The use of copper isotopes for understanding metal transfer mechanisms within the continuum mine-river-dam (Huelva Region, Spain)

Mining areas and in particular those containing massive sulfides have left a heavy environmental legacy with soils and hydrographic networks highly contaminated with metals and metalloids as for example in the Iberian Pyrite Belt (Huelva, Spain). Here, we present new data on copper (Cu) isotopic composition of waters and solids collected along a continuum Mine (Tharsis)-River (Meca)-Lake (Sancho) in the Iberian Pyrite Belt. Our results show that the isotopic signature of pit lakes is spatially variable, but remains stable over the seasons; this signature seems to be controlled by water-rock interaction processes. The data obtained on the Meca River imply a number of attenuation processes such as decrease in the metal concentration by precipitation of secondary minerals. This is accompanied by preferential retention of the heavy isotope (⁶⁵Cu) with a possibility of living organisms (e.g., algae) participation. The terminal Sancho lake demonstrated constant isotopic signature over the entire depth of the water column despite sizable variations in Cu concentrations, which can be tentatively explained by a superposition of counter-interacting biotic and abiotic processes of Cu fractionation. Overall, the understanding of the isotopic variations along the hydrological continuum is useful for a better understanding of metal element transfer within mining environments and surrounding surface waters.

Assessment of a Large-Scale Unbiased Malignant Pleural Effusion Proteomics Study of a Real-Life Cohort

Simple Summary

Pleural effusion (PE) occurs as a consequence of various pathologies. Malignant effusion due to lung cancer is one of the most frequent causes. A method for accurate differentiation of malignant from benign PE is an unmet clinical need. Proteomics profiling of PE has shown promising results. However, mass spectrometry (MS) analysis typically involves the tedious elimination of abundant proteins before analysis, and clinical annotation of proteomics profiled cohorts is limited. This study compares the proteomes of malignant PE and nonmalignant PE, identifies lung cancer malignant markers in agreement with other studies, and identifies markers strongly associated with patient survival.

Abstract

Background: Pleural effusion (PE) is common in advanced-stage lung cancer patients and is related to poor prognosis. Identification of cancer cells is the standard method for the diagnosis of a malignant PE (MPE). However, it only has moderate sensitivity. Thus, more sensitive diagnostic tools are urgently needed. Methods: The present study aimed to discover potential protein targets to distinguish malignant pleural effusion (MPE) from other non-malignant pathologies. We have collected PE from 97 patients to explore PE proteomes by applying state-of-the-art liquid chromatography-mass spectrometry (LC-MS) to identify potential biomarkers that correlate with immunohistochemistry assessment of tumor biopsy or with survival data. Functional analyses were performed to elucidate functional differences in PE proteins in malignant and benign samples. Results were integrated into a clinical risk prediction model to identify likely malignant cases. Sensitivity, specificity, and negative predictive value were calculated. Results: In total, 1689 individual proteins were identified by MS-based proteomics analysis of the 97 PE samples, of which 35 were diagnosed as malignant. A comparison between MPE and benign PE (BPE) identified 58 differential regulated proteins after correction of the p-values for multiple testing. Furthermore, functional analysis revealed an up-regulation of matrix intermediate filaments and cellular movement-related proteins. Additionally, gene ontology analysis identified the involvement of metabolic pathways such as glycolysis/gluconeogenesis, pyruvate metabolism and cysteine and methionine metabolism. Conclusion: This study demonstrated a partial least squares regression model with an area under the curve of 98 and an accuracy of 0.92 when evaluated on the holdout test data set. Furthermore, highly significant survival markers were identified (e.g., PSME1 with a log-rank of 1.68 × 10⁻⁶).

OS08.6.A Glioblastoma treatment response machine learning monitoring biomarkers: a systematic review and meta-analysis

BACKGROUND

The aim of the systematic review was to assess recently published studies on diagnostic test accuracy of glioblastoma treatment response monitoring biomarkers in adults, developed through machine learning (ML).

MATERIAL AND METHODS

PRISMA methodology was followed. Articles published 09/2018-01/2021 (since previous reviews) were searched for using MEDLINE, EMBASE, and the Cochrane Register by two reviewers independently. Included study participants were adult patients with high grade glioma who had undergone standard treatment (maximal resection, radiotherapy with concomitant and adjuvant temozolomide) and subsequently underwent follow-up imaging to determine treatment response status (specifically, distinguishing progression/recurrence from progression/recurrence mimics - the target condition). Risk of bias and applicability was assessed with QUADAS 2. A third reviewer arbitrated any discrepancy. Contingency tables were created for hold-out test sets and recall, specificity, precision, F1-score, balanced accuracy calculated. A meta-analysis was performed using a bivariate model for recall, false positive rate and area-under the receiver operator characteristic curve (AUC).

RESULTS

Eighteen studies were included with 1335 patients in training sets and 384 in test sets. To determine whether there was progression or a mimic, the reference standard combination of follow-up imaging and histopathology at re-operation was applied in 67% (13/18) of studies. The small numbers of patient included in studies, the high risk of bias and concerns of applicability in the study designs (particularly in relation to the reference standard and patient selection due to confounding), and the low level of evidence, suggest that limited conclusions can be drawn from the data. Ten studies (10/18, 56%) had internal or external hold-out test set data that could be included in a meta-analysis of monitoring biomarker studies. The pooled sensitivity was 0.77 (0.65–0.86). The pooled false positive rate (1-specificity) was 0.35 (0.25–0.47). The summary point estimate for the AUC was 0.77.

