1
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Tchanque-Fossuo CN, Ravichandran N, Barbosa NS. Characteristics of non-melanoma skin cancers in Native American patients treated with Mohs micrographic surgery. Dermatol Online J 2022; 28. [DOI: 10.5070/d328458511] [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] [Received: 08/23/2022] [Accepted: 08/23/2022] [Indexed: 11/08/2022] Open
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2
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Casale F, Elwood HR, Tchanque-Fossuo CN. Exophytic growth on nasal ala. JAAD Case Rep 2022; 19:48-50. [PMID: 34917724 PMCID: PMC8669240 DOI: 10.1016/j.jdcr.2021.10.035] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Fiore Casale
- University of New Mexico, School of Medicine, Albuquerque, New Mexico
| | - Hillary R. Elwood
- Pathology Associates of Albuquerque, Albuquerque, New Mexico
- Department of Dermatology, University of New Mexico, School of Medicine, Albuquerque, New Mexico
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3
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Joo J, Pourang A, Tchanque-Fossuo CN, Armstrong AW, Tartar DM, King TH, Sivamani RK, Eisen DB. Undermining during cutaneous wound closure for wounds less than 3 cm in diameter: a randomized split wound comparative effectiveness trial. Arch Dermatol Res 2021; 314:697-703. [PMID: 34546436 PMCID: PMC9307554 DOI: 10.1007/s00403-021-02280-5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/28/2021] [Accepted: 09/03/2021] [Indexed: 11/30/2022]
Abstract
Undermining is thought to improve wound outcomes; however, randomized controlled data regarding its efficacy are lacking in humans. The objective of this randomized clinical trial was to determine whether undermining low to moderate tension wounds improves scar cosmesis compared to wound closure without undermining. Fifty-four patients, 18 years or older, undergoing primary linear closure of a cutaneous defect with predicted postoperative closure length of ≥ 3 cm on any anatomic site were screened. Four patients were excluded, 50 patients were enrolled, and 48 patients were seen in follow-up. Wounds were divided in half and one side was randomized to receive either no undermining or 2 cm of undermining. The other side received the unselected intervention. Three months, patients and 2 masked observers evaluated each scar using the Patient and Observer Scar Assessment Scale (POSAS). A total of 50 patients [mean (SD) age, 67.6 (11.5) years; 31 (64.6%) male; 48 (100%) white] were enrolled in the study. The mean (SD) sum of the POSAS observer component scores was 12.0 (6.05) for the undermined side and 11.1 (4.68) for the non-undermined side (P = .60). No statistically significant difference was found in the mean (SD) sum of the patient component for the POSAS score between the undermined side [15.9 (9.07)] and the non-undermined side [13.33 (6.20)] at 3 months. For wounds under low to moderate perceived tension, no statistically significant differences in scar outcome or total complications were noted between undermined wound halves and non-undermined halves. Trail Registry: Clinical trials.gov Identifier NCT02289859. https://clinicaltrials.gov/ct2/show/NCT02289859.
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Affiliation(s)
- Jayne Joo
- Department of Dermatology, University of California, Davis, School of Medicine, 3301 C St, Ste 1400, Sacramento, CA, 95816, USA
| | - Aunna Pourang
- Department of Dermatology, University of California, Davis, School of Medicine, 3301 C St, Ste 1400, Sacramento, CA, 95816, USA
| | | | - April W Armstrong
- Department of Dermatology, Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
| | - Danielle M Tartar
- Department of Dermatology, University of California, Davis, School of Medicine, 3301 C St, Ste 1400, Sacramento, CA, 95816, USA
| | - Thomas H King
- Department of Dermatology, University of California, Davis, School of Medicine, Sacramento, CA, USA
| | - Raja K Sivamani
- Department of Dermatology, University of California, Davis, School of Medicine, 3301 C St, Ste 1400, Sacramento, CA, 95816, USA.,Department of Biological Sciences, California State University, Sacramento, CA, USA.,College of Medicine, California Northstate University, Elk Grove, CA, USA.,Pacific Skin Institute, Sacramento, CA, USA
| | - Daniel B Eisen
- Department of Dermatology, University of California, Davis, School of Medicine, 3301 C St, Ste 1400, Sacramento, CA, 95816, USA.
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Casale F, Tchanque-Fossuo CN, Durkin JR. Successful Clearance of Linear Porokeratosis With Aminolevulinic Acid and Pulsed Dye Laser. Dermatol Surg 2021; 47:1300-1301. [PMID: 34448766 DOI: 10.1097/dss.0000000000002996] [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: 11/25/2022]
Affiliation(s)
- Fiore Casale
- University of New Mexico, School of Medicine, Albuquerque, New Mexico
| | | | - John R Durkin
- Department of Dermatology, University of New Mexico, School of Medicine, Albuquerque, New Mexico
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5
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Tchanque-Fossuo CN, Osmani S, Yardman-Frank JM, Barbosa NS. Mohs Micrographic Surgery During the COVID-19 Pandemic: Considering the Patient Perspective. Cutis 2021; 107:271-272. [PMID: 34288857 DOI: 10.12788/cutis.0253] [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: 11/20/2022]
Affiliation(s)
| | - Sabah Osmani
- Department of Dermatology, University of New Mexico School of Medicine, Albuquerque
| | | | - Naiara S Barbosa
- Department of Dermatology, University of New Mexico School of Medicine, Albuquerque
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6
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Wu V, Tchanque-Fossuo CN, Stepenaskie S, Holguin T. Curvilinear violaceous plaques along Blaschko lines. JAAD Case Rep 2021; 12:29-31. [PMID: 34013012 PMCID: PMC8113992 DOI: 10.1016/j.jdcr.2021.04.004] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Victor Wu
- Department of Dermatology, University of New Mexico, School of Medicine, Albuquerque, New Mexico
| | | | - Shelly Stepenaskie
- Tricore Reference Laboratories, Department of Dermatopathology, Albuquerque, New Mexico
| | - Therese Holguin
- Department of Dermatology, University of New Mexico, School of Medicine, Albuquerque, New Mexico
- Correspondence to: Therese Holguin, MD, Department of Dermatology, University of New Mexico, School of Medicine, 1021 Medical Arts Avenue, NE, Albuquerque, NM 87102.
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Durkin JR, Tchanque-Fossuo CN, Rose AN, Elwood HR, Stepenaskie S, Barbosa NS. Surgical Margin Mapping of Melanoma In Situ Using In Vivo Reflectance Confocal Microscopy Mosaics. Dermatol Surg 2021; 47:605-608. [PMID: 33905390 DOI: 10.1097/dss.0000000000002926] [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] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Melanoma in situ (MIS) can have poorly defined borders and subclinical extension that makes margin control challenging. Reflectance confocal microscopy (RCM) is a promising noninvasive technique that can be used to assess subclinical spread. OBJECTIVE To optimize surgical margins of histology-proven MIS using RCM mosaics. MATERIALS AND METHODS Prospective review of 22 patients with histology-proven MIS who underwent RCM margin mapping prior to staged excision, between August 1, 2018, and August 13, 2020, at the Department of Dermatology, University of New Mexico, School of Medicine. RESULTS Twenty patients (91%) had tumor clearance on the first stage using a 3-mm surgical margin after confocal margin mapping. CONCLUSION Reflectance confocal microscopy margin mapping using the mosaic device tends to clear MIS in one stage, and the use of the handheld device may improve the accuracy for difficult anatomic areas. Current Procedural Terminology codes for RCM do not reflect the time required and complexity of the procedure. Reflectance confocal microscopy margin mapping prior to excision has the potential to decrease the number of stages needed for melanoma removal, reduce treatment time, and cost.
