Pseudocirrhosis: A Case Series with Clinical and Radiographic Correlation and Review of the Literature.

BACKGROUND AND AIMS: Pseudocirrhosis is a poorly understood acquired morphologic change of the liver that occurs in the setting of metastatic malignancy and radiographically resembles cirrhosis. Pseudocirrhosis has been primarily described in metastatic breast carcinoma, with few case reports arising from other primary malignancies. We present 29 cases of pseudocirrhosis, including several cases from primary malignancies not previously described. METHODS: Radiologic, clinical, demographic, and biomedical data were collected retrospectively and analyzed. We compared clinical and radiologic characteristics and outcomes between patients with pseudocirrhosis arising in metastatic breast cancer and non-breast primary malignancies. RESULTS: Among the 29 patients, 14 had breast cancer and 15 had non-breast primaries including previously never reported primaries associated with pseudocirrhosis, melanoma, renal cell carcinoma, appendiceal carcinoid, and cholangiocarcinoma. Median time from cancer diagnosis to development of pseudocirrhosis was 80.8 months for patients with primary breast cancer and 29.8 months for non-breast primary (p = 0.02). Among all patients, 15 (52%) had radiographic features of portal hypertension. Radiographic evidence of portal hypertension was identified in 28.6% of breast cancer patients, compared to 73.3% of those with non-breast malignancies (p = 0.03). CONCLUSION: Pseudocirrhosis has most commonly been described in the setting of metastatic breast cancer but occurs in any metastatic disease to the liver. Our study suggests that portal hypertensive complications are more common in the setting of non-breast primary cancers than in metastatic breast cancer. Prior exposure to multiple chemotherapeutic agents, and agents known to cause sinusoidal injury, is a common feature but not essential for the development of pseudocirrhosis.

Use of predictive spatial modeling to reveal that primary cancers have distinct central nervous system topography patterns of brain metastasis.

OBJECTIVE: Brain metastasis is the most common intracranial neoplasm. Although anatomical spatial distributions of brain metastasis may vary according to primary cancer subtype, these patterns are not understood and may have major implications for treatment. METHODS: To test the hypothesis that the spatial distribution of brain metastasis varies according to cancer origin in nonrandom patterns, the authors leveraged spatial 3D coordinate data derived from stereotactic Gamma Knife radiosurgery procedures performed to treat 2106 brain metastases arising from 5 common cancer types (melanoma, lung, breast, renal, and colorectal). Two predictive topographic models (regional brain metastasis echelon model [RBMEM] and brain region susceptibility model [BRSM]) were developed and independently validated. RESULTS: RBMEM assessed the hierarchical distribution of brain metastasis to specific brain regions relative to other primary cancers and showed that distinct regions were relatively susceptible to metastasis, as follows: bilateral temporal/parietal and left frontal lobes were susceptible to lung cancer; right frontal and occipital lobes to melanoma; cerebellum to breast cancer; and brainstem to renal cell carcinoma. BRSM provided probability estimates for each cancer subtype, independent of other subtypes, to metastasize to brain regions, as follows: lung cancer had a propensity to metastasize to bilateral temporal lobes; breast cancer to right cerebellar hemisphere; melanoma to left temporal lobe; renal cell carcinoma to brainstem; and colon cancer to right cerebellar hemisphere. Patient topographic data further revealed that brain metastasis demonstrated distinct spatial patterns when stratified by patient age and tumor volume. CONCLUSIONS: These data support the hypothesis that there is a nonuniform spatial distribution of brain metastasis to preferential brain regions that varies according to cancer subtype in patients treated with Gamma Knife radiosurgery. These topographic patterns may be indicative of the abilities of various cancers to adapt to regional neural microenvironments, facilitate colonization, and establish metastasis. Although the brain microenvironment likely modulates selective seeding of metastasis, it remains unknown how the anatomical spatial distribution of brain metastasis varies according to primary cancer subtype and contributes to diagnosis. For the first time, the authors have presented two predictive models to show that brain metastasis, depending on its origin, in fact demonstrates distinct geographic spread within the central nervous system. These findings could be used as a predictive diagnostic tool and could also potentially result in future translational and therapeutic work to disrupt growth of brain metastasis on the basis of anatomical region.

A Removable Long-arm Soft Cast to Treat Nondisplaced Pediatric Elbow Fractures: A Randomized, Controlled Trial.

