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In the majority of these claims order maxalt without a prescription pain management for old dogs, the ing attempted epidural/caudal anesthesia if there is injuries were judged as temporary or nondisabling accidental intrathecal injection (see below) generic maxalt 10mg fast delivery urmc pain treatment center sawgrass drive rochester ny. Serious injuries in the remaining claims is more ofen the result of severe sustained hypoten- included death (13%) purchase maxalt 10mg fast delivery neuropathic pain treatment guidelines 2013, permanent nerve injury sion and medullary hypoperfusion than a response (10%) maxalt 10mg free shipping pain treatment for scoliosis, permanent brain damage (8%), and other to phrenic nerve paralysis from anesthesia of C3–C5 permanent injuries (4%). Anterior spinal artery syndrome has been anesthesia claims involved either lumbar epidural reported following neuraxial anesthesia, presumably anesthesia (42%) or spinal anesthesia (34%) and due to prolonged severe hypotension together with tended to occur mostly in obstetric patients. Of note is that caudal respiratory insufciency becomes evident, in addi- anesthesia was utilized in only 2% of claims. Hypotension can be treated with rapid Excessive Responses to Appropriately administration of intravenous fuids, a head-down Placed Drug position, and intravenous vasopressors. High Neural Blockade epinephrine can also increase heart rate and arterial Exaggerated dermatomal spread of neural block- blood pressure. If respiratory and hemodynamic ade can occur readily with either spinal or epidural control can be readily achieved and maintained afer anesthesia. Administration of an excessive dose, high or total spinal anesthesia, surgery may proceed. Patients may complain of dys- Project identifed several cases of cardiac arrest dur- pnea and have numbness or weakness in the upper ing spinal anesthesia. Extremely high many physicians believed oversedation and unrecog- levels of local anesthetics afect the central ner- nized hypoventilation and hypoxia were the causes. Because the dosage of of cardiac arrest in patients having received a spinal medication for spinal anesthesia is relatively small, anesthetic, Many of the cardiac arrests were preceded this complication is seen afer epidural and caudal by bradycardia, and many occurred in young healthy (but not spinal) blocks. Examination of this problem identifed vagal injected directly into a vessel through a needle or responses and decreased preload as key factors and later through a catheter that has entered a blood suggests that patients with high baseline vagal tone are vessel (vein). To prevent this from occurring, hypovolemia tion can be minimized by carefully aspirating the should be corrected. Prompt drug treatment of hypo- needle (or catheter) before every injection, using a tension and bradycardia are recommended. Many test dose, always injecting local anesthetic in incre- clinicians will not allow the heart rate to fall below mental doses, and close observation for early signs 50 beats per minute during spinal anesthetic blockade. Local anesthetic block of S2–S4 root fbers decreases The local anesthetics vary in their propensity urinary bladder tone and inhibits the voiding refex. The rank order Epidural opioids can also interfere with normal of local anesthetic potency at producing seizures voiding. Tese efects are most pronounced in male and cardiac toxicity is the same as the rank order patients. If a cath- relatively low potency and also is metabolized very eter is not present postoperatively, close observation rapidly; lidocaine and mepivacaine are intermediate for voiding is necessary. Persistent bladder dysfunc- in potency and toxicity; and levobupivacaine, ropi- tion can also be a manifestation of serious neural vacaine, bupivacaine, and tetracaine are most potent injury, as discussed below. Total Spinal Anesthesia Needle or Catheter Insertion Total spinal anesthesia can occur following A. Inadequate Anesthesia or Analgesia attempted epidural/caudal anesthesia if there is As with other regional anesthesia techniques, accidental intrathecal injection. Onset is usually neuraxial blocks are associated with a small, but rapid, because the amount of anesthetic required measureable, failure rate that is usually inversely for epidural and caudal anesthesia is 5–10 times that proportional to the clinician’s experience. Movement