A histologically defined subset of high-grade dysplasia in Barrett mucosa is predictive of associated carcinoma.

To ascertain the prevalence of carcinoma in esophagi resected for high-grade dysplasia (HGD) using current criteria and to evaluate histologic features that may predict concurrent carcinoma, we studied specimens from 127 esophagectomies performed for HGD, or HGD "suspicious" for carcinoma (HGD/S) in Barrett mucosa. Corresponding biopsy specimens in 69 cases were reviewed and reclassified. Based on original diagnoses, carcinoma was present in 15 (17%) of 89 HGD and 28 (74%) of 38 HGD/S cases. By reclassification, only 1 (5%) of 21 cases with HGD had carcinoma in the resection specimen. Of 25 cases reclassified as HGD/S, 18 (72%) had carcinoma in the resection specimen, as did 17 (74%) of 23 reclassified as adenocarcinoma. With 1 additional select histologic feature, the risk of carcinoma was 39%; with 2 or more features, the risk increased to 83% to 88%. Based on current criteria, no more than 5% of esophagectomies performed for a biopsy diagnosis of Barrett HGD harbor carcinoma. When HGD/S is diagnosed based on certain additional features, carcinoma is found in nearly 40% of cases with 1 feature and more than 80% with 2 or more features. Our findings highlight the evolution of diagnostic criteria for Barrett dysplasia.

Multiple brain infarcts and Balint syndrome in aortic arch angiosarcoma.

A 50-year-old woman presented with subacute cognitive decline, impaired eye movements, and simultanagnosia, components of the Balint syndrome. She had relatively low blood pressure in the left arm and left finger clubbing. Brain imaging identified multiple acute infarcts. Transesophageal echocardiography showed no cardiac abnormalities but demonstrated a thickened aortic wall and an intraluminal aortic arch mass. The surgical specimen revealed angiosarcoma. Of the few reported angiosarcomas involving the aorta, most have been located in the abdominal segment. This is only the second reported case of aortic arch sarcoma presenting with stroke.

Valve sparing aortic root replacement for dilatation of the pulmonary autograft and aortic regurgitation after the Ross procedure.

BACKGROUND: Aortic insufficiency secondary to progressive dilatation of the pulmonary autograft is being recognized with increasing frequency after the Ross procedure. We reviewed our experience with valve-sparing aortic root replacement concomitant with aortic annuloplasty to assess the effectiveness of this approach. METHODS: Four patients, aged 8 to 27 years, presented with moderate to severe aortic insufficiency associated with progressive root dilatation from 1 to 8 years after a Ross procedure. All patients had 0 to 1+ aortic insufficiency early after the Ross procedure, with a mean maximal sinus diameter of 37 mm (range 30 to 45 mm). At reoperation the maximum diameter of the root ranged from 45 to 55 mm (mean 50 +/- 4 mm). A valve-sparing aortic root replacement with annular reduction was performed. The annulus was decreased from a mean of 27 mm to 23 mm. For the root replacement, 1 patient underwent a standard root remodeling procedure; in the others, a separate piece of scalloped Dacron (C.R. Bard, Haverhill, PA) graft material was used for each sinus to facilitate optimal exposure. RESULTS: All 4 patients are in New York Heart Association functional class I at a mean follow-up of 6 months. The most recent echocardiography demonstrated 0 to 1+ aortic insufficiency with good left ventricular function. Histology of the excised pulmonary autograft walls demonstrated severe elastin fragmentation. CONCLUSIONS: Aortic root remodeling with annular reduction is an effective treatment for aortic root dilatation and aortic insufficiency after the Ross operation. This procedure allows correction of aortic insufficiency and avoids the need for a prosthetic valve and anticoagulation.