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Clinicopathological Conference Department of Surgery Aclan.Agbanlog.Agoncillo.Alianza Ame.Ancheta.Ang Ping. Ang A. Ang,J. Ang,V. Arguelles.

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Presentation on theme: "Clinicopathological Conference Department of Surgery Aclan.Agbanlog.Agoncillo.Alianza Ame.Ancheta.Ang Ping. Ang A. Ang,J. Ang,V. Arguelles."— Presentation transcript:

1 Clinicopathological Conference Department of Surgery Aclan.Agbanlog.Agoncillo.Alianza Ame.Ancheta.Ang Ping. Ang A. Ang,J. Ang,V. Arguelles

2 Identifying Data 52 y/o Female, Filipino, Married, from Cainta, Rizal Admitted for the 1 st time: June 20, 2010

3 Chief Complaint Right posterolateral thigh mass of 1 year duration Weakness of 1 week duration

4 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

5 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

6 HPI 1 week PTA Generalized weakness, anorexia, inc in size with excessive bloody discharge (daily) Incision & Drainage done

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

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

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

10 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

11 Diagnostic Work-up CBC6/20/106/22/10Normal Values Hemoglobin42 (Decreased) 115 (Normal) Hematocrit16% (Decreased) 37 (Normal) 35.4 – 44.4 RBC2.3 x /L(Decre ased) 4.8 (Normal) WBC10.5 x /L(Incre ased) 8 (Normal) 5- 10

12 Diagnostic Work-up Differential Count 6/20/106/22/10Normal Values Neutrophils69% (N)73(↑)40-70 Lymphocytes15% (↓)25(N)20-50 Monocytes3% (N)__4 - 8 Eosinophils13% (↑)2(N)0-6 Platelets731(↑)508(↑) RBC morphology Hypochromic, Sli. Anisocytosis, Sli. Poikilocytosis Normochromi c, normocytic

13 Diagnostic Work-up PT11.6 sec Control INR % Activity 12 sec % PTT25.6 sec (↓) Control30 sec

14 Diagnostic Work-up CreatinineN NaN KN ClN CK-MB↑ Troponin I(+) CholesterolN < 5.17 FBSN

15 Diagnostic Work-up CXR and EKG are normal Wound specimen revealed heavy growth of P. mirabilis mixed with P. aeruginosa

16 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.

17 Problem #1 Right posterolateral thigh mass

18 Problem #2 Anemia & Unstable Angina

19 Problem #3 Infection

20 Differential Diagnoses Dermatofibrosarcoma Protuberans Liposarcoma Malignant Fibrous Histiocytoma

21 Dermatofibrosarcoma Protuberans HISTORY AND PE – Primary fibrosarcoma of the skin – Incidence: 5% (relatively uncommon) – Age of incidence: y/o Rare in very young or very old – Slight male predominance – Locally aggressive – High recurrence rate

22 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

23 Dermatofibrosarcoma Protuberans RADIOLOGIC FINDINGS – CT: Attached to the skin; used to visualize bone invasion

24 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

25 Liposarcoma HISTORY AND PE – Old age; Mean age of incidence: y/o Peak incidence during 50’s – 2nd most common soft tissue sarcoma – Incidence: 14% – Male predilection – Mass is painful in 5% of patients

26 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

27 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

28 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

29 Liposarcoma RADIOLOGIC FINDINGS – X-ray: radio opaque – CT: indistinguishable from other soft tissue sarcomas such as MFH, dermotofibrosarcoma protuberans, etc. – MRI: not preferred

30 Malignant Fibrous Histiocytoma HISTORY AND PE – Old age; mean age of occurrence: 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

31 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

32 Malignant Fibrous Histiocytoma RADIOLOGIC FINDINGS – X-ray: soft tissue mass density 10% will show diffuse calcifications – MRI – appears with same density as muscle

33 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

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


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