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Posted by
Jane on March 21, 2002 at 05:27:38:

Dear Dr Stoll,

You may remember I wrote to you last year following 2 unsuccessful operations for Pilonidal Sinus which had left me with deep wound infections and in a lot of pain.

I asked a Pathology expert to examine samples from
both operations, and below is his opinion. I can't understand why my first Surgeon operated twice for a pilonidal sinus when he must have know that the Op. 1 samples found no evidence of this condition.

I have 2 questions I would like to ask you:-

1. does this probable diagnosis explain the post-op infections I've experienced with my wound? (It frequently re-opens to discharge pus. Although the wound itself is not painful - the real pain is at the top of my right leg, and has reached a stage where pressing against the site produces a wave of nausea.) Antibiotics have had no effect.

2. can this probable condition (Hemangioma) be treated by means other than surgery? If so, do you have any suggestions?

My Doctor is searching for a new specialist, as the best my old Surgeon could offer was an extensive wide excision described as major surgery involving a reconstructed bottom with a plastic surgeon. Although a 'designer-bum' has some appeal... modeled on Rachael Welch? Kylie Monogue?.... having experienced 2 unsuccessful operations where progressively bigger 'holes' were dug in the dark, this is my least favored option!

Thank you very much for your advice,
Yours sincerely,

Pathology diagnosis:-
"Many thanks for sending this material representing lesions from the back thought initially to be pilonidal sinus in September 2000, and now with a further excision in May 2001.
The second specimen shows a poorly defined area of subcutaneous fibrous tissue with numerous dilated blood vessels without anastomosis or atypia. The lesion extends into subcutaneous fat and reaches muscle. Small similar foci are present in the initial excision. This appears to be a hemangioma or, noting the extension of blood vessels into fat or muscle, just possibly a localised form of angiomatosis. However, the fibrous tissue component would be unusual; I even considered fibromatosis with an unusual vascular pattern noting the mast cells, but I suspect that at least some of the fibrosis relates to previous surgery and the pattern of focally myxoid areas with bundles of fibroblasts between is unusual. Thus, I am not sure exactly how to classify this but it would seem reasonable to manage as for a hemangioma with possibly recurrent potential if incompletely excised. I did not see definite features of malignancy. I should be very interested to know of any further information in due course."

Re: Hemangioma vs pilonidal (Archive.)

Posted by Walt Stoll on March 22, 2002 at 09:55:18:

In Reply to: Hemangioma posted by Jane on March 21, 2002 at 05:27:38:

Hi, Jane.

Do you have the first pathology report? I am assuming that this one is a second opinion.

In MY opinion, this should have been obvious at surgery but I need to hear what the first pathologist said.

The "bum reconstruction" may sound glamorous but, if you have seen any pictures of them you would immediately appreciate how well Mother Nature does and how poorly the best surgeon does in contrast. I know you said that you put this last on the list.



Re: Hemangioma vs pilonidal (Archive.)

Posted by
Jane on March 24, 2002 at 04:50:24:

In Reply to: Re: Hemangioma vs pilonidal (Archive.) posted by Walt Stoll on March 22, 2002 at 09:55:18:

Dear Dr Stoll,

You are correct, this report is a 3rd (expert) opinion. It concurs with the person making the 2nd opinion (a hemangioma). I dearly wish I had the 1st (original) opinion, as this would be the pathologist who assisted the decision-making of my 1st surgeon... which perhaps convinced him to carry out the 2nd pilonidal procedure?

I only found 1 'hemangioma' story in your archives, which mentioned lots of different ideas:-

1. a Doppler MRI to determine the density of the mass of the hemangioma.
2. a MRI, with GAD dye
3. a radiologist that specializes in embolizing the hemangioma via a clip implanted through a catheter
4. a plastic surgeon

The end of that particular story was that the patient consulted a radiologist for a doppler MRI to find the blood vessel(s) that were supplying the hemangioma. The plan was to inject the vein in order to cutoff the blood supply, causing the hemangioma to 'die-off' and (hopefully) be re-absorbed in the body, thus not requiring any surgery. I have written to the email address given to see if this was in fact successful back in 1999, but no response as yet.

Of these procedures mentioned, I have had 2 MRI scans and an isotopic scan. All these (apparently) reported high levels of inflammation in the area, which at the time the doctors put down to the poor state of my operation wound. Do you recommend any of the other procedures mentioned?

Reading around the net, I've found various references to T2 weighted MRI scans clearly showing hemangioma, reporting high signal intensity,eg. :-

· “The T2W MRI confirms the diagnosis by showing the bright signal on the heavily T2-weighted pulse sequence.”
· “T1 weighted MRI scans vary from low to high intensity depending on the amount of adipose tissue present. T2 weighted MRI scans demonstrate lesions with high intensity due to the vascularity.”

I have no idea if the 2 MRI scans carried out on me between surgery were T1 or T2 (the 2nd scan I had done should have clearly showed the tumour, since it was taken just before the surgery relating to tissue sample 2).

I've found treatment comments on the net relating to case studies, in 'medical speak' which I can hardly understand. 1,2 and 3 don't sound promising - I wonder if you could expand further on options 4 & 5 below?

1. Intracapsular excision is often followed by recurrence as the lesion rarely forms a pseudocapsule. It is most often diffusely infiltrative.
2. In theory extracapsular excision should provide a definitive procedure for stage 2 hemangioma, but it is impossible to dissect between the periphery of the lesion and the normal tissues without inadvertent transsectoin of occult extensions.
3. Wide excision does not always lead to complete cure, and is often injustified due to excessive morbidity.
4. Cryosurgery.
5. Injection with sclerosing agents.

I take your point about 'bum reconstruction', when the surgeon discussed it with me I thought it sounded like a terrible idea, and there MUST be other treatment options!

Many thanks for your help and advice.
(Berkshire, England).

Re: Hemangioma vs pilonidal (Archive.)

Posted by Walt Stoll on March 25, 2002 at 09:28:14:

In Reply to: Re: Hemangioma vs pilonidal (Archive.) posted by Jane on March 24, 2002 at 04:50:24:

Thanks, Jane.

The "clip" clotting procedure sounds good to me IF you can get them to respond.

My second choice would be a sclerosing injection.

My 3rd choice would be the cryosurgery and the others further down the line.

HOWEVER, I am not an expert in this field. I am just saying what I would do in your position--knowing what I DO know.

Your problem is that NO ONE is a specialist in this condition since the invasive type is SO uncommon.

Let us know how you do.


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