched MAPK hyperactivation in vitro, and treatment of two patients caused rapid improvement in bulk tissue, improving bodily movement and reducing inflammation and severe pruritus. These findings offer a genetic diagnosis to an additional group of patients and trametinib as a treatment option for the severe associated phenotypes.

Management of the Congenital Cleft Earlobe with a Conchal Cartilage Graft

Congenital earlobe clefts are the most common lower auricular malformations. They represent a unique reconstructive challenge. The goal of surgery includes restoration of a natural lobular contour and volume as well as a fine surgical scar. Several surgical techniques have been described, most of which only address the cleft deformity but not the soft tissue deficiency. We hereby describe a technique which addresses both the cleft and improves soft tissue deficiency through a conchal cartilage graft.

Management of the infected preauricular sinus

INTRODUCTION

The preauricular sinus is a common finding in children and may often be complicated by infection. Complete excision of the sinus is the only definitive cure. Failure to recognise the presence of a sinus, particularly when infection erupts away from the sinus, may lead to inadequate management and unnecessary surgery.

AIM

We report our experience in managing infected preauricular sinuses and highlight important points in our surgical technique.

METHODS

A retrospective review was performed of our electronic patient database for all paediatric patients who underwent surgical excision of preauricular sinuses by the senior author at Great Ormond Street Hospital for Children between January 2013 and October 2022.

RESULTS

A total of 10 patients underwent surgical management of 11 preauricular sinuses with a median follow-up time of 40 months (range 1-136). Eight patients underwent excision of the preauricular sinus due to infection. All infected cases affected the preauricular cheek skin and had previously undergone at least one unsuccessful surgical drainage prior to a referral to our unit. All cases were successfully operated on at our unit with no reported complications or recurrence.

CONCLUSION

A lack of awareness of the presence of a sinus and identification of a preauricular pit by the inexperienced clinician will result in inadequate treatment of this condition and potentially unnecessary surgical procedures. Our paper highlights the importance of correctly identifying the extent of the sinus and describes a safe and reliable technique to ensure complete removal of the preauricular sinus with satisfactorily low recurrence rates.

Short-Term Treatment with Rho-Associated Kinase Inhibitor Preserves Keratinocyte Stem Cell Characteristics In Vitro

Primary keratinocytes including keratinocyte stem cells (KSCs) can be cultured as epidermal sheets in vitro and are attractive for cell and gene therapies for genetic skin disorders. However, the initial slow growth of freshly isolated keratinocytes hinders clinical applications. Rho-associated kinase inhibitor (ROCKi) has been used to overcome this obstacle, but its influence on the characteristics of KSC and its safety for clinical application remains unknown. In this study, primary keratinocytes were treated with ROCKi Y-27632 for six days (short-term). Significant increases in colony formation and cell proliferation during the six-day ROCKi treatment were observed and confirmed by related protein markers and single-cell transcriptomic analysis. In addition, short-term ROCKi-treated cells maintained their differentiation ability as examined by 3D-organotypic culture. However, these changes could be reversed and became indistinguishable between treated and untreated cells once ROCKi treatment was withdrawn. Further, the short-term ROCKi treatment did not reduce the number of KSCs. In addition, AKT and ERK pathways were rapidly activated upon ROCKi treatment. In conclusion, short-term ROCKi treatment can transiently and reversibly accelerate initial primary keratinocyte expansion while preserving the holoclone-forming cell population (KSCs), providing a safe avenue for clinical applications.

Abstract 2014: Mosaic BRAF fusions are a recurrent cause of multiple congenital melanocytic naevi

