BAGIAN PATOLOGI ANATOMI FAKULTAS KEDOKTERAN USU – MEDAN 2007

NORMAL ANATOMY PalpebraeConjunctivaCorneaLens Uvea tract Retina Vitreous humor NerveGlandMuscle Blood vessels

NORMAL ANATOMY A - Vitreous humor B - Lens C - Cornea D - Pupil E - Iris F - Sclera G - Optic Nerve H - Retina

CHOROID CHOROID = MIDDLE LAYER EYE CHOROID = MIDDLE LAYER EYE CONTAINS : CONTAINS : BLOOD VESSELS &BLOOD VESSELS & CONNECTIVE TISSUECONNECTIVE TISSUE SUPPLIES NUTRIENTS TO INNER PORTION OF EYESUPPLIES NUTRIENTS TO INNER PORTION OF EYE

CILIARY BODY CILIARY BODY = ring of tissue  encircles the lens. CILIARY BODY = ring of tissue  encircles the lens. Contains : Contains : smooth muscle fibers (ciliary muscles)smooth muscle fibers (ciliary muscles) control the shape of the lens.control the shape of the lens. Posterior surface lens (CILIARY PROCESSES) Posterior surface lens (CILIARY PROCESSES) Contain : capillaries Contain : capillaries Secrete fluid (vitreous humor)  into the anterior segment of the eyeball.Secrete fluid (vitreous humor)  into the anterior segment of the eyeball.

LACRIMAL SYSTEM LARGELY : SEROUS TYPE MINOR MUCINOUS

DISORDER OF EYE MICRO ORGANISMS * MICRO ORGANISMS * ANTIGEN * ANTIGEN * TOXIC CHEMICAL * TOXIC CHEMICAL * SOLAR RADIATION * SOLAR RADIATION * SYSTEMIC DISEASE * SYSTEMIC DISEASE * *  BLINDNESS

CONGENITAL ANOMALI RARELY : RARELY : - ANOPTHTHALMOS - EYE’S (-) - EYE’S (-) - MICROPHTHALMOS - MEDIAN EYE - MEDIAN EYE - HYPOPLASIA EYE’S - COLOBOMA - CONGENITAL CATARACTS - COLOR BLIND - COLOR BLIND

COLOBOMA (Defect in iris) Appear : black notch  pupil : irregular (shape) Appear : black notch  pupil : irregular (shape) May be associated with : May be associated with : Hereditary conditionsHereditary conditions Trauma to the eye, orTrauma to the eye, or Eye surgeryEye surgery

CONGENITAL CATARACTS The number of people born with cataracts is low. The number of people born with cataracts is low. Possible causes : Possible causes : GalactosemiaGalactosemiaGalactosemia Chondrodysplasia syndromeChondrodysplasia syndrome Congenital rubella syndromeCongenital rubella syndromerubella Down syndrome (trisomy 21)Down syndrome (trisomy 21)Down syndromeDown syndrome Pierre-Robin syndromePierre-Robin syndrome Familial congenital cataractsFamilial congenital cataracts Hallerman-Streiff syndromeHallerman-Streiff syndrome Lowe syndromeLowe syndrome Trisomy 13Trisomy 13Trisomy 13Trisomy 13 Conradi syndromeConradi syndrome Ectodermal dysplasia syndromeEctodermal dysplasia syndromeEctodermal dysplasiaEctodermal dysplasia Marinesco-Sjogren syndromeMarinesco-Sjogren syndrome

CONGENITAL CATARACTS

PIGMENTATION EXOGENENDOGEN ALBUMIN  MELANOSIS MELANIN HEMOSIDERINE I.O.H IRONCOPPERSILVER

PIGMENTATION KAYSER - FLEISCHER RING  WILSON’S DISEASE (HEPATOLENTI KAYSER - FLEISCHER RING  WILSON’S DISEASE (HEPATOLENTI CULAR DEGENERATION) CULAR DEGENERATION) DEPIGMENTATION VITILIGO

PHYSICAL & CHEMICAL INJURIES TRAUMA : ECCHYMOSIS TRAUMA : ECCHYMOSIS SUP.FICIAL : SUP.FICIAL : CONTACT LENSCONTACT LENS FOREIGN BODIESFOREIGN BODIES ULTRA VIOLETULTRA VIOLET CAUSTIC CHEMICAL CAUSTIC CHEMICAL BLUNT TRAUMA  FRACTURE OF BONE BLUNT TRAUMA  FRACTURE OF BONE

