H. Hauser

Aneurysms of Hemodialysis Access Grafts: Treatment with Covered Stents: A Report of Three Cases

Abstract Three patients with dialysis access graft shunts, having a symptomatic pseudoaneurysm and a hemodynamically significant stenosis at the anastomosis between the graft shunt and the subclavian vein, were treated with percutaneous transluminal angioplasty and insertion of a Wallstent. Pseudoaneurysms were excluded by percutaneous insertion of a Cragg Endo-Pro stent-graft with a diameter of 6 mm and a length of 6–10 cm. All three aneurysms were excluded successfully. In two patients, the stent-graft was punctured repeatedly during follow-up and the aneurysms recurred after 7 and 8 months, respectively. The patency of the dialysis shunt after stent-graft insertion was 8 (n= 1) and 9 months (n= 2). Due to the recurrence of the aneurysm (n= 2) or recurrent thrombosis (n= 1) the use of these shunts was discontinued.

Vascular complications of lumbar disc surgery

SummaryOver a period of seven years nine patients with vascular complications after lumber discectomy received medical care at the Clinic of Vascular Surgery, University of Graz Medical School. We report five acute bleeding complications occurring during the operation and four late manifestations of vascular lesions.Five patients presented with acute life-threatening iatrogenic haemorrhages from pelvic vessels. Three patients made a complete recovery, one patient died from acute haemorrhagic shock, one further patient died from sepsis due to an associated complication — an injury to the ureter.Over a period of two to ten years after primary surgery we corrected late complications such as 1 case of posttraumatic aneurysm of the aortic bifurcation found to have eroded the body of the fifth lumbar vertebra, and three cases of arteriovenous fistula between the common iliac artery and the common iliac vein.The four cases described below are an attempt to document the vascular surgical procedures involved and to provide typical findings.The risk of injuring the pelvic vessels intra-operatively can be explained by the close anatomical relation between the retroperitoneal vessels and the vertebral column and furthermore not only by the fact that pre-existent deficiencies but also injury to the anterior longitudinal ligament give access to the retroperitoneal space.

Cystic retroperitoneal lymphangiomas in adults

Lymphangioma (LA) is a rare benign tumour of the lymphatic tissue, most common in the neck and head, and clinically manifests itself mostly in childhood. Within this group, intra-abdominal and retroperitonal LA are the rarest tumours, especially when occurring in adults. We report four LAs localized in the retroperitoneum of patients aged between 28 and 72 years. One of these tumours infiltrated the transverse mesocolon and greater omentum, others were situated in the left retroperitoneum and retroperitoneally at the duodeno-jejunal flexure, and in the retrosplenal and retropancreatic area. Diagnosis was made by light microscopy supported by immunohistochemistry. In three cases the tumour could be removed by radical surgery and none of these patients had a recurrence (median follow-up time: 4 years). The tumour could not be removed completely from one patient with pre-operative chylascos. Six months after diagnosis of LA this patient died of cardiopulmonary failure due to progressive tumour chylascos. Isolation and ligation of the cystic LAs peduncle as well as ligation of lymph channels can prevent recurrences and chylascos.

Neuroendocrine tumours in various organ systems in a ten-year period

Neuroendocrine cells are present in various organ systems. These widely distributed cells as well as their histogenetically related tumours can produce various peptides and peptide hormones. From 1984 to 1993, 349 neuroendocrine tumours were found among 511,382 histological diagnoses at the Institute of Pathology of the Medical School of the Karl Franzens University in Graz. In 30% carcinoid of the appendix was diagnosed, in 16% carcinoid of the colorectum, in 9% carcinoid of the small intestine and in 2% duodenal carcinoid. Carcinoid of the stomach was detected in 14%. Seven of these cases showed microcarcinoidosis and five of them were combined with an adenocarcinoma. Carcinoid of the oesophagus was present in 1%, neuroendocrine pancreatic tumours in 6%. Neuroendocrine tumours of the bronchial system were found in 12%, medullary thyroid cancer in 5%. In 1% a Merkel-cell tumour was diagnosed. Other more rare localizations of neuroendocrine tumours were the uterus, ovary, breast, testes, epididymis, anal region and the upper respiratory tract.

