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By: H. Milten, M.B. B.CH. B.A.O., M.B.B.Ch., Ph.D.
Professor, University of Texas Medical Branch School of Medicine
Myelopathic symptoms include limb weakness in a pyramidal distribution antibiotic resistance neisseria gonorrhoeae purchase azithrox cheap, numbness and paresthesia antibiotics mixed with alcohol order azithrox australia, and sphincter disturbance (urinary retention antibiotics used for sinus infections uk proven 100 mg azithrox, urinary urgency virus 72 hours 250 mg azithrox with mastercard, constipation, or fecal urgency). At the time of diagnosis, 76% of patients complain of weakness, 87% are weak on examination, 57% have autonomic dysfunction, 51% have sensory symptoms, and 78% have sensory deficits on examination (16). Signs of a myelopathy include paraparesis or quadriparesis, increased tone, clonus, hyperreflexia, extensor-plantar responses, a distended bladder, or a sensory level. The sensory, motor, and reflex levels are only an approximate indication of the site of pathology; because sensory fibers retain their somatotopic organization as they ascend in the cord, the actual site of cord compression may be several segments above the apparent sensory level. The entire spinal cord should, therefore, be imaged in all patients with myelopathy. Dorsal column sensation (vibration and proprioception) and spinothalamic sensation (pain and temperature) must be assessed independently in all patients with cancer and back pain. Because the subjective appreciation of light touch involves both sensory pathways, lighttouch sensation may be reasonably well preserved, even in the presence of a clear cut sensory level for pain or vibration sense when these are tested separately. Involvement of spinocerebellar tracts in the spinal cord can lead to lower extremity ataxia out of proportion to the degree of weakness. Dorsal column involvement can lead to a sensory ataxia with positive rombergism while sparing power and reflexes. Both of these clinical presentations may focus the attention of the unwary examiner on the cerebellum, thereby delaying diagnosis (20). Patients may also present with herpes zoster, presumably as a result of reactivation of latent virus by compression of the dorsal root ganglion by tumor (16). Conus lesions typically present with early and marked sphincter disturbance and perineal sensory loss. Cauda equina lesions produce patchy lower motor neuron signs related to the lumbar and sacral nerveroots- yporeflexiaorareflexia,myotomallegweakh ness, and dermatomal sensory loss; sphincter disturbance tends to occur late and to be less marked than in conus lesions. When the signs include a mixture of upper and lower motor neuron features or dermatomal sensory loss as well as a sensory level, the possibility of coexistent nerve root involvement and cord compression should be considered. Radionuclide Bone Scan: Bone scintigraphy is more sensitive than plain radiography in the detection of epidural metastasis (24). Spinal metastases as small as 2 mm can be detected and will pick up bone metastasis 3 to 18 months beforex-rays. However,itispoorindelineatingtheanatomy, and in cancers causing osteolytic lesions, it is less useful (23). Its sensitivity is limited to about 66% and diagnostic accuracy to approximately 89% in detecting areas of vertebral destruction, assessment of extent of paravertebral soft-tissue extension and impingement of the actual spinal cord (26). The entire spine should be imaged, as epidural disease may be present at multiple levels, and the spinal level indicated by clinical examination may be several segments below the level of the lesion (29). A "screening" midline sagittal scan is inadequate; multiple sagittal scans using thin slices should be performed. When ordering radiologic investigations, a clear distinction should be made between the suspected neurologic level of involvement and the suspected vertebral level; the discrepancy between these is greatest at the inferior end of the spinal cord. In patients with a clinical picture that is strongly suggestive of epidural metastasis. In patients with local back pain with characteristics that are not strongly suggestive of epidural metastasis, definitive imaging of the epidural space is not indicated if a plain radiograph is normal. Radiculopathy Radiculopathy is associated with a high incidence of epidural metastases. In one series of patients with cancer and back pain, 27 of 43 (63%) patients with radiculopathy and without signs of spinal cord involvement were found to have epidural metastases, compared with 27 of 61 (44%) patients with local back pain alone (27). When plain radiographs were abnormal, epidural metastases were found in 20 of 22 (91%) patients with radiculopathy. The entire spine