Pulmonary Pathology Case 8

 

1.  The patient is a 54 year old male who first noticed multiple "muscle cramps" in March 2003 and self-treated with aspirin, up to 15 tablets a day. His pain progressed, such that he began using crutches to walk because of low back pain. He went to a doctor for evaluation about two weeks ago, where an x-ray revealed multiple lytic lesions and he was referred to the Orthopedics Clinic for evaluation.  The patient underwent pinning of a femoral neck fracture but additional pathologic fractures were found and a work up was initiated by Oncology for metastatic cancer of unknown primary.  His past history is significant for diabetes mellitus and a previous CABG. On his final hospitalization he suffered a myocardial infarction.

 

Admission & Discharge Summary for        6-9-03 to 6-20-03

Operative note                                            6-14-03

Surgical Report Images                              6-14-03

Oncology Office Note                                 6-28-03

Death Summary                                         6-29-03

Labs                                                            6-7-03

Labs                                                            6-18-03

Labs                                                            6-28-03

Troponin Trends

Microbiology Report

Autopsy Report                                         6-29-03

Autopsy Gross Images

Autopsy Microscopic Images

 

Radiology Reports                 X-ray Images

          NM Scan 6-3-03            NM Scan 6-3-03

          CXR 6-7-03                   CXR 6-7-03

          CT 6-8-03                      CT 6-8-03

          CXR 6-14-03                 CXR 6-14-03

          CXR 6-18-03                 CXR 6-18-03

          CXR 6-28-03                 CXR 6-28-03

 

2. Review the case in order to answer the following questions:

 

1. What is the pertinent Clinical History?

2. What is his lung disease?

3. What treatment did he receive for this disease?

4. What are the pertinent Laboratory findings to his lung disease and cause of death?

5. What was his final hospital course?

6. Why did he die?

          7. Give an academic review of:

          Adenocarcinoma of the lung, diagnosis and treatment

          Explain the work-up for metastatic tumor of unknown origin and the use of frozen section at surgery

 

3. Prepare a power point presentation including the above material to present to the entire class.  Make this a formal presentation as if you were presenting at a major conference.  You will have ten minutes to present and 5 minutes for questions.  Be prepared to answer questions about the case from the clinical faculty.

 

Radiology

Nuclear medicine Scan 6-3-03           report

 

 

 

 

CXR 6-7-03                   report

 

 

CT 6-8-03            report

 

 

 

 

 

CXR 6-14-03                 report

 

CXR 6-18-03                 report

 

 

CXR 6-28-03                 report

 

 

Surgical Pathology Bone Biopsy 6-14-03 report

 

Autopsy Gross Images

Lung with puckered pleura, underlying parenchymal mass and enlarged lymph nodes

  

 

  

 

Hamartoma of Right Lower Lobe

 

Autopsy Microscopic Images

Microscopic images of the lung tumor with intravascular metastases

 

 

 

 

Section of the adrenal with metastasis

 

 

Section of the liver with metastasis

 

 

Incidental finding in the lung, hamartoma

 

 

 

 

Admission and Discharge Summary 6-9-03 to 6-20-03

Discharge Summary     Adm Date: 06/09/03
                     Disc Date: 06/20/03

HISTORY OF PRESENT ILLNESS: This is a 54-year-old male with recently discovered metastatic cancer of unknown primary who was admitted with a possible left lower lobe pneumonia. The patient first noticed multiple "muscle cramps" in March 2003 and self-treated with aspirin, up to 15 tablets a day. His pain progressed, such that he began using crutches to walk approximately one month ago secondary to low back pain. He went to a doctor for evaluation about two weeks ago, where an x-ray of some sort revealed lytic lesions and he was referred to the Orthopedics Clinic for evaluation.

His workup included a CT of the chest, abdomen and pelvis, as well as a bone scan. The CT workup revealed extensive mediastinal left hilar subcarinal and paraesophageal lymphadenopathy, with a large lymphadenopathy in the AP window measuring 3 x 3 cm. The patient also had multiple lytic lesions in several vertebrae of the right ribs, with pathologic fracture of ribs, and a right proximal clavicle pathologic fracture. The CT of the abdomen revealed a 1 cm mass in the right lobe of the liver, diffuse osseus metastatic lesions, including left iliac wing, a right trochanter lesion, and a left hip lesion. Bone scan with multiple diffuse metastases.

The patient was scheduled for pinning of the left trochanter, but he was found to have left lower lobe pneumonia and was thus not felt to be surgically stable by anesthesiology. He does have symptoms of chronic mild cough with some scant sputum production and has a low-grade fever. The patient is transferred from the medicine service to the hematology/oncology service for further workup.

PAST MEDICAL HISTORY: 1) Coronary artery disease status post CABG 11 years ago. 2) Hypertension. 3) Diabetes, requiring insulin for approximately one year. 4) Status post right carotid endarterectomy approximately 11 years ago. 5) GERD. 6) BPH. 7) Right inguinal herniorrhaphy.

CURRENT MEDICATIONS: Insulin, Accupril, Flomax, clonidine, multivitamin, aspirin.

ALLERGIES: Codeine.

SOCIAL HISTORY: The patient works as a manager of a half-way house. He is divorced with four children. He has a 30 to 40-pack-year tobacco history; quit ten years ago. Occasional alcohol use.

FAMILY HISTORY: The patient is adopted.

PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 38.1, pulse 96, blood pressure 160/76, respirations 20. Weight 180 pounds. GENERAL: Alert and oriented, in mild distress secondary to pain. No respiratory distress.

HEENT: Pupils equal, round, reactive to light. Extraocular
motions intact. Cranial nerves intact. Edentulous. Normal oropharynx.

NECK: Supple, no JVD elevation. Some questionable left cervical adenopathy.

CARDIOVASCULAR: Regular with a I/VI systolic ejection murmur at the left sternal border.

CHEST: Decreased breath sounds at the left base, with occasional crackles.

ABDOMEN: Diffuse tenderness. No organomegaly. Normal bowel sounds. No guarding, no rebound.

EXTREMITIES: No edema, no rash. MUSCULOSKELETAL: Full range of motion at both hips but with pain in the left hip. The patient was unable to stand secondary to this pain. NEUROLOGIC: Essentially nonfocal.

LABORATORY DATA: White count 8, hemoglobin 36, platelets 223. Sodium 137, potassium 3.8, BUN 26, creatinine 1.5. Alkaline phosphatase 152, AST 48, albumin 3.3.

HOSPITAL COURSE: 1. Pathologic left hip lesion with pain and instability. The patient underwent a left hip pinning procedure by orthopedic surgery, which was successful and was done with the intent of subsequent radiation to this area to stabilize the joint.

2. Cardiovascular. In the perioperative period from the patient's hip repair, the patient had perioperative chest pain and an elevated troponin after this procedure. His EKG was essentially unchanged except in lead V4 with some ST depression, and troponin I was found to be elevated at 14.7. The patient was in mild respiratory distress with wheezes and increased oxygen requirement. Chest x-ray revealed pulmonary edema, which responded to diuretics. The patient spent approximately a day and a half in the MICU for hemodynamic stabilization and was subsequently discharged to the floor to the hematology/oncology service for continuation of his care.

3. Oncology. Tissue procured from the patient's left hip repair revealed non-small cell adenocarcinoma, likely from lung cancer. The patient was scheduled for radiation therapy as an outpatient. A left lower lobe lung nodule was discovered on chest CT and was felt to be the primary source of his adenocarcinoma. This area, along with the patient's pathologic fractures and bony metastases, may be considered as the potential site for palliative radiation. The patient was counseled at length about the seriousness of this diagnosis, and he opted for ECF rehabilitation and pain management and would like to return to his home with hospice nursing care.

4. Pain. The patient had significant pain in many bony areas while hospitalized. This was ultimately reasonably controlled with oral medication. It is expected that radiation treatment may help tremendously with his rib, clavicle, and hip pain in a palliative fashion.

5. Infectious diseases. The patient was intermittently febrile while hospitalized. This was suspicious for left lower lobe postobstructive pneumonia, although chest x-ray was equivocal for this. He received approximately one week of IV antibiotics and will be maintained as an outpatient on oral antibiotics in case the patient has residual postobstructive pneumonia.

