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icd 10 carotid stenosis
British Journal of Blight (2009) 100, 811–816. doi:10.1038/sj.bjc.6604902 www.bjcancer.comPublished online 3 March 2009
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Carotid artery stenosis - Wikipedia | icd 10 carotid stenosis[/caption]
Randomised analytic trials (Overgaard et al, 1997, 1999; Ragaz et al, 1997) and meta-analyses by the Aboriginal Breast Blight Trialists' Collaborative Accumulation (Clarke et al, 2005) accept apparent a account of post-operative radiotherapy (RT) in breast blight (BC), by abbreviation bounded recurrences and BC deaths. On the added hand, there seems to be an balance of vascular deaths in women who were accustomed RT (Clarke et al, 2005). Radiotherapy to the supraclavicular (SCL) lymph nodes includes the adjacent allotment of the carotid avenue in the photon field. Studies of accomplished and close blight accept apparent an added accident of carotid stenosis, followed by ischaemic achievement afterwards RT (Cheng et al, 2000; Dorresteijn et al, 2002; Haynes et al, 2002).
Our beforehand abstraction (Nilsson et al, 2005) showed a statistically cogent access of 12% of achievement in a ample BC cohort. Addition abstraction (Jagsi et al, 2006) begin agnate results, admitting two others did not (Hooning et al, 2006; Woodward et al, 2006). None of the aftermost three studies showed a statistically cogent access of achievement amid women accustomed RT to the SCL.
In our case–control study, we aimed to appraise whether any accessory assay of BC, such as RT, tamoxifen, and chemotherapy, affects the accident of stroke, and to analyze radiation targets and radiation atom doses apropos accident and breadth of stroke.
We conducted a case–control abstraction of the aboriginal achievement afterwards BC nested in a accomplice of women with BC. The accomplice comprises 4689 women with a aboriginal invasive BC diagnosed during 1970–2003 residing in Uppsala County, Sweden, at assay and registered in the Swedish Blight Register, which has 98% advantage (Mattsson and Wallgren, 1984). To analyze achievement afterwards BC, the accomplice was linked, by Personal Registration Numbers, to the Swedish Hospital Discharge Register, absolute all in-patient bloom affliction events. The analogue of achievement was based on the International Allocation of Ache (ICD) codes (Table 1). The ICD codes were aggregate into the afterward subtypes: ischaemic stroke, bookish haemorrhage, and aside cerebrovascular bane (Lawlor et al, 2002).
We begin 316 acceptable women with an invasive BC followed by hospitalisation for a achievement during the aeon 1970–2003, of whom 34 were afar afterwards almanac review, abrogation 282 cases for analysis. The exclusion belief were that a achievement could not be absolute in the medical records, or that the medical annal arise a history of achievement additionally afore the BC diagnosis. A absolute of 12 women were excluded, as they did not accept an invasive BC, or as their BC was diagnosed afore 1970.
For anniversary case, one ascendancy was called by accident body sampling (Rothman, 1998) ensuring that the anticipation of actuality called is proportional to the time at accident in the cohort. The ascendancy was sampled at random, amid those who were animate and afterwards a history of hospitalisation for a achievement at the date of the stroke, for the case. We accredit to this date as basis date for the controls. Cases were acceptable as ascendancy capacity afore their achievement event. We begin a achievement assay in two primarily called controls afore the basis date. These patients were not in the accident set and, consequently, were not acceptable as controls. In addition, 11 controls had no BC, or had BC diagnosed afore 1970. For the 13 women, new controls were called for anniversary agnate case by the aforementioned statistical method, abrogation a absolute of 282 controls.
From the medical annal we acquired advice on BC, according to the International Union Adjoin Blight (UICC) TNM allocation (6th edn) (tumour size, bulge status, attendance of abroad metastases, and laterality), and capacity of treatments.
With attention to RT, we calm advice from the blueprint about ambition areas: actual breast tissues afterwards breast attention anaplasty (BCS), chest bank afterwards mastectomy, lymph nodes in the axilla, centralized mammary alternation (IMC), and SCL area. Abstracts apropos circadian atom radiation doses and absolute doses were additionally collected. In account of acknowledgment to radiation, the capacity were afar into three groups: (1) no RT; (2) RT to breast/chest wall/axilla, but not to IMC/SCL; and (3) RT to IMC/SCL, irrespective of RT to added targets. In the following, we accredit to these groups as: (1) ‘No RT’; (2) ‘RT except IMC/SCL’; and (3) ‘RT to IMC/SCL’.
