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University of the East Ramon Magsaysay Memorial Medical Center , Inc. Department of Surgery. Clinicopathological Conference. Aclan , Beltran Alexis Agbanlog , Nadinne Agoncillo , Karen Eloqui Alianza , Michael Ame , Renalin Ancheta , Melanie Jasmine Ang Ping, Krista Claudine - PowerPoint PPT Presentation
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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
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