should be imaged, as epidural disease may be present at multiple levels, and the spinal level indicated by clinical examination may be several segments below the level of the lesion. Because the spinal cord terminates at the first lumbar vertebra, all of the lumbar segments and some of the sacral segments of the cord are usually situated within the thoracic spine. Summary Isolated Back Pain: Definitive imaging of the epidural space should be performed if plain films are abnormal. Plexopathy the possibility of epidural metastasis must be considered in patients with breast cancer and a malignant brachial plexopathy because tumor may infiltrate directly along the plexus to the epidural space. Brachial plexus lesions present with pain (usually in the shoulder girdle with radiation to the elbow, medial side of the forearm, and medial two digits) as well as weakness and sensory symptoms in a segmental distribution. The presence of back pain also suggests that the tumor has grown proximally, but back pain may be absent with epidural extension. If a paraspinal mass is seen definitive imaging of the epidural space should be performed. Apart from the standard pain scales and performance status assessments, specific scales assessing neurological impairment for spinal cord issues (American Spinal Injury Association and Frankel Score) may be helpful, and these are discussed in more detail in the scoring systems section (15,31). However, a contrast-enhanced scan should also Pain Control Nonsteroidal anti-inflammatory agents, narcotic analgesics, and medications for neuropathic pain such as gabapentin are the mainstay of pain control (32). Steroids may then be tapered over 2 to 3 weeks while the patient receives definitive therapy. In patients who have persistent or worsening pain, steroids may need to be increased or tapered gradually.
Ipsilateral Breast Tumor Recurrence Ipsilateral breast tumor recurrence following breast conserving surgery is experienced by 5 years in approximately 7% of patients with whole breast irradiation and 26% of patients without whole breast irradiation (14) virus cheap azithrox 250mg amex. The addition of a radiation boost to the tumor bed decreases in-breast recurrence rates by approximately 41% compared with whole breast irradiation alone (15) bacteria escherichia coli generic azithrox 500 mg on line. Approximately 70% of ipsilateral breast tumor recurrences occur within the first 5 years of primary diagnosis (14 infection url mal purchase azithrox 500mg amex,16) virus black muslim in the white house purchase discount azithrox on line. Breast recurrence during the first 5 years of follow-up is associated with a substantially worse overall prognosis than are in-breast recurrences that manifest later. Detection of ipsilateral breast tumor recurrence is often difficult because of post-surgical, post-radiotherapy changes in the breast. The sensitivity of mammography for ipsilateral breast tumor recurrences is approximately 50% to 70% and ultrasonography 80% to 85%. Overall, approximately two thirds of local recurrences are detected by the patient or on clinical examination (17,18). These studies all suffer from being relatively small in sample size and are non-randomized. Thus, it is impossible to correct for confounding by leadtime and length-time biases. Local-Regional Recurrence Postmastectomy Local-regional recurrence following mastectomy is experienced by 5 years in approximately 6% of patients with postmastectomy regional irradiation and 23% of patients without postmastectomy irradiation (21). In the overview analysis, axillary lymph node status strongly predicted for absolute risk for local-regional recurrence (21). In women with axillary lymph node-negative disease, the 5-year local recurrence risk following surgery alone was 6%, and this was reduced to 2% with the use of local-regional irradiation. In women with axillary lymph node-positive disease, the 5-year local recurrence risk following surgery alone was 23% and this was reduced to 6% with the addition of local-regional irradiation. Increasing tumor grade, tumor size, and number of involved axillary lymph nodes increases the risk of localregional recurrence. Detection of local-regional recurrences following mastectomy with or without radiation is typically the result of either patient identification or of a routine clinical examination. Local-regional recurrences are rarely detected by radiographs or other screening studies. Breast cancer metastases occur in a generally predictable pattern, with synchronous multiple sites of recurrence being common. Bone is the most common site of disseminated disease, and represents approximately 40% of first recurrences. The most commonly involved bones are the spine, ribs, pelvis, skull, femur, and humerus. Other common sites