BACKGROUND: The ideal type of immobilization for nondisplaced pediatric elbow fractures has not been established. We hypothesized that the use of a long-arm cylinder made of soft cast material will result in similar outcomes to those obtained with a traditional long-arm hard cast. METHODS: We randomly assigned 100 consecutive children who presented with a closed, nondisplaced, type I supracondylar humeral fracture or an occult, closed, acute elbow injury, to 1 of 2 groups: group A (n=50) received a long-arm, traditional fiberglass (hard) cast. Group B (n=50) received a long-arm, soft fiberglass cast. After 4 weeks, the cast was removed in group A by a member of our staff using a cast saw, and in group B by one of the patient's parents by rolling back the soft fiberglass material. We compared the amount of fracture displacement and/or angulation, recovery of range of motion, elbow pain, and patient satisfaction. RESULTS: There were no instances of unplanned removal of the cast by the patient or parent. No evidence of fracture displacement or angulation was seen in either group. The final carrying angle of the affected elbow was nearly identical of that of the normal, contralateral elbow in both groups (P=0.64). At the latest follow-up appointment, elbows in groups A and B had a similar mean arc of motion (156 vs. 154 degrees; P=0.45), and had achieved identical relative arc of motion of 99.6% and 99.5% of that of the normal, contralateral side, respectively (P=0.94). Main pain scores were low and comparable over the study period. All patients in both groups reported the highest rate of satisfaction at the eighth week of follow-up. CONCLUSIONS: The results indicate that children with nondisplaced supracondylar humeral fractures can be successfully managed with the use of a removable long-arm soft cast, maintaining fracture alignment and resulting in comparable rates of range of motion, pain, and patient satisfaction. The use of a removable immobilization that can reliably maintain fracture alignment and result in similar outcomes, while minimizing the risk of noncompliance, could be advantageous. Although we elected to remove the soft cast during a scheduled follow-up, it appears that such immobilization could be removed easily and safely at home, potentially resulting in a lower number of patient visits, decreased health care costs, and higher patient/parent satisfaction. LEVEL OF EVIDENCE: Level I.

Outcomes of ORIF >7 Days After Injury in Displaced Pediatric Lateral Condyle Fractures.

BACKGROUND: The purpose of the present study was to evaluate the effects of surgical timing on the outcome of pediatric lateral condyle fractures (LCF). We hypothesize that performing open reduction and internal fixation (ORIF) for a displaced LCF between 7 and 14 days after the occurrence of injury does not result in significant changes in outcome, as compared with those treated within the first 7 days. METHODS: A total of 181 pediatric LCFs treated with ORIF, with a mean follow-up of 38 weeks and a mean age of 5 years, were included. All information related to the patient's elbow injury was prospectively collected. We identified 2 specific groups: 133 LCFs that were treated within the first 7 days after injury (group 1), and 48 that were treated between 7 and 14 days after injury (group 2). A satisfactory outcome was one in which there was evidence of healing of the fracture, a range of motion of at least 85% of the normal, contralateral side at the latest follow-up, and no evidence of complications, loss of fixation, infection, or avascular necrosis of the lateral condyle. RESULTS: Overall, the mean time from injury to surgery was 5 days (range, 0 to 14 d). Initial fracture displacement was slightly larger in group 1 versus group 2, by a mean of 2.6 mm (P=0.004). There were no iatrogenic nerve injuries or vascular complications in either group. There was no difference in the mean surgical time between groups (P=0.004). At the latest follow-up appointment, elbows in both groups had similar range of motion (P=0.5), a low and similar rate of complications, and comparable rates of satisfactory outcomes (88.0% vs. 87.5%; P=0.6). CONCLUSION: Our study suggests that performing an ORIF for a displaced pediatric LCF up to 14 days after the original injury does not adversely affect the outcome of the procedure. LEVEL OF EVIDENCE: Level II-comparative study.

It is not just comfort: waterproof casting increases physical functioning in children with minimally angulated distal radius fractures.

Waterproof casting has been reported to increase patient comfort and satisfaction, and decrease skin irritation. There are no available data on the influence of waterproof casting materials on physical function in pediatric patients. Our aim was to determine whether the use of waterproof casting would result in faster recovery of physical function while maintaining similar clinical outcomes as those obtained with nonwaterproof materials. Twenty-six children with nonangulated or minimally angulated distal radius fractures were assigned randomly to initially receive a short-arm cast made of one of two optional materials: a hybrid mesh material with a waterproof lining or fiberglass with a nonwaterproof skin protector. Two weeks later, the initial cast was removed and replaced with a short-arm cast made of the alternative option. We compared the rate of fracture displacement, physical function, pain, skin changes, itchiness, and patient satisfaction. No evidence of displacement was found in either group. The mean Activities Scale for Kids - Performance (ASK-P) (physical function) score was 10% higher during the period of time when a waterproof cast was used (P=0.04). When a waterproof cast was used during the first 2 weeks of treatment, the mean total ASK-P scores were 23% higher than that when a nonwaterproof one was used during the same period of time (P=0.003). Patients who received a waterproof cast as the initial treatment reported lower functional scores overall and in almost every domain of the ASK-P once they were in a nonwaterproof one; similarly, those who received a nonwaterproof cast as the initial treatment reported higher functional scores overall and in every domain of the ASK-P once they were in a waterproof cast. Compared with a nonwaterproof cast, the use of waterproof casting resulted in comparable levels of pain, itchiness, skin irritability, and overall patient satisfaction. The results of this randomized, cross-over trial suggest that the use of waterproof casting material for the treatment of nondisplaced or minimally displaced distal radius fractures in children can result in a faster recovery of physical function, while providing comparable stability, pain, itchiness, skin irritability, and overall patient satisfaction. LEVEL OF EVIDENCE: II.