J. Sancho. Central Connecticut State University.

In the lower nasal third generic elavil 10 mg with visa, these include and intermediate crus purchase genuine elavil on line, there is more deprojection and less rota- external nasal valve collapse cheap elavil 50mg, caudal septal deflection buy elavil 25mg on-line, and ves- tion. Additionally, during the septal evaluation, the rotation and less deprojection. The lobular arch is composed of the paired domal or apical arches The M-arch model further recognizes that these changes can deformity does not by itself render a poor surgical candidate. It is a fool’s game to col- mediate crura shortens the length of the infratip lobule and lapse under the pressure of patient distress and embark upon a increases the angle of the domal arch, thereby rounding the journey that has no reasonable course, the result of which will external soft tissue triangle. If the vertical division of the inter- be both an unhappy patient and an unhappy surgeon. The sur- mediate crus is performed near the angle or junction of the geon must sense that a sound rapport has been developed with medial crura and intermediate crura, a hanging infratip lobule the prospective patient—one that will weather potential turbu- can be reduced. The patient must also be physically and psy- or biconvex lobular arch can be narrowed. It is important to get an accurate sense of the technical and psycho- In the authors’ hands, the open approach provides the best logical challenges involved. The ideal rhinoplasty patient has a exposure for accurate tip structure diagnosis and surgical cor- clearly defined and realistic complaint of a long duration. Using scissors allows exact visual definition of the tip cartilages, even in revision cases—there is no guessing as to the position of the caudal mar- gins of the lower lateral cartilages as there may be in revision cases using the marginal incision. Once the nasal soft tissue has been adequately reflected and the underlying tip structures are visualized, diagnosis can be adequately performed. As stated previously, the length, tip pro- jection, and tip rotation have been previously assessed during the external physical exam. Now with the nasal tip fully exposed in its natural state, accurate diagnosis can be made as to the cause of these foundational abnormalities. Consideration should be given to the following tip assessments with the tip structures exposed: (1) medial crural length; (2) lateral crural length; (3) symmetry of the two paired medial and two paired lower lateral cartilages; (4) domal position and symmetry; (5) Fig. This previously placed tip grafts; (7) stability and strength of the tip technique allows complete exposure of the caudal septum for repair. Many variations and abnormalities may be encountered with proper diagnosis, including twisted and crooked tip complexes, caudal septum may be completely distorted or severely weak- asymmetric lower medial cartilages, asymmetric lower lateral ened and/or previously transected. In cases of curvature, scor- cartilages, biconvex or broadly curved lower lateral cartilages, ing can be successfully employed to straighten the curvature by asymmetric knuckling of cartilages at the domes, overresected scoring the cartilage along its concave side. Care is taken to cartilages, previously placed tip grafts, and weakened tip score superficially, avoiding complete transection and over- complexes. In cases of base deflection off the With tip assessment completed, attention should then be maxilla, a No. Many times, the length of the cartilage base must deformities of the caudal septum include curvature of the sep- be shortened to allow it to sit properly in the midline without tum and/or deflection of the septum and septal base off the midline anterior nasal spine. Other abnormalities may include a weakened or severely deformed caudal septal strut as a result of previous septorhinoplasty. Once diagnosis (and when done properly, confirmation of physical exam) is complete, attention should be turned first at correction of any caudal septal abnor- malities. We prefer to divide the soft tissue between the medial crura and domes to expose the caudal septum at the anterior septal angle. In cases of septal cartilage harvest or septoplasty, these procedures can be per- formed at this time. The strut is then secured in erally consists of either septal curvature, deflection of the base place. In cases of previously transected, severely deformed, or an overly weakened caudal septum, the caudal septum must be completely reconstructed and replaced or reinforced with a strong cartilage graft. This is best done with a straight portion of harvested septal cartilage combined with extended spreader grafts when necessary. Though removing the entire caudal sep- tum may seem daunting to the novice rhinoplasty surgeon, inadequate correction of a severe caudal septal deformity will inhibit adequate correction of the twisted tip and ultimately result in patient and surgeon dissatisfaction. This is done using a strong columellar strut to ensure that the base