Para-aortic lymphoma simulating mycotic abdominal aortic aneurysm

A Case of Periaortic Lymphoma Mimicking Complicated Type B Acute Aortic Dissection: A Pitfall in the Endovascular Surgery Era

We report a case of periaortic lymphoma mimicking Stanford type B acute aortic dissection treated for impending rupture by thoracic endovascular aortic repair. Although no endoleak was detected, the aneurysm enlarged continuously. Repeat computed tomography scans showed that an aortic aneurysm-like structure around the stent graft had enlarged irregularly. Histopathological examination revealed diffuse large B-cell malignant lymphoma. Post-chemotherapy, the aneurysm-like structure disappeared without any fistula or rupture. In open surgery, differentiating between aneurysms and malignancy is easy under direct vision; however, in the endovascular surgery era, this is a pitfall because no surgical specimen of the lesion can be obtained.

Emergence of a lymphoma imitating an infectious infiltration surrounding the infrarenal aorta after EVAR

Primary retroperitoneal localization of non-Hodgkin's lymphoma is rare but should be considered, even if the circumstances surrounding its emergence point to other direction. We present a case of an appearance of periaortic infiltration after successful endovascular treatment which turned out to be of malignant origin.

Aggressive Phenotype of Intravascular Lymphoma Relative to Other Malignant Intraabdominal Tumors Requiring Vascular Reconstruction

BACKGROUND

Safe resection of intraabdominal and retroperitoneal malignancies with a goal of negative margins may require vascular surgical assistance with grafting of the aorta and/or vena cava. The current report reviews malignancies associated with major vascular reconstructions at a single tertiary referral center.

METHODS

Adults with abdominal or retroperitoneal tumors involving the aorta, vena cava, or iliac arteries that underwent reconstruction with vascular grafts at the University of Michigan from 2010 to 2016 were reviewed retrospectively. The initial presentation, surgical management, and outcomes were analyzed.

RESULTS

Twelve patients with tumors involving the abdominal aorta, vena cava, or iliac arteries underwent major vascular reconstruction in this seven-year study period. Tumor pathology included solid tumors (leiomyosarcoma [n = 7], germ cell tumor [n = 3], and intravascular lymphoma [n = 2]). Surgical treatment included grafting of the vena cava (n = 6), aorta (n = 3), iliac artery (n = 4), or both the aorta and vena cava (n = 1). Patients with intravascular lymphoma were identified incidentally during treatment of abdominal aortic aneurysm or on pathological analysis of thromboembolism from an aortic source. Other patients had planned resection. Follow-up ranged from 9 to 86 months (median: 28.9). There were no graft occlusions. Tumor metastasized or recurred in patients with sarcoma (n = 2; 28.6%), germ cell tumor (n = 1; 33.3%), and intravascular lymphoma (n = 2; 100%). Both patients with lymphoma had multiple anastomotic or tumor-embolic pseudoaneurysms for <14 months after vascular reconstruction. Both lymphoma patients died during follow-up.

CONCLUSIONS

This single-center review suggests that sarcoma and germ cell tumors may be safely resected in conjunction with major vascular reconstruction in carefully selected patients. In comparison, intravascular lymphoma identified incidentally at the time of aortic reconstruction resulted in a more malignant course with pseudoaneurysm formation of anastomoses or native vessels, cancer recurrence, and 100% mortality. Aneurysm contents and emboli should be carefully reviewed perioperatively by pathologists.

Abdominal aortic aneurysm with periaortic malignant lymphoma differentiated from aneurysmal rupture by clinical presentation and magnetic resonance imaging

Abdominal aortic aneurysm (AAA) associated with periaortic malignant lymphoma is difficult to differentiate from aneurysmal rupture because of similarities in their clinical presentation and appearance on computed tomography images. We here report a case of AAA associated with periaortic malignant lymphoma diagnosed preoperatively with an absence of typical symptoms, showing that AAA in periaortic malignant lymphoma can present without any clinical correlates. Magnetic resonance imaging was used to confirm the diagnosis. The patient was treated by endovascular repair, which may be safer and more effective than open surgery for AAA associated with malignant lymphoma because of the tight adhesion between the aneurysm and the lymphoid tissue.

Endovascular Treatment of Symptomatic Thoracic Aneurysm Due to Periaortic Lymphoma

An aggressive periaortic lymphoma could very rarely invade the aortic wall. We present a unique case of a patient with symptomatic thoracic aneurysm and imminent rupture due to the periaortic lymphoma, in which endovascular treatment using stent graft was applied. After stabilization of the aorta and histological confirmation of aggressive B-cell lymphoma by computed tomography-guided biopsy, the antilymphoma therapy was initiated. Despite the full treatment, the patient died 12 months later.

Thoracic Pseudoaneurysm Caused By Malignant Lymphoma

We describe the case of a 69-year-old man with a thoracic pseudoaneurysm caused by a diffuse large B-cell lymphoma. He had a large mass inside the aortic arch. Five weeks later, an asymptomatic aneurysm protruding from the minor curvature of the distal aortic arch was observed. We suspected a mycotic pseudoaneurysm and performed total arch replacement with an omental pedicle flap graft. Intraoperative tissue cultures and histopathologic tests identified no bacteria, however. Eventually, a pathologic examination revealed that the structure initially suspected to be an intramural thrombus was a diffuse large B-cell lymphoma.

Clinical experience of positron-emission tomography in infective aortic disease

Background

Fluorine-18-fluorodeoxyglucose positron-emission tomography with computed tomography has revolutionized medical diagnosis by adding functional activity to anatomic imaging. We report our experience with this technique in patients with mycotic aortic pathology and aortic vascular graft infection.

Methods

We conducted a retrospective review of a prospective database of patients who underwent 18F-fluorodeoxyglucose positron-emission tomography with computed tomography for suspected infective aortic disease. From 2012 to 2016, 13 patients underwent 18F-fluorodeoxyglucose positron-emission tomography. Of these, 9 (69%) had a vascular graft infection (5 infrarenal aorta, 1 para-visceral, 2 descending, and 1 arch; 2 had previous open surgery and 7 had endovascular interventions) and 4 (31%) had a mycotic aneurysm (2 aortic arch, 1 infrarenal aorta, and 1 distal aorta and common iliac; 3 had endografts). The indications for imaging, location of pathology, 18F uptake, and clinical outcomes were analyzed.

Results

Eight (62%) patients had a single scan and 5 (38%) had serial scans performed. Among the 5 patients who had serial imaging, 3 showed decreased 18F uptake and 2 had increased uptake. Only one patient underwent subsequent endograft removal; the others were treated with lifelong antibiotics. There were 5 (38%) deaths on follow-up.

Conclusion

18F-fluorodeoxyglucose positron-emission tomography with computed tomography could be a valuable adjunct in the diagnosis and surveillance of patients with aortic infection. Serial scans may be useful for monitoring disease activity and response to antibiotic therapy.

Thoraco-abdominal aortic aneurysm rupture secondary to lymphocytic lymphoma

We present the case of a 60-year old woman with a ruptured thoraco-abdominal aortic aneurysm (TAAA). It was a Type IV TAAA in the Crawford Classification. A mycotic origin was suspected as she had a known history of lymphocytic lymphoma. She underwent thoraco-abdominal aortic replacement with a good surgical result. Histopathological examination revealed destruction of the aortic layers due to inflammatory lymphomatous aortic infiltration. The patient fully recovered.