for metastatic disease include lung, liver, lymph nodes, and soft tissue. The site of first metastasis from breast cancer is influenced by estrogen receptor status (Table 67-1). Estrogen receptor-positive breast cancer is more likely to spread to bone, while receptor-negative breast cancer is more likely to spread to viscera and soft tissues and is associated with a higher rate of early recurrence (Table 67-1) (22,23). Even in those patients undergoing routine surveillance during follow-up, most recurrent disease is symptomatic at time of diagnosis (24,25). Infiltrating lobular breast cancer has a propensity for recurrences in intra-abdominal and retroperitoneal sites including stomach, intestine, peritoneum, and ureter (often bilateral) (26). Currently available treatment of recurrent or metastatic breast cancer is rarely curative, even when the recurrence is limited (2). Further, the amount of tumor burden in asymptomatic or minimally symptomatic patients does not predict disease response to systemic treatment, ability to palliate symptoms, or overall survival. Thus, there is no advantage to diagnosing asymptomatic, early, subclinical disease. At the time of analysis, 2,140 patients had experienced a relapse, 93 had a second non-breast primary tumor, and 111 had died without relapse during 10-years median follow-up. In this analysis, only alkaline phosphatase was abnormal in at least 20% of patients with recurrent disease, and was abnormal in 32% of patients with bone metastasis and 71% of patients with liver metastasis. Aspartate aminotransferase and -glutamyl transferase were elevated in 62% and 75% of patients with liver metastasis. Bilirubin, calcium, and creatinine were of no value in detecting recurrent disease. Thus, while alkaline phosphatase was the most reliable of the blood tests, it was of low sensitivity for bone or liver disease. In another study of 1,371 patients with node positive breast cancer, serial alkaline phosphatase determinations were found to have low sensitivity and specificity for bone recurrence (28). Thus, monitoring of routine blood tests as a part of breast cancer surveillance is not recommended. In a study of 1,601 women with node positive breast cancer, 1,441 had a baseline and repeat bone scan at one year of follow-up (28). This study documented the inability of the one year bone scan to predict for the eventual development of bone recurrence. With a median of 4 years of follow-up, those women with a normal one year bone scan had a 6.
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The Wise pattern breast reduction pattern is the most common skin pattern design used to reduce and lift the breast and was originally based on patterns used for making bras antibiotics to treat kidney infection purchase azithrox 500 mg on line. In this technique antibiotic resistance in bacteria is the result of purchase azithrox 250 mg without a prescription, a variable amount of skin is removed from the horizontal and vertical portions of the breast in order to lift the breast and reposition the nipple centrally on the breast mound antibiotics for uti sulfa allergy buy cheap azithrox 500mg online. Although some authors have criticized the aesthetic outcomes (long scars virus scanner free cheap 500 mg azithrox otc, boxy-wide breasts) and durability (late ptosis or bottoming out) of this pattern for breast reduction or lift, it remains the workhorse for most plastic surgeons in the United States. This is based on the fact that if properly performed, the Wise pattern can have excellent cosmetic outcomes and the incisions are mostly hidden in the inframammary fold. However, a number of other patterns have been reported to address some of these concerns. For example, the vertical pattern utilizes only the vertical limb of the incision in an effort to avoid the long horizontal inframammary incision and is useful in some patients. Mastopexy, or breast lift, is performed to remove excess skin and reposition the breast more centrally on the chest. Similar to breast reductions, Wise patterns are used commonly due to their ease and proven reliability. However, other skin patterns such as circumareolar or vertical can also be used depending on the amount of excess skin, breast size and shape, and skin tone. Skin-only mastopexies refer to breast lifts that rely primarily on tightening the breast skin to reshape the breast. However, these procedures often fail to have long-lasting results with stretching of the skin and recurrent ptosis. As a result, a variety of breast parenchymal procedures have been described that aim to lift the breast by reshaping the breast and simply redraping the skin. These techniques are applicable also to some patients for partial breast reconstruction (see below). Augmentation mammoplasty is also