Optimal Timing of Delayed Microvascular Breast Reconstruction after Radiation Therapy.

BACKGROUND: The purpose of this study was to determine the optimal timing of delayed microvascular breast reconstruction after completion of postmastectomy radiation therapy (PMRT). The authors evaluated whether the timing of reconstruction after PMRT completion affects the development of major postoperative complications. We hypothesize that delayed microvascular breast reconstruction can be safely performed within 12 months of PMRT completion. METHODS: A retrospective chart review of microvascular, autologous breast reconstructions at Brigham and Women's Hospital from 2007 to 2019 was performed. Logistic regression analysis and marginal estimation methods were used to estimate the probability of any major complication (flap compromise requiring operative intervention, hematoma formation requiring evacuation, infection requiring readmission, and flap necrosis requiring operative debridement) occurring in 2-month intervals after PMRT. Patients were classified as having undergone reconstruction 0 to 12 months after PMRT (group 1), 12 to 18 months after PMRT (group 2), or 18 to 50 months after PMRT (group 3). RESULTS: A total of 303 patients were identified. All patients received postmastectomy radiation (n = 143 group 1, n = 57 group 2, n = 103 group 3). Mean follow-up time was 71.4 ± 38 months. Patients in group 1 were significantly younger and more likely to have undergone neoadjuvant chemotherapy (p < 0.05). Major complications occurred in 10% of patients. There was no significant difference in the development of major complications between the three groups (p = 0.57). Although not statistically significant, the probability of any major complication peaked 2 to 6 months after PMRT completion. CONCLUSION: There was no significant difference in major complications among patients who underwent delayed, microvascular breast reconstruction within versus beyond 1 year of PMRT completion. These findings suggest that delayed microvascular breast reconstruction can be safely performed beginning 6 months after PMRT completion.

Delayed diagnosis of childhood low-grade glioma: causes, consequences, and potential solutions.

PURPOSE: Diagnosis of childhood brain tumors is delayed more than diagnosis of other pediatric cancers. However, the contribution of the most common pediatric brain tumors, lowgrade gliomas (LGG), to this delay has never been investigated. METHODS: We retrospectively reviewed cases of childhood LGG diagnosed from January 1995 through December 2005 at our institution. The pre-diagnosis symptom interval (PSI) was conservatively calculated, and its association with race, sex, age, tumor site, tumor grade, and outcome measures (survival, disease progression, shunt use, seizures, extent of resection) was analyzed. Cases of neurofibromatosis type 1 were reported separately. RESULTS: The 258 children had a median follow-up of 11.1 years, and 226 (88 %) remained alive. Greater pre-diagnosis symptom interval (PSI) was significantly associated with grade I (vs. grade II) tumors (p = 0.03) and age >10 years at diagnosis (p = 0.03). Half of the 16 spinal tumors had a PSI > 6 months. PSI was significantly associated with progression (p = 0.02) in grade I tumors (n = 195) and in grade I tumors outside the posterior fossa (n = 134, p = 0.03). Among children with grade I tumors, median PSI was longer in those who had seizures (10.3 months) than in those who did not (2.5 months) (p = 0.09). CONCLUSIONS: Delayed diagnosis of childhood LGG allows tumor progression. To reduce time to diagnosis, medical curricula should emphasize inclusion of LGG in the differential diagnosis of CNS neoplasm.

Optimizing Breast Reconstruction through Integration of Plastic Surgery and Radiation Oncology.

Post-mastectomy radiation therapy (PMRT) is an important adjunct to improve oncologic outcomes and survival in select breast cancer patients at increased risk for local recurrence. As recommendations for PMRT broaden, an increasing number of patients will have it included as part of their breast cancer treatment plan. METHODS: This overview of the literature strives to broaden the exposure of the plastic surgeon to PMRT and describe the indications, guidelines, and considerations relevant to reconstructive surgery. The primary targets and dosing considerations will also be reviewed. Finally, the short- and long-term toxicities are outlined with the goal of providing the plastic surgeon insights with which to recognize certain toxicities in the clinic during follow up and to develop the fluency to be able to talk to patients about the potential for certain toxicities. RESULTS: Generally, PMRT is safe and well tolerated. Considerations in breast reconstruction should be made on a patient-by-patient basis. Plastic surgeon familiarity with PMRT, its indications, and complications will amplify the surgeon's ability to optimize outcomes. CONCLUSIONS: As more women undergo breast reconstruction, an increasing number of patients will have PMRT as part of their breast cancer treatment plan. By understanding the basic principles of PMRT, plastic surgeons can engage patients in conversations of shared decision-making and maximize outcomes.

