Patients and referring physicians around the world have turned to POSO since 1997.
Affiliates of the Partners HealthCare system include Harvard Medical School teaching hospitals.
We assign a dedicated case coordinator to each organization that contracts with us, ensuring superior service and support.
Identifying the most appropriate expert specialists in our network to comment on particular diagnoses
Conducting imaging and biopsy reviews to affirm, adjust or change original diagnoses
Confirming treatment plans, therapies and interventions—or recommending alternatives
Providing guidance on medication management and pain management strategies
POSO eliminates the time and expense of traveling to receive the very best second opinion. And by giving employees and their doctors greater confidence through our diagnosis and treatment plan reviews, we help them avoid unnecessary testing and procedures—and enjoy peace of mind.
Dear Referring Physician,
Thank you very much for your consultation regarding female patient, DOB: 1/25/1967. I have reviewed the medical records that were provided as well as the imaging. My findings and opinion regarding her case follows:(1)
Chief complaint: Bilateral forefoot pain(2)
She has suffered with bilateral hallux valgus for a few years, however, in 2015 following a 3-day trekking holiday the condition worsened considerably.
Walking is limited and has declined markedly over the last 2 years.
She describes pain as chronic, although reluctant to take oral analgesia she prefers topical treatments, ice packs etc. Although provided with Orthotics, she was never advised to change them after wearing them of 6-7 months, and consequently her foot pain increased. She is now waiting for new ones, and expects them next week.
Generally, in good health, no associated health problems that may affect her hallux valgus.
She is awaiting new pair of orthotics, only to be worn with comfortable low heeled walking shoes. She is reluctant to take oral analgesia despite chronic pain; prefers topical remedies such as ice packs.
No pain when wearing house slippers, otherwise pain is experienced when wearing all types of other foot wear. She expresses concern that having to wear orthotics in the summer will only increase her foot pain, as she is unable to wear sandals.
The patient has been advised that if it is progressing it was likely to continue to do so and so she should consider surgery sooner rather than later as it will be a smaller operation with greater probability of success. Currently the patient doesn't feel it is bad enough to warrant surgery.
Radiographs that were provided consist of 3 views of each foot done in a weight bearing position. No fractures or dislocations are noted. Joint spaces appear well preserved. There is no soft tissue abnormality noted. There is a mild hallux valgus deformity of each foot. There appears to be a bipartite tibial sesamoid on the left. The sesamoids appeared to be well located underneath the first metatarsal head. There is some prominence to each medial eminence on the first metatarsals. Although I was not able to accurately measure the hallux valgus angle or the 1-2 intermetatarsal angle these do not seem much greater than values that have been determined in the normal, non-affected population.
Answers to Specific Questions:(5)
1. Is surgery needed?(6)
I do not believe that surgery is needed at this time. Perhaps the primary determinant for undergoing surgery is whether the patient feels that it is warranted given their current set of circumstances. The patient very clearly states that she "...doesn't feel it is bad enough to warrant surgery."
2. What is the recommended timeframe for the surgery?
It is quite possible that she will have worsening of the deformity with concomitant worsening of her pain and decrease in function. If this occurs reassessment of the value of surgical correction should be undertaken at that time.
3. Is it advisable to wait?
4. What are the risks a) if she has it now b) if she waits until she is more symptomatic?(7)
Some of the risks that surgery poses would be present whether it is performed now or in the future. These include but are not limited to wound healing complications, infection, nerve damage, blood vessel damage, failure to achieve correction, recurrence of deformity, joint stiffness, continuing pain and overcorrection of deformity. The complications might differ if she waits until she is more symptomatic if alternative methods of erection including soft tissue/bone fixation are used. These would be specific to the procedure that was used.
5. What other alternatives exist?
The alternatives that exist for the treatment of her problem include comfortable shoe wear with a wide toebox. Although I do not think that any one brand is superior to others I have found that Keen shoes are very effective in providing comfort in patients such as this. They have a large toebox and can be used for many different types of activities/active lifestyles. I would avoid fashionable shoes that have a narrow, tapered toebox with high heels.
In addition to altering shoe wear her current shoe wear might be able to be modified using a ball and ring shoe stretcher. The goal of this device is to stretch out the shoe upper material to better accommodate the medial eminence where most people have pain with hallux valgus deformity. These can be obtained on line for a quite modest price and can be used repeatedly and in all of the patient's shoe wear.