DISPOSITION: The patient was discharged in stable condition to a rehab ECF for subacute care, to include physical therapy, occupational therapy, evaluation and treatment, as well as pain management. The patient requested to be DNR and would like hospice care from here on out. The patient will be transported daily to the hospital for radiation therapy. He will follow up in the chronic pain clinic in approximately one week. He will also follow up with oncology and orthopedics in approximately one week.

DISCHARGE MEDICATIONS:
Aspirin 325 mg p.o. q.d.; cefuroxime 503 mg p.o. b.i.d. times four days; Colace 103 mg p.o. b.i.d.; Imdur 30 mg p.o. q.d.; Prevacid 30 mg p.o. q.d.; metoprolol 12.5 mg p.o. b.i.d.; MS-Contin 60 mg p.o. t.i.d.; sublingual nitroglycerin one tablet every five minutes times three p.r.n.; Senokot two tablets p.o. b.i.d.; Flomax 0.4 mg p.o. b.i.d.; albuterol metered dose inhaler two puffs q.i.d. p.r.n.; Dulcolax suppository one per rectum b.i.d. p.r.n.; MSIR 30 mg p.o. q.3h. p.r.n.

 

Operation Report

Operation Report         Proc Date: 06/14/03
 

PREOPERATIVE DIAGNOSIS:       Lytic lesion left femur, lesser trochanter.
POSTOPERATIVE DIAGNOSIS:      Metastatic non-small cell carcinoma to left
                              femur, lesser trochanter
.

OPERATION:          1. Biopsy.
                    2. Prophylactic nailing of left femur.

Anesthesia:              General.
Implant:                 12 x 38 cm reconstruction nail, no distal
                         interlocks.

INDICATIONS: The patient is a 54-year-old male with left hip pain with workup revealing metastatic disease to multiple sites. The CT scan revealed a probable lung primary. He was scheduled for the above mentioned procedure. He was at significant fracture risk. The risks, benefits, goals, and possible complications of the procedure were explained to the patient in detail and all questions were answered and thereafter operative consent was obtained. The patient understands the risks included but were not limited to intraoperative fracture, progression of disease, persistent pain, infection.

PROCEDURE: The patient was brought to the operating room theater and transferred to a well-padded operating table in the supine position. General anesthesia was administered by the anesthesia service and he was placed in the right side down decubitus position with all pressure points padded and well stabilized with the bean bag. The left lower extremity was prepped and draped in the usual hind quarter fashion and prophylactic antibiotics were given.

A standard approach to the piriformis fossa via a lateral incision was done. This involved approximately a 4 cm incision just proximal to the tip of the greater trochanter. We incised down to the fascia and spread the gluteus maximus and came down upon the piriformis fossa. We then used fluoroscopy to confirm placement on the AP and lateral plane. After gaining assess we just reamed proximally to the level of the lesion to a
size 12. We then used a pituitary rongeur and curets to obtain tissue from the lesser trochanter that was confirmed under fluoroscopic image. We then sent this off for frozen. The frozen came back as consistent with non-small cell carcinoma.

We then proceeded with standard placement of the nail with reaming distally. We reamed up to a size 13 for a 12 mm nail. We got the appropriate length using the standard technique and placed the reconstruction device in the standard manner. We placed two locking screws up into the neck. We got the AP and lateral images to confirm adequate length. Because of the proximal extent of the disease it was decided not to place distal interlocks. We then irrigated and closed.

We closed the proximal incision over a medium Hemovac drain. All incisions (the main incision and the incision for the interlock screws) were closed with #0 Vicryl for the fascia, 2-0 for the subcutaneous tissue, and 3-0 Vicryl for the subcuticular. Estimated blood loss was 250 cc. There were no untoward events and the patient was taken to the PACU in stable condition after reversal of anesthetic and a sterile
dressing had been applied.

Specimens included all reamings to pathology as well as the specimen mentioned in the frozen.

 

 

 

Surgical Pathology Report

06/14/03

SP FINAL REPORT

SP CLINICAL HISTORY

Left femur metastatic pathology.

SP GROSS DESCRIPTION: This case comes in three parts.
Part one labeled "#1 femur pathology" is received fresh for frozen section in
a container labeled with the patient's name and information. It contains an
aggregate of brown soft tissue and bone that measures in aggregate 5.0 x 2.0 x
1.0 cm. A representative portion is frozen and its remains are submitted as
1FA. The remainder of the tissue is submitted entirely in 1A and 1B.
Part two labeled with the patient's name and information and "#2 femur
metastatic" is received fresh and contains an aggregate of brown soft tissue
that measures 3.0 x 2.0 x 0.4 cm and is somewhat sticky. This is entirely
submitted in 2A.
Part three received fresh in a container labeled with the patient's name and
information and "#3 intramedullary tissue femur" contains an aggregate of
red-brown, sticky to runny soft tissue that measures 6.3 x 0.6 x 0.5 cm in
aggregate. A representation is submitted in cassette 3A.
______________________________

SP FROZEN SECTION DIAGNOSIS:

Frozen section diagnosis
1FA - "Malignant cells present most consistent with non-small cell carcinoma."
______________________________

SP DIAGNOSIS

1. "FEMUR," (CURETTAGE):
- METASTATIC NON-SMALL CELL CARCINOMA WITH FEATURES SUGGESTIVE OF
  ADENOCARCINOMA.

2. "FEMUR," (CURETTINGS):
- METASTATIC NON-SMALL CELL CARCINOMA WITH FEATURES MOST CONSISTENT WITH
  AN ADENOCARCINOMA.

3. "INTRAMEDULLARY TISSUE FEMUR," (CURETTINGS):
- METASTATIC NON-SMALL CELL CARCINOMA WITH FEATURES MOST CONSISTENT WITH
  ADENOCARCINOMA.
____________________

Image

 

 

Office Visit Note


Hematology/Oncology, 6/28/03

The Patient is a 54-year-old man with widely metastatic non-small cell lung cancer who comes for follow-up. He was initially evaluated in the hospital when he was admitted for pinning of his left femur. His femur was successfully pinned but unfortunately, he suffered a postoperative myocardial infarction requiring a brief CCU stay. He was discharged to a rehabilitation facility and is continuing XRT to the left femur, right clavicle, and chest.

Presently, the Patient presents in a wheelchair. He looks more acutely ill. He is complaining of inadequate pain control, stating that he needs two Percocet every two hours during the night in order to sleep. He is also not eating well. His pain appears to be diffuse, but especially in the right clavicle, across the anterior chest, and his left femur.

He is also complaining of some hallucinations and experienced visual hallucinations during our visit. Otherwise, he was complaining of no cough or shortness of breath.

PHYSICAL EXAMINATION: Vital Signs- Weight 184 lbs, temperature 103.1F, blood pressure 165/87, pulse 73, and KPS 30%. In general, he appeared chronically ill, falling asleep periodically during our conversation. Occasionally, he described visual hallucinations and did not seem entirely coherent. HEENT- remarkable for pinpoint pupils. Throat- clear. Lungs- clear. Heart- regular rate and rhythm. Abdomen- soft. Extremities- 3+ bipedal edema.

ASSESSMENT: 54-year-old man with widely metastatic non-small cell lung cancer with change in mental status. This is probably due to narcotics but may be related to hypercalcemia or brain metastases.

PLAN:

(1) He will be admitted to the hospital for work up of his change in mental status.

(2) XRT will continue.

(3) No chemotherapy is warranted at this time as his performance status is not acceptable.

 

 

Death Summary

Death Summary         Adm Date: 06/28/03
                     Disc Date: 06/29/03

HISTORY OF PRESENT ILLNESS: The Patient was a 54-year-old male who was diagnosed with metastatic lung cancer in April of 2003. He was admitted for change of mental status, increased shortness of breath and bilateral leg edema.

PAST MEDICAL HISTORY: Wide spread metastatic bone disease, carcinoma of the lung as primary cancer. Coronary artery disease, status post coronary artery bypass graft 11 years ago. Hypertension. Diabetes mellitus requiring insulin. Status post right carotid endarterectomy 11 years ago. Gastroesophageal reflux disease. Benign prostatic hyperplasia. Right inguinal herniorrhaphy.

