Comparison of long-term outcome of laparoscopic and conventional Nissen fundo- plication: a prospective randomized study with an 11-year follow- up buy procyclidine with amex medicine 4h2 pill. Mechanisms of gastric and esophageal perforations during laparoscopic fundoplication order procyclidine 5 mg visa medicine 8 capital rocka. Total versus partial fundo- plication in the treatment of gastroesophageal reﬂux disease: a Fig generic procyclidine 5mg otc medicine zetia. Successful execution of this operation requires that the The median arcuate ligament constitutes the anterior esophagus be long enough to suture the esophagogastric portion of the aortic hiatus, the aperture in the diaphragm junction to the level of the median arcuate ligament without through which the aorta passes. This band of ﬁbrous tissue cov- ers about 3 cm of the aorta above the celiac axis and is in See Chap. It can be identiﬁed by exposing the celiac artery and pushing it posteriorly with the ﬁnger at the inferior rim of the median arcuate liga- Pitfalls and Danger Points ment. For Hill’s operation, the surgeon dissects the celiac artery and celiac ganglion away from the overlying median Hemorrhage from laceration of celiac or inferior phrenic arcuate ligament in the midline, avoiding the two inferior artery phrenic arteries that arise from the aorta just to the right Injury to spleen and just to the left of the midline. Nerve ﬁbers from the Improper calibration of lumen of lower esophageal sphincter celiac ganglion must be cut to liberate the median arcuate Excessive narrowing of diaphragmatic hiatus ligament. Failure to identify the median arcuate ligament An alternative method for identifying the median arcuate Injury to left hepatic vein or vena cava when incising trian- ligament is to visualize the anterior surface of the aorta gular ligament to liberate left lobe of liver above the aortic hiatus. Then with the left index ﬁngernail push- ing the anterior wall of the aorta posteriorly, pass the ﬁnger- tip in a caudal direction. The ﬁngertip passes behind a strong layer of preaortic fascia and median arcuate liga- ment. At a point about 2–3 cm caudal to the upper margin of the preaortic fascia, blocking further passage of the ﬁnger- C. Carver arcuate ligament to the aorta at the origin of the celiac College of Medicine, University of Iowa, artery. Vansant and colleagues believed that the foregoing maneuver constitutes sufﬁcient mobilization J. Chassin of the median arcuate ligament and that the ligament need not be dissected free from the celiac artery and ganglion to perform a posterior gastropexy. We believe that a surgeon who has not had considerable experience liberating the median arcuate ligament from the celiac artery may ﬁnd Vansant’s modiﬁcation to be safer than Hill’s approach. If one succeeds in catching a good bite of the preaortic fascia and median arcuate ligament by Vansant’s technique, the end result should be satisfactory. If the celiac artery or the aorta is lacerated during the course of the Hill operation, do not hesitate to divide the median arcu- ate ligament and preaortic fascia in the midline. Calibration of this turn-in is important if With the patient in the supine position, elevate the head reﬂux is to be prevented without at the same time causing of the table about 10–15° from the horizontal. Hill (1977) used intraoperative manom- midline incision from the xiphoid to a point about 4 cm etry to measure the pressure at the esophagocardiac junction below the umbilicus (Fig. He believed that Upper Hand retractor to elevate the lower portion of the a pressure of 50–55 mmHg ensures that the calibration is sternum and draw it forcefully in a cephalad direction. If intraoperative manometry is not used, the adequacy of the repair should be tested by invaginating the anterior wall Mobilizing the Esophagogastric Junction of the stomach along the indwelling nasogastric tube upward into the esophagogastric junction. Prior to the repair, the Identify the peritoneum overlying the abdominal esophagus index ﬁnger can pass freely into the esophagus because of by palpating the indwelling nasogastric tube. After the peritoneum with Metzenbaum scissors and continue the inci- sutures have been placed and drawn together but not tied, the sion over the right and left branches of the crus (Fig. If the esophagus is inﬂamed owing to inadequately treated esophagitis, it is easy to perforate it by rough ﬁnger dissec- Liberating Left Lobe of Liver tion. Continue this incision in a cephalad Documentation Basics direction toward the right side of the hiatus. When dividing the gastrohepatic ligament, it is often necessary to divide • Findings an accessory left hepatic branch of the left gastric artery • Placement of sutures (Fig. At the conclusion of this step, the muscular 21 Posterior Gastropexy (Hill