of the needle during niques during epidural and caudal anesthesia can injection, incomplete entry of the needle opening help avoid this complication. Causes for failed epidural blocks As with accidental intravascular injection, and were discussed above (see “Failed Epidural Blocks”). Intravascular Injection anesthetic during attempted epidural anesthesia is Accidental intravascular injection of the local much more serious than during attempted spinal anesthetic for epidural and caudal anesthesia can anesthesia. It may be throbbing or constant and associ- nal subdural space is a potential space between the ated with photophobia and nausea. Unlike the epidural space, the sub- is aggravated by sitting or standing and relieved or dural space extends intracranially, so that anesthetic decreased by lying down fat. The onset of headache injected into the spinal subdural space can ascend is usually 12–72 hr following the procedure; how- to higher levels than epidural medications. Untreated, high spinal anesthesia, treatment is supportive and the pain may last weeks, and in rare instances, has may require intubation, mechanical ventilation, and required surgical repair. Backache causes traction on structures supporting the brain, As a needle passes through skin, subcutaneous tis- particularly the meninges, dura, and tentorium. Traction on tory response with or without refex muscle spasm the cranial nerves may occasionally cause diplopia may be responsible for postoperative backache. If treatment is sought, acetaminophen, include young age, female sex, and pregnancy. Although backache is usually benign, it may accidental wet tap with a large epidural needle in a be an important clinical sign of much more seri- young woman (perhaps as high as 20% to 50%). The ous complications, such as epidural hematoma and lowest incidence would be expected in an elderly abscess (see below). Headache may persist nerve dysfunction, including paralysis of the biceps for days, despite conservative therapy. Not all neurological defcits occur- autologous blood into the epidural space at, or one ring afer a regional anesthetic are the result of the interspace below, the level of the dural puncture. Approximately 90% of cits, including lateral femoral cutaneous neuropathy, patients will respond to a single blood patch, and foot drop, and paraplegia, were recognized before 90% of initial nonresponders will obtain relief from the modern era of anesthesia and still occur in the a second injection. Less clear are the postanes- lactic blood patching through an epidural catheter thetic cases complicated by concurrent conditions that was placed afer a wet tap. Neurological Injury be about 1:150,000 for epidural blocks and 1:220,000 Perhaps no complication is more perplexing or for spinal anesthetics. The vast majority of reported distressing than persistent neurological defcits fol- cases have occurred in patients with abnormal coag- lowing an apparently routine neuraxial block. An ulation either secondary to disease or pharmaco- epidural hematoma or abscess must be ruled out. The latter may be avoided if the neuraxial blockade Tus, insertion and removal of an epidural catheter is performed below the termination of the conus are risk factors. Postoperative The pathological insult to the spinal cord and peripheral neuropathies can be due to direct physi- nerves is due to the hematoma’s mass efect, com- cal trauma to nerve roots. Although most resolve pressing neural tissue and causing direct pressure spontaneously, some are permanent. The diagnosis and treatment defcits have been associated with paresthesia from must be accomplished promptly, if permanent neu- the needle or catheter or complaints of pain during rological sequelae are to be avoided. Some studies have suggested that multiple symptoms is typically more sudden than with epi- attempts during a technically difcult block are also dural abscess. Any sustained paresthesia should alert leg pain with a motor weakness and/or sphincter the clinician to redirect the needle. Practice anesthesia-related cases involve epidural cath- guidelines should be reviewed when considering eters. In one reported series, there was a mean of neuraxial anesthesia in such patients, and the risk 5 days from catheter insertion to the development versus beneft of these techniques should be weighed of symptoms, although presentation can be delayed and delineated in the informed consent process.