Congenital melanocytic naevi (CMN) are moles present at birth, and when multiple or very extensive can involve other organ systems as well as predisposing to melanoma. Some CMN patients develop a highly proliferative multinodular phenotype leading to chronic intense pruritus, and the causes for that specific phenotype progression are poorly understood. Genotypically CMN are mosaic single gene disorders. Thus far only two recurrent variants have been described as clearly causative: NRAS missense variants affecting codon 61 accounting for 68% of cases, and BRAF missense variants affecting codon 600 accounting for 7% of cases. Small numbers of cases of CMN have been reported to carry gene-fusions, and in 2 cases in the world literature (one BRAF-fusion and one RAF1-fusion) these have been shown to be clonal and therefore likely causal. We sought to address the issue of causation of the remaining 25%. From an initial large cohort study, skin biopsies from 19 patients were shown to be double wildtype for NRAS/BRAF and had sufficient tissue for further study after deep whole exome sequencing. These 19 samples then underwent transcriptome-wide paired-end RNA sequencing with bioinformatics analysis (STAR-Fusion v1.6 and Fusion Inspector v2.3) for gene fusion transcripts. 11/19 patients were found to have BRAFgene fusions, of which 7 had the multinodular proliferative phenotype. Fusions were confirmed on Sanger sequencing of the cDNA across the fusion junction, specifically demonstrated in 8 children from more than one separate skin lesion, confirming clonality. In the fusions identified, BRAF was fused to 11 different partner genes (GOLGA4, QKI, STRN3, AGAP3, MKRN2, PHIP, LCA5, EEA1, AKAP9, SEC31A, MIER3). This resulted in loss of the 5’ regulatory domain of BRAF but preservation of the kinase domain, such that expression was driven by the 5’ fusion partner. This structure follows the pattern of somatic BRAF-fusions reported previously in solid tumors including melanoma. Potential dimerization domains in the partner genes were identified in 9 cases. We identify here mosaic BRAF fusions as a recurrent cause of multiple CMN allowing genetic diagnosis in a further 15% of cases and linking this genotype to a highly proliferative pruritic phenotype. In vitro data from melanoma cell lines have suggested that higher expression levels of the fusion protein as well as dimerization domains in the partner gene correlate with resistance and/or paradoxical MAP-kinase activation after treatment with RAF and MEK inhibitors. This may have implications for the use of targeted therapies for attempted reduction of the nodular phenotype, or where melanoma arises in CMN patients caused by mosaic BRAF-fusions.

Citation Format: Sara Barberan Martin, Satyamaanasa Polubothu, Alicia Bruzos, Neil Bulstrode, Gavin Kelly, Veronica Kinsler. Mosaic BRAF fusions are a recurrent cause of multiple congenital melanocytic naevi [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2014.

64 An Audit of Same Day Theatre List Cancellations

Introduction

Given the reduction in elective operating during the Covid pandemic, efficient use of theatre time is paramount to reduce elective waiting list times. The aims of this audit were to identify the proportion of patients who were cancelled from theatre lists on the day, reasons for cancellation, and the proportion of patients who were cancelled due to non-adherence to pre-operative fasting rules.

Method

The previous 30 patients on a single surgeon’s elective operating list were reviewed using electronic patient records, admissions teams list, and surgeon recall to identify numbers of and reasons for on the day cancellations.

The standards used were the perioperative fasting in adults and children guideline from the European Society of Anaesthesiology, and a local trust guideline on pre-operative fasting.

Results

30 patients had been scheduled for elective surgery on a single surgeon’s paediatric plastic surgery list between April and May 2021. 3 patients (10%) cancelled on the day of their planned procedures. Of these patients cancelling on the day, 2 (66%) cancelled due to non-adherence to pre-operative fasting rules, 1 (33%) cancelled due to parents choosing to defer the operation.

Conclusions

Non-adherence to pre-operative fasting rules was an important reason for on the day cancellations on this elective operating list. A pre-operative fasting information sheet was developed for patients and parents to explain the fasting rules and timings. Once sufficient patients and parents receive the information sheet, the audit will be repeated. If successful, it may be sent to patients and parents for all elective operating lists.

The Impact of COVID-19 on Plastic Surgery Training in the United Kingdom, Canada and Australia-A Cross-Sectional Study

Background Surgical trainees worldwide have been thrust into a period of uncertainty, with respect to the implications COVID-19 pandemic will have on their roles, training, and future career prospects. It is currently unclear how plastic surgery trainees are being affected by COVID-19. This study examined the experience of plastic surgery trainees in Canada, the UK, and Australia to determine trainee roles during the early COVID-19 emergency response and how training changed during this time.

Methods A cross-sectional survey-based study was designed for plastic surgery trainees in the UK, Canada and Australia. In total, 110 trainees responded to the survey. Statistical tests were conducted to determine differences in responses, based on year of training and country of residence.