CONCLUSION

There is likely good diagnostic performance of machine learning models that use MRI features to distinguish between progression and mimics. The diagnostic performance of ML using implicit features did not appear to be superior to ML using explicit features. There are a range of ML-based solutions poised to become treatment response monitoring biomarkers for glioblastoma. To achieve this, the development and validation of ML models require large, well-annotated datasets where the potential for confounding in the study design has been carefully considered. Therefore, multidisciplinary efforts and multicentre collaborations are necessary.

P12.03 A Delphi survey to inform core ‘red flag’ symptoms for an electronic patient reported outcome system in glioblastoma follow up

BACKGROUND

Glioblastoma is a common and aggressive primary malignant brain tumour in adults associated with a poor prognosis and considerable symptom burden. Clinical review and serial neuroimaging remain the primary monitoring tools to assess for disease status. However, the evidence base for the existing surveillance imaging schedule is yet to be established. New models of follow up care are needed to demonstrate better patient outcomes in this patient cohort. There are indications that patient-reported outcome measures (PROMs) can contribute to improved survival and maintaining an optimal quality of life in other oncology populations.

MATERIALS AND METHODS

There are no standardised PROMs for the priority symptoms in glioblastoma patients, which can be used for evaluation in clinical care as a surrogate marker for disease progression. A broad set of symptoms were therefore initially identified in a targeted literature search and were further refined via Delphi methodology, with the aim to obtain consensus amongst a small expert panel involved in the care of glioblastoma patients. A three round Delphi email survey was conducted. Consensus was defined as 70% agreement.

RESULTS

Symptom and function constructs were assessed for relevance, relationship to disease and treatment, sensitivity to change, psychometric properties and patient acceptability. Consensus was reached on the red flag symptoms and symptom clusters to monitor, as well as the minimum severity thresholds needed to trigger an alert on an electronic symptom reporting system, which has been developed to allow patient self-reporting of symptoms during treatment.

CONCLUSION

The red flag symptoms to monitor, along with the symptom severity thresholds, informed an app-based symptom reporting system, which is currently being piloted in a feasibility study exploring triggered imaging using ePROMs. This has the potential to inform future clinical practice through development of patient reported biomarkers.

Intraoperative finding of immobile leaflet(s) following freshly implanted bioprosthetic valves: clinical characteristics and impact on outcomes

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Detection of immobile leaflets immediately following bioprosthetic valve implantation is a rare but important intraoperative finding. Restriction of leaflet movement can occur in the closed or open position, leading to abnormal prosthesis function. We sought to determine the clinical implications of immobile leaflets seen on intraoperative echocardiography.

METHODS

Patients with immobile leaflets identified on intra-operative/procedure echocardiography immediately post implantation between 2009-2020 were identified from an institutional database. All echocardiograms were reviewed de-novo to confirm immobile leaflets in the immediate post-implantation period. Identified cases were matched 1:2 to controls for age; sex; prosthesis position, model and size; and implantation approach (surgical vs. transcatheter).  Nominal logistic regression and proportional hazards were used to analyze outcomes.

RESULTS

Thirty patients with immobile leaflets immediately post-bioprosthesis implantation were included. Clinical characteristics are summarized in the Table. Immobile leaflets were documented in procedural reports in only 18 (60%) patients. Moderate stenosis was present intraoperatively in 1 patient, none demonstrated ≥moderate regurgitation, and none resulted in immediate corrective action. In 3 (10%), valve re-intervention was required within 30 days due to symptomatic prosthesis dysfunction. Presence of restricted leaflet motion was associated with higher need for post-operative extracorporeal membrane oxygenation use (odds-ratio 7.3, p = 0.02) and composite end-point of death, valve re-replacement, prosthesis thrombosis, or cardiac hospitalizations (risk ratio 2.1, p = 0.03, Figure).

CONCLUSION

Immobile leaflet(s) immediately post-bioprosthetic valve implantation is an uncommon, under-reported, and under-treated phenomenon. Even in the absence of significant prosthetic valve dysfunction, it can be associated with worse post-operative course as well as worse outcomes.

Baseline characteristics Age 76 (67-84) Sex, male 10 (33%) Surgical approach 25 (83%) Aortic 5 (17%) Mitral 12 (40%) Tricuspid 12 (40%) Pulmonary 1 (3%) Re-intervention within 10 days 3 (10%) Numbers are presented as median (interquartile range) or number (percentage). Abstract Figure. Clinical outcome of stuck leaflets

Access to breast/ovarian genetic testing: 20 years of a multidisciplinary program

