Clinicopathological Conference

Department of SurgeryAclan.Agbanlog.Agoncillo.Alianza

Ame.Ancheta.Ang Ping. Ang A. Ang,J. Ang,V. Arguelles

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

Pertinent Negatives

• (-) Hyptertension, 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-up

CBC 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(Decre

ased)

4.8(Normal)

4- 5.2

WBC 10.5 x 1012/L(Increa

sed)

8(Normal)

5- 10

Diagnostic Work-upDifferential

Count6/20/10 6/22/10 Normal Values

Neutrophils 69% (N) 73(↑) 40-70Lymphocytes 15% (↓) 25(N) 20-50

Monocytes 3% (N) __ 4 - 8Eosinophils 13% (↑) 2(N) 0-6

Platelets 731(↑) 508(↑) 165-415RBC

morphologyHypochromic,

Sli.Anisocytosis,

Sli.Poikilocytosis

Normochromic, normocytic

Diagnostic Work-up

PT 11.6 sec

ControlINR% Activity

12 sec0.97105.3%

PTT 25.6 sec (↓)

Control 30 sec

Diagnostic Work-up

Creatinine N

Na N 136 - 146

K N 3.5 - 5

Cl N 102- 109

CK-MB ↑ 0- 5.5

Troponin I (+)

Cholesterol N < 5.17

FBS 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

Problem #2Anemia & Unstable Angina

Problem #3Infection

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