Results In total, 9.7% (10/103) of respondents reported being deployed to cover another service. There was a significant difference between redeployment based on country ( p = 0.001). Within the UK group, 28.9% of respondents were redeployed. For trainees not deployed, 95.5% (85/89) reported that there has been a reduction in operative volume. Ninety-seven (94.1%) respondents reported that there were ongoing teaching activities offered by their program. The majority of trainees (66.4%) were concerned about their training. There was a significant difference between overall concern and country ( p < 0.05).

Conclusion In these unprecedented times, training programs in plastic surgery should be aware of the major impact that COVID-19 has had on trainees and will have on their training. The majority of plastic surgery trainees have experienced a reduction in surgical exposure but have maintained some form of regular teaching.

1249 A 3D Morphable Model of the Apert Mandible

Aim

Assess the three-dimensional Morphable Model (3DMM) of the Apert mandible, investigate differences between sex and age, and characterise growth by age. Additionally, compare with a healthy mandible 3DMM.

Method

High-quality CT scans of children with Apert’s Syndrome (without previous mandibular surgery) between November1987-January2020 were sourced from Great Ormond Street (GOSH) and Necker Hospitals. DICOM files were constructed to 3D meshes through isolation of mandibles and artifact removal (MeshMixer, Mimics) and annotation using standardized landmarks (Wrapped). A 3DMM was constructed using an existing pipeline, and experiments performed to compare with the healthy mandible 3DMM, investigating differences between sex and age, and to characterise growth by age. A healthy mandible 3DMM has been created by our team using healthy mandible CT scans sourced from a GOSH database.

Results

A 3DMM of the unoperated Apert mandible was successfully constructed from 276 Apert CT scans, male=137 (aged0-20), female=139 (aged0-23), and the first components of the morphable model identified.

Conclusions

Apert’s Syndrome is a rare genetic condition, with characteristic extremity (syndactyly) and craniofacial features (craniosynostosis), however breathing problems, sleep apnoea, relative prognathism and Angle class III malocclusion have been reported. Few studies have analysed the potential role of the Apert mandible. 3DMMs are statistical tools used to represent 3D shapes and have been used to create shape and texture parameters for anatomical areas. The 3DMM of the unoperated Apert mandible has potential applications for further understanding of Apert’s Syndrome, diagnostic purposes and may be used to develop further management of these patients, such as surgical planning.

1173 Airway and Breathing Problems in Pierre Robin Sequence: A Systematic Review Protocol

Aim

The primary aim is to systematically review the specific airway and/or breathing problems which have been reported in Pierre Robin Sequence (PRS). Secondary aims are to understand the prevalence and severity of these airway and breathing problems, and options for screening, assessment, and monitoring.

Method

A search strategy will be designed to search the following databases: MEDLINE, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials(CENTRAL) including a grey literature search, to identify publications on airway and/or breathing problems in Pierre Robin Sequence patients. Airway or breathing problems to be included are defined upper airway conditions (e.g., sleep apnoea) or clinically or objectively defined airway/breathing problems (e.g., increased respiratory rate, polysomnography). Screening will exclude non-English articles, abstracts, letters, editorials, expert opinions and breathing problems not anatomically related to craniofacial underdevelopment.

Results

This systematic review has been successfully registered on the PROSPERO International Prospective Register of Systematic Reviews (CRD42020210572)

Conclusions

PRS is a rare craniofacial condition which presents at birth, consisting of micrognathia, glossoptosis and airway problems, and is usually, but not always, associated with a cleft palate. There is no consensus on the type of airway problems that affect patients with PRS. The findings of this systematic review will help to develop a consensus on the airway and breathing problems in PRS and options for assessment and monitoring of the airway and breathing problem. This data may also contribute to development of a standardized guideline for management of airway and breathing problems in PRS.

FACE-Q Craniofacial Module: Part 1 validation of CLEFT-Q scales for use in children and young adults with facial conditions

BACKGROUND

The CLEFT-Q includes 12 independently functioning scales that measure appearance (face, nose, nostrils, teeth, lips, jaws), health-related quality of life (psychological, social, school, speech distress), and speech function, and an eating/drinking checklist. Previous qualitative research revealed that the CLEFT-Q has content validity in noncleft craniofacial conditions. This study aimed to examine the psychometric performance of the CLEFT-Q in an international sample of patients with a broad range of facial conditions.

