Dupuytren’s Disease

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

You will have noticed a lump or band in the palm of your hand developing over the past months to years. Some people will have noticed nothing else but some patients will notice that the band extends into one or more fingers and the fingers will not straighten fully. The lump or band is the Dupuytren’s tissue and the bending of the fingers is due to this band getting shorter.

We do not fully understand the nature of this tissue but we do know it is similar to scar tissue. The condition can occur in other parts of the body as well when it is known by other names:

• Soles of feet – Ledderhose Disease (plantar fibromatosis)
• Penis – Peyronie's disease
• Over the knuckles – Garrod's pads

Who gets it?
We know that the commonest reason for getting Dupuytren’s is

• Genetic – you are born with the tendency to develop the problem. The greater your tendency then the earlier you will develop it and the more severe it will be. However, other things can increase your risk or make the disease worse:
• Alcohol abuse
• Smoking
• Taking medication for epilepsy
• In other diseases such as Diabetes people develop a type of Dupuytren’s but it tends to be less severe.

How does the disease develop?
The first thing most people notice is the lump (or sometimes a little hole or pit) in the skin of the palm near the base of the ring finger. This lump is usually painless but can be tender to direct pressure.

Months or even years later the lump can develop into a band passing into the finger or fingers. Again months or years later this can start to pull the finger down to the hand so the finger will not fully straighten. This is called a Dupuytren’s contracture. People often notice this when they cannot put their hand down flat or have problems putting their hand in a pocket or putting on gloves.

The disease usually affects both hands but one hand may be much worse. Eventually in the worst cases all the fingers and even the thumb can be affected.

The ability to grip is not affected until the very severe stages when the fingers are pulled so far down that it is impossible to open them to hold things.

Many people find that the condition is a nuisance but does not preclude most normal activities. Some activities you may have problems with include:

• Holding some tools
• Holding a ball eg for bowling
• Getting your hand into small places.

Treatment

Many people with Dupuytren’s do not require surgery. Surgery is offered for three reasons:

1. There is a significant contracture progressing rapidly which will require major surgery if left for longer.
2. There is a contracture causing significant problems with your hand function
3. The lump in the palm is very painful

There are various types of treatment available which your surgeon will discuss with you.

Conservative: This means treatment without operation. There is some evidence that splints will help Dupuytrens and so some people can be given a splint to wear at night time to prevent progression of their problem. However most surgeons believe that the success rate of this treatment is very low and will not suggest it for rapidly advancing disease.

Injections: Patients with painful lumps in the palm can be treated with a steroid injection into the lump. This injection is quite painful and probably has a 50% success rate in the short term. There is no evidence that this prevents progression of the disease into a band.

Surgery:

This is the mainstay of treatment and can be of several types varying in complexity and complications.

Needle Aponeurotomy is a technique that dates back to Dupuytren and his earlier English colleagues Cline and Astley Cooper. The needle technique uses small hypodermic needles to poke into the skin and then transect the fibrous cords of Dupuytren's contracture with a back and forth cutting motion. It is an office technique using local anesthesia and without a need for a surgicenter or anesthesia costs. This technique does not address joint and tendon releases which may be necessary to fully release the contracted proximal interphalangeal joint (PIP or middle joint).

Segmental fasciectomy is the simplest and easiest operation which is usually reserved for disease confined to the palm although it can be used for the fingers. A series of small cuts are made in the palm and the Dupuytren's tissue removed. You will usually have a few stitches and a dressing with a splint. The operation will usually be done as a day case.

Fasciectomy is the standard operation for Dupuytren's Contracture. This operation will usually be done under a general anaesthetic although alternatives are often available. The operation involves making a cut from the palm into the finger to remove as much of the tissue as possible. We will then make the cut into a series of zig-zags to try and reduce recurrence. There will be a lot of stitches in the finger. We will usually do all the affected fingers at the same time. You will have a lot of dressings and a plaster on your hand. Dermofasciectomy is the operation we use for people with very severe or advanced disease and involves removing the skin on the front of the finger and replacing it with a skin graft. We usually take the skin graft from the inner arm or groin region. This is a more major operation and you will normally be in hospital for a couple of days.

Repeat operations are often a mixture of the above operations but may require more surgery to the actual joints in the fingers which adds to the recovery time.

Joint fusion is a last stage operation as is amputation when there is no other way of improving the function of the hand. They are very rare operations.