Repair): Surgical Legacy Technique 217 Fig. The only structure binding the gastric fundus to the poste- rior abdominal wall now is the gastrophrenic ligament. The best way to divide this ligament is to insert the left hand Inserting the Crural Sutures behind the esophagogastric junction and then bring the left index ﬁnger between the esophagogastric junction and the Ask the ﬁrst assistant to retract the esophagus toward the diaphragm. Divide this patient’s left; then narrow the aperture of the hiatus by avascular ligament (Fig. Use junction along the greater curvature down to the ﬁrst short 0 Tevdek atraumatic sutures on a substantial needle. Include the overlying peritoneum together with the may be done by applying a hemoclip to the splenic side and crural muscle (Fig. Do not tie these sutures at this time a 2-0 silk ligature to the gastric side of the short gastric but tag each with a small hemostat. Do not apply excessive traction with these clamps or rior surface of this organ prior to dissection in this region. Insert three or four sutures of this type as 21 Posterior Gastropexy (Hill Repair): Surgical Legacy Technique 219 Fig. Then tentatively draw the sutures together and Vansant’s Method insert the index ﬁnger into the remaining hiatal aperture. It Vansant and colleagues described another technique for should be possible to insert a ﬁngertip into the remaining identifying and liberating the median arcuate ligament by aperture alongside the esophagus with its indwelling naso- approaching it from its superior margin: Identify the anterior gastric tube. Narrowing the hiatal aperture more than this surface of the aorta in the hiatal aperture between the right may cause permanent dysphagia and does not help reduce and left branches of the crus. With the left index ﬁnger- nail pressing posteriorly against the aorta about 4 cm cepha- lad to the diaphragm, slide the index ﬁnger in a caudal Identifying the Median Arcuate Ligament direction. Deep behind the conﬂuence of the diaphragmatic crura, the tip of the index ﬁnger passes behind a dense band Hill’s Method of preaortic fascia that crosses over the aorta as the aorta After the lower esophagus and proximal stomach have been passes through the aortic hiatus in the posterior diaphragm. If the index At the lower margin of this band, the ﬁngertip encounters ﬁnger slides in a cephalad direction, its tip meets the lower pulsation of the celiac artery, which arises from the anterior border of the median arcuate ligament. Between the aorta wall of the aorta at the inferior margin of the median arcuate and median arcuate ligament are branches of the celiac gan- ligament. The median arcuate ligament lies between the ﬁn- glion as well as the right and left inferior phrenic arteries, gertip and a thin layer of muscle ﬁbers representing the cau- which arise from the aorta in this vicinity. With the index divide some of the nerve ﬁbers; but once the inferior margin ﬁnger in place, Vansant and associates inserted three of the ligament is freed from the aorta in the midline, it is interrupted atraumatic sutures of no. Hill passed a Goodell stat, leaving each needle attached for later use when suturing cervical dilator between the median arcuate ligament and the the posterior gastropexy. He stated that if a small diaphragmatic branch of the aorta is disrupted, the bleeding Suturing Posterior Gastropexy often subsides with pressure. However, it is possible for the inexperienced surgeon to induce major hemorrhage by trau- Rotate the esophagogastric junction so the lesser curvature matizing the arteries in this vicinity.
On pelvic examination there is a well-defined purchase procyclidine overnight delivery medicine allergic reaction, 1 cm white lesion of the left labia minora order procyclidine american express medicine grace potter lyrics. No other lesions in the vulva are noted; however best procyclidine 5mg symptoms testicular cancer, there is a clinical enlargement of a left inguinal node. The most common symptom of both benign and malignant lesions is vulvar itching, resulting in scratching. Differential diagnosis includes sexually transmitted diseases, benign vulvar dermatosis, or cancers. Premalignant vulvar dermatosis These are benign lesions with malignant predisposition. These lesions appear as whitish focal or diffuse areas that are firm and cartilaginous on palpation. These lesions appear as white, red, or pigmented and are often multifocal in location. Histologically, they show cellular atypia restricted to the epithelium without breaking through the basement membrane. Histologically, the cellular atypia is full thickness but does not penetrate the basement membrane. Malignant vulvar lesions Vulvar carcinoma is an uncommon gynecologic malignancy, with mean age at diagnosis age 65. The second most common histologic type of vulvar cancer is