Liceo de Cagayan University- College of Medicine

LICEO DE CAGAYAN UNIVERSITY

COLLEGE OF MEDICINE
SURGERY DEPARTMENT

CLINICO-PATHOLOGIC CONFERENCE

“BOY OVER CAULIFLOWER”

By: TEAM TWO-MUR

Presenters:

Abdulbasit, Omira
Apil, Hasib
Bernal, Fiona Lois
Dajao, Danica Rose
Guro, Ainah Salam
Maclood, Sophia Marie
Musa, Nasrah
Ranuja, Cathy
Tominaman, Abdul Hakim

APRIL 2021
Liceo de Cagayan University- College of Medicine

I. IDENTIFYING DATA

VM. Male. 40yo. Married. Resides at Galas, Dipolog City, Zamboanga Del
Norte. Roman Catholic. SMART Reloader.

Reliability: 85%

II. CHIEF COMPLAINT:

Right shoulder mass

III. HISTORY OF PRESENT ILLNESS

Four years prior to admission, the patient noticed a brown, firm,

marble-size mass in his right shoulder described as “ibabaw sa kili-kili, lusay
nga mo sayaw-sayaw ilalom sa panit”. This was associated with
undocumented fever and chills of 3 days duration with inguinal
lymphadenopathy. There was no associated tenderness, itchiness, and
discharges in his mass around this time. No medications nor traditional
remedies were taken. The patient was still able to work and do his daily
activities.

Six months PTA, the patient noticed that the mass was slowly growing
as big as a calamansi and already protruding the skin. The mass was still firm
and movable. There was no associated tenderness, discharges, and fever
during this time. With this progression, it prompted him to seek consultation.
During his visit, the doctor was reluctant to remove the mass because of his
high blood pressure, so instead he gave him 10mg Amlodipine for 2 weeks.
He wasn’t able to do a follow-up as the lockdown was already implemented in
their place this time around.

Three months PTA, the patient had a follow-up check-up. The mass
was still protruding and as big as a calamansi. It was still firm and movable.
There was no associated tenderness, discharges, and fever. The patient
didn’t take any remedies. He underwent right shoulder mass incisional biopsy
at Dipolog City. By this time, the patient stopped working.

Two months PTA, the patient noticed that the first mass was already
growing aggressively. It was the size of a fist and was starting to get reddish
and lumpy in appearance with clear, watery discharge that eventually
developed into brown, foul-smelling discharges. No medications taken and
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dressing was only done using a dry cotton. There was also an associated
gnawing pain, weight loss, and loss of appetite due to the sight and smell of
the mass. The patient also noticed another brown mass growing supero-
medially from the first mass. It was described by the patient as “ilalom sa
panit murag taklob sa coke kadako”. He also stated that the mass was
“humok nga murag naay tubig sa sulod”. The patient received the result of the
biopsy and it showed Poorly Differentiated Squamous Cell Carcinoma.
Patient was then referred to a tertiary hospital in Cebu City but opted to seek
consultation in Cagayan de Oro City instead.

One month PTA, the patient went to Cagayan de Oro City for
consultation and was later on referred to a tumor specialist.

One week PTA, consultation was done with the specialist. By this time,
the first mass was already the size of a melon. It appears like a cauliflower
with a firm, smooth reddish base and a red lumpy top with necrotic areas and
brown, foul-smelling discharges. There was also an associated gnawing pain.
The second mass also grew in size like of a fist and became reddish in
appearance with small bumps on its surface. The patient underwent right
shoulder and right arm MRI with contrast and showed a soft tissue mass. He
was then advised for wide resection of the mass hence the admission.

Maintenance: Patient was taking 500mg Multivitamins capsule, 500mg

Ascorbic acid tablet, and 1 glass of Barley powder herbal supplement every
day as recommended by his sister.

Allergies: No known allergies.

Tobbacco: 25.3-pack years smoker. Stopped at 37yo. Continued at present.

Alcohol: Occasional alcoholic beverage drinker.

Drugs: History of illicit drug use of Methamphetamine HCl started at the age
of 31 until 38.

IV. PAST MEDICAL HISTORY

A. Childhood illness

He was 9 years old when he experienced Chickenpox. He did not

experience any mumps nor measles. Coughs and colds and fever were also
common and relieved with over-the-counter medications. The patient received
Liceo de Cagayan University- College of Medicine

vaccination as a child such as oral polio, tetanus toxoid and BCG. However,
no booster dose given.

B. Adult illnesses

MEDICAL HISTORY
He had no previous hospitalization. Gouty arthritis started 5 years with
occasional flares and relieved with allopurinol. Elevated blood pressure of
140/90 first noted 3 years ago per health center check-up but no maintenance
taken.

SURGICAL HISTORY
He had no previous surgery.

PSYCHIATRIC HISTORY
No previous psychiatric diagnosis.

V. FAMILY HISTORY
FAMILY GENOGRAM

His father died at the age of 57 years old due to bleeding ulcer
complications and acute kidney disease. Mother is still alive with type 2
diabetes mellitus and hypertension. Eldest brother 55 years old, experiencing
hypertension. The second brother 49 years old apparently well and the third
sibling is a female 45 years old also well. The patient is the fourth child and
his youngest sister is 36 years old and also apparently well. The wife of the
patient is 36 years old apparently healthy. He only has one child, a 12 years
Liceo de Cagayan University- College of Medicine

old daughter also well. The patient had no family history of any type of cancer,
tumors and tuberculosis.