Postoperative care

Dressings: You will have a big bandage and Plaster of Paris on your hand which will be changed somewhere between 24 hours and 10 days from the time of surgery. You will have to come back to the hospital for the dressings to be changed for up to six weeks. The stitches will usually be removed after approximately 2 weeks. Some wounds and skin grafts need dressings for even longer or require special pressure garments to help the scar to soften.
Splints: Almost every patient will be made a special splint which must be worn at night time for six months.
Physiotherapy: Every patient will be referred to physiotherapy for advice on mobilising the hand. This can be quite painful and may need to be continued for up to six months

Complications

• Incomplete correction: In some patients it is not possible to fully straighten the finger. This is especially common if the finger has been bent for many years or if the finger is bent at the small joints as well as at the knuckle.
• Nerve damage: The Dupuytren's tissue is always wrapped around the small nerves in the finger. In a small proportion of patients (5-10%) the nerve is damaged and you will be left with some permanent or temporary loss of feeling at the tip of the finger. In addition a number of patients will find that the finger is painful in cold weather (10%).
• Recurrence: Dupuytren's is a disease that can come back. However the majority of patients will not require further surgery to an operated finger. Approximately 15% of patients requiring surgery to the little finger will develop a recurrent contracture of the same or worse severity in the first six months after surgery.
• Infection: A small proportion of patients will develop infection (more common in patients with diabetes) and require further surgery or even amputation.
• Skin graft failure: 10% of skin grafts can be expected to fail partially or completely and require either prolonged dressings or a further skin graft.
• Reflex Sympathetic Dystrophy: This is a condition that affects 1 in 2000 patients having hand surgery. The patients develop severe pain, swelling and stiffness in the hand. Despite treatment no patient will have a normal hand after this problem.

Despite this list of complications please remember that the vast majority of patients have an uncomplicated routine operation with a very satisfactory recovery.
Experimental--"Clinical trials are in progress to investigate non-operative therapy for Dupuytren's disease using BioSpecifics injectable Collagenase (Cordase tm). The FDA has accorded "Orphan Drug Status" to this usage and a U.S. patent has been granted. A research grant for continued clinical investigation in this area at Stony Brook Medical Center was awarded to BioSpecifics by the New York State Center for Advanced Technology in Medical Biotechnology. The FDA Office of Orphan Product Development has provided some of the funding for the trials in Stony Brook. A second double blind controlled trial is now underway to further define collagenase's usefulness for this condition."


References

• Duputren's Disease: History, Diagnosis, and Treatment; Plastic and Reconstructive Surgery, Vol 120, No 3, 790-
• The Vikings and Baron Dupuytren’s Disease--ADRIAN E. FLATT, MD, Baylor Health (very nice article)
• Dupuytren's Contracture by Charles Eaton, MD
• Dupuytren's Contracture--American Society for Surgery of the Hand (ASSH)
• A Patient's Guide to Dupuytren's Contracture--eOrthopod article
• Collagenase in the Treatment of Dupuytrens Disease--ClinicalTrials.gov
• Dupuytren's Disease--Pulver Taft Hand Centre
• Dupuytren's Contracture--NHS Choices
• Collagenase

It's Military Week at Ground Rounds

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

"The High Visibility Wrap,” by Joseph Hirsch. (photo credit)

Ground Rounds is up over at Nurse Ratched. I would like to echo her sentiments:

"I want to thank all the men and women who are serving in uniform, and those individuals who are taking care of wounded troops around the world. Your service is invaluable. You not only touch the lives of your patients, but you touch the lives of all of us as well."

Thank you all for your service. Be safe.

Culture Filled Weekend

This past weekend my husband and I celebrated our 17th wedding anniversary. We went to the Arkansas Blues &Heritage Festival on Saturday in Helena, Arkansas. I'm not a Blues aficionado, but I did enjoy it. Here are a few pictures.

Man sit up on street.
Eugene "Hideaway" Bridges

Then on Sunday, we went down to the Little Rock River Market to an outdoor Sculptor Exhibit. Wow! Some lovely pieces. Here are just a few.

"Mayura" by Bruce Gueswel

"Grief" by Edward Fleming

piece by Kevin Kresse of Little Rock, AR

"High Four" by Lousie Peterson

SurgExperience 106

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

Trauma Junkie (IntraopOrate) is hosting the next edition of surgeXperiences 106 on Sunday October 14th. You may submit here, or send them directly to her at makeminetrauma (at) gmail (dot) com. Deadline for entries is Friday, October 12. (photo credit)

If you have any surgery related posts, please, submit them. Any viewpoint (surgeon, nurse, tech, patient) is welcome.

Ooooh that smell

 Updated 3/2017-- photo/video and all links (except to my own posts) removed as many no longer active.

"Ooooh that smell
Can't you smell that smell "
[Apologies to Lynyrd Skynyrd, lyrics ]

Every now and then a patient in the operating room will loose control of his/her bowels. It has happened to a couple of my patients over the years. Two very memorable times.

One was a liposuction patient in a prone jack-knife position. We were working on her lateral and upper posterior thighs. My scrub tech was marvelous! She simply helped me clean the patient up while protecting our instruments and open incisions (granted small ones, but open none the less). Our circulating nurse then reprepped the patient. We re-draped, marshaled on and finished the procedure. The patient did great--no problems. I never even told the patient about the event (why embarrass her?).

The second one involved a procedure above the hip bones and was in a supine position. The patient had been allowed to leave her cotton underpants on for modesty. At the end of the case, as we were preparing to move the patient the smell hit our noses. We were an all woman crew. Each worked together. A new scrub tech (being oriented) and I got the job of removing the soiled underpants without getting much on her legs and removing the soiled sheets. The circulating nurse and main scrub tech both grabbed lap sponges with Techni-Care and saline. They treated the woman as if she was one of their grandbabies. Such tender care! All we needed was talcum powder. Bless them! We took the patient to recovery clean and on clean sheets. I had to tell this patient's friend why she would be going home with no underwear.

