Scapular

deformity

in

obstetric

brachial

plexus

palsy

a

new

finding

While

most

obstetric

brachial

plexus

palsy

patients

recover

arm

and

hand

function

the

residual

nerve

weakness

leads

to

muscle

imbalances

about

the

shoulder

which

may

cause

bony

deformities

In

this

paper

we

describe

abnormalities

in

the

developing

scapula

and

the

glenohumeral

joint

We

introduce

a

classification

for

the

deformity

which

we

term

Scapular

Hypoplasia

Elevation

and

Rotation

Multiple

anatomic

parameters

were

measured

in

bilateral

CT

images

and

three-dimensional

CT

reconstruction

of

the

shoulder

girdle

of

obstetric

brachial

plexus

palsy

patients

-LRB-

age

range

months

years

-RRB-

The

affected

scapulae

were

found

to

be

hypoplastic

by

an

average

of

while

the

ratio

of

the

height

to

the

width

of

the

body

of

scapula

-LRB-

excluding

acromion

-RRB-

were

not

significantly

changed

the

acromion

was

significantly

elongated

by

an

average

of

These

parameters

as

well

as

subluxation

of

the

humeral

head

-LRB-

average

-RRB-

and

downward

rotation

in

the

scapular

plane

were

found

to

correlate

with

the

area

of

scapula

visible

over

the

clavicle

This

finding

provides

a

classification

tool

for

diagnosis

and

objective

evaluation

of

the

bony

deformity

and

its

severity

in

obstetric

brachial

plexus

palsy

patients

Introduction

The

most

commonly

injured

brachial

plexus

nerve

root

in

obstetric

injuries

is

the

fifth

cervical

-LRB-

-RRB-

root

The

supplied

shoulder

girdle

musculature

is

therefore

most

commonly

affected

and

indeed

shoulder

deformities

comprise

the

most

significant

problems

in

this

injury

-LSB-

-RSB-

Within

the

context

of

shoulder

deformity

the

medial

rotation

contracture

-LRB-

MRC

-RRB-

deformity

results

in

the

greatest

morbidity

The

pathophysiology

of

deformity

has

been

known

for

over

years

paralysis

of

the

shoulder

abductors

and

external

rotators

leads

to

relative

dominance

of

already

strong

internal

rotators

of

the

shoulder

with

eventual

clinically

observed

changes

of

arm

posture

The

imbalance

causes

progressive

deformity

in

the

growing

shoulder

which

may

progress

to

a

fixed

medial

rotation

position

of

the

humerus

as

well

as

posterior

subluxation

of

the

humeral

head

-LSB-

-RSB-

This

constant

position

of

the

shoulder

has

a

deleterious

effect

on

glenohumeral

development

-LSB-

-RSB-

and

is

accompanied

by

a

characteristic

flexion

and

MRC

of

the

shoulder

Furthermore

scapular

growth

is

impaired

compared

to

the

normal

side

-LSB-

-RSB-

The

patients

exhibit

a

persistent

elbow-bent

posture

pronation

position

of

the

forearm

and

apparent

shortening

of

the

arm

-LRB-

Fig.

-RRB-

In

movement

there

is

loss

of

supination

due

to

the

abnormally

situated

arm

in

medial

rotation

obvious

elbow

flare

when

the

biceps

is

flexed

the

bugler

's

position

and

awkward

external

rotation

This

secondary

structural

shoulder

deformity

develops

early

and

may

persist

despite

improvement

in

neurological

status

-LSB-

-RSB-

Fig.

rest

the

child

is

noted

to

exhibit

an

internal

rotation

posture

at

the

shoulder

with

elbow

flexion

and

pronation

of

the

forearm

There

is

apparent

shortening

of

the

arm

There

have

been

previous

radiologic

demonstrations

of

scapular

deformity

as

a

sequela

of

obstetric

brachial

plexus

palsy

using

plain

radiographs

or

computed

axial

tomography

were

used

but

attention

was

directed

solely

to

the

glenoid

fossa

and

adjacent

structures

without

evaluating

the

body

spine

and

acromion

process

-LSB-

-RSB-

In

the

current

study

we

describe

dysplasia

and

malposition

of

the

entire

scapula

in

obstetric

brachial

plexus

palsy

patients

We

introduce

a

classification

of

this

deformity

which

we

term

collectively

Scapular

Hypoplasia

Elevation

and

Rotation

-LRB-

SHEAR

-RRB-

Methods

Patients

A

total

of

obstetric

brachial

plexus

palsy

patients

with

glenohumeral

internal

rotation

were

evaluated

in

the

past

months

We

reviewed

the

clinical

data

on

these

patients

and

diagnosed

and

classified

the

scapular

elevation

according

to

the

results

of

clinical

examination

and

analysis

There

were

boys

and

girls

ranging

in

age

from

months

to

years

Three

of

the

children

had

not

undergone

any

surgery

Twenty-four

of

the

children

had

undergone

latissimus

dorsi

and

teres

major

muscle

transfer

subscapularis

pectoralis

major

and

minor

contracture

releases

and

axillary

nerve

decompression

and

neurolysis

for

correction

of

abduction

at

our

institute

in

the

past

Twelve

of

the

latter

group

and

one

that

had

not

undergone

the

aforementioned

procedure

had

undergone

primary

neurological

repair

surgery

Measurements

Transverse

CT

section

and

three-dimensional

reconstructions

of

bilateral

computerized

tomograms

-LRB-

-RRB-

were

used

in

the

evaluation

process

Trunk

anterior

and

trunk

posterior

views

of

the

whole

shoulder

girdle

as

well

as

superior

trunk

outlet

and

scapular

posterior

and

medial

views

were

examined

The

contralateral

scapulae

were

assessed

for

comparison

The

height

-LRB-

H

-RRB-

of

the

scapula

was

measured

on

the

scapular

medial

view

as

the

length

of

the

medial

border

between

the

superior

angle

and

the

inferior

angle

Width

was

measured

along

the

spine

of

the

scapula

on

the

scapular

posterior

view

The

total

width

-LRB-

W

-RRB-

was

measured

from

the

lateral

end

of

the

acromion

to

the

most

medial

part

of

the

scapula

Width

of

the

body

of

the

scapula

-LRB-

w

-RRB-

was

measured

as

the

distance

from

the

glenoid

to

the

most

medial

part

of

the

scapula

-LRB-

Fig.

