Unsuspected Malignant Tumors

Grossly evident malignant tumors were found at autopsy in the absence of antemortem clinical diagnosis. It appears that a thorough workup for a hospitalized patient should include screening for malignant tumors, especially in the elderly.

DEBA P. SARMA, MD New Orleans

rhile reviewing autopsy records of our department, I came across a few cases in which grossly evident malignant tumors were found at autopsy in the absence of antemortem clinical diagnosis. A retrospective analysis of autopsy cases was undertaken to determine how often such cases occur in our institution.

marrow. The family did not permit examination of the patient's brain. Cause of death was thought to be advanced cancer with bronchopneumonia. Case 2. A 63-year-old man was admitted with a five-day history of swelling of lower extremities. He was slightly dyspneic. He had no significant history of illness in the past. On admission, laboratory studies of liver function, renal functions, blood, urine, and serum electrolytes were within normal limits. A diagnosis of thrombophlebitis of the legs was made and heparin, Lasix, and digitalis were administered. During the next two weeks the patient's serum bilirubin level gradually rose to over 30 mg%. Urinary output gradually decreased with increasing serum levels of blood urea nitrogen and creatinine. Finally, he lapsed into coma and died. Clinical diagnosis remained as hepatic and renal failure of unknown cause. At autopsy, the inferior vena cava and large hepatic veins were found to be obstructed by hepatocellular carcinoma that invaded the liver parenchyma diffusely. No distant metastases were present. Case 3. A 55-year-old man with vascular malformation of the brain diagnosed by craniotomy 27 years ago had been suffering from left hemiplegia and a seizure disorder. He was on anticonvulsant therapy. The patient was admitted to the hospital with a diagnosis of pneumonia and during a two-week period of hospitalization he developed cardiac arrhythmia and heart failure. He also developed phlebitis of the right leg. He was found dead in bed, and the cause was thought to be pulmonary embolism. At autopsy, in addition to pulmonary emboli, bronchopneumonia, and lung abscesses,

the patient was found to have a 6 x 3 cm renal cell carcinoma of the right kidney without any metastases.

Materials and Methods

All autopsy records as well as the clinical summaries of 452 autopsies performed at the Veterans Administration Medical Center, New Orleans from January 1, 1976 to December 31, 1977 were reviewed. Of the 452 autopsies, 366 were complete autopsies and 86 were restricted ones where the brains were not examined. All patients in which no diagnoses of malignant tumors were made clinically but in which grossly visible and microscopically proved malignant tumors were found at autopsy were considered as cases of unsuspected malignant tumors. The cases of malignant tumors not seen on gross examination at autopsy but seen as minute foci of malignancy only on microscopic examination were not counted as unsuspected malignant tumors. Such minute foci of cancer, most of which were found in the prostate, were not considered to be clinically significant problems for the patients.

Illustrative Cases
Case 1. A 48-year-old man had been followed for five years for psychogenic vomiting. He was admitted multiple times during which all work-up to evaluate his electrolyte imbalances, peripheral neuropathy, orthostatic hypotension, osteomalacia, and chronic brain syndrome with memory loss was nonproductive. At the last admission to the hospital, he presented with a history of head injury due to a fall. Angiographic studies did not show any cranial lesion. The patient became febrile; chest roentgenograms showed patchy consolidation of the lungs that was interpreted as pneumonia. He died 11 days after admission. At autopsy, a small cell undifferentiated carcinoma was found that originated in the right upper lobe and extended into the middle and lower lobes of the right lung, with metastases to hilar lymph nodes, liver, and bone

*Dr. Sarma is Associate Professor of Pathology, LSU School of Medicine and Staff Pathologist. VA Medical Center, New Orleans, LA.

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UNSUSPECTED MALIGNANT TUMORS - SARMA

Results and Discussion

Thirty-four cases of clinically unsuspected malignant tumors were found (Table 1). This represented an occurrence rate of unsuspected malignant tumor at autopsy of 7.4% (34/452 x 100). There were 4 cases of microscopic occult adenocarcinomas of the prostate that were not included among the 34 cases of grossly evident tumors. I believe that the unsuspected cancers in those 34 cases either caused death of the patients (Example: Case 1 and 2) or would have caused morbidity and probably death in other cases, (Example: Case 3) if these patients would not have died due to other causes. In 14 cases among the 34 cases of unsuspected malignant tumors, a cancer of another site was clinically diagnosed (Table 2). An overall occurrence rate for multiple cancers was found to be about 3% in a study of a large number of cases.1 It appears that a thorough workup for a hospitalized patient should include screening for malignant tumors, especially in an elderly pa-

tient population such as ours (about 87% of the autopsied patients were 50 years or older). Reference
'Moertel CG: Incidence and significance of multiple primary neoplasms. Ann NY Acad Sci 114:886-895, 1964

__________ Table 1 __________

Unsuspected Malignant Tumors at Autopsy (34 cases among 452 autopsies) Site of Cancer Prostate Lung Kidney Colon Liver Pancreas Thyroid Rectum Urinary bladder No. of Cases 11 8 4 3 2 2 2 1 1

Table 2 Multiple Primary Malignant Tumors 14 cases

Clinically Diagnosed Cancers Lung (4 cases) Pancreas (3 cases) Larynx (1 case) Rectum (1 case) Brain (1 case) Colon (1 case) Small intestine (1 case) Tonsil (1 case) Prostate (1 case)

Unsuspected Cancers Colon, prostate, kidney, rectum Thyroid, prostate, colon Prostate Prostate Urinary bladder Prostate Colon Prostate Kidney

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Sarma DP (1981): Unsuspected malignant tumors. J La State Med Soc. 133:105-106. PMID: 6268722 [PubMed - indexed for MEDLINE]