Post-radiation atypical vascular proliferation on the head of a young woman: a diagnostic challenge

With improved outcomes associated with radiotherapy (RT), post-irradiation tumors are increasingly seen in long-term cancer survivors. We report a case of a young woman who presented with a three-year history of a vascular lesion on the temple, previously irradiated for a childhood brain tumor. The history of radiation, the clinical appearance, and the biopsy findings of an atypical vascular proliferation in the dermis, were worrisome for a malignant vascular neoplasm and prompted surgical excision. However, further tissue analysis of the excised specimen confirmed a benign atypical vascular lesion (AVL) overlying a banal pilar cyst. Distinguishing post-radiation benign from malignant vascular lesions can be difficult because they share overlapping clinical and histopathologic features. Thus, any vascular lesion that occurs in a previously irradiated field should be excised completely with tumor-free margins and examined histologically.

Carotid sheath lipoma: first case report in the English literature

Lipomas are the most commonly encountered benign mesenchymal tumour, arising in any location where fat is normally present. Lipomas in the head and neck are rare in all age groups. Cases of vascular sheath lipomas in the femoral region have only been reported in adults. In children, vascular sheath lipomas have not been described to date. We report the first case of a carotid sheath lipoma in a seven-year-old boy. He had a non-tender soft mass with ill defined borders occupying the left upper part of the neck. Magnetic resonance imaging showed a mass at the bifurcation of the left common carotid artery without involving the same. The mass was hyperintense on T1 and T2 weighted sequences, suggestive of a lipoma. The lipoma was enucleated after incising the carotid sheath, safeguarding its contents. Histopathology confirmed it as a lipoma.

Biological distinctions between juvenile nasopharyngeal angiofibroma and vascular malformation: an immunohistochemical study

The exact nature of juvenile nasopharyngeal angiofibroma (JNA) is still in dispute. In recent years, the main controversy of its nature has focused on hemangioma and vascular malformation. In this study, the immunolocalization of vascular endothelial growth factor (VEGF), VEGF receptor-1/fms-like tyrosine kinase-1 (VEGFR-1/Flt-1), VEGF receptor-2/fetal liver kinase-1 (VEGFR-2/Flk-1), proliferating cell nuclear antigen (PCNA), and CD34 was investigated in 28 cases of JNA and 20 cases of orbital cavernous hemangiomas (OCH). The immunostaining levels of VEGF, Flt-1, and Flk-1 were higher and more frequent in vascular endothelial cells of JNA than those of OCH (p<0.05). The average microvessel density (MVD) marked by CD34 in JNA was (49.3 ± 9.1)/HPF (high power field), which was higher than OCH (29.1 ± 6.7)/HPF (p<0.05). Immunoreactivity of PCNA was localized in both endothelial and stromal cell components of JNA, but was predominantly seen in the stromal cells. However, no PCNA immunoreactivity was identified in any of the stromal and endothelial cells in cases of OCH. The immunostaining levels of CD34, VEGF, Flt-1, Flk-1, and PCNA in JNA were higher than those in OCH. These data support the view that JNA has biological characteristics of an angiogenic histogenetic tumor. In the future, anti-angiogenic therapy may represent a novel treatment strategy for JNA.

Ruptured duodenal varices successfully treated by mini-loop ligation: report of a case

Bleeding from duodenal varices is a rare, but often fatal manifestation of portal hypertension and these ectopic varices are more common in extrahepatic portal venous obstruction. There are over 160 cases of duodenal varices reported in the English literature. A 47-year-old female presented with massive hematemesis and prolonged shock. Initial endoscopy revealed non-bleeding small esophageal varices and large varices in the first portion of the duodenum with spurting bleeding. Endoscopic hemostasis was obtained with 5 detachable nylon loops. Portal hypertension was caused by liver cirrhosis and postthrombotic portal cavernoma. To the best of our knowledge this is the first case of successful mini-loop ligation of bleeding duodenal varices reported in the literature.

Leiomyosarcoma of the inferior vena cava involving the renal veins: a simple method of right renal vein reimplantation

In this report we describe a case of leiomyosarcoma of the inferior vena cava involving the renal veins. The abdominal computed tomography scan showed a tumor in the infrahepatic portion of the inferior vena cava and the confluence of the renal veins. After resection of the tumor, venous reconstruction involved the replacement of the inferior vena cava with a prosthetic graft and the implantation of the right renal vein into the portal vein. The left renal vein was ligated distally, with preservation of collateral pathways. To our knowledge, no other reports of such venous reconstruction have been published. After a follow-up of 30 months, the patient has shown no further symptoms, and the abdominal computed tomography scan demonstrates patency of the renal portal anastomosis. Tests indicated normal renal and hepatic function, suggesting good tolerance of the renal portal anastomosis. We believe that the technique described in this report should be adopted routinely for tumors located in the renal veins, provided complete resection of the tumor with a comfortable resection margin is possible.