SKIN APPENDAGES OF EYELIDS 1. SEBACEOUS GLANDS (ZEIS & MEIBOMIAN) 2. APOCRINE GLANDS (MOLL) 3. ECCRINE SWEAT GLANDS

MOLUSCUM CONTANGIOSUM VIRAL INFECT  WART LIKE VIRAL INFECT  WART LIKE CENTRAL UMBILICAL  KERATIN CENTRAL UMBILICAL  KERATIN CYSTIC LESSION SUDORIFERA SUDORIFERA SEBACEA SEBACEA MEIBOMIAN MEIBOMIAN DERMOID DERMOID

HORDEOLUM ( = STYE ) ZEIS GLAND (SEBACEOUS GLANDS) ZEIS GLAND (SEBACEOUS GLANDS)  EXTERNAL HORDEOLUM  EXTERNAL HORDEOLUM MEIBOMIAN GLANDS  INTERNAL HORDEOLUM MEIBOMIAN GLANDS  INTERNAL HORDEOLUM FOLICLE FOLICLE  INFECTION STAPHYLLOCOCUS  CELLULITIS  INFECTION STAPHYLLOCOCUS  CELLULITIS

HORDEOLUM EXTERNAL INTERNAL

CHALAZION (MEIBOMIAN GLAND LIPOGRANULOMA) A PAINLESS GRANULOMA OF THE MEIBOMIAN GLANDS A PAINLESS GRANULOMA OF THE MEIBOMIAN GLANDS MEIBOMIAN GLAND  OCCLUTION MEIBOMIAN GLAND  OCCLUTION CHRONIC  GRANULATION CHRONIC  GRANULATION

MICROSCOPIC MULTIPLE FOCI OF GRANULOMATOUS INFLAMMATION

XANTHELASMA SHARPLY DEMARCATED YELLOWISH (COLLECTION CHOLESTEROL) - UNDERNEATH SKIN SHARPLY DEMARCATED YELLOWISH (COLLECTION CHOLESTEROL) - UNDERNEATH SKIN USUALLY : ON / AROUND EYELIDS USUALLY : ON / AROUND EYELIDS ASSOCIATIONS : ASSOCIATIONS : CHOLESTEROL ↑ (FAMILIAL HYPERCHOL)CHOLESTEROL ↑ (FAMILIAL HYPERCHOL) PRIMARY BILIARY CIRRHOSISPRIMARY BILIARY CIRRHOSIS MENOPAUSEMENOPAUSE DIABETESDIABETES

EXOPTHALMUS ( = PROPTOSIS ) EXOPTHALMUS ( = PROPTOSIS ) PROTUSION (EYEBALL) BILATERAL THYROID DISEASE EARLY ADULT LIFE (WOMEN), 4/1 + EDEMA (EYELID, CHEMOSIS)

EXOPTHALMUS ( = PROPTOSIS ) PATHOLOGY: PATHOLOGY: ORBITAL WATER >>ORBITAL WATER >> EXT.OCULAR MUSCLE >>EXT.OCULAR MUSCLE >> ( + LYMPHOCYTES & MN ) ( + LYMPHOCYTES & MN ) CLINIC : CLINIC : EXPOSURE CONJ’TIVA  BLIDING, ULCERATION, OPTIC NERVE COMPRESSIONEXPOSURE CONJ’TIVA  BLIDING, ULCERATION, OPTIC NERVE COMPRESSION

CONJUNCTIVA DISORDER HYPEREMIA HYPEREMIA HEMORRHAGE HEMORRHAGE INFLAMATION INFLAMATION THRACHOMA THRACHOMA CHLAMYDIAL INFECTION CHLAMYDIAL INFECTION OPHTHALMIA NEONATORUM OPHTHALMIA NEONATORUM DRY-EYE SYNDROME DRY-EYE SYNDROME PINGUECULA & PTERYGIUM PINGUECULA & PTERYGIUM

HYPEREMIA - CONJUCTIVA DILATASI BLOOD VESEL DILATASI BLOOD VESEL CONJUNCTIVITIS CONJUNCTIVITIS CORNEA DISEASE CORNEA DISEASE IRIDOCYCLITIS IRIDOCYCLITIS CORNEA DEFECT CORNEA DEFECT GLAUCOMA GLAUCOMA IRITIS IRITIS