-RRB-

Fig.

of

the

different

scapular

variables

a

The

width

is

assessed

in

the

posterior

scapular

view

-LRB-

left

-RRB-

along

the

axis

of

the

scapular

spine

The

total

width

-LRB-

W

-RRB-

is

calculated

as

the

length

from

the

end

of

the

acromion

to

the

most

medial

aspect

of

the

scapula

The

scapular

body

width

-LRB-

w

-RRB-

is

calculated

as

the

distance

from

the

mid

glenoid

to

the

most

medial

aspect

of

the

scapula

The

acromion

length

-LRB-

acr

-RRB-

is

also

calculated

on

this

view

The

height

-LRB-

H

-RRB-

is

measured

along

the

medial

border

of

the

scapula

in

the

medial

scapular

view

-LRB-

right

-RRB-

b

Lines

are

drawn

from

the

center

of

the

glenoid

cavity

perpendicular

to

the

vertebral

axis

line

on

the

posterior

trunk

view

Superior

displacement

A/H

Downward/upward

rotation

around

an

axis

perpendicular

to

the

scapular

plane

is

defined

as

the

difference

between

the

angles

α

defined

by

the

vertebral

axis

and

the

extension

of

the

lines

connecting

the

center

of

the

glenoid

cavity

and

the

medial

end

of

the

spine

of

the

scapula

c

In

the

anterior

trunk

view

three

lines

are

drawn

Line

is

the

line

between

the

sternoclavicular

joint

and

the

center

of

the

acromio-clavicular

joint

line

is

the

line

between

the

center

of

the

acromio-clavicular

joint

and

the

inferior

angle

of

the

scapula

line

is

the

vertebral

axis

The

superior

scapular

angle

γ

is

the

angle

defined

between

lines

and

and

the

inferior

scapular

angle

δ

is

the

angle

between

lines

and

d

In

the

superior

outlet

view

the

anterior/posterior

rotation

is

calculated

as

the

angle

ϕ

between

the

line

connecting

the

acromio-clavicular

joint

to

the

superomedial

angle

and

the

line

between

the

sterno-clavicular

joint

and

the

center

of

the

acromio-clavicular

joint

-LRB-

clavicular

axis

-RRB-

e

Schematic

drawing

showing

the

method

of

calculating

glenoscapular

angle

-LRB-

glenoid

version

θ

-RRB-

posterior

subluxation

of

the

humeral

head

and

spinoscapular

angle

-LRB-

ζ

-RRB-

The

scapular

line

that

connects

the

medial

aspect

of

the

scapula

and

the

mid

glenoid

is

drawn

A

second

line

is

drawn

connecting

the

posterior

and

anterior

margins

of

the

glenoid

are

subtracted

from

the

angle

of

the

posterior

medial

quadrant

defined

by

these

lines

to

determine

the

glenoid

version

θ

A

line

perpendicular

to

the

scapular

line

is

drawn

and

the

percentage

of

posterior

subluxation

is

defined

as

the

ratio

of

the

distance

from

the

scapular

line

to

the

anterior

portion

of

the

head

to

the

diameter

of

the

humeral

head

-LRB-

LM/LN

-RRB-

The

spinoscapular

angle

-LRB-

ζ

-RRB-

is

measured

as

the

angle

between

the

scapular

line

and

the

medial

plane

Vertical

displacement

was

measured

on

the

trunk

posterior

view

with

reference

to

the

contralateral

side

Lines

were

drawn

from

the

center

of

the

glenoid

cavity

perpendicular

to

the

vertebral

axis

line

Vertical

displacement

is

the

percentage

of

the

difference

between

the

levels

of

the

two

glenoids

-LRB-

A

-RRB-

divided

by

the

height

of

the

contralateral

scapula

-LRB-

H

-RRB-

Positive

sign

denotes

superior

displacement

and

negative

sign

inferior

displacement

-LRB-

Fig.

-RRB-

In

order

to

define

the

rotation

of

the

affected

scapula

on

an

axis

perpendicular

to

the

scapular

plane

-LRB-

downward/upward

-RRB-

we

calculated

the

angle

-LRB-

α

-RRB-

between

the

extension

of

the

line

connecting

the

mid

glenoid

to

the

base

of

the

spine

of

the

scapula

and

the

vertebral

axis

line

-LRB-

Fig.

-RRB-

We

also

calculated

two

angles

between

three

lines

forming

a

triangle

Line

was

drawn

between

the

sterno-clavicular

joint

and

the

center

of

the

acromio-clavicular

joint

and

line

between

the

center

of

the

acromio-clavicular

joint

and

the

inferior

angle

of

the

scapula

Line

was

the

vertebral

axis

line

The

superior

scapular

angle

-LRB-

γ

-RRB-

is

the

angle

defined

between

lines

and

and

the

inferior

scapular

angle

-LRB-

δ

-RRB-

is

the

angle

between

lines

and

-LRB-

Fig.

-RRB-

The

rotation

on

the

axis

of

the

scapular

spine

-LRB-

anterior/posterior

-RRB-

was

assessed

on

the

superior

outlet

view

by

measuring

the

angle

-LRB-

ϕ

-RRB-

of

convergence

of

the

longitudinal

lines

of

the

shaft

of

the

clavicle

and

the

line

connecting

the

superomedial

angle

of

the

scapula

to

the

acromio-clavicular

joint

-LRB-

Fig.

-RRB-

The

total

area

of

the

scapula

was

calculated

on

the

scapular

posterior

view

The

area

of

the

scapula

visible

on

the

anterior

view

above

the

clavicle

with

reference

to

the

contralateral

side

was

measured

on

the

trunk

anterior

view

For

distance

and

area

measurements

graphic

software

-LRB-

Universal

Desktop

Ruler

AVPSoft.com

-RRB-

was

used

On

a

transverse

CT

image

at

the

mid-glenoid

level

a

scapular

line

was

constructed

that

connected

the

medial

margin

of

the

scapula

to

the

middle

of

the

glenoid

fossa

The

glenoscapular

angle

-LRB-

glenoid

version

-RRB-

was

measured

according

to

Friedman

et

al.