MEDICATIONS: Aspirin, metoprolol, Nitroglycerin, albuterol, MSIR, MS Contin, insulin, Prevacid, Imdur, Colace, Senokot, Flomax, Dulcolax.

ALLERGIES: Codeine.

SOCIAL HISTORY: The patient worked as a manager of a halfway house. He was divorced and has four children which he has completely lost touch with. He has a 30 to 40 pack year history of tobacco use and occasional alcohol use.

FAMILY HISTORY: The patient was adopted and there is no knowledge of blood relatives.

PHYSICAL EXAMINATION: GENERAL: This is a 54-year-old male with shortness of breath, sitting in bed in moderate distress.

VITAL SIGNS: Temperature 36.9, pulse 112, respirations 24, blood pressure 128/64.

HEENT: Oral mucosa erythematous. Pupils are miotic and round and reactive to light.

NECK: Supple, no lymphadenopathy, no thyromegaly.

CHEST: Minimal crackles or rales bilaterally. Good breath sounds, no wheeze. HEART: S1 and S2, tachycardiac and rate and rhythm.

ABDOMEN: Soft, mildly tender, active guarding, positive rebound and positive bowel sounds.

EXTREMITIES: Arms, pulse 2+ and clubbing. Legs 2+ edema, pulse is 1+. NEUROLOGIC: Cranial nerves II through VII intact, and IX to XII intact. The patient has difficulty hearing on the right. Deep tendon reflexes 1+.

HOSPITAL COURSE: This 54-year-old man was admitted to the hospital for increased shortness of breath and change in mental status with underlying metastatic lung cancer. The patient's shortness of breath improved temporarily. Later that evening, the patient became more confused and disoriented. At the same time, the shortness of breath had increased again. Blood gases obtained at that time showed a pH of 7.43, CO2 of 36, O2 of 64 and O2 saturations above 90 on 4 liters of oxygen with nasal cannula. Respiratory therapy was called and treated the patient. Over the next several hours, the patient became increasingly disoriented and his shortness of breath increased. His O2 saturations remained above 90. The patient was checked every 15 to 30 minutes during the night. At 5 o'clock the nurse walked into the room and found the patient pulseless.

The patient had declared at a previous hospital stay that he wanted to donate his body for science. An autopsy was obtained. It was not possible to track down any family members of the patient.

CAUSE OF DEATH: Ischemic cardiomyopathy due to severe occlusive coronary arteriosclerosis due to diabetes mellitus. Adenocarcinoma of the left lung with metastases.

 

Clinical Laboratory Report

06/07/03:

CBC with PLATELET COUNT

Name

Result/Unit

 

Ref Interval

Status

White Blood Cell Count

7.9 K/uL

 

3.1-10.1

 

Red Blood Cell Count

4.04 M/uL

L

4.32-5.84

 

Hemoglobin

12.1 g/dL

L

13.5-17.5

 

Hematocrit

35.6 %

L

41.2-52.4

 

Mean Corpuscular Volume

88.1 fL

 

84.0-103.0

 

Mean Corpuscular Hemoglobin

30.0 pg

 

27.6-33.2

 

Mean Corpuscular Hgb Conc

34.0 g/dL

 

31.9-36.0

 

Red Cell Distribution Width

14.1 %

 

12.0-16.0

 

Platelets

223 K/uL

 

140-440

 

Mean Platelet Volume

8.1 fL

 

7.4-10.5

 

06/07/03

COMPREHENSIVE METABOLIC PANEL

Name

Result/Unit

 

Ref Interval

Status

Alkaline Phosphatase

152 U/L

H

45-150

 

Potassium

3.8 mmol/L

 

3.3-5.0

 

Sodium

137 mmol/L

 

136-144

 

Glucose

126 mg/dL

 

64-128

 

Bilirubin, Total

1.2 mg/dL

 

0.2-1.3

 

Calcium

9.7 mg/dL

 

8.4-10.2

 

Albumin

3.3 g/dL

L

3.5-4.6

 

Total Protein

7.2 g/dL

 

6.3-8.2

 

CREATININE, SERUM - mg/dL

1.5 mg/dL

H

0.8-1.4

 

Chloride

103 mmol/L

 

98-107

 

AST/SGOT

48 U/L

 

15-59

 

Urea Nitrogen

26 mg/dL

H

7-20

 

Carbon Dioxide

23 mmol/L

 

20-29

 

ANION GAP

14 mmol/L

 

8-14

 



Clinical Laboratory Report

06/19/03

Manual Differential

Name

Result/Unit

 

Ref Interval

Status

Polymorphonuclear

81 %

H

45-79

 

Band

2 %

 

0-5

 

Lymphocyte

12 %

L

16-47

 

Monocyte

5 %

 

0-9

 

Normocytic/Normochromic

NC/NC

 

 

 

Platelet Estimate

INCREASE

A

NORMAL

 

06/18/03

Oximetry Spot Check

Name

Result/Unit

 

Ref Interval

Status

FiO2

21 %

 

 

 

Pulse Oxim

87 %

L

90-98

 

Pb

635 mmHg

 

 

 

Temp

37 C

 

 

 

Allen`s Test

N

 

 

 

06/18/03

BASIC METABOLIC PANEL

Name

Result/Unit

 

Ref Interval

Status

Sodium

134 mmol/L

L

136-144

 

Potassium

4.0 mmol/L

 

3.3-5.0

 

Chloride

03 mmol/L

 

98-107

 

Carbon Dioxide

28 mmol/L

 

20-29

 

Urea Nitrogen

30 mg/dL

H

7-20

 

CREATININE, SERUM - mg/dL

1.6 mg/dL

H

0.8-1.4

 

Glucose

138 mg/dL

H

64-128

 

ANION GAP

7 mmol/L

L

8-14

 

06/18/03

CBC WITHOUT PLATELET

Name

Result/Unit

 

Ref Interval

Status

White Blood Cell Count

9.6 K/uL

 

3.1-10.1

 

Red Blood Cell Count

3.21 M/uL

L

4.32-5.84

 

Hemoglobin

9.6 g/dL

L

13.5-17.5

 

Hematocrit

28.4 %

L

41.2-52.4

 

Mean Corpuscular Volume

88.3 fL

 

84.0-103.0

 

Mean Corpuscular Hemoglobin

30.0 pg

 

27.6-33.2

 

Mean Corpuscular Hgb Conc

33.9 g/dL

 

31.9-36.0

 

Red Cell Distribution Width

13.9 %

 

12.0-16.0

 



Clinical Laboratory Report

06/29/

URINALYSIS, COMPLETE

Name

Result/Unit

 

Ref Interval

Status

URINE COLLECTION

VOIDED

 

 

 

URINE COLOR

YELLOW

 

 

 

URINE APPEARANCE

HAZY

A

 

 

SPECIFIC GRAVITY, URINE

1.011

 

1.033-1.030

 

pH, URINE

5.0

 

5.0-7.5

 

URINE PROTEIN

NEG

 

NEG

 

URINE GLUCOSE

NEG

 

NEG

 

URINE KETONES

NEG

 

NEG

 

URINE BILIRUBIN

NEG

 

NEG

 

URINE BLOOD

SMALL

A

NEG

 

URINE NITRITE

NEG

 

NEG

 

URINE WBC SCREEN

NEG

 

NEG

 

URINE MUCUS

NEG

 

NEG

 

URINE SQUAMOUS EPITHELIAL CELL

<1 /HPF

 

NEG

 

URINE BACTERIA

NEG

 

NEG

 

URINE AMORPHOUS SEDIMENT

MANY

A

NEG

 

URINE UROBILINOGEN

0.2 mg/dL

 

0.2-1.0

 

06/28/03

CBC with PLT COUNT T AUTO DIFF

Name

Result/Unit

 

Ref Interval

Status

WHITE BLOOD CELL COUNT

13.4 K/uL

H

3.1-10.1

 

RED BLOOD CELL COUNT

3.07 M/uL

L

4.32-5.84

 

HEMOGLOBIN

9.2 g/dL

L

13.5-17.5

 

HEMATOCRIT

27.2 %

L

41.2-52.4

 

MEAN CORPUSCULAR VOLUME

88.6 fL

 

84.0-103.0

 

MEAN CORPUSCULAR HEMOGLOBIN

30.1 pg

 

27.6-33.2

 

MEAN CORPUSCULAR HGB CONC

34.0 g/dL

 