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Affiliation(s)
- John R Durkin
- Department of Dermatology, University of New Mexico, School of Medicine, Albuquerque, New Mexico
| | | | - Alexander N Rose
- Department of Dermatology, University of New Mexico, School of Medicine, Albuquerque, New Mexico
| | - Hillary R Elwood
- Department of Dermatology, University of New Mexico, School of Medicine, Albuquerque, New Mexico
- Tricore Reference Laboratories, Albuquerque, New Mexico
| | | | - Naiara S Barbosa
- Department of Dermatology, University of New Mexico, School of Medicine, Albuquerque, New Mexico
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Singh AG, Tchanque-Fossuo CN, Elwood H, Durkin JR. BRAF inhibitor and hairy cell leukemia-related transient acantholytic dermatosis. Dermatol Online J 2020; 26:13030/qt3ps33564. [PMID: 32239892] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 03/26/2020] [Indexed: 06/11/2023] Open
Abstract
Grover disease (GD) is an acquired, nonfamilial, nonimmune mediated, transient or persistent acantholytic dermatosis. Herein, we present a 72-year-old man who had clinical and histopathologic findings of GD following two weeks of treatment with vemurafenib without MEK inhibitor. The patient was successfully treated with topical emollients and a high-potency corticosteroid. Meanwhile, vemurafenib was temporarily discontinued. Drug-induced GD has increasingly been reported in patients on BRAF inhibitor monotherapy as an immune-related adverse event. The cutaneous side effects seem to arise secondary to a paradoxical activation of the mitogen-activated protein kinase signaling of BRAF inhibitor treatment, leading to keratinocyte proliferation. Although the pathogenesis of GD has not been delineated, there is suggestion of activation of T lymphocytes, particularly helper cells under the action of pro-inflammatory cytokines, resulting in proliferation of keratinocytes. Combination therapy with a MEK inhibitor appears to prevent BRAF-induced GD. Given that there is a higher prevalence of GD in patients with hematologic malignancy, a direct causal relationship between the initiation of vemurafenib therapy and development of GD in this case may be difficult to establish.
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Affiliation(s)
| | | | | | - John R Durkin
- Department of Dermatology, University of New Mexico, School of Medicine, Albuquerque, NM.
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Singh AG, Tchanque-Fossuo CN, Elwood H, Durkin JR. BRAF inhibitor and hairy cell leukemia-related transient acantholytic dermatosis. Dermatol Online J 2020. [DOI: 10.5070/d3262047420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Gallegos AC, Davis MJ, Tchanque-Fossuo CN, West K, Eisentrout-Melton A, Peavy TR, Dixon RW, Patel RP, Dahle SE, Isseroff RR. Absorption and Safety of Topically Applied Timolol for Treatment of Chronic Cutaneous Wounds. Adv Wound Care (New Rochelle) 2019; 8:538-545. [PMID: 31637100 DOI: 10.1089/wound.2019.0970] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 02/22/2019] [Accepted: 06/03/2019] [Indexed: 12/14/2022] Open
Abstract
Objective: There are no safety or absorption studies to guide topical timolol therapy for treatment of chronic wounds. This study was undertaken to address this gap. Approach: A prospective, observational, cross-sectional comparative study of timolol plasma levels in patients after topical administration to a chronic wound, compared with levels in patients after timolol ocular administration for the indication of glaucoma. Results: There was no statistically significant difference in the average plasma level of timolol in wound as compared with glaucoma patients. No bradycardia or wheezing was observed after administration. Innovation: We determined the single time point concentration of timolol in plasma 1 h after application of timolol 0.5% gel-forming solution to debrided chronic wounds, providing insight as to the safety of this emerging off-label treatment. Conclusion: The topical application of timolol for chronic wounds shares the same safety profile as the widely used application of ocular administration for glaucoma.
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Affiliation(s)
- Anthony Cole Gallegos
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, California
| | - Michael James Davis
- Department of Surgery, University of California Davis School of Medicine, Sacramento, California
| | - Catherine N. Tchanque-Fossuo
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, California
- Dermatology Service; Department of Surgery; VA Northern California, Sacramento VA Medical Center, Mather, California
| | - Kaitlyn West
- Dermatology Service; Department of Surgery; VA Northern California, Sacramento VA Medical Center, Mather, California
| | - Angela Eisentrout-Melton
- Dermatology Service; Department of Surgery; VA Northern California, Sacramento VA Medical Center, Mather, California
| | - Thomas R. Peavy
- Department of Biological Sciences, California State University, Sacramento, Sacramento, California
| | - Roy W. Dixon
- Department of Chemistry, California State University, Sacramento, Sacramento, California
| | - Roma P. Patel
- Ophthalmology Service; Department of Surgery; VA Northern California, Sacramento VA Medical Center, Mather, California
- UC Davis Health System Eye Center, UC Davis School of Medicine, Sacramento, California
| | - Sara Evona Dahle
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, California
- Podiatry Section, Department of Surgery; VA Northern California, Sacramento VA Medical Center, Mather, California
| | - Roslyn Rivkah Isseroff
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, California
- Dermatology Service; Department of Surgery; VA Northern California, Sacramento VA Medical Center, Mather, California
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11
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Dahle SE, Martin K, Williams JC, Tchanque-Fossuo CN, West KI, Schulman JM. Limb salvage of the foot with Lisfranc amputation following squamous cell carcinoma. JRSM Open 2019; 10:2054270419853144. [PMID: 31308950 PMCID: PMC6604120 DOI: 10.1177/2054270419853144] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The indolent character of squamous cell carcinoma of the foot can be misleading
and might result in unwarranted excisions or delayed treatment.
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Affiliation(s)
- Sara E Dahle
- Department of Surgery, Podiatry Section, VA Northern California Health Care System, Sacramento VA Medical Center, Mather, CA 95655, USA.,Department of Dermatology, University of California Davis Medical Center, Sacramento, CA 95817, USA
| | - Kennon Martin
- Department of Surgery, Podiatry Section, VA Northern California Health Care System, Sacramento VA Medical Center, Mather, CA 95655, USA
| | - John C Williams
- Department of Surgery, Podiatry Section, VA Northern California Health Care System, Sacramento VA Medical Center, Mather, CA 95655, USA
| | - Catherine N Tchanque-Fossuo
- Department of Dermatology, University of California Davis Medical Center, Sacramento, CA 95817, USA.,Dermatology Service, VA Northern California Health Care System, Sacramento VA Medical Center, Mather, CA 95655, USA
| | - Kaitlyn Im West
- Department of Surgery, Podiatry Section, VA Northern California Health Care System, Sacramento VA Medical Center, Mather, CA 95655, USA
| | - Joshua M Schulman
- Department of Dermatology, University of California Davis Medical Center, Sacramento, CA 95817, USA.,Dermatology Service, VA Northern California Health Care System, Sacramento VA Medical Center, Mather, CA 95655, USA
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12
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Tchanque-Fossuo CN, Dahle SE, Kiuru M, Isseroff RR. Vitiligo and melanocytic nevi: New findings in Coffin-Siris syndrome associated with ARID1 germline mutation. JAAD Case Rep 2018; 5:50-53. [PMID: 30581937 PMCID: PMC6287087 DOI: 10.1016/j.jdcr.2018.08.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Key Words
- ARID1A, AT-rich interactive domain 1A gene
- ARID1B
- ARID1B, AT-rich interactive domain 1B gene
- CDK, cyclin-dependent kinase
- CSS, Coffin-Siris syndrome
- Coffin-Siris syndrome
- MITF, microphthalmia transcription factor
- SMARB1, SWI/SNF–related, matrix-associated, actin-dependent regulator of chromatin subfamily B member 1
- SMARCA4, SWI/SNF–related, matrix-associated, actin-dependent regulator of chromatin subfamily A member 4
- SMARCE1, SWI/SNF–related, matrix-associated, actin-dependent regulator of chromatin subfamily E member 1
- SWI/SNF, switch/sucrose nonfermenting
- melanoma
- nevi
- vitiligo
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Affiliation(s)
- Catherine N. Tchanque-Fossuo
- Department of Dermatology, University of California, Davis, Sacramento, California
- Dermatology Service, VA Northern California, Sacramento VA Medical Center, Mather, California
- Correspondence to: Catherine N. Tchanque-Fossuo, MD, MS, Department of Dermatology, University of California, Davis, School of Medicine, 3301 C St, Ste 1400, Sacramento, CA 95816.
