University of Perpetual Help Rizal

Jonelta Foundation School of Medicine

Clinico-Pathological
Conference

November 20, 2010

• Texture
• Firmness
• Location of mass
Constitutional Symptoms
Weakness Anorexia Fever Weight loss

CHRONIC MALIGNANCY
INFECTION
Infectious Cause: Tuberculosis
• 6th leading cause of
morbidity and mortality*

• (+) PTB 18 years prior,

treated

Philippine Health Statistics and Field Health Service Information System , 2002
Pulmonary Tuberculosis
• Previous vs active TB

• (-) AFB smear

• TB – PCR assay
PTB vs Disseminated TB
• Severe anemia is quite
uncommon in PTB but
common in disseminated TB1

• Thrombocytopenia is very
rare in PTB, but relatively
common in disseminated TB2
1
Mandell G.L. et al (2000) Principles and Practice of Infectious Disease. Mycobacterial
Infections
2
Perez de Llano LA (1998) Immune thrombocytopenic purpura as Presenting form of
Miliary Tuberculosis 34:411-412
 Disseminated Patient
Tuberculosis
Areas of Bone – spine (40%) Skull – rare site
Dissemination (1%)

Bone Marrow – (+) Teardrop cells &

Myelophthisis Burr cells on PBS

Visceral Organs: (+) liver masses on

Liver – rare site abdominal UTZ

LeRoux PD, Griffin GE, Marsh HT, Winn HR (1990) Tuberculosis of the skull - a rare condition: case report and

review of the literature. Neurosurgery 26: 851–856

Malignant Cause: Lymphoma
• Lymphoma is the most
common hematological
malignancy

• Median age > 50 years old

 Disseminated Patient
Lymphoma

Signs and fever, night sweats, (+)fever, weight

Symptoms weight loss, loss, and fatigue
and fatigue, (-) night sweats
Lymphadenopathy (-) palpable
– most common* lymphadenopathy

*Harrison’s Principles of Internal Medicine, 17th ed.

 Disseminated Patient
Lymphoma
Areas of Bone (15%) – axial (+) skull lytic lesion
Dissemination bones*

Bone Marrow – (+) Teardrop cells &

Myelophthisis Burr cells on PBS;
Bicytopenia

Liver – common (+) liver masses on

(usually nodular) abdominal UTZ

* Reimer RR, Chabner BA, Young RC et al. Lyphoma presenting in bone. Results of Histopathology with

clinical correlates. 87; 50-5

 Disseminated Patient
Lymphoma
Labs Elevated LDH* Normal LDH

* Francesco Cavalli. Textbook of Medical Oncology. 3rd ed

Multiple Myeloma

• 2nd most common

hematological malignancy

• Malignant proliferation of
plasma cells
 Multiple Patient
Myeloma
Clinical Bone pain – most Upper back pain
Manifestations common (70%)* radiating to
usually back & ribs epigastric area
(+) punched out (+) skull lytic lesion
osteolytic lesions
Susceptibility to (+) prod. Cough
bact. Infections (+) leucocytosis
(pneumonias; UA: 2-5/hpf WBC
pyelonephritis)* 50,000 cfu E. cloacae

*Harrison’s Principles of Internal Medicine, 17th ed.

 Multiple Patient
Myeloma

Clinical Hypercalcemia 2.87 mmol/L Ca

Manifestations (30%)* during 10th & 14th
HD

Renal Failure Normal serum

(25%)* creatinine
Normocytic (+) pallor, fatigue
normochromic Decreased
Anemia (80%)* hemoglobin &
hematocrit

*Harrison’s Principles of Internal Medicine, 17th ed.