foundation is as straight as it can be. Analogous to building a house, if the foundation is crooked, the entire house will follow. In the case of the crooked tip, the foundation is likely already uneven and setting the new foundation will set up the rest of the procedure for success. Once the base is set, the upper half of the tip (top of the house) can be fine-tuned for symmetry. A second Keith needle is then placed just behind the first with a 4–0 Vicryl suture and the columella. The author’s technique for ensuring a straight base foundation follows: Construct an adequate columellar strut from the harvested cartilage (again, septum is best and rib base of the columella. A pocket needs to be dissected between the domes and retracted anteriorly straight up to provide optimal lower medial cartilages down to the anterior nasal spine. The nee- strut is then placed between the medial crura, with the base of dle is then passed through the opposite medial crura and mem- the graft resting on the spine. A second needle is then passed behind the col- through the membranous septum, through the right medial lat- umellar strut near the most caudal posterior aspect of the sep- eral cartilage, and into the columellar strut, low near the very tum from one side to the other; 4–0 Vicryl is used and the strut is secured in place. At this point, the surgeon assesses the straightness of the nasal base from the true basal view. If the columella is canting to one side or the other, or the columella is not straight, the sutures are removed and the process is repeated until the columella is completely straight up the midline. The key to this maneuver is focusing only on the nasal base at this point—pay no attention to the domes, as they may be uneven at this point. As long as the base has been corrected and straightened, the domes can be fine- tuned at a later step. In fact, when the cut cartilage edges are overlapped and stabilized, the M- arch is actually strengthened as compared with its native state. The arch is incised vertically and overlapped cartilage to analyze the lower two thirds of the columella and make sure that the construct is straight. Alternatively, 4–0 Vicryl sutures can be used to stabilize the cartilages through the ves- applied. This technique can be applied predictably to ally or bilaterally depending on the anatomic diagnosis at this achieve rotation, deprojection, and lobular refinement; to cor- point. Again, understanding the ideal tip structure will allow rect asymmetries; or to improve the nostril:columellar ratio any surgeon to assess and treat each of the problems associated. Alar Strut Grafting (Lateral Crural Grafting) Cephalic Trim Often, tip asymmetry is a direct result of the intrinsic asymmet- ric shape of the lower lateral cartilages. One cartilage may be The lateral crura are initially addressed to effect some degree of relatively convex, or biconvex, compared with the opposite car- lobule refinement. Horizontal resection of the cephalic margin of the lower lateral cartilage can achieve some reduction in supratip fullness and may allow for rotation by other means, though it does not in itself produce substantial rotation. Consid- erably more important than the cartilage resected is the amount and symmetry of cartilage retained, a principle that is readily noted using the open technique. Reduction of the crural arch to less than 8 to 10mm will serve only to heighten the risks of postoperative alar retraction and buckling. Lateral Crural Flap When significant domal asymmetry exists as a consequence of asymmetric lower lateral cartilage length, or when the nasal tip needs to be deprojected and rotated, a vertical division of the lower lateral cartilages with overlapping flap stabilization can be employed to achieve better symmetry and the desired result. Though warned against by some surgeons because of the pro- pensity for tip irregularities, we find this maneuver, when Fig. It is important to overlap the cartilages, rather than 327 Tip Rhinoplasty the lateral crus. The same principle is applied as with the alar strut graft, and it is important to make sure the graft spans from the remaining domal segment down over the pyriform edge 42. The difference is the location of vertical division, this time on the medial or intermediate crus. By shortening the excessive cartilage length of the M-arch directly, there is greater potential for achieving adequate deprojection, more predictive healing out- comes, and preservation or even strengthening of the tip com- plex. Vertical division of the M-arch with overlapping suture stabilization of the divided segments can provide a very desir- able and effective outcome. If lobular definition is satisfac- tory and the goal is to deproject, division at the medial crural feet preserves lobular contour and counterrotates. Furthermore, when the lobular contour is asymmetric, verti- cal division within the domal arch segment may be used to simultaneously correct arch length and asymmetry in addition to irregularities of the lobular-columellar relationship, such as a hanging infratip.