31.9-36.0

 

RED CELL DISTRIBUTION WIDTH

14.8 %

 

12.0-16.0

 

PLATELETS

285 K/uL

 

140-440

 

MEAN PLATELET VOLUME

7.9 fL

 

7.4-10.5

 

06/28/03

CREATINE KINASE, TOTAL

Name

Result/Unit

 

Ref Interval

Status

CREATINE KINASE, TOTAL

63 U/L

 

20-203

 

06/28/03

CALCIUM, SERUM OR PLASMA

 

Name

Result/Unit

 

Ref Interval

Status

CALCIUM, SERUM OR PLASMA

10.0 mg/dL

 

8.4-10.2

 

06/28/03

MAGNESIUM, SERUM or PLASMA

Name

Result/Unit

 

Ref Interval

Status

MAGNESIUM, SERUM or PLASMA

2.0 mg/dL

 

1.6-2.3

 

06/28/03

HEPATIC FUNCTION PANEL

Name

Result/Unit

 

Ref Interval

Status

ALBUMIN

2.5 g/dL

L

3.5-4.6

 

BILIRUBIN, TOTAL

0.8 mg/dL

 

0.2-1.3

 

ALKALINE PHOSPHATASE

140 U/L

 

45-150

 

ASPARTATE AMINOTRANSFERASE

36 U/L

 

15-59

 

ALANINE AMINOTRANSFERASE

23 U/L

 

6-50

 

BILIRUBIN, DIRECT

0.2 mg/dL

 

0.0-0.4

 

06/28/03

BASIC METABOLIC PANEL

Name

Result/Unit

 

Ref Interval

Status

SODIUM

135 mmol/L

L

136-144

 

POTASSIUM

4.6 mmol/L

 

3.3-5.0

 

CHLORIDE

03 mmol/L

 

98-107

 

CARBON DIOXIDE

27 mmol/L

 

20-29

 

UREA NITROGEN

55 mg/dL

H

7-20

 

CREATININE, SERUM - mg/dL

1.5 mg/dL

H

0.8-1.4

 

GLUCOSE

181 mg/dL

H

64-128

 

ANION GAP

9 mmol/L

 

8-14

 

06/28/03

PROTHROMBIN TIME

Name

Result/Unit

 

Ref Interval

Status

PROTHROMBIN TIME

18.2 sec

H

10.7-15.0

 

06/28/03

PARTIAL THROMBOPLASTIN TIME

Name

Result/Unit

 

Ref Interval

Status

PARTIAL THROMBOPLASTIN TIME

44 sec

H

25-40

 

06/28/03

MANUAL DIFFERENTIAL

Name

Result/Unit

 

Ref Interval

Status

POLYMORPHONUCLEAR

84 %

H

45-79

 

BAND

7 %

H

0-5

 

LYMPHOCYTE

7 %

L

16-47

 

MONOCYTE

2 %

 

0-9

 

PLATELET ESTIMATE

ADEQUATE

 

NORMAL

 

POLYCHROMASIA

1+

A

 

 



TROPONIN I Trend

 

06/15/03 08:10 AM 

21.2 ng/mL 

H

0.0-2.0  

Interpretation:
Less than 0.4 ng/mL ..... Negative, repeat in 4-6 hours if
                          clinically indicated.
 
0.4 - 2.0 ng/mL ......... Suspicious for myocardial injury. Serial
                          measurements may be necessary to confirm
                          or exclude the diagnosis of acute
                          coronary syndrome. Repeat in 4-6 hours
                          if indicated.
 
Greater than 2.0 ng/mL .. Consistent with myocardial injury.
                          Clinical and laboratory correlation

                                               recommended.

06/15/03 03:05 AM 

22.1 ng/mL 

H

0.0-2.0  

Interpretation:
Less than 0.4 ng/mL ..... Negative, repeat in 4-6 hours if
                          clinically indicated.
 
0.4 - 2.0 ng/mL ......... Suspicious for myocardial injury. Serial
                          measurements may be necessary to confirm
                          or exclude the diagnosis of acute
                          coronary syndrome. Repeat in 4-6 hours
                          if indicated.
 
Greater than 2.0 ng/mL .. Consistent with myocardial injury.
                          Clinical and laboratory correlation

                                                           recommended.

06/14/03 08:09 PM 

15.9 ng/mL 

H

0.0-2.0  

Interpretation:
Less than 0.4 ng/mL ..... Negative, repeat in 4-6 hours if
                          clinically indicated.
 
0.4 - 2.0 ng/mL ......... Suspicious for myocardial injury. Serial
                          measurements may be necessary to confirm
                          or exclude the diagnosis of acute
                          coronary syndrome. Repeat in 4-6 hours
                          if indicated.
 
Greater than 2.0 ng/mL .. Consistent with myocardial injury.
                          Clinical and laboratory correlation

                                               recommended.

06/14/03 01:55 PM 

14.7 ng/mL 

H

0.0-2.0  

Interpretation:
Less than 0.4 ng/mL ..... Negative, repeat in 4-6 hours if
                          clinically indicated.
 
0.4 - 2.0 ng/mL ......... Suspicious for myocardial injury. Serial
                          measurements may be necessary to confirm
                          or exclude the diagnosis of acute
                          coronary syndrome. Repeat in 4-6 hours
                          if indicated.
 
Greater than 2.0 ng/mL .. Consistent with myocardial injury.
                          Clinical and laboratory correlation

                     recommended.

 

Microbiology Report

06/28/03

RESPIRATORY CULTURE

Name

Result

GRAM STAIN

3+~GRAM POSITIVE COCCI

GRAM STAIN

1+~GRAM POSITIVE RODS

GRAM STAIN

1+~YEAST

GRAM STAIN

1+~YEAST

GRAM STAIN

1+~YEAST

GRAM STAIN

1+~YEAST

PRELIMINARY REPORT

3+~NORMAL FLORA ISOLATED

06/28/03

RESPIRATORY CULTURE

Name

Result

GRAM STAIN

3+~GRAM POSITIVE COCCI

GRAM STAIN

1+~GRAM POSITIVE RODS

GRAM STAIN

1+~YEAST

GRAM STAIN

1+~YEAST

GRAM STAIN

1+~YEAST

GRAM STAIN

1+~YEAST

FINAL REPORT

3+~NORMAL FLORA ISOLATED

FINAL REPORT

3+~YEAST

06/19/03

BLOOD CULTURE, BOTTLE SYSTEM, BLOOD, #2 LEFT ANTECUBITAL

Name

Result

FINAL REPORT

NO GROWTH

06/19/03

BLOOD CULTURE, BOTTLE SYSTEM, BLOOD, #1 LEFT ANTECUBITAL

Name

Result

FINAL REPORT

NO GROWTH



Radiology Report

06/28/2003

CHEST XRAY 2V

PA AND LATERAL CHEST 6/28/03

HISTORY: metastatic lung carcinoma and mental status changes, worsening pitting edema in the lower extremities.

FINDINGS: Comparison is made to a study dated 6/18/03.

There has been increased opacity in the mid to lower lungs in the interval. Kerley lines are noted in the right lower lung. The vascular pedicle and cardiac silhouette have increased in size. Findings are most consistent with pulmonary edema from congestive heart failure. Right peritracheal lymphadenopathy and the left hilar mass have not changed. The left pleural effusion has increased slightly. The right pleural effusion is unchanged.

Anterior compression of two vertebral bodies, probably T9 and L1 is noted, possibly increased when compared with the prior study.


IMPRESSION:

WORSENING HAZY PULMONARY OPACITIES MOST CONSISTENT WITH CONGESTIVE HEART FAILURE. UNDERLYING ASPIRATION PNEUMONIA CANNOT BE ENTIRELY EXCLUDED.

LEFT HILAR MASS AND RIGHT PERITRACHIAL LYMPHADENOPATHY, UNCHANGED.

SLIGHT INCREASE IN THE LEFT PLEURAL EFFUSION AND UNCHANGED RIGHT PLEURAL EFFUSION.

POSSIBLE WORSENING ANTERIOR COMPRESSION OF T9 AND L1 WHICH CAN BE FURTHER EVALUATED WITH THORACIC SPINE FILMS IF THERE IS CONTINUED CLINICAL CONCERN.


