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Copy of CPC

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Roberto Vailati Facchini

on 28 April 2013

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Transcript of Copy of CPC

SALIENT FEATURES Interscholastic ClinicoPathologicConference Anterior Mediastinal Mass BACTERIA

Staphylococcus
Pneumococcus
Melioidosis
Tuberculosis Neurogenic Tumor
Bronchogenic Tumor
Enteric Cyst
Xanthgranuloma
Diaphragmatic Hernia
Meningocoele
Paravertebral abscess Chest Mass Middle Mediastinal Mass Posterior Mediastinal Mass OTHER CAUSES TIMELINE 2 skin colored papules - sternal area

on and off cough
easy fatigability
body weakness
anorexia
weight loss
apyrexia 7 months PTA Admission Patient was diagnosed with ANTERIOR MEDIASTINAL MASS on CXR Hypertensive
Tachycardic
Tachypneic
10x10cm mediastinal mass, non tender, non movable
(+) NVE, abdominal veins 1 month PTA 2nd HD 3rd HD Dyspneic at rest
Tachycardic
Hypertensive
Supraclavicular retractions
Upper extremity edema Lymphoma
Pericardial Cyst
Bronchogenic Cyst
Metastatic Cyst
Systemic Granuloma coalescing mass
increase in size
hemoptysis Bilateral Axillary Lymphadenopathy
Firm, Movable, NonTender, 5th HD 6th-7th HD Probably due to Metastases from the Primary site 4th HD Sitting orthopnea
Worsening dyspnea
Crackles Dyspnea improved
Tachycardic
Hypertensive
Melena
Hypercalcemia 8th-12th HD Hypertensive
Tachycardic
Tachypneic
Pleuritic chest pain
Supraclavicular retractions
Occ'l wheezing
Decreased breath sounds L upper lung field MEDIASTINAL
MASS LOCATION
OF MASS AGE AND
GENDER SIGNS AND
SYMPTOMS FUNGAL

Histoplasma
Aspergillus
Actinomycosis PRIMARY CBC
Leukocytosis with Segmenters Predominance MELIOIDOSIS, STAPHYLOCOCCUS, PNEUMOCOCCUS Fever of less than 2 months duration with Meliodosis Melioidosis is rare in Philippines and No History of Travel to Endemic Areas Mediastinal lymphadenopathy is rare in melioidosis. Clarithromycin 500mg BID x 7days
Co-Amoxiclav 625mg BID

Azithromycin 500mg

Piperacillin Tazobactam 4.5g IV 1 month prior to admission 1st Hospital Day 3rd Hospital Day EMPIRIC TREATMENT If bacterial agent was considered, then the patient would have improved with such trial in antibiotics. Castlemans Disease
Thymoma
Thymic Carcinoma
Thymic Carcinoid
Lymphoma
Hodgkins
Non-Hodgkins
Primary Mediastinal B-Cell Lymphoma
Lymphoblastic Lymphoma
Germ Cell Tumors
Teratoma
Seminoma
NonSeminomatous Incubation period of 1 - 21 days for Melioidosis No toxic granulations seen in PBS No risk factors such as DM and previous operations. Bungay HK, Shefler AG, McHugh K. CT of staphylococcal anterior mediastinal abscess in an infant. Pediatr Radiol 1995;25:S205-6. CBC
Leukocytosis with Segmenters Predominance ASPERGILLUS, HISTOPLASMA, ACTINOMYCOSIS Sputum exam negative on hyphal and yeast cells Myalgias and arthralgias are common symptoms during acute infection of pulmonary histoplasmosis The disease progresses slowly over years,
gradually encroaching mediastinal structures. Massive hemoptysis suggests the development of an aspergilloma in a cavity lesion Gram Stain and Culture studies were unremarkable DIFFERENTIAL
DIAGNOSIS EXTRAPULMONARY TUBERCULOSIS Signs and symptoms consistent with pulmonary TB Lymphadenitis is the most commonly occurring form of extrapulmonary tuberculosis. It is a great imitator of various entities in the thoracic cavity TB is endemic in Philippines EXTRAPULMONARY TUBERCULOSIS Hematological abnormalities associated with extra-pulmonary TB include anemia, leukemoid reaction, thrombocytosis or thrombocytopenia, and rarely pancytopenia. Serum LDH level is not consistent with TB or extrapulmonary TB. The most frequent localization for tuberculosis lymphadenitis is the head and neck region.
Mediastinal lymph nodes = 5% Avasthi R, Mohanty D, Chaudhary SC, Mishra K. Disseminated tuberculosis: interesting hematological observations. J Assoc Physicians India. 2010;58:243-4. DANDAPART M. C., MISHRA B. M., DASH S. P., KAR P. K. Peripheral
lymph node tuberculosis : a review of 80 cases. Br J Surg, 1990, 77 : 911-2. EXTRAPULMONARY TUBERCULOSIS Serum Lactate Dehydrogenase (LDH) in Pneumocystis carinii Pneumonia, Tuberculosis, and Bacterial Pneumonia
Joseph Quist; A. Ross Hill
CHEST. 1995;108(2):p415-418 In a study by Quist, J. (1995), he found out that the LDH levels in patients with disseminated TB had a value of 569 +/- 338 U/L, while in patients with pulmonary TB, it was only 258 +/- 66 U/L. is this a neoplastic entity? AGE PREDILECTION CHILDREN / YOUNG ADULT ELDERLY Castlemans Disease Castlemans Disease Thymoma Thymic Carcinoma Thymic Carcinoid Hodgkins Lymphoma NonHodgkins Lymphoma Primary Mediastinal B Cell/ T Cell Lymphoma Lymphoblastic Lymphoma Teratoma Seminomatous Germ Cell Tumor NonSeminomatous Germ Cell Tumor (frequent in 5th to 6th decade) (affects in 4th to 5th decade) Thymoma Suster S, Rosai J: Thymic carcinoma. A clinicopathological study of 60 cases. Cancer 67:1025-1032, 1991 NonHodgkins Lymphoma Wick MR, Bernatz PE, Carney JA, et al. Primary mediastinal carcinoid tumors. Am J Surg Pathol 1982; 6:195-205
Wick MR, Scott RE, Li CY, et al. Carcinoid tumor of the thymus. Mayo Clin Proc 1980; 55:246-54 GENDER PREDILECTION MALE FEMALE Castlemans Disease Castlemans Disease Thymoma Hodgkins Lymphoma NonHodgkins Lymphoma Primary Mediastinal B Cell/ T Cell Lymphoma Lymphoblastic Lymphoma Teratoma Seminomatous Germ Cell Tumor NonSeminomatous Germ Cell Tumor Thymoma NonHodgkins Lymphoma Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: clinical characteristics and evolving etiology.Medicine (Baltimore) 2006;85:37-42 Most common symptoms of presentation of mediastinal tumours are with cough, dyspnea, and chest pain.

