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Volume 23 � Number 8 � August � 2012 1101

of the medial right thigh. Repeat US of the access siteshowed no interval vascular complications, abscess, oredema. The patient received a second US-guided blockof the right femoral nerve in the same location by thesame anesthesiologist, with repeated resolution of pain.The patient was discharged 3 days after admission withadequate pain control with oral medications (oxycodone/acetaminophen 5/325 mg). At his 4-week follow-up ap-pointment, the patient reported complete resolution ofhis pain and decreased sensation. In addition, he was nolonger dependent on oral pain medication.

The anterior cutaneous branches of the femoral nervedivide from the anterior femoral nerve inferior to the inguinalligament and consist of two main branches: the intermediatecutaneous nerve of the thigh and the medial cutaneous nerve ofthe thigh. Classically, these nerves variably follow the courseof the femoral artery, vein, and nerve before diverging medi-ally and superficially and providing sensation to the medialthigh from the inguinal crease to the level of the knee joint (2).The nerves variably provide sensation to the medial thigh,even though the intermediate cutaneous nerve is described aschiefly providing sensation to the superior thigh whereas the

Figure 3. Longitudinal image from sonographic evaluation ofthe vascular closure site demonstrates appropriate intraluminalpositioning of the Angio-Seal footplate as well as normal vas-cular anatomy at the level of the common femoral artery, withno evidence of pseudoaneurysm or dissection. (Available incolor online at www.jvir.org.)

medial cutaneous nerve innervates the inferior thigh. S

The known complications of Angio-Seal VCD use are thoseommon to other VCDs (eg, aneurysm, bleeding, infection).iven the mechanism of action of this VCD (ie, extrinsic and

ntrinsic compression on a vessel wall), it is feasible for the deviceo involve the fibers of crossing superficial nerves when deployed.iven that the anchor and plug of the device are bioabsorbable,

nd typically fully absorb in 8–12 weeks (3), the resolution of theatient’s symptoms at the 1-month follow-up visit were mostikely secondary to the device’s ongoing absorption.

We have provided a brief report of a patient withransient injury of a superficial branch of the femoral nerveuring placement of a VCD at the end of a vascular inter-ention with right common femoral artery access. Thealient findings that indicated nerve injury in this case wereronounced pain at the time of VCD placement and focalecreased sensation of the medial ipsilateral thigh. Theppropriate placement of the VCD, as well as the vari-ble anatomy of branching cutaneous nerves of the leg,imits prospective evaluation for this complication. How-ver, in this singular case, the patient’s symptoms wereontrollable with minimally invasive intervention by thenesthesiology service and outpatient oral analgesia andere ultimately transient. This case could provide anutline for treatment of any future occurrences of thisare complication of VCD placement.

EFERENCES

. Dauerman HL, Applegate RJ, Cohen DJ. Vascular closure devices: thesecond decade. J Am Coll Cardiol 2007; 50:1617–1626.

. Grey H. Anatomy of the human body. Philadelphia: Lea and Febiger, 1918.

. Sanborn TA, Gibbs HH, Brinker JA, Knopf WD, Kosinski EJ, Roubin GS.A multicenter randomized trial comparing a percutaneous collagenhemostasis device with conventional manual compression after diag-nostic angiography and angioplasty. J Am Coll Cardiol 1993;22:1273–1279.

uccessful Iterative Percutaneous

ryoablation of Multiple Extraabdominal

esmoid Tumors in a Patient with

ardner Syndrome

rom: Francois Cornelis, MDntoine Italiano, MD, PhDultan Al-Ammari, MDichèle Kind, MD

berhard Stoeckle, MDfshin Gangi, MD, PhD

ean Palussière, MDin Nguyen Bui, MDepartments of Radiology (F.C., S.A.-A., M.K., J.P.)ncology (A.I., B.N.B.), andurgery (E.S.)nstitut Bergonié29 Cours de l’Argonne3076 Bordeaux, France; andepartment of Radiology (A.G.), Civil Hospital

trasbourg, France

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1102 � Letters to the Editor Cornelis et al � JVIR

