A recent European trial (MOSAIC) has documented significant improvement in 3-year disease-free survival when oxaliplatin (Eloxatin) was added to infusional 5-FU and leucovorin in the FOLFOX regimen.
Continuous infusion 5-FU: patient handout from scotland
cost of various chemoregimens: what is in store for the future if we start looking at cost/benefit ratios?
patient's blog on experience with treatment for colon cancer.
IVC Filters and Splenectomy
When should you remove a temporary ivc filter after a splenectomy?
Austrian June 12 2008 study: controversial. It seems that the high risk is the first week or two after the splenectomy both for dvt and spvt (splenoportal venous thrombosis).
Austrian June 12 2008 study: controversial. It seems that the high risk is the first week or two after the splenectomy both for dvt and spvt (splenoportal venous thrombosis).
Warnings about Medications: Legal Responsibility
http://www.rmf.harvard.edu/files/documents/cricormf_coombes.pdf
http://content.nejm.org/cgi/content/short/359/5/521
http://lawprofessors.typepad.com/tortsprof/2007/12/expansion-of-du.html
Does this mean a dramatic change in
prescribing practices?
It should not. Physicians already owe patients the duty to warn
them about medication side effects and restricted activities
(in particular, driving). Careful adherence to that duty—and
documentation that such warnings were presented and
understood—should be sufficient to protect the physician from
claims from a non-patient harmed by his or her patient.
http://content.nejm.org/cgi/content/short/359/5/521
http://lawprofessors.typepad.com/tortsprof/2007/12/expansion-of-du.html
Does this mean a dramatic change in
prescribing practices?
It should not. Physicians already owe patients the duty to warn
them about medication side effects and restricted activities
(in particular, driving). Careful adherence to that duty—and
documentation that such warnings were presented and
understood—should be sufficient to protect the physician from
claims from a non-patient harmed by his or her patient.
Methylene Blue Dye problems
Int Semin Surg Oncol. 2005; 2: 26.
Published online 2005 November 28. doi: 10.1186/1477-7800-2-26.
PMCID: PMC1308848
Copyright © 2005 Salhab et al; licensee BioMed Central Ltd.
Skin and fat necrosis of the breast following methylene blue dye injection for sentinel node biopsy in a patient with breast cancer
M Salhab,1 W Al sarakbi,1 and K Mokbel1
1St Georges and The Princess Grace Hospitals, London, UK
Corresponding author.
M Salhab: msalhab1@excite.com
; W Al sarakbi: walsarakbi@hotmail.com
; K Mokbel: kefahmokbel@hotmail.com
Received September 27, 2005; Accepted November 28, 2005.
The technique of blue dye mapping was first described for breast cancer by Giuliano et al [3]. Isosulfan blue dye has been traditionally used the dye used for SLNB for breast cancer. However, its use was associated with a significant number of allergic reactions [4], some of which are life threatening. Because methylene blue dye has been shown to be equally effective and does not pose a serious risk of severe allergic and hypersensitivity reactions, it was regarded as an acceptable substitute for isosulfan blue dye for SLNB [5-8]. Although, the use of the MB dye for SLNB in breast cancer has fewer allergic reactions, its use has been associated with a number of local and systematic complications. Stradling et al, was the first to report adverse skin reactions to methylene blue dye in patients with breast cancer [9]. In addition, skin eruptions and rashes [10], subcutaneous tissue necrosis and abscess formation [11] have been reported in association with the injection of this dye. Furthermore, capsular contraction following breast reconstruction using an implant with intense blue discoloration of the prosthesis was reported in a patient in whom methylene blue dye was used to identify the sentinel lymph node [12].
In our reported case, severe skin and fat necrosis complicated the peri-tumoral injection of methylene blue dye; This might be due to that methylene blue dye may induce an early foreign body-type reaction characterized by ischemic ulceration, fibrinoid necrosis with eosinophilic infiltration [13].
Therefore, we recommend the use of Patent Blue V dye instead of MB for SLNB localization in patients with breast cancer in order to avoid such significant complications which may delay subsequent treatment. Patent Blue dye has been reported to cause minor local complications in form of long-term discoloring of the skin at the site of injection [14]. Although no cases of severe local tissue necrosis has been reported in association with Patent Blue V dye, however, anaphylactic shock has been observed following its injection for SLNB localization [15,16]. The risk of allergic reactions can be reduced by using corticosteroids and antihistamines [4,17,18]
In conclusion, the use of MB dye for SLNB identification should be avoided and replace with alternative types of blue dye such as Patent Blue V preferably in conjunction with a radioactive isotope tracer.
In our reported case, severe skin and fat necrosis complicated the peri-tumoral injection of methylene blue dye; This might be due to that methylene blue dye may induce an early foreign body-type reaction characterized by ischemic ulceration, fibrinoid necrosis with eosinophilic infiltration [13].
