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Preoperative Vascular Embolization as an Adjunct to Successful Resection of Large Retroperitoneal Hemangiopericytoma
Vol. 115, February Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
PREOPERATIVE VASCULAR EMBOLIZATION AS AN ADJUNCT TO SUCCESSFUL RESECTION OF LARGE RETROPERITONEAL HEMANGIOPERICYTOMA ROBERT B. SMITH,* HERBERT I. MACHLEDER, ROBERT W. RAND, JOHN BENTSON AND PATRICE TOUBAS From the Department of Surgery, Divisions of Urology, General Surgery and Neurosurgery, and the Department of Radiological Sciences University of California School of Medicine and the Department of Surgery, Division of Urology, Wadsworth Veterans Administration Hospital.' Los Angeles, California
ABSTRACT
A large retroperitoneal hemangiopericytoma was resected successfully with the aid of preoperative control of the blood supply of the lesion with percutaneous intra-arterial gelfoam and ferromagnetic sil~cone embolization. We believe that this resection would not have been possible without this adJu_van1: techniq1;1e. ~uture application of this combined technique will enable more aggressive surgical mtervent10n m unresectable vascular tumors and arteriovenous malformations. Vascular neoplasms such as hemangiopericytoma often present a tremendous challenge to the surgeon with regard to inordinate blood loss associated with excision. The following case report illustrates the contribution of preoperative vascular control in the management of vascular lesions. CASE REPORT
A 28-year-old French physician was admitted to the hospital in April 1974 for evaluation and possible resection of a large retroperitoneal mass. He had noted the onset of a renal colic-like pain in the right flank 7 months previously. An excretory urogram (IVP) performed in Paris at that time demonstrated a large mass in the right retroperitoneum that deviated the bladder and right ureter across the midline. An angiogram revealed this to be a vascular tumor with blood supply originating from the right third lumbar artery, right and left hypogastric arteries and the right lateral femoral circumflex artery. The patient underwent exploratory laparotomy and the lesion was deemed unresectable. A 1 cm. wedge biopsy resulted in a blood loss in excess of 5,000 cc that required 6 hours to control. The third lumbar artery was ligated during this procedure. Convalescence was uneventful except for weakness in the right proximal thigh and foot. Pathologic examination of the specimen revealed the tumor to be a hemangiopericytoma. An IVP revealed no change in the size of the mass (fig. 1). Cystoscopy confirmed the tumor to be extrinsic to the urinary tract. Bimanual examination revealed its fixation to the right lateral pelvic side wall and possibly to the right base of the prostate gland. An angiogram disclosed essentially the same vascular supply as the one performed 6 months previously in Paris. However, the right fourth lumbar artery was now also supplying the tumor (fig. 2, A). Attempted embolization with ferromagnetic silicone injections 1 was only partially successful because the silicone was not radiopaque. The silicone has since been made radiopaque to prevent overfilling and injection of only the superior feeding vessel (right fourth lumbar artery) was accomplished. In addition, the patient experienced back Accepted for publication August 1, 1975. Read at annual meeting of Western Section, American Urological Association, Portland, Oregon, April 13-17, 1975. *Requests for reprints: Department of Surgery, Division of Urology, University of California School of Medicine, Los Angeles, California 90024.
pain associated with a right femoral nerve palsy and the procedure was terminated. During the next 24 hours the back pain and femoral palsy cleared. The patient and his family desired that an exploration be performed and after radiologic consultation it was elected to attempt preoperative embolization of the 3 remaining feeding vessels with intra-arterial injection of particles of gelfoam. 2 • 3 A repeat arteriogram before gelfoam embolization revealed successful occlusion of the fourth lumbar artery by the ferromagnetic technique (fig. 2, B). Successful embolization of the remaining feeding vessels was accomplished by selective arterial injection of gelfoam particles (fig. 3). At exploration the lesion was seen fixed to the right lateral pelvic side wall and encasing the right external iliac artery and vein. The right external iliac artery and vein were excised en bloc with the lesion. The right ureter, bladder and prostate were mobilized with difficulty from the lesion without entry into the urinary tract. The rectum was also spared. However, the cecum was densely attached to the prior biopsy site. Feeding vessels were individually controlled with hemostatic clips as the dissection progressed and complete excision was accomplished. Pathologic examination revealed a 16 by 13 cm. mass weighing 650 gm. (fig. 4) that was typical of hemangiopericytoma. Mitotic figures were described as very scarce. A 6 mm. dacron external velour graft was implanted to bridge the defect between the common iliac artery and femoral artery. The external iliac vein was ligated. Blood loss from this procedure was 3,300 cc. The patient did well until 1 week postoperatively when high spiking fevers occurred. Blood culture yielded Escherichia coli. Despite parenteral antibiotic therapy the fevers persisted and signs of peritonitis developed. Emergency exploration revealed an intra-abdominal abscess secondary to a cecal fistula. Drainage with a Chaffin-Pratt tube was instituted and the patient's condition stabilized with intensive antibiotic therapy. The cecal fistula closed spontaneously with prolonged hyperalimentation. Postoperative radiation therapy was advised. A recent letter from the patient revealed that he returned to full-time activity as a physician in October 1974, 6 months postoperatively, and that he went skiing in March 1975. He has regained his preoperative weight and feels well with no evidence of recurrence although a slight weakness of dorsiflexion of the right foot persists.
