CLINICO-PATHOLOGICAL CONFERENCE

Sebelas Maret University School of Medicine

Prof Dr.R Soeharso Orthopaedic Hospital
Dr.Moewardi General Hospital
CASE 1

Name : Mrs. Winarni

Age : 64 y.o
RM : 01372641
Ward : Cendana 1
History Taking
Chief Complaint :
Pain on her right upper arm
Recent History :
Patient started to feel intermittent pain on her right upper
arm from 3 weeks before admission. She then felt more pain and
couldnt lift her arm after waking up from sleep during
chemotherapy process by internist at Moewardi hospital.
1 month before admission patient also complained about
lump on her left thigh. The lump getting bigger. At first she didnt
feel any pain but later got progressively pain. The lump had been
excised and examined at Caruban Hospital and the result was
metastatic tumor. After that, patient being referred to Moewardi
Hospital.
History of trauma (-), anorexia (-), night pain(+), loss of body
weight (+), dyspnea (-), chronic cough (-), chronic fever (-),
mixturition still normal, history of small rounded shape faeces (-)
History Taking

Past History:
History of trauma (-)
Significant weight body loss (+)
Chronic cough (-)

FAMILY
Cancer History (-)

SOSIOECONOMIC
housewife
Physical Examination

Karnofsky score : 70
Head : no abnormality
Neck : no abnormality, no mass nor
thyroid gland enlargement
Eyes : no abnormality
Nose : no abnormality
Ears : no abnormality
Mouth : no abnormality
Chest : no abnormality
Shoulder : no abnormality
Extermities : look at local examination
Abdominal : no abnormality
Physical Examination
Local Physical Examination

Right upper arm region:

L : Skin intact, swelling (+), deformity unclear
venectation (-), skin color same with around
F : tenderness (+), NVD (-)
M : ROM shoulder-elbow restricted due to pain
Laboratory Examination
April 19th, 2016
Hb : 9,4 g/dl
Hematokrit : 30 %
Leukosit : 8300 rb/ul
Trombosit : 632 rb/ul
Eri : 3.64

PT : 13.3
APTT : 28.9

GDS : 195
HbsAg : (-)
Na : 135
K : 3.9
Cl : 107
Ca : 1.35
X-Ray Right Humerus (April 14th, 2016)
MRI (March 31th, 2017)
1 April 2016
MRI (March 31th, 2017)
1 April 2016
MRI (March 31th, 2017)
1 April 2016
MRI (March 31th, 2017)
1 April 2016
Bone survey (April 17th, 2017)
1 April 2016
Hasil bone survey (April 17th, 2017)

Kesimpulan :
Bone metastasis (Fraktur
Patologis pada os humerus
1/3 proximal dan lesi osteolitik
Pada humerus kanan dan kiri)
 INITIAL ASSESSMENT

Pathological Fracture of Right Proximal

Humerus ec MBD Ca Ovarii
 PLAN

ORIF Reconstruction+ Bone cement + PA

Post Op
Hasil PA (April 19th, 2017)
CLINICO-PATHOLOGICAL CONFERENCE

Sebelas Maret University School of Medicine

Prof Dr.R Soeharso Orthopaedic Hospital
Dr.Moewardi General Hospital
CASE 1

Name : Damar
Age : 7 y.o
RM : 01358234
Ward :
 History Taking

Chief Complaint :
Lump on his left knee
Recent History :
4 months ago patient complained about lump on his left
leg. The lump was getting bigger. Patient also complain about
pain, that increase with progressivity of the mass and increase
with weight bearing. Patient can walk without device.
History of trauma (-), night pain (+), anorexia (-), loss of
body weight (-), dyspnea (-), chronic cough (-), chronic fever (-),
mixturition still normal, history of small rounded shape faeces (-
)
History Taking

Past History:
History of trauma (-)
Significant weight body loss (-)
Chronic cough (-)

FAMILY
Cancer History (-)

SOSIOECONOMIC
Labour
Physical Examination
Karnofsky score : 90
Head : no abnormality
Neck : no abnormality, no mass nor
thyroid gland
enlargement
Eyes : no abnormality
Nose : no abnormality
Ears : no abnormality
Mouth : no abnormality
Chest : no abnormality
Shoulder : no abnormality
Extermities : look at local examination
Physical Examination After Neoadjuvant
Chemotherapy
Local Physical Examination

Left Leg Region:

L : mass (+) on around knee, venectation (+), skin
color same with around
F : Mass with diameter 23 cm, hard consistency,
clear margin, wavy surface, tenderness (-), immobile,
NVD (-), warm (+)
M : ROM 0-130o
Laboratory Examination
Aug 13th, 2016
Hb : 13,6 g/dl
Hematokrit : 38 %
Leukosit : 6500 rb/ul
Trombosit : 199 rb/ul
Golongan darah :A
LED 1: 94
HbsAg : (-) LED 2: 106
Ur : 24 mg/dl CRP: positif
Cr : 0,8 mg/dl ALP: 1519
SGOT : 17 u/l
SGPT : 12 u/l
ALP : 126 u/l
Alb : 4.1
Glb : 3.2
LDH : 462 U/L
HsCRP : 1,33
X-Ray Left Knee (Sept 17th, 2016)