| | - Sara E. Dahle
- Department of Dermatology, University of California, Davis, Sacramento, California
- Podiatry Section, Department of Surgery, VA Northern California, Sacramento VA Medical Center, Mather, California
| | - Maija Kiuru
- Department of Dermatology, University of California, Davis, Sacramento, California
- Department of Pathology and Laboratory Medicine, University of California, Davis, Sacramento, California
| | - R. Rivkah Isseroff
- Department of Dermatology, University of California, Davis, Sacramento, California
- Dermatology Service, VA Northern California, Sacramento VA Medical Center, Mather, California
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13
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Tchanque-Fossuo CN, Eisen DB. A systematic review on the use of cryotherapy versus other treatments for basal cell carcinoma. Dermatol Online J 2018; 24:13030/qt49k1c38t. [PMID: 30695972] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 12/16/2018] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Cryotherapy is a commonly discussed method for treatment of basal cell carcinoma skin cancer. Some uncertainty remains about its efficacy relative to other modalities. OBJECTIVE To determine the efficacy and adverse events profile of cryotherapy for the treatment of basal cell carcinoma compared to other therapeutic options or non-intervention. METHODS We systematically searched PubMed, OVID, Cochrane Library, EMBASE, CINHAL, and CANCERLIT databases for the following terms: "cryotherapy", AND "basal cell carcinoma", OR "cryosurgery" OR "cryoablation" up to April 2018. Two independent reviewers screened the results and extracted the data. Study endpoints included basal cell carcinoma recurrence, cosmetic outcome, and healing time. Study quality was assessed using the Jadad scale. RESULTS Six clinical studies met our inclusion criteria. The efficacy and safety of cryotherapy alone or with curettage in the treatment of primary superficial and nodular basal cell carcinoma was comparable to photodynamic therapy and surgery, respectively. Cryotherapy was inferior to radiation in terms of recurrence rate. Most patients had better cosmetic outcomes with photodynamic therapy and surgery compared to cryotherapy alone, and cryotherapy with curettage. CONCLUSION Current available data suggests equivalent efficacy of cryotherapy alone compared to photodynamic therapy or surgery, but inferior to radiotherapy. More studies are necessary to draw definitive conclusions.
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Affiliation(s)
| | - Daniel B Eisen
- Department of Dermatology, University of California Davis, Sacramento, CA.
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14
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Tchanque-Fossuo CN, Eisen DB. A systematic review on the use of cryotherapy versus other treatments for basal cell carcinoma. Dermatol Online J 2018. [DOI: 10.5070/d32411042000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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15
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Tchanque-Fossuo CN, Dahle SE, Lev-Tov H, Li CS, Isseroff RR. Cellular versus acellular grafts for diabetic foot ulcers: altering the protocol to improve recruitment to a comparative efficacy trial. Cutis 2017; 100:E18-E21. [PMID: 29232436] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Diabetic foot ulcers (DFUs) have a substantial impact on public health. The standard of care (SOC) for DFUs consists of a multidisciplinary approach involving glycemic control, wound care with debridement of necrotic tissue, application of a moist dressing, infection control, use of off-loading devices, and patient education. New therapeutic devices aim to target the extracellular matrix (ECM) that is impaired in DFU; however, there is insufficient data on the effectiveness of such therapies along with lack of evidence on their long-term effectiveness. We hypothesized that there is no difference in healing between the cellular matrix and an acellular matrix relative to SOC. To test this hypothesis, we conducted a randomized, single-blind clinical trial in patients with nonhealing DFUs that included 3 treatment arms: (1) SOC, (2) SOC plus a bioengineered ECM with living fibroblasts, and (3) SOC plus a bioengineered ECM devoid of cells. Our trial currently is closed for enrollment, as we have reached our target population size. Amendments to the protocol were made to help reach this threshold.
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Affiliation(s)
| | | | | | | | - R Rivkah Isseroff
- University of California Davis, Department of Dermatology, 3301 C St, Ste 1400, Sacramento, CA 95816, USA.
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16
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Monson LA, Nelson NS, Donneys A, Farberg AS, Tchanque-Fossuo CN, Deshpande SS, Buchman SR. Amifostine Treatment Mitigates the Damaging Effects of Radiation on Distraction Osteogenesis in the Murine Mandible. Ann Plast Surg 2017; 77:164-8. [PMID: 27070667 DOI: 10.1097/sap.0000000000000276] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
According to the American Society of Clinical Oncology, in 2012, more than 53,000 new cases of head and neck cancers (HNCs) were reported in the United States alone and nearly 12,000 deaths occurred relating to HNC. Although radiotherapy (XRT) has increased survival, the adverse effects can be unrelenting and their management is rarely remedial. Current treatment dictates surgical mandibular reconstruction using free tissue transfer. These complex operations entail extended hospitalizations and attendant complications often lead to delays in initiation of adjuvant therapy, jeopardizing prognosis as well as quality of life. The creation of new bone by distraction osteogenesis (DO) generates a replacement of deficient tissue from local substrate and could have immense potential therapeutic ramifications. Radiotherapy drastically impairs bone healing, precluding its use as a reconstructive method for HNC. We posit that the deleterious effects of XRT on bone formation could be pharmacologically mitigated. To test this hypothesis, we used a rodent model of DO and treated with amifostine, a radioprotectant, to assuage the XRT-induced injury on new bone formation. Amifostine had a profound salutary effect on bone regeneration, allowing the successful implementation of DO as a reconstructive technique. The optimization of bone regeneration in the irradiated mandible has immense potential for translation from the bench to the bedside, providing improved therapeutic options for patients subjected to XRT.