melanoma of the vulva, and the most important prognostic factor for this type of tumor is the depth of invasion. Any dark or black lesion in the vulva should be biopsied and considered for melanoma. Patients with vulvar pruritus should be considered for the possibility of preinvasive or invasive vulvar carcinomas if there is a vulvar lesion. A biopsy of this patient’s lesion reveals invasive squamous cell carcinoma of the vulva. Pattern of spread starts with local growth and extension that embolizes to inguinal lymph nodes, and then sees hematogenous spread to distant sites. In addition to radical vulvectomy, it involves removal of cervix, vagina, and ovaries in addition to lower colon, rectum, and bladder (with creation of appropriate stomas); seldom indicated or performed due to high morbidity. These small, fragile growths hang from a stalk and push through the cervical opening. Their cause is not completely understood; they may be associated with chronic inflammation, an abnormal response to increased levels of estrogen, or thrombosed cervical blood vessels. In most cases only a single polyp is present, but sometimes two or three are found. History is usually positive for vaginal bleeding, often after intercourse; this bleeding occurs between normal menstrual periods. Speculum examination reveals smooth, red or purple finger-like projections from cervical canal. Remove with gentle twisting or by tying a surgical string around the base and cutting it off (the base is removed by electrocautery or laser). Post- removal, give antibiotics even in the absence of infection because many polyps are infected. Although most cervical polyps are benign, the removed tissue should be sent to pathology. These endocervical glands can become covered by squamous epithelium through metaplasia. Rarely, cysts may become so numerous or enlarged that the cervix becomes clinically enlarged. These nests of glandular cells (nabothian glands) on the cervix may become filled with secretions. As secretions accumulate, a smooth, rounded lump may form just under the surface of the cervix and become large enough to be seen or felt upon examination. The cysts are more common in women of reproductive age, especially women who have already had children. Pelvic examination reveals a small, smooth, rounded lump (or collection of lumps) on the surface of the cervix. Rarely, a colposcopic exam is necessary to distinguish nabothian cysts from other types of cervical lesions. They can be easily cured through electrocautery or cryotherapy, either of which can be done in the doctor’s office. This diagnostic finding is confirmed by endocervical bleeding easily induced by passage of a cotton swab through the cervical os. She has been on combination steroid vaginal ring contraception for the past four years. The progression from premalignant to invasive cancer has been reported to be approximately 8– 10 years. Most lesions will spontaneously regress; others remain static, with only a minority progressing to cancer. Screening and Performing of a Pap smear The best screening test for premalignant lesions is cytology. Two specimens are obtained with the Pap smear: an ectocervical sample performed by scraping the T-zone with a spatula and an endocervical sample obtained with a cytobrush in a nonpregnant woman or a cotton-tip applicator in a pregnant woman. With the conventional method, the specimens are smeared onto a glass slide, which is placed in fixative and then microscopically examined. With the thin-layer, liquid-based cytology, the specimens are rinsed into a preserving solution and then deposited on a slide as a thin layer of processed cells. If repeat cytology is anything other than negative, proceed to colposcopy and biopsies. Colposcopy is a magnification of the cervix (10–12x); it is aided by acetic acid, which makes the vascular patterns more visible. Satisfactory or adequate colposcopy is diagnosed if the entire T-zone is visualized and no lesions disappear into the endocervical canal. Unsatisfactory or inadequate colposcopy is diagnosed if the entire T- zone cannot be fully visualized. Compare Pap smear and biopsy: When the biopsy histology is complete, it is compared with the level of Pap smear abnormality to ensure the level of severity is comparable. Cone biopsy: If the Pap smear is worse than the histology (suggesting the site of abnormal Pap smear cells was not biopsied), then a cone biopsy is performed. On pelvic examination a 3 cm exophytic mass is seen from the anterior lip of the cervix. The rest of the pelvic examination, including a rectovaginal examination, is normal. Invasive cervical cancer is cervical neoplasia that has penetrated through the basement membrane. Other symptoms include irregular vaginal bleeding and, in advanced stages, lower extremity pain and edema.