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The most frequent terhemispheric fssure cheap maxalt 10mg mastercard marianjoy integrative pain treatment center, and choroid plexus order cheap maxalt line pain management for dogs after neutering, which is the result locations of subdural empyemas are the convex brain surface of the combination of hypervascularity of infected meninges Head Trauma 905 Fig order maxalt 10 mg on line pain treatment centers of america colorado springs. Lateral and third ventri- cumulation of contrast medium in the ependyma of the lat- cles may be narrowed due to difuse brain oedema generic 10mg maxalt with visa pain treatment goals. Narrowing mulation of contrast medium is more ofen seen along the of subarachnoid spaces, and thickening and hyperintensity of walls of the lateral ventricles. Pathogenesis of posttraumatic hydrocephalus secondarily to leptomeningitis in retrograde expansion of in- is variable. Obstruction usually involves convex subarachnoid Afer surgical interventions (shunting, etc. Blood resorption and asep- tic infammation lead to sclerosis (or desolation) of arachnoid 9. Sylvian aqueduct by biochemical tests showing the level of glucose over 30 may also be dilated. In other cases, it developed later, and in several cases in especially in skull base fractures, in fractures of frontal sinus, the delayed period—months or years later. Pneumocephalus is as Omnipaque and Omniscan or Ultravist and Magnevist or one of the features that prove communication of the suba- Gadovist was used at the Burdenko Neurosurgery Institute. However, it should be noted that frst week afer injury, more frequently within the frst 24–48 h. Delayed intracerebral haematomas the signal of bones of the anterior cranial fossa base is hy- are most always lobar, and frequently multifocal, and may be podense, thus providing a highly diagnostic method. Frontal found in those areas where contusion lesions have been seen and sagittal projections are most informative. New neuroimaging methods examine intracerebral haematomas, even if a patient was admitted for complex and ultrastructural neuropathophysiological events small extracerebral haematomas. References Aarabi B (1988) Traumatic aneurysms of the brain due to high-ve- Babchin A, Kondakov E, Zotov I (1995) [Traumatic subdural hygro- locity missile head wounds. Lippincott Williams & Wilkinson, ing of the Radiological Society of North America, Chicago, pp New York, pp 257–271 150–151 918 Chapter 9 Cooper P (1982) Head injury. Lippincott, Williams & Wilkinson, Lebedev V, Krylov V (1998) [Remarks on the pathogenesis of brain New York contusions occurring by a counterimpact mechanism in the acute Evans S, Gean A (1999) Craniocerebral trauma. Neuroimaging Clin N Firsching R et al (2001) Classifcation of severe head injury based Am12:2 on magnetic resonance imaging. Acta Neurochir (Vienna) Lichterman L, Potapov A (1998) [Classifcation of head trauma. In: Evidence-based neurotrauma- and apparent difusion coefcient in the evaluation of severe tology. McGraw-Hill, Gentleman S et al (1995) Axonal injury: a universal consequence of New York, pp 2773–2782 fatal closed head injsury. Louis, pp delphia, pp 884–915 149–169 Osborn A (1991) Secondary efects of intracranial trauma. Neuroimaging Clin N Am 10:309–331 Ann Neurol 33:159–170 Kim S, Chang K, Song I et al (1997) Brain abscess and brain tumor. Medicine, Moscow (in Russian) Russian) Wilde E, Chu Z, Bigler E et al (2006) Difusion tensor imaging in the Kornienko V (1981) Angiographic study of the brain hemodynamic corpus callosum in children afer moderate to severe traumatic in neurosurgery patients with irreversible changes. McGraw-Hill, New York, pp 413–452 Chapter 10Chapter 10 Hydrocephalus 10 in collaboration with V. However, such conformity has not been experience allowed elaborating the most complete model found. However, biphasic fow in the basal cistern, the aqueduct of Sylvius, and the spinal channel is not coherent due to delay caused by the motion of brain tissue. The most complete admixture occurs in the subarachnoid space of the spinal cord, especially in the cervical and the thoracic regions. When techniques is limited by a Т1 value of blood and the value of the second image is registered, polarities of the additional the blood velocity in a vessel. Brightness of signal on phase- gradient pulses invert, and the resulting shifs in phase of a contrast images immediately corresponds to the spin motion single proton on two sequential images will be identical in velocity, i. In the sig- blood fow visually, but also to obtain quantitative parameters nals of stationary protons, shifs in phase for the time of ac- of the fow velocity (Figs. Tey will be mutually reduced on the subtraction im- Afer that, changes of velocity may be observed in all phases age. The signals of protons moving with fow will difer in am- of the cardiac cycle, and it is possible to acquire associations plitude and phase, and will not be reduced. Secondly, velocity changes with performed before the Fourier transformation procedure dur- acceleration what may also cause additional shifs in phase ing the reconstruction. To view images in the cine regimen, ity may be directed in any dimension S/I, A/P, or R/L of the measurement may be synchronised with the peripheral pulse scanner system of coordinates. In cardiac synchronising, the moment of velocity es- characterise the direction of fow motion as a whole, separate timation is usually set to the certain phase of a cardiac cycle components of a fow should be identifed along each of three (i. Due to delay of pulse during the peripheral