Extramedullary intradural spinal tumors: a review of modern diagnostic and treatment options and a report of a series.

Extramedullary intradural spinal tumors are rare. Less than 15% of all central nervous system (CNS) tumors are spinal. Ninety percent of these patients are older than 20 years. Most of spinal tumors are extradural (50-55%) whereas 40-45% are intradural. Furthermore, 5% are intramedullary and 40% are extramedullary. Most common are Schwannomas (29%), followed by meningiomas (25%) and gliomas (22%). These tumors produce pain syndromes, a variety of neurological symptoms- motor, sensory, sphincter or a combination of thereof. All spinal levels may be involved. The diagnostics includes magnetic resonance imaging (MRI) including contrast enhancement, computerizing tomography (CT) scanning (bone windows with reconstruction) and possibly CT myelograms. Preferred treatment is the microsurgical radical resection. Perioperative mortality is very low as is serious morbidity.We herein discuss various aspects of presenting symptomatology, diagnostics, preoperative planning and tactics, surgical treatment and complications. In addition, we include our own retrospective experience with 14 patients treated over the 5.5 years time interval.

Pediatric and adult Chiari malformation Type I surgical series 1965-2013: a review of demographics, operative treatment, and outcomes.

OBJECT: Chiari malformation Type I (CM-I) is a hindbrain disorder associated with elongation of the cerebellar tonsils, which descend below the foramen magnum into the spinal canal. It occurs in children and adults. Clinical symptoms mainly develop from alterations in CSF flow at the foramen magnum and the common subsequent development of syringomyelia. METHODS: The authors reviewed English-language reports of pediatric, adult, and combined (adult and pediatric) surgical series of patients with CM-I published from 1965 through August 31, 2013, to investigate the following: 1) geographical distribution of reports; 2) demographics of patients; 3) follow-up lengths; 4) study durations; 5) spectrum and frequency of surgical techniques; 6) outcomes for neurological status, syrinx, and headache; 7) frequency and scope of complications; 8) mortality rates; and 9) differences between pediatric and adult populations. Research and inclusion criteria were defined, and all series that contained at least 4 cases and all publications with sufficient data for analysis were included. RESULTS: The authors identified 145 operative series of patients with CM-I, primarily from the United States and Europe, and divided patient ages into 1 of 3 categories: adult (>18 years of age; 27% of the cases), pediatric (≤18 years of age; 30%), or unknown (43%). Most series (76%) were published in the previous 21 years. The median number of patients in the series was 31. The mean duration of the studies was 10 years, and the mean follow-up time was 43 months. The peak ages of presentation in the pediatric studies were 8 years, followed by 9 years, and in the adult series, 41 years, followed by 46 years. The incidence of syringomyelia was 65%. Most of the studies (99%) reported the use of posterior fossa/foramen magnum decompression. In 92%, the dura was opened, and in 65% of these cases, the arachnoid was opened and dissected; tonsillar resection was performed in 27% of these patients. Postoperatively, syringomyelia improved or resolved in 78% of the patients. Most series (80%) reported postoperative neurological outcomes as follows: 75% improved, 17% showed no change, and 9% experienced worsening. Postoperative headaches improved or resolved in 81% of the patients, with a statistical difference in favor of the pediatric series. Postoperative complications were reported for 41% of the series, most commonly with CSF leak, pseudomeningocele, aseptic meningitis, wound infection, meningitis, and neurological deficit, with a mean complication rate of 4.5%. Complications were reported for 37% of pediatric, 20% of adult, and 43% of combined series. Mortality was reported for 11% of the series. No difference in mortality rates was seen between the pediatric and adult series. CONCLUSIONS: Before undergoing surgical treatment for CM-I, symptomatic patients and their families should be given clear information about the success of treatment and potential complications. Furthermore, surgeons may benefit from comparing published data with their own. In the future, operative CM-I reports should provide all details of each case for the purpose of comparison.