Junnu Leikola

Posterior cranial vault expansion performed with rapid distraction and time-reduced consolidation in infants with syndromic craniosynostosis

Posterior cranial vault expansion performed with rapid distraction and time-reduced consolidation in infants with syndromic craniosynostosis

Positive sentinel lymph node biopsy predicts local metastases during the course of disease in Merkel cell carcinoma

Abstract The purpose was to investigate the predictive power of sentinel lymph node biopsy (SLNB) in Merkel cell carcinoma (MCC) patients, using clinical data collected during treatment. The aim was also to review the treatment protocols for MCC patients in Finland. These data were retrieved and compared after identification in the Finnish Cancer Registry from 1979–2009. Hospital files were reviewed for demographic and treatment-related data. Statistical analysis was performed for survival comparing sentinel lymph node positive and negative patients. Specific inclusion criteria yielded a cohort of 33 patient records, which accounted for 15% of the 225 diagnosed MCC patients during the study period. The male:female ratio was 1:1.5. On average, in the lymphoscintigraphy 2 ± 1.62 sentinel lymph nodes visualised and 2 ± 2.4 sentinel lymph nodes were removed in the operation. The mean primary tumour size in sentinel lymph node positive patients was 12.7 mm and in sentinel lymph node negative patients it was 19 mm. Nine patients had micrometastases in their removed sentinel lymph nodes. The patients with positive sentinel lymph node developed local metastases during the course of disease more often than sentinel lymph node negative patients (p < 0.003). However, there was no statistical difference in overall survival in sentinel lymph node negative and positive patients (p > 0.12). This study emphasises that SLNB appears to be a useful tool in determining the stage of MCC patients regardless of tumour size. A positive sentinel lymph node predicts the metastatic course of disease.

Predicting invasion in patients with DCIS in the preoperative percutaneous biopsy

When ductal carcinoma in situ (DCIS) is suspected in mammography, core needle biopsy or vacuum assisted biopsy is recommended. However, invasion remains undetected with percutaneous biopsy techniques in 10–20% of the patients. Our aim was to evaluate the prevalence of and predictive factors for invasion in the surgical specimen in patients with DCIS in the preoperative biopsy. Sixty-seven consecutive participants of the Helsinki City Mammography Screening program with DCIS in the preoperative percutaneous biopsy were included. The palpability, the mammographical size and appearance and the visibility of the lesion in breast ultrasound were evaluate as factors predictive for invasion, as well as the histopathological features of DCIS in the preoperative biopsy. Twenty patients had invasion in the surgical specimen. The only predictive factor for invasion was the visibility of the lesion in ultrasound, but even this finding failed to reach statistical significance. Thirteen of the 26 patients with lesions visible in US had invasion in their surgical specimens, while only seven of the 41 patients without such a lesion had invasive or microinvasive cancer, Pc = 0.0686. In conclusion, the visibility of the lesion in US may predict detecting invasion in the surgical specimen in patients with DCIS in the preoperative biopsy.

Brain anomalies in 121 children with non-syndromic single suture craniosynostosis by MR imaging.

INTRODUCTION The aim of this study was to evaluate prevalence of intracranial abnormalities in children with non-syndromic single suture craniosynostosis scheduled for cranial vault remodelling surgery using pre-operative magnetic resonance imaging. PATIENTS AND METHODS A retrospective analysis of brain magnetic resonance imaging studies of 129 non-syndromic single suture craniosynostosis children undergoing craniofacial surgery between January, 2004-October, 2010 was conducted. Statistical analysis was performed for child, maternal and sibling related predisposing factors for abnormal brain magnetic resonance imaging findings. The mean age of these 121 patients at the time of imaging was 21.6 months. The majority, 78% were males and 74% of the patients were scaphocephalic. RESULTS In 18 (15%) patients abnormal brain findings were noted. The most common finding was Chiari 1 malformation in 11 (9%). Chiari 1 malformation comprised over half (61%) of the brain anomalies identified. None of these findings required any additional surgical procedures. None of the statistical analysis reached statistical significance. CONCLUSIONS Brain anomalies in connection with non-syndromic single suture craniosynostosis patients seem to be a coincidental event. We did not establish any specific craniosynostosis form to be regularly associated with abnormal brain magnetic resonance imaging findings. The routine use of pre-operative magnetic resonance imaging in non-syndromic single suture craniosynostosis patients seems to be of limited value in the search for associated intracranial malformations necessitating additional interventions.