-LSB-

-RSB-

as

the

angle

between

the

scapular

line

-LRB-

connecting

the

scapular

medial

margin

to

the

middle

of

the

glenoid

-RRB-

and

the

line

connecting

the

base

of

the

anterior

labrum

and

posterior

labrum

By

definition

are

subtracted

from

the

posteromedial

quadrant

angle

to

define

the

glenoscapular

angle

-LRB-

θ

-RRB-

-LRB-

Fig.

-RRB-

The

same

scapular

line

is

used

to

determine

the

degree

of

humeral

head

subluxation

The

greatest

diameter

of

the

head

was

measured

-LRB-

LN

-RRB-

as

the

distance

of

the

scapular

line

to

the

anterior

portion

of

the

head

-LRB-

LM

-RRB-

The

percentage

of

subluxation

was

calculated

as

the

ratio

of

these

distances

multiplied

by

-LRB-

Fig.

-RRB-

Rotation

about

an

approximately

vertical

axis

-LRB-

internal/external

-RRB-

was

assessed

by

measuring

the

spinoscapular

angle

-LRB-

ζ

-RRB-

between

the

scapular

line

and

the

median

plane

Both

the

affected

and

contralateral

sides

were

assessed

and

the

values

discussed

take

into

account

comparison

between

sides

unless

specifically

indicated

Statistics

Descriptive

statistics

were

calculated

for

each

variable

including

mean

standard

deviation

and

range

Comparisons

of

means

for

continuous

variables

were

performed

by

the

Pearson

product

correlation

coefficients

and

the

paired

Student

t

test

with

Microsoft

Excel

software

-LRB-

Microsoft

Redmond

WA

USA

-RRB-

P

values

were

two-tailed

and

P

values

of

were

considered

to

be

significant

Results

The

patients

were

noted

to

have

unilateral

scapular

elevation

as

a

result

of

downward

rotation

to

various

extents

The

data

for

the

patients

as

well

as

the

significance

value

between

affected

and

contralateral

side

and

the

correlation

coefficient

of

each

variable

to

the

area

of

affected

scapula

visible

above

the

clavicle

are

summarized

in

Table

The

area

of

scapula

visible

above

the

clavicle

significantly

correlated

with

downward

rotational

deformity

-LRB-

r

-RRB-

affected

to

contralateral

height

ratio

-LRB-

r

-RRB-

ratio

of

affected

acromion

to

total

width

-LRB-

r

-RRB-

ratio

of

affected

acromion

to

height

-LRB-

r

-RRB-

affected

to

contralateral

acromion

length

-LRB-

r

-RRB-

affected

to

contralateral

area

-LRB-

r

-RRB-

superior

scapular

angle

-LRB-

r

-RRB-

inferior

scapular

angle

-LRB-

r

-RRB-

and

subluxation

-LRB-

r

-RRB-

Table

of

the

computed

tomography

data

on

the

patientsAffectedContralateralAffected

to

contralateralPraMeanRangeMeanRangeMeanRangeHypoplasiaAcromion

as

percentage

of

widthacr/W

to

to

to

Acromion

as

percentage

of

heightacr/H

to

to

to

Affected

acromion/control

to

Percent

scapular

area

visible

above

to

Percent

ratio

affected

to

contralateral

scapular

to

Affected

to

contralateral

height

to

Affected

to

contralateral

width

to

NS

Height

to

scapular

body

to

to

to

NS

Affected

to

contralateral

scapular

body

to

Height

to

total

width

to

to

to

ElevationPercent

vertical

displacementA/H

to

RotationDownward/Upward

displacement

to

to

to

Internal/External

displacement

ζ

to

to

to

NS

Anterior/Posterior

displacement

to

to

to

Superior

scapular

angle

to

to

to

Inferior

scapular

angle

to

to

to

Percent

subluxationLM/LN

to

to

to

Glenoscapular

angle

θ

to

to

to

The

exact

measurements

-LRB-

as

abbreviated

in

the

second

column

-RRB-

are

defined

in

Fig.

between

ratio

or

difference

of

affected

to

contralateral

side

value

to

scapular

area

visible

over

clavicle

Age

did

not

significantly

correlate

with

any

of

the

parameters

measured

Vertical

displacement

was

noted

to

be

either

superior

-LRB-

patients

-RRB-

or

inferior

-LRB-

patients

-RRB-

and

did

not

significantly

correlate

with

any

of

the

parameters

measured

Downward

rotational

deformity

was

found

to

correlate

with

superior

-LRB-

r

-RRB-

and

inferior

-LRB-

r

-RRB-

scapular

angle

Internal/external

rotation

did

not

significantly

correlate

with

any

of

the

parameters

measured

although

only

three

patients

had

external

rotation

and

two

no

rotation

Anterior/posterior

rotation

did

not

correlate

significantly

with

any

of

the

parameters

measured

although

only

one

patient

had

posterior

rotation

and

one

no

rotation

Area

of

scapula

was

found

to

correlate

with

superior

scapular

angle

-LRB-

r

-RRB-

Affected

acromion

to

height

ratio

correlated

with

affected

superior

scapular

angle

-LRB-

r

-RRB-

inferior

scapular

angle

-LRB-

r

-RRB-

and

with

subluxation

-LRB-

r

-RRB-

Affected

to

contralateral

acromion

to

height

ratio

correlated

with

superior

scapular

angle

-LRB-

r

-RRB-

inferior

scapular

angle

-LRB-

r

-RRB-

and

with

subluxation

-LRB-

r

-RRB-

Superior

and

inferior

scapular

angles

correlated

with

subluxation

-LRB-

r

and

r

respectively

-RRB-

Subluxation

correlated

with

glenoscapular

angle

-LRB-

r

-RRB-

A

grading

scale

was

devised

for

assessing

scapular

deformity

in

brachial

plexus

palsy

based

on

the

of

the

observed

patients

The

different

stages

are

illustrated

in

Fig.

