Esophagus, Barrett's, Cancer.. Oh My!

(From: http://www.oncolink.org/types/article.cfm?c=133&id=9465)

What is the esophagus?

The esophagus is a muscular tube which connects the mouth to the stomach. The wall of the esophagus is composed of a series of muscles that are responsible for peristalsis, or the muscular motion that moves food down the throat into the stomach. The esophagus is lined with two layers of tissue known as the mucosa and submucosa, which are where most cancers of the esophagus develop. The esophagus is a long tube, with an average length of 25 cm. The throat (or pharynx) is continuous with the esophagus, and although the two are indistinguishable, the esophagus is thought to start a few centimeters below the thyroid cartilage (Adam's apple). The esophagus travels down through the chest, between the lungs. It then passes through a hole in the diaphragm to connect with the stomach. There is a ring of muscle, also known as the lower esophageal sphincter, between the stomach and esophagus, which prevents food and stomach acid from going back up into the esophagus.

What is esophageal cancer?

The definition of a tumor is a mass of quickly and abnormally growing cells. Tumors can be either benign or malignant. Benign tumors have uncontrolled cell growth, but without any invasion into normal tissues and without any spread. A malignant tumor is called cancer when these tumor cells have the ability to invade tissues and spread locally and/or to distant parts of the body. Esophageal cancer occurs when cells in the lining of the esophagus grow uncontrollably and form tumors that can invade normal tissues and spread to other parts of the body.

Cancers are described by the types of cells from which they arise. The vast majority of esophageal cancers develop from the inner lining (mucosa) of the esophagus and not from the muscle or cartilage cells that make up the rest of the esophagus. The lining of the esophagus is somewhat unique as it changes as it goes from the throat to the stomach. In the upper (proximal) esophagus, the lining of the esophagus resembles the lining of the throat, made up of squamous cells. Hence, when cancers develop in this region, they are usually squamous cell carcinomas. In the lower (distal) esophagus, the more common type of cancer is called adenocarcinoma, which is what the cancer is called when it develops from an area of the lining that contains glands.

In addition to invasive cancers, patients are sometimes diagnosed with precancerous lesions, called carcinoma-in-situ. These precancerous lesions can be seen prior to the development of either squamous cell carcinoma or adenocarcinoma. Carcinoma-in-situ occurs when the lining of the esophagus undergoes changes similar to cancerous changes without any invasion into the deeper tissues. Hence, while the cells themselves have cancer-like qualities, there has been no spread or invasion by the cancer cells. Another type of lesion that is considered to be a precursor to cancer itself is called Barrett's esophagus, which is explained in depth below.

Am I at risk for esophageal cancer?

Esophageal cancer occurs in approximately 13,500 Americans per year, causing about 12,500 deaths. Most patients are diagnosed in their 50s or 60s, with approximately four times as many men diagnosed than women. This being said, there are two different groups of patients who develop esophageal cancer. In the past, the vast majority (85%) of the esophageal cancers diagnosed were squamous cell cancers that occurred in the upper esophagus. Risk factors for this type of cancer include smoking and alcohol use. Although both are thought to be independent risk factors (with smoking being the stronger), there seems to be a synergistic effect, when both are combined, for the development of esophageal cancer. In other words, people that both smoke and drink heavily are at an exceptionally high risk to develop esophageal cancer when compared to non-smokers and non-drinkers. Other potential carcinogens for the development of squamous cell carcinoma of the esophagus are nitrosamines, asbestos fibers, and petroleum products.

However, in recent years the number of adenocarcinomas have been on the rise, and these are now the most common type of esophageal cancer seen. In contrast with squamous cell carcinomas of the esophagus, adenocarcinomas of the esophagus tend to involve the lower part of the esophagus. Adenocarcinoma is thought to almost always arise in the setting of Barrett's esophagus, which is a condition in which the normal lining of the esophagus is replaced by lining normally found in the stomach. Barrett's esophagus is diagnosed by endoscopy, which is a procedure that uses a fiberoptic camera to look down into the esophagus. A gastroenterologist usually performs this test and if any suspicious lesions are seen, they can be biopsied during the endoscopy. Adenocarcinoma of the esophagus is thought to develop from Barrett's esophagus due to further carcinogenic changes in the abnormal lining.

Barrett's esophagus is thought to be caused by chronic irritation due to stomach acid. This happens due to a defect in the lower esophageal sphincter, which separates the stomach from the esophagus. This sphincter is located at approximately the level of the diaphragm. When it is dysfunctional, acid can reflux, or pass from the stomach into the esophagus. This condition is commonly known as gastroesophageal reflux disease or GERD. This can result in heartburn, bloating, loss of appetite, and stomach pain. Additionally, some people complain of chronic cough from the reflux due to irritation of the voice box from the acid reflux. Patients with chronic GERD are at risk for developing Barrett's esophagus and hence are at higher risk for developing adenocarcinoma of the esophagus. It is not clear if GERD outside the setting of Barrett's esophagus increases the risk of esophageal cancer, though it appears a long or severe history of reflux may increase the risk of esophageal cancer. There are several conditions which can cause or worsen GERD, including a condition known as a hiatal hernia, where portions of the stomach herniate or improperly move through the diaphragm into the chest, causing sphincter dysfunction and resulting reflux. Additionally, obesity, smoking, and certain foods such as coffee and chocolate may potentially worsen reflux.

How can I prevent esophageal cancer?

There is not a clear link between a family medical history of esophageal cancer and an individual's risk of developing esophageal cancer. Smoking is by far the strongest risk factor associated with the development of squamous cell cancer of the esophagus, with alcohol likely playing a supporting role. Therefore, smoking cessation and decreasing alcohol intake are by far the best methods of decreasing the risk of developing squamous cell carcinoma of the esophagus. There are several dietary factors which have been linked with squamous cell carcinoma of the esophagus, predominantly foods containing N-nitroso compounds, as seen in pickled, dried or smoked foods. Pre-existing esophageal conditions may also increase the risk of developing squamous cell carcinoma of the esophagus. Conditions like achalasia, which is a condition where there is ineffective peristalsis in the esophagus, as well as caustic esophageal injury, say from lye ingestion, can increase the risk of esophageal cancer. Some experts believe a history of bulimia, which chronically exposes the esophagus to stomach contents, may also be a risk factor.

Adenocarcinomas of the esophagus tend to be more common in Caucasian males. As it is thought that the majority of adenocarcinomas develop from Barrett's esophagus, the best prevention of adenocarcinoma would be decreasing the risk of chronic GERD, the cause of Barrett's esophagus in the first place. Smoking, particularly in the setting of Barrett's esophagus, may increase the risk of developing adenocarcinomas of the esophagus. As previously mentioned, obesity may also increase the risk of developing adenocarcinoma of the esophagus. Additionally, decreasing caffeine intake may decrease the risk of adenocarcinoma of the esophagus. Decreasing alcohol intake may also reduce the risk of esophageal adenocarcinoma, but this is controversial. Certain genetic conditions which cause increased acid secretion, such as Zollinger-Ellison syndrome, may increase the risk of adenocarcinomas of the esophagus. Although pharmaceutical agents for the prevention of acid secretion (histamine blockers, proton pump inhibitors) can be effective for the prevention of GERD symptoms, there is no proof that they decrease the incidence of Barrett's esophagus. In fact, many think that it increases the risk, as it decreases the pressure of the sphincter between the esophagus and the stomach, making it easier for acid to reach the esophagus. More research into this is required before the answer is known. Once Barrett's esophagus has developed, there is also little evidence that medical treatments (histamine blockers and proton pump inhibitors) prevent the development of cancer. Some believe that proton pump inhibitors may cause Barrett's esophagus to regress and hence not develop into cancer. Again, this is mainly unproven. Surgical manipulation of the aforementioned esophageal sphincter, making it more difficult for acid to reach the esophagus, may lead to regression, though again, this is unproven. The most important recommendation for someone with Barrett's esophagus is persistent surveillance, which will be discussed below under screening.

What screening tests are available?

There are no mass screening recommendations for the general public per se, and there is no specific screening test that exists for squamous cell carcinoma of the esophagus. This makes it even more important to reduce the risk factors for squamous cell cancer-mainly smoking and heavy alcohol use. However, screening and surveillance is very important in patients with Barrett's esophagus (BE), to insure that it does not progress to adenocarcinoma.

The "gold standard" for diagnosis of BE is endoscopy and biopsy. Cost and the invasiveness of the procedure have fueled efforts to find an alternative diagnostic method. A new screening test for Barrett's called Cytosponge has been tested in the UK. Cytosponge is a gelatin capsule attached to a string that when swallowed releases a mesh that collects esophageal cells. The cells collected using the Cytosponge were stained for trefoil factor 3, a biomarker for intestinal metaplasia (microscopic changes in the tissue) associated with BE. This has been shown to be an effective screening tool and research continues.

