Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

👉The MILAN I trial compared 701 patients with invasive breast cancer up to 2 cm in size without clinically positive axillary lymph nodes and randomized them into those who received Halsted mastectomy and those who received quadrantectomy plus axillary dissection and radiotherapy.

👉A recent analysis of the trial showed no differences in OS between the two study groups.

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👉Incubation period

• The exact incubation period is not known.
• It is presumed to be between 2 to 14 days after exposure, with most cases occurring within 5 days after exposure.

👉The spectrum of illness severity

• Most infections are self limiting.
• COVID-19 tends to cause more severe illness in elderly population or in patients with underlying medical problems.
• As per the report from Chinese center for disease control and prevention that included approximately 44,500 confirmed infections with an estimation of disease severity:
  • Mild illness was reported in 81% patients
  • Severe illness was reported in 14% patients:
    • Definition of severe illness:
      • Hypoxemia
      • Greater than 50% lung involvement on imaging within 24 to 48 hours
  • Critical Disease was reported in 5% patients:
    • Definition of critical disease:
      • Respiratory failure
      • Shock
      • Multi-organ dysfunction syndrome
• Overall case fatality rate was:
  • Between 2.3% to 5%

👉Age affected

• Mostly middle aged (>30 years) and elderly.
• Symptomatic infection in children appears to be uncommon, and when it occurs, it is usually mild

👉Clinical Presentation

• In a study describing 1099 patients with COVID-19 pneumonia in Wuhan, the most common clinical features at the onset of illness were:
  • Fever in 88%
  • Dry cough in 67%
  • Fatigue in 38%
  • Dyspnea in 18.7%
  • Myalgias in 14.9%
• Pneumonia appears to be the most common and severe manifestation of infection:
  • In this group of patients breathing difficulty developed after a median of five days of illness.
  • Acute respiratory distress syndrome:
    • Developed in 3.4% of patients.
• Other symptoms
  • Headache
  • Sore throat
  • Rhinorrhea
  • Gastrointestinal symptoms
• About 80% of confirmed COVID-19 cases:
  • Suffer from only mild to moderate disease
• Nearly 13% have severe disease:
  • Dyspnea
  • Respiratory frequency ≥ 30/minute
  • Blood oxygen saturation ≤ 93%
  • PaO2/FiO2 ratio less than 300
  • Lung infiltrates of greater than 50% of the lung filed within 24 to 48 hours
• Critical illness is seen in approximately 6% of the cases:
  • Respiratory failure
  • Septic shock
  • Mutliple organ dysfunction /failure

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👉The NSABP B-06, Phase III Trial Total Mastectomy/Axillary Dissection vs Segmental Mastectomy/Axillary Dissection with or without Radiotherapy for Potentially Curable Breast Carcinoma.

👉Compared lumpectomy and axillary node dissection with or without breast irradiation with modified radical mastectomy (MRM) in patients with tumors 4 cm or less in greatest diameter.

👉After 20 years of follow-up, there are no observed differences in OS, or distant disease-free survival between the MRM group and the groups treated with breast-conserving surgery (BCS), with or without radiation.

👉The hazard ratio (HR) for death with BCS alone was 1.05 (95% confidence interval [CI], 0.90–1.23; P=0.51).

👉The HR for death with BCS plus radiation was 0.97 (95% CI, 0.83–1.14; P=0.74).

👉These are comparable to MRM.

👉The results of this trial demonstrating equivalent survival between the two surgical options establish BCS as a viable surgical option for most patients with invasive breast cancer.

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👉Since the first reports of cases from Wuhan, at the end of 2019, more than 80,000 COVID-19 cases have been reported in China; including all laboratory-confirmed cases as well as clinically diagnosed cases in the Hubei Province.

👉Increasing numbers of cases have also been reported in other countries across all continents except Antarctica.

👉The rate of new cases outside of China has outpaced the rate in China which led world health organization (WHO) to declare COVID-19 as a pandemic.

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👉A consequencia de la pandemia mundial por el virus COVID-19 voy a tener que modificar la manera que atiendo a pacientes.

👉Voy a estar disponible para poder dar cosultas médicas por video conferencias:

• Nos pondríamos de acuerdo por medio de email o por celular, o WhatsApp.

👉En casos de urgencia seria en el departamento de urgencias del Hospital ABC Santa Fe.

Rodrigo Arrangoiz MS, MD, FACS

Cirugía General y Gastrointestinal – Michigan State University

Cirugía Oncológica Fox Chase Cancer CenterTumores de Cabeza y Cuello / Cirugía Endocrina – Fox Chase Cancer Center

Tumores de Cabeza y Cuello / Cirugía Endocrina – IFHNOS / Memorial Sloan Kettering Cancer Center

Maestría en Ciencias de Investigación – Drexel University

Certificado por el Colegio Americano de Cirugía

Fellow del Colegio Americano de Cirugía

Fellow de la Sociedad de Cirugia Oncológica

Sociedad Quirúrgica S.C.