I write this to praise these women that I have the privilege to work with. No one tried to shirk the work that needed to be done. No one made fun of the patient or situation.

These women with whom I get to work

ARE Marvelous!

(Billy Crystal as Fernando Lamas accent)

Flying Geese Variation

 Updated 3/2017-- photos (except my own) and all links (except to my own posts) removed as many no longer active.

I found this Flying Geese Variation (FGV) use the blocks I received from Kate. Kate has a weekly give-a-way, and makes lovely quilts. The link for this FGV pattern can be found here (photo credit).

She sent me twenty sets of three identical blocks. So it worked very nicely with this variation of the Flying Geese pattern. My quilt is 43" X 52", a nice size for a baby or toddler. Here are a couple of pictures of the pieced top. It still needs to be quilted.

Rusty thought he needed to be in the picture.

Breast Reconstruction--Part II

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

A breast formed from autologous (your own) tissue can feel to the touch, look, and move like a real breast. For these reasons, autologous tissue provides the highest quality breast reconstruction currently available. 

Autologous tissue-based reconstruction involves the use of a flap. This flap may be a pedicle flap (the blood vessels that supply the pedicled flap remain intact as the flap is transferred to the breast site) or a free flap (the blood vessels that supply the free flap are severed and reattached to blood vessels at the chest). Either way the flap will consist of an area of skin and fatty tissue that is removed from a flap donor site and transferred to the chest to reconstruct the missing breast. The choice of which flap is best for any particular patient depends on many factors, including the patient’s anatomy, smoking history, and breast size and on the hospital and the plastic surgeon who performs the operation. 

Autologous tissue-based reconstruction offers many advantages over implant-based reconstruction. Although failure can occur with any technique, the chances for long-term success are significantly higher if autologous tissue is used instead of an implant. Like a real breast, a breast reconstructed with autologous tissue will become larger when the patient gains weight and smaller when she loses weight. The breast will also develop ptosis (drooping) just as the opposite breast does, so the symmetry achieved at surgery tends to remain over time. The breast reconstructed with living tissue seems to be a real part of the body because it is a real part of the body and in most cases will last the patient’s entire lifetime without ever having to be replaced.

The most common flap for breast reconstruction is the TRAM (transverse rectus abdominis myocutaneous) flap. It consists of skin, fat, and some muscle from the lower abdomen, where many women have some excess tissue. The original TRAM flap was first described by a plastic surgeon from Atlanta, Carl Hartrampf Jr. It is the TRAM pedicled flap based on a single rectus abdominis muscle. Over the years variation of the TRAM flap have been developed. The two most important variations are the conventional version (the TRAM pedicled flap) and the TRAM free flap.

A surprisingly large amount of skin and fat can be removed from the abdomen without compromising the plastic surgeon’s ability to close the resulting wound and without creating a deformity of the abdomen. When transferred to the chest wall, this tissue can be used to make an excellent facsimile of the missing breast. The abdominal donor site is often flatter and tighter than it was before the surgery, a result that appeals to many patients. Although a long scar is created, it is usually easy to conceal with clothing and is not objectionable to most women, who consider it a worthwhile tradeoff for the new breast.

The flap skin and fat of a single pedicle TRAM flap reconstruction survive on perforators through the rectus abdominis muscle. Although this muscle has a dual blood supply, the superior epigastric artery and the inferior epigastric artery, this operation relies only on the superior epigastric arterial system. Because of the distant nature of this blood supply, only tissues directly over or immediately adjacent to the muscle have adequate vascularity. If more tissues are needed, consider other procedures (midabdominal TRAM, delay procedure, double pedicle TRAM, super-charged TRAM, free TRAM flap, deep inferior epigastric perforator flap "DIEP").

Contraindications

The TRAM flap operation is major surgery and should not be undertaken lightly by the patient or surgeon. There are certain characteristics that place patients at higher risk for complications.

• Cardiac disease (ie, myocardial infarction, angina, congestive heart failure)
• Pulmonary disease (ie, emphysema, chronic obstructive pulmonary disease)
• History of pulmonary embolus or deep venous thrombosis
• Collagen-vascular disease, lupus, scleroderma, polyarteritis, (small vessel disease)
• Unstable psychiatric disease
• Obesity (>25% ideal body weight)
• Older patient (physiologic age older than 70 yr)
• Cigarette smoking; unwilling to quit
• Previous abdominal surgery that has interrupted blood supply to the TRAM flap
• Although not an absolute contraindication, advise patients who wish to have more children to consider another method of reconstruction.
• Patients who desire no or little muscle to be removed with the TRAM flap should consider a free TRAM or deep inferior epigastric perforator [DIEP] flap.

More than one procedure is required for a successful TRAM flap breast reconstruction.
Stage I - TRAM flap

This may be performed at mastectomy or some time afterward. Belly tissues are used to create the breast mound. This stage may also include a procedure on the opposite breast for optimal symmetry. The operation may last from 4-8 hours. During this procedure, 90% of the reconstructive work is performed. 