taking them into account, a velocity weighted image is calcu- synchronisation, the systolic part of a signal of changing fow lated within the given slice plane. The direction of speed encoding is chosen such as the sensitivity of registration to a fow throughout a slice is provided. Several minutes are also required for the image reconstruction, and slices for fows in the А/Р, S/I, and R/L directions may be ob- tained, respectively—60 amplitude images, and 20 new phase projection images, for 80 images for a whole study. On the one Hydrocephalus 925 hand, decrease of resorption may be a result of blockage of cerebral subarachnoid space is completely or partially absent arachnoid pili or lymphatic canal of cranial and spinal nerves (as afer infammatory process in meninges), then resorption and adventitia of cerebral vessels. The causes of hydrocephalus may infuence a developing On X-ray craniograms in young children, increase of skull brain in the intrauterine period (congenital hydrocephalus) size is seen, and its shape acquire hydrocephalic features: fron- as well as afer birth (acquired hydrocephalus). Factors medi- tal tubers protrude, and the vault bows transit to each other ating hydrocephalus are cerebral malformations (up to 30%), creating a spherical surface. In rapid progression, the major stenosis and gliosis of the aqueduct of Sylvius, congenital vas- fonticulus becomes strained, and sutures are pulled aside cular malformations, pathology of arachnoid pili and granu- and yawn. The sella turcica is usually preserved, only in long- lations, brain tumours and nontumoral mass lesions, cranio- standing hydrocephalus does it depresses together with other cerebral injury, haemorrhages, ischaemia, acute and chronic cranial bones and turns towards the anteroposterior direction. Smoothening of the vault bows and promi- Open or communicating (internal, external, mixed) hydro- nent “fngerprints” point out the internal hydrocephalus. The connection between the fourth ven- dren younger than 2 years are progressive increase of head cir- tricle and cisterna magna is clearly seen. The latter may have cumference, stain and out-pouching of the major fonticulus, normal or markedly increased size. The bottom of the third thinning of cranial vault bones, diversion of suture margins, ventricle (especially its anterior portions) is depressed and is and dilatation of subcutaneous head veins. The cerebral cisterns and the interpeduncular cistern are clearly seen on the appropriate slices. In younger children, they are usually increased in size, and the brainstem is as if 10. The ambient cistern in rapidly progressive hydrocephalus is narrowed, and in slowly In open hydrocephalus, communication between the ventric- progressive hydrocephalus, it remains intact. CТ (a,b): cisterns of the posterior fossa are free, and cisterns magna communicates with the wide fourth ven- tricle. The aqueduct of Sylvius, and the third and the lateral ventricles are dilated, their borders are uneven, and the subarachnoid fssures are not visible 926 Chapter 10 Fig 10.

Computations cheap maxalt 10 mg line pain management treatment, such as for mean and standard deviation order maxalt canada canadian pain treatment guidelines, have to The third use of the clinical tolerance range is in assessing the needlessly assume that all the values in the interval are equal to acceptable doses such as of a drug or of radiation in radiotherapy buy 10 mg maxalt with mastercard treatment of chronic pain guidelines. Minor side effects in small percent- interval 80–84 mmHg buy on line maxalt southern california pain treatment center, the calculations will be done as though all age of subjects are tolerated, but drugs with major side effects or 17 values are 82 mmHg. This may be far too much of an approxi- with side effects in a large percentage of cases are not approved. Moreover, if exact values are available, Sometimes the normal range of medical parameters is termed as there is no need to resort to any approximation. Infuence of hyper- From the etiological point of view, clinical trials can be divided oxia on muscle metabolic responses and the power-duration relation- into six broad categories: therapeutic trials, diagnostic trials, screen- ship during severe-intensity exercise in humans: A 31P magnetic ing trails, prophylactic trials, feld trials, and vaccine trials. Hemoglobin A1c is positively correlated with Framingham risk score in older, appar- Therapeutic Trials—Effcacy and Side Effects ently healthy nondiabetic Korean adults. Extreme clinical trials (overview) care is required because therapeutic trials generally involve exog- More for convention than semantics, medical experiments on human enous material that may have side effects, and may not be benefcial beings are called trials. The objective is to study the cause–effecThat all relative to the existing modes of therapy. For this reason, before relationship between a medical intervention and a health outcome a therapeutic trial is undertaken, it is necessary to be suffciently in human subjects. Since the subjects are human, a large number of convinced regarding intoxicity and potentiality as a benefcial regi- issues crop up ranging from stricter ethics to profound variations. Thus, the previous phases in the laboratory must have provided Thus, trials do need extra care. Since the clinical trials are precarious, they are Clinical trials have a long history. Laplace wrote in 1825 that it pursued in phases, particularly for a new formulation or substance is suffcient to “test each treatment on the same number of patients, as for drug development. Terms such