Case 4: A suspicious haematoma

A 75 years old man presented with an enlarging left thigh lump after he fell down from a roof 6 months ago.

He saw a general practitioner few weeks after the injury. Two ultrasounds were performed and the diagnosis of a large intramuscular haematoma was made. He was advised to manage the swelling with warm compress and simple analgesic.

He re-presented today because he noticed that the lump was enlarging and it started to affect his walking, however, there was minimal pain. In addition, he reported weight loss of around 10 kg and feeling fatigue over the last few months.

Physical examination revealed a large firm immobile mass in the medial-posterior aspect of the left thigh. There was significant oedema on his left leg. There was no evidence of neuromuscular compromise of the extremity.

An urgent MRI was performed. (Figure 1)

 
Figure 1



1. What does the MRI show?

Case continues: Patient was referred to an orthopaedic surgeon with a special interest in sarcoma. A biopsy confirmed the diagnosis of a myxofibroidsarcoma.

2. Could this lesion be associated with his injury?

3. Can the use of imaging differentiate a soft tissue sarcoma from a benign haematoma ?

4. Is the delay in diagnosis of soft tissue tumour common?

5. How would you manage this patient?


1. The MRI showed a large intra muscular mass with heterogeneous enhancement measuring in the posteromedial thigh. It rose the possible diagnosis of a sarcoma.


2. An association between trauma and soft tissue sarcoma has been suggested for over 200 years.(5) Currently, there is no evidence to say that the relationship is causal. The usual history is of a traumatic incident occurring shortly prior to the awareness of the mass. Because of the relatively short time frame, we think that the trauma merely brings the patient's attention to the mass. (5)(7).

3. Even with the advances in modern technology, we cannot use imaging to safely differentiate a soft tissue sarcoma from a haematoma.  (2,5,7,8). Gomez et al reported three cases similar to our case study. All three patients had history of trauma prior to consulting their family physicians with lumps. They had MRIs and CTs, and were all initially reported as haematomas. This highlights the difficulty in differentiating malignant tumour from a benign haematoma using imaging alone. The imaging results need to be interpreted in the context of clinical history and examination. When there is enough clinical suspicion of a soft tissue sarcoma, patient should be referred to a specialist unit for biopsy. (8)

4. The delay in diagnosis of soft tissue sarcoma is a common problem. Many studies were conducted in an attempt to identify the sources of delay.  (2,3,4) The identified sources of delay include patient delay in presentation, mis-diagnosis, and waiting for investigations such as imaging and biopsy. The average time frame between the onset of symptoms to patient presentation is around 12 months, and the average time frame between patient presentation to referral to a specialist unit is 13.5 months.

Sarcoma is a rare tumour. There are around 800 new cases diagnosed in Australia per year. Most general surgeons or general practitioners will only encounter a soft tissue sarcoma once or twice in their careers. Therefore, it is important to be vigilant and treat any lump greater than 5 cm or deep to the fascia as sarcoma until proven otherwise.

5. Studies have shown that early referral to a specialist unit improves survival rate and treatment outcome.  Imaging and biopsies at non-specialist units are often inadequate and further delay the diagnosis. Poor biopsy techniques can potentially complicate future surgical excisions. Hence, an early referral for biopsy or management is recommended.

Case continue

Further imaging at the specialist unit showed pulmonary metastases. He underwent radiotherapy and definite surgical excision. The surgical excision was of palliative intent due to his pulmonary metastases. At the time of writing, he had returned home and recovered well from his surgery. He will require regular review and ongoing surveillance .

Key points:
- Any lumps greater than 5cm in diameter or deep in fascia should be treated as sarcoma until proven otherwise.
- Imaging results need to interpreted in the context of clinical history and examination. A biopsy is required to exclude soft tissue sarcoma.
- An early referral to a specialist unit provides the best survival rate and treatment outcome.


References:

Cancer Council Australia Sarcoma Guidelines Working Party. Clinical practice guidelines for the management of adult onset sarcoma.

Sydney: Cancer Council Australia. [Version URL: http://wiki.cancer.org.au/australiawiki/index.php?oldid=138276, cited 2017 Apr 11].

Available from: http://wiki.cancer.org.au/australia/Guidelines:Sarcoma

2. Ashwood N, Witt JD, Hallam PJ, Cobb JP. Analysis of the referral pattern to a supraregional bone and soft tissue tumour service. Ann R Coll Surg Engl 2003 Jul;85(4):272-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12855033.
4. Stiller CA, Passmore SJ, Kroll ME, Brownbill PA, Wallis JC, Craft AW. Patterns of care and survival for patients aged under 40 years with bone sarcoma in Britain, 1980-1994. Br J Cancer 2006 Jan 16;94(1):22-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16317433
5. Soft tissue sarcomas of the extremities. Blake A. Morrison. Available at
6. Uptodate pathogenetic factors in soft tissue and bone sarcomas
7. http://www.bcmj.org/article/soft-tissue-sarcomas-extremities-how-stay-out-trouble
8. High grade sarcomas mimicking traumatic intramuscular hematoms: a report of three cases. Pablo Gomez and jose Morcuende Available at:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1888428/pdf/1555-1377v024p106.pdf
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Case 3: Lung function test

68 yr old male came for regular check up.

