1. Clinicopathological Conference Aclan, Beltran Alexis Agbanlog, Nadinne Agoncillo, Karen Eloqui Alianza, Michael Ame, Renalin Ancheta, Melanie Jasmine Ang Ping, Krista Claudine Ang, Abigail Ang, Jorge Ang, Vincent Arguelles, Carmen University of the East Ramon Magsaysay Memorial Medical Center, Inc. Department of Surgery

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. TEMPORAL PROFILE

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

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

10. Pertinent Positives (+) Anorexia (+) Bleeding, ulcerating lesion

11. 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

12. Diagnostic Work-up CBC6/20/106/22/10Normal Values Hemoglobin42 (Decreased) 115 (Normal) 120-158 Hematocrit16% (Decreased) 37 (Normal) 35.4 – 44.4 RBC2.3 x 10 12 /L(Decreased) 4.8 (Normal) 4- 5.2 WBC10.5 x 10 12 /L(Increased) 8 (Normal) 5- 10

13. 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(↑)165-415 RBC morphologyHypochromic, Sli. Anisocytosis, Sli. Poikilocytosis Normochromic, normocytic

14. Diagnostic Work-up PT11.6 sec Control INR % Activity 12 sec 0.97 105.3% PTT25.6 sec (↓) Control30 sec

15. Diagnostic Work-up CreatinineN NaN136 - 146 KN3.5 - 5 ClN102- 109 CK-MB↑ 0- 5.5 Troponin I(+) CholesterolN < 5.17 FBSN

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

17. 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.

18. Problem #1 Right posterolateral thigh mass

19. 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 #1 Right posterolateral thigh mass

20. Problem #2 Anemia & Unstable Angina

21. Problem #2 Anemia & 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

22. Problem #3 Infection

23. 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

24. Problem #3 Infection Treatment : – Unasyn Ampicillin + Sulfabactam Indicated for P.mirabilis, S. aures, E.coli – Metronidazole anaerobic bacteria eg. P. aeruginosa

25. Differential Diagnoses Dermatofibrosarcoma Protuberans Liposarcoma Malignant Fibrous Histiocytoma

26. 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

27. 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

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

29. 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

30. 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

31. 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

32. 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

33. 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

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

35. 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

36. 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

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

38. 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

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