206
PREOPERATIVE VASCULAR EMBOLIZATION DISCUSSION
Hemangiopericytoma, a more indolent variant of hemangioendothelioma, has a variable clinical course. •- 6 Although some
FIG. 1. IVP shows marked deviation in right ureter and bladder across midline.
207
patients with this tumor die of metastatic disease the major risk is local recurrence. These tumors occur wherever capillaries are found, most often in the soft tissue of the lower extremities, but they also have been reported in the retroperitoneum, peritoneal cavity, genitourinary tract, thoracic cavity, head and neck region and bone. The treatment of choice is wide local excision. Problems encountered with the extirpation of this lesion can be considerable because of exorbitant blood loss and adherence to local structures. Removal of the entire capsule is ideal when technically feasible since nests of potentially malignant cells often reside in the periphery of the capsule. The radiosensitivity of this lesion remains controversial. 5 · 9 Occasionally, radiation therapy may convert a non-resectable lesion into a resectable one.• This tumor also may be responsive to chemotherapy with the combined administration of vincristine and actinomycin D. 10 There was no evidence of metastatic disease in our patient. The major problem was control of the massive blood supply to allow possible resection. The prior blood loss in excess of 5,000 cc from a simple biopsy generated in us extreme respect for this lesion. Recent reports of arterial catheterization and selective embolization encouraged us to proceed.2· 3 In 1931 Brooks first used an embolization technique by direct injection of foreign material into a surgically exposed vessel for the treatment of a carotid-cavernous fistula. 11 Percutaneous arterial catheterization has been used before successfully to control severe gastrointestinal hemorrhage, 2 • 3 as well as hemorrhage of branches of the hypogastric artery in cases of pelvic fracture. 12 Epinephrine infusion with autogenous blood clot has been used as the embolization material but the use of a material such as gelfoam may have a distinct advantage compared to the aforementioned method. Rosch and associates noted that autogenous blood clots tended to break apart within the arterial catheter and dissolve within the distal vessels.2 Vasoconstriction with epinephrine before and after em bolization helped to decrease this occurrence. This problem does not exist with gelfoam. Vasodilation instead of vasoconstriction is advisable before injecting the gelfoam. Initially, small particles of gelfoam are used to occlude the smaller radicals of the vessel to be embolized. As the small branches are occluded progressively larger gelfoam particles are injected until the major branch is occluded (fig. 3). The ferromagnetic silicone technique of Masso and Rand offers great promise with regard to greater control of embolization. 1 With control of the ferromagnetic silicone
FIG. 2. A, angiogram on April 23, 1974 reveals ligated right third lumbar artery and new supply from ipsilateral fourth lumbar artery (subtraction film). B, angiogram after embolization with ferromagnetic silicone but before embolization with gelfoam. Note occluded fourth lumbar artery.
208
SMITH AND ASSOCIATES
Fm. 3. A, post-gelfoam embolization. Note marked decrease in vascularity of lesion. B, subtraction film REFERENCES
Fm. 4. Gross pathologic specimen
solution by the superconducting electromagnet until vulcanization of the silicone mixture occurs (20 minutes), it seems possible to embolize large arteriovenous fistulas preoperatively. This would not be feasible with other techniques because of possible distal embolization through the arteriovenous channels. Recent modification of this technique by the addition of barium to the silicone mixture has allowed more simplified and accurate radiographic monitoring of the silicone injection.