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While this effect may be insignificant for a single drug discount elavil 75 mg without a prescription, when combined this can be especially concerning for patients purchase elavil with visa. Isoniazid Identifying High-Risk Patients Isoniazid is contraindicated for patients with acute liver disease or a history of isoniazid-induced hepatotoxicity elavil 50mg lowest price. Use with caution in alcohol abusers purchase elavil 25 mg otc, diabetic patients, patients with vitamin B6 deficiency, patients older than 50 years, and patients who are taking phenytoin, rifampin, rifabutin, rifapentine, or pyrazinamide. Ongoing Monitoring and Interventions Minimizing Adverse Effects Peripheral Neuropathy. Peripheral neuritis can be reversed by prescribing daily doses of pyridoxine (vitamin B ). Isoniazid can suppress the metabolism of phenytoin, thereby causing phenytoin levels to rise. Use with caution in alcohol abusers, patients with liver disease, and patients taking warfarin. Ongoing Monitoring and Interventions Minimizing Adverse Effects Discoloration of Body Fluids. Rifampin may impart a harmless red-orange color to urine, sweat, saliva, and tears. If your patient wears soft contact lenses, be certain that they are aware that permanent staining may occur. Rifampin can accelerate the metabolism of many drugs, thereby reducing their effects. Pyrazinamide Identifying High-Risk Patients Pyrazinamide is contraindicated for patients with severe liver dysfunction or acute gout. Ongoing Monitoring and Interventions Minimizing Adverse Effects Nongouty Polyarthralgias. Ethambutol Identifying High-Risk Patients Ethambutol is contraindicated for patients with optic neuritis. Symptoms include blurred vision, altered color discrimination, and constriction of visual fields. However, unlike nalidixic acid, the fluoroquinolones are broad-spectrum agents that have multiple applications. As a result, these drugs are attractive alternatives for people who might otherwise require intravenous antibacterial therapy. Although side effects are generally mild, all fluoroquinolones can cause tendinitis and tendon rupture, usually of the Achilles tendon. Bacterial resistance develops slowly but has become common in Neisseria gonorrhoeae, and hence these drugs are no longer recommended for this infection. Fluoroquinolones used solely for topical treatment of the eyes are discussed in Chapter 84. Ciprofloxacin Ciprofloxacin [Cipro] was among the first fluoroquinolones available and will serve as our prototype for the group. Oral ciprofloxacin has been used as an alternative to parenteral antibiotics for treatment of several serious infections. Antimicrobial Spectrum Ciprofloxacin is active against a broad spectrum of bacteria, including most aerobic gram-negative bacteria and some gram-positive bacteria. Most urinary tract pathogens, including Escherichia coli and Klebsiella species, are sensitive. Other sensitive organisms include Bacillus anthracis, Pseudomonas aeruginosa, Haemophilus influenzae, meningococci, and many streptococci. Bacterial Resistance Resistance to fluoroquinolones has developed during treatment of infections caused by Staphylococcus aureus, Serratia marcescens, C. Bacteria do not directly inactivate fluoroquinolones, and there have been no reports of resistance through transfer of R factors. High concentrations are achieved in urine, stool, bile, saliva, bone, and prostate tissue. Also, ciprofloxacin is a preferred drug for preventing anthrax in people who have inhaled anthrax spores. Because ciprofloxacin is active against a variety of pathogens and can be given orally, the drug represents an alternative to parenteral treatment for