Philadelphia, Pa. (April 8, 2013) – A new functional magnetic resonance imaging (fMRI) technique may provide neurosurgeons with a non-invasive tool to help in mapping critical areas of the brain before surgery, reports a study in the April issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

Evaluating brain fMRI responses to a “single, short auditory language task” can reliably localize critical language areas of the brain—in healthy people as well as patients requiring brain surgery for epilepsy or tumors, according to the new research by Melanie Genetti, PhD, and colleagues of Geneva University Hospitals, Switzerland.

Brief fMRI Task for Functional Brain Mapping

The researchers designed and evaluated a quick and simple fMRI task for use in functional brain mapping. Functional MRI can show brain activity in response to stimuli (in contrast to conventional brain MRI, which shows anatomy only). Before neurosurgery for severe epilepsy or brain tumors, functional brain mapping provides essential information on the location of critical brain areas governing speech and other functions.

The standard approach to brain mapping is direct electrocortical stimulation (ECS)—recording brain activity from electrodes placed on the brain surface. However, this requires several hours of testing and may not be applicable in all patients. Previous studies have compared fMRI techniques with ECS, but mainly for determining the side of language function (lateralization) rather than the precise location (localization).

The new fMRI task was developed and evaluated in 28 healthy volunteers and in 35 patients undergoing surgery for brain tumors or epilepsy. The test used a brief (eight minutes) auditory language stimulus in which the patients heard a series of sense and nonsense sentences.

Functional MRI scans were obtained to localize the brain areas activated by the language task—activated areas would “light up,” reflecting increased oxygenation. A subgroup of patients also underwent ECS, the results of which were compared to fMRI.

Non-invasive Test Accurately Localizes Critical Brain Areas

Based on responses to the language stimulus, fMRI showed activation of the anterior and posterior (front and rear) language areas of the brain in about 90 percent of subjects—neurosurgery patients as well as healthy volunteers. Functional MRI activation was weaker and the language centers more spread-out in the patient group. These differences may have reflected brain adaptations to slow-growing tumors or longstanding epilepsy.

Five of the epilepsy patients also underwent ECS using brain electrodes, the results of which agreed well with the fMRI findings. Two patients had temporary problems with language function after surgery. In both cases, the deficits were related to surgery or complications (bleeding) in the language area identified by fMRI.

Functional brain mapping is important for planning for complex neurosurgery procedures. It provides a guide for the neurosurgeon to navigate safely to the tumor or other diseased area, while avoiding damage to critical areas of the brain. An accurate, non-invasive approach to brain mapping would provide a valuable alternative to the time-consuming ECS procedure.

“The proposed fast fMRI language protocol reliably localized the most relevant language areas in individual subjects,” Dr. Genetti and colleagues conclude. In its current state, the new test probably isn’t suitable as the only approach to planning surgery—too many areas “light up” with fMRI, which may limit the surgeon’s ability to perform more extensive surgery with necessary confidence. The researchers add, “Rather than a substitute, our current fMRI protocol can be considered as a valuable complementary tool that can reliably guide ECS in the surgical planning of epileptogenic foci and of brain tumors.”

About Neurosurgery

Neurosurgery, the Official Journal of the Congress of Neurological Surgeons, is your most complete window to the contemporary field of neurosurgery. Members of the Congress and non-member subscribers receive 3,000 pages per year packed with the very latest science, technology, and medicine, not to mention full-text online access to the world’s most complete, up-to-the-minute neurosurgery resource. For professionals aware of the rapid pace of developments in the field, Neurosurgery is nothing short of indispensable.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes.

LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2012 annual revenues of €3.6 billion ($4.6 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (April 8, 2013) – The recent discovery of circulating “nano-sized extracellular vesicles” (EVs) carrying proteins and nucleic acids derived from brain tumors may lead to exciting new avenues for brain cancer diagnosis, monitoring, and treatment, according to a special article in the April issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

The review article by Dr. David Gonda from the laboratory of the corresponding author Dr. Clark C. Chen, with contributions from the senior author, Dr. Bob S. Carter of University of California, San Diego, Dr. Fred Hochberg at Massachusetts General Hospital and Dr. Steve Kalkanis of the Henry Ford Hospital brain tumor programs discusses “the biological processes mediated by these EVs and their applications as biomarkers for brain tumor diagnosis, monitoring, and therapeutic development.” The researchers add, “Opportunity exists to use EVs as delivery vehicles or immune modulatory tools” for brain cancer treatment.

Nano-Sized EVs Play Role in Cancer Growth and Survival

The authors use the term EVs to refer to various types of “membrane-encapsulated cellular components” released from cells. Microscopic EVs—tiny even in relation to the cells that produce them—have been isolated from all bodily fluids, including the blood and cerebrospinal fluid of patients with brain tumors. Extracellular vesicles are like nano-sized “bubbles” of material sent out by cells, containing proteins and other cellular materials—including nucleic acids that carry genetic information.