1. Mosso, J. A. and Rand, R. W.: Ferromagnetic silicone vascular occlusion: a technic for selective infarction of tumors and organs. Ann. Surg., 178: 663, 1973. 2. Rosch, J., Dotter, C. T. and Brown, M. J.: Selective arterial embolization. A new method for control of acute gastrointestinal bleeding. Radiology, 102: 303, 1972. 3. Carey, L. S. and Grace, D. M.: The brisk bleed: control by arterial catheterization and gelfoam plug. J. Canad. Ass. Radiol., 25: 113, 1974. 4. Gerner, R. E., Moore, G. E. and Pickren, J. W.: Hemangiopericytoma. Ann. Surg., 179: 128, 1974. 5. Binder, S. C., Wolf, H.J. and Deterling, R. A., Jr.: Intra-abdominal hemangiopericytoma. Report of four cases and review of the literature. Arch. Surg., 107: 536, 1973. 6. Daeke, D. A. and Lindodorfer, D. B.: Malignant retroperitoneal hemangio-pericytoma with associated hypoglycemia. Treatment via radiotherapy. Wis. Med. J., 73: 592, 1974. 7. O'Brien, P. and Brasfield, R. D.: Hemangiopericytoma. Cancer, 18: 249, 1965. 8. Kent, K. H.: Hemangiopericytoma; report of a case with special reference to roentgen therapy. Amer. J. Roentgen., 77: 347, 1957. 9. Mujahed, Z., Vasilas, A. and Evans, J. A.: Hemangiopericytoma. A report of 4 cases with a review of the literature. Amer. J. Roentgen., 82: 658, 1959. 10. Bredt, A. B. and Serpick, A. A.: Metastatic hemangiopericytoma treated with vincristine and actinomycin D. Cancer, 24: 266, 1969. 11. Brooks, B.: Discussion of article by Noland, L. and Taylor, A. S.: Pulsating exophthalmos, result of injury. Trans. South. Surg. Ass., 43: 171, 1931. 12. Margolies, M. N., Ring, E. J., Waltman, A. C., Kerr, W. S., Jr. and Baum, S.: Arteriography in the management of hemorrhage from pelvic fractures. New Engl. J. Med., 287: 317, 1972.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
PREOPERATIVE VASCULAR EMBOLIZATION AS AN ADJUNCT TO SUCCESSFUL RESECTION OF LARGE RETROPERITONEAL HEMANGIOPERICYTOMA ROBERT B. SMITH,* HERBERT I. MACHLEDER, ROBERT W. RAND, JOHN BENTSON AND PATRICE TOUBAS From the Department of Surgery, Divisions of Urology, General Surgery and Neurosurgery, and the Department of Radiological Sciences University of California School of Medicine and the Department of Surgery, Division of Urology, Wadsworth Veterans Administration Hospital.' Los Angeles, California
ABSTRACT
A large retroperitoneal hemangiopericytoma was resected successfully with the aid of preoperative control of the blood supply of the lesion with percutaneous intra-arterial gelfoam and ferromagnetic sil~cone embolization. We believe that this resection would not have been possible without this adJu_van1: techniq1;1e. ~uture application of this combined technique will enable more aggressive surgical mtervent10n m unresectable vascular tumors and arteriovenous malformations. Vascular neoplasms such as hemangiopericytoma often present a tremendous challenge to the surgeon with regard to inordinate blood loss associated with excision. The following case report illustrates the contribution of preoperative vascular control in the management of vascular lesions. CASE REPORT
A 28-year-old French physician was admitted to the hospital in April 1974 for evaluation and possible resection of a large retroperitoneal mass. He had noted the onset of a renal colic-like pain in the right flank 7 months previously. An excretory urogram (IVP) performed in Paris at that time demonstrated a large mass in the right retroperitoneum that deviated the bladder and right ureter across the midline. An angiogram revealed this to be a vascular tumor with blood supply originating from the right third lumbar artery, right and left hypogastric arteries and the right lateral femoral circumflex artery. The patient underwent exploratory laparotomy and the lesion was deemed unresectable. A 1 cm. wedge biopsy resulted in a blood loss in excess of 5,000 cc that required 6 hours to control. The third lumbar artery was ligated during this procedure. Convalescence was uneventful except for weakness in the right proximal thigh and foot. Pathologic examination of the specimen revealed the tumor to be a hemangiopericytoma. An IVP revealed no change in the size of the mass (fig. 1). Cystoscopy confirmed the tumor to be extrinsic to the urinary tract. Bimanual examination revealed its fixation to the right lateral pelvic side wall and possibly to the right base of the prostate gland. An angiogram disclosed essentially the same vascular supply as the one performed 6 months previously in Paris. However, the right fourth lumbar artery was now also supplying the tumor (fig. 2, A). Attempted embolization with ferromagnetic silicone injections 1 was only partially successful because the silicone was not radiopaque. The silicone has since been made radiopaque to prevent overfilling and injection of only the superior feeding vessel (right fourth lumbar artery) was accomplished. In addition, the patient experienced back Accepted for publication August 1, 1975. Read at annual meeting of Western Section, American Urological Association, Portland, Oregon, April 13-17, 1975. *Requests for reprints: Department of Surgery, Division of Urology, University of California School of Medicine, Los Angeles, California 90024.
