CLINICO-PATHOLOGICAL

CORRELATION
MEDICAL ONCOLOGY

JR PRESENTER DR RAVI KUMAR FACULTY PRECEPTOR

JR MODERATOR DR KLP VAISHNAVI DR PANKAJ JORWAL
DR DEEPAM PUSHPAM
 CASE- DEMOGRAPHY

 23 years old female

 Unmarried
 Resident of Chhattisgarh, Bilaspur
 Medical student in Russian institution
 CHIEF COMPLAINTS

Apparently normal till 5th of February 2022

 Intermittent fever X 2 months

 Swelling all over body X 1.5 months
 Generalized weakness X 1.5 months
 Dyspnoea on exertion X 1 months
 HOPI

Fever
 Documented -101 F
 associated with chills and dry cough
 Was relieved on Oral Paracetamol.
 No history of diarrhoea, vomiting, burning micturition,
frothing of urine, red/cola coloured urine, jaundice.
 HOPI

Generalised body swelling

 First noticed on face (by mother).
 Progressed to involve both lower limbs and abdomen.
 Was associated with abdominal discomfort.
 Not associated with yellowish discoloration of body,
burning micturition, frothing of urine, red/cola coloured
urine.
 HOPI

Shortness of breath
 Since 1month
 Exertional (mMRC II)
 Not associated with orthopnoea and PND
 not associated with cough , chest pain , palpitation.
 Relieved on paracentesis
 PAST HISTORY

 No history of similar complaints in the past.

 No history of any other major surgery in the past.
 recently diagnosed hypothyroidism
 No history of diabetes mellitus, hypertension, seizure
disorder, kidney disease, liver disease, coronary artery
disease.
 No history of blood transfusions or known allergies.
 No history of contact with case of active TB
 PERSONAL HISTORY

 Non-smoker
 Non-alcoholic
 Decreased appetite
 Normal bowel and bladder habits
 FAMILY HISTORY

 No similar complaints in the family

 No history of any genetic disease or malignancy in family.
 TREATMENT HISTORY

Russian Hospital
 Underwent paracentesis(about 2L)

Private hospital (India)

 Received IV antibiotics (Meropenem and doxycycline)
 Underwent diagnostic laparotomy with random omental
biopsy
 Was started on IV hydrocortisone but had no relief in
symptoms
 NEGATIVE HISTORY

 No history of constipation, diarrhoea, vomiting, burning micturition, frothing of

urine, red/cola coloured urine, jaundice.
 No history altered mental sensorium, seizures, headache, focal neurological
deficits.
 No h/o oral or genital ulcers, photosensitivity, joint pains, skin rash, hair loss,
dry eye/mouth, visual abnormalities, skin thickening or discoloration of
finger/toes
 TILL NOW

Intermittent
fever

Generalised
body
swelling

23 year
Dyspnea
female on
exertion
 D/D TILL NOW

• INFECTIVE VS AUTOIMMUNE VS NEOPLASTIC

• RENAL VS HEPATIC CAUSE OF SWELLING
• DYSPNEA DUE TO ASCITIS OR UNDERLYING LUNG
PATHOLOGY
APPROACH TO EDEMA
 PATIENT WITH
EDEMA

LOCALIZE GENERALIZE
D D

ACUTE
BEDSIDE
CHRONIC
USG
RULE OUT DVT
VENOUS SUFFICIENCY CARDIOGENIC NON CARDIOGENIC
LYMPHEDEMA
EXTRINSIC COMPRESSION SKIN AND SOFT
DRUG-INDUCED   TISSUE INFECTION HEART FAILURE ALBUMINEMI
LIPEDEMA COMPARTMENT CONSTRICTIVE A
  SYDROME
SKIN AND SOFT TISSUE PERICARDITIS
INFECTION MUSCLE STRAIN PERICARDIAC EFFUSION NORMAL
BAKER’S CYST REDUCED
24 HR
LIVER FAILURE PROTEINURI TFT
A
LIVER <3.5GM/ NORMAL REDUCED
>3.5GM/
IMPAIRED FUNCTION DAY DAY
IDIOPATHIC DRUG MYXEDEMA
NORMAL
INDUCED
NEPHRITIC NEPHROTIC
MALNUTRITION SYNDROME SYNDROME
 GENERALIZED EDEMA