e14015

Background: After institutional and ethical review, a multidisciplinary Breast/Ovarian Cancer Family Risk program started in January 2000. Core team included medical oncologists, molecular biologists, medical geneticists and specialized nurses. Besides access to genetic testing (GT), predictive risk analysis and tailored surveillance plans were provided for women without criteria for GT, and carriers of germline pathogenic/likely pathogenic variants (PV/LPV) were included in prospective follow up. Methods: Descriptive statistics concerning patients (pts), medical visits and genetic tests performed under the program from January 2000-December 2019. Results:A total of 28400 medical appointments (including multidisciplinary meetings with radiology, breast and plastic surgery and gynecology) were performed for 10100 pts: 9281 women (92%) and 819 men (8%), with an average of 46,0 years (45,6 and 51,1 respectively). Most pts were referred from our cancer center or were invited for cascade testing (8044, 79,6%), although we accepted referrals from external health services (2056 pts). GT: 5665 tests performed (4454 for index pts (IP) and 1211 for family relatives); 3170 (71%) IP consented only in BRCA1/2 and 1284 IP (29%) in sequential/panel testing. Detection rate for IP testing was 12,5% [440 BRCA1/2; 118 Other Hereditary Syndromes (OSH)]. OHS IP: CHEK2(32), ATM(14), TP53(11), MUTYH(12), PALB2(10), RAD51D(10), RAD51C(9), BLM(5), BRIP1(4), RAD50 (4), PTEN(2), MSH2(2), MLH1(1) FAM175A(1), BARD1(1). Six- hundred and twenty-six IP with previous inconclusive results consented on panel testing and 62(9,9%) were diagnosed with a non- BRCA1/2 PV/LPV. Until June 2019, 915 BRCA1/2 pts were included in a registry for prospective follow up. Conclusions: our program has allowed for access to Breast/Ovarian GT and risk management in the National Health Service, for the past 20 years. Twenty per cent of all pts are referrals from external health services. The ever increasing challenges to the resources of the program include: new indications for GT, the increase in priority pts for GT due to more therapy options, risk dynamics in previous registered families, evolving molecular methodologies and the management of families with complex genetic variants. The growing number of pts, including men, led to a recent change in the label of the program (Breast/Ovarian/Prostate Cancer Family Risk) and new approaches to promote access of specific populations to GT (like telegenetics) are being tested.

Abstract P6-08-36: Uptake of preventive surgeries in a prospective cohort of BRCA1/2 healthy women

PURPOSE

Previous studies referred to uptake of preventive surgeries (PS) in BRCA1/2 healthy carriers in ages older than recommended (35yrs). Since our population has a higher prevalence of BRCA2 mutations (usually associated with an older age at Breast Cancer diagnosis) we proposed to study ages and type of preventive surgeries uptaken by BRCA1/2 women included in prospective follow up.

PATIENTS AND METHODS

Review of all healthy (without a previous cancer diagnosis) BRCA1/2 carriers included in our program from January 2000 to June 2019. Follow-up started after genetic testing. Men were excluded from this analysis.

RESULTS

A total of 5504 cases (4021 index, 1483 relatives) consented for BRCA1/2 testing. We identified 238 healthy BRCA1/2 carriers (BRCA2:158 (66.4%) vs BRCA1 80 (33.6%). Median age at genetic diagnosis was 38.9 yrs (16-78). With a median follow up of 4yrs, bilateral adnexectomy (BA) was the most frequent PS observed (45 BRCA2 and 28 BRCA1 cases) with 15/45 % and 6/28% undergoing BA and bilateral mastectomy (BM) simultaneously. Bilateral mastectomy was uptaken by 14% BRCA2 women and 10% BRCA1 women. Median ages for PS were: BRCA2-AB: 47,4 (28-71), BRCA1-AB: 46.7 (37-59); BRCA2-BM: 36.6 (31-52) and BRCA1-BM:42.5 (30-55). Isolated BM was observed in 7 BRCA2 cases and 2 BRCA1 cases. Most of women submitted to BA, also underwent total hysterectomy (HT): 65% for BRCA2 and 61% BRCA1. Most cases (88% non-adherent) adhere to radiological surveillance, 111/238 with annual breast S MRI and mammography. All pts submitted to BM are prescribed at least one breast MRI to check for remaining breast tissue.

CONCLUSION

Our data reveal that even if, in general, BRCA1/2 women uptake preventive surgeries at a later age that recommended, we observed a strong adherence to radiological (most with breast MRI) surveillance. BA is the PS most frequently observed but, surprisingly for healthy women, most cases also underwent TH. BRCA2 healthy women uptaken bilateral mastectomy at an earlier age than BRCA1 women. It´s possible that BRCA1 women, when deciding for BM also decided for BA.

Citation Format: Priscila Nejo, Catarina Bexiga, S. Fragoso, A Mayer, S Santos, P Louro, A Luis, C Moura, Ana Clara, Fatima Vaz. Uptake of preventive surgeries in a prospective cohort of BRCA1/2 healthy women [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-08-36.

Machine learning and glioma imaging biomarkers

AIM

To review how machine learning (ML) is applied to imaging biomarkers in neuro-oncology, in particular for diagnosis, prognosis, and treatment response monitoring.

MATERIALS AND METHODS

The PubMed and MEDLINE databases were searched for articles published before September 2018 using relevant search terms. The search strategy focused on articles applying ML to high-grade glioma biomarkers for treatment response monitoring, prognosis, and prediction.

RESULTS

Magnetic resonance imaging (MRI) is typically used throughout the patient pathway because routine structural imaging provides detailed anatomical and pathological information and advanced techniques provide additional physiological detail. Using carefully chosen image features, ML is frequently used to allow accurate classification in a variety of scenarios. Rather than being chosen by human selection, ML also enables image features to be identified by an algorithm. Much research is applied to determining molecular profiles, histological tumour grade, and prognosis using MRI images acquired at the time that patients first present with a brain tumour. Differentiating a treatment response from a post-treatment-related effect using imaging is clinically important and also an area of active study (described here in one of two Special Issue publications dedicated to the application of ML in glioma imaging).

CONCLUSION

Although pioneering, most of the evidence is of a low level, having been obtained retrospectively and in single centres. Studies applying ML to build neuro-oncology monitoring biomarker models have yet to show an overall advantage over those using traditional statistical methods. Development and validation of ML models applied to neuro-oncology require large, well-annotated datasets, and therefore multidisciplinary and multi-centre collaborations are necessary.