VI. PERSONAL, SOCIOECONOMIC AND ENVIRONMENTAL HISTORY

Born and raised in Dipolog City, Zamboanga del Norte, finished high
school and some college education, married at 24 years old. After few years
of marriage, he decided to move with his wife to Manila. While in Manila, he
worked as a delivery man for various fast-food chain using a two-wheel
vehicle during the day and sideline as a tricycle driver at night while his wife
worked as a teacher in a private institution. After that he also worked as a
family driver.

Then after 10 years they decided to move back to Dipolog City, where
he work as a smart reloader for various stores earning approximately 380
pesos per day for almost 4 years now while the wife applied and worked in
Kuwait as a teacher earning approximately 38,000 pesos per month. Patient
also shared that despite the distance they were able to maintain a good
relationship and communicate everyday through messenger.

He was a teenager when he first tried smoking 1 to 2 sticks per day but
was already 25 years old when he started consuming 2 packs per day. He
decided to quit at the age of 37 but started smoking again approximately 5
sticks per day when he was 40 and stop completely when he noticed the
mass started growing.

He started drinking alcohol at the age of 28 years old. While working

as a delivery man he consumes approximately 14 ounces of 80% spirit almost
every Friday night after work but he stop 3 years ago. He also used
methamphetamine hcl when he was 32 years old on some occasions with
friends but also stop completely at the age of 38.

His hobbies include raising derby chickens and he don’t usually

perform any exercise regimen. His diet consists of eating barbeque, organ
meats and “kinilaw” before switching to eating fish and vegetables. He
consumes approximately 2-3 liters of water per day. Source of drinking water
is through refilling stations. He describes to experienced emotional stress due
to his present condition but describes no signs of depression or anxiety.

At present, he is living with his daughter, sister, nephew and mother

assisting him while he is still recovering. He is currently in a rented concrete
apartment, gated and described as peaceful environment. They segregate
Liceo de Cagayan University- College of Medicine

their waste and picked up by the garbage truck every week. No exposure to
environmental chemicals, radiations or pollution.

VII. REVIEW OF SYSTEMS

General: (+) Recent 6kg weight loss.

Skin: (+) Dry skin, (+) Erythematous mass @ Right shoulder, No rashes, no
nail changes.

HEENT:
Head: No history of head injury, no headache, no dizziness.
Eyes: No use of eyeglasses. no eye pain, no redness of eyes, no doubling of
vision.
Ears: No tinnitus, vertigo, earaches, discharges.
Nose and sinuses: no colds, no painful sinuses
Throat: No dysphagia, no odynophagia, and dysphonia. No use of dentures.

Neck: No neck stiffness, swollen lumps and no pain.

Breast: No lumps, pain, or discomfort, no nipple discharge. Does not do

breast self-examination

Respiratory: No tachypnea, no dyspnea. No cough. No hemoptysis.

Cardiovascular: No chest pains. No Shortness of breath. No palpitations

Gastrointestinal: No trouble swallowing, No heartburn. No Abdominal pain.

No food intolerance. No changes in bowel movements. No Rectal Bleeding,
Black or tarry stool.

Genitourinary: No painful urination, no testicular pain, no discharges, doesn’t

perform testicular exam.

Musculoskeletal: (+) Right shoulder mass, (+) Limited ROM @ right upper
extremity, Abduction of 90° and Flexion of 90°. (+) Gout arthritis. No history of
trauma.

Psychiatric: No depression. No suicidal ideation. No past counselling,

psychotherapy or psychiatric admission.
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Neurologic: No mood, attention or speech changes. No dizziness, vertigo or

black-outs episodes. No weakness or paralysis. No tingling sensation. No
seizures.

Hematologic: No easy bruising or bleeding. No anemia.

Endocrine: No excessive sweating. No heat or cold intolerance.

VIII. PHYSICAL EXAMINATION

General Survey:
Patient was initially seen awake in a sitting position, mesomorphic with a right
shoulder mass. He appears anxious and in pain. He is oriented to time, place,
person.
Vital Signs
Temperature: 36.7, Axillary
Pulse Rate: 89bpm, Radial
Respiratory Rate: 20cpm
Blood Pressure: 120/80mmhg, Left Arm
Weight: 62kg
Height: 166cm
BMI: 22.5 (Normal)

Skin: Exophytic and Erythematous mass @ Right Shoulder, Brown-skinned

complexion, Warm and dry skin with good turgor,Normal hair texture and
distribution, No nail changes, clubbing or cyanosis, Capillary refill time is
normal at <2 seconds.

