29.10.2013

Pelvic cancer leg pain

Approximately 85% of bone tumors in dogs are osteosarcomas (cancer bone destruction and distant metastasis) and spread to other organs.
A study of 683 Rottweilers published in 2002, was established the risk for bone sarcoma was significantly influenced by the age at which the dogs were sterilized. Both male Rottweilers and female Rottweilers spayed or neutered before one year of age, there was a one in four lifetime risk for bone cancer. Another study conducted on 3,062 German Shepherds, a large breed dog, was using the Veterinary Medical Database for the period 1980 through 1994. Pakistan has moved from a low-risk to a moderate-risk country for cervical cancer, with incidence of the disease more than doubling between 2002 and 2008.
Young girls were at much higher risk of the disease and everyone should unite to help “these innocent future victims of today’s health policies”. If the woman is diagnosed with cervical cancer, the health care provider will order more tests to determine how far the cancer has spread. Lymphatic SystemThe lymphatic system is a fine network of vessels that can be found throughout the body. Ascites is detected on physical examination of the abdomen by visible bulging of the flanks in the reclining patient ("flank bulging"), "shifting dullness" (difference in percussion note in the flanks that shifts when the patient is turned on the side) or in massive ascites with a "fluid thrill" or "fluid wave" (tapping or pushing on one side will generate a wave-like effect through the fluid that can be felt in the opposite side of the abdomen). Routine complete blood count (CBC), basic metabolic profile, liver enzymes, and coagulation should be performed. Ultrasound investigation is often performed prior to attempts to remove fluid from the abdomen. Portal hypertension plays an important role in the production of ascites by raising capillary hydrostatic pressure within the splanchnic bed.
Regardless of the cause, sequestration of fluid within the abdomen leads to additional fluid retention by the kidneys due to stimulatory effect on blood pressure hormones, notably aldosterone. Ascites is generally treated while an underlying etiology is sought, in order to prevent complications, relieve symptoms, and prevent further progression. Salt restriction is the initial treatment, which allows diuresis (production of urine) since the patient now has more fluid than salt concentration.
Since salt restriction is the basic concept in treatment, and aldosterone is one of the hormones that acts to increase salt retention, a medication that counteracts aldosterone should be sought. In those with severe (tense) ascites, therapeutic paracentesis may be needed in addition to medical treatments listed above.[8][9] As this may deplete serum albumin levels in the blood, albumin is generally administered intravenously in proportion to the amount of ascites removed. Ascites that is refractory to medical therapy is considered an indication for liver transplantation. In a minority of patients with advanced cirrhosis that have recurrent ascites, shunts may be used. Exudative ascites generally does not respond to manipulation of the salt balance or diuretic therapy.
Complications involve portal vein thrombosis and splenic vein thrombosis: clotting of blood affects the hepatic portal vein or varices associated with splenic vein.
Lymph nodes are small organs, size of which measures 1-2 cm and is present throughout the body.
The main function of the lymph nodes is eliminating the dead cells of bacteria and other viruses from the lymphatic fluid and thus is serves as cleansing agent for the body. When the body’s natural defense mechanism (immune system) response to the chemical substances released by the harmful bacteria, the powerful antibodies (large number) are sent into the lymph nodes which make them expand and look swollen. Though lymph nodes are present throughout our body, let us see some of the important lymph nodes depending on the location. Mediastinal nodes are found in the lung sacs located between the pleural sacs and behind the sternum.
There will be slight tenderness or warmth in the area of lymph nodes indicating that it has enlarged or swollen. In the neck, it may develop swelling due to tonsillitis, throat infection or ear infection and sometimes due to skin infection. This is one of the cancer types that occur in white blood cells of the blood and is difficult to cure.
This is similar to prostate cancer in the male: Once there are symptoms of pain or bloody discharge, it often is too late to be able to offer effective therapy.
At times there might be a coexisting vaginal discharge from an unrelated problem, which in the process of a work-up by the physician leads the physician to recognize that there is also a cervical cancer.