So far, researchers have identified three general biological functions of EVs: remodeling and removal of cellular components; elimination of “toxic metabolites or unneeded membrane components” from cells; and intercellular communication, providing a means for transferring proteins or genetic information from one cell to another.

In patients with brain cancer, EVs may also provide a way for tumor cells to alter the microenvironment in which they grow. Different types of EVs may perform functions enabling cancers to grow and spread while evading the immune responses that would target tumor cells for destruction.

Could EVs Be Used for Cancer Detection and Treatment?

Scientific efforts to understand EVs and their functions—in normal physiology as well as in cancers and other disease states—are just getting started. But researchers envision new opportunities for the development of biomarkers for diagnosis and monitoring of brain cancers, as well as possible new treatment strategies based on EVs.

Approaches based on identifying specific proteins and genetic material carried by EVs could be useful in identifying brain cancers, and monitoring their status over time. For example, EVs might be used in identifying specific mutations of the IDH1 gene, recently linked to a type of brain cancer called glioblastoma multiforme.  Corresponding author Dr. Chen noted in correspondence that “A large consortium effort among neurosurgeons and neuro-oncologists is emerging to assess the clinical utility of the basic science findings highlighted in our review.  We anticipate that the next several years will yield important information as teams of scientists and clinicians work to study these questions.”

Further studies of the function of EVs may open at least three directions for brain cancer treatment. Treatments could be devised to inhibit the secretion and uptake of tumor-related EVs, which might interfere with their ability to grow or spread. New approaches to immunotherapy might be developed, using EVs to stimulate immune responses against tumor cells. It might also be possible to engineer EVs to serve as “delivery vehicles” to target drugs directly to cancer cells.

“Enhanced secretion of EVs by tumors offers an opportunity to detect tumor-specific genetic material as biomarkers for diagnostic or therapeutic monitoring,” the authors conclude. While extensive research is still needed to understand how EVs work and how they can be exploited for specific uses, they write, “Awareness of these developments should augment the armamentarium available to oncology-dedicated neurosurgeons.”   

About Neurosurgery

Neurosurgery, the Official Journal of the Congress of Neurological Surgeons, is your most complete window to the contemporary field of neurosurgery. Members of the Congress and non-member subscribers receive 3,000 pages per year packed with the very latest science, technology, and medicine, not to mention full-text online access to the world’s most complete, up-to-the-minute neurosurgery resource. For professionals aware of the rapid pace of developments in the field, Neurosurgery is nothing short of indispensable.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes.

LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2012 annual revenues of €3.6 billion ($4.6 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (February 13, 2013) – For many patients with difficult-to-treat neuropathic pain, deep brain stimulation (DBS) can lead to long-term improvement in pain scores and other outcomes, according to a study in the February issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

About two-thirds of eligible patients who undergo DBS achieve significant and lasting benefits in terms of pain, quality of life, and overall health, according to the report by Sandra G.J. Boccard, PhD, and colleagues of University of Oxford, led by Tipu Aziz FMedSci and Alex Green, MD. Some outcomes show continued improvement after the first year, according to the new report, which is one of the largest studies of DBS for neuropathic pain performed to date.

Most Patients Benefit from DBS for Neuropathic Pain

The authors reviewed their 12-year experience with DBS for neuropathic pain. Neuropathic pain is a common and difficult-to-treat type of pain caused by nerve damage, seen in patients with trauma, diabetes, and other conditions. Phantom limb pain after amputation is an example of neuropathic pain.

In DBS, a small electrode is surgically placed in a precise location in the brain. A mild electrical current is delivered to stimulate that area of the brain, with the goal of interrupting abnormal activity. Deep brain stimulation has become a standard and effective treatment for movement disorders such as Parkinson’s disease. Although DBS has also been used to treat various types of chronic pain, its role in patients with neuropathic pain remains unclear.

Between 1999 and 2011, that authors’ program evaluated 197 patients with chronic neuropathic pain for eligibility for DBS. Of these, 85 patients proceeded to DBS treatment. The remaining patients did not receive DBS—most commonly because they were unable to secure funding from the U.K. National Health Service or decided not to undergo electrode placement surgery.

The patients who underwent DBS were 60 men and 25 women, average age 52 years. Stroke was the most common cause of neuropathic pain, followed by head and face pain, spinal disease, amputation, and injury to nerves from the upper spinal cord (brachial plexus).

In 74 patients, a trial of DBS produced sufficient pain relief to proceed with implantation of an electrical pulse generator. Of 59 patients with sufficient follow-up data, 39 had significant improvement in their overall health status up to four years later. Thus, 66 percent of patients “gained benefit and efficacy” by undergoing DBS.