It has been estimated that there is approximately a 0.2%-2% risk annually of someone with Barrett's esophagus developing esophageal cancer, or a 10% lifetime risk. As above, various medical or surgical procedures can be done to attempt to reverse Barrett's esophagus, but the effect of these is unsubstantiated. Therefore, the best way to insure that Barrett's esophagus causes no problems is repeat evaluations through biopsy via endoscopy. The primary goal of endoscopy is to detect dysplasia early. Although Barrett's esophagus, by definition, is when the lining of the esophagus is abnormal, there can be varied levels of "abnormal". This is graded in terms of dysplasia, which is a term that refers to how likely the Barrett's esophagus is to progress to cancer. In patients without dysplasia, but just simple replacement of normal esophageal lining with stomach lining, endoscopy is recommended every two to three years. In patients with mild or low grade dysplasia, at least two endoscopies should be done six months apart, then yearly if those are OK. Patients with Barrett's esophagus with high grade dysplasia should be followed by endoscopy every 3 months or actually undergo treatment, as these are considered premalignant changes that have a high likelihood of progressing to cancer. Areas of dysplasia can be treated during endoscopy. Ablative techniques exist, such as with a laser. Photodynamic therapy can be used to treat high-grade lesions using a compound to sensitize tumors to a specific wavelength of light, followed by light exposure to the tumor. Endoscopic resection of an involved portion of mucosa can also be used.

What are signs of esophageal cancer?

Over 90% of people with esophageal cancer present with problems swallowing, often leading to a significant amount of weight loss prior to the actual diagnosis. Equal often complain of a sensation that food "gets stuck" somewhere in the chest, where the growing of the cancer precludes the passage of food. Problems usually start with food, though eventually even liquids could "get stuck" if the cancer progresses and continues to grow into the hollow tube that the esophagus is. This is similar to a bathroom drain being clogged-if something is in the pipe preventing water from draining, it backs up and is not allowed to pass. People with esophageal cancer often have pain with swallowing as well. Though these are the most common symptoms, others could exist, especially if the tumor grows through the esophageal wall or into other organs. Chest pain can occur in patients who have esophageal spasm, again from irritation from the tumor. A larger tumor can erode the wall to the point where it causes bleeding. This can cause patients to cough up blood, or vomits blood. Additionally, if the blood is swallowed, one may notice blood in the stool or black tarry stools also known as melena. The trachea (windpipe) is located directly in front of the esophagus, and it is possible for an esophageal cancer to erode the entire way through the esophageal wall and into the trachea, creating what is called a tracheoesophageal (respiratory) fistula. This causes cough, an irritating sensation with breathing (especially with deep breaths), and hoarseness.

How is esophageal cancer diagnosed and staged?

Diagnosis

Work up of an esophageal cancer usually starts after the patient presents with symptoms. In the case of esophageal cancer, this usually means problems with swallowing. The first step is to establish the diagnosis of esophageal cancer. Initial tests sometimes include a barium swallow, where the person swallows barium to permit visualization of the contours of the esophagus on x-rays. Generally, the esophagus is smooth, and if there is a defect in the smooth contour of the esophagus, this may suggest a cancer. An endoscopy is commonly done when people first present with symptoms. Using endoscopy, the area of concern in the esophagus can be viewed directly with the fiber-optic camera, and the location of the abnormality, the presence or absence of bleeding, and the amount of obstruction can all be seen. Endoscopy also allows a biopsy to be performed. Once a biopsy is performed, the pathologist can determine if there is esophageal cancer, and whether it is adenocarcinoma or squamous cell carcinoma.

Once the diagnosis has been established, it is important to determine how much cancer is present in the esophagus, as well as whether it has spread to any other parts of the body (metastasis). This is known as cancer staging and plays an important role in selecting the optimal treatment for the cancer. If your doctor suspects that the tumor may have grown into the trachea, a bronchoscopy may be ordered, which allows the airways to be visualized. The standard of care today would also include performing an ultrasound during the endoscopy, called an endoscopic ultrasound examination (EUS). This allows for the prediction of how much of the esophageal wall is involved by tumor with over 90% accuracy and the presence of any lymph nodes that are involved with spread of tumor with over 75% accuracy. A CT ("CAT") scan is also usually done to determine the amount of disease in the chest, though it is seemingly less accurate than the EUS. The CT scan should include imaging through the upper abdomen so that the liver and lymph nodes in the area of the stomach can be visualized. Other, more routine tests done before treatment include blood screening tests, to insure that overall blood counts are within normal limits, and that a patient's liver, kidneys, and overall health are normal. Other tests may also be included, as symptoms require. Granted, that is a lot of tests, though all are important to offer the best individual treatment for every person.

Staging

After all of these tests are performed, the stage of the cancer is known. The staging of a cancer describes how much cancer has grown within the esophagus as well as whether it has spread This is often extremely important in terms of what treatment is offered to each individual patient. Before the staging systems are introduced, first some background on how cancers grow and spread, and therefore advance in stage.

Cancers cause problems because they spread and can disrupt the functioning of normal organs. One way esophageal cancer can spread is by local extension to invade through the normal structures in the chest and into adjacent structures. These include the trachea, the diaphragm, and even into the large veins and arteries emanating from the heart. All cancers can spread via local extension, and it is very common for esophageal cancer to spread quite extensively locally before diagnosis is obtained. This is what causes the many symptoms of esophageal cancer, including difficulties with swallowing, cough, bleeding, and subsequent fatigue and weight loss due to malnutrition.

Esophageal cancer can also spread by accessing the lymphatic system. The lymphatic circulation is a complete circulation system in the body (somewhat like the blood circulatory system) that drains into various lymph nodes. When cancer cells access this lymphatic circulation, they can travel to lymph nodes and start new sites of cancer. This is called lymphatic spread. Within the wall of the esophagus, there is an extensive network of lymphatic channels, hence a large proportion of patients present with lymph nodes already involved with cancer.

The first lymph nodes that cancer cells spread to are the lymph nodes found just along the side of the esophagus (peri-esophageal lymph nodes. Cancer can then spread into the middle of the chest (mediastinal lymph nodes) and into the areas of the neck above the collar bone (supraclavicular lymph nodes) or into the abdomen (peri-gastric and celiac lymph nodes), depending where the primary esophageal cancer is located.

Esophageal cancers can also spread through the bloodstream. Cancer cells gain access to distant organs via the bloodstream and the tumors that arise from cells' travel to other organs are called metastases. Cancers of the esophagus generally spread locally or to lymph nodes before spreading distantly through the bloodstream. Hence, the incidence of distant metastases upon diagnosis is fairly low. It was previously thought that esophageal cancer almost never spread distantly. However, as more and more patients are cured of their local disease with advancements in therapy, this is unfortunately now known not to be the case.

The staging system used in esophageal cancer is designed to describe the extent of disease within the esophagus, in the surrounding lymph nodes, and distantly. The staging system used to describe esophageal tumors is the "TNM system", as described by the American Joint Committee on Cancer. The TNM systems are used to describe many types of cancers. They have three components: T-describing the extent of the "primary" tumor (the tumor in the esophagus itself); N-describing the spread to the lymph nodes; M-describing the spread to other organs (i.e.-metastases). The staging system for esophageal cancer is complex. The most recent 7th edition (2010), TNM staging system provides a separate staging for squamous cell carcinoma and adenocarcinoma of the esophagus.

The "T" stage is as follows:

Tis-carcinoma in situ

T1-tumor confined to the inner layer of the esophageal wall (submucosa , T1a or lamina propria, T1b)T2-tumor invades into the muscular layer of the wallT3-tumor invades into the outer layer of the wall (adventitia)T4-tumor invades into other structures or organsT4a - resectable tumor invading pleura, pericardium, or diaphragmT4b - unresectable tumor invading other adjacent structures, such as aorta, vertebral body, trachea, etc.

The "N" stage is as follows for any subsite:

N0-no spread to lymph nodesN1-tumor spread to 1-2 regional lymph nodesN2- tumor spread to 3-6 regional nodesN3- tumor spread to seven or more regional nodes

The "M" stage is as follows:

M0-no tumor spread to other organsM1-tumor spread to other organs

The overall stage is based on a combination of these T, N, and Mparameters:

Overall stage:

 

Squamous Cell

Adenocarcinoma

IA - Any location: T1 N0 and Grade 1 (or Grade unknown)IB - Any location: T1 N0 and Grade 2-3

 

IB - Lower tumor: T2-3 N0 and Grade 1

IIA - Upper or middle tumor: T2-3 N0 and Grade 1 (or grade unknown)

 

IIA - Lower tumor/X: T2-3 N0 and Grade 2-3

IIB - Upper or middle tumor: T2-3 N0 and Grade 2-3

 

IIB - Any location: T1-2 N1

IA - T1 N0 and Grade 1-2 (or Grade unknown)IB - T1 N0 and Grade 3, T2 N0 and Grade 1-2 (or grade unknown)IIA - T2 N0 and Grade 3IIB - T3 N0, T1-2 N1

 

The following stages are the same for squamous cell & adenocarcinoma:

IIIA - T1-2 N2, T3 N1, T4a N0IIIB - T3 N2IIIC - T4a N1-2, T4b, N3IV - the presence of any metastases (M1)

What are the treatments for esophageal cancer?

The treatment chosen for a person with esophageal cancer is greatly dependent on two main factors: the extent of the cancer and the general health state of the person. In people who have very early stage disease where it has not spread to lymph nodes or deep into the esophagus, surgery alone may be appropriate. Certain very early tumors, limited to the submucosa (the superficial layer of the esophagus), may be treated with endoscopic resection. However there are no head to head trials comparing surgical resection with endoscopic resection. More commonly, people present with advanced stage disease because symptoms often develop only after the tumor has grown to a large size or has spread. Therefore, there is often a large amount of tumor present before cancer treatment can even begin. There are a number of different modalities that can be used to treat esophageal cancer including surgery, radiation, and chemotherapy. However, in people who can tolerate it, combined modality treatment with surgery, radiation and chemotherapy is preferred.

