Erika Roddy

Late Effects of Treatment of Pediatric Central Nervous System Tumors

Central nervous system tumors represent the most common solid malignancy in childhood. Improvement in treatment approaches have led to a significant increase in survival rates, with over 70% of children now surviving beyond 5 years. As more and more children with CNS tumors have longer survival times, it is important to be aware of the long-term morbidities caused not only by the tumor itself but also by tumor treatment. The most common side effects including poor neurocognition, endocrine dysfunction, neurological and vascular late effects, as well as secondary malignancies, are discussed within this article.

Enhanced Recovery Pathways for Improving Outcomes After Minimally Invasive Gynecologic Oncology Surgery.

OBJECTIVE: To estimate whether an enhanced recovery after surgery pathway facilitates early recovery and discharge in gynecologic oncology patients undergoing minimally invasive surgery. METHODS: This was a retrospective case–control study. Consecutive gynecologic oncology patients undergoing laparoscopic or robotic surgery between July 1 and November 5, 2014, were treated on an enhanced recovery pathway. Enhanced recovery pathway components included patient education, multimodal analgesia, opioid minimization, nausea prophylaxis as well as early catheter removal, ambulation, and feeding. Cases were matched in a one-to-two ratio with historical control patients on the basis of surgery type and age. Primary endpoints were length of hospital stay, rates of discharge by noon, 30-day hospital readmission rates, and hospital costs. RESULTS: There were 165 patients included in the final cohort, 55 of whom were enhanced recovery pathway patients. Enhanced recovery patients were more likely to be discharged on postoperative day 1 compared with patients in the control group (91% compared with 60%, P<.001, odds ratio 6.7, 95% confidence interval 2.46–18.04). Fifteen percent of enhanced recovery patients achieved discharge by noon compared with 4% of historical control patients (P=.03). Postoperative pain scores decreased (2.6 compared with 3.12, P=.03) despite a 30% reduction in opioid use. Average total hospital costs were decreased by 12% in the enhanced recovery group (

Rates and characteristics of radiographically detected intracerebral cavernous malformations after cranial radiation therapy in pediatric cancer patients

13,771 compared with

Post-operative enteral immunonutrition for gynecologic oncology patients undergoing laparotomy decreases wound complications

15,649, P=.01). Readmission rates, mortality, and reoperation rates did not differ between the two groups. CONCLUSION: An enhanced recovery pathway in patients undergoing gynecologic oncology minimally invasive surgery is associated with significant improvements in recovery time, decreased pain despite reduced opioid use, and overall lower hospital costs.

Treatment of critical-sized bone defects: clinical and tissue engineering perspectives

Rates and characteristics of intracerebral cavernous malformations after cranial radiation therapy remain poorly understood. Herein we report on intracerebral cavernous malformations detected on follow-up imaging in pediatric cancer patients who received cranial radiation therapy at age ≤18 years from 1980 to 2009. Through chart reviews (n = 362) and phone interviews (n = 104) of a retrospective cohort, we identified 10 patients with intracerebral cavernous malformations. The median latency time for detection of intracerebral cavernous malformations after cranial radiation therapy was 12 years (range 1-24 years) at a median age of 21.4 years (interquartile range = 15-28). The cumulative incidence was 3% (95% confidence interval 1%-8%) at 10 years post cranial radiation therapy and 14% (95% confidence interval 7%-26%) at 15 years. Three patients underwent surgical resection. Two surgical specimens were pathologically similar to sporadically occurring intracerebral cavernous malformations; one was consistent with capillary telangiectasia. Intracerebral cavernous malformations are common after cranial radiation therapy and can show a spectrum of histologic features.

Rates and risk factors associated with unplanned hospital readmission after fusion for pediatric spinal deformity

OBJECTIVES The aim of this study is to determine if peri-operative immune modulating dietary supplements decrease wound complications in gynecologic oncology patients undergoing laparotomy. METHODS In July 2013 we instituted a practice change and recommended pre- and post-operative oral immune modulating diets (IMDs) to patients undergoing laparotomy. We retrospectively compared patients who received IMDs to those who did not for the study period July 2012 to June 2014. Our outcome of interest was the frequency of Centers for Disease Control surgical site infections (CDC SSIs). RESULTS Of the 338 patients who underwent laparotomy during the study period, 112 (33%) received IMDs post-operatively. There were 89 (26%) wound complications, including 69 (78%) CDC SSI class 1, 7(8%) class 2 and 13(15%) class 3. Patients receiving IMDs had fewer wound complications than those who did not (19.6% vs. 33%, p=0.049). After controlling for variables significantly associated with the development of a wound complication (ASA classification, body mass index (BMI), history of diabetes mellitus or pelvic radiation, length of surgery and blood loss) consumption of IMDs remained protective against wound complications (OR 0.45, CI 0.25-0.84, p=0.013) and was associated with a 78% reduction in the incidence of CDC SSI class 2 and 3 infections (OR=0.22, CI 0.05-0.95, p=0.044). CONCLUSIONS Post-operative IMDs are associated with fewer wound complications in patients undergoing laparotomy for gynecologic malignancy and may reduce the incidence of CDC SSI class 2 and 3 infections.