pain associated with a right femoral nerve palsy and the procedure was terminated. During the next 24 hours the back pain and femoral palsy cleared. The patient and his family desired that an exploration be performed and after radiologic consultation it was elected to attempt preoperative embolization of the 3 remaining feeding vessels with intra-arterial injection of particles of gelfoam. 2 • 3 A repeat arteriogram before gelfoam embolization revealed successful occlusion of the fourth lumbar artery by the ferromagnetic technique (fig. 2, B). Successful embolization of the remaining feeding vessels was accomplished by selective arterial injection of gelfoam particles (fig. 3). At exploration the lesion was seen fixed to the right lateral pelvic side wall and encasing the right external iliac artery and vein. The right external iliac artery and vein were excised en bloc with the lesion. The right ureter, bladder and prostate were mobilized with difficulty from the lesion without entry into the urinary tract. The rectum was also spared. However, the cecum was densely attached to the prior biopsy site. Feeding vessels were individually controlled with hemostatic clips as the dissection progressed and complete excision was accomplished. Pathologic examination revealed a 16 by 13 cm. mass weighing 650 gm. (fig. 4) that was typical of hemangiopericytoma. Mitotic figures were described as very scarce. A 6 mm. dacron external velour graft was implanted to bridge the defect between the common iliac artery and femoral artery. The external iliac vein was ligated. Blood loss from this procedure was 3,300 cc. The patient did well until 1 week postoperatively when high spiking fevers occurred. Blood culture yielded Escherichia coli. Despite parenteral antibiotic therapy the fevers persisted and signs of peritonitis developed. Emergency exploration revealed an intra-abdominal abscess secondary to a cecal fistula. Drainage with a Chaffin-Pratt tube was instituted and the patient's condition stabilized with intensive antibiotic therapy. The cecal fistula closed spontaneously with prolonged hyperalimentation. Postoperative radiation therapy was advised. A recent letter from the patient revealed that he returned to full-time activity as a physician in October 1974, 6 months postoperatively, and that he went skiing in March 1975. He has regained his preoperative weight and feels well with no evidence of recurrence although a slight weakness of dorsiflexion of the right foot persists.
206
PREOPERATIVE VASCULAR EMBOLIZATION DISCUSSION
Hemangiopericytoma, a more indolent variant of hemangioendothelioma, has a variable clinical course. •- 6 Although some
FIG. 1. IVP shows marked deviation in right ureter and bladder across midline.