Benefits Vary by Cause; Some Outcomes Improve with Time

The benefits of DBS varied for patients with different causes of neuropathic pain. Treatment was beneficial for 89 percent for patients with amputation and 70 percent of those with stroke, compared to 50 percent of those with brachial plexus injury.

On average, scores on a 10-point pain scale (with 10 indicating the most severe pain) decreased from about 8 to 4 within the first three months, remaining about the same with longer follow-up. Continued follow-up in a small number of patients suggested further improvement in other outcomes, including quality-of-life scores.

Deep brain stimulation has long been regarded as potentially useful for patients with severe neuropathic pain that is not relieved by other treatments. However, because of the difficulties of performing studies of this highly specialized treatment, there has been relatively little research to confirm its benefits; only about 1,500 patients have been treated worldwide. The new study—accounting for about five percent of all reported patients—used up-to-date DBS technologies, imaging, and surgical techniques.

Dr. Boccard and coauthors acknowledge some important limitations of their study—especially the lack of complete patient follow-up. However, they believe their experience is sufficiently encouraging to warrant additional studies, especially with continued advances in stimulation approaches and technology. The researchers conclude, “Clinical trials retaining patients in long-term follow-up are desirable to confirm findings from prospectively assessed case series.”

About Neurosurgery

Neurosurgery, the Official Journal of the Congress of Neurological Surgeons, is your most complete window to the contemporary field of neurosurgery. Members of the Congress and non-member subscribers receive 3,000 pages per year packed with the very latest science, technology, and medicine, not to mention full-text online access to the world’s most complete, up-to-the-minute neurosurgery resource. For professionals aware of the rapid pace of developments in the field, Neurosurgery is nothing short of indispensable.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes. LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (February 12, 2013) – The field of surgery lost a giant last year with the death of Joseph E. Murray, MD, Nobel laureate in medicine and biology and a pioneer in both transplantation and craniofacial surgery. A special tribute to Dr. Murray appears in the January issue of The Journal of Craniofacial Surgery, published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

Mutaz Habal, MD, Editor-in-Chief of The Journal of Craniofacial Surgery, shares an editorial celebrating the career and contributions of Dr. Murray as a mentor, colleague, and friend. Dr. Habal’s is one of several tributes included in the special January issue, which also features updates on new research developments and clinical problems of interest to plastic, reconstructive, and craniofacial surgeons.

Memories of Dr. Murray by a Colleague and Friend

Dr. Murray died last November at age 93. His place in history is assured as the surgeon who performed the first successful human kidney transplant, between a pair of identical twins, in 1954. Dr. Murray went on to perform groundbreaking research in transplantation biology and tissue and organ rejection.

Dr. Murray was also instrumental in developing immunosuppressive drugs that led to the development of modern organ transplantation. In 1990, he shared the shared the Nobel Prize in Physiology or Medicine with Dr. E. Donnall Thomas “for their discoveries concerning organ and cell transplantation in the treatment of human disease.” (Dr. Thomas, a pioneer in bone marrow transplantation, also died last year.)

At a time when transplantation surgery is a specialty in its own right, it may be surprising to learn that Dr Murray’s specialty was plastic surgery. His interest in transplantation developed from his experience with skin grafting as a military surgeon treating seriously burned patients.

In his editorial, Dr. Habal recalls his first encounter Dr. Murray during a lecture question-and-answer period more than four decades ago. Dr. Habal went on to train with Dr. Murray in the Department of Plastic Surgery at Harvard University and Brigham and Women’s Hospital. It was a time of groundbreaking contributions to craniofacial surgery—including the first mid-face advancement surgery, and the correction of hypertelorism. Dr. Murray inspired all the young surgeons who became the spear head of the development of the field of craniofacial surgery with his work on composite transplantation with Dr. John Woods, which was the grounds for the development of face transplant at the same medical institution. This was well discussed as the new frontier in plastic surgery.

“This special issue of the journal should serve as an inspiration to the young and newcomers of the specialty as a model for the advancement of their careers,” Dr. Habal writes. “Dr. Murray taught us all that the patient comes first, and self-promotion is out of the formula of patient care.”

New Research on Wound Healing, and Two Unusual Injuries

The special issue includes a number of other tributes to Dr. Murray—including one by Elof Eriksson, MD, PhD, who succeeded Dr. Murray as Chief of Plastic Surgery at Brigham and Women’s Hospital. Along with his colleagues Johan P.E. Junker, PhD, and E.-J. Caterson, MD, PhD, Dr. Eriksson is coauthor of an update on the microenvironment of wound healing. They report on recent research showing that a “wet, incubator-like environment provides the fastest healing with fewest aberrations and least scar formation.”