METHODS

Data were collected between October 2016 and December 2019 from 2132 patients aged 8 to 29 years with noncleft facial conditions. Rasch measurement theory (RMT) analysis was used to examine Differential Item Function (DIF) by comparing the original CLEFT-Q sample and the new FACE-Q craniofacial sample. Reliability and validity of the scales in a combined cleft and craniofacial sample (n=4743) were examined.

RESULTS

DIF was found for 23 CLEFT-Q items when the datasets for the two samples were compared. When items with DIF were split by sample, correlations between the original and split person locations showed that DIF had negligible impact on scale scoring (correlations ≥0.995). In the combined sample, RMT analysis led to the retention of original content for ten CLEFT-Q scales, modification of the Teeth scale, and the addition of an Eating/Drinking scale. Data obtained fit with the Rasch model for 11 scales (exception School, p=0.04). Person Separation Index and Cronbach alpha values met the criteria.

CONCLUSION

The scales described in this study can be used to measure outcomes in children and young adults with cleft and noncleft craniofacial conditions.

FACE-Q craniofacial module: Part 2 Psychometric properties of newly developed scales for children and young adults with facial conditions

BACKGROUND

The FACE-Q Craniofacial Module is a patient-reported outcome measure designed for patients aged 8 to 29 years with conditions associated with a facial difference. In part 1, we describe the psychometric findings for the original CLEFT-Q scales tested in patients with cleft and noncleft facial conditions. The aim of this study was to examine psychometric performance of new FACE-Q Craniofacial Module scales.

METHODS

Data were collected between December 2016 and December 2019 from patients aged 8 to 29 years with conditions associated with a visible or functional facial difference. Rasch measurement theory (RMT) analysis was used to examine psychometric properties of each scale. Scores were transformed from 0 (worst) to 100 (best) for tests of construct validity.

RESULTS

1495 participants were recruited with a broad range of conditions (e.g., birthmarks, facial paralysis, craniosynostosis, craniofacial microsomia, etc.) RMT analysis resulted in the refinement of 7 appearance scales (Birthmark, Cheeks, Chin, Eyes, Forehead, Head Shape, Smile), two function scales (Breathing, Facial), and an Appearance Distress scale. Person separation index and Cronbach alpha values met criteria. Three checklists were also formed (Eye Function, and Eye and Face Adverse Effects). Significantly lower scores on eight of nine scales were reported by participants whose appearance or functional difference was rated as a major rather than minor or no difference. Higher appearance distress correlated with lower appearance scale scores.

CONCLUSION

The FACE-Q Craniofacial Module scales can be used to collect and compare patient reported outcomes data in children and young adults with a facial condition.

Concepts Important to Patients With Facial Differences: A Qualitative Study Informing a New Module of the FACE-Q for Children and Young Adults

Objective:

The concepts important to children and young adults who undergo treatments for facial differences are not well-defined. Measurement of treatment outcomes from the patient’s perspective is necessary to ensure goals of treatment are met. We aimed to identify concepts important to children and young adults with facial differences through a qualitative study.

Design:

An interpretive description qualitative approach was followed. Semistructured interviews were conducted, transcribed verbatim, and coded using a line-by-line approach. Qualitative analysis led to the development of a conceptual framework of outcomes important to patients.

Setting:

Interviews were conducted in Canada and the United Kingdom at home, by telephone, or in the hospital.

Participants:

Participants (N = 72) were recruited between May and June 2014 from craniofacial clinics at the Hospital for Sick Children (Toronto) and Great Ormond Street Hospital (London). Participants included anyone with a visible and/or functional facial difference aged 8 to 29 years and fluent in English, excluding patients with a cleft. The sample included 38 females and 34 males, with a mean age of 13.9 years, and included 28 facial conditions (11 facial paralysis, 18 ear anomalies, 26 skeletal conditions, and 17 soft tissue conditions).

Results:

Analysis led to identification of important concepts within 4 overarching domains: facial appearance, facial function, adverse effects of treatment, and health-related quality of life (psychological, social, and school function).

Conclusions:

Our study provides an understanding of concepts important to children and young adults with facial differences.

Does the gene matter? Genotype-phenotype and genotype-outcome associations in congenital melanocytic naevi

Background

Genotype–phenotype studies can identify subgroups of patients with specific clinical features or differing outcomes, which can help shape management.