Editor:

Desmoid tumors, also called aggressive fibromatosis, arerare fibrous benign neoplasms originating in muscu-loaponeurotic structure (1) that are classified into intra-and extraabdominal types. Although they never metasta-size, extraabdominal desmoid tumors are challenging tomanage as a result of locally infiltrative extension. Sur-gical excision with wide margins is the main therapy forextraabdominal desmoid tumors, but local recurrence iscommon, even after apparent complete surgical excision,and occurs in an average of 40% of cases (range, 19%–77%) (2).

Recent studies indicate the benefits of a first-lineconservative approach to prevent mutilating surgical in-terventions for primary tumors close to critical anatomicstructures, or for recurrent lesions (2). Percutaneous pro-cedures such as radiofrequency ablation and cryoabla-tion, which are increasingly used in several tumor typesas alternatives to surgery, may be offered as less invasiveprocedures, especially for patients who are poor surgicalcandidates, although data about the role of such proce-dures in the management of desmoids tumors is currentlyscarce (3). We investigated whether the minimally inva-sive option of cryoablation could prevent the tumorregrowth and local relapse that are commonly observedafter surgery (4). Here we report, to our knowledge, thefirst experience of successive percutaneous cryotherapiesof multiple extraabdominal desmoid tumors for a patientwith Gardner syndrome.

A 34-year-old woman with a familial history of Gard-ner syndrome who had undergone surgery for five intraab-dominal desmoid tumors and a colectomy was treated withcryoablation successively in January 2011, June 2011, andOctober 2011 for newly successively appearing painfuldesmoid tumors. The first one was located at the thoraco-lumbar junction (pain score of five of 10 on the visualanalog scale), measuring 46 � 21 � 18 mm on magneticresonance (MR) imaging (Figure, a, arrow); the secondwas located on the left abdominal wall (24 � 22 � 14 mm),and the third was located in the right lumbar region (55 �31 � 11 mm). The second and the third symptomaticmasses appeared respectively on MR images 6 months afterthe first procedure and 2 months after the second procedure,although nothing was visible retrospectively. For all theselesions, MR imaging showed heterogeneous masses onT2-weighted and T1-weighted sequences before contrastagent injection. After contrast agent injection (Figure, b,arrow), there was an intense enhancement on T1-weightedimages of the mass that was consistent with the diagnosis ofdesmoid tumor. Two asymptomatic 1-cm intraabdominaldesmoid tumors were also observed at each follow-up(Figure, c, arrow).

None of the authors have identified a conflict of interest.

rhttp://dx.doi.org/10.1016/j.jvir.2012.05.041

Although a wait-and-see approach was first proposedor the first mass, pain progressively increased to a score ofeven of 10 on the visual analog scale after 2 months.urgery was not recommended because of the expectedorbidity of the procedure, and cryoablation was proposed

s an alternative to surgery. The patient gave her consent for therocedure.

Each of the three single sessions of cryotherapy wereerformed under ultrasound (US) and computed tomog-aphy (CT) guidance and general anesthesia. Two per-utaneous cryoprobes (IceRod; Galil Medical, Yokneam,srael) were introduced systematically. During all cryo-blation cycles (10-min freeze/10-min thaw/7-minreeze), no skin extension of the ice was observed, al-hough it covered the entire targeted tumor (Figure, d).t the end of the cryoablation procedure, the probes were

emoved without complication by active thawing. Noomplications were reported, and the hospital stay was 1ay for each procedure.

No residual pain was reported at 1, 3, 6 and 12 months.n the 3-month and 6-month MR follow-up, tumor sizeecreased progressively, and all tumors had disappearedompletely at 6 months. No residual enhancement wasbserved within the masses at 3 months (Figure, e, arrow),nd no tumor needed to be treated again. In addition, on theast MR examination performed 12 months after the firstryotherapy, no evolution of the intraabdominal desmoidumors was reported (Figure, f, arrow).