Non-meningeal tumours of the cavernous sinus: a surgical analysis

The popularisation of cavernous sinus approaches and subsequent experience has shaped our treatment paradigms for cavernous sinus meningiomas. However, pathologies in this region are diverse and each one requires individual consideration. The purpose of this study was first to analyse, define and summarise the individual characteristics of different non-meningeal tumours of the cavernous sinus and, secondly, to stress that their surgery can be accomplished with acceptable morbidity and rewarding results when those characteristics are considered. A retrospective analysis of 42 cases of benign non-meningeal tumours of the cavernous sinus operated on at Marmara University between April 1992 and April 2003 is presented. The patients were 15 males and 27 females aged 24-72 years. The study cohort consisted of 13 pituitary adenomas, 11 trigeminal schwannomas, seven chordomas, three chondrosarcomas, two juvenile angiofibromas, two epidermoid tumours, one plasmacytoma, one cavernous haemangioma and one internal carotid plexus schwannoma. The 42 patients underwent 46 operations aimed at radical surgical excision. Total resection was achieved in 50% and subtotal resection in 50% of cases. The majority of incompletely resected tumours were pituitary adenomas and chordomas, and 95% required further treatment. Twenty-nine percent of patients developed complications, namely cerebrospinal fluid fistula, haematoma, hydrocephalus, diabetes insipidus, cerebral infarction and cranial nerve palsies. Recurrence was seen in 7.1% of patients. At final follow up at an average of 48.2 months after surgery, the mean Karnofsky performance scale had risen from 83.4 to 87.4. Non-meningeal tumours of the cavernous sinus can be surgically resected with acceptable morbidity and mortality. In selected tumours the results are better than those for cavernous sinus meningiomas. The best surgical results are achieved with interdural tumours of the lateral sinus wall and the worst surgical results are seen in invasive tumours such as chordomas and pituitary adenomas. Individual tumour characteristics are presented in the text.

Perivascular myoma of myopericytoma and myofibromatosis-type arising in a chronic scar

We describe a case of a cutaneous perivascular myoma with features overlapping between the myofibromatosis and the myopericytoma type. The patient is a 58-year-old woman with a painless plaque-like and multinodular lesion in the pretibial dermis and subcutaneous tissue. She had repeated trauma to this site, first in her early youth that left an area of hyperpigmentation, and then again at age 40. The biopsy showed a biphasic pattern with a myofibromatosis-type component composed of spindle cell myoid nodules and more cellular round cell areas. The myopericytoma-like areas appeared to be infiltrating along vessels. These areas contained aggregates of immature-appearing cells arranged concentrically around vascular lumina in a manner reminiscent of pericytes. Immunohistochemical stains showed focal positivity for smooth muscle actin. Immunohistochemical and ultrastructural studies have showed these pericyte-like cells to be of a myoid origin. The reason for the neoplastic proliferation of perivascular myoid cells is presently unknown. The association of trauma and neoplastic transformation of the skin is rare. We report the first case of a cutaneous perivascular myoma arising in a chronic scar.

Intraoperative MR imaging: preliminary results with 3 tesla MR system

Aim of this study is to present the initial clinical experience with 3 tesla intraoperative MR (ioMR).

MATERIAL AND METHODS

The 3T MRI suite is built adjacent to the neurosurgical operation theatre. The magnet room and the operation theatre are interconnected by a door and both RF-shielded. Before the operation, the magnet (3T Trio, Siemens) and the console rooms are disinfected. Whenever imaging is needed during the operation, the door is opened and the patient is transferred from the operation table to the magnet cradle. Axial, sagittal and/or coronal TSE T2, SE T1 and 3D Flash T1 weighted images (4-6 mm section thickness, 1 mm interslice gap) are obtained according to the lesion. Total examination time is approximately 10 minutes.

RESULTS

Twenty-six patients were examined with ioMR. There were ten female and seven male patients. Lesions were pituitary adenoma in 10, low grade glial tumor in 9, meningioma and high grade glial tumor in 2 each and metastasis, haemangioblastoma and chordoma in one each. Follow-up time was 1 to 9 months. In 16 patients the first intraoperative examination revealed gross total tumor excision. However, in 10 patients due to tumor remnants surgical intervention was continued and a second examination revealed gross total tumor excision in all. Postoperative routine MR examinations confirmed total tumor excision in all patients. No complication occurred in this series.