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Affiliation(s)
- Laura A Monson
- From the *Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, MI; and †Department of Surgery, Plastic Surgery Section, Baylor College of Medicine, Houston, TX
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Larsen L, Tchanque-Fossuo CN, Gorouhi F, Boudreault D, Nguyen C, Fuentes JJ, Crawford RW, Dahle SE, Whetzel T, Isseroff RR. Combination therapy of autologous adipose mesenchymal stem cell-enriched, high-density lipoaspirate and topical timolol for healing chronic wounds. J Tissue Eng Regen Med 2017; 12:186-190. [PMID: 27943665 DOI: 10.1002/term.2390] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [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: 04/20/2016] [Revised: 11/12/2016] [Accepted: 12/06/2016] [Indexed: 12/12/2022]
Abstract
Chronic venous leg ulcers are profoundly debilitating and result in billions in health care expenditure. Thus, there is a quest for engineered and innovative approaches. Herein we present a 63-year-old patient with a 30 year history of venous stasis and left lower extremity ulcers, which have been refractory to standard of care, anticoagulation and venous stripping. The medial ulcer was treated with transplantation of autologous adipose mesenchymal stem cell (AMSC)-enriched, high-density lipoaspirate (HDL) on OASIS wound matrix and compression therapy. The lateral ulcer was treated as a control with standard debridement and compression therapy. Four weeks later, both ulcers received daily topical timolol. Three months later, the test ulcer was completely epithelized and remains healed for over 15 months. However, the control showed minimal signs of improvement. In companion studies in our laboratory, human AMSC were cultured in Minimum Essential Medium Eagle Alpha Modifications (MEMα) with fetal bovine serum (FBS). Timolol was administered to AMSC prior to treatment with epinephrine and 104 bacteria/ml heat-killed Staphylococcus aureus. The MEMα with FBS devoid of AMSC served as a background control. After 24 h, cell culture supernatants and protein lysates were collected to determine cytokine production. There was a statistical significant decrease in pro-inflammatory interleukin-6 and -8 induced by the bacteria (to model the wound environment) in AMSC in the presence of timolol compared with control (p < 0.5). This is the first case of a successful combination of autologous AMSC-enriched, HDL with topical timolol for the healing of chronic venous leg ulcers. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Larissa Larsen
- Department of Dermatology, University of California, Davis, Sacramento, CA, USA
| | - Catherine N Tchanque-Fossuo
- Department of Dermatology, University of California, Davis, Sacramento, CA, USA.,Department of Dermatology, Veterans Administration, Northern California Health Care System, Mather, CA, USA
| | - Farzam Gorouhi
- Department of Dermatology, University of California, Davis, Sacramento, CA, USA
| | - David Boudreault
- Department of Plastic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Chuong Nguyen
- Department of Dermatology, University of California, Davis, Sacramento, CA, USA
| | - Jaime J Fuentes
- Department of Biological Sciences, California State University, Sacramento, CA, USA
| | - Robert W Crawford
- Department of Biological Sciences, California State University, Sacramento, CA, USA
| | - Sara E Dahle
- Department of Dermatology, University of California, Davis, Sacramento, CA, USA.,Department of Surgery, Podiatry Section, Veterans Administration, Northern California Health Care System, Mather, CA, USA
| | - Thomas Whetzel
- Department of Plastic Surgery, University of California, Davis, Sacramento, CA, USA.,Plastic Surgery, Veterans Administration, Northern California Health Care System, Mather, CA, USA
| | - R Rivkah Isseroff
- Department of Dermatology, University of California, Davis, Sacramento, CA, USA.,Department of Dermatology, Veterans Administration, Northern California Health Care System, Mather, CA, USA
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Tchanque-Fossuo CN, Isseroff RR, Silverstein MA. Fluoroscopy induced chronic radiation dermatitis should be included in the differential diagnosis of notalgia paresthetica. Dermatol Online J 2016; 22:13030/qt0kh726m9. [PMID: 28329575] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 11/16/2016] [Indexed: 06/06/2023] Open
Abstract
We report a patient with radiation (fluoroscopic)-induced dermatitis that produced symptoms similar to notalgia paresthetica.
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Affiliation(s)
| | | | - Marc A Silverstein
- Department of Dermatology, University of California Davis, Sacramento, CA
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Tchanque-Fossuo CN, Kamangar F, Ho B, Chang S, Dahle SE, Schulman JM, Isseroff RR. Fluoroscopy-induced radionecrosis. Dermatol Online J 2016. [DOI: 10.5070/d3228032090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Tchanque-Fossuo CN, Kamangar F, Ho B, Chang S, Dahle SE, Schulman JM, Isseroff RR. Fluoroscopy-induced radionecrosis. Dermatol Online J 2016; 22:13030/qt68w910t2. [PMID: 27617939] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 08/17/2016] [Indexed: 06/06/2023] Open
Abstract
Complications from radiation exposure during fluoroscopic guidance of cardiac catheterization may occur. With repeated procedures, the risk for cutaneous injuries increases. Herein, we describe a 59-year-old man with extensive coronary artery disease, who had undergone multiple revascularization procedures and developed a non-healing ulcer on his left inferior scapula. The patient's medical history, physical exam findings, and histopathology gave clues to a case of radiation-induced dermatitis and necrosis.
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Affiliation(s)
| | | | | | | | | | | | - R Rivkah Isseroff
- Dermatology Service, Sacramento VA Medical Center, Mather, CA Department of Dermatology, University of California Davis, Sacramento, CA.
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Tchanque-Fossuo CN, Ho D, Dahle SE, Koo E, Isseroff RR, Jagdeo J. Low-level Light Therapy for Treatment of Diabetic Foot Ulcer: A Review of Clinical Experiences. J Drugs Dermatol 2016; 15:843-848. [PMID: 27391634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Diabetic foot ulcers (DFU) represent a significant complication of diabetes mellitus (DM). DFU affect one in four patients with DM and treatments of DFU are limited and challenging. The management of DFU remains a significant healthcare and socioeconomic burden ($245 billion). There is a wide range of advanced therapies for DFU, but these are costly and have demonstrated only minimal efficacy in limited published studies. An emerging treatment modality to improve DFU and optimize wound healing is the use of low-level light therapy (LLLT). LLLT involves the use of light in the form of low-level or low-power laser or light emitting diodes to alter biochemical pathways, which may result in changes to cell shape, cell migration, and cell signaling.<br/> OBJECTIVE To review published clinical experiences (case series and case reports) using LLLT for treatment of DFU, and provide evidence-based recommendations and future directions on the potential of LLLT as a therapeutic modality for DFU.<br/> METHODS AND MATERIALS On January 16, 2016 we searched the published literature using databases: PubMed, EMBASE, CINAHL, and Web of Science with key terms: "diabetic foot" AND ("low level laser therapy" OR "low level light therapy" OR "LLLT" OR "light emitting diode" OR "phototherapy" OR "laser").<br/> RESULTS After screening of titles, abstracts and/or full-text, 7 original articles were suitable in our review. Our review contains 5 case series and 2 case reports that evaluated LLLT for treatment of DFU, and all reviewed studies have shown positive improvement of DFU using LLLT with no adverse events, albeit with limitations that may be minimized with future RCTs.<br/> CONCLUSIONS LLLT is an emerging and promising treatment modality to current alternatives that are costly and have shown limited success. Based upon the published evidence, we envision additional research may allow for stronger recommendation with LLLT for treatment of DFU. <br /><br /> <em>J Drugs Dermatol.</em> 2016;15(7):843-848.
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Tchanque-Fossuo CN, Isseroff RR, Silverstein MA. Fluoroscopy induced chronic radiation dermatitis should be included in the differential diagnosis of notalgia paresthetica. Dermatol Online J 2016. [DOI: 10.5070/d32211033162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Donneys A, Nelson NS, Page EE, Deshpande SS, Felice PA, Tchanque-Fossuo CN, Spiegel JP, Buchman SR. Targeting angiogenesis as a therapeutic means to reinforce osteocyte survival and prevent nonunions in the aftermath of radiotherapy. Head Neck 2014; 37:1261-7. [PMID: 24801669 DOI: 10.1002/hed.23744] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 03/19/2014] [Accepted: 05/03/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Radiotherapy (XRT) exerts detrimental collateral effects on bone tissue through mechanisms of vascular damage and impediments to osteocytes, ultimately predisposing patients to the debilitating problems of late pathologic fractures and nonunions. We posit that angiogenic therapy will reverse these pathologic effects in a rat model of radiated fracture healing. METHODS Three groups of rats underwent mandibular osteotomy. Radiated groups received a fractionated 35-Gy dose before surgery. The deferoxamine (DFO) group received local injections postoperatively. A 40-day healing period was allowed before histology. Analysis of variance (ANOVA; p < .05) was used for group comparisons. RESULTS Radiated fractures revealed a significantly decreased osteocyte count and corresponding increase in empty lacunae when compared to nonradiated fractures (p = .001). With the addition of DFO, these differences were not appreciated. Further, a 42% increase in bony unions was observed after DFO therapy. CONCLUSION Targeting angiogenesis is a useful means for promoting osteocyte survival and preventing bone pathology after XRT.