As illustrated in the initial report of Kujak et al (3), ourxperience supports the proposal that cryoablation can ben effective alternative to surgery for the treatment ofxtraabdominal desmoid tumors if the ablation zone com-letely covers the tumor. Because of its minimally invasiveature, cryoablation causes less damage to surroundingissues than surgery. Pain and recovery after the procedure,s well as the risk of complications, are mild with cryoab-ation compared with surgery. For extraabdominal desmoidumors treated with cryotherapy, planning, guidance, andollow-up are particularly easy with the use of US, CT, or

R imaging, which render tumor borders or recurrencesisible. In addition to the outcomes observed in the fiveases of extraabdominal desmoid tumors (3–10 cm) re-orted by Kujak et al (3) that were treated with cryoabla-ion—with local control of three of them obtained at 6, 19,nd 43 months—our report indicates that this procedurean be repeated successfully and safely as clinically re-uired. In addition, as indicated by the absence of progres-ion of the untreated abdominal lesion, it appears thatryoablation discourages tumor regrowth outside the abla-ive site. This point is particularly important because sur-ical trauma has been associated with tumor regrowth andocal relapse (4).

Desmoid tumors are benign tumors, but they may affectuality of life. Our experiences confirm that cryoablation rep-

esents a minimally invasive and effective therapeutic option

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Volume 23 � Number 8 � August � 2012 1103

for patients with symptomatic disease that warrants furtherprospective investigations.

ACKNOWLEDGMENT

The authors thank Pippa McKelvie-Sebileau of Institut Ber-gonié for medical editorial services.

REFERENCES

1. Alman BA, Pajerski ME, Diaz-Cano S, Corboy K, Wolfe HJ. Aggressivefibromatosis (desmoid tumor) is a monoclonal disorder. Diagn Mol Pathol1997; 6:98–101.

2. Fiore M, Rimareix F, Mariani L, et al. Desmoid-type fibromatosis: afront-line conservative approach to select patients for surgical treatment.Ann Surg Oncol 2009; 16:2587–2593.

3. Kujak JL, Liu PT, Johnson GB, Callstrom MR. Early experience with

Figure. (a) Sagittal T2-weighted MR image shows heterogeneouL1. (b) Axial T1-weighted postcontrast MR image with fat saturaAxial-enhanced CT scan shows centimeter-scale intraabdominal deIce was well visible as a hypodensity including the mass (arrow). (e

axial plane at 6 months shows absence of enhancement within the abof size and enhancement of the intraabdominal desmoid tumor (arro

percutaneous cryoablation of extra-abdominal desmoid tumors. SkeletalRadiol 2010; 39:175–182. S

. Okuno S. The enigma of desmoid tumors. Curr Treat Options Oncol2006; 7:438–443.

ecrotizing Fasciitis following

ndovenous Laser Treatment and Stab

vulsions of Lower-Limb Varicose Veins

rom: Syed Arafat Aftab, BScaren Wei-Ee Sng, MBChB, MRCS(Edin), MMed, FAMSiang Hiong Tay, MBBS, FRCR, FAMSepartments of Diagnostic Radiology (K.H.T.), andlastic, Reconstructive and Aesthetic Surgery (K.W.-E.S.)ingapore General Hospitalepartment of Medicine (S.A.A.), Duke–National University ofingapore Graduate Medical Schoollk 154 LOR 2, Toa Payoh 11-616

oid tumor (arrow) between the two spinous process of T12 andnfirmed the presence of a well-circumscribed mass (arrow). (c)

tumor (arrow). (d) CT scan after injection during the freezing time.eighted enhanced MR image with fat saturation performed in theite. (f) MR images with contrast agent injection showed no evolutionmonths after the first cryoablation and 3 months after the last.

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