Surgery (removing the esophagus-an esophagectomy-and exploration of the regional lymph nodes) is a very aggressive procedure that is often not attempted on patients who are not in fairly good health. There are several different surgical procedures remove the esophagus however, generally the esophagus is removed either with the incision through the ribs and abdomen or the neck and abdomen. When the esophagus is removed, the stomach is pulled up into the chest to keep the passageway for food intact. Not only is there a risk of infection and bleeding from the surgery itself, but the recovery period after surgery can be difficult. Additionally, there is the risk of a leak forming at the new connection that is formed between the stomach and the remaining portion of the esophagus (known as an anastamosis), which can then require further surgery and potentially lead to fatal complications. In advanced esophageal cancer, there is still a high failure rate with surgery alone. These failures occur both locally (in the region of the primary tumor or regional lymph nodes) or distantly (from metastatic spread of cancer through the bloodstream). Many studies have looked into adding chemotherapy and radiation therapy to esophagectomy to attempt to add to the cure rate. Though the results of these studies are somewhat mixed, it is thought that both radiation and chemotherapy add a benefit. Therefore, radiation therapy (for local tumor control) and chemotherapy (for distant control as well as to potentiate the effectiveness of radiation therapy) is almost always recommended either before or after the surgery.

Radiation therapy makes the use of high energy x-rays to kill cancer cells. It does this by damaging the DNA in tumor cells. Normal cells in our body can repair radiation damage much quicker than tumor cells, so while tumor cells are killed by radiation, many normal cells are not. This is the basis for the use of radiation therapy in cancer treatment. Radiation is delivered using large machines that produce the high energy x-rays. After radiation oncologists set up the radiation fields ("radiation fields" are the areas of the body that will be treated by radiation), treatment is begun. Radiation is given 5 days a week for approximately 5-7 weeks at a radiation treatment center. The treatment takes just a few minutes each day and is completely painless. It is designed to kill tumor cells in the area that is at risk to contain cancer cells, whether it is in the esophagus or the regional lymph nodes. Typical side effects mainly include a sore throat, skin irritation (resembling a sunburn), and fatigue.

Chemotherapy is defined as drugs that are used to kill tumor cells. The large advantage in using chemotherapy is that, since it is a medicine, is travels throughout the entire body. Hence, if some tumor cells have spread outside of what surgery or radiation can treat, they can potentially be killed by chemotherapy. The additional important benefit from chemotherapy in the treatment of esophageal cancer is that it works with radiation, resulting in more killing of cancer cells. Similar to radiation, some normal cells are damaged during treatment, resulting in side effects. The exact side effects depend on which type of chemotherapy is used, though fatigue, some nausea, skin chapping, and a decrease in blood counts can result from any chemotherapy.

There is some debate as to the optimal order in which to deliver these treatments to the esophagus. Different institutions may vary the order in which they use these three modalities in the attempt to cure esophageal cancer. Many will use radiation therapy combined with chemotherapy pre-operatively. Combination platinum based chemotherapy is used; combinations include 5-FU and cisplatin (or oxaliplatin), carboplatinum and paclitaxel, and cisplatin and etoposide. The advantage of using chemo and radiation together is that it often results in the decrease in the amount of tumor that needs to be removed and is able to be given in a patient who has not already had to undergo an extensive procedure. This allows for easier tolerance of the radiation and chemotherapy and also decreases the size of the radiation field required which reduces this toxicity from surgery. However, the toxicity from combining radiation with chemotherapy is worse than either alone. It is very important for the people to maintain their nutrition such that they can heal well in anticipation of surgery, which usually takes place around 4-8 weeks after chemoradiation. Surgery after chemotherapy and radiation appears to improve the local control further. However, some centers recommend post-operative treatment. The main advantage of this method is that surgery can be performed in an unirradiated field, allowing for a better surgical technique. Since the surgical removal of the entire tumor is the crucial step in therapy, this consideration often trumps any other.

In some cases, the person is too sick to undergo surgery, or may choose not to undergo surgery. In these cases, a combined, concurrent use of chemotherapy with radiation therapy is usually employed. This method has been proven better than radiation alone, and some think it can reach cure rates comparable to surgery, however this is still being studied. The combined use of radiation therapy and chemotherapy has toxicities as well-mainly irritation of the esophagus making it extremely painful and hence difficult to swallow towards the end of treatment. Some people are too sick to tolerate combined treatment and are treated with radiation or chemotherapy alone.

Alternatively, people can be treated with techniques to open the esophagus in the event that they are too sick to undergo radiation or chemotherapy. Advanced esophageal cancer that is incurable often leaves the patient with difficulty swallowing or unable to swallow at all. Chest pain and bleeding are other common symptoms that can require palliation. Radiation therapy is often used to achieve palliation, with varying success-especially with obstruction, though studies have reported palliation of the obstruction of swallowing in approximately 80% of patients. Actual mechanical stents can also be placed in this scenario or laser removal of tumor can be attempted. These can achieve symptom relief quicker, though they are invasive procedures with their own inherent risks and are also only temporary measures. Hence, these are usually followed by radiation therapy.

As different treatments may be effective in treating a patient's cancer, the more well-informed the better. Regardless of the treatment chosen, it is very important to work with the physicians involved as well as specialists (nutritionists, speech pathologists, etc.) to maximize chance of cure and function after treatment. Obviously the best treatment for cancer is prevention of ever developing cancer. By far, the best prevention is not smoking or immediate smoking and alcohol cessation.

Lymphoedema

From dermnetnz

What is lymphoedema?

Lymphoedema (American spelling ‘lymphedema’) is a swelling of part or parts of the body that occurs when the lymphatic system is not working properly. To understand how lymphoedema occurs we need to know a bit about what the lymphatic system is and how it works.

What is the lymphatic system?

The lymphatic system forms part of the immune system and part of the vascular system. It is made up of many tiny vessels that run throughout the body and gradually join together to form bigger vessels. Running through these vessels is a clear fluid called lymph. Lymph contains the excess protein, water, bacteria and waste products that the body doesn’t require and travels along the lymphatic system until it reaches the lymph nodes (glands). The lymph nodes, which are situated in the neck, armpits, groins and deep inside the chest and abdomen, filter and cleanse the lymph to remove any foreign matter (e.g. bacteria) and start any necessary immune reactions. Once passed through the lymph nodes, lymph finally drains into large veins located in the lower neck. Movement of adjacent muscles helps to keep the lymph moving along the lymphatic system. In addition the walls of the lymphatic vessels contract and valves inside the vessels keep things pumping.

Why does lymphoedema occur?

Oedema (swelling) occurs when excess fluid and protein from damaged blood vessels (e.g. after a burn or ankle sprain) enters into the lymphatic system at a rate too fast for the lymph to be carried away. This produces a temporary swelling which gradually resolves on its own as the damaged tissue heals, blood vessels no longer leak excessively and the lymphatic system can keep pace with the normal flow of lymph.

Lymphoedema is the name given to the swelling that occurs because of a damaged or blocked lymphatic system. Protein, water and waste products are released into tissue in the normal way but a damaged lymphatic system prevents the drainage away and swelling of the affected area results. In addition, the limb may become inflamed. There is an increased risk of infection.

There are basically two types of lymphoedema based on the underlying causes. Primary lymphoedema is also known as Milroy disease.

Primary lymphoedemaSecondary lymphoedemaDamaged lymphatic system is usually present at birth (usually as a result of underdevelopment)Affects both sexes, although 70-80% of cases are femaleAge of onset varies – swelling is present at birth in 10% of cases, 80% develop swelling before 35 years and 10% after 35 yearsCommonest sites for swelling are the legs, arms, genitals and faceImpaired functioning of the lymphatic system is caused by some other condition or factorChronic venous disease – due to incompetent superficial and/or deep veins in the lower legs resulting in venous hypertension (increased pressure) and secondary damage to the lymphatic systemSurgery – removal of lymph nodes when treating some cancers, e.g. breast, prostateRadiotherapy – used to treat cancer but can cause scar tissue that interrupts lymphatic flowAccidental trauma, injury or infection that directly damages lymph vesselsReduced mobility – movement keeps the muscle contracting which helps the flow of lymph

What are the clinical features of lymphoedema?

Initially the symptoms and signs of lymphoedema may be very slight and almost unnoticeable. If left untreated, the swelling may get bigger and eventually become permanent. Some or all of the following symptoms may be experienced.

Feeling of tightness and heaviness in a limbAltered sensation, such as pins and needles, shooting pains or feeling of heatJoint discomfort due to the swelling, e.g. elbow, kneeTenderness in the groin of an affected legChanges in temperature of the limb or affected skinReduced range of movement

At first the swollen area will pit if pressed with a thumb. However, as it becomes bigger and harder it will no longer pit. If lymphoedema is left untreated and the swelling gets worse, skin changes may occur. The skin may get very thick with folds, bulges and dry warty spots (elephantiasis nostras verruciformis, or lymphatic papillomatosis) and make it prone to infection (cellulitis). This is particularly the case if lymph leaks through to the skin.