HEMORRHAGE CONJUNCTIVA TRAUMA TRAUMA ANOXIA ANOXIA SEVERE COUCHING  SPONTANEUS SEVERE COUCHING  SPONTANEUS

SUBCONJUNCTIVAL HEMORRHAGE Causes : Causes : Minor eye traumaMinor eye trauma Spontaneously (venous press ↑)Spontaneously (venous press ↑) Streneuous ExercisingStreneuous Exercising CoughingCoughing Touching/widening eyesTouching/widening eyes SneezingSneezing Vomiting (bulimia nervosa)Vomiting (bulimia nervosa) Severe alcohol intoxication,  blood press ↑Severe alcohol intoxication,  blood press ↑ Severe hypertensionSevere hypertension

CONJUNCTIVITIS MICRO-ORG  CONJUNCTIVITIS MICRO-ORG  CONJUNCTIVITIS  KERATITIS  KERATITIS  CORNEAL ULCER  CORNEAL ULCER HEMATOGEN HEMATOGEN  IATROGENIC INFECTION  IATROGENIC INFECTION  SURGICAL : CATARACT CATARACT CORNEAL GRAFT CORNEAL GRAFT PROSTHETIC LENS PROSTHETIC LENS

CONJUNCTIVITIS EXUDATE/DISCHARGE : EXUDATE/DISCHARGE : - PURULENT  CLOSE - FIBRINOUS - SEROUS - HEMORRHAGIC

CONJUNCTIVITIS

TRACHOMA INF.CHRONIC (CLAMYDIA TRACHOMATIS) INF.CHRONIC (CLAMYDIA TRACHOMATIS) = SWIMMING POOL CONJUNCTIVITIS = SWIMMING POOL CONJUNCTIVITIS OCULAR, GENITAL, SYST’MIC OCULAR, GENITAL, SYST’MIC  BLIND CHILD  REMISION (SP) CHILD  REMISION (SP) ADULT  PROGRESSIVE ADULT  PROGRESSIVE BILATERAL, SUP > INF BILATERAL, SUP > INF

NEW BORN : PURULENT CONJUNC. (BLENORRHOE) NEW BORN : PURULENT CONJUNC. (BLENORRHOE) ADULT : ADULT : CHRONIC FOLLICLE CONJ.CHRONIC FOLLICLE CONJ. LYMPHOCYTE (+)LYMPHOCYTE (+) HYPERPLASIA  GERM. CENTRE NECROTICHYPERPLASIA  GERM. CENTRE NECROTIC TRACHOMATOUS PANNUSTRACHOMATOUS PANNUS (EPIT – BOWMANN ZONE) (EPIT – BOWMANN ZONE) FIBROSIS (CONJ. & EYELIDS)FIBROSIS (CONJ. & EYELIDS)  DISTORS EYELIDS  DISTORS EYELIDS PATHOLOGY : PATHOLOGY : LOWER TARSAL CONJUNTIVALOWER TARSAL CONJUNTIVA SCAR & NECROTIC (-)SCAR & NECROTIC (-) KERATITIS (-)KERATITIS (-)

TRACHOMA (CHLAMYDIAL CONJUNCTIVITIS)

OPHTHALMIA NEONATORUM ACUTE  SEVERE CONJUNCTIVITIS ACUTE  SEVERE CONJUNCTIVITIS COPIUS PURULENT DISCHARGE COPIUS PURULENT DISCHARGE GO  GO-NEONATORUM GO  GO-NEONATORUM ULC.CORNEA, PERFORATION  ULC.CORNEA, PERFORATION  SCAR & PANOPH’ITIS  BLIND PREVENT  SILVER NITRAT (PNC)

OPTHALMIA NEONATORIUM Microbial Agent : Neisseria gonorrhoeae Mode of Transmission: From mother to newborn Classic Feature: purulent destructive eye disease

DRY EYE SYNDROME Common condition Common condition Tear production << (ocular & systemic disease) Tear production << (ocular & systemic disease) Older ♀, menopause Older ♀, menopause Assc.: “SJOGREN DISEASE” (keratoconjunctivitis sicca) Assc.: “SJOGREN DISEASE” (keratoconjunctivitis sicca)  middle aged ♀  middle aged ♀ (atrophy of lacrimal glands) (atrophy of lacrimal glands)