By the time there is a vaginal discharge or vaginal bleeding from cervical cancer, it usually is already invasive cervical cancer (a late stage). With a larger tumor there might be superinfection leading to a smelly, pus containing vaginal discharge (=purulent discharge). No woman has to experience any of these symptoms: A yearly Pap test and pelvic exam will prevent these symptoms from occurring! This outline is only a teaching aid to patients and should stimulate you to ask the right questions when seeing your doctor. Osteosarcoma commonly affects the parts of the skeleton (skull, ribs, vertebrae, and pelviosteo (bone, sarcoma). Pakistan’s incidence of cervical cancer in 2008 was 19.5 per 100,000, compared to less than 9 per 100,000 in 2002.
Patients with cervical cancer do not usually have problems until the cancer is advanced and has spread. Limit the amount of sexual partners you have.Studies have shown women who have many sexual partners increase their risk for cervical cancer. The medical condition is also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more archaically as abdominal dropsy. Patients with ascites generally will complain of progressive abdominal heaviness and pressure as well as shortness of breath due to mechanical impingement on the diaphragm. For instance, in portal hypertension (perhaps due to cirrhosis or fibrosis of the liver) patients may also complain of leg swelling, bruising, gynecomastia, hematemesis, or mental changes due to encephalopathy. Most experts recommend a diagnostic paracentesis be performed if the ascites is new or if the patient with ascites is being admitted to the hospital. This may reveal the size and shape of the abdominal organs, and Doppler studies may show the direction of flow in the portal vein, as well as detecting Budd-Chiari syndrome and portal vein thrombosis. The sympathetic nervous system is also activated, and renin production is increased due to decreased perfusion of the kidney. Spironolactone (or other distal-tubule diuretics such as triamterene or amiloride) is the drug of choice since they block the aldosterone receptor in the collecting tubule.
In the United States, the MELD score (online calculator)[18] is used to prioritize patients for transplantation. Typical shunts used are portacaval shunt, peritoneovenous shunt, and the transjugular intrahepatic portosystemic shunt (TIPS). Very often their size is small but it may develop and grow bigger than normal size when it is infected due to certain medical disorder.
Swollen nodes increase in size from 1-2 inches and the nature and length of swelling depends on the location and the intensity of infection.
Drug allergy, lymphoma, benign cyst and hernia are some of the other causes for swelling of lymph nodes in the groin. This cancer can cause damage to the lymph nodes and underlying bone marrow and even the internal organs. We report a retrospective evaluation of a series of cases of Ewing's sarcoma managed with chemotherapy, surgery with or without radiotherapy.
It is the second most common primary malignant bone tumor in children, although some studies have found it to be more common than osteosarcoma in some populations.
Incidence of primary bone tumours and tumour like lesions in and around Dakshina Kannada district of Karnataka. Addition of ifosfamide and etoposide to standard chemotherapy for Ewing's sarcoma and primitive neuroectodermal tumor of bone.
Osteoarticular allografts for reconstruction after resection of a musculoskeletal tumor in the proximal end of the tibia.


Allograft prosthetic composite arthroplasty for osteosarcoma and other aggressive bone tumors.
Osteoarticular and intercalary allograft transplantation in the management of malignant tumors of bone. Biological reconstruction after resection of bone tumours around the knee: long-term follow-up. Efficacy and survival of 92 cases of Ewing's sarcoma family of tumor initially treated with multidisciplinary therapy. Spotting between periods or vaginal bleeding after intercourse is common (=postcoital spotting). Osteosarcomas are highly aggressive tumors, characterized by painful local limbs of large or giant breed dogs, but can also occur in other parts of the skeleton.