The researchers have created a “wound chamber” that creates a wet environment, promoting survival and proliferation of transplanted cells and tissues. Dr. Eriksson and colleagues conclude, “With the addition of various active molecules and cells, it also provides a platform technology for regeneration in vivo.”

The special issue also present brief reports on unusual wounds of special interest to plastic, reconstructive, and craniofacial surgeons. One report describes “conductive contact burns” as a serious injury caused by overexposure to Korean-style hot dry saunas. Another suggests that titanium miniplates used in reconstructive surgery may be a risk factor for osteonecrosis in elderly patients taking bisphosphonate drugs for osteoporosis.

Dr. Habal comments, “We believe the tributes to Dr. Murray, along with the cutting-edge research and practical clinical information presented in our special issue, are a fitting memorial to a surgeon-scientist who contributed so much to the fields of plastic, transplantation, and craniofacial surgery—thus affecting the lives of countless patients, now and in the future.”

About The Journal of Craniofacial Surgery

The Journal of Craniofacial Surgery, under the guidance of Editor-in-Chief Mutaz B. Habal, MD, serves as a forum of communication for all those involved in craniofacial and maxillofacial surgery. Coverage ranges from practical aspects of craniofacial surgery to the basic science that underlies surgical practice. Affiliates include 14 major specialty societies around the world, including the American Association of Pediatric Plastic Surgeons, the American Academy of Pediatrics Section of Pediatric Plastic Surgery, the American Society of Craniofacial Surgeons, the American Society of Maxillofacial Surgeons, the Argentine Society of Plastic Surgery Section of Pediatric Plastic Surgery, the Asian Pacific Craniofacial Association, the Association of Military Plastic Surgeons of the U.S., the Brazilian Society of Craniofacial Surgeons, the European Society of Craniofacial Surgery, the International Society of Craniofacial Surgery, the Japanese Society of Craniofacial Surgery, the Korean Society of Craniofacial Surgery, the Thai Cleft and Craniofacial Association, and the World Craniofacial Foundation.

About Lippincott Williams & WilkinsLippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes.

LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (January 16, 2013) – With the rapidly expanding use of brain and spinal cord stimulation therapy (neuromodulation), new “remote presence” technologies may help to meet the demand for experts to perform stimulator programming, reports a study in the January issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

The preliminary study by Dr. Ivar Mendez of Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, Canada, supports the feasibility and safety of using a remote presence robot—called the “RP-7″—to increase access to specialists qualified to program the brain and spine stimulators used in neuromodulation.

Robot Lets Experts Guide Nurses in Programming Stimulators

Dr. Mendez and his group developed the RP-7 as a way of allowing experts to “telementor” nonexpert nurses in programming stimulator devices. Already widely used for Parkinson’s disease and severe chronic pain, neuromodulation is being explored for use in other conditions, such as epilepsy, severe depression, and obsessive-compulsive disorder.

In this form of therapy, a small electrode is surgically placed in a precise location in the brain or spine. A mild electrical current is delivered to stimulate that area, with the goal of interrupting abnormal activity.  As more patients undergo brain and spine stimulation therapy, there’s a growing demand for experts to program the stimulators that generate the electrical current.

The RP-7 is a mobile, battery-powered robot that can be controlled using a laptop computer. It is equipped with digital cameras and microphones, allowing the expert, nurse, and patient to communicate. The robot’s “head” consists of a flat-screen monitor that displays the face of the expert operator.

The RP-7 also has an “arm” equipped with a touch-screen programmer, which the nurse can use to program the stimulator. The expert can “telestrate” to indicate to the nurse the correct buttons to push on the programming device.

Access to Specialists in the Next Room—or Miles Away

In the preliminary study, patients with neuromodulation devices were randomly assigned to conventional programming, with the expert in the room; or remote programming, with the expert using the RP-7 to guide a nurse in programming the stimulator. For the study, the expert operators were simply in another room of the same building. However, since the RP-7 operates over a conventional wireless connection, the expert can be anyplace that has Internet access.

On analysis of 20 patients (10 in each group), there was no significant difference in the accuracy or clinical outcomes of remote-presence versus conventional programming. No adverse events occurred with either type of session.

The remote-presence sessions took a little more time: 33 versus 26 minutes, on average. Patients, experts, and nonexpert nurses all gave high satisfaction scores for the programming experience.

“This study demonstrated that remote presence can be used for point-of-care programming of neuromodulation devices,” Dr. Mendez and coauthors write. The study provides “proof of principle” that the RP-7 or similar devices can help to meet the need for experts needed to serve the rapidly expanding number of patients with neuromodulation therapies.

The researchers have also started a pilot study using a new mobile device, called the RP-Xpress. About the size of a small suitcase, the RP-Xpress is being used to perform long-distance home visits for patients living hundreds of miles away, using existing local cell phone networks. Dr. Mendez and colleagues conclude, “We envision a time, in the near future, when patients with implanted neuromodulation devices will have real-time access to an expert clinician from the comfort of their own home.”

