Velayo, James Philip S.

PATHOLOGY CASE STUDY

1ST SEM 2019-20
Pathomicro PT4y1-1 Case: 9
Sonnie P. Talavera, MD RMT

Case 9:
A 55y/o nulligravid female has experienced increasing pain in the back, right chest, left shoulder, and left
upper thigh for the past 6 months. The pain is dull but constant. She has now developed a sudden, severe,
sharp pain in the left thigh. On physical examination, she is afebrile. She has intense pain on palpation of
the upper thigh, and the left leg is shorter than the right. A radiograph of the left leg shows a fracture
through the upper diaphyseal region of the femur in a 5-cm lytic area that extends through the entire
thickness of the bone. A bone scan shows multiple areas of increased uptake in the left femur, pelvis,
vertebrae, right third and fourth ribs, upper left humerus, and left scapula. Laboratory studies show serum
Na+, 140 mmol/L; K+, 4.1 mmol/L; Cl−, 99 mmol/L; CO2, 26 mmol/L; glucose, 78 mg/dL; creatinine,
0.9 mg/dL; total protein, 6.7 g/dL; albumin, 4.5 g/dL; total bilirubin, 1 mg/dL; AST, 28 U/L; ALT, 22
U/L; and alkaline phosphatase, 202 U/L. What is the most likely diagnosis?

 Age: 55y/o
 Sex: Female
 Job: Factory Worker (packager)
 Hx: Pain in the back (PS: 5/10), ® chest (PS: 4/10), (L) shoulder (PS: 4/10), (L) upper thigh (PS:
5/10)
 Laboratory: Radiograph shows (L) leg fracture through the upper diaphysial region of femur
: Bone scan: multiple areas of increased uptake in (L) femur, pelvis, vertebrae, ® third
and fourth ribs, upper (L) humerus, and (L) scapula.
: serum Na+, 140 mmol/L; K+, 4.1 mmol/L; Cl−, 99 mmol/L; CO2, 26 mmol/L;
glucose, 78 mg/dL; creatinine, 0.9 mg/dL; total protein, 6.7 g/dL; albumin, 4.5 g/dL; total
bilirubin, 1 mg/dL; AST, 28 U/L; ALT, 22 U/L; and alkaline phosphatase, 202 U/L.

A. DIFFERENTIAL DIAGNOSIS:
Differential Diagnosis Rule in Rule out
1. Leg length discrepancy The left leg is shorter than
the right
2. Scoliosis Also base on the case that
she has a leg length
discrepancy.
3. Osteoarthritis Osteoarthritis is a
degenerative disease that
commonly affects the joints
and worsens over time, often
resulting in chronic pain.

B. CASE DEFINITIVE DIAGNOSIS

BONE METASTASIS

 Epidemiology:
The bone is a common site for metastasis. Bone metastasis or "bone mets" occurs when
cancer cells from the primary tumor relocate to the bone. Prostate, breast, and lung cancers are
most likely to spread to the bone. However, other cancers are not excluded.
 Pathogenesis:
Bone metastases do not begin from the bones but move there from the primary tumor site.
On the other hand, primary bone cancers are rare cancers where the primary tumor actually
starts in the bone. Therefore, bone cancer and bone metastases are not the same.

 Molecular/ Morphologic/ Biochemical Changes:

When cancer cells metastasize to the bone, they can cause changes to the bone. The
process by which portions of the bone are damaged is called osteolysis. Oftentimes, small holes
 result from osteolysis. These holes in the bone are referred to as osteolytic lesions or lytic
lesions. Lytic lesions can weaken the bones and increase the risk of breakage or other problems.
It is also common for bone metastasis patients to experience pain with lesions.

Clinical Manifestations:

1. Pain - Pain is usually the first symptom patients notice. It is most often felt at the site of the
metastasis, which is referred to as localized pain. There are also cases where patients experience pain in
areas surrounding the metastasis. Depending upon the location of the metastasis, the pain may vary. Bone
metastasis patients often describe the pain as gradually increasing over a period of time and becoming
more severe. Patients with metastases to the spinal cord often have pain or discomfort that is worse at
night or with bed rest. However, those patients with lesions involving the long bones, such as the arms
and legs, have pain with activity or movement.

2. Fractures - Bone metastases can weaken your bones and put you at risk for fractures. Not all
patients will fracture bones, but it is important to be aware of that possibility. Impending
fractures describe those bones that are about to break. If found early, your doctor may be able to treat the
bone to keep it from breaking.

Other Complications:

a. If secondary tumor is located in the spinal area, it can result in spinal cord compression. Spinal
cord compression occurs when the tumor squeezes the spinal cord. This can lead to back pain or make
walking painful and difficult. Other symptoms might include numbness and weakness in the legs,
problems with the bowels or bladder, or numbness in the abdominal area.

b. If your level of red blood cells drops, you might become anemic and have symptoms of
fatigue, weakness, and shortness of breath.

c. Patients whose white blood cells are affected may be more likely to have infections, which
could cause fevers, chills, fatigue, or pain.

d. Lastly, if your platelet count is low, you may have abnormal bleeding.

C. TREATMENT AND MANAGEMENT:

1. RADIATION THERAPY
The radiologist directs these rays to
injure or destroy cancer cells in the area of the
bone metastasis or tumor.
2. SURGICAL THERAPY
The type of surgery will depend upon
the location and size of the bone metastasis
tumor. Surgery usually involves removing all or
part of the tumor and stabilizing the bone to
prevent breakage. With fractures or impending
fractures, surgery could include placement of
metal plates, rods, screws, wires, nails, and/or
pins, or prostheses.

3. RADIOPHARMACEUTICAL THERAPY
The purpose of radiopharmaceutical
therapy is to deliver radiation to tumor cells
without harming normal cells. This type of
therapy involves the injection of active metals
that give off radiation particles in the patient.

4. PAIN MANAGEMENT THERAPY

The purpose of radiopharmaceutical
therapy is to deliver radiation to tumor cells
without harming normal cells. This type of
therapy involves the injection of active metals
that give off radiation particles in the patient.

REFERENCES:
https://onco.com/about-cancer/cancer-types/bone-cancer/treatment/radiation-therapy/
https://medizzy.com/feed/796277
https://link.springer.com/referenceworkentry/10.1007%2F978-3-319-26067-9_27-1
https://healthcare.utah.edu/healthfeed/postings/2016/11/pain_relief.phpp