commonly performed as a symmetry procedure after mastectomy reconstruction. These procedures are most useful in smallbreasted women to match a contralateral implant reconstruction and can be performed either with or without a simultaneous mastopexy. Augmentation of the nonreconstructed breast can also be performed to match a larger autologous tissue reconstruction. In some cases, augmentation is performed to augment an autogenous tissue reconstruction. This scenario is encountered in cases where the amount of autogenous tissues available. Implants used for augmentation are most commonly placed under the pectoralis muscle; however, the implant is not completely covered by the pectoralis. Instead, similar to cosmetic augmentation procedures, implants used for augmentation of the native breast in cancer survivors are covered by only the muscle superiorly. The inferior portion of the pectoralis flap is dis-inserted such that the lower portion of the implant is in a submammary position. Subpectoral implant placement is thought to decrease the rate of capsular contracture, diminish visible rippling of the implant, and facilitate mammographic surveillance of the breast. The most common surgical complication of breast reduction or mastopexy is minor wound healing complications. These occur most commonly at the "T-point" where the vertical and horizontal incisions come together. Fortunately, most of these complications are minor and heal spontaneously with conservative management. Hypertrophic scars or keloids can also be troublesome particularly in African American or Asian patients. These complications can, on occasion, be treated with steroid injections, laser, or reexcision. Reexcision combined with low-dose radiation therapy delivered directly to the scar immediately after scar excision is very successful with low rates of recurrence but require coordination with radiation oncologist (50). It is estimated that 3% to 5% of women who undergo mastopexy or reduction experience loss of nipple sensation (51). On rare occasions (<1%), women complain of long-term pain after mastopexy, reduction, or augmentation. The cause of these pain syndromes is unknown but likely reflects nerve damage or scarring. Late infections (more than 3 months after surgery) are also a rare complication but can present with erythema, pain, and fevers. These complications usually respond to antibiotic treatment but on occasion require imaging, long-term antibiotic treatment, or drainage. Another rare complication in these cases is diagnosis of incidental breast cancers or high-grade lesions. Surprisingly, reports in breast cancer survivors treated with contralateral procedures have reported even lower rates most likely reflecting the fact that this patient population is more closely followed with breast imaging (52). The main problem in cases of incidental breast cancer diagnosis is positive margins. This situation creates a treatment dilemma and in some cases may require conversion to mastectomy.
In addition antibiotics price purchase azithrox without a prescription, immediate reconstruction has important psychological benefits resulting in decreased anxiety and improved selfimage can antibiotics for acne delay your period generic 100 mg azithrox free shipping, and enabling patients to cope with their diagnosis and treatment (3) infection merca quality 250 mg azithrox. From a practical standpoint antibiotics guide discount 500mg azithrox overnight delivery, immediate reconstruction saves the patient an additional trip to the operating room. One consideration is an increased risk of complications associated with combining oncological treatment and reconstruction. Although this idea makes intuitive sense, very few studies have actually compared complication rates in the same patient cohorts. In addition, the majority of complications that occur in the setting of immediate reconstruction are minor in nature and rarely delay adjuvant therapy (4,5). Mastectomy skin flap necrosis is much more common after immediate reconstruction and likely reflects the more extensive dissection that is performed at the time of mastectomy. Note that although both outcomes have excellent shape or contour, patients treated with delayed reconstruction have longer and more noticeable scars. Implant reconstructions make up the bulk of breast reconstructions that are performed annually in the United States. Implant reconstruction is simpler to perform, is associated with low rates of complications, and does not significantly increase hospital stay or recovery as compared with mastectomy alone. Although most patients are candidates for implant reconstruction, there are some relative contraindications including severe medical comorbidities, oncologic factors necessitating massive skin excision, severe