Hospital ABC Santa Fé

Av. Carlos Graef Fernández # 154 Consultorio 515. Col. Tlaxala, Delg. Cuajimalpa México, D.F. 05300.

Tel: 1103 – 1600 Ext 4515 a la 4517. Fax:1664 – 7164

Urgencias:

Radio: (55) 5629 9800 / 629 9800 Pin 9981843

Celular: 5551039427

rodrigo.arrangoiz@gmail.com http://www.sociedadquirurgica.com http://www.cirugiatiroides.com http://www.hiperparatiroidismo.info

👉Our understanding of the mode of transmission is currently incomplete.

👉Epidemiologic investigation in Wuhan at the beginning of the outbreak identified an initial association with a seafood market where most patients had worked or visited.

👉The seafood market also sold live rabbits, snakes and other animals.

👉The initial concept was that the virus originated from snakes, however later studies proved that it had more similarity with bats.

👉However, as the outbreak progressed, person-to-person transmission through droplets and fomites became the primary mode of transmission.

👉How does Person-to-person transmission occur?

👉Droplet transmission:

• The virus is released in the respiratory secretions when an infected person coughs, sneezes or talks.
• These droplets can infect others if they make direct contact with the mucous membranes.
• Infection can also occur by touching an infected surface and followed by eyes, nose or mouth.
• Droplets typically do not travel more than six feet (about two meters) and do not linger in the air.
• However, given the current uncertainty regarding transmission mechanisms, airborne precautions are recommended routinely in some countries and in the setting of specific high risk procedures.
• Patients are thought to be most contagious when they are symptomatic.
• Some spread might be possible before symptoms appear, but this is not thought to be a common occurrence.
• Other possible modes of transmission:
  • It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this is not thought to be the main way the virus spreads.
  • One study suggested that the virus may also be present in feces and could contaminate places like toilet bowls and bathroom sinks:
    • But the researchers noted the possibility of this being a mode of transmission needs more research.
  • In February a Chinese newborn was diagnosed with the new coronavirus just 30 hours after birth:
    • The baby’s mother tested positive before she gave birth.
    • It is unclear how the disease was transmitted – in the womb, or after birth.
  • Recently in London another newborn was tested positive for the coronavirus, marking what appears to be the second such case as the pandemic worsens.

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👉The National Comprehensive Cancer Network (NCCN) guidelines support genetic counseling for any woman diagnosed with early-onset breast cancer.

👉The current definition of early onset is age less than or equal to 50 year.

👉In addition, these guidelines support genetic counseling for any woman diagnosed with triple-negative breast cancer who is age 60 or younger.

👉This is because pathologic BRCA1 gene mutations are associated with basal-type triple-negative breast cancer.

👉The results of a genetic test would directly inform estimation of ipsilateral breast tumor recurrence risk with breast conservation, contralateral breast cancer risk, and risk for other cancers, such as ovarian cancer.

👉Genetic testing can be inexpensive depending on the provider.

#Arrangoiz #BreastSurgeon #BreastCancer #HereditaryBreastCancer #CancerSurgeon #SurigalOncologist

👉The NSABP B-04, A Protocol for the Evaluation of Radical Mastectomy (RM) and Total Mastectomy (TM) With and Without Radiation in the Primary Treatment of Cancer of the Female Breast.

👉It enrolled 1079 patients with clinically node-negative disease, and randomized them to RM, TM plus local-regional axillary irradiation, or TM alone.

👉In a parallel trial, 586 patients with clinically node-positive disease were randomized to RM or TM plus radiation.

👉After 25 years of follow-up, the study showed no significant difference in long-term outcome between clinically node-negative patients who received RM and those who received TM plus radiation, or between clinically node-positive patients who received RM and those who received TM with nodal irradiation.

👉When comparing the hazard ratio for death within the two arms, the results show no survival advantage from RM.

👉In patients with clinically node-negative disease, pathologic examination of the mastectomy specimen revealed that 40% of the patients had pathologically positive nodes.

👉However, because the axillary failure rate in the TM alone arm was only 19%, we are led to conclude that occult axillary disease may not always progress into clinically overt disease.

👉The similar overall survival (OS) among the three arms in this trial also indicates that an axillary dissection in this trial would be largely prophylactic, and the outcome would not be compromised should the dissection be deferred until there is clinical evidence of a diseased axilla.

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Generalities

👉Corona virus comprises of a large family of viruses that are common in human beings as well animals (camels, cattle, cats, and bats).