Fig.

different

SHEAR

stages

of

scapular

deformity

as

determined

by

three

dimensional

computer

tomography

In

SHEAR

Grade

less

than

of

the

scapula

less

than

of

the

superior

border

and

less

than

of

the

medial

border

are

visible

above

the

clavicle

In

SHEAR

Grade

of

the

scapular

area

of

the

superior

border

and

of

the

medial

border

are

visible

over

the

clavicle

In

SHEAR

Grade

of

the

scapular

area

of

the

superior

border

and

of

the

medial

border

are

visible

above

the

clavicle

In

SHEAR

Grade

of

the

scapula

of

the

superior

border

and

of

the

medial

border

are

visible

over

the

scapula

In

SHEAR

Grade

more

than

of

the

area

of

the

scapula

more

than

of

the

superior

border

and

more

than

of

the

medial

border

are

visible

over

the

scapula

Discussion

The

position

of

the

affected

scapula

did

not

follow

the

symptoms

and

characteristics

of

Sprengel

's

deformity

with

congenital

origin

of

scapular

elevation

The

hypoplasia

and

positioning

of

the

scapula

result

from

the

brachial

plexus

injury

and

the

apparent

elevation

is

the

result

of

downward

rotation

about

an

axis

perpendicular

to

the

scapular

plane

The

lack

of

substantial

forces

applied

to

the

scapula

by

the

weakened

scapula

stabilizer

muscles

leads

to

a

decreased

rate

of

bone

growth

-LSB-

-RSB-

The

observed

decreased

height

to

total

width

is

partly

the

result

of

enlargement

of

the

acromion

which

may

be

caused

by

traction

through

the

deltoid

-LSB-

-RSB-

The

acromion

was

found

to

be

always

tapered

in

the

presence

of

the

mildest

deformity

and

often

beaked

and

its

ratio

to

both

the

total

scapular

width

and

height

were

significantly

larger

than

the

contralateral

side

-LRB-

both

P

-RRB-

The

ratio

of

affected

acromion

to

height

correlated

with

the

area

of

scapula

visible

over

the

clavicle

-LRB-

r

-RRB-

with

both

affected

superior

scapular

angle

-LRB-

r

-RRB-

and

inferior

scapular

angle

-LRB-

r

-RRB-

and

with

subluxation

-LRB-

r

-RRB-

It

seems

that

while

the

growth

of

height

and

width

of

the

body

of

the

scapula

are

impaired

the

acromion

follows

a

different

pattern

of

growth

at

the

normal

rate

or

at

an

aberrant

rate

if

the

deformity

is

more

severe

-LRB-

correlation

coefficient

of

affected

to

contralateral

acromion

and

area

of

scapula

visible

over

clavicle

r

-RRB-

and

often

impinges

on

the

humeral

head

The

vertical

displacement

which

was

either

negative

or

positive

did

not

significantly

correlate

with

any

of

the

parameters

assessed

implying

that

the

apparent

elevation

of

the

scapula

is

the

result

of

rotational

displacement

unlike

congenital

scapular

elevation

where

the

severity

of

the

deformity

correlates

with

the

level

of

the

shoulder

joint

-LSB-

-RSB-

The

affected

scapula

is

not

only

malpositioned

it

is

also

hypoplastic

Previous

radiological

assessments

have

used

oblique

images

of

the

scapula

-LSB-

-RSB-

and

no

report

has

utilized

and

measured

these

characteristics

In

fact

in

posterior

trunk

views

the

hypoplasia

looks

more

exaggerated

than

by

measurement

in

the

scapular

posterior

view

because

the

view

is

affected

by

the

internal

rotation

The

total

area

of

the

hypoplastic

scapula

averages

less

than

the

contralateral

scapula

and

correlates

with

the

severity

of

the

deformity

-LRB-

r

-RRB-

While

the

rotation

about

a

vertical

axis

was

usually

internal

in

three

instances

it

was

external

with

no

correlation

to

the

severity

of

the

deformity

or

to

any

other

parameter

assessed

Rotation

about

the

axis

of

the

scapular

spine

was

in

all

but

one

instance

anterior

forming

a

narrower

scapuloclavicular

space

on

the

superior

trunk

outlet

view

During

the

development

of

scapular

dysplasia

both

downward

rotational

deformity

-LRB-

angle

of

the

spine

of

the

scapula

-RRB-

and

decreased

height

to

width

ratio

contribute

to

change

in

superior

scapular

angle

and

inferior

scapular

angle

and

both

indeed

strongly

correlated

with

area

of

scapula

visible

above

clavicle

-LRB-

r

and

r

-RRB-

and

degree

of

subluxation

-LRB-

r

and

r

-RRB-

The

clinical

prognostic

relevance

of

the

various

measurement

methods

is

still

under

discussion

-LSB-

-RSB-

Global

abduction

has

been

correlated

with

glenoid

version

-LSB-

-RSB-

In

the

literature

there

seems

to

be

no

significant

correlation

between

Mallet

functional

parameters

other

than

global

abduction

and

either

radiographic

parameters

or

age

-LSB-

-RSB-

because

active

shoulder

function

is

affected

by

the

glenohumeral

relationship

shoulder

capsule

strength

and

physical

properties

of

the

muscles

and

the

nervous

system

In

many

patients

different

versions

of

muscle

release

of

the

contracted

internal

rotators

with

or

without

muscle

transfer

of

latissimus

dorsi

and

teres

major

to

the

teres

minor

is

performed

early

in

life

so

that

the

weakened

deltoid

and

supraspinatus

muscles

can

achieve

active

abduction

The

success

of

this

intervention

is

very

impressive

and

the

abduction

is

often

significantly

improved

-LRB-

-LSB-

-RSB-

and

our

unpublished

data

-RRB-

While

glenohumeral

incongruence

is

delayed

after

muscle

contracture

release

-LRB-

-LSB-

-RSB-

and

our

unpublished

data

-RRB-

internal

rotation

of

the

arm

and

winging

scapula

often

develop

The

lack

of

correlation

between

age

and

any

of

the

parameters

of

the

anatomical

deformity

in

our

study

unlike

reports

by

others

-LSB-

-RSB-

may

reflect

the

fact

that

most

of

our

patients

had

undergone

contracture

releases

of

the

latissimus

dorsi

teres

major

subscapularis

and

pectoralis

major

and

minor

with

tendon

transfer

of

latissimus

dorsi

and

teres

major

While

global

abduction

in

our

series

was

near

normal

the

forces

exerted

by

the

muscles

on

the

two

scapulas

are

not

equivalent

obviously

upholding

impaired

growth

to

the

affected

scapula

The

rate

of

progression

of

the

deformity

is

individual

to

the

child

The

rotation

of

the

scapula

causes

positional

changes

in

the

acromio-clavicular

joint

This

causes

impingement

of

the

distal

acromion

and

clavicle

with

the

humeral

head

resulting

in

the

MRC

positioning

described

above

The

clinical

implications

of

the

SHEAR

and

resulting

MRC

are

clear

and

have

been

described

by

Birch

in

detail

-LSB-

-RSB-

The

current

standard

of

practice

for

treatment

of

MRC

is

muscle

transfer

if

the

shoulder

is

congruent

-LSB-

-RSB-

corresponding

to

SHEAR

and

humeral

derotational

osteotomy

if

the

humeral

head

is

incongruent

corresponding

to

SHEAR

-LSB-

-RSB-

While

derotational

osteotomy

may

restore

external

rotation

by

placing

the

arm

in

a

more

functional

position

it

addresses

neither

the

scapular

nor

the

glenohumeral

deformities

Our

findings

that

SHEAR

score

based

on

the

percentage

of

scapula

visible

over

the

clavicle

strongly

correlates

with

rotation

of

the

scapula

hypoplasia

and

subluxation

provides

a

convenient

diagnostic

tool

to

assess

the

presence

of

the

MRC

deformity

With

the

pathophysiology

being

thus

established

anatomical

correction

of

the

deformity

can

be

considered

and

planned

hopefully

with

improvement

in

functional

parameters

Conclusion

Scapular

deformities

common

to

the

population

of

obstetric

brachial

plexus

palsy

patients

due

to

muscular

imbalances

resulting

from

residual

neurological

deficit

can

be

diagnosed

and

classified

using

the

SHEAR

classification

and

enable

objective

evaluation

of

the

bony

deformity

and

its

severity

as

guide

for

treatment

O O O B B I O O O O O O O B B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B B I O O O O O O O O B I O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B O B B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

brachial plexus
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acromion
paralysis
obstetric