Paragangliomas of the carotid bifurcation: oncological aspects of vascular surgery

The present study reviews in concise form the past 12 years of our clinical experience with paragangliomas of the carotid body. Every aspect of the anatomical, histological and biological and biological behaviour of paragangliomas of the carotid body has been recorded in order to be able to define better surgical management and the clinical prognosis. In addition to the conventional histological methods of investigation we also applied immunohistochemistry and made use of electron microscopy. Eighteen tumours of the carotid body in 12 female and four male patients with a mean age of 54 years (34 to 70 years) were treated surgically. Angiography of the aortic arch and supra-aortic branches was undertaken diagnostically in every case. In three patients computer tomography and magnetic resonance imaging demonstrated spreading of the tumour up to the base of the skull and pre-operative embolization of the arteries supplying the tumour was performed to decrease tumour vascularity. In four cases (22%) resection of the internal carotid artery and its reconstruction by a saphenous vein graft was required in order to achieve the therapeutic aim of a complete extirpation of tumourous tissue and preserving the vascular system of the internal carotid artery. In three cases (16%) there was histological evidence of a metastasizing process to the local lymph nodes of the neck and, due to this criterion of malignancy, 50-60 Gy of radiation was applied to the site of the tumour after surgery. Four patients experienced a transient neurological deficit in the supply area of the hypoglossal and the recurrent nerves. In one case, the vagus nerve could not be retained. In an average follow-up of 102 months we recorded one case of local recurrence 13 months after the initial resection and radiation treatment applied to a malignant paraganglioma. All the other patients were doing well without evidence of recurrent disease.

Endocavitary Ir-192 radiation and laser treatment for palliation of obstructive rectal cancer.

Endoscopic laser therapy (ELT) either alone or combined with endocavitary Ir-192 radiation is performed for advanced, inoperable rectal cancer and when patients are ineligible for surgery due to severe concomitant medical illness. During the period from January 1984 to January 1997 we treated 81 patients (51 males, 30 females). Sixty-seven patients had ELT only using a ND-Yag Laser system. Twenty-five patients (average age: 80.5 years) were ineligible for surgery (Group I). Forty-two patients (74.1 years) had an advanced locally inoperable tumour (Group II). Fourteen patients (76.5 years) underwent a combined therapeutic regime with endocavitary Ir-192 afterloading following ELT (Group III). Adequate desobliteration was achieved in 100% (groups I and III) and 97% (group II) of the patients. The average interval to aftertreatment was 8.4 weeks in group I and 9.4 weeks in group II, compared to 11.5 weeks in group III. Serious complications (perianal abscess, rectovaginal fistula) occurred in 3.7%, minor complications (laser-induced bleedings, unclear fever) in 12.3%. All laser-induced bleedings could be dealt with using laser therapy. The frequency of treatment was governed by tumour mass and the patients survival. The results suggest that additional endocavitary radiation significantly prolongs the maintenance of normal bowel function compared with laser therapy alone.

Colliding/concomitant tumors of the intestine: Report of 3 cases

Collision/concomitant tumors of the intestine involving lymphomas are very rare. For these cases molecular genetic analyses are valuable diagnostic adjuncts. We report one collision tumor of the rectum (adenocarcinoma and peripheral T-cell lymphoma, unspecified), and two cases of concomitant tumors (carcinoma in the cecum and lymphoma in the ileum; carcinoma in the sigmoid and lymphoma in the ileum). The collision tumor (poorly differentiated adenocarcinoma and a peripheral T-cell lymphoma, unspezified) showed a variable proportion of the anaplastic tumor cells expressing lymphatic markers as well as cytokeratin. Only polymerase chain reaction (PCR) analysis revealing T-cell monoclonality of the anaplastic part of the colliding tumor allowed the correct diagnosis. In the second case, a moderately differentiated adenocarcinoma in the cecum with a concomitant B-cell Non-Hodgkin lymphoma in the ileum, PCR analysis was non contributary. In the third case (adenocarcinoma in the sigmoid colon and a follicular center lymphoma in the ileum) PCR analysis revealed gene rearrangement of the immunoglobulin heavy chain gene. We would like to emphasize that collision and concomitant tumors of the gut are rare and that molecular genetic analysis may be mandatory for correct diagnosis. It is our impression, that these tumors may be diagnosed more often in the intestinal tract if molecular genetic analysis and immunohistochemistry are used routinely, at least for all anaplastic tumors.