as Fisher introduced randomization that helped eliminate biases due recovery and discharge are vague for the outcomes. They must be to uncontrolled factors and provided basis for using statistical infer- specifed either in terms of measurements such as glomerular fltra- ential method. The frst randomized clinical trial was done in 1946 tion rate for kidney diseases, in terms of images such as x-ray for on streptomycin by British Medical Research Council for the treat- dislocated joint, or in terms of any such objective criterion. The methodology of double blinding reached the duration after which the outcome is to be assessed should be maturity in the 1970s [1]. This applies to death Clinical trials are mostly done to investigate new modes of ther- also. Research on new diagnostic procedures also falls in this cate- should this be ascribed to the surgery? Most clinical trials are carried out meticulously involving heavy ferent outcomes of interest must also be fully specifed. Since variation between and within subjects occurs due There are other issues as well relating to the outcomes. The actual to a large number of factors, it is quite often a challenge to take full interest may be in cardiovascular outcomes, but for expediency, care of all of them. Epistemic uncertainties also play a signifcant change in blood pressure level can be considered as a surrogate end- role. For example, microalbuminuria is a in controlled conditions so that the infuence of extraneous factors is promising surrogate of renal protection in many cases. Examine frst whether they are a suffcient number of patients so that a trend, if any, can be success- indeed valid markers for the hard endpoint you are looking for. Clinical trials are done in ideal conditions as much as surrogate should accurately assess not only the beneft or the lack possible to provide a realistic estimate of the effcacy. A human experimentation cannot be done unless suffcient rea- This can help in discontinuing a trial if confrmed results are avail- sons are present. Desired effcacy may be proved, or unac- tain about the effect of the intervention under the trial. Sample size can also be must have passed through rigors of preclinical phases before reach- reassessed. Except possibly those that alter lifestyle, no intervention likely to be benefcial than harmful. Thus, the beneft must scrupulously followed in all medical research including trials. This has special relevance unsuspecting harm is detected later on, the intervention is immedi- to potentially hazardous drugs. For an account of beneft–risk assessment of ing considerations instead of the researchers. By their very nature, all trials are prospective studies where the Some of the side effects, now generally termed adverse events, antecedent is the intervention and the effcacy and safety are the may be preexisting or may occur in any case in a person or even outcomes. All trials involve careful consideration of issues such help to categorize side effects into those that are defnitely due to the as selection of subjects and controls, randomization and matching, regimen, possibly due to the regimen, and unlikely to be due to the and blinding, masking, and concealment of allocation. For this, one procedure is to withdraw the treatment and are presented separately under the concerned topic. Of course, this will depend nostic trial to determine the sensitivity and specifcity of electro- on the nature of the side effect. We have provided a guideline in the diagnostic consultation for the clinical syndrome of lumbar spinal topic adverse effects and adverse patient outcomes that applies stenosis. For this, it is necessary to defne all side clinical consensus on diagnosis was reached for 55 cases. This was effects and record them, including time of onset, time of resolution, considered the gold standard for this study. Electrodiagnostic mea- severity, relation to study regimen, action taken, and outcome. Among other issues related to therapeutic trials are (i) effcacy Prophylaxis is a procedure that promotes health or controls pri- and effectiveness; (ii) equivalence and noninferiority trials; mordial factors that adversely affect health. A prophylactic trial is (iii) various designs of the trials such as randomized controlled generally conducted in the feld where a community is involved. But it can be conducted in a clini- and (iv) biostatistical ethics that comprise issues such as equipoises. An example is prophylactic nasal continuous positive These are discussed under the respective topics. Amnioinfusion for meconium stained amniotic fuid in labor at the time of childbirth Clinical Trials for Diagnostic and Prophylactic Modalities is a prophylactic procedure that can be tried for specifc types of births. As with all other trials, prophylactic trials are also restricted Diagnostic trials are for modalities that help in diagnosis rather than to a particular segment of the subjects. Prophylactic trials can be conducted The principles of clinic-based prophylactic trials are the same as in clinic as well as in the feld in a community. Perhaps a prophylactic procedure is somewhat The intervention in a diagnostic trial is not a therapeutic agent insulated against harmful effects, and thus slight relaxation in ethics but a procedure that can change the diagnosis and thus the course of may allow stricter control over confounding factors. Thus, it has the potential to improve decision-making based trials in the feld have a different setup, whether for therapeu- and patient management. From the ethics point of view, noninvasive procedures such as These are discussed next.