Resource-theoretic approach to vectorial coherence

We propose a formal resource-theoretic approach to assess the coherence between partially polarized electromagnetic fields. From this framework, we identify two resource theories for the vectorial coherence: polarization-sensitive coherence and polarization-insensitive coherence. For each theory, we find the set of incoherent states and a class of operations that preserve this set (i.e., the incoherent operations). Both resource theories are endowed with a certain preorder relation that provides a hierarchy among the coherence-polarization states; thus, a necessary condition to consider in deciding whether a quantity is proper to measure the vectorial coherence is that it respects such a hierarchy. Finally, we examine most previously introduced coherence measures from this perspective.

Men seeking counselling in a Breast Cancer Risk Evaluation Clinic

BACKGROUND

Hereditary breast and ovary cancer syndrome affects both genders but little is known about the uptake of genetic services by men. The objective of this study is to characterise the male population counselled through a multidisciplinary breast/ovarian program.

METHODS

Descriptive analysis of male patients counselled from January 2000 to December 2015. Data in this analysis include new cancer diagnoses during prospective follow up.

RESULTS

From 4,320 families registered, 362 male patients were identified: 236 (65.2%) from hereditary cancer families (HCF) and 126 (34.8%) from non-HCF. In HCF, 121 patients (51.3%) were mutation carriers (MC): BRCA2 - 102 (84.3%), BRCA1 - 16 (13.2%), CHEK2 - 1 (0.8%) and TP53 - 2 (1.7%). Non-HCF included 126 patients: 85 (67.5%) belonged to families without pathogenic mutations or with variants of unknown clinical significance; 22 (17.5%) refused testing after counselling and 19 (15.0%) did not meet criteria for testing. Both HCF and non-HCF included patients with previous cancer diagnoses: HCF- Breast Cancer (BC) - 18; prostate cancer (PC) - 13; melanoma - 1; others - 7) and non-HCF (BC - 77; PC - 20; gastric cancer (GC) - 1; melanoma - 8; bladder cancer - 1; others - 22). From the 121 MC identified (including the TP53 and CHEK2 carriers), 97 patients (80.2%) adhered to prospective surveillance. With a median follow-up of 36.9 months, 17 cancers were diagnosed in 14 patients, PC being the most frequently diagnosed neoplasia (5 cases). Eleven patients (78.6%) are alive and three patients died of advanced cancer (2 with GC, 1 with disseminated adenocarcinoma).

CONCLUSION

We observed a high adherence to counselling, genetic testing and active surveillance by men belonging to hereditary BC families. Male carriers of pathogenic DNA variants are at risk for several cancers and should be included in prospective follow-up studies.

Rectal cancer management in elderly patients: experience of a single Portuguese institution

BACKGROUND

The incidence of rectal cancer increases with age, and older patients are more likely to have other chronic conditions that can affect outcome and tolerability of treatment.

OBJECTIVE

The incidence of rectal cancer increases with age, and older patients are more likely to have other chronic conditions that can affect outcome and tolerability of treatment.

METHODS

59 patients aged 75 years and older with stage II-III rectal cancer who were treated during a 3-year period were included in the study. Comorbidities were assessed using the Charlson Comorbidity Index (CCI) and the patients were divided into 2 groups based on their CCI scores: Fit (score of 0-1 points) and Vulnerable (score of greater than or = 2). Primary endpoint was survival at 1 and 3 years.

RESULTS

The sample included 43 patients (72.9%) in the Fit group and 16 patients (27.1%) in the Vulnerable group. The most common comorbidities were myocardial infarction, diabetes, and chronic lung disease. One-year survival the same between the groups (P = .330), but 3-year survival was lower in the Vulnerable group patients (83.7% vs 56.3%, respectively; P = .040). The rates of neoadjuvant chemo- and radiotherapy use and low anterior resection performance were the same between the groups. Colostomy closure was achieved more frequently in the Fit group compared with the Vulnerable group (83.3% vs 55.6%; P = .083). There was no difference in mean disease-free survival, grade 3-4 toxicity, and dose reduction between the groups.

CONCLUSIONS

Comorbidity assessment should always be included in standard oncological management of elderly patients. Fit patients can be managed with standard treatment and may bene¦t from a conventional, more aggressive approach in their therapy.

Rectal carcinoma in pregnancy--a case report

The authors present a case of a pregnant woman suffering from colorectal cancer in order to contribute to the knowledge regarding this situation and to optimise its management. Rectal cancer in pregnancy is a rare disease, challenging clinicians as there are no generally accepted guidelines regarding diagnosis or treatment. Early diagnosis remains to be the key. When the disease is particularly aggressive, the prognosis remains poor despite pregnancy cessation and radical therapy.

[Whipple's Disease: retrospective analysis of twelve cases and review of the literature]

BACKGROUND

Whipple's disease is a rare and chronic bacterial disease with multiorganic involvement. Although there is no valid estimate of its actual prevalence, only about 1,000 cases have been reported.

OBJECTIVE

To describe the demographic, clinical, laboratory, endoscopic and pathologic features, type of treatment used, its duration and response.