Aktuelle klinischpathologische Klassifikation von Karzinomen des Analkanales

ZusammenfassungGrundlagen: Eine exakte Tumorklassifikation ist sowohl für die Wahl des Behandlungsverfahrens im Rahmen einer modernen multimodalen Therapie von Karzinomen des Analkanals als auch für die Schätzung der Prognose und der Analyse von Therapieergebnissen wesentlich. Voraussetzung dafür ist eine exakte Unterscheidung der Karzinome des Analkanals von solchen des Rektums einerseits und Karzinomen des Analrandes andererseits.Methodik: Die aktuelle klinisch-pathologische Klassifikation von Karzinomen des Analkanals wird anhand einer Literaturübersicht besprochen. Sie basiert im Wesentlichen auf dem histopathologischen Tumortyping und Grading der WHO sowie dem Tumorstaging nach dem TNM-System und der Residualtumor-Klassifikation (R-Klassifikation) der UICC.Ergebnisse: Dem histopathologischen Typing nach WHO kommt vielfach eine therapeutische Weichenstellung zu, da Plattenepithelkarzinome verschiedener Subtypen heute vor allem mit simultaner Radiochemotherapie, die verschiedenen Adenokarzinomtypen hingegen vorzugsweise mit radikaler chirurgischer Resektion behandelt werden. Durch das histopathologische Grading von WHO und UICC können die prognostisch günstigeren Karzinome mit niedrigem Malignitätsgrad von solchen mit hohem Malignitätsgrad ungünstigerer Prognose unterschieden werden. Die anatomische Ausbreitung des Tumors wird durch die TNM/pTNM-Klassifikation und die darauf beruhende Stadiengruppierung der UICC beurteilt. Sie dient in Kombination mit der R-Klassifikation der Schätzung der Prognose. Weitere selbständige Prognosefaktoren sind der prätherapeutische SCCAg-Serumspiegel und wahrscheinlich auch der Ploidiestatus.Schlußfolgerungen: Eine enge, klinisch-pathologische Kooperation ist die unabdingbare Voraussetzung für eine histologieund stadiengerechte moderne Tumorbehandlung von Karzinomen des Analkanals im Rahmen multimodaler Therapiekonzepte.SummaryBackground: The careful classification of carcinomas of the anal canal is required for planning of treatment including the modern multimodal concepts as well as for estimation of prognosis and analysis of treatment results. An exact discrimination of carcinomas of the anal canal from those of the rectum as well as from tumors of the anal margin represents a precondition for tumor classification.Methods: The actual clinico-pathological classification of carcinomas of the anal canal is discussed by reviewing the literature. It is based on histopathological tumor typing and grading of the WHO as well as on the tumorstaging according to the TNM-system and the R-(residual tumor)-classification of the UICC.Results: The histopathological tumor typing according to the WHO is a guideline for the choice of therapeutic procedures because squamous cell carcinomas of different subtypes are nowadays usually treated by simultaneous radiochemotherapy, whereas adenocarcinomas predominantly undergo primary surgical resection. On the basis of histopathological grading according to the WHO and UICC carcinomas of low grade malignancy with better prognosis can be discriminated from those of high grade malignancy with usually worse prognosis. The anatomical spread of tumor is classified according to TNM/pTNM and stage grouping of the UICC. Together with the R-classification staging enables the estimation of prognosis. Further independent prognostic factors are the pretherapeutic SCCAg serum level and probably ploidy status.Conclusions: A close cooperation between clinicians and pathologists is an essential precondition for the present histology and stage adapted multimodal treatment of carcinomas of the anal canal.

Malignant mesenchymoma: a very rare tumor of the peritoneum

ZusammenfassungWir berichten uber den Fall eines 82jährigen Patienten mit einem malignen Mesenchymom. Der Tumor entsprang vom parietalen Peritoneum mit enger Beziehung zum Colon ascendens. Wie die Immunhistochemie zeigen konnte, bestand der Tumor aus einem großen liposarkomatösen und einem kleineren leiomyosarkomatösen Anteil. Soweit wir wissen, ist dies der erste Bericht uber ein malignes Mesenchymom dieser histologischen Zusammensetzung im paritealen Peritoneum. Der Tumor konnie chirurgisch radikal entfernt werden. In Übereinstimmung mit anderen Autoren glauben wir, daß maligne Mesenchymome aus primitiven mesenchymalen Zellen mit totipotenten Differenzierungs-möglichkeiten entstehen.SummaryWe report the case of an 82-year-old male patient with a malignant mesenchymoma. The tumor arose from the parietal peritoneum closely attached to the ascending colon. It consisted of a larger liposarcomatous and a smaller leiomyosarcomatous component which was demonstrated by immunohistochemistry. To our knowledge this is the first report of a malignant mesenchymoma of this histological composition originating from the parietal peritoneum. The tumor was completely removed surgically, which is the treatment of choice for such tumors. In agreement with other authors, we believe that malignant mesenchymomas arise from a primitive mesenchymal cell with the capacity for totipotent differentiation.

Experience with a high speed biopsy gun in breast cancer diagnosis

Pre-operative determination of histology and receptor status is important in optimizing the management of breast cancer. The purpose of our study was to evaluate the high speed biopsy gun in 109 patients with palpable breast tumours. High speed biopsies were performed using the system BIP High Speed Multi 22 with 16-gauge-needles at a speed of 30 m/s. All biopsies could be used for frozen sections and for determination of receptor status. In 81 patients (74.3%) malignant breast tumours were diagnosed, and three patients (2.8%) had highly suspicious lesions. The oestrogen receptor status was negative in 32%, progesterone receptor status negative in 41%. In one patient (0.9%) a high grade non-Hodgkins lymphoma of B-cell-type was diagnosed. In 21.1% benign tumours were found. In one patient a malignant tumour was missed at biopsy (0.9% false-negative). It was concluded that high speed biopsy is a reliable and simple method for preoperative sampling of breast lesions.