A silicone toe spacer can be placed between the first and second toes to realign the deformity and potentially provide her with some relief.
6. Based upon the history and images, what are your recommendations for the best patient outcome?
Currently, I would pursue non-operative means for controlling the patient's symptoms and to prevent progression of her deformity. If these fail to provide relief she may want to consider surgery when she feels that non-operative methods have been exhausted and that she has no alternative.
I do not advise her undergoing hallux valgus surgery at this time. I think that using the aforementioned non-operative methods could provide her with significant relief and allow her to participate in the activities that she would like to. If the deformity she has progresses and the feet become more painful she may want to consider surgery at that time. Unless there is a worsening of great magnitude in her deformity the surgical correction would not be that much more difficult to perform compared to the surgical procedures that could be considered currently.
Please do not hesitate to contact me in the future if there are additional questions or concerns. Thank you for the opportunity for providing treatment recommendations regarding this patient.
Dear Dr. XX:
Thank you for referring Ms. Female Patient to Partners Online Second Opinions.(1)
The patient is a 51-year-old with a history of uterine myomas (fibroids), presenting with abdominal discomfort. She has undergone imaging by both pelvic ultrasound and MRI and has been recommended surgery for possible uterine sarcoma. I am not able to offer an opinion on the imaging given that it is outside my scope of practice as a gynecologic oncologist and I am not a radiologist. My opinion is based on the available ultrasound report enclosed with the documents available for my review.(2)
Uterine sarcoma accounts for 3 to 9 percent of all uterine malignant neoplasms. Uterine sarcomas arise from dividing cell populations in the myometrium or connective tissue elements within the endometrium. Compared with the more common endometrial carcinomas (epithelial neoplasms), uterine sarcomas, particularly leiomyosarcomas (connective tissue neoplasms), behave aggressively and are associated with a poorer prognosis.(3)
Risk factors for uterine sarcoma include: black race (for leiomyosarcoma, but not endometrial stromal sarcoma), long-term use of tamoxifen (five years or more), and pelvic radiation. Genetic conditions associated with uterine sarcoma are hereditary leiomyomatosis and renal cell carcinoma (HLRCC) syndrome and hereditary childhood retinoblastoma. Uterine sarcomas typically present with vaginal bleeding, pelvic pressure symptoms (eg, pressure, urinary frequency, constipation), or abdominal distension. On pelvic examination, the uterus is often enlarged.
The findings on examination and imaging for uterine sarcoma are nearly identical to those for benign uterine leiomyomas, as well as for atypical leiomyoma variants. Thus, the diagnosis of uterine sarcoma is often made after myomectomy or hysterectomy. That is, there is no way to make a definitive diagnosis of this highly malignant tumor other than by surgical removal of the “fibroid” or by removal of the uterus. Unfortunately, imaging studies cannot reliably differentiate between a uterine sarcoma and other uterine findings (eg, leiomyomas, adenomyosis). The diagnosis of uterine sarcoma is based upon histologic examination. Data regarding diagnostic accuracy of serum markers, biopsy, or imaging are limited in this rare disease.(4)
Thus, given the concern for a sarcoma raised by the ultrasound and the fact that it is not medically possible to make a definitive diagnosis of sarcoma without surgical tissue, I agree with the recommendation for surgery and would recommend a total hysterectomy and removal of both ovaries and fallopian tubes given that the area of concern extends to the adnexal region, which would also include the ovaries and the fallopian tubes. The operation should be done so as to allow removal of all of these structures as a whole, without morcellating or cutting the tissue. The choice of treatment after surgery depends entirely on the final pathology. There are data to support use of chemotherapy in the setting of advanced-stage leiomysarcoma but the final recommendation regarding post operative treatment is entirely dependent on the surgical histologic findings.(5)
1. Nordal RR, Thoresen SO. Uterine sarcomas in Norway 1956-1992: incidence, survival and mortality. Eur J Cancer 1997; 33:907.
2. Tropé CG, Abeler VM, Kristensen GB. Diagnosis and treatment of sarcoma of the uterus. A review. Acta Oncol 2012; 51:694.