METHODS

Based on the duodenal histology, we identified twelve cases of Whipple's disease in the Hospital Centre of Vila Nova de Gaia, between 1997 and 2010. RESULTS. Nine patients (75%) were male and the mean age at diagnosis was 58 years. All patients experienced at least one gastrointestinal and general symptom. Arthralgia were reported in four patients (33%) and occurred on average six years before the onset of gastrointestinal and general symptoms. In 10 patients the initial treatment was trimethoprim-sulfamethoxazole. The initial treatment duration was one year in 8 cases (80%). Seven patients (70%) had a symptomatic resolution between the third and sixth months of antibiotic therapy, as well as an endoscopic and histological improvement. Even in these patients, there was maintenance of periodic acid-Schiff positive macrophages, although in small number and with a more diffuse distribution. Gastrointestinal symptoms predominated in cases of clinical relapse.

CONCLUSIONS

The gastrointestinal and general symptoms as well as the arthralgia were the predominant manifestations. The majority of patients showed clinical and endoscopic improvement in response to treatment with trimethoprim-sulfamethoxazole. However, in these cases periodic acid-Schiff positive macrophages can remain for years. Thus, in the absence of clinical deterioration, the presence of these structures is not indicative ofactive disease.

MicroRNA profile: a promising ancillary tool for accurate renal cell tumour diagnosis

Background:

Renal cell tumours (RCTs) are clinically, morphologically and genetically heterogeneous. Accurate identification of renal cell carcinomas (RCCs) and its discrimination from normal tissue and benign tumours is mandatory. We, thus, aimed to define a panel of microRNAs that might aid in the diagnostic workup of RCTs.

Methods:

Fresh-frozen tissues from 120 RCTs (clear-cell RCC, papillary RCC, chromophobe RCC (chRCC) and oncocytomas: 30 cases each), 10 normal renal tissues and 60 cases of ex-vivo fine-needle aspiration biopsies from RCTs (15 of each subtype validation set) were collected. Expression levels of miR-21, miR-141, miR-155, miR-183 and miR-200b were assessed by quantitative reverse transcription–PCR. Receiver operator characteristic curves were constructed and the areas under the curve were calculated to assess diagnostic performance. Disease-specific survival curves and a Cox regression model comprising all significant variables were computed.

Results:

Renal cell tumours displayed significantly lower expression levels of miR-21, miR-141 and miR-200b compared with that of normal tissues, and expression levels of all miRs differed significantly between malignant and benign RCTs. Expression analysis of miR-141 or miR-200b accurately distinguished RCTs from normal renal tissues, oncocytoma from RCC and chRCC from oncocytoma. The diagnostic performance was confirmed in the validation set. Interestingly, miR-21, miR-141 and miR-155 expression levels showed prognostic significance in a univariate analysis.

Conclusion:

The miR-141 or miR-200b panel accurately distinguishes RCC from normal kidney and oncocytoma in tissue samples, discriminating from normal kidney and oncocytoma, whereas miR-21, miR-141 and miR-155 convey prognostic information. This approach is feasible in fine-needle aspiration biopsies and might provide an ancillary tool for routine diagnosis.

[Bladder malformations in a model of myelomeningocele. Preliminary report]

PURPOSE

To describe the presence of bladder malformations in a surgically induced model of myelomeningocele (MMC).

METHODS

A MMC like defect was created in the mid gestation using the previously described model in sheep. Bladders were examined macroscopically and histopathological changes were assessed using H-E.

RESULTS

Non prenatally corrected animals presented dilated bladders and separation between muscle bundles. Those malformations were not found in corrected animals or controls.

CONCLUSIONS

Some bladder changes can be described in a surgically-induced model of MMC. These changes could be prevented using open fetal surgery.

[Prenatal techniques to prevent central nervous system malformations in the surgically induced model of myelomeningocele]

AIM

To describe central nervous system malformations in the surgically induced model of Myelomeningocele (MMC) and their prevention using different prenatal treatments.

METHODS

MMC was surgically created in 33 fetal lambs. Fifteen did not undergo fetal repair (group A). Of the lambs that did undergo repair, 10 were repaired with open two layer surgical closure (group B), 5 with fetoscopic coverage using bioglue (group C) and 3 fetoscopically using a patch (group D). All procedures were recorded and lamb brains and spinal cords were examined grossly and microscopically in coronal sections for structural organization anomalies. Histopathological changes were assessed using HE and S-100 neural marker.

RESULTS

Hydrocephalus, Arnold-Chiari type II (AC-II) malformation and some neuronal migration disorders were observed in group A. Brains from group B and D were not hydrocephalic and had neither cell migration disorders nor hindbrain herniation. Group C presents mild degrees of hydrocephalus and AC-II. In group C lumbar lesion was covered by fibrous tissue.

CONCLUSIONS

Some of the central nervous system abnormalities observed in human disease are present in the surgically induced model of MMC. In this model avoidance of fluid drainage using open fetal surgery limits malformation severity.

Meningeal carcinomatosis and uterine carcinoma: three different clinical settings and review of the literature

INTRODUCTION

Leptomeningeal carcinomatosis is a rare metastatic event in gynecological neoplasias, and most cases occur in ovarian cancer. It is extremely infrequent in cervical cancer, and so far, there are not any reports of this complication in association with endometrial cancer.

PATIENTS AND METHODS

We report a case of leptomeningeal carcinomatosis secondary to endometrial carcinoma and 2 complex cervix cancer cases. A MEDLINE search was done to review all published cases of this complication in gynecological cancer to identify predictive factors for this diagnosis.

RESULTS AND DISCUSSION

Leptomeningeal carcinomatosis is usually diagnosed late in the course of the disease, and most reports concern ovarian cancer patients. The number of cases describing this neurologic complication in cervix cancer is increasing. Gadolinium-enhanced magnetic resonance imaging may be necessary for this diagnosis, because cerebrospinal fluid analysis results may be negative. Most cervix cases had squamous cell (8/14) or neuroendocrine histologic subtype (3/14), and when reported, differentiation was usually poor. The case we report of endometrial carcinoma, unique in the literature, is a serous adenocarcinoma.