About Neurosurgery

Neurosurgery, the Official Journal of the Congress of Neurological Surgeons, is your most complete window to the contemporary field of neurosurgery. Members of the Congress and non-member subscribers receive 3,000 pages per year packed with the very latest science, technology, and medicine, not to mention full-text online access to the world’s most complete, up-to-the-minute neurosurgery resource. For professionals aware of the rapid pace of developments in the field, Neurosurgery is nothing short of indispensable.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes. LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (January 16, 2013) – Researchers using sophisticated genetic testing techniques have identified a promising new biomarker for diagnosis of glioma—the most common type of malignant brain tumor, reports the January issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

The biomarker ELTD1 “may serve as an additional biomarker for gliomas in preclinical and clinical diagnosis of gliomas,” according to the study by Rheal A. Towner of Oklahoma Medical Research Foundation, Oklahoma City.

Biomarker Reflects Rapid Blood Vessel Development

Dr. Towner and colleagues used advanced “data mining and bioinformatic” techniques to evaluate genes and gene products potentially associated with gliomas. Glioma is a general term referring to tumors originating in the glial cells of the brain and spinal cord. Gliomas make up about 40 percent of all brain tumors and 80 percent of central nervous system cancers. Especially for advanced (high-grade) gliomas such as glioblastoma multiforme (GBM), expected survival is very poor.

Out of nearly 200 possible markers analyzed, ELTD1 was identified as the strongest candidate for a significant association with glioma. There’s special interest in ELTD1 because it is linked to development of new blood vessels, or angiogenesis—a characteristic of rapidly growing cancers. (ELTD1 stands for “epidermal growth factor, latrophilin and seven transmembrane domain-containing protein 1.”)

Studies in human patients suggested that ELTD1 was strongly associated with gliomas. ELTD1 was more highly expressed in specimens from 50 patients with high-grade gliomas, compared to 21 patients with lower-grade gliomas.

Higher levels of ELDT1 expression were associated with a higher grade of glioma, and with lower survival. ELTD1 compared well with other known markers of glioma, such as vascular endothelial growth factor. It also appeared to be associated with one specific subtype of GBM (mesenchymal GBM).

In further experiments, the researchers transplanted glioma cells into the brains of rats. As the tumors developed, they showed elevated levels of ELTD1, compared to normal brain tissue. The rat studies included evaluation of a “molecular MRI technique” for measuring ELDT1 levels in the living brain.

A Helpful Marker for Glioma Diagnosis?

Even with modern treatments, GBM and other malignant gliomas are devastating cancers. In recent years, advances in research have led to the identification of biomarkers associated with glioma. Dr. Towner and colleagues write, “Validation of more biomarkers for GBM could be beneficial in the diagnosis and therapeutic intervention of this disease.”

With further study, ELTD1 could become a useful new marker of glioma, including GBM. Gliomas show increased expression of ELTD1, and higher levels of ELTD1 expression are associated with higher tumor grade and a worse prognosis. “Any increase in ELTD1 will more than likely be associated with increased angiogenesis or neovascularization [new blood vessel development] in gliomas,” the researchers write.

Although the findings are only preliminary, Dr. Towner and coauthors suggest that ELTD1 could be useful in detecting the presence and grade of gliomas—particularly high-grade gliomas such as GBM. They conclude, “[T]his biomarker may play an important diagnostic role in addition to currently used markers for gliomas, particularly as a histological marker for identifying vascular proliferation.”

About Neurosurgery

Neurosurgery, the Official Journal of the Congress of Neurological Surgeons, is your most complete window to the contemporary field of neurosurgery. Members of the Congress and non-member subscribers receive 3,000 pages per year packed with the very latest science, technology, and medicine, not to mention full-text online access to the world’s most complete, up-to-the-minute neurosurgery resource. For professionals aware of the rapid pace of developments in the field, Neurosurgery is nothing short of indispensable.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes. LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (December 20, 2012) – Robotic technologies have the potential to help neurosurgeons perform precise, technically demanding operations, together with virtual reality environments to help them navigate through the brain, according to a special supplement to Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

“Virtual Reality (VR) and robotics are two rapidly expanding fields with growing application within neurosurgery,” according to an introductory article by Garnette Sutherland, MD. The 22 reviews, commentaries, and original studies in the special supplement provide an up-to-the-minute overview of “the benefits and ongoing challenges related to the latest incarnations of these technologies.”

Robotics and VR in Neurosurgery—What’s Here and What’s Next

Virtual reality and robotic technologies present exciting opportunities for training, planning, and actual performance of neurosurgical procedures. Robotic tools under development or already in use can provide mechanical assistance, such as steadying the surgeon’s hand or “scaling” hand movements. “Current robots work in tandem with human operators to combine the advantages of human thinking with the capabilities of robots to provide data, to optimize localization on a moving subject, to operate in difficult positions, or to perform without muscle fatigue,” writes Dr. Sutherland.