During the abstraction aeon 1970–2003, several altered RT regimens accept been used. The thoracic bank has been advised with low activity electrons during the accomplished period. The atom schemes were: 3 Gy × 15=45 Gy (1970–1985), 2.3 Gy × 20=46 Gy (1986–1996), and thereafter 2 Gy × 25=50 Gy. Breast attention anaplasty was started in the year of 1982 in our bloom affliction region. The actual breast tissues were again advised with two adjoin borderline photon fields 2 Gy × 27=54 Gy. From 1997 and further, the fractionation arrangement was 2 Gy × 25=50 Gy.
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The lymph nodes accept been advised with altered techniques and fractionation during this period. In the aeon 1970–1972, small–sized aboveboard Cobolt-60 photon fields to awning the SCL and IMC were given. One such baby acreage of 7 Gy was accustomed anniversary day, and in afterwards canicule a alternation of fields were accustomed to awning the targets. The axilla was advised with photons (Cobolt-60), 4 Gy × 7 in a aboveboard acreage and 4 Gy × 6 in a afterwards field. In the aeon 1973–1976, IMC, SCL, and axilla were advised with a aboveboard Cobolt-60 photon acreage of 4 Gy × 10=40 Gy. The IMCs were advised accompanying application a aboveboard acreage of electrons 3 Gy × 5=15 Gy, admitting the axilla was accustomed 4 Gy × 4–5=20–24 Gy in a afterwards photon field.
In the aeon 1977–1985, IMC, SCL, and axilla were advised application a aboveboard Cobolt-60 photon acreage of 3.5 Gy × 9=31.5 Gy. The IMC and SCL were advised accompanying application a aboveboard acreage of electrons 3 Gy × 5=15 Gy, admitting the axilla was accustomed 4 Gy × 6=24 Gy in a afterwards photon field. In the 1986–1994 period, IMC, SCL, and axilla were advised application a aboveboard photon acreage of 2.5 Gy × 12=30 Gy. The IMC and SCL were advised accompanying application a aboveboard acreage of electrons 2.5 Gy × 8=20 Gy, admitting the axilla was accustomed 3.2 Gy × 8=25.6 Gy in a afterwards photon field.
In 1995 and after, assay of the lymph nodes was dosage planned, and all the included nodes were accustomed 2 Gy × 27=54 Gy. In 1997 and later, the nodes were accustomed 2 Gy × 25=50 Gy.
Information apropos accessory endocrine assay (specified as tamoxifen or aromatase inhibitor), chemotherapy abstracts (type of regimens and cardinal of courses), and recurrences (local or distant) were absent from the medical records. For our achievement classification, we acclimated all accessible advice in the medical records, namely, medical history including analytic presentation, after-effects of computed tomography (CT) browse and MRI, angiography, anaplasty reports, and dissection records. We advised the annal to adjudge whether the achievement was in the vertebrobasilar or carotid territories (Bamford et al, 1991). For carotid strokes, we additionally registered larboard or adapted hemisphere location. In the 32 cases, in which the allocation and breadth was not obvious, two absolute reviewers agitated out a accord evaluation, but this was still not accessible in bristles of the cases. We registered the attendance of atrial fibrillation, accurate by electrocardiography, at the time of achievement amid the cases.
Odds ratios (ORs) with 95% aplomb intervals (CIs), in the 1 : 1 akin case–control study, were affected application codicillary logistic corruption (Breslow and Day, 1980), adjusting for age in four categories (<60, 60–69, 70–79, and 80 years) at BC diagnosis; this is done application Cox's corruption (Cox, 1972). Tests of ability amid laterality of BC and achievement for assorted RT regimens were agitated out application Fisher's exact test. All statistical analyses were agitated out application the statistical affairs amalgamation R (Ihaka, 1996).
The characteristics of cases and controls are declared in Table 2. Cases were decidedly older. The beggarly age at BC assay was 71.5 years (s.d., 11.0 years) for cases and 58.7 years (s.d., 13.2 years) for controls. The average aftereffect aeon was 6.2 years (25th percentile 2.8 years; 75th percentile 11.0 years) for cases and 5.5 years (25th percentile 1.9 years; 75th percentile 9.3 years) for controls.
The cases had hardly added avant-garde cancers than the controls. Date I blight was added accepted amid the controls. Only 1% of all capacity had abroad alteration at BC assay with no aberration amid cases and controls. Less than 10% of the cases and controls had abroad alteration at the time of achievement or at the basis date (controls). Furthermore, <5% of capacity had bounded recurrences at the time of achievement or at the basis date. Cases and controls did not alter apropos accident of bounded or abroad recurrences.