HEENT
Head: NC/AT. Hair is average in texture Scalp is dry and without lesion. No
lumps and tenderness noted.
Eyes: Visual acuity OD – 20/20 OS – 20/20, Anicteric Sclerae. Palpebral
conjunctivae pink. Visual fields full by confrontation, PERL, 4mm constricting
to 2mm bilaterally consensual reaction present. No eye trauma, no abnormal
lacrimation. Extraocular movement is intact. Red-orange reflex present upon
fundoscopy.
Ears: Acuity good to whispered voice. Schwabbach test normal in both ears.
Weber midline Rinne Test AC>BC both ears. Right and left tympanic
membrane intact with good cone of light.
Nose: Nasal mucosa pink. Septum midline. No tenderness on maxillary and
frontal sinuses. No nasal obstruction. No discharges present.
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Throat: Lips is dry. Oral mucosa pink. No mouth sores, uvula midline, gag
reflex present.

Neck: Neck supple, trachea midline. No thyroid enlargement noted.

Lymph nodes: (+) Left Cervical Lymphadenopathy

Respiratory: No signs of respiratory distress. No cyanosis nor pallor noted.

Thorax symmetric with good excursion. No tenderness and crepitus. Lungs
resonant. Breath sounds vesicular. No crackles, wheezes, or rhonchi. Anterior
and posterior tactile fremitus normal.

Cardiovascular: Carotid upstroke brisk, without bruits. Apical impulse is

discrete and tapping with normal amplitude and duration, palpable in the 5th
left interspace measuring 2cm. Good S1 and S2 with no S3 and S4. At the
base, S2 is louder than S1. At the apex, S1 is louder than S2. No systolic or
diastolic murmurs heard. No extra systolic or diastolic sounds heard.

Abdomen: Abdomen is round, nondistended. Tympanitic. Normal bowel

sounds. Liver span not assessed.

Musculoskeletal:
14x14x6cm Fungating Mass with Roughened Necrotic tissue on the surface
with purulent foul-smelling discharge @ Right upper extremity, Rubbery in
consistency, slightly movable over the anterior part of the deltoid área.
5x3x3cm Fungating mass, erythematous with superficial varicosities, soft to
rubbery in consistency, slightly movable located medially to the first mass.
Muscle strength 5/5 @ Right upper extremity with limited ROM, Abduction of
90°, Flexion of 90°. Intact distal pulses, no palsy.

NEUROLOGICAL
Mental status:
Conscious and cooperative. Thought process coherent. Oriented to person,
place, and time. GCS 15.
• Cranial Nerve I: Red orange reflex present in both eyes.
• Cranial Nerve II: Visual acuity, 20/20; both visual fields normal.
• Cranial Nerve III, IV, V: Extraocular movements intact
• Cranial Nerve VI: Temporal and masseter strength intact, corneal
reflexes present, facial sensation responsive.
• Cranial Nerve VII: Facial movements present and intact
• Cranial Nerve VIII: Hearing intact bilaterally to whispered voice.
• Cranial Nerve IX: Swallowing and rise of palate present and normal;
Gag reflex present (IX, X)
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• Cranial Nerve X: Voice and speech coherent and intact. No deviation of

uvula present.
• Cranial Nerve XI: Shoulder and neck movements present, can move
against resistance
• Cranial Nerve XII: Tongue midline, is symmetrical and movement is
normal.

Motor: Good muscle bulk and tone. Strength 5/5 throughout.

Cerebellar: Rapid alternating movements, finger-to-nose, heel-to-shin intact.

Gait with normal base.

Sensory: Pinprick, light touch, position, and vibration sense intact. No

numbness.

Reflexes: Deep tendon reflex grade of 2+ and symmetric; Babinski reflex

negative and down going; Clonus test negative.

Musculoskeletal: Muscle strength 5/5 @ both upper and lower extremities -

full range of motion in all joints of the upper left and both lower extremities.

Peripheral vascular: Extremities are warm and without edema. No

varicosities or stasis changes. Calves are supple and nontender. No femoral
or abdominal bruits. Pulses are 2+, brisk, regular, symmetric

IX. SALIENT FEATURES

• 40 year-old, Male
• Rapidly growing mass, exophytic
• Pain on right shoulder
• Fever
• Lymphadenopathies
• Weight Loss
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X. ADMITTING IMPRESSION:

SOFT TISSUE SARCOMA, RIGHT SHOULDER

Rule In Rule Out

• Clinical: ✓ No family history of sarcoma
✓ Progressively enlarging painless lump
✓ Rapidly growing exophytic mass
✓ Limitation of Movement on the
shoulder Cannot be completely ruled out until
✓ Fever and Lymphadenopathies further work-up
✓ Weight Loss
• Radiologic
✓ Soft tissue mass
✓ Heterogeneously enhancing

XI. DIFFERENTIAL DIAGNOSES

1. Squamous Cell Carcinoma

Rule In Rule out
• Risk Factors ✓ No precursor lesions
✓ 40yo, male ✓ No family history of cancer
✓ Sun exposure ✓ Brown skin Complexion
✓ Smoker ✓ Marjolin’s Ulcer
✓ Alcohol drinker ✓ no squamous pearls on biopsy
✓ Type IV verrucous carcinoma
• Clinical
✓ Large, rapidly growing mass
✓ Pain on right shoulder, anterior
✓ Fever with Lymphadenopathies
✓ Weight Loss
• Radiologic
✓ Lobulated, heterogeneously
enhancing
mass
✓ Non-enhancing areas within mass
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2. Non-Hodgkin’s Lymphoma
Rule In Rule Out
• Risk Factors: ✓ Night sweats
✓ Smoker ✓ Itching
✓ Male ✓ Laboratories within normal range
• Clinical: ✓ Excisional Biopsy
✓ Rapidly increasing mass
✓ Fever
✓ Unexpected weight loss
✓ Peripheral Lymphadenopathies
• Radiologic
✓ Regional Lymph node metastasis