Common causes : Common causes : AgingAging Dry environment or workplace (wind, air conditioning)Dry environment or workplace (wind, air conditioning) Sun exposureSun exposure Smoking / smoke exposureSmoking / smoke exposure Cold / allergy medicinesCold / allergy medicines Sjogren's syndromeSjogren's syndrome  includes dry eyes, mouth & mucus membranes  includes dry eyes, mouth & mucus membranes  often RA / other joint disorder  often RA / other joint disorder The result of : The result of : Sensitivity of the cornea ↓Sensitivity of the cornea ↓ Evaporation of tears ↑Evaporation of tears ↑ Disorder in the glandsDisorder in the glands

PINGUECULA LUMP  YELLOWISH LUMP  YELLOWISH NASAL TO THE CORNEOSCLERAL NASAL TO THE CORNEOSCLERAL SUN DAMAGED  INJURY SUN DAMAGED  INJURY DOES NOT GROW ONTO CORNEA DEPOSIT OF PROTEIN & FAT PARTICULARLY OLDER PEOPLE

PINGUECULA

PTERYGIUM FOLD OF VASCULARIZED – RECURS AFTER EXISION (PINGUECULA) FOLD OF VASCULARIZED – RECURS AFTER EXISION (PINGUECULA) GROWS : TRIANGULAR SHAPE OVER THE CORNEA (THE TRANSPARENT PART OR FRONT WINDOW OF THE EYEBALL). MAY GROW LARGE ENOUGH TO INTERFERE WITH VISION COMMONLY : INNER CORNER OF THE EYE (APEX – PUPIL)

PTERYGIUM

CLOUDY CORNEA CORNEA : TRANSPARENT STRUCTURE CORNEA : TRANSPARENT STRUCTURE LESS TRANSPARENT & CLOUDY : LESS TRANSPARENT & CLOUDY : METABOLIC DISEASESMETABOLIC DISEASES TRAUMATRAUMA INFECTIOUS DISEASESINFECTIOUS DISEASES NUTRITIONAL DEFICIENCIES &NUTRITIONAL DEFICIENCIES & ENVIRONMENTALENVIRONMENTAL IT CAN LEAD TO VARIOUS DEGREES OF VISION LOSS. IT CAN LEAD TO VARIOUS DEGREES OF VISION LOSS.

CORNEA HERPES SIMPLEX HERPES SIMPLEX ONCHOCERCIASIS ONCHOCERCIASIS ARCUS SENILIS ARCUS SENILIS BAND KERATOPATHY BAND KERATOPATHY CORNEAL DYSTROPHIES CORNEAL DYSTROPHIES

HERPES KERATITIS

HYPEREMIA (TRAUMA)

EYE LENS ANATOMY THE LENS OF THE EYE IS NORMALLY CLEAR.

LENS CATARACT CATARACT PRESBYOPIA PRESBYOPIA PHACO ANAPHYLACTIC ENDOPHTHALMITIS PHACO ANAPHYLACTIC ENDOPHTHALMITIS

CATARACT THE LENS OF THE EYE IS NORMALLY CLEAR. IF THE LENS BECOMES CLOUDY OR IS OPACIFIED IT IS CALLED A CATARACT

NORMAL, NEAR & FARSIGHTEDNESS

UVEA SYMPATHETIC OPHTHALMITIS SYMPATHETIC OPHTHALMITIS SARCOIDOSIS SARCOIDOSIS

RETINA HEMORRHAGE HEMORRHAGE OCCLUSIVE VASC.DISEASE OCCLUSIVE VASC.DISEASE - CENTRAL R. ART.OCCLUSION - CENTRAL R. VEIN OCCLUSION HYPERTENSIVE RETINOPATHY HYPERTENSIVE RETINOPATHY DIABETIC RETINOPATHY DIABETIC RETINOPATHY RETINAL DETACHMENT RETINAL DETACHMENT

RETINA RETINITIS PIGMENTOSA RETINITIS PIGMENTOSA MACULAR DEGENERATION MACULAR DEGENERATION CHERRY-RED SPOT AT THE MACULA CHERRY-RED SPOT AT THE MACULA ANGIOID STREAKS ANGIOID STREAKS RETINOPATHY OF PREMATURITY RETINOPATHY OF PREMATURITY