The presence of SVC syndrome, hoarseness, and phrenic nerve palsy are all suggestive of malignant etiology Castlemans Disease or Angiofollicular Mediastinal Lymphnode Hyperplasia Young healthy people with age less than 30. Signs and symptoms of Compression Unicentric disease classically present as a mediastinal mass (70%) but they can occur anywhere along the lymphatic chains. Rule In: Castlemans Disease or Angiofollicular Mediastinal Lymphnode Hyperplasia Generalized lymphadenopathy = 80%
Enlargement of the liver or spleen = 65% Pro-Inflammatory State where patient develops thrombocytosis and increase in fibrinogen. Associated with Neuropathy which can occur in 20% of patients and is typically of the sensory, glove-and-stocking variety. Rule Out: Chan TM, Cheng IK, Wong KL, Chan KW. Resolution of membranoproliferativeglomerulonephritis complicating angiofollicular lymph node hyperplasia(Castleman’s disease). Nephron. 1993;65:628-632. LDH can be elevated but is usually normal
Liver enzymes are elevated Pro-Inflammatory state leads to severe constitutional symptoms. Aoki Y, Jaffe ES, Chang Y, et al. Angiogenesis and hematopoiesis induced by Kaposi’s sarcoma-associated herpesvirus-encoded interleukin-6. Blood. 1999;93:4034-4043. Thymoma Rule In: Most common neoplasm of the anterior mediastinum
20% of anterior mediastinal mass in adults Engels EA, Pfeiffer RM. Malignant thymoma in the United States: demographic patterns in incidence and associations with subsequent malignancies. Int J Cancer 2003; 105:546551 Most patients present with:
Cough
shortness of breath
chest pain
Fatigue
Weight loss and Anorexia Superior Vena Cava Syndrome Thymoma Rule Out: Thirty percent to 50% of patients with thymoma have myasthenia gravis Diaphoresis is uncommon with thymoma, symptomatology is more on compressive effect of the mass. Lymphogenous and hematogenous spread is rare in thymoma Lewis JE, Wick MR, Scheithauer BW, et al. Thymoma: a clinicopathologic review. Cancer 1987; 60:2727–2743

