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<Case
History>
A 35 y/o man was
admitted due to steatorrhea and exertional dyspnea for 6
months.
The patient had a history of
left maxillary osteogenic sarcoma at the age of 20 with
initial presentation of left facial mass and painless swelling
of left buccal mucosa for 2 months. He received left partial
maxillectomy, and adjuvant radiotherapy (5500cGy/ 40day)
thereafter and no local recurrence was detected during
follow-up. Left eye keratoconjunctivitis, cataract and
vitreous hemorrhage were complicated subsequently due to
radiotherapy and ophthalmic operation were performed for 2
times. His left eye cannot have visual acquisition since then.
The patient began to have
steatorrhea and frequent flatulence since 6 months ago. He
visited our clinic and was treated as functional
gastrointestinal disorder but in vain. Then, he began to have
dyspepsia since 4 months ago, followed by exertional dyspnea 2
months later. He visited our OPD again, when anemia with
hemoglobin 5.2 g/dL only was noted. For searching the etiology
of profound anemia, PES was arranged which showed an
ulcerative mass at the second portion of the duodenum. Body
weight loss was detected from 90 to 80 kg in 6 months. Febrile
sensation without chills was suffered also in recent 2 months.
He claimed that he had no tarry/clay-color stool, cough,
abdominal pain, nor dysuria.
After admission, the body
temperature was 38.2°C, the pulse rate was 110/min, and the
respiratory rate was 20/min. The blood pressure was 110/70
mmHg.
On Physical examination, the
patient appeared pale with mild febrile. The conjunctiva was
pale, the sclera was anicteric. The pupil of the left eye was
dilated due to cataract surgery. No lymphadenopathy was found.
There was a Grade 2/6 systolic ejection murmur at left upper
sternum border. The lungs and abdomen were unremarkable and no
clubbing fingers noted.
<Laboratory Data>
[ CBC+PLT ]
| |
WBC |
RBC |
HB |
HCT |
MCV |
MCH |
MCHC |
PLT |
| 日期 |
K/μL |
M/μL |
g/dL |
% |
fL |
pg |
g/dL |
K/μL |
| 0910408 |
4.87 |
2.32 |
4.1 |
15.1 |
65.1 |
17.7 |
27.2 |
205.0 |
[ Biochemistry ]
| 項 目: |
|
UN |
CRE |
Na |
K |
T-BIL |
AMY |
Lipase |
Ca |
AST |
ALP |
| |
|
mg/dl |
mg/dl |
mmole/l |
mmole/l |
mg/dl |
U/l |
U/l |
mmole/l |
U/l |
U/l |
| 日期 |
0910408 |
12.7 |
0.93 |
135.5 |
4.87 |
0.39 |
56.0 |
159.0 |
1.89 |
38.0 |
368 |
| 項 目 |
日 期 |
檢驗值 |
參考值 (單位) |
| Ferritin |
910409 |
2.61 |
♂ 17.9~464, ♀ <50y: 6.31~151;
♀>=
50y: 10.2~265
(ng/mL) |
| Iron |
910409 |
18.0 |
♂ 51 ~ 180, ♀ 33 ~ 167 (μg/dL) |
| TIBC |
910409 |
451 |
275 ~ 332 (μg/dL) |
[ STOOL ]
| 日期 |
Appearance |
O.B.(Stool) |
Fat |
| 0910410 (1445) |
YB;S |
4+ |
+ |
[Tumor marker] (91-04-09)
| RIA: CA 19-9(Serum) |
7.3 |
U/ml |
| RIA: CEA (Serum) |
0.47 |
ng/ml |
| ALP |
368 |
U/l |
91/04/09,
CHEST: PA VIEW (STANDING) (Fig.1
): pleural calcification in the right upper
thorax. no definite active lung lesion is found. heart size is
normal.
KUB (Fig.2 ): Radiopaque mass with granular
radiodensity or calcification over the middle upper abdomen.
91/04/09,
CT scan of abdomen with & without contrast (Fig.3
):
* A tumor of about 6cm in size
arising from the duodenal wall at the 2nd and the 3rd portion.
Marked calcifications within the tumor is noted. No definite
LAP is found in the adjacent mesentery paraaortic regions,
celiac trunk or SMA root.
* Multiple hepatic tumors in
bil. lobes of liver. calcifications are found in some of the
tumors. Liver meta. is considered. No definite focal lesion is
found in the pancreas, spleen, bil. kidneys or lung base.
91/04/10, Whole body scanning of the entire
skeleton shows the followings:
1. A focal hot
spot was noted at right lateral upper rib. It could be due to
trauma. Close follow up is advised.
2. A large soft tissue
uptake was noted at right ant. mid abdomen. It could be due to
tracer tumor uptake.
3. Normal excretory activity is noted
in bilateral kidneys and urinary bladder.
91/04/12, SMALL BOWEL |BAR.MEAL
FOLLOW-THR:
Small bowel series with barium under
fluoroscopic control shows:
1. Smooth passage of barium
through whole course of the small bowel with fine peristalsis.
2. Widening of duodenal C-loop is noted. A polypoid mass
lesion with surface ulcerations and focal narrowing noted at
third portion of duodenum.
3. Normal ileo-cecal valve.
4. Transit time through the small bowel about 25 minutes.
91/4/29,
Chest CT (Fig.4 ): There is a
small calcification noted at the left lobe of liver dome area
and multiple heterogeneously hypodense mass associated with
calcification noted at left and right lobe of liver. Focal
pathological fracture with adjacent pleural thickening and
chest wall thickening noted at the lateral aspect of the right
4th
rib.
Pathology Report:
91-04-08 (endoscopic biopsy specimen):
Microscopically, it shows clusters of hyperchromatic and
pleomorphic anaplastic cells embedded within a hyalinized
stroma resembling chondroid background. Necrosis is also
prominent. Review his history and according to his age, a
metastatic chondroblastic osteosarcoma is compatible.
91-04-23(surgical specimen): A: duodenum
tumor and B: hepatic tumor. Microscopically, all the sections
show tumors composed of epithelioid to spindle cells arranged
in a tubular, sheet or lacunar pattern embedded within a
mucicarmine positive chondroid stroma. The tumor cells have
hyperchromatic to vesicular nuclei and clear cytoplasm. The
tumor cells are reactive to vimentin, focally reactive to S100
protein and negative for cytokeratin. Malignant osteoid
formation is noted and the whole picture is a metastatic
osteosarcoma.
Course and Management:
After admission, staging work-up was performed. Abdominal
CT showed a duodenal tumor and multiple hepatic tumors with
calcifications. Liver metastasis was considered. Whole body
bone scanning showed a focal hot spot at right ant. mid
abdomen, probably due to tumor uptake. Small bowel series
disclosed an ulcerative tumor at the duodenum. We consulted
oncologist and chemotherapy was indicated after the nature of
liver metastasis determined. Severe anemia due to GI blood
loss was noted. We consulted general surgeon and they
suggested palliative operation for anemia symptom relief.
During operation, the duodenal tumor couldn't be removed
thoroughly due to vessel encasement. Double bypass surgery
(Gastrojejunostomy and choledochojejunostomy) was performed.
Open biopsy of the hepatic tumor located at the left lobe of
the liver was taken. However, the pathology reports of
duodenum tumor and hepatic one were both osteosarcoma. After
insertion of Port-A catheter, he was discharged. He received
chemotherapy with regimen of Adriamycin and Cisplatin in the
oncology ward since May 24, 2002
smoothly.
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Case Discussion
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