Pakistan’s eligibility for specific international funding, “the political will to establish cervical vaccination seems severely lacking”. Up to 80 per cent of women would acquire an HPV infection in their lifetime, and 80 per cent of deaths related to cervical cancer occur in developing countries like Pakistan. Pieces of tissue are surgically removed (biopsied) during this procedure and sent to a laboratory for examination. Smoking cigarettes increases your risk of developing many cancers, including cervical cancer. Having unprotected sex puts you at risk for HIV and other STD’s which can increase your risk factor for developing cervical cancer. If you have had an abnormal Pap smear, it is important to follow up with regular Pap smears or colposcopies, whatever your doctor has decided for you. If you are under 27, you may be eligible to receive the HPV vaccine, which prevents high risk strains of HPV in women. Although most commonly due to cirrhosis and severe liver disease, its presence can portend other significant medical problems. Those with ascites due to cancer (peritoneal carcinomatosis) may complain of chronic fatigue or weight loss. The fluid is then reviewed for its gross appearance, protein level, albumin, and cell counts (red and white). Additionally, the sonographer can make an estimation of the amount of ascitic fluid, and difficult-to-drain ascites may be drained under ultrasound guidance. However, none of these shunts has been shown to extend life expectancy, and are considered to be bridges to liver transplantation. When a liver cirrhosis patient is suffering from thrombosis, it is not possible to perform a liver transplant, unless the thrombosis is very minor. Basically the white blood corpuscles or lymphocytes reside in the lymphatic fluid of lymph nodes. If there is any abnormal movement of lymph cells in this area, it may cause plump in the neck, resulting in change of voice, coughing and formation of yellow phlegm.
There are plenty of causes for inflammation of lymph nodes ranging from common cold to cancer.
Materials and Methods: 54 patients of biopsy-proven Ewing's sarcoma of the bone, except craniofacial and vertebral bones were included.
There can be bleeding abnormalities, either that there is unexpected bleeding between two regular periods, or that there is more bleeding at the regular time.
This is an emergency as quick ways have to be found to save the woman from kidney failure and coma.
You can also see black hole like spots which means the cancer is also in the center of the leg.
If you have been treated for cervical dysplasia, you still need to follow up with Pap smears or colposcopies. Diagnosis of the cause is usually with blood tests, an ultrasound scan of the abdomen, and direct removal of the fluid by needle or paracentesis (which may also be therapeutic).
Those with ascites due to heart failure may also complain of shortness of breath as well as wheezing and exercise intolerance.
Abdominal CT scan is a more accurate alternate to reveal abdominal organ structure and morphology. Other complications of ascites include spontaneous bacterial peritonitis (SBP), due to decreased antibacterial factors in the ascitic fluid such as complement. In case of minor thrombosis, there are some chances of survival using cadaveric liver transplant. When antigens are secreted from the bacteria and passed into the lymph system, it is the lymph nodes which produce antibodies to destroy the pathogen released from the bacteria during blood circulation. You need to consult an expert health practitioner to identify the real cause of swollen lymph nodes. Symptoms relating to the urinary tract and rectum or pain in the pelvic area are all late symptoms of an invading cancer of the cervix. The upper left photo of the pelvis also shows bone cancer is inbetween the joint and socket.
Check cervical cancer screening guidelines to find out how often you should have a Pap smear, or check with your doctor. The vaccine is most effective when given to young women before they become sexually active.
Treatment may be with medication (diuretics), paracentesis, or other treatments directed at the cause. Clinically, the most useful measure is the difference between ascitic and serum albumin concentrations. Local and systemic extent of the sarcoma was defined, staged, and patients were subjected to the chemotherapy, surgery, and in some cases radiotherapy.
Institute Rotary Cancer Hospital, Delhi, India2 Department of Medical Oncology, All India Institute of Medical Sciences, Dr.
Secondary systemic cancer symptoms such as vomiting, rapid weight loss and depression are often apparent in the later stages.
Inguinal lymph nodes are responsible for filtering the fluid and draining bacteria from the areas like feet, groin, genitals and legs.
Twenty-one patients (38.9%) underwent resection and intercalary reconstruction with bone grafting, fixed with locking plates. We do not own German Shepherds but a vet here in Nashville allowed us to use these photos as a example.
Sixteen patients underwent resection and reconstruction with endoprosthesis, while seven patients (13.0%) underwent resection and arthrodesis. Mesh was used for containing the graft longitudinally in five patients (femoral and tibial intercalary reconstructions) and for soft tissue attachment in two patients (hip and shoulder endoprostheses).