Lymphoedema of the legs is often worse than that of the arms as lymphatic drainage from the legs is more difficult. Walking becomes difficult as the patient carries the excess weight.

Elephantiasis nostras verruciformis

CellulitisComplications of lymphoedema

How is the diagnosis made?

Diagnosis of lymphoedema is made from a patient's history and observation. The possibility of cancer should be investigated if a cause cannot be found for swelling. In some difficult cases a radiographic test called lymphoscintigraphy may be performed. This measures lymphatic function and gives a fair image of the lymphatic system.

Lymphoedema should be distinguished fromlipoedema, in which swelling of both thighs and lower legs is due to the accumulation of fat under the skin.

What is the treatment for lymphoedema?

Lymphoedema is an ongoing condition that has no known cure. The main goal of treatment is to reduce the swelling and keep it to a minimum. It is very important to treat lymphoedema in its early stages to prevent further swelling and complications such as infection. If a cause is found then the cause needs to be treated, e.g. cancer.

For patients with mild to moderate swelling of their limbs a treatment regimen called Complex Physical (Lymphatic/Lymphoedema) Therapy (C.P.T./C.L.T.) is recommended. This regimen consists of 4 main parts.

Skin care – this involves keeping the skin clean to reduce infection, the use of emollients to restore and maintain skin suppleness, and keratolytics to remove hard, dead skin.Simple lymphatic drainage – this is a gentle massage technique that uses simple hand movements to try to move the swelling out of the affected area. The patient, relative or caregiver is taught the technique.Compression bandaging, sleeve or stocking to help prevent swelling from building up in the limb again.Exercise and movement – specially designed programme to supplement the massage and help by maximising lymph drainage without over exertion

For people with more severe swelling, additional treatments are usually recommended. These include:

Manual Lymphatic Drainage – specialised form of massage carried out by a trained therapist to move the skin in specific directions based on the underlying anatomy and physiology of the lymphatic system.Multi-Layer Lymphoedema Bandaging – multi-layer system of compression bandagesDrug therapy – research is ongoing as to the effectiveness of drug therapy in lymphoedema. Benzopyrenes including flavonoids have been used. Coumarin use has been discontinued due to hepatic toxicity.Surgery – rarely performed but may be of benefit for eyelid or genital swelling. Only surgeons who have experience with lymphoedema and the lymphatic system should perform surgery.

Related information

References:

Book: Textbook of Dermatology. Ed Rook A, Wilkinson DS, Ebling FJB, Champion RH, Burton JL. Fourth edition. Blackwell Scientific Publications.Milroy's disease – GeneTests GeneReviewsKerchner K, Fleischer A, Yosipovitch G. Lower extremity lymphedema update: pathophysiology, diagnosis, and treatment guidelines. J Am Acad Dermatol. 2008 Aug;59(2):324-31. Medline.

Cauda Equina : 3+ yrs (webmd ref)

Cauda Equina and Conus Medullaris Syndromes  

Patients can present with symptoms of isolated cauda equina syndrome, isolated conus medullaris syndrome, or a combination. The symptoms and signs of cauda equina syndrome tend to be mostly lower motor neuron (LMN) in nature, while those of conus medullaris syndrome are a combination of LMN and upper motor neuron (UMN) effects (see Table 1, below). The history of onset, the duration of symptoms, and the presence of other features or symptoms could point to the possible causes.

Table 1. Symptoms and Signs of Conus Medullaris and Cauda Equina Syndromes (Open Table in a new window)

Symptoms of cauda equina syndrome include the following:

Low back pain

Unilateral or bilateral sciatica

Saddle and perineal hypoesthesia or anesthesia

Bowel and bladder disturbances

Lower extremity motor weakness and sensory deficits

Reduced or absent lower extremity reflexes

Low back pain can be divided into local and radicular pain. Local pain is generally a deep, aching pain resulting from soft-tissue and vertebral body irritation. Radicular pain is generally a sharp, stabbing pain resulting from compression of the dorsal nerve roots. Radicular pain projects in dermatomal distributions. Low back pain in cauda equina syndrome may have some characteristic that suggests something different from the far more common lumbar strain. Patients may report severity or a trigger, such as head turning, that seems unusual.

Severe pain is an early finding in 96% of patients with cauda equina syndrome secondary to spinal neoplasm. Later findings include lower extremity weakness due to involvement of the ventral roots. Patients generally develop hypotonia and hyporeflexia. Sensory loss and sphincter dysfunction are also common.

Urinary manifestations of cauda equina syndrome include the following:

Retention

Difficulty initiating micturition

Decreased urethral sensation

Typically, urinary manifestations begin with urinary retention and are later followed by an overflow urinary incontinence.

Bell et al demonstrated that the accuracy of urinary retention, urinary frequency, urinary incontinence, altered urinary sensation, and altered perineal sensation as indications of possible disk prolapse justified urgent MRI assessment.^{[75, 76]}

Bowel disturbances may include the following:

Incontinence

Constipation

Loss of anal tone and sensation

The initial presentation of bladder/bowel dysfunction may be of difficulty starting or stopping a stream of urine. It may be followed by frank incontinence, first of urine then of stool. The urinary incontinence is on the basis of overflow. It is usually with associated saddle (perineal) anesthesia (the examiner can inquire if toilet paper feels different when the patient wipes)

Tissue in urine?? / neropathy

(From Medline plus / http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3286418/?report=classic)

Renal papillary necrosis

Renal papillary necrosis is a disorder of the kidneys in which all or part of the renal papillae die. The renal papillae are the areas where the openings of the collecting ducts enter the kidney, and where the urine flows into the ureters.

Causes

Renal papillary necrosis usually occurs with analgesic nephropathy. However, a number of other conditions can cause it, including:

Diabetic nephropathyKidney infection (pyelonephritis)Kidney transplant rejectionSickle cell anemiaUrinary tract blockage

Sickle cell anemia is a common cause of renal papillary necrosis in children.

Symptoms

Tissue death (necrosis) of the renal papillae may make the kidney unable to concentrate the urine. Symptoms may include:

Back pain or flank painBloody urineCloudy urineDark, rust-colored, or brown urineTissue pieces in the urine

Other symptoms that may ocur with this disease:

ChillsFeverPainful urinationUrinary frequency or urgencyUrinary hesitancyUrinary incontinenceUrinating large amountsUrinating often at night

Exams and Tests

The area over the affected kidney (in the flank) may feel tender during an exam. There may be a history of urinary tract infections. There may be signs ofobstructive uropathy or kidney failure.

A urinalysis may show infection or dead tissue in the urine.

An intravenous pyelogram (IVP) may show a blockage or tissue in the renal pelvis or ureter.

Outlook (Prognosis)

How well a person does depends on what is causing the condition. If the cause can be controlled, the condition may go away on its own. In some cases, persons with this condition develop kidney failure and will need dialysis or a kidney transplant.

Treatment

There is no specific treatment for renal papillary necrosis. Treatment depends on the cause. For example, if analgesic nephropathy is the cause, your doctor will recommend that you stop using the medicine that is causing it. This may allow the kidney to heal over time.

Possible Complications

Acute kidney failureAcute bilateral obstructive uropathyAcute unilateral obstructive uropathyChronic bilateral obstructive uropathyChronic kidney diseaseChronic or recurrent urinary tract infection (UTI)Chronic unilateral obstructive uropathyHyperkalemiaHypovolemiaMetabolic acidosis

When to Contact a Medical Professional

Call for an appointment with your health care provider if:

You have bloody urineYou develop other symptoms of renal papillary necrosis, especially after taking over-the-counter pain medications

Prevention

Controlling diabetes or sickle cell anemia may reduce your risk. To prevent renal papillary necrosis from analgesic nephropathy, be careful when using medications, including over-the-counter pain relievers.

Alternative Names

Necrosis - renal papillae; Renal medullary necrosis

My Neck!!

Symptoms of Pinched Nerve in Neck

Pain, tingling, and numbness are some of the most common symptoms of a pinched nerve in the neck. The following write-up provides information on the symptoms of a compressed nerve and the circumstances under which one or more nerves in the neck region may get compressed.

The term 'nerves' refers to the bundles of fibers that conduct sensory and motor impulses between the brain and other parts of the body. They are categorized into sensory, motor, and autonomic nerves. The nerve roots in the spinal cord could get pinched or compressed if the surrounding bones, tendons, muscles, and cartilage exert pressure on them. Cervical radiculopathy refers to a condition wherein the compression of a nerve root in the cervical spine causes symptoms such as pain or numbness along the course of the nerve. While pain is often felt in the neck, it may also radiate to the adjoining areas such as the shoulders, arms, and upper or lower back.

Symptoms Associated with Pinched Nerves in the Neck

☞ Pain is usually one of the most common symptoms of a compressed nerve in the neck.

☞ Mild numbness, tingling, or burning sensation in the adjoining areas like shoulder, arms, and fingers may be experienced by the affected individuals.

☞ Affected individuals may experience muscle spasms in adjoining areas.

☞ Cervicobrachial syndrome refers to a condition wherein pinched nerves in the neck cause symptoms such as pain, numbness, weakness, and swelling in the neck. The pain usually gets referred to the upper limbs.

☞ The affected individual could experience headaches in the back region of head (the occipital region) or the temples.

