Single Institution's Plastic Surgery Case Trends and Considerations in the Midst of COVID-19

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Diagnostic and Therapeutic Use of Botox for Breast Reconstruction

INTRODUCTION

Breast reconstruction is most commonly performed using implant-based reconstruction. Patients with subpectoral implant placement with or without latissimus dorsi (LD) muscle coverage can experience muscle pain and animation deformity. Due to minimal literature describing the use of botulinum toxin (BTX-A) treatment for these side effects from implant-based reconstruction, we report our outcomes.

METHODS

A retrospective chart review of breast reconstructive patients for a single surgeon was performed. Patients who underwent BTX-A injection for muscular pain, spasm, or animation deformity were identified and outcomes reviewed. They were also stratified based on radiation treatment and type of muscle flap used.

RESULTS

Eleven patients were identified who had a submuscular pectoralis pocket and/or a pedicled latissimus dorsi flap. Nineteen breasts were treated. The average amount of time from the patient's last surgery to BTX-A injection was 11.2 months. 25-100 units were used per injection with an average of 60 units. Non-irradiated patients had signifycantly lower post-injection capsular contracture Baker grades and significantly lower amounts of BTX-A were injected. Patients who had both pectoralis major muscle and LD implant-reconstruction were significantly less likely to have improvement in pain/tightness. Most patients reported improvement or resolution of their pain and/or animation deformities.

CONCLUSION

Implant-based reconstruction using the pectoralis major and/or LD muscles can be plagued with muscular pain, spasm, and animation deformities. The use of BTX-A is a diagnostic and therapeutic modality for these post-breast reconstruction patients with most patients having resolution of symptoms without the need for additional surgery.

Relapsed hepatoblastoma confined to the lung is effectively treated with pulmonary metastasectomy

BACKGROUND

In children diagnosed with hepatoblastoma (HB), the lungs are the most common site of metastasis at both initial presentation and relapse. Previous studies have encouraged pulmonary metastasectomy to achieve a disease-free state after resection of the primary hepatic lesion. However, there is no consensus about how to manage recurrent pulmonary metastasis.

PROCEDURE

A retrospective, multi-institutional review was performed from 2005 to 2014 to identify HB patients ≤18years of age who had disease recurrence associated with pulmonary metastases alone.

RESULTS

Ten patients between the ages of 8 and 33months were identified. Pulmonary metastatic recurrence was detected by measuring alpha-fetoprotein (AFP) levels and/or with CT scans of the chest. All patients subsequently underwent pulmonary metastasectomy without post-operative complications. At last follow-up, 8 patients were alive and had normal AFP levels. The 8 survivors had a median follow-up from therapy completion of 18.5months. Two patients who presented with extrapulmonary recurrence subsequently died of treatment refractory disease.

CONCLUSIONS

This review supports surgical resection as a safe and, in the context of multimodal therapy, efficacious approach to manage HB patients who present with isolated pulmonary relapse.

Gastrointestinal Complications After Bariatric Surgery

Bariatric surgery is increasingly being performed in the medically complicated obese population as convincing data continue to mount, documenting the success of surgery not only in achieving meaningful weight loss but also in correcting obesity-related illnesses. Several surgical procedures with varying degrees of success and complications are currently being performed. This article discusses the short- and long-term gastrointestinal complications for the 4 most common bariatric surgical procedures: laparoscopic adjustable gastric banding, vertical sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch.

VEGF mRNA and protein concentrations in the developing human eye

BACKGROUND

Vascular endothelial growth factor (VEGF), a well-characterized regulator of angiogenesis, has been mechanistically implicated in retinal neovascularization and in the pathogenesis of retinopathy of prematurity. However, the ontogeny of VEGF expression in the human fetal retina is not well known. Because retinal vasculature grows with gestational maturation, we hypothesized that VEGF expression also increases in the midgestation human fetal eye as a function of gestational age.

METHODS

To identify changes in VEGF gene expression during normal human development, we measured VEGF mRNA by quantitative PCR and measured VEGF protein by enzyme-linked immunosorbent assay and western blots in 10-24 wk gestation fetal vitreous, retina, and serum.

RESULTS

VEGF mRNA expression in the retina increased with gestational age. VEGF isoform A, particularly its VEGF121 splice variant, contributed to this positive correlation. Consistent with these findings, we detected increasing VEGF121 protein concentrations in vitreous humor from fetuses of 10-24 wk gestation, while VEGF concentrations decreased in fetal serum.

CONCLUSION

VEGF121 mRNA and protein concentrations increase with increasing gestational age in the developing human retina. We speculate that VEGF plays an important role in normal retinal vascular development, and that preterm delivery affects production of this vascular growth factor.

Focal nodular hyperplasia in children: an institutional experience with review of the literature

BACKGROUND

Focal nodular hyperplasia (FNH) is uncommonly diagnosed in pediatric patients and may be difficult to distinguish from a malignancy. We present a review of all children with a tissue diagnosis of FNH at our institution, describe the diagnostic modalities, and provide recommendations for diagnosis and follow-up based on our experience and review of the literature.