Blastic lesion,
permeative type,
periosteal reaction,
soft tissue swelling
Chest X-Ray (Oct 11th, 2016)

No Metastatic nodule
MRI (Oct 18th, 2016)
1 April 2016
MRI (Oct 18th, 2016)
1 April 2016
MRI (Oct 18th, 2016)
1 April 2016
MRI (Oct 18th, 2016)
1 April 2016
MRI (Oct 18th, 2016)
1 April 2016
MRI (Oct 18th, 2016)
1 April 2016
Histopathology (Oct 27th, 2016)
1 April 2016
 INITIAL ASSESSMENT

Primary bone tumor of the left proximal Tibia

e.c osteosarcoma
 PLAN

Neoadjuvant Chemotherapy
(6x siklus: Carboplatin&Etopuside)
 Evaluation

Pain decrease
Size decrease
MRI (April 10th, 2016)
1 April 2016
MRI (April 10th, 2016)
1 April 2016
MRI (April 10th, 2016)
1 April 2016
MRI (April 10th, 2016)
1 April 2016
MRI (April 10th, 2016)
1 April 2016
MRI (April 10th, 2016)
1 April 2016
MRI (April 10 th, 2016)
1 April 2016
 PLAN

Limb salvage surgery (Wide Excisi+Biological

reconstruction)
Durante Op
Durante Op
Durante Op
Post Op
CASE 1

Name : Ali Khoirul

Age :11 y.o
RM : 01373805
Ward :
 History Taking

Chief Complaint :
Lump on his right hand
Recent History :
3 months ago patient started to complain about lump on
his right hand. The lump getting bigger. At first he didnt feel any
pain but later he felt pain as the lump get bigger.
Patient had haemophilia type A and routine to get Injection
Factor VIII.
History of trauma (-), anorexia (-), loss of body weight (-),
night pain(-), dyspnea (-), chronic cough (-), chronic fever (-),
mixturition still normal, history of small rounded shape faeces (-
)
History Taking

Past History:
History of trauma (-)
Significant weight body loss (-)
Chronic cough (-)
Haemophilia type A

FAMILY
Cancer History (-)

SOSIOECONOMIC
seller
Physical Examination

Lansky score : 100

Head : no abnormality
Neck : no abnormality, no mass nor
thyroid gland
enlargement
Eyes : no abnormality
Nose : no abnormality
Ears : no abnormality
Mouth : no abnormality
Chest : no abnormality
Shoulder : no abnormality
Physical Examination
Local Physical Examination

Right Hand Region:

L : mass (+) on metacarpal 5, skin intact (+), skin
color same with around
F : Mass with diameter 5 cm, hard consistency, clear
margin, tenderness (-), immobile, NVD (-), warm (-)
M : ROM Metacarpophalangeal 5 full
Laboratory Examination
April 24th, 2017
Hb : 12,4 g/dl
Hematokrit : 37 %
Leukosit : 6.8 rb/ul
Trombosit : 346 rb/ul
Eri : 4.77

PT : 13.9
APTT : 89.3

GDS : 99
Alb : 4.3
HbsAg : (-)
Ur : 14 mg/dl
Cr : 0,5 mg/dl
X-Ray Right Hand (March 25th, 2017)
MRI (April 17th, 2017)
1 April 2016
MRI (April 17th, 2017)
1 April 2016
MRI (April 17th, 2017)
1 April 2016
MRI (April 17th, 2017)
1 April 2016
MRI (April 17th, 2017)
1 April 2016
MRI (April 17th, 2017)
1 April 2016
 INITIAL ASSESSMENT

Aneurysm Bone Cyst Metacarpal V Right Hand

with Haemofilia
 PLAN

Decompression + Steroid Injection

Durante Op
CASE

Name : Ngatmi
Age : 57 y.o
RM : 01322304
Address : Karanganyar, Central Java
Ward : Outpatient
 Anamnesis
Chief Complaint : Pain on the left shoulder
Recent History :
6 months before admission patient complained about
pain on her left shoulder that aggravated by shoulder
movement. Continuous pain(+), not relieved with analgesic.
Patient also complained lump appeared on her left shoulder.
History of trauma (-), anorexia (+), night pain(+) loss of
body weight (+), dyspnea (-), chronic cough (-), chronic fever (-
), mixturition and defecation still normal.
Past history :
Radical Mastectomy 2010 & refused to continue
chemotherapy (1x chemotherapy)
Pathological Fracture on left shaft humerus 2016
 Physical Examination
Left shoulder region
L : scar OP on shaft humerus, swelling (+),
deformity unclear
F : NVD (-), tenderness (+), venectation (-), mass
(+) firm (+),unclear border line, lymphnode axilla
& supraclavicle(+)
M : ROM shoulder limited by pain
Local Physical Examination
Local Physical Examination
 Laboratory Examination
(16/04/2017)
Hb 12,8 g/dl
Hct 38 %
AL 6,4 thousand/ul
AT 201 thousand/ul
Eritrosit 5,10 million/ul
Glucose level 109 mg/dl
SGOT 37 u/l
SGPT 14 u/l
Albumin 4,2 g/dl
Hbsag negative
 Radiological Examination