3. Bell SW, Kempson RL, Hendrickson MR. Problematic uterine smooth muscle neoplasms. A clinicopathologic study of 213 cases. Am J Surg Pathol 1994; 18:535.
4. Silverberg SG, Kurman RJ. Tumors of the uterine corpus and gestational trophoblastic disease. In: Atlas of Tumor Pathology - Armed Forces Institute of Pathology, electronic fascicle version 2.0, Washington DC.
5. Kurma RJ. Pathology of the Female Genital Tract, 4th, Springer Verlag, New York p.499.
6. Sandberg AA. Updates on the cytogenetics and molecular genetics of bone and soft tissue tumors: leiomyosarcoma. Cancer Genet Cytogenet 2005; 161:1.
7. Sandberg AA. Updates on the cytogenetics and molecular genetics of bone and soft tissue tumors: leiomyoma. Cancer Genet Cytogenet 2005; 158:1.
8. Morton CC. Genetic approaches to the study of uterine leiomyomata. Environ Health Perspect 2000; 108 Suppl 5:775.
9. Bodner K, Bodner-Adler B, Kimberger O, et al. Estrogen and progesterone receptor expression in patients with uterine leiomyosarcoma and correlation with different clinicopathological parameters. Anticancer Res 2003; 23:729.
10. Wade K, Quinn MA, Hammond I, et al. Uterine sarcoma: steroid receptors and response to hormonal therapy. Gynecol Oncol 1990; 39:364.
11. Moinfar F, Azodi M, Tavassoli FA. Uterine sarcomas. Pathology 2007; 39:55.
12. Karpathiou G, Sivridis E, Giatromanolaki A. Myxoid leiomyosarcoma of the uterus: a diagnostic challenge. Eur J Gynaecol Oncol 2010; 31:446.
13. Oliva E, Clement PB, Young RH, Scully RE. Mixed endometrial stromal and smooth muscle tumors of the uterus: a clinicopathologic study of 15 cases. Am J Surg Pathol 1998; 22:997.
14. Kir G, Gurbuz A, Karateke A, Dayicioglu V. Stromomyomas of the uterus-- importance of total circumferential evaluation of the margin. Eur J Gynaecol Oncol 2004; 25:489.
15. Clement PB, Scully RE. Mullerian adenosarcoma of the uterus: a clinicopathologic analysis of 100 cases with a review of the literature. Hum Pathol 1990; 21:363.
16. Krivak TC, Seidman JD, McBroom JW, et al. Uterine adenosarcoma with sarcomatous overgrowth versus uterine carcinosarcoma: comparison of treatment and survival. Gynecol Oncol 2001; 83:89.
17. Toro JR, Travis LB, Wu HJ, et al. Incidence patterns of soft tissue sarcomas, regardless of primary site, in the surveillance, epidemiology and end results program, 1978-2001: An analysis of 26,758 cases. Int J Cancer 2006; 119:2922.
18. Brooks SE, Zhan M, Cote T, Baquet CR. Surveillance, epidemiology, and end results analysis of 2677 cases of uterine sarcoma 1989-1999. Gynecol Oncol 2004; 93:204.
19. Ueda SM, Kapp DS, Cheung MK, et al. Trends in demographic and clinical characteristics in women diagnosed with corpus cancer and their potential impact on the increasing number of deaths. Am J Obstet Gynecol 2008; 198:218.e1.
20. Norris HJ, Taylor HB. Mesenchymal tumors of the uterus. I. A clinical and pathological study of 53 endometrial stromal tumors. Cancer 1966; 19:755.
21. Sherman ME, Devesa SS. Analysis of racial differences in incidence, survival, and mortality for malignant tumors of the uterine corpus. Cancer 2003; 98:176.
22. Mourits MJ, De Vries EG, Willemse PH, et al. Tamoxifen treatment and gynecologic side effects: a review. Obstet Gynecol 2001; 97:855.
23. Yildirim Y, Inal MM, Sanci M, et al. Development of uterine sarcoma after tamoxifen treatment for breast cancer: report of four cases. Int J Gynecol Cancer 2005; 15:1239.
