Rupture of the perivisceral aorta: atherosclerotic versus mycotic aneurysm.

Twelve patients with rupture of the perivisceral abdominal aorta were admitted to the UCLA Medical Center between 1984 and 1996. Six patients had atherosclerotic thoracoabdominal aneurysms (TAA) which ruptured in the visceral segment of the aorta. The remaining 6 patients proved to have ruptured mycotic aneurysm (MA). Clinical presentation was different in the two groups. Whereas all 6 patients with TAA and < 24 hr history of abdominal, chest, or back pain, patients with MA had these symptoms for 2-5 weeks (mean 3.4 weeks). History of sepsis was present in 4/6 MA and in 0/6 TAA patients. No difference in risk factors for atherosclerosis were seen between these two groups. Clinical outcomes were also different. Operation consisted of in situ vascular grafting in all patients. Operative mortality for TAA was 33% (2/6), whereas all patients with MA survived repair with no operative mortality. Two patients had cardiac arrest prior to surgery. One of these had a TAA and died 5 days after surgery, whereas the other survived repair of an MA. Follow-up ranges from 1-84 months (mean 48 months). Four survivors in the TAA group are alive at 6, 8, 14, and 84 months, with the latter having a pseudoaneurysm of the visceral patch-graft anastomosis. All 6 patients with MA are alive at 1-73 months (mean 39 months) without evidence of graft sepsis or recurrent aneurysm. We conclude that rupture of the visceral portion of the aorta is often associated with a mycotic process, with important differences noted in clinical presentation when compared to atherosclerotic TAA. Surgical intervention is effective in both MA and TAA. Operative mortality, however, is significantly higher in patients with ruptured TAA. In situ prosthetic replacement for ruptured MA is associated with low mortality and excellent long-term results.

Effect of tumor size on the prognosis of carcinoma of the uterine cervix treated with irradiation alone.

The authors conducted a retrospective analysis of 1178 patients with histologically proven invasive carcinoma of the uterine cervix treated with irradiation alone. The minimum follow-up time was 3 years. The 10-year actuarial pelvic failure rate in Stage IB was 6% for tumors less than 3 cm, 15% for tumors 3 to 5 cm, and 30% for tumors more than 5 cm (P = 0.0018). The 10-year actuarial pelvic failure rate in Stage IIA was 10% for tumors less than 3 cm, 28% for tumors 3 to 5 cm, and 20% for tumors more than 5 cm (P = 0.09). Stage IIB unilateral nonbulky tumors (less than 5 cm) had a 20% pelvic failure rate compared with 28% for bilateral lesions and 35% for unilateral bulky tumors (more than 5 cm) (P = 0.35). In Stage IIB, pelvic failures were greater when disease extended into the lateral parametrium (30%) compared with medial parametrial involvement only (17%) (P = 0.01). In Stage III unilateral nonbulky tumors, the pelvic failure rate was 28% compared with 45% to 50% for unilateral bulky lesions (P = 0.002). Bilateral parametrial disease in Stage IIB did not increase the pelvic failure rate (21% in both subgroups) (P = 0.83), whereas in Stage III, bilateral parametrial involvement was associated with a 48% pelvic failure rate versus 28% for unilateral extension (P less than or equal to 0.01). Five-year disease-free survival (DFS) rates for IB tumors less than or equal to 3 cm was 90% versus 67% for tumors more than 3 cm (P = 0.01). In Stage IIA tumors less than or equal to 3 cm, 5-year DFS was 70% versus 45% for tumors more than 3 cm. Patients with Stage IIB nonbulky tumors (less than or equal to 5 cm in diameter) had better 10-year DFS (65% to 70%) compared with those with bilateral bulky tumors (45% to 55%) (P = 0.10). Stage III patients with unilateral nonbulky tumors had a 55% 10-year DFS compared with 35% to 40% for bulky tumors or bilateral parametrial involvement (P = 0.002). The authors concluded that clinical stage and size of tumor are critical factors in the prognosis, therapy selection, and evaluation of results in carcinoma of the uterine cervix.