Overdiagnosis and overtreatment of early detected prostate cancer Early detection of prostate cancer is associated with the diagnosis of a considerable proportion of cancers that are indolent , and that will hardly ever become symptomatic during lifetime . Such overdiagnosis should be avoided in all forms of screening because of potential adverse psychological and somatic side effects . The main threat of overdiagnosis is overtreatment of indolent disease . Men with prostate cancer that is likely to be indolent may be offered active surveillance . Evaluation of active surveillance studies and validation of new biological parameters for risk assessment are expected . Introduction What is the rationale for screening ? Screening for diseases , especially cancer , has become part of modern medicine . Screening for breast , cervical and colorectal cancer is already normal practice in some countries , and will probably become routine in other countries in the future . Screening for prostate , melanoma and lung cancer are subject to ongoing studies -LSB- 1 -- 5 -RSB- . The rationale behind screening is simple : to detect cancers at an early stage , when they are still curable . Screening is currently performed using one of the three methods : mass screening -LRB- i.e. large scale screening of an entire population -RRB- , selective screening -LRB- i.e. screening of high-risk populations -RRB- or opportunistic screening -LRB- e.g. incorporated as part of a medical consultation -RRB- . Diagnostic testing differs from screening because it attempts to identify the disease in the presence of symptoms , while screening is offered to symptom-free individuals . In any population screened for cancer , four basic groups of patients exist : those diagnosed with cancer who would not have developed cancer symptoms during their lifetime -LRB- overdiagnosis -RRB- ; those diagnosed with cancer at an early stage that might otherwise have led to symptoms and/or the need for more aggressive curative treatment ; those diagnosed with cancer at a curable stage with aggressive disease that might otherwise have progressed to metastatic disease at the time of diagnosis ; and those whose cancer is diagnosed by screening at the same stage as it would have been diagnosed through clinical routines , and that involves cancers that are too late for curative therapy . Ideally , screening should reduce the number of patients in the fourth group -LRB- that can not be cured -RRB- , and increase those in the second and third group . The window of opportunity for decreasing cancer-mortality by screening for cancer lies with the second and third group . Randomized clinical trials , considered the gold standard for the evaluation of a screening test , have to show how sizeable the window of opportunity is . The difference between the first group and the second is however not always clear at the time of initial diagnosis . Any screening procedure carries a risk of overdiagnosis and overtreatment , which should be balanced against the benefits for those in which the cancers are diagnosed at a curative stage . Whether this balance is justifiable depends on more than mortality differences of randomized study groups only , but also on quality of life issues measured against the cultural background of the population studied . Incidence Does screening influence prostate cancer incidence ? Since the potential value of PSA for the early detection of prostate cancer was described in the early 1990s , both prostate cancer incidence and mortality rates have changed profoundly -LSB- 6 -RSB- . Between 1989 and 2003 , for example , the age-standardized incidence rate of prostate cancer increased by 48.4 % in The Netherlands -LRB- reaching an incidence of 93.2 cases per 100,000 men -RRB- . Based on rates from 2001 to 2003 , 17.1 % of U.S. men born today will be diagnosed with cancer of the prostate at some time during their lifetime -LSB- http://www.cancer.gov -RSB- . It is now the most frequently diagnosed non-cutaneous cancer , with 225,000 new cases reported each year in Europe alone -LSB- 7 -RSB- . This increase of incidence suggests that this is due to the detection of cancers in the first three groups described above . This is supported by the reports on autopsy studies . These autopsy studies have revealed that histologic prostate cancer occurs in an even larger proportion of men compared to the screening incidence : up to 55 % of men in their fifties , and 64 % of men in their seventies have prostate cancer diagnosed at autopsy , while only 5 -- 10 % are detectable in a screening setting during life -LSB- 8 -RSB- . A number of influences might have contributed to the increase of cancer diagnosis over the last decades , apart from the structured screening studies that have been initiated at various places . First , the PSA thresholds for biopsy appears to have been reduced gradually in some areas of the world due to the detection of significant cancers in the low PSA range -LSB- 9 -RSB- . Most guidelines , however , still mention the traditional cut-off of 4 ng/ml as an indication for biopsy . Secondly , an increase in the number of core samples per biopsy have been advocated , based on the observation that more cancers are diagnosed when more biopsies are taken . Thirdly , awareness of prostate cancer within the general population has increased stimulated by the information obtained predominantly from the urologic profession -LSB- 10 -RSB- . If these current trends continue , the number of living men diagnosed with prostate cancer will increase even further -LSB- 11 -RSB- . Mortality What happens to prostate cancer mortality by screening and detecting indolent tumors ? Despite this rising incidence , the age-standardized prostate cancer mortality rate has decreased in many countries around the world with or without early detection programs . In The Netherlands , for example , rates fell by 11 % between 1989 and 2003 , to 28.4 deaths per 100,000 men or 2,349 in total -LSB- http://www.cancer.gov -RSB- . It is however unclear whether the stage and grade migration observed in screening studies results in a reduction in the mortality , although case-control studies with conflicting results are available -LSB- 12 -- 14 -RSB- . A decrease of mortality shown in randomized studies would form a strong argument in favor of population screening . Screening results in the more frequent detection of small volume , low grade and organ confined prostate cancers , which are diagnosed earlier in their course -LSB- 6 , 15 -RSB- . Many of these tumors have the histological characteristic of autopsy tumors , that is , tumors that have not become symptomatic during life -LSB- 16 -RSB- . They have been called indolent or clinically insignificant cancers . Various definitions of clinically insignificant tumors have been designed based on the characteristics of the autopsy studies , of which the Epstein definition is widely known -LSB- 17 -RSB- . Detecting such tumors will increase the detection frequency of cancer , but it is unlikely that they will influence the prostate cancer specific mortality , as they do not alter the course of life . Early diagnosis Screen detected tumors are diagnosed more early Screen detected tumors are not only diagnosed more often , but can be expected more early during their natural course . Lead-time is defined as the time period from detection by a screening procedure to the time of diagnosis in absence of screening due to symptoms . If the patient dies during the lead-time period of the tumor , the lead-time is indefinite and therefore equal to overdiagnosis . Early detection by PSA advances prostate cancer diagnosis in time -LRB- i.e. lead time -RRB- -LSB- 18 -RSB- . For men aged 55 -- 75 years lead time amounts to 12.3 years in a screening setting -LSB- 19 -RSB- . The lead-time is likely to be shorter for aggressive cancers and longer for indolent ones . Early detection also causes a significant stage shift towards more locally confined and less aggressive cancers -LSB- 20 -RSB- . The long lead-time , stage reduction and natural history data cited above indicate that for properly selected cases there is a long ` time-window ' during which observation is safe without losing the opportunity for cure . This is supported by evidence from nomograms , prognostic tables , and by the only available randomized study of observation against radical prostatectomy -LSB- 21 -RSB- . The impact of overdiagnosis and unnecessary treatment and of its side effects on patient health is also unclear ; however , application of a mathematical model -LRB- the Miscan model -RRB- on data from the ERSPC has shown that , in an annual screening program for men aged 55 -- 67 years , 56 % of diagnosed cases would constitute instances of overdiagnosis -LSB- 22 -RSB- . If this estimate proves to be realistic -LRB- as it appears to be the case -RRB- , nationwide screening programs may not be acceptable using the present screening regimens , even if benefits in terms of mortality reduction were shown . Research aimed at the development of more selective screening tools is therefore very important . The natural course of screen-detected cancers The current knowledge of the natural history of prostate cancer is mainly based on clinically detected cases , diagnosed by disease-related symptoms , or coincidentally at the time of unrelated symptoms of the urinary tract . Natural history data on screen-detected cases of prostate cancer will be created as a result of the large ongoing screening studies worldwide in which tumors might have been treated without invasive therapy -LSB- 1 -RSB- . Most studies show histological and cytological grade to be the most important prognostic variable -LSB- 23 , 24 -RSB- . There is a steep decline in the 5 - , 10 - and 15-year cancer-specific survival with increasing grade . Most prostate cancer cases diagnosed with present diagnostic techniques fall into the moderately differentiated group -LRB- grade 2 , Gleason 6 -RRB- , of which the cancer-specific 10 -- 15-year mortality is 18 -- 30 % . This is even lower in the group of prostate cancers diagnosed with grade 1 and 2 or Gleason 4 -- 6 , and there are subgroups of patients who are not at risk of dying from prostate cancer even within 15 years . Overall mortality is then determined by comorbidity . The majority of these men are currently treated for their prostatic disease with invasive procedures , which might not be needed . Adequate prediction of the outcome of comorbid diseases would be of great support in predicting the outcome of the prostate cancer patient . Overdiagnosis Overdiagnosis and overtreatment , what does it mean ? During recent years , increased interest has risen to the possibility that increased detection of prostate cancer may lead to the diagnosis of cancers that rather should not have been diagnosed , and certainly should not have been treated , as their detection and subsequent treatment is unlikely to benefit patients , or even might harm them . Related to this , the terms ` overdiagnosis ' and ` overtreatment ' are being used . So , when is prostate cancer overdiagnosed ? By using the clinical definition of overdiagnosis , that is diagnosing tumors that would otherwise remain clinically unrecognized until the individual died from other causes , it is clear that this definition can only be applied in retrospect in the evaluation of studies . There are currently no clinical or biological parameters that can identify such tumors 100 % adequately at the time of diagnosis . By studying the natural course of prostate cancer , and comparing autopsy results with findings from screened populations , clinical and histological parameters can be identified that predict indolent tumors best . Those indolent tumors are likely to be only a subset of the tumors that are overdiagnosed in retrospect . Overdiagnosis is predominantly being associated with early detection or screening programs . Overdiagnosis appears to be especially harmful when it results in invasive treatment of the tumors that would unlikely to be harmful . This is called overtreatment . Overdiagnosis occurs when screening detects small tumors that would otherwise remain clinically unrecognized until the individual dies from other causes . Such tumors are predominantly found in the low PSA ranges . Unfortunately , an unknown number of biologically more aggressive cancers may hide between the larger number of detectable tumors with favorable stages . Though some of the aggressive tumors can be diagnosed by adverse histological criteria such as high Gleason score in the biopsy , some of these features might be missed due to the heterogeneity of prostate cancers and their representation in the biopsy sampling . This might justify the amount of overtreatment that has been practiced in various areas of the world . Overtreatment is thus defined as unnecessary invasive treatment with respect to the outcome of the natural course of the tumor in combination with its host . One can wonder what number needed-to-treat to prevent one prostate cancer death we are prepared to accept . Based on the Swedish randomized trial of radical prostatectomy versus watchful waiting -LSB- 22 -RSB- , the Connecticut observation series -LSB- 15 -RSB- , and the Toronto active surveillance experience -LSB- 25 -RSB- , a number needed to treat analysis of the benefit of radical treatment of all newly diagnosed favorable-risk prostate cancer patients , compared with a strategy of active surveillance with selective