Clinicopathological Conference

Aclan, Beltran AlexisAgbanlog, Nadinne

Agoncillo, Karen EloquiAlianza, Michael

Ame, RenalinAncheta, Melanie JasmineAng Ping, Krista Claudine

Ang, AbigailAng, Jorge

Ang, VincentArguelles, Carmen

University of the East Ramon Magsaysay Memorial Medical Center, Inc.Department of Surgery

Identifying Data• 52 y/o Female, Filipino, Married, from

Cainta, Rizal• Admitted for the 1st time: June 20, 2010

Chief Complaint• Right posterolateral thigh mass of 1 year

duration• Weakness of 1 week duration

HPI• 1 year PTA – initial symptoms• Soft, nontender, non erythematous, raised,

movable, 1.5 cm posterior thigh, progressive growth

• Pertinent positives: • Pertinent negatives: no bloody discharge

HPI• 2 months PTA- • 3 cm , inc in size, bloody discharge on

manipulation• Pertinent negatives: no fever, wt loss,

anorexia, nausea, vomiting, pain, limitation on movement

HPI• 1 week PTA• Generalized weakness, anorexia, inc in size

with excessive bloody discharge (daily)• Incision & Drainage done

TEMPORAL PROFILE

Pertinent Negatives• (-) Hypertension, DM• (-) Past hospitalization, surgery• (-) Smoking, alcohol intake, drug abuse• (-) Family History of HTN, DM, CA

Pertinent Negatives• (-) Weight loss• (-) Limitation in movement• (-) Pain• (-) Exposure to radiation

Pertinent Positives• (+) Anorexia• (+) Bleeding, ulcerating lesion

Notes upon Admission• - ECOG• - Karnofsky• - pale conjunctiva, lips• - pale dry skin• - post. Lateral thigh mass• - 10x10 cm• - firm• - non movable• - pruritic on manipulation

• - poorly defined borders• - Excoriating pain, necrotic• - anorexia

Diagnostic Work-upCBC 6/20/10 6/22/10 Normal Values

Hemoglobin 42 (Decreased)

115 (Normal)

120-158

Hematocrit 16% (Decreased)

37(Normal)

35.4 – 44.4

RBC 2.3 x 1012/L(Decreased)

4.8(Normal)

4- 5.2

WBC 10.5 x 1012/L(Increased)

8(Normal)

5- 10

Diagnostic Work-upDifferential

Count6/20/10 6/22/10 Normal Values

Neutrophils 69% (N) 73(↑) 40-70Lymphocytes 15% (↓) 25(N) 20-50Monocytes 3% (N) __ 4 - 8Eosinophils 13% (↑) 2(N) 0-6

Platelets 731(↑) 508(↑) 165-415RBC morphology Hypochromic, Sli.

Anisocytosis, Sli.Poikilocytosis

Normochromic, normocytic

Diagnostic Work-up

PT 11.6 secControlINR% Activity

12 sec0.97105.3%

PTT 25.6 sec (↓)Control 30 sec

Diagnostic Work-up

Creatinine NNa N 136 - 146K N 3.5 - 5Cl N 102- 109CK-MB ↑ 0- 5.5Troponin I (+)Cholesterol N < 5.17FBS N

Diagnostic Work-up• CXR and EKG are normal• Wound specimen revealed heavy growth of

P. mirabilis mixed with P. aeruginosa

Diagnostic Work-up• CT Scan (6/22/10):• An irregular mass-like density (2.0 x 4.3 x 4.6 cm) with

central air density was seen on subcutaneous region of the right posterolateral thigh surrounded with fat stranding. A nodular, soft density (0.9 x 1.1 x 0.9 cm), most likely an enlarged lymph node, identified in the right inguinal region. No abnormal findings in osseous and soft tissue structures of the left thigh.