Objectives

To characterize the frequency of different causative genotypes in congenital melanocytic naevi (CMN), and to investigate genotype–phenotype and genotype–outcome associations.

Methods

We conducted a large cohort study in which we undertook MC1R genotyping from blood, and high‐sensitivity genotyping of NRAS and BRAF hotspots in 156 naevus biopsies from 134 patients with CMN [male 40%; multiple CMN 76%; projected adult size (PAS) > 20 cm, 59%].

Results

Mosaic NRAS mutations were detected in 68%, mutually exclusive with BRAF mutations in 7%, with double wild‐type in 25%. Two separate naevi were sequenced in five of seven patients with BRAF mutations, confirming clonality. Five of seven patients with BRAF mutations had a dramatic multinodular phenotype, with characteristic histology distinct from classical proliferative nodules. NRAS mutation was the commonest in all sizes of CMN, but was particularly common in naevi with PAS > 60 cm, implying more tolerance to that mutation early in embryogenesis. Facial features were less common in double wild‐type patients. Importantly, the incidence of congenital neurological disease, and apparently of melanoma, was not altered by genotype; no cases of melanoma were seen in BRAF‐mutant multiple CMN, however, this genotype is rare.

Conclusions

CMN of all sizes are most commonly caused by mutations in NRAS. BRAF is confirmed as a much rarer cause of multiple CMN, and appears to be commonly associated with a multinodular phenotype. Genotype in this cohort was not associated with differences in incidence of neurological disease in childhood. However, genotyping should be undertaken in suspected melanoma, for guidance of treatment.

What's already known about this topic?

Multiple congenital melanocytic naevi (CMN) have been shown to be caused by NRAS mosaic mutations in 70–80% of cases, by BRAF mosaicism in one case report and by inference in some previous cases.

There has been debate about genotypic association with different sizes of CMN, and no data on genotype–outcome.

What does this study add?

NRAS mosaicism was found in 68%, BRAF in 7% and double wild‐type in 25% of cases of CMN.

NRAS was the commonest mutation in all sizes of CMN, but was nearly universal in projected adult size > 60 cm.

BRAF is often associated with a distinct multinodular clinical/histological phenotype.

Adverse outcomes did not differ between genotypes on current numbers.

https://doi.org/10.1111/bjd.18747 available online

International Consensus Recommendations on Microtia, Aural Atresia and Functional Ear Reconstruction

The aim of this report is to provide international recommendations for functional ear reconstruction in patients with microtia and aural atresia. All patients with microtia and external auditory atresia should be seen in the setting of a multidisciplinary team and agreed treatment outcomes should be measured, so that techniques, approaches, and results can be compared. The methods are expert opinion from the members of the International Microtia and Atresia Workgroup (IMAW). The consensus recommendations reported herein take into account the variability in practice patterns present among experts in the field; the degree of consensus was quantified by presenting the percentage of above authors who agree or partially agree with each statement. Recommendations include the definition and classification of microtia/atresia, treatment of microtia, treatment of congenital aural atresia, flowchart of functional ear reconstruction, and future research directions. Patients with microtia and aural atresia can be guided by the consensus recommendations provided herein.

Mosaic RAS/MAPK variants cause sporadic vascular malformations which respond to targeted therapy

BACKGROUND. Sporadic vascular malformations (VMs) are complex congenital anomalies of blood vessels that lead to stroke, life-threatening bleeds, disfigurement, overgrowth, and/or pain. Therapeutic options are severely limited, and multidisciplinary management remains challenging, particularly for high-flow arteriovenous malformations (AVM).

METHODS. To investigate the pathogenesis of sporadic intracranial and extracranial VMs in 160 children in which known genetic causes had been excluded, we sequenced DNA from affected tissue and optimized analysis for detection of low mutant allele frequency.

RESULTS. We discovered multiple mosaic-activating variants in 4 genes of the RAS/MAPK pathway, KRAS, NRAS, BRAF, and MAP2K1, a pathway commonly activated in cancer and responsible for the germline RAS-opathies. These variants were more frequent in high-flow than low-flow VMs. In vitro characterization and 2 transgenic zebrafish AVM models that recapitulated the human phenotype validated the pathogenesis of the mutant alleles. Importantly, treatment of AVM-BRAF mutant zebrafish with the BRAF inhibitor vemurafinib restored blood flow in AVM.