3. Soft Tissue Sarcoma (Clear Cell Carcinoma)

Rule In Rule Out
• Risk Factors • Radiologic
✓ Age ✓ Homogenous, lobulated well-
• Clinical circumscribed lesions
✓ Painless, slow growing , slightly
movable lump ✓ Incisional or Core Needle Biopsy
✓ anterior, right shoulder
✓ Weight loss
• Radiologic
✓ No bone involvement

4. Extraskeletal Ewing’s Sarcoma

Rule In Rule Out
• Risk Factors: ✓ Rare in patients older than 30 yo
✓ Smoker
✓ Alcohol drinker ✓ Serpentine high-flow vascular
✓ Male channels
• Clinical:
✓ Large, destructive mass ✓ CT-guided core needle Biopsy
✓ Proximal humerus
✓ Painful and tender
✓ Fever, ESR 40
✓ Trauma upon incision
• Radiologic
✓ Heterogenously enhancing
✓ Large mass
✓ Lytic lesion
✓ No osseous involvement on MRI
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XII. Course In The Ward

1ST HOSPITAL DAY 02-08-2021 @2:00PM

Plan:
- Admit to ortho ward; IVF: none for now; DAT; monitor v/s q4h; monitor I&O
qshift; limb salvage of right shoulder vs disarticulation vs forequarter
amputation; prepare 5 units PRBC of patient’s blood type for or use.
Diagnostics:
• Blood type with RH;
• Serum Na, K+, Ca, Creatinine, SGPT, SGOT, alkaline
Phosphatase, ESR, CRP;
• HBsAg;
• Chest MRI With Contrast To include Shoulders;
• Chest CT Scan with Contrast to include Shoulders;
• Angiography of Right Upper Extremity;
• 12 Lead ECG; CBC with Platelet Count.
Intervention:
- Admitted and managed as case of squamous cell carcinoma, shoulder,
right; therapeutics given are Celecoxib 200 mg/cap 1 cap 2x a day.
- Diagnostics ordered; Secured consent for care; secured consent for
procedure; CXR done; R shoulder AP+ Axillary view+ scapular Y-view
done.

2ND HOSPITAL DAY 02-09-2021 @ 01:15PM

Plan:
- Still for scheduling: MRI Chest to include Right Shoulder; For Change of
Dressing; Refer
@4:16pm: Ultrasound Of Axilla And Ipsilateral Neck; Refer
Intervention:
- Continue Meds

3RD HOSPITAL DAY 02-10-2021 @ 10:00PM

Plan:
- Refer to IM Oncology, plastic recon, and GS for Co-mgt; Secure 3 U PRBC
Typed And Screened For OR Use; Shoulder Disarticulation Vs Forequarter
Amputation R Shoulder, Refer
Intervention:
- Daily Wound Care advised
Liceo de Cagayan University- College of Medicine

4TH HOSPITAL DAY 02-11-2021 @ 3:00PM

Subjective:
- Awake, Nird; (-) Bm
Objective:
- Unremarkable Heart &L Lung Findings; Soft Tissue Mass Density, R
Shoulder; Suspicious Lytic Change In R Humoral Head; Clear Bs; Huge
Mass, Deformed, Fungating
V/S:
- T- 36 Degrees C, Hr-87 Bpm, Rr- 22 Cpm, Bp-100/70 Mm Hg, O2 Sat-
99%, I&o- Input:4500, Output 2800; Wbc-14.16, Hgb-12.4, Hct-36.5, Plt-
254, Esr- 40, Creatinine-0.9, K-4.23, Na-132.82, Calcium-10.16, SGOT-24,
SGPT-9, Alkaline phosphatase- 76, HBsAg- Non Reactive
Assessment:
- Squamous Cell Ca, R Shoulder
Plan:
- Diagnostics:
• Ultrasound Of Whole Axilla;
• Chest Ct Scan With Contrast On 02/15/21;
• Follow Up Biopsy Result;
- Refer Accordingly
- Refer To IM For Co-management;
- Follow CT Scan With Contrast;
Intervention:
- Continue Meds

5TH HOSPITAL DAY 02-12-2021

Objective:
- MRI: right shoulder done @ COMC - 1/28/22
- Result: large lobulated heterogenous enhancing mass with involvement of
anterior deltoid muscle and lateral aspect of pectoralis major muscle; right
axillary lymphadenopathy
Plan:
- @11:10 AM: For follow up blood request; follow up plastic cancer referral;
still for ultrasound of axilla, and ipsilateral neck; refer.
- @1:30PM: Suggest defer ultrasound; suggest CT scan of the chest with
contrast to include the neck; revised plan: latissimus dorsi flap for coverage
of amputation stump and cervical lymphadenopathy
- @8:00PM:
o For chest CT scan;
o for OR scheduling;
o shoulder disarticulation vs forequarter;
o amputation, right
Intervention:
- Continue meds; daily wound care
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5TH HOSPITAL DAY 02-12-2021 @ 12:00PM