Stage II - Revisions and nipple reconstruction

For more accurate positioning of the nipple reconstruction, approximately 3-4 months after the TRAM flap procedure are needed for tissues to settled enough and scar tissue to relax. At this time, small revisions and reconstruction of the nipple can then be done. All adjuvant therapies should be completed, and the patient should have regained her preoperative energy level. If the breast mound revision is more major, the nipple reconstruction should be delayed another 3-4 months to accurately position nipple reconstruction. Nipple reconstruction can be performed as a local tissue rearrangement or as a graft from the opposite nipple. The anatomy of the patient and the preference of the surgeon dictate the choice.

Stage III - Nipple and areolar tattoo

This final procedure, which is performed in the office, adds color to the breast reconstruction. This finishing touch to the reconstruction helps make the reconstructed breast more symmetric with the opposite breast and minimizes the visual effect of other scars that may be present on the breast mound. The tattoo usually is performed 2 months after nipple creation, as the scar tissues are softer and facilitate pigment uptake in the scar.

Postoperative Details

• An uncomplicated TRAM flap requires 4-5 days of hospitalization.
• Ambulation begins on the first postoperative day.
• To remove tension on the abdominal closure, place the patient in a flexed position at the waist for the first few days (consider use of a walker as it aids in "reinforcing" the flexed position). Begin to allow a more upright position by the end of the first week.
• Drain tubes are necessary and are usually in place for 1-2 weeks. You will go home with them and have them removed in the doctor's office at a postop visit.
• Patients require 6 weeks to 2 months to regain their energy level and resume normal activities. You (the patient) should keep this in mind when planning your return to work or activities (family reunions, holidays, etc).
• Begin full range-of-motion exercises for the shoulder at 10-14 days postoperatively. Limited range will be allowed initially, so that the flap is not disturbed.
• Patients may resume abdominal exercises in 8 weeks.
• Anesthesia (decreased skin sensation) of the mastectomy site and central abdominal skin resolves over the next 6-12 months. The degree of sensory reinnervation to the TRAM flap is variable and patient dependent.
• Because of the tight closure of the underlying muscle fascia of the abdomen, most patients experience a painless tight feeling for many months.
• Patients with preexisting back pain may have an exacerbation of this pain from the procedure and may want to consider an alternative method of reconstruction (eg, implant reconstruction).
• Prolonged convalescence and discomfort coupled with a cancer diagnosis may be depressing and emotionally draining.

Complications

Because of the magnitude of the TRAM procedure, complications can occur even in the best of hands. Possible complications from a TRAM flap procedure are listed below. Fortunately, major complications are uncommon.

• Fat necrosis and/or partial flap loss (5-15% of patients)
• Complete loss of TRAM tissue ( <1% of patients)
• Seroma (fluid collection, usually in abdominal donor site)
• Hematoma (bleeding at either chest or abdomen)
• Infection
• Hernia (1-5% of patients)
• Abdominal bulge without hernia (5-15% of patients)
• Deep venous thrombosis and/or pulmonary embolus ( <1% of patients)
• Death ( <1% of patients)

WebMD Video on free TRAM flap reconstruction.
References
Breast Reconstruction: TRAM, Unipedicled by Michael R Zenn MD--eMedicine Article
Breast Reconstruction--American Society of Plastic Surgeons
Breast Reconstruction--CancerBackUp.org
Breast Reconstruction--Medline Plus
Breast Reconstruction After Mastectomy--American Cancer Society
Breast Reconstruction after Mastectomy--Mayo Clinic
Breast Reconstruction Guide for Patients by Stephen S. Kroll, M.D.
Reoperative Plastic Surgery of the Breast by Kenneth C. Shestak, MD; Lippincott Williams & Wilkins, December 2005

Breast Reconstruction--Part I

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

The decision to have breast reconstruction is a matter of personal choice. Whether the reconstruction should be "immediate" or "delayed" is one that is not always easily answered. Nor is the answer the same for everyone. Learn as much as you can about the process before making a decision. No single source of information can provide every fact or give you all the answers. You and those close to you should discuss any questions and concerns about reconstructive surgery with your health care team.

Women choose breast reconstruction for different reasons. It is important for you to understand what your own reasons are. The surgical goals of reconstruction are:

• To make your breasts look balanced when you are wearing a bra, not necessarily "the same" when you are not wearing a bra. The breasts should be close enough to one another in size and shape that you will feel comfortable about how you look in most types of clothing.
• To permanently regain your breast contour. Breast reconstruction cannot restore your normal breast sensation. With time, the skin on the reconstructed breast can become more sensitive, but it will not give you the same kind of pleasure as before a mastectomy.
• To give the convenience of not needing an external prosthesis

Your body image and self-esteem may improve after your reconstruction surgery, but this is not always the case. Breast reconstruction does not fix things you were unhappy about before your surgery. Also, you may be disappointed with how your breast looks after surgery. You and those close to you must be realistic about what to expect from reconstruction. Reconstruction will not give you back the pre-cancer breast.

There are three main types of breast reconstruction:

• Reconstruction using an implant of some kind.