many serious infections. Owing to high rates of resistance, ciprofloxacin is a poor choice for staphylococcal infections. Because of concerns about tendon injury (see later), systemic ciprofloxacin is generally avoided in children younger than 18 years. Nonetheless, the drug does have two approved pediatric uses: (1) treatment of complicated urinary tract and kidney infections caused by E. In older adults, ciprofloxacin poses a significant risk for confusion, somnolence, psychosis, and visual disturbances. Because of concerns regarding tendon injury, fluoroquinolones are generally avoided in this population. Pregnant women Although data reveal little potential for fluoroquinolone toxicity in the fetus, these data are limited. Breast-feeding Effects of fluoroquinolones on the nursing infant are largely unknown. B l a c k B o x Wa r n i n g : F l u ro q u i n a l o n e s a n d The n d o n R u p t u re Rarely, ciprofloxacin and other fluoroquinolones have caused tendon rupture, usually of the Achilles tendon. People at highest risk are those 60 years and older, those taking glucocorticoids, and those who have undergone heart, lung, or kidney transplantation. Fluoroquinolones damage tendons by disrupting the extracellular matrix of cartilage in immature animals. Because tendon injury is reversible if diagnosed early, fluoroquinolones should be discontinued at the first sign of tendon pain, swelling, or inflammation. In addition, patients should refrain from exercise until tendinitis has been ruled out. Although there are no controlled studies on the use of ciprofloxacin during pregnancy or lactation, limited data indicate that such use poses little or no risk for tendon damage to either the fetus or nursing infant. Because of the relative lack of data, alternative drugs should be given if possible. Ciprofloxacin and other fluoroquinolones pose a risk for phototoxicity (severe sunburn), characterized by burning, erythema, exudation, vesicles, blistering, and edema. These can occur after exposure to direct sunlight, indirect sunlight, and sunlamps—even if a sunscreen has been applied. Patients should be warned about phototoxicity and advised to avoid sunlight and sunlamps. People who must go outdoors should wear protective clothing and apply a sunscreen. B l a c k B o x Wa r n i n g : C i p ro f l o x a c i n a n d M y a s t h e n i a G r a v i s Ciprofloxacin and other fluoroquinolones can exacerbate muscle weakness in patients with myasthenia gravis. Accordingly, patients with a history of myasthenia gravis should not receive these drugs. Drug and Food Interactions Cationic Compounds Absorption of ciprofloxacin can be reduced by compounds that contain cations. Among these are (1) aluminum- or magnesium-containing antacids, (2) iron salts, (3) zinc salts, (4) sucralfate, (5) calcium supplements, and (6) milk and other dairy products, all of which contain calcium ions. These cationic agents should be administered at least 6 hours before ciprofloxacin or 2 hours after. Elevation of Drug Levels Ciprofloxacin can increase plasma levels of several drugs, including theophylline (used for asthma), warfarin (an anticoagulant), and tinidazole (an antifungal drug). For patients taking theophylline, drug levels should be monitored and the dosage adjusted accordingly. For patients taking warfarin, prothrombin time should be monitored and the dosage of warfarin reduced as appropriate. Ciprofloxacin is used to reduce the incidence of anthrax or prevent anthrax progression in people who have inhaled B. Other Systemic Fluoroquinolones Ofloxacin Basic Pharmacology Ofloxacin is similar to ciprofloxacin in mechanism of action, antimicrobial spectrum, therapeutic applications, and adverse effects.