☞ The occipital headaches could cause pain in areas behind the eyes.

☞ There may be a delayed reflex response or a feeling of weakness in muscles.

☞ The symptoms could worsen due to sudden jerky movements like coughing, sneezing, etc.

Causative Factors

Arthritis of the Neck: Also known as cervical spondylosis, arthritis of the neck is a joint condition wherein the bones in the cervical spine degenerate over time. This condition could result from wear and tear of the joints due to osteoarthritis, which is a degenerative joint disease that is characterized by the breakdown of cartilage in the joints. This disease could also lead to the formation of osteophytes or bone spurs, that may compress a nerve root in the cervical spine.

Degenerative Disc Disease: Mostly seen in the elderly, the degenerative disc disease is characterized by the degeneration of the intervertebral discs that separate the bones of the spine. The disc has a hard outer coating (annulus), and within the tough exterior lies a jelly-like material (nucleus pulposus). These discs act like shock absorbers. As we age, these discs could either dry up or their outer coverings might weaken due to continuous wear and tear. As these discs dry up, the bones of the spine could come closer to each other. Under such circumstances, the nerves located in this region could become trapped.

Herniated Disc: Often referred to as slipped disc, a herniated disc is a medical condition wherein the gelatinous material within the disc comes out through a tear in the hard outer wall of the intervertebral disc. A herniated disc can compress the surrounding nerves, thereby causing symptoms such as pain, soreness, tingling, numbness, etc.

Whiplash Injury: A whiplash injury refers to a neck injury that occurs when the neck suddenly moves backward and then forward due to a sudden jerk. Such an injury can cause damage to the cervical vertebrae, leading to a pinched nerve in the neck.

Spinal Stenosis: Spinal stenosis is a medical condition that is characterized by the narrowing of the spinal canal or the neural foramina, which are the openings from which the nerves leave the spine. The spinal nerves could get compressed if the foramina become constricted. This condition may be caused due to arthritis, herniated disc, presence of a tumor in the spine, or an injury that puts pressure on the spinal cord.

Treatment Options

☞ If the pain is severe, the use of painkillers, muscle relaxants, and non-steroidal anti-inflammatory drugs might be recommended.

☞ Massage therapy and application of heating pads or ice packs may help to bring down inflammation.

☞ Doctors don't suggest the continuous use of a cervical collar, but it can be used as per doctor's advice to restrict the movement of the neck in some cases.

☞ Impingement of nerves in the cervical spine may occur due to neck arthritis or bone spurs in cervical spine. These conditions may restrict the range of motion of the neck. Physical therapy can certainly prove beneficial in such cases. Performing exercises can help to strengthen the neck muscles and restore the range of motion.

☞ Alternative therapies such as acupressure, acupuncture, and aromatherapy may also help to provide relief.

☞ The administration of steroids and anesthetic agents into the epidural space of the spinal cord is recommended when a nerve in the cervical spine is compressed by a herniated disc.

☞ Surgery is resorted to only if the other treatment options have not been able to provide relief from pain.

The symptoms of a pinched nerve in the neck can be alleviated by following the non-surgical treatment options. Though the symptoms may sometimes resolve on their own, do seek medical help if pain and numbness persists, and home remedies don't provide relief.

Disclaimer: The information provided in this article is solely for educating the reader. It is not intended to be a substitute for the advice of a medical expert.

ABNORMALITIES IN THE OSTEOARTHRITIS SYNOVIUM

(Wikipedia def)

Synovitis is the medical term forinflammation of the synovial membrane. This membrane lines joints which possess cavities, known as synovial joints. The condition is usually painful, particularly when the joint is moved. The joint usually swells due to synovial fluid collection.

Synovitis may occur in association witharthritis as well as lupus, gout, and other conditions. Synovitis is more commonly found in rheumatoid arthritis than in other forms of arthritis, and can thus serve as a distinguishing factor, although it can be present to a lesser degree in osteoarthritis. Long term occurrence of synovitis can result in degeneration of the joint.

(Medscape select portions)

The Role of Synovitis in Osteoarthritis

Claire Y. J. Wenham, BM BS, MRCP, Philip G. Conaghan, MBBS, PhD, FRACP, FRCP

Disclosures

Ther Adv Musculoskel Dis. 2010;2(6):349-359. 

Synovitis is very common in the OA joint and has been associated both with symptoms and with structural progression. Many of the current effective treatments used for OA have an antisynovial effect but further large-scale clinical trials are needed to confirm the role of antisynovial agents in symptom and structure modification.

The gold standard for the diagnosis of synovitis is histology. The normal synovium is composed of 1–4 layers of cells which merge on their deep surface with a zone of loosely arranged fibrocollagenous tissue containing adipocytes, fibroblasts, mast cells and macrophages. The synovial membrane has an abundant blood and nerve supply running throughout the loose fibrocollagenous tissue. Biopsies from the synovium of OA knees (taken at arthroscopy for knee pain or at joint replacement) have demonstrated several key changes in the synovium, which although more pronounced in advanced OA, are present from the earliest stages of the OA process [Loeuille et al. 2005; Smith et al. 1997; Myers et al. 1990]. These synovial abnormalities include: thickening of the lining layer; increased vascularity; inflammatory cell infiltration.

Synovial membrane histology in classical inflammatory arthritides such as rheumatoid arthritis (RA) is characterized by a wide heterogeneity. OA synovium also displays this spectrum of changes, although there is a lesser degree of inflammation than in RA. The OA spectrum ranges from marked hyperplasia of the lining layer, with a dense cellular infiltrate composed largely of lymphocytes and monocytes, through to a synovial membrane which is thickened by fibrotic tissue [Haraoui et al. 1991]. Surface fibrin deposition and fibrosis within the synovium is common in OA, particularly in the later stages [Loeuille et al. 2005]. Direct comparison of the synovium between 12 OA subjects and 18 RA subjects at time of total knee replacement has shown more hyperplasia of the lining cell layer and cellular infiltrate in severe RA (treated with steroids and methotrexate) than in OA. However, in milder RA (subjects treated with nonsteroidal anti-inflammatory drugs [NSAIDs] only) the histological changes are similar to those seen in OA [Haraoui et al. 1991]. The synovitis seen in OA knees tends to be diffuse and is generally not localized to areas of chondral defects, although an association has been reported between chondral defects and associated synovitis in the medial tibiofemoral compartment of the knee [Ayral et al. 2005; Loeuille et al. 2005]. Interestingly, work by Blom and colleagues demonstrated that in an OA mice model, using an MMP3-knockout model, macrophage activation in the synovium is essential for cartilage damage via the production of matrix metalloproteinases (MMPs), suggesting that inflammation within the synovium may be pivotal for cartilage damage [Blom et al. 2007].

Extramammary pain - Costochrondritis

Extramammary pain due to various conditions may present as breast pain. There are many such conditions but most common are costochondritis and other chest wall syndromes.

Thoracic outlet

What is the thoracic outlet?

The thoracic outlet is a space, or passageway, that lies just above your first rib and behind your collarbone (clavicle). There are also some muscles that surround the thoracic outlet. The thoracic outlet runs from the base of your neck to your armpit. You have a thoracic outlet on the left and the right side of your body.

A number of structures pass through your thoracic outlet, including some important blood vessels and nerves. The brachial plexus, a group of nerves passing from your neck to your arm, passes through the thoracic outlet. The subclavian artery and subclavian vein are blood vessels that pass through the thoracic outlet as they connect between your chest and your arm.

What is thoracic outlet syndrome and what causes it?

If you have thoracic outlet syndrome, the nerves and/or blood vessels in the thoracic outlet are squashed (compressed) for some reason. In most cases, it is nerves that are compressed. This compression causes the typical symptoms (see below). In some people, the subclavian artery or subclavian vein may be compressed. Sometimes, a combination of both nerves and blood vessels may be compressed.

Thoracic outlet syndrome usually only affects one side of your body. However, rarely, compression can occur in the thoracic outlet on both sides and so symptoms then occur on both sides. There are a number of different things that can cause compression of the nerves or blood vessels in thoracic outlet syndrome.

Having a cervical rib

About 1 in 10 people who have a cervical rib develop thoracic outlet syndrome. So, most people with a cervical rib do not develop any symptoms. Having a cervical rib can cause narrowing of your thoracic outlet, making compression of the structures that pass through it more likely.

Other congenital causes

Some people are born with an extra band of tissue underneath their skin around the thoracic outlet area, called a fibrous band. This can act a bit like an extra rib and cause compression of the thoracic outlet in some people. Extra (anomalous) muscles around the thoracic outlet that you may be born with can also cause narrowing and compression. Also, some people are born with an enlarged or elongated part of a vertebra in their neck which can cause compression in their thoracic outlet.

A recent accident

It is quite common for people with thoracic outlet syndrome to have a history of some kind of recent trauma to their neck. For example, whiplash following a car accident. Trauma during an accident can cause structures in your neck and chest wall to move slightly and narrow the thoracic outlet. If you break (fracture) your collarbone (clavicle), broken bone fragments or bleeding due to the fracture can also cause narrowing of the thoracic outlet.