207
patients with this tumor die of metastatic disease the major risk is local recurrence. These tumors occur wherever capillaries are found, most often in the soft tissue of the lower extremities, but they also have been reported in the retroperitoneum, peritoneal cavity, genitourinary tract, thoracic cavity, head and neck region and bone. The treatment of choice is wide local excision. Problems encountered with the extirpation of this lesion can be considerable because of exorbitant blood loss and adherence to local structures. Removal of the entire capsule is ideal when technically feasible since nests of potentially malignant cells often reside in the periphery of the capsule. The radiosensitivity of this lesion remains controversial. 5 · 9 Occasionally, radiation therapy may convert a non-resectable lesion into a resectable one.• This tumor also may be responsive to chemotherapy with the combined administration of vincristine and actinomycin D. 10 There was no evidence of metastatic disease in our patient. The major problem was control of the massive blood supply to allow possible resection. The prior blood loss in excess of 5,000 cc from a simple biopsy generated in us extreme respect for this lesion. Recent reports of arterial catheterization and selective embolization encouraged us to proceed.2· 3 In 1931 Brooks first used an embolization technique by direct injection of foreign material into a surgically exposed vessel for the treatment of a carotid-cavernous fistula. 11 Percutaneous arterial catheterization has been used before successfully to control severe gastrointestinal hemorrhage, 2 • 3 as well as hemorrhage of branches of the hypogastric artery in cases of pelvic fracture. 12 Epinephrine infusion with autogenous blood clot has been used as the embolization material but the use of a material such as gelfoam may have a distinct advantage compared to the aforementioned method. Rosch and associates noted that autogenous blood clots tended to break apart within the arterial catheter and dissolve within the distal vessels.2 Vasoconstriction with epinephrine before and after em bolization helped to decrease this occurrence. This problem does not exist with gelfoam. Vasodilation instead of vasoconstriction is advisable before injecting the gelfoam. Initially, small particles of gelfoam are used to occlude the smaller radicals of the vessel to be embolized. As the small branches are occluded progressively larger gelfoam particles are injected until the major branch is occluded (fig. 3). The ferromagnetic silicone technique of Masso and Rand offers great promise with regard to greater control of embolization. 1 With control of the ferromagnetic silicone
FIG. 2. A, angiogram on April 23, 1974 reveals ligated right third lumbar artery and new supply from ipsilateral fourth lumbar artery (subtraction film). B, angiogram after embolization with ferromagnetic silicone but before embolization with gelfoam. Note occluded fourth lumbar artery.
208
SMITH AND ASSOCIATES
Fm. 3. A, post-gelfoam embolization. Note marked decrease in vascularity of lesion. B, subtraction film REFERENCES
Fm. 4. Gross pathologic specimen
solution by the superconducting electromagnet until vulcanization of the silicone mixture occurs (20 minutes), it seems possible to embolize large arteriovenous fistulas preoperatively. This would not be feasible with other techniques because of possible distal embolization through the arteriovenous channels. Recent modification of this technique by the addition of barium to the silicone mixture has allowed more simplified and accurate radiographic monitoring of the silicone injection.
1. Mosso, J. A. and Rand, R. W.: Ferromagnetic silicone vascular occlusion: a technic for selective infarction of tumors and organs. Ann. Surg., 178: 663, 1973. 2. Rosch, J., Dotter, C. T. and Brown, M. J.: Selective arterial embolization. A new method for control of acute gastrointestinal bleeding. Radiology, 102: 303, 1972. 3. Carey, L. S. and Grace, D. M.: The brisk bleed: control by arterial catheterization and gelfoam plug. J. Canad. Ass. Radiol., 25: 113, 1974. 4. Gerner, R. E., Moore, G. E. and Pickren, J. W.: Hemangiopericytoma. Ann. Surg., 179: 128, 1974. 5. Binder, S. C., Wolf, H.J. and Deterling, R. A., Jr.: Intra-abdominal hemangiopericytoma. Report of four cases and review of the literature. Arch. Surg., 107: 536, 1973. 6. Daeke, D. A. and Lindodorfer, D. B.: Malignant retroperitoneal hemangio-pericytoma with associated hypoglycemia. Treatment via radiotherapy. Wis. Med. J., 73: 592, 1974. 7. O'Brien, P. and Brasfield, R. D.: Hemangiopericytoma. Cancer, 18: 249, 1965. 8. Kent, K. H.: Hemangiopericytoma; report of a case with special reference to roentgen therapy. Amer. J. Roentgen., 77: 347, 1957. 9. Mujahed, Z., Vasilas, A. and Evans, J. A.: Hemangiopericytoma. A report of 4 cases with a review of the literature. Amer. J. Roentgen., 82: 658, 1959. 10. Bredt, A. B. and Serpick, A. A.: Metastatic hemangiopericytoma treated with vincristine and actinomycin D. Cancer, 24: 266, 1969. 11. Brooks, B.: Discussion of article by Noland, L. and Taylor, A. S.: Pulsating exophthalmos, result of injury. Trans. South. Surg. Ass., 43: 171, 1931. 12. Margolies, M. N., Ring, E. J., Waltman, A. C., Kerr, W. S., Jr. and Baum, S.: Arteriography in the management of hemorrhage from pelvic fractures. New Engl. J. Med., 287: 317, 1972.