• Tissue flap reconstruction, in which skin, muscle and fat from your back or abdomen (tummy) is tunneled through to the chest to create a new breast. The skin, muscle and fat stays connected to the area of the body from which it was taken.

• Free flap reconstruction, in which skin and fat from your lower abdomen, or occasionally buttock, is grafted to the breast area. The skin and fat is completely removed from the original area and a new blood supply is created for the new breast tissue, using microsurgery.

Or you can think of the types of reconstruction as implant based or tissue based or a combination of implant and tissue.

Implant-based reconstruction does not require removal of tissue from some other part of the patient’s body, so the procedure does not result in additional scars at a donor site. Breast reconstruction is easier and simpler with implants than with autologous (your own) tissue, and almost all plastic surgeons know how to do implant-based reconstruction. For these reasons, implant-based reconstruction is the most commonly used type of breast reconstruction in all parts of the world. The results are not always as natural as are those of autologous tissue-based reconstruction, and the quality of the outcome may be lower, but the risk of being hurt by the reconstruction is also lower. To make up the missing breast volume, the breast implant is placed beneath the muscle and skin of the chest wall. This can be done at the time of the mastectomy or as a delayed procedure, even years later.

During a mastectomy, both breast gland tissue and some of the overlying skin are removed. If the original breast was a very large one, the skin remaining after the mastectomy may be enough to adequately cover an implant. In those cases, using the remaining skin results in a breast that is smaller than the original one but may still be adequate. In many cases, however, missing breast skin will need to be replaced in some way. This is most commonly done by one of two methods: tissue expansion or a Latissimus Dorsi flap. A tissue expander is a balloon-like device that, as it is gradually filled with saline, stretches the breast skin remaining after a mastectomy until there is enough skin to cover an implant without tension. This skin expansion is performed gradually over a period of about two months. It may be inconvenient (will require weekly or bi-weekly visits to your surgeon's office), but usually is not painful.

Most plastic surgeons over-expand the breast being reconstructed to a volume 5% to 10% larger than the opposite breast. When the breast skin has been expanded to the desired size, it is then necessary to wait four to six months to let the expanded skin lose its elasticity so that the stretch becomes permanent before removing the tissue expander and inserting the permanent breast implant. The expanded skin will have redundancy and droop down on the chest wall as a normal breast would. This effect of drooping (ptosis) is important in achieving a shape like that of an original breast. Ptosis is difficult to achieve with tissue expansion and an implant. To achieve symmetry, the opposite breast may need to be enlarged with an implant, reduced, or lifted.

The main advantage of implant-based techniques, compared with autologous tissue-based approaches, is that most or all of the material used to make up the breast volume comes from a box on a shelf. Therefore, the initial operation for implant-based reconstruction is relatively minor. In general, the risks of the surgery (apart from failure to achieve a successful reconstruction) are also less serious than those of autologous tissue-based reconstruction. Special equipment and subspecialized surgical training are not required, so the breast reconstruction can be done in almost any hospital.

Complications of implant based surgery include hematoma, infection, capsular contracture, rippling, and asymmetry.

References

• Breast Reconstruction--American Society of Plastic Surgeons
• Back to the Latissimus Dorsi by Dana Khuthaila, MD, and Dennis Hammond, MD, PSP August 2005 (very nice article)
• Breast Reconstruction--CancerBackUp.org
• Breast Reconstruction--Medline Plus
• Breast Reconstruction After Mastectomy--American Cancer Society
• Breast Reconstruction after Mastectomy--Mayo Clinic
• Breast Reconstruction Guide for Patients by Stephen S. Kroll, M.D.
• Reoperative Plastic Surgery of the Breast by Kenneth C. Shestak, MD; Lippincott Williams & Wilkins, December 2005

Breast Cancer Information

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

As a plastic surgeon, I don't treat breast cancer. So I'm going to give you some nice references. These first five are blog posts from Dr. Sid Schwab, Surgeonsblog. They are nice discussions of breast cancer form the basics to the treatment choices. (photo)
Breast Cancer: Some Basics
Breast Cancer: Scary Tales
Breast Cancer Women
Breast Cancer, Prologue
The Old Man and the C

This next one is a blog post from Buckeye Surgeon. It is the handout he gives to his new breast cancer patients to aid in his discussions with them. It, also, gives them something for later, if they are overwhelmed with information. Breast Cancer Handout

I also want to remind you women that some of the breast changes in our lifetime are benign (well maybe you don't consider sagging benign, but it won't kill you). So review these, please: Breast Changes During Your Lifetime That Are Not Cancer--National Cancer Institute.

The National Cancer Institute has a wealth of information at their site on the range of treatment--surgery, radiation therapy, chemotherapy, hormone therapy, biological therapy, and treatment choices by stage of disease. Breast Cancer Treatment

Risk Factors for Breast Cancer

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

October is breast cancer awareness month. It's a good time to review the risk factors for breast cancer. A risk factor is anything that affects your chance of getting a disease, such as cancer. But having a risk factor, or even several, does not mean that you will get the disease. Most women who have one or more breast cancer risk factors never develop the disease, while many women with breast cancer have no apparent risk factors (other than being a woman and growing older). Even when a woman with breast cancer has a risk factor, there is no way to prove that it actually caused her cancer. The National Cancer Institute has an interactive Breast Cancer Risk Assessment Tool that can be used to measure risk of invasive breast cancer.