He had a lung function test last year.

He used to be a heavy smoker, quit last year. His exercise tolerance is limited to around 50m.

What is your diagnosis ?

With a long smoking history and shortness of breath, this lung function indicates Chronic Obstructive Pulmonary Disease (COPD) . COPD is confirmed by the presence of persistent airflow limitation. FEV1/FVC < 0.7.

The problem we are having now is that we over diagnose people with COPD. Around 20-30% of patients who have a diagnosis of COPD has never had spirometry. Remember, COPD is a spirometry diagnosis.

What are your differential diagnoses?

COPD has many causes including asthma, smoking, occupation exposures, and anti tripsin 1 deficiency.

Is this severe disease ?

The current classification from lung foundation Australia classify this patient with severe disease.

How would you manage this patient?

This patient requires multi-disciplinary approach. 

1. GP management plan and TCA
2. Prevention of exacerbation: flu vaccination and pneumococcal vaccination
3. Stop smoking 
4. Optimise medications: use COPD stepwise treatment flowchart (link)
5. COPD action plan 
6. Refer to lung rehabilitation or physiotherapist or exercise physiologist to improve lung function 
7. Regular review and assess inhaler techniques 

According to the latest COPD guideline, severe COPD with more than 2 exacerbations per year should be managed by LABA + Inhale corticosteroid. 

Reference:

1. COPD-X concise guideline

Jaundice

68 yr old woman presented with jaundice. (Really jaundice, sort of like simpson kind of yellow)

It started 2 weeks ago. There is intermittent abdominal discomfort but mostly pain free. She noted that her stool is getting pale and hard to flush. The urine is getting darker and darker.

She is otherwise well. Not any medication. Denies ETOH abuse or any new medications.

This is the first time you see her.

Examination is essentially normal other than jaundice. She is haemodynamically stable, afebrile. Abdomen is soft, non tender, no ascites and no hepatomegaly.

What are your differentials at this stage ? How would you manage this patient ?

A structured approach will break down jaundice into pre, intra and post hepatic cause.

 In my mind, I thought this is going to be carcinoma of head of the pancreas. (Painless jaundice).

I was putting all my money on post hepatic jaundice.

The differentials listed in Murtagh

• Intrahepatic 
• Alcoholic hepatitis/cirrhosis 
• Drugs
• Primary biliary cirrhosis 
• Viral hepatitis 
• Extrahepatic 
• Cancer of bile ducts
• Cancer of pancreas
• Other cancer: primary or secondary spread
• Cholangitis
• Pimary sclerosing cholangitis 
• Common bile duct gallstones
• Pancreatitis
• Post-surgical biliary stricture or oedema 

I spoke to my supervisor because I thought about sending this patient to the hospital. 

The final decision was that we started the initial work up first. 

What investigations would you order? Any bedside test?

I contemplated whether to send this woman to hospital to work up in the community. Because she was well so I decided to order some blood tests and review her in a few days time. 

The blood tests I ordered at that time: FBE, LFT, Ca-125, ESR, CRP, UEC, Hepatitis B, Hepatitis A and hepatitis C serology, urinalysis

Hepatitis screen is normal.

The following is the LFT.   What does it tell you and What would you do now ?

This LFT picture is worrying. The bilirubin is 20 times over the normal limit. Combining this with the derrange ALP and GGT. This lady requires an urgent decompression. I ordered an urgent CT chest, abdo and pelvis. The following is the report. 

 It shows gross intrahepatic biliary dilatation likely secondary to cholangiocarcinoma. I contacted one of the local surgeons and he said this patient needs urgent decompression. 

She was transferred to a tertiary hospital for urgent decompression. An ERCP was performed and a stent was inserted. The surgery was complicated by post-op haematoma and re-obstruction. The obstruction subsequently resolve by itself and patient was discharged with out patient upper GI follow up for curable surgery. 

Lessons learned from this case:

- Get advice from other people when you are not sure

- Needs a structured approach to jaundice 

- Clinical appearance can be deceiving
- Urinalysis can be helpful in determining the cause of jaundice. The presence of bilirubin in urine  and the absence of urobilinogen indicates post hepatic obstruction.