GS NOTES
Plan:
- Pectoralis Major myocutaneous Flap;
- Suggest Ultrasound for Neck and Axilla;
- Refer
Intervention:
- Patient Seen and History Reviewed
Evaluation:

6TH HOSPITAL DAY 02-13-2021 @ 01:06AM

Plan:
- May Start IVF Of PLR 1L @ 20 gtts/min;
Intervention:
- May Give Tramadol 50 Mg IVTT Every 8 Hours with BP Precaution

7TH HOSPITAL DAY 02-14-2021 @ 01:06PM

ENT NOTES
Plan:
- For follow up FNAB Result; Inform Any ENT ROD with the Result
Intervention:

8TH HOSPITAL DAY 02-15-2021 @ 4:36PM

Plan:
- Pre-op planning: limb salvage vs disarticulation; to ff up ct scan with 3d
recon
Intervention:
- Daily dressing

10TH HOSPITAL DAY 02-17-2021 @ 11:49AM

Plan:
- Patient scheduled for surgery
Intervention:
- CP clearance prepared; blood procurement followed-up.

11TH HOSPITAL DAY 02-18-2021 @ 7:20AM

Assessment:
- Squamous cell ca on the right shoulder; thyroid nodule, left; cervical
lymphadenopathy
Plan:
- No ENT surgical management as of this time; for TSH; suggest to do FNAB
of cervical lymphadenopathy, care of pathology.
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11TH HOSPITAL DAY 02-18-2021 @3PM

Plan:
- Axillary dissection, right and cervical lymphadenopathy with frozen section
possible, MRND; Will Schedule for frozen section tomorrow; @7:30pm,
secure 9 units or PRBC, 6 FFP, 6 Platelet concentrate without fail.
Intervention:

12TH HOSPITAL DAY 02-19-2021 @ 4:20PM

Plan:
- May do ROMs of hand; Procure arm sling
- May elevate head of bed gradually
- May sit upright once fully awake
- For optimum nutrition; Follow up referral to IM oncology
Intervention:
- Patient underwent series of operations including resection of mass, lymph
node biopsy and musculocutaneous flaps; monitored post-operatively and
brought back to the ward;
13TH HOSPITAL DAY 02-20-2021 @9:53AM
Plan:
- Keep right upper extremity abducted at 30deg from torso. Never let 0 deg
adducted, this will compress vascular supply of flap.
Intervention:
- Dressing done

14TH HOSPITAL DAY 02-21-2021 @7:00AM

Cues:
- 8:00AM: + Dizziness; + pain post op site; - fever
Plan:
- Keep right upper extremity abducted at all times
- Keep closed suction drain with negative pressure
Intervention:
- Give tramadol 50mg IVTT every 8 hours for 3 days; Daily dressing done;
continue medication.

15TH HOSPITAL DAY 02-22-2021

GS NOTES
Plan:
- Keep negative pressure on closed suction drain; keep right upper extremity
abducted at 70 degrees; refer; Refer to ortho resident to dress flap cage;
daily and STSG every 3 days; for removal of staples after 5-6 weeks; repeat
CBC
Intervention:
- Daily dressing done
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16TH HOSPITAL DAY 02-23-2021 @6:30AM

Plan:
- Wound dressing done; waiting result from histopathology lab for possible
debridement of right shoulder; Sutures released from operated site;
Maintain shoulder on abducted position; follow up biopsy results
Intervention:
- Start Cefazolin, Gentamycin, Penicillin; Daily dressing;

17TH HOSPITAL DAY 02-24-2021@ 9:00 AM

Plan:
- Maintain shoulder on abducted position

Intervention:
- Continue meds
- Daily wound care; advised

18TH HOSPITAL DAY 02-25-2021 @3:30PM

Cues:
- (+) Dehiscence over pectoralis major flap
Plan:
- Wound care every 3 days; refer
Intervention:
- Applied negative pressure wound therapy over the dehisced area; released
some of sutures

19TH HOSPITAL DAY 02-26-2021@ 7:00 AM

Plan:
- Maintain shoulder on abducted position;
- @1:00pm: Refer to IM oncology
Intervention:
- Continue meds;
- daily wound care; advised

20TH HOSPITAL DAY 02-27-2021 @12NOON

Assessment:
- S/P mass excision with biopsy
Plan:
- @1pm: Daily wound care
- Request for CBC, ESR, CRP
Intervention:
- Will refer to oncology service
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22ND HOSPITAL DAY 03-01-2021@ 6:00 PM

Plan:
- Continue NPWT x 2 weeks; take down NPWT after 3 days; refer
Intervention:
- Negative pressure wound therapy applied; daily wound dressing for areas
not covered w/ NPWT; repeat vac; summary of medications: Cefazolin 1g
ivtt every 8 hours and Celecoxib 200 mg cap bid;
- Day 7 of cefazolin complete