IMAGE



06/18/2003

CHEST XRAY 2V

TWO VIEWS OF THE CHEST, 6/18/03.

HISTORY: Lung cancer.

FINDINGS: PA and lateral chest x-ray 6/18/03, compared to 6/16/03. The comparison study is a supine portable.

The heart size is upper limits of normal. The vascular pedicle width is increased and there appears to be right paratracheal adenopathy. There is a left hilar mass. The left lung shows a pattern of fine nodular densities. This is also apparent on the right but less marked. Small pleural effusion is present on the right.

Calcified opacity in the right lower zone unchanged. On the frontal film, an area of density is seen projecting through the cardiac silhouette, but I cannot accurately localize this on the lateral.

IMPRESSION:

PATIENT WITH A HISTORY OF LUNG CANCER. THERE APPEARS TO BE EXTENSIVE MEDIASTINAL AND LEFT HILAR ADENOPATHY AND BILATERAL PLEURAL EFFUSIONS. THE FINE NODULAR TEXTURE TO THE LUNG
PARENCHYMA RAISES CONCERN FOR LYMPHANGITIC TUMOR SPREAD PARTICULARLY ON THE LEFT. A PREVIOUS CT SCAN DOCUMENTED 2.7 CM LEFT LOWER LOBE MASS. I DO NOT IDENTIFY THIS WITH CONFIDENCE ON THE PLAIN FILM BUT IT MAY BE THE OPACITY THAT IS SEEN THROUGH THE HEART SILHOUETTE.

IMAGE

 

 

06/14/2003

CHEST XRAY 1V

PORTABLE CHEST, 6/14/03.

The comparison study is dated 6/7/03.

HISTORY: Status post femur reconstruction, respiratory distress.

FINDINGS: The lungs demonstrate diffuse reticular opacities, most marked in both lower lobes. This is most suggestive for an underlying pulmonary edema. A concurrent pneumonia, especially within the left lower lobe remains of concern. No evidence for pneumothorax. The cardiac silhouette is borderline large. Mediastinal widening is also present, likely from adenopathy given the comparison films lateral view findings. The patient has had prior granulomatous disease with calcified right hilar lymph nodes present.

IMPRESSION:

FINDINGS MOST CONSISTENT WITH MILD PULMONARY EDEMA. A CONCURRENT
LEFT LOWER LOBE PNEUMONIA MAY BE PRESENT. SUGGEST RE-EVALUATION
AFTER CHF THERAPY.

 

IMAGE

 

06/08/2003

THORAX CT WO

CT SCAN OF THE CHEST WITH CONTRAST, 6/8/03.

No previous films are available for comparison.

HISTORY: Metastatic disease to the spine and rib cage. Assess for underlying malignancy.

TECHNIQUE: 5 mm scans were obtained from the lung apices through the domes of the diaphragm. IV contrast was employed without complication.

FINDINGS: No evidence for supraclavicular or axillary adenopathy, however, there is extensive adenopathy involving the mediastinum, left hilum, subcarinal and paraesophageal areas. No evidence for retrocrural or pericardiophrenic adenopathy. The heart size is borderline normal. There is no evidence for pericardial effusion. A very small left pleural effusion is seen posteriorly. The largest conglomeration of lymph nodes lies within the aortic pulmonary window. It measures 3.0 x 3.2 cm. The largest precardinal lymph node measures 17 mm in short axis. The thoracic aorta demonstrates mild atherosclerotic disease through much of its length. Pulmonary arteries appear unremarkable. The largest lymph node involving the left infrahilar region measures 2 cm in short axis. The osseous structures demonstrate multiple lytic lesions throughout much of the vertebral bodies, scattered ribs which demonstrate pathologic fractures. In addition, the right proximal clavicle demonstrates
multiple lytic lesions with a pathologic fracture. There may be also involvement of the left superior sternum. These multiple lytic bone lesions can be better evaluated with a bone scan. Limited evaluation of the upper abdomen demonstrates a 15 mm low density lesion involving the anterior segment of the right lobe of the liver. No other lesions are definitely seen. There is no evidence of upper abdominal adenopathy. However, please see the
accompanying report from the abdominal CT scan which was obtained on the same day. The distal esophagus demonstrates mild thickening which could represent a small hiatal hernia or
esophagitis. A distal esophageal tumor is considered less likely. The right lower lobe posterior basal segment demonstrates a well defined pulmonary nodule with heavy calcification within it. It measures 17 mm. Given its large amount of central calcification, it is likely a benign lesion such as a hamartoma or less likely an old granuloma. However, there is a 2.7 cm slightly ill-defined nodule involving the left lower lobe posterior basal segment. It does not demonstrate central calcification. It is suspicious for an underlying neoplasm. There are no other definite pulmonary nodules identified. Given that it appears to be solitary, metastases is considered less likely. This could represent a primary bronchogenic neoplasm, especially given that there is extensive adenopathy involving the left hilar region. A peripheral adenocarcinoma or potentially a small cell carcinoma could give extensive adenopathy. Focal areas of ground glass are present involving the left upper lobe anterior segment, posterior segment. This may represent a focal area of inflammation such as a resolving or evolving pneumonia. Additionally, it could represent a small amount of pulmonary hemorrhage.

IMPRESSION:

EXTENSIVE ADENOPATHY THROUGHOUT MUCH OF THE MEDIASTINUM AND LEFT HILUM.

2.7 CM LEFT LOWER LOBE POSTERIOR BASAL SEGMENT ILL-DEFINED NODULE WHICH IS SUSPICIOUS FOR A NEOPLASM. GIVEN THAT IT IS A SOLITARY NODULE, THIS MOST LIKELY REPRESENTS A PRIMARY BRONCHOGENIC TUMOR VERSUS A SOLITARY METASTASES.

LOW DENSITY LESION WITHIN THE RIGHT LOBE OF THE LIVER WHICH IS SUSPICIOUS FOR A FOCAL METASTATIC LESION.

WIDE SPREAD METASTATIC BONE LESIONS WITH PATHOLOGIC FRACTURES IDENTIFIED INVOLVING AT LEAST TWO RIBS ON THE RIGHT AND A RIGHT PROXIMAL CLAVICULAR FRACTURE.

PROBABLE GRANULOMA OR HAMARTOMA WITHIN THE RIGHT LOWER LOBE POSTERIOR BASAL SEGMENT.

SMALL LEFT PLEURAL EFFUSION.

IMAGE



06/07/2003

CHEST XRAY 2V

TWO VIEWS OF THE CHEST, 6/7/03.

HISTORY: Postoperative film, status post left hip surgery.

FINDINGS: No previous films are available for comparison.

There is an ill-defined area of alveolar opacification present overlying the left lower lobe superior segmental region. The lungs otherwise appear clear. The cardiac silhouette and pulmonary vascularity are within normal limits. I see no definitive evidence for lymphadenopathy although the left hilar region is somewhat obscured by the aforementioned opacity. There is some degenerative change of the spine. The adjacent soft tissue and bony structures appear unremarkable.

IMPRESSION:

ILL-DEFINED AREA OF ALVEOLAR OPACIFICATION INVOLVING LEFT LOWER LOBE SUPERIOR SEGMENT. THIS IS A NONSPECIFIC FINDING WITH DIFFERENTIAL POSSIBILITIES INCLUDING PNEUMONIA OR SEQUELAE OF ASPIRATION. RECOMMEND CORRELATION WITH CLINICAL HISTORY. THE PATIENT SHOULD BE FOLLOWED UP WITH A CHEST X-RAY TO ASSURE RESOLUTION AND EXCLUDE A MORE CHRONIC UNDERLYING PROCESS, AS EVEN MALIGNANCY CAN GIVE THIS APPEARANCE.

IMAGE



06/03/2003

NM BONE SCAN

BONE SCAN, 6/3/03.

HISTORY: 54-year-old male with recent diagnosis of femur tumor with concern for possible other bony lesions.

PROCEDURE: Following the intravenous administration of 21.5 mCi Tc03m MDP, multiple images over the entire body were obtained at two hours post injection.

FINDINGS: The delayed images were obtained following angiographic and tissue phase images. Please see acc. 949586 for further information regarding the angiographic and tissue phased images.