A job that involves repetitive movements

Thoracic outlet syndrome can be more common in someone who has a job that involves very repetitive movements or a lot of overhead work. These movements can lead to 'wear and tear' of the nerves of their brachial plexus. Also, people who play a lot of sport, particularly sports that involve lots of arm movement are also more likely to develop thoracic outlet syndrome. For example, swimmers, javelin throwers and shot putters.

Poor posture

People with a poor posture and 'droopy' shoulders may be more likely to develop thoracic outlet syndrome. Sitting in front of a computer for long hours with a poor posture, an incorrect desk position, and an inadequate chair may be a cause. This poor posture can cause narrowing of your thoracic outlet.

Also, thoracic outlet syndrome can be a problem for women who have large breasts. Their breasts pull the muscles of their chest wall forwards and can cause narrowing of their thoracic outlet, leading to the typical symptoms.

Artery and vein problems

Narrowing and blockage of your subclavian artery or vein is another cause of thoracic outlet syndrome. Some people can have a congenital narrowing of one of these blood vessels. In these people, a blood clot can form if there is a period where the arm is overused. For example, weightlifting or working for long periods with arms raised above the head.

In other people, the blood vessel narrowing may be caused by, for example, a cervical rib. Because of this narrowing, a blood clot is more likely to form in the subclavian artery or vein, which can lead to the typical symptoms of blood vessel compression (see below).

Who gets thoracic outlet syndrome?

Overall, thoracic outlet syndrome is more common in women than in men. It can occur from the ages of 20 to 80 but is most common around the age of 40. As mentioned above, people with thoracic outlet syndrome have often had a recent injury to their neck. It is more common in people whose jobs involve repetitive movements or in some athletes whose sport involves a lot of arm movement.

What are the symptoms of thoracic outlet syndrome?

The symptoms of thoracic outlet syndrome depend on what is being squashed (compressed) in your thoracic outlet. As mentioned above, in most cases it is the nerves of the brachial plexus rather than blood vessels that are compressed. Therefore, symptoms are more likely to be due to nerve compression. However, sometimes a combination of nerves and blood vessels may be compressed at the same time. This can give rise to a mixture of symptoms.

Symptoms are usually just felt on one side of the body. Rarely, symptoms can occur on both sides.

Symptoms due to nerve compression

The symptoms depend on which nerves of the brachial plexus are compressed. Most commonly you will develop pain and pins and needles in your hand and arm. You may particularly feel these along the inside of your arm and into your ring and little finger. Pins and needles are usually worse at night and can sometimes wake you from your sleep.

If different brachial plexus nerves are compressed, you may have neck, ear, upper back, upper chest and outer arm pain on the affected side. Some people also have headaches.

Your affected arm may feel weak. You may also notice that your affected hand gets very cold, especially in cold weather.

Symptoms due to blood vessel compression or blockage

In rare cases when your subclavian vein is compressed, your arm may become swollen and may sometimes appear a blue colour. The swelling may lead to pins and needles in your affected arm. Some people also develop pain in their arm. The symptoms tend to come and go and may be brought on at times when you are using your arms a lot. If you have a blood clot in your subclavian vein causing blockage of the vein, these symptoms will become constant and urgent treatment is needed.

In rare cases, when your subclavian artery is compressed, this means that blood is unable to get through to your arm and hand on the affected side as readily as it should do. Again this can lead to pain and pins and needles. Your arm and/or hand can appear pale white in colour and it can also feel cold. Like with the vein-related symptoms, the symptoms may be brought on by using your arms a lot.

How is thoracic outlet syndrome diagnosed?

Your doctor will usually start by asking you questions about your symptoms and examining you. If they suspect that you may have thoracic outlet syndrome, they may ask you to move your arms and shoulders into certain positions when they examine you. This is to try to bring on (induce) your symptoms. They may then suggest certain tests to look for the underlying cause. Usually, thoracic outlet syndrome is diagnosed after other conditions that can cause pain or pins and needles in one of your arms have been excluded. You may also be referred to a specialist.

A chest X-ray and X-ray of your neck can show if you have a cervical rib. Other tests including an MRI scan or CT scan of your neck and upper chest area may help to rule out other causes for your symptoms. For example, arthritis in your neck may be causing compression of the nerves in your neck. Special tests called nerve conduction studies may sometimes be suggested. These look at the electrical activity of your nerves and can help to show which nerves are being compressed.

If your doctor suspects that you have compression of your subclavian artery or vein, other tests may be carried out to look for this. A test called angiography looks at your arteries and venography looks at your veins. Special tests known as Doppler studies can also look at blood flow through your arteries and veins.

What is the treatment for thoracic outlet syndrome?

Treatment depends on the underlying cause.

Blood vessel compression or blockage

In the rare case that you have blockage of one of your blood vessels by a blood clot, treatment with a medicine is needed urgently to break down the clot. This used to be in the form of an anticoagulant such as warfarin but recently 'clot busters' such as urokinase have also been used. Treatment with an anticoagulant may then be continued for a period of time to prevent further clots. Surgery may also be needed to relieve any squashing (compression) of your blood vessels. For example, removal of a cervical rib that may be squashing a blood vessel.

Nerve compression

There is not currently a general agreement about what treatment is best for this type of thoracic outlet syndrome. More trials are needed to determine the best treatment. However, in general, treatment is aimed at relieving your symptoms.

Physiotherapy may be helpful for some people and may include stretching exercises, exercises to improve posture and exercises to increase muscle strength and endurance. These exercises may all help to open up the thoracic outlet and relieve the compression.

You may also need to modify or change your work or sport activities. This may involve looking at the way that you sit in a chair or at your desk. An occupational therapist may be able to help with this.

Medicines such as non-steroidal anti-inflammatory drugs (NSAIDs) - for example,ibuprofen - may be helpful in relieving pain in some people. Paracetamol or stronger painkillers may sometimes be needed. Other treatments occasionally tried include a group of medicines called calcium-channel blockers and botulinum toxin injections.

In some cases, surgery to relieve the cause of the compression may be advised. For example, to ease pressure from a cervical rib, or from an extra muscle or fibrous band in your neck, or to repair a broken collarbone (clavicle) that is pressing on nerves (or blood vessels). Surgery is sometimes better performed at an early stage in the condition, before too much damage occurs. Your specialist will be able to advise.

What is the outlook (prognosis) for thoracic outlet syndrome?

In most people with thoracic outlet syndrome, the outlook is generally good and symptoms often improve over time.

If squashing (compression) or blockage of the subclavian artery or vein is diagnosed quickly and treated, a good recovery is possible. However, nerve compression symptoms can be difficult to treat in a few people. Persistent (chronic) pain and weakness with some loss of ability to use the affected arm may be experienced by some. This can sometimes be severe enough to affect your quality of life.

Thoracic Outlet..