Virtual reality technologies play an important role, providing “spatial orientation” between robotic instruments and the surgeon. Virtual reality environments “recreate the surgical space” in which the surgeon works, providing 3-D visual images as well as haptic (sense of touch) feedback. The ability to plan, rehearse, and “play back” operations in the brain could be particularly valuable for training neurosurgery residents—especially since recent work hour changes have limited opportunities for operating room experience.

The special supplement to Neurosurgery presents authoritative updates by experts working in the field of surgical robotics and VR technology, drawn from a wide range of disciplines. Topics include robotic technologies already in use, such as the “neuroArm” image-guided neurosurgical robot; reviews of progress in areas such as 3-D neurosurgical planning and virtual endoscopy; and new thinking on the best approaches to development, evaluation, and clinical uses of VR and robotic technologies.

But numerous and daunting technical challenges remain to be met before robotic and VR technologies become widely used in clinical neurosurgery. For example, VR environments require extremely fast processing times to provide the surgeon with continuously updated sensory information—equal to or faster than the brain’s ability to perceive it.

Economic challenges include the high costs of developing and implementing VR and robotic technologies, especially in terms of showing that the costs are justified by benefits to the patient. Continued progress in miniaturization will play an important role both in overcoming the technical challenges and in making the technology cost-effective.

The editors of Neurosurgery hope their supplement will stimulate interest and further progress in the development and practical implementation of VR and robotic technologies for neurosurgery. Dr. Sutherland adds, “Collaboration between the fields of medicine, engineering, science, and technology will allow innovations in these fields to converge in new products that will benefit patients with neurosurgical disease.”

About Neurosurgery

Neurosurgery, the Official Journal of the Congress of Neurological Surgeons, is your most complete window to the contemporary field of neurosurgery. Members of the Congress and non-member subscribers receive 3,000 pages per year packed with the very latest science, technology, and medicine, not to mention full-text online access to the world’s most complete, up-to-the-minute neurosurgery resource. For professionals aware of the rapid pace of developments in the field, Neurosurgery is nothing short of indispensable.

About Lippincott Williams & Wilkins
Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes.

LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (December 10, 2012) – As surgical teams gain experience with facial transplantation, a careful approach to planning based on the principles of craniofacial surgery can help to maximize patient outcomes in terms of facial form and function, according to an article in The Journal of Craniofacial Surgery. The journal, under the editorship of Mutaz B. Habal, MD, is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

In patients with extensive facial defects including loss of the normal bone and soft tissue landmarks, a “reverse craniofacial planning” approach can restore normal facial relationships, the report suggests. The lead author was Dr. Edward J. Caterson, a member of the facial transplant team at Brigham and Women’s Hospital/Harvard Medical School, Boston.

Craniofacial Principles Applied to Facial Transplantation

Dr. Caterson and colleagues apply some basic principles of craniofacial surgery to the planning and performance of facial transplants. Although still a rare and relatively new procedure, facial transplantation now offers a reconstructive option for patients with severe facial deficits. Most patients who are candidates for facial transplant have loss of soft tissues only (such as skin, muscle, blood vessels, and nerves).

However, some patients also have defects of the underlying facial bones. In these cases, the challenge for the facial transplant team is nothing less than “the complete restoration of the structural anatomy of the craniofacial skeleton,” the authors write.

Through their experience with reconstructive surgery in patients with severe congenital deformities, craniofacial surgeons have developed an understanding of the “intimate functional relationship” between the facial soft tissue and supporting bone. In the traditional craniofacial procedure, the surgeon carefully plans and designs “bone movements that will translate into a desired change of the attached soft tissues.”

But in facial transplantation, the situation is essentially reversed: the degree of injury and the subsequent transplantation of facial soft tissues dictate the “osteosynthesis” of the craniofacial skeleton. Dr. Caterson and colleagues describe a simple but practical technique for surgical planning to promote proper positioning of the facial transplant. The technique applies “normative” data on facial landmarks and relationships and then transposes them onto the recipient.

Understanding the relationships of facial structure allows surgeons to compensate for missing bony or soft tissue landmarks. The authors provide a straightforward approach to establishing a plane of reference, allowing the facial transplant to be positioned in a proper relationship with the skull base and occlusal plane (teeth and lower face).

Optimal positioning of the facial transplant is essential not only to achieve the most normal-appearing result, but also to maximize function—particularly in eating and breathing. Dr. Caterson and colleagues emphasize that “proper positioning of the hard tissues of the allograft is the fundamental starting point for functional and aesthetic restoration.” As long as the bony structure is right, any cosmetic soft tissue problems that remain after surgery are relatively easy to correct.