CONCLUSION

This small group of patients examined with ioMR demonstrated that the procedure is simple, helpful in achieving gross total tumor excision without complications.

Tumor-induced hypophosphatemic osteomalacia associated with tertiary hyperparathyroidism: a case report

BACKGROUND

Tumor-induced hypophosphatemic osteomalacia is a syndrome characterized by urinary phosphate wasting related to the presence of a slowly-growing tumor of mesenchymal origin. The characteristic laboratory findings are normal serum calcium, marked hypophosphatemia, increased serum alkaline phosphatase, markedly reduced renal tubular reabsorption of phosphorus and inappropriately low levels of 1,25-dihydroxyvitamin D [1,25-(OH)2D].

CASE PRESENTATION

A 65-year-old woman presented with a 17-year clinical history of musculoskeletal pain, muscular weakness in the pelvic girdle, spontaneous fractures and difficulty in walking. Over the ensuing years the patient suffered other multiple spontaneous fractures, surgically treated, and the muscular pains worsened until she became bedridden. During the years before hospital admission the patient received treatment with clodronate, oral calcium salts and vitamin D therapy. Standard laboratory, ultrasonography and scintigraphic findings provided a "convenient" diagnosis of primary hyperparathyroidism, but the low plasma level of phosphorus induced to perform an Indium111-octreotide scintigraphy. Scintigraphy visualized an area of pathologic increased signal uptake in the left groin, consistent with a mass containing a high density of somatostatin receptors. After surgery, histologic examination and immunostaining of the resected specimen indicated an hemangiopericytoma. Nevertheless, the persistently low blood phosphorus level, in association with the increased serum calcium and PTH levels, were attributed to the prolonged phosphate therapy the patient underwent over the years, and the persisting abnormal laboratory indexes indicated the development of a tertiary hyperparathyroidism. We performed a subtotal parathyroidectomy and intraoperative assay of serum PTH showed that levels had diminished by more than 80% from preoperative values. Over the ensuing months Ca+2, PTH and serum phosphorus values returned to normal, and the pain symptoms disappeared.

CONCLUSIONS

Tumour-induced osteomalacia is a very rare syndrome associated in 5% of cases with tertiary hyperparathyroidism due to long-term therapy with phosphorus and vitamin D. The initial diagnosis of primary hyperparathyroidism, confirmed by the parathyroid MIBI-scintigraphy, would lead us to an inappropriate surgical treatment. Therefore we want to stress the importance of In111-octreotide scintigraphy in detecting tumours, rich in somatostatin receptors, in presence of an hypophosphatemic syndrome.

[Leiomyosarcoma of the inferior vena cava. Review of a rare disease]

Primary sarcomas of the great vessels are rare. Their most common site is the inferior vena cava. We report a primary leiomyosarcoma of a 41 year old female patient localised just below the right renal vein. The resected tumour showed the histological signs of a well differentiated, progesterone positive leiomyosarcoma. The case is discussed on the data of the reviewed literature.

Surgical Treatment of a Huge Cavernous Hemangioma Surrounding the Right Coronary Artery

Hemangioma of the heart is an extremely rare benign cardiac tumor. A 61-year-old woman presented with a huge hemangioma on the right ventricle. The tumor was completely surrounding the right coronary artery. Under cardiopulmonary bypass, the right coronary artery was transected from the aortic sinus and the supplying arteries of the tumor were divided. The tumor was successfully resected, and the right coronary artery was reanastomosed to the aortic sinus.

Surgical management of parapharyngeal space masses

BACKGROUND

We sought to examine surgical techniques used to remove parapharyngeal space (PPS) masses.

METHODS

This retrospective search was conducted from 1980 to 2003. Age, sex, diagnosis, surgical approach, complications, and outcome were collected.

RESULTS

One hundred sixty-six PPS masses were identified: 21 (12.7%) were malignant, 145 (87.3%) were benign, 76 (45.8%) were vascular, and 69 (41.6 %) involved the skull base. Transcervical techniques were used in all cases. Removing the styloid and its musculature and level II lymphadenectomies enhanced exposure for vascular and skull base tumors. Thirty transcervical-transmastoid dissections (20.4%) facilitated removal of vascular skull base tumors. To identify the facial nerve, 20 transparotid-transcervical approaches (13.6%) were performed. Three mandibulotomies (2.0%) were required for internal carotid artery involvement. Expected neurologic sequelae resulted from cranial nerve involvement by tumor. Three patients (2.0%), all presenting with recurrent cancer, had local recurrences.