delayed intervention , has been presented by Klotz -LSB- 25 -RSB- . This suggested that approximately 73 patients will require radical treatment for each prostate cancer death averted . This translates into a 3 - to 4-week survival benefit , unadjusted for quality of life . If any , the number of life-years gained will be small , because of the fact that prostate cancer is a disease of old age . This should be contrasted to the side-effects of all applied treatments . As a minimum , the number of men needed to treat should be higher than the number of men dying from intervention related causes . Informed decision making , reduction of unnecessary prostate biopsies The increasing number of diagnostic procedures and subsequently of prostate cancer diagnosis in various areas of the world is partly fed by an increased awareness of prostate cancer and the anxiety raised of suffering from a devastating disease at the end of life . Men should ask themselves if they are at specific risk for having prostate cancer , and if they want to follow the step wise procedure of PSA testing , urologic investigations , prostate biopsies , and potential treatment . Balanced information regarding this procedure and its consequences should be offered to every man considering prostate testing . Validated information -LRB- that is : well understandable text that delivers the information that is required -RRB- has been made available in several countries around the world , and it has been shown that such information reduces the number of men who initially wanted to be screened . Based on population data it is possible to provide risk assessments for every step of the screening procedure . Such assessments produce an individual risk calculation based on relevant risk parameters . This might support patients and doctors in their decision to follow or refrain from further steps , dependent on their interpretation of the risk calculated . At the time of cancer diagnosis , it may provide information on the risk of the presence of an indolent tumor , as discussed above . Current risk calculators have incorporated family history , age , micturition complaints , PSA , DRE , TRUS results , and histologic features of the prostate biopsies into their assessment . With an increasing number of relevant parameters , the level of predictive accuracy is enhanced . It is likely that new parameters might be added once tested in population-based biorepositories . Candidate parameters therefore obviously are serum and urine markers for the early diagnostic steps , and histologic markers at the time that biopsies have been taken . Much interest has been given to the increase of specificity of the biopsy procedure in the general population with serum markers like PSA isoforms and kallekreins in order to diminish the number of false negative biopsies -LSB- 26 , 27 -RSB- . Enhancing specificity always resulted in a reduction of sensitivity of prostate cancers . As we have seen based on autopsy incidence , the number of potentially detectable tumors is manifold the number of currently diagnosed cancers . It is therefore not the absolute number , but the number of clinically relevant cancers that is of interest -LSB- 28 -RSB- . The PSA isoforms and kallekreins should therefore ideally be related to the characteristics of the cancers detected . Screening efficiency A small number of studies already have provided evidence that supports strategies to reduce the number of screens in the general population . Such strategies will inevitably lead to the reduction of overdiagnosis of prostate cancer . Information obtained from population based screening studies illustrates that the absolute value of serum PSA is related to the proportion of detectable carcinomas in subsequent screening rounds . Data from the ERSPC as well as from the PLCO -LSB- 29 , 30 -RSB- showed that men with a PSA less than 1 ng/ml did not develop invasive cancer over the time period of more than 5 years of repeated check-ups . In the Rotterdam site of the ERSPC , 1703 men with an initial PSA of less than 1 ng/ml men were followed during two consecutive 4 year screening rounds . Eighty percent of men attended the second screening round , and 77 % the third round . In total , only 8 cancers were found in 47 prostate biopsies on the indication of PSA of > 3 ng/ml . In the PLCO screening , every 5 years for baseline PSA less than 1 ng/ml and every 2 years for PSA 1 -- 2 ng/ml could result in a 50 % reduction in PSA tests and in less than 1.5 % of men missing earlier positive screens . In men who were enrolled onto a cardiovascular study in Sweden , 21,277 men aged < 50 years old were assessed over a period of more than 20 years starting between 1974 and 1986 . Two decades later , 498 -LRB- 2.3 % -RRB- were eventually diagnosed with prostate cancer -LRB- outside a structured screening procedure -RRB- . In retrospect , the level of serum kallikreins -LRB- hK2 , total PSA , and free PSA -RRB- at baseline and thereafter were strongly associated with emerging prostate cancer . This supports the idea of risk stratification for screening on prostate cancer in an early age , that is during the fourth decade of life . Men at low risk may refrain from frequent serum testing for long periods of time based on their individual risk assessment that incorporates the information obtained from currently available and newly validated parameters . Overtreatment Side effects of treatment are substantial Treatment for prostate cancer may involve surgery , external beam radiation therapy , brachytherapy , high intensity focused ultrasound -LRB- HIFU -RRB- , watchful waiting , active surveillance , chemotherapy , cryosurgery , hormonal therapy , or combinations . The most frequently applied treatments for organ confined prostate cancer are radical prostatectomy , external beam radiotherapy and brachytherapy . Although , severe or life-threatening complications with radical prostatectomy are rare , the adverse effects of greatest concern are damage to the urinary sphincter and erectile nerves -LRB- nervi erigenti -RRB- , resulting in urinary incontinence and impotence , respectively . Complete incontinence is uncommon after radical prostatectomy , although a significant number of men experience some degree of stress-urinary incontinence -LSB- 31 -- 33 -RSB- . In the Prostate Cancer Outcomes Study , a population-based study of 1,291 men who underwent radical prostatectomy for localized prostate cancer and were followed for 2 years , 1.6 % reported no urinary control at 24 months following surgery -LRB- compared with 0.7 % at baseline prior to surgery -RRB- , while 7 and 42 % reported frequent and occasional leakage , respectively -LRB- compared with 2 and 9 % at baseline -RRB- -LSB- 32 -RSB- . Age