Clinical Pathological Conference Shrujal Baxi, M.D. Chief Resident Department of Medicine November...
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Transcript of Clinical Pathological Conference Shrujal Baxi, M.D. Chief Resident Department of Medicine November...
Clinical Pathological Clinical Pathological ConferenceConference
Shrujal Baxi, M.D.Shrujal Baxi, M.D.Chief Resident Chief Resident
Department of MedicineDepartment of MedicineNovember 9, 2007November 9, 2007
Chief ComplaintChief Complaint
An 83 year-old man presents with An 83 year-old man presents with three days of intermittent chest pain three days of intermittent chest pain
History of Present IllnessHistory of Present Illness Six months prior to admission when he noted decreased Six months prior to admission when he noted decreased
exercise tolerance and was found to have a normocytic exercise tolerance and was found to have a normocytic
anemiaanemia thought to be Myelodysplastic syndrome, but no thought to be Myelodysplastic syndrome, but no work up done at that timework up done at that time
About five months prior to admission, pt noted a About five months prior to admission, pt noted a nonproductive, chronic cough that was worse in nonproductive, chronic cough that was worse in
evenings and relieved with prn albuterol therapyevenings and relieved with prn albuterol therapy
One month prior to admission, the patient again started One month prior to admission, the patient again started experiencing increasing shortness of breath.experiencing increasing shortness of breath.
5-10lb weight loss over last few months, night sweats, 5-10lb weight loss over last few months, night sweats, subjective feverssubjective fevers
History of Present IllnessHistory of Present Illness
On day of admission, pt presented with three days On day of admission, pt presented with three days of intermittent chest pain that was substernal and of intermittent chest pain that was substernal and radiated to his left arm and shoulder. It was radiated to his left arm and shoulder. It was sharp and stabbing in nature and worse with sharp and stabbing in nature and worse with inspiration. The episodes would last hours and inspiration. The episodes would last hours and were variably relieved with sublingual were variably relieved with sublingual
nitroglycerin.nitroglycerin.
Past Medical History:Past Medical History: Hypertension ≥ 20 yearsHypertension ≥ 20 yearsDiabetes ≥ 10 yearsDiabetes ≥ 10 yearsHypercholesterolemia ≥ 10 yearsHypercholesterolemia ≥ 10 years
Past Surgical HistoryPast Surgical History::
Appendectomy Appendectomy
Medications:Medications: (outpatient) (outpatient)
GlyburideGlyburide
RamiprilRamipril
AtenololAtenolol
Erythropoietin and ironErythropoietin and iron
albuterol prnalbuterol prn
Allergies:Allergies: nonenone
Family HistoryFamily History:: Brother died at 55 of MI. No family history of Brother died at 55 of MI. No family history of
malignancy, inflammatory conditionsmalignancy, inflammatory conditions
Social History:Social History: Born in the United States, patient fought in East Born in the United States, patient fought in East
Asia during World War II. He has no recent Asia during World War II. He has no recent travel. travel.
50 pack year tobacco history, quit 35 years ago. No 50 pack year tobacco history, quit 35 years ago. No alcohol use. No illicit drug use. Pt lives with wife alcohol use. No illicit drug use. Pt lives with wife in upstate New York. Pt worked in construction in upstate New York. Pt worked in construction prior to retiring at the age of 69. prior to retiring at the age of 69.