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Affiliation(s)
- Alexis Donneys
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan
| | - Noah S Nelson
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan
| | - Erin E Page
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan
| | - Sagar S Deshpande
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan
| | - Peter A Felice
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan.,Department of General Surgery, University of South Carolina School of Medicine, Columbia, South Carolina
| | | | - Joshua P Spiegel
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan
| | - Steven R Buchman
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan
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Tchanque-Fossuo CN, Donneys A, Sarhaddi D, Poushanchi B, Deshpande SS, Weiss DM, Buchman SR. The effect of Amifostine prophylaxis on bone densitometry, biomechanical strength and union in mandibular pathologic fracture repair. Bone 2013; 57:56-61. [PMID: 23860272 PMCID: PMC3804002 DOI: 10.1016/j.bone.2013.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 07/02/2013] [Accepted: 07/03/2013] [Indexed: 01/23/2023]
Abstract
BACKGROUND Pathologic fractures (Fx) of the mandibles are severely debilitating consequences of radiation (XRT) in the treatment of craniofacial malignancy. We have previously demonstrated Amifostine's effect (AMF) in the remediation of radiation-induced cellular damage. We posit that AMF prophylaxis will preserve bone strength and drastically reverse radiotherapy-induced non-union in a murine mandibular model of pathologic fracture repair. MATERIALS AND METHODS Twenty-nine rats were randomized into 3 groups: Fx, XRT/Fx, and AMF/XRT/Fx. A fractionated human equivalent dose of radiation was delivered to the left hemimandibles of XRT/Fx and AMF/XRT/Fx. AMF/XRT/Fx was pre-treated with AMF. All groups underwent left mandibular osteotomy with external fixation and setting of a 2.1mm fracture gap post-operatively. Utilizing micro-computed tomography and biomechanical testing, the healed fracture was evaluated for strength. RESULTS All radiomorphometrics and biomechanical properties were significantly diminished in XRT/Fx compared to both Fx and AMF/XRT/Fx. No difference was demonstrated between Fx and AMF/XRT/Fx in both outcomes. CONCLUSION Our investigation establishes the significant and substantial capability of AMF prophylaxis to preserve and enhance bone union, quality and strength in the setting of human equivalent radiotherapy. Such novel discoveries establish the true potential to utilize pharmacotherapy to prevent and improve the treatment outcomes of radiation-induced late pathologic fractures.
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Affiliation(s)
- Catherine N. Tchanque-Fossuo
- University of Michigan Hospital and Health Systems, Pediatric Plastic Surgery Section, 1540 E. Hospital Drive, Ann Arbor, MI 48109, Phone: (734) 936 5881, Fax: (734) 936 7815
| | - Alexis Donneys
- University of Michigan Hospital and Health Systems, Pediatric Plastic Surgery Section, 1540 E. Hospital Drive, Ann Arbor, MI 48109, Phone: (734) 936 5881, Fax: (734) 936 7815
| | - Deniz Sarhaddi
- University of Michigan Hospital and Health Systems, Pediatric Plastic Surgery Section, 1540 E. Hospital Drive, Ann Arbor, MI 48109, Phone: (734) 936 5881, Fax: (734) 936 7815
| | - Behdod Poushanchi
- University of Michigan Hospital and Health Systems, Pediatric Plastic Surgery Section, 1540 E. Hospital Drive, Ann Arbor, MI 48109, Phone: (734) 936 5881, Fax: (734) 936 7815
| | - Sagar S. Deshpande
- University of Michigan Hospital and Health Systems, Pediatric Plastic Surgery Section, 1540 E. Hospital Drive, Ann Arbor, MI 48109, Phone: (734) 936 5881, Fax: (734) 936 7815
| | - Daniela M. Weiss
- University of Michigan Hospital and Health Systems, Pediatric Plastic Surgery Section, 1540 E. Hospital Drive, Ann Arbor, MI 48109, Phone: (734) 936 5881, Fax: (734) 936 7815
| | - Steven R. Buchman
- 4-730 C.S. Mott Children’s Hospital, 1540 E. Hospital Drive, Ann Arbor, MI 48109-4215, Phone: (734) 936-5881, Fax: (734) 936-7815
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Donneys A, Deshpande SS, Tchanque-Fossuo CN, Johnson KL, Blough JT, Perosky JE, Kozloff KM, Felice PA, Nelson NS, Farberg AS, Levi B, Buchman SR. Deferoxamine expedites consolidation during mandibular distraction osteogenesis. Bone 2013; 55:384-90. [PMID: 23598047 PMCID: PMC4162399 DOI: 10.1016/j.bone.2013.04.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Revised: 03/29/2013] [Accepted: 04/07/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND A limitation of mandibular distraction osteogenesis (DO) is the length of time required for consolidation. This drawback subjects patients to possible pin-site infections, as well as a prolonged return to activities of normal daily living. Developing innovative techniques to abridge consolidation periods could be immensely effective in preventing these problematic morbidities. Deferoxamine (DFO) is an angiogenic activator that triggers the HIF-1α pathway through localized iron depletion. We previously established the effectiveness of DFO in enhancing regenerate vascularity at a full consolidation period (28 days) in a murine mandibular DO model. To investigate whether this augmentation in vascularity would function to accelerate consolidation, we progressively shortened consolidation periods prior to μCT imaging and biomechanical testing (BMT). MATERIALS AND METHODS Three time points (14d, 21d and 28d) were selected and six groups of Sprague-Dawley rats (n = 60) were equally divided into control (C) and experimental (E) groups for each time period. Each group underwent external fixator placement, mandibular osteotomy, and a 5.1 mm distraction. During distraction, the experimental groups were treated with DFO injections into the regenerate gap. After consolidation, mandibles were imaged and tension tested to failure. ANOVA was conducted between groups, and p < 0.05 was considered statistically significant. RESULTS At 14 days of consolidation the experimental group demonstrated significant increases in bone volume fraction (BVF), bone mineral density (BMD) and ultimate load (UL) in comparison to non-treated controls. The benefit of treatment was further substantiated by a striking 100% increase in the number of bony unions at this early time-period (C:4/10 vs. E:8/10). Furthermore, metrics of BVF, BMD, Yield and UL at 14 days with treatment demonstrated comparable metrics to those of the fully consolidated 28d control group. CONCLUSION Based on these findings, we contend that augmentation of vascular density through localized DFO injection delivers an efficient means for accelerating bone regeneration without significantly impacting bone quality or strength.
