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SYB Case #1

SYB Case #1. Jordan Torok Class of 2010 December 4 th , 2008. History. CC: 35 year old male presents to the ED with left-sided weakness and headache.

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SYB Case #1

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  1. SYB Case #1 Jordan Torok Class of 2010 December 4th, 2008

  2. History • CC: 35 year old male presents to the ED with left-sided weakness and headache. • HPI: Episode lasted a period of 5 minutes and was associated with chest heaviness and apparent spasms in his chest, leg and arm. Has had several episodes of left-sided weakness, numbness and feeling of “heaviness” lasting several minutes over the past several years. Has had occipital headaches since 2004, becoming increasingly severe over the past week. Describes pain as having radiated temporally. Headaches are not relieved by NSAIDs. Also reports difficulty concentrating, increasing in severity over the past week.

  3. Differential Diagnosis?

  4. PMH • Significant for subarachnoid hemorrhage secondary to multiple aneurysms in 2004, left carotid terminus and basilar artery aneurysms treated with endovascular coils. Medically treated with aspirin and Plavix, although takes the Plavix intermittently. • Hypertension treated with lisinopril • 50 pack year history

  5. Physical • Vitals: Wt 82 T 36.7 HR 74 O2 100%on RA RR 18 BP 138/92 • General Exam: No apparent distress. Sitting in bed. Appropriate. Pleasant. • HEENT: Pupils equal, round, reactive to light, no scleral icterus. EOMi. No sinus tenderness. Nares patent. Moist mucus membranes. Oral pharynx without lesions. Chipped teeth and fillings. • Neck: Supple, no lymphadenopathy. No thyroidmegaly. No JVD. No bruit. • Chest: CTAB. No wheezes, rales, or rhonchi. • Cardiovascular: Regular, rate and rhythm. Normal S1, S2. No murmur, gallop, rub. Capillary refill is < 2 seconds. +2 pulses in 4 extremities. • Abdomen: Soft, nontender, nondistended, normal active bowel sounds. No hepatospenomegaly. • Extremities: No clubbing, cyanosis, or edema. • Muscle: 5/5 Right upper and lower extremities. 5/5 left hand. 4/5 left shoulder. 4/5 hip flexion. 5/5 ankle. • Neuro: Facies is symmetric. PERRL. EOMi. Tongue is midline. Sensation is decreased over left leg to light touch. Decreased concentration, unable to repeat a series of 6 number backwards. Did do serial 7s with a lot of trouble. Oriented.

  6. Imaging • Sagittal T1 weighted, post gad sagittal T1 weighted, axial T1 weighted, axial T1 weighted post gadolinium, axial stealth post-gad, T2 axial, axial FLAIR, axial gradient echo, axial diffusion/ADC, and coronal T1-weighted post gad were performed through the brain. Routine MRA of the head was performed.

  7. MRA findings/impression • Signal dropout at the tip of the basilar artery and left carotid terminus, consistent with prior coiling. There is residual basilar aneurysm, slightly increased in size, measuring 1.2 x 0.9 cm, compared with the prior MRA. There are no other aneurysms or areas of flow limiting stenosis • Slight interval increase in basilar artery aneurysm compared with the prior MRA dated

  8. Head MRI

  9. T1 T2

  10. Stealth FLAIR

  11. Head MRI findings • There is a rim enhancing large mass within the right parietal lobe that extends to the dura with adjacent dural tail. • There is extensive vasogenic edema within the right frontal and parietal lobes on the T2 and FLAIR images. • There is an additional ring enhancing mass noted within the left frontal white matter with mild adjacent edema. • There is extensive mass effect on the right lateral ventricle. There is right to left midline shift measuring 7 mm. • There is low signal intensity within the masses on the gradient echo image which may represent hemorrhage. There is a focal area of hemosiderin within the left parietal white matter without enhancement or adjacent edema. There is a small area of rim enhancement within the right thalamus.

  12. Head MRI Impression Brain metastatic disease with extensive vasogenic edema within the right frontal and parietal lobes with mass effect on the right lateral ventricle and right to left midline shift. Additional metastatic lesion is identified within the right thalamus compared with prior CTA head.

  13. Primary?

  14. CT Chest Abd w/ contrast • Large mass within the right lung apex, measuring approximately 4 cm x 4 cm. The mass demonstrates lobulated contours. • There is no mediastinal, hilar, or axillary lymphadenopathy

  15. CT findings/impression • There are hypodensities within the liver in segments 8, 4A, and 4/2, that measure greater than simple fluid attenuation, which may represent metastatic disease • There is a tiny nodule off the medial limb of the of the right adrenal gland, measuring 0.8 x 0.8 cm. • 2.0 x 1.5cm hypodense mass in the pancreatic tail. This may represent a metastasis from the lung mass.

  16. CT-guided Biopsy • 11/14 • Fine needle aspirates obtained, satisfactory to proceed with core biopsy. Preliminary pathology showed sheets of uniform tall columnar cells; could be normal versus cholangiocarcinoma versus bronchoalveolar carcinoma. • Core biopsy samples of liver mass most consistent with benign liver parenchyma and bile ductular epithelium and not that of metastatic neoplasm

  17. CT-guided Biopsy • 11/26 • Two fine needle aspirates obtained, satisfactory to proceed with core biopsy. Preliminary pathology consistent with poorly differentiated carcinoma versus sarcoma. • Five core biopsy samples of the lung mass obtained. Final pathology consistent with pleomorphic carcinoma, a subtype of sarcomatoid carcinoma