Loss of all modalities in a dermatomal distribution would suggest radiculopathy because of herniated disk cheap procyclidine express treatment xanthelasma, tumor purchase procyclidine with paypal medicine 8 iron stylings, or arthritic spurs discount 5 mg procyclidine fast delivery medicine 93 5298. Platybasia and foramen magnum tumors may cause selective loss of vibratory and position sense in one or more extremities or loss of sensation to all modalities in one or more extremities. Findings of a clear-cut sensory loss are a good reason to consult a neurologist at this point. When one is not available, further workup depends on what part of the body is affected. If peripheral neuropathy is suspected, a neuropathy workup (see page 378) should be done. If pernicious anemia is suspected, a serum B12 and folic acid and possibly a Schilling test should be done. Guillain–Barré syndrome is diagnosed by a spinal fluid examination, which will show a markedly elevated spinal fluid protein in the face of a normal cell count. Entrapment syndromes, such as carpal tunnel syndrome, ulnar nerve entrapment, or tarsal tunnel syndrome are diagnosed by nerve conduction velocity studies. If so, and there are abnormal liver function tests then, cirrhosis and other liver disease must be considered. This finding would suggest a nephrotic syndrome (from diabetes, collagen disease, and many other disorders). If the albumin is decreased along with the globulins one should consider dilutional hypoalbuminemia from congestive heart failure or poor nutrition, malabsorption syndrome and protein loosing enteropathy. Immunoelectrophoresis will assist in the diagnosis of multiple myeloma and macroglobulinemia as well as skeletal survey. It is wise to consult a hematologist, hepatologist, or nephrologist before ordering expensive diagnostic tests. The presence of significant radiation of pain down the arm would suggest thoracic outlet syndrome, herpes zoster, herniated cervical disk, spinal cord tumor, brachial plexus neuritis, myocardial infarction, sympathetic dystrophy, Pancoast’s tumor, and aortic aneurysm. The presence of transient radiation of pain down the arm would suggest coronary insufficiency. Are there hypoactive reflexes or significant dermatomal loss of sensation in the involved extremity? These findings would suggest spinal cord tumor, herniated cervical disk, and brachial plexus neuritis, among other disorders. Pain on active motion only is more frequently found in subacromial bursitis, calcific tendinitis, and torn rotator cuff. This finding would suggest osteoarthritis, rheumatoid arthritis, gout, dislocation of the shoulder, adhesive capsulitis, shoulder–hand syndrome, aseptic bone necrosis, and osteomyelitis. Is there normal range of motion of the shoulder and normal neurologic examination? These findings would suggest that the pain is referred from gallbladder disease, pancreatitis, ruptured peptic ulcer, pleurisy, or tuberculosis. These findings would suggest occlusion of the subclavian artery, thoracic 573 outlet syndrome, or dissecting aneurysm. If this is normal, a trial of conservative therapy may be initiated before ordering an expensive diagnostic workup. A neurologist should be consulted before ordering these expensive diagnostic tests. If there are focal trigger points in the bursa or shoulder joints, a therapeutic trial of lidocaine hydrochloride (Xylocaine) and corticosteroid injections should be done if the x-ray of the shoulder is negative or show only calcific tendinitis. Stellate ganglion blocks may be diagnostic and therapeutic for sympathetic dystrophy. If there are abnormalities of the brachial or radial pulses, angiography may need to be done. When there is intermittent pain down the arm, an exercise tolerance test may need to be ordered. However, it may be wise to refer the patient to a cardiologist before ordering this test. A gastroenterologist may need to be consulted to rule out cholecystitis, pancreatitis, and peptic ulcer disease. Thickening of the skin of the lower legs may also be seen in lymphedema, carcinoid syndrome, and vascular insufficiency. Thickening of the skin of the face is seen in Chagas disease and porphyria cutanea tarda. Excessive snoring would indicate obstructive sleep apnea from large tonsils, deviated nasal septum, cleft palate, other abnormalities, and obesity. More than 60% of patients with sleep apnea have obesity, and Pickwickian syndrome should be considered in these patients, as well as idiopathic obesity. The presence of neurologic abnormalities should make one think of poliomyelitis, Shy–Drager syndrome, brain stem tumors, and other neurologic disorders. If obstructive sleep apnea is suspected, a referral should be made to an ear, nose, and throat specialist. If there are abnormalities on the neurologic examination, a neurologic consultation should be sought. If idiopathic