CONCLUSION. Our findings uncover a major cause of sporadic VMs of different clinical types and thereby offer the potential of personalized medical treatment by repurposing existing licensed cancer therapies.

FUNDING. This work was funded or supported by grants from the AVM Butterfly Charity, the Wellcome Trust (UK), the Medical Research Council (UK), the UK National Institute for Health Research, the L’Oreal-Melanoma Research Alliance, the European Research Council, and the National Human Genome Research Institute (US).

Melanoma in congenital melanocytic naevi

Congenital melanocytic naevi (CMN) are a known risk factor for melanoma, with the greatest risk currently thought to be in childhood. There has been controversy over the years about the incidence of melanoma, and therefore over the clinical management of CMN, due partly to the difficulties of histological diagnosis and partly to publishing bias towards cases of malignancy. Large cohort studies have demonstrated that melanoma risk in childhood is related to the severity of the congenital phenotype. New understanding of the genetics of CMN offers the possibility of improvement in diagnosis of melanoma, identification of those at highest risk, and new treatment options. We review the world literature and our centre's experience over the last 25 years, including the molecular characteristics of melanoma in these patients and new melanoma incidence and outcome data from our prospective cohort. Management strategies are proposed for presentation of suspected melanoma of the skin and the central nervous system in patients with CMN, including use of oral mitogen-activated protein kinase kinase inhibitors in NRAS-mutated tumours.

Microvascular reconstruction of facial defects in settings where resources are limited

The surgical treatment of defects caused by noma is challenging for the surgeon and the patient. Local flaps are preferred, but sometimes, because of the nature of the disease, there is not enough local tissue available. We describe our experience of free tissue transfer in Ethiopia. Between 2008 and 2014, 34 microsurgical procedures were done over 11 missions with the charity Facing Africa, predominantly for the treatment of defects caused by noma (n=32). The mean duration of operation was 442 minutes (range 200 - 720). Six minor wound infections were treated conservatively and did not affect outcome, a return to theatre was required in 4 patients with wound infections and one with a haemorrhage; 2 flaps failed and 2 partially failed, one patient developed an oronasal fistula, and one had an infection at the donor site that required a repeat graft. In settings where resources are limited, free flaps can be used when local tissue is not available and they cause less morbidity than pedicled tissue transfer.

Total reconstruction of the nose in settings where resources are limited

We describe a series of 8 patients who had total reconstruction of the nose during 4 separate missions to Ethiopia. The aetiology was noma (n=3), assault (n=2), acid burn (n=1), squamous cell carcinoma (n=1), and a sequela of meningococcal septicaemia (n=1). Reconstruction was with forehead flaps when adequate tissue was available (n=6) and with radial forearm flaps when it was not (n=2). Some reconstructive approaches require procedures to be done in stages, and in settings where resources are limited, difficulties with the continuity of care and provision for the management of complications, must be overcome.

Intrathoracic saline-filled prosthesis to treat postpneumonectomy syndrome

Postpneumonectomy syndrome is a rare complication following pneumonectomy with its related change in mediastinal configuration. Symptoms range from airway obstruction to esophageal symptoms, leading at times to a persistent requirement for respiratory support. Surgery is often beneficial, which is in the form of placement of a prosthesis, with variable results. We report 2 cases of postpneumonectomy syndrome: one with successful relief, and the other in which the saline-filled prosthesis failed to achieve the desired result.

One-stage sequential bilateral thoracic expansion for asphyxiating thoracic dystrophy (Jeune syndrome)

OBJECTIVES

Jeune syndrome (asphyxiating thoracic dystrophy) is a rare disorder characterized by skeletal dysplasia, reduced diameter of the thoracic cage and extrathoracic organ involvement. Fatal, early respiratory insufficiency may occur. Two-stage lateral thoracic expansion has been reported, addressing each side sequentially over 3-12 months. While staged repair theoretically provides less invasive surgery in a small child with respiratory distress, we utilized a single stage, bilateral procedure aiming to rapidly maximize lung development. Combined bilateral surgery also offered the chance of rapid recovery, and reduced hospital stay. We present our early experience of this modification of existing surgical treatment for an extremely rare condition, thought to be generally fatal in early childhood.