CONCLUSION

Careful patient assessment and surgical techniques allow the oncologically safe removal of benign, vascular, and skull base PPS tumors.

Vascular tumors

Proliferative conditions involving blood vessels and masses that mimic vascular tumors can present to hand surgeons. Patient age at presentation can range from neonates with congenital tumors to adults with malignancies, such as angiosarcoma. This article reviews three basic categories of vascular tumors in the upper extremity: benign, congenital,and malignant.

Location of Vessel Occlusion of Calibrated Tris-acryl Gelatin Microspheres for Tumor and Arteriovenous Malformation Embolization

PURPOSE

To evaluate (i). the presence and number of calibrated tris-acryl gelatin microspheres (TGMS) in targeted organs after embolization of tumors or arteriovenous malformations (AVMs) and (ii). the possible correlations among the size of TGMS used for embolization, the size of TGMS found in specimens, and the size of the occluded vessels.

MATERIALS AND METHODS

Histologic slides were reviewed of 92 specimens from 80 patients with primarily head and neck tumors or AVMs operatively treated after embolization with TGMS of various sizes (40-120 microm, 100-300 microm, 300-500 microm, 500-700 microm, 700-900 microm, and 900-1200 microm). The diameters of the vessels containing TGMS, the size of TGMS, and the thickness of the inflammatory reactions developed around them were measured, and the location of the microspheres was recorded.

RESULTS

TGMS were found in 88% of the specimens; 1985 embolized vessels containing TGMS were analyzed. The median number of TGMS per vessel was one (mean +/- SD, 3.1 +/- 6.9). The diameter of the occluded vessels increased significantly (P <.0001) with increased size of TGMS used for embolization. In tumors, 92% of the occluded vessels were located inside the tumor.

CONCLUSION

There is an obvious correspondence between the size of the TGMS used for embolization and the diameter of the occluded vessels. This correlation confirms the possibility that the vessels to be occluded can be precisely targeted with the use of a proper TGMS size range.

Algorithm for using a long-pulsed Nd:YAG laser in the treatment of deep cutaneous vascular lesions

BACKGROUND

Conventional therapies for deep cutaneous vascular anomalies have demonstrated poor efficacy and many side effects. New laser systems offer greater potential to treat these difficult lesions, but the lack of specific treatment guidelines has restricted consistent success.

OBJECTIVE

To establish a rational, user-friendly algorithm that incorporates basic components of deep vascular lesions to define the correct laser settings required for safe, effective, and reproducible treatment.

METHODS

Within 18 months, 162 deep vascular lesions of various types and anatomic sites were evaluated for vessel size, depth, color, and pressure. An algorithm incorporating these characteristics was employed to determine laser parameter settings. Using a high-peak power, long-pulse 1064-nm Nd:YAG laser system, the vascular lesions were then treated.

RESULTS

Within 6 months of follow-up, 80% of treated areas demonstrated a 50% or greater resolution after a single treatment session, with complete clearance shown in 19%. Only minimal and transient side effects were observed. Of note, 74% of areas on the extremities and 83% within the oral cavity showed a 50% or greater resolution after one treatment.

CONCLUSION

Previously challenging deep cutaneous vascular anomalies may be safely reduced or cleared with the use of an appropriate laser system and this algorithm-directed technique. This represents a significant breakthrough in the management of vascular lesions.

Giant fetal hepatic hemangioma. Case report and literature review

The purpose of this case report is to demonstrate the importance of prenatal imaging for treatment management of fetal giant hepatic hemangiomas. Prenatal ultrasound revealed an abdominal mass with several cystic areas and punctate calcifications in a fetus at 29 weeks' gestation. Doppler scans confirmed the highly vascular nature of the mass. In this case, ultrasound diagnosed the mass was of hepatic origin, while magnetic resonance imaging at 32 weeks' gestation was more equivocal with respect to the anatomy source of the lesion. Imminent hydrops caused by a rapidly enlarged liver tumor was sonographically demonstrated at 34 weeks' gestation. An elective C-section and immediate tumor resection was performed. At the age of 20 months the infant is thriving. This case supports the notion that the survival rates for giant hepatic hemangiomas improve when fetal hydrops is averted and specific pre- and postnatal treatment is applied based on correct prenatal imaging diagnostics.

Postmenopausal intravenous leiomyomatosis with high levels of estradiol and estrogen receptor

BACKGROUND

Intravenous leiomyomatosis is a rare variant of leiomyoma.