The eligibility criteria were children and adults with Ewing's sarcoma of the bone excluding craniofacial bones, patients who had not received treatment elsewhere, and a histologically proven diagnosis. All patients were followed up for a minimum of 2 years or till death, if they died before 2 years.
Out of a total of 57 patients treated, 3 were lost to followup at an early stage (less than 2 years) and were excluded. The study did not include patients managed with non-surgical treatment with chemotherapy and radiotherapy. At presentation, all patients were investigated with local radiographs and MRI, followed by a core biopsy.
Histological assessment included hematoxylin and eosin-stained sections, staining for PAS, as well as assessment of MIC2 expression. Further staging included chest radiograph, non contrast CT (NCCT) chest, and Technitium-MDP bone scan. All patients first underwent neoadjuvant chemotherapy using cycles of vincristine, actinomycin-D, cyclophosphamide, and doxorubicin alternating with courses of ifosfamide and etoposide. Patients having large tumor were subjected to initial radiotherapy to reduce the size of the local tumor before surgery.


Two of such patients did not respond to radiotherapy and were subjected to limb ablation surgery. A repeat local site radiograph, MRI, and bone scan were performed before surgery to restage the tumor. Surgical planning was based on the age of the patient, the site and local extent of the tumor, involvement of neurovascular bundle, and clinical response to chemotherapy.
The options included resection followed by intercalary reconstruction with fibular graft or endoprosthesis insertion, arthrodesis, and amputation. Patients with purely diaphyseal Ewing's sarcomas were subjected to intercalary reconstruction with fibular autograft and morcellized allograft.
Patients having diametaphyseal tumors were treated with resection - endoprosthesis or resection - arthrodesis based on age and preferences of the patient. Patients having neurovascular involvement and skin fungation were treated with limb ablation surgery.Postoperatively, wound was examined at 2 nd postoperative day with drain removal.
Patients with arthrodesis and with intercalary reconstruction were immobilized in an above-knee plaster of paris slab till suture removal followed by above-knee cast for initial 3-4 months and later mobilization in above-knee caliper brace till radiological union. A total of 48 weeks of chemotherapy was given including neoadjuvant and adjuvant chemotherapy. The patients were followed up with radiographs of local site and chest at 3, 6, 9, 12, 18, and 24 months, and a bone scan and NCCT chest at 6 months. Further bone scan and CT were ordered if indicated by clinical examination and radiography.
Only two patients had axially located tumors - one in clavicle [Figure 1]a and b and another in the pelvis. All other tumors were located in the tibia (10 patients), humerus (3 patients), femur (34 patients; [Figure 2]a-c), fibula (4 patients), and ulna (1 patient). Patients with stage IV tumor received 8-10 cycles of neoadjuvant chemotherapy, while others received 6 cycles of neoadjuvant chemotherapy (average 7 cycles). Twenty-one of the 54 patients (38.9%) underwent resection of tumor and intercalary reconstruction fixed with locking plates with autogenous fibular graft and autogenous iliac crest corticocancellous graft in all of them [Figure 3]a and b, [Table 2].
The decision was based on the age of the patient, location of tumor, as well as patient's occupation and preference. Endoprosthesis was used in three proximal femoral tumors [Figure 2]a-c, seven distal femoral, two proximal tibial, three proximal humeral, and one proximal ulnar tumors. Knee arthrodesis was performed in four patients with distal femoral and three patients with proximal tibial tumors.
In arthrodesed knee, the bone gap following tumor resection was according to the length of the tumor and it was bridged with autogenous fibula along with morcellized allograft maintaining a shortening of not more than 5 cm (2-5 cm shortening).
Six patients (11.2%) had only resection of the tumor in the form of partial fibulectomy (four patients), claviculectomy (one patient) [Figure 1]a and b, and resection of pelvic tumor (one patient). In five cases of intercalary reconstruction, the mesh was used for reattachment of muscles, tendons and capsule, and to hold the bone graft pieces. The bone gap following resection was bridged with fibular autograft surrounded by morcellized allograft. This whole reconstruction was circumferentially enclosed in mesh, and the surrounding muscles and fascia were attached to the mesh. In two cases, it was used in the periarticular area following reconstruction with endoprosthesis, for stability, and reattachment of abductors and other soft tissues.Postoperatively, all patients with intercalary reconstruction or endoprosthesis achieved adequate functional range of motion, although all of them had varying degrees of stiffness.