immune deficiency, heavy smoking history, massive obesity, and history of breast irradiation. These circumstances increase the rates of complications associated with implant reconstruction, but do not preclude their use in select cases. Although implant technology has improved considerably over the past two decades, most modern implants have an average life span of approximately 10 years. A recent study demonstrated a 4-year leak rate of 4% to 15% in saline implants depending on the manufacturer used (6). In addition, because implants are a foreign substance and are placed underneath the pectoralis muscle, these reconstructions do not feel as natural as a normal breast. It is also difficult to obtain perfect or near perfect symmetry with implants in unilateral reconstructions even when contralateral symmetry procedures such as augmentation, reduction, or mastopexy are performed. Asymmetry of implant reconstructions with the normal breast tends to worsen over time, particularly if patients gain or lose weight, since the implant size does not change and the implant pocket does not sag. Thus, although aesthetic results have improved over the years, the primary goal of implant reconstructions is to have reasonable symmetry in clothes, a bra, or a bathing suit. By far the biggest disadvantage of implant reconstructions is the potential for developing capsular contracture. A capsule is a fibrous covering that develops around any prosthetic device that is placed subcutaneously. Capsular contracture develops when the capsule surrounding the implant becomes thickened and tight, causing patients to complain about tightness, pain, or implant malposition. The degree of contracture can be quantified using the Baker scale and uses a four-point scale based on physical exam and symptoms. In these procedures, a combination of skin, fat, and muscle is transferred to the breast to reconstruct either the entire breast or a portion thereof. Tissues can be transferred from adjacent areas such as the back (latissimus flap) or abdomen or from sites located distant to the breast including the gluteal region or the inner thigh. Reconstruction can be performed either purely with autologous tissues or in combination with an implant. Autologous tissues are transferred to the breast site either by keeping their local blood supply intact (pedicled flaps) or by disconnecting and reconnecting the arterial and venous circulation using microsurgical techniques (microsurgical or free flaps). Similar to implants, autologous tissue reconstruction has high success rates and patient satisfaction. For example, a patient who has undergone mastectomy and radiation is unlikely to have a successful reconstruction using an implant alone since the remaining mastectomy skin has been injured. In these circumstances, a portion of the damaged mastectomy skin is usually replaced by healthy tissues from a distant flap donor site and reconstruction is completed. Another example is a patient who has very large, ptotic breasts that are unlikely to be adequately matched with an implant reconstruction. The main advantage of autologous tissues is the fact that reconstruction is performed with living tissues. These tissues age with the patient, changing over time to maintain symmetry with the contralateral breast. In contrast to implants, autologous tissues are tailored to the patient and more likely to have symmetry immediately after reconstruction. Tissue reconstructions feel and look more natural because, unlike implants, the tissues are placed in the subcutaneous plane simply replacing the breast rather than in a subpectoral position. Tissue reconstructions also do not develop fibrous capsules and can help replace damaged tissues to break up scar and relieve contracture. As a result of these advantages, tissue-based reconstructions are considered the gold standard for aesthetic reconstruction. The "cost" in the case of autologous tissues is donor site morbidity that increases recovery time and can have long-term consequences. At the minimum, patients reconstructed with their own tissues will have donor site scarring that in some cases may be unaesthetic. Chronic donor site pain and bothersome loss of sensation have also been reported for patients reconstructed with various types of autogenous tissues. Similarly, patients reconstructed with latissimus flaps may have decreased upper extremity strength and range of motion that in some cases may necessitate physical therapy. Absolute contraindications to implant reconstruction include severe tissue deficiency from resection or secondary to tissue damage from radiation. Some surgeons also consider the need for postmastectomy radiation therapy as a relative contraindication; however, this concept has been debated and there is no uniform consensus.
