C-51 Long Term Neuropsychological Follow-Up of Radiation Induced Cognitive Decline (RICD) in Cerebellar Medulloblastoma

Objective

We expanded upon an early case study suggesting long-term, sequential neurocognitive evaluation and academic interventions following pediatric cerebellar medulloblastoma. This five-year-old patient (now forty) has indeed undergone lifespan assessment and clearly benefitted from appropriate interventions to date.

Method

This left-handed, white, male is status post (s/p) gross total resection and whole brain radiation. In adulthood, he developed radiation necrosis with hemorrhage and refractory seizures (s/p right temporal lobectomy). More recently, radiation induced bilateral parietal meningiomas were identified (s/p gamma knife).

Results

We analyzed cognitive, medical/oncological, imaging and interventional data at developmentally meaningful time points and found consistent declines in intellectual skills and cognitive function spanning attention/concentration, processing speed, visual perceptual/organization and visually based learning/memory; however, we noted stabilization and even improvement in important areas. Areas of age-appropriate functioning were noted in expressive vocabulary, verbal abstract reasoning, delayed verbal memory, and problem-solving, among others.

Conclusions

Although some studies have addressed long-term outcomes in pediatric medulloblastoma, we provide a unique perspective to the literature by documenting serial neurocognitive findings in addition to interventions across the lifespan. Our findings suggest that appropriate academic interventions/neurocognitive rehabilitation strategies are in fact meaningful at the individual level and propose that a focus on strengths can improve outcomes. We propose that this previously recommended model of assessment/intervention truly become the available standard of care in all pediatric oncologic populations.

Histologic evaluation of fetal brains following maternal pneumoperitoneum

BACKGROUND

The purpose of this study was to determine if maternal pneumoperitoneum with carbon dioxide (CO2) produces evidence of central nervous system (CNS) injury in preterm fetal guinea pigs.

METHODS

Thirty pregnant guinea pigs at gestational day (GD) 45 were assigned at random to one of three treatment groups: anesthesia only, CO2 pneumoperitoneum (5 mmHg), or laparotomy. Dams were killed 3 or 5 days postprocedure and fetal brains (83 total) harvested and fixed for subsequent histopathologic evaluation. For comparative purposes, histologic features of fetal guinea pig brain injury were defined from examination of fetal brains harvested from an additional dam that underwent laparotomy with 20 min of uterine arterial occlusion.

RESULTS

Carbon dioxide pneumoperitoneum did not increase maternal/fetal morbidity. No evidence of brain injury was found in fetuses from any of the treatment groups.

CONCLUSION

Carbon dioxide pneumoperitoneum at 5 mmHg for 40 min in the pregnant guinea pig does not produce evidence of fetal brain injury.

Use of tape-recorded food records in assessing children's dietary intake

BACKGROUND

Dietary assessment among children is particularly problematic when techniques are dependent on memory skills or advanced cognitive development.

OBJECTIVE

The current study explored the use of self-report by tape recorders to document children's dietary intake immediately upon consumption, and compared this method with the traditional, interviewer-guided recall technique. In addition, the influence of body fatness and sociodemographic characteristics on the accuracy of recall and tape-recorded food records was determined.

RESEARCH METHODS AND PROCEDURES

The sample included 30 black and white children aged 6.5 to 11.6 years (x = 9.5). Energy intake (EI), measured by six 24-hour food records (three for each method), was compared with total energy expenditure calculated by the doubly labeled water technique. Paired t tests, correlation analyses, and multiple regression analyses were performed.

RESULTS

The analyses revealed poor validity of the tape recorder method (x misreporting score = -1.13+/-2.62 MJ/day, r for total energy expenditure and EI = -0.06, p = 0.74). Estimates of EI differed significantly between the tape recorder and recall methods (p<0.01). The traditional recall method was confirmed as a valid estimate of energy intake (x misreporting score = 0.04+/-2.38 MJ/day), although demonstrating a modest correlation with TEE (r = 0.32, p = 0.08). Although no significant predictors of misreporting using the recall method were identified in the multivariate analyses, older children and children with higher adiposity were more likely to misreport using the tape recorder method.

DISCUSSION

The results suggest that the use of the tape recorder for estimating EI does not result in accurate assessments among children, although this technique may be useful for specific subgroups (i.e., younger and leaner children).