Limiting CT radiation dose in children with craniosynostosis: phantom study using model-based iterative reconstruction

BackgroundMedical professionals need to exercise particular caution when developing CT scanning protocols for children who require multiple CT studies, such as those with craniosynostosis.ObjectiveTo evaluate the utility of ultra-low-dose CT protocols with model-based iterative reconstruction techniques for craniosynostosis imaging.Materials and methodsWe scanned two pediatric anthropomorphic phantoms with a 64-slice CT scanner using different low-dose protocols for craniosynostosis. We measured organ doses in the head region with metal-oxide-semiconductor field-effect transistor (MOSFET) dosimeters. Numerical simulations served to estimate organ and effective doses. We objectively and subjectively evaluated the quality of images produced by adaptive statistical iterative reconstruction (ASiR) 30%, ASiR 50% and Veo (all by GE Healthcare, Waukesha, WI). Image noise and contrast were determined for different tissues.ResultsMean organ dose with the newborn phantom was decreased up to 83% compared to the routine protocol when using ultra-low-dose scanning settings. Similarly, for the 5-year phantom the greatest radiation dose reduction was 88%. The numerical simulations supported the findings with MOSFET measurements. The image quality remained adequate with Veo reconstruction, even at the lowest dose level.ConclusionCraniosynostosis CT with model-based iterative reconstruction could be performed with a 20-μSv effective dose, corresponding to the radiation exposure of plain skull radiography, without compromising required image quality.

A Second Radioisotope Injection Enhances Intraoperative Sentinel Node Identification in Breast Cancer Patients without Visualized Nodes on Preoperative Lymphoscintigraphy

Purpose: To evaluate the influence of a second radioisotope injection on the intraoperative success rate in patients with non-visualized axillary sentinel nodes (SN). Material and Methods: Altogether, 534 consecutive breast cancer patients with lymphoscintigraphy (LS) and SN biopsy and were included. An intratumoral injection of 99mTc-labeled human albumin colloid with a median dose of 93 MBq was applied. Forty-two of the 80 patients without axillary hot spots on LS received a second tracer injection with a median dose of 70 MBq. Results: The visualization rate of axillary SN was 454/534 (85%). The intraoperative SN identification rate was 97% in patients with and 69% in patients without visualized SN in the axilla (P<0.00005), but the success rate was higher (88%) with a second radioisotope injection than without it (47%; P<0.0002). Conclusion: The failure rate in intraoperative SN identification was minimized using a second radioisotope injection in patients without axillary SN on LS.

Ultrasonography of the axilla in the follow-up of breast cancer patients who have a negative sentinel node biopsy and who avoid axillary clearance

The clinical value of ultrasonography of the axilla in detection of breast cancer recurrence is not known among patients who have a negative sentinel node biopsy and avoid axillary clearance. We studied a cohort of 205 such patients using ultrasonography one and three years after breast surgery. A recurrent tumour was found in the axilla in only two (0.5%) of the total of 383 ultrasound examinations performed during the study, and only one (0.3%) of the 369 examinations performed at the scheduled study visits revealed cancer. None of the ultrasound examinations was false positive, and no study participant was subjected to unnecessary surgery due to ultrasound monitoring. We conclude that the rate of breast cancer recurrence in the ipsilateral axilla is low following sparing of the axillary contents, and that monitoring of such patients with repeated ultrasound examinations is unlikely to be cost-effective.