24. Wysowski DK, Honig SF, Beitz J. Uterine sarcoma associated with tamoxifen use. N Engl J Med 2002; 346:1832.
25. Wickerham DL, Fisher B, Wolmark N, et al. Association of tamoxifen and uterine sarcoma. J Clin Oncol 2002; 20:2758.
For 10 years, Julie had battled several chronic conditions, including a bleeding disorder, high blood pressure,high cholesterol, gout and chronic kidney disease of unknown origin. During this period, she took a combination of medicines to manage her conditions and was feeling well.
Eventually, however, Julie's kidney function began to worsen. After undergoing two rounds of hemodialysis and starting a second round of oral steroids, she requested a second opinion through her health care benefits provider, which has a contract with POSO.
We coordinated a case review by specialists at Brigham and Women's Hospital. The team determined she was suffering from a drug-induced rhabdomyolysis, a condition that can cause kidney failure secondary to drug toxicity. The medications she was taking for gout and cholesterol were pinpointed as the source of the problem.
The POSO specialist recommended that Julie discontinue those medications as well as the oral steroids (which were actually contraindicated for chronic kidney disease).Since these adjustments were made to her treatment plan, Julie has experienced stable kidney function and has not required further rounds of hemodialysis or steroids.
"The second opinion, I believe, saved my life," Julie says. "It wasn't in time to change the damage already done, but I believe that it has extended the time I do have...which certainly would be shorter without your wonderful, top-notch physicians and the diligent work you did to give those doctors a thorough picture of my case."
Mr. P was diagnosed with colon cancer at age 60. His local physician recommended a chemotherapy regimen to treat the cancer, with the possibility of surgery depending on how the disease responded to treatment.
To confirm that no other viable treatment options were available, Mr. P requested a second opinion. Through POSO, Brigham and Women's Hospital specialists validated his diagnosis and treatment plan, noting that many patients following this particular combination of chemotherapy agents have seen decreased tumor size and a greatly improved long-term prognosis.
"I am really grateful to POSO for guiding me through the second opinion process," Mr. P says."The expertise of your company provided me the best support in validating the treatment I am going through in India."
A woman from China who had lung cancer requested a second opinion through her health care benefits provider, which has a contract with POSO. The resulting report evaluated her current treatment plan and listed alternate plans based on possible future scenarios, including a clinical trial program.
"The hospitals that were recommended to do my medical second opinion were all leading and top-ranking hospitals in the field, like Dana-Farber Cancer Institute and Massachusetts General Hospital. The final report was professional and got high praise from my attending physician," she says. "Also, the process was convenient; all I had to do was provide medical records and test reports."
An eight-year-old boy from India was diagnosed with a very rare infection in his brain, a condition that can cause epilepsy. His parents wanted to be sure the treatment plan outlined by their local physician was on target.
Through POSO, specialists at the Massachusetts General Hospital for Children reviewed the boy's medical records and brain imaging. They agreed with the prescribed course of treatment and added a few recommendations for his long-term treatment. His parents were grateful for the expert perspective.
"We received the opinion in a very timely manner; it was very thorough and insightful," the parents wrote. "We got the comfort that the doctors who were selected have taken afresh and an independent view on our son's medical condition and made useful observations. Overall, we had an excellent experience."
We work with large-scale employers, insurers that offer our service to members and health care facilitation companies around the world.
Our offerings, which are designed to meet the needs of a diverse patient population, include:
The base cost for a medical second opinion is $950. Additional charges apply in certain cases, such as if a formal imaging or biopsy review is performed by our radiologists or pathologists. See this page for more details.
Companies that have an agreement with us:
We can structure our model according to your desired degree of integration: You can send us cases through our website, or our offering can be co-branded or white-labeled.
Our team includes case coordinators with years of experience recruiting and working with physicians at all Partners HealthCare hospitals. The case coordinators leverage their experience — and physician input — to identify the best qualified specialist based on each patient’s medical situation and the questions that the patient and his or her doctor submit.
Partners HealthCare is a not-for-profit healthcare delivery network based in Boston, Massachusetts. Member institutions include prestigious Harvard Medical School teaching hospitals, including Brigham & Women's Hospital and Massachusetts General Hospital, which co-founded Partners in 1994.
Partners HealthCare Connected Health, which manages POSO, is a leading force in the use of technology to deliver care outside of hospitals and doctor's offices. Applying personal health technologies, including remote monitoring, mobile health, personal health trackers and sensors, its people are creating new solutions for empowering individuals and providers to better manage health and wellness.