Delayed images of the axial and appendicular skeleton demonstrate multiple sites of abnormal increased radiotracer activity suggestive of wide-spread osseous metastatic disease. The areas of increased activity suggestive of metastatic disease include the left lesser trochanter, left iliac wing and anterior superior iliac spine region, right scapular spine, right proximal clavicle, right second or third posterior ribs, right anterolateral approximately 6th rib, right posterolateral approximately 11th rib, right greater trochanter, right intertrochanteric region, right proximal femoral diaphysis, approximately T12 or L1, approximately T8 or T9, within the manubrium, within the sternomanubrial junction, and within the right sacrum at approximately S1 and S2.

Sites of increased activity likely representing post traumatic change are within the anterolateral, approximately 8th through 10th ribs on the left. These sites of activity are focal and sequential, and, therefore, are likely post traumatic.

Sites of increased activity likely representing degenerative change are noted within the AC joints, right greater than left, glenohumeral joints, right greater than left, and within the right hip.

An additional site of increased activity is identified at the superior orbital rim on the left. This is slightly more prominent than that seen on the contralateral side. This is of uncertain significance, but metastatic disease to this site cannot be excluded.

IMPRESSION:

MULTIPLE SITES OF ABNORMAL INCREASED OSSEOUS ACTIVITY CONSISTENT WITH WHITE SPREAD OSSEOUS METASTATIC DISEASE.

DIMINUTIVE LEFT KIDNEY LIKELY SECONDARY TO CONGENITAL ABNORMALITY.

SEVERAL SITES OF ACTIVITY SUGGESTIVE OF DEGENERATIVE CHANGE AS DESCRIBED.

QUERY POST TRAUMATIC CHANGES TO THE LEFT ANTEROLATERAL APPROXIMATELY 8TH THROUGH 10TH RIBS.

 

IMAGE

 

Autopsy Report

06/29/03

AUTOPSY FINAL REPORT

AU CASE INFORMATION

SEX: Male AGE: 54
DATE ADMITTED: 06/28/03
DATE OF DEATH: 06/29/03
DATE OF AUTOPSY: 06/29/03

CONSENT: No restrictions


AUTOPSY CAUSE OF DEATH: Ischemic cardiomyopathy
DUE TO: Severe occlusive coronary atherosclerosis
DUE TO: Diabetes mellitus
OTHER CONDITIONS: Adenocarcinoma of left lung with metastases

AU CLINICAL HISTORY

The patient was a 54-year-old male who was diagnosed with metastatic non-small cell carcinoma of the left lung in April of 2003. In March, 2003, The Patient developed low back and subsequent chest pain. Evaluation of his symptoms revealed widespread metastatic bone disease with an apparent primary lung tumor. On 6/14/03, he underwent prophylactic pinning of his left femur to stabilize a lytic lesion in the lesser trochanter area. Tissue submitted from this site revealed metastatic adenocarcinoma.  The patient received palliative radiation therapy to the lung, mediastinum, right clavicle and left femur. On 6/28/03, he presented to the Emergency Department with acute change in mental status, dyspnea and bilateral leg edema. Later that evening, he became more confused and disoriented. Over the next several hours, the patient became increasingly disoriented and his shortness of breath increased. The patient had previously requested a "Do Not Resuscitate" status. The next morning, the patient was found pulseless and was declared dead on 6/29/03.

PAST MEDICAL HISTORY: Wide spread metastatic bone disease, carcinoma of the lung. Coronary artery disease, status post coronary artery bypass graft 11 years ago. Hypertension. Diabetes mellitus requiring insulin. Status post right carotid endarterectomy 11 years ago. Gastroesophageal reflux disease. Benign prostatic hyperplasia. Right inguinal hernia repair.

 

MEDICATIONS: Aspirin, metoprolol, Nitroglycerin, albuterol, MSIR, MS Contin, insulin, Prevacid, Imdur, Colace, Senokot, Flomax, Dulcolax.

ALLERGIES: Codeine.

SOCIAL HISTORY: The patient worked as a manager of a halfway house. He was divorced and had four children which he had lost touch with. He had a 30 to 40 pack year history of tobacco use and occasional alcohol use. He was without any knowledge of any blood relatives with malignancy in that he was adopted.

LABORATORY DATA AND X-RAYS: A previous CT workup revealed extensive mediastinal, left hilar, subcarinal and paraesophageal lymphadenopathy, and a large lymph node in the AP window measuring 3 x 3 cm. The patient also had multiple lytic lesions in several vertebrae of the right ribs, with pathologic fracture of ribs, and a right proximal clavicle pathologic fracture. The CT of the abdomen revealed a 1 cm mass in the right lobe of the liver, diffuse osseus metastatic lesion, including left iliac wing, a right trochanter lesion, and a left hip lesion. Bone scan with multiple diffuse metastases. CORTISOL, SERUM 140.0 ug/dL. PARTIAL THROMBOPLASTIN TIME 44 sec. PROTHROMBIN TIME 18.2 sec. BASIC METABOLIC PANEL: Sodium 135 mmol/L; potassium 4.6 mmol/L;
chloride 03 mmol/L; carbon dioxide 27 mmol/L; urea nitrogen 55 mg/dL; creatinine 1.5 mg/dL glucose; 181 mg/dL; anion gap 9 mmol/L. HEPATIC FUNCTION PANEL: Albumin 2.5 g/dL; bilirubin total 0.8 mg/dL; alkaline phosphatase; 140  U/L aspartate aminotransferase; 36 U/L; alanine aminotransferase 23 U/L. Bilirubin, direct 0.2 mg/dL. Magnesium 2.0mg/dL. Calcium 10.0 mg/dL. Creatinine kinase 63 U/L CBC: White blood cell count 13.4 K/uL; hemoglobin 9.2g/dL; hematocrit 27.2% ; platelets 285 K/uL

 
AU CASE SUMMARY

The patient was a 54-year-old male diagnosed with metastatic non-small cell carcinoma of the left lung and widespread metastatic disease in April/March of this year. He underwent palliative radiation treatment, and pinning of his left femur for an unstable metastatic lytic lesion. On 6/28/03, he presented to the Emergency Department with an acute change in mental status, dyspnea and bilateral leg edema. The patient had previously expressed that he wished for no resuscitative measures to be undertaken. His respiratory distress worsened, and he died on 6/29/03.

 

Autopsy revealed a moderately differentiated adenocarcinoma of the left lung with widespread metastatic disease involving the lungs, lymph nodes, adrenal glands, and skeleton. The patient's immediate cause of death, however, related to his severe coronary artery disease which showed evidence of recent thrombosis and total occlusion of the right coronary artery. His history of hypertension (related to his diabetes and "Goldblatt kidney"), diabetes and smoking likely contributed to his severe atherosclerotic disease. Factors contributing to his demise would include congestive heart failure associated with his hypertension and ischemic cardiomyopathy, and the multisystemic affects of his metastatic cancer.

 

Chronic ischemic heart disease is a term used to describe long standing, inadequate perfusion of the myocardium. Individuals with CIHD, may develop congestive heart failure as a consequence of ischemic myocardial damage.  Often, patients will have a history of remote myocardial infarction and their associated cardiac decompensation may be directly related to hypertrophy and dysfunction of noninfarcted viable myocardium. Patients with CIHD may be unable to compensate for even minor ischemic events.
REFERENCE:
1. Cotran, R. S., Kumar, V., Robbins, S.L, Robbins Pathologic Basis of
Disease; Fifth Edition. W. B Saunder Company 1034. 12; 524-541.
------------------------