Problem #1Right posterolateral thigh mass

• Origin- subcutaneous region (CT scan)• Lesion- lobulated; same radio-density as muscle;

continuous with the skin• Presence of fat stranding:

- damage to the surrounding fat tissue- deeper infiltration - non-movable nodule

Problem #1Right posterolateral thigh mass

Problem #2Anemia & Unstable Angina

Problem #2Anemia & UNSTABLE ANGINA

• Growing mass with bloody discharge Anemia• Evidenced by: decreased hemoglobin and hematocrit levels

• ↓Systemic Oxygen Transportation• ↓ Oxygen reaching Cardiac Muscles• Heart compensates via vasoconstriction and ↑ HR• Sustained anemia, inadequate oxygenation Cardiac

muscles become fatigued Bradycardia• Imbalance in myocardial oxygen demand and supply

Unstable angina and NSTEMI

Problem #3Infection

Problem #3Infection

• 1 week PTA: incision and drainage• Predisposed to nosocomial infection• Local infection: (-) fever, unremarkable PE• ↑WBC with neutrophil predominance

-Indicating subclinical infectious process present

• (+) P. aeruginosa and P. mirabilis - most common bacteria in nosocomial infections

Problem #3Infection

• Treatment : – Unasyn• Ampicillin + Sulfabactam• Indicated for P.mirabilis, S. aures, E.coli

– Metronidazole• anaerobic bacteria eg. P. aeruginosa

Differential Diagnoses• Dermatofibrosarcoma Protuberans• Liposarcoma• Malignant Fibrous Histiocytoma

Dermatofibrosarcoma Protuberans

• HISTORY AND PE– Primary fibrosarcoma of the skin– Incidence: 5% (relatively uncommon)– Age of incidence: 20-50 y/o• Rare in very young or very old

– Slight male predominance– Locally aggressive– High recurrence rate

Dermatofibrosarcoma Protuberans

• HISTORY AND PE– Presentation: Aggregated protuberant tumors

within a firm indurated plaque that may ulcerate– Mobile on palpation– Bloody in latter stages– Varying color from fleshy to reddish brown

Dermatofibrosarcoma Protuberans

• RADIOLOGIC FINDINGS– CT: Attached to the skin; used to visualize bone

invasion

Dermatofibrosarcoma Protuberans

• DIAGNOSTIC TESTS– Biopsy• Expected findings: Cellular neoplasm, composed of

fibroblasts arranged radially, in a storiform pattern; Mitoses may be present; Epidermis is thinned

Liposarcoma• HISTORY AND PE– Old age; Mean age of incidence: 40-60 y/o• Peak incidence during 50’s

– 2nd most common soft tissue sarcoma– Incidence: 14%– Male predilection– Mass is painful in 5% of patients

Liposarcoma• HISTORY AND PE– Presentation: slowly enlarging, painless, non-

ulcerating mass– May be retroperitoneal– 40% occuring in lower extremities• Popliteal, thigh, or gluteal areas

– Most patients are asymptomatic until tumor is large

Liposarcoma• RADIOLOGIC FINDINGS– X-ray: radio opaque– CT: indistinguishable from other soft tissue

sarcomas such as MFH, dermotofibrosarcoma protuberans, etc.

– MRI: may appear cystic; not preferred

Liposarcoma• DIAGNOSTIC TESTS– Depends on biopsy• Expected findings: lipoblasts are almost always

present indicate fatty differentiation; they mimic fetal fat cells and contain round, clear cytoplasmic vacuoles that scallop the nucleus

Liposarcoma• RADIOLOGIC FINDINGS– X-ray: radio opaque– CT: indistinguishable from other soft tissue

sarcomas such as MFH, dermotofibrosarcoma protuberans, etc.

– MRI: not preferred

Malignant Fibrous Histiocytoma

• HISTORY AND PE– Old age; mean age of occurrence: 50-70 y/o– Most common soft tissue sarcoma– Incidence: 24%– Presentation: Enlarging, painless mass in the thigh– Typically 5-10 cm in diameter– Occurs in deep fascia or skeletal muscle– 75% occurring in lower extremities

Malignant Fibrous Histiocytoma

• RADIOLOGIC FINDINGS– CT: nonspecific; lobulated; soft tissue; same

radiodensity as muscle; • Permeative and lytic, often extending into adjacent soft

tissue• if with bone involvement, parallel with that of the long bone• if subcutaneous involvement – continuous with the skin;

ill defined borders • fat attenuation is not found in the tumor

Malignant Fibrous Histiocytoma

• RADIOLOGIC FINDINGS– X-ray: soft tissue mass density

• 10% will show diffuse calcifications– MRI – appears with same density as muscle

Malignant Fibrous Histiocytoma

• DIAGNOSTIC TESTS– Needs core biopsy• Expected findings: background of spindled fibroblasts

arranged in a storiform pattern admixed wit large, ovoid, bizarre multinucleated tumor giant cells

Clinical Impression• Soft tissue sarcoma• To Consider:– Malignant Fibrous Histiocytoma– Liposarcoma