Clinical use of molecular information in the management of multiple endocrine neoplasia type 2A

One hundred and ninety-seven members of 28 kindreds with multiple endocrine neoplasia type 2A (MEN 2A) were screened for RET proto-oncogene exon 10 and 11 mutations. Seventy-one known affected individuals had mutations of codons 609, 618, 620 or 634, whereas 53 unaffected individuals had no abnormalities. Nineteen out of 54 individuals of unknown status, mostly children, had RET mutations. Four of these children had thyroidectomy based on this analysis and were found to have C-cell abnormalities. We identified one false negative mutation analysis because of a codon 691 polymorphism. We conclude that RET mutational analysis is a cost-effective and accurate method for determination of gene carrier status in MEN 2A.

Amyloid tumor of the sacrum. A case report

The second published case of amyloidoma in the pelvis and sacrum is reported. Fine needle aspiration biopsy revealed multinucleate giant cells, lymphocytes and plasma cells, some atypical. Congo red staining of the cell block and aspirate showed focal, apple-green birefringence consistent with amyloid. The histologic, radiologic and clinical features of this case are discussed, and the cytologic findings in previously reported fine needle aspiration biopsies of amyloidomas are reviewed.

Neer's classification system: a critical appraisal

The purpose of this study was to examine the interobserver agreement using Neer's classification system for fractures of the proximal humerus. A preliminary series of 28 fractures of the proximal humerus admitted to the hospital over a 5-year retrospective period was independently assessed by two radiologists and two orthopedic surgeons. The degree of agreement between paired observations was determined using a kappa statistic. The observations were assessed according to the number of fracture segments, as well as site of fracture segment. Most of the patients assessed were multisegment tuberosity fractures (n = 18). Results showed that the overall agreement between pairs of observers was 65% (average kappa = 0.45). It was also shown that, within the tuberosity group, the percentage agreement was 50%, with an average kappa = 0.35, indicating only fair interobserver agreement. Clinical implications of these findings are such that, as major surgical decisions are made dependent on Neer's classification, closer evaluation techniques--such as the computerized tomography scan and magnetic resonance imaging--should be used to classify the fracture segments accurately. This is particularly true with the fractured tuberosity subgroup.

Genetic linkage studies map the multiple endocrine neoplasia type 2 loci to a small interval on chromosome 10q11.2

We have carried out genetic linkage analyses using fifteen polymorphic loci in the pericentromeric region of chromosome 10 in families with the inherited cancer syndromes multiple endocrine neoplasia (MEN) type 2A or 2B. A highly polymorphic microsatellite from the locus D10S141 in q11.2 was found to be recombinant with respect to the disease locus in two individuals and defines a new proximal flanking marker for both MEN2A and 2B. An additional recombination provides evidence that the locus D10S94, also in q11.2, is the closet distal flanking marker for MEN2A. This localises the MEN2A gene to a small region of 10q11.2 flanked by the loci D10S141 and D10S94, which are separated by a sex-averaged genetic distance of 0.55 cM. The MEN2B gene maps to a larger region, flanked by D10S141 and RBP3.

High-sensitivity serum calcitonin assays applied to screening for thyroid C-cell disease in multiple endocrine neoplasia type 2A

Two serum calcitonin assays with sensitivities < or = 10 pg/mL were compared to our standard radioimmunoassay (sensitivity 100 pg/mL) in multiple endocrine neoplasia type 2A (MEN 2A) screening. Values from the Nichols displacement radioimmunoassay averaged 38% higher than values from the CIS immunoradiometric assay; values from both were highly correlated, r = 0.845. In three individuals, both of the newer assays revealed abnormalities in pentagastrin tests three to four years before abnormalities were detected by the standard assay. Pentagastrin tests after total thyroidectomy were assayed by the newer methods in patients with medullary thyroid carcinoma (MTC) diagnosed at initial testing (group I); in patients with early MTC diagnosed by prospective screening (group II); and in patients with pure C-cell hyperplasia detected by prospective screening (group III). At least 64% of group I, at least 25% of group II, but none of group III had detectable postoperative C-cell function.

CONCLUSIONS

1) The previous estimate of 12 years as median age of onset of C-cell disease in MEN 2A is probably three to four years too old. 2) Patients diagnosed with early MTC by screening had not necessarily skipped a preneoplastic phase of C-cell hyperplasias. At least some early disease was not detected by the standard assay. Higher sensitivity assay should improve screening for C-cell disease by earlier disease detection. 3) Biochemical cure by thyroidectomy after the development of MTC is not as frequent as previously thought, but the apparent cure rate of pure C-cell hyperplasia remains 100%.

