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Clinicopathological Conference

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Presentation on theme: "Clinicopathological Conference"— 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 1st 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
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 - poorly defined borders - Karnofsky
- Excoriating pain, necrotic - pale conjunctiva, lips - anorexia - pale dry skin - post. Lateral thigh mass - 10x10 cm - firm - non movable - pruritic on manipulation

11 Diagnostic Work-up CBC 6/20/10 6/22/10 Normal Values Hemoglobin 42
(Decreased) 115 (Normal) Hematocrit 16% 37 35.4 – 44.4 RBC 2.3 x 1012/L(Decreased) 4.8 4- 5.2 WBC 10.5 x 1012/L(Increased) 8 5- 10

12 Normochromic, normocytic
Diagnostic Work-up Differential Count 6/20/10 6/22/10 Normal Values Neutrophils 69% (N) 73(↑) 40-70 Lymphocytes 15% (↓) 25(N) 20-50 Monocytes 3% (N) __ 4 - 8 Eosinophils 13% (↑) 2(N) 0-6 Platelets 731(↑) 508(↑) RBC morphology Hypochromic, Sli. Anisocytosis, Sli. Poikilocytosis Normochromic, normocytic

13 Diagnostic Work-up PT 11.6 sec Control INR % Activity 12 sec 0.97
105.3% PTT 25.6 sec (↓) 30 sec

14 Diagnostic Work-up Creatinine N Na 136 - 146 K 3.5 - 5 Cl 102- 109
CK-MB 0- 5.5 Troponin I (+) Cholesterol < 5.17 FBS

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: 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

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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