CLINICO-PATHOLOGICAL CONFERENCE CLASS OF 2007/2012 PHASE IIIB SESSION 2010/2012

Transcription

1 CLINICO-PATHOLOGICAL CONFERENCE CLASS OF 2007/2012 PHASE IIIB SESSION 2010/2012 PRESENTATION OF CASE A 62-year-old woman was seen in the outpatient cancer center of this hospital because of anemia and paraspinal masses. The patient was in her usual state of health, with a history of asthma, until 8 months before this evaluation, when exertional dyspnea, shortness of breath, and fatigue developed. She went to the emergency department at another hospital. A chest radiograph reportedly showed a paraspinal mass in the right lower thorax. Two months later, a repeat chest radiograph showed clear lung fields; the paraspinal mass was unchanged. The next week, computed tomography (CT) of the chest reportedly revealed a well-marginated paraspinal mass (3 cm by 5 cm by 5 cm) on the right, extending from the T9 vertebral body to the T11, with no extension into or widening of the neural foramina and no expansion or cortical erosion of the ribs or vertebral bodies. There was also a mass (1.2 cm in diameter) adjacent to the right posterior eighth rib and another mass (1.0 cm in diameter) adjacent to the left posterior ninth rib. Two weeks later, magnetic resonance imaging (MRI) of the thoracic spine after the administration of gadolinium reportedly showed a paraspinal mass (3 cm by 5 cm) on the right, extending from T9 to T11, with a heterogeneous pattern and mild enhancement. The mass had no effect on the neural foramina, caused no expansion of the ribs or vertebral bodies, and had no evidence of signal suppression on fat-suppressed sequences to suggest the presence of fat. Six weeks later, 3 months before this evaluation, the patient was seen in follow-up by her internist. The vital signs and examination were normal; laboratory-test results are shown in Table 1. The following week, a percutaneous, CT-guided needle biopsy of a right paravertebral mass was performed at another hospital; pathological examination of the tissue revealed maturing myeloid and erythroid precursors and megakaryocytes, features consistent with extramedullary hematopoiesis (myeloid metaplasia). Seventeen days before this evaluation, the patient was evaluated by a hematologist at another hospital. Serum levels of electrolytes, glucose, and lactate dehydrogenase were normal, as were tests of renal and liver function. Examination of a peripheral-blood smear revealed moderate hypochromia, microcytosis, and anisocytosis and occasional elliptocytes, schistocytes, teardrop red cells, and polychromatophilic red cells; other test results are shown in Table 1. Additional test results were pending. On evaluation in the hematology clinic of this hospital, the patient reported occasional mild dyspnea on exertion and no fevers, chills, or night sweats, no diarrhea, and no sinopulmonary infections. Her appetite was normal, and the Eastern Cooperative Oncology Group performance status was 1 (symptomatic but ambulatory and working) on a scale of 0 to 5, where 0 is normal and 5 signifies death. She had arthritis in the left knee and asthma and had had a lung biopsy in the past for unclear reasons; examination of the biopsy specimen reportedly showed no abnormalities. Medications in the recent past included albuterol and ipratropium metered-dose inhalers, tramadol hydrochloride, and iron supplements; she had no known allergies. She was born in Cambodia, lived in the

2 northeastern United States with her daughter, and worked in a health-related field. She had stopped smoking cigarettes 15 years earlier, drank alcohol in moderation, and did not use illicit drugs. Two sisters had died of heart disease; there was no family history of hematologic cancer. On examination, the patient appeared well, without respiratory distress. The weight was 63.5 kg, the temperature 36.1 C, the blood pressure 122/68 mm Hg, the pulse 85 beats per minute, and the oxygen saturation 100% while she was breathing ambient air. There were occasional expiratory wheezes, without rales or rhonchi. The spleen tip was palpated approximately 12 cm below the left costal margin, and there was no hepatomegaly. The remainder of the examination was normal. Serum levels of electrolytes, glucose, protein, albumin, globulin, calcium, magnesium, and lactate dehydrogenase were normal, as were results of tests of coagulation, renal function, and liver function. Examination of a peripheral-blood smear showed features similar to those of the earlier specimen; other test results are shown in Table 1. Later that day, bone marrow aspiration and biopsy were performed. Pathological examination of the core-biopsy specimen revealed a normocellular marrow for the patient's age (overall cellularity of approximately 40%), with erythroid hyperplasia and marked dyserythropoiesis. Megakaryocytes were normal in number and morphology. There were no morphologic abnormalities in the granulocytic series. Reticulin deposition was not increased. Storage iron was present, and there were no ring sideroblasts. Flow cytometry showed normal B cells and T cells and no increase in myeloid blasts. Cytogenetic analysis revealed a normal female karyotype (46,XX). A diagnostic-test result was received.

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4 Table 1

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