CASE

The patient was a 49-year-old gravida 3, para 3 woman with menopause at age 46. She presented with a history of syncope. Vaginal examination revealed an enlarged and elastic-soft mass of the uterus. A pelvic ultrasound, computed tomography scan, and magnetic resonance imaging showed a heterogeneous, irregularly shaped 8- to 10-cm tumor. In addition, the inferior vena cava was almost completely occluded. Cardiac ultrasound demonstrated a mobile mass in the right atrium. The serum estradiol was 208 pg/mL (normal 0-59). Intravenous leiomyomatosis with cardiac extension was diagnosed preoperatively. A resection of the intracardiac and intracaval mass and a subtotal hysterectomy with bilateral salpingo-oophorectomy were performed. The uterine tumor weighed 600 g, and the cordlike intravascular tumor extending from the internal iliac vein into the right ventricle was 40 cm long and weighed 60 g. Pathologic examination confirmed intravenous leiomyomatosis with no evidence of atypia. The level of estrogen receptor in the tissue was 140 fmol/mg protein. The postoperative course was uneventful, and she has been in good health for 17 months after the operation.

CONCLUSION

We report a case of intravenous leiomyomatosis extending into the right ventricle treated with a one-stage operation. It is possible that a high concentration of serum estradiol and high level of tissue estrogen receptor are related to the intravenous leiomyomatosis.

Intravascular myopericytoma

BACKGROUND

Myopericytoma is a benign tumor composed of cells that show apparent differentiation towards putative perivascular myoid cells called myopericytes. It arises most commonly in the dermis or subcutaneous tissue of the extremities in adults.

METHODS

We describe a myopericytoma that was unusual in its intravascular location.

RESULTS

A 54-year-old man presented with a 10-year history of a painful slowly growing 1.5-cm nodule in the subcutaneous tissue of the thigh. Histologic examination of the excised lesion showed that is was entirely contained within the lumen of a vein. It was composed of a proliferation of myoid-appearing spindle cells, which were arranged in a striking concentric pattern around numerous blood vessels, in a manner that accentuated the vessel walls. This pattern is characteristic of myopericytoma. In some areas, fascicles of spindle cells, embedded in a myxoid stroma, bulged into the lumina of lesional vessels, reminiscent of myofibroma/myofibromatosis. Lesional spindle cells were diffusely positive for smooth muscle actin, focally positive for CD34 and were negative for desmin, cytokeratin, S100 protein, HMB-45 and CD31.

CONCLUSION

This case illustrates that myopericytoma can be entirely intravascular in its location.

Cavernous malformation of the hypoglossal nerve: case report and review of the literature

OBJECTIVE

To describe a patient who presented with a hypoglossal nerve palsy caused by a cavernous malformation, review the literature on cavernous malformations associated with cranial nerves and the differential diagnosis of hypoglossal palsy.

RESULTS

Partial resection of the lesion was achieved and the diagnosis of cavernous malformation proven histologically.

CONCLUSIONS

Involvement of a cranial nerve by a cavernous malformation is very uncommon and the facial nerve is the example most frequently reported. This case report adds another possible site for this rare occurrence.

Primary intimal sarcoma of the aorta: role of transesophageal echocardiography

Diagnosis of primary tumors of the aorta is difficult. A patient who had a primary intimal sarcoma of the aorta with metastasis presented with obstructive symptoms and computed tomography showed a thrombus-like mass in the aorta. However, transesophageal echocardiography revealed an inhomogeneous and echo-dense mass with an outer membrane, unlike a thrombus, and suggestive of a primary aortic tumor. Pathologic examination of specimens from exploration and autopsy revealed a primary intimal sarcoma.

Intra- and postoperative factors determining neurological complications after surgery under deep hypothermic circulatory arrest: a retrospective somatosensory evoked potential study

OBJECTIVES

Intraoperative median nerve SEP monitoring uses the disappearance of cortical and brain stem activities as the criterion to determine that brain cooling is sufficient in deep hypothermic circulatory arrest (CA) surgery. This study presents the results of a retrospective SEP analysis of intraoperative events that engendered neurological complications.

METHODS

Median nerve SEP monitoring was performed on 58 consecutive patients who underwent surgery under deep hypothermic CA. The monitoring was retrospectively analyzed and compared with intraoperative events, and postoperative symptoms.

RESULTS

Intraoperative SEP abnormalities were observed in 9 out of the 16 patients who presented neurological complications. Among the 7 others, the abnormalities either were present preoperatively (n = 2), occurred postoperatively (n = 3) or only involved the lower limbs (n = 2). Although the mere inspection of the intraoperative SEPs was insufficient to determine the origin of the alterations, their comparison with intraoperative events facilitated the identification of hemodynamic factors in 7 cases and embolism in two cases. There were no patients in whom CA per se caused neurological complications.

