Safety and efficacy of selumetinib in pediatric and adult patients with neurofibromatosis type 1 and plexiform neurofibroma.

BACKGROUND: The MEK inhibitor, selumetinib, reduces plexiform neurofibroma (PN) in pediatric patients with neurofibromatosis type 1 (NF1). Its safety and efficacy in adults with PN and effectiveness in other NF1manifestations (e.g., neurocognitive function, growth reduction, and café-au-lait spots) are unknown. METHODS: This open-label, phase 2 trial enrolled 90 pediatric or adult NF1 patients with inoperable, symptomatic, or potentially morbid, measurable PN (≥ 3 cm). Selumetinib was administered at doses of 20 or 25 mg/m2 or 50 mg q 12 hrs for 2 years. Pharmacokinetics, PN volume, growth parameters, neurocognitive function, café-au-lait spots, and quality of life (QoL) were evaluated. RESULTS: Fifty-nine children and 30 adults (median age, 16 years; range, 3-47) received an average of 22±5 (4-26) cycles of selumetinib. Eighty-eight (98.9%) out of 89 per-protocol patients showed volume reduction in the target PN (median, 40.8%; 4.2%-92.2%), and 81 (91%) patients showed partial response (≥ 20% volume reduction). The response lasted until cycle 26. Scores of neurocognitive functions (verbal comprehension, perceptual reasoning, processing speed, and full-scale IQ) significantly improved in both pediatric and adult patients (P <0.05). Prepubertal patients showed increases in height score and growth velocity (P <0.05). Café-au-lait spot intensity decreased significantly (P <0.05). Improvements in QoL and pain scores were observed in both children and adults. All adverse events were CTCAE grade 1 or 2 and were successfully managed without drug discontinuation. CONCLUSION: Selumetinib decrease PN volume in the majority of pediatric and adult NF1 patients while also showing efficacy in non-malignant diverse NF1 manifestations.

Comparing outcomes of prepectoral, partial muscle-splitting subpectoral, and dual-plane subpectoral direct-to-implant reconstruction: implant upward migration and the pectoralis muscle.

Background: Although dual-plane subpectoral breast reconstruction has been widely implemented in implant-based breast reconstruction, animation deformities remain an issue. Recent advances in skin flap circulation detection have increased the use of prepectoral reconstruction. A partial muscle-splitting subpectoral plane was introduced to decrease the visibility of the implant edge. However, there is yet to be a direct comparison of these methods for optimal results, including changes in implant position after reconstruction. This study aims to compare the incidence of complications such as rippling, animation deformity, implant upward migration between the dual-plane, the partial muscle splitting subpectoral and the prepectoral reconstruction group. In addition, multivariate analysis was conducted to identify the risk factors of complications. Methods: We retrospectively investigated 349 patients who underwent unilateral direct-to-implant breast reconstruction from January 2017 to October 2020. Implants were inserted into the dual-plane subpectoral (P2) or partial muscle-splitting subpectoral (P1, the muscle slightly covering the upper edge of the implant) or the prepectoral pocket (P0). Postoperative outcomes and at least 2 years of follow-up complications were compared. Results: There was no significant difference in rippling (P=0.62) or visible implant edges on the upper pole (P=0.62) among the three groups. In contrast, the P0 group had a lower incidence of seroma (P=0.008), animation deformity (P<0.001), breast pain (P=0.002), and upward implant migration (P0: 1.09%, P1: 4.68%, P2: 38.37%, P<0.001). According to the multivariate analysis, P2 resulted in a greater risk of seroma (odds ratio: 4.223, P=0.002) and implant upward migration (odds ratio: 74.292, P<0.001) than did P0. Conclusions: P0 and P1 showed better postoperative outcomes than P2. Additionally, P0 had less implant migration than P1. Even though P1 minimally dissects the muscle, the location of the implant may change. Considering that muscle contraction can deteriorate symmetry and aesthetic results, the P0 method may be the most favorable.