ROS:ROS: otherwise noncontributoryotherwise noncontributory
General: General: Well developed male with evidence of Well developed male with evidence of respiratory distress who appears younger than respiratory distress who appears younger than stated agestated age
Vital SignsVital Signs: BP 105/68 HR 120, regular, RR 20, Temp : BP 105/68 HR 120, regular, RR 20, Temp 98.2, SpO2 92% room air98.2, SpO2 92% room air
HEENTHEENT: Oropharynx clear and dry: Oropharynx clear and dry
Lymph Nodes: Lymph Nodes: No cervical, axillary or inguinal No cervical, axillary or inguinal lymphadenopathy lymphadenopathy
NeckNeck: Supple, jugular venous distention difficult to : Supple, jugular venous distention difficult to assessassess
Physical ExamPhysical Exam
PulmonaryPulmonary: Decreased breath sounds at bases, 1/3 : Decreased breath sounds at bases, 1/3 up bilaterally. Dull to percussionup bilaterally. Dull to percussion
HeartHeart: Decreased heart sounds, tachycardic, : Decreased heart sounds, tachycardic, regular rhythm, pulsus paradoxus of 22regular rhythm, pulsus paradoxus of 22
AbdominalAbdominal: Soft, nontender, nondistended, normal : Soft, nontender, nondistended, normal bowel sounds, with liver span of 14cm and dullness bowel sounds, with liver span of 14cm and dullness in Traube’s space in Traube’s space
ExtremitiesExtremities: No peripheral edema, 2+ peripheral : No peripheral edema, 2+ peripheral pulsespulses
SkinSkin: No rashes, no purpura, no petechia: No rashes, no purpura, no petechia
Physical ExamPhysical Exam
Admission LabsAdmission LabsLaboratoryLaboratory On AdmissionOn Admission Reference RangeReference Range
Hemoglobin (g/dl)Hemoglobin (g/dl) 10.110.1 13-1813-18
HematocritHematocrit (%)(%) 29.529.5 40-5240-52
White Cell Count (per mm3)White Cell Count (per mm3) 7,2007,200 4,500-11,0004,500-11,000
Differential Count (%) Differential Count (%)
NeutrophilsNeutrophils 5353 42-75%42-75%
LymphocytesLymphocytes 2222 20-50%20-50%
MonocytesMonocytes 77 2-12%2-12%
EosinophilsEosinophils 1818 0-7%0-7%
Mean Corpuscular VolumeMean Corpuscular Volume 83.283.2 80-9580-95
Platelet Count (per mm3)Platelet Count (per mm3) 195,000195,000 150-450,000150-450,000
MVPMVP 7.37.3 7.5-10.57.5-10.5
Partial-thromboplastin time, activated (sec)Partial-thromboplastin time, activated (sec) 33.6 33.6 23.3-35.623.3-35.6
Prothrombin time (sec) Prothrombin time (sec) 18.218.2 10.0-13.810.0-13.8
INRINR 1.51.5 .9-1.2.9-1.2
Lactate Dehydrogenase/LDHLactate Dehydrogenase/LDH 348348 110-225110-225
Admission LabsAdmission Labs
LaboratoryLaboratory On AdmissionOn Admission Reference RangeReference Range
Sodium (mmol/liter)Sodium (mmol/liter) 141141 135-145 135-145
Potassium (mmol/liter)Potassium (mmol/liter) 4.14.1 3.5-5.03.5-5.0
Chloride (mmol/liter)Chloride (mmol/liter) 104104 100-110100-110
Carbon dioxide (mmol/liter)Carbon dioxide (mmol/liter) 2828 24-3224-32
Urea nitrogen (mg/dl)Urea nitrogen (mg/dl) 2121 6-226-22
Creatinine (mg/dl)Creatinine (mg/dl) .7.7 .4-1.2.4-1.2
GlucoseGlucose 9595 65-11565-115
Calcium (mg/dl)Calcium (mg/dl) 8.58.5 8.5-10.58.5-10.5
Magnesium (mmol/liter)Magnesium (mmol/liter) 0.80.8 0.7-1.00.7-1.0
Phosphorus (mmol/liter)Phosphorus (mmol/liter) 2.92.9 2.6-4.52.6-4.5
Aspartate aminotransferase (U/liter)Aspartate aminotransferase (U/liter) 2525 10-4210-42
Alanine aminotransferase (U/liter)Alanine aminotransferase (U/liter) 1818 10-4210-42
Total Bilirubin (g/dl)Total Bilirubin (g/dl) 2.62.6 0.1-1.20.1-1.2
