Aggressive angiomyxoma: irradiation for recurrent disease

BACKGROUND

Aggressive angiomyxoma (AAM) is a tumor of the soft tissues predominately occurring in the genital and pelvic area with a strong propensity to local recurrences. The entity was first described in 1983. The tumor is regarded as low-grade sarcoma by some authors; its cause and pathogenesis are presently unknown.

PATIENT AND METHOD

This is a case report on a 27-year-old man who underwent 4 surgical procedures of the left lower extremity because of a recurrent soft tissue neoplasm, initially (August 1993) diagnosed as a myxolipoma. The patient suffered from recurrences in February 1995, September 1996 and February 1998. The diagnosis was revised at the time of the latest recurrence. A palliative resection with macroscopic residuals left was performed in February 1998, followed by a radiation therapy with 56 Gy total dose and a concomitant administration of the radiosensitizer razoxane per os. The single radiation doses were 200 cGy 5 times a week.

RESULTS

The small residuals of the tumor obviously regressed although an objective response could not be shown because the lesion was not clearly measurable. A follow-up 2 years after the radiation treatment revealed no recurrence. The time of the local control achieved as yet is already longer than any former time to regrowth between the surgical procedures. This is, to our knowledge, the first description of a therapeutic irradiation of a recurrent aggressive angiomyxoma.

CONCLUSION

Radiation therapy combined with the sensitizer razoxane is able to control a recurrent AAM for an unknown time. It remains open whether a radiation treatment alone would have had a similar effect.

Transient neurological events during dipyridamole stress test: an arterial steal phenomenon?

Dipyridamole-associated adverse neurological side effects have not been extensively described. We present two cases of dipyridamole-associated transient motor neurological events with no evidence of residual neurological deficits detected clinically or by head CT. The patients showed no evidence of significant extracranial (internal carotid) artery disease. We propose the presence of a regional cerebral perfusion disturbance due to an intracranial vascular steal phenomenon as the mechanism for the above side effects of dipyridamole.

[Case study of a Legionella epidemic in a rehabilitation clinic]

A series of nosocomial Legionella infections in a rehabilitation center is reported. In a three months period a total of 10 pneumonias with 3 deaths occurred (8 patients, 1 companion, 1 staff member). Serologic analysis proved additional Legionella infections within the nursing staff. The warm-water system was proved to be the source of infection by isolating Legionella pneumophila serogroup 1 subtype Pontiac both in warm-water and patients samples. The air conditioning system could not be ruled out as another (secondary) route of exposure because of shortcomings in construction. Conclusions about prevention and the course of the disease are discussed and standards for warm-water and air conditioning systems are proposed.

Non-invasive assessment of carotid arteries: a comparison of techniques used in two laboratories

Fifty-one patients were examined non-invasively in two different laboratories and underwent angiography for carotid artery disease. Results of the two examinations and angiography were compared. In one laboratory continuous wave Doppler ultrasonography of the accessible extracranial arteries was used; in the other laboratory spectral analysis of the Doppler signals and angioscan imaging of the bifurcation was carried out. Accuracy of the two examinations (when compared with angiography) were similar for stenoses of more than 50%; spectral analysis and angioscan were better than continuous wave Doppler in detection of less than 50% stenoses.

Long-term results of surgical repair of coarctation of the aorta--evaluation by exercise test

Thirty-six patients have been operated on for coarctation of the aorta. The age at operation ranged from 4 to 45 years with a mean of 14 years. Preoperative systolic blood pressure (BP) was above the normal mean + 2 SD in 34 (94%) of the patients. The surgical techniques used for correction of coarctation were: resection and end-to-end anastomosis (50%), resection and graft interposition (25%), patch graft angioplasty (22%) and subclavian artery to descending aorta bypass graft (3%). There was no hospital mortality. Systolic BP measured on hospital discharge available in 30 patients showed an average decrease of 26 mm Hg. The mean follow-up period in 16 of 30 patients (53%) was 7.2 years. All of these patients had a further decrease in systolic BP, and in 14 of 16 (87%) BP was within the mean + 2 SD. Twelve patients were examined in the vascular diagnostic laboratory to determine adequacy of the repair by hemodynamic measures. After average of 7.8 years following operation, all of them had ankle systolic BP higher than brachial systolic pressure; ankle BP did not drop after treadmill walking exercise and the directional Doppler velocity curves from the legs were normal. This study suggested that BP continued to decrease after hospital discharge. We were unable to demonstrate correlation between age at operation and decrease in BP. The adequacy of surgical repair can be assessed by mild effort stress test combined with ankle/arm ratio measurement and directional Doppler velocity curves.

