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Interesting case

. 43 year oldFemale Known case of : Systemic Hypertension

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Interesting case

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    1. Interesting case Dr Chaitanya Vemuri

    2. 43 year old Female Known case of : Systemic Hypertension – 4 yrs Diabetes mellitus type 2 – 4 yrs Hypothyroidism on eltroxine – 2 yrs Bronchial asthma Hystrectomy -13 years ago Incisional hernia s/p hystrectomy

    3. Was referred to Gen.Med for control of blood sugars and hypertension before surgery for incisional hernia. She complained of breathlessness since 3 months, insidious in onset. Started as exertional dyspnea , progressively increased in intensity & now develops breathlessness even on doing minimal work No h/o paroxysmal nocturnal dyspnea No h/o chest pain, palpitations, syncope

    4. No h/o cough No h/o vomitings / abdominal pain No h/o genitourinary complaints No h/o focal neurologic deficits h/o loss of weight + h/o loss of appetite + Not a known case of dyslipidemia

    5. On examination Conscious and coherent No pallor, icterus, cyanosis, clubbing, pedal edema, lymphadenopathy Pulse : 64/min BP : 120/80 mm Hg RR : 32 / min, regular, thoraco-abdominal Temp : 98.6 F No Thyroid swelling No lump in breasts Dry skin + Icthyosis +

    6. CVS : S1+,S2+, No murmurs RS : b/l wheeze crepitations in left > right decreased chest movements,BS – Left side decreased VF, VR – Left sided P/A : distended 5X3 cm mass in periumbilical area cough impulse + hystrectomy scar + no hepatosplenomegaly bowel sounds + NS : Within normal limits

    7. CXR

    8. investigations WBC : TC : 6.97 K /il DC : N – 62 % L – 32.8 % Hb : 15.6 g % Plt : 272 k /ul RFT : within normal limits LFT : within normal limitss S.Electrolytes : within normal limits

    9. S.LDH : 179.4 U/L S.FERRITIN : 105.94 ng/ml ( 4.63 – 204 ) Urine r/e : within normal limits Stool for occult blood : negative Stool r/e : within normal limits Peripheral blood smear : normocytic normochromic blood picture

    10. echocardiogram Very poor echo window Tachycardia during study Normal chamber dimensions No RWMA Good LV systolic function Trivial MR Mild TR No clot No pericardial effusion EF : 65 %

    11. MDCT CHEST AND ABDOMEN MULTIPLE WELL DEFINED LESIONS IN BOTH LUNG FIELDS AND PLEURA – METASTASES THE PRIMARY COULD BE FROM THE HETEROGENOUSLY ENHANCING MASS IN LEFT LOWER LOBE OF LUNG AND BULKY OVARIAN MASSES

    12. MDCT …..

    13. DIAGNOSIS DIABETES MELLITUS TYPE 2 SYSTEMIC HYPERTENSION HYPOTHYROIDISM BRONCHIAL ASTHMA S/P HYSTRECTOMY INCISIONAL HERNIA MULTIPLE PULMONARY AND PLEURAL METASTASES IN SEARCH FOR THE PRIMARY ?

    14. Blood c/s : no growth Sputum c/s : no growth Cervical smear : negative for intraepithelial lesion / malignancy USG neck : normal sonographic morphology of thyroid Mammogram : benign calcification of right breast

    15. TPO Antibody : 488.34 U/ml ( < 5.61 ) Thyroglobulin antibody : 28.99 IU/ml (< 4.11) AFP : 1.03ng/ml ( 0 – 8.4 ) CA 19-9 : < 2 U/ml ( 0 – 37 ) Beta HCG : < 1.20 m IU /ml CEA : 1.95 ng/ml ( 0 – 5 ) FNAC from RT and LT LUNG LESION : INADEQUATE SAMPLE , REPEAT SAMPLE REQUIRED

    16. PULMONARY METASTASES Common in tumors with rich systemic venous drainage. Eg : renal cancer bone sarcoma choriocarcinoma melanoma testicular teratoma thyroid carcinoma Detection of pulmonary metastases is crucial in treatment of patients with cancer.

    17. incidence In UNITED STATES, autopsy series have demonstrated – pulmonary metastases in 20 – 54 % of all patients who die of cancer.

    18. MORBIDITY & MORTALITY The presence of pulmonary metastases is a bad prognostic factor – that indicates disseminated disease Mortality depends on the primary tumor.

    19. Age and sex Age Incidence of common tumors increases with patient age, as does the frequency of pulmonary metastases. However, pulmonary metastases can also be seen in children with neoplasms, such as Wilms tumors. Sex no much of difference b/w male and female incidence.

    20. Pulmonary metastases are common because the entire output of the right heart and the lymphatic system flow through the pulmonary vascular system. The initial event occurs at the primary tumor site. Fragments of tumor are dislodged after venous invasion, and carried as tumor emboli to the lungs via the systemic circulation.

    21. The majority of these fragments lodge in the small pulmonary arteries or arterioles, where they may proliferate and extend into the lung parenchyma and ultimately form nodules. Nodules are most commonly located either subpleurally or in the lung bases rather than in the upper lung, locations that reflect the pulmonary arterial circulation

    22. Tumor emboli remain confined to the perivascular interstitium and spread along the lymphatic channels toward the hilum or lung periphery. lymphangitis carcinomatosis. Retrograde spread from hilar lymph nodes via lymphatic channels. Pulmonary nodules are the most common manifestation of secondary neoplastic disease in the lungs.

    23. Pulmonary nodules are usually multiple, spherical, and variably sized. Symptoms are usually absent in patients with multiple metastases (80-95%). Dyspnea may develop as a result of parenchymal replacement by a large tumor load, airway obstruction, or pleural effusion. Sudden dyspnea is associated with the rapid development of a pleural effusion, pneumothorax, or hemorrhage into a lesion.

    24. Percutaneous biopsy or fine-needle aspiration may be used in certain patients to confirm the nature of suggested pulmonary metastases. Transthoracic biopsy and needle aspiration may be helpful in determining the nature of the nodules. Transthoracic needle aspiration has a positive yield of 85-95% in the evaluation of pulmonary nodules

    25. Lymphangitic tumor spread : requires transbronchial biopsy or thoracoscopic wedge resection for the histologic diagnosis Sputum cytologic analysis findings of malignant cells or bronchial brushings may be positive in 35-50% of patients with pulmonary metastases. Cytologic analysis of any pleural fluid of malignant origin may yield positive results in as many as 50% of patients. Such analysis usually does not distinguish between primary and secondary malignant lesions

    26. Bronchoscopy may be a useful examination in assessing pulmonary metastases with endobronchial extension.

    27. DIFFERENTIAL DIAGNOSIS Sarcoidosis Granulomatous abscessess Septic emboli Multiple infarcts Wegeners granulomatosus Multiple metastatic lesions

    28. CAVITATING METASTASES RARE Usually it is Squamous cell carcinoma More specifically involving upper lobes

    29. Thank you

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