CARDIAC HEPATIC RENAL

Pedal Edema predominates Ascites predominates Edema in loose subcutaneous tissue

Legs Face Ascites Ascites Generalised Face Legs ascites

Worsens towards the day No Diurnal variation Maximum in the morning

Tender hepatomegaly Hypoalbuminemia

Engorged jugulars Hypertension
Exertional dyspnoea Proteinuria
 EXAMINATION

 Poorly nourished, normal built, BMI- 18.0 kg/m2

 GCS= E4 V5M6, conscious and oriented, lethargic
 Pulse rate- 100/min, regular rhythm, all peripheral pulses felt.
 BP- 110/70 mmHg
 Afebrile
 Respiratory rate- 22/ min
 SpO2-96 % room air
 GENERAL PHYSICAL
EXAMINATION

 Pallor present
 No clubbing
 No icterus
 No cyanosis
 No palpable cervical, axillary or inguinal lymphadenopathy
 Bilateral pedal edema upto knee present
 JVP not raised
 Abdominal pigtail catheter was insitu with drain
 SYSTEMIC EXAMINATION

• Chest–​Bilateral vesicular breath sound with decreased bilateral basal air

entry, no adventitious sounds
• CVS- ​S1,S2 heard, no murmurs were heard
• CNS – ​No neck rigidity, no focal neurologic deficits, no cerebellar signs, B/L
plantar down going, bilateral pupils equal and reactive to light, fundus
examination was normal
• Abdomen – soft, no tenderness, distended with flanks full, abdominal drain
in situ, organomegaly could not be appreciated, bowel sounds were present .
 CLUES TILL NOW

Intermittent fever, generalised

body swelling, and dyspnea

Pallor, Pedal Edema +

23 year
old Decreased breath sounds ,
Abdominal distention
female
 APPROACH TO A PATIENT WITH
ASCITES

• Pathogenesis
• Causes
• Evaluation
• Ascitic fluid analysis
 CAUSES

Portal hypertension Cirrhosis

Alcoholic hepatitis
Hepatic congestion
- Congestive cardiac failure
- Constrictive pericarditis
- Hepatic venous outflow obstruction (hepatic vein
thrombosis, sinusoidal obstruction syndrome)
Portal vein thrombosis
Non-cirrhotic portal hypertension

Infectious Spontaneous bacterial peritonitis

Secondary bacterial peritonitis
Tuberculous peritonitis
Chlamydia

Malignancy Peritoneal carcinomatosis

Hepatocellular carcinoma
Mesothelioma
Metastatic liver disease
Other intra-abdominal malignancies

Miscellaneous Pancreatitis
Hypalbuminaemia
Nephrotic syndrome
Lymphatic leakage
Myxoedema
Urinary leakage
 EVALUATION

• History- Weight gain, tightening of cloths, ankle edema , addiction and

medication used.
• Physical examination-
1. Signs of liver disease- Palmar erythema , Spider naevi, splenomegaly
2. Signs of heart failure- Peripheral edema , raised JVP, third heart sound,
pulmonary rales.
3. Features of malignancy – Lymphadenopathy.
• Blood tests- CBC, LFT, RFT, PT/INR, LDH
• Abdominal USG- Liver size and echo texture, Spleen,
• Abdominal paracentesis
 ABDOMINAL PARACENTESIS

Appearence Etiology Lab Evaluation

Routine-Total Counts , Differential counts,Albumin,
Clear Cirrhosis Protein ,Culture.
Special situations -Glucose , LDH, Amylase, ADA, Gene Xpert.
Turbid Infection/tumor
Milky /white Chylous/Injury
Secondary peritonitis Glucose<50mg/dL
Dark brown Bile duct injury
d/t bowel rupture Ascitic LDH> Serum LDH
Black Pancreatic Polymicrobial culture report
necrosis/Melanoma
Pancreatitis Ideally to be done in the1000mg/dL
Amylase> left lower
quadrant because of grater depth of
Tuberculosis AFP (sensitivity-0-3%)
ascites and thinner abdominal wall.
Culture- (sensitivity-35-50%)
ADA (30-45IU/L) (sensitivity-
90%)
PCR – (sensitivity-94%)
SAAG
 ROUTINE BLOOD INVESTIGATIONS