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  • Cardiovascular collapse (shock)
  • Hair loss
  • Dry eyes
  • Fainting or feeling lightheaded
  • Indications of back pain or pain in the flanks (the area towards the sides of the body between the ribs and the pelvis)
  • Burns
  • With open surgery, the surgeon makes one large surgical cut to remove the gland.
  • Your child does not start puberty

Effects of rence should be limited to a single location without radiotherapy and surgery in early breast cancer: an overview evidence of systemic disease order maxalt 10 mg on line pain research treatment journal. Chest wall resection in the treatment of locally recurrent breast cancer: indications tively prolonged survival time is expected buy maxalt 10mg with mastercard knee pain treatment guidelines. Reconstruction generally involves permanent mesh Fisher B cheap 10 mg maxalt with visa elbow pain treatment exercises, Jeong J order cheap maxalt on line canadian pain treatment guidelines, Anderson S, et al. Randomized, double- combined into one meta-analysis examined the role blind, placebo-controlled, multicenter trial of 6% miltefosine solution, a topical chemotherapy in cutaneous metastases of irradiation alone versus combined hyperthermia from breast cancer. A heterogeneous group was eligible, Waeber M, Castiglione-Gertsch M, Dietrich D, et al. Locoregional recurrence of breast cancer following mastectomy: always a fatal event? Int J Radiat Oncol Biol >40 Gy depending on whether they had previously Phys 1997;37:853–863. Presentation A 36-year-old multiparous Hispanic woman, 20- Discussion weeks pregnant, presents in clinic with a complaint of a persistent, tender left breast mass of 3 weeks’ du- Mammography is both safe and useful in the evalu- ration. She is otherwise healthy, has no past history ation of the breast in pregnant women. The radia- of breast problems and no family history of breast or tion dose to the properly shielded fetus is only 0. Physical examination owing to the increased density of breast tissue in discloses a firm but not hard, slightly tender, mostly younger and pregnant women, mammography has discrete 2. A should be used in most cases, especially when the targeted left breast ultrasound is obtained. Differential Diagnosis The differential diagnosis includes cancer, fibroade- noma, lobular hyperplasia, lipoma, and (rarely) leukemia, lymphoma, sarcoma, neuroma, and tu- berculosis. Because the mass has persisted longer than 2 weeks, it requires further evaluation by completion of a modified triple test (addition of a needle biopsy to the clinical breast ex- amination and ultrasound). Alkaline mm macrolobulated hypoechoic mass, taller than phosphatase level is elevated, but a chest x-ray and 241 242 Case 55 low-dose bone scan are normal. A subsequent core 10% of women younger than 40 with breast cancer biopsy shows a high-grade invasive ductal cancer, are pregnanThat diagnosis. Breast cancers in pregnant women are histologically simi- Discussion lar to those in nonpregnant women, with 75% to Because of the tendency for delayed diagnosis of 90% being ductal cancers in either group. Many pregnancy-associated breast cancer, a high index of studies have shown decreased estrogen-receptor suspicion and an easy, rapid, “one-stop” method of positivity in pregnancy-associated cancers, possibly evaluating suspicious masses in the pregnant pa- due to receptor downregulation in pregnancy. Chest x-rays ciples used for nonpregnant patients, that is, aggres- are safe throughout pregnancy, but alkaline phos- sively for cure in most cases. Low-dose bone treatment for pregnancy-associated cancers, and the scans reduce the fetal radiation exposure by half choice of operation is based not only on the same (from 0. Thus, breast radiation during preg- nancy is contraindicated, and lumpectomy and ra- diation should be offered only if the radiation can Diagnosis and Recommendation be given postpartum (i. Because ter stages of the pregnancy), or if the radiation will this patient was already in her second trimester and be delayed by prior chemotherapy. Otherwise, a was likely to be a candidate for chemotherapy, she is mastectomy is typically chosen. Reconstruction af- offered either mastectomy or lumpectomy and radia- ter mastectomy should be delayed until after deliv- tion. With either approach, the standard axillary ■ Approach evaluation for invasive cancer is still two-level axil- Once thought to be rare, pregnancy-associated