What is the thoracic outlet? The thoracic outlet is a space, or passageway, that lies just above your first rib and behind your collarbone (clavicle). There are also some muscles that surround the thoracic outlet. The thoracic outlet runs from the base of your neck to your armpit. You have a thoracic outlet on the left and the right side of your body. A number of structures pass through your thoracic outlet, including some important blood vessels and nerves. The brachial plexus, a group of nerves passing from your neck to your arm, passes through the thoracic outlet. The subclavian artery and subclavian vein are blood vessels that pass through the thoracic outlet as they connect between your chest and your arm. What is thoracic outlet syndrome and what causes it? If you have thoracic outlet syndrome, the nerves and/or blood vessels in the thoracic outlet are squashed (compressed) for some reason. In most cases, it is nerves that are compressed. This compression causes the typical symptoms (see below). In some people, the subclavian artery or subclavian vein may be compressed. Sometimes, a combination of both nerves and blood vessels may be compressed. Thoracic outlet syndrome usually only affects one side of your body. However, rarely, compression can occur in the thoracic outlet on both sides and so symptoms then occur on both sides. There are a number of different things that can cause compression of the nerves or blood vessels in thoracic outlet syndrome. Having a cervical rib About 1 in 10 people who have a cervical rib develop thoracic outlet syndrome. So, most people with a cervical rib do not develop any symptoms. Having a cervical rib can cause narrowing of your thoracic outlet, making compression of the structures that pass through it more likely. Other congenital causes Some people are born with an extra band of tissue underneath their skin around the thoracic outlet area, called a fibrous band. This can act a bit like an extra rib and cause compression of the thoracic outlet in some people. Extra (anomalous) muscles around the thoracic outlet that you may be born with can also cause narrowing and compression. Also, some people are born with an enlarged or elongated part of a vertebra in their neck which can cause compression in their thoracic outlet. A recent accident It is quite common for people with thoracic outlet syndrome to have a history of some kind of recent trauma to their neck. For example, whiplash following a car accident. Trauma during an accident can cause structures in your neck and chest wall to move slightly and narrow the thoracic outlet. If you break (fracture) your collarbone (clavicle), broken bone fragments or bleeding due to the fracture can also cause narrowing of the thoracic outlet. A job that involves repetitive movements Thoracic outlet syndrome can be more common in someone who has a job that involves very repetitive movements or a lot of overhead work. These movements can lead to 'wear and tear' of the nerves of their brachial plexus. Also, people who play a lot of sport, particularly sports that involve lots of arm movement are also more likely to develop thoracic outlet syndrome. For example, swimmers, javelin throwers and shot putters. Poor posture People with a poor posture and 'droopy' shoulders may be more likely to develop thoracic outlet syndrome. Sitting in front of a computer for long hours with a poor posture, an incorrect desk position, and an inadequate chair may be a cause. This poor posture can cause narrowing of your thoracic outlet. Also, thoracic outlet syndrome can be a problem for women who have large breasts. Their breasts pull the muscles of their chest wall forwards and can cause narrowing of their thoracic outlet, leading to the typical symptoms. Artery and vein problems Narrowing and blockage of your subclavian artery or vein is another cause of thoracic outlet syndrome. Some people can have a congenital narrowing of one of these blood vessels. In these people, a blood clot can form if there is a period where the arm is overused. For example, weightlifting or working for long periods with arms raised above the head. In other people, the blood vessel narrowing may be caused by, for example, a cervical rib. Because of this narrowing, a blood clot is more likely to form in the subclavian artery or vein, which can lead to the typical symptoms of blood vessel compression (see below). Who gets thoracic outlet syndrome? Overall, thoracic outlet syndrome is more common in women than in men. It can occur from the ages of 20 to 80 but is most common around the age of 40. As mentioned above, people with thoracic outlet syndrome have often had a recent injury to their neck. It is more common in people whose jobs involve repetitive movements or in some athletes whose sport involves a lot of arm movement. What are the symptoms of thoracic outlet syndrome? The symptoms of thoracic outlet syndrome depend on what is being squashed (compressed) in your thoracic outlet. As mentioned above, in most cases it is the nerves of the brachial plexus rather than blood vessels that are compressed. Therefore, symptoms are more likely to be due to nerve compression. However, sometimes a combination of nerves and blood vessels may be compressed at the same time. This can give rise to a mixture of symptoms. Symptoms are usually just felt on one side of the body. Rarely, symptoms can occur on both sides. Symptoms due to nerve compression The symptoms depend on which nerves of the brachial plexus are compressed. Most commonly you will develop pain and pins and needles in your hand and arm. You may particularly feel these along the inside of your arm and into your ring and little finger. Pins and needles are usually worse at night and can sometimes wake you from your sleep. If different brachial plexus nerves are compressed, you may have neck, ear, upper back, upper chest and outer arm pain on the affected side. Some people also have headaches. Your affected arm may feel weak. You may also notice that your affected hand gets very cold, especially in cold weather. Symptoms due to blood vessel compression or blockage In rare cases when your subclavian vein is compressed, your arm may become swollen and may sometimes appear a blue colour. The swelling may lead to pins and needles in your affected arm. Some people also develop pain in their arm. The symptoms tend to come and go and may be brought on at times when you are using your arms a lot. If you have a blood clot in your subclavian vein causing blockage of the vein, these symptoms will become constant and urgent treatment is needed. In rare cases, when your subclavian artery is compressed, this means that blood is unable to get through to your arm and hand on the affected side as readily as it should do. Again this can lead to pain and pins and needles. Your arm and/or hand can appear pale white in colour and it can also feel cold. Like with the vein-related symptoms, the symptoms may be brought on by using your arms a lot. How is thoracic outlet syndrome diagnosed? Your doctor will usually start by asking you questions about your symptoms and examining you. If they suspect that you may have thoracic outlet syndrome, they may ask you to move your arms and shoulders into certain positions when they examine you. This is to try to bring on (induce) your symptoms. They may then suggest certain tests to look for the underlying cause. Usually, thoracic outlet syndrome is diagnosed after other conditions that can cause pain or pins and needles in one of your arms have been excluded. You may also be referred to a specialist. A chest X-ray and X-ray of your neck can show if you have a cervical rib. Other tests including an MRI scan or CT scan of your neck and upper chest area may help to rule out other causes for your symptoms. For example, arthritis in your neck may be causing compression of the nerves in your neck. Special tests called nerve conduction studies may sometimes be suggested. These look at the electrical activity of your nerves and can help to show which nerves are being compressed. If your doctor suspects that you have compression of your subclavian artery or vein, other tests may be carried out to look for this. A test called angiography looks at your arteries and venography looks at your veins. Special tests known as Doppler studies can also look at blood flow through your arteries and veins. What is the treatment for thoracic outlet syndrome? Treatment depends on the underlying cause. Blood vessel compression or blockage In the rare case that you have blockage of one of your blood vessels by a blood clot, treatment with a medicine is needed urgently to break down the clot. This used to be in the form of an anticoagulant such as warfarin but recently 'clot busters' such as urokinase have also been used. Treatment with an anticoagulant may then be continued for a period of time to prevent further clots. Surgery may also be needed to relieve any squashing (compression) of your blood vessels. For example, removal of a cervical rib that may be squashing a blood vessel. Nerve compression There is not currently a general agreement about what treatment is best for this type of thoracic outlet syndrome. More trials are needed to determine the best treatment. However, in general, treatment is aimed at relieving your symptoms. Physiotherapy may be helpful for some people and may include stretching exercises, exercises to improve posture and exercises to increase muscle strength and endurance. These exercises may all help to open up the thoracic outlet and relieve the compression. You may also need to modify or change your work or sport activities. This may involve looking at the way that you sit in a chair or at your desk. An occupational therapist may be able to help with this. Medicines such as non-steroidal anti-inflammatory drugs (NSAIDs) - for example, ibuprofen - may be helpful in relieving pain in some people. Paracetamol or stronger painkillers may sometimes be needed. Other treatments occasionally tried include a group of medicines called calcium-channel blockers and botulinum toxin injections. In some cases, surgery to relieve the cause of the compression may be advised. For example, to ease pressure from a cervical rib, or from an extra muscle or fibrous band in your neck, or to repair a broken collarbone (clavicle) that is pressing on nerves (or blood vessels). Surgery is sometimes better performed at an early stage in the condition, before too much damage occurs. Your specialist will be able to advise. What is the outlook (prognosis) for thoracic outlet syndrome? In most people with thoracic outlet syndrome, the outlook is generally good and symptoms often improve over time. If squashing (compression) or blockage of the subclavian artery or vein is diagnosed quickly and treated, a good recovery is possible. However, nerve compression symptoms can be difficult to treat in a few people. Persistent (chronic) pain and weakness with some loss of ability to use the affected arm may be experienced by some. This can sometimes be severe enough to affect your quality of life.

Pufas.. Polyunsaturated fat.. Hypothyroid ~hashimoto~ Fix!

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Lymphoscintigraphy Overview Background

Lymphoscintigraphy Overview Background Lymphoscintigraphy (sentinel lymph node mapping) is an imaging technique used to identify the lymph drainage basin, determine the number of sentinel nodes, differentiate sentinel nodes from subsequent nodes, locate the sentinel node in an unexpected location, and mark the sentinel node over the skin for biopsy. Sentinel node mapping is rapidly becoming an alternate staging procedure for the axilla in managing early breast cancer.[1] Several well-conducted studies have provided high-quality evidence for its usefulness.[2] Sentinel node scanning was initially studied in cutaneous melanomas to detect lymphatic drainage patterns prior to surgery. The procedure is applicable to almost all regions of the body, but the greatest impetus to the technique came with the application of the procedure to identify breast sentinel nodes. The sentinel node is the first node to receive metastatic deposits in a malignancy. Lymphoscintigraphy is an important procedure because if the sentinel node is free of metastasis, subsequent nodes are also likely to be free of disease. The sentinel node is generally defined as follows: The node closest to the primary lesion The node with a radioactive channel leading to it The node with the highest count rate on lymphoscintigraphic imaging and probe counting The first node visible on lymphoscintigraphic imaging The blue node on dye injection technique The node with a blue channel leading to it Lymphoscintigraphy allows the patient to avoid axillary clearance surgery (axillary lymph node dissection) if the sentinel node is negative for metastatic disease. Given the high prevalence of breast cancer worldwide, the possibility of avoiding axillary clearance surgery in a significant number of patients makes this an extremely valuable procedure. This topic is limited to lymphoscintigraphy in breast cancer. Applications for malignant melanoma will be introduced, but a detailed discussion is beyond the scope of this article. Both radionuclide and nonradionuclide methods (blue-dye methods) will be discussed. Indications Lymphoscintigraphy is indicated for proven palpable or nonpalpable invasive breast carcinoma for which removal of the primary tumor and axillary node dissection would be indicated.[3] Contraindications Absolute contraindications to lymphoscintigraphy include clinically positive (N1) axilla and allergy to component used.[1] Relative contraindications to lymphoscintigraphy include the following[4] : Prior biopsy (especially excisional biopsy) Previous breast and axillary surgery Advanced disease (associated with fatty degeneration of nodes with reduced function) Neoadjuvant chemotherapy Multicentric and multifocal disease Ductal carcinoma in situ High body mass index and old age Pregnancy Surgeon’s experience and skills Other Applications Lymphoscintigraphy has become widely accepted in several other applications besides breast cancer,[5, 6] including malignant melanoma (stage I and II disease). Tc 99m tilmanocept is also approved for intradermal or SC injection for melanoma mapping.[7] The Multicenter Selective Lymphadenectomy Trial concluded that sentinel node scanning is a low-morbidity procedure for evaluating the regional nodal basin in early melanoma and should become the standard of care.[8] Other applications include head and neck cancer, thyroid cancer, non–small cell lung cancer, gastric cancer,[6] penile cancer,[9] and vulvar cancers.[10