The clinical and screening age-at-onset distribution for the MEN-2 syndrome

The decision to screen for multiple endocrine neoplasia type 2 (MEN-2) is generally based on family history, the rationale for this approach being the presumed 100% penetrance of the disease. To determine the validity of this presumption we have estimated--by applying modifications of the life-table method--the clinical and screening age-at-diagnosis distributions for MEN-2, using families from the Cancer Research Campaign Medullary Thyroid Cancer Register and one large American family. The clinical penetrance of MEN-2 is shown to be incomplete, an estimated 41% of gene carriers not presenting with symptoms by age 70 on the basis of clinical history. Screening by the standard tests for detecting the earliest manifestations of the syndrome increases the penetrance to an estimated 93% by age 31. There is no evidence of a difference in the age-at-diagnosis distributions between maternal and paternal transmission, or among different families, but there is some suggestion of an earlier onset of medullary thyroid cancer in female gene carriers, and of a tendency of pheochromocytoma to cluster in families. These results can be used to calculate risks to relatives of affected individuals, which in turn can be used to guide decisions on which individuals to screen.

The clinical outcome of prospective screening for multiple endocrine neoplasia type 2a. An 18-year experience

An important question facing physicians who care for families with multiple endocrine neoplasia type 2a is whether prospective screening to detect early abnormalities of the thyroid, parathyroid, or adrenal glands favorably influences the ultimate course of the disease. An 18-year study of a large family has allowed us to examine the effect of early treatment on the clinical course of the disease. Of 22 patients who underwent thyroidectomy for early C-cell abnormalities, 19 remained free of detectable medullary thyroid carcinoma according to all criteria, at a mean of 11 years after thyroidectomy. None of the 22 patients had evidence of parathyroid disease either at the time of surgery or after a mean follow-up of 10 years. Prospective screening for adrenal medullary abnormalities by means of measurement of 24-hour urinary epinephrine excretion and the ratio of urinary epinephrine to norepinephrine was predictive of pheochromocytoma in 10 of 11 patients (with a false negative result in one patient) but was not useful in diagnosing adrenal medullary hyperplasia. We conclude that regular, prospective screening and early treatment of the manifestations of multiple endocrine neoplasia can prevent metastasis of medullary thyroid carcinoma and the morbidity and mortality caused by pheochromocytoma.

Computed tomography of life-threatening complications of abdominal aortic aneurysm. The disrupted aortic wall

A localized disruption of the conspicuity of the wall of the aorta was noted on intravenous contrast-enhanced computed tomography (CT) scans of ten patients with ruptured abdominal aortic aneurysm (n = 6) or aortoenteric fistula (n = 4). Subsequently, we reviewed 84 scans of patients with uncomplicated aneurysm (n = 70) or aneurysm graft repair (n = 14) to determine if a disrupted wall has diagnostic implications. In this control group, the wall of the aneurysm was conspicuous throughout in 95% of 64 patients who received iodinated contrast material intravenously and in 55% of 20 patients who did not. In the proper clinical setting, CT scans performed with intravenous administration of iodinated contrast material can provide direct evidence of disruption of the wall of an abdominal aortic aneurysm. In selected cases, this may be important for the diagnosis of rupture. Disrupted conspicuity of the wall, in combination with effacement of the fat plane between an aneurysm and the juxtaposed intestine, increases the accuracy of CT for the diagnosis of aortoenteric fistula.

Bile-duct dilatation after laparotomy: a potential effect of intestinal hypomotility

Dilatation of unobstructed extrahepatic bile ducts was observed in patients with conditions associated with intestinal hypomotility. For further investigation of this association, a prospective study was undertaken in which the common hepatic duct was measured in 15 patients before and 1 day after laparotomy, when all patients had postoperative paralytic ileus. A statistically significant (p less than 0.01) increase in the mean diameter of the hepatic duct was observed postoperatively. When compared with the preoperative measurement, the mean diameter of the duct almost doubled, from 3.3 to 5.9 mm. This phenomenon may be due to persistent contraction of the sphincter of Oddi that occurs when intestinal hypomotility eliminates the stimuli for cholecystokinin release.