AU FINAL DIAGNOSIS

1. Coronary atherosclerosis, severe, occlusive
   A. 103% occlusion of native right coronary artery
   B. 50% occlusion of native left anterior descending artery
   C. 50% occlusion of hypoplastic native circumflex artery
2. Status post autogenous vein coronary bypass grafting, 1988, with:
   A. Occlusion of graft to left anterior descending distal branch,
   with thrombus
   B. Occlusion of graft to obtuse marginal circumflex branch, with
   luminal fibrosis
3. Ischemic cardiomyopathy
   A. Cardiomegaly, 540 gm
   B. Left ventricular hypertrophy
   C. Myocardial infarction, posterior left ventricular free wall,
   remote
   D. Congestive heart failure:
      i. splenomegaly, 509 gm
      ii. hepatomegaly, 2070 gm
      iii. peripheral edema, lower legs, pitting
      iv. pleural effusions, 803 right and 1203 left, serous
4. Diabetes mellitus, by history
5. Aorta, moderate to severe atherosclerosis with abundant mural
thrombosis
   A. Occlusion of inferior mesenteric artery orifice
   B. Occlusion of left renal artery orifice
6. Kidney, left, atrophy (64 gm), with compensatory hyperplasia of right
kidney (261 gm) - "Goldblatt kidney"
7. History of hypertension
8. Cerebral artery atherosclerosis, moderate
9. Adenocarcinoma of left lower lung lobe, with some features of squamous
carcinoma, peripheral in location, with metastases to:
   A. Adrenals
   B. Lymph nodes, with massive mediastinal lymphadenopathy
   C. Liver
   D. Bone, extensive, with partial collapse of T9 and L1, and pathologic
   fracture of left femur, status post operative repair with rod
   placement
   E. Lungs, extensive micrometastases
10. Status post radiation therapy
11. History of smoking
12. Miscellaneous findings:
   A. Lung, right lower lobe, hamartoma, calcified
   B. Right kidney, lower pole calyces, lithiasis
   C. Bladder "scale"
   D. Prostate, nodular hyperplasia
   E. Testes, atrophy
   F. Gallbladder, dilation
   G. Pulmonary thromboembolus, peripheral, recent
   H. Liver, steatosis, moderate
   I. Brain, remote cystic infarct of right and left caudate nuclei
   J. Brain, venous malformation in right occipital lobe
   K. Skin, seborrheic keratoses
------------------------

AU GROSS DESCRIPTION

EXTERNAL EXAMINATION: A duly executed permit for autopsy is received and the body is identified by right toe tag. The body length is 170 cm crown to heel and 95 cm crown to rump. The body is estimated to weigh 80 kg. The body is that of a Caucasian male who appears to be the stated age of 54 years. The body habitus is normal. The head circumference is 56.5 cm and the head is normal in size and is symmetric. Hair distribution is normal and the texture is fine. Scalp hair is brown-gray and medium length. The face is unremarkable. The eyes are brown and unremarkable. The ears show bilateral, vertical earlobe creases. The nose, mouth and neck are normal. The upper and lower jaws are edentulous. Multiple dark-brown scaly nodules are seen on the skin surface of the neck and shoulders and range up to 0.5 cm in greatest diameter. The lesions have well defined borders. The skin is tanned and shows dependant livor. A 26 cm well healed scar is found at the midline over the sternum. A 3 cm partially healed scar is seen over the left hip. A 56 cm well healed scar is seen on the medial surface of the leg extending from the mid thigh to the ankle. The chest circumference is 68 cm and the chest is symmetric. The breasts are normal on palpation. The abdominal circumference is 92 cm and the abdomen is flat. The back is normal. External genitalia are normal for male sex. The extremities show clubbing of the finger nails. There is four plus edema in the legs to the level of the mid thighs, bilaterally.
CENTRAL NERVOUS SYSTEM: The scalp is normal. The skull is of average thickness. The middle ears are not examined. The dura is normal. The meninges are normal. The brain weighs 1503 grams. The convolutions show normal gyri and sulci. The brain and spinal cord are saved for neuropathologic examination. After formalin fixation, the brain and spinal cord are examined at Neuropathology Conference on 7/7/03. Cerebral arteries at the base of the brain show moderate atherosclerosis. There is no hemorrhage or edema. Multiple coronal sections show a 0.5 x 0.4 x 0.2 cm cystic space in the right head of the caudate nucleus. The left caudate head has a 0.4 x 0.3 x 0.2 cm similar cystic lesion. There is a cavum septum pellucidum. Sections of brainstem and cerebellum are unremarkable. There are thin white fibrous plaques in a 0.5 x 0.8 cm area over the lumbar cord. Sections of the cord are unremarkable. There is a focus of prominent vessels in the right occipital lobe.
THORACIC CAVITY: A "Y" incision is made. The subcutaneous fat measures 1.3 cm at the level of the nipples. Organ situs in thorax is normal. The breasts are normal upon sectioning. The pleural surfaces are smooth. There is a firm, retracted scar which measures approximately 1 x 1 cm on the posterior surface of the left lower lung lobe. The right pleural cavity contains 803 cc of a serous fluid and the left pleural cavity contains 1203 cc of serous fluid. Marked left hilar lymphadenopathy is seen with a matted chain of lymph nodes extending from the level of the carina up the left lateral aspect of the larynx. The mass of lymph nodes measures approximately 8.5 x 2.5 x 2.5 cm. A pneumothorax is not found. The mediastinum is clear. The thymus is mostly fatty. There is a palpable firm, light-tan, bosselated nodule in the right lower lobe base which measures approximately 3.0 x 2.5 cm. The perihilar pleura of the right lobe show  multiple approximate 2 mm light-tan, firm nodules.
ABDOMINAL CAVITY: A midline incision is made. The subcutaneous fat measures 2.4 cm at the level of the liver. Organ situs in the abdomen is normal. The diaphragmatic dome heights are at the level of the sixth rib on the right and the seventh rib on the left. The liver is 3 cm below the right costal margin at the midclavicular line and the spleen is at the costal margin at the left midclavicular line. The peritoneal surfaces are smooth and the peritoneal cavity contains a minimal amount of serous fluid. The retroperitoneum is clear.
CARDIOVASCULAR SYSTEM: The heart weighs 540 grams. The epicardium is extensively adhered to the pericardial tissues. Two coronary bypass grafts can be seen coursing across the epicardial surface of the heart. A minimal amount of loculated pericardial fluid is identified. The left ventricle shows hypertrophy. The right ventricle is 0.5 cm thick and 9 cm long. The left ventricular thickness is 1.3 cm and the length is 9 cm. The atrial appendages are clear. The foramen ovale is closed. The myocardium is firm and red-brown and shows a mottled, tan, fibrotic region which measures approximately 6.5 x
3.0 cm in the left ventricular myocardium at the region of the posterior apex. This region is associated with a peripheral hyperemic, softened area of myocardium. The endocardium is thin and translucent. The trabeculae carneae have a light tan mildly fibrotic appearance in the region of the posterior left ventricular lesion. The papillary muscles of the left ventricle have a tan to yellow mottled appearance. The chordae tendineae are normal and intact. The heart valves are thin and pliable. The heart valve ring circumferences are 12.2 cm tricuspid, 7.2cm pulmonic, 11.0 cm mitral and 7.9 cm aortic. The heart valves show no vegetations. There is venous graft extending from aorta above the left coronary ostia to the distal left anterior descending coronary artery. There is a venous coronary bypass graft which extends from the aorta, in a region above the left coronary ostia, to an obtuse marginal circumflex artery branch. Extensive, severe occlusive atherosclerotic disease is seen in the native coronary arteries. 103% occlusion of the native right coronary artery is seen. There is 50% occlusion of the native left anterior descending artery. There is 50% occlusion of the hypoplastic native circumflex artery. The venous bypass graft which extends to the distal left anterior descending coronary artery shows total occlusion with thrombus formation. The venous bypass graft which extends to the obtuse marginal circumflex branch artery shows total occlusion with luminal fibrosis. The abdominal aorta shows severe atherosclerosis with abundant mural thrombosis. This mural thrombosis appears to involve, and occlude the inferior mesenteric artery orifice. Total occlusion of the left renal artery orifice is found. The remainder of the aorta contains moderate to severe atherosclerosis with calcifications and loosely adherent plaques. The major branches of the aorta are clear. The venae cavae are clear and leg veins milk freely. 