OPTIC NERVE OPTIC NERVE HEAD EDEMA OPTIC NERVE HEAD EDEMA OPTIC ATROPHY OPTIC ATROPHY

EFFECTS OF INCREASE INTRAOCULAR PRESSURE GLAUCOMA GLAUCOMA CORNEA/SCLERA BULGES CORNEA/SCLERA BULGES OPTIC ATROPHY OPTIC ATROPHY

GLAUCOMA Increased pressure causes compression of : Increased pressure causes compression of : Retina and Retina and Optic nerve  Nerve damage. Optic nerve  Nerve damage. Glaucoma can cause : Glaucoma can cause : Partial vision loss,Partial vision loss, Blindness as a possible eventual outcome.Blindness as a possible eventual outcome. GLAUCOMA IS A CONDITION OF INCREASED FLUID PRESSURE INSIDE THE EYE.

GLAUCOMA CONGENITAL GLAUCOMA CONGENITAL GLAUCOMA INFANTILE GLAUCOMA, BUPHTHALMOS INFANTILE GLAUCOMA, BUPHTHALMOS PRIMARY OPEN-ANGLE GLAUCOMA PRIMARY OPEN-ANGLE GLAUCOMA PRIMARY CLOSED-ANGLE GLAUCOMA PRIMARY CLOSED-ANGLE GLAUCOMA SECONDARY GLAUCOMA SECONDARY GLAUCOMA LOW-TENSION GLAUCOMA LOW-TENSION GLAUCOMA

GLAUCOMA

NEOPLASMA XANTHELASMA XANTHELASMA NEUROFIBROMA NEUROFIBROMA PAPILLOMA PAPILLOMA LIPOMA LIPOMA HEMANGIOMA HEMANGIOMA LIMPHANGIOMA LIMPHANGIOMA NEVUS NEVUS BENIGN MALIGNANT BOWEN DISEASE BOWEN DISEASE SQ.CELL.CA SQ.CELL.CA BASAL CELL CA BASAL CELL CA MALIG. MELANOMA MALIG. MELANOMA AD. CARCINOMA AD. CARCINOMA SARCOMA SARCOMA LYMPHOMA LYMPHOMA

XANTHELASMA HYPERCHOLESTEROLEMIA  DM HYPERCHOLESTEROLEMIA  DM REPRODUCTION WOMAN REPRODUCTION WOMAN LOC :  CANTUS INTERNAL  PAL LOC :  CANTUS INTERNAL  PAL PEBRAE XANTHELASMA PEBRAE XANTHELASMA FOAMY CELLS  MICRO INTRA CYTO FOAMY CELLS  MICRO INTRA CYTO PLASMA VACUOLE.

NEUROFIBROMA SINGLE OR MULTIPLE  NEUROFIBRO SINGLE OR MULTIPLE  NEUROFIBRO MATOSIS (VON RECKING HAUSEN.D) LOC.  PALPEBRAE LOC.  PALPEBRAE OTHER SITE (+) OTHER SITE (+)

PAPILLOMA STOLK (+) STOLK (+) SQ.EPITH.CELL  PROLIFERATION SQ.EPITH.CELL  PROLIFERATION

LYMPHANGIOMA LESS COMMON LESS COMMON LYMPH VESSEL LYMPH VESSEL PROLIFERATION PROLIFERATION LUMP LUMP

NEVUS EPITHELIAL CELLS EPITHELIAL CELLS NEVI CELLS NEVI CELLS TYPE: - INTRA DERMAL TYPE: - INTRA DERMAL - JUNCTIONAL - JUNCTIONAL - COMPOUND - COMPOUND

BOWEN DIASEASE INTRA EPITHELIAL NEOPLASM INTRA EPITHELIAL NEOPLASM CA INSITU CA INSITU ATIPICAL CELLS ATIPICAL CELLS PLEOMORFISM PLEOMORFISM UNCOMMON UNCOMMON

SQUAMOUS CELL CA EPITHELIAL CELLS EPITHELIAL CELLS FORM : - NON KERATINIZING FORM : - NON KERATINIZING - KERATINIZING PLEOMORFISM CELLS PLEOMORFISM CELLS HYPERCHROMATIC NUCLEUS HYPERCHROMATIC NUCLEUS KERATIN (+/-) KERATIN (+/-)

