งานนำเสนอกำลังจะดาวน์โหลด โปรดรอ

งานนำเสนอกำลังจะดาวน์โหลด โปรดรอ

Inter-hospital Conference 20 March 2012 Hematology/Oncology Department of Pediatric Queen Sirikit National Institute of Child Health Hospital.

งานนำเสนอที่คล้ายกัน


งานนำเสนอเรื่อง: "Inter-hospital Conference 20 March 2012 Hematology/Oncology Department of Pediatric Queen Sirikit National Institute of Child Health Hospital."— ใบสำเนางานนำเสนอ:

1 Inter-hospital Conference 20 March 2012 Hematology/Oncology Department of Pediatric Queen Sirikit National Institute of Child Health Hospital

2 ผู้ป่วยเด็กชายไทย อายุ 8 ปี ภูมิลำเนา จ. ปทุมธานี หายใจเหนื่อยมากขึ้น 2 วัน ก่อนมา รพ.

3 4 วัน ก่อนมา รพ. สังเกตุว่าเหนื่อยง่าย ไม่มีไข้ ไอแห้งๆ นอนราบได้ 2 วัน ก่อนมา รพ. หายใจเร็วมากขึ้น ดู เหนื่อย บางครั้งมีเสียง หายใจดังเหมือนนกหวีด ไอแห้งๆ ท้องอืดมากขึ้น ไม่มีไข้ จึงมา รพ. Present illness

4 2 เดือน ก่อนมา รพ. เหนื่อยง่ายขึ้น เดิน แล้วต้องนั่งพัก ไม่ไอ ไม่มีไข้ นั่งเรียน แล้วหมดสติไป พามาตรวจที่ รพ. เด็ก ตรวจร่างกาย subcostal retraction,pulsus paradoxus 20 mmHg, distant heart sound, wheezing both lungs, liver 2 cm. below RCM Past History

5 • Enlargement of cardiac shadow • CT ratio = 0.65 • No pulmonary infiltration is seen CXR

6 • CBC: Hb 14.1 g/dl, Hct 42.1%, Platelet 477,000/mm 3 WBC 10,800/mm 3 (N-65, L-21, E-1, Ba-1, Mo-8, ATL-4%) MCV 86.5 fl, MCH 29.5 pg/cell, MCHC 34.1 g/dl, RDW 12% • Echocardiogram: massive pericardial effusion Past History

7 • Pericardial tapping: – straw color with fibrin, WBC 850 (Mono 100%), RBC 365 – Pericardial fluid Protein 2.44 g/dl, Serum Protein 6.1 g/dl – Pericardial fluid sugar 84 mg/dl, Blood Sugar 111 mg/dl – Pericardial fluid LDH 351 U/L, serum LDH 849 U/L – Pericardial fluid ADA 106, serum ADA 19 U/L – Pericardial fluid Culture: no growth, PCR for TB: negative • Tuberculin Skin Test : negative 0 mm. • Sputum for AFB x 3days: negative Past History

8 • Treat as TB pericarditis: – IRZS + Dexamethasone • F/U Echocardiogram (1 week after treatment) : – no pericardial effusion • Continue IRZS Past History

9 •Vital signs: BT 37 o C, RR 28/min., PR 130/min, BP 120/70 mmHg, Pulsus paradoxus •BW 29 Kg.(P ) Ht 123 cm.(P ) •General Appearance: A Thai boy, good consciousness, not pale, no jaundice, no neck vein engorged •Heart: no active precordium, no distant heart sound, normal S1,S2, no murmur Physical examination

10 •Lungs: expiratory wheezing both lungs •Abdomen : no distention, active bowel sound, soft, liver 1 cm. below RCM, spleen was not palpable •Extremities: no edema Physical examination

11 •Previous treatment for TB pericarditis •Progressive dyspnea •Cardiac tamponade Problem lists

12 investigation

13 CBC •Hb 14 g/dl •Hct 40.8% •WBC 16,140/ mm3 (N-94%, L- 5%, M-1%) •Platelet 358,000/µL •MCV 81.3 fl, MCH 28.9 pg, MCHC 35.4 g/dl •RDW 13.5%

14 U/A •Sp.gr •pH 7.0 •Urobilinogen : negative •Bilirubin : negative •Protein negative •Epithelial cell 0-1/HPF •WBC 1-2/HPF •No RBC

15 Liver Function Test •Total protein 6.18 g/dl ( ) •Albumin 3.8 g/dl ( ) •Globulin 2.38 g/dl ( ) •Total bilirubin 0.51 mg/dl (< 1.00) •Direct Bilirubin 0.24 mg/dl (<0.10) •Indirect bilirubim 0.27 mg/dl (0-0.5) •AST /.ALT57 / 36 U/L (10-30) •ALP95 U/L ( )

16 Blood Chemistry •BUN 8.05 mg/dl •Cr 0.46 mg/dl •Na 135 mmol/L •K 4.53 mmol/L •Cl 101 mmol/L •CO mmol/L •Calcium 8.2 mg/dL •Magnesium 0.83 mmol/L •Phosphorus 6.0 mg/dl •LDH 860 U/L •Uric acid mg/dl

17 CXR • Enlargement of cardiac shadow • Progression of BLL infiltration, combined congestion cannot exclude

18 EKG

19 • Low voltage in lead I, aVR, aVL and V1 • HR 120/min • RAE, LAE, no chamber hypertrophy • Axis 90 o o