Out of 33 cases of lower limb Ewing's sarcoma treated with intercalary reconstruction or endoprosthesis, twenty patients had a good functional range of motion (0-90° flexion in hip and 0-90° flexion in knee). Six patients had mild restriction of movements (5-80° flexion arc in hip and 5-80° flexion arc in knee).
The remaining seven patients had a flexion deformity of 10° at hip or knee joint (range of motion 10-70° flexion at hip and 10-70° flexion at knee). Three patients with proximal humeral endoprosthesis had abduction in the range of 0-20°, flexion 0-40°, and external rotation 0-10°. Five patients had superficial wound complications including superficial necrosis of margins and superficial infection (one patient following fibulectomy, two patients with intercalary reconstruction, and two patients with endoprosthesis insertion). They required debridement of wound and removal of allograft bone chips, followed by regular wound dressings and eventual healing of wound [Table 3]. One of the patients with intercalary reconstruction of femur with fibula and long locking plate presented 1 year later with implant failure and fracture of the fibular graft. Postoperatively, out of the 40 patients without preoperative metastases, 17 patients had developed local or distant recurrence by 2 year followup: 11 patients developed isolated pulmonary metastases, 5 patients developed pulmonary as well as local recurrence, and 1 patient developed isolated local recurrence. This patient with isolated local recurrence and four other patients with local recurrence underwent amputation.
Overall, 13 out of 40 patients without pre-operative metastases had died by the 2 year follow-up. Eight of the 14 patients with preoperative metastases had persistent pulmonary metastases at the time of 2-year followup or death. Resection of tumor in these patients with delayed presentation required more surgical time, blood replacements, mobilization of adjascent muscles for coverage (eg. Although advances in multimodal therapy have considerably improved the prognosis, distant metastases still have an incidence of 37-60% at 5 years. This late presentation makes planning and execution of surgery difficult due to increased local vascularity, muscle involvement, and close proximity of the neurovascular bundles. Reconstruction of the residual long skeletal defect after resection of these tumors becomes more challenging due to nonavailability of the allograft.
We found the disease-free survival rate in such patients following chemotherapy and surgery to be 53.7% at 2 years, which is comparable to the rates reported by other authors. For example, a tumor extending to a joint was managed with resection and either endoprosthesis insertion or arthrodesis, depending on the age of the patient, patient's needs and preferences, and non availability of endoprostheses.
Early joint mobilization, starting at 7-8 days, in patients with endoprosthesis insertion, resulted in an acceptable functional range of motion in all patients, although varying degrees of stiffness persisted. Various modalities of intercalary and joint reconstruction using osseous allograft, osteoarticular allograft, and allograft-prosthetic composites have been described in literature. Two of these patients developed deep wound infection requiring debridement and removal of allograft chips. In view of scarcity of allogenic bone grafts and nonavailability of bone banks in many places, intercalary reconstruction with autogenous fibula graft fixed with locking plate is a good option. Ten of our patients were offered this procedure, with good results and only minor wound complications in two of them. There was only one major complication of the reconstruction procedure due to implant pull out, which was managed with replating.
None of the patients with mesh insertion developed wound discharge postoperatively and no complications which might be attributable to mesh insertion were seen.
The soft tissue and fascial defects resulting from resection of tumor with wide soft tissue cuff may be covered with muscle grafts. However, in cases with extensive soft tissue dissection, the surgeon may not always have the luxury of being able to use such flaps.
Often it becomes impossible to reattach the soft tissues unless the gap is covered with something.
It physically bridges and stabilizes the soft tissue defect till adequate healing has occurred, and thus preserves muscle function and joint motion.The prognosis of Ewing's sarcoma with multimodality treatment has been proven to be better than with single modality treatment. These figures changed to 93% patients undergoing surgery and only 51% patients receiving radiotherapy in the second group.



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