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Clinicopathological Conference. Department of Surgery Aclan.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 1 st time: June 20, 2010. Chief Complaint.
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Clinicopathological Conference Department of Surgery Aclan.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 • 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.
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