CONCLUSIONS

Intraoperative SEP monitoring helps identify intraoperative events responsible for neurological complications and prevent these in subsequent procedures. However, the neurological complications of deep hypothermic CA can also be due to pre- or postoperative factors that escape the domain of intraoperative monitoring.

Intravenous tufted angioma

A case of a rare vascular tumor, intravenous tufted angioma, is described. A 51-year-old Japanese man presented with a 12x8 mm solitary reddish nodule on the right foot, which had been found at birth. Histologically, the tumor was confined to a malformed vein and was characterized by nodular aggregates of plump cells. The aggregates showed a compact proliferation of round cells, including capillary-forming cells. Venous angiomatous areas were also observed. No multinucleated giant cells were seen. Immunohistochemically, the capillary-forming cells in the aggregates and the endothelial cells in the angiomatous areas were positive for endothelial markers (factor VIII-related antigen, CD31, CD34). Pericyte-like cells expressing alpha-smooth muscle actin and muscle actin, and macrophage-like cells, which stained for factor XIIIa, were intermingled in the cellular aggregates. Flow cytometric analysis showed diploidy. The tumor may be a hamartomatous lesion modified by secondary reactive changes, and it may represent a distinctive clinicopathological entity that is closely related histogenetically and perhaps pathologically to tufted angioma and the recently described "giant cell angioblastoma".

Intraosseous epithelioid hemangioendothelioma of the mandible: a case report with an immunohistochemical study

Epithelioid hemangioma is the prototype of a group of vascular tumors characterized by epithelioid endothelial cells. Hemangioendothelioma of bone is a rare lesion that constitutes less than 0.5% of primary malignant skeletal tumors. We report and discuss a case of epithelioid hemangioendothelioma arising intraosseously in the anterior portion of the mandible in a 76-year-old woman. The case was treated successfully by wide resection. Radiographically, the tumor mass showed osteolysis and expansion. Histologically, the tumor showed invasive and destructive growth, although it lacked frequent mitotic figures and severe atypia. On immunohistochemical study, tumor cells exhibited characteristics of mesenchymal and endothelial origin, i.e., strong to moderate immune reactivity against vimentin, factor VIII-related antigen (F8RA), Ulex europaeus agglutinin type 1 lectin (UEA-1), and CD 34, but not against keratin, epithelial membrane antigen (EMA) or S-100 protein (S100). The proliferating cell nuclear antigen (PCNA)-positive cell index was 27.5%. These pathological findings suggested a borderline malignant potential for this tumor. Thus, clinically, wide resection with or without dissection of regional lymph nodes is recommended.

Vascular anomalies. A primer for pediatricians

The future is bright for children with vascular anomalies. Children with vascular anomalies no longer have to languish in the interface between various medical specialties. Vascular anomalies centers are available for consultation. Not only are specialists focusing on the conditions, but basic science has brought us to the horizon of new insights into etiology and thus the possibility for new treatment. For children with vascular tumors, newer antiangiogenic agents are already in clinical trials. For children with vascular malformations, research in molecular genetics has begun to uncover the genes responsible for normal fetal vasculogenesis and angiogenesis. Molecular studies of familial vascular malformative syndromes are just beginning to pinpoint causative mutations. Next, animal models of vascular abnormalities will be engineered to elucidate pathogenesis, and these studies, in turn, should lead to development of novel therapies.

The results of surgery for benign tumors of the cavernous sinus

CAVERNOUS SINUS SURGERY has been performed increasingly in the last 2 decades because of new knowledge and technologies. With increasing international expertise in cavernous sinus surgery, the results must be analyzed critically to search for accurate prognosticators of outcome. We performed a retrospective review of 124 patients (40 male, 84 female; mean age, 45 years) who underwent cavernous sinus surgery for benign tumors from 1983 to 1992. Sixty-five percent had tumors encasing the internal carotid artery. Mean follow-up was 29 months (median, 26 mo). Gross total or near-total resection was possible in 80%. Patients with neurilemomas, angiofibromas, epidermoids, chondroblastomas, and hemangiomas were more likely to have total or near-total resection (100% versus 75%, P < 0.025). Disabling complications (five cerebral infarctions, two meningitis, and one hydrocephalus with chiasmal prolapse) occurred only in patients with meningiomas or pituitary adenomas. On follow-up, excellent/good binocular vision was achieved in 53% of patients entering surgery with excellent/good function versus 25% who entered surgery with fair/poor binocular vision (P < 0.025). Ninety-three percent of patients had a Karnofsky score > or = 70 on follow-up. There were a total of 12 recurrences (10%), 6 in patients with meningiomas, 2 in patients with angiofibromas, 2 in patients with craniopharyngiomas, 1 in a patient with a pituitary adenoma, and 1 in a patient with an osteoblastoma. Patients with tumor growth or neurological symptoms indicative of progressive cavernous sinus involvement should undergo cavernous sinus exploration. This surgery has acceptable morbidity and mortality and, if the tumor can be removed easily, the surgeon should try to perform radical tumor resection. To avoid major complications, the surgeon must exercise utmost care to preserve the neurovascular structures of the cavernous sinus, with special attention to tumors that extend into the petroclival region. Better results from surgery can be expected in those patients with neurilemomas, hemangiomas, or epidermoids than in patients with meningiomas, craniopharyngiomas, or pituitary adenomas. Good functional outcome can be expected, particularly if the patient's preoperative clinical status is good. Particular attention must be paid to the reconstruction of anatomic barriers in order to prevent cerebrospinal fluid leakage and subsequent meningitis.

