(Stroke. 1996;27:536-537.)
© 1996 American Heart Association, Inc.
Articles |
From the Departments of Neuropathology (M.-L.M.-N., G.B., C.V.) and Neurology (J.-M.O.), CHR Pellegrin, Bordeaux, France.
| Abstract |
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Case Description We describe a patient who 1 year after a left carotid endarterectomy for typical atheromatous lesions presented with several transient ischemic attacks with stepwise worsening of the deficit and rapid death. A few weeks before, a tumor of the neck had appeared at the site of the previous endarterectomy. At postmortem examination, we found a malignant histiocytofibroma occluding the left carotid artery, with several recent ischemic foci in the corresponding cerebral hemisphere without metastasis or tumor emboli.
Conclusions This observation is unusual owing to the histological type of the neoplasm and to the circumstance of emergence of the neoplasm.
Key Words: carotid arteries histiocytoma, fibrous foreign bodies sarcoma
| Introduction |
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| Case Report |
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At postmortem examination a firm, solitary, multilobated, pseudoencapsulated tumor 10x6x4 cm was found in the area of the left carotid bifurcation. On cut sections the mass was surrounding the carotid artery, and surgical threads (from the previous carotid endarterectomy) were found within the tumor. Microscopic examination revealed a relatively well-circumscribed tumor consisting of clump spindle cells arranged in a storiform pattern and in giant multinucleated cells. The mitotic activity was high, with 17 mitoses per 10 high-power fields. The stroma consisted of collagen fibrils, occasionally with a marked collagenization or focal myxoid change. The vasculature consisted of small vessels with areas of hemangiopericytoid pattern. Large areas of necrosis were widespread in the tumor. This malignant proliferation was surrounding, infiltrating, and occluding the carotid artery. At immunochemistry, the tumor was negative for the epithelial markers (CYTO K-, EMA-) and for protein S 100 (a marker of melanoma and Schwann cell tumor), positive for vimentin (mesenchymal marker), and negative for desmin and HHF35 (muscular markers). The diagnosis of storiform pleomorphic type grade 3 malignant fibrous histiocytoma was made. Multiple foreign body granulomatous reactions were found in the proximity of the tumor around the surgical threads of the previous endarterectomy.
Macroscopic examination of the brain showed a few small nonocclusive atheromatous deposits in the vessels of the circle of Willis. The coronal sections revealed several whitish areas in the subcortical white matter of the left cerebral hemisphere. At the microscopic level, recent ischemic lesions were observed in the left temporal, frontal, and parietal cortex and in the left hemispheric white matter. No metastasis or emboli of the malignant fibrous histiocytoma were seen in the brain.
The diagnosis of left multiple ischemic brain foci secondary to left carotid occlusion by the malignant fibrous histiocytoma was established.
| Discussion |
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The development of a malignant tumor at the site of an operation is very unusual. Although it seems unlikely, the first possibility is that the tumor was present at the time of the endartectomy, in the absence of pathological examination to rule out this hypothesis. The second possibility, which we find more plausible, is the emergence of the malignant tumor on the scar of the endarterectomy. Indeed, a few cases of sarcoma arising at the site of a previous operation have been reported.1 2 3 In most of these cases, the sarcoma was associated with foreign material and arose after a very variable latency period.1 2 3 The foreign material may have different physicochemical characteristics and mainly is associated with prostheses for joint replacement and vascular grafts.1 2 3 In our case surgical threads were found within and in the vicinity of the malignant proliferation and therefore could have induced tumorigenesis. Studies in animals have shown that the physical presence and not the chemical components of the implant of foreign bodies may be responsible for tumorigenesis.7 The most critical factor in the induction of these sarcomas is the formation of a fibrous capsule around the foreign body.7 In our case the persistence of a foreign body granulomatous reaction and the presence of large extensive fibrosis areas in the tumor seem to be in agreement with this possibility. Since the number of carotid endarterectomies is increasing after the positive results of several prevention trials, the possibility of occasional induction of sarcomas at the site of the operation should be kept in mind.
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| Acknowledgments |
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| Footnotes |
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Received August 21, 1995; revision received November 6, 1995; accepted November 21, 1995.
| References |
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2. Ben-Izhak O, Kerner H, Brenner B, Lichtig C. Angiosarcoma of the colon developing in a capsule of a foreign body: report of a case with associated hemorrhagic diathesis. Am J Clin Pathol. 1992;97:416-420. [Medline] [Order article via Infotrieve]
3.
Tait NP, Hacking PM, Malcolm AJ. Malignant
fibrous histiocytoma occurring at the site of a previous total hip
replacement. Br J Radiol. 1988;61:73-76.
4. Enzinger FM, Weiss SW. Malignant fibrohistiocytic tumors. In: Stamathis G, ed. Soft Tissue Tumors. St Louis, Mo: CV Mosby; 1988:269-300.
5. Weiss SW. Malignant fibrous histiocytoma: a reaffirmation. Am J Surg Pathol. 1982;8:773-784.
6. Grigoriev BA, Orlov KK. Malignant fibrous histiocytoma of the neck with metastases to the brain. Arkh Patol. 1989;51:67-70.
7. Brand KG, Johnson KH, Buoen LC. Foreign body tumorigenesis. Crit Rev Toxicol. 1976;4:353-394.
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