CONCLUSIONS

A high index of suspicion is necessary, and leptomeningeal carcinomatosis should be considered in patients with unexplained neurologic symptoms whose gynecologic tumors are poorly undifferentiated or have a serous component.

Giant urethral calculus in a 6-year-old girl

Urinary stones are rarely seen in the urethra and are usually encountered in men with urethral stricture or diverticulum. Primary urethral calculi are extremely infrequent in females. We describe a case of a giant urethral stone impacted in a 6-year-old girl.

[Orthotopic liver transplantation in children younger than one year]

BACKGROUND

Orthotopic liver transplantation (OLT) in children younger than one year is associated to higher waiting list mortality and alternative graft sources are required. We present our experience with this particular group of age.

METHODS

Infants younger than one year who received an OLT between 1986 and 2005 were reviewed focused on graft and children survival depending on period and type of graft. Periods were 1:1986-1995; 2:1996-2000 and 3:2001-2005. We also evaluate cold ischemia time (CIT), graft lost causes and differences between CIT and anhepatic time (AT) depending on graft type.

RESULTS

Eighty-three children received 103 OLT. Liver transplant indications were 59 (72%) biliary atresia, 8 (10%) metabolic causes, 6 (8%) liver failure, 3 (4%) cirrhosis and 7 (6%) miscelaneous. Patient and graft survival after 5 years was increased depending on period: 45% and 65% on period 1, 70% and 80% on period 2, 94% y 97% on period 3 (p < 0.0198). Thirty-seven grafts were reduced lobes (42%); 8 (21%), 17 (45%) and 12 (35%) during periods 1, 2 and 3 respectively and their 5 years survival rate was 68%. Twenty-four were whole grafts (31%); 11 (45%), 10 (45%) and 3 (14%) during periods 1, 2 and 3 and their 5 years survival rate was 63%. Fourteen grafts were living-related donor (16%); 1 (7%), 2 (14%) and 11 (79%) during periods 1, 2 and 3 and their 5 years survival rate was 93%. Eight (11%) were split; 0, 1 (12%) and 7 (90%) during periods 1, 2 and 3 and their 5 years survival rate was 100%. Average CIT depending on graft was: living donor 5,5 hours (IQR: 4-7), split 6,1 hours (IQR: 5-8), whole 9.2 hours (IQR: 6-11) and reduced 8.5 hours (IQR: 6-11) (p < 0.05). Average AT depending on graft was: living donor 1 hour (IQR: 0.5-1.5), split 1 hour (IQR: 0.5-1.4), whole 1,1 hours (IQR: 0.5-1.5) (p > 0.1). Twenty-four grafts were lost (28%): 10 (41%) were surgical related causes and 6/10 (60%) of them were whole grafts.

CONCLUSIONS

Survival rates in children younger than one year are similar to another groups of age. There was a significant increase on graft survival according to transplantation group experience. A higher rate of graft lost is associated to whole grafts. Most frequent reasons of graft lose were related to sepsis and immunosuppresion. A significant shortening of CIT is observed in related living donor and split grafts.

[Surgical treatment in severe dog bites injures in pediatric children]

INTRODUCTION

We report a retrospective study of dog-bitten-children who underwent surgical treatment in our department between 1995 and 2005. We checked the different surgical techniques used to cover the defect as well as short and long-term functional and aesthetic results, considering also infection and hospital stay.

MATERIALS AND METHODS

During this period of time, 21 patients received surgical treatment because of dogs bites. Surgical approach was decided considering location and severity of lessions.

RESULTS

Our serie consists of 12 males and 9 females. Head (71%) and extremities (23%) were the most frequent affected areas. Primary closure was carried out in 18 cases and in the remaining 3 artificial skin or tissue flaps were needed; in these 3 cases the resulting scar was later removed. Surgical infection occurred in less than 10% of the children and in all cases, long-term aesthetic results were considered excellent.

CONCLUSIONS

Primary closure of dog-bites-injures improves functional and aesthetic results and reduces the surgical procedures in those patients.

[Aplasia cutis congenita: surgical treatment and results in 36 cases]

INTRODUCTION

Aplasia cutis congenita is a rare congenital absence of skin most commonly affecting the scalp. Although most defects are small and superficial, approximately 20% of cases involve absence of the skull. Such defects expose the brain and sagital sinus, with concomitant risk of fatal hemorrage, infection, or both. This anomaly most commonly presents as a solitary defect, but sometimes it may occur as multiple lesions. The lesions are noninflammatory and well demarcated, and range is variable from 0.5 cm to 10 cm or more. Although the majority of these scalp defects occurs sporadically, many family cases have been reported. Multiple causes have been suggested for aplasia cutis: genetic causes, syndromes and teratogens, intrauterine infection -varicella zoster virus, herpes simplex virus-, fetal exposure to cocaine, heroin, alcohol or antithyroid drugs.

MATERIALS AND METHODS

A retrospective study of children with Aplasia Cutis Congenita who received treatment in Hospital La Paz, in Madrid between 1995 and 2005 was undertaken. We checked location, moment of the surgery, type of surgery and aesthetic results.