Percutaneous chemical lumbar sympathectomy with alcohol with computed tomography control

Percutaneous chemical lumbar sympathectomy with alcohol (PCLSA) using computed tomography (CT) control was performed in 8 patients suffering from advanced peripheral arterial occlusive disease. PCLSA under CT guidance was found to be a simple and safe procedure. The use of CT control added precision in the guidance of needle placement. Positive results were obtained in all patients, without significant morbidity. PCLSA may be an alternative to surgical sympathectomy.

Non invasive testing in carotid artery occlusive disease: the value of direct Doppler ultrasonography

Non invasive examination of carotid artery occlusive disease, as performed in our vascular laboratory, was compared to angiographic and operative findings in 65 patients (74 arteries). The sensitivity of carotid phonoangiography alone in detecting carotid artery stenosis was 73%. Ophthalmic flow direction was reversed in only 32% of stenosed arteries. Resistance index of directional Doppler sonography was high in only 15% of stenosed arteries. The most reliable part of the whole examination proved to be the direct "auscultation" of the carotid vessels in the neck. The overall sensitivity and specificity of this test was 88% and 64%, respectively; sensitivity being 94% for stenoses of over 50% in diameter and 55% for stenoses less than 50% in diameter. The major drawback of the test was its subjectiveness.

On the correlation of acoustical sounds and ultrasound velocimetry in the subclavian steal syndrome

Patients with suspected subclavian steal syndrome were examined by Doppler ultrasonography and by auscultation, particular attention being paid to the velocity profiles and "augmentation bruits" in the vertebral arteries, and the findings being compared with angiography. This was done with the patients at rest and during and after ischemic exercise of the affected arm. The recorded bruits were analyzed for their frequency content and it was found that the bruits in a particular kind of vessel are well characterized by the first moment of the spectrum. A good correlation between the Doppler ultrasound results and the acoustical sound pattern accompanying hyperemic flow was found. The two methods are supplementary and complementary in the non-invasive diagnosis of subclavian steal syndrome. To demonstrate the multifacetted appearances of the syndrome three cases are discussed.

Influence of physical activity on the thermic effect of food in young men

Oxygen consumption and heart rate of young fasting men were examined at rest and during 2 h following food intake (400 or 1,200 kcal mixed or 1,200 kcal high-protein diet). In a series of experiments, this procedure was carried out after complete recovery from moderate exercise (10 min at 50% maximal aerobic power) performed immediately after the meal. The calorigenic effect of food was exhibited by all subjects. The magnitude of the postprandial rise in oxygen consumption was related to the caloric content of food, being similar after mixed and protein-rich diets. Moderate exercise after meals augmented dietary thermogenesis.

[On the etiology of water excretion inhibition in Addison's disease]

Micropuncture experiments, performed on adrenalectomized rats disclosed an impairment of the hypertonic sodium chloride transport of the thick ascending limb of Henle's loop (the diluting segment). This transport inhibition was documented by a delayed time course of NaCl-concentration decrease within the diluting segment. Assuming a pump leak model of the hypertonic NaCl-transport, we calculated a 50% inhibition of the NaCl-transport velocity compared with controls. Dexamethasone treatment for 3 days led to a normalization of the impaired transport velocity. Both, the reduced GFR as well as the impaired free water clearance are functionally linked to the diminished transport capacity of the diluting segment by the tubuloglomerular feedback mechanism and the ADH mechanism respectively. A new hypothesis on the pathogenesis of the water excretion inhibition in adrenal insufficiency is discussed.

Role of the vascular laboratory in the diagnosis of aortic arch occlusive disease: Screening of 2000 patients

A significant difference in bilateral systolic brachial artery pressures and the presence of systolic bruit over a subclavian artery suggests occlusive disease in the innominate or subclavian arteries. Two thousand patients with these signs underwent ultrasonography of the carotid, subclavian, and brachial arteries in our laboratory. Doppler recordings of a vertebral artery, with hyperemia testing of the ipsilateral arm, identified those with a subclavian steal syndrome. In each case, angiography confirmed the laboratory diagnosis. The effectiveness of corrective surgery was evaluated noninvasively. Illustrative cases are presented and discussed.