Surgical Pathology Report

 Surgical Pathology - 1995-05-26  08:12

MICROSOCOPIC DESCRIPTION:

1. The section show skin with an extensive vascular lesion involving all levels of the dermis and subcutis. The lesion consists of vascular spaces of variable diameter, most of which have thin walls. The vascular spaces are separated by sclerotic stroma throughout much of the specimen. There is no significant cytologic atypia of the vascular endothelial cells, and papillary structures are not identified. The lesion extends to the margins of the specimen.

DIAGNOSIS:

1. HEMANGIOMA WITH EXTENSIVE INVOLVEMENT OF THE DERMIS AND SUBCUTIS, SEE NOTE. (T-01000; T-02800; M-91200)  ICD9-V72.6  AND 216.90

NOTE: 

THE PREVIOUS BIOPSY (D91-4031), WAS REVIEWED. THAT SPECIMEN ALSO REPRESENTS A HEMANGIOMA WITH EXTENSIVE INVOLVEMENT OF THE PAPILLARY AND UPPER RETICULAR DERMIS. IF THIS LESION INVOLVES THE UNDERLYING SKELETAL MUSCLE OF BONE IT MAY REPRESENT A DIFFUSE HEMANGIOMA (ANGIOMATOSIS). CLINICAL-PATHOLOGIC CORRELATION IS NECESSARY.

Jon A. Reed, M.D./N. Scott McNutt, M.D.

JAR/NSM/lt
06/15/95
doc#6186S
doc#9238D
Surgical pathology billing 23, 025
TDWD: Dx. discussed with Dr. Hoffman, 6/14/95, 4 pm - JAR.

Status: Pending
Accno: CISWANGPATH-S95-12120

NYC:1001795690 NYP/WC:002492702 WMC:100554653 NYP/Q:03197633 NYPMG/QNS:501293 - KO, KANG WEI - Oct 24, 1976 - 48y - M

Hemangioma Removal

THE NEW YORK HOSPITAL
05-25-95

KO, KANG WEI

249-27-02



PREOPERATIVE DIAGNOSIS: GIANT HEMANGIOMA, LEFT THIGH AND LOWER LEG.

POSTOPERATIVE DIAGNOSIS: SAME.

OPERATION:

1. EXCISION OF MASSIVE HEMANGIOMA, LEFT THIGH AND LEFT LOWER LEG.
2. SPLIT THICKNESS SKIN GRAFT GREATER THAN 200 SQ. CENTIMETERS.

SURGEON: LLOYD HOFFMAN, M.D.

ASSISTANT: SCHWARTZ, M.D.

ANESTHESIA: GENERAL ENDOTRACHEAL ANESTHESIA.

ANESTHESIOLOGIST:

INDICATIONS:
The patient is a 17 year old Asian male who has a massive hemangioma of the left posterior thigh and posterior calf as well as the popliteal fossa.  This hemangioma has been present since birth.  It was treated with herbal wraps and the patient subsequently developed a burn over the skin.  This area continually becomes infected and has often bled.  MRI reveals a deep hemangioma and the angiogram revealed normal vessels.

PROCEDURE:
The patient was taken to the Operating Room where he underwent extensive preoperative preparation including Foley catheterization, IV lines, warming blankets and he was rotated into position following the induction of endotracheal anesthesia. The patient is a massive individual weighing greater than 112 kilos.

The entire leg and left upper thigh and buttocks were prepped and draped in the usual fashion.  Consideration was given to the latissmus dorsi flap and this area was prepped in as well.  A tourniquet was applied to the left upper thigh and the left leg was exsanguinated as fully as possible.  The tourniquet was inflated to 350 mmHg.

Incision was designed involving the medial aspect of the upper thigh extending inferiorly encompassing a large ellipse of involved skin and then proceeding inferiorly to a straight line again.  The incision was made using a 10 blade and skin flaps were elevated.  Even the normal appearing skin was involved with the hemangiomatous component.  Extensive dissection was carried out sharply and bluntly to remove hemangioma from between muscle groups as well as fascia.  The semimembranosus and semitendonosus and gracilis muscles were dissected out as the popliteal fossa was crossed and the gastroc muscles came into view.  The fascia was removed with the specimen and hemostatis was achieved.  Following excision of this large mass and submission to Pathology, the remaining skin was trimmed using the scissors.

The defect measured approximately 12 centimeters in width by 48 centimeters in length.  The decision was not to use the flap and skin graft this area.  The dermis was then tacked down to muscle and skin harvested with the Padgett dermatome from the upper thigh and buttock area.

The skin was meshed and secured with staples and wet clips.  Carefully molded splint was prepared and the graft secured with moist cotton and Xeroform.

The patient tolerated this procedure well and was transferred to the Recovery area in stable condition.  The sponge and instrument counts were correct.  The estimated blood loss was 200 cc.

DICTATED BY: LLOYD HOFFMAN, M.D.

LH/FVB/RR

TAPE: 6714

D: 05-26-95

T: 05-31-95

531NY03.FVB

Arteriogram and Venogram Radiology Report

THE NEW YORK HOSPITAL
05-24-95

KO, KANG WEI

2492702

0351 ARTERIOGR SEL              844288

05-24-95   HOFFMAN, LLOYD MD    HO029

RADIOLOGY REPORT

ICD code: 228.01
ACR code: 928.149, 938.124

Radiologists: Dr. Trost, Dr. Napp.


LEFT LOWER EXTREMITY ARTERIOGRAM AND LEFT LOWER EXTREMITY VENOGRAM - 5/24/95.


Clinical history: 19 year old Asian male with left lower thigh and upper leg medial soft tissue hemangiomas which are painful and crusting. For arteriogram and possible embolization.

Procedure:

The right groin was prepped and draped in standard sterile fashion.  Local anesthesia was obtained with Lidocaine.  Using standard aseptic technique, the right common femoral artery was cannulated.  Using Seldinger technique, a catheter was advanced over a wire and selectively placed in the left common liliac artery.  Standard left lower extremity arteriogram was performed.

Then, a 20 gauge angiocath was placed in the left foot.  Under fluoroscopic guidance, contrast was injected and multiple venogram images obtained.

Findings:

Left lower extremity arteriogram demonstrates normal anatomy and appearance of the common femoral artery, superficial femoral artery, profunda femoris artery, politeal artery, and politeal trifucation.  The known medical soft tissue hemangiomas were not identified as vascular structures on the arteriogram.  Specifically, no major arterial feeders could be identified.  Therefore, embolization could not be performed.

Left lower extremity venogram demonstrates no evidence of venous thrombus.  Venogram is unremarkable with the exception of a partially duplicated superficial femoral vein.  No venous connection to the known soft tissue hemangiomas was identified.

Unremarkable left lower extremity arteriogram and venogram.  The known soft tissue hemangiomas demonstrated no major arterial or venous connections.



                                                        TRACY NAPP, M.D.
dd 05-31-95
dd 06-02-95