The authors believe that such craniofacial principles are likely to become an increasingly important consideration—”especially with the trend toward full face transplantation.” In early experience, donor selection for face transplantation has focused mainly on immunological factors—similar to those used in organ transplantation.

In the future, transplant teams may become more sophisticated in donor selection—including assessment of the degree of “craniofacial match” between donors and recipients. In the meantime, Dr. Caterson and coauthors conclude, “[C]areful attention to the soft tissue relationships with the skeletal anatomy requires that face transplantation include ‘reverse craniofacial planning’ to optimize the form and function of the recipient’s new face.”

About The Journal of Craniofacial Surgery

The Journal of Craniofacial Surgery serves as a forum of communication for all those involved in craniofacial and maxillofacial surgery. Coverage ranges from practical aspects of craniofacial surgery to the basic science that underlies surgical practice. Affiliates include 14 major specialty societies around the world, including the American Association of Pediatric Plastic Surgeons, the American Academy of Pediatrics Section of Pediatric Plastic Surgery, the American Society of Craniofacial Surgeons, the American Society of Maxillofacial Surgeons, the Argentine Society of Plastic Surgery Section of Pediatric Plastic Surgery, the Asian Pacific Craniofacial Association, the Association of Military Plastic Surgeons of the U.S., the Brazilian Society of Craniofacial Surgeons, the European Society of Craniofacial Surgery, the International Society of Craniofacial Surgery, the Japanese Society of Craniofacial Surgery, the Korean Society of Craniofacial Surgery, the Thai Cleft and Craniofacial Association, and the World Craniofacial Foundation.

About Lippincott Williams & WilkinsLippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes.

LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (November 20. 2012) – Meningiomas are a common type of benign brain tumor that sometimes grows dramatically in pregnant women. A new study suggests that this sudden tumor growth likely results from “hemodynamic changes” associated with pregnancy, reports the November issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

The study also identifies some key characteristics associated with rapid growth of meningiomas in pregnant women. The lead author was Dr. Eriks A. Lusis of Washington University School of Medicine, St Louis, Mo.

‘Dramatic Growth’ of Meningiomas in Pregnant Women

From the records of four university medical centers, the researchers identified 17 women with meningiomas requiring surgery during pregnancy, or shortly afterward. Meningiomas are relatively common, usually benign (noncancerous) tumors that arise in the tissues lining the brain (meninges). They cause problems when they grow large enough to affect brain functions.

Over the years, there have been several reports of meningiomas enlarging or becoming symptomatic during pregnancy. For this reason—and because meningiomas occur more often in women than men—it has sometimes been assumed that rapid tumor growth is related to changes in hormone levels during pregnancy. Dr. Lusis and colleagues sought to evaluate this theory, as well as to look at other characteristics of meningiomas in pregnant women.

Surgery for meningioma was successful in 16 of the 17 patients; the remaining patient died before surgery. Most of the women developed meningioma-related symptoms during the third trimester of pregnancy or within eight days after delivery. The most common symptoms of enlarging meningioma were changes in vision and facial paralysis or other cranial nerve palsies.

Most of the tumors were located in the skull base region and were typical, “low-grade” benign tumors. At surgery, the tumors showed an unusual “hypervascular” pattern, which was not seen in other cases of meningioma in non-pregnant patients. There was also a high rate of edema (swelling) in and around the tumor.

These and other findings strongly suggested that the rapid tumor growth resulted from “potentially reversible hemodynamic changes”—changes in blood flow—related to pregnancy. The pattern did not support the theory that meningioma growth resulted from “hormone-induced cellular proliferation.”

The results may help to explain the uncommon but well-documented occurrence of rapid meningioma growth during pregnancy. Since most meningiomas don’t cause any symptoms, they may go undetected. Even if they are detected, they may require no treatment unless they grow.

Together with previous evidence, the findings may have implications for the management of meningiomas in women of child-bearing age. Dr. Lusis and coauthors write, “[F]or the vast majority of women of child bearing age, we would not consider the presence of residual or unresected meningioma to be a contraindication to pregnancy.” In contrast, for patients with evidence of tumor growth or swelling, the authors suggest they might consider treating the tumor before pregnancy.

About Neurosurgery

Neurosurgery, the Official Journal of the Congress of Neurological Surgeons, is your most complete window to the contemporary field of neurosurgery. Members of the Congress and non-member subscribers receive 3,000 pages per year packed with the very latest science, technology, and medicine, not to mention full-text online access to the world’s most complete, up-to-the-minute neurosurgery resource. For professionals aware of the rapid pace of developments in the field, Neurosurgery is nothing short of indispensable.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes. LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com

Philadelphia, Pa. (October 2, 2012) – Breast cancer patients who have received radiation therapy after mastectomy have more problems related to the use of implants for breast reconstruction, according to a review in the October issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

Although women should be aware of these increased risks, implant-based breast reconstruction after radiation therapy is still successful in most cases, according to the paper by Dr. Steven J. Kronowitz of The University of Texas MD Anderson Cancer Center, Houston.

