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Extra-anatomic lateral bypass combined with embolization of the femoral stump for management of groin infection and bleeding due to metastatic carcinoma of the penis
Andrea Agostinucci
0
Nadia Sandrone
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Claudio Baracco
0
Ferruccio Ferrero
0
0
Division of Vascular Surgery
, Ospedale San Giovanni Bosco, Piazza del Donatore del Sangue 3, 10154 Turin,
Italy
We report a possible treatment strategy for a patient with squamous cell carcinoma of the penis in hemorrhagic shock, due to erosion of the right femoral artery by metastatic inguinal lymph nodes. Because of coexistent groin infection and the inability to perform radical excision, the patient was treated with a lateral extra-anatomic iliac femoral prosthetic bypass; to prevent further bleeding, the femoral stump was embolized percutaneously. The patient was discharged home and did not experience any vascular complications during the follow-up, until death due to pulmonary metastasis. 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
1. Introduction
Squamous cell carcinoma (SCC) is the most common tumor
of the penis. It is relatively rare in Western countries,
accounting for 0.40.6% of all cancers in the male
population w1x. Groin lymph nodes metastasis occurs in 30% of the
patients and is associated with poor prognosis w2x.
Cutaneous erosion secondary to recurrence of disease or radiation
therapy may result in groin infection, hemorrhagic shock
due to vascular involvement, and even loss of a limb. In
case of the inability to perform a radical excision, palliative
treatment is based on avoiding death due to bleeding and
trying to improve the patients quality of life by proceeding
with limb-sparing surgery w3x. Here, we report the case of
a patient with a groin infection and erosion of femoral
vessels due to recurrence of SCC metastasis. Radical
treatment was not possible. An extra-anatomic lateral bypass
combined with percutaneous embolization of the arterial
femoral stump was successful in managing bleeding and
achieving adequate perfusion of the affected limb.
2. Case report
A 55-year-old male with a metastatic carcinoma of the
penis involving inguinal lymph nodes developed a large
necrotic groin lesion on the right side that eroded the
common femoral artery, causing hemorrhagic shock (Fig.
1). Three years previously the patient underwent partial
penectomy for SCC. After 18 months, a lump of confluent
*Corresponding author. Tel.: q39-347-8731218; fax: q39-011-2402940.
E-mail address: (A. Agostinucci).
2011 Published by European Association for Cardio-Thoracic Surgery
right inguinal lymph nodes was observed and a biopsy
revealed SCC metastasis. A right lymphadenectomy was
carried out, and the patient was subsequently treated with
local radiotherapy and systemic chemotherapy. Six months
following radiotherapy, an 18 fluorine-fluorodeoxyglucose
(18 F-FDG) positron emission tomography (PET)-scan
revealed high levels of FDG uptake in the affected groin.
An additional biopsy revealed the recurrence of disease.
Moreover, an iliac-femoral vein thrombosis was also
detected on the affected side. Chemotherapy was discontinued
due to the development of skin ulceration and infection.
Due to the inability to perform a radical excision and due
to the poor prognosis, the only treatment was local wound
care and antibiotics. The patient was referred to our center
due to hemorrhagic shock caused by massive arterial groin
bleeding and an emergency operation was carried out.
Proximal and distal control was obtained through a
retroperitoneal approach to the external iliac artery and the
superficial femoral artery at the level of the mid-thigh. A
7-mm Dacron graft was anastomosed in an end-to-side
fashion to the external iliac artery, followed by distal
ligation. The graft was tunneled underneath the ileopsoas
fascia close to the anterior superior spine of the iliac crest,
proceeding in a subcutaneous fashion. Distal anastomosis
to the superficial femoral artery at the medial side of the
thigh was performed in an end-to-end fashion. A subsequent
computed tomography (CT) angiographic examination
demonstrated functional bypass and a patent common femoral
stump, as evidenced by retrograde flow from the profunda
(Fig. 2). To prevent further bleeding, a percutaneous
anterior mid-thigh transcatheter coil embolization was
performed using the ipsilateral retrograde approach. Arterial
A. Agostinucci et al. / Interactive CardioVascular and Thoracic Surgery 12 (2011) 860862
Fig. 1. Ulcerated groin lesion due to SCC metastasis. SCC, squamous cell
carcinoma.
access was gained via the superficial femoral artery and
successful vessel occlusion was achieved with deployment
of 0.0350 fibered platinum coils (Boston Scientific, Cork,
Ireland) in the femoral stump. The postoperative period
was uneventful and the patient was discharged after two
weeks. While the patient regained good functional use of
his right limb and did not experience any further bleeding,
at six months after the vascular procedure, he died of
pulmonary metastasis.
3. Discussion Groin metastases, particularly with involvement of femoral vasculat (...truncated)