23RD HOSPITAL DAY 03-02-2021@ 12:35AM

Cues:
- Objective data: on NPWT
Plan:
- For take down; continue meds
Intervention:
- Reapplication of NPWT done

25TH HOSPITAL DAY 03-04-2021@ 8:00 PM

Plan:
- For reapplication of vac today; prepare the ff. Materials: Blade #1; Feeding
tube #1; Sterile Gloves #1; Sterile os; Irrigating NSS 1L #1
Intervention: For takedown of vac done; give tramadol 50 mg IV now

26TH HOSPITAL DAY 03-05-2021 @ 10:36AM

Cues:
- Objective data: on NPWT
Plan:
- NPWT removal; For OR scheduling revision of flap
- @4;20pm: Musculocutaneous flap and re-suturing flap dehiscence; secure
consent to procedure; cp eval c/o IM service; diagnostics: CBC w/ PC, 12
lead ECG, NA, K, CXR APL, CREA; refer accordingly
Intervention: Continue meds

27th hospital day 03-06-2021 @2pm

Plan:
- Trapeziomusculocutaneous rotational flap; Repositioning of pectoralis
major musculocutaneous flap, right. Debridement; Secure 2 PRBC of
patient’s blood type for OR use; will refer to oncology service.
Intervention:
- Give: Cefazolin IV 1gram IV q8; clindamycin 300mg capsule; celecoxib
200mg capsule 1capBID; tramadol 50mg IV prn for pain;
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29TH HOSPITAL DAY 03-08-2021 @7:30PM

Cues:
- Patient seen to examined; History and laboratory reviewed
- No known co morbidities; No previous hospitalization
- Previous smoker and alcoholic drinker
Assessment:
- SCCA at right shoulder; Status post limb salvage with wide resection
- Latissimus dorsi flap and pectoralis major flap, STSG.
Plan:
- @11:00am: For OR tomorrow; NPO post-midnight; Secure 2 units PRBC
of patient’s blood type properly screened and crossmatched for OR use;
Attached latest laboratory
- May proceed with contemplated surgery and stratified as intermediate risk.

30TH HOSPITAL DAY 03-09-2021@ 11:27 AM

Subjective data: tolerated procedure well
Objective data: no complications noted
Plan:
- @9:00pm: suggest to shift cefazolin to pip+taz 4.5 g IV q8h ANST; keep
right shoulder abducted at 60 degrees angle; prepare the ff. Materials at
bedside for wound dressing:
Intervention:
- Continue meds; revision/re-orientation of pectoralis major and latissimus
dorsi musculocutaneous flap, STSG; drain;
- Under general anesthesia ordered Bactigras #3; Dakin’s solution #1; OS
#10; Elastic bandages 4 “#4; Betadine #1
Evaluation:
- @9:00pm: Wound GS/CS taken and submitted; active suctioning of JP
drain

32ND HOSPITAL DAY 03-11-2021@ 11:00 AM

Plan:
- Maintain abduction right upper extremity; follow up GS/CS results; may
remove FBC now
Intervention:
Summary of meds
1. Celecoxib 200 mg cap, 1 cap bid
2. Pip-taz iv 4.5 g every 8 hours
3. Clindamycin cap every 6 hours po x 3 days
Discontinue tramadol
Daily wound care , care of gs
Liceo de Cagayan University- College of Medicine

33RD HOSPITAL DAY 03-12-2021@ 6:00 PM

GSNOTES
Plan:
- Keep right upper extremity abducted at all times; keep negative pressure
on closed suction drain; refer
Intervention:
- Wound dressing done; continue meds

34TH HOSPITAL DAY 03-13-2021@ 5:18PM

ENT NOTES
Plan:
- Keep negative pressure on closed; suction drain; maintain right upper
extremity abduction; follow up FNAB result; inform ent-rod about the
result; refer accordingly
Intervention:
- Continue meds
- @6:00pm: daily wound care

35TH HOSPITAL DAY 03-14-2021@ 2:00 PM

Plan:
- Maintain on vac; follow up biopsy results
Intervention:
- Continue meds

36TH HOSPITAL DAY 03-15-2021@ 10:00 AM

Plan:
- Follow up GS/CS result; refer
Intervention:
- Wound care

37TH HOSPITAL DAY 03-16-2021@ 5:19 PM

Plan:
- Follow up c/s result; refer
Intervention:
- Dressing done by plastic surgery; continue meds

42ND HOSPITAL DAY 03-21-2021@ 10:00 AM

Plan:
- @6:17am: Possible send out of tumor sample to manila for
immunohistochemical study
- @10:00am: For immunohistochemical studies on vimentin, cd 99, cd 45 of
sample to other private hospitals; for CBC with platelet count; possible
MGH tomorrow
Liceo de Cagayan University- College of Medicine

Intervention:
- Daily wound care, care of GS plastics; Review of medications: Day 11 of
Pip-taz 4.5 g iv every 8 hours; Celecoxib 200 mg/cap, 1 cap po bid

