Diagnostic Criteria for Breast Cancer-Related Lymphedema of the Upper Extremity: The Need for Universal Agreement

With advances in breast cancer treatments and resultant increased survival rates, emphasis has been placed on post-treatment complications such as breast cancer-related lymphedema (BCRL), a chronic, negative sequela of breast cancer treatment. Accurate BCRL diagnosis necessitates longitudinal screening beginning at preoperative baseline. Prospective screening programs incorporating symptoms, objective measurements and clinical examination allow for early detection, early intervention, and improved BCRL prognosis. Currently, varied diagnostic criteria for BCRL exist, and this lack of consensus leads to variation in diagnostic and screening practices across institutions. This review outlines current diagnostic tools, including subjective and objective measurement methods and clinical examination. The merits of different criteria are evaluated and recommendations are made regarding measurement tools and diagnostic criteria for BCRL. Ultimately, the BCRL diagnostic process should be universalized and combine objective measurements, clinical evaluation, and symptoms assessment, and adhere to the best practices of the measurement tools used.

Acute haemorrhagic tamponade in cancer patients receiving direct oral anticoagulant: case series

The use of direct oral anticoagulants (DOACs) is on the rise in the general population. However, data related to the safety of DOACs in patients with malignancy are limited. In this brief report, we present a series of three cases of haemorrhagic pericardial effusions and tamponade in patients receiving DOACs while undergoing cancer therapy. These three cases were all observed within a period of 6 weeks at a single institution and occurred shortly after the initiation of anticoagulation with one of the DOACs. Two of these patients had evidence of neoplastic pericardial process and were being treated with immunotherapy. The third patient was receiving targeted cancer therapy with a drug known to be associated with increased bleeding risks. Haemorrhagic pericarditis may represent a unique type of DOACs-related complications in subgroups of cancer patients with neoplastic pericardial disease and/or complex pharmacodynamics drug–drug interaction. The purpose of this report is to raise awareness of the lack of conclusive safety data of DOACs in certain cancer patients and to remind clinical providers of the National Comprehensive Cancer Network guidelines recommending against their use in patients with malignancy on the basis of limited safety data in patients undergoing cancer therapies.

Endoscopic palliation of malignant gastric outlet obstruction using self-expandable metallic stents: results of a multicenter study

BACKGROUND AND STUDY AIMS

Gastric outlet obstruction is a late event in the natural history of biliopancreatic tumours. Metallic self-expanding stents inserted under endoscopic and fluoroscopic guidance can be used for palliation. The aim of this study was to evaluate the feasibility, efficacy, and complications of endoscopic duodenal stenting in patients with malignant gastric outlet obstruction.

PATIENTS AND METHODS

Between August 1998 and November 2001, 63 patients (31 women, 32 men; mean age 73 +/- 12) presenting with clinical symptoms of duodenal obstruction underwent endoscopic stenting with large metallic prostheses. Complications and clinical outcome were assessed both retrospectively and prospectively.

RESULTS

Of the patients, 58 needed one duodenal stent and two overlapping stents were required in five patients. Stenting was immediately successful in 60/63 patients (95%). At the time of the duodenal procedure, 25 previously inserted biliary stents were still patent; biliary stenting was attempted during the same procedure in 18 patients; and 20 patients had no biliary stricture. There was no procedure-related mortality. There were complications in 30 % of patients: 13 stent obstructions, 4 stent migrations and 2 duodenal perforations (treated surgically). For 44 patients (70%) there were no minor or major digestive problem during their remaining lifetime. An exclusively peroral diet was possible in 58 patients (92%), but was considered satisfactory (solid or soft) in 46/63 patients (73%). Of the patients, 53 (84 %) died between 1 and 64 weeks after the duodenal stenting (median survival 7 weeks).

CONCLUSIONS

Endoscopic stenting for the palliation of malignant gastric outlet obstruction is feasible and well-tolerated in most patients. Most dysfunctions can be managed endoscopically.

Post-traumatic distal nerve entrapment syndrome

Eleven patients with paralysis of muscle groups in the upper or lower extremity were clinically diagnosed after previous proximal direct trauma to the corresponding peripheral nerves, without complete nerve disruption. Patients were seen within an average of 8 months after trauma (minimum 3 months and maximum 2 years after). Nerve lesions were caused either by gunshot, motor-vehicle accident, and other direct trauma or, in one case, after tumor excision. All patients presented with complete sensory and motor loss distal to the trauma site, but demonstrated a positive Tinel sign and pain on testing over the "classic" (distal) anatomic nerve entrapment sites only. After surgical release through decompression of the nerve compression site distal to the trauma, a recovery of sensory function was achieved after surgery in all cases. Good-to-excellent restoration of motor function (M4/M5) was achieved in 63 percent of all cases. Twenty-five percent had no or only poor improvement in motor function, despite a good sensory recovery. Those patients in whom nerve compression sites were surgically released before 6 months after trauma had an improvement in almost all neural functions, compared to those patients who underwent surgery later than 9 months post trauma. A possible explanation of traumatically caused neurogenic paralysis with subsequent distal nerve compressions is provided, using the "double crush syndrome" hypothesis.

[Tissue expanders in plastic surgery of the head and neck. Indications and use]

Tissue expansion allows a functional as well as an aesthetic reconstruction of local defects and thus corresponds to the actual state of the art in plastic surgery.-Tissue expansion provides tissue of the same quality for the repair of defects without leaving deformities on the donor site. It creates local flaps with skin of the same texture, colour and preserved sensitivity.-The use of tissue expanders has grown enormously during the last few years.-A higher rate of complications on the cheek and on the neck must be taken into account.