  6/4/22 3/5/22 16/5/22 31/5/22

Urea 250.1     mg/dL 81.6     mg/dL 76     mg/dL 31.9     mg/dL
Creatinine 2.0     mg/dL 0.5     mg/dL 0.5     mg/dL 0.4     mg/dL
Uric Acid 14.1     mg/dL 4.9     mg/dL 6.7     mg/dL 7.5     mg/dL
Calcium 7.8     mg/dL 8.2     mg/dL 8.4     mg/dL 7.8     mg/dL
Phosphorus 6.4     mg/dL 4.3     mg/dL 4.5     mg/dL 3.0     mg/dL
Sodium 131     mmo/L 132     mmo/L 136     mmo/L 135     mmo/L
Potassium 5.7     mmo/L 4.0     mmo/L 4.5     mmo/L 3.6     mmo/L
Bilirubin (T) 0.34     mg/dL 0.6     mg/dL 0.3     mg/dL 0.3     mg/dL
ALT 25     U/L 19     U/L 27     U/L 22     U/L
AST 34     U/L 19     U/L 21     U/L 20     U/L
ALP 133     U/L 167     U/L 102     U/L 84     U/L
Total protein 4.5     gm/dl 5.2     gm/dl 5.1     gm/dl 4.6     gm/dl
Albumin 2.1     gm/dl 3.1     gm/dl 2.7     gm/dl 2.5     gm/dl
 ROUTINE BLOOD
INVESTIGATIONS

18/5/2022 31/5/2022
  5/4/2022 24/4/2022 12/5/2022

T.L.C 34500/µL 26140/µL 21250/µL 15930/µL 15480/µL

NEUTRO 75.8     % 72.6     % 71.5     % 64.4     % 72.0     %

LYMPHO 11.6     % 17.9     % 12.2     % 24.7     % 18.2     %

11.5     g/
HB 8.5     g/dL 9.0     g/dL 9.6     g/dL 9.0     g/dL
dL
PLATELET
100000/µL 201000/µL 150000/µL 230000/µL 97000/µL
COUNT
CHEST X-RAY

•Bilateral moderate pleural effusion

 ANEMIA PROFILE

Investigation RESULT Peripheral smear:

Iron 59 mcg/dl Normo-microcytic hypochromic
RBC, 2% spherocytes, neutrophilic
Transferrin 173 mg/dl
leucocytosis, adequate platelets
Ferritin 1025 mg/dl
TIBC 252 mcg/dl
T Sat% 23%
Peripheral blood flowcytometry:
Vitamin B12 526 pg/ml Peripheral blood sample sent for flow
Serum Folate 12.3 ng/ml cytometric analysis shows
Corrected retic count neutrophilic leucocytosis.
RETIC COUNT
3.1
Stool OBT Negative
 INFECTIOUS DISEASE WORKUP

•Multiple blood cultures- sterile

•Blood culture for anaerobes: Negative
•Leptospira IgM: negative
•Brucella SAT: Negative
•VDRL: non reactive
•Bone marrow for aerobic and anaerobic culture: Negative
•Bone marrow for ZN stain, Gene Xpert: Negative
•LN biopsy genexpert: Negative
•Blood fungal culture: Sterile
•Urine Histoplasma Antigen – Negative  
 A S C I T I C F L U I D A N A LY S I S

Ascitic Fluid 26/5/2022  

TLC 80/mm3  
DLC N20 L80  
Sugar 119  
Impression:
Albumin <1   lymphocytic predominant high
SAAG 1.4   SAAG low protein ascites
Protein <2  
Bacterial culture Sterile  
AFB Negative  
GeneXpert Not detected  
Fungal culture Sterile  
Cytology: Many lymphocytes and few
mesothelial cells in proteinaceous
background
 PLEURAL FLUID ANALYSIS