  18. Pleomorphic Carcinoma • Subgroup of sarcomatoid carcinoma, a heterogeneous group of NSCLCs containing sarcoma or sarcoma-like elements • Defined as either a non–small cell lung carcinoma combined with neoplastic spindle and/or giant cells or a carcinoma that consists of only spindle and giant cells. At least 10% of the carcinoma should comprise spindle and/or giant cells for it to be classified as a pleomorphic carcinoma • These tumors account for 0.1%–0.4% of all lung malignancies • They occur mainly in men who smoke heavily • The average age at which a diagnosis is made is 60 years • These tumors pursue an aggressive clinical course • Tae Hoon Kim, MD, Sang Jin Kim, MD, Young Hoon Ryu, MD, Hyun Ju Lee, MD, Jin Mo Goo, MD, Jung-Gi Im, MDHyung Joong Kim, MD, Doo Yun Lee, MD, Sang Ho Cho, MD and Kyu Ok Choe, MDPleomorphic Carcinoma of Lung: Comparison of CT Features and Pathologic Findings. Journal of Radiology (online) June 23, 2004, 10.1148/radiol.2322031201

  19. Pleomorphic Carcinoma • 57 of the 70 cases were diagnosed in men • Mean age of diagnosis was 66 • 68 of the 70 contained epithelial components • 40/70 had a large cell carcinoma component • 34/70 had an adenocarcinoma component • 13/70 had a squamous cell carcinoma comp • Overall survival rate of 36.6% • Massive necrosis predicts poor prognosis • Mochizuki, Takahiro MD ; Ishii, Genichiro MD, PhD ; Nagai, Kanji MD, PhD ; Yoshida, Junji MD, PhD ; Nishimura, Mitsuyo MD, PhD ; Mizuno, Tetsuya MD ; Yokose, Tomoyuki MD, PhD ; Suzuki, Kazuya MD, PhD; Ochiai, Atsushi MD, PhD. Pleomorphic Carcinoma of the Lung: Clinicopathologic Characteristics of 70 Cases. American Journal of Surgical Pathology. 32(11):1727-1735, November 2008.

  20. Gross pathology • Myxoid degeneration (arrowheads) and necrosis with hemorrhagic foci (arrows) on cut surface of tumor • Intraparenchymal or intrabronchial polypoid masses • http://radiology.rsnajnls.org/cgi/content-nw/full/232/2/554/F5B

  21. Histology • Neoplastic spindle cells • Heterogeneous type of carcinoma exhibiting biphasic mesenchymal differentiation; may have identifiable epithelial elements, sarcoma-like components and osteoclast-like giant cells • http://www.pathconsultddx.com/pathCon/largeImage?pii=S1559-8675(06)70499-5&figureId=fig7&ecomponentId=mmc7

  22. Histology (cont) Pleomorphic carcinoma of lung (adenocarcinoma and spindle cell subtype) in 46-year-old man. Photomicrograph shows mixed composition of adenocarcinoma (arrows) and spindle cell carcinoma (asterisk). Tae Sung Kim, Joungho Han, Kyung Soo Lee, Yeon Joo Jeong, Seo Hyun Kwak, Hong Sik Byun, Myung Jin Chung, Hojoong Kim and O Jung Kwon. CT Findings of Surgically Resected Pleomorphic Carcinoma of the Lung in 30 Patients. AJR Am J Roentgenol. 2005 Jul;185(1):120-5 Pleomorphic carcinoma of lung (large cell and giant cell subtype) in 63-year-old man (case 30 in Table 1). Photomicrograph shows mixed composition of large cell carcinoma and pleomorphic multinucleated giant cells (arrows). (H and E, x200)

  23. Pleomorphic carcinoma of lung (squamous cell and spindle cell subtype) in 58-year-old man (case 10 in Table 1). Photomicrograph shows mixed composition of squamous cell carcinoma (arrows) and spindle cell carcinoma (asterisk). (H and E, x100) Pleomorphic carcinoma of lung (large cell and giant cell subtype) in 63-year-old man (case 30 in Table 1). Photomicrograph of histopathologic specimen shows solid tumor (T) with poorly defined margin and central necrosis. Surrounding lung parenchyma (H) shows intraalveolar macrophage aggregation and interstitial thickening due to inflammatory cell infiltration. (H and E, x12) Tae Sung Kim, Joungho Han, Kyung Soo Lee, Yeon Joo Jeong, Seo Hyun Kwak, Hong Sik Byun, Myung Jin Chung, Hojoong Kim and O Jung Kwon. CT Findings of Surgically Resected Pleomorphic Carcinoma of the Lung in 30 Patients. AJR Am J Roentgenol. 2005 Jul;185(1):120-5

  24. Radiographic Findings • Typically located at the lung periphery, most studies demonstrating upper lobe preference • Tumors enhance with contrast material (~30 HU non-con, ~90 HU with con) representing collagenous and cellular rich component, low attenuation areas may be prominent in larger tumors representing regions of myxoid degeneration and necrosis with hemorrhagic foci • Mediastinal lymphadenopathy may or may not be present • Has a tendency to invade local structures including pleura and chest wall (may see rib destruction), possibly with pleural effusion • Less likely to cavitate or calcify • Chest radiograph unable to discriminate characteristic features from other primary lung malignancies

  25. Tae Hoon Kim, MD, Sang Jin Kim, MD, Young Hoon Ryu, MD, Hyun Ju Lee, MD, Jin Mo Goo, MD, Jung-Gi Im, MDHyung Joong Kim, MD, Doo Yun Lee, MD, Sang Ho Cho, MD and Kyu Ok Choe, MDPleomorphic Carcinoma of Lung: Comparison of CT Features and Pathologic Findings. Journal of Radiology (online) June 23, 2004, 10.1148/radiol.2322031201

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