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The management of women of reproductive age attending non- genitourinary medicine settings complaining of vaginal discharge purchase elavil uk. The management of women of reproductive age attending non- genitourinary medicine settings complaining of vaginal discharge discount elavil 25 mg mastercard. Her son died at 6 years of age in Pakistan but had not been tested for any genetic condition cheap elavil amex. For her future pregnancies pre-implantation genetic testing can be ofered to detect the following order 75 mg elavil with visa, except which one condition? She is now 16 weeks’ pregnant and her booking bloods reveal normal haematological and biochemical tests. A 43-year-old woman gravid 1 para 0 is referred to the antenatal clinic for booking. A 35-year-old woman presents to the early pregnancy unit with moderate vaginal bleeding. What would be the genetic complement and parental origin of the complete molar pregnancy? What is the most likely chromosomal abnormality responsible for truncus arteriosus? The following ofspring in her family are at risk of developing haemophilia in the scenarios described below except for which one? A female child whose mother is a carrier and has an afected father with haemophilia b. Which one of the following statements is true regarding foetal isoimmune erythroblastic anaemia? Repeated amniocentesis does not help in reliable monitoring of anti-Kell disease e. The following conditions are transmitted as autosomal dominant except for which one? The following genetic conditions except one, only manifest when an individual is homozygous and heterozygous for the mutant allele. The following conditions except one manifest only when the individual is homozygous for the mutant allele. One or two cells (blastomeres) are aspirated from the pre-implantation embryo on day 3 of development (6–10 cell stage). This is a condition which results from non-disjunction (95% of cases) or chromosomal translocation (5% of cases). Foetal serum concentration rises from the fourth week and peaks at 12–14 weeks of gestation. The majority (95%) occur due to non-disjunction and 5% are due to chromosomal translocations (inherited from a parent with balanced chromosomal translocation carrier). In approximately 80% of these, a possible mechanism is that a single sperm fertilises an empty egg followed by a duplication of all of the chromosomes. The genetics of gestational trophoblastic disease: A rare complication of pregnancy. Mostly it occurs spontaneously but can also be caused by chromosomal abnormalities and teratogens. In 40%–50% of the cases, the associated chromosomal abnormality is chromosome 22q11 deletions (DiGeorge Syndrome). The other features of chromosome 22q11 deletions include cardiac abnormality especially tetralogy of Fallot, abnormal facies, thymic aplasia, clef palate, hypocalcemia, hypoparathyroidism and learning disability. If the father is afected and the mother is a carrier, the ofspring will have the probability of being one afected female, one afected male, one normal and one carrier female. Anti-Kell antibodies do not afect haemolysis but rather infuence red cell production; therefore, amniocentesis is not reliable in monitoring the disease. The mirror syndrome is seen in hydrops fetalis, when the mother develops pre-eclampsia and the severity of her condition ‘mirrors’ that of the foetus. Doppler umbilical (not uterine) artery waveforms may provide guidance in the diagnosis of foetal anaemia. When this results from an additional set of maternal chromosomes, the placenta is small. Triploid cells contain three sets of the haploid number of chromosomes (23 × 3 = 69). It is rarely seen in live born, and when this happens survival beyond the early neonatal period can occur only in children who are mosaics (cells with diploid and triploid cells). Tey occur in both women and men and are not related to whether the foetus is male or female. Autosomal dominant inheritance Both homozygous and heterozygous individuals for the mutant allele will be affected in people who have autosomal dominant inherited conditions. The offspring of an individual with this condition has a one in two (50%) chance of being affected. Often it is possible to trace the disorder through generations in the family, and this condition affects every generation. Autosomal dominant inheritance conditions are as follows: • Adult polycystic kidney disease • Achondroplasia • Ehlers-Danlos syndrome • Familial hypercholesterolaemia • Familial adenomatous polyposis coli • Gilbert syndrome • Huntington chorea • Neurofbromatosis types 1 and 2 • Tuberose sclerosis • Myotonic dystrophy • Marfan syndrome • Von Hippel-Lindau disease • Von Willebrand disease 174 12. Autosomal recessive inheritance Autosomal recessive inheritance manifests only in individuals who are homozygous for the mutant allele. Individuals who are heterozygous for the condition often show no features and are completely healthy (carriers). Which one of the following is a recognised indication for ovum donation treatment in her case? A 40-year-old woman attends early pregnancy unit at 10 weeks for vaginal spotting. A 40-year-old woman has been trying to conceive for the last 2 years but has not been successful. She and her husband underwent all the investigations and they have been reported normal. Which one of the following is not true regarding the success rate of artifcial insemination? The use of fresh sperm is associated with a higher conception rate than frozen-thawed sperm. Of the women who do not conceive within the frst six cycles of artifcial insemination, 50% will do so with a further six cycles. She is attending her follow-up appointment afer being on the gonadotrophin stimulation protocol. Which one of the following results indicates a higher response to gonadotrophin stimulation? Her husband’s semen analysis results are reported as follows: Percentage of abnormal form: 85% Progressive motility: 35% pH: 7. She has been trying to conceive for the last 2 years with her menstrual cycles every 6 weeks. Her ultrasound scan shows two small intramural fbroids and two large subserosal fbroids and polycystic ovaries. Kallmann syndrome) chromosome deletion) (associated with cystic fbrosis in 70%) Acquired Following infection or surgery (e. Egg donation with surrogacy is required in the former case; while in the latter surrogacy with the patient’s own eggs could be used. In premature ovarian failure, the ovaries stop producing normal levels of oestrogen and may not produce eggs. It afects about one in 100 women before the age of 40 and fve in 100 women before the age of 45. Around 5%–10% of women will have sporadic ovulation and therefore should be advised to use contraception to avoid pregnancy if they have already completed their family. Causes of premature ovarian failure • Idiopathic • Autoimmune • Congenital: chromosomal, metabolic • Immunologic Iatrogenic causes include surgery, radiotherapy and chemotherapy. Management of premature ovarian failure • Hormone replacement therapy for vaso-motor symptoms, end-organ atrophy and prevention of osteoporosis Chances of fertility in women with premature ovarian failure • About 25%–30% pregnancy rate per cycle with oocyte donation. Dizygotic twins (fraternal twins) are twins formed from fertilization of two separate eggs by two separate sperms. If more than two eggs are released and fertilized with sperms it becomes mutizygotic twins and this can be triplets, quadruplets, quintuplets, sextuplets, septuplets and octuplets.

A subsolid nod- ule is a lesion with less density than a solitary pulmonary nodule buy generic elavil line. Adenocarcinoma is one of t he clinically import ant different ial diagnoses for subsolid nodules order elavil 50 mg with mastercard. Since primary adenocarcinoma of the lung can occur in younger patient s without smok- ing hist ories purchase elavil 25mg with visa, a h ist ory of smoking is not a considerat ion in t he management of subsolid nodules cheap elavil 25 mg online. G lobally, the lung can- cer incidence and mort ality closely parallel each other, which reflect the high case- fat alit y of the disease. T h e incidence of lung cancer h as been rising, part icularly in developed high-income countries. Lung cancer is the third most common cancer in t he United St at es beh ind breast and prost at e cancers. Cigarette smoking is t he single most import ant risk fact or for t he development of lung cancers, and radon exposure is the second leading cause of lung cancers in the Unit ed St at es. D ue t o the asymptomat ic nature of lung cancers during t he early st ages, many pat ient s wit h the disease are unfortunately diagnosed at rather advanced incurable stages. Malignant cells generally have higher metabolic rates than normal tissues and can therefore be differentiated from nonmalignant structures. T h ese scr een in g r ecom m en d at ion s h ave cau sed sign ifi- cant cont r over sy wit h in the m edical commu n it y, as scr een in g for lu n g can cer is expect ed t o lead t o early cancer det ect ion for some individuals. H owever, large- scale lung cancer