Pleural Fluid 8/5/2022

TLC 200/mm3
DLC N10 L90
Glucose 94   
Fluid LDH 106 
Serum LDH 189 U/L
Protein 2.5    Impression:
Serum protein 5.8 Lymphocytic predominant
Bacterial culture Sterile transudative pleural effusion
AFB Negative
GeneXpert ULTRA Not detected
ADA 4.0
Fungal culture Sterile
Cytology: No atypical cells found
 TUMOR MARKERS

CA-125 57.8     U/mL < 35 U/mL

0.89 - 8.78
AFP 1.40     ng/mL
ng/mL
CEA 1.01     ng/mL < 5 ng/mL
688.65     U/
CA 19.9 < 37 U/mL
mL
 AUTOIMMUNE PROFILE

Investigation RESULT
Rheumatoid Factor NEGATIVE   IU/mL
ANA (Method: IIF) 2+, cytoplasmic pattern
ANCA (Method: IIF) NEGATIVE
Anti dS DNA (Method: ELISA) Negative
ENA profile Anti-Ro 52 +
APLA work up Negative
M Band (Serum and urine) Negative
SFLC 1.59
IgG, total 620
IgA, total 157
 RADIOLOGICAL
INVESTIGATIONS

• USG Abdomen (12/3/2022)

Hepatomegaly(15.3cm) , Splenomegaly(12.7cm), Gross Ascites, B/L Pleural
effusion
• HPA Doppler (6/4/2022):
Normal hepatic venous and portal blood flow, portal vein not dilated
• CECT Chest, Abdomen, Head ( 20/4/2022)
Hepatosplenomegaly. Multiple geographical hypodensities in spleen - s/o infarct.
Few well-defined hypodensities in splenic parenchyma - ?secondary to infiltrative
disorder.
Moderate ascites with moderate B/L pleural effusion.
• Whole body 19FDG PET Scan (18/4/2022 )
Metabolically active cervical, right scalene, supraclavicular, axillary and
abdomino-pelvic lymph nodes along with bilateral pleural effusion, moderate
ascites and anasarca
 OTHER INVESTIGATIONS

• Liver Biopsy (16/4/2022)

Liver biopsy shows multiple cores of hepatic parenchyma with maintained architecture.
There is no significant portal inflammation. Hepatocytes are predominantly unremarkable
except for focal presence of lipofuschin. No spotty necrosis, steatosis or cholestasis. No
organism, granuloma or atypical cells. No fibrosis . Overall features are non diagnostic.
• Bone marrow biopsy (23/4/2022)
Bone marrow biopsy is adequate, normocellular for age. Hematopoietic cells of all three
series are seen with myeloid preponderance. There is no appreciable increase in immature
cells (blasts). Reticulin stain show grade 1 marrow fibrosis .
• Splenic FNAC (2/5/2022):
Ultrasound guided aspirate from splenic lesion shows predominantly blood and crushed
lymphoid tissue. Granulomas are not seen.
• Lymph node FNAC- (26/4/2022)
Ultrasound guided aspirate from left level II lymph node shows blood mixed reactive
lymphoid tissue only.
 SUMMARY

• 23 years female , 2months duration of illness

• Hypothyroidism
• Fever , Anasarca , Generalised weakness , Dyspnea
• AKI , Hypoalbuminemia, Leucocytosis, Bicytopenia ,
Proteinuria , ANA ++
• Bilateral Pleural effusion, mild pericardial effusion, high SAAG
low protein ascites, transudative pleural effusion
• Hepatosplenomegaly
• Grade I Marrow fibrosis.
 CAUSES OF LYMPHADENOPATHY

Malignancies Lymphomas, leukaemia, Kaposi sarcoma, metastases, skin neoplasms

Infections •    Bacterial: brucellosis, cat-scratch disease (Bartonella), chancroid, cutaneous
infections (staphylococcal or streptococcal), lymphogranuloma venereum,
primary and secondary syphilis, tuberculosis, tularaemia, typhoid fever
    Granulomatous: berylliosis, coccidioidomycosis, cryptococcosis,
histoplasmosis, silicosis
Viral: adenovirus, cytomegalovirus, hepatitis, herpes zoster, human immuno-
deficiency virus, infectious mononucleosis (Epstein-Barr virus), rubella
Other: fungal, helminthic, Lyme disease, rickettsia, scrub typhus,
toxoplasmosis

Autoimmune disorders Systemic lupus erythematosus, Dermatomyositis, rheumatoid arthritis,

Sjögren syndrome.