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Affiliation(s)
- Alexis Donneys
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan, USA
| | - Sagar S. Deshpande
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Kelsey L. Johnson
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan, USA
| | - Jordan T. Blough
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph E. Perosky
- Orthopedic Research Laboratory, Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Kenneth M. Kozloff
- Orthopedic Research Laboratory, Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Peter A. Felice
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan, USA
| | - Noah S. Nelson
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan, USA
| | - Aaron S. Farberg
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan, USA
| | - Benjamin Levi
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan, USA
| | - Steven R. Buchman
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan, USA
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Deshpande SS, Gallagher KK, Donneys A, Tchanque-Fossuo CN, Sarhaddi D, Sun H, Krebsbach PH, Buchman SR. Stem cell therapy remediates reconstruction of the craniofacial skeleton after radiation therapy. Stem Cells Dev 2013; 22:1625-32. [PMID: 23282102 PMCID: PMC3657278 DOI: 10.1089/scd.2012.0472] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [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: 08/29/2012] [Accepted: 12/30/2012] [Indexed: 11/13/2022] Open
Abstract
This study utilized transplanted bone marrow stromal cells (BMSCs) as a cellular replacement therapy to remedy radiation-induced injury and restore impaired new bone formation during distraction osteogenesis (DO). BMSC therapy brought about the successful generation of new bone and significantly improved both the rate and quality of a bony union of irradiated, distracted [X-ray radiation therapy (XRT)/DO] murine mandibles to the level of nonirradiated DO animals. The bone mineral density and bone volume fraction were also significantly improved by the BMSC replacement therapy showing no difference when compared to nonirradiated animals. Finally, a biomechanical analysis examining the yield, failure load, and ultimate load also demonstrated a significantly improved structural integrity in BMSC-treated XRT/DO mandibles over XRT/DO alone. These results indicate that administration of BMSCs intraoperatively to a radiated distraction gap can function as an adequate stimulant to rescue the ability for irradiated bone to undergo DO and produce a healed regenerate of a vastly superior quality and strength. We believe that the fundamental information on the optimization of bone regeneration in the irradiated mandible provided by this work has immense potential to be translated from the bench to the bedside to lead to improved therapeutic options for patients suffering from the disastrous sequelae of radiation therapy.
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Affiliation(s)
- Sagar S. Deshpande
- Craniofacial Research Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Kathleen K. Gallagher
- Craniofacial Research Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Alexis Donneys
- Craniofacial Research Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Catherine N. Tchanque-Fossuo
- Craniofacial Research Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Deniz Sarhaddi
- Craniofacial Research Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Hongli Sun
- Department of Biologic and Materials Sciences, School of Dentistry, University of Michigan, Ann Arbor, Michigan
| | - Paul H. Krebsbach
- Department of Biologic and Materials Sciences, School of Dentistry, University of Michigan, Ann Arbor, Michigan
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Steven R. Buchman
- Craniofacial Research Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Tchanque-Fossuo CN, Gong B, Poushanchi B, Donneys A, Sarhaddi D, Gallagher KK, Deshpande SS, Goldstein SA, Morris MD, Buchman SR. Raman spectroscopy demonstrates Amifostine induced preservation of bone mineralization patterns in the irradiated murine mandible. Bone 2013; 52:712-717. [PMID: 22885239 PMCID: PMC3789510 DOI: 10.1016/j.bone.2012.07.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 07/26/2012] [Accepted: 07/27/2012] [Indexed: 12/28/2022]
Abstract
PURPOSE Adjuvant radiotherapy in the management of head and neck cancer remains severely debilitating. Fortunately, newly developed agents aimed at decreasing radiation-induced damage have shown great promise. Amifostine (AMF) is a compound, which confers radio-protection to the exposed normal tissues, such as bone. Our intent is to utilize Raman spectroscopy to demonstrate how AMF preserves the mineral composition of the murine mandible following human equivalent radiation. METHODS Sprague Dawley rats were randomized into 3 experimental groups: control (n=5), XRT (n=5), and AMF-XRT (n=5). Both XRT and AMF groups underwent bioequivalent radiation of 70Gy in 5 fractions to the left hemimandible. AMF-XRT received Amifostine prior to radiation. Fifty-six days post-radiation, the hemimandibles were harvested, and Raman spectra were taken in the region of interest spanning 2mm behind the last molar. Bone mineral and matrix-specific Raman bands were analyzed using one-way ANOVA, with statistical significance at p<0.05. RESULTS The full-width at half-maximum of the primary phosphate band (FWHM) and the ratio of carbonate/phosphate intensities demonstrated significant differences between AMF-XRT versus XRT (p<0.01) and XRT versus control (p<0.01). There was no difference between AMF-XRT and control (p>0.05) in both Raman metrics. Computer-aided spectral subtraction further confirmed these results where AMF-XRT was spectrally similar to the control. Interestingly, the collagen cross-link ratio did not differ between XRT and AMF-XRT (p<0.01) but was significantly different from the control (p<0.01). CONCLUSION Our novel findings demonstrate that AMF prophylaxis maintains and protects bone mineral quality in the setting of radiation. Raman spectroscopy is an emerging and exceptionally attractive clinical translational technology to investigate and monitor both the destructive effects of radiation and the therapeutic remediation of AMF on the structural, physical and chemical qualities of bone.
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Affiliation(s)
- Catherine N. Tchanque-Fossuo
- University of Michigan Hospital and Health Systems, Pediatric Plastic Surgery Section, 1540 E. Hospital Drive, MI 48109, USA
| | - Bo Gong
- University of Michigan Hospital and Health Systems, Department of Chemistry, 930 N. University, Ann Arbor, MI 48109, USA
| | - Behdod Poushanchi
- University of Michigan Hospital and Health Systems, Pediatric Plastic Surgery Section, 1540 E. Hospital Drive, MI 48109, USA
| | - Alexis Donneys
- University of Michigan Hospital and Health Systems, Pediatric Plastic Surgery Section, 1540 E. Hospital Drive, MI 48109, USA
| | - Deniz Sarhaddi
- University of Michigan Hospital and Health Systems, Pediatric Plastic Surgery Section, 1540 E. Hospital Drive, MI 48109, USA
| | - K. Kelly Gallagher
- University of Michigan Hospital and Health Systems, Department of Otolaryngology–Head and Neck Surgery, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Sagar S. Deshpande
- University of Michigan Hospital and Health Systems, Pediatric Plastic Surgery Section, 1540 E. Hospital Drive, MI 48109, USA
| | - Steven A. Goldstein
- University of Michigan, Department of Orthopaedic Surgery, A. Alfred Taubman Biomedical Science Research Building, 109 Zina Pitcher Pl, Ann Arbor, MI, 48109, USA
| | - Michael D. Morris
- University of Michigan Hospital and Health Systems, Department of Chemistry, 930 N. University, Ann Arbor, MI 48109, USA
| | - Steven R. Buchman
- University of Michigan Hospital and Health Systems, Pediatric Plastic Surgery Section, 1540 E. Hospital Drive, MI 48109, USA
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Gallagher KK, Deshpande S, Tchanque-Fossuo CN, Donneys A, Sarhaddi D, Nelson NS, Chepeha DB, Buchman SR. Role of parathyroid hormone therapy in reversing radiation-induced nonunion and normalization of radiomorphometrics in a murine mandibular model of distraction osteogenesis. Head Neck 2013; 35:1732-7. [PMID: 23335324 DOI: 10.1002/hed.23216] [Citation(s) in RCA: 14] [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] [Subscribe] [Scholar Register] [Accepted: 09/28/2012] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The use of mandibular distraction osteogenesis (MDO) for tissue replacement after oncologic resection or for defects caused by osteoradionecrosis has been described but, in fact, has seen limited clinical utility. Previous laboratory work has shown that radiation (XRT) causes decreased union formation, decreased cellularity, and decreased mineral density in an animal model of MDO. Our global hypothesis is that radiation-induced bone damage is partly driven by the pathologic depletion of both the number and function of osteogenic cells. Parathyroid hormone (PTH) is a U.S. Food and Drug Administration-approved anabolic hormonal therapy that has demonstrated efficacy for increasing bone mineral density for the treatment of osteoporosis. We postulate that intermittent systemic administration of PTH will serve as an anabolic stimulant to cellular function that will act to reverse radiation-induced damage and enhance bone regeneration in a murine mandibular model of DO. METHODS A total of 20 isogenic male Lewis rats were randomly assigned into 3 groups. Group 1 (XRT-DO, n = 7) and group 2 (XRT-DO-PTH, n = 5) received a human bioequivalent dose of 70 Gy fractionated over 5 days. All groups including group 3 (DO, n = 8) underwent a left unilateral mandibular osteotomy with bilateral external fixator placement. Four days later, mandibular DO was performed at a rate of 0.3 mm every 12 hours to reach a maximum gap of 5.1 mm. Group 2 was injected PTH (60 μg/kg) subcutaneously daily for 3 weeks following the start of MDO. On postoperative day 41, all left hemimandibles were harvested. Micro-CT at 45-μm voxel size was performed and radiomorphometrics parameters of bone mineralization were generated. Union quality was evaluated on a 4-point qualitative grading scale. Radiomorphometric data were analyzed using 1-way ANOVA, and union quality assessment was analyzed via the Mann-Whitney test. Statistical significance was considered at p ≤ .05. RESULTS Groups 1 and 2 appropriately demonstrated clinical signs of radiation-induced stress ranging from alopecia to mucositis. Union quality was significantly higher in PTH-treated XRT-DO animals, compared with XRT-DO group animals (p = .02). Mineralization metrics, including bone volume fraction (BVF) and bone mineral density (BMD), also showed statistically significant improvement. The groups that were treated with PTH showed no statistical differences in union or radiomorphometrics when compared with DO in nonradiated animals. CONCLUSION We have successfully demonstrated the therapeutic efficacy of PTH to stimulate and enhance bone regeneration in our irradiated murine mandibular model of DO. Our investigation effectively resulted in statistically significant increases in BMD, BVF, and clinical unions in PTH-treated mandibles. PTH demonstrates immense potential to treat clinical pathologies where remediation of bone regeneration is essential.