20 Bone Marrow Aspiration

21

22

23 • Clotted specimen • M : E : L = 61 : 12 : 18 • Histiocyte 3%, not increased hemophagocytic activity • Tumor cell 5%

24 Bone Scan No evidence of bony metastasis

25 CT-Chest

26

27

28 • Hypodensity infiltrative mass extending from lower neck, superior-anterior mediastinum, subcarina and hili, posterior aspected of the heart down to diaphram, encasing and compressing mediastinal structures • Invasion into LA chamber

29 CT Abdomen

30 CT Abdomen

31 CT Abdomen

32 CT-Abdomen • Multiple soft tissue densities in abdomen are DDx unopacified bowel loops, but cannot R/O mesenteric mass/node

33 Echocardiogram • RAE, LAE • Pulmonary vein obstruction due to hypertrophy of Pulmonary vein and extracardiac mass. • PV PG 20 mmHg • Multiple mass in LA chamber, AV groove • Hyperechoic pericardium, no pericardial effusion. • LVEF 70% • Right pleural effusion 18 mm

34 Pathology • Pericadiectomy: Pericardium

35 Pathology – Suspected Malignant lymphoma – Immunohistochemistry study • Positively react with CD3, CD5, CD7 and weekly CD4 • CD10, Bcl-2, TdT are positive • MPO, CD20, CD34, CD8, CD117, PAX-5 and AE1/AE3 are negative T lymphoblastic lymphoma is diagnosed

36 Progression • Start Dexamethasone 0.6mg/kg/day • Set OR for Pericardiectomy • Patho: T lymphoblastic lymphoma stage IV • Treatment: TPOG-ALL • F/U Echocardiogram 1 mo after treatment – No mass in cardiac chamber – Good LV function – No pericardial effusion

37 Approach to cardiac mass

38 Clinical Features • Determined by location of tumor rather than its histological type – Rapidly progressive heart failure – Arrhythmia – Chest pain – Cardiac tamponade – Superior vena cava syndrome Bruce C J, Heart 2011;97:

39 Differential Diagnosis • Primary cardiac neoplasm • Secondary cardiac neoplasm Bruce C J, Heart 2011;97:

40 J Am Soc Echocardiogr, 2000;13:

41 Primary cardiac neoplasm – Assessment of the specific location • Endocardium : cardiac myxoma • Myocardium : myofibroblastic sarcoma, fibroma, Rhabdomyoma • Pericardium: teratoma, mesothelioma, hemangioma, Lymphoma ( Right side heart, multifocal) Grebenc M L, et al, RSNA 2000;20:

42 Cardiac Lymphoma RA

43 Secondary cardiac neoplasm – Most common malignancies that metastasize to the heart are • Carcinomas of lung and Breast • Lymphoma • Leukemia – Pericardium is the most commonly affected site Grebenc M L, et al, RSNA 2000;20:

44 10-year-old boy presented with progressive breathlessness • CXR: marked cardiomegaly • Echo: – large pericardial effusion – Compromising function of the heart • Bradycardia after insertion of pericardial drain, cardiac arrest and died Patel J, et al, Annual of Oncology 2010: 21;

45 10-year-old boy presented with progressive breathlessness Patel J, et al, Annual of Oncology 2010: 21; • Patho: small lymphocytes infiltrattion of RV and LV, stained positively for CD45, CD3, CD8 and TdT • Dx: T-cell Lymphoblastic Lymphoma

46 10-year-old boy presented with progressive dyspnea and abdominal pain • CXR • Echo: massive pericardial effusion, LV decompensation • Pericardial tapping • Pleural tapping – Straw-color fiuld – P/S protien ratio: 0.39 – P/S LDH ratio : 0.8 – Culture: nogrowth – AFB: negative Schraader E B, et al, SAMJ 1987: 72;

47 10-year-old boy presented with progressive dyspnea and abdominal pain • Start IRZS+ Prednisolone • 2 wk after treatment Clinical improved, D/C • Readmitted 25 days after D/C, progressive dyspnea • Pleural and pericardial effusion – P/S protien ratio: 0.52 – P/S LDH ratio : 0.48 – ADA : 11.5 U/L Schraader E B, et al, SAMJ 1987: 72;

48 10-year-old boy presented with progressive dyspnea and abdominal pain • Cytology: – Numerous primitive Lymphocytes • CT: medistinal mass • Pericardial biopsy – Tissue infiltration suggestive of lymphoma Schraader E B, et al, SAMJ 1987: 72;

49 Conclusion • Primary cardiac lymphoma is very rare. • Both B-cell and T-cell lymphoma have been reported • RA and RV are the most common sites • 20% of NHL presented with pleural effusion • High ADA level may be present in pleural effusion cause by TB, SLE, Lymphoma and Leukemia Michael G. Alexandrakis, et al, CHEST 2004;125: Patel J, et al, Cardiovascular Pathology, 2010;19: Patel J, et al, Annual of Oncology 2010: 21;


ดาวน์โหลด ppt Inter-hospital Conference 20 March 2012 Hematology/Oncology Department of Pediatric Queen Sirikit National Institute of Child Health Hospital.

งานนำเสนอที่คล้ายกัน


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