Verstandig AG, Epstein DM, Miller WT, et al. Thymoma report of 71 cases and a review. Crit Rev Diagn Imaging1992; 33:201–230 Paraneoplastic phenomena such as
hypogammaglobulinemia
pure red-cell aplasia (10% of cases) Can be asymptomatic and which, in 50-60% of cases is diagnosed incidentally on chest x-ray Rule in: Rule out: Castlemans Disease Thymoma Lymphoblastic Lymphoma Teratoma Seminomatous Germ Cell Tumor NonSeminomatous Germ Cell Tumor NonHodgkins Lymphoma Castlemans Disease Thymoma Lymphoblastic Lymphoma Teratoma Seminomatous Germ Cell Tumor NonSeminomatous Germ Cell Tumor NonHodgkins Lymphoma Thymoma Lymphoblastic Lymphoma Teratoma Seminomatous Germ Cell Tumor NonSeminomatous Germ Cell Tumor NonHodgkins Lymphoma Thymoma Lymphoblastic Lymphoma Teratoma Seminomatous Germ Cell Tumor NonSeminomatous Germ Cell Tumor NonHodgkins Lymphoma Wright CD Panos F Choi NCH Shepard JO Hasserjian RP
Case 16-2007: A 61- year old man with a mediastinal mass.NEJM 2007:356:2185-93 Souadjian JV, Enriquez P, Silverstein M, PCpin J-M. The spectrum of diseases associated with thymoma: Coincidence or syndrome?
Arch Intern Med 1974; 134:374-379. Rosenow EC 111, Hurley BT. Disorders ofthe thymus: A review. Arch Intern Med 1984; 144:763-770. Non Hodgkins Lymphoma
Lymphoblastic Lymphoma Rule Out: Non-Hodgkins Lymphoma
Lymphoblastic Lymphoma Lymphoblastic Lymphoma Teratoma Seminomatous Germ Cell Tumor NonSeminomatous Germ Cell Tumor NonHodgkins Lymphoma Lymphoblastic Lymphoma Teratoma Seminomatous Germ Cell Tumor NonSeminomatous Germ Cell Tumor NonHodgkins Lymphoma Mostly occur in patients in the 1st to 2nd decades of life, most often in male adolescents Rapidly enlarging primary mediastinal mass with signs and symptoms of mediastinal invasion to include SVC syndrome. Bragg DG, Colby TV, Ward JH. New concepts in the Non-Hodgkin lymphomas: radiologic implications. Radiology 1986; 159:289-330 Lichtenstein AK, Levine A, Taylor CR, et al. Primary mediastinal lymphoma in adults. Am J Med 1980; 68:509-14 Usually presents as acute leukemias with involvement of bone marrow and peripheral blood. Wright CD Panos F Choi NCH Shepard JO Hasserjian RP Case 16-2007: A 61- year old man with a mediastinal mass. NEJM 2007:356:2185-93 Anemia, neutropenia, and thrombocytopenia are common. Profound neutropenia is found in 20 - 40% of patients. Stage IV disease (80%) and B symptoms (50%) and in the majority of cases elevated serum lactate dehydrogenase (LDH) levels. Cortelazzo, S. et al (2011). Lymphoblastic lymphoma. Critical Reviews in Oncology/Hematology, 79, 330-343. Primary Care Medicine: Office Evaluation and Management of the Adult Patient 6th Edition Most common extranodal site of involvement is the gastrointestinal tract. Rule in: Teratoma Rule In: Teratoma Seminomatous Germ Cell Tumor NonSeminomatous Germ Cell Tumor 60% of all mediastinal germ cell tumors
15–20% of all anterior mediastinal masses. 95% of mediastinal teratomas are located in anterior mediastinum Deshmukh AG, Murab MV, Jadhav SR, Mhaiskar DG, Deversi DB Anterior mediastinal mass: dermoid cyst – a case report. Indian Med Gaz 206; CXL:290–292 Teratoma Rule Out: Teratoma Seminomatous Germ Cell Tumor NonSeminomatous Germ Cell Tumor These tumors are slow growing and up to 50–60% of patients may be asymptomatic at time of diagnosis. It is uncommon for teratomas to occur as a disseminated disease with occurence of lymphadenopathy. Park SB, Cho KS, Kim JK. CT findings of mature cystic teratoma with malignant transformation: comparison with mature cystic teratoma. Clin Imaging. 2011 Jul-Aug;35(4):294-300. doi: 10.1016/j.clinimag.2010.08.016. In a study involving 1313 case of benign teratomas, Park et al (2011) they reported that
none of the benign teratomas showed transmural growth, lymphadenopathy or disseminated disease Deshmukh AG, Murab MV, Jadhav SR, Mhaiskar DG, Deversi DB Anterior mediastinal mass: dermoid cyst – a case report. Indian Med Gaz 206; CXL:290–292 Takeda S et al. Primary germ cell tumors in the mediastinum: a 50-year experience at a single Japanese institution. Cancer January 2003 vol. 97 no. 2 367-376 Chest pain, cough and fever were typical of adult cases while dyspnea occurred more in children with their more collapsible mediastinal structures. They are more commonly associated with compression of adjacent structures GERM CELL TUMORS
Seminoma Rule In: Seminomatous Germ Cell Tumor NonSeminomatous Germ Cell Tumor Most common extragonadal site of primary germ cell tumors is the anterior mediastinum Most common primary malignant germ cell tumor of the mediastinum

approximately 25%-40% of all primary malignant mediastinal germ cell tumors Elevation of serum lactic dehydrogenase levels in approximately 80% of patients Mainly occurs in men of the second to fourth decades 30% of the patients are asymptomatic
Non-specific signs and symptoms
chest pain or pressure
shortness of breath
weight loss
hoarseness
dysphagia
fever GERM CELL TUMORS
Seminoma Rule Out: Seminomatous Germ Cell Tumor NonSeminomatous Germ Cell Tumor Slow growing, bulky tumours that invade locally early in the growth process with less potential for early metastasis The occurrence of signs and symptoms of SVCS in primary mediastinal seminoma is extremely rare. SVCS occurs in only 10% of all patients. Moran CA, Suster S, Przygodzki RM, Koss MN. Primary germ cell tumours of the mediastinum: II. Mediastinal seminomas--a clinicopathologic and immunohistochemical study of 120 cases. Cancer 1997; 80: 691-8. Polansky SM, Barwick KW, Ravin CE. Primary mediastinal seminoma. AJR Am J Roentgenol 1979; 132: 17-21. Moran CA, Suster S, Przygodzki RM, Koss MN. Primary germ cell tumours of the mediastinum: II. Mediastinal seminomas--a clinicopathologic and immunohistochemical study of 120 cases. Cancer 1997; 80: 691-8. 12 papers in total reported mediastinal seminoma with SVCS in the English language literature from 1958 to 2010. Fatimi SH, Shahid B, Hanif HM, Muzaffar M. Mediastinal seminoma presenting as superior vena cava syndrome and tracheal obstruction.
J Pak Med Assoc 60: 861-862, 2010. GERM CELL TUMORS
Non-Seminomatous Rule In: NonSeminomatous Germ Cell Tumor rare and occur almost exclusively in young men in 2nd to 3rd decade. account for 50–70 % of all malignant Germ Cell Tumors Grow rapidly, causing compression and invasion of mediastinal structures. 91% percent of patients in the current series
had symptoms due to large mediastinal NSGCT 85–95% of NSGCT patients have at least
one metastatic site at presentation Moran CA, Suster S, Koss MN. Primary germ cell tumors of the mediastinum: III. Yolk sac tumor, embryonal carcinoma, choriocarcinoma, and combined nonteratomatous germ cell tumors of the mediastinum-a clinicopathologic and immunohistochemical study of 64 cases.
Cancer. 1997;80:699–707. 20% develops Superior Vena Cava Syndrome Merrick, SH. Tumors of the Mediastinum, Pleura, Chest wall, and Diaphragm In: Baum. GL, Crapo. JD. Textbook of Pulmonary Diseases; 6th ed; vol. I; New York: Lippincott Raven Publishers; 1998, 1408 GERM CELL TUMORS
Non-Seminomatous Rule In: NonSeminomatous Germ Cell Tumor GERM CELL TUMORS
Non-Seminomatous Rule In: NonSeminomatous Germ Cell Tumor Constitutional symptoms are observed in 90 to 100% cases of Mediastinal Nonseminomatous Germ Cell Tumors Knapp RH, Hurt RD. Payne WS, Farrow GM , Lewis BD, Hahn RG, et al. Malignant germ cell tumors of the mediastinum. J Thorac Cardiovasc Surg 1985; 89:82-89 Pleural and pericardial effusions are common. Lewis BD, Hurt RD. Payne WS, Farrow GM, Knapp Ru, Muhm JR. Benign teratoma of the mediastinum. J Thorac Cardiovasc Surg 1983; 86:727-31 Lactate dehydrogenase and serologic markers such as AFP and b-HCG are frequently positive. GERM CELL TUMORS
Non-Seminomatous Rule Out: NonSeminomatous Germ Cell Tumor Cannot totally rule out this entity

Further laboratory examination such as AFP, Beta HCG determination or Tissue Biopsy required 14th HD Hypotension
Weak Peripheral Pulses
Tachycardia
Desaturation (70-80)
Patient Coded and Expired PATHOPHYSIOLOGY 21 year old Male
Anterior Mediastinal Mass progressive dyspnea, tachycardia, tachypnea, pleurisy, orthopnea, occasional disorientation, and pulmonary compromise. hypotension with weak peripheral pulses elevated Alveolar Arterial Gradient for his age Cardiopulmonary Arrest
secondary to Acute Respiratory Failure
secondary to Pulmonary Embolism
secondary to Mediastinal Non-Seminomatous Germ Cell Tumor
in the background of Superior Vena Cava Syndrome ECG tracing of sinus tachycardia, non specific ST-T wave changes Wells Criteria of >4 value

Immobilization for 3 days
Malignancy
Tachycardia
alternative diagnosis is less likely PE FINAL DIAGNOSIS
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