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Connections What do these terms mean? The patient has been advised that if it is progressing it was likely to continue to do so and so she should consider surgery sooner rather than later as it will be a smaller operation with greater probability of success.

Currently the patient doesn't feel it is bad enough to warrant surgery. Radiographs that were provided consist of 3 views of each foot done in a weight bearing position. No fractures or dislocations are noted. Joint spaces appear well preserved. There is no soft tissue abnormality noted. There is a mild hallux valgus deformity of each foot. There appears to be a bipartite tibial sesamoid on the left.

The sesamoids appeared to be well located underneath the first metatarsal head. There is some prominence to each medial eminence on the first metatarsals. Although I was not able to accurately measure the hallux valgus angle or the intermetatarsal angle these do not seem much greater than values that have been determined in the normal, non-affected population.

I do not believe that surgery is needed at this time. Perhaps the primary determinant for undergoing surgery is whether the patient feels that it is warranted given their current set of circumstances. The patient very clearly states that she " It is quite possible that she will have worsening of the deformity with concomitant worsening of her pain and decrease in function.

If this occurs reassessment of the value of surgical correction should be undertaken at that time. What are the risks a if she has it now b if she waits until she is more symptomatic? Some of the risks that surgery poses would be present whether it is performed now or in the future. These include but are not limited to wound healing complications, infection, nerve damage, blood vessel damage, failure to achieve correction, recurrence of deformity, joint stiffness, continuing pain and overcorrection of deformity.

These would be specific to the procedure that was used. The alternatives that exist for the treatment of her problem include comfortable shoe wear with a wide toebox. Although I do not think that any one brand is superior to others I have found that Keen shoes are very effective in providing comfort in patients such as this.

I would avoid fashionable shoes that have a narrow, tapered toebox with high heels. In addition to altering shoe wear her current shoe wear might be able to be modified using a ball and ring shoe stretcher. The goal of this device is to stretch out the shoe upper material to better accommodate the medial eminence where most people have pain with hallux valgus deformity.

These can be obtained on line for a quite modest price and can be used repeatedly and in all of the patient's shoe wear. A silicone toe spacer can be placed between the first and second toes to realign the deformity and potentially provide her with some relief.

Based upon the history and images, what are your recommendations for the best patient outcome? Currently, I would pursue non-operative means for controlling the patient's symptoms and to prevent progression of her deformity. If these fail to provide relief she may want to consider surgery when she feels that non-operative methods have been exhausted and that she has no alternative. I do not advise her undergoing hallux valgus surgery at this time.

I think that using the aforementioned non-operative methods could provide her with significant relief and allow her to participate in the activities that she would like to.

If the deformity she has progresses and the feet become more painful she may want to consider surgery at that time. Unless there is a worsening of great magnitude in her deformity the surgical correction would not be that much more difficult to perform compared to the surgical procedures that could be considered currently.

Please do not hesitate to contact me in the future if there are additional questions or concerns. Thank you for the opportunity for providing treatment recommendations regarding this patient. Sincerely, Orthopedic Physician. Dear Dr. XX: Thank you for referring Ms.

Female Patient to Online Second Opinions. The patient is a year-old with a history of uterine myomas fibroids , presenting with abdominal discomfort. She has undergone imaging by both pelvic ultrasound and MRI and has been recommended surgery for possible uterine sarcoma. I am not able to offer an opinion on the imaging given that it is outside my scope of practice as a gynecologic oncologist and I am not a radiologist. My opinion is based on the available ultrasound report enclosed with the documents available for my review.

Uterine sarcoma accounts for 3 to 9 percent of all uterine malignant neoplasms. Uterine sarcomas arise from dividing cell populations in the myometrium or connective tissue elements within the endometrium. Compared with the more common endometrial carcinomas epithelial neoplasms , uterine sarcomas, particularly leiomyosarcomas connective tissue neoplasms , behave aggressively and are associated with a poorer prognosis.

Risk factors for uterine sarcoma include: black race for leiomyosarcoma, but not endometrial stromal sarcoma , long-term use of tamoxifen five years or more , and pelvic radiation. Genetic conditions associated with uterine sarcoma are hereditary leiomyomatosis and renal cell carcinoma HLRCC syndrome and hereditary childhood retinoblastoma. Uterine sarcomas typically present with vaginal bleeding, pelvic pressure symptoms eg, pressure, urinary frequency, constipation , or abdominal distension.

On pelvic examination, the uterus is often enlarged. The findings on examination and imaging for uterine sarcoma are nearly identical to those for benign uterine leiomyomas, as well as for atypical leiomyoma variants. Thus, the diagnosis of uterine sarcoma is often made after myomectomy or hysterectomy. Unfortunately, imaging studies cannot reliably differentiate between a uterine sarcoma and other uterine findings eg, leiomyomas, adenomyosis. The diagnosis of uterine sarcoma is based upon histologic examination.

Data regarding diagnostic accuracy of serum markers, biopsy, or imaging are limited in this rare disease. Thus, given the concern for a sarcoma raised by the ultrasound and the fact that it is not medically possible to make a definitive diagnosis of sarcoma without surgical tissue, I agree with the recommendation for surgery and would recommend a total hysterectomy and removal of both ovaries and fallopian tubes given that the area of concern extends to the adnexal region, which would also include the ovaries and the fallopian tubes.

The operation should be done so as to allow removal of all of these structures as a whole, without morcellating or cutting the tissue. The choice of treatment after surgery depends entirely on the final pathology. There are data to support use of chemotherapy in the setting of advanced-stage leiomysarcoma but the final recommendation regarding post operative treatment is entirely dependent on the surgical histologic findings.

Uterine sarcomas in Norway incidence, survival and mortality. Eur J Cancer ; Diagnosis and treatment of sarcoma of the uterus. A review. Acta Oncol ; Problematic uterine smooth muscle neoplasms. A clinicopathologic study of cases. Am J Surg Pathol ; Tumors of the uterine corpus and gestational trophoblastic disease.

Kurma RJ. Sandberg AA.