Abdominal Wall Hernias Following High-intensity Focused Ultrasound Therapy: Three Case Reports.

Although many studies reported the safety and efficacy of high-intensity focused ultrasound (HIFU) therapy, there are still worries about internal organ injury. However, reports of abdominal wall hernias after HIFU therapy are rare. We present three cases of abdominal wall hernias without skin injury after HIFU therapy in uterine adenomyosis or fibroids. The diagnosis was often delayed because of vague symptoms, inadequate clinical suspicion, and delayed proper image studies. Abdominal wall hernia should be recognized as a possible complication after HIFU and be suspected when the patient presents with unordinary abdominal swelling and/or pain that lasts for more than a few months after the procedure.

The effect of preoperative botulinum toxin a injection on traction force during hernia repair: a prospective, single-blind study, intra-patient comparison using contralateral side as a control.

PURPOSE: Ventral hernias are a common complication of laparotomy, posing challenges particularly when primary fascial closure is unattainable. Although chemical component separation using preoperative botulinum toxin A (BTX) injections has emerged as a promising adjunct, objective evidence of its efficacy remains limited. This study aimed to objectively assess the effect of preoperative BTX on traction force during ventral hernia repair. METHODS: A prospective, single-blind study was conducted on patients with midline incisional hernias following liver transplantation. BTX was administered unilaterally, and the traction force required to medially advance the anterior rectus sheath was measured intraoperatively. Pre- and post-injection CT scans were analyzed for changes in hernia size and LAW muscle measurements. Statistical analyses were performed to evaluate traction force differences between BTX-injected and uninjected sides. RESULTS: Ten patients underwent hernia repair with primary fascial closure achieved in all cases. Comparison of pre- and post-injection CT scans showed no significant changes in hernia size. LAW muscle length increased by 1.8 cm, while thickness decreased by 0.2 cm. Intraoperative traction force measurements revealed a significant reduction on the BTX-injected side compared to the uninjected side (p < 0.0001). The traction force ratio on the BTX-injected to the uninjected side averaged 57%, indicating the efficacy of BTX in reducing tension. CONCLUSION: Preoperative BTX significantly reduces traction force during ventral hernia repair, highlighting its potential as an adjunctive therapy in complex cases. While challenges remain in patient selection and outcome assessment, BTX offers a promising avenue for enhancing abdominal wall reconstruction outcomes and reducing surgical complications.

Factors influencing the decision-making process in breast reconstruction from the perspective of reconstructive surgeons: A qualitative study involving Korean plastic surgeons.

BACKGROUND: Little research has been conducted on factors influencing the decision-making process for immediate breast reconstruction (IBR) options from the perspective of reconstructive surgeons, despite its significant impact on doctor-patient communication and shared decision-making. This study aims to explore the multiple factors and the mechanisms by which they interact using a qualitative methodology. We also address potential barriers to shared decision-making in IBR. METHODS: Semistructured interviews were conducted with a purposive sample of reconstructive surgeons. Thematic analysis was used to identify key influences on IBR decision-making process from the perspective of reconstructive surgeons. RESULTS: Four major themes were identified: 1. Patient clinical scenarios; 2. Nonclinical practice environments; 3. Reconstructive surgeon preferences; and 4. Patient consultation. Reconstructive surgeons demonstrated diverse approaches to patient clinical scenarios. High-volume centers were significantly influenced by nonclinical factors such as scheduling and operating room allocation systems. Reconstructive surgeons often had strong personal preferences for specific IBR options, shaped by their expertise, experience, and clinical environment. Based on the preliminary decision, surgeons provided information with varying degrees of neutrality. Patients varied in their knowledge and participation, resulting in variation in the final decision authority among surgeons. CONCLUSIONS: This study highlights the need to address nonclinical environmental constraints to improve shared decision-making process in IBR. Surgeons should recognize power imbalances in the doctor-patient relationship and be aware of their biases.