RESULTS

In the 20 year period between 1985-2005, we treated 36 patients with Aplasia Cutis. 33 of them have the scalp affected and only in 3 cases the trunk was involved. In 4 cases there was an absence of the skull, two slight and two severe. 3 patients had Adams-Oliver and one Cutis Marmorata Telangiectasica syndrome. Fifteen patients were operated in neonatal period with direct closure or advancement or rotational flaps, and in 17 cases the late treatment included use of tissue expanders to cover definitely the defect. One of the patients died for bleeding of the sagital sinus while was waiting for the secondary closure of the wound, and other patient required complex skull reconstruction to achieve a complete coverage.

CONCLUSIONS

In view of our experience and results, we believe that early surgery prevents vital risks, reduces local complications and makes easier the final reconstruction.

[Multidisciplinary approach in the management of intestinal failure]

OBJECTIVE

[corrected] Our aim was to analyze our results in the management of intestinal failure with a multidisciplinary approach including optimized parenteral nutrition, reconstructive surgery and intestinal transplantation (ITx).

MATERIAL AND METHODS

We included all patients evaluated by our team with the diagnosis of IF. We assessed outcome, mortality and complications in children that achieved adaptation and those listed for ITx.

RESULTS

Seventy one children (40 boys, 31 girls) were evaluated between 1997 and 2006 because of IF. Forty eight (76%) were referred from other institutions. In 56 cases (80%) IF began in the newborn period. Causes of IF were: short bowel syndrome (52) intestinal motility disorders (16) and intestinal epithelial disorders (3). Median birth weight in the group of SBS was 2.2 Kg and prematurity was an associated condition in 15% of them. Overall, fourteen patients (20%) achieved intestinal adaptation with progressive weaning from PN, the management of these children consisted of optimized parenteral and enteral nutrition and autologous intestinal reconstructive surgery. Nine (13%) are stable under home parenteral nutrition regimen. Eight children (11%), all of them listed for liver and small bowel transplantation, died in the waiting list after a mean waiting time of more than 300 days, with a median of 4 laparotomies and 4 episodes of catheter related sepsis. Four children (5.6%) died in the adaptation process or before their inclusion on the waiting list. Finally, twenty five (35,2%) children underwent 28 intestinal transplantation: 9 isolated small bowel transplantation (SBTx), 16 combined liver and small bowel (CLSB) and 3 multivisceral (MVTx). Among transplanted patients, 9 (36%) died, (3 MVTx, 1 SBTx and 8 CLSB) and four were retransplanted.

CONCLUSIONS

Intestinal Transplantation is an established alternative to parenteral nutrition in the treatment of IF, although complications and mortality rates are still considerable, especially MVTx and CLSBTx. Mortality in children listed for intestinal transplantation remains also high. Intestinal adaptation can be achieved with adequate rehabilitation therapy even in some cases with apparently irreversible intestinal transplantation. Early referral before liver failure or other complications arise is crucial is crucial in order to improve the outcome of these patients.

[Congenital cystic adenomatoid malformation: prenatal diagnosis, surgical treatment results and long-term follow-up]

PURPOSE

(PD), possibility of regresion and hidden mortality are open questions in congenital cystic adenomatoid malformation (CCAM) treatment.

METHODS

Children with CCAM were reviewed focused on: PD, postnatal diagnosis, clinic, radiology, histology and evolution.

RESULTS

Seventeen fetus had PD of CCAM. Five gestations were electively finished (41%) with PD of CCAM previous to 20th week, 3/5 (60%) were type III and 2/5 (40%) type I; 4/5 (80%) presented mediastinal shift and 1/5 (20%) hidrops. Two fetuses (11%) suffered fetal demise in 20th and 32th week; 1 type 1 and 1 type III; 1/2 (50%) presented hidrops and 2/2 (100%) mediastinal shift. Two (12%) died before 24 hours after birth without intervention possibility due to respiratory instability, 1 type II and 1 type III, both with mediastinal shift (100%). In one fetus with a type III malformation the image disappeared completely in 32th week and no intervention was done. Fourteen patients were operated (8 girls and 6 boys); 7/14 (50%) had PD, average diagnosis week was 21.9 (range 19.1-35.5), 5/7 (71%) was type I, 1/7 (14%) type II and 1/7 (14%) type III. None had mediastinal shift or hidrops. Average postnatal diagnosis week was 7 months (range 0.1-29). In 10/14 (71.4%) there were not respiratory difficulty during neonatal period and 3/10 (30%) suffered respiratory infections afterwards. Average week of operation was 8 months (range 0.1-30). PD was according with histology in 6/7 (86%) patients. After an average follow-up period of 4.3 years (range 1-9.5) the only complication is a pectus excavatum.

CONCLUSIONS

More than half of patients with PD of CCAM died without intervention. Half of cases of CCAM are diagnosed prenatally. Type of CCAM in PD is according to histology in 86% of the cases. Fetuses with hidrops present a worse prognosis. Surgical timing do not seem to influence on outcome.

Nutritional status after intestinal transplantation in children

INTRODUCTION

The management of children receiving small bowel grafts involves potentially life-threatening complications that affect their nutritional status. The aim of this paper was to define these factors and their influence on nutritional outcome.

PATIENTS AND METHODS

Patients with intestinal failure (IF) who received an isolated small bowel transplantation (SBT) or small bowel/liver transplantation (SBLT) at our hospital during the last 6 years were reviewed for weight Z-score, biochemical nutritional parameters, total parenteral nutrition (TPN) weaning, catheter-related sepsis, rejection and steroid treatment.