43RD HOSPITAL DAY 03-22-2021@ 6:00 AM

DISCHARGE
Plan:
- May go home today once seen by tumor specialist; for wound dressing
prior to discharge; every other day wound care; follow up after 1 week in
orthopedics OPD; follow up official histopathology result in pathology
office
Intervention:
Advised to stay in CDO 1 week after discharge; home meds:
1. Celecoxib 200 mg/cap, 1 cap 2x a day
2. Co-amoxiclav 625 mg/tab, 1 tab 3x a day for 7 days

XIII. Surgical Plan

A. Impression
• Fungating mass, right shoulder,
• Secondary infection
• Suspicious Regional Lymph Node Metastasis, Right Axillary, Right and
Left Cervical Area

B. Surgical Plan
• Limb Salvage by Wide Resection, Shoulder Mass, Right
• Latissimus Dorsi vs. Pectoralis Major Island Pedicle Flap, Right
• Split Thickness Skin Graft of the Donor/Recipient Site Flap
• Cervical Lymphadenectomy, Left and Right
• Thyroid Nodule Excision, Left

C. Laboratory Results
• WBC = 14.16
• Neutrophils = 67.4
• RBC = 4.3
• Hgb = 12.4
• Hct = 36.5
• Lymph = 20
• Mono = 7.1
• Eos = 5.2
• Baso = 0.3
• Plt Cnt = 254
Liceo de Cagayan University- College of Medicine

• Crea = 0.98
• ESR = 40
• K = 4.23
• Na = 132.82
• Ca = 10.16
• SGOT = 24
• SGPT = 9
• Alk Phos = 76

D. Imaging

February 8, 2021
a. Scapulary right
b. Chest PAL
c. Shoulder AP and Axillary view right
d. February 15, 2021
e. Neck, chest to include shoulder right with contrast JSE
February 16, 2021
f. Ultrasound of whole abdomen
g. Ultrasound of neck and axillae
h. February 18, 2021
i. Chest AP
March 7, 2021
j. Chest AP

CHEST PA (Feb. 8, 2021)

Unremarkable Radiograpgic Heart and Lungs Findings
Soft Tissue Mass Density in the included view of the right shoulder
Suspicious lytic change in the humeral head
Liceo de Cagayan University- College of Medicine

SHOULDER AP AND AXILLARY VIEW RIGHT (Feb. 8, 2021)

Soft tissue mass density in the included view of the right shoulder
Suspicious Lytic change in the right humeral head

CT SCAN WITH CONTRAST OF THE NECK, CHEST THAT INCLUDES THE

RIGHT SHOULDER (Feb. 8, 2021)
Left Thyroid Nodule with moderately suspicious features
Bilateral subcentimeter cervical and right sided axillary lymph node with features
worrisome for a metastatic process in the setting of a known primary
Sonographically unremarkable submandibular and parotid glands
Liceo de Cagayan University- College of Medicine

ULTRASOUND OF THE NECK AND BILATERAL AXILLAE (Feb. 16, 2021)

Left Thyroid Nodule with Moderately suspicious features.
Bilateral Subcentimeter cervical and right sided axillary lymph node with features
worrisome for a metastatic process in the setting of a known primary.
Sonographically unremarkable submandibular and parotid glands

E. Available Surgical Options

• Limb Sparing (Wide Excision)
• Amputation
• Pectoralis Major Flap
• Latissimus Dorsi Flap

F. Operation Done
• First operation: February 19, 2021
✓ Resection of mass
✓ Lymph Node Biopsy
✓ Musculocutaneous Flaps
• Second operation: March 9, 2021
✓ Revision / Re-rotation of Pectoral Major and Latissimus Dorsi
Musculocutaneous Flap
✓ Split-thickness Skin Grafts (STSG)

G. Post-Operative Regimen
• Daily wound care ℅ GS Plastics
• Right upper extremity maintained on abduction at 70 degrees from
torso, keep wound dry at all times, protect the flap from direct sunlight,
keep flap site eleveted at all thimes
• Adjuvant radiotherapy for patients with uncertain or positive surgical
margins or advanced nerve involvement
Liceo de Cagayan University- College of Medicine

• Post-treatment follow up every 3-6 months for 24 months, depending

on the clinical risk, it may be appropriate to schedule one 3-year follow
up appointment

XIV. DISCHARGE DISPOSITION

Patient had daily wound care. Wound was kept dry at all times. Right
upper extremity maintained on abduction at 70 degrees from torso. Flap was
protected from direct sunlight. Flap site was kept elevated at all times.
Adjuvant radiotherapy and chemotherapy for patients with uncertain or
positive surgical margins or advanced nerve involvement. Celecoxib were
given while patient was on close monitoring. Rest of the hospital stay was
uneventful leading to patient discharge.

XV. FINAL DIAGNOSIS

FINAL HISTOPATHOLOGIC DIAGNOSIS:

MALIGNANT SMALL ROUND CELL TUMOR, FAVOR
EXTRASKELETAL EWING’S SARCOMA

Histopathologic Findings
Liceo de Cagayan University- College of Medicine

Gross Description

The specimen labeled “shoulder mass” consists consist of previously

opened, elliptical mound of fleshy tissue surrounded by an elliptical skin with
an over-lying tan brown, multilobulated, friable, exophytic mass. The whole
specimen measures 17x13x11 cm. The exophytic mas measures 14x11x3.5
cm. The skin flap measures 17x13x4.5 cm. Serial sections show tan-brown,
multilobulated, friable cut surface with infiltrative growth pattern, focal
hemorrhages with few appreciable muscle and fascia. The specimen received
has no labeled tags of the surgical margin noted. The mass is 2 cm from the
arbitrary superior margin, 3 cm from the inferior, 3 cm from the medial margin,
2 cm from the arbitrary lateral margin and 1 cm from the absolute basal
margin.