BASAL CELL CA BASAL CELLS BASAL CELLS MONOTON MONOTON NUCLEUS  BASOPHYLIC NUCLEUS  BASOPHYLIC STRAND STRAND PALISADE (+) PALISADE (+)

MALIGNANT MELANOMA UVEAL MELANOMA UVEAL MELANOMA MELANOCYTE OR NEVI CELLS MELANOCYTE OR NEVI CELLS CHOROID (COMMON SITE) CHOROID (COMMON SITE) TYPE : MELANOCYTE/AMELANOCYTE TYPE : MELANOCYTE/AMELANOCYTE MACR: - CIRCUMSCRIBED MACR: - CIRCUMSCRIBED - INV.BRUCH’S MEMBRANE - INV.BRUCH’S MEMBRANE MICR: - SPINDLE CELLS MICR: - SPINDLE CELLS - POLYGONAL CELLS - POLYGONAL CELLS - EPITHELOID CELLS - EPITHELOID CELLS

ADENO CARCINOMA GLAND PATERN GLAND PATERN UNCOMMON UNCOMMON DIFFERENTIATED : DIFFERENTIATED : - WELL - MODERATE - POORLY

SARCOMA CONNECTIVE TISSUE CONNECTIVE TISSUE RHABDO/LEIOMYO SA RHABDO/LEIOMYO SA FIBRO SA FIBRO SA LIPO SA LIPO SA

LYMPHOMA LYMPHOID TISSUE LYMPHOID TISSUE ROUND CELLS ROUND CELLS MONOTONE MONOTONE TYPE: - IMMATURE CELLS TYPE: - IMMATURE CELLS - MATURE CELLS - MATURE CELLS

RETINOBLASTOMA IMMATURE CELLS IMMATURE CELLS CHILD ( >> ) CHILD ( >> ) FIRST 2 YRS OF LIFE FIRST 2 YRS OF LIFE BIRTH ( +/- ) BIRTH ( +/- )

RETINOBLASTOMA PATH: - INTERNAL  VITR.BODY PATH: - INTERNAL  VITR.BODY - EXTERNAL - EXTERNAL CREAM COLORED CREAM COLORED CALCIFIED  YELLOW CALCIFIED  YELLOW MICR: - SMALL CELLS MICR: - SMALL CELLS - ROUND CELLS - ROUND CELLS - ROSET (+) - ROSET (+) - NECROSIS - NECROSIS - HEMORRHAGIC - HEMORRHAGIC

RETINOBLASTOMA EARLY DIAG  OPERATIVE EARLY DIAG  OPERATIVE SURVIVAL ( 90 % ) SURVIVAL ( 90 % ) UNTREATED  FATAL UNTREATED  FATAL INCIDENT 1/20000 (BIRTH) INCIDENT 1/20000 (BIRTH) FAMILIAL ( 5 – 10 % ) FAMILIAL ( 5 – 10 % ) CHROMOSOME 13 (-)  Q 14 BAND CHROMOSOME 13 (-)  Q 14 BAND

RETINOBLASTOMA CLINIC: CLINIC: WHITE PUPILS ( LEUCORIA) WHITE PUPILS ( LEUCORIA) POOR VISION POOR VISION HYPEMIA HYPEMIA STARBISMUS STARBISMUS RED RED PAINFUL EYE PAINFUL EYE

INTRAOCULAR PHOTOGRAPH OF AN ISOLATED "ENDOPHYTIC" RETINOBLASTOMA

GLIOMA NERVE OPTICUS UNCOMMON UNCOMMON CHILD AND ADULT CHILD AND ADULT NEUROFIBROMATOSIS  GLIOMA NEUROFIBROMATOSIS  GLIOMA VISION  << (PROGRESIVA) VISION  << (PROGRESIVA) PROPTOSIS PROPTOSIS PAPIL EDEMA PAPIL EDEMA MICR: - ASTROSITOMA LIKE CELLS MICR: - ASTROSITOMA LIKE CELLS - WELL DIFFERENTIATED - WELL DIFFERENTIATED SURGICAL AND RADIOTH/  OK SURGICAL AND RADIOTH/  OK 5 YSR  90 % 5 YSR  90 %

METASTATIC NEOPLASM MORE COMMON X PRIMER MORE COMMON X PRIMER PRIMER LESSION : PRIMER LESSION : - LEUKEMIA - BREAST CA - LUNG CA DIAG :  AFTER DEATH DIAG :  AFTER DEATH