screening can be costly and cause potent ial harm, including unnecessary diagnostic procedures following false-positive findings, radiation- induced malignancies, and psychological st ress associat ed posit ive screening tests. The potential harm from radiation exposure from medical imaging is a well- publicized concern among practitioners and the general public. To put this issue in perspect ive, naturally occurring background radiation exposure for an average person in the U. Dia g n o sis a n d Tre a t m e n t Most patients with primary lung cancers are symptomatic at diagnosis, with cough, ch est pain, an d r espir at or y dist r ess bein g the most com mon sympt oms. Ad en ocar- cin oma is the most common t ype of lung can cer respon sible for 45% of all cases, wit h most of t he lesions located in the periphery of the lungs. Squamous cell carcinomas make up approximately 30% of the lung can cers, t en d t o be more cent rally locat ed in the lun gs, an d are more likely t o undergo central necrosis and compressions of the airways. Small cell carcinomas make up 20% of the lung cancers and are most likely centrally located. Regional metastases occur frequently within the lungs and to mediastinal lymph nodes. A new lung nodule presenting in smokers have as high as 70% chance of being can cer ou s; t h er efor e, lung lesions in smokers should be approached with a high degree of suspicion. W ith serial x-rays, the radiologist can determine the rate of growth that helps differentiate between benign and malignant causes. When the clinical and radiographic pictures are suggest ive of pneumonia, a 10 to 14 day course of antibiotics can be prescribed with re-imaging performed following the completion of the treatment course. Lun g n odu les or masses locat ed cent rally are more likely t o cau se sympt oms and are often amenable to bronchoscopic evaluat ions. All patients who are under consider- at ions for lung resect ion for primary lung cancers should have cardiopulmonary evaluat ions to det ermine if he/ she can t olerat e an anat omic pulmonary resect ion. Anatomic resect ions for primary lung cancers have been shown to be associated wit h greater disease-free survival in comparison to nonanatomic resect ions (eg, wedge resect ions). T h e lung resect ion can be done eit h er by open surgery or t h o- racoscopically; resections by thoracoscopic approach have shown to produce more rapid postoperative recoveries and good oncologic outcomes. Recently, the use of focu sed radiat ion t h erapy or st ereot act ic ablat ive radiat ion t h erapy (G amma Kn ife) has been applied for curative intent in patients who do not have sufficient physi- ologic reserve to withstand surgery. Results of Gamma Knife treatments have been quite favorable, with local disease control rates reported at 30% to 50% and 5-year sur vival rat es report ed at 10% t o 30%. T h ere are current ly on-going clinical t rials directed at widening the applications of this technique. Adjuvant ch emot h erapy wit h cisplat in-based doublet adjuvant regimen is the most often prescribed therapy. In some patients, lung metastases represent the only active disease for the individuals; therefore, it is conceivable that these patients may receive benefit from resection of their pulmonary metas- tases (metastasectomy). Any associated atelectasis or obstructive pneumonitis must involve less than the entire lung T3 A t u m o r o f a n y s iz e w it h d ir e c t e x t e n s io n in t o the c h e s t w a ll (in c lu d in g s u p e r io r sulcus tumors), diaphragm, or mediastinal pleura or pericardium without invo lvin g the h e art, g re at ve sse ls, t rach e a, e so p h ag u s o r ve rt e b ral b o d y, or a tumor in the main bronchus within 2 cm of the carina without involving the carina, or associated atelectasis or obstructive pneumonitis of the entire lung T4 A t u m o r o f a n y s iz e w it h in v a s io n o f the m e d ia s t in u m o r in vo lv in g the h e a r t, g r e a t vessels, trache a, esop hag us, verteb ral b od y, or carina, or with the p resence of b malignant pleural or pericardial effusion or wit h sate llite t um or nod u le s wit h in the ip silat e ral, p rim ary t u m o r lo b e o f the lu n g N: Nodal involvement N0 No d e m o n st ra b le m e t a st a sis t o re g io n a l lym p h n o d e s N1 Me t a s t a sis t o lym p h n o d e s in the p e rib ro n c h ia l o r the ip s ila t e ra l h ila r re g io n o r b o t h, in clu d in g d ire ct e xt e n sio n N2 Me t a s t a sis t o ip s ila t e ra l m e d ia st in a l lym p h n o d e s a n d s u b ca rin a l