Representative sections are taken for study:

A1 – Exophytic mass A5 – Arbitrary superior margin

A2 – Mass with skin A6 – Arbitrary inferior margin
A3 – Deep seated mass A7 – Arbitrary medial margin
A4 – Absolute basal margin A8 – Arbitrary lateral margin

The specimen labeled right axillary “lymph nodes” consists of

fibrofatty tissue with palpable nodular structures. There are over all 16, firm,
gray-brown lymph nodes harvested ranging 0.8 cm to 3 cm with serial
sections showing tan-brown to tan-white, hemorrhagic, smooth, solid cut
surface.

Microscopic Description

Microsections A1 to A3 disclose a neoplastic tissue with packed

sheets of cells with hyperchromatic, uniformly round nuclei, inconspicuous
nucleoli and coarse chromatin granules, palisaded by cells with pleomorphic
and vesicular nuclei, prominent nuclei and coarse chromatin granules,
arranged in lobular pattern, with intervening fibrocollagenous stroma between
lobules.

Microsection A4 disclose surgical margins with no tumor involvement.

Microsection B disclose 16 lymph nodes with sinuses infiltrated histocytes. No
evidence of tumor involvement is seen.
Liceo de Cagayan University- College of Medicine

Case Discussion

EWING’S SARCOMA

A malignant bone tumor characterized by primitive round cells without obvious

differentiation. Usually arise in the diaphysis of long tubular bones, especially
the femur and the flat bones of the pelvis.

A. Epidemiology
Ewing’s sarcoma account for approximately 6% to 10% of primary
malignant bone tumors and follow osteosarcoma as the second most
common primary bone tumor in patients under 30. Of all bone sarcomas,
Boys are affected slightly more frequently than girls, and there is a striking
predilection for whites. Blacks and Asians are rarely afflicted.

B. Etiology
Associated with various chromosomal translocation of the EWR1 gene
t(11;22)(q24;q12).

C. Clinical Manifestation
Painful enlarging masses. Affected site are frequently tender, warm and
swollen. Some affected individuals have systemic findings that mimic
infection.

D. Pathophysiology
Liceo de Cagayan University- College of Medicine

E. Diagnosis
• Complete Medical History
• Plain Radiography
• Onion-skin appearance
• Isotope scans
• Angiogram
• CT scanning
• MRI scanning
• Incisional Biopsy

F. Management
• Goal
✓ Make patient free from disease
✓ Minimize pain and preserve function
• Includes neoadjuvant and adjuvant chemotherapy
✓ Drugs effective are Doxorubicin (DXR), Cyclophosphamide
(CPA), Vincristine (VCR), Actinomycin-D(ACT), Ifosfamide
(IFM) and Etopside (VP16), G-CSF
• Radiation therapy
• Surgery

G. Prognosis
• Unfavorable - distant metastasis
• Even with aggressive treatment, long term survival is 20% in distant
metastasis
• Bone or bone marrow metastasis at the time of initial diagnosis
have worse prognosis than with isolated pulmonary metastasis
• More central lesions (as in the pelvis or spine)
• Poor response to chemotherapy
• Fever, anemia, and elevation of the number and values of WBC,
ESR, and LDH have been reported to indicate more extensive
disease and a poorer prognosis.

5-year survival
✓ 65-80% for localized disease
✓ 25-40% for metastatic disease
10-year survival
✓ 60% for localized disease
✓ 30% for metastatic disease
Liceo de Cagayan University- College of Medicine

REFERENCES:

• Schwartz, Seymour I., et. Al., 2011, Schwartz’s Principles of Surgery, 10th
Edition
• Campbell's Operative Orthopaedics, 12th edition
• Ewing’s Sarcoma Family of Tumors: Current Management (Oncologist 2006,
11:503- 519.)
• Robbins and Cotran, 2014, Pathologic Basis of Disease 9th Edition
• Turek -Orthopaedics & their application 4th edition
• An Atlas of Flaps in Limb Reconstruction by Masquelet and Gilbert.
• Dahalins- Bone Tumors- 6th edition
• Robbins basic pathology- 9th edition
• Human Pathology Volume 55, September 2016, Pages 91-100
• Bone Tumor Book
• Dr. Neilson Palabrica DPBO, FPOA Algorithm based from NCC Guidelines
and Soft Tissue Sarcoma on sarcoma.org
• Jpn J Clin Oncol 2007;37(2)79–89 doi:10.1093/jjco/hyl142
• https://pubs.rsna.org/doi/pdf/10.1148/rg.333135005
• https://www.ncbi.nlm.nih.gov/books/NBK559328/#:~:text=Patients%20present
%20with%20complaints%20of,presents%20with%20painless%20peripheral%
20lymphadenopathy.
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6676724/