RESPIRATORY TRACT: The larynx, trachea and main stem bronchi show erythematous, slightly edematous mucosa. The right lung weighs 760 grams and the left lung weighs 803 grams. There is a pale-tan, slightly firm retracted scar seen on the posterior surface of the left lower lung lobe. There is a firm, tan, glossy nodular mass seen peripherally and laterally at the base of the right lower lobe. There are multiple small light-tan firm nodules on the pleural surface around the hilum of the right lung. The nodules measures up to 0.3 cm in greatest diameter. The pulmonary parenchyma is well aerated. Atelectasis is not present. On sectioning, the parenchyma of the right lung shows no consolidation. There is a right lower lung lobe nodule which measures approximately 3 x 2.5 cm and is firm and of a cartilaginous consistency upon sectioning. The nodule is solid. Sectioning of the left lung reveals a 2.5 x 2.5 x 1.5 cm slightly firm, light-tan, stellate lesion in lower lung lobe. This lesion is adjacent to the scar described previously on the posterior surface of the left lower lung lobe. Multiple perihilar lymph nodes around the left lung are enlarged and measures up to 2.5 cm in greatest diameter. Sectioning of the nodes reveals infiltration with a pale-white to gray or tan soft nodular tissue. The remaining lung parenchyma is pink to red without consolidation. Granulomas are not seen. The cut surfaces of the
lungs exude a pale-red fluid. A moderate, diffuse anthracotic pigmentation is seen. The bronchi are normal. Brachial tumor involvement is not seen. The pulmonary arteries do not have pre mortem thromboemboli or atherosclerosis. The pulmonary veins are clear.
GASTROINTESTINAL TRACT: The esophagus shows a tan-pink mucosa without lesions. The stomach contains approximately 103 cc of a dark-brown fluid with vegetable matter consistent with asparagus. The gastric mucosa shows congestion. The pylorus is patent and the duodenum is normal. The remaining small intestine shows few, focal areas of slightly hyperemic mucosa. The appendix is normal and present in the right lower quadrant. The large intestine is normal. The bowel contents consist of a moderate amount of soft green stool. The mesenteric arteries and veins are normal.

PANCREAS: The pancreas measures 16 x 3.5 x 2 cm and is of the usual size. The pancreas is firm and shows a tan lobular architecture upon sectioning. Fat necrosis is not present. The pancreatic duct is patent with no stones and enters the duodenum at the ampulla of Vater.
HEPATOBILIARY SYSTEM: The liver weighs 2070 grams. The liver capsule is smooth and glistening. The liver edge is slightly blunted. The hepatic parenchyma is firm and red-brown. Cirrhosis is not present and the lobular pattern is not visible. Two small, light-tan, <3 cm tumor nodules are seen within the hepatic parenchyma. One tumor nodule can be seen from the hepatic surface on the right lateral portion of the liver. The portal vein is clear. The hepatic artery and veins are clear. The gallbladder measures 12 x 6 cm and is slightly dilated. The gallbladder contains liquid green bile and no stones. The gallbladder mucosa is velvety and the wall is thin. The cystic duct, extrahepatic duct, and intrahepatic duct are patent and contain no stones. The ampulla of Vater is normal.
SPLEEN AND LYMPHATIC SYSTEM: The spleen weighs 509 grams. The splenic capsule is smooth and purple with no lesions. The splenic parenchyma is dark-red, slightly firm. The follicular and trabecular pattern is not visible. No accessory spleens are found. The splenic artery and vein are clear. The hilar and cervical and mediastinal lymph nodes are enlarged as previously described. The mesenteric and pelvic lymph nodes are of the usual size, pink-tan and moderately firm upon sectioning.

URINARY SYSTEM: The right kidney is slightly enlarged and weighs 261.5 grams. The left kidney is small and weighs 63.7 grams. The cortical surface of the left kidney is pink-red and granular. The cortical surface of the right kidney is pale-red and smooth. The cortex of the right kidney measures approximately 0.5 cm and the cortex of the left kidney measures up to 0.3 cm. Corticomedullary demarcations are good. The medullae are red. There are scattered small simple cysts present. The calyces of the lower pole of the right kidney show lithiasis, with a few small hard tan stones. The ureters are normal and enter the bladder at the trigone. The bladder is of the usual size with a thin, trabeculated wall showing a pale tan scale. A catheter is  not present. The bladder contains a moderate amount of yellow urine and no calculi. The urethra is patent. The left renal artery appears to be totally occluded at its origin.
MALE GENITAL SYSTEM: The prostate is firm and shows yellow to tan-white nodularity upon sectioning. The seminal vesicles are normal. The testes are normal in size. On sectioning, they are pale-brown in color and soft in consistency. The tubules string fairly well. The epididymides are normal.
ENDOCRINE ORGANS: The pituitary is of the usual size, shape, color and consistency. The thyroid weighs 22.2 grams and is of the usual size. The thyroid has the usual shape, color and consistency. On sectioning, the parenchyma is red-brown and firm with no nodules. Four possible parathyroid glands are identified and are of the usual size. The right adrenal gland weighs 7.2 grams and the left adrenal gland weighs 8.4 grams. The right adrenal gland shows an apparent 0.5 x 0.4 cm white-tan nodule. The left adrenal gland shows a 0.3 x 0.3 cm, tan tissue infiltration.
MUSCULOSKELETAL SYSTEM: The body and extremities are symmetric. The skeletal muscles are red-brown and there is no evidence of muscle wasting. Bone deformities are not present. Cardiopulmonary resuscitation was not performed. The joints are not examined. The vertebral bone marrow is red and normal in consistency. Dissection of the vertebral column reveals infiltration and destruction of vertebral bone by soft, tan tissues which are present from the cervical to the lumbar region.
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AU MICROSCOPIC DESCRIPTION

CARDIOVASCULAR SYSTEM: Irregular interstitial fibrosis with associated myocytes hypertrophy are seen within the posterior left ventricular free wall (slide K). Organizing fibrin and lipid material with abundant cholesterol clefts are seen on the wall of the aorta (slide E). Organizing fibrin material, cholesterol clefts and focal collections of red blood cells are seen occluding the lumen of the right coronary artery (slide J).
RESPIRATORY SYSTEM: Infiltration of malignant cells with large, pleomorphic vesicular nuclei are seen in nests and glandular arrangements containing mucin (demonstrated by PAS stain) within the left lung lower lobe (slide S).
Scattered nest of tumor cells also show squamous features with abundant pink cytoplasm and hyperchromatic nuclei. Micro vascular and lymphatic tumor invasion are seen in sections of left and right lungs (slides F, S, T, U). A well circumscribed, cartilaginous mass with bland nuclear features is seen within the right lung lower lobe (slide P). Alveoli containing pulmonary corpora amylacea with scattered intraalveolar laminated concretions are seen in the right lung upper lobe (slide F). A small, thrombus showing fibrin organization and hemorrhage with "lines of Zahn" is seen in a small, peripheral branch of the right pulmonary artery (slide F).
URINARY SYSTEM: Dilation of tubules with a pink, proteinaceous fluid is seen within the left and right kidneys (left greater than right) (slides P, Q). Interstitial fibrosis with scattered glomerulosclerosis and focal subcapsular and intraparenchymal infiltrations of lymphoid cells are also seen within the left and right kidneys (slides P, Q).
GASTROINTESTINAL SYSTEM: The stomach shows diffuse vascular congestion (slide M).
HEPATOBILIARY SYSTEM: Focal invasion with moderately differentiated adenocarcinoma similar to that seen within the left lung tumor, is seen in section of the liver (slide L). Additionally, the surrounding hepatocytes show diffuse macro and microvesicular steatosis.
ENDOCRINE SYSTEM: Focal invasion with moderately differentiated adenocarcinoma as seen in section of the left lung tumor is present in sections of the right and left adrenal glands (slide B). A well-circumscribed lesion with dilated colloid-filled follicles and bland follicular cell features are seen in section of the thyroid (slide C).
REPRODUCTIVE SYSTEM: Focal atrophy with reduced numbers of germ cells, intersitial fibrosis and tubular thickening is seen in sections of the left and right testes (slide D). Fibrous, glandular nodularity is seen in section of the prostate (slide N).
LYMPH NODES: Cervical and mediastinal lymph nodes (slides C, G) show replacement of lymph node with moderately differentiated adenocarcinoma with features similar to the left lung tumor.
MUSCULOSKELETAL SYSTEM: A lytic invasive lesion with histological features of the moderately differentiated adenocarcinoma described in the left lung is seen with in the vertebral column (slide O).
SKIN: Section of the brown nodules on the neck reveals seborrheic keratosis (slide A).
BRAIN: A cystic lesion with ependymal granulation and astrocytosis is seen within the right caudate nucleus (slide BA). Focal thick-walled venules with abundant, associated corpora amylacea are seen in section of the right occipital cortex (slide BB).