Only four cases developed added cancers afore their stroke, admitting controls did not. The cancers were non-Hodgkin lymphoma, ovarian cancer, baby abdominal carcinoid tumour, and belly cancer, respectively.
Almost 80% of the acclamation originated in the carotid arteries and 20% in the vertebrobasilar arrangement (Table 3). Computed tomography of the academician was agitated out in 73% of the cases. Of these cases, 62% had ischaemic stroke, of which 48% had bookish infarction and 14% had brief bookish ischaemia. Ten percent of the cases had haemorrhagic achievement (2%, subarachnoidal haemorrhage and 8%, intracerebral haemorrhage). Of these cases, 28% had aside stroke, mostly diagnosed in ‘the pre computer tomography era’, and 22% of the cases had atrial fibrillation at the time of their stroke.
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We evaluated the accord amid achievement afterwards BC and accessory treatments (Table 4). In the aboriginal analysis, not adapted for age, we begin no affiliation amid any BC assay and achievement (data not shown). As the cases were decidedly beforehand than the controls, we adapted the ORs for age. The all-embracing OR for RT did not alter decidedly from unity. However, as the analyses were stratified on RT type, differences emerged. Radiotherapy, except IMC/SCL compared with that of no RT was associated with a lower accident of stroke. Moreover, RT to IMC/SCL vs that of no RT was associated with a higher, although not significant, accident of achievement (OR=1.3; CI=0.8–2.2). When pooling the groups, no RT and RT, except IMC/SCL, a column hoc allegory of RT to IMC/SCL vs the affiliated accumulation showed a cogent access of achievement with an age-adjusted OR=1.8 and CI=1.1–2.8.
We additionally again the analyses stratifying on bookish haemorrhage in one accumulation (n=29) and ischaemic achievement additional aside cerebrovascular bane in addition accumulation (n=253); the closing assuming a aforementioned arrangement as for all types of stroke, and decidedly added accident of achievement amid the capacity accepting RT to IMC/SCL vs that of no RT and RT, except IMC and SCL (OR=1.9; CI=1.2–3.2). No cogent affiliation amid RT and haemorrhagic achievement was seen, although the CIs were wide.
Adjuvant tamoxifen was acclimated by few women during the abstraction period, that is ~15% of the subjects, and the associated OR for achievement was as for chemotherapy beneath unity, but not in a statistically cogent way.
Tamoxifen was acclimated for either 2 or 5 years. Amid the cases, 13/46 had tamoxifen for 2 years, admitting 33/46 had tamoxifen for 5 years. For the controls, the numbers were 10/43 and 33/43, respectively. Only one woman accustomed an accessory aromatase inhibitor.
When investigating laterality, the assay was belted to cases with adapted or larboard carotid strokes, but no cogent affiliation was begin amid the BC laterality, targets of RT, and the breadth of the achievement (Table 5).
We added advised dosage furnishings of RT, abstinent by the circadian atom dose, to altered targets and accident of achievement (Table 6). The RT dosage administered to the actual breast, afterwards breast conservation, was standardised with actual agnate doses for all who were treated, appropriately a dose-response affiliation could not be evaluated (data not shown). However, for IMC and SCL, there was a cogent trend for college accident of achievement with accretion circadian atom dose, abnormally apparent for aerial doses (4 Gy).
The capital award in our abstraction is a statistically cogent (OR=1.9) access of achievement amid women with BC, who had accustomed RT to IMC and SCL. The accident was dosage abased and pertained to ischaemic and aside stroke, but not to haemorrhagic achievement (although, we attention that the statistical attention for haemorrhagic achievement is low). There was no added accident apparent for the RT accumulation as a accomplished or afterwards acknowledgment to hormonal assay or chemotherapy. However, in the advised time period, few women were recommended for analytical accessory treatments.
This abstraction is based on population-based registries with aerial advantage (Mattsson and Wallgren, 1984). This abstraction covers a continued aeon of follow-up. The medical annal could be retrieved for around all cases and controls. We accept no acumen to accept that cases and controls were followed abnormally with account to bookish vascular disease.
The alternative of controls followed accepted accident density-based sampling nested aural a categorical accomplice (Rothman, 1998). We advisedly abhorred analogous for age, date of disease, and time aeon of diagnosis, as break and methods for RT are associated with these factors. Indeed, our allegation announce that such a analogous would accept basal over-matching, and the accident of achievement may accept been underestimated. Thus, we aimed to fulfil one of the basal abstruse rules in a case–control study: the controls will be called adjoin criteria, which are not associated with a likelihood of or blazon of exposure.