Risk Factors that can not be changed

• Gender--Just being a woman puts you at risk of having breast cancer. Yes, men can develop breast cancer, but this disease is 100 X's more likely to develop in a woman.
• Age--Your risk goes up as you get older. [I'm with George Burns--"don't like the alternative"] Close to 80 percent of breast cancers occur in women older than age 50. In your 30s, you have a one in 233 chance of developing breast cancer. By age 85, your chance is one in eight.
• Genetic Risk Factors--Between 5 percent and 10 percent of breast cancers are inherited. Defects in one of several genes, especially BRCA1 or BRCA2, put you at greater risk of developing breast, ovarian and colon cancers. Usually these genes help prevent cancer by making proteins that keep cells from growing abnormally. But if they have a mutation, the genes aren't as effective at protecting you from cancer.
• Race--While white women are slightly more likely to develop breast cancer than are African-American women, the African-American women are more likely to die of this cancer. Asian, Hispanic, and Native-American women have a lower risk of developing and dying from breast cancer.
• Personal History of Breast Cancer--A woman with cancer in one breast has a 3- to 4-fold increased risk of developing a new cancer in the other breast or in another part of the same breast. This is different from a recurrence (return) of the first cancer.
• Family History of Breast Cancer--If you have one first-degree relative — a mother, sister or daughter — who was diagnosed with the disease before age 50, your risk is doubled. If you have two or more relatives, your risk increases even more. Just because you have a family history of breast cancer doesn't mean it's hereditary, though.
• Abnormal Breast Biopsy Results--The proliferative lesions without atypia (those with excessive growth of cells in the ducts or lobules of the breast tissue) seem to raise a woman's risk of breast cancer slightly (1½ to 2 times normal). The proliferative lesions with atypia (those with excessive growth of cells in the ducts or lobules of the breast tissue, and in which the cells no longer appear normal) have a stronger effect on breast cancer risk, raising it 4 to 5 times higher than normal.
• Menstrual Periods--Women who started menstruating at an early age (before age 12) or who went through menopause at a late age (after age 55) have a slightly higher risk of breast cancer.
• Previous Chest Radiation--Women who, as children or young adults, had radiation therapy to the chest area as treatment for another cancer (such as Hodgkin disease or non-Hodgkin lymphoma) are at significantly increased risk for breast cancer. This varies with the age of the patient at the time of radiation.
• Diethylstilbestrol (DES) Exposure--For more information on DES see the separate American Cancer Society document, DES Exposure: Questions and Answers. (Table credit)

Risk Factors Related to Life Style (ones that can often be changed)

• Oral Contraceptive Use --While women are taking oral contraceptives and for 10 years after stopping these agents, there is a small increase in the relative risk of developing breast cancer. There is no significantly increased risk of having breast cancer diagnosed 10 or more years following cessation of the oral contraceptive agent.
• Postmenopausal Hormone Therapy (PHT)--Among current users of HRT and those who have ceased use 1-4 years previously the relative risk of having breast cancer diagnosed increases by a factor of 1.023 for each year of use. The risk of breast cancer appears higher with combined oestrogen and progestogen combinations. Mammograms of patient before and after three years of hormone replacement therapy showing increase in density caused by treatment 
• Not Having Children, or Having Them Later in Life--Women who have had no children or who had their first child after age 30 have a slightly higher breast cancer risk. Having multiple pregnancies and becoming pregnant at an early age reduces breast cancer risk.
• Breast-feeding--Some studies suggest that breast-feeding may slightly lower breast cancer risk, especially if breast-feeding is continued for 1.5 to 2 years. But this has been a difficult area to study, especially in countries such as the United States, where long-term breast-feeding is uncommon.
• Physical Activity--Evidence is growing that physical activity in the form of exercise reduces breast cancer risk. The question is how much exercise is needed. In one study from the Women's Health Initiative (WHI) as little as 1.25 to 2.5 hours per week of brisk walking reduced a woman's risk by 18%. So lace up.
• Alcohol--A recent study showed the following: Compared to women who consumed less than one drink per day, risk of breast cancer was increased by 10% among women who consumed one to two drinks per day, and by 30% among women who consumed three or more drinks per day. Each type of alcohol (beer, wine, or spirits) appeared to have a similar effect on breast cancer risk. The link between alcohol and breast cancer did not appear to vary by age or ethnicity.