nonobstructive sleep apnea is suspected, the patient should be referred to a pulmonologist. Some cases should have evaluation for a pituitary tumor, a thyroid profile, and a trial of tricyclic drugs and progesterone. It should be distinguished from night terrors which occur in stages 3 and 4 of non-rapid eye movement sleep. When it is frequent, it is a sign of significant emotional disturbances, and a referral to a psychiatrist is in order. When environmental irritants, such as tobacco (especially snuff), ammonia, and other irritant gases, have been eliminated, it is almost invariably caused by allergy. The only exception is prolonged repetitive sneezing, which is usually psychological. Patients with prolonged repetitive sneezing and a negative workup for allergy should be referred to a psychiatrist. A careful ear, nose, and throat examination may disclose hypertrophic tonsils and adenoids, deviated septum, bifid uvula, large floppy palate, and hypertrophic turbinates, among other conditions. A careful neurologic examination may disclose bulbar palsy, pseudobulbar palsy, myasthenia gravis, and cerebral vascular disease, among other conditions. If there are ear, nose, and throat abnormalities, a referral to an ear, nose, and throat specialist should be made. If there are neurologic abnormalities, a referral to a neurologist should be made. A therapeutic trial of continuous positive airway pressure may be useful (see page 469). Most cases of sore throat with exudates will be found to have streptococcal pharyngitis.
A large cyst may simulate malignancy or lead to pathologic fractures and bizarre deformities discount procyclidine 5 mg with mastercard medicine for the people. Localized myeloma Expansile cheap 5 mg procyclidine free shipping symptoms 8 days post 5 day transfer, often trabeculated lucency that Infrequent condition in which a single plasma cell (solitary plasmacytoma) predominantly involves the ribs buy discount procyclidine 5 mg line symptoms 4 weeks 3 days pregnant, long bones, tumor presents as an apparently solitary destruc- (Figs B 6-13 and B 6-14) and pelvis. A highly destructive tumor may tive bone lesion with no evidence of the major expand or balloon bone before it breaks through disease complications usually associated with the cortex. Metastasis Single large metastatic focus appearing as Typically secondary to carcinomas of the kidneys (Figs B 6-15 and B 6-16) an expansile, trabeculated lesion (blowout and thyroid. There may be Mottled pattern of destruction and sclerosis may (Fig B 6-17) endosteal scalloping of the cortex. There is often outer tables, and often contain a central bone den- endosteal scalloping and local or extensive sity (button sequestrum). Characteristic finding is a spotty destruction in a vertebral body that pro- peculiar beveled contour of the lesion that ceeds to collapse the vertebra into a thin flat disk produces a “hole-within-a-hole” effect. Highly destructive tumor that has obliterated virtually all of the left half of the pelvis. Some residual streaks of bone remain in this osteolytic lesion, producing a soap-bubble appearance. Large area of entirely lytic, Fig B 6-15 expansile destruction (arrows) involves the left ilium. Approximately half involve the produce a soft-tissue component surrounded by vertebral column (most frequently the neural a thin calcific shell. Although predominantly lytic, osteoblastomas may have some internal calcification, and their aggressive appearance often simulates that of a malignant lesion. Chondroblastoma Eccentric, round or oval lucency in an epiphysis Rare, benign cartilaginous tumor of the epiphysis (Fig B 6-20) that often has a thin sclerotic rim and may con- that occurs in children and young adults (most tain flocculent calcification. May also involve frequently males) before enchondral bone growth the greater trochanter of the femur and the ceases. Chondromyxoid fibroma Eccentric, round or oval lucency arising in the Uncommon benign bone tumor originating from (Fig B 6-21) metaphysis of a long bone. The overlying cortex cartilage-forming connective tissue and predomi- is usually bulging and thinned, and the inner nantly occurring in young adults. Calcification is border is generally thick and sclerotic, often with infrequent (unlike chondroblastoma and other scalloped margins. Intraosseous ganglion Well-defined lucency with a sclerotic margin Most commonly involves the proximal tibia (near (Fig B 6-22) adjacent to the articular surface. May Rare tumor that arises in the calcaneus, skull, ribs, break through the cortex and have an adjacent or extremities. Glomus tumor Central well-circumscribed lucency that pri- May mimic an enchondroma, but a glomus tumor marily involves the distal aspect of the terminal is painful. Ossifying fibroma Smooth, round, or expansile mass involving the Rare tumor