Miscellaneous/unusual Castleman disease, histiocytosis, Sarcoidosis,

conditions Kawasaki disease, Kikuchi lymphadenitis, Kimura disease,

Iatrogenic causes Medications, serum sickness

 APPROACH TO
LYMPHADENOPATHY

• Medical history
• Physical examination
• Laboratory testing
• Imaging
• Histopathology
 MEDICAL HISTORY

• Age
• Sore throat
• Cough
• Fever
• Night sweats
• Weight loss
• Pain in nodes
• Exposure to pets
• Travel history
• Use of medications
 PHYSICAL EXAMINATION

Extent Localized or Generalized

Site Cervical , Supraclavicular, Axillary, Inguinal , Retroperitoneal

Size Significant size (cervical >1cm , Inguinal> 2cm)

Texture Soft, Hard , Rubbery, Discrete , Matted , Movable or Fixed.

Tenderness Seen in rapid enlargement (due to capsule stretch) or

inflammatory causes.
Overlying skin Redness, Sinus tract. Ulceration.

Association to Systemic illness like

splenomegaly
 REGIONAL LYMPHADENOPATHY
Involvement of single or multiple contiguous lymph nodes.

Lymph node group Cause

Occipital Scalp infection
Preauricular Conjunctival infection, Cat scratch disease
Cervical (m.c.site) Benign- URTI, oral and dental infections , infectious mononucleosis , other viral
infection.
Malignant - metastatic cancers from head and neck, breast, thyroid and lung.

Scalene and Benign- Tuberculosis , Sarcoidosis, Toxoplasmosis etc.

Supraclavicular Malignant- Lymphoma, Lung cancer,

Axillary Benign – I/L upper limb local infection or injury.

Malignant- Breast cancer , Lymphoma , Melanoma.

Inguinal Benign – Infection/Trauma of lower extremities, STDs.

Malignant- Lymphoma , metastasis from rectum, genitalia and lower
extremities.
 GENERALIZED LYMPHADENOPATHY

Involvement of 2 non contiguous lymph node groups.

Common etiology Uncommon etiology

Mycobacterial infection Kikuchi- Fujimoto Disease
Infectious mononucleosis Amyloidosis
HIV infection Castleman’s Disease
SLE Kimura Disease
Sarcoidosis IgG4-related disease
Lymphoma
Medications
 DIFFERENTIALS

INFECTION MALIGNANCY AUTOIMMUNE

Disseminated Hodgkin lymphoma Systemic lupus
tuberculosis erythematosus

Non-Hodgkin lymphoma
(B cell)

Multicentric Castleman
disease
 SYSTEMIC LUPUS
ERYTHEMATOSUS

POINTS FOR POINTS AGAINST

• Female • No history of rash,
• Age photosensitivity, ulcers
• Polyserositis • Anti ds DNA negative
• ANA positivity
• Normal C3/C4
• Cytopenia
• Lymphadenopathy
• Hepatosplenomegaly
• Renal dysfunction
 DISSEMINATED TUBERCULOSIS

POINTS FOR POINTS AGAINST

• Age • No microbiological
evidence
• Sex
• High SAAG
• Lymphadenopathy
• Transudative
• Serositis
effusion
• Lymphocytic predominant
picture of fluids
 NON HODGKIN LYMPHOMA

POINTS FOR POINTS AGAINST

• Female sex • Age
• Generalized
lymphadenopathy
• Presence of B
symptoms
• Cytopenia
 MULTICENTRIC CASTLEMAN
DISEASE

POINTS FOR POINTS AGAINST

• Age • High SAAG ascites
• Female sex • Renal involvement
• Organomegaly
• Recurrent ascites
• Cytopenia
• Generalized
lymphadenopathy
• Grade I Marrow
fibrosis