METHODS

Nine children (6 males, 3 females; median age 30 months [3.5-75]) underwent thoracic expansion for Jeune syndrome in our centre. All patients required preoperative respiratory support (5 with tracheostomy, 8 requiring positive pressure ventilation regularly within each day/night cycle). Two children underwent sequential unilateral (2-month interval between stages) and 7 children bilateral thoracic expansion by means of staggered osteotomies of third to eighth ribs and plate fixation of fourth to fifth rib and sixth to seventh rib, leaving the remaining ribs floating.

RESULTS

There was no operative mortality. There were 2 deaths within 3 months of surgery, due to pulmonary hypertension (1 following two-stage and 1 following single-stage thoracic expansion). At the median follow-up of 11 months (1-15), 3 children have been discharged home from their referring unit and 2 have significantly reduced respiratory support. One child remains on non-invasive ventilation and another is still ventilated with a high oxygen requirement.

CONCLUSION

Jeune syndrome is a difficult condition to manage, but bilateral thoracic expansion offers an effective reduction in ventilator requirements in these children. While two-stage repair has been described previously, this is the first report of single-stage bilateral thoracic expansion. Single-stage repair is feasible and may offer better resource management and significant cost savings by potentially reducing theatre usage and overall length of stay (intensive care and hospital) without compromising clinical outcomes.

Lipofibromatosis of the knee in a 19-month-old child

Lipofibromatosis is a rare benign fibrofatty tumor of childhood. The typical presentation of this tumor is as a poorly demarcated and slow-growing mass involving the subcutaneous or deep soft tissues. Lipofibromatosis was first described in 2000, and since then, a small number of cases have been reported in the literature. We report a case of a 19-month-old boy who presented with a swelling of the anterior aspect of the right knee since birth, which had increased in size out of proportion with his growth. Magnetic resonance imaging was extremely useful because it showed the lipomatous nature of the mass, narrowing the differential diagnosis to the pediatric fibrofatty soft tissue tumors. The histologic biopsy revealed the specific diagnosis of lipofibromatosis. We describe the radiologic and pathologic features of this entity and discuss the differential diagnosis in a young child with a fat-containing limb mass.

Breast volume assessment: comparing five different techniques

Breast volume assessment is not routinely performed pre-operatively because as yet there is no accepted technique. There have been a variety of methods published, but this is the first study to compare these techniques. We compared volume measurements obtained from mammograms (previously compared to mastectomy specimens) with estimates of volume obtained from four other techniques: thermoplastic moulding, magnetic resonance imaging, Archimedes principle and anatomical measurements. We also assessed the acceptability of each method to the patient. Measurements were performed on 10 women, which produced results for 20 breasts. We were able to calculate regression lines between volume measurements obtained from mammography to the other four methods: (1) magnetic resonance imaging (MRI), 379+(0.75 MRI) [r=0.48], (2) Thermoplastic moulding, 132+(1.46 Thermoplastic moulding) [r=0.82], (3) Anatomical measurements, 168+(1.55 Anatomical measurements) [r=0.83]. (4) Archimedes principle, 359+(0.6 Archimedes principle) [r=0.61] all units in cc. The regression curves for the different techniques are variable and it is difficult to reliably compare results. A standard method of volume measurement should be used when comparing volumes before and after intervention or between individual patients, and it is unreliable to compare volume measurements using different methods. Calculating the breast volume from mammography has previously been compared to mastectomy samples and shown to be reasonably accurate. However we feel thermoplastic moulding shows promise and should be further investigated as it gives not only a volume assessment but a three-dimensional impression of the breast shape, which may be valuable in assessing cosmesis following breast-conserving-surgery.

The outcome of drug smuggling by 'body packers'--the British experience

Body packing or internal concealment used by drug dealers to smuggle illicit substances, puts the body packer at risk of both imprisonment and death. We report our experience over a 4 year period from January 1996 to December 1999 of suspects presenting to our hospital (the largest series in Europe). A total of 572 cases were assessed radiographically and 180 were shown to be carrying foreign bodies. The commonest reasons for admission were suspected overdose or gastrointestinal obstruction. Thirty-six cases were admitted, of whom 7 required surgical intervention. No deaths occurred. Of all people detained for smuggling by internal concealment into Britain during this period, 27% were seen in our hospital. These cases may present alone or escorted by Her Majesty's Customs and Excise personnel, and one must be aware of this possibility even when situated away from a port of entry.