Craniofacial Cephalometric Morphology and Later Need for Orthognathic Surgery in 6-Year-Old Children With Bilateral Cleft Lip And Palate

Objective Six-year-old children with bilateral cleft lip and palate (BCLP) were examined to evaluate the need for orthognathic surgery later in life and to cephalometrically compare the craniofacial morphology of those needing orthognathic surgery with those not needing surgery. Design Retrospective longitudinal study. Patients Thirty-eight consecutive nonsyndromic patients with BCLP (29 boys). Main Outcome Measures Children with BCLP were analyzed from lateral cephalograms taken at a mean age of 6.1 years (range 5.8 to 6.6 years). The need for orthognathic surgery in these patients was determined from hospital records at the mean age of 18.2 years (range 15.5 to 20.2 years). Students t test and chi-square test were used in statistical analysis. Results The overall frequency of maxillary or bimaxillary osteotomy was 66% (25 of 38). The patients needing maxillary or bimaxillary osteotomies had flatter soft tissue profiles (n-sn-gn), shorter lower facial heights (ANS-ME), and smaller mean values of the ANB angle (sagittal maxillomandibular relationship) at the age of 6 years than those who did not. ANB angle was the most significant predictor for later osteotomy. Despite individual variation, all children (n = 13) whose ANB angle was less than 7°, needed later orthognathic surgery; whereas, none of those whose ANB angle was greater than 12.5° (n = 6) needed maxillary osteotomies. Conclusions Two thirds of children with BCLP needed orthognathic surgery later in life. Half of the children who needed later osteotomies could be identified at the age of 6 years by having an ANB angle less than 7°.

BMI1 expression identifies subtypes of Merkel cell carcinoma

Merkel cell carcinoma (MCC) is a rare cutaneous neuroendocrine carcinoma. The aims of this study were to investigate the expression of the transcription factors B-lymphoma Moloney murine leukaemia virus insertion (BMI1), myelocytomatosis viral oncogene homologue (c-Myc) and Snail in MCC tumour specimens and to examine the relationship of these markers to Merkel cell polyoma virus (MCV). The study comprised of 133 patients with primary MCC. The expression of BMI1, Snail and c-Myc protein was assessed by immunohistochemistry and compared with clinical parameters, MCV status and patient survival. The presence of MCV was inversely correlated with the expression of BMI1 protein. Tumours expressing BMI1 protein more often presented with lymph node metastases. Snail protein expression was decreased in cases with metastatic dissemination. This study identified two subgroups of MCC: tumours expressing BMI1 but negative for MCV DNA and tumours negative for BMI1 expression but positive for MCV. Importantly, BMI1-positive cases often presented with lymph node metastases. Combined, these results suggest that subtypes of this malignancy exist.

The use of patient-specific implants in orthognathic surgery: A series of 30 mandible sagittal split osteotomy patients

PURPOSE Virtual surgery combined with patient-specific saw and drill guides and osteosynthesis materials are rapidly spreading from reconstructive surgery to orthognathic surgery. Most commercial partners are already providing computer-aided design and computer-aided manufacture (CAD/CAM) wafers and patient-specific saw guides. Clear benefits have been demonstrated for custom-made drill guides combined with individually designed three-dimensional (3D) printed patient-specific implants (PSI) as a reposition and fixation system in Le Fort I osteotomy. MATERIALS AND METHODS We treated 30 patients who underwent bilateral sagittal split osteotomy (BSSO) due to class II dento-skeletal deformities with the additional use of drill guides combined with PSI as a fixation and positioning system. RESULTS The PSIs fitted bilaterally with total precision in 11 of the 30 patients. In 17 patients, the PSIs were used with some modifications. In 2 of 30 patients, the PSIs could not be used as a fixation due to misfit. CONCLUSION Due to unpredictable fitting, the use of PSIs with drill guides alone in BSSO without wafers cannot be recommended. Further studies are needed to evaluate the interfering parts, which seem to be related to condylar positioning and bony interferences at the osteotomy sites.