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Affiliation(s)
- K Kelly Gallagher
- Departments of Otolaryngology-Head and Neck Surgery and Plastic Surgery, University of Michigan Health System, Ann Arbor, Michigan
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Donneys A, Weiss DM, Deshpande SS, Ahsan S, Tchanque-Fossuo CN, Sarhaddi D, Levi B, Goldstein SA, Buchman SR. Localized deferoxamine injection augments vascularity and improves bony union in pathologic fracture healing after radiotherapy. Bone 2013; 52:318-25. [PMID: 23085084 PMCID: PMC3513581 DOI: 10.1016/j.bone.2012.10.014] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 10/11/2012] [Accepted: 10/12/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND Medically based efforts and alternative treatment strategies to prevent or remediate the corrosive effects of radiotherapy on pathologic fracture healing have failed to produce clear and convincing evidence of success. Establishing an effective pharmacologic option to prevent or treat the development of non-unions in this setting could have immense therapeutic potential. Experimental studies have shown that deferoxamine (DFO), an iron-chelating agent, bolsters vascularity and subsequently enhances normal fracture healing when injected locally into a fracture callus in long bone animal models. Since radiotherapy is known to impede angiogenesis, we hypothesized that the pharmacologic addition of DFO would serve to mitigate the effects of radiotherapy on new vessel formation in vitro and in vivo. MATERIALS AND METHODS In vitro investigation of angiogenesis was conducted utilizing HUVEC cells in Matrigel. Endothelial tubule formation assays were divided into four groups: Control, Radiated, Radiated+Low-Dose DFO and Radiated+High-Dose DFO. Tubule formation was quantified microscopically and video recorded for the four groups simultaneously during the experiment. In vivo, three groups of Sprague-Dawley rats underwent external fixator placement and fracture osteotomy of the left mandible. Two groups received pre-operative fractionated radiotherapy, and one of these groups was treated with DFO after fracture repair. After 40 days, the animals were perfused and imaged with micro-CT to calculate vascular radiomorphometrics. RESULTS In vitro, endothelial tubule formation assays demonstrated that DFO mitigated the deleterious effects of radiation on angiogenesis. Further, high-dose DFO cultures appeared to organize within 2h of incubation and achieved a robust network that was visibly superior to all other experimental groups in an accelerated fashion. In vivo, animals subjected to a human equivalent dose of radiotherapy (HEDR) and left mandibular fracture demonstrated quantifiably diminished μCT metrics of vascular density, as well as a 75% incidence of associated non-unions. The addition of DFO in this setting markedly improved vascularity as demonstrated with 3D angiographic modeling. In addition, we observed an increased incidence of bony unions in the DFO treated group when compared to radiated fractures without treatment (67% vs. 25% respectively). CONCLUSION Our data suggest that selectively targeting angiogenesis with localized DFO injections is sufficient to remediate the associated severe vascular diminution resulting from a HEDR. Perhaps the most consequential and clinically relevant finding was the ability to reduce the incidence of non-unions in a model where fracture healing was not routinely observed.
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Affiliation(s)
- Alexis Donneys
- Craniofacial Research Laboratory, Department of Plastic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniela M. Weiss
- Craniofacial Research Laboratory, Department of Plastic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Sagar S. Deshpande
- Craniofacial Research Laboratory, Department of Plastic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Salman Ahsan
- Craniofacial Research Laboratory, Department of Plastic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Catherine N. Tchanque-Fossuo
- Craniofacial Research Laboratory, Department of Plastic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Deniz Sarhaddi
- Craniofacial Research Laboratory, Department of Plastic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Benjamin Levi
- Craniofacial Research Laboratory, Department of Plastic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Steven A. Goldstein
- Orthopedic Research Laboratory, Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Steven R. Buchman
- Craniofacial Research Laboratory, Department of Plastic Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Jing XL, Farberg AS, Monson LA, Donneys A, Tchanque-Fossuo CN, Buchman SR. Radiomorphometric quantitative analysis of vasculature utilizing micro-computed tomography and vessel perfusion in the murine mandible. Craniomaxillofac Trauma Reconstr 2012; 5:223-30. [PMID: 24294405 DOI: 10.1055/s-0032-1329540] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 03/01/2012] [Indexed: 10/27/2022] Open
Abstract
Purpose Biomechanical, densitometric, and histological analyses have been the mainstay for reproducible outcome measures for investigation of new bone formation and osseous healing. Here we report the addition of radiomorphometric vascular analysis as a quantitative measure of vascularity in the murine mandible. To our knowledge this is the first description of using micro-computed tomography (micro-CT) to evaluate the temporal and spatial pattern of angiogenesis in the craniofacial skeleton. Methods The vessel perfusion technique was performed on 10 Sprague-Dawley rats using Microfil (MV-122, Flow Tech; Carver, MA). After decalcification, hemimandibles were imaged using high-resolution micro-CT. Six separate radiomorphometric vascular metrics were calculated. Results Radiomorphometric values were analyzed using three different thresholds on micro-CT. Experimentally, 1000 Hounsfield units was found to be the optimal threshold for analysis to capture the maximal vascular content of the bone. Data from seven hemimandibles were analyzed. Minimal statistical variance in each of the quantitative measures of vascularity resulted in reproducible metrics for each of the radiomorphometric parameters. Conclusions We have demonstrated that micro-CT vascular imaging provides a robust methodology for evaluation of vascular networks in the craniofacial skeleton. This technique provides 3D quantitative data analysis that differs significantly from laser Doppler and microsphere methods, which simply measure flow. This technique is advantageous over labor-intensive 2D conventional analyses using histology and X-ray microangiography. Our data establish the appropriate thresholding for optimal vascular analyses and provide baseline measurements that can be used to analyze the role of angiogenesis in bone regeneration and repair in the craniofacial skeleton.