Right side breast pain, chestwall, associated with costochrondritis/tietze

By Christine Haran Jan 6, 2006, 9:08 AM N E W Y O R K — Tender breasts are just one of the many uncomfortable and annoying symptoms millions of women experience prior to their periods. While most women have just mild breast discomfort, others experience more severe pain each month. And some women have breast pain that is not associated with their menstrual cycle, which is known as noncyclic pain. Sudden or severe breast pain is often a very alarming symptom for women. Breast pain is not usually a sign of breast cancer, but experts say it's important that women with breast pain, particularly severe pain associated with their menstrual cycle, or any kind of noncyclic pain, be evaluated for breast cancer. "The reassurance is a big part of the evaluation of breast pain," says Dr. Sandhya Pruthi, the section head for the Breast Diagnostic and Cancer Clinics at Mayo Clinic in Rochester, Minn. Below, Pruthi and other members of the team at Mayo's Breast Diagnostic and Cancer Clinics, Dr. Robin Smith, and Jennifer Hazelton, a clinical nurse specialist, talk about the most common causes of breast pain, as well as strategies for easing the pain. What are the most common kinds of breast pain? Dr. Robin Smith: The breast pain that women experience has been broken down into three primary types. The first is called cyclic mastalgia, and this is pain that is associated with the menstrual cycle. Typically a woman's symptoms start within the two weeks prior to her menstrual cycle, worsening until the onset of her menstrual period, and then they tend to get better. Some women have pain throughout the entire month, but it improves and worsens according to the time in the cycle. The second type of pain that women experience is called noncyclic mastalgia, which is pain that may be intermittent or constantly present, but does not appear to be associated with the menstrual cycle at all. And the third type is breast pain that is actually pain from another source, such as the chest wall. Conditions such as costochondritis, caused by inflammation in the rib joints, can sometimes be perceived as breast pain, as can a number of other medical conditions in the same area. How do women describe their symptoms? Smith: Women with cyclical breast pain tend to experience pain in both breasts. It is often described as heaviness, aching, or fullness. It seems as though the patients with noncyclic breast pain have pain that can involve both breasts, but it's more often one-sided, and it tends to be localized to one area in the breast. Sometimes patients will use terms such as "sharp" or "burning" to describe it. There's a wide spectrum in terms of severity because we often pick up breast pain simply by asking patients about their breast symptoms, and most of these women are not very bothered by their pain. Other women actually do have pain severe enough to cause interference with school and work, their physical activities, leisure activities and sexual activity. Why do hormonal fluctuations cause breast pain? Smith: I wish we had the answer to that. It seems obvious to all of us that there's a hormonal role in the cyclical type of breast pain, because it changes with the menstrual cycle and it tends to improve with changes in hormones, such as pregnancy or with menopause. There have been a number of studies performed over many years trying to detect a hormonal abnormality that might explain why some women experience pain and others don't, or why some women experience severe pain and others have only mild symptoms. Unfortunately, there have not been consistent results. One potential explanation is that certain women may have breast tissues that may be more sensitive to normal circulating hormones. What causes noncyclic breast pain? Smith: When someone presents with noncyclic breast pain, we carefully evaluate them to see if we can find an explanation. And of course, what the patient is usually concerned about is the possibility of cancer. Fortunately, the risk of cancer is low, but it's not insignificant. About 2 to 3 percent of women who come to a clinic for evaluation for breast pain—usually that's reasonably severe breast pain—have a cancer at the site. So the majority of noncyclic breast pain is caused by benign conditions. Sometimes we will find benign tumors in the breast, such as a fibroadenoma, which is a common benign tumor, or a breast cyst that may have been causing her localized pain. But most of the time we don't find a clear-cut explanation for noncyclic breast pain. Why isn't breast pain usually a symptom of breast cancer? Smith: Although pain can be a symptom of cancer, it is surprising how seldom this is the case. Cancers start out as small clusters of abnormal cells that grow over time and may spread to other sites. Malignant tumors in the breast may not cause any symptoms for months, or occasionally, years. Cancers can cause pain by inducing inflammation or swelling, by invading a region with a rich nerve supply or by putting pressure on other sensitive tissues, but this does not occur until the tumor becomes larger. The risk of breast cancer in women with localized breast pain is low, but not insignificant, and merits appropriate medical evaluation. Do infections cause breast pain? Smith: We do see patients with mastitis, an infection of the mammary gland, or sometimes an abscess. Quite often these occur around the time of pregnancy and lactation, and it can be very painful. Usually, these women have other clinical findings of redness, swelling, maybe some discharge from the nipple. Dr. Sandhya Pruthi: Postmenopausal women describe pain around the areola that is called periductal mastitis. They don't always have the classic red breast, nipple discharge or even the sign of an abscess. It's just a very subtle set of symptoms where the woman says, "You know, it just hurts behind the nipple." What role does diet play in causing breast pain? Smith: There have been some studies supporting an association between caffeine and breast pain, but other studies have really not supported a relationship. But I have many patients come in and simply tell me that they know that if they drink too much coffee or soda that has caffeine, they experience a worsening of their symptoms. Other women don't find a relationship between caffeine and their symptoms. I think it's worthwhile, in a woman whose symptoms are severe and who has a significant caffeine intake, to undertake a trial of bringing that caffeine consumption down. When would you advise a woman with breast pain to be tested for breast cancer? Pruthi: Right away. If a woman has breast pain, particularly if it's new, we advise her to make an appointment with their doctor and have it evaluated. Then it's up to the doctor and the patient to decide on the next workup. But definitely, any woman who says, "I'm having breast pain that's new or bothersome," should be evaluated. Smith: In a woman over 30 to 35 we would start with a mammogram, and usually for localized breast pain, our practice has been to also perform an ultrasound of that area that is causing the symptoms. In a younger woman, we would often start by doing an ultrasound of the area and then proceed depending on what is found. What can be done to deal with breast pain not caused by breast cancer? Smith: What we typically do is meet with our patients and go over a variety of simple measures that they can do that don't involve medication. We talk with them about their diet, wearing a supportive bra, sometimes wearing a soft bra at night that can provide support. Jennifer Hazelton: I think a lot of women, just being women, kind of let their shopping for themselves go. And I see women with bras that have absolutely no elastic whatever left in them, and we've had a number of women call back and say, "Wow, I can't believe what a difference that made." Another thing we recommend is a cold compress to the area of pain for 20 minutes at a time. It seems to be more helpful with a focal pain that's noncyclic. Exercise helps because endorphins are released when people exercise, which provide a natural kind of relief. But there's a lot of exercise that involves movement of the breasts, so, we recommend biking or kind of a gentle walking while wearing a very supportive bra. Pruthi: We'll also often recommend anti-inflammatory pain medication, such as acetaminophen or ibuprofen, when a woman first comes to the clinic about breast pain. What is the next step after lifestyle modification and pain relievers? Smith: We're still determining what the next best step is. There have been a number of medications used for cyclical breast pain, and those include tamoxifen, danazol, bromocriptine and others. The difficulty is that, while these medications are very effective in relieving breast pain, they are associated with some potentially serious and very bothersome symptoms. The side effects of tamoxifen are usually similar to menopause (hot flashes, vaginal dryness or discharge), but also include endometrial carcinoma and blood clots. The side effects of danazol are less serious, but it can be associated with masculine side effects, including acne and an increase in facial hair or other hair growth. And so we have a great deal of interest in measures that we could use short of those very potent medications. Pruthi: Usually if the lifestyle modifications aren't working women can try taking 400 international units of vitamin E twice a day. We say, "Try this for three months and see if it works, and then if it does, great. Keep taking it. And if it doesn't let us know." And then my personal next step is to try capsules of evening oil of primrose, which is a gamma linoleic acid that has actually been approved in the United Kingdom for managing cyclical breast pain. We're conducing an open, randomized, double-blinded, placebo-controlled study looking at the effectiveness of vitamin E, evening oil of primrose, or a combination of the two, compared to a placebo. It is expected that the study will also open soon at other sites. Hazelton: We are doing a study looking at the effectiveness of four acupuncture treatments over a two-week period in women with noncylic breast pain. Preliminary results are promising. When is surgery recommended? Smith: I try everything short of surgery for my patients so they can avoid a procedure that has anesthesia risk and potentially deforming consequences. And surgery in and of itself can cause future breast pain. So a woman could remove a tender area of the breast in exchange for pain related to a scar in the same vicinity. But sometimes we do find that our patients experience pain relief when a cyst is drained, and that can be done by using a needle to drain the fluid out the cyst. Sometimes that cyst fluid will recur, but often the pain will be relieved for quite a while or indefinitely. And a benign growth like a fibroadenoma that causes localized pain at the site can also be removed. What is your advice to a woman who is having pain? Smith: I think that a woman who has some fairly mild symptoms of cyclical breast discomfort that is not interfering with her activities and always resolves with her menstrual cycle just needs to know that that is common and that nothing particular needs to be done with regard to evaluation and treatment. She should continue with breast cancer screen appropriate for her age. Women who have more severe cyclical breast pain can manage the symptoms with their doctor or talk to their doctor about a referral for a consultation in a breast center. For a woman with noncylic breast pain, particularly localized to an area of the breast, I would recommend she undergo a careful evaluation in a breast center. It is also reasonable for women with a new onset of breast pain or a change in breast pain symptoms to undergo medical evaluation