lym p h n o d e s N3 Me t a s t a sis t o co n t ra la t e ra l m e d ia st in a l lym p h n o d e s, co n t ra la t e ra l h ila r lym p h nodes, ipsilateral or contralateral scalene, or supraclavicular lymph nodes M: Dis t a n t m e t a s t a s is M0 No (kn o wn ) d ist a n t m e t a st a sis c M1 Dist a n t m e t a st a sis p re se n t. Sp e cify site (s) a An u n c o m m o n s u p e r c ia l t u m o r o a n y s iz e w it h it s in va s ive c o m p o n e n t li m it e d t o the b r o n c h ia l w a ll t h a t m a y e xt e n d proximal to the main bronchus is classi ed as T1. Th e re a re, h o we ve r, a e w p a t ie n t s in wh o m cyt o - pathologic examination o pleural f uid (on more than one specimen) is or tumor; the f uid is nonbloody and is not an exudate. In such cases where these elements and clinical judgment dictate that the e usion is not related to the tumor, the patient should be staged T1, T2, or T3 excluding e usion as a staging element. The selec- tion of patients for metastasectomies is not straightforward, as the majority of patients with metastatic disease do not benefit from metastasectomies. Some important considerations for patient selection include pri- mary tumor type, the locations of the lesions, the number of metastatic lesions, and interval bet ween primary disease and met ast at ic disease present at ion. W it h regards to primary tumor type, it appears that patients with germ cell tumors, melanomas, sarcomas, and epithelial cancers (most commonly colorect al carcinoma) are the most likely to benefit from metastasectomies. Whereas, patients with metastatic can cer s from the lu n g an d br east r ar ely ben efit from r esect ion s of t h eir m et ast ases. In some cases where the indications for resection are in question, additional obser- vat io n t im e can oft en h elp an swer the q u est io n. Results of metastasectomies from several institutions have suggested that thoraco- scopic approach in these pat ient s can result in potent ially missing some met ast at ic Figure 37–1. Sim p lifie d t re a t m e n t a p p ro a ch fo r n o n sm a ll ce ll a n d sm a ll ce ll lu n g ca n ce r. A 33-year-old female nonsmoker presents with two isolated left lung masses each measuring 3 cm in diameter. A 4 6 - year - o ld m an wit h a h ist o r y of left t h igh soft t issu e sar co m a, wh o underwent complete resection of the primary tumor. An 86-year-old woman with a history of chronic obstructive pulmonary disease who had undergone resection of rectal cancer 3 years prior. At that time, she did not receive systemic chemotherapy because of her poor physiologic condition. She now has a solitary left middle lobe metastatic lesion measuring 2 cm in diameter D. A 23-year-old man with a pigmented lesion on the left shoulder with biopsy demonstrating malignant melanoma. Imaging studies demon- st rated a suspicious mass in the left front al portion of his brain and two 1-cm nodules in the left lung E. A 45-year-old man with a 6-cm left lung mass with biopsy demonstrating small cell lung cancer 37. Which of the following is the most appropriat e management for this pat ient? A 33-year-old man with malignant melanoma of the leg who has two 3-cm metastatic lung lesions involving the left upper lobe and right middle lobe, and t h ree 1-cm lesion s in the left lobe of the liver B. A 4 4 - year - o ld m an wit h a 8 - cm sm all cell car cin o m a of the lu n g wit h t wo brain metastases C. A 28-year-old man with a history of a 2-mm deep melanoma of the leg wh o h ad wide local resect ion, and sent inel lymph node biopsy that was negative. Four years after resection of the primary tumor, he presents wit h six 1-cm lung masses in t he periphery of t he left upper lobe and right lower lobe D. A 63-year-old woman with left breast T 2N 1 invasive ductal carcinoma wh o present s wit h t wo left lung nodules, a brain met ast asis, and a left adrenal lesion 2 years aft er her init ial resect ion E. A 44-year-old man with a 6-cm left calf soft tissue sarcoma resected by wide local resect ion. T hree years after t he resect ion he present s wit h a single 4-cm met ast asis t o t he right middle lobe of his lung 37. N onanatomic resection and anatomic resections of primary lung cancers have similar cancer-related outcomes B. C o n t r alat er al su b car in al n o d e in vo lvem en t wit h m et ast at ic d isease is a cont r ain d icat ion for p u lm on ar y r esect ion C. Stereotactic ablative radiation treatment of lung cancer only provides local disease palliat ion D.

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