Primary pulmonary artery sarcoma: a report of six cases

Pulmonary artery tumors are rare and a frequently overlooked cause of pulmonary artery occlusion. The presentation is one of progressive pulmonary dysfunction and right ventricular failure. The diagnosis seldom is made preoperatively. We report 6 cases of primary sarcoma of the pulmonary artery identified at operation, which were treated surgically. Resection with or without adjuvant therapy currently offers the only chance for survival. Emphasis must be placed on earlier identification of these tumors.

Histogenesis of vascular tumors in the Proteus syndrome

Proteus syndrome (PS) is a congenital disorder manifesting with severe deformities, the salient features being gigantism and vascular tumors. The disorder is poorly understood, and there has been much discrepancy in the terminology regarding the vascular tumors in PS. The purpose of this study was to elucidate the histogenesis of these tumors by correlating microscopic observations with immunohistologic information. The value of immunoperoxidase studies in the pathologic evaluation of PS was also assessed. Fourteen formalin-fixed, paraffin-embedded tissue specimens obtained from vascular tumors of six children with PS were stained with Ulex europaeus agglutinin I (UEA-I) lectin and the following immunohistochemical reagents: anti-factor VIII-related antigen (FVIII-RAg) and anti-CD34. The tumors showed varied proportions of vascular, lipomatous, and fibrous tissue components consistent with vascular hamartomas. The predominant vascular channels of the tumors were morphologically consistent with lymphatic vessels. Immunostaining of the endothelium of these vessels was most consistently positive with UEA-I lectin. Although a color reaction product was present in small vessels and some larger blood vessels, anti-CD34 immunostaining spared the lumens of lymphatic channels. In addition, a striking population of dendritic spindle cells was noted with the anti-CD34 but was unnoticed with the other reagents. We concluded that the vascular tumors of PS are primarily lymphatic hamartomas. The spindle cells noted with anti-CD34 immunostaining may relate to angiogenesis and need further delineation.

Vascular abnormalities of the extremities: clinical findings and management

A retrospective review identified 41 patients with angiodysplastic lesions of the extremities. Twenty-two patients had a mass, 11 had limb length discrepancy and/or hemihypertrophy, and two had recurrent joint effusions. Enhanced computed tomography (CT) and magnetic resonance imaging (MRI) were most valuable for both diagnosis and preoperative planning. Many patients were diagnosed clinically and treated symptomatically. Twenty-nine patients (71%) required operation. Descriptive pathology and histologic diagnosis were not determinants of clinical outcome, whereas anatomic location and overall size were predictive of symptomatology. Subcutaneous hemangiomas irritated sensory nerves, intramuscular lesions mimicked compartment syndromes, intraarticular lesions caused recurrent hemarthroses, and periarticular or large lesions resulted in hypertrophy or limb length discrepancy. Simple excision under tourniquet control with incomplete exsanguination is possible but often incomplete (48% recurrence) owing to the invasive nature of the lesion.

Vascular malformation: case report and literature review

The therapeutic outcome of congenital vascular malformations generally parallels the complexity of the lesion. The less extensive malformations that are prone to regression may be observed. Larger lesions that produce facial asymmetry or have diffuse extremity involvement require a more aggressive approach. Even with the limitations of current treatment methods these extensive malformations can usually be controlled thus affording the patient a better life.

[Developmental defect of the veins of the cranial vault (sinus pericranii) involving the upper eyelid]

Two rare observations of sinus pericranii are presented, characterized by a soft intumescence containing venous blood and growing in size if the head is bent or during tension. The condition may be diagnosed by local introduction of a contrast agent into the intumescence. Surgical treatment of this developmental venous defect is recommended.