The Susan G Komen Foundation has a very nice interactive program (audiovisual) that will enable you to better understand the development of breast cancer, the risk factors of breast cancer, diagnosis and prognostic factors and treatment options. Anatomy of Breast Cancer - Updated

References

• All Types of Alcohol Increase Breast Cancer Risk--CancerConsultants.com
• Abortion and Breast Cancer--Once Again, There is no Link--TBTAM
• National Cancer Institute-- Breast Cancer Information Page
• Clinical Review--ABC of Breast Diseases--Breast Cancer--Epidemiology, Risk Factors, and Genetics; BMJ 2000;321(7261):624 (9 September); K McPherson, C M Steel, J M Dixon
• Rating the Risk Factors for Breast Cancer; Ann Surg. 2003 April; 237(4): 474–482; S. Eva Singletary, MD, FACS
• What Are the Risk Factors for Breast Cancer?--American Cancer Society article
• Breast Cancer--MayoClinic.com article
• breast cancer risk factors-- Susan G. Komen Breast Cancer Foundation

Mammograms

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

First, please, refer to my post on breast self-exam. It is important to do your monthly self-exam. It is important to do it properly. Also, check out this article on breast changes during your lifetime that are not cancer from the National Cancer Institute.

Mammography is a low-dose x-ray system to examine breasts. A mammography exam, commonly known as a mammogram, is used to aid in the diagnosis of breast diseases in women. Mammograms are used for both screening and diagnosis.

Screening Mammogram
Mammography can show changes in the breast up to two years before a patient or physician can feel them. Cure rates are much higher when the breast cancer can be found at this stage. Current guidelines from the U.S. Department of Health and Human Services (HHS), the American Cancer Society (ACS), the American Medical Association (AMA) and the American College of Radiology (ACR) recommend screening mammography every year for women, beginning at age 40.

The National Cancer Institute (NCI) adds that women who have had breast cancer and those who are at increased risk due to a genetic history of breast cancer should seek expert medical advice about whether they should begin screening before age 40 and about the frequency of screening.

Diagnostic Mammogram
Diagnostic mammography is used to evaluate a patient with abnormal clinical findings—such as a breast lump or lumps—that have been found by her or her doctor. Diagnostic mammography may also be done after an abnormal screening mammography in order to determine the cause of the area of concern on the screening exam.

Important Things to Know and Do Prior to Mammogram

Before scheduling a mammogram, discuss any new findings or problems in your breasts with your doctor. At the time of the mammogram, inform the radiologist (or the techs) of any prior surgeries, hormone use, and family or personal history of breast cancer. Try not to schedule your mammogram for the week before your period if your breasts are usually tender during this time. The best time for a mammogram is one week following your period. Always inform your doctor or x-ray technologist if there is any possibility that you are pregnant.

• Do not wear deodorant, talcum powder or lotion under your arms or on your breasts on the day of the exam. These can appear on the mammogram as calcium spots.
• If possible, obtain prior mammograms and make them available to the radiologist at the time of the current exam. Or try to use the same facility each year so they will already have prior mammograms.
• Ask when your results will be available; do not assume the results are normal if you do not hear from your doctor or the mammography facility. Make sure you state who should get a copy of your mammogram results--family doctor, general surgeon, oncologist, plastic surgeon, etc.

What a Mammogram Can Show

The radiologist will look at your x-rays for breast changes that do not look normal. The doctor will look for differences between your breasts. He or she will compare your past mammograms with your most recent one to check for changes. The doctor will also look for lumps and calcifications.

• Lumps (or "mass")--The size, shape, and edges of a lump sometimes can give doctors more information about whether or not it is cancer. A growth that is benign often looks smooth and round with a clear, defined edge. On the other hand, breast cancer often has a jagged outline and an irregular shape.
  
• Calcifications--A calcification is a deposit of the mineral calcium in the breast tissue. Calcifications appear as small white spots on a mammogram. There are two types:

1. Macrocalcifications are large calcium deposits often caused by aging. These are usually not cancer.
2. Microcalcifications are tiny specks of calcium that may be found in an area of rapidly dividing cells. If they are found grouped together in a certain way, it may be a sign of cancer.

Depending on how many calcium specks you have, how big they are, and what they look like, your doctor may suggest that you--1) have a different type of mammogram that allows the radiologist to have a closer look at the area, 2) have another screening mammogram, usually within 6 months, or 3) have a biopsy done.

Mammograms are not perfect, but are currently the best method to find breast changes. If your mammogram shows a change in your breast, sometimes other tests will be needed to better understand it. These follow-up tests include ultrasound or more mammograms views. The only way to find out if an abnormal result is cancer is to do a biopsy. It is important to know that most abnormal findings are not cancer.

References

• Mammography--RadiologyInfo
• Mammograms--National Cancer Institute
• Mammograms in Women under 50--TBTAM
• MRI Urged for High Breast Cancer Risk--WebMD

SurgExperiences 105

 Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.


"Harree! Harree! Step Right Up! Get your Handbook of Medical Eponyms at Inside Surgery.

If you are thinking about going into medicine as a career, read this post by EM Physician-Backstage Pass. She notes this regarding the specialties, "Also important is, finding a specialty that fits your personality. If you want to be an involved parent, surgery isn't for you. If you want to have a comfortable lifestyle, you might wanna rethink primary care. If you like to interact with people, radiology/pathology may not bring you satisfaction." An earlier post discusses choosing surgery as a specialty.

Pin-Chieh Chiang takes you through the experience of Getting Caught Unprepared and the grilling your surgery attending can (and often does) give you as a medical student (or resident). Anyone who has been there knows it is not fun as Anna Burkhead posts about ”Pimping” in Getting Grilled! These Signs and helpful tips in Sleeve (Up) by Dr. Schwab over at Surgeonsblog will help you find your way. And through it all, take Someonetc's advice and Don't Forget to Breathe.