 Multiple Patient
Myeloma

Clinical Diffuse hepatic Nodular hepatic

Manifestations infiltration (50%)1 lesion – rare2

1
Oshima K, Kanda Y, Nannya Y, Kaneko M, Hamaki T, Suguro M, et al. Clinical and pathologic
findings in 52 consecutively autopsied cases with multiple myeloma. Am J Hematol 2001; 67:1-5

2
Chemlal K, Couvelard A, Grange MJ, Marmuse JP, Charneau C, Launay O, et al. Nodular lesions of
the liver revealing multiple myeloma. Leuk Lymphoma 1999 ; 33 :389-92
Hepatocellular Carcinoma

• Most common primary

hepatic tumor
 Hepatocellular Patient
Carcinoma
Clinical abdominal pain (+) abdominal pain,
Manifestations (40%), fever (50%), fever, weight loss,
weight loss (20%), weakness, and
weakness (15%), anorexia
anorexia (11%) and (-) jaundice
jaundice (5%)*
Hepatomegaly (-) hepatomegaly
(50%-90%) – most
common*
Laboratory Exams Ascites (30%-60%)* (+) Ascites

*Harrison’s Principles of Internal Medicine, 17th ed.

 Hepatocellular Patient
Carcinoma
Clinical Elevated liver Normal liver
Manifestations enzymes (24%)* enzymes

Multiple tumors (+) multiple hepatic

(65%) involving masses right lobe,
both lobes (75%)* (+) complex mass
inferior left lobe

*Harrison’s Principles of Internal Medicine, 17th ed.

 Hepatocellular Patient
Carcinoma
Sites of Metastasis Lungs, lymph (+) skull lytic lesion,
nodes, bone (28%) (+) upper back pain
frequently the
lumbar spine
Skull – uncommon1
Paraneoplastic Hypoglycemia2 (+) elevated blood
Syndrome glucose on 10th &
14th HD

1
Sanjeev Katyal, James H. Oliver III, et al. Extrahepatic Metastasis of Hepatocellular Carcinoma.
Radiological Society of North America

2
Kew CM. Hepatic tumours and cysts In : Feldman M. Sleisenger and Fordtran‘ s Gastro intestinal
and liver diseases, 7th edition WB Saunder’s company 2002
Pancreatic Carcinoma

• Pancreatic carcinoma is
among the most aggressive
of all cancers
• Difficult to diagnose in its
early stages
• Age is the most significant
risk factor for pancreatic
cancer*
* Cancer Facts and Figures 2009. American Cancer Society
 Pancreatic Patient
Carcinoma
Clinical anorexia, body (+) anorexia, body
Manifestations weakness, fatigue, weakness, fatigue,
and mid-epigastric and upper back
or back pain* pain radiating to
epigastric area
Significant weight (+) 50% weight loss
loss* in 3 months
Jaundice – some (-) Jaundice
patients

*Harrison’s Principles of Internal Medicine, 17th ed.

 Pancreatic Patient
Carcinoma
Clinical Body and tail – (+) complex mass
Manifestations large primary 5.3x6.0cm
tumor* encroaching
peripancreatic area
Metastasis to (+) multiple
lymph nodes, liver heterogenous
masses right liver
lobe
Ascites – (+) Ascites
peritoneal spread

*Harrison’s Principles of Internal Medicine, 17th ed.

 Pancreatic Patient
Carcinoma
Clinical Bone metastasis (+) back pain,
Manifestations (5%-20%), osteodegenerative
frequently the changes of spine,
vertebrae, blastic (+) skull lytic
or lytic* lesions
Bone Marrow (+) Teardrop cells &
dissemination - Burr cells on PBS;
Myelophthisis Bicytopenia
Hyperglycemia, (+) elevated blood
late onset DM glucose on two
separate occasions

*
Hatfield DR, Leland FH, Maruyama Y. Skeletal metastases in pancreatic carcinoma: Study by
Isotopic bone scanning. Oncology. 1976;33(1):44–47
 Final Diagnosis

Pancreatic Carcinoma, Stage IV;

with poss. metastasis to the liver,
peritoneum, bone and bone marrow;
Anemia and Thrombocytopenia sec. to
poss. bone marrow myelophthisis;
Malnutrition
“Pancreatic cancer should be at least thought
of in a patient older than 70 years with a new
diagnosis of diabetes and without any other
diabetic risk factors”

Chari ST, Leibson CL, Rabe KG, Ransom J, de Andrade M, Petersen

GM. Probability of pancreatic cancer following diabetes: a population-
based study. Gastroenterology. Aug 2005;129:504-11
THANK YOU!