METHODS

A retrospective review of children <18years of age diagnosed with FNH at a single institution was performed from 2000 to 2013.

RESULTS

Twelve patients were identified with a tissue diagnosis of FNH. Two patients required surgical resection of their lesion owing to concern for malignancy. Ten patients were managed expectantly with imaging surveillance after biopsy confirmed a diagnosis of FNH. All patients who underwent MRI had very typical findings including hypointensity on T1 weighted sequences, hyperintensity on T2, and homogenous uptake of contrast on the arterial phase. On follow-up all patients had either a stable lesion or reduction in size.

CONCLUSIONS

Focal nodular hyperplasia presents typically in children with liver disease, have undergone chemotherapy, and adolescent females. Young children, particularly <5years of age, without underlying liver disease or history of chemotherapy can pose a diagnostic dilemma. In this unique subgroup of children with FNH, MRI and/or needle biopsy should be adequate diagnostic modalities for these lesions.

Abstract LB-352: DUSP26 inhibition: a new therapeutic pathway in neuroblastoma

Introduction: Dual specificity phosphatase 26 (DUSP26) is overexpressed in high risk neuroblastoma (NB) and contributes to chemoresistance by inhibiting p53 function. In vitro, DUSP26 has also been shown to effectively inhibit p38 MAP kinase. We hypothesize that inhibiting DUSP26 will result in decreased NB cell growth in a p53 and/or p38 mediated manner.

Methods: We developed 2 small hairpin RNA's (shRNA) against DUSP26 and stably transduced them into NB cell lines. With these cell lines, we studied the effects of DUSP26 knockdown on anchorage independent growth, cell cycle, and in vivo tumor growth using an orthotopic NB mouse model. We then tested the effects of a known DUSP26 inhibitor, NSC-87877 (NSC), on NB cytotoxicity, in combination with doxorubicin and SB203580 (p38 inhibitor), and in vivo as a single agent.

Results: Both sh-RNA sequences achieved &gt;80% knockdown of DUSP26 expression. Colony formation in soft agar was significantly reduced (p&lt;0.05) in the sh-DUSP26 cell lines compared to control cell lines. Cell cycle analysis was also performed comparing the sh-Control and sh-DUSP26 cell lines that showed a G1 cell cycle arrest (46.8% vs. 80.6%, p&lt;0.03). In vivo, SH-SY5Y cells transduced with sh-DUSP26 had significantly lower tumor weights after 4 weeks of growth compared to the sh-Control transduced cells (1.8gm vs. 4.2gm, p&lt;0.01). Cytotoxicity assays testing NSC were performed on multiple NB cell lines. After 24 to 48 hours of exposure, NSC caused significantly decreased (p&lt;0.005) cell viability at 10µM in IMR32 (18% viable), NB-19 (40%), LAN-1 (41%), SH-SY5Y (53%), and SK-N-SH (38 %). In contrast, the SHEP cell line, known to have very little DUSP26 expression, actually grew in the setting of NSC treatment (200%, p&lt;0.005). In combination with doxorubicin (0.025 µM), NSC resulted in a significant additive decrease (p&lt;0.05) in cell viability for the MYCN amplified cell lines (IMR-32, 26% less; LAN-1, 24%; NB-19, 20%). The p53 pathway was evaluated by Western blot using both DUSP26 inhibition techniques, shRNA and NSC. Increased p53 stability and phosphorylation at Ser46 demonstrated a possible role for p38 MAP kinase. With NSC treatment, cells displayed increased p38 phosphorylation and PARP cleavage. This was further supported with the reversal of NSC-mediated cytotoxity (p&lt;0.01) by the p38 inhibitor SB203580 on IMR32 (54% vs. 124% viability) and NB-19 (69% vs. 102% viability). After 2 weeks of tumor growth in vivo, NSC was administered to mice once daily at 15mg/kg for a total of 21 days. Tumor weights were significantly decreased (p&lt;0.03) in the treated cohort of mice (0.1 gm, n=3) compared to placebo control (0.8 gm, n=2).

Conclusion: DUSP26 is an essential protein for NB cell growth in vitro and in vivo. By inhibiting DUSP26, pro-apoptotic pathways, such as p53 and/or p38, potentially become disinhibited. DUSP26 targeted therapy may prove to be a useful single agent or adjuvant to current chemotherapy for NB.

Citation Format: Irene T. Ma, Yihui Fan, Roma H. Patel, Jin Cheng, Eugene S. Kim, Jason M. Shohet, Jianhua Yang, Sanjeev A. Vasudevan. DUSP26 inhibition: a new therapeutic pathway in neuroblastoma. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr LB-352. doi:10.1158/1538-7445.AM2013-LB-352