Alk PhosAlk Phos 109109 42-12142-121
Total Protein (g/dl)Total Protein (g/dl) 6.16.1 6.4-8.26.4-8.2
Albumin (g/dl)Albumin (g/dl) 4.24.2 3.8-5.13.8-5.1
Upon AdmissionUpon Admission
A prompt cardiac evaluation revealed a moderate to A prompt cardiac evaluation revealed a moderate to large pericardial effusion with right atrial collapse large pericardial effusion with right atrial collapse with a question of a right atrial mass. Pt was with a question of a right atrial mass. Pt was admitted to CCU for further evaluation. A admitted to CCU for further evaluation. A diagnostic procedure was performed…diagnostic procedure was performed…
Final DiagnosisFinal Diagnosis
Diffuse Large B-Cell Lymphoma Diffuse Large B-Cell Lymphoma (DLBCL) with primary cardiac (DLBCL) with primary cardiac involvementinvolvement
- CD45+, CD20+ - CD45+, CD20+
- CD3-, CD15-, CD30-, CD10-- CD3-, CD15-, CD30-, CD10-
Primary Cardiac TumorsPrimary Cardiac Tumors
Prevalence-.002-.025% at autopsyPrevalence-.002-.025% at autopsy 75% benign in nature75% benign in nature Systemic embolization is presenting Systemic embolization is presenting
symptom in 25-50% of casessymptom in 25-50% of cases Metastatic tumors 10-40X more likely Metastatic tumors 10-40X more likely
than primary tumor than primary tumor
Primary Cardiac TumorsPrimary Cardiac Tumors
Benign (75% of all cases)Benign (75% of all cases) MyxomaMyxoma RhabdomyomaRhabdomyoma FibromaFibroma TeratomaTeratoma
Malignant (25% of all cases)Malignant (25% of all cases) Sarcoma (majority)Sarcoma (majority)
• AngiosarcomaAngiosarcoma• RhabdomyosarcomaRhabdomyosarcoma
LymphomaLymphoma HistiocytomaHistiocytoma
Malignant (25 of all cases)Malignant (25 of all cases)SarcomaSarcoma
AngiosarcomaAngiosarcomaRhabdomyosarcomaRhabdomyosarcomaFibrosarcomaFibrosarcomaLeiomyosarcomaLeiomyosarcoma
OtherOtherLymphomaLymphomaHistiocytomaHistiocytoma
Primary Cardiac Lymphoma (PCL)Primary Cardiac Lymphoma (PCL) Defined as presence of Non-Hodgkin’s Defined as presence of Non-Hodgkin’s
Lymphoma confined to the heart or Lymphoma confined to the heart or pericardiumpericardium
PCL represents <2.0% of 1° cardiac tumors PCL represents <2.0% of 1° cardiac tumors
and 0.5% of extranodal lymphomasand 0.5% of extranodal lymphomas
More common in immunocompromisedMore common in immunocompromised
Increased incidence due to AIDS and Increased incidence due to AIDS and
improved imaging techniquesimproved imaging techniques
LymphomaLymphoma
Now the 5Now the 5thth most common cancer most common cancer diagnosed in both men and womendiagnosed in both men and women
Represent 4% of all cancersRepresent 4% of all cancers Approximately 63,000 cases diagnosed Approximately 63,000 cases diagnosed
annuallyannually Age at diagnosis is 60 with more than 50% Age at diagnosis is 60 with more than 50%
over the age of 65over the age of 65 5 year survival is 63% and 10 year survival 5 year survival is 63% and 10 year survival
is 49%is 49%
PathophysiologyPathophysiology
Kuppers R et al. N Engl J Med 1999;341:1520-1529
Assignment of Human B-Cell Lymphomas to Their Normal B-Cell Counterparts
PCLPCL
Common presentations of this uncommon Common presentations of this uncommon diagnosis are based on location of tumordiagnosis are based on location of tumor