Survival after chemotherapy and stem cell transplant followed by delayed craniospinal irradiation is comparable to upfront craniospinal irradiation in pediatric embryonal brain tumor patients

Critical-sized bone defects are defined as those that will not heal spontaneously within a patient’s lifetime. Current treatment options include vascularized bone grafts, distraction osteogenesis, and the induced membrane technique. The induced membrane technique is an increasingly utilized method with favorable results including high rates of union. Tissue engineering holds promise in the treatment of large bone defects due to advancement of stem cell biology, novel biomaterials, and 3D bioprinting. In this review, we provide an overview of the current operative treatment strategies of critical-sized bone defects as well as the current state of tissue engineering for such defects.

Genomic insights in gynecologic cancer

BACKGROUND CONTEXT Short-term readmission rates are becoming widely used as a quality and performance metric for hospitals. Data on unplanned short-term readmission after spine fusion for deformity in pediatric patients are limited. PURPOSE To characterize the rate and risk factors for short-term readmission after spine fusion for deformity in pediatric patients. STUDY DESIGN This is a retrospective cohort study. PATIENT SAMPLE Data were obtained from the State Inpatient Database from New York, Utah, Nebraska, Florida, North Carolina (years 2006-2010), and California (years 2006-2011). OUTCOME MEASURES Outcome measures included 30- and 90-day readmission rates. MATERIALS AND METHODS Inclusion criteria were patients aged 0-21 years, a primary diagnosis of spine deformity, and a primary 3+-level lumbar or thoracic fusion. Exclusion criteria included revision surgery at index admission and cervical fusion. Readmission rates were calculated and logistic analyses were used to identify independent predictors of readmission. RESULTS There were a total of 13,287 patients with a median age of 14 years. Sixty-seven percent were girls. The overall 30- and 90-day readmission rates were 4.7% and 6.1%. The most common reasons for readmission were infection (38% at 30 days and 33% at 90 days), wound dehiscence (19% and 17%), and pulmonary complications (12% and 13%). On multivariate analysis, predictors of 30-day readmission included male sex (p=.008), neuromuscular (p<.0001) or congenital scoliosis (p=.006), Scheuermann kyphosis (p=.003), Medicaid insurance (p<.0001), length of stay of ≤3 days or ≥6 days (p<.0001), and surgery at a teaching hospital (p=.011). Surgery at a hospital performing >80 operations/year was associated with a 34% reduced risk of 30-day readmission (95% confidence interval 12%-50%, p=.005) compared with hospitals performing <20 operations/year. CONCLUSIONS The short-term readmission rate for pediatric spine deformity surgery is driven by patient-related factors, as well as several risk factors that may be modified to reduce this rate.

Large Vessel Arteriopathy After Cranial Radiation Therapy in Pediatric Brain Tumor Survivors

Pediatric embryonal brain tumor patients treated with craniospinal irradiation (CSI) are at risk for adverse effects, with greater severity in younger patients. Here we compare outcomes of CSI vs. high-dose chemotherapy (HD), stem cell transplant (SCT) and delayed CSI in newly diagnosed patients. Two hundred one consecutive patients treated for medulloblastoma (72 %), supratentorial primitive neuroectodermal tumor (sPNET; 18 %) or pineoblastoma (10 %) at two institutions between 1988 and 2014 were retrospectively identified. Progression free survival (PFS) and overall survival (OS) were estimated using the Kaplan–Meier method and compared by log-rank tests. Adjuvant CSI regimens were used for 56 % of patients (upfront-CSI), and HD/SCT regimens were used in 32 % of patients. HD/SCT patients were significantly younger than those receiving upfront-CSI (2.9 vs. 7.8 years; P < 0.0001). There were no differences in metastases, extent of resection, or CSI dose between upfront-CSI and HD/SCT patients, but median follow-up was shorter in the HD/SCT group (6.2 vs. 3.9 years; P = 0.007). There were no significant outcome differences between upfront-CSI and HD/SCT patients who received CSI as a prophylaxis or following relapse (OS 66 % vs. 61 %, P = 0.13; PFS 67 % vs. 62 %, P = 0.12). Outcomes were equivalent when restricting analyses to HD/SCT patients who received prophylactic CSI prior to relapse (OS 66 % vs. 65 %, P = 0.5; PFS 67 % vs. 74 %, P = 0.8). At last follow-up, 48 % of HD/SCT patients had received neither definitive nor salvage radiotherapy. In this retrospective cohort, outcomes with adjuvant HD/SCT followed by delayed CSI are comparable to upfront-CSI for carefully surveyed pediatric embryonal brain tumor patients. Future prospective studies are required to validate this finding, and also to assess the impact of delayed CSI on neurocognitive outcomes.

Presence of cerebral microbleeds is associated with worse executive function in pediatric brain tumor survivors

Recent technological advances in DNA sequencing have enabled a remarkably detailed understanding of the molecular changes that define gynecologic and other cancers. Several groups have carried out large-scale genomic analyses of ovarian, uterine, and most recently, cervical cancer. These analyses have led to new insights into the molecular changes characterizing these cancers, which provide insight into clinical outcomes. These molecular characterizations have similarly led to new genomic-based classification schemas, which may better stratify clinical outcomes, help prognosticate and guide treatments. Discovery of characteristic mutations may also provide potential new targets for molecularly targeted chemotherapies, as has been already described with poly-ADP ribose polymerase inhibitors and ovarian cancer. The purpose of this article is to provide an overview of the defining molecular abnormalities and markers in gynecologic cancer, to discuss the clinical implications, and to provide a comprehensive view of the current state of genomic knowledge in gynecologic cancer.