Humerus Sinistra
(17/03/2017)

Lytic lesion metadiaphysis

geographic type,
periosteal reaction(-),
soft tissue swelling on
proximal humerus,
internal fixation + cement
on shaft
 Chest x-ray

17/04/2017
Cor : CTR < 50%
Pulmo : Trachea in the middle, no
infiltrates in both lungs,
bronchovascular pattern in normal
limit, left and right sinus
phrenicocostalis sharp
No osteolytic or osteoblastic lesions
shown

Conclusion : no appearance of pulmonal metastasis

MRI 17/03/17
MRI 17/03/17
Pathology Examination

Macroscopic :
Soft tissue preparations 2.5 cc, black and
white, soft and hard

Microscopic :
Preparations from left humerus made up
from fibrocollagen which compound
malignant tumor adenocarcinoma

Conclusion : metastatic Ca Mammae

 INITIAL ASSESSMENT

Destruction Left Proximal Humerus ec MBD Ca

Mammae

Mirel Score 10
 PLAN

Limb salvage surgery (Wide Excision+

Arthrodesis Fixation +Bone cement+PA)
Durante Op
Durante Op
Post Op
CASE

Name : Mr. Sutarjo

Age : 60 th
RM : 01344778
 Anamnesis
Chief Complaint :
Lump on the around left knee
Recent History :
6 months before admission patient complained about pain
on her left knee. Continous pain usually worser when he
standing or walks. This pain accompanied by lump appeared 2
months ago on around his left knee until as bigger as pear fruit.
History of trauma (-), anorexia (+), loss of body weight (+),
dyspnea (-), chronic cough (-), chronic fever (-), mixturition and
defecation still normal.
 Anamnesis
Past History:
History of trauma (-)
Loss of appetite (+)
Weight loss (+)
Night pain (+)
Chronic cough (-)
FAMILY
Cancer History (-)
 PHYSICAL EXAMINATION
General Condition
Vital sign:
BP : 140/80 mmHg;
HR : 98 bpm;
RR : 19 x /mnt
T : 36,7C
 Physical Examination
Karnofsky score : 80
Head : no abnormality
Neck : no abnormality
Eyes : no abnormality
Nose : no abnormality
Ears : no abnormality
Mouth : no abnormality
Chest : no abnormality
Shoulder : no abnormality
Extermities : look at local examination
Abdominal : no abnormality
 Local examination
Distal Thigh (L) :
L : skin intact, lump diameter 45cm on
anteromedial, fixated, shiny (-), veinectasis (+)
F : NVD (-) tenderness (+), hard on palpable,
immobile
M : ROM hip full, ROM genu fixed,
ROM ankle full
Local Physical Examination
Local Physical Examination
 Laboratory Examination
20th February 2017
EXAMINATION RESULT RANGE

HEMOGLOBIN 13.4 g/dl 12.0 - 15.6

HEMATOKRIT 40 % 33 - 45
LEUKOCYTE 8.4 ribu/ul 4.5 - 11.0
THROMBOCYTE 285 ribu/ul 150 - 450
ERITROCYTE 4.79 juta/ul 4.10 - 5.10

PT 11.7 detik 10.0 - 15.0

APTT 25.9 detik 20.0 - 40.0

INR 0.900

BLOOD SUGAR 87 60 - 140 60 - 140

ALBUMIN 3.6 g/dl 3.5 - 5.2
CREATININ 0.9 mg/dl 0.6 - 1.1
UREUM 13 mg/dl <50

NATRIUM 134 mmol/L 136 - 145

KALIUM 3.6 mmol/L 3.3 - 5.1
CHLORIDE 98 mmol/L 98 - 106
PLAIN X Ray ( Genue )
13rd December 2016
PLAIN X Ray ( Thorak )
6th February 2017
 Bone Survey
30th January 2017
Anatomical Patologist
23th November 2016
Anatomical Patologist
25th February 2017
 FNAB
15th February 2017
Anatomical Patologist
25th February 2017
Anatomical Patologist
10th March 2017
 M R A ( THIGH )
30th January 2017
MRI

Condylus Mass Tumor of

Medial Femur (S) with
destruction of Chondrium layer
and expansion of intraarticular,
half of burst suprapatella +
Infrapatella Fat pad with
extension of mass to cranial
until 1/3 distal of femur with
No. appearance of expansion
to tendon and subcutan fat
with no affect of neurovascular
bundle Suspect GCT
dd : Osteosarcoma
Osteomyelitis
Immunohistochemistry
10th March 2017
 INITIAL ASSESSMENT

Destruksi femur distal dd MBD dd Secondary

Osteosarcoma
 PLAN

Wide excision + arthrodesis + biopsy PA

Durante Op
Durante Op
Post Op
THANK YOU