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Of all the strokes, ~90% are ischaemic and 10% are haemorrhagic (Rothwell et al, 2005). This should additionally be accurate apropos aside stroke. Thus, we accounted it adapted to analyse ischaemic and aside achievement together.
Of the cases, 22% had atrial fibrillation at the time of their stroke, agnate able-bodied to epidemiological studies (Sandercock et al, 1992). We accept no advice on cardiovascular accident factors, such as hypertension, smoking, and hyperlipidaemia at the time of RT. However, if anything, it is acceptable that these factors are associated with added astringent co-morbidity and, thus, may be associated with a contraindication for RT, thereby active our estimates to the bourgeois side. For example, RT, which was not delivered to IMC and SCL, was associated with a lower accident of achievement that apparently reflects a alternative bias. There is no believable biological account for RT to abatement the accident of stroke. Best women in this accumulation underwent RT to the actual breast afterwards breast conservation; the affidavit for alienated RT afterwards breast conservation, during this period, accommodate a low-performance cachet and austere cardiovascular disease.
Given the achievability of alternative bent mentioned above, we account it acceptable that RT not delivered to IMC and SCL is associated with either low or no accident of stroke. Furthermore, we begin no affiliation amid BC laterality and the agnate hemisphere breadth of the carotid stroke. Thus, if there is a absolute causal articulation amid RT and stroke, we brainstorm that it is the dosage to the above allotment of the affection and the aortic accomplished (corresponding to the IMC radiation field) that is adverse rather than the dosage to the adjacent allotment of the carotid avenue (SCL radiation field). In that way, IMC radiation would access the accident of atherosclerosis (Schultz-Hector and Trott, 2007) and, furthermore, thrombo-embolic achievement and barricade may chase the claret beck to either the adapted or larboard carotid artery, irrespective of BC laterality and SCL irradiation. However, we could not analyse the targets, IMC or SCL, as abstracted accident factors, as best capacity accustomed RT to both targets combined. The administration of achievement breadth is agnate to that in epidemiological studies (Bamford et al, 1991), neither supporting, nor authoritative a case adjoin a causal account for RT as a accident agency for stroke.
In adverse to our findings, addition abstraction begin a cogent affiliation amid tamoxifen and stroke, but not amid RT to SCL and achievement (Hooning et al, 2006). However, the capacity were ~20 years younger, and the abstraction accumulation was belted to 10-year BC survivors. In two studies (Jagsi et al, 2006; Woodward et al, 2006), there was no affiliation amid RT to SCL and stroke, but no advice apropos RT to IMC was given. A contempo abstraction (Woodward et al, 2008) begin no access of carotid binding afterwards radiation, abstinent by ultrasound.
Our aftereffect agrees with addition abstraction (Bowers et al, 2005), which showed a ample access of stroke, About Risk=4.3, amid adolescence Hodgkin survivors who had accustomed crimson irradiation, involving IMC and SCL bilaterally. In befitting with our belief that IMC radiation is detrimental, 50% of the Hodgkin survivors with achievement had accessory affection or valve problems, predisposing to cardio-embolic stroke.
High circadian atom radiation doses access the accident of backward toxicity, such as myocardial infarction (Cuzick et al, 1994), lymph oedema, and brachial plexopathy (Johansson et al, 2002). Similarly, we begin a dose-dependent accord amid radiation dosage to IMC and SCL and achievement (Table 6). It is difficult to analyze old RT techniques with avant-garde techniques, as about bang atom was acclimated in the former. When application the beforehand techniques no dosage planning was used, implicating an added accident of radiation acknowledgment to added organs in the mediastinum, namely, the affection and the aortic accomplished and its branches. Furthermore, the radiation volumes were beyond and the dosage accord was poorer.
Taken together, our beforehand award of a 12% added accident of achievement in about agreement afterwards BC assay (Nilsson et al, 2005), the present target-specific added accident of a stroke, a dose-response accord for circadian atom dose, and a advancement of an added accident of ischaemic stroke, announce that there may be a causal accord amid RT to the IMC and SCL and accident of stroke. Calm with added studies, our allegation announce that an added accident of achievement has to be taken into application in appearance of giving RT to IMC or SCL. The advancing randomised European Organisation for Assay and Assay of Blight (EORTC) abstraction apropos RT to IMC will accommodate important abstracts apropos that risk; however, these furnishings will booty a continued time to appear.
This abstraction was accurate by grants from the Assay Fund of the Department of Oncology, Uppsala University Hospital, the Lions Blight Foundation, and the Erik, Karin and Gösta Selander Foundation.
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