had an impact on the degree of incontinence ; 14 % of men aged between 75 and 79 years experienced the highest level of incontinence compared with 0.7 -- 4 % of younger men . In the Prostate Cancer Outcomes Study , 42 % of men reported that sexual performance was a moderate to large problem at 24 months -LRB- compared with 18 % at baseline -RRB- ; 60 % were not able to have erections firm enough for sexual intercourse -LRB- compared with 16 % at baseline -RRB- -LSB- 32 -RSB- . At 24 months postoperatively , men over the age of 60 were more likely to be impotent than younger men -LRB- 78 -- 85 vs. 61 % , respectively -RRB- . Complications after external beam radiotherapy include bladder irritation -LRB- urgency , pain , frequency -RRB- in up to 5 % of men , and impotence in 40 -- 50 % -LSB- 34 -RSB- . In contrast to surgery , these complications tend to increase over time . The reported incidence of radiation proctitis ranges from 2 to 39 % , depending upon the definition used , and the dose field , and technique of radiotherapy . Prostate inflammation and swelling can occur acutely following brachytherapy , suggesting that men with significant urinary symptoms or a large prostate are not good candidates . Urinary retention can be severe enough to require self-catheterization ; transurethral resection to improve micturition is contraindicated until a substantial portion of the radioactivity -LRB- usually five half-lives -RRB- has dissipated because of the risk of incontinence and radiation risks to the surgeon and pathologist . Later complications include irritative voiding symptoms , urinary retention , rectal urgency , bowel frequency , rectal bleeding or ulceration , and prostatorectal fistulas -LSB- 35 -- 37 -RSB- . The incidence of erectile dysfunction ranges from 14 to 52 % , depending on whether it is physician - or patient-reported . It is obvious that invasive treatment may influence the quality of life of men with prostate cancer and their families substantially . But so does a potential threat of prostate cancer that is not actively treated or not even diagnosed yet . It is unlikely that quality of life studies will be able to indicate the best balance between these points of view for management decisions on an individual patient level . Active surveillance as alternative to invasive treatment Because not all cancers diagnosed require treatment , one of the major challenges for the future is to determine which diagnosed cancers should be treated , and which can be managed by active surveillance . Active Surveillance manages selected men with prostate cancer expectantly with curative intent . This means men are carefully selected and subsequently actively observed in order to have the possibility to offer them deferred curative treatment once the tumor seems to progress . Active surveillance should be clearly differentiated from watchful waiting . Watchful waiting entails a strategy for all men who are managed expectantly , whereas active surveillance focuses on men for whom therapy is delayed until the tumor becomes progressive and curative treatment can be offered . This offers an attitude of active control over the cancer diagnosed for patients and their doctors . The stage migration that screening provides has resulted in an over-representation of low-risk cancers . Therefore , studies which validate monitoring algorithms in active surveillance regimens are ongoing -LSB- 38 -RSB- . Risk stratification for indolent disease Over the last decade , a number of nomograms have been composed to predict the presence of an indolent cancer -LSB- 39 , 40 -RSB- . The identification of indolent cancers was strongly based on histologic information of prostate biopsies , and power of Gleason score as a predictive parameter for aggressiveness of prostate cancer was unsurpassed . As a single serum parameter at the time of diagnosis , the level of PSA contributed most to prognosis . These nomograms were based on extensive clinical series . A new nomogram recently appeared based on information obtained from a screening series of the general population -LSB- 41 -RSB- . Screening series differ from clinical studies , as the incidence of indolent cancer is almost 50 % compared to maximal 20 % in multicentred clinical series . With the use of the nomogram , at a 70 % probability cut-off , at least 69 % of all indolent cancers would be diagnosed as such , and be treated with active surveillance . Conclusions It is still too early to say whether population-based prostate cancer screening is a useful tool with regard to cancer mortality . We must wait until the results of ongoing prostate cancer screening trials are available . Until then , opportunistic screening should not be encouraged and those men who do want a PSA test should participate in carefully designed , balanced information program . Even if PSA screening is found to reduce prostate-cancer-specific mortality , levels of overdiagnosis may remain unacceptable for population-based screening . To reduce overdiagnosis in a screening setting , markers are needed that reduce the risk on a positive prostate biopsy , increasing the specificity of this procedure . Men from the age of forty , as well as their advising doctors , need instruments to reduce their doubts and anxiety of the potential presence of a prostate cancer . This , together with balanced information about the benefits and risks of the individual outcome of screening procedures , might induce a more selective and step-wise screening action . Risk assessment , incorporating the main determinants known for the presence of prostate cancer from the age of 50 , such as age , family history , and micturition complaints , should form the base of an individual screening approach . Objective values of serum markers might enhance the accuracy of such of risk predictors . Various efforts are performed to find new markers in the proteome and genome of blood and urine . Based on large and longitudinal serum collections of men diagnosed with prostate cancer in screening settings , the EC-sponsored P-MARK consortium evaluates candidate markers as prognostic tools -LSB- 42 -RSB- . Until alternative screening tools are found , PSA will continue to be used , and overdiagnosis will remain an unavoidable drawback of prostate cancer screening . The current challenge is to ensure that in the still growing numbers of men diagnosed with prostate cancer world-wide , overdiagnosis does not result in overtreatment . To this end , research efforts presently focus on clarifying which cancers can be managed through active surveillance .

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O O O O O O O O O O O B I O

rationale for screening
overdiagnosis
overtreatment
prostate cancer
active surveillance