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Affiliation(s)
- Xi Lin Jing
- Department of General Surgery, Henry Ford Health System, Detroit, Michigan ; Department of Plastic Surgery, University of Michigan, Ann Arbor, Michigan
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Deshpande SS, Buchman SR, Donneys A, Gallagher KK, Tchanque-Fossuo CN, Sarhaddi D, Weiss DM, Sun H, Krebsbach PH. Stem cell and intermittent parathyroid hormone therapy creates superior regenerate in murine mandibular distraction osteogenesis following radiation. J Am Coll Surg 2012. [DOI: 10.1016/j.jamcollsurg.2012.06.220] [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: 10/28/2022]
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Felice PA, Donneys A, Deshpande SS, Tchanque-Fossuo CN, Nelson NS, Sarhaddi D, Perosky JE, Kozloff KM, Buchman SR. Amifostine prophylaxis preserves biomechanical properties of irradiated bone: A murine mandibular model. J Am Coll Surg 2012. [DOI: 10.1016/j.jamcollsurg.2012.06.219] [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: 11/25/2022]
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Farberg AS, Jing XL, Monson LA, Donneys A, Tchanque-Fossuo CN, Deshpande SS, Buchman SR. Deferoxamine reverses radiation induced hypovascularity during bone regeneration and repair in the murine mandible. Bone 2012; 50:1184-7. [PMID: 22314387 PMCID: PMC3322244 DOI: 10.1016/j.bone.2012.01.019] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 01/23/2012] [Accepted: 01/24/2012] [Indexed: 02/05/2023]
Abstract
BACKGROUND Deferoxamine (DFO) is an iron-chelating agent that has also been shown to increase angiogenesis. We hypothesize that the angiogenic properties of DFO will improve bone regeneration in distraction osteogenesis (DO) after x-ray radiation therapy (XRT) by restoring the vascularity around the distraction site. MATERIAL AND METHODS Three groups of Sprague-Dawley rats underwent distraction of the left mandible. Two groups received pre-operative fractionated XRT, and one of these groups was treated with DFO during distraction. After consolidation, the animals were perfused and imaged with micro-CT to calculate vascular radiomorphometrics. RESULTS Radiation inflicted a severe diminution in the vascular metrics of the distracted regenerate and consequently led to poor clinical outcome. The DFO treated group revealed improved DO bone regeneration with a substantial restoration and proliferation of vascularity. CONCLUSIONS This set of experiments quantitatively demonstrates the ability of DFO to temper the anti-angiogenic effect of XRT in mandibular DO. These exciting results suggest that DFO may be a viable treatment option aimed at mitigating the damaging effects of XRT on new bone formation.
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Affiliation(s)
- Aaron S. Farberg
- Craniofacial Research Laboratory, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Xi L. Jing
- Craniofacial Research Laboratory, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Dept of Surgery, Henry Ford Health System, Detroit, Michigan, USA
| | - Laura A. Monson
- Craniofacial Research Laboratory, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Alexis Donneys
- Craniofacial Research Laboratory, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - Sagar S. Deshpande
- Craniofacial Research Laboratory, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Steven R. Buchman
- Craniofacial Research Laboratory, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Donneys A, Tchanque-Fossuo CN, Farberg AS, Deshpande SS, Buchman SR. Bone regeneration in distraction osteogenesis demonstrates significantly increased vascularity in comparison to fracture repair in the mandible. J Craniofac Surg 2012; 23:328-32. [PMID: 22337436 PMCID: PMC3502076 DOI: 10.1097/scs.0b013e318241db26] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [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] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Tissue analysis of bone regenerate has suggested an intense vascular response after mandibular distraction osteogenesis (DO). Quantifying and three-dimensionally imaging this vascular response could be of immense clinical import in efforts to advance the utility of bone regeneration and repair. Conventional quantification of vascular responses has heretofore focused on inexact, cumbersome measurements of blood flow and histologic vessel counting. Using micro-computed tomography after vessel perfusion, we posit that quantitative vascular metrics will be significantly higher in mandibular DO compared with those observed in fracture repair (FxR) after bony union. METHODS Sprague-Dawley rats underwent mandibular osteotomy and external fixator placement. A DO group (n=9) underwent a 5.1-mm distraction, whereas a FxR group (n=12) had a 2.1-mm fixed gap set. Forty days after surgery, Microfil was perfused into the vasculature, and imaging ensued. Vascular radiomorphometrics were calculated for the regions of interest. Independent-samples t-test was performed for comparison, with statistical significance set at P≤0.05. RESULTS Stereological analysis demonstrated statistically significant increases in the distracted vasculature compared with fracture repair: vessel volume fraction (5.4% versus 2.8%, P=0.030) and vessel number (0.86 versus 0.50 mm, P=0.014). CONCLUSIONS We report robust and quantifiable increases in vascular density in DO compared with FxR. Our findings support a significant distinction between the regenerative processes of mandibular DO from the reparative mechanisms controlling fracture healing. A better understanding of the differences between the 2 types of bone formation may enable clinicians to selectively optimize therapeutic outcomes in the future.
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Affiliation(s)
- Alexis Donneys
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan Ann Arbor, Michigan 28109-4217, USA
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Tchanque-Fossuo CN, Monson LA, Farberg AS, Donneys A, Deshpande SS, Razdolsky ER, Halonen NR, Goldstein SA, Buchman SR. Dose-response effect of human equivalent radiation in the murine mandible: Part II. A biomechanical assessment. Plast Reconstr Surg 2011; 128:480e-487e. [PMID: 22030507 DOI: 10.1097/prs.0b013e31822b67ae] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite the widespread use of adjuvant irradiation for head and neck cancer, the extent of damage to the underlying bone is not well understood. However, patients can suffer serious clinical consequences, including pathologic fractures, nonunion, and osteoradionecrosis. The authors' specific aim was to objectively quantify the human equivalent radiation dose-response effect of radiation on the biomechanical properties of the murine mandible. METHODS Twelve Sprague-Dawley rats were randomized into three radiation dosage groups--low (5.91 Gy), middle (7 Gy), and high (8.89 Gy)--delivered in five daily fractions. The fractionation regimen was used to approximate 75, 100, and 150 percent, respectively, of the bioequivalent dose humans receive in conventional head and neck cancer treatment. Fifty-six days after irradiation, hemimandibles were loaded to failure in a uniaxial tension at 0.5 mm/second. Load displacement curves were analyzed for yield and breaking load, and values were considered statistically significant at p<0.05. RESULTS The authors' data demonstrated a statistically significant decrease in the yield and breaking load metrics. The authors' reported averages for low, middle, and high radiation dosages were 162, 136, and 69 N, respectively, for yield; and 215, 211, and 141 N, respectively, for breaking load. Both of these quantitative biomechanical properties were diminished in a dose-response pattern. CONCLUSIONS In this article, the authors report a dose-response effect in the degradation of the biomechanical properties of the mandible after fractionated human equivalent radiation. The authors' findings and model can now be used to formulate therapies aimed at remediating those effects and augmenting bone regeneration and healing after adjuvant radiotherapy in head and neck cancer patients.
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Farberg AS, Jing XL, Monson LA, Tchanque-Fossuo CN, Donneys A, Deshpande SS, Buchman SR. 49B: DEFEROXAMINE TREATMENT RESTORES VASCULARITY IN IRRADIATED MANDIBULAR DISTRACTION OSTEOGENESIS. Plast Reconstr Surg 2010. [DOI: 10.1097/01.prs.0000371785.23290.76] [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: 11/25/2022]
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