RESULTS

Twenty patients, 11 females and 9 males, received a SBT or a SBLT and survived the postoperative period; in the present study we only included 11 children with follow-up periods longer than 1 year. Seven males and 4 females with a mean age of 4.5 years (range, 1 to 20 years) received 6 SBLT and 5 SBT. Nine (82%) were weaned from TPN to an amino-acid or peptide enteral formula during the first 6 months after surgery. During the first year there was a significant increase in total protein from 5.11 +/- 1.8 mg/dl to 6.1 +/- 1.5 mg/dl (p < 0.05) and an increase in albumin from 3.8 +/- 0.9 mg/dl to 4.5 +/- 1.1 mg/dl (p < 0.05). There was an increase in weight Z-score in 9 patients (82%) during the first year. Mean Z-score improved from - 2.6 +/- 1 at transplant to - 1.0 +/- 0.6 (p < 0.05) after 1 year. Three patients (27.2%) had at least one rejection period, which was treated with steroids alone or in combination. Mean weight Z-score 1 year after surgery was - 0.9 +/- 0.6 for patients without rejection and - 1.24 +/- 0.8 for those with at least one rejection episode treated with steroids (p > 0.1). Four patients (36%) had at least one catheter-related sepsis episode. Mean weight Z-score 1 year after surgery was - 1.01 +/- 0.6 for patients without catheter-related sepsis and - 1.24 +/- 0.8 for those with at least one catheter-related sepsis episode (p > 0.1).

CONCLUSIONS

There was a significant improvement in weight Z-score and biochemical nutritional parameters 1 year after receiving a small bowel graft. No influence of steroids or catheter-related sepsis on children's nutritional status was noted 1 year after surgery, although this point will need further evaluation.

[Bronchial and appendiceal carcinoid tumors]

BACKGROUND

Carcinoid tumor (CT) is an unusual neoplasm observed in several locations and associated with the production of vasoactive substances and occasionally with carcinoid syndrome (flushing, diarrhea, wheezing).

PATIENTS AND METHODS

A retrospective review of the medial records of all children with a diagnosis of CT treated in our service between 1966 and 2003 was performed.

RESULTS

Ten patients (5 boys and 5 girls with a mean age of 8 years) were diagnosed with CT. Eight had CT of the appendix, of which 4 showed the typical clinical presentation of acute appendicitis. Seven of these tumors were localized at the tip of the appendix and measured 2 cm or less. In one patient, the tumor was located at the cecum and measured 3.5 cm. In this patient, reoperation with ileocecal resection was performed. Two patients (4 and 6 years old) had bronchial CT associated with chronic respiratory manifestations. An accurate diagnosis was made after a 1-year follow-up. Pneumonectomy and tracheobronchial sleeve resection were carried out. None of the patients showed symptoms of carcinoid syndrome. All the patients underwent biochemical and radiological studies and fiberoptic bronchoscopy during follow-up. All the patients are currently disease-free.

CONCLUSIONS

Typical symptoms of acute appendicitis were not observed in half of patients with CT of the appendix. CT associated with carcinoid syndrome is exceptional in pediatric patients. In most CT of the appendix, simple appendicectomy was associated with an excellent prognosis. Diagnosis of bronchial TC tends to be delayed and consequently CT should be considered in the differential diagnosis of children with respiratory symptoms unresponsive to standard medical treatment.

[Arterial trauma in the first year of life]

Traumatic vascular lesions in neonates are usually due to preoperative iatrogeny. In the last ten years, we attended 11 patients aged less than one year with arterial lesions due to deliberate puncture. All required endovascular, surgical or combined treatment. The intra- and postoperative follow-up of severe congenital malformations necessitates appropriate arterial access. This should be achieved following strict protocols, with a limited number of punctures carried out by experienced staff and only in large arteries. When a vascular lesion occurs, first an endovascular and then a surgical approach is required in the shortest time period possible. In conclusion, care of arterial routes of access and their maintenance is the best preventive therapy. Appropriate and early treatment in fistulas, pseudoaneurysms and thrombosis must be provided to prevent serious complications, especially in underweight patients.

Luis and sánchez-soto reply:

A Reply to the Comment by Englert, Scully, and Walther.

[Autotransfusion and pregnancy]

PURPOSE

To analyse the results of a pre-deposit autologous transfusion programme in pregnant women on their third period of pregnancy.

MATERIAL AND METHODS

Fifty donor/pregnant women were included in the study. They were in the third trimester of their pregnancy and had risk of requiring transfusion during or after surgery. Haemoglobin above 11 g/dL and haematocrit above 34% were required in each case. Phlebotomy was performed at one-week intervals, iron and folate being supplied. Constants such as foetal heart frequency were evaluated, the programme being interrupted in case of foetal bradycardia. Apart from weight, Apgar and Silverman scores were applied to each newborn.

RESULTS

Cephalopelvic disproportion was the commonest obstetric indication, 26 cases (52%). For autologous blood transfusion, rare blood groups, 12 cases (24%), followed by intra- or post-operative bleeding risk, 10 cases (20%) and being Jehovah's Witnesses, 9 cases (18%), were the major indications. Ninety-four blood units were drawn, 34 of them being used. The remaining 60 units were used for homologous transfusion. No complications developed during phlebotomy and the neonatal determinations showed no significant anomalies.

CONCLUSIONS

(1) Autologous blood transfusion with pre-deposit in the third trimester of pregnancy is a safe and effective way of collecting blood. (2) Its indication is not reduced to rare blood groups. (3) The procedure seems to be safe for both the mother and the newborn.