Therefore, we recommend the use of Patent Blue V dye instead of MB for SLNB localization in patients with breast cancer in order to avoid such significant complications which may delay subsequent treatment. Patent Blue dye has been reported to cause minor local complications in form of long-term discoloring of the skin at the site of injection [14]. Although no cases of severe local tissue necrosis has been reported in association with Patent Blue V dye, however, anaphylactic shock has been observed following its injection for SLNB localization [15,16]. The risk of allergic reactions can be reduced by using corticosteroids and antihistamines [4,17,18]
In conclusion, the use of MB dye for SLNB identification should be avoided and replace with alternative types of blue dye such as Patent Blue V preferably in conjunction with a radioactive isotope tracer.
Breast MRI
Aug 2008 Am J Surg: impact of breast MRI in preop patients.
multicentric disease discovered on MRI 7.7%;
contralateral cancer 3.6%;
total occult disease discovery = 7.7 + 3.6 = 11.3%;
changed surgical management in 20%.
---------------
multicentric disease discovered on MRI 7.7%;
contralateral cancer 3.6%;
total occult disease discovery = 7.7 + 3.6 = 11.3%;
changed surgical management in 20%.
---------------
Compared with triple assessment for symptomatic and occult breast disease, magnetic resonance mammography (MRM) offers higher sensitivity for the detection of multifocal cancer, which is important in selecting patients appropriately for breast-conserving surgery. It is an ideal tool for the screening of patients with a high risk of breast cancer or where there is axillary disease or nipple discharge and conventional imaging has not revealed the primary focus. Techniques are now available to biopsy lesions only apparent on MRM. MRM can differentiate scar tissue from tumour; therefore, it is useful in patients in which there is possible recurrent disease. Clinical and X-ray mammographic assessment of response to neoadjuvant chemotherapy may be unreliable because of replacement of the tumour with scar tissue. MRM can identify responders and nonresponders with more accuracy. It is the modality of choice for the assessment of breast implants for rupture with accuracy higher than X-ray mammography and ultrasound. Advances in both spatial and temporal resolutions, the imaging sequences employed, pharmacokinetic modelling of contrast uptake, the use of dedicated and now phased-array breast coils, and gadolinium-based contrast agents have all played their part in the advancement of this imaging technique. Despite the limitations of patient compliance, scan-time and cost, this review describes how MRM has become a valuable tool in breast disease, especially in cases of diagnostic uncertainty.
Digital vs Traditional Mammography
November 2005:
who benefits from digital mammography:
Dr Pisano explained that the results from DMIST, a large clinical trial of digital versus film mammography, showed certain groups may benefit significantly from digital mammograms:
- women with dense breasts
- women who are premenopausal or perimenopausal
- women who are younger than age 50
For the general population of women, digital and film mammography were equally effective.
Plavix
highest risk for adverse cardiac events when stopping plavix: first 90 days for patients with Acute Coronary Syndrome.
Parathyroidectomy
Lateral approach minimally invasive parathyroidectomy:
Superior adenoma: 2 cm incision 1 cm superior to the neck crease line and lateral to the medial margin of the SCM.
Inferior adenoma: 2 cm incision 1 cm inferior to the neck crease line and MEDIAL to the medial margin of the SCM.
SCM retracted laterally and strap muscles retracted medially.
Space of dissection: medial to CCA and posterior to the thyroid gland - pretracheal fascia to prevertebral fascia.
Source paper: JACS 2006, Australia
Superior adenoma: 2 cm incision 1 cm superior to the neck crease line and lateral to the medial margin of the SCM.
Inferior adenoma: 2 cm incision 1 cm inferior to the neck crease line and MEDIAL to the medial margin of the SCM.
SCM retracted laterally and strap muscles retracted medially.
Space of dissection: medial to CCA and posterior to the thyroid gland - pretracheal fascia to prevertebral fascia.
Source paper: JACS 2006, Australia
Obstruction after laparoscopic gastric bypass
Source: UC Irvine, 2004, paper on obstruction after laparoscopic gastric bypass
Figure 1. Three potential spaces that could lead to internal
herniation (1 - Petersen hernia defect, 2 - jejunojejunostomy
mesenteric defect, and 3 - transverse mesocolon
defect).
Silicone Breast Implant Rupture
042707 emedicine review
Dec 1995, Ann Plast Surg: monitoring the axilla: recommends biopsy
102404 CHEST review: migration to lymph nodes present but usually asymptomatic. Not associated with breast cancer.
2003: book - No association with rheumatologic disorders.
1999: imaging extracapsular rupture
Dec 1995, Ann Plast Surg: monitoring the axilla: recommends biopsy
102404 CHEST review: migration to lymph nodes present but usually asymptomatic. Not associated with breast cancer.
2003: book - No association with rheumatologic disorders.
1999: imaging extracapsular rupture
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