that may be associated with reactive skull, face, or mandible. Adamantinoma Large loculated, expansile lucent mass that Rare tumor that primarily affects adolescents and usually involves the midportion of the tibia. Echinococcal cyst Large, central radiolucent area associated with Usually monostotic and predominantly involves endosteal scalloping and expansion. Expansile, eccentric mass in the proximal Fig B 6-20 humerus causes thinning of the cortex (arrows). There that most commonly involves the femur, pelvis, may be cortical erosion suggesting a sarcoma. Cystic osteomyelitis Single or multiple small oval lucencies lying in Rare manifestation of disseminated tuberculosis. Primarily involves lesions usually affect the peripheral skeleton, are the skull, shoulder, pelvic girdles, and axial symmetric in distribution, and are unaccompanied skeleton. Desmoplastic fibroma Osteolytic lesion that destroys medullary bone Extremely rare benign neoplasm characterized with cortical erosion and expansion. Most commonly has an aggressive appearance simulating that involves the pelvis, mandible, humerus, tibia, and of a malignant tumor. Ovoid, eccentric metaphyseal lucency with thinning of the overlying cortex and a sclerotic inner margin. Usually there is widespread involvement of multiple long bones, flat bones, and the skull. Typical well-marginated, Fig B 6-24 punched-out lytic defect in the head of the third Hemophilia. Multiple osteolytic lesions throughout the phalanges, having a typical punched-out appearance. Lytic lesion in the proximal left hu- merus (arrow) with relatively well-defined lobular margins and minimal marginal sclerosis. Multiple lesions were seen elsewhere in the axial and proximal appendicular skeleton. Large lucent lesion (arrowheads) in the proximal tibia extending to the articular surface, mimicking a giant cell tumor. Kidney and thyroid metastases bones containing red marrow, such as the spine, typically produce a single large metastatic focus pelvis, ribs, skull, and the upper ends of the that may appear as an expansile trabeculated lesion humerus and femur. Elliptical lytic bone lesions knees and elbows are infrequent but do occur, suggest lymphoma. Spinal metastases typically destroy the pedicles, unlike multiple myeloma (in which the pedicles are infrequently involved). Because almost half the mineral content of a bone must be lost before it is detectable on plain radiographs, radionuclide bone scanning is far more sensitive for screening (false-negative bone scans occur with aggressively osteolytic lesions, especially multiple myeloma). Multiple myeloma Multiple punched-out osteolytic lesions scat- Disseminated malignancy of plasma cells that (Figs B 7-1 and B 7-2) tered throughout the skeletal system. Because primarily affects persons between 40 and 70 years bone destruction is due to proliferation of of age. Typical laboratory findings include an plasma cells distributed throughout the bone abnormal spike of monoclonal immunoglobulin marrow, the flat bones containing red marrow and the presence of Bence Jones protein in the (vertebrae, skull, ribs, pelvis) are primarily af- urine. Extensive plasma cell proliferation from that of metastatic carcinoma, though the in the bone marrow with no tendency to form lytic defects in myeloma tend to be more discrete discrete tumor masses may produce generalized and uniform in size. Sharply circumscribed lytic skeletal deossification simulating postmenopausal lesions tend to eventually coalesce, destroying osteoporosis. In the spine, there are often multiple large segments of bone and often breaking vertebral compression fractures and usually through the cortex and periosteum to form a sparing of the pedicles (lacking red marrow), which soft-tissue mass (especially involving a rib). Pathologic fractures are common, especially in Because there is little or no stimulation of new the ribs, vertebrae, and long bones. Solitary or diffuse areas of sclerosis (simulating osteoblastic metastases) may rarely occur. Ewing’s sarcoma Classic appearance (though seen in a majority Primary malignant tumor of children and young (Fig B 7-3; see Fig B 8-2) of cases) is an ill-defined permeative area of adults (peak incidence in the midteens) that arises bone destruction that involves a large central in the bone marrow and most commonly involves portion of the shaft of a long bone and is the long bones of the extremities (especially the associated with a fusiform lamellated periosteal femur and tibia). Other appearances of periosteal reactions include a thin periosteal Ewing’s sarcoma include a purely lytic lesion or a elevation (Codman’s triangle) or a sunburst mass of increased density (suggesting osteogenic pattern with horizontal spicules of bone sarcoma) in the metaphyseal region.
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