Leiomyoma of a digital artery

Benign, soft-tissue masses of the hand are common. A vascular leiomyoma is an unusual tumor of smooth-muscle origin. In a 62-year-old man, the tumor arose from within a digital artery. Persistent symptoms prompted an excisional biopsy, requiring resection of a portion of the artery. Adequate collateral circulation preempted the need for a vascular graft. Vascular repair or grafting may be necessary if collateral circulation is not adequate.

Intravenous leiomyomatosis with cardiac extension: successful surgical management and histopathologic study

A case of intravenous leiomyomatosis with cardiac extension was treated successfully with a two-stage operation: resection of the intracardiac and intracaval mass for the first stage and total hysterectomy with bilateral salpingo-oophorectomy for the second. Tumors were located either within or in continuity to dilated uterine veins. A leiomyomatous protrusion of the wall of a small uterine vein was found in two remote sections. The involved veins were located alone in the layer of apparently normal uterine smooth muscles. The findings suggest that intravenous leiomyomatosis originates from the smooth-muscle component of uterine veins.

Leiomyoma in the hand. A case report

A 60-year-old woman developed an avascular leiomyoma arising from a digital artery in the thumb and was successfully treated by en bloc excision. Leiomyomas in the hand are very rare, and thus the diagnosis will seldom be made on clinical evaluation. They may be more painful than other common, benign tumors, however, and may originate from a digital artery. Preoperative evaluation of vascular function may give a clue to the presence of a leiomyoma. A spectrum of vascular smooth-muscle tumors from very vascular to relatively avascular is noteworthy.

Intracranial tumor-forming papillary endothelial hyperplasia--a case report

This is a report of extensive intracranial papillary endothelial hyperplasia in a 12-day-old twin. The infant presented with progressive macrocephaly, anemia and hydrocephalus. An MR image showed a large (6 x 5 cm) mass in the right middle cranial fossa. Histologic examination of the resected mass revealed multifocal hemorrhage, organizing in a floridly papillary pattern, in proximity to numerous fibrous bands containing reactive fibroblasts, scattered chronic inflammatory cells and foci of extramedullary hematopoiesis. Although the pattern was complex, neither the papillary regions nor the other areas in the lesion displayed solid proliferations of endothelial cells to support a diagnosis of angiosarcoma. Subsequent to the resection, the infant continued to have hemostatic abnormalities and increasing hydrocephalus. Repeat scans showed a recurrent mass (4 x 4 cm). The child was placed on a protocol for chemotherapy treatment. We hypothesize that the hemorrhage and subsequent organization could have been superimposed upon a preexistent vascular malformation or hemangioma even though Masson's trichrome stain does not unequivocally demonstrate this feature. Most importantly, we would like to emphasize the dilemmas involved in diagnosis and management of this benign disorder.

Sapphire tip technology for YAG laser excisions in plastic surgery

Thirty-two patients with a variety of vascular and nonvascular lesions have been resected over a 3-year period with the neodymium:YAG laser utilizing sapphire peripheral scalpel devices. These innovative peripheral devices concentrate the YAG laser energy to a small area at the end of the scalpel, providing precise incisions with excellent hemostasis. In addition, the tactile sensation of the scalpel contacting tissue is more comfortable and familiar than the "no touch" aspect of other lasers that are held away from the surface and depend on laser light transmission to approach the skin. Total excision with excellent hemostasis was achieved in 17 patients, while 15 patients had subtotal resection. The YAG laser with sapphire scalpels has allowed resection of very difficult and massive hemangiomas previously considered unresectable by standard techniques.

Applications of lasers in plastic surgery

Laser application for treatment of vascular lesions continues to be refined as newer techniques and lasers become available. Capillary cavernous hemangiomas can be treated by shrinking or excision with the laser; however, early treatment in the neonatal period is indicated in many instances to prevent growth of the lesion and complications. Treatment of port wine stain and telangiectasia lesions continues to improve with the advent of newer laser instruments.

Cavernous sinus syndrome as the presentation of malignant lymphoma: case report and review of the literature

Cavernous sinus syndrome (CSS) is an unusual presentation of malignant lymphoma. We report a patient with lymphoma that presented with CSS, and we review the literature on nine other reported cases. Sharp retroorbital pain, paraesthesia around the orbit, and complete 6th nerve palsy were dominant presenting symptoms. In all cases, the tumor developed on the right side. The computed tomographic scan was abnormal in only two of the nine patients during the early stages of the disease. The dominant histological type was large cell lymphoma. The mean age of the patients was 45 years. The mean survival time after the first presenting symptom was 8.7 months. Two of the reported patients as well as our patient had disseminated disease, which became evident at autopsy.