While you're learning, may I suggest take you use Dr. Bruce Campbell as someone to emulate. Read his post, How to Avoid Becoming Another Ionitch, and learn how he relates to his patients. And don't be like this cardiac surgeon who falsified his expertise (courtesy of Dr. Kevin).

More from the medical students as Ali Tabatabaey argues for and against surgery as a specialty. For in Surgery is Addictive, "Once you’ve tasted it you just want more. You crave bigger cuts and more complex operations. The simple appendectomy won’t be enough anymore; Deeper cuts, more blood, bigger sutures … ha ha ha (evil laugh)! Wow! I guess it’s got all the characteristics of a true addiction." and the against in The Lure of Surgery Can Be Fleeting-- Wow! What an experience. If you feel that you’re unwillingly being seduced into mastering the art of “the Blade” instead of the science of medicine, there is nothing like a back breaking seven-hour session at the operating room to change your mind back!

Chris (I Made a Difference) in Iraq writes about the First Night as the SOD (surgeon on duty) and how he survived it. Chris you have my deep respect.

Vanessa Ruiz is a graduate student in Biomedical Visualization at the University of Illinois at Chicago, one of the few medical illustration programs in the nation. Check out her recent post, "I don't like Wearing a Helmet, it Ruins my Hair" on her blog Street Anatomy. In it, she tells you why she now always wears a helmet when riding her bicycle.

Don't you just love going to carnivals or festivals. Well, TC over at Donorcycle writes about why she enjoys being in the operating room in Why I <3 Surgery. I can relate, as can most if not all of you.

The food at festivals in the USA is not "lite" but is often tasty. We like to bless our food before we eat and Dr. Campbell has the perfect "muscular" invocation. Don't I wish I could try the brisket Doc Shazam's butcher made. This man truly knows his craft in The Butcher's Silver Skin - Part 3. ...mmm good!

Buckeye Surgeon reviews a case of necrotizing pancreatitis (NP) in Acute Abdomen and other thoughts. This kind of case seems to be the Curses of the new surgeon in town, as described by Dr. Schwab. And why Respectful Insolence "One Reason I Don't Do General Surgery Anymore". NP is one disease that "distinguishes general surgeons from all other specialties."

NP get more attention as Aggravated DocSurg writes in Dr. Phibes meets the Pancreas, Hospital stays are long, complications are frequent, and the one thing required above all else in the patient with necrotizing pancreatitis is found in very short supply in our pharmacy: patience. But it is with a hefty dose of patience on the part of the surgeon, patient, and family that we manage to get the majority of these folks back on their feet. And then, it's Hammer time for all! (image of Hammer from his post, it makes me want to get up and dance)

Any time you have a gunshot wound patient, "don't be caught out" if you don't find the expected. Keep looking, as Bongi explains-- what the hell!!! i thought. but of course all i said was "hmmm?"

Ready to cool down? Then head over to The Ether Way where Mitch Keamy discusses Deep Hypothermic Circulatory Arrest for Aortic Arch Surgery….A .Global Brain Ischemia Situation.

May need to eat some more fair food. You will certainly need the energy to keep up with MakeMineTrauma. She takes us through a night of call with an orthopedic doc in her post-Stomped, Beat Up and Whooped! Day 1, then follows up with a second edition of same Day 2. The food's not the only thing that needs a stick or IM rod in MMT's case.

More skewering as Someonetc in his post Think before you shoot... discusses the placement of percutaneous pins (K-wires).

Midwife with a Knife reminds us that the proper tools are very helpful in her post, Forceps are Your Friends. MakeMineTrauma spent part of her night looking for the proper tools. TBTAM's post In Defense of the Hysterectomy covers the correct indications and why the choice should be between the patient and her doctor. And if you are still hungry, try TBTAM's recipe for Fig and Plum Tarts.

Check out Harvest provided by Bongi at other things amanzi. Yes, TC we need to be "green and recycle", but sometimes it requires much and not all can be given--check out Dr. Oliver's post on the question "Can skin from gastric bypass surgery be donated to children for skin grafts?"

Don't get lost as you head over to Dr Wes' to read Lost in Transition. He reminds us about the side effects of drugs (Versed) given during procedures as he tells of the $400 grocery shopping trip of one patient post-procedure. Not a good time to do anything that involves your pocketbook. If you haven't had any Versed, then enjoy the carnival game.

Now pour yourself a glass of Arkansas' own Weiderkehr Wine, coffee, or tea. Relax and enjoy the reading. Or maybe you're ready for some Karaoke. If so head over to Dr. Val's (Let's pick on anesthesiology) for the words and link to a youtube video of a young anesthesiologist singing a song about what his profession does during surgery to the tune of Total Eclipse of the Heart by Bonnie Tyler. [I passed this by my friend Dr Dan the Diprovan Man who loved it. No disrespect is intended. It's just for fun.]

Thanks Jeffrey for asking me to host this Carnival. The next one will be held over at IntraopOrate, Oct 14th.