👉There are seven different strains of corona virus:

• 229E (alpha coronavirus)
• NL63 (alpha coronavirus)
• OC43 (beta coronavirus)
• HKU1 (beta coronavirus)
• MERS-CoV (the beta coronavirus that causes Middle East Respiratory Syndrome, or MERS)
• SARS-CoV (the beta coronavirus that causes severe acute respiratory syndrome, or SARS)
• SARS-CoV-2 (the novel coronavirus that causes coronavirus disease 2019, or COVID-19)

👉Sometimes corona virus from animals infect people and spread further via human to human transmission such as with MERS-CoV, SARS-CoV, and now with this COVID 19 (Corona disease 2019).

👉The virus that causes COVID-19 is designated severe acute respiratory syndrome corona virus 2 (SARS-CoV-2); previously, referred to as 2019-nCoV.

👉Towards December 2019, this novel corona virus was identified as a cause of upper and lower respiratory tract infections in Wuhan, a city in the Hubei Province of China.

👉It rapidly spread, resulting in an epidemic throughout China and then gradually spreading to other parts of the world in pandemic proportions.

👉It has affected almost every continent in this world, except Antarctica.

👉In February 2020, the World Health Organization designated the disease COVID-19, which stands for corona virus disease 2019.

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👉The soft palate is located in the oropharynx posteriorly.

👉It is mobile, and comprised of muscle fibres covered by a mucous membrane (stratified squamous epithelium).

👉The soft palate is a musculoaponeurotic curtain that hangs down from the posterior border of the hard palate and maintains velopharyngeal competence during speech and swallowing.

👉The midline uvula is located on the free inferior border and the sides blend into the faucial arches that attach to the lateral pharyngeal walls.

👉The mucosa of the soft palate is of the stratified squamous epithelium.

👉The submucosa of the soft palate contains minor salivary glands that mainly secret mucus.

👉The muscles of the soft palate include the palatopharyngeus, palatoglossus, tensor veli palatini, levator veli palatini, and musculus uvulae.

👉Anteriorly, the soft palate is continuous with the hard palate and with the palatine aponeurosis.

👉The posterior border of the soft palate is free (i.e. not connected to any structure), and has a central process that hangs from the midline – the uvula.

👉The soft palate also forms the roof of the fauces; an area connecting the oral cavity and the pharynx.

👉Two arches bind the palate to the tongue and pharynx:

👉The palatoglossal arches anteriorly and the palatopharyngeal arches posteriorly.

👉Between these two arches lie the palatine tonsils, which reside in the tonsillar fossae of the oropharynx.

Muscles of the Soft Palate

👉There are five muscles which give the actions of the soft palate.

👉They are all innervated by the pharyngeal branch of the vagus nerve (CN X).

👉The Tensor veli palatini is the only muscle of the soft palate that is not innervated by the pharyngeal plexus derived from the vagus nerve.

👉The Tensor Veli palatini is innervated by the medial pterygoid nerve (madibular division of the trigeminal nerve / CN V).

Tensor Veli Palatini

• Attachments: Originates from the medial pterygoid plate of the sphenoid bone and inserts into the palatine aponeurosis.
• Function: Tenses the soft palate.

Levator Veli Palatini

• Attachments: Arises from the petrous portion of the temporal bone and the eustachian tube, before inserting into the palatine aponeurosis.
• Function: Elevation of the soft palate.

Palatoglossus

• Attachments: Originates from the palatine aponeurosis, and travels anteriorly, laterally and inferiorly to insert into the side of the tongue.
• Function: Pulls the soft palate towards the tongue.

Palatopharyngeus

• Attachments: Arises from the palatine aponeurosis and the hard palate, and inserts into the upper border of the thyroid cartilage.
• Function: Tenses soft palate and draws the pharynx anteriorly on swallowing.

Musculus Uvulae

• Attachments: Arises from the posterior nasal spine and the palatine aponeurosis, and inserts into the mucous membrane of the uvula.
• Function: Shortens the uvula.

Vasculature of the Soft Palate

👉The palate receives its arterial supply primarily from the greater palatine arteries, which run anteriorly from the greater palatine foramen.

👉In addition, the anastomosis between the lesser palatine artery and ascending palatine artery provide collateral supply to the palate.

👉Venous drainage is into the pterygoid venous plexus.

Innervation of the Soft Palate

👉Sensory innervation of the palate is derived from the maxillary branch of the trigeminal nerve (CN V).

👉The greater palatine nerve innervates most of the glandular structures of the hard palate.

👉The nasopalatine nerve innervates the mucous membrane of the anterior hard palate and the lesser palatine nerves innervate the soft palate.

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