Breast Implants after Radiation Carry Increased Risks

Dr. Kronowitz reviews and synthesizes recent research on breast reconstruction using implants for patients receiving radiation therapy.  To reduce the risk of recurrent breast cancer, increasing numbers of women are being treated with radiation therapy after mastectomy (postmastectomy radiation therapy, or PMRT).  Radiation has toxic effects on tissues that can cause problems with healing. 

Reconstructive surgeons agree that breast reconstruction results after radiation therapy tend to be better when the patient’s own (autologous) tissue is used.  However, in some situations implants may be the preferred option for reconstruction, or the only choice.  The goal of the review was to analyze the best available evidence on the use of breast implants after radiation therapy.

Dr. Kronowitz identified 19 studies, of varying quality, evaluating the results of implant-based reconstruction in patients receiving PMRT.  He writes, “In general, radiation increases the risk of complications and poor aesthetic outcomes of implant-based reconstruction.”

In one of the largest studies performed to date, the risk of major complications was about 45 percent for women receiving implants with radiation therapy, compared to 24 percent in patients not exposed to radiation.  Complications were more common when radiation was given before versus after implant-based reconstruction: 64 versus 58 percent.

The highest-quality study found that, among women undergoing implant reconstruction, patient satisfaction scores were lower for those receiving radiation therapy.  Another study reported that women receiving implants after radiation therapy were more likely to need major corrective surgery.

Newer Techniques May Lead to Improved Results

One paper suggested that radiation-related skin damage predicted higher complication rates and poorer aesthetic outcomes after implant-based reconstruction.  Some recent research indicated that the results of implant reconstruction after PMRT could be improved by the addition of autologous fat transfer—using the patient’s own fat tissue to enhance the results.

“Despite advances in reconstructive devices and materials, PMRT still appears to have an adverse impact on outcomes of implant-based breast reconstruction,” Dr. Kronowitz writes.  “However,” he adds,” the majority of patients who undergo implant-based reconstruction and PMRT ultimately keep the implant-based reconstruction.”  Outcomes appear better with two-stage reconstruction, where the implant is placed after PMRT, rather than immediately after mastectomy.

Autologous fat grafting and other new approaches hold promise for improving the results of implant-based reconstruction after radiation therapy for breast cancer, Dr. Kronowitz believes.  “In the meantime, patients who will receive or have received radiation should be advised of the risks of implant-based breast reconstruction.”  In an upcoming article, Dr. Kronowitz will review recent data on the results of autologous tissue-based breast reconstruction after radiation therapy.

Plastic and Reconstructive Surgery® is published by Lippincott Williams & Wilkins, part of Wolters Kluwer Health.

About Plastic and Reconstructive Surgery

For more than 60 years, Plastic and Reconstructive Surgery® (http://journals.lww.com/plasreconsurg/) has been the one consistently excellent reference for every specialist who uses plastic surgery techniques or works in conjunction with a plastic surgeon. The official journal of the American Society of Plastic Surgeons, Plastic and Reconstructive Surgery® brings subscribers up-to-the-minute reports on the latest techniques and follow-up for all areas of plastic and reconstructive surgery, including breast reconstruction, experimental studies, maxillofacial reconstruction, hand and microsurgery, burn repair, and cosmetic surgery, as well as news on medico-legal issues.

About ASPS

The American Society of Plastic Surgeons (ASPS) is the world’s largest organization of board-certified plastic surgeons. Representing more than 7,000 Member Surgeons, the Society is recognized as a leading authority and information source on aesthetic and reconstructive plastic surgery. ASPS comprises more than 94 percent of all board-certified plastic surgeons in the United States. Founded in 1931, the Society represents physicians certified by The American Board of Plastic Surgery or The Royal College of Physicians and Surgeons of Canada. ASPS advances quality care to plastic surgery patients by encouraging high standards of training, ethics, physician practice and research in plastic surgery. You can learn more and visit the American Society of Plastic Surgeons at www.plasticsurgery.org or www.facebook.com/PlasticSurgeryASPS and www.twitter.com/ASPS_news.

About Lippincott Williams & Wilkins

Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes. LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

Contacts:

Robert Dekker
Director of Communications
Wolters Kluwer Health
+1 (215) 521-8928
Robert.Dekker@wolterskluwer.com

Connie Hughes
Director, Marketing Communications
Wolters Kluwer Health Medical Research
+1 (646) 674-6348
Connie.Hughes@wolterskluwer.com