Transcript SYB Case #1 - MyPACS.net

Jordan Torok
Class of 2010
December 4th, 2008
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CC: 35 year old male presents to the ED with leftsided 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.
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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
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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.
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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.
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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
T1
T2
Stealth
FLAIR
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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.
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.
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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
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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.
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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
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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
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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, JungGi Im, MDHyung Joong Kim, MD, Doo Yun Lee, MD, Sang Ho Cho, MD and Kyu Ok Choe, MD
Pleomorphic 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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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.
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Myxoid degeneration
(arrowheads) and
necrosis with
hemorrhagic foci
(arrows) on cut surface
of tumor
Intraparenchymal or
intrabronchial
polypoid masses
http://radiology.rsnaj
nls.org/cgi/contentnw/full/232/2/554/F
5B
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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.c
om/pathCon/largeImage?pii=
S1559-8675(06)704995&figureId=fig7&ecomponentI
d=mmc7
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)
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
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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
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, MD Pleomorphic Carcinoma of Lung:
Comparison of CT Features and Pathologic
Findings. Journal of Radiology (online) June 23,
2004, 10.1148/radiol.2322031201