lary dissection. The accuracy and safety of sentinel breast cancer (breast cancer during, or within a year node biopsy in pregnancy is unknown, and preg- after, a pregnancy) is expected to increase in fre- nant patients are excluded from pending national quency as women delay childbearing until later in trials of this technique. Further, while technetium life, when the general risk of breast cancer begins to does not cross the placenta and the standard dose of rise. At present, breast cancer is the second most 1 mCi (or less) may give a very low dose to the fetus, common malignancy in pregnancy (after cervical isosulfan blue dye is a class C drug, and has not cancer), occurring in 1 in 5,000 deliveries. No data exist to compare patient outcomes after General anesthesia and breast operations are gener- chemotherapy in patients who received it during ally safe throughout pregnancy. Nevertheless, for pregnancy with patient outcomes for those in whom pregnancies more advanced than 32 weeks, consid- systemic treatment was delayed until after delivery. Anthracyclines are considered safer than general principles of operation during pregnancy alkylating agents in pregnancy. Taxane use was apply; the surgical team should be aware of the found safe in one case report. Recent studies of physiologic changes of pregnancy that can com- dose-dense schedules excluded pregnant patients. The pregnant patient should be ing increased plasma volume, decreased albumin given preoxygenation, antacids or acid-decreasing concentration, increased liver and kidney function, medications, fetal monitoring, rapid-sequence in- and decreased gastric motility, may affect chemo- duction with cricoid pressure, and elevation of the therapy dosing. Many drugs be decreased, and that lactation after radiation is of- typically used to treat chemotherapy side effects are ten difficult due to changes in the nipple and milk safe in pregnancy, including ondansetron, haloperi- ducts. The patient recovers well and is seen in consultation by The patient begins chemotherapy at 24 weeks’ ges- a medical oncologist who advises four cycles of tation. She receives two cycles, and then, following chemotherapy with doxorubicin (Adriamycin) and a rest period, delivers a healthy 7-pound baby girl by cyclophosphamide, followed by a taxane. The patient expresses an interest in possi- Discussion bly having another child in the future. Although all chemotherapy drugs are category D (ter- atogenic), these risks have generally been seen only in Discussion the first trimester; later in pregnancy they are surpris- ingly safe, with only a 1. In the only prospec- There is no evidence that therapeutic abortion im- tive trial of chemotherapy in pregnancy to date, proves the outcome in pregnancy-associated breast Berry, at the M. A large meta-analysis recently showed no tions were few, but did include preterm delivery link between previous abortion and subsequent in- (three cases), transient newborn tachypnea (two creased risk of breast cancer. The long- malities, is not recommended during pregnancy, 244 Case 55 and is usually stopped if a breast cancer patient Suggested Readings subsequently becomes pregnant. Oophorectomy has not been shown to improve the prognosis in Beral V, Bull D, Doll R, et al. Similarly, future rative reanalysis of data from 53 epidemiological studies, in- pregnancies do not appear to increase the likelihood cluding 83,000 women with breast cancer from 16 countries. J Clin On- gest that breast cancer survivors who subsequently col 1999;17:855–861. Management of general sur- become pregnant have a better 5-year survival than gical problems in the pregnant patient. A review of A 45-year-old asymptomatic woman with no signifi- her current mammogram, with magnification views, cant past medical history undergoes annual screen- demonstrates indeterminate microcalcifications in ing mammography and presents to your office with the upper outer quadrant of the right breast. Within these cat- egories, the percentages of cases with a surgical pathologic diagnosis of malignant involvement were as follows: benign calcification (0% malignant); in- determinate calcification (22%); malignant calcifica- tion (92%); smooth mass (1%); irregular mass (40%); architectural distortion (47%); asymmetric breast tissue (3%); smooth mass with calcification (0%); irregular mass with calcification (66%); architectural distortion with calcification (57%); and asymmetric breast tissue with calcification (29%).