Right-sided heart failureRight-sided heart failure Precordial chest painPrecordial chest pain Pericardial effusionPericardial effusion Superior vena cava syndromeSuperior vena cava syndrome ArrhythmiaArrhythmia CHFCHF Constitutional SymptomsConstitutional Symptoms
Pathogenesis of DiseasePathogenesis of Disease
Environmental Factors
Mutation to Oncogene
of Lymphoid Cell
Tumor Mass fromreplicating atypical
lymphoma cells
Release of Cytokines (TNF, IL-6)
Pericardial Effusion
Tissue invasion of right atriumand septal wall
Atrial Fibrillation
Pleural effusions
cough dyspnea chest pain
Anemia of Chronic Disease
WeightLoss
fatigue
Night Sweats
Diagnostic StudiesDiagnostic Studies
Labs: Labs: LDH, LDH, IL-2, IL-2, ESR ESR ECG: AV block, RBBB, Inverted T waves, ECG: AV block, RBBB, Inverted T waves,
Low voltageLow voltage CXR: Pleural Effusion and/or CardiomegalyCXR: Pleural Effusion and/or Cardiomegaly Echocardiography: Echocardiography:
• Hypoechoic masses in the R atrium with pericardial Hypoechoic masses in the R atrium with pericardial effusioneffusion
• TTE: difficulty visualizing pulmonary vessels, SVC, R TTE: difficulty visualizing pulmonary vessels, SVC, R atriumatrium
Diagnostic StudiesDiagnostic Studies CTCT
• Appears hypodense or isodense relative to adjacent Appears hypodense or isodense relative to adjacent myocardium myocardium
• + Contrast: heterogenous enhancement+ Contrast: heterogenous enhancement MRIMRI
• T1 images: Hypointense and Dark T1 images: Hypointense and Dark • T2 images: Hyperintense and BrightT2 images: Hyperintense and Bright• + Gadolinium: Heterogenous enhancement+ Gadolinium: Heterogenous enhancement• Useful in making diagnosis and assessing response to RXUseful in making diagnosis and assessing response to RX
Nuclear medicine techniquesNuclear medicine techniques• Gallium 67Gallium 67• Technetium-99m hexakis-2-methoxyisobutyl isonitrileTechnetium-99m hexakis-2-methoxyisobutyl isonitrile• Thallium-201Thallium-201
Diagnostic StudiesDiagnostic Studies
Tissue is the Issue…Tissue is the Issue… Pericardial fluid Pericardial fluid
• Diagnostic in 67 % of casesDiagnostic in 67 % of cases
Tissue biopsyTissue biopsy• MediastinoscopyMediastinoscopy• Thoracoscopic biopsyThoracoscopic biopsy• TEE guided biopsyTEE guided biopsy• Endomyocardial transvenous biopsyEndomyocardial transvenous biopsy• Exploratory thoracotomyExploratory thoracotomy
TreatmentTreatment
Treatment for DLBCL is the chemotherapy Treatment for DLBCL is the chemotherapy regimen of R-CHOPregimen of R-CHOP
R=RituximabR=Rituximab C=CyclophosphamideC=Cyclophosphamide H=AdriamycinH=Adriamycin O=VincristineO=Vincristine P=PrednisoneP=Prednisone
Alternative regimens include: Alternative regimens include: COPCOP CHOPCHOP Bone Marrow TransplantBone Marrow Transplant
Follow-UpFollow-Up
Upon admission, pt had pleural and Upon admission, pt had pleural and pericardial drains placedpericardial drains placed
While work-up continuing, patient While work-up continuing, patient developed rapid afib controlled with low-developed rapid afib controlled with low-dose b-blockerdose b-blocker
Due to concern of significant atrial wall Due to concern of significant atrial wall involvement of disease, first 2 cycles of R-involvement of disease, first 2 cycles of R-CHOP given in CCU setting with continuous CHOP given in CCU setting with continuous cardiac monitoringcardiac monitoring
Patient is currently disease free after Patient is currently disease free after receiving a complete course of R-CHOPreceiving a complete course of R-CHOP