presented by Drs. Douglas Johnson and George Reizner
(Note: We recognize that the person's eyes should be blacked out to preserve anonymity; but have decided not to do so initially as seeing this man as he is may help when thinking about therapy. After 1 - 2 weeks, we will change the image to comply with standard presentations)
The patient is an otherwise healthy 94 year old man who lives in a rural Amazonian village that has limited access to medical care. History reveals that he has had a growing vascular lesion of the left elbow for at least three years. Biopsy showed a capillary hemangioma without atypical features. He has congestive heart failure and hypertension but his only medication is metoprolol. He declined surgery in 2024. His only abnormal finding is that he cannot dorsiflex his left thumb.
Pathology: Biopsy is reported to show a proliferation of blood vessels without atypia suspended in a fibrous stroma, This image was taken from the path report.
Diarnosis: Giant Hemangioms of the left elbow. Another dermatopathologist questioned whether this is an angiosarcoma.
Few dermatologists have much experience with lesions like this. What therapy, if any, should be offered this patient? He lives in a medically underserved rural village..
Angiosarcoma seems likley .
ReplyDeletePatrick Kenny
A localized lesion of long standing and has no histological evidence of malignancy, should normally rule of angio-sarcoma.
ReplyDeleteLocal excision if possible or amputation- which of course is too much for a man at the age of 94.
Bhushan
Challenging case as always. From the MRI, the tumor appeared to be well encapsulated and benign though it sometimes may be locally invasive in view of the size of the tumor. A wide excision of the tumor would be recommended for definitive treatment and functional use of his arm as long as he is medically fit for the op. This is best done by an orthopedic oncology surgeon. Soft tissue esp the peripheral nerves may be affected post op. Since it is a hemangioma, I guess bleeding will be a major issue and a pre-op transarterial embolisation to reduce bleeding during the op would be useful adjunctive treatment. By blocking